2016 Cigna-HealthSpring Rx
COMPREHENSIVE DRUG LIST
(Formulary)
Please read: This document contains information about
all of the drugs we cover in this plan.
Plan covered
Cigna-HealthSpring Rx Secure (PDP)
This drug list was updated on September 1, 2016. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when
necessary. For more recent information or other questions, please contact Cigna-HealthSpring Rx Customer Service, at 1-800-222-6700 or, for TTY users, 711, 8 a.m. 8 p.m., local time, 7 days a week. Our automated phone system may answer your call during weekends from Feb. 15 – Sept. 30. Or visit www.cigna.com/part-d. CignaHealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring
depends on contract renewal.
HPMS Approved Formulary File Submission ID 16150, Version Number 17
Y0036_16_32224c_Final_5h Approved 08102015
Note to existing customers: This drug list has changed since last year. Please review this document to make sure
that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Cigna-HealthSpring Rx. When it refers to
“plan” or “our plan,” it means Cigna-HealthSpring Rx Secure (PDP).
This document includes a list of the drugs (formulary) for our plans, which is current as of September 2016. For an
updated formulary, please contact us. Our contact information, along with the date we last updated the formulary,
appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy
network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year.
What is the Cigna-HealthSpring Rx
Comprehensive Drug List?
A drug list is a list of covered drugs selected by CignaHealthSpring Rx in consultation with a team of health care
providers, which represents the prescription therapies believed
to be a necessary part of a quality treatment program. CignaHealthSpring Rx will generally cover the drugs listed in our drug
list as long as the drug is medically necessary, the prescription
is filled at a Cigna-HealthSpring Rx network pharmacy, and
other plan rules are followed. For more information on how to fill
your prescriptions, please review your Evidence of Coverage.
becomes effective, or at the time the customer requests a refill
of the drug, at which time the customer will receive a 60-day
supply of the drug. If the Food and Drug Administration deems
a drug on our drug list to be unsafe or the drug’s manufacturer
removes the drug from the market, we will immediately remove
the drug from our drug list and provide notice to customers who
take the drug. The enclosed drug list is current as of September
2016. To get updated information about the drugs covered
by Cigna-HealthSpring Rx, please contact us. Our contact
information appears on the front and back cover pages. If there
are significant changes made to the printed drug list within
the covered year, you may be notified by mail identifying the
changes. Drug lists located on our website are reviewed and
updated on a monthly basis.
Can the Drug List (formulary) change?
Generally, if you are taking a drug on our 2016 drug list that was
covered at the beginning of the year, we will not discontinue
or reduce coverage of the drug during the 2016 coverage year
except when a new, less expensive generic drug becomes
available or when new adverse information about the safety
or effectiveness of a drug is released. Other types of drug list
changes, such as removing a drug from our drug list, will not
affect customers who are currently taking the drug. It will remain
available at the same cost-sharing for those customers taking
it for the remainder of the coverage year. We feel it is important
that you have continued access for the remainder of the
coverage year to the drugs that were available when you chose
our plan, except for cases in which you can save additional
money or we can ensure your safety.
How do I use the Drug List?
There are two ways to find your drug within the drug list:
Medical Condition
The drug list begins on page 16. The drugs in this drug list
are grouped into categories depending on the type of medical
conditions that they are used to treat. For example, drugs
used to treat a heart condition are listed under the category,
“CARDIOVASCULAR AGENTS”. If you know what your drug
is used for, look for the category name in the list that begins on
page 16. Then look under the category name for your drug.
Covered Drug Index
If you are not sure what category to look under, you should look
for your drug in the Covered Drugs Index section that begins on
page 56. The Covered Drugs Index provides a list of all of the
drugs included in this document. Both brand name drugs and
generic drugs are in the Drug List.
If we remove drugs from our drug list, add prior authorization,
quantity limits and/or step therapy restrictions on a drug or move
a drug to a higher cost-sharing tier, we must notify affected
customers of the change at least 60 days before the change
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What are generic drugs?
Cigna-HealthSpring Rx covers both brand name drugs and
generic drugs. A generic drug is approved by the FDA as having
the same active ingredient as the brand name drug. Generally,
generic drugs cost less than brand name drugs.
maintenance medications. As part of our commitment to
coordinating your healthcare needs, we have set a goal of
helping you take your medications at least 80% of the time.
There are several ways we can work together to accomplish
this goal:
• Talk with your doctor about whether a 90 day supply of your
ongoing, stable medications may be appropriate. Taking
these medications every day as prescribed is important for
your overall health, and getting 90 day prescriptions of these
medications can ensure that you don’t miss a dose.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits
on coverage. These requirements and limits may include:
• Prior Authorization: Cigna-HealthSpring Rx requires you
or your doctor to get prior authorization for certain drugs.
This means that you will need to get approval from CignaHealthSpring Rx before you fill your prescriptions. If you don’t
get approval, Cigna-HealthSpring Rx may not cover the drug.
• You can receive a 90-day supply at most retail pharmacies or
through one of our mail-order pharmacies.
• Talk to your pharmacist if you are experiencing any new
challenges with your maintenance medications.
• Quantity Limits: For certain drugs, Cigna-HealthSpring Rx
limits the amount of the drug that Cigna-HealthSpring Rx will
cover. For example, Cigna-HealthSpring Rx allows for 1 tablet
per day for CRESTOR. This applies to standard one-month
supply (for total quantity of 30 per 30 days) or three-month
supply (for total quantity of 90 per 90 days).
How can I use my prescription drug coverage to save
money on my medications?
There may be opportunities for you to save money on your
medications using your Cigna-HealthSpring Rx coverage.
• Ask your doctor (or other prescriber) if there are any lowercost generic alternatives available for any of your current
medications.
• Step Therapy: In some cases, Cigna-HealthSpring Rx
requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition.
For example, if Drug A and Drug B both treat your medical
condition, Cigna-HealthSpring Rx may not cover Drug B
unless you try Drug A first. If Drug A does not work for you,
Cigna-HealthSpring Rx will then cover Drug B.
• Explore whether the ‘CMS extra help’ program may offer
additional financial support for your medications.
• If your medication is not covered on the Cigna-HealthSpring
Rx drug list, talk with your doctor about alternative
medications which are covered in the drug list.
You can find out if your drug has any additional requirements
or limits by looking in the drug list that begins on page 16. You
can also get more information about the restrictions applied to
specific covered drugs by visiting our Web site. We have posted
online documents that explain our prior authorization and step
therapy restrictions. You may also ask us to send you a copy.
Our contact information, along with the date we last updated the
drug list, appears on the front and back cover pages.
What if my drug is not in the Drug List?
If your drug is not included in this drug list, you should first
contact Customer Service and ask if your drug is covered. If you
learn that Cigna-HealthSpring Rx does not cover your drug, you
have two options:
• You can ask Customer Service for a list of similar drugs that
are covered by Cigna-HealthSpring Rx. When you receive the
list, show it to your doctor and ask him or her to prescribe a
similar drug that is covered by Cigna-HealthSpring Rx.
You can ask Cigna-HealthSpring Rx to make an exception to
these restrictions or limits or for a list of other, similar drugs
that may treat your health condition. See the section, “How do
I request an exception to the Cigna-HealthSpring Rx drug list?”
on this page for information about how to request an exception.
• You can ask Cigna-HealthSpring Rx to make an exception
and cover your drug. See below for information about how to
request an exception.
Options for Maintenance Medications
Taking the medications prescribed by your doctor (or other
prescriber) is important to your health.
How do I request an exception to the
Cigna-HealthSpring Rx Drug List?
You can ask Cigna-HealthSpring Rx to make an exception to
our coverage rules. There are several types of exceptions that
you can ask us to make.
We are committed to helping you achieve control of
chronic conditions by making it easy for you to receive your
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What do I do before I can talk to my doctor about changing
my drugs or requesting an exception?
As a new or continuing customer in our plan you may be taking
drugs that are not in our drug list. Or, you may be taking a drug
that is on our drug list but your ability to get it is limited. For
example, you may need a prior authorization from us before
you can fill your prescription. You should talk to your doctor
to decide if you should switch to an appropriate drug that we
cover or request a drug list exception so that we will cover the
drug you take. While you talk to your doctor to determine the
right course of action for you, we may cover your drug in certain
cases during the first 90 days you are a customer of our plan.
• You can ask us to cover a drug even if it is not in our drug
list. If approved, this drug will be covered at a pre-determined
cost-sharing level, and you would not be able to ask us to
provide the drug at a lower cost-sharing level.
• You can ask us to waive coverage restrictions or limits on
your drug. For example, for certain drugs, Cigna-HealthSpring
Rx limits the amount of the drug that we will cover. If your
drug has a quantity limit, you can ask us to waive the limit and
cover a greater amount.
• You can ask us to provide a tiering exception for a higher
cost sharing drug to be covered at a lower cost-sharing tier.
If your drug is contained in the Non-Preferred Brand tier or
the Generic tier, you can ask us to cover it at the cost-sharing
amount that applies to drugs in the respective Preferred
Brand or Preferred Generic tier instead. This would lower the
amount you must pay for your drug. If your drug is contained
in our Brand tier you can ask to cover it at the cost-sharing
amount that applies to drugs in the respective Generic tier if
all generic alternatives in the lower cost tier used to treat the
same condition/disease are determined to be not as effective
as the Brand. Please note, if we grant your request to cover a
drug that is not in our drug list, you may not ask us to provide
a higher level of coverage for the drug. Also, you may not ask
us to provide a higher level of coverage for drugs that are in
the Specialty tier.
For each of your drugs that is not on our drug list or if your
ability to get your drugs is limited, we will cover a temporary
30-day supply (unless you have a prescription written for fewer
days) when you go to a network pharmacy. After your first 30day supply, we will not pay for these drugs, even if you have
been a customer of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you
to refill your prescription until we have provided you with a 91- to
98-day transition supply, consistent with dispensing increment,
(unless you have a prescription written for fewer days). We will
cover more than one refill of these drugs for the first 90 days
you are a customer of our plan. If you need a drug that is not
in our drug list or if your ability to get your drugs is limited, but
you are past the first 90 days of membership in our plan, we
will cover a 31-day emergency supply of that drug (unless you
have a prescription for fewer days) while you pursue a drug list
exception.
Generally, Cigna-HealthSpring Rx will only approve your
request for an exception if the alternative drugs included on
the plan’s drug list, the lower cost-sharing drug or additional
utilization restrictions would not be as effective in treating your
condition and/or would cause you to have adverse medical
effects.
In order to accommodate unexpected transitions of our
customers that do not leave time for advanced planning, such
as level-of-care changes due to discharge from a hospital to a
nursing facility or to a home, Cigna-HealthSpring Rx will allow
a one-time 31-day supply (unless the prescription is written for
fewer days).
You should contact us to ask us for an initial coverage decision
for a drug list, tiering or utilization restriction exception. When
you request a drug list, tiering or utilization restriction
exception you should submit a statement from your
prescriber or doctor supporting your request. Generally,
we must make our decision within 72 hours of getting your
prescriber’s supporting statement. You can request an
expedited (fast) exception if you or your doctor believe that your
health could be seriously harmed by waiting up to 72 hours for
a decision. If your request to expedite is granted, we must give
you a decision no later than 24 hours after we get a supporting
statement from your doctor or other prescriber.
Cigna-HealthSpring Rx’s Drug List
The comprehensive drug list provides coverage information
about all of the drugs covered by Cigna-HealthSpring Rx. If you
have trouble finding your drug in the list, turn to the Covered
Drug Index that begins on page 56.
The first column of the chart lists the drug name. Brand name
drugs are capitalized (e.g., CRESTOR) and generic drugs are
listed in lower-case italics (e.g., simvastatin).
3
The information in the Requirements/Limits column tells you
if Cigna-HealthSpring Rx has any special requirements for
coverage of your drug.
along with the amount dispensed per the days supplied. (For
example: CRESTOR 30/30; this means the drug CRESTOR
is limited to 30 tablets per 30 days. For 90-day supplies, this
quantity limit would be expanded to 90 tablets per 90 days).
We provide quantity limits on certain drugs which are indicated
with a QL in the Covered Drugs by Category list on page 16
For more information
For more detailed information about your Cigna-HealthSpring Rx prescription drug coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about Cigna-HealthSpring Rx, please contact us. Our contact information, along with the date we last
updated the drug list, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE
(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
Key:
B/D – This prescription drug has a Part B versus D
administrative prior authorization requirement. This drug
may be covered under Medicare Part B or D depending on
circumstances.
Generally all medications in the drug list are available
through mail order, except when special circumstances
or situations prohibit mailing a particular medication to
your home.
PA – This drug requires prior authorization
QL – This drug has quantity limits
ST – This drug has step therapy requirements
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Drug Tier and Cost-Share Table
The following table represents the plan name, plan service area,
the drug tier number as it appears in the drug list, and the costshare amount for that tier number. Tier 1 is for Preferred Generic
drugs. Tier 2 is for Generic drugs. Tier number 3 is for Preferred
Brand drugs. Tier number 4 is for Non-Preferred Brand drugs.
Tier 5 is for Specialty tier drugs. You may also refer to your
Evidence of Coverage document for additional details.
Note for customers receiving Extra Help: Your LIS copay level
will be based on how the Food and Drug Administration (FDA)
classifies certain drugs. Due to this, a generic drug may receive
a preferred brand copay, or a preferred brand drug may receive
a generic drug copay. Please see your LIS Rider for additional
information on these copay levels. Or call Customer Service for
further clarification regarding a specific drug.
To locate your drug cost, please refer to the table(s) below to find your service area and the Prescription Drug plan
in which you are currently enrolled or would like to enroll.
Cigna-HealthSpring Rx has pharmacies with preferred cost-shares. See your Pharmacy Directory or visit
www.cigna.com/part-d for information on which stores with preferred cost-shares are near you.
Preferred
Retail
Cost-Sharing
30/60/90 Days
Standard
Retail
Cost-Sharing
30/60/90 Days
Preferred
Mail Order
Cost-Sharing
30/90 Days
Standard
Mail Order
Cost-Sharing
30/90 Days
Long-term Care
31 days
Out-of-network
30 days*
$2/$4/$6
$8/$16/$24
$2/$6
$8/$24
$8
$5/$10/$15
$13/$26/$39
$5/$15
$13/$39
$13
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$9/$18/$27
$2/$6
$9/$27
$9
$5/$10/$15
$12/$24/$36
$5/$15
$12/$36
$12
Tier 3: Preferred Brand Drugs
15%
18%
15%
18%
18%
Tier 4: Non-Preferred Brand Drugs
46%
50%
46%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Cigna-HealthSpring Rx
Secure (PDP)
ALABAMA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
ALASKA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
Cigna-HealthSpring Rx’s pharmacy network offers limited access to pharmacies with preferred cost sharing in rural Alaska. The lower costs advertised in our plan
materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including pharmacies with
preferred cost sharing, please call 1-800-222-6700 (TTY 711) or consult the online pharmacy directory at www.cigna.com/part-d.
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard
Retail pharmacy billed costs.
5
Preferred
Retail
Cost-Sharing
30/60/90 Days
Standard
Retail
Cost-Sharing
30/60/90 Days
Preferred
Mail Order
Cost-Sharing
30/90 Days
Standard
Mail Order
Cost-Sharing
30/90 Days
Long-term Care
31 days
Out-of-network
30 days*
$2/$4/$6
$19/$38/$57
$2/$6
$19/$57
$19
$8/$16/$24
$20/$40/$60
$8/$24
$20/$60
$20
Tier 3: Preferred Brand Drugs
15%
17%
15%
17%
17%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$10/$20/$30
$2/$6
$10/$30
$10
$6/$12/$18
$16/$32/$48
$6/$18
$16/$48
$16
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$10/$20/$30
$3/$9
$10/$30
$10
$5/$10/$15
$12/$24/$36
$5/$15
$12/$36
$12
Tier 3: Preferred Brand Drugs
15%
18%
15%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$10/$20/$30
$3/$9
$10/$30
$10
$6/$12/$18
$13/$26/$39
$6/$18
$13/$39
$13
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$7/$14/$21
$2/$6
$7/$21
$7
$6/$12/$18
$11/$22/$33
$6/$18
$11/$33
$11
Tier 3: Preferred Brand Drugs
17%
19%
17%
19%
19%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Cigna-HealthSpring Rx
Secure (PDP)
ARIZONA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
ARKANSAS
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
CALIFORNIA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
COLORADO
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
CONNECTICUT
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard
Retail pharmacy billed costs.
6
Preferred
Retail
Cost-Sharing
30/60/90 Days
Standard
Retail
Cost-Sharing
30/60/90 Days
Preferred
Mail Order
Cost-Sharing
30/90 Days
Standard
Mail Order
Cost-Sharing
30/90 Days
Long-term Care
31 days
Out-of-network
30 days*
$2/$4/$6
$12/$24/$36
$2/$6
$12/$36
$12
$6/$12/$18
$16/$32/$48
$6/$18
$16/$48
$16
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$12/$24/$36
$2/$6
$12/$36
$12
$6/$12/$18
$16/$32/$48
$6/$18
$16/$48
$16
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$7/$14/$21
$2/$6
$7/$21
$7
$5/$10/$15
$10/$20/$30
$5/$15
$10/$30
$10
Tier 3: Preferred Brand Drugs
16%
20%
16%
20%
20%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$9/$18/$27
$3/$9
$9/$27
$9
$5/$10/$15
$11/$22/$33
$5/$15
$11/$33
$11
Tier 3: Preferred Brand Drugs
15%
19%
15%
19%
19%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Tier 1: Preferred Generic Drugs
$7/$14/$21
$19/$38/$57
$7/$21
$19/$57
$19
Tier 2: Generic Drugs
$15/$30/$45
$20/$40/$60
$15/$45
$20/$60
$20
Tier 3: Preferred Brand Drugs
13%
14%
13%
14%
14%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Cigna-HealthSpring Rx
Secure (PDP)
DELAWARE
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
DISTRICT OF COLUMBIA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
FLORIDA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
GEORGIA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
HAWAII
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard
Retail pharmacy billed costs.
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Preferred
Retail
Cost-Sharing
30/60/90 Days
Standard
Retail
Cost-Sharing
30/60/90 Days
Preferred
Mail Order
Cost-Sharing
30/90 Days
Standard
Mail Order
Cost-Sharing
30/90 Days
Long-term Care
31 days
Out-of-network
30 days*
$2/$4/$6
$16/$32/$48
$2/$6
$16/$48
$16
$6/$12/$18
$19/$38/$57
$6/$18
$19/$57
$19
Tier 3: Preferred Brand Drugs
15%
17%
15%
17%
17%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$10/$20/$30
$2/$6
$10/$30
$10
$6/$12/$18
$20/$40/$60
$6/$18
$20/$60
$20
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$8/$16/$24
$2/$6
$8/$24
$8
$5/$10/$15
$12/$24/$36
$5/$15
$12/$36
$12
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$10/$20/$30
$3/$9
$10/$30
$10
$6/$12/$18
$12/$24/$36
$6/$18
$12/$36
$12
Tier 3: Preferred Brand Drugs
18%
20%
18%
20%
20%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$11/$22/$33
$2/$6
$11/$33
$11
$6/$12/$18
$15/$30/$45
$6/$18
$15/$45
$15
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Cigna-HealthSpring Rx
Secure (PDP)
IDAHO
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
ILLINOIS
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
INDIANA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
IOWA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
KANSAS
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard
Retail pharmacy billed costs.
8
Preferred
Retail
Cost-Sharing
30/60/90 Days
Standard
Retail
Cost-Sharing
30/60/90 Days
Preferred
Mail Order
Cost-Sharing
30/90 Days
Standard
Mail Order
Cost-Sharing
30/90 Days
Long-term Care
31 days
Out-of-network
30 days*
$2/$4/$6
$8/$16/$24
$2/$6
$8/$24
$8
$5/$10/$15
$12/$24/$36
$5/$15
$12/$36
$12
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$11/$22/$33
$2/$6
$11/$33
$11
$6/$12/$18
$16/$32/$48
$6/$18
$16/$48
$16
Tier 3: Preferred Brand Drugs
15%
17%
15%
17%
17%
Tier 4: Non-Preferred Brand Drugs
46%
50%
46%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$7/$14/$21
$2/$6
$7/$21
$7
$5/$10/$15
$11/$22/$33
$5/$15
$11/$33
$11
Tier 3: Preferred Brand Drugs
16%
20%
16%
20%
20%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$12/$24/$36
$2/$6
$12/$36
$12
$6/$12/$18
$16/$32/$48
$6/$18
$16/$48
$16
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$7/$14/$21
$2/$6
$7/$21
$7
$6/$12/$18
$11/$22/$33
$6/$18
$11/$33
$11
Tier 3: Preferred Brand Drugs
17%
19%
17%
19%
19%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Cigna-HealthSpring Rx
Secure (PDP)
KENTUCKY
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
LOUISIANA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
MAINE
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
MARYLAND
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
MASSACHUSETTS
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard
Retail pharmacy billed costs.
9
Preferred
Retail
Cost-Sharing
30/60/90 Days
Standard
Retail
Cost-Sharing
30/60/90 Days
Preferred
Mail Order
Cost-Sharing
30/90 Days
Standard
Mail Order
Cost-Sharing
30/90 Days
Long-term Care
31 days
Out-of-network
30 days*
$2/$4/$6
$10/$20/$30
$2/$6
$10/$30
$10
$5/$10/$15
$14/$28/$42
$5/$15
$14/$42
$14
Tier 3: Preferred Brand Drugs
17%
19%
17%
19%
19%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$10/$20/$30
$3/$9
$10/$30
$10
$6/$12/$18
$12/$24/$36
$6/$18
$12/$36
$12
Tier 3: Preferred Brand Drugs
18%
20%
18%
20%
20%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$10/$20/$30
$2/$6
$10/$30
$10
$6/$12/$18
$16/$32/$48
$6/$18
$16/$48
$16
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Tier 1: Preferred Generic Drugs
$4/$8/$12
$10/$20/$30
$4/$12
$10/$30
$10
Tier 2: Generic Drugs
$6/$12/$18
$12/$24/$36
$6/$18
$12/$36
$12
Tier 3: Preferred Brand Drugs
15%
20%
15%
20%
20%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$10/$20/$30
$3/$9
$10/$30
$10
$6/$12/$18
$12/$24/$36
$6/$18
$12/$36
$12
Tier 3: Preferred Brand Drugs
18%
20%
18%
20%
20%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Cigna-HealthSpring Rx
Secure (PDP)
MICHIGAN
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
MINNESOTA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
MISSISSIPPI
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
MISSOURI
MONTANA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard
Retail pharmacy billed costs.
10
Preferred
Retail
Cost-Sharing
30/60/90 Days
Standard
Retail
Cost-Sharing
30/60/90 Days
Preferred
Mail Order
Cost-Sharing
30/90 Days
Standard
Mail Order
Cost-Sharing
30/90 Days
Long-term Care
31 days
Out-of-network
30 days*
$3/$6/$9
$10/$20/$30
$3/$9
$10/$30
$10
$6/$12/$18
$12/$24/$36
$6/$18
$12/$36
$12
Tier 3: Preferred Brand Drugs
18%
20%
18%
20%
20%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Tier 1: Preferred Generic Drugs
$5/$10/$15
$12/$24/$36
$5/$15
$12/$36
$12
Tier 2: Generic Drugs
$7/$14/$21
$14/$28/$42
$7/$21
$14/$42
$14
Tier 3: Preferred Brand Drugs
15%
17%
15%
17%
17%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$7/$14/$21
$2/$6
$7/$21
$7
$5/$10/$15
$11/$22/$33
$5/$15
$11/$33
$11
Tier 3: Preferred Brand Drugs
16%
20%
16%
20%
20%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$7/$14/$21
$2/$6
$7/$21
$7
$5/$10/$15
$10/$20/$30
$5/$15
$10/$30
$10
Tier 3: Preferred Brand Drugs
15%
18%
15%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$10/$20/$30
$3/$9
$10/$30
$10
$6/$12/$18
$12/$24/$36
$6/$18
$12/$36
$12
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Cigna-HealthSpring Rx
Secure (PDP)
NEBRASKA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
NEVADA
NEW HAMPSHIRE
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
NEW JERSEY
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
NEW MEXICO
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard
Retail pharmacy billed costs.
11
Preferred
Retail
Cost-Sharing
30/60/90 Days
Standard
Retail
Cost-Sharing
30/60/90 Days
Preferred
Mail Order
Cost-Sharing
30/90 Days
Standard
Mail Order
Cost-Sharing
30/90 Days
Long-term Care
31 days
Out-of-network
30 days*
$0/$0/$0
$5/$10/$15
$0/$0
$5/$15
$5
$7/$14/$21
$14/$28/$42
$7/$21
$14/$42
$14
Tier 3: Preferred Brand Drugs
17%
19%
17%
19%
19%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$9/$18/$27
$3/$9
$9/$27
$9
$5/$10/$15
$11/$22/$33
$5/$15
$11/$33
$11
Tier 3: Preferred Brand Drugs
16%
19%
16%
19%
19%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$10/$20/$30
$3/$9
$10/$30
$10
$6/$12/$18
$12/$24/$36
$6/$18
$12/$36
$12
Tier 3: Preferred Brand Drugs
18%
20%
18%
20%
20%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$10/$20/$30
$3/$9
$10/$30
$10
$6/$12/$18
$12/$24/$36
$6/$18
$12/$36
$12
Tier 3: Preferred Brand Drugs
15%
18%
15%
18%
18%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$7/$14/$21
$2/$6
$7/$21
$7
$5/$10/$15
$10/$20/$30
$5/$15
$10/$30
$10
Tier 3: Preferred Brand Drugs
15%
19%
15%
19%
19%
Tier 4: Non-Preferred Brand Drugs
46%
50%
46%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Cigna-HealthSpring Rx
Secure (PDP)
NEW YORK
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
NORTH CAROLINA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
NORTH DAKOTA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
OHIO
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
OKLAHOMA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard
Retail pharmacy billed costs.
12
Preferred
Retail
Cost-Sharing
30/60/90 Days
Standard
Retail
Cost-Sharing
30/60/90 Days
Preferred
Mail Order
Cost-Sharing
30/90 Days
Standard
Mail Order
Cost-Sharing
30/90 Days
Long-term Care
31 days
Out-of-network
30 days*
$2/$4/$6
$19/$38/$57
$2/$6
$19/$57
$19
$6/$12/$18
$20/$40/$60
$6/$18
$20/$60
$20
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$8/$16/$24
$2/$6
$8/$24
$8
$5/$10/$15
$13/$26/$39
$5/$15
$13/$39
$13
Tier 3: Preferred Brand Drugs
15%
18%
15%
18%
18%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$7/$14/$21
$2/$6
$7/$21
$7
$6/$12/$18
$11/$22/$33
$6/$18
$11/$33
$11
Tier 3: Preferred Brand Drugs
17%
19%
17%
19%
19%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$9/$18/$27
$3/$9
$9/$27
$9
$5/$10/$15
$11/$22/$33
$5/$15
$11/$33
$11
Tier 3: Preferred Brand Drugs
16%
19%
16%
19%
19%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$10/$20/$30
$3/$9
$10/$30
$10
$6/$12/$18
$12/$24/$36
$6/$18
$12/$36
$12
Tier 3: Preferred Brand Drugs
18%
20%
18%
20%
20%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Cigna-HealthSpring Rx
Secure (PDP)
OREGON
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
PENNSYLVANIA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
RHODE ISLAND
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
SOUTH CAROLINA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
SOUTH DAKOTA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard
Retail pharmacy billed costs.
13
Preferred
Retail
Cost-Sharing
30/60/90 Days
Standard
Retail
Cost-Sharing
30/60/90 Days
Preferred
Mail Order
Cost-Sharing
30/90 Days
Standard
Mail Order
Cost-Sharing
30/90 Days
Long-term Care
31 days
Out-of-network
30 days*
$2/$4/$6
$8/$16/$24
$2/$6
$8/$24
$8
$5/$10/$15
$13/$26/$39
$5/$15
$13/$39
$13
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$12/$24/$36
$2/$6
$12/$36
$12
$6/$12/$18
$18/$36/$54
$6/$18
$18/$54
$18
Tier 3: Preferred Brand Drugs
15%
17%
15%
17%
17%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$16/$32/$48
$2/$6
$16/$48
$16
$6/$12/$18
$19/$38/$57
$6/$18
$19/$57
$19
Tier 3: Preferred Brand Drugs
15%
17%
15%
17%
17%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$7/$14/$21
$2/$6
$7/$21
$7
$6/$12/$18
$11/$22/$33
$6/$18
$11/$33
$11
Tier 3: Preferred Brand Drugs
17%
19%
17%
19%
19%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$9/$18/$27
$3/$9
$9/$27
$9
$5/$10/$15
$11/$22/$33
$5/$15
$11/$33
$11
Tier 3: Preferred Brand Drugs
16%
19%
16%
19%
19%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Cigna-HealthSpring Rx
Secure (PDP)
TENNESSEE
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
TEXAS
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
UTAH
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
VERMONT
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
VIRGINIA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard
Retail pharmacy billed costs.
14
Preferred
Retail
Cost-Sharing
30/60/90 Days
Standard
Retail
Cost-Sharing
30/60/90 Days
Preferred
Mail Order
Cost-Sharing
30/90 Days
Standard
Mail Order
Cost-Sharing
30/90 Days
Long-term Care
31 days
Out-of-network
30 days*
$2/$4/$6
$19/$38/$57
$2/$6
$19/$57
$19
$6/$12/$18
$20/$40/$60
$6/$18
$20/$60
$20
Tier 3: Preferred Brand Drugs
16%
18%
16%
18%
18%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$8/$16/$24
$2/$6
$8/$24
$8
$5/$10/$15
$13/$26/$39
$5/$15
$13/$39
$13
Tier 3: Preferred Brand Drugs
15%
18%
15%
18%
18%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$2/$4/$6
$11/$22/$33
$2/$6
$11/$33
$11
$5/$10/$15
$15/$30/$45
$5/$15
$15/$45
$15
Tier 3: Preferred Brand Drugs
17%
19%
17%
19%
19%
Tier 4: Non-Preferred Brand Drugs
47%
50%
47%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
$3/$6/$9
$10/$20/$30
$3/$9
$10/$30
$10
$6/$12/$18
$12/$24/$36
$6/$18
$12/$36
$12
Tier 3: Preferred Brand Drugs
18%
20%
18%
20%
20%
Tier 4: Non-Preferred Brand Drugs
48%
50%
48%
50%
50%
Tier 5: Specialty Tier
25%
25%
25%
25%
25%
Cigna-HealthSpring Rx
Secure (PDP)
WASHINGTON
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
WEST VIRGINIA
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
WISCONSIN
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
WYOMING
Tier 1: Preferred Generic Drugs
Tier 2: Generic Drugs
*You will pay the copay or percentage of the drug cost shown above plus the difference between the Out–of–Network pharmacy billed charge and our typical Standard
Retail pharmacy billed costs.
15
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
piroxicam
salsalate
sulindac
tolmetin sodium
Opioid Analgesics, Long-acting
DURAMORPH
fentanyl
INFUMORPH 200
INFUMORPH 500
levorphanol tartrate
methadone hcl conc
methadone hcl inj
methadone hcl intensol
methadone hcl oral soln
10mg/5ml
methadone hcl oral soln
5mg/5ml
methadone hcl tabs
morphine sulfate er tbcr
morphine sulfate inj 0.5mg/ml,
1mg/ml
oxymorphone hydrochloride er
tramadol hcl er tb24
XARTEMIS XR
Opioid Analgesics, Short-acting
acetaminophen/caffeine/
dihydrocodeine
acetaminophen/codeine #2
acetaminophen/codeine #3
acetaminophen/codeine #4
acetaminophen/codeine oral
soln
acetaminophen/codeine
phosphate tabs 300mg; 60mg
acetaminophen/codeine tabs
300mg; 60mg
acetaminophen/codeine tabs
300mg; 15mg
ascomp/codeine
butalbital/acetaminophen/
caffeine/codeine
Analgesics
Analgesics
butalbital/acetaminophen/
2
PA QL(180/30)
caffeine caps
2
PA QL(180/30)
butalbital/acetaminophen/
caffeine tabs 325mg; 50mg;
40mg
butalbital/aspirin/caffeine
2
PA QL(180/30)
esgic caps
2
PA QL(180/30)
margesic
2
PA QL(180/30)
zebutal caps 325mg; 50mg;
2
PA QL(180/30)
40mg
Nonsteroidal Anti-inflammatory Drugs
celecoxib
3
QL(60/30)
diclofenac potassium
2
diclofenac sodium dr tbec
2
25mg, 50mg
diclofenac sodium dr tbec 75mg 1
diclofenac sodium er
2
diflunisal
2
etodolac
2
etodolac er
2
fenoprofen calcium caps
2
400mg
fenoprofen calcium tabs
2
flurbiprofen
2
ibuprofen susp
1
ibuprofen tabs 400mg, 600mg,
1
800mg
ketoprofen
2
ketoprofen er
2
meclofenamate sodium
2
meloxicam tabs
1
nabumetone
2
naproxen dr
2
naproxen sodium tabs 275mg,
2
550mg
naproxen susp
2
naproxen tabs
1
oxaprozin
2
16
2
2
2
2
4
2
4
4
2
2
4
2
2
QL(15/30)
QL(180/30)
QL(500/30)
QL(500/30)
QL(2000/30)
2
QL(4000/30)
2
2
4
QL(360/30)
QL(90/30)
2
2
4
QL(60/30)
QL(30/30)
QL(120/30)
2
QL(360/30)
2
2
2
2
QL(360/30)
QL(360/30)
QL(240/30)
QL(5000/30)
2
QL(240/30)
2
QL(240/30)
2
QL(360/30)
2
2
PA QL(180/30)
PA QL(180/30)
Covered Drugs By Category
DRUG NAME
butalbital/aspirin/caffeine/
codeine
butorphanol tartrate inj
butorphanol tartrate nasal soln
endocet
fentanyl citrate inj 100mcg/2ml
fentanyl citrate oral
transmucosal
hydrocodone bitartrate/
acetaminophen oral soln
325mg/15ml; 7.5mg/15ml
hydrocodone bitartrate/
acetaminophen tabs 325mg;
2.5mg
hydrocodone bitartrate/
acetaminophen tabs 300mg;
10mg, 300mg; 5mg, 300mg;
7.5mg
hydrocodone/acetaminophen
tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg
hydrocodone/ibuprofen
hydromorphone hcl dosette
hydromorphone hcl inj 1mg/ml,
2mg/ml, 4mg/ml, 500mg/50ml
hydromorphone hcl liqd
hydromorphone hcl tabs
ibudone tabs 5mg; 200mg
LAZANDA
lorcet
lorcet hd
lorcet plus tabs 325mg; 7.5mg
lortab tabs
MORPHINE SULFATE ADDVANTAGE
DRUG REQUIREMENTS/
TIER LIMITS
2
PA QL(180/30)
4
2
2
4
5
QL(6/30)
QL(360/30)
B/D PA
PA QL(120/30)
2
QL(5400/30)
2
QL(360/30)
2
QL(390/30)
2
QL(360/30)
2
4
4
QL(150/30)
2
2
2
5
2
2
2
2
4
QL(1200/30)
QL(240/30)
QL(150/30)
PA QL(44/28)
QL(360/30)
QL(360/30)
QL(360/30)
QL(360/30)
DRUG NAME
morphine sulfate inj 10mg/ml,
150mg/30ml, 15mg/ml, 1mg/
ml, 25mg/ml, 2mg/ml, 4mg/ml,
50mg/ml, 8mg/ml
morphine sulfate oral soln
100mg/5ml
morphine sulfate oral soln
20mg/5ml
morphine sulfate oral soln
10mg/5ml
MORPHINE SULFATE TABS
nalbuphine hcl
oxycodone hcl caps
oxycodone hcl conc
oxycodone hcl oral soln
oxycodone hcl tabs
oxycodone/acetaminophen tabs
325mg; 10mg, 325mg; 2.5mg,
325mg; 5mg, 325mg; 7.5mg
oxycodone/aspirin
oxycodone/ibuprofen
reprexain tabs 10mg; 200mg
roxicet tabs
TALWIN
tramadol hcl
trezix caps 320.5mg; 30mg;
16mg
vicodin es tabs 300mg; 7.5mg
vicodin hp tabs 300mg; 10mg
vicodin tabs 300mg; 5mg
xylon
DRUG REQUIREMENTS/
TIER LIMITS
4
2
QL(540/30)
2
QL(2700/30)
2
QL(5400/30)
3
4
2
2
2
2
2
QL(360/30)
2
2
2
2
4
2
2
QL(360/30)
QL(150/30)
QL(150/30)
QL(360/30)
2
2
2
2
QL(390/30)
QL(390/30)
QL(390/30)
QL(150/30)
QL(240/30)
QL(360/30)
QL(1200/30)
QL(240/30)
QL(360/30)
QL(240/30)
QL(360/30)
Anesthetics
Local Anesthetics
glydo
lidocaine hcl external soln
lidocaine hcl gel
2
2
2
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
17
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
lidocaine hcl inj 0.5%, 1%, 2%,
4%
lidocaine hcl jelly
lidocaine hcl mouth/throat soln
lidocaine hcl viscous
lidocaine oint
lidocaine ptch
lidocaine viscous
lidocaine/prilocaine crea
premium lidocaine
DRUG NAME
4
2
2
1
2
2
1
2
2
gentamicin sulfate oint
gentamicin sulfate ophthalmic
soln
gentamicin sulfate pediatric
gentamicin sulfate/0.9% sodium
chloride
isotonic gentamicin inj 0.8mg/
ml; 0.9%
neomycin sulfate
neomycin/polymyxin b sulfates
paromomycin sulfate
streptomycin sulfate
tobramycin sulfate inj 1.2gm,
10mg/ml, 40mg/ml, 80mg/2ml
tobramycin sulfate ophthalmic
soln
TOBREX OINT
ZYLET
Antibacterials, Other
alcohol prep pads
baciim
bacitracin inj
bacitracin ophthalmic oint
bacitracin/polymyxin b
BACTROBAN NASAL
chloramphenicol sodium
succinate
clindacin etz pledgets
clindacin-p
clindamax
clindamycin hcl
clindamycin phosphate addvantage
clindamycin phosphate crea
clindamycin phosphate external
soln
clindamycin phosphate gel
clindamycin phosphate in d5w
clindamycin phosphate inj
300mg/2ml, 600mg/4ml,
900mg/6ml
PA QL(90/30)
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium dr
disulfiram
Opioid Dependence Treatments
buprenorphine hcl inj
buprenorphine hcl subl
buprenorphine hcl/naloxone hcl
naltrexone hcl
SUBOXONE
Opioid Reversal Agents
naloxone hcl
NARCAN
Smoking Cessation Agents
buproban
bupropion hcl sr tb12 150mg
CHANTIX
CHANTIX CONTINUING
MONTH PAK
CHANTIX STARTING MONTH
PAK
NICOTROL INHALER
NICOTROL NS
2
2
PA
4
2
2
2
3
PA QL(90/30)
PA QL(90/30)
PA
PA QL(90/30)
2
3
QL(4/30)
2
2
3
3
QL(60/30)
QL(60/30)
QL(336/365)
QL(336/365)
3
QL(106/365)
3
3
PA QL(504/30)
QL(40/30)
Antibacterials
Aminoglycosides
amikacin sulfate
gentak
gentamicin sulfate crea
gentamicin sulfate inj
4
2
2
4
18
DRUG REQUIREMENTS/
TIER LIMITS
2
4
4
4
4
2
4
2
4
4
2
3
3
1
4
4
2
2
3
1
2
2
2
2
4
2
2
2
4
4
ST
Covered Drugs By Category
DRUG NAME
clindamycin phosphate lotn
clindamycin phosphate
pharmacy bulk package
clindamycin phosphate swab
colistimethate sodium
CUBICIN
lansoprazole/amoxicillin/
clarithromycin
LINCOCIN
lincomycin hcl
linezolid inj 600mg/300ml
linezolid susr
linezolid tabs
methenamine hippurate
metronidazole crea
metronidazole gel
metronidazole in nacl 0.79%
metronidazole inj
metronidazole lotn
metronidazole tabs
metronidazole vaginal
mupirocin
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin/
hydrocortisone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/
hydrocortisone
nitrofurantoin
nitrofurantoin macrocrystals
caps 100mg, 50mg
nitrofurantoin monohydrate
nitrofurantoin monohydrate/
macrocrystals
NORITATE
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
2
4
2
4
5
2
4
4
4
5
5
2
2
2
4
4
2
1
2
2
2
2
polycin
polymyxin b sulfate
polymyxin b sulfate/
trimethoprim sulfate
PRIMSOL
rosadan
silver sulfadiazine
SSD
SYNERCID
trimethoprim
trimethoprim sulfate/polymyxin
b sulfate
TYGACIL
vancomycin
vancomycin hcl caps 125mg
vancomycin hcl caps 250mg
vancomycin hcl in dextrose
vancomycin hcl inj
vandazole
XIFAXAN TABS 200MG
XIFAXAN TABS 550MG
ZYVOX SUSR
Beta-lactam, Cephalosporins
cefaclor
cefaclor er
cefadroxil
CEFAZOLIN
cefazolin sodium inj 10gm,
1gm, 1gm; 5%, 500mg
cefazolin sodium/dextrose inj
2gm; 3%
cefdinir
cefepime
cefepime/dextrose
cefixime
B/D PA
PA
PA
PA
2
2
2
2
QL(90/365)
2
2
QL(90/365)
QL(90/365)
3
DRUG REQUIREMENTS/
TIER LIMITS
2
4
2
3
2
3
3
4
2
2
5
4
5
5
4
4
2
4
5
5
QL(40/10)
QL(80/10)
PA QL(9/30)
PA QL(60/30)
PA
2
2
2
4
4
4
2
4
4
2
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
19
Covered Drugs By Category
DRUG NAME
cefotaxime sodium inj 1gm,
2gm, 500mg
cefoxitin sodium inj 10gm, 1gm,
2gm
cefpodoxime proxetil
cefprozil
ceftazidime
ceftazidime/dextrose
ceftriaxone in iso-osmotic
dextrose
ceftriaxone sodium inj 10gm,
1gm, 250mg, 2gm, 500mg
cefuroxime axetil
cefuroxime sodium inj 1.5gm,
7.5gm, 750mg, 75gm
cephalexin caps 250mg, 500mg
cephalexin susr
cephalexin tabs
SUPRAX SUSR
tazicef inj 1gm, 2gm, 6gm
TEFLARO
Beta-lactam, Other
AZACTAM IN ISO-OSMOTIC
DEXTROSE
aztreonam
cefotetan
imipenem/cilastatin
INVANZ
meropenem
Beta-lactam, Penicillins
amoxicillin caps
amoxicillin chew
amoxicillin susr
amoxicillin tabs
amoxicillin/clavulanate
potassium
amoxicillin/clavulanate
potassium er
ampicillin
ampicillin sodium
ampicillin-sulbactam
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
4
AUGMENTIN SUSR
125MG/5ML; 31.25MG/5ML
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium
oxacillin sodium
penicillin g potassium inj
20000000unit, 5000000unit
penicillin v potassium oral soln
penicillin v potassium tabs
250mg
penicillin v potassium tabs
500mg
pfizerpen-g
piperacillin sodium/ tazobactam
sodium
piperacillin sodium/tazobactam
sodium
piperacillin/tazobactam
ZOSYN INJ 5%; 2GM/50ML;
0.25GM/50ML, 5%; 3GM/50ML;
0.375GM/50ML, 5%;
4GM/100ML; 0.5GM/100ML
Macrolides
AZASITE
azithromycin inj
azithromycin pack
azithromycin susr 200mg/5ml
azithromycin susr 100mg/5ml
azithromycin tabs
clarithromycin
clarithromycin er
e.e.s. 400
E.E.S. GRANULES
ery
ERY-TAB
ERYPED 200
ERYPED 400
ERYTHROCIN
LACTOBIONATE
erythrocin stearate
4
2
2
4
4
4
4
2
4
1
2
2
3
4
4
4
4
4
2
4
2
1
2
1
2
2
2
2
4
4
20
DRUG REQUIREMENTS/
TIER LIMITS
3
4
2
4
4
4
1
1
2
4
4
4
4
4
3
4
3
2
2
2
2
2
2
3
2
3
3
3
4
2
QL(3/30)
QL(75/30)
QL(150/30)
QL(12/28)
QL(60/30)
Covered Drugs By Category
DRUG NAME
erythromycin base
erythromycin ethylsuccinate
erythromycin external soln
erythromycin gel
erythromycin oint
erythromycin pads
ilotycin
KETEK
ZMAX
Quinolones
AVELOX INJ
BESIVANCE
CILOXAN OINT
CIPRO HC
CIPRODEX
ciprofloxacin er
ciprofloxacin hcl ophthalmic
soln
ciprofloxacin hcl tabs 100mg,
750mg
ciprofloxacin hcl tabs 250mg,
500mg
ciprofloxacin i.v.-in d5w
ciprofloxacin inj 400mg/40ml
ciprofloxacin susr
levofloxacin in d5w
levofloxacin inj
levofloxacin oral soln
levofloxacin tabs
MOXEZA
moxifloxacin hcl inj
moxifloxacin hcl tabs
ofloxacin
VIGAMOX
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
2
2
2
2
3
4
DRUG NAME
Sulfonamides
BLEPHAMIDE
blephamide s.o.p.
sodium sulfacetamide
ophthalmic soln
sulfacetamide sodium
ophthalmic soln
sulfacetamide sodium susp
sulfacetamide sodium/
prednisolone sodium
phosphate
sulfadiazine
sulfamethoxazole/trimethoprim
ds
sulfamethoxazole/trimethoprim
inj
sulfamethoxazole/trimethoprim
susp
sulfamethoxazole/trimethoprim
tabs
sulfatrim pediatric
Tetracyclines
demeclocycline hcl
doxy 100
doxycycline caps 75mg
doxycycline hyclate caps
doxycycline hyclate inj
doxycycline hyclate tabs 100mg
doxycycline hyclate tabs 20mg
doxycycline monohydrate
doxycycline susr
minocycline hcl
mondoxyne nl
morgidox 1x100mg caps
morgidox 2x100mg caps
tetracycline hcl
QL(20/30)
QL(60/30)
4
4
3
3
3
2
2
2
1
4
4
2
4
4
2
2
3
4
2
2
3
DRUG REQUIREMENTS/
TIER LIMITS
3
2
2
2
2
2
2
1
4
1
1
1
2
4
2
1
4
1
2
2
2
2
2
1
1
1
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
21
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
GABITRIL TABS 16MG
GABITRIL TABS 12MG
ONFI SUSP
ONFI TABS 10MG
ONFI TABS 20MG
phenobarbital
primidone
SABRIL PACK
SABRIL TABS
tiagabine hydrochloride tabs
4mg
tiagabine hydrochloride tabs
2mg
valproate sodium
valproic acid
Glutamate Reducing Agents
felbamate
lamotrigine
lamotrigine er
lamotrigine odt
topiramate
Sodium Channel Agents
BANZEL SUSP
BANZEL TABS 400MG
BANZEL TABS 200MG
carbamazepine
carbamazepine er
dilantin caps 30mg
DILANTIN CAPS 100MG
DILANTIN INFATABS
epitol
fosphenytoin sodium
oxcarbazepine
PEGANONE
phenytoin
phenytoin infatabs
phenytoin sodium
phenytoin sodium extended
TEGRETOL TABS
Anticonvulsants
Anticonvulsants, Other
APTIOM TABS 200MG,
4
QL(30/30) ST
400MG, 800MG
APTIOM TABS 600MG
4
QL(60/30) ST
BRIVIACT INJ
5
QL(600/30) ST
BRIVIACT ORAL SOLN
5
QL(1200/30) ST
BRIVIACT TABS 10MG, 25MG,
5
QL(60/30) ST
50MG, 75MG
BRIVIACT TABS 100MG
5
QL(120/30) ST
FYCOMPA
4
ST
levetiracetam er
2
levetiracetam inj
4
levetiracetam oral soln
2
levetiracetam tabs
2
POTIGA
3
PA QL(90/30)
roweepra
2
SPRITAM TB3D 1000MG,
4
QL(60/30)
250MG, 500MG
SPRITAM TB3D 750MG
4
QL(120/30)
Calcium Channel Modifying Agents
CELONTIN
3
ethosuximide
2
LYRICA CAPS 225MG, 300MG
3
QL(60/30)
3
QL(90/30)
LYRICA CAPS 100MG,
150MG, 200MG, 25MG, 50MG,
75MG
LYRICA ORAL SOLN
3
QL(900/30)
zonisamide
2
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam odt tbdp 0.125mg,
2
QL(150/30)
0.25mg, 0.5mg, 1mg
clonazepam odt tbdp 2mg
2
QL(300/30)
clonazepam tabs 0.5mg, 1mg
2
QL(150/30)
clonazepam tabs 2mg
2
QL(300/30)
diazepam gel
3
divalproex sodium
2
divalproex sodium dr
2
divalproex sodium er
2
gabapentin
2
22
DRUG REQUIREMENTS/
TIER LIMITS
3
3
3
3
3
2
2
5
5
2
QL(90/30) ST
QL(120/30) ST
QL(480/30)
QL(60/30)
QL(120/30)
2
QL(240/30) ST
PA QL(200/30)
PA QL(180/30)
ST
4
2
2
2
2
2
2
5
5
4
2
2
2
4
4
2
4
2
3
2
2
4
2
4
PA
PA
PA
Covered Drugs By Category
DRUG NAME
TEGRETOL-XR TB12 200MG,
400MG
TEGRETOL-XR TB12 100MG
VIMPAT INJ
VIMPAT ORAL SOLN
VIMPAT TABS
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
4
Antidepressants
3
4
3
3
Antidepressants, Other
bupropion hcl
2
bupropion hcl sr tb12 100mg,
2
QL(60/30)
200mg
bupropion hcl sr tb12 150mg
2
QL(90/30)
bupropion hcl xl tb24 300mg
2
QL(30/30)
bupropion hcl xl tb24 150mg
2
QL(90/30)
maprotiline hcl
2
mirtazapine
2
QL(30/30)
mirtazapine odt
2
QL(30/30)
nefazodone hcl
2
QL(60/30)
trazodone hcl tabs 300mg
2
trazodone hcl tabs 100mg,
1
150mg, 50mg
TRINTELLIX
4
QL(30/30) ST
Monoamine Oxidase Inhibitors
EMSAM
3
MARPLAN
4
phenelzine sulfate
2
tranylcypromine sulfate
2
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/
Serotonin and Norepinephrine Reuptake Inhibitor
citalopram hydrobromide oral
1
QL(600/30)
soln
citalopram hydrobromide tabs
1
QL(30/30)
40mg
citalopram hydrobromide tabs
1
QL(60/30)
10mg, 20mg
duloxetine hcl cpep 20mg,
2
QL(60/30)
60mg
duloxetine hcl cpep 30mg
2
QL(90/30)
escitalopram oxalate
2
FETZIMA
4
QL(30/30) ST
4
QL(28/28) ST
FETZIMA TITRATION PACK
QL(1200/30) ST
QL(1200/30) ST
QL(60/30) ST
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates
2
PA
NAMZARIC
3
QL(30/30)
Cholinesterase Inhibitors
donepezil hcl tabs 23mg, 5mg
2
QL(30/30)
donepezil hcl tabs 10mg
2
QL(60/30)
donepezil hcl tbdp 5mg
2
QL(30/30)
donepezil hcl tbdp 10mg
2
QL(60/30)
galantamine hydrobromide
2
QL(30/30)
cp24
galantamine hydrobromide oral
2
QL(200/30)
soln
galantamine hydrobromide tabs 2
QL(60/30)
rivastigmine tartrate
2
QL(60/30)
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl tabs 10mg
2
QL(60/30)
memantine hcl tabs 5mg
2
QL(90/30)
memantine hcl titration pak
2
QL(49/28)
memantine hydrochloride
2
QL(300/30)
NAMENDA ORAL SOLN
3
QL(300/30)
NAMENDA TABS 10MG
3
QL(60/30)
NAMENDA TABS 5MG
3
QL(90/30)
NAMENDA TITRATION PAK
3
QL(49/28)
NAMENDA XR
3
QL(30/30)
NAMENDA XR TITRATION
3
QL(28/28)
PACK
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
23
Covered Drugs By Category
DRUG NAME
fluoxetine
fluoxetine dr
fluoxetine hcl caps
fluoxetine hcl oral soln
fluoxetine hcl tabs 10mg, 20mg
fluvoxamine maleate
fluvoxamine maleate er cp24
150mg
fluvoxamine maleate er cp24
100mg
olanzapine/fluoxetine
paroxetine hcl er tb24 12.5mg
paroxetine hcl er tb24 37.5mg
paroxetine hcl er tb24 25mg
paroxetine hcl tabs 30mg,
40mg
paroxetine hcl tabs 10mg
paroxetine hcl tabs 20mg
PAXIL SUSP
PRISTIQ
sertraline hcl conc
sertraline hcl tabs 25mg
sertraline hcl tabs 100mg
sertraline hcl tabs 50mg
venlafaxine hcl
venlafaxine hcl er cp24
venlafaxine hcl er tb24 150mg,
37.5mg, 75mg
VIIBRYD
VIIBRYD STARTER PACK
Tricyclics
amitriptyline hcl tabs 150mg
amitriptyline hcl tabs 100mg,
10mg, 25mg, 50mg, 75mg
amoxapine
clomipramine hcl
desipramine hcl
doxepin hcl
imipramine hcl
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
2
2
2
2
QL(60/30)
2
QL(90/30)
2
2
2
2
2
QL(30/30)
QL(30/30)
QL(60/30)
QL(90/30)
QL(60/30)
1
1
3
4
2
2
2
2
2
2
2
QL(30/30)
QL(60/30)
QL(900/30)
QL(30/30) ST
QL(300/30)
QL(30/30)
QL(60/30)
QL(90/30)
4
4
QL(30/30) ST
QL(30/30) ST
2
1
PA
PA
2
2
2
2
2
DRUG NAME
imipramine pamoate
nortriptyline hcl caps
nortriptyline hcl oral soln
perphenazine/amitriptyline
protriptyline hcl
SURMONTIL
trimipramine maleate
DRUG REQUIREMENTS/
TIER LIMITS
2
1
2
2
2
4
2
PA
4
B/D PA
2
2
2
4
2
2
2
2
PA
PA
PA
PA
PA
PA
PA
1
2
3
PA
PA
QL(12/36)
2
3
3
3
3
4
PA QL(90/30)
B/D PA QL(2/30)
B/D PA QL(4/30)
B/D PA QL(8/30)
B/D PA QL(12/30)
B/D PA
2
4
B/D PA QL(60/30)
2
1
1
1
B/D PA
B/D PA
B/D PA QL(90/30)
B/D PA QL(90/30)
PA
PA
PA
Antiemetics
Antiemetics
granisetron hcl inj 1mg/ml
Antiemetics, Other
meclizine hcl tabs
phenadoz
phenergan supp
promethazine hcl inj
promethazine hcl plain
promethazine hcl supp
promethazine hcl syrp
promethazine hcl tabs 12.5mg,
50mg
promethazine hcl tabs 25mg
promethegan
TRANSDERM-SCOP
Emetogenic Therapy Adjuncts
dronabinol
EMEND CAPS 40MG
EMEND CAPS 125MG
EMEND CAPS 80MG
EMEND CAPS
granisetron hcl inj 0.1mg/ml,
1mg/ml
granisetron hcl tabs
ondansetron hcl inj 40mg/20ml,
4mg/2ml
ondansetron hcl oral soln
ondansetron hcl tabs 24mg
ondansetron hcl tabs 4mg, 8mg
ondansetron odt
PA
PA
PA
24
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
NOXAFIL SUSP
NOXAFIL TBEC
nyamyc
nystatin crea
nystatin oint
nystatin powd 100000unit/gm
nystatin susp
nystatin tabs
nystatin/triamcinolone
nystop
SPORANOX ORAL SOLN
TERAZOL 3
TERAZOL 7
terbinafine hcl tabs
terconazole
voriconazole inj
voriconazole susr
voriconazole tabs
Antifungals
Antifungals
ABELCET
AMBISOME
amphotericin b
CANCIDAS
ciclodan
ciclopirox nail lacquer
ciclopirox olamine
ciclopirox sham
ciclopirox susp
clotrimazole external crea
clotrimazole external soln
clotrimazole troc
clotrimazole/betamethasone
dipropionate
econazole nitrate
fluconazole in dextrose
fluconazole in nacl
fluconazole susr
fluconazole tabs 100mg,
200mg, 50mg
fluconazole tabs 150mg
flucytosine
griseofulvin microsize
griseofulvin ultramicrosize
itraconazole
ketoconazole crea
ketoconazole sham
ketoconazole tabs
naftifine hcl
naftifine hydrochloride
NAFTIN
NATACYN
5
4
4
5
2
2
2
2
2
2
2
2
2
PA
PA
PA
PA
2
4
4
2
2
1
5
2
2
2
2
2
2
2
2
3
3
DRUG REQUIREMENTS/
TIER LIMITS
5
5
2
2
2
2
2
2
2
2
3
4
4
1
2
4
5
5
PA QL(600/30)
PA QL(93/30)
PA
QL(180/365)
PA
PA
PA
Antigout Agents
Antigout Agents
allopurinol
ALOPRIM
colchicine
COLCRYS
probenecid
probenecid/colchicine
ULORIC
QL(8/30)
PA QL(120/30)
1
4
2
3
2
2
3
ST
Antimigraine Agents
Ergot Alkaloids
cafergot
dihydroergotamine mesylate inj
migergot
2
2
2
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
25
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
Serotonin (5-HT) 1b/1d Receptor Agonists
naratriptan hcl
2
QL(9/30)
rizatriptan benzoate
2
QL(12/30)
rizatriptan benzoate odt
2
QL(12/30)
sumatriptan
3
QL(12/30)
sumatriptan succinate inj
2
QL(8/30)
sumatriptan succinate refill
2
QL(8/30)
sumatriptan succinate tabs
2
QL(9/30)
BUSULFEX
cyclophosphamide caps
cyclophosphamide inj
dacarbazine
EVOMELA
GLEOSTINE
HEXALEN
ifosfamide
LEUKERAN
MATULANE
melphalan hydrochloride
MUSTARGEN
thiotepa
TREANDA
VALCHLOR
YONDELIS
ZANOSAR
Antiandrogens
bicalutamide
flutamide
NILANDRON
XTANDI
ZYTIGA
Antiangiogenic Agents
POMALYST
REVLIMID
THALOMID CAPS 150MG,
200MG, 50MG
THALOMID CAPS 100MG
Antiestrogens/Modifiers
EMCYT
FARESTON
FASLODEX
SOLTAMOX
tamoxifen citrate
Antimetabolites
adrucil
ALIMTA INJ 500MG
ARRANON
Antimyasthenic Agents
Parasympathomimetics
GUANIDINE HCL
MESTINON TIMESPAN
pyridostigmine bromide
REGONOL
3
3
2
4
Antimycobacterials
Antimycobacterials, Other
dapsone
rifabutin
Antituberculars
CAPASTAT SULFATE
cycloserine
ethambutol hcl
isoniazid inj
isoniazid syrp
isoniazid tabs 100mg
isoniazid tabs 300mg
PASER
pyrazinamide
rifampin caps
rifampin inj
RIFATER
SIRTURO
TRECATOR
2
2
4
2
2
4
2
2
1
3
2
2
4
3
4
3
PA
Antineoplastics
Alkylating Agents
BENDEKA
BICNU
5
4
B/D PA
B/D PA
26
DRUG REQUIREMENTS/
TIER LIMITS
5
3
4
4
5
3
5
4
3
5
5
4
4
5
5
5
4
B/D PA
B/D PA
B/D PA
B/D PA
PA
B/D PA
B/D PA
B/D PA
PA
B/D PA
PA
PA
B/D PA
2
2
5
5
5
PA QL(120/30)
PA QL(120/30)
5
5
5
PA QL(21/28)
PA QL(28/28)
PA QL(60/30)
5
PA QL(90/30)
3
5
5
3
2
B/D PA
4
5
4
B/D PA
B/D PA
Covered Drugs By Category
DRUG NAME
cladribine
CLOLAR
cytarabine
cytarabine aqueous
DROXIA
ELITEK
fluorouracil inj
FOLOTYN
gemcitabine
gemcitabine hcl
hydroxyurea
LONSURF TABS 8.19MG;
20MG
LONSURF TABS 6.14MG;
15MG
mercaptopurine
NIPENT
PURIXAN
TABLOID
Antineoplastics, Other
ABRAXANE
amifostine
azacitidine
BELEODAQ
bleomycin sulfate
carboplatin inj 150mg/15ml,
450mg/45ml, 50mg/5ml
cisplatin
COSMEGEN
daunorubicin hcl
decitabine
dexrazoxane
DOCEFREZ INJ 20MG
docetaxel
doxorubicin hcl
DRUG REQUIREMENTS/
TIER LIMITS
4
4
4
4
3
5
4
5
4
5
2
5
B/D PA
B/D PA
B/D PA
B/D PA
5
PA QL(100/28)
2
5
4
3
B/D PA
PA
DRUG NAME
doxorubicin hcl liposome
ELLENCE INJ 200MG/100ML
epirubicin hcl inj 50mg/25ml
epirubicin hcl inj 200mg/100ml
ERWINAZE
fludarabine phosphate
FUSILEV
HALAVEN
IBRANCE
idarubicin hcl inj 10mg/10ml
irinotecan
ISTODAX
IXEMPRA KIT
JEVTANA
leucovorin calcium inj 100mg,
350mg, 500mg, 50mg
leucovorin calcium tabs
levoleucovorin calcium
levoleucovorin inj 250mg/25ml
LYNPARZA
mesna
MESNEX TABS
mitomycin
mitoxantrone hcl
NINLARO
ODOMZO
ONCASPAR
oxaliplatin
paclitaxel
PORTRAZZA
PROLEUKIN
SYLATRON
SYNRIBO
TAXOTERE INJ 80MG/4ML
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
PA QL(80/28)
5
5
5
5
4
4
B/D PA
B/D PA
B/D PA
PA
B/D PA
B/D PA
4
5
4
5
4
5
5
2
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
DRUG REQUIREMENTS/
TIER LIMITS
5
4
4
5
5
4
5
5
5
5
4
5
5
5
4
2
5
5
5
2
5
4
2
5
5
5
5
4
5
5
5
5
5
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
PA
PA QL(21/28)
B/D PA
B/D PA
PA
B/D PA
B/D PA
PA QL(480/30)
B/D PA
B/D PA
B/D PA
PA QL(3/28)
PA QL(30/30)
B/D PA
B/D PA
B/D PA
PA QL(100/21)
B/D PA
PA
PA
B/D PA
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
27
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
TRISENOX
4
VELCADE
5
VENCLEXTA STARTING PACK
5
VENCLEXTA TABS 100MG
5
VENCLEXTA TABS 50MG
4
VENCLEXTA TABS 10MG
4
vinblastine sulfate
4
vincasar pfs
4
vincristine sulfate
4
vinorelbine tartrate
4
ZINECARD INJ 250MG
4
ZOLINZA
5
Aromatase Inhibitors, 3rd Generation
anastrozole
2
exemestane
2
letrozole
2
Enzyme Inhibitors
ETOPOPHOS
4
etoposide inj 100mg/5ml,
4
1gm/50ml
etoposide inj 500mg/25ml
3
toposar inj 1gm/50ml
3
toposar inj 100mg/5ml,
4
500mg/25ml
topotecan hcl inj 4mg
5
Molecular Target Inhibitors
AFINITOR DISPERZ TBSO
5
2MG, 3MG
AFINITOR DISPERZ TBSO
5
5MG
AFINITOR TABS 2.5MG, 5MG,
5
7.5MG
AFINITOR TABS 10MG
5
ALECENSA
5
BOSULIF
5
CABOMETYX TABS 20MG,
5
60MG
CABOMETYX TABS 40MG
5
CAPRELSA
5
COMETRIQ
5
DRUG NAME
B/D PA
B/D PA
PA QL(84/365)
PA QL(120/30)
PA QL(30/30)
PA QL(60/30)
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
QL(120/30)
COTELLIC
ERIVEDGE
FARYDAK
GILOTRIF
GLEEVEC
ICLUSIG
imatinib mesylate
IMBRUVICA
INLYTA TABS 5MG
INLYTA TABS 1MG
IRESSA
JAKAFI
LENVIMA 10 MG DAILY DOSE
LENVIMA 14 MG DAILY DOSE
LENVIMA 18 MG DAILY DOSE
LENVIMA 20 MG DAILY DOSE
LENVIMA 24 MG DAILY DOSE
LENVIMA 8 MG DAILY DOSE
MEKINIST
NEXAVAR
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TAGRISSO
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYDELIG
ZYKADIA
Monoclonal Antibodies
AVASTIN
CYRAMZA
DARZALEX
EMPLICITI
ERBITUX
QL(30/30)
QL(30/30)
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
PA QL(60/30)
PA QL(120/30)
PA QL(30/30)
PA QL(60/30)
PA QL(240/30)
PA
PA QL(30/30)
PA QL(60/30)
PA
PA
28
DRUG REQUIREMENTS/
TIER LIMITS
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
PA QL(63/28)
PA QL(30/30)
PA QL(9/28)
PA QL(30/30)
PA QL(60/30)
PA
PA QL(60/30)
PA QL(120/30)
PA QL(120/30)
PA QL(240/30)
PA QL(30/30)
PA QL(60/30)
PA
PA
PA QL(90/30)
PA
PA
PA QL(60/30)
PA
PA
PA
PA QL(84/21)
PA
PA
PA QL(30/30)
PA
PA
PA
PA QL(120/30)
PA QL(60/30)
PA QL(240/30)
PA QL(60/30)
PA
5
5
5
5
5
B/D PA
PA
PA
PA
B/D PA
Covered Drugs By Category
DRUG NAME
GAZYVA
HERCEPTIN
KADCYLA
KEYTRUDA
OPDIVO
PERJETA
RITUXAN INJ 500MG/50ML
TECENTRIQ
UNITUXIN
VECTIBIX INJ 100MG/5ML
YERVOY
ZALTRAP
Retinoids
bexarotene
PANRETIN
TARGRETIN
tretinoin caps
DRUG REQUIREMENTS/
TIER LIMITS
5
5
5
5
5
5
5
5
5
3
5
5
DRUG NAME
PA
B/D PA
PA
PA
PA
PA
PA
PA QL(20/21)
PA
B/D PA
B/D PA
PA
quinine sulfate
Pediculicides/Scabicides
lindane
malathion
permethrin
2
2
2
Anticholinergics
benztropine mesylate inj
4
benztropine mesylate tabs 2mg
1
PA
benztropine mesylate tabs
2
PA
0.5mg, 1mg
trihexyphenidyl hcl elix
2
PA
trihexyphenidyl hcl tabs 5mg
2
PA
trihexyphenidyl hcl tabs 2mg
1
PA
Antiparkinson Agents, Other
entacapone
2
tolcapone
5
Dopamine Agonists
APOKYN
5
PA QL(60/30)
bromocriptine mesylate
2
NEUPRO
4
QL(30/30)
pramipexole dihydrochloride
2
QL(90/30)
2
QL(30/30)
pramipexole dihydrochloride
er tb24 2.25mg, 3.75mg, 3mg,
4.5mg
pramipexole dihydrochloride er
2
QL(90/30)
tb24 0.375mg, 0.75mg, 1.5mg
ropinirole hcl
2
Dopamine Precursors/L- Amino Acid Decarboxylase
Inhibitors
carbidopa
2
carbidopa/levodopa
2
carbidopa/levodopa er
2
carbidopa/levodopa odt
2
5
5
5
5
3
2
3
3
5
2
2
3
3
2
2
3
3
3
1
Antiparkinson Agents
Antiparasitics
Anthelmintics
ALBENZA
ivermectin
STROMECTOL
Antiprotozoals
ALINIA
atovaquone
atovaquone/proguanil hcl
chloroquine phosphate
COARTEM
DARAPRIM
hydroxychloroquine sulfate
mefloquine hcl
NEBUPENT
PENTAM 300
PRIMAQUINE PHOSPHATE
DRUG REQUIREMENTS/
TIER LIMITS
B/D PA
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
29
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
2nd Generation/Atypical
ABILIFY MAINTENA INJ
300MG
ABILIFY MAINTENA INJ
400MG
aripiprazole odt
aripiprazole oral soln
aripiprazole tabs
ARISTADA INJ 441MG/1.6ML
ARISTADA INJ 662MG/2.4ML
ARISTADA INJ 882MG/3.2ML
FANAPT TABS 10MG, 12MG,
6MG, 8MG
FANAPT TABS 1MG, 2MG,
4MG
FANAPT TITRATION PACK
GEODON INJ
INVEGA SUSTENNA INJ
117MG/0.75ML
INVEGA SUSTENNA INJ
156MG/ML
INVEGA SUSTENNA INJ
234MG/1.5ML
INVEGA SUSTENNA INJ
39MG/0.25ML
INVEGA SUSTENNA INJ
78MG/0.5ML
INVEGA TB24 9MG
INVEGA TB24 1.5MG, 3MG
INVEGA TB24 6MG
INVEGA TRINZA INJ
273MG/0.875ML
INVEGA TRINZA INJ
410MG/1.315ML
INVEGA TRINZA INJ
546MG/1.75ML
INVEGA TRINZA INJ
819MG/2.625ML
LATUDA TABS 120MG, 20MG,
40MG, 60MG
LATUDA TABS 80MG
NUPLAZID
carbidopa/levodopa/
3
entacapone
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
3
selegiline hcl
2
Antipsychotics
1st Generation/Typical
chlorpromazine hcl inj
50mg/2ml
chlorpromazine hcl tabs
compro
fluphenazine decanoate
fluphenazine hcl conc
fluphenazine hcl elix
fluphenazine hcl inj
fluphenazine hcl tabs 1mg
fluphenazine hcl tabs 10mg,
2.5mg, 5mg
haloperidol conc
haloperidol decanoate
haloperidol lactate
haloperidol tabs 0.5mg, 1mg,
2mg, 5mg
haloperidol tabs 10mg, 20mg
loxapine
loxapine succinate
ORAP
perphenazine
pimozide
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate tabs
10mg
prochlorperazine maleate tabs
5mg
thioridazine hcl
thiothixene caps 10mg, 1mg,
5mg
thiothixene caps 2mg
trifluoperazine hcl
4
2
2
4
2
2
4
1
2
2
4
4
1
2
2
2
3
2
2
2
4
1
2
2
2
PA
1
2
30
DRUG REQUIREMENTS/
TIER LIMITS
5
QL(1.5/30)
5
QL(2/30)
5
2
2
5
5
5
5
QL(60/30) ST
QL(900/30) ST
QL(30/30) ST
QL(1.6/30)
QL(2.4/30)
QL(3.2/30)
QL(60/30) ST
4
QL(60/30) ST
4
4
5
QL(16/30) ST
QL(60/30)
QL(0.75/28)
5
QL(1/28)
5
QL(1.5/28)
4
QL(0.25/28)
4
QL(0.5/28)
5
4
4
5
QL(30/30) ST
QL(30/30) ST
QL(60/30) ST
QL(0.88/90)
5
QL(1.32/90)
5
QL(1.75/90)
5
QL(2.63/90)
4
QL(30/30) ST
4
5
QL(60/30) ST
PA QL(60/30)
Covered Drugs By Category
DRUG NAME
olanzapine inj
olanzapine odt
olanzapine tabs
paliperidone er tb24 1.5mg,
3mg
paliperidone er tb24 6mg
paliperidone er tb24 9mg
quetiapine fumarate
REXULTI
RISPERDAL CONSTA INJ
37.5MG, 50MG
RISPERDAL CONSTA INJ
12.5MG, 25MG
risperidone m-tab tbdp 0.5mg,
1mg, 2mg, 3mg
risperidone m-tab tbdp 4mg
risperidone odt tbdp 0.25mg,
0.5mg, 1mg, 2mg, 3mg
risperidone odt tbdp 4mg
risperidone oral soln
risperidone tabs 0.25mg,
0.5mg, 1mg, 2mg, 3mg
risperidone tabs 4mg
SAPHRIS
SEROQUEL XR TB24 150MG,
200MG
SEROQUEL XR TB24 300MG,
400MG, 50MG
VRAYLAR CAPS
VRAYLAR CPPK
ziprasidone hcl
ZYPREXA RELPREVV
Antipsychotics
molindone hydrochloride
Treatment-Resistant
clozapine
DRUG REQUIREMENTS/
TIER LIMITS
4
2
2
2
2
5
2
5
5
DRUG NAME
clozapine odt
FAZACLO TBDP 100MG,
12.5MG, 25MG
VERSACLOZ
QL(30/30)
QL(30/30)
QL(30/30) ST
DRUG REQUIREMENTS/
TIER LIMITS
3
4
ST
5
Antispasticity Agents
QL(60/30) ST
QL(30/30) ST
QL(90/30)
QL(30/30) ST
Antispasticity Agents
baclofen tabs 10mg
baclofen tabs 20mg
dantrolene sodium
tizanidine hcl tabs
4
1
2
2
2
Antivirals
2
QL(90/30)
2
2
QL(120/30)
QL(90/30)
2
2
2
QL(120/30)
QL(360/30)
QL(90/30)
2
3
3
QL(120/30)
QL(60/30) ST
QL(30/30)
3
QL(60/30)
5
4
2
5
QL(30/30) ST
QL(14/365) ST
QL(60/30)
Anti-cytomegalovirus (CMV) Agents
cidofovir
5
ganciclovir inj
4
VALCYTE
5
valganciclovir
5
ZIRGAN
3
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil
5
BARACLUDE ORAL SOLN
3
5
BARACLUDE TABS
entecavir
2
EPIVIR HBV ORAL SOLN
3
INTRON A INJ 18MU, 50MU,
4
6000000UNIT/ML
INTRON A INJ 10MU, 10MU/
5
ML
INTRON A W/DILUENT INJ
5
18MU
INTRON A W/DILUENT INJ
4
10MU, 50MU
lamivudine
2
TYZEKA
5
2
B/D PA
ST
QL(30/30)
PA
2
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
31
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
Anti-hepatitis C (HCV) Agents
HARVONI
5
PA QL(28/28)
moderiba 1200 dose pack
5
PA
moderiba 800 dose pack
5
PA
moderiba misc
5
PA
moderiba tabs
2
PA
OLYSIO
5
PA QL(28/28)
PEG-INTRON REDIPEN
5
PA
PEG-INTRON REDIPEN PAK 4 5
PA
PEGINTRON
5
PA
REBETOL ORAL SOLN
4
PA
ribasphere caps
2
PA
RIBASPHERE RIBAPAK
5
PA
RIBASPHERE TABS 600MG
5
PA
ribasphere tabs 200mg
2
PA
RIBASPHERE TABS 400MG
4
PA
ribavirin
2
PA
SOVALDI
5
PA QL(28/28)
Anti-HIV Agents, Integrase Inhibitors (INSTI)
GENVOYA
5
ISENTRESS CHEW 100MG
3
QL(180/30)
ISENTRESS CHEW 25MG
3
QL(360/30)
ISENTRESS PACK
3
ISENTRESS TABS
5
QL(60/30)
TIVICAY TABS 50MG
5
QL(60/30)
TIVICAY TABS 10MG, 25MG
4
QL(60/30)
VITEKTA
5
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA
5
EDURANT
3
INTELENCE TABS 200MG
5
QL(60/30)
5
QL(120/30)
INTELENCE TABS 100MG
INTELENCE TABS 25MG
4
QL(180/30)
nevirapine er
2
nevirapine susp
3
nevirapine tabs
2
ODEFSEY
5
QL(30/30)
RESCRIPTOR
3
DRUG REQUIREMENTS/
TIER LIMITS
STRIBILD
5
SUSTIVA
3
VIRAMUNE XR TB24 100MG
3
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
abacavir
2
abacavir sulfate/lamivudine/
5
zidovudine
DESCOVY
5
QL(30/30)
didanosine
2
EMTRIVA
3
EPIVIR ORAL SOLN
3
EPZICOM
5
lamivudine
2
lamivudine/zidovudine
4
RETROVIR IV INFUSION
4
stavudine
2
TRUVADA
5
VIDEX PEDIATRIC
3
VIREAD
5
ZIAGEN ORAL SOLN
3
zidovudine
2
Anti-HIV Agents, Other
ATRIPLA
5
FUZEON
5
QL(60/30)
SELZENTRY TABS 150MG
5
QL(60/30)
SELZENTRY TABS 300MG
5
QL(120/30)
TRIUMEQ
5
QL(30/30)
TYBOST
3
Anti-HIV Agents, Protease Inhibitors
APTIVUS
5
CRIXIVAN
3
EVOTAZ
5
INVIRASE
5
KALETRA ORAL SOLN
5
KALETRA TABS 200MG;
5
50MG
KALETRA TABS 100MG;
4
25MG
LEXIVA SUSP
4
32
Covered Drugs By Category
DRUG NAME
LEXIVA TABS
NORVIR
PREZCOBIX
PREZISTA SUSP
PREZISTA TABS 800MG
PREZISTA TABS 600MG
PREZISTA TABS 150MG
PREZISTA TABS 75MG
REYATAZ
VIRACEPT
Anti-influenza Agents
amantadine hcl
rimantadine hcl
TAMIFLU CAPS 75MG
TAMIFLU CAPS 45MG
TAMIFLU CAPS 30MG
TAMIFLU SUSR
Antiherpetic Agents
acyclovir
acyclovir sodium inj 50mg/ml
DENAVIR
famciclovir
trifluridine
valacyclovir hcl tabs 1000mg
valacyclovir hcl tabs 500mg
DRUG REQUIREMENTS/
TIER LIMITS
5
3
5
5
5
5
4
4
5
5
2
2
3
3
3
3
2
4
3
2
2
2
2
DRUG NAME
alprazolam odt tbdp 2mg
alprazolam tabs 0.25mg, 0.5mg
alprazolam tabs 1mg
alprazolam tabs 2mg
clorazepate dipotassium tabs
3.75mg, 7.5mg
clorazepate dipotassium tabs
15mg
diazepam inj 5mg/ml
diazepam oral soln
diazepam tabs
lorazepam conc
lorazepam inj 2mg/ml, 4mg/ml
lorazepam intensol
lorazepam tabs
oxazepam
QL(400/30)
QL(30/30)
QL(60/30)
QL(180/30)
QL(360/30)
QL(56/365)
QL(60/365)
QL(120/365)
QL(700/365)
Mood Stabilizers
lithium carbonate caps 300mg
lithium carbonate caps 150mg,
600mg
lithium carbonate er
lithium carbonate tabs
QL(21/7)
QL(30/30)
QL(60/30)
QL(90/30)
2
QL(120/30)
QL(150/30)
QL(90/30)
QL(120/30)
QL(150/30)
QL(90/30)
2
QL(120/30)
2
2
2
2
4
2
2
2
QL(1200/30)
QL(120/30)
QL(150/30)
QL(150/30)
QL(120/30)
QL(120/30)
1
2
2
2
Blood Glucose Regulators
Antidiabetic Agents
acarbose
BYDUREON
BYETTA
glimepiride tabs 1mg, 2mg
glimepiride tabs 4mg
glipizide
glipizide er
glipizide xl
glipizide/metformin hcl
1
2
2
2
2
2
2
2
Bipolar Agents
Anxiolytics
Anxiolytics, Other
buspirone hcl tabs 10mg, 5mg
buspirone hcl tabs 15mg,
30mg, 7.5mg
Benzodiazepines
alprazolam odt tbdp 0.25mg,
0.5mg
alprazolam odt tbdp 1mg
DRUG REQUIREMENTS/
TIER LIMITS
2
3
3
1
1
1
1
1
1
QL(90/30)
QL(4/28)
QL(2.4/30)
QL(30/30)
QL(60/30)
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
33
Covered Drugs By Category
DRUG NAME
glyburide/metformin hcl
GLYSET
INVOKAMET
INVOKANA
JENTADUETO
JENTADUETO XR TB24 5MG;
1000MG
JENTADUETO XR TB24
2.5MG; 1000MG
metformin hcl
metformin hcl er tb24 500mg,
750mg
miglitol
nateglinide
pioglitazone hcl
pioglitazone hcl-glimepiride
pioglitazone hcl/metformin hcl
repaglinide
RIOMET
TRADJENTA
TRULICITY
Glycemic Agents
GLUCAGEN HYPOKIT
PROGLYCEM
Insulins
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50
KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25
KWIKPEN
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500
(CONCENTRATED)
DRUG REQUIREMENTS/
TIER LIMITS
2
3
3
3
3
3
PA
3
QL(60/30)
DRUG NAME
HUMULIN R U-500 KWIKPEN
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
TOUJEO SOLOSTAR
TRESIBA FLEXTOUCH
QL(60/30)
QL(30/30)
QL(60/30)
QL(30/30)
3
3
3
3
3
3
3
Blood Products/Modifiers/Volume Expanders
1
1
2
2
2
2
2
2
3
3
3
DRUG REQUIREMENTS/
TIER LIMITS
Anticoagulants
COUMADIN
ELIQUIS TABS 2.5MG
ELIQUIS TABS 5MG
enoxaparin sodium inj
120mg/0.8ml
enoxaparin sodium inj 100mg/
ml, 150mg/ml
enoxaparin sodium inj
30mg/0.3ml
enoxaparin sodium inj
40mg/0.4ml
enoxaparin sodium inj
60mg/0.6ml
enoxaparin sodium inj
80mg/0.8ml
enoxaparin sodium inj
300mg/3ml
fondaparinux sodium inj
2.5mg/0.5ml
fondaparinux sodium inj
5mg/0.4ml
fondaparinux sodium inj
7.5mg/0.6ml
fondaparinux sodium inj
10mg/0.8ml
heparin sodium inj 10000unit/
ml, 1000unit/ml, 20000unit/
ml, 2000unit/ml, 2500unit/ml,
5000unit/ml
heparin sodium/d5w
heparin sodium/nacl 0.45% inj
50unit/ml; 0.45%
heparin sodium/nacl 0.9%
QL(90/30)
QL(30/30)
QL(30/30)
QL(90/30)
QL(30/30)
QL(2/28)
4
3
3
3
3
3
3
3
3
3
3
3
3
3
34
4
3
3
5
PA QL(60/30)
PA QL(74/30)
QL(24/30)
5
QL(30/30)
4
QL(9/30)
4
QL(12/30)
4
QL(18/30)
4
QL(24/30)
4
QL(90/30)
4
QL(15/30)
5
QL(12/30)
5
QL(18/30)
5
QL(24/30)
4
4
4
4
Covered Drugs By Category
DRUG NAME
heparin sodium/sodium chloride
0.9%
heparin sodium/sodium chloride
0.9% premix
jantoven
PRADAXA
warfarin sodium
XARELTO STARTER PACK
XARELTO TABS 10MG, 20MG
XARELTO TABS 15MG
Blood Formation Modifiers
anagrelide hydrochloride
ARANESP ALBUMIN
FREE INJ 10MCG/0.4ML,
25MCG/0.42ML, 25MCG/ML,
40MCG/0.4ML, 40MCG/ML,
60MCG/0.3ML, 60MCG/ML
ARANESP ALBUMIN
FREE INJ 100MCG/0.5ML,
100MCG/ML, 150MCG/0.3ML,
200MCG/0.4ML, 200MCG/ML,
300MCG/0.6ML, 300MCG/ML,
500MCG/ML
LEUKINE INJ 250MCG
NEULASTA
NEUPOGEN
PROCRIT INJ 20000UNIT/ML,
40000UNIT/ML
PROCRIT INJ 10000UNIT/ML,
2000UNIT/ML, 3000UNIT/ML,
4000UNIT/ML
PROMACTA TABS 12.5MG,
25MG, 50MG
ZARXIO
Coagulants
tranexamic acid inj
tranexamic acid tabs
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
Platelet Modifying Agents
AGGRENOX
aspirin/dipyridamole
BRILINTA
cilostazol
clopidogrel tabs 300mg
clopidogrel tabs 75mg
dipyridamole tabs
EFFIENT TABS 10MG
EFFIENT TABS 5MG
4
4
1
3
1
3
3
3
2
4
5
PA QL(60/30)
PA QL(102/365)
PA QL(30/30)
PA QL(60/30)
DRUG REQUIREMENTS/
TIER LIMITS
4
2
3
2
2
2
2
4
4
QL(60/30)
QL(60/30)
QL(60/30)
QL(1/30)
QL(30/30)
PA
QL(36/30)
QL(42/30)
Cardiovascular Agents
PA
Alpha-adrenergic Agonists
clonidine hcl ptwk 0.1mg/24hr,
2
0.2mg/24hr
clonidine hcl ptwk 0.3mg/24hr
2
clonidine hcl tabs 0.3mg
2
clonidine hcl tabs 0.1mg, 0.2mg 1
methyldopate hcl
2
midodrine hcl
2
Alpha-adrenergic Blocking Agents
DIBENZYLINE
3
phenoxybenzamine
2
hydrochloride
prazosin hcl
1
Angiotensin II Receptor Antagonists
candesartan cilexetil
2
candesartan cilexetil/
2
hydrochlorothiazide
COZAAR TABS 100MG
4
COZAAR TABS 50MG
4
COZAAR TABS 25MG
4
ENTRESTO
3
HYZAAR TABS 12.5MG;
4
100MG, 25MG; 100MG
HYZAAR TABS 12.5MG; 50MG
4
PA
5
5
5
5
PA
PA
PA
PA
4
PA
5
PA QL(30/30)
5
PA
2
2
PA
QL(4/28)
QL(8/28)
PA
QL(60/30)
QL(90/30)
PA QL(60/30)
QL(30/30)
QL(60/30)
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
35
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
irbesartan
1
irbesartan/hydrochlorothiazide
1
losartan potassium tabs 100mg
1
losartan potassium tabs 50mg
1
QL(60/30)
losartan potassium tabs 25mg
1
QL(90/30)
1
QL(30/30)
losartan potassium/
hydrochlorothiazide tabs
12.5mg; 100mg, 25mg; 100mg
1
QL(60/30)
losartan potassium/
hydrochlorothiazide tabs
12.5mg; 50mg
telmisartan
2
QL(30/30)
telmisartan/amlodipine
2
QL(30/30)
telmisartan/hydrochlorothiazide
2
QL(30/30)
valsartan
2
valsartan/hydrochlorothiazide
2
Angiotensin-converting Enzyme (ACE) Inhibitors
4
ACCUPRIL
ACCURETIC
4
ACEON
4
ALTACE
4
benazepril hcl
1
benazepril hcl/
2
hydrochlorothiazide
captopril
1
captopril/hydrochlorothiazide
2
enalapril maleate
1
enalapril maleate/
1
hydrochlorothiazide
fosinopril sodium
2
fosinopril sodium/
2
hydrochlorothiazide
lisinopril
1
lisinopril/hydrochlorothiazide
1
LOTENSIN TABS 20MG, 40MG 4
MAVIK
4
moexipril hcl
2
moexipril/hydrochlorothiazide
2
perindopril erbumine
1
PRINIVIL
4
quinapril hcl
1
DRUG REQUIREMENTS/
TIER LIMITS
quinapril/hydrochlorothiazide
2
ramipril
1
trandolapril
2
VASERETIC
4
VASOTEC
4
ZESTORETIC
4
ZESTRIL
4
Antiarrhythmics
amiodarone hcl inj
4
amiodarone hcl tabs
2
dofetilide
3
flecainide acetate
2
lidocaine hcl inj 10mg/ml,
4
20mg/ml
mexiletine hcl
2
MULTAQ
3
pacerone
2
propafenone hcl
2
propafenone hcl er
2
quinidine sulfate
2
sorine
2
sotalol hcl
2
sotalol hcl (af)
2
TIKOSYN
3
Beta-adrenergic Blocking Agents
acebutolol hcl
2
atenolol
1
atenolol/chlorthalidone
1
betaxolol hcl
2
bisoprolol fumarate
2
bisoprolol fumarate/
1
hydrochlorothiazide
BYSTOLIC TABS 20MG
3
BYSTOLIC TABS 2.5MG, 5MG
3
BYSTOLIC TABS 10MG
3
carvedilol
1
COREG CR
4
labetalol hcl inj
4
labetalol hcl tabs
2
metoprolol succinate er
2
36
QL(60/30)
QL(60/30)
QL(90/30)
QL(120/30)
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
metoprolol tartrate inj
4
metoprolol tartrate tabs
1
metoprolol/hydrochlorothiazide
2
nadolol tabs 80mg
2
nadolol tabs 20mg, 40mg
1
nadolol/bendroflumethiazide
2
pindolol
1
propranolol hcl er
2
propranolol hcl inj
4
propranolol hcl oral soln
2
propranolol hcl tabs 60mg
2
propranolol hcl tabs 10mg,
1
20mg, 40mg, 80mg
propranolol/hydrochlorothiazide
2
timolol maleate tabs
2
Calcium Channel Blocking Agents
afeditab cr
2
amlodipine besylate
1
amlodipine besylate/benazepril
2
hydrochloride
amlodipine besylate/valsartan
2
amlodipine/valsartan/hctz
2
cartia xt
2
dilt-xr
2
diltiazem cd
2
diltiazem hcl cd
2
diltiazem hcl er
2
4
diltiazem hcl inj 100mg,
125mg/25ml, 25mg/5ml,
50mg/10ml
diltiazem hcl tabs
1
felodipine er
2
isradipine
2
matzim la
2
nicardipine hcl caps
2
DRUG REQUIREMENTS/
TIER LIMITS
nicardipine hcl inj
4
nifedical xl
2
nifedipine er
2
nimodipine
2
nisoldipine
2
nisoldipine er
2
taztia xt
2
verapamil hcl er
2
verapamil hcl inj
4
verapamil hcl sr cp24 360mg
2
verapamil hcl tabs 120mg,
1
80mg
verapamil hcl tabs 40mg
2
Cardiovascular Agents, Other
DEMSER
5
digitek tabs 0.125mg
1
QL(30/30)
digitek tabs 0.25mg
1
PA
digox tabs 125mcg
1
QL(30/30)
digox tabs 250mcg
1
PA
digoxin inj
4
PA
digoxin tabs 125mcg
1
QL(30/30)
digoxin tabs 250mcg
1
PA
LANOXIN PEDIATRIC
4
PA
LANOXIN TABS 125MCG
4
QL(30/30)
LANOXIN TABS 250MCG
4
PA
NORTHERA
5
PA QL(180/30)
pentoxifylline er
2
RANEXA TB12 1000MG
3
QL(60/30) ST
RANEXA TB12 500MG
3
QL(120/30) ST
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide
2
acetazolamide sodium
4
Diuretics, Loop
bumetanide inj
4
bumetanide tabs 2mg
2
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
37
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
bumetanide tabs 0.5mg, 1mg
1
EDECRIN
3
ethacrynate sodium
4
ethacrynic acid
3
furosemide inj
2
furosemide oral soln
2
furosemide tabs
1
SODIUM EDECRIN
4
torsemide
2
Diuretics, Potassium-sparing
amiloride hcl
2
amiloride/hydrochlorothiazide
1
spironolactone tabs 25mg
1
spironolactone tabs 100mg,
2
50mg
spironolactone/
2
hydrochlorothiazide
triamterene/hydrochlorothiazide 2
caps 25mg; 50mg
triamterene/hydrochlorothiazide 1
caps 25mg; 37.5mg
triamterene/hydrochlorothiazide 1
tabs
Diuretics, Thiazide
chlorothiazide
2
chlorothiazide sodium
4
chlorthalidone tabs 25mg,
1
50mg
hydrochlorothiazide caps
1
hydrochlorothiazide tabs 25mg,
1
50mg
hydrochlorothiazide tabs
2
12.5mg
indapamide
1
metolazone
2
Dyslipidemics, Fibric Acid Derivatives
fenofibrate caps
2
fenofibrate micronized
2
fenofibrate tabs 145mg, 160mg, 2
48mg, 54mg
fenofibric acid dr
2
DRUG REQUIREMENTS/
TIER LIMITS
gemfibrozil
2
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
2
QL(30/30)
CRESTOR
3
QL(30/30)
fluvastatin caps 20mg
2
QL(30/30)
fluvastatin caps 40mg
2
QL(60/30)
lovastatin tabs 40mg
2
QL(60/30)
lovastatin tabs 10mg, 20mg
1
QL(90/30)
pravastatin sodium tabs 80mg
1
QL(30/30)
pravastatin sodium tabs 40mg
1
QL(60/30)
pravastatin sodium tabs 10mg,
1
QL(90/30)
20mg
rosuvastatin calcium
4
PA QL(30/30)
simvastatin tabs 20mg, 40mg,
1
QL(30/30)
80mg
simvastatin tabs 10mg, 5mg
1
QL(90/30)
Dyslipidemics, Other
cholestyramine
2
cholestyramine light
2
colestipol hcl gran
2
colestipol hcl tabs
2
KYNAMRO
5
PA
niacin er tbcr 500mg
2
QL(30/30)
niacin er tbcr 1000mg, 750mg
2
QL(60/30)
niacor
2
omega-3-acid ethyl esters
2
QL(120/30)
prevalite
2
REPATHA
5
PA QL(3/30)
REPATHA SURECLICK
5
PA QL(3/30)
VASCEPA
4
QL(120/30)
ZETIA
3
QL(30/30)
Vasodilators, Direct-acting Arterial
hydralazine hcl inj
4
hydralazine hcl tabs
2
minoxidil
2
Vasodilators, Direct-acting Arterial/Venous
BIDIL
3
QL(180/30)
isosorbide dinitrate er
2
isosorbide dinitrate tabs
2
38
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
isosorbide mononitrate
isosorbide mononitrate er
minitran
nitroglycerin
nitroglycerin lingual translingual
soln
nitroglycerin transdermal
NITROSTAT
DRUG NAME
2
2
2
4
2
DRUG REQUIREMENTS/
TIER LIMITS
methylphenidate hcl tabs
STRATTERA
Central Nervous System, Other
HETLIOZ
NUEDEXTA
riluzole
tetrabenazine tabs 12.5mg
tetrabenazine tabs 25mg
XENAZINE TABS 12.5MG
XENAZINE TABS 25MG
Multiple Sclerosis Agents
AMPYRA
AVONEX
AVONEX PEN
COPAXONE INJ 40MG/ML
glatopa
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION
PACK
REBIF TITRATION PACK
TYSABRI
2
3
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents,
Amphetamines
amphetamine/
2
QL(60/30)
dextroamphetamine cp24
amphetamine/
2
QL(90/30)
dextroamphetamine tabs
dextroamphetamine sulfate er
2
QL(90/30)
cp24 10mg, 5mg
dextroamphetamine sulfate er
2
QL(120/30)
cp24 15mg
dextroamphetamine sulfate oral 2
QL(1800/30)
soln
dextroamphetamine sulfate
2
QL(90/30)
tabs 5mg
dextroamphetamine sulfate
2
QL(180/30)
tabs 10mg
procentra
2
QL(1800/30)
Attention Deficit Hyperactivity Disorder Agents,
Non-amphetamines
clonidine hcl er
2
dexmethylphenidate hcl
2
QL(60/30)
metadate er
2
QL(90/30)
methylphenidate hcl er tbcr
2
QL(90/30)
20mg
methylphenidate hcl er tbcr
2
QL(180/30)
10mg
methylphenidate hcl sr
2
QL(90/30)
2
4
QL(90/30)
5
3
4
5
5
5
5
PA QL(30/30)
5
5
5
5
5
5
5
5
PA QL(60/30)
QL(4/28)
QL(4/28)
5
5
QL(4.2/28)
PA
PA QL(90/30)
PA QL(120/30)
PA QL(90/30)
PA QL(120/30)
QL(30/30)
QL(6/28)
QL(6/28)
QL(4.2/28)
Dental and Oral Agents
Dental and Oral Agents
chlorhexidine gluconate oral
rinse
oralone
paroex
periogard
pilocarpine hcl tabs
pilocarpine hydrochloride
triamcinolone acetonide pste
triamcinolone in orabase
1
2
1
1
2
2
2
2
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
39
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
VECTICAL
VOLTAREN GEL
zenatane
ZONALON
ZYCLARA
ZYCLARA PUMP CREA 2.5%
Dermatological Agents
Dermatological Agents
acitretin
ammonium lactate
calcipotriene crea
calcipotriene external soln
calcipotriene oint
calcitrene
calcitriol oint
CARAC
claravis
curity gauze pads 2”x2”
diclofenac sodium gel 1%
diclofenac sodium transdermal
soln
doxepin hydrochloride
ELIDEL
erythromycin/benzoyl peroxide
fluorouracil crea 5%
fluorouracil crea 0.5%
fluorouracil external soln
imiquimod
methoxsalen
myorisan
PICATO
podofilox
PROTOPIC
PRUDOXIN
REGRANEX
SANTYL
selenium sulfide lotn
tacrolimus oint
TAZORAC CREA
TAZORAC GEL
tretinoin crea
tretinoin gel 0.01%, 0.025%
tretinoin microsphere
tretinoin microsphere pump
UVADEX
5
2
2
2
2
2
3
3
2
2
4
2
2
3
2
2
3
2
2
5
2
4
2
3
3
5
3
1
2
3
3
2
2
2
2
4
DRUG REQUIREMENTS/
TIER LIMITS
PA
3
3
2
3
5
5
QL(1000/30) ST
Enzyme Replacement/Modifiers
QL(120/30)
QL(120/30)
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
BUPHENYL TABS
CEREZYME
CREON
CYSTADANE
CYSTAGON
ELAPRASE
FABRAZYME
KUVAN
LUMIZYME
NAGLAZYME
ORFADIN
sodium phenylbutyrate
VPRIV
ZAVESCA
ZENPEP
PA QL(1000/30)
ST
5
5
5
5
3
5
3
5
5
5
5
5
5
5
5
5
3
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
anaspaz
2
atropine sulfate inj 0.05mg/ml,
4
0.1mg/ml, 0.4mg/ml, 1mg/ml
dicyclomine hcl caps
1
dicyclomine hcl oral soln
2
dicyclomine hcl tabs
1
ed-spaz
2
glycopyrrolate inj 0.2mg/ml,
4
0.4mg/2ml, 1mg/5ml, 4mg/20ml
glycopyrrolate tabs
2
hyoscyamine sulfate elix
2
PA
QL(120/30)
QL(100/30)
PA QL(45/30)
PA QL(45/30)
PA
PA
B/D PA
40
PA
PA
B/D PA
PA
B/D PA
PA
PA
PA
PA
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
hyoscyamine sulfate odt
2
hyoscyamine sulfate subl
2
hyoscyamine sulfate tabs
2
hyoscyamine sulfate tbdp
2
hyosyne elix
2
methscopolamine bromide
2
nulev
2
oscimin
2
propantheline bromide
2
symax-sl
2
Gastrointestinal Agents, Other
cromolyn sodium conc
2
diphenoxylate/atropine
2
GATTEX
5
PA
loperamide hcl caps
2
metoclopramide hcl inj
4
metoclopramide hcl oral soln
1
metoclopramide hcl tabs 10mg
1
metoclopramide hcl tabs 5mg
2
OSMOPREP
4
4
PA QL(12/30)
RELISTOR INJ 8MG/0.4ML
RELISTOR INJ 12MG/0.6ML
4
PA QL(18/28)
ursodiol
2
Histamine2 (H2) Receptor Antagonists
cimetidine
2
cimetidine hcl
2
famotidine inj
4
famotidine premixed
4
famotidine tabs 20mg
1
famotidine tabs 40mg
2
nizatidine caps
2
ranitidine hcl caps
2
ranitidine hcl inj
4
DRUG REQUIREMENTS/
TIER LIMITS
ranitidine hcl syrp
2
ranitidine hcl tabs
1
Irritable Bowel Syndrome Agents
alosetron hydrochloride
5
AMITIZA
3
LINZESS
4
Laxatives
constulose
1
enulose
1
gavilyte-c
2
gavilyte-g
2
gavilyte-n/flavor pack
2
generlac
1
lactulose
1
MOVIPREP
4
peg 3350/electrolytes
2
peg-3350/electrolytes
2
peg-3350/nacl/na bicarbonate/
2
kcl
polyethylene glycol 3350 powd
2
SUPREP BOWEL PREP
4
trilyte
2
Protectants
CARAFATE SUSP
3
misoprostol
2
sucralfate
2
Proton Pump Inhibitors
DEXILANT
4
esomeprazole magnesium
2
esomeprazole sodium
4
lansoprazole
2
omeprazole cpdr
2
pantoprazole sodium tbec
2
PA QL(60/30)
QL(60/30)
QL(30/30)
QL(60/30) ST
QL(60/30)
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
41
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
Genitourinary Agents
DRUG REQUIREMENTS/
TIER LIMITS
Hormonal Agents, Stimulant/Replacement/Modifying
(Adrenal)
Antispasmodics, Urinary
flavoxate hcl
2
oxybutynin chloride
1
oxybutynin chloride er tb24
2
QL(30/30)
5mg
oxybutynin chloride er tb24
2
QL(60/30)
10mg, 15mg
tolterodine tartrate
1
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er
2
QL(30/30)
AVODART
3
doxazosin
1
QL(30/30)
doxazosin mesylate tabs 1mg,
1
QL(30/30)
2mg
doxazosin mesylate tabs 8mg
1
QL(60/30)
dutasteride
2
dutasteride/tamsulosin
2
hydrochloride
finasteride tabs 5mg
2
QL(30/30)
JALYN
3
tamsulosin hcl
2
terazosin hcl caps 1mg, 5mg
1
QL(30/30)
terazosin hcl caps 10mg, 2mg
1
QL(60/30)
Genitourinary Agents, Other
bethanechol chloride
2
ELMIRON
3
phenazopyridine hcl
2
Phosphate Binders
AURYXIA
4
calcium acetate caps
2
calcium acetate tabs 667mg
2
FOSRENOL
5
ST
PHOSLYRA
4
RENVELA PACK
3
QL(180/30)
RENVELA TABS
3
QL(540/30)
VELPHORO
4
Hormonal Agents, Stimulant/Replacement/Modifying
(Adrenal)
a-hydrocort
4
ala cort
1
ALA SCALP
3
alclometasone dipropionate
2
amcinonide
2
augmented betamethasone
2
dipropionate
betamethasone dipropionate
2
betamethasone valerate
2
clobetasol propionate crea
2
clobetasol propionate e
2
clobetasol propionate emollient
2
clobetasol propionate external
2
soln
clobetasol propionate foam
2
clobetasol propionate gel
2
clobetasol propionate oint
2
clobetasol propionate sham
2
clodan
2
cormax scalp application
2
cortisone acetate
2
DEPO-MEDROL INJ 20MG/ML
4
desonide lotn
2
desonide oint
2
desoximetasone crea
2
desoximetasone gel
2
desoximetasone oint 0.25%
2
dexamethasone elix
2
dexamethasone intensol
2
dexamethasone oral soln
2
4
dexamethasone sodium
phosphate inj 10mg/ml,
120mg/30ml, 20mg/5ml, 4mg/
ml
dexamethasone tabs 1.5mg,
2
1mg, 2mg, 6mg
42
Covered Drugs By Category
DRUG NAME
dexamethasone tabs 0.5mg,
0.75mg, 4mg
diflorasone diacetate
fludrocortisone acetate
fluocinolone acetonide body
fluocinolone acetonide crea
fluocinolone acetonide ear
drops
fluocinolone acetonide external
soln
fluocinolone acetonide oint
fluocinolone acetonide scalp
fluocinonide
fluocinonide-e
fluticasone propionate crea
fluticasone propionate oint
halobetasol propionate
hydrocortisone butyrate
hydrocortisone butyrate
(lipophilic)
hydrocortisone crea 1%, 2.5%
hydrocortisone in absorbase
hydrocortisone lotn 2.5%
hydrocortisone oint 1%, 2.5%
hydrocortisone tabs
hydrocortisone valerate
MEDROL TABS 2MG
methylprednisolone
methylprednisolone acetate
methylprednisolone dose pack
methylprednisolone
sodiumsuccinate inj 125mg,
40mg
mometasone furoate crea
mometasone furoate external
soln
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
1
mometasone furoate oint
prednicarbate oint
prednisolone oral soln
prednisolone sodium
phosphate oral soln
prednisone intensol
prednisone oral soln
prednisone tabs 50mg
prednisone tabs 10mg, 1mg,
2.5mg, 20mg, 5mg
prednisone tbpk
procto-med hc
procto-pak
proctosol hc
proctozone-hc
SOLU-CORTEF
TEXACORT
triamcinolone acetonide crea
0.025%, 0.5%
triamcinolone acetonide crea
0.1%
triamcinolone acetonide lotn
triamcinolone acetonide oint
trianex
triderm
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
3
2
4
2
4
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
2
2
2
2
1
1
2
2
2
2
4
3
2
1
2
2
2
1
Hormonal Agents, Stimulant/Replacement/Modifying
(Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying
(Pituitary)
chorionic gonadotropin
4
PA
desmopressin acetate inj
4
desmopressin acetate nasal
2
soln
desmopressin acetate tabs
2
INCRELEX
4
PA
2
2
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
43
Covered Drugs By Category
DRUG NAME
NOVAREL
PREGNYL W/DILUENT
BENZYL ALCOHOL/NACL
SAIZEN
SAIZEN CLICK.EASY
STIMATE
DRUG REQUIREMENTS/
TIER LIMITS
4
4
PA
PA
5
5
3
PA
PA
DRUG NAME
caziant
chateal
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
cyred
dasetta 1/35
dasetta 7/7/7
DELESTROGEN
delyla
DEPO-ESTRADIOL
desogestrel/ethinyl estradiol
elinest
emoquette
enpresse-28
enskyce
estarylla
estradiol pttw
estradiol ptwk
estradiol tabs
estradiol valerate
estradiol/norethindrone acetate
ESTRING
falmina
FEMRING
gildagia
gildess 1.5/30
gildess 1/20
gildess fe 1.5/30
gildess fe 1/20
introvale
juleber
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
kariva
kelnor 1/35
kimidess
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
KORLYM
5
PA QL(120/30)
Hormonal Agents, Stimulant/Replacement/Modifying
(Sex Hormones/Modifiers)
Anabolic Steroids
ANADROL-50
oxandrolone tabs 10mg
oxandrolone tabs 2.5mg
Androgens
ANDROXY
danazol
TESTIM
testosterone cypionate
testosterone enanthate
Estrogens
ALORA
altavera
alyacen 1/35
alyacen 7/7/7
amethia lo
apri
aranelle
aubra
aviane
azurette
balziva
bekyree
blisovi fe 1.5/30
blisovi fe 1/20
briellyn
5
2
2
PA
PA QL(60/30)
PA QL(120/30)
3
2
3
4
4
PA
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
PA QL(8/28)
PA
PA
PA
44
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
2
2
2
2
2
4
2
4
2
2
2
2
2
2
2
2
2
4
2
3
2
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
PA QL(8/28)
PA QL(4/28)
PA
PA
QL(1/90)
Covered Drugs By Category
DRUG NAME
kurvelo
larin 1.5/30
larin 1/20
larin fe 1.5/30
larin fe 1/20
lessina
levonest
levonorgestrel and ethinyl
estradiol tabs 0; 0
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
lopreeza
low-ogestrel
lutera
marlissa
MENEST
MENOSTAR
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
mimvey
mimvey lo
MINIVELLE
mono-linyah
myzilra
necon 0.5/35-28
necon 1/35
necon 1/50-28
necon 10/11-28
necon 7/7/7
norethindrone acetate/ethinyl
estradiol tabs 20mcg; 1mg
norethindrone acetate/ethinyl
estradiol/ferrous fumarate
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
2
2
2
2
2
2
3
2
2
2
2
2
2
2
2
norgestimate/ethinyl estradiol
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
ogestrel
orsythia
philith
pimtrea
pirmella 1/35
pirmella 7/7/7
portia-28
PREMARIN CREA
PREMARIN INJ
PREMARIN TABS
previfem
quasense
reclipsen
setlakin
sprintec 28
sronyx
tarina fe 1/20
tri-estarylla
tri-legest fe
tri-linyah
tri-previfem
tri-sprintec
trivora-28
VAGIFEM
velivet
vienva
viorele
VIVELLE-DOT
vyfemla
wera
PA
PA
PA QL(4/28)
PA
PA
PA QL(8/28)
2
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
2
2
2
2
2
2
2
2
3
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
3
2
2
2
3
2
2
PA QL(30/30)
PA QL(8/28)
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
45
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
zenchent
2
zovia 1/35e
2
zovia 1/50e
2
Progesterone Agonists/Antagonists
ELLA
3
Progestins
camila
2
deblitane
2
DEPO-PROVERA
4
errin
2
heather
2
hydroxyprogesterone caproate
5
jencycla
2
lyza
2
MAKENA
5
medroxyprogesterone acetate
4
QL(1/90)
inj
medroxyprogesterone acetate
1
tabs
megestrol acetate susp 40mg/
2
PA
ml
megestrol acetate tabs
2
PA
norethindrone
2
norethindrone acetate
2
norlyroc
2
progesterone caps
2
sharobel
2
Selective Estrogen Receptor Modifying Agents
raloxifene hydrochloride
2
QL(30/30)
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
UNITHROID
DRUG REQUIREMENTS/
TIER LIMITS
3
3
3
4
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
3
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABS 30MG
3
QL(60/30)
SENSIPAR TABS 60MG
5
QL(60/30)
SENSIPAR TABS 90MG
5
QL(120/30)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline
2
ELIGARD INJ 30MG
4
PA QL(1/120)
ELIGARD INJ 45MG
4
PA QL(1/180)
ELIGARD INJ 7.5MG
4
PA QL(1/30)
ELIGARD INJ 22.5MG
4
PA QL(1/90)
FIRMAGON INJ 80MG
4
B/D PA QL(4/28)
FIRMAGON INJ 120MG
5
B/D PA QL(6/365)
leuprolide acetate
4
PA QL(5.6/28)
LUPRON DEPOT INJ 30MG
5
PA QL(1/112)
LUPRON DEPOT INJ 45MG
5
PA QL(1/168)
LUPRON DEPOT INJ 3.75MG,
5
PA QL(1/30)
7.5MG
LUPRON DEPOT INJ 22.5MG
5
PA QL(1/84)
LUPRON DEPOT INJ 11.25MG
5
PA QL(1/90)
LUPRON DEPOT-PED
5
PA QL(1/30)
octreotide acetate inj 1000mcg/
5
PA
ml, 500mcg/ml
octreotide acetate inj 100mcg/
4
PA
ml, 200mcg/ml, 50mcg/ml
SANDOSTATIN LAR DEPOT
5
PA
SIGNIFOR
5
PA
SOMATULINE DEPOT
5
PA
SOMAVERT INJ 25MG, 30MG
5
PA QL(30/30)
SOMAVERT INJ 15MG, 20MG
5
PA QL(60/30)
Hormonal Agents, Stimulant/Replacement/Modifying
(Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying
(Thyroid)
levothyroxine sodium tabs
1
LEVOXYL
4
liothyronine sodium inj
4
liothyronine sodium tabs
2
SYNTHROID
4
THYROLAR-1
3
THYROLAR-1/2
3
46
Covered Drugs By Category
DRUG NAME
SOMAVERT INJ 10MG
SYNAREL
TRELSTAR INJ 3.75MG
TRELSTAR INJ 11.25MG
TRELSTAR MIXJECT INJ
22.5MG
TRELSTAR MIXJECT INJ
3.75MG
TRELSTAR MIXJECT INJ
11.25MG
DRUG REQUIREMENTS/
TIER LIMITS
5
5
5
5
5
PA QL(90/30)
PA
PA QL(2/28)
PA QL(2/84)
PA QL(2/168)
5
PA QL(2/28)
5
PA QL(2/84)
DRUG NAME
HUMIRA INJ 10MG/0.2ML,
20MG/0.4ML
HUMIRA INJ 40MG/0.8ML
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK
HUMIRA PEN
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMIRA PEN-PSORIASIS
STARTER
KINERET
methotrexate
methotrexate sodium inj 1gm,
1gm/40ml, 250mg/10ml,
50mg/2ml
mycophenolate mofetil
mycophenolic acid dr
NULOJIX
PROGRAF INJ
RAPAMUNE ORAL SOLN
RAPAMUNE TABS 1MG, 2MG
REMICADE
SANDIMMUNE ORAL SOLN
sirolimus
tacrolimus caps
TORISEL
ZORTRESS TABS 0.5MG,
0.75MG
ZORTRESS TABS 0.25MG
Immunizing Agents, Passive
ATGAM
BIVIGAM INJ 10GM/100ML
BIVIGAM INJ 5GM/50ML
FLEBOGAMMA DIF
GAMASTAN S/D
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole
propylthiouracil
2
2
Immunological Agents
Angioedema (HAE) Agents
CINRYZE
FIRAZYR
Immune Suppressants
ASTAGRAF XL
AZASAN
azathioprine inj
azathioprine tabs
BENLYSTA
CELLCEPT INTRAVENOUS
CELLCEPT SUSR
cyclosporine caps
cyclosporine inj
cyclosporine modified
ENBREL
ENBREL SURECLICK
ENVARSUS XR
gengraf
5
5
PA
PA
4
3
4
2
5
4
3
2
4
2
5
5
4
2
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA QL(8/28)
PA QL(8/28)
PA
PA
DRUG REQUIREMENTS/
TIER LIMITS
5
PA QL(2/28)
5
5
PA QL(6/28)
PA QL(6/28)
5
5
PA QL(6/28)
PA QL(6/28)
5
PA QL(6/28)
5
2
4
PA QL(20.1/30)
2
2
5
4
3
3
5
4
2
2
3
5
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
B/D PA
PA
4
PA
4
4
5
5
4
PA
B/D PA
B/D PA
B/D PA
B/D PA
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
47
Covered Drugs By Category
DRUG NAME
GAMMAGARD LIQUID INJ
2.5GM/25ML
GAMMAGARD LIQUID INJ
30GM/300ML
GAMMAKED
GAMMAPLEX INJ 5GM/100ML
GAMMAPLEX INJ
10GM/200ML
GAMUNEX-C INJ 1GM/10ML
GAMUNEX-C INJ
10GM/100ML, 2.5GM/25ML,
20GM/200ML, 40GM/400ML,
5GM/50ML
OCTAGAM INJ 10GM/100ML,
1GM/20ML, 20GM/200ML,
2GM/20ML, 5GM/50ML
PRIVIGEN INJ 10GM/100ML,
5GM/50ML
PRIVIGEN INJ 20GM/200ML
THYMOGLOBULIN
Immunomodulators
ACTIMMUNE
ARCALYST
ILARIS
leflunomide
RIDAURA
SIMULECT
SYNAGIS INJ 50MG/0.5ML
Vaccines
ACTHIB
ADACEL
BEXSERO
BOOSTRIX
CERVARIX
DAPTACEL
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC
ENGERIX-B
GARDASIL
GARDASIL 9
DRUG REQUIREMENTS/
TIER LIMITS
4
B/D PA
5
B/D PA
5
5
4
B/D PA
B/D PA
B/D PA
4
5
B/D PA
B/D PA
5
B/D PA
5
B/D PA
4
3
B/D PA
B/D PA
5
5
5
2
5
5
5
PA
PA
PA
QL(30/30)
DRUG NAME
HAVRIX
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
M-M-R II
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
PEDVAX HIB
PROQUAD
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TENIVAC
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
TRUMENBA
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
VARIZIG INJ 125UNIT/1.2ML
YF-VAX
ZOSTAVAX
B/D PA
PA
4
4
4
4
4
4
4
4
4
4
DRUG REQUIREMENTS/
TIER LIMITS
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
3
4
4
4
4
4
4
4
4
4
4
Inflammatory Bowel Disease Agents
Aminosalicylates
APRISO
balsalazide disodium
DELZICOL
mesalamine
Glucocorticoids
budesonide cpep
colocort
B/D PA
48
3
2
3
2
2
2
B/D PA
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
hydrocortisone enem
Sulfonamides
sulfasalazine
DRUG NAME
LACTATED RINGERS
IRRIGATION
levocarnitine inj
levocarnitine oral soln
levocarnitine tabs
NATPARA
novofine 30gx8mm
novofine 31
novofine 32gx6mm
novofine autocover 30gx8mm
novotwist 30gx8mm
novotwist 32gx5mm
PHYSIOLYTE
PHYSIOSOL IRRIGATION
RINGERS IRRIGATION
sodium chloride 0.9%
sterile water irrigation
2
2
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate sodium tabs 35mg,
70mg
alendronate sodium tabs 10mg,
40mg, 5mg
calcitonin-salmon
calcitriol caps
calcitriol inj
calcitriol oral soln
doxercalciferol caps
doxercalciferol inj
etidronate disodium
FORTEO
ibandronate sodium tabs
MIACALCIN INJ
pamidronate disodium
paricalcitol caps
PROLIA
risedronate sodium tabs 150mg
risedronate sodium tabs 35mg
risedronate sodium tabs 30mg,
5mg
XGEVA
zoledronic acid
ZOMETA INJ 4MG/100ML
1
QL(4/28)
2
QL(30/30)
2
2
4
2
2
4
2
5
2
4
4
2
4
2
2
2
QL(3.7/30)
5
4
5
PA
B/D PA
B/D PA
PA QL(2.4/28)
QL(1/28)
4
4
2
2
5
2
2
2
2
2
2
4
4
4
4
4
PA
QL(200/30)
QL(200/30)
QL(200/30)
QL(200/30)
QL(200/30)
QL(200/30)
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
bimatoprost
2
QL(5/30)
COMBIGAN
3
latanoprost
2
QL(5/30)
LUMIGAN
4
QL(5/30)
TRAVATAN Z
3
QL(5/30)
ZIOPTAN
4
QL(30/30)
Ophthalmic Agents, Other
atropine sulfate ophthalmic soln 2
LACRISERT
3
naphazoline hcl
2
proparacaine hcl
2
RESTASIS
3
QL(64/30)
tropicamide
2
Ophthalmic Anti-allergy Agents
ALOCRIL
3
B/D PA
QL(1/180) ST
QL(1/28)
QL(4/28)
QL(30/30)
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
bd safetyglide 27g x 5/8”
2
FERRIPROX
5
fomepizole
5
DRUG REQUIREMENTS/
TIER LIMITS
QL(200/30)
PA
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
49
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
azelastine hcl ophthalmic soln
2
cromolyn sodium ophthalmic
2
soln
epinastine hcl
2
olopatadine hcl ophthalmic soln
2
PATADAY
3
PAZEO
3
Ophthalmic Anti-inflammatories
bromfenac
2
dexamethasone sodium
2
phosphate ophthalmic soln
diclofenac sodium ophthalmic
2
soln
DUREZOL
3
fluorometholone
3
flurbiprofen sodium
2
ILEVRO
3
ketorolac tromethamine
2
ophthalmic soln
LOTEMAX
4
neomycin/polymyxin/
2
dexamethasone
PRED MILD
3
PRED-G
3
PRED-G S.O.P.
3
prednisolone acetate
3
prednisolone sodium
1
phosphate ophthalmic soln
TOBRADEX OINT
3
tobramycin/dexamethasone
2
Ophthalmic Antiglaucoma Agents
acetazolamide er
2
apraclonidine
2
AZOPT
3
betaxolol hcl
2
brimonidine tartrate ophthalmic
2
soln 0.2%
brimonidine tartrate ophthalmic
3
soln 0.15%
carteolol hcl
2
dorzolamide hcl
2
dorzolamide hcl/timolol maleate
levobunolol hcl
methazolamide
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic soln
SIMBRINZA
timolol maleate ophthalmic soln
DRUG REQUIREMENTS/
TIER LIMITS
2
1
2
2
4
3
4
1
Otic Agents
Otic Agents
acetasol hc
acetic acid
acetic acid/aluminum acetate
COLY-MYCIN S
fluocinolone acetonide oil
hydrocortisone/acetic acid
neomycin/polymyxin/hc
neomycin/polymyxin/
hydrocortisone
2
2
2
3
2
2
2
2
Respiratory Tract/Pulmonary Agents
Anti-inflammatories, Inhaled Corticosteroids
budesonide susp 32mcg/act
2
QL(17.2/30)
budesonide susp 0.25mg/2ml,
2
B/D PA QL(120/30)
0.5mg/2ml, 1mg/2ml
DULERA
3
QL(18/30)
FLOVENT DISKUS AEPB
3
QL(120/30)
250MCG/BLIST, 50MCG/BLIST
FLOVENT DISKUS AEPB
3
QL(180/30)
100MCG/BLIST
FLOVENT HFA AERO 44MCG/
3
QL(22/30)
ACT
FLOVENT HFA AERO
3
QL(24/30)
110MCG/ACT, 220MCG/ACT
flunisolide
1
fluticasone propionate susp
2
QL(16/30)
QVAR
3
QL(18/30)
SYMBICORT AERO 160MCG/
3
QL(12/30)
ACT; 4.5MCG/ACT
SYMBICORT AERO 80MCG/
3
QL(14/30)
ACT; 4.5MCG/ACT
50
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
Antihistamines
azelastine hcl nasal soln
2
desloratadine
2
desloratadine odt
2
diphenhydramine hcl inj
4
levocetirizine dihydrochloride
2
oral soln
levocetirizine dihydrochloride
2
tabs
Antileukotrienes
montelukast sodium
2
zafirlukast
2
Bronchodilators, Anticholinergic
COMBIVENT RESPIMAT
3
ipratropium bromide inhalation
2
soln
ipratropium bromide nasal soln
2
0.06%
ipratropium bromide nasal soln
2
0.03%
ipratropium bromide/albuterol
2
sulfate
SPIRIVA HANDIHALER
3
SPIRIVA RESPIMAT
3
Bronchodilators, Sympathomimetic
albuterol
1
albuterol sulfate er
2
albuterol sulfate nebu 0.5%
1
albuterol sulfate nebu 0.083%
1
albuterol sulfate nebu
2
0.63mg/3ml, 1.25mg/3ml
albuterol sulfate syrp
1
albuterol sulfate tabs
1
epinephrine hcl
4
EPIPEN 2-PAK
3
EPIPEN-JR 2-PAK
3
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
FORADIL AEROLIZER
3
QL(60/30)
metaproterenol sulfate
2
PERFOROMIST
3
B/D PA QL(120/30)
PROAIR HFA
3
QL(17/30)
PROAIR RESPICLICK
3
QL(1.3/30)
SEREVENT DISKUS
3
QL(60/30)
STRIVERDI RESPIMAT
3
QL(4/30)
terbutaline sulfate inj
4
terbutaline sulfate tabs
2
Cystic Fibrosis Agents
CAYSTON
5
PA
KALYDECO
5
PA QL(60/30)
PULMOZYME
5
B/D PA
TOBI PODHALER
5
QL(1568/365)
tobramycin
4
B/D PA
Mast Cell Stabilizers
cromolyn sodium nebu
2
B/D PA
Phosphodiesterase Inhibitors, Airways Disease
aminophylline
4
DALIRESP
3
PA QL(30/30)
THEO-24
4
theochron
2
theophylline cr
2
theophylline er
2
Pulmonary Antihypertensives
ADEMPAS
5
PA QL(90/30)
LETAIRIS
5
PA QL(30/30)
OPSUMIT
5
PA QL(30/30)
REMODULIN
5
B/D PA
sildenafil tabs
2
PA QL(90/30)
Respiratory Tract Agents, Other
acetylcysteine inhalation soln
2
B/D PA
ARALAST NP INJ 500MG
5
B/D PA
ESBRIET
5
PA
QL(60/30)
QL(30/30)
QL(30/30)
QL(300/30)
QL(30/30)
QL(30/30)
QL(8/30)
B/D PA QL(300/30)
QL(30/30)
QL(60/30)
B/D PA QL(540/30)
QL(30/30)
QL(4/30)
B/D PA QL(360/30)
B/D PA QL(375/30)
B/D PA QL(375/30)
QL(2/30)
QL(2/30)
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
51
Covered Drugs By Category
DRUG NAME
PROLASTIN-C
STIOLTO RESPIMAT
TYZINE PEDIATRIC NASAL
DROPS
VIRAZOLE
XOLAIR
ZEMAIRA
DRUG REQUIREMENTS/
TIER LIMITS
5
3
3
B/D PA
5
5
5
B/D PA
PA
B/D PA
DRUG NAME
SODIUM LACTATE INJ 5MEQ/
4
ML
sodium polystyrene sulfonate
2
powd
sodium polystyrene sulfonate
2
susp 15gm/60ml, 30gm/120ml
sps
2
SYPRINE
5
Electrolyte/Mineral Replacement
AMINOSYN 7%/
4
ELECTROLYTES
AMINOSYN 8.5%/
4
ELECTROLYTES
AMINOSYN II
4
AMINOSYN II 8.5%/
4
ELECTROLYTES
4
AMINOSYN INJ 90MEQ/L;
1100MG/100ML;
850MG/100ML; 35MEQ/L;
1100MG/100ML;
260MG/100ML; 620MG/100ML;
810MG/100ML; 624MG/100ML;
340MG/100ML; 380MG/100ML;
5.4MEQ/L; 750MG/100ML;
370MG/100ML; 460MG/100ML;
150MG/100ML; 44MG/100ML;
680MG/100ML
AMINOSYN M
4
AMINOSYN-HBC
4
AMINOSYN-PF
4
AMINOSYN-PF 7%
4
AMINOSYN-RF
4
CARBAGLU
5
CLINIMIX 2.75%/DEXTROSE
4
5%
CLINIMIX 4.25%/DEXTROSE
4
10%
CLINIMIX 4.25%/DEXTROSE
4
20%
CLINIMIX 4.25%/DEXTROSE
4
25%
CLINIMIX 4.25%/DEXTROSE
4
5%
CLINIMIX 5%/DEXTROSE 15% 4
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
chlorzoxazone
cyclobenzaprine hcl tabs 10mg,
5mg
orphenadrine citrate er
2
2
PA
PA
2
PA
Sleep Disorder Agents
GABA Receptor Modulators
temazepam
zaleplon
zolpidem tartrate tabs
Sleep Disorders, Other
armodafinil
modafinil tabs 100mg
modafinil tabs 200mg
NUVIGIL
ROZEREM
SILENOR
XYREM
2
2
2
QL(90/365)
QL(90/365)
4
4
4
4
3
3
5
PA QL(30/30)
PA QL(30/30)
PA QL(60/30)
PA QL(30/30)
QL(30/30)
QL(30/30)
PA QL(540/30)
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
CHEMET
CUPRIMINE
DEPEN TITRATABS
EXJADE
JADENU
kionex
SAMSCA TABS 30MG
SAMSCA TABS 15MG
sodium bicarbonate inj
sodium bicarbonate partial fill
3
5
3
5
5
2
5
5
4
4
DRUG REQUIREMENTS/
TIER LIMITS
PA QL(60/30)
PA QL(90/30)
52
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
Covered Drugs By Category
DRUG NAME
CLINIMIX 5%/DEXTROSE 20%
CLINIMIX 5%/DEXTROSE 25%
CLINIMIX E 2.75%/
DEXTROSE 10%
CLINIMIX E 4.25%/
DEXTROSE 10%
CLINIMIX E 4.25%/
DEXTROSE 25%
CLINIMIX E 5%/DEXTROSE
25%
CLINISOL SF 15%
dextrose 10%/nacl 0.45%
dextrose 5% /electrolyte #48
viaflex
DEXTROSE 10% FLEX
CONTAINER
dextrose 10%/nacl 0.2%
dextrose 2.5%/nacl 0.45%
dextrose 2.5%/sodium chloride
0.45%
DEXTROSE 20%
DEXTROSE 25%
DEXTROSE 30%
DEXTROSE 40%
DEXTROSE 5%
DEXTROSE 5%/LACTATED
RINGERS
dextrose 5%/nacl 0.2%
dextrose 5%/nacl 0.225%
DEXTROSE 5%/NACL 0.3%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
dextrose 5%/potassium
chloride 0.15%
dextrose 5%/sodium chloride
0.2%
DRUG REQUIREMENTS/
TIER LIMITS
4
4
4
B/D PA
B/D PA
B/D PA
3
B/D PA
3
B/D PA
3
B/D PA
4
4
4
B/D PA
B/D PA
B/D PA
4
B/D PA
4
4
4
B/D PA
B/D PA
B/D PA
4
4
4
4
4
4
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
4
4
4
4
4
4
4
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
4
B/D PA
DRUG NAME
dextrose 5%/sodium chloride
0.45%
DEXTROSE 50%
DEXTROSE 70%
fluoride chew 0.25mg, 1.1mg,
2.2mg
fluoritab chew 0.5mg, 1mg
FREAMINE HBC 6.9%
FREAMINE III INJ
89MEQ/L; 710MG/100ML;
950MG/100ML; 3MEQ/L;
24MG/100ML; 1400MG/100ML;
280MG/100ML; 690MG/100ML;
910MG/100ML; 730MG/100ML;
530MG/100ML; 560MG/100ML;
10MMOLE/L; 120MG/100ML;
1120MG/100ML;
590MG/100ML; 10MEQ/L;
400MG/100ML; 150MG/100ML;
660MG/100ML
HEPATAMINE
k-sol
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/ nacl 0.3%
kcl 0.15%/d5w/lr
kcl 0.15%/d5w/nacl 0.2%
kcl 0.15%/d5w/nacl 0.225%
kcl 0.15%/d5w/nacl 0.45%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/lr iv lac ring
kcl 0.3%/d5w/nacl 0.45%
kcl 0.3%/d5w/nacl 0.9%
klor-con
klor-con 10
klor-con 8
klor-con m10
klor-con m20
DRUG REQUIREMENTS/
TIER LIMITS
4
B/D PA
4
4
1
B/D PA
B/D PA
1
4
4
4
2
4
4
4
4
4
4
4
4
4
4
2
1
1
1
1
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
53
Covered Drugs By Category
DRUG NAME
klor-con sprinkle
LACTATED RINGERS
DEXTROSE 5% VIAFLEX
LACTATED RINGERS INJ
3MEQ/L; 109MEQ/L; 28MEQ/L;
4MEQ/L; 130MEQ/L
LACTATED RINGERS
VIAFLEX
ludent
magnesium sulfate in d5w inj
5%; 10mg/ml
MAGNESIUM SULFATE INJ
20GM/500ML, 2GM/50ML,
40GM/1000ML
magnesium sulfate inj
20gm/500ml, 2gm/50ml,
40gm/1000ml, 4gm/100ml,
4gm/50ml, 50%
MOZOBIL
NEPHRAMINE
NORMOSOL -R
NORMOSOL-M IN D5W
NORMOSOL-R
NORMOSOL-R IN D5W
NUTRILYTE INJ 2.03MEQ/
ML; 0.25MEQ/ML; 1.68MEQ/
ML; 0.25MEQ/ML; 0.4MEQ/ML;
2.03MEQ/ML; 1.25MEQ
PERIKABIVEN
phospha 250 neutral
PLENAMINE
potassium chloride 0.15% /nacl
0.45% viaflex
potassium chloride 0.15% d5w/
nacl 0.33%
potassium chloride 0.15% d5w/
nacl 0.45%
potassium chloride 0.15% d5w/
nacl 0.45% viaflex
POTASSIUM CHLORIDE
0.15% W/NACL 0.9% VIAFLEX
potassium chloride 0.15%/d5w
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
2
4
potassium chloride 0.15%/nacl
0.9%
potassium chloride 0.22% d5w/
nacl 0.45%
potassium chloride 0.224%/
d5w/nacl 0.45%
potassium chloride 0.3%/ nacl
0.9%
potassium chloride 0.3%/d5w
potassium chloride 0.3%/nacl
0.9%/viaflex
potassium chloride cr
potassium chloride er cpcr
potassium chloride er tbcr
potassium chloride inj
10meq/100ml, 20meq/100ml,
2meq/ml, 40meq/100ml
potassium chloride oral soln
potassium chloride pack
potassium chloride sr
potassium citrate er
PREMASOL INJ 52MEQ/L;
1760MG/100ML;
880MG/100ML; 34MEQ/L;
1760MG/100ML;
372MG/100ML; 406MG/100ML;
526MG/100ML; 492MG/100ML;
492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML;
390MG/100ML; 34MG/100ML;
152MG/100ML
premasol inj 56meq/l;
320mg/100ml; 730mg/100ml;
190mg/100ml; 3meq/l;
20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml;
490mg/100ml; 840mg/100ml;
490mg/100ml; 200mg/100ml;
290mg/100ml; 410mg/100ml;
230mg/100ml; 5meq/l;
15mg/100ml; 250mg/100ml;
120mg/100ml; 140mg/100ml;
470mg/100ml
PROCALAMINE
PROSOL
4
4
1
4
B/D PA
4
B/D PA
4
B/D PA
5
4
4
4
4
4
4
QL(9.6/30)
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
4
2
4
4
B/D PA
4
B/D PA
4
B/D PA
4
B/D PA
4
B/D PA
4
B/D PA
B/D PA
B/D PA
54
DRUG REQUIREMENTS/
TIER LIMITS
4
B/D PA
4
B/D PA
4
B/D PA
4
B/D PA
4
4
B/D PA
B/D PA
1
2
1
4
B/D PA
2
2
1
2
4
B/D PA
4
B/D PA
4
4
B/D PA
B/D PA
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
RINGERS INJECTION
4
sodium chloride 0.45% viaflex
4
sodium chloride inj 0.9%,
4
2.5meq/ml, 3%, 5%
sodium fluoride chew 0.5mg,
1
1mg
sodium fluoride tabs
1
TPN ELECTROLYTES
4
B/D PA
TRAVASOL
4
B/D PA
TROPHAMINE
4
B/D PA
virt-phos 250 neutral
2
Therapeutic Nutrients/Minerals/Electrolytes
INTRALIPID
4
B/D PA
KABIVEN
4
B/D PA
NUTRILIPID
4
B/D PA
Vitamins
VP-PNV-DHA
3
Needles And Syringes
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
bd eclipse syringe/1ml/30gx1/2” 2
bd insulin syringe
2
safetyglide/1ml/29g x 1/2”
bd insulin syringe
2
ultrafine/0.3ml/31g x 5/16”
bd insulin syringe
2
ultrafine/0.5ml/30g x 1/2”
bd insulin syringe
2
ultrafine/1ml/31g x 5/16”
bd pen needle/mini/
2
ultrafine/31g x 3/16”
bd pen needle/nano/ultra
2
fine/32g x 4mm
bd pen needle/ultrafine/29g x
2
12.7mm
QL(200/30)
QL(200/30)
QL(200/30)
QL(200/30)
QL(200/30)
QL(200/30)
QL(200/30)
QL(200/30)
CAPITALIZED = BRAND NAME DRUG
Lower case italic = Generic drug
QL = Quantity Limits listed as (qty/days)
ST = Step Therapy rules apply
PA = Prior Authorization may be required
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
55
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
A
adefovir dipivoxil . . . . . . . . . . . . . . . . . 31
ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . 51
adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
afeditab cr . . . . . . . . . . . . . . . . . . . . . . . 37
AFINITOR DISPERZ TBSO
2MG, 3MG. . . . . . . . . . . . . . . . . . . . . . . . 28
AFINITOR DISPERZ TBSO 5MG. . . 28
AFINITOR TABS
2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 28
AFINITOR TABS 10MG. . . . . . . . . . . . 28
AGGRENOX . . . . . . . . . . . . . . . . . . . . . 35
a-hydrocort . . . . . . . . . . . . . . . . . . . . . . 42
ala cort . . . . . . . . . . . . . . . . . . . . . . . . . . 42
ALA SCALP . . . . . . . . . . . . . . . . . . . . . . 42
ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . 29
albuterol . . . . . . . . . . . . . . . . . . . . . . . . . 51
albuterol sulfate er . . . . . . . . . . . . . . . . 51
albuterol sulfate nebu 0.5% . . . . . . . . 51
albuterol sulfate nebu
0.63mg/3ml, 1.25mg/3ml. . . . . . . . . . . 51
albuterol sulfate nebu 0.083%. . . . . . 51
albuterol sulfate syrp . . . . . . . . . . . . . . 51
albuterol sulfate tabs . . . . . . . . . . . . . . 51
alclometasone dipropionate . . . . . . . 42
alcohol prep pads . . . . . . . . . . . . . . . . 18
ALDURAZYME . . . . . . . . . . . . . . . . . . . 40
ALECENSA . . . . . . . . . . . . . . . . . . . . . . 28
alendronate sodium tabs
10mg, 40mg, 5mg . . . . . . . . . . . . . . . . . 49
alendronate sodium tabs
35mg, 70mg. . . . . . . . . . . . . . . . . . . . . . . 49
alfuzosin hcl er . . . . . . . . . . . . . . . . . . . 42
ALIMTA INJ 500MG . . . . . . . . . . . . . . . 26
ALINIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
allopurinol . . . . . . . . . . . . . . . . . . . . . . . 25
ALOCRIL . . . . . . . . . . . . . . . . . . . . . . . . 49
ALOPRIM . . . . . . . . . . . . . . . . . . . . . . . . 25
ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . 44
alosetron hydrochloride . . . . . . . . . . . 41
alprazolam odt tbdp
0.25mg, 0.5mg . . . . . . . . . . . . . . . . . . . . 33
alprazolam odt tbdp 1mg. . . . . . . . . . . 33
alprazolam odt tbdp 2mg. . . . . . . . . . . 33
alprazolam tabs 0.25mg, 0.5mg . . . . 33
alprazolam tabs 1mg . . . . . . . . . . . . . . 33
alprazolam tabs 2mg . . . . . . . . . . . . . . 33
ALTACE . . . . . . . . . . . . . . . . . . . . . . . . . 36
altavera . . . . . . . . . . . . . . . . . . . . . . . . . . 44
alyacen 1/35 . . . . . . . . . . . . . . . . . . . . . 44
alyacen 7/7/7 . . . . . . . . . . . . . . . . . . . . 44
amantadine hcl . . . . . . . . . . . . . . . . . . . 33
AMBISOME . . . . . . . . . . . . . . . . . . . . . . 25
amcinonide . . . . . . . . . . . . . . . . . . . . . . 42
amethia lo . . . . . . . . . . . . . . . . . . . . . . . 44
amifostine . . . . . . . . . . . . . . . . . . . . . . . 27
amikacin sulfate . . . . . . . . . . . . . . . . . . 18
amiloride hcl . . . . . . . . . . . . . . . . . . . . . 38
amiloride/hydrochlorothiazide . . . . . 38
aminophylline . . . . . . . . . . . . . . . . . . . . 51
AMINOSYN 7%/
ELECTROLYTES . . . . . . . . . . . . . . . . 52
AMINOSYN 8.5%/
ELECTROLYTES . . . . . . . . . . . . . . . . 52
AMINOSYN-HBC . . . . . . . . . . . . . . . . . 52
AMINOSYN II . . . . . . . . . . . . . . . . . . . . 52
AMINOSYN II 8.5%/
ELECTROLYTES . . . . . . . . . . . . . . . . 52
AMINOSYN INJ
90MEQ/L; 1100MG/100ML;
850MG/100ML; 35MEQ/L;
1100MG/100ML; 260MG/100ML;
620MG/100ML; 810MG/100ML;
624MG/100ML; 340MG/100ML;
380MG/100ML; 5.4MEQ/L;
750MG/100ML; 370MG/100ML;
460MG/100ML; 150MG/100ML;
44MG/100ML; 680MG/100ML. . . . . . 52
AMINOSYN M . . . . . . . . . . . . . . . . . . . 52
AMINOSYN-PF . . . . . . . . . . . . . . . . . . 52
AMINOSYN-PF 7% . . . . . . . . . . . . . . . 52
AMINOSYN-RF . . . . . . . . . . . . . . . . . . 52
amiodarone hcl inj . . . . . . . . . . . . . . . . 36
amiodarone hcl tabs . . . . . . . . . . . . . . 36
abacavir . . . . . . . . . . . . . . . . . . . . . . . . . 32
abacavir sulfate/
lamivudine/zidovudine . . . . . . . . . . . . 32
ABELCET . . . . . . . . . . . . . . . . . . . . . . . . 25
ABILIFY MAINTENA INJ 300MG . . . 30
ABILIFY MAINTENA INJ 400MG . . . 30
ABRAXANE . . . . . . . . . . . . . . . . . . . . . . 27
acamprosate calcium dr . . . . . . . . . . 18
acarbose . . . . . . . . . . . . . . . . . . . . . . . . 33
ACCUPRIL . . . . . . . . . . . . . . . . . . . . . . 36
ACCURETIC . . . . . . . . . . . . . . . . . . . . . 36
acebutolol hcl . . . . . . . . . . . . . . . . . . . . 36
ACEON . . . . . . . . . . . . . . . . . . . . . . . . . . 36
acetaminophen/caffeine/
dihydrocodeine . . . . . . . . . . . . . . . . . . . 16
acetaminophen/codeine #2 . . . . . . . 16
acetaminophen/codeine #3 . . . . . . . 16
acetaminophen/codeine #4 . . . . . . . 16
acetaminophen/codeine oral soln . . 16
acetaminophen/codeine
phosphate tabs 300mg; 60mg. . . . . . 16
acetaminophen/codeine tabs
300mg; 15mg . . . . . . . . . . . . . . . . . . . . . 16
acetaminophen/codeine tabs
300mg; 60mg . . . . . . . . . . . . . . . . . . . . . 16
acetasol hc . . . . . . . . . . . . . . . . . . . . . . 50
acetazolamide . . . . . . . . . . . . . . . . . . . 37
acetazolamide er . . . . . . . . . . . . . . . . . 50
acetazolamide sodium . . . . . . . . . . . . 37
acetic acid . . . . . . . . . . . . . . . . . . . . . . . 50
acetic acid/aluminum acetate . . . . . 50
acetylcysteine inhalation soln . . . . . . 51
acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . 40
ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . 48
ACTIMMUNE . . . . . . . . . . . . . . . . . . . . 48
acyclovir . . . . . . . . . . . . . . . . . . . . . . . . . 33
acyclovir sodium inj 50mg/ml. . . . . . . 33
ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . 48
ADAGEN . . . . . . . . . . . . . . . . . . . . . . . . 40
56
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . 41
amitriptyline hcl tabs 100mg,
10mg, 25mg, 50mg, 75mg . . . . . . . . . 24
amitriptyline hcl tabs 150mg. . . . . . . . 24
amlodipine besylate . . . . . . . . . . . . . . 37
amlodipine besylate/benazepril
hydrochloride . . . . . . . . . . . . . . . . . . . . 37
amlodipine besylate/valsartan . . . . . 37
amlodipine/valsartan/hctz . . . . . . . . . 37
ammonium lactate . . . . . . . . . . . . . . . . 40
amoxapine . . . . . . . . . . . . . . . . . . . . . . . 24
amoxicillin caps . . . . . . . . . . . . . . . . . . . 20
amoxicillin chew . . . . . . . . . . . . . . . . . . 20
amoxicillin/clavulanate potassium. . . 20
amoxicillin/clavulanate
potassium er . . . . . . . . . . . . . . . . . . . . . 20
amoxicillin susr . . . . . . . . . . . . . . . . . . . 20
amoxicillin tabs . . . . . . . . . . . . . . . . . . . 20
amphetamine/
dextroamphetamine cp24 . . . . . . . . . . 39
amphetamine/
dextroamphetamine tabs . . . . . . . . . . 39
amphotericin b . . . . . . . . . . . . . . . . . . . 25
ampicillin . . . . . . . . . . . . . . . . . . . . . . . . 20
ampicillin sodium . . . . . . . . . . . . . . . . . 20
ampicillin-sulbactam . . . . . . . . . . . . . . 20
AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . 39
ANADROL-50 . . . . . . . . . . . . . . . . . . . . 44
anagrelide hydrochloride . . . . . . . . . . 35
anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . 40
anastrozole . . . . . . . . . . . . . . . . . . . . . . 28
ANDROXY . . . . . . . . . . . . . . . . . . . . . . . 44
APOKYN . . . . . . . . . . . . . . . . . . . . . . . . 29
apraclonidine . . . . . . . . . . . . . . . . . . . . 50
apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
APRISO . . . . . . . . . . . . . . . . . . . . . . . . . 48
APTIOM TABS
200MG, 400MG, 800MG. . . . . . . . . . . 22
APTIOM TABS 600MG. . . . . . . . . . . . . 22
APTIVUS . . . . . . . . . . . . . . . . . . . . . . . . 32
ARALAST NP INJ 500MG. . . . . . . . . . 51
aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . 44
ARANESP ALBUMIN FREE INJ
10MCG/0.4ML, 25MCG/0.42ML,
25MCG/ML, 40MCG/0.4ML,
40MCG/ML, 60MCG/0.3ML,
60MCG/ML . . . . . . . . . . . . . . . . . . . . . . . 35
ARANESP ALBUMIN FREE INJ
100MCG/0.5ML, 100MCG/ML,
150MCG/0.3ML, 200MCG/0.4ML,
200MCG/ML, 300MCG/0.6ML,
300MCG/ML, 500MCG/ML. . . . . . . . . 35
ARCALYST . . . . . . . . . . . . . . . . . . . . . . 48
aripiprazole odt . . . . . . . . . . . . . . . . . . . 30
aripiprazole oral soln . . . . . . . . . . . . . . 30
aripiprazole tabs . . . . . . . . . . . . . . . . . . 30
ARISTADA INJ 441MG/1.6ML. . . . . . 30
ARISTADA INJ 662MG/2.4ML. . . . . . 30
ARISTADA INJ 882MG/3.2ML. . . . . . 30
armodafinil . . . . . . . . . . . . . . . . . . . . . . . 52
ARRANON . . . . . . . . . . . . . . . . . . . . . . . 26
ascomp/codeine . . . . . . . . . . . . . . . . . . 16
aspirin/dipyridamole . . . . . . . . . . . . . . 35
ASTAGRAF XL . . . . . . . . . . . . . . . . . . . 47
atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . 36
atenolol/chlorthalidone . . . . . . . . . . . . 36
ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . 47
atorvastatin calcium . . . . . . . . . . . . . . 38
atovaquone . . . . . . . . . . . . . . . . . . . . . . 29
atovaquone/proguanil hcl . . . . . . . . . 29
ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . 32
atropine sulfate inj 0.05mg/ml,
0.1mg/ml, 0.4mg/ml, 1mg/ml . . . . . . . 40
atropine sulfate ophthalmic soln . . . . 49
aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
augmented betamethasone
dipropionate . . . . . . . . . . . . . . . . . . . . . 42
AUGMENTIN SUSR
125MG/5ML; 31.25MG/5ML. . . . . . . . 20
AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . 42
AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . 28
AVELOX INJ . . . . . . . . . . . . . . . . . . . . . . 21
aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
AVODART . . . . . . . . . . . . . . . . . . . . . . . 42
AVONEX . . . . . . . . . . . . . . . . . . . . . . . . 39
AVONEX PEN . . . . . . . . . . . . . . . . . . . 39
azacitidine . . . . . . . . . . . . . . . . . . . . . . . 27
AZACTAM IN ISO-OSMOTIC
DEXTROSE . . . . . . . . . . . . . . . . . . . . . 20
AZASAN . . . . . . . . . . . . . . . . . . . . . . . . . 47
AZASITE . . . . . . . . . . . . . . . . . . . . . . . . 20
azathioprine inj . . . . . . . . . . . . . . . . . . . 47
azathioprine tabs . . . . . . . . . . . . . . . . . 47
azelastine hcl nasal soln . . . . . . . . . . . 51
azelastine hcl ophthalmic soln . . . . . 50
AZILECT . . . . . . . . . . . . . . . . . . . . . . . . 30
azithromycin inj . . . . . . . . . . . . . . . . . . . 20
azithromycin pack . . . . . . . . . . . . . . . . . 20
azithromycin susr 100mg/5ml . . . . . . 20
azithromycin susr 200mg/5ml . . . . . . 20
azithromycin tabs . . . . . . . . . . . . . . . . . 20
AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . 50
aztreonam . . . . . . . . . . . . . . . . . . . . . . . 20
azurette . . . . . . . . . . . . . . . . . . . . . . . . . . 44
57
B
baciim . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
bacitracin inj . . . . . . . . . . . . . . . . . . . . . . 18
bacitracin ophthalmic oint . . . . . . . . . . 18
bacitracin/polymyxin b . . . . . . . . . . . . 18
baclofen tabs 10mg. . . . . . . . . . . . . . . . 31
baclofen tabs 20mg. . . . . . . . . . . . . . . . 31
BACTROBAN NASAL . . . . . . . . . . . . 18
balsalazide disodium . . . . . . . . . . . . . 48
balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
BANZEL SUSP . . . . . . . . . . . . . . . . . . . 22
BANZEL TABS 200MG . . . . . . . . . . . . 22
BANZEL TABS 400MG . . . . . . . . . . . . 22
BARACLUDE ORAL SOLN . . . . . . . . 31
BARACLUDE TABS . . . . . . . . . . . . . . . 31
bd safetyglide 27g x 5/8” . . . . . . . . . . 49
bekyree . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
BELEODAQ . . . . . . . . . . . . . . . . . . . . . 27
benazepril hcl . . . . . . . . . . . . . . . . . . . . 36
benazepril hcl/hydrochlorothiazide. . 36
BENDEKA . . . . . . . . . . . . . . . . . . . . . . . 26
BENLYSTA . . . . . . . . . . . . . . . . . . . . . . 47
benztropine mesylate inj . . . . . . . . . . . 29
benztropine mesylate tabs
0.5mg, 1mg . . . . . . . . . . . . . . . . . . . . . . . 29
benztropine mesylate tabs 2mg. . . . . 29
BESIVANCE . . . . . . . . . . . . . . . . . . . . . 21
betamethasone dipropionate . . . . . . 42
betamethasone valerate . . . . . . . . . . 42
betaxolol hcl . . . . . . . . . . . . . . . . . . . . . 36
betaxolol hcl . . . . . . . . . . . . . . . . . . . . . 50
bethanechol chloride . . . . . . . . . . . . . 42
bexarotene . . . . . . . . . . . . . . . . . . . . . . . 29
BEXSERO . . . . . . . . . . . . . . . . . . . . . . . 48
bicalutamide . . . . . . . . . . . . . . . . . . . . . 26
BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . 20
BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
bimatoprost . . . . . . . . . . . . . . . . . . . . . . 49
bisoprolol fumarate . . . . . . . . . . . . . . . 36
bisoprolol fumarate/
hydrochlorothiazide . . . . . . . . . . . . . . . 36
BIVIGAM INJ 5GM/50ML . . . . . . . . . . 47
BIVIGAM INJ 10GM/100ML. . . . . . . . 47
bleomycin sulfate . . . . . . . . . . . . . . . . . 27
BLEPHAMIDE . . . . . . . . . . . . . . . . . . . 21
blephamide s.o.p. . . . . . . . . . . . . . . . . 21
blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . 44
blisovi fe 1/20 . . . . . . . . . . . . . . . . . . . . 44
BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . 48
BOSULIF . . . . . . . . . . . . . . . . . . . . . . . . 28
briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . 44
BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . 35
brimonidine tartrate
ophthalmic soln 0.2%. . . . . . . . . . . . . . 50
brimonidine tartrate
ophthalmic soln 0.15%. . . . . . . . . . . . . 50
BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 22
BRIVIACT ORAL SOLN . . . . . . . . . . . 22
BRIVIACT TABS
10MG, 25MG, 50MG, 75MG . . . . . . . 22
BRIVIACT TABS 100MG. . . . . . . . . . . 22
bromfenac . . . . . . . . . . . . . . . . . . . . . . . 50
bromocriptine mesylate . . . . . . . . . . . 29
budesonide cpep . . . . . . . . . . . . . . . . . 48
budesonide susp 0.25mg/2ml,
0.5mg/2ml, 1mg/2ml. . . . . . . . . . . . . . . 50
budesonide susp 32mcg/act. . . . . . . . 50
bumetanide inj . . . . . . . . . . . . . . . . . . . . 37
bumetanide tabs 0.5mg, 1mg. . . . . . . 38
bumetanide tabs 2mg. . . . . . . . . . . . . . 37
BUPHENYL TABS . . . . . . . . . . . . . . . . 40
buprenorphine hcl inj . . . . . . . . . . . . . . 18
buprenorphine hcl/naloxone hcl . . . 18
buprenorphine hcl subl . . . . . . . . . . . . 18
buproban . . . . . . . . . . . . . . . . . . . . . . . . 18
bupropion hcl . . . . . . . . . . . . . . . . . . . . 23
bupropion hcl sr tb12
100mg, 200mg . . . . . . . . . . . . . . . . . . . . 23
bupropion hcl sr tb12 150mg . . . . . . . 18
bupropion hcl sr tb12 150mg . . . . . . . 23
bupropion hcl xl tb24 150mg . . . . . . . 23
bupropion hcl xl tb24 300mg . . . . . . . 23
buspirone hcl tabs 10mg, 5mg. . . . . . 33
buspirone hcl tabs
15mg, 30mg, 7.5mg . . . . . . . . . . . . . . . 33
BUSULFEX . . . . . . . . . . . . . . . . . . . . . . 26
butalbital/acetaminophen/
caffeine caps . . . . . . . . . . . . . . . . . . . . . 16
butalbital/acetaminophen/
caffeine/codeine . . . . . . . . . . . . . . . . . . 16
butalbital/acetaminophen/
caffeine tabs 325mg; 50mg; 40mg. . 16
butalbital/aspirin/caffeine . . . . . . . . . . 16
butalbital/aspirin/caffeine/codeine . 17
butorphanol tartrate inj . . . . . . . . . . . . 17
butorphanol tartrate nasal soln . . . . . 17
BYDUREON . . . . . . . . . . . . . . . . . . . . . 33
BYETTA . . . . . . . . . . . . . . . . . . . . . . . . . 33
BYSTOLIC TABS 2.5MG, 5MG. . . . . 36
BYSTOLIC TABS 10MG . . . . . . . . . . . 36
BYSTOLIC TABS 20MG . . . . . . . . . . . 36
58
C
cabergoline . . . . . . . . . . . . . . . . . . . . . . 46
CABOMETYX TABS
20MG, 60MG. . . . . . . . . . . . . . . . . . . . . . 28
CABOMETYX TABS 40MG . . . . . . . . 28
cafergot . . . . . . . . . . . . . . . . . . . . . . . . . . 25
calcipotriene crea . . . . . . . . . . . . . . . . . 40
calcipotriene external soln . . . . . . . . . 40
calcipotriene oint . . . . . . . . . . . . . . . . . . 40
calcitonin-salmon . . . . . . . . . . . . . . . . . 49
calcitrene . . . . . . . . . . . . . . . . . . . . . . . . 40
calcitriol caps . . . . . . . . . . . . . . . . . . . . . 49
calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 49
calcitriol oint . . . . . . . . . . . . . . . . . . . . . . 40
calcitriol oral soln . . . . . . . . . . . . . . . . . 49
calcium acetate caps . . . . . . . . . . . . . . 42
calcium acetate tabs 667mg. . . . . . . . 42
camila . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
CANCIDAS . . . . . . . . . . . . . . . . . . . . . . 25
candesartan cilexetil . . . . . . . . . . . . . . 35
candesartan cilexetil/
hydrochlorothiazide . . . . . . . . . . . . . . . 35
CAPASTAT SULFATE . . . . . . . . . . . . 26
CAPRELSA . . . . . . . . . . . . . . . . . . . . . . 28
captopril . . . . . . . . . . . . . . . . . . . . . . . . . 36
captopril/hydrochlorothiazide . . . . . . 36
CARAC . . . . . . . . . . . . . . . . . . . . . . . . . . 40
CARAFATE SUSP . . . . . . . . . . . . . . . . 41
CARBAGLU . . . . . . . . . . . . . . . . . . . . . 52
carbamazepine . . . . . . . . . . . . . . . . . . . 22
carbamazepine er . . . . . . . . . . . . . . . . 22
carbidopa . . . . . . . . . . . . . . . . . . . . . . . . 29
carbidopa/levodopa . . . . . . . . . . . . . . 29
carbidopa/levodopa/entacapone . . . 30
carbidopa/levodopa er . . . . . . . . . . . . 29
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
carbidopa/levodopa odt . . . . . . . . . . . 29
carboplatin inj 150mg/15ml,
450mg/45ml, 50mg/5ml. . . . . . . . . . . . 27
carteolol hcl . . . . . . . . . . . . . . . . . . . . . . 50
cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . 37
carvedilol . . . . . . . . . . . . . . . . . . . . . . . . 36
CAYSTON . . . . . . . . . . . . . . . . . . . . . . . 51
caziant . . . . . . . . . . . . . . . . . . . . . . . . . . 44
cefaclor . . . . . . . . . . . . . . . . . . . . . . . . . . 19
cefaclor er . . . . . . . . . . . . . . . . . . . . . . . 19
cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . 19
CEFAZOLIN . . . . . . . . . . . . . . . . . . . . . 19
cefazolin sodium/dextrose inj
2gm; 3%. . . . . . . . . . . . . . . . . . . . . . . . . . 19
cefazolin sodium inj
10gm, 1gm, 1gm; 5%, 500mg . . . . . . 19
cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . 19
cefepime . . . . . . . . . . . . . . . . . . . . . . . . . 19
cefepime/dextrose . . . . . . . . . . . . . . . . 19
cefixime . . . . . . . . . . . . . . . . . . . . . . . . . 19
cefotaxime sodium inj
1gm, 2gm, 500mg . . . . . . . . . . . . . . . . . 20
cefotetan . . . . . . . . . . . . . . . . . . . . . . . . 20
cefoxitin sodium inj
10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 20
cefpodoxime proxetil . . . . . . . . . . . . . . 20
cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . 20
ceftazidime . . . . . . . . . . . . . . . . . . . . . . 20
ceftazidime/dextrose . . . . . . . . . . . . . . 20
ceftriaxone in iso-osmotic dextrose . 20
ceftriaxone sodium inj 10gm,
1gm, 250mg, 2gm, 500mg . . . . . . . . . 20
cefuroxime axetil . . . . . . . . . . . . . . . . . 20
cefuroxime sodium inj
1.5gm, 7.5gm, 750mg, 75gm. . . . . . . 20
celecoxib . . . . . . . . . . . . . . . . . . . . . . . . 16
CELLCEPT INTRAVENOUS . . . . . . 47
CELLCEPT SUSR . . . . . . . . . . . . . . . . 47
CELONTIN . . . . . . . . . . . . . . . . . . . . . . 22
cephalexin caps 250mg, 500mg. . . . 20
cephalexin susr . . . . . . . . . . . . . . . . . . . 20
cephalexin tabs . . . . . . . . . . . . . . . . . . . 20
CEREZYME . . . . . . . . . . . . . . . . . . . . . 40
CERVARIX . . . . . . . . . . . . . . . . . . . . . . 48
CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . 18
CHANTIX CONTINUING
MONTH PAK . . . . . . . . . . . . . . . . . . . . . 18
CHANTIX STARTING
MONTH PAK . . . . . . . . . . . . . . . . . . . . . 18
chateal . . . . . . . . . . . . . . . . . . . . . . . . . . 44
CHEMET . . . . . . . . . . . . . . . . . . . . . . . . 52
chloramphenicol sodium succinate. . 18
chlorhexidine gluconate oral rinse . . 39
chloroquine phosphate . . . . . . . . . . . 29
chlorothiazide . . . . . . . . . . . . . . . . . . . . 38
chlorothiazide sodium . . . . . . . . . . . . 38
chlorpromazine hcl inj 50mg/2ml. . . . 30
chlorpromazine hcl tabs . . . . . . . . . . . 30
chlorthalidone tabs 25mg, 50mg. . . . 38
chlorzoxazone . . . . . . . . . . . . . . . . . . . 52
cholestyramine . . . . . . . . . . . . . . . . . . . 38
cholestyramine light . . . . . . . . . . . . . . 38
chorionic gonadotropin . . . . . . . . . . . 43
ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . 25
ciclopirox nail lacquer . . . . . . . . . . . . . 25
ciclopirox olamine . . . . . . . . . . . . . . . . 25
ciclopirox sham . . . . . . . . . . . . . . . . . . . 25
ciclopirox susp . . . . . . . . . . . . . . . . . . . . 25
cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . 31
cilostazol . . . . . . . . . . . . . . . . . . . . . . . . 35
CILOXAN OINT . . . . . . . . . . . . . . . . . . . 21
cimetidine . . . . . . . . . . . . . . . . . . . . . . . . 41
cimetidine hcl . . . . . . . . . . . . . . . . . . . . 41
CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . 47
CIPRODEX . . . . . . . . . . . . . . . . . . . . . . 21
ciprofloxacin er . . . . . . . . . . . . . . . . . . . 21
ciprofloxacin hcl ophthalmic soln . . . 21
ciprofloxacin hcl tabs
100mg, 750mg . . . . . . . . . . . . . . . . . . . . 21
ciprofloxacin hcl tabs
250mg, 500mg . . . . . . . . . . . . . . . . . . . . 21
ciprofloxacin inj 400mg/40ml . . . . . . . 21
ciprofloxacin i.v.-in d5w . . . . . . . . . . . 21
ciprofloxacin susr . . . . . . . . . . . . . . . . . 21
CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . 21
cisplatin . . . . . . . . . . . . . . . . . . . . . . . . . . 27
citalopram hydrobromide oral soln. . 23
citalopram hydrobromide
tabs 10mg, 20mg. . . . . . . . . . . . . . . . . . 23
citalopram hydrobromide
tabs 40mg . . . . . . . . . . . . . . . . . . . . . . . . 23
cladribine . . . . . . . . . . . . . . . . . . . . . . . . 27
claravis . . . . . . . . . . . . . . . . . . . . . . . . . . 40
clarithromycin . . . . . . . . . . . . . . . . . . . . 20
clarithromycin er . . . . . . . . . . . . . . . . . 20
clindacin etz pledgets . . . . . . . . . . . . . 18
clindacin-p . . . . . . . . . . . . . . . . . . . . . . . 18
clindamax . . . . . . . . . . . . . . . . . . . . . . . . 18
clindamycin hcl . . . . . . . . . . . . . . . . . . . 18
clindamycin phosphate
add-vantage . . . . . . . . . . . . . . . . . . . . . 18
clindamycin phosphate crea . . . . . . . 18
clindamycin phosphate
external soln . . . . . . . . . . . . . . . . . . . . . . 18
clindamycin phosphate gel . . . . . . . . 18
clindamycin phosphate in d5w . . . . . 18
clindamycin phosphate inj
300mg/2ml, 600mg/4ml,
900mg/6ml. . . . . . . . . . . . . . . . . . . . . . . . 18
clindamycin phosphate lotn . . . . . . . . 19
clindamycin phosphate
pharmacy bulk package . . . . . . . . . . . 19
clindamycin phosphate swab . . . . . . 19
CLINIMIX 2.75%/DEXTROSE 5% . . 52
CLINIMIX 4.25%/DEXTROSE 5% . . 52
CLINIMIX 4.25%/DEXTROSE 10%. . 52
CLINIMIX 4.25%/DEXTROSE 20%. . 52
CLINIMIX 4.25%/DEXTROSE 25%. . 52
CLINIMIX 5%/DEXTROSE 15%. . . . 52
CLINIMIX 5%/DEXTROSE 20%. . . . 53
CLINIMIX 5%/DEXTROSE 25%. . . . 53
59
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
CLINIMIX E 2.75%/
DEXTROSE 10% . . . . . . . . . . . . . . . . . 53
CLINIMIX E 4.25%/
DEXTROSE 10% . . . . . . . . . . . . . . . . . 53
CLINIMIX E 4.25%/
DEXTROSE 25% . . . . . . . . . . . . . . . . . 53
CLINIMIX E 5%/DEXTROSE 25%. . . 53
CLINISOL SF 15% . . . . . . . . . . . . . . . 53
clobetasol propionate crea . . . . . . . . . 42
clobetasol propionate e . . . . . . . . . . . 42
clobetasol propionate emollient . . . . 42
clobetasol propionate
external soln . . . . . . . . . . . . . . . . . . . . . . 42
clobetasol propionate foam . . . . . . . . 42
clobetasol propionate gel . . . . . . . . . . 42
clobetasol propionate oint . . . . . . . . . 42
clobetasol propionate sham . . . . . . . . 42
clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
CLOLAR . . . . . . . . . . . . . . . . . . . . . . . . . 27
clomipramine hcl . . . . . . . . . . . . . . . . . 24
clonazepam odt tbdp
0.125mg, 0.25mg, 0.5mg, 1mg . . . . . 22
clonazepam odt tbdp 2mg. . . . . . . . . . 22
clonazepam tabs 0.5mg, 1mg . . . . . . 22
clonazepam tabs 2mg . . . . . . . . . . . . . 22
clonidine hcl er . . . . . . . . . . . . . . . . . . . 39
clonidine hcl ptwk 0.1mg/24hr,
0.2mg/24hr. . . . . . . . . . . . . . . . . . . . . . . . 35
clonidine hcl ptwk 0.3mg/24hr. . . . . . 35
clonidine hcl tabs 0.1mg, 0.2mg . . . . 35
clonidine hcl tabs 0.3mg . . . . . . . . . . . 35
clopidogrel tabs 75mg . . . . . . . . . . . . . 35
clopidogrel tabs 300mg . . . . . . . . . . . . 35
clorazepate dipotassium tabs
3.75mg, 7.5mg . . . . . . . . . . . . . . . . . . . . 33
clorazepate dipotassium
tabs 15mg . . . . . . . . . . . . . . . . . . . . . . . . 33
clotrimazole/
betamethasone dipropionate . . . . . . 25
clotrimazole external crea . . . . . . . . . 25
clotrimazole external soln . . . . . . . . . . 25
clotrimazole troc . . . . . . . . . . . . . . . . . . 25
clozapine . . . . . . . . . . . . . . . . . . . . . . . . 31
clozapine odt . . . . . . . . . . . . . . . . . . . . . 31
COARTEM . . . . . . . . . . . . . . . . . . . . . . . 29
colchicine . . . . . . . . . . . . . . . . . . . . . . . . 25
COLCRYS . . . . . . . . . . . . . . . . . . . . . . . 25
colestipol hcl gran . . . . . . . . . . . . . . . . . 38
colestipol hcl tabs . . . . . . . . . . . . . . . . . 38
colistimethate sodium . . . . . . . . . . . . . 19
colocort . . . . . . . . . . . . . . . . . . . . . . . . . . 48
COLY-MYCIN S . . . . . . . . . . . . . . . . . . 50
COMBIGAN . . . . . . . . . . . . . . . . . . . . . . 49
COMBIVENT RESPIMAT . . . . . . . . . 51
COMETRIQ . . . . . . . . . . . . . . . . . . . . . . 28
COMPLERA . . . . . . . . . . . . . . . . . . . . . 32
compro . . . . . . . . . . . . . . . . . . . . . . . . . . 30
constulose . . . . . . . . . . . . . . . . . . . . . . . 41
COPAXONE INJ 40MG/ML. . . . . . . . . 39
COREG CR . . . . . . . . . . . . . . . . . . . . . . 36
cormax scalp application . . . . . . . . . . 42
cortisone acetate . . . . . . . . . . . . . . . . . 42
COSMEGEN . . . . . . . . . . . . . . . . . . . . . 27
COTELLIC . . . . . . . . . . . . . . . . . . . . . . . 28
COUMADIN . . . . . . . . . . . . . . . . . . . . . . 34
COZAAR TABS 25MG. . . . . . . . . . . . . 35
COZAAR TABS 50MG. . . . . . . . . . . . . 35
COZAAR TABS 100MG. . . . . . . . . . . . 35
CREON . . . . . . . . . . . . . . . . . . . . . . . . . . 40
CRESTOR . . . . . . . . . . . . . . . . . . . . . . . 38
CRIXIVAN . . . . . . . . . . . . . . . . . . . . . . . 32
cromolyn sodium conc . . . . . . . . . . . . 41
cromolyn sodium nebu . . . . . . . . . . . . 51
cromolyn sodium ophthalmic soln. . . 50
cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . 44
CUBICIN . . . . . . . . . . . . . . . . . . . . . . . . 19
CUPRIMINE . . . . . . . . . . . . . . . . . . . . . 52
curity gauze pads 2”x2” . . . . . . . . . . . 40
cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . 44
cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . 44
cyclobenzaprine hcl tabs
10mg, 5mg. . . . . . . . . . . . . . . . . . . . . . . . 52
cyclophosphamide caps . . . . . . . . . . . 26
cyclophosphamide inj . . . . . . . . . . . . . 26
cycloserine . . . . . . . . . . . . . . . . . . . . . . . 26
cyclosporine caps . . . . . . . . . . . . . . . . . 47
cyclosporine inj . . . . . . . . . . . . . . . . . . . 47
cyclosporine modified . . . . . . . . . . . . . 47
CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . 28
cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
CYSTADANE . . . . . . . . . . . . . . . . . . . . 40
CYSTAGON . . . . . . . . . . . . . . . . . . . . . 40
cytarabine . . . . . . . . . . . . . . . . . . . . . . . 27
cytarabine aqueous . . . . . . . . . . . . . . 27
60
D
dacarbazine . . . . . . . . . . . . . . . . . . . . . . 26
DALIRESP . . . . . . . . . . . . . . . . . . . . . . . 51
danazol . . . . . . . . . . . . . . . . . . . . . . . . . . 44
dantrolene sodium . . . . . . . . . . . . . . . . 31
dapsone . . . . . . . . . . . . . . . . . . . . . . . . . 26
DAPTACEL . . . . . . . . . . . . . . . . . . . . . . 48
DARAPRIM . . . . . . . . . . . . . . . . . . . . . . 29
DARZALEX . . . . . . . . . . . . . . . . . . . . . . 28
dasetta 1/35 . . . . . . . . . . . . . . . . . . . . . 44
dasetta 7/7/7 . . . . . . . . . . . . . . . . . . . . . 44
daunorubicin hcl . . . . . . . . . . . . . . . . . . 27
deblitane . . . . . . . . . . . . . . . . . . . . . . . . . 46
decitabine . . . . . . . . . . . . . . . . . . . . . . . 27
DELESTROGEN . . . . . . . . . . . . . . . . . 44
delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
DELZICOL . . . . . . . . . . . . . . . . . . . . . . . 48
demeclocycline hcl . . . . . . . . . . . . . . . 21
DEMSER . . . . . . . . . . . . . . . . . . . . . . . . 37
DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . 33
DEPEN TITRATABS . . . . . . . . . . . . . . 52
DEPO-ESTRADIOL . . . . . . . . . . . . . . 44
DEPO-MEDROL INJ 20MG/ML. . . . . 42
DEPO-PROVERA . . . . . . . . . . . . . . . . 46
DESCOVY . . . . . . . . . . . . . . . . . . . . . . . 32
desipramine hcl . . . . . . . . . . . . . . . . . . 24
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
desloratadine . . . . . . . . . . . . . . . . . . . . 51
desloratadine odt . . . . . . . . . . . . . . . . . 51
desmopressin acetate inj . . . . . . . . . . 43
desmopressin acetate nasal soln . . 43
desmopressin acetate tabs . . . . . . . . 43
desogestrel/ethinyl estradiol . . . . . . . 44
desonide lotn . . . . . . . . . . . . . . . . . . . . . 42
desonide oint . . . . . . . . . . . . . . . . . . . . . 42
desoximetasone crea . . . . . . . . . . . . . 42
desoximetasone gel . . . . . . . . . . . . . . . 42
desoximetasone oint 0.25%. . . . . . . . 42
dexamethasone elix . . . . . . . . . . . . . . . 42
dexamethasone intensol . . . . . . . . . . 42
dexamethasone oral soln . . . . . . . . . . 42
dexamethasone sodium
phosphate inj 10mg/ml,
120mg/30ml, 20mg/5ml, 4mg/ml. . . . 42
dexamethasone sodium
phosphate ophthalmic soln . . . . . . . . 50
dexamethasone tabs
0.5mg, 0.75mg, 4mg. . . . . . . . . . . . . . . 43
dexamethasone tabs
1.5mg, 1mg, 2mg, 6mg . . . . . . . . . . . . 42
DEXILANT . . . . . . . . . . . . . . . . . . . . . . . 41
dexmethylphenidate hcl . . . . . . . . . . . 39
dexrazoxane . . . . . . . . . . . . . . . . . . . . . 27
dextroamphetamine sulfate er
cp24 10mg, 5mg . . . . . . . . . . . . . . . . . . 39
dextroamphetamine sulfate er
cp24 15mg. . . . . . . . . . . . . . . . . . . . . . . . 39
dextroamphetamine sulfate
oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 39
dextroamphetamine sulfate
tabs 5mg. . . . . . . . . . . . . . . . . . . . . . . . . . 39
dextroamphetamine sulfate
tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 39
dextrose 2.5%/nacl 0.45% . . . . . . . . 53
dextrose 2.5%/
sodium chloride 0.45% . . . . . . . . . . . 53
DEXTROSE 5% . . . . . . . . . . . . . . . . . . 53
dextrose 5% /
electrolyte #48 viaflex . . . . . . . . . . . . . 53
DEXTROSE 5%/
LACTATED RINGERS . . . . . . . . . . . . 53
dextrose 5%/nacl 0.2% . . . . . . . . . . . 53
DEXTROSE 5%/NACL 0.3% . . . . . . 53
dextrose 5%/nacl 0.9% . . . . . . . . . . . 53
dextrose 5%/nacl 0.33% . . . . . . . . . . 53
dextrose 5%/nacl 0.45% . . . . . . . . . . 53
dextrose 5%/nacl 0.225% . . . . . . . . . 53
dextrose 5%/
potassium chloride 0.15% . . . . . . . . . 53
dextrose 5%/sodium chloride 0.2% . . 53
dextrose 5%/
sodium chloride 0.45% . . . . . . . . . . . 53
DEXTROSE 10%
FLEX CONTAINER . . . . . . . . . . . . . . . 53
dextrose 10%/nacl 0.2% . . . . . . . . . . 53
dextrose 10%/nacl 0.45% . . . . . . . . 53
DEXTROSE 20% . . . . . . . . . . . . . . . . . 53
DEXTROSE 25% . . . . . . . . . . . . . . . . . 53
DEXTROSE 30% . . . . . . . . . . . . . . . . . 53
DEXTROSE 40% . . . . . . . . . . . . . . . . . 53
DEXTROSE 50% . . . . . . . . . . . . . . . . . 53
DEXTROSE 70% . . . . . . . . . . . . . . . . . 53
diazepam gel . . . . . . . . . . . . . . . . . . . . . 22
diazepam inj 5mg/ml. . . . . . . . . . . . . . . 33
diazepam oral soln . . . . . . . . . . . . . . . . 33
diazepam tabs . . . . . . . . . . . . . . . . . . . . 33
DIBENZYLINE . . . . . . . . . . . . . . . . . . . 35
diclofenac potassium . . . . . . . . . . . . . 16
diclofenac sodium dr tbec
25mg, 50mg. . . . . . . . . . . . . . . . . . . . . . . 16
diclofenac sodium dr tbec 75mg. . . . 16
diclofenac sodium er . . . . . . . . . . . . . . 16
diclofenac sodium gel 1%. . . . . . . . . . 40
diclofenac sodium ophthalmic soln. . 50
diclofenac sodium
transdermal soln . . . . . . . . . . . . . . . . . . 40
dicloxacillin sodium . . . . . . . . . . . . . . . 20
dicyclomine hcl caps . . . . . . . . . . . . . . 40
dicyclomine hcl oral soln . . . . . . . . . . . 40
dicyclomine hcl tabs . . . . . . . . . . . . . . . 40
didanosine . . . . . . . . . . . . . . . . . . . . . . . 32
diflorasone diacetate . . . . . . . . . . . . . 43
diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . 16
digitek tabs 0.25mg. . . . . . . . . . . . . . . . 37
digitek tabs 0.125mg. . . . . . . . . . . . . . . 37
digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 37
digoxin tabs 125mcg. . . . . . . . . . . . . . . 37
digoxin tabs 250mcg. . . . . . . . . . . . . . . 37
digox tabs 125mcg . . . . . . . . . . . . . . . . 37
digox tabs 250mcg . . . . . . . . . . . . . . . . 37
dihydroergotamine mesylate inj . . . . 25
dilantin caps 30mg. . . . . . . . . . . . . . . . . 22
DILANTIN CAPS 100MG. . . . . . . . . . . 22
DILANTIN INFATABS . . . . . . . . . . . . . 22
diltiazem cd . . . . . . . . . . . . . . . . . . . . . . 37
diltiazem hcl cd . . . . . . . . . . . . . . . . . . . 37
diltiazem hcl er . . . . . . . . . . . . . . . . . . . 37
diltiazem hcl inj
100mg, 125mg/25ml,
25mg/5ml, 50mg/10ml . . . . . . . . . . . . . 37
diltiazem hcl tabs . . . . . . . . . . . . . . . . . 37
dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
diphenhydramine hcl inj . . . . . . . . . . . 51
diphenoxylate/atropine . . . . . . . . . . . . 41
DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC . . . . . . . . . 48
dipyridamole tabs . . . . . . . . . . . . . . . . . 35
disulfiram . . . . . . . . . . . . . . . . . . . . . . . . 18
divalproex sodium . . . . . . . . . . . . . . . . 22
divalproex sodium dr . . . . . . . . . . . . . 22
divalproex sodium er . . . . . . . . . . . . . 22
DOCEFREZ INJ 20MG . . . . . . . . . . . . 27
docetaxel . . . . . . . . . . . . . . . . . . . . . . . . 27
dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . 36
donepezil hcl tabs 10mg . . . . . . . . . . . 23
donepezil hcl tabs 23mg, 5mg. . . . . . 23
donepezil hcl tbdp 5mg . . . . . . . . . . . . 23
donepezil hcl tbdp 10mg . . . . . . . . . . . 23
dorzolamide hcl . . . . . . . . . . . . . . . . . . 50
dorzolamide hcl/timolol maleate . . . 50
61
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
doxazosin . . . . . . . . . . . . . . . . . . . . . . . . 42
doxazosin mesylate tabs
1mg, 2mg. . . . . . . . . . . . . . . . . . . . . . . . . 42
doxazosin mesylate tabs 8mg. . . . . . 42
doxepin hcl . . . . . . . . . . . . . . . . . . . . . . 24
doxepin hydrochloride . . . . . . . . . . . . 40
doxercalciferol caps . . . . . . . . . . . . . . . 49
doxercalciferol inj . . . . . . . . . . . . . . . . . 49
doxorubicin hcl . . . . . . . . . . . . . . . . . . . 27
doxorubicin hcl liposome . . . . . . . . . . 27
doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . 21
doxycycline caps 75mg . . . . . . . . . . . . 21
doxycycline hyclate caps . . . . . . . . . . 21
doxycycline hyclate inj . . . . . . . . . . . . . 21
doxycycline hyclate tabs 20mg . . . . . 21
doxycycline hyclate tabs 100mg. . . . 21
doxycycline monohydrate . . . . . . . . . 21
doxycycline susr . . . . . . . . . . . . . . . . . . 21
dronabinol . . . . . . . . . . . . . . . . . . . . . . . 24
DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . 27
DULERA . . . . . . . . . . . . . . . . . . . . . . . . . 50
duloxetine hcl cpep 20mg, 60mg . . . 23
duloxetine hcl cpep 30mg. . . . . . . . . . 23
DURAMORPH . . . . . . . . . . . . . . . . . . . 16
DUREZOL . . . . . . . . . . . . . . . . . . . . . . . 50
dutasteride . . . . . . . . . . . . . . . . . . . . . . . 42
dutasteride/
tamsulosin hydrochloride . . . . . . . . . 42
ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 46
ELIGARD INJ 22.5MG. . . . . . . . . . . . . 46
ELIGARD INJ 30MG. . . . . . . . . . . . . . . 46
ELIGARD INJ 45MG. . . . . . . . . . . . . . . 46
elinest . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
ELIQUIS TABS 2.5MG. . . . . . . . . . . . . 34
ELIQUIS TABS 5MG. . . . . . . . . . . . . . . 34
ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . 27
ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
ELLENCE INJ 200MG/100ML. . . . . . 27
ELMIRON . . . . . . . . . . . . . . . . . . . . . . . 42
EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . 26
EMEND CAPS . . . . . . . . . . . . . . . . . . . . 24
EMEND CAPS 40MG. . . . . . . . . . . . . . 24
EMEND CAPS 80MG. . . . . . . . . . . . . . 24
EMEND CAPS 125MG. . . . . . . . . . . . . 24
emoquette . . . . . . . . . . . . . . . . . . . . . . . 44
EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . 28
EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . 23
EMTRIVA . . . . . . . . . . . . . . . . . . . . . . . . 32
enalapril maleate . . . . . . . . . . . . . . . . . 36
enalapril maleate/
hydrochlorothiazide . . . . . . . . . . . . . . . 36
ENBREL . . . . . . . . . . . . . . . . . . . . . . . . . 47
ENBREL SURECLICK . . . . . . . . . . . . 47
endocet . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ENGERIX-B . . . . . . . . . . . . . . . . . . . . . 48
enoxaparin sodium inj 30mg/0.3ml. . 34
enoxaparin sodium inj 40mg/0.4ml. . 34
enoxaparin sodium inj 60mg/0.6ml. . 34
enoxaparin sodium inj 80mg/0.8ml. . 34
enoxaparin sodium inj
100mg/ml, 150mg/ml . . . . . . . . . . . . . . 34
enoxaparin sodium inj
120mg/0.8ml. . . . . . . . . . . . . . . . . . . . . . 34
enoxaparin sodium inj 300mg/3ml . . 34
enpresse-28 . . . . . . . . . . . . . . . . . . . . . 44
enskyce . . . . . . . . . . . . . . . . . . . . . . . . . 44
entacapone . . . . . . . . . . . . . . . . . . . . . . 29
entecavir . . . . . . . . . . . . . . . . . . . . . . . . . 31
ENTRESTO . . . . . . . . . . . . . . . . . . . . . . 35
enulose . . . . . . . . . . . . . . . . . . . . . . . . . . 41
ENVARSUS XR . . . . . . . . . . . . . . . . . . 47
epinastine hcl . . . . . . . . . . . . . . . . . . . . 50
epinephrine hcl . . . . . . . . . . . . . . . . . . . 51
EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . 51
EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . 51
epirubicin hcl inj 50mg/25ml. . . . . . . . 27
epirubicin hcl inj 200mg/100ml . . . . . 27
epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
EPIVIR HBV ORAL SOLN . . . . . . . . . 31
EPIVIR ORAL SOLN . . . . . . . . . . . . . . 32
EPZICOM . . . . . . . . . . . . . . . . . . . . . . . 32
ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . 28
ergoloid mesylates . . . . . . . . . . . . . . . 23
ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . 28
errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
ERWINAZE . . . . . . . . . . . . . . . . . . . . . . 27
ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
ERYPED 200 . . . . . . . . . . . . . . . . . . . . 20
ERYPED 400 . . . . . . . . . . . . . . . . . . . . 20
ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . 20
ERYTHROCIN LACTOBIONATE . . 20
erythrocin stearate . . . . . . . . . . . . . . . 20
erythromycin base . . . . . . . . . . . . . . . . 21
erythromycin/benzoyl peroxide . . . . 40
erythromycin ethylsuccinate . . . . . . . 21
erythromycin external soln . . . . . . . . . 21
erythromycin gel . . . . . . . . . . . . . . . . . . 21
erythromycin oint . . . . . . . . . . . . . . . . . 21
erythromycin pads . . . . . . . . . . . . . . . . 21
ESBRIET . . . . . . . . . . . . . . . . . . . . . . . . 51
escitalopram oxalate . . . . . . . . . . . . . . 23
esgic caps . . . . . . . . . . . . . . . . . . . . . . . . 16
esomeprazole magnesium . . . . . . . . 41
esomeprazole sodium . . . . . . . . . . . . 41
estarylla . . . . . . . . . . . . . . . . . . . . . . . . . 44
estradiol/norethindrone acetate . . . . 44
estradiol pttw . . . . . . . . . . . . . . . . . . . . . 44
estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 44
E
econazole nitrate . . . . . . . . . . . . . . . . . 25
EDECRIN . . . . . . . . . . . . . . . . . . . . . . . . 38
ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . 40
EDURANT . . . . . . . . . . . . . . . . . . . . . . . 32
e.e.s. 400 . . . . . . . . . . . . . . . . . . . . . . . . 20
E.E.S. GRANULES . . . . . . . . . . . . . . . 20
EFFIENT TABS 5MG . . . . . . . . . . . . . . 35
EFFIENT TABS 10MG. . . . . . . . . . . . . 35
ELAPRASE . . . . . . . . . . . . . . . . . . . . . . 40
ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . 40
62
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
estradiol tabs . . . . . . . . . . . . . . . . . . . . . 44
estradiol valerate . . . . . . . . . . . . . . . . . 44
ESTRING . . . . . . . . . . . . . . . . . . . . . . . . 44
ethacrynate sodium . . . . . . . . . . . . . . 38
ethacrynic acid . . . . . . . . . . . . . . . . . . . 38
ethambutol hcl . . . . . . . . . . . . . . . . . . . 26
ethosuximide . . . . . . . . . . . . . . . . . . . . . 22
etidronate disodium . . . . . . . . . . . . . . 49
etodolac . . . . . . . . . . . . . . . . . . . . . . . . . 16
etodolac er . . . . . . . . . . . . . . . . . . . . . . . 16
ETOPOPHOS . . . . . . . . . . . . . . . . . . . . 28
etoposide inj
100mg/5ml, 1gm/50ml . . . . . . . . . . . . . 28
etoposide inj 500mg/25ml. . . . . . . . . . 28
EVOMELA . . . . . . . . . . . . . . . . . . . . . . . 26
EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . 32
exemestane . . . . . . . . . . . . . . . . . . . . . . 28
EXJADE . . . . . . . . . . . . . . . . . . . . . . . . . 52
fenofibrate micronized . . . . . . . . . . . . 38
fenofibrate tabs
145mg, 160mg, 48mg, 54mg. . . . . . . 38
fenofibric acid dr . . . . . . . . . . . . . . . . . 38
fenoprofen calcium caps 400mg. . . . 16
fenoprofen calcium tabs . . . . . . . . . . . 16
fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . 16
fentanyl citrate inj 100mcg/2ml . . . . . 17
fentanyl citrate oral transmucosal. . . 17
FERRIPROX . . . . . . . . . . . . . . . . . . . . . 49
FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . 23
FETZIMA TITRATION PACK . . . . . . 23
finasteride tabs 5mg. . . . . . . . . . . . . . . 42
FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . 47
FIRMAGON INJ 80MG. . . . . . . . . . . . . 46
FIRMAGON INJ 120MG . . . . . . . . . . . 46
flavoxate hcl . . . . . . . . . . . . . . . . . . . . . 42
FLEBOGAMMA DIF . . . . . . . . . . . . . . 47
flecainide acetate . . . . . . . . . . . . . . . . . 36
FLOVENT DISKUS AEPB
100MCG/BLIST . . . . . . . . . . . . . . . . . . . 50
FLOVENT DISKUS AEPB
250MCG/BLIST, 50MCG/BLIST . . . . 50
FLOVENT HFA AERO
44MCG/ACT . . . . . . . . . . . . . . . . . . . . . . 50
FLOVENT HFA AERO
110MCG/ACT, 220MCG/ACT. . . . . . . 50
fluconazole in dextrose . . . . . . . . . . . 25
fluconazole in nacl . . . . . . . . . . . . . . . . 25
fluconazole susr . . . . . . . . . . . . . . . . . . 25
fluconazole tabs
100mg, 200mg, 50mg. . . . . . . . . . . . . . 25
fluconazole tabs 150mg. . . . . . . . . . . . 25
flucytosine . . . . . . . . . . . . . . . . . . . . . . . 25
fludarabine phosphate . . . . . . . . . . . . 27
fludrocortisone acetate . . . . . . . . . . . 43
flunisolide . . . . . . . . . . . . . . . . . . . . . . . . 50
fluocinolone acetonide body . . . . . . . 43
fluocinolone acetonide crea . . . . . . . . 43
fluocinolone acetonide ear drops . . 43
fluocinolone acetonide
external soln . . . . . . . . . . . . . . . . . . . . . . 43
fluocinolone acetonide oil . . . . . . . . . . 50
fluocinolone acetonide oint . . . . . . . . 43
fluocinolone acetonide scalp . . . . . . 43
fluocinonide . . . . . . . . . . . . . . . . . . . . . . 43
fluocinonide-e . . . . . . . . . . . . . . . . . . . . 43
fluoride chew
0.25mg, 1.1mg, 2.2mg. . . . . . . . . . . . . 53
fluoritab chew 0.5mg, 1mg . . . . . . . . . 53
fluorometholone . . . . . . . . . . . . . . . . . . 50
fluorouracil crea 0.5%. . . . . . . . . . . . . . 40
fluorouracil crea 5% . . . . . . . . . . . . . . . 40
fluorouracil external soln . . . . . . . . . . . 40
fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 27
fluoxetine . . . . . . . . . . . . . . . . . . . . . . . . 24
fluoxetine dr . . . . . . . . . . . . . . . . . . . . . . 24
fluoxetine hcl caps . . . . . . . . . . . . . . . . 24
fluoxetine hcl oral soln . . . . . . . . . . . . . 24
fluoxetine hcl tabs 10mg, 20mg. . . . . 24
fluphenazine decanoate . . . . . . . . . . 30
fluphenazine hcl conc . . . . . . . . . . . . . 30
fluphenazine hcl elix . . . . . . . . . . . . . . 30
fluphenazine hcl inj . . . . . . . . . . . . . . . . 30
fluphenazine hcl tabs 1mg . . . . . . . . . 30
fluphenazine hcl tabs
10mg, 2.5mg, 5mg. . . . . . . . . . . . . . . . . 30
flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . 16
flurbiprofen sodium . . . . . . . . . . . . . . . 50
flutamide . . . . . . . . . . . . . . . . . . . . . . . . . 26
fluticasone propionate crea . . . . . . . . 43
fluticasone propionate oint . . . . . . . . . 43
fluticasone propionate susp . . . . . . . . 50
fluvastatin caps 20mg. . . . . . . . . . . . . . 38
fluvastatin caps 40mg. . . . . . . . . . . . . . 38
fluvoxamine maleate . . . . . . . . . . . . . . 24
fluvoxamine maleate er
cp24 100mg. . . . . . . . . . . . . . . . . . . . . . . 24
fluvoxamine maleate er
cp24 150mg. . . . . . . . . . . . . . . . . . . . . . . 24
FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . 27
F
FABRAZYME . . . . . . . . . . . . . . . . . . . . 40
falmina . . . . . . . . . . . . . . . . . . . . . . . . . . 44
famciclovir . . . . . . . . . . . . . . . . . . . . . . . 33
famotidine inj . . . . . . . . . . . . . . . . . . . . . 41
famotidine premixed . . . . . . . . . . . . . . 41
famotidine tabs 20mg. . . . . . . . . . . . . . 41
famotidine tabs 40mg. . . . . . . . . . . . . . 41
FANAPT TABS 1MG, 2MG, 4MG. . . 30
FANAPT TABS
10MG, 12MG, 6MG, 8MG. . . . . . . . . . 30
FANAPT TITRATION PACK . . . . . . . 30
FARESTON . . . . . . . . . . . . . . . . . . . . . . 26
FARYDAK . . . . . . . . . . . . . . . . . . . . . . . 28
FASLODEX . . . . . . . . . . . . . . . . . . . . . . 26
FAZACLO TBDP
100MG, 12.5MG, 25MG . . . . . . . . . . . 31
felbamate . . . . . . . . . . . . . . . . . . . . . . . . 22
felodipine er . . . . . . . . . . . . . . . . . . . . . . 37
FEMRING . . . . . . . . . . . . . . . . . . . . . . . 44
fenofibrate caps . . . . . . . . . . . . . . . . . . . 38
63
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
fomepizole . . . . . . . . . . . . . . . . . . . . . . . 49
fondaparinux sodium inj
2.5mg/0.5ml. . . . . . . . . . . . . . . . . . . . . . . 34
fondaparinux sodium inj
5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 34
fondaparinux sodium inj
7.5mg/0.6ml. . . . . . . . . . . . . . . . . . . . . . . 34
fondaparinux sodium inj
10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 34
FORADIL AEROLIZER . . . . . . . . . . . 51
FORTEO . . . . . . . . . . . . . . . . . . . . . . . . 49
fosinopril sodium . . . . . . . . . . . . . . . . . 36
fosinopril sodium/
hydrochlorothiazide . . . . . . . . . . . . . . . 36
fosphenytoin sodium . . . . . . . . . . . . . . 22
FOSRENOL . . . . . . . . . . . . . . . . . . . . . . 42
FREAMINE HBC 6.9% . . . . . . . . . . . . 53
FREAMINE III INJ
89MEQ/L; 710MG/100ML;
950MG/100ML; 3MEQ/L;
24MG/100ML; 1400MG/100ML;
280MG/100ML; 690MG/100ML;
910MG/100ML; 730MG/100ML;
530MG/100ML; 560MG/100ML;
10MMOLE/L; 120MG/100ML;
1120MG/100ML; 590MG/100ML;
10MEQ/L; 400MG/100ML;
150MG/100ML; 660MG/100ML. . . . . 53
furosemide inj . . . . . . . . . . . . . . . . . . . . 38
furosemide oral soln . . . . . . . . . . . . . . 38
furosemide tabs . . . . . . . . . . . . . . . . . . . 38
FUSILEV . . . . . . . . . . . . . . . . . . . . . . . . 27
FUZEON . . . . . . . . . . . . . . . . . . . . . . . . 32
FYCOMPA . . . . . . . . . . . . . . . . . . . . . . . 22
GAMASTAN S/D . . . . . . . . . . . . . . . . . 47
GAMMAGARD LIQUID INJ
2.5GM/25ML. . . . . . . . . . . . . . . . . . . . . . 48
GAMMAGARD LIQUID INJ
30GM/300ML . . . . . . . . . . . . . . . . . . . . . 48
GAMMAKED . . . . . . . . . . . . . . . . . . . . . 48
GAMMAPLEX INJ 5GM/100ML. . . . . 48
GAMMAPLEX INJ 10GM/200ML . . . 48
GAMUNEX-C INJ 1GM/10ML . . . . . . 48
GAMUNEX-C INJ 10GM/100ML,
2.5GM/25ML, 20GM/200ML,
40GM/400ML, 5GM/50ML. . . . . . . . . . 48
ganciclovir inj . . . . . . . . . . . . . . . . . . . . . 31
GARDASIL . . . . . . . . . . . . . . . . . . . . . . 48
GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . 48
GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . 41
gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . 41
gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . 41
gavilyte-n/flavor pack . . . . . . . . . . . . . 41
GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . 29
gemcitabine . . . . . . . . . . . . . . . . . . . . . . 27
gemcitabine hcl . . . . . . . . . . . . . . . . . . 27
gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . 38
generlac . . . . . . . . . . . . . . . . . . . . . . . . . 41
gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . 47
gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
gentamicin sulfate/
0.9% sodium chloride . . . . . . . . . . . . . 18
gentamicin sulfate crea . . . . . . . . . . . . 18
gentamicin sulfate inj . . . . . . . . . . . . . . 18
gentamicin sulfate oint . . . . . . . . . . . . 18
gentamicin sulfate ophthalmic soln. . 18
gentamicin sulfate pediatric . . . . . . . 18
GENVOYA . . . . . . . . . . . . . . . . . . . . . . . 32
GEODON INJ . . . . . . . . . . . . . . . . . . . . 30
gildagia . . . . . . . . . . . . . . . . . . . . . . . . . . 44
gildess 1.5/30 . . . . . . . . . . . . . . . . . . . . 44
gildess 1/20 . . . . . . . . . . . . . . . . . . . . . . 44
gildess fe 1.5/30 . . . . . . . . . . . . . . . . . . 44
gildess fe 1/20 . . . . . . . . . . . . . . . . . . . 44
GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . 28
glatopa . . . . . . . . . . . . . . . . . . . . . . . . . . 39
GLEEVEC . . . . . . . . . . . . . . . . . . . . . . . 28
GLEOSTINE . . . . . . . . . . . . . . . . . . . . . 26
glimepiride tabs 1mg, 2mg . . . . . . . . . 33
glimepiride tabs 4mg. . . . . . . . . . . . . . . 33
glipizide . . . . . . . . . . . . . . . . . . . . . . . . . . 33
glipizide er . . . . . . . . . . . . . . . . . . . . . . . 33
glipizide/metformin hcl . . . . . . . . . . . . 33
glipizide xl . . . . . . . . . . . . . . . . . . . . . . . 33
GLUCAGEN HYPOKIT . . . . . . . . . . . 34
glyburide/metformin hcl . . . . . . . . . . . 34
glycopyrrolate inj 0.2mg/ml,
0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 40
glycopyrrolate tabs . . . . . . . . . . . . . . . . 40
glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
GLYSET . . . . . . . . . . . . . . . . . . . . . . . . . 34
granisetron hcl inj
0.1mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 24
granisetron hcl inj 1mg/ml. . . . . . . . . . 24
granisetron hcl tabs . . . . . . . . . . . . . . . 24
griseofulvin microsize . . . . . . . . . . . . . 25
griseofulvin ultramicrosize . . . . . . . . 25
GUANIDINE HCL . . . . . . . . . . . . . . . . . 26
G
gabapentin . . . . . . . . . . . . . . . . . . . . . . . 22
GABITRIL TABS 12MG . . . . . . . . . . . . 22
GABITRIL TABS 16MG . . . . . . . . . . . . 22
galantamine hydrobromide cp24 . . . 23
galantamine hydrobromide
oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 23
galantamine hydrobromide tabs . . . . 23
64
H
HALAVEN . . . . . . . . . . . . . . . . . . . . . . . 27
halobetasol propionate . . . . . . . . . . . 43
haloperidol conc . . . . . . . . . . . . . . . . . . 30
haloperidol decanoate . . . . . . . . . . . . 30
haloperidol lactate . . . . . . . . . . . . . . . . 30
haloperidol tabs
0.5mg, 1mg, 2mg, 5mg . . . . . . . . . . . . 30
haloperidol tabs 10mg, 20mg. . . . . . . 30
HARVONI . . . . . . . . . . . . . . . . . . . . . . . . 32
HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . 48
heather . . . . . . . . . . . . . . . . . . . . . . . . . . 46
heparin sodium/d5w . . . . . . . . . . . . . . 34
heparin sodium inj
10000unit/ml, 1000unit/ml,
20000unit/ml, 2000unit/ml,
2500unit/ml, 5000unit/ml. . . . . . . . . . . 34
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
heparin sodium/nacl 0.9% . . . . . . . . 34
heparin sodium/nacl 0.45% inj
50unit/ml; 0.45% . . . . . . . . . . . . . . . . . . 34
heparin sodium/
sodium chloride 0.9% . . . . . . . . . . . . . 35
heparin sodium/
sodium chloride 0.9% premix . . . . . . 35
HEPATAMINE . . . . . . . . . . . . . . . . . . . . 53
HERCEPTIN . . . . . . . . . . . . . . . . . . . . . 29
HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . 39
HEXALEN . . . . . . . . . . . . . . . . . . . . . . . 26
HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . 48
HUMALOG . . . . . . . . . . . . . . . . . . . . . . 34
HUMALOG KWIKPEN . . . . . . . . . . . . 34
HUMALOG MIX 50/50 . . . . . . . . . . . . 34
HUMALOG MIX 50/50 KWIKPEN. . . 34
HUMALOG MIX 75/25 . . . . . . . . . . . . . 34
HUMALOG MIX 75/25 KWIKPEN. . . 34
HUMIRA INJ
10MG/0.2ML, 20MG/0.4ML . . . . . . . . 47
HUMIRA INJ 40MG/0.8ML . . . . . . . . . 47
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK . . . . . . . 47
HUMIRA PEN . . . . . . . . . . . . . . . . . . . . 47
HUMIRA PEN-CROHNS
DISEASESTARTER . . . . . . . . . . . . . . 47
HUMIRA PEN-PSORIASIS
STARTER . . . . . . . . . . . . . . . . . . . . . . . 47
HUMULIN 70/30 . . . . . . . . . . . . . . . . . 34
HUMULIN 70/30 KWIKPEN . . . . . . . 34
HUMULIN N . . . . . . . . . . . . . . . . . . . . . 34
HUMULIN N KWIKPEN . . . . . . . . . . . 34
HUMULIN R . . . . . . . . . . . . . . . . . . . . . 34
HUMULIN R U-500
(CONCENTRATED) . . . . . . . . . . . . . . 34
HUMULIN R U-500 KWIKPEN . . . . 34
hydralazine hcl inj . . . . . . . . . . . . . . . . . 38
hydralazine hcl tabs . . . . . . . . . . . . . . . 38
hydrochlorothiazide caps . . . . . . . . . . 38
hydrochlorothiazide tabs 12.5mg . . . 38
hydrochlorothiazide tabs
25mg, 50mg. . . . . . . . . . . . . . . . . . . . . . . 38
hydrocodone/acetaminophen
tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg . . . . . . . . . . . . . . . 17
hydrocodone bitartrate/
acetaminophen oral soln
325mg/15ml; 7.5mg/15ml . . . . . . . . . . 17
hydrocodone bitartrate/
acetaminophen tabs 300mg; 10mg,
300mg; 5mg, 300mg; 7.5mg. . . . . . . . 17
hydrocodone bitartrate/
acetaminophen tabs
325mg; 2.5mg. . . . . . . . . . . . . . . . . . . . . 17
hydrocodone/ibuprofen . . . . . . . . . . . 17
hydrocortisone/acetic acid . . . . . . . . 50
hydrocortisone butyrate . . . . . . . . . . . 43
hydrocortisone butyrate (lipophilic). . 43
hydrocortisone crea 1%, 2.5%. . . . . . 43
hydrocortisone enem . . . . . . . . . . . . . . 49
hydrocortisone in absorbase . . . . . . 43
hydrocortisone lotn 2.5%. . . . . . . . . . . 43
hydrocortisone oint 1%, 2.5% . . . . . . 43
hydrocortisone tabs . . . . . . . . . . . . . . . 43
hydrocortisone valerate . . . . . . . . . . . 43
hydromorphone hcl dosette . . . . . . . 17
hydromorphone hcl inj 1mg/ml,
2mg/ml, 4mg/ml, 500mg/50ml . . . . . . 17
hydromorphone hcl liqd . . . . . . . . . . . 17
hydromorphone hcl tabs . . . . . . . . . . . 17
hydroxychloroquine sulfate . . . . . . . . 29
hydroxyprogesterone caproate . . . . 46
hydroxyurea . . . . . . . . . . . . . . . . . . . . . 27
hyoscyamine sulfate elix . . . . . . . . . . . 40
hyoscyamine sulfate odt . . . . . . . . . . 41
hyoscyamine sulfate subl . . . . . . . . . . 41
hyoscyamine sulfate tabs . . . . . . . . . . 41
hyoscyamine sulfate tbdp . . . . . . . . . . 41
hyosyne elix . . . . . . . . . . . . . . . . . . . . . . 41
HYZAAR TABS 12.5MG; 50MG . . . . 35
HYZAAR TABS 12.5MG;
100MG, 25MG; 100MG. . . . . . . . . . . . 35
I
65
ibandronate sodium tabs . . . . . . . . . . 49
IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . 27
ibudone tabs 5mg; 200mg. . . . . . . . . . 17
ibuprofen susp . . . . . . . . . . . . . . . . . . . . 16
ibuprofen tabs
400mg, 600mg, 800mg . . . . . . . . . . . . 16
ICLUSIG . . . . . . . . . . . . . . . . . . . . . . . . . 28
idarubicin hcl inj 10mg/10ml. . . . . . . . 27
ifosfamide . . . . . . . . . . . . . . . . . . . . . . . 26
ILARIS . . . . . . . . . . . . . . . . . . . . . . . . . . 48
ILEVRO . . . . . . . . . . . . . . . . . . . . . . . . . 50
ilotycin . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
imatinib mesylate . . . . . . . . . . . . . . . . . 28
IMBRUVICA . . . . . . . . . . . . . . . . . . . . . 28
imipenem/cilastatin . . . . . . . . . . . . . . . 20
imipramine hcl . . . . . . . . . . . . . . . . . . . 24
imipramine pamoate . . . . . . . . . . . . . . 24
imiquimod . . . . . . . . . . . . . . . . . . . . . . . 40
IMOVAX RABIES (H.D.C.V.) . . . . . . 48
INCRELEX . . . . . . . . . . . . . . . . . . . . . . . 43
indapamide . . . . . . . . . . . . . . . . . . . . . . 38
INFANRIX . . . . . . . . . . . . . . . . . . . . . . . 48
INFUMORPH 200 . . . . . . . . . . . . . . . . 16
INFUMORPH 500 . . . . . . . . . . . . . . . . 16
INLYTA TABS 1MG. . . . . . . . . . . . . . . . 28
INLYTA TABS 5MG. . . . . . . . . . . . . . . . 28
INTELENCE TABS 25MG. . . . . . . . . . 32
INTELENCE TABS 100MG. . . . . . . . . 32
INTELENCE TABS 200MG. . . . . . . . . 32
INTRALIPID . . . . . . . . . . . . . . . . . . . . . 55
INTRON A INJ 10MU, 10MU/ML. . . . 31
INTRON A INJ 18MU, 50MU,
6000000UNIT/ML . . . . . . . . . . . . . . . . . 31
INTRON A W/DILUENT INJ
10MU, 50MU. . . . . . . . . . . . . . . . . . . . . . 31
INTRON A W/DILUENT INJ 18MU. . 31
introvale . . . . . . . . . . . . . . . . . . . . . . . . . 44
INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
INVEGA SUSTENNA INJ
39MG/0.25ML. . . . . . . . . . . . . . . . . . . . . 30
INVEGA SUSTENNA INJ
78MG/0.5ML. . . . . . . . . . . . . . . . . . . . . . 30
INVEGA SUSTENNA INJ
117MG/0.75ML. . . . . . . . . . . . . . . . . . . . 30
INVEGA SUSTENNA INJ
156MG/ML. . . . . . . . . . . . . . . . . . . . . . . . 30
INVEGA SUSTENNA INJ
234MG/1.5ML. . . . . . . . . . . . . . . . . . . . . 30
INVEGA TB24 1.5MG, 3MG. . . . . . . . 30
INVEGA TB24 6MG . . . . . . . . . . . . . . . 30
INVEGA TB24 9MG . . . . . . . . . . . . . . . 30
INVEGA TRINZA INJ
273MG/0.875ML . . . . . . . . . . . . . . . . . . 30
INVEGA TRINZA INJ
410MG/1.315ML . . . . . . . . . . . . . . . . . . 30
INVEGA TRINZA INJ
546MG/1.75ML. . . . . . . . . . . . . . . . . . . . 30
INVEGA TRINZA INJ
819MG/2.625ML . . . . . . . . . . . . . . . . . . 30
INVIRASE . . . . . . . . . . . . . . . . . . . . . . . 32
INVOKAMET . . . . . . . . . . . . . . . . . . . . . 34
INVOKANA . . . . . . . . . . . . . . . . . . . . . . 34
IPOL INACTIVATED IPV . . . . . . . . . . 48
ipratropium bromide/
albuterol sulfate . . . . . . . . . . . . . . . . . . 51
ipratropium bromide
inhalation soln . . . . . . . . . . . . . . . . . . . . 51
ipratropium bromide
nasal soln 0.03%. . . . . . . . . . . . . . . . . . 51
ipratropium bromide
nasal soln 0.06%. . . . . . . . . . . . . . . . . . 51
irbesartan . . . . . . . . . . . . . . . . . . . . . . . . 36
irbesartan/hydrochlorothiazide . . . . 36
IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . 28
irinotecan . . . . . . . . . . . . . . . . . . . . . . . . 27
ISENTRESS CHEW 25MG. . . . . . . . . 32
ISENTRESS CHEW 100MG . . . . . . . 32
ISENTRESS PACK . . . . . . . . . . . . . . . 32
ISENTRESS TABS . . . . . . . . . . . . . . . . 32
isoniazid inj . . . . . . . . . . . . . . . . . . . . . . . 26
isoniazid syrp . . . . . . . . . . . . . . . . . . . . . 26
isoniazid tabs 100mg . . . . . . . . . . . . . . 26
isoniazid tabs 300mg . . . . . . . . . . . . . . 26
isosorbide dinitrate er . . . . . . . . . . . . . 38
isosorbide dinitrate tabs . . . . . . . . . . . 38
isosorbide mononitrate . . . . . . . . . . . 39
isosorbide mononitrate er . . . . . . . . . 39
isotonic gentamicin inj
0.8mg/ml; 0.9%. . . . . . . . . . . . . . . . . . . . 18
isradipine . . . . . . . . . . . . . . . . . . . . . . . . 37
ISTODAX . . . . . . . . . . . . . . . . . . . . . . . . 27
itraconazole . . . . . . . . . . . . . . . . . . . . . . 25
ivermectin . . . . . . . . . . . . . . . . . . . . . . . 29
IXEMPRA KIT . . . . . . . . . . . . . . . . . . . . 27
IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . 48
KALYDECO . . . . . . . . . . . . . . . . . . . . . . 51
kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
kcl 0.3%/d5w/lr iv lac ring . . . . . . . . . 53
kcl 0.3%/d5w/nacl 0.9% . . . . . . . . . . . 53
kcl 0.3%/d5w/nacl 0.45% . . . . . . . . . 53
kcl 0.15%/d5w/lr . . . . . . . . . . . . . . . . . . 53
kcl 0.15%/d5w/nacl 0.2% . . . . . . . . . 53
kcl 0.15%/d5w/ nacl 0.3% . . . . . . . . . 53
kcl 0.15%/d5w/nacl 0.9% . . . . . . . . . 53
kcl 0.15%/d5w/nacl 0.45% . . . . . . . . 53
kcl 0.15%/d5w/nacl 0.225% . . . . . . . 53
kcl 0.075%/d5w/nacl 0.45% . . . . . . . 53
kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . 44
KETEK . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ketoconazole crea . . . . . . . . . . . . . . . . 25
ketoconazole sham . . . . . . . . . . . . . . . 25
ketoconazole tabs . . . . . . . . . . . . . . . . . 25
ketoprofen . . . . . . . . . . . . . . . . . . . . . . . 16
ketoprofen er . . . . . . . . . . . . . . . . . . . . . 16
ketorolac tromethamine
ophthalmic soln . . . . . . . . . . . . . . . . . . . 50
KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . 29
kimidess . . . . . . . . . . . . . . . . . . . . . . . . . 44
KINERET . . . . . . . . . . . . . . . . . . . . . . . . 47
KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . 48
kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . 53
klor-con 8 . . . . . . . . . . . . . . . . . . . . . . . . 53
klor-con 10 . . . . . . . . . . . . . . . . . . . . . . . 53
klor-con m10 . . . . . . . . . . . . . . . . . . . . . 53
klor-con m20 . . . . . . . . . . . . . . . . . . . . . 53
klor-con sprinkle . . . . . . . . . . . . . . . . . . 54
KORLYM . . . . . . . . . . . . . . . . . . . . . . . . 44
k-sol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . 45
KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . 40
KYNAMRO . . . . . . . . . . . . . . . . . . . . . . 38
J
JADENU . . . . . . . . . . . . . . . . . . . . . . . . . 52
JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . 28
JALYN . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
jantoven . . . . . . . . . . . . . . . . . . . . . . . . . 35
jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . 46
JENTADUETO . . . . . . . . . . . . . . . . . . . 34
JENTADUETO XR TB24
2.5MG; 1000MG. . . . . . . . . . . . . . . . . . . 34
JENTADUETO XR TB24
5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 34
JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . 27
juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . 44
junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . 44
junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 44
junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 44
K
KABIVEN . . . . . . . . . . . . . . . . . . . . . . . . 55
KADCYLA . . . . . . . . . . . . . . . . . . . . . . . 29
KALETRA ORAL SOLN . . . . . . . . . . . 32
KALETRA TABS 100MG; 25MG. . . . 32
KALETRA TABS 200MG; 50MG. . . . 32
66
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
L
LENVIMA 18 MG DAILY DOSE . . . . 28
LENVIMA 20 MG DAILY DOSE . . . . 28
LENVIMA 24 MG DAILY DOSE . . . . 28
lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . 51
letrozole . . . . . . . . . . . . . . . . . . . . . . . . . 28
leucovorin calcium inj
100mg, 350mg, 500mg, 50mg. . . . . . 27
leucovorin calcium tabs . . . . . . . . . . . 27
LEUKERAN . . . . . . . . . . . . . . . . . . . . . . 26
LEUKINE INJ 250MCG . . . . . . . . . . . . 35
leuprolide acetate . . . . . . . . . . . . . . . . 46
LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . 34
LEVEMIR FLEXTOUCH . . . . . . . . . . 34
levetiracetam er . . . . . . . . . . . . . . . . . . 22
levetiracetam inj . . . . . . . . . . . . . . . . . . 22
levetiracetam oral soln . . . . . . . . . . . . 22
levetiracetam tabs . . . . . . . . . . . . . . . . 22
levobunolol hcl . . . . . . . . . . . . . . . . . . . 50
levocarnitine inj . . . . . . . . . . . . . . . . . . . 49
levocarnitine oral soln . . . . . . . . . . . . . 49
levocarnitine tabs . . . . . . . . . . . . . . . . . 49
levocetirizine dihydrochloride
oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 51
levocetirizine dihydrochloride tabs . . 51
levofloxacin in d5w . . . . . . . . . . . . . . . 21
levofloxacin inj . . . . . . . . . . . . . . . . . . . . 21
levofloxacin oral soln . . . . . . . . . . . . . . 21
levofloxacin tabs . . . . . . . . . . . . . . . . . . 21
levoleucovorin calcium . . . . . . . . . . . . 27
levoleucovorin inj 250mg/25ml . . . . . 27
levonest . . . . . . . . . . . . . . . . . . . . . . . . . 45
levonorgestrel and ethinyl
estradiol tabs 0; 0 . . . . . . . . . . . . . . . . . 45
levonorgestrel/ethinyl estradiol . . . . 45
levora 0.15/30-28 . . . . . . . . . . . . . . . . . 45
levorphanol tartrate . . . . . . . . . . . . . . . 16
levothyroxine sodium tabs . . . . . . . . . 46
LEVOXYL . . . . . . . . . . . . . . . . . . . . . . . . 46
LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 32
LEXIVA TABS . . . . . . . . . . . . . . . . . . . . . 33
lidocaine hcl external soln . . . . . . . . . 17
lidocaine hcl gel . . . . . . . . . . . . . . . . . . . 17
lidocaine hcl inj 0.5%, 1%, 2%, 4% . 18
lidocaine hcl inj 10mg/ml, 20mg/ml. . 36
lidocaine hcl jelly . . . . . . . . . . . . . . . . . 18
lidocaine hcl mouth/throat soln . . . . . 18
lidocaine hcl viscous . . . . . . . . . . . . . . 18
lidocaine oint . . . . . . . . . . . . . . . . . . . . . 18
lidocaine/prilocaine crea . . . . . . . . . . . 18
lidocaine ptch . . . . . . . . . . . . . . . . . . . . . 18
lidocaine viscous . . . . . . . . . . . . . . . . . 18
LINCOCIN . . . . . . . . . . . . . . . . . . . . . . . 19
lincomycin hcl . . . . . . . . . . . . . . . . . . . . 19
lindane . . . . . . . . . . . . . . . . . . . . . . . . . . 29
linezolid inj 600mg/300ml . . . . . . . . . . 19
linezolid susr . . . . . . . . . . . . . . . . . . . . . 19
linezolid tabs . . . . . . . . . . . . . . . . . . . . . 19
LINZESS . . . . . . . . . . . . . . . . . . . . . . . . 41
liothyronine sodium inj . . . . . . . . . . . . . 46
liothyronine sodium tabs . . . . . . . . . . . 46
lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . 36
lisinopril/hydrochlorothiazide . . . . . . 36
lithium carbonate caps
150mg, 600mg . . . . . . . . . . . . . . . . . . . . 33
lithium carbonate caps 300mg. . . . . . 33
lithium carbonate er . . . . . . . . . . . . . . 33
lithium carbonate tabs . . . . . . . . . . . . . 33
LONSURF TABS 6.14MG; 15MG. . . 27
LONSURF TABS 8.19MG; 20MG. . . 27
loperamide hcl caps . . . . . . . . . . . . . . . 41
lopreeza . . . . . . . . . . . . . . . . . . . . . . . . . 45
lorazepam conc . . . . . . . . . . . . . . . . . . . 33
lorazepam inj 2mg/ml, 4mg/ml. . . . . . 33
lorazepam intensol . . . . . . . . . . . . . . . 33
lorazepam tabs . . . . . . . . . . . . . . . . . . . 33
lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . 17
lorcet plus tabs 325mg; 7.5mg. . . . . . 17
lortab tabs . . . . . . . . . . . . . . . . . . . . . . . . 17
labetalol hcl inj . . . . . . . . . . . . . . . . . . . . 36
labetalol hcl tabs . . . . . . . . . . . . . . . . . . 36
LACRISERT . . . . . . . . . . . . . . . . . . . . . 49
LACTATED RINGERS
DEXTROSE 5% VIAFLEX . . . . . . . . 54
LACTATED RINGERS INJ
3MEQ/L; 109MEQ/L; 28MEQ/L;
4MEQ/L; 130MEQ/L. . . . . . . . . . . . . . . 54
LACTATED RINGERS
IRRIGATION . . . . . . . . . . . . . . . . . . . . . 49
LACTATED RINGERS VIAFLEX. . . . 54
lactulose . . . . . . . . . . . . . . . . . . . . . . . . . 41
lamivudine . . . . . . . . . . . . . . . . . . . . . . . 31
lamivudine . . . . . . . . . . . . . . . . . . . . . . . 32
lamivudine/zidovudine . . . . . . . . . . . . 32
lamotrigine . . . . . . . . . . . . . . . . . . . . . . . 22
lamotrigine er . . . . . . . . . . . . . . . . . . . . 22
lamotrigine odt . . . . . . . . . . . . . . . . . . . 22
LANOXIN PEDIATRIC . . . . . . . . . . . . 37
LANOXIN TABS 125MCG. . . . . . . . . . 37
LANOXIN TABS 250MCG. . . . . . . . . . 37
lansoprazole . . . . . . . . . . . . . . . . . . . . . 41
lansoprazole/amoxicillin/
clarithromycin . . . . . . . . . . . . . . . . . . . . 19
LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . 34
LANTUS SOLOSTAR . . . . . . . . . . . . . 34
larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 45
larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . 45
larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 45
larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 45
latanoprost . . . . . . . . . . . . . . . . . . . . . . . 49
LATUDA TABS 80MG. . . . . . . . . . . . . . 30
LATUDA TABS
120MG, 20MG, 40MG, 60MG . . . . . . 30
LAZANDA . . . . . . . . . . . . . . . . . . . . . . . 17
leflunomide . . . . . . . . . . . . . . . . . . . . . . 48
LENVIMA 8 MG DAILY DOSE . . . . . 28
LENVIMA 10 MG DAILY DOSE . . . . 28
LENVIMA 14 MG DAILY DOSE . . . . 28
67
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
losartan potassium/
hydrochlorothiazide tabs
12.5mg; 50mg. . . . . . . . . . . . . . . . . . . . . 36
losartan potassium/
hydrochlorothiazide tabs
12.5mg; 100mg, 25mg; 100mg . . . . . 36
losartan potassium tabs 25mg. . . . . . 36
losartan potassium tabs 50mg. . . . . . 36
losartan potassium tabs 100mg. . . . . 36
LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . 50
LOTENSIN TABS 20MG, 40MG . . . . 36
lovastatin tabs 10mg, 20mg . . . . . . . . 38
lovastatin tabs 40mg. . . . . . . . . . . . . . . 38
low-ogestrel . . . . . . . . . . . . . . . . . . . . . . 45
loxapine . . . . . . . . . . . . . . . . . . . . . . . . . 30
loxapine succinate . . . . . . . . . . . . . . . . 30
ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . 49
LUMIZYME . . . . . . . . . . . . . . . . . . . . . . 40
LUPRON DEPOT INJ
3.75MG, 7.5MG . . . . . . . . . . . . . . . . . . . 46
LUPRON DEPOT INJ 11.25MG . . . . 46
LUPRON DEPOT INJ 22.5MG . . . . . 46
LUPRON DEPOT INJ 30MG . . . . . . . 46
LUPRON DEPOT INJ 45MG . . . . . . . 46
LUPRON DEPOT-PED . . . . . . . . . . . 46
lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
LYNPARZA . . . . . . . . . . . . . . . . . . . . . . 27
LYRICA CAPS 100MG, 150MG,
200MG, 25MG, 50MG, 75MG . . . . . . 22
LYRICA CAPS 225MG, 300MG. . . . . 22
LYRICA ORAL SOLN . . . . . . . . . . . . . . 22
LYSODREN . . . . . . . . . . . . . . . . . . . . . . 46
lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
magnesium sulfate inj
20gm/500ml, 2gm/50ml,
40gm/1000ml, 4gm/100ml,
4gm/50ml, 50%. . . . . . . . . . . . . . . . . . . . 54
MAKENA . . . . . . . . . . . . . . . . . . . . . . . . 46
malathion . . . . . . . . . . . . . . . . . . . . . . . . 29
maprotiline hcl . . . . . . . . . . . . . . . . . . . 23
margesic . . . . . . . . . . . . . . . . . . . . . . . . . 16
marlissa . . . . . . . . . . . . . . . . . . . . . . . . . 45
MARPLAN . . . . . . . . . . . . . . . . . . . . . . . 23
MATULANE . . . . . . . . . . . . . . . . . . . . . . 26
matzim la . . . . . . . . . . . . . . . . . . . . . . . . 37
MAVIK . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
meclizine hcl tabs . . . . . . . . . . . . . . . . . 24
meclofenamate sodium . . . . . . . . . . . 16
MEDROL TABS 2MG. . . . . . . . . . . . . . 43
medroxyprogesterone acetate inj . . 46
medroxyprogesterone
acetate tabs . . . . . . . . . . . . . . . . . . . . . . 46
mefloquine hcl . . . . . . . . . . . . . . . . . . . 29
megestrol acetate susp 40mg/ml . . . 46
megestrol acetate tabs . . . . . . . . . . . . 46
MEKINIST . . . . . . . . . . . . . . . . . . . . . . . 28
meloxicam tabs . . . . . . . . . . . . . . . . . . . 16
melphalan hydrochloride . . . . . . . . . . 26
memantine hcl tabs 5mg. . . . . . . . . . . 23
memantine hcl tabs 10mg. . . . . . . . . . 23
memantine hcl titration pak . . . . . . . . 23
memantine hydrochloride . . . . . . . . . 23
MENACTRA . . . . . . . . . . . . . . . . . . . . . 48
MENEST . . . . . . . . . . . . . . . . . . . . . . . . 45
MENHIBRIX . . . . . . . . . . . . . . . . . . . . . 48
MENOMUNE-A/C/Y/W-135 . . . . . . . 48
MENOSTAR . . . . . . . . . . . . . . . . . . . . . 45
MENVEO . . . . . . . . . . . . . . . . . . . . . . . . 48
mercaptopurine . . . . . . . . . . . . . . . . . . 27
meropenem . . . . . . . . . . . . . . . . . . . . . . 20
mesalamine . . . . . . . . . . . . . . . . . . . . . . 48
mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
MESNEX TABS . . . . . . . . . . . . . . . . . . . 27
MESTINON TIMESPAN . . . . . . . . . . . 26
metadate er . . . . . . . . . . . . . . . . . . . . . . 39
metaproterenol sulfate . . . . . . . . . . . . 51
metformin hcl . . . . . . . . . . . . . . . . . . . . 34
metformin hcl er tb24
500mg, 750mg . . . . . . . . . . . . . . . . . . . . 34
methadone hcl conc . . . . . . . . . . . . . . . 16
methadone hcl inj . . . . . . . . . . . . . . . . . 16
methadone hcl intensol . . . . . . . . . . . 16
methadone hcl oral soln 5mg/5ml. . . 16
methadone hcl oral soln 10mg/5ml. . 16
methadone hcl tabs . . . . . . . . . . . . . . . 16
methazolamide . . . . . . . . . . . . . . . . . . . 50
methenamine hippurate . . . . . . . . . . . 19
methimazole . . . . . . . . . . . . . . . . . . . . . 47
methotrexate . . . . . . . . . . . . . . . . . . . . . 47
methotrexate sodium inj
1gm, 1gm/40ml, 250mg/10ml,
50mg/2ml. . . . . . . . . . . . . . . . . . . . . . . . . 47
methoxsalen . . . . . . . . . . . . . . . . . . . . . 40
methscopolamine bromide . . . . . . . . 41
methyldopate hcl . . . . . . . . . . . . . . . . . 35
methylphenidate hcl er tbcr 10mg. . . 39
methylphenidate hcl er tbcr 20mg. . . 39
methylphenidate hcl sr . . . . . . . . . . . . 39
methylphenidate hcl tabs . . . . . . . . . . 39
methylprednisolone . . . . . . . . . . . . . . . 43
methylprednisolone acetate . . . . . . . 43
methylprednisolone dose pack . . . . 43
methylprednisolone
sodiumsuccinate inj 125mg, 40mg. . 43
metipranolol . . . . . . . . . . . . . . . . . . . . . . 50
metoclopramide hcl inj . . . . . . . . . . . . 41
metoclopramide hcl oral soln . . . . . . 41
metoclopramide hcl tabs 5mg . . . . . . 41
metoclopramide hcl tabs 10mg . . . . . 41
metolazone . . . . . . . . . . . . . . . . . . . . . . 38
metoprolol/hydrochlorothiazide . . . . 37
metoprolol succinate er . . . . . . . . . . . 36
metoprolol tartrate inj . . . . . . . . . . . . . . 37
M
magnesium sulfate in d5w inj
5%; 10mg/ml. . . . . . . . . . . . . . . . . . . . . . 54
MAGNESIUM SULFATE INJ
20GM/500ML, 2GM/50ML,
40GM/1000ML . . . . . . . . . . . . . . . . . . . . 54
68
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
metoprolol tartrate tabs . . . . . . . . . . . . 37
metronidazole crea . . . . . . . . . . . . . . . . 19
metronidazole gel . . . . . . . . . . . . . . . . . 19
metronidazole inj . . . . . . . . . . . . . . . . . . 19
metronidazole in nacl 0.79% . . . . . . 19
metronidazole lotn . . . . . . . . . . . . . . . . 19
metronidazole tabs . . . . . . . . . . . . . . . . 19
metronidazole vaginal . . . . . . . . . . . . 19
mexiletine hcl . . . . . . . . . . . . . . . . . . . . 36
MIACALCIN INJ . . . . . . . . . . . . . . . . . . 49
microgestin 1.5/30 . . . . . . . . . . . . . . . . 45
microgestin 1/20 . . . . . . . . . . . . . . . . . 45
microgestin fe . . . . . . . . . . . . . . . . . . . . 45
microgestin fe 1.5/30 . . . . . . . . . . . . . 45
midodrine hcl . . . . . . . . . . . . . . . . . . . . 35
migergot . . . . . . . . . . . . . . . . . . . . . . . . . 25
miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
mimvey . . . . . . . . . . . . . . . . . . . . . . . . . . 45
mimvey lo . . . . . . . . . . . . . . . . . . . . . . . . 45
minitran . . . . . . . . . . . . . . . . . . . . . . . . . . 39
MINIVELLE . . . . . . . . . . . . . . . . . . . . . . 45
minocycline hcl . . . . . . . . . . . . . . . . . . . 21
minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . 38
mirtazapine . . . . . . . . . . . . . . . . . . . . . . 23
mirtazapine odt . . . . . . . . . . . . . . . . . . . 23
misoprostol . . . . . . . . . . . . . . . . . . . . . . 41
mitomycin . . . . . . . . . . . . . . . . . . . . . . . . 27
mitoxantrone hcl . . . . . . . . . . . . . . . . . 27
M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . 48
modafinil tabs 100mg. . . . . . . . . . . . . . 52
modafinil tabs 200mg. . . . . . . . . . . . . . 52
moderiba 800 dose pack . . . . . . . . . . 32
moderiba 1200 dose pack . . . . . . . . 32
moderiba misc . . . . . . . . . . . . . . . . . . . . 32
moderiba tabs . . . . . . . . . . . . . . . . . . . . 32
moexipril hcl . . . . . . . . . . . . . . . . . . . . . 36
moexipril/hydrochlorothiazide . . . . . 36
molindone hydrochloride . . . . . . . . . . 31
mometasone furoate crea . . . . . . . . . 43
mometasone furoate external soln. . 43
mometasone furoate oint . . . . . . . . . . 43
mondoxyne nl . . . . . . . . . . . . . . . . . . . . 21
mono-linyah . . . . . . . . . . . . . . . . . . . . . . 45
montelukast sodium . . . . . . . . . . . . . . 51
morgidox 1x100mg caps . . . . . . . . . . 21
morgidox 2x100mg caps . . . . . . . . . . 21
MORPHINE SULFATE
ADD-VANTAGE . . . . . . . . . . . . . . . . . . 17
morphine sulfate er tbcr . . . . . . . . . . . 16
morphine sulfate inj
0.5mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 16
morphine sulfate inj
10mg/ml, 150mg/30ml, 15mg/ml,
1mg/ml, 25mg/ml, 2mg/ml,
4mg/ml, 50mg/ml, 8mg/ml. . . . . . . . . . 17
morphine sulfate oral soln
10mg/5ml. . . . . . . . . . . . . . . . . . . . . . . . . 17
morphine sulfate oral soln
20mg/5ml. . . . . . . . . . . . . . . . . . . . . . . . . 17
morphine sulfate oral soln
100mg/5ml. . . . . . . . . . . . . . . . . . . . . . . . 17
MORPHINE SULFATE TABS . . . . . . 17
MOVIPREP . . . . . . . . . . . . . . . . . . . . . . 41
MOXEZA . . . . . . . . . . . . . . . . . . . . . . . . 21
moxifloxacin hcl inj . . . . . . . . . . . . . . . . 21
moxifloxacin hcl tabs . . . . . . . . . . . . . . 21
MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . 54
MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . 36
mupirocin . . . . . . . . . . . . . . . . . . . . . . . . 19
MUSTARGEN . . . . . . . . . . . . . . . . . . . . 26
mycophenolate mofetil . . . . . . . . . . . . 47
mycophenolic acid dr . . . . . . . . . . . . . 47
myorisan . . . . . . . . . . . . . . . . . . . . . . . . . 40
myzilra . . . . . . . . . . . . . . . . . . . . . . . . . . 45
naftifine hcl . . . . . . . . . . . . . . . . . . . . . . 25
naftifine hydrochloride . . . . . . . . . . . . 25
NAFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 25
NAGLAZYME . . . . . . . . . . . . . . . . . . . . 40
nalbuphine hcl . . . . . . . . . . . . . . . . . . . 17
naloxone hcl . . . . . . . . . . . . . . . . . . . . . 18
naltrexone hcl . . . . . . . . . . . . . . . . . . . . 18
NAMENDA ORAL SOLN . . . . . . . . . . 23
NAMENDA TABS 5MG. . . . . . . . . . . . . 23
NAMENDA TABS 10MG . . . . . . . . . . . 23
NAMENDA TITRATION PAK . . . . . . 23
NAMENDA XR . . . . . . . . . . . . . . . . . . . 23
NAMENDA XR TITRATION PACK . . 23
NAMZARIC . . . . . . . . . . . . . . . . . . . . . . 23
naphazoline hcl . . . . . . . . . . . . . . . . . . 49
naproxen dr . . . . . . . . . . . . . . . . . . . . . . 16
naproxen sodium tabs
275mg, 550mg . . . . . . . . . . . . . . . . . . . . 16
naproxen susp . . . . . . . . . . . . . . . . . . . . 16
naproxen tabs . . . . . . . . . . . . . . . . . . . . 16
naratriptan hcl . . . . . . . . . . . . . . . . . . . . 26
NARCAN . . . . . . . . . . . . . . . . . . . . . . . . 18
NATACYN . . . . . . . . . . . . . . . . . . . . . . . 25
nateglinide . . . . . . . . . . . . . . . . . . . . . . . 34
NATPARA . . . . . . . . . . . . . . . . . . . . . . . . 49
NEBUPENT . . . . . . . . . . . . . . . . . . . . . . 29
necon 0.5/35-28 . . . . . . . . . . . . . . . . . . 45
necon 1/35 . . . . . . . . . . . . . . . . . . . . . . . 45
necon 1/50-28 . . . . . . . . . . . . . . . . . . . . 45
necon 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 45
necon 10/11-28 . . . . . . . . . . . . . . . . . . . 45
nefazodone hcl . . . . . . . . . . . . . . . . . . . 23
neomycin/bacitracin/polymyxin . . . . 19
neomycin/polymyxin/bacitracin/
hydrocortisone . . . . . . . . . . . . . . . . . . . 19
neomycin/polymyxin b sulfates . . . . 18
neomycin/polymyxin/
dexamethasone . . . . . . . . . . . . . . . . . . 50
neomycin/polymyxin/gramicidin . . . 19
neomycin/polymyxin/hc . . . . . . . . . . . 50
N
nabumetone . . . . . . . . . . . . . . . . . . . . . 16
nadolol/bendroflumethiazide . . . . . . 37
nadolol tabs 20mg, 40mg . . . . . . . . . . 37
nadolol tabs 80mg. . . . . . . . . . . . . . . . . 37
nafcillin sodium . . . . . . . . . . . . . . . . . . . 20
69
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
neomycin/polymyxin/
hydrocortisone . . . . . . . . . . . . . . . . . . . 19
neomycin/polymyxin/
hydrocortisone . . . . . . . . . . . . . . . . . . . 50
neomycin sulfate . . . . . . . . . . . . . . . . . 18
NEPHRAMINE . . . . . . . . . . . . . . . . . . . 54
NEULASTA . . . . . . . . . . . . . . . . . . . . . . 35
NEUPOGEN . . . . . . . . . . . . . . . . . . . . . 35
NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . 29
nevirapine er . . . . . . . . . . . . . . . . . . . . . 32
nevirapine susp . . . . . . . . . . . . . . . . . . . 32
nevirapine tabs . . . . . . . . . . . . . . . . . . . 32
NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . 28
niacin er tbcr 500mg. . . . . . . . . . . . . . . 38
niacin er tbcr 1000mg, 750mg. . . . . . 38
niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
nicardipine hcl caps . . . . . . . . . . . . . . . 37
nicardipine hcl inj . . . . . . . . . . . . . . . . . 37
NICOTROL INHALER . . . . . . . . . . . . 18
NICOTROL NS . . . . . . . . . . . . . . . . . . . 18
nifedical xl . . . . . . . . . . . . . . . . . . . . . . . 37
nifedipine er . . . . . . . . . . . . . . . . . . . . . . 37
NILANDRON . . . . . . . . . . . . . . . . . . . . . 26
nimodipine . . . . . . . . . . . . . . . . . . . . . . . 37
NINLARO . . . . . . . . . . . . . . . . . . . . . . . . 27
NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . 27
nisoldipine . . . . . . . . . . . . . . . . . . . . . . . 37
nisoldipine er . . . . . . . . . . . . . . . . . . . . . 37
nitrofurantoin . . . . . . . . . . . . . . . . . . . . . 19
nitrofurantoin macrocrystals
caps 100mg, 50mg . . . . . . . . . . . . . . . . 19
nitrofurantoin monohydrate . . . . . . . . 19
nitrofurantoin monohydrate/
macrocrystals . . . . . . . . . . . . . . . . . . . . 19
nitroglycerin . . . . . . . . . . . . . . . . . . . . . . 39
nitroglycerin lingual
translingual soln . . . . . . . . . . . . . . . . . . 39
nitroglycerin transdermal . . . . . . . . . . 39
NITROSTAT . . . . . . . . . . . . . . . . . . . . . 39
nizatidine caps . . . . . . . . . . . . . . . . . . . . 41
norethindrone . . . . . . . . . . . . . . . . . . . . 46
norethindrone acetate . . . . . . . . . . . . 46
norethindrone acetate/ethinyl
estradiol/ferrous fumarate . . . . . . . . . 45
norethindrone acetate/ethinyl
estradiol tabs 20mcg; 1mg . . . . . . . . . 45
norgestimate/ethinyl estradiol . . . . . 45
NORITATE . . . . . . . . . . . . . . . . . . . . . . . 19
norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . 46
NORMOSOL-M IN D5W . . . . . . . . . . 54
NORMOSOL -R . . . . . . . . . . . . . . . . . . 54
NORMOSOL-R . . . . . . . . . . . . . . . . . . 54
NORMOSOL-R IN D5W . . . . . . . . . . 54
NORTHERA . . . . . . . . . . . . . . . . . . . . . 37
nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . 45
nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . 45
nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 45
nortriptyline hcl caps . . . . . . . . . . . . . . 24
nortriptyline hcl oral soln . . . . . . . . . . . 24
NORVIR . . . . . . . . . . . . . . . . . . . . . . . . . 33
NOVAREL . . . . . . . . . . . . . . . . . . . . . . . 44
novofine 30gx8mm . . . . . . . . . . . . . . . 49
novofine 31 . . . . . . . . . . . . . . . . . . . . . . 49
novofine 32gx6mm . . . . . . . . . . . . . . . 49
novofine autocover 30gx8mm . . . . . 49
novotwist 30gx8mm . . . . . . . . . . . . . . 49
novotwist 32gx5mm . . . . . . . . . . . . . . 49
NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 25
NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 25
NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . 39
nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . 47
NUPLAZID . . . . . . . . . . . . . . . . . . . . . . . 30
NUTRILIPID . . . . . . . . . . . . . . . . . . . . . 55
NUTRILYTE INJ 2.03MEQ/ML;
0.25MEQ/ML; 1.68MEQ/ML;
0.25MEQ/ML; 0.4MEQ/ML;
2.03MEQ/ML; 1.25MEQ . . . . . . . . . . . 54
NUVIGIL . . . . . . . . . . . . . . . . . . . . . . . . . 52
nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . 25
nystatin crea . . . . . . . . . . . . . . . . . . . . . . 25
nystatin oint . . . . . . . . . . . . . . . . . . . . . . 25
nystatin powd 100000unit/gm . . . . . . 25
nystatin susp . . . . . . . . . . . . . . . . . . . . . 25
nystatin tabs . . . . . . . . . . . . . . . . . . . . . . 25
nystatin/triamcinolone . . . . . . . . . . . . 25
nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
70
Needles and Syringes
bd eclipse syringe/1ml/30gx1/2” . . . 55
bd insulin syringe safetyglide/
1ml/29g x 1/2” . . . . . . . . . . . . . . . . . . . . 55
bd insulin syringe ultrafine/
0.3ml/31g x 5/16” . . . . . . . . . . . . . . . . . 55
bd insulin syringe ultrafine/
0.5ml/30g x 1/2” . . . . . . . . . . . . . . . . . . 55
bd insulin syringe ultrafine/
1ml/31g x 5/16” . . . . . . . . . . . . . . . . . . 55
bd pen needle/mini/ultrafine/
31g x 3/16” . . . . . . . . . . . . . . . . . . . . . . . 55
bd pen needle/nano/ultra fine/
32g x 4mm . . . . . . . . . . . . . . . . . . . . . . . 55
bd pen needle/ultrafine/
29g x 12.7mm . . . . . . . . . . . . . . . . . . . . 55
O
OCTAGAM INJ 10GM/100ML,
1GM/20ML, 20GM/200ML,
2GM/20ML, 5GM/50ML. . . . . . . . . . . . 48
octreotide acetate inj 100mcg/ml,
200mcg/ml, 50mcg/ml . . . . . . . . . . . . . 46
octreotide acetate inj
1000mcg/ml, 500mcg/ml. . . . . . . . . . . 46
ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . 32
ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . 27
ofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . 21
ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . 45
olanzapine/fluoxetine . . . . . . . . . . . . . 24
olanzapine inj . . . . . . . . . . . . . . . . . . . . . 31
olanzapine odt . . . . . . . . . . . . . . . . . . . 31
olanzapine tabs . . . . . . . . . . . . . . . . . . . 31
olopatadine hcl ophthalmic soln . . . . 50
OLYSIO . . . . . . . . . . . . . . . . . . . . . . . . . 32
omega-3-acid ethyl esters . . . . . . . . 38
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
omeprazole cpdr . . . . . . . . . . . . . . . . . . 41
ONCASPAR . . . . . . . . . . . . . . . . . . . . . 27
ondansetron hcl inj
40mg/20ml, 4mg/2ml . . . . . . . . . . . . . . 24
ondansetron hcl oral soln . . . . . . . . . . 24
ondansetron hcl tabs 4mg, 8mg . . . . 24
ondansetron hcl tabs 24mg . . . . . . . . 24
ondansetron odt . . . . . . . . . . . . . . . . . . 24
ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 22
ONFI TABS 10MG. . . . . . . . . . . . . . . . . 22
ONFI TABS 20MG. . . . . . . . . . . . . . . . . 22
OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . 29
OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . 51
oralone . . . . . . . . . . . . . . . . . . . . . . . . . . 39
ORAP . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . 40
orphenadrine citrate er . . . . . . . . . . . . 52
orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . 45
oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . 41
OSMOPREP . . . . . . . . . . . . . . . . . . . . . 41
oxacillin sodium . . . . . . . . . . . . . . . . . . 20
oxaliplatin . . . . . . . . . . . . . . . . . . . . . . . . 27
oxandrolone tabs 2.5mg . . . . . . . . . . . 44
oxandrolone tabs 10mg. . . . . . . . . . . . 44
oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . 16
oxazepam . . . . . . . . . . . . . . . . . . . . . . . 33
oxcarbazepine . . . . . . . . . . . . . . . . . . . 22
oxybutynin chloride . . . . . . . . . . . . . . . 42
oxybutynin chloride er tb24 5mg. . . . 42
oxybutynin chloride er tb24
10mg, 15mg. . . . . . . . . . . . . . . . . . . . . . . 42
oxycodone/acetaminophen tabs
325mg; 10mg, 325mg; 2.5mg,
325mg; 5mg, 325mg; 7.5mg. . . . . . . . 17
oxycodone/aspirin . . . . . . . . . . . . . . . . 17
oxycodone hcl caps . . . . . . . . . . . . . . . 17
oxycodone hcl conc . . . . . . . . . . . . . . . 17
oxycodone hcl oral soln . . . . . . . . . . . 17
oxycodone hcl tabs . . . . . . . . . . . . . . . 17
oxycodone/ibuprofen . . . . . . . . . . . . . 17
oxymorphone hydrochloride er . . . . 16
PERFOROMIST . . . . . . . . . . . . . . . . . . 51
PERIKABIVEN . . . . . . . . . . . . . . . . . . . 54
perindopril erbumine . . . . . . . . . . . . . . 36
periogard . . . . . . . . . . . . . . . . . . . . . . . . 39
PERJETA . . . . . . . . . . . . . . . . . . . . . . . . 29
permethrin . . . . . . . . . . . . . . . . . . . . . . . 29
perphenazine . . . . . . . . . . . . . . . . . . . . 30
perphenazine/amitriptyline . . . . . . . . 24
pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . 20
phenadoz . . . . . . . . . . . . . . . . . . . . . . . . 24
phenazopyridine hcl . . . . . . . . . . . . . . 42
phenelzine sulfate . . . . . . . . . . . . . . . . 23
phenergan supp . . . . . . . . . . . . . . . . . . 24
phenobarbital . . . . . . . . . . . . . . . . . . . . 22
phenoxybenzamine hydrochloride . . 35
phenytoin . . . . . . . . . . . . . . . . . . . . . . . . 22
phenytoin infatabs . . . . . . . . . . . . . . . . 22
phenytoin sodium . . . . . . . . . . . . . . . . 22
phenytoin sodium extended . . . . . . . 22
philith . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . 42
phospha 250 neutral . . . . . . . . . . . . . . 54
PHOSPHOLINE IODIDE . . . . . . . . . . 50
PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . 49
PHYSIOSOL IRRIGATION . . . . . . . . 49
PICATO . . . . . . . . . . . . . . . . . . . . . . . . . 40
pilocarpine hcl ophthalmic soln . . . . . 50
pilocarpine hcl tabs . . . . . . . . . . . . . . . 39
pilocarpine hydrochloride . . . . . . . . . 39
pimozide . . . . . . . . . . . . . . . . . . . . . . . . . 30
pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . 45
pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . 37
pioglitazone hcl . . . . . . . . . . . . . . . . . . 34
pioglitazone hcl-glimepiride . . . . . . . 34
pioglitazone hcl/metformin hcl . . . . . 34
piperacillin sodium/
tazobactam sodium . . . . . . . . . . . . . . . 20
piperacillin sodium/
tazobactam sodium . . . . . . . . . . . . . . . 20
piperacillin/tazobactam . . . . . . . . . . . 20
P
pacerone . . . . . . . . . . . . . . . . . . . . . . . . 36
paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . 27
paliperidone er tb24 1.5mg, 3mg . . . 31
paliperidone er tb24 6mg. . . . . . . . . . . 31
paliperidone er tb24 9mg. . . . . . . . . . . 31
pamidronate disodium . . . . . . . . . . . . 49
PANRETIN . . . . . . . . . . . . . . . . . . . . . . . 29
pantoprazole sodium tbec . . . . . . . . . 41
paricalcitol caps . . . . . . . . . . . . . . . . . . . 49
paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
paromomycin sulfate . . . . . . . . . . . . . 18
paroxetine hcl er tb24 12.5mg. . . . . . 24
paroxetine hcl er tb24 25mg. . . . . . . . 24
paroxetine hcl er tb24 37.5mg. . . . . . 24
paroxetine hcl tabs 10mg . . . . . . . . . . 24
paroxetine hcl tabs 20mg . . . . . . . . . . 24
paroxetine hcl tabs 30mg, 40mg. . . . 24
PASER . . . . . . . . . . . . . . . . . . . . . . . . . . 26
PATADAY . . . . . . . . . . . . . . . . . . . . . . . . 50
PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 24
PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . 50
PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . 48
peg 3350/electrolytes . . . . . . . . . . . . . 41
peg-3350/electrolytes . . . . . . . . . . . . . 41
peg-3350/nacl/na bicarbonate/kcl. . . 41
PEGANONE . . . . . . . . . . . . . . . . . . . . . 22
PEGINTRON . . . . . . . . . . . . . . . . . . . . 32
PEG-INTRON REDIPEN . . . . . . . . . . 32
PEG-INTRON REDIPEN PAK 4 . . . 32
penicillin g potassium inj
20000000unit, 5000000unit . . . . . . . . 20
penicillin v potassium oral soln . . . . . 20
penicillin v potassium tabs 250mg . . 20
penicillin v potassium tabs 500mg . . 20
PENTAM 300 . . . . . . . . . . . . . . . . . . . . 29
pentoxifylline er . . . . . . . . . . . . . . . . . . 37
71
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . 45
pirmella 7/7/7 . . . . . . . . . . . . . . . . . . . . 45
piroxicam . . . . . . . . . . . . . . . . . . . . . . . . 16
PLENAMINE . . . . . . . . . . . . . . . . . . . . . 54
podofilox . . . . . . . . . . . . . . . . . . . . . . . . . 40
polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
polyethylene glycol 3350 powd . . . . . 41
polymyxin b sulfate . . . . . . . . . . . . . . . 19
polymyxin b sulfate/
trimethoprim sulfate . . . . . . . . . . . . . . 19
POMALYST . . . . . . . . . . . . . . . . . . . . . . 26
portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . 45
PORTRAZZA . . . . . . . . . . . . . . . . . . . . 27
potassium chloride 0.3%/d5w . . . . . 54
potassium chloride 0.3%/
nacl 0.9% . . . . . . . . . . . . . . . . . . . . . . . . 54
potassium chloride 0.3%/
nacl 0.9%/viaflex . . . . . . . . . . . . . . . . . 54
potassium chloride 0.15%/d5w . . . . 54
potassium chloride 0.15% d5w/
nacl 0.33% . . . . . . . . . . . . . . . . . . . . . . . 54
potassium chloride 0.15% d5w/
nacl 0.45% . . . . . . . . . . . . . . . . . . . . . . . 54
potassium chloride 0.15% d5w/
nacl 0.45% viaflex . . . . . . . . . . . . . . . 54
potassium chloride 0.15%/
nacl 0.9% . . . . . . . . . . . . . . . . . . . . . . . . 54
potassium chloride 0.15% /
nacl 0.45% viaflex . . . . . . . . . . . . . . . . 54
POTASSIUM CHLORIDE 0.15%
W/NACL 0.9% VIAFLEX . . . . . . . . . . 54
potassium chloride 0.22% d5w/
nacl 0.45% . . . . . . . . . . . . . . . . . . . . . . . 54
potassium chloride 0.224%/d5w/
nacl 0.45% . . . . . . . . . . . . . . . . . . . . . . . 54
potassium chloride cr . . . . . . . . . . . . . 54
potassium chloride er cpcr . . . . . . . . . 54
potassium chloride er tbcr . . . . . . . . . 54
potassium chloride inj
10meq/100ml, 20meq/100ml,
2meq/ml, 40meq/100ml. . . . . . . . . . . . 54
potassium chloride oral soln . . . . . . . 54
potassium chloride pack . . . . . . . . . . . 54
potassium chloride sr . . . . . . . . . . . . . 54
potassium citrate er . . . . . . . . . . . . . . 54
POTIGA . . . . . . . . . . . . . . . . . . . . . . . . . 22
PRADAXA . . . . . . . . . . . . . . . . . . . . . . . 35
pramipexole dihydrochloride . . . . . . 29
pramipexole dihydrochloride er
tb24 0.375mg, 0.75mg, 1.5mg. . . . . . 29
pramipexole dihydrochloride er
tb24 2.25mg, 3.75mg, 3mg, 4.5mg. . 29
pravastatin sodium tabs
10mg, 20mg. . . . . . . . . . . . . . . . . . . . . . . 38
pravastatin sodium tabs 40mg. . . . . . 38
pravastatin sodium tabs 80mg. . . . . . 38
prazosin hcl . . . . . . . . . . . . . . . . . . . . . . 35
PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . 50
PRED-G S.O.P. . . . . . . . . . . . . . . . . . . 50
PRED MILD . . . . . . . . . . . . . . . . . . . . . . 50
prednicarbate oint . . . . . . . . . . . . . . . . . 43
prednisolone acetate . . . . . . . . . . . . . 50
prednisolone oral soln . . . . . . . . . . . . . 43
prednisolone sodium phosphate
ophthalmic soln . . . . . . . . . . . . . . . . . . . 50
prednisolone sodium phosphate
oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 43
prednisone intensol . . . . . . . . . . . . . . . 43
prednisone oral soln . . . . . . . . . . . . . . 43
prednisone tabs
10mg, 1mg, 2.5mg, 20mg, 5mg. . . . . 43
prednisone tabs 50mg . . . . . . . . . . . . . 43
prednisone tbpk . . . . . . . . . . . . . . . . . . . 43
PREGNYL W/DILUENT BENZYL
ALCOHOL/NACL . . . . . . . . . . . . . . . . . 44
PREMARIN CREA . . . . . . . . . . . . . . . . 45
PREMARIN INJ . . . . . . . . . . . . . . . . . . . 45
PREMARIN TABS . . . . . . . . . . . . . . . . 45
PREMASOL INJ 52MEQ/L;
1760MG/100ML; 880MG/100ML;
34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML;
526MG/100ML; 492MG/100ML;
492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML;
390MG/100ML; 34MG/100ML;
152MG/100ML . . . . . . . . . . . . . . . . . . . . 54
premasol inj 56meq/l; 320mg/100ml;
730mg/100ml; 190mg/100ml;
3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml;
490mg/100ml; 840mg/100ml;
490mg/100ml; 200mg/100ml;
290mg/100ml; 410mg/100ml;
230mg/100ml; 5meq/l; 15mg/100ml;
250mg/100ml; 120mg/100ml;
140mg/100ml; 470mg/100ml . . . . . . . 54
premium lidocaine . . . . . . . . . . . . . . . . 18
prevalite . . . . . . . . . . . . . . . . . . . . . . . . . 38
previfem . . . . . . . . . . . . . . . . . . . . . . . . . 45
PREZCOBIX . . . . . . . . . . . . . . . . . . . . . 33
PREZISTA SUSP . . . . . . . . . . . . . . . . . 33
PREZISTA TABS 75MG. . . . . . . . . . . . 33
PREZISTA TABS 150MG. . . . . . . . . . . 33
PREZISTA TABS 600MG. . . . . . . . . . . 33
PREZISTA TABS 800MG. . . . . . . . . . . 33
PRIMAQUINE PHOSPHATE . . . . . . 29
primidone . . . . . . . . . . . . . . . . . . . . . . . . 22
PRIMSOL . . . . . . . . . . . . . . . . . . . . . . . . 19
PRINIVIL . . . . . . . . . . . . . . . . . . . . . . . . 36
PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . 24
PRIVIGEN INJ 10GM/100ML,
5GM/50ML. . . . . . . . . . . . . . . . . . . . . . . . 48
PRIVIGEN INJ 20GM/200ML. . . . . . . 48
PROAIR HFA . . . . . . . . . . . . . . . . . . . . 51
PROAIR RESPICLICK . . . . . . . . . . . . 51
probenecid . . . . . . . . . . . . . . . . . . . . . . . 25
probenecid/colchicine . . . . . . . . . . . . . 25
PROCALAMINE . . . . . . . . . . . . . . . . . . 54
procentra . . . . . . . . . . . . . . . . . . . . . . . . 39
prochlorperazine . . . . . . . . . . . . . . . . . 30
72
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
prochlorperazine edisylate . . . . . . . . 30
prochlorperazine maleate
tabs 5mg. . . . . . . . . . . . . . . . . . . . . . . . . . 30
prochlorperazine maleate
tabs 10mg . . . . . . . . . . . . . . . . . . . . . . . . 30
PROCRIT INJ
10000UNIT/ML, 2000UNIT/ML,
3000UNIT/ML, 4000UNIT/ML . . . . . . 35
PROCRIT INJ
20000UNIT/ML, 40000UNIT/ML. . . . 35
procto-med hc . . . . . . . . . . . . . . . . . . . . 43
procto-pak . . . . . . . . . . . . . . . . . . . . . . . 43
proctosol hc . . . . . . . . . . . . . . . . . . . . . . 43
proctozone-hc . . . . . . . . . . . . . . . . . . . . 43
progesterone caps . . . . . . . . . . . . . . . . 46
PROGLYCEM . . . . . . . . . . . . . . . . . . . . 34
PROGRAF INJ . . . . . . . . . . . . . . . . . . . 47
PROLASTIN-C . . . . . . . . . . . . . . . . . . . 52
PROLEUKIN . . . . . . . . . . . . . . . . . . . . . 27
PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . 49
PROMACTA TABS
12.5MG, 25MG, 50MG. . . . . . . . . . . . . 35
promethazine hcl inj . . . . . . . . . . . . . . . 24
promethazine hcl plain . . . . . . . . . . . . 24
promethazine hcl supp . . . . . . . . . . . . 24
promethazine hcl syrp . . . . . . . . . . . . . 24
promethazine hcl tabs
12.5mg, 50mg. . . . . . . . . . . . . . . . . . . . . 24
promethazine hcl tabs 25mg . . . . . . . 24
promethegan . . . . . . . . . . . . . . . . . . . . . 24
propafenone hcl . . . . . . . . . . . . . . . . . . 36
propafenone hcl er . . . . . . . . . . . . . . . 36
propantheline bromide . . . . . . . . . . . . 41
proparacaine hcl . . . . . . . . . . . . . . . . . 49
propranolol hcl er . . . . . . . . . . . . . . . . . 37
propranolol hcl inj . . . . . . . . . . . . . . . . . 37
propranolol hcl oral soln . . . . . . . . . . . 37
propranolol hcl tabs
10mg, 20mg, 40mg, 80mg . . . . . . . . . 37
propranolol hcl tabs 60mg. . . . . . . . . . 37
propranolol/hydrochlorothiazide . . . 37
propylthiouracil . . . . . . . . . . . . . . . . . . . 47
PROQUAD . . . . . . . . . . . . . . . . . . . . . . 48
PROSOL . . . . . . . . . . . . . . . . . . . . . . . . 54
PROTOPIC . . . . . . . . . . . . . . . . . . . . . . 40
protriptyline hcl . . . . . . . . . . . . . . . . . . . 24
PRUDOXIN . . . . . . . . . . . . . . . . . . . . . . 40
PULMOZYME . . . . . . . . . . . . . . . . . . . . 51
PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . 27
pyrazinamide . . . . . . . . . . . . . . . . . . . . 26
pyridostigmine bromide . . . . . . . . . . . 26
reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . 45
RECOMBIVAX HB . . . . . . . . . . . . . . . 48
REGONOL . . . . . . . . . . . . . . . . . . . . . . . 26
REGRANEX . . . . . . . . . . . . . . . . . . . . . 40
RELISTOR INJ 8MG/0.4ML. . . . . . . . 41
RELISTOR INJ 12MG/0.6ML. . . . . . . 41
REMICADE . . . . . . . . . . . . . . . . . . . . . . 47
REMODULIN . . . . . . . . . . . . . . . . . . . . 51
RENVELA PACK . . . . . . . . . . . . . . . . . . 42
RENVELA TABS . . . . . . . . . . . . . . . . . . 42
repaglinide . . . . . . . . . . . . . . . . . . . . . . . 34
REPATHA . . . . . . . . . . . . . . . . . . . . . . . . 38
REPATHA SURECLICK . . . . . . . . . . . 38
reprexain tabs 10mg; 200mg. . . . . . . 17
RESCRIPTOR . . . . . . . . . . . . . . . . . . . 32
RESTASIS . . . . . . . . . . . . . . . . . . . . . . . 49
RETROVIR IV INFUSION . . . . . . . . . 32
REVLIMID . . . . . . . . . . . . . . . . . . . . . . . 26
REXULTI . . . . . . . . . . . . . . . . . . . . . . . . 31
REYATAZ . . . . . . . . . . . . . . . . . . . . . . . . 33
ribasphere caps . . . . . . . . . . . . . . . . . . . 32
RIBASPHERE RIBAPAK . . . . . . . . . . 32
ribasphere tabs 200mg . . . . . . . . . . . . 32
RIBASPHERE TABS 400MG. . . . . . . 32
RIBASPHERE TABS 600MG. . . . . . . 32
ribavirin . . . . . . . . . . . . . . . . . . . . . . . . . . 32
RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . 48
rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . 26
rifampin caps . . . . . . . . . . . . . . . . . . . . . 26
rifampin inj . . . . . . . . . . . . . . . . . . . . . . . 26
RIFATER . . . . . . . . . . . . . . . . . . . . . . . . 26
riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . 39
rimantadine hcl . . . . . . . . . . . . . . . . . . . 33
RINGERS INJECTION . . . . . . . . . . . . 55
RINGERS IRRIGATION . . . . . . . . . . 49
RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . 34
risedronate sodium tabs
30mg, 5mg. . . . . . . . . . . . . . . . . . . . . . . . 49
risedronate sodium tabs 35mg . . . . . 49
risedronate sodium tabs 150mg . . . . 49
Q
QUADRACEL . . . . . . . . . . . . . . . . . . . . 48
quasense . . . . . . . . . . . . . . . . . . . . . . . . 45
quetiapine fumarate . . . . . . . . . . . . . . 31
quinapril hcl . . . . . . . . . . . . . . . . . . . . . . 36
quinapril/hydrochlorothiazide . . . . . . 36
quinidine sulfate . . . . . . . . . . . . . . . . . . 36
quinine sulfate . . . . . . . . . . . . . . . . . . . 29
QVAR . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
R
RABAVERT . . . . . . . . . . . . . . . . . . . . . . 48
raloxifene hydrochloride . . . . . . . . . . 46
ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . 36
RANEXA TB12 500MG . . . . . . . . . . . . 37
RANEXA TB12 1000MG . . . . . . . . . . . 37
ranitidine hcl caps . . . . . . . . . . . . . . . . . 41
ranitidine hcl inj . . . . . . . . . . . . . . . . . . . 41
ranitidine hcl syrp . . . . . . . . . . . . . . . . . 41
ranitidine hcl tabs . . . . . . . . . . . . . . . . . 41
RAPAMUNE ORAL SOLN . . . . . . . . . 47
RAPAMUNE TABS 1MG, 2MG . . . . . 47
REBETOL ORAL SOLN . . . . . . . . . . . 32
REBIF . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
REBIF REBIDOSE . . . . . . . . . . . . . . . 39
REBIF REBIDOSE
TITRATION PACK . . . . . . . . . . . . . . . . 39
REBIF TITRATION PACK . . . . . . . . . 39
73
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
RISPERDAL CONSTA INJ
12.5MG, 25MG. . . . . . . . . . . . . . . . . . . . 31
RISPERDAL CONSTA INJ
37.5MG, 50MG. . . . . . . . . . . . . . . . . . . . 31
risperidone m-tab tbdp
0.5mg, 1mg, 2mg, 3mg . . . . . . . . . . . . 31
risperidone m-tab tbdp 4mg . . . . . . . . 31
risperidone odt tbdp
0.25mg, 0.5mg, 1mg, 2mg, 3mg. . . . 31
risperidone odt tbdp 4mg. . . . . . . . . . . 31
risperidone oral soln . . . . . . . . . . . . . . 31
risperidone tabs
0.25mg, 0.5mg, 1mg, 2mg, 3mg. . . . 31
risperidone tabs 4mg . . . . . . . . . . . . . . 31
RITUXAN INJ 500MG/50ML. . . . . . . . 29
rivastigmine tartrate . . . . . . . . . . . . . . 23
rizatriptan benzoate . . . . . . . . . . . . . . 26
rizatriptan benzoate odt . . . . . . . . . . . 26
ropinirole hcl . . . . . . . . . . . . . . . . . . . . . 29
rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . 19
rosuvastatin calcium . . . . . . . . . . . . . . 38
ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . 48
ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . 48
roweepra . . . . . . . . . . . . . . . . . . . . . . . . 22
roxicet tabs . . . . . . . . . . . . . . . . . . . . . . . 17
ROZEREM . . . . . . . . . . . . . . . . . . . . . . . 52
selenium sulfide lotn . . . . . . . . . . . . . . 40
SELZENTRY TABS 150MG . . . . . . . . 32
SELZENTRY TABS 300MG . . . . . . . . 32
SENSIPAR TABS 30MG . . . . . . . . . . . 46
SENSIPAR TABS 60MG . . . . . . . . . . . 46
SENSIPAR TABS 90MG . . . . . . . . . . . 46
SEREVENT DISKUS . . . . . . . . . . . . . 51
SEROQUEL XR TB24
150MG, 200MG . . . . . . . . . . . . . . . . . . . 31
SEROQUEL XR TB24
300MG, 400MG, 50MG. . . . . . . . . . . . 31
sertraline hcl conc . . . . . . . . . . . . . . . . . 24
sertraline hcl tabs 25mg. . . . . . . . . . . . 24
sertraline hcl tabs 50mg. . . . . . . . . . . . 24
sertraline hcl tabs 100mg . . . . . . . . . . 24
setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . 45
sharobel . . . . . . . . . . . . . . . . . . . . . . . . . 46
SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . 46
sildenafil tabs . . . . . . . . . . . . . . . . . . . . . 51
SILENOR . . . . . . . . . . . . . . . . . . . . . . . . 52
silver sulfadiazine . . . . . . . . . . . . . . . . 19
SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . 50
SIMULECT . . . . . . . . . . . . . . . . . . . . . . 48
simvastatin tabs 10mg, 5mg. . . . . . . . 38
simvastatin tabs
20mg, 40mg, 80mg. . . . . . . . . . . . . . . . 38
sirolimus . . . . . . . . . . . . . . . . . . . . . . . . . 47
SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . 26
sodium bicarbonate inj . . . . . . . . . . . . 52
sodium bicarbonate partial fill . . . . . 52
sodium chloride 0.9% . . . . . . . . . . . . . 49
sodium chloride 0.45% viaflex . . . . . 55
sodium chloride inj
0.9%, 2.5meq/ml, 3%, 5%. . . . . . . . . . 55
SODIUM EDECRIN . . . . . . . . . . . . . . 38
sodium fluoride chew 0.5mg, 1mg . . 55
sodium fluoride tabs . . . . . . . . . . . . . . . 55
SODIUM LACTATE INJ 5MEQ/ML. . 52
sodium phenylbutyrate . . . . . . . . . . . . 40
sodium polystyrene
sulfonate powd . . . . . . . . . . . . . . . . . . . 52
sodium polystyrene sulfonate
susp 15gm/60ml, 30gm/120ml. . . . . . 52
sodium sulfacetamide
ophthalmic soln . . . . . . . . . . . . . . . . . . . 21
SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . 26
SOLU-CORTEF . . . . . . . . . . . . . . . . . . 43
SOMATULINE DEPOT . . . . . . . . . . . 46
SOMAVERT INJ 10MG . . . . . . . . . . . . 47
SOMAVERT INJ 15MG, 20MG . . . . . 46
SOMAVERT INJ 25MG, 30MG . . . . . 46
sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . 36
sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . 36
SOVALDI . . . . . . . . . . . . . . . . . . . . . . . . 32
SPIRIVA HANDIHALER . . . . . . . . . . . 51
SPIRIVA RESPIMAT . . . . . . . . . . . . . . 51
spironolactone/hydrochlorothiazide. . 38
spironolactone tabs 25mg. . . . . . . . . . 38
spironolactone tabs 100mg, 50mg. . 38
SPORANOX ORAL SOLN . . . . . . . . . 25
sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . 45
SPRITAM TB3D 750MG . . . . . . . . . . . 22
SPRITAM TB3D
1000MG, 250MG, 500MG. . . . . . . . . . 22
SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . 28
sps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
SSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
stavudine . . . . . . . . . . . . . . . . . . . . . . . . 32
sterile water irrigation . . . . . . . . . . . . . 49
STIMATE . . . . . . . . . . . . . . . . . . . . . . . . 44
STIOLTO RESPIMAT . . . . . . . . . . . . . 52
STIVARGA . . . . . . . . . . . . . . . . . . . . . . . 28
STRATTERA . . . . . . . . . . . . . . . . . . . . . 39
streptomycin sulfate . . . . . . . . . . . . . . 18
STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . 32
STRIVERDI RESPIMAT . . . . . . . . . . 51
STROMECTOL . . . . . . . . . . . . . . . . . . 29
SUBOXONE . . . . . . . . . . . . . . . . . . . . . 18
sucralfate . . . . . . . . . . . . . . . . . . . . . . . . 41
S
SABRIL PACK . . . . . . . . . . . . . . . . . . . . 22
SABRIL TABS . . . . . . . . . . . . . . . . . . . . 22
SAIZEN . . . . . . . . . . . . . . . . . . . . . . . . . . 44
SAIZEN CLICK.EASY . . . . . . . . . . . . 44
salsalate . . . . . . . . . . . . . . . . . . . . . . . . . 16
SAMSCA TABS 15MG. . . . . . . . . . . . . 52
SAMSCA TABS 30MG. . . . . . . . . . . . . 52
SANDIMMUNE ORAL SOLN . . . . . . 47
SANDOSTATIN LAR DEPOT . . . . . . 46
SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . 40
SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . 31
selegiline hcl . . . . . . . . . . . . . . . . . . . . . 30
74
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
sulfacetamide sodium
ophthalmic soln . . . . . . . . . . . . . . . . . . . 21
sulfacetamide sodium/
prednisolone sodium phosphate . . . 21
sulfacetamide sodium susp . . . . . . . . 21
sulfadiazine . . . . . . . . . . . . . . . . . . . . . . 21
sulfamethoxazole/trimethoprim ds . . 21
sulfamethoxazole/trimethoprim inj . . 21
sulfamethoxazole/
trimethoprim susp . . . . . . . . . . . . . . . . . 21
sulfamethoxazole/
trimethoprim tabs . . . . . . . . . . . . . . . . . 21
sulfasalazine . . . . . . . . . . . . . . . . . . . . . 49
sulfatrim pediatric . . . . . . . . . . . . . . . . 21
sulindac . . . . . . . . . . . . . . . . . . . . . . . . . 16
sumatriptan . . . . . . . . . . . . . . . . . . . . . . 26
sumatriptan succinate inj . . . . . . . . . . 26
sumatriptan succinate refill . . . . . . . . 26
sumatriptan succinate tabs . . . . . . . . 26
SUPRAX SUSR . . . . . . . . . . . . . . . . . . 20
SUPREP BOWEL PREP . . . . . . . . . . 41
SURMONTIL . . . . . . . . . . . . . . . . . . . . . 24
SUSTIVA . . . . . . . . . . . . . . . . . . . . . . . . 32
SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . 28
SYLATRON . . . . . . . . . . . . . . . . . . . . . . 27
symax-sl . . . . . . . . . . . . . . . . . . . . . . . . . 41
SYMBICORT AERO
80MCG/ACT; 4.5MCG/ACT . . . . . . . . 50
SYMBICORT AERO
160MCG/ACT; 4.5MCG/ACT. . . . . . . 50
SYNAGIS INJ 50MG/0.5ML. . . . . . . . 48
SYNAREL . . . . . . . . . . . . . . . . . . . . . . . 47
SYNERCID . . . . . . . . . . . . . . . . . . . . . . 19
SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . 27
SYNTHROID . . . . . . . . . . . . . . . . . . . . . 46
SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . 52
tacrolimus oint . . . . . . . . . . . . . . . . . . . . 40
TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . 28
TAGRISSO . . . . . . . . . . . . . . . . . . . . . . 28
TALWIN . . . . . . . . . . . . . . . . . . . . . . . . . 17
TAMIFLU CAPS 30MG . . . . . . . . . . . . 33
TAMIFLU CAPS 45MG . . . . . . . . . . . . 33
TAMIFLU CAPS 75MG . . . . . . . . . . . . 33
TAMIFLU SUSR . . . . . . . . . . . . . . . . . . 33
tamoxifen citrate . . . . . . . . . . . . . . . . . 26
tamsulosin hcl . . . . . . . . . . . . . . . . . . . . 42
TARCEVA . . . . . . . . . . . . . . . . . . . . . . . . 28
TARGRETIN . . . . . . . . . . . . . . . . . . . . . 29
tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . 45
TASIGNA . . . . . . . . . . . . . . . . . . . . . . . . 28
TAXOTERE INJ 80MG/4ML. . . . . . . . 27
tazicef inj 1gm, 2gm, 6gm. . . . . . . . . . 20
TAZORAC CREA . . . . . . . . . . . . . . . . . 40
TAZORAC GEL . . . . . . . . . . . . . . . . . . . 40
taztia xt . . . . . . . . . . . . . . . . . . . . . . . . . . 37
TECENTRIQ . . . . . . . . . . . . . . . . . . . . . 29
TEFLARO . . . . . . . . . . . . . . . . . . . . . . . 20
TEGRETOL TABS . . . . . . . . . . . . . . . . 22
TEGRETOL-XR TB12 100MG. . . . . . 23
TEGRETOL-XR TB12
200MG, 400MG . . . . . . . . . . . . . . . . . . . 23
telmisartan . . . . . . . . . . . . . . . . . . . . . . . 36
telmisartan/amlodipine . . . . . . . . . . . . 36
telmisartan/hydrochlorothiazide . . . 36
temazepam . . . . . . . . . . . . . . . . . . . . . . 52
TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . 48
TERAZOL 3 . . . . . . . . . . . . . . . . . . . . . . 25
TERAZOL 7 . . . . . . . . . . . . . . . . . . . . . . 25
terazosin hcl caps 1mg, 5mg. . . . . . . 42
terazosin hcl caps 10mg, 2mg. . . . . . 42
terbinafine hcl tabs . . . . . . . . . . . . . . . . 25
terbutaline sulfate inj . . . . . . . . . . . . . . 51
terbutaline sulfate tabs . . . . . . . . . . . . 51
terconazole . . . . . . . . . . . . . . . . . . . . . . 25
TESTIM . . . . . . . . . . . . . . . . . . . . . . . . . 44
testosterone cypionate . . . . . . . . . . . . 44
testosterone enanthate . . . . . . . . . . . 44
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED . . . . . . . . . . . 48
tetrabenazine tabs 12.5mg. . . . . . . . . 39
tetrabenazine tabs 25mg. . . . . . . . . . . 39
tetracycline hcl . . . . . . . . . . . . . . . . . . . 21
TEXACORT . . . . . . . . . . . . . . . . . . . . . . 43
THALOMID CAPS 100MG . . . . . . . . . 26
THALOMID CAPS
150MG, 200MG, 50MG. . . . . . . . . . . . 26
THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . 51
theochron . . . . . . . . . . . . . . . . . . . . . . . . 51
theophylline cr . . . . . . . . . . . . . . . . . . . 51
theophylline er . . . . . . . . . . . . . . . . . . . 51
thioridazine hcl . . . . . . . . . . . . . . . . . . . 30
thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . 26
thiothixene caps 2mg . . . . . . . . . . . . . . 30
thiothixene caps 10mg, 1mg, 5mg. . . 30
THYMOGLOBULIN . . . . . . . . . . . . . . . 48
THYROLAR-1 . . . . . . . . . . . . . . . . . . . . 46
THYROLAR-1/2 . . . . . . . . . . . . . . . . . . 46
THYROLAR-1/4 . . . . . . . . . . . . . . . . . . 46
THYROLAR-2 . . . . . . . . . . . . . . . . . . . . 46
THYROLAR-3 . . . . . . . . . . . . . . . . . . . . 46
tiagabine hydrochloride tabs 2mg. . . 22
tiagabine hydrochloride tabs 4mg. . . 22
TIKOSYN . . . . . . . . . . . . . . . . . . . . . . . . 36
timolol maleate ophthalmic soln . . . . 50
timolol maleate tabs . . . . . . . . . . . . . . . 37
TIVICAY TABS 10MG, 25MG. . . . . . . 32
TIVICAY TABS 50MG. . . . . . . . . . . . . . 32
tizanidine hcl tabs . . . . . . . . . . . . . . . . . 31
TOBI PODHALER . . . . . . . . . . . . . . . . 51
TOBRADEX OINT . . . . . . . . . . . . . . . . 50
tobramycin . . . . . . . . . . . . . . . . . . . . . . . 51
tobramycin/dexamethasone . . . . . . . 50
tobramycin sulfate inj 1.2gm,
10mg/ml, 40mg/ml, 80mg/2ml . . . . . . 18
tobramycin sulfate ophthalmic soln . . 18
TOBREX OINT . . . . . . . . . . . . . . . . . . . 18
T
TABLOID . . . . . . . . . . . . . . . . . . . . . . . . 27
tacrolimus caps . . . . . . . . . . . . . . . . . . . 47
75
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
tolcapone . . . . . . . . . . . . . . . . . . . . . . . . 29
tolmetin sodium . . . . . . . . . . . . . . . . . . 16
tolterodine tartrate . . . . . . . . . . . . . . . . 42
topiramate . . . . . . . . . . . . . . . . . . . . . . . 22
toposar inj 1gm/50ml . . . . . . . . . . . . . . 28
toposar inj
100mg/5ml, 500mg/25ml. . . . . . . . . . . 28
topotecan hcl inj 4mg . . . . . . . . . . . . . . 28
TORISEL . . . . . . . . . . . . . . . . . . . . . . . . 47
torsemide . . . . . . . . . . . . . . . . . . . . . . . . 38
TOUJEO SOLOSTAR . . . . . . . . . . . . 34
TPN ELECTROLYTES . . . . . . . . . . . . 55
TRADJENTA . . . . . . . . . . . . . . . . . . . . . 34
tramadol hcl . . . . . . . . . . . . . . . . . . . . . . 17
tramadol hcl er tb24 . . . . . . . . . . . . . . . 16
trandolapril . . . . . . . . . . . . . . . . . . . . . . . 36
tranexamic acid inj . . . . . . . . . . . . . . . . 35
tranexamic acid tabs . . . . . . . . . . . . . . 35
TRANSDERM-SCOP . . . . . . . . . . . . . 24
tranylcypromine sulfate . . . . . . . . . . . 23
TRAVASOL . . . . . . . . . . . . . . . . . . . . . . 55
TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . 49
trazodone hcl tabs
100mg, 150mg, 50mg. . . . . . . . . . . . . . 23
trazodone hcl tabs 300mg. . . . . . . . . . 23
TREANDA . . . . . . . . . . . . . . . . . . . . . . . 26
TRECATOR . . . . . . . . . . . . . . . . . . . . . . 26
TRELSTAR INJ 3.75MG . . . . . . . . . . . 47
TRELSTAR INJ 11.25MG . . . . . . . . . . 47
TRELSTAR MIXJECT INJ 3.75MG. . . 47
TRELSTAR MIXJECT INJ
11.25MG. . . . . . . . . . . . . . . . . . . . . . . . . . 47
TRELSTAR MIXJECT INJ 22.5MG. . . 47
TRESIBA FLEXTOUCH . . . . . . . . . . . 34
tretinoin caps . . . . . . . . . . . . . . . . . . . . . 29
tretinoin crea . . . . . . . . . . . . . . . . . . . . . 40
tretinoin gel 0.01%, 0.025% . . . . . . . . 40
tretinoin microsphere . . . . . . . . . . . . . 40
tretinoin microsphere pump . . . . . . . 40
trezix caps 320.5mg; 30mg; 16mg. . 17
triamcinolone acetonide crea 0.1% . . 43
triamcinolone acetonide crea
0.025%, 0.5%. . . . . . . . . . . . . . . . . . . . . 43
triamcinolone acetonide lotn . . . . . . . 43
triamcinolone acetonide oint . . . . . . . 43
triamcinolone acetonide pste . . . . . . 39
triamcinolone in orabase . . . . . . . . . . 39
triamterene/hydrochlorothiazide
caps 25mg; 37.5mg. . . . . . . . . . . . . . . . 38
triamterene/hydrochlorothiazide
caps 25mg; 50mg . . . . . . . . . . . . . . . . . 38
triamterene/
hydrochlorothiazide tabs . . . . . . . . . . . 38
trianex . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
triderm . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . 45
trifluoperazine hcl . . . . . . . . . . . . . . . . 30
trifluridine . . . . . . . . . . . . . . . . . . . . . . . . 33
trihexyphenidyl hcl elix . . . . . . . . . . . . 29
trihexyphenidyl hcl tabs 2mg . . . . . . . 29
trihexyphenidyl hcl tabs 5mg . . . . . . . 29
tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . 45
tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . 45
trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
trimethoprim . . . . . . . . . . . . . . . . . . . . . 19
trimethoprim sulfate/
polymyxin b sulfate . . . . . . . . . . . . . . . 19
trimipramine maleate . . . . . . . . . . . . . 24
TRINTELLIX . . . . . . . . . . . . . . . . . . . . . 23
tri-previfem . . . . . . . . . . . . . . . . . . . . . . . 45
TRISENOX . . . . . . . . . . . . . . . . . . . . . . 28
tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . 45
TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . 32
trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . 45
TROPHAMINE . . . . . . . . . . . . . . . . . . . 55
tropicamide . . . . . . . . . . . . . . . . . . . . . . 49
TRULICITY . . . . . . . . . . . . . . . . . . . . . . 34
TRUMENBA . . . . . . . . . . . . . . . . . . . . . 48
TRUVADA . . . . . . . . . . . . . . . . . . . . . . . 32
TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . 48
TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . 32
TYGACIL . . . . . . . . . . . . . . . . . . . . . . . . 19
TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . 28
TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . 48
TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . 39
TYZEKA . . . . . . . . . . . . . . . . . . . . . . . . . 31
TYZINE PEDIATRIC
NASAL DROPS . . . . . . . . . . . . . . . . . . 52
76
U
ULORIC . . . . . . . . . . . . . . . . . . . . . . . . . 25
UNITHROID . . . . . . . . . . . . . . . . . . . . . 46
UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . 29
ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . 41
UVADEX . . . . . . . . . . . . . . . . . . . . . . . . . 40
V
VAGIFEM . . . . . . . . . . . . . . . . . . . . . . . . 45
valacyclovir hcl tabs 500mg . . . . . . . . 33
valacyclovir hcl tabs 1000mg. . . . . . . 33
VALCHLOR . . . . . . . . . . . . . . . . . . . . . . 26
VALCYTE . . . . . . . . . . . . . . . . . . . . . . . . 31
valganciclovir . . . . . . . . . . . . . . . . . . . . 31
valproate sodium . . . . . . . . . . . . . . . . . 22
valproic acid . . . . . . . . . . . . . . . . . . . . . 22
valsartan . . . . . . . . . . . . . . . . . . . . . . . . . 36
valsartan/hydrochlorothiazide . . . . . 36
vancomycin . . . . . . . . . . . . . . . . . . . . . . 19
vancomycin hcl caps 125mg . . . . . . . 19
vancomycin hcl caps 250mg . . . . . . . 19
vancomycin hcl in dextrose . . . . . . . 19
vancomycin hcl inj . . . . . . . . . . . . . . . . 19
vandazole . . . . . . . . . . . . . . . . . . . . . . . 19
VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . 48
VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . 48
VARIZIG INJ 125UNIT/1.2ML . . . . . . 48
VASCEPA . . . . . . . . . . . . . . . . . . . . . . . . 38
VASERETIC . . . . . . . . . . . . . . . . . . . . . 36
VASOTEC . . . . . . . . . . . . . . . . . . . . . . . 36
VECTIBIX INJ 100MG/5ML . . . . . . . . 29
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
VECTICAL . . . . . . . . . . . . . . . . . . . . . . . 40
VELCADE . . . . . . . . . . . . . . . . . . . . . . . 28
velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
VELPHORO . . . . . . . . . . . . . . . . . . . . . 42
VENCLEXTA STARTING PACK . . . 28
VENCLEXTA TABS 10MG . . . . . . . . . 28
VENCLEXTA TABS 50MG . . . . . . . . . 28
VENCLEXTA TABS 100MG . . . . . . . . 28
venlafaxine hcl . . . . . . . . . . . . . . . . . . . 24
venlafaxine hcl er cp24 . . . . . . . . . . . . 24
venlafaxine hcl er tb24
150mg, 37.5mg, 75mg. . . . . . . . . . . . . 24
verapamil hcl er . . . . . . . . . . . . . . . . . . 37
verapamil hcl inj . . . . . . . . . . . . . . . . . . 37
verapamil hcl sr cp24 360mg. . . . . . . 37
verapamil hcl tabs 40mg . . . . . . . . . . . 37
verapamil hcl tabs 120mg, 80mg . . . 37
VERSACLOZ . . . . . . . . . . . . . . . . . . . . 31
vicodin es tabs 300mg; 7.5mg. . . . . . 17
vicodin hp tabs 300mg; 10mg . . . . . . 17
vicodin tabs 300mg; 5mg. . . . . . . . . . . 17
VIDEX PEDIATRIC . . . . . . . . . . . . . . . 32
vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . 21
VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . 24
VIIBRYD STARTER PACK . . . . . . . . 24
VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 23
VIMPAT ORAL SOLN . . . . . . . . . . . . . 23
VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 23
vinblastine sulfate . . . . . . . . . . . . . . . . 28
vincasar pfs . . . . . . . . . . . . . . . . . . . . . . 28
vincristine sulfate . . . . . . . . . . . . . . . . . 28
vinorelbine tartrate . . . . . . . . . . . . . . . 28
viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
VIRACEPT . . . . . . . . . . . . . . . . . . . . . . . 33
VIRAMUNE XR TB24 100MG . . . . . . 32
VIRAZOLE . . . . . . . . . . . . . . . . . . . . . . . 52
VIREAD . . . . . . . . . . . . . . . . . . . . . . . . . 32
virt-phos 250 neutral . . . . . . . . . . . . . . 55
VITEKTA . . . . . . . . . . . . . . . . . . . . . . . . . 32
VIVELLE-DOT . . . . . . . . . . . . . . . . . . . 45
VOLTAREN GEL . . . . . . . . . . . . . . . . . . 40
voriconazole inj . . . . . . . . . . . . . . . . . . . 25
voriconazole susr . . . . . . . . . . . . . . . . . 25
voriconazole tabs . . . . . . . . . . . . . . . . . 25
VOTRIENT . . . . . . . . . . . . . . . . . . . . . . 28
VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . 55
VPRIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 31
VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 31
vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Z
W
warfarin sodium . . . . . . . . . . . . . . . . . . 35
wera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
X
XALKORI . . . . . . . . . . . . . . . . . . . . . . . . 28
XARELTO STARTER PACK . . . . . . . 35
XARELTO TABS 10MG, 20MG. . . . . 35
XARELTO TABS 15MG . . . . . . . . . . . . 35
XARTEMIS XR . . . . . . . . . . . . . . . . . . . 16
XENAZINE TABS 12.5MG . . . . . . . . . 39
XENAZINE TABS 25MG . . . . . . . . . . . 39
XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . 49
XIFAXAN TABS 200MG. . . . . . . . . . . . 19
XIFAXAN TABS 550MG. . . . . . . . . . . . 19
XOLAIR . . . . . . . . . . . . . . . . . . . . . . . . . 52
XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . 26
xylon . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Y
YERVOY . . . . . . . . . . . . . . . . . . . . . . . . 29
YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . 48
YONDELIS . . . . . . . . . . . . . . . . . . . . . . 26
77
zafirlukast . . . . . . . . . . . . . . . . . . . . . . . . 51
zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . 52
ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . 29
ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . 26
ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . 35
ZAVESCA . . . . . . . . . . . . . . . . . . . . . . . . 40
zebutal caps 325mg; 50mg; 40mg. . 16
ZELBORAF . . . . . . . . . . . . . . . . . . . . . . 28
ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . 52
zenatane . . . . . . . . . . . . . . . . . . . . . . . . 40
zenchent . . . . . . . . . . . . . . . . . . . . . . . . . 46
ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . 40
ZESTORETIC . . . . . . . . . . . . . . . . . . . . 36
ZESTRIL . . . . . . . . . . . . . . . . . . . . . . . . . 36
ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
ZIAGEN ORAL SOLN . . . . . . . . . . . . . 32
zidovudine . . . . . . . . . . . . . . . . . . . . . . . 32
ZINECARD INJ 250MG. . . . . . . . . . . . 28
ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . 49
ziprasidone hcl . . . . . . . . . . . . . . . . . . . 31
ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . 31
ZMAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
zoledronic acid . . . . . . . . . . . . . . . . . . . 49
ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . 28
zolpidem tartrate tabs . . . . . . . . . . . . . 52
ZOMETA INJ 4MG/100ML . . . . . . . . . 49
ZONALON . . . . . . . . . . . . . . . . . . . . . . . 40
zonisamide . . . . . . . . . . . . . . . . . . . . . . 22
ZORTRESS TABS
0.5MG, 0.75MG . . . . . . . . . . . . . . . . . . . 47
ZORTRESS TABS 0.25MG . . . . . . . . 47
ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . 48
ZOSYN INJ
5%; 2GM/50ML; 0.25GM/50ML,
5%; 3GM/50ML; 0.375GM/50ML,
5%; 4GM/100ML; 0.5GM/100ML . . . 20
zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . 46
zovia 1/50e . . . . . . . . . . . . . . . . . . . . . . 46
ZYCLARA . . . . . . . . . . . . . . . . . . . . . . . 40
Covered Drugs Index
DRUGPAGE
DRUGPAGE
ZYCLARA PUMP CREA 2.5%. . . . . . 40
ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . 28
ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . 28
ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ZYPREXA RELPREVV . . . . . . . . . . . 31
ZYTIGA . . . . . . . . . . . . . . . . . . . . . . . . . . 26
ZYVOX SUSR . . . . . . . . . . . . . . . . . . . . 19
78
DRUGPAGE
1-800-222-6700 (TTY 711)
8 a.m. - 8 p.m., local time, 7 days a week.
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during weekends from Feb. 15 – Sept. 30.
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This drug list was updated on September 1, 2016. For more recent information or other questions, please contact Cigna-HealthSpring Rx Customer Service, at 1-800-2226700 or, for TTY users, 711, 8 a.m. - 8 p.m., local time, 7 days a week. Our automated phone system may answer your call during weekends from Feb. 15 – Sept. 30. Or visit
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