It’s Personal.
2016
PLEASE READ:
This document contains information
about the drugs we cover in the Plan
Desert Preferred Choice (HMO).
This formulary was updated on
08/19/2015.
For more recent information or other
questions, please contact Inter Valley
Health Plan’s Pharmacy Specialist at
866-632-7890, 7:30 am to 8 pm,
7 days a week. TTY/TDD users
should call 866-706-4757.
Formulary ID 16259, Version 6
H0545_FUY2016_28A Accepted
Comprehensive
Formulary
LIST OF COVERED DRUGS
Desert Preferred Choice (HMO)
Table of Contents
What is the Inter Valley Health Plan
Desert Preferred Choice (HMO) Formulary?..........................................pg 2
Can the Formulary (drug list) change?.................................................pg 2
How do I use the Formulary?................................................................pg 3
What are generic drugs?.......................................................................pg 3
Are there any restrictions on my coverage?.........................................pg 3
What if my drug is not on the Formulary?...........................................pg 4
How do I request an exception to the Inter Valley Health Plan
Desert Preferred Choice (HMO) Formulary?.........................................pg 4
What do I do before I can talk to my doctor
about changing my drugs or requesting an exception?......................pg 5
For more information............................................................................pg 6
Inter Valley Health Plan Desert Preferred Choice (HMO)
Copay Amounts......................................................................................pg 7
Formulary (List of covered drugs).......................................................pg 10
Drugs Requiring Prior Authorization................................................pg 103
Drugs With Quantity Limits...............................................................pg 108
Free First Fill Program........................................................................pg 122
Index of Drugs....................................................................................pg 127
1
This formulary 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 Inter Valley
Health Plan Desert Preferred Choice (HMO).
When it refers to “plan” or “our plan,”
it means Inter Valley Health Plan Desert
Preferred Choice (HMO).
This document includes a list of the drugs
(formulary) for our plan which is current as of
August 19, 2015. 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 copay­
ments/coinsurance may change on January 1,
2016, and from time to time during the year.
What is the Inter Valley Health Plan
Desert Preferred Choice (HMO)
Formulary?
A formulary is a list of covered drugs selected by
Inter Valley Health Plan Desert Preferred Choice
(HMO) in consultation with a team of healthcare
providers, which represents the prescrip­tion
therapies believed to be a necessary part of
a quality treatment program. The Plan will
generally cover the drugs listed in our formulary
as long as the drug is medically necessary, the
prescription is filled at an Inter Valley Health
Plan network pharmacy, and other plan rules are
followed. For more information on how to fill
your prescriptions, please review your Evidence
of Coverage.
2
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2016
formulary 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 formulary
changes, such as removing a drug from our
formulary, will not affect members who are
currently taking the drug. It will remain available
at the same cost-sharing for those members
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 formulary 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.
If we remove drugs from our formulary, 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 members of the change at least 60
days before the change becomes effective,
or at the time the member requests a refill
of the drug, at which time the member will
receive a 60-day supply of the drug. If the
Food and Drug Administration (FDA) deems
a drug on our formulary to be unsafe or the
drug’s manufacturer removes the drug from
the market, we will immediately remove the
drug from our formulary and provide notice to
members who take the drug.
The enclosed formulary is current as of August
19, 2015. To get updated information about
the drugs covered by Inter Valley Health Plan,
please visit our web site at http://www.ivhp.
com/Site/PrescriptionDrugSearch.aspx or
call our Pharmacy Specialist at 866-632-7890,
7:30 am to 8 pm, 7 days a week. TTY/TDD
users should call 866-706-4757. Inter Valley
Health Plan provides updates to the Formulary
in our quarterly newsletter, InterView, or on
our website at http://www.ivhp.com/Site/
PrescriptionDrugSearch.aspx.
How do I use the Formulary?
There are two ways to find your drug within
the formulary:
MEDICAL CONDITION
The formulary begins on page 10. The drugs
in this formulary 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 10. Then
look under the category name for your drug.
ALPHABETICAL LISTING
If you are not sure what category to look under,
you should look for your drug in the Index that
begins on page 127. The Index provides an
alphabetical list of all of the drugs included in
this document. Both brand name drugs and
generic drugs are listed in the Index. Look in the
Index and find your drug. Next to your drug, you
will see the page number where you can find
coverage information. Turn to the page listed in
the Index and find the name of your drug in the
first column of the list.
What are generic drugs?
Inter Valley Health Plan Desert Preferred Choice
(HMO) 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.
Are there any restrictions on my coverage?
Some covered drugs may have additional require­
ments or limits on coverage. These requirements
and limits may include:
Prior Authorization: Inter Valley Health Plan
Desert Preferred Choice (HMO) requires you or
your physician to get prior authorization for
certain drugs. This means that you will need
to get approval from us before you fill your
prescriptions. If you don’t get approval, we may
not cover the drug.
Quantity Limits: For certain drugs, Inter Valley
Health Plan Desert Preferred Choice (HMO) limits
the amount of the drug that the Plan will cover.
3
For example, Inter Valley Health Plan Desert
Preferred Choice (HMO) provides 30 tablets
per 30 days prescription for Atorvastatin. This
may be in addition to a standard one-month or
three-month supply.
Step Therapy: In some cases, Inter Valley
Health Plan Desert Preferred Choice (HMO)
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 1 and Drug 2 both treat your medical
condition, the Plan may not cover Drug 2 unless
you try Drug 1 first. If Drug 1 does not work for
you, the Plan will then cover Drug 2.
You can find out if your drug has any addi­
tional requirements or limits by looking in
the formulary that begins on page 10. 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 formulary, appears on the
front and back cover pages.
You can ask us 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 Inter Valley Health Plan
Desert Preferred Choice (HMO) formulary?”
on this page for information about how to
request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary
(list of covered drugs), you should first contact
our Pharmacy Specialist and ask if your drug is
covered.
4
If you learn that Inter Valley Health Plan Desert
Preferred Choice (HMO) does not cover your
drug, you have two options:
You can ask our Pharmacy Specialist for a list of
similar drugs that are covered by the Plan. When
you receive the list, show it to your doctor and
ask him or her to prescribe a similar drug that is
covered by the Plan.
You can ask us to make an exception and cover
your drug. See below for information about how
to request an exception.
How do I request an exception to
the Inter Valley Health Plan Desert
Preferred Choice (HMO) Formulary?
You can ask us to make an exception to our
coverage rules. There are several types of
exceptions that you can ask us to make.
• You can ask us to cover a drug even if it is
not on our formulary. If approved, this drug
will be covered at a pre-determined costsharing level, and you would not be able to
ask us to provide the drug at a lower costsharing level.
• You can ask us to cover a formulary drug at
a lower cost-sharing level if this drug is not
on the specialty tier. If approved this would
lower the amount you must pay for your
drug.
• You can ask us to waive coverage restrictions
or limits on your drug. For example, for
certain drugs, Inter Valley Health Plan Desert
Preferred Choice (HMO) 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.
Generally, Inter Valley Health Plan Desert
Preferred Choice (HMO) will only approve
your request for an exception if the alternative
drugs included on the plan’s formulary,
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.
You should contact us to ask us for an initial
coverage decision for a formulary, tiering or
utilization restriction exception. When you
request a formulary, tiering or utilization
restriction exception you should submit a
statement from your prescriber or physician
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.
What do I do before I can talk to my
doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan
you may be taking drugs that are not on our
formulary. Or, you may be taking a drug that
is on our formulary 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 formulary
exception so that we will cover the drug
you take. While you talk to your doctor to
determine the right course of action for you,
we may cover your drug in certain cases during
the first 90 days you are a member of our plan.
For each of your drugs that is not on our
formulary or if your ability to get your drugs
is limited, we will cover a temporary 31-day
supply (unless you have a prescription written
for fewer days) when you go to a network
pharmacy. After your first 31-day supply, we
will not pay for these drugs, even if you have
been a member 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-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 member of our
plan. If you need a drug that is not on our
5
formulary 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 formulary exception.
Exceptions are also available when you have
experienced a change in the level of care you
are receiving which requires you to transition
from one facility or treatment center to another.
Examples of situations in which you would be
eligible for the one-time temporary fill exception
when you are outside of the three month
effective date with the Plan are as follows:
If you are discharged from the hospital and
provided a discharge list of medications based
upon the Formulary of the hospital.
If you end your skilled nursing facility
Medicare Part A stay (where payments include
all pharmacy charges) and you need to
revert back to the Inter Valley Health Plan
Desert Preferred Choice (HMO) formulary.
If you give up hospice status to revert back to
standard Medicare Part A and Part B benefits.
If you are discharged from Chronic Psychiatric
Hospitals with medication regimens that are
highly individualized.
All of these situations would warrant a
temporary one-time fill exception regardless
of your effective date with the Plan.
For more information
For more detailed information about your
Inter Valley Health Plan Desert Preferred Choice
(HMO) prescription drug coverage, please
review your Evidence of Coverage and other
plan materials.
If you have questions about Inter Valley
Health Plan Desert Preferred Choice (HMO),
please contact us. Our contact information,
along with the date we last updated the
formulary, 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.
6
Inter Valley Health Plan Desert Preferred Choice (HMO) Copay Amounts
INITIAL
COVERAGE
LIMIT
TIER
1
Preferred
Generic Drugs
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
TIER
2
Generic Drugs
$12 Copay
$36 Copay
$12 Copay
$36 Copay
$12 Copay
TIER
3
Preferred Brand
Drugs
$47 Copay
$141 Copay
$47 Copay
$141 Copay
$47 Copay
TIER
4
Non-Preferred
Brand Drugs
$95 Copay
$285 Copay
$95 Copay
$285 Copay
$95 Copay
TIER
5
Specialty Drugs
33%
Coinsurance
N/A
33%
Coinsurance
N/A
33%
Coinsurance
TIER
1
Preferred
Generic Drugs
$0 Copay
$ 0 Copay
$0 Copay
$0 Copay
$0 Copay
TIER
2
Non-Preferred
Generic Drugs
$12 Copay
$36 Copay
$12 Copay
$36 Copay
$12 Copay
TIER
3
Preferred Brand
Drugs
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
TIER
4
Retail
Retail
Network LongMail Order
Out of Network
Copayment / Copayment /
Term Care
Copayment /
Copayment/
Coinsurance
Coinsurance
Cost-Sharing
Coinsurance
Coinsurance
(30 day Supply) (90 day Supply) (30 day Supply) (90 day Supply) (30 day Supply)*
Non-Preferred
Brand Drugs
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
45%
Coinsurance
TIER
5
Drug Tier
$3310, the total yearly drug cost in the initial coverage limit paid by both you
and Inter Valley Health Plan
Specialty Drugs
**
N/A
**
N/A
**
COVERAGE GAP
CATASTROPHIC After your yearly out-of-pocket drug cost reach $4,850 you pay the greater of a
$2.95 copay for generic (including brand drugs treated as generic) and $7.40 for
COVERAGE
all other drugs, or a 5% coinsurance.
*You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out of network pharmacy.
**You pay 58% for the total cost of the generic or 45% for the brand.
7
Inter Valley Health Plan Desert Preferred Choice (HMO) Formulary
The formulary that begins on page 10 provides coverage information about some of the
drugs covered by Inter Valley Health Plan Desert Preferred Choice (HMO). If you have trouble
finding your drug in the list, turn to the Index that begins on page 127.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,
ZETIA) and generic drugs are listed in lower-case italics (e.g., simvastatin).
The second column of the chart lists the alternate drug name (this is for reference only and if
the drug name is in this column it is NOT a covered benefit).
The third column of the chart lists the Tier number for each covered medication. Please refer
to page 7 for Inter Valley Health Plan Desert Preferred Choice (HMO) copay chart. This
copay chart will show you what the copayment is for each Tier.
The fourth column of the chart will show you if the listed medication has any special
requirements or limits. The information in the Requirements/Limits column tells you if Inter
Valley Health Plan Desert Preferred Choice (HMO) has any special requirements for coverage
of your drug.
The fifth column of the chart will show you the route of the listed medication.
8
The following explains the abbreviations used in the Formulary: PA-Prior Authorization;
QL‑Quantity Limits; ST-Step Therapy; Inj-Injection; TD-Transdermal; Rec-Rectal; Top-Topical;
NS-Nasal; Vag-Vaginal; Inh-Inhalation; OP-Ophthalmic; OT-Otic; MT-Mucus Membrane Topical;
SL-Sublingual; IR-Irrigation; BU-Buccal; TL-Translingual.
Drugs marked with a “*” are the designated generic drugs offered in the Free First Fill
Program. See page 122 for complete details.
Drugs marked with “**” indicates the prescription drug is not normally covered in a Medicare
Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does
not count towards your total drug costs (that is, the amount you pay does not help you
qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your
prescriptions, you will not get any extra help to pay for this drug.
9
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
Route
ANALGESICS
Analgesics
apap/codeine sol 120-12/5ml
apap/codeine tab 300-15mg
apap/codeine tab 300-30mg
apap/codeine tab 300-60mg
ascomp/cod cap 30mg
bupap tab 50-300mg
but/apap/caf cap 50-300-40mg
but/apap/caf cap 50-325-40mg
but/apap/caf cap codeine 50-300-40-30mg
but/apap/caf cap codeine 50-325-40-30mg
but/apap/caf tab 50-325-40mg
but/asa/caff cap 50-325-40mg
butal/apap tab 50-325mg
diclo/misopr tab 50-0.2mg
diclo/misopr tab 75-0.2mg
endocet tab 10-325mg
endocet tab 5-325mg
endocet tab 7.5-325mg
HYCET SOL 7.5-325MG
hydroco/apap sol 7.5-325mg
hydroco/apap tab 10-300mg
hydroco/apap tab 10-325mg
hydroco/apap tab 2.5-325mg
hydroco/apap tab 5-300mg
hydroco/apap tab 5-325mg
hydroco/apap tab 7.5-300mg
hydroco/apap tab 7.5-325mg
hydrocod/ibu tab 7.5-200mg
lorcet plus tab 7.5-325mg
lorcet tab 10-325mg
lorcet tab 5-325mg
lortab tab 10-325mg
lortab tab 5-325mg
lortab tab 7.5-325mg
norco tab 10-325mg
norco tab 5-325mg
norco tab 7.5-325mg
oxycod/apap tab 10-325mg
10
TYLENOL WITH CODEINE SOLN
TYLENOL WITH CODEINE
TYLENOL WITH CODEINE
TYLENOL WITH CODEINE
FIORINAL - CODEINE
butalbital - acetaminophen
butalbital - acetaminophen - caffeine
butalbital - acetaminophen - caffeine
FIORICET - CODEINE
FIORICET - CODEINE
butalbital - acetaminophen - caffeine
butalbital - aspirin - caffeine
butalbital - acetaminophen
ARTHROTEC 50
ARTHROTEC 75
ENDOCET, PERCOCET
ENDOCET, PERCOCET
ENDOCET, PERCOCET
acetaminophen -hydrocodone
HYCET
XODOL
NORCO
hydrocodone - acetaminophen
XODOL
NORCO
XODOL
NORCO
VICOPROFEN
hydrocodone - acetaminophen
hydrocodone - acetaminophen
hydrocodone - acetaminophen
hydrocodone - acetaminophen
hydrocodone - acetaminophen
hydrocodone - acetaminophen
hydrocodone - acetaminophen
hydrocodone - acetaminophen
hydrocodone - acetaminophen
ENDOCET, PERCOCET
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
QL (4500 per 30 days)
QL (400 per 30 days)
QL (400 per 30 days)
QL (400 per 30 days)
PA, QL (120 per 30 days)
PA
PA
PA, QL (120 per 30 days)
PA, QL (120 per 30 days)
PA, QL (360 per 30 days)
PA, QL (120 per 30 days)
PA, QL (180 per 30 days)
PA, QL (180 per 30 days)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (3600 per 30 days)
QL (3600 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
16
17
18
19
20
21
22
23
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
24
25
26
27
28
29
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
30
31
32
33
34
35
36
37
38
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
oxycod/apap tab 2.5-325mg
oxycod/apap tab 5-325mg
oxycod/apap tab 7.5-325mg
oxycod/asa tab
oxycod/ibu tab 5-400mg
tramadl/apap tab 37.5-325mg
vicodin es tab 7.5-300mg
vicodin hp tab 10-300mg
vicodin tab 5-300mg
XODOL TAB 10-300MG
XODOL TAB 5-300MG
XODOL TAB 7.5-300MG
Alternate Drug Name
PERCOCET
ENDOCET, PERCOCET
ENDOCET, PERCOCET
PERCODAN
COMBUNOX
ULTRCET
acetaminophen -hydrocodone
acetaminophen -hydrocodone
acetaminophen -hydrocodone
acetaminophen -hydrocodone
acetaminophen -hydrocodone
acetaminophen -hydrocodone
Nonsteroidal Anti-inflammatory Drugs
celecoxib cap 100mg
CELEBREX
celecoxib cap 200mg
CELEBREX
celecoxib cap 400mg
CELEBREX
celecoxib cap 50mg
CELEBREX
diclofen pot tab 50mg
CATAFLAM
diclofenac tab 100mg er
VOLTAREN - XR
diclofenac tab 25mg dr
VOLTAREN
diclofenac tab 50mg dr
VOLTAREN
diclofenac tab 75mg dr
VOLTAREN
diflunisal tab 500mg
diflunisal
etodolac cap 200mg
LODINE
etodolac cap 300mg
LODINE
etodolac er tab 400mg
LODINE XL
etodolac er tab 500mg
LODINE XL
etodolac er tab 600mg
LODINE XL
etodolac tab 400mg
LODINE
etodolac tab 500mg
LODINE
fenoprofen tab 600mg
FENOPROFEN
FLECTOR DIS 1.3%
diclofenac patch
flurbiprofen tab 100mg
ANSAID
flurbiprofen tab 50mg
ANSAID
ibuprofen sus 100/5ml
MOTRIN
ibuprofen tab 400mg *
MOTRIN
ibuprofen tab 600mg *
MOTRIN
ibuprofen tab 800mg *
MOTRIN
indomethacin cap 25mg
INDOCIN SR
Tier
Requirements/
Limits
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (240 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
Route
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
PA
69
70
71
72
73
74
75
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
76
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
TD
Oral
Oral
Oral
Oral
Oral
Oral
Oral
11
Formulary
Covered Drug Name
indomethacin cap 50mg
indomethacin cap 75mg er
ketoprofen cap 200mg er
ketoprofen cap 50mg
ketoprofen cap 75mg
meclofen sod cap 100mg
meclofen sod cap 50mg
mefenam acid cap 250mg
meloxicam tab 15mg *
meloxicam tab 7.5mg *
nabumetone tab 500mg
nabumetone tab 750mg
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen sod tab 275mg
naproxen sod tab 550mg
naproxen sus 125/5ml
naproxen tab 250mg
naproxen tab 375mg
naproxen tab 500mg
oxaprozin tab 600mg
piroxicam cap 10mg
piroxicam cap 20mg
sulindac tab 150mg
sulindac tab 200mg
tolmetin sod cap 400mg
tolmetin sod tab 600mg
Alternate Drug Name
INDOCIN SR
INDOCIN SR
ORUVAIL
KETOPROFEN
KETOPROFEN
meclofenamate
meclofenamate
PONSTEL
MOBIC
MOBIC
RELAFEN
RELAFEN
NAPROSYN
NAPROSYN
ANAPROX
ANAPROX DS
NAPROSYN
NAPROXYN
NAPROSYN
NAPROSYN
DAYPRO
FELDENE
FELDENE
CLINORIL
CLINORIL
TOLECTIN DS
TOLECTIN
Opioid Analgesics, Long-acting
fentanyl dis 100mcg/hr
DURAGESIC
fentanyl dis 12mcg/hr
DURAGESIC
fentanyl dis 25mcg/hr
DURAGESIC
fentanyl dis 50mcg/hr
DURAGESIC
fentanyl dis 75mcg/hr
DURAGESIC
levorphanol tab 2mg
LEVO-DROMORAN
methadone inj 10mg/ml
methadone
methadone sol 10mg/5ml
methadone
methadone sol 5mg/5ml
methadone
methadone tab 10mg
DOLOPHINE
methadone tab 5mg
DOLOPHINE
12
Tier
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
PA
PA
Route
77
78
79
80
81
82
83
84
QL (30 per 30 days)
QL (30 per 30 days)
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (120 per 30 days)
PA, QL (120 per 30 days)
QL (600 per 30 days)
QL (1200 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
104
105
106
107
108
109
110
111
112
113
114
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
TD
TD
TD
TD
TD
Oral
Inj
Oral
Oral
Oral
Oral
Formulary
Tier
Requirements/
Limits
KADIAN
KADIAN
AVINZA
KADIAN
AVINZA
KADIAN
AVINZA
KADIAN
AVINZA
KADIAN
AVINZA
KADIAN
AVINZA
MS CONTIN
MS CONTIN
MS CONTIN
MS CONTIN
MS CONTIN
oxycodone er
oxycodone er
oxycodone er
oxycodone er
oxycodone er
oxycodone er
oxycodone er
ULTRAM ER
ULTRAM ER
ULTRAM ER
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Opioid Analgesics, Short-acting
butorphanol sol 10mg/ml
butorphanol
DURAMORPH INJ 0.5MG/ML
morphine
DURAMORPH INJ 1MG/ML
morphine
fentanyl ot loz 1200mcg
ACTIQ
fentanyl ot loz 1600mcg
ACTIQ
fentanyl ot loz 200mcg
ACTIQ
fentanyl ot loz 400mcg
ACTIQ
fentanyl ot loz 600mcg
ACTIQ
fentanyl ot loz 800mcg
ACTIQ
hydromorphon tab 2mg
DILAUDID
Tier 2
Tier 4
Tier 4
Tier 5
Tier 5
Tier 2
Tier 5
Tier 5
Tier 5
Tier 2
QL (10 per 30 days)
PA, QL (180 per 30 days)
PA, QL (180 per 30 days)
PA, QL (120 per 30 days)
PA, QL (120 per 30 days)
PA, QL (120 per 30 days)
PA, QL (120 per 30 days)
PA, QL (120 per 30 days)
PA, QL (120 per 30 days)
QL (120 per 30 days)
Covered Drug Name
morphine sul cap 100mg er
morphine sul cap 10mg er
morphine sul cap 120mg er
morphine sul cap 20mg er
morphine sul cap 30mg er
morphine sul cap 30mg er
morphine sul cap 45mg er
morphine sul cap 50mg er
morphine sul cap 60mg er
morphine sul cap 60mg er
morphine sul cap 75mg er
morphine sul cap 80mg er
morphine sul cap 90mg er
morphine sul tab 100mg er
morphine sul tab 15mg er
morphine sul tab 200mg er
morphine sul tab 30mg er
morphine sul tab 60mg er
OXYCONTIN TAB 10MG CR
OXYCONTIN TAB 15MG CR
OXYCONTIN TAB 20MG CR
OXYCONTIN TAB 30MG CR
OXYCONTIN TAB 40MG CR
OXYCONTIN TAB 60MG CR
OXYCONTIN TAB 80MG CR
tramadol hcl tab 100mg er
tramadol hcl tab 200mg er
tramadol hcl tab 300mg er
Alternate Drug Name
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
Route
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
NS
Inj
Inj
BU
BU
BU
BU
BU
BU
Oral
13
Formulary
Covered Drug Name
hydromorphon tab 4mg
hydromorphon tab 8mg
MORPHINE SUL INJ 10MG/ML
MORPHINE SUL INJ 2MG/ML
MORPHINE SUL INJ 4MG/ML
MORPHINE SUL INJ 8MG/ML
morphine sul sol 10mg/5ml
morphine sul sol 20mg/5ml
morphine sul sol 20mg/ml
morphine sul tab 15mg
morphine sul tab 30mg
nalbuphine inj 10mg/ml
nalbuphine inj 20mg/ml
oxycodone cap 5mg
oxycodone con 100/5ml
oxycodone sol 5mg/5ml
oxycodone tab 10mg
oxycodone tab 15mg
oxycodone tab 20mg
oxycodone tab 30mg
oxycodone tab 5mg
tramadol hcl tab 50mg
Tier
Requirements/
Limits
DILAUDID
DILAUDID
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine soln
morphine soln
morphine
morphine
morphine
NUBAIN
NUBAIN
ROXICODONE
ROXICODONE
ROXICODONE
ROXICODONE
ROXICODONE
ROXICODONE
ROXICODONE
ROXICODONE
ULTRAM
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
QL (120 per 30 days)
QL (120 per 30 days)
PA
PA
PA
PA
QL (1800 per 30 days)
QL (900 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
PA, QL (120 per 30 days)
PA, QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (1800 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (240 per 30 days)
EMLA
lidocaine
XYLOCAINE
XYLOCAINE
xylocaine
LIDODERM
XYLOCAINE
XYLOCAINE
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Alternate Drug Name
Route
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
Oral
Oral
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
ANESTHETICS
Local Anesthetics
lido/prilocn cre 2.5-2.5%
lidocaine gel 2% jelly
lidocaine gel 2% jelly
lidocaine inj 0.5%
lidocaine oin 5%
lidocaine pad 5%
lidocaine sol 2% visc
lidocaine sol 4%
175
176
177
PA
178
179
PA, QL (90 per 30 days)
180
181
182
Top
Top
Top
Inj
Top
Top
MT
Top
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
Alcohol Deterrents/Anti-craving
acampro cal tab 333mg
acamprosate
disulfiram tab 250mg
ANTABUSE
disulfiram tab 500mg
ANTABUSE
VIVITROL INJ 380MG
naltrexone suspension
14
Tier 2
Tier 2
Tier 2
Tier 5
183
184
185
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
186
Oral
Oral
Oral
Inj
Formulary
Tier
Requirements/
Limits
Opioid Dependence Treatments
bupren/nalox sub 2-0.5mg
SUBOXONE
bupren/nalox sub 8-2mg
SUBOXONE
buprenorphin inj 0.3mg/ml
BUPRENEX
buprenorphin sub 2mg
SUBUTEX
buprenorphin sub 8mg
SUBUTEX
BUTRANS DIS 10MCG/HR
buprenorphine patch
BUTRANS DIS 15MCG/HR
buprenorphine patch
BUTRANS DIS 20MCG/HR
buprenorphine patch
BUTRANS DIS 5MCG/HR
buprenorphine patch
SUBOXONE MIS 12-3MG
buprenorphine - naloxone
SUBOXONE MIS 2-0.5MG
buprenorphine - naloxone
SUBOXONE MIS 4-1MG
buprenorphine - naloxone
SUBOXONE MIS 8-2MG
buprenorphine - naloxone
Tier 2
Tier 2
Tier 3
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
QL (120 per 30 days)
QL (120 per 30 days)
PA
QL (120 per 30 days)
QL (120 per 30 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (45 per 30 days)
QL (90 per 30 days)
Opioid Reversal Agents
naloxone inj 1mg/ml
naltrexone tab 50mg
NARCAN
naltrexone
Tier 3
Tier 2
Smoking Cessation Agents
buproban tab 150mg
bupropion tab 100mg
bupropion tab 100mg sr
bupropion tab 150mg sr
bupropion tab 200mg sr
bupropion tab 75mg
bupropn hcl tab 150mg xl
bupropn hcl tab 300mg xl
CHANTIX PAK 0.5& 1MG
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
FORFIVO XL TAB 450MG
NICOTROL NS SPR 10MG/ML
bupropion
WELLBUTRIN
WELLBUTRIN SR, BUDEPRION SR
WELLBUTRIN SR, BUDEPRION SR
WELLBUTRIN SR, BUDEPRION SR
WELLBUTRIN
WELLBUTRIN XL
WELLBUTRIN XL
varenicline
varenicline
varenicline
bupropion er
nicotine
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 4
Tier 3
Covered Drug Name
Alternate Drug Name
Route
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
QL (90 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (180 per 30 days)
QL (30 per 30 days)
QL (45 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (40 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
202
203
204
205
206
207
208
209
210
211
212
213
214
SL
SL
Inj
SL
SL
TD
TD
TD
TD
SL
SL
SL
SL
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
NS
15
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
Route
ANTIBACTERIALS
16
Aminoglycosides
gentak oin 0.3%
gentamicin cre 0.1%
gentamicin inj 10mg/ml
gentamicin inj 40mg/ml
gentamicin oin 0.1%
gentamicin oin 0.3%
gentamicin sol 0.3%
neomycin tab 500mg
paromomycin cap 250mg
streptomycin inj 1gm
TOBRADEX OIN 0.3-0.1%
tobramycin inj 10mg/ml
tobramycin inj 80mg/2ml
tobramycin neb 300/5ml
tobramycin sol 0.3%
GENTAK
gentamicin
GENTAMICIN
GENTAMICIN
gentamicin
GENTAK
GENTAK
NEOMYCIN
PARAMOMYCIN
streptomycin
tobramycin - dexamethasone
NEBCIN
tobramycin
TOBI
TOBREX
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 5
Tier 2
Antibacterials
colistimeth inj 150mg
neo/poly gu sol 40/ml
SYNERCID INJ 500MG
colistimethate
NEOSPORIN GU
dalfopristin - quinupristin
Tier 4
Tier 2
Tier 5
Antibacterials, Other
acetic acid sol 2%
baciim inj 50000unt
bacitracin oin
chloramphen inj 1gm
clindamycin aer 1%
clindamycin cap 150mg
clindamycin cap 300mg
clindamycin cap 75mg
clindamycin cre 2%
clindamycin gel 1%
clindamycin inj 150mg/ml
clindamycin inj 300mg
clindamycin inj 600mg
ACETIC ACID
BACITRACIN
bacitracin
chloramphenicol
CLEOCIN-T
CLEOCIN
CLEOCIN
CLEOCIN
CLEOCIN
CLEOCIN-T
CLEOCIN
CLEOCIN
CLEOCIN
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
215
216
PA
PA
217
218
219
220
221
222
223
PA
224
225
PA
PA
PA
226
227
228
229
PA
230
231
PA
232
233
PA
234
235
PA
236
237
238
239
240
241
242
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
243
244
245
OP
Top
Inj
Inj
Top
OP
OP
Oral
Oral
Inj
OP
Inj
Inj
Inh
OP
Inj
IR
Inj
OT
Inj
OP
Inj
Top
Oral
Oral
Oral
Vag
Top
Inj
Inj
Inj
Formulary
Covered Drug Name
clindamycin inj 900mg
clindamycin lot 1%
clindamycin pad 1%
clindamycin sol 1%
CUBICIN SOL 500MG
linezolid inj 2mg/ml
methenam hip tab 1gm
metron/nacl inj 500mg
metronidazol cap 375mg
metronidazol cre 0.75%
metronidazol gel 0.75%
metronidazol gel 0.75%
metronidazol gel 1%
metronidazol lot 0.75%
metronidazol tab 250mg
metronidazol tab 500mg
mupirocin cre 2%
mupirocin oin 2%
nitrofur mac cap 50mg
nitrofurantn cap 100mg
nitrofurantn sus 25mg/5ml
nitrofurantoin mac cap 100mg
PRIMSOL SOL 50MG/5ML
SULFAMYLON CRE 85MG/GM
tinidazole tab 250mg
tinidazole tab 500mg
trimethoprim tab 100mg
TYGACIL INJ 50MG
vancomycin cap 125mg
vancomycin cap 250mg
vancomycin inj 1000mg
vancomycin inj 10gm
vancomycin inj 500mg
ZYVOX SUS 100MG/5ML
ZYVOX TAB 600MG
Alternate Drug Name
CLEOCIN
CLEOCIN-T
CLEOCIN-T
CLEOCIN-T
daptomycin
ZYVOX
HIPREX
FLAGYL
FLAGYL
metronidazole
METROGEL-VAG, VANDAZOLE
metronidazole
FLAGYL
metronidazole
FLAGYL
FLAGYL
BACTROBAN
BACTROBAN
MACRODANTIN
MACROBID
FURADANTIN
MACRODANTIN
trimethoprim
mafenide
TINDAMAX
TINDAMAX
PROLOPRIM
tigecycline
VANCOCIN
VANCOCIN
VANCOMYCIN
VANCOCIN
VANCOCIN
linezolid
linezolid
Beta-lactam, Cephalosporins
cefaclor cap 250mg
CECLOR
cefaclor cap 500mg
CECLOR
cefaclor er tab 500mg
CECLOR
Tier
Tier 4
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 4
Tier 5
Tier 5
Requirements/
Limits
PA
Route
246
247
248
249
PA
PA
250
251
252
PA
253
254
255
256
257
258
259
260
261
262
263
PA
PA
PA
PA
264
265
266
267
268
269
270
271
272
PA
PA, QL (40 per 30 days)
PA, QL (80 per 30 days)
PA
PA
PA
PA
PA, QL (28 per 14 days)
Tier 2
Tier 2
Tier 2
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
273
274
275
276
277
278
279
280
281
282
283
Inj
Top
Top
Top
Inj
Inj
Oral
Inj
Oral
Top
Vag
Top
Top
Top
Oral
Oral
Top
Top
Oral
Oral
Oral
Oral
Oral
Top
Oral
Oral
Oral
Inj
Oral
Oral
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
17
Formulary
Covered Drug Name
cefaclor sus 125/5ml
cefaclor sus 250/5ml
cefaclor sus 375/5ml
cefadroxil cap 500mg
cefadroxil sus 250/5ml
cefadroxil sus 500/5ml
cefadroxil tab 1gm
cefazolin inj 10gm
cefazolin inj 1gm
cefazolin inj 1gm/50ml
cefazolin inj 500mg
cefdinir cap 300mg
cefdinir sus 125/5ml
cefdinir sus 250/5ml
cefepime inj 1gm
cefepime inj 2gm
cefoxitin inj 10gm
cefoxitin inj 1gm
cefoxitin inj 1gm
cefoxitin inj 2gm
cefoxitin inj 2gm
cefpodo prox sus 100/5ml
cefpodo prox sus 50mg/5ml
cefpodoxime tab 100mg
cefpodoxime tab 200mg
cefprozil sus 125/5ml
cefprozil sus 250/5ml
cefprozil tab 250mg
cefprozil tab 500mg
ceftriaxone inj 10gm
ceftriaxone inj 1gm
ceftriaxone inj 250mg
ceftriaxone inj 2gm
ceftriaxone inj 500mg
cefuroxime inj 1.5gm
cefuroxime inj 7.5gm
cefuroxime inj 750mg
cefuroxime tab 250mg
cefuroxime tab 500mg
cephalexin cap 250mg
cephalexin cap 500mg
cephalexin cap 750mg
18
Alternate Drug Name
CECLOR
CECLOR
CECLOR
DURICEF
DURICEF
DURICEF
DURICEF
ANCEF
ANCEF
ANCEF
ANCEF
OMNICEF
OMNICEF
OMNICEF
MAXIPIME
MAXIPIME
MEFOXIN
MEFOXIN
MEFOXIN
MEFOXIN
MEFOXIN
VANTIN
VANTIN
VANTIN
VANTIN
CEFZIL
CEFZIL
CEFZIL
CEFZIL
ROCEPHIN
ROCEPHIN
ROCEPHIN
ROCEPHIN
ROCEPHIN
ZINACEF
ZINACEF
ZINACEF
CEFTIN
CEFTIN
KEFLEX
KEFLEX
KEFLEX
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
Route
284
285
286
287
288
289
290
PA
PA
PA
PA
291
292
293
294
295
296
297
PA
PA
PA
PA
PA
PA
PA
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
PA
PA
PA
PA
PA
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
313
314
315
316
317
318
319
320
321
322
323
324
325
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
cephalexin sus 125/5ml
cephalexin sus 250/5ml
cephalexin tab 250mg
cephalexin tab 500mg
SUPRAX SUS 100/5ML
SUPRAX SUS 200/5ML
TEFLARO INJ 400MG
TEFLARO INJ 600MG
KEFLEX
KEFLEX
KEFLEX
KEFLEX
cefixime
cefixime
ceftaroline
ceftaroline
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 5
Tier 5
Beta-lactam, Other
AZACTAM/DEX INJ 1GM
AZACTAM/DEX INJ 2GM
aztreonam inj 1gm
imipenem/cil inj 250mg
imipenem/cil inj 500mg
INVANZ INJ 1GM
meropenem inj 500mg
aztreonam
aztreonam
AZACTAM
MERREM
imipenem-cilastatin
ertapenem
MERREM
Tier 4
Tier 5
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Beta-lactam, Penicillins
amox-pot cla tab er
amox/k clav chw 200mg
amox/k clav chw 400mg
amox/k clav sus 200/5ml
amox/k clav sus 250/5ml
amox/k clav sus 400/5ml
amox/k clav sus 600/5ml
amox/k clav tab 250mg
amox/k clav tab 500mg
amox/k clav tab 875mg
amoxicillin cap 250mg
amoxicillin cap 500mg
amoxicillin chw 125mg
amoxicillin chw 250mg
amoxicillin sus 125/5ml
amoxicillin sus 200/5ml
amoxicillin sus 250/5ml
amoxicillin sus 400/5ml
amoxicillin tab 500mg
amoxicillin tab 875mg
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AUGMENTIN
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
AMOXIL
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/
Limits
Route
326
327
328
329
330
331
PA
PA
PA
PA
PA
PA
PA
332
333
334
335
336
337
338
339
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
19
Formulary
Covered Drug Name
Tier
Tier 4
Tier 4
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 4
BICILLIN L-A INJ 1200000
BICILLIN L-A INJ 2400000
BICILLIN L-A INJ 600000
dicloxacill cap 250mg
dicloxacill cap 500mg
nafcillin inj 10gm
nafcillin inj 1gm
pen g proc inj 600000
pen g sod inj 5000000
penicill gk/ inj dex 2mu
penicill gk/ inj dex 3mu
penicilln gk inj 5mu
penicilln vk sol 125/5ml
penicilln vk sol 250/5ml
penicilln vk tab 250mg
penicilln vk tab 500mg
piper/tazoba inj 3-0.375gm
piper/tazoba inj 4-0.5gm
ZOSYN SOL 2-0.25GM
ZOSYN SOL 3-0.375GM
UNASYN
UNASYN
ampicillin
ampicillin
ampicillin
ampicillin
ampicillin
ampicillin
ampicillin
penicillin g benzathine - penicillin g
procaine
penicillin g benzathine - penicillin g
procaine
penicillin g benzathine
penicillin g benzathine
penicillin g benzathine
DYCIL, DYNAPEN
DYCIL, DYNAPEN
nafcillin
NAFCILLIN
PENICILLIN G PROCAINE
pen g sod
penicill gk
penicill gk
penicillin g
VEETIDS
VEETIDS
VEETIDS
VEETIDS
ZOSYN
ZOSYN
piperacillin - tazobactam
piperacillin - tazobactam
Macrolides
azithromycin inj 500mg
azithromycin pow 1gm pak
azithromycin sus 100/5ml
azithromycin sus 200/5ml
azithromycin tab 250mg
azithromycin tab 500mg
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
ZITHROMAX
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
amp-sulbacta inj 15gm
amp-sulbacta inj 3gm
ampicillin cap 250mg
ampicillin cap 500mg
ampicillin inj 10gm
AMPICILLIN INJ 125MG
ampicillin inj 1gmg
ampicillin sus 125/5ml
ampicillin sus 250/5ml
BICILLIN C-R INJ 1200000
BICILLIN C-R INJ 900/300
20
Alternate Drug Name
Requirements/
Limits
PA
PA
361
362
363
364
PA
PA
PA
365
366
367
368
369
370
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 5
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 4
Tier 4
Route
371
372
373
374
375
376
PA
PA
PA
PA
PA
PA
PA
377
378
379
380
381
382
383
384
385
386
387
PA
PA
PA
PA
PA
388
389
390
391
392
393
QL (30 per 5 days)
QL (90 per 5 days)
QL (6 per 5 days)
QL (6 per 5 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
394
395
396
397
Inj
Inj
Oral
Oral
Inj
Inj
Inj
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
azithromycin tab 600mg
clarithromyc sus 125/5ml
clarithromyc sus 250/5ml
clarithromyc tab 250mg
clarithromyc tab 500mg
clarithromyc tab 500mg er
e.e.s. 400 tab 400mg
ery pad 2%
ery-tab tab 250mg ec
ery-tab tab 333mg ec
ery-tab tab 500mg ec
erythrocin inj 500mg
erythrocin tab 250mg
erythrom eth tab 400mg
erythromycin gel 2%
erythromycin oin
erythromycin sol 2%
erythromycin tab 250mg bs
erythromycin tab 500mg bs
ZMAX SUS 2GM
ZITHROMAX
BIAXIN
BIAXIN
BIAXIN
BIAXIN
BIAXIN XL
ERY-TAB, E.E.S.
ERY
erythromycin
erythromycin
erythromycin
erythromycin
ERYTHROCIN
E.E.S.
ERYGEL
ROMYCIN
ERYGEL
ERY-TAB, E.E.S.
ERY-TAB, E.E.S.
azithromycin
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Quinolones
ciprofloxacn inj 200mg
ciprofloxacn inj 400mg
ciprofloxacn sol 0.3%
ciprofloxacn tab 1000mg
ciprofloxacn tab 100mg
ciprofloxacn tab 250mg
ciprofloxacn tab 500mg
ciprofloxacn tab 500mg er
ciprofloxacn tab 750mg
levoflox/d5w inj 500/100ml
levofloxacin inj 25mg/ml
levofloxacin sol 0.5%
levofloxacin sol 25mg/ml
levofloxacin tab 250mg
levofloxacin tab 500mg
levofloxacin tab 750mg
ofloxacin dro 0.3%
ofloxacin dro 0.3%
CIPRO
CIPRO
CILOXAN
CIPRO XR
CIPRO
CIPRO
CIPRO
CIPRO XR
CIPRO
LEVAQUIN
LEVAQUIN
QUIXIN
LEVAQUIN
LEVAQUIN
LEVAQUIN
LEVAQUIN
FLOXIN OTIC
OCUFLOX
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
QL (6 per 5 days)
Route
398
399
400
QL (28 per 14 days)
QL (28 per 14 days)
QL (28 per 14 days)
401
402
403
404
405
406
407
408
PA
409
410
411
412
413
414
415
416
QL (60 per 30 days)
PA
PA
417
418
419
420
421
422
423
424
425
426
PA
PA
427
428
429
430
QL (14 per 14 days)
QL (14 per 14 days)
QL (14 per 14 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
431
432
433
434
435
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Top
Oral
Oral
Oral
Inj
Oral
Oral
Top
OP
Top
Oral
Oral
Oral
Inj
Inj
OP
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
OP
Oral
Oral
Oral
Oral
OT
OP
21
Formulary
Covered Drug Name
22
Alternate Drug Name
Tier
ofloxacin tab 400mg
VIGAMOX DRO 0.5%
FLOXIN
moxifloxacin
Tier 2
Tier 4
Sulfonamides
silver sulfa cre 1%
smz-tmp inj 400-80/5ml
smz-tmp sus 200-40/5ml
smz-tmp tab 400-80mg
smz/tmp ds tab 800-160mg
sod sulfacet sol 10%
ssd cre 1%
sulfacet sod oin 10%
sulfacetamid sus 10%
sulfadiazine tab 500mg
SILVADENE - SSD
BACTRIM, SEPTRA
BACTRIM, SEPTRA
BACTRIM, SEPTRA
BACTRAM DS, SEPTRA DS
BLEPH-10
SILVADENE - SSD
BLEPH-10
KLARON
sulfadiazine
Tier 1
Tier 4
Tier 1
Tier 1
Tier 1
Tier 2
Tier 1
Tier 2
Tier 2
Tier 2
Tetracyclines
demeclocycl tab 150mg
demeclocycl tab 300mg
doxycyc mono tab 150mg
doxycyc mono tab 50mg
doxycyc mono tab 75mg
doxycycl hyc cap 100mg
doxycycl hyc cap 50mg
doxycycl hyc inj 100mg
doxycycl hyc tab 100mg
doxycycl hyc tab 100mg dr
doxycycl hyc tab 150mg dr
doxycycl hyc tab 75mg dr
doxycycline cap 150mg
doxycycline cap 75mg
doxycycline mono cap 100mg
doxycycline mono cap 50mg
doxycycline mono tab 100mg
doxycycline mono tab 50mg
doxycycline sus 25mg/5ml
minocycline cap 100mg
minocycline cap 50mg
minocycline cap 75mg
minocycline tab 100mg
DECLOMYCIN
DECLOMYCIN
VIBRATAB
VIBRATAB
VIBRATAB
ADOXA
ADOXA
vibramycin
ADOXA
VIBRATAB
DORYX
VIBRATAB
doxycycline
doxycycline
doxycycline
doxycycline
doxycycline
doxycycline
doxycycline sus
MINOCIN
MINOCIN
MINOCIN
DYNACIN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
Route
436
437
438
PA
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
455
456
457
458
459
460
461
2243
2244
2245
2246
462
463
464
465
466
Oral
OP
Top
Inj
Oral
Oral
Oral
OP
Top
OP
Top
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
minocycline tab 135mg er
minocycline tab 45mg er
minocycline tab 50mg
minocycline tab 75mg
minocycline tab 90mg er
Alternate Drug Name
Tier
SOLODYN
SOLODYN
DYNACIN
DYNACIN
SOLODYN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
eslicarbazepine
eslicarbazepine
eslicarbazepine
eslicarbazepine
KEPPRA
KEPPRA
KEPPRA
KEPPRA
KEPPRA XR
KEPPRA
KEPPRA XR
KEPPRA
ezogabine
ezogabine
ezogabine
ezogabine
Tier 4
Tier 5
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Requirements/
Limits
Route
467
468
469
470
471
Oral
Oral
Oral
Oral
Oral
ANTICONVULSANTS
Anticonvulsants, Other
APTIOM TAB 200MG
APTIOM TAB 400MG
APTIOM TAB 600MG
APTIOM TAB 800MG
levetiraceta sol 100mg/ml
levetiraceta tab 1000mg
levetiraceta tab 250mg
levetiraceta tab 500mg
levetiraceta tab 500mg er
levetiraceta tab 750mg
levetiraceta tab 750mg er
levetiracetm inj 500/5ml
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
POTIGA TAB 50MG
Calcium Channel Modifying Agents
CELONTIN CAP 300MG
methsuximide
ethosuximide cap 250mg
ZARONTIN
ethosuximide sol 250/5ml
ZARONTIN
LYRICA CAP 100MG
pregabalin
LYRICA CAP 150MG
pregabalin
LYRICA CAP 200MG
pregabalin
LYRICA CAP 225MG
pregabalin
LYRICA CAP 25MG
pregabalin
LYRICA CAP 300MG
pregabalin
LYRICA CAP 50MG
pregabalin
LYRICA CAP 75MG
pregabalin
LYRICA SOL 20MG/ML
pregabalin
zonisamide cap 100mg
ZONEGRAN
Tier 4
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
QL (180 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (45 per 30 days)
472
473
474
475
476
477
478
479
QL (180 per 30 days)
480
481
QL (120 per 30 days)
PA
QL (180 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
QL (720 per 30 days)
482
483
484
485
486
487
488
489
490
QL (180 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (720 per 30 days)
QL (60 per 30 days)
QL (360 per 30 days)
QL (240 per 30 days)
QL (900 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
491
492
493
494
495
496
497
498
499
500
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
23
Formulary
Covered Drug Name
zonisamide cap 25mg
zonisamide cap 50mg
Alternate Drug Name
ZONEGRAN
ZONEGRAN
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazep odt tab 0.125mg
KLONOPIN ODT
clonazep odt tab 0.25mg
KLONOPIN ODT
clonazep odt tab 0.5mg
KLONOPIN ODT
clonazep odt tab 1mg
KLONOPIN ODT
clonazep odt tab 2mg
KLONOPIN ODT
clonazepam tab 0.5mg
KLONOPIN
clonazepam tab 1mg
KLONOPIN
clonazepam tab 2mg
KLONOPIN
cloraz dipot tab 15mg
TRANXENE
cloraz dipot tab 3.75mg
TRANXENE
cloraz dipot tab 7.5mg
TRANXENE
DIASTAT ACDL GEL 12.5-20MG
diazepam gel
DIASTAT ACDL GEL 5-10MG
diazepam gel
DIASTAT PED GEL 2.5MG
diazepam gel
diazepam con 5mg/ml
VALIUM
DIAZEPAM GEL 10MG
VALIUM
DIAZEPAM GEL 2.5MG
VALIUM
DIAZEPAM GEL 20MG
VALIUM
diazepam sol 1mg/ml
VALIUM
diazepam tab 10mg
VALIUM
diazepam tab 2mg
VALIUM
diazepam tab 5mg
VALIUM
divalproex cap 125mg
DEPAKOTE
divalproex tab 125mg dr
DEPAKOTE
divalproex tab 250mg dr
DEPAKOTE
divalproex tab 250mg er
DEPAKOTE
divalproex tab 500mg dr
DEPAKOTE
divalproex tab 500mg er
DEPAKOTE
FYCOMPA TAB 10MG
perampanel
FYCOMPA TAB 12MG
perampanel
FYCOMPA TAB 2MG
perampanel
FYCOMPA TAB 4MG
perampanel
FYCOMPA TAB 6MG
perampanel
FYCOMPA TAB 8MG
perampanel
gabapentin cap 100mg
NEURONTIN
gabapentin cap 300mg
NEURONTIN
24
Tier
Requirements/
Limits
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 2
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Route
501
502
QL (4800 per 30 days)
QL (2400 per 30 days)
QL (1200 per 30 days)
QL (600 per 30 days)
QL (300 per 30 days)
QL (1200 per 30 days)
QL (600 per 30 days)
QL (300 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (40 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (240 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (40 per 30 days)
QL (1200 per 30 days)
QL (180 per 30 days)
QL (90 per 30 days)
QL (240 per 30 days)
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
QL (30 per 30 days)
QL (30 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (360 per 30 days)
QL (360 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
531
532
533
534
535
536
537
538
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Rec
Rec
Rec
Oral
Rec
Rec
Rec
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
gabapentin cap 400mg
gabapentin sol 250/5ml
gabapentin tab 600mg
gabapentin tab 800mg
GABITRIL TAB 12MG
GABITRIL TAB 16MG
lorazepam con 2mg/ml
lorazepam tab 0.5mg
lorazepam tab 1mg
lorazepam tab 2mg
ONFI SUS 2.5MG/ML
ONFI TAB 10MG
ONFI TAB 20MG
phenobarb elx 20mg/5ml
phenobarb tab 100mg
phenobarb tab 15mg
phenobarb tab 16.2mg
phenobarb tab 30mg
phenobarb tab 32.4mg
phenobarb tab 60mg
PHENOBARB TAB 64.8MG
PHENOBARB TAB 97.2MG
primidone tab 250mg
primidone tab 50mg
SABRIL POW 500MG
SABRIL TAB 500MG
tiagabine tab 2mg
tiagabine tab 4mg
valproate inj 100mg/ml
valproic acd cap 250mg
valproic acd syp 250/5ml
NEURONTIN
NEURONTIN
NEURONTIN
NEURONTIN
tiagabine
tiagabine
ATIVAN
ATIVAN
ATIVAN
ATIVAN
clobazam
clobazam
clobazam
phenobarbital
phenobarbital
phenobarbital
phenobarbital
phenobarbital
phenobarbital
phenobarbital
phenobarbital
phenobarbital
MYSOLINE
MYSOLINE
vigabatrin
vigabatrin
GABITRIL
GABITRIL
DEPAKENE
DEPAKENE
DEPAKENE
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Glutamate Reducing Agents
felbamate sus 600/5ml
felbamate tab 400mg
felbamate tab 600mg
lamotrigine chw 25mg
lamotrigine chw 5mg
lamotrigine tab 100mg
lamotrigine tab 100mg er
FELBATOL
FELBATOL
FELBATOL
LAMICTAL CHEWABLE
LAMICTAL CHEWABLE
LAMICTAL
LAMICTAL ER
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
QL (270 per 30 days)
QL (2160 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
Route
539
540
541
542
543
544
545
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (480 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (1500 per 30 days)
QL (90 per 30 days)
QL (120 per 30 days)
QL (360 per 30 days)
QL (195 per 30 days)
QL (180 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
546
547
548
549
550
551
552
553
554
555
556
557
558
559
560
561
562
QL (180 per 30 days)
QL (180 per 30 days)
563
564
565
566
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
567
568
569
570
571
572
573
574
575
576
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
25
Formulary
Covered Drug Name
26
Alternate Drug Name
Tier
lamotrigine tab 150mg
lamotrigine tab 200mg
lamotrigine tab 200mg er
lamotrigine tab 250mg er
lamotrigine tab 25mg
lamotrigine tab 25mg er
lamotrigine tab 300mg er
lamotrigine tab 50mg er
lamotrigine tab odt 25mg
lamotrigine tab odt 50mg
lamotrigine tab odt/100mg
lamotrigine tab odt/200mg
topiramate cap 15mg
topiramate cap 25mg
topiramate tab 100mg
topiramate tab 200mg
topiramate tab 25mg
topiramate tab 50mg
TROKENDI XR CAP 100MG
TROKENDI XR CAP 200MG
TROKENDI XR CAP 25MG
TROKENDI XR CAP 50MG
LAMICTAL
LAMICTAL
LAMICTAL ER
LAMICTAL ER
LAMICTAL
LAMICTAL ER
LAMICTAL ER
LAMICTAL ER
LAMICTAL ODT
LAMICTAL ODT
LAMICTAL ODT
LAMICTAL ODT
TOPAMAX
TOPAMAX
TOPAMAX
TOPAMAX
TOPAMAX
TOPAMAX
topiramate
topiramate
topiramate
topiramate
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 5
Tier 4
Tier 4
Sodium Channel Agents
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
carbamazepin cap 100mg er
carbamazepin cap 200mg er
carbamazepin cap 300mg er
carbamazepin chw 100mg
carbamazepin sus 100/5ml
carbamazepin tab 200mg
carbamazepin tab 200mg er
carbamazepin tab 400mg er
DILANTIN CAP 30MG
epitol tab 200mg
EQUETRO CAP 100MG
EQUETRO CAP 200MG
EQUETRO CAP 300MG
rufinamide
rufinamide
rufinamide
TEGRETOL XR
TEGRETOL XR
TEGRETOL XR
TEGRETOL
TEGRETOL
TEGRETOL
TEGRETOL XR
TEGRETOL XR
phenytoin
TEGRETOL
carbamazepine sr
carbamazepine sr
carbamazepine sr
Tier 5
Tier 4
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 2
Tier 4
Tier 4
Tier 4
Requirements/
Limits
Route
577
578
579
580
581
582
583
584
585
586
587
588
589
590
QL (480 per 30 days)
QL (240 per 30 days)
QL (1920 per 30 days)
QL (960 per 30 days)
591
592
593
594
595
596
597
598
QL (2400 per 30 days)
QL (240 per 30 days)
QL (240 per 30 days)
599
600
601
602
603
604
605
606
607
608
609
610
611
QL (480 per 30 days)
QL (240 per 30 days)
QL (180 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
612
613
614
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
fosphenytoin inj 100/2ml
oxcarbazepin sus 300mg/5ml
oxcarbazepin tab 150mg
oxcarbazepin tab 300mg
oxcarbazepin tab 600mg
OXTELLAR XR TAB 150MG
OXTELLAR XR TAB 300MG
OXTELLAR XR TAB 600MG
PEGANONE TAB 250MG
phenytek cap 200mg
phenytek cap 300mg
phenytoin chw 50mg
phenytoin ex cap 100mg
phenytoin ex cap 200mg
phenytoin ex cap 300mg
phenytoin inj 50mg/ml
phenytoin sus 125/5ml
TEGRETOL-XR TAB 100MG
VIMPAT INJ 200MG/20ML
VIMPAT SOL 10MG/ML
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
VIMPAT TAB 50MG
Alternate Drug Name
CEREBYX
TRILEPTAL
TRILEPTAL
TRILEPTAL
TRILEPTAL
oxcarbazepine
oxcarbazepine
oxcarbazepine
ethotoin
phenytoin
phenytoin
DILANTIN CHEWABLE
DILANTIN
DILANTIN
DILANTIN
DILANTIN
DILANTIN
carbamazepine er
lacosamide
lacosamide
lacosamide
lacosamide
lacosamide
lacosamide
Tier
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 4
Tier 1
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Requirements/
Limits
PA
Route
615
616
617
618
619
QL (480 per 30 days)
QL (240 per 30 days)
QL (120 per 30 days)
620
621
622
623
624
625
626
627
628
629
PA
630
631
632
QL (1200 per 30 days)
QL (1200 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
633
634
635
636
637
638
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
ANTIDEMENTIA AGENTS
Antidementia Agents, Other
ergoloid mes tab 1mg
ergoloid mesylates
Tier 2
Cholinesterase Inhibitors
donepezil tab 10mg
donepezil tab 10mg odt
donepezil tab 5mg
donepezil tab 5mg odt
donepezil tab hcl 23mg
EXELON DIS 13.3/24HR
EXELON DIS 4.6MG/24HR
EXELON DIS 9.5MG/24HR
galantamine cap 16mg er
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 2
ARICEPT
ARICEPT ODT
ARICEPT
ARICEPT ODT
ARICEPT
rivastigmine patch
rivastigmine patch
rivastigmine patch
RAZADYNE ER
639
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
640
641
642
643
644
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
645
646
647
648
Oral
Oral
Oral
Oral
Oral
Oral
TD
TD
TD
Oral
27
Formulary
Covered Drug Name
galantamine cap 24mg er
galantamine cap 8mg er
galantamine sol 4mg/ml
galantamine tab 12mg
galantamine tab 4mg
galantamine tab 8mg
rivastigmine cap 1.5mg
rivastigmine cap 3mg
rivastigmine cap 4.5mg
rivastigmine cap 6mg
Alternate Drug Name
RAZADYNE ER
RAZADYNE ER
REMINYL, RAZADYNE
REMINYL, RAZADYNE
REMINYL, RAZADYNE
REMINYL, RAZADYNE
EXELON
EXELON
EXELON
EXELON
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA SOL 10MG/5ML
memantine
NAMENDA TAB 10MG
memantine
NAMENDA TAB 5-10MG
memantine
NAMENDA TAB 5MG
memantine
Tier
Requirements/
Limits
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
QL (30 per 30 days)
QL (30 per 30 days)
QL (180 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
Tier 3
Tier 3
Tier 3
Tier 3
QL (360 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
Route
649
650
651
652
653
654
655
656
657
658
659
660
661
662
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
ANTIDEPRESSANTS
28
Antidepressants
olanza/fluox cap 12-25mg
olanza/fluox cap 12-50mg
olanza/fluox cap 3-25mg
olanza/fluox cap 6-25mg
olanza/fluox cap 6-50mg
perphen/amit tab 2-10mg
perphen/amit tab 2-25mg
perphen/amit tab 4-10mg
perphen/amit tab 4-25mg
perphen/amit tab 4-50mg
SYMBYAX
SYMBYAX
SYMBYAX
SYMBYAX
SYMBYAX
perphenazine - amitriptyline
perphenazine - amitriptyline
perphenazine - amitriptyline
perphenazine - amitriptyline
perphenazine - amitriptyline
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
Antidepressants, Other
ABILIFY DISC TAB 10MG
ABILIFY DISC TAB 15MG
ABILIFY MAIN INJ 300MG
ABILIFY MAIN INJ 300MG
ABILIFY MAIN INJ 400MG
ABILIFY TAB 10MG
ABILIFY TAB 15MG
aripiprazole disintegrating
aripiprazole disintegrating
aripiprazole
aripiprazole
aripiprazole
aripiprazole
aripiprazole
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
QL (90 per 30 days)
QL (60 per 30 days)
QL (1 per 28 days)
PA, QL (2 per 28 days)
QL (1 per 28 days)
QL (90 per 30 days)
QL (60 per 30 days)
663
664
665
666
667
668
669
670
671
672
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
673
674
675
676
677
678
679
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Oral
Oral
Formulary
Tier
Requirements/
Limits
aripiprazole
aripiprazole
aripiprazole
aripiprazole
REMERON
REMERON
REMERON
REMERON
REMERON
REMERON
REMERON
SEROQUEL
SEROQUEL
SEROQUEL
SEROQUEL
SEROQUEL
SEROQUEL
quetiapine er
quetiapine er
quetiapine er
quetiapine er
quetiapine er
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
QL (60 per 30 days)
QL (450 per 30 days)
QL (30 per 30 days)
QL (180 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (240 per 30 days)
QL (120 per 30 days)
QL (960 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (480 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
Monoamine Oxidase Inhibitors
EMSAM DIS 12MG/24HR
selegiline
EMSAM DIS 6MG/24HR
selegiline
EMSAM DIS 9MG/24HR
selegiline
MARPLAN TAB 10MG
isocarboxazid
phenelzine tab 15mg
NARDIL
tranylcyprom tab 10mg
PARNATE
Tier 5
Tier 5
Tier 5
Tier 4
Tier 2
Tier 2
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Covered Drug Name
ABILIFY TAB 20MG
ABILIFY TAB 2MG
ABILIFY TAB 30MG
ABILIFY TAB 5MG
mirtazapine tab 15mg
mirtazapine tab 15mg odt
mirtazapine tab 30mg
mirtazapine tab 30mg odt
mirtazapine tab 45mg
mirtazapine tab 45mg odt
mirtazapine tab 7.5mg
quetiapine tab 100mg
quetiapine tab 200mg
quetiapine tab 25mg
quetiapine tab 300mg
quetiapine tab 400mg
quetiapine tab 50mg
SEROQUEL XR TAB 150MG
SEROQUEL XR TAB 200MG
SEROQUEL XR TAB 300MG
SEROQUEL XR TAB 400MG
SEROQUEL XR TAB 50MG
Alternate Drug Name
Route
680
681
682
683
684
685
686
687
688
689
690
691
692
693
694
695
696
697
698
699
700
701
702
703
704
705
706
707
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
TD
TD
TD
Oral
Oral
Oral
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin Norepinephrine Reuptake
Inhibitors)
BRINTELLIX TAB 10MG
vortioxetine
Tier 4
QL (60 per 30 days)
Oral
BRINTELLIX TAB 20MG
vortioxetine
Tier 4
QL (30 per 30 days)
Oral
BRINTELLIX TAB 5MG
vortioxetine
Tier 4
QL (120 per 30 days)
Oral
citalopram sol 10mg/5ml
CELEXA
Tier 1
QL (600 per 30 days)
Oral
citalopram tab 10mg *
CELEXA
Tier 1
QL (30 per 30 days)
Oral
citalopram tab 20mg *
CELEXA
Tier 1
QL (30 per 30 days)
Oral
citalopram tab 40mg *
CELEXA
Tier 1
QL (30 per 30 days)
Oral
708
709
710
711
712
713
714
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
29
Formulary
Covered Drug Name
desvenlafax tab 100mg er
desvenlafax tab 50mg er
DULOXETINE CAP 20MG
duloxetine cap 30mg
duloxetine cap 40mg
duloxetine cap 60mg
escitalopram sol 5mg/5ml
escitalopram tab 10mg
escitalopram tab 20mg
escitalopram tab 5mg
FETZIMA CAP 120MG
FETZIMA CAP 20MG
FETZIMA CAP 40MG
FETZIMA CAP 80MG
FETZIMA CAP TITRATION
fluoxetine cap 10mg
fluoxetine cap 20mg
fluoxetine cap 40mg
fluoxetine cap 90mg dr
fluoxetine sol 20mg/5ml
fluoxetine tab 10mg
fluoxetine tab 20mg
fluvoxamine cap 100mg er
fluvoxamine cap 150mg er
fluvoxamine tab 100mg
fluvoxamine tab 25mg
fluvoxamine tab 50mg
irenka cap 40mg
KHEDEZLA TAB 100MG ER
KHEDEZLA TAB 50MG ER
maprotiline tab 25mg
maprotiline tab 50mg
maprotiline tab 75mg
nefazodone tab 100mg
nefazodone tab 150mg
nefazodone tab 200mg
nefazodone tab 250mg
nefazodone tab 50mg
paroxetin er tab 12.5mg
paroxetin er tab 37.5mg
paroxetine tab 10mg *
paroxetine tab 20mg *
30
Alternate Drug Name
KHEDEZLA
KHEDEZLA
CYMBALTA
CYMBALTA
CYMBALTA
CYMBALTA
LEXAPRO
LEXAPRO
LEXAPRO
LEXAPRO
levomilnacipran
levomilnacipran
levomilnacipran
levomilnacipran
levomilnacipran
PROZAC
PROZAC
PROZAC
PROZAC WEEKL
PROZAC
PROZAC
PROZAC
LUVOX CR
LUVOX CR
LUVOX
LUVOX
LUVOX
duloxetine
desvenlafaxine er
desvenlafaxine er
LUDIOMIL
LUDIOMIL
LUDIOMIL
SERZONE
SERZONE
SERZONE
SERZONE
SERZONE
PAXIL CR
PAXIL CR
PAXIL
PAXIL
Tier
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
QL (120 per 30 days)
QL (240 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (620 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (120 per 30 days)
QL (30 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
QL (30 per 30 days)
QL (28 per 28 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (5 per 30 days)
QL (600 per 30 days)
QL (240 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (360 per 30 days)
QL (180 per 30 days)
QL (90 per 30 days)
QL (120 per 30 days)
QL (240 per 30 days)
QL (270 per 30 days)
QL (135 per 30 days)
Route
715
716
717
718
719
720
721
722
723
724
725
726
727
728
729
730
731
732
733
734
735
736
737
738
739
740
741
742
743
744
745
746
747
QL (180 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
QL (72 per 30 days)
QL (360 per 30 days)
QL (150 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
748
749
750
751
752
753
754
755
756
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
paroxetine tab 25mg er
paroxetine tab 30mg *
paroxetine tab 40mg *
PAXIL SUS 10MG/5ML
PRISTIQ TAB 100MG
PRISTIQ TAB 25MG
PRISTIQ TAB 50MG
sertraline con 20mg/ml
sertraline tab 100mg
sertraline tab 25mg
sertraline tab 50mg
trazodone tab 100mg
trazodone tab 150mg
trazodone tab 300mg
trazodone tab 50mg
venlafaxine cap 150mg er *
venlafaxine cap 37.5mg *
venlafaxine cap 75mg er *
venlafaxine tab 100mg
venlafaxine tab 150mg er
venlafaxine tab 225mg er
venlafaxine tab 25mg
venlafaxine tab 37.5 er
venlafaxine tab 37.5mg
venlafaxine tab 50mg
venlafaxine tab 75mg
venlafaxine tab 75mg er
VIIBRYD KIT
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
PAXIL CR
PAXIL
PAXIL
paroxetine
desvenlafaxine
desvenlafaxine
desvenlafaxine
ZOLOFT
ZOLOFT
ZOLOFT
ZOLOFT
DESYREL,OLEPTRO
DESYREL,OLEPTRO
DESYREL,OLEPTRO
DESYREL,OLEPTRO
EFFEXOR ER
EFFEXOR ER
EFFEXOR ER
EFFEXOR
EFFEXOR ER
EFFEXOR ER
EFFEXOR
EFFEXOR XR
EFFEXOR
EFFEXOR
EFFEXOR
EFFEXOR ER
vilazodone
vilazodone
vilazodone
vilazodone
Tier 2
Tier 2
Tier 2
Tier 4
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tricyclics
amitriptylin tab 100mg
amitriptylin tab 10mg
amitriptylin tab 150mg
amitriptylin tab 25mg
amitriptylin tab 50mg
amitriptylin tab 75mg
amoxapine tab 100mg
ELAVIL
ELAVIL
ELAVIL
ELAVIL
ELAVIL
ELAVIL
ASENDIN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
QL (90 per 30 days)
QL (60 per 30 days)
QL (45 per 30 days)
QL (900 per 30 days)
QL (30 per 30 days)
QL (240 per 30 days)
QL (240 per 30 days)
QL (300 per 30 days)
QL (60 per 30 days)
QL (240 per 30 days)
QL (120 per 30 days)
Route
757
758
759
760
761
762
763
764
765
766
767
768
769
770
771
QL (60 per 30 days)
QL (180 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (270 per 30 days)
QL (180 per 30 days)
QL (180 per 30 days)
QL (150 per 30 days)
QL (150 per 30 days)
QL (90 per 30 days)
772
773
774
775
776
777
778
779
780
781
782
783
784
QL (120 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
785
786
787
788
789
790
791
792
793
794
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
31
Formulary
Covered Drug Name
amoxapine tab 150mg
amoxapine tab 25mg
amoxapine tab 50mg
clomipramine cap 25mg
clomipramine cap 50mg
clomipramine cap 75mg
desipramine tab 100mg
desipramine tab 10mg
desipramine tab 150mg
desipramine tab 25mg
desipramine tab 50mg
desipramine tab 75mg
doxepin hcl cap 100mg
doxepin hcl cap 10mg
doxepin hcl cap 150mg
doxepin hcl cap 25mg
doxepin hcl cap 50mg
doxepin hcl cap 75mg
doxepin hcl con 10mg/ml
imipram hcl tab 10mg
imipram hcl tab 25mg
imipram hcl tab 50mg
nortriptylin cap 10mg
nortriptylin cap 25mg
nortriptylin cap 50mg
nortriptylin cap 75mg
nortriptylin sol 10mg/5ml
protriptylin tab 10mg
protriptylin tab 5mg
SURMONTIL CAP 100MG
SURMONTIL CAP 25MG
SURMONTIL CAP 50MG
Alternate Drug Name
Tier
ASENDIN
ASENDIN
ASENDIN
ANAFRANIL
ANAFRANIL
ANAFRANIL
NORPRAMIN
NORPRAMIN
NORPRAMIN
NORPRAMIN
NORPRAMIN
NORPRAMIN
SINEQUAN
SINEQUAN
SINEQUAN
SINEQUAN
SINEQUAN
SINEQUAN
SINEQUAN
TOFRANIL
TOFRANIL
TOFRANIL
PAMELOR
PAMELOR
PAMELOR
PAMELOR
PAMELOR
VIVACTIL
VIVACTIL
trimipramine
trimipramine
trimipramine
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
THORAZINE
THORAZINE
THORAZINE
THORAZINE
THORAZINE
THORAZINE
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
Route
795
796
797
798
799
800
801
802
803
804
805
806
807
808
809
810
811
812
813
814
815
816
817
818
819
820
821
822
823
824
825
826
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
ANTIEMETICS
Antiemetics, Other
chlorpromaz inj 25mg/ml
chlorpromaz tab 100mg
chlorpromaz tab 10mg
chlorpromaz tab 200mg
chlorpromaz tab 25mg
chlorpromaz tab 50mg
32
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
827
828
829
830
831
832
Inj
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
compro sup 25mg
diphenhydram inj 50mg/ml
meclizine tab 12.5mg
meclizine tab 25mg
metoclopram inj 5mg/ml
metoclopram sol 5mg/5ml
metoclopram tab 10mg
metoclopram tab 5mg
perphenazine tab 16mg
perphenazine tab 2mg
perphenazine tab 4mg
perphenazine tab 8mg
prochlorper inj 5mg/ml
prochlorper sup 25mg
prochlorper tab 10mg
prochlorper tab 5mg
promethazine syp 6.25/5ml
promethazine tab 12.5mg
promethazine tab 25mg
promethazine tab 50mg
TRANSDERM-SC DIS 1.5MG
Alternate Drug Name
prochlorperazine
BENADRYL
ANTIVERT
ANTIVERT
REGLAN
REGLAN
REGLAN
REGLAN
TRILAFON
TRILAFON
TRILAFON
TRILAFON
COMPAZINE
COMPRO
COMPAZINE
COMPAZINE
PHENERGAN
PHENERGAN
PHENERGAN
PHENERGAN
scopolamine transdermal patch
Emetogenic Therapy Adjuncts
ALOXI INJ 0.25MG/5ML
palonosetron
ANZEMET INJ 20MG/ML
dolasetron
ANZEMET TAB 100MG
dolasetron
ANZEMET TAB 50MG
dolasetron
dronabinol cap 10mg
MARINOL
dronabinol cap 2.5mg
MARINOL
dronabinol cap 5mg
MARINOL
EMEND CAP 125MG
aprepitant
EMEND CAP 40MG
aprepitant
EMEND CAP 80MG
aprepitant
EMEND PAK 80 & 125MG
aprepitant
granisetron tab 1mg
KYTRIL
ondansetron inj 4mg/2ml
ZOFRAN
ondansetron sol 4mg/5ml
ZOFRAN
ondansetron tab 24mg
ZOFRAN
ondansetron tab 4mg
ZOFRAN
ondansetron tab 4mg odt
ZOFRAN ODT
Tier
Requirements/
Limits
Tier 2
Tier 4
Tier 2
Tier 2
Tier 4
Tier 1
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
QL (24 per 30 days)
Tier 5
Tier 4
Tier 4
Tier 4
Tier 5
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
PA, QL (30 per 30 days)
PA, QL (50 per 30 days)
PA, QL (30 per 30 days)
PA, QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA, QL (30 per 30 days)
PA, QL (30 per 30 days)
PA, QL (30 per 30 days)
PA, QL (30 per 30 days)
PA, QL (30 per 30 days)
PA
PA, QL (150 per 5 days)
PA, QL (30 per 30 days)
PA, QL (12 per 5 days)
PA, QL (12 per 5 days)
Route
833
PA
834
835
836
PA
837
838
839
840
841
842
843
844
PA
845
846
847
848
849
850
851
852
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
853
854
855
856
857
858
859
860
861
862
863
864
865
866
867
868
869
870
Rec
Inj
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Rec
Oral
Oral
Oral
Oral
Oral
Oral
TD
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
33
Formulary
Covered Drug Name
ondansetron tab 8mg
ondansetron tab 8mg odt
Tier
Requirements/
Limits
ZOFRAN
ZOFRAN ODT
Tier 2
Tier 2
PA, QL (12 per 5 days)
PA, QL (12 per 5 days)
amphotericin b liposomal
amphotericin b liposomal 4 mg/ml
FUNGIZONE
caspofungin
caspofungin
LOPROX
LOPROX
LOPROX
PENLAC
LOPROX
LOTRIMIN
clotrimazole
MYCELEX
SPECTAZOLE
anidulafungin
sulconazole
sulconazole
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN
DIFLUCAN - DEXTROSE
ANCOBON
ANCOBON
GRIFULVIN V
GRIFULVIN V
GRIS-PEG
GRIS-PEG
SPORANOX
NIZORAL
NIZORAL
NIZORAL
MICONAZOLE
posaconazole
Tier 5
Tier 5
Tier 4
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
PA
PA
PA
PA
PA
Alternate Drug Name
Route
871
872
Oral
Oral
ANTIFUNGALS
Antifungals
ABELCET INJ 5MG/ML
AMBISOME INJ 50MG
amphotericin inj 50mg
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
ciclopirox cre 0.77%
ciclopirox gel 0.77%
ciclopirox sha 1%
ciclopirox sol 8%
ciclopirox sus 0.77%
clotrimazole cre 1%
clotrimazole sol 1%
clotrimazole tro 10mg
econazole cre 1%
ERAXIS INJ 100MG
EXELDERM CRE 1%
EXELDERM SOL 1%
fluconazole sus 10mg/ml
fluconazole sus 40mg/ml
fluconazole tab 100mg
fluconazole tab 150mg
fluconazole tab 200mg
fluconazole tab 50mg
fluconazole/ inj dex 400mg
flucytosine cap 250mg
flucytosine cap 500mg
griseofulvin sus 125/5ml
griseofulvin tab micr 500mg
griseofulvin tab ultr 125mg
griseofulvin tab ultr 250mg
itraconazole cap 100mg
ketoconazole cre 2%
ketoconazole sha 2%
ketoconazole tab 200mg
miconazole 3 sup 200mg
NOXAFIL SUS 40MG/ML
34
873
874
875
876
877
878
879
880
881
882
883
884
885
886
PA
887
888
889
890
891
892
QL (180 per 30 days)
893
894
895
PA
896
897
898
899
900
901
902
903
904
905
906
QL (3 per 3 days)
QL (630 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
907
908
Inj
Inj
Inj
Inj
Inj
Top
Top
Top
Top
Top
Top
Top
MT
Top
Inj
Top
Top
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Top
Top
Oral
Vag
Oral
Formulary
Covered Drug Name
NOXAFIL TAB 100MG
nyamyc pow 100000
nystat/triam cre
nystat/triam oin
nystatin cre 100000
nystatin oin 100000
nystatin pow 100000
nystatin sus 100000
nystatin tab 500000
nystop pow 100000
terbinafine tab 250mg
terconazole cre 0.4%
terconazole cre 0.8%
terconazole sup 80mg
voriconazole inj 200mg
voriconazole sus 40mg/ml
voriconazole tab 200mg
voriconazole tab 50mg
zazole cre 0.4%
Alternate Drug Name
Tier
posaconazole
nystatin
NYSTATIN - TRIAMCINOLONE
NYSTATIN - TRIAMCINOLONE
MYCOSTATIN
MYCOSTATIN
MYCOSTATIN
NYSTATIN
NYSTATIN
MYCOSTATIN
LAMISIL
TERAZOL, ZAZOLE
TERAZOL, ZAZOLE
TERAZOL, ZAZOLE
VFEND
VFEND
VFEND
VFEND
TERAZOL, ZAZOLE
Tier 5
Tier 1
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 2
ZYLOPRIM
ZYLOPRIM
colchicine
COLCHICINE - PROBENECID
PROBENECID
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Requirements/
Limits
Route
909
910
911
912
913
914
915
916
917
918
QL (30 per 30 days)
919
920
921
QL (3 per 3 days)
PA
PA
PA, QL (60 per 30 days)
PA, QL (120 per 30 days)
922
923
924
925
926
927
Oral
Top
Top
Top
Top
Top
Top
MT
Oral
Top
Oral
Vag
Vag
Vag
Inj
Oral
Oral
Oral
Vag
ANTIGOUT AGENTS
Antigout Agents
allopurinol tab 100mg
allopurinol tab 300mg
COLCRYS TAB 0.6MG
proben/colch tab 500-0.5mg
probenecid tab 500mg
928
929
QL (120 per 30 days)
930
931
932
Oral
Oral
Oral
Oral
Oral
ANTIMIGRAINE AGENTS
Antimigraine Agents
migergot sup 2/100
caffeine-ergotamine
Tier 2
Ergot Alkaloids
dihydroergot inj 1mg/ml
OTEZLA 30MG
OTEZLA TAB 10/20/30MG
D.H.E. 45
apremilast
apremilast
Tier 3
Tier 5
Tier 4
933
934
QL (60 per 30 days)
QL (60 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
935
936
Rec
Inj
Oral
Oral
35
Formulary
Covered Drug Name
Prophylactic
timolol mal tab 10mg
timolol mal tab 20mg
timolol mal tab 5mg
Alternate Drug Name
BLOCADREN
BLOCADREN
BLOCADREN
Serotonin (5-HT) 1b/1d Receptor Agonists
naratriptan tab 1mg
AMERGE
naratriptan tab 2.5mg
AMERGE
sumatriptan inj 6mg/0.5ml
IMITREX
sumatriptan inj 6mg/0.5ml
IMITREX
sumatriptan spr 20mg/act
IMITREX NASAL SPRAY
sumatriptan spr 5mg/act
IMITREX
sumatriptan tab 100mg
IMITREX
sumatriptan tab 25mg
IMITREX
sumatriptan tab 50mg
IMITREX
Tier
Requirements/
Limits
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Route
937
938
939
QL (9 per 30 days)
QL (9 per 30 days)
QL (6 per 30 days)
QL (6 per 30 days)
940
941
942
943
944
945
QL (9 per 30 days)
QL (9 per 30 days)
QL (9 per 30 days)
946
947
948
Oral
Oral
Oral
Oral
Oral
Inj
Inj
NS
NS
Oral
Oral
Oral
ANTIMYASTHENIC AGENTS
Parasympathomimetics
GUANIDINE TAB 125MG
MESTINON SYP 60MG/5ML
MESTINON TAB TIMESPAN
pyridostigm tab 60mg
guanidine
pyridostigmine
pyridostigmine
MESTINON
Tier 4
Tier 4
Tier 4
Tier 2
949
950
951
952
Oral
Oral
Oral
Oral
ANTIMYCOBACTERIALS
36
Antimycobacterials, Other
dapsone tab 100mg
dapsone tab 25mg
rifabutin cap 150mg
dapsone
dapsone
MYCOBUTIN
Tier 2
Tier 2
Tier 2
Antituberculars
CAPASTAT SUL INJ 1GM
ethambutol tab 100mg
ethambutol tab 400mg
isoniazid syp 50mg/5ml
isoniazid tab 100mg
capreomycin
MYAMBUTOL
MYAMBUTOL
TUBIZID
TUBIZID
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
953
954
955
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
956
957
958
959
960
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
TUBIZID
aminosalicylic acid
PYRAZINAMIDE
RIFADIN
RIFADIN
RIFADIN
isoniazid - rifampin
bedaquiline
ethionamide
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 5
Tier 4
Alkylating Agents
BUSULFEX INJ 6MG/ML
cyclophosph cap 25mg
cyclophosph cap 50mg
HEXALEN CAP 50MG
LEUKERAN TAB 2MG
MATULANE CAP 50MG
melphalan inj 50mg
MUSTARGEN INJ 10MG
busulfan
CYTOXAN
CYTOXAN
altretamine
chlorambucil
procarbazine
ALKERAN
mechlorethamine
Tier 4
Tier 4
Tier 4
Tier 5
Tier 3
Tier 5
Tier 4
Tier 4
PA
PA
PA
Antiandrogens
bicalutamide tab 50mg
flutamide cap 125mg
NILANDRON TAB 150MG
XTANDI CAP 40MG
ZYTIGA TAB 250MG
CASODEX
EULEXIN
nilutamide
enzalutamide
abiraterone
Tier 2
Tier 2
Tier 4
Tier 5
Tier 5
QL (30 per 30 days)
QL (30 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
Antiangiogenic Agents
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 2.5MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
pomalidomide
pomalidomide
pomalidomide
pomalidomide
lenalidomide
lenalidomide
lenalidomide
lenalidomide
lenalidomide
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
QL (120 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
isoniazid tab 300mg
PASER GRA 4GM
pyrazinamide tab 500mg
rifampin cap 150mg
rifampin cap 300mg
rifampin inj 600 mg
RIFATER TAB
SIRTURO TAB 100MG
TRECATOR TAB 250MG
Route
961
962
963
964
965
PA
966
967
968
969
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
ANTINEOPLASTICS
970
971
972
973
974
975
PA
PA
976
977
978
979
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
980
981
982
983
984
985
986
987
988
989
990
991
Inj
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
37
Formulary
Covered Drug Name
38
Alternate Drug Name
Tier
Requirements/
Limits
QL (150 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
REVLIMID CAP 5MG
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG
THALOMID CAP 50MG
lenalidomide
thalidomide
thalidomide
thalidomide
thalidomide
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Antiestrogens/Modifiers
EMCYT CAP 140MG
FARESTON TAB 60MG
SOLTAMOX SOL 10MG/5ML
tamoxifen tab 10mg
tamoxifen tab 20mg
estramustine
toremifene
tamoxifen
NOLVADEX
NOLVADEX
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Antimetabolites
DROXIA CAP 200MG
DROXIA CAP 300MG
DROXIA CAP 400MG
hydroxyurea cap 500mg
mercaptopur tab 50mg
PURIXAN SUS 20MG/ML
TABLOID TAB 40MG
hydroxyurea
hydroxyurea
hydroxyurea
HYDREA
PURINETHOL
mercaptopurine
thioguanine
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 5
Tier 4
Antineoplastics
ABRAXANE INJ 100MG
ALIMTA INJ 500MG
amifostine inj 500mg
ARRANON INJ 5MG/ML
AVASTIN INJ
azacitidine inj 100mg
BELEODAQ INJ 500MG
bleomycin inj 30unit
carboplatin inj 150/15ml
cisplatin inj 100mg
cladribine inj 1mg/ml
cytarabine inj 100mg/ml
cytarabine inj 20mg/ml
dacarbazine inj 200mg
daunorubicin inj 5mg/ml
paclitaxel
pemetrexed
ETHYOL
nelarabine
bevacizumab
VIDAZA
belinostat
BLENOXANE
PARAPLATIN
PLATINOL AQ
LEUSTATIN
CYTOSAR-U
CYTARABINE
DTIC-DOME
DAUNORUBICIN
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Route
992
993
994
995
996
997
QL (30 per 30 days)
998
999
1000
1001
1002
1003
1004
1005
1006
1007
1008
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1009
1010
1011
1012
1013
1014
1015
1016
1017
1018
1019
1020
1021
1022
1023
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Formulary
Covered Drug Name
decitabine inj 50mg
DOCEFREZ INJ 20MG
docetaxel inj 80mg/4ml
docetaxel inj 80mg/8ml
doxorubicin inj 50mg
ELITEK INJ 1.5MG
epirubicin inj 50/25ml
ERBITUX INJ 100MG
FARYDAK CAP 10MG
FARYDAK CAP 15MG
FARYDAK CAP 20MG
FASLODEX INJ 250MG
fluorouracil inj 2.5g/50ml
FUSILEV INJ 50MG
gemcitabine inj 1gm
GLEOSTINE CAP 100MG
GLEOSTINE CAP 10MG
GLEOSTINE CAP 40MG
HALAVEN INJ 1MG/2ML
HERCEPTIN INJ 440MG
IBRANCE CAP 100MG
IBRANCE CAP 125MG
IBRANCE CAP 75MG
idarubicin inj 10/10ml
ifosfamide inj 1gm
irinotecan inj 100/5ml
ISTODAX INJ 10MG
IXEMPRA KIT INJ 45MG
JEVTANA INJ 60/1.5ML
KEYTRUDA SOL 50MG
lomustine cap 100mg
lomustine cap 10mg
lomustine cap 40mg
mesna inj 1gm
MESNEX TAB 400MG
mitomycin inj 20mg
OPDIVO INJ 40MG/4ML
oxaliplatin inj 100mg
paclitaxel inj 300/50ml
PERJETA INJ 420/14ML
PROLEUKIN INJ 22MU
SYNRIBO INJ 3.5MG
Alternate Drug Name
DACOGEN
docetaxel
TAXOTERE
TAXOTERE
ADRIAMYCIN
rasburicase
ELLENCE
cetuximab
panobinostat
panobinostat
panobinostat
fulvestrant
ADRUCIL
levoleucovorin
GEMZAR
lomustine
lomustine
lomustine
eribulin
trastuzumab
palbociclib
palbociclib
palbociclib
IDAMYCIN PFS
IFEX
CAMPTOSAR
romidepsin
ixabepilone
cabazitaxel
pembrolizumab
CEENU
CEENU
CEENU
MESNEX
mesna
MUTAMYCIN
nivolumab
ELOXATIN
TAXOL
pertuzumab
aldesleukin
omacetaxine
Tier
Tier 5
Tier 5
Tier 4
Tier 4
Tier 4
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 4
Tier 5
Tier 4
Tier 5
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
Tier 5
Tier 4
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Requirements/
Limits
PA
PA
PA
PA
PA
PA
PA
PA
Route
1024
1025
1026
1027
1028
1029
1030
1031
1032
1033
1034
PA
PA
PA
PA
1035
1036
1037
1038
1039
1040
1041
PA
PA
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA
PA
PA
PA
PA
PA
PA
1042
1043
1044
1045
1046
1047
1048
1049
1050
1051
1052
1053
1054
1055
1056
PA
1057
1058
PA
PA
PA
PA
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1059
1060
1061
1062
1063
1064
1065
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Inj
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
39
Formulary
Covered Drug Name
40
Alternate Drug Name
Tier
Requirements/
Limits
TREANDA INJ 100MG
TREANDA INJ 45/0.5ML
TRISENOX SOL 10MG/10ML
VECTIBIX INJ 100MG
VELCADE INJ 3.5MG
VINBLASTINE INJ 10MG
vincasar pfs inj 1mg/ml
vincristine inj 1mg/ml
vinorelbine inj 10mg/ml
YERVOY INJ 50MG
ZALTRAP INJ 100/4ML
ZANOSAR INJ 1GM
bendamustine
bendamustine
arsenic trioxide
panitumumab
bortezomib
vinblastine
vincristine
VINCASAR
NAVELBINE
ipilimumab
ziv-aflibercept
streptozocin
Tier 5
Tier 5
Tier 5
Tier 4
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
Tier 5
Tier 5
Tier 4
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Antineoplastics, Other
ERWINAZE INJ 10000UNT
fludarabine inj 50mg
leucovor ca inj 100mg
leucovor ca inj 350mg
leucovor ca tab 10mg
leucovor ca tab 15mg
leucovor ca tab 25mg
leucovor ca tab 5mg
mitoxantron inj 2mg/ml
ONCASPAR INJ 750/ML
ZOLINZA CAP 100MG
erwinia asparaginase
FLUDARA
LEUCOVORIN
LEUCOVORIN
LEUCOVORIN
LEUCOVORIN
LEUCOVORIN
LEUCOVORIN
NOVANTRONE
pegaspargase
vorinostat
Tier 5
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 5
Tier 5
PA
PA
PA
PA
PA
PA
QL (120 per 30 days)
Aromatase Inhibitors, 3rd Generation
anastrozole tab 1mg
ARIMIDEX
exemestane tab 25mg
AROMASIN
letrozole tab 2.5mg
FEMARA
Tier 2
Tier 2
Tier 2
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
Enzyme Inhibitors
ETOPOPHOS INJ 100MG
etoposide inj 20mg/ml
toposar inj 1gm/50ml
topotecan inj 4mg
Tier 4
Tier 3
Tier 4
Tier 5
PA
PA
PA
PA
etoposide
VEPESID
VEPESID
HYCAMTIN
Route
1066
1067
1068
1069
1070
1071
1072
1073
1074
1075
1076
1077
1078
1079
1080
1081
1082
1083
1084
1085
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1086
1087
1088
1089
1090
1091
1092
1093
1094
1095
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Formulary
Covered Drug Name
Molecular Target Inhibitors
AFINITOR DIS TAB 2MG
AFINITOR DIS TAB 3MG
AFINITOR DIS TAB 5MG
AFINITOR TAB 10MG
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
BOSULIF TAB 100MG
BOSULIF TAB 500MG
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
COMETRIQ KIT 60MG
ERIVEDGE CAP 150MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
IMBRUVICA CAP 140MG
INLYTA TAB 1MG
INLYTA TAB 5MG
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
JAKAFI TAB 5MG
LENVIMA CAP 10MG
LENVIMA CAP 14MG
LENVIMA CAP 20MG
LENVIMA CAP 24MG
LYNPARZA CAP 50MG
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
NEXAVAR TAB 200MG
SPRYCEL TAB 100MG
Alternate Drug Name
everolimus
everolimus
everolimus
everolimus
everolimus
everolimus
everolimus
bosutinib
bosutinib
vandetanib
vandetanib
cabozantinib
cabozantinib
cabozantinib
vismodegib
afatinib
afatinib
afatinib
imatinib
imatinib
ponatinib
ponatinib
ibrutinib
axitinib
axitinib
ruxolitinib
ruxolitinib
ruxolitinib
ruxolitinib
ruxolitinib
lenvatinib
lenvatinib
lenvatinib
lenvatinib
olaparib
trametinib
trametinib
sorafenib
dasatinib
Tier
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Requirements/
Limits
QL (150 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (56 per 28 days)
QL (112 per 28 days)
QL (84 per 28 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
Route
1096
1097
1098
1099
1100
1101
1102
1103
1104
1105
1106
1107
1108
1109
1110
1111
1112
1113
1114
1115
1116
1117
QL (120 per 30 days)
QL (240 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
1118
1119
1120
1121
1122
1123
1124
1125
1126
1127
1128
1129
QL (480 per 30 days)
QL (120 per 30 days)
QL (30 per 30 days)
QL (120 per 30 days)
QL (30 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1130
1131
1132
1133
1134
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
41
Formulary
Covered Drug Name
42
Alternate Drug Name
Tier
Requirements/
Limits
SPRYCEL TAB 140MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
STIVARGA TAB 40MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TARCEVA TAB 25MG
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TYKERB TAB 250MG
VOTRIENT TAB 200MG
XALKORI CAP 200MG
XALKORI CAP 250MG
ZELBORAF TAB 240MG
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
ZYKADIA CAP 150MG
dasatinib
dasatinib
dasatinib
dasatinib
dasatinib
sorafenib
sunitinib
sunitinib
sunitinib
sunitinib
dabrafenib
dabrafenib
erlotinib
erlotinib
erlotinib
nilotinib
nilotinib
lapatinib
pazopanib
crizotinib
crizotinib
vemurafenib
idelalisib
idelalisib
ceritinib
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (84 per 28 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (240 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (150 per 30 days)
Monoclonal Antibodies
ARZERRA CON 100/5ML
KADCYLA INJ 100MG
RITUXAN INJ 500MG
ofatumumab
ado-trastuzumab
rituximab
Tier 3
Tier 5
Tier 5
PA
Retinoids
PANRETIN GEL 0.1%
TARGRETIN CAP 75MG
TARGRETIN GEL 1%
tretinoin cap 10mg
alitretinoin
bexarotene
bexarotene
VESANOID
Tier 5
Tier 5
Tier 5
Tier 5
Route
1135
1136
1137
1138
1139
1140
1141
1142
1143
1144
1145
1146
1147
1148
1149
1150
1151
1152
1153
1154
1155
1156
1157
1158
1159
1160
1161
PA
1162
1163
1164
QL (60 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1165
1166
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Top
Oral
Top
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
Route
ANTIPARASITICS
Antihelminthics
ALBENZA TAB 200MG
BILTRICIDE TAB 600MG
ivermectin tab 3mg
albendazole
praziquantel
STROMECTOL
Tier 5
Tier 4
Tier 2
Antiprotozoals
ALINIA SUS 100/5ML
ALINIA TAB 500MG
atovaq/progu tab 250-100mg
atovaq/progu tab 62.5-25mg
atovaquone sus 750/5ml
chloroquine tab 250mg
chloroquine tab 500mg
COARTEM TAB 20-120MG
DARAPRIM TAB 25MG
hydroxychlor tab 200mg
mefloquine tab 250mg
NEBUPENT INH 300MG
PENTAM 300 INJ 300MG
PRIMAQUINE TAB 26.3MG
quinine sulf cap 324mg
nitazoxanide
nitazoxanide
MALARONE
MALARONE
MEPRON
ARALEN
ARALEN
artemether - lumefantrine
pyrimethamine
PLAQUENIL
LARIAM
pentamidine neb
pentamidine
primaquine
QUALAQUIN
Tier 4
Tier 4
Tier 2
Tier 2
Tier 5
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 2
Pediculicides/Scabicides
lindane lot 1%
lindane sha 1%
malathion lot 0.5%
permethrin cre 5%
LINDANE
LINDANE
OVIDE
ELIMITE
Tier 2
Tier 2
Tier 2
Tier 2
1167
1168
1169
QL (180 per 3 days)
1170
1171
1172
1173
1174
1175
1176
1177
1178
1179
1180
PA
PA
1181
1182
1183
1184
1185
1186
1187
1188
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inh
Inj
Oral
Oral
Top
Top
Top
Top
ANTIPARKINSON AGENTS
Anticholinergics
benztropine inj 1mg/ml
benztropine tab 0.5mg
benztropine tab 1mg
benztropine tab 2mg
trihexyphen elx 0.4mg/ml
COGENTIN
COGENTIN
COGENTIN
COGENTIN
ARTANE, TRIHEXANE
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
PA
PA
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1189
1190
1191
1192
1193
Inj
Oral
Oral
Oral
Oral
43
Formulary
Covered Drug Name
trihexyphen tab 2mg
trihexyphen tab 5mg
44
Alternate Drug Name
ARTANE, TRIHEXANE
ARTANE, TRIHEXANE
Tier
Requirements/
Limits
Tier 2
Tier 2
PA
PA
Antiparkinson Agents, Other
amantadine cap 100mg
SYMMETREL
amantadine syp 50mg/5ml
SYMMETREL
amantadine tab 100mg
SYMMETREL
entacapone tab 200mg
COMTAN
TASMAR TAB 100MG
tolcapone
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Dopamine Agonists
APOKYN INJ 10MG/ML
bromocriptin cap 5mg
bromocriptin tab 2.5mg
NEUPRO DIS 1MG/24HR
NEUPRO DIS 2MG/24HR
NEUPRO DIS 3MG/24HR
NEUPRO DIS 4MG/24HR
NEUPRO DIS 6MG/24HR
NEUPRO DIS 8MG/24HR
pramipexole tab 0.125mg
pramipexole tab 0.25mg
pramipexole tab 0.5mg
pramipexole tab 0.75mg
pramipexole tab 1.5mg
pramipexole tab 1mg
ropinirole tab 0.25mg
ropinirole tab 0.5mg
ropinirole tab 12mg er
ropinirole tab 1mg
ropinirole tab 2mg
ropinirole tab 2mg er
ropinirole tab 3mg
ropinirole tab 4mg
ropinirole tab 4mg er
ropinirole tab 5mg
ropinirole tab 6mg er
ropinirole tab 8mg er
Tier 5
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
apomorphine
PARLODEL
PARLODEL
rotigotine transdermal patch
rotigotine transdermal patch
rotigotine transdermal patch
rotigotine transdermal patch
rotigotine transdermal patch
rotigotine transdermal patch
MIRAPEX
MIRAPEX
MIRAPEX
MIRAPEX
MIRAPEX
MIRAPEX
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
REQUIP
Route
1194
1195
1196
1197
1198
QL (270 per 30 days)
1199
1200
PA
1201
1202
1203
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1204
1205
1206
1207
1208
1209
1210
1211
1212
1213
1214
1215
1216
1217
1218
1219
1220
1221
1222
1223
1224
1225
1226
1227
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
TD
TD
TD
TD
TD
TD
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carb/levo er tab 25-100mg
SINEMET CR
Tier 2
carb/levo er tab 50-200mg
SINEMET CR
Tier 2
carb/levo tab 10-100mg
PERCOPA
Tier 2
carb/levo tab 10-100mg
SINEMET
Tier 2
carb/levo tab 25-100mg
PERCOPA
Tier 2
carb/levo tab 25-100mg
SINEMET
Tier 2
carb/levo tab 25-250mg
PERCOPA
Tier 2
carb/levo tab 25-250mg
SINEMET
Tier 2
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT TAB 0.5MG
rasagiline
AZILECT TAB 1MG
rasagiline
selegiline cap 5mg
ELDEPRYL
selegiline tab 5mg
ELDEPRYL
Route
1228
1229
1230
1231
1232
1233
1234
1235
Tier 4
Tier 4
Tier 2
Tier 2
1236
1237
1238
1239
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
ANTIPSYCHOTICS
1st Generation/Typical
fluphenaz de inj 25mg/ml
fluphenazine con 5mg/ml
fluphenazine elx 2.5/5ml
fluphenazine inj 2.5mg/ml
fluphenazine tab 10mg
fluphenazine tab 1mg
fluphenazine tab 2.5mg
fluphenazine tab 5mg
haloper dec inj 100mg/ml
haloper dec inj 50mg/ml
haloper lac inj 5mg/ml
haloperidol con 2mg/ml
haloperidol tab 0.5mg
haloperidol tab 10mg
haloperidol tab 1mg
haloperidol tab 20mg
haloperidol tab 2mg
haloperidol tab 5mg
loxapine cap 10mg
PROLIXIN
PROLIXIN
PROLIXIN
PROLIXIN
PROLIXIN
PROLIXIN
PROLIXIN
PROLIXIN
HALDOL DEC
HALDOL DEC
HALDOL LAC
HALDOL LAC
HALDOL
HALDOL
HALDOL
HALDOL
HALDOL
HALDOL
LOXITANE
Tier 4
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
PA
1240
1241
1242
PA
1243
1244
1245
1246
1247
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1248
1249
1250
1251
1252
1253
1254
1255
1256
1257
1258
Inj
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
45
Formulary
Covered Drug Name
46
Alternate Drug Name
Tier
loxapine cap 25mg
loxapine cap 50mg
loxapine cap 5mg
ORAP TAB 1MG
ORAP TAB 2MG
thioridazine tab 100mg
thioridazine tab 10mg
thioridazine tab 25mg
thioridazine tab 50mg
thiothixene cap 10mg
thiothixene cap 1mg
thiothixene cap 2mg
thiothixene cap 5mg
trifluoperaz tab 10mg
trifluoperaz tab 1mg
trifluoperaz tab 2mg
trifluoperaz tab 5mg
LOXITANE
LOXITANE
LOXITANE
pimozide
pimozide
MELLARIL
MELLARIL
MELLARIL
MELLARIL
NAVANE
NAVANE
NAVANE
NAVANE
STELAZINE
STELAZINE
STELAZINE
STELAZINE
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
2nd Generation/Atypical
FANAPT PAK
FANAPT TAB 10MG
FANAPT TAB 12MG
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
GEODON INJ 20MG
INVEGA SUST INJ 117/0.75ML
INVEGA SUST INJ 156MG/ML
INVEGA SUST INJ 234/1.5ML
INVEGA SUST INJ 39/0.25ML
INVEGA SUST INJ 78/0.5ML
INVEGA TAB 1.5MG
INVEGA TAB 3MG
INVEGA TAB 6MG
INVEGA TAB 9MG
LATUDA TAB 120MG
LATUDA TAB 20MG
LATUDA TAB 40MG
iloperidone
iloperidone
iloperidone
iloperidone
iloperidone
iloperidone
iloperidone
iloperidone
ziprasidone
paliperidone palmitate im
paliperidone palmitate im
paliperidone palmitate im
paliperidone palmitate im
paliperidone palmitate im
paliperidone
paliperidone
paliperidone
paliperidone
lurasidone
lurasidone
lurasidone
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Requirements/
Limits
Route
1259
1260
1261
1262
1263
1264
1265
1266
1267
1268
1269
1270
1271
1272
1273
1274
1275
QL (60 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (720 per 30 days)
QL (360 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
1276
1277
1278
1279
1280
1281
1282
1283
1284
QL (2 per 28 days)
QL (2 per 28 days)
QL (2 per 28 days)
QL (2 per 28 days)
QL (2 per 28 days)
QL (240 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1285
1286
1287
1288
1289
1290
1291
1292
1293
1294
1295
1296
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
LATUDA TAB 60MG
LATUDA TAB 80MG
olanzapine inj 10mg
olanzapine tab 10mg *
olanzapine tab 10mg odt
olanzapine tab 15mg *
olanzapine tab 15mg odt
olanzapine tab 2.5mg *
olanzapine tab 20mg *
olanzapine tab 20mg odt
olanzapine tab 5mg *
olanzapine tab 5mg odt
olanzapine tab 7.5mg *
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
risperidone sol 1mg/ml
risperidone tab 0.25 odt
risperidone tab 0.25mg *
risperidone tab 0.5mg *
risperidone tab 0.5mg odt
risperidone tab 1mg *
risperidone tab 1mg odt
risperidone tab 2mg *
risperidone tab 2mg odt
risperidone tab 3mg *
risperidone tab 3mg odt
risperidone tab 4mg *
risperidone tab 4mg odt
SAPHRIS SUB 10MG
SAPHRIS SUB 2.5MG
SAPHRIS SUB 5MG
ziprasidone cap 20mg
ziprasidone cap 40mg
ziprasidone cap 60mg
ziprasidone cap 80mg
ZYPREXA RELP INJ 210MG
Alternate Drug Name
lurasidone
lurasidone
ZYPREXA
ZYPREXA
ZYPREXA ZYDIS
ZYPREXA
ZYPREXA ZYDIS
ZYPREXA
ZYPREXA
ZYPREXA ZYDIS
ZYPREXA
ZYPREXA ZYDIS
ZYPREXA
risperidone
risperidone
risperidone
risperidone
RISPERDAL
RISPERDAL M
RISPERDAL
RISPERDAL
RISPERDAL M
RISPERDAL
RISPERDAL M
RISPERDAL
RISPERDAL M
RISPERDAL
RISPERDAL M
RISPERDAL
RISPERDAL M
asenapine
asenapine
asenapine
GEODON
GEODON
GEODON
GEODON
olanzapine susp
Tier
Tier 5
Tier 5
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 5
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Requirements/
Limits
QL (60 per 30 days)
QL (30 per 30 days)
PA, QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (240 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
QL (8 per 28 days)
QL (4 per 28 days)
QL (3 per 28 days)
Route
1297
1298
1299
1300
1301
1302
1303
1304
1305
1306
1307
1308
1309
1310
1311
1312
1313
QL (480 per 30 days)
QL (1920 per 30 days)
QL (1920 per 30 days)
QL (960 per 30 days)
QL (960 per 30 days)
QL (480 per 30 days)
QL (480 per 30 days)
QL (240 per 30 days)
QL (240 per 30 days)
QL (180 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (240 per 30 days)
QL (120 per 30 days)
QL (240 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1314
1315
1316
1317
1318
1319
1320
1321
1322
1323
1324
1325
1326
1327
1328
1329
1330
1331
1332
1333
1334
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
SL
Oral
SL
Oral
Oral
Oral
Oral
Inj
47
Formulary
Covered Drug Name
Treatment-Resistant
clozapine tab 100/odt
clozapine tab 100mg
clozapine tab 12.5/odt
clozapine tab 150/odt
clozapine tab 200/odt
clozapine tab 25mg
clozapine tab 25mg odt
clozapine tab 50mg
FAZACLO TAB 100/ODT
FAZACLO TAB 12.5/ODT
FAZACLO TAB 150MG
FAZACLO TAB 200MG
FAZACLO TAB 25MG ODT
VERSACLOZ SUS 50MG/ML
Alternate Drug Name
FAZACLO
CLOZARIL
FAZACLO
CLOZAPINE
CLOZAPINE
CLOZARIL
FAZACLO
CLOZARIL
clozapine
clozapine
clozapine
clozapine
clozapine
clozapine
Tier
Requirements/
Limits
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 5
QL (270 per 30 days)
QL (120 per 30 days)
QL (2160 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (1080 per 30 days)
QL (120 per 30 days)
QL (270 per 30 days)
QL (90 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
QL (270 per 30 days)
QL (540 per 30 days)
Route
1336
1337
1338
1339
1340
1341
1342
1343
1344
1345
1346
1347
1348
1349
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
ANTISPASTICITY AGENTS
Antispasticity Agents
baclofen tab 10mg
baclofen tab 20mg
dantrolene cap 100mg
dantrolene cap 25mg
dantrolene cap 50mg
tizanidine cap 2mg
tizanidine cap 4mg
tizanidine cap 6mg
tizanidine tab 2mg
tizanidine tab 4mg
KEMSTRO, LIORESAL
KEMSTRO, LIORESAL
DANTRIUM
DANTRIUM
DANTRIUM
ZANAFLEX
ZANAFLEX
ZANAFLEX
ZANAFLEX
ZANAFLEX
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
1350
1351
1352
1353
1354
1355
1356
1357
1358
1359
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
ANTIVIRALS
Anti-cytomegalovirus (CMV) Agents
adefov dipiv tab 10mg
HEPSERA
FOSCARNET INJ 24MG/ML
foscarnet
ganciclovir inj 500mg
CYTOVENE
VALCYTE SOL 50MG/ML
valganciclovir
valganciclov tab 450mg
VALCYTE
ZIRGAN GEL 0.15%
ganciclovir
48
Tier 5
Tier 4
Tier 2
Tier 5
Tier 2
Tier 4
1360
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1361
1362
1363
1364
1365
Oral
Inj
Inj
Oral
Oral
OP
Formulary
Covered Drug Name
Alternate Drug Name
Anti-hepatitis B (HBV) Agents
BARACLUDE SOL .05MG/ML
entecavir
entecavir tab 0.5mg
BARACLUDE
entecavir tab 1mg
BARACLUDE
EPIVIR HBV SOL 5MG/ML
lamivudine
INTRON A INJ 18MU
interferon alfa-2b
INTRON A INJ 50MU
interferon alfa-2b
INTRON-A INJ 10MU
interferon alfa-2b
INTRON-A INJ 18MU
interferon alfa-2b
lamivudine tab 100mg
EPIVIR
moderiba tab 200mg
ribavirin
PEG-INTRON KIT 120 RP
peginterferon alfa-2b
PEG-INTRON KIT 120MCG
peginterferon alfa-2b
PEG-INTRON KIT 150 RP
peginterferon alfa-2b
PEG-INTRON KIT 150MCG
peginterferon alfa-2b
PEG-INTRON KIT 50MCG
peginterferon alfa-2b
PEG-INTRON KIT 50MCG RP
peginterferon alfa-2b
PEG-INTRON KIT 80MCG
peginterferon alfa-2b
PEG-INTRON KIT 80MCG RP
peginterferon alfa-2b
PEGASYS INJ 180MCG/0.5ML
peginterferon alfa-2a
PEGASYS INJ 180MCG/ML
peginterferon alfa-2a
PEGASYS INJ PROCLICK
peginterferon alfa-2a
PEGASYS PROCLICK
peginterferon alfa-2a
RIBAPAK PAK 1000/DAY
ribavirin
ribapak pak 1200/day
ribavirin
ribapak pak 800/day
ribavirin
ribasphere cap 200mg
REBETOL
ribasphere tab 200mg
REBETOL-COPEGUS
RIBASPHERE TAB 400MG
ribavirin
RIBASPHERE TAB 600MG
ribavirin
ribavirin cap 200mg
RIBASPHERE, REBETOL
ribavirin tab 200mg
RIBASPHERE, REBETOL-COPEGUS
SYLATRON KIT 296MCG
peginterferon alfa-2b
SYLATRON KIT 444MCG
peginterferon alfa-2b
SYLATRON KIT 888MCG
peginterferon alfa-2b
TYZEKA TAB 600MG
telbivudine
Tier
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 4
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 4
Tier 5
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Requirements/
Limits
PA, QL (600 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Route
1366
1367
1368
1369
1370
1371
1372
1373
1374
1375
PA, QL (4 per 28 days)
PA, QL (4 per 28 days)
PA, QL (4 per 28 days)
PA, QL (4 per 28 days)
PA, QL (5 per 28 days)
PA, QL (4 per 28 days)
PA, QL (4 per 28 days)
PA, QL (4 per 28 days)
PA, QL (2 per 28 days)
PA, QL (4 per 28 days)
PA
PA, QL (2 per 28 days)
1376
1377
1378
1379
1380
1381
1382
1383
1384
1385
1386
1387
1388
1389
1390
1391
1392
1393
1394
1395
1396
QL (5 per 28 days)
QL (5 per 28 days)
QL (5 per 28 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1397
1398
1399
1400
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Oral
49
Formulary
Tier
Requirements/
Limits
Anti-hepatitis C (HCV) Agents
HARVONI TAB 90-400MG
ledipasvir - sofosbuvir
OLYSIO CAP 150MG
simeprevir 150 mg
SOVALDI TAB 400MG
sofosbuvir 400 mg
VIEKIRA PAK TAB
dasabuvir - ombitasvir - paritaprevir ritonavir
Tier 5
Tier 5
Tier 5
Tier 5
PA, QL (28 per 28 days)
PA, QL (30 per 30 days)
PA, QL (30 per 30 days)
PA, QL (112 per 28 days)
Anti-HIV Agents, Integrase Inhibitors (INSTI)
ISENTRESS CHW 100MG
raltegravir
ISENTRESS CHW 25MG
raltegravir
ISENTRESS POW 100MG
raltegravir
ISENTRESS TAB 400MG
raltegravir
STRIBILD TAB
cobicistat-elvitegravir-emtricitabinetenofovir
Tier 5
Tier 4
Tier 4
Tier 5
Tier 3
QL (180 per 30 days)
QL (720 per 30 days)
QL (300 per 30 days)
QL (120 per 30 days)
QL (30 per 30 days)
Covered Drug Name
Alternate Drug Name
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)
COMPLERA TAB
emtricitabine-rilpivirine-tenofovir
Tier 5
QL (30 per 30 days)
EDURANT TAB 25MG
rilpivirine
Tier 5
QL (30 per 30 days)
INTELENCE TAB 100MG
etravirine
Tier 5
QL (120 per 30 days)
INTELENCE TAB 200MG
etravirine
Tier 5
QL (60 per 30 days)
INTELENCE TAB 25MG
etravirine
Tier 4
QL (480 per 30 days)
nevirapine 400 mg extended release
VIRAMUNE XR
Tier 2
QL (30 per 30 days)
nevirapine sus 50mg/5ml
VIRAMUNE
Tier 2
QL (1200 per 30 days)
nevirapine tab 200mg
VIRAMUNE
Tier 2
QL (60 per 30 days)
RESCRIPTOR TAB 100 MG
delavirdine
Tier 4
QL (360 per 30 days)
RESCRIPTOR TAB 200MG
delavirdine
Tier 4
QL (180 per 30 days)
SUSTIVA CAP 200MG
efavirenz
Tier 4
QL (120 per 30 days)
SUSTIVA CAP 50MG
efavirenz
Tier 4
QL (360 per 30 days)
SUSTIVA TAB 600MG
efavirenz
Tier 4
QL (30 per 30 days)
TYBOST TAB 150MG
cobicistat
Tier 4
QL (30 per 30 days)
VIRAMUNE SUS 50MG/5ML
nevirapine
Tier 4
VIRAMUNE XR TAB 100MG
nevirapine xr
Tier 4
QL (120 per 30 days)
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)
abacav/lamiv/zidovud
TRIZIVIR
Tier 5
QL (60 per 30 days)
abacavir tab 300mg
ZIAGEN
Tier 2
QL (60 per 30 days)
50
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
Route
1401
1402
1403
1404
1405
1406
1407
1408
1409
1410
1411
1412
1413
1414
1415
1416
1417
1418
1419
1420
1421
1422
1423
1424
1425
1426
1427
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
didanosine cap 125mg
didanosine cap 200mg
didanosine cap 250mg
didanosine cap 400mg
EMTRIVA CAP 200MG
EMTRIVA SOL 10MG/ML
EPZICOM TAB 600-300MG
EVOTAZ TAB 300-150MG
lamivud/zido tab 150-300mg
lamivudine sol 10mg/ml
lamivudine tab 150mg
lamivudine tab 300mg
PREZCOBIX TAB 800-150MG
RETROVIR INJ 10MG/ML
stavudine cap 15mg
stavudine cap 20mg
stavudine cap 30mg
stavudine cap 40mg
stavudine sol 1mg/ml
TRIUMEQ TAB
TRUVADA TAB 200-300MG
VIDEX SOL 2GM
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100mg
zidovudine syp 50mg/5ml
zidovudine tab 300mg
VIDEX EC
VIDEX EC
VIDEX EC
VIDEX EC
emtricitabine
emtricitabine
abacavir-lamivudine
atazanavir - cobicistat
COMBIVIR
EPIVIR
EPIVIR
EPIVIR
cobicistat - darunavir
zidovudine
ZERIT
ZERIT
ZERIT
ZERIT
ZERIT
abacavir - dolutegravir - lamivudine
emtricitabine - tenofovir
didanosine
tenofovir
tenofovir
tenofovir
tenofovir
tenofovir
abacavir
RETROVIR
RETROVIR
RETROVIR
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
Tier 2
Tier 2
Tier 2
QL (90 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (850 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (900 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (2400 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (1200 per 30 days)
QL (240 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (960 per 30 days)
QL (180 per 30 days)
QL (1920 per 30 days)
QL (60 per 30 days)
Anti-HIV Agents, Other
FUZEON INJ 90MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
TIVICAY TAB 50MG
VITEKTA TAB 150MG
VITEKTA TAB 85MG
enfuvirtide
maraviroc
maraviroc
dolutegravir
elvitegravir
elvitegravir
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
Tier 3
QL (60 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Route
1428
1429
1430
1431
1432
1433
1434
1435
1436
1437
1438
1439
1440
1441
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1442
1443
1444
1445
1446
1447
1448
1449
1450
1451
1452
1453
1454
1455
1456
1457
1458
1459
1460
1461
1462
1463
1464
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
51
Formulary
Tier
Requirements/
Limits
Anti-HIV Agents, Protease Inhibitors
APTIVUS CAP 250MG
tipranavir
APTIVUS SOL
tipranavir
CRIXIVAN CAP 200MG
indinavir
CRIXIVAN CAP 400MG
indinavir
INVIRASE CAP 200MG
saquinavir
INVIRASE TAB 500MG
saquinavir
KALETRA SOL
lopinavir - ritonavir
KALETRA TAB 100-25MG
lopinavir - ritonavir
KALETRA TAB 200-50MG
lopinavir - ritonavir
LEXIVA SUS 50MG/ML
fosamprenavir
LEXIVA TAB 700MG
fosamprenavir
NORVIR CAP 100MG
ritonavir
NORVIR SOL 80MG/ML
ritonavir
NORVIR TAB 100MG
ritonavir
PREZISTA SUS 100MG/ML
darunavir
PREZISTA TAB 150MG
darunavir
PREZISTA TAB 600MG
darunavir
PREZISTA TAB 75MG
darunavir
PREZISTA TAB 800MG
darunavir
REYATAZ CAP 150MG
atazanavir
REYATAZ CAP 200MG
atazanavir
REYATAZ CAP 300MG
atazanavir
REYATAZ POW 50MG
atazanavir
VIRACEPT TAB 250MG
nelfinavir
VIRACEPT TAB 625MG
nelfinavir
Tier 5
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 4
Tier 5
Tier 4
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
Tier 5
Tier 5
QL (120 per 30 days)
QL (300 per 30 days)
QL (360 per 30 days)
QL (180 per 30 days)
QL (300 per 30 days)
QL (120 per 30 days)
QL (480 per 30 days)
QL (300 per 30 days)
QL (120 per 30 days)
QL (1800 per 30 days)
QL (120 per 30 days)
QL (360 per 30 days)
QL (480 per 30 days)
QL (360 per 30 days)
QL (400 per 30 days)
QL (180 per 30 days)
QL (60 per 30 days)
QL (300 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (240 per 30 days)
QL (300 per 30 days)
QL (120 per 30 days)
Anti-influenza Agents
RELENZA MIS DISKHALE
rimantadine tab 100mg
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
zanamivir
FLUMADINE
oseltamivir
oseltamivir
oseltamivir
oseltamivir
Tier 4
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
QL (60 per 180 days)
Antiherpetic Agents
acyclovir cap 200mg
ZOVIRAX
Tier 2
Covered Drug Name
52
Alternate Drug Name
Route
1465
1466
1467
1468
1469
1470
1471
1472
1473
1474
1475
1476
1477
1478
1479
1480
1481
1482
1483
1484
1485
1486
1487
1488
1489
1490
1491
QL (84 per 180 days)
QL (42 per 180 days)
QL (42 per 180 days)
QL (900 per 180 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1492
1493
1494
1495
1496
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inh
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
acyclovir na inj 500mg
acyclovir oin 5%
acyclovir sus 200/5ml
acyclovir tab 400mg
acyclovir tab 800mg
DENAVIR CRE 1%
famciclovir tab 125mg
famciclovir tab 250mg
famciclovir tab 500mg
trifluridine sol 1%
valacyclovir tab 1gm
valacyclovir tab 500mg
ZOVIRAX CRE 5%
ZOVIRAX
ZOVIRAX
ZOVIRAX
ZOVIRAX
ZOVIRAX
penciclovir
FAMVIR
FAMVIR
FAMVIR
VIROPTIC
VALTREX
VALTREX
acyclovir
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
PA
QL (30 per 30 days)
Antivirals
ATRIPLA TAB
VIRAZOLE INH 6GM
efavirenz - emtricitabine -tenofovir
ribavirin 20 mg/ml inhalant
Tier 5
Tier 5
QL (30 per 30 days)
Anxiolytics, Other
buspirone tab 10mg
buspirone tab 15mg
buspirone tab 30mg
buspirone tab 5mg
buspirone tab 7.5mg
HYDROXYZ HCL INJ 25MG/ML
hydroxyz hcl inj 50mg/ml
hydroxyz hcl tab 25mg
hydroxyz hcl tab 50mg
meprobamate tab 200mg
meprobamate tab 400mg
BUSPAR
BUSPAR
BUSPAR
BUSPAR
BUSPAR
hydroxyzine
VISTARIL
VISTARIL
VISTARIL
MILTOWN
MILTOWN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 1
Tier 1
Tier 2
Tier 2
Benzodiazepines
alprazolam con 1 mg/ml
alprazolam tab 0.25 odt
alprazolam tab 0.25mg
alprazolam tab 0.5mg
alprazolam tab 0.5mg er
XANAX
NIRAVAM
XANAX
XANAX
XANAX XR
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Route
1497
1498
1499
1500
1501
QL (1.5 per 28 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
1502
1503
1504
1505
1506
QL (30 per 1 days)
QL (30 per 1 days)
QL (10 per 30 days)
1507
1508
1509
1510
1511
Inj
Top
Oral
Oral
Oral
Top
Oral
Oral
Oral
OP
Oral
Oral
Top
Oral
Inh
ANXIOLYTICS
1512
1513
1514
1515
1516
PA
PA
1517
1518
1519
1520
PA
PA
1521
1522
1523
1524
QL (90 per 30 days)
QL (90 per 30 days)
QL (120 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1525
1526
1527
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
53
Formulary
Covered Drug Name
alprazolam tab 0.5mg odt
alprazolam tab 1mg
alprazolam tab 1mg er
alprazolam tab 1mg odt
alprazolam tab 2mg
alprazolam tab 2mg er
alprazolam tab 2mg odt
alprazolam tab 3mg er
chlordiazep cap 10mg
chlordiazep cap 25mg
chlordiazep cap 5mg
Alternate Drug Name
Tier
NIRAVAM
XANAX
XANAX XR
NIRAVAM
XANAX
XANAX XR
NIRAVAM
XANAX XR
LIBRIUM
LIBRIUM
LIBRIUM
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
LITHOBID
LITHOBID
LITHOBID
LITHOBID
LITHOBID
LITHOBID
lithium citr
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Requirements/
Limits
Route
1528
QL (90 per 30 days)
QL (120 per 30 days)
1529
1530
1531
QL (150 per 30 days)
QL (120 per 30 days)
QL (150 per 30 days)
QL (120 per 30 days)
PA
PA
PA
1532
1533
1534
1535
1536
1537
1538
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
BIPOLAR AGENTS
Mood Stabilizers
lithium carb cap 150mg
lithium carb cap 300mg
lithium carb cap 600mg
lithium carb tab 300mg
lithium carb tab 300mg er
lithium carb tab 450mg er
LITHIUM CITR SOL 8MEQ/5ML
1539
1540
1541
1542
1543
1544
1545
Oral
Oral
Oral
Oral
Oral
Oral
Oral
BLOOD GLUCOSE REGULATORS
Antidiabetic Agents
acarbose tab 100mg
acarbose tab 25mg
acarbose tab 50mg
BYDUREON INJ
BYDUREON INJ
BYETTA INJ 10MCG
BYETTA INJ 5MCG
chlorpropam tab 100mg
chlorpropam tab 250mg
CYCLOSET TAB 0.8MG
glimepiride tab 1mg
glimepiride tab 2mg
glimepiride tab 4mg
glipizide er tab 10mg
glipizide er tab 2.5mg
glipizide er tab 5mg
54
PRECOSE
PRECOSE
PRECOSE
exenatide
exenatide
exenatide
exenatide
chlorpropamide
chlorpropamide
bromocriptine
AMARYL
AMARYL
AMARYL
GLUCOTROL XL
GLUCOTROL XL
GLUCOTROL XL
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (4.5 per 30 days)
QL (4 per 28 days)
PA, QL (2.4 per 30 days)
PA, QL (2.4 per 30 days)
PA, QL (120 per 30 days)
PA, QL (90 per 30 days)
PA, QL (180 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (240 per 30 days)
QL (120 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1546
1547
1548
1549
1550
1551
1552
1553
1554
1555
1556
1557
1558
1559
1560
1561
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
glipizide tab 10mg
glipizide tab 5mg
JARDIANCE TAB 10MG
JARDIANCE TAB 25MG
metformin er tab 1000mg
metformin tab 1000mg
metformin tab 500mg
metformin tab 500mg er
metformin tab 750mg er
metformin tab 850mg
nateglinide tab 120mg
nateglinide tab 60mg
ONGLYZA TAB 2.5MG
ONGLYZA TAB 5MG
pioglitazone tab 15mg
pioglitazone tab 30mg
pioglitazone tab 45mg
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG
tolazamide tab 250mg
tolazamide tab 500mg
tolbutamide tab 500mg
TRULICITY INJ 0.75/0.5ML
TRULICITY INJ 1.5/0.5ML
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
GLUCOTROL
GLUCOTROL
empagliflozin
empagliflozin
FORTAMET
GLUCOPHAGE
GLUCOPHAGE
GLUCOPHAGE XL
GLUCOPHAGE XL
GLUCOPHAGE
STARLIX
STARLIX
saxagliptin
saxagliptin
ACTOS
ACTOS
ACTOS
pramlintide
pramlintide
tolazamide
tolazamide
tolazamide
dulaglutide
dulaglutide
colesevelam
colesevelam
Tier 1
Tier 1
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 4
Tier 4
QL (120 per 30 days)
QL (240 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (150 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA, QL (10.8 per 30 days)
PA, QL (10.8 per 30 days)
Blood Glucose Regulators
glip/metform tab 2.5-250mg
glip/metform tab 2.5-500mg
glip/metform tab 5-500mg
JANUMET TAB 50-1000MG
JANUMET TAB 50-500MG
JANUMET XR TAB 100-1000MG
JANUMET XR TAB 50-1000MG
JANUMET XR TAB 50-500MG
pioglit/glim tab 30-2mg
pioglit/glim tab 30-4mg
pioglita/met tab 15-500mg
pioglita/met tab 15-850mg
METAGLIP
METAGLIP
METAGLIP
metformin - sitagliptin
metformin - sitagliptin
metformin - sitagliptin sr
metformin - sitagliptin sr
metformin - sitagliptin sr
DUETACT
DUETACT
ACTOPLUS
ACTOPLUS
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
QL (240 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
Route
1562
1563
1564
1565
1566
1567
1568
1569
1570
1571
1572
1573
1574
1575
1576
1577
1578
1579
1580
1581
1582
1583
1584
1585
1586
1587
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1588
1589
1590
1591
1592
1593
1594
1595
1596
1597
1598
1599
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
55
Formulary
Covered Drug Name
Glycemic Agents
GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
KORLYM TAB 300MG
PROGLYCEM SUS 50MG/ML
Insulins
APIDRA INJ SOLOSTAR
APIDRA INJ U-100
HUMALOG 100/ML
HUMALOG INJ 100/ML
HUMALOG INJ 100/ML
HUMALOG KWIK 100/ML
HUMALOG KWIK 200/ML
HUMALOG MIX INJ 50/50
HUMALOG MIX INJ 50/50KWP
HUMALOG MIX INJ 75/25KWP
HUMALOG MIX SUS 75/25
HUMULIN INJ 70/30
HUMULIN N INJ U-100
HUMULIN N PN INJ U-100
HUMULIN PEN INJ 70/30
HUMULIN R INJ U-100
HUMULIN R INJ U-500
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
LEVEMIR INJ
LEVEMIR INJ FLEXPEN
Alternate Drug Name
Tier
Requirements/
Limits
glucagon
glucagon rdna
mifepristone
diazoxide
Tier 4
Tier 4
Tier 5
Tier 3
QL (30 per 30 days)
QL (2 per 30 days)
PA, QL (120 per 30 days)
insulin glulisine
insulin glulisine
insulin lispro
insulin lispro
insulin lispro
insulin lispro
insulin lispro
insulin lispro
insulin lispro
insulin lispro
insulin lispro
nph insulin, human unt/ml - regular
insulin
insulin human, isophane (nph)
insulin human, isophane (nph)
insulin human (regular) - insulin human,
isophane
insulin human (regular)
regular insulin
insulin glargine
insulin glargine
insulin detemir
insulin detemir
Tier 4
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Tier 3
Tier 3
Tier 3
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Tier 3
Tier 3
Tier 4
Tier 4
Tier 4
Tier 4
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Route
1600
1601
1602
1603
1604
1605
1606
1607
1608
1609
1610
1611
1612
1613
1614
1615
1616
1617
1618
1619
1620
1621
1622
1623
1624
Inj
Inj
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
Anticoagulants
COUMADIN TAB 10MG
COUMADIN TAB 1MG
COUMADIN TAB 2.5MG
COUMADIN TAB 2MG
COUMADIN TAB 3MG
56
warfarin
warfarin
warfarin
warfarin
warfarin
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1625
1626
1627
1628
1629
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
COUMADIN TAB 4MG
COUMADIN TAB 5MG
COUMADIN TAB 6MG
COUMADIN TAB 7.5MG
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
enoxaparin inj 100mg/ml
enoxaparin inj 120/0.8ml
enoxaparin inj 150mg/ml
enoxaparin inj 30/0.3ml
enoxaparin inj 300/3ml
enoxaparin inj 40/0.4ml
enoxaparin inj 60/0.6ml
enoxaparin inj 80/0.8ml
fondaparinux sol 10/0.8ml
fondaparinux sol 2.5/0.5ml
fondaparinux sol 5.0/0.4ml
fondaparinux sol 7.5/0.6ml
FRAGMIN INJ 10000/ML
FRAGMIN INJ 12500UNT
FRAGMIN INJ 15000UNT
FRAGMIN INJ 18000UNT
FRAGMIN INJ 2500/0.2ML
FRAGMIN INJ 5000/0.2ML
hep sod/d5w inj 20000unt
HEP SOD/D5W INJ 25000UNT
HEP SOD/D5W INJ 25000UNT
heparin sod inj 1000/ml
heparin sod inj 10000/ml
heparin sod inj 20000/ml
heparin sod inj 5000/ml
jantoven tab 10mg
jantoven tab 1mg
jantoven tab 2.5mg
jantoven tab 2mg
jantoven tab 3mg
jantoven tab 4mg
jantoven tab 5mg
jantoven tab 6mg
jantoven tab 7.5mg
PRADAXA CAP 150MG
PRADAXA CAP 75MG
Alternate Drug Name
warfarin
warfarin
warfarin
warfarin
apixaban
apixaban
LOVENOX
LOVENOX
LOVENOX
LOVENOX
LOVENOX
LOVENOX
LOVENOX
LOVENOX
ARIXTRA
ARIXTRA
ARIXTRA
ARIXTRA
dalteparin
dalteparin
dalteparin
dalteparin
dalteparin
dalteparin
heparin - d5w
heparin
heparin
heparin
heparin
heparin
heparin
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
dabigatran
dabigatran
Tier
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
Tier 5
Tier 5
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Tier 3
Requirements/
Limits
Route
1630
1631
1632
1633
QL (60 per 30 days)
QL (60 per 30 days)
PA, QL (28 per 30 days)
PA, QL (22.4 per 30 days)
PA, QL (28 per 30 days)
PA, QL (8.4 per 30 days)
QL (84 per 30 days)
PA, QL (11.2 per 30 days)
PA, QL (16.8 per 30 days)
PA, QL (22.4 per 30 days)
PA, QL (20 per 30 days)
PA, QL (15 per 30 days)
PA, QL (20 per 30 days)
PA, QL (20 per 30 days)
PA, QL (20 per 30 days)
PA, QL (20 per 30 days)
PA, QL (20 per 30 days)
PA, QL (20 per 30 days)
PA, QL (20 per 30 days)
PA, QL (20 per 30 days)
PA
PA
PA
PA
PA
PA
PA
1634
1635
1636
1637
1638
1639
1640
1641
1642
1643
1644
1645
1646
1647
1648
1649
1650
1651
1652
1653
1654
1655
1656
1657
1658
1659
1660
1661
1662
1663
1664
1665
1666
1667
1668
1669
QL (60 per 30 days)
QL (60 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1670
1671
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
57
Formulary
Covered Drug Name
58
Alternate Drug Name
Tier
warfarin tab 10mg
warfarin tab 1mg
warfarin tab 2.5mg
warfarin tab 2mg
warfarin tab 3mg
warfarin tab 4mg
warfarin tab 5mg
warfarin tab 6mg
warfarin tab 7.5mg
XARELTO STAR TAB 15/20MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
COUMADIN
rivaroxaban
rivaroxaban
rivaroxaban
rivaroxaban
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 4
Tier 4
Blood Formation Modifiers
anagrelide cap 0.5mg
anagrelide cap 1mg
ARANESP INJ 100MCG/0.5ML
ARANESP INJ 100MCG/1ML
ARANESP INJ 150MCG/0.3ML
ARANESP INJ 200MCG/0.4ML
ARANESP INJ 200MCG/1ML
ARANESP INJ 25MCG/0.42ML
ARANESP INJ 25MCG/1ML
ARANESP INJ 300MCG/0.6ML
ARANESP INJ 300MCG/1ML
ARANESP INJ 40MCG/0.4ML
ARANESP INJ 40MCG/1ML
ARANESP INJ 500MCG/1ML
ARANESP INJ 60MCG/0.3ML
ARANESP INJ 60MCG/1ML
EPOGEN INJ 10000/ML
EPOGEN INJ 2000/ML
EPOGEN INJ 20000/ML
EPOGEN INJ 3000/ML
EPOGEN INJ 4000/ML
LEUKINE INJ 250MCG
MOZOBIL INJ
NEULASTA INJ 6MG/0.6ML
NEUPOGEN 300MCG
AGRYLIN
AGRYLIN
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
darbepoetin alfa
epoetin alfa
epoetin alfa
epoetin alfa
epoetin alfa
epoetin alfa
sargramostim
plerixafor
pegfilgrastim
filgrastim
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 4
Tier 4
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Requirements/
Limits
Route
1672
1673
1674
1675
1676
1677
1678
1679
1680
QL (51 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
1681
1682
1683
1684
1685
1686
PA, QL (4 per 28 days)
PA, QL (2 per 28 days)
PA, QL (1.2 per 28 days)
PA, QL (1.6 per 28 days)
PA, QL (4 per 28 days)
PA, QL (1.68 per 28 days)
PA, QL (4 per 28 days)
PA, QL (2.4 per 28 days)
PA, QL (4 per 28 days)
PA, QL (1.6 per 28 days)
PA, QL (4 per 28 days)
PA, QL (4 per 28 days)
PA, QL (1.2 per 28 days)
PA, QL (4 per 28 days)
PA
PA, QL (12 per 28 days)
PA
PA, QL (12 per 28 days)
PA, QL (12 per 28 days)
PA
PA
PA, QL (2 per 30 days)
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1687
1688
1689
1691
1690
1693
1692
1695
1694
1697
1696
1698
1700
1699
1701
1702
1703
1704
1705
1706
1707
1708
1709
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Formulary
Tier
Requirements/
Limits
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
PA
PA
PA
PA, QL (12 per 28 days)
PA, QL (12 per 28 days)
PA, QL (12 per 28 days)
PA, QL (12 per 28 days)
PA, QL (12 per 28 days)
PA, QL (12 per 28 days)
PA, QL (90 per 30 days)
PA, QL (90 per 30 days)
PA, QL (90 per 30 days)
PA, QL (90 per 30 days)
Blood Products/Modifiers/Volume Expanders
NEUMEGA INJ 5MG
oprelvekin
Tier 5
PA, QL (21 per 21 days)
Coagulants
tranex acid tab 650mg
tranexamic acid
Tier 2
Platelet Modifying Agents
AGGRENOX CAP 25-200MG
BRILINTA TAB 90MG
cilostazol tab 100mg
cilostazol tab 50mg
clopidogrel tab 300mg
clopidogrel tab 75mg
EFFIENT TAB 10MG
EFFIENT TAB 5MG
ticlopidine tab 250mg
aspirin - dipyridamole
ticagrelor
PLETAL
PLETAL
PLAVIX
PLAVIX
prasugrel
prasugrel
TICLID
Tier 4
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 2
Covered Drug Name
NEUPOGEN INJ 300/0.5ML
NEUPOGEN INJ 480/0.8ML
NEUPOGEN INJ 480MCG
PROCRIT INJ 10000/ML
PROCRIT INJ 2000/ML
PROCRIT INJ 20000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 40000/ML
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
Alternate Drug Name
filgrastim
filgrastim
filgrastim
epoetin alfa
epoetin alfa
epoetin alfa
epoetin alfa
epoetin alfa
epoetin alfa
eltrombopag
eltrombopag
eltrombopag
eltrombopag
Route
1710
1711
1712
1713
1714
1715
1716
1717
1718
1719
1720
1721
1722
1723
1724
QL (60 per 30 days)
QL (60 per 30 days)
1725
1726
1727
1728
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA, QL (60 per 30 days)
1729
1730
1731
1732
1733
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
CARDIOVASCULAR AGENTS
Alpha-adrenergic Agonists
clonidine dis 0.1/24hr
clonidine dis 0.2/24hr
clonidine dis 0.3/24hr
clonidine tab 0.1mg
CATAPRES TTS
CATAPRES TTS
CATAPRES TTS
CATAPRES
Tier 2
Tier 2
Tier 2
Tier 2
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1734
1735
1736
1737
TD
TD
TD
Oral
59
Formulary
Covered Drug Name
clonidine tab 0.1mg er
clonidine tab 0.2mg
clonidine tab 0.3mg
guanfacine tab 1mg
guanfacine tab 2mg
methyldopa tab 250mg
methyldopa tab 500mg
methyldopate inj 250/5ml
midodrine tab 10mg
midodrine tab 2.5mg
midodrine tab 5mg
60
Alternate Drug Name
KAPVAY
CATAPRES
CATAPRES
TENEX
TENEX
ALDOMET
ALDOMET
ALDOMET
PROAMATINE
PROAMATINE
PROAMATINE
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Requirements/
Limits
Route
1738
1739
1740
PA
PA
PA
PA
PA
1741
1742
1743
1744
1745
1746
1747
1748
Alpha-adrenergic Blocking Agents
doxazosin tab 1mg
CARDURA
doxazosin tab 2mg
CARDURA
doxazosin tab 4mg
CARDURA
doxazosin tab 8mg
CARDURA
prazosin hcl cap 1mg
MINIPRESS
prazosin hcl cap 2mg
MINIPRESS
prazosin hcl cap 5mg
MINIPRESS
terazosin cap 10mg
HYTRIN
terazosin cap 1mg
HYTRIN
terazosin cap 2mg
HYTRIN
terazosin cap 5mg
HYTRIN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
Angiotensin II Receptor Antagonists
candesartan tab 16mg
ATACAND
candesartan tab 32mg
ATACAND
candesartan tab 4mg
ATACAND
candesartan tab 8mg
ATACAND
eprosart mes tab 600mg
TEVETEN
irbesartan tab 150mg
AVAPRO
irbesartan tab 300mg
AVAPRO
irbesartan tab 75mg
AVAPRO
losartan pot tab 100mg *
COZAAR
losartan pot tab 25mg *
COZAAR
losartan pot tab 50mg *
COZAAR
telmisartan tab 20mg
MICARDIS
telmisartan tab 40mg
MICARDIS
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
1749
1750
1751
1752
1753
1754
1755
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1756
1757
1758
1759
1760
1761
1762
1763
1764
1765
1766
1767
1768
1769
1770
1771
1772
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
telmisartan tab 80mg
valsartan tab 160mg
valsartan tab 320mg
valsartan tab 40mg
valsartan tab 80mg
Alternate Drug Name
MICARDIS
DIOVAN
DIOVAN
DIOVAN
DIOVAN
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril tab 10mg
LOTENSIN
benazepril tab 20mg
LOTENSIN
benazepril tab 40mg
LOTENSIN
benazepril tab 5mg
LOTENSIN
captopril tab 100mg
CAPOTEN
captopril tab 12.5mg
CAPOTEN
captopril tab 25mg
CAPOTEN
captopril tab 50mg
CAPOTEN
enalapril tab 10mg
VASOTEC
enalapril tab 2.5mg
VASOTEC
enalapril tab 20mg
VASOTEC
enalapril tab 5mg
VASOTEC
fosinopril tab 10mg
MONOPRIL
fosinopril tab 20mg
MONOPRIL
fosinopril tab 40mg
MONOPRIL
lisinopril tab 10mg
ZESTRIL, PRINIVIL
lisinopril tab 2.5mg
ZESTRIL, PRINIVIL
lisinopril tab 20mg
ZESTRIL, PRINIVIL
lisinopril tab 30mg
ZESTRIL, PRINIVIL
lisinopril tab 40mg
ZESTRIL, PRINIVIL
lisinopril tab 5mg
ZESTRIL, PRINIVIL
moexipril tab 15mg
UNIVASC
moexipril tab 7.5mg
UNIVASC
perindopril tab 2mg
ACEON
perindopril tab 4mg
ACEON
perindopril tab 8mg
ACEON
quinapril tab 10mg
ACCUPRIL
quinapril tab 20mg
ACCUPRIL
quinapril tab 40mg
ACCUPRIL
quinapril tab 5mg
ACCUPRIL
ramipril cap 1.25mg
ALTACE
ramipril cap 10mg
ALTACE
ramipril cap 2.5mg
ALTACE
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
Route
1773
QL (60 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
1774
1775
1776
1777
1778
1779
1780
1781
1782
1783
1784
1785
1786
1787
1788
1789
1790
1791
1792
1793
1794
1795
1796
1797
1798
1799
1800
1801
1802
1803
1804
1805
1806
1807
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1808
1809
1810
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
61
Formulary
Covered Drug Name
62
Alternate Drug Name
Tier
Requirements/
Limits
ramipril cap 5mg
trandolapril tab 1mg
trandolapril tab 2mg
trandolapril tab 4mg
ALTACE
MAVIK
MAVIK
MAVIK
Tier 2
Tier 2
Tier 2
Tier 2
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
Antiarrhythmics
amiodarone inj 50mg/ml
amiodarone tab 200mg
amiodarone tab 400mg
disopyramide cap 100mg
disopyramide cap 150mg
flecainide tab 100mg
flecainide tab 150mg
flecainide tab 50mg
mexiletine cap 150mg
mexiletine cap 200mg
mexiletine cap 250mg
MULTAQ TAB 400MG
pacerone tab 100mg
pacerone tab 200mg
PACERONE TAB 400MG
procainamide inj 100mg/ml
procainamide inj 500mg/ml
propafenone cap 225mg er
propafenone cap 325mg er
propafenone cap 425mg sr
propafenone tab 150mg
propafenone tab 225mg
propafenone tab 300mg
quinidine gl inj 80mg/ml
quinidine gl tab 324mg cr
quinidine su tab 200mg
quinidine su tab 300mg
quinidine su tab 300mg er
sorine tab 120mg
sorine tab 160mg
sorine tab 240mg
sorine tab 80mg
sotalol af tab 120mg
sotalol hcl tab 160mg
CORDARONE, PACERONE
CORDARONE, PACERONE
CORDARONE, PACERONE
NORPACE
NORPACE
TAMBOCOR
TAMBOCOR
TAMBOCOR
MEXITIL
MEXITIL
MEXITIL
dronedarone
CORDARONE
CORDARONE
amiodarone
procainamide
procainamide
RYTHMOL
RYTHMOL
RYTHMOL
RYTHMOL
RYTHMOL
RYTHMOL
quinidine gluconate
quinidine gl
quinidine su
quinidine su
quinidine sulfate er
SORINE, BETAPACE
SORINE, BETAPACE
SORINE, BETAPACE
SORINE, BETAPACE
SORINE, BETAPACE
SORINE, BETAPACE
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
PA
Route
1811
1812
1813
1814
1815
1816
1817
PA
PA
1818
1819
1820
1821
1822
1823
1824
1825
PA, QL (60 per 30 days)
1826
1827
1828
1829
PA
PA
1830
1831
1832
1833
1834
1835
1836
1837
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1838
1839
1840
1841
1842
1843
1844
1845
1846
1847
1848
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
sotalol hcl tab 240mg
sotalol hcl tab 80mg
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
Alternate Drug Name
SORINE, BETAPACE
SORINE, BETAPACE
dofetilide
dofetilide
dofetilide
Beta-adrenergic Blocking Agents
acebutolol cap 200mg
SECTRAL
acebutolol cap 400mg
SECTRAL
atenolol tab 100mg
TENORMIN
atenolol tab 25mg
TENORMIN
atenolol tab 50mg
TENORMIN
betaxolol tab 10mg
KERLONE
betaxolol tab 20mg
KERLONE
bisoprol fum tab 10mg
ZEBETA
bisoprol fum tab 5mg
ZEBETA
carvedilol tab 12.5mg *
COREG
carvedilol tab 25mg *
COREG
carvedilol tab 3.125mg *
COREG
carvedilol tab 6.25mg *
COREG
labetalol inj 5mg/ml
TRANDATE
labetalol tab 100mg
TRANDATE
labetalol tab 200mg
TRANDATE
labetalol tab 300mg
TRANDATE
metoprol tar tab 100mg
LOPRESSOR
metoprol tar tab 25mg
LOPRESSOR
metoprol tar tab 50mg
LOPRESSOR
metoprolol inj 1mg/ml
LOPRESSOR
metoprolol tab 100mg er
TOPROL XL
metoprolol tab 200mg er
TOPROL XL
metoprolol tab 25mg er
TOPROL XL
metoprolol tab 50mg er
TOPROL XL
nadolol tab 20mg
CORGARD
nadolol tab 40mg
CORGARD
nadolol tab 80mg
CORGARD
pindolol tab 10mg
VISKEN
pindolol tab 5mg
VISKEN
propranolol cap 120mg er
INDERAL LA
propranolol cap 160mg er
INDERAL LA
propranolol cap 60mg er
INDERAL LA
Tier
Requirements/
Limits
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Route
1849
1850
1851
1852
1853
1854
1855
1856
1857
1858
1859
1860
1861
1862
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA
1863
1864
1865
1866
1867
1868
1869
1870
1871
1872
1873
PA
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1874
1875
1876
1877
1878
1879
1880
1881
1882
1883
1884
1885
1886
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
63
Formulary
Covered Drug Name
propranolol cap 80mg er
propranolol inj 1mg/ml
propranolol sol 20mg/5ml
propranolol sol 40mg/5ml
propranolol tab 10mg
propranolol tab 20mg
propranolol tab 40mg
propranolol tab 60mg
propranolol tab 80mg
Alternate Drug Name
INDERAL LA
INDERAL
INDERAL
INDERAL
INDERAL
INDERAL
INDERAL
INDERAL
INDERAL
Calcium Channel Blocking Agents
afeditab tab 30mg cr
PROCARDIA XL, ADALAT CC
afeditab tab 60mg cr
PROCARDIA XL, ADALAT CC
amlodipine tab 10mg
NORVASC
amlodipine tab 2.5mg
NORVASC
amlodipine tab 5mg
NORVASC
cartia xt cap 120/24hr
DILT-CD
cartia xt cap 180/24hr
DILT-CD
cartia xt cap 240/24hr
DILT-CD
cartia xt cap 300/24hr
DILT-CD
dilt-xr cap 120mg
DILT-CD
dilt-xr cap 180mg
DILTIAZEM CD
dilt-xr cap 240mg
DILTIAZEM CD
diltiazem cap 120mg cd
DILT-CD
diltiazem cap 120mg er
CARDIZEM SR
diltiazem cap 180mg/24hr
TAZTIA XT, DILTZAC
diltiazem cap 240mg cd
DILT-CD
diltiazem cap 300mg er
DILT-CD
diltiazem cap 360mg/24hr
TAZTIA XT, DILTZAC
diltiazem cap 420mg/24hr
TAZTIA XT, DILTZAC
diltiazem cap 60mg er
CARDIZEM SR
diltiazem cap 90mg er
CARDIZEM SR
diltiazem inj 100mg
CARDIZEM
diltiazem inj 50/10ml
CARDIZEM
diltiazem tab 120mg
CARDIZEM
diltiazem tab 30mg
CARDIZEM
diltiazem tab 60mg
CARDIZEM
diltiazem tab 90mg
CARDIZEM
felodipine tab 10mg er
PLENDIL
felodipine tab 2.5mg er
PLENDIL
64
Tier
Tier 1
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
Route
1887
PA
1888
1889
1890
1891
1892
1893
1894
1895
1896
1897
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
1898
1899
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1917
1918
1919
1920
1921
1922
1923
1924
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
felodipine tab 5mg er
isradipine cap 2.5mg
isradipine cap 5mg
nicardipine cap 20mg
nicardipine cap 30mg
nicardipine inj 25/10ml
nifedical xl tab 30mg
nifedical xl tab 60mg
nifedipine tab 30mg er
nifedipine tab 60mg er
nifedipine tab 90mg er
nimodipine cap 30mg
nisoldipine tab 17mg er
nisoldipine tab 20mg
nisoldipine tab 25.5mg
nisoldipine tab 30mg
nisoldipine tab 34mg er
nisoldipine tab 40mg
nisoldipine tab 8.5mg er
taztia xt cap 120mg/24hr
taztia xt cap 180mg/24hr
taztia xt cap 240mg/24hr
taztia xt cap 300mg/24hr
taztia xt cap 360mg/24hr
verapamil cap 100mg er
verapamil cap 120mg er
verapamil cap 180mg er
verapamil cap 200mg er
verapamil cap 240mg er
verapamil cap 300mg er
verapamil cap 360mg sr
verapamil inj 2.5mg/ml
verapamil tab 120mg
verapamil tab 120mg er
verapamil tab 180mg er
verapamil tab 240mg er
verapamil tab 40mg
verapamil tab 80mg
Alternate Drug Name
PLENDIL
DYNACIRC
DYNACIRC
CARDENE
CARDENE
CARDENE I.V.
PROCARDIA XL, ADALAT CC
PROCARDIA XL, ADALAT CC
PROCARDIA XL, ADALAT CC
PROCARDIA XL, ADALAT CC
PROCARDIA XL, ADALAT CC
NIMOTOP
SULAR
SULAR
SULAR
SULAR
SULAR
SULAR
SULAR
TAZTIA XT, DILTZAC
TAZTIA XT, DILTZAC
TAZTIA XT, DILTZAC
TAZTIA XT, DILTZAC
TAZTIA XT, DILTZAC
VERELAN PM
VERELAN
VERELAN
VERELAN PM
VERELAN
VERELAN PM
VERELAN PM
CALAN
CALAN
CALAN SR
CALAN SR
CALAN SR
CALAN
CALAN
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
Route
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1956
1957
1958
1959
1960
1961
1962
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
65
Formulary
Covered Drug Name
Cardiovascular Agents
amilor/hctz tab 5-50mg
amlod/atorva tab 10-10mg
amlod/atorva tab 10-20mg
amlod/atorva tab 10-40mg
amlod/atorva tab 10-80mg
amlod/atorva tab 2.5-10mg
amlod/atorva tab 2.5-20mg
amlod/atorva tab 2.5-40mg
amlod/atorva tab 5-10mg
amlod/atorva tab 5-20mg
amlod/atorva tab 5-40mg
amlod/atorva tab 5-80mg
amlod/benazp cap 10-20mg
amlod/benazp cap 10-40mg
amlod/benazp cap 2.5-10mg
amlod/benazp cap 5-10mg
amlod/benazp cap 5-20mg
amlod/benazp cap 5-40mg
amlod/valsar tab 10-160mg
amlod/valsar tab 10-320mg
amlod/valsar tab 5-160mg
amlod/valsar tab 5-320mg
amlod/valsar/hctz tab 10-160-12.5mg
amlod/valsar/hctz tab 10-160-25mg
amlod/valsar/hctz tab 10-320-25mg
amlod/valsar/hctz tab 5-160-12.5mg
amlod/valsar/hctz tab 5-160-25mg
atenol/chlor tab 100-25mg
atenol/chlor tab 50-25mg
benazep/hctz tab 10-12.5mg
benazep/hctz tab 20-12.5mg
benazep/hctz tab 20-25mg
benazep/hctz tab 5-6.25mg
bisoprl/hctz tab 10/6.25mg
bisoprl/hctz tab 2.5/6.25mg
bisoprl/hctz tab 5-6.25mg
candesa/hctz tab 16-12.5mg
candesa/hctz tab 32-12.5mg
candesa/hctz tab 32-25mg
66
Alternate Drug Name
MODURETIC
CADUET
CADUET
CADUET
CADUET
CADUET
CADUET
CADUET
CADUET
CADUET
CADUET
CADUET
LOTREL
LOTREL
LOTREL
LOTREL
LOTREL
LOTREL
EXFORGE
EXFORGE
EXFORGE
EXFORGE
EXFORGE HCT
EXFORGE HCT
EXFORGE HCT
EXFORGE HCT
EXFORGE HCT
TENORETIC
TENORETIC
LOTENSIN HCT
LOTENSIN HCT
LOTENSIN HCT
LOTENSIN HCT
ZIAC
ZIAC
ZIAC
ATACAND HCT
ATACAND HCT
ATACAND HCT
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
Route
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
1999
2000
2001
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
captopr/hctz tab 25-15mg
captopr/hctz tab 25-25mg
captopr/hctz tab 50-15mg
captopr/hctz tab 50-25mg
CLORPRES TAB 0.1-15MG
CLORPRES TAB 0.2-15MG
CLORPRES TAB 0.3-15MG
DEMSER CAP 250MG
enalapr/hctz tab 10-25mg
enalapr/hctz tab 5-12.5mg
fosinop/hctz tab 10/12.5mg
fosinop/hctz tab 20/12.5mg
irbesar/hctz tab 150-12.5mg
irbesar/hctz tab 300-12.5mg
lisinop/hctz tab 10-12.5mg
lisinop/hctz tab 20-12.5mg
lisinop/hctz tab 20-25mg
losartan/hct tab 100-12.5mg *
losartan/hct tab 100-25mg *
losartan/hct tab 50-12.5mg *
methyld/hctz tab 250/15mg
methyld/hctz tab 250/25mg
metoprl/hctz tab 100-25mg
metoprl/hctz tab 100-50mg
metoprl/hctz tab 50-25mg
moexipr/hctz tab 15-12.5mg
moexipr/hctz tab 15-25mg
moexipr/hctz tab 7.5-12.5mg
nadolol/bend tab 40-5mg
nadolol/bend tab 80-5mg
NORTHERA CAP 100MG
NORTHERA CAP 200MG
NORTHERA CAP 300MG
propran/hctz tab 40/25mg
propran/hctz tab 80/25mg
qnapril/hctz tab 10-12.5mg
qnapril/hctz tab 20-12.5mg
qnapril/hctz tab 20-25mg
reserpine tab 0.1mg
reserpine tab 0.25mg
SIMCOR TAB 1000-20MG
SIMCOR TAB 1000-40MG
Alternate Drug Name
Tier
CAPOZIDE
CAPOZIDE
CAPOZIDE
CAPOZIDE
clonidine - chlorthalidone
clonidine - chlorthalidone
clonidine - chlorthalidone
metyrosine
VASERETIC
VASERETIC
MONOPRIL HCT
MONOPRIL HCT
AVALIDE
AVALIDE
ZESTORETIC, PRINZIDE
ZESTORETIC, PRINZIDE
ZESTORETIC, PRINZIDE
HYZAAR
HYZAAR
HYZAAR
ALDORIL
ALDORIL
LOPRESSOR HCT
LOPRESSOR HCT
LOPRESSOR HCT
UNIRETIC
UNIRETIC
UNIRETIC
CORZIDE
CORZIDE
droxidopa
droxidopa
droxidopa
propranolol - hydrochlorothiazide
propranolol - hydrochlorothiazide
ACCURETIC
ACCURETIC
ACCURETIC
reserpine
reserpine
niacin - simvastatin er
niacin - simvastatin er
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 5
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Requirements/
Limits
Route
2002
2003
2004
2005
2006
2007
2008
PA, QL (480 per 30 days)
2009
2010
2011
2012
2013
QL (30 per 30 days)
QL (30 per 30 days)
2014
2015
2016
2017
2018
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA
PA
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
PA, QL (14 per 1 days)
PA, QL (14 per 1 days)
PA, QL (14 per 1 days)
2032
2033
2034
2035
2036
2037
2038
2039
PA
PA
QL (60 per 30 days)
QL (60 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2040
2041
2042
2043
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
67
Formulary
Covered Drug Name
SIMCOR TAB 500-20MG
SIMCOR TAB 500-40MG
SIMCOR TAB 750-20MG
spirono/hctz tab 25/25mg
TEKTURNA HCT TAB 150-12.5MG
TEKTURNA HCT TAB 150-25MG
TEKTURNA HCT TAB 300-12.5MG
TEKTURNA HCT TAB 300-25MG
telmis/amlod tab 40-10mg
telmis/amlod tab 40-5mg
telmis/amlod tab 80-10mg
telmis/amlod tab 80-5mg
telmisa/hctz tab 40-12.5mg
telmisa/hctz tab 80-12.5mg
telmisa/hctz tab 80-25mg
triamt/hctz cap 37.5-25mg
triamt/hctz cap 50-25mg
triamt/hctz tab 37.5-25mg
triamt/hctz tab 75-50mg
valsart/hctz tab 160-12.5mg
valsart/hctz tab 160-25mg
valsart/hctz tab 320-12.5mg
valsart/hctz tab 320-25mg
valsart/hctz tab 80-12.5mg
VYTORIN TAB 10-10MG
VYTORIN TAB 10-20MG
VYTORIN TAB 10-40MG
VYTORIN TAB 10-80MG
Alternate Drug Name
niacin - simvastatin er
niacin - simvastatin er
niacin - simvastatin er
ALDACTAZIDE
aliskiren - hct
aliskiren - hct
aliskiren - hct
aliskiren - hct
TWYNSTA
TWYNSTA
TWYNSTA
TWYNSTA
MICARDIS HCT
MICARDIS HCT
MICARDIS HCT
DYAZIDE
MAXZIDE, DYAZIDE
MAXZIDE, DYAZIDE
MAXZIDE, DYAZIDE
DIOVAN HCT
DIOVAN HCT
DIOVAN HCT
DIOVAN HCT
DIOVAN HCT
simvastatin - ezetimibe
simvastatin - ezetimibe
simvastatin - ezetimibe
ezetimibe - simvastatin
Cardiovascular Agents, Other
digitek tab 0.125mg
digoxin
digitek tab 0.25mg
digoxin
digoxin inj 0.25mg/1ml
LANOXIN
digoxin sol 50mcg/ml
LANOXIN
digoxin tab 0.125mg
LANOXIN
digoxin tab 0.25mg
LANOXIN
pentoxifylli tab 400mg er
TRENTAL
RANEXA TAB 1000MG
ranolazine
RANEXA TAB 500MG
ranolazine
TEKTURNA TAB 150MG
aliskiren
68
Tier
Tier 3
Tier 3
Tier 3
Tier 1
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 4
Tier 1
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
Tier 3
Requirements/
Limits
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
Route
2044
2045
2046
2047
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
2048
2049
2050
2051
2052
2053
2054
2055
QL (30 per 30 days)
2056
2057
QL (30 per 30 days)
2058
2059
2060
2061
2062
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days), ST
QL (30 per 30 days), ST
QL (30 per 30 days), ST
QL (30 per 30 days), ST
PA
PA
PA
PA
PA
PA
2063
2064
2065
2066
2067
2068
2069
2070
2071
2072
2073
2074
2075
2076
2077
2078
QL (120 per 30 days)
QL (120 per 30 days)
QL (30 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2079
2080
2081
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
TEKTURNA TAB 300MG
Alternate Drug Name
aliskiren
Tier
Requirements/
Limits
Tier 3
QL (30 per 30 days)
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamid cap 500mg er
DIAMOX SEQUELS
acetazolamid inj 500mg
DIAMOX
acetazolamid tab 125mg
DIAMOX
acetazolamid tab 250mg
DIAMOX
methazolamid tab 25mg
METHAZOLAMIDE
methazolamid tab 50mg
METHAZOLAMIDE
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Diuretics, Loop
bumetanide inj 0.25/ml
bumetanide tab 0.5mg
bumetanide tab 1mg
bumetanide tab 2mg
furosemide inj 10mg/ml
furosemide inj 10mg/ml
furosemide sol 10mg/ml
furosemide sol 8mg/ml
furosemide tab 20mg
furosemide tab 40mg
furosemide tab 80mg
torsemide tab 100mg
torsemide tab 10mg
torsemide tab 20mg
torsemide tab 5mg
BUMEX
BUMEX
BUMEX
BUMEX
LASIX
LASIX
LASIX
LASIX
LASIX
LASIX
LASIX
DEMADEX
DEMADEX
DEMADEX
DEMADEX
Tier 4
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Diuretics, Potassium-sparing
amiloride tab 5mg
eplerenone tab 25mg
eplerenone tab 50mg
spironolact tab 100mg
spironolact tab 25mg
spironolact tab 50mg
MIDAMOR
INSPRA
INSPRA
ALDACTONE
ALDACTONE
ALDACTONE
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Route
2082
2083
PA
2084
2085
2086
2087
2088
PA
2089
2090
2091
2092
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2093
2094
2095
2096
2097
2098
2099
2100
2101
2102
2103
2104
2105
2106
2107
2108
2109
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
69
Formulary
Covered Drug Name
Diuretics, Thiazide
chlorothiaz inj 500mg
chlorothiaz tab 250mg
chlorothiaz tab 500mg
chlorthalid tab 25mg
chlorthalid tab 50mg
hydrochlorot cap 12.5mg
hydrochlorot tab 12.5mg
hydrochlorot tab 25mg
hydrochlorot tab 50mg
indapamide tab 1.25mg
indapamide tab 2.5mg
methyclothia tab 5mg
metolazone tab 10mg
metolazone tab 2.5mg
metolazone tab 5mg
70
Alternate Drug Name
DIURIL
DIURIL
DIURIL
THALITONE
THALITONE
MICROZIDE
HYDRODIURIL
HYDRODIURIL
HYDRODIURIL
LOZOL
LOZOL
AQUATENSEN, ENDURON
ZAROXOLYN
ZAROXOLYN
ZAROXOLYN
Tier
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Dyslipidemics, Fibric Acid Derivatives
fenofibrate cap 130mg
fenofibrate
fenofibrate cap 134mg
LOFIBRA
fenofibrate cap 200mg
LOFIBRA
fenofibrate cap 43mg
fenofibrate
fenofibrate cap 67mg
LOFIBRA
fenofibrate tab 145mg
fenofibrate
fenofibrate tab 160mg
TRICOR
fenofibrate tab 48mg
TRICOR
fenofibrate tab 54mg
TRICOR
fenofibric cap 135mg dr
TRILIPIX
fenofibric cap 45mg dr
TRILIPIX
gemfibrozil tab 600mg
LOPID
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin tab 10mg *
LIPITOR
atorvastatin tab 20mg *
LIPITOR
atorvastatin tab 40mg *
LIPITOR
atorvastatin tab 80mg *
LIPITOR
CRESTOR TAB 10MG
rosuvastatin
Tier 1
Tier 1
Tier 1
Tier 1
Tier 3
Requirements/
Limits
PA
Route
2110
2111
2112
2113
2114
2115
2116
2117
2118
2119
2120
2121
2122
2123
2124
2125
QL (30 per 30 days)
QL (30 per 30 days)
2126
2127
2128
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
2129
2130
2131
2132
2133
2134
2135
2136
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2137
2138
2139
2140
2141
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
CRESTOR TAB 20MG
CRESTOR TAB 40MG
CRESTOR TAB 5MG
fluvastatin cap 20mg
fluvastatin cap 40mg
lovastatin tab 10mg
lovastatin tab 20mg
lovastatin tab 40mg
pravastatin tab 10mg
pravastatin tab 20mg
pravastatin tab 40mg
pravastatin tab 80mg
simvastatin tab 10mg *
simvastatin tab 20mg *
simvastatin tab 40mg *
simvastatin tab 5mg *
simvastatin tab 80mg *
rosuvastatin
rosuvastatin
rosuvastatin
LESCOL
LESCOL
MEVACOR
MEVACOR
MEVACOR
PRAVACHOL
PRAVACHOL
PRAVACHOL
PRAVACHOL
ZOCOR
ZOCOR
ZOCOR
ZOCOR
ZOCOR
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Dyslipidemics, Other
cholestyram pow 4gm lite
colestipol gra 5gm
colestipol tab 1gm
JUXTAPID CAP 10MG
JUXTAPID CAP 20MG
JUXTAPID CAP 5MG
KYNAMRO INJ 200MG/ML
niacor tab 500mg
omega-3-acid cap 1gm
prevalite pow 4gm
questran pow 4gm
ZETIA TAB 10MG
QUESTRAN
COLESTID
COLESTID
lomitapide
lomitapide
lomitapide
mipomersen sodium
NIACOR
LOVAZA
QUESTRAN
cholestyramine resin
ezetimibe
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Vasodilators, Direct-acting Arterial
hydralazine inj 20mg/ml
APRESOLINE
hydralazine tab 100mg
APRESOLINE
hydralazine tab 10mg
APRESOLINE
hydralazine tab 25mg
APRESOLINE
hydralazine tab 50mg
APRESOLINE
minoxidil tab 10mg
LONITEN
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Route
2142
2143
2144
2145
2146
2147
2148
2149
2150
2151
2152
2153
2154
2155
2156
2157
2158
2159
2160
2161
PA, QL (180 per 30 days)
PA, QL (90 per 30 days)
PA, QL (360 per 30 days)
PA, QL (4 per 28 days)
2162
2163
2164
2165
2166
QL (120 per 30 days)
2167
2168
2169
QL (30 per 30 days)
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2170
2171
2172
2173
2174
2175
2176
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
71
Formulary
Covered Drug Name
minoxidil tab 2.5mg
Alternate Drug Name
LONITEN
Vasodilators, Direct-acting Arterial/Venous
isosorb din tab 10mg
ISORDIL
isosorb din tab 20mg
ISORDIL
isosorb din tab 30mg
ISORDIL
isosorb din tab 40mg er
DILATRATE-SR
isosorb din tab 5mg
ISORDIL
isosorb mono tab 10mg
ISMO, MONOKET
isosorb mono tab 120mg er
IMDUR
isosorb mono tab 20mg
ISMO, MONOKET
isosorb mono tab 30mg er
IMDUR
isosorb mono tab 60mg er
IMDUR
NITRO-BID OIN 2%
nitroglycerin ointment
nitroglycer dis 0.1mg/hr
NITRO-DUR
nitroglycer dis 0.2mg/hr
NITRO-DUR
nitroglycer dis 0.4mg/hr
NITRO-DUR
NITROGLYCER INJ 5MG/ML
nitroglycerin
nitroglyceri dis 0.6mg/hr
NITRO-DUR
NITROMIST AER 400MCG
nitroglycerin mucosal spray
NITROSTAT SUB 0.3MG
nitroglycerin
NITROSTAT SUB 0.4MG
nitroglycerin
NITROSTAT SUB 0.6MG
nitroglycerin
Tier
Requirements/
Limits
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 3
Tier 3
Tier 3
Tier 3
Route
2177
2178
2179
2180
2181
2182
2183
2184
2185
2186
2187
2188
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
PA
QL (30 per 30 days)
2189
2190
2191
2192
2193
2194
2195
2196
2197
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
TD
TD
TD
TD
Inj
TD
TL
SL
SL
SL
CENTRAL NERVOUS SYSTEM AGENTS
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine tab 10mg
ADDERALL
Tier 2
amphetamine tab 12.5mg
ADDERALL
Tier 2
amphetamine tab 15mg
ADDERALL
Tier 2
amphetamine tab 20mg
ADDERALL
Tier 2
amphetamine tab 30mg
ADDERALL
Tier 2
amphetamine tab 5mg
ADDERALL
Tier 2
amphetamine tab 7.5mg
ADDERALL
Tier 2
dextroamphet tab 10mg
DEXEDRINE
Tier 2
dextroamphet tab 5mg
DEXEDRINE
Tier 2
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (180 per 30 days)
QL (90 per 30 days)
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
dexmethylph tab 10mg
FOCALIN
Tier 2
QL (90 per 30 days)
72
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2198
2199
2200
2201
2202
2203
2204
2205
2206
2207
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Requirements/
Limits
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
Central Nervous System, Other
NUEDEXTA CAP 20-10MG
dextromethorphan - quinidine sulfate
riluzole tab 50mg
RILUTEK
XENAZINE TAB 12.5MG
tetrabenazine
XENAZINE TAB 25MG
tetrabenazine
Tier 3
Tier 2
Tier 5
Tier 5
QL (60 per 30 days)
PA
PA, QL (240 per 30 days)
PA, QL (120 per 30 days)
Multiple Sclerosis Agents
AMPYRA TAB 10MG
AVONEX KIT 30MCG
AVONEX PEN KIT 30MCG
AVONEX PREFL KIT 30MCG
BETASERON INJ 0.3MG
COPAXONE KIT 20MG/ML
GILENYA CAP 0.5MG
REBIF INJ 22/0.5ML
REBIF INJ 44/0.5ML
REBIF TITRTN SOL PACK
TYSABRI INJ 300/15ML
Tier 5
Tier 5
Tier 5
Tier 5
Tier 3
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
PA
PA, QL (4 per 28 days)
PA, QL (4 per 28 days)
PA, QL (4 per 28 days)
QL (15 per 30 days)
PA, QL (30 per 30 days)
PA, QL (30 per 30 days)
PA, QL (12 per 30 days)
PA, QL (12 per 30 days)
PA, QL (6 per 30 days)
PA
dexmethylph tab 2.5mg
dexmethylph tab 5mg
metadate tab 20mg er
methylphenid tab 10mg
methylphenid tab 10mg er
methylphenid tab 18mg er
methylphenid tab 20mg
methylphenid tab 20mg er
methylphenid tab 27mg er
methylphenid tab 36mg er
methylphenid tab 54mg er
methylphenid tab 5mg
STRATTERA CAP 100MG
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
STRATTERA CAP 80MG
FOCALIN
FOCALIN
RITALIN SR
RITALIN
metadate
CONCERTA
RITALIN
CONCERTA
CONCERTA
CONCERTA
CONCERTA
RITALIN
atomoxetine
atomoxetine
atomoxetine
atomoxetine
atomoxetine
atomoxetine
atomoxetine
Tier
dalfampridine er
interferon beta-1a
interferon beta-1a
interferon beta-1a
interferon beta-1b
glatiramer
fingolimod
interferon beta-1a
interferon beta-1a
interferon beta-1a
natalizumab
Route
2208
2209
2210
2211
2212
2213
QL (90 per 30 days)
QL (90 per 30 days)
2214
2215
2216
2217
2218
QL (90 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2219
2220
2221
2222
2223
2224
2225
2226
2227
2228
2229
2230
2231
2232
2233
2234
2235
2236
2237
2238
2239
2240
2241
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Oral
Inj
Inj
Inj
Inj
73
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
Route
DENTAL AND ORAL AGENTS
Dental and Oral Agents
chlorhex glu sol 0.12%
doxycycline tab 20mg
KEPIVANCE INJ 6.25MG
periogard sol 0.12%
pilocarpine tab 5mg
pilocarpine tab 7.5mg
triamcin/ora pst 0.1%
PERIDEX ORAL RINSE
VIBRATAB
palifermin
PERIDEX ORAL RINSE
SALAGEN
SALAGEN
KENALOG-ORABORALONE
Tier 2
Tier 2
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
2242
2247
PA
2248
2249
2250
2251
2252
MT
Oral
Inj
MT
Oral
Oral
MT
DERMATOLOGICAL AGENTS
Dermatological Agents
8-MOP CAP 10MG
acitretin cap 10mg
acitretin cap 17.5mg
acitretin cap 25mg
adapalene cre 0.1%
adapalene gel 0.1%
adapalene gel 0.3%
ammonium lac cre 12%
ammonium lac lot 12%
amnesteem cap 10mg
amnesteem cap 20mg
amnesteem cap 40mg
CALCIPOTRIEN OIN 0.005%
claravis cap 10mg
claravis cap 20mg
claravis cap 30mg
claravis cap 40mg
clotrim/beta cre diprop
clotrim/beta lot diprop
diclofenac gel 3%
diclofenac sol 1.5%
ELIDEL CRE 1%
erythromycin gel /benzoyl
fluorouracil cre 5%
fluorouracil sol 2%
fluorouracil sol 5%
imiquimod cre 5%
74
methoxsalen
SORIATANE
SORIATANE
SORIATANE
DIFFERIN
DIFFERIN
DIFFERIN
LAC-HYDRIN
LAC-HYDRIN
isotretinoin
isotretinoin
isotretinoin
calcipotriene
isotretinoin
isotretinoin
isotretinoin
isotretinoin
LOTRISONE
LOTRISONE
SOLARAZE
diclofenac top sol
pimecrolimus
BENZAMYCIN
EFUDEX
EFUDEX
EFUDEX
ALDARA
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
PA
2253
2254
2255
2256
PA
PA
2257
2258
2259
2260
2261
2262
2263
2264
2265
2266
2267
2268
2269
2270
2271
QL (100 per 30 days)
2272
2273
PA, QL (30 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2274
2275
2276
2277
2278
2279
Oral
Oral
Oral
Oral
Top
Top
Top
Top
Top
Oral
Oral
Oral
Top
Oral
Oral
Oral
Oral
Top
Top
TD
TD
Top
Top
Top
Top
Top
Top
Formulary
Covered Drug Name
myorisan cap 10mg
myorisan cap 20mg
myorisan cap 40mg
ORACEA CAP 40MG
podofilox sol 0.5%
SANTYL OIN 250/GM
selenium sul lot 2.5%
TAZORAC CRE 0.05%
TAZORAC CRE 0.1%
TAZORAC GEL 0.05%
TAZORAC GEL 0.1%
tretinoin cre 0.025%
tretinoin cre 0.05%
tretinoin cre 0.1%
tretinoin gel 0.01%
tretinoin gel 0.025%
tretinoin gel 0.04%
tretinoin gel 0.1%
UVADEX INJ 20MCG/ML
VALCHLOR GEL 0.016%
zenatane cap 10mg
zenatane cap 20mg
zenatane cap 40mg
Alternate Drug Name
Tier
isotretinoin
isotretinoin
isotretinoin
doxycycline
CONDYLOX
collagenase
SELSUN
tazarotene
tazarotene
tazarotene
tazarotene
RETIN-A, AVITA
RETIN-A
RETIN-A
RETIN-A
RETIN-A, AVITA
RETIN-A
RETIN-A
methoxsalen
MECHLORETHAMINE
isotretinoin
isotretinoin
isotretinoin
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 4
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 5
Tier 2
Tier 2
Tier 2
isopropyl alcohol pad
GAUZE PADS AND DRESSING - 2X2
insulin syringe (disp) u-100
insulin syringe (disp) u-100
insulin syringe (disp) u-100
insulin syringe (disp) u-100
insulin pen needle
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Requirements/
Limits
Route
2280
2281
2282
2283
2284
QL (30 per 30 days)
2285
2286
2287
2288
2289
2290
QL (45 per 30 days)
QL (45 per 30 days)
QL (45 per 30 days)
QL (45 per 30 days)
QL (45 per 30 days)
2291
2292
2293
2294
2295
2296
2297
PA
2298
2299
2300
2301
2302
Oral
Oral
Oral
Oral
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Inj
Top
Oral
Oral
Oral
DIABETES SUPPLIES
Diabetes Supplies
ALCOHOL PREP PAD
GAUZE PAD 2X2
insulin syrg mis 0.3/31g
insulin syrg mis 0.5/30g
insulin syrg mis 1ml/29g
insulin syrg mis 1ml/31g
pen needles mis 29gx1/2
2303
2304
2305
2306
2307
2308
2309
Top
Top
Top
Top
Top
Top
Top
ENZYME REPLACEMENT/ MODIFIERS
Enzyme Replacement/Modifiers
ADAGEN INJ 250/ML
pegademase bovine
ALDURAZYME INJ 2.9MG/5ML
laronidase
CEREZYME INJ 400UNIT
imiglucerase
CYSTADANE POW
betaine (trimethylglycine)
Tier 5
Tier 5
Tier 5
Tier 5
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2310
2311
2312
2313
Inj
Inj
Inj
Oral
75
Formulary
Covered Drug Name
CYSTAGON CAP 150MG
CYSTAGON CAP 50MG
ELAPRASE INJ 6MG/3ML
FABRAZYME INJ 35MG
NAGLAZYME INJ 1MG/ML
VPRIV INJ 400UNIT
ZAVESCA CAP 100MG
Alternate Drug Name
cysteamine
cysteamine
idursulfase
agalsidase beta
galsulfase
velaglucerase alfa
miglustat
Tier
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Requirements/
Limits
Route
2314
2315
PA
PA
PA
PA
PA
2316
2317
2318
2319
2320
Oral
Oral
Inj
Inj
Inj
Inj
Oral
ENZYME REPLACEMENT/MODIFIERS
Enzyme Replacement/Modifiers
CREON CAP 12000UNT
amylases - endopeptidase - lipase
CREON CAP 24000UNT
amylases - endopeptidase - lipase
CREON CAP 6000UNIT
amylases - endopeptidase - lipase
MYOZYME INJ 50MG
alglucosidase
RAVICTI LIQ 1.1GM/ML
glycerol phenylbutyrate
ZENPEP CAP 10000UNT
amylases - endopeptidase - lipase
ZENPEP CAP 15000UNT
amylases - endopeptidase - lipase
ZENPEP CAP 20000UNT
amylases - endopeptidase - lipase
ZENPEP CAP 5000UNIT
amylases - endopeptidase - lipase
Tier 3
Tier 3
Tier 3
Tier 5
Tier 5
Tier 4
Tier 4
Tier 4
Tier 4
2321
2322
2323
PA
PA, QL (525 per 30 days)
2324
2325
2326
2327
2328
2329
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
ENZYME REPLACEMENTS/ MODIFIERS
Enzyme Replacement/Modifiers
KUVAN TAB 100MG
sapropterin
Tier 5
PA
2330
Oral
GASTROINTESTINAL AGENTS
76
Antispasmodics, Gastrointestinal
CANTIL TAB 25MG
mepenzolate
dicyclomine cap 10mg
BENTYL
dicyclomine sol 10mg/5ml
BENTYL
dicyclomine tab 20mg
BENTYL
glycopyrrol tab 1mg
ROBINUL
glycopyrrol tab 2mg
ROBINUL FORTE
methscopolam tab 2.5mg
PAMINE
methscopolam tab 5mg
PAMINE
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Gastrointestinal Agents
CREON CAP 3000UNIT
Tier 3
amylases - endopeptidase - lipase
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2331
2332
2333
2334
2335
2336
2337
2338
2339
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
CREON CAP 36000UNT
gavilyte-c sol
gavilyte-g sol
gavilyte-n sol flav pk
trilyte sol
ZENPEP CAP 25000UNT
ZENPEP CAP 3000UNIT
ZENPEP CAP 40000UNT
Alternate Drug Name
amylases - endopeptidase - lipase
COLYTE-FLAVR
GOLYTELY
TRILYTE, GAVILYTE-N
TRILYTE, GAVILYTE-N
amylases - endopeptidase - lipase
amylases - endopeptidase - lipase
amylases - endopeptidase - lipase
Tier
Requirements/
Limits
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Gastrointestinal Agents, Other
GATTEX KIT 5MG
teduglutide
GENOTROPIN INJ 12MG
somatropin
loperamide cap 2mg
IMODIUM
NUTROPIN AQ INJ NUSPIN 5
somatropin
RELISTOR KIT 12/0.6ML
methylnaltrexone
SEROSTIM INJ 4MG
somatropin
SEROSTIM INJ 5MG
somatropin
SEROSTIM INJ 6MG
somatropin
ursodiol cap 300mg
ACTIGALL
ursodiol tab 250mg
URSO 250
ursodiol tab 500mg
URSO FORTE
ZORBTIVE INJ 8.8MG
somatropin
Tier 5
Tier 5
Tier 2
Tier 5
Tier 4
Tier 5
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 5
Histamine2 (H2) Receptor Antagonists
cimetidine sol 300/5ml
TAGAMET
cimetidine tab 200mg
TAGAMET
cimetidine tab 300mg
TAGAMET
cimetidine tab 400mg
TAGAMET
cimetidine tab 800mg
TAGAMET
famotidine inj 10mg/ml
PEPCID I.V.
famotidine inj 20mg/50ml
PEPCID I.V.
famotidine sus 40mg/5ml
PEPCID
famotidine tab 20mg
PEPCID
famotidine tab 40mg
PEPCID
nizatidine cap 150mg
AXID
nizatidine cap 300mg
AXID
nizatidine sol 15mg/ml
AXID
ranitidine cap 150mg
ZANTAC
ranitidine cap 300mg
ZANTAC
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Route
2340
2341
2342
2343
2344
2345
2346
2347
PA
PA
2348
2349
2350
PA
PA
PA
PA
PA
2351
2352
2353
2354
2355
2356
2357
2358
PA
2359
2360
2361
2362
2363
2364
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2365
2369
2366
2367
2368
2370
2371
2372
2373
2374
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
77
Formulary
Covered Drug Name
ZANTAC
ZANTAC
ZANTAC
ZANTAC
Tier
Requirements/
Limits
Tier 4
Tier 2
Tier 2
Tier 2
PA
Irritable Bowel Syndrome Agents
AMITIZA CAP 24MCG
lubiprostone
AMITIZA CAP 8MCG
lubiprostone
LOTRONEX TAB 0.5MG
alosetron
LOTRONEX TAB 1MG
alosetron
Tier 4
Tier 4
Tier 3
Tier 5
QL (60 per 30 days)
QL (60 per 30 days)
PA, QL (60 per 30 days)
PA, QL (60 per 30 days)
Laxatives
constulose sol 10gm/15ml
enulose sol 10gm/15ml
generlac sol 10gm/15ml
lactulose sol 10gm/15ml
polyeth glyc pow 3350 nf
CONSTULOSE, CEPHULAC, ENULOSE
LACTULOSE
lactulose
CONSTULOSE, CEPHULAC, ENULOSE
MIRALAX
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Protectants
misoprostol tab 100mcg
misoprostol tab 200mcg
sucralfate tab 1gm
CYTOTEC
CYTOTEC
CARAFATE
Tier 2
Tier 2
Tier 2
Proton Pump Inhibitors
esomepra mag cap 20mg dr
esomeprazole inj 20mg
esomeprazole inj 40mg
lansoprazole cap 15mg dr
lansoprazole cap 30mg dr
omeprazole cap 10mg *
omeprazole cap 20mg *
omeprazole cap 40mg *
pantoprazole tab 20mg
pantoprazole tab 40mg
rabeprazole tab 20mg
NEXIUM
NEXIUM
NEXIUM
PREVACID
PREVACID
PRILOSEC
PRILOSEC
PRILOSEC
PROTONIX
PROTONIX
ACIPHEX
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
ranitidine inj 150/6ml
ranitidine syp 15mg/ml
ranitidine tab 150mg
ranitidine tab 300mg
78
Alternate Drug Name
Route
2375
2376
2377
2378
2379
2380
2381
2382
2383
2384
2385
2386
2387
2388
2389
2390
QL (60 per 30 days)
PA
PA
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2391
2392
2393
2394
2395
2396
2397
2398
2399
2400
2401
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
Route
GENITOURINARY AGENTS
Antispasmodics, Urinary
ENABLEX TAB 15MG
ENABLEX TAB 7.5MG
flavoxate tab 100mg
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
oxybutynin syp 5mg/5ml
oxybutynin tab 10mg er
oxybutynin tab 15mg er
oxybutynin tab 5mg
oxybutynin tab 5mg er
OXYTROL DIS 3.9MG/24HR
tolterodine cap 2mg er
tolterodine cap 4mg er
tolterodine tab 1mg
tolterodine tab 2mg
TOVIAZ TAB 4MG
TOVIAZ TAB 8MG
Tier 3
Tier 3
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
QL (30 per 30 days)
QL (30 per 30 days)
QL (600 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
QL (180 per 30 days)
QL (8 per 28 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
Benign Prostatic Hypertrophy Agents
alfuzosin tab 10mg
UROXATRAL
AVODART CAP 0.5MG
dutasteride
finasteride tab 5mg *
PROSCAR
tamsulosin cap 0.4mg *
FLOMAX
Tier 2
Tier 3
Tier 2
Tier 2
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
Genitourinary Agents, Other
bethanechol tab 10mg
bethanechol tab 25mg
bethanechol tab 50mg
bethanechol tab 5mg
CIALIS TAB 10MG **
CIALIS TAB 20MG **
DEPEN TITRA TAB 250MG
VIAGRA TAB 100MG **
VIAGRA TAB 25MG **
VIAGRA TAB 50MG **
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 5
Tier 4
Tier 4
Tier 4
darifenacin
darifenacin
URISPAS
mirabegron er
mirabegron er
DITROPAN
DITROPAN XL
DITROPAN XL
DITROPAN
DITROPAN XL
oxybutynin transdermal patch
DETROL LA
DETROL LA
DETROL
DETROL
fesoterodine
fesoterodine
URECHOLINE
URECHOLINE
URECHOLINE
URECHOLINE
taralafil
taralafil
penicillamine
sildenafil
sildenafil
sildenafil
QL (30 per 30 days)
QL (30 per 30 days)
2402
2403
2404
2405
2406
2407
2408
2409
2410
2411
2412
2413
2414
2415
2416
2417
2418
2419
2420
2421
2422
2423
2424
2425
2426
QL (6 per 30 days)
QL (6 per 30 days)
2427
2428
2429
QL (6 per 30 days)
QL (6 per 30 days)
QL (6 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2430
2431
2432
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
TD
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
79
Formulary
Covered Drug Name
Phosphate Binders
calc acetate cap 667mg
FOSRENOL CHW 1000MG
FOSRENOL CHW 500MG
FOSRENOL CHW 750MG
RENAGEL TAB 400MG
RENAGEL TAB 800MG
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
Alternate Drug Name
PHOSLO
lanthanum
lanthanum
lanthanum
sevelamer
sevelamer
sevelamer
sevelamer
sevelamer
Tier
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Requirements/
Limits
Route
2433
2434
2435
2436
2437
2438
QL (180 per 30 days)
QL (90 per 30 days)
QL (270 per 30 days)
2439
2440
2441
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
ala cort cre 1%
PROCTOCORT, ALA-CORT
Tier 2
alclometason cre 0.05%
ACLOVATE
Tier 2
alclometason oin 0.05%
ACLOVATE
Tier 2
amcinonide cre 0.1%
CYCLOCORT
Tier 2
amcinonide lot 0.1%
CYCLOCORT
Tier 2
amcinonide oin 0.1%
CYCLOCORT
Tier 2
aug betamet cre 0.05%
DIPROLENE
Tier 2
aug betamet gel 0.05%
DIPROLENE
Tier 2
aug betamet lot 0.05%
DIPROLENE
Tier 2
aug betamet oin 0.05%
DIPROLENE
Tier 2
betameth dip cre 0.05%
DEL-BETA
Tier 2
betameth dip lot 0.05%
DEL-BETA
Tier 2
betameth dip oin 0.05%
DEL-BETA
Tier 2
betameth val aer 0.12%
LUXIQ
Tier 2
betameth val cre 0.1%
BETA-VAL
Tier 2
betameth val lot 0.1%
BETA-VAL
Tier 2
betameth val oin 0.1%
BETA-VAL
Tier 2
budesonide cap 3mg/24hr
ENTOCORT EC
Tier 2
CAPEX SHA 0.01%
fluocinolone acetonide
Tier 4
colocort ene 100mg
COLOCORT
Tier 2
CORTISONE AC TAB 25MG
cortisone
Tier 2
desonide cre 0.05%
DESOWEN
Tier 2
desonide lot 0.05%
DESOWEN
Tier 2
desonide oin 0.05%
DESOWEN
Tier 2
desoximetas cre 0.05%
TOPICORT
Tier 2
desoximetas cre 0.25%
TOPICORT
Tier 2
80
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2442
2443
2444
2445
2446
2447
2448
2449
2450
2451
2452
2453
2454
2455
2456
2457
2458
2459
2460
2461
2462
2463
2464
2465
2466
2467
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Oral
Top
Rec
Oral
Top
Top
Top
Top
Top
Formulary
Covered Drug Name
desoximetas gel 0.05%
desoximetas oin 0.05%
desoximetas oin 0.25%
dexameth pho inj 10mg/ml
dexameth pho inj 120mg/30ml
dexamethason con 1mg/ml
dexamethason elx 0.5/5ml
dexamethason tab 0.5mg
dexamethason tab 0.75mg
dexamethason tab 1.5mg
dexamethason tab 1mg
dexamethason tab 2mg
dexamethason tab 4mg
dexamethason tab 6mg
diflorasone cre 0.05%
diflorasone oin 0.05%
fludrocort tab 0.1mg
fluocin acet cre 0.01%
fluocin acet cre 0.025%
fluocin acet oil 0.01%
fluocin acet oil body
fluocin acet oin 0.025%
fluocin acet sol 0.01%
fluocinonide cre -e 0.05%
fluocinonide cre 0.1%
fluocinonide gel 0.05%
fluocinonide oin 0.05%
fluocinonide sol 0.05%
fluticasone cre 0.05%
fluticasone lot 0.05%
fluticasone oin 0.005%
halobetasol cre 0.05%
halobetasol oin 0.05%
HALOG CRE 0.1%
HALOG OIN 0.1%
hc butyrate cre 0.1%
hc butyrate oin 0.1%
hc butyrate sol 0.1%
hc valerate cre 0.2%
hc valerate oin 0.2%
hydrocort cre 1%
hydrocort cre 2.5%
Alternate Drug Name
TOPICORT
TOPICORT
TOPICORT
DECADRON, DEXASONE
DECADRON, DEXASONE
BAYCADRON
BAYCADRON
DECADRON, DEXASONE
DECADRON, DEXASONE
DECADRON, DEXASONE
DECADRON, DEXASONE
DECADRON, DEXASONE
DECADRON, DEXASONE
DECADRON, DEXASONE
PSORCON
PSORCON
FLORINEF
SYNALAR
SYNALAR
DERMOTIC
DERMA-SMOOTH
SYNALAR
SYNALAR
LIDEX-E
LIDEX
LIDEX
LIDEX
LIDEX
CUTIVATE
CUTIVATE
CUTIVATE
ULTRAVATE
ULTRAVATE
halcinonide
halcinonide
LOCOID
LOCOID
LOCOID
hydrocortisone
hydrocortisone
PROCTOCORT, ALA-CORT
HYTONE
Tier
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
Route
2468
2469
2470
2471
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2472
2473
2474
2475
2476
2477
2478
2479
2480
2481
2482
2483
2484
2485
2486
2487
2488
2489
2490
2491
2492
2493
2494
2495
2496
2497
2498
2499
2500
2501
2502
2503
2504
2505
2506
2507
2508
2509
Top
Top
Top
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Top
Top
Oral
Top
Top
OT
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
Top
81
Formulary
Covered Drug Name
hydrocort ene 100mg
hydrocort lot 2.5%
hydrocort oin 1%
hydrocort oin 2.5%
hydrocort tab 10mg
hydrocort tab 20mg
hydrocort tab 5mg
lokara lot 0.05%
methylpr ace inj 40mg/ml
methylpr ace inj 80mg/ml
methylpr ss inj 125mg
methylpr ss inj 40mg
methylpred pak 4mg
methylpred tab 16mg
methylpred tab 32mg
methylpred tab 4mg
methylpred tab 8mg
mometasone cre 0.1%
mometasone oin 0.1%
mometasone sol 0.1%
pred sod pho sol 5mg/5ml
prednicarbat cre 0.1%
prednicarbat oin 0.1%
prednisolone sol 15mg/5ml
prednisone con 5mg/ml
prednisone sol 5mg/5ml
prednisone tab 10mg
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 20mg
prednisone tab 50mg
prednisone tab 5mg
procto-pak cre 1%
proctozone cre -hc 2.5%
triamcinolon cre 0.025%
triamcinolon cre 0.1%
triamcinolon cre 0.5%
triamcinolon lot 0.025%
triamcinolon lot 0.1%
triamcinolon oin 0.025%
triamcinolon oin 0.1%
triamcinolon oin 0.5%
82
Alternate Drug Name
COLOCORT
HYTONE
HYTONE
HYTONE
CORTEF
CORTEF
CORTEF
DESOWEN
DEPO-MEDROL
DEPO-MEDROL
SOLU-MEDROL
SOLU-MEDROL
MEDROL
MEDROL
MEDROL
MEDROL
MEDROL
ELOCON
ELOCON
ELOCON
ORAPRED
DERMATOP
DERMATOP
ORAPRED
prednisone
prednisone
prednisone
prednisone
prednisone
prednisone
prednisone
prednisone
PROCTO-PAK
hydrocortisone
triamcinolone
triamcinolone
triamcinolone
triamcinolone
triamcinolone
triamcinolone
triamcinolone
triamcinolone
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
Route
2510
2511
2512
2513
2514
2515
2516
2517
PA
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2518
2519
2520
2521
2522
2523
2524
2525
2526
2527
2528
2529
2530
2531
2532
2533
2534
2535
2536
2537
2538
2539
2540
2541
2542
2543
2544
2545
2546
2547
2548
2549
2550
2551
Rec
Top
Top
Top
Oral
Oral
Oral
Top
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Top
Top
Top
Oral
Top
Top
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Rec
Rec
Top
Top
Top
Top
Top
Top
Top
Top
Formulary
Covered Drug Name
triamcinolon spr 55mcg/ac
triderm cre 0.1%
Alternate Drug Name
NASACORT AQ
triamcinolone
Tier
Tier 2
Tier 2
Requirements/
Limits
QL (33 per 30 days)
Route
2552
2553
NS
Top
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin inj 4mcg/ml
DDAVP
Tier 4
desmopressin spr 0.01%
DDAVP
Tier 2
desmopressin tab 0.1mg
DDAVP
Tier 2
desmopressin tab 0.2mg
DDAVP
Tier 2
GENOTROPIN INJ 0.2MG
somatropin
Tier 4
GENOTROPIN INJ 0.4MG
somatropin
Tier 5
GENOTROPIN INJ 0.6MG
somatropin
Tier 5
GENOTROPIN INJ 0.8MG
somatropin
Tier 5
GENOTROPIN INJ 1.2MG
somatropin
Tier 5
GENOTROPIN INJ 1.4MG
somatropin
Tier 5
GENOTROPIN INJ 1.6MG
somatropin
Tier 5
GENOTROPIN INJ 1.8MG
somatropin
Tier 5
GENOTROPIN INJ 1MG
somatropin
Tier 5
GENOTROPIN INJ 2MG
somatropin
Tier 5
GENOTROPIN INJ 5MG
somatropin
Tier 5
HUMATROPE INJ 12MG
somatropin
Tier 5
HUMATROPE INJ 24MG
somatropin
Tier 5
HUMATROPE INJ 5MG
somatropin
Tier 5
HUMATROPE INJ 6MG
somatropin
Tier 5
INCRELEX INJ 40MG/4ML
mecasermin
Tier 5
NORDITROPIN INJ 10/1.5ML
somatropin
Tier 5
NORDITROPIN INJ 15/1.5ML
somatropin
Tier 5
NORDITROPIN INJ 5/1.5ML
somatropin
Tier 5
NUTROPIN AQ INJ 10MG/2ML
somatropin
Tier 5
NUTROPIN AQ INJ 20MG/2ML
somatropin
Tier 5
OMNITROPE INJ 10/1.5ML
somatropin
Tier 5
OMNITROPE INJ 5.8MG
somatropin
Tier 5
OMNITROPE INJ 5/1.5ML
somatropin
Tier 5
SAIZEN INJ 5MG
somatropin
Tier 5
SAIZEN INJ 8.8MG
somatropin
Tier 5
STIMATE SOL 1.5MG/ML
desmopressin
Tier 4
PA
2554
2555
2556
2557
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2558
2559
2560
2561
2562
2563
2564
2565
2566
2567
2568
2569
2570
2571
2572
2573
2574
2575
2576
2577
2578
2579
2580
2581
2582
2583
2584
Inj
NS
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
NS
83
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
Route
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING
(SEX HORMONES/MODIFIERS)
Androgens
ANDROGEL GEL 1.62%
ANDROGEL GEL 1.62%
ANDROGEL GEL PUMP 1.62%
AXIRON SOL 30MG/ACT
danazol cap 100mg
danazol cap 200mg
danazol cap 50mg
testost enan inj 200mg/ml
testosterone
testosterone
testosterone
testosterone
DANOCRINE
DANOCRINE
DANOCRINE
DELATESTRYL
Tier 3
Tier 3
Tier 3
Tier 3
Tier 2
Tier 2
Tier 2
Tier 4
QL (300 per 30 days)
QL (300 per 30 days)
QL (300 per 30 days)
Estrogens
ALORA DIS 0.025MG
ALORA DIS 0.05MG
ALORA DIS 0.075MG
ALORA DIS 0.1MG
estradiol tab 0.5mg
estradiol tab 1mg
estradiol tab 2mg
ESTRING MIS 2MG
estropipate tab 0.75mg
estropipate tab 1.5mg
estropipate tab 3mg
PREMARIN INJ 25MG
PREMARIN TAB 0.3MG
PREMARIN TAB 0.45MG
PREMARIN TAB 0.625MG
PREMARIN TAB 0.9MG
PREMARIN TAB 1.25MG
PREMARIN VAG CRE 0.625MG
estradiol transdermal patch
estradiol transdermal patch
estradiol transdermal patch
estradiol transdermal patch
ESTRACE
ESTRACE
ESTRACE
estradiol vag ring
OGEN
OGEN
OGEN
estrogens, conjugated
estrogens, conjugated
estrogens, conjugated
estrogens, conjugated
estrogens, conjugated
estrogens, conjugated
estrogens, conjugated
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 4
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
Tier 3
PA, QL (8 per 28 days)
PA, QL (8 per 28 days)
PA, QL (8 per 28 days)
PA, QL (8 per 28 days)
PA
PA
PA
QL (1 per 90 days)
PA
PA
PA
PA
2586
2587
2588
2589
2590
2591
PA
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
apri
ORTHO-CEPT
Tier 2
aranelle
LEENA, ARANELLE
Tier 2
aubra tab 0.1-0.02
ethinyl estradiol - levonorgestrel
Tier 2
aviane
ALESSE, AVIANE, LESSINA, LUTERA
Tier 2
84
2585
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2592
2593
2594
2595
2596
2597
2598
2599
2600
2601
2602
2603
2604
2605
2606
2607
2608
2609
2610
2611
2612
2613
2614
TD
TD
TD
TD
Oral
Oral
Oral
Inj
TD
TD
TD
TD
Oral
Oral
Oral
Vag
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Vag
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
balziva tab
briellyn tab
cryselle-28 tab
cyclafem tab 7/7/7
delyla tab 0.1-0.02
drospir/ethi tab 3-0.03mg
DUAVEE TAB 0.45-20MG
enpresse-28 tab
estra/noreth tab 0.5-0.1mg
estra/noreth tab 1-0.5mg
falmina tab
gildagia tab 0.4-35
gildess tab 1.5/30
introvale tab
JINTELI TAB 1MG-5MCG
junel 1.5/30
junel 1/20
junel fe 24 tab 1/20
junel fe tab 1.5/30
junel fe tab 1/20
kariva tab 28 day
kelnor tab 1/35
larin tab 1.5/30
lessina
levonor/ethi tab estradio
levora-28 tab 0.15/30
loryna tab 3-0.02mg
lutera
microgestin tab 1.5/30
microgestin tab 1/20
microgestin tab fe 1/20
microgestin tab fe1.5/30
necon tab 0.5/35
necon tab 1/35
NECON TAB 1/50-28
necon tab 10/11-28
nortrel tab 0.5/35
nortrel tab 1/35
nortrel tab 7/7/7
NUVARING MIS
OGESTREL TAB
Alternate Drug Name
OVCON-35
ethinyl estradiol - norethindrone
LO/OVRAL, CRYSELLE
ethinyl estradiol - norethindrone
ethinyl estradiol - levonorgestrel
drospirenone - ethinyl estradiol
bazedoxifene - estrogens, conjugated
ENPRESSE, TRIVORA, TRI-LEVEN
ACTIVELLA
ACTIVELLA
ethinyl estradiol - levonorgestrel
norethindrone
ethinyl estradiol - norethindrone
ethinyl estradiol - levonorgestrel
ethinyl estradiol - norethindrone
ethinyl estradiol - norethindrone
ethinyl estradiol - norethindrone
ethinyl estradiol,norethidrone and
ferrous fumarate
ethinyl estradiol - norethindrone
ethinyl estradiol - norethindrone
ORTHO-CEPT
DEMULEN, KELNOR, ZOVIA
ethinyl estradiol - norethindrone
ALESSE, AVIANE, LESSINA, LUTERA
ethinyl estradiol - levonorgestrel
PORTIA, LEVORA
drospirenone - ethinyl estradiol
ALESSE, AVIANE, LESSINA, LUTERA
ethinyl - norethindrone
ethinyl - norethindrone
ethinyl - norethindrone
ethinyl - norethindrone
ethinyl estradiol - norethindrone
ethinyl estradiol - norethindrone
mestranol - norethindrone
ethinyl estradiol - norethindrone
BREVICON, NORTREL, NECON
NORTREL, NECON
ORTHO-NOVUM, NORTREL, NECON
ethinyl estradiol - etonogestrel vag ring
ethinyl estradiol - norgestrel
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
Route
2615
2616
2617
2618
2619
2620
PA, QL (30 per 30 days)
2621
2622
PA
PA
2623
2624
2625
2626
2627
2628
PA
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 1
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2629
2630
2631
2632
2633
2634
2635
2636
2637
2638
2639
2640
2641
2642
2643
2644
2645
2646
2647
2648
2649
2650
2651
2652
2653
2654
2655
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Vag
Oral
85
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Tier 2
Tier 2
Tier 2
Tier 2
Tier 3
Tier 3
trivora-28
velivet pak
vestura tab 3-0.02mg
zovia 1/35e
zovia 1/50e
ethinyl estradiol - levonorgestrel
OXANDRIN
OXANDRIN
PORTIA, LEVORA
estradiol - norgestimate
estrogens, conjugatedmedroxyprogesterone
estrogens, conjugatedmedroxyprogesterone
estrogens, conjugatedmedroxyprogesterone
estrogens, conjugatedmedroxyprogesterone
estrogens, conjugatedmedroxyprogesterone
ORTHO-CYCLEN
SEASONALE
ORTHO-CEPT
ORTHO-CYCLEN, SPRINTEC, MONONESSA
ALESSE
ESTROSTEP
ORTHO TRI-CYCLEN LO, TRI-SPRINTEC,
TRINESSA, TRI-PREVIFEM
ORTHO TRI-CYCLEN LO, TRI-SPRINTEC,
TRINESSA, TRI-PREVIFEM
ENPRESSE, TRIVORA, TRI-LEVEN
CYCLESSA, VELIVET, CESIA
drospirenone - ethinyl estradiol
DEMULEN, KELNOR, ZOVIA
DEMULEN
Progestins
camila tab 0.35mg
DEPO-PROVERA INJ 400/ML
errin tab 0.35mg
medroxypr ac inj 150mg/ml
medroxypr ac tab 10mg
medroxypr ac tab 2.5mg
medroxypr ac tab 5mg
MEGACE ES SUS 625/5ML
megestrol ac sus 40mg/ml
megestrol ac tab 20mg
ORTHO MICRON
medroxyprogesterone suspension
ORTHO MICRONOR
DEPO-PROVERA
PROVERA
PROVERA
PROVERA
megestrol acetate
MEGACE
MEGACE
Tier 2
Tier 4
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 5
Tier 2
Tier 2
orsythia tab
oxandrolone tab 10mg
oxandrolone tab 2.5mg
portia-28
PREFEST TAB
PREMPHASE TAB
PREMPRO TAB .625-2.5MG
PREMPRO TAB 0.3-1.5MG
PREMPRO TAB 0.45-1.5MG
PREMPRO TAB 0.625-5MG
previfem tab
quasense
reclipsen tab
sprintec 28 tab
sronyx tab
tri-legest tab fe
tri-previfem
tri-sprintec
86
Requirements/
Limits
Route
2656
QL (60 per 30 days)
QL (120 per 30 days)
2657
2658
2659
PA
2660
2661
Tier 3
2662
Tier 3
2663
Tier 3
2664
Tier 3
2665
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
2666
2667
2668
2669
2670
2671
2672
Tier 2
2673
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
2674
2675
2676
2677
2678
2679
2680
2681
QL (1 per 90 days)
2682
2683
2684
2685
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2686
2687
2688
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
megestrol ac tab 40mg
norethin ace tab 5mg
Alternate Drug Name
MEGACE
AYGESTIN
Selective Estrogen Receptor Modifying Agents
raloxifene tab 60mg
EVISTA
Tier
Requirements/
Limits
Tier 2
Tier 2
Tier 2
Route
2689
2690
QL (30 per 30 days)
2691
Oral
Oral
Oral
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxin tab 100mcg
LEVOTHROID, SYNTHROID
Tier 2
levothyroxin tab 112mcg
LEVOTHROID, SYNTHROID
Tier 2
levothyroxin tab 125mcg
LEVOTHROID, SYNTHROID
Tier 2
levothyroxin tab 137mcg
LEVOTHROID, SYNTHROID
Tier 2
levothyroxin tab 150mcg
LEVOTHROID, SYNTHROID
Tier 2
levothyroxin tab 175mcg
LEVOTHROID, SYNTHROID
Tier 2
levothyroxin tab 200mcg
LEVOTHROID, SYNTHROID
Tier 2
levothyroxin tab 25mcg
LEVOTHROID, SYNTHROID
Tier 2
levothyroxin tab 300mcg
LEVOTHROID, SYNTHROID
Tier 2
levothyroxin tab 50mcg
LEVOTHROID, SYNTHROID
Tier 2
levothyroxin tab 75mcg
LEVOTHROID, SYNTHROID
Tier 2
levothyroxin tab 88mcg
LEVOTHROID, SYNTHROID
Tier 2
liothyronine tab 25mcg
CYTOMEL
Tier 2
liothyronine tab 50mcg
CYTOMEL
Tier 2
liothyronine tab 5mcg
CYTOMEL
Tier 2
SYNTHROID TAB 100MCG
levothyroxine
Tier 3
SYNTHROID TAB 112MCG
levothyroxine
Tier 3
SYNTHROID TAB 125MCG
levothyroxine
Tier 3
SYNTHROID TAB 137MCG
levothyroxine
Tier 3
SYNTHROID TAB 150MCG
levothyroxine
Tier 3
SYNTHROID TAB 175MCG
levothyroxine
Tier 3
SYNTHROID TAB 200MCG
levothyroxine
Tier 3
SYNTHROID TAB 25MCG
levothyroxine
Tier 3
SYNTHROID TAB 300MCG
levothyroxine
Tier 3
SYNTHROID TAB 50MCG
levothyroxine
Tier 3
SYNTHROID TAB 75MCG
levothyroxine
Tier 3
SYNTHROID TAB 88MCG
levothyroxine
Tier 3
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2692
2693
2694
2695
2696
2697
2698
2699
2700
2701
2702
2703
2704
2705
2706
2707
2708
2709
2710
2711
2712
2713
2714
2715
2716
2717
2718
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
87
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
Route
HORMONAL AGENTS, SUPPRESSANT (ADRENAL)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN TAB 500MG
mitotane
Tier 3
2719
Oral
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TAB 30MG
cinacalcet
SENSIPAR TAB 60MG
cinacalcet
SENSIPAR TAB 90MG
cinacalcet
Tier 4
Tier 3
Tier 3
QL (60 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
2720
2721
2722
Oral
Oral
Oral
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
Hormonal Agents, Suppressant (Pituitary)
cabergoline tab 0.5mg
DOSTINEX
FIRMAGON INJ 120MG
degarelix
FIRMAGON INJ 80MG
degarelix
leuprolide inj 1mg/0.2ml
LUPRON SC
LUPR DEP-PED INJ 11.25MG
leuprolide acetate
LUPR DEP-PED INJ 15MG
leuprolide dep ped
LUPRON DEPOT INJ 11.25MG
leuprolide dep ped
LUPRON DEPOT INJ 22.5MG
leuprolide depot
LUPRON DEPOT INJ 3.75MG
leuprolide acetate
LUPRON DEPOT INJ 30MG
leuprolide depot
LUPRON DEPOT INJ 45MG
leuprolide depot
LUPRON DEPOT INJ 7.5MG
leuprolide depot
octreotide inj 1000mcg
SANDOSTATIN
octreotide inj 100mcg
SANDOSTATIN
octreotide inj 200mcg
SANDOSTATIN
octreotide inj 500mcg
SANDOSTATIN
octreotide inj 50mcg/ml
SANDOSTATIN
SANDOSTATIN KIT LAR 10MG
octreotide
SANDOSTATIN KIT LAR 20MG
octreotide
SANDOSTATIN KIT LAR 30MG
octreotide
SIGNIFOR INJ 0.3MG/ML
pasireotide
SIGNIFOR INJ 0.6MG/ML
pasireotide
SIGNIFOR INJ 0.9MG/ML
pasireotide
SOMATULINE INJ 120/.5ML
lanreotide
SOMATULINE INJ 60/0.2ML
lanreotide
SOMATULINE INJ 90/0.3ML
lanreotide
88
Tier 2
Tier 5
Tier 4
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
2723
PA
PA
PA
PA
PA
PA
PA
PA, QL (1 per 28 days)
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2724
2725
2726
2727
2728
2729
2730
2731
2732
2733
2734
2735
2736
2737
2738
2739
2740
2741
2742
2743
2744
2745
2746
2747
2748
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Formulary
Covered Drug Name
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
SOMAVERT INJ 25MG
SOMAVERT INJ 30MG
SYNAREL SOL 2MG/ML
TRELSTAR DEP INJ 3.75MG
TRELSTAR LA INJ 11.25MG
TRELSTAR MIX INJ 22.5MG
Alternate Drug Name
pegvisomant
pegvisomant
pegvisomant
pegvisomant
pegvisomant
nafarelin
triptorelin
triptorelin
triptorelin
Tier
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Requirements/
Limits
PA
PA
PA
PA
PA
PA
Route
2749
2750
2751
2752
2753
2754
2755
2756
QL (1 per 168 days)
2757
Inj
Inj
Inj
Inj
Inj
NS
Inj
Inj
Inj
HORMONAL AGENTS, SUPPRESSANT (THYROID)
Antithyroid Agents
methimazole tab 10mg
methimazole tab 5mg
propylthiour tab 50mg
TAPAZOLE
TAPAZOLE
propylthiouracil
Tier 2
Tier 2
Tier 2
2758
2759
2760
Oral
Oral
Oral
IMMUNOLOGICAL AGENTS
Angioedema (HAE) Agents
CINRYZE SOL 500 UNIT
FIRAZYR INJ 30MG/3ML
c1 inhibitor (human)
icatibant
Tier 5
Tier 5
PA
PA, QL (9 per 30 days)
Immune Suppressants
ASTAGRAF XL CAP 0.5MG
ASTAGRAF XL CAP 1MG
ASTAGRAF XL CAP 5MG
AZASAN TAB 100MG
AZASAN TAB 75 MG
azathioprine tab 50mg
CELLCEPT CAP 250MG
CELLCEPT IV INJ 500MG
CELLCEPT SUS 200MG/ML
CELLCEPT TAB 500MG
cyclosporine cap 100mg
cyclosporine cap 100mg md
cyclosporine cap 25mg
cyclosporine cap 25mg mod
cyclosporine cap 50mg mod
cyclosporine inj 50mg/ml
tacrolimus er
tacrolimus er
tacrolimus er
azathioprine
azathioprine
IMURAN
mycophenolate
mycophenolate
mycophenolate
mycophenolate
SANDIMMUNE
NEORAL
SANDIMMUNE
NEORAL
NEORAL
SANDIMMUNE
Tier 4
Tier 4
Tier 5
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2761
2762
2763
2764
2765
2766
2767
2768
2769
2770
2771
2772
2773
2774
2775
2776
2777
2778
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
89
Formulary
Covered Drug Name
cyclosporine sol modified
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
ENBREL SRCLK 50MG/ML
gengraf cap 100mg
gengraf cap 25mg
gengraf sol 100mg/ml
HUMIRA INJ 10MG/0.2ML
HUMIRA KIT 20MG/0.4ML
HUMIRA KIT 40MG/0.8ML
HUMIRA PEN KIT CROHNS
KINERET INJ
methotrexate inj 1gm
methotrexate inj 25mg/ml
methotrexate tab 2.5mg
mycophenolat cap 250mg
mycophenolat sus 200mg/ml
mycophenolat tab 500mg
mycophenolic tab 180mg dr
mycophenolic tab 360mg dr
ORENCIA INJ 125MG/ML
ORENCIA INJ 250MG
PROGRAF INJ 5MG/ML
RAPAMUNE SOL 1MG/ML
REMICADE INJ 100MG
RHEUMATREX TAB 2.5MG
SANDIMMUNE SOL 100MG/ML
SIMPONI INJ 50MG
sirolimus tab 0.5mg
sirolimus tab 1mg
sirolimus tab 2mg
tacrolimus cap 0.5mg
tacrolimus cap 1mg
tacrolimus cap 5mg
TREXALL TAB 10MG
TREXALL TAB 15MG
TREXALL TAB 5MG
TREXALL TAB 7.5MG
XELJANZ TAB 5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.5MG
90
Alternate Drug Name
NEORAL
etanercept
etanercept
etanercept
etanercept
NEORAL
NEORAL
NEORAL
adalimumab
adalimumab
adalimumab
adalimumab penfill
anakinra
TREXALL
TREXALL
TREXALL
CELLCEPT
CELLCEPT
CELLCEPT
CELLCEPT
CELLCEPT
abatacept
abatacept
tacrolimus
sirolimus
infliximab
methotrexate
cyclosporine
golimumab
RAPAMUNE
RAPAMUNE
RAPAMUNE
PROGRAF
PROGRAF
PROGRAF
methotrexate
methotrexate
methotrexate
methotrexate
tofacitinib
everolimus
everolimus
Tier
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 4
Tier 4
Tier 2
Tier 2
Tier 5
Tier 2
Tier 2
Tier 5
Tier 5
Tier 5
Tier 4
Tier 5
Tier 5
Tier 4
Tier 4
Tier 5
Tier 2
Tier 2
Tier 5
Tier 2
Tier 2
Tier 5
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 4
Tier 5
Requirements/
Limits
PA
PA, QL (8 per 28 days)
PA, QL (16 per 28 days)
PA, QL (8 per 28 days)
PA, QL (8 per 28 days)
PA
PA
PA
PA, QL (6 per 28 days)
PA, QL (8 per 28 days)
PA, QL (8 per 28 days)
PA, QL (8 per 28 days)
PA, QL (28 per 28 days)
PA
PA
Route
2779
2780
2781
2782
2783
2784
2785
2786
2787
2788
2789
2790
2791
2792
2793
2794
PA
PA
PA
PA
PA
PA, QL (4 per 28 days)
PA
PA
PA
PA
2795
2796
2797
2798
2799
2800
2801
2802
2803
2804
2805
PA
PA, QL (1 per 28 days)
PA
PA
PA
PA
PA
PA
2806
2807
2808
2809
2810
2811
2812
2813
2814
2815
2816
2817
2818
PA, QL (60 per 30 days)
PA, QL (60 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2819
2820
Oral
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Oral
Inj
Oral
Oral
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
ZORTRESS TAB 0.75MG
everolimus
Tier 5
PA, QL (60 per 30 days)
Immunizing Agents, Passive
CARIMUNE NF INJ 3GM
GAMASTAN S/D INJ
GAMMAGARD INJ 2.5GM/25ML
THYMOGLOBULN INJ 25MG
globulin, immune
immune globulin (human)
globulin, immune
rabbit anti-human t-lymphocyte globulin
Tier 5
Tier 3
Tier 5
Tier 5
PA
PA
PA
PA
Immunological Agents
NULOJIX INJ 250MG
SIMULECT INJ 20MG
SYNAGIS INJ 50MG
belatacept
basiliximab
palivizumab
Tier 5
Tier 5
Tier 5
PA
PA
PA
Immunomodulators
ACTIMMUNE INJ 2MU/0.5ML
ARCALYST INJ 220MG
BENLYSTA INJ 120MG
ILARIS INJ 180MG
leflunomide tab 10mg
leflunomide tab 20mg
RIDAURA CAP 3MG
interferon gamma-1b
rilonacept
belimumab
canakinumab
ARAVA
ARAVA
auranofin
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 2
Tier 5
PA
PA
PA
PA
QL (30 per 30 days)
QL (30 per 30 days)
haemophilus b conjugate vaccine
bordetella pertussis filamentous
hemagglutinin vaccine
bcg, live, tice strain 50 mg/ml injectable
suspension
boostrix
human papillomavirus
haemophilus b polysaccharide conj vacc
- hepatitis
bordetella pertussis
hepatitis b virus vaccine
hepatitis b virus vaccine
uman papillomavirus - quadrivalent hpv
(6,11,16,18) vac
Tier 4
Tier 4
Vaccines
ACTHIB INJ
ADACEL INJ
BCG VACCINE INJ
BOOSTRIX INJ
CERVARIX INJ
COMVAX INJ
DAPTACEL INJ
ENGERIX-B INJ 10/0.5ML
ENGERIX-B INJ 20MCG/ML
GARDASIL 9 INJ
2821
2822
2823
2824
2825
2826
2827
2828
2829
2830
2831
2832
2833
2834
2835
2836
2837
Tier 4
2838
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Route
2839
2840
2841
2842
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2843
2844
2845
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
91
Formulary
Covered Drug Name
GARDASIL 9 INJ
GARDASIL INJ
HAVRIX INJ 1440UNIT
HAVRIX INJ 720UNIT
IMOVAX RABIE INJ 2.5/ML
INFANRIX INJ
IPOL INJ INACTIVE
IPOL INJ INACTIVE
IXIARO INJ
M-M-R II INJ LIVE
MENACTRA INJ
MENOMUNE INJ A/C/Y/W
MENVEO INJ
PEDVAX HIB INJ
PROQUAD INJ
RABAVERT INJ
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA HB INJ 5MCG/0.5ML
RECOMBIVA-HB INJ 40MCG/ML
ROTARIX SUS
ROTATEQ SOL
TET/DIP TOX INJ 2-2 LF
TRUMENBA INJ
TWINRIX INJ
TYPHIM VI INJ
VAQTA INJ 25/0.5ML
VAQTA INJ 50UNT/ML
VARIVAX INJ
VARIZIG 125 UNIT
YF-VAX INJ
ZOSTAVAX INJ
92
Alternate Drug Name
Tier
Requirements/
Limits
uman papillomavirus - quadrivalent hpv
(6,11,16,18) vac
uman papillomavirus - quadrivalent hpv
(6,11,16,18) vac
hepatitis a virus vaccine
hepatitis a virus vaccine
rabies vaccine human diploid cell
diphtheria - tetanus toxoids - acellular
pertussis
poliovirus vaccine
poliovirus vaccine
japanese encephalitis virus vaccine
measles virus - mumps virus vaccine
meningococcal polysaccharide vac a-c-y-w
meningococcal polysaccharide vac a-c-y-w
meninggococcal oligosaccharide
conjugate vaccine
haemophilus b polysaccharide conj
vaccine
measles virus vaccine - mumps virus
vaccine - rubella virus vaccine varicella-zoster virus vaccine
rabies virus vaccine
hepatitis b virus vaccine
hepatitis b virus vaccine
hepatitis b virus vaccine
rotavirus vaccine
rotavirus vaccine
diphtheria toxoid - tetanus toxoid
neisseria meningitidis serogroup b
recombinant
hepatitis a - hepatitis b virus vaccine
typhoid vi polysaccharide vaccine
hepatitis a virus vaccine
hepatitis a virus vaccine
varicella virus vaccine
varicella zoster immune globulin
yellow fever vaccine
varicella-zoster virus vaccine
Tier 4
PA
Tier 4
PA
Tier 4
Tier 4
Tier 4
Tier 4
2846
2847
2848
2849
2850
2851
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
2852
2853
2854
2855
2856
2857
2858
Tier 4
2859
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Route
2860
2861
PA
PA
PA
2862
2863
2864
2865
2866
PA
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 3
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2867
2868
2869
2870
2871
2872
2873
2874
2875
2876
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
Route
INFLAMMATORY BOWEL DISEASE AGENTS
Aminosalicylates
balsalazide cap 750mg
CANASA SUP 1000MG
DELZICOL CAP 400MG
DIPENTUM CAP 250MG
mesalamine kit 4gm
PENTASA CAP 250MG CR
PENTASA CAP 500MG CR
COLAZAL
mesalamine (5-asa)
mesalamine ec
olsalazine
ROWASA
mesalamine (5-asa)
mesalamine (5-asa)
Tier 2
Tier 5
Tier 4
Tier 5
Tier 2
Tier 4
Tier 5
Sulfonamides
sulfasalazin tab 500mg
sulfazine ec tab 500mg
AZULFIDINE
AZULFIDINE
Tier 2
Tier 2
2877
2878
2879
2880
2881
2882
2883
2884
2885
Oral
Rec
Oral
Oral
Rec
Oral
Oral
Oral
Oral
METABOLIC BONE DISEASE AGENTS
Metabolic Bone Disease Agents
alendronate sol 70/75ml
FOSAMAX
alendronate tab 10mg *
FOSAMAX
alendronate tab 35mg *
FOSAMAX
alendronate tab 40mg *
FOSAMAX
alendronate tab 5mg *
FOSAMAX
alendronate tab 70mg *
FOSAMAX
calcitonin spr 200/act
MIACALCIN
calcitriol cap 0.25mcg
ROCALTROL
calcitriol cap 0.5mcg
ROCALTROL
calcitriol inj 1mcg/ml
CALCIJEX
calcitriol sol 1mcg/ml
ROCALTROL
etidron disd tab 200mg
DIDRONEL
etidron disd tab 400mg
DIDRONEL
FORTEO SOL 600/2.4ML
teriparatide
FORTICAL SPR 200/ACT
calcitonin, salmon
ibandronate inj 3mg/3ml
BONIVA
ibandronate tab 150mg
BONIVA
MIACALCIN INJ 200/ML
salmon calcitonin
NATPARA INJ 100MCG
parathyroid hormone
NATPARA INJ 25MCG
parathyroid hormone
NATPARA INJ 50MCG
parathyroid hormone
NATPARA INJ 75MCG
parathyroid hormone
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 5
Tier 4
Tier 4
Tier 2
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
2886
QL (120 per 30 days)
QL (5 per 30 days)
QL (30 per 30 days)
QL (240 per 30 days)
QL (5 per 30 days)
2887
2888
2889
2890
2891
2892
2893
2894
PA
2895
2896
2897
2898
PA, QL (3 per 28 days)
2899
2900
PA
QL (1 per 28 days)
PA
PA, QL (2 per 28 days)
PA, QL (2 per 28 days)
PA, QL (2 per 28 days)
PA, QL (2 per 28 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2901
2902
2903
2904
2905
2906
2907
Oral
Oral
Oral
Oral
Oral
Oral
NS
Oral
Oral
Inj
Oral
Oral
Oral
Inj
NS
Inj
Oral
Inj
Inj
Inj
Inj
Inj
93
Formulary
Covered Drug Name
Alternate Drug Name
Tier
AREDIA
AREDIA
AREDIA
denosumab
ACTONEL
denosumab
paricalcitol
paricalcitol
ZOMETA
RECLAST
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 5
Tier 4
Tier 4
Tier 2
Tier 2
Ophthalmic Agents
bacit/polymy oin
BLEPHAMIDE OIN S.O.P.
BLEPHAMIDE SUS
dorzol/timol sol 2-0.5%
neo/bac/poly oin
neo/poly/bac oin /hc 1%
neo/poly/dex oin 0.1%
neo/poly/dex sus 0.1%
neo/poly/gra sol
neo/poly/hc sus
polymyxin b/ sol trimethp
PRED-G S.O.P OIN
PRED-G SUS
proparacaine sol 0.5%
sulf/pred na sol
tobra/dexame sus 0.3-0.1%
POLYSPORIN
prednisolone - sulfacetamide
prednisolone - sulfacetamide
COSOPT
TRIPLE ANTIBIOTIC
CORTISPORIN
MAXITROL
MAXITROL
NEOSPORIN
CORTISPORIN
POLYTRIM
gentamicin - prednisolone
gentamicin - prednisolone
ALCAINE
BLEPHAMIDE
TOBRADEX
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Ophthalmic Agents, Other
NAPHAZOLINE SOL 0.1%
RESTASIS EMU 0.05%
naphazoline
cyclosporine
Tier 2
Tier 4
Ophthalmic Anti-allergy Agents
ALOCRIL SOL 2%
nedocromil
ALOMIDE SOL 0.1%
lodoxamide
azelastine dro 0.05%
OPTIVAR
Tier 4
Tier 4
Tier 2
pamidronate inj 30/10ml
pamidronate inj 6mg/ml
pamidronate inj 90/10ml
PROLIA SOL 60MG/ML
risedronate tab 150mg
XGEVA INJ
ZEMPLAR INJ 2MCG/ML
ZEMPLAR INJ 5MCG/ML
zoledronic inj 4mg/5ml
zoledronic inj 5/100ml
Requirements/
Limits
PA
PA
PA
PA, QL (2 per 365 days)
Route
2908
2909
2910
2911
2912
PA, QL (1.7 per 28 days)
PA
PA
PA
PA
2913
2914
2915
2916
2917
Inj
Inj
Inj
Inj
Oral
Inj
Inj
Inj
Inj
Inj
OPHTHALMIC AGENTS
94
2918
2919
2920
2921
2922
2923
2924
2925
2926
2927
2928
2929
2930
2931
2932
2933
2934
QL (60 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2935
2936
2937
2938
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
Formulary
Covered Drug Name
cromolyn sod sol 4%
PATANOL SOL 0.1%
Alternate Drug Name
CROLOM
olopatadine
Tier
Requirements/
Limits
Tier 2
Tier 4
Ophthalmic Anti-inflammatories
ALREX SUS 0.2%
loteprednol etabonate
bromfenac sol 0.09%
XIBROM
dexameth pho sol 0.1%
DEXASOL
diclofenac sol 0.1%
VOLTAREN
DUREZOL EMU 0.05%
difluprednate
FLAREX SUS 0.1%
fluorometholone
flurbiprofen sol 0.03%
OCUFEN
FML FORTE SUS 0.25%
fluorometholone
FML OIN 0.1%
fluorometholone
ketorolac sol 0.4%
KETOROLAC
ketorolac sol 0.5%
KETOROLAC
MAXIDEX SUS 0.1%
dexamethasone
NEVANAC SUS 0.1%
nepafenac
PRED MILD SUS 0.12%
prednisolone
pred sod pho sol 1%
INFLAMASE
VEXOL SUS 1%
rimexolone
Tier 4
Tier 2
Tier 1
Tier 2
Tier 4
Tier 4
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
Tier 2
Tier 4
Ophthalmic Antiglaucoma Agents
apraclonidin sol 0.5%
IOPIDINE
AZOPT SUS 1%
brinzolamide
betaxolol sol 0.5%
BETAXOLOL
BETOPTIC-S SUS 0.25%
betaxolol
brimonidine sol 0.15%
ALPHAGAN
brimonidine sol 0.2%
ALPHAGAN
carteolol sol 1%
OCUPRESS
dorzolamide sol 2%
TRUSOPT
IOPIDINE SOL 1%
apraclonidine
levobunolol sol 0.5%
BETAGAN
metipranolol sol 0.3%
OPTIPRANOLOL
PHOSPHOLINE SOL 0.125%
phospholine
timolol gel sol 0.25%
TIMOPTIC-XE
timolol gel sol 0.5%
TIMOPTIC-XE
timolol mal sol 0.25%
TIMOPTIC
timolol mal sol 0.5%
TIMOPTIC
Tier 2
Tier 4
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
Route
2939
2940
2941
2942
2943
2944
2945
2946
2947
2948
2949
2950
2951
2952
2953
2954
2955
2956
2957
2958
2959
2960
2961
2962
2963
2964
2965
2966
2967
2968
2969
2970
2971
2972
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
OP
95
Formulary
Covered Drug Name
Alternate Drug Name
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost sol 0.005% *
XALATAN
LUMIGAN SOL 0.01%
bimatoprost
Tier
Requirements/
Limits
Tier 2
Tier 4
QL (5 per 30 days)
QL (7.5 per 30 days)
Route
2973
2974
OP
OP
OTIC AGENTS
Otic Agents
acetasol hc sol
CIPRO HC SUS
CIPRODEX SUS 0.3-0.1%
hc/acet acid sol
neo/poly/hc sol 1%
neo/poly/hc sus 1%
ACETASOL HC, VOSOL HC
ciprofloxacin hc
ciprofloxacin
ACETASOL HC, VOSOL HC
CORTISPORIN
CORTISPORIN
Tier 2
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
2975
2976
2977
2978
2979
2980
OT
OT
OT
OT
OT
OT
RESPIRATORY TRACT/PULMONARY AGENTS
96
Anti-inflammatories, Inhaled Corticosteroids
ASMANEX 120 AER 220MCG
mometasone furoate
ASMANEX 30 AER 110MCG
mometasone furoate
ASMANEX 30 AER 220MCG
mometasone furoate
ASMANEX 60 AER 220MCG
mometasone furoate
BECONASE AQ SUS 0.042%
beclomethasone dipropionate
FLOVENT DISK AER 100MCG
fluticasone
FLOVENT DISK AER 250MCG
fluticasone
FLOVENT DISK AER 50MCG
fluticasone
FLOVENT HFA AER 110MCG
fluticasone
FLOVENT HFA AER 220MCG
fluticasone
FLOVENT HFA AER 44MCG
fluticasone
flunisolide spr 0.025%
NASALIDE
fluticasone spr 50mcg *
FLONASE
PULMICORT INH 180MCG
budesonide
PULMICORT INH 90MCG
budesonide
PULMICORT SUS 1MG/2ML
budesonide
QVAR AER 40MCG
beclomethasone
VERAMYST SPR 27.5MCG
fluticasone furoate
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 1
Tier 3
Tier 3
Tier 3
Tier 4
Tier 3
QL (2 per 30 days)
QL (2 per 30 days)
QL (2 per 30 days)
QL (2 per 30 days)
QL (50 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
QL (24 per 30 days)
QL (24 per 30 days)
QL (21.2 per 30 days)
QL (50 per 30 days)
QL (16 per 30 days)
QL (2 per 30 days)
QL (2 per 30 days)
Antihistamines
azelastine spr 0.1%
Tier 2
QL (30 per 30 days)
ASTELIN
2981
2982
2983
2984
2985
2986
2987
2988
2989
2990
2991
2992
2993
2994
2995
2996
QL (34.8 per 30 days)
QL (20 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
2997
2998
2999
Inh
Inh
Inh
Inh
NS
Inh
Inh
Inh
Inh
Inh
Inh
NS
NS
Inh
Inh
Inh
Inh
NS
NS
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
azelastine spr 0.15%
carbinoxamin sol 4mg/5ml
carbinoxamin tab 4mg
cetirizine syp 5mg/5ml
clemastine tab 2.68mg
cyproheptad syp 2mg/5ml
cyproheptad tab 4mg
levocetirizi sol 2.5/5ml
levocetirizi tab 5mg
ASTEPRO
PALGIC
PALGIC
ZYRTEC
TAVIST
PERIACTIN
PERIACTIN
XYZAL
XYZAL
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
QL (30 per 30 days)
Antileukotrienes
montelukast chw 4mg
montelukast chw 5mg
montelukast gra 4mg
montelukast tab 10mg
zafirlukast tab 10mg
zafirlukast tab 20mg
ZYFLO CR TAB 600MG
ZYFLO TAB 600MG
SINGULAIR
SINGULAIR
SINGULAIR
SINGULAIR
ACCOLATE
ACCOLATE
zileuton er
zileuton
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 5
Tier 5
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
QL (120 per 30 days)
Bronchodilators, Anticholinergic
ATROVENT HFA AER 17MCG
ipratropium
ipratropium spr 0.03%
IPRATROPIUM
ipratropium spr 0.06%
IPRATROPIUM
SPIRIVA CAP HANDIHLR
tiotropium
Tier 4
Tier 2
Tier 2
Tier 3
QL (25.8 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
Bronchodilators, Sympathomimetic
albuterol neb 0.083%
VENTOLIN NEB
albuterol neb 0.5%
VENTOLIN NEB
albuterol neb 0.63mg/3ml
ACCUNEB
albuterol neb 1.25mg/3ml
ACCUNEB
albuterol syp 2mg/5ml
PROVENTIL - VENTOLIN
albuterol tab 2mg
PROVENTIL - VENTOLIN
albuterol tab 4mg
PROVENTIL - VENTOLIN
albuterol tab 4mg er
VOSPIRE ER
albuterol tab 8mg er
VOSPIRE ER
ARCAPTA CAP 75MCG
indacaterol
EPIPEN 2-PAK INJ 0.3MG
epinephrine
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 2
Tier 3
Tier 4
PA, QL (360 per 30 days)
PA, QL (60 per 30 days)
PA, QL (360 per 30 days)
PA, QL (360 per 30 days)
Route
3000
PA
PA
3001
3002
3003
PA
PA
PA
3004
3005
3006
3007
3008
3009
3010
3011
3012
3013
3014
3015
3016
3017
3018
3019
3020
3021
3022
3023
3024
3025
3026
3027
3028
3029
QL (30 per 30 days)
QL (1 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
3030
3031
NS
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inh
NS
NS
Inh
Inh
Inh
Inh
Inh
Oral
Oral
Oral
Oral
Oral
Inh
Inj
97
Formulary
Covered Drug Name
Alternate Drug Name
EPIPEN-JR INJ 2-PAK
FORADIL CAP AEROLIZE
metaproteren syp 10mg/5ml
METAPROTEREN TAB 10MG
METAPROTEREN TAB 20MG
PROAIR HFA AER
PROVENTIL AER HFA
SEREVENT DIS AER 50MCG
terbutaline inj 1mg/ml
terbutaline tab 2.5mg
terbutaline tab 5mg
VENTOLIN HFA AER
VOSPIRE ER TAB 4MG
VOSPIRE ER TAB 8MG
epinephrine
formoterol fumarate
METAPROTERENOL
metaproterenol sulfate
metaproterenol sulfate
albuterol
albuterol
salmeterol
BRETHINE
BRETHINE
BRETHINE
albuterol
albuterol
albuterol
Tier 4
Tier 4
Tier 2
Tier 2
Tier 2
Tier 4
Tier 4
Tier 3
Tier 4
Tier 2
Tier 2
Tier 4
Tier 2
Tier 2
Cystic Fibrosis Agents
CAYSTON INH 75MG
KALYDECO PAK 50MG
KALYDECO PAK 75MG
KALYDECO TAB 150MG
TOBI PODHALR CAP 28MG
aztreonam
ivacaftor
ivacaftor
ivacaftor
tobramycin inhalant powder
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Mast Cell Stabilizers
cromolyn sod con 100/5ml
cromolyn sod neb 20mg/2ml
GASTROCROM
INTAL
Tier 2
Tier 2
Phosphodiesterase Inhibitors, Airways Disease
DALIRESP TAB 500MCG
roflumilast
theophylline tab 100mg cr
THEO-DUR
theophylline tab 200mg cr
THEOCHRON SR
theophylline tab 300mg er
THEOCHRON SR
theophylline tab 400mg er
THEO-DUR
theophylline tab 450mg er
THEO-DUR
theophylline tab 600mg er
THEO-DUR
98
Tier
Tier 4
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Requirements/
Limits
QL (1 per 30 days)
QL (60 per 30 days)
Route
3032
3033
3034
3035
3036
QL (17 per 30 days)
QL (13.4 per 30 days)
QL (60 per 30 days)
PA
3037
3038
3039
3040
3041
3042
QL (36 per 30 days)
3043
3044
3045
3046
PA, QL (60 per 30 days)
PA, QL (60 per 30 days)
PA, QL (60 per 30 days)
3047
3048
3049
3050
3051
PA, QL (240 per 30 days)
QL (30 per 30 days)
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
3052
3053
3054
3055
3056
3057
3058
3059
Inj
Inh
Oral
Oral
Oral
Inh
Inh
Inh
Inj
Oral
Oral
Inh
Oral
Oral
Inh
Oral
Oral
Oral
Inh
Oral
Inh
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Tier
Requirements/
Limits
Pulmonary Antihypertensives
ADCIRCA TAB 20MG
tadalafil
ADEMPAS TAB 0.5MG
riociguat
ADEMPAS TAB 1.5MG
riociguat
ADEMPAS TAB 1MG
riociguat
ADEMPAS TAB 2.5MG
riociguat
ADEMPAS TAB 2MG
riociguat
LETAIRIS TAB 10MG
ambrisentan
LETAIRIS TAB 5MG
ambrisentan
OPSUMIT TAB 10MG
macitentan
REMODULIN INJ 10MG/ML
treprostinil
REMODULIN INJ 1MG/ML
treprostinil
REMODULIN INJ 2.5MG/ML
treprostinil
REMODULIN INJ 5MG/ML
treprostinil
sildenafil tab 20mg
REVATIO
TRACLEER TAB 125MG
bosentan
TRACLEER TAB 62.5MG
bosentan
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
Tier 5
Tier 5
PA, QL (60 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
PA, QL (30 per 30 days)
PA, QL (60 per 30 days)
PA, QL (30 per 30 days)
PA
PA
PA
PA
PA, QL (90 per 30 days)
PA, QL (60 per 30 days)
PA, QL (120 per 30 days)
Respiratory Tract Agents, Other
acetylcyst sol 10%
MUCOMYST-10
acetylcyst sol 20%
MUCOMYST
ARALAST NP INJ 400MG
alpha-1-proteinase inhibitor
BREO ELLIPTA INH 100-25
fluticasone - vilanterol
SYMBICORT AER 160-4.5
budesonide - formoterol
SYMBICORT AER 80-4.5
budesonide - formoterol
TYZINE PED DRO 0.05%
tetrahydrozoline
ZEMAIRA INJ 1000MG
alpha 1-proteinase inhibitor
Tier 2
Tier 2
Tier 5
Tier 4
Tier 3
Tier 3
Tier 2
Tier 5
PA
PA
PA
QL (60 per 30 days)
QL (10.2 per 30 days)
QL (10.2 per 30 days)
Respiratory Tract/Pulmonary Agents
ESBRIET CAP 267MG
pirfenidone
OFEV CAP 100MG
nintedanib
OFEV CAP 150MG
nintedanib
PULMOZYME SOL 1MG/ML
dornase alfa
XOLAIR SOL 150MG
omalizumab
Tier 5
Tier 5
Tier 5
Tier 5
Tier 5
PA, QL (270 per 30 days)
PA, QL (60 per 30 days)
PA, QL (60 per 30 days)
PA
PA
Covered Drug Name
Alternate Drug Name
Route
3060
3061
3062
3063
3064
3065
3066
3067
3068
3069
3070
3071
3072
3073
3074
3075
3076
3077
3078
3079
3080
3081
3082
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
3083
3084
3085
3086
3087
3088
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Inh
Inh
Inj
Inh
Inh
Inh
NS
Inj
Oral
Oral
Oral
Inh
Inj
99
Formulary
Covered Drug Name
Alternate Drug Name
Tier
Requirements/
Limits
Tier 2
Tier 2
Tier 2
Tier 4
PA
PA
PA
PA
Route
SKELETAL MUSCLE RELAXANTS
Skeletal Muscle Relaxants
cyclobenzapr tab 10mg
cyclobenzapr tab 5mg
cyclobenzapr tab 7.5mg
orphenadrine inj 30mg/ml
FLEXERIL
FLEXERIL
FEXMID
NORFLEX
3089
3090
3091
3092
Oral
Oral
Oral
Inj
SLEEP DISORDER AGENTS
GABA Receptor Modulators
zaleplon cap 10mg
zaleplon cap 5mg
zolpidem er tab 12.5mg
zolpidem er tab 6.25mg
zolpidem tab 10mg
zolpidem tab 5mg
SONATA
SONATA
AMBIEN CR
AMBIEN CR
AMBIEN
AMBIEN
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
Tier 2
PA, QL (60 per 30 days)
PA, QL (30 per 30 days)
PA, QL (30 per 30 days)
PA, QL (30 per 30 days)
PA, QL (30 per 30 days)
PA, QL (30 per 30 days)
Sleep Disorders, Other
HETLIOZ CAP 20MG
modafinil tab 100mg
modafinil tab 200mg
ROZEREM TAB 8MG
XYREM SOL 500MG/ML
tasimelteon
PROVIGIL
PROVIGIL
ramelteon
sodium oxybate
Tier 5
Tier 2
Tier 2
Tier 4
Tier 5
PA, QL (30 per 30 days)
PA, QL (60 per 30 days)
PA, QL (60 per 30 days)
QL (30 per 30 days)
PA, QL (540 per 30 days)
3093
3094
3095
3096
3097
3098
3099
3100
3101
3102
3103
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Oral
THERAPEUTIC NUTRIENTS/ MINERALS/ ELECTROLYTES
Therapeutic Nutrients/ Minerals/ Electrolytes
levocarnitin sol 1gm/10ml
CARNITOR
levocarnitin tab 330mg
CARNITOR
Tier 2
Tier 2
3104
3105
Oral
Oral
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
Electrolyte/Mineral Modifiers
CHEMET CAP 100MG
succimer
EXJADE TAB 125MG
deferasirox
EXJADE TAB 250MG
deferasirox
EXJADE TAB 500MG
deferasirox
FERRIPROX TAB 500MG
deferiprone
sod poly sul sus 15gm/60ml
KAYEXALATE - SPS
100
Tier 4
Tier 5
Tier 5
Tier 5
Tier 5
Tier 2
3106
PA
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
3107
3108
3109
3110
3111
Oral
Oral
Oral
Oral
Oral
Oral
Formulary
Covered Drug Name
SYPRINE CAP 250MG
Alternate Drug Name
trientine
Tier
Requirements/
Limits
Tier 5
Route
3112
Electrolyte/Mineral Replacement
ammonium chl inj 5meq/ml
ammonium chloride
CARBAGLU TAB 200MG
carglumic acid
kcl in nacl
kcl/sodium chloride
klor-con 10 tab 10meq er
MICRO-K / KLOR-CON / K-TAB
klor-con 8 tab 8meq er
MICRO-K / KLOR-CON / K-TAB
klor-con m15 tab
potassium chloride er
klor-con m20 tab 20meq er
MICRO-K / KLOR-CON / K-TAB
magnesium su inj 50%
MAGNESIUM SULF
physiosol sol
PHYSIOSOL
pot chloride cap 10meq er
MICRO-K / KLOR-CON / K-TAB
pot chloride cap 8meq er
MICRO-K / KLOR-CON / K-TAB
POT CHLORIDE INJ 10MEQ
potassium chloride
POT CHLORIDE INJ 20MEQ
potassium chloride
pot chloride inj 2meq/ml
potassium chloride
POT CHLORIDE INJ 40MEQ
potassium chloride
pot chloride tab 8meq er
MICRO-K / KLOR-CON / K-TAB
pot citrate tab 1080mg
UROCIT-K
pot citrate tab 1620mg
UROCIT-K
pot citrate tab 540mg
UROCIT-K
pot cl micro tab 10meq er
MICRO-K / KLOR-CON / K-TAB
pot cl micro tab 20meq er
MICRO-K / KLOR-CON / K-TAB
prenatabs tab obn
prenatal rx vitamin
sod chloride inj 0.45%
sod chloride 0.45%
sod chloride inj 0.9%
sod chloride 0.9%
sod chloride inj 2.5/ml
sodium chloride
sod chloride inj 3%
sodium chloride
sod chloride inj 5%
sodium chloride
sodium chlor sol 0.9%
SODIUM CHLORIDE IRRIGATION
Tier 4
Tier 5
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 2
Tier 1
Tier 1
Tier 1
Tier 1
Tier 4
Tier 4
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 1
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
PA
PA
PA
Therapeutic Nutrients/Minerals/Electrolytes
AMINOSYN II INJ 10%
aminosyn ii
AMINOSYN II INJ 7%
aminosyn ii
aminosyn ii inj 8.5/lyte
AMINOSYN
AMINOSYN II INJ 8.5%
aminosyn ii
aminosyn inj 8.5/lyte
AMINOSYN
AMINOSYN M INJ 3.5%
aminosyn ii
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
PA
PA
PA
PA
PA
PA
3113
3114
3115
3116
3117
3118
3119
PA
3120
3121
3122
3123
PA
3124
3125
PA
PA
3126
3127
3128
3129
3130
3131
3132
3133
3134
PA
PA
PA
PA
PA
3135
3136
3137
3138
3139
3140
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
3141
3142
3143
3144
3145
3146
Oral
Inj
Oral
Inj
Oral
Oral
Oral
Oral
Inj
IR
Oral
Oral
Inj
Inj
Inj
Inj
Oral
Oral
Oral
Oral
Oral
Oral
Oral
Inj
Inj
Inj
Inj
Inj
IR
Inj
Inj
Inj
Inj
Inj
Inj
101
Formulary
Covered Drug Name
AMINOSYN-HBC INJ 7%
AMINOSYN-PF INJ 10%
AMINOSYN-PF INJ 7%
D10W/NACL INJ 0.2%
D10W/NACL INJ 0.45%
d2.5w/nacl inj 0.45%
d5w/lr
d5w/nacl inj 0.2%
D5W/NACL INJ 0.225%
d5w/nacl inj 0.33%
d5w/nacl inj 0.45%
d5w/nacl inj 0.9%
dextrose inj 10%
dextrose inj 5%
folic acid tab 1mg **
intralipid inj 20%
kcl/d5w inj 0.15%
kcl/d5w inj 0.3%
kcl/d5w/lr inj 0.15%
kcl/d5w/nacl inj .075/.45%
kcl/d5w/nacl inj .15/.33%
kcl/d5w/nacl inj .15/.45%
kcl/d5w/nacl inj .22/.45%
KCL/D5W/NACL INJ 0.15/0.2%
kcl/d5w/nacl inj 0.15/0.2%
kcl/d5w/nacl inj 0.15/0.9%
kcl/d5w/nacl inj 0.3/0.45%
KCL/D5W/NACL INJ 0.3/0.9%
lactated rin
lactated rin sol
NORMOSOL -M INJ /D5W
NUTRILIPID EMU 20%
ringers
ringers sol
steril water sol
tpn electrol
TRAVASOL INJ 10%
TROPHAMINE INJ 10%
102
Requirements/
Limits
Alternate Drug Name
Tier
aminosyn-hbc
aminosyn-pf
aminosyn-pf
glucose - sodium chloride soln
glucose - sodium chloride soln
dextrose 2.5% - sodium chloride 0.45%
kcl/d5w/lr
dextrose 5% - sodium chloride 0.2%
dextrose 5% - sodium chloride 0.225%
dextrose 5% - sodium chloride 0.33%
dextrose 5% - sodium chloride 0.45%
dextrose 5% - sodium chloride 0.9%
dextrose 10%
dextrose 5%
folic acid
intralipid
kcl/d5w
kcl/d5w
kcl/d5w/lr
kcl/d5w/nacl
kcl/d5w/nacl
kcl/d5w/nacl
kcl/d5w/nacl
glucose - potassium chloride - sodium
chloride soln
kcl/d5w/nacl
kcl/d5w/nacl
kcl/d5w/nacl
glucose - potassium chloride - sodium
chloride soln
lactated rigners
LACTATED RINGERS
glucose 50 mg/ml / magnesium acetate
0.000979 meq/ml / potassium acetate sodium chloride
phospholipids - glycerin - soybean oil
lactated ringers
ringers irrigation soln
STERILE WATER IRRIGATION
tpn multilyte
travasol
trophamine
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 2
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
Tier 4
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Tier 4
Tier 4
Tier 4
Tier 4
PA
PA
PA
PA
Tier 4
Tier 2
Tier 4
PA
PA
PA
Tier 4
Tier 4
Tier 2
Tier 2
Tier 4
Tier 4
Tier 4
PA
PA
PA
PA
PA
PA
PA
Route
3147
3148
3149
3150
3151
3152
3153
3154
3155
3156
3157
3158
3159
3160
3161
PA
PA
PA
PA
PA
PA
PA
PA
PA
Please go to page 7 to confirm copays, to find the meaning of symbols or abbreviations go to page 9.
3162
3163
3164
3165
3166
3167
3168
3169
3170
3171
3172
3173
3174
3175
3176
3177
3178
3179
3180
3181
3182
3183
3184
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Oral
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
Inj
IR
Inj
Inj
Inj
IR
IR
Inj
Inj
Inj
Drugs Requiring Prior Authorization
8-MOP CAP 10MG
ABELCET INJ 5MG/ML
ABILIFY MAIN INJ 300MG
ABRAXANE INJ 100MG
acetazolamid inj 500mg
acetylcyst sol 10%
acetylcyst sol 20%
ACTIMMUNE INJ 2MU/0.5ML
acyclovir na inj 500mg
ADAGEN INJ 250/ML
adapalene cre 0.1%
adapalene gel 0.1%
ADCIRCA TAB 20MG
albuterol neb 0.083%
albuterol neb 0.5%
albuterol neb 0.63mg/3ml
albuterol neb 1.25mg/3ml
ALDURAZYME INJ 2.9MG/5ML
ALIMTA INJ 500MG
ALORA DIS 0.025MG
ALORA DIS 0.05MG
ALORA DIS 0.075MG
ALORA DIS 0.1MG
ALOXI INJ 0.25MG/5ML
AMBISOME INJ 50MG
amifostine inj 500mg
AMINOSYN II INJ 10%
AMINOSYN II INJ 7%
aminosyn ii inj 8.5/lyte
AMINOSYN II INJ 8.5%
aminosyn inj 8.5/lyte
AMINOSYN M INJ 3.5%
AMINOSYN-HBC INJ 7%
AMINOSYN-PF INJ 10%
AMINOSYN-PF INJ 7%
amiodarone inj 50mg/ml
ammonium chl inj 5meq/ml
amp-sulbacta inj 15gm
amp-sulbacta inj 3gm
amphotericin inj 50mg
ampicillin inj 10gm
AMPICILLIN INJ 125MG
ampicillin inj 1gmg
AMPYRA TAB 10MG
ANZEMET INJ 20MG/ML
ANZEMET TAB 100MG
ANZEMET TAB 50MG
APOKYN INJ 10MG/ML
ARALAST NP INJ 400MG
ARANESP INJ 100MCG/0.5ML
ARANESP INJ 100MCG/1ML
ARANESP INJ 150MCG/0.3ML
ARANESP INJ 200MCG/0.4ML
ARANESP INJ 200MCG/1ML
ARANESP INJ 25MCG/0.42ML
ARANESP INJ 25MCG/1ML
ARANESP INJ 300MCG/0.6ML
ARANESP INJ 300MCG/1ML
ARANESP INJ 40MCG/0.4ML
ARANESP INJ 40MCG/1ML
ARANESP INJ 500MCG/1ML
ARANESP INJ 60MCG/0.3ML
ARANESP INJ 60MCG/1ML
ARCALYST INJ 220MG
ARRANON INJ 5MG/ML
ARZERRA CON 100/5ML
ascomp/cod cap 30mg
ASTAGRAF XL CAP 0.5MG
ASTAGRAF XL CAP 1MG
ASTAGRAF XL CAP 5MG
AVASTIN INJ
AVONEX KIT 30MCG
AVONEX PEN KIT 30MCG
AVONEX PREFL KIT 30MCG
azacitidine inj 100mg
AZACTAM/DEX INJ 1GM
AZACTAM/DEX INJ 2GM
AZASAN TAB 100MG
AZASAN TAB 75 MG
azathioprine tab 50mg
azithromycin inj 500mg
aztreonam inj 1gm
baciim inj 50000unt
BARACLUDE SOL .05MG/ML
BELEODAQ INJ 500MG
BENLYSTA INJ 120MG
benztropine inj 1mg/ml
benztropine tab 0.5mg
benztropine tab 1mg
benztropine tab 2mg
bleomycin inj 30unit
bumetanide inj 0.25/ml
bupap tab 50-300mg
buprenorphin inj 0.3mg/ml
BUSULFEX INJ 6MG/ML
but/apap/caf cap 50-300-40mg
but/apap/caf cap 50-325-40mg
but/apap/caf cap codeine 50-300-40-30mg
but/apap/caf cap codeine 50-325-40-30mg
but/apap/caf tab 50-325-40mg
but/asa/caff cap 50-325-40mg
butal/apap tab 50-325mg
BYETTA INJ 10MCG
BYETTA INJ 5MCG
calcitriol inj 1mcg/ml
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
CAPASTAT SUL INJ 1GM
CARBAGLU TAB 200MG
carbinoxamin sol 4mg/5ml
carbinoxamin tab 4mg
carboplatin inj 150/15ml
CARIMUNE NF INJ 3GM
cefazolin inj 10gm
cefazolin inj 1gm
cefazolin inj 1gm/50ml
cefazolin inj 500mg
cefepime inj 1gm
cefepime inj 2gm
cefoxitin inj 10gm
cefoxitin inj 1gm
cefoxitin inj 2gm
ceftriaxone inj 10gm
ceftriaxone inj 1gm
ceftriaxone inj 250mg
ceftriaxone inj 2gm
ceftriaxone inj 500mg
cefuroxime inj 1.5gm
cefuroxime inj 7.5gm
cefuroxime inj 750mg
CELLCEPT CAP 250MG
CELLCEPT IV INJ 500MG
CELLCEPT SUS 200MG/ML
CELLCEPT TAB 500MG
CEREZYME INJ 400UNIT
chloramphen inj 1gm
chlordiazep cap 10mg
chlordiazep cap 25mg
chlordiazep cap 5mg
chlorothiaz inj 500mg
chlorpromaz inj 25mg/ml
chlorpropam tab 100mg
chlorpropam tab 250mg
CINRYZE SOL 500 UNIT
ciprofloxacn inj 200mg
ciprofloxacn inj 400mg
cisplatin inj 100mg
103
Drugs Requiring Prior Authorization
cladribine inj 1mg/ml
clemastine tab 2.68mg
clindamycin inj 150mg/ml
clindamycin inj 300mg
clindamycin inj 600mg
clindamycin inj 900mg
colistimeth inj 150mg
COPAXONE KIT 20MG/ML
cromolyn sod neb 20mg/2ml
CUBICIN SOL 500MG
cyclobenzapr tab 10mg
cyclobenzapr tab 5mg
cyclobenzapr tab 7.5mg
cyclophosph cap 25mg
cyclophosph cap 50mg
CYCLOSET TAB 0.8MG
cyclosporine cap 100mg
cyclosporine cap 100mg md
cyclosporine cap 25mg
cyclosporine cap 25mg mod
cyclosporine cap 50mg mod
cyclosporine inj 50mg/ml
cyclosporine sol modified
cyproheptad syp 2mg/5ml
cyproheptad tab 4mg
cytarabine inj 100mg/ml
cytarabine inj 20mg/ml
D10W/NACL INJ 0.2%
D10W/NACL INJ 0.45%
d2.5w/nacl inj 0.45%
d5w/lr
d5w/nacl inj 0.2%
D5W/NACL INJ 0.225%
d5w/nacl inj 0.33%
d5w/nacl inj 0.45%
d5w/nacl inj 0.9%
dacarbazine inj 200mg
daunorubicin inj 5mg/ml
decitabine inj 50mg
DEMSER CAP 250MG
desmopressin inj 4mcg/ml
dexameth pho inj 120mg/30ml
dextrose inj 10%
dextrose inj 5%
digitek tab 0.125mg
digitek tab 0.25mg
digoxin inj 0.25mg/1ml
digoxin sol 50mcg/ml
digoxin tab 0.125mg
104
digoxin tab 0.25mg
diltiazem inj 100mg
diltiazem inj 50/10ml
diphenhydram inj 50mg/ml
disopyramide cap 100mg
disopyramide cap 150mg
DOCEFREZ INJ 20MG
docetaxel inj 80mg/4ml
docetaxel inj 80mg/8ml
doxorubicin inj 50mg
doxycycl hyc inj 100mg
DUAVEE TAB 0.45-20MG
DURAMORPH INJ 0.5MG/ML
DURAMORPH INJ 1MG/ML
ELAPRASE INJ 6MG/3ML
ELIDEL CRE 1%
ELITEK INJ 1.5MG
EMEND CAP 125MG
EMEND CAP 40MG
EMEND CAP 80MG
EMEND PAK 80 & 125MG
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
ENBREL SRCLK 50MG/ML
ENGERIX-B INJ 10/0.5ML
ENGERIX-B INJ 20MCG/ML
enoxaparin inj 100mg/ml
enoxaparin inj 120/0.8ml
enoxaparin inj 150mg/ml
enoxaparin inj 30/0.3ml
enoxaparin inj 40/0.4ml
enoxaparin inj 60/0.6ml
enoxaparin inj 80/0.8ml
epirubicin inj 50/25ml
EPOGEN INJ 10000/ML
EPOGEN INJ 2000/ML
EPOGEN INJ 20000/ML
EPOGEN INJ 3000/ML
EPOGEN INJ 4000/ML
ERAXIS INJ 100MG
ERBITUX INJ 100MG
ERWINAZE INJ 10000UNT
erythrocin inj 500mg
ESBRIET CAP 267MG
esomeprazole inj 20mg
esomeprazole inj 40mg
estra/noreth tab 0.5-0.1mg
estra/noreth tab 1-0.5mg
estradiol tab 0.5mg
estradiol tab 1mg
estradiol tab 2mg
estropipate tab 0.75mg
estropipate tab 1.5mg
estropipate tab 3mg
ETOPOPHOS INJ 100MG
etoposide inj 20mg/ml
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
FABRAZYME INJ 35MG
famotidine inj 10mg/ml
famotidine inj 20mg/50ml
FASLODEX INJ 250MG
fentanyl ot loz 1200mcg
fentanyl ot loz 1600mcg
fentanyl ot loz 200mcg
fentanyl ot loz 400mcg
fentanyl ot loz 600mcg
fentanyl ot loz 800mcg
FERRIPROX TAB 500MG
FIRAZYR INJ 30MG/3ML
FIRMAGON INJ 120MG
FIRMAGON INJ 80MG
FLECTOR DIS 1.3%
fluconazole/ inj dex 400mg
fludarabine inj 50mg
fluorouracil inj 2.5g/50ml
fluphenaz de inj 25mg/ml
fluphenazine inj 2.5mg/ml
fondaparinux sol 10/0.8ml
fondaparinux sol 2.5/0.5ml
fondaparinux sol 5.0/0.4ml
fondaparinux sol 7.5/0.6ml
FORTEO SOL 600/2.4ML
FOSCARNET INJ 24MG/ML
fosphenytoin inj 100/2ml
FRAGMIN INJ 10000/ML
FRAGMIN INJ 12500UNT
FRAGMIN INJ 15000UNT
FRAGMIN INJ 18000UNT
FRAGMIN INJ 2500/0.2ML
FRAGMIN INJ 5000/0.2ML
furosemide inj 10mg/ml
FUSILEV INJ 50MG
GAMASTAN S/D INJ
GAMMAGARD INJ 2.5GM/25ML
ganciclovir inj 500mg
Drugs Requiring Prior Authorization
GARDASIL 9 INJ
GARDASIL INJ
GATTEX KIT 5MG
gemcitabine inj 1gm
gengraf cap 100mg
gengraf cap 25mg
gengraf sol 100mg/ml
GENOTROPIN INJ 0.2MG
GENOTROPIN INJ 0.4MG
GENOTROPIN INJ 0.6MG
GENOTROPIN INJ 0.8MG
GENOTROPIN INJ 1.2MG
GENOTROPIN INJ 1.4MG
GENOTROPIN INJ 1.6MG
GENOTROPIN INJ 1.8MG
GENOTROPIN INJ 12MG
GENOTROPIN INJ 1MG
GENOTROPIN INJ 2MG
GENOTROPIN INJ 5MG
gentamicin inj 10mg/ml
gentamicin inj 40mg/ml
GILENYA CAP 0.5MG
granisetron tab 1mg
guanfacine tab 1mg
guanfacine tab 2mg
HALAVEN INJ 1MG/2ML
haloper dec inj 100mg/ml
haloper dec inj 50mg/ml
haloper lac inj 5mg/ml
HARVONI TAB 90-400MG
hep sod/d5w inj 20000unt
HEP SOD/D5W INJ 25000UNT
heparin sod inj 1000/ml
heparin sod inj 10000/ml
heparin sod inj 20000/ml
heparin sod inj 5000/ml
HERCEPTIN INJ 440MG
HETLIOZ CAP 20MG
HUMATROPE INJ 12MG
HUMATROPE INJ 24MG
HUMATROPE INJ 5MG
HUMATROPE INJ 6MG
HUMIRA INJ 10MG/0.2ML
HUMIRA KIT 20MG/0.4ML
HUMIRA KIT 40MG/0.8ML
HUMIRA PEN KIT CROHNS
hydralazine inj 20mg/ml
HYDROXYZ HCL INJ 25MG/ML
hydroxyz hcl inj 50mg/ml
ibandronate inj 3mg/3ml
idarubicin inj 10/10ml
ifosfamide inj 1gm
ILARIS INJ 180MG
imipenem/cil inj 250mg
imipenem/cil inj 500mg
INCRELEX INJ 40MG/4ML
indomethacin cap 25mg
indomethacin cap 50mg
indomethacin cap 75mg er
intralipid inj 20%
irinotecan inj 100/5ml
ISTODAX INJ 10MG
IXEMPRA KIT INJ 45MG
JEVTANA INJ 60/1.5ML
JINTELI TAB 1MG-5MCG
JUXTAPID CAP 10MG
JUXTAPID CAP 20MG
JUXTAPID CAP 5MG
KALYDECO PAK 50MG
KALYDECO PAK 75MG
KALYDECO TAB 150MG
kcl in nacl
kcl/d5w inj 0.15%
kcl/d5w inj 0.3%
kcl/d5w/lr inj 0.15%
kcl/d5w/nacl inj .075/.45%
kcl/d5w/nacl inj .15/.33%
kcl/d5w/nacl inj .15/.45%
kcl/d5w/nacl inj .22/.45%
kcl/d5w/nacl inj 0.15/0.2%
kcl/d5w/nacl inj 0.15/0.9%
kcl/d5w/nacl inj 0.3/0.45%
KCL/D5W/NACL INJ 0.3/0.9%
KEPIVANCE INJ 6.25MG
KEYTRUDA SOL 50MG
KINERET INJ
KORLYM TAB 300MG
KUVAN TAB 100MG
KYNAMRO INJ 200MG/ML
labetalol inj 5mg/ml
lactated rin
lactated rin sol
LETAIRIS TAB 10MG
LETAIRIS TAB 5MG
leucovor ca inj 100mg
leucovor ca inj 350mg
LEUKINE INJ 250MCG
leuprolide inj 1mg/0.2ml
levetiracetm inj 500/5ml
levoflox/d5w inj 500/100ml
levofloxacin inj 25mg/ml
lidocaine inj 0.5%
lidocaine pad 5%
linezolid inj 2mg/ml
LOTRONEX TAB 0.5MG
LOTRONEX TAB 1MG
LUPR DEP-PED INJ 11.25MG
LUPR DEP-PED INJ 15MG
LUPRON DEPOT INJ 11.25MG
LUPRON DEPOT INJ 22.5MG
LUPRON DEPOT INJ 3.75MG
LUPRON DEPOT INJ 30MG
LUPRON DEPOT INJ 45MG
LUPRON DEPOT INJ 7.5MG
magnesium su inj 50%
MEGACE ES SUS 625/5ML
megestrol ac sus 40mg/ml
melphalan inj 50mg
meprobamate tab 200mg
meprobamate tab 400mg
meropenem inj 500mg
mesna inj 1gm
methadone inj 10mg/ml
methotrexate inj 1gm
methotrexate inj 25mg/ml
methyld/hctz tab 250/15mg
methyld/hctz tab 250/25mg
methyldopa tab 250mg
methyldopa tab 500mg
methyldopate inj 250/5ml
methylpr ace inj 40mg/ml
methylpr ace inj 80mg/ml
methylpr ss inj 125mg
methylpr ss inj 40mg
metoclopram inj 5mg/ml
metoprolol inj 1mg/ml
metron/nacl inj 500mg
MIACALCIN INJ 200/ML
mitomycin inj 20mg
mitoxantron inj 2mg/ml
modafinil tab 100mg
modafinil tab 200mg
MORPHINE SUL INJ 10MG/ML
MORPHINE SUL INJ 2MG/ML
MORPHINE SUL INJ 4MG/ML
MORPHINE SUL INJ 8MG/ML
MOZOBIL INJ
105
Drugs Requiring Prior Authorization
MULTAQ TAB 400MG
MUSTARGEN INJ 10MG
mycophenolat cap 250mg
mycophenolat sus 200mg/ml
mycophenolat tab 500mg
mycophenolic tab 180mg dr
mycophenolic tab 360mg dr
MYOZYME INJ 50MG
nafcillin inj 10gm
nafcillin inj 1gm
NAGLAZYME INJ 1MG/ML
nalbuphine inj 10mg/ml
nalbuphine inj 20mg/ml
NATPARA INJ 100MCG
NATPARA INJ 25MCG
NATPARA INJ 50MCG
NATPARA INJ 75MCG
NEBUPENT INH 300MG
NEULASTA INJ 6MG/0.6ML
NEUMEGA INJ 5MG
NEUPOGEN 300MCG
NEUPOGEN INJ 300/0.5ML
NEUPOGEN INJ 480/0.8ML
NEUPOGEN INJ 480MCG
nitrofur mac cap 50mg
nitrofurantn cap 100mg
nitrofurantn sus 25mg/5ml
nitrofurantoin mac cap 100mg
NITROGLYCER INJ 5MG/ML
NORDITROPIN INJ 10/1.5ML
NORDITROPIN INJ 15/1.5ML
NORDITROPIN INJ 5/1.5ML
NORMOSOL -M INJ /D5W
NORTHERA CAP 100MG
NORTHERA CAP 200MG
NORTHERA CAP 300MG
NULOJIX INJ 250MG
NUTRILIPID EMU 20%
NUTROPIN AQ INJ 10MG/2ML
NUTROPIN AQ INJ 20MG/2ML
NUTROPIN AQ INJ NUSPIN 5
octreotide inj 1000mcg
octreotide inj 100mcg
octreotide inj 200mcg
octreotide inj 500mcg
octreotide inj 50mcg/ml
OFEV CAP 100MG
OFEV CAP 150MG
olanzapine inj 10mg
106
OLYSIO CAP 150MG
OMNITROPE INJ 10/1.5ML
OMNITROPE INJ 5.8MG
OMNITROPE INJ 5/1.5ML
ONCASPAR INJ 750/ML
ondansetron inj 4mg/2ml
ondansetron sol 4mg/5ml
ondansetron tab 24mg
ondansetron tab 4mg
ondansetron tab 4mg odt
ondansetron tab 8mg
ondansetron tab 8mg odt
OPDIVO INJ 40MG/4ML
OPSUMIT TAB 10MG
ORENCIA INJ 125MG/ML
ORENCIA INJ 250MG
orphenadrine inj 30mg/ml
oxaliplatin inj 100mg
paclitaxel inj 300/50ml
pamidronate inj 30/10ml
pamidronate inj 6mg/ml
pamidronate inj 90/10ml
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 120MCG
PEG-INTRON KIT 150 RP
PEG-INTRON KIT 150MCG
PEG-INTRON KIT 50MCG
PEG-INTRON KIT 50MCG RP
PEG-INTRON KIT 80MCG
PEG-INTRON KIT 80MCG RP
PEGASYS INJ 180MCG/0.5ML
PEGASYS INJ 180MCG/ML
PEGASYS INJ PROCLICK
PEGASYS PROCLICK
pen g proc inj 600000
pen g sod inj 5000000
penicill gk/ inj dex 2mu
penicill gk/ inj dex 3mu
penicilln gk inj 5mu
PENTAM 300 INJ 300MG
PERJETA INJ 420/14ML
phenytoin inj 50mg/ml
piper/tazoba inj 3-0.375gm
piper/tazoba inj 4-0.5gm
POT CHLORIDE INJ 10MEQ
pot chloride inj 2meq/ml
POT CHLORIDE INJ 40MEQ
PREFEST TAB
PREMARIN INJ 25MG
procainamide inj 100mg/ml
procainamide inj 500mg/ml
prochlorper inj 5mg/ml
PROCRIT INJ 10000/ML
PROCRIT INJ 2000/ML
PROCRIT INJ 20000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 40000/ML
PROGRAF INJ 5MG/ML
PROLEUKIN INJ 22MU
PROLIA SOL 60MG/ML
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
propranolol inj 1mg/ml
PULMOZYME SOL 1MG/ML
quinidine gl inj 80mg/ml
ranitidine inj 150/6ml
RAPAMUNE SOL 1MG/ML
RAVICTI LIQ 1.1GM/ML
REBIF INJ 22/0.5ML
REBIF INJ 44/0.5ML
REBIF TITRTN SOL PACK
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA HB INJ 5MCG/0.5ML
RECOMBIVA-HB INJ 40MCG/ML
RELISTOR KIT 12/0.6ML
REMICADE INJ 100MG
REMODULIN INJ 10MG/ML
REMODULIN INJ 1MG/ML
REMODULIN INJ 2.5MG/ML
REMODULIN INJ 5MG/ML
reserpine tab 0.1mg
reserpine tab 0.25mg
rifampin inj 600 mg
riluzole tab 50mg
ringers
ringers sol
RITUXAN INJ 500MG
SAIZEN INJ 5MG
SAIZEN INJ 8.8MG
SANDIMMUNE SOL 100MG/ML
SANDOSTATIN KIT LAR 10MG
SANDOSTATIN KIT LAR 20MG
SANDOSTATIN KIT LAR 30MG
SEROSTIM INJ 4MG
SEROSTIM INJ 5MG
Drugs Requiring Prior Authorization
SEROSTIM INJ 6MG
SIGNIFOR INJ 0.3MG/ML
SIGNIFOR INJ 0.6MG/ML
SIGNIFOR INJ 0.9MG/ML
sildenafil tab 20mg
SIMPONI INJ 50MG
SIMULECT INJ 20MG
sirolimus tab 0.5mg
sirolimus tab 1mg
sirolimus tab 2mg
smz-tmp inj 400-80/5ml
sod chloride inj 0.45%
sod chloride inj 0.9%
sod chloride inj 2.5/ml
sod chloride inj 3%
sod chloride inj 5%
SOMATULINE INJ 120/.5ML
SOMATULINE INJ 60/0.2ML
SOMATULINE INJ 90/0.3ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
SOMAVERT INJ 25MG
SOMAVERT INJ 30MG
SOVALDI TAB 400MG
steril water sol
streptomycin inj 1gm
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG
SYNAGIS INJ 50MG
SYNAREL SOL 2MG/ML
SYNERCID INJ 500MG
SYNRIBO INJ 3.5MG
tacrolimus cap 0.5mg
tacrolimus cap 1mg
tacrolimus cap 5mg
TEFLARO INJ 400MG
TEFLARO INJ 600MG
terbutaline inj 1mg/ml
testost enan inj 200mg/ml
TET/DIP TOX INJ 2-2 LF
THYMOGLOBULN INJ 25MG
ticlopidine tab 250mg
tobramycin inj 10mg/ml
tobramycin inj 80mg/2ml
tobramycin neb 300/5ml
toposar inj 1gm/50ml
topotecan inj 4mg
tpn electrol
TRACLEER TAB 125MG
TRACLEER TAB 62.5MG
TRAVASOL INJ 10%
TREANDA INJ 100MG
TREANDA INJ 45/0.5ML
trihexyphen elx 0.4mg/ml
trihexyphen tab 2mg
trihexyphen tab 5mg
TRISENOX SOL 10MG/10ML
TROPHAMINE INJ 10%
TYGACIL INJ 50MG
TYSABRI INJ 300/15ML
UVADEX INJ 20MCG/ML
valproate inj 100mg/ml
vancomycin cap 125mg
vancomycin cap 250mg
vancomycin inj 1000mg
vancomycin inj 10gm
vancomycin inj 500mg
VECTIBIX INJ 100MG
VELCADE INJ 3.5MG
verapamil inj 2.5mg/ml
VIEKIRA PAK TAB
VINBLASTINE INJ 10MG
vincasar pfs inj 1mg/ml
vincristine inj 1mg/ml
vinorelbine inj 10mg/ml
VIVITROL INJ 380MG
voriconazole inj 200mg
voriconazole sus 40mg/ml
voriconazole tab 200mg
voriconazole tab 50mg
VPRIV INJ 400UNIT
XENAZINE TAB 12.5MG
XENAZINE TAB 25MG
XGEVA INJ
XOLAIR SOL 150MG
XYREM SOL 500MG/ML
YERVOY INJ 50MG
zaleplon cap 10mg
zaleplon cap 5mg
ZALTRAP INJ 100/4ML
ZANOSAR INJ 1GM
ZAVESCA CAP 100MG
ZEMAIRA INJ 1000MG
ZEMPLAR INJ 2MCG/ML
ZEMPLAR INJ 5MCG/ML
zoledronic inj 4mg/5ml
zoledronic inj 5/100ml
zolpidem er tab 12.5mg
zolpidem er tab 6.25mg
zolpidem tab 10mg
zolpidem tab 5mg
ZORBTIVE INJ 8.8MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.75MG
ZOSYN SOL 2-0.25GM
ZOSYN SOL 3-0.375GM
ZYVOX SUS 100MG/5ML
ZYVOX TAB 600MG
107
Drugs With Quantity Limits
108
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
abacav/lamiv/zidovud
abacavir tab 300mg
ABILIFY DISC TAB 10MG
ABILIFY DISC TAB 15MG
ABILIFY MAIN INJ 300MG
ABILIFY MAIN INJ 300MG
ABILIFY MAIN INJ 400MG
ABILIFY TAB 10MG
ABILIFY TAB 15MG
ABILIFY TAB 20MG
ABILIFY TAB 2MG
ABILIFY TAB 30MG
ABILIFY TAB 5MG
acarbose tab 100mg
acarbose tab 25mg
acarbose tab 50mg
acyclovir oin 5%
ADCIRCA TAB 20MG
ADEMPAS TAB 0.5MG
ADEMPAS TAB 1.5MG
ADEMPAS TAB 1MG
ADEMPAS TAB 2.5MG
ADEMPAS TAB 2MG
AFINITOR DIS TAB 2MG
AFINITOR DIS TAB 3MG
AFINITOR DIS TAB 5MG
AFINITOR TAB 10MG
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AGGRENOX CAP 25-200MG
albuterol neb 0.083%
albuterol neb 0.5%
albuterol neb 0.63mg/3ml
albuterol neb 1.25mg/3ml
alendronate tab 10mg
alendronate tab 35mg
alendronate tab 40mg
alendronate tab 5mg
alendronate tab 70mg
alfuzosin tab 10mg
ALINIA SUS 100/5ML
ALORA DIS 0.025MG
ALORA DIS 0.05MG
ALORA DIS 0.075MG
ALORA DIS 0.1MG
ALOXI INJ 0.25MG/5ML
alprazolam tab 0.25mg
60/30 days
60/30 days
90/30 days
60/30 days
1/28 days
2/28 days
1/28 days
90/30 days
60/30 days
60/30 days
450/30 days
30/30 days
180/30 days
90/30 days
90/30 days
90/30 days
30/30 days
60/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
150/30 days
90/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
360/30 days
60/30 days
360/30 days
360/30 days
120/30 days
5/30 days
30/30 days
240/30 days
5/30 days
30/30 days
180/3 days
8/28 days
8/28 days
8/28 days
8/28 days
30/30 days
90/30 days
90/30 days
120/30 days
90/30 days
120/30 days
150/30 days
120/30 days
150/30 days
120/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
30/30 days
300/30 days
300/30 days
50/30 days
30/30 days
30/30 days
4500/30 days
400/30 days
400/30 days
400/30 days
30/30 days
30/30 days
180/30 days
90/30 days
60/30 days
45/30 days
120/30 days
300/30 days
4/28 days
2/28 days
1.2/28 days
1.6/28 days
alprazolam tab 0.5mg
alprazolam tab 0.5mg er
alprazolam tab 1mg
alprazolam tab 1mg er
alprazolam tab 2mg
alprazolam tab 2mg er
alprazolam tab 2mg odt
alprazolam tab 3mg er
AMITIZA CAP 24MCG
AMITIZA CAP 8MCG
amlod/benazp cap 10-20mg
amlod/benazp cap 10-40mg
amlod/benazp cap 2.5-10mg
amlod/benazp cap 5-10mg
amlod/benazp cap 5-20mg
amlod/benazp cap 5-40mg
amlodipine tab 10mg
amlodipine tab 2.5mg
amlodipine tab 5mg
amphetamine tab 10mg
amphetamine tab 12.5mg
amphetamine tab 15mg
amphetamine tab 20mg
amphetamine tab 30mg
amphetamine tab 5mg
amphetamine tab 7.5mg
anastrozole tab 1mg
ANDROGEL GEL 1.62%
ANDROGEL GEL PUMP 1.62%
ANZEMET INJ 20MG/ML
ANZEMET TAB 100MG
ANZEMET TAB 50MG
apap/codeine sol 120-12/5ml
apap/codeine tab 300-15mg
apap/codeine tab 300-30mg
apap/codeine tab 300-60mg
APIDRA INJ SOLOSTAR
APIDRA INJ U-100
APTIOM TAB 200MG
APTIOM TAB 400MG
APTIOM TAB 600MG
APTIOM TAB 800MG
APTIVUS CAP 250MG
APTIVUS SOL
ARANESP INJ 100MCG/0.5ML
ARANESP INJ 100MCG/1ML
ARANESP INJ 150MCG/0.3ML
ARANESP INJ 200MCG/0.4ML
Drugs With Quantity Limits
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
ARANESP INJ 200MCG/1ML
ARANESP INJ 25MCG/0.42ML
ARANESP INJ 25MCG/1ML
ARANESP INJ 300MCG/0.6ML
ARANESP INJ 300MCG/1ML
ARANESP INJ 40MCG/0.4ML
ARANESP INJ 40MCG/1ML
ARANESP INJ 500MCG/1ML
ARANESP INJ 60MCG/0.3ML
ARANESP INJ 60MCG/1ML
ARCAPTA CAP 75MCG
ascomp/cod cap 30mg
ASMANEX 120 AER 220MCG
ASMANEX 30 AER 110MCG
ASMANEX 30 AER 220MCG
ASMANEX 60 AER 220MCG
atorvastatin tab 10mg
atorvastatin tab 20mg
atorvastatin tab 40mg
atorvastatin tab 80mg
ATRIPLA TAB
ATROVENT HFA AER 17MCG
AVODART CAP 0.5MG
AVONEX KIT 30MCG
AVONEX PEN KIT 30MCG
AVONEX PREFL KIT 30MCG
azelastine spr 0.1%
azithromycin sus 100/5ml
azithromycin sus 200/5ml
azithromycin tab 250mg
azithromycin tab 500mg
azithromycin tab 600mg
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
BARACLUDE SOL .05MG/ML
BECONASE AQ SUS 0.042%
BETASERON INJ 0.3MG
bicalutamide tab 50mg
BOSULIF TAB 100MG
BOSULIF TAB 500MG
BREO ELLIPTA INH 100-25
BRILINTA TAB 90MG
BRINTELLIX TAB 10MG
BRINTELLIX TAB 20MG
BRINTELLIX TAB 5MG
bupren/nalox sub 2-0.5mg
bupren/nalox sub 8-2mg
4/28 days
1.68/28 days
4/28 days
2.4/28 days
4/28 days
1.6/28 days
4/28 days
4/28 days
1.2/28 days
4/28 days
30/30 days
120/30 days
2/30 days
2/30 days
2/30 days
2/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
25.8/30 days
30/30 days
4/28 days
4/28 days
4/28 days
30/30 days
30/5 days
90/5 days
6/5 days
6/5 days
6/5 days
2400/30 days
240/30 days
240/30 days
600/30 days
50/30 days
15/30 days
30/30 days
120/30 days
30/30 days
60/30 days
60/30 days
60/30 days
30/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
90/30 days
120/30 days
60/30 days
90/30 days
30/30 days
180/30 days
30/30 days
45/30 days
120/30 days
120/30 days
360/30 days
120/30 days
180/30 days
180/30 days
10/30 days
4/28 days
4/28 days
4/28 days
4/28 days
4.5/30 days
4/28 days
2.4/30 days
2.4/30 days
30/30 days
30/30 days
30/30 days
60/30 days
30/30 days
60/30 days
60/30 days
60/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
120/30 days
90/30 days
6/30 days
buprenorphin sub 2mg
buprenorphin sub 8mg
buproban tab 150mg
bupropion tab 100mg
bupropion tab 100mg sr
bupropion tab 150mg sr
bupropion tab 200mg sr
bupropion tab 75mg
bupropn hcl tab 150mg xl
bupropn hcl tab 300mg xl
but/apap/caf cap 50-325-40mg
but/apap/caf cap codeine 50-300-40-30mg
but/apap/caf cap codeine 50-325-40-30mg
but/apap/caf tab 50-325-40mg
but/asa/caff cap 50-325-40mg
butal/apap tab 50-325mg
butorphanol sol 10mg/ml
BUTRANS DIS 10MCG/HR
BUTRANS DIS 15MCG/HR
BUTRANS DIS 20MCG/HR
BUTRANS DIS 5MCG/HR
BYDUREON INJ
BYDUREON INJ
BYETTA INJ 10MCG
BYETTA INJ 5MCG
candesa/hctz tab 16-12.5mg
candesa/hctz tab 32-12.5mg
candesa/hctz tab 32-25mg
candesartan tab 16mg
candesartan tab 32mg
candesartan tab 4mg
candesartan tab 8mg
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
carvedilol tab 12.5mg
carvedilol tab 25mg
carvedilol tab 3.125mg
carvedilol tab 6.25mg
celecoxib cap 100mg
celecoxib cap 200mg
celecoxib cap 400mg
celecoxib cap 50mg
CHANTIX PAK 0.5& 1MG
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
chlorpropam tab 100mg
chlorpropam tab 250mg
CIALIS TAB 10MG
109
Drugs With Quantity Limits
110
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
CIALIS TAB 20MG
citalopram sol 10mg/5ml
citalopram tab 10mg
citalopram tab 20mg
citalopram tab 40mg
clarithromyc tab 250mg
clarithromyc tab 500mg
clarithromyc tab 500mg er
clonazep odt tab 0.125mg
clonazep odt tab 0.25mg
clonazep odt tab 0.5mg
clonazep odt tab 1mg
clonazep odt tab 2mg
clonazepam tab 0.5mg
clonazepam tab 1mg
clonazepam tab 2mg
clonidine dis 0.1/24hr
clonidine dis 0.2/24hr
clonidine dis 0.3/24hr
clopidogrel tab 300mg
clopidogrel tab 75mg
cloraz dipot tab 15mg
cloraz dipot tab 3.75mg
cloraz dipot tab 7.5mg
clozapine tab 100/odt
clozapine tab 100mg
clozapine tab 12.5/odt
clozapine tab 150/odt
clozapine tab 200/odt
clozapine tab 25mg
clozapine tab 25mg odt
clozapine tab 50mg
COLCRYS TAB 0.6MG
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
COMETRIQ KIT 60MG
COMPLERA TAB
COPAXONE KIT 20MG/ML
CRESTOR TAB 10MG
CRESTOR TAB 20MG
CRESTOR TAB 40MG
CRESTOR TAB 5MG
CRIXIVAN CAP 200MG
CRIXIVAN CAP 400MG
cromolyn sod neb 20mg/2ml
CYCLOSET TAB 0.8MG
DALIRESP TAB 500MCG
DEMSER CAP 250MG
6/30 days
600/30 days
30/30 days
30/30 days
30/30 days
28/14 days
28/14 days
28/14 days
4800/30 days
2400/30 days
1200/30 days
600/30 days
300/30 days
1200/30 days
600/30 days
300/30 days
4/28 days
4/28 days
4/28 days
30/30 days
30/30 days
90/30 days
90/30 days
90/30 days
270/30 days
120/30 days
2160/30 days
120/30 days
120/30 days
120/30 days
1080/30 days
120/30 days
120/30 days
56/28 days
112/28 days
84/28 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
360/30 days
180/30 days
240/30 days
180/30 days
30/30 days
480/30 days
1.5/28 days
120/30 days
240/30 days
90/30 days
90/30 days
90/30 days
180/30 days
90/30 days
40/30 days
30/30 days
30/30 days
240/30 days
30/30 days
30/30 days
40/30 days
1200/30 days
180/30 days
90/30 days
240/30 days
100/30 days
90/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
30/30 days
180/30 days
120/30 days
90/30 days
60/30 days
180/30 days
180/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
DENAVIR CRE 1%
desvenlafax tab 100mg er
desvenlafax tab 50mg er
dexmethylph tab 10mg
dexmethylph tab 2.5mg
dexmethylph tab 5mg
dextroamphet tab 10mg
dextroamphet tab 5mg
DIASTAT ACDL GEL 12.5-20MG
DIASTAT ACDL GEL 5-10MG
DIASTAT PED GEL 2.5MG
diazepam con 5mg/ml
DIAZEPAM GEL 10MG
DIAZEPAM GEL 2.5MG
DIAZEPAM GEL 20MG
diazepam sol 1mg/ml
diazepam tab 10mg
diazepam tab 2mg
diazepam tab 5mg
diclofenac gel 3%
didanosine cap 125mg
didanosine cap 200mg
didanosine cap 250mg
didanosine cap 400mg
donepezil tab 10mg
donepezil tab 10mg odt
donepezil tab 5mg
donepezil tab 5mg odt
doxazosin tab 1mg
doxazosin tab 2mg
doxazosin tab 4mg
doxazosin tab 8mg
dronabinol cap 10mg
dronabinol cap 2.5mg
dronabinol cap 5mg
DUAVEE TAB 0.45-20MG
DULOXETINE CAP 20MG
duloxetine cap 30mg
duloxetine cap 40mg
duloxetine cap 60mg
DURAMORPH INJ 0.5MG/ML
DURAMORPH INJ 1MG/ML
EDURANT TAB 25MG
EFFIENT TAB 10MG
EFFIENT TAB 5MG
ELIDEL CRE 1%
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
Drugs With Quantity Limits
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
EMEND CAP 125MG
EMEND CAP 40MG
EMEND CAP 80MG
EMEND PAK 80 & 125MG
EMSAM DIS 12MG/24HR
EMSAM DIS 6MG/24HR
EMSAM DIS 9MG/24HR
EMTRIVA CAP 200MG
EMTRIVA SOL 10MG/ML
ENABLEX TAB 15MG
ENABLEX TAB 7.5MG
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
ENBREL SRCLK 50MG/ML
endocet tab 10-325mg
endocet tab 5-325mg
endocet tab 7.5-325mg
enoxaparin inj 100mg/ml
enoxaparin inj 120/0.8ml
enoxaparin inj 150mg/ml
enoxaparin inj 30/0.3ml
enoxaparin inj 300/3ml
enoxaparin inj 40/0.4ml
enoxaparin inj 60/0.6ml
enoxaparin inj 80/0.8ml
entacapone tab 200mg
entecavir tab 0.5mg
entecavir tab 1mg
EPIPEN 2-PAK INJ 0.3MG
EPIPEN-JR INJ 2-PAK
EPOGEN INJ 2000/ML
EPOGEN INJ 3000/ML
EPOGEN INJ 4000/ML
eprosart mes tab 600mg
EPZICOM TAB 600-300MG
EQUETRO CAP 100MG
EQUETRO CAP 200MG
EQUETRO CAP 300MG
ERIVEDGE CAP 150MG
ESBRIET CAP 267MG
escitalopram sol 5mg/5ml
escitalopram tab 10mg
escitalopram tab 20mg
escitalopram tab 5mg
esomepra mag cap 20mg dr
ESTRING MIS 2MG
EVOTAZ TAB 300-150MG
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
850/30 days
30/30 days
30/30 days
8/28 days
16/28 days
8/28 days
8/28 days
120/30 days
120/30 days
120/30 days
28/30 days
22.4/30 days
28/30 days
8.4/30 days
84/30 days
11.2/30 days
16.8/30 days
22.4/30 days
270/30 days
30/30 days
30/30 days
1/30 days
1/30 days
12/28 days
12/28 days
12/28 days
30/30 days
30/30 days
480/30 days
240/30 days
180/30 days
30/30 days
270/30 days
620/30 days
60/30 days
30/30 days
120/30 days
60/30 days
1/90 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
90/30 days
60/30 days
720/30 days
360/30 days
180/30 days
120/30 days
90/30 days
30/30 days
270/30 days
90/30 days
180/30 days
120/30 days
270/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
30/30 days
180/30 days
120/30 days
30/30 days
28/28 days
30/30 days
9/30 days
120/30 days
120/30 days
EXELON DIS 13.3/24HR
EXELON DIS 4.6MG/24HR
EXELON DIS 9.5MG/24HR
exemestane tab 25mg
famciclovir tab 125mg
famciclovir tab 250mg
famciclovir tab 500mg
FANAPT PAK
FANAPT TAB 10MG
FANAPT TAB 12MG
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
FARESTON TAB 60MG
FAZACLO TAB 100/ODT
FAZACLO TAB 12.5/ODT
FAZACLO TAB 150MG
FAZACLO TAB 200MG
FAZACLO TAB 25MG ODT
fenofibrate cap 134mg
fenofibrate cap 200mg
fenofibrate cap 67mg
fenofibrate tab 145mg
fenofibrate tab 160mg
fenofibrate tab 48mg
fenofibrate tab 54mg
fentanyl dis 100mcg/hr
fentanyl dis 12mcg/hr
fentanyl dis 25mcg/hr
fentanyl dis 50mcg/hr
fentanyl dis 75mcg/hr
fentanyl ot loz 1200mcg
fentanyl ot loz 1600mcg
fentanyl ot loz 200mcg
fentanyl ot loz 400mcg
fentanyl ot loz 600mcg
fentanyl ot loz 800mcg
FETZIMA CAP 120MG
FETZIMA CAP 20MG
FETZIMA CAP 40MG
FETZIMA CAP 80MG
FETZIMA CAP TITRATION
finasteride tab 5mg
FIRAZYR INJ 30MG/3ML
FLOVENT DISK AER 100MCG
FLOVENT DISK AER 250MCG
111
Drugs With Quantity Limits
112
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
FLOVENT DISK AER 50MCG
FLOVENT HFA AER 110MCG
FLOVENT HFA AER 220MCG
FLOVENT HFA AER 44MCG
fluconazole tab 150mg
flunisolide spr 0.025%
fluoxetine cap 10mg
fluoxetine cap 20mg
fluoxetine cap 40mg
fluoxetine cap 90mg dr
fluoxetine sol 20mg/5ml
fluoxetine tab 10mg
fluoxetine tab 20mg
fluticasone spr 50mcg
fluvastatin cap 20mg
fluvastatin cap 40mg
fluvoxamine cap 100mg er
fluvoxamine cap 150mg er
fluvoxamine tab 100mg
fluvoxamine tab 25mg
fluvoxamine tab 50mg
fondaparinux sol 10/0.8ml
fondaparinux sol 2.5/0.5ml
fondaparinux sol 5.0/0.4ml
fondaparinux sol 7.5/0.6ml
FORADIL CAP AEROLIZE
FORFIVO XL TAB 450MG
FORTEO SOL 600/2.4ML
FRAGMIN INJ 10000/ML
FRAGMIN INJ 12500UNT
FRAGMIN INJ 15000UNT
FRAGMIN INJ 18000UNT
FRAGMIN INJ 2500/0.2ML
FRAGMIN INJ 5000/0.2ML
FUZEON INJ 90MG
FYCOMPA TAB 10MG
FYCOMPA TAB 12MG
FYCOMPA TAB 2MG
FYCOMPA TAB 4MG
FYCOMPA TAB 6MG
FYCOMPA TAB 8MG
gabapentin cap 100mg
gabapentin cap 300mg
gabapentin cap 400mg
gabapentin sol 250/5ml
gabapentin tab 600mg
gabapentin tab 800mg
galantamine cap 16mg er
120/30 days
24/30 days
24/30 days
21.2/30 days
180/30 days
50/30 days
30/30 days
30/30 days
60/30 days
5/30 days
600/30 days
240/30 days
120/30 days
16/30 days
60/30 days
60/30 days
60/30 days
60/30 days
90/30 days
360/30 days
180/30 days
20/30 days
15/30 days
20/30 days
20/30 days
60/30 days
30/30 days
3/28 days
20/30 days
20/30 days
20/30 days
20/30 days
20/30 days
20/30 days
60/30 days
30/30 days
30/30 days
120/30 days
90/30 days
60/30 days
30/30 days
360/30 days
360/30 days
270/30 days
2160/30 days
180/30 days
120/30 days
30/30 days
30/30 days
30/30 days
180/30 days
60/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
90/30 days
60/30 days
60/30 days
60/30 days
60/30 days
240/30 days
120/30 days
120/30 days
60/30 days
240/30 days
120/30 days
120/30 days
240/30 days
30/30 days
2/30 days
30/30 days
28/28 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
6/28 days
8/28 days
8/28 days
8/28 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
3600/30 days
3600/30 days
galantamine cap 24mg er
galantamine cap 8mg er
galantamine sol 4mg/ml
galantamine tab 12mg
galantamine tab 4mg
galantamine tab 8mg
GILENYA CAP 0.5MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
GLEEVEC TAB 100MG
GLEEVEC TAB 400MG
glimepiride tab 1mg
glimepiride tab 2mg
glimepiride tab 4mg
glip/metform tab 2.5-250mg
glip/metform tab 2.5-500mg
glip/metform tab 5-500mg
glipizide er tab 10mg
glipizide er tab 2.5mg
glipizide er tab 5mg
glipizide tab 10mg
glipizide tab 5mg
GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
granisetron tab 1mg
HARVONI TAB 90-400MG
HETLIOZ CAP 20MG
HUMALOG 100/ML
HUMALOG INJ 100/ML
HUMALOG KWIK 100/ML
HUMALOG KWIK 200/ML
HUMALOG MIX INJ 50/50
HUMALOG MIX INJ 50/50KWP
HUMALOG MIX INJ 75/25KWP
HUMALOG MIX SUS 75/25
HUMIRA INJ 10MG/0.2ML
HUMIRA KIT 20MG/0.4ML
HUMIRA KIT 40MG/0.8ML
HUMIRA PEN KIT CROHNS
HUMULIN INJ 70/30
HUMULIN N INJ U-100
HUMULIN N PN INJ U-100
HUMULIN PEN INJ 70/30
HUMULIN R INJ U-100
HUMULIN R INJ U-500
HYCET SOL 7.5-325MG
hydroco/apap sol 7.5-325mg
Drugs With Quantity Limits
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
hydroco/apap tab 10-300mg
hydroco/apap tab 10-325mg
hydroco/apap tab 5-300mg
hydroco/apap tab 5-325mg
hydroco/apap tab 7.5-300mg
hydroco/apap tab 7.5-325mg
hydrocod/ibu tab 7.5-200mg
hydromorphon tab 2mg
hydromorphon tab 4mg
hydromorphon tab 8mg
ibandronate tab 150mg
IBRANCE CAP 100MG
IBRANCE CAP 125MG
IBRANCE CAP 75MG
ICLUSIG TAB 15MG
IMBRUVICA CAP 140MG
INLYTA TAB 1MG
INLYTA TAB 5MG
INTELENCE TAB 100MG
INTELENCE TAB 200MG
INTELENCE TAB 25MG
INVEGA SUST INJ 117/0.75ML
INVEGA SUST INJ 156MG/ML
INVEGA SUST INJ 234/1.5ML
INVEGA SUST INJ 39/0.25ML
INVEGA SUST INJ 78/0.5ML
INVEGA TAB 1.5MG
INVEGA TAB 3MG
INVEGA TAB 6MG
INVEGA TAB 9MG
INVIRASE CAP 200MG
INVIRASE TAB 500MG
ipratropium spr 0.03%
ipratropium spr 0.06%
irbesar/hctz tab 150-12.5mg
irbesar/hctz tab 300-12.5mg
irbesartan tab 150mg
irbesartan tab 300mg
irbesartan tab 75mg
irenka cap 40mg
ISENTRESS CHW 100MG
ISENTRESS CHW 25MG
ISENTRESS POW 100MG
ISENTRESS TAB 400MG
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
1/28 days
30/30 days
30/30 days
30/30 days
90/30 days
120/30 days
240/30 days
120/30 days
120/30 days
60/30 days
480/30 days
2/28 days
2/28 days
2/28 days
2/28 days
2/28 days
240/30 days
120/30 days
60/30 days
60/30 days
300/30 days
120/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
90/30 days
180/30 days
720/30 days
300/30 days
120/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
30/30 days
30/30 days
180/30 days
90/30 days
360/30 days
480/30 days
300/30 days
120/30 days
60/30 days
60/30 days
60/30 days
120/30 days
240/30 days
28/28 days
120/30 days
4/28 days
60/30 days
900/30 days
60/30 days
30/30 days
60/30 days
60/30 days
30/30 days
30/30 days
5/30 days
30/30 days
120/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
30/30 days
30/30 days
30/30 days
180/30 days
120/30 days
30/30 days
14/14 days
14/14 days
JAKAFI TAB 5MG
JANUMET TAB 50-1000MG
JANUMET TAB 50-500MG
JANUMET XR TAB 100-1000MG
JANUMET XR TAB 50-1000MG
JANUMET XR TAB 50-500MG
JARDIANCE TAB 10MG
JARDIANCE TAB 25MG
JUXTAPID CAP 10MG
JUXTAPID CAP 20MG
JUXTAPID CAP 5MG
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
KALYDECO PAK 50MG
KALYDECO PAK 75MG
KALYDECO TAB 150MG
KHEDEZLA TAB 100MG ER
KHEDEZLA TAB 50MG ER
KINERET INJ
KORLYM TAB 300MG
KYNAMRO INJ 200MG/ML
lamivud/zido tab 150-300mg
lamivudine sol 10mg/ml
lamivudine tab 150mg
lamivudine tab 300mg
lansoprazole cap 15mg dr
lansoprazole cap 30mg dr
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
latanoprost sol 0.005%
LATUDA TAB 120MG
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
leflunomide tab 10mg
leflunomide tab 20mg
LETAIRIS TAB 10MG
LETAIRIS TAB 5MG
letrozole tab 2.5mg
LEVEMIR INJ
LEVEMIR INJ FLEXPEN
levetiraceta tab 500mg er
levetiraceta tab 750mg er
levocetirizi tab 5mg
levofloxacin tab 250mg
levofloxacin tab 500mg
113
Drugs With Quantity Limits
114
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
levofloxacin tab 750mg
levorphanol tab 2mg
LEXIVA SUS 50MG/ML
LEXIVA TAB 700MG
lidocaine pad 5%
lorazepam tab 0.5mg
lorazepam tab 1mg
lorazepam tab 2mg
lorcet tab 10-325mg
lorcet tab 5-325mg
lortab tab 10-325mg
lortab tab 5-325mg
lortab tab 7.5-325mg
losartan pot tab 100mg
losartan pot tab 25mg
losartan pot tab 50mg
losartan/hct tab 100-12.5mg
losartan/hct tab 100-25mg
losartan/hct tab 50-12.5mg
LOTRONEX TAB 0.5MG
LOTRONEX TAB 1MG
lovastatin tab 10mg
lovastatin tab 20mg
lovastatin tab 40mg
LUMIGAN SOL 0.01%
LUPRON DEPOT INJ 3.75MG
LYNPARZA CAP 50MG
LYRICA CAP 100MG
LYRICA CAP 150MG
LYRICA CAP 200MG
LYRICA CAP 225MG
LYRICA CAP 25MG
LYRICA CAP 300MG
LYRICA CAP 50MG
LYRICA CAP 75MG
LYRICA SOL 20MG/ML
maprotiline tab 25mg
maprotiline tab 50mg
medroxypr ac inj 150mg/ml
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
meloxicam tab 15mg
meloxicam tab 7.5mg
metadate tab 20mg er
metformin er tab 1000mg
metformin tab 1000mg
metformin tab 500mg
metformin tab 500mg er
14/14 days
120/30 days
1800/30 days
120/30 days
90/30 days
60/30 days
60/30 days
60/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
30/30 days
30/30 days
60/30 days
7.5/30 days
1/28 days
480/30 days
180/30 days
120/30 days
90/30 days
60/30 days
720/30 days
60/30 days
360/30 days
240/30 days
900/30 days
270/30 days
135/30 days
1/90 days
120/30 days
30/30 days
30/30 days
30/30 days
90/30 days
60/30 days
90/30 days
150/30 days
120/30 days
90/30 days
90/30 days
120/30 days
600/30 days
1200/30 days
120/30 days
120/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
30/30 days
60/30 days
30/30 days
30/30 days
3/3 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
1800/30 days
900/30 days
180/30 days
120/30 days
120/30 days
120/30 days
120/30 days
metformin tab 750mg er
metformin tab 850mg
methadone inj 10mg/ml
methadone sol 10mg/5ml
methadone sol 5mg/5ml
methadone tab 10mg
methadone tab 5mg
methylphenid tab 10mg
methylphenid tab 10mg er
methylphenid tab 20mg
methylphenid tab 20mg er
methylphenid tab 5mg
metoprolol tab 100mg er
metoprolol tab 200mg er
metoprolol tab 25mg er
metoprolol tab 50mg er
miconazole 3 sup 200mg
mirtazapine tab 15mg
mirtazapine tab 15mg odt
mirtazapine tab 30mg
mirtazapine tab 30mg odt
mirtazapine tab 45mg
mirtazapine tab 45mg odt
mirtazapine tab 7.5mg
modafinil tab 100mg
modafinil tab 200mg
montelukast chw 4mg
montelukast chw 5mg
montelukast gra 4mg
montelukast tab 10mg
morphine sul cap 100mg er
morphine sul cap 10mg er
morphine sul cap 120mg er
morphine sul cap 20mg er
morphine sul cap 30mg er
morphine sul cap 45mg er
morphine sul cap 50mg er
morphine sul cap 60mg er
morphine sul cap 75mg er
morphine sul cap 80mg er
morphine sul cap 90mg er
morphine sul sol 10mg/5ml
morphine sul sol 20mg/5ml
morphine sul sol 20mg/ml
morphine sul tab 100mg er
morphine sul tab 15mg
morphine sul tab 15mg er
morphine sul tab 200mg er
Drugs With Quantity Limits
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
morphine sul tab 30mg
morphine sul tab 30mg er
morphine sul tab 60mg er
MULTAQ TAB 400MG
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
nalbuphine inj 10mg/ml
nalbuphine inj 20mg/ml
NAMENDA SOL 10MG/5ML
NAMENDA TAB 10MG
NAMENDA TAB 5-10MG
NAMENDA TAB 5MG
naratriptan tab 1mg
naratriptan tab 2.5mg
nateglinide tab 120mg
nateglinide tab 60mg
NATPARA INJ 100MCG
NATPARA INJ 25MCG
NATPARA INJ 50MCG
NATPARA INJ 75MCG
nefazodone tab 100mg
nefazodone tab 150mg
nefazodone tab 200mg
nefazodone tab 250mg
nefazodone tab 50mg
NEULASTA INJ 6MG/0.6ML
NEUMEGA INJ 5MG
NEUPRO DIS 1MG/24HR
NEUPRO DIS 2MG/24HR
NEUPRO DIS 3MG/24HR
NEUPRO DIS 4MG/24HR
NEUPRO DIS 6MG/24HR
NEUPRO DIS 8MG/24HR
nevirapine 400 mg extended release
nevirapine sus 50mg/5ml
nevirapine tab 200mg
NEXAVAR TAB 200MG
NICOTROL NS SPR 10MG/ML
NILANDRON TAB 150MG
nitroglycer dis 0.1mg/hr
nitroglycer dis 0.2mg/hr
nitroglycer dis 0.4mg/hr
nitroglyceri dis 0.6mg/hr
norco tab 10-325mg
norco tab 5-325mg
norco tab 7.5-325mg
NORTHERA CAP 100MG
NORTHERA CAP 200MG
120/30 days
120/30 days
120/30 days
60/30 days
30/30 days
30/30 days
120/30 days
120/30 days
360/30 days
60/30 days
60/30 days
60/30 days
9/30 days
9/30 days
90/30 days
90/30 days
2/28 days
2/28 days
2/28 days
2/28 days
180/30 days
120/30 days
90/30 days
72/30 days
360/30 days
2/30 days
21/21 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
1200/30 days
60/30 days
120/30 days
40/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
120/30 days
120/30 days
120/30 days
14/1 days
14/1 days
14/1 days
360/30 days
480/30 days
360/30 days
630/30 days
60/30 days
60/30 days
60/30 days
30/30 days
30/30 days
90/30 days
90/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
60/30 days
240/30 days
30/30 days
30/30 days
120/30 days
120/30 days
90/30 days
30/30 days
120/30 days
60/30 days
60/30 days
60/30 days
150/5 days
30/30 days
12/5 days
12/5 days
12/5 days
12/5 days
480/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
4/28 days
60/30 days
60/30 days
60/30 days
120/30 days
480/30 days
240/30 days
NORTHERA CAP 300MG
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
NOXAFIL SUS 40MG/ML
NUEDEXTA CAP 20-10MG
OFEV CAP 100MG
OFEV CAP 150MG
olanza/fluox cap 12-25mg
olanza/fluox cap 12-50mg
olanza/fluox cap 3-25mg
olanza/fluox cap 6-25mg
olanza/fluox cap 6-50mg
olanzapine inj 10mg
olanzapine tab 10mg
olanzapine tab 10mg odt
olanzapine tab 15mg
olanzapine tab 15mg odt
olanzapine tab 2.5mg
olanzapine tab 20mg
olanzapine tab 20mg odt
olanzapine tab 5mg
olanzapine tab 5mg odt
olanzapine tab 7.5mg
OLYSIO CAP 150MG
omega-3-acid cap 1gm
omeprazole cap 10mg
omeprazole cap 20mg
omeprazole cap 40mg
ondansetron sol 4mg/5ml
ondansetron tab 24mg
ondansetron tab 4mg
ondansetron tab 4mg odt
ondansetron tab 8mg
ondansetron tab 8mg odt
ONFI SUS 2.5MG/ML
ONFI TAB 10MG
ONFI TAB 20MG
ONGLYZA TAB 2.5MG
ONGLYZA TAB 5MG
OPSUMIT TAB 10MG
ORENCIA INJ 125MG/ML
OTEZLA 30MG
OTEZLA TAB 10/20/30MG
oxandrolone tab 10mg
oxandrolone tab 2.5mg
OXTELLAR XR TAB 150MG
OXTELLAR XR TAB 300MG
115
Drugs With Quantity Limits
116
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
OXTELLAR XR TAB 600MG
oxybutynin syp 5mg/5ml
oxybutynin tab 10mg er
oxybutynin tab 15mg er
oxybutynin tab 5mg
oxybutynin tab 5mg er
oxycod/apap tab 10-325mg
oxycod/apap tab 2.5-325mg
oxycod/apap tab 5-325mg
oxycod/apap tab 7.5-325mg
oxycod/asa tab
oxycod/ibu tab 5-400mg
oxycodone cap 5mg
oxycodone con 100/5ml
oxycodone sol 5mg/5ml
oxycodone tab 10mg
oxycodone tab 15mg
oxycodone tab 20mg
oxycodone tab 30mg
oxycodone tab 5mg
OXYCONTIN TAB 10MG CR
OXYCONTIN TAB 15MG CR
OXYCONTIN TAB 20MG CR
OXYCONTIN TAB 30MG CR
OXYCONTIN TAB 40MG CR
OXYCONTIN TAB 60MG CR
OXYCONTIN TAB 80MG CR
OXYTROL DIS 3.9MG/24HR
pantoprazole tab 20mg
pantoprazole tab 40mg
paroxetin er tab 12.5mg
paroxetin er tab 37.5mg
paroxetine tab 10mg
paroxetine tab 20mg
paroxetine tab 25mg er
paroxetine tab 30mg
paroxetine tab 40mg
PAXIL SUS 10MG/5ML
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 120MCG
PEG-INTRON KIT 150 RP
PEG-INTRON KIT 150MCG
PEG-INTRON KIT 50MCG
PEG-INTRON KIT 50MCG RP
PEG-INTRON KIT 80MCG
PEG-INTRON KIT 80MCG RP
PEGASYS INJ 180MCG/0.5ML
PEGASYS INJ 180MCG/ML
PEGASYS PROCLICK
120/30 days
600/30 days
90/30 days
60/30 days
120/30 days
180/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
1800/30 days
120/30 days
120/30 days
120/30 days
120/30 days
120/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
8/28 days
60/30 days
60/30 days
150/30 days
60/30 days
90/30 days
60/30 days
90/30 days
60/30 days
45/30 days
900/30 days
4/28 days
4/28 days
4/28 days
4/28 days
5/28 days
4/28 days
4/28 days
4/28 days
2/28 days
4/28 days
2/28 days
1500/30 days
90/30 days
120/30 days
360/30 days
195/30 days
180/30 days
60/30 days
90/30 days
60/30 days
90/30 days
90/30 days
90/30 days
90/30 days
30/30 days
30/30 days
30/30 days
120/30 days
60/30 days
30/30 days
30/30 days
180/30 days
120/30 days
90/30 days
720/30 days
60/30 days
60/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
90/30 days
30/30 days
30/30 days
60/30 days
30/30 days
30/30 days
400/30 days
180/30 days
60/30 days
300/30 days
60/30 days
30/30 days
240/30 days
240/30 days
17/30 days
12/28 days
12/28 days
12/28 days
phenobarb elx 20mg/5ml
phenobarb tab 100mg
phenobarb tab 15mg
phenobarb tab 16.2mg
phenobarb tab 30mg
phenobarb tab 32.4mg
phenobarb tab 60mg
PHENOBARB TAB 64.8MG
PHENOBARB TAB 97.2MG
pioglit/glim tab 30-2mg
pioglit/glim tab 30-4mg
pioglita/met tab 15-500mg
pioglita/met tab 15-850mg
pioglitazone tab 15mg
pioglitazone tab 30mg
pioglitazone tab 45mg
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
POTIGA TAB 50MG
PRADAXA CAP 150MG
PRADAXA CAP 75MG
pramipexole tab 0.125mg
pramipexole tab 0.25mg
pramipexole tab 0.5mg
pramipexole tab 0.75mg
pramipexole tab 1.5mg
pramipexole tab 1mg
pravastatin tab 10mg
pravastatin tab 20mg
pravastatin tab 40mg
pravastatin tab 80mg
PREZCOBIX TAB 800-150MG
PREZISTA SUS 100MG/ML
PREZISTA TAB 150MG
PREZISTA TAB 600MG
PREZISTA TAB 75MG
PREZISTA TAB 800MG
PRISTIQ TAB 100MG
PRISTIQ TAB 25MG
PRISTIQ TAB 50MG
PROAIR HFA AER
PROCRIT INJ 10000/ML
PROCRIT INJ 2000/ML
PROCRIT INJ 20000/ML
Drugs With Quantity Limits
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 40000/ML
PROLIA SOL 60MG/ML
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
PROVENTIL AER HFA
PULMICORT INH 180MCG
PULMICORT INH 90MCG
quetiapine tab 100mg
quetiapine tab 200mg
quetiapine tab 25mg
quetiapine tab 300mg
quetiapine tab 400mg
quetiapine tab 50mg
QVAR AER 40MCG
rabeprazole tab 20mg
raloxifene tab 60mg
ramipril cap 1.25mg
ramipril cap 10mg
ramipril cap 2.5mg
ramipril cap 5mg
RANEXA TAB 1000MG
RANEXA TAB 500MG
RAVICTI LIQ 1.1GM/ML
REBIF INJ 22/0.5ML
REBIF INJ 44/0.5ML
REBIF TITRTN SOL PACK
RELENZA MIS DISKHALE
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 200MG
RESTASIS EMU 0.05%
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 2.5MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
REVLIMID CAP 5MG
REYATAZ CAP 150MG
REYATAZ CAP 200MG
REYATAZ CAP 300MG
REYATAZ POW 50MG
RISPERDAL INJ 12.5MG
12/28 days
12/28 days
12/28 days
2/365 days
90/30 days
90/30 days
90/30 days
90/30 days
13.4/30 days
2/30 days
2/30 days
240/30 days
120/30 days
960/30 days
90/30 days
60/30 days
480/30 days
34.8/30 days
60/30 days
30/30 days
30/30 days
60/30 days
30/30 days
30/30 days
120/30 days
120/30 days
525/30 days
12/30 days
12/30 days
6/30 days
60/180 days
180/30 days
90/30 days
270/30 days
360/30 days
180/30 days
60/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
150/30 days
60/30 days
60/30 days
30/30 days
240/30 days
8/28 days
4/28 days
3/28 days
480/30 days
1920/30 days
1920/30 days
960/30 days
960/30 days
480/30 days
480/30 days
240/30 days
240/30 days
180/30 days
180/30 days
120/30 days
120/30 days
60/30 days
60/30 days
60/30 days
60/30 days
30/30 days
180/30 days
180/30 days
30/30 days
60/30 days
240/30 days
120/30 days
120/30 days
120/30 days
60/30 days
60/30 days
120/30 days
60/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
300/30 days
60/30 days
240/30 days
120/30 days
90/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
1/28 days
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
risperidone sol 1mg/ml
risperidone tab 0.25 odt
risperidone tab 0.25mg
risperidone tab 0.5mg
risperidone tab 0.5mg odt
risperidone tab 1mg
risperidone tab 1mg odt
risperidone tab 2mg
risperidone tab 2mg odt
risperidone tab 3mg
risperidone tab 3mg odt
risperidone tab 4mg
risperidone tab 4mg odt
rivastigmine cap 1.5mg
rivastigmine cap 3mg
rivastigmine cap 4.5mg
rivastigmine cap 6mg
ROZEREM TAB 8MG
SABRIL POW 500MG
SABRIL TAB 500MG
SANTYL OIN 250/GM
SAPHRIS SUB 10MG
SAPHRIS SUB 2.5MG
SAPHRIS SUB 5MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
SENSIPAR TAB 30MG
SENSIPAR TAB 60MG
SENSIPAR TAB 90MG
SEREVENT DIS AER 50MCG
SEROQUEL XR TAB 150MG
SEROQUEL XR TAB 200MG
SEROQUEL XR TAB 300MG
SEROQUEL XR TAB 400MG
SEROQUEL XR TAB 50MG
sertraline con 20mg/ml
sertraline tab 100mg
sertraline tab 25mg
sertraline tab 50mg
sildenafil tab 20mg
SIMCOR TAB 1000-20MG
SIMCOR TAB 1000-40MG
SIMCOR TAB 500-20MG
SIMCOR TAB 500-40MG
SIMCOR TAB 750-20MG
SIMPONI INJ 50MG
117
Drugs With Quantity Limits
118
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
simvastatin tab 10mg
simvastatin tab 20mg
simvastatin tab 40mg
simvastatin tab 5mg
simvastatin tab 80mg
SOVALDI TAB 400MG
SPIRIVA CAP HANDIHLR
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
stavudine cap 15mg
stavudine cap 20mg
stavudine cap 30mg
stavudine cap 40mg
stavudine sol 1mg/ml
STIVARGA TAB 40MG
STRATTERA CAP 100MG
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
STRATTERA CAP 80MG
STRIBILD TAB
SUBOXONE MIS 12-3MG
SUBOXONE MIS 2-0.5MG
SUBOXONE MIS 4-1MG
SUBOXONE MIS 8-2MG
sumatriptan inj 6mg/0.5ml
sumatriptan tab 100mg
sumatriptan tab 25mg
sumatriptan tab 50mg
SUSTIVA CAP 200MG
SUSTIVA CAP 50MG
SUSTIVA TAB 600MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
SYLATRON KIT 296MCG
SYLATRON KIT 444MCG
SYLATRON KIT 888MCG
SYMBICORT AER 160-4.5
SYMBICORT AER 80-4.5
SYMLINPEN 60 INJ 1000MCG
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
90/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
120/30 days
120/30 days
60/30 days
60/30 days
2400/30 days
84/28 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
60/30 days
30/30 days
60/30 days
90/30 days
45/30 days
90/30 days
6/30 days
9/30 days
9/30 days
9/30 days
120/30 days
360/30 days
30/30 days
90/30 days
30/30 days
30/30 days
30/30 days
5/28 days
5/28 days
5/28 days
10.2/30 days
10.2/30 days
10.8/30 days
10.8/30 days
180/30 days
120/30 days
84/180 days
42/180 days
42/180 days
900/180 days
60/30 days
30/30 days
30/30 days
90/30 days
60/30 days
120/30 days
120/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
30/30 days
30/30 days
30/30 days
30/30 days
3/3 days
30/30 days
60/30 days
60/30 days
30/30 days
60/30 days
60/30 days
30/30 days
30/30 days
60/30 days
60/30 days
480/30 days
240/30 days
1920/30 days
960/30 days
30/30 days
30/30 days
60/30 days
120/30 days
240/30 days
30/30 days
SYMLNPEN 120 INJ 1000MCG
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
tamsulosin cap 0.4mg
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TARCEVA TAB 25MG
TARGRETIN GEL 1%
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TEKTURNA HCT TAB 150-12.5MG
TEKTURNA HCT TAB 150-25MG
TEKTURNA HCT TAB 300-12.5MG
TEKTURNA HCT TAB 300-25MG
TEKTURNA TAB 150MG
TEKTURNA TAB 300MG
telmisa/hctz tab 40-12.5mg
telmisa/hctz tab 80-25mg
terazosin cap 10mg
terazosin cap 1mg
terazosin cap 2mg
terazosin cap 5mg
terbinafine tab 250mg
terconazole sup 80mg
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG
THALOMID CAP 50MG
ticlopidine tab 250mg
TIVICAY TAB 50MG
tolterodine cap 2mg er
tolterodine cap 4mg er
tolterodine tab 1mg
tolterodine tab 2mg
topiramate tab 100mg
topiramate tab 200mg
topiramate tab 25mg
topiramate tab 50mg
TOVIAZ TAB 4MG
TOVIAZ TAB 8MG
TRACLEER TAB 125MG
TRACLEER TAB 62.5MG
tramadl/apap tab 37.5-325mg
tramadol hcl tab 100mg er
Drugs With Quantity Limits
Covered Drug
Quantity Limit Covered Drug
Quantity Limit
tramadol hcl tab 200mg er
tramadol hcl tab 300mg er
tramadol hcl tab 50mg
trandolapril tab 1mg
trandolapril tab 2mg
trandolapril tab 4mg
TRANSDERM-SC DIS 1.5MG
TRELSTAR MIX INJ 22.5MG
tretinoin cre 0.025%
tretinoin cre 0.05%
tretinoin cre 0.1%
tretinoin gel 0.01%
tretinoin gel 0.025%
triamcinolon spr 55mcg/ac
TRIUMEQ TAB
TRUVADA TAB 200-300MG
TYBOST TAB 150MG
TYKERB TAB 250MG
valacyclovir tab 1gm
valacyclovir tab 500mg
valsart/hctz tab 160-12.5mg
valsart/hctz tab 160-25mg
valsart/hctz tab 320-12.5mg
valsart/hctz tab 320-25mg
valsart/hctz tab 80-12.5mg
valsartan tab 160mg
valsartan tab 320mg
valsartan tab 40mg
valsartan tab 80mg
vancomycin cap 125mg
vancomycin cap 250mg
venlafaxine cap 150mg er
venlafaxine cap 37.5mg
venlafaxine cap 75mg er
venlafaxine tab 100mg
venlafaxine tab 150mg er
venlafaxine tab 225mg er
venlafaxine tab 25mg
venlafaxine tab 37.5 er
venlafaxine tab 37.5mg
venlafaxine tab 50mg
venlafaxine tab 75mg
venlafaxine tab 75mg er
VENTOLIN HFA AER
VERAMYST SPR 27.5MCG
VERSACLOZ SUS 50MG/ML
VIAGRA TAB 100MG
VIAGRA TAB 25MG
30/30 days
30/30 days
240/30 days
30/30 days
30/30 days
60/30 days
24/30 days
1/168 days
45/30 days
45/30 days
45/30 days
45/30 days
45/30 days
33/30 days
30/30 days
30/30 days
30/30 days
180/30 days
30/1 days
30/1 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
30/30 days
90/30 days
90/30 days
40/30 days
80/30 days
60/30 days
180/30 days
90/30 days
90/30 days
60/30 days
30/30 days
270/30 days
180/30 days
180/30 days
150/30 days
150/30 days
90/30 days
36/30 days
20/30 days
540/30 days
6/30 days
6/30 days
6/30 days
120/30 days
120/30 days
120/30 days
1200/30 days
112/28 days
120/30 days
60/30 days
30/30 days
1200/30 days
1200/30 days
60/30 days
60/30 days
60/30 days
60/30 days
300/30 days
120/30 days
120/30 days
240/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
120/30 days
120/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
51/30 days
30/30 days
30/30 days
30/30 days
240/30 days
120/30 days
1.7/28 days
120/30 days
120/30 days
120/30 days
120/30 days
540/30 days
60/30 days
60/30 days
VIAGRA TAB 50MG
vicodin es tab 7.5-300mg
vicodin hp tab 10-300mg
vicodin tab 5-300mg
VIDEX SOL 2GM
VIEKIRA PAK TAB
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
VIMPAT INJ 200MG/20ML
VIMPAT SOL 10MG/ML
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
VIMPAT TAB 50MG
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
VIRAMUNE XR TAB 100MG
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
VITEKTA TAB 150MG
VITEKTA TAB 85MG
voriconazole tab 200mg
voriconazole tab 50mg
VOTRIENT TAB 200MG
VYTORIN TAB 10-10MG
VYTORIN TAB 10-20MG
VYTORIN TAB 10-40MG
VYTORIN TAB 10-80MG
XALKORI CAP 200MG
XALKORI CAP 250MG
XARELTO STAR TAB 15/20MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
XENAZINE TAB 12.5MG
XENAZINE TAB 25MG
XGEVA INJ
XODOL TAB 10-300MG
XODOL TAB 5-300MG
XODOL TAB 7.5-300MG
XTANDI CAP 40MG
XYREM SOL 500MG/ML
zafirlukast tab 10mg
zafirlukast tab 20mg
119
Drugs With Quantity Limits
120
Covered Drug
Quantity Limit Covered Drug
zaleplon cap 10mg
zaleplon cap 5mg
ZELBORAF TAB 240MG
ZETIA TAB 10MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100mg
zidovudine syp 50mg/5ml
zidovudine tab 300mg
ziprasidone cap 20mg
ziprasidone cap 40mg
ziprasidone cap 60mg
ziprasidone cap 80mg
ZMAX SUS 2GM
ZOLINZA CAP 100MG
zolpidem er tab 12.5mg
zolpidem er tab 6.25mg
zolpidem tab 10mg
zolpidem tab 5mg
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.75MG
ZOVIRAX CRE 5%
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
ZYFLO CR TAB 600MG
ZYFLO TAB 600MG
ZYKADIA CAP 150MG
ZYTIGA TAB 250MG
ZYVOX TAB 600MG
60/30 days
30/30 days
240/30 days
30/30 days
960/30 days
180/30 days
1920/30 days
60/30 days
240/30 days
120/30 days
90/30 days
60/30 days
60/30 days
120/30 days
30/30 days
30/30 days
30/30 days
30/30 days
60/30 days
60/30 days
60/30 days
10/30 days
90/30 days
60/30 days
120/30 days
120/30 days
150/30 days
120/30 days
28/14 days
Quantity Limit
Step Therapy Criteria
Cardiovascular Agents, Dyslipidemics
A one month trial of TWO Step1 drugs are required to use this Step 2 drug.
Step 1 Drugs
Step 2 Drugs
atorvastatin 10mg Tablets
VYTORIN 10-10MG TABLETS
atorvastatin 20mg Tablets
VYTORIN 10-20MG TABLETS
atorvastatin 40mg Tablets
VYTORIN 10-40MG TABLETS
atorvastatin 80mg Tablets
VYTORIN 10-80MG TABLETS
CRESTOR 5MG TABLETS
CRESTOR 10MG TABLETS
CRESTOR 20MG TABLETS
CRESTOR 40MG TABLETS
lovastatin 10mg Tablets
lovastatin 20mg Tablets
lovastatin 40mg Tablets
pravastatin 10mg Tablets
pravastatin 20mg Tablets
pravastatin 40mg Tablets
pravastatin 80mg Tablets
simvastatin 5mg Tablets
simvastatin 10mg Tablets
simvastatin 20mg Tablets
simvastatin 40mg Tablets
simvastatin 80mg Tablets
Pharmacy claims will be reviewed using a look back period of 180 days.
121
Free First Fill Program
Free First Fill Criteria
The Free First Fill Program offers members the opportunity to change therapy from a brand
(Targeted Medication list below) over to a designated generic medication (Generic Alternative
list below) in which the member would receive their first 30 day fill on that generic medication for
a $0 copayment. Members taking a targeted brand name medication are sent a letter notifying
them that they have the opportunity to receive one of the designated generic alternative at a
$0 copayment if they choose to change their therapy to this alternative agent.
THERAPEUTIC CLASS
METABOLIC BONE DISEASE
THERAPEUTIC CLASS
CARDIOVASCULAR AGENTS
THERAPEUTIC CLASS
CARDIOVASCULAR AGENTS
122
TARGETED BRAND MEDICATIONS
ACTONEL TAB 5MG, 30MG,
35MG, 75MG, 150MG
ATELVIA TAB
BINOSTO TAB 70MG
BONIVA TAB 2.5MG,150MG
FOSAMAX TAB 5MG,10MG,
35MG, 40MG, 70MG
TARGETED BRAND MEDICATIONS
COREG CR CAP
10MG,20MG,40MG,80MG
COREG TAB 3.125MG,
6.25MG, 12.5MG, 25MG
TARGETED BRAND MEDICATIONS
ATACAND HCT TAB
16-12.5MG,32-12.5MG,3225MG
ATACAND TAB
4MG,8MG,16MG,32MG
AVALIDE TAB
150-12.5MG,300-12.5MG
AVAPRO TAB
75MG,150MG,300MG
BENICAR HCT TAB
20-12.5MG,40-12.5MG,4025MG
BENICAR TAB
5MG,20MG,40MG
COZAAR TAB
25MG,50MG,100MG
DIOVAN HCT TAB
80-12.5MG,160-12.5MG,16025MG, 320-12.5MG,320-25MG
DIOVAN TAB
40MG,80MG,160MG,320MG
EDARBI TAB 40MG,80MG
GENERIC ALTERNATIVES
ALENDRONATE TAB
5MG,10MG, 35MG,
40MG,70MG
GENERIC ALTERNATIVES
CARVEDILOL TAB 3.125MG,
6.25MG, 12.5MG, 25MG
GENERIC ALTERNATIVES
LOSARTAN POT TAB
25MG,50MG,100MG
LOSARTAN HCT TAB
50-12.5MG,100-12.5MG,10025MG
Free First Fill Program
EDARBYCLOR TAB
40-12.5MG,40-25MG
HYZAAR TAB 50-12.5MG,10012.5MG, 100-25MG
MICARDIS HCT TAB
40-12.5MG,80-12.5MG,80CARDIOVASCULAR AGENTS 25MG
(Continued)
MICARDIS TAB
20MG,40MG,80MG
TEVETEN HCT TAB
600-12.5MG,600-25MG
TEVETEN TAB 600MG
THERAPEUTIC CLASS
TARGETED BRAND MEDICATIONS
ALTOPREV TAB 20MG
ER,40MG ER,60MG ER
CRESTOR TAB
5MG,10MG,20MG,40MG
LESCOL CAP 20MG,40MG
LESCOL XL TAB 80MG
LIPITOR TAB
10MG,20MG,40MG,80MG
CARDIOVASCULAR AGENTS LIPTRUZET 10-10MG, 1020MG, 10-40MG, 10-80MG
LIVALO TAB 1MG,2MG,4MG
MEVACOR TAB 20MG,40MG
PRAVACHOL TAB
20MG,40MG,80MG
VYTORIN TAB 10-10MG,1020MG,10-40MG,10-80MG
ZOCOR TAB
5MG,10MG,20MG,
40MG,80MG
THERAPEUTIC CLASS
TARGETED BRAND MEDICATIONS
ASTELIN NASAL SPR 137MCG
ASTEPRO SPR 0.15%
ASTEPRO SPR 137MCG
BECONASE AQ SUS 0.042%
RESPIRATORY TRACT AGENTS FLONASE SPR 0.05%
NASACORT AQ AER 55MCG/AC
NASAREL SPR 29MCG
NASONEX SPR 50MCG/AC
OMNARIS SPR
LOSARTAN POT TAB
25MG,50MG,100MG
LOSARTAN HCT TAB
50-12.5MG,100-12.5MG,10025MG
GENERIC ALTERNATIVES
ATORVASTATIN 10MG,20MG,
40MG,80MG
SIMVASTATIN TAB
5MG,10MG,20MG,40MG,
80MG
GENERIC ALTERNATIVES
FLUTICASONE SPR 50MCG
123
Free First Fill Program
PATANASE SPR 0.6%
QNASL AER 80MCG
RESPIRATORY TRACT AGENTS RHINOCORT SUS AQUA
(Continued)
VERAMYST SPR 27.5MCG
ZETONNA AER 37MCG
THERAPEUTIC CLASS
TARGETED BRAND MEDICATIONS
ACIPHEX TAB 20MG
DEXILANT CAP 30MG DR,60MG DR
NEXIUM CAP 20MG,40MG
NEXIUM GRA 10MG DR,20MG
DR,40MG DR
GASTROINTESTINAL AGENTS PREVACID CAP 15MG DR,30MG DR
PREVACID TAB 15MG
STB,30MG STB
PRILOSEC CAP
10MG,20MG,40MG
PROTONIX TAB 20MG,40MG
THERAPEUTIC CLASS
TARGETED BRAND MEDICATIONS
AVODART CAP 0.5MG
GENITOURINARY AGENTS
PROSCAR TAB 5MG
THERAPEUTIC CLASS
TARGETED BRAND MEDICATIONS
CARDURA XL TAB 4MG,8MG
FLOMAX CAP 0.4MG
GENITOURINARY AGENTS
JALYN CAP
RAPAFLO CAP 4MG,8MG
UROXATRAL TAB 10MG
THERAPEUTIC CLASS
TARGETED BRAND MEDICATIONS
CELEXA SOL 10MG/5ML
CELEXA TAB
10MG,20MG,40MG
EFFEXOR TAB 75MG
EFFEXOR XR CAP
37.5MG,75MG,150MG
FETZIMA CAP
20MG,40MG,80MG,120MG
ANTIDEPRESSANTS
FETZIMA CAP TITRATION
KHEDEZLA TAB 50MG
ER,100MG ER
LEXAPRO SOL 5MG/5ML
LEXAPRO TAB
5MG,10MG,20MG
LUVOX CR CAP 100MG,150MG
124
FLUTICASONE SPR 50MCG
GENERIC ALTERNATIVES
OMEPRAZOLE CAP
10MG,20MG,40MG
GENERIC ALTERNATIVES
FINASTERIDE TAB 5MG
GENERIC ALTERNATIVES
TAMSULOSIN CAP 0.4MG
GENERIC ALTERNATIVES
CITALOPRAM TAB
10MG,20MG,40MG,
PAROXETINE TAB
10MG,20MG,30MG,40MG,
VENLAFAXINE ER CAP
37.5MG,75MG,150MG
Free First Fill Program
ANTIDEPRESSANTS
(Continued)
THERAPEUTIC CLASS
ANTIPSYCHOTICS
PAXIL CR TAB
12.5MG,25MG,37.5MG
PAXIL SUS 10MG/5ML
PAXIL TAB
10MG,20MG,30MG,40MG
PEXEVA TAB
10MG,20MG,30MG,40MG
PRISTIQ TAB 50MG,100MG
PROZAC CAP
10MG,20MG,40MG
PROZAC SOL 20MG/5ML
PROZAC WEEKLY CAP 90MG
VENLAFAXINE TAB 225MG ER
ZOLOFT TAB
25MG,50MG,100MG
TARGETED BRAND MEDICATIONS
ABILIFY DISC TAB 10MG,15MG
ABILIFY TAB 2MG, 5MG,
10MG, 15MG, 20MG, 30MG
EQUETRO CAP
100MG,200MG,300MG
FANAPT TAB 1MG, 2MG, 4MG,
6MG, 8MG, 10MG, 12MG
FAZACLO TAB 12.5MG, 25MG,
100MG, 150MG, 200MG
GEODON CAP
20MG,40MG,60MG,80MG
INVEGA TAB 3MG,6MG,9MG
LATUDA TAB
20MG,40MG,80MG
RISPERDAL M TAB
0.5MG,1MG,2MG,3MG,4MG
RISPERDAL TAB 0.25MG,
0.5MG, 1MG, 2MG, 3MG, 4MG
SEROQUEL TAB 25MG,50MG,
100MG,200MG,300MG,400MG
SEROQUEL XR TAB
200MG,300MG,400MG
ZYPREXA TAB 2.5MG, 5MG,
7.5MG, 10MG, 15MG, 20MG
ZYPREXA ZYDIS TAB
5MG,10MG,15MG,20MG
CITALOPRAM TAB
10MG,20MG,40MG,
PAROXETINE TAB
10MG,20MG,30MG,40MG,
VENLAFAXINE ER CAP
37.5MG,75MG,150MG
GENERIC ALTERNATIVES
RISPERIDONE TAB 0.25MG,
0.5MG, 1MG, 2MG, 3MG, 4MG
OLANZAPINE TAB 2.5MG,
5MG, 7.5MG, 10MG, 15MG,
20MG
125
Free First Fill Program
THERAPEUTIC CLASS
ANALGESICS
THERAPEUTIC CLASS
OPHTHALMIC AGENTS
126
TARGETED BRAND MEDICATIONS
ARTHROTEC TAB 50MG,75MG
CELEBREX CAP
50MG,100MG,200MG,400MG
MOBIC TAB 7.5MG,15MG
PONSTEL CAP 250MG
TARGETED BRAND MEDICATIONS
LUMIGAN SOL 0.01%,0.03%
RESCULA SOL 0.15%
TRAVATAN DROP 0.004%
TRAVATAN Z DROP 0.004%
XALATAN SOL 0.005%
ZIOPTAN DRO 0.0015%
GENERIC ALTERNATIVES
IBUPROFEN TAB
400MG,600MG,800MG
MELOXICAM TAB
7.5MG,15MG
GENERIC ALTERNATIVES
LATANOPROST SOL 0.005%
Index of Drugs
A
abacav/lamiv/zidovud . . . . . . . . . . . . . . 50
abacavir . . . . . . . . . . . . . . . . . . . . . . . . . 51
abacavir - dolutegravir - . . . . . . . . . . . 51
lamivudine
abacavir tab 300mg . . . . . . . . . . . . . . . 50
abacavir-lamivudine . . . . . . . . . . . . . . . 51
abatacept . . . . . . . . . . . . . . . . . . . . . . . 90
ABELCET INJ 5MG/ML . . . . . . . . . . . . . . 34
ABILIFY DISC TAB 10MG . . . . . . . . . . . . 28
ABILIFY DISC TAB 15MG . . . . . . . . . . . . 28
ABILIFY MAIN INJ 300MG . . . . . . . . . . 28
ABILIFY MAIN INJ 400MG . . . . . . . . . . 28
ABILIFY TAB 10MG . . . . . . . . . . . . . . . . 28
ABILIFY TAB 15MG . . . . . . . . . . . . . . . . 28
ABILIFY TAB 20MG . . . . . . . . . . . . . . . . 29
ABILIFY TAB 2MG . . . . . . . . . . . . . . . . . 29
ABILIFY TAB 30MG . . . . . . . . . . . . . . . . 29
ABILIFY TAB 5MG . . . . . . . . . . . . . . . . . 29
abiraterone . . . . . . . . . . . . . . . . . . . . . . 37
ABRAXANE INJ 100MG . . . . . . . . . . . . 38
acampro cal tab 333mg . . . . . . . . . . . . 14
acamprosate . . . . . . . . . . . . . . . . . . . . . 14
acarbose tab 100mg . . . . . . . . . . . . . . . 54
acarbose tab 25mg . . . . . . . . . . . . . . . . 54
acarbose tab 50mg . . . . . . . . . . . . . . . . 54
ACCOLATE . . . . . . . . . . . . . . . . . . . . . . . 97
ACCUNEB . . . . . . . . . . . . . . . . . . . . . . . 97
ACCUPRIL . . . . . . . . . . . . . . . . . . . . . . . 61
ACCURETIC . . . . . . . . . . . . . . . . . . . . . . 67
acebutolol cap 200mg . . . . . . . . . . . . . 63
acebutolol cap 400mg . . . . . . . . . . . . . 63
ACEON . . . . . . . . . . . . . . . . . . . . . . . . . 61
acetaminophen -hydrocodone . . . . . . 10
acetasol hc sol . . . . . . . . . . . . . . . . . . . . 96
ACETASOL HC, VOSOL HC . . . . . . . . . . 96
acetazolamid cap 500mg er . . . . . . . . . 69
acetazolamid inj 500mg . . . . . . . . . . . . 69
acetazolamid tab 125mg . . . . . . . . . . . 69
acetazolamid tab 250mg . . . . . . . . . . . 69
ACETIC ACID . . . . . . . . . . . . . . . . . . . . . 16
acetic acid sol 2% . . . . . . . . . . . . . . . . . 16
acetylcyst sol 10% . . . . . . . . . . . . . . . . 99
acetylcyst sol 20% . . . . . . . . . . . . . . . . 99
ACIPHEX . . . . . . . . . . . . . . . . . . . . . . . . 78
acitretin cap 10mg . . . . . . . . . . . . . . . . 74
acitretin cap 17.5mg . . . . . . . . . . . . . . 74
acitretin cap 25mg . . . . . . . . . . . . . . . . 74
ACLOVATE . . . . . . . . . . . . . . . . . . . . . . . 80
ACTHIB INJ . . . . . . . . . . . . . . . . . . . . . . 91
ACTIGALL . . . . . . . . . . . . . . . . . . . . . . . 77
ACTIMMUNE INJ 2MU/0.5ML . . . . . . . . 91
ACTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ACTIVELLA . . . . . . . . . . . . . . . . . . . . . . 85
ACTONEL . . . . . . . . . . . . . . . . . . . . . . . . 94
ACTOPLUS . . . . . . . . . . . . . . . . . . . . . . . 55
ACTOS . . . . . . . . . . . . . . . . . . . . . . . . . . 55
acyclovir . . . . . . . . . . . . . . . . . . . . . . . . 53
acyclovir cap 200mg . . . . . . . . . . . . . . . 52
acyclovir na inj 500mg . . . . . . . . . . . . . 53
acyclovir oin 5% . . . . . . . . . . . . . . . . . . 53
acyclovir sus 200/5ml . . . . . . . . . . . . . . 53
acyclovir tab 400mg . . . . . . . . . . . . . . . 53
acyclovir tab 800mg . . . . . . . . . . . . . . . 53
ADACEL INJ . . . . . . . . . . . . . . . . . . . . . . 91
ADAGEN INJ 250/ML . . . . . . . . . . . . . . 75
adalimumab . . . . . . . . . . . . . . . . . . . . . 90
adalimumab penfill . . . . . . . . . . . . . . . 90
adapalene cre 0.1% . . . . . . . . . . . . . . . 74
adapalene gel 0.1% . . . . . . . . . . . . . . . 74
adapalene gel 0.3% . . . . . . . . . . . . . . . 74
ADCIRCA TAB 20MG . . . . . . . . . . . . . . . 99
ADDERALL . . . . . . . . . . . . . . . . . . . . . . 72
adefov dipiv tab 10mg . . . . . . . . . . . . . 48
ADEMPAS TAB 0.5MG . . . . . . . . . . . . . 99
ADEMPAS TAB 1.5MG . . . . . . . . . . . . . 99
ADEMPAS TAB 1MG . . . . . . . . . . . . . . . 99
ADEMPAS TAB 2.5MG . . . . . . . . . . . . . 99
ADEMPAS TAB 2MG . . . . . . . . . . . . . . . 99
ado-trastuzumab . . . . . . . . . . . . . . . . . 42
ADOXA . . . . . . . . . . . . . . . . . . . . . . . . . 22
ADRIAMYCIN . . . . . . . . . . . . . . . . . . . . 39
ADRUCIL . . . . . . . . . . . . . . . . . . . . . . . . 39
afatinib . . . . . . . . . . . . . . . . . . . . . . . . . 41
afeditab tab 30mg cr . . . . . . . . . . . . . . 64
afeditab tab 60mg cr . . . . . . . . . . . . . . 64
AFINITOR DIS TAB 2MG . . . . . . . . . . . . 41
AFINITOR DIS TAB 3MG . . . . . . . . . . . . 41
AFINITOR DIS TAB 5MG . . . . . . . . . . . . 41
AFINITOR TAB 10MG . . . . . . . . . . . . . . 41
AFINITOR TAB 2.5MG . . . . . . . . . . . . . . 41
AFINITOR TAB 5MG . . . . . . . . . . . . . . . 41
AFINITOR TAB 7.5MG . . . . . . . . . . . . . . 41
agalsidase beta . . . . . . . . . . . . . . . . . . . 76
AGGRENOX CAP 25-200MG . . . . . . . . . 59
AGRYLIN . . . . . . . . . . . . . . . . . . . . . . . . 58
ala cort cre 1% . . . . . . . . . . . . . . . . . . . 80
albendazole . . . . . . . . . . . . . . . . . . . . . 43
ALBENZA TAB 200MG . . . . . . . . . . . . . 43
albuterol . . . . . . . . . . . . . . . . . . . . . . . . 98
albuterol neb 0.083% . . . . . . . . . . . . . 97
albuterol neb 0.5% . . . . . . . . . . . . . . . 97
albuterol neb 0.63mg/3ml . . . . . . . . . . 97
albuterol neb 1.25mg/3ml . . . . . . . . . . 97
albuterol syp 2mg/5ml . . . . . . . . . . . . . 97
albuterol tab 2mg . . . . . . . . . . . . . . . . 97
albuterol tab 4mg . . . . . . . . . . . . . . . . 97
albuterol tab 4mg er . . . . . . . . . . . . . . 97
albuterol tab 8mg er . . . . . . . . . . . . . . 97
ALCAINE . . . . . . . . . . . . . . . . . . . . . . . . 94
alclometason cre 0.05% . . . . . . . . . . . . 80
alclometason oin 0.05% . . . . . . . . . . . 80
ALCOHOL PREP PAD . . . . . . . . . . . . . . . 75
ALDACTAZIDE . . . . . . . . . . . . . . . . . . . . 68
ALDACTONE . . . . . . . . . . . . . . . . . . . . . 69
ALDARA . . . . . . . . . . . . . . . . . . . . . . . . 74
aldesleukin . . . . . . . . . . . . . . . . . . . . . . 39
ALDOMET . . . . . . . . . . . . . . . . . . . . . . . 60
ALDORIL . . . . . . . . . . . . . . . . . . . . . . . . 67
ALDURAZYME INJ 2.9MG/5ML . . . . . . 75
alendronate sol 70/75ml . . . . . . . . . . . 93
alendronate tab 10mg . . . . . . . . . . . . . 93
alendronate tab 35mg . . . . . . . . . . . . . 93
alendronate tab 40mg . . . . . . . . . . . . . 93
alendronate tab 5mg . . . . . . . . . . . . . . 93
alendronate tab 70mg . . . . . . . . . . . . . 93
ALESSE . . . . . . . . . . . . . . . . . . . . . . . . . . 86
ALESSE, AVIANE, LESSINA, LUTERA . . . 84
alfuzosin tab 10mg . . . . . . . . . . . . . . . 79
alglucosidase . . . . . . . . . . . . . . . . . . . . 76
ALIMTA INJ 500MG . . . . . . . . . . . . . . . 38
ALINIA SUS 100/5ML . . . . . . . . . . . . . . . 43
ALINIA TAB 500MG . . . . . . . . . . . . . . . 43
aliskiren . . . . . . . . . . . . . . . . . . . . . . . . . 68
aliskiren - hct . . . . . . . . . . . . . . . . . . . . 68
alitretinoin . . . . . . . . . . . . . . . . . . . . . . 42
ALKERAN . . . . . . . . . . . . . . . . . . . . . . . 37
allopurinol tab 100mg . . . . . . . . . . . . . 35
allopurinol tab 300mg . . . . . . . . . . . . . 35
ALOCRIL SOL 2% . . . . . . . . . . . . . . . . . 94
ALOMIDE SOL 0.1% . . . . . . . . . . . . . . . 94
ALORA DIS 0.025MG . . . . . . . . . . . . . . 84
ALORA DIS 0.05MG . . . . . . . . . . . . . . . 84
ALORA DIS 0.075MG . . . . . . . . . . . . . . 84
ALORA DIS 0.1MG . . . . . . . . . . . . . . . . 84
alosetron . . . . . . . . . . . . . . . . . . . . . . . . 78
ALOXI INJ 0.25MG/5ML . . . . . . . . . . . . 33
alpha 1-proteinase inhibitor . . . . . . . . 99
alpha-1-proteinase inhibitor . . . . . . . . 99
ALPHAGAN . . . . . . . . . . . . . . . . . . . . . . 95
alprazolam con 1 mg/ml . . . . . . . . . . . 53
alprazolam tab 0.25 odt . . . . . . . . . . . 53
alprazolam tab 0.25mg . . . . . . . . . . . . 53
alprazolam tab 0.5mg . . . . . . . . . . . . . 53
alprazolam tab 0.5mg er . . . . . . . . . . . 53
alprazolam tab 0.5mg odt . . . . . . . . . . 54
alprazolam tab 1mg . . . . . . . . . . . . . . . 54
alprazolam tab 1mg er . . . . . . . . . . . . 54
127
Index of Drugs
alprazolam tab 1mg odt . . . . . . . . . . . 54
alprazolam tab 2mg . . . . . . . . . . . . . . . 54
alprazolam tab 2mg er . . . . . . . . . . . . 54
alprazolam tab 2mg odt . . . . . . . . . . . 54
alprazolam tab 3mg er . . . . . . . . . . . . 54
ALREX SUS 0.2% . . . . . . . . . . . . . . . . . . 95
ALTACE . . . . . . . . . . . . . . . . . . . . . . . . . 61
altretamine . . . . . . . . . . . . . . . . . . . . . . 37
amantadine cap 100mg . . . . . . . . . . . . 44
amantadine syp 50mg/5ml . . . . . . . . . 44
amantadine tab 100mg . . . . . . . . . . . . 44
AMARYL . . . . . . . . . . . . . . . . . . . . . . . . 54
AMBIEN . . . . . . . . . . . . . . . . . . . . . . . . 100
AMBIEN CR . . . . . . . . . . . . . . . . . . . . . 100
AMBISOME INJ 50MG . . . . . . . . . . . . . 34
ambrisentan . . . . . . . . . . . . . . . . . . . . . 99
amcinonide cre 0.1% . . . . . . . . . . . . . . 80
amcinonide lot 0.1% . . . . . . . . . . . . . . 80
amcinonide oin 0.1% . . . . . . . . . . . . . . 80
AMERGE . . . . . . . . . . . . . . . . . . . . . . . . 36
amifostine inj 500mg . . . . . . . . . . . . . . 38
amilor/hctz tab 5-50mg . . . . . . . . . . . . 66
amiloride tab 5mg . . . . . . . . . . . . . . . . 69
aminosalicylic acid . . . . . . . . . . . . . . . . 37
AMINOSYN . . . . . . . . . . . . . . . . . . . . . 101
aminosyn ii . . . . . . . . . . . . . . . . . . . . . 101
AMINOSYN II INJ 10% . . . . . . . . . . . . 101
AMINOSYN II INJ 7% . . . . . . . . . . . . . 101
aminosyn ii inj 8.5/lyte . . . . . . . . . . . . 101
AMINOSYN II INJ 8.5% . . . . . . . . . . . . 101
aminosyn inj 8.5/lyte . . . . . . . . . . . . . 101
AMINOSYN M INJ 3.5% . . . . . . . . . . . 101
aminosyn-hbc . . . . . . . . . . . . . . . . . . . 102
AMINOSYN-HBC INJ 7% . . . . . . . . . . . 102
aminosyn-pf . . . . . . . . . . . . . . . . . . . . 102
AMINOSYN-PF INJ 10% . . . . . . . . . . . 102
AMINOSYN-PF INJ 7% . . . . . . . . . . . . 102
amiodarone . . . . . . . . . . . . . . . . . . . . . 62
amiodarone inj 50mg/ml . . . . . . . . . . . 62
amiodarone tab 200mg . . . . . . . . . . . . 62
amiodarone tab 400mg . . . . . . . . . . . . 62
AMITIZA CAP 24MCG . . . . . . . . . . . . . . 78
AMITIZA CAP 8MCG . . . . . . . . . . . . . . . 78
amitriptylin tab 100mg . . . . . . . . . . . . 31
amitriptylin tab 10mg . . . . . . . . . . . . . 31
amitriptylin tab 150mg . . . . . . . . . . . . 31
amitriptylin tab 25mg . . . . . . . . . . . . . 31
amitriptylin tab 50mg . . . . . . . . . . . . . 31
amitriptylin tab 75mg . . . . . . . . . . . . . 31
amlod/atorva tab 10-10mg . . . . . . . . . 66
amlod/atorva tab 10-20mg . . . . . . . . . 66
amlod/atorva tab 10-40mg . . . . . . . . . 66
amlod/atorva tab 10-80mg . . . . . . . . . 66
128
amlod/atorva tab 2.5-10mg . . . . . . . . . 66
amlod/atorva tab 2.5-20mg . . . . . . . . . 66
amlod/atorva tab 2.5-40mg . . . . . . . . . 66
amlod/atorva tab 5-10mg . . . . . . . . . . 66
amlod/atorva tab 5-20mg . . . . . . . . . . 66
amlod/atorva tab 5-40mg . . . . . . . . . . 66
amlod/atorva tab 5-80mg . . . . . . . . . . 66
amlod/benazp cap 10-20mg . . . . . . . . 66
amlod/benazp cap 10-40mg . . . . . . . . 66
amlod/benazp cap 2.5-10mg . . . . . . . . 66
amlod/benazp cap 5-10mg . . . . . . . . . 66
amlod/benazp cap 5-20mg . . . . . . . . . 66
amlod/benazp cap 5-40mg . . . . . . . . . 66
amlod/valsar tab 10-160mg . . . . . . . . . 66
amlod/valsar tab 10-320mg . . . . . . . . . 66
amlod/valsar tab 5-160mg . . . . . . . . . . 66
amlod/valsar tab 5-320mg . . . . . . . . . . 66
amlod/valsar/hctz tab . . . . . . . . . . . . . . 66
10-160-12.5mg
amlod/valsar/hctz tab 10-160-25mg . . 66
amlod/valsar/hctz tab 10-320-25mg . . 66
amlod/valsar/hctz tab 5-160-12.5mg . . 66
amlod/valsar/hctz tab 5-160-25mg . . . 66
amlodipine tab 10mg . . . . . . . . . . . . . . 64
amlodipine tab 2.5mg . . . . . . . . . . . . . 64
amlodipine tab 5mg . . . . . . . . . . . . . . . 64
ammonium chl inj 5meq/ml . . . . . . . . 101
ammonium chloride . . . . . . . . . . . . . . 101
ammonium lac cre 12% . . . . . . . . . . . . 74
ammonium lac lot 12% . . . . . . . . . . . . 74
amnesteem cap 10mg . . . . . . . . . . . . . 74
amnesteem cap 20mg . . . . . . . . . . . . . 74
amnesteem cap 40mg . . . . . . . . . . . . . 74
amox-pot cla tab er . . . . . . . . . . . . . . . 19
amox/k clav chw 200mg . . . . . . . . . . . . 19
amox/k clav chw 400mg . . . . . . . . . . . . 19
amox/k clav sus 200/5ml . . . . . . . . . . . . 19
amox/k clav sus 250/5ml . . . . . . . . . . . . 19
amox/k clav sus 400/5ml . . . . . . . . . . . . 19
amox/k clav sus 600/5ml . . . . . . . . . . . . 19
amox/k clav tab 250mg . . . . . . . . . . . . 19
amox/k clav tab 500mg . . . . . . . . . . . . 19
amox/k clav tab 875mg . . . . . . . . . . . . 19
amoxapine tab 100mg . . . . . . . . . . . . . 31
amoxapine tab 150mg . . . . . . . . . . . . . 32
amoxapine tab 25mg . . . . . . . . . . . . . . 32
amoxapine tab 50mg . . . . . . . . . . . . . . 32
amoxicillin cap 250mg . . . . . . . . . . . . . 19
amoxicillin cap 500mg . . . . . . . . . . . . . 19
amoxicillin chw 125mg . . . . . . . . . . . . 19
amoxicillin chw 250mg . . . . . . . . . . . . 19
amoxicillin sus 125/5ml . . . . . . . . . . . . 19
amoxicillin sus 200/5ml . . . . . . . . . . . . 19
amoxicillin sus 250/5ml . . . . . . . . . . . . 19
amoxicillin sus 400/5ml . . . . . . . . . . . . 19
amoxicillin tab 500mg . . . . . . . . . . . . . 19
amoxicillin tab 875mg . . . . . . . . . . . . . 19
AMOXIL . . . . . . . . . . . . . . . . . . . . . . . . . 19
amp-sulbacta inj 15gm . . . . . . . . . . . . . 20
amp-sulbacta inj 3gm . . . . . . . . . . . . . . 20
amphetamine tab 10mg . . . . . . . . . . . 72
amphetamine tab 12.5mg . . . . . . . . . . 72
amphetamine tab 15mg . . . . . . . . . . . 72
amphetamine tab 20mg . . . . . . . . . . . 72
amphetamine tab 30mg . . . . . . . . . . . 72
amphetamine tab 5mg . . . . . . . . . . . . 72
amphetamine tab 7.5mg . . . . . . . . . . . 72
amphotericin b liposomal . . . . . . . . . . 34
amphotericin b liposomal 4 mg/ml . . . 34
amphotericin inj 50mg . . . . . . . . . . . . . 34
ampicillin . . . . . . . . . . . . . . . . . . . . . . . 20
ampicillin cap 250mg . . . . . . . . . . . . . . 20
ampicillin cap 500mg . . . . . . . . . . . . . . 20
ampicillin inj 10gm . . . . . . . . . . . . . . . . 20
AMPICILLIN INJ 125MG . . . . . . . . . . . . 20
ampicillin inj 1gmg . . . . . . . . . . . . . . . . 20
ampicillin sus 125/5ml . . . . . . . . . . . . . 20
ampicillin sus 250/5ml . . . . . . . . . . . . . 20
AMPYRA TAB 10MG . . . . . . . . . . . . . . . 73
amylases - endopeptidase - lipase . . . . 76
ANAFRANIL . . . . . . . . . . . . . . . . . . . . . . 32
anagrelide cap 0.5mg . . . . . . . . . . . . . 58
anagrelide cap 1mg . . . . . . . . . . . . . . . 58
anakinra . . . . . . . . . . . . . . . . . . . . . . . . 90
ANAPROX . . . . . . . . . . . . . . . . . . . . . . . 12
ANAPROX DS . . . . . . . . . . . . . . . . . . . . 12
anastrozole tab 1mg . . . . . . . . . . . . . . 40
ANCEF . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ANCOBON . . . . . . . . . . . . . . . . . . . . . . . 34
ANDROGEL GEL 1.62% . . . . . . . . . . . . 84
ANDROGEL GEL PUMP 1.62% . . . . . . . 84
anidulafungin . . . . . . . . . . . . . . . . . . . . 34
ANSAID . . . . . . . . . . . . . . . . . . . . . . . . . 11
ANTABUSE . . . . . . . . . . . . . . . . . . . . . . 14
ANTIVERT . . . . . . . . . . . . . . . . . . . . . . . 33
ANZEMET INJ 20MG/ML . . . . . . . . . . . . 33
ANZEMET TAB 100MG . . . . . . . . . . . . . 33
ANZEMET TAB 50MG . . . . . . . . . . . . . . 33
apap/codeine sol 120-12/5ml . . . . . . . . 10
apap/codeine tab 300-15mg . . . . . . . . 10
apap/codeine tab 300-30mg . . . . . . . . 10
apap/codeine tab 300-60mg . . . . . . . . 10
APIDRA INJ SOLOSTAR . . . . . . . . . . . . . 56
APIDRA INJ U-100 . . . . . . . . . . . . . . . . . 56
apixaban . . . . . . . . . . . . . . . . . . . . . . . . 57
APOKYN INJ 10MG/ML . . . . . . . . . . . . . 44
Index of Drugs
apomorphine . . . . . . . . . . . . . . . . . . . . 44
apraclonidin sol 0.5% . . . . . . . . . . . . . 95
apraclonidine . . . . . . . . . . . . . . . . . . . . 95
apremilast . . . . . . . . . . . . . . . . . . . . . . . 35
aprepitant . . . . . . . . . . . . . . . . . . . . . . . 33
APRESOLINE . . . . . . . . . . . . . . . . . . . . . 71
apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
APTIOM TAB 200MG . . . . . . . . . . . . . . 23
APTIOM TAB 400MG . . . . . . . . . . . . . . 23
APTIOM TAB 600MG . . . . . . . . . . . . . . 23
APTIOM TAB 800MG . . . . . . . . . . . . . . 23
APTIVUS CAP 250MG . . . . . . . . . . . . . . 52
APTIVUS SOL . . . . . . . . . . . . . . . . . . . . . 52
AQUATENSEN, ENDURON . . . . . . . . . . 70
ARALAST NP INJ 400MG . . . . . . . . . . . 99
ARALEN . . . . . . . . . . . . . . . . . . . . . . . . . 43
aranelle . . . . . . . . . . . . . . . . . . . . . . . . . 84
ARANESP INJ 100MCG/0.5ML . . . . . . . 58
ARANESP INJ 100MCG/1ML . . . . . . . . . 58
ARANESP INJ 150MCG/0.3ML . . . . . . . 58
ARANESP INJ 200MCG/0.4ML . . . . . . . 58
ARANESP INJ 200MCG/1ML . . . . . . . . . 58
ARANESP INJ 25MCG/0.42ML . . . . . . . 58
ARANESP INJ 25MCG/1ML . . . . . . . . . . 58
ARANESP INJ 300MCG/0.6ML . . . . . . . 58
ARANESP INJ 300MCG/1ML . . . . . . . . . 58
ARANESP INJ 40MCG/0.4ML . . . . . . . . 58
ARANESP INJ 40MCG/1ML . . . . . . . . . . 58
ARANESP INJ 500MCG/1ML . . . . . . . . . 58
ARANESP INJ 60MCG/0.3ML . . . . . . . . 58
ARANESP INJ 60MCG/1ML . . . . . . . . . . 58
ARAVA . . . . . . . . . . . . . . . . . . . . . . . . . 91
ARCALYST INJ 220MG . . . . . . . . . . . . . 91
ARCAPTA CAP 75MCG . . . . . . . . . . . . . 97
AREDIA . . . . . . . . . . . . . . . . . . . . . . . . . 94
ARICEPT . . . . . . . . . . . . . . . . . . . . . . . . . 27
ARICEPT ODT . . . . . . . . . . . . . . . . . . . . 27
ARIMIDEX . . . . . . . . . . . . . . . . . . . . . . . 40
aripiprazole . . . . . . . . . . . . . . . . . . . . . 28
aripiprazole disintegrating . . . . . . . . . 28
ARIXTRA . . . . . . . . . . . . . . . . . . . . . . . . 57
AROMASIN . . . . . . . . . . . . . . . . . . . . . . 40
ARRANON INJ 5MG/ML . . . . . . . . . . . . 38
arsenic trioxide . . . . . . . . . . . . . . . . . . . 40
ARTANE, TRIHEXANE . . . . . . . . . . . . . . 43
artemether - lumefantrine . . . . . . . . . 43
ARTHROTEC 50 . . . . . . . . . . . . . . . . . . . 10
ARTHROTEC 75 . . . . . . . . . . . . . . . . . . . 10
ARZERRA CON 100/5ML . . . . . . . . . . . . 42
ascomp/cod cap 30mg . . . . . . . . . . . . . 10
asenapine . . . . . . . . . . . . . . . . . . . . . . . 47
ASENDIN . . . . . . . . . . . . . . . . . . . . . . . . 31
ASMANEX 120 AER 220MCG . . . . . . . . 96
ASMANEX 30 AER 110MCG . . . . . . . . . 96
ASMANEX 30 AER 220MCG . . . . . . . . . 96
ASMANEX 60 AER 220MCG . . . . . . . . . 96
aspirin - dipyridamole . . . . . . . . . . . . . 59
ASTAGRAF XL CAP 0.5MG . . . . . . . . . . 89
ASTAGRAF XL CAP 1MG . . . . . . . . . . . . 89
ASTAGRAF XL CAP 5MG . . . . . . . . . . . . 89
ASTELIN . . . . . . . . . . . . . . . . . . . . . . . . . 96
ASTEPRO . . . . . . . . . . . . . . . . . . . . . . . . 97
ATACAND . . . . . . . . . . . . . . . . . . . . . . . 60
ATACAND HCT . . . . . . . . . . . . . . . . . . . 66
atazanavir . . . . . . . . . . . . . . . . . . . . . . . 52
atazanavir - cobicistat . . . . . . . . . . . . . 51
atenol/chlor tab 100-25mg . . . . . . . . . 66
atenol/chlor tab 50-25mg . . . . . . . . . . 66
atenolol tab 100mg . . . . . . . . . . . . . . . 63
atenolol tab 25mg . . . . . . . . . . . . . . . . 63
atenolol tab 50mg . . . . . . . . . . . . . . . . 63
ATIVAN . . . . . . . . . . . . . . . . . . . . . . . . . 25
atomoxetine . . . . . . . . . . . . . . . . . . . . . 73
atorvastatin tab 10mg . . . . . . . . . . . . . 70
atorvastatin tab 20mg . . . . . . . . . . . . . 70
atorvastatin tab 40mg . . . . . . . . . . . . . 70
atorvastatin tab 80mg . . . . . . . . . . . . . 70
atovaq/progu tab 250-100mg . . . . . . . 43
atovaq/progu tab 62.5-25mg . . . . . . . . 43
atovaquone sus 750/5ml . . . . . . . . . . . 43
ATRIPLA TAB . . . . . . . . . . . . . . . . . . . . . 53
ATROVENT HFA AER 17MCG . . . . . . . . 97
aubra tab 0.1-0.02 . . . . . . . . . . . . . . . . 84
aug betamet cre 0.05% . . . . . . . . . . . . 80
aug betamet gel 0.05% . . . . . . . . . . . . 80
aug betamet lot 0.05% . . . . . . . . . . . . 80
aug betamet oin 0.05% . . . . . . . . . . . . 80
AUGMENTIN . . . . . . . . . . . . . . . . . . . . . 19
auranofin . . . . . . . . . . . . . . . . . . . . . . . 91
AVALIDE . . . . . . . . . . . . . . . . . . . . . . . . 67
AVAPRO . . . . . . . . . . . . . . . . . . . . . . . . 60
AVASTIN INJ . . . . . . . . . . . . . . . . . . . . . 38
aviane . . . . . . . . . . . . . . . . . . . . . . . . . . 84
AVINZA . . . . . . . . . . . . . . . . . . . . . . . . . 13
AVODART CAP 0.5MG . . . . . . . . . . . . . 79
AVONEX KIT 30MCG . . . . . . . . . . . . . . 73
AVONEX PEN KIT 30MCG . . . . . . . . . . . 73
AVONEX PREFL KIT 30MCG . . . . . . . . . 73
AXID . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
AXIRON SOL 30MG/ACT . . . . . . . . . . . . 84
axitinib . . . . . . . . . . . . . . . . . . . . . . . . . 41
AYGESTIN . . . . . . . . . . . . . . . . . . . . . . . 87
azacitidine inj 100mg . . . . . . . . . . . . . . 38
AZACTAM . . . . . . . . . . . . . . . . . . . . . . . 19
AZACTAM/DEX INJ 1GM . . . . . . . . . . . 19
AZACTAM/DEX INJ 2GM . . . . . . . . . . . 19
AZASAN TAB 100MG . . . . . . . . . . . . . . 89
AZASAN TAB 75 MG . . . . . . . . . . . . . . . 89
azathioprine . . . . . . . . . . . . . . . . . . . . . 89
azathioprine tab 50mg . . . . . . . . . . . . 89
azelastine dro 0.05% . . . . . . . . . . . . . . 94
azelastine spr 0.1% . . . . . . . . . . . . . . . 96
azelastine spr 0.15% . . . . . . . . . . . . . . 97
AZILECT TAB 0.5MG . . . . . . . . . . . . . . . 45
AZILECT TAB 1MG . . . . . . . . . . . . . . . . 45
azithromycin . . . . . . . . . . . . . . . . . . . . . 21
azithromycin inj 500mg . . . . . . . . . . . . 20
azithromycin pow 1gm pak . . . . . . . . . 20
azithromycin sus 100/5ml . . . . . . . . . . . 20
azithromycin sus 200/5ml . . . . . . . . . . . 20
azithromycin tab 250mg . . . . . . . . . . . 20
azithromycin tab 500mg . . . . . . . . . . . 20
azithromycin tab 600mg . . . . . . . . . . . 21
AZOPT SUS 1% . . . . . . . . . . . . . . . . . . . 95
aztreonam . . . . . . . . . . . . . . . . . . . . . . 19
aztreonam inj 1gm . . . . . . . . . . . . . . . . 19
AZULFIDINE . . . . . . . . . . . . . . . . . . . . . . 93
B
baciim inj 50000unt . . . . . . . . . . . . . . . 16
bacit/polymy oin . . . . . . . . . . . . . . . . . . 94
bacitracin . . . . . . . . . . . . . . . . . . . . . . . 16
bacitracin oin . . . . . . . . . . . . . . . . . . . . 16
baclofen tab 10mg . . . . . . . . . . . . . . . . 48
baclofen tab 20mg . . . . . . . . . . . . . . . . 48
BACTRAM DS, SEPTRA DS . . . . . . . . . . 22
BACTRIM, SEPTRA . . . . . . . . . . . . . . . . 22
BACTROBAN . . . . . . . . . . . . . . . . . . . . . 17
balsalazide cap 750mg . . . . . . . . . . . . . 93
balziva tab . . . . . . . . . . . . . . . . . . . . . . 85
BANZEL SUS 40MG/ML . . . . . . . . . . . . . 26
BANZEL TAB 200MG . . . . . . . . . . . . . . . 26
BANZEL TAB 400MG . . . . . . . . . . . . . . . 26
BARACLUDE . . . . . . . . . . . . . . . . . . . . . 49
BARACLUDE SOL .05MG/ML . . . . . . . . 49
basiliximab . . . . . . . . . . . . . . . . . . . . . . 91
BAYCADRON . . . . . . . . . . . . . . . . . . . . . 81
bazedoxifene - estrogens, . . . . . . . . . . 85
conjugated
BCG VACCINE INJ . . . . . . . . . . . . . . . . . 91
bcg, live, tice strain 50 mg/ml . . . . . . . 91
injectable suspension
beclomethasone . . . . . . . . . . . . . . . . . . 96
beclomethasone dipropionate . . . . . . 96
BECONASE AQ SUS 0.042% . . . . . . . . . 96
bedaquiline . . . . . . . . . . . . . . . . . . . . . . 37
belatacept . . . . . . . . . . . . . . . . . . . . . . . 91
BELEODAQ INJ 500MG . . . . . . . . . . . . . 38
belimumab . . . . . . . . . . . . . . . . . . . . . . 91
129
Index of Drugs
belinostat . . . . . . . . . . . . . . . . . . . . . . . 38
BENADRYL . . . . . . . . . . . . . . . . . . . . . . 33
benazep/hctz tab 10-12.5mg . . . . . . . . 66
benazep/hctz tab 20-12.5mg . . . . . . . . 66
benazep/hctz tab 20-25mg . . . . . . . . . 66
benazep/hctz tab 5-6.25mg . . . . . . . . . 66
benazepril tab 10mg . . . . . . . . . . . . . . 61
benazepril tab 20mg . . . . . . . . . . . . . . 61
benazepril tab 40mg . . . . . . . . . . . . . . 61
benazepril tab 5mg . . . . . . . . . . . . . . . 61
bendamustine . . . . . . . . . . . . . . . . . . . . 40
BENLYSTA INJ 120MG . . . . . . . . . . . . . . 91
BENTYL . . . . . . . . . . . . . . . . . . . . . . . . . 76
BENZAMYCIN . . . . . . . . . . . . . . . . . . . . 74
benztropine inj 1mg/ml . . . . . . . . . . . . 43
benztropine tab 0.5mg . . . . . . . . . . . . 43
benztropine tab 1mg . . . . . . . . . . . . . . 43
benztropine tab 2mg . . . . . . . . . . . . . . 43
BETA-VAL . . . . . . . . . . . . . . . . . . . . . . . 80
BETAGAN . . . . . . . . . . . . . . . . . . . . . . . 95
betaine (trimethylglycine) . . . . . . . . . 75
betameth dip cre 0.05% . . . . . . . . . . . 80
betameth dip lot 0.05% . . . . . . . . . . . . 80
betameth dip oin 0.05% . . . . . . . . . . . 80
betameth val aer 0.12% . . . . . . . . . . . 80
betameth val cre 0.1% . . . . . . . . . . . . . 80
betameth val lot 0.1% . . . . . . . . . . . . . 80
betameth val oin 0.1% . . . . . . . . . . . . 80
BETASERON INJ 0.3MG . . . . . . . . . . . . . 73
BETAXOLOL . . . . . . . . . . . . . . . . . . . . . 95
betaxolol sol 0.5% . . . . . . . . . . . . . . . . 95
betaxolol tab 10mg . . . . . . . . . . . . . . . 63
betaxolol tab 20mg . . . . . . . . . . . . . . . 63
bethanechol tab 10mg . . . . . . . . . . . . . 79
bethanechol tab 25mg . . . . . . . . . . . . . 79
bethanechol tab 50mg . . . . . . . . . . . . . 79
bethanechol tab 5mg . . . . . . . . . . . . . . 79
BETOPTIC-S SUS 0.25% . . . . . . . . . . . . . 95
bevacizumab . . . . . . . . . . . . . . . . . . . . . 38
bexarotene . . . . . . . . . . . . . . . . . . . . . . 42
BIAXIN . . . . . . . . . . . . . . . . . . . . . . . . . . 21
BIAXIN XL . . . . . . . . . . . . . . . . . . . . . . . 21
bicalutamide tab 50mg . . . . . . . . . . . . 37
BICILLIN C-R INJ 1200000 . . . . . . . . . . . 20
BICILLIN C-R INJ 900/300 . . . . . . . . . . . 20
BICILLIN L-A INJ 1200000 . . . . . . . . . . . 20
BICILLIN L-A INJ 2400000 . . . . . . . . . . . 20
BICILLIN L-A INJ 600000 . . . . . . . . . . . . 20
BILTRICIDE TAB 600MG . . . . . . . . . . . . 43
bimatoprost . . . . . . . . . . . . . . . . . . . . . 96
bisoprl/hctz tab 10/6.25mg . . . . . . . . . 66
bisoprl/hctz tab 2.5/6.25mg . . . . . . . . . 66
bisoprl/hctz tab 5-6.25mg . . . . . . . . . . 66
130
bisoprol fum tab 10mg . . . . . . . . . . . . 63
bisoprol fum tab 5mg . . . . . . . . . . . . . 63
BLENOXANE . . . . . . . . . . . . . . . . . . . . . 38
bleomycin inj 30unit . . . . . . . . . . . . . . 38
BLEPH-10 . . . . . . . . . . . . . . . . . . . . . . . . 22
BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . 94
BLEPHAMIDE OIN S.O.P. . . . . . . . . . . . . 94
BLEPHAMIDE SUS . . . . . . . . . . . . . . . . . 94
BLOCADREN . . . . . . . . . . . . . . . . . . . . . 36
BONIVA . . . . . . . . . . . . . . . . . . . . . . . . . 93
boostrix . . . . . . . . . . . . . . . . . . . . . . . . . 91
BOOSTRIX INJ . . . . . . . . . . . . . . . . . . . . 91
bordetella pertussis . . . . . . . . . . . . . . . 91
bordetella pertussis filamentous . . . . . 91
hemagglutinin vaccine
bortezomib . . . . . . . . . . . . . . . . . . . . . . 40
bosentan . . . . . . . . . . . . . . . . . . . . . . . . 99
BOSULIF TAB 100MG . . . . . . . . . . . . . . 41
BOSULIF TAB 500MG . . . . . . . . . . . . . . 41
bosutinib . . . . . . . . . . . . . . . . . . . . . . . . 41
BREO ELLIPTA INH 100-25 . . . . . . . . . . 99
BRETHINE . . . . . . . . . . . . . . . . . . . . . . . 98
BREVICON, NORTREL, NECON . . . . . . . 85
briellyn tab . . . . . . . . . . . . . . . . . . . . . . 85
BRILINTA TAB 90MG . . . . . . . . . . . . . . . 59
brimonidine sol 0.15% . . . . . . . . . . . . . 95
brimonidine sol 0.2% . . . . . . . . . . . . . . 95
BRINTELLIX TAB 10MG . . . . . . . . . . . . . 29
BRINTELLIX TAB 20MG . . . . . . . . . . . . . 29
BRINTELLIX TAB 5MG . . . . . . . . . . . . . . 29
brinzolamide . . . . . . . . . . . . . . . . . . . . 95
bromfenac sol 0.09% . . . . . . . . . . . . . . 95
bromocriptin cap 5mg . . . . . . . . . . . . . 44
bromocriptin tab 2.5mg . . . . . . . . . . . . 44
bromocriptine . . . . . . . . . . . . . . . . . . . . 54
budesonide . . . . . . . . . . . . . . . . . . . . . . 96
budesonide - formoterol . . . . . . . . . . . 99
budesonide cap 3mg/24hr . . . . . . . . . . 80
bumetanide inj 0.25/ml . . . . . . . . . . . . 69
bumetanide tab 0.5mg . . . . . . . . . . . . 69
bumetanide tab 1mg . . . . . . . . . . . . . . 69
bumetanide tab 2mg . . . . . . . . . . . . . . 69
BUMEX . . . . . . . . . . . . . . . . . . . . . . . . . 69
bupap tab 50-300mg . . . . . . . . . . . . . . 10
bupren/nalox sub 2-0.5mg . . . . . . . . . . 15
bupren/nalox sub 8-2mg . . . . . . . . . . . 15
BUPRENEX . . . . . . . . . . . . . . . . . . . . . . . 15
buprenorphin inj 0.3mg/ml . . . . . . . . . 15
buprenorphin sub 2mg . . . . . . . . . . . . 15
buprenorphin sub 8mg . . . . . . . . . . . . 15
buprenorphine - naloxone . . . . . . . . . 15
buprenorphine patch . . . . . . . . . . . . . . 15
buproban tab 150mg . . . . . . . . . . . . . . 15
bupropion . . . . . . . . . . . . . . . . . . . . . . . 15
bupropion er . . . . . . . . . . . . . . . . . . . . 15
bupropion tab 100mg . . . . . . . . . . . . . 15
bupropion tab 100mg sr . . . . . . . . . . . 15
bupropion tab 150mg sr . . . . . . . . . . . 15
bupropion tab 200mg sr . . . . . . . . . . . 15
bupropion tab 75mg . . . . . . . . . . . . . . 15
bupropn hcl tab 150mg xl . . . . . . . . . . 15
bupropn hcl tab 300mg xl . . . . . . . . . . 15
BUSPAR . . . . . . . . . . . . . . . . . . . . . . . . . 53
buspirone tab 10mg . . . . . . . . . . . . . . . 53
buspirone tab 15mg . . . . . . . . . . . . . . . 53
buspirone tab 30mg . . . . . . . . . . . . . . . 53
buspirone tab 5mg . . . . . . . . . . . . . . . . 53
buspirone tab 7.5mg . . . . . . . . . . . . . . 53
busulfan . . . . . . . . . . . . . . . . . . . . . . . . 37
BUSULFEX INJ 6MG/ML . . . . . . . . . . . . 37
but/apap/caf cap 50-300-40mg . . . . . . 10
but/apap/caf cap 50-325-40mg . . . . . . 10
but/apap/caf cap codeine . . . . . . . . . . 10
50-300-40-30mg
but/apap/caf cap codeine . . . . . . . . . . 10
50-325-40-30mg
but/apap/caf tab 50-325-40mg . . . . . . 10
but/asa/caff cap 50-325-40mg . . . . . . . 10
butal/apap tab 50-325mg . . . . . . . . . . 10
butalbital - acetaminophen . . . . . . . . . 10
butalbital - acetaminophen - . . . . . . . . 10
caffeine
butalbital - aspirin - caffeine . . . . . . . . 10
butorphanol . . . . . . . . . . . . . . . . . . . . . 13
butorphanol sol 10mg/ml . . . . . . . . . . 13
BUTRANS DIS 10MCG/HR . . . . . . . . . . . 15
BUTRANS DIS 15MCG/HR . . . . . . . . . . . 15
BUTRANS DIS 20MCG/HR . . . . . . . . . . . 15
BUTRANS DIS 5MCG/HR . . . . . . . . . . . . 15
BYDUREON INJ . . . . . . . . . . . . . . . . . . . 54
BYETTA INJ 10MCG . . . . . . . . . . . . . . . 54
BYETTA INJ 5MCG . . . . . . . . . . . . . . . . 54
C
c1 inhibitor (human) . . . . . . . . . . . . . . 89
cabazitaxel . . . . . . . . . . . . . . . . . . . . . . 39
cabergoline tab 0.5mg . . . . . . . . . . . . . 88
cabozantinib . . . . . . . . . . . . . . . . . . . . . 41
CADUET . . . . . . . . . . . . . . . . . . . . . . . . . 66
caffeine-ergotamine . . . . . . . . . . . . . . 35
CALAN . . . . . . . . . . . . . . . . . . . . . . . . . . 65
CALAN SR . . . . . . . . . . . . . . . . . . . . . . . 65
calc acetate cap 667mg . . . . . . . . . . . . 80
CALCIJEX . . . . . . . . . . . . . . . . . . . . . . . . 93
CALCIPOTRIEN OIN 0.005% . . . . . . . . . 74
calcipotriene . . . . . . . . . . . . . . . . . . . . . 74
Index of Drugs
calcitonin spr 200/act . . . . . . . . . . . . . . 93
calcitonin, salmon . . . . . . . . . . . . . . . . 93
calcitriol cap 0.25mcg . . . . . . . . . . . . . . 93
calcitriol cap 0.5mcg . . . . . . . . . . . . . . . 93
calcitriol inj 1mcg/ml . . . . . . . . . . . . . . 93
calcitriol sol 1mcg/ml . . . . . . . . . . . . . . 93
camila tab 0.35mg . . . . . . . . . . . . . . . . 86
CAMPTOSAR . . . . . . . . . . . . . . . . . . . . . 39
canakinumab . . . . . . . . . . . . . . . . . . . . 91
CANASA SUP 1000MG . . . . . . . . . . . . . 93
CANCIDAS INJ 50MG . . . . . . . . . . . . . . 34
CANCIDAS INJ 70MG . . . . . . . . . . . . . . 34
candesa/hctz tab 16-12.5mg . . . . . . . . 66
candesa/hctz tab 32-12.5mg . . . . . . . . 66
candesa/hctz tab 32-25mg . . . . . . . . . . 66
candesartan tab 16mg . . . . . . . . . . . . . 60
candesartan tab 32mg . . . . . . . . . . . . . 60
candesartan tab 4mg . . . . . . . . . . . . . . 60
candesartan tab 8mg . . . . . . . . . . . . . . 60
CANTIL TAB 25MG . . . . . . . . . . . . . . . . 76
CAPASTAT SUL INJ 1GM . . . . . . . . . . . . 36
CAPEX SHA 0.01% . . . . . . . . . . . . . . . . 80
CAPOTEN . . . . . . . . . . . . . . . . . . . . . . . 61
CAPOZIDE . . . . . . . . . . . . . . . . . . . . . . . 67
CAPRELSA TAB 100MG . . . . . . . . . . . . . 41
CAPRELSA TAB 300MG . . . . . . . . . . . . . 41
capreomycin . . . . . . . . . . . . . . . . . . . . . 36
captopr/hctz tab 25-15mg . . . . . . . . . . 67
captopr/hctz tab 25-25mg . . . . . . . . . . 67
captopr/hctz tab 50-15mg . . . . . . . . . . 67
captopr/hctz tab 50-25mg . . . . . . . . . . 67
captopril tab 100mg . . . . . . . . . . . . . . . 61
captopril tab 12.5mg . . . . . . . . . . . . . . 61
captopril tab 25mg . . . . . . . . . . . . . . . . 61
captopril tab 50mg . . . . . . . . . . . . . . . . 61
CARAFATE . . . . . . . . . . . . . . . . . . . . . . . 78
carb/levo er tab 25-100mg . . . . . . . . . . 45
carb/levo er tab 50-200mg . . . . . . . . . . 45
carb/levo tab 10-100mg . . . . . . . . . . . . 45
carb/levo tab 25-100mg . . . . . . . . . . . . 45
carb/levo tab 25-250mg . . . . . . . . . . . . 45
CARBAGLU TAB 200MG . . . . . . . . . . . 101
carbamazepin cap 100mg er . . . . . . . . 26
carbamazepin cap 200mg er . . . . . . . . 26
carbamazepin cap 300mg er . . . . . . . . 26
carbamazepin chw 100mg . . . . . . . . . . 26
carbamazepin sus 100/5ml . . . . . . . . . . 26
carbamazepin tab 200mg . . . . . . . . . . 26
carbamazepin tab 200mg er . . . . . . . . 26
carbamazepin tab 400mg er . . . . . . . . 26
carbamazepine er . . . . . . . . . . . . . . . . . 27
carbamazepine sr . . . . . . . . . . . . . . . . . 26
carbinoxamin sol 4mg/5ml . . . . . . . . . . 97
carbinoxamin tab 4mg . . . . . . . . . . . . . 97
carboplatin inj 150/15ml . . . . . . . . . . . 38
CARDENE . . . . . . . . . . . . . . . . . . . . . . . 65
CARDENE I.V. . . . . . . . . . . . . . . . . . . . . 65
CARDIZEM . . . . . . . . . . . . . . . . . . . . . . . 64
CARDIZEM SR . . . . . . . . . . . . . . . . . . . . 64
CARDURA . . . . . . . . . . . . . . . . . . . . . . . 60
carglumic acid . . . . . . . . . . . . . . . . . . . 101
CARIMUNE NF INJ 3GM . . . . . . . . . . . . 91
CARNITOR . . . . . . . . . . . . . . . . . . . . . . 100
carteolol sol 1% . . . . . . . . . . . . . . . . . . 95
cartia xt cap 120/24hr . . . . . . . . . . . . . . 64
cartia xt cap 180/24hr . . . . . . . . . . . . . . 64
cartia xt cap 240/24hr . . . . . . . . . . . . . . 64
cartia xt cap 300/24hr . . . . . . . . . . . . . . 64
carvedilol tab 12.5mg . . . . . . . . . . . . . 63
carvedilol tab 25mg . . . . . . . . . . . . . . . 63
carvedilol tab 3.125mg . . . . . . . . . . . . 63
carvedilol tab 6.25mg . . . . . . . . . . . . . 63
CASODEX . . . . . . . . . . . . . . . . . . . . . . . 37
caspofungin . . . . . . . . . . . . . . . . . . . . . 34
CATAFLAM . . . . . . . . . . . . . . . . . . . . . . 11
CATAPRES . . . . . . . . . . . . . . . . . . . . . . . 59
CATAPRES TTS . . . . . . . . . . . . . . . . . . . . 59
CAYSTON INH 75MG . . . . . . . . . . . . . . 98
CECLOR . . . . . . . . . . . . . . . . . . . . . . . . . 17
CEENU . . . . . . . . . . . . . . . . . . . . . . . . . . 39
cefaclor cap 250mg . . . . . . . . . . . . . . . 17
cefaclor cap 500mg . . . . . . . . . . . . . . . 17
cefaclor er tab 500mg . . . . . . . . . . . . . 17
cefaclor sus 125/5ml . . . . . . . . . . . . . . . 18
cefaclor sus 250/5ml . . . . . . . . . . . . . . . 18
cefaclor sus 375/5ml . . . . . . . . . . . . . . . 18
cefadroxil cap 500mg . . . . . . . . . . . . . . 18
cefadroxil sus 250/5ml . . . . . . . . . . . . . 18
cefadroxil sus 500/5ml . . . . . . . . . . . . . 18
cefadroxil tab 1gm . . . . . . . . . . . . . . . . 18
cefazolin inj 10gm . . . . . . . . . . . . . . . . 18
cefazolin inj 1gm . . . . . . . . . . . . . . . . . 18
cefazolin inj 1gm/50ml . . . . . . . . . . . . . 18
cefazolin inj 500mg . . . . . . . . . . . . . . . 18
cefdinir cap 300mg . . . . . . . . . . . . . . . . 18
cefdinir sus 125/5ml . . . . . . . . . . . . . . . 18
cefdinir sus 250/5ml . . . . . . . . . . . . . . . 18
cefepime inj 1gm . . . . . . . . . . . . . . . . . 18
cefepime inj 2gm . . . . . . . . . . . . . . . . . 18
cefixime . . . . . . . . . . . . . . . . . . . . . . . . . 19
cefoxitin inj 10gm . . . . . . . . . . . . . . . . 18
cefoxitin inj 1gm . . . . . . . . . . . . . . . . . 18
cefoxitin inj 2gm . . . . . . . . . . . . . . . . . 18
cefpodo prox sus 100/5ml . . . . . . . . . . 18
cefpodo prox sus 50mg/5ml . . . . . . . . . 18
cefpodoxime tab 100mg . . . . . . . . . . . 18
cefpodoxime tab 200mg . . . . . . . . . . . 18
cefprozil sus 125/5ml . . . . . . . . . . . . . . 18
cefprozil sus 250/5ml . . . . . . . . . . . . . . 18
cefprozil tab 250mg . . . . . . . . . . . . . . . 18
cefprozil tab 500mg . . . . . . . . . . . . . . . 18
ceftaroline . . . . . . . . . . . . . . . . . . . . . . 19
CEFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ceftriaxone inj 10gm . . . . . . . . . . . . . . 18
ceftriaxone inj 1gm . . . . . . . . . . . . . . . 18
ceftriaxone inj 250mg . . . . . . . . . . . . . 18
ceftriaxone inj 2gm . . . . . . . . . . . . . . . 18
ceftriaxone inj 500mg . . . . . . . . . . . . . 18
cefuroxime inj 1.5gm . . . . . . . . . . . . . . 18
cefuroxime inj 7.5gm . . . . . . . . . . . . . . 18
cefuroxime inj 750mg . . . . . . . . . . . . . 18
cefuroxime tab 250mg . . . . . . . . . . . . . 18
cefuroxime tab 500mg . . . . . . . . . . . . . 18
CEFZIL . . . . . . . . . . . . . . . . . . . . . . . . . . 18
CELEBREX . . . . . . . . . . . . . . . . . . . . . . . 11
celecoxib cap 100mg . . . . . . . . . . . . . . 11
celecoxib cap 200mg . . . . . . . . . . . . . . 11
celecoxib cap 400mg . . . . . . . . . . . . . . 11
celecoxib cap 50mg . . . . . . . . . . . . . . . 11
CELEXA . . . . . . . . . . . . . . . . . . . . . . . . . 29
CELLCEPT . . . . . . . . . . . . . . . . . . . . . . . . 90
CELLCEPT CAP 250MG . . . . . . . . . . . . . 89
CELLCEPT IV INJ 500MG . . . . . . . . . . . . 89
CELLCEPT SUS 200MG/ML . . . . . . . . . . 89
CELLCEPT TAB 500MG . . . . . . . . . . . . . 89
CELONTIN CAP 300MG . . . . . . . . . . . . . 23
cephalexin cap 250mg . . . . . . . . . . . . . 18
cephalexin cap 500mg . . . . . . . . . . . . . 18
cephalexin cap 750mg . . . . . . . . . . . . . 18
cephalexin sus 125/5ml . . . . . . . . . . . . 19
cephalexin sus 250/5ml . . . . . . . . . . . . 19
cephalexin tab 250mg . . . . . . . . . . . . . 19
cephalexin tab 500mg . . . . . . . . . . . . . 19
CEREBYX . . . . . . . . . . . . . . . . . . . . . . . . 27
CEREZYME INJ 400UNIT . . . . . . . . . . . . 75
ceritinib . . . . . . . . . . . . . . . . . . . . . . . . . 42
CERVARIX INJ . . . . . . . . . . . . . . . . . . . . 91
cetirizine syp 5mg/5ml . . . . . . . . . . . . . 97
cetuximab . . . . . . . . . . . . . . . . . . . . . . . 39
CHANTIX PAK 0.5& 1MG . . . . . . . . . . . 15
CHANTIX TAB 0.5MG . . . . . . . . . . . . . . 15
CHANTIX TAB 1MG . . . . . . . . . . . . . . . . 15
CHEMET CAP 100MG . . . . . . . . . . . . . 100
chlorambucil . . . . . . . . . . . . . . . . . . . . . 37
chloramphen inj 1gm . . . . . . . . . . . . . . 16
chloramphenicol . . . . . . . . . . . . . . . . . . 16
chlordiazep cap 10mg . . . . . . . . . . . . . 54
chlordiazep cap 25mg . . . . . . . . . . . . . 54
chlordiazep cap 5mg . . . . . . . . . . . . . . 54
131
Index of Drugs
chlorhex glu sol 0.12% . . . . . . . . . . . . . 74
chloroquine tab 250mg . . . . . . . . . . . . 43
chloroquine tab 500mg . . . . . . . . . . . . 43
chlorothiaz inj 500mg . . . . . . . . . . . . . 70
chlorothiaz tab 250mg . . . . . . . . . . . . . 70
chlorothiaz tab 500mg . . . . . . . . . . . . . 70
chlorpromaz inj 25mg/ml . . . . . . . . . . . 32
chlorpromaz tab 100mg . . . . . . . . . . . 32
chlorpromaz tab 10mg . . . . . . . . . . . . 32
chlorpromaz tab 200mg . . . . . . . . . . . 32
chlorpromaz tab 25mg . . . . . . . . . . . . 32
chlorpromaz tab 50mg . . . . . . . . . . . . 32
chlorpropam tab 100mg . . . . . . . . . . . 54
chlorpropam tab 250mg . . . . . . . . . . . 54
chlorpropamide . . . . . . . . . . . . . . . . . . 54
chlorthalid tab 25mg . . . . . . . . . . . . . . 70
chlorthalid tab 50mg . . . . . . . . . . . . . . 70
cholestyram pow 4gm lite . . . . . . . . . . 71
cholestyramine resin . . . . . . . . . . . . . . 71
CIALIS TAB 10MG . . . . . . . . . . . . . . . . . 79
CIALIS TAB 20MG . . . . . . . . . . . . . . . . . 79
ciclopirox cre 0.77% . . . . . . . . . . . . . . . 34
ciclopirox gel 0.77% . . . . . . . . . . . . . . . 34
ciclopirox sha 1% . . . . . . . . . . . . . . . . . 34
ciclopirox sol 8% . . . . . . . . . . . . . . . . . 34
ciclopirox sus 0.77% . . . . . . . . . . . . . . . 34
cilostazol tab 100mg . . . . . . . . . . . . . . 59
cilostazol tab 50mg . . . . . . . . . . . . . . . 59
CILOXAN . . . . . . . . . . . . . . . . . . . . . . . . 21
cimetidine sol 300/5ml . . . . . . . . . . . . . 77
cimetidine tab 200mg . . . . . . . . . . . . . 77
cimetidine tab 300mg . . . . . . . . . . . . . 77
cimetidine tab 400mg . . . . . . . . . . . . . 77
cimetidine tab 800mg . . . . . . . . . . . . . 77
cinacalcet . . . . . . . . . . . . . . . . . . . . . . . 88
CINRYZE SOL 500 UNIT . . . . . . . . . . . . . 89
CIPRO . . . . . . . . . . . . . . . . . . . . . . . . . . 21
CIPRO HC SUS . . . . . . . . . . . . . . . . . . . . 96
CIPRO XR . . . . . . . . . . . . . . . . . . . . . . . . 21
CIPRODEX SUS 0.3-0.1% . . . . . . . . . . . 96
ciprofloxacin . . . . . . . . . . . . . . . . . . . . . 96
ciprofloxacin hc . . . . . . . . . . . . . . . . . . 96
ciprofloxacn inj 200mg . . . . . . . . . . . . 21
ciprofloxacn inj 400mg . . . . . . . . . . . . 21
ciprofloxacn sol 0.3% . . . . . . . . . . . . . . 21
ciprofloxacn tab 1000mg . . . . . . . . . . . 21
ciprofloxacn tab 100mg . . . . . . . . . . . . 21
ciprofloxacn tab 250mg . . . . . . . . . . . . 21
ciprofloxacn tab 500mg . . . . . . . . . . . . 21
ciprofloxacn tab 500mg er . . . . . . . . . . 21
ciprofloxacn tab 750mg . . . . . . . . . . . . 21
cisplatin inj 100mg . . . . . . . . . . . . . . . . 38
citalopram sol 10mg/5ml . . . . . . . . . . . 29
132
citalopram tab 10mg . . . . . . . . . . . . . . 29
citalopram tab 20mg . . . . . . . . . . . . . . 29
citalopram tab 40mg . . . . . . . . . . . . . . 29
cladribine inj 1mg/ml . . . . . . . . . . . . . . 38
claravis cap 10mg . . . . . . . . . . . . . . . . . 74
claravis cap 20mg . . . . . . . . . . . . . . . . . 74
claravis cap 30mg . . . . . . . . . . . . . . . . . 74
claravis cap 40mg . . . . . . . . . . . . . . . . . 74
clarithromyc sus 125/5ml . . . . . . . . . . . 21
clarithromyc sus 250/5ml . . . . . . . . . . . 21
clarithromyc tab 250mg . . . . . . . . . . . . 21
clarithromyc tab 500mg . . . . . . . . . . . . 21
clarithromyc tab 500mg er . . . . . . . . . 21
clemastine tab 2.68mg . . . . . . . . . . . . . 97
CLEOCIN . . . . . . . . . . . . . . . . . . . . . . . . 16
CLEOCIN-T . . . . . . . . . . . . . . . . . . . . . . . 16
clindamycin aer 1% . . . . . . . . . . . . . . . 16
clindamycin cap 150mg . . . . . . . . . . . . 16
clindamycin cap 300mg . . . . . . . . . . . . 16
clindamycin cap 75mg . . . . . . . . . . . . . 16
clindamycin cre 2% . . . . . . . . . . . . . . . 16
clindamycin gel 1% . . . . . . . . . . . . . . . 16
clindamycin inj 150mg/ml . . . . . . . . . . 16
clindamycin inj 300mg . . . . . . . . . . . . . 16
clindamycin inj 600mg . . . . . . . . . . . . . 16
clindamycin inj 900mg . . . . . . . . . . . . . 17
clindamycin lot 1% . . . . . . . . . . . . . . . . 17
clindamycin pad 1% . . . . . . . . . . . . . . . 17
clindamycin sol 1% . . . . . . . . . . . . . . . . 17
CLINORIL . . . . . . . . . . . . . . . . . . . . . . . . 12
clobazam . . . . . . . . . . . . . . . . . . . . . . . . 25
clomipramine cap 25mg . . . . . . . . . . . 32
clomipramine cap 50mg . . . . . . . . . . . 32
clomipramine cap 75mg . . . . . . . . . . . 32
clonazep odt tab 0.125mg . . . . . . . . . . 24
clonazep odt tab 0.25mg . . . . . . . . . . . 24
clonazep odt tab 0.5mg . . . . . . . . . . . . 24
clonazep odt tab 1mg . . . . . . . . . . . . . 24
clonazep odt tab 2mg . . . . . . . . . . . . . 24
clonazepam tab 0.5mg . . . . . . . . . . . . 24
clonazepam tab 1mg . . . . . . . . . . . . . . 24
clonazepam tab 2mg . . . . . . . . . . . . . . 24
clonidine - chlorthalidone . . . . . . . . . . 67
clonidine dis 0.1/24hr . . . . . . . . . . . . . . 59
clonidine dis 0.2/24hr . . . . . . . . . . . . . . 59
clonidine dis 0.3/24hr . . . . . . . . . . . . . . 59
clonidine tab 0.1mg . . . . . . . . . . . . . . . 59
clonidine tab 0.1mg er . . . . . . . . . . . . . 60
clonidine tab 0.2mg . . . . . . . . . . . . . . . 60
clonidine tab 0.3mg . . . . . . . . . . . . . . . 60
clopidogrel tab 300mg . . . . . . . . . . . . . 59
clopidogrel tab 75mg . . . . . . . . . . . . . . 59
cloraz dipot tab 15mg . . . . . . . . . . . . . 24
cloraz dipot tab 3.75mg . . . . . . . . . . . . 24
cloraz dipot tab 7.5mg . . . . . . . . . . . . . 24
CLORPRES TAB 0.1-15MG . . . . . . . . . . . 67
CLORPRES TAB 0.2-15MG . . . . . . . . . . . 67
CLORPRES TAB 0.3-15MG . . . . . . . . . . . 67
clotrim/beta cre diprop . . . . . . . . . . . . 74
clotrim/beta lot diprop . . . . . . . . . . . . 74
clotrimazole . . . . . . . . . . . . . . . . . . . . . 34
clotrimazole cre 1% . . . . . . . . . . . . . . . 34
clotrimazole sol 1% . . . . . . . . . . . . . . . 34
clotrimazole tro 10mg . . . . . . . . . . . . . 34
CLOZAPINE . . . . . . . . . . . . . . . . . . . . . . . . clozapine tab 100/odt . . . . . . . . . . . . . 48
clozapine tab 100mg . . . . . . . . . . . . . . 48
clozapine tab 12.5/odt . . . . . . . . . . . . . 48
clozapine tab 150/odt . . . . . . . . . . . . . 48
clozapine tab 200/odt . . . . . . . . . . . . . . . clozapine tab 25mg . . . . . . . . . . . . . . . 48
clozapine tab 25mg odt . . . . . . . . . . . . 48
clozapine tab 50mg . . . . . . . . . . . . . . . 48
CLOZARIL . . . . . . . . . . . . . . . . . . . . . . . 48
COARTEM TAB 20-120MG . . . . . . . . . . 43
cobicistat . . . . . . . . . . . . . . . . . . . . . . . . 50
cobicistat - darunavir . . . . . . . . . . . . . . 51
cobicistat-elvitegravir-emtricitabinetenofovir . . . . . . . . . . . . . . . . . . . . . 50
COGENTIN . . . . . . . . . . . . . . . . . . . . . . . 43
COLAZAL . . . . . . . . . . . . . . . . . . . . . . . . 93
colchicine . . . . . . . . . . . . . . . . . . . . . . . 35
COLCHICINE - PROBENECID . . . . . . . . . 35
COLCRYS TAB 0.6MG . . . . . . . . . . . . . . 35
colesevelam . . . . . . . . . . . . . . . . . . . . . 55
COLESTID . . . . . . . . . . . . . . . . . . . . . . . 71
colestipol gra 5gm . . . . . . . . . . . . . . . . 71
colestipol tab 1gm . . . . . . . . . . . . . . . . 71
colistimeth inj 150mg . . . . . . . . . . . . . . 16
colistimethate . . . . . . . . . . . . . . . . . . . . 16
collagenase . . . . . . . . . . . . . . . . . . . . . . 75
COLOCORT . . . . . . . . . . . . . . . . . . . . . . 80
colocort ene 100mg . . . . . . . . . . . . . . . 80
COLYTE-FLAVR . . . . . . . . . . . . . . . . . . . 77
COMBIVIR . . . . . . . . . . . . . . . . . . . . . . . 51
COMBUNOX . . . . . . . . . . . . . . . . . . . . . 11
COMETRIQ KIT 100MG . . . . . . . . . . . . . 41
COMETRIQ KIT 140MG . . . . . . . . . . . . . 41
COMETRIQ KIT 60MG . . . . . . . . . . . . . . 41
COMPAZINE . . . . . . . . . . . . . . . . . . . . . 33
COMPLERA TAB . . . . . . . . . . . . . . . . . . 50
COMPRO . . . . . . . . . . . . . . . . . . . . . . . . 33
compro sup 25mg . . . . . . . . . . . . . . . . . 33
COMTAN . . . . . . . . . . . . . . . . . . . . . . . . 44
COMVAX INJ . . . . . . . . . . . . . . . . . . . . . 91
CONCERTA . . . . . . . . . . . . . . . . . . . . . . 73
Index of Drugs
CONDYLOX . . . . . . . . . . . . . . . . . . . . . . 75
constulose sol 10gm/15ml . . . . . . . . . . 78
CONSTULOSE, CEPHULAC, ENULOSE . . 78
COPAXONE KIT 20MG/ML . . . . . . . . . . 73
CORDARONE . . . . . . . . . . . . . . . . . . . . . 62
CORDARONE, PACERONE . . . . . . . . . . 62
COREG . . . . . . . . . . . . . . . . . . . . . . . . . . 63
CORGARD . . . . . . . . . . . . . . . . . . . . . . . 63
CORTEF . . . . . . . . . . . . . . . . . . . . . . . . . 82
cortisone . . . . . . . . . . . . . . . . . . . . . . . . 80
CORTISONE AC TAB 25MG . . . . . . . . . . 80
CORTISPORIN . . . . . . . . . . . . . . . . . . . . 94
CORZIDE . . . . . . . . . . . . . . . . . . . . . . . . 67
COSOPT . . . . . . . . . . . . . . . . . . . . . . . . . 94
COUMADIN . . . . . . . . . . . . . . . . . . . . . . 57
COUMADIN TAB 10MG . . . . . . . . . . . . 56
COUMADIN TAB 1MG . . . . . . . . . . . . . 56
COUMADIN TAB 2.5MG . . . . . . . . . . . . 56
COUMADIN TAB 2MG . . . . . . . . . . . . . 56
COUMADIN TAB 3MG . . . . . . . . . . . . . 56
COUMADIN TAB 4MG . . . . . . . . . . . . . 57
COUMADIN TAB 5MG . . . . . . . . . . . . . 57
COUMADIN TAB 6MG . . . . . . . . . . . . . 57
COUMADIN TAB 7.5MG . . . . . . . . . . . . 57
COZAAR . . . . . . . . . . . . . . . . . . . . . . . . 60
CREON CAP 12000UNT . . . . . . . . . . . . . 76
CREON CAP 24000UNT . . . . . . . . . . . . . 76
CREON CAP 3000UNIT . . . . . . . . . . . . . 76
CREON CAP 36000UNT . . . . . . . . . . . . . 77
CREON CAP 6000UNIT . . . . . . . . . . . . . 76
CRESTOR TAB 10MG . . . . . . . . . . . . . . . 70
CRESTOR TAB 20MG . . . . . . . . . . . . . . . 71
CRESTOR TAB 40MG . . . . . . . . . . . . . . . 71
CRESTOR TAB 5MG . . . . . . . . . . . . . . . . 71
CRIXIVAN CAP 200MG . . . . . . . . . . . . . 52
CRIXIVAN CAP 400MG . . . . . . . . . . . . . 52
crizotinib . . . . . . . . . . . . . . . . . . . . . . . . 42
CROLOM . . . . . . . . . . . . . . . . . . . . . . . . 95
cromolyn sod con 100/5ml . . . . . . . . . . 98
cromolyn sod neb 20mg/2ml . . . . . . . . 98
cromolyn sod sol 4% . . . . . . . . . . . . . . 95
cryselle-28 tab . . . . . . . . . . . . . . . . . . . . 85
CUBICIN SOL 500MG . . . . . . . . . . . . . . 17
CUTIVATE . . . . . . . . . . . . . . . . . . . . . . . 81
cyclafem tab 7/7/7 . . . . . . . . . . . . . . . . 85
CYCLESSA, VELIVET, CESIA . . . . . . . . . . 86
cyclobenzapr tab 10mg . . . . . . . . . . . 100
cyclobenzapr tab 5mg . . . . . . . . . . . . 100
cyclobenzapr tab 7.5mg . . . . . . . . . . . 100
CYCLOCORT . . . . . . . . . . . . . . . . . . . . . 80
cyclophosph cap 25mg . . . . . . . . . . . . . 37
cyclophosph cap 50mg . . . . . . . . . . . . . 37
CYCLOSET TAB 0.8MG . . . . . . . . . . . . . 54
cyclosporine . . . . . . . . . . . . . . . . . . . . . 90
cyclosporine cap 100mg . . . . . . . . . . . . 89
cyclosporine cap 100mg md . . . . . . . . 89
cyclosporine cap 25mg . . . . . . . . . . . . . 89
cyclosporine cap 25mg mod . . . . . . . . 89
cyclosporine cap 50mg mod . . . . . . . . 89
cyclosporine inj 50mg/ml . . . . . . . . . . . 89
cyclosporine sol modified . . . . . . . . . . 90
CYMBALTA . . . . . . . . . . . . . . . . . . . . . . 30
cyproheptad syp 2mg/5ml . . . . . . . . . . 97
cyproheptad tab 4mg . . . . . . . . . . . . . 97
CYSTADANE POW . . . . . . . . . . . . . . . . . 75
CYSTAGON CAP 150MG . . . . . . . . . . . . 76
CYSTAGON CAP 50MG . . . . . . . . . . . . . 76
cysteamine . . . . . . . . . . . . . . . . . . . . . . 76
CYTARABINE . . . . . . . . . . . . . . . . . . . . . 38
cytarabine inj 100mg/ml . . . . . . . . . . . 38
cytarabine inj 20mg/ml . . . . . . . . . . . . 38
CYTOMEL . . . . . . . . . . . . . . . . . . . . . . . 87
CYTOSAR-U . . . . . . . . . . . . . . . . . . . . . . 38
CYTOTEC . . . . . . . . . . . . . . . . . . . . . . . . 78
CYTOVENE . . . . . . . . . . . . . . . . . . . . . . 48
CYTOXAN . . . . . . . . . . . . . . . . . . . . . . . 37
D
D.H.E. 45 . . . . . . . . . . . . . . . . . . . . . . . . 35
D10W/NACL INJ 0.2% . . . . . . . . . . . . . 102
D10W/NACL INJ 0.45% . . . . . . . . . . . . 102
d2.5w/nacl inj 0.45% . . . . . . . . . . . . . 102
d5w/lr . . . . . . . . . . . . . . . . . . . . . . . . . 102
d5w/nacl inj 0.2% . . . . . . . . . . . . . . . . 102
D5W/NACL INJ 0.225% . . . . . . . . . . . . 102
d5w/nacl inj 0.33% . . . . . . . . . . . . . . . 102
d5w/nacl inj 0.45% . . . . . . . . . . . . . . . 102
d5w/nacl inj 0.9% . . . . . . . . . . . . . . . . 102
dabigatran . . . . . . . . . . . . . . . . . . . . . . 57
dabrafenib . . . . . . . . . . . . . . . . . . . . . . 42
dacarbazine inj 200mg . . . . . . . . . . . . . 38
DACOGEN . . . . . . . . . . . . . . . . . . . . . . . 39
dalfampridine er . . . . . . . . . . . . . . . . . 73
dalfopristin - quinupristin . . . . . . . . . . 16
DALIRESP TAB 500MCG . . . . . . . . . . . . 98
dalteparin . . . . . . . . . . . . . . . . . . . . . . . 57
danazol cap 100mg . . . . . . . . . . . . . . . 84
danazol cap 200mg . . . . . . . . . . . . . . . 84
danazol cap 50mg . . . . . . . . . . . . . . . . 84
DANOCRINE . . . . . . . . . . . . . . . . . . . . . 84
DANTRIUM . . . . . . . . . . . . . . . . . . . . . . 48
dantrolene cap 100mg . . . . . . . . . . . . . 48
dantrolene cap 25mg . . . . . . . . . . . . . . 48
dantrolene cap 50mg . . . . . . . . . . . . . . 48
dapsone . . . . . . . . . . . . . . . . . . . . . . . . 36
dapsone tab 100mg . . . . . . . . . . . . . . . 36
dapsone tab 25mg . . . . . . . . . . . . . . . . 36
DAPTACEL INJ . . . . . . . . . . . . . . . . . . . . 91
daptomycin . . . . . . . . . . . . . . . . . . . . . . 17
DARAPRIM TAB 25MG . . . . . . . . . . . . . 43
darbepoetin alfa . . . . . . . . . . . . . . . . . 58
darifenacin . . . . . . . . . . . . . . . . . . . . . . 79
darunavir . . . . . . . . . . . . . . . . . . . . . . . 52
dasabuvir - ombitasvir - . . . . . . . . . . . . 50
paritaprevir - ritonavir
dasatinib . . . . . . . . . . . . . . . . . . . . . . . . 41
DAUNORUBICIN . . . . . . . . . . . . . . . . . . 38
daunorubicin inj 5mg/ml . . . . . . . . . . . 38
DAYPRO . . . . . . . . . . . . . . . . . . . . . . . . 12
DDAVP . . . . . . . . . . . . . . . . . . . . . . . . . 83
DECADRON, DEXASONE . . . . . . . . . . . 81
decitabine inj 50mg . . . . . . . . . . . . . . . 39
DECLOMYCIN . . . . . . . . . . . . . . . . . . . . 22
deferasirox . . . . . . . . . . . . . . . . . . . . . 100
deferiprone . . . . . . . . . . . . . . . . . . . . . 100
degarelix . . . . . . . . . . . . . . . . . . . . . . . . 88
DEL-BETA . . . . . . . . . . . . . . . . . . . . . . . 80
DELATESTRYL . . . . . . . . . . . . . . . . . . . . 84
delavirdine . . . . . . . . . . . . . . . . . . . . . . 50
delyla tab 0.1-0.02 . . . . . . . . . . . . . . . . 85
DELZICOL CAP 400MG . . . . . . . . . . . . . 93
DEMADEX . . . . . . . . . . . . . . . . . . . . . . . 69
demeclocycl tab 150mg . . . . . . . . . . . . 22
demeclocycl tab 300mg . . . . . . . . . . . . 22
DEMSER CAP 250MG . . . . . . . . . . . . . . 67
DEMULEN . . . . . . . . . . . . . . . . . . . . . . . 86
DEMULEN, KELNOR, ZOVIA . . . . . . . . . 85
DENAVIR CRE 1% . . . . . . . . . . . . . . . . . 53
denosumab . . . . . . . . . . . . . . . . . . . . . . 94
DEPAKENE . . . . . . . . . . . . . . . . . . . . . . 25
DEPAKOTE . . . . . . . . . . . . . . . . . . . . . . 24
DEPEN TITRA TAB 250MG . . . . . . . . . . 79
DEPO-MEDROL . . . . . . . . . . . . . . . . . . . 82
DEPO-PROVERA . . . . . . . . . . . . . . . . . . 86
DEPO-PROVERA INJ 400/ML . . . . . . . . . 86
DERMA-SMOOTH . . . . . . . . . . . . . . . . . 81
DERMATOP . . . . . . . . . . . . . . . . . . . . . . 82
DERMOTIC . . . . . . . . . . . . . . . . . . . . . . 81
desipramine tab 100mg . . . . . . . . . . . . 32
desipramine tab 10mg . . . . . . . . . . . . . 32
desipramine tab 150mg . . . . . . . . . . . . 32
desipramine tab 25mg . . . . . . . . . . . . . 32
desipramine tab 50mg . . . . . . . . . . . . . 32
desipramine tab 75mg . . . . . . . . . . . . . 32
desmopressin . . . . . . . . . . . . . . . . . . . . 83
desmopressin inj 4mcg/ml . . . . . . . . . . 83
desmopressin spr 0.01% . . . . . . . . . . . 83
desmopressin tab 0.1mg . . . . . . . . . . . 83
desmopressin tab 0.2mg . . . . . . . . . . . 83
133
Index of Drugs
desonide cre 0.05% . . . . . . . . . . . . . . . 80
desonide lot 0.05% . . . . . . . . . . . . . . . 80
desonide oin 0.05% . . . . . . . . . . . . . . . 80
DESOWEN . . . . . . . . . . . . . . . . . . . . . . . 80
desoximetas cre 0.05% . . . . . . . . . . . . 80
desoximetas cre 0.25% . . . . . . . . . . . . 80
desoximetas gel 0.05% . . . . . . . . . . . . 81
desoximetas oin 0.05% . . . . . . . . . . . . 81
desoximetas oin 0.25% . . . . . . . . . . . . 81
desvenlafax tab 100mg er . . . . . . . . . . 30
desvenlafax tab 50mg er . . . . . . . . . . . 30
desvenlafaxine . . . . . . . . . . . . . . . . . . . 31
desvenlafaxine er . . . . . . . . . . . . . . . . . 30
DESYREL,OLEPTRO . . . . . . . . . . . . . . . . 31
DETROL . . . . . . . . . . . . . . . . . . . . . . . . . 79
DETROL LA . . . . . . . . . . . . . . . . . . . . . . 79
dexameth pho inj 10mg/ml . . . . . . . . . 81
dexameth pho inj 120mg/30ml . . . . . . 81
dexameth pho sol 0.1% . . . . . . . . . . . . 95
dexamethason con 1mg/ml . . . . . . . . . 81
dexamethason elx 0.5/5ml . . . . . . . . . . 81
dexamethason tab 0.5mg . . . . . . . . . . 81
dexamethason tab 0.75mg . . . . . . . . . 81
dexamethason tab 1.5mg . . . . . . . . . . 81
dexamethason tab 1mg . . . . . . . . . . . . 81
dexamethason tab 2mg . . . . . . . . . . . . 81
dexamethason tab 4mg . . . . . . . . . . . . 81
dexamethason tab 6mg . . . . . . . . . . . . 81
dexamethasone . . . . . . . . . . . . . . . . . . 95
DEXASOL . . . . . . . . . . . . . . . . . . . . . . . . 95
DEXEDRINE . . . . . . . . . . . . . . . . . . . . . . 72
dexmethylph tab 10mg . . . . . . . . . . . . 72
dexmethylph tab 2.5mg . . . . . . . . . . . . 73
dexmethylph tab 5mg . . . . . . . . . . . . . 73
dextroamphet tab 10mg . . . . . . . . . . . 72
dextroamphet tab 5mg . . . . . . . . . . . . 72
dextromethorphan - quinidine . . . . . . 73
sulfate
dextrose 10% . . . . . . . . . . . . . . . . . . . 102
dextrose 2.5% - sodium chloride . . . . 102
0.45%
dextrose 5% . . . . . . . . . . . . . . . . . . . . 102
dextrose 5% - sodium chloride . . . . . 102
0.2%
dextrose 5% - sodium chloride . . . . . 102
0.225%
dextrose 5% - sodium chloride . . . . . 102
0.33%
dextrose 5% - sodium chloride . . . . . 102
0.45%
dextrose 5% - sodium chloride . . . . . 102
0.9%
dextrose inj 10% . . . . . . . . . . . . . . . . 102
134
dextrose inj 5% . . . . . . . . . . . . . . . . . 102
DIAMOX . . . . . . . . . . . . . . . . . . . . . . . . 69
DIAMOX SEQUELS . . . . . . . . . . . . . . . . 69
DIASTAT ACDL GEL 12.5-20MG . . . . . . 24
DIASTAT ACDL GEL 5-10MG . . . . . . . . . 24
DIASTAT PED GEL 2.5MG . . . . . . . . . . . 24
diazepam con 5mg/ml . . . . . . . . . . . . . 24
diazepam gel . . . . . . . . . . . . . . . . . . . . 24
DIAZEPAM GEL 10MG . . . . . . . . . . . . . 24
DIAZEPAM GEL 2.5MG . . . . . . . . . . . . . 24
DIAZEPAM GEL 20MG . . . . . . . . . . . . . 24
diazepam sol 1mg/ml . . . . . . . . . . . . . . 24
diazepam tab 10mg . . . . . . . . . . . . . . . 24
diazepam tab 2mg . . . . . . . . . . . . . . . . 24
diazepam tab 5mg . . . . . . . . . . . . . . . . 24
diazoxide . . . . . . . . . . . . . . . . . . . . . . . 56
diclo/misopr tab 50-0.2mg . . . . . . . . . . 10
diclo/misopr tab 75-0.2mg . . . . . . . . . . 10
diclofen pot tab 50mg . . . . . . . . . . . . . 11
diclofenac gel 3% . . . . . . . . . . . . . . . . . 74
diclofenac patch . . . . . . . . . . . . . . . . . . 11
diclofenac sol 0.1% . . . . . . . . . . . . . . . 95
diclofenac sol 1.5% . . . . . . . . . . . . . . . 74
diclofenac tab 100mg er . . . . . . . . . . . 11
diclofenac tab 25mg dr . . . . . . . . . . . . 11
diclofenac tab 50mg dr . . . . . . . . . . . . 11
diclofenac tab 75mg dr . . . . . . . . . . . . 11
diclofenac top sol . . . . . . . . . . . . . . . . . 74
dicloxacill cap 250mg . . . . . . . . . . . . . . 20
dicloxacill cap 500mg . . . . . . . . . . . . . . 20
dicyclomine cap 10mg . . . . . . . . . . . . . 76
dicyclomine sol 10mg/5ml . . . . . . . . . . 76
dicyclomine tab 20mg . . . . . . . . . . . . . 76
didanosine . . . . . . . . . . . . . . . . . . . . . . 51
didanosine cap 125mg . . . . . . . . . . . . . 51
didanosine cap 200mg . . . . . . . . . . . . . 51
didanosine cap 250mg . . . . . . . . . . . . . 51
didanosine cap 400mg . . . . . . . . . . . . . 51
DIDRONEL . . . . . . . . . . . . . . . . . . . . . . . 93
DIFFERIN . . . . . . . . . . . . . . . . . . . . . . . . 74
diflorasone cre 0.05% . . . . . . . . . . . . . 81
diflorasone oin 0.05% . . . . . . . . . . . . . 81
DIFLUCAN . . . . . . . . . . . . . . . . . . . . . . . 34
DIFLUCAN - DEXTROSE . . . . . . . . . . . . 34
diflunisal . . . . . . . . . . . . . . . . . . . . . . . . 11
diflunisal tab 500mg . . . . . . . . . . . . . . 11
difluprednate . . . . . . . . . . . . . . . . . . . . 95
digitek tab 0.125mg . . . . . . . . . . . . . . . 68
digitek tab 0.25mg . . . . . . . . . . . . . . . . 68
digoxin . . . . . . . . . . . . . . . . . . . . . . . . . 68
digoxin inj 0.25mg/1ml . . . . . . . . . . . . 68
digoxin sol 50mcg/ml . . . . . . . . . . . . . . 68
digoxin tab 0.125mg . . . . . . . . . . . . . . 68
digoxin tab 0.25mg . . . . . . . . . . . . . . . 68
dihydroergot inj 1mg/ml . . . . . . . . . . . 35
DILANTIN . . . . . . . . . . . . . . . . . . . . . . . 27
DILANTIN CAP 30MG . . . . . . . . . . . . . . 26
DILANTIN CHEWABLE . . . . . . . . . . . . . 27
DILATRATE-SR . . . . . . . . . . . . . . . . . . . . 72
DILAUDID . . . . . . . . . . . . . . . . . . . . . . . 13
DILT-CD . . . . . . . . . . . . . . . . . . . . . . . . . 64
dilt-xr cap 120mg . . . . . . . . . . . . . . . . . 64
dilt-xr cap 180mg . . . . . . . . . . . . . . . . . 64
dilt-xr cap 240mg . . . . . . . . . . . . . . . . . 64
diltiazem cap 120mg cd . . . . . . . . . . . . 64
diltiazem cap 120mg er . . . . . . . . . . . . 64
diltiazem cap 180mg/24hr . . . . . . . . . . 64
diltiazem cap 240mg cd . . . . . . . . . . . . 64
diltiazem cap 300mg er . . . . . . . . . . . . 64
diltiazem cap 360mg/24hr . . . . . . . . . . 64
diltiazem cap 420mg/24hr . . . . . . . . . . 64
diltiazem cap 60mg er . . . . . . . . . . . . . 64
diltiazem cap 90mg er . . . . . . . . . . . . . 64
DILTIAZEM CD . . . . . . . . . . . . . . . . . . . . 64
diltiazem inj 100mg . . . . . . . . . . . . . . . 64
diltiazem inj 50/10ml . . . . . . . . . . . . . . 64
diltiazem tab 120mg . . . . . . . . . . . . . . 64
diltiazem tab 30mg . . . . . . . . . . . . . . . 64
diltiazem tab 60mg . . . . . . . . . . . . . . . 64
diltiazem tab 90mg . . . . . . . . . . . . . . . 64
DIOVAN . . . . . . . . . . . . . . . . . . . . . . . . . 61
DIOVAN HCT . . . . . . . . . . . . . . . . . . . . . 68
DIPENTUM CAP 250MG . . . . . . . . . . . . 93
diphenhydram inj 50mg/ml . . . . . . . . . 33
diphtheria - tetanus toxoids - . . . . . . . 92
acellular pertussis
diphtheria toxoid - tetanus toxoid . . . 92
DIPROLENE . . . . . . . . . . . . . . . . . . . . . . 80
disopyramide cap 100mg . . . . . . . . . . . 62
disopyramide cap 150mg . . . . . . . . . . . 62
disulfiram tab 250mg . . . . . . . . . . . . . . 14
disulfiram tab 500mg . . . . . . . . . . . . . . 14
DITROPAN . . . . . . . . . . . . . . . . . . . . . . . 79
DITROPAN XL . . . . . . . . . . . . . . . . . . . . 79
DIURIL . . . . . . . . . . . . . . . . . . . . . . . . . . 70
divalproex cap 125mg . . . . . . . . . . . . . 24
divalproex tab 125mg dr . . . . . . . . . . . 24
divalproex tab 250mg dr . . . . . . . . . . . 24
divalproex tab 250mg er . . . . . . . . . . . 24
divalproex tab 500mg dr . . . . . . . . . . . 24
divalproex tab 500mg er . . . . . . . . . . . 24
DOCEFREZ INJ 20MG . . . . . . . . . . . . . . 39
docetaxel . . . . . . . . . . . . . . . . . . . . . . . 39
docetaxel inj 80mg/4ml . . . . . . . . . . . . 39
docetaxel inj 80mg/8ml . . . . . . . . . . . . 39
dofetilide . . . . . . . . . . . . . . . . . . . . . . . 63
Index of Drugs
dolasetron . . . . . . . . . . . . . . . . . . . . . . . 33
DOLOPHINE . . . . . . . . . . . . . . . . . . . . . 12
dolutegravir . . . . . . . . . . . . . . . . . . . . . 51
donepezil tab 10mg . . . . . . . . . . . . . . . 27
donepezil tab 10mg odt . . . . . . . . . . . 27
donepezil tab 5mg . . . . . . . . . . . . . . . . 27
donepezil tab 5mg odt . . . . . . . . . . . . 27
donepezil tab hcl 23mg . . . . . . . . . . . . 27
dornase alfa . . . . . . . . . . . . . . . . . . . . . 99
DORYX . . . . . . . . . . . . . . . . . . . . . . . . . 22
dorzol/timol sol 2-0.5% . . . . . . . . . . . . 94
dorzolamide sol 2% . . . . . . . . . . . . . . . 95
DOSTINEX . . . . . . . . . . . . . . . . . . . . . . . 88
doxazosin tab 1mg . . . . . . . . . . . . . . . . 60
doxazosin tab 2mg . . . . . . . . . . . . . . . . 60
doxazosin tab 4mg . . . . . . . . . . . . . . . . 60
doxazosin tab 8mg . . . . . . . . . . . . . . . . 60
doxepin hcl cap 100mg . . . . . . . . . . . . 32
doxepin hcl cap 10mg . . . . . . . . . . . . . 32
doxepin hcl cap 150mg . . . . . . . . . . . . 32
doxepin hcl cap 25mg . . . . . . . . . . . . . 32
doxepin hcl cap 50mg . . . . . . . . . . . . . 32
doxepin hcl cap 75mg . . . . . . . . . . . . . 32
doxepin hcl con 10mg/ml . . . . . . . . . . . 32
doxorubicin inj 50mg . . . . . . . . . . . . . . 39
doxycyc mono tab 150mg . . . . . . . . . . 22
doxycyc mono tab 50mg . . . . . . . . . . . 22
doxycyc mono tab 75mg . . . . . . . . . . . 22
doxycycl hyc cap 100mg . . . . . . . . . . . . 22
doxycycl hyc cap 50mg . . . . . . . . . . . . . 22
doxycycl hyc inj 100mg . . . . . . . . . . . . 22
doxycycl hyc tab 100mg . . . . . . . . . . . . 22
doxycycl hyc tab 100mg dr . . . . . . . . . 22
doxycycl hyc tab 150mg dr . . . . . . . . . 22
doxycycl hyc tab 75mg dr . . . . . . . . . . 22
doxycycline . . . . . . . . . . . . . . . . . . . . . . 22
doxycycline cap 150mg . . . . . . . . . . . . 22
doxycycline cap 75mg . . . . . . . . . . . . . 22
doxycycline mono cap 100mg . . . . . . . 22
doxycycline mono cap 50mg . . . . . . . . 22
doxycycline mono tab 100mg . . . . . . . 22
doxycycline mono tab 50mg . . . . . . . . 22
doxycycline sus . . . . . . . . . . . . . . . . . . . 22
doxycycline sus 25mg/5ml . . . . . . . . . . 22
doxycycline tab 20mg . . . . . . . . . . . . . 74
dronabinol cap 10mg . . . . . . . . . . . . . . 33
dronabinol cap 2.5mg . . . . . . . . . . . . . 33
dronabinol cap 5mg . . . . . . . . . . . . . . . 33
dronedarone . . . . . . . . . . . . . . . . . . . . . 62
drospir/ethi tab 3-0.03mg . . . . . . . . . . 85
drospirenone - ethinyl estradiol . . . . . 85
DROXIA CAP 200MG . . . . . . . . . . . . . . 38
DROXIA CAP 300MG . . . . . . . . . . . . . . 38
DROXIA CAP 400MG . . . . . . . . . . . . . . 38
droxidopa . . . . . . . . . . . . . . . . . . . . . . . 67
DTIC-DOME . . . . . . . . . . . . . . . . . . . . . . 38
DUAVEE TAB 0.45-20MG . . . . . . . . . . . 85
DUETACT . . . . . . . . . . . . . . . . . . . . . . . . 55
dulaglutide . . . . . . . . . . . . . . . . . . . . . . 55
duloxetine . . . . . . . . . . . . . . . . . . . . . . . 30
DULOXETINE CAP 20MG . . . . . . . . . . . 30
duloxetine cap 30mg . . . . . . . . . . . . . . 30
duloxetine cap 40mg . . . . . . . . . . . . . . 30
duloxetine cap 60mg . . . . . . . . . . . . . . 30
DURAGESIC . . . . . . . . . . . . . . . . . . . . . . 12
DURAMORPH INJ 0.5MG/ML . . . . . . . . 13
DURAMORPH INJ 1MG/ML . . . . . . . . . 13
DUREZOL EMU 0.05% . . . . . . . . . . . . . 95
DURICEF . . . . . . . . . . . . . . . . . . . . . . . . 18
dutasteride . . . . . . . . . . . . . . . . . . . . . . 79
DYAZIDE . . . . . . . . . . . . . . . . . . . . . . . . 68
DYCIL, DYNAPEN . . . . . . . . . . . . . . . . . 20
DYNACIN . . . . . . . . . . . . . . . . . . . . . . . . 22
DYNACIRC . . . . . . . . . . . . . . . . . . . . . . . 65
E
E.E.S. . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
e.e.s. 400 tab 400mg . . . . . . . . . . . . . . 21
econazole cre 1% . . . . . . . . . . . . . . . . . 34
EDURANT TAB 25MG . . . . . . . . . . . . . . 50
efavirenz . . . . . . . . . . . . . . . . . . . . . . . . 50
efavirenz - emtricitabine . . . . . . . . . . . 53
-tenofovir
EFFEXOR . . . . . . . . . . . . . . . . . . . . . . . . 31
EFFEXOR ER . . . . . . . . . . . . . . . . . . . . . 31
EFFEXOR XR . . . . . . . . . . . . . . . . . . . . . 31
EFFIENT TAB 10MG . . . . . . . . . . . . . . . . 59
EFFIENT TAB 5MG . . . . . . . . . . . . . . . . . 59
8-MOP CAP 10MG . . . . . . . . . . . . . . . . 74
EFUDEX . . . . . . . . . . . . . . . . . . . . . . . . . 74
ELAPRASE INJ 6MG/3ML . . . . . . . . . . . 76
ELAVIL . . . . . . . . . . . . . . . . . . . . . . . . . . 31
ELDEPRYL . . . . . . . . . . . . . . . . . . . . . . . 45
ELIDEL CRE 1% . . . . . . . . . . . . . . . . . . . 74
ELIMITE . . . . . . . . . . . . . . . . . . . . . . . . . 43
ELIQUIS TAB 2.5MG . . . . . . . . . . . . . . . 57
ELIQUIS TAB 5MG . . . . . . . . . . . . . . . . . 57
ELITEK INJ 1.5MG . . . . . . . . . . . . . . . . . 39
ELLENCE . . . . . . . . . . . . . . . . . . . . . . . . 39
ELOCON . . . . . . . . . . . . . . . . . . . . . . . . 82
ELOXATIN . . . . . . . . . . . . . . . . . . . . . . . 39
eltrombopag . . . . . . . . . . . . . . . . . . . . . 59
elvitegravir . . . . . . . . . . . . . . . . . . . . . . 51
EMCYT CAP 140MG . . . . . . . . . . . . . . . 38
EMEND CAP 125MG . . . . . . . . . . . . . . . 33
EMEND CAP 40MG . . . . . . . . . . . . . . . . 33
EMEND CAP 80MG . . . . . . . . . . . . . . . . 33
EMEND PAK 80 & 125MG . . . . . . . . . . 33
EMLA . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
empagliflozin . . . . . . . . . . . . . . . . . . . . 55
EMSAM DIS 12MG/24HR . . . . . . . . . . . 29
EMSAM DIS 6MG/24HR . . . . . . . . . . . . 29
EMSAM DIS 9MG/24HR . . . . . . . . . . . . 29
emtricitabine . . . . . . . . . . . . . . . . . . . . 51
emtricitabine - tenofovir . . . . . . . . . . . 51
emtricitabine-rilpivirine-tenofovir . . . 50
EMTRIVA CAP 200MG . . . . . . . . . . . . . 51
EMTRIVA SOL 10MG/ML . . . . . . . . . . . . 51
ENABLEX TAB 15MG . . . . . . . . . . . . . . 79
ENABLEX TAB 7.5MG . . . . . . . . . . . . . . 79
enalapr/hctz tab 10-25mg . . . . . . . . . . 67
enalapr/hctz tab 5-12.5mg . . . . . . . . . . 67
enalapril tab 10mg . . . . . . . . . . . . . . . . 61
enalapril tab 2.5mg . . . . . . . . . . . . . . . 61
enalapril tab 20mg . . . . . . . . . . . . . . . . 61
enalapril tab 5mg . . . . . . . . . . . . . . . . . 61
ENBREL INJ 25/0.5ML . . . . . . . . . . . . . . 90
ENBREL INJ 25MG . . . . . . . . . . . . . . . . . 90
ENBREL INJ 50MG/ML . . . . . . . . . . . . . . 90
ENBREL SRCLK 50MG/ML . . . . . . . . . . . 90
endocet tab 10-325mg . . . . . . . . . . . . . 10
endocet tab 5-325mg . . . . . . . . . . . . . . 10
endocet tab 7.5-325mg . . . . . . . . . . . . 10
ENDOCET, PERCOCET . . . . . . . . . . . . . . 10
enfuvirtide . . . . . . . . . . . . . . . . . . . . . . 51
ENGERIX-B INJ 10/0.5ML . . . . . . . . . . . 91
ENGERIX-B INJ 20MCG/ML . . . . . . . . . . 91
enoxaparin inj 100mg/ml . . . . . . . . . . . 57
enoxaparin inj 120/0.8ml . . . . . . . . . . . 57
enoxaparin inj 150mg/ml . . . . . . . . . . . 57
enoxaparin inj 30/0.3ml . . . . . . . . . . . . 57
enoxaparin inj 300/3ml . . . . . . . . . . . . 57
enoxaparin inj 40/0.4ml . . . . . . . . . . . . 57
enoxaparin inj 60/0.6ml . . . . . . . . . . . . 57
enoxaparin inj 80/0.8ml . . . . . . . . . . . . 57
enpresse-28 tab . . . . . . . . . . . . . . . . . . 85
ENPRESSE, TRIVORA, TRI-LEVEN . . . . . 85
entacapone tab 200mg . . . . . . . . . . . . 44
entecavir . . . . . . . . . . . . . . . . . . . . . . . . 49
entecavir tab 0.5mg . . . . . . . . . . . . . . . 49
entecavir tab 1mg . . . . . . . . . . . . . . . . 49
ENTOCORT EC . . . . . . . . . . . . . . . . . . . . 80
enulose sol 10gm/15ml . . . . . . . . . . . . 78
enzalutamide . . . . . . . . . . . . . . . . . . . . 37
epinephrine . . . . . . . . . . . . . . . . . . . . . 97
EPIPEN 2-PAK INJ 0.3MG . . . . . . . . . . . 97
EPIPEN-JR INJ 2-PAK . . . . . . . . . . . . . . . 98
epirubicin inj 50/25ml . . . . . . . . . . . . . 39
epitol tab 200mg . . . . . . . . . . . . . . . . . 26
135
Index of Drugs
EPIVIR . . . . . . . . . . . . . . . . . . . . . . . . . . 49
EPIVIR HBV SOL 5MG/ML . . . . . . . . . . . 49
eplerenone tab 25mg . . . . . . . . . . . . . 69
eplerenone tab 50mg . . . . . . . . . . . . . 69
epoetin alfa . . . . . . . . . . . . . . . . . . . . . 58
EPOGEN INJ 10000/ML . . . . . . . . . . . . . 58
EPOGEN INJ 2000/ML . . . . . . . . . . . . . . 58
EPOGEN INJ 20000/ML . . . . . . . . . . . . . 58
EPOGEN INJ 3000/ML . . . . . . . . . . . . . . 58
EPOGEN INJ 4000/ML . . . . . . . . . . . . . . 58
eprosart mes tab 600mg . . . . . . . . . . . 60
EPZICOM TAB 600-300MG . . . . . . . . . . 51
EQUETRO CAP 100MG . . . . . . . . . . . . . 26
EQUETRO CAP 200MG . . . . . . . . . . . . . 26
EQUETRO CAP 300MG . . . . . . . . . . . . . 26
ERAXIS INJ 100MG . . . . . . . . . . . . . . . . 34
ERBITUX INJ 100MG . . . . . . . . . . . . . . . 39
ergoloid mes tab 1mg . . . . . . . . . . . . . 27
ergoloid mesylates . . . . . . . . . . . . . . . . 27
eribulin . . . . . . . . . . . . . . . . . . . . . . . . . 39
ERIVEDGE CAP 150MG . . . . . . . . . . . . . 41
erlotinib . . . . . . . . . . . . . . . . . . . . . . . . 42
errin tab 0.35mg . . . . . . . . . . . . . . . . . . 86
ertapenem . . . . . . . . . . . . . . . . . . . . . . 19
ERWINAZE INJ 10000UNT . . . . . . . . . . 40
erwinia asparaginase . . . . . . . . . . . . . . 40
ERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ery pad 2% . . . . . . . . . . . . . . . . . . . . . . 21
ery-tab tab 250mg ec . . . . . . . . . . . . . . 21
ery-tab tab 333mg ec . . . . . . . . . . . . . . 21
ery-tab tab 500mg ec . . . . . . . . . . . . . . 21
ERY-TAB, E.E.S. . . . . . . . . . . . . . . . . . . . 21
ERYGEL . . . . . . . . . . . . . . . . . . . . . . . . . 21
ERYTHROCIN . . . . . . . . . . . . . . . . . . . . . 21
erythrocin inj 500mg . . . . . . . . . . . . . . 21
erythrocin tab 250mg . . . . . . . . . . . . . 21
erythrom eth tab 400mg . . . . . . . . . . . 21
erythromycin . . . . . . . . . . . . . . . . . . . . 21
erythromycin gel /benzoyl . . . . . . . . . . 74
erythromycin gel 2% . . . . . . . . . . . . . . 21
erythromycin oin . . . . . . . . . . . . . . . . . 21
erythromycin sol 2% . . . . . . . . . . . . . . 21
erythromycin tab 250mg bs . . . . . . . . . 21
erythromycin tab 500mg bs . . . . . . . . . 21
ESBRIET CAP 267MG . . . . . . . . . . . . . . . 99
escitalopram sol 5mg/5ml . . . . . . . . . . 30
escitalopram tab 10mg . . . . . . . . . . . . 30
escitalopram tab 20mg . . . . . . . . . . . . 30
escitalopram tab 5mg . . . . . . . . . . . . . 30
eslicarbazepine . . . . . . . . . . . . . . . . . . . 23
esomepra mag cap 20mg dr . . . . . . . . 78
esomeprazole inj 20mg . . . . . . . . . . . . 78
esomeprazole inj 40mg . . . . . . . . . . . . 78
136
estra/noreth tab 0.5-0.1mg . . . . . . . . . 85
estra/noreth tab 1-0.5mg . . . . . . . . . . . 85
ESTRACE . . . . . . . . . . . . . . . . . . . . . . . . 84
estradiol - norgestimate . . . . . . . . . . . 86
estradiol tab 0.5mg . . . . . . . . . . . . . . . 84
estradiol tab 1mg . . . . . . . . . . . . . . . . . 84
estradiol tab 2mg . . . . . . . . . . . . . . . . . 84
estradiol transdermal patch . . . . . . . . 84
estradiol vag ring . . . . . . . . . . . . . . . . . 84
estramustine . . . . . . . . . . . . . . . . . . . . . 38
ESTRING MIS 2MG . . . . . . . . . . . . . . . . 84
estrogens, conjugated . . . . . . . . . . . . . 84
estrogens, . . . . . . . . . . . . . . . . . . . . . . . 86
conjugated-medroxyprogesterone
estropipate tab 0.75mg . . . . . . . . . . . . 84
estropipate tab 1.5mg . . . . . . . . . . . . . 84
estropipate tab 3mg . . . . . . . . . . . . . . 84
ESTROSTEP . . . . . . . . . . . . . . . . . . . . . . 86
etanercept . . . . . . . . . . . . . . . . . . . . . . 90
ethambutol tab 100mg . . . . . . . . . . . . 36
ethambutol tab 400mg . . . . . . . . . . . . 36
ethinyl - norethindrone . . . . . . . . . . . . 85
ethinyl estradiol - etonogestrel . . . . . . 85
vag ring
ethinyl estradiol - levonorgestrel . . . . 84
ethinyl estradiol - norethindrone . . . . 85
ethinyl estradiol - norgestrel . . . . . . . . 85
ethinyl estradiol,norethidrone and . . . 85
ferrous fumarate
ethionamide . . . . . . . . . . . . . . . . . . . . . 37
ethosuximide cap 250mg . . . . . . . . . . . 23
ethosuximide sol 250/5ml . . . . . . . . . . 23
ethotoin . . . . . . . . . . . . . . . . . . . . . . . . 27
ETHYOL . . . . . . . . . . . . . . . . . . . . . . . . . 38
etidron disd tab 200mg . . . . . . . . . . . . 93
etidron disd tab 400mg . . . . . . . . . . . . 93
etodolac cap 200mg . . . . . . . . . . . . . . . 11
etodolac cap 300mg . . . . . . . . . . . . . . . 11
etodolac er tab 400mg . . . . . . . . . . . . . 11
etodolac er tab 500mg . . . . . . . . . . . . . 11
etodolac er tab 600mg . . . . . . . . . . . . . 11
etodolac tab 400mg . . . . . . . . . . . . . . . 11
etodolac tab 500mg . . . . . . . . . . . . . . . 11
ETOPOPHOS INJ 100MG . . . . . . . . . . . . 40
etoposide . . . . . . . . . . . . . . . . . . . . . . . 40
etoposide inj 20mg/ml . . . . . . . . . . . . . 40
etravirine . . . . . . . . . . . . . . . . . . . . . . . 50
EULEXIN . . . . . . . . . . . . . . . . . . . . . . . . 37
everolimus . . . . . . . . . . . . . . . . . . . . . . 41
EVISTA . . . . . . . . . . . . . . . . . . . . . . . . . . 87
EVOTAZ TAB 300-150MG . . . . . . . . . . . 51
EXELDERM CRE 1% . . . . . . . . . . . . . . . 34
EXELDERM SOL 1% . . . . . . . . . . . . . . . 34
EXELON . . . . . . . . . . . . . . . . . . . . . . . . . 28
EXELON DIS 13.3/24HR . . . . . . . . . . . . . 27
EXELON DIS 4.6MG/24HR . . . . . . . . . . . 27
EXELON DIS 9.5MG/24HR . . . . . . . . . . . 27
exemestane tab 25mg . . . . . . . . . . . . . 40
exenatide . . . . . . . . . . . . . . . . . . . . . . . 54
EXFORGE . . . . . . . . . . . . . . . . . . . . . . . . 66
EXFORGE HCT . . . . . . . . . . . . . . . . . . . . 66
EXJADE TAB 125MG . . . . . . . . . . . . . . 100
EXJADE TAB 250MG . . . . . . . . . . . . . . 100
EXJADE TAB 500MG . . . . . . . . . . . . . . 100
ezetimibe . . . . . . . . . . . . . . . . . . . . . . . 71
ezetimibe - simvastatin . . . . . . . . . . . . 68
ezogabine . . . . . . . . . . . . . . . . . . . . . . . 23
F
FABRAZYME INJ 35MG . . . . . . . . . . . . . 76
falmina tab . . . . . . . . . . . . . . . . . . . . . . 85
famciclovir tab 125mg . . . . . . . . . . . . . 53
famciclovir tab 250mg . . . . . . . . . . . . . 53
famciclovir tab 500mg . . . . . . . . . . . . . 53
famotidine inj 10mg/ml . . . . . . . . . . . . 77
famotidine inj 20mg/50ml . . . . . . . . . . 77
famotidine sus 40mg/5ml . . . . . . . . . . 77
famotidine tab 20mg . . . . . . . . . . . . . . 77
famotidine tab 40mg . . . . . . . . . . . . . . 77
FAMVIR . . . . . . . . . . . . . . . . . . . . . . . . . 53
FANAPT PAK . . . . . . . . . . . . . . . . . . . . . 46
FANAPT TAB 10MG . . . . . . . . . . . . . . . 46
FANAPT TAB 12MG . . . . . . . . . . . . . . . 46
FANAPT TAB 1MG . . . . . . . . . . . . . . . . 46
FANAPT TAB 2MG . . . . . . . . . . . . . . . . 46
FANAPT TAB 4MG . . . . . . . . . . . . . . . . 46
FANAPT TAB 6MG . . . . . . . . . . . . . . . . 46
FANAPT TAB 8MG . . . . . . . . . . . . . . . . 46
FARESTON TAB 60MG . . . . . . . . . . . . . 38
FARYDAK CAP 10MG . . . . . . . . . . . . . . 39
FARYDAK CAP 15MG . . . . . . . . . . . . . . 39
FARYDAK CAP 20MG . . . . . . . . . . . . . . 39
FASLODEX INJ 250MG . . . . . . . . . . . . . 39
FAZACLO . . . . . . . . . . . . . . . . . . . . . . . . 48
FAZACLO TAB 100/ODT . . . . . . . . . . . . 48
FAZACLO TAB 12.5/ODT . . . . . . . . . . . . 48
FAZACLO TAB 150MG . . . . . . . . . . . . . 48
FAZACLO TAB 200MG . . . . . . . . . . . . . 48
FAZACLO TAB 25MG ODT . . . . . . . . . . 48
felbamate sus 600/5ml . . . . . . . . . . . . . 25
felbamate tab 400mg . . . . . . . . . . . . . 25
felbamate tab 600mg . . . . . . . . . . . . . 25
FELBATOL . . . . . . . . . . . . . . . . . . . . . . . 25
FELDENE . . . . . . . . . . . . . . . . . . . . . . . . 12
felodipine tab 10mg er . . . . . . . . . . . . 64
felodipine tab 2.5mg er . . . . . . . . . . . . 64
Index of Drugs
felodipine tab 5mg er . . . . . . . . . . . . . 65
FEMARA . . . . . . . . . . . . . . . . . . . . . . . . 40
fenofibrate . . . . . . . . . . . . . . . . . . . . . . 70
fenofibrate cap 130mg . . . . . . . . . . . . 70
fenofibrate cap 134mg . . . . . . . . . . . . 70
fenofibrate cap 200mg . . . . . . . . . . . . 70
fenofibrate cap 43mg . . . . . . . . . . . . . 70
fenofibrate cap 67mg . . . . . . . . . . . . . 70
fenofibrate tab 145mg . . . . . . . . . . . . 70
fenofibrate tab 160mg . . . . . . . . . . . . 70
fenofibrate tab 48mg . . . . . . . . . . . . . 70
fenofibrate tab 54mg . . . . . . . . . . . . . 70
fenofibric cap 135mg dr . . . . . . . . . . . 70
fenofibric cap 45mg dr . . . . . . . . . . . . 70
FENOPROFEN . . . . . . . . . . . . . . . . . . . . 11
fenoprofen tab 600mg . . . . . . . . . . . . 11
fentanyl dis 100mcg/hr . . . . . . . . . . . . 12
fentanyl dis 12mcg/hr . . . . . . . . . . . . . 12
fentanyl dis 25mcg/hr . . . . . . . . . . . . . 12
fentanyl dis 50mcg/hr . . . . . . . . . . . . . 12
fentanyl dis 75mcg/hr . . . . . . . . . . . . . 12
fentanyl ot loz 1200mcg . . . . . . . . . . . 13
fentanyl ot loz 1600mcg . . . . . . . . . . . 13
fentanyl ot loz 200mcg . . . . . . . . . . . . 13
fentanyl ot loz 400mcg . . . . . . . . . . . . 13
fentanyl ot loz 600mcg . . . . . . . . . . . . 13
fentanyl ot loz 800mcg . . . . . . . . . . . . 13
FERRIPROX TAB 500MG . . . . . . . . . . . 100
fesoterodine . . . . . . . . . . . . . . . . . . . . . 79
FETZIMA CAP 120MG . . . . . . . . . . . . . . 30
FETZIMA CAP 20MG . . . . . . . . . . . . . . . 30
FETZIMA CAP 40MG . . . . . . . . . . . . . . . 30
FETZIMA CAP 80MG . . . . . . . . . . . . . . . 30
FETZIMA CAP TITRATION . . . . . . . . . . . 30
FEXMID . . . . . . . . . . . . . . . . . . . . . . . . 100
filgrastim . . . . . . . . . . . . . . . . . . . . . . . . 58
finasteride tab 5mg . . . . . . . . . . . . . . . 79
fingolimod . . . . . . . . . . . . . . . . . . . . . . 73
FIORICET - CODEINE . . . . . . . . . . . . . . . 10
FIORINAL - CODEINE . . . . . . . . . . . . . . 10
FIRAZYR INJ 30MG/3ML . . . . . . . . . . . . 89
FIRMAGON INJ 120MG . . . . . . . . . . . . . 88
FIRMAGON INJ 80MG . . . . . . . . . . . . . . 88
FLAGYL . . . . . . . . . . . . . . . . . . . . . . . . . 17
FLAREX SUS 0.1% . . . . . . . . . . . . . . . . . 95
flavoxate tab 100mg . . . . . . . . . . . . . . 79
flecainide tab 100mg . . . . . . . . . . . . . . 62
flecainide tab 150mg . . . . . . . . . . . . . . 62
flecainide tab 50mg . . . . . . . . . . . . . . . 62
FLECTOR DIS 1.3% . . . . . . . . . . . . . . . . 11
FLEXERIL . . . . . . . . . . . . . . . . . . . . . . . 100
FLOMAX . . . . . . . . . . . . . . . . . . . . . . . . 79
FLONASE . . . . . . . . . . . . . . . . . . . . . . . . 96
FLORINEF . . . . . . . . . . . . . . . . . . . . . . . . 81
FLOVENT DISK AER 100MCG . . . . . . . . 96
FLOVENT DISK AER 250MCG . . . . . . . . 96
FLOVENT DISK AER 50MCG . . . . . . . . . 96
FLOVENT HFA AER 110MCG . . . . . . . . 96
FLOVENT HFA AER 220MCG . . . . . . . . 96
FLOVENT HFA AER 44MCG . . . . . . . . . 96
FLOXIN . . . . . . . . . . . . . . . . . . . . . . . . . 22
FLOXIN OTIC . . . . . . . . . . . . . . . . . . . . . 21
fluconazole sus 10mg/ml . . . . . . . . . . . 34
fluconazole sus 40mg/ml . . . . . . . . . . . 34
fluconazole tab 100mg . . . . . . . . . . . . 34
fluconazole tab 150mg . . . . . . . . . . . . 34
fluconazole tab 200mg . . . . . . . . . . . . 34
fluconazole tab 50mg . . . . . . . . . . . . . 34
fluconazole/ inj dex 400mg . . . . . . . . . 34
flucytosine cap 250mg . . . . . . . . . . . . . 34
flucytosine cap 500mg . . . . . . . . . . . . . 34
FLUDARA . . . . . . . . . . . . . . . . . . . . . . . 40
fludarabine inj 50mg . . . . . . . . . . . . . . 40
fludrocort tab 0.1mg . . . . . . . . . . . . . . 81
FLUMADINE . . . . . . . . . . . . . . . . . . . . . 52
flunisolide spr 0.025% . . . . . . . . . . . . . 96
fluocin acet cre 0.01% . . . . . . . . . . . . . 81
fluocin acet cre 0.025% . . . . . . . . . . . . 81
fluocin acet oil 0.01% . . . . . . . . . . . . . 81
fluocin acet oil body . . . . . . . . . . . . . . 81
fluocin acet oin 0.025% . . . . . . . . . . . . 81
fluocin acet sol 0.01% . . . . . . . . . . . . . 81
fluocinolone acetonide . . . . . . . . . . . . 80
fluocinonide cre -e 0.05% . . . . . . . . . . 81
fluocinonide cre 0.1% . . . . . . . . . . . . . 81
fluocinonide gel 0.05% . . . . . . . . . . . . 81
fluocinonide oin 0.05% . . . . . . . . . . . . 81
fluocinonide sol 0.05% . . . . . . . . . . . . 81
fluorometholone . . . . . . . . . . . . . . . . . 95
fluorouracil cre 5% . . . . . . . . . . . . . . . 74
fluorouracil inj 2.5g/50ml . . . . . . . . . . 39
fluorouracil sol 2% . . . . . . . . . . . . . . . . 74
fluorouracil sol 5% . . . . . . . . . . . . . . . . 74
fluoxetine cap 10mg . . . . . . . . . . . . . . 30
fluoxetine cap 20mg . . . . . . . . . . . . . . 30
fluoxetine cap 40mg . . . . . . . . . . . . . . 30
fluoxetine cap 90mg dr . . . . . . . . . . . . 30
fluoxetine sol 20mg/5ml . . . . . . . . . . . 30
fluoxetine tab 10mg . . . . . . . . . . . . . . 30
fluoxetine tab 20mg . . . . . . . . . . . . . . 30
fluphenaz de inj 25mg/ml . . . . . . . . . . 45
fluphenazine con 5mg/ml . . . . . . . . . . 45
fluphenazine elx 2.5/5ml . . . . . . . . . . . 45
fluphenazine inj 2.5mg/ml . . . . . . . . . . 45
fluphenazine tab 10mg . . . . . . . . . . . . 45
fluphenazine tab 1mg . . . . . . . . . . . . . 45
fluphenazine tab 2.5mg . . . . . . . . . . . 45
fluphenazine tab 5mg . . . . . . . . . . . . . 45
flurbiprofen sol 0.03% . . . . . . . . . . . . . 95
flurbiprofen tab 100mg . . . . . . . . . . . . 11
flurbiprofen tab 50mg . . . . . . . . . . . . . 11
flutamide cap 125mg . . . . . . . . . . . . . . 37
fluticasone . . . . . . . . . . . . . . . . . . . . . . 96
fluticasone - vilanterol . . . . . . . . . . . . 99
fluticasone cre 0.05% . . . . . . . . . . . . . . 81
fluticasone furoate . . . . . . . . . . . . . . . . 96
fluticasone lot 0.05% . . . . . . . . . . . . . . 81
fluticasone oin 0.005% . . . . . . . . . . . . 81
fluticasone spr 50mcg . . . . . . . . . . . . . 96
fluvastatin cap 20mg . . . . . . . . . . . . . . 71
fluvastatin cap 40mg . . . . . . . . . . . . . . 71
fluvoxamine cap 100mg er . . . . . . . . . 30
fluvoxamine cap 150mg er . . . . . . . . . 30
fluvoxamine tab 100mg . . . . . . . . . . . . 30
fluvoxamine tab 25mg . . . . . . . . . . . . . 30
fluvoxamine tab 50mg . . . . . . . . . . . . . 30
FML FORTE SUS 0.25% . . . . . . . . . . . . . 95
FML OIN 0.1% . . . . . . . . . . . . . . . . . . . . 95
FOCALIN . . . . . . . . . . . . . . . . . . . . . . . . 72
folic acid . . . . . . . . . . . . . . . . . . . . . . . 102
folic acid tab 1mg . . . . . . . . . . . . . . . . 102
fondaparinux sol 10/0.8ml . . . . . . . . . . 57
fondaparinux sol 2.5/0.5ml . . . . . . . . . 57
fondaparinux sol 5.0/0.4ml . . . . . . . . . 57
fondaparinux sol 7.5/0.6ml . . . . . . . . . 57
FORADIL CAP AEROLIZE . . . . . . . . . . . . 98
FORFIVO XL TAB 450MG . . . . . . . . . . . 15
formoterol fumarate . . . . . . . . . . . . . . 98
FORTAMET . . . . . . . . . . . . . . . . . . . . . . 55
FORTEO SOL 600/2.4ML . . . . . . . . . . . . 93
FORTICAL SPR 200/ACT . . . . . . . . . . . . 93
FOSAMAX . . . . . . . . . . . . . . . . . . . . . . . 93
fosamprenavir . . . . . . . . . . . . . . . . . . . 52
foscarnet . . . . . . . . . . . . . . . . . . . . . . . . 48
FOSCARNET INJ 24MG/ML . . . . . . . . . . 48
fosinop/hctz tab 10/12.5mg . . . . . . . . . 67
fosinop/hctz tab 20/12.5mg . . . . . . . . . 67
fosinopril tab 10mg . . . . . . . . . . . . . . . 61
fosinopril tab 20mg . . . . . . . . . . . . . . . 61
fosinopril tab 40mg . . . . . . . . . . . . . . . 61
fosphenytoin inj 100/2ml . . . . . . . . . . . 27
FOSRENOL CHW 1000MG . . . . . . . . . . 80
FOSRENOL CHW 500MG . . . . . . . . . . . 80
FOSRENOL CHW 750MG . . . . . . . . . . . 80
FRAGMIN INJ 10000/ML . . . . . . . . . . . . 57
FRAGMIN INJ 12500UNT . . . . . . . . . . . 57
FRAGMIN INJ 15000UNT . . . . . . . . . . . 57
FRAGMIN INJ 18000UNT . . . . . . . . . . . 57
FRAGMIN INJ 2500/0.2ML . . . . . . . . . . 57
137
Index of Drugs
FRAGMIN INJ 5000/0.2ML . . . . . . . . . . 57
fulvestrant . . . . . . . . . . . . . . . . . . . . . . 39
FUNGIZONE . . . . . . . . . . . . . . . . . . . . . . 34
FURADANTIN . . . . . . . . . . . . . . . . . . . . 17
furosemide inj 10mg/ml . . . . . . . . . . . . 69
furosemide sol 10mg/ml . . . . . . . . . . . 69
furosemide sol 8mg/ml . . . . . . . . . . . . 69
furosemide tab 20mg . . . . . . . . . . . . . . 69
furosemide tab 40mg . . . . . . . . . . . . . . 69
furosemide tab 80mg . . . . . . . . . . . . . . 69
FUSILEV INJ 50MG . . . . . . . . . . . . . . . . 39
FUZEON INJ 90MG . . . . . . . . . . . . . . . . 51
FYCOMPA TAB 10MG . . . . . . . . . . . . . . 24
FYCOMPA TAB 12MG . . . . . . . . . . . . . . 24
FYCOMPA TAB 2MG . . . . . . . . . . . . . . . 24
FYCOMPA TAB 4MG . . . . . . . . . . . . . . . 24
FYCOMPA TAB 6MG . . . . . . . . . . . . . . . 24
FYCOMPA TAB 8MG . . . . . . . . . . . . . . . 24
G
gabapentin cap 100mg . . . . . . . . . . . . 24
gabapentin cap 300mg . . . . . . . . . . . . 24
gabapentin cap 400mg . . . . . . . . . . . . 25
gabapentin sol 250/5ml . . . . . . . . . . . . 25
gabapentin tab 600mg . . . . . . . . . . . . 25
gabapentin tab 800mg . . . . . . . . . . . . 25
GABITRIL . . . . . . . . . . . . . . . . . . . . . . . . 25
GABITRIL TAB 12MG . . . . . . . . . . . . . . . 25
GABITRIL TAB 16MG . . . . . . . . . . . . . . . 25
galantamine cap 16mg er . . . . . . . . . . 27
galantamine cap 24mg er . . . . . . . . . . 28
galantamine cap 8mg er . . . . . . . . . . . 28
galantamine sol 4mg/ml . . . . . . . . . . . 28
galantamine tab 12mg . . . . . . . . . . . . 28
galantamine tab 4mg . . . . . . . . . . . . . 28
galantamine tab 8mg . . . . . . . . . . . . . 28
galsulfase . . . . . . . . . . . . . . . . . . . . . . . 76
GAMASTAN S/D INJ . . . . . . . . . . . . . . . 91
GAMMAGARD INJ 2.5GM/25ML . . . . . 91
ganciclovir . . . . . . . . . . . . . . . . . . . . . . . 48
ganciclovir inj 500mg . . . . . . . . . . . . . . 48
GARDASIL 9 INJ . . . . . . . . . . . . . . . . . . 91
GARDASIL INJ . . . . . . . . . . . . . . . . . . . . 92
GASTROCROM . . . . . . . . . . . . . . . . . . . 98
GATTEX KIT 5MG . . . . . . . . . . . . . . . . . 77
GAUZE PAD 2X2 . . . . . . . . . . . . . . . . . . 75
GAUZE PADS AND DRESSING - 2X2 . . . 75
gavilyte-c sol . . . . . . . . . . . . . . . . . . . . . 77
gavilyte-g sol . . . . . . . . . . . . . . . . . . . . 77
gavilyte-n sol flav pk . . . . . . . . . . . . . . 77
gemcitabine inj 1gm . . . . . . . . . . . . . . 39
gemfibrozil tab 600mg . . . . . . . . . . . . 70
GEMZAR . . . . . . . . . . . . . . . . . . . . . . . . 39
138
generlac sol 10gm/15ml . . . . . . . . . . . . 78
gengraf cap 100mg . . . . . . . . . . . . . . . 90
gengraf cap 25mg . . . . . . . . . . . . . . . . 90
gengraf sol 100mg/ml . . . . . . . . . . . . . 90
GENOTROPIN INJ 0.2MG . . . . . . . . . . . 83
GENOTROPIN INJ 0.4MG . . . . . . . . . . . 83
GENOTROPIN INJ 0.6MG . . . . . . . . . . . 83
GENOTROPIN INJ 0.8MG . . . . . . . . . . . 83
GENOTROPIN INJ 1.2MG . . . . . . . . . . . 83
GENOTROPIN INJ 1.4MG . . . . . . . . . . . 83
GENOTROPIN INJ 1.6MG . . . . . . . . . . . 83
GENOTROPIN INJ 1.8MG . . . . . . . . . . . 83
GENOTROPIN INJ 12MG . . . . . . . . . . . . 77
GENOTROPIN INJ 1MG . . . . . . . . . . . . . 83
GENOTROPIN INJ 2MG . . . . . . . . . . . . . 83
GENOTROPIN INJ 5MG . . . . . . . . . . . . . 83
GENTAK . . . . . . . . . . . . . . . . . . . . . . . . . 16
gentak oin 0.3% . . . . . . . . . . . . . . . . . . 16
gentamicin . . . . . . . . . . . . . . . . . . . . . . 16
gentamicin - prednisolone . . . . . . . . . 94
gentamicin cre 0.1% . . . . . . . . . . . . . . 16
gentamicin inj 10mg/ml . . . . . . . . . . . . 16
gentamicin inj 40mg/ml . . . . . . . . . . . . 16
gentamicin oin 0.1% . . . . . . . . . . . . . . 16
gentamicin oin 0.3% . . . . . . . . . . . . . . 16
gentamicin sol 0.3% . . . . . . . . . . . . . . . 16
GEODON . . . . . . . . . . . . . . . . . . . . . . . . 47
GEODON INJ 20MG . . . . . . . . . . . . . . . 46
gildagia tab 0.4-35 . . . . . . . . . . . . . . . . 85
gildess tab 1.5/30 . . . . . . . . . . . . . . . . . 85
GILENYA CAP 0.5MG . . . . . . . . . . . . . . 73
GILOTRIF TAB 20MG . . . . . . . . . . . . . . . 41
GILOTRIF TAB 30MG . . . . . . . . . . . . . . . 41
GILOTRIF TAB 40MG . . . . . . . . . . . . . . . 41
glatiramer . . . . . . . . . . . . . . . . . . . . . . . 73
GLEEVEC TAB 100MG . . . . . . . . . . . . . . 41
GLEEVEC TAB 400MG . . . . . . . . . . . . . . 41
GLEOSTINE CAP 100MG . . . . . . . . . . . . 39
GLEOSTINE CAP 10MG . . . . . . . . . . . . . 39
GLEOSTINE CAP 40MG . . . . . . . . . . . . . 39
glimepiride tab 1mg . . . . . . . . . . . . . . 54
glimepiride tab 2mg . . . . . . . . . . . . . . 54
glimepiride tab 4mg . . . . . . . . . . . . . . 54
glip/metform tab 2.5-250mg . . . . . . . . 55
glip/metform tab 2.5-500mg . . . . . . . . 55
glip/metform tab 5-500mg . . . . . . . . . 55
glipizide er tab 10mg . . . . . . . . . . . . . . 54
glipizide er tab 2.5mg . . . . . . . . . . . . . 54
glipizide er tab 5mg . . . . . . . . . . . . . . . 54
glipizide tab 10mg . . . . . . . . . . . . . . . . 55
glipizide tab 5mg . . . . . . . . . . . . . . . . . 55
globulin, immune . . . . . . . . . . . . . . . . . 91
GLUCAGEN INJ HYPOKIT . . . . . . . . . . . 56
glucagon . . . . . . . . . . . . . . . . . . . . . . . . 56
GLUCAGON KIT 1MG . . . . . . . . . . . . . . 56
glucagon rdna . . . . . . . . . . . . . . . . . . . 56
GLUCOPHAGE . . . . . . . . . . . . . . . . . . . . 55
GLUCOPHAGE XL . . . . . . . . . . . . . . . . . 55
glucose - potassium chloride - . . . . . . 102
sodium chloride soln
glucose - sodium chloride soln . . . . . 102
glucose 50 mg/ml / magnesium . . . . . 102
acetate 0.000979 meq/ml / potassium
acetate - sodium chloride
GLUCOTROL . . . . . . . . . . . . . . . . . . . . . 55
GLUCOTROL XL . . . . . . . . . . . . . . . . . . . 54
glycerol phenylbutyrate . . . . . . . . . . . . 76
glycopyrrol tab 1mg . . . . . . . . . . . . . . . 76
glycopyrrol tab 2mg . . . . . . . . . . . . . . . 76
golimumab . . . . . . . . . . . . . . . . . . . . . . 90
GOLYTELY . . . . . . . . . . . . . . . . . . . . . . . 77
granisetron tab 1mg . . . . . . . . . . . . . . 33
GRIFULVIN V . . . . . . . . . . . . . . . . . . . . . 34
GRIS-PEG . . . . . . . . . . . . . . . . . . . . . . . . 34
griseofulvin sus 125/5ml . . . . . . . . . . . . 34
griseofulvin tab micr 500mg . . . . . . . . 34
griseofulvin tab ultr 125mg . . . . . . . . . 34
griseofulvin tab ultr 250mg . . . . . . . . . 34
guanfacine tab 1mg . . . . . . . . . . . . . . . 60
guanfacine tab 2mg . . . . . . . . . . . . . . . 60
guanidine . . . . . . . . . . . . . . . . . . . . . . . 36
GUANIDINE TAB 125MG . . . . . . . . . . . 36
H
haemophilus b conjugate vaccine . . . . 91
haemophilus b polysaccharide conj . . 91
vacc - hepatitis
haemophilus b polysaccharide conj . . 92
vaccine
HALAVEN INJ 1MG/2ML . . . . . . . . . . . . 39
halcinonide . . . . . . . . . . . . . . . . . . . . . . 81
HALDOL . . . . . . . . . . . . . . . . . . . . . . . . 45
HALDOL DEC . . . . . . . . . . . . . . . . . . . . . 45
HALDOL LAC . . . . . . . . . . . . . . . . . . . . . 45
halobetasol cre 0.05% . . . . . . . . . . . . . 81
halobetasol oin 0.05% . . . . . . . . . . . . . 81
HALOG CRE 0.1% . . . . . . . . . . . . . . . . . 81
HALOG OIN 0.1% . . . . . . . . . . . . . . . . . 81
haloper dec inj 100mg/ml . . . . . . . . . . 45
haloper dec inj 50mg/ml . . . . . . . . . . . 45
haloper lac inj 5mg/ml . . . . . . . . . . . . . 45
haloperidol con 2mg/ml . . . . . . . . . . . . 45
haloperidol tab 0.5mg . . . . . . . . . . . . . 45
haloperidol tab 10mg . . . . . . . . . . . . . 45
haloperidol tab 1mg . . . . . . . . . . . . . . 45
haloperidol tab 20mg . . . . . . . . . . . . . 45
Index of Drugs
haloperidol tab 2mg . . . . . . . . . . . . . . 45
haloperidol tab 5mg . . . . . . . . . . . . . . 45
HARVONI TAB 90-400MG . . . . . . . . . . . 50
HAVRIX INJ 1440UNIT . . . . . . . . . . . . . 92
HAVRIX INJ 720UNIT . . . . . . . . . . . . . . 92
hc butyrate cre 0.1% . . . . . . . . . . . . . . 81
hc butyrate oin 0.1% . . . . . . . . . . . . . . 81
hc butyrate sol 0.1% . . . . . . . . . . . . . . 81
hc valerate cre 0.2% . . . . . . . . . . . . . . . 81
hc valerate oin 0.2% . . . . . . . . . . . . . . 81
hc/acet acid sol . . . . . . . . . . . . . . . . . . . 96
hep sod/d5w inj 20000unt . . . . . . . . . . 57
HEP SOD/D5W INJ 25000UNT . . . . . . . 57
heparin . . . . . . . . . . . . . . . . . . . . . . . . . 57
heparin - d5w . . . . . . . . . . . . . . . . . . . . 57
heparin sod inj 1000/ml . . . . . . . . . . . . 57
heparin sod inj 10000/ml . . . . . . . . . . . 57
heparin sod inj 20000/ml . . . . . . . . . . . 57
heparin sod inj 5000/ml . . . . . . . . . . . . 57
hepatitis a - hepatitis b virus . . . . . . . . 92
vaccine
hepatitis a virus vaccine . . . . . . . . . . . . 92
hepatitis b virus vaccine . . . . . . . . . . . . 91
HEPSERA . . . . . . . . . . . . . . . . . . . . . . . . 48
HERCEPTIN INJ 440MG . . . . . . . . . . . . . 39
HETLIOZ CAP 20MG . . . . . . . . . . . . . . 100
HEXALEN CAP 50MG . . . . . . . . . . . . . . 37
HIPREX . . . . . . . . . . . . . . . . . . . . . . . . . 17
HUMALOG 100/ML . . . . . . . . . . . . . . . . 56
HUMALOG INJ 100/ML . . . . . . . . . . . . . 56
HUMALOG KWIK 100/ML . . . . . . . . . . . 56
HUMALOG KWIK 200/ML . . . . . . . . . . . 56
HUMALOG MIX INJ 50/50 . . . . . . . . . . 56
HUMALOG MIX INJ 50/50KWP . . . . . . 56
HUMALOG MIX INJ 75/25KWP . . . . . . 56
HUMALOG MIX SUS 75/25 . . . . . . . . . . 56
human papillomavirus . . . . . . . . . . . . . 91
HUMATROPE INJ 12MG . . . . . . . . . . . . 83
HUMATROPE INJ 24MG . . . . . . . . . . . . 83
HUMATROPE INJ 5MG . . . . . . . . . . . . . 83
HUMATROPE INJ 6MG . . . . . . . . . . . . . 83
HUMIRA INJ 10MG/0.2ML . . . . . . . . . . 90
HUMIRA KIT 20MG/0.4ML . . . . . . . . . . 90
HUMIRA KIT 40MG/0.8ML . . . . . . . . . . 90
HUMIRA PEN KIT CROHNS . . . . . . . . . . 90
HUMULIN INJ 70/30 . . . . . . . . . . . . . . . 56
HUMULIN N INJ U-100 . . . . . . . . . . . . . 56
HUMULIN N PN INJ U-100 . . . . . . . . . . 56
HUMULIN PEN INJ 70/30 . . . . . . . . . . . 56
HUMULIN R INJ U-100 . . . . . . . . . . . . . 56
HUMULIN R INJ U-500 . . . . . . . . . . . . . 56
HYCAMTIN . . . . . . . . . . . . . . . . . . . . . . 40
HYCET . . . . . . . . . . . . . . . . . . . . . . . . . . 10
HYCET SOL 7.5-325MG . . . . . . . . . . . . . 10
hydralazine inj 20mg/ml . . . . . . . . . . . 71
hydralazine tab 100mg . . . . . . . . . . . . 71
hydralazine tab 10mg . . . . . . . . . . . . . 71
hydralazine tab 25mg . . . . . . . . . . . . . 71
hydralazine tab 50mg . . . . . . . . . . . . . 71
HYDREA . . . . . . . . . . . . . . . . . . . . . . . . 38
hydrochlorot cap 12.5mg . . . . . . . . . . . 70
hydrochlorot tab 12.5mg . . . . . . . . . . . 70
hydrochlorot tab 25mg . . . . . . . . . . . . 70
hydrochlorot tab 50mg . . . . . . . . . . . . 70
hydroco/apap sol 7.5-325mg . . . . . . . . 10
hydroco/apap tab 10-300mg . . . . . . . . 10
hydroco/apap tab 10-325mg . . . . . . . . 10
hydroco/apap tab 2.5-325mg . . . . . . . 10
hydroco/apap tab 5-300mg . . . . . . . . . 10
hydroco/apap tab 5-325mg . . . . . . . . . 10
hydroco/apap tab 7.5-300mg . . . . . . . 10
hydroco/apap tab 7.5-325mg . . . . . . . 10
hydrocod/ibu tab 7.5-200mg . . . . . . . . 10
hydrocodone - acetaminophen . . . . . . 10
hydrocort cre 1% . . . . . . . . . . . . . . . . . 81
hydrocort cre 2.5% . . . . . . . . . . . . . . . . 81
hydrocort ene 100mg . . . . . . . . . . . . . . 82
hydrocort lot 2.5% . . . . . . . . . . . . . . . . 82
hydrocort oin 1% . . . . . . . . . . . . . . . . . 82
hydrocort oin 2.5% . . . . . . . . . . . . . . . 82
hydrocort tab 10mg . . . . . . . . . . . . . . . 82
hydrocort tab 20mg . . . . . . . . . . . . . . . 82
hydrocort tab 5mg . . . . . . . . . . . . . . . . 82
hydrocortisone . . . . . . . . . . . . . . . . . . . 81
HYDRODIURIL . . . . . . . . . . . . . . . . . . . . 70
hydromorphon tab 2mg . . . . . . . . . . . 13
hydromorphon tab 4mg . . . . . . . . . . . 14
hydromorphon tab 8mg . . . . . . . . . . . 14
hydroxychlor tab 200mg . . . . . . . . . . . 43
hydroxyurea . . . . . . . . . . . . . . . . . . . . . 38
hydroxyurea cap 500mg . . . . . . . . . . . 38
HYDROXYZ HCL INJ 25MG/ML . . . . . . 53
hydroxyz hcl inj 50mg/ml . . . . . . . . . . . 53
hydroxyz hcl tab 25mg . . . . . . . . . . . . . 53
hydroxyz hcl tab 50mg . . . . . . . . . . . . . 53
hydroxyzine . . . . . . . . . . . . . . . . . . . . . 53
HYTONE . . . . . . . . . . . . . . . . . . . . . . . . 81
HYTRIN . . . . . . . . . . . . . . . . . . . . . . . . . 60
HYZAAR . . . . . . . . . . . . . . . . . . . . . . . . 67
I
ibandronate inj 3mg/3ml . . . . . . . . . . . 93
ibandronate tab 150mg . . . . . . . . . . . . 93
IBRANCE CAP 100MG . . . . . . . . . . . . . . 39
IBRANCE CAP 125MG . . . . . . . . . . . . . . 39
IBRANCE CAP 75MG . . . . . . . . . . . . . . . 39
ibrutinib . . . . . . . . . . . . . . . . . . . . . . . . 41
ibuprofen sus 100/5ml . . . . . . . . . . . . . 11
ibuprofen tab 400mg . . . . . . . . . . . . . . 11
ibuprofen tab 600mg . . . . . . . . . . . . . . 11
ibuprofen tab 800mg . . . . . . . . . . . . . . 11
icatibant . . . . . . . . . . . . . . . . . . . . . . . . 89
ICLUSIG TAB 15MG . . . . . . . . . . . . . . . . 41
ICLUSIG TAB 45MG . . . . . . . . . . . . . . . . 41
IDAMYCIN PFS . . . . . . . . . . . . . . . . . . . 39
idarubicin inj 10/10ml . . . . . . . . . . . . . 39
idelalisib . . . . . . . . . . . . . . . . . . . . . . . . 42
idursulfase . . . . . . . . . . . . . . . . . . . . . . 76
IFEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
ifosfamide inj 1gm . . . . . . . . . . . . . . . . 39
ILARIS INJ 180MG . . . . . . . . . . . . . . . . . 91
iloperidone . . . . . . . . . . . . . . . . . . . . . . 46
imatinib . . . . . . . . . . . . . . . . . . . . . . . . . 41
IMBRUVICA CAP 140MG . . . . . . . . . . . 41
IMDUR . . . . . . . . . . . . . . . . . . . . . . . . . . 72
imiglucerase . . . . . . . . . . . . . . . . . . . . . 75
imipenem-cilastatin . . . . . . . . . . . . . . . 19
imipenem/cil inj 250mg . . . . . . . . . . . . 19
imipenem/cil inj 500mg . . . . . . . . . . . . 19
imipram hcl tab 10mg . . . . . . . . . . . . . 32
imipram hcl tab 25mg . . . . . . . . . . . . . 32
imipram hcl tab 50mg . . . . . . . . . . . . . 32
imiquimod cre 5% . . . . . . . . . . . . . . . . 74
IMITREX . . . . . . . . . . . . . . . . . . . . . . . . . 36
IMITREX NASAL SPRAY . . . . . . . . . . . . 36
immune globulin (human) . . . . . . . . . . 91
IMODIUM . . . . . . . . . . . . . . . . . . . . . . . 77
IMOVAX RABIE INJ 2.5/ML . . . . . . . . . . 92
IMURAN . . . . . . . . . . . . . . . . . . . . . . . . 89
INCRELEX INJ 40MG/4ML . . . . . . . . . . . 83
indacaterol . . . . . . . . . . . . . . . . . . . . . . 97
indapamide tab 1.25mg . . . . . . . . . . . . 70
indapamide tab 2.5mg . . . . . . . . . . . . . 70
INDERAL . . . . . . . . . . . . . . . . . . . . . . . . 64
INDERAL LA . . . . . . . . . . . . . . . . . . . . . 63
indinavir . . . . . . . . . . . . . . . . . . . . . . . . 52
INDOCIN SR . . . . . . . . . . . . . . . . . . . . . . 11
indomethacin cap 25mg . . . . . . . . . . . 11
indomethacin cap 50mg . . . . . . . . . . . 12
indomethacin cap 75mg er . . . . . . . . . 12
INFANRIX INJ . . . . . . . . . . . . . . . . . . . . 92
INFLAMASE . . . . . . . . . . . . . . . . . . . . . . 95
infliximab . . . . . . . . . . . . . . . . . . . . . . . 90
INLYTA TAB 1MG . . . . . . . . . . . . . . . . . 41
INLYTA TAB 5MG . . . . . . . . . . . . . . . . . 41
INSPRA . . . . . . . . . . . . . . . . . . . . . . . . . 69
insulin detemir . . . . . . . . . . . . . . . . . . . 56
insulin glargine . . . . . . . . . . . . . . . . . . . 56
insulin glulisine . . . . . . . . . . . . . . . . . . . 56
139
Index of Drugs
insulin human (regular) . . . . . . . . . . . . 56
insulin human (regular) - insulin . . . . . 56
human, isophane
insulin human, isophane (nph) . . . . . . 56
insulin lispro . . . . . . . . . . . . . . . . . . . . . 56
insulin pen needle . . . . . . . . . . . . . . . . 75
insulin syrg mis 0.3/31g . . . . . . . . . . . . 75
insulin syrg mis 0.5/30g . . . . . . . . . . . . 75
insulin syrg mis 1ml/29g . . . . . . . . . . . . 75
insulin syrg mis 1ml/31g . . . . . . . . . . . . 75
insulin syringe (disp) u-100 . . . . . . . . . 75
INTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
INTELENCE TAB 100MG . . . . . . . . . . . . 50
INTELENCE TAB 200MG . . . . . . . . . . . . 50
INTELENCE TAB 25MG . . . . . . . . . . . . . 50
interferon alfa-2b . . . . . . . . . . . . . . . . . 49
interferon beta-1a . . . . . . . . . . . . . . . . 73
interferon beta-1b . . . . . . . . . . . . . . . . 73
interferon gamma-1b . . . . . . . . . . . . . 91
intralipid . . . . . . . . . . . . . . . . . . . . . . . 102
intralipid inj 20% . . . . . . . . . . . . . . . . 102
INTRON A INJ 18MU . . . . . . . . . . . . . . . 49
INTRON A INJ 50MU . . . . . . . . . . . . . . . 49
INTRON-A INJ 10MU . . . . . . . . . . . . . . . 49
INTRON-A INJ 18MU . . . . . . . . . . . . . . . 49
introvale tab . . . . . . . . . . . . . . . . . . . . . 85
INVANZ INJ 1GM . . . . . . . . . . . . . . . . . 19
INVEGA SUST INJ 117/0.75ML . . . . . . . 46
INVEGA SUST INJ 156MG/ML . . . . . . . . 46
INVEGA SUST INJ 234/1.5ML . . . . . . . . 46
INVEGA SUST INJ 39/0.25ML . . . . . . . . 46
INVEGA SUST INJ 78/0.5ML . . . . . . . . . 46
INVEGA TAB 1.5MG . . . . . . . . . . . . . . . 46
INVEGA TAB 3MG . . . . . . . . . . . . . . . . . 46
INVEGA TAB 6MG . . . . . . . . . . . . . . . . . 46
INVEGA TAB 9MG . . . . . . . . . . . . . . . . . 46
INVIRASE CAP 200MG . . . . . . . . . . . . . 52
INVIRASE TAB 500MG . . . . . . . . . . . . . 52
IOPIDINE . . . . . . . . . . . . . . . . . . . . . . . . 95
IOPIDINE SOL 1% . . . . . . . . . . . . . . . . . 95
ipilimumab . . . . . . . . . . . . . . . . . . . . . . 40
IPOL INJ INACTIVE . . . . . . . . . . . . . . . . 92
IPRATROPIUM . . . . . . . . . . . . . . . . . . . . 97
ipratropium spr 0.03% . . . . . . . . . . . . . 97
ipratropium spr 0.06% . . . . . . . . . . . . . 97
irbesar/hctz tab 150-12.5mg . . . . . . . . 67
irbesar/hctz tab 300-12.5mg . . . . . . . . 67
irbesartan tab 150mg . . . . . . . . . . . . . . 60
irbesartan tab 300mg . . . . . . . . . . . . . . 60
irbesartan tab 75mg . . . . . . . . . . . . . . . 60
irenka cap 40mg . . . . . . . . . . . . . . . . . . 30
irinotecan inj 100/5ml . . . . . . . . . . . . . 39
ISENTRESS CHW 100MG . . . . . . . . . . . . 50
140
ISENTRESS CHW 25MG . . . . . . . . . . . . . 50
ISENTRESS POW 100MG . . . . . . . . . . . . 50
ISENTRESS TAB 400MG . . . . . . . . . . . . . 50
ISMO, MONOKET . . . . . . . . . . . . . . . . . 72
isocarboxazid . . . . . . . . . . . . . . . . . . . . 29
isoniazid - rifampin . . . . . . . . . . . . . . . 37
isoniazid syp 50mg/5ml . . . . . . . . . . . . 36
isoniazid tab 100mg . . . . . . . . . . . . . . . 36
isoniazid tab 300mg . . . . . . . . . . . . . . . 37
isopropyl alcohol pad . . . . . . . . . . . . . . 75
ISORDIL . . . . . . . . . . . . . . . . . . . . . . . . . 72
isosorb din tab 10mg . . . . . . . . . . . . . . 72
isosorb din tab 20mg . . . . . . . . . . . . . . 72
isosorb din tab 30mg . . . . . . . . . . . . . . 72
isosorb din tab 40mg er . . . . . . . . . . . . 72
isosorb din tab 5mg . . . . . . . . . . . . . . . 72
isosorb mono tab 10mg . . . . . . . . . . . . 72
isosorb mono tab 120mg er . . . . . . . . . 72
isosorb mono tab 20mg . . . . . . . . . . . . 72
isosorb mono tab 30mg er . . . . . . . . . . 72
isosorb mono tab 60mg er . . . . . . . . . . 72
isotretinoin . . . . . . . . . . . . . . . . . . . . . . 74
isradipine cap 2.5mg . . . . . . . . . . . . . . 65
isradipine cap 5mg . . . . . . . . . . . . . . . . 65
ISTODAX INJ 10MG . . . . . . . . . . . . . . . 39
itraconazole cap 100mg . . . . . . . . . . . . 34
ivacaftor . . . . . . . . . . . . . . . . . . . . . . . . 98
ivermectin tab 3mg . . . . . . . . . . . . . . . 43
ixabepilone . . . . . . . . . . . . . . . . . . . . . . 39
IXEMPRA KIT INJ 45MG . . . . . . . . . . . . 39
IXIARO INJ . . . . . . . . . . . . . . . . . . . . . . . 92
J
JAKAFI TAB 10MG . . . . . . . . . . . . . . . . 41
JAKAFI TAB 15MG . . . . . . . . . . . . . . . . 41
JAKAFI TAB 20MG . . . . . . . . . . . . . . . . 41
JAKAFI TAB 25MG . . . . . . . . . . . . . . . . 41
JAKAFI TAB 5MG . . . . . . . . . . . . . . . . . 41
jantoven tab 10mg . . . . . . . . . . . . . . . . 57
jantoven tab 1mg . . . . . . . . . . . . . . . . . 57
jantoven tab 2.5mg . . . . . . . . . . . . . . . 57
jantoven tab 2mg . . . . . . . . . . . . . . . . . 57
jantoven tab 3mg . . . . . . . . . . . . . . . . . 57
jantoven tab 4mg . . . . . . . . . . . . . . . . . 57
jantoven tab 5mg . . . . . . . . . . . . . . . . . 57
jantoven tab 6mg . . . . . . . . . . . . . . . . . 57
jantoven tab 7.5mg . . . . . . . . . . . . . . . 57
JANUMET TAB 50-1000MG . . . . . . . . . 55
JANUMET TAB 50-500MG . . . . . . . . . . 55
JANUMET XR TAB 100-1000MG . . . . . . 55
JANUMET XR TAB 50-1000MG . . . . . . . 55
JANUMET XR TAB 50-500MG . . . . . . . . 55
japanese encephalitis virus . . . . . . . . . 92
vaccine
JARDIANCE TAB 10MG . . . . . . . . . . . . . 55
JARDIANCE TAB 25MG . . . . . . . . . . . . . 55
JEVTANA INJ 60/1.5ML . . . . . . . . . . . . . 39
JINTELI TAB 1MG-5MCG . . . . . . . . . . . . 85
junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . 85
junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . 85
junel fe 24 tab 1/20 . . . . . . . . . . . . . . . 85
junel fe tab 1.5/30 . . . . . . . . . . . . . . . . 85
junel fe tab 1/20 . . . . . . . . . . . . . . . . . . 85
JUXTAPID CAP 10MG . . . . . . . . . . . . . . 71
JUXTAPID CAP 20MG . . . . . . . . . . . . . . 71
JUXTAPID CAP 5MG . . . . . . . . . . . . . . . 71
K
KADCYLA INJ 100MG . . . . . . . . . . . . . . 42
KADIAN . . . . . . . . . . . . . . . . . . . . . . . . . 13
KALETRA SOL . . . . . . . . . . . . . . . . . . . . 52
KALETRA TAB 100-25MG . . . . . . . . . . . 52
KALETRA TAB 200-50MG . . . . . . . . . . . 52
KALYDECO PAK 50MG . . . . . . . . . . . . . 98
KALYDECO PAK 75MG . . . . . . . . . . . . . 98
KALYDECO TAB 150MG . . . . . . . . . . . . 98
KAPVAY . . . . . . . . . . . . . . . . . . . . . . . . . 60
kariva tab 28 day . . . . . . . . . . . . . . . . . 85
KAYEXALATE - SPS . . . . . . . . . . . . . . . 100
kcl in nacl . . . . . . . . . . . . . . . . . . . . . . 101
kcl/d5w . . . . . . . . . . . . . . . . . . . . . . . . 102
kcl/d5w inj 0.15% . . . . . . . . . . . . . . . . 102
kcl/d5w inj 0.3% . . . . . . . . . . . . . . . . . 102
kcl/d5w/lr . . . . . . . . . . . . . . . . . . . . . . 102
kcl/d5w/lr inj 0.15% . . . . . . . . . . . . . . 102
kcl/d5w/nacl . . . . . . . . . . . . . . . . . . . . 102
kcl/d5w/nacl inj .075/.45% . . . . . . . . . 102
kcl/d5w/nacl inj .15/.33% . . . . . . . . . . 102
kcl/d5w/nacl inj .15/.45% . . . . . . . . . . 102
kcl/d5w/nacl inj .22/.45% . . . . . . . . . . 102
kcl/d5w/nacl inj 0.15/0.2% . . . . . . . . . 102
kcl/d5w/nacl inj 0.15/0.9% . . . . . . . . . 102
kcl/d5w/nacl inj 0.3/0.45% . . . . . . . . . 102
KCL/D5W/NACL INJ 0.3/0.9% . . . . . . . 102
kcl/sodium chloride . . . . . . . . . . . . . . 101
KEFLEX . . . . . . . . . . . . . . . . . . . . . . . . . 18
kelnor tab 1/35 . . . . . . . . . . . . . . . . . . . 85
KEMSTRO, LIORESAL . . . . . . . . . . . . . . 48
KENALOG-ORABORALONE . . . . . . . . . 74
KEPIVANCE INJ 6.25MG . . . . . . . . . . . . 74
KEPPRA . . . . . . . . . . . . . . . . . . . . . . . . . 23
KEPPRA XR . . . . . . . . . . . . . . . . . . . . . . 23
KERLONE . . . . . . . . . . . . . . . . . . . . . . . . 63
ketoconazole cre 2% . . . . . . . . . . . . . . 34
ketoconazole sha 2% . . . . . . . . . . . . . . 34
ketoconazole tab 200mg . . . . . . . . . . . 34
Index of Drugs
KETOPROFEN . . . . . . . . . . . . . . . . . . . . 12
ketoprofen cap 200mg er . . . . . . . . . . 12
ketoprofen cap 50mg . . . . . . . . . . . . . 12
ketoprofen cap 75mg . . . . . . . . . . . . . 12
KETOROLAC . . . . . . . . . . . . . . . . . . . . . 95
ketorolac sol 0.4% . . . . . . . . . . . . . . . . 95
ketorolac sol 0.5% . . . . . . . . . . . . . . . . 95
KEYTRUDA SOL 50MG . . . . . . . . . . . . . 39
KHEDEZLA . . . . . . . . . . . . . . . . . . . . . . . 30
KHEDEZLA TAB 100MG ER . . . . . . . . . . 30
KHEDEZLA TAB 50MG ER . . . . . . . . . . . 30
KINERET INJ . . . . . . . . . . . . . . . . . . . . . 90
KLARON . . . . . . . . . . . . . . . . . . . . . . . . 22
KLONOPIN . . . . . . . . . . . . . . . . . . . . . . . 24
KLONOPIN ODT . . . . . . . . . . . . . . . . . . 24
klor-con 10 tab 10meq er . . . . . . . . . 101
klor-con 8 tab 8meq er . . . . . . . . . . . 101
klor-con m15 tab . . . . . . . . . . . . . . . . 101
klor-con m20 tab 20meq er . . . . . . . . 101
KORLYM TAB 300MG . . . . . . . . . . . . . . 56
KUVAN TAB 100MG . . . . . . . . . . . . . . . 76
KYNAMRO INJ 200MG/ML . . . . . . . . . . 71
KYTRIL . . . . . . . . . . . . . . . . . . . . . . . . . . 33
L
labetalol inj 5mg/ml . . . . . . . . . . . . . . . 63
labetalol tab 100mg . . . . . . . . . . . . . . . 63
labetalol tab 200mg . . . . . . . . . . . . . . . 63
labetalol tab 300mg . . . . . . . . . . . . . . . 63
LAC-HYDRIN . . . . . . . . . . . . . . . . . . . . . 74
lacosamide . . . . . . . . . . . . . . . . . . . . . . 27
lactated rigners . . . . . . . . . . . . . . . . . 102
lactated rin . . . . . . . . . . . . . . . . . . . . . 102
lactated rin sol . . . . . . . . . . . . . . . . . . 102
LACTATED RINGERS . . . . . . . . . . . . . . 102
lactulose . . . . . . . . . . . . . . . . . . . . . . . . 78
lactulose sol 10gm/15ml . . . . . . . . . . . . 78
LAMICTAL . . . . . . . . . . . . . . . . . . . . . . . 25
LAMICTAL ER . . . . . . . . . . . . . . . . . . . . 26
LAMICTAL CHEWABLE . . . . . . . . . . . . . 25
LAMICTAL ER . . . . . . . . . . . . . . . . . . . . 25
LAMICTAL ODT . . . . . . . . . . . . . . . . . . . 26
LAMISIL . . . . . . . . . . . . . . . . . . . . . . . . . 35
lamivud/zido tab 150-300mg . . . . . . . . 51
lamivudine . . . . . . . . . . . . . . . . . . . . . . 49
lamivudine sol 10mg/ml . . . . . . . . . . . . 51
lamivudine tab 100mg . . . . . . . . . . . . . 49
lamivudine tab 150mg . . . . . . . . . . . . . 51
lamivudine tab 300mg . . . . . . . . . . . . . 51
lamotrigine chw 25mg . . . . . . . . . . . . . 25
lamotrigine chw 5mg . . . . . . . . . . . . . . 25
lamotrigine tab 100mg . . . . . . . . . . . . 25
lamotrigine tab 100mg er . . . . . . . . . . 25
lamotrigine tab 150mg . . . . . . . . . . . . 26
lamotrigine tab 200mg . . . . . . . . . . . . 26
lamotrigine tab 200mg er . . . . . . . . . . 26
lamotrigine tab 250mg er . . . . . . . . . . 26
lamotrigine tab 25mg . . . . . . . . . . . . . 26
lamotrigine tab 25mg er . . . . . . . . . . . 26
lamotrigine tab 300mg er . . . . . . . . . . 26
lamotrigine tab 50mg er . . . . . . . . . . . 26
lamotrigine tab odt 25mg . . . . . . . . . . 26
lamotrigine tab odt 50mg . . . . . . . . . . 26
lamotrigine tab odt/100mg . . . . . . . . . 26
lamotrigine tab odt/200mg . . . . . . . . . 26
LANOXIN . . . . . . . . . . . . . . . . . . . . . . . . 68
lanreotide . . . . . . . . . . . . . . . . . . . . . . . 88
lansoprazole cap 15mg dr . . . . . . . . . . 78
lansoprazole cap 30mg dr . . . . . . . . . . 78
lanthanum . . . . . . . . . . . . . . . . . . . . . . 80
LANTUS INJ 100/ML . . . . . . . . . . . . . . . 56
LANTUS INJ SOLOSTAR . . . . . . . . . . . . . 56
lapatinib . . . . . . . . . . . . . . . . . . . . . . . . 42
LARIAM . . . . . . . . . . . . . . . . . . . . . . . . . 43
larin tab 1.5/30 . . . . . . . . . . . . . . . . . . . 85
laronidase . . . . . . . . . . . . . . . . . . . . . . . 75
LASIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
latanoprost sol 0.005% . . . . . . . . . . . . 96
LATUDA TAB 120MG . . . . . . . . . . . . . . 46
LATUDA TAB 20MG . . . . . . . . . . . . . . . 46
LATUDA TAB 40MG . . . . . . . . . . . . . . . 46
LATUDA TAB 60MG . . . . . . . . . . . . . . . 47
LATUDA TAB 80MG . . . . . . . . . . . . . . . 47
ledipasvir - sofosbuvir . . . . . . . . . . . . . 50
LEENA, ARANELLE . . . . . . . . . . . . . . . . 84
leflunomide tab 10mg . . . . . . . . . . . . . 91
leflunomide tab 20mg . . . . . . . . . . . . . 91
lenalidomide . . . . . . . . . . . . . . . . . . . . . 37
lenvatinib . . . . . . . . . . . . . . . . . . . . . . . 41
LENVIMA CAP 10MG . . . . . . . . . . . . . . 41
LENVIMA CAP 14MG . . . . . . . . . . . . . . 41
LENVIMA CAP 20MG . . . . . . . . . . . . . . 41
LENVIMA CAP 24MG . . . . . . . . . . . . . . 41
LESCOL . . . . . . . . . . . . . . . . . . . . . . . . . 71
lessina . . . . . . . . . . . . . . . . . . . . . . . . . . 85
LETAIRIS TAB 10MG . . . . . . . . . . . . . . . 99
LETAIRIS TAB 5MG . . . . . . . . . . . . . . . . 99
letrozole tab 2.5mg . . . . . . . . . . . . . . . 40
leucovor ca inj 100mg . . . . . . . . . . . . . 40
leucovor ca inj 350mg . . . . . . . . . . . . . 40
leucovor ca tab 10mg . . . . . . . . . . . . . . 40
leucovor ca tab 15mg . . . . . . . . . . . . . . 40
leucovor ca tab 25mg . . . . . . . . . . . . . . 40
leucovor ca tab 5mg . . . . . . . . . . . . . . . 40
LEUCOVORIN . . . . . . . . . . . . . . . . . . . . 40
LEUKERAN TAB 2MG . . . . . . . . . . . . . . 37
LEUKINE INJ 250MCG . . . . . . . . . . . . . . 58
leuprolide acetate . . . . . . . . . . . . . . . . 88
leuprolide dep ped . . . . . . . . . . . . . . . . 88
leuprolide depot . . . . . . . . . . . . . . . . . 88
leuprolide inj 1mg/0.2ml . . . . . . . . . . . 88
LEUSTATIN . . . . . . . . . . . . . . . . . . . . . . . 38
LEVAQUIN . . . . . . . . . . . . . . . . . . . . . . . 21
LEVEMIR INJ . . . . . . . . . . . . . . . . . . . . . 56
LEVEMIR INJ FLEXPEN . . . . . . . . . . . . . 56
levetiraceta sol 100mg/ml . . . . . . . . . . 23
levetiraceta tab 1000mg . . . . . . . . . . . 23
levetiraceta tab 250mg . . . . . . . . . . . . 23
levetiraceta tab 500mg . . . . . . . . . . . . 23
levetiraceta tab 500mg er . . . . . . . . . . 23
levetiraceta tab 750mg . . . . . . . . . . . . 23
levetiraceta tab 750mg er . . . . . . . . . . 23
levetiracetm inj 500/5ml . . . . . . . . . . . 23
LEVO-DROMORAN . . . . . . . . . . . . . . . . 12
levobunolol sol 0.5% . . . . . . . . . . . . . . 95
levocarnitin sol 1gm/10ml . . . . . . . . . 100
levocarnitin tab 330mg . . . . . . . . . . . 100
levocetirizi sol 2.5/5ml . . . . . . . . . . . . . 97
levocetirizi tab 5mg . . . . . . . . . . . . . . . 97
levoflox/d5w inj 500/100ml . . . . . . . . . 21
levofloxacin inj 25mg/ml . . . . . . . . . . . 21
levofloxacin sol 0.5% . . . . . . . . . . . . . . 21
levofloxacin sol 25mg/ml . . . . . . . . . . . 21
levofloxacin tab 250mg . . . . . . . . . . . . 21
levofloxacin tab 500mg . . . . . . . . . . . . 21
levofloxacin tab 750mg . . . . . . . . . . . . 21
levoleucovorin . . . . . . . . . . . . . . . . . . . 39
levomilnacipran . . . . . . . . . . . . . . . . . . 30
levonor/ethi tab estradio . . . . . . . . . . . 85
levora-28 tab 0.15/30 . . . . . . . . . . . . . . 85
levorphanol tab 2mg . . . . . . . . . . . . . . 12
LEVOTHROID, SYNTHROID . . . . . . . . . 87
levothyroxin tab 100mcg . . . . . . . . . . . 87
levothyroxin tab 112mcg . . . . . . . . . . . 87
levothyroxin tab 125mcg . . . . . . . . . . . 87
levothyroxin tab 137mcg . . . . . . . . . . . 87
levothyroxin tab 150mcg . . . . . . . . . . . 87
levothyroxin tab 175mcg . . . . . . . . . . . 87
levothyroxin tab 200mcg . . . . . . . . . . . 87
levothyroxin tab 25mcg . . . . . . . . . . . . 87
levothyroxin tab 300mcg . . . . . . . . . . . 87
levothyroxin tab 50mcg . . . . . . . . . . . . 87
levothyroxin tab 75mcg . . . . . . . . . . . . 87
levothyroxin tab 88mcg . . . . . . . . . . . . 87
levothyroxine . . . . . . . . . . . . . . . . . . . . 87
LEXAPRO . . . . . . . . . . . . . . . . . . . . . . . . 30
LEXIVA SUS 50MG/ML . . . . . . . . . . . . . 52
LEXIVA TAB 700MG . . . . . . . . . . . . . . . 52
LIBRIUM . . . . . . . . . . . . . . . . . . . . . . . . 54
141
Index of Drugs
LIDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
LIDEX-E . . . . . . . . . . . . . . . . . . . . . . . . . 81
lido/prilocn cre 2.5-2.5% . . . . . . . . . . . 14
lidocaine . . . . . . . . . . . . . . . . . . . . . . . . 14
lidocaine gel 2% jelly . . . . . . . . . . . . . . 14
lidocaine inj 0.5% . . . . . . . . . . . . . . . . . 14
lidocaine oin 5% . . . . . . . . . . . . . . . . . 14
lidocaine pad 5% . . . . . . . . . . . . . . . . . 14
lidocaine sol 2% visc . . . . . . . . . . . . . . 14
lidocaine sol 4% . . . . . . . . . . . . . . . . . . 14
LIDODERM . . . . . . . . . . . . . . . . . . . . . . 14
LINDANE . . . . . . . . . . . . . . . . . . . . . . . . 43
lindane lot 1% . . . . . . . . . . . . . . . . . . . 43
lindane sha 1% . . . . . . . . . . . . . . . . . . . 43
linezolid . . . . . . . . . . . . . . . . . . . . . . . . 17
linezolid inj 2mg/ml . . . . . . . . . . . . . . . 17
liothyronine tab 25mcg . . . . . . . . . . . . 87
liothyronine tab 50mcg . . . . . . . . . . . . 87
liothyronine tab 5mcg . . . . . . . . . . . . . 87
LIPITOR . . . . . . . . . . . . . . . . . . . . . . . . . 70
lisinop/hctz tab 10-12.5mg . . . . . . . . . 67
lisinop/hctz tab 20-12.5mg . . . . . . . . . 67
lisinop/hctz tab 20-25mg . . . . . . . . . . . 67
lisinopril tab 10mg . . . . . . . . . . . . . . . . 61
lisinopril tab 2.5mg . . . . . . . . . . . . . . . 61
lisinopril tab 20mg . . . . . . . . . . . . . . . . 61
lisinopril tab 30mg . . . . . . . . . . . . . . . . 61
lisinopril tab 40mg . . . . . . . . . . . . . . . . 61
lisinopril tab 5mg . . . . . . . . . . . . . . . . . 61
lithium carb cap 150mg . . . . . . . . . . . . 54
lithium carb cap 300mg . . . . . . . . . . . . 54
lithium carb cap 600mg . . . . . . . . . . . . 54
lithium carb tab 300mg . . . . . . . . . . . . 54
lithium carb tab 300mg er . . . . . . . . . . 54
lithium carb tab 450mg er . . . . . . . . . . 54
lithium citr . . . . . . . . . . . . . . . . . . . . . . 54
LITHIUM CITR SOL 8MEQ/5ML . . . . . . . 54
LITHOBID . . . . . . . . . . . . . . . . . . . . . . . . 54
LO/OVRAL, CRYSELLE . . . . . . . . . . . . . . 85
LOCOID . . . . . . . . . . . . . . . . . . . . . . . . . 81
LODINE . . . . . . . . . . . . . . . . . . . . . . . . . 11
LODINE XL . . . . . . . . . . . . . . . . . . . . . . . 11
lodoxamide . . . . . . . . . . . . . . . . . . . . . . 94
LOFIBRA . . . . . . . . . . . . . . . . . . . . . . . . 70
lokara lot 0.05% . . . . . . . . . . . . . . . . . . 82
lomitapide . . . . . . . . . . . . . . . . . . . . . . 71
lomustine . . . . . . . . . . . . . . . . . . . . . . . 39
lomustine cap 100mg . . . . . . . . . . . . . . 39
lomustine cap 10mg . . . . . . . . . . . . . . . 39
lomustine cap 40mg . . . . . . . . . . . . . . . 39
LONITEN . . . . . . . . . . . . . . . . . . . . . . . . 71
loperamide cap 2mg . . . . . . . . . . . . . . 77
LOPID . . . . . . . . . . . . . . . . . . . . . . . . . . 70
142
lopinavir - ritonavir . . . . . . . . . . . . . . . 52
LOPRESSOR . . . . . . . . . . . . . . . . . . . . . . 63
LOPRESSOR HCT . . . . . . . . . . . . . . . . . . 67
LOPROX . . . . . . . . . . . . . . . . . . . . . . . . . 34
lorazepam con 2mg/ml . . . . . . . . . . . . 25
lorazepam tab 0.5mg . . . . . . . . . . . . . . 25
lorazepam tab 1mg . . . . . . . . . . . . . . . 25
lorazepam tab 2mg . . . . . . . . . . . . . . . 25
lorcet plus tab 7.5-325mg . . . . . . . . . . 10
lorcet tab 10-325mg . . . . . . . . . . . . . . . 10
lorcet tab 5-325mg . . . . . . . . . . . . . . . . 10
lortab tab 10-325mg . . . . . . . . . . . . . . 10
lortab tab 5-325mg . . . . . . . . . . . . . . . 10
lortab tab 7.5-325mg . . . . . . . . . . . . . . 10
loryna tab 3-0.02mg . . . . . . . . . . . . . . . 85
losartan pot tab 100mg . . . . . . . . . . . . 60
losartan pot tab 25mg . . . . . . . . . . . . . 60
losartan pot tab 50mg . . . . . . . . . . . . . 60
losartan/hct tab 100-12.5mg . . . . . . . . 67
losartan/hct tab 100-25mg . . . . . . . . . . 67
losartan/hct tab 50-12.5mg . . . . . . . . . 67
LOTENSIN . . . . . . . . . . . . . . . . . . . . . . . 61
LOTENSIN HCT . . . . . . . . . . . . . . . . . . . 66
loteprednol etabonate . . . . . . . . . . . . 95
LOTREL . . . . . . . . . . . . . . . . . . . . . . . . . 66
LOTRIMIN . . . . . . . . . . . . . . . . . . . . . . . 34
LOTRISONE . . . . . . . . . . . . . . . . . . . . . . 74
LOTRONEX TAB 0.5MG . . . . . . . . . . . . 78
LOTRONEX TAB 1MG . . . . . . . . . . . . . . 78
lovastatin tab 10mg . . . . . . . . . . . . . . . 71
lovastatin tab 20mg . . . . . . . . . . . . . . . 71
lovastatin tab 40mg . . . . . . . . . . . . . . . 71
LOVAZA . . . . . . . . . . . . . . . . . . . . . . . . 71
LOVENOX . . . . . . . . . . . . . . . . . . . . . . . 57
loxapine cap 10mg . . . . . . . . . . . . . . . . 45
loxapine cap 25mg . . . . . . . . . . . . . . . . 46
loxapine cap 50mg . . . . . . . . . . . . . . . . 46
loxapine cap 5mg . . . . . . . . . . . . . . . . . 46
LOXITANE . . . . . . . . . . . . . . . . . . . . . . . 45
LOZOL . . . . . . . . . . . . . . . . . . . . . . . . . . 70
lubiprostone . . . . . . . . . . . . . . . . . . . . . 78
LUDIOMIL . . . . . . . . . . . . . . . . . . . . . . . 30
LUMIGAN SOL 0.01% . . . . . . . . . . . . . . 96
LUPR DEP-PED INJ 11.25MG . . . . . . . . . 88
LUPR DEP-PED INJ 15MG . . . . . . . . . . . 88
LUPRON DEPOT INJ 11.25MG . . . . . . . 88
LUPRON DEPOT INJ 22.5MG . . . . . . . . 88
LUPRON DEPOT INJ 3.75MG . . . . . . . . 88
LUPRON DEPOT INJ 30MG . . . . . . . . . . 88
LUPRON DEPOT INJ 45MG . . . . . . . . . . 88
LUPRON DEPOT INJ 7.5MG . . . . . . . . . 88
LUPRON SC . . . . . . . . . . . . . . . . . . . . . . 88
lurasidone . . . . . . . . . . . . . . . . . . . . . . . 46
lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
LUVOX . . . . . . . . . . . . . . . . . . . . . . . . . . 30
LUVOX CR . . . . . . . . . . . . . . . . . . . . . . . 30
LUXIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 80
LYNPARZA CAP 50MG . . . . . . . . . . . . . 41
LYRICA CAP 100MG . . . . . . . . . . . . . . . 23
LYRICA CAP 150MG . . . . . . . . . . . . . . . 23
LYRICA CAP 200MG . . . . . . . . . . . . . . . 23
LYRICA CAP 225MG . . . . . . . . . . . . . . . 23
LYRICA CAP 25MG . . . . . . . . . . . . . . . . 23
LYRICA CAP 300MG . . . . . . . . . . . . . . . 23
LYRICA CAP 50MG . . . . . . . . . . . . . . . . 23
LYRICA CAP 75MG . . . . . . . . . . . . . . . . 23
LYRICA SOL 20MG/ML . . . . . . . . . . . . . 23
LYSODREN TAB 500MG . . . . . . . . . . . . 88
M
M-M-R II INJ LIVE . . . . . . . . . . . . . . . . . 92
macitentan . . . . . . . . . . . . . . . . . . . . . . 99
MACROBID . . . . . . . . . . . . . . . . . . . . . . 17
MACRODANTIN . . . . . . . . . . . . . . . . . . 17
mafenide . . . . . . . . . . . . . . . . . . . . . . . . 17
magnesium su inj 50% . . . . . . . . . . . . 101
MAGNESIUM SULF . . . . . . . . . . . . . . . 101
MALARONE . . . . . . . . . . . . . . . . . . . . . . 43
malathion lot 0.5% . . . . . . . . . . . . . . . 43
maprotiline tab 25mg . . . . . . . . . . . . . 30
maprotiline tab 50mg . . . . . . . . . . . . . 30
maprotiline tab 75mg . . . . . . . . . . . . . 30
maraviroc . . . . . . . . . . . . . . . . . . . . . . . 51
MARINOL . . . . . . . . . . . . . . . . . . . . . . . 33
MARPLAN TAB 10MG . . . . . . . . . . . . . . 29
MATULANE CAP 50MG . . . . . . . . . . . . 37
MAVIK . . . . . . . . . . . . . . . . . . . . . . . . . . 62
MAXIDEX SUS 0.1% . . . . . . . . . . . . . . . 95
MAXIPIME . . . . . . . . . . . . . . . . . . . . . . . 18
MAXITROL . . . . . . . . . . . . . . . . . . . . . . 94
MAXZIDE, DYAZIDE . . . . . . . . . . . . . . . 68
measles virus - mumps virus . . . . . . . . . 92
vaccine
measles virus vaccine - mumps . . . . . . 92
virus vaccine - rubella virus vaccine varicella-zoster virus vaccine
mecasermin . . . . . . . . . . . . . . . . . . . . . . 83
mechlorethamine . . . . . . . . . . . . . . . . . 37
meclizine tab 12.5mg . . . . . . . . . . . . . . 33
meclizine tab 25mg . . . . . . . . . . . . . . . 33
meclofen sod cap 100mg . . . . . . . . . . . 12
meclofen sod cap 50mg . . . . . . . . . . . . 12
meclofenamate . . . . . . . . . . . . . . . . . . 12
MEDROL . . . . . . . . . . . . . . . . . . . . . . . . 82
medroxypr ac inj 150mg/ml . . . . . . . . . 86
medroxypr ac tab 10mg . . . . . . . . . . . . 86
Index of Drugs
medroxypr ac tab 2.5mg . . . . . . . . . . . 86
medroxypr ac tab 5mg . . . . . . . . . . . . . 86
medroxyprogesterone suspension . . . 86
mefenam acid cap 250mg . . . . . . . . . . 12
mefloquine tab 250mg . . . . . . . . . . . . 43
MEFOXIN . . . . . . . . . . . . . . . . . . . . . . . . 18
MEGACE . . . . . . . . . . . . . . . . . . . . . . . . 86
MEGACE ES SUS 625/5ML . . . . . . . . . . . 86
megestrol ac sus 40mg/ml . . . . . . . . . . 86
megestrol ac tab 20mg . . . . . . . . . . . . 86
megestrol ac tab 40mg . . . . . . . . . . . . 87
megestrol acetate . . . . . . . . . . . . . . . . 86
MEKINIST TAB 0.5MG . . . . . . . . . . . . . . 41
MEKINIST TAB 2MG . . . . . . . . . . . . . . . 41
MELLARIL . . . . . . . . . . . . . . . . . . . . . . . 46
meloxicam tab 15mg . . . . . . . . . . . . . . 12
meloxicam tab 7.5mg . . . . . . . . . . . . . . 12
melphalan inj 50mg . . . . . . . . . . . . . . . 37
memantine . . . . . . . . . . . . . . . . . . . . . . 28
MENACTRA INJ . . . . . . . . . . . . . . . . . . . 92
meninggococcal oligosaccharide . . . . 92
conjugate vaccine
meningococcal polysaccharide vac . . . 92
a-c-y-w
MENOMUNE INJ A/C/Y/W . . . . . . . . . . 92
MENVEO INJ . . . . . . . . . . . . . . . . . . . . . 92
mepenzolate . . . . . . . . . . . . . . . . . . . . . 76
meprobamate tab 200mg . . . . . . . . . . 53
meprobamate tab 400mg . . . . . . . . . . 53
MEPRON . . . . . . . . . . . . . . . . . . . . . . . . 43
mercaptopur tab 50mg . . . . . . . . . . . . 38
mercaptopurine . . . . . . . . . . . . . . . . . . 38
meropenem inj 500mg . . . . . . . . . . . . . 19
MERREM . . . . . . . . . . . . . . . . . . . . . . . . 19
mesalamine (5-asa) . . . . . . . . . . . . . . . . 93
mesalamine ec . . . . . . . . . . . . . . . . . . . 93
mesalamine kit 4gm . . . . . . . . . . . . . . . 93
mesna . . . . . . . . . . . . . . . . . . . . . . . . . . 39
mesna inj 1gm . . . . . . . . . . . . . . . . . . . 39
MESNEX . . . . . . . . . . . . . . . . . . . . . . . . 39
MESNEX TAB 400MG . . . . . . . . . . . . . . 39
MESTINON . . . . . . . . . . . . . . . . . . . . . . 36
MESTINON SYP 60MG/5ML . . . . . . . . . 36
MESTINON TAB TIMESPAN . . . . . . . . . . 36
mestranol - norethindrone . . . . . . . . . 85
metadate . . . . . . . . . . . . . . . . . . . . . . . 73
metadate tab 20mg er . . . . . . . . . . . . . 73
METAGLIP . . . . . . . . . . . . . . . . . . . . . . . 55
metaproteren syp 10mg/5ml . . . . . . . . 98
METAPROTEREN TAB 10MG . . . . . . . . 98
METAPROTEREN TAB 20MG . . . . . . . . 98
METAPROTERENOL . . . . . . . . . . . . . . . 98
metaproterenol sulfate . . . . . . . . . . . . 98
metformin - sitagliptin . . . . . . . . . . . . . 55
metformin - sitagliptin sr . . . . . . . . . . . 55
metformin er tab 1000mg . . . . . . . . . . 55
metformin tab 1000mg . . . . . . . . . . . . 55
metformin tab 500mg . . . . . . . . . . . . . 55
metformin tab 500mg er . . . . . . . . . . . 55
metformin tab 750mg er . . . . . . . . . . . 55
metformin tab 850mg . . . . . . . . . . . . . 55
methadone . . . . . . . . . . . . . . . . . . . . . . 12
methadone inj 10mg/ml . . . . . . . . . . . 12
methadone sol 10mg/5ml . . . . . . . . . . 12
methadone sol 5mg/5ml . . . . . . . . . . . 12
methadone tab 10mg . . . . . . . . . . . . . 12
methadone tab 5mg . . . . . . . . . . . . . . 12
methazolamid tab 25mg . . . . . . . . . . . 69
methazolamid tab 50mg . . . . . . . . . . . 69
METHAZOLAMIDE . . . . . . . . . . . . . . . . 69
methenam hip tab 1gm . . . . . . . . . . . . 17
methimazole tab 10mg . . . . . . . . . . . . 89
methimazole tab 5mg . . . . . . . . . . . . . 89
methotrexate . . . . . . . . . . . . . . . . . . . . 90
methotrexate inj 1gm . . . . . . . . . . . . . 90
methotrexate inj 25mg/ml . . . . . . . . . . 90
methotrexate tab 2.5mg . . . . . . . . . . . 90
methoxsalen . . . . . . . . . . . . . . . . . . . . . 74
methscopolam tab 2.5mg . . . . . . . . . . 76
methscopolam tab 5mg . . . . . . . . . . . . 76
methsuximide . . . . . . . . . . . . . . . . . . . . 23
methyclothia tab 5mg . . . . . . . . . . . . . 70
methyld/hctz tab 250/15mg . . . . . . . . . 67
methyld/hctz tab 250/25mg . . . . . . . . . 67
methyldopa tab 250mg . . . . . . . . . . . . 60
methyldopa tab 500mg . . . . . . . . . . . . 60
methyldopate inj 250/5ml . . . . . . . . . . 60
methylnaltrexone . . . . . . . . . . . . . . . . . 77
methylphenid tab 10mg . . . . . . . . . . . 73
methylphenid tab 10mg er . . . . . . . . . 73
methylphenid tab 18mg er . . . . . . . . . 73
methylphenid tab 20mg . . . . . . . . . . . 73
methylphenid tab 20mg er . . . . . . . . . 73
methylphenid tab 27mg er . . . . . . . . . 73
methylphenid tab 36mg er . . . . . . . . . 73
methylphenid tab 54mg er . . . . . . . . . 73
methylphenid tab 5mg . . . . . . . . . . . . 73
methylpr ace inj 40mg/ml . . . . . . . . . . 82
methylpr ace inj 80mg/ml . . . . . . . . . . 82
methylpr ss inj 125mg . . . . . . . . . . . . . 82
methylpr ss inj 40mg . . . . . . . . . . . . . . 82
methylpred pak 4mg . . . . . . . . . . . . . . 82
methylpred tab 16mg . . . . . . . . . . . . . 82
methylpred tab 32mg . . . . . . . . . . . . . 82
methylpred tab 4mg . . . . . . . . . . . . . . 82
methylpred tab 8mg . . . . . . . . . . . . . . 82
metipranolol sol 0.3% . . . . . . . . . . . . . 95
metoclopram inj 5mg/ml . . . . . . . . . . . 33
metoclopram sol 5mg/5ml . . . . . . . . . . 33
metoclopram tab 10mg . . . . . . . . . . . . 33
metoclopram tab 5mg . . . . . . . . . . . . . 33
metolazone tab 10mg . . . . . . . . . . . . . 70
metolazone tab 2.5mg . . . . . . . . . . . . . 70
metolazone tab 5mg . . . . . . . . . . . . . . 70
metoprl/hctz tab 100-25mg . . . . . . . . . 67
metoprl/hctz tab 100-50mg . . . . . . . . . 67
metoprl/hctz tab 50-25mg . . . . . . . . . . 67
metoprol tar tab 100mg . . . . . . . . . . . 63
metoprol tar tab 25mg . . . . . . . . . . . . 63
metoprol tar tab 50mg . . . . . . . . . . . . 63
metoprolol inj 1mg/ml . . . . . . . . . . . . . 63
metoprolol tab 100mg er . . . . . . . . . . 63
metoprolol tab 200mg er . . . . . . . . . . 63
metoprolol tab 25mg er . . . . . . . . . . . 63
metoprolol tab 50mg er . . . . . . . . . . . 63
METROGEL-VAG, VANDAZOLE . . . . . . 17
metron/nacl inj 500mg . . . . . . . . . . . . . 17
metronidazol cap 375mg . . . . . . . . . . . 17
metronidazol cre 0.75% . . . . . . . . . . . 17
metronidazol gel 0.75% . . . . . . . . . . . 17
metronidazol gel 1% . . . . . . . . . . . . . . 17
metronidazol lot 0.75% . . . . . . . . . . . . 17
metronidazol tab 250mg . . . . . . . . . . . 17
metronidazol tab 500mg . . . . . . . . . . . 17
metronidazole . . . . . . . . . . . . . . . . . . . 17
metyrosine . . . . . . . . . . . . . . . . . . . . . . 67
MEVACOR . . . . . . . . . . . . . . . . . . . . . . . 71
mexiletine cap 150mg . . . . . . . . . . . . . 62
mexiletine cap 200mg . . . . . . . . . . . . . 62
mexiletine cap 250mg . . . . . . . . . . . . . 62
MEXITIL . . . . . . . . . . . . . . . . . . . . . . . . . 62
MIACALCIN . . . . . . . . . . . . . . . . . . . . . . 93
MIACALCIN INJ 200/ML . . . . . . . . . . . . 93
MICARDIS . . . . . . . . . . . . . . . . . . . . . . . 60
MICARDIS HCT . . . . . . . . . . . . . . . . . . . 68
MICONAZOLE . . . . . . . . . . . . . . . . . . . . 34
miconazole 3 sup 200mg . . . . . . . . . . . 34
MICRO-K / KLOR-CON / K-TAB . . . . . . 101
microgestin tab 1.5/30 . . . . . . . . . . . . . 85
microgestin tab 1/20 . . . . . . . . . . . . . . 85
microgestin tab fe 1/20 . . . . . . . . . . . . 85
microgestin tab fe1.5/30 . . . . . . . . . . . 85
MICROZIDE . . . . . . . . . . . . . . . . . . . . . . 70
MIDAMOR . . . . . . . . . . . . . . . . . . . . . . . 69
midodrine tab 10mg . . . . . . . . . . . . . . 60
midodrine tab 2.5mg . . . . . . . . . . . . . . 60
midodrine tab 5mg . . . . . . . . . . . . . . . 60
mifepristone . . . . . . . . . . . . . . . . . . . . . 56
migergot sup 2/100 . . . . . . . . . . . . . . . 35
143
Index of Drugs
miglustat . . . . . . . . . . . . . . . . . . . . . . . . 76
MILTOWN . . . . . . . . . . . . . . . . . . . . . . . 53
MINIPRESS . . . . . . . . . . . . . . . . . . . . . . . 60
MINOCIN . . . . . . . . . . . . . . . . . . . . . . . . 22
minocycline cap 100mg . . . . . . . . . . . . 22
minocycline cap 50mg . . . . . . . . . . . . . 22
minocycline cap 75mg . . . . . . . . . . . . . 22
minocycline tab 100mg . . . . . . . . . . . . 22
minocycline tab 135mg er . . . . . . . . . . 23
minocycline tab 45mg er . . . . . . . . . . . 23
minocycline tab 50mg . . . . . . . . . . . . . 23
minocycline tab 75mg . . . . . . . . . . . . . 23
minocycline tab 90mg er . . . . . . . . . . . 23
minoxidil tab 10mg . . . . . . . . . . . . . . . 71
minoxidil tab 2.5mg . . . . . . . . . . . . . . . 72
mipomersen sodium . . . . . . . . . . . . . . . 71
mirabegron er . . . . . . . . . . . . . . . . . . . 79
MIRALAX . . . . . . . . . . . . . . . . . . . . . . . . 78
MIRAPEX . . . . . . . . . . . . . . . . . . . . . . . . 44
mirtazapine tab 15mg . . . . . . . . . . . . . 29
mirtazapine tab 15mg odt . . . . . . . . . . 29
mirtazapine tab 30mg . . . . . . . . . . . . . 29
mirtazapine tab 30mg odt . . . . . . . . . . 29
mirtazapine tab 45mg . . . . . . . . . . . . . 29
mirtazapine tab 45mg odt . . . . . . . . . . 29
mirtazapine tab 7.5mg . . . . . . . . . . . . 29
misoprostol tab 100mcg . . . . . . . . . . . 78
misoprostol tab 200mcg . . . . . . . . . . . 78
mitomycin inj 20mg . . . . . . . . . . . . . . . 39
mitotane . . . . . . . . . . . . . . . . . . . . . . . . 88
mitoxantron inj 2mg/ml . . . . . . . . . . . . 40
MOBIC . . . . . . . . . . . . . . . . . . . . . . . . . . 12
modafinil tab 100mg . . . . . . . . . . . . . 100
modafinil tab 200mg . . . . . . . . . . . . . 100
moderiba tab 200mg . . . . . . . . . . . . . . 49
MODURETIC . . . . . . . . . . . . . . . . . . . . . 66
moexipr/hctz tab 15-12.5mg . . . . . . . . 67
moexipr/hctz tab 15-25mg . . . . . . . . . . 67
moexipr/hctz tab 7.5-12.5mg . . . . . . . . 67
moexipril tab 15mg . . . . . . . . . . . . . . . 61
moexipril tab 7.5mg . . . . . . . . . . . . . . . 61
mometasone cre 0.1% . . . . . . . . . . . . . 82
mometasone furoate . . . . . . . . . . . . . . 96
mometasone oin 0.1% . . . . . . . . . . . . . 82
mometasone sol 0.1% . . . . . . . . . . . . . 82
MONOPRIL . . . . . . . . . . . . . . . . . . . . . . 61
MONOPRIL HCT . . . . . . . . . . . . . . . . . . 67
montelukast chw 4mg . . . . . . . . . . . . . 97
montelukast chw 5mg . . . . . . . . . . . . . 97
montelukast gra 4mg . . . . . . . . . . . . . . 97
montelukast tab 10mg . . . . . . . . . . . . . 97
morphine . . . . . . . . . . . . . . . . . . . . . . . 13
morphine soln . . . . . . . . . . . . . . . . . . . 14
144
morphine sul cap 100mg er . . . . . . . . . 13
morphine sul cap 10mg er . . . . . . . . . . 13
morphine sul cap 120mg er . . . . . . . . . 13
morphine sul cap 20mg er . . . . . . . . . . 13
morphine sul cap 30mg er . . . . . . . . . . 13
morphine sul cap 45mg er . . . . . . . . . . 13
morphine sul cap 50mg er . . . . . . . . . . 13
morphine sul cap 60mg er . . . . . . . . . . 13
morphine sul cap 75mg er . . . . . . . . . . 13
morphine sul cap 80mg er . . . . . . . . . . 13
morphine sul cap 90mg er . . . . . . . . . . 13
MORPHINE SUL INJ 10MG/ML . . . . . . . 14
MORPHINE SUL INJ 2MG/ML . . . . . . . . 14
MORPHINE SUL INJ 4MG/ML . . . . . . . . 14
MORPHINE SUL INJ 8MG/ML . . . . . . . . 14
morphine sul sol 10mg/5ml . . . . . . . . . 14
morphine sul sol 20mg/5ml . . . . . . . . . 14
morphine sul sol 20mg/ml . . . . . . . . . . 14
morphine sul tab 100mg er . . . . . . . . . 13
morphine sul tab 15mg . . . . . . . . . . . . 14
morphine sul tab 15mg er . . . . . . . . . . 13
morphine sul tab 200mg er . . . . . . . . . 13
morphine sul tab 30mg . . . . . . . . . . . . 14
morphine sul tab 30mg er . . . . . . . . . . 13
morphine sul tab 60mg er . . . . . . . . . . 13
morphine sulfate . . . . . . . . . . . . . . . . . 14
MOTRIN . . . . . . . . . . . . . . . . . . . . . . . . . 11
moxifloxacin . . . . . . . . . . . . . . . . . . . . . 22
MOZOBIL INJ . . . . . . . . . . . . . . . . . . . . . 58
MS CONTIN . . . . . . . . . . . . . . . . . . . . . . 13
MUCOMYST . . . . . . . . . . . . . . . . . . . . . 99
MUCOMYST-10 . . . . . . . . . . . . . . . . . . . 99
MULTAQ TAB 400MG . . . . . . . . . . . . . . 62
mupirocin cre 2% . . . . . . . . . . . . . . . . . 17
mupirocin oin 2% . . . . . . . . . . . . . . . . . 17
MUSTARGEN INJ 10MG . . . . . . . . . . . . 37
MUTAMYCIN . . . . . . . . . . . . . . . . . . . . . 39
MYAMBUTOL . . . . . . . . . . . . . . . . . . . . 36
MYCELEX . . . . . . . . . . . . . . . . . . . . . . . 34
MYCOBUTIN . . . . . . . . . . . . . . . . . . . . . 36
mycophenolat cap 250mg . . . . . . . . . . 90
mycophenolat sus 200mg/ml . . . . . . . . 90
mycophenolat tab 500mg . . . . . . . . . . 90
mycophenolate . . . . . . . . . . . . . . . . . . . 89
mycophenolic tab 180mg dr . . . . . . . . 90
mycophenolic tab 360mg dr . . . . . . . . 90
MYCOSTATIN . . . . . . . . . . . . . . . . . . . . 35
myorisan cap 10mg . . . . . . . . . . . . . . . 75
myorisan cap 20mg . . . . . . . . . . . . . . . 75
myorisan cap 40mg . . . . . . . . . . . . . . . 75
MYOZYME INJ 50MG . . . . . . . . . . . . . . 76
MYRBETRIQ TAB 25MG . . . . . . . . . . . . 79
MYRBETRIQ TAB 50MG . . . . . . . . . . . . 79
MYSOLINE . . . . . . . . . . . . . . . . . . . . . . . 25
N
nabumetone tab 500mg . . . . . . . . . . . 12
nabumetone tab 750mg . . . . . . . . . . . 12
nadolol tab 20mg . . . . . . . . . . . . . . . . . 63
nadolol tab 40mg . . . . . . . . . . . . . . . . . 63
nadolol tab 80mg . . . . . . . . . . . . . . . . . 63
nadolol/bend tab 40-5mg . . . . . . . . . . 67
nadolol/bend tab 80-5mg . . . . . . . . . . 67
nafarelin . . . . . . . . . . . . . . . . . . . . . . . . 89
NAFCILLIN . . . . . . . . . . . . . . . . . . . . . . . 20
nafcillin inj 10gm . . . . . . . . . . . . . . . . . 20
nafcillin inj 1gm . . . . . . . . . . . . . . . . . . 20
NAGLAZYME INJ 1MG/ML . . . . . . . . . . 76
nalbuphine inj 10mg/ml . . . . . . . . . . . . 14
nalbuphine inj 20mg/ml . . . . . . . . . . . . 14
naloxone inj 1mg/ml . . . . . . . . . . . . . . 15
naltrexone . . . . . . . . . . . . . . . . . . . . . . 15
naltrexone suspension . . . . . . . . . . . . . 14
naltrexone tab 50mg . . . . . . . . . . . . . . 15
NAMENDA SOL 10MG/5ML . . . . . . . . . 28
NAMENDA TAB 10MG . . . . . . . . . . . . . 28
NAMENDA TAB 5-10MG . . . . . . . . . . . 28
NAMENDA TAB 5MG . . . . . . . . . . . . . . 28
naphazoline . . . . . . . . . . . . . . . . . . . . . 94
NAPHAZOLINE SOL 0.1% . . . . . . . . . . . 94
NAPROSYN . . . . . . . . . . . . . . . . . . . . . . 12
naproxen dr tab 375mg . . . . . . . . . . . . 12
naproxen dr tab 500mg . . . . . . . . . . . . 12
naproxen sod tab 275mg . . . . . . . . . . . 12
naproxen sod tab 550mg . . . . . . . . . . . 12
naproxen sus 125/5ml . . . . . . . . . . . . . 12
naproxen tab 250mg . . . . . . . . . . . . . . 12
naproxen tab 375mg . . . . . . . . . . . . . . 12
naproxen tab 500mg . . . . . . . . . . . . . . 12
NAPROXYN . . . . . . . . . . . . . . . . . . . . . . 12
naratriptan tab 1mg . . . . . . . . . . . . . . 36
naratriptan tab 2.5mg . . . . . . . . . . . . . 36
NARCAN . . . . . . . . . . . . . . . . . . . . . . . . 15
NARDIL . . . . . . . . . . . . . . . . . . . . . . . . . 29
NASACORT AQ . . . . . . . . . . . . . . . . . . . 83
NASALIDE . . . . . . . . . . . . . . . . . . . . . . . 96
natalizumab . . . . . . . . . . . . . . . . . . . . . 73
nateglinide tab 120mg . . . . . . . . . . . . 55
nateglinide tab 60mg . . . . . . . . . . . . . 55
NATPARA INJ 100MCG . . . . . . . . . . . . . 93
NATPARA INJ 25MCG . . . . . . . . . . . . . . 93
NATPARA INJ 50MCG . . . . . . . . . . . . . . 93
NATPARA INJ 75MCG . . . . . . . . . . . . . . 93
NAVANE . . . . . . . . . . . . . . . . . . . . . . . . 46
NAVELBINE . . . . . . . . . . . . . . . . . . . . . . 40
NEBCIN . . . . . . . . . . . . . . . . . . . . . . . . . 16
Index of Drugs
NEBUPENT INH 300MG . . . . . . . . . . . . 43
necon tab 0.5/35 . . . . . . . . . . . . . . . . . . 85
necon tab 1/35 . . . . . . . . . . . . . . . . . . . 85
NECON TAB 1/50-28 . . . . . . . . . . . . . . . 85
necon tab 10/11-28 . . . . . . . . . . . . . . . . 85
nedocromil . . . . . . . . . . . . . . . . . . . . . . 94
nefazodone tab 100mg . . . . . . . . . . . . 30
nefazodone tab 150mg . . . . . . . . . . . . 30
nefazodone tab 200mg . . . . . . . . . . . . 30
nefazodone tab 250mg . . . . . . . . . . . . 30
nefazodone tab 50mg . . . . . . . . . . . . . 30
neisseria meningitidis serogroup b . . . 92
recombinant
nelarabine . . . . . . . . . . . . . . . . . . . . . . . 38
nelfinavir . . . . . . . . . . . . . . . . . . . . . . . . 52
neo/bac/poly oin . . . . . . . . . . . . . . . . . . 94
neo/poly gu sol 40/ml . . . . . . . . . . . . . . 16
neo/poly/bac oin /hc 1% . . . . . . . . . . . 94
neo/poly/dex oin 0.1% . . . . . . . . . . . . . 94
neo/poly/dex sus 0.1% . . . . . . . . . . . . . 94
neo/poly/gra sol . . . . . . . . . . . . . . . . . . 94
neo/poly/hc sol 1% . . . . . . . . . . . . . . . . 96
neo/poly/hc sus . . . . . . . . . . . . . . . . . . . 94
neo/poly/hc sus 1% . . . . . . . . . . . . . . . . 96
NEOMYCIN . . . . . . . . . . . . . . . . . . . . . . 16
neomycin tab 500mg . . . . . . . . . . . . . . 16
NEORAL . . . . . . . . . . . . . . . . . . . . . . . . . 89
NEOSPORIN . . . . . . . . . . . . . . . . . . . . . . 94
NEOSPORIN GU . . . . . . . . . . . . . . . . . . . 16
nepafenac . . . . . . . . . . . . . . . . . . . . . . . 95
NEULASTA INJ 6MG/0.6ML . . . . . . . . . . 58
NEUMEGA INJ 5MG . . . . . . . . . . . . . . . 59
NEUPOGEN 300MCG . . . . . . . . . . . . . . 58
NEUPOGEN INJ 300/0.5ML . . . . . . . . . . 59
NEUPOGEN INJ 480/0.8ML . . . . . . . . . . 59
NEUPOGEN INJ 480MCG . . . . . . . . . . . 59
NEUPRO DIS 1MG/24HR . . . . . . . . . . . . 44
NEUPRO DIS 2MG/24HR . . . . . . . . . . . . 44
NEUPRO DIS 3MG/24HR . . . . . . . . . . . . 44
NEUPRO DIS 4MG/24HR . . . . . . . . . . . . 44
NEUPRO DIS 6MG/24HR . . . . . . . . . . . . 44
NEUPRO DIS 8MG/24HR . . . . . . . . . . . . 44
NEURONTIN . . . . . . . . . . . . . . . . . . . . . 24
NEVANAC SUS 0.1% . . . . . . . . . . . . . . . 95
nevirapine . . . . . . . . . . . . . . . . . . . . . . . 50
nevirapine 400 mg extended release . 50
nevirapine sus 50mg/5ml . . . . . . . . . . . 50
nevirapine tab 200mg . . . . . . . . . . . . . 50
nevirapine xr . . . . . . . . . . . . . . . . . . . . . 50
NEXAVAR TAB 200MG . . . . . . . . . . . . . 41
NEXIUM . . . . . . . . . . . . . . . . . . . . . . . . . 78
niacin - simvastatin er . . . . . . . . . . . . . 67
NIACOR . . . . . . . . . . . . . . . . . . . . . . . . . 71
niacor tab 500mg . . . . . . . . . . . . . . . . . 71
nicardipine cap 20mg . . . . . . . . . . . . . . 65
nicardipine cap 30mg . . . . . . . . . . . . . . 65
nicardipine inj 25/10ml . . . . . . . . . . . . 65
nicotine . . . . . . . . . . . . . . . . . . . . . . . . . 15
NICOTROL NS SPR 10MG/ML . . . . . . . . 15
nifedical xl tab 30mg . . . . . . . . . . . . . . 65
nifedical xl tab 60mg . . . . . . . . . . . . . . 65
nifedipine tab 30mg er . . . . . . . . . . . . 65
nifedipine tab 60mg er . . . . . . . . . . . . 65
nifedipine tab 90mg er . . . . . . . . . . . . 65
NILANDRON TAB 150MG . . . . . . . . . . . 37
nilotinib . . . . . . . . . . . . . . . . . . . . . . . . 42
nilutamide . . . . . . . . . . . . . . . . . . . . . . 37
nimodipine cap 30mg . . . . . . . . . . . . . 65
NIMOTOP . . . . . . . . . . . . . . . . . . . . . . . 65
nintedanib . . . . . . . . . . . . . . . . . . . . . . 99
NIRAVAM . . . . . . . . . . . . . . . . . . . . . . . 53
nisoldipine tab 17mg er . . . . . . . . . . . . 65
nisoldipine tab 20mg . . . . . . . . . . . . . . 65
nisoldipine tab 25.5mg . . . . . . . . . . . . 65
nisoldipine tab 30mg . . . . . . . . . . . . . . 65
nisoldipine tab 34mg er . . . . . . . . . . . . 65
nisoldipine tab 40mg . . . . . . . . . . . . . . 65
nisoldipine tab 8.5mg er . . . . . . . . . . . 65
nitazoxanide . . . . . . . . . . . . . . . . . . . . . 43
NITRO-BID OIN 2% . . . . . . . . . . . . . . . . 72
NITRO-DUR . . . . . . . . . . . . . . . . . . . . . . 72
nitrofur mac cap 50mg . . . . . . . . . . . . 17
nitrofurantn cap 100mg . . . . . . . . . . . 17
nitrofurantn sus 25mg/5ml . . . . . . . . . 17
nitrofurantoin mac cap 100mg . . . . . . 17
nitroglycer dis 0.1mg/hr . . . . . . . . . . . . 72
nitroglycer dis 0.2mg/hr . . . . . . . . . . . . 72
nitroglycer dis 0.4mg/hr . . . . . . . . . . . . 72
NITROGLYCER INJ 5MG/ML . . . . . . . . . 72
nitroglyceri dis 0.6mg/hr . . . . . . . . . . . 72
nitroglycerin . . . . . . . . . . . . . . . . . . . . . 72
nitroglycerin mucosal spray . . . . . . . . . 72
nitroglycerin ointment . . . . . . . . . . . . . 72
NITROMIST AER 400MCG . . . . . . . . . . . 72
NITROSTAT SUB 0.3MG . . . . . . . . . . . . 72
NITROSTAT SUB 0.4MG . . . . . . . . . . . . 72
NITROSTAT SUB 0.6MG . . . . . . . . . . . . 72
nivolumab . . . . . . . . . . . . . . . . . . . . . . . 39
nizatidine cap 150mg . . . . . . . . . . . . . . 77
nizatidine cap 300mg . . . . . . . . . . . . . . 77
nizatidine sol 15mg/ml . . . . . . . . . . . . . 77
NIZORAL . . . . . . . . . . . . . . . . . . . . . . . . 34
NOLVADEX . . . . . . . . . . . . . . . . . . . . . . 38
NORCO . . . . . . . . . . . . . . . . . . . . . . . . . 10
norco tab 10-325mg . . . . . . . . . . . . . . . 10
norco tab 5-325mg . . . . . . . . . . . . . . . . 10
norco tab 7.5-325mg . . . . . . . . . . . . . . 10
NORDITROPIN INJ 10/1.5ML . . . . . . . . . 83
NORDITROPIN INJ 15/1.5ML . . . . . . . . . 83
NORDITROPIN INJ 5/1.5ML . . . . . . . . . . 83
norethin ace tab 5mg . . . . . . . . . . . . . 87
norethindrone . . . . . . . . . . . . . . . . . . . 85
NORFLEX . . . . . . . . . . . . . . . . . . . . . . . 100
NORMOSOL -M INJ /D5W . . . . . . . . . . 102
NORPACE . . . . . . . . . . . . . . . . . . . . . . . 62
NORPRAMIN . . . . . . . . . . . . . . . . . . . . . 32
NORTHERA CAP 100MG . . . . . . . . . . . . 67
NORTHERA CAP 200MG . . . . . . . . . . . . 67
NORTHERA CAP 300MG . . . . . . . . . . . . 67
nortrel tab 0.5/35 . . . . . . . . . . . . . . . . . 85
nortrel tab 1/35 . . . . . . . . . . . . . . . . . . 85
nortrel tab 7/7/7 . . . . . . . . . . . . . . . . . . 85
NORTREL, NECON . . . . . . . . . . . . . . . . . 85
nortriptylin cap 10mg . . . . . . . . . . . . . 32
nortriptylin cap 25mg . . . . . . . . . . . . . 32
nortriptylin cap 50mg . . . . . . . . . . . . . 32
nortriptylin cap 75mg . . . . . . . . . . . . . 32
nortriptylin sol 10mg/5ml . . . . . . . . . . 32
NORVASC . . . . . . . . . . . . . . . . . . . . . . . 64
NORVIR CAP 100MG . . . . . . . . . . . . . . . 52
NORVIR SOL 80MG/ML . . . . . . . . . . . . . 52
NORVIR TAB 100MG . . . . . . . . . . . . . . . 52
NOVANTRONE . . . . . . . . . . . . . . . . . . . 40
NOXAFIL SUS 40MG/ML . . . . . . . . . . . . 34
NOXAFIL TAB 100MG . . . . . . . . . . . . . . 35
nph insulin, human unt/ml - . . . . . . . . 56
regular insulin
NUBAIN . . . . . . . . . . . . . . . . . . . . . . . . . 14
NUEDEXTA CAP 20-10MG . . . . . . . . . . 73
NULOJIX INJ 250MG . . . . . . . . . . . . . . . 91
NUTRILIPID EMU 20% . . . . . . . . . . . . 102
NUTROPIN AQ INJ 10MG/2ML . . . . . . . 83
NUTROPIN AQ INJ 20MG/2ML . . . . . . . 83
NUTROPIN AQ INJ NUSPIN 5 . . . . . . . . 77
NUVARING MIS . . . . . . . . . . . . . . . . . . . 85
nyamyc pow 100000 . . . . . . . . . . . . . . . 35
nystat/triam cre . . . . . . . . . . . . . . . . . . 35
nystat/triam oin . . . . . . . . . . . . . . . . . . 35
nystatin . . . . . . . . . . . . . . . . . . . . . . . . . 35
NYSTATIN - TRIAMCINOLONE . . . . . . . 35
nystatin cre 100000 . . . . . . . . . . . . . . . 35
nystatin oin 100000 . . . . . . . . . . . . . . . 35
nystatin pow 100000 . . . . . . . . . . . . . . 35
nystatin sus 100000 . . . . . . . . . . . . . . . 35
nystatin tab 500000 . . . . . . . . . . . . . . . 35
nystop pow 100000 . . . . . . . . . . . . . . . 35
O
octreotide . . . . . . . . . . . . . . . . . . . . . . . 88
145
Index of Drugs
octreotide inj 1000mcg . . . . . . . . . . . . 88
octreotide inj 100mcg . . . . . . . . . . . . . 88
octreotide inj 200mcg . . . . . . . . . . . . . 88
octreotide inj 500mcg . . . . . . . . . . . . . 88
octreotide inj 50mcg/ml . . . . . . . . . . . . 88
OCUFEN . . . . . . . . . . . . . . . . . . . . . . . . . 95
OCUFLOX . . . . . . . . . . . . . . . . . . . . . . . 21
OCUPRESS . . . . . . . . . . . . . . . . . . . . . . . 95
ofatumumab . . . . . . . . . . . . . . . . . . . . . 42
OFEV CAP 100MG . . . . . . . . . . . . . . . . . 99
OFEV CAP 150MG . . . . . . . . . . . . . . . . . 99
ofloxacin dro 0.3% . . . . . . . . . . . . . . . . 21
ofloxacin tab 400mg . . . . . . . . . . . . . . 22
OGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
OGESTREL TAB . . . . . . . . . . . . . . . . . . . 85
olanza/fluox cap 12-25mg . . . . . . . . . . 28
olanza/fluox cap 12-50mg . . . . . . . . . . 28
olanza/fluox cap 3-25mg . . . . . . . . . . . 28
olanza/fluox cap 6-25mg . . . . . . . . . . . 28
olanza/fluox cap 6-50mg . . . . . . . . . . . 28
olanzapine inj 10mg . . . . . . . . . . . . . . 47
olanzapine susp . . . . . . . . . . . . . . . . . . 47
olanzapine tab 10mg . . . . . . . . . . . . . . 47
olanzapine tab 10mg odt . . . . . . . . . . 47
olanzapine tab 15mg . . . . . . . . . . . . . . 47
olanzapine tab 15mg odt . . . . . . . . . . 47
olanzapine tab 2.5mg . . . . . . . . . . . . . 47
olanzapine tab 20mg . . . . . . . . . . . . . . 47
olanzapine tab 20mg odt . . . . . . . . . . 47
olanzapine tab 5mg . . . . . . . . . . . . . . . 47
olanzapine tab 5mg odt . . . . . . . . . . . 47
olanzapine tab 7.5mg . . . . . . . . . . . . . 47
olaparib . . . . . . . . . . . . . . . . . . . . . . . . . 41
olopatadine . . . . . . . . . . . . . . . . . . . . . 95
olsalazine . . . . . . . . . . . . . . . . . . . . . . . 93
OLYSIO CAP 150MG . . . . . . . . . . . . . . . 50
omacetaxine . . . . . . . . . . . . . . . . . . . . . 39
omalizumab . . . . . . . . . . . . . . . . . . . . . 99
omega-3-acid cap 1gm . . . . . . . . . . . . . 71
omeprazole cap 10mg . . . . . . . . . . . . . 78
omeprazole cap 20mg . . . . . . . . . . . . . 78
omeprazole cap 40mg . . . . . . . . . . . . . 78
OMNICEF . . . . . . . . . . . . . . . . . . . . . . . . 18
OMNITROPE INJ 10/1.5ML . . . . . . . . . . 83
OMNITROPE INJ 5.8MG . . . . . . . . . . . . 83
OMNITROPE INJ 5/1.5ML . . . . . . . . . . . 83
ONCASPAR INJ 750/ML . . . . . . . . . . . . . 40
ondansetron inj 4mg/2ml . . . . . . . . . . 33
ondansetron sol 4mg/5ml . . . . . . . . . . 33
ondansetron tab 24mg . . . . . . . . . . . . 33
ondansetron tab 4mg . . . . . . . . . . . . . 33
ondansetron tab 4mg odt . . . . . . . . . . 33
ondansetron tab 8mg . . . . . . . . . . . . . 34
146
ondansetron tab 8mg odt . . . . . . . . . . 34
ONFI SUS 2.5MG/ML . . . . . . . . . . . . . . . 25
ONFI TAB 10MG . . . . . . . . . . . . . . . . . . 25
ONFI TAB 20MG . . . . . . . . . . . . . . . . . . 25
ONGLYZA TAB 2.5MG . . . . . . . . . . . . . 55
ONGLYZA TAB 5MG . . . . . . . . . . . . . . . 55
OPDIVO INJ 40MG/4ML . . . . . . . . . . . . 39
oprelvekin . . . . . . . . . . . . . . . . . . . . . . . 59
OPSUMIT TAB 10MG . . . . . . . . . . . . . . 99
OPTIPRANOLOL . . . . . . . . . . . . . . . . . . 95
OPTIVAR . . . . . . . . . . . . . . . . . . . . . . . . 94
ORACEA CAP 40MG . . . . . . . . . . . . . . . 75
ORAP TAB 1MG . . . . . . . . . . . . . . . . . . 46
ORAP TAB 2MG . . . . . . . . . . . . . . . . . . 46
ORAPRED . . . . . . . . . . . . . . . . . . . . . . . 82
ORENCIA INJ 125MG/ML . . . . . . . . . . . 90
ORENCIA INJ 250MG . . . . . . . . . . . . . . 90
orphenadrine inj 30mg/ml . . . . . . . . . 100
orsythia tab . . . . . . . . . . . . . . . . . . . . . . 86
ORTHO MICRON . . . . . . . . . . . . . . . . . . 86
ORTHO MICRONOR . . . . . . . . . . . . . . . 86
ORTHO TRI-CYCLEN LO, TRI-SPRINTEC, 86
TRINESSA, TRI-PREVIFEM
ORTHO-CEPT . . . . . . . . . . . . . . . . . . . . . 84
ORTHO-CYCLEN . . . . . . . . . . . . . . . . . . 86
ORTHO-CYCLEN, SPRINTEC,
MONONESSA . . . . . . . . . . . . . . . . . . 86
ORTHO-NOVUM, NORTREL, NECON . . 85
ORUVAIL . . . . . . . . . . . . . . . . . . . . . . . . 12
oseltamivir . . . . . . . . . . . . . . . . . . . . . . 52
OTEZLA 30MG . . . . . . . . . . . . . . . . . . . 35
OTEZLA TAB 10/20/30MG . . . . . . . . . . . 35
OVCON-35 . . . . . . . . . . . . . . . . . . . . . . . 85
OVIDE . . . . . . . . . . . . . . . . . . . . . . . . . . 43
oxaliplatin inj 100mg . . . . . . . . . . . . . . 39
OXANDRIN . . . . . . . . . . . . . . . . . . . . . . 86
oxandrolone tab 10mg . . . . . . . . . . . . 86
oxandrolone tab 2.5mg . . . . . . . . . . . . 86
oxaprozin tab 600mg . . . . . . . . . . . . . . 12
oxcarbazepin sus 300mg/5ml . . . . . . . . 27
oxcarbazepin tab 150mg . . . . . . . . . . . 27
oxcarbazepin tab 300mg . . . . . . . . . . . 27
oxcarbazepin tab 600mg . . . . . . . . . . . 27
oxcarbazepine . . . . . . . . . . . . . . . . . . . 27
OXTELLAR XR TAB 150MG . . . . . . . . . . 27
OXTELLAR XR TAB 300MG . . . . . . . . . . 27
OXTELLAR XR TAB 600MG . . . . . . . . . . 27
oxybutynin syp 5mg/5ml . . . . . . . . . . . 79
oxybutynin tab 10mg er . . . . . . . . . . . 79
oxybutynin tab 15mg er . . . . . . . . . . . 79
oxybutynin tab 5mg . . . . . . . . . . . . . . . 79
oxybutynin tab 5mg er . . . . . . . . . . . . 79
oxybutynin transdermal patch . . . . . . 79
oxycod/apap tab 10-325mg . . . . . . . . . 10
oxycod/apap tab 2.5-325mg . . . . . . . . 11
oxycod/apap tab 5-325mg . . . . . . . . . . 11
oxycod/apap tab 7.5-325mg . . . . . . . . 11
oxycod/asa tab . . . . . . . . . . . . . . . . . . . 11
oxycod/ibu tab 5-400mg . . . . . . . . . . . 11
oxycodone cap 5mg . . . . . . . . . . . . . . . 14
oxycodone con 100/5ml . . . . . . . . . . . . 14
oxycodone er . . . . . . . . . . . . . . . . . . . . 13
oxycodone sol 5mg/5ml . . . . . . . . . . . . 14
oxycodone tab 10mg . . . . . . . . . . . . . . 14
oxycodone tab 15mg . . . . . . . . . . . . . . 14
oxycodone tab 20mg . . . . . . . . . . . . . . 14
oxycodone tab 30mg . . . . . . . . . . . . . . 14
oxycodone tab 5mg . . . . . . . . . . . . . . . 14
OXYCONTIN TAB 10MG CR . . . . . . . . . 13
OXYCONTIN TAB 15MG CR . . . . . . . . . 13
OXYCONTIN TAB 20MG CR . . . . . . . . . 13
OXYCONTIN TAB 30MG CR . . . . . . . . . 13
OXYCONTIN TAB 40MG CR . . . . . . . . . 13
OXYCONTIN TAB 60MG CR . . . . . . . . . 13
OXYCONTIN TAB 80MG CR . . . . . . . . . 13
OXYTROL DIS 3.9MG/24HR . . . . . . . . . 79
P
pacerone tab 100mg . . . . . . . . . . . . . . 62
pacerone tab 200mg . . . . . . . . . . . . . . 62
PACERONE TAB 400MG . . . . . . . . . . . . 62
paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . 38
paclitaxel inj 300/50ml . . . . . . . . . . . . . 39
palbociclib . . . . . . . . . . . . . . . . . . . . . . . 39
PALGIC . . . . . . . . . . . . . . . . . . . . . . . . . 97
palifermin . . . . . . . . . . . . . . . . . . . . . . . 74
paliperidone . . . . . . . . . . . . . . . . . . . . . 46
paliperidone palmitate im . . . . . . . . . . 46
palivizumab . . . . . . . . . . . . . . . . . . . . . 91
palonosetron . . . . . . . . . . . . . . . . . . . . 33
PAMELOR . . . . . . . . . . . . . . . . . . . . . . . 32
pamidronate inj 30/10ml . . . . . . . . . . . 94
pamidronate inj 6mg/ml . . . . . . . . . . . 94
pamidronate inj 90/10ml . . . . . . . . . . . 94
PAMINE . . . . . . . . . . . . . . . . . . . . . . . . . 76
panitumumab . . . . . . . . . . . . . . . . . . . . 40
panobinostat . . . . . . . . . . . . . . . . . . . . 39
PANRETIN GEL 0.1% . . . . . . . . . . . . . . . 42
pantoprazole tab 20mg . . . . . . . . . . . . 78
pantoprazole tab 40mg . . . . . . . . . . . . 78
PARAMOMYCIN . . . . . . . . . . . . . . . . . . 16
PARAPLATIN . . . . . . . . . . . . . . . . . . . . . 38
parathyroid hormone . . . . . . . . . . . . . 93
paricalcitol . . . . . . . . . . . . . . . . . . . . . . 94
PARLODEL . . . . . . . . . . . . . . . . . . . . . . . 44
PARNATE . . . . . . . . . . . . . . . . . . . . . . . . 29
Index of Drugs
paromomycin cap 250mg . . . . . . . . . . 16
paroxetin er tab 12.5mg . . . . . . . . . . . 30
paroxetin er tab 37.5mg . . . . . . . . . . . 30
paroxetine . . . . . . . . . . . . . . . . . . . . . . 31
paroxetine tab 10mg . . . . . . . . . . . . . . 30
paroxetine tab 20mg . . . . . . . . . . . . . . 30
paroxetine tab 25mg er . . . . . . . . . . . . 31
paroxetine tab 30mg . . . . . . . . . . . . . . 31
paroxetine tab 40mg . . . . . . . . . . . . . . 31
PASER GRA 4GM . . . . . . . . . . . . . . . . . . 37
pasireotide . . . . . . . . . . . . . . . . . . . . . . 88
PATANOL SOL 0.1% . . . . . . . . . . . . . . . 95
PAXIL . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
PAXIL CR . . . . . . . . . . . . . . . . . . . . . . . . 30
PAXIL SUS 10MG/5ML . . . . . . . . . . . . . 31
pazopanib . . . . . . . . . . . . . . . . . . . . . . . 42
PEDVAX HIB INJ . . . . . . . . . . . . . . . . . . 92
PEG-INTRON KIT 120 RP . . . . . . . . . . . . 49
PEG-INTRON KIT 120MCG . . . . . . . . . . 49
PEG-INTRON KIT 150 RP . . . . . . . . . . . . 49
PEG-INTRON KIT 150MCG . . . . . . . . . . 49
PEG-INTRON KIT 50MCG . . . . . . . . . . . 49
PEG-INTRON KIT 50MCG RP . . . . . . . . . 49
PEG-INTRON KIT 80MCG . . . . . . . . . . . 49
PEG-INTRON KIT 80MCG RP . . . . . . . . . 49
pegademase bovine . . . . . . . . . . . . . . . 75
PEGANONE TAB 250MG . . . . . . . . . . . . 27
pegaspargase . . . . . . . . . . . . . . . . . . . . 40
PEGASYS INJ 180MCG/0.5ML . . . . . . . . 49
PEGASYS INJ 180MCG/ML . . . . . . . . . . 49
PEGASYS INJ PROCLICK . . . . . . . . . . . . 49
PEGASYS PROCLICK . . . . . . . . . . . . . . . 49
pegfilgrastim . . . . . . . . . . . . . . . . . . . . 58
peginterferon alfa-2a . . . . . . . . . . . . . 49
peginterferon alfa-2b . . . . . . . . . . . . . 49
pegvisomant . . . . . . . . . . . . . . . . . . . . . 89
pembrolizumab . . . . . . . . . . . . . . . . . . 39
pemetrexed . . . . . . . . . . . . . . . . . . . . . 38
pen g proc inj 600000 . . . . . . . . . . . . . 20
pen g sod . . . . . . . . . . . . . . . . . . . . . . . 20
pen g sod inj 5000000 . . . . . . . . . . . . . 20
pen needles mis 29gx1/2 . . . . . . . . . . . 75
penciclovir . . . . . . . . . . . . . . . . . . . . . . . 53
penicill gk . . . . . . . . . . . . . . . . . . . . . . . 20
penicill gk/ inj dex 2mu . . . . . . . . . . . . 20
penicill gk/ inj dex 3mu . . . . . . . . . . . . 20
penicillamine . . . . . . . . . . . . . . . . . . . . 79
penicillin g . . . . . . . . . . . . . . . . . . . . . . 20
penicillin g benzathine . . . . . . . . . . . . 20
penicillin g benzathine - . . . . . . . . . . . 20
penicillin g procaine
PENICILLIN G PROCAINE . . . . . . . . . . . . 20
penicilln gk inj 5mu . . . . . . . . . . . . . . . 20
penicilln vk sol 125/5ml . . . . . . . . . . . . 20
penicilln vk sol 250/5ml . . . . . . . . . . . . 20
penicilln vk tab 250mg . . . . . . . . . . . . . 20
penicilln vk tab 500mg . . . . . . . . . . . . . 20
PENLAC . . . . . . . . . . . . . . . . . . . . . . . . . 34
PENTAM 300 INJ 300MG . . . . . . . . . . . 43
pentamidine . . . . . . . . . . . . . . . . . . . . . 43
pentamidine neb . . . . . . . . . . . . . . . . . 43
PENTASA CAP 250MG CR . . . . . . . . . . . 93
PENTASA CAP 500MG CR . . . . . . . . . . . 93
pentoxifylli tab 400mg er . . . . . . . . . . 68
PEPCID . . . . . . . . . . . . . . . . . . . . . . . . . . 77
PEPCID I.V. . . . . . . . . . . . . . . . . . . . . . . . 77
perampanel . . . . . . . . . . . . . . . . . . . . . 24
PERCOCET . . . . . . . . . . . . . . . . . . . . . . . 11
PERCODAN . . . . . . . . . . . . . . . . . . . . . . 11
PERCOPA . . . . . . . . . . . . . . . . . . . . . . . . 45
PERIACTIN . . . . . . . . . . . . . . . . . . . . . . . 97
PERIDEX ORAL RINSE . . . . . . . . . . . . . . 74
perindopril tab 2mg . . . . . . . . . . . . . . . 61
perindopril tab 4mg . . . . . . . . . . . . . . . 61
perindopril tab 8mg . . . . . . . . . . . . . . . 61
periogard sol 0.12% . . . . . . . . . . . . . . . 74
PERJETA INJ 420/14ML . . . . . . . . . . . . . 39
permethrin cre 5% . . . . . . . . . . . . . . . . 43
perphen/amit tab 2-10mg . . . . . . . . . . 28
perphen/amit tab 2-25mg . . . . . . . . . . 28
perphen/amit tab 4-10mg . . . . . . . . . . 28
perphen/amit tab 4-25mg . . . . . . . . . . 28
perphen/amit tab 4-50mg . . . . . . . . . . 28
perphenazine - amitriptyline . . . . . . . . 28
perphenazine tab 16mg . . . . . . . . . . . 33
perphenazine tab 2mg . . . . . . . . . . . . 33
perphenazine tab 4mg . . . . . . . . . . . . 33
perphenazine tab 8mg . . . . . . . . . . . . 33
pertuzumab . . . . . . . . . . . . . . . . . . . . . 39
phenelzine tab 15mg . . . . . . . . . . . . . . 29
PHENERGAN . . . . . . . . . . . . . . . . . . . . . 33
phenobarb elx 20mg/5ml . . . . . . . . . . . 25
phenobarb tab 100mg . . . . . . . . . . . . . 25
phenobarb tab 15mg . . . . . . . . . . . . . . 25
phenobarb tab 16.2mg . . . . . . . . . . . . 25
phenobarb tab 30mg . . . . . . . . . . . . . . 25
phenobarb tab 32.4mg . . . . . . . . . . . . 25
phenobarb tab 60mg . . . . . . . . . . . . . . 25
PHENOBARB TAB 64.8MG . . . . . . . . . . 25
PHENOBARB TAB 97.2MG . . . . . . . . . . 25
phenobarbital . . . . . . . . . . . . . . . . . . . . 25
phenytek cap 200mg . . . . . . . . . . . . . . 27
phenytek cap 300mg . . . . . . . . . . . . . . 27
phenytoin . . . . . . . . . . . . . . . . . . . . . . . 26
phenytoin chw 50mg . . . . . . . . . . . . . . 27
phenytoin ex cap 100mg . . . . . . . . . . . 27
phenytoin ex cap 200mg . . . . . . . . . . . 27
phenytoin ex cap 300mg . . . . . . . . . . . 27
phenytoin inj 50mg/ml . . . . . . . . . . . . . 27
phenytoin sus 125/5ml . . . . . . . . . . . . . 27
PHOSLO . . . . . . . . . . . . . . . . . . . . . . . . . 80
phospholine . . . . . . . . . . . . . . . . . . . . . 95
PHOSPHOLINE SOL 0.125% . . . . . . . . . 95
phospholipids - glycerin - . . . . . . . . . . 102
soybean oil
PHYSIOSOL . . . . . . . . . . . . . . . . . . . . . 101
physiosol sol . . . . . . . . . . . . . . . . . . . . 101
pilocarpine tab 5mg . . . . . . . . . . . . . . . 74
pilocarpine tab 7.5mg . . . . . . . . . . . . . 74
pimecrolimus . . . . . . . . . . . . . . . . . . . . 74
pimozide . . . . . . . . . . . . . . . . . . . . . . . . 46
pindolol tab 10mg . . . . . . . . . . . . . . . . 63
pindolol tab 5mg . . . . . . . . . . . . . . . . . 63
pioglit/glim tab 30-2mg . . . . . . . . . . . . 55
pioglit/glim tab 30-4mg . . . . . . . . . . . . 55
pioglita/met tab 15-500mg . . . . . . . . . 55
pioglita/met tab 15-850mg . . . . . . . . . 55
pioglitazone tab 15mg . . . . . . . . . . . . 55
pioglitazone tab 30mg . . . . . . . . . . . . 55
pioglitazone tab 45mg . . . . . . . . . . . . 55
piper/tazoba inj 3-0.375gm . . . . . . . . . 20
piper/tazoba inj 4-0.5gm . . . . . . . . . . . 20
piperacillin - tazobactam . . . . . . . . . . . 20
pirfenidone . . . . . . . . . . . . . . . . . . . . . . 99
piroxicam cap 10mg . . . . . . . . . . . . . . . 12
piroxicam cap 20mg . . . . . . . . . . . . . . . 12
PLAQUENIL . . . . . . . . . . . . . . . . . . . . . . 43
PLATINOL AQ . . . . . . . . . . . . . . . . . . . . 38
PLAVIX . . . . . . . . . . . . . . . . . . . . . . . . . 59
PLENDIL . . . . . . . . . . . . . . . . . . . . . . . . . 64
plerixafor . . . . . . . . . . . . . . . . . . . . . . . 58
PLETAL . . . . . . . . . . . . . . . . . . . . . . . . . . 59
podofilox sol 0.5% . . . . . . . . . . . . . . . . 75
poliovirus vaccine . . . . . . . . . . . . . . . . . 92
polyeth glyc pow 3350 nf . . . . . . . . . . 78
polymyxin b/ sol trimethp . . . . . . . . . . 94
POLYSPORIN . . . . . . . . . . . . . . . . . . . . . 94
POLYTRIM . . . . . . . . . . . . . . . . . . . . . . . 94
pomalidomide . . . . . . . . . . . . . . . . . . . 37
POMALYST CAP 1MG . . . . . . . . . . . . . . 37
POMALYST CAP 2MG . . . . . . . . . . . . . . 37
POMALYST CAP 3MG . . . . . . . . . . . . . . 37
POMALYST CAP 4MG . . . . . . . . . . . . . . 37
ponatinib . . . . . . . . . . . . . . . . . . . . . . . 41
PONSTEL . . . . . . . . . . . . . . . . . . . . . . . . 12
portia-28 . . . . . . . . . . . . . . . . . . . . . . . . 86
PORTIA, LEVORA . . . . . . . . . . . . . . . . . 85
posaconazole . . . . . . . . . . . . . . . . . . . . 34
pot chloride cap 10meq er . . . . . . . . . 101
147
Index of Drugs
pot chloride cap 8meq er . . . . . . . . . . 101
POT CHLORIDE INJ 10MEQ . . . . . . . . 101
POT CHLORIDE INJ 20MEQ . . . . . . . . 101
pot chloride inj 2meq/ml . . . . . . . . . . 101
POT CHLORIDE INJ 40MEQ . . . . . . . . 101
pot chloride tab 8meq er . . . . . . . . . . 101
pot citrate tab 1080mg . . . . . . . . . . . 101
pot citrate tab 1620mg . . . . . . . . . . . 101
pot citrate tab 540mg . . . . . . . . . . . . 101
pot cl micro tab 10meq er . . . . . . . . . 101
pot cl micro tab 20meq er . . . . . . . . . 101
potassium chloride . . . . . . . . . . . . . . . 101
potassium chloride er . . . . . . . . . . . . . 101
POTIGA TAB 200MG . . . . . . . . . . . . . . . 23
POTIGA TAB 300MG . . . . . . . . . . . . . . . 23
POTIGA TAB 400MG . . . . . . . . . . . . . . . 23
POTIGA TAB 50MG . . . . . . . . . . . . . . . . 23
PRADAXA CAP 150MG . . . . . . . . . . . . . 57
PRADAXA CAP 75MG . . . . . . . . . . . . . . 57
pramipexole tab 0.125mg . . . . . . . . . . 44
pramipexole tab 0.25mg . . . . . . . . . . . 44
pramipexole tab 0.5mg . . . . . . . . . . . . 44
pramipexole tab 0.75mg . . . . . . . . . . . 44
pramipexole tab 1.5mg . . . . . . . . . . . . 44
pramipexole tab 1mg . . . . . . . . . . . . . . 44
pramlintide . . . . . . . . . . . . . . . . . . . . . . 55
prasugrel . . . . . . . . . . . . . . . . . . . . . . . . 59
PRAVACHOL . . . . . . . . . . . . . . . . . . . . . 71
pravastatin tab 10mg . . . . . . . . . . . . . . 71
pravastatin tab 20mg . . . . . . . . . . . . . . 71
pravastatin tab 40mg . . . . . . . . . . . . . . 71
pravastatin tab 80mg . . . . . . . . . . . . . . 71
praziquantel . . . . . . . . . . . . . . . . . . . . . 43
prazosin hcl cap 1mg . . . . . . . . . . . . . . 60
prazosin hcl cap 2mg . . . . . . . . . . . . . . 60
prazosin hcl cap 5mg . . . . . . . . . . . . . . 60
PRECOSE . . . . . . . . . . . . . . . . . . . . . . . . 54
PRED MILD SUS 0.12% . . . . . . . . . . . . . 95
pred sod pho sol 1% . . . . . . . . . . . . . . 95
pred sod pho sol 5mg/5ml . . . . . . . . . . 82
PRED-G S.O.P OIN . . . . . . . . . . . . . . . . . 94
PRED-G SUS . . . . . . . . . . . . . . . . . . . . . . 94
prednicarbat cre 0.1% . . . . . . . . . . . . . 82
prednicarbat oin 0.1% . . . . . . . . . . . . . 82
prednisolone . . . . . . . . . . . . . . . . . . . . . 95
prednisolone - sulfacetamide . . . . . . . 94
prednisolone sol 15mg/5ml . . . . . . . . . 82
prednisone . . . . . . . . . . . . . . . . . . . . . . 82
prednisone con 5mg/ml . . . . . . . . . . . . 82
prednisone sol 5mg/5ml . . . . . . . . . . . . 82
prednisone tab 10mg . . . . . . . . . . . . . . 82
prednisone tab 1mg . . . . . . . . . . . . . . . 82
prednisone tab 2.5mg . . . . . . . . . . . . . 82
148
prednisone tab 20mg . . . . . . . . . . . . . . 82
prednisone tab 50mg . . . . . . . . . . . . . . 82
prednisone tab 5mg . . . . . . . . . . . . . . . 82
PREFEST TAB . . . . . . . . . . . . . . . . . . . . . 86
pregabalin . . . . . . . . . . . . . . . . . . . . . . 23
PREMARIN INJ 25MG . . . . . . . . . . . . . . 84
PREMARIN TAB 0.3MG . . . . . . . . . . . . . 84
PREMARIN TAB 0.45MG . . . . . . . . . . . . 84
PREMARIN TAB 0.625MG . . . . . . . . . . . 84
PREMARIN TAB 0.9MG . . . . . . . . . . . . . 84
PREMARIN TAB 1.25MG . . . . . . . . . . . . 84
PREMARIN VAG CRE 0.625MG . . . . . . . 84
PREMPHASE TAB . . . . . . . . . . . . . . . . . 86
PREMPRO TAB .625-2.5MG . . . . . . . . . 86
PREMPRO TAB 0.3-1.5MG . . . . . . . . . . 86
PREMPRO TAB 0.45-1.5MG . . . . . . . . . 86
PREMPRO TAB 0.625-5MG . . . . . . . . . . 86
prenatabs tab obn . . . . . . . . . . . . . . . 101
prenatal rx vitamin . . . . . . . . . . . . . . . 101
PREVACID . . . . . . . . . . . . . . . . . . . . . . . 78
prevalite pow 4gm . . . . . . . . . . . . . . . . 71
previfem tab . . . . . . . . . . . . . . . . . . . . . 86
PREZCOBIX TAB 800-150MG . . . . . . . . 51
PREZISTA SUS 100MG/ML . . . . . . . . . . . 52
PREZISTA TAB 150MG . . . . . . . . . . . . . . 52
PREZISTA TAB 600MG . . . . . . . . . . . . . . 52
PREZISTA TAB 75MG . . . . . . . . . . . . . . . 52
PREZISTA TAB 800MG . . . . . . . . . . . . . . 52
PRILOSEC . . . . . . . . . . . . . . . . . . . . . . . . 78
primaquine . . . . . . . . . . . . . . . . . . . . . . 43
PRIMAQUINE TAB 26.3MG . . . . . . . . . . 43
primidone tab 250mg . . . . . . . . . . . . . 25
primidone tab 50mg . . . . . . . . . . . . . . 25
PRIMSOL SOL 50MG/5ML . . . . . . . . . . . 17
PRISTIQ TAB 100MG . . . . . . . . . . . . . . . 31
PRISTIQ TAB 25MG . . . . . . . . . . . . . . . . 31
PRISTIQ TAB 50MG . . . . . . . . . . . . . . . . 31
PROAIR HFA AER . . . . . . . . . . . . . . . . . 98
PROAMATINE . . . . . . . . . . . . . . . . . . . . 60
proben/colch tab 500-0.5mg . . . . . . . . 35
PROBENECID . . . . . . . . . . . . . . . . . . . . . 35
probenecid tab 500mg . . . . . . . . . . . . . 35
procainamide . . . . . . . . . . . . . . . . . . . . 62
procainamide inj 100mg/ml . . . . . . . . . 62
procainamide inj 500mg/ml . . . . . . . . . 62
procarbazine . . . . . . . . . . . . . . . . . . . . . 37
PROCARDIA XL, ADALAT CC . . . . . . . . 64
prochlorper inj 5mg/ml . . . . . . . . . . . . 33
prochlorper sup 25mg . . . . . . . . . . . . . 33
prochlorper tab 10mg . . . . . . . . . . . . . 33
prochlorper tab 5mg . . . . . . . . . . . . . . 33
prochlorperazine . . . . . . . . . . . . . . . . . 33
PROCRIT INJ 10000/ML . . . . . . . . . . . . . 59
PROCRIT INJ 2000/ML . . . . . . . . . . . . . . 59
PROCRIT INJ 20000/ML . . . . . . . . . . . . . 59
PROCRIT INJ 3000/ML . . . . . . . . . . . . . . 59
PROCRIT INJ 4000/ML . . . . . . . . . . . . . . 59
PROCRIT INJ 40000/ML . . . . . . . . . . . . . 59
PROCTO-PAK . . . . . . . . . . . . . . . . . . . . 82
procto-pak cre 1% . . . . . . . . . . . . . . . . 82
PROCTOCORT, ALA-CORT . . . . . . . . . . 80
proctozone cre -hc 2.5% . . . . . . . . . . . 82
PROGLYCEM SUS 50MG/ML . . . . . . . . . 56
PROGRAF . . . . . . . . . . . . . . . . . . . . . . . 90
PROGRAF INJ 5MG/ML . . . . . . . . . . . . . 90
PROLEUKIN INJ 22MU . . . . . . . . . . . . . 39
PROLIA SOL 60MG/ML . . . . . . . . . . . . . 94
PROLIXIN . . . . . . . . . . . . . . . . . . . . . . . . 45
PROLOPRIM . . . . . . . . . . . . . . . . . . . . . 17
PROMACTA TAB 12.5MG . . . . . . . . . . . 59
PROMACTA TAB 25MG . . . . . . . . . . . . 59
PROMACTA TAB 50MG . . . . . . . . . . . . 59
PROMACTA TAB 75MG . . . . . . . . . . . . 59
promethazine syp 6.25/5ml . . . . . . . . . 33
promethazine tab 12.5mg . . . . . . . . . . 33
promethazine tab 25mg . . . . . . . . . . . 33
promethazine tab 50mg . . . . . . . . . . . 33
propafenone cap 225mg er . . . . . . . . . 62
propafenone cap 325mg er . . . . . . . . . 62
propafenone cap 425mg sr . . . . . . . . . 62
propafenone tab 150mg . . . . . . . . . . . 62
propafenone tab 225mg . . . . . . . . . . . 62
propafenone tab 300mg . . . . . . . . . . . 62
proparacaine sol 0.5% . . . . . . . . . . . . . 94
propran/hctz tab 40/25mg . . . . . . . . . . 67
propran/hctz tab 80/25mg . . . . . . . . . . 67
propranolol - hydrochlorothiazide . . . 67
propranolol cap 120mg er . . . . . . . . . . 63
propranolol cap 160mg er . . . . . . . . . . 63
propranolol cap 60mg er . . . . . . . . . . . 63
propranolol cap 80mg er . . . . . . . . . . . 64
propranolol inj 1mg/ml . . . . . . . . . . . . 64
propranolol sol 20mg/5ml . . . . . . . . . . 64
propranolol sol 40mg/5ml . . . . . . . . . . 64
propranolol tab 10mg . . . . . . . . . . . . . 64
propranolol tab 20mg . . . . . . . . . . . . . 64
propranolol tab 40mg . . . . . . . . . . . . . 64
propranolol tab 60mg . . . . . . . . . . . . . 64
propranolol tab 80mg . . . . . . . . . . . . . 64
propylthiour tab 50mg . . . . . . . . . . . . 89
propylthiouracil . . . . . . . . . . . . . . . . . . 89
PROQUAD INJ . . . . . . . . . . . . . . . . . . . . 92
PROSCAR . . . . . . . . . . . . . . . . . . . . . . . . 79
PROTONIX . . . . . . . . . . . . . . . . . . . . . . . 78
protriptylin tab 10mg . . . . . . . . . . . . . 32
protriptylin tab 5mg . . . . . . . . . . . . . . 32
Index of Drugs
PROVENTIL - VENTOLIN . . . . . . . . . . . . 97
PROVENTIL AER HFA . . . . . . . . . . . . . . 98
PROVERA . . . . . . . . . . . . . . . . . . . . . . . 86
PROVIGIL . . . . . . . . . . . . . . . . . . . . . . . 100
PROZAC . . . . . . . . . . . . . . . . . . . . . . . . . 30
PROZAC WEEKL . . . . . . . . . . . . . . . . . . 30
PSORCON . . . . . . . . . . . . . . . . . . . . . . . 81
PULMICORT INH 180MCG . . . . . . . . . . 96
PULMICORT INH 90MCG . . . . . . . . . . . 96
PULMICORT SUS 1MG/2ML . . . . . . . . . 96
PULMOZYME SOL 1MG/ML . . . . . . . . . 99
PURINETHOL . . . . . . . . . . . . . . . . . . . . . 38
PURIXAN SUS 20MG/ML . . . . . . . . . . . . 38
PYRAZINAMIDE . . . . . . . . . . . . . . . . . . 37
pyrazinamide tab 500mg . . . . . . . . . . . 37
pyridostigm tab 60mg . . . . . . . . . . . . . 36
pyridostigmine . . . . . . . . . . . . . . . . . . . 36
pyrimethamine . . . . . . . . . . . . . . . . . . . 43
Q
qnapril/hctz tab 10-12.5mg . . . . . . . . . 67
qnapril/hctz tab 20-12.5mg . . . . . . . . . 67
qnapril/hctz tab 20-25mg . . . . . . . . . . 67
QUALAQUIN . . . . . . . . . . . . . . . . . . . . . 43
quasense . . . . . . . . . . . . . . . . . . . . . . . . 86
QUESTRAN . . . . . . . . . . . . . . . . . . . . . . 71
questran pow 4gm . . . . . . . . . . . . . . . . 71
quetiapine er . . . . . . . . . . . . . . . . . . . . 29
quetiapine tab 100mg . . . . . . . . . . . . . 29
quetiapine tab 200mg . . . . . . . . . . . . . 29
quetiapine tab 25mg . . . . . . . . . . . . . . 29
quetiapine tab 300mg . . . . . . . . . . . . . 29
quetiapine tab 400mg . . . . . . . . . . . . . 29
quetiapine tab 50mg . . . . . . . . . . . . . . 29
quinapril tab 10mg . . . . . . . . . . . . . . . 61
quinapril tab 20mg . . . . . . . . . . . . . . . 61
quinapril tab 40mg . . . . . . . . . . . . . . . 61
quinapril tab 5mg . . . . . . . . . . . . . . . . 61
quinidine gl . . . . . . . . . . . . . . . . . . . . . 62
quinidine gl inj 80mg/ml . . . . . . . . . . . 62
quinidine gl tab 324mg cr . . . . . . . . . . 62
quinidine gluconate . . . . . . . . . . . . . . . 62
quinidine su . . . . . . . . . . . . . . . . . . . . . 62
quinidine su tab 200mg . . . . . . . . . . . . 62
quinidine su tab 300mg . . . . . . . . . . . . 62
quinidine su tab 300mg er . . . . . . . . . . 62
quinidine sulfate er . . . . . . . . . . . . . . . 62
quinine sulf cap 324mg . . . . . . . . . . . . 43
QUIXIN . . . . . . . . . . . . . . . . . . . . . . . . . 21
QVAR AER 40MCG . . . . . . . . . . . . . . . . 96
R
RABAVERT INJ . . . . . . . . . . . . . . . . . . . . 92
rabbit anti-human t-lymphocyte . . . . . 91
globulin
rabeprazole tab 20mg . . . . . . . . . . . . . 78
rabies vaccine human diploid cell . . . . 92
rabies virus vaccine . . . . . . . . . . . . . . . . 92
raloxifene tab 60mg . . . . . . . . . . . . . . . 87
raltegravir . . . . . . . . . . . . . . . . . . . . . . . 50
ramelteon . . . . . . . . . . . . . . . . . . . . . . 100
ramipril cap 1.25mg . . . . . . . . . . . . . . . 61
ramipril cap 10mg . . . . . . . . . . . . . . . . 61
ramipril cap 2.5mg . . . . . . . . . . . . . . . . 61
ramipril cap 5mg . . . . . . . . . . . . . . . . . 62
RANEXA TAB 1000MG . . . . . . . . . . . . . 68
RANEXA TAB 500MG . . . . . . . . . . . . . . 68
ranitidine cap 150mg . . . . . . . . . . . . . . 77
ranitidine cap 300mg . . . . . . . . . . . . . . 77
ranitidine inj 150/6ml . . . . . . . . . . . . . . 78
ranitidine syp 15mg/ml . . . . . . . . . . . . 78
ranitidine tab 150mg . . . . . . . . . . . . . . 78
ranitidine tab 300mg . . . . . . . . . . . . . . 78
ranolazine . . . . . . . . . . . . . . . . . . . . . . . 68
RAPAMUNE . . . . . . . . . . . . . . . . . . . . . . 90
RAPAMUNE SOL 1MG/ML . . . . . . . . . . 90
rasagiline . . . . . . . . . . . . . . . . . . . . . . . 45
rasburicase . . . . . . . . . . . . . . . . . . . . . . 39
RAVICTI LIQ 1.1GM/ML . . . . . . . . . . . . 76
RAZADYNE ER . . . . . . . . . . . . . . . . . . . 27
REBETOL . . . . . . . . . . . . . . . . . . . . . . . . 49
REBETOL-COPEGUS . . . . . . . . . . . . . . . 49
REBIF INJ 22/0.5ML . . . . . . . . . . . . . . . . 73
REBIF INJ 44/0.5ML . . . . . . . . . . . . . . . . 73
REBIF TITRTN SOL PACK . . . . . . . . . . . . 73
RECLAST . . . . . . . . . . . . . . . . . . . . . . . . 94
reclipsen tab . . . . . . . . . . . . . . . . . . . . . 86
RECOMBIVA HB INJ 10MCG/ML . . . . . . 92
RECOMBIVA HB INJ 5MCG/0.5ML . . . . 92
RECOMBIVA-HB INJ 40MCG/ML . . . . . . 92
REGLAN . . . . . . . . . . . . . . . . . . . . . . . . . 33
regular insulin . . . . . . . . . . . . . . . . . . . 56
RELAFEN . . . . . . . . . . . . . . . . . . . . . . . . 12
RELENZA MIS DISKHALE . . . . . . . . . . . 52
RELISTOR KIT 12/0.6ML . . . . . . . . . . . . 77
REMERON . . . . . . . . . . . . . . . . . . . . . . . 29
REMICADE INJ 100MG . . . . . . . . . . . . . 90
REMINYL, RAZADYNE . . . . . . . . . . . . . 28
REMODULIN INJ 10MG/ML . . . . . . . . . 99
REMODULIN INJ 1MG/ML . . . . . . . . . . 99
REMODULIN INJ 2.5MG/ML . . . . . . . . . 99
REMODULIN INJ 5MG/ML . . . . . . . . . . 99
RENAGEL TAB 400MG . . . . . . . . . . . . . 80
RENAGEL TAB 800MG . . . . . . . . . . . . . 80
RENVELA PAK 0.8GM . . . . . . . . . . . . . . 80
RENVELA PAK 2.4GM . . . . . . . . . . . . . . 80
RENVELA TAB 800MG . . . . . . . . . . . . . 80
REQUIP . . . . . . . . . . . . . . . . . . . . . . . . . 44
RESCRIPTOR TAB 100 MG . . . . . . . . . . . 50
RESCRIPTOR TAB 200MG . . . . . . . . . . . 50
reserpine . . . . . . . . . . . . . . . . . . . . . . . . 67
reserpine tab 0.1mg . . . . . . . . . . . . . . . 67
reserpine tab 0.25mg . . . . . . . . . . . . . . 67
RESTASIS EMU 0.05% . . . . . . . . . . . . . . 94
RETIN-A . . . . . . . . . . . . . . . . . . . . . . . . . 75
RETIN-A, AVITA . . . . . . . . . . . . . . . . . . . 75
RETROVIR . . . . . . . . . . . . . . . . . . . . . . . 51
RETROVIR INJ 10MG/ML . . . . . . . . . . . . 51
REVATIO . . . . . . . . . . . . . . . . . . . . . . . . 99
REVLIMID CAP 10MG . . . . . . . . . . . . . . 37
REVLIMID CAP 15MG . . . . . . . . . . . . . . 37
REVLIMID CAP 2.5MG . . . . . . . . . . . . . 37
REVLIMID CAP 20MG . . . . . . . . . . . . . . 37
REVLIMID CAP 25MG . . . . . . . . . . . . . . 37
REVLIMID CAP 5MG . . . . . . . . . . . . . . . 38
REYATAZ CAP 150MG . . . . . . . . . . . . . . 52
REYATAZ CAP 200MG . . . . . . . . . . . . . . 52
REYATAZ CAP 300MG . . . . . . . . . . . . . . 52
REYATAZ POW 50MG . . . . . . . . . . . . . . 52
RHEUMATREX TAB 2.5MG . . . . . . . . . . 90
RIBAPAK PAK 1000/DAY . . . . . . . . . . . . 49
ribapak pak 1200/day . . . . . . . . . . . . . . 49
ribapak pak 800/day . . . . . . . . . . . . . . . 49
ribasphere cap 200mg . . . . . . . . . . . . . 49
ribasphere tab 200mg . . . . . . . . . . . . . 49
RIBASPHERE TAB 400MG . . . . . . . . . . . 49
RIBASPHERE TAB 600MG . . . . . . . . . . . 49
RIBASPHERE, REBETOL . . . . . . . . . . . . . 49
RIBASPHERE, REBETOL-COPEGUS . . . . 49
ribavirin . . . . . . . . . . . . . . . . . . . . . . . . . 49
ribavirin 20 mg/ml inhalant . . . . . . . . . 53
ribavirin cap 200mg . . . . . . . . . . . . . . . 49
ribavirin tab 200mg . . . . . . . . . . . . . . . 49
RIDAURA CAP 3MG . . . . . . . . . . . . . . . 91
rifabutin cap 150mg . . . . . . . . . . . . . . . 36
RIFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 37
rifampin cap 150mg . . . . . . . . . . . . . . . 37
rifampin cap 300mg . . . . . . . . . . . . . . . 37
rifampin inj 600 mg . . . . . . . . . . . . . . . 37
RIFATER TAB . . . . . . . . . . . . . . . . . . . . . 37
rilonacept . . . . . . . . . . . . . . . . . . . . . . . 91
rilpivirine . . . . . . . . . . . . . . . . . . . . . . . . 50
RILUTEK . . . . . . . . . . . . . . . . . . . . . . . . . 73
riluzole tab 50mg . . . . . . . . . . . . . . . . . 73
rimantadine tab 100mg . . . . . . . . . . . . 52
rimexolone . . . . . . . . . . . . . . . . . . . . . . 95
ringers . . . . . . . . . . . . . . . . . . . . . . . . . 102
ringers irrigation soln . . . . . . . . . . . . 102
ringers sol . . . . . . . . . . . . . . . . . . . . . . 102
149
Index of Drugs
riociguat . . . . . . . . . . . . . . . . . . . . . . . . 99
risedronate tab 150mg . . . . . . . . . . . . 94
RISPERDAL . . . . . . . . . . . . . . . . . . . . . . 47
RISPERDAL INJ 12.5MG . . . . . . . . . . . . 47
RISPERDAL INJ 25MG . . . . . . . . . . . . . . 47
RISPERDAL INJ 37.5MG . . . . . . . . . . . . 47
RISPERDAL INJ 50MG . . . . . . . . . . . . . . 47
RISPERDAL M . . . . . . . . . . . . . . . . . . . . 47
risperidone . . . . . . . . . . . . . . . . . . . . . . 47
risperidone sol 1mg/ml . . . . . . . . . . . . 47
risperidone tab 0.25 odt . . . . . . . . . . . 47
risperidone tab 0.25mg . . . . . . . . . . . . 47
risperidone tab 0.5mg . . . . . . . . . . . . . 47
risperidone tab 0.5mg odt . . . . . . . . . . 47
risperidone tab 1mg . . . . . . . . . . . . . . . 47
risperidone tab 1mg odt . . . . . . . . . . . 47
risperidone tab 2mg . . . . . . . . . . . . . . . 47
risperidone tab 2mg odt . . . . . . . . . . . 47
risperidone tab 3mg . . . . . . . . . . . . . . . 47
risperidone tab 3mg odt . . . . . . . . . . . 47
risperidone tab 4mg . . . . . . . . . . . . . . . 47
risperidone tab 4mg odt . . . . . . . . . . . 47
RITALIN . . . . . . . . . . . . . . . . . . . . . . . . . 73
RITALIN SR . . . . . . . . . . . . . . . . . . . . . . . 73
ritonavir . . . . . . . . . . . . . . . . . . . . . . . . 52
RITUXAN INJ 500MG . . . . . . . . . . . . . . 42
rituximab . . . . . . . . . . . . . . . . . . . . . . . 42
rivaroxaban . . . . . . . . . . . . . . . . . . . . . . 58
rivastigmine cap 1.5mg . . . . . . . . . . . . 28
rivastigmine cap 3mg . . . . . . . . . . . . . . 28
rivastigmine cap 4.5mg . . . . . . . . . . . . 28
rivastigmine cap 6mg . . . . . . . . . . . . . . 28
rivastigmine patch . . . . . . . . . . . . . . . . 27
ROBINUL . . . . . . . . . . . . . . . . . . . . . . . . 76
ROBINUL FORTE . . . . . . . . . . . . . . . . . . 76
ROCALTROL . . . . . . . . . . . . . . . . . . . . . 93
ROCEPHIN . . . . . . . . . . . . . . . . . . . . . . . 18
roflumilast . . . . . . . . . . . . . . . . . . . . . . 98
romidepsin . . . . . . . . . . . . . . . . . . . . . . 39
ROMYCIN . . . . . . . . . . . . . . . . . . . . . . . 21
ropinirole tab 0.25mg . . . . . . . . . . . . . 44
ropinirole tab 0.5mg . . . . . . . . . . . . . . 44
ropinirole tab 12mg er . . . . . . . . . . . . . 44
ropinirole tab 1mg . . . . . . . . . . . . . . . . 44
ropinirole tab 2mg . . . . . . . . . . . . . . . . 44
ropinirole tab 2mg er . . . . . . . . . . . . . . 44
ropinirole tab 3mg . . . . . . . . . . . . . . . . 44
ropinirole tab 4mg . . . . . . . . . . . . . . . . 44
ropinirole tab 4mg er . . . . . . . . . . . . . . 44
ropinirole tab 5mg . . . . . . . . . . . . . . . . 44
ropinirole tab 6mg er . . . . . . . . . . . . . . 44
ropinirole tab 8mg er . . . . . . . . . . . . . . 44
rosuvastatin . . . . . . . . . . . . . . . . . . . . . 70
150
ROTARIX SUS . . . . . . . . . . . . . . . . . . . . 92
ROTATEQ SOL . . . . . . . . . . . . . . . . . . . . 92
rotavirus vaccine . . . . . . . . . . . . . . . . . . 92
rotigotine transdermal patch . . . . . . . 44
ROWASA . . . . . . . . . . . . . . . . . . . . . . . . 93
ROXICODONE . . . . . . . . . . . . . . . . . . . . 14
ROZEREM TAB 8MG . . . . . . . . . . . . . . 100
rufinamide . . . . . . . . . . . . . . . . . . . . . . 26
ruxolitinib . . . . . . . . . . . . . . . . . . . . . . . 41
RYTHMOL . . . . . . . . . . . . . . . . . . . . . . . 62
S
SABRIL POW 500MG . . . . . . . . . . . . . . . 25
SABRIL TAB 500MG . . . . . . . . . . . . . . . 25
SAIZEN INJ 5MG . . . . . . . . . . . . . . . . . . 83
SAIZEN INJ 8.8MG . . . . . . . . . . . . . . . . . 83
SALAGEN . . . . . . . . . . . . . . . . . . . . . . . . 74
salmeterol . . . . . . . . . . . . . . . . . . . . . . . 98
salmon calcitonin . . . . . . . . . . . . . . . . . 93
SANDIMMUNE . . . . . . . . . . . . . . . . . . . 89
SANDIMMUNE SOL 100MG/ML . . . . . . 90
SANDOSTATIN . . . . . . . . . . . . . . . . . . . . 88
SANDOSTATIN KIT LAR 10MG . . . . . . . 88
SANDOSTATIN KIT LAR 20MG . . . . . . . 88
SANDOSTATIN KIT LAR 30MG . . . . . . . 88
SANTYL OIN 250/GM . . . . . . . . . . . . . . 75
SAPHRIS SUB 10MG . . . . . . . . . . . . . . . 47
SAPHRIS SUB 2.5MG . . . . . . . . . . . . . . . 47
SAPHRIS SUB 5MG . . . . . . . . . . . . . . . . 47
sapropterin . . . . . . . . . . . . . . . . . . . . . . 76
saquinavir . . . . . . . . . . . . . . . . . . . . . . . 52
sargramostim . . . . . . . . . . . . . . . . . . . . 58
saxagliptin . . . . . . . . . . . . . . . . . . . . . . 55
scopolamine transdermal patch . . . . . 33
SEASONALE . . . . . . . . . . . . . . . . . . . . . . 86
SECTRAL . . . . . . . . . . . . . . . . . . . . . . . . 63
selegiline . . . . . . . . . . . . . . . . . . . . . . . . 29
selegiline cap 5mg . . . . . . . . . . . . . . . . 45
selegiline tab 5mg . . . . . . . . . . . . . . . . 45
selenium sul lot 2.5% . . . . . . . . . . . . . . 75
SELSUN . . . . . . . . . . . . . . . . . . . . . . . . . 75
SELZENTRY TAB 150MG . . . . . . . . . . . . 51
SELZENTRY TAB 300MG . . . . . . . . . . . . 51
SENSIPAR TAB 30MG . . . . . . . . . . . . . . 88
SENSIPAR TAB 60MG . . . . . . . . . . . . . . 88
SENSIPAR TAB 90MG . . . . . . . . . . . . . . 88
SEREVENT DIS AER 50MCG . . . . . . . . . 98
SEROQUEL . . . . . . . . . . . . . . . . . . . . . . . 29
SEROQUEL XR TAB 150MG . . . . . . . . . 29
SEROQUEL XR TAB 200MG . . . . . . . . . 29
SEROQUEL XR TAB 300MG . . . . . . . . . 29
SEROQUEL XR TAB 400MG . . . . . . . . . 29
SEROQUEL XR TAB 50MG . . . . . . . . . . 29
SEROSTIM INJ 4MG . . . . . . . . . . . . . . . . 77
SEROSTIM INJ 5MG . . . . . . . . . . . . . . . . 77
SEROSTIM INJ 6MG . . . . . . . . . . . . . . . . 77
sertraline con 20mg/ml . . . . . . . . . . . . 31
sertraline tab 100mg . . . . . . . . . . . . . . 31
sertraline tab 25mg . . . . . . . . . . . . . . . 31
sertraline tab 50mg . . . . . . . . . . . . . . . 31
SERZONE . . . . . . . . . . . . . . . . . . . . . . . . 30
sevelamer . . . . . . . . . . . . . . . . . . . . . . . 80
SIGNIFOR INJ 0.3MG/ML . . . . . . . . . . . . 88
SIGNIFOR INJ 0.6MG/ML . . . . . . . . . . . . 88
SIGNIFOR INJ 0.9MG/ML . . . . . . . . . . . . 88
sildenafil . . . . . . . . . . . . . . . . . . . . . . . . 79
sildenafil tab 20mg . . . . . . . . . . . . . . . 99
SILVADENE - SSD . . . . . . . . . . . . . . . . . . 22
silver sulfa cre 1% . . . . . . . . . . . . . . . . 22
SIMCOR TAB 1000-20MG . . . . . . . . . . . 67
SIMCOR TAB 1000-40MG . . . . . . . . . . . 67
SIMCOR TAB 500-20MG . . . . . . . . . . . . 68
SIMCOR TAB 500-40MG . . . . . . . . . . . . 68
SIMCOR TAB 750-20MG . . . . . . . . . . . . 68
simeprevir 150 mg . . . . . . . . . . . . . . . . 50
SIMPONI INJ 50MG . . . . . . . . . . . . . . . . 90
SIMULECT INJ 20MG . . . . . . . . . . . . . . . 91
simvastatin - ezetimibe . . . . . . . . . . . . 68
simvastatin tab 10mg . . . . . . . . . . . . . . 71
simvastatin tab 20mg . . . . . . . . . . . . . . 71
simvastatin tab 40mg . . . . . . . . . . . . . . 71
simvastatin tab 5mg . . . . . . . . . . . . . . . 71
simvastatin tab 80mg . . . . . . . . . . . . . . 71
SINEMET . . . . . . . . . . . . . . . . . . . . . . . . 45
SINEMET CR . . . . . . . . . . . . . . . . . . . . . 45
SINEQUAN . . . . . . . . . . . . . . . . . . . . . . . 32
SINGULAIR . . . . . . . . . . . . . . . . . . . . . . 97
sirolimus . . . . . . . . . . . . . . . . . . . . . . . . 90
sirolimus tab 0.5mg . . . . . . . . . . . . . . . 90
sirolimus tab 1mg . . . . . . . . . . . . . . . . . 90
sirolimus tab 2mg . . . . . . . . . . . . . . . . . 90
SIRTURO TAB 100MG . . . . . . . . . . . . . . 37
smz-tmp inj 400-80/5ml . . . . . . . . . . . . 22
smz-tmp sus 200-40/5ml . . . . . . . . . . . . 22
smz-tmp tab 400-80mg . . . . . . . . . . . . 22
smz/tmp ds tab 800-160mg . . . . . . . . . 22
sod chloride 0.45% . . . . . . . . . . . . . . 101
sod chloride 0.9% . . . . . . . . . . . . . . . 101
sod chloride inj 0.45% . . . . . . . . . . . . 101
sod chloride inj 0.9% . . . . . . . . . . . . . 101
sod chloride inj 2.5/ml . . . . . . . . . . . . 101
sod chloride inj 3% . . . . . . . . . . . . . . 101
sod chloride inj 5% . . . . . . . . . . . . . . 101
sod poly sul sus 15gm/60ml . . . . . . . . 100
sod sulfacet sol 10% . . . . . . . . . . . . . . . 22
sodium chlor sol 0.9% . . . . . . . . . . . . 101
Index of Drugs
sodium chloride . . . . . . . . . . . . . . . . . 101
SODIUM CHLORIDE IRRIGATION . . . . 101
sodium oxybate . . . . . . . . . . . . . . . . . 100
sofosbuvir 400 mg . . . . . . . . . . . . . . . . 50
SOLARAZE . . . . . . . . . . . . . . . . . . . . . . . 74
SOLODYN . . . . . . . . . . . . . . . . . . . . . . . 23
SOLTAMOX SOL 10MG/5ML . . . . . . . . . 38
SOLU-MEDROL . . . . . . . . . . . . . . . . . . . 82
somatropin . . . . . . . . . . . . . . . . . . . . . . 77
SOMATULINE INJ 120/.5ML . . . . . . . . . 88
SOMATULINE INJ 60/0.2ML . . . . . . . . . 88
SOMATULINE INJ 90/0.3ML . . . . . . . . . 88
SOMAVERT INJ 10MG . . . . . . . . . . . . . . 89
SOMAVERT INJ 15MG . . . . . . . . . . . . . . 89
SOMAVERT INJ 20MG . . . . . . . . . . . . . . 89
SOMAVERT INJ 25MG . . . . . . . . . . . . . . 89
SOMAVERT INJ 30MG . . . . . . . . . . . . . . 89
SONATA . . . . . . . . . . . . . . . . . . . . . . . . 100
sorafenib . . . . . . . . . . . . . . . . . . . . . . . . 41
SORIATANE . . . . . . . . . . . . . . . . . . . . . . 74
sorine tab 120mg . . . . . . . . . . . . . . . . . 62
sorine tab 160mg . . . . . . . . . . . . . . . . . 62
sorine tab 240mg . . . . . . . . . . . . . . . . . 62
sorine tab 80mg . . . . . . . . . . . . . . . . . . 62
SORINE, BETAPACE . . . . . . . . . . . . . . . . 62
sotalol af tab 120mg . . . . . . . . . . . . . . 62
sotalol hcl tab 160mg . . . . . . . . . . . . . . 62
sotalol hcl tab 240mg . . . . . . . . . . . . . . 63
sotalol hcl tab 80mg . . . . . . . . . . . . . . . 63
SOVALDI TAB 400MG . . . . . . . . . . . . . . 50
SPECTAZOLE . . . . . . . . . . . . . . . . . . . . . 34
SPIRIVA CAP HANDIHLR . . . . . . . . . . . . 97
spirono/hctz tab 25/25mg . . . . . . . . . . 68
spironolact tab 100mg . . . . . . . . . . . . . 69
spironolact tab 25mg . . . . . . . . . . . . . . 69
spironolact tab 50mg . . . . . . . . . . . . . . 69
SPORANOX . . . . . . . . . . . . . . . . . . . . . . 34
sprintec 28 tab . . . . . . . . . . . . . . . . . . . 86
SPRYCEL TAB 100MG . . . . . . . . . . . . . . 41
SPRYCEL TAB 140MG . . . . . . . . . . . . . . 42
SPRYCEL TAB 20MG . . . . . . . . . . . . . . . 42
SPRYCEL TAB 50MG . . . . . . . . . . . . . . . 42
SPRYCEL TAB 70MG . . . . . . . . . . . . . . . 42
SPRYCEL TAB 80MG . . . . . . . . . . . . . . . 42
sronyx tab . . . . . . . . . . . . . . . . . . . . . . . 86
ssd cre 1% . . . . . . . . . . . . . . . . . . . . . . . 22
STARLIX . . . . . . . . . . . . . . . . . . . . . . . . . 55
stavudine cap 15mg . . . . . . . . . . . . . . . 51
stavudine cap 20mg . . . . . . . . . . . . . . . 51
stavudine cap 30mg . . . . . . . . . . . . . . . 51
stavudine cap 40mg . . . . . . . . . . . . . . . 51
stavudine sol 1mg/ml . . . . . . . . . . . . . . 51
STELAZINE . . . . . . . . . . . . . . . . . . . . . . . 46
steril water sol . . . . . . . . . . . . . . . . . . 102
STERILE WATER IRRIGATION . . . . . . . 102
STIMATE SOL 1.5MG/ML . . . . . . . . . . . 83
STIVARGA TAB 40MG . . . . . . . . . . . . . . 42
STRATTERA CAP 100MG . . . . . . . . . . . . 73
STRATTERA CAP 10MG . . . . . . . . . . . . . 73
STRATTERA CAP 18MG . . . . . . . . . . . . . 73
STRATTERA CAP 25MG . . . . . . . . . . . . . 73
STRATTERA CAP 40MG . . . . . . . . . . . . . 73
STRATTERA CAP 60MG . . . . . . . . . . . . . 73
STRATTERA CAP 80MG . . . . . . . . . . . . . 73
streptomycin . . . . . . . . . . . . . . . . . . . . . 16
streptomycin inj 1gm . . . . . . . . . . . . . . 16
streptozocin . . . . . . . . . . . . . . . . . . . . . 40
STRIBILD TAB . . . . . . . . . . . . . . . . . . . . 50
STROMECTOL . . . . . . . . . . . . . . . . . . . . 43
SUBOXONE . . . . . . . . . . . . . . . . . . . . . . 15
SUBOXONE MIS 12-3MG . . . . . . . . . . . 15
SUBOXONE MIS 2-0.5MG . . . . . . . . . . . 15
SUBOXONE MIS 4-1MG . . . . . . . . . . . . 15
SUBOXONE MIS 8-2MG . . . . . . . . . . . . 15
SUBUTEX . . . . . . . . . . . . . . . . . . . . . . . . 15
succimer . . . . . . . . . . . . . . . . . . . . . . . 100
sucralfate tab 1gm . . . . . . . . . . . . . . . . 78
SULAR . . . . . . . . . . . . . . . . . . . . . . . . . . 65
sulconazole . . . . . . . . . . . . . . . . . . . . . . 34
sulf/pred na sol . . . . . . . . . . . . . . . . . . . 94
sulfacet sod oin 10% . . . . . . . . . . . . . . 22
sulfacetamid sus 10% . . . . . . . . . . . . . . 22
sulfadiazine . . . . . . . . . . . . . . . . . . . . . 22
sulfadiazine tab 500mg . . . . . . . . . . . . 22
SULFAMYLON CRE 85MG/GM . . . . . . . 17
sulfasalazin tab 500mg . . . . . . . . . . . . 93
sulfazine ec tab 500mg . . . . . . . . . . . . 93
sulindac tab 150mg . . . . . . . . . . . . . . . 12
sulindac tab 200mg . . . . . . . . . . . . . . . 12
sumatriptan inj 6mg/0.5ml . . . . . . . . . 36
sumatriptan spr 20mg/act . . . . . . . . . . 36
sumatriptan spr 5mg/act . . . . . . . . . . . 36
sumatriptan tab 100mg . . . . . . . . . . . . 36
sumatriptan tab 25mg . . . . . . . . . . . . . 36
sumatriptan tab 50mg . . . . . . . . . . . . . 36
sunitinib . . . . . . . . . . . . . . . . . . . . . . . . 42
SUPRAX SUS 100/5ML . . . . . . . . . . . . . . 19
SUPRAX SUS 200/5ML . . . . . . . . . . . . . . 19
SURMONTIL CAP 100MG . . . . . . . . . . . 32
SURMONTIL CAP 25MG . . . . . . . . . . . . 32
SURMONTIL CAP 50MG . . . . . . . . . . . . 32
SUSTIVA CAP 200MG . . . . . . . . . . . . . . 50
SUSTIVA CAP 50MG . . . . . . . . . . . . . . . 50
SUSTIVA TAB 600MG . . . . . . . . . . . . . . 50
SUTENT CAP 12.5MG . . . . . . . . . . . . . . 42
SUTENT CAP 25MG . . . . . . . . . . . . . . . . 42
SUTENT CAP 37.5MG . . . . . . . . . . . . . . 42
SUTENT CAP 50MG . . . . . . . . . . . . . . . . 42
SYLATRON KIT 296MCG . . . . . . . . . . . . 49
SYLATRON KIT 444MCG . . . . . . . . . . . . 49
SYLATRON KIT 888MCG . . . . . . . . . . . . 49
SYMBICORT AER 160-4.5 . . . . . . . . . . . 99
SYMBICORT AER 80-4.5 . . . . . . . . . . . . 99
SYMBYAX . . . . . . . . . . . . . . . . . . . . . . . 28
SYMLINPEN 60 INJ 1000MCG . . . . . . . . 55
SYMLNPEN 120 INJ 1000MCG . . . . . . . 55
SYMMETREL . . . . . . . . . . . . . . . . . . . . . 44
SYNAGIS INJ 50MG . . . . . . . . . . . . . . . . 91
SYNALAR . . . . . . . . . . . . . . . . . . . . . . . . 81
SYNAREL SOL 2MG/ML . . . . . . . . . . . . . 89
SYNERCID INJ 500MG . . . . . . . . . . . . . . 16
SYNRIBO INJ 3.5MG . . . . . . . . . . . . . . . 39
SYNTHROID TAB 100MCG . . . . . . . . . . 87
SYNTHROID TAB 112MCG . . . . . . . . . . 87
SYNTHROID TAB 125MCG . . . . . . . . . . 87
SYNTHROID TAB 137MCG . . . . . . . . . . 87
SYNTHROID TAB 150MCG . . . . . . . . . . 87
SYNTHROID TAB 175MCG . . . . . . . . . . 87
SYNTHROID TAB 200MCG . . . . . . . . . . 87
SYNTHROID TAB 25MCG . . . . . . . . . . . 87
SYNTHROID TAB 300MCG . . . . . . . . . . 87
SYNTHROID TAB 50MCG . . . . . . . . . . . 87
SYNTHROID TAB 75MCG . . . . . . . . . . . 87
SYNTHROID TAB 88MCG . . . . . . . . . . . 87
SYPRINE CAP 250MG . . . . . . . . . . . . . 101
T
TABLOID TAB 40MG . . . . . . . . . . . . . . . 38
tacrolimus . . . . . . . . . . . . . . . . . . . . . . . 90
tacrolimus cap 0.5mg . . . . . . . . . . . . . . 90
tacrolimus cap 1mg . . . . . . . . . . . . . . . 90
tacrolimus cap 5mg . . . . . . . . . . . . . . . 90
tacrolimus er . . . . . . . . . . . . . . . . . . . . . 89
tadalafil . . . . . . . . . . . . . . . . . . . . . . . . . 99
TAFINLAR CAP 50MG . . . . . . . . . . . . . . 42
TAFINLAR CAP 75MG . . . . . . . . . . . . . . 42
TAGAMET . . . . . . . . . . . . . . . . . . . . . . . 77
TAMBOCOR . . . . . . . . . . . . . . . . . . . . . . 62
TAMIFLU CAP 30MG . . . . . . . . . . . . . . . 52
TAMIFLU CAP 45MG . . . . . . . . . . . . . . . 52
TAMIFLU CAP 75MG . . . . . . . . . . . . . . . 52
TAMIFLU SUS 6MG/ML . . . . . . . . . . . . . 52
tamoxifen . . . . . . . . . . . . . . . . . . . . . . . 38
tamoxifen tab 10mg . . . . . . . . . . . . . . 38
tamoxifen tab 20mg . . . . . . . . . . . . . . 38
tamsulosin cap 0.4mg . . . . . . . . . . . . . 79
TAPAZOLE . . . . . . . . . . . . . . . . . . . . . . . 89
taralafil . . . . . . . . . . . . . . . . . . . . . . . . . 79
TARCEVA TAB 100MG . . . . . . . . . . . . . 42
151
Index of Drugs
TARCEVA TAB 150MG . . . . . . . . . . . . . 42
TARCEVA TAB 25MG . . . . . . . . . . . . . . 42
TARGRETIN CAP 75MG . . . . . . . . . . . . . 42
TARGRETIN GEL 1% . . . . . . . . . . . . . . . 42
TASIGNA CAP 150MG . . . . . . . . . . . . . . 42
TASIGNA CAP 200MG . . . . . . . . . . . . . . 42
tasimelteon . . . . . . . . . . . . . . . . . . . . . 100
TASMAR TAB 100MG . . . . . . . . . . . . . . 44
TAVIST . . . . . . . . . . . . . . . . . . . . . . . . . . 97
TAXOL . . . . . . . . . . . . . . . . . . . . . . . . . . 39
TAXOTERE . . . . . . . . . . . . . . . . . . . . . . . 39
tazarotene . . . . . . . . . . . . . . . . . . . . . . 75
TAZORAC CRE 0.05% . . . . . . . . . . . . . . 75
TAZORAC CRE 0.1% . . . . . . . . . . . . . . . 75
TAZORAC GEL 0.05% . . . . . . . . . . . . . . 75
TAZORAC GEL 0.1% . . . . . . . . . . . . . . . 75
taztia xt cap 120mg/24hr . . . . . . . . . . . 65
taztia xt cap 180mg/24hr . . . . . . . . . . . 65
taztia xt cap 240mg/24hr . . . . . . . . . . . 65
taztia xt cap 300mg/24hr . . . . . . . . . . . 65
taztia xt cap 360mg/24hr . . . . . . . . . . . 65
TAZTIA XT, DILTZAC . . . . . . . . . . . . . . . 64
teduglutide . . . . . . . . . . . . . . . . . . . . . . 77
TEFLARO INJ 400MG . . . . . . . . . . . . . . 19
TEFLARO INJ 600MG . . . . . . . . . . . . . . 19
TEGRETOL . . . . . . . . . . . . . . . . . . . . . . . 26
TEGRETOL XR . . . . . . . . . . . . . . . . . . . . 26
TEGRETOL-XR TAB 100MG . . . . . . . . . . 27
TEKTURNA HCT TAB 150-12.5MG . . . . 68
TEKTURNA HCT TAB 150-25MG . . . . . . 68
TEKTURNA HCT TAB 300-12.5MG . . . . 68
TEKTURNA HCT TAB 300-25MG . . . . . . 68
TEKTURNA TAB 150MG . . . . . . . . . . . . 68
TEKTURNA TAB 300MG . . . . . . . . . . . . 69
telbivudine . . . . . . . . . . . . . . . . . . . . . . 49
telmis/amlod tab 40-10mg . . . . . . . . . . 68
telmis/amlod tab 40-5mg . . . . . . . . . . . 68
telmis/amlod tab 80-10mg . . . . . . . . . . 68
telmis/amlod tab 80-5mg . . . . . . . . . . . 68
telmisa/hctz tab 40-12.5mg . . . . . . . . . 68
telmisa/hctz tab 80-12.5mg . . . . . . . . . 68
telmisa/hctz tab 80-25mg . . . . . . . . . . 68
telmisartan tab 20mg . . . . . . . . . . . . . . 60
telmisartan tab 40mg . . . . . . . . . . . . . . 60
telmisartan tab 80mg . . . . . . . . . . . . . . 61
TENEX . . . . . . . . . . . . . . . . . . . . . . . . . . 60
tenofovir . . . . . . . . . . . . . . . . . . . . . . . . 51
TENORETIC . . . . . . . . . . . . . . . . . . . . . . 66
TENORMIN . . . . . . . . . . . . . . . . . . . . . . 63
TERAZOL, ZAZOLE . . . . . . . . . . . . . . . . 35
terazosin cap 10mg . . . . . . . . . . . . . . . 60
terazosin cap 1mg . . . . . . . . . . . . . . . . 60
terazosin cap 2mg . . . . . . . . . . . . . . . . 60
152
terazosin cap 5mg . . . . . . . . . . . . . . . . 60
terbinafine tab 250mg . . . . . . . . . . . . . 35
terbutaline inj 1mg/ml . . . . . . . . . . . . . 98
terbutaline tab 2.5mg . . . . . . . . . . . . . 98
terbutaline tab 5mg . . . . . . . . . . . . . . . 98
terconazole cre 0.4% . . . . . . . . . . . . . . 35
terconazole cre 0.8% . . . . . . . . . . . . . . 35
terconazole sup 80mg . . . . . . . . . . . . . 35
teriparatide . . . . . . . . . . . . . . . . . . . . . . 93
testost enan inj 200mg/ml . . . . . . . . . . 84
testosterone . . . . . . . . . . . . . . . . . . . . . 84
TET/DIP TOX INJ 2-2 LF . . . . . . . . . . . . . 92
tetrabenazine . . . . . . . . . . . . . . . . . . . . 73
tetrahydrozoline . . . . . . . . . . . . . . . . . 99
TEVETEN . . . . . . . . . . . . . . . . . . . . . . . . 60
thalidomide . . . . . . . . . . . . . . . . . . . . . 38
THALITONE . . . . . . . . . . . . . . . . . . . . . . 70
THALOMID CAP 100MG . . . . . . . . . . . . 38
THALOMID CAP 150MG . . . . . . . . . . . . 38
THALOMID CAP 200MG . . . . . . . . . . . . 38
THALOMID CAP 50MG . . . . . . . . . . . . . 38
THEO-DUR . . . . . . . . . . . . . . . . . . . . . . . 98
THEOCHRON SR . . . . . . . . . . . . . . . . . . 98
theophylline tab 100mg cr . . . . . . . . . 98
theophylline tab 200mg cr . . . . . . . . . 98
theophylline tab 300mg er . . . . . . . . . 98
theophylline tab 400mg er . . . . . . . . . 98
theophylline tab 450mg er . . . . . . . . . 98
theophylline tab 600mg er . . . . . . . . . 98
thioguanine . . . . . . . . . . . . . . . . . . . . . 38
thioridazine tab 100mg . . . . . . . . . . . . 46
thioridazine tab 10mg . . . . . . . . . . . . . 46
thioridazine tab 25mg . . . . . . . . . . . . . 46
thioridazine tab 50mg . . . . . . . . . . . . . 46
thiothixene cap 10mg . . . . . . . . . . . . . 46
thiothixene cap 1mg . . . . . . . . . . . . . . 46
thiothixene cap 2mg . . . . . . . . . . . . . . 46
thiothixene cap 5mg . . . . . . . . . . . . . . 46
THORAZINE . . . . . . . . . . . . . . . . . . . . . . 32
THYMOGLOBULN INJ 25MG . . . . . . . . 91
tiagabine . . . . . . . . . . . . . . . . . . . . . . . . 25
tiagabine tab 2mg . . . . . . . . . . . . . . . . 25
tiagabine tab 4mg . . . . . . . . . . . . . . . . 25
ticagrelor . . . . . . . . . . . . . . . . . . . . . . . 59
TICLID . . . . . . . . . . . . . . . . . . . . . . . . . . 59
ticlopidine tab 250mg . . . . . . . . . . . . . 59
tigecycline . . . . . . . . . . . . . . . . . . . . . . . 17
TIKOSYN CAP 125MCG . . . . . . . . . . . . . 63
TIKOSYN CAP 250MCG . . . . . . . . . . . . . 63
TIKOSYN CAP 500MCG . . . . . . . . . . . . . 63
timolol gel sol 0.25% . . . . . . . . . . . . . . 95
timolol gel sol 0.5% . . . . . . . . . . . . . . . 95
timolol mal sol 0.25% . . . . . . . . . . . . . 95
timolol mal sol 0.5% . . . . . . . . . . . . . . 95
timolol mal tab 10mg . . . . . . . . . . . . . 36
timolol mal tab 20mg . . . . . . . . . . . . . 36
timolol mal tab 5mg . . . . . . . . . . . . . . 36
TIMOPTIC . . . . . . . . . . . . . . . . . . . . . . . 95
TIMOPTIC-XE . . . . . . . . . . . . . . . . . . . . . 95
TINDAMAX . . . . . . . . . . . . . . . . . . . . . . 17
tinidazole tab 250mg . . . . . . . . . . . . . . 17
tinidazole tab 500mg . . . . . . . . . . . . . . 17
tiotropium . . . . . . . . . . . . . . . . . . . . . . 97
tipranavir . . . . . . . . . . . . . . . . . . . . . . . 52
TIVICAY TAB 50MG . . . . . . . . . . . . . . . . 51
tizanidine cap 2mg . . . . . . . . . . . . . . . . 48
tizanidine cap 4mg . . . . . . . . . . . . . . . . 48
tizanidine cap 6mg . . . . . . . . . . . . . . . . 48
tizanidine tab 2mg . . . . . . . . . . . . . . . . 48
tizanidine tab 4mg . . . . . . . . . . . . . . . . 48
TOBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
TOBI PODHALR CAP 28MG . . . . . . . . . 98
tobra/dexame sus 0.3-0.1% . . . . . . . . . 94
TOBRADEX . . . . . . . . . . . . . . . . . . . . . . 94
TOBRADEX OIN 0.3-0.1% . . . . . . . . . . . 16
tobramycin . . . . . . . . . . . . . . . . . . . . . . 16
tobramycin - dexamethasone . . . . . . . 16
tobramycin inhalant powder . . . . . . . . 98
tobramycin inj 10mg/ml . . . . . . . . . . . . 16
tobramycin inj 80mg/2ml . . . . . . . . . . . 16
tobramycin neb 300/5ml . . . . . . . . . . . 16
tobramycin sol 0.3% . . . . . . . . . . . . . . 16
TOBREX . . . . . . . . . . . . . . . . . . . . . . . . . 16
tofacitinib . . . . . . . . . . . . . . . . . . . . . . . 90
TOFRANIL . . . . . . . . . . . . . . . . . . . . . . . 32
tolazamide . . . . . . . . . . . . . . . . . . . . . . 55
tolazamide tab 250mg . . . . . . . . . . . . . 55
tolazamide tab 500mg . . . . . . . . . . . . . 55
tolbutamide tab 500mg . . . . . . . . . . . . 55
tolcapone . . . . . . . . . . . . . . . . . . . . . . . 44
TOLECTIN . . . . . . . . . . . . . . . . . . . . . . . 12
TOLECTIN DS . . . . . . . . . . . . . . . . . . . . . 12
tolmetin sod cap 400mg . . . . . . . . . . . 12
tolmetin sod tab 600mg . . . . . . . . . . . 12
tolterodine cap 2mg er . . . . . . . . . . . . 79
tolterodine cap 4mg er . . . . . . . . . . . . 79
tolterodine tab 1mg . . . . . . . . . . . . . . . 79
tolterodine tab 2mg . . . . . . . . . . . . . . . 79
TOPAMAX . . . . . . . . . . . . . . . . . . . . . . . 26
TOPICORT . . . . . . . . . . . . . . . . . . . . . . . 80
topiramate . . . . . . . . . . . . . . . . . . . . . . 26
topiramate cap 15mg . . . . . . . . . . . . . . 26
topiramate cap 25mg . . . . . . . . . . . . . . 26
topiramate tab 100mg . . . . . . . . . . . . . 26
topiramate tab 200mg . . . . . . . . . . . . . 26
topiramate tab 25mg . . . . . . . . . . . . . . 26
Index of Drugs
topiramate tab 50mg . . . . . . . . . . . . . . 26
toposar inj 1gm/50ml . . . . . . . . . . . . . . 40
topotecan inj 4mg . . . . . . . . . . . . . . . . 40
TOPROL XL . . . . . . . . . . . . . . . . . . . . . . 63
toremifene . . . . . . . . . . . . . . . . . . . . . . 38
torsemide tab 100mg . . . . . . . . . . . . . . 69
torsemide tab 10mg . . . . . . . . . . . . . . . 69
torsemide tab 20mg . . . . . . . . . . . . . . . 69
torsemide tab 5mg . . . . . . . . . . . . . . . . 69
TOVIAZ TAB 4MG . . . . . . . . . . . . . . . . . 79
TOVIAZ TAB 8MG . . . . . . . . . . . . . . . . . 79
tpn electrol . . . . . . . . . . . . . . . . . . . . . 102
tpn multilyte . . . . . . . . . . . . . . . . . . . . 102
TRACLEER TAB 125MG . . . . . . . . . . . . . 99
TRACLEER TAB 62.5MG . . . . . . . . . . . . 99
tramadl/apap tab 37.5-325mg . . . . . . . 11
tramadol hcl tab 100mg er . . . . . . . . . 13
tramadol hcl tab 200mg er . . . . . . . . . 13
tramadol hcl tab 300mg er . . . . . . . . . 13
tramadol hcl tab 50mg . . . . . . . . . . . . 14
trametinib . . . . . . . . . . . . . . . . . . . . . . . 41
TRANDATE . . . . . . . . . . . . . . . . . . . . . . 63
trandolapril tab 1mg . . . . . . . . . . . . . . 62
trandolapril tab 2mg . . . . . . . . . . . . . . 62
trandolapril tab 4mg . . . . . . . . . . . . . . 62
tranex acid tab 650mg . . . . . . . . . . . . . 59
tranexamic acid . . . . . . . . . . . . . . . . . . 59
TRANSDERM-SC DIS 1.5MG . . . . . . . . . 33
TRANXENE . . . . . . . . . . . . . . . . . . . . . . 24
tranylcyprom tab 10mg . . . . . . . . . . . . 29
trastuzumab . . . . . . . . . . . . . . . . . . . . . 39
travasol . . . . . . . . . . . . . . . . . . . . . . . . 102
TRAVASOL INJ 10% . . . . . . . . . . . . . . 102
trazodone tab 100mg . . . . . . . . . . . . . 31
trazodone tab 150mg . . . . . . . . . . . . . 31
trazodone tab 300mg . . . . . . . . . . . . . 31
trazodone tab 50mg . . . . . . . . . . . . . . 31
TREANDA INJ 100MG . . . . . . . . . . . . . . 40
TREANDA INJ 45/0.5ML . . . . . . . . . . . . 40
TRECATOR TAB 250MG . . . . . . . . . . . . 37
TRELSTAR DEP INJ 3.75MG . . . . . . . . . . 89
TRELSTAR LA INJ 11.25MG . . . . . . . . . . 89
TRELSTAR MIX INJ 22.5MG . . . . . . . . . 89
TRENTAL . . . . . . . . . . . . . . . . . . . . . . . . 68
treprostinil . . . . . . . . . . . . . . . . . . . . . . 99
tretinoin cap 10mg . . . . . . . . . . . . . . . . 42
tretinoin cre 0.025% . . . . . . . . . . . . . . 75
tretinoin cre 0.05% . . . . . . . . . . . . . . . 75
tretinoin cre 0.1% . . . . . . . . . . . . . . . . 75
tretinoin gel 0.01% . . . . . . . . . . . . . . . 75
tretinoin gel 0.025% . . . . . . . . . . . . . . 75
tretinoin gel 0.04% . . . . . . . . . . . . . . . 75
tretinoin gel 0.1% . . . . . . . . . . . . . . . . 75
TREXALL . . . . . . . . . . . . . . . . . . . . . . . . 90
TREXALL TAB 10MG . . . . . . . . . . . . . . . 90
TREXALL TAB 15MG . . . . . . . . . . . . . . . 90
TREXALL TAB 5MG . . . . . . . . . . . . . . . . 90
TREXALL TAB 7.5MG . . . . . . . . . . . . . . 90
tri-legest tab fe . . . . . . . . . . . . . . . . . . . 86
tri-previfem . . . . . . . . . . . . . . . . . . . . . . 86
tri-sprintec . . . . . . . . . . . . . . . . . . . . . . 86
triamcin/ora pst 0.1% . . . . . . . . . . . . . . 74
triamcinolon cre 0.025% . . . . . . . . . . . 82
triamcinolon cre 0.1% . . . . . . . . . . . . . 82
triamcinolon cre 0.5% . . . . . . . . . . . . . 82
triamcinolon lot 0.025% . . . . . . . . . . . 82
triamcinolon lot 0.1% . . . . . . . . . . . . . 82
triamcinolon oin 0.025% . . . . . . . . . . . 82
triamcinolon oin 0.1% . . . . . . . . . . . . . 82
triamcinolon oin 0.5% . . . . . . . . . . . . . 82
triamcinolon spr 55mcg/ac . . . . . . . . . . 83
triamcinolone . . . . . . . . . . . . . . . . . . . . 82
triamt/hctz cap 37.5-25mg . . . . . . . . . . 68
triamt/hctz cap 50-25mg . . . . . . . . . . . 68
triamt/hctz tab 37.5-25mg . . . . . . . . . . 68
triamt/hctz tab 75-50mg . . . . . . . . . . . 68
TRICOR . . . . . . . . . . . . . . . . . . . . . . . . . 70
triderm cre 0.1% . . . . . . . . . . . . . . . . . 83
trientine . . . . . . . . . . . . . . . . . . . . . . . 101
trifluoperaz tab 10mg . . . . . . . . . . . . . 46
trifluoperaz tab 1mg . . . . . . . . . . . . . . 46
trifluoperaz tab 2mg . . . . . . . . . . . . . . 46
trifluoperaz tab 5mg . . . . . . . . . . . . . . 46
trifluridine sol 1% . . . . . . . . . . . . . . . . 53
trihexyphen elx 0.4mg/ml . . . . . . . . . . 43
trihexyphen tab 2mg . . . . . . . . . . . . . . 44
trihexyphen tab 5mg . . . . . . . . . . . . . . 44
TRILAFON . . . . . . . . . . . . . . . . . . . . . . . 33
TRILEPTAL . . . . . . . . . . . . . . . . . . . . . . . 27
TRILIPIX . . . . . . . . . . . . . . . . . . . . . . . . . 70
trilyte sol . . . . . . . . . . . . . . . . . . . . . . . . 77
TRILYTE, GAVILYTE-N . . . . . . . . . . . . . . 77
trimethoprim . . . . . . . . . . . . . . . . . . . . 17
trimethoprim tab 100mg . . . . . . . . . . . 17
trimipramine . . . . . . . . . . . . . . . . . . . . . 32
TRIPLE ANTIBIOTIC . . . . . . . . . . . . . . . . 94
triptorelin . . . . . . . . . . . . . . . . . . . . . . . 89
TRISENOX SOL 10MG/10ML . . . . . . . . . 40
TRIUMEQ TAB . . . . . . . . . . . . . . . . . . . . 51
trivora-28 . . . . . . . . . . . . . . . . . . . . . . . 86
TRIZIVIR . . . . . . . . . . . . . . . . . . . . . . . . . 50
TROKENDI XR CAP 100MG . . . . . . . . . . 26
TROKENDI XR CAP 200MG . . . . . . . . . . 26
TROKENDI XR CAP 25MG . . . . . . . . . . . 26
TROKENDI XR CAP 50MG . . . . . . . . . . . 26
trophamine . . . . . . . . . . . . . . . . . . . . . 102
TROPHAMINE INJ 10% . . . . . . . . . . . . 102
TRULICITY INJ 0.75/0.5ML . . . . . . . . . . 55
TRULICITY INJ 1.5/0.5ML . . . . . . . . . . . 55
TRUMENBA INJ . . . . . . . . . . . . . . . . . . . 92
TRUSOPT . . . . . . . . . . . . . . . . . . . . . . . . 95
TRUVADA TAB 200-300MG . . . . . . . . . 51
TUBIZID . . . . . . . . . . . . . . . . . . . . . . . . . 36
TWINRIX INJ . . . . . . . . . . . . . . . . . . . . . 92
TWYNSTA . . . . . . . . . . . . . . . . . . . . . . . 68
TYBOST TAB 150MG . . . . . . . . . . . . . . . 50
TYGACIL INJ 50MG . . . . . . . . . . . . . . . . 17
TYKERB TAB 250MG . . . . . . . . . . . . . . . 42
TYLENOL WITH CODEINE . . . . . . . . . . . 10
TYLENOL WITH CODEINE SOLN . . . . . . 10
TYPHIM VI INJ . . . . . . . . . . . . . . . . . . . . 92
typhoid vi polysaccharide vaccine . . . . 92
TYSABRI INJ 300/15ML . . . . . . . . . . . . . 73
TYZEKA TAB 600MG . . . . . . . . . . . . . . . 49
TYZINE PED DRO 0.05% . . . . . . . . . . . . 99
U
ULTRAM . . . . . . . . . . . . . . . . . . . . . . . . 14
ULTRAM ER . . . . . . . . . . . . . . . . . . . . . . 13
ULTRAVATE . . . . . . . . . . . . . . . . . . . . . . 81
ULTRCET . . . . . . . . . . . . . . . . . . . . . . . . 11
uman papillomavirus - quadrivalent . . 91
hpv (6,11,16,18) vac
UNASYN . . . . . . . . . . . . . . . . . . . . . . . . 20
UNIRETIC . . . . . . . . . . . . . . . . . . . . . . . . 67
UNIVASC . . . . . . . . . . . . . . . . . . . . . . . . 61
URECHOLINE . . . . . . . . . . . . . . . . . . . . . 79
URISPAS . . . . . . . . . . . . . . . . . . . . . . . . . 79
UROCIT-K . . . . . . . . . . . . . . . . . . . . . . 101
UROXATRAL . . . . . . . . . . . . . . . . . . . . . 79
URSO 250 . . . . . . . . . . . . . . . . . . . . . . . 77
URSO FORTE . . . . . . . . . . . . . . . . . . . . . 77
ursodiol cap 300mg . . . . . . . . . . . . . . . 77
ursodiol tab 250mg . . . . . . . . . . . . . . . 77
ursodiol tab 500mg . . . . . . . . . . . . . . . 77
UVADEX INJ 20MCG/ML . . . . . . . . . . . . 75
V
valacyclovir tab 1gm . . . . . . . . . . . . . . 53
valacyclovir tab 500mg . . . . . . . . . . . . 53
VALCHLOR GEL 0.016% . . . . . . . . . . . . 75
VALCYTE . . . . . . . . . . . . . . . . . . . . . . . . 48
VALCYTE SOL 50MG/ML . . . . . . . . . . . . 48
valganciclov tab 450mg . . . . . . . . . . . . 48
valganciclovir . . . . . . . . . . . . . . . . . . . . 48
VALIUM . . . . . . . . . . . . . . . . . . . . . . . . . 24
valproate inj 100mg/ml . . . . . . . . . . . . 25
valproic acd cap 250mg . . . . . . . . . . . . 25
valproic acd syp 250/5ml . . . . . . . . . . . 25
153
Index of Drugs
valsart/hctz tab 160-12.5mg . . . . . . . . 68
valsart/hctz tab 160-25mg . . . . . . . . . . 68
valsart/hctz tab 320-12.5mg . . . . . . . . 68
valsart/hctz tab 320-25mg . . . . . . . . . . 68
valsart/hctz tab 80-12.5mg . . . . . . . . . 68
valsartan tab 160mg . . . . . . . . . . . . . . 61
valsartan tab 320mg . . . . . . . . . . . . . . 61
valsartan tab 40mg . . . . . . . . . . . . . . . 61
valsartan tab 80mg . . . . . . . . . . . . . . . 61
VALTREX . . . . . . . . . . . . . . . . . . . . . . . . 53
VANCOCIN . . . . . . . . . . . . . . . . . . . . . . 17
VANCOMYCIN . . . . . . . . . . . . . . . . . . . 17
vancomycin cap 125mg . . . . . . . . . . . . 17
vancomycin cap 250mg . . . . . . . . . . . . 17
vancomycin inj 1000mg . . . . . . . . . . . . 17
vancomycin inj 10gm . . . . . . . . . . . . . . 17
vancomycin inj 500mg . . . . . . . . . . . . . 17
vandetanib . . . . . . . . . . . . . . . . . . . . . . 41
VANTIN . . . . . . . . . . . . . . . . . . . . . . . . . 18
VAQTA INJ 25/0.5ML . . . . . . . . . . . . . . 92
VAQTA INJ 50UNT/ML . . . . . . . . . . . . . 92
varenicline . . . . . . . . . . . . . . . . . . . . . . 15
varicella virus vaccine . . . . . . . . . . . . . . 92
varicella zoster immune globulin . . . . 92
varicella-zoster virus vaccine . . . . . . . . 92
VARIVAX INJ . . . . . . . . . . . . . . . . . . . . . 92
VARIZIG 125 UNIT . . . . . . . . . . . . . . . . . 92
VASERETIC . . . . . . . . . . . . . . . . . . . . . . 67
VASOTEC . . . . . . . . . . . . . . . . . . . . . . . . 61
VECTIBIX INJ 100MG . . . . . . . . . . . . . . 40
VEETIDS . . . . . . . . . . . . . . . . . . . . . . . . . 20
velaglucerase alfa . . . . . . . . . . . . . . . . . 76
VELCADE INJ 3.5MG . . . . . . . . . . . . . . . 40
velivet pak . . . . . . . . . . . . . . . . . . . . . . 86
vemurafenib . . . . . . . . . . . . . . . . . . . . . 42
venlafaxine cap 150mg er . . . . . . . . . . 31
venlafaxine cap 37.5mg . . . . . . . . . . . . 31
venlafaxine cap 75mg er . . . . . . . . . . . 31
venlafaxine tab 100mg . . . . . . . . . . . . 31
venlafaxine tab 150mg er . . . . . . . . . . 31
venlafaxine tab 225mg er . . . . . . . . . . 31
venlafaxine tab 25mg . . . . . . . . . . . . . 31
venlafaxine tab 37.5 er . . . . . . . . . . . . 31
venlafaxine tab 37.5mg . . . . . . . . . . . . 31
venlafaxine tab 50mg . . . . . . . . . . . . . 31
venlafaxine tab 75mg . . . . . . . . . . . . . 31
venlafaxine tab 75mg er . . . . . . . . . . . 31
VENTOLIN HFA AER . . . . . . . . . . . . . . . 98
VENTOLIN NEB . . . . . . . . . . . . . . . . . . . 97
VEPESID . . . . . . . . . . . . . . . . . . . . . . . . . 40
VERAMYST SPR 27.5MCG . . . . . . . . . . . 96
verapamil cap 100mg er . . . . . . . . . . . 65
verapamil cap 120mg er . . . . . . . . . . . 65
154
verapamil cap 180mg er . . . . . . . . . . . 65
verapamil cap 200mg er . . . . . . . . . . . 65
verapamil cap 240mg er . . . . . . . . . . . 65
verapamil cap 300mg er . . . . . . . . . . . 65
verapamil cap 360mg sr . . . . . . . . . . . . 65
verapamil inj 2.5mg/ml . . . . . . . . . . . . 65
verapamil tab 120mg . . . . . . . . . . . . . . 65
verapamil tab 120mg er . . . . . . . . . . . . 65
verapamil tab 180mg er . . . . . . . . . . . . 65
verapamil tab 240mg er . . . . . . . . . . . . 65
verapamil tab 40mg . . . . . . . . . . . . . . . 65
verapamil tab 80mg . . . . . . . . . . . . . . . 65
VERELAN . . . . . . . . . . . . . . . . . . . . . . . . 65
VERELAN PM . . . . . . . . . . . . . . . . . . . . . 65
VERSACLOZ SUS 50MG/ML . . . . . . . . . 48
VESANOID . . . . . . . . . . . . . . . . . . . . . . . 42
vestura tab 3-0.02mg . . . . . . . . . . . . . . 86
VEXOL SUS 1% . . . . . . . . . . . . . . . . . . . 95
VFEND . . . . . . . . . . . . . . . . . . . . . . . . . . 35
VIAGRA TAB 100MG . . . . . . . . . . . . . . . 79
VIAGRA TAB 25MG . . . . . . . . . . . . . . . . 79
VIAGRA TAB 50MG . . . . . . . . . . . . . . . . 79
vibramycin . . . . . . . . . . . . . . . . . . . . . . 22
VIBRATAB . . . . . . . . . . . . . . . . . . . . . . . 22
vicodin es tab 7.5-300mg . . . . . . . . . . . 11
vicodin hp tab 10-300mg . . . . . . . . . . . 11
vicodin tab 5-300mg . . . . . . . . . . . . . . 11
VICOPROFEN . . . . . . . . . . . . . . . . . . . . . 10
VIDAZA . . . . . . . . . . . . . . . . . . . . . . . . . 38
VIDEX EC . . . . . . . . . . . . . . . . . . . . . . . . 51
VIDEX SOL 2GM . . . . . . . . . . . . . . . . . . 51
VIEKIRA PAK TAB . . . . . . . . . . . . . . . . . 50
vigabatrin . . . . . . . . . . . . . . . . . . . . . . . 25
VIGAMOX DRO 0.5% . . . . . . . . . . . . . . 22
VIIBRYD KIT . . . . . . . . . . . . . . . . . . . . . 31
VIIBRYD TAB 10MG . . . . . . . . . . . . . . . 31
VIIBRYD TAB 20MG . . . . . . . . . . . . . . . 31
VIIBRYD TAB 40MG . . . . . . . . . . . . . . . 31
vilazodone . . . . . . . . . . . . . . . . . . . . . . 31
VIMPAT INJ 200MG/20ML . . . . . . . . . . 27
VIMPAT SOL 10MG/ML . . . . . . . . . . . . . 27
VIMPAT TAB 100MG . . . . . . . . . . . . . . . 27
VIMPAT TAB 150MG . . . . . . . . . . . . . . . 27
VIMPAT TAB 200MG . . . . . . . . . . . . . . . 27
VIMPAT TAB 50MG . . . . . . . . . . . . . . . . 27
vinblastine . . . . . . . . . . . . . . . . . . . . . . 40
VINBLASTINE INJ 10MG . . . . . . . . . . . . 40
VINCASAR . . . . . . . . . . . . . . . . . . . . . . . 40
vincasar pfs inj 1mg/ml . . . . . . . . . . . . 40
vincristine . . . . . . . . . . . . . . . . . . . . . . . 40
vincristine inj 1mg/ml . . . . . . . . . . . . . . 40
vinorelbine inj 10mg/ml . . . . . . . . . . . . 40
VIRACEPT TAB 250MG . . . . . . . . . . . . . 52
VIRACEPT TAB 625MG . . . . . . . . . . . . . 52
VIRAMUNE . . . . . . . . . . . . . . . . . . . . . . 50
VIRAMUNE SUS 50MG/5ML . . . . . . . . . 50
VIRAMUNE XR . . . . . . . . . . . . . . . . . . . 50
VIRAMUNE XR TAB 100MG . . . . . . . . . 50
VIRAZOLE INH 6GM . . . . . . . . . . . . . . . 53
VIREAD POW 40MG/GM . . . . . . . . . . . 51
VIREAD TAB 150MG . . . . . . . . . . . . . . . 51
VIREAD TAB 200MG . . . . . . . . . . . . . . . 51
VIREAD TAB 250MG . . . . . . . . . . . . . . . 51
VIREAD TAB 300MG . . . . . . . . . . . . . . . 51
VIROPTIC . . . . . . . . . . . . . . . . . . . . . . . . 53
VISKEN . . . . . . . . . . . . . . . . . . . . . . . . . 63
vismodegib . . . . . . . . . . . . . . . . . . . . . . 41
VISTARIL . . . . . . . . . . . . . . . . . . . . . . . . 53
VITEKTA TAB 150MG . . . . . . . . . . . . . . 51
VITEKTA TAB 85MG . . . . . . . . . . . . . . . 51
VIVACTIL . . . . . . . . . . . . . . . . . . . . . . . . 32
VIVITROL INJ 380MG . . . . . . . . . . . . . . 14
VOLTAREN . . . . . . . . . . . . . . . . . . . . . . . 11
VOLTAREN - XR . . . . . . . . . . . . . . . . . . . 11
voriconazole inj 200mg . . . . . . . . . . . . 35
voriconazole sus 40mg/ml . . . . . . . . . . 35
voriconazole tab 200mg . . . . . . . . . . . 35
voriconazole tab 50mg . . . . . . . . . . . . 35
vorinostat . . . . . . . . . . . . . . . . . . . . . . . 40
vortioxetine . . . . . . . . . . . . . . . . . . . . . 29
VOSPIRE ER . . . . . . . . . . . . . . . . . . . . . . 97
VOSPIRE ER TAB 4MG . . . . . . . . . . . . . . 98
VOSPIRE ER TAB 8MG . . . . . . . . . . . . . . 98
VOTRIENT TAB 200MG . . . . . . . . . . . . . 42
VPRIV INJ 400UNIT . . . . . . . . . . . . . . . . 76
VYTORIN TAB 10-10MG . . . . . . . . . . . . 68
VYTORIN TAB 10-20MG . . . . . . . . . . . . 68
VYTORIN TAB 10-40MG . . . . . . . . . . . . 68
VYTORIN TAB 10-80MG . . . . . . . . . . . . 68
W
warfarin . . . . . . . . . . . . . . . . . . . . . . . . 56
warfarin tab 10mg . . . . . . . . . . . . . . . . 58
warfarin tab 1mg . . . . . . . . . . . . . . . . . 58
warfarin tab 2.5mg . . . . . . . . . . . . . . . 58
warfarin tab 2mg . . . . . . . . . . . . . . . . . 58
warfarin tab 3mg . . . . . . . . . . . . . . . . . 58
warfarin tab 4mg . . . . . . . . . . . . . . . . . 58
warfarin tab 5mg . . . . . . . . . . . . . . . . . 58
warfarin tab 6mg . . . . . . . . . . . . . . . . . 58
warfarin tab 7.5mg . . . . . . . . . . . . . . . 58
WELCHOL PAK 3.75GM . . . . . . . . . . . . 55
WELCHOL TAB 625MG . . . . . . . . . . . . . 55
WELLBUTRIN . . . . . . . . . . . . . . . . . . . . . 15
WELLBUTRIN SR, BUDEPRION SR . . . . . 15
WELLBUTRIN XL . . . . . . . . . . . . . . . . . . 15
Index of Drugs
X
XALATAN . . . . . . . . . . . . . . . . . . . . . . . 96
XALKORI CAP 200MG . . . . . . . . . . . . . . 42
XALKORI CAP 250MG . . . . . . . . . . . . . . 42
XANAX . . . . . . . . . . . . . . . . . . . . . . . . . 53
XANAX XR . . . . . . . . . . . . . . . . . . . . . . 53
XARELTO STAR TAB 15/20MG . . . . . . . 58
XARELTO TAB 10MG . . . . . . . . . . . . . . 58
XARELTO TAB 15MG . . . . . . . . . . . . . . 58
XARELTO TAB 20MG . . . . . . . . . . . . . . 58
XELJANZ TAB 5MG . . . . . . . . . . . . . . . . 90
XENAZINE TAB 12.5MG . . . . . . . . . . . . 73
XENAZINE TAB 25MG . . . . . . . . . . . . . . 73
XGEVA INJ . . . . . . . . . . . . . . . . . . . . . . . 94
XIBROM . . . . . . . . . . . . . . . . . . . . . . . . . 95
XODOL . . . . . . . . . . . . . . . . . . . . . . . . . 10
XODOL TAB 10-300MG . . . . . . . . . . . . 11
XODOL TAB 5-300MG . . . . . . . . . . . . . 11
XODOL TAB 7.5-300MG . . . . . . . . . . . . 11
XOLAIR SOL 150MG . . . . . . . . . . . . . . . 99
XTANDI CAP 40MG . . . . . . . . . . . . . . . . 37
xylocaine . . . . . . . . . . . . . . . . . . . . . . . . 14
XYREM SOL 500MG/ML . . . . . . . . . . . 100
XYZAL . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Y
yellow fever vaccine . . . . . . . . . . . . . . . 92
YERVOY INJ 50MG . . . . . . . . . . . . . . . . 40
YF-VAX INJ . . . . . . . . . . . . . . . . . . . . . . 92
Z
zafirlukast tab 10mg . . . . . . . . . . . . . . 97
zafirlukast tab 20mg . . . . . . . . . . . . . . 97
zaleplon cap 10mg . . . . . . . . . . . . . . . 100
zaleplon cap 5mg . . . . . . . . . . . . . . . . 100
ZALTRAP INJ 100/4ML . . . . . . . . . . . . . 40
ZANAFLEX . . . . . . . . . . . . . . . . . . . . . . . 48
zanamivir . . . . . . . . . . . . . . . . . . . . . . . 52
ZANOSAR INJ 1GM . . . . . . . . . . . . . . . . 40
ZANTAC . . . . . . . . . . . . . . . . . . . . . . . . . 77
ZARONTIN . . . . . . . . . . . . . . . . . . . . . . . 23
ZAROXOLYN . . . . . . . . . . . . . . . . . . . . . 70
ZAVESCA CAP 100MG . . . . . . . . . . . . . 76
zazole cre 0.4% . . . . . . . . . . . . . . . . . . 35
ZEBETA . . . . . . . . . . . . . . . . . . . . . . . . . 63
ZELBORAF TAB 240MG . . . . . . . . . . . . . 42
ZEMAIRA INJ 1000MG . . . . . . . . . . . . . 99
ZEMPLAR INJ 2MCG/ML . . . . . . . . . . . . 94
ZEMPLAR INJ 5MCG/ML . . . . . . . . . . . . 94
zenatane cap 10mg . . . . . . . . . . . . . . . 75
zenatane cap 20mg . . . . . . . . . . . . . . . 75
zenatane cap 40mg . . . . . . . . . . . . . . . 75
ZENPEP CAP 10000UNT . . . . . . . . . . . . 76
ZENPEP CAP 15000UNT . . . . . . . . . . . . 76
ZENPEP CAP 20000UNT . . . . . . . . . . . . 76
ZENPEP CAP 25000UNT . . . . . . . . . . . . 77
ZENPEP CAP 3000UNIT . . . . . . . . . . . . . 77
ZENPEP CAP 40000UNT . . . . . . . . . . . . 77
ZENPEP CAP 5000UNIT . . . . . . . . . . . . . 76
ZERIT . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
ZESTORETIC, PRINZIDE . . . . . . . . . . . . . 67
ZESTRIL, PRINIVIL . . . . . . . . . . . . . . . . . 61
ZETIA TAB 10MG . . . . . . . . . . . . . . . . . 71
ZIAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
ZIAGEN . . . . . . . . . . . . . . . . . . . . . . . . . 50
ZIAGEN SOL 20MG/ML . . . . . . . . . . . . . 51
zidovudine . . . . . . . . . . . . . . . . . . . . . . 51
zidovudine cap 100mg . . . . . . . . . . . . . 51
zidovudine syp 50mg/5ml . . . . . . . . . . 51
zidovudine tab 300mg . . . . . . . . . . . . . 51
zileuton . . . . . . . . . . . . . . . . . . . . . . . . . 97
zileuton er . . . . . . . . . . . . . . . . . . . . . . 97
ZINACEF . . . . . . . . . . . . . . . . . . . . . . . . 18
ziprasidone . . . . . . . . . . . . . . . . . . . . . . 46
ziprasidone cap 20mg . . . . . . . . . . . . . 47
ziprasidone cap 40mg . . . . . . . . . . . . . 47
ziprasidone cap 60mg . . . . . . . . . . . . . 47
ziprasidone cap 80mg . . . . . . . . . . . . . 47
ZIRGAN GEL 0.15% . . . . . . . . . . . . . . . . 48
ZITHROMAX . . . . . . . . . . . . . . . . . . . . . 20
ziv-aflibercept . . . . . . . . . . . . . . . . . . . . 40
ZMAX SUS 2GM . . . . . . . . . . . . . . . . . . 21
ZOCOR . . . . . . . . . . . . . . . . . . . . . . . . . . 71
ZOFRAN . . . . . . . . . . . . . . . . . . . . . . . . . 33
ZOFRAN ODT . . . . . . . . . . . . . . . . . . . . 33
zoledronic inj 4mg/5ml . . . . . . . . . . . . 94
zoledronic inj 5/100ml . . . . . . . . . . . . . 94
ZOLINZA CAP 100MG . . . . . . . . . . . . . . 40
ZOLOFT . . . . . . . . . . . . . . . . . . . . . . . . . 31
zolpidem er tab 12.5mg . . . . . . . . . . . 100
zolpidem er tab 6.25mg . . . . . . . . . . . 100
zolpidem tab 10mg . . . . . . . . . . . . . . 100
zolpidem tab 5mg . . . . . . . . . . . . . . . 100
ZOMETA . . . . . . . . . . . . . . . . . . . . . . . . 94
ZONEGRAN . . . . . . . . . . . . . . . . . . . . . . 23
zonisamide cap 100mg . . . . . . . . . . . . 23
zonisamide cap 25mg . . . . . . . . . . . . . 24
zonisamide cap 50mg . . . . . . . . . . . . . 24
ZORBTIVE INJ 8.8MG . . . . . . . . . . . . . . 77
ZORTRESS TAB 0.25MG . . . . . . . . . . . . 90
ZORTRESS TAB 0.5MG . . . . . . . . . . . . . 90
ZORTRESS TAB 0.75MG . . . . . . . . . . . . 91
ZOSTAVAX INJ . . . . . . . . . . . . . . . . . . . 92
ZOSYN . . . . . . . . . . . . . . . . . . . . . . . . . . 20
ZOSYN SOL 2-0.25GM . . . . . . . . . . . . . 20
ZOSYN SOL 3-0.375GM . . . . . . . . . . . . 20
zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . 86
zovia 1/50e . . . . . . . . . . . . . . . . . . . . . . 86
ZOVIRAX . . . . . . . . . . . . . . . . . . . . . . . . 52
ZOVIRAX CRE 5% . . . . . . . . . . . . . . . . . 53
ZYDELIG TAB 100MG . . . . . . . . . . . . . . 42
ZYDELIG TAB 150MG . . . . . . . . . . . . . . 42
ZYFLO CR TAB 600MG . . . . . . . . . . . . . 97
ZYFLO TAB 600MG . . . . . . . . . . . . . . . . 97
ZYKADIA CAP 150MG . . . . . . . . . . . . . 42
ZYLOPRIM . . . . . . . . . . . . . . . . . . . . . . . 35
ZYPREXA . . . . . . . . . . . . . . . . . . . . . . . . 47
ZYPREXA RELP INJ 210MG . . . . . . . . . . 47
ZYPREXA ZYDIS . . . . . . . . . . . . . . . . . . 47
ZYRTEC . . . . . . . . . . . . . . . . . . . . . . . . . 97
ZYTIGA TAB 250MG . . . . . . . . . . . . . . . 37
ZYVOX . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ZYVOX SUS 100MG/5ML . . . . . . . . . . . 17
ZYVOX TAB 600MG . . . . . . . . . . . . . . . 17
155
It’s Personal.
866-632-7890
TTY/TDD 866-706-4757
7:30 am to 8 pm, 7 days a week.
300 S. Park Avenue
P.O. Box 6002, Pomona, CA 91769-6002
www.ivhp.com
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MED317 DPC 09/15