Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.
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Plan PHP Care Complete FIDA-IDD (Plan Medicare-Medicaid) | Lista de
medicamentos cubiertos para 2019 (Formulario)
Introducción
Este documento se llama la Lista de medicamentos cubiertos (también llamada la Lista de medicamentos).
Le informa sobre cuáles de sus medicamentos de receta y medicamentos sin receta y artículos están
cubiertos por el Plan PHP Care Complete FIDA-IDD. La Lista de medicamentos también le notifica si hay
reglas especiales o restricciones en algunos de los medicamentos cubiertos por el Plan PHP Care
Complete FIDA-IDD. Términos clave y sus definiciones se encuentran en el último capítulo del Manual del
participante.
Actualizado en 03/2019
Tabla de Contenido
A. Renuncias de garantías .............................................................................................................................. 2
B. Preguntas frecuentes (FAQ) ....................................................................................................................... 3
B1. ¿Qué medicamentos de receta se encuentran en la Lista de medicamentos cubiertos?
(Para abreviar, llamamos “Lista de medicamentos” a la Lista de medicamentos cubiertos). ............ 3
B2. ¿La Lista de medicamentos cambia alguna vez? ................................................................................ 4
B3. ¿Qué sucede si hay un cambio en la Lista de medicamentos? ........................................................... 5
B4. ¿La cobertura de medicamentos tiene alguna restricción o límite o hay que hacer algo en
particular para obtener ciertos medicamentos? .................................................................................. 6
B5. ¿Cómo sabrá si el medicamento que usted quiere tiene limitaciones o si tiene que hacer
algo para obtenerlo? ........................................................................................................................... 6
B6. ¿Qué sucederá si cambiamos nuestras reglas sobre algunos medicamentos (por ejemplo,
autorización (aprobación) previa, límites de cantidad y/o restricciones de tratamiento
progresivo)? ........................................................................................................................................ 7
B7. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos? .......................................... 7
B8. ¿Qué pasará si el medicamento que usted quiere tomar no está en la Lista de
medicamentos? ................................................................................................................................... 7
B9. ¿Qué pasará si usted es un Participante nuevo del Plan PHP Care Complete FIDA-IDD y
no puede encontrar su medicamento en la Lista o tiene problemas para obtener su
medicamento? ................................................................................................................................................ 8
Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.
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B10. ¿Puede pedir al plan que haga una excepción para cubrir su medicamento? .................................. 8
B11. ¿Cómo puede pedir una excepción? ................................................................................................. 9
B12. ¿Cuánto tiempo toma obtener una excepción? ................................................................................. 9
B13. ¿Qué son los medicamentos genéricos? ........................................................................................... 9
B14. ¿Qué son los medicamentos de venta libre (OTC)? .......................................................................... 9
B15. ¿El Plan PHP Care Complete FIDA-IDD cubre algún producto de venta libre que no sea
un medicamento? ................................................................................................................................ 9
B16. ¿Cuánto es su copago? ................................................................................................................... 10
B17. ¿Qué son los niveles de medicamentos? ........................................................................................ 10
C. Lista de medicamentos cubiertos ............................................................................................................. 10
D. Lista de medicamentos por enfermedad .................................................................................................. 11
E. Índice de medicamentos cubiertos ..........................................................................................................166
A. Renuncias de garantías
Ésta es una lista de medicamentos que los participantes pueden obtener en el Plan PHP Care Complete
FIDA-IDD.
❖ Partners Health Plan es un plan de cuidados administrados que tiene contratos con Medicare y
New York State Department of Health (Medicaid), para ofrecer beneficios a los Participantes a
través del programa piloto Fully Integrated Duals Advantage for individuals with Intellectual and
Developmental Disabilities (FIDA-IDD, programa para personas con discapacidades intelectuales y
del desarrollo que tienen Medicare y Medicaid).
❖ ATTENTION: If you speak a language other than English, language assistance services, free of
charge, are available to you. Call 41T1-855-747-5483 and 711 for TTY users, 8AM to 8PM, seven
days a week 41T. The call is free.
❖ Si usted habla español, se encuentran disponibles para usted servicios sin cargo de asistencia
con el idioma. Llame al 1-855-747-5483 y al 711 para los usuarios de TTY de 8:00 a. m. a
8:00 p. m., los siete días de la semana. La llamada es gratuita.
❖ Если Вы говорите на русском языке, Вам доступна бесплатная языковая поддержка.
Звоните по телефону 1-855-747-5483 и 711 для пользователей линии TTY/TDD с 08:00 до
20:00, без выходных. Звонок бесплатный.
Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.
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❖ 如果您說中文,您可以獲得免費的語言協助服務。請致電 1-855-747-5483,TTY 使用者請致電
711,服務時間為每週七天,上午 8 時至晚上 8 時。本電話為免付費電話。
❖ Usted puede pedir esta información en otros formatos, como letra grande, braille o audio de
manera gratuita. Llame al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a
8 p. m., los siete días de la semana. La llamada es gratuita.
❖ Si quiere realizar una solicitud permanente o cambiarla para un idioma o formato preferido,
llame a Servicios al participante del Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al
711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es
gratuita.
❖ El estado de New York creó un programa del ombudsman del Participante, llamado
Independent Consumer Advocacy Network (ICAN), para proporcionarle a los Participantes
asistencia gratuita, confidencial para los servicios que ofrece el Plan PHP Care Complete
FIDA-IDD. Para comunicarse con ICAN, llame, de manera gratuita, al 1-844-614-8800 (los
usuarios de TTY deben llamar al 711 y luego siga las indicaciones para marcar 844-614-8800)
o vaya a icannys.org.
B. Preguntas frecuentes (FAQ)
Encuentre aquí las respuestas a las preguntas que usted tenga sobre esta Lista de medicamentos
cubiertos. Usted puede leer todas las Preguntas frecuentes para saber más o buscar preguntas y
respuestas.
B1. ¿Qué medicamentos de receta se encuentran en la Lista de medicamentos cubiertos?
(Para abreviar, llamamos “Lista de medicamentos” a la Lista de medicamentos
cubiertos).
Los medicamentos de la Lista de medicamentos cubiertos que comienza en la página 12 son los
medicamentos cubiertos por el Plan PHP Care Complete FIDA-IDD. Estos medicamentos están
disponibles en las farmacias dentro de nuestra red. Una farmacia está en nuestra red si tenemos un
acuerdo con ellos para trabajar con nosotros y proporcionarle servicios a usted. Nos referimos a estas
farmacias como “farmacias de la red”.
• El Plan PHP Care Complete FIDA-IDD cubrirá todos los medicamentos de la Lista, si:
o su médico u otro proveedor dice que usted los necesita para mejorar su salud o para
seguir sano,
o el medicamento es médicamente necesario para su enfermedad, y
Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.
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o usted surte la receta en una farmacia de la red del Plan PHP Care Complete FIDA-
IDD.
• El Plan PHP Care Complete FIDA-IDD podría tener pasos adicionales para tener acceso a
ciertos tipos de medicamentos (lea la pregunta B4 de abajo). En algunos casos, es probable
que usted tenga que hacer algo antes de obtener un medicamento, por ejemplo, primero probar
otros medicamentos.
Usted puede también leer una lista actualizada de los medicamentos que cubrimos en nuestro sitio web en
www.phpcares.org o llame a Servicios al participante al 1-855-747-5483 y al 711 para los usuarios de TTY,
de 8 a. m. a 8 p. m., los siete días de la semana.
B2. ¿La Lista de medicamentos cambia alguna vez?
Sí. El Plan PHP Care Complete FIDA-IDD podría agregar o quitar medicamentos de la Lista de
medicamentos durante el año.
También podemos cambiar nuestras reglas sobre algunos medicamentos. Por ejemplo, podríamos:
• Decidir si exigir o no una aprobación previa para algún medicamento. (Aprobación previa
es el permiso del Plan PHP Care Complete FIDA-IDD o su Equipo interdisciplinario (IDT)
antes de que usted pueda obtener un medicamento).
• Aumentar o cambiar la cantidad de un medicamento que usted puede obtener (llamado
límite de cantidad).
• Agregar o cambiar restricciones de tratamiento progresivo de un medicamento. (Terapia
progresiva significa que usted podría tener que probar un medicamento antes que
cubramos otro medicamento).
Para obtener más información acerca de estas reglas para los medicamentos, lea la pregunta B4.
Si está tomando algún medicamento que estuvo cubierto al principio del año, por general no le quitamos o
cambiamos la cobertura de ese medicamento durante el resto del año, a menos que:
• un medicamento nuevo y más económico que es igual de eficiente que un medicamento
que se encuentra actualmente en la Lista de medicamentos llega a estar disponible, o
• nos damos cuenta de que un medicamento no es seguro, o
• un medicamento es eliminado del mercado.
Las preguntas B3 y B6 de abajo tienen más información sobre lo que sucederá cuando cambie la Lista de
medicamentos.
• Usted siempre puede leer la Lista de medicamentos actualizada del Plan PHP Care
Complete FIDA-IDD en internet, en www.phpcares.org.
Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.
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• También puede llamar a Servicios al participante para revisar la Lista de medicamentos
actual al 1-855-747-5483 y al 711 para usuarios de TTY, de 8 a. m. a 8 p. m., los siete días
de la semana.
B3. ¿Qué sucede si hay un cambio en la Lista de medicamentos?
Algunos cambios a la Lista de Medicamentos ocurren inmediatamente. Por ejemplo:
• Un medicamento genérico nuevo llega a estar disponible. A veces, un medicamento
nuevo y más económico que es igual de eficiente que un medicamento que se encuentra
actualmente en la Lista de medicamentos llega a estar disponible. Cuando eso ocurre,
podemos eliminar el medicamento actual, pero su costo para el medicamento nuevo será
el mismo. Cuando agregamos el medicamento genérico nuevo, también podemos decidir
mantener el medicamento actual en la lista, pero cambiar sus reglas o límites de cobertura.
o Es posible que no le notifiquemos cuando se haga este cambio, pero le mandaremos
información sobre el cambio específico o los cambios que hemos hecho.
o Usted o su proveedor pueden solicitar una excepción de estos cambios. Le mandaremos
una notificación con los pasos que puede tomar para solicitar una excepción. Por favor lea
la pregunta B10 para más información sobre excepciones.
• Un medicamento es eliminado del mercado. Si la Administración de alimentos y
medicamentos (FDA) dice que algún medicamento que usted toma no es seguro o el
fabricante del medicamento lo retira del mercado, lo quitaremos inmediatamente de la Lista
de medicamentos. Si usted está tomando el medicamento, también le enviaremos una carta y
lo llamaremos para avisarle que el medicamento que no es seguro fue quitado de la Lista de
medicamentos. Si está tomando un medicamento que no es seguro y le enviamos una carta
para informarle de esto, comuníquese con el proveedor que se lo recetó para que elija un
medicamento alternativo.
Podemos hacer otros cambios que pueden afectar las medicinas que usted toma. Podemos
notificarle por adelantado sobre esos otros cambios a la Lista de Medicamentos. Estos cambios pueden
ocurrir si:
• La FDA publica nuevas directrices o hay nuevos lineamientos clínicos sobre un medicamento.
• Agregamos un medicamento genérico que no es nuevo en el Mercado y
o Reemplazamos un medicamento de marca actualmente en la Lista de Medicamentos
o
o Cambiamos las reglas de cobertura o los límites del medicamento de marca.
Cuando ocurren estos cambios, le notificaremos por lo menos 30 días antes de que hagamos el cambio a
la Lista de Medicamentos o cuando vaya a rellenar su medicamento. Esto le dará tiempo para hablar con
su médico u otro recetador. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la
Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.
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Lista de Medicamentos que usted pueda tomar en su lugar o si tiene que pedir una excepción. Después
usted puede:
• Recibir un suministro de 30 días antes de que se haga el cambio a la Lista de
Medicamentos, o
• Solicitar una excepción de estos cambios. Para más información sobre las excepciones,
por favor lea la pregunta B10.
B4. ¿La cobertura de medicamentos tiene alguna restricción o límite o hay que hacer algo
en particular para obtener ciertos medicamentos?
Sí, algunos medicamentos tienen reglas de cobertura o tienen límites en la cantidad que usted puede
obtener. En algunos casos, usted o su médico u otro proveedor tendrán que hacer algo antes de poder
obtener el medicamento. Por ejemplo:
• Aprobación previa (o autorización previa): Para algunos medicamentos, usted o su
médico u otro proveedor debe obtener una aprobación del Plan PHP Care Complete FIDA-
IDD o su Equipo interdisciplinario (IDT) antes de surtir su receta. El Plan PHP Care
Complete FIDA-IDD podría no cubrir el medicamento si usted no consigue la aprobación.
• Límites de cantidad: A veces el Plan PHP Care Complete FIDA-IDD limita la cantidad de
un medicamento que usted puede obtener.
• Tratamiento progresivo: A veces el Plan PHP Care Complete FIDA-IDD exige que usted
siga un tratamiento progresivo. Esto significa que usted tendrá que probar los
medicamentos en un cierto orden para su enfermedad. Usted podría tener que probar un
medicamento antes de que cubramos otro medicamento. Si a su médico le parece que el
primer medicamento no funciona para usted, entonces cubriremos el segundo.
Usted puede verificar si su medicamento tiene algún requisito o límite adicional leyendo las tablas de la
página 12. Usted también puede obtener más información en nuestro sitio web en www.phpcares.org. En
nuestra página web encontrará documentos que explican nuestras restricciones de aprobación previa y
tratamiento progresivo. Usted también puede pedirnos que le enviemos una copia.
Usted también puede pedir una excepción a esos límites. Esto le dará tiempo para hablar con su médico u
otro proveedor médico. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la Lista de
medicamentos que usted pueda tomar en su lugar o si tiene que pedir una excepción. Por favor lea las
preguntas B10-B12 para más información sobre las excepciones.
B5. ¿Cómo sabrá si el medicamento que usted quiere tiene limitaciones o si tiene que hacer
algo para obtenerlo?
La Lista de medicamentos cubiertos de la página 12 tiene una columna llamada "Medidas
necesarias, restricciones o límites de uso".
Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.
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B6. ¿Qué sucederá si cambiamos nuestras reglas sobre algunos medicamentos (por
ejemplo, autorización (aprobación) previa, límites de cantidad y/o restricciones de
tratamiento progresivo)?
En algunos casos, le avisaremos por adelantado si agregamos o cambiamos requisitos de aprobación
previa, límites de cantidad y/o restricciones de tratamiento progresivo a un medicamento. Para más
información sobre esta notificación por adelantado y situaciones cuando no le notificaremos por adelantado
cuando nuestras reglas sobre los medicamentos en la Lista de medicamentos cambian, por favor lea la
pregunta B3.
B7. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos?
Hay dos maneras de encontrar un medicamento:
• Puede buscar por orden alfabético (si usted sabe cómo se escribe el nombre del
medicamento), o
• Puede buscar por enfermedad.
Para buscar por orden alfabético, vaya a la sección del Índice de medicamentos cubiertos en la página
166. Luego busque el nombre en la Lista de medicamentos.
Para buscar por enfermedad, busque la sección titulada “Lista de medicamentos por enfermedad” de la
página 12. Los medicamentos de esta sección están agrupados en categorías, de acuerdo al tipo de
enfermedades para las que se usan como tratamiento. Por ejemplo, si usted tiene una enfermedad del
corazón, usted debe buscar en la categoría Inhibidores de la enzima convertidora de angiotensina (ACE).
Ahí encontrará los medicamentos que tratan enfermedades del corazón.
B8. ¿Qué pasará si el medicamento que usted quiere tomar no está en la Lista de
medicamentos?
Si usted no encuentra su medicamento en la Lista de medicamentos, llame a Servicios al participante al 1-
855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana, y
pregunte por él. Si se entera que el Plan PHP Care Complete FIDA-IDD no cubrirá el medicamento, usted
puede hacer uno de los siguientes:
• Pida a Servicios al participante una lista de medicamentos similares al que quiera tomar.
Luego, muestre la lista a su médico u otro proveedor médico. Éste podrá recetarle un
medicamento de la Lista de medicamentos que sea similar al que usted quiere tomar. O,
• Usted también puede pedir al plan o a su Equipo interdisciplinario (IDT) que haga una
excepción para cubrir su medicamento. Por favor lea las preguntas B10-B12 para más
información sobre las excepciones.
Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.
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B9. ¿Qué pasará si usted es un Participante nuevo del Plan PHP Care Complete FIDA-IDD y
no puede encontrar su medicamento en la Lista o tiene problemas para obtener su
medicamento?
Podemos ayudarle. Debemos cubrir un suministro temporario de 30 días de su medicamento, cuando sea
necesario, durante los primeros 90 días que usted sea Participante del Plan PHP Care Complete FIDA-
IDD. Esto le dará tiempo para hablar con su médico u otro proveedor médico. Ellos podrán ayudarle a
decidir si hay algún otro medicamento similar en la Lista de medicamentos que usted pueda tomar en su
lugar o si tiene que pedir una excepción.
Si su receta es escrita por menos de los días indicados, le permitiremos múltiples suministros hasta un
máximo de 30 días de su medicamento.
Cubriremos un suministro de 30 días de su medicamento si:
• Usted está tomando algún medicamento que no esté en nuestra Lista de medicamentos, o
• Las reglas del plan de salud no le permiten obtener la cantidad recetada por su proveedor
médico, o
• El medicamento requiere aprobación previa del Plan PHP Care Complete FIDA-IDD o de su
Equipo interdisciplinario (IDT), o
• Usted toma algún medicamento que forme parte de una restricción de tratamiento progresivo.
Si usted está en una institución de cuidados intermedios u otra institución de cuidados a largo plazo, y
necesita un medicamento que no está en la Lista de Medicamentos o si no puede obtener el medicamento
que necesita, podemos ayudarle. Usted ha estado en el plan por más de 90 días, vive en una institución de
cuidados a largo plazo y necesita un suministro de inmediato:
• Le cubriremos un suministro de 31 días del medicamento que necesite (a menos que
tenga una receta para menos días), aunque sea o no un nuevo Participante del Plan PHP
Care Complete FIDA-IDD.
• Esto es adicional al suministro temporario durante los primeros 90 días de ser Participante
del Plan PHP Care Complete FIDA-IDD.
Si ha estado en el Plan PHP Care Complete FIDA-IDD durante más de 90 días y necesita cambiar su
nivel de cuidados, le cubriremos un suministro transitorio de los medicamentos de receta.
B10. ¿Puede pedir al plan que haga una excepción para cubrir su medicamento?
Sí. Usted puede pedirle al Plan PHP Care Complete FIDA-IDD o a su Equipo interdisciplinario (IDT) que haga
una excepción para cubrir su medicamento si éste no está en la Lista de medicamentos.
Usted también puede pedirle al Plan PHP Care Complete FIDA-IDD o a su IDT un cambio a las reglas de
su medicamento.
Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.
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• Por ejemplo, el Plan PHP Care Complete FIDA-IDD podría limitar la cantidad que
cubriremos de un medicamento. Si su medicamento tiene un límite, usted puede pedirnos
a nosotros o a su IDT que cambiemos el límite y que cubramos más.
• Otros ejemplos: Usted puede pedirnos a nosotros o a su IDT que quitemos las
restricciones de tratamiento progresivo o los requisitos de aprobación previa.
B11. ¿Cómo puede pedir una excepción?
Para pedir una excepción, llame a su Administrador de cuidados. Su Administrador de cuidados trabajará
con usted y su proveedor para ayudarle a pedir una excepción. Usted también puede leer el Capítulo 9,
Sección 6.3, página 193, del Manual del participante, para más información sobre excepciones.
B12. ¿Cuánto tiempo toma obtener una excepción?
Primero, el Plan PHP Care Complete FIDA-IDD o su Equipo interdisciplinario (IDT) deben recibir una
declaración de su proveedor médico apoyando su pedido de una excepción. Después de recibir la declaración,
le daremos una decisión sobre su pedido de excepción a más tardar en 72 horas.
Si usted o su proveedor médico piensan que su salud podría deteriorarse si tiene que esperar 72 horas
para obtener una decisión, entonces usted puede pedir una excepción acelerada. Ésta es una decisión
más rápida. Si su proveedor médico apoya su pedido, le daremos una decisión dentro de las 24 horas
después de recibir la declaración de apoyo de su proveedor médico.
B13. ¿Qué son los medicamentos genéricos?
Los medicamentos genéricos están hechos con los mismos ingredientes activos que los medicamentos de
marca. Generalmente cuestan menos que los medicamentos de marca y no tienen marcas tan conocidas.
Los medicamentos genéricos son aprobados por la Administración de alimentos y medicamentos (FDA).
El Plan PHP Care Complete FIDA-IDD cubre tanto medicamentos de marca como medicamentos
genéricos.
B14. ¿Qué son los medicamentos de venta libre (OTC)?
OTC quiere decir “medicamentos que se venden sin receta”. El Plan PHP Care Complete FIDA-IDD cubre
algunos medicamentos de venta libre cuando su proveedor escribe una receta para ellos.
Usted puede leer la Lista de medicamentos del Plan PHP Care Complete FIDA-IDD para ver qué
medicamentos de venta libre están cubiertos.
B15. ¿El Plan PHP Care Complete FIDA-IDD cubre algún producto de venta libre que no sea
un medicamento?
El Plan PHP Care Complete FIDA-IDD cubre algunos productos de venta libre que no son medicamentos
cuando su proveedor escribe una receta para ellos.
Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.
H9869_2019 Formulary Approved 10
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Ejemplos de productos sin receta, que no son medicamentos, incluyen los comprimidos orales de Bufferin
Extra-Strength y las cremas tópicas de hidrocortisona.
Usted puede leer la Lista de medicamentos del Plan PHP Care Complete FIDA-IDD para ver qué productos
de venta libre, que no son medicamentos, están cubiertos.
B16. ¿Cuánto es su copago?
Como Participante del Plan PHP Care Complete FIDA-IDD, usted no tiene copagos por medicamentos de
receta y de venta libre (OTC), siempre y cuando siga las reglas del Plan PHP Care Complete FIDA-IDD.
B17. ¿Qué son los niveles de medicamentos?
Los niveles son grupos de medicamentos de nuestra Lista de medicamentos. Ningún nivel tiene copago.
• Los medicamentos de Nivel 1 son medicamentos genéricos que están cubiertos por
Medicare Parte D.
• Los medicamentos de Nivel 2 son medicamentos de marca que están cubiertos por
Medicare Parte D.
• Los medicamentos de nivel 3 son medicamentos cubiertos por Medicare y medicamentos
sin receta cubiertos por Medicaid (tanto genéricos como de marca).
C. Lista de medicamentos cubiertos
La siguiente lista de medicamentos cubiertos le da información sobre los medicamentos cubiertos por el
Plan PHP Care Complete FIDA-IDD. Si usted tiene problemas para encontrar su medicamento en la lista,
lea el Índice de medicamentos cubiertos que comienza en la página 166. El índice alfabético nombra todos los medicamentos cubiertos por el Plan PHP Care Complete FIDA-IDD.
La primera columna de la tabla tiene el nombre del medicamento. Los medicamentos de marca están
escritos en mayúsculas (por ejemplo, PAXIL o LAMISIL) y los medicamentos genéricos están escritos en
cursivas minúsculas (por ejemplo, ibuprofeno).
La información de la columna titulada “Medidas necesarias, restricciones o límites de uso”, le indica si el
Plan PHP Care Complete FIDA-IDD tiene alguna regla para cubrir su medicamento.
Nota: El símbolo DP (programa dual) junto a un medicamento significa que el medicamento no es un
“medicamento de Parte D”. Estos medicamentos tienen reglas diferentes para las apelaciones.
• Una apelación es una manera formal de pedirnos que revisemos alguna decisión de
cobertura y que la cambiemos, si le parece que hemos cometido un error. Por ejemplo, el
Plan PHP Care Complete FIDA-IDD o su Equipo interdisciplinario (IDT) podría decidir que
un medicamento que usted quiere ya no está cubierto por Medicare o Medicaid.
Usted puede encontrar información sobre el significado de los símbolos y las abreviaciones de esta tabla en las páginas 11 y 12. Si tiene alguna pregunta, por favor llame al Plan PHP Care Complete FIDA-IDD al 1-855-747-5483 y al 711 para los usuarios de TTY, de 8 a. m. a 8 p. m., los siete días de la semana. La llamada es gratuita. Para obtener más información, visite www.phpcares.org.
H9869_2019 Formulary Approved 11
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• Si usted, su médico u otro proveedor no están de acuerdo con nuestra decisión, usted
puede apelar. Para pedir instrucciones sobre cómo apelar:
o Llame a Servicios al participante al 1-855-747-5483 y al 711 para los usuarios de TTY,
de 8 a. m. a 8 p. m., los siete días de la semana.
o Comuníquese con el Independent Consumer Advocacy Network (ICAN) llamando sin
costo al 1-844-614-8800 (los usuarios de TTY deben llamar al 711 y luego seguir las
indicaciones para llamar al 844-614-8800) o por internet en icannys.org.
o Lea el Capítulo 9 del Manual del participante para aprender como apelar una decisión.
D. Lista de medicamentos por enfermedad
Los medicamentos de esta sección están agrupados en categorías de acuerdo con el tipo de enfermedad
para la que se usan como tratamiento. Por ejemplo, si usted tiene una enfermedad del corazón, usted debe
buscar en la categoría la enzima convertidora de angiotensina (ACE). Ahí encontrará los medicamentos
que tratan enfermedades del corazón.
Estos son los significados de los códigos usados en la columna “Pasos necesarios,
restricciones o límites de uso”:
(g) = Sólo se cubre la versión genérica de este medicamento. La versión de marca no está
cubierta.
M = La versión de marca de este medicamento está en Nivel 3. La versión genérica está en
el Nivel 1.
PA = Autorización previa (aprobación): Usted debe tener aprobación del plan o su Equipo
interdisciplinario (IDT) antes de poder obtener este medicamento.
ST = Terapia progresiva: Usted debe probar otro medicamento antes de poder obtener éste.
12
2019 3 Tier MMP – Partners
Document: 2019 Formulary
Formulary ID: 19410
Updated 02/2019
Effective Date: 03/01/2019
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ANALGESICS
ANALGESICS, OTHER
8HR MUSCLE ACHE-PAIN ER 650 MG 650
MG
3 DP
ACEPHEN 120 MG SUPPOSITORY 120 MG 3 DP
ACEPHEN 120 MG SUPPOSITORY OUTER
120 MG
3 DP
ACEPHEN 325 MG SUPPOSITORY 325 MG 3 DP
ACEPHEN 325 MG SUPPOSITORY OUTER
325 MG
3 DP
ACEPHEN 650 MG SUPPOSITORY 650 MG 3 DP
ACEPHEN 650 MG SUPPOSITORY OUTER
650 MG
3 DP
acetaminophen 120 mg suppos 120 mg 3 DP
acetaminophen 120 mg suppos outer 120 mg 3 DP
acetaminophen 160 mg/5 ml liq a/f,s/f,cherry 160
mg/5 ml
3 DP
acetaminophen 325 mg tablet 325 mg 3 DP
acetaminophen 325 mg tablet u-d,25x30,uncoated
325 mg
3 DP
acetaminophen 325 mg/10.15 ml outer 325
mg/10.15 ml
3 DP
acetaminophen 500 mg caplet caplet,ex-strength
500 mg
3 DP
acetaminophen 500 mg tablet 500 mg 3 DP
acetaminophen 500 mg tablet asa-free,ex-str 500
mg
3 DP
acetaminophen 500 mg tablet extra strength 500
mg
3 DP
acetaminophen 650 mg suppos 650 mg 3 DP
acetaminophen 650 mg suppos outer 650 mg 3 DP
13
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
acetaminophen 650 mg/20.3 ml outer 650 mg/20.3
ml
3 DP
acetaminophen 80 mg tab chew fruit flavored 80
mg
3 DP
acetaminophen er 650 mg tablet outer 650 mg 3 DP
acetaminophen-codeine oral solution 120 mg-12
mg /5 ml (5 ml), 120-12 mg/5 ml, 300 mg-30 mg
/12.5 ml
1
acetaminophen-codeine oral tablet 300-15 mg,
300-30 mg, 300-60 mg
1
ARTHRITIS PAIN ER 650 MG CAPLT 8 HOUR,
CAPLET 650 MG
3 DP
ARTHRITIS PAIN ER 650 MG CAPLT CAPLET
650 MG
3 DP
ARTHRITIS PAIN ER 650 MG CAPLT
CAPLET, 8 HOUR 650 MG
3 DP
ARTHRITIS PAIN RELIEF ER 650 MG
CAPLET CAPLET 650 MG
3 DP
ascomp with codeine oral capsule 30-50-325-40
mg
1 PA
butalbital compound w/codeine oral capsule 30-
50-325-40 mg
1 PA; MO
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
1 PA
butalbital-acetaminophen oral tablet 50-325 mg 1 PA
butalbital-acetaminophen-caff oral capsule 50-
325-40 mg
1 PA
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg
1 PA
butalbital-aspirin-caffeine oral capsule 50-325-40
mg
1 PA
carisoprodol-asa-codeine oral tablet 200-325-16
mg
1 PA
carisoprodol-aspirin oral tablet 200-325 mg 1 PA
CHILD PAIN-FEVER 160 MG/5 ML 160 MG/5
ML
3 DP
14
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
CHILD PAIN-FEVER 160 MG/5 ML 160 MG/5
ML
3 DP
CHILD PAIN-FEVER 160 MG/5 ML A/F 160
MG/5 ML
3 DP
CHILD PAIN-FEVER 80 MG TAB CHW 80 MG 3 DP
CHILDREN'S MAPAP 80 MG RAPID 80 MG 3 DP
CHILDREN'S SILAPAP ELIXIR 160 MG/5 ML 3 DP
CHILD'S PAIN RELIEVER RAPID TB RAPID
TAB'S 80 MG
3 DP
CHLD ACETAMINOPHEN 160 MG/5 ML A/F,
GLUTEN/F, GRAPE 160 MG/5 ML
3 DP
CHLD ACETAMINOPHEN 160 MG/5 ML
A/F,GLUTEN/F,CHERRY 160 MG/5 ML
3 DP
CHLD ACETAMINOPHEN 160 MG/5 ML
INNER 160 MG/5 ML (5 ML)
3 DP
CHLD ACETAMINOPHEN 160 MG/5 ML
OUTER 160 MG/5 ML (5 ML)
3 DP
codeine-butalbital-asa-caff oral capsule 30-50-
325-40 mg
1 PA
FEVERALL 120 MG SUPPOSITORY
CHILDRENS, OUTER 120 MG
3 DP
FEVERALL 120 MG SUPPOSITORY
CHILDREN'S, OUTER 120 MG
3 DP
FEVERALL 325 MG SUPPOSITORY JUNIOR
STR, OUTER 325 MG
3 DP
FEVERALL 650 MG SUPPOSITORY ADULT,
OUTER 650 MG
3 DP
FEVERALL 80 MG SUPPOSITORY INFANT'S,
OUTER 80 MG
3 DP
FEVERALL RECTAL SUPPOSITORY 325 MG,
650 MG
3
GS ARTHRITIS PAIN ER 650 MG CAPLET 650
MG
3 DP
GS INFANT PAIN-FEVER 160 MG/5 CHERRY,
DYE-FREE 160 MG/5 ML
3 DP
GS PAIN RELIEF 500 MG CAPLET 500 MG 3 DP
GS PAIN RELIEF 500 MG TABLET 500 MG 3 DP
15
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
HM ARTHRITIS PAIN ER 650 MG CAPLET, 8
HOUR 650 MG
3 DP
HM CHLD PAIN-FEVER 160 MG/5 ML A/F,
DYE-FREE 160 MG/5 ML
3 DP
HM CHLD PAIN-FEVER 160 MG/5 ML
GLUTEN-F,A/F,ASA/F 160 MG/5 ML
3 DP
HM INFANT PAIN-FEVER 160 MG/5
A/F,GRAPE,W/SYRINGE 160 MG/5 ML
3 DP
HM PAIN RELIEF 500 MG CAPLET 500 MG 3 DP
HM PAIN RELIEF 500 MG CAPLET CAPLET,
EX-STRENGTH 500 MG
3 DP
HM PAIN RELIEF 500 MG TABLET EX-STR,
GLUTEN-FREE 500 MG
3 DP
HM PAIN RELIEVER 325 MG TABLET
REGULAR STRENGTH 325 MG
3 DP
hydrocodone-acetaminophen oral tablet 10-325
mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
1
hydrocodone-ibuprofen oral tablet 10-200 mg,
7.5-200 mg
1
IBU ORAL TABLET 600 MG, 800 MG 1 MO
ibuprofen-oxycodone oral tablet 400-5 mg 1
INFANT PAIN-FEVER 160 MG/5 ML 160 MG/5
ML
3 DP
MAPAP 160 MG/5 ML LIQUID 160 MG/5 ML 3 DP
MAPAP 160 MG/5 ML SUSPENSION 160 MG/5
ML
3 DP
MAPAP 325 MG TABLET 325 MG 3 DP
MAPAP 325 MG TABLET BOXED 325 MG 3 DP
MAPAP 325 MG TABLET REGULAR
STRENGTH 325 MG
3 DP
MAPAP 325 MG TABLET U-D 325 MG 3 DP
MAPAP 500 MG CAPLET CAPLET 500 MG 3 DP
MAPAP 500 MG CAPLET CAPLET,BOXED
500 MG
3 DP
MAPAP 500 MG CAPSULE 500 MG 3 DP
MAPAP 500 MG GELCAP GELCAP 500 MG 3 DP
16
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
MAPAP 500 MG TABLET 500 MG 3 DP
MAPAP 500 MG TABLET BOXED 500 MG 3 DP
MAPAP 500 MG TABLET U-D 500 MG 3 DP
MAPAP 80 MG TABLET CHEW 80 MG 3 DP
MAPAP ARTHRITIS ER 650 MG CPLT 650 MG 3 DP
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg
1
oxycodone-aspirin oral tablet 4.8355-325 mg 1
PAIN & FEVER 325 MG TABLET 325 MG 3 DP
PAIN & FEVER 500 MG CAPLET CAPLET 500
MG
3 DP
PAIN & FEVER 500 MG CAPLET CAPTABS
500 MG
3 DP
PAIN & FEVER 500 MG TABLET EXTRA
STRENGTH 500 MG
3 DP
PAIN & FEVER 500 MG TABLET WITHOUT
ASPIRIN 500 MG
3 DP
PAIN RELIEF 500 MG CAPLET CAPLET, EX-
STRENGTH 500 MG
3 DP
PAIN RELIEF 500 MG CAPLET CAPLET,EX-
STRENGTH 500 MG
3 DP
PAIN RELIEF 500 MG CAPLET EXTRA STR,
CAPLET 500 MG
3 DP
PAIN RELIEF 500 MG TABLET EX-
STRENGTH 500 MG
3 DP
PAIN RELIEF 500 MG TABLET EXTRA
STRENGTH 500 MG
3 DP
PAIN RELIEF ER 650 MG CAPLET
ARTHRITIS PAIN 650 MG
3 DP
PAIN RELIEF ER 650 MG CAPLET CAPLET, 8
HOUR 650 MG
3 DP
PAIN RELIEF ER 650 MG CAPLET CAPLET,
ARTHRITIS 650 MG
3 DP
PAIN RELIEVER 325 MG TABLET REGULAR
STRENGTH 325 MG
3 DP
PAIN RELIEVER 500 MG CAPLET CAPLET,
EX-STRENGTH 500 MG
3 DP
17
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
PAIN RELIEVER 500 MG CAPLET CAPLET,
EX-STRENGTH 500 MG
3 DP
PAIN RELIEVER 500 MG CAPLET CAPLET,X-
STRENGTH 500 MG
3 DP
PAIN RELIEVER 500 MG CAPLET EX-STR,
CAPLET 500 MG
3 DP
PAIN RELIEVER 500 MG TABLET 500 MG 3 DP
PAIN RELIEVER 500 MG TABLET EX-
STR,EASY TAB 500 MG
3 DP
pentazocine-naloxone oral tablet 50-0.5 mg 1 PA
PHARBETOL 325 MG TABLET REG
STRENGTH, BULK 325 MG
3 DP
PHARBETOL 325 MG TABLET REGULAR
STRENGTH 325 MG
3 DP
qc acetaminophen 8-hr 650 mg 650 mg 3 DP
QC ARTHRITIS PAIN ER 650 MG CAPLET 650
MG
3 DP
QC CHILD PAIN RLF 160 MG/5 ML 160 MG/5
ML
3 DP
QC INFNT PAIN RLF 160 MG/5 ML 160 MG/5
ML
3 DP
QC NON-ASPIRIN 500 MG CAPLET XTRA
STRENGTH,CAPLET 500 MG
3 DP
QC NON-ASPIRIN 500 MG GELCAP GELCAP,
EX-STR 500 MG
3 DP
QC NON-ASPIRIN PAIN RELIEF TB EXTRA
STRENGTH 500 MG
3 DP
SB EX-STRENGTH NON-ASPIRIN TAB
SAFETY SEALED 500 MG
3 DP
SB NON-ASPIRIN 325 MG TABLET
REGULAR STR 325 MG
3 DP
SB NON-ASPIRIN 325 MG TABLET
REGULAR STRENGTH 325 MG
3 DP
SB NON-ASPIRIN 500 MG CAPLET CAPLET
500 MG
3 DP
SB PAIN RELIEVER 500 MG CAPLET EXTRA-
STR,NON-ASA 500 MG
3 DP
18
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
SB PAIN RELIEVER 500 MG GELCAP EX-
STRENGTH, GELCAP 500 MG
3 DP
SM 8 HOUR PAIN RELIEF 650 MG CAPLET
650 MG
3 DP
SM ARTHRITIS PAIN ER 650 MG CAPLET 650
MG
3 DP
SM CHLD PAIN-FEVER 160 MG/5 ML A/F,
ASA/F, GLUTEN-F 160 MG/5 ML
3 DP
SM PAIN RELIEVER 500 MG CAPLET
CAPLET, EXTRA STR 500 MG
3 DP
SM PAIN RELIEVER 500 MG CAPLET
CAPLET, EXTRA STR 500 MG
3 DP
SM PAIN RELIEVER 500 MG GELCAP
GELCAP,EX STRENGTH 500 MG
3 DP
SM PAIN RELIEVER 500 MG TABLET EX-
STR, GLUTEN-FREE 500 MG
3 DP
SM PAIN RELIEVER 500 MG TABLET EXTRA
STRENGTH 500 MG
3 DP
TACTINAL 325 MG TABLET 325 MG 3 DP
TACTINAL 500 MG CAPLET CAPLET,X-
STRENGTH 500 MG
3 DP
TACTINAL 500 MG TABLET EXTRA-
STRENGTH 500 MG
3 DP
tramadol-acetaminophen oral tablet 37.5-325 mg 1
TRI-BUFFERED ASPIRIN 325 MG BOXED 325
MG
3 DP
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
aspirin 300 mg suppository 300 mg 3 DP
aspirin 325 mg tablet 325 mg 3 DP
aspirin 325 mg tablet coated 325 mg 3 DP
aspirin 325 mg tablet regular strength 325 mg 3 DP
aspirin 600 mg suppository 600 mg 3 DP
aspirin ec 325 mg tablet 325 mg 3 DP
aspirin ec 325 mg tablet orange 325 mg 3 DP
aspirin ec 325 mg tablet regular strength 325 mg 3 DP
19
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
celecoxib oral capsule 100 mg, 200 mg, 400 mg,
50 mg
1 MO
CHILD IBUPROFEN 100 MG/5 ML 100 MG/5
ML
3 DP
CHILDREN IBUPROFEN 100 MG/5 ML 100
MG/5 ML
3 DP
CHILDREN IBUPROFEN 100 MG/5 ML A/F
100 MG/5 ML
3 DP
CHILDREN IBUPROFEN 100 MG/5 ML A/F,
D/F 100 MG/5 ML
3 DP
CHILDREN IBUPROFEN 100 MG/5 ML A/F,
GLUTEN/F, BERRY 100 MG/5 ML
3 DP
CHILDREN IBUPROFEN 100 MG/5 ML A/F,
GLUTEN/F, GRAPE 100 MG/5 ML
3 DP
CHILDREN IBUPROFEN 100 MG/5 ML A/F,
GRAPE 100 MG/5 ML
3 DP
CHILDREN IBUPROFEN 100 MG/5 ML
A/F,BUBBLE GUM 100 MG/5 ML
3 DP
CHILDREN IBUPROFEN 100 MG/5 ML
A/F,GLUTEN/F,BUBBLE 100 MG/5 ML
3 DP
CHILDREN IBUPROFEN 100 MG/5 ML
BERRY FLAVOR 100 MG/5 ML
3 DP
diclofenac potassium oral tablet 50 mg 1
diclofenac sodium oral tablet extended release 24
hr 100 mg
1
diclofenac sodium oral tablet,delayed release
(dr/ec) 25 mg, 50 mg, 75 mg
1
DICLOZOR TOPICAL KIT 1 % 1
diflunisal oral tablet 500 mg 1
ECPIRIN EC 325 MG TABLET 325 MG 3 DP
etodolac oral capsule 200 mg, 300 mg 1 MO
etodolac oral tablet 400 mg, 500 mg 1 MO
etodolac oral tablet extended release 24 hr 400
mg, 500 mg, 600 mg
1 MO
flurbiprofen oral tablet 100 mg, 50 mg 1
gs aspirin 325 mg tablet 325 mg 3 DP
20
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
GS CHILD IBUPROFEN 100 MG/5 ML
D/F,A/F,BERRY FLAVOR 100 MG/5 ML
3 DP
gs ibuprofen 200 mg caplet 200 mg 3 DP
gs ibuprofen 200 mg tablet 200 mg 3 DP
hm aspirin 325 mg tablet 325 mg 3 DP
hm aspirin 325 mg tablet adult, gluten-free 325 mg 3 DP
hm aspirin ec 325 mg tablet reg strength 325 mg 3 DP
HM CHILD IBUPROFEN 100 MG/5 ML 100
MG/5 ML
3 DP
HM CHILD IBUPROFEN 100 MG/5 ML A/F,
BERRY 100 MG/5 ML
3 DP
HM CHILD IBUPROFEN 100 MG/5 ML A/F,
BUBBLE GUM 100 MG/5 ML
3 DP
HM CHILD IBUPROFEN 100 MG/5 ML A/F,
GRAPE 100 MG/5 ML
3 DP
hm ibuprofen 200 mg caplet caplet 200 mg 3 DP
hm ibuprofen 200 mg capsule liquid filled sftgel
200 mg
3 DP
hm ibuprofen 200 mg tablet coated,gluten-free 200
mg
3 DP
HM IBUPROFEN IB 200 MG CAPLET
COATED, GLUTEN-FREE 200 MG
3 DP
HM IBUPROFEN IB 200 MG TABLET
COATED. GLUTEN-FREE 200 MG
3 DP
hydrocodone-ibuprofen oral tablet 5-200 mg 1
IBU-200 200 MG TABLET 200 MG 3 DP
ibuprofen 200 mg caplet caplet 200 mg 3 DP
ibuprofen 200 mg caplet caplet, coated 200 mg 3 DP
ibuprofen 200 mg caplet coated caplet 200 mg 3 DP
ibuprofen 200 mg softgel softgel 200 mg 3 DP
ibuprofen 200 mg tablet 200 mg 3 DP
ibuprofen 200 mg tablet coated 200 mg 3 DP
ibuprofen 200 mg tablet coated caplet 200 mg 3 DP
ibuprofen 200 mg/10 ml susp 100's, u-d cups (otc)
100 mg/5 ml
3 MO; DP
21
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ibuprofen 200 mg/10 ml susp 30's, u-d cups (otc)
100 mg/5 ml
3 MO; DP
ibuprofen 200 mg/10 ml susp u-d (otc) 100 mg/5
ml
3 MO; DP
ibuprofen oral suspension 100 mg/5 ml 1 MO
ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MO
indomethacin oral capsule 25 mg, 50 mg 1 PA
indomethacin oral capsule, extended release 75
mg
1 PA
ketorolac oral tablet 10 mg 1 PA; QL (20 EA per 30 days)
meclofenamate oral capsule 100 mg, 50 mg 1
meloxicam oral tablet 15 mg, 7.5 mg 1 MO
nabumetone oral tablet 500 mg, 750 mg 1
naproxen oral suspension 125 mg/5 ml 1 MO
naproxen oral tablet 250 mg, 375 mg, 500 mg 1 MO
naproxen oral tablet,delayed release (dr/ec) 375
mg, 500 mg
1 MO
naproxen sodium oral tablet 275 mg, 550 mg 1 MO
piroxicam oral capsule 10 mg, 20 mg 1
PROVIL 200 MG TABLET 200 MG 3 DP
qc aspirin 325 mg tablet 325 mg 3 DP
QC CHILD IBUPROFEN 100 MG/5 ML A/F,
BUBBLE GUM 100 MG/5 ML
3 DP
qc ibuprofen 100 mg/5 ml susp children's (otc) 100
mg/5 ml
3 MO; DP
sb aspirin 325 mg tablet 325 mg 3 DP
sb aspirin 325 mg tablet na/f, caffeine-free 325 mg 3 DP
sb ibuprofen 200 mg caplet caplet 200 mg 3 DP
sb ibuprofen 200 mg tablet 200 mg 3 DP
sb ibuprofen 200 mg tablet safety sealed 200 mg 3 DP
sm aspirin 325 mg tablet 325 mg 3 DP
sm ibuprofen 100 mg/5 ml susp (otc) 100 mg/5 ml 3 MO; DP
sm ibuprofen 100 mg/5 ml susp a/f (otc) 100 mg/5
ml
3 MO; DP
22
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
sm ibuprofen 100 mg/5 ml susp children's (otc)
100 mg/5 ml
3 MO; DP
sm ibuprofen 200 mg caplet caplet 200 mg 3 DP
sm ibuprofen 200 mg tablet 200 mg 3 DP
SM IBUPROFEN IB 200 MG CAPLET CAPLET
200 MG
3 DP
SM IBUPROFEN IB 200 MG CAPLET CAPLET,
GLUTEN-FREE 200 MG
3 DP
sulindac oral tablet 150 mg, 200 mg 1
OPIOID ANALGESICS, LONG-ACTING
buprenorphine transdermal patch weekly 10
mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour,
7.5 mcg/hour
1 QL (4 EA per 28 days)
fentanyl transdermal patch 72 hour 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr,
62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour
1 QL (10 EA per 30 days)
methadone oral solution 10 mg/5 ml 1 QL (1200 ML per 30 days)
methadone oral solution 5 mg/5 ml 1 QL (2400 ML per 30 days)
methadone oral tablet 10 mg 1 QL (240 EA per 30 days)
methadone oral tablet 5 mg 1 QL (180 EA per 30 days)
morphine oral tablet extended release 100 mg, 15
mg, 200 mg, 30 mg, 60 mg
1 QL (60 EA per 30 days)
oxycodone oral tablet,oral only,ext.rel.12 hr 10
mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg
1 PA
OPIOID ANALGESICS, SHORT-ACTING
butorphanol tartrate nasal spray,non-aerosol 10
mg/ml
1 QL (5 ML per 30 days)
duramorph (pf) injection solution 0.5 mg/ml, 1
mg/ml
1 B/D
fentanyl citrate buccal lozenge on a handle 1,200
mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800
mcg
1 PA; QL (120 EA per 30 days)
hydromorphone (pf) injection solution 1 mg/ml, 10
(mg/ml) (5 ml), 10 mg/ml, 4 mg/ml
1
hydromorphone injection syringe 2 mg/ml 1
hydromorphone oral tablet 2 mg, 4 mg, 8 mg 1 QL (120 EA per 30 days)
23
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
LAZANDA NASAL SPRAY,NON-AEROSOL
100 MCG/SPRAY
2 PA; QL (600 EA per 30 days)
LAZANDA NASAL SPRAY,NON-AEROSOL
300 MCG/SPRAY, 400 MCG/SPRAY
2 PA; QL (150 EA per 30 days)
meperidine oral solution 50 mg/5 ml 1 PA; QL (900 ML per 30 days)
meperidine oral tablet 100 mg, 50 mg 1 PA; QL (180 EA per 30 days)
morphine oral tablet 15 mg, 30 mg 1 QL (120 EA per 30 days)
nalbuphine injection solution 10 mg/ml 1 B/D
oxycodone oral solution 5 mg/5 ml 1 QL (5400 ML per 30 days)
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30
mg, 5 mg
1 QL (120 EA per 30 days)
tramadol oral tablet 50 mg 1 QL (240 EA per 30 days)
ANESTHETICS
LOCAL ANESTHETICS
ANODYNE LPT TOPICAL KIT 2.5-2.5 % 1
dermacinrx empricaine topical kit 2.5-2.5 % 1
diclofenac sodium topical gel 1 % 1 MO
LEVA SET TOPICAL KIT 2.5-2.5 % 1
lidocaine hcl laryngotracheal solution 4 % 1
lidocaine hcl mucous membrane jelly 2 % 1
lidocaine hcl mucous membrane jelly in applicator
2 %
1
lidocaine hcl mucous membrane solution 4 % (40
mg/ml)
1
lidocaine topical adhesive patch,medicated 5 % 1 PA; QL (90 EA per 30 days)
lidocaine topical ointment 5 % 1
lidocaine-prilocaine topical cream 2.5-2.5 % 1
lidocaine-prilocaine topical kit 2.5-2.5 % 1
LIDOPAC TOPICAL KIT 5 % 1
lidopril topical kit 2.5-2.5 % 1
lidopril xr topical kit 2.5-2.5 % 1
LIDO-PRILO CAINE PACK TOPICAL KIT 2.5-
2.5 %
1
24
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
liprozonepak topical kit 2.5-2.5 % 1
livixil pak topical kit 2.5-2.5 % 1
MEDOLOR PAK TOPICAL KIT 2.5-2.5 % 1
prilolid topical kit 2.5-2.5 % 1
ZTLIDO TOPICAL ADHESIVE
PATCH,MEDICATED 1.8 %
2 PA
ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ ANTI-CRAVING
acamprosate oral tablet,delayed release (dr/ec)
333 mg
1 MO
disulfiram oral tablet 250 mg, 500 mg 1 MO
OPIOID DEPENDENCE TREATMENTS
buprenorphine hcl sublingual tablet 2 mg, 8 mg 1
buprenorphine-naloxone sublingual tablet 2-0.5
mg, 8-2 mg
1 MO
LUCEMYRA ORAL TABLET 0.18 MG 2 PA; QL (224 EA per 14 days)
naltrexone oral tablet 50 mg 1
OPIOID REVERSAL AGENTS
naloxone injection solution 0.4 mg/ml 1
naloxone injection syringe 0.4 mg/ml, 1 mg/ml 1
NARCAN NASAL SPRAY,NON-AEROSOL 4
MG/ACTUATION
2
SMOKING CESSATION AGENTS
bupropion hcl (smoking deter) oral tablet extended
release 12 hr 150 mg
1
CHANTIX CONTINUING MONTH BOX ORAL
TABLET 1 MG
2 QL (336 EA per 365 days)
CHANTIX ORAL TABLET 0.5 MG, 1 MG 2 QL (336 EA per 365 days)
CHANTIX STARTING MONTH BOX ORAL
TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)
2 QL (106 EA per 365 days)
hm nicotine 14 mg/24hr patch step 2 (otc) 14
mg/24 hr
3 DP
hm nicotine 2 mg chewing gum mint 2 mg 3 DP
hm nicotine 2 mg lozenge mint, 3 quittube 2 mg 3 DP
25
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
hm nicotine 21 mg/24hr patch step 1 (otc) 21
mg/24 hr
3 DP
hm nicotine 7 mg/24hr patch step 3 (otc) 7 mg/24
hr
3 DP
NICODERM CQ 14 MG/24HR PATCH 14
MG/24 HR
3 DP
NICODERM CQ 14 MG/24HR PATCH OUTER
14 MG/24 HR
3 DP
NICODERM CQ 21 MG/24HR PATCH 21
MG/24 HR
3 DP
NICODERM CQ 21 MG/24HR PATCH CLEAR
PATCH 21 MG/24 HR
3 DP
NICODERM CQ 21 MG/24HR PATCH OUTER
21 MG/24 HR
3 DP
NICODERM CQ 7 MG/24HR PATCH 7 MG/24
HR
3 DP
NICORELIEF 2 MG GUM 2 MG 3 DP
NICORELIEF 4 MG GUM 4 MG 3 DP
NICORETTE 2 MG CHEWING GUM
CINNAMON SURGE 2 MG
3 DP
NICORETTE 2 MG CHEWING GUM FRESH
MINT 2 MG
3 DP
NICORETTE 2 MG CHEWING GUM FRUIT
CHILL 2 MG
3 DP
NICORETTE 2 MG CHEWING GUM MINT 2
MG
3 DP
NICORETTE 2 MG CHEWING GUM
ORIGINAL FLAVOR 2 MG
3 DP
NICORETTE 2 MG CHEWING GUM STARTER
KIT 2 MG
3 DP
NICORETTE 2 MG CHEWING GUM WHITE
ICE MINT 2 MG
3 DP
NICORETTE 2 MG LOZENGE 2 MG 3 DP
NICORETTE 2 MG LOZENGE CHERRY 2 MG 3 DP
NICORETTE 2 MG LOZENGE MINT 2 MG 3 DP
NICORETTE 2 MG LOZENGE ORIGINAL 2
MG
3 DP
26
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
NICORETTE 2 MG MINI LOZENGE 2 MG 3 DP
NICORETTE 2 MG MINI LOZENGE MINT 2
MG
3 DP
NICORETTE 4 MG CHEWING GUM 4 MG 3 DP
NICORETTE 4 MG CHEWING GUM
CINNAMON SURGE 4 MG
3 DP
NICORETTE 4 MG CHEWING GUM FRESH
MINT 4 MG
3 DP
NICORETTE 4 MG CHEWING GUM FRUIT
CHILL 4 MG
3 DP
NICORETTE 4 MG CHEWING GUM
ORIGINAL 4 MG
3 DP
NICORETTE 4 MG CHEWING GUM
ORIGINAL FLAVOR 4 MG
3 DP
NICORETTE 4 MG CHEWING GUM WHITE
ICE MINT 4 MG
3 DP
NICORETTE 4 MG LOZENGE 4 MG 3 DP
NICORETTE 4 MG LOZENGE CHERRY 4 MG 3 DP
NICORETTE 4 MG LOZENGE MINT 4 MG 3 DP
NICORETTE 4 MG LOZENGE ORIGINAL 4
MG
3 DP
NICORETTE 4 MG MINI LOZENGE 4 MG 3 DP
nicotine 14 mg/24hr patch (otc) 14 mg/24 hr 3 DP
nicotine 14 mg/24hr patch clear, step 2, outer (otc)
14 mg/24 hr
3 DP
nicotine 14 mg/24hr patch outer (otc) 14 mg/24 hr 3 DP
nicotine 14 mg/24hr patch step 2 (otc) 14 mg/24 hr 3 DP
nicotine 2 mg chewing gum 2 mg 3 DP
nicotine 2 mg chewing gum coated,cinnamon,s/f 2
mg
3 DP
nicotine 2 mg chewing gum cool mint/coated 2 mg 3 DP
nicotine 2 mg chewing gum fruit wave, coated 2
mg
3 DP
nicotine 2 mg chewing gum mint 2 mg 3 DP
nicotine 2 mg chewing gum original 2 mg 3 DP
nicotine 2 mg chewing gum refill 2 mg 3 DP
27
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
nicotine 2 mg chewing gum s/f 2 mg 3 DP
nicotine 2 mg chewing gum s/f,coated 2 mg 3 DP
nicotine 2 mg chewing gum s/f,coated fruit 2 mg 3 DP
nicotine 2 mg chewing gum starter kit 2 mg 3 DP
nicotine 2 mg chewing gum sugar free 2 mg 3 DP
nicotine 2 mg lozenge mint 2 mg 3 DP
nicotine 2 mg lozenge mint, 3 quittube 2 mg 3 DP
nicotine 2 mg lozenge outer 2 mg 3 DP
nicotine 2 mg mini lozenge mini,mint,3 quittube 2
mg
3 DP
nicotine 21 mg/24hr patch (otc) 21 mg/24 hr 3 DP
nicotine 21 mg/24hr patch outer (otc) 21 mg/24 hr 3 DP
nicotine 21 mg/24hr patch outer, clear, step 1 (otc)
21 mg/24 hr
3 DP
nicotine 21 mg/24hr patch step 1 (otc) 21 mg/24 hr 3 DP
nicotine 4 mg chewing gum 4 mg 3 DP
nicotine 4 mg chewing gum coated, mint 4 mg 3 DP
nicotine 4 mg chewing gum coated,cinnamon,s/f 4
mg
3 DP
nicotine 4 mg chewing gum cool mint/coated 4 mg 3 DP
nicotine 4 mg chewing gum fruit wave/coated 4 mg 3 DP
nicotine 4 mg chewing gum mint 4 mg 3 DP
nicotine 4 mg chewing gum original 4 mg 3 DP
nicotine 4 mg chewing gum refill kit,s/f 4 mg 3 DP
nicotine 4 mg chewing gum s/f,coated 4 mg 3 DP
nicotine 4 mg chewing gum s/f,coated fruit 4 mg 3 DP
nicotine 4 mg chewing gum starter kit 4 mg 3 DP
nicotine 4 mg lozenge 4 mg 3 DP
nicotine 4 mg lozenge mint 4 mg 3 DP
nicotine 4 mg lozenge mint, 3 quittube 4 mg 3 DP
nicotine 4 mg lozenge outer 4 mg 3 DP
nicotine 4 mg mini lozenge mini,mint,3 quittube 4
mg
3 DP
28
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
nicotine 7 mg/24hr patch (otc) 7 mg/24 hr 3 DP
nicotine 7 mg/24hr patch outer (otc) 7 mg/24 hr 3 DP
nicotine 7 mg/24hr patch outer, clear, step 3 (otc)
7 mg/24 hr
3 DP
nicotine 7 mg/24hr patch step 3 (otc) 7 mg/24 hr 3 DP
NICOTROL INHALATION CARTRIDGE 10
MG
2
NICOTROL NS NASAL SPRAY,NON-
AEROSOL 10 MG/ML
2
sm nicotine 14 mg/24hr patch step 2 (otc) 14
mg/24 hr
3 DP
sm nicotine 2 mg chewing gum 2 mg 3 DP
sm nicotine 2 mg lozenge 2 mg 3 DP
sm nicotine 21 mg/24hr patch outer (otc) 21 mg/24
hr
3 DP
sm nicotine 4 mg chewing gum 4 mg 3 DP
sm nicotine 4 mg lozenge 4 mg 3 DP
sm nicotine 7 mg/24hr patch step 3 (otc) 7 mg/24
hr
3 DP
ANTIBACTERIALS
AMINOGLYCOSIDES
amikacin injection solution 500 mg/2 ml 1
gentak ophthalmic (eye) ointment 0.3 % (3
mg/gram)
1
gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/100 ml, 60 mg/50 ml, 80
mg/100 ml, 80 mg/50 ml
1
gentamicin injection solution 40 mg/ml 1
gentamicin ophthalmic (eye) drops 0.3 % 1
gentamicin ophthalmic (eye) ointment 0.3 % (3
mg/gram)
1
gentamicin topical cream 0.1 % 1
gentamicin topical ointment 0.1 % 1
neomycin oral tablet 500 mg 1
paromomycin oral capsule 250 mg 1
29
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
streptomycin intramuscular recon soln 1 gram 1
TOBRADEX OPHTHALMIC (EYE)
OINTMENT 0.3-0.1 %
2
tobramycin ophthalmic (eye) drops 0.3 % 1
tobramycin sulfate injection recon soln 1.2 gram 1
tobramycin sulfate injection solution 10 mg/ml, 40
mg/ml
1
tobramycin-dexamethasone ophthalmic (eye)
drops,suspension 0.3-0.1 %
1
ANTIBACTERIALS, OTHER
acetic acid otic (ear) solution 2 % 1
ak-poly-bac ophthalmic (eye) ointment 500-10,000
unit/gram
1
bacitracin 500 unit/gm ointmnt 500 unit/gram 3 DP
bacitracin 500 unit/gm ointmnt 500 unit/gram 3 DP
bacitracin ophthalmic (eye) ointment 500
unit/gram
1
bacitracin zn 500 unit/gm oint 500 unit/gram 3 DP
bacitracin zn 500 unit/gm oint u-d,144x.94gm pkt
500 unit/gram
3 DP
bacitracin zn 500 unit/gm oint usp 500 unit/gram 3 DP
bacitracin-polymyxin b ophthalmic (eye) ointment
500-10,000 unit/gram
1
BACTROBAN NASAL NASAL OINTMENT 2
%
2
CASTELLANI PAINT MODIFIED 1.5 % 3 DP
clindamycin hcl oral capsule 150 mg, 300 mg, 75
mg
1
clindamycin in 0.9 % sod chlor intravenous
piggyback 300 mg/50 ml, 600 mg/50 ml, 900
mg/50 ml
1
clindamycin in 5 % dextrose intravenous
piggyback 300 mg/50 ml, 600 mg/50 ml, 900
mg/50 ml
1
clindamycin palmitate hcl oral recon soln 75 mg/5
ml
1
30
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
clindamycin pediatric oral recon soln 75 mg/5 ml 1
clindamycin phosphate injection solution 150
(mg/ml) (6 ml), 150 mg/ml
1
clindamycin phosphate intravenous solution 300
mg/2 ml, 600 mg/4 ml, 900 mg/6 ml
1
clindamycin phosphate topical gel 1 % 1
clindamycin phosphate topical lotion 1 % 1
clindamycin phosphate topical solution 1 % 1
clindamycin phosphate topical swab 1 % 1
clindamycin phosphate vaginal cream 2 % 1
colistin (colistimethate na) injection recon soln
150 mg
1
daptomycin intravenous recon soln 350 mg, 500
mg
1 PA
hm bacitracin zn 500 unit/gm 500 unit/gram 3 DP
linezolid in dextrose 5% intravenous piggyback
600 mg/300 ml
1 B/D
linezolid oral suspension for reconstitution 100
mg/5 ml
1
linezolid oral tablet 600 mg 1
linezolid-0.9% sodium chloride intravenous
parenteral solution 600 mg/300 ml
1 B/D
methenamine hippurate oral tablet 1 gram 1
metro i.v. intravenous piggyback 500 mg/100 ml 1
metronidazole in nacl (iso-os) intravenous
piggyback 500 mg/100 ml
1
metronidazole oral capsule 375 mg 1
metronidazole oral tablet 250 mg, 500 mg 1
metronidazole topical cream 0.75 % 1
metronidazole topical gel 0.75 %, 1 % 1
metronidazole topical gel with pump 1 % 1
metronidazole topical lotion 0.75 % 1
metronidazole vaginal gel 0.75 % 1
mupirocin topical ointment 2 % 1
31
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
neomycin-bacitracin-poly-hc ophthalmic (eye)
ointment 3.5-400-10,000 mg-unit/g-1%
1
neomycin-bacitracin-polymyxin ophthalmic (eye)
ointment 3.5-400-10,000 mg-unit-unit/g
1
neomycin-polymyxin b-dexameth ophthalmic (eye)
drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %
1
neomycin-polymyxin b-dexameth ophthalmic (eye)
ointment 3.5 mg/g-10,000 unit/g-0.1 %
1
neomycin-polymyxin-gramicidin ophthalmic (eye)
drops 1.75 mg-10,000 unit-0.025mg/ml
1
neomycin-polymyxin-hc ophthalmic (eye)
drops,suspension 3.5-10,000-10 mg-unit-mg/ml
1
nitrofurantoin macrocrystal oral capsule 100 mg,
25 mg, 50 mg
1 QL (360 EA per 365 days)
nitrofurantoin monohyd/m-cryst oral capsule 100
mg
1 QL (180 EA per 365 days)
nitrofurantoin monohyd/m-cryst oral capsule 100
mg (75/25)
1 QL (360 EA per 365 days)
polymyxin b sulfate injection recon soln 500,000
unit
1
polymyxin b sulf-trimethoprim ophthalmic (eye)
drops 10,000 unit- 1 mg/ml
1
SM ANTIBIOTIC 500 UNIT/GM OINT 500
UNIT/GRAM
3 DP
tinidazole oral tablet 250 mg, 500 mg 1
trimethoprim oral tablet 100 mg 1
TRIPLE ANTIBIOTIC OINTMENT 3.5MG-400
UNIT- 5,000 UNIT/GRAM
3 DP
vancomycin injection recon soln 100 gram 1
vancomycin intravenous recon soln 1,000 mg, 1.25
gram, 1.5 gram, 10 gram, 250 mg, 5 gram, 500
mg, 750 mg
1
vancomycin oral capsule 125 mg, 250 mg 1
BETA-LACTAM, CEPHALOSPORINS
cefaclor oral capsule 250 mg, 500 mg 1
cefaclor oral tablet extended release 12 hr 500 mg 1
32
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
cefadroxil oral capsule 500 mg 1
cefadroxil oral suspension for reconstitution 250
mg/5 ml, 500 mg/5 ml
1
cefadroxil oral tablet 1 gram 1
cefazolin in dextrose (iso-os) intravenous
piggyback 1 gram/50 ml
1
cefazolin injection recon soln 1 gram, 500 mg 1
cefazolin intravenous recon soln 1 gram 1
cefdinir oral capsule 300 mg 1
cefdinir oral suspension for reconstitution 125
mg/5 ml, 250 mg/5 ml
1
cefepime in dextrose 5 % intravenous piggyback 1
gram/50 ml, 2 gram/50 ml
1
cefepime in dextrose,iso-osm intravenous
piggyback 1 gram/50 ml, 2 gram/100 ml
1
cefepime injection recon soln 1 gram, 2 gram 1
cefotaxime injection recon soln 1 gram, 2 gram,
500 mg
1
cefoxitin in dextrose, iso-osm intravenous
piggyback 1 gram/50 ml, 2 gram/50 ml
1
cefoxitin intravenous recon soln 1 gram, 10 gram,
2 gram
1
cefpodoxime oral suspension for reconstitution
100 mg/5 ml, 50 mg/5 ml
1
cefpodoxime oral tablet 100 mg, 200 mg 1
cefprozil oral suspension for reconstitution 125
mg/5 ml, 250 mg/5 ml
1
cefprozil oral tablet 250 mg, 500 mg 1
ceftazidime in d5w intravenous piggyback 1
gram/50 ml, 2 gram/50 ml
1
ceftazidime injection recon soln 1 gram, 2 gram, 6
gram
1
ceftriaxone in dextrose,iso-os intravenous
piggyback 1 gram/50 ml, 2 gram/50 ml
1
ceftriaxone injection recon soln 1 gram, 10 gram,
100 gram, 2 gram, 250 mg, 500 mg
1
ceftriaxone intravenous recon soln 1 gram, 2 gram 1
33
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
cefuroxime axetil oral tablet 250 mg, 500 mg 1
cefuroxime sodium injection recon soln 750 mg 1
cefuroxime sodium intravenous recon soln 1.5
gram, 7.5 gram
1
cephalexin oral capsule 250 mg, 500 mg 1
cephalexin oral suspension for reconstitution 125
mg/5 ml, 250 mg/5 ml
1
cephalexin oral tablet 250 mg, 500 mg 1
SUPRAX ORAL CAPSULE 400 MG 2
TAZICEF INJECTION RECON SOLN 1 GRAM,
2 GRAM, 6 GRAM
1
TAZICEF INTRAVENOUS RECON SOLN 1
GRAM, 2 GRAM
1
TEFLARO INTRAVENOUS RECON SOLN 400
MG, 600 MG
2 PA
BETA-LACTAM, OTHER
aztreonam injection recon soln 1 gram 1
doripenem intravenous recon soln 500 mg 1 PA
ertapenem injection recon soln 1 gram 1 PA
imipenem-cilastatin intravenous recon soln 250
mg, 500 mg
1 B/D
meropenem intravenous recon soln 1 gram, 500
mg
1
meropenem-0.9% sodium chloride intravenous
piggyback 1 gram/50 ml, 500 mg/50 ml
1
VABOMERE INTRAVENOUS RECON SOLN 2
GRAM
2 PA
BETA-LACTAM, PENICILLINS
amoxicillin oral capsule 250 mg, 500 mg 1
amoxicillin oral suspension for reconstitution 125
mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml
1
amoxicillin oral tablet 500 mg, 875 mg 1
amoxicillin oral tablet,chewable 125 mg, 250 mg 1
34
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
amoxicillin-pot clavulanate oral suspension for
reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5
ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml
1
amoxicillin-pot clavulanate oral tablet 250-125
mg, 500-125 mg, 875-125 mg
1
amoxicillin-pot clavulanate oral tablet extended
release 12 hr 1,000-62.5 mg
1
amoxicillin-pot clavulanate oral tablet,chewable
200-28.5 mg, 400-57 mg
1
ampicillin oral capsule 500 mg 1
ampicillin sodium injection recon soln 1 gram, 10
gram, 125 mg
1
ampicillin sodium intravenous recon soln 1 gram 1
ampicillin-sulbactam injection recon soln 1.5
gram, 15 gram, 3 gram
1
ampicillin-sulbactam intravenous recon soln 1.5
gram, 3 gram
1
BICILLIN L-A INTRAMUSCULAR SYRINGE
1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML,
600,000 UNIT/ML
2
dicloxacillin oral capsule 250 mg, 500 mg 1
nafcillin in dextrose iso-osm intravenous
piggyback 1 gram/50 ml
1
nafcillin injection recon soln 1 gram 1
nafcillin intravenous recon soln 1 gram, 2 gram 1
penicillin g procaine intramuscular syringe 1.2
million unit/2 ml
1
penicillin g sodium injection recon soln 5 million
unit
1
penicillin v potassium oral recon soln 125 mg/5
ml, 250 mg/5 ml
1
penicillin v potassium oral tablet 250 mg, 500 mg 1
piperacillin-tazobactam intravenous recon soln
13.5 gram, 2.25 gram, 3.375 gram, 4.5 gram, 40.5
gram
1
MACROLIDES
azithromycin intravenous recon soln 500 mg 1
35
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
azithromycin oral packet 1 gram 1
azithromycin oral suspension for reconstitution
100 mg/5 ml, 200 mg/5 ml
1
azithromycin oral tablet 250 mg, 250 mg (6 pack),
500 mg, 500 mg (3 pack), 600 mg
1
clarithromycin oral suspension for reconstitution
125 mg/5 ml, 250 mg/5 ml
1
clarithromycin oral tablet 250 mg, 500 mg 1
clarithromycin oral tablet extended release 24 hr
500 mg
1
DIFICID ORAL TABLET 200 MG 2 PA
ery pads topical swab 2 % 1
erythrocin (as stearate) oral tablet 250 mg 1
ERYTHROCIN INTRAVENOUS RECON SOLN
500 MG
2
erythromycin ethylsuccinate oral suspension for
reconstitution 200 mg/5 ml
1
erythromycin ethylsuccinate oral tablet 400 mg 1
erythromycin ophthalmic (eye) ointment 5
mg/gram (0.5 %)
1
erythromycin oral tablet 250 mg, 500 mg 1
erythromycin with ethanol topical gel 2 % 1
erythromycin with ethanol topical solution 2 % 1
QUINOLONES
ciprofloxacin (mixture) oral tablet, er multiphase
24 hr 1,000 mg, 500 mg
1
ciprofloxacin hcl ophthalmic (eye) drops 0.3 % 1
ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500
mg, 750 mg
1
ciprofloxacin in 5 % dextrose intravenous
piggyback 200 mg/100 ml
1
ciprofloxacin oral suspension,microcapsule recon
250 mg/5 ml, 500 mg/5 ml
1
levofloxacin in d5w intravenous piggyback 500
mg/100 ml, 750 mg/150 ml
1
36
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
levofloxacin intravenous solution 25 mg/ml 1
levofloxacin oral solution 250 mg/10 ml 1
levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1
moxifloxacin in nacl (iso-osm) intravenous
piggyback 400 mg/250 ml
1
moxifloxacin ophthalmic (eye) drops 0.5 % 1
moxifloxacin oral tablet 400 mg 1
moxifloxacin-sod.ace,sul-water intravenous
piggyback 400 mg/250 ml
1
ofloxacin ophthalmic (eye) drops 0.3 % 1
ofloxacin oral tablet 300 mg, 400 mg 1
SULFONAMIDES
silver sulfadiazine topical cream 1 % 1
ssd topical cream 1 % 1
sulfacetamide sodium (acne) topical suspension 10
%
1
sulfacetamide sodium ophthalmic (eye) drops 10
%
1
sulfacetamide sodium ophthalmic (eye) ointment
10 %
1
sulfadiazine oral tablet 500 mg 1
sulfamethoxazole-trimethoprim oral suspension
200-40 mg/5 ml
1
sulfamethoxazole-trimethoprim oral tablet 400-80
mg, 800-160 mg
1
TETRACYCLINES
doxy-100 intravenous recon soln 100 mg 1
doxycycline hyclate oral capsule 100 mg, 50 mg 1
doxycycline hyclate oral tablet 100 mg, 20 mg 1
doxycycline monohydrate oral capsule 100 mg, 50
mg
1
doxycycline monohydrate oral tablet 100 mg, 150
mg, 50 mg, 75 mg
1
minocycline oral capsule 100 mg, 50 mg, 75 mg 1
minocycline oral tablet 100 mg, 50 mg, 75 mg 1
37
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
MORGIDOX 1X 50 KIT 50 MG 1
morgidox oral capsule 50 mg 1
tetracycline oral capsule 250 mg, 500 mg 1
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
BRIVIACT ORAL SOLUTION 10 MG/ML 2 ST; MO
BRIVIACT ORAL TABLET 10 MG, 100 MG, 25
MG, 50 MG, 75 MG
2 ST; MO
EPIDIOLEX ORAL SOLUTION 100 MG/ML 2 PA; MO
levetiracetam oral solution 100 mg/ml, 500 mg/5
ml (5 ml)
1 MO
levetiracetam oral tablet 1,000 mg, 250 mg, 500
mg, 750 mg
1 MO
levetiracetam oral tablet extended release 24 hr
500 mg, 750 mg
1 MO
ROWEEPRA ORAL TABLET 1,000 MG, 750
MG
1 MO
roweepra oral tablet 500 mg 1 MO
ROWEEPRA XR ORAL TABLET EXTENDED
RELEASE 24 HR 500 MG, 750 MG
1 MO
SPRITAM ORAL TABLET FOR SUSPENSION
1,000 MG, 250 MG, 500 MG
2 ST; MO; QL (60 EA per 30 days)
SPRITAM ORAL TABLET FOR SUSPENSION
750 MG
2 ST; MO; QL (120 EA per 30 days)
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN ORAL CAPSULE 300 MG 2 MO
ethosuximide oral capsule 250 mg 1 MO
ethosuximide oral solution 250 mg/5 ml 1 MO
LYRICA ORAL CAPSULE 100 MG, 150 MG,
200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75
MG
2 MO
LYRICA ORAL SOLUTION 20 MG/ML 2 MO
zonisamide oral capsule 100 mg, 25 mg, 50 mg 1 MO
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
38
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
clobazam oral suspension 2.5 mg/ml 1 PA; MO; QL (480 ML per 30 days)
clobazam oral tablet 10 mg, 20 mg 1 PA; MO; QL (60 EA per 30 days)
DIASTAT ACUDIAL RECTAL KIT 12.5-15-
17.5-20 MG, 5-7.5-10 MG
2
DIASTAT RECTAL KIT 2.5 MG 2
diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-
7.5-10 mg
1 MO
divalproex oral capsule, delayed rel sprinkle 125
mg
1 MO
divalproex oral tablet extended release 24 hr 250
mg, 500 mg
1 MO
divalproex oral tablet,delayed release (dr/ec) 125
mg, 250 mg, 500 mg
1 MO
gabapentin oral capsule 100 mg, 300 mg, 400 mg 1 MO
gabapentin oral solution 250 mg/5 ml, 250 mg/5
ml (5 ml), 300 mg/6 ml (6 ml)
1 MO
gabapentin oral tablet 600 mg, 800 mg 1 MO
phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) 1 PA; MO
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg,
30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
1 PA; MO
primidone oral tablet 250 mg, 50 mg 1 MO
SABRIL ORAL TABLET 500 MG 2 PA; MO; QL (180 EA per 30 days)
SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG 2 PA; QL (60 EA per 30 days)
tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg 1 MO
valproic acid (as sodium salt) oral solution 250
mg/5 ml, 250 mg/5 ml (5 ml), 500 mg/10 ml (10
ml)
1 MO
valproic acid oral capsule 250 mg 1 MO
vigabatrin oral powder in packet 500 mg 1 PA; MO
vigabatrin oral tablet 500 mg 1 PA; QL (180 EA per 30 days)
VIGADRONE ORAL POWDER IN PACKET
500 MG
1 PA; MO
GLUTAMATE REDUCING AGENTS
felbamate oral suspension 600 mg/5 ml 1 MO
felbamate oral tablet 400 mg, 600 mg 1 MO
39
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
FYCOMPA ORAL SUSPENSION 0.5 MG/ML 2 ST; MO
FYCOMPA ORAL TABLET 10 MG, 12 MG, 2
MG, 4 MG, 6 MG, 8 MG
2 ST; MO; QL (30 EA per 30 days)
lamotrigine oral tablet extended release 24hr 100
mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg
1 MO
lamotrigine oral tablet, chewable dispersible 25
mg, 5 mg
1 MO
SUBVENITE ORAL TABLET 100 MG, 150 MG,
200 MG, 25 MG
1 MO
SUBVENITE STARTER (BLUE) KIT ORAL
TABLETS,DOSE PACK 25 MG (35)
1
SUBVENITE STARTER (GREEN) KIT ORAL
TABLETS,DOSE PACK 25 MG (84) -100 MG
(14)
1
SUBVENITE STARTER (ORANGE) KIT ORAL
TABLETS,DOSE PACK 25 MG (42) -100 MG
(7)
1
topiramate oral capsule, sprinkle 15 mg, 25 mg 1 MO
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50
mg
1 MO
SODIUM CHANNEL AGENTS
APTIOM ORAL TABLET 200 MG, 400 MG, 800
MG
2 ST; MO; QL (30 EA per 30 days)
APTIOM ORAL TABLET 600 MG 2 ST; MO; QL (60 EA per 30 days)
BANZEL ORAL SUSPENSION 40 MG/ML 2 PA; MO; QL (2400 ML per 30 days)
BANZEL ORAL TABLET 200 MG, 400 MG 2 PA; MO; QL (240 EA per 30 days)
carbamazepine oral suspension 100 mg/5 ml 1 MO
carbamazepine oral tablet 200 mg 1 MO
carbamazepine oral tablet extended release 12 hr
100 mg, 200 mg, 400 mg
1 MO
carbamazepine oral tablet,chewable 100 mg 1 MO
DILANTIN ORAL CAPSULE 30 MG 2 MO
epitol oral tablet 200 mg 1 MO
oxcarbazepine oral suspension 300 mg/5 ml (60
mg/ml)
1 MO
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 1 MO
40
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
PEGANONE ORAL TABLET 250 MG 2 MO
PHENYTEK ORAL CAPSULE 200 MG, 300 MG 2 MO
phenytoin oral suspension 100 mg/4 ml, 125 mg/5
ml
1 MO
phenytoin oral tablet,chewable 50 mg 1 MO
phenytoin sodium extended oral capsule 100 mg,
200 mg, 300 mg
1 MO
VIMPAT ORAL SOLUTION 10 MG/ML 2 ST; MO; QL (1200 ML per 30 days)
VIMPAT ORAL TABLET 100 MG, 150 MG, 200
MG, 50 MG
2 ST; MO; QL (60 EA per 30 days)
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid oral tablet 1 mg 1 PA; MO
CHOLINESTERASE INHIBITORS
donepezil oral tablet 10 mg, 23 mg, 5 mg 1 MO
donepezil oral tablet,disintegrating 10 mg, 5 mg 1 MO
galantamine oral capsule,ext rel. pellets 24 hr 16
mg, 24 mg, 8 mg
1 MO
galantamine oral tablet 12 mg, 4 mg, 8 mg 1 MO
rivastigmine tartrate oral capsule 1.5 mg, 3 mg,
4.5 mg, 6 mg
1 MO
rivastigmine transdermal patch 24 hour 13.3
mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr
1 MO
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine oral capsule,sprinkle,er 24hr 14 mg,
21 mg, 28 mg, 7 mg
1 MO; QL (30 EA per 30 days)
memantine oral tablet 10 mg, 5 mg 1 MO
memantine oral tablets,dose pack 5-10 mg 1
NAMENDA XR ORAL CAP,SPRINKLE,ER
24HR DOSE PACK 7-14-21-28 MG
2
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
bupropion hcl oral tablet 100 mg, 75 mg 1 MO
bupropion hcl oral tablet extended release 24 hr
150 mg, 300 mg, 450 mg
1 MO
41
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
bupropion hcl oral tablet sustained-release 12 hr
100 mg, 150 mg, 200 mg
1 MO
FORFIVO XL ORAL TABLET EXTENDED
RELEASE 24 HR 450 MG
2 MO
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5
mg
1 MO
mirtazapine oral tablet,disintegrating 15 mg, 30
mg, 45 mg
1 MO
nefazodone oral tablet 100 mg, 150 mg, 200 mg,
250 mg, 50 mg
1 MO
perphenazine-amitriptyline oral tablet 2-10 mg, 2-
25 mg, 4-10 mg, 4-25 mg, 4-50 mg
1 PA; MO
trazodone oral tablet 100 mg, 150 mg, 300 mg, 50
mg
1 MO
MONOAMINE OXIDASE INHIBITORS
EMSAM TRANSDERMAL PATCH 24 HOUR
12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR
2 MO
MARPLAN ORAL TABLET 10 MG 2 MO
phenelzine oral tablet 15 mg 1 MO
tranylcypromine oral tablet 10 mg 1 MO
SSRIS/ SNRIS
citalopram oral solution 10 mg/5 ml 1 MO
citalopram oral tablet 10 mg, 20 mg, 40 mg 1 MO
desvenlafaxine succinate oral tablet extended
release 24 hr 100 mg, 25 mg, 50 mg
1 MO
escitalopram oxalate oral solution 5 mg/5 ml 1 MO
escitalopram oxalate oral tablet 10 mg, 20 mg, 5
mg
1 MO
FETZIMA ORAL CAPSULE,EXT REL 24HR
DOSE PACK 20 MG (2)- 40 MG (26)
2 ST
FETZIMA ORAL CAPSULE,EXTENDED
RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80
MG
2 ST; MO
fluoxetine oral capsule 10 mg, 20 mg, 40 mg 1 MO
fluoxetine oral capsule,delayed release(dr/ec) 90
mg
1 MO
42
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
fluoxetine oral solution 20 mg/5 ml (4 mg/ml) 1 MO
fluoxetine oral tablet 10 mg, 20 mg 1 MO
fluvoxamine oral tablet 100 mg, 25 mg, 50 mg 1 MO
maprotiline oral tablet 25 mg, 50 mg, 75 mg 1 MO
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40
mg
1 MO
paroxetine hcl oral tablet extended release 24 hr
12.5 mg, 25 mg, 37.5 mg
1 MO
PAXIL ORAL SUSPENSION 10 MG/5 ML 2 MO
sertraline oral concentrate 20 mg/ml 1 MO
sertraline oral tablet 100 mg, 25 mg, 50 mg 1 MO
TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5
MG
2 ST; MO
venlafaxine oral capsule,extended release 24hr
150 mg, 37.5 mg, 75 mg
1 MO
venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50
mg, 75 mg
1 MO
venlafaxine oral tablet extended release 24hr 150
mg, 225 mg, 37.5 mg, 75 mg
1 MO
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40
MG
2 ST; MO
VIIBRYD ORAL TABLETS,DOSE PACK 10
MG (7)- 20 MG (23)
2 ST
TRICYCLICS
amitriptyline oral tablet 10 mg, 100 mg, 150 mg,
25 mg, 50 mg, 75 mg
1 PA; MO
amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50
mg
1 MO
clomipramine oral capsule 25 mg, 50 mg, 75 mg 1 PA; MO
desipramine oral tablet 10 mg, 100 mg, 150 mg,
25 mg, 50 mg, 75 mg
1 MO
doxepin oral capsule 10 mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
1 PA; MO
doxepin oral concentrate 10 mg/ml 1 PA; MO
imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA; MO
43
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
imipramine pamoate oral capsule 100 mg, 125 mg,
150 mg, 75 mg
1 PA; MO
nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75
mg
1 MO
nortriptyline oral solution 10 mg/5 ml 1 MO
protriptyline oral tablet 10 mg, 5 mg 1 MO
trimipramine oral capsule 100 mg, 25 mg, 50 mg 1 PA; MO
ANTIEMETICS
ANTIEMETICS, OTHER
chlorpromazine oral tablet 10 mg, 100 mg, 200
mg, 25 mg, 50 mg
1 MO
DRIMINATE 50 MG TABLET 50 MG 3 DP
meclizine 12.5 mg caplet caplet (otc) 12.5 mg 3 DP
meclizine 12.5 mg tablet (otc) 12.5 mg 3 DP
meclizine 25 mg tablet chew 25 mg 3 DP
meclizine 25 mg tablet chew raspberry 25 mg 3 DP
meclizine oral tablet 12.5 mg, 25 mg 1
metoclopramide hcl oral solution 5 mg/5 ml 1
metoclopramide hcl oral tablet 10 mg, 5 mg 1
MOTION SICKNESS 50 MG TABLET 50 MG 3 DP
MOTION-TIME 25 MG TABLET CHEW 25 MG 3 DP
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 1 MO
prochlorperazine maleate oral tablet 10 mg, 5 mg 1
prochlorperazine rectal suppository 25 mg 1
promethazine oral tablet 12.5 mg, 25 mg, 50 mg 1 PA
promethazine rectal suppository 12.5 mg, 25 mg 1 PA
promethazine rectal suppository 50 mg 1
promethegan rectal suppository 50 mg 1 PA
SB MOTION SICKNESS 50 MG TAB 50 MG 3 DP
scopolamine base transdermal patch 3 day 1 mg
over 3 days
1
SM MOTION SICKNESS 50 MG TAB 50 MG 3 DP
44
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
TRAVEL SICKNESS 25 MG TAB CHEW 25
MG
3 DP
TRAVEL SICKNESS 50 MG TABLET 50 MG 3 DP
trimethobenzamide oral capsule 300 mg 1 PA
EMETOGENIC THERAPY ADJUNCTS
aprepitant oral capsule 125 mg, 40 mg, 80 mg 1 B/D
aprepitant oral capsule,dose pack 125 mg (1)- 80
mg (2)
1 B/D
dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1 B/D
EMEND ORAL SUSPENSION FOR
RECONSTITUTION 125 MG (25 MG/ ML
FINAL CONC.)
2 B/D
granisetron hcl oral tablet 1 mg 1 B/D
ondansetron hcl oral solution 4 mg/5 ml 1 B/D
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 B/D
ondansetron oral tablet,disintegrating 4 mg, 8 mg 1 B/D
SYNDROS ORAL SOLUTION 5 MG/ML 2 PA
ANTIFUNGALS
ANTIFUNGALS
abelcet intravenous suspension 5 mg/ml 2 B/D
ALEVAZOL 1% OINTMENT 1 % 3 DP
AMBISOME INTRAVENOUS SUSPENSION
FOR RECONSTITUTION 50 MG
2 B/D
amphotericin b injection recon soln 50 mg 1 B/D
ANTIFUNGAL 1% CREAM 1 % 3 DP
ANTIFUNGAL 1% CREAM 1 % 3 DP
ANTI-FUNGAL 1% POWDER 1 % 3 DP
ANTIFUNGAL 2% CREAM 2 % 3 DP
CARRINGTON ANTIFUNGAL 2% CREAM 2 % 3 DP
caspofungin intravenous recon soln 50 mg, 70 mg 1 PA
ciclopirox topical cream 0.77 % 1
ciclopirox topical solution 8 % 1
ciclopirox topical suspension 0.77 % 1
45
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ciclopirox-ure-camph-menth-euc topical solution 8
%
1
clotrimazole 1% cream (otc) 1 % 3 DP
clotrimazole 1% cream 1 % 3 DP
clotrimazole mucous membrane troche 10 mg 1
clotrimazole topical cream 1 % 1
clotrimazole topical solution 1 % 1
econazole topical cream 1 % 1
ERAXIS(WATER DILUENT) INTRAVENOUS
RECON SOLN 100 MG, 50 MG
2 PA
fluconazole in dextrose(iso-o) intravenous
piggyback 200 mg/100 ml, 400 mg/200 ml
1
fluconazole in nacl (iso-osm) intravenous
piggyback 200 mg/100 ml, 400 mg/200 ml
1
fluconazole oral suspension for reconstitution 10
mg/ml, 40 mg/ml
1
fluconazole oral tablet 100 mg, 150 mg, 200 mg,
50 mg
1
flucytosine oral capsule 250 mg, 500 mg 1
griseofulvin microsize oral suspension 125 mg/5
ml
1
INZO ANTIFUNGAL 2% CREAM 2 % 3 DP
itraconazole oral capsule 100 mg 1
itraconazole oral solution 10 mg/ml 1
ketoconazole oral tablet 200 mg 1
ketoconazole topical cream 2 % 1
ketoconazole topical shampoo 2 % 1
LAMISIL AF DEFENS 1% SPRAY PWD 1 % 3 DP
MENTAX TOPICAL CREAM 1 % 2
miconazole 100 mg vag supp 100 mg 3 DP
MICONAZOLE 7 100 MG VAG SUPP 100 MG 3 DP
MICONAZOLE 7 CREAM 2 % 3 DP
miconazole nitrate 2% cream 2 % 3 DP
miconazole nitrate 2% cream 2 % 3 DP
46
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
miconazole nitrate 2% cream w/applicator 2 % 3 DP
MYCAMINE INTRAVENOUS RECON SOLN
100 MG, 50 MG
2 PA
NOXAFIL ORAL SUSPENSION 200 MG/5 ML
(40 MG/ML)
2 PA
NOXAFIL ORAL TABLET,DELAYED
RELEASE (DR/EC) 100 MG
2 PA
nyamyc topical powder 100,000 unit/gram 1
nystatin oral suspension 100,000 unit/ml 1
nystatin oral tablet 500,000 unit 1
nystatin topical cream 100,000 unit/gram 1
nystatin topical ointment 100,000 unit/gram 1
nystatin topical powder 100,000 unit/gram 1
nystop topical powder 100,000 unit/gram 1
qc tolnaftate 1% cream 1 % 3 DP
SM ANTIFUNGAL 1% CREAM 1 % 3 DP
SM ANTIFUNGAL 1% CREAM 1 % 3 DP
SM ATHLETE'S 1% FOOT CREAM 1 % 3 DP
SM MICONAZOLE 7 100 MG VAG SUP 100
MG
3 DP
SM MICONAZOLE 7 CREAM W/REUSABLE
APPLIC 2 %
3 DP
sm miconazole nitrate 2% cream w/disp
applicators 2 %
3 DP
terbinafine 1% cream 1 % 3 DP
terbinafine 1% cream antifungal 1 % 3 DP
terbinafine hcl oral tablet 250 mg 1
terconazole vaginal cream 0.4 %, 0.8 % 1
terconazole vaginal suppository 80 mg 1
tolnaftate 1% cream 1 % 3 DP
tolnaftate 1% powder 1 % 3 DP
tolnaftate af 1% cream 1 % 3 DP
voriconazole intravenous solution 200 mg 1
voriconazole oral suspension for reconstitution
200 mg/5 ml (40 mg/ml)
1
47
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
voriconazole oral tablet 200 mg, 50 mg 1
ANTIGOUT AGENTS
ANTIGOUT AGENTS
allopurinol oral tablet 100 mg, 300 mg 1 MO
colchicine oral capsule 0.6 mg 1 MO
colchicine oral tablet 0.6 mg 1 MO
probenecid oral tablet 500 mg 1 MO
probenecid-colchicine oral tablet 500-0.5 mg 1 MO
ULORIC ORAL TABLET 40 MG, 80 MG 2 ST; MO
ANTI-INFLAMMATORY AGENTS
GLUCOCORTICOIDS
ala-cort topical cream 1 %, 2.5 % 1
alclometasone topical cream 0.05 % 1
alclometasone topical ointment 0.05 % 1
betamethasone dipropionate topical cream 0.05 % 1
betamethasone dipropionate topical lotion 0.05 % 1
betamethasone dipropionate topical ointment 0.05
%
1
betamethasone valerate topical cream 0.1 % 1
betamethasone valerate topical lotion 0.1 % 1
betamethasone valerate topical ointment 0.1 % 1
betamethasone, augmented topical cream 0.05 % 1
betamethasone, augmented topical gel 0.05 % 1
betamethasone, augmented topical lotion 0.05 % 1
betamethasone, augmented topical ointment 0.05
%
1
clobetasol scalp solution 0.05 % 1
clobetasol topical cream 0.05 % 1
clobetasol topical gel 0.05 % 1
clobetasol topical ointment 0.05 % 1
clobetasol-emollient topical cream 0.05 % 1
desonide topical cream 0.05 % 1
48
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
desonide topical lotion 0.05 % 1
desonide topical ointment 0.05 % 1
desoximetasone topical cream 0.05 %, 0.25 % 1
desoximetasone topical gel 0.05 % 1
desoximetasone topical ointment 0.05 %, 0.25 % 1
dexamethasone intensol oral drops 1 mg/ml 1
dexamethasone oral elixir 0.5 mg/5 ml 1
dexamethasone oral solution 0.5 mg/5 ml 1
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg,
1.5 mg, 2 mg, 4 mg, 6 mg
1
fluocinolone topical cream 0.01 %, 0.025 % 1
fluocinolone topical ointment 0.025 % 1
fluocinolone topical solution 0.01 % 1
fluocinonide topical gel 0.05 % 1
fluocinonide topical ointment 0.05 % 1
fluocinonide topical solution 0.05 % 1
fluocinonide-e topical cream 0.05 % 1
fluocinonide-emollient topical cream 0.05 % 1
fluticasone topical cream 0.05 % 1
fluticasone topical lotion 0.05 % 1
fluticasone topical ointment 0.005 % 1
halobetasol propionate topical cream 0.05 % 1
halobetasol propionate topical ointment 0.05 % 1
hm hydrocortisone 1% cream max str, w/aloe (otc)
1 %
3 DP
hm hydrocortisone 1% cream plus 12 moisturizers
(otc) 1 %
3 DP
hydrocortisone 1% cream (otc) 1 % 3 DP
hydrocortisone 1% cream carton (otc) 1 % 3 DP
hydrocortisone 1% cream maximum strength (otc)
1 %
3 DP
hydrocortisone 1% cream u-d, 48's, foil 1 % 3 DP
hydrocortisone 1% ointment (otc) 1 % 3 DP
hydrocortisone 1% ointment carton (otc) 1 % 3 DP
49
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
hydrocortisone 1% ointment maximum strength
(otc) 1 %
3 DP
hydrocortisone butyrate topical cream 0.1 % 1
hydrocortisone butyrate topical ointment 0.1 % 1
hydrocortisone butyrate topical solution 0.1 % 1
hydrocortisone butyr-emollient topical cream 0.1
%
1
hydrocortisone plus 1% cream moisturizer,max.
str (otc) 1 %
3 DP
hydrocortisone topical cream 1 %, 2.5 % 1
hydrocortisone topical cream with perineal
applicator 1 %
1
hydrocortisone topical lotion 2.5 % 1
hydrocortisone topical ointment 1 %, 2.5 % 1
hydrocortisone valerate topical cream 0.2 % 1
hydrocortisone valerate topical ointment 0.2 % 1
hydrocortisone-aloe 1% cream 1 % 3 DP
HYDROSKIN 1% CREAM 1 % 3 DP
methylprednisolone oral tablets,dose pack 4 mg 1
mometasone topical cream 0.1 % 1
mometasone topical ointment 0.1 % 1
mometasone topical solution 0.1 % 1
prednisolone oral solution 15 mg/5 ml 1
prednisolone sodium phosphate oral solution 15
mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg
base/5 ml (6.7 mg/5 ml)
1
prednisone oral solution 5 mg/5 ml 1
prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20
mg, 5 mg, 50 mg
1
prednisone oral tablets,dose pack 10 mg, 10 mg
(48 pack), 5 mg, 5 mg (48 pack)
1
sb hydrocortisone 1% ointment maximum strength
(otc) 1 %
3 DP
SB HYDROCORTISONE PLUS 1% CRM MAX
STR, W/ALOE 1 %
3 DP
50
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
sm hydrocortisone 1% ointment maximum strength
(otc) 1 %
3 DP
sm hydrocortisone-aloe 1% crm 1 % 3 DP
triamcinolone acetonide topical cream 0.025 %,
0.1 %, 0.5 %
1
triamcinolone acetonide topical lotion 0.025 %,
0.1 %
1
triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %
1
triderm topical cream 0.1 % 1
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
dihydroergotamine injection solution 1 mg/ml 1 PA
dihydroergotamine nasal spray,non-aerosol 0.5
mg/pump act. (4 mg/ml)
1 QL (8 ML per 30 days)
ergotamine-caffeine oral tablet 1-100 mg 1
PROPHYLACTIC
AIMOVIG AUTOINJECTOR (2 PACK)
SUBCUTANEOUS AUTO-INJECTOR 70
MG/ML
2 PA; MO
AIMOVIG AUTOINJECTOR SUBCUTANEOUS
AUTO-INJECTOR 70 MG/ML
2 PA; MO
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
rizatriptan oral tablet 10 mg, 5 mg 1 QL (12 EA per 30 days)
rizatriptan oral tablet,disintegrating 10 mg, 5 mg 1 QL (12 EA per 30 days)
sumatriptan nasal spray,non-aerosol 20
mg/actuation, 5 mg/actuation
1 QL (12 EA per 30 days)
sumatriptan succinate oral tablet 100 mg, 25 mg,
50 mg
1 QL (9 EA per 30 days)
sumatriptan succinate subcutaneous cartridge 4
mg/0.5 ml, 6 mg/0.5 ml
1 QL (4 ML per 30 days)
sumatriptan succinate subcutaneous pen injector 4
mg/0.5 ml, 6 mg/0.5 ml, 6 mg/0.5 ml (auto-
injector)
1 QL (4 ML per 30 days)
sumatriptan succinate subcutaneous solution 6
mg/0.5 ml
1 QL (4 ML per 30 days)
51
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
sumatriptan succinate subcutaneous syringe 6
mg/0.5 ml
1 QL (4 ML per 30 days)
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
guanidine oral tablet 125 mg 1
pyridostigmine bromide oral tablet 60 mg 1 MO
pyridostigmine bromide oral tablet extended
release 180 mg
1 MO
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone oral tablet 100 mg, 25 mg 1 MO
rifabutin oral capsule 150 mg 1
ANTITUBERCULARS
ethambutol oral tablet 100 mg, 400 mg 1
isoniazid oral tablet 100 mg, 300 mg 1
PASER ORAL GRANULES DR FOR SUSP IN
PACKET 4 GRAM
2
PRIFTIN ORAL TABLET 150 MG 2
pyrazinamide oral tablet 500 mg 1
rifampin intravenous recon soln 600 mg 1
rifampin oral capsule 150 mg, 300 mg 1
RIFATER ORAL TABLET 50-120-300 MG 2
SIRTURO ORAL TABLET 100 MG 2 PA
TRECATOR ORAL TABLET 250 MG 2
ANTINEOPLASTICS
ALKYLATING AGENTS
cyclophosphamide oral capsule 25 mg, 50 mg 1 B/D
GLEOSTINE ORAL CAPSULE 10 MG, 100 MG,
40 MG
2 PA
HEXALEN ORAL CAPSULE 50 MG 2 PA
LEUKERAN ORAL TABLET 2 MG 2
MATULANE ORAL CAPSULE 50 MG 2
52
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
VALCHLOR TOPICAL GEL 0.016 % 2 MO
ANTIANDROGENS
abiraterone oral tablet 250 mg 1 PA; MO
bicalutamide oral tablet 50 mg 1 MO
ERLEADA ORAL TABLET 60 MG 2 PA; MO
flutamide oral capsule 125 mg 1 MO
nilutamide oral tablet 150 mg 1 MO
XTANDI ORAL CAPSULE 40 MG 2 PA; MO
YONSA ORAL TABLET 125 MG 2 PA; MO
ZYTIGA ORAL TABLET 500 MG 2 PA; MO
ANTIANGIOGENIC AGENTS
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3
MG, 4 MG
2 PA; MO
REVLIMID ORAL CAPSULE 10 MG, 15 MG,
2.5 MG, 20 MG, 25 MG, 5 MG
2 PA; MO; LA
THALOMID ORAL CAPSULE 100 MG, 150
MG, 200 MG, 50 MG
2 MO
ANTIESTROGENS/MODIFIERS
DEPO-PROVERA INTRAMUSCULAR
SUSPENSION 400 MG/ML
2 PA; MO
EMCYT ORAL CAPSULE 140 MG 2
FARESTON ORAL TABLET 60 MG 2 PA; MO
SOLTAMOX ORAL SOLUTION 10 MG/5 ML 2 MO
tamoxifen oral tablet 10 mg, 20 mg 1 MO
toremifene oral tablet 60 mg 1 PA
ANTIMETABOLITES
DROXIA ORAL CAPSULE 200 MG, 300 MG,
400 MG
2 MO
fluorouracil topical cream 0.5 %, 5 % 1
fluorouracil topical solution 2 %, 5 % 1
hydroxyurea oral capsule 500 mg 1 MO
mercaptopurine oral tablet 50 mg 1 MO
PURIXAN ORAL SUSPENSION 20 MG/ML 2 MO
53
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
TABLOID ORAL TABLET 40 MG 2 PA
ANTINEOPLASTICS, OTHER
diclofenac sodium topical gel 3 % 1
leucovorin calcium oral tablet 10 mg, 15 mg, 25
mg, 5 mg
1
LONSURF ORAL TABLET 15-6.14 MG, 20-8.19
MG
2 PA
LYNPARZA ORAL CAPSULE 50 MG 2 PA; MO
LYNPARZA ORAL TABLET 100 MG, 150 MG 2 PA; MO
MESNEX ORAL TABLET 400 MG 2
NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4
MG
2 PA; MO
ODOMZO ORAL CAPSULE 200 MG 2 PA; MO
SYLATRON SUBCUTANEOUS KIT 200 MCG,
300 MCG, 600 MCG
2 PA; MO
SYNRIBO SUBCUTANEOUS RECON SOLN
3.5 MG
2 PA; MO
VENCLEXTA ORAL TABLET 10 MG, 100 MG,
50 MG
2 PA; MO
VENCLEXTA STARTING PACK ORAL
TABLETS,DOSE PACK 10 MG-50 MG- 100 MG
2 PA
ZOLINZA ORAL CAPSULE 100 MG 2 PA
ZYDELIG ORAL TABLET 100 MG, 150 MG 2 PA; MO
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole oral tablet 1 mg 1 MO
exemestane oral tablet 25 mg 1 MO
letrozole oral tablet 2.5 mg 1 MO
ENZYME INHIBITORS
COPIKTRA ORAL CAPSULE 15 MG, 25 MG 2 PA; MO
TALZENNA ORAL CAPSULE 0.25 MG, 1 MG 2 PA
VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45
MG
2 PA; MO
MOLECULAR TARGET INHIBITORS
54
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
AFINITOR DISPERZ ORAL TABLET FOR
SUSPENSION 2 MG, 3 MG, 5 MG
2 PA; MO
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5
MG, 7.5 MG
2 PA; MO
ALECENSA ORAL CAPSULE 150 MG 2 PA; MO
ALUNBRIG ORAL TABLET 180 MG, 30 MG,
90 MG
2 PA; MO
ALUNBRIG ORAL TABLETS,DOSE PACK 90
MG (7)- 180 MG (23)
2 PA
BOSULIF ORAL TABLET 100 MG, 400 MG,
500 MG
2 PA; MO
BRAFTOVI ORAL CAPSULE 50 MG, 75 MG 2 PA; MO
CABOMETYX ORAL TABLET 20 MG, 40 MG,
60 MG
2 PA; MO
CALQUENCE ORAL CAPSULE 100 MG 2 PA; MO
CAPRELSA ORAL TABLET 100 MG, 300 MG 2 PA; MO
COMETRIQ ORAL CAPSULE 100 MG/DAY(80
MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20
MG X3), 60 MG/DAY (20 MG X 3/DAY)
2 PA; MO
COTELLIC ORAL TABLET 20 MG 2 PA; MO
ERIVEDGE ORAL CAPSULE 150 MG 2 PA; MO
FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20
MG
2 PA
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40
MG
2 PA; MO
IBRANCE ORAL CAPSULE 100 MG, 125 MG,
75 MG
2 PA; MO
ICLUSIG ORAL TABLET 15 MG, 45 MG 2 PA; MO
IDHIFA ORAL TABLET 100 MG, 50 MG 2 PA; MO
imatinib oral tablet 100 mg, 400 mg 1 PA; MO
IMBRUVICA ORAL CAPSULE 140 MG, 70 MG 2 PA; MO
IMBRUVICA ORAL TABLET 140 MG, 280 MG,
420 MG, 560 MG
2 PA; MO
INLYTA ORAL TABLET 1 MG, 5 MG 2 PA; MO
IRESSA ORAL TABLET 250 MG 2 PA
55
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
JAKAFI ORAL TABLET 10 MG, 15 MG, 20
MG, 25 MG, 5 MG
2 PA; MO
KISQALI FEMARA CO-PACK ORAL TABLET
200 MG/DAY(200 MG X 1)-2.5 MG, 400
MG/DAY(200 MG X 2)-2.5 MG, 600
MG/DAY(200 MG X 3)-2.5 MG
2 PA; MO
KISQALI ORAL TABLET 200 MG/DAY (200
MG X 1), 400 MG/DAY (200 MG X 2), 600
MG/DAY (200 MG X 3)
2 PA; MO
LENVIMA ORAL CAPSULE 10 MG/DAY (10
MG X 1), 12 MG/DAY (4 MG X 3), 14
MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY
(10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X
2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8
MG/DAY (4 MG X 2)
2 PA; MO
LORBRENA ORAL TABLET 100 MG, 25 MG 2 PA; MO
MEKINIST ORAL TABLET 0.5 MG, 2 MG 2 PA; MO
MEKTOVI ORAL TABLET 15 MG 2 PA; MO
NERLYNX ORAL TABLET 40 MG 2 PA
NEXAVAR ORAL TABLET 200 MG 2 PA
RUBRACA ORAL TABLET 200 MG, 250 MG,
300 MG
2 PA; MO
RYDAPT ORAL CAPSULE 25 MG 2 PA; MO
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20
MG, 50 MG, 70 MG, 80 MG
2 PA; MO
STIVARGA ORAL TABLET 40 MG 2 PA
SUTENT ORAL CAPSULE 12.5 MG, 25 MG,
37.5 MG, 50 MG
2 PA
TAFINLAR ORAL CAPSULE 50 MG, 75 MG 2 PA; MO
TAGRISSO ORAL TABLET 40 MG, 80 MG 2 PA
TARCEVA ORAL TABLET 100 MG, 150 MG,
25 MG
2 PA; MO
TASIGNA ORAL CAPSULE 150 MG, 200 MG,
50 MG
2 PA; MO
TIBSOVO ORAL TABLET 250 MG 2 PA; MO
TYKERB ORAL TABLET 250 MG 2 PA; MO
56
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
VERZENIO ORAL TABLET 100 MG, 150 MG,
200 MG, 50 MG
2 PA; MO
VOTRIENT ORAL TABLET 200 MG 2 PA; MO
XALKORI ORAL CAPSULE 200 MG, 250 MG 2 PA; MO
ZEJULA ORAL CAPSULE 100 MG 2 PA; MO
ZELBORAF ORAL TABLET 240 MG 2 PA; MO
ZYKADIA ORAL CAPSULE 150 MG 2 PA; MO
RETINOIDS
bexarotene oral capsule 75 mg 1 MO
PANRETIN TOPICAL GEL 0.1 % 2 PA
TARGRETIN TOPICAL GEL 1 % 2 PA
tretinoin (chemotherapy) oral capsule 10 mg 1
TREATMENT ADJUNCTS
LYSODREN ORAL TABLET 500 MG 2 MO
MOLECULAR TARGET INHIBITORS
DAURISMO ORAL TABLET 100 MG, 25 MG 2 PA; MO
VITRAKVI ORAL CAPSULE 100 MG, 25 MG 2 PA; MO
VITRAKVI ORAL SOLUTION 20 MG/ML 2 PA; MO
XOSPATA ORAL TABLET 40 MG 2 PA; MO
ANTIPARASITICS
ANTHELMINTICS
albendazole oral tablet 200 mg 1
ALBENZA ORAL TABLET 200 MG 2
BILTRICIDE ORAL TABLET 600 MG 2
ivermectin oral tablet 3 mg 1
praziquantel oral tablet 600 mg 1
ANTIPROTOZOALS
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
2
ALINIA ORAL TABLET 500 MG 2
atovaquone oral suspension 750 mg/5 ml 1
atovaquone-proguanil oral tablet 250-100 mg,
62.5-25 mg
1
57
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
BENZNIDAZOLE ORAL TABLET 100 MG,
12.5 MG
1 PA
chloroquine phosphate oral tablet 250 mg, 500 mg 1
COARTEM ORAL TABLET 20-120 MG 2
DARAPRIM ORAL TABLET 25 MG 2
hydroxychloroquine oral tablet 200 mg 1 MO
mefloquine oral tablet 250 mg 1
NEBUPENT INHALATION RECON SOLN 300
MG
2 B/D; MO
PENTAM INJECTION RECON SOLN 300 MG 2 PA
PRIMAQUINE ORAL TABLET 26.3 MG 1
quinine sulfate oral capsule 324 mg 1
PEDICULICIDES/ SCABICIDES
GS LICE KILLING SHAMPOO W/NIT COMB
0.33-4 %
3 DP
HM LICE TREATMENT 1% CRM RINSE 1 % 3 DP
LICE KILLING SHAMPOO W/COMB 0.33-4 % 3 DP
LICE KILLING SHAMPOO W/NIT COMB 0.33-
4 %
3 DP
LICE TREATMENT 1% CREME RINSE 1 NIT
REMOVAL COMB 1 %
3 DP
LICE TREATMENT SHAMPOO 1 NIT COMB
INCLUDED 0.33-4 %
3 DP
lindane topical shampoo 1 % 1
malathion topical lotion 0.5 % 1
permethrin topical cream 5 % 1
SB LICE KILLING SHAMPOO MAXIMUM
STRENGTH 0.33-4 %
3 DP
SM LICE TREATMENT 1% CRM RINSE 1 % 3 DP
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine oral tablet 0.5 mg, 1 mg, 2 mg 1 PA; MO
trihexyphenidyl oral elixir 0.4 mg/ml 1 PA; MO
trihexyphenidyl oral tablet 2 mg, 5 mg 1 PA; MO
58
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ANTIPARKINSON AGENTS, OTHER
amantadine hcl oral capsule 100 mg 1 MO
amantadine hcl oral solution 50 mg/5 ml 1 MO
amantadine hcl oral tablet 100 mg 1 MO
entacapone oral tablet 200 mg 1 MO
GOCOVRI ORAL CAPSULE,EXTENDED
RELEASE 24HR 137 MG, 68.5 MG
2 PA; MO
tolcapone oral tablet 100 mg 1 MO
DOPAMINE AGONISTS
APOKYN SUBCUTANEOUS CARTRIDGE 10
MG/ML
2 PA; MO
bromocriptine oral capsule 5 mg 1 MO
bromocriptine oral tablet 2.5 mg 1 MO
NEUPRO TRANSDERMAL PATCH 24 HOUR 1
MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24
HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8
MG/24 HOUR
2 MO
pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5
mg, 0.75 mg, 1 mg, 1.5 mg
1 MO
pramipexole 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
1 MO
ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg,
3 mg, 4 mg, 5 mg
1 MO
ropinirole oral tablet extended release 24 hr 12
mg, 2 mg, 4 mg, 6 mg, 8 mg
1 MO
DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa-levodopa oral tablet 10-100 mg, 25-100
mg, 25-250 mg
1 MO
carbidopa-levodopa oral tablet extended release
25-100 mg, 50-200 mg
1 MO
carbidopa-levodopa oral tablet,disintegrating 10-
100 mg, 25-100 mg, 25-250 mg
1 MO
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
1 MO
59
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
rasagiline oral tablet 0.5 mg, 1 mg 1 MO
selegiline hcl oral capsule 5 mg 1 MO
selegiline hcl oral tablet 5 mg 1 MO
ANTIPSYCHOTICS
1ST GENERATION/ TYPICAL
fluphenazine decanoate injection solution 25
mg/ml
1 MO
fluphenazine hcl injection solution 2.5 mg/ml 1
fluphenazine hcl oral concentrate 5 mg/ml 1
fluphenazine hcl oral elixir 2.5 mg/5 ml 1 MO
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5
mg
1 MO
haloperidol decanoate intramuscular solution 100
mg/ml, 50 mg/ml
1 MO
haloperidol lactate injection solution 5 mg/ml 1
haloperidol lactate intramuscular syringe 5 mg/ml 1
haloperidol lactate oral concentrate 2 mg/ml 1 MO
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg,
20 mg, 5 mg
1 MO
loxapine succinate oral capsule 10 mg, 25 mg, 5
mg, 50 mg
1 MO
molindone oral tablet 10 mg, 25 mg, 5 mg 1 MO
pimozide oral tablet 1 mg, 2 mg 1 MO
thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50
mg
1 PA; MO
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 MO
trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5
mg
1 MO
2ND GENERATION/ ATYPICAL
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON 300
MG, 400 MG
2 PA; MO; QL (1 EA per 28 days)
60
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 300
MG, 400 MG
2 PA; MO; QL (1 EA per 28 days)
aripiprazole oral solution 1 mg/ml 1 MO; QL (900 ML per 30 days)
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20
mg, 30 mg, 5 mg
1 MO; QL (30 EA per 30 days)
aripiprazole oral tablet,disintegrating 10 mg, 15
mg
1 MO; QL (60 EA per 30 days)
ARISTADA INITIO INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 675
MG/2.4 ML
2 PA
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 1,064
MG/3.9 ML
2 PA; MO; QL (3.9 ML per 56 days)
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 441
MG/1.6 ML
2 PA; MO; QL (1.6 ML per 28 days)
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 662
MG/2.4 ML
2 PA; MO; QL (2.4 ML per 28 days)
ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING 882
MG/3.2 ML
2 PA; MO; QL (3.2 ML per 28 days)
FANAPT ORAL TABLET 1 MG, 10 MG, 12
MG, 2 MG, 4 MG, 6 MG, 8 MG
2 PA; MO; QL (60 EA per 30 days)
FANAPT ORAL TABLETS,DOSE PACK
1MG(2)-2MG(2)- 4MG(2)-6MG(2)
2 PA
GEODON INTRAMUSCULAR RECON SOLN
20 MG/ML (FINAL CONC.)
2 B/D; QL (6 EA per 3 days)
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 117 MG/0.75 ML
2 PA; MO; QL (0.75 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 156 MG/ML
2 PA; MO; QL (1 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 234 MG/1.5 ML
2 PA; MO; QL (1.5 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 39 MG/0.25 ML
2 PA; MO; QL (0.25 ML per 28 days)
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 78 MG/0.5 ML
2 PA; MO; QL (0.5 ML per 28 days)
61
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 273 MG/0.875 ML
2 PA; MO; QL (0.875 ML per 84 days)
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 410 MG/1.315 ML
2 PA; MO; QL (1.315 ML per 84 days)
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 546 MG/1.75 ML
2 PA; MO; QL (1.75 ML per 84 days)
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 819 MG/2.625 ML
2 PA; MO; QL (2.625 ML per 84 days)
LATUDA ORAL TABLET 120 MG, 20 MG, 40
MG, 60 MG
2 PA; MO; QL (30 EA per 30 days)
LATUDA ORAL TABLET 80 MG 2 PA; MO; QL (60 EA per 30 days)
NUPLAZID ORAL CAPSULE 34 MG 2 PA; MO; QL (30 EA per 30 days)
NUPLAZID ORAL TABLET 10 MG 2 PA; MO; QL (30 EA per 30 days)
NUPLAZID ORAL TABLET 17 MG 2 PA; MO; QL (60 EA per 30 days)
olanzapine intramuscular recon soln 10 mg 1 QL (90 EA per 30 days)
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20
mg, 5 mg, 7.5 mg
1 MO; QL (30 EA per 30 days)
olanzapine oral tablet,disintegrating 10 mg, 15
mg, 20 mg, 5 mg
1 MO; QL (30 EA per 30 days)
paliperidone oral tablet extended release 24hr 1.5
mg, 3 mg, 9 mg
1 PA; MO; QL (30 EA per 30 days)
paliperidone oral tablet extended release 24hr 6
mg
1 PA; MO; QL (60 EA per 30 days)
PERSERIS ABDOMINAL SUBCUTANEOUS
SUSPENSION,EXTEND REL SYR KIT 120 MG,
90 MG
2 PA; MO
quetiapine oral tablet 100 mg, 200 mg, 300 mg,
400 mg
1 MO; QL (60 EA per 30 days)
quetiapine oral tablet 25 mg, 50 mg 1 MO; QL (90 EA per 30 days)
quetiapine oral tablet extended release 24 hr 150
mg, 200 mg
1 MO; QL (30 EA per 30 days)
quetiapine oral tablet extended release 24 hr 300
mg, 400 mg, 50 mg
1 MO; QL (60 EA per 30 days)
REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1
MG, 2 MG, 3 MG, 4 MG
2 PA; MO; QL (30 EA per 30 days)
62
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5
MG/2 ML, 50 MG/2 ML
2 PA; MO; QL (2 EA per 28 days)
risperidone oral solution 1 mg/ml 1 MO; QL (240 ML per 30 days)
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg
1 MO; QL (60 EA per 30 days)
risperidone oral tablet 4 mg 1 MO; QL (120 EA per 30 days)
risperidone oral tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3 mg
1 MO; QL (60 EA per 30 days)
risperidone oral tablet,disintegrating 4 mg 1 MO; QL (120 EA per 30 days)
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 10 MG, 5 MG
2 QL (60 EA per 30 days)
SAPHRIS SUBLINGUAL TABLET 10 MG, 5
MG
2 QL (60 EA per 30 days)
SAPHRIS SUBLINGUAL TABLET 2.5 MG 2 MO; QL (60 EA per 30 days)
VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5
MG, 6 MG
2 PA; MO; QL (30 EA per 30 days)
VRAYLAR ORAL CAPSULE,DOSE PACK 1.5
MG (1)- 3 MG (6)
2 PA; QL (28 EA per 28 days)
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg,
80 mg
1 MO; QL (60 EA per 30 days)
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 210
MG, 300 MG
2 PA; MO; QL (2 EA per 28 days)
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 405
MG
2 PA; MO; QL (1 EA per 28 days)
TREATMENT-RESISTANT
clozapine oral tablet 100 mg 1 MO; QL (270 EA per 30 days)
clozapine oral tablet 200 mg 1 MO; QL (120 EA per 30 days)
clozapine oral tablet 25 mg, 50 mg 1 MO; QL (90 EA per 30 days)
clozapine oral tablet,disintegrating 100 mg 1 MO; QL (270 EA per 30 days)
clozapine oral tablet,disintegrating 12.5 mg, 25
mg
1 MO
clozapine oral tablet,disintegrating 150 mg 1 MO; QL (180 EA per 30 days)
clozapine oral tablet,disintegrating 200 mg 1 MO; QL (120 EA per 30 days)
VERSACLOZ ORAL SUSPENSION 50 MG/ML 2 MO; QL (540 ML per 30 days)
63
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ANTISPASTICITY AGENTS
ANTISPASTICITY AGENTS
baclofen oral tablet 10 mg, 20 mg, 5 mg 1 MO
dantrolene oral capsule 100 mg, 25 mg, 50 mg 1 MO
tizanidine oral tablet 2 mg, 4 mg 1 MO
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
ganciclovir sodium intravenous solution 50 mg/ml 1 B/D
PREVYMIS ORAL TABLET 240 MG, 480 MG 2 PA
valganciclovir oral recon soln 50 mg/ml 1 MO
valganciclovir oral tablet 450 mg 1 MO
ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % 2 ST
ANTI-HEPATITIS B (HBV) AGENTS
ADEFOVIR ORAL TABLET 10 MG 1 PA
BARACLUDE ORAL SOLUTION 0.05 MG/ML 2 MO
entecavir oral tablet 0.5 mg, 1 mg 1 MO
EPIVIR HBV ORAL SOLUTION 25 MG/5 ML
(5 MG/ML)
2 MO
lamivudine oral solution 10 mg/ml 1 MO
lamivudine oral tablet 100 mg, 300 mg 1 MO; QL (30 EA per 30 days)
lamivudine oral tablet 150 mg 1 MO; QL (60 EA per 30 days)
PEGASYS PROCLICK SUBCUTANEOUS PEN
INJECTOR 180 MCG/0.5 ML
2 PA
PEGASYS SUBCUTANEOUS SOLUTION 180
MCG/ML
2 PA
PEGASYS SUBCUTANEOUS SYRINGE 180
MCG/0.5 ML
2 PA
tenofovir disoproxil fumarate oral tablet 300 mg 1 MO
VEMLIDY ORAL TABLET 25 MG 2 MO
VIREAD ORAL POWDER 40 MG/SCOOP (40
MG/GRAM)
2 MO
VIREAD ORAL TABLET 150 MG, 200 MG, 250
MG
2 MO
64
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS
MAVYRET ORAL TABLET 100-40 MG 2 PA
VOSEVI ORAL TABLET 400-100-100 MG 2 PA
ANTI-HEPATITIS C (HCV) AGENTS, OTHER
INTRON A INJECTION RECON SOLN 10
MILLION UNIT (1 ML), 18 MILLION UNIT (1
ML), 50 MILLION UNIT (1 ML)
2 PA
INTRON A INJECTION SOLUTION 10
MILLION UNIT/ML, 6 MILLION UNIT/ML
2 PA
RIBAVIRIN ORAL CAPSULE 200 MG 1
RIBAVIRIN ORAL TABLET 200 MG 1
ANTIHERPETIC AGENTS
ABREVA 10% CREAM 10 % 3 DP
acyclovir oral capsule 200 mg 1 MO
acyclovir oral suspension 200 mg/5 ml 1 MO
acyclovir oral tablet 400 mg, 800 mg 1 MO
acyclovir sodium intravenous solution 50 mg/ml 1 B/D
acyclovir topical ointment 5 % 1
DENAVIR TOPICAL CREAM 1 % 2
famciclovir oral tablet 125 mg, 250 mg, 500 mg 1 MO
trifluridine ophthalmic (eye) drops 1 % 1
valacyclovir oral tablet 1 gram, 500 mg 1 MO
ZOVIRAX TOPICAL CREAM 5 % 2
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
GENVOYA ORAL TABLET 150-150-200-10
MG
2 MO; QL (30 EA per 30 days)
ISENTRESS HD ORAL TABLET 600 MG 2 MO; QL (60 EA per 30 days)
ISENTRESS ORAL POWDER IN PACKET 100
MG
2 MO
ISENTRESS ORAL TABLET 400 MG 2 MO; QL (120 EA per 30 days)
ISENTRESS ORAL TABLET,CHEWABLE 100
MG, 25 MG
2 MO; QL (180 EA per 30 days)
JULUCA ORAL TABLET 50-25 MG 2 MO; QL (30 EA per 30 days)
65
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
STRIBILD ORAL TABLET 150-150-200-300
MG
2 MO; QL (30 EA per 30 days)
TIVICAY ORAL TABLET 10 MG 2 MO; QL (300 EA per 30 days)
TIVICAY ORAL TABLET 25 MG 2 MO; QL (120 EA per 30 days)
TIVICAY ORAL TABLET 50 MG 2 MO; QL (60 EA per 30 days)
TRIUMEQ ORAL TABLET 600-50-300 MG 2 MO; QL (30 EA per 30 days)
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
(NNRTI)
ATRIPLA ORAL TABLET 600-200-300 MG 2 MO; QL (30 EA per 30 days)
COMPLERA ORAL TABLET 200-25-300 MG 2 MO; QL (30 EA per 30 days)
DELSTRIGO ORAL TABLET 100-300-300 MG 2 MO; QL (30 EA per 30 days)
EDURANT ORAL TABLET 25 MG 2 MO; QL (30 EA per 30 days)
efavirenz oral capsule 200 mg 1 MO; QL (120 EA per 30 days)
efavirenz oral capsule 50 mg 1 MO; QL (360 EA per 30 days)
efavirenz oral tablet 600 mg 1 MO; QL (30 EA per 30 days)
INTELENCE ORAL TABLET 100 MG, 25 MG 2 MO; QL (120 EA per 30 days)
INTELENCE ORAL TABLET 200 MG 2 MO; QL (60 EA per 30 days)
nevirapine oral tablet 200 mg 1 MO; QL (60 EA per 30 days)
nevirapine oral tablet extended release 24 hr 100
mg
1 MO; QL (120 EA per 30 days)
nevirapine oral tablet extended release 24 hr 400
mg
1 MO; QL (30 EA per 30 days)
ODEFSEY ORAL TABLET 200-25-25 MG 2 MO; QL (30 EA per 30 days)
PIFELTRO ORAL TABLET 100 MG 2 MO; QL (30 EA per 30 days)
RESCRIPTOR ORAL TABLET 200 MG 2 MO; QL (180 EA per 30 days)
RESCRIPTOR ORAL TABLET, DISPERSIBLE
100 MG
2 MO; QL (360 EA per 30 days)
SYMFI LO ORAL TABLET 400-300-300 MG 2 MO; QL (30 EA per 30 days)
VIRAMUNE ORAL SUSPENSION 50 MG/5 ML 2 MO
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE
INHIBITORS (NRTI)
abacavir oral solution 20 mg/ml 1 MO
abacavir oral tablet 300 mg 1 MO; QL (60 EA per 30 days)
66
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
abacavir-lamivudine oral tablet 600-300 mg 1 MO; QL (30 EA per 30 days)
abacavir-lamivudine-zidovudine oral tablet 300-
150-300 mg
1 MO; QL (60 EA per 30 days)
CIMDUO ORAL TABLET 300-300 MG 2 MO; QL (30 EA per 30 days)
DESCOVY ORAL TABLET 200-25 MG 2 MO; QL (30 EA per 30 days)
didanosine oral capsule,delayed release(dr/ec)
125 mg
1 MO; QL (90 EA per 30 days)
didanosine oral capsule,delayed release(dr/ec)
200 mg
1 MO; QL (60 EA per 30 days)
didanosine oral capsule,delayed release(dr/ec)
250 mg, 400 mg
1 MO; QL (30 EA per 30 days)
EMTRIVA ORAL CAPSULE 200 MG 2 MO; QL (30 EA per 30 days)
EMTRIVA ORAL SOLUTION 10 MG/ML 2 MO
lamivudine-zidovudine oral tablet 150-300 mg 1 MO; QL (60 EA per 30 days)
stavudine oral capsule 15 mg, 20 mg 1 MO; QL (120 EA per 30 days)
stavudine oral capsule 30 mg, 40 mg 1 MO; QL (60 EA per 30 days)
TRUVADA ORAL TABLET 100-150 MG, 133-
200 MG, 167-250 MG, 200-300 MG
2 MO; QL (30 EA per 30 days)
VIDEX 2 GRAM PEDIATRIC ORAL RECON
SOLN 10 MG/ML (FINAL)
2 MO
VIDEX 4 GRAM PEDIATRIC ORAL RECON
SOLN 10 MG/ML (FINAL)
2 MO
VIDEX EC ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 125 MG
2 MO; QL (90 EA per 30 days)
ZERIT ORAL RECON SOLN 1 MG/ML 2 MO
zidovudine oral capsule 100 mg 1 MO; QL (180 EA per 30 days)
zidovudine oral syrup 10 mg/ml 1 MO
zidovudine oral tablet 300 mg 1 MO; QL (60 EA per 30 days)
ANTI-HIV AGENTS, OTHER
BIKTARVY ORAL TABLET 50-200-25 MG 2 MO; QL (30 EA per 30 days)
FUZEON SUBCUTANEOUS RECON SOLN 90
MG
2 MO
selzentry oral solution 20 mg/ml 2 MO
SELZENTRY ORAL TABLET 150 MG, 75 MG 2 MO; QL (60 EA per 30 days)
SELZENTRY ORAL TABLET 25 MG, 300 MG 2 MO; QL (120 EA per 30 days)
67
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
SYMFI ORAL TABLET 600-300-300 MG 2 MO; QL (30 EA per 30 days)
SYMTUZA ORAL TABLET 800-150-200-10 MG 2 MO; QL (30 EA per 30 days)
TYBOST ORAL TABLET 150 MG 2 MO; QL (30 EA per 30 days)
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS ORAL CAPSULE 250 MG 2 MO; QL (120 EA per 30 days)
APTIVUS ORAL SOLUTION 100 MG/ML 2 MO
atazanavir oral capsule 150 mg, 300 mg 1 MO; QL (30 EA per 30 days)
atazanavir oral capsule 200 mg 1 MO; QL (60 EA per 30 days)
CRIXIVAN ORAL CAPSULE 200 MG 2 MO; QL (360 EA per 30 days)
CRIXIVAN ORAL CAPSULE 400 MG 2 MO; QL (180 EA per 30 days)
EVOTAZ ORAL TABLET 300-150 MG 2 MO; QL (30 EA per 30 days)
fosamprenavir oral tablet 700 mg 1 MO; QL (120 EA per 30 days)
INVIRASE ORAL TABLET 500 MG 2 MO; QL (120 EA per 30 days)
KALETRA ORAL TABLET 100-25 MG 2 MO; QL (240 EA per 30 days)
KALETRA ORAL TABLET 200-50 MG 2 MO; QL (120 EA per 30 days)
LEXIVA ORAL SUSPENSION 50 MG/ML 2 MO
lopinavir-ritonavir oral solution 400-100 mg/5 ml 1 MO
NORVIR ORAL POWDER IN PACKET 100 MG 2 MO; QL (360 EA per 30 days)
NORVIR ORAL SOLUTION 80 MG/ML 2 MO
PREZCOBIX ORAL TABLET 800-150 MG-MG 2 MO; QL (30 EA per 30 days)
PREZISTA ORAL SUSPENSION 100 MG/ML 2 MO
PREZISTA ORAL TABLET 150 MG 2 MO; QL (180 EA per 30 days)
PREZISTA ORAL TABLET 600 MG 2 MO; QL (60 EA per 30 days)
PREZISTA ORAL TABLET 75 MG 2 MO; QL (300 EA per 30 days)
PREZISTA ORAL TABLET 800 MG 2 MO; QL (30 EA per 30 days)
REYATAZ ORAL POWDER IN PACKET 50
MG
2 MO
ritonavir oral tablet 100 mg 1 MO; QL (360 EA per 30 days)
VIRACEPT ORAL TABLET 250 MG 2 MO; QL (300 EA per 30 days)
VIRACEPT ORAL TABLET 625 MG 2 MO; QL (120 EA per 30 days)
ANTI-INFLUENZA AGENTS
oseltamivir oral capsule 30 mg 1 QL (84 EA per 180 days)
68
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
oseltamivir oral capsule 45 mg, 75 mg 1 QL (42 EA per 180 days)
oseltamivir oral suspension for reconstitution 6
mg/ml
1 QL (540 ML per 180 days)
RELENZA DISKHALER INHALATION
BLISTER WITH DEVICE 5 MG/ACTUATION
2 QL (60 EA per 180 days)
rimantadine oral tablet 100 mg 1
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg,
7.5 mg
1 MO
hydroxyzine pamoate oral capsule 100 mg, 25 mg,
50 mg
1 PA
BENZODIAZEPINES
ALPRAZOLAM INTENSOL ORAL
CONCENTRATE 1 MG/ML
1 QL (300 ML per 30 days)
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg 1 QL (120 EA per 30 days)
alprazolam oral tablet 2 mg 1 QL (150 EA per 30 days)
alprazolam oral tablet extended release 24 hr 0.5
mg, 1 mg
1 QL (30 EA per 30 days)
alprazolam oral tablet extended release 24 hr 2
mg
1 QL (150 EA per 30 days)
alprazolam oral tablet extended release 24 hr 3
mg
1 QL (90 EA per 30 days)
clonazepam oral tablet 0.5 mg, 1 mg 1 PA; MO; QL (90 EA per 30 days)
clonazepam oral tablet 2 mg 1 PA; MO; QL (300 EA per 30 days)
clonazepam oral tablet,disintegrating 0.125 mg,
0.25 mg, 0.5 mg, 1 mg
1 PA; MO; QL (90 EA per 30 days)
clonazepam oral tablet,disintegrating 2 mg 1 PA; MO; QL (300 EA per 30 days)
clorazepate dipotassium oral tablet 15 mg 1 PA; QL (180 EA per 30 days)
clorazepate dipotassium oral tablet 3.75 mg, 7.5
mg
1 PA; QL (90 EA per 30 days)
diazepam intensol oral concentrate 5 mg/ml 1 PA; QL (240 ML per 30 days)
diazepam oral concentrate 5 mg/ml 1 PA; QL (240 ML per 30 days)
diazepam oral solution 5 mg/5 ml (1 mg/ml), 5
mg/5 ml (1 mg/ml, 5 ml)
1 PA; QL (1200 ML per 30 days)
diazepam oral tablet 10 mg, 2 mg, 5 mg 1 PA; QL (120 EA per 30 days)
69
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
lorazepam intensol oral concentrate 2 mg/ml 1 QL (150 ML per 30 days)
lorazepam oral concentrate 2 mg/ml 1 QL (150 ML per 30 days)
lorazepam oral tablet 0.5 mg, 1 mg 1 QL (90 EA per 30 days)
lorazepam oral tablet 2 mg 1 QL (150 EA per 30 days)
BIPOLAR AGENTS
MOOD STABILIZERS
carbamazepine oral capsule, er multiphase 12 hr
100 mg, 200 mg, 300 mg
1 MO
EQUETRO ORAL CAPSULE, ER
MULTIPHASE 12 HR 100 MG, 200 MG, 300
MG
2 MO
lamotrigine oral tablet 100 mg, 150 mg, 200 mg,
25 mg
1 MO
lithium carbonate oral capsule 150 mg, 300 mg,
600 mg
1 MO
lithium carbonate oral tablet 300 mg 1 MO
lithium carbonate oral tablet extended release 300
mg, 450 mg
1 MO
lithium citrate oral solution 8 meq/5 ml 1 MO
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose oral tablet 100 mg, 25 mg, 50 mg 1 ST; MO; QL (90 EA per 30 days)
alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg 1 ST; MO; QL (30 EA per 30 days)
alogliptin-metformin oral tablet 12.5-1,000 mg,
12.5-500 mg
1 ST; MO; QL (60 EA per 30 days)
alogliptin-pioglitazone oral tablet 12.5-15 mg,
12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25-
45 mg
1 ST; MO; QL (30 EA per 30 days)
AVANDIA ORAL TABLET 2 MG, 4 MG 2 ST; MO; QL (60 EA per 30 days)
DM2 COMBO PACK, TABLET AND STRIP 500
MG
1 QL (60 EA per 30 days)
glimepiride oral tablet 1 mg 1 MO; QL (240 EA per 30 days)
glimepiride oral tablet 2 mg 1 MO; QL (120 EA per 30 days)
glimepiride oral tablet 4 mg 1 MO; QL (60 EA per 30 days)
70
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
glipizide oral tablet 10 mg 1 MO; QL (120 EA per 30 days)
glipizide oral tablet 5 mg 1 MO; QL (240 EA per 30 days)
glipizide oral tablet extended release 24hr 10 mg 1 MO; QL (60 EA per 30 days)
glipizide oral tablet extended release 24hr 2.5 mg 1 MO; QL (240 EA per 30 days)
glipizide oral tablet extended release 24hr 5 mg 1 MO; QL (90 EA per 30 days)
glipizide-metformin oral tablet 2.5-250 mg 1 MO; QL (240 EA per 30 days)
glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg
1 MO; QL (120 EA per 30 days)
glyburide micronized oral tablet 1.5 mg, 3 mg 1 PA; MO; QL (90 EA per 30 days)
glyburide micronized oral tablet 6 mg 1 PA; MO; QL (60 EA per 30 days)
glyburide oral tablet 1.25 mg, 2.5 mg 1 PA; MO; QL (60 EA per 30 days)
glyburide oral tablet 5 mg 1 PA; MO
glyburide-metformin oral tablet 1.25-250 mg 1 PA; MO; QL (240 EA per 30 days)
glyburide-metformin oral tablet 2.5-500 mg, 5-500
mg
1 PA; MO; QL (120 EA per 30 days)
INVOKAMET ORAL TABLET 150-1,000 MG,
150-500 MG, 50-1,000 MG
2 ST; MO; QL (60 EA per 30 days)
INVOKAMET ORAL TABLET 50-500 MG 2 ST; MO; QL (120 EA per 30 days)
INVOKAMET XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 150-1,000 MG, 150-500 MG,
50-1,000 MG, 50-500 MG
2 ST; MO; QL (60 EA per 30 days)
INVOKANA ORAL TABLET 100 MG, 300 MG 2 ST; MO; QL (30 EA per 30 days)
JANUMET ORAL TABLET 50-1,000 MG, 50-
500 MG
2 ST; MO; QL (60 EA per 30 days)
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG
2 ST; MO; QL (30 EA per 30 days)
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG
2 ST; MO; QL (60 EA per 30 days)
JANUVIA ORAL TABLET 100 MG, 25 MG, 50
MG
2 ST; MO; QL (30 EA per 30 days)
JENTADUETO ORAL TABLET 2.5-1,000 MG,
2.5-500 MG, 2.5-850 MG
2 ST; MO; QL (60 EA per 30 days)
JENTADUETO XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 2.5-1,000 MG
2 ST; MO; QL (60 EA per 30 days)
JENTADUETO XR ORAL TABLET, IR - ER,
BIPHASIC 24HR 5-1,000 MG
2 ST; MO; QL (30 EA per 30 days)
71
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
KORLYM ORAL TABLET 300 MG 2 PA; MO
metformin oral tablet 1,000 mg 1 MO; QL (75 EA per 30 days)
metformin oral tablet 500 mg 1 MO; QL (150 EA per 30 days)
metformin oral tablet 850 mg 1 MO; QL (90 EA per 30 days)
metformin oral tablet extended release 24 hr 500
mg
1 MO; QL (120 EA per 30 days)
metformin oral tablet extended release 24 hr 750
mg
1 MO; QL (60 EA per 30 days)
nateglinide oral tablet 120 mg, 60 mg 1 ST; MO; QL (90 EA per 30 days)
OZEMPIC SUBCUTANEOUS PEN INJECTOR
0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1
MG/DOSE (2 MG/1.5 ML)
2 ST; MO; QL (3 ML per 28 days)
pioglitazone oral tablet 15 mg, 30 mg, 45 mg 1 ST; MO; QL (30 EA per 30 days)
pioglitazone-metformin oral tablet 15-500 mg, 15-
850 mg
1 ST; MO; QL (90 EA per 30 days)
repaglinide oral tablet 0.5 mg, 1 mg 1 ST; MO; QL (120 EA per 30 days)
repaglinide oral tablet 2 mg 1 ST; MO
SEGLUROMET ORAL TABLET 2.5-1,000 MG,
7.5-1,000 MG, 7.5-500 MG
2 ST; MO; QL (60 EA per 30 days)
SEGLUROMET ORAL TABLET 2.5-500 MG 2 ST; MO; QL (120 EA per 30 days)
STEGLATRO ORAL TABLET 15 MG, 5 MG 2 ST; MO; QL (30 EA per 30 days)
STEGLUJAN ORAL TABLET 15-100 MG, 5-100
MG
2 ST; MO; QL (30 EA per 30 days)
SYMLINPEN 120 SUBCUTANEOUS PEN
INJECTOR 2,700 MCG/2.7 ML
2 PA; MO
SYMLINPEN 60 SUBCUTANEOUS PEN
INJECTOR 1,500 MCG/1.5 ML
2 PA; MO
TRADJENTA ORAL TABLET 5 MG 2 ST; MO; QL (30 EA per 30 days)
TRULICITY SUBCUTANEOUS PEN
INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML
2 ST; MO; QL (2 ML per 28 days)
VICTOZA 2-PAK SUBCUTANEOUS PEN
INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)
2 ST; MO; QL (9 ML per 30 days)
VICTOZA 3-PAK SUBCUTANEOUS PEN
INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)
2 ST; MO; QL (9 ML per 30 days)
BLOOD GLUCOSE REGULATORS
72
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
alcohol pads topical pads, medicated 1
assure id insulin safety syringe 1 ml 29 gauge x
1/2"
1 MO
gauze pad topical bandage 2 x 2 " 1
insulin syringe-needle u-100 syringe 0.3 ml 29
gauge, 1/2 ml 28 gauge
1
insulin syringe-needle u-100 syringe 1 ml 29
gauge x 1/2"
1 MO
pen needle, diabetic needle 29 gauge x 1/2" 1
GLYCEMIC AGENTS
GLUCAGEN DIAGNOSTIC KIT INJECTION
RECON SOLN 1 MG/ML
2 QL (4 EA per 30 days)
GLUCAGEN HYPOKIT INJECTION RECON
SOLN 1 MG
2 QL (4 EA per 30 days)
GLUCAGON EMERGENCY KIT (HUMAN)
INJECTION RECON SOLN 1 MG
2 QL (4 EA per 30 days)
GLUCAGON HCL INJECTION RECON SOLN 1
MG
1 QL (2 EA per 30 days)
hm glucose 4 gram tablet chew orange flavor 4
gram
3 DP
hm glucose 4 gram tablet chew raspberry flavor 4
gram
3 DP
PROGLYCEM ORAL SUSPENSION 50 MG/ML 2 MO
sm glucose 4 gram tab chew 6's 4 gram 3 DP
INSULINS
HUMALOG JUNIOR KWIKPEN U-100
SUBCUTANEOUS INSULIN PEN, HALF-UNIT
100 UNIT/ML
2 MO
HUMALOG KWIKPEN INSULIN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML, 200 UNIT/ML (3 ML)
2 MO
HUMALOG MIX 50-50 INSULN U-100
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
(50-50)
2 MO
HUMALOG MIX 50-50 KWIKPEN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (50-50)
2 MO
73
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
HUMALOG MIX 75-25 KWIKPEN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (75-25)
2 MO
HUMALOG MIX 75-25(U-100)INSULN
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
(75-25)
2 MO
HUMALOG U-100 INSULIN SUBCUTANEOUS
CARTRIDGE 100 UNIT/ML
2 MO
HUMALOG U-100 INSULIN SUBCUTANEOUS
SOLUTION 100 UNIT/ML
2 MO
HUMALOG U-100 INSULIN SUBCUTANEOUS
SOLUTION 100 UNIT/ML (PREFILLED
SYRINGE)
2
HUMULIN 70/30 U-100 INSULIN
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
(70-30)
2
HUMULIN N NPH U-100 INSULIN
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
2
HUMULIN R REGULAR U-100 INSULN
INJECTION SOLUTION 100 UNIT/ML
2
HUMULIN R U-500 (CONC) INSULIN
SUBCUTANEOUS SOLUTION 500 UNIT/ML
2 MO
HUMULIN R U-500 (CONC) KWIKPEN
SUBCUTANEOUS INSULIN PEN 500
UNIT/ML (3 ML)
2 MO
LANTUS SOLOSTAR U-100 INSULIN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
2 MO
LANTUS U-100 INSULIN SUBCUTANEOUS
SOLUTION 100 UNIT/ML
2 MO
LEVEMIR FLEXTOUCH U-100 INSULN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (3 ML)
2 MO
LEVEMIR U-100 INSULIN SUBCUTANEOUS
SOLUTION 100 UNIT/ML
2 MO
NOVOLIN 70/30 U-100 INSULIN
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
(70-30)
2
74
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
NOVOLIN N NPH U-100 INSULIN
SUBCUTANEOUS SUSPENSION 100 UNIT/ML
2
NOVOLIN R REGULAR U-100 INSULN
INJECTION SOLUTION 100 UNIT/ML
2
NOVOLOG FLEXPEN U-100 INSULIN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML
2 MO
NOVOLOG MIX 70-30 U-100 INSULN
SUBCUTANEOUS SOLUTION 100 UNIT/ML
(70-30)
2 MO
NOVOLOG MIX 70-30FLEXPEN U-100
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (70-30)
2 MO
NOVOLOG PENFILL U-100 INSULIN
SUBCUTANEOUS CARTRIDGE 100 UNIT/ML
2 MO
NOVOLOG U-100 INSULIN ASPART
SUBCUTANEOUS SOLUTION 100 UNIT/ML
2 MO
TOUJEO MAX U-300 SOLOSTAR
SUBCUTANEOUS INSULIN PEN 300
UNIT/ML (3 ML)
2 MO
TOUJEO SOLOSTAR U-300 INSULIN
SUBCUTANEOUS INSULIN PEN 300
UNIT/ML (1.5 ML)
2 MO
BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERS
ANTICOAGULANTS
COUMADIN ORAL TABLET 1 MG, 10 MG, 2
MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG
2 MO
ELIQUIS ORAL TABLET 2.5 MG, 5 MG 2 MO
ELIQUIS ORAL TABLETS,DOSE PACK 5 MG
(74 TABS)
2
enoxaparin subcutaneous solution 300 mg/3 ml 1
enoxaparin subcutaneous syringe 100 mg/ml, 120
mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml,
60 mg/0.6 ml, 80 mg/0.8 ml
1
fondaparinux subcutaneous syringe 10 mg/0.8 ml,
2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml
1
FRAGMIN SUBCUTANEOUS SOLUTION
25,000 ANTI-XA UNIT/ML
2
75
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
FRAGMIN SUBCUTANEOUS SYRINGE 10,000
ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5
ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000
ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA
UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML,
7,500 ANTI-XA UNIT/0.3 ML
2
heparin (porcine) injection cartridge 5,000 unit/ml
(1 ml)
1
heparin (porcine) injection solution 1,000 unit/ml 1
heparin (porcine) injection solution 10,000
unit/ml, 5,000 unit/ml
1 B/D
heparin, porcine (pf) injection solution 1,000
unit/ml, 5,000 unit/0.5 ml
1
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3
mg, 4 mg, 5 mg, 6 mg, 7.5 mg
1 MO
PRADAXA ORAL CAPSULE 110 MG, 150 MG,
75 MG
2 MO
warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3
mg, 4 mg, 5 mg, 6 mg, 7.5 mg
1 MO
XARELTO ORAL TABLET 10 MG, 15 MG, 2.5
MG, 20 MG
2 MO
XARELTO ORAL TABLETS,DOSE PACK 15
MG (42)- 20 MG (9)
2
BLOOD FORMATION MODIFIERS
anagrelide oral capsule 0.5 mg, 1 mg 1 MO
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION 100 MCG/ML, 150 MCG/0.75 ML,
200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40
MCG/ML, 60 MCG/ML
2 PA; MO
ARANESP (IN POLYSORBATE) INJECTION
SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML,
150 MCG/0.3 ML, 200 MCG/0.4 ML, 25
MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4
ML, 500 MCG/ML, 60 MCG/0.3 ML
2 PA; MO
DOPTELET (10 TAB PACK) ORAL TABLET 20
MG
2 PA
DOPTELET (15 TAB PACK) ORAL TABLET 20
MG
2 PA
76
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
DOPTELET ORAL TABLET 20 MG, 20 MG (15
PACK)
2 PA
EPOGEN INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,
20,000 UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
2 PA; MO
GRANIX SUBCUTANEOUS SOLUTION 300
MCG/ML, 480 MCG/1.6 ML
2 PA
GRANIX SUBCUTANEOUS SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
2 PA
LEUKINE INJECTION RECON SOLN 250 MCG 2 PA
NEULASTA SUBCUTANEOUS SYRINGE 6
MG/0.6ML
2 PA
NEULASTA SUBCUTANEOUS SYRINGE, W/
WEARABLE INJECTOR 6 MG/0.6 ML
2 PA
NEUPOGEN INJECTION SOLUTION 300
MCG/ML, 480 MCG/1.6 ML
2 PA
NEUPOGEN INJECTION SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
2 PA
NIVESTYM SUBCUTANEOUS SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
2 PA
PROCRIT INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,
20,000 UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML, 40,000 UNIT/ML
2 PA; MO
PROMACTA ORAL TABLET 12.5 MG, 25 MG,
50 MG, 75 MG
2 PA; MO; QL (30 EA per 30 days)
ZARXIO INJECTION SYRINGE 300 MCG/0.5
ML, 480 MCG/0.8 ML
2 PA
HEMOSTASIS AGENTS
MEPHYTON 5 MG TABLET 5 MG 3 DP
tranexamic acid oral tablet 650 mg 1 MO
VITAMIN K-1 1 MG/0.5 ML AMPUL LATEX-
FREE, SDV 1 MG/0.5 ML
3 DP
VITAMIN K-1 1 MG/0.5 ML AMPUL
SDV,LATEX-FREE 1 MG/0.5 ML
3 DP
VITAMIN K-1 10 MG/ML AMPUL LATEX-
FREE, SDV 10 MG/ML
3 DP
77
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
VITAMIN K-1 10 MG/ML AMPUL
SDV,LATEX-FREE 10 MG/ML
3 DP
PLATELET MODIFYING AGENTS
ASPIR EC 81 MG TABLET 81 MG 3 DP
aspirin 81 mg chewable tablet 81 mg 3 DP
aspirin 81 mg chewable tablet child low dose 81
mg
3 DP
aspirin 81 mg chewable tablet gluten-free, orange
81 mg
3 DP
aspirin 81 mg chewable tablet low dose 81 mg 3 DP
aspirin 81 mg chewable tablet low dose, cherry 81
mg
3 DP
aspirin 81 mg chewable tablet orange 81 mg 3 DP
aspirin 81 mg chewable tablet orange,gluten-free
81 mg
3 DP
aspirin 81 mg chewable tablet tab chew,orange 81
mg
3 DP
aspirin 81 mg chewable tablet u-d 81 mg 3 DP
aspirin ec 81 mg tablet 81 mg 3 DP
aspirin ec 81 mg tablet adult low dose 81 mg 3 DP
aspirin ec 81 mg tablet low dose 81 mg 3 DP
aspirin ec 81 mg tablet low dose sfty coated 81 mg 3 DP
aspirin ec 81 mg tablet u-d,10x10 81 mg 3 DP
aspirin ec 81 mg tablet u-d,25x30 81 mg 3 DP
aspirin-dipyridamole oral capsule, er multiphase
12 hr 25-200 mg
1 MO
ASPIR-LOW EC 81 MG TABLET 81 MG 3 DP
BRILINTA ORAL TABLET 60 MG, 90 MG 2 MO
CHILD ASPIRIN 81 MG CHEW TAB
CHILDREN'S 81 MG
3 DP
cilostazol oral tablet 100 mg, 50 mg 1 MO
clopidogrel oral tablet 75 mg 1 MO
dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 PA; MO
gs aspirin 81 mg chewable tab 81 mg 3 DP
78
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
hm aspirin 81 mg chewable tab adlt low
dose,orange 81 mg
3 DP
hm aspirin ec 81 mg tablet 81 mg 3 DP
hm aspirin ec 81 mg tablet low dose 81 mg 3 DP
prasugrel oral tablet 10 mg, 5 mg 1 MO
qc aspirin 81 mg chewable tab low dose, orange
81 mg
3 DP
qc aspirin ec 81 mg tablet 81 mg 3 DP
sb aspirin ec 81 mg tablet adult low strength 81
mg
3 DP
sb aspirin ec 81 mg tablet low dose,sfty coated 81
mg
3 DP
sm aspirin 81 mg chewable tab adult low strength
81 mg
3 DP
sm aspirin ec 81 mg tablet adult low strength 81
mg
3 DP
SM CHILD ASPIRIN 81 MG CHW TAB
CHILDREN'S 81 MG
3 DP
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 MO
clonidine transdermal patch weekly 0.1 mg/24 hr,
0.2 mg/24 hr, 0.3 mg/24 hr
1 MO
guanfacine oral tablet 1 mg, 2 mg 1 PA; MO
methyldopa oral tablet 250 mg, 500 mg 1 PA; MO
midodrine oral tablet 10 mg, 2.5 mg, 5 mg 1
NORTHERA ORAL CAPSULE 100 MG, 200
MG, 300 MG
2 MO
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 MO
phenoxybenzamine oral capsule 10 mg 1 PA
prazosin oral capsule 1 mg, 2 mg, 5 mg 1 MO
terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 MO
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 MO
79
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
losartan oral tablet 100 mg, 25 mg, 50 mg 1 MO
olmesartan oral tablet 20 mg, 40 mg, 5 mg 1 MO
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80
mg
1 MO
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 MO
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50
mg
1 MO
enalapril maleate oral tablet 10 mg, 2.5 mg, 20
mg, 5 mg
1 MO
fosinopril oral tablet 10 mg, 20 mg, 40 mg 1 MO
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg,
40 mg, 5 mg
1 MO
moexipril oral tablet 15 mg, 7.5 mg 1 MO
quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 MO
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5
mg
1 MO
trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 MO
ANTIARRHYTHMICS
amiodarone oral tablet 100 mg, 200 mg, 400 mg 1 MO
disopyramide phosphate oral capsule 100 mg, 150
mg
1 PA; MO
dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg 1 MO
flecainide oral tablet 100 mg, 150 mg, 50 mg 1 MO
mexiletine oral capsule 150 mg, 200 mg, 250 mg 1 MO
MULTAQ ORAL TABLET 400 MG 2 MO
NORPACE CR ORAL CAPSULE, EXTENDED
RELEASE 100 MG, 150 MG
2 PA; MO
propafenone oral tablet 150 mg, 225 mg, 300 mg 1 MO
quinidine gluconate oral tablet extended release
324 mg
1 MO
quinidine sulfate oral tablet 200 mg, 300 mg 1 MO
sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 MO
sotalol af oral tablet 120 mg, 160 mg, 80 mg 1 MO
80
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg 1 MO
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol oral capsule 200 mg, 400 mg 1 MO
atenolol oral tablet 100 mg, 25 mg, 50 mg 1 MO
betaxolol oral tablet 10 mg, 20 mg 1 MO
bisoprolol fumarate oral tablet 10 mg, 5 mg 1 MO
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20
MG, 5 MG
2 MO
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg,
6.25 mg
1 MO
labetalol oral tablet 100 mg, 200 mg, 300 mg 1 MO
metoprolol succinate oral tablet extended release
24 hr 100 mg, 200 mg, 25 mg, 50 mg
1 MO
metoprolol ta-hydrochlorothiaz oral tablet 100-25
mg, 100-50 mg, 50-25 mg
1 MO
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
1 MO
nadolol oral tablet 20 mg, 40 mg, 80 mg 1 MO
pindolol oral tablet 10 mg, 5 mg 1 MO
propranolol oral capsule,extended release 24 hr
120 mg, 160 mg, 60 mg, 80 mg
1 MO
propranolol oral solution 20 mg/5 ml (4 mg/ml),
40 mg/5 ml (8 mg/ml)
1 MO
propranolol oral tablet 10 mg, 20 mg, 40 mg, 60
mg, 80 mg
1 MO
timolol maleate oral tablet 10 mg, 20 mg, 5 mg 1 MO
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine oral tablet 10 mg, 2.5 mg, 5 mg 1 MO
cartia xt oral capsule,extended release 24hr 120
mg, 180 mg, 240 mg, 300 mg
1 MO
diltiazem hcl oral capsule,ext.rel 24h degradable
120 mg, 180 mg, 240 mg
1 MO
diltiazem hcl oral capsule,extended release 12 hr
120 mg, 60 mg, 90 mg
1 MO
diltiazem hcl oral capsule,extended release 24 hr
120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
1 MO
81
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
diltiazem hcl oral capsule,extended release 24hr
120 mg, 180 mg, 240 mg, 300 mg, 360 mg
1 MO
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90
mg
1 MO
dilt-xr oral capsule,ext.rel 24h degradable 120
mg, 180 mg, 240 mg
1 MO
felodipine oral tablet extended release 24 hr 10
mg, 2.5 mg, 5 mg
1 MO
isradipine oral capsule 2.5 mg, 5 mg 1 MO
nifedical xl oral tablet extended release 24hr 30
mg, 60 mg
1 MO
nifedipine oral capsule 10 mg, 20 mg 1 PA; MO
nifedipine oral tablet extended release 24hr 30 mg,
60 mg, 90 mg
1 MO
nifedipine oral tablet extended release 30 mg, 60
mg, 90 mg
1 MO
nimodipine oral capsule 30 mg 1
taztia xt oral capsule,extended release 24 hr 120
mg, 180 mg, 240 mg, 300 mg, 360 mg
1 MO
verapamil oral capsule, 24 hr er pellet ct 100 mg,
200 mg, 300 mg
1 MO
verapamil oral capsule,ext rel. pellets 24 hr 120
mg, 180 mg, 240 mg, 360 mg
1 MO
verapamil oral tablet 120 mg, 40 mg, 80 mg 1 MO
verapamil oral tablet extended release 120 mg (24
hours)
1
verapamil oral tablet extended release 120 mg,
180 mg, 240 mg
1 MO
CARDIOVASCULAR AGENTS, OTHER
amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 MO
amlodipine-benazepril oral capsule 10-20 mg, 10-
40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg
1 MO
amlodipine-olmesartan oral tablet 10-20 mg, 10-
40 mg, 5-20 mg, 5-40 mg
1 MO
amlodipine-valsartan oral tablet 10-160 mg, 10-
320 mg, 5-160 mg, 5-320 mg
1 MO
82
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
amlodipine-valsartan-hcthiazid oral tablet 10-160-
12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5
mg, 5-160-25 mg
1 MO
atenolol-chlorthalidone oral tablet 100-25 mg, 50-
25 mg
1 MO
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg
1 MO
bisoprolol-hydrochlorothiazide oral tablet 10-6.25
mg, 2.5-6.25 mg, 5-6.25 mg
1 MO
captopril-hydrochlorothiazide oral tablet 25-15
mg, 25-25 mg, 50-15 mg, 50-25 mg
1 MO
CORLANOR ORAL TABLET 5 MG, 7.5 MG 2 PA; MO
DEMSER ORAL CAPSULE 250 MG 2 PA
digitek oral tablet 125 mcg 1 MO; QL (30 EA per 30 days)
digitek oral tablet 250 mcg 1 PA; MO
digox oral tablet 125 mcg 1 MO; QL (30 EA per 30 days)
digox oral tablet 250 mcg 1 PA; MO
digoxin oral solution 50 mcg/ml 1 PA; MO
digoxin oral tablet 125 mcg 1 MO; QL (30 EA per 30 days)
digoxin oral tablet 250 mcg 1 PA; MO
enalapril-hydrochlorothiazide oral tablet 10-25
mg, 5-12.5 mg
1 MO
ENTRESTO ORAL TABLET 24-26 MG, 49-51
MG, 97-103 MG
2 MO
fosinopril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg
1 MO
irbesartan-hydrochlorothiazide oral tablet 150-
12.5 mg, 300-12.5 mg
1 MO
lisinopril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 20-25 mg
1 MO
losartan-hydrochlorothiazide oral tablet 100-12.5
mg, 100-25 mg, 50-12.5 mg
1 MO
methyldopa-hydrochlorothiazide oral tablet 250-
15 mg, 250-25 mg
1 PA; MO
moexipril-hydrochlorothiazide oral tablet 15-12.5
mg, 15-25 mg, 7.5-12.5 mg
1 MO
83
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
olmesartan-amlodipin-hcthiazid 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
1 MO
olmesartan-hydrochlorothiazide oral tablet 20-
12.5 mg, 40-12.5 mg, 40-25 mg
1 MO
pentoxifylline oral tablet extended release 400 mg 1 MO
propranolol-hydrochlorothiazid oral tablet 40-25
mg, 80-25 mg
1 MO
quinapril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 20-25 mg
1 MO
RANEXA ORAL TABLET EXTENDED
RELEASE 12 HR 1,000 MG, 500 MG
2 ST; MO
spironolacton-hydrochlorothiaz oral tablet 25-25
mg
1 MO
TEKTURNA HCT ORAL TABLET 150-12.5
MG, 150-25 MG, 300-12.5 MG, 300-25 MG
2 MO
TEKTURNA ORAL TABLET 150 MG, 300 MG 2 MO
triamterene-hydrochlorothiazid oral capsule 37.5-
25 mg
1 MO
triamterene-hydrochlorothiazid oral tablet 37.5-25
mg, 75-50 mg
1 MO
valsartan-hydrochlorothiazide oral tablet 160-12.5
mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5
mg
1 MO
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide oral capsule, extended release 500
mg
1 MO
acetazolamide oral tablet 125 mg, 250 mg 1 MO
KEVEYIS ORAL TABLET 50 MG 2 PA; MO
methazolamide oral tablet 25 mg, 50 mg 1 MO
DIURETICS, LOOP
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1 MO
furosemide injection solution 10 mg/ml 1
furosemide injection syringe 10 mg/ml 1
furosemide oral solution 10 mg/ml, 40 mg/5 ml (8
mg/ml)
1 MO
84
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
furosemide oral tablet 20 mg, 40 mg, 80 mg 1 MO
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 1 MO
DIURETICS, POTASSIUM-SPARING
amiloride oral tablet 5 mg 1 MO
eplerenone oral tablet 25 mg, 50 mg 1 MO
spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 MO
DIURETICS, THIAZIDE
chlorothiazide oral tablet 250 mg, 500 mg 1 MO
chlorthalidone oral tablet 25 mg, 50 mg 1 MO
hydrochlorothiazide oral capsule 12.5 mg 1 MO
hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50
mg
1 MO
indapamide oral tablet 1.25 mg, 2.5 mg 1 MO
methyclothiazide oral tablet 5 mg 1 MO
metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1 MO
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
fenofibrate micronized oral capsule 134 mg, 200
mg, 43 mg, 67 mg
1 MO
fenofibrate nanocrystallized oral tablet 145 mg,
160 mg, 48 mg
1 MO
fenofibrate oral tablet 160 mg, 54 mg 1 MO
fenofibric acid (choline) oral capsule,delayed
release(dr/ec) 135 mg, 45 mg
1 MO
fenofibric acid oral tablet 35 mg 1 MO
gemfibrozil oral tablet 600 mg 1 MO
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80
mg
1 MO
LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG 2 MO
lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 MO
pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80
mg
1 MO
rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5
mg
1 MO
85
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg,
80 mg
1 MO
DYSLIPIDEMICS, OTHER
cholestyramine (with sugar) oral powder 4 gram 1 MO
cholestyramine (with sugar) oral powder in packet
4 gram
1 MO
cholestyramine light oral powder 4 gram 1 MO
cholestyramine light oral powder in packet 4 gram 1 MO
colesevelam oral powder in packet 3.75 gram 1 MO
colesevelam oral tablet 625 mg 1 MO
colestipol oral granules 5 gram 1 MO
colestipol oral packet 5 gram 1 MO
colestipol oral tablet 1 gram 1 MO
ezetimibe oral tablet 10 mg 1 MO
ezetimibe-simvastatin oral tablet 10-10 mg, 10-20
mg, 10-40 mg, 10-80 mg
1 MO
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30
MG, 40 MG, 5 MG, 60 MG
2 PA; MO
KYNAMRO SUBCUTANEOUS SYRINGE 200
MG/ML
2 PA; MO
niacin 500 mg tablet 500 mg 3 DP
niacin oral tablet extended release 24 hr 1,000 mg,
500 mg, 750 mg
1 MO
niacin tr 500 mg caplet caplet 500 mg 3 DP
niacin tr 500 mg capsule 500 mg 3 DP
niacinamide 500 mg tablet 500 mg 3 DP
omega-3 acid ethyl esters oral capsule 1 gram 1 MO
prevalite oral powder 4 gram 1 MO
prevalite oral powder in packet 4 gram 1 MO
REPATHA PUSHTRONEX SUBCUTANEOUS
WEARABLE INJECTOR 420 MG/3.5 ML
2 PA; MO
REPATHA SURECLICK SUBCUTANEOUS
PEN INJECTOR 140 MG/ML
2 PA; MO
86
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
REPATHA SYRINGE SUBCUTANEOUS
SYRINGE 140 MG/ML
2 PA; MO
TRIKLO ORAL CAPSULE 1 GRAM 1 MO
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50
mg
1 MO
minoxidil oral tablet 10 mg, 2.5 mg 1 MO
VASODILATORS, DIRECT-ACTING ARTERIAL/ VENOUS
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30
mg, 5 mg
1 MO
isosorbide dinitrate oral tablet extended release 40
mg
1 MO
isosorbide mononitrate oral tablet 10 mg, 20 mg 1 MO
isosorbide mononitrate oral tablet extended
release 24 hr 120 mg, 30 mg, 60 mg
1 MO
NITRO-BID TRANSDERMAL OINTMENT 2 % 2 MO
NITRO-DUR TRANSDERMAL PATCH 24
HOUR 0.3 MG/HR, 0.8 MG/HR
2 MO
nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6
mg
1 MO
nitroglycerin transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
1 MO
nitroglycerin translingual aerosol,spray 400
mcg/spray
1 MO
nitroglycerin translingual spray,non-aerosol 400
mcg/spray
1 MO
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
dextroamphetamine oral capsule, extended release
10 mg
1 PA; MO; QL (150 EA per 30 days)
dextroamphetamine oral capsule, extended release
15 mg
1 PA; MO; QL (120 EA per 30 days)
dextroamphetamine oral capsule, extended release
5 mg
1 PA; MO; QL (90 EA per 30 days)
dextroamphetamine oral tablet 10 mg 1 PA; MO; QL (180 EA per 30 days)
dextroamphetamine oral tablet 5 mg 1 PA; MO; QL (60 EA per 30 days)
87
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15 mg, 20
mg, 25 mg, 30 mg, 5 mg
1 PA; MO; QL (30 EA per 30 days)
dextroamphetamine-amphetamine oral tablet 10
mg, 20 mg, 30 mg, 5 mg, 7.5 mg
1 PA; MO; QL (60 EA per 30 days)
dextroamphetamine-amphetamine oral tablet 12.5
mg
1 PA; MO; QL (120 EA per 30 days)
dextroamphetamine-amphetamine oral tablet 15
mg
1 PA; MO; QL (90 EA per 30 days)
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-
AMPHETAMINES
atomoxetine oral capsule 10 mg, 100 mg, 18 mg,
25 mg, 40 mg, 60 mg, 80 mg
1 MO
clonidine hcl oral tablet extended release 12 hr 0.1
mg
1 MO; QL (120 EA per 30 days)
dexmethylphenidate oral capsule,er biphasic 50-
50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40
mg, 5 mg
1 PA; MO
dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5
mg
1 PA; MO
guanfacine oral tablet extended release 24 hr 1
mg, 2 mg, 3 mg, 4 mg
1 MO
methylphenidate hcl oral capsule, er biphasic 30-
70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg
1 PA; MO
methylphenidate hcl oral capsule,er biphasic 50-
50 20 mg, 30 mg, 40 mg, 60 mg
1 PA; MO
methylphenidate hcl oral solution 10 mg/5 ml, 5
mg/5 ml
1 PA; MO
methylphenidate hcl oral tablet 10 mg, 20 mg, 5
mg
1 PA; MO
methylphenidate hcl oral tablet extended release
10 mg
1 PA; MO
methylphenidate hcl oral tablet extended release
20 mg
1 PA; MO; QL (90 EA per 30 days)
methylphenidate hcl oral tablet extended release
24hr 18 mg
1 PA; MO; QL (120 EA per 30 days)
methylphenidate hcl oral tablet extended release
24hr 27 mg
1 PA; MO; QL (90 EA per 30 days)
88
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
methylphenidate hcl oral tablet extended release
24hr 36 mg
1 PA; MO; QL (60 EA per 30 days)
methylphenidate hcl oral tablet extended release
24hr 54 mg
1 PA; MO; QL (30 EA per 30 days)
methylphenidate hcl oral tablet,chewable 10 mg,
2.5 mg, 5 mg
1 PA; MO
CENTRAL NERVOUS SYSTEM, OTHER
AUSTEDO ORAL TABLET 12 MG, 6 MG, 9
MG
2 PA; MO
FIRDAPSE ORAL TABLET 10 MG 2 PA
INGREZZA ORAL CAPSULE 40 MG, 80 MG 2 PA; MO
NUEDEXTA ORAL CAPSULE 20-10 MG 2 PA
riluzole oral tablet 50 mg 1 MO
tetrabenazine oral tablet 12.5 mg, 25 mg 1 PA; MO
FIBROMYALGIA AGENTS
duloxetine oral capsule,delayed release(dr/ec) 20
mg, 30 mg, 60 mg
1 MO
SAVELLA ORAL TABLET 100 MG, 12.5 MG,
25 MG, 50 MG
2 MO
SAVELLA ORAL TABLETS,DOSE PACK 12.5
MG (5)-25 MG(8)-50 MG(42)
2
MULTIPLE SCLEROSIS AGENTS
AUBAGIO ORAL TABLET 14 MG, 7 MG 2 PA; MO
BETASERON SUBCUTANEOUS KIT 0.3 MG 2 PA; MO
BETASERON SUBCUTANEOUS RECON
SOLN 0.3 MG
2 PA
dalfampridine oral tablet extended release 12 hr
10 mg
1 PA; MO
EXTAVIA SUBCUTANEOUS RECON SOLN
0.3 MG
2 PA; MO
GILENYA ORAL CAPSULE 0.5 MG 2 PA; MO
glatiramer subcutaneous syringe 20 mg/ml, 40
mg/ml
1 PA; MO
GLATOPA SUBCUTANEOUS SYRINGE 20
MG/ML, 40 MG/ML
1 PA; MO
89
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
REBIF (WITH ALBUMIN) SUBCUTANEOUS
SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML
2 PA; MO
REBIF REBIDOSE SUBCUTANEOUS PEN
INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML
2 PA; MO
REBIF REBIDOSE SUBCUTANEOUS PEN
INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)
2 PA
REBIF TITRATION PACK SUBCUTANEOUS
SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)
2 PA
TECFIDERA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)- 240 MG (46)
2 PA
TECFIDERA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG, 240 MG
2 PA; MO
DENTAL AND ORAL AGENTS
DENTAL AND ORAL AGENTS
cevimeline oral capsule 30 mg 1 MO
chlorhexidine gluconate mucous membrane
mouthwash 0.12 %
1
periogard mucous membrane mouthwash 0.12 % 1
pilocarpine hcl oral tablet 5 mg, 7.5 mg 1 MO
triamcinolone acetonide dental paste 0.1 % 1
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS
acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 PA
ACNE MEDICATION 10% GEL 10 % 3 DP
ACNE MEDICATION 5% GEL 5 % 3 DP
adapalene topical gel 0.1 % 1
adapalene-benzoyl peroxide topical gel with pump
0.1-2.5 %
1
ammonium lactate topical cream 12 % 1
ammonium lactate topical lotion 12 % 1
AMNESTEEM ORAL CAPSULE 10 MG, 20
MG, 40 MG
1
benzoyl peroxide 10% gel aqueous (otc) 10 % 3 DP
calcipotriene scalp solution 0.005 % 1
90
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
calcipotriene topical cream 0.005 % 1
calcipotriene topical ointment 0.005 % 1
CLARAVIS ORAL CAPSULE 10 MG, 20 MG,
30 MG, 40 MG
1
clindamycin-benzoyl peroxide topical gel 1-5 %,
1.2 %(1 % base) -5 %
1
clindamycin-benzoyl peroxide topical gel with
pump 1-5 %, 1.2-2.5 %
1
clotrimazole-betamethasone topical cream 1-0.05
%
1
clotrimazole-betamethasone topical lotion 1-0.05
%
1
COLEMAN BOTANICALS INSECT SPR 30 % 3 DP
COLEMAN HIGH-DRY 25% REPEL SPR 25 % 3 DP
COLEMAN SKINSMART INSECT REP 20 % 3 DP
COLEMAN SKINSMART INSECT REP 20 % 3 DP
COLEMAN SPORTSMN 40% REPEL SPR 40 % 3 DP
COSENTYX (2 SYRINGES) SUBCUTANEOUS
SYRINGE 150 MG/ML
2 PA; MO
COSENTYX PEN (2 PENS) SUBCUTANEOUS
PEN INJECTOR 150 MG/ML
2 PA; MO
COSENTYX PEN SUBCUTANEOUS PEN
INJECTOR 150 MG/ML
2 PA; MO
COSENTYX SUBCUTANEOUS SYRINGE 150
MG/ML
2 PA; MO
CUTTER BACKWOODS 25% SPRAY 25 % 3 DP
CUTTER BACKWOODS 25% SPRAY 25 % 3 DP
CUTTER BACKWOODS DRY 25% SPRAY 25
%
3 DP
CUTTER LEMON EUCALYPTUS SPRAY 30 % 3 DP
CUTTER NATURAL REPELLENT2 SPRY 5-2
%
3 DP
CUTTER SKINSATIONS 7% SPRAY 7 % 3 DP
CVS INSECT REPELLENT 15% SPRAY 15 % 3 DP
CVS TOTAL HOME INSECT 30% SPR 30 % 3 DP
DOXEPIN TOPICAL CREAM 5 % 1 MO
91
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
DUPIXENT SUBCUTANEOUS SYRINGE 200
MG/1.14 ML, 300 MG/2 ML
2 PA; MO
ELIDEL TOPICAL CREAM 1 % 2 ST
erythromycin-benzoyl peroxide topical gel 3-5 % 1
EUCRISA TOPICAL OINTMENT 2 % 2 PA
GS ANTI-ITCH 1% CREAM 1 % 3 DP
HYDRO SKIN 1% LOTION 1 % 3 DP
hydrocortisone 1% cream 1 % 3 DP
hydrocortisone-min oil-wht pet topical ointment 1
%
1
imiquimod topical cream in packet 5 % 1
isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40
mg
1
methoxsalen oral capsule,liqd-filled,rapid rel 10
mg
1 PA
myorisan oral capsule 10 mg, 20 mg, 30 mg, 40
mg
1
NATRAPEL 20% SPRAY 20 % 3 DP
nystatin-triamcinolone topical cream 100,000-0.1
unit/g-%
1
nystatin-triamcinolone topical ointment 100,000-
0.1 unit/gram-%
1
OFF ACTIVE 15% SPRAY 15 % 3 DP
OFF DEEP WOODS 25% SPRAY 25 % 3 DP
OFF DEEP WOODS 25% SPRAY 25 % 3 DP
OFF DEEP WOODS DRY 25% SPRAY 25 % 3 DP
OFF DEEP WOODS SPORTMN 25% SPR 25 % 3 DP
OFF DEEP WOODS SPORTMN 30% SPR 30 % 3 DP
OFF DEEP WOODS SPORTMN 98.25% 98.25 % 3 DP
OFF FAMILYCARE 15% RPLNT I SPR 15 % 3 DP
OFF FAMILYCARE 5% RPLNT II SPR 5 % 3 DP
OFF FAMILYCARE 7% RPLNT SPRAY 7 % 3 DP
pimecrolimus topical cream 1 % 1 ST
podofilox topical solution 0.5 % 1
92
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
prednicarbate topical cream 0.1 % 1
prednicarbate topical ointment 0.1 % 1
REGRANEX TOPICAL GEL 0.01 % 2 PA; QL (15 GM per 30 days)
REPEL 100 98.11% SPRAY 98.11 % 3 DP
REPEL FAMILY 10% SPRAY 10 % 3 DP
REPEL FAMILY 15% SPRAY 15 % 3 DP
REPEL HUNTER'S 25% SPRAY 25 % 3 DP
REPEL LEMON EUCALYPTUS 30% SPR 30 % 3 DP
REPEL SPORTSMEN 25% SPRAY 25 % 3 DP
REPEL SPORTSMEN DRY 25% SPRAY 25 % 3 DP
REPEL SPORTSMEN MAX 40% LOTION 40 % 3 DP
REPEL SPORTSMEN MAX 40% SPRAY 40 % 3 DP
REPEL SPORTSMEN MAX 40% SPRAY 40 % 3 DP
REPEL TICK DEFENSE 15% SPRAY 15 % 3 DP
SANTYL TOPICAL OINTMENT 250
UNIT/GRAM
2
selenium sulfide topical lotion 2.5 % 1
STELARA SUBCUTANEOUS SOLUTION 45
MG/0.5 ML
2 PA; MO
STELARA SUBCUTANEOUS SYRINGE 45
MG/0.5 ML, 90 MG/ML
2 PA; MO
tacrolimus topical ointment 0.03 %, 0.1 % 1 ST
tazarotene topical cream 0.1 % 1
TAZORAC TOPICAL CREAM 0.05 % 2
TAZORAC TOPICAL GEL 0.05 %, 0.1 % 2
TREMFYA SUBCUTANEOUS SYRINGE 100
MG/ML
2 PA; MO
tretinoin (emollient) topical cream 0.05 % 1
tretinoin topical cream 0.025 %, 0.05 %, 0.1 % 1
tretinoin topical gel 0.01 %, 0.025 % 1
ULTRATHON 25% REPELLENT SPRAY 25 % 3 DP
ULTRATHON 34.34% REPEL LOTION 34.34 % 3 DP
ZENATANE ORAL CAPSULE 10 MG, 20 MG,
30 MG, 40 MG
1
93
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
zinc oxide 20% ointment 20 % 3 DP
ELECTROLYTES/MINERALS/ METALS/ VITAMINS
ELECTROLYTE/MINERAL REPLACEMENT
AMINOSYN 7 % WITH ELECTROLYTES
INTRAVENOUS PARENTERAL SOLUTION 7
%
2 B/D
aminosyn 8.5 %-electrolytes intravenous
parenteral solution 8.5 %
1 B/D
AMINOSYN II 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
2 B/D
AMINOSYN II 15 % INTRAVENOUS
PARENTERAL SOLUTION 15 %
2 B/D
AMINOSYN II 8.5 % INTRAVENOUS
PARENTERAL SOLUTION 8.5 %
2 B/D
aminosyn ii 8.5 %-electrolytes intravenous
parenteral solution 8.5 %
1 B/D
AMINOSYN-HBC 7% INTRAVENOUS
PARENTERAL SOLUTION 7 %
2 B/D
AMINOSYN-PF 10 % INTRAVENOUS
PARENTERAL SOLUTION 10 %
2 B/D
AMINOSYN-PF 7 % (SULFITE-FREE)
INTRAVENOUS PARENTERAL SOLUTION 7
%
2 B/D
AMINOSYN-RF 5.2 % INTRAVENOUS
PARENTERAL SOLUTION 5.2 %
2 B/D
AQUADEKS PEDIATRIC LIQUID 400
MCG/ML
3 DP
BALANCED B-50 TABLET 3 DP
biotin 300 mcg tablet s/f,p/f,lactose-free 300 mcg 3 DP
biotin 5 mg tablet 5 mg 3 DP
CALCITRATE 200 MG (950 MG) TAB 200 MG
(950 MG)
3 DP
calcium 600 mg tablet 600 mg calcium (1,500 mg) 3 DP
CALCIUM 600 MG TABLET 600 MG
CALCIUM (1,500 MG)
3 DP
CALCIUM 600-VIT D3 200 TABLET 600
MG(1,500MG) -200 UNIT
3 DP
94
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
calcium carb 1,250 mg/5 ml sus 40's,u-d,a/f 500
mg/5 ml (1,250 mg/5 ml)
3 DP
calcium carb 1,250 mg/5 ml sus 500 mg/5 ml
(1,250 mg/5 ml)
3 DP
calcium carb 1,250 mg/5 ml sus s/f, a/f, na/f 500
mg/5 ml (1,250 mg/5 ml)
3 DP
calcium carb 500 (1,250) mg tb 500 mg calcium
(1,250 mg)
3 DP
calcium carbonate 1.25 gm tab 500 mg calcium
(1,250 mg)
3 DP
calcium carbonate 648 mg tab 260 mg calcium
(648 mg)
3 DP
calcium gluconate 500 mg tab 45 mg (500 mg) 3 DP
CARBAGLU ORAL TABLET, DISPERSIBLE
200 MG
2 PA; MO
CERTAVITE SR-ANTIOXIDANT TAB 0.4-300-
250 MG-MCG-MCG
3 DP
CHILD CHEW + IRON TAB CHEW 3 DP
CHILD CHEW VITAMIN TABLET 3 DP
child ferrous sulfate 15 mg/ml 15 mg iron (75
mg)/ml
3 DP
clinimix 4.25%/d10w sulf free intravenous
parenteral solution 4.25 %
1 B/D
clinimix 4.25%-d25w sulf-free intravenous
parenteral solution 4.25 %
1 B/D
clinisol sf 15 % intravenous parenteral solution 15
%
1 B/D
d10 %-0.45 % sodium chloride intravenous
parenteral solution
1
d2.5 %-0.45 % sodium chloride intravenous
parenteral solution
1
d5 % and 0.9 % sodium chloride intravenous
parenteral solution
1
d5 %-0.45 % sodium chloride intravenous
parenteral solution
1
DEKAS ESSENTIAL CAPSULE 2,000 UNIT-
2000 UNIT-1,000 MCG
3 DP
95
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
DEKAS ESSENTIAL LIQUID 2,000 UNIT-
2,000 MCG/ML
3 DP
DEKAS PLUS CHEWABLE TABLET 200
MCG-1,000 MCG-10 MG
3 DP
DEKAS PLUS LIQUID 500 MCG/ML 3 DP
DEKAS PLUS SOFTGEL 200 MCG-1,000 MCG-
10 MG
3 DP
dextrose 10 % and 0.2 % nacl intravenous
parenteral solution
1
dextrose 10 % in water (d10w) intravenous
parenteral solution 10 %
1
dextrose 5 % in water (d5w) intravenous
parenteral solution
1
dextrose 5 % in water (d5w) intravenous
piggyback 5 %
1
dextrose 5%-0.2 % sod chloride intravenous
parenteral solution
1
dextrose 5%-0.3 % sod.chloride intravenous
parenteral solution
1
DEXTROSE WITH SODIUM CHLORIDE
INTRAVENOUS PARENTERAL SOLUTION 5-
0.2 %
1
ELDERTONIC ELIXIR 0.5-0.6-7-0.7 MG 3 DP
ENDARI ORAL POWDER IN PACKET 5
GRAM
2 PA
FERGON 27 MG TABLET 240 MG (27 MG
IRON)
3 DP
FER-IN-SOL 15 MG/ML DROPS 15 MG IRON
(75 MG)/ML
3 DP
FEROSUL 220 MG/5 ML ELIXIR 220 MG (44
MG IRON)/5 ML
3 DP
FEROSUL 325 MG TABLET F/C 325 MG (65
MG IRON)
3 DP
FEROSUL 325 MG TABLET F/C,BLISTER
PACK 325 MG (65 MG IRON)
3 DP
FERRO-TIME 325 MG TABLET F/C, GREEN
325 MG (65 MG IRON)
3 DP
96
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ferrous fumarate 324 mg tab 324 mg (106 mg
iron)
3 DP
ferrous gluconate 324 mg tab 324 mg (37.5 mg
iron), 324 mg (38 mg iron)
3 DP
ferrous sulf 15 mg iron/ml drp 15 mg iron (75
mg)/ml
3 DP
ferrous sulf 15 mg iron/ml drp gluten-free 15 mg
iron (75 mg)/ml
3 DP
ferrous sulf 220 mg/5 ml elix 220 mg (44 mg
iron)/5 ml
3 DP
ferrous sulf 220 mg/5 ml liq 220 mg (44 mg iron)/5
ml
3 DP
ferrous sulf 300 mg/5 ml liq 300 mg (60 mg iron)/5
ml
3 DP
ferrous sulf ec 324 mg tablet 324 mg (65 mg iron) 3 DP
ferrous sulf ec 325 mg tablet 325 mg (65 mg iron) 3 DP
ferrous sulf ec 325 mg tablet u-d, inner 325 mg (65
mg iron)
3 DP
ferrous sulf ec 325 mg tablet u-d, outer 325 mg (65
mg iron)
3 DP
ferrous sulfate 325 mg tablet 325 mg (65 mg iron) 3 DP
ferrous sulfate 325 mg tablet f/c 325 mg (65 mg
iron)
3 DP
ferrous sulfate 325 mg tablet f/c, green 325 mg (65
mg iron)
3 DP
ferrous sulfate 325 mg tablet f/c, red 325 mg (65
mg iron)
3 DP
ferrous sulfate 325 mg tablet u-d,10x10, film coat
325 mg (65 mg iron)
3 DP
FERROUSUL 325 MG TABLET 325 MG (65
MG IRON)
3 DP
FLUORIDE (SODIUM) ORAL TABLET 1 MG
(2.2 MG SOD. FLUORIDE)
1
folic acid 1 mg tablet (rx) 1 mg 3 MO; DP
folic acid 1 mg tablet 10x10, u-d, inner (rx) 1 mg 3 MO; DP
folic acid 1 mg tablet inner,u-d,robot-rdy (rx) 1 mg 3 MO; DP
folic acid 1 mg tablet outer,u-d,robot-rdy (rx) 1 mg 3 MO; DP
97
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
folic acid 1 mg tablet u-d,inner,10x10 (rx) 1 mg 3 MO; DP
folic acid 1 mg tablet u-d,outer,10x10 (rx) 1 mg 3 MO; DP
folic acid 400 mcg tablet 400 mcg 3 DP
folic acid 400 mcg tablet s/f,p/f,lactose-free 400
mcg
3 DP
folic acid 5 mg/ml vial latex-free, mdv 5 mg/ml 3 DP
HEMOCYTE TABLET 324 MG (106 MG IRON) 3 DP
hydroxocobalamin 1,000 mcg/ml 1,000 mcg/ml 3 DP
ICAPS MV TABLET 100-1.66-0.83 MCG-MG-
MG
3 DP
IFEREX 150 CAPSULE 150 MG IRON 3 DP
INFED 100 MG/2 ML VIAL
10S,OUTER,L/F,SDV 50 MG/ML
3 DP
intralipid intravenous emulsion 20 % 2 B/D
INTRALIPID INTRAVENOUS EMULSION 30
%
2 B/D
IRON 325 MG TABLET 325 MG (65 MG IRON) 3 DP
ISOLYTE S PH 7.4 INTRAVENOUS
PARENTERAL SOLUTION
2
ISOLYTE-P IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL SOLUTION 5
%
2
ISOLYTE-S INTRAVENOUS PARENTERAL
SOLUTION
2
klor-con 10 oral tablet extended release 10 meq 1 MO
klor-con 8 oral tablet extended release 8 meq 1 MO
klor-con m10 oral tablet,er particles/crystals 10
meq
1 MO
KLOR-CON M15 ORAL TABLET,ER
PARTICLES/CRYSTALS 15 MEQ
2 MO
klor-con m20 oral tablet,er particles/crystals 20
meq
1 MO
KLOR-CON SPRINKLE ORAL CAPSULE,
EXTENDED RELEASE 10 MEQ, 8 MEQ
1 MO
K-SOL ORAL LIQUID 20 MEQ/15 ML 1 MO
98
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
levocarnitine (with sugar) oral solution 100 mg/ml 1 MO
levocarnitine oral tablet 330 mg 1 MO
MAG64 DR 64 MG TABLET 64 MG 3 DP
MAGNEBIND 300 TABLET 250-300 MG 3 DP
magnesium 250 mg tablet 250 mg 3 DP
magnesium oxide 400 mg tablet 400 mg (241.3 mg
magnesium)
3 DP
magnesium oxide 400 mg tablet p/f,soy-free 400
mg (241.3 mg magnesium)
3 DP
magnesium oxide 400 mg tablet s/f,p/f,gluten-free
400 mg (241.3 mg magnesium)
3 DP
magnesium oxide 420 mg tablet 420 mg 3 DP
magnesium oxide 500 mg tablet p/f,s/f,lactose-free
500 mg
3 DP
magnesium sulfate injection solution 4 meq/ml (50
%)
1
MERIBIN 5 MG CAPSULE 5 MG 3 DP
NASCOBAL 500 MCG NASAL SPRAY OUTER
500 MCG/SPRAY
3 MO; DP
normosol-r intravenous parenteral solution 1
normosol-r ph 7.4 intravenous parenteral solution 1
NU-MAG 71.5 MG TABLET 71.5 MG 3 DP
OCUVITE WITH LUTEIN TABLET 1,000
UNIT-200 MG-60 UNIT-2 MG
3 DP
ONCOVITE TABLET 3 DP
ONE DAILY TABLET 3 DP
ONE DAILY TABLET MEN'S FORMULA 3 DP
OS-CAL 500-VIT D3 600 CAPLET 500MG
(1,250MG) -600 UNIT
3 DP
OYSCO-500 TABLET 500 MG CALCIUM
(1,250 MG)
3 DP
OYSTER SHELL CALCIUM 500 MG
CAPLET,P/F,SOY-FREE 500 MG CALCIUM
(1,250 MG)
3 DP
OYSTER SHELL CALCIUM 500 MG TB 500
MG CALCIUM (1,250 MG)
3 DP
99
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
OYSTER SHELL CALCIUM 500 MG TB
500MG ELEMENTAL 500 MG CALCIUM
(1,250 MG)
3 DP
OYSTER SHELL CALCIUM 500 MG TB
500MG ELEMENTAL CA 500 MG CALCIUM
(1,250 MG)
3 DP
PEDIALYTE ELECTROLYTE SINGLES 4'S 3 DP
PEDIALYTE FREEZER POPS 3 DP
PEDIALYTE SOLUTION 3 DP
PEDIALYTE SOLUTION READY-TO-USE 3 DP
plenamine intravenous parenteral solution 15 % 1 B/D
POLY-VI-SOL DROPS 750-35-400 UNIT-MG-
UNIT/ML
3 DP
POLY-VI-SOL WITH IRON DROPS 750 UNIT-
400 UNIT-10 MG/ML
3 DP
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 20 meq/l
1
potassium chloride in water intravenous
piggyback 40 meq/100 ml
1
potassium chloride oral capsule, extended release
10 meq, 8 meq
1 MO
potassium chloride oral liquid 20 meq/15 ml, 40
meq/15 ml
1 MO
potassium chloride oral tablet extended release 10
meq, 20 meq, 8 meq
1 MO
potassium chloride oral tablet,er particles/crystals
10 meq, 20 meq
1 MO
potassium citrate oral tablet extended release 10
meq (1,080 mg), 15 meq, 5 meq (540 mg)
1 MO
PROSIGHT TABLET 5,000-60-30 UNIT-MG-
UNIT
3 DP
SM CALCIUM 500-VIT D3 400 TAB 500
MG(1,250MG) -400 UNIT
3 DP
sod fer gluc cplx 62.5 mg/5 ml 10's,sdv,outer 62.5
mg/5 ml
3 DP
sod fer gluc cplx 62.5 mg/5 ml sdv,inner 62.5 mg/5
ml
3 DP
100
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
sod fer gluc cplx 62.5 mg/5 ml sdv,outer 62.5 mg/5
ml
3 DP
sodium bicarb 10 grain tablet 650 mg 3 DP
sodium bicarb 650 mg tablet 10 gr 650 mg 3 DP
sodium chloride 0.45 % intravenous parenteral
solution 0.45 %
1
sodium chloride 0.9 % injection solution 1
sodium chloride 0.9 % intravenous parenteral
solution
1
sodium chloride 0.9 % intravenous piggyback 1
sodium chloride 1,000 mg tab inner 1,000 mg 3 DP
sodium chloride 1,000 mg tab outer 1,000 mg 3 DP
sodium chloride 3 % intravenous parenteral
solution 3 %
1
sodium chloride irrigation solution 0.9 % 1
STRESS FORMULA WITH IRON TAB 500 MG-
400 MCG- 18 MG IRON
3 DP
STRESS FORMULA WITH ZINC TAB 3 DP
THERA M PLUS TABLET 9 MG IRON-400
MCG
3 DP
TOTAL B WITH VIT C CAPLET 3 DP
TRI-VI-SOL DROPS 750 UNIT-35 MG -400
UNIT/ML
3 DP
VENOFER 200 MG/10 ML VIAL 200 MG
IRON/10 ML
3 DP
VENOFER 50 MG/2.5 ML VIAL 10'S,SDV,P/F
50 MG IRON/2.5 ML
3 DP
VITA-BEE WITH C TABLET 3 DP
ELECTROLYTE/MINERAL/METAL MODIFIERS
biotin 5,000 mcg capsule mx-str 5 mg 3 DP
biotin 5,000 mcg softgel s/f, p/f,gluten-free 5 mg 3 DP
EXJADE ORAL TABLET, DISPERSIBLE 125
MG, 250 MG, 500 MG
2 PA; MO
FERRIPROX ORAL TABLET 500 MG 2 PA
FERRLECIT 62.5 MG/5 ML VIAL 10'S,SUV,NO
LATEX 62.5 MG/5 ML
3 DP
101
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
FERRLECIT 62.5 MG/5 ML VIAL LATEX-
FREE, SUV 62.5 MG/5 ML
3 DP
JADENU ORAL TABLET 180 MG, 360 MG, 90
MG
2 PA; MO
JADENU SPRINKLE ORAL GRANULES IN
PACKET 180 MG, 360 MG, 90 MG
2 PA; MO
JYNARQUE ORAL TABLETS, SEQUENTIAL
45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG
(PM), 90 MG (AM)/ 30 MG (PM)
2 PA; MO
kionex (with sorbitol) oral suspension 15-19.3
gram/60 ml
1
kionex oral powder 1
SAMSCA ORAL TABLET 15 MG, 30 MG 2
sodium polystyrene (sorb free) oral suspension 15
gram/60 ml
1
sodium polystyrene sulfonate oral powder 1
sodium polystyrene sulfonate oral suspension 15
gram/60 ml
1
sodium polystyrene sulfonate rectal enema 30
gram/120 ml, 50 gram/200 ml
1
sps (with sorbitol) oral suspension 15-20 gram/60
ml
1
sps (with sorbitol) rectal enema 30-40 gram/120
ml
1
trientine oral capsule 250 mg 1 PA
VENOFER 100 MG/5 ML VIAL 10'S,SDV,P/F
100 MG IRON/5 ML
3 DP
VENOFER 100 MG/5 ML VIAL 25'S,SDV,P/F
100 MG IRON/5 ML
3 DP
VENOFER 100 MG/5 ML VIAL LATEX-
FREE,SUV,P/F 100 MG IRON/5 ML
3 DP
PHOSPHATE BINDERS
calcium acetate oral capsule 667 mg 1 MO
FOSRENOL ORAL POWDER IN PACKET
1,000 MG, 750 MG
2 MO
lanthanum oral tablet,chewable 1,000 mg, 500 mg,
750 mg
1 MO
102
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
sevelamer carbonate oral powder in packet 0.8
gram, 2.4 gram
1 MO
sevelamer carbonate oral tablet 800 mg 1 MO
VITAMINS
ANIMAL SHAPES TABLET CHEW
CHILDREN'S
3 DP
BALANCED B-100 TABLET 100 MG 3 DP
B-COMPLEX WITH B12 TABLET 3 DP
CALCITRATE + VIT D CAPLET 315-250 MG-
UNIT
3 DP
calcitriol oral capsule 0.25 mcg, 0.5 mcg 1 MO
calcitriol oral solution 1 mcg/ml 1 MO
calcitriol topical ointment 3 mcg/gram 1
calcium 500 mg chewable tablet p/f,s/f,gluten-f
500-100 mg-unit
3 DP
calcium 500+d tablet chew 500 mg(1,250mg) -400
unit
3 DP
calcium 600-vit d3 400 tablet 600 mg(1,500mg) -
400 unit
3 DP
CERTAVITE-ANTIOXIDANT TABLET 18-400
MG-MCG
3 DP
cyanocobalamin 1,000 mcg/ml 25's, latex-free,suv
1,000 mcg/ml
3 MO; DP
cyanocobalamin 1,000 mcg/ml 25's, mdv 1,000
mcg/ml
3 MO; DP
cyanocobalamin 1,000 mcg/ml inner,latex-free
1,000 mcg/ml
3 MO; DP
cyanocobalamin 1,000 mcg/ml latex-
free,mdv,inner 1,000 mcg/ml
3 MO; DP
cyanocobalamin 1,000 mcg/ml latex-
free,outer,mdv 1,000 mcg/ml
3 MO; DP
cyanocobalamin 1,000 mcg/ml mdv,5's 1,000
mcg/ml
3 MO; DP
cyanocobalamin 1,000 mcg/ml mdv,inner,latex-
free 1,000 mcg/ml
3 MO; DP
cyanocobalamin 1,000 mcg/ml mdv,outer,latex-
free 1,000 mcg/ml
3 MO; DP
103
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
cyanocobalamin 1,000 mcg/ml outer,latex-free
1,000 mcg/ml
3 MO; DP
cyanocobalamin 10,000 mcg/10 inner,latex-
free,mdv 1,000 mcg/ml
3 MO; DP
cyanocobalamin 10,000 mcg/10 mdv, inner, l/f
1,000 mcg/ml
3 MO; DP
cyanocobalamin 10,000 mcg/10 mdv, outer, l/f
1,000 mcg/ml
3 MO; DP
cyanocobalamin 10,000 mcg/10 outer,latex-
free,mdv 1,000 mcg/ml
3 MO; DP
cyanocobalamin 30,000 mcg/30 inner,latex-
free,mdv 1,000 mcg/ml
3 MO; DP
cyanocobalamin 30,000 mcg/30 mdv, inner, l/f
1,000 mcg/ml
3 MO; DP
cyanocobalamin 30,000 mcg/30 mdv, outer, l/f
1,000 mcg/ml
3 MO; DP
cyanocobalamin 30,000 mcg/30 outer,latex-
free,mdv 1,000 mcg/ml
3 MO; DP
ergocalciferol 8,000 units/ml 8,000 unit/ml 3 DP
OYSCO 500-VIT D3 200 TABLET 500
MG(1,250MG) -200 UNIT
3 DP
OYSTER SHELL 500-VIT D3 200 TB 500
MG(1,250MG) -200 UNIT
3 DP
OYSTER SHELL 500-VIT D3 200 TB CAPLET
500 MG(1,250MG) -200 UNIT
3 DP
OYSTER SHELL 500-VIT D3 200 TB U-D,
10X10 500 MG(1,250MG) -200 UNIT
3 DP
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 1 MO
PRENATAL VITAMIN PLUS LOW IRON
ORAL TABLET 27 MG IRON- 1 MG
2 MO
PRENATAL VITAMIN TABLET (OTC) 27 MG
IRON- 0.8 MG
3 DP
PRENATAL VITAMINS TABLET W/ FOLIC
ACID 28 MG IRON- 800 MCG
3 DP
pyridoxine 100 mg/ml vial 25's, mdv 100 mg/ml 3 DP
pyridoxine 100 mg/ml vial inner,p/f,mdv,ltx-fr 100
mg/ml
3 DP
104
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
pyridoxine 100 mg/ml vial outer,p/f,mdv,ltx-fr 100
mg/ml
3 DP
RENAL VITAMIN TABLET 0.8 MG 3 DP
SM PEDIATRIC ELECTROLYTE SOLN 3 DP
SM VITAMIN B-1 100 MG TABLET 100 MG 3 DP
STRESS FORMULA TABLET 3 DP
SUPERPLEX-T TABLET 3 DP
TAB-A-VITE TABLET 3 DP
TAB-A-VITE WITH IRON TABLET 3 DP
THERA TABLET 400 MCG 3 DP
THERA-M TABLET W/BETA CAROTENE 9
MG IRON-400 MCG
3 DP
thiamine 200 mg/2 ml vial 25's, mdv 100 mg/ml 3 DP
thiamine 200 mg/2 ml vial mdv 100 mg/ml 3 DP
vitamin a 10,000 unit capsule soluble 10,000 unit 3 DP
VITAMIN AND MINERALS TABLET 3 DP
VITAMIN B COMPLEX CAPSULE 3 DP
VITAMIN B-1 100 MG TABLET 100 MG 3 DP
VITAMIN B-12 1,000 MCG TABLET 1,000
MCG
3 DP
VITAMIN B-12 1,000 MCG TABLET
P/F,STARCH/SOY-FREE 1,000 MCG
3 DP
VITAMIN B-6 100 MG TABLET 100 MG 3 DP
VITAMIN B-6 50 MG TABLET 50 MG 3 DP
VITAMIN C 250 MG TABLET 250 MG 3 DP
VITAMIN C 250 MG TABLET CHEW 250 MG 3 DP
VITAMIN C 500 MG CAPLET COATED
CAPLET 500 MG
3 DP
VITAMIN C 500 MG TABLET 500 MG 3 DP
VITAMIN C 500 MG TABLET CHEW 500 MG 3 DP
VITAMIN C 500 MG TABLET U-D 500 MG 3 DP
VITAMIN D2 1.25 MG(50,000 UNIT) 50,000
UNIT
3 MO; DP
VITAMIN D2 1.25 MG(50,000 UNIT) CAPSULE
50,000 UNIT
3 MO; DP
105
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
vitamin d2 1.25 mg(50,000 unit) softgel 50,000
unit
3 MO; DP
VITAMIN D2 1.25 MG(50,000 UNIT) U-
D,10X10,INNER 50,000 UNIT
3 MO; DP
VITAMIN D2 1.25 MG(50,000 UNIT) U-
D,10X10,OUTER 50,000 UNIT
3 MO; DP
VITAMIN D3 1,000 UNIT TABLET 1,000 UNIT 3 DP
vitamin d3 1,000 unit tablet gluten/f, d/f 1,000 unit 3 DP
VITAMIN D3 1,000 UNIT TABLET S/F,P/F
1,000 UNIT
3 DP
VITAMIN D3 2,000 UNIT SOFTGEL 2,000
UNIT
3 DP
VITAMIN D3 2,000 UNIT SOFTGEL SOY-
FREE,SOFTGEL 2,000 UNIT
3 DP
vitamin d3 2,000 unit tablet 2,000 unit 3 DP
VITAMIN D3 2,000 UNIT TABLET 2,000 UNIT 3 DP
vitamin d3 400 unit/ml drop supplement drop 400
unit/ml
3 DP
V-R VITAMIN C 250 MG TAB CHEW 250 MG 3 DP
V-R VITAMIN C 500 MG TAB CHEW 500 MG 3 DP
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
dicyclomine oral capsule 10 mg 1 MO
dicyclomine oral solution 10 mg/5 ml 1 MO
dicyclomine oral tablet 20 mg 1 MO
diphenoxylate-atropine oral liquid 2.5-0.025 mg/5
ml
1
diphenoxylate-atropine oral tablet 2.5-0.025 mg 1
glycopyrrolate oral tablet 1 mg, 2 mg 1 MO
GASTROINTESTINAL AGENTS, OTHER
ACID GONE ANTACID LIQUID 95-358 MG/15
ML
3 DP
ALMACONE CHEWABLE TABLET 200-200-25
MG
3 DP
106
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ALMACONE SUSPENSION 200-200-20 MG/5
ML
3 DP
ALMACONE-2 LIQUID 400-400-40 MG/5 ML 3 DP
aluminum hydroxide gel sugar-free 320 mg/5 ml 3 DP
ANTACID 500 MG CHEWABLE TABLET
INNER 200 MG CALCIUM (500 MG)
3 DP
ANTACID 500 MG CHEWABLE TABLET
OUTER 200 MG CALCIUM (500 MG)
3 DP
ANTACID ANTI-GAS LIQUID MAXIMUM
STRENGTH 400-400-40 MG/5 ML
3 DP
ANTACID EX-STR 750 MG TAB CHEW
GLUTEN-F,ASSTD BERRY 300 MG (750 MG)
3 DP
ANTACID LIQUID 200-200-20 MG/5 ML 3 DP
ANTACID MAXIMUM STRENGTH LIQ 400-
400-40 MG/5 ML
3 DP
ANTACID PLUS ANTI-GAS RELF LIQ
MINT,REG-STRENGTH 200-200-20 MG/5 ML
3 DP
ANTACID PLUS ANTI-GAS RELF LIQ
REGULAR STR,ORIGINAL 200-200-20 MG/5
ML
3 DP
ANTACID PLUS ANTI-GAS SUSP MAX STR,
CHERRY 400-400-40 MG/5 ML
3 DP
ANTACID SUSPENSION 200-200-20 MG/5 ML 3 DP
ANTACID XTRA STRENGTH CHEW TAB
EXTRA STRENGTH 300 MG (750 MG)
3 DP
ANTACID-ANTIGAS LIQUID 200-200-20 MG/5
ML
3 DP
ANTACID-SIMETHICONE LIQUID 400-400-40
MG/5 ML
3 DP
ANTI-DIARRHEAL 2 MG CAPLET 2 MG 3 DP
ANTI-DIARRHEAL 2 MG CAPLET CAPLET 2
MG
3 DP
ANTI-DIARRHEAL 2 MG CAPLET CPLT
EASY TO SWALLOW 2 MG
3 DP
ANTI-DIARRHEAL 2 MG SOFTGEL SOFTGEL
2 MG
3 DP
ANTI-DIARRHEAL 2 MG TABLET 2 MG 3 DP
107
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
BISMATROL 525 MG/30 ML SUSP 262 MG/15
ML
3 DP
BISMATROL TABLET CHEW 262 MG 3 DP
bismuth 262 mg tablet chew 262 mg 3 DP
CALCIUM ANTACID 1,000 MG TAB ULTRA,
MAX-STR 400 MG CALCIUM (1,000 MG)
3 DP
CALCIUM ANTACID 500 MG CHW TAB
ASSORTED FRUIT 200 MG CALCIUM (500
MG)
3 DP
CALCIUM ANTACID 500 MG CHW TAB
GLUTEN-F, PEPPERMINT 200 MG CALCIUM
(500 MG)
3 DP
CALCIUM ANTACID 500 MG CHW TAB REG
STR, PEPPERMINT 200 MG CALCIUM (500
MG)
3 DP
CALCIUM ANTACID 750 MG TB CHEW
GLUTEN-FREE 300 MG (750 MG)
3 DP
CAL-GEST 500 MG TABLET CHEW 200 MG
CALCIUM (500 MG)
3 DP
enulose oral solution 10 gram/15 ml 1 MO
GAS RELIEF 125 MG SOFTGEL SOFTGEL 125
MG
3 DP
GATTEX 30-VIAL SUBCUTANEOUS KIT 5
MG
2 PA; MO
GATTEX ONE-VIAL SUBCUTANEOUS KIT 5
MG
2 PA; MO
gavilyte-c oral recon soln 240-22.72-6.72 -5.84
gram
1
GAVISCON 80-14.2 MG TAB CHEW 80-14.2
MG
3 DP
GAVISCON ES TABLET CHEW EXTRA
STRENGTH 160-105 MG
3 DP
GAVISCON EXTRA STRENGTH LIQUID 254-
237.5 MG/5 ML
3 DP
GAVISCON LIQUID 95-358 MG/15 ML 3 DP
generlac oral solution 10 gram/15 ml 1 MO
108
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
GS ADV ANTACID-ANTIGAS LIQUID 200-
200-20 MG/5 ML
3 DP
GS ANTACID 500 MG CHEWABLE TAB 215
MG CALCIUM (500 MG)
3 DP
GS ANTACID PLUS ANTI-GAS LIQ 200-200-
20 MG/5 ML
3 DP
GS ANTI-DIARRHEAL 2 MG CAPLET 2 MG 3 DP
GS CAL ANTACID 500 MG CHEW TAB 200
MG CALCIUM (500 MG)
3 DP
GS STOMACH RLF 262 MG CHEW TAB
GLUTEN-FREE 262 MG
3 DP
HM ADV ANTACID-ANTIGAS SUSP MAX-
STRENGTH, CHERRY 400-400-40 MG/5 ML
3 DP
HM ANTACID ANTI-GAS SUSPENSION
ORIGINAL, MAX STR 400-400-40 MG/5 ML
3 DP
HM ANTACID-ANTIGAS SUSPENSION 200-
200-20 MG/5 ML
3 DP
HM ANTACID-ANTIGAS SUSPENSION REG
STR, MINT 200-200-20 MG/5 ML
3 DP
HM ANTACID-ANTIGAS SUSPENSION REG
STR, ORIGINAL 200-200-20 MG/5 ML
3 DP
HM ANTI-DIARRHEAL 2 MG CAPLET
CAPLET, GLUTEN-FREE 2 MG
3 DP
HM CAL ANTACID 500 MG CHEW TAB
ASSORTED FRUIT 200 MG CALCIUM (500
MG)
3 DP
HM CAL ANTACID 750 MG CHEW TAB 320
MG CALCIUM (750 MG)
3 DP
HM CAL ANTACID 750 MG CHEW TAB
EXTRA STRENGTH 300 MG (750 MG)
3 DP
HM CAL ANTACID 750 MG CHEW TAB
S/F,EX-STR, ORANGE 300 MG (750 MG)
3 DP
LIQUID ANTACID SUSPENSION REGULAR
STRENGTH 200-200-20 MG/5 ML
3 DP
loperamide 1 mg/5 ml liquid 1 mg/5 ml 3 DP
loperamide oral capsule 2 mg 1 MO
MAG-AL PLUS SUSPENSION 200-200-20
MG/5 ML
3 DP
109
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
MI ACID SUSPENSION 200-200-20 MG/5 ML,
400-400-40 MG/5 ML
3 DP
MI-ACID DS TABLET 700-300 MG 3 DP
MINTOX PLUS TABLET CHEWABLE 200-200-
25 MG
3 DP
MINTOX SUSPENSION MINT CREME 200-
200-20 MG/5 ML
3 DP
OCALIVA ORAL TABLET 10 MG, 5 MG 2 PA; MO
PEPTIC RELIEF 262 MG CHEW TAB 262 MG 3 DP
PEPTIC RELIEF 262 MG/15 ML 262 MG/15 ML 3 DP
QC ANTACID 500 MG CHEW TABLET 200
MG CALCIUM (500 MG)
3 DP
QC ANTACID SUSPENSION REGULAR
STRENGTH 200-200-20 MG/5 ML
3 DP
QC ANTACID-ANTIGAS SUSPENSION
REGULAR STRENGTH 200-200-20 MG/5 ML
3 DP
QC ANTI-DIARRHEAL 2 MG CAPLET
CAPLET 2 MG
3 DP
RECTIV RECTAL OINTMENT 0.4 % (W/W) 2
RELISTOR ORAL TABLET 150 MG 2 PA
RELISTOR SUBCUTANEOUS SOLUTION 12
MG/0.6 ML
2 PA
RELISTOR SUBCUTANEOUS SYRINGE 12
MG/0.6 ML, 8 MG/0.4 ML
2 PA
RULOX SUSPENSION 200-200-20 MG/5 ML 3 DP
SB ANTACID 500 MG CHEW TABLET 200 MG
CALCIUM (500 MG)
3 DP
SB ANTACID XTRA STR CHEW TAB EXTRA
STRENGTH 300 MG (750 MG)
3 DP
SB ANTI-DIARRHEA 2 MG CAPLET 2 MG 3 DP
SEROSTIM SUBCUTANEOUS RECON SOLN 4
MG, 5 MG, 6 MG
2 PA; MO
SM ADV ANTACID-ANTIGAS LIQUID 200-
200-20 MG/5 ML
3 DP
SM ANTACID MAX STRENGTH SUSP
ORIGINAL 400-400-40 MG/5 ML
3 DP
110
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
SM ANTACID SUSPENSION 200-200-20 MG/5
ML
3 DP
SM ANTACID-ANTIGAS LIQUID 200-200-20
MG/5 ML
3 DP
SM ANTI-DIARRHEAL 2 MG CAPLET 2 MG 3 DP
SM ANTI-DIARRHEAL 2 MG CAPLET
CAPLET 2 MG
3 DP
SM CAL ANTACID 500 MG CHEW TAB 215
MG CALCIUM (500 MG)
3 DP
SM CAL ANTACID 750 MG CHEW TAB 320
MG CALCIUM (750 MG)
3 DP
SM CAL ANTACID 750 MG CHEW TAB
EXTRA STRENGTH 300 MG (750 MG)
3 DP
SM GAS RELIEF 125 MG SOFTGEL SOFTGEL
125 MG
3 DP
SM STOMACH RELIEF 262 MG/15 ML
REGULAR STRENGTH 262 MG/15 ML
3 DP
SM STOMACH RLF 262 MG CHEW TAB 262
MG
3 DP
STOMACH RLF 262 MG/15 ML SUSP
ORIGINAL STRENGTH 262 MG/15 ML
3 DP
TUMS 750 MG CHEWY BITES 300 MG (750
MG)
3 DP
TUMS E-X TABLET CHEWABLE ASSORTED
FRUIT 300 MG (750 MG)
3 DP
TUMS E-X TABLET CHEWABLE E-X 300 MG
(750 MG)
3 DP
TUMS E-X TABLET CHEWABLE E-X 300 MG
(750 MG)
3 DP
TUMS E-X TABLET CHEWABLE E-X,
SINGLE ROLL 300 MG (750 MG)
3 DP
TUMS E-X TABLET CHEWABLE E-X,3-ROLL
300 MG (750 MG)
3 DP
TUMS E-X TABLET CHEWABLE S/F,
ORANGE CREAM 300 MG (750 MG)
3 DP
TUMS KIDS 300 MG (750) CHEWTAB
CHERRY BLAST 300 MG (750 MG)
3 DP
111
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
TUMS SMOOTHIES CHEW TABLET 300 MG
(750 MG)
3 DP
TUMS SMOOTHIES CHEW TABLET ASSTD
TROPICAL FRUIT 300 MG (750 MG)
3 DP
TUMS SMOOTHIES CHEW TABLET BERRY
FUSION, EX-STR 300 MG (750 MG)
3 DP
TUMS SMOOTHIES CHEW TABLET
PEPPERMINT, EX-STR 300 MG (750 MG)
3 DP
TUMS TABLET CHEWABLE 200 MG
CALCIUM (500 MG)
3 DP
TUMS TABLET CHEWABLE 3-ROLL,
PEPPERMINT 200 MG CALCIUM (500 MG)
3 DP
TUMS TABLET CHEWABLE ASSORTED
FRUIT 200 MG CALCIUM (500 MG)
3 DP
TUMS TABLET CHEWABLE PEPPERMINT
200 MG CALCIUM (500 MG)
3 DP
TUMS ULTRA TABLET CHEWABLE 400 MG
CALCIUM (1,000 MG)
3 DP
TUMS ULTRA TABLET CHEWABLE
ASSORTED BERRIES 400 MG CALCIUM
(1,000 MG)
3 DP
TUMS ULTRA TABLET CHEWABLE
ASSORTED FRUIT 400 MG CALCIUM (1,000
MG)
3 DP
TUMS ULTRA TABLET CHEWABLE TROP
FRUIT,GLUTEN-F 400 MG CALCIUM (1,000
MG)
3 DP
TUMS X-STR 750 TABLET CHEWABLE
ASST'D FRUIT FLAVOR 300 MG (750 MG)
3 DP
ursodiol oral capsule 300 mg 1 MO
ursodiol oral tablet 250 mg, 500 mg 1 MO
XERMELO ORAL TABLET 250 MG 2 PA
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
ACID CONTROLLER 20 MG TABLET
MAXIMUM STRENGTH 20 MG
3 DP
ACID REDUCER 10 MG TABLET 10 MG 3 DP
112
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ACID REDUCER 10 MG TABLET ORIGINAL
STRENGTH 10 MG
3 DP
ACID REDUCER 20 MG TABLET MAX
STRENGTH 20 MG
3 DP
ACID REDUCER 20 MG TABLET MAXIMUM
STRENGTH 20 MG
3 DP
ACID REDUCER 20 MG TABLET MAX-STR
20 MG
3 DP
cimetidine 200 mg tablet blister pack (otc) 200 mg 3 MO; DP
cimetidine hcl oral solution 300 mg/5 ml 1 MO
cimetidine oral tablet 200 mg, 300 mg, 400 mg,
800 mg
1 MO
famotidine 10 mg tablet 10 mg 3 DP
famotidine oral tablet 20 mg, 40 mg 1 MO
HEARTBURN RELIEF 10 MG TABLET 10 MG 3 DP
HM ACID REDUCER 150 MG TABLET
MAXIMUM STRENGTH 150 MG
3 DP
HM ACID REDUCER 75 MG TABLET
REGULAR STRENGTH 75 MG
3 DP
hm famotidine 10 mg tablet original strength 10
mg
3 DP
ranitidine 150 mg tablet maximum strength (otc)
150 mg
3 MO; DP
ranitidine 75 mg tablet s/f, sodium-free 75 mg 3 DP
ranitidine hcl oral syrup 15 mg/ml 1 MO
ranitidine hcl oral tablet 150 mg, 300 mg 1 MO
SB ACID REDUCER 150 MG TABLET
MAXIMUM STRENGTH 150 MG
3 DP
SM ACID REDUCER 10 MG TABLET 10 MG 3 DP
SM ACID REDUCER 150 MG TABLET 150 MG 3 DP
SM ACID REDUCER 150 MG TABLET
MAXIMUM STRENGTH 150 MG
3 DP
SM ACID REDUCER 200 MG TABLET 200 MG 3 DP
SM ACID REDUCER 75 MG TABLET 75 MG 3 DP
SM ACID REDUCER 75 MG TABLET
REGULAR STRENGTH 75 MG
3 DP
113
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
SM HEARTBURN RELIEF 200 MG TAB 200
MG
3 DP
IRRITABLE BOWEL SYNDROME AGENTS
alosetron oral tablet 0.5 mg, 1 mg 1 QL (60 EA per 30 days)
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 2 MO; QL (60 EA per 30 days)
LINZESS ORAL CAPSULE 145 MCG, 290
MCG, 72 MCG
2 MO; QL (30 EA per 30 days)
XIFAXAN ORAL TABLET 200 MG 2 PA
XIFAXAN ORAL TABLET 550 MG 2 PA; MO
LAXATIVES
BISAC-EVAC 10 MG SUPPOSITORY 10 MG 3 DP
BISAC-EVAC 10 MG SUPPOSITORY OUTER
10 MG
3 DP
bisacodyl 10 mg suppository 10 mg 3 DP
bisacodyl ec 5 mg tablet 5 mg 3 DP
BISA-LAX EC 5 MG TABLET 5 MG 3 DP
BISCOLAX 10 MG SUPPOSITORY 10 MG 3 DP
calcium polycarbophil 625 mg 625 mg 3 DP
CITRUCEL 500 MG CAPLET 500 MG 3 DP
CITRUCEL POWDER 3 DP
CITRUCEL POWDER S-F S/F 3 DP
CLEARLAX POWDER 14 ONCE-DAILY
DOSES 17 GRAM/DOSE
3 DP
CLEARLAX POWDER 17 GRAM/DOSE 3 DP
CLEARLAX POWDER 30 ONCE-DAILY
DOSES 17 GRAM/DOSE
3 DP
CLEARLAX POWDER 7 ONCE-DAILY DOSES
17 GRAM/DOSE
3 DP
constulose oral solution 10 gram/15 ml 1 MO
DOC-Q-LACE 100 MG SOFTGEL 100 MG 3 DP
DOCU LIQUID 100 MG/10 ML INNER 50 MG/5
ML
3 DP
DOCU LIQUID 100 MG/10 ML OUTER 50
MG/5 ML
3 DP
114
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
DOCU LIQUID 50 MG/5 ML 50 MG/5 ML 3 DP
docusate sodium 100 mg softgel inner, softgel 100
mg
3 DP
docusate sodium 100 mg softgel outer, softgel 100
mg
3 DP
docusate sodium 100 mg softgel softgel 100 mg 3 DP
docusate sodium 50 mg/5 ml liq 100's, u-d 50 mg/5
ml
3 DP
DOCUSATE SODIUM-SENNA TABLET 8.6-50
MG
3 DP
DOCUSIL 100 MG SOFTGEL 100 MG 3 DP
DOCUSOL MINI-ENEMA OUTER 283 MG 3 DP
DOK 100 MG SOFTGEL SOFTGEL 100 MG 3 DP
DOK 100 MG TABLET 100 MG 3 DP
DUCODYL EC 5 MG TABLET 5 MG 3 DP
ENEMA DISPOSABLE 19-7 GRAM/118 ML 3 DP
ENEMA READY TO USE LATEX-FREE 19-7
GRAM/118 ML
3 DP
ENEMEEZ MINI ENEMA 5CC TUBES, OUTER
283 MG/5 ML
3 DP
ENEMEEZ PLUS MINI ENEMA OUTER 283-20
MG/5 ML
3 DP
EX-LAX MAXIMUM STR 25 MG TAB 25 MG 3 DP
FIBER LAXATIVE 625 MG CAPLET CAPLET
625 MG
3 DP
FIBER LAXATIVE 625 MG TABLET 625 MG 3 DP
FIBER TABLET UNBOXED 625 MG 3 DP
FIBER TABS 625 MG 3 DP
FIBER THERAPY POWDER 2 GRAM/19
GRAM
3 DP
FIBER-LAX CAPTABS 500MG
POLYCARBOPHIL 625 MG
3 DP
FLEET BISACODYL 10 MG ENEMA 10 MG/30
ML
3 DP
FLEET ENEMA 2X133ML, TWIN PACK 19-7
GRAM/118 ML
3 DP
115
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
FLEET PEDIA-LAX ENEMA 9.5-3.5 GRAM/59
ML
3 DP
FLEET PEDIA-LAX SUPPOSITORIES 3 DP
GAVILAX POWDER 14 DAY 17 GRAM/DOSE 3 DP
GAVILAX POWDER 30 DAY 17 GRAM/DOSE 3 DP
gavilyte-g oral recon soln 236-22.74-6.74 -5.86
gram
1
gavilyte-n oral recon soln 420 gram 1
glycerin pediatric suppository infants & children 3 DP
GLYCOLAX POWDER 15 DOSES (OTC) 17
GRAM/DOSE
3 DP
GLYCOLAX POWDER 31 DOSES (OTC) 17
GRAM/DOSE
3 DP
GLYCOLAX POWDER 7 DOSES (OTC) 17
GRAM/DOSE
3 DP
GS MILK OF MAGNESIA SUSPENSION 400
MG/5 ML
3 DP
HEALTHYLAX POWDER PACKET 14X17GM,
INNER 17 GRAM
3 DP
HEALTHYLAX POWDER PACKET 14X17GM,
OUTER 17 GRAM
3 DP
HM CLEARLAX POWDER 14 ONCE-DAILY
DOSES 17 GRAM/DOSE
3 DP
HM CLEARLAX POWDER 30 ONCE-DAILY
DOSES 17 GRAM/DOSE
3 DP
HM CLEARLAX POWDER 7 ONCE-DAILY
DOSES 17 GRAM/DOSE
3 DP
HM ENEMA READY TO USE 19-7 GRAM/118
ML
3 DP
HM ENEMA READY TO USE TWIN PAK
LATEX-FREE 19-7 GRAM/118 ML
3 DP
HM FIBER 500 MG CAPLET 500 MG 3 DP
HM FIBER POWDER 3.4 GRAM/5.8 GRAM 3 DP
HM LAXATIVE EC 5 MG TABLET 5 MG 3 DP
HM MILK OF MAGNESIA SUSPENSION
MINT 400 MG/5 ML
3 DP
116
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
HM MILK OF MAGNESIA SUSPENSION
ORIGINAL 400 MG/5 ML
3 DP
HM SENNA 8.6 MG TABLET 8.6 MG 3 DP
HM STOOL SOFTENER 100 MG SFTGL
SOFTGEL 100 MG
3 DP
HM STOOL SOFTENER 100 MG TAB 100 MG 3 DP
KAO-TIN 240 MG SOFTGEL 240 MG 3 DP
KONSYL 6 GM PACKET S/F, GLUTEN-F,
OUTER 6 GRAM
3 DP
KONSYL EASY MIX FIBER POWDER 4.3
GRAM/6 GRAM
3 DP
KONSYL FIBER 625 MG CAPLET CAPLET
625 MG
3 DP
KONSYL FIBER 625 MG CAPLET CAPLET,
S/F 625 MG
3 DP
KONSYL FORMULA-D FIBER POWDER
GLUTEN FREE,61 DOSES 3.4 GRAM/ 6.5
GRAM
3 DP
KONSYL ORIGINAL FIBER POWDER S/F,
GLUTEN FREE 6 GRAM/6 GRAM
3 DP
KONSYL ORIGINAL FIBER POWDER
S/F,GLUTN-F,75 DOSES 6 GRAM/6 GRAM
3 DP
KONSYL PSYLLIUM FIBER POWDER
GLUTEN FREE, ORANGE 3.4 GRAM/11
GRAM
3 DP
KONSYL PSYLLIUM FIBER POWDER
S/F,GLUTEN/F,ORANGE 3.5 GRAM/5.8 GRAM
3 DP
KRISTALOSE ORAL PACKET 20 GRAM 2 ST; MO
lactulose oral packet 10 gram 1 ST; MO
lactulose oral solution 10 gram/15 ml, 10 gram/15
ml (15 ml), 20 gram/30 ml
1 MO
LAXATIVE EC 5 MG TABLET 5 MG 3 DP
magnesium citrate solution lemon 3 DP
MILK OF MAGNESIA SUSPENSION 100'S, U-
D 400 MG/5 ML
3 DP
MILK OF MAGNESIA SUSPENSION 400 MG/5
ML
3 DP
117
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
MILK OF MAGNESIA SUSPENSION CHERRY
400 MG/5 ML
3 DP
MILK OF MAGNESIA SUSPENSION MINT 400
MG/5 ML
3 DP
MILK OF MAGNESIA SUSPENSION NA/F 400
MG/5 ML
3 DP
MILK OF MAGNESIA SUSPENSION
REGULAR 400 MG/5 ML
3 DP
MILK OF MAGNESIA SUSPENSION
STIMULANT FREE 400 MG/5 ML
3 DP
mineral oil usp 3 DP
NATURAL FIBER LAX POWDER 3 DP
NATURAL FIBER LAX POWDER ORIGINAL
TEXTURE 3.4 GRAM/7 GRAM
3 DP
peg 3350-electrolytes oral recon soln 240-22.72-
6.72 -5.84 gram
1
peg-3350 with flavor packs oral recon soln 420
gram
1
peg-electrolyte soln oral recon soln 420 gram 1
polyethylene glycol 3350 oral powder 17
gram/dose
1
polyethylene glycol 3350 oral powder in packet 17
gram
1
polyethylene glycol 3350 powd 14 once-daily
doses (otc) 17 gram/dose
3 DP
polyethylene glycol 3350 powd 30 once-daily
doses (otc) 17 gram/dose
3 DP
polyethylene glycol 3350 powd 7 once-daily doses
(otc) 17 gram/dose
3 DP
polyethylene glycol 3350 powd inner (otc) 17
gram
3 DP
polyethylene glycol 3350 powd outer (otc) 17
gram
3 DP
QC MILK OF MAGNESIA SUSPENSION 400
MG/5 ML
3 DP
QC NATURAL VEG LAXATIVE TABLET 8.6
MG
3 DP
118
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
QC NATURA-LAX 17 GM POWDER 17
GRAM/DOSE
3 DP
QC READY TO USE ENEMA LATEX-FREE 19-
7 GRAM/118 ML
3 DP
QC READY TO USE ENEMA TWIN PACK 19-7
GRAM/118 ML
3 DP
REGULOID LAXATIVE POWDER 3 DP
REGULOID POWDER 3 DP
REGULOID POWDER ORANGE 3 DP
sb bisacodyl ec 5 mg tablet 5 mg 3 DP
SENEXON 8.6 MG TABLET 8.6 MG 3 DP
SENEXON-S TABLET 8.6-50 MG 3 DP
SENNA 8.6 MG TABLET 8.6 MG 3 DP
SENNA 8.8 MG/5 ML SYRUP A/F,
CHOCOLATE 8.8 MG/5 ML
3 DP
SENNA LAXATIVE 8.6 MG TABLET 8.6 MG 3 DP
SENNA PLUS TABLET 8.6-50 MG 3 DP
SENNA-LAX 8.6 MG TABLET 8.6 MG 3 DP
SENNA-TIME 8.6 MG TABLET 8.6 MG 3 DP
SENNA-TIME S TABLET 8.6-50 MG 3 DP
SENNO TABLET 8.6 MG 3 DP
sennosides-docusate sodium tab 8.6-50 mg 3 DP
SENOKOT 8.6 MG TABLET 8.6 MG 3 DP
SILACE 50 MG/5 ML LIQUID 50 MG/5 ML 3 DP
SILACE 60 MG/15 ML SYRUP 60 MG/15 ML 3 DP
SM CLEARLAX POWDER 14 ONCE-DAILY
DOSES 17 GRAM/DOSE
3 DP
SM CLEARLAX POWDER 17 GRAM/DOSE 3 DP
SM CLEARLAX POWDER 30 ONCE-DAILY
DOSES 17 GRAM/DOSE
3 DP
SM CLEARLAX POWDER 7 ONCE-DAILY
DOSES 17 GRAM/DOSE
3 DP
SM FIBER 625 MG CAPLET 625 MG 3 DP
SM FIBER LAXATIVE 500 MG CPLT 500 MG 3 DP
119
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
SM FIBER LAXATIVE 625 MG TAB CAPLET
625 MG
3 DP
SM FIBER POWDER 3 DP
SM FIBER POWDER 3.4 GRAM/11 GRAM 3 DP
SM GENTLE LAXATIVE EC 5 MG TAB 5 MG 3 DP
SM MILK OF MAGNESIA SUSPENSION 400
MG/5 ML
3 DP
SM NAT LAX PLUS STOOL SOFTENER 8.6-50
MG
3 DP
SM SENNA LAXATIVE 8.6 MG TAB 8.6 MG 3 DP
SM STOOL SOFTENER 100 MG SFTGL
GLUTEN-FREE, SOFTGEL 100 MG
3 DP
SM STOOL SOFTENER 100 MG SFTGL
SOFTGEL 100 MG
3 DP
SM STOOL SOFTENER 240 MG SFTGL
SOFTGEL,GLUTEN-FREE 240 MG
3 DP
SM STOOL SOFTENER 250 MG SFTGL
SOFTGEL, EX-STR 250 MG
3 DP
SM STOOL SOFTENER-LAXATIVE TAB 8.6-
50 MG
3 DP
STOOL SOFTENER 100 MG CAPSULE 100 MG 3 DP
STOOL SOFTENER 100 MG CAPSULE
ORIGINAL 100 MG
3 DP
STOOL SOFTENER 100 MG SOFTGEL
SOFTGEL 100 MG
3 DP
STOOL SOFTENER 240 MG SOFTGEL
SOFTGEL 240 MG
3 DP
STOOL SOFTENER 250 MG SOFTGEL
SOFTGEL, EX-STR 250 MG
3 DP
STOOL SOFTENER-LAXATIVE TABLET 8.6-
50 MG
3 DP
STOOL SOFTENER-STIM LAX TABLET 8.6-50
MG
3 DP
trilyte with flavor packets oral recon soln 420
gram
1
WOMEN'S LAXATIVE 5 MG TABLET 5 MG 3 DP
120
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
PROTECTANTS
misoprostol oral tablet 100 mcg, 200 mcg 1 MO
sucralfate oral tablet 1 gram 1 MO
PROTON PUMP INHIBITORS
gs omeprazole dr 20 mg tablet 14 day course 20
mg
3 DP
HEARTBURN TREATMNT 24 HR 15 MG
1X14, SODIUM FREE 15 MG
3 DP
HEARTBURN TREATMNT 24 HR 15 MG
3X14, SODIUM FREE 15 MG
3 DP
hm lansoprazole dr 15 mg cap gluten-free,1 bottle
(otc) 15 mg
3 MO; DP
hm lansoprazole dr 15 mg cap gluten-free,2 bottle
(otc) 15 mg
3 MO; DP
hm lansoprazole dr 15 mg cap gluten-free,3 bottle
(otc) 15 mg
3 MO; DP
hm omeprazole dr 20 mg tablet 2x14 day course
20 mg
3 DP
hm omeprazole dr 20 mg tablet 3x14 day course
20 mg
3 DP
lansoprazole dr 15 mg capsule (otc) 15 mg 3 MO; DP
lansoprazole dr 15 mg capsule 1x14 day course
(otc) 15 mg
3 MO; DP
lansoprazole dr 15 mg capsule 1x14 day
course,na/f (otc) 15 mg
3 MO; DP
lansoprazole dr 15 mg capsule 2-14 day treatment
(otc) 15 mg
3 MO; DP
lansoprazole dr 15 mg capsule 24hr, 3 bottles
(otc) 15 mg
3 MO; DP
lansoprazole dr 15 mg capsule 2x14 day course
(otc) 15 mg
3 MO; DP
lansoprazole dr 15 mg capsule 3x14 day course
(otc) 15 mg
3 MO; DP
lansoprazole dr 15 mg capsule 3x14 day
course,na/f (otc) 15 mg
3 MO; DP
lansoprazole dr 15 mg capsule na/f (otc) 15 mg 3 MO; DP
121
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
lansoprazole oral capsule,delayed release(dr/ec)
15 mg, 30 mg
1 MO
omeprazole dr 20 mg tablet 14 day course 20 mg 3 DP
omeprazole dr 20 mg tablet 1x14 day course 20
mg
3 DP
omeprazole dr 20 mg tablet 20 mg 3 DP
omeprazole dr 20 mg tablet 2x14 day course 20
mg
3 DP
omeprazole dr 20 mg tablet 3x14 day course 20
mg
3 DP
omeprazole oral capsule,delayed release(dr/ec) 10
mg, 20 mg, 40 mg
1 MO
pantoprazole oral tablet,delayed release (dr/ec) 20
mg, 40 mg
1 MO
PREVACID 24HR DR 15 MG CAPSULE NA/F
15 MG
3 DP
PREVACID 24HR DR 15 MG CAPSULE NA/F,
2 BOTTLES 15 MG
3 DP
PREVACID 24HR DR 15 MG CAPSULE NA/F,
3 BOTTLES 15 MG
3 DP
sm lansoprazole dr 15 mg cap gluten-free,1 bottle
(otc) 15 mg
3 MO; DP
sm lansoprazole dr 15 mg cap gluten-free,3 bottle
(otc) 15 mg
3 MO; DP
sm omeprazole dr 20 mg tablet 14 day course 20
mg
3 DP
sm omeprazole dr 20 mg tablet 2x14 day course 20
mg
3 DP
sm omeprazole dr 20 mg tablet 3x14 day course 20
mg
3 DP
GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT
GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT
ARALAST NP INTRAVENOUS RECON SOLN
1,000 MG, 500 MG
2 PA; MO
CERDELGA ORAL CAPSULE 84 MG 2 PA; MO
CHOLBAM ORAL CAPSULE 250 MG, 50 MG 2 PA; MO
122
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT,
24,000-76,000 -120,000 UNIT, 3,000-9,500-
15,000 UNIT, 36,000-114,000- 180,000 UNIT,
6,000-19,000 -30,000 UNIT
2 MO
CYSTADANE ORAL POWDER 1 GRAM/1.7
ML
2 MO
CYSTAGON ORAL CAPSULE 150 MG, 50 MG 2 PA; MO
GALAFOLD ORAL CAPSULE 123 MG 2 PA; MO
GLASSIA INTRAVENOUS SOLUTION 1
GRAM/50 ML (2 %)
2 PA; MO
KUVAN ORAL POWDER IN PACKET 100 MG,
500 MG
2 PA; MO
KUVAN ORAL TABLET,SOLUBLE 100 MG 2 PA; MO
NITYR ORAL TABLET 10 MG, 2 MG, 5 MG 2 PA; MO
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20
MG, 5 MG
2 PA; MO
ORFADIN ORAL SUSPENSION 4 MG/ML 2 PA; MO
PROLASTIN-C INTRAVENOUS RECON SOLN
1,000 MG
2 PA; MO
PROLASTIN-C INTRAVENOUS SOLUTION
1,000 MG (+/-)/20 ML
2 PA; MO
RAVICTI ORAL LIQUID 1.1 GRAM/ML 2 PA; MO
sodium phenylbutyrate oral powder 0.94
gram/gram
1 PA; MO
sodium phenylbutyrate oral tablet 500 mg 1 PA; MO
SUCRAID ORAL SOLUTION 8,500 UNIT/ML 2 PA; MO
XURIDEN ORAL GRANULES IN PACKET 2
GRAM
2 PA; MO
ZEMAIRA INTRAVENOUS RECON SOLN
1,000 MG
2 PA; MO
ZENPEP ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT,
15,000-47,000 -63,000 UNIT, 20,000-63,000-
84,000 UNIT, 25,000-79,000- 105,000 UNIT,
3,000-10,000 -14,000-UNIT, 40,000-126,000-
168,000 UNIT, 5,000-17,000- 24,000 UNIT
2 MO
GENITOURINARY AGENTS
123
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ANTISPASMODICS, URINARY
darifenacin oral tablet extended release 24 hr 15
mg, 7.5 mg
1 ST; MO
flavoxate oral tablet 100 mg 1 MO
MYRBETRIQ ORAL TABLET EXTENDED
RELEASE 24 HR 25 MG, 50 MG
2 ST; MO; QL (30 EA per 30 days)
oxybutynin chloride oral syrup 5 mg/5 ml 1 MO
oxybutynin chloride oral tablet 5 mg 1 MO
oxybutynin chloride oral tablet extended release
24hr 10 mg, 15 mg, 5 mg
1 MO
tolterodine oral capsule,extended release 24hr 2
mg, 4 mg
1 MO
tolterodine oral tablet 1 mg, 2 mg 1 MO
TOVIAZ ORAL TABLET EXTENDED
RELEASE 24 HR 4 MG, 8 MG
2 MO
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin oral tablet extended release 24 hr 10 mg 1 MO
dutasteride oral capsule 0.5 mg 1 MO
finasteride oral tablet 5 mg 1 MO
tamsulosin oral capsule 0.4 mg 1 MO
GENITOURINARY AGENTS, OTHER
bethanechol chloride oral tablet 10 mg, 25 mg, 5
mg, 50 mg
1
ELMIRON ORAL CAPSULE 100 MG 2
THIOLA ORAL TABLET 100 MG 2 PA
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)
ACTHAR H.P. INJECTION GEL 80 UNIT/ML 2 PA
cortisone oral tablet 25 mg 1
dexamethasone sodium phosphate injection
solution 4 mg/ml
1 B/D
fludrocortisone oral tablet 0.1 mg 1 MO
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 1 MO
124
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
hydrocortisone topical cream with perineal
applicator 2.5 %
1
methylprednisolone acetate injection suspension
40 mg/ml, 80 mg/ml
1
prednisone intensol oral concentrate 5 mg/ml 1
procto-med hc topical cream with perineal
applicator 2.5 %
1
procto-pak topical cream with perineal applicator
1 %
1
proctosol hc topical cream with perineal
applicator 2.5 %
1
proctozone-hc topical cream with perineal
applicator 2.5 %
1
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS)
ANABOLIC STEROIDS
ANADROL-50 ORAL TABLET 50 MG 2 PA
oxandrolone oral tablet 10 mg, 2.5 mg 1 MO
ANDROGENS
DANAZOL ORAL CAPSULE 100 MG, 200 MG,
50 MG
1
methyltestosterone oral capsule 10 mg 1 PA; MO
testosterone cypionate intramuscular oil 100
mg/ml, 200 mg/ml
1 MO
testosterone enanthate intramuscular oil 200
mg/ml
1
testosterone transdermal gel 50 mg/5 gram (1 %) 1 PA; MO
testosterone transdermal gel in metered-dose
pump 12.5 mg/ 1.25 gram (1 %)
1 PA; MO
testosterone transdermal gel in packet 1 % (25
mg/2.5gram), 1 % (50 mg/5 gram), 1.62 % (20.25
mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram)
1 PA; MO
testosterone transdermal solution in metered pump
w/app 30 mg/actuation (1.5 ml)
1 PA; MO
ESTROGENS
estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1 MO
125
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
estradiol transdermal patch semiweekly 0.025
mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075
mg/24 hr, 0.1 mg/24 hr
1 MO
estradiol transdermal patch weekly 0.025 mg/24
hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24
hr, 0.075 mg/24 hr, 0.1 mg/24 hr
1 MO
estradiol vaginal cream 0.01 % (0.1 mg/gram) 1 MO
estradiol vaginal tablet 10 mcg 1 MO
estradiol valerate intramuscular oil 20 mg/ml, 40
mg/ml
1
ESTRING VAGINAL RING 2 MG (7.5 MCG /24
HOUR)
2 MO
estropipate oral tablet 0.75 mg 1 PA; MO
MENEST ORAL TABLET 0.3 MG, 0.625 MG,
1.25 MG
2 PA; MO
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG,
0.625 MG, 0.9 MG, 1.25 MG
2 MO
PREMARIN VAGINAL CREAM 0.625
MG/GRAM
2 MO
yuvafem vaginal tablet 10 mcg 1 MO
HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS)
AFTERA 1.5 MG TABLET 1.5 MG 3 DP
ALTAVERA (28) ORAL TABLET 0.15-0.03 MG 1 MO
alyacen 1/35 (28) oral tablet 1-35 mg-mcg 1 MO
amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 1 MO
apri oral tablet 0.15-0.03 mg 1 MO
aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg 1 MO
AUBRA EQ ORAL TABLET 0.1-20 MG-MCG 1 MO
aubra oral tablet 0.1-20 mg-mcg 1 MO
aviane oral tablet 0.1-20 mg-mcg 1 MO
balziva (28) oral tablet 0.4-35 mg-mcg 1 MO
blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg
(21)/75 mg (7)
1 MO
126
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg
(21)/75 mg (7)
1 MO
briellyn oral tablet 0.4-35 mg-mcg 1 MO
caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg 1 MO
CHATEAL EQ (28) ORAL TABLET 0.15-0.03
MG
1 MO
COMBIPATCH TRANSDERMAL PATCH
SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25
MG/24 HR
2 MO
cryselle (28) oral tablet 0.3-30 mg-mcg 1 MO
cyclafem 1/35 (28) oral tablet 1-35 mg-mcg 1 MO
cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35
mcg
1 MO
CYRED EQ ORAL TABLET 0.15-0.03 MG 1 MO
CYRED ORAL TABLET 0.15-0.03 MG 1 MO
delyla (28) oral tablet 0.1-20 mg-mcg 1 MO
desog-e.estradiol/e.estradiol oral tablet 0.15-0.02
mgx21 /0.01 mg x 5
1 MO
desogestrel-ethinyl estradiol oral tablet 0.15-0.03
mg
1 MO
drospirenone-ethinyl estradiol oral tablet 3-0.03
mg
1 MO
ECONTRA EZ 1.5 MG TABLET INNER 1.5 MG 3 DP
ECONTRA EZ 1.5 MG TABLET OUTER 1.5
MG
3 DP
emoquette oral tablet 0.15-0.03 mg 1 MO
enpresse oral tablet 50-30 (6)/75-40 (5)/125-
30(10)
1 MO
ENSKYCE ORAL TABLET 0.15-0.03 MG 1 MO
ESTARYLLA ORAL TABLET 0.25-35 MG-
MCG
1 MO
estradiol-norethindrone acet oral tablet 0.5-0.1
mg, 1-0.5 mg
1 MO
ethynodiol diac-eth estradiol oral tablet 1-35 mg-
mcg, 1-50 mg-mcg
1 MO
falmina (28) oral tablet 0.1-20 mg-mcg 1 MO
127
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
femynor oral tablet 0.25-35 mg-mcg 1 MO
FYAVOLV ORAL TABLET 0.5-2.5 MG-MCG 1 MO
fyavolv oral tablet 1-5 mg-mcg 1 MO
introvale oral tablets,dose pack,3 month 0.15 mg-
30 mcg (91)
1 MO
ISIBLOOM ORAL TABLET 0.15-0.03 MG 1 MO
jinteli oral tablet 1-5 mg-mcg 1 MO
juleber oral tablet 0.15-0.03 mg 1 MO
junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg 1 MO
junel 1/20 (21) oral tablet 1-20 mg-mcg 1 MO
junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg
(21)/75 mg (7)
1 MO
junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75
mg (7)
1 MO
kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg x
5
1 MO
kelnor 1/35 (28) oral tablet 1-35 mg-mcg 1 MO
KELNOR 1-50 ORAL TABLET 1-50 MG-MCG 1 MO
kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01
mg x 5
1 MO
KURVELO (28) ORAL TABLET 0.15-0.03 MG 1 MO
larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg 1 MO
larin 1/20 (21) oral tablet 1-20 mg-mcg 1 MO
larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg
(21)/75 mg (7)
1 MO
larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75
mg (7)
1 MO
larissia oral tablet 0.1-20 mg-mcg 1 MO
leena 28 oral tablet 0.5/1/0.5-35 mg-mcg 1 MO
lessina oral tablet 0.1-20 mg-mcg 1 MO
levonest (28) oral tablet 50-30 (6)/75-40 (5)/125-
30(10)
1 MO
levonorgestrel-ethinyl estrad oral tablet 0.1-20
mg-mcg, 0.15-0.03 mg
1 MO
128
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
levonorgestrel-ethinyl estrad oral tablets,dose
pack,3 month 0.15 mg-30 mcg (91)
1 MO
levonorg-eth estrad triphasic oral tablet 50-30
(6)/75-40 (5)/125-30(10)
1 MO
levora-28 oral tablet 0.15-0.03 mg 1 MO
LILLOW (28) ORAL TABLET 0.15-0.03 MG 1 MO
lopreeza oral tablet 1-0.5 mg 1 MO
low-ogestrel (28) oral tablet 0.3-30 mg-mcg 1 MO
lutera (28) oral tablet 0.1-20 mg-mcg 1 MO
marlissa (28) oral tablet 0.15-0.03 mg 1 MO
microgestin 1.5/30 (21) oral tablet 1.5-30 mg-mcg 1 MO
microgestin 1/20 (21) oral tablet 1-20 mg-mcg 1 MO
microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30
mcg (21)/75 mg (7)
1 MO
microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg
(21)/75 mg (7)
1 MO
MILI ORAL TABLET 0.25-35 MG-MCG 1 MO
mimvey lo oral tablet 0.5-0.1 mg 1 MO
MIMVEY ORAL TABLET 1-0.5 MG 1 MO
mononessa (28) oral tablet 0.25-35 mg-mcg 1 MO
MY WAY 1.5 MG TABLET (OTC) 1.5 MG 3 DP
necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 MO
necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg 1 MO
norethindrone ac-eth estradiol oral tablet 1-20
mg-mcg, 1-5 mg-mcg
1 MO
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg
1 MO
NORLYDA ORAL TABLET 0.35 MG 1 MO
nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 1 MO
nortrel 1/35 (21) oral tablet 1-35 mg-mcg (21) 1 MO
nortrel 1/35 (28) oral tablet 1-35 mg-mcg 1 MO
nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35
mcg
1 MO
NUVARING VAGINAL RING 0.12-0.015
MG/24 HR
2 MO
129
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ocella oral tablet 3-0.03 mg 1 MO
OPCICON ONE-STEP 1.5 MG TABLET 1.5 MG 3 DP
OPTION 2 1.5 MG TABLET 1.5 MG 3 DP
orsythia oral tablet 0.1-20 mg-mcg 1 MO
pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 mg
x 5
1 MO
pirmella oral tablet 1-35 mg-mcg 1 MO
PLAN B ONE-STEP 1.5 MG TABLET (OTC) 1.5
MG
3 DP
portia 28 oral tablet 0.15-0.03 mg 1 MO
PREMPHASE ORAL TABLET 0.625 MG (14)/
0.625MG-5MG(14)
2 MO
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-
1.5 MG, 0.625-2.5 MG, 0.625-5 MG
2 MO
previfem oral tablet 0.25-35 mg-mcg 1 MO
quasense oral tablets,dose pack,3 month 0.15 mg-
30 mcg (91)
1 MO
REACT 1.5 MG TABLET 1.5 MG 3 DP
reclipsen (28) oral tablet 0.15-0.03 mg 1 MO
setlakin oral tablets,dose pack,3 month 0.15 mg-30
mcg (91)
1 MO
sprintec (28) oral tablet 0.25-35 mg-mcg 1 MO
sronyx oral tablet 0.1-20 mg-mcg 1 MO
TAKE ACTION 1.5 MG TABLET 1.5 MG 3 DP
tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75
mg (7)
1 MO
TARINA FE 1-20 EQ (28) ORAL TABLET 1
MG-20 MCG (21)/75 MG (7)
1 MO
TRI FEMYNOR ORAL TABLET 0.18/0.215/0.25
MG-35 MCG (28)
1 MO
TRI-ESTARYLLA ORAL TABLET
0.18/0.215/0.25 MG-35 MCG (28)
1 MO
tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-
35mcg (9)
1 MO
130
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG-
35 MCG (28)
1 MO
trinessa (28) oral tablet 0.18/0.215/0.25 mg-35
mcg (28)
1 MO
tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35
mcg (28)
1 MO
tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35
mcg (28)
1 MO
trivora (28) oral tablet 50-30 (6)/75-40 (5)/125-
30(10)
1 MO
tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg
(28)
1 MO
velivet triphasic regimen (28) oral tablet
0.1/.125/.15-25 mg-mcg
1 MO
vienva oral tablet 0.1-20 mg-mcg 1 MO
vyfemla (28) oral tablet 0.4-35 mg-mcg 1 MO
vylibra oral tablet 0.25-35 mg-mcg 1 MO
xulane transdermal patch weekly 150-35 mcg/24
hr
1 MO
zarah oral tablet 3-0.03 mg 1 MO
zovia 1/35e (28) oral tablet 1-35 mg-mcg 1 MO
PROGESTINS
camila oral tablet 0.35 mg 1 MO
deblitane oral tablet 0.35 mg 1 MO
DEPO-SUBQ PROVERA 104
SUBCUTANEOUS SYRINGE 104 MG/0.65 ML
2 MO
errin oral tablet 0.35 mg 1 MO
INCASSIA ORAL TABLET 0.35 MG 1 MO
jolivette oral tablet 0.35 mg 1 MO
lyza oral tablet 0.35 mg 1 MO
medroxyprogesterone intramuscular suspension
150 mg/ml
1 MO
medroxyprogesterone intramuscular syringe 150
mg/ml
1 MO
medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5
mg
1 MO
131
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
megestrol oral suspension 400 mg/10 ml (10 ml),
400 mg/10 ml (40 mg/ml), 625 mg/5 ml
1 PA; MO
megestrol oral tablet 20 mg, 40 mg 1 PA
nora-be oral tablet 0.35 mg 1 MO
norethindrone (contraceptive) oral tablet 0.35 mg 1 MO
norethindrone acetate oral tablet 5 mg 1 MO
norlyroc oral tablet 0.35 mg 1 MO
progesterone micronized oral capsule 100 mg, 200
mg
1 MO
sharobel oral tablet 0.35 mg 1 MO
TULANA ORAL TABLET 0.35 MG 1 MO
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
DUAVEE ORAL TABLET 0.45-20 MG 2 MO
raloxifene oral tablet 60 mg 1 MO
HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY)
HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY)
desmopressin nasal spray with pump 10 mcg/spray
(0.1 ml)
1 MO
desmopressin nasal spray,non-aerosol 10
mcg/spray (0.1 ml)
1 MO
desmopressin oral tablet 0.1 mg, 0.2 mg 1 MO
EGRIFTA SUBCUTANEOUS RECON SOLN 1
MG, 2 MG
2 PA; MO
GENOTROPIN MINIQUICK SUBCUTANEOUS
SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML,
0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25
ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6
MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML
2 PA; MO
GENOTROPIN SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36 UNIT/ML), 5
MG/ML (15 UNIT/ML)
2 PA; MO
HUMATROPE INJECTION CARTRIDGE 12
MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18
UNIT)
2 PA; MO
HUMATROPE INJECTION RECON SOLN 5 (15
UNIT) MG
2 PA; MO
132
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
INCRELEX SUBCUTANEOUS SOLUTION 10
MG/ML
2 PA
NOCTIVA NASAL SPRAY,NON-AEROSOL
0.83 MCG/SPRAY (0.1 ML), 1.66 MCG/SPRAY
(0.1 ML)
2 PA; MO
NORDITROPIN FLEXPRO SUBCUTANEOUS
PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML),
15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10
MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
2 PA; MO
NUTROPIN AQ NUSPIN SUBCUTANEOUS
PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20
MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5
MG/ML)
2 PA; MO
OMNITROPE SUBCUTANEOUS CARTRIDGE
10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3
MG/ML)
2 PA; MO
OMNITROPE SUBCUTANEOUS RECON
SOLN 5.8 MG
2 PA; MO
HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID)
HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID)
LEVO-T 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
2 MO
levothyroxine 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 MO
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
2 MO
liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg 1 MO
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
2 MO
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
2 MO
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
133
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
cabergoline oral tablet 0.5 mg 1 MO
ELIGARD (3 MONTH) SUBCUTANEOUS
SYRINGE 22.5 MG
2 PA; MO
ELIGARD (4 MONTH) SUBCUTANEOUS
SYRINGE 30 MG
2 PA; MO
ELIGARD (6 MONTH) SUBCUTANEOUS
SYRINGE 45 MG
2 PA; MO
ELIGARD SUBCUTANEOUS SYRINGE 7.5
MG (1 MONTH)
2 PA; MO
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 120 MG
2 PA
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 80 MG
2 PA; MO
FIRMAGON SUBCUTANEOUS RECON SOLN
120 MG
2 PA
leuprolide subcutaneous kit 1 mg/0.2 ml 1 MO
leuprolide subcutaneous solution 1 mg/0.2 ml 1
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 11.25 MG
2 PA
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 22.5 MG
2 PA; MO
LUPRON DEPOT (4 MONTH)
INTRAMUSCULAR SYRINGE KIT 30 MG
2 PA; MO
LUPRON DEPOT (6 MONTH)
INTRAMUSCULAR SYRINGE KIT 45 MG
2 PA; MO
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 3.75 MG
2 PA
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 7.5 MG
2 PA; MO
LUPRON DEPOT-PED (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 11.25 MG
2 PA; MO
LUPRON DEPOT-PED INTRAMUSCULAR KIT
7.5 MG (PED)
2 PA; MO
octreotide acetate injection solution 1,000 mcg/ml,
500 mcg/ml
1 PA; MO
134
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
OCTREOTIDE ACETATE INJECTION
SOLUTION 100 MCG/ML, 200 MCG/ML, 50
MCG/ML
1 PA; MO
ORILISSA ORAL TABLET 150 MG 2 PA; MO
ORILISSA ORAL TABLET 200 MG 2 PA
SIGNIFOR SUBCUTANEOUS SOLUTION 0.3
MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML
(1 ML)
2 PA; MO
SOMATULINE DEPOT SUBCUTANEOUS
SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90
MG/0.3 ML
2 PA; MO
SOMAVERT SUBCUTANEOUS RECON SOLN
10 MG, 15 MG, 20 MG, 25 MG, 30 MG
2 PA; MO
SYNAREL NASAL SPRAY,NON-AEROSOL 2
MG/ML
2 PA
TRELSTAR INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 11.25 MG, 3.75 MG
2 PA; MO
TRELSTAR INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 22.5 MG
2 PA
TRELSTAR INTRAMUSCULAR SYRINGE
11.25 MG/2 ML, 3.75 MG/2 ML
2 PA; MO
TRELSTAR INTRAMUSCULAR SYRINGE
22.5 MG/2 ML
2 PA
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole oral tablet 10 mg, 5 mg 1 MO
propylthiouracil oral tablet 50 mg 1 MO
IMMUNOLOGICAL AGENTS
ANGIOEDEMA AGENTS
CINRYZE INTRAVENOUS RECON SOLN 500
UNIT (5 ML)
2 PA; MO
FIRAZYR SUBCUTANEOUS SYRINGE 30
MG/3 ML
2 PA
HAEGARDA SUBCUTANEOUS RECON SOLN
2,000 UNIT, 3,000 UNIT
2 PA; MO
IMMUNE SUPPRESSANTS
135
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ASTAGRAF XL ORAL CAPSULE,EXTENDED
RELEASE 24HR 0.5 MG, 1 MG, 5 MG
2 B/D; MO
azathioprine oral tablet 50 mg 1 B/D; MO
CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT 400 MG (200 MG X 2
VIALS)
2 PA; MO
CIMZIA STARTER KIT SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)
2 PA; MO
CIMZIA SUBCUTANEOUS SYRINGE KIT 400
MG/2 ML (200 MG/ML X 2)
2 PA; MO
cyclosporine modified oral capsule 100 mg, 25
mg, 50 mg
1 B/D; MO
cyclosporine modified oral solution 100 mg/ml 1 B/D; MO
cyclosporine oral capsule 100 mg, 25 mg 1 B/D; MO
DEPEN TITRATABS ORAL TABLET 250 MG 2 PA; MO
ENBREL MINI SUBCUTANEOUS
CARTRIDGE 50 MG/ML (0.98 ML)
2 PA; MO
ENBREL SUBCUTANEOUS RECON SOLN 25
MG (1 ML)
2 PA; MO
ENBREL SUBCUTANEOUS SYRINGE 25
MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
2 PA; MO
ENBREL SURECLICK SUBCUTANEOUS PEN
INJECTOR 50 MG/ML (0.98 ML)
2 PA; MO
ENVARSUS XR ORAL TABLET EXTENDED
RELEASE 24 HR 0.75 MG, 1 MG, 4 MG
2 B/D; MO
gengraf oral capsule 100 mg, 25 mg 1 B/D; MO
gengraf oral solution 100 mg/ml 1 B/D; MO
HUMIRA PEDIATRIC CROHNS START
SUBCUTANEOUS SYRINGE KIT 40 MG/0.8
ML
2 PA; MO
HUMIRA PEDIATRIC CROHNS START
SUBCUTANEOUS SYRINGE KIT 40 MG/0.8
ML (6 PACK)
2 PA
HUMIRA PEN CROHNS-UC-HS START
SUBCUTANEOUS PEN INJECTOR KIT 40
MG/0.8 ML
2 PA; MO
136
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
HUMIRA PEN PSOR-UVEITS-ADOL HS
SUBCUTANEOUS PEN INJECTOR KIT 40
MG/0.8 ML
2 PA; MO
HUMIRA PEN SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.8 ML
2 PA; MO
HUMIRA SUBCUTANEOUS SYRINGE KIT 10
MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML
2 PA; MO
HUMIRA(CF) PEDI CROHNS STARTER
SUBCUTANEOUS SYRINGE KIT 80 MG/0.8
ML
2 PA; MO
HUMIRA(CF) PEDI CROHNS STARTER
SUBCUTANEOUS SYRINGE KIT 80 MG/0.8
ML-40 MG/0.4 ML
2 PA
HUMIRA(CF) PEN CROHNS-UC-HS
SUBCUTANEOUS PEN INJECTOR KIT 80
MG/0.8 ML
2 PA
HUMIRA(CF) PEN PSOR-UV-ADOL HS
SUBCUTANEOUS PEN INJECTOR KIT 80
MG/0.8 ML-40 MG/0.4 ML
2 PA
HUMIRA(CF) PEN SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.4 ML
2 PA; MO
HUMIRA(CF) PEN SUBCUTANEOUS PEN
INJECTOR KIT 80 MG/0.8 ML
2 PA
HUMIRA(CF) SUBCUTANEOUS SYRINGE
KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4
ML
2 PA; MO
KINERET SUBCUTANEOUS SYRINGE 100
MG/0.67 ML
2 PA; MO
methotrexate sodium (pf) injection solution 25
mg/ml
1
methotrexate sodium injection solution 25 mg/ml 1
methotrexate sodium oral tablet 2.5 mg 1 MO
mycophenolate mofetil oral capsule 250 mg 1 B/D; MO
mycophenolate mofetil oral suspension for
reconstitution 200 mg/ml
1 B/D; MO
mycophenolate mofetil oral tablet 500 mg 1 B/D; MO
mycophenolate sodium oral tablet,delayed release
(dr/ec) 180 mg, 360 mg
1 B/D; MO
137
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ORENCIA CLICKJECT SUBCUTANEOUS
AUTO-INJECTOR 125 MG/ML
2 PA; MO
ORENCIA SUBCUTANEOUS SYRINGE 125
MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML
2 PA; MO
RAPAMUNE ORAL SOLUTION 1 MG/ML 2 B/D; MO
SANDIMMUNE ORAL SOLUTION 100 MG/ML 2 B/D; MO
SIMPONI SUBCUTANEOUS PEN INJECTOR
100 MG/ML, 50 MG/0.5 ML
2 PA; MO
SIMPONI SUBCUTANEOUS SYRINGE 100
MG/ML, 50 MG/0.5 ML
2 PA; MO
sirolimus oral solution 1 mg/ml 1
sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1 B/D; MO
tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 B/D; MO
TREXALL ORAL TABLET 10 MG, 15 MG, 5
MG, 7.5 MG
2 ST; MO
XATMEP ORAL SOLUTION 2.5 MG/ML 2 PA; MO
ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG,
0.75 MG, 1 MG
2 B/D; MO
IMMUNIZING AGENTS, PASSIVE
BIVIGAM INTRAVENOUS SOLUTION 10 % 2 B/D; MO
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 6 GRAM
2 B/D; MO
FLEBOGAMMA DIF INTRAVENOUS
SOLUTION 10 %
2 B/D; MO
GAMMAGARD LIQUID INJECTION
SOLUTION 10 %
2 B/D; MO
GAMMAGARD S-D (IGA < 1 MCG/ML)
INTRAVENOUS RECON SOLN 10 GRAM, 5
GRAM
2 B/D; MO
GAMMAKED INJECTION SOLUTION 1
GRAM/10 ML (10 %)
2 B/D; MO
GAMMAPLEX (WITH SORBITOL)
INTRAVENOUS SOLUTION 5 %
2 B/D; MO
GAMMAPLEX INTRAVENOUS SOLUTION 10
%
2 B/D; MO
138
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
GAMMAPLEX INTRAVENOUS SOLUTION 10
% (100 ML), 10 % (200 ML)
2 B/D
GAMUNEX-C INJECTION SOLUTION 1
GRAM/10 ML (10 %)
2 B/D; MO
HYPERRAB (PF) INTRAMUSCULAR
SOLUTION 300 UNIT/ML
2
HYPERRAB S/D (PF) INTRAMUSCULAR
SOLUTION 150 UNIT/ML, 150 UNIT/ML (10
ML)
2
PRIVIGEN INTRAVENOUS SOLUTION 10 % 2 B/D; MO
IMMUNOMODULATORS
ACTEMRA ACTPEN SUBCUTANEOUS PEN
INJECTOR 162 MG/0.9 ML
2 PA; MO
ACTEMRA SUBCUTANEOUS SYRINGE 162
MG/0.9 ML
2 PA; MO
ACTIMMUNE SUBCUTANEOUS SOLUTION
100 MCG/0.5 ML
2 PA
ARCALYST SUBCUTANEOUS RECON SOLN
220 MG
2 PA; MO
BENLYSTA SUBCUTANEOUS AUTO-
INJECTOR 200 MG/ML
2 PA; MO
BENLYSTA SUBCUTANEOUS SYRINGE 200
MG/ML
2 PA; MO
leflunomide oral tablet 10 mg, 20 mg 1 MO
OTEZLA ORAL TABLET 30 MG 2 PA; MO
OTEZLA STARTER ORAL TABLETS,DOSE
PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG
(4)-20 MG (4)-30 MG(19)
2 PA
XOLAIR SUBCUTANEOUS RECON SOLN 150
MG
2 PA; MO
XOLAIR SUBCUTANEOUS SYRINGE 150
MG/ML, 75 MG/0.5 ML
2 PA; MO
VACCINES
ACTHIB (PF) INTRAMUSCULAR RECON
SOLN 10 MCG/0.5 ML
2
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-
3-5 MCG)-5LF/0.5 ML
2
139
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5
MCG)-5LF/0.5 ML
2
BCG VACCINE, LIVE (PF) PERCUTANEOUS
SUSPENSION FOR RECONSTITUTION 50 MG
2
BEXSERO INTRAMUSCULAR SYRINGE 50-
50-50-25 MCG/0.5 ML
2
BOOSTRIX TDAP INTRAMUSCULAR
SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML
2
BOOSTRIX TDAP INTRAMUSCULAR
SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML
2
DAPTACEL (DTAP PEDIATRIC) (PF)
INTRAMUSCULAR SUSPENSION 15-10-5 LF-
MCG-LF/0.5ML
2
ENGERIX-B (PF) INTRAMUSCULAR
SYRINGE 20 MCG/ML
2 B/D
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML
2 B/D
GARDASIL 9 (PF) INTRAMUSCULAR
SUSPENSION 0.5 ML
2
GARDASIL 9 (PF) INTRAMUSCULAR
SYRINGE 0.5 ML
2
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA UNIT/ML, 720
ELISA UNIT/0.5 ML
2
HAVRIX (PF) INTRAMUSCULAR SYRINGE
1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5
ML
2
HEPLISAV-B (PF) INTRAMUSCULAR
SOLUTION 20 MCG/0.5 ML
2 B/D
HEPLISAV-B (PF) INTRAMUSCULAR
SYRINGE 20 MCG/0.5 ML
2 B/D
HIBERIX (PF) INTRAMUSCULAR RECON
SOLN 10 MCG/0.5 ML
2
IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN 2.5 UNIT
2
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SUSPENSION 25-58-10 LF-MCG-LF/0.5ML
2
140
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SYRINGE 25-58-10 LF-MCG-LF/0.5ML
2
IPOL INJECTION SUSPENSION 40-8-32
UNIT/0.5 ML
2
IXIARO (PF) INTRAMUSCULAR SYRINGE 6
MCG/0.5 ML
2
KEDRAB (PF) INTRAMUSCULAR SOLUTION
150 UNIT/ML
2
KINRIX (PF) INTRAMUSCULAR
SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML
2
KINRIX (PF) INTRAMUSCULAR SYRINGE 25
LF-58 MCG-10 LF/0.5 ML
2
MENACTRA (PF) INTRAMUSCULAR
SOLUTION 4 MCG/0.5 ML
2
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT 10-5 MCG/0.5 ML
2
M-M-R II (PF) SUBCUTANEOUS RECON
SOLN 1,000-12,500 TCID50/0.5 ML
2
PEDIARIX (PF) INTRAMUSCULAR SYRINGE
10 MCG-25LF-25 MCG-10LF/0.5 ML
2
PEDVAX HIB (PF) INTRAMUSCULAR
SOLUTION 7.5 MCG/0.5 ML
2
PENTACEL ACTHIB COMPONENT (PF)
INTRAMUSCULAR RECON SOLN 10 MCG/0.5
ML
2
PROQUAD (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION
10EXP3-4.3-3- 3.99 TCID50/0.5
2
QUADRACEL (PF) INTRAMUSCULAR
SUSPENSION 15 LF-48 MCG- 5 LF
UNIT/0.5ML
2
RABAVERT (PF) INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 2.5
UNIT
2
RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION 10 MCG/ML, 40 MCG/ML
2 B/D
RECOMBIVAX HB (PF) INTRAMUSCULAR
SYRINGE 10 MCG/ML, 5 MCG/0.5 ML
2 B/D
141
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ROTARIX ORAL SUSPENSION FOR
RECONSTITUTION 10EXP6 CCID50/ML
2
ROTATEQ VACCINE ORAL SOLUTION 2 ML 2
SHINGRIX (PF) INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 50
MCG/0.5 ML
2 QL (2 EA per 999 days)
SHINGRIX GE ANTIGEN COMPONENT
INTRAMUSCULAR SUSPENSION FOR
RECONSTITUTION 50 MCG
2
TENIVAC (PF) INTRAMUSCULAR
SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML
2
TENIVAC (PF) INTRAMUSCULAR SYRINGE
5-2 LF UNIT/0.5 ML
2
tetanus,diphtheria tox ped(pf) intramuscular
suspension 5-25 lf unit/0.5 ml
1
tetanus-diphtheria toxoids-td intramuscular
suspension 2-2 lf unit/0.5 ml
1
TICE BCG INTRAVESICAL SUSPENSION
FOR RECONSTITUTION 50 MG
2
TRUMENBA INTRAMUSCULAR SYRINGE
120 MCG/0.5 ML
2
TWINRIX (PF) INTRAMUSCULAR SYRINGE
720 ELISA UNIT- 20 MCG/ML
2
TYPHIM VI INTRAMUSCULAR SOLUTION 25
MCG/0.5 ML
2
TYPHIM VI INTRAMUSCULAR SYRINGE 25
MCG/0.5 ML
2
VAQTA (PF) INTRAMUSCULAR
SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML
2
VAQTA (PF) INTRAMUSCULAR SYRINGE 25
UNIT/0.5 ML, 50 UNIT/ML
2
VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION 1,350
UNIT/0.5 ML
2
VARIZIG INTRAMUSCULAR RECON SOLN
125 UNIT
2
VARIZIG INTRAMUSCULAR SOLUTION 125
UNIT/1.2 ML
2
142
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
VAXCHORA BUFFER COMPONENT ORAL
SUSPENSION FOR RECONSTITUTION
2
VAXCHORA VACCINE ORAL SUSPENSION
FOR RECONSTITUTION 4X10EXP8 TO 2X
10EXP9 CF UNIT
2
YF-VAX (PF) SUBCUTANEOUS SUSPENSION
FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5
ML
2
ZOSTAVAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION 19,400
UNIT/0.65 ML
2 QL (1 EA per 999 days)
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
balsalazide oral capsule 750 mg 1
DELZICOL ORAL CAPSULE (WITH DEL REL
TABLETS) 400 MG
2 MO
DIPENTUM ORAL CAPSULE 250 MG 2 MO
mesalamine oral tablet,delayed release (dr/ec) 1.2
gram
1 MO
mesalamine rectal enema 4 gram/60 ml 1 MO
mesalamine rectal suppository 1,000 mg 1 MO
mesalamine with cleansing wipe rectal enema kit 4
gram/60 ml
1 MO
PENTASA ORAL CAPSULE, EXTENDED
RELEASE 250 MG, 500 MG
2 MO
GLUCOCORTICOIDS
BUDESONIDE ORAL
CAPSULE,DELAYED,EXTEND.RELEASE 3
MG
1
hydrocortisone rectal enema 100 mg/60 ml 1
methylprednisolone oral tablet 16 mg, 32 mg, 4
mg, 8 mg
1
SULFONAMIDES
sulfasalazine oral tablet 500 mg 1 MO
sulfasalazine oral tablet,delayed release (dr/ec)
500 mg
1 MO
METABOLIC BONE DISEASE AGENTS
143
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
METABOLIC BONE DISEASE AGENTS
alendronate oral tablet 10 mg, 35 mg, 40 mg, 5
mg, 70 mg
1 MO
calcitonin (salmon) nasal spray,non-aerosol 200
unit/actuation
1 MO
doxercalciferol intravenous solution 4 mcg/2 ml 1 MO
doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5
mcg
1 MO
etidronate disodium oral tablet 200 mg, 400 mg 1 MO
FORTEO SUBCUTANEOUS PEN INJECTOR
20 MCG/DOSE - 600 MCG/2.4 ML
2 PA; MO
ibandronate oral tablet 150 mg 1 MO
NATPARA SUBCUTANEOUS CARTRIDGE
100 MCG/DOSE, 25 MCG/DOSE, 50
MCG/DOSE, 75 MCG/DOSE
2 PA; MO
PROLIA SUBCUTANEOUS SYRINGE 60
MG/ML
2 PA; MO
risedronate oral tablet 150 mg, 35 mg, 5 mg 1 MO
risedronate oral tablet 30 mg, 35 mg (12 pack), 35
mg (4 pack)
1
SENSIPAR ORAL TABLET 30 MG, 60 MG 2 MO; QL (60 EA per 30 days)
SENSIPAR ORAL TABLET 90 MG 2 MO; QL (120 EA per 30 days)
TYMLOS SUBCUTANEOUS PEN INJECTOR
80 MCG (3,120 MCG/1.56 ML)
2 PA; MO
XGEVA SUBCUTANEOUS SOLUTION 120
MG/1.7 ML (70 MG/ML)
2 PA
OPHTHALMIC AGENTS
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
latanoprost ophthalmic (eye) drops 0.005 % 1 MO
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01
%
2 MO
TRAVATAN Z OPHTHALMIC (EYE) DROPS
0.004 %
2 MO
OPHTHALMIC AGENTS, OTHER
ARTIFICIAL TEARS 1.4% DROPS 1.4 % 3 DP
144
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ARTIFICIAL TEARS EYE OINTMENT 83-15 % 3 DP
CYSTARAN OPHTHALMIC (EYE) DROPS
0.44 %
2 MO
GENTEAL GEL DROPS 0.25-0.3 % 3 DP
GENTEAL MILD-MODERATE EYE DROP P/F,
DRY EYE RELIEF 0.3 %
3 DP
GENTEAL TEARS 0.1%-0.2%-0.3% 0.1-0.3-0.2
%
3 DP
GENTEAL TEARS 0.1%-0.3% DROP 0.1-0.3 % 3 DP
GENTEAL TEARS 0.1%-0.3% DROP 0.1-0.3 % 3 DP
GENTEAL TEARS SEVERE 0.3% GEL OUTER
0.3 %
3 DP
GS LUBRICAT PLUS 0.5% EYE DRPS P/F,
30X0.4ML 0.5 %
3 DP
HM LUBRICAT PLUS 0.5% EYE DRPS P/F,
SUV, STERILE 0.5 %
3 DP
HM LUBRICATING TEARS EYE DROPS 0.4-
0.3 %
3 DP
LIQUITEARS 1.4% DROPS 1.4 % 3 DP
LUBRICANT 0.5-0.9% EYE DROPS 0.5-0.9 % 3 DP
LUBRICANT EYE 0.4%-0.3% DROP P/F 0.4-0.3
%
3 DP
LUBRICANT EYE DROPS 0.4-0.3 % 3 DP
LUBRICANT EYE DROPS DRY EYE
THERAPY 0.4-0.3 %
3 DP
LUBRICANT PM EYE OINTMENT P/F 57.3-
42.5 %
3 DP
LUBRICATING PLUS 0.5% EYE DRPS P/F,
30X0.4ML 0.5 %
3 DP
LUBRIFRESH PM EYE OINTMENT 83-15 % 3 DP
MURO-128 2% EYE DROPS 2 % 3 DP
MURO-128 5% EYE DROPS 5 % 3 DP
MURO-128 5% EYE OINTMENT 5 % 3 DP
NATACYN OPHTHALMIC (EYE)
DROPS,SUSPENSION 5 %
2
NATURE'S TEARS EYE DROPS 0.1-0.3 % 3 DP
145
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
OXERVATE OPHTHALMIC (EYE) DROPS
0.002 %
2 PA
proparacaine ophthalmic (eye) drops 0.5 % 1
REFRESH CELLUVISC 1% EYE DROPS 1 % 3 DP
REFRESH CLASSIC EYE DROPS U-
D,P/F,30X.4ML 1.4-0.6 %
3 DP
REFRESH CLASSIC EYE DROPS U-
D,P/F,50X.4ML 1.4-0.6 %
3 DP
REFRESH LACRI-LUBE OINTMENT 56.8-42.5
%
3 DP
REFRESH OPTIVE ADVANCED DROPS 0.5-1-
0.5 %
3 DP
REFRESH OPTIVE EYE DROPS 0.5-0.9 % 3 DP
REFRESH OPTIVE SENSITIVE DROPS
30X0.4ML, P/F 0.5-0.9 %
3 DP
REFRESH OPTIVE SENSITIVE DROPS
60X0.4ML, P/F 0.5-0.9 %
3 DP
REFRESH PLUS 0.5% EYE DROPS 30X0.4ML
0.5 %
3 DP
REFRESH PLUS 0.5% EYE DROPS
70X0.4ML,U-D 0.5 %
3 DP
REFRESH PLUS 0.5% EYE DROPS U-
D,50X.4ML 0.5 %
3 DP
REFRESH TEARS 0.5% EYE DROP 0.5 % 3 DP
RESTASIS MULTIDOSE OPHTHALMIC (EYE)
DROPS 0.05 %
2 MO; QL (11 ML per 30 days)
RESTASIS OPHTHALMIC (EYE)
DROPPERETTE 0.05 %
2 MO; QL (60 EA per 30 days)
SM LUBRICANT EYE DROPS STRL 0.4-0.3 % 3 DP
SM LUBRICATING TEARS EYE DROPS
STERILE 0.4-0.3 %
3 DP
sodium chloride 5% eye drop 5 % 3 DP
sodium chloride 5% eye oint 5 % 3 DP
sodium chloride 5% eye oint sterile 5 % 3 DP
sulfacetamide-prednisolone ophthalmic (eye)
drops 10 %-0.23 % (0.25 %)
1
146
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
SYSTANE 0.3% EYE GEL 0.3 % 3 DP
SYSTANE 0.3-0.4% EYE DROP P/F 0.4-0.3 % 3 DP
SYSTANE 0.3-0.4% EYE DROP U-
D,P/F,0.014X28 VL 0.4-0.3 %
3 DP
SYSTANE 0.3-0.4% EYE DROPS 0.4-0.3 % 3 DP
SYSTANE 0.3-0.4% EYE DROPS POCKET
PACK, 2X5ML 0.4-0.3 %
3 DP
SYSTANE 0.3-0.4% EYE DROPS TWIN PACK,
2X20ML 0.4-0.3 %
3 DP
SYSTANE BALANCE 0.6% EYE DROP
CLINICAL STRENGTH 0.6 %
3 DP
SYSTANE ULTRA 0.4-0.3% EYE DRP 0.4-0.3
%
3 DP
TEARS NATURALE FREE DROPS U-
D,36X.9ML,P/F 0.1-0.3 %
3 DP
ULTRA LUBRICANT EYE DROPS 0.4-0.3 % 3 DP
XIIDRA OPHTHALMIC (EYE) DROPPERETTE
5 %
2 MO; QL (60 EA per 30 days)
OPHTHALMIC ANTI-ALLERGY AGENTS
azelastine ophthalmic (eye) drops 0.05 % 1
cromolyn ophthalmic (eye) drops 4 % 1
epinastine ophthalmic (eye) drops 0.05 % 1
olopatadine ophthalmic (eye) drops 0.1 % 1
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P OPHTHALMIC (EYE) DROPS
0.1 %
2 MO
atropine ophthalmic (eye) drops 1 % 1 MO
AZOPT OPHTHALMIC (EYE)
DROPS,SUSPENSION 1 %
2 ST; MO
brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % 1 MO
carteolol ophthalmic (eye) drops 1 % 1 MO
COMBIGAN OPHTHALMIC (EYE) DROPS 0.2-
0.5 %
2 MO
dorzolamide ophthalmic (eye) drops 2 % 1 MO
dorzolamide-timolol ophthalmic (eye) drops 22.3-
6.8 mg/ml
1 MO
147
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
FML FORTE OPHTHALMIC (EYE)
DROPS,SUSPENSION 0.25 %
2
levobunolol ophthalmic (eye) drops 0.5 % 1 MO
PHOSPHOLINE IODIDE OPHTHALMIC (EYE)
DROPS 0.125 %
2 MO
pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %,
4 %
1 MO
SIMBRINZA OPHTHALMIC (EYE)
DROPS,SUSPENSION 1-0.2 %
2 MO
timolol maleate ophthalmic (eye) drops 0.25 %,
0.5 %
1 MO
timolol maleate ophthalmic (eye) gel forming
solution 0.25 %, 0.5 %
1 MO
OPHTHALMIC ANTI-INFLAMMATORIES
dexamethasone sodium phosphate ophthalmic
(eye) drops 0.1 %
1
diclofenac sodium ophthalmic (eye) drops 0.1 % 1
DUREZOL OPHTHALMIC (EYE) DROPS 0.05
%
2
fluorometholone ophthalmic (eye)
drops,suspension 0.1 %
1
flurbiprofen sodium ophthalmic (eye) drops 0.03
%
1
ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % 1
prednisolone acetate ophthalmic (eye)
drops,suspension 1 %
1
prednisolone sodium phosphate ophthalmic (eye)
drops 1 %
1
OTIC AGENTS
OTIC AGENTS
acetic acid-aluminum acetate otic (ear) drops 2 % 1
CIPRODEX OTIC (EAR) DROPS,SUSPENSION
0.3-0.1 %
2
hydrocortisone-acetic acid otic (ear) drops 1-2 % 1
neomycin-polymyxin-hc otic (ear)
drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%
1
148
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
neomycin-polymyxin-hc otic (ear) solution 3.5-
10,000-1 mg/ml-unit/ml-%
1
ofloxacin otic (ear) drops 0.3 % 1
RESPIRATORY TRACT/ PULMONARY AGENTS
ANTIHISTAMINES
ALL DAY ALLERGY 10 MG CHEW TAB 10
MG
3 DP
ALL DAY ALLERGY 10 MG TABLET 10 MG 3 DP
ALL DAY ALLERGY 10 MG TABLET
INDOOR/OUTDOOR 10 MG
3 DP
ALL DAY ALLERGY 10 MG TABLET
INDOOR/OUTDOOR 24 HR 10 MG
3 DP
ALLER-CHLOR 4 MG TABLET 4 MG 3 DP
ALLERGY (LORATADINE) 10 MG TAB 10 MG 3 DP
ALLERGY 25 MG CAPSULE 25 MG 3 DP
ALLERGY 4 MG TABLET 4 MG 3 DP
ALLERGY RELIEF 10 MG TABLET 10 MG 3 DP
ALLERGY RELIEF 10 MG TABLET NON-
DROWSY,24 HOUR 10 MG
3 DP
ALLERGY RELIEF 180 MG TABLET 180 MG 3 DP
ALLERGY RELIEF 25 MG SOFTGEL
SOFTGEL 25 MG
3 DP
ALLERGY RELIEF 5 MG/5 ML SOLN A/F 5
MG/5 ML
3 DP
ALLERGY RELIEF SYRUP A/F 5 MG/5 ML 3 DP
ALLERGY-TIME 4 MG TABLET 4 MG 3 DP
azelastine nasal aerosol,spray 137 mcg (0.1 %) 1 MO
azelastine nasal spray,non-aerosol 0.15 % (205.5
mcg)
1 MO
BANOPHEN 12.5 MG/5 ML SOLUTION 12.5
MG/5 ML
3 DP
BANOPHEN 25 MG CAPSULE 25 MG 3 DP
BANOPHEN 25 MG TABLET 25 MG 3 DP
BANOPHEN 50 MG CAPSULE 50 MG 3 DP
cetirizine hcl 1 mg/ml soln (otc) 1 mg/ml 3 DP
149
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
cetirizine hcl 1 mg/ml soln children, s/f, grape
(otc) 1 mg/ml
3 DP
cetirizine hcl 1 mg/ml soln children's (otc) 1 mg/ml 3 DP
cetirizine hcl 10 mg tablet 10 mg 3 DP
cetirizine hcl 10 mg tablet f/c,u-d,10x10,inner 10
mg
3 DP
cetirizine hcl 10 mg tablet f/c,u-d,10x10,outer 10
mg
3 DP
cetirizine hcl 10 mg tablet indoor & outdoor 10
mg
3 DP
cetirizine hcl 10 mg tablet indoor/outdoor 24 hr 10
mg
3 DP
cetirizine hcl 10 mg tablet indoor-outdoor,24hr 10
mg
3 DP
cetirizine hcl 10 mg tablet outer 10 mg 3 DP
cetirizine hcl 10 mg tablet u-d,10x10 10 mg 3 DP
cetirizine hcl 5 mg tablet 5 mg 3 DP
cetirizine hcl 5 mg tablet indoor & outdoor 5 mg 3 DP
cetirizine hcl 5 mg/5 ml soln inner 5 mg/5 ml 3 DP
cetirizine hcl 5 mg/5 ml soln outer 5 mg/5 ml 3 DP
cetirizine hcl 5 mg/5 ml syrup 40's, u-d cups 5
mg/5 ml
3 DP
cetirizine oral solution 1 mg/ml 1
cetirizine-pse er 5-120 mg tab 12 hr relief 5-120
mg
3 DP
cetirizine-pse er 5-120 mg tab 5-120 mg 3 DP
CHILD ALL DAY ALLERGY 1 MG/ML 1
MG/ML
3 DP
CHILD ALL DAY ALLERGY 1 MG/ML 1
MG/ML
3 DP
CHILD ALL DAY ALLERGY 1 MG/ML
BUBBLE GUM 1 MG/ML
3 DP
CHILD ALL DAY ALLERGY 1 MG/ML
D/F,GLUTEN/F,GRAPE 1 MG/ML
3 DP
CHILD ALLERGY 5 MG/5 ML SOLN 5 MG/5
ML
3 DP
150
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
CHILD ALLERGY RELIEF 1 MG/ML
S/F,D/F,GLUTEN-FREE 1 MG/ML
3 DP
CHILD ALLERGY RLF 12.5 MG/5 ML 12.5
MG/5 ML
3 DP
CHILD CETIRIZINE 10 MG CHEW TB
CHEWABLE, ALLERGY 10 MG
3 DP
child loratadine 5 mg/5 ml syr 5 mg/5 ml 3 DP
child loratadine 5 mg/5 ml syr grape, s/f 5 mg/5 ml 3 DP
CHILD'S ALLERGY 12.5 MG/5 ML
A/F,CHERRY,CHILD 12.5 MG/5 ML
3 DP
chlorpheniramine 4 mg tablet 4 mg 3 DP
clemastine oral tablet 2.68 mg 1 PA
cyproheptadine oral syrup 2 mg/5 ml 1 PA
cyproheptadine oral tablet 4 mg 1 PA
DIPHEDRYL ALLERGY CAPSULE 25 MG 3 DP
DIPHENHIST 12.5 MG/5 ML SOLN 12.5 MG/5
ML
3 DP
DIPHENHIST 25 MG CAPTAB CAPTAB 25
MG
3 DP
diphenhydramine 25 mg caplet caplet 25 mg 3 DP
diphenhydramine 25 mg capsule (otc) 25 mg 3 DP
diphenhydramine 25 mg capsule u-d, 10x10 (otc)
25 mg
3 DP
diphenhydramine 50 mg capsule (otc) 50 mg 3 DP
diphenhydramine hcl injection solution 50 mg/ml 1 B/D
ED-A-HIST 4 MG-10 MG TABLET 4-10 MG 3 DP
fexofenadine hcl 180 mg tablet 24 hour, non-
drowsy (otc) 180 mg
3 DP
fexofenadine hcl 180 mg tablet 24 hour, outer (otc)
180 mg
3 DP
fexofenadine hcl 180 mg tablet 24hr,original str
(otc) 180 mg
3 DP
fexofenadine hcl 180 mg tablet allergy, 24hr (otc)
180 mg
3 DP
fexofenadine hcl 180 mg tablet f/c, 10x10,u-d,inner
(otc) 180 mg
3 DP
151
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
fexofenadine hcl 180 mg tablet f/c, 10x10,u-d,outer
(otc) 180 mg
3 DP
fexofenadine hcl 180 mg tablet non-drowsy, 24hr
(otc) 180 mg
3 DP
fexofenadine hcl 30 mg/5 ml 30 mg/5 ml 3 DP
fexofenadine hcl 60 mg tablet (otc) 60 mg 3 DP
fexofenadine hcl 60 mg tablet 12 hour, non-drowsy
(otc) 60 mg
3 DP
fexofenadine hcl 60 mg tablet indoor/outdoor (otc)
60 mg
3 DP
fexofenadine hcl 60 mg tablet u-d, 10x10,outer
(otc) 60 mg
3 DP
GS ALL DAY ALLERGY 10 MG TAB 10 MG 3 DP
GS ALLER-EASE 180 MG TABLET 180 MG 3 DP
GS NIGHTTIME SLEEP AID 25 MG 25 MG 3 DP
HM ALL DAY ALLERGY 10 MG TAB
INDOOR/OUTDOOR 24 HR 10 MG
3 DP
HM ALLERGY 25 MG CAPSULE MULTI-
SYMPTOM 25 MG
3 DP
HM ALLERGY 25 MG TABLET MINITABS 25
MG
3 DP
HM ALLERGY RELIEF 25 MG CAP 25 MG 3 DP
HM ALLERGY RELIEF 4 MG TABLET 4
HOUR, GLUTEN-FREE 4 MG
3 DP
HM CHILD ALLERGY 12.5 MG/5 ML
A/F,CHERRY 12.5 MG/5 ML
3 DP
HM CHILD CETIRIZINE 1 MG/ML D/F, S/F,
BUBBLEGUM 1 MG/ML
3 DP
HM CHILD CETIRIZINE 1 MG/ML
D/F,GRAPE,S/F,GLUT-F 1 MG/ML
3 DP
hm child loratadine 5 mg/5 ml a/f, grape 5 mg/5
ml
3 DP
hm child loratadine 5 mg/5 ml a/f, s/f, grape 5
mg/5 ml
3 DP
hm fexofenadine hcl 180 mg tab (otc) 180 mg 3 DP
152
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
hm fexofenadine hcl 180 mg tab 24 hour, gluten-
free (otc) 180 mg
3 DP
hm fexofenadine hcl 180 mg tab 24 hour, non-
drowsy (otc) 180 mg
3 DP
hm fexofenadine hcl 60 mg tab 12 hour, non-
drowsy (otc) 60 mg
3 DP
hm loratadine 10 mg tablet 10 mg 3 DP
hydroxyzine hcl oral solution 10 mg/5 ml 1 PA
hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA
levocetirizine oral solution 2.5 mg/5 ml 1 MO
levocetirizine oral tablet 5 mg 1 MO
loratadine 10 mg softgel 10 mg 3 DP
loratadine 10 mg tablet 10 mg 3 DP
loratadine 10 mg tablet 10x10,u-d,outer 10 mg 3 DP
loratadine 10 mg tablet non-drowsy 10 mg 3 DP
loratadine 10 mg tablet non-drowsy, 24hr 10 mg 3 DP
loratadine 5 mg/5 ml soln child's,a/f,s/f,d/f 5 mg/5
ml
3 DP
loratadine 5 mg/5 ml syrup children's 5 mg/5 ml 3 DP
loratadine 5 mg/5 ml syrup children's, a/f, d/f 5
mg/5 ml
3 DP
loratadine allergy 5 mg/5 ml d/f, a/f, s/f 5 mg/5 ml 3 DP
NIGHTTIME SLEEP AID 25 MG CPLT MINI-
CAPLET 25 MG
3 DP
NON-DROWSY ALLERGY 10 MG TAB 10 MG 3 DP
PHARBEDRYL 25 MG CAPSULE 25 MG 3 DP
promethazine oral syrup 6.25 mg/5 ml 1 PA
QC CHILD ALLERGY 12.5 MG/5 ML 12.5
MG/5 ML
3 DP
qc loratadine 10 mg tablet non-drowsy 10 mg 3 DP
QC NIGHTTIME SLEEP 25 MG TAB 25 MG 3 DP
SB ALLERGY 10 MG TABLET ORIGINAL
STRENGTH 10 MG
3 DP
SB ALLERGY MED 25 MG TABLET
MINITABS 25 MG
3 DP
153
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
SB ALLERGY MEDICINE 25 MG CAP 25 MG 3 DP
sb chlorpheniramine 4 mg tab 4 mg 3 DP
SB SLEEP TABLET 25 MG 3 DP
SILADRYL 12.5 MG/5 ML LIQUID 12.5 MG/5
ML
3 DP
SLEEP TABS 25 MG TABLET 25 MG 3 DP
SM ALL DAY ALLERGY 10 MG TAB
INDOOR/OUTDOOR 24 HR 10 MG
3 DP
SM ALLERGY 4-HR 4 MG TABLET 4 MG 3 DP
SM ALLERGY RELIEF 12.5 MG/5 ML 12.5
MG/5 ML
3 DP
SM ALLERGY RELIEF 12.5 MG/5 ML
CHILDREN'S, CHERRY 12.5 MG/5 ML
3 DP
SM ALLERGY RELIEF 25 MG CAP 25 MG 3 DP
SM ALLERGY RELIEF 25 MG CAP GLUTEN
FREE 25 MG
3 DP
SM CHILD ALL DAY ALLER 1 MG/ML
CHERRY 1 MG/ML
3 DP
SM CHILD ALL DAY ALLER 1 MG/ML S/F,
GRAPE 1 MG/ML
3 DP
sm child loratadine 5 mg/5 ml s/f, a/f, gluten/f 5
mg/5 ml
3 DP
sm fexofenadine hcl 180 mg tab 24hr, gluten-free
(otc) 180 mg
3 DP
sm loratadine 10 mg tablet 10 mg 3 DP
sm loratadine 10 mg tablet non-drowsy 10 mg 3 DP
sm loratadine 10 mg tablet non-drowsy,gluten-f 10
mg
3 DP
sm loratadine 5 mg/5 ml syrup 5 mg/5 ml 3 DP
SM SLEEP AID NIGHT TIME CAPLET
CAPLET 25 MG
3 DP
SUDOGEST SINUS AND ALLERGY TAB 4-60
MG
3 DP
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
154
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ARNUITY ELLIPTA INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION, 200
MCG/ACTUATION, 50 MCG/ACTUATION
2 MO
budesonide inhalation suspension for nebulization
0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml
1 B/D; MO
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION, 250
MCG/ACTUATION, 50 MCG/ACTUATION
2 MO
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 110 MCG/ACTUATION, 220
MCG/ACTUATION, 44 MCG/ACTUATION
2 MO
flunisolide nasal spray,non-aerosol 25 mcg (0.025
%)
1 MO
fluticasone nasal spray,suspension 50
mcg/actuation
1 MO
mometasone nasal spray,non-aerosol 50
mcg/actuation
1 MO
QVAR INHALATION AEROSOL 40
MCG/ACTUATION, 80 MCG/ACTUATION
2 MO
QVAR REDIHALER INHALATION HFA
AEROSOL BREATH ACTIVATED 40
MCG/ACTUATION, 80 MCG/ACTUATION
2 MO
ANTILEUKOTRIENES
montelukast oral granules in packet 4 mg 1 MO
montelukast oral tablet 10 mg 1 MO
montelukast oral tablet,chewable 4 mg, 5 mg 1 MO
XYREM ORAL SOLUTION 500 MG/ML 2 PA; LA
zafirlukast oral tablet 10 mg, 20 mg 1 ST; MO
BRONCHODILATORS, ANTICHOLINERGIC
INCRUSE ELLIPTA INHALATION BLISTER
WITH DEVICE 62.5 MCG/ACTUATION
2 MO
ipratropium bromide inhalation solution 0.02 % 1 B/D; MO
SPIRIVA RESPIMAT INHALATION MIST 1.25
MCG/ACTUATION, 2.5 MCG/ACTUATION
2 MO
SPIRIVA WITH HANDIHALER INHALATION
CAPSULE, W/INHALATION DEVICE 18 MCG
2 MO
155
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
TUDORZA PRESSAIR INHALATION
AEROSOL POWDR BREATH ACTIVATED 400
MCG/ACTUATION
2 MO
TUDORZA PRESSAIR INHALATION
AEROSOL POWDR BREATH ACTIVATED 400
MCG/ACTUATION (30 ACTUAT)
2
BRONCHODILATORS, SYMPATHOMIMETIC
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3
ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml
1 B/D; MO
albuterol sulfate oral syrup 2 mg/5 ml 1 MO
albuterol sulfate oral tablet 2 mg, 4 mg 1 MO
albuterol sulfate oral tablet extended release 12 hr
4 mg, 8 mg
1 MO
epinephrine injection auto-injector 0.15 mg/0.15
ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml
1 QL (2 EA per 30 days)
levalbuterol hcl inhalation solution for
nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25
mg/3 ml
1 B/D; MO
metaproterenol oral syrup 10 mg/5 ml 1 MO
metaproterenol oral tablet 10 mg, 20 mg 1 MO
SEREVENT DISKUS INHALATION BLISTER
WITH DEVICE 50 MCG/DOSE
2 MO
STRIVERDI RESPIMAT INHALATION MIST
2.5 MCG/ACTUATION
2 MO
terbutaline oral tablet 2.5 mg, 5 mg 1 MO
VENTOLIN HFA INHALATION HFA
AEROSOL INHALER 90 MCG/ACTUATION
2 MO
CYSTIC FIBROSIS AGENTS
KALYDECO ORAL GRANULES IN PACKET
50 MG, 75 MG
2 PA; MO
KALYDECO ORAL TABLET 150 MG 2 PA; MO
ORKAMBI ORAL GRANULES IN PACKET
100-125 MG, 150-188 MG
2 PA; MO
ORKAMBI ORAL TABLET 100-125 MG, 200-
125 MG
2 PA; MO
156
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
PULMOZYME INHALATION SOLUTION 1
MG/ML
2 B/D; MO
SYMDEKO ORAL TABLETS, SEQUENTIAL
100-150 MG (D)/ 150 MG (N)
2 PA; MO
tobramycin in 0.225 % nacl inhalation solution for
nebulization 300 mg/5 ml
1 B/D; MO
tobramycin with nebulizer inhalation solution for
nebulization 300 mg/5 ml
1 B/D; MO
MAST CELL STABILIZERS
cromolyn inhalation solution for nebulization 20
mg/2 ml
1 B/D; MO
cromolyn sodium nasal spray 5.2 mg/spray (4 %) 3 DP
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
DALIRESP ORAL TABLET 250 MCG, 500
MCG
2 MO
theophylline oral elixir 80 mg/15 ml 1 MO
theophylline oral solution 80 mg/15 ml 1 MO
theophylline oral tablet extended release 12 hr 100
mg, 200 mg, 300 mg, 450 mg
1 MO
theophylline oral tablet extended release 24 hr 400
mg, 600 mg
1 MO
PULMONARY ANTIHYPERTENSIVES
ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5
MG, 2 MG, 2.5 MG
2 PA; MO
LETAIRIS ORAL TABLET 10 MG, 5 MG 2 PA; MO
REVATIO ORAL SUSPENSION FOR
RECONSTITUTION 10 MG/ML
2 PA; MO
sildenafil (antihypertensive) oral tablet 20 mg 1 PA; MO
VENTAVIS INHALATION SOLUTION FOR
NEBULIZATION 10 MCG/ML, 20 MCG/ML
2 PA; MO
PULMONARY FIBROSIS AGENTS
ESBRIET ORAL CAPSULE 267 MG 2 PA; MO
ESBRIET ORAL TABLET 267 MG, 801 MG 2 PA; MO
OFEV ORAL CAPSULE 100 MG, 150 MG 2 PA; MO
RESPIRATORY TRACT AGENTS, OTHER
157
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
acetylcysteine solution 100 mg/ml (10 %), 200
mg/ml (20 %)
1 B/D
ADVAIR DISKUS INHALATION BLISTER
WITH DEVICE 100-50 MCG/DOSE, 250-50
MCG/DOSE, 500-50 MCG/DOSE
2 MO
ADVAIR HFA INHALATION HFA AEROSOL
INHALER 115-21 MCG/ACTUATION, 230-21
MCG/ACTUATION, 45-21 MCG/ACTUATION
2 MO
ALL DAY ALLERGY-D TABLET 12 HOUR 5-
120 MG
3 DP
ALL DAY ALLERGY-D TABLET 5-120 MG 3 DP
ALL DAY ALLERGY-D TABLET INDOOR &
OUTDOOR 5-120 MG
3 DP
ALLERGY D-12 TABLET TAB.SR 12H 5-120
MG
3 DP
ALLERGY RELIEF D-24HR TABLET 10-240
MG
3 DP
ALLERGY RELIEF-NASAL DECONG TB
NON-DROWSY 10-240 MG
3 DP
ALLERGY-CONGESTION RLF 12H TAB NON-
DROWSY 5-120 MG
3 DP
ANORO ELLIPTA INHALATION BLISTER
WITH DEVICE 62.5-25 MCG/ACTUATION
2 MO
APRODINE TABLET 2.5-60 MG 3 DP
benzonatate 100 mg capsule 100 mg 3 DP
benzonatate 100 mg capsule softgel 100 mg 3 DP
benzonatate 200 mg capsule 200 mg 3 DP
benzonatate 200 mg capsule softgel 200 mg 3 DP
BREO ELLIPTA INHALATION BLISTER
WITH DEVICE 100-25 MCG/DOSE, 200-25
MCG/DOSE
2 MO
BROTAPP DM LIQUID 1-15-5 MG/5 ML 3 DP
CHEST CONGST-COUGH RELIEF TAB 20-400
MG
3 DP
CHEST-SINUS CONGST RLF TABLET 10-400
MG
3 DP
158
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
CHILD MUCUS RELIEF COUGH LIQ A/F,
CHERRY 5-100 MG/5 ML
3 DP
CHILD MUCUS RELIEF COUGH LIQ
A/F,CHERRY,CHILD 5-100 MG/5 ML
3 DP
CHILDREN'S COLD-ALLERGY ELIXIR
A/F,GRAPE,CHILD 1-2.5 MG/5 ML
3 DP
CHILDREN'S COLD-COUGH ELIXIR A/F,RED
GRAPE,CHILD 1-2.5-5 MG/5 ML
3 DP
CHILDREN'S MUCUS RELIEF LIQ A/F 100
MG/5 ML
3 DP
CHILDREN'S MUCUS RELIEF LIQ
A/F,GRAPE,CHILD 100 MG/5 ML
3 DP
CHILDREN'S SILFEDRINE LIQ 15 MG/5 ML 3 DP
CHL MUCINEX CHEST CONGEST LIQ A/F
100 MG/5 ML
3 DP
COLD-ALLERGY ELIXIR CHILDRENS, A/F 1-
2.5 MG/5 ML
3 DP
COLD-ALLERGY ELIXIR CHILDREN'S,A/F 1-
2.5 MG/5 ML
3 DP
COLD-COUGH ELIXIR 1-2.5-5 MG/5 ML 3 DP
COMBIVENT RESPIMAT INHALATION MIST
20-100 MCG/ACTUATION
2 ST; MO
COUGH DM ER 30 MG/5 ML SUSP 12 HOUR,
A/F 30 MG/5 ML
3 DP
COUGH DM ER 30 MG/5 ML SUSP
12HR,A/F,GLUTEN-FREE 30 MG/5 ML
3 DP
COUGH SYRUP 10-100 MG/5 ML 3 DP
COUGH SYRUP 200 MG/10 ML 100 MG/5 ML 3 DP
COUGH-COLD TABLET 4-30 MG 3 DP
COUGHTAB 200 MG TABLET 200 MG 3 DP
cromolyn oral concentrate 100 mg/5 ml 1
CUVPOSA ORAL SOLUTION 1 MG/5 ML (0.2
MG/ML)
2 MO
DEEP SEA 0.65% NOSE SPRAY 0.65 % 3 DP
dextromethorphan er 30 mg/5 ml 30 mg/5 ml 3 DP
DIABETIC SILTUSSIN DAS-NA LIQ 100 MG/5
ML
3 DP
159
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
DIABETIC SILTUSSIN-DM LIQUID 10-100
MG/5 ML
3 DP
DIMAPHEN DM ELIXIR GRAPE,
A/F,GLUTEN-F 1-2.5-5 MG/5 ML
3 DP
DIMAPHEN ELIXIR A/F, GRAPE, GLUTEN-F
1-2.5 MG/5 ML
3 DP
DIMAPHEN ELIXIR GRAPE,A/F,GLUTEN-F 1-
2.5 MG/5 ML
3 DP
DULERA INHALATION HFA AEROSOL
INHALER 100-5 MCG/ACTUATION, 200-5
MCG/ACTUATION
2 MO
ENDACOF-DM LIQUID 1-2.5-5 MG/5 ML 3 DP
EXTRA ACTION COUGH SYRUP 10-100 MG/5
ML
3 DP
fluticasone-salmeterol inhalation aerosol powdr
breath activated 113-14 mcg/actuation, 232-14
mcg/actuation, 55-14 mcg/actuation
1 MO
GNP ALL DAY ALLERGY-D TABLET 5-120
MG
3 DP
GS CHILD COLD-ALLERGY SOLUTION 1-2.5
MG/5 ML
3 DP
GS CHILD MUCUS RLF COUGH LIQ 5-100
MG/5 ML
3 DP
GS NASAL DECONG PE 10 MG TAB 10 MG 3 DP
GS NASAL SPRAY 0.05% 0.05 % 3 DP
GS TUSSIN DM COUGH SYRUP 10-100 MG/5
ML
3 DP
GS TUSSIN DM COUGH-CHEST SOLN 10-100
MG/5 ML
3 DP
GS TUSSIN DM MAX LIQUID 10-200 MG/5
ML
3 DP
GS TUSSIN MUCUS-CONG 100 MG/5 100
MG/5 ML
3 DP
GS TUSSIN MUCUS-CONG 200 MG/10 100
MG/5 ML
3 DP
guaifenesin 100 mg/5 ml liquid 100 mg/5 ml 3 DP
guaifenesin 100 mg/5 ml soln outer 100 mg/5 ml 3 DP
160
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
guaifenesin 100 mg/5 ml syrup 100 mg/5 ml 3 DP
guaifenesin 200 mg/10 ml soln 100's,u-d, outer,a/f
100 mg/5 ml
3 DP
guaifenesin 200 mg/10 ml soln inner 100 mg/5 ml 3 DP
guaifenesin 200 mg/10 ml soln outer 100 mg/5 ml 3 DP
guaifenesin 300 mg/15 ml soln 100's,u-d,outer, a/f
100 mg/5 ml
3 DP
guaifenesin 300 mg/15 ml soln inner 100 mg/5 ml 3 DP
guaifenesin 300 mg/15 ml soln outer 100 mg/5 ml 3 DP
guaifenesin dm syrup (otc) 10-100 mg/5 ml 3 DP
guaifenesin dm syrup inner (otc) 10-100 mg/5 ml 3 DP
guaifenesin dm syrup outer (otc) 10-100 mg/5 ml 3 DP
guaifenesin er 1,200 mg tablet 1,200 mg 3 DP
HM ADT TUSSIN COUGH CONG DM LQ 10-
100 MG/5 ML
3 DP
HM ADULT TUSSIN CHEST CONG LIQ
A/F,CHERRY,NO-DROWSY 100 MG/5 ML
3 DP
HM ADULT TUSSIN CHEST CONG LIQ
A/F,GLUTEN-FREE 100 MG/5 ML
3 DP
HM ADULT TUSSIN DM SYRUP 10-100 MG/5
ML
3 DP
HM ALLERGY COMPLETE-D TABLET 5-120
MG
3 DP
HM ALLERGY RLF-NASAL DECONG TB
NON-DROWSY,24 HR RLF 10-240 MG
3 DP
HM CHEST CONGEST RLF 400 MG TB
CAPLET,D/F 400 MG
3 DP
HM MUCUS ER 1,200 MG TABLET 1,200 MG 3 DP
HM MUCUS ER 600 MG TABLET GLUTEN-
FREE, 12 HOUR 600 MG
3 DP
HM NASAL DECONGEST 30 MG TAB NON-
DROWSY, MAX STR 30 MG
3 DP
ipratropium bromide nasal spray,non-aerosol 0.03
%
1 MO
ipratropium bromide nasal spray,non-aerosol 42
mcg (0.06 %)
1
161
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ipratropium-albuterol inhalation solution for
nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml
1 B/D; MO
KIDKARE COUGH & COLD LIQUID 1-15-5
MG/5 ML
3 DP
LORATADINE-D 12 HOUR TABLET 12 HOUR
5-120 MG
3 DP
LORATADINE-D 12 HOUR TABLET NON-
DROWSY 5-120 MG
3 DP
LORATADINE-D 24HR TABLET 10-240 MG 3 DP
LORATADINE-D 24HR TABLET NON-
DROWSY 10-240 MG
3 DP
MUCINEX DM ER 1,200-60 MG TAB BI-
LAYER, MAX-STR 60-1,200 MG
3 DP
MUCINEX DM ER 600-30 MG TABLET 30-600
MG
3 DP
MUCINEX ER 1,200 MG TABLET MAX STR,
BI-LAYER 1,200 MG
3 DP
MUCINEX ER 600 MG TABLET 600 MG 3 DP
MUCINEX ER 600 MG TABLET BI-LAYER, 12
HOURS 600 MG
3 DP
MUCINEX ER 600 MG TABLET INNER 600
MG
3 DP
MUCINEX ER 600 MG TABLET OUTER 600
MG
3 DP
MUCINEX FAST-MAX DM MAX LIQUID
MAXIMUM STRENGTH 5-100 MG/5 ML
3 DP
MUCUS RELIEF 400 MG TABLET 400 MG 3 DP
MUCUS RELIEF 400 MG TABLET D/F 400 MG 3 DP
MUCUS RELIEF DM TABLET D/F 20-400 MG 3 DP
MUCUS RELIEF SINUS TABLET 10-400 MG 3 DP
NASAL DECONGESTANT 0.05% SPRAY 0.05
%
3 DP
NASAL DECONGESTANT 0.05% SPRAY
12HR, MAXIMUM STR. 0.05 %
3 DP
NASAL DECONGESTANT 30 MG TAB 30 MG 3 DP
162
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
NASAL DECONGESTANT 30 MG TAB NON-
DROWSY,MAX-STR 30 MG
3 DP
NASAL DECONGESTANT PE 10 MG TB 10
MG
3 DP
NASAL DECONGESTANT PE 10 MG TB
MAX-STR 10 MG
3 DP
NASAL DECONGESTANT PE 10 MG TB NON-
DROWSY, MAX STR. 10 MG
3 DP
NASAL
DECONGESTANT(PSEUDOEPHEDRINE)30
MG/5 ML 30 MG/5 ML
3 DP
NASAL SPRAY 0.05% 12 HOUR RELIEF 0.05
%
3 DP
NASAL SPRAY 0.05% 12 HOUR,NO DRIP 0.05
%
3 DP
NASAL SPRAY 0.05% 12 HOUR,ORIGINAL
0.05 %
3 DP
NASAL SPRAY 0.05% 12 HOUR,SINUS 0.05 % 3 DP
NASAL SPRAY 0.05% 12HR, ORIGINAL 0.05
%
3 DP
PEDIA RELIEF COUGH-COLD LIQUID A/F,
CHERRY 1-15-5 MG/5 ML
3 DP
PEDIATRIC COUGH-COLD LIQUID 1-15-5
MG/5 ML
3 DP
promethazine vc oral syrup 6.25-5 mg/5 ml 1 PA
promethazine-phenylephrine oral syrup 6.25-5
mg/5 ml
1 PA
pseudoephed 30 mg/5 ml soln 30 mg/5 ml 3 DP
pseudoephedrine 30 mg tablet 30 mg 3 DP
QC MUCUS RELIEF 400 MG CAPLET 400 MG 3 DP
QC MUCUS RELIEF DM TABLET 20-400 MG 3 DP
QC TUSSIN CF LIQUID 5-10-100 MG/5 ML 3 DP
ROBAFEN 100 MG/5 ML SYRUP 100 MG/5 ML 3 DP
ROBAFEN CF LIQUID A/F,MULTI-CLD
SYMPTM 5-10-100 MG/5 ML
3 DP
ROBAFEN DM CGH-CHEST CONG SYRP 10-
100 MG/5 ML
3 DP
163
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
ROBAFEN DM COUGH LIQUID 10-100 MG/5
ML
3 DP
ROBAFEN-DM SYRUP A/F, NON-NARCOTIC
10-100 MG/5 ML
3 DP
ROBAFEN-DM SYRUP A/F,NON-DROWSY
10-100 MG/5 ML
3 DP
SB 12HR NASAL SPRAY 0.05% 0.05 % 3 DP
SB ALLERFED COLD-ALLERGY TAB 4-10
MG
3 DP
SB COUGH CONTROL SYRUP 100 MG/5 ML 3 DP
SB MUCUS RELIEF DM TABLET DYE-FREE
20-400 MG
3 DP
SILTUSSIN DM COUGH SYRUP 10-100 MG/5
ML
3 DP
SILTUSSIN DM DAS LIQUID 10-100 MG/5 ML 3 DP
SILTUSSIN SA 100 MG/5 ML SYR 100 MG/5
ML
3 DP
SINUS RELIEF 0.05% NASAL SPRAY ULTRA
FINE,12 HOUR 0.05 %
3 DP
SM ALL DAY ALLERGY-D TABLET 5-120
MG
3 DP
SM CHEST CONG RELIEF PE CAPLET 10-400
MG
3 DP
SM CHEST CONGEST RLF DM CAPLET
CAPLET,D/F 20-400 MG
3 DP
SM CHEST CONGESTION RELIEF CAP
CAPLET,D/F 400 MG
3 DP
SM CHILD COLD-ALLERGY LIQUID
CHILDRENS 1-2.5 MG/5 ML
3 DP
SM LORATA-DINE D 24HR TABLET 10-240
MG
3 DP
SM MUCUS RELIEF COUGH LIQUID
CHILDRENS, A/F 5-100 MG/5 ML
3 DP
SM NASAL 0.05% SPRAY 12 HOUR,
ORIGINAL 0.05 %
3 DP
SM NASAL DECONGEST 30 MG TAB 30 MG 3 DP
SM NASAL SPRAY 0.05% 0.05 % 3 DP
164
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
SM TUSSIN CF SYRUP A/F 5-10-100 MG/5 ML 3 DP
SM TUSSIN DM LIQUID 10-100 MG/5 ML 3 DP
SM TUSSIN DM SYRUP 10-100 MG/5 ML 3 DP
SM TUSSIN DM SYRUP A/F 10-100 MG/5 ML 3 DP
STIOLTO RESPIMAT INHALATION MIST 2.5-
2.5 MCG/ACTUATION
2 MO
SUDOGEST 30 MG TABLET 30 MG 3 DP
SUDOGEST 30 MG TABLET BOXED 30 MG 3 DP
SUDOGEST PE 10 MG TABLET 10 MG 3 DP
SUPHEDRIN 30 MG TABLET 30 MG 3 DP
SUPHEDRINE SINUS CONG 30 MG TB 30 MG 3 DP
SYMBICORT INHALATION HFA AEROSOL
INHALER 160-4.5 MCG/ACTUATION, 80-4.5
MCG/ACTUATION
2 MO
TESSALON PERLE 100 MG CAP 100 MG 3 DP
TRELEGY ELLIPTA INHALATION BLISTER
WITH DEVICE 100-62.5-25 MCG
2 MO
TUSNEL DIABETIC LIQUID (OTC) 10-100
MG/5 ML
3 DP
TUSSIN CF COUGH-COLD LIQUID A/F,NON-
DROWSY 5-10-100 MG/5 ML
3 DP
TUSSIN CF COUGH-COLD SYRUP A/F 5-10-
100 MG/5 ML
3 DP
TUSSIN CF COUGH-COLD SYRUP A/F, NON-
DROWSY 5-10-100 MG/5 ML
3 DP
TUSSIN CF COUGH-COLD SYRUP A/F,NON-
DROWSY 5-10-100 MG/5 ML
3 DP
TUSSIN DM LIQUID A/F 10-100 MG/5 ML 3 DP
TUSSIN DM LIQUID S/F,A/F 10-100 MG/5 ML 3 DP
TUSSIN DM MAX LIQUID A/F 10-200 MG/5
ML
3 DP
TUSSIN DM MAX LIQUID A/F, NON-
DROWSY 10-200 MG/5 ML
3 DP
TUSSIN DM SYRUP 10-100 MG/5 ML 3 DP
TUSSIN MUCUS-CONG 200 MG/10 100 MG/5
ML
3 DP
165
Name of Drug Drug Tier Necessary actions, restrictions, or
limits on use
SKELETAL MUSCLE RELAXANTS
SKELETAL MUSCLE RELAXANTS
carisoprodol oral tablet 250 mg, 350 mg 1 PA
chlorzoxazone oral tablet 500 mg 1 PA
cyclobenzaprine oral tablet 10 mg, 5 mg 1 PA
METAXALL ORAL TABLET 800 MG 1
metaxalone oral tablet 800 mg 1
methocarbamol oral tablet 500 mg, 750 mg 1 PA
orphenadrine citrate oral tablet extended release
100 mg
1 PA
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
temazepam oral capsule 15 mg, 22.5 mg, 30 mg,
7.5 mg
1 QL (90 EA per 365 days)
zaleplon oral capsule 10 mg, 5 mg 1 QL (90 EA per 365 days)
zolpidem oral tablet 10 mg, 5 mg 1 QL (90 EA per 365 days)
SLEEP DISORDERS, OTHER
armodafinil oral tablet 150 mg, 200 mg, 250 mg,
50 mg
1 PA; MO
HETLIOZ ORAL CAPSULE 20 MG 2 PA; MO
MODAFINIL ORAL TABLET 100 MG, 200 MG 1 PA; MO
ROZEREM ORAL TABLET 8 MG 2 QL (30 EA per 30 days)
SILENOR ORAL TABLET 3 MG, 6 MG 2
166
E. Index of Covered Drugs
1 12 HOUR NASAL SPRAY 163
8 8 HOUR PAIN RELIEVER . 18
8HR MUSCLE ACHES-PAIN
.......................................... 12
A abacavir ................................ 65
abacavir-lamivudine ............. 66
abacavir-lamivudine-
zidovudine ........................ 66
abelcet................................... 44
ABILIFY MAINTENA .. 59, 60
abiraterone ............................ 52
ABREVA ............................. 64
acamprosate .......................... 24
acarbose ................................ 69
acebutolol ............................. 80
ACEPHEN ........................... 12
acetaminophen .......... 12, 13, 17
acetaminophen-codeine ........ 13
acetazolamide ....................... 83
acetic acid ............................. 29
acetic acid-aluminum acetate
........................................ 147
acetylcysteine ..................... 157
ACID CONTROLLER ....... 111
ACID GONE ANTACID ... 105
ACID REDUCER
(CIMETIDINE) .............. 112
ACID REDUCER
(FAMOTIDINE) .... 111, 112
ACID REDUCER
(RANITIDINE) .............. 112
acitretin ................................. 89
ACNE MEDICATION ......... 89
ACTEMRA ........................ 138
ACTEMRA ACTPEN ........ 138
ACTHAR H.P. ................... 123
ACTHIB (PF) ..................... 138
ACTIMMUNE ................... 138
acyclovir ............................... 64
acyclovir sodium .................. 64
ADACEL(TDAP
ADOLESN/ADULT)(PF)
................................ 138, 139
adapalene .............................. 89
adapalene-benzoyl peroxide . 89
ADEFOVIR .......................... 63
ADEMPAS ......................... 156
ADULT TUSSIN CHEST
CONGESTION ...... 159, 160
ADULT TUSSIN COUGH
CONGEST DM .............. 160
ADULT TUSSIN DM ........ 160
ADVAIR DISKUS ............. 157
ADVAIR HFA ................... 157
ADVANCED ANTACID-
ANTIGAS .............. 108, 109
AFINITOR ........................... 54
AFINITOR DISPERZ .......... 54
AFTERA ............................ 125
AIMOVIG AUTOINJECTOR
.......................................... 50
AIMOVIG AUTOINJECTOR
(2 PACK) .......................... 50
ak-poly-bac ........................... 29
ala-cort .................................. 47
albendazole ........................... 56
ALBENZA ........................... 56
albuterol sulfate .................. 155
alclometasone ....................... 47
alcohol pads .......................... 72
ALECENSA ......................... 54
alendronate ......................... 143
ALEVAZOL ......................... 44
alfuzosin ............................. 123
ALINIA ................................ 56
ALL DAY ALLERGY
(CETIRIZINE) ...... 148, 149,
151, 153
ALL DAY ALLERGY-D .. 157,
159, 163
ALLER-CHLOR ................ 148
ALLER-EASE .................... 151
ALLERFED COLD AND
ALLERGY ..................... 163
ALLERGY
(CHLORPHENIRAMINE)
........................................ 148
ALLERGY
(DIPHENHYDRAMINE)
................................ 148, 151
ALLERGY 4-HOUR .......... 153
ALLERGY AND
CONGESTION RELIEF 157
ALLERGY COMPLETE-D
........................................ 160
ALLERGY D-12 ................ 157
ALLERGY MEDICINE .... 152,
153
ALLERGY RELIEF
(CETIRIZINE) ............... 152
ALLERGY RELIEF
(FEXOFENADINE) ....... 148
ALLERGY RELIEF
(LORATADINE) ............ 148
ALLERGY RELIEF D-24HR
........................................ 157
ALLERGY
RELIEF(CHLORPHENIRA
MN) ................................ 151
ALLERGY
RELIEF(DIPHENHYDRA
MIN) ....................... 148, 153
ALLERGY RELIEF,NASAL
DECONGEST ........ 157, 160
ALLERGY-TIME .............. 148
allopurinol ............................. 47
ALMACONE ............. 105, 106
ALMACONE-2 .................. 106
alogliptin ............................... 69
alogliptin-metformin ............. 69
alogliptin-pioglitazone .......... 69
alosetron ............................. 113
ALPHAGAN P ................... 146
alprazolam ............................ 68
ALPRAZOLAM INTENSOL
.......................................... 68
ALTAVERA (28) ............... 125
aluminum hydroxide gel ..... 106
ALUNBRIG ......................... 54
alyacen 1/35 (28) ................ 125
amabelz ............................... 125
amantadine hcl ...................... 58
AMBISOME ......................... 44
amikacin ............................... 28
amiloride ............................... 84
amiloride-hydrochlorothiazide
.......................................... 81
AMINOSYN 7 % WITH
ELECTROLYTES ............ 93
aminosyn 8.5 %-electrolytes 93
AMINOSYN II 10 % ............ 93
167
AMINOSYN II 15 % ........... 93
AMINOSYN II 8.5 % .......... 93
aminosyn ii 8.5 %-electrolytes
.......................................... 93
AMINOSYN-HBC 7% ........ 93
AMINOSYN-PF 10 % ......... 93
AMINOSYN-PF 7 %
(SULFITE-FREE) ............ 93
AMINOSYN-RF 5.2 % ........ 93
amiodarone ........................... 79
AMITIZA ........................... 113
amitriptyline ......................... 42
amlodipine ............................ 80
amlodipine-benazepril .......... 81
amlodipine-olmesartan ......... 81
amlodipine-valsartan ............ 81
amlodipine-valsartan-hcthiazid
.......................................... 82
ammonium lactate ................ 89
AMNESTEEM ..................... 89
amoxapine ............................ 42
amoxicillin ............................ 33
amoxicillin-pot clavulanate .. 34
amphotericin b ...................... 44
ampicillin .............................. 34
ampicillin sodium ................. 34
ampicillin-sulbactam ............ 34
ANADROL-50 ................... 124
anagrelide ............................. 75
anastrozole ............................ 53
ANIMAL SHAPE VITAMINS
........................................ 102
ANODYNE LPT .................. 23
ANORO ELLIPTA ............ 157
ANTACID .......... 106, 109, 110
ANTACID (CALCIUM
CARBONATE) ..... 106, 108,
109
ANTACID ANTI-GAS ..... 106,
108, 110
ANTACID CALCIUM ...... 110
ANTACID EXT STR
(CALCIUM CARB) ....... 106
ANTACID EXTRA-
STRENGTH ........... 106, 109
ANTACID MAXIMUM
STRENGTH ........... 106, 109
ANTACID PLUS ANTI-GAS
................................ 106, 108
ANTACID-ANTIGAS ...... 108,
109
ANTACID-SIMETHICONE
........................................ 106
ANTIBIOTIC (BACITRACIN
ZINC) ............................... 31
ANTI-DIARRHEA ............ 109
ANTI-DIARRHEAL
(LOPERAMIDE)... 106, 108,
109, 110
ANTIFUNGAL
(CLOTRIMAZOLE) .. 44, 46
ANTIFUNGAL
(TOLNAFTATE) ....... 44, 46
ANTIFUNGAL CREAM
(MICONAZOLE) ............. 44
ANTI-ITCH (HC)................. 91
APOKYN ............................. 58
aprepitant .............................. 44
apri ...................................... 125
APRODINE ........................ 157
APTIOM ............................... 39
APTIVUS ............................. 67
AQUADEKS PEDIATRIC .. 93
ARALAST NP ................... 121
aranelle (28) ........................ 125
ARANESP (IN
POLYSORBATE) ............ 75
ARCALYST ....................... 138
aripiprazole ........................... 60
ARISTADA .......................... 60
ARISTADA INITIO............. 60
armodafinil ......................... 165
ARNUITY ELLIPTA ......... 154
ARTHRITIS PAIN RELIEF
(ACETAM) ... 13, 14, 15, 17,
18
ARTIFICIAL TEARS
(PETRO/MIN) ................ 144
ARTIFICIAL TEARS
(POLYVIN ALC) ........... 143
ascomp with codeine ............ 13
ASPIR-81 ............................. 77
aspirin ..... 18, 19, 20, 21, 77, 78
aspirin-dipyridamole ............ 77
ASPIR-LOW ........................ 77
assure id insulin safety ......... 72
ASTAGRAF XL................. 135
atazanavir.............................. 67
atenolol ................................. 80
atenolol-chlorthalidone ......... 82
ATHLETE'S FOOT
(TERBINAFINE) ............. 46
atomoxetine .......................... 87
atorvastatin ........................... 84
atovaquone ............................ 56
atovaquone-proguanil ........... 56
ATRIPLA ............................. 65
atropine ............................... 146
AUBAGIO ............................ 88
aubra ................................... 125
AUBRA EQ ........................ 125
AUSTEDO ........................... 88
AVANDIA ........................... 69
aviane .................................. 125
azathioprine ........................ 135
azelastine .................... 146, 148
azithromycin ................... 34, 35
AZOPT ............................... 146
aztreonam ............................. 33
B B COMPLEX-VITAMIN B12
........................................ 102
bacitracin .............................. 29
bacitracin zinc ................. 29, 30
bacitracin-polymyxin b ......... 29
baclofen ................................ 63
BACTROBAN NASAL ....... 29
BALANCED B-100 ........... 102
BALANCED B-50 ............... 93
balsalazide .......................... 142
balziva (28) ......................... 125
BANOPHEN ...................... 148
BANZEL .............................. 39
BARACLUDE ...................... 63
BCG VACCINE, LIVE (PF)
........................................ 139
benazepril ............................. 79
benazepril-hydrochlorothiazide
.......................................... 82
BENLYSTA ....................... 138
BENZNIDAZOLE ............... 57
benzonatate ......................... 157
benzoyl peroxide .................. 89
benztropine ........................... 57
betamethasone dipropionate . 47
betamethasone valerate ......... 47
betamethasone, augmented ... 47
BETASERON ....................... 88
betaxolol ............................... 80
168
bethanechol chloride .......... 123
bexarotene ............................ 56
BEXSERO .......................... 139
bicalutamide ......................... 52
BICILLIN L-A ..................... 34
BIKTARVY ......................... 66
BILTRICIDE ........................ 56
biotin............................. 93, 100
BISAC-EVAC .................... 113
bisacodyl..................... 113, 118
BISA-LAX ......................... 113
BISCOLAX ........................ 113
BISMATROL ..................... 107
bismuth subsalicylate ......... 107
bisoprolol fumarate .............. 80
bisoprolol-hydrochlorothiazide
.......................................... 82
BIVIGAM .......................... 137
blisovi fe 1.5/30 (28) .......... 125
blisovi fe 1/20 (28) ............. 126
BOOSTRIX TDAP ............ 139
BOSULIF ............................. 54
BRAFTOVI .......................... 54
BREO ELLIPTA ................ 157
briellyn ............................... 126
BRILINTA ........................... 77
brimonidine ........................ 146
BRIVIACT ........................... 37
bromocriptine ....................... 58
BROTAPP DM .................. 157
budesonide .......................... 154
BUDESONIDE .................. 142
bumetanide ........................... 83
buprenorphine....................... 22
buprenorphine hcl ................. 24
buprenorphine-naloxone....... 24
bupropion hcl.................. 40, 41
bupropion hcl (smoking deter)
.......................................... 24
buspirone .............................. 68
butalbital compound w/codeine
.......................................... 13
butalbital-acetaminop-caf-cod
.......................................... 13
butalbital-acetaminophen ..... 13
butalbital-acetaminophen-caff
.......................................... 13
butalbital-aspirin-caffeine .... 13
butorphanol tartrate .............. 22
BYSTOLIC .......................... 80
C cabergoline ......................... 133
CABOMETYX ..................... 54
calcipotriene ................... 89, 90
calcitonin (salmon) ............. 143
CALCITRATE ..................... 93
CALCITRATE-VITAMIN D
........................................ 102
calcitriol .............................. 102
CALCIUM 500 WITH D ..... 99
CALCIUM 600..................... 93
CALCIUM 600 + D(3) ......... 93
calcium acetate ................... 101
CALCIUM ANTACID...... 107,
108, 110
CALCIUM ANTACID
ULTRA MAX ST ........... 107
calcium carbonate ........... 93, 94
calcium carbonate-vitamin d3
........................................ 102
calcium gluconate ................. 94
calcium polycarbophil ........ 113
CAL-GEST ANTACID ...... 107
CALQUENCE ...................... 54
camila ................................. 130
CAPRELSA.......................... 54
captopril ................................ 79
captopril-hydrochlorothiazide
.......................................... 82
CARBAGLU ........................ 94
carbamazepine ................ 39, 69
carbidopa-levodopa .............. 58
carbidopa-levodopa-
entacapone ........................ 58
CARIMUNE NF
NANOFILTERED.......... 137
carisoprodol ........................ 165
carisoprodol-asa-codeine ...... 13
carisoprodol-aspirin .............. 13
carteolol .............................. 146
cartia xt ................................. 80
carvedilol .............................. 80
caspofungin .......................... 44
CASTELLANI PAINT
MODIFIED ...................... 29
caziant (28) ......................... 126
cefaclor ................................. 31
cefadroxil .............................. 32
cefazolin ............................... 32
cefazolin in dextrose (iso-os) 32
cefdinir .................................. 32
cefepime ............................... 32
cefepime in dextrose 5 % ..... 32
cefepime in dextrose,iso-osm
.......................................... 32
cefotaxime ............................ 32
cefoxitin ................................ 32
cefoxitin in dextrose, iso-osm
.......................................... 32
cefpodoxime ......................... 32
cefprozil ................................ 32
ceftazidime ........................... 32
ceftazidime in d5w ............... 32
ceftriaxone ............................ 32
ceftriaxone in dextrose,iso-os
.......................................... 32
cefuroxime axetil .................. 33
cefuroxime sodium ............... 33
celecoxib ............................... 19
CELONTIN .......................... 37
cephalexin ............................. 33
CERDELGA ....................... 121
CERTAVITE SENIOR-
ANTIOXIDANT .............. 94
CERTAVITE-
ANTIOXIDANT ............ 102
cetirizine ..................... 148, 149
cetirizine-pseudoephedrine . 149
cevimeline ............................. 89
CHANTIX ............................ 24
CHANTIX CONTINUING
MONTH BOX .................. 24
CHANTIX STARTING
MONTH BOX .................. 24
CHATEAL EQ (28) ........... 126
CHEST CONGESTION
RELIEF ................... 160, 163
CHEST CONGESTION
RELIEF DM ................... 163
CHEST CONGESTION
RELIEF PE ..................... 163
CHEST CONGESTION-
COUGH RELIEF ........... 157
CHEST-SINUS
CONGESTION RELIEF 157
CHILD ALLERGY
RELF(CETIRIZINE) ...... 150
CHILD IBUPROFEN ........... 19
CHILD MUCINEX CHEST
CONGESTION ............... 158
169
CHILD MUCUS RELIEF
COUGH .................. 158, 159
CHILD MUCUS RELIEF
EXPECTORANT ........... 158
CHILDREN'S
ACETAMINOPHEN ....... 14
CHILDREN'S ALLERGY
(DIPHENHYD) ..... 150, 151,
152
CHILDREN'S ALLERGY
RELIEF(LOR) ................ 149
CHILDREN'S ASPIRIN 77, 78
CHILDREN'S CETIRIZINE
................................ 150, 151
CHILDREN'S COLD AND
COUGH (PE) ................. 158
CHILDREN'S COLD-
ALLERGY (PE) ..... 158, 159
CHILDREN'S IBUPROFEN
.............................. 19, 20, 21
CHILDREN'S MAPAP ........ 14
CHILDREN'S PAIN RELIEF
.......................................... 17
CHILDREN'S PAIN
RELIEVER....................... 14
CHILDREN'S PAIN-FEVER
RELIEF .......... 13, 14, 15, 18
CHILDREN'S SILAPAP ..... 14
CHILDREN'S SILFEDRINE
........................................ 158
CHILD'S ALL DAY
ALLERGY(CETIR) ...... 149,
153
CHILDS CHEW VITE......... 94
CHILDS/IRON..................... 94
chlorhexidine gluconate ....... 89
chloroquine phosphate.......... 57
chlorothiazide ....................... 84
chlorpheniramine maleate . 150,
153
chlorpromazine ..................... 43
chlorthalidone ....................... 84
chlorzoxazone..................... 165
CHOLBAM ........................ 121
cholecalciferol (vitamin d3) 105
cholestyramine (with sugar) . 85
cholestyramine light ............. 85
ciclopirox .............................. 44
ciclopirox-ure-camph-menth-
euc .................................... 45
cilostazol ............................... 77
CIMDUO .............................. 66
cimetidine ........................... 112
cimetidine hcl ..................... 112
CIMZIA .............................. 135
CIMZIA POWDER FOR
RECONST ...................... 135
CIMZIA STARTER KIT ... 135
CINRYZE ........................... 134
CIPRODEX ........................ 147
ciprofloxacin ......................... 35
ciprofloxacin (mixture)......... 35
ciprofloxacin hcl ................... 35
ciprofloxacin in 5 % dextrose
.......................................... 35
citalopram ............................. 41
CITRUCEL ........................ 113
CITRUCEL (SUCROSE) ... 113
CITRUCEL SUGAR FREE
........................................ 113
CLARAVIS .......................... 90
clarithromycin ...................... 35
CLEARLAX ....... 113, 115, 118
clemastine ........................... 150
clindamycin hcl .................... 29
clindamycin in 0.9 % sod chlor
.......................................... 29
clindamycin in 5 % dextrose 29
clindamycin palmitate hcl .... 29
clindamycin pediatric ........... 30
clindamycin phosphate ......... 30
clindamycin-benzoyl peroxide
.......................................... 90
clinimix 4.25%/d10w sulf free
.......................................... 94
clinimix 4.25%-d25w sulf-free
.......................................... 94
clinisol sf 15 % ..................... 94
clobazam ............................... 38
clobetasol .............................. 47
clobetasol-emollient ............. 47
clomipramine ........................ 42
clonazepam ........................... 68
clonidine ............................... 78
clonidine hcl ................... 78, 87
clopidogrel ............................ 77
clorazepate dipotassium ....... 68
clotrimazole .......................... 45
clotrimazole-betamethasone . 90
clozapine ............................... 62
COARTEM ........................... 57
codeine-butalbital-asa-caff ... 14
colchicine .............................. 47
COLD AND ALLERGY
(BROMPHEN-PE) . 158, 163
COLD AND COUGH ELIXIR
........................................ 158
COLEMAN BOTANICALS
INSECT ............................ 90
COLEMAN HIGH-DRY
INSECT REPEL ............... 90
COLEMAN SKINSMART
INSECT REP .................... 90
COLEMAN SPORTSMEN
INSECT REPEL ............... 90
colesevelam .......................... 85
colestipol ............................... 85
colistin (colistimethate na) ... 30
COMBIGAN ...................... 146
COMBIPATCH .................. 126
COMBIVENT RESPIMAT 158
COMETRIQ ......................... 54
COMPLERA ........................ 65
constulose ........................... 113
COPIKTRA .......................... 53
CORLANOR ........................ 82
cortisone ............................. 123
COSENTYX ......................... 90
COSENTYX (2 SYRINGES)
.......................................... 90
COSENTYX PEN ................ 90
COSENTYX PEN (2 PENS) 90
COTELLIC ........................... 54
COUGH AND COLD
(CHLORPHEN-DM) ...... 158
COUGH CONTROL
(GUAIFENESIN) ........... 163
COUGH DM ER ................ 158
COUGH SUPPRESSANT-
EXPECTORANT ........... 158
COUGH SYRUP ................ 158
COUGH SYRUP DM ......... 159
COUGHTAB ...................... 158
COUMADIN ........................ 74
CREON ............................... 122
CRIXIVAN ........................... 67
cromolyn ............. 146, 156, 158
cryselle (28) ........................ 126
CUTTER BACKWOODS .... 90
170
CUTTER BACKWOODS
DRY ................................. 90
CUTTER LEMON
EUCALYPTUS ................ 90
CUTTER NATURAL
REPELLENT2 ................. 90
CUTTER SKINSATIONS ... 90
CUVPOSA ......................... 158
cyanocobalamin (vitamin b-12)
................................ 102, 103
cyclafem 1/35 (28) ............. 126
cyclafem 7/7/7 (28) ............ 126
cyclobenzaprine .................. 165
cyclophosphamide ................ 51
cyclosporine ....................... 135
cyclosporine modified ........ 135
cyproheptadine ................... 150
CYRED .............................. 126
CYRED EQ ........................ 126
CYSTADANE .................... 122
CYSTAGON ...................... 122
CYSTARAN ...................... 144
D d10 %-0.45 % sodium chloride
.......................................... 94
d2.5 %-0.45 % sodium
chloride ............................. 94
d5 % and 0.9 % sodium
chloride ............................. 94
d5 %-0.45 % sodium chloride
.......................................... 94
dalfampridine ....................... 88
DALIRESP ......................... 156
DANAZOL......................... 124
dantrolene ............................. 63
dapsone ................................. 51
DAPTACEL (DTAP
PEDIATRIC) (PF).......... 139
daptomycin ........................... 30
DARAPRIM ......................... 57
darifenacin .......................... 123
DAURISMO......................... 56
deblitane ............................. 130
DEEP SEA NASAL ........... 158
DEKAS ESSENTIAL .... 94, 95
DEKAS PLUS (FOLIC ACID)
.......................................... 95
DEKAS PLUS LIQUID ....... 95
DELSTRIGO ........................ 65
delyla (28) .......................... 126
DELZICOL ........................ 142
DEMSER .............................. 82
DENAVIR ............................ 64
DEPEN TITRATABS ........ 135
DEPO-PROVERA................ 52
DEPO-SUBQ PROVERA 104
........................................ 130
dermacinrx empricaine ......... 23
DESCOVY ........................... 66
desipramine .......................... 42
desmopressin ...................... 131
desog-e.estradiol/e.estradiol
........................................ 126
desogestrel-ethinyl estradiol
........................................ 126
desonide .......................... 47, 48
desoximetasone .................... 48
desvenlafaxine succinate ...... 41
dexamethasone ..................... 48
dexamethasone intensol ........ 48
dexamethasone sodium
phosphate ................ 123, 147
dexmethylphenidate.............. 87
dextroamphetamine .............. 86
dextroamphetamine-
amphetamine .................... 87
dextromethorphan polistirex
........................................ 158
dextromethorphan-guaifenesin
........................................ 160
dextrose 10 % and 0.2 % nacl
.......................................... 95
dextrose 10 % in water (d10w)
.......................................... 95
dextrose 5 % in water (d5w). 95
dextrose 5%-0.2 % sod
chloride ............................. 95
dextrose 5%-0.3 %
sod.chloride ...................... 95
DEXTROSE WITH SODIUM
CHLORIDE ...................... 95
DIABETIC SILTUSSIN DAS-
NA .................................. 158
DIABETIC SILTUSSIN-DM
........................................ 159
DIASTAT ............................. 38
DIASTAT ACUDIAL .......... 38
diazepam ......................... 38, 68
diazepam intensol ................. 68
diclofenac potassium ............ 19
diclofenac sodium .... 19, 23, 53,
147
dicloxacillin .......................... 34
DICLOZOR .......................... 19
dicyclomine ........................ 105
didanosine ............................. 66
DIFICID ............................... 35
diflunisal ............................... 19
digitek ................................... 82
digox ..................................... 82
digoxin .................................. 82
dihydroergotamine ................ 50
DILANTIN ........................... 39
diltiazem hcl ................... 80, 81
dilt-xr .................................... 81
DIMAPHEN (PE) ............... 159
DIMAPHEN DM ................ 159
DIPENTUM ....................... 142
DIPHEDRYL ..................... 150
DIPHENHIST ..................... 150
diphenhydramine hcl .......... 150
diphenoxylate-atropine ....... 105
dipyridamole ......................... 77
disopyramide phosphate ....... 79
disulfiram .............................. 24
divalproex ............................. 38
DM2 ...................................... 69
DOC-Q-LACE .................... 113
DOCU ......................... 113, 114
docusate sodium ................. 114
DOCUSIL ........................... 114
DOCUSOL ......................... 114
dofetilide ............................... 79
DOK ................................... 114
donepezil ............................... 40
DOPTELET .......................... 76
DOPTELET (10 TAB PACK)
.......................................... 75
DOPTELET (15 TAB PACK)
.......................................... 75
doripenem ............................. 33
dorzolamide ........................ 146
dorzolamide-timolol ........... 146
doxazosin .............................. 78
doxepin ................................. 42
DOXEPIN ............................. 90
doxercalciferol .................... 143
doxy-100 ............................... 36
doxycycline hyclate .............. 36
doxycycline monohydrate .... 36
171
DRIMINATE ....................... 43
dronabinol............................. 44
drospirenone-ethinyl estradiol
........................................ 126
DROXIA .............................. 52
DUAVEE ........................... 131
DUCODYL ........................ 114
DULERA ............................ 159
duloxetine ............................. 88
DUPIXENT .......................... 91
duramorph (pf) ..................... 22
DUREZOL ......................... 147
dutasteride .......................... 123
E E.C. PRIN ............................. 19
econazole .............................. 45
ECONTRA EZ ................... 126
ED A-HIST ........................ 150
EDURANT ........................... 65
efavirenz ............................... 65
EGRIFTA ........................... 131
ELDERTONIC ..................... 95
ELIDEL ................................ 91
ELIGARD .......................... 133
ELIGARD (3 MONTH) ..... 133
ELIGARD (4 MONTH) ..... 133
ELIGARD (6 MONTH) ..... 133
ELIQUIS .............................. 74
ELMIRON .......................... 123
EMCYT ................................ 52
EMEND ................................ 44
emoquette ........................... 126
EMSAM ............................... 41
EMTRIVA ............................ 66
enalapril maleate .................. 79
enalapril-hydrochlorothiazide
.......................................... 82
ENBREL ............................ 135
ENBREL MINI .................. 135
ENBREL SURECLICK ..... 135
ENDACOF - DM ............... 159
ENDARI ............................... 95
ENEMA ...................... 114, 118
ENEMA DISPOSABLE .... 114
ENEMEEZ ......................... 114
ENEMEEZ PLUS .............. 114
ENGERIX-B (PF) .............. 139
ENGERIX-B PEDIATRIC
(PF) ................................. 139
enoxaparin ............................ 74
enpresse .............................. 126
ENSKYCE.......................... 126
entacapone ............................ 58
entecavir ............................... 63
ENTRESTO.......................... 82
enulose ................................ 107
ENVARSUS XR ................ 135
EPIDIOLEX ......................... 37
epinastine ............................ 146
epinephrine ......................... 155
epitol ..................................... 39
EPIVIR HBV ........................ 63
eplerenone ............................ 84
EPOGEN .............................. 76
EQUETRO ........................... 69
ERAXIS(WATER DILUENT)
.......................................... 45
ergocalciferol (vitamin d2) 103,
105
ergoloid ................................. 40
ergotamine-caffeine .............. 50
ERIVEDGE .......................... 54
ERLEADA ........................... 52
errin .................................... 130
ertapenem ............................. 33
ery pads................................. 35
ERYTHROCIN .................... 35
erythrocin (as stearate) ......... 35
erythromycin ........................ 35
erythromycin ethylsuccinate. 35
erythromycin with ethanol.... 35
erythromycin-benzoyl peroxide
.......................................... 91
ESBRIET ............................ 156
escitalopram oxalate ............. 41
ESTARYLLA ..................... 126
estradiol ...................... 124, 125
estradiol valerate................. 125
estradiol-norethindrone acet
........................................ 126
ESTRING ........................... 125
estropipate .......................... 125
ethambutol ............................ 51
ethosuximide ........................ 37
ethynodiol diac-eth estradiol
........................................ 126
etidronate disodium ............ 143
etodolac ................................ 19
EUCRISA ............................. 91
EVOTAZ .............................. 67
exemestane ........................... 53
EXJADE ............................. 100
EX-LAX MAXIMUM
STRENGTH ................... 114
EXTAVIA ............................ 88
ezetimibe ............................... 85
ezetimibe-simvastatin ........... 85
F falmina (28) ........................ 126
famciclovir ............................ 64
famotidine ........................... 112
FANAPT ............................... 60
FARESTON ......................... 52
FARYDAK ........................... 54
felbamate .............................. 38
felodipine .............................. 81
femynor ............................... 127
fenofibrate ............................. 84
fenofibrate micronized .......... 84
fenofibrate nanocrystallized . 84
fenofibric acid ....................... 84
fenofibric acid (choline) ....... 84
fentanyl ................................. 22
fentanyl citrate ...................... 22
FERGON .............................. 95
FER-IN-SOL ........................ 95
FEROSUL ............................ 95
FERRIPROX ...................... 100
FERRLECIT ............... 100, 101
FERRO-TIME ...................... 95
ferrous fumarate .................... 96
ferrous gluconate .................. 96
ferrous sulfate ................. 94, 96
FERROUSUL ....................... 96
FETZIMA ............................. 41
FEVERALL .......................... 14
fexofenadine ...... 150, 151, 152,
153
FIBER ................................. 119
FIBER (CALCIUM
POLYCARBOPHIL) ..... 114,
118
FIBER (PSYLLIUM
HUSK/SUGAR) ............. 119
FIBER (WITH ASPARTAME)
........................................ 115
FIBER LAXATIVE (CA
POLYCARBO) ....... 114, 119
172
FIBER LAXATIVE
(METHYLCELLULO) . 115,
118
FIBER THERAPY (M-
CELL/SUGAR) .............. 114
FIBER-LAX ....................... 114
FIBER-TABS ..................... 114
finasteride ........................... 123
FIRAZYR ........................... 134
FIRDAPSE ........................... 88
FIRMAGON....................... 133
FIRMAGON KIT W
DILUENT SYRINGE .... 133
flavoxate ............................. 123
FLEBOGAMMA DIF ........ 137
flecainide .............................. 79
FLEET BISACODYL ........ 114
FLEET ENEMA ................. 114
FLEET GLYCERIN (CHILD)
........................................ 115
FLEET PEDIATRIC .......... 115
FLOVENT DISKUS .......... 154
FLOVENT HFA ................. 154
fluconazole ........................... 45
fluconazole in dextrose(iso-o)
.......................................... 45
fluconazole in nacl (iso-osm)45
flucytosine ............................ 45
fludrocortisone ................... 123
flunisolide ........................... 154
fluocinolone .......................... 48
fluocinonide .......................... 48
fluocinonide-e....................... 48
fluocinonide-emollient ......... 48
FLUORIDE (SODIUM) ....... 96
fluorometholone ................. 147
fluorouracil ........................... 52
fluoxetine ........................ 41, 42
fluphenazine decanoate ........ 59
fluphenazine hcl ................... 59
flurbiprofen........................... 19
flurbiprofen sodium ............ 147
flutamide............................... 52
fluticasone .................... 48, 154
fluticasone-salmeterol ........ 159
fluvoxamine .......................... 42
FML FORTE ...................... 147
folic acid ......................... 96, 97
fondaparinux......................... 74
FORFIVO XL ...................... 41
FORTEO ............................ 143
fosamprenavir ....................... 67
fosinopril .............................. 79
fosinopril-hydrochlorothiazide
.......................................... 82
FOSRENOL ....................... 101
FRAGMIN...................... 74, 75
furosemide ...................... 83, 84
FUZEON .............................. 66
fyavolv ................................ 127
FYAVOLV ......................... 127
FYCOMPA ........................... 39
G gabapentin ............................ 38
GALAFOLD ...................... 122
galantamine .......................... 40
GAMMAGARD LIQUID .. 137
GAMMAGARD S-D (IGA < 1
MCG/ML) ...................... 137
GAMMAKED .................... 137
GAMMAPLEX .......... 137, 138
GAMMAPLEX (WITH
SORBITOL) ................... 137
GAMUNEX-C.................... 138
ganciclovir sodium ............... 63
GARDASIL 9 (PF) ............. 139
GAS RELIEF ..................... 107
GAS RELIEF EXTRA
STRENGTH ................... 110
GATTEX 30-VIAL ............ 107
GATTEX ONE-VIAL ........ 107
gauze pad .............................. 72
GAVILAX .......................... 115
gavilyte-c ............................ 107
gavilyte-g ............................ 115
gavilyte-n ............................ 115
GAVISCON ....................... 107
GAVISCON EXTRA
STRENGTH ................... 107
gemfibrozil ........................... 84
generlac .............................. 107
gengraf ................................ 135
GENOTROPIN .................. 131
GENOTROPIN MINIQUICK
........................................ 131
gentak ................................... 28
gentamicin ............................ 28
gentamicin in nacl (iso-osm) 28
GENTEAL MILD TO
MODERATE .................. 144
GENTEAL GEL ................. 144
GENTEAL TEARS MILD . 144
GENTEAL TEARS
MODERATE .................. 144
GENTEAL TEARS
MODERATE (PF) .......... 144
GENTEAL TEARS SEVERE
GEL ................................ 144
GENTLE LAXATIVE ....... 119
GENVOYA .......................... 64
GEODON ............................. 60
GILENYA ............................ 88
GILOTRIF ............................ 54
GLASSIA ........................... 122
glatiramer .............................. 88
GLATOPA ........................... 88
GLEOSTINE ........................ 51
glimepiride ............................ 69
glipizide ................................ 70
glipizide-metformin .............. 70
GLUCAGEN DIAGNOSTIC
KIT ................................... 72
GLUCAGEN HYPOKIT ...... 72
GLUCAGON EMERGENCY
KIT (HUMAN) ................. 72
GLUCAGON HCL ............... 72
glucose .................................. 72
glyburide ............................... 70
glyburide micronized ............ 70
glyburide-metformin ............. 70
glycerin (child) ................... 115
GLYCOLAX ...................... 115
glycopyrrolate ..................... 105
GOCOVRI ............................ 58
granisetron hcl ...................... 44
GRANIX ............................... 76
griseofulvin microsize .......... 45
guaifenesin .................. 159, 160
guanfacine ....................... 78, 87
guanidine .............................. 51
H HAEGARDA ...................... 134
halobetasol propionate .......... 48
haloperidol ............................ 59
haloperidol decanoate ........... 59
haloperidol lactate ................ 59
HAVRIX (PF) .................... 139
HEALTHYLAX ................. 115
HEARTBURN RELIEF
(CIMETIDINE) .............. 113
173
HEARTBURN RELIEF
(FAMOTIDINE) ............ 112
HEARTBURN TREATMENT
24 HOUR........................ 120
HEMOCYTE ........................ 97
heparin (porcine) .................. 75
heparin, porcine (pf) ............. 75
HEPLISAV-B (PF) ............ 139
HETLIOZ ........................... 165
HEXALEN ........................... 51
HIBERIX (PF).................... 139
HUMALOG JUNIOR
KWIKPEN U-100 ............ 72
HUMALOG KWIKPEN
INSULIN .......................... 72
HUMALOG MIX 50-50
INSULN U-100 ................ 72
HUMALOG MIX 50-50
KWIKPEN ....................... 72
HUMALOG MIX 75-25
KWIKPEN ....................... 73
HUMALOG MIX 75-25(U-
100)INSULN .................... 73
HUMALOG U-100 INSULIN
.......................................... 73
HUMATROPE ................... 131
HUMIRA ............................ 136
HUMIRA PEDIATRIC
CROHNS START .......... 135
HUMIRA PEN ................... 136
HUMIRA PEN CROHNS-UC-
HS START ..................... 135
HUMIRA PEN PSOR-
UVEITS-ADOL HS ....... 136
HUMIRA(CF) .................... 136
HUMIRA(CF) PEDI
CROHNS STARTER ..... 136
HUMIRA(CF) PEN............ 136
HUMIRA(CF) PEN
CROHNS-UC-HS .......... 136
HUMIRA(CF) PEN PSOR-
UV-ADOL HS................ 136
HUMULIN 70/30 U-100
INSULIN .......................... 73
HUMULIN N NPH U-100
INSULIN .......................... 73
HUMULIN R REGULAR U-
100 INSULN .................... 73
HUMULIN R U-500 (CONC)
INSULIN .......................... 73
HUMULIN R U-500 (CONC)
KWIKPEN........................ 73
hydralazine ........................... 86
hydrochlorothiazide .............. 84
hydrocodone-acetaminophen 15
hydrocodone-ibuprofen .. 15, 20
hydrocortisone . 48, 49, 50, 123,
124, 142
hydrocortisone acetate .......... 91
hydrocortisone butyrate ........ 49
hydrocortisone butyr-emollient
.......................................... 49
HYDROCORTISONE PLUS
.......................................... 49
hydrocortisone valerate ........ 49
hydrocortisone-acetic acid .. 147
hydrocortisone-aloe vera 49, 50
hydrocortisone-min oil-wht pet
.......................................... 91
hydromorphone .................... 22
hydromorphone (pf) ............. 22
HYDROSKIN ...................... 91
HYDROSKIN WITH ALOE 49
hydroxocobalamin ................ 97
hydroxychloroquine.............. 57
hydroxyurea .......................... 52
hydroxyzine hcl .................. 152
hydroxyzine pamoate ........... 68
HYPERRAB (PF)............... 138
HYPERRAB S/D (PF) ....... 138
I ibandronate ......................... 143
IBRANCE ............................ 54
IBU ....................................... 15
IBU-200 ................................ 20
ibuprofen .................. 20, 21, 22
IBUPROFEN IB ............. 20, 22
ibuprofen-oxycodone............ 15
ICAPS MV ........................... 97
ICLUSIG .............................. 54
IDHIFA ................................ 54
IFEREX 150 ......................... 97
imatinib ................................. 54
IMBRUVICA ....................... 54
imipenem-cilastatin .............. 33
imipramine hcl ...................... 42
imipramine pamoate ............. 43
imiquimod ............................ 91
IMOVAX RABIES VACCINE
(PF) ................................. 139
INCASSIA .......................... 130
INCRELEX ........................ 132
INCRUSE ELLIPTA .......... 154
indapamide ........................... 84
indomethacin ........................ 21
INFANRIX (DTAP) (PF) .. 139,
140
INFANTS' PAIN AND
FEVER ....................... 14, 15
INFANTS' PAIN RELIEF ... 15,
17
INFED .................................. 97
INGREZZA .......................... 88
INLYTA ............................... 54
INSECT REPELLENT
(DEET) ............................. 90
insulin syringe-needle u-100 72
INTELENCE ........................ 65
intralipid ............................... 97
INTRALIPID ........................ 97
INTRON A ........................... 64
introvale .............................. 127
INVEGA SUSTENNA ......... 60
INVEGA TRINZA ............... 61
INVIRASE ........................... 67
INVOKAMET ...................... 70
INVOKAMET XR ............... 70
INVOKANA ......................... 70
INZO ANTIFUNGAL .......... 45
IPOL ................................... 140
ipratropium bromide ... 154, 160
ipratropium-albuterol .......... 161
irbesartan .............................. 78
irbesartan-hydrochlorothiazide
.......................................... 82
IRESSA ................................ 54
IRON .................................... 97
ISENTRESS ......................... 64
ISENTRESS HD .................. 64
ISIBLOOM ......................... 127
ISOLYTE S PH 7.4 .............. 97
ISOLYTE-P IN 5 %
DEXTROSE ..................... 97
ISOLYTE-S .......................... 97
isoniazid ................................ 51
isosorbide dinitrate ............... 86
isosorbide mononitrate ......... 86
isotretinoin ............................ 91
isradipine .............................. 81
itraconazole ........................... 45
174
ivermectin ............................. 56
IXIARO (PF) ...................... 140
J JADENU ............................ 101
JADENU SPRINKLE ........ 101
JAKAFI ................................ 55
jantoven ................................ 75
JANUMET ........................... 70
JANUMET XR ..................... 70
JANUVIA............................. 70
JENTADUETO .................... 70
JENTADUETO XR.............. 70
jinteli................................... 127
jolivette ............................... 130
juleber ................................. 127
JULUCA............................... 64
junel 1.5/30 (21) ................. 127
junel 1/20 (21) .................... 127
junel fe 1.5/30 (28) ............. 127
junel fe 1/20 (28) ................ 127
JUXTAPID ........................... 85
JYNARQUE ....................... 101
K KALETRA ........................... 67
KALYDECO ...................... 155
KAO-TIN (DOCUSATE
CALCIUM) .................... 116
kariva (28) .......................... 127
KEDRAB (PF) ................... 140
kelnor 1/35 (28) .................. 127
KELNOR 1-50 ................... 127
ketoconazole ......................... 45
ketorolac ....................... 21, 147
KEVEYIS ............................. 83
KIDKARE COUGH/COLD
........................................ 161
kimidess (28) ...................... 127
KINERET ........................... 136
KINRIX (PF) ...................... 140
kionex ................................. 101
kionex (with sorbitol) ......... 101
KISQALI .............................. 55
KISQALI FEMARA CO-
PACK ............................... 55
klor-con 10 ........................... 97
klor-con 8 ............................. 97
klor-con m10 ........................ 97
KLOR-CON M15 ................. 97
klor-con m20 ........................ 97
KLOR-CON SPRINKLE ..... 97
KONSYL (SUGAR)........... 116
KONSYL EASY MIX........ 116
KONSYL FIBER ............... 116
KONSYL FORMULA-D ... 116
KONSYL SUGAR-FREE .. 116
KONSYL SUGAR-FREE
(ASPARTAME) ............. 116
KORLYM ............................. 71
KRISTALOSE.................... 116
K-SOL .................................. 97
KURVELO (28) ................. 127
KUVAN.............................. 122
KYNAMRO ......................... 85
L labetalol ................................ 80
lactulose .............................. 116
LAMISIL AF ........................ 45
lamivudine ............................ 63
lamivudine-zidovudine ......... 66
lamotrigine...................... 39, 69
lansoprazole ................ 120, 121
lanthanum ........................... 101
LANTUS SOLOSTAR U-100
INSULIN .......................... 73
LANTUS U-100 INSULIN .. 73
larin 1.5/30 (21) .................. 127
larin 1/20 (21) ..................... 127
larin fe 1.5/30 (28) .............. 127
larin fe 1/20 (28) ................. 127
larissia ................................. 127
latanoprost .......................... 143
LATUDA.............................. 61
LAXATIVE (BISACODYL)
................................ 115, 116
LAXATIVE PLUS STOOL
SOFTENER .................... 119
LAZANDA ........................... 23
leena 28............................... 127
leflunomide ......................... 138
LENVIMA............................ 55
lessina ................................. 127
LETAIRIS .......................... 156
letrozole ................................ 53
leucovorin calcium ............... 53
LEUKERAN ........................ 51
LEUKINE ............................. 76
leuprolide ............................ 133
LEVA SET ........................... 23
levalbuterol hcl ................... 155
LEVEMIR FLEXTOUCH U-
100 INSULN .................... 73
LEVEMIR U-100 INSULIN 73
levetiracetam ......................... 37
levobunolol ......................... 147
levocarnitine ......................... 98
levocarnitine (with sugar) ..... 98
levocetirizine ...................... 152
levofloxacin .......................... 36
levofloxacin in d5w .............. 35
levonest (28) ....................... 127
levonorgestrel-ethinyl estrad
................................ 127, 128
levonorg-eth estrad triphasic
........................................ 128
levora-28 ............................. 128
LEVO-T .............................. 132
levothyroxine ...................... 132
levoxyl ................................ 132
LEXIVA ............................... 67
LICE KILLING .................... 57
LICE TREATMENT ............ 57
LICE TREATMENT
(PERMETHRIN) .............. 57
lidocaine ............................... 23
lidocaine hcl .......................... 23
lidocaine-prilocaine .............. 23
LIDOPAC ............................. 23
lidopril .................................. 23
lidopril xr .............................. 23
LIDO-PRILO CAINE PACK
.......................................... 23
LILLOW (28) ..................... 128
lindane .................................. 57
linezolid ................................ 30
linezolid in dextrose 5% ....... 30
linezolid-0.9% sodium chloride
.......................................... 30
LINZESS ............................ 113
liothyronine ......................... 132
liprozonepak ......................... 24
LIQUID ANTACID ........... 108
LIQUITEARS ..................... 144
lisinopril ................................ 79
lisinopril-hydrochlorothiazide
.......................................... 82
lithium carbonate .................. 69
lithium citrate ........................ 69
LIVALO ............................... 84
livixil pak .............................. 24
175
LONSURF ............................ 53
loperamide .......................... 108
lopinavir-ritonavir ................ 67
lopreeza .............................. 128
loratadine .... 150, 151, 152, 153
LORATA-DINE D ............. 163
LORATADINE-D .............. 161
lorazepam ............................. 69
lorazepam intensol................ 69
LORBRENA ........................ 55
losartan ................................. 79
losartan-hydrochlorothiazide 82
lovastatin .............................. 84
low-ogestrel (28) ................ 128
loxapine succinate ................ 59
LUBRICANT EYE ............ 144
LUBRICANT EYE (CMC-
GLYCERIN) .................. 144
LUBRICANT EYE (PG-PEG
400)......................... 144, 145
LUBRICANT EYE (PG-PEG
400)(PF) ......................... 144
LUBRICATING PLUS ...... 144
LUBRIFRESH PM ............. 144
LUCEMYRA ....................... 24
LUMIGAN ......................... 143
LUPRON DEPOT .............. 133
LUPRON DEPOT (3
MONTH) ........................ 133
LUPRON DEPOT (4
MONTH) ........................ 133
LUPRON DEPOT (6
MONTH) ........................ 133
LUPRON DEPOT-PED ..... 133
LUPRON DEPOT-PED (3
MONTH) ........................ 133
lutera (28) ........................... 128
LYNPARZA......................... 53
LYRICA ............................... 37
LYSODREN......................... 56
lyza ..................................... 130
M MAG 64................................ 98
MAG-AL PLUS ................. 108
MAGNEBIND 300 .............. 98
magnesium ........................... 98
magnesium citrate .............. 116
magnesium oxide.................. 98
magnesium sulfate ................ 98
malathion .............................. 57
MAPAP
(ACETAMINOPHEN) .... 15,
16
MAPAP ARTHRITIS PAIN 16
MAPAP EXTRA STRENGTH
.................................... 15, 16
maprotiline............................ 42
marlissa (28) ....................... 128
MARPLAN .......................... 41
MATULANE........................ 51
MAVYRET .......................... 64
meclizine .............................. 43
meclofenamate...................... 21
MEDOLOR PAK ................. 24
medroxyprogesterone ......... 130
mefloquine ............................ 57
megestrol ............................ 131
MEKINIST ........................... 55
MEKTOVI............................ 55
meloxicam ............................ 21
memantine ............................ 40
MENACTRA (PF) ............. 140
MENEST ............................ 125
MENTAX ............................. 45
MENVEO A-C-Y-W-135-DIP
(PF) ................................. 140
meperidine ............................ 23
MEPHYTON ........................ 76
mercaptopurine ..................... 52
MERIBIN ............................. 98
meropenem ........................... 33
meropenem-0.9% sodium
chloride ............................. 33
mesalamine ......................... 142
mesalamine with cleansing
wipe ................................ 142
MESNEX.............................. 53
metaproterenol .................... 155
METAXALL ...................... 165
metaxalone.......................... 165
metformin ............................. 71
methadone ............................ 22
methazolamide...................... 83
methenamine hippurate ........ 30
methimazole ....................... 134
methocarbamol ................... 165
methotrexate sodium .......... 136
methotrexate sodium (pf) ... 136
methoxsalen .......................... 91
methyclothiazide .................. 84
methyldopa ........................... 78
methyldopa-
hydrochlorothiazide .......... 82
methylphenidate hcl ........ 87, 88
methylprednisolone ...... 49, 142
methylprednisolone acetate 124
methyltestosterone .............. 124
metoclopramide hcl .............. 43
metolazone ............................ 84
metoprolol succinate ............. 80
metoprolol ta-hydrochlorothiaz
.......................................... 80
metoprolol tartrate ................ 80
metro i.v. ............................... 30
metronidazole ....................... 30
metronidazole in nacl (iso-os)
.......................................... 30
mexiletine ............................. 79
MI-ACID ............................ 109
MICONAZOLE 7 ........... 45, 46
miconazole nitrate .......... 45, 46
microgestin 1.5/30 (21) ...... 128
microgestin 1/20 (21) ......... 128
microgestin fe 1.5/30 (28) .. 128
microgestin fe 1/20 (28) ..... 128
midodrine .............................. 78
MILI ................................... 128
MILK OF MAGNESIA ..... 115,
116, 117, 119
MIMVEY ........................... 128
mimvey lo ........................... 128
mineral oil ........................... 117
minocycline .......................... 36
minoxidil ............................... 86
MINTOX ............................ 109
MINTOX PLUS ................. 109
mirtazapine ........................... 41
misoprostol ......................... 120
M-M-R II (PF) .................... 140
MODAFINIL ...................... 165
moexipril ............................... 79
moexipril-hydrochlorothiazide
.......................................... 82
molindone ............................. 59
mometasone .................. 49, 154
mononessa (28) ................... 128
montelukast ......................... 154
morgidox ............................... 37
MORGIDOX 1X 50 ............. 37
morphine ......................... 22, 23
176
MOTION SICKNESS .......... 43
MOTION SICKNESS RELIEF
.......................................... 43
MOTION-TIME ................... 43
moxifloxacin......................... 36
moxifloxacin in nacl (iso-osm)
.......................................... 36
moxifloxacin-sod.ace,sul-water
.......................................... 36
MUCINEX ......................... 161
MUCINEX DM .................. 161
MUCINEX FAST-MAX DM
MAX............................... 161
MUCUS RELIEF ....... 161, 162
MUCUS RELIEF COUGH 163
MUCUS RELIEF DM ....... 161,
162, 163
MUCUS RELIEF ER ......... 160
MUCUS RELIEF SINUS .. 161
MULTAQ ............................. 79
mupirocin ............................. 30
MURO 128 ......................... 144
MY WAY ........................... 128
MYCAMINE ........................ 46
mycophenolate mofetil ....... 136
mycophenolate sodium ....... 136
myorisan ............................... 91
MYRBETRIQ .................... 123
N nabumetone .......................... 21
nadolol .................................. 80
nafcillin................................. 34
nafcillin in dextrose iso-osm 34
nalbuphine ............................ 23
naloxone ............................... 24
naltrexone ............................. 24
NAMENDA XR ................... 40
naproxen ............................... 21
naproxen sodium .................. 21
NARCAN ............................. 24
NASAL DECONGESTANT
(OXYMETAZL) ............ 161
NASAL DECONGESTANT
(PE)......................... 159, 162
NASAL DECONGESTANT
(PSEUDOEPH) ..... 160, 161,
162, 163
NASAL SPRAY
(OXYMETAZOLINE) .. 159,
162
NASAL SPRAY 12 HOUR
........................ 161, 162, 163
NASCOBAL ........................ 98
NATACYN ........................ 144
nateglinide ............................ 71
NATPARA ......................... 143
NATRAPEL ......................... 91
NATURAL FIBER
LAXATIVE (SUGAR)... 117
NATURAL FIBER
LAXATIVE THERAPY 117
NATURAL VEG
LAXATIVE(SENNOSID)
........................................ 117
NATURA-LAX .................. 118
NATURE'S TEARS ........... 144
NEBUPENT ......................... 57
necon 0.5/35 (28) ................ 128
necon 7/7/7 (28).................. 128
nefazodone............................ 41
neomycin .............................. 28
neomycin-bacitracin-poly-hc 31
neomycin-bacitracin-
polymyxin ......................... 31
neomycin-polymyxin b-
dexameth .......................... 31
neomycin-polymyxin-
gramicidin ......................... 31
neomycin-polymyxin-hc ..... 31,
147, 148
NERLYNX ........................... 55
NEULASTA ......................... 76
NEUPOGEN ........................ 76
NEUPRO .............................. 58
nevirapine ............................. 65
NEXAVAR .......................... 55
niacin .................................... 85
niacinamide .......................... 85
NICODERM CQ .................. 25
NICORELIEF ....................... 25
NICORETTE .................. 25, 26
nicotine ......... 24, 25, 26, 27, 28
nicotine (polacrilex) 24, 26, 27,
28
NICOTROL .......................... 28
NICOTROL NS .................... 28
nifedical xl ............................ 81
nifedipine .............................. 81
NIGHTTIME SLEEP AID
(DIPHEN) ....................... 152
nilutamide ............................. 52
nimodipine ............................ 81
NINLARO ............................ 53
NITRO-BID .......................... 86
NITRO-DUR ........................ 86
nitrofurantoin macrocrystal .. 31
nitrofurantoin monohyd/m-
cryst .................................. 31
nitroglycerin ......................... 86
NITYR ................................ 122
NIVESTYM ......................... 76
NOCTIVA .......................... 132
NON-ASPIRIN ..................... 17
NON-ASPIRIN EXTRA
STRENGTH ..................... 17
NON-ASPIRIN PAIN RELIEF
.......................................... 17
NON-DROWSY ALLERGY
........................................ 152
nora-be ................................ 131
NORDITROPIN FLEXPRO
........................................ 132
norethindrone (contraceptive)
........................................ 131
norethindrone acetate .......... 131
norethindrone ac-eth estradiol
........................................ 128
norgestimate-ethinyl estradiol
........................................ 128
NORLYDA ......................... 128
norlyroc ............................... 131
normosol-r ............................ 98
normosol-r ph 7.4 ................. 98
NORPACE CR ..................... 79
NORTHERA ........................ 78
nortrel 0.5/35 (28) ............... 128
nortrel 1/35 (21) .................. 128
nortrel 1/35 (28) .................. 128
nortrel 7/7/7 (28) ................. 128
nortriptyline .......................... 43
NORVIR ............................... 67
NOVOLIN 70/30 U-100
INSULIN .......................... 73
NOVOLIN N NPH U-100
INSULIN .......................... 74
NOVOLIN R REGULAR U-
100 INSULN .................... 74
NOVOLOG FLEXPEN U-100
INSULIN .......................... 74
177
NOVOLOG MIX 70-30 U-100
INSULN ........................... 74
NOVOLOG MIX 70-
30FLEXPEN U-100 ......... 74
NOVOLOG PENFILL U-100
INSULIN .......................... 74
NOVOLOG U-100 INSULIN
ASPART........................... 74
NOXAFIL ............................ 46
NUEDEXTA ........................ 88
NU-MAG ............................. 98
NUPLAZID .......................... 61
NUTROPIN AQ NUSPIN . 132
NUVARING....................... 128
nyamyc ................................. 46
nystatin ................................. 46
nystatin-triamcinolone .......... 91
nystop ................................... 46
O OCALIVA .......................... 109
ocella .................................. 129
octreotide acetate ................ 133
OCTREOTIDE ACETATE 134
OCUVITE WITH LUTEIN . 98
ODEFSEY ............................ 65
ODOMZO ............................ 53
OFEV ................................. 156
OFF ACTIVE ....................... 91
OFF DEEP WOODS ............ 91
OFF DEEP WOODS DRY .. 91
OFF DEEP WOODS
SPORTSMEN .................. 91
OFF FAMILYCARE (WITH
DEET) .............................. 91
OFF FAMILYCARE(WITH
PICARIDIN) .................... 91
ofloxacin ....................... 36, 148
olanzapine............................. 61
olmesartan ............................ 79
olmesartan-amlodipin-
hcthiazid ........................... 83
olmesartan-
hydrochlorothiazide .......... 83
olopatadine ......................... 146
omega-3 acid ethyl esters ..... 85
omeprazole ................. 120, 121
OMNITROPE..................... 132
ONCOVITE ......................... 98
ondansetron .......................... 44
ondansetron hcl .................... 44
ONE DAILY ........................ 98
OPCICON ONE-STEP....... 129
OPTION-2 .......................... 129
ORENCIA .......................... 137
ORENCIA CLICKJECT .... 137
ORFADIN .......................... 122
ORILISSA .......................... 134
ORKAMBI ......................... 155
orphenadrine citrate ............ 165
orsythia ............................... 129
OS-CAL 500 + D3 ............... 98
oseltamivir ...................... 67, 68
OTEZLA ............................ 138
OTEZLA STARTER .......... 138
oxandrolone ........................ 124
oxcarbazepine ....................... 39
OXERVATE ...................... 145
oxybutynin chloride ............ 123
oxycodone ...................... 22, 23
oxycodone-acetaminophen ... 16
oxycodone-aspirin ................ 16
OYSCO 500/D ................... 103
OYSCO-500 ......................... 98
OYSTER SHELL CALCIUM
500 .............................. 98, 99
OYSTER SHELL CALCIUM-
VIT D3 ........................... 103
OZEMPIC ............................ 71
P PAIN AND FEVER ............. 16
PAIN RELIEF ................ 14, 16
PAIN RELIEF EXTRA
STRENGTH ............... 15, 16
PAIN RELIEVER ... 15, 16, 17,
18
PAIN RELIEVER EXTRA
STRENGTH ............... 17, 18
paliperidone .......................... 61
PANRETIN .......................... 56
pantoprazole ....................... 121
paricalcitol .......................... 103
paromomycin ........................ 28
paroxetine hcl ....................... 42
PASER.................................. 51
PAXIL .................................. 42
PEDIA RELIEF COUGH-
COLD ............................. 162
PEDIALYTE ........................ 99
PEDIALYTE FREEZER
POPS ................................ 99
PEDIALYTE SINGLES ....... 99
PEDIARIX (PF) ................. 140
PEDIATRIC COUGH AND
COLD ............................. 162
PEDIATRIC ELECTROLYTE
........................................ 104
PEDVAX HIB (PF) ............ 140
peg 3350-electrolytes .......... 117
peg-3350 with flavor packs 117
PEGANONE ......................... 40
PEGASYS ............................ 63
PEGASYS PROCLICK ........ 63
peg-electrolyte soln ............ 117
pen needle, diabetic .............. 72
penicillin g procaine ............. 34
penicillin g sodium ............... 34
penicillin v potassium ........... 34
PENTACEL ACTHIB
COMPONENT (PF) ....... 140
PENTAM .............................. 57
PENTASA .......................... 142
pentazocine-naloxone ........... 17
pentoxifylline ........................ 83
PEPTIC RELIEF ................ 109
periogard ............................... 89
permethrin ............................. 57
perphenazine ......................... 43
perphenazine-amitriptyline ... 41
PERSERIS ............................ 61
PHARBEDRYL ................. 152
PHARBETOL ....................... 17
phenelzine ............................. 41
phenobarbital ........................ 38
phenoxybenzamine ............... 78
PHENYTEK ......................... 40
phenytoin .............................. 40
phenytoin sodium extended .. 40
PHOSPHOLINE IODIDE .. 147
PIFELTRO ........................... 65
pilocarpine hcl .............. 89, 147
pimecrolimus ........................ 91
pimozide ............................... 59
pimtrea (28) ........................ 129
pindolol ................................. 80
pioglitazone .......................... 71
pioglitazone-metformin ........ 71
piperacillin-tazobactam ........ 34
pirmella ............................... 129
piroxicam .............................. 21
PLAN B ONE-STEP .......... 129
178
plenamine ............................. 99
podofilox .............................. 91
polyethylene glycol 3350 ... 117
polymyxin b sulfate .............. 31
polymyxin b sulf-trimethoprim
.......................................... 31
POLY-VI-SOL ..................... 99
POLY-VI-SOL WITH IRON
.......................................... 99
POMALYST ........................ 52
portia 28.............................. 129
potassium chlorid-d5-
0.45%nacl ......................... 99
potassium chloride................ 99
potassium chloride in water.. 99
potassium citrate ................... 99
PRADAXA........................... 75
pramipexole .......................... 58
prasugrel ............................... 78
pravastatin ............................ 84
praziquantel .......................... 56
prazosin ................................ 78
prednicarbate ........................ 92
prednisolone ......................... 49
prednisolone acetate ........... 147
prednisolone sodium phosphate
.................................. 49, 147
prednisone ............................ 49
prednisone intensol ............. 124
PREMARIN ....................... 125
PREMPHASE .................... 129
PREMPRO ......................... 129
PRENATAL ....................... 103
PRENATAL VITAMIN ..... 103
PRENATAL VITAMIN PLUS
LOW IRON .................... 103
PREVACID 24HR ............. 121
prevalite ................................ 85
previfem ............................. 129
PREVYMIS .......................... 63
PREZCOBIX ........................ 67
PREZISTA ........................... 67
PRIFTIN ............................... 51
prilolid .................................. 24
PRIMAQUINE ..................... 57
primidone ............................. 38
PRIVIGEN ......................... 138
probenecid ............................ 47
probenecid-colchicine .......... 47
prochlorperazine ................... 43
prochlorperazine maleate ..... 43
PROCRIT ............................. 76
procto-med hc ..................... 124
procto-pak ........................... 124
proctosol hc ........................ 124
proctozone-hc ..................... 124
progesterone micronized .... 131
PROGLYCEM ..................... 72
PROLASTIN-C .................. 122
PROLIA.............................. 143
PROMACTA ........................ 76
promethazine ................ 43, 152
promethazine vc ................. 162
promethazine-phenylephrine
........................................ 162
promethegan ......................... 43
propafenone .......................... 79
proparacaine ....................... 145
propranolol ........................... 80
propranolol-hydrochlorothiazid
.......................................... 83
propylthiouracil .................. 134
PROQUAD (PF)................. 140
PROSIGHT .......................... 99
protriptyline .......................... 43
PROVIL................................ 21
pseudoephedrine hcl ........... 162
PULMOZYME ................... 156
PURIXAN ............................ 52
pyrazinamide ........................ 51
pyridostigmine bromide ....... 51
pyridoxine (vitamin b6) ..... 103,
104
Q QUADRACEL (PF) ........... 140
quasense.............................. 129
quetiapine ............................. 61
quinapril................................ 79
quinapril-hydrochlorothiazide
.......................................... 83
quinidine gluconate .............. 79
quinidine sulfate ................... 79
quinine sulfate ...................... 57
QVAR ................................. 154
QVAR REDIHALER ......... 154
R RABAVERT (PF) .............. 140
raloxifene ............................ 131
ramipril ................................. 79
RANEXA ............................. 83
ranitidine hcl ....................... 112
RAPAMUNE ...................... 137
rasagiline ............................... 59
RAVICTI ............................ 122
REACT ............................... 129
READY-TO-USE ENEMA 115
REBIF (WITH ALBUMIN) . 89
REBIF REBIDOSE .............. 89
REBIF TITRATION PACK . 89
reclipsen (28) ...................... 129
RECOMBIVAX HB (PF) ... 140
RECTIV .............................. 109
REFRESH CELLUVISC .... 145
REFRESH CLASSIC (PF) . 145
REFRESH LACRI-LUBE .. 145
REFRESH OPTIVE ........... 145
REFRESH OPTIVE
ADVANCED .................. 145
REFRESH OPTIVE
SENSITIVE (PF) ............ 145
REFRESH PLUS ................ 145
REFRESH TEARS ............. 145
REGRANEX ........................ 92
REGULOID ........................ 118
REGULOID, SUGAR FREE
........................................ 118
RELENZA DISKHALER .... 68
RELISTOR ......................... 109
RENAL VITAMIN ............ 104
repaglinide ............................ 71
REPATHA PUSHTRONEX 85
REPATHA SURECLICK .... 85
REPATHA SYRINGE ......... 86
REPEL 100 ........................... 92
REPEL FAMILY .................. 92
REPEL HUNTER'S .............. 92
REPEL LEMON
EUCALYPTUS ................ 92
REPEL SPORTSMEN ......... 92
REPEL SPORTSMEN DRY 92
REPEL SPORTSMEN MAX
.......................................... 92
REPEL TICK DEFENSE ..... 92
RESCRIPTOR ...................... 65
RESTASIS .......................... 145
RESTASIS MULTIDOSE .. 145
REVATIO ........................... 156
REVLIMID ........................... 52
REXULTI ............................. 61
REYATAZ ........................... 67
179
RIBAVIRIN ......................... 64
rifabutin ................................ 51
rifampin ................................ 51
RIFATER ............................. 51
riluzole .................................. 88
rimantadine ........................... 68
risedronate .......................... 143
RISPERDAL CONSTA ....... 62
risperidone ............................ 62
ritonavir ................................ 67
rivastigmine .......................... 40
rivastigmine tartrate.............. 40
rizatriptan ............................. 50
ROBAFEN ......................... 162
ROBAFEN CF
(PHENYLEPHRINE)..... 162
ROBAFEN DM .................. 163
ROBAFEN DM COUGH... 163
ROBAFEN DM COUGH-
CHEST CONGEST ........ 162
ropinirole .............................. 58
rosuvastatin........................... 84
ROTARIX .......................... 141
ROTATEQ VACCINE ...... 141
roweepra ............................... 37
ROWEEPRA ........................ 37
ROWEEPRA XR ................. 37
ROZEREM ......................... 165
RUBRACA........................... 55
RULOX .............................. 109
RYDAPT .............................. 55
S SABRIL ................................ 38
SAMSCA ........................... 101
SANDIMMUNE ................ 137
SANTYL .............................. 92
SAPHRIS ............................. 62
SAPHRIS (BLACK
CHERRY) ........................ 62
SAVELLA ............................ 88
scopolamine base.................. 43
SEGLUROMET ................... 71
selegiline hcl ......................... 59
selenium sulfide.................... 92
selzentry ............................... 66
SELZENTRY ....................... 66
SENEXON ......................... 118
SENEXON-S ...................... 118
SENNA....................... 116, 118
SENNA LAX ..................... 118
SENNA LAXATIVE . 118, 119
SENNA PLUS .................... 118
SENNA WITH DOCUSATE
SODIUM ........................ 114
SENNA-TIME S ................ 118
SENNO ............................... 118
sennosides-docusate sodium
........................................ 118
SENOKOT ......................... 118
SENSIPAR ......................... 143
SEREVENT DISKUS ........ 155
SEROSTIM ........................ 109
sertraline ............................... 42
setlakin................................ 129
sevelamer carbonate ........... 102
sharobel .............................. 131
SHINGRIX (PF) ................. 141
SHINGRIX GE ANTIGEN
COMPONENT ............... 141
SIGNIFOR.......................... 134
SILACE .............................. 118
SILADRYL SA .................. 153
sildenafil (antihypertensive)
........................................ 156
SILENOR ........................... 165
SILTUSSIN DM DAS........ 163
SILTUSSIN SA .................. 163
SILTUSSIN-DM ................ 163
silver sulfadiazine ................. 36
SIMBRINZA ...................... 147
SIMPONI............................ 137
simvastatin ............................ 85
SINUS RELIEF
(OXYMETAZOLINE) ... 163
sirolimus ............................. 137
SIRTURO ............................. 51
SLEEP ................................ 153
SLEEP AID
(DIPHENHYDRAMINE)
................................ 151, 153
SLEEP-TABS ..................... 153
sodium bicarbonate............. 100
sodium chloride .......... 100, 145
sodium chloride 0.45 % ...... 100
sodium chloride 0.9 % ........ 100
sodium chloride 3 % ........... 100
sodium ferric gluconat-sucrose
.................................. 99, 100
sodium phenylbutyrate ....... 122
sodium polystyrene (sorb free)
........................................ 101
sodium polystyrene sulfonate
........................................ 101
SOLTAMOX ........................ 52
SOMATULINE DEPOT .... 134
SOMAVERT ...................... 134
sorine .................................... 79
sotalol ................................... 80
sotalol af ............................... 79
SPIRIVA RESPIMAT ........ 154
SPIRIVA WITH
HANDIHALER .............. 154
spironolactone ....................... 84
spironolacton-hydrochlorothiaz
.......................................... 83
sprintec (28) ........................ 129
SPRITAM ............................. 37
SPRYCEL ............................. 55
sps (with sorbitol) ............... 101
sronyx ................................. 129
ssd ......................................... 36
stavudine ............................... 66
STEGLATRO ....................... 71
STEGLUJAN ....................... 71
STELARA ............................ 92
STIOLTO RESPIMAT ....... 164
STIVARGA .......................... 55
STOMACH RELIEF .. 108, 110
STOMACH RELIEF
ORIGINAL ..................... 110
STOOL SOFTENER .. 116, 119
STOOL SOFTENER
(DOCUSATE CAL) ....... 119
STOOL SOFTENER-
LAXATIVE .................... 119
STOOL SOFTENER-
STIMULANT LAXAT .. 119
streptomycin ......................... 29
STRESS FORMULA ......... 104
STRESS FORMULA WITH
IRON .............................. 100
STRESS FORMULA WITH
ZINC ............................... 100
STRIBILD ............................ 65
STRIVERDI RESPIMAT .. 155
SUBVENITE ........................ 39
SUBVENITE STARTER
(BLUE) KIT ..................... 39
180
SUBVENITE STARTER
(GREEN) KIT .................. 39
SUBVENITE STARTER
(ORANGE) KIT ............... 39
SUCRAID .......................... 122
sucralfate ............................ 120
SUDOGEST ....................... 164
SUDOGEST PE ................. 164
SUDOGEST SINUS AND
ALLERGY ..................... 153
sulfacetamide sodium ........... 36
sulfacetamide sodium (acne) 36
sulfacetamide-prednisolone 145
sulfadiazine........................... 36
sulfamethoxazole-trimethoprim
.......................................... 36
sulfasalazine ....................... 142
sulindac................................. 22
sumatriptan ........................... 50
sumatriptan succinate ..... 50, 51
SUPERPLEX-T .................. 104
SUPHEDRIN ..................... 164
SUPHEDRINE ................... 164
SUPRAX .............................. 33
SUTENT............................... 55
SYLATRON......................... 53
SYMBICORT..................... 164
SYMDEKO ........................ 156
SYMFI .................................. 67
SYMFI LO ........................... 65
SYMLINPEN 120 ................ 71
SYMLINPEN 60 .................. 71
SYMPAZAN ........................ 38
SYMTUZA........................... 67
SYNAREL ......................... 134
SYNDROS ........................... 44
SYNRIBO ............................ 53
SYNTHROID ..................... 132
SYSTANE (PF) .................. 146
SYSTANE (PROPYLENE
GLYCOL) ...................... 146
SYSTANE BALANCE ...... 146
SYSTANE GEL ................. 146
SYSTANE ULTRA............ 146
T TAB-A-VITE ..................... 104
TAB-A-VITE/IRON .......... 104
TABLOID ............................ 53
tacrolimus ..................... 92, 137
TACTINAL .......................... 18
TACTINAL EXTRA
STRENGTH ..................... 18
TAFINLAR .......................... 55
TAGRISSO .......................... 55
TAKE ACTION ................. 129
TALZENNA ......................... 53
tamoxifen .............................. 52
tamsulosin ........................... 123
TARCEVA ........................... 55
TARGRETIN ....................... 56
tarina fe 1/20 (28) ............... 129
TARINA FE 1-20 EQ (28) . 129
TASIGNA ............................ 55
tazarotene.............................. 92
TAZICEF.............................. 33
TAZORAC ........................... 92
taztia xt ................................. 81
TEARS NATURALE FREE
(PF) ................................. 146
TECFIDERA ........................ 89
TEFLARO ............................ 33
TEKTURNA ........................ 83
TEKTURNA HCT ............... 83
temazepam .......................... 165
TENIVAC (PF) .................. 141
tenofovir disoproxil fumarate
.......................................... 63
terazosin................................ 78
terbinafine hcl ....................... 46
terbutaline ........................... 155
terconazole............................ 46
TESSALON PERLES ........ 164
testosterone ......................... 124
testosterone cypionate ........ 124
testosterone enanthate......... 124
tetanus,diphtheria tox ped(pf)
........................................ 141
tetanus-diphtheria toxoids-td
........................................ 141
tetrabenazine ......................... 88
tetracycline ........................... 37
THALOMID ......................... 52
theophylline ........................ 156
THERA ............................... 104
THERA M PLUS (FERROUS
FUMARAT) ................... 100
THERA-M .......................... 104
thiamine hcl (vitamin b1) ... 104
THIOLA ............................. 123
thioridazine ........................... 59
thiothixene ............................ 59
tiagabine ............................... 38
TIBSOVO ............................. 55
TICE BCG .......................... 141
timolol maleate ............. 80, 147
tinidazole .............................. 31
TIVICAY .............................. 65
tizanidine .............................. 63
TOBRADEX ........................ 29
tobramycin ............................ 29
tobramycin in 0.225 % nacl 156
tobramycin sulfate ................ 29
tobramycin with nebulizer .. 156
tobramycin-dexamethasone .. 29
tolcapone ............................... 58
tolnaftate ............................... 46
tolterodine ........................... 123
topiramate ............................. 39
toremifene ............................. 52
torsemide .............................. 84
TOTAL B/C ........................ 100
TOTAL HOME INSECT
REPELLENT .................... 90
TOUJEO MAX U-300
SOLOSTAR ..................... 74
TOUJEO SOLOSTAR U-300
INSULIN .......................... 74
TOVIAZ ............................. 123
TRADJENTA ....................... 71
tramadol ................................ 23
tramadol-acetaminophen ...... 18
trandolapril ........................... 79
tranexamic acid ..................... 76
tranylcypromine .................... 41
TRAVATAN Z ................... 143
TRAVEL SICKNESS .......... 44
TRAVEL SICKNESS
(MECLIZINE) .................. 44
trazodone .............................. 41
TRECATOR ......................... 51
TRELEGY ELLIPTA ......... 164
TRELSTAR ........................ 134
TREMFYA ........................... 92
tretinoin ................................. 92
tretinoin (chemotherapy) ...... 56
tretinoin (emollient) .............. 92
TREXALL .......................... 137
TRI FEMYNOR ................. 129
triamcinolone acetonide .. 50, 89
181
triamterene-hydrochlorothiazid
.......................................... 83
TRI-BUFFERED ASPIRIN . 18
triderm .................................. 50
trientine............................... 101
TRI-ESTARYLLA ............. 129
trifluoperazine ...................... 59
trifluridine............................. 64
trihexyphenidyl..................... 57
TRIKLO ............................... 86
tri-legest fe.......................... 129
trilyte with flavor packets ... 119
trimethobenzamide ............... 44
trimethoprim ......................... 31
TRI-MILI ........................... 130
trimipramine ......................... 43
trinessa (28) ........................ 130
TRINTELLIX....................... 42
TRIPLE ANTIBIOTIC ........ 31
tri-previfem (28) ................. 130
tri-sprintec (28) ................... 130
TRIUMEQ ............................ 65
TRI-VI-SOL ....................... 100
trivora (28).......................... 130
tri-vylibra ............................ 130
TRULICITY ......................... 71
TRUMENBA ..................... 141
TRUVADA .......................... 66
TUDORZA PRESSAIR ..... 155
TULANA ........................... 131
TUMS ......................... 110, 111
TUMS E-X ................. 110, 111
TUMS EXTRA STRENGTH
SMOOTHIES ................. 111
TUMS ULTRA .................. 111
TUSNEL DIABETIC ......... 164
TUSSIN CF (PE-DM-GUAIF)
................................ 162, 164
TUSSIN CF COUGH-COLD
........................................ 164
TUSSIN DM .............. 159, 164
TUSSIN DM COUGH AND
CHEST ........................... 159
TUSSIN DM MAX .... 159, 164
TUSSIN MUCUS-CHEST
CONGESTION .............. 164
TWINRIX (PF) .................. 141
TYBOST .............................. 67
TYKERB .............................. 55
TYMLOS ........................... 143
TYPHIM VI ....................... 141
U ULORIC ............................... 47
ULTRA LUBRICANT EYE
........................................ 146
ULTRATHON...................... 92
unithroid ............................. 132
ursodiol ............................... 111
V VABOMERE........................ 33
valacyclovir .......................... 64
VALCHLOR ........................ 52
valganciclovir ....................... 63
valproic acid ......................... 38
valproic acid (as sodium salt)
.......................................... 38
valsartan................................ 79
valsartan-hydrochlorothiazide
.......................................... 83
vancomycin .......................... 31
VAQTA (PF) ...................... 141
VARIVAX (PF) ................. 141
VARIZIG............................ 141
VAXCHORA BUFFER
COMPONENT ............... 142
VAXCHORA VACCINE... 142
velivet triphasic regimen (28)
........................................ 130
VEMLIDY............................ 63
VENCLEXTA ...................... 53
VENCLEXTA STARTING
PACK ............................... 53
venlafaxine ........................... 42
VENOFER.................. 100, 101
VENTAVIS ........................ 156
VENTOLIN HFA ............... 155
verapamil .............................. 81
VERSACLOZ ...................... 62
VERZENIO .......................... 56
VICTOZA 2-PAK ................ 71
VICTOZA 3-PAK ................ 71
VIDEX 2 GRAM PEDIATRIC
.......................................... 66
VIDEX 4 GRAM PEDIATRIC
.......................................... 66
VIDEX EC ........................... 66
vienva ................................. 130
vigabatrin .............................. 38
VIGADRONE ...................... 38
VIIBRYD ............................. 42
VIMPAT ............................... 40
VIRACEPT ........................... 67
VIRAMUNE ......................... 65
VIREAD ............................... 63
VITA-BEE WITH C ........... 100
vitamin a ............................. 104
VITAMIN B-1 .................... 104
VITAMIN B-12 .................. 104
VITAMIN B-6 .................... 104
VITAMIN C ............... 104, 105
VITAMIN D2 ............. 104, 105
VITAMIN D3 ..................... 105
VITAMIN K ......................... 76
VITAMIN K1 ................. 76, 77
VITAMINS AND MINERALS
........................................ 104
VITAMINS B COMPLEX . 104
VITRAKVI ........................... 56
VIZIMPRO ........................... 53
voriconazole ................... 46, 47
VOSEVI ............................... 64
VOTRIENT .......................... 56
VRAYLAR ........................... 62
vyfemla (28) ....................... 130
vylibra ................................. 130
W warfarin ................................. 75
WOMEN'S LAXATIVE
(BISACODYL) ............... 119
X XALKORI ............................ 56
XARELTO ........................... 75
XATMEP ............................ 137
XERMELO ......................... 111
XGEVA .............................. 143
XIFAXAN .......................... 113
XIIDRA .............................. 146
XOLAIR ............................. 138
XOSPATA ............................ 56
XTANDI ............................... 52
xulane ................................. 130
XURIDEN .......................... 122
XYREM .............................. 154
Y YF-VAX (PF) ..................... 142
YONSA ................................ 52
yuvafem .............................. 125
Z zafirlukast ........................... 154
zaleplon ............................... 165
182
zarah ................................... 130
ZARXIO ............................... 76
ZEJULA ............................... 56
ZELBORAF ......................... 56
ZEMAIRA .......................... 122
ZENATANE......................... 92
ZENPEP ............................. 122
ZERIT................................... 66
zidovudine ............................ 66
zinc oxide ............................. 93
ziprasidone hcl ...................... 62
ZIRGAN ............................... 63
ZOLINZA ............................. 53
zolpidem ............................. 165
zonisamide ............................ 37
ZORTRESS ........................ 137
ZOSTAVAX (PF) .............. 142
zovia 1/35e (28) .................. 130
ZOVIRAX ............................ 64
ZTLIDO ................................ 24
ZYDELIG ............................. 53
ZYKADIA ............................ 56
ZYPREXA RELPREVV ...... 62
ZYTIGA ............................... 52