2016 Cigna
COMPREHENSIVE DRUG LIST
(Formulary)
Please read: This document contains information about
all of the drugs we cover in this plan.
Plans covered
Cigna-HealthSpring Preferred (HMO)
Cigna-HealthSpring Preferred Plus (HMO)
Cigna-HealthSpring Achieve Plus (HMO SNP)
This drug list was updated on September 1, 2016. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when
necessary. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m.,
hours apply Monday – Friday, February 15 – September 30, or visit www.CignaHealthSpring.com. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and
PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.
HPMS Approved Formulary File Submission ID 16158, Version Number 16
Y0036_16_32224c_Final_3h Approved 08102015
Note to existing customers: This drug list has changed since last year. Please review this document to make sure
that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Cigna. When it refers to “plan” or “our plan,”
it means Cigna-HealthSpring Preferred (HMO), Cigna-HealthSpring Preferred Plus (HMO) and Cigna-HealthSpring
Achieve Plus (HMO SNP).
This document includes a list of the drugs (formulary) for our plans, which is current as of September 2016. For an
updated formulary, please contact us. Our contact information, along with the date we last updated the formulary,
appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy
network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year.
What is the Cigna Comprehensive Drug List?
A drug list is a list of covered drugs selected by Cigna in
consultation with a team of health care providers, which
represents the prescription therapies believed to be a necessary
part of a quality treatment program. Cigna will generally
cover the drugs listed in our drug list as long as the drug
is medically necessary, the prescription is filled at a Cigna
network pharmacy, and other plan rules are followed. For more
information on how to fill your prescriptions, please review your
Evidence of Coverage.
of the drug, at which time the customer will receive a 60-day
supply of the drug. If the Food and Drug Administration deems
a drug on our drug list to be unsafe or the drug’s manufacturer
removes the drug from the market, we will immediately remove
the drug from our drug list and provide notice to customers who
take the drug. The enclosed drug list is current as of September
2016. To get updated information about the drugs covered by
Cigna, please contact us. Our contact information appears on
the front and back cover pages. If there are significant changes
made to the printed drug list within the covered year, you may
be notified by mail identifying the changes. Drug lists located on
our website are reviewed and updated on a monthly basis.
Can the Drug List (formulary) change?
Generally, if you are taking a drug on our 2016 drug list that was
covered at the beginning of the year, we will not discontinue
or reduce coverage of the drug during the 2016 coverage year
except when a new, less expensive generic drug becomes
available or when new adverse information about the safety
or effectiveness of a drug is released. Other types of drug list
changes, such as removing a drug from our drug list, will not
affect customers who are currently taking the drug. It will remain
available at the same cost-sharing for those customers taking
it for the remainder of the coverage year. We feel it is important
that you have continued access for the remainder of the
coverage year to the drugs that were available when you chose
our plan, except for cases in which you can save additional
money or we can ensure your safety.
How do I use the Drug List?
There are two ways to find your drug within the drug list:
Medical Condition
The drug list begins on page 7. The drugs in this drug list are
grouped into categories depending on the type of medical
conditions that they are used to treat. For example, drugs
used to treat a heart condition are listed under the category,
“CARDIOVASCULAR AGENTS”. If you know what your drug
is used for, look for the category name in the list that begins on
page 7. Then look under the category name for your drug.
Covered Drug Index
If you are not sure what category to look under, you should look
for your drug in the Covered Drugs Index section that begins on
page 50. The Covered Drugs Index provides a list of all of the
drugs included in this document. Both brand name drugs and
generic drugs are in the Drug List.
If we remove drugs from our drug list, add prior authorization,
quantity limits and/or step therapy restrictions on a drug or move
a drug to a higher cost-sharing tier, we must notify affected
customers of the change at least 60 days before the change
becomes effective, or at the time the customer requests a refill
1
What are generic drugs?
Cigna 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.
helping you take your medications at least 80% of the time.
There are several ways we can work together to accomplish
this goal:
• Talk with your doctor about whether a 90 day supply of your
ongoing, stable medications may be appropriate. Taking
these medications every day as prescribed is important for
your overall health, and getting 90 day prescriptions of these
medications can ensure that you don’t miss a dose.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits
on coverage. These requirements and limits may include:
• You can receive a 90-day supply at most retail pharmacies or
through one of our mail-order pharmacies.
• Prior Authorization: Cigna requires you or your doctor to
get prior authorization for certain drugs. This means that
you will need to get approval from Cigna before you fill your
prescriptions. If you don’t get approval, Cigna may not cover
the drug.
• Talk to your pharmacist if you are experiencing any new
challenges with your maintenance medications.
How can I use my prescription drug coverage to save
money on my medications?
There may be opportunities for you to save money on your
medications using your Cigna coverage.
• Quantity Limits: For certain drugs, Cigna limits the amount
of the drug that Cigna will cover. For example, Cigna allows
for 1 tablet per day for CRESTOR. This applies to standard
one-month supply (for total quantity of 30 per 30 days) or
three-month supply (for total quantity of 90 per 90 days).
• Ask your doctor (or other prescriber) if there are any lowercost generic alternatives available for any of your current
medications.
• Step Therapy: In some cases, Cigna requires you to first try
certain drugs to treat your medical condition before we will
cover another drug for that condition. For example, if Drug A
and Drug B both treat your medical condition, Cigna may not
cover Drug B unless you try Drug A first. If Drug A does not
work for you, Cigna will then cover Drug B.
• Explore whether the ‘CMS extra help’ program may offer
additional financial support for your medications.
• If your medication is not covered on the Cigna drug list, talk
with your doctor about alternative medications which are
covered in the drug list.
You can find out if your drug has any additional requirements
or limits by looking in the drug list that begins on page 7. You
can also get more information about the restrictions applied to
specific covered drugs by visiting our Web site. We have posted
online documents that explain our prior authorization and step
therapy restrictions. You may also ask us to send you a copy.
Our contact information, along with the date we last updated the
drug list, appears on the front and back cover pages.
What if my drug is not in the Drug List?
If your drug is not included in this drug list, you should first
contact Customer Service and ask if your drug is covered. If
you learn that Cigna does not cover your drug, you have two
options:
• You can ask Customer Service for a list of similar drugs that
are covered by Cigna. When you receive the list, show it to
your doctor and ask him or her to prescribe a similar drug that
is covered by Cigna.
You can ask Cigna to make an exception to these restrictions
or limits or for a list of other, similar drugs that may treat
your health condition. See the section, “How do I request an
exception to the Cigna drug list?” on this page for information
about how to request an exception.
• You can ask Cigna to make an exception and cover your
drug. See below for information about how to request an
exception.
Options for Maintenance Medications
Taking the medications prescribed by your doctor (or other
prescriber) is important to your health.
How do I request an exception to the Cigna Drug List?
You can ask Cigna to make an exception to our coverage rules.
There are several types of exceptions that you can ask us to
make.
We are committed to helping you achieve control of
chronic conditions by making it easy for you to receive your
maintenance medications. As part of our commitment to
coordinating your healthcare needs, we have set a goal of
• You can ask us to cover a drug even if it is not in our drug
list. If approved, this drug will be covered at a pre-determined
2
cost-sharing level, and you would not be able to ask us to
provide the drug at a lower cost-sharing level.
you can fill your prescription. You should talk to your doctor
to decide if you should switch to an appropriate drug that we
cover or request a drug list exception so that we will cover the
drug you take. While you talk to your doctor to determine the
right course of action for you, we may cover your drug in certain
cases during the first 90 days you are a customer of our plan.
• You can ask us to waive coverage restrictions or limits on
your drug. For example, for certain drugs, Cigna 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.
For each of your drugs that is not on our drug list or if your
ability to get your drugs is limited, we will cover a temporary
30-day supply (unless you have a prescription written for fewer
days) when you go to a network pharmacy. After your first 30day supply, we will not pay for these drugs, even if you have
been a customer of the plan less than 90 days.
• You can ask us to provide a tiering exception for a higher
cost sharing drug to be covered at a lower cost-sharing tier.
If your drug is contained in the Non-Preferred Brand tier or
the Generic tier, you can ask us to cover it at the cost-sharing
amount that applies to drugs in the respective Preferred
Brand or Preferred Generic tier instead. This would lower the
amount you must pay for your drug. If your drug is contained
in our Brand tier you can ask to cover it at the cost-sharing
amount that applies to drugs in the respective Generic tier if
all generic alternatives in the lower cost tier used to treat the
same condition/disease are determined to be not as effective
as the Brand. Please note, if we grant your request to cover a
drug that is not in our drug list, you may not ask us to provide
a higher level of coverage for the drug. Also, you may not ask
us to provide a higher level of coverage for drugs that are in
the Specialty tier.
If you are a resident of a long-term care facility, we will allow you
to refill your prescription until we have provided you with a 91- to
98-day transition supply, consistent with dispensing increment,
(unless you have a prescription written for fewer days). We will
cover more than one refill of these drugs for the first 90 days
you are a customer of our plan. If you need a drug that is not
in our drug list or if your ability to get your drugs is limited, but
you are past the first 90 days of membership in our plan, we
will cover a 31-day emergency supply of that drug (unless you
have a prescription for fewer days) while you pursue a drug list
exception.
Generally, Cigna will only approve your request for an exception
if the alternative drugs included on the plan’s drug list, the lower
cost-sharing drug or additional utilization restrictions would not
be as effective in treating your condition and/or would cause you
to have adverse medical effects.
In order to accommodate unexpected transitions of our
customers that do not leave time for advanced planning, such
as level-of-care changes due to discharge from a hospital to a
nursing facility or to a home, Cigna will allow a one-time 31-day
supply (unless the prescription is written for fewer days).
You should contact us to ask us for an initial coverage decision
for a drug list, tiering or utilization restriction exception. When
you request a drug list, tiering or utilization restriction
exception you should submit a statement from your
prescriber or doctor supporting your request. Generally,
we must make our decision within 72 hours of getting your
prescriber’s supporting statement. You can request an
expedited (fast) exception if you or your doctor believe that your
health could be seriously harmed by waiting up to 72 hours for
a decision. If your request to expedite is granted, we must give
you a decision no later than 24 hours after we get a supporting
statement from your doctor or other prescriber.
Cigna’s Drug List
The comprehensive drug list provides coverage information
about all of the drugs covered by Cigna. If you have trouble
finding your drug in the list, turn to the Covered Drug Index that
begins on page 50.
The first column of the chart lists the drug name. Brand name
drugs are capitalized (e.g., CRESTOR) and generic drugs are
listed in lower-case italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if
Cigna has any special requirements for coverage of your drug.
We provide quantity limits on certain drugs which are indicated
with a QL in the Covered Drugs by Category list on page 7
along with the amount dispensed per the days supplied. (For
example: CRESTOR 30/30; this means the drug CRESTOR
is limited to 30 tablets per 30 days. For 90-day supplies, this
quantity limit would be expanded to 90 tablets per 90 days).
What do I do before I can talk to my doctor about changing
my drugs or requesting an exception?
As a new or continuing customer in our plan you may be taking
drugs that are not in our drug list. Or, you may be taking a drug
that is on our drug list but your ability to get it is limited. For
example, you may need a prior authorization from us before
3
For more information
For more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage and
other plan materials.
If you have questions about Cigna, please contact us. Our contact information, along with the date we last updated the drug
list, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE
(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
Key:
B/D – This prescription drug has a Part B versus D
administrative prior authorization requirement. This drug
may be covered under Medicare Part B or D depending on
circumstances.
QL – This drug has quantity limits
ST – This drug has step therapy requirements
Generally all medications in the drug list are available
through mail order, except when special circumstances
or situations prohibit mailing a particular medication to
your home.
HI (Home Infusion) – This prescription drug may be
covered under our medical benefit. For more information,
contact Customer Service.
PA – This drug requires prior authorization
Drug Tier and Cost-Share Table
The following table represents the plan name, plan service area,
the drug tier number as it appears in the drug list, and the costshare amount for that tier number. Tier 1 is for Preferred Generic
drugs. Tier 2 is for Generic drugs. Tier number 3 is for Preferred
Brand drugs. Tier number 4 is for Non-Preferred Brand drugs.
Tier 5 is for Specialty tier drugs. You may also refer to your
Evidence of Coverage document for additional details.
Note for customers receiving Extra Help: Your LIS copay level
will be based on how the Food and Drug Administration (FDA)
classifies certain drugs. Due to this, a generic drug may receive
a preferred brand copay, or a preferred brand drug may receive
a generic drug copay. Please see your LIS Rider for additional
information on these copay levels. Or call Customer Service for
further clarification regarding a specific drug.
4
To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage
plan in which you are currently enrolled or would like to enroll.
Service Area: Arizona
H0354-001
Cigna-HealthSpring Preferred (HMO)
H0354-027
Cigna-HealthSpring Achieve Plus (HMO SNP)
Maricopa county and select zip codes in Pinal county (85117,
85118, 85119, 85120, 85140, 85143, 85178), Arizona
Standard Retail
Cost-Sharing
Standard Mail Order
Cost-Sharing
30/60/90 Days
30/90 Days
$0/$0/$0
$0/$0
Tier 2: Generic Drugs
$15/$30/$45
$15/$45
Tier 3: Preferred Brand Drugs
$45/$90/$135
$45/$135
$100/$200/$300
$100/$300
33%
33%
Standard Retail
Cost-Sharing
Standard Mail Order
Cost-Sharing
30/60/90 Days
30/90 Days
$0/$0/$0
$0/$0
Tier 2: Generic Drugs
$10/$20/$30
$10/$30
Tier 3: Preferred Brand Drugs
$45/$90/$135
$45/$135
Tier 4: Non-Preferred Brand Drugs
$95/$190/$285
$95/$285
33%
33%
Tier 1: Preferred Generic Drugs
Tier 4: Non-Preferred Brand Drugs
Tier 5: Specialty Tier
Service Area: Arizona
H0354-023
Cigna-HealthSpring Preferred Plus (HMO)
Maricopa county and select zip codes in Pinal county (85117,
85118, 85119, 85120, 85140, 85143, 85178), Arizona
H0354-024
Cigna-HealthSpring Preferred (HMO)
Pima County, Arizona
Tier 1: Preferred Generic Drugs
Tier 5: Specialty Tier
5
Service Area: Arizona
Standard Retail
Cost-Sharing
Standard Mail Order
Cost-Sharing
30/60/90 Days
30/90 Days
Tier 1: Preferred Generic Drugs
$0/$0/$0
$0/$0
Tier 2: Generic Drugs
$5/$10/$15
$5/$15
Tier 3: Preferred Brand Drugs
$45/$90/$135
$45/$135
Tier 4: Non-Preferred Brand Drugs
$95/$190/$285
$95/$285
33%
33%
H0354-026
Cigna-HealthSpring Preferred Plus (HMO)
Pima County, Arizona
Tier 5: Specialty Tier
My Medications
In this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list
pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page
and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800627-7534, 7 days a week, 8 a.m. – 8 p.m., hours apply Monday – Friday, February 15 – September 30. TTY users can call 711.
My Medications
Page Number
in the Drug List
6
Cost-Share
through Cigna
Generic
Available?
Generic
Cost-Share
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
ibuprofen tabs 400mg, 600mg,
800mg
ketoprofen
ketoprofen er
meclofenamate sodium
meloxicam
nabumetone
naproxen
naproxen dr
naproxen sodium tabs 275mg,
550mg
NEOPROFEN
oxaprozin
piroxicam
salsalate
sulindac
tolmetin sodium
Opioid Analgesics, Long-acting
BUTRANS
DURAMORPH
fentanyl
INFUMORPH 200
INFUMORPH 500
levorphanol tartrate
methadone hcl conc
methadone hcl inj
methadone hcl intensol
methadone hcl oral soln
10mg/5ml
methadone hcl oral soln
5mg/5ml
methadone hcl tabs
methadone hcl tbso
methadose conc
methadose sugar-free
Analgesics
Analgesics
butalbital/acetaminophen
2
PA QL(180/30)
butalbital/acetaminophen/
2
PA QL(180/30)
caffeine caps
2
PA QL(180/30)
butalbital/acetaminophen/
caffeine tabs 325mg; 50mg;
40mg
butalbital/aspirin/caffeine
2
PA QL(180/30)
esgic caps
2
PA QL(180/30)
margesic
2
PA QL(180/30)
marten-tab
2
PA QL(180/30)
PRIALT
5
B/D PA
tencon tabs 325mg; 50mg
2
PA QL(180/30)
zebutal caps 325mg; 50mg;
2
PA QL(180/30)
40mg
Nonsteroidal Anti-inflammatory Drugs
CAMBIA
4
celecoxib
2
QL(60/30)
choline magnesium trisalicylate
2
liqd
diclofenac potassium
2
diclofenac sodium dr
2
diclofenac sodium er
2
diclofenac sodium/misoprostol
2
diflunisal
2
etodolac
2
etodolac er
2
fenoprofen calcium caps
2
400mg
fenoprofen calcium tabs
2
flurbiprofen
2
ibuprofen lysine
2
ibuprofen susp
2
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
2
2
2
2
2
2
3
2
2
2
2
2
3
4
2
4
4
2
2
2
2
2
QL(4/28)
2
QL(4000/30)
2
2
2
2
QL(360/30)
QL(90/30)
QL(500/30)
QL(500/30)
QL(15/30)
QL(180/30)
QL(500/30)
QL(500/30)
QL(2000/30)
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
7
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
methadose tbso
morphine sulfate er cp24
morphine sulfate er tbcr
morphine sulfate inj 0.5mg/ml,
10mg/0.7ml, 1mg/ml
morphine sulfate supp
OPANA ER (CRUSH
RESISTANT) T12A 40MG
OPANA ER (CRUSH
RESISTANT) T12A 10MG,
15MG, 20MG, 30MG, 5MG,
7.5MG
oxymorphone hydrochloride er
tramadol hcl er tb24
Opioid Analgesics, Short-acting
acetaminophen/codeine #2
acetaminophen/codeine #3
acetaminophen/codeine #4
acetaminophen/codeine oral
soln
acetaminophen/codeine
phosphate tabs 300mg; 60mg
acetaminophen/codeine tabs
300mg; 60mg
acetaminophen/codeine tabs
300mg; 15mg
ascomp/codeine
aspirin-caffeine-dihydrocodeine
butalbital/aspirin/caffeine/
codeine
butorphanol tartrate inj
butorphanol tartrate nasal soln
CAPITAL/CODEINE
codeine sulfate tabs 60mg
codeine sulfate tabs 30mg
codeine sulfate tabs 15mg
endocet
fentanyl citrate inj 100mcg/2ml
fentanyl citrate oral
transmucosal lpop 200mcg
2
2
2
2
DRUG NAME
QL(90/30)
QL(60/30)
QL(90/30)
2
5
QL(120/30)
3
QL(60/30)
2
2
QL(60/30)
QL(30/30)
2
2
2
2
QL(360/30)
QL(360/30)
QL(240/30)
QL(5000/30)
2
QL(240/30)
2
QL(240/30)
2
QL(360/30)
2
2
2
PA QL(180/30)
QL(330/30)
PA QL(180/30)
2
2
3
2
2
2
2
2
2
QL(6/30)
QL(5000/30)
QL(180/30)
QL(360/30)
QL(720/30)
QL(360/30)
B/D PA
PA QL(120/30)
fentanyl citrate oral
transmucosal lpop 1200mcg,
1600mcg, 400mcg, 600mcg,
800mcg
hydrocodone bitartrate/
acetaminophen oral soln
325mg/15ml; 7.5mg/15ml
hydrocodone bitartrate/
acetaminophen tabs 325mg;
2.5mg
hydrocodone bitartrate/
acetaminophen tabs 300mg;
10mg, 300mg; 5mg, 300mg;
7.5mg
hydrocodone/acetaminophen
tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg
hydrocodone/ibuprofen tabs
5mg; 200mg, 7.5mg; 200mg
hydrocodone/ibuprofen tabs
10mg; 200mg
hydromorphone hcl dosette
hydromorphone hcl inj 1mg/ml,
2mg/ml, 4mg/ml, 500mg/50ml
hydromorphone hcl liqd
hydromorphone hcl supp
hydromorphone hcl tabs
ibudone tabs 5mg; 200mg
LAZANDA
lorcet
lorcet hd
lorcet plus tabs 325mg; 7.5mg
lortab tabs
morphine sulfate add-vantage
morphine sulfate inj 10mg/ml,
150mg/30ml, 15mg/ml, 1mg/
ml, 25mg/ml, 2mg/ml, 4mg/ml,
50mg/ml, 5mg/ml, 8mg/ml
morphine sulfate oral soln
100mg/5ml
morphine sulfate oral soln
20mg/5ml
morphine sulfate oral soln
10mg/5ml
8
DRUG REQUIREMENTS/
TIER LIMITS
5
PA QL(120/30)
2
QL(5400/30)
2
QL(360/30)
2
QL(390/30)
2
QL(360/30)
2
QL(150/30)
2
QL(180/30)
2
2
2
2
2
2
5
2
2
2
2
2
2
QL(1200/30)
2
QL(540/30)
2
QL(2700/30)
2
QL(5400/30)
QL(240/30)
QL(150/30)
PA QL(44/28)
QL(360/30)
QL(360/30)
QL(360/30)
QL(360/30)
Covered Drugs By Category
DRUG NAME
morphine sulfate tabs
nalbuphine hcl
OPIUM
OPIUM TINCTURE
oxycodone hcl caps
oxycodone hcl conc
oxycodone hcl oral soln
oxycodone hcl tabs
oxycodone/acetaminophen oral
soln
oxycodone/acetaminophen tabs
325mg; 10mg, 325mg; 2.5mg,
325mg; 5mg, 325mg; 7.5mg
oxycodone/aspirin
oxycodone/ibuprofen
oxymorphone hydrochloride
reprexain tabs 10mg; 200mg
roxicet oral soln
roxicet tabs
SYNALGOS-DC
TALWIN
tramadol hcl
tramadol hydrochloride/
acetaminophen
xylon
DRUG REQUIREMENTS/
TIER LIMITS
2
2
3
3
2
2
2
2
2
QL(240/30)
QL(360/30)
QL(1200/30)
QL(240/30)
QL(1800/30)
2
QL(360/30)
2
2
2
2
2
2
3
4
2
2
QL(360/30)
QL(150/30)
QL(180/30)
QL(180/30)
QL(1800/30)
QL(360/30)
QL(330/30)
2
QL(180/30)
DRUG NAME
QL(360/30)
lidocaine oint
lidocaine ptch
lidocaine viscous
lidocaine/prilocaine crea
premium lidocaine
SYNERA
Alcohol Deterrents/Anti-craving
acamprosate calcium dr
disulfiram
VIVITROL
Opioid Dependence Treatments
buprenorphine hcl inj
buprenorphine hcl subl
buprenorphine hcl/naloxone hcl
naltrexone hcl
SUBOXONE
Opioid Reversal Agents
naloxone hcl
NARCAN
Smoking Cessation Agents
buproban
bupropion hcl sr tb12 150mg
CHANTIX
CHANTIX CONTINUING
MONTH PAK
CHANTIX STARTING MONTH
PAK
NICOTROL INHALER
NICOTROL NS
QL(240/30)
QL(240/30)
2
2
2
2
PA QL(90/30)
B/D PA
2
2
5
2
2
2
2
3
PA
QL(90/30)
2
3
QL(4/30)
2
2
3
3
QL(60/30)
QL(60/30)
QL(336/365)
QL(336/365)
3
QL(106/365)
3
3
Antibacterials
2
2
2
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
2
2
2
2
2
4
Anti-Addiction/Substance Abuse Treatment Agents
Anesthetics
Local Anesthetics
glydo
lidocaine hcl external soln
lidocaine hcl gel
lidocaine hcl inj 0.5%, 1%,
1.5%, 2%, 4%
lidocaine hcl jelly
lidocaine hcl mouth/throat soln
lidocaine hcl viscous
DRUG REQUIREMENTS/
TIER LIMITS
Aminoglycosides
amikacin sulfate
2
HI
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
9
Covered Drugs By Category
DRUG NAME
gentak
gentamicin sulfate
gentamicin sulfate pediatric
gentamicin sulfate/0.9% sodium
chloride inj 0.9mg/ml; 0.9%,
1.2mg/ml; 0.9%, 1.4mg/ml;
0.9%, 1.6mg/ml; 0.9%, 1mg/ml;
0.9%, 2mg/ml; 0.9%
isotonic gentamicin inj 0.8mg/
ml; 0.9%
neomycin sulfate
neomycin/polymyxin b sulfates
paromomycin sulfate
streptomycin sulfate
tobramycin sulfate
TOBREX OINT
ZYLET
Antibacterials, Other
ALCOHOL PREP PADS
ALTABAX
baciim
bacitracin inj
bacitracin ophthalmic oint
bacitracin/polymyxin b
chloramphenicol sodium
succinate
CLEOCIN SUPP
clindacin etz pledgets
clindacin-p
clindamax
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate addvantage
clindamycin phosphate crea
clindamycin phosphate external
soln
clindamycin phosphate foam
clindamycin phosphate gel
clindamycin phosphate in d5w
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
2
2
2
2
clindamycin phosphate inj
300mg/2ml, 600mg/4ml,
900mg/6ml
clindamycin phosphate lotn
clindamycin phosphate
pharmacy bulk package
clindamycin phosphate swab
CLINDESSE
colistimethate sodium
CORTISPORIN CREA
CORTISPORIN OINT
CUBICIN
FEM PH
FLAGYL ER
lansoprazole/amoxicillin/
clarithromycin
LINCOCIN
lincomycin hcl
linezolid inj 600mg/300ml
linezolid susr
linezolid tabs
methenamine hippurate
methenamine mandelate
METRO IV
metronidazole caps
metronidazole crea
metronidazole gel
metronidazole in nacl 0.79%
metronidazole inj
metronidazole lotn
metronidazole tabs
metronidazole vaginal
MONUROL
mupirocin
neomycin/bacitracin/polymyxin
neomycin/polymyxin/bacitracin/
hydrocortisone
neomycin/polymyxin/gramicidin
neomycin/polymyxin/
hydrocortisone
2
2
2
2
2
2
3
4
3
4
2
2
2
2
2
4
2
2
2
2
2
2
HI
2
2
2
2
2
HI
10
DRUG REQUIREMENTS/
TIER LIMITS
2
HI
2
2
HI
2
4
2
3
3
5
4
4
2
3
2
2
5
5
2
2
3
2
2
2
2
2
2
2
2
4
2
2
2
2
2
HI
QL(224/30)
QL(1680/28)
QL(56/28)
HI
HI
HI
Covered Drugs By Category
DRUG NAME
nitrofurantoin
nitrofurantoin macrocrystals
caps 100mg, 50mg
nitrofurantoin monohydrate
nitrofurantoin monohydrate/
macrocrystals
polymyxin b sulfate
polymyxin b sulfate/
trimethoprim sulfate
PRIMSOL
RELAGARD
rosadan
SILVER NITRATE EXTERNAL
SOLN
silver sulfadiazine
ssd
SULFAMYLON
SYNERCID
trimethoprim
trimethoprim sulfate/polymyxin
b sulfate
TYGACIL
vancomycin
vancomycin hcl caps 125mg
vancomycin hcl caps 250mg
vancomycin hcl in dextrose
vancomycin hcl inj 0.9%;
1gm/200ml, 1000mg, 10gm,
500mg, 750mg
vancomycin hcl inj 5000mg
vandazole
VIBATIV
XIFAXAN TABS 200MG
XIFAXAN TABS 550MG
ZYVOX SUSR
DRUG REQUIREMENTS/
TIER LIMITS
2
2
QL(90/365)
2
2
QL(90/365)
QL(90/365)
DRUG NAME
Beta-lactam, Cephalosporins
CEDAX CAPS
cefaclor
cefaclor er
cefadroxil
cefazolin
cefazolin sodium
cefazolin sodium/dextrose
cefdinir
cefditoren pivoxil
cefepime
cefepime/dextrose
cefixime
cefotaxime sodium inj 1gm,
2gm, 500mg
cefotetan/dextrose
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime
ceftazidime/dextrose
ceftibuten
CEFTIN SUSR
ceftriaxone in iso-osmotic
dextrose
ceftriaxone sodium inj 10gm,
1gm, 250mg, 2gm, 500mg
ceftriaxone/dextrose
cefuroxime axetil
cefuroxime sodium inj 1.5gm,
7.5gm, 750mg, 75gm
cephalexin
FORTAZ INJ 500MG
MAXIPIME
SPECTRACEF TABS 400MG
2
2
4
4
2
3
2
2
4
5
2
2
5
2
5
5
2
2
2
2
4
5
5
5
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
HI
HI
QL(40/10)
QL(80/10)
HI
HI
B/D PA
HI
PA QL(9/30)
PA QL(60/30)
QL(1680/28)
DRUG REQUIREMENTS/
TIER LIMITS
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
2
HI
HI
HI
HI
HI
HI
HI
HI
2
2
2
2
2
4
4
4
HI
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
11
Covered Drugs By Category
DRUG NAME
SUPRAX CAPS
SUPRAX CHEW
SUPRAX SUSR 500MG/5ML
tazicef
TEFLARO
Beta-lactam, Other
AZACTAM IN ISO-OSMOTIC
DEXTROSE INJ 1GM; 0
AZACTAM IN ISO-OSMOTIC
DEXTROSE INJ 2GM; 0
AZACTAM INJ 1GM
AZACTAM INJ 2GM
aztreonam
cefotetan
DORIBAX
imipenem/cilastatin
INVANZ
meropenem
MERREM
PRIMAXIN IV
PRIMAXIN IV ADD-VANTAGE
Beta-lactam, Penicillins
amoxicillin
amoxicillin/clavulanate
potassium
ampicillin
ampicillin sodium inj 125mg,
250mg, 500mg
ampicillin sodium inj 10gm,
1gm, 2gm
ampicillin-sulbactam
bactocill in dextrose
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
NAFCILLIN
nafcillin sodium
oxacillin sodium
penicillin g potassium in isoosmotic dextrose
DRUG REQUIREMENTS/
TIER LIMITS
4
4
4
2
4
HI
4
HI
5
HI
4
5
2
2
4
2
4
2
4
4
4
HI
HI
HI
DRUG NAME
penicillin g potassium inj
20000000unit, 5000000unit
penicillin g procaine
penicillin g sodium
penicillin v potassium
pfizerpen-g
piperacillin sodium/ tazobactam
sodium
piperacillin sodium/tazobactam
sodium
piperacillin/tazobactam
UNASYN
UNASYN BULK PACK
ZOSYN
Macrolides
AZASITE
azithromycin inj
azithromycin pack
azithromycin susr
azithromycin tabs
clarithromycin
clarithromycin er
DIFICID
e.e.s. 400
E.E.S. GRANULES
ery
ERY-TAB
ERYPED 200
ERYPED 400
ERYTHROCIN
LACTOBIONATE
erythrocin stearate
erythromycin
erythromycin base
erythromycin ethylsuccinate
ilotycin
KETEK
PCE
ZMAX
HI
HI
HI
HI
HI
HI
HI
2
2
2
2
2
HI
2
2
4
4
2
3
2
2
2
HI
HI
HI
HI
HI
HI
12
DRUG REQUIREMENTS/
TIER LIMITS
2
HI
2
2
2
2
2
HI
HI
2
HI
2
3
3
3
HI
HI
HI
HI
3
2
2
2
2
2
2
5
2
3
2
3
3
3
3
2
2
2
2
2
4
3
4
HI
PA QL(20/30)
QL(60/30)
Covered Drugs By Category
DRUG NAME
Quinolones
AVELOX INJ
BESIVANCE
CILOXAN OINT
CIPRO HC
CIPRODEX
ciprofloxacin er
ciprofloxacin hcl
ciprofloxacin i.v.-in d5w
ciprofloxacin inj 400mg/40ml
ciprofloxacin susr
gatifloxacin
levofloxacin in d5w
levofloxacin inj
levofloxacin ophthalmic soln
levofloxacin oral soln
levofloxacin tabs
MOXEZA
moxifloxacin hcl inj
moxifloxacin hcl tabs
ofloxacin
VIGAMOX
Sulfonamides
BLEPHAMIDE
BLEPHAMIDE S.O.P.
sodium sulfacetamide
ophthalmic soln
sulfacetamide sodium oint
sulfacetamide sodium susp
sulfacetamide sodium/
prednisolone sodium
phosphate
sulfadiazine
sulfamethoxazole/trimethoprim
DRUG REQUIREMENTS/
TIER LIMITS
3
4
3
3
3
2
2
2
2
2
2
2
2
2
2
2
3
2
2
2
3
DRUG NAME
sulfamethoxazole/trimethoprim
ds
sulfatrim pediatric
Tetracyclines
demeclocycline hcl
doxy 100
doxycycline caps 150mg, 75mg
doxycycline hyclate
doxycycline hyclate dr tbec
100mg, 150mg, 75mg
doxycycline monohydrate
minocycline hcl
mondoxyne nl
tetracycline hcl
HI
HI
HI
HI
2
2
2
2
2
2
2
2
2
2
2
Anticonvulsants
Anticonvulsants, Other
APTIOM TABS 200MG,
4
400MG, 800MG
APTIOM TABS 600MG
4
BRIVIACT INJ
5
BRIVIACT ORAL SOLN
5
BRIVIACT TABS 10MG, 25MG,
5
50MG, 75MG
BRIVIACT TABS 100MG
5
FYCOMPA
4
levetiracetam
2
levetiracetam er
2
POTIGA TABS 50MG
4
POTIGA TABS 200MG,
5
300MG, 400MG
roweepra
2
SPRITAM
4
Calcium Channel Modifying Agents
CELONTIN
4
ethosuximide
2
QL(30/30)
QL(30/30)
4
4
2
2
2
2
2
2
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
QL(30/30)
QL(60/30)
QL(600/30)
QL(1200/30)
QL(60/30)
QL(120/30)
QL(90/30)
QL(90/30)
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
13
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
LYRICA CAPS 225MG, 300MG
3
QL(60/30)
3
QL(90/30)
LYRICA CAPS 100MG,
150MG, 200MG, 25MG, 50MG,
75MG
LYRICA ORAL SOLN
3
QL(900/30)
zonisamide
2
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam odt tbdp 0.125mg,
2
QL(150/30)
0.25mg, 0.5mg, 1mg
clonazepam odt tbdp 2mg
2
QL(300/30)
clonazepam tabs 0.5mg, 1mg
2
QL(150/30)
clonazepam tabs 2mg
2
QL(300/30)
diazepam gel
2
divalproex sodium
2
divalproex sodium dr
2
divalproex sodium er
2
gabapentin
2
ONFI SUSP
4
QL(480/30)
ONFI TABS 10MG
4
QL(60/30)
ONFI TABS 20MG
4
QL(120/30)
phenobarbital
2
primidone
2
SABRIL PACK
5
QL(200/30)
SABRIL TABS
5
QL(180/30)
tiagabine hydrochloride
2
valproate sodium
2
valproic acid
2
Glutamate Reducing Agents
felbamate susp
5
felbamate tabs
2
lamotrigine
2
lamotrigine er
2
lamotrigine odt
2
topiramate
2
Sodium Channel Agents
BANZEL SUSP
5
BANZEL TABS 400MG
5
BANZEL TABS 200MG
4
carbamazepine
2
carbamazepine er
2
DILANTIN
DILANTIN INFATABS
DILANTIN-125
epitol
EQUETRO
fosphenytoin sodium inj 100mg
pe/2ml
oxcarbazepine
OXTELLAR XR
PEGANONE
PHENYTEK
phenytoin
phenytoin sodium
phenytoin sodium extended
TEGRETOL-XR TB12 100MG
VIMPAT INJ
VIMPAT ORAL SOLN
VIMPAT TABS
DRUG REQUIREMENTS/
TIER LIMITS
4
4
4
2
4
2
2
4
4
4
2
2
2
4
3
3
3
QL(1200/30)
QL(60/30)
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates
2
PA
Cholinesterase Inhibitors
donepezil hcl tabs 23mg, 5mg
2
QL(30/30)
donepezil hcl tabs 10mg
2
QL(60/30)
donepezil hcl tbdp 5mg
2
QL(30/30)
donepezil hcl tbdp 10mg
2
QL(60/30)
EXELON PT24
3
QL(30/30)
galantamine hydrobromide
2
QL(30/30)
cp24
galantamine hydrobromide oral
2
QL(200/30)
soln
galantamine hydrobromide tabs 2
QL(60/30)
rivastigmine tartrate
2
QL(60/30)
rivastigmine transdermal
2
QL(30/30)
system
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl tabs 10mg
2
QL(60/30)
memantine hcl tabs 5mg
2
QL(90/30)
memantine hcl titration pak
2
QL(49/28)
14
Covered Drugs By Category
DRUG NAME
memantine hydrochloride
NAMENDA ORAL SOLN
NAMENDA TABS 10MG
NAMENDA TABS 5MG
NAMENDA TITRATION PAK
NAMENDA XR
NAMENDA XR TITRATION
PACK
DRUG REQUIREMENTS/
TIER LIMITS
2
3
3
3
3
3
3
DRUG NAME
QL(300/30)
QL(300/30)
QL(60/30)
QL(90/30)
QL(49/28)
QL(30/30)
QL(28/28)
citalopram hydrobromide tabs
40mg
citalopram hydrobromide tabs
10mg, 20mg
duloxetine hcl cpep 20mg,
60mg
duloxetine hcl cpep 30mg
escitalopram oxalate oral soln
escitalopram oxalate tabs
FETZIMA
FETZIMA TITRATION PACK
fluoxetine
fluoxetine hcl
fluvoxamine maleate
olanzapine/fluoxetine
paroxetine hcl tabs 10mg
paroxetine hcl tabs 20mg,
30mg, 40mg
PAXIL SUSP
PRISTIQ
sertraline hcl conc
sertraline hcl tabs 25mg
sertraline hcl tabs 100mg
sertraline hcl tabs 50mg
venlafaxine hcl
venlafaxine hcl er cp24 150mg,
37.5mg
venlafaxine hcl er cp24 75mg
VENLAFAXINE HCL ER TB24
150MG, 225MG, 37.5MG
VENLAFAXINE HCL ER TB24
75MG
VIIBRYD
VIIBRYD STARTER PACK
Tricyclics
amitriptyline hcl
Antidepressants
Antidepressants, Other
APLENZIN
4
QL(30/30)
bupropion hcl
2
bupropion hcl er tb12 100mg
2
QL(60/30)
bupropion hcl er tb12 150mg
2
QL(90/30)
bupropion hcl sr tb12 100mg,
2
QL(60/30)
200mg
bupropion hcl sr tb12 150mg
2
QL(90/30)
bupropion hcl xl tb24 300mg
2
QL(30/30)
bupropion hcl xl tb24 150mg
2
QL(90/30)
maprotiline hcl
2
mirtazapine
2
mirtazapine odt
2
nefazodone hcl
2
trazodone hcl
2
TRINTELLIX
4
QL(30/30)
Monoamine Oxidase Inhibitors
EMSAM
5
MARPLAN
4
phenelzine sulfate
2
tranylcypromine sulfate
2
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/
Serotonin and Norepinephrine Reuptake Inhibitor
citalopram hydrobromide oral
2
QL(600/30)
soln
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
2
QL(30/30)
2
QL(60/30)
2
QL(60/30)
2
2
2
4
4
2
2
2
2
2
2
QL(90/30)
QL(600/30)
QL(60/30)
QL(30/30)
QL(28/28)
4
3
2
2
2
2
2
2
QL(900/30)
QL(30/30)
QL(300/30)
QL(30/30)
QL(60/30)
QL(90/30)
2
4
QL(90/30)
QL(30/30)
4
QL(90/30)
3
3
QL(30/30)
QL(30/30)
2
PA
QL(30/30)
QL(30/30)
QL(60/30)
QL(30/30)
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
15
Covered Drugs By Category
DRUG NAME
amoxapine
clomipramine hcl
desipramine hcl
doxepin hcl
imipramine hcl
imipramine pamoate
nortriptyline hcl
perphenazine/amitriptyline
protriptyline hcl
SURMONTIL
trimipramine maleate
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
2
2
2
2
2
2
4
2
DRUG NAME
ondansetron hcl tabs 24mg
ondansetron hcl tabs 4mg, 8mg
ondansetron odt
SANCUSO
PA
PA
PA
PA
2
2
2
2
2
2
2
2
2
4
Antifungals
ABELCET
AMBISOME
amphotericin b
BENSAL HP
CANCIDAS
ciclodan
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine
ciclopirox topical solution kit
ciclopirox treatment
clotrimazole external crea
clotrimazole external soln
clotrimazole troc
clotrimazole/betamethasone
dipropionate
econazole nitrate
ERAXIS
ERTACZO
fluconazole
fluconazole in dextrose
fluconazole in nacl inj
100mg/50ml; 0.9%,
200mg/100ml; 0.9%
flucytosine
griseofulvin microsize
griseofulvin ultramicrosize
GYNAZOLE-1
itraconazole
ketoconazole crea
ketoconazole sham
ketoconazole tabs
miconazole 3
PA
PA
PA
HI
PA
PA
PA
PA
PA
4
4
4
5
2
3
3
3
3
2
2
2
B/D PA
PA
B/D PA QL(5/30)
B/D PA
B/D PA
B/D PA QL(2/30)
B/D PA QL(4/30)
B/D PA QL(8/30)
B/D PA QL(12/30)
HI
B/D PA QL(60/30)
B/D PA
2
B/D PA QL(900/30)
2
2
2
5
B/D PA
B/D PA QL(90/30)
B/D PA QL(90/30)
PA QL(4/30)
5
5
2
3
5
2
2
2
2
2
2
2
2
2
2
B/D PA
B/D PA
B/D PA
Antifungals
Antiemetics
Antiemetics
granisetron hcl inj
Antiemetics, Other
dimenhydrinate inj
droperidol
meclizine hcl tabs
phenadoz
phenergan supp
promethazine hcl
promethazine hcl plain
promethegan
TRANSDERM-SCOP
Emetogenic Therapy Adjuncts
ALOXI
ANZEMET INJ
ANZEMET TABS
CESAMET
dronabinol
EMEND CAPS 40MG
EMEND CAPS 125MG
EMEND CAPS 80MG
EMEND CAPS
granisetron hcl inj
granisetron hcl tabs
ondansetron hcl inj 40mg/20ml,
4mg/2ml
ondansetron hcl oral soln
DRUG REQUIREMENTS/
TIER LIMITS
16
2
5
4
2
2
2
5
2
2
4
2
2
2
2
2
HI
HI
HI
Covered Drugs By Category
DRUG NAME
MYCAMINE
naftifine hcl
naftifine hydrochloride
NAFTIN
NATACYN
NOXAFIL SUSP
NOXAFIL TBEC
nyamyc
nystatin crea
nystatin oint
nystatin powd 100000unit/gm
nystatin susp
nystatin tabs
nystatin/triamcinolone
nystop
oxiconazole nitrate
OXISTAT
SPORANOX ORAL SOLN
terbinafine hcl tabs
terconazole
voriconazole inj
voriconazole susr
voriconazole tabs
zazole crea
DRUG REQUIREMENTS/
TIER LIMITS
5
2
2
3
4
5
5
2
2
2
2
2
2
2
2
2
4
5
2
2
2
5
5
2
DRUG NAME
HI
Antimigraine Agents
Ergot Alkaloids
CAFERGOT
4
dihydroergotamine mesylate inj
2
dihydroergotamine mesylate
2
QL(8/30)
nasal soln
ERGOMAR
4
migergot
2
MIGRANAL
5
QL(8/30)
Serotonin (5-HT) 1b/1d Receptor Agonists
almotriptan malate tabs 12.5mg 2
QL(12/30) ST
almotriptan malate tabs 6.25mg 2
QL(18/30) ST
AXERT TABS 12.5MG
4
QL(12/30) ST
AXERT TABS 6.25MG
4
QL(18/30) ST
FROVA
4
QL(18/30) ST
frovatriptan succinate
2
QL(18/30) ST
naratriptan hcl
2
QL(9/30) ST
RELPAX TABS 40MG
4
QL(6/30) ST
RELPAX TABS 20MG
4
QL(12/30) ST
rizatriptan benzoate
2
QL(12/30)
rizatriptan benzoate odt
2
QL(12/30)
sumatriptan
2
QL(12/30)
sumatriptan succinate inj
2
QL(8/30)
sumatriptan succinate refill
2
QL(8/30)
sumatriptan succinate tabs
2
QL(9/30)
zolmitriptan odt tbdp 5mg
2
QL(6/30)
zolmitriptan odt tbdp 2.5mg
2
QL(12/30)
zolmitriptan tabs 5mg
2
QL(6/30)
zolmitriptan tabs 2.5mg
2
QL(12/30)
Antigout Agents
Antigout Agents
allopurinol
ALOPRIM
colchicine
COLCRYS
probenecid
probenecid/colchicine
ULORIC
2
4
2
3
2
2
3
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
Antimyasthenic Agents
Parasympathomimetics
GUANIDINE HCL
MESTINON SYRP
QL(30/30) ST
3
3
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
17
Covered Drugs By Category
DRUG NAME
MESTINON TIMESPAN
pyridostigmine bromide
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
Antiandrogens
bicalutamide
flutamide
NILANDRON
XTANDI
ZYTIGA
Antiangiogenic Agents
POMALYST
REVLIMID
THALOMID
Antiestrogens/Modifiers
EMCYT
FARESTON
FASLODEX
SOLTAMOX
tamoxifen citrate
Antimetabolites
adrucil
ALIMTA
ARRANON
cladribine
CLOLAR
cytarabine aqueous
cytarabine inj 100mg/ml
DROXIA
ELITEK
floxuridine
fluorouracil inj
FOLOTYN
gemcitabine
gemcitabine hcl
hydroxyurea
LONSURF TABS 8.19MG;
20MG
LONSURF TABS 6.14MG;
15MG
mercaptopurine
NIPENT
PURIXAN
3
2
Antimycobacterials
Antimycobacterials, Other
dapsone
rifabutin
Antituberculars
CAPASTAT SULFATE
cycloserine
ethambutol hcl
isoniazid
PASER
pyrazinamide
RIFAMATE
rifampin
RIFATER
SIRTURO
TRECATOR
2
2
3
2
2
2
4
2
4
2
4
5
3
Antineoplastics
Alkylating Agents
BENDEKA
BICNU
BUSULFEX
cyclophosphamide
dacarbazine
EVOMELA
GLEOSTINE
HEXALEN
ifosfamide
LEUKERAN
MATULANE
melphalan hydrochloride
MUSTARGEN
thiotepa
TREANDA
VALCHLOR
YONDELIS
ZANOSAR
5
3
3
2
2
5
3
5
2
3
5
2
3
2
5
5
5
4
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
18
DRUG REQUIREMENTS/
TIER LIMITS
2
2
5
5
5
5
5
5
QL(28/28)
3
5
5
4
2
B/D PA
2
5
5
5
5
2
2
3
5
2
2
5
2
2
2
5
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
5
QL(100/28)
2
5
4
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
QL(80/28)
Covered Drugs By Category
DRUG NAME
TABLOID
Antineoplastics, Other
ABRAXANE
amifostine
azacitidine
BELEODAQ
bleomycin sulfate
carboplatin inj 150mg/15ml,
450mg/45ml, 50mg/5ml
cisplatin
COSMEGEN
daunorubicin hcl
decitabine
dexrazoxane
DOCEFREZ INJ 20MG
docetaxel
doxorubicin hcl
doxorubicin hcl liposome
epirubicin hcl inj 200mg/100ml,
50mg/25ml
ERWINAZE
fludarabine phosphate
HALAVEN
IBRANCE
idarubicin hcl
irinotecan
ISTODAX
IXEMPRA KIT
JEVTANA
leucovorin calcium
levoleucovorin calcium
levoleucovorin inj 250mg/25ml
LYNPARZA
MARQIBO
mesna
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
4
5
5
5
5
2
2
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
2
5
2
5
2
5
5
2
5
2
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
5
2
5
5
5
2
5
5
5
2
5
5
5
5
2
B/D PA
B/D PA
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
MESNEX TABS
5
mitomycin
2
mitoxantrone hcl
2
NINLARO
5
ODOMZO
5
ONCASPAR
5
oxaliplatin
5
paclitaxel
2
PHOTOFRIN
5
PORTRAZZA
5
PROLEUKIN
5
SYLATRON
5
SYNRIBO
5
teniposide
2
THERACYS
4
TICE BCG
3
TRISENOX
4
VELCADE
5
VENCLEXTA STARTING PACK
5
VENCLEXTA TABS 50MG
4
VENCLEXTA TABS 10MG
4
VENCLEXTA TABS 100MG
5
vinblastine sulfate
2
vincasar pfs
2
vincristine sulfate
2
vinorelbine tartrate
2
ZOLINZA
5
Aromatase Inhibitors, 3rd Generation
anastrozole
2
exemestane
2
letrozole
2
Enzyme Inhibitors
ETOPOPHOS
4
etoposide inj
2
QL(21/28)
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
QL(480/30)
B/D PA
B/D PA
B/D PA
B/D PA
QL(3/28)
QL(30/30)
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
PA
B/D PA
B/D PA
B/D PA
B/D PA
QL(84/365)
QL(30/30)
QL(60/30)
QL(120/30)
B/D PA
B/D PA
B/D PA
B/D PA
QL(30/30)
B/D PA
B/D PA
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
19
Covered Drugs By Category
DRUG NAME
toposar
topotecan hcl
ZYDELIG
Molecular Target Inhibitors
AFINITOR DISPERZ TBSO
2MG, 3MG
AFINITOR DISPERZ TBSO
5MG
AFINITOR TABS 2.5MG, 5MG,
7.5MG
AFINITOR TABS 10MG
ALECENSA
BOSULIF
CABOMETYX TABS 20MG,
60MG
CABOMETYX TABS 40MG
CAPRELSA
COMETRIQ
COTELLIC
ERIVEDGE
FARYDAK
GILOTRIF
GLEEVEC
ICLUSIG
imatinib mesylate
IMBRUVICA
INLYTA
IRESSA
JAKAFI
LENVIMA 10 MG DAILY DOSE
LENVIMA 14 MG DAILY DOSE
LENVIMA 18 MG DAILY DOSE
LENVIMA 20 MG DAILY DOSE
LENVIMA 24 MG DAILY DOSE
LENVIMA 8 MG DAILY DOSE
MEKINIST
NEXAVAR
SPRYCEL
STIVARGA
SUTENT
DRUG REQUIREMENTS/
TIER LIMITS
2
5
5
B/D PA
B/D PA
QL(60/30)
5
QL(60/30)
5
QL(120/30)
5
QL(30/30)
5
5
5
5
QL(60/30)
QL(240/30)
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
PA QL(60/30)
DRUG NAME
TAFINLAR
TAGRISSO
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYKADIA
Monoclonal Antibodies
AVASTIN
CYRAMZA
DARZALEX
EMPLICITI
ERBITUX
GAZYVA
HERCEPTIN
KADCYLA
KEYTRUDA
OPDIVO
PERJETA
RITUXAN INJ 500MG/50ML
TECENTRIQ
UNITUXIN
VECTIBIX
YERVOY
ZALTRAP
Retinoids
bexarotene
PANRETIN
TARGRETIN
tretinoin caps
PA QL(30/30)
QL(63/28)
QL(9/28)
DRUG REQUIREMENTS/
TIER LIMITS
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Antiparasitics
Anthelmintics
ALBENZA
ivermectin
Antiprotozoals
ALINIA
20
4
2
4
QL(30/30)
QL(150/30)
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
PA
PA QL(20/21)
B/D PA
B/D PA
B/D PA
B/D PA
Covered Drugs By Category
DRUG NAME
atovaquone
atovaquone/proguanil hcl
chloroquine phosphate
COARTEM
DARAPRIM
hydroxychloroquine sulfate
mefloquine hcl
NEBUPENT
PENTAM 300
PRIMAQUINE PHOSPHATE
quinine sulfate
tinidazole
Pediculicides/Scabicides
EURAX
lindane
malathion
permethrin
SKLICE
DRUG REQUIREMENTS/
TIER LIMITS
5
2
2
4
4
2
2
4
4
4
2
2
DRUG NAME
Dopamine Precursors/L- Amino Acid Decarboxylase
Inhibitors
carbidopa
2
carbidopa/levodopa
2
carbidopa/levodopa er
2
carbidopa/levodopa odt
2
carbidopa/levodopa/
2
entacapone
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
3
selegiline hcl
2
ZELAPAR
4
QL(24/30)
B/D PA
PA
Antipsychotics
4
2
2
2
4
1st Generation/Typical
chlorpromazine hcl inj
50mg/2ml
chlorpromazine hcl tabs
compro
fluphenazine decanoate
fluphenazine hcl
haloperidol
haloperidol decanoate
haloperidol lactate
loxapine succinate
ORAP
perphenazine
pimozide
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
thioridazine hcl
thiothixene
trifluoperazine hcl
Antiparkinson Agents
Anticholinergics
benztropine mesylate inj
benztropine mesylate tabs
trihexyphenidyl hcl
Antiparkinson Agents, Other
entacapone
tolcapone
Dopamine Agonists
APOKYN
bromocriptine mesylate
NEUPRO
pramipexole dihydrochloride
pramipexole dihydrochloride er
ropinirole er
ropinirole hcl
2
2
2
PA
PA
2
5
5
2
4
2
2
2
2
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
QL(30/30)
2
2
2
2
2
2
2
2
2
4
2
2
2
2
2
2
2
2
PA
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
21
Covered Drugs By Category
DRUG NAME
2nd Generation/Atypical
ABILIFY MAINTENA INJ
300MG
ABILIFY MAINTENA INJ
400MG
aripiprazole odt
aripiprazole oral soln
aripiprazole tabs
ARISTADA INJ 441MG/1.6ML
ARISTADA INJ 662MG/2.4ML
ARISTADA INJ 882MG/3.2ML
FANAPT TABS 10MG, 12MG,
6MG, 8MG
FANAPT TABS 1MG, 2MG,
4MG
FANAPT TITRATION PACK
GEODON INJ
INVEGA SUSTENNA INJ
39MG/0.25ML, 78MG/0.5ML
INVEGA SUSTENNA INJ
117MG/0.75ML, 156MG/ML,
234MG/1.5ML
INVEGA TB24 9MG
INVEGA TB24 1.5MG, 3MG
INVEGA TB24 6MG
INVEGA TRINZA
LATUDA TABS 120MG, 20MG,
40MG, 60MG
LATUDA TABS 80MG
NUPLAZID
olanzapine inj
olanzapine odt
olanzapine tabs 10mg, 15mg,
20mg, 5mg, 7.5mg
olanzapine tabs 2.5mg
paliperidone er tb24 1.5mg,
3mg
paliperidone er tb24 6mg
paliperidone er tb24 9mg
quetiapine fumarate
REXULTI
DRUG REQUIREMENTS/
TIER LIMITS
5
QL(1.5/30)
5
QL(2/30)
5
2
2
5
5
5
5
QL(60/30)
QL(900/30)
QL(30/30)
QL(1.6/30)
QL(2.4/30)
QL(3.2/30)
QL(60/30)
4
QL(60/30)
4
4
4
QL(16/30)
DRUG NAME
RISPERDAL CONSTA INJ
37.5MG, 50MG
RISPERDAL CONSTA INJ
12.5MG, 25MG
risperidone m-tab tbdp 0.5mg,
2mg
risperidone odt tbdp 0.25mg,
0.5mg, 1mg, 2mg, 3mg
risperidone odt tbdp 4mg
risperidone oral soln
risperidone tabs 0.25mg,
0.5mg, 1mg, 2mg, 3mg
risperidone tabs 4mg
SAPHRIS
SEROQUEL XR TB24 150MG,
200MG
SEROQUEL XR TB24 300MG,
400MG, 50MG
VRAYLAR CAPS
VRAYLAR CPPK
ziprasidone hcl
ZYPREXA RELPREVV INJ
405MG
ZYPREXA RELPREVV INJ
300MG
ZYPREXA RELPREVV INJ
210MG
Antipsychotics
molindone hydrochloride
Treatment-Resistant
clozapine
clozapine odt
FAZACLO TBDP 100MG,
12.5MG, 25MG
VERSACLOZ
5
5
4
4
5
3
QL(30/30)
QL(30/30)
QL(60/30)
3
5
2
2
2
QL(60/30)
PA QL(60/30)
2
2
QL(60/30)
QL(30/30)
2
5
2
5
QL(60/30)
QL(30/30)
QL(90/30)
QL(30/30)
QL(30/30)
QL(30/30)
QL(30/30)
DRUG REQUIREMENTS/
TIER LIMITS
5
4
2
QL(90/30)
2
QL(90/30)
2
2
2
QL(120/30)
QL(360/30)
QL(90/30)
2
3
3
QL(120/30)
QL(60/30)
QL(30/30)
3
QL(60/30)
5
4
2
5
QL(30/30)
QL(14/365)
QL(60/30)
QL(1/28)
5
QL(2/28)
5
QL(2.8/28)
2
2
2
4
5
Antispasticity Agents
Antispasticity Agents
baclofen tabs
dantrolene sodium
tizanidine hcl
XEOMIN
22
2
2
2
4
PA
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
Anti-HIV Agents, Integrase Inhibitors (INSTI)
GENVOYA
5
ISENTRESS CHEW
3
ISENTRESS PACK
3
ISENTRESS TABS
5
TIVICAY TABS 50MG
5
TIVICAY TABS 10MG, 25MG
4
VITEKTA
5
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA
5
EDURANT
5
INTELENCE TABS 100MG,
5
200MG
INTELENCE TABS 25MG
4
nevirapine
2
nevirapine er
2
ODEFSEY
5
RESCRIPTOR
4
STRIBILD
5
SUSTIVA CAPS 200MG
5
SUSTIVA CAPS 50MG
3
SUSTIVA TABS
5
VIRAMUNE XR TB24 100MG
4
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
abacavir
2
abacavir sulfate/lamivudine/
5
zidovudine
DESCOVY
5
QL(30/30)
didanosine
2
EMTRIVA
4
EPZICOM
5
lamivudine
2
lamivudine/zidovudine
2
Antivirals
Anti-cytomegalovirus (CMV) Agents
cidofovir
5
ganciclovir inj
2
VALCYTE ORAL SOLN
5
valganciclovir
5
ZIRGAN
4
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil
5
BARACLUDE ORAL SOLN
5
entecavir
2
EPIVIR HBV ORAL SOLN
4
INTRON A
5
INTRON A W/DILUENT
5
lamivudine
2
TYZEKA
5
Anti-hepatitis C (HCV) Agents
HARVONI
5
moderiba 1200 dose pack
5
moderiba 800 dose pack
5
moderiba misc
5
moderiba tabs
2
OLYSIO
5
PEG-INTRON REDIPEN
5
PEG-INTRON REDIPEN PAK 4 5
PEGINTRON
5
REBETOL ORAL SOLN
5
ribasphere caps
2
ribasphere ribapak
5
ribasphere tabs 200mg, 400mg
2
ribasphere tabs 600mg
5
ribavirin
2
SOVALDI
5
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
B/D PA
PA QL(28/28)
PA QL(28/28)
PA
PA
PA
PA QL(28/28)
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
23
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
RETROVIR IV INFUSION
4
stavudine
2
TRUVADA
5
VIDEX PEDIATRIC
3
VIREAD
5
ZIAGEN ORAL SOLN
4
zidovudine
2
Anti-HIV Agents, Other
ATRIPLA
5
FUZEON
5
SELZENTRY
5
TRIUMEQ
5
TYBOST
3
Anti-HIV Agents, Protease Inhibitors
APTIVUS
5
CRIXIVAN
3
EVOTAZ
5
INVIRASE CAPS
4
INVIRASE TABS
5
KALETRA ORAL SOLN
5
KALETRA TABS 200MG;
5
50MG
KALETRA TABS 100MG;
4
25MG
LEXIVA SUSP
4
LEXIVA TABS
5
NORVIR
4
PREZCOBIX
5
PREZISTA SUSP
5
PREZISTA TABS 600MG,
5
800MG
PREZISTA TABS 150MG,
4
75MG
REYATAZ
5
VIRACEPT
5
Anti-influenza Agents
amantadine hcl
2
RELENZA DISKHALER
4
QL(120/365)
rimantadine hcl
2
TAMIFLU CAPS 75MG
3
QL(56/365)
TAMIFLU CAPS 45MG
TAMIFLU CAPS 30MG
TAMIFLU SUSR
Antiherpetic Agents
acyclovir
acyclovir sodium inj 500mg,
50mg/ml
DENAVIR
famciclovir
trifluridine
valacyclovir hcl
ZOVIRAX CREA
DRUG REQUIREMENTS/
TIER LIMITS
3
3
3
2
2
QL(60/365)
QL(120/365)
B/D PA
3
2
2
2
4
Anxiolytics
Anxiolytics, Other
buspirone hcl
Benzodiazepines
alprazolam er tb24 1mg, 2mg,
3mg
alprazolam intensol
alprazolam odt tbdp 0.25mg,
0.5mg
alprazolam odt tbdp 1mg
alprazolam odt tbdp 2mg
alprazolam tabs 0.25mg, 0.5mg
alprazolam tabs 1mg
alprazolam tabs 2mg
alprazolam xr
clorazepate dipotassium tabs
3.75mg, 7.5mg
clorazepate dipotassium tabs
15mg
diazepam conc
diazepam inj
diazepam intensol
diazepam oral soln
diazepam tabs
lorazepam conc
lorazepam inj 20mg/10ml, 2mg/
ml, 4mg/ml
lorazepam intensol
24
2
2
QL(90/30)
2
2
QL(300/30)
QL(90/30)
2
2
2
2
2
2
2
QL(120/30)
QL(150/30)
QL(90/30)
QL(120/30)
QL(150/30)
QL(90/30)
QL(90/30)
2
QL(120/30)
2
2
2
2
2
2
2
QL(240/30)
2
QL(150/30)
QL(240/30)
QL(1200/30)
QL(120/30)
QL(150/30)
Covered Drugs By Category
DRUG NAME
lorazepam tabs
oxazepam
DRUG REQUIREMENTS/
TIER LIMITS
2
2
DRUG NAME
QL(120/30)
QL(120/30)
miglitol
nateglinide
pioglitazone hcl
pioglitazone hcl-glimepiride
pioglitazone hcl/metformin hcl
repaglinide
RIOMET
SYMLINPEN 120
SYMLINPEN 60
TRADJENTA
TRULICITY
VICTOZA
Glycemic Agents
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY
KIT
PROGLYCEM
Insulins
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50/50
HUMALOG MIX 50/50
KWIKPEN
HUMALOG MIX 75/25
HUMALOG MIX 75/25
KWIKPEN
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500
(CONCENTRATED)
HUMULIN R U-500 KWIKPEN
LANTUS
Bipolar Agents
Mood Stabilizers
lithium
lithium carbonate
lithium carbonate er
2
2
2
Blood Glucose Regulators
Antidiabetic Agents
acarbose
AVANDIA
BYDUREON
BYETTA
glimepiride
glipizide
glipizide er
glipizide xl
glipizide/metformin hcl
GLYSET
INVOKAMET
INVOKANA
JANUMET
JANUMET XR TB24 1000MG;
100MG
JANUMET XR TB24 1000MG;
50MG, 500MG; 50MG
JANUVIA
JENTADUETO
JENTADUETO XR TB24 5MG;
1000MG
JENTADUETO XR TB24
2.5MG; 1000MG
metformin hcl
metformin hcl er
2
4
3
3
1
1
1
1
1
4
3
3
3
3
QL(60/30)
QL(4/28)
QL(2.4/30)
QL(60/30)
QL(30/30)
QL(60/30)
QL(30/30)
3
QL(60/30)
3
3
3
QL(30/30)
QL(60/30)
QL(30/30)
3
QL(60/30)
1
1
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
2
1
1
2
2
2
3
4
4
3
3
3
QL(30/30)
QL(30/30)
QL(90/30)
QL(11/30)
QL(6/30)
QL(30/30)
QL(2/28)
QL(9/30)
3
3
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
25
Covered Drugs By Category
DRUG NAME
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
NOVOLIN 70/30
NOVOLIN 70/30 RELION
NOVOLIN N
NOVOLIN N RELION
NOVOLIN R
NOVOLIN R INNOLET
NOVOLIN R RELION
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30
PREFILLED FLEXPEN
NOVOLOG PENFILL
TOUJEO SOLOSTAR
TRESIBA FLEXTOUCH
DRUG REQUIREMENTS/
TIER LIMITS
3
3
3
4
4
4
4
4
4
4
4
4
4
4
4
3
3
DRUG NAME
fondaparinux sodium inj
7.5mg/0.6ml
fondaparinux sodium inj
10mg/0.8ml
fondaparinux sodium inj
2.5mg/0.5ml
FRAGMIN INJ
7500UNIT/0.3ML
FRAGMIN INJ
12500UNIT/0.5ML
FRAGMIN INJ
15000UNIT/0.6ML
FRAGMIN INJ
18000UNT/0.72ML
FRAGMIN INJ
95000UNIT/3.8ML
FRAGMIN INJ 10000UNIT/ML
FRAGMIN INJ
2500UNIT/0.2ML,
5000UNIT/0.2ML
heparin sodium
heparin sodium/d5w
heparin sodium/nacl 0.45%
heparin sodium/nacl 0.9%
heparin sodium/sodium chloride
0.9%
heparin sodium/sodium chloride
0.9% premix
jantoven
PRADAXA
warfarin sodium
XARELTO STARTER PACK
XARELTO TABS 10MG, 20MG
XARELTO TABS 15MG
Blood Formation Modifiers
anagrelide hydrochloride
ARANESP ALBUMIN
FREE INJ 10MCG/0.4ML,
25MCG/0.42ML, 25MCG/ML,
40MCG/0.4ML, 40MCG/ML,
60MCG/0.3ML, 60MCG/ML
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
Blood Products/Modifiers/Volume Expanders
Anticoagulants
COUMADIN
ELIQUIS TABS 2.5MG
ELIQUIS TABS 5MG
enoxaparin sodium inj
30mg/0.3ml
enoxaparin sodium inj
40mg/0.4ml
enoxaparin sodium inj
60mg/0.6ml
enoxaparin sodium inj
80mg/0.8ml
enoxaparin sodium inj 100mg/
ml
enoxaparin sodium inj
300mg/3ml
enoxaparin sodium inj
120mg/0.8ml
enoxaparin sodium inj 150mg/
ml
fondaparinux sodium inj
5mg/0.4ml
4
3
3
2
QL(60/30)
QL(74/30)
QL(9/30)
2
QL(12/30)
2
QL(18/30)
2
QL(24/30)
2
QL(30/30)
2
QL(90/30)
5
QL(24/30)
5
QL(30/30)
5
QL(12/30)
26
DRUG REQUIREMENTS/
TIER LIMITS
5
QL(18/30)
5
QL(24/30)
2
QL(15/30)
5
QL(9/30) ST
5
QL(15/30) ST
5
QL(18/30) ST
5
QL(21.6/30) ST
5
QL(22.8/30) ST
5
4
QL(30/30) ST
QL(6/30) ST
2
2
2
2
2
2
2
3
2
3
3
3
2
3
QL(60/30)
QL(102/365)
QL(30/30)
QL(60/30)
PA
Covered Drugs By Category
DRUG NAME
ARANESP ALBUMIN
FREE INJ 100MCG/0.5ML,
100MCG/ML, 150MCG/0.3ML,
200MCG/0.4ML, 200MCG/ML,
300MCG/0.6ML, 300MCG/ML,
500MCG/ML
EPOGEN
GRANIX
LEUKINE INJ 250MCG
NEULASTA
NEUPOGEN
PROCRIT INJ 20000UNIT/ML,
40000UNIT/ML
PROCRIT INJ 10000UNIT/ML,
2000UNIT/ML, 3000UNIT/ML,
4000UNIT/ML
PROMACTA TABS 12.5MG,
25MG, 50MG
ZARXIO
Coagulants
aminocaproic acid
tranexamic acid inj
tranexamic acid tabs
Platelet Modifying Agents
AGGRENOX
aspirin/dipyridamole
BRILINTA
cilostazol
clopidogrel tabs 75mg
clopidogrel tabs 300mg
EFFIENT TABS 10MG
EFFIENT TABS 5MG
DRUG REQUIREMENTS/
TIER LIMITS
5
PA
4
5
5
5
5
5
PA
3
PA
DRUG NAME
clonidine hcl ptwk 0.3mg/24hr
2
clonidine hcl tabs
2
clorpres
2
midodrine hcl
2
Alpha-adrenergic Blocking Agents
DIBENZYLINE
3
phenoxybenzamine
2
hydrochloride
prazosin hcl
2
Angiotensin II Receptor Antagonists
BENICAR
3
BENICAR HCT
3
candesartan cilexetil
1
candesartan cilexetil/
1
hydrochlorothiazide
ENTRESTO
3
eprosartan mesylate
2
irbesartan
1
irbesartan/hydrochlorothiazide
1
losartan potassium tabs 100mg
1
losartan potassium tabs 50mg
1
losartan potassium tabs 25mg
1
1
losartan potassium/
hydrochlorothiazide tabs
12.5mg; 100mg, 25mg; 100mg
1
losartan potassium/
hydrochlorothiazide tabs
12.5mg; 50mg
telmisartan
1
telmisartan/amlodipine
2
telmisartan/hydrochlorothiazide
1
valsartan tabs 320mg
1
valsartan tabs 160mg, 40mg,
1
80mg
valsartan/hydrochlorothiazide
1
PA
5
5
2
2
2
QL(180/30)
3
2
3
2
2
2
4
4
QL(60/30)
QL(60/30)
QL(60/30)
2
QL(4/28)
QL(1/30)
QL(36/30)
QL(42/30)
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine hcl ptwk 0.1mg/24hr,
0.2mg/24hr
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
QL(8/28)
QL(30/30)
QL(30/30)
QL(30/30)
QL(30/30)
PA QL(60/30)
QL(30/30)
QL(30/30)
QL(30/30)
QL(30/30)
QL(60/30)
QL(90/30)
QL(30/30)
QL(60/30)
QL(30/30)
QL(30/30)
QL(30/30)
QL(30/30)
QL(60/30)
QL(30/30)
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
27
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl
1
benazepril hcl/
1
hydrochlorothiazide
captopril
1
captopril/hydrochlorothiazide
1
enalapril maleate
1
enalapril maleate/
1
hydrochlorothiazide
enalaprilat
2
fosinopril sodium
1
fosinopril sodium/
1
hydrochlorothiazide
lisinopril
1
lisinopril/hydrochlorothiazide
1
moexipril hcl
1
moexipril/hydrochlorothiazide
1
perindopril erbumine
1
quinapril hcl
1
quinapril/hydrochlorothiazide
1
ramipril
1
trandolapril
1
2
QL(30/30)
trandolapril/verapamil hcl er
tbcr 1mg; 240mg, 2mg; 180mg,
2mg; 240mg
trandolapril/verapamil hcl er
2
QL(60/30)
tbcr 4mg; 240mg
2
QL(30/30)
trandolapril/verapamil hcl tbcr
1mg; 240mg, 2mg; 180mg,
2mg; 240mg
trandolapril/verapamil hcl tbcr
2
QL(60/30)
4mg; 240mg
Antiarrhythmics
amiodarone hcl
2
dofetilide
4
flecainide acetate
2
lidocaine hcl inj 10mg/ml,
2
20mg/ml
mexiletine hcl
2
MULTAQ
3
QL(60/30)
pacerone
2
DRUG REQUIREMENTS/
TIER LIMITS
procainamide hcl
2
propafenone hcl
2
propafenone hcl er
2
quinidine gluconate
2
quinidine gluconate cr
2
quinidine gluconate er
2
quinidine sulfate
2
sorine
2
sotalol hcl
2
sotalol hcl (af)
2
TIKOSYN
4
Beta-adrenergic Blocking Agents
acebutolol hcl
2
atenolol
2
atenolol/chlorthalidone
2
betaxolol hcl
2
bisoprolol fumarate
2
bisoprolol fumarate/
2
hydrochlorothiazide
BYSTOLIC TABS 20MG
3
BYSTOLIC TABS 2.5MG, 5MG
3
BYSTOLIC TABS 10MG
3
carvedilol
2
COREG CR
3
DUTOPROL
4
esmolol hcl inj 10mg/ml
2
INNOPRAN XL
4
labetalol hcl
2
metoprolol succinate er tb24
2
200mg
metoprolol succinate er tb24
2
100mg, 25mg, 50mg
metoprolol tartrate
2
metoprolol/hydrochlorothiazide
2
nadolol
2
nadolol/bendroflumethiazide
2
pindolol
2
propranolol hcl
2
propranolol hcl er
2
propranolol/hydrochlorothiazide
2
28
QL(60/30)
QL(90/30)
QL(120/30)
QL(30/30)
QL(60/30)
QL(90/30)
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
timolol maleate
2
Calcium Channel Blocking Agents
afeditab cr
2
amlodipine besylate tabs 10mg, 2
5mg
amlodipine besylate tabs 2.5mg 2
amlodipine besylate/
2
atorvastatin calcium
amlodipine besylate/benazepril
2
hydrochloride
amlodipine besylate/valsartan
2
amlodipine/valsartan/hctz
2
CARDENE IV
4
cartia xt
2
dilt-xr
2
diltiazem cd
2
diltiazem hcl cd
2
diltiazem hcl er
2
2
diltiazem hcl inj 100mg,
125mg/25ml, 25mg/5ml,
50mg/10ml
diltiazem hcl tabs
2
felodipine er
2
isradipine
2
matzim la
2
nicardipine hcl
2
nifedical xl
2
nifedipine er
2
nimodipine
2
nisoldipine er
2
nisoldipine tb24 30mg
2
nisoldipine tb24 17mg, 20mg,
2
34mg, 40mg, 8.5mg
NYMALIZE
5
taztia xt
2
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
verapamil hcl
2
verapamil hcl er
2
verapamil hcl sr cp24
2
Cardiovascular Agents, Other
DEMSER
3
digitek tabs 0.125mg
2
QL(30/30)
digitek tabs 0.25mg
2
PA
digox tabs 125mcg
2
QL(30/30)
digox tabs 250mcg
2
PA
digoxin inj
2
PA
digoxin oral soln
2
PA
digoxin tabs 125mcg
2
QL(30/30)
digoxin tabs 250mcg
2
PA
LANOXIN PEDIATRIC
3
PA
LANOXIN TABS 62.5MCG
4
QL(30/30)
LANOXIN TABS 187.5MCG
4
PA
NORTHERA
5
PA QL(180/30)
pentoxifylline er
2
RANEXA
3
TEKTURNA
4
QL(30/30)
TEKTURNA HCT
4
QL(30/30)
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide
2
acetazolamide sodium
2
Diuretics, Loop
bumetanide
2
EDECRIN
3
ethacrynate sodium
2
ethacrynic acid
3
furosemide
2
SODIUM EDECRIN
3
torsemide
2
Diuretics, Potassium-sparing
amiloride hcl
2
QL(60/30)
QL(90/30)
QL(30/30)
QL(30/30)
QL(30/30)
QL(30/30)
QL(60/30)
QL(30/30)
QL(30/30)
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
29
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
amiloride/hydrochlorothiazide
2
DYRENIUM
4
eplerenone
2
spironolactone
2
spironolactone/
2
hydrochlorothiazide
triamterene/hydrochlorothiazide 2
Diuretics, Thiazide
chlorothiazide
2
chlorothiazide sodium
2
chlorthalidone tabs 25mg,
2
50mg
DIURIL
3
hydrochlorothiazide
2
indapamide
2
methyclothiazide
2
metolazone
2
Dyslipidemics, Fibric Acid Derivatives
fenofibrate caps 130mg,
2
QL(30/30)
150mg, 43mg
fenofibrate caps 50mg
2
QL(60/30)
fenofibrate micronized
2
QL(30/30)
fenofibrate tabs 145mg, 160mg
2
QL(30/30)
fenofibrate tabs 48mg, 54mg
2
QL(60/30)
fenofibric acid dr cpdr 135mg
2
QL(30/30)
fenofibric acid dr cpdr 45mg
2
QL(60/30)
gemfibrozil
2
TRIGLIDE
4
QL(30/30)
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium
1
QL(30/30)
CRESTOR
3
QL(30/30)
fluvastatin caps 20mg
1
QL(30/30)
fluvastatin caps 40mg
1
QL(60/30)
fluvastatin sodium er
2
QL(30/30)
LESCOL XL
4
QL(30/30)
lovastatin tabs 40mg
1
QL(60/30)
lovastatin tabs 10mg, 20mg
1
QL(90/30)
pravastatin sodium tabs 80mg
1
QL(30/30)
pravastatin sodium tabs 40mg
1
QL(60/30)
DRUG REQUIREMENTS/
TIER LIMITS
pravastatin sodium tabs 10mg,
1
QL(90/30)
20mg
simvastatin tabs 20mg, 40mg,
1
QL(30/30)
80mg
simvastatin tabs 10mg, 5mg
1
QL(90/30)
Dyslipidemics, Other
cholestyramine
2
cholestyramine light
2
colestipol hcl
2
JUXTAPID
5
KYNAMRO
5
niacin er tbcr 500mg
2
QL(30/30)
niacin er tbcr 1000mg, 750mg
2
QL(60/30)
niacor
2
omega-3-acid ethyl esters
2
QL(120/30)
prevalite
2
VASCEPA
4
QL(120/30)
VYTORIN
4
QL(30/30)
WELCHOL
3
ZETIA
3
QL(30/30)
Vasodilators, Direct-acting Arterial
hydralazine hcl
2
minoxidil
2
Vasodilators, Direct-acting Arterial/Venous
BIDIL
4
isosorbide dinitrate er
2
isosorbide dinitrate tabs
2
isosorbide mononitrate
2
isosorbide mononitrate er
2
minitran
2
NITRO-BID
4
NITRO-DUR PT24 0.3MG/HR,
4
0.8MG/HR
nitroglycerin
2
nitroglycerin lingual translingual
2
soln
nitroglycerin transdermal
2
NITROSTAT
3
RECTIV
4
30
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
tetrabenazine
XENAZINE
Fibromyalgia Agents
SAVELLA
SAVELLA TITRATION PACK
Multiple Sclerosis Agents
AMPYRA
AUBAGIO
AVONEX
AVONEX PEN
COPAXONE INJ 40MG/ML
EXTAVIA
GILENYA
glatopa
REBIF
REBIF REBIDOSE
REBIF REBIDOSE TITRATION
PACK
REBIF TITRATION PACK
TYSABRI
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents,
Amphetamines
amphetamine/
2
QL(60/30)
dextroamphetamine cp24
amphetamine/
2
dextroamphetamine tabs
dextroamphetamine sulfate
2
dextroamphetamine sulfate er
2
methamphetamine hcl
2
PA
Attention Deficit Hyperactivity Disorder Agents,
Non-amphetamines
clonidine hcl er
2
QL(120/30)
DAYTRANA
4
QL(30/30)
dexmethylphenidate hcl
2
metadate er
2
QL(90/30)
METHYLIN CHEW
4
methylphenidate hcl
2
methylphenidate hcl cd
2
methylphenidate hcl er cp24
2
20mg, 40mg
methylphenidate hcl er tb24
2
QL(30/30)
methylphenidate hcl er tbcr
2
QL(90/30)
20mg
methylphenidate hcl er tbcr
2
QL(180/30)
10mg
methylphenidate hydrochloride
2
STRATTERA CAPS 100MG,
3
QL(30/30)
60MG, 80MG
STRATTERA CAPS 10MG,
3
QL(60/30)
18MG, 25MG, 40MG
Central Nervous System, Other
HETLIOZ
5
PA QL(30/30)
HORIZANT
4
NUEDEXTA
3
QL(60/30)
riluzole
2
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
5
5
3
3
QL(60/30)
QL(55/30)
5
5
5
5
5
5
5
5
5
5
5
PA QL(60/30)
PA QL(30/30)
5
5
PA
PA QL(30/30)
PA
Dental and Oral Agents
Dental and Oral Agents
ARESTIN
cevimeline hcl
chlorhexidine gluconate mouth/
throat soln
chlorhexidine gluconate oral
rinse
fluoridex daily defense
sensitivity relief pste
KEPIVANCE
oralone
paroex
periogard
4
2
2
2
2
5
2
2
2
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
31
Covered Drugs By Category
DRUG NAME
pilocarpine hcl
pilocarpine hydrochloride
triamcinolone acetonide pste
triamcinolone in orabase
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
2
2
2
2
ORACEA
OXSORALEN
podocon 25 in benzoin tincture
podofilox
PRUDOXIN
rea lo 39
rea lo 40 crea
REGRANEX
remeven
SANTYL
selenium sulfide
TAZORAC
tretinoin crea
tretinoin gel 0.01%, 0.025%
tretinoin microsphere
tretinoin microsphere pump
umecta
umecta mousse
urea 40% nail film
urea crea 39%, 40%, 45%,
47%, 50%
urea gel
urea nail gel
urea susp
UVADEX
VELTIN
VOLTAREN GEL
XERAC AC
zenatane
ZIANA
ZONALON
ZYCLARA
ZYCLARA PUMP
Dermatological Agents
Dermatological Agents
8-MOP
acitretin
adapalene
ammonium lactate
AZELEX
BENZAMYCINPAK
bpo
calcipotriene
calcitrene
CARAC
claravis
clindamycin phosphate/tretinoin
clindamycin/benzoyl peroxide
CONDYLOX GEL
CURITY GAUZE PADS 2”X2”
diclofenac sodium gel 3%
DIFFERIN LOTN
doxepin hydrochloride
doxycycline cpdr
DRITHO-CREME HP
ELIDEL
erythromycin/benzoyl peroxide
FINACEA
fluorouracil crea
fluorouracil external soln
GORDONS UREA OINT 40%
imiquimod
latrix
LEVULAN KERASTICK
methoxsalen
myorisan
neuac
DRUG REQUIREMENTS/
TIER LIMITS
3
5
2
2
3
4
2
2
2
4
2
4
2
4
3
2
4
2
2
3
4
2
3
2
2
4
2
2
3
5
2
2
4
4
2
2
3
2
2
5
2
3
2
4
2
2
2
2
2
2
2
2
2
2
2
3
4
3
3
2
4
3
3
3
PA
PA
PA
PA
PA
B/D PA
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
BUPHENYL TABS
CEREZYME
32
5
5
5
5
B/D PA
Covered Drugs By Category
DRUG NAME
CREON
CYSTADANE
CYSTAGON
ELAPRASE
ELELYSO
FABRAZYME
KUVAN
LUMIZYME
NAGLAZYME
ORFADIN
RAVICTI
sodium phenylbutyrate
SUCRAID
VPRIV
XIAFLEX
ZAVESCA
ZENPEP
DRUG REQUIREMENTS/
TIER LIMITS
3
5
3
5
5
5
5
5
5
5
5
5
5
5
5
5
3
DRUG NAME
hyoscyamine sulfate odt
2
hyoscyamine sulfate subl
2
hyoscyamine sulfate tabs
2
hyoscyamine sulfate tbdp
2
hyosyne
2
methscopolamine bromide
2
nulev
2
oscimin
2
propantheline bromide
2
symax-sl
2
Gastrointestinal Agents, Other
CHENODAL
5
cromolyn sodium conc
5
diphenoxylate/atropine
2
GATTEX
5
PA
loperamide hcl caps
2
metoclopramide hcl
2
MOTOFEN
3
OSMOPREP
4
PAREGORIC
3
RELISTOR
3
ursodiol
2
Histamine2 (H2) Receptor Antagonists
cimetidine
2
cimetidine hcl
2
famotidine inj
2
famotidine premixed
2
famotidine susr
2
famotidine tabs 20mg, 40mg
2
nizatidine caps
2
ranitidine hcl
2
Irritable Bowel Syndrome Agents
alosetron hydrochloride
5
PA
AMITIZA
3
QL(60/30)
B/D PA
B/D PA
PA
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
anaspaz
2
2
atropine sulfate inj 0.05mg/ml,
0.1mg/ml, 0.4mg/ml, 0.8mg/ml,
1mg/ml
belladonna & opium
2
belladonna alkaloids & opium
2
CUVPOSA
4
dicyclomine hcl caps
2
dicyclomine hcl oral soln
2
dicyclomine hcl tabs
2
ed-spaz
2
glycopyrrolate inj 0.2mg/ml,
2
0.4mg/2ml, 1mg/5ml, 4mg/20ml
glycopyrrolate tabs
2
hyoscyamine sulfate elix
2
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
33
Covered Drugs By Category
DRUG NAME
LINZESS
Laxatives
constulose
enulose
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
generlac
GOLYTELY
KRISTALOSE
lactulose
MOVIPREP
NULYTELY/FLAVOR PACKS
peg 3350/electrolytes
peg-3350/electrolytes
peg-3350/nacl/na bicarbonate/
kcl
polyethylene glycol 3350
SUPREP BOWEL PREP
trilyte
Protectants
CARAFATE SUSP
misoprostol
sucralfate
Proton Pump Inhibitors
DEXILANT
esomeprazole magnesium
esomeprazole sodium
lansoprazole
omeprazole cpdr
omeprazole/sodium
bicarbonate caps
omeprazole/sodium
bicarbonate pack
pantoprazole sodium inj
pantoprazole sodium tbec
rabeprazole sodium
ZEGERID PACK
DRUG REQUIREMENTS/
TIER LIMITS
4
DRUG NAME
QL(30/30)
Genitourinary Agents
Antispasmodics, Urinary
azuphen mb
2
flavoxate hcl
2
GELNIQUE
3
QL(30/30)
HYOLEV MB
4
MYRBETRIQ
4
QL(30/30)
oxybutynin chloride
2
oxybutynin chloride er tb24
2
QL(30/30)
5mg
oxybutynin chloride er tb24
2
QL(60/30)
10mg, 15mg
phosphasal
2
tolterodine tartrate
2
QL(60/30)
tolterodine tartrate er
2
QL(30/30)
trospium chloride
2
QL(60/30)
trospium chloride er
2
QL(30/30)
ur n-c
2
uramit mb
2
URELLE
4
uribel
2
urin d/s
2
URO-L
4
uro-mp
2
ustell
2
utira-c
2
VESICARE
3
QL(30/30)
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er
2
QL(30/30)
AVODART
3
QL(30/30)
CIALIS TABS 2.5MG, 5MG
3
PA QL(30/30)
doxazosin
2
doxazosin mesylate tabs 1mg,
2
2mg, 8mg
dutasteride
2
QL(30/30)
dutasteride/tamsulosin
2
QL(30/30)
hydrochloride
finasteride tabs 5mg
2
JALYN
3
QL(30/30)
2
2
2
2
2
2
3
4
2
3
3
2
2
2
2
3
2
4
2
2
4
2
2
2
2
2
QL(60/30)
QL(60/30)
4
QL(60/30)
2
2
2
4
QL(60/30)
QL(60/30)
QL(60/30)
DRUG REQUIREMENTS/
TIER LIMITS
QL(60/30)
QL(60/30)
QL(60/30)
34
Covered Drugs By Category
DRUG NAME
tamsulosin hcl
terazosin hcl
Genitourinary Agents, Other
acetic acid 0.25%
bethanechol chloride
ELMIRON
LITHOSTAT
phenazopyridine hcl
Phosphate Binders
AURYXIA
calcium acetate caps
calcium acetate tabs 667mg
FOSRENOL
PHOSLYRA
RENVELA
VELPHORO
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
2
2
clobetasol propionate e
clobetasol propionate emollient
foam
clocortolone pivalate
clocortolone pivalate pump
clodan
CORDRAN TAPE
cormax scalp application
CORTIFOAM
cortisone acetate
DEPO-MEDROL INJ 20MG/ML
DESONATE
desonide
desoximetasone
dexamethasone
dexamethasone intensol
dexamethasone sodium
phosphate
diflorasone diacetate
fludrocortisone acetate
fluocinolone acetonide
fluocinolone acetonide body
fluocinolone acetonide ear
drops
fluocinolone acetonide scalp
fluocinonide
fluocinonide-e
flurandrenolide
fluticasone propionate
halobetasol propionate
hydrocortisone butyrate
hydrocortisone crea 1%, 2.5%
hydrocortisone lotn 2.5%
hydrocortisone oint 1%, 2.5%
hydrocortisone tabs
2
2
4
4
2
4
2
2
5
4
3
4
ST
ST
Hormonal Agents, Stimulant/Replacement/Modifying
(Adrenal)
Hormonal Agents, Stimulant/Replacement/Modifying
(Adrenal)
a-hydrocort
2
ala cort
2
ALA SCALP
3
alclometasone dipropionate
2
amcinonide
2
ARISTOSPAN INTRA4
ARTICULAR
augmented betamethasone
2
dipropionate
betamethasone dipropionate
2
2
betamethasone sodium
phosphate/betamethasone
acetate
betamethasone valerate
2
clobetasol propionate
2
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
2
2
3
2
4
2
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
35
Covered Drugs By Category
DRUG NAME
hydrocortisone valerate
KENALOG
lokara
MEDROL TABS 2MG
methylprednisolone
methylprednisolone acetate
methylprednisolone dose pack
methylprednisolone
sodiumsuccinate inj 125mg,
40mg
methylprednisolone
sodiumsuccinate inj 1000mg
mometasone furoate crea
mometasone furoate external
soln
mometasone furoate oint
PANDEL
prednicarbate
prednisolone oral soln
prednisolone sodium
phosphate
prednisone
prednisone intensol
procto-med hc
procto-pak
proctosol hc
proctozone-hc
SOLU-CORTEF
SOLU-MEDROL INJ 500MG
SOLU-MEDROL INJ 2GM
TEXACORT
triamcinolone acetonide aers
triamcinolone acetonide crea
triamcinolone acetonide lotn
triamcinolone acetonide oint
trianex
triderm
VERDESO
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
2
4
2
4
2
2
2
2
2
Hormonal Agents, Stimulant/Replacement/Modifying
(Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying
(Pituitary)
desmopressin acetate
2
EGRIFTA INJ 1MG
5
PA QL(60/30)
H.P. ACTHAR
5
PA
SAIZEN
5
PA
SAIZEN CLICK.EASY
5
PA
SEROSTIM
5
PA
ZORBTIVE
5
PA
HI
2
2
Hormonal Agents, Stimulant/Replacement/Modifying
(Sex Hormones/Modifiers)
Anabolic Steroids
ANADROL-50
oxandrolone
Androgens
ANDRODERM
ANDROGEL
ANDROGEL PUMP GEL 1.62%
ANDROXY
danazol
methitest
STRIANT
TESTIM
testosterone cypionate
testosterone enanthate
testosterone gel 25mg/2.5gm
testosterone pump
Estrogens
ALORA
altavera
amethia
amethia lo
amethyst
ANGELIQ
apri
aranelle
2
3
2
2
2
2
2
2
2
2
2
3
3
3
3
2
2
2
2
2
2
4
DRUG REQUIREMENTS/
TIER LIMITS
HI
36
5
2
PA
PA
3
3
3
4
2
2
4
3
2
2
2
2
4
2
2
2
2
4
2
2
PA
PA
Covered Drugs By Category
DRUG NAME
ashlyna
aubra
aviane
azurette
balziva
bekyree
blisovi fe 1.5/30
blisovi fe 1/20
briellyn
camrese
camrese lo
chateal
CLIMARA PRO
COMBIPATCH
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
cyred
daysee
delyla
DEPO-ESTRADIOL
desogestrel/ethinyl estradiol
DIVIGEL GEL 0.25MG/0.25GM,
0.5MG/0.5GM
drospirenone/ethinyl estradiol
emoquette
ENJUVIA
enpresse-28
enskyce
estarylla
ESTRACE CREA
estradiol pttw
estradiol ptwk
estradiol tabs
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
2
2
2
2
2
2
2
2
2
4
4
2
2
2
2
2
2
3
2
4
2
2
3
2
2
2
4
2
2
2
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG NAME
estradiol/norethindrone acetate
ESTRING
ESTROGEL
estropipate
falmina
FEMRING
fyavolv
gianvi
gildagia
gildess 1.5/30
gildess 1/20
gildess 24 fe
gildess fe 1.5/30
gildess fe 1/20
introvale
jevantique lo
jinteli
jolessa
juleber
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
junel fe 24
kaitlib fe
kariva
kelnor 1/35
kimidess
kurvelo
larin 1.5/30
larin 1/20
larin fe 1.5/30
larin fe 1/20
layolis fe
PA QL(4/28)
PA
PA
PA
PA
DRUG REQUIREMENTS/
TIER LIMITS
2
4
4
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
PA
PA
QL(1/90)
PA
PA
PA
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
37
Covered Drugs By Category
DRUG NAME
leena
lessina
levonest
levonorgestrel and ethinyl
estradiol
levonorgestrel/ethinyl estradiol
levora 0.15/30-28
lomedia 24 fe
lopreeza
loryna
low-ogestrel
lutera
marlissa
MENEST
MENOSTAR
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
mimvey
mimvey lo
mono-linyah
mononessa
myzilra
necon 0.5/35-28
necon 1/35
necon 1/50-28
necon 10/11-28
necon 7/7/7
nikki
norethindrone & ethinyl
estradiol ferrous fumarate
norethindrone acetate/ethinyl
estradiol tabs 20mcg; 1mg
norethindrone acetate/ethinyl
estradiol tabs 2.5mcg; 0.5mg,
5mcg; 1mg
norethindrone acetate/ethinyl
estradiol/ferrous fumarate
norgestimate/ethinyl estradiol
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
2
2
2
2
2
2
2
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
nortrel 0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
NUVARING
ocella
ogestrel
orsythia
ORTHO TRI-CYCLEN LO
pimtrea
pirmella 1/35
portia-28
PREFEST
PREMARIN CREA
PREMARIN INJ
PREMARIN TABS
PREMPHASE
PREMPRO
previfem
quasense
reclipsen
setlakin
sprintec 28
sronyx
tarina fe 1/20
tri-estarylla
tri-legest fe
tri-linyah
tri-lo-estarylla
tri-lo-marzia
tri-lo-sprintec
tri-previfem
tri-sprintec
trinessa
trinessa lo
trivora-28
VAGIFEM
velivet
vestura
vienva
PA
PA
PA
PA
PA
2
2
PA
2
2
38
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
4
2
2
2
4
2
2
2
4
3
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
2
2
2
PA
PA QL(30/30)
PA
PA
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
viorele
2
vyfemla
2
wymzya fe
2
xulane
2
zenchent
2
zenchent fe
2
zovia 1/35e
2
zovia 1/50e
2
Progestins
camila
2
deblitane
2
DEPO-PROVERA
3
DEPO-SUBQ PROVERA 104
3
errin
2
heather
2
hydroxyprogesterone caproate
5
PA
jencycla
2
jolivette
2
lyza
2
MAKENA
5
PA
medroxyprogesterone acetate
2
MEGACE ES
3
PA
megestrol acetate
2
PA
nora-be
2
norethindrone
2
norethindrone acetate
2
norlyroc
2
progesterone
2
sharobel
2
Selective Estrogen Receptor Modifying Agents
raloxifene hydrochloride
2
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
Hormonal Agents, Stimulant/Replacement/Modifying
(Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying
(Thyroid)
levothyroxine sodium inj
5
levothyroxine sodium tabs
2
LEVOXYL
3
liothyronine sodium
2
SYNTHROID
4
THYROLAR-1
4
THYROLAR-1/2
4
THYROLAR-1/4
4
THYROLAR-2
4
THYROLAR-3
4
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
3
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABS 30MG
3
QL(60/30)
SENSIPAR TABS 60MG
5
QL(60/30)
SENSIPAR TABS 90MG
5
QL(120/30)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline
2
ELIGARD INJ 30MG
4
PA QL(1/120)
ELIGARD INJ 45MG
4
PA QL(1/180)
ELIGARD INJ 7.5MG
4
PA QL(1/30)
ELIGARD INJ 22.5MG
4
PA QL(1/90)
FIRMAGON INJ 80MG
4
B/D PA
FIRMAGON INJ 120MG
5
B/D PA
leuprolide acetate
2
PA
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
39
Covered Drugs By Category
DRUG NAME
LUPRON DEPOT
LUPRON DEPOT-PED
octreotide acetate inj 1000mcg/
ml, 500mcg/ml
octreotide acetate inj 100mcg/
ml, 200mcg/ml, 50mcg/ml
SANDOSTATIN LAR DEPOT
SIGNIFOR
SOMATULINE DEPOT
SOMAVERT
SYNAREL
TRELSTAR INJ 3.75MG
TRELSTAR INJ 11.25MG
TRELSTAR MIXJECT INJ
22.5MG
TRELSTAR MIXJECT INJ
3.75MG
TRELSTAR MIXJECT INJ
11.25MG
ZOLADEX
DRUG REQUIREMENTS/
TIER LIMITS
5
5
5
DRUG NAME
PA
PA
cyclosporine modified
ENBREL
ENBREL SURECLICK
ENVARSUS XR
gengraf
HUMIRA
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK
HUMIRA PEN
HUMIRA PEN-CROHNS
DISEASESTARTER
HUMIRA PEN-PSORIASIS
STARTER
KINERET
methotrexate
methotrexate sodium inj 1gm,
1gm/40ml, 250mg/10ml
mycophenolate mofetil
mycophenolic acid dr
MYFORTIC
NEORAL
NULOJIX
ORENCIA INJ 250MG
PROGRAF CAPS 5MG
PROGRAF CAPS 0.5MG, 1MG
PROGRAF INJ
RAPAMUNE ORAL SOLN
RAPAMUNE TABS 1MG, 2MG
RAPAMUNE TABS 0.5MG
REMICADE
RHEUMATREX
SANDIMMUNE
sirolimus
tacrolimus caps
TORISEL
TREXALL
ZORTRESS TABS 0.25MG
ZORTRESS TABS 0.5MG,
0.75MG
2
5
5
5
5
5
5
5
5
PA
PA QL(2/28)
PA QL(2/84)
PA QL(2/168)
5
PA QL(2/28)
5
PA QL(2/84)
4
PA
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole
propylthiouracil
2
2
Immunological Agents
Angioedema (HAE) Agents
BERINERT
CINRYZE
FIRAZYR
KALBITOR
Immune Suppressants
ASTAGRAF XL
azathioprine
BENLYSTA
CELLCEPT CAPS
CELLCEPT INTRAVENOUS
CELLCEPT SUSR
CELLCEPT TABS
cyclosporine
5
5
5
5
4
2
5
4
4
5
5
2
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
40
DRUG REQUIREMENTS/
TIER LIMITS
2
5
5
4
2
5
5
PA
PA
PA
PA
PA
PA
PA
5
5
PA
PA
5
PA
5
2
2
PA
2
2
3
4
5
5
5
4
4
5
5
4
5
4
3
2
2
5
4
4
5
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
B/D PA
B/D PA
B/D PA
Covered Drugs By Category
DRUG NAME
Immunizing Agents, Passive
ATGAM
BIVIGAM
CARIMUNE NANOFILTERED
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID INJ
2.5GM/25ML, 30GM/300ML
GAMMAGARD S/D IGA LESS
THAN 1MCG/ML
GAMMAKED INJ 1GM/10ML
GAMMAPLEX
GAMUNEX-C
HIZENTRA
OCTAGAM INJ 10GM/100ML,
1GM/20ML, 20GM/200ML,
2GM/20ML, 5GM/50ML
PRIVIGEN
THYMOGLOBULIN
Immunomodulators
ACTIMMUNE
ARCALYST
ILARIS
leflunomide
RIDAURA
SIMULECT
SYNAGIS
Vaccines
ACTHIB
ADACEL
BCG VACCINE
BEXSERO
BOOSTRIX
CERVARIX
DAPTACEL
DRUG REQUIREMENTS/
TIER LIMITS
5
5
5
5
3
5
PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
5
B/D PA
5
5
5
5
5
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
5
5
B/D PA
B/D PA
5
5
5
2
5
5
5
DRUG NAME
DIPHTHERIA/TETANUS
TOXOIDS ADSORBED
PEDIATRIC
ENGERIX-B
GARDASIL
GARDASIL 9
HAVRIX
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
M-M-R II
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
PEDIARIX
PEDVAX HIB
PENTACEL
PROQUAD
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TENIVAC
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
TRUMENBA
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
PA
PA
B/D PA
PA
3
3
3
3
3
3
3
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
B/D PA
B/D PA
3
3
3
3
3
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
41
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
VARIZIG INJ 125UNIT/1.2ML
YF-VAX
ZOSTAVAX
DRUG NAME
4
3
3
zoledronic acid
3
4
2
3
3
3
2
3
Miscellaneous Therapeutic Agents
BD SAFETYGLIDE 27G X 5/8”
3
BOTOX
4
DYSPORT
4
FERRIPROX
5
fomepizole
5
KORLYM
5
LACTATED RINGERS
3
IRRIGATION
levocarnitine
2
methylergonovine maleate
2
5
NATPARA
NOVOFINE 30GX8MM
3
NOVOFINE 31
3
NOVOFINE 32GX6MM
3
NOVOFINE AUTOCOVER
3
30GX8MM
NOVOTWIST 30GX8MM
3
NOVOTWIST 32GX5MM
3
PHYSIOLYTE
3
PHYSIOSOL IRRIGATION
3
RINGERS IRRIGATION
3
sodium chloride 0.9%
2
sterile water irrigation
2
V-GO 20
4
V-GO 30
4
V-GO 40
4
XEOMIN
4
ST
2
2
2
2
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate sodium
calcitonin-salmon
calcitriol caps
calcitriol inj
calcitriol oral soln
doxercalciferol
etidronate disodium
FORTEO
FORTICAL
FOSAMAX PLUS D
ibandronate sodium
MIACALCIN INJ
pamidronate disodium
paricalcitol
PROLIA
risedronate sodium tabs 150mg
XGEVA
2
2
2
2
2
2
2
5
3
4
2
4
2
2
4
2
5
2
B/D PA
Miscellaneous Therapeutic Agents
Inflammatory Bowel Disease Agents
Aminosalicylates
APRISO
ASACOL HD
balsalazide disodium
CANASA
DIPENTUM
LIALDA
mesalamine
PENTASA
Glucocorticoids
budesonide cpep
colocort
hydrocortisone enem
Sulfonamides
sulfasalazine
DRUG REQUIREMENTS/
TIER LIMITS
PA
PA
PA QL(120/30)
PA
B/D PA
B/D PA
PA
Ophthalmic Agents
QL(4/28) ST
Ophthalmic Prostaglandin and Prostamide Analogs
bimatoprost
2
QL(5/30)
COMBIGAN
3
latanoprost
2
LUMIGAN
3
QL(5/30)
TRAVATAN Z
3
QL(5/30)
travoprost
2
QL(5/30)
B/D PA
PA
42
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
ZIOPTAN
Ophthalmic Agents, Other
atropine sulfate oint
atropine sulfate ophthalmic soln
CYCLOGYL OPHTHALMIC
SOLN 0.5%
CYCLOMYDRIL
cyclopentolate hcl
cyclopentolate hydrochloride
CYSTARAN
homatropaire
LACRISERT
naphazoline hcl
phenylephrine hcl ophthalmic
soln 10%, 2.5%
polycin
PROCYSBI
proparacaine hcl
RESTASIS
tropicamide
Ophthalmic Anti-allergy Agents
ALOCRIL
ALOMIDE
azelastine hcl
cromolyn sodium ophthalmic
soln
EMADINE
epinastine hcl
olopatadine hcl ophthalmic soln
PATADAY
PAZEO
Ophthalmic Anti-inflammatories
bromfenac
dexamethasone sodium
phosphate
4
DRUG NAME
QL(30/30)
diclofenac sodium ophthalmic
2
soln
DUREZOL
3
FLAREX
4
fluorometholone
2
flurbiprofen sodium
2
FML
4
FML FORTE
4
ketorolac tromethamine
2
ophthalmic soln
LOTEMAX
4
MAXIDEX
4
neomycin/polymyxin/
2
dexamethasone
NEVANAC
3
PRED MILD
4
PRED-G
3
PRED-G S.O.P.
3
prednisolone acetate
2
prednisolone sodium
2
phosphate
TOBRADEX OINT
4
tobramycin/dexamethasone
2
VEXOL
4
Ophthalmic Antiglaucoma Agents
acetazolamide er
2
ALPHAGAN P OPHTHALMIC
3
SOLN 0.1%
apraclonidine
2
AZOPT
3
betaxolol hcl
2
BETIMOL
4
BETOPTIC-S
3
brimonidine tartrate
2
carteolol hcl
2
dorzolamide hcl
2
2
2
3
3
2
2
5
2
4
2
2
2
5
2
3
2
4
4
2
2
4
2
2
3
3
2
2
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG REQUIREMENTS/
TIER LIMITS
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
43
Covered Drugs By Category
DRUG NAME
dorzolamide hcl/timolol maleate
IOPIDINE OPHTHALMIC
SOLN 1%
isopto carpine
ISTALOL
levobunolol hcl
methazolamide
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl
SIMBRINZA
timolol maleate
timolol maleate ophthalmic gel
forming
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
2
4
ASMANEX TWISTHALER 30
3
METERED DOSES
ASMANEX TWISTHALER 60
3
METERED DOSES
ASMANEX TWISTHALER 7
3
METERED DOSES
budesonide susp 0.25mg/2ml,
2
0.5mg/2ml, 1mg/2ml
FLOVENT DISKUS
3
FLOVENT HFA
3
flunisolide
2
fluticasone propionate
2
PULMICORT FLEXHALER
4
PULMICORT SUSP 1MG/2ML
4
QVAR
3
SYMBICORT
3
Antihistamines
azelastine hcl
2
CLARINEX-D 12 HOUR
4
desloratadine
2
desloratadine odt
2
diphenhydramine hcl inj
2
DYMISTA
3
levocetirizine dihydrochloride
2
oral soln
levocetirizine dihydrochloride
2
tabs
promethazine hcl
2
SEMPREX-D
4
Antileukotrienes
montelukast sodium
2
zafirlukast
2
Bronchodilators, Anticholinergic
COMBIVENT RESPIMAT
3
ipratropium bromide inhalation
2
soln
ipratropium bromide nasal soln
2
ipratropium bromide/albuterol
2
sulfate
SPIRIVA HANDIHALER
3
SPIRIVA RESPIMAT
3
2
4
2
2
2
4
2
4
2
2
Otic Agents
Otic Agents
acetasol hc
acetic acid
acetic acid/aluminum acetate
antipyrine/benzocaine otic soln
54mg/ml; 14mg/ml
aurodex
COLY-MYCIN S
fluocinolone acetonide
hydrocortisone/acetic acid
neomycin/polymyxin/hc
neomycin/polymyxin/
hydrocortisone
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
2
2
4
2
2
2
2
Respiratory Tract/Pulmonary Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
3
ADVAIR HFA
3
ALVESCO
4
ASMANEX HFA
3
ASMANEX TWISTHALER 120
3
METERED DOSES
ASMANEX TWISTHALER 14
3
METERED DOSES
44
B/D PA
ST
B/D PA
QL(60/30)
QL(30/30)
QL(30/30)
QL(300/30)
QL(30/30)
PA
B/D PA
B/D PA
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
TUDORZA PRESSAIR
3
Bronchodilators, Sympathomimetic
ADRENALIN INJ
3
albuterol
2
albuterol sulfate er
2
albuterol sulfate nebu
2
albuterol sulfate syrp
2
albuterol sulfate tabs
2
ARCAPTA NEOHALER
4
BROVANA
4
epinephrine
2
epinephrine hcl
2
EPIPEN 2-PAK
3
EPIPEN-JR 2-PAK
3
FORADIL AEROLIZER
3
ISUPREL
3
levalbuterol
2
levalbuterol hcl
2
metaproterenol sulfate
2
PERFOROMIST
4
PROAIR HFA
3
PROAIR RESPICLICK
3
PROVENTIL HFA
4
SEREVENT DISKUS
3
STRIVERDI RESPIMAT
3
terbutaline sulfate
2
XOPENEX HFA
4
Cystic Fibrosis Agents
BETHKIS
5
CAYSTON
5
KALYDECO
5
PULMOZYME
5
TOBI PODHALER
5
tobramycin
5
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
Mast Cell Stabilizers
cromolyn sodium nebu
2
B/D PA
Phosphodiesterase Inhibitors, Airways Disease
aminophylline
2
DALIRESP
3
ELIXOPHYLLIN
4
THEO-24
3
theochron
2
theophylline
2
theophylline cr
2
theophylline er
2
theophylline/d5w inj 5%; 0.8mg/ 2
ml
Pulmonary Antihypertensives
5
PA QL(60/30)
ADCIRCA
ADEMPAS
5
QL(90/30)
LETAIRIS
5
OPSUMIT
5
PA QL(30/30)
REMODULIN
5
B/D PA
sildenafil tabs
2
PA
TRACLEER
5
TYVASO
5
B/D PA
VENTAVIS
5
PA
Respiratory Tract Agents, Other
acetylcysteine inhalation soln
2
B/D PA
ARALAST NP INJ 500MG
5
B/D PA
ESBRIET
5
PA
GLASSIA
5
B/D PA
PROLASTIN-C
5
B/D PA
promethazine vc plain
2
PA
STIOLTO RESPIMAT
3
TYZINE PEDIATRIC NASAL
4
DROPS
VIRAZOLE
5
B/D PA
XOLAIR
5
PA
B/D PA
B/D PA
QL(2/30)
QL(2/30)
QL(2/30)
B/D PA
B/D PA
B/D PA
B/D PA
PA QL(60/30)
B/D PA
B/D PA
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
45
Covered Drugs By Category
DRUG NAME
ZEMAIRA
DRUG REQUIREMENTS/
TIER LIMITS
5
DRUG NAME
Electrolyte/Mineral Replacement
AMINOSYN
3
AMINOSYN 7%/
3
ELECTROLYTES
AMINOSYN 8.5%/
3
ELECTROLYTES
AMINOSYN II
3
AMINOSYN II 8.5%/
3
ELECTROLYTES
AMINOSYN M
3
AMINOSYN-HBC
3
AMINOSYN-PF
3
AMINOSYN-PF 7%
3
AMINOSYN-RF
3
ammonium chloride
2
calcium chloride
2
calcium gluconate inj
2
CARBAGLU
5
citric acid/sodium citrate
2
CLINIMIX 2.75%/DEXTROSE
3
5%
CLINIMIX 4.25%/DEXTROSE
3
10%
CLINIMIX 4.25%/DEXTROSE
3
20%
CLINIMIX 4.25%/DEXTROSE
3
25%
CLINIMIX 4.25%/DEXTROSE
3
5%
CLINIMIX 5%/DEXTROSE 15% 3
CLINIMIX 5%/DEXTROSE 20% 3
CLINIMIX 5%/DEXTROSE 25% 3
CLINIMIX E 2.75%/
3
DEXTROSE 10%
CLINIMIX E 2.75%/
3
DEXTROSE 5%
CLINIMIX E 4.25%/
3
DEXTROSE 10%
CLINIMIX E 4.25%/
3
DEXTROSE 25%
CLINIMIX E 4.25%/
3
DEXTROSE 5%
B/D PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
cyclobenzaprine hcl tabs 10mg,
5mg
orphenadrine citrate er
2
PA
2
PA
2
2
2
QL(90/365)
QL(90/365)
QL(90/365)
4
2
2
4
4
4
5
PA QL(30/30)
PA QL(30/30)
PA QL(60/30)
PA QL(30/30)
QL(30/30)
QL(30/30)
Sleep Disorder Agents
GABA Receptor Modulators
temazepam
zaleplon
zolpidem tartrate tabs
Sleep Disorders, Other
armodafinil
modafinil tabs 100mg
modafinil tabs 200mg
NUVIGIL
ROZEREM
SILENOR
XYREM
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
CHEMET
CUPRIMINE
DEPEN TITRATABS
EXJADE
JADENU
kionex
SAMSCA TABS 30MG
SAMSCA TABS 15MG
sodium bicarbonate inj
sodium bicarbonate partial fill
SODIUM LACTATE INJ 5MEQ/
ML
sodium polystyrene sulfonate
powd
sodium polystyrene sulfonate
susp 15gm/60ml, 30gm/120ml
SYPRINE
4
5
3
5
5
2
5
5
2
2
3
DRUG REQUIREMENTS/
TIER LIMITS
QL(60/30)
QL(90/30)
B/D PA
B/D PA
B/D PA
2
2
5
46
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
Covered Drugs By Category
DRUG NAME
CLINIMIX E 5%/DEXTROSE
15%
CLINIMIX E 5%/DEXTROSE
20%
CLINIMIX E 5%/DEXTROSE
25%
CLINISOL SF 15%
clinpro 5000
cytra k crystals
cytra-2
cytra-3
cytra-k
denta 5000 plus
dentagel
DEXTROSE 10%/NACL 0.45%
DEXTROSE 5% /
ELECTROLYTE #48 VIAFLEX
dextrose 10% flex container
DEXTROSE 10%/NACL 0.2%
DEXTROSE 2.5%/NACL 0.45%
DEXTROSE 2.5%/SODIUM
CHLORIDE 0.45%
dextrose 20%
dextrose 25%
dextrose 30%
dextrose 40%
dextrose 5%
DEXTROSE 5%/LACTATED
RINGERS
DEXTROSE 5%/NACL 0.2%
DEXTROSE 5%/NACL 0.225%
DEXTROSE 5%/NACL 0.3%
DEXTROSE 5%/NACL 0.33%
DEXTROSE 5%/NACL 0.45%
DEXTROSE 5%/NACL 0.9%
DRUG REQUIREMENTS/
TIER LIMITS
3
B/D PA
3
B/D PA
3
B/D PA
3
2
2
2
2
2
2
2
3
3
B/D PA
B/D PA
B/D PA
2
3
3
3
B/D PA
B/D PA
B/D PA
B/D PA
2
2
2
2
2
3
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
3
3
3
3
3
3
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
DRUG NAME
DEXTROSE 5%/POTASSIUM
CHLORIDE 0.15%
DEXTROSE 5%/SODIUM
CHLORIDE 0.2%
DEXTROSE 5%/SODIUM
CHLORIDE 0.45%
dextrose 50%
dextrose 70%
effer-k tbef 25meq
effervescent pot chloride
fluor-a-day
fluoride chew 0.25mg, 1.1mg,
2.2mg
fluoridex daily defense
fluoritab chew 0.5mg, 1mg
fluoritab oral soln
flura-drops oral soln 0.25mg/
drop
FREAMINE HBC 6.9%
FREAMINE III INJ
89MEQ/L; 710MG/100ML;
950MG/100ML; 3MEQ/L;
24MG/100ML; 1400MG/100ML;
280MG/100ML; 690MG/100ML;
910MG/100ML; 730MG/100ML;
530MG/100ML; 560MG/100ML;
10MMOLE/L; 120MG/100ML;
1120MG/100ML;
590MG/100ML; 10MEQ/L;
400MG/100ML; 150MG/100ML;
660MG/100ML
HEPATAMINE
hyperlyte-cr
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE 5%
ISOLYTE-P/DEXTROSE 5%
ISOLYTE-S
ISOLYTE-S PH 7.4
DRUG REQUIREMENTS/
TIER LIMITS
3
B/D PA
3
B/D PA
3
B/D PA
2
2
2
2
2
2
B/D PA
B/D PA
2
2
2
2
3
3
B/D PA
B/D PA
3
2
3
3
3
3
3
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
47
Covered Drugs By Category
DRUG NAME
k-effervescent
K-PHOS
K-PHOS NO 2
k-sol
K-TAB TBCR 10MEQ, 20MEQ
k-vescent tbef
KCL 0.075%/D5W/NACL 0.45%
KCL 0.15%/D5W/ NACL 0.3%
KCL 0.15%/D5W/LR
KCL 0.15%/D5W/NACL 0.2%
KCL 0.15%/D5W/NACL 0.225%
KCL 0.15%/D5W/NACL 0.45%
KCL 0.15%/D5W/NACL 0.9%
KCL 0.3%/D5W/LR IV LAC
RING
KCL 0.3%/D5W/NACL 0.45%
KCL 0.3%/D5W/NACL 0.9%
klor-con
KLOR-CON 10
KLOR-CON 8
klor-con m10
klor-con m15
klor-con m20
klor-con sprinkle
klor-con/25
LACTATED RINGERS
DEXTROSE 5% VIAFLEX
LACTATED RINGERS
VIAFLEX
ludent
magnesium sulfate in d5w inj
5%; 10mg/ml
magnesium sulfate inj
MOZOBIL
NEPHRAMINE
NORMOSOL -R
NORMOSOL-M IN D5W
NORMOSOL-R
NORMOSOL-R IN D5W
DRUG REQUIREMENTS/
TIER LIMITS
2
3
3
2
3
2
3
3
3
3
3
3
3
3
3
3
2
3
3
2
2
2
2
2
3
DRUG NAME
NUTRILYTE INJ 2.03MEQ/
ML; 0.25MEQ/ML; 1.68MEQ/
ML; 0.25MEQ/ML; 0.4MEQ/ML;
2.03MEQ/ML; 1.25MEQ
phospha 250 neutral
PLASMA-LYTE A
PLASMA-LYTE-148
PLASMA-LYTE-56/D5W
PLENAMINE
POTASSIUM CHLORIDE
0.15% /NACL 0.45% VIAFLEX
POTASSIUM CHLORIDE
0.15% D5W/NACL 0.33%
POTASSIUM CHLORIDE
0.15% D5W/NACL 0.45%
POTASSIUM CHLORIDE
0.15% D5W/NACL 0.45%
VIAFLEX
POTASSIUM CHLORIDE
0.15% NACL 0.9%
POTASSIUM CHLORIDE
0.15% W/NACL 0.9% VIAFLEX
POTASSIUM CHLORIDE
0.15%/NACL 0.9%
POTASSIUM CHLORIDE
0.22% D5W/NACL 0.45%
POTASSIUM CHLORIDE 0.3%/
NACL 0.9%
POTASSIUM CHLORIDE 0.3%/
D5W
potassium chloride cr
potassium chloride er
potassium chloride inj 0.4meq/
ml, 10meq/100ml, 10meq/50ml,
20meq/100ml, 2meq/ml,
40meq/100ml
potassium chloride oral soln
potassium chloride pack
potassium chloride sr
potassium citrate er
potassium citrate-citric acid
crystals
potassium citrate/citric acid
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
3
2
2
2
5
3
3
3
3
3
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
48
DRUG REQUIREMENTS/
TIER LIMITS
4
B/D PA
2
3
3
3
3
3
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
3
B/D PA
3
B/D PA
3
B/D PA
3
B/D PA
3
B/D PA
3
B/D PA
3
B/D PA
3
B/D PA
3
B/D PA
2
2
2
B/D PA
2
2
2
2
2
2
Covered Drugs By Category
DRUG NAME
DRUG REQUIREMENTS/
TIER LIMITS
DRUG NAME
PREMASOL
3
B/D PA
PROCALAMINE
3
B/D PA
PROSOL
4
B/D PA
RINGERS INJECTION
3
sf
2
sf 5000 plus
2
sodium chloride 0.45% viaflex
2
sodium chloride bacteriostatic
2
sodium chloride bacteriostatic/
2
benzyl alcohol
sodium chloride inj
2
sodium fluoride chew 0.5mg,
2
1mg
sodium fluoride oral soln
2
sodium fluoride tabs
2
TPN ELECTROLYTES
3
B/D PA
TRAVASOL
4
B/D PA
TROPHAMINE
3
B/D PA
virt-phos 250 neutral
2
virtrate-2
2
virtrate-k
2
Therapeutic Nutrients/Minerals/Electrolytes
INTRALIPID
3
B/D PA
KABIVEN
4
B/D PA
NUTRILIPID
3
B/D PA
PERIKABIVEN
4
B/D PA
Vitamins
mult-vitamin/fluoride
2
multi vitamin/fluoride
2
multi-vit/fluoride
2
2
multi-vit/iron/fluoride oral soln
35mg/ml; 400unit/ml; 10mg/ml;
8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.25mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml
CAPITALIZED = BRAND NAME DRUG
QL = Quantity Limits listed as (qty/days)
PA = Prior Authorization may be required
HI = Home Infusion
multi-vitamin/fluoride oral soln
35mg/ml; 400unit/ml; 2mcg/
ml; 5unit/ml; 8mg/ml; 0.4mg/ml;
0.6mg/ml; 0.25mg/ml; 0.5mg/
ml; 1500unit/ml, 35mg/ml;
400unit/ml; 2mcg/ml; 5unit/ml;
8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.5mg/ml; 0.5mg/ml; 1500unit/
ml
multivitamin with fluoride
multivitamin/fluoride chew
60mg; 400unit; 4.5mcg; 0.3mg;
13.5mg; 1.05mg; 1.2mg;
0; 0.25mg; 1.05mg; 15unit;
2500unit
mvc-fluoride
tl-fluorivite
tri-vit/fluoride
tri-vit/fluoride/iron
tri-vitamin/fluoride
triple-vitamin/fluoride
vitamins a/c/d/fluoride
VP-PNV-DHA
DRUG REQUIREMENTS/
TIER LIMITS
2
2
2
2
2
2
2
2
2
2
3
Needles And Syringes
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
bd eclipse syringe/1ml/30gx1/2” 3
bd insulin syringe
3
safetyglide/1ml/29g x 1/2”
bd insulin syringe
3
ultrafine/0.3ml/31g x 5/16”
bd insulin syringe
3
ultrafine/0.5ml/30g x 1/2”
bd insulin syringe
3
ultrafine/1ml/31g x 5/16”
bd pen needle/ultrafine/29g x
3
12.7mm
Lower case italic = Generic drug
ST = Step Therapy rules apply
B/D = Drugs covered under Medicare Part B or Part D
You can find more information on the symbols by going to page 4.
49
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
8
adapalene . . . . . . . . . . . . . . . . . . . . . . . 32
ADCIRCA . . . . . . . . . . . . . . . . . . . . . . . . 45
adefovir dipivoxil . . . . . . . . . . . . . . . . . 23
ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . 45
ADRENALIN INJ . . . . . . . . . . . . . . . . . . 45
adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ADVAIR DISKUS . . . . . . . . . . . . . . . . . 44
ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . 44
afeditab cr . . . . . . . . . . . . . . . . . . . . . . . 29
AFINITOR DISPERZ TBSO
2MG, 3MG. . . . . . . . . . . . . . . . . . . . . . . . 20
AFINITOR DISPERZ TBSO 5MG. . . 20
AFINITOR TABS
2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 20
AFINITOR TABS 10MG. . . . . . . . . . . . 20
AGGRENOX . . . . . . . . . . . . . . . . . . . . . 27
a-hydrocort . . . . . . . . . . . . . . . . . . . . . . 35
ala cort . . . . . . . . . . . . . . . . . . . . . . . . . . 35
ALA SCALP . . . . . . . . . . . . . . . . . . . . . . 35
ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . 20
albuterol . . . . . . . . . . . . . . . . . . . . . . . . . 45
albuterol sulfate er . . . . . . . . . . . . . . . . 45
albuterol sulfate nebu . . . . . . . . . . . . . 45
albuterol sulfate syrp . . . . . . . . . . . . . . 45
albuterol sulfate tabs . . . . . . . . . . . . . . 45
alclometasone dipropionate . . . . . . . 35
ALCOHOL PREP PADS . . . . . . . . . . 10
ALDURAZYME . . . . . . . . . . . . . . . . . . . 32
ALECENSA . . . . . . . . . . . . . . . . . . . . . . 20
alendronate sodium . . . . . . . . . . . . . . 42
alfuzosin hcl er . . . . . . . . . . . . . . . . . . . 34
ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ALINIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
allopurinol . . . . . . . . . . . . . . . . . . . . . . . 17
almotriptan malate tabs 6.25mg . . . . 17
almotriptan malate tabs 12.5mg . . . . 17
ALOCRIL . . . . . . . . . . . . . . . . . . . . . . . . 43
ALOMIDE . . . . . . . . . . . . . . . . . . . . . . . . 43
ALOPRIM . . . . . . . . . . . . . . . . . . . . . . . . 17
ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . 36
alosetron hydrochloride . . . . . . . . . . . 33
ALOXI . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ALPHAGAN P
OPHTHALMIC SOLN 0.1% . . . . . . . . 43
alprazolam er tb24
1mg, 2mg, 3mg. . . . . . . . . . . . . . . . . . . . 24
alprazolam intensol . . . . . . . . . . . . . . . 24
alprazolam odt tbdp
0.25mg, 0.5mg . . . . . . . . . . . . . . . . . . . . 24
alprazolam odt tbdp 1mg. . . . . . . . . . . 24
alprazolam odt tbdp 2mg. . . . . . . . . . . 24
alprazolam tabs 0.25mg, 0.5mg . . . . 24
alprazolam tabs 1mg . . . . . . . . . . . . . . 24
alprazolam tabs 2mg . . . . . . . . . . . . . . 24
alprazolam xr . . . . . . . . . . . . . . . . . . . . 24
ALTABAX . . . . . . . . . . . . . . . . . . . . . . . . 10
altavera . . . . . . . . . . . . . . . . . . . . . . . . . . 36
ALVESCO . . . . . . . . . . . . . . . . . . . . . . . 44
amantadine hcl . . . . . . . . . . . . . . . . . . . 24
AMBISOME . . . . . . . . . . . . . . . . . . . . . . 16
amcinonide . . . . . . . . . . . . . . . . . . . . . . 35
amethia . . . . . . . . . . . . . . . . . . . . . . . . . . 36
amethia lo . . . . . . . . . . . . . . . . . . . . . . . 36
amethyst . . . . . . . . . . . . . . . . . . . . . . . . . 36
amifostine . . . . . . . . . . . . . . . . . . . . . . . 19
amikacin sulfate . . . . . . . . . . . . . . . . . . . . 9
amiloride hcl . . . . . . . . . . . . . . . . . . . . . 29
amiloride/hydrochlorothiazide . . . . . 30
aminocaproic acid . . . . . . . . . . . . . . . . 27
aminophylline . . . . . . . . . . . . . . . . . . . . 45
AMINOSYN . . . . . . . . . . . . . . . . . . . . . . 46
AMINOSYN 7%/ELECTROLYTES. . . 46
AMINOSYN 8.5%/
ELECTROLYTES . . . . . . . . . . . . . . . . 46
AMINOSYN-HBC . . . . . . . . . . . . . . . . . 46
AMINOSYN II . . . . . . . . . . . . . . . . . . . . 46
AMINOSYN II 8.5%/
ELECTROLYTES . . . . . . . . . . . . . . . . 46
AMINOSYN M . . . . . . . . . . . . . . . . . . . 46
AMINOSYN-PF . . . . . . . . . . . . . . . . . . 46
AMINOSYN-PF 7% . . . . . . . . . . . . . . . 46
8-MOP . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
A
abacavir . . . . . . . . . . . . . . . . . . . . . . . . . 23
abacavir sulfate/lamivudine/
zidovudine . . . . . . . . . . . . . . . . . . . . . . . 23
ABELCET . . . . . . . . . . . . . . . . . . . . . . . . 16
ABILIFY MAINTENA INJ 300MG . . . 22
ABILIFY MAINTENA INJ 400MG . . . 22
ABRAXANE . . . . . . . . . . . . . . . . . . . . . . 19
acamprosate calcium dr . . . . . . . . . . . . 9
acarbose . . . . . . . . . . . . . . . . . . . . . . . . 25
acebutolol hcl . . . . . . . . . . . . . . . . . . . . 28
acetaminophen/codeine #2 . . . . . . . . . 8
acetaminophen/codeine #3 . . . . . . . . . 8
acetaminophen/codeine #4 . . . . . . . . . 8
acetaminophen/codeine oral soln. . . . . 8
acetaminophen/codeine
phosphate tabs 300mg; 60mg. . . . . . . . 8
acetaminophen/codeine tabs
300mg; 15mg . . . . . . . . . . . . . . . . . . . . . . . 8
acetaminophen/codeine tabs
300mg; 60mg . . . . . . . . . . . . . . . . . . . . . . . 8
acetasol hc . . . . . . . . . . . . . . . . . . . . . . 44
acetazolamide . . . . . . . . . . . . . . . . . . . 29
acetazolamide er . . . . . . . . . . . . . . . . . 43
acetazolamide sodium . . . . . . . . . . . . 29
acetic acid . . . . . . . . . . . . . . . . . . . . . . . 44
acetic acid 0.25% . . . . . . . . . . . . . . . . 35
acetic acid/aluminum acetate . . . . . 44
acetylcysteine inhalation soln . . . . . . 45
acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . 32
ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . 41
ACTIMMUNE . . . . . . . . . . . . . . . . . . . . 41
acyclovir . . . . . . . . . . . . . . . . . . . . . . . . . 24
acyclovir sodium inj
500mg, 50mg/ml . . . . . . . . . . . . . . . . . . 24
ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . 41
ADAGEN . . . . . . . . . . . . . . . . . . . . . . . . 32
50
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
AMINOSYN-RF . . . . . . . . . . . . . . . . . . 46
amiodarone hcl . . . . . . . . . . . . . . . . . . . 28
AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . 33
amitriptyline hcl . . . . . . . . . . . . . . . . . . 15
amlodipine besylate/
atorvastatin calcium . . . . . . . . . . . . . . 29
amlodipine besylate/benazepril
hydrochloride . . . . . . . . . . . . . . . . . . . . 29
amlodipine besylate tabs 2.5mg . . . . 29
amlodipine besylate tabs
10mg, 5mg. . . . . . . . . . . . . . . . . . . . . . . . 29
amlodipine besylate/valsartan . . . . . 29
amlodipine/valsartan/hctz . . . . . . . . . 29
ammonium chloride . . . . . . . . . . . . . . 46
ammonium lactate . . . . . . . . . . . . . . . . 32
amoxapine . . . . . . . . . . . . . . . . . . . . . . . 16
amoxicillin . . . . . . . . . . . . . . . . . . . . . . . 12
amoxicillin/clavulanate potassium. . . 12
amphetamine/
dextroamphetamine cp24 . . . . . . . . . . 31
amphetamine/
dextroamphetamine tabs . . . . . . . . . . 31
amphotericin b . . . . . . . . . . . . . . . . . . . 16
ampicillin . . . . . . . . . . . . . . . . . . . . . . . . 12
ampicillin sodium inj
10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 12
ampicillin sodium inj
125mg, 250mg, 500mg . . . . . . . . . . . . 12
ampicillin-sulbactam . . . . . . . . . . . . . . 12
AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . 31
ANADROL-50 . . . . . . . . . . . . . . . . . . . . 36
anagrelide hydrochloride . . . . . . . . . . 26
anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . 33
anastrozole . . . . . . . . . . . . . . . . . . . . . . 19
ANDRODERM . . . . . . . . . . . . . . . . . . . 36
ANDROGEL . . . . . . . . . . . . . . . . . . . . . 36
ANDROGEL PUMP GEL 1.62% . . . . 36
ANDROXY . . . . . . . . . . . . . . . . . . . . . . . 36
ANGELIQ . . . . . . . . . . . . . . . . . . . . . . . . 36
antipyrine/benzocaine otic soln
54mg/ml; 14mg/ml. . . . . . . . . . . . . . . . . 44
ANZEMET INJ . . . . . . . . . . . . . . . . . . . . 16
ANZEMET TABS . . . . . . . . . . . . . . . . . . 16
APLENZIN . . . . . . . . . . . . . . . . . . . . . . . 15
APOKYN . . . . . . . . . . . . . . . . . . . . . . . . 21
apraclonidine . . . . . . . . . . . . . . . . . . . . 43
apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
APRISO . . . . . . . . . . . . . . . . . . . . . . . . . 42
APTIOM TABS
200MG, 400MG, 800MG. . . . . . . . . . . 13
APTIOM TABS 600MG. . . . . . . . . . . . . 13
APTIVUS . . . . . . . . . . . . . . . . . . . . . . . . 24
ARALAST NP INJ 500MG. . . . . . . . . . 45
aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . 36
ARANESP ALBUMIN FREE INJ
10MCG/0.4ML, 25MCG/0.42ML,
25MCG/ML, 40MCG/0.4ML,
40MCG/ML, 60MCG/0.3ML,
60MCG/ML . . . . . . . . . . . . . . . . . . . . . . . 26
ARANESP ALBUMIN FREE INJ
100MCG/0.5ML, 100MCG/ML,
150MCG/0.3ML, 200MCG/0.4ML,
200MCG/ML, 300MCG/0.6ML,
300MCG/ML, 500MCG/ML. . . . . . . . . 27
ARCALYST . . . . . . . . . . . . . . . . . . . . . . 41
ARCAPTA NEOHALER . . . . . . . . . . . 45
ARESTIN . . . . . . . . . . . . . . . . . . . . . . . . 31
aripiprazole odt . . . . . . . . . . . . . . . . . . . 22
aripiprazole oral soln . . . . . . . . . . . . . . 22
aripiprazole tabs . . . . . . . . . . . . . . . . . . 22
ARISTADA INJ 441MG/1.6ML. . . . . . 22
ARISTADA INJ 662MG/2.4ML. . . . . . 22
ARISTADA INJ 882MG/3.2ML. . . . . . 22
ARISTOSPAN
INTRA-ARTICULAR . . . . . . . . . . . . . . 35
armodafinil . . . . . . . . . . . . . . . . . . . . . . . 46
ARRANON . . . . . . . . . . . . . . . . . . . . . . . 18
ASACOL HD . . . . . . . . . . . . . . . . . . . . . 42
ascomp/codeine . . . . . . . . . . . . . . . . . . . . 8
ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . 37
ASMANEX HFA . . . . . . . . . . . . . . . . . . 44
ASMANEX TWISTHALER
7 METERED DOSES . . . . . . . . . . . . . 44
ASMANEX TWISTHALER
14 METERED DOSES . . . . . . . . . . . . 44
ASMANEX TWISTHALER
30 METERED DOSES . . . . . . . . . . . . 44
ASMANEX TWISTHALER
60 METERED DOSES . . . . . . . . . . . . 44
ASMANEX TWISTHALER
120 METERED DOSES . . . . . . . . . . 44
aspirin-caffeine-dihydrocodeine. . . . . . . 8
aspirin/dipyridamole . . . . . . . . . . . . . . 27
ASTAGRAF XL . . . . . . . . . . . . . . . . . . . 40
atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . 28
atenolol/chlorthalidone . . . . . . . . . . . . 28
ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . 41
atorvastatin calcium . . . . . . . . . . . . . . 30
atovaquone . . . . . . . . . . . . . . . . . . . . . . 21
atovaquone/proguanil hcl . . . . . . . . . 21
ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . 24
atropine sulfate inj
0.05mg/ml, 0.1mg/ml, 0.4mg/ml,
0.8mg/ml, 1mg/ml . . . . . . . . . . . . . . . . . 33
atropine sulfate oint . . . . . . . . . . . . . . . 43
atropine sulfate ophthalmic soln . . . . 43
AUBAGIO . . . . . . . . . . . . . . . . . . . . . . . 31
aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
augmented betamethasone
dipropionate . . . . . . . . . . . . . . . . . . . . . 35
aurodex . . . . . . . . . . . . . . . . . . . . . . . . . . 44
AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . 35
AVANDIA . . . . . . . . . . . . . . . . . . . . . . . . 25
AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . 20
AVELOX INJ . . . . . . . . . . . . . . . . . . . . . . 13
aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
AVODART . . . . . . . . . . . . . . . . . . . . . . . 34
AVONEX . . . . . . . . . . . . . . . . . . . . . . . . 31
AVONEX PEN . . . . . . . . . . . . . . . . . . . 31
AXERT TABS 6.25MG. . . . . . . . . . . . . 17
AXERT TABS 12.5MG. . . . . . . . . . . . . 17
azacitidine . . . . . . . . . . . . . . . . . . . . . . . 19
AZACTAM IN ISO-OSMOTIC
DEXTROSE INJ 1GM; 0 . . . . . . . . . . . 12
51
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
AZACTAM IN ISO-OSMOTIC
DEXTROSE INJ 2GM; 0 . . . . . . . . . . . 12
AZACTAM INJ 1GM . . . . . . . . . . . . . . . 12
AZACTAM INJ 2GM . . . . . . . . . . . . . . . 12
AZASITE . . . . . . . . . . . . . . . . . . . . . . . . 12
azathioprine . . . . . . . . . . . . . . . . . . . . . . 40
azelastine hcl . . . . . . . . . . . . . . . . . . . . 43
azelastine hcl . . . . . . . . . . . . . . . . . . . . 44
AZELEX . . . . . . . . . . . . . . . . . . . . . . . . . 32
AZILECT . . . . . . . . . . . . . . . . . . . . . . . . 21
azithromycin inj . . . . . . . . . . . . . . . . . . . 12
azithromycin pack . . . . . . . . . . . . . . . . . 12
azithromycin susr . . . . . . . . . . . . . . . . . 12
azithromycin tabs . . . . . . . . . . . . . . . . . 12
AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . 43
aztreonam . . . . . . . . . . . . . . . . . . . . . . . 12
azuphen mb . . . . . . . . . . . . . . . . . . . . . 34
azurette . . . . . . . . . . . . . . . . . . . . . . . . . . 37
benazepril hcl/hydrochlorothiazide. . . 28
BENDEKA . . . . . . . . . . . . . . . . . . . . . . . 18
BENICAR . . . . . . . . . . . . . . . . . . . . . . . . 27
BENICAR HCT . . . . . . . . . . . . . . . . . . . 27
BENLYSTA . . . . . . . . . . . . . . . . . . . . . . 40
BENSAL HP . . . . . . . . . . . . . . . . . . . . . 16
BENZAMYCINPAK . . . . . . . . . . . . . . . 32
benztropine mesylate inj . . . . . . . . . . . 21
benztropine mesylate tabs . . . . . . . . . 21
BERINERT . . . . . . . . . . . . . . . . . . . . . . 40
BESIVANCE . . . . . . . . . . . . . . . . . . . . . 13
betamethasone dipropionate . . . . . . 35
betamethasone sodium phosphate/
betamethasone acetate . . . . . . . . . . . 35
betamethasone valerate . . . . . . . . . . 35
betaxolol hcl . . . . . . . . . . . . . . . . . . . . . 28
betaxolol hcl . . . . . . . . . . . . . . . . . . . . . 43
bethanechol chloride . . . . . . . . . . . . . 35
BETHKIS . . . . . . . . . . . . . . . . . . . . . . . . 45
BETIMOL . . . . . . . . . . . . . . . . . . . . . . . . 43
BETOPTIC-S . . . . . . . . . . . . . . . . . . . . 43
bexarotene . . . . . . . . . . . . . . . . . . . . . . . 20
BEXSERO . . . . . . . . . . . . . . . . . . . . . . . 41
bicalutamide . . . . . . . . . . . . . . . . . . . . . 18
BICILLIN C-R . . . . . . . . . . . . . . . . . . . . 12
BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . 12
BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
bimatoprost . . . . . . . . . . . . . . . . . . . . . . 42
bisoprolol fumarate . . . . . . . . . . . . . . . 28
bisoprolol fumarate/
hydrochlorothiazide . . . . . . . . . . . . . . . 28
BIVIGAM . . . . . . . . . . . . . . . . . . . . . . . . 41
bleomycin sulfate . . . . . . . . . . . . . . . . . 19
BLEPHAMIDE . . . . . . . . . . . . . . . . . . . 13
BLEPHAMIDE S.O.P. . . . . . . . . . . . . . 13
blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . 37
blisovi fe 1/20 . . . . . . . . . . . . . . . . . . . . 37
BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . 41
BOSULIF . . . . . . . . . . . . . . . . . . . . . . . . 20
BOTOX . . . . . . . . . . . . . . . . . . . . . . . . . . 42
bpo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . 37
BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . 27
brimonidine tartrate . . . . . . . . . . . . . . . 43
BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 13
BRIVIACT ORAL SOLN . . . . . . . . . . . 13
BRIVIACT TABS
10MG, 25MG, 50MG, 75MG . . . . . . . 13
BRIVIACT TABS 100MG. . . . . . . . . . . 13
bromfenac . . . . . . . . . . . . . . . . . . . . . . . 43
bromocriptine mesylate . . . . . . . . . . . 21
BROVANA . . . . . . . . . . . . . . . . . . . . . . . 45
budesonide cpep . . . . . . . . . . . . . . . . . 42
budesonide susp 0.25mg/2ml,
0.5mg/2ml, 1mg/2ml. . . . . . . . . . . . . . . 44
bumetanide . . . . . . . . . . . . . . . . . . . . . . 29
BUPHENYL TABS . . . . . . . . . . . . . . . . 32
buprenorphine hcl inj . . . . . . . . . . . . . . . . 9
buprenorphine hcl/naloxone hcl . . . . . 9
buprenorphine hcl subl . . . . . . . . . . . . . . 9
buproban . . . . . . . . . . . . . . . . . . . . . . . . . . 9
bupropion hcl . . . . . . . . . . . . . . . . . . . . 15
bupropion hcl er tb12 100mg. . . . . . . 15
bupropion hcl er tb12 150mg. . . . . . . 15
bupropion hcl sr tb12
100mg, 200mg . . . . . . . . . . . . . . . . . . . . 15
bupropion hcl sr tb12 150mg . . . . . . . . . 9
bupropion hcl sr tb12 150mg . . . . . . . 15
bupropion hcl xl tb24 150mg . . . . . . . 15
bupropion hcl xl tb24 300mg . . . . . . . 15
buspirone hcl . . . . . . . . . . . . . . . . . . . . 24
BUSULFEX . . . . . . . . . . . . . . . . . . . . . . 18
butalbital/acetaminophen . . . . . . . . . . . 7
butalbital/acetaminophen/
caffeine caps . . . . . . . . . . . . . . . . . . . . . . . 7
butalbital/acetaminophen/
caffeine tabs 325mg; 50mg; 40mg. . . . 7
butalbital/aspirin/caffeine . . . . . . . . . . . . 7
butalbital/aspirin/caffeine/codeine. . . . . 8
butorphanol tartrate inj . . . . . . . . . . . . . . 8
B
baciim . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
bacitracin inj . . . . . . . . . . . . . . . . . . . . . . 10
bacitracin ophthalmic oint . . . . . . . . . . 10
bacitracin/polymyxin b . . . . . . . . . . . . 10
baclofen tabs . . . . . . . . . . . . . . . . . . . . . 22
bactocill in dextrose . . . . . . . . . . . . . . 12
balsalazide disodium . . . . . . . . . . . . . 42
balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
BANZEL SUSP . . . . . . . . . . . . . . . . . . . 14
BANZEL TABS 200MG . . . . . . . . . . . . 14
BANZEL TABS 400MG . . . . . . . . . . . . 14
BARACLUDE ORAL SOLN . . . . . . . . 23
BCG VACCINE . . . . . . . . . . . . . . . . . . . 41
BD SAFETYGLIDE 27G X 5/8” . . . . 42
bekyree . . . . . . . . . . . . . . . . . . . . . . . . . . 37
BELEODAQ . . . . . . . . . . . . . . . . . . . . . 19
belladonna alkaloids & opium . . . . . 33
belladonna & opium . . . . . . . . . . . . . . 33
benazepril hcl . . . . . . . . . . . . . . . . . . . . 28
52
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
butorphanol tartrate nasal soln . . . . . . . 8
BUTRANS . . . . . . . . . . . . . . . . . . . . . . . . . 7
BYDUREON . . . . . . . . . . . . . . . . . . . . . 25
BYETTA . . . . . . . . . . . . . . . . . . . . . . . . . 25
BYSTOLIC TABS 2.5MG, 5MG. . . . . 28
BYSTOLIC TABS 10MG . . . . . . . . . . . 28
BYSTOLIC TABS 20MG . . . . . . . . . . . 28
CARBAGLU . . . . . . . . . . . . . . . . . . . . . 46
carbamazepine . . . . . . . . . . . . . . . . . . . 14
carbamazepine er . . . . . . . . . . . . . . . . 14
carbidopa . . . . . . . . . . . . . . . . . . . . . . . . 21
carbidopa/levodopa . . . . . . . . . . . . . . 21
carbidopa/levodopa/entacapone . . . 21
carbidopa/levodopa er . . . . . . . . . . . . 21
carbidopa/levodopa odt . . . . . . . . . . . 21
carboplatin inj 150mg/15ml,
450mg/45ml, 50mg/5ml. . . . . . . . . . . . 19
CARDENE IV . . . . . . . . . . . . . . . . . . . . 29
CARIMUNE NANOFILTERED . . . . . 41
carteolol hcl . . . . . . . . . . . . . . . . . . . . . . 43
cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . 29
carvedilol . . . . . . . . . . . . . . . . . . . . . . . . 28
CAYSTON . . . . . . . . . . . . . . . . . . . . . . . 45
CEDAX CAPS . . . . . . . . . . . . . . . . . . . . . 11
cefaclor . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 11
cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 11
cefazolin . . . . . . . . . . . . . . . . . . . . . . . . . . 11
cefazolin sodium . . . . . . . . . . . . . . . . . . 11
cefazolin sodium/dextrose . . . . . . . . . 11
cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
cefditoren pivoxil . . . . . . . . . . . . . . . . . . 11
cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 11
cefepime/dextrose . . . . . . . . . . . . . . . . . 11
cefixime . . . . . . . . . . . . . . . . . . . . . . . . . . 11
cefotaxime sodium inj
1gm, 2gm, 500mg . . . . . . . . . . . . . . . . . . 11
cefotetan . . . . . . . . . . . . . . . . . . . . . . . . 12
cefotetan/dextrose . . . . . . . . . . . . . . . . . 11
cefoxitin sodium . . . . . . . . . . . . . . . . . . . 11
cefpodoxime proxetil . . . . . . . . . . . . . . . 11
cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ceftazidime . . . . . . . . . . . . . . . . . . . . . . . 11
ceftazidime/dextrose . . . . . . . . . . . . . . . 11
ceftibuten . . . . . . . . . . . . . . . . . . . . . . . . . 11
CEFTIN SUSR . . . . . . . . . . . . . . . . . . . . . 11
ceftriaxone/dextrose . . . . . . . . . . . . . . . 11
ceftriaxone in iso-osmotic dextrose . . . 11
ceftriaxone sodium inj 10gm,
1gm, 250mg, 2gm, 500mg . . . . . . . . . . 11
cefuroxime axetil . . . . . . . . . . . . . . . . . . 11
cefuroxime sodium inj
1.5gm, 7.5gm, 750mg, 75gm. . . . . . . . 11
celecoxib . . . . . . . . . . . . . . . . . . . . . . . . . . 7
CELLCEPT CAPS . . . . . . . . . . . . . . . . 40
CELLCEPT INTRAVENOUS . . . . . . 40
CELLCEPT SUSR . . . . . . . . . . . . . . . . 40
CELLCEPT TABS . . . . . . . . . . . . . . . . . 40
CELONTIN . . . . . . . . . . . . . . . . . . . . . . 13
cephalexin . . . . . . . . . . . . . . . . . . . . . . . . 11
CEREZYME . . . . . . . . . . . . . . . . . . . . . 32
CERVARIX . . . . . . . . . . . . . . . . . . . . . . 41
CESAMET . . . . . . . . . . . . . . . . . . . . . . . 16
cevimeline hcl . . . . . . . . . . . . . . . . . . . . 31
CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CHANTIX CONTINUING
MONTH PAK . . . . . . . . . . . . . . . . . . . . . . . 9
CHANTIX STARTING MONTH PAK. . . . 9
chateal . . . . . . . . . . . . . . . . . . . . . . . . . . 37
CHEMET . . . . . . . . . . . . . . . . . . . . . . . . 46
CHENODAL . . . . . . . . . . . . . . . . . . . . . 33
chloramphenicol
sodium succinate . . . . . . . . . . . . . . . . . 10
chlorhexidine gluconate
mouth/throat soln . . . . . . . . . . . . . . . . . 31
chlorhexidine gluconate oral rinse . . . 31
chloroquine phosphate . . . . . . . . . . . 21
chlorothiazide . . . . . . . . . . . . . . . . . . . . 30
chlorothiazide sodium . . . . . . . . . . . . 30
chlorpromazine hcl inj 50mg/2ml. . . . 21
chlorpromazine hcl tabs . . . . . . . . . . . 21
chlorthalidone tabs 25mg, 50mg. . . . 30
cholestyramine . . . . . . . . . . . . . . . . . . . 30
cholestyramine light . . . . . . . . . . . . . . 30
choline magnesium
trisalicylate liqd . . . . . . . . . . . . . . . . . . . . . 7
CIALIS TABS 2.5MG, 5MG. . . . . . . . . 34
ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . 16
C
cabergoline . . . . . . . . . . . . . . . . . . . . . . 39
CABOMETYX TABS 20MG, 60MG. . . 20
CABOMETYX TABS 40MG . . . . . . . . 20
CAFERGOT . . . . . . . . . . . . . . . . . . . . . 17
calcipotriene . . . . . . . . . . . . . . . . . . . . . 32
calcitonin-salmon . . . . . . . . . . . . . . . . . 42
calcitrene . . . . . . . . . . . . . . . . . . . . . . . . 32
calcitriol caps . . . . . . . . . . . . . . . . . . . . . 42
calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 42
calcitriol oral soln . . . . . . . . . . . . . . . . . 42
calcium acetate caps . . . . . . . . . . . . . . 35
calcium acetate tabs 667mg. . . . . . . . 35
calcium chloride . . . . . . . . . . . . . . . . . . 46
calcium gluconate inj . . . . . . . . . . . . . . 46
CAMBIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
camila . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
camrese . . . . . . . . . . . . . . . . . . . . . . . . . 37
camrese lo . . . . . . . . . . . . . . . . . . . . . . . 37
CANASA . . . . . . . . . . . . . . . . . . . . . . . . . 42
CANCIDAS . . . . . . . . . . . . . . . . . . . . . . 16
candesartan cilexetil . . . . . . . . . . . . . . 27
candesartan cilexetil/
hydrochlorothiazide . . . . . . . . . . . . . . . 27
CAPASTAT SULFATE . . . . . . . . . . . . 18
CAPITAL/CODEINE . . . . . . . . . . . . . . . . 8
CAPRELSA . . . . . . . . . . . . . . . . . . . . . . 20
captopril . . . . . . . . . . . . . . . . . . . . . . . . . 28
captopril/hydrochlorothiazide . . . . . . 28
CARAC . . . . . . . . . . . . . . . . . . . . . . . . . . 32
CARAFATE SUSP . . . . . . . . . . . . . . . . 34
53
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
ciclopirox . . . . . . . . . . . . . . . . . . . . . . . . 16
ciclopirox nail lacquer . . . . . . . . . . . . . 16
ciclopirox olamine . . . . . . . . . . . . . . . . 16
ciclopirox topical solution kit . . . . . . . 16
ciclopirox treatment . . . . . . . . . . . . . . . 16
cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . 23
cilostazol . . . . . . . . . . . . . . . . . . . . . . . . 27
CILOXAN OINT . . . . . . . . . . . . . . . . . . . 13
cimetidine . . . . . . . . . . . . . . . . . . . . . . . . 33
cimetidine hcl . . . . . . . . . . . . . . . . . . . . 33
CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . 40
CIPRODEX . . . . . . . . . . . . . . . . . . . . . . 13
ciprofloxacin er . . . . . . . . . . . . . . . . . . . 13
ciprofloxacin hcl . . . . . . . . . . . . . . . . . . 13
ciprofloxacin inj 400mg/40ml . . . . . . . 13
ciprofloxacin i.v.-in d5w . . . . . . . . . . . 13
ciprofloxacin susr . . . . . . . . . . . . . . . . . 13
CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . 13
cisplatin . . . . . . . . . . . . . . . . . . . . . . . . . . 19
citalopram hydrobromide oral soln. . . 15
citalopram hydrobromide tabs
10mg, 20mg. . . . . . . . . . . . . . . . . . . . . . . 15
citalopram hydrobromide
tabs 40mg . . . . . . . . . . . . . . . . . . . . . . . . 15
citric acid/sodium citrate . . . . . . . . . . 46
cladribine . . . . . . . . . . . . . . . . . . . . . . . . 18
claravis . . . . . . . . . . . . . . . . . . . . . . . . . . 32
CLARINEX-D 12 HOUR . . . . . . . . . . 44
clarithromycin . . . . . . . . . . . . . . . . . . . . 12
clarithromycin er . . . . . . . . . . . . . . . . . 12
CLEOCIN SUPP . . . . . . . . . . . . . . . . . . 10
CLIMARA PRO . . . . . . . . . . . . . . . . . . . 37
clindacin etz pledgets . . . . . . . . . . . . . 10
clindacin-p . . . . . . . . . . . . . . . . . . . . . . . 10
clindamax . . . . . . . . . . . . . . . . . . . . . . . . 10
clindamycin/benzoyl peroxide . . . . . 32
clindamycin hcl . . . . . . . . . . . . . . . . . . . 10
clindamycin palmitate hcl . . . . . . . . . 10
clindamycin phosphate
add-vantage . . . . . . . . . . . . . . . . . . . . . 10
clindamycin phosphate crea . . . . . . . 10
clindamycin phosphate
external soln . . . . . . . . . . . . . . . . . . . . . . 10
clindamycin phosphate foam . . . . . . . 10
clindamycin phosphate gel . . . . . . . . 10
clindamycin phosphate in d5w . . . . . 10
clindamycin phosphate inj
300mg/2ml, 600mg/4ml,
900mg/6ml. . . . . . . . . . . . . . . . . . . . . . . . 10
clindamycin phosphate lotn . . . . . . . . 10
clindamycin phosphate
pharmacy bulk package . . . . . . . . . . . 10
clindamycin phosphate swab . . . . . . 10
clindamycin phosphate/tretinoin . . . . 32
CLINDESSE . . . . . . . . . . . . . . . . . . . . . 10
CLINIMIX 2.75%/DEXTROSE 5%. . . 46
CLINIMIX 4.25%/DEXTROSE 5%. . . 46
CLINIMIX 4.25%/DEXTROSE 10% . . 46
CLINIMIX 4.25%/DEXTROSE 20% . . 46
CLINIMIX 4.25%/DEXTROSE 25% . . 46
CLINIMIX 5%/DEXTROSE 15%. . . . 46
CLINIMIX 5%/DEXTROSE 20%. . . . 46
CLINIMIX 5%/DEXTROSE 25%. . . . 46
CLINIMIX E 2.75%/
DEXTROSE 5% . . . . . . . . . . . . . . . . . . 46
CLINIMIX E 2.75%/
DEXTROSE 10% . . . . . . . . . . . . . . . . . 46
CLINIMIX E 4.25%/
DEXTROSE 5% . . . . . . . . . . . . . . . . . . 46
CLINIMIX E 4.25%/
DEXTROSE 10% . . . . . . . . . . . . . . . . . 46
CLINIMIX E 4.25%/
DEXTROSE 25% . . . . . . . . . . . . . . . . . 46
CLINIMIX E 5%/DEXTROSE 15%. . . 47
CLINIMIX E 5%/DEXTROSE 20%. . . 47
CLINIMIX E 5%/DEXTROSE 25%. . . 47
CLINISOL SF 15% . . . . . . . . . . . . . . . 47
clinpro 5000 . . . . . . . . . . . . . . . . . . . . . . 47
clobetasol propionate . . . . . . . . . . . . . 35
clobetasol propionate e . . . . . . . . . . . 35
clobetasol propionate
emollient foam . . . . . . . . . . . . . . . . . . . . 35
clocortolone pivalate . . . . . . . . . . . . . . 35
clocortolone pivalate pump . . . . . . . . 35
clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
CLOLAR . . . . . . . . . . . . . . . . . . . . . . . . . 18
clomipramine hcl . . . . . . . . . . . . . . . . . 16
clonazepam odt tbdp
0.125mg, 0.25mg, 0.5mg, 1mg . . . . . 14
clonazepam odt tbdp 2mg. . . . . . . . . . 14
clonazepam tabs 0.5mg, 1mg . . . . . . 14
clonazepam tabs 2mg . . . . . . . . . . . . . 14
clonidine hcl er . . . . . . . . . . . . . . . . . . . 31
clonidine hcl ptwk
0.1mg/24hr, 0.2mg/24hr. . . . . . . . . . . . 27
clonidine hcl ptwk 0.3mg/24hr. . . . . . 27
clonidine hcl tabs . . . . . . . . . . . . . . . . . 27
clopidogrel tabs 75mg . . . . . . . . . . . . . 27
clopidogrel tabs 300mg . . . . . . . . . . . . 27
clorazepate dipotassium tabs
3.75mg, 7.5mg . . . . . . . . . . . . . . . . . . . . 24
clorazepate dipotassium tabs
15mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
clorpres . . . . . . . . . . . . . . . . . . . . . . . . . . 27
clotrimazole/
betamethasone dipropionate . . . . . . 16
clotrimazole external crea . . . . . . . . . 16
clotrimazole external soln . . . . . . . . . . 16
clotrimazole troc . . . . . . . . . . . . . . . . . . 16
clozapine . . . . . . . . . . . . . . . . . . . . . . . . 22
clozapine odt . . . . . . . . . . . . . . . . . . . . . 22
COARTEM . . . . . . . . . . . . . . . . . . . . . . . 21
codeine sulfate tabs 15mg . . . . . . . . . . . 8
codeine sulfate tabs 30mg . . . . . . . . . . . 8
codeine sulfate tabs 60mg . . . . . . . . . . . 8
colchicine . . . . . . . . . . . . . . . . . . . . . . . . 17
COLCRYS . . . . . . . . . . . . . . . . . . . . . . . 17
colestipol hcl . . . . . . . . . . . . . . . . . . . . . 30
colistimethate sodium . . . . . . . . . . . . . 10
colocort . . . . . . . . . . . . . . . . . . . . . . . . . . 42
COLY-MYCIN S . . . . . . . . . . . . . . . . . . 44
COMBIGAN . . . . . . . . . . . . . . . . . . . . . . 42
COMBIPATCH . . . . . . . . . . . . . . . . . . . 37
54
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
COMBIVENT RESPIMAT . . . . . . . . . 44
COMETRIQ . . . . . . . . . . . . . . . . . . . . . . 20
COMPLERA . . . . . . . . . . . . . . . . . . . . . 23
compro . . . . . . . . . . . . . . . . . . . . . . . . . . 21
CONDYLOX GEL . . . . . . . . . . . . . . . . . 32
constulose . . . . . . . . . . . . . . . . . . . . . . . 34
COPAXONE INJ 40MG/ML. . . . . . . . . 31
CORDRAN TAPE . . . . . . . . . . . . . . . . 35
COREG CR . . . . . . . . . . . . . . . . . . . . . . 28
cormax scalp application . . . . . . . . . . 35
CORTIFOAM . . . . . . . . . . . . . . . . . . . . 35
cortisone acetate . . . . . . . . . . . . . . . . . 35
CORTISPORIN CREA . . . . . . . . . . . . . 10
CORTISPORIN OINT . . . . . . . . . . . . . 10
COSMEGEN . . . . . . . . . . . . . . . . . . . . . 19
COTELLIC . . . . . . . . . . . . . . . . . . . . . . . 20
COUMADIN . . . . . . . . . . . . . . . . . . . . . . 26
CREON . . . . . . . . . . . . . . . . . . . . . . . . . . 33
CRESTOR . . . . . . . . . . . . . . . . . . . . . . . 30
CRIXIVAN . . . . . . . . . . . . . . . . . . . . . . . 24
cromolyn sodium conc . . . . . . . . . . . . 33
cromolyn sodium nebu . . . . . . . . . . . . 45
cromolyn sodium ophthalmic soln . . . 43
cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . 37
CUBICIN . . . . . . . . . . . . . . . . . . . . . . . . 10
CUPRIMINE . . . . . . . . . . . . . . . . . . . . . 46
CURITY GAUZE PADS 2”X2” . . . . . 32
CUVPOSA . . . . . . . . . . . . . . . . . . . . . . . 33
cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . 37
cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . 37
cyclobenzaprine hcl tabs
10mg, 5mg. . . . . . . . . . . . . . . . . . . . . . . . 46
CYCLOGYL
OPHTHALMIC SOLN 0.5% . . . . . . . . 43
CYCLOMYDRIL . . . . . . . . . . . . . . . . . . 43
cyclopentolate hcl . . . . . . . . . . . . . . . . 43
cyclopentolate hydrochloride . . . . . . 43
cyclophosphamide . . . . . . . . . . . . . . . 18
cycloserine . . . . . . . . . . . . . . . . . . . . . . . 18
cyclosporine . . . . . . . . . . . . . . . . . . . . . 40
cyclosporine modified . . . . . . . . . . . . . 40
CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . 20
cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
CYSTADANE . . . . . . . . . . . . . . . . . . . . 33
CYSTAGON . . . . . . . . . . . . . . . . . . . . . 33
CYSTARAN . . . . . . . . . . . . . . . . . . . . . . 43
cytarabine aqueous . . . . . . . . . . . . . . 18
cytarabine inj 100mg/ml. . . . . . . . . . . . 18
cytra-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
cytra-3 . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
cytra-k . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
cytra k crystals . . . . . . . . . . . . . . . . . . . 47
desipramine hcl . . . . . . . . . . . . . . . . . . 16
desloratadine . . . . . . . . . . . . . . . . . . . . 44
desloratadine odt . . . . . . . . . . . . . . . . . 44
desmopressin acetate . . . . . . . . . . . . 36
desogestrel/ethinyl estradiol . . . . . . . 37
DESONATE . . . . . . . . . . . . . . . . . . . . . . 35
desonide . . . . . . . . . . . . . . . . . . . . . . . . . 35
desoximetasone . . . . . . . . . . . . . . . . . . 35
dexamethasone . . . . . . . . . . . . . . . . . . 35
dexamethasone intensol . . . . . . . . . . 35
dexamethasone
sodium phosphate . . . . . . . . . . . . . . . . 35
dexamethasone
sodium phosphate . . . . . . . . . . . . . . . . 43
DEXILANT . . . . . . . . . . . . . . . . . . . . . . . 34
dexmethylphenidate hcl . . . . . . . . . . . 31
dexrazoxane . . . . . . . . . . . . . . . . . . . . . 19
dextroamphetamine sulfate . . . . . . . 31
dextroamphetamine sulfate er . . . . . 31
DEXTROSE 2.5%/NACL 0.45% . . . 47
DEXTROSE 2.5%/
SODIUM CHLORIDE 0.45% . . . . . . 47
dextrose 5% . . . . . . . . . . . . . . . . . . . . . 47
DEXTROSE 5% /
ELECTROLYTE #48 VIAFLEX . . . . 47
DEXTROSE 5%/
LACTATED RINGERS . . . . . . . . . . . . 47
DEXTROSE 5%/NACL 0.2% . . . . . . 47
DEXTROSE 5%/NACL 0.3% . . . . . . 47
DEXTROSE 5%/NACL 0.9% . . . . . . 47
DEXTROSE 5%/NACL 0.33% . . . . . 47
DEXTROSE 5%/NACL 0.45% . . . . . 47
DEXTROSE 5%/NACL 0.225% . . . . 47
DEXTROSE 5%/POTASSIUM
CHLORIDE 0.15% . . . . . . . . . . . . . . . 47
DEXTROSE 5%/
SODIUM CHLORIDE 0.2% . . . . . . . 47
DEXTROSE 5%/
SODIUM CHLORIDE 0.45% . . . . . . 47
dextrose 10% flex container . . . . . . . 47
DEXTROSE 10%/NACL 0.2% . . . . . 47
D
dacarbazine . . . . . . . . . . . . . . . . . . . . . . 18
DALIRESP . . . . . . . . . . . . . . . . . . . . . . . 45
danazol . . . . . . . . . . . . . . . . . . . . . . . . . . 36
dantrolene sodium . . . . . . . . . . . . . . . . 22
dapsone . . . . . . . . . . . . . . . . . . . . . . . . . 18
DAPTACEL . . . . . . . . . . . . . . . . . . . . . . 41
DARAPRIM . . . . . . . . . . . . . . . . . . . . . . 21
DARZALEX . . . . . . . . . . . . . . . . . . . . . . 20
daunorubicin hcl . . . . . . . . . . . . . . . . . . 19
daysee . . . . . . . . . . . . . . . . . . . . . . . . . . 37
DAYTRANA . . . . . . . . . . . . . . . . . . . . . . 31
deblitane . . . . . . . . . . . . . . . . . . . . . . . . . 39
decitabine . . . . . . . . . . . . . . . . . . . . . . . 19
delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
demeclocycline hcl . . . . . . . . . . . . . . . 13
DEMSER . . . . . . . . . . . . . . . . . . . . . . . . 29
DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . 24
denta 5000 plus . . . . . . . . . . . . . . . . . . 47
dentagel . . . . . . . . . . . . . . . . . . . . . . . . . 47
DEPEN TITRATABS . . . . . . . . . . . . . . 46
DEPO-ESTRADIOL . . . . . . . . . . . . . . 37
DEPO-MEDROL INJ 20MG/ML. . . . . 35
DEPO-PROVERA . . . . . . . . . . . . . . . . 39
DEPO-SUBQ PROVERA 104 . . . . . 39
DESCOVY . . . . . . . . . . . . . . . . . . . . . . . 23
55
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
DEXTROSE 10%/NACL 0.45% . . . 47
dextrose 20% . . . . . . . . . . . . . . . . . . . . 47
dextrose 25% . . . . . . . . . . . . . . . . . . . . 47
dextrose 30% . . . . . . . . . . . . . . . . . . . . 47
dextrose 40% . . . . . . . . . . . . . . . . . . . . 47
dextrose 50% . . . . . . . . . . . . . . . . . . . . 47
dextrose 70% . . . . . . . . . . . . . . . . . . . . 47
diazepam conc . . . . . . . . . . . . . . . . . . . 24
diazepam gel . . . . . . . . . . . . . . . . . . . . . 14
diazepam inj . . . . . . . . . . . . . . . . . . . . . . 24
diazepam intensol . . . . . . . . . . . . . . . . 24
diazepam oral soln . . . . . . . . . . . . . . . . 24
diazepam tabs . . . . . . . . . . . . . . . . . . . . 24
DIBENZYLINE . . . . . . . . . . . . . . . . . . . 27
diclofenac potassium . . . . . . . . . . . . . . . 7
diclofenac sodium dr . . . . . . . . . . . . . . . . 7
diclofenac sodium er . . . . . . . . . . . . . . . . 7
diclofenac sodium gel 3%. . . . . . . . . . 32
diclofenac sodium/misoprostol . . . . . . 7
diclofenac sodium ophthalmic soln. . . 43
dicloxacillin sodium . . . . . . . . . . . . . . . 12
dicyclomine hcl caps . . . . . . . . . . . . . . 33
dicyclomine hcl oral soln . . . . . . . . . . . 33
dicyclomine hcl tabs . . . . . . . . . . . . . . . 33
didanosine . . . . . . . . . . . . . . . . . . . . . . . 23
DIFFERIN LOTN . . . . . . . . . . . . . . . . . . 32
DIFICID . . . . . . . . . . . . . . . . . . . . . . . . . . 12
diflorasone diacetate . . . . . . . . . . . . . 35
diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
digitek tabs 0.25mg. . . . . . . . . . . . . . . . 29
digitek tabs 0.125mg. . . . . . . . . . . . . . . 29
digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 29
digoxin oral soln . . . . . . . . . . . . . . . . . . 29
digoxin tabs 125mcg. . . . . . . . . . . . . . . 29
digoxin tabs 250mcg. . . . . . . . . . . . . . . 29
digox tabs 125mcg . . . . . . . . . . . . . . . . 29
digox tabs 250mcg . . . . . . . . . . . . . . . . 29
dihydroergotamine mesylate inj . . . . 17
dihydroergotamine mesylate
nasal soln . . . . . . . . . . . . . . . . . . . . . . . . 17
DILANTIN . . . . . . . . . . . . . . . . . . . . . . . 14
DILANTIN-125 . . . . . . . . . . . . . . . . . . . 14
DILANTIN INFATABS . . . . . . . . . . . . . 14
diltiazem cd . . . . . . . . . . . . . . . . . . . . . . 29
diltiazem hcl cd . . . . . . . . . . . . . . . . . . . 29
diltiazem hcl er . . . . . . . . . . . . . . . . . . . 29
diltiazem hcl inj
100mg, 125mg/25ml,
25mg/5ml, 50mg/10ml . . . . . . . . . . . . . 29
diltiazem hcl tabs . . . . . . . . . . . . . . . . . 29
dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
dimenhydrinate inj . . . . . . . . . . . . . . . . 16
DIPENTUM . . . . . . . . . . . . . . . . . . . . . . 42
diphenhydramine hcl inj . . . . . . . . . . . 44
diphenoxylate/atropine . . . . . . . . . . . . 33
DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC . . . . . . . . . 41
disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . . 9
DIURIL . . . . . . . . . . . . . . . . . . . . . . . . . . 30
divalproex sodium . . . . . . . . . . . . . . . . 14
divalproex sodium dr . . . . . . . . . . . . . 14
divalproex sodium er . . . . . . . . . . . . . 14
DIVIGEL GEL 0.25MG/0.25GM,
0.5MG/0.5GM. . . . . . . . . . . . . . . . . . . . . 37
DOCEFREZ INJ 20MG . . . . . . . . . . . . 19
docetaxel . . . . . . . . . . . . . . . . . . . . . . . . 19
dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . 28
donepezil hcl tabs 10mg . . . . . . . . . . . 14
donepezil hcl tabs 23mg, 5mg. . . . . . 14
donepezil hcl tbdp 5mg . . . . . . . . . . . . 14
donepezil hcl tbdp 10mg . . . . . . . . . . . 14
DORIBAX . . . . . . . . . . . . . . . . . . . . . . . . 12
dorzolamide hcl . . . . . . . . . . . . . . . . . . 43
dorzolamide hcl/timolol maleate . . . 44
doxazosin . . . . . . . . . . . . . . . . . . . . . . . . 34
doxazosin mesylate tabs
1mg, 2mg, 8mg. . . . . . . . . . . . . . . . . . . . 34
doxepin hcl . . . . . . . . . . . . . . . . . . . . . . 16
doxepin hydrochloride . . . . . . . . . . . . 32
doxercalciferol . . . . . . . . . . . . . . . . . . . 42
doxorubicin hcl . . . . . . . . . . . . . . . . . . . 19
doxorubicin hcl liposome . . . . . . . . . . 19
doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . 13
doxycycline caps 150mg, 75mg . . . . 13
doxycycline cpdr . . . . . . . . . . . . . . . . . . 32
doxycycline hyclate . . . . . . . . . . . . . . . 13
doxycycline hyclate dr tbec
100mg, 150mg, 75mg. . . . . . . . . . . . . . 13
doxycycline monohydrate . . . . . . . . . 13
DRITHO-CREME HP . . . . . . . . . . . . . 32
dronabinol . . . . . . . . . . . . . . . . . . . . . . . 16
droperidol . . . . . . . . . . . . . . . . . . . . . . . . 16
drospirenone/ethinyl estradiol . . . . . 37
DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . 18
duloxetine hcl cpep 20mg, 60mg . . . 15
duloxetine hcl cpep 30mg. . . . . . . . . . 15
DURAMORPH . . . . . . . . . . . . . . . . . . . . . 7
DUREZOL . . . . . . . . . . . . . . . . . . . . . . . 43
dutasteride . . . . . . . . . . . . . . . . . . . . . . . 34
dutasteride/
tamsulosin hydrochloride . . . . . . . . . 34
DUTOPROL . . . . . . . . . . . . . . . . . . . . . 28
DYMISTA . . . . . . . . . . . . . . . . . . . . . . . . 44
DYRENIUM . . . . . . . . . . . . . . . . . . . . . . 30
DYSPORT . . . . . . . . . . . . . . . . . . . . . . . 42
56
E
econazole nitrate . . . . . . . . . . . . . . . . . 16
EDECRIN . . . . . . . . . . . . . . . . . . . . . . . . 29
ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . 33
EDURANT . . . . . . . . . . . . . . . . . . . . . . . 23
e.e.s. 400 . . . . . . . . . . . . . . . . . . . . . . . . 12
E.E.S. GRANULES . . . . . . . . . . . . . . . 12
effer-k tbef 25meq. . . . . . . . . . . . . . . . . 47
effervescent pot chloride . . . . . . . . . . 47
EFFIENT TABS 5MG . . . . . . . . . . . . . . 27
EFFIENT TABS 10MG. . . . . . . . . . . . . 27
EGRIFTA INJ 1MG . . . . . . . . . . . . . . . . 36
ELAPRASE . . . . . . . . . . . . . . . . . . . . . . 33
ELELYSO . . . . . . . . . . . . . . . . . . . . . . . . 33
ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 39
ELIGARD INJ 22.5MG. . . . . . . . . . . . . 39
ELIGARD INJ 30MG. . . . . . . . . . . . . . . 39
ELIGARD INJ 45MG. . . . . . . . . . . . . . . 39
ELIQUIS TABS 2.5MG. . . . . . . . . . . . . 26
ELIQUIS TABS 5MG. . . . . . . . . . . . . . . 26
ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ELIXOPHYLLIN . . . . . . . . . . . . . . . . . . 45
ELMIRON . . . . . . . . . . . . . . . . . . . . . . . 35
EMADINE . . . . . . . . . . . . . . . . . . . . . . . 43
EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . 18
EMEND CAPS . . . . . . . . . . . . . . . . . . . . 16
EMEND CAPS 40MG. . . . . . . . . . . . . . 16
EMEND CAPS 80MG. . . . . . . . . . . . . . 16
EMEND CAPS 125MG. . . . . . . . . . . . . 16
emoquette . . . . . . . . . . . . . . . . . . . . . . . 37
EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . 20
EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . 15
EMTRIVA . . . . . . . . . . . . . . . . . . . . . . . . 23
enalaprilat . . . . . . . . . . . . . . . . . . . . . . . 28
enalapril maleate . . . . . . . . . . . . . . . . . 28
enalapril maleate/
hydrochlorothiazide . . . . . . . . . . . . . . . 28
ENBREL . . . . . . . . . . . . . . . . . . . . . . . . . 40
ENBREL SURECLICK . . . . . . . . . . . . 40
endocet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ENGERIX-B . . . . . . . . . . . . . . . . . . . . . 41
ENJUVIA . . . . . . . . . . . . . . . . . . . . . . . . 37
enoxaparin sodium inj 30mg/0.3ml . . 26
enoxaparin sodium inj 40mg/0.4ml . . 26
enoxaparin sodium inj 60mg/0.6ml . . 26
enoxaparin sodium inj 80mg/0.8ml . . 26
enoxaparin sodium inj 100mg/ml . . . 26
enoxaparin sodium inj
120mg/0.8ml. . . . . . . . . . . . . . . . . . . . . . 26
enoxaparin sodium inj 150mg/ml . . . 26
enoxaparin sodium inj 300mg/3ml. . . 26
enpresse-28 . . . . . . . . . . . . . . . . . . . . . 37
enskyce . . . . . . . . . . . . . . . . . . . . . . . . . 37
entacapone . . . . . . . . . . . . . . . . . . . . . . 21
entecavir . . . . . . . . . . . . . . . . . . . . . . . . . 23
ENTRESTO . . . . . . . . . . . . . . . . . . . . . . 27
enulose . . . . . . . . . . . . . . . . . . . . . . . . . . 34
ENVARSUS XR . . . . . . . . . . . . . . . . . . 40
epinastine hcl . . . . . . . . . . . . . . . . . . . . 43
epinephrine . . . . . . . . . . . . . . . . . . . . . . 45
epinephrine hcl . . . . . . . . . . . . . . . . . . . 45
EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . 45
EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . 45
epirubicin hcl inj
200mg/100ml, 50mg/25ml. . . . . . . . . . 19
epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
EPIVIR HBV ORAL SOLN . . . . . . . . . 23
eplerenone . . . . . . . . . . . . . . . . . . . . . . . 30
EPOGEN . . . . . . . . . . . . . . . . . . . . . . . . 27
eprosartan mesylate . . . . . . . . . . . . . . 27
EPZICOM . . . . . . . . . . . . . . . . . . . . . . . 23
EQUETRO . . . . . . . . . . . . . . . . . . . . . . . 14
ERAXIS . . . . . . . . . . . . . . . . . . . . . . . . . 16
ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . 20
ergoloid mesylates . . . . . . . . . . . . . . . 14
ERGOMAR . . . . . . . . . . . . . . . . . . . . . . 17
ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . 20
errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
ERTACZO . . . . . . . . . . . . . . . . . . . . . . . 16
ERWINAZE . . . . . . . . . . . . . . . . . . . . . . 19
ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ERYPED 200 . . . . . . . . . . . . . . . . . . . . 12
ERYPED 400 . . . . . . . . . . . . . . . . . . . . 12
ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . 12
ERYTHROCIN LACTOBIONATE . . . 12
erythrocin stearate . . . . . . . . . . . . . . . 12
erythromycin . . . . . . . . . . . . . . . . . . . . . 12
erythromycin base . . . . . . . . . . . . . . . . 12
erythromycin/benzoyl peroxide . . . . 32
erythromycin ethylsuccinate . . . . . . . 12
ESBRIET . . . . . . . . . . . . . . . . . . . . . . . . 45
escitalopram oxalate oral soln . . . . . 15
escitalopram oxalate tabs . . . . . . . . . 15
esgic caps . . . . . . . . . . . . . . . . . . . . . . . . . . 7
esmolol hcl inj 10mg/ml . . . . . . . . . . . . 28
esomeprazole magnesium . . . . . . . . 34
esomeprazole sodium . . . . . . . . . . . . 34
estarylla . . . . . . . . . . . . . . . . . . . . . . . . . 37
ESTRACE CREA . . . . . . . . . . . . . . . . . 37
estradiol/norethindrone acetate . . . . 37
estradiol pttw . . . . . . . . . . . . . . . . . . . . . 37
estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 37
estradiol tabs . . . . . . . . . . . . . . . . . . . . . 37
ESTRING . . . . . . . . . . . . . . . . . . . . . . . . 37
ESTROGEL . . . . . . . . . . . . . . . . . . . . . . 37
estropipate . . . . . . . . . . . . . . . . . . . . . . . 37
ethacrynate sodium . . . . . . . . . . . . . . 29
ethacrynic acid . . . . . . . . . . . . . . . . . . . 29
ethambutol hcl . . . . . . . . . . . . . . . . . . . 18
ethosuximide . . . . . . . . . . . . . . . . . . . . . 13
etidronate disodium . . . . . . . . . . . . . . 42
etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
etodolac er . . . . . . . . . . . . . . . . . . . . . . . . . 7
ETOPOPHOS . . . . . . . . . . . . . . . . . . . . 19
etoposide inj . . . . . . . . . . . . . . . . . . . . . . 19
EURAX . . . . . . . . . . . . . . . . . . . . . . . . . . 21
EVOMELA . . . . . . . . . . . . . . . . . . . . . . . 18
EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . 24
EXELON PT24 . . . . . . . . . . . . . . . . . . . 14
exemestane . . . . . . . . . . . . . . . . . . . . . . 19
EXJADE . . . . . . . . . . . . . . . . . . . . . . . . . 46
EXTAVIA . . . . . . . . . . . . . . . . . . . . . . . . . 31
57
F
FABRAZYME . . . . . . . . . . . . . . . . . . . . 33
falmina . . . . . . . . . . . . . . . . . . . . . . . . . . 37
famciclovir . . . . . . . . . . . . . . . . . . . . . . . 24
famotidine inj . . . . . . . . . . . . . . . . . . . . . 33
famotidine premixed . . . . . . . . . . . . . . 33
famotidine susr . . . . . . . . . . . . . . . . . . . 33
famotidine tabs 20mg, 40mg . . . . . . . 33
FANAPT TABS 1MG, 2MG, 4MG. . . 22
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
FANAPT TABS
10MG, 12MG, 6MG, 8MG. . . . . . . . . . 22
FANAPT TITRATION PACK . . . . . . . 22
FARESTON . . . . . . . . . . . . . . . . . . . . . . 18
FARYDAK . . . . . . . . . . . . . . . . . . . . . . . 20
FASLODEX . . . . . . . . . . . . . . . . . . . . . . 18
FAZACLO TBDP
100MG, 12.5MG, 25MG . . . . . . . . . . . 22
felbamate susp . . . . . . . . . . . . . . . . . . . 14
felbamate tabs . . . . . . . . . . . . . . . . . . . . 14
felodipine er . . . . . . . . . . . . . . . . . . . . . . 29
FEM PH . . . . . . . . . . . . . . . . . . . . . . . . . 10
FEMRING . . . . . . . . . . . . . . . . . . . . . . . 37
fenofibrate caps 50mg . . . . . . . . . . . . . 30
fenofibrate caps
130mg, 150mg, 43mg. . . . . . . . . . . . . . 30
fenofibrate micronized . . . . . . . . . . . . 30
fenofibrate tabs 48mg, 54mg. . . . . . . 30
fenofibrate tabs 145mg, 160mg. . . . . 30
fenofibric acid dr cpdr 45mg. . . . . . . . 30
fenofibric acid dr cpdr 135mg. . . . . . . 30
fenoprofen calcium caps 400mg. . . . . . 7
fenoprofen calcium tabs . . . . . . . . . . . . . 7
fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
fentanyl citrate inj 100mcg/2ml . . . . . . . 8
fentanyl citrate oral
transmucosal lpop 200mcg. . . . . . . . . . . 8
fentanyl citrate oral transmucosal
lpop 1200mcg, 1600mcg, 400mcg,
600mcg, 800mcg. . . . . . . . . . . . . . . . . . . . 8
FERRIPROX . . . . . . . . . . . . . . . . . . . . . 42
FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . 15
FETZIMA TITRATION PACK . . . . . . 15
FINACEA . . . . . . . . . . . . . . . . . . . . . . . . 32
finasteride tabs 5mg. . . . . . . . . . . . . . . 34
FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . 40
FIRMAGON INJ 80MG. . . . . . . . . . . . . 39
FIRMAGON INJ 120MG . . . . . . . . . . . 39
FLAGYL ER . . . . . . . . . . . . . . . . . . . . . . 10
FLAREX . . . . . . . . . . . . . . . . . . . . . . . . . 43
flavoxate hcl . . . . . . . . . . . . . . . . . . . . . 34
FLEBOGAMMA DIF . . . . . . . . . . . . . . 41
flecainide acetate . . . . . . . . . . . . . . . . . 28
FLOVENT DISKUS . . . . . . . . . . . . . . . 44
FLOVENT HFA . . . . . . . . . . . . . . . . . . . 44
floxuridine . . . . . . . . . . . . . . . . . . . . . . . 18
fluconazole . . . . . . . . . . . . . . . . . . . . . . 16
fluconazole in dextrose . . . . . . . . . . . 16
fluconazole in nacl inj 100mg/50ml;
0.9%, 200mg/100ml; 0.9% . . . . . . . . . 16
flucytosine . . . . . . . . . . . . . . . . . . . . . . . 16
fludarabine phosphate . . . . . . . . . . . . 19
fludrocortisone acetate . . . . . . . . . . . 35
flunisolide . . . . . . . . . . . . . . . . . . . . . . . . 44
fluocinolone acetonide . . . . . . . . . . . . 35
fluocinolone acetonide . . . . . . . . . . . . 44
fluocinolone acetonide body . . . . . . . 35
fluocinolone acetonide ear drops . . . 35
fluocinolone acetonide scalp . . . . . . 35
fluocinonide . . . . . . . . . . . . . . . . . . . . . . 35
fluocinonide-e . . . . . . . . . . . . . . . . . . . . 35
fluor-a-day . . . . . . . . . . . . . . . . . . . . . . . 47
fluoride chew
0.25mg, 1.1mg, 2.2mg. . . . . . . . . . . . . 47
fluoridex daily defense . . . . . . . . . . . . 47
fluoridex daily defense
sensitivity relief pste . . . . . . . . . . . . . . . 31
fluoritab chew 0.5mg, 1mg . . . . . . . . . 47
fluoritab oral soln . . . . . . . . . . . . . . . . . 47
fluorometholone . . . . . . . . . . . . . . . . . . 43
fluorouracil crea . . . . . . . . . . . . . . . . . . . 32
fluorouracil external soln . . . . . . . . . . . 32
fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 18
fluoxetine . . . . . . . . . . . . . . . . . . . . . . . . 15
fluoxetine hcl . . . . . . . . . . . . . . . . . . . . . 15
fluphenazine decanoate . . . . . . . . . . 21
fluphenazine hcl . . . . . . . . . . . . . . . . . . 21
flura-drops oral soln 0.25mg/drop. . . 47
flurandrenolide . . . . . . . . . . . . . . . . . . . 35
flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . . 7
flurbiprofen sodium . . . . . . . . . . . . . . . 43
flutamide . . . . . . . . . . . . . . . . . . . . . . . . . 18
fluticasone propionate . . . . . . . . . . . . 35
fluticasone propionate . . . . . . . . . . . . 44
fluvastatin caps 20mg. . . . . . . . . . . . . . 30
fluvastatin caps 40mg. . . . . . . . . . . . . . 30
fluvastatin sodium er . . . . . . . . . . . . . . 30
fluvoxamine maleate . . . . . . . . . . . . . . 15
FML . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
FML FORTE . . . . . . . . . . . . . . . . . . . . . 43
FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . 18
fomepizole . . . . . . . . . . . . . . . . . . . . . . . 42
fondaparinux sodium inj
2.5mg/0.5ml. . . . . . . . . . . . . . . . . . . . . . . 26
fondaparinux sodium inj
5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 26
fondaparinux sodium inj
7.5mg/0.6ml. . . . . . . . . . . . . . . . . . . . . . . 26
fondaparinux sodium inj
10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 26
FORADIL AEROLIZER . . . . . . . . . . . 45
FORTAZ INJ 500MG. . . . . . . . . . . . . . . . 11
FORTEO . . . . . . . . . . . . . . . . . . . . . . . . 42
FORTICAL . . . . . . . . . . . . . . . . . . . . . . . 42
FOSAMAX PLUS D . . . . . . . . . . . . . . 42
fosinopril sodium . . . . . . . . . . . . . . . . . 28
fosinopril sodium/
hydrochlorothiazide . . . . . . . . . . . . . . . 28
fosphenytoin sodium inj
100mg pe/2ml. . . . . . . . . . . . . . . . . . . . . 14
FOSRENOL . . . . . . . . . . . . . . . . . . . . . . 35
FRAGMIN INJ 2500UNIT/0.2ML,
5000UNIT/0.2ML. . . . . . . . . . . . . . . . . . 26
FRAGMIN INJ 7500UNIT/0.3ML . . . . 26
FRAGMIN INJ 10000UNIT/ML. . . . . . 26
FRAGMIN INJ 12500UNIT/0.5ML . . . 26
FRAGMIN INJ 15000UNIT/0.6ML . . . 26
FRAGMIN INJ 18000UNT/0.72ML. . . 26
FRAGMIN INJ 95000UNIT/3.8ML . . . 26
FREAMINE HBC 6.9% . . . . . . . . . . . . 47
58
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
FREAMINE III INJ
89MEQ/L; 710MG/100ML;
950MG/100ML; 3MEQ/L;
24MG/100ML; 1400MG/100ML;
280MG/100ML; 690MG/100ML;
910MG/100ML; 730MG/100ML;
530MG/100ML; 560MG/100ML;
10MMOLE/L; 120MG/100ML;
1120MG/100ML; 590MG/100ML;
10MEQ/L; 400MG/100ML;
150MG/100ML; 660MG/100ML. . . . . 47
FROVA . . . . . . . . . . . . . . . . . . . . . . . . . . 17
frovatriptan succinate . . . . . . . . . . . . . 17
furosemide . . . . . . . . . . . . . . . . . . . . . . . 29
FUZEON . . . . . . . . . . . . . . . . . . . . . . . . 24
fyavolv . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
FYCOMPA . . . . . . . . . . . . . . . . . . . . . . . 13
gemcitabine . . . . . . . . . . . . . . . . . . . . . . 18
gemcitabine hcl . . . . . . . . . . . . . . . . . . 18
gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . 30
generlac . . . . . . . . . . . . . . . . . . . . . . . . . 34
gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . 40
gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
gentamicin sulfate . . . . . . . . . . . . . . . . 10
gentamicin sulfate/
0.9% sodium chloride inj 0.9mg/ml;
0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml;
0.9%, 1.6mg/ml; 0.9%, 1mg/ml;
0.9%, 2mg/ml; 0.9% . . . . . . . . . . . . . . . 10
gentamicin sulfate pediatric . . . . . . . 10
GENVOYA . . . . . . . . . . . . . . . . . . . . . . . 23
GEODON INJ . . . . . . . . . . . . . . . . . . . . 22
gianvi . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
gildagia . . . . . . . . . . . . . . . . . . . . . . . . . . 37
gildess 1.5/30 . . . . . . . . . . . . . . . . . . . . 37
gildess 1/20 . . . . . . . . . . . . . . . . . . . . . . 37
gildess 24 fe . . . . . . . . . . . . . . . . . . . . . 37
gildess fe 1.5/30 . . . . . . . . . . . . . . . . . . 37
gildess fe 1/20 . . . . . . . . . . . . . . . . . . . 37
GILENYA . . . . . . . . . . . . . . . . . . . . . . . . 31
GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . 20
GLASSIA . . . . . . . . . . . . . . . . . . . . . . . . 45
glatopa . . . . . . . . . . . . . . . . . . . . . . . . . . 31
GLEEVEC . . . . . . . . . . . . . . . . . . . . . . . 20
GLEOSTINE . . . . . . . . . . . . . . . . . . . . . 18
glimepiride . . . . . . . . . . . . . . . . . . . . . . . 25
glipizide . . . . . . . . . . . . . . . . . . . . . . . . . . 25
glipizide er . . . . . . . . . . . . . . . . . . . . . . . 25
glipizide/metformin hcl . . . . . . . . . . . . 25
glipizide xl . . . . . . . . . . . . . . . . . . . . . . . 25
GLUCAGEN HYPOKIT . . . . . . . . . . . 25
GLUCAGON EMERGENCY KIT. . . . 25
glycopyrrolate inj 0.2mg/ml,
0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 33
glycopyrrolate tabs . . . . . . . . . . . . . . . . 33
glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
GLYSET . . . . . . . . . . . . . . . . . . . . . . . . . 25
GOLYTELY . . . . . . . . . . . . . . . . . . . . . . 34
GORDONS UREA OINT 40% . . . . . . 32
granisetron hcl inj . . . . . . . . . . . . . . . . . 16
granisetron hcl inj . . . . . . . . . . . . . . . . . 16
granisetron hcl tabs . . . . . . . . . . . . . . . 16
GRANIX . . . . . . . . . . . . . . . . . . . . . . . . . 27
griseofulvin microsize . . . . . . . . . . . . . 16
griseofulvin ultramicrosize . . . . . . . . 16
GUANIDINE HCL . . . . . . . . . . . . . . . . . 17
GYNAZOLE-1 . . . . . . . . . . . . . . . . . . . . 16
G
gabapentin . . . . . . . . . . . . . . . . . . . . . . . 14
galantamine hydrobromide cp24 . . . 14
galantamine hydrobromide
oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 14
galantamine hydrobromide tabs . . . . 14
GAMASTAN S/D . . . . . . . . . . . . . . . . . 41
GAMMAGARD LIQUID INJ
2.5GM/25ML, 30GM/300ML. . . . . . . . 41
GAMMAGARD S/D IGA
LESS THAN 1MCG/ML . . . . . . . . . . . 41
GAMMAKED INJ 1GM/10ML. . . . . . . 41
GAMMAPLEX . . . . . . . . . . . . . . . . . . . . 41
GAMUNEX-C . . . . . . . . . . . . . . . . . . . . 41
ganciclovir inj . . . . . . . . . . . . . . . . . . . . . 23
GARDASIL . . . . . . . . . . . . . . . . . . . . . . 41
GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . 41
gatifloxacin . . . . . . . . . . . . . . . . . . . . . . . 13
GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . 33
gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . 34
gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . 34
gavilyte-n/flavor pack . . . . . . . . . . . . . 34
GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . 20
GELNIQUE . . . . . . . . . . . . . . . . . . . . . . 34
59
H
HALAVEN . . . . . . . . . . . . . . . . . . . . . . . 19
halobetasol propionate . . . . . . . . . . . 35
haloperidol . . . . . . . . . . . . . . . . . . . . . . . 21
haloperidol decanoate . . . . . . . . . . . . 21
haloperidol lactate . . . . . . . . . . . . . . . . 21
HARVONI . . . . . . . . . . . . . . . . . . . . . . . . 23
HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . 41
heather . . . . . . . . . . . . . . . . . . . . . . . . . . 39
heparin sodium . . . . . . . . . . . . . . . . . . . 26
heparin sodium/d5w . . . . . . . . . . . . . . 26
heparin sodium/nacl 0.9% . . . . . . . . 26
heparin sodium/nacl 0.45% . . . . . . . 26
heparin sodium/
sodium chloride 0.9% . . . . . . . . . . . . . 26
heparin sodium/
sodium chloride 0.9% premix . . . . . . 26
HEPATAMINE . . . . . . . . . . . . . . . . . . . . 47
HERCEPTIN . . . . . . . . . . . . . . . . . . . . . 20
HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . 31
HEXALEN . . . . . . . . . . . . . . . . . . . . . . . 18
HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . 41
HIZENTRA . . . . . . . . . . . . . . . . . . . . . . . 41
homatropaire . . . . . . . . . . . . . . . . . . . . . 43
HORIZANT . . . . . . . . . . . . . . . . . . . . . . 31
H.P. ACTHAR . . . . . . . . . . . . . . . . . . . . 36
HUMALOG . . . . . . . . . . . . . . . . . . . . . . 25
HUMALOG KWIKPEN . . . . . . . . . . . . 25
HUMALOG MIX 50/50 . . . . . . . . . . . . 25
HUMALOG MIX 50/50 KWIKPEN . . . 25
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
HUMALOG MIX 75/25 . . . . . . . . . . . . 25
HUMALOG MIX 75/25 KWIKPEN. . . 25
HUMIRA . . . . . . . . . . . . . . . . . . . . . . . . . 40
HUMIRA PEDIATRIC CROHNS
DISEASE STARTER PACK . . . . . . . 40
HUMIRA PEN . . . . . . . . . . . . . . . . . . . . 40
HUMIRA PEN-CROHNS
DISEASESTARTER . . . . . . . . . . . . . . 40
HUMIRA PEN-PSORIASIS
STARTER . . . . . . . . . . . . . . . . . . . . . . . 40
HUMULIN 70/30 . . . . . . . . . . . . . . . . . 25
HUMULIN 70/30 KWIKPEN . . . . . . . 25
HUMULIN N . . . . . . . . . . . . . . . . . . . . . 25
HUMULIN N KWIKPEN . . . . . . . . . . . 25
HUMULIN R . . . . . . . . . . . . . . . . . . . . . 25
HUMULIN R U-500
(CONCENTRATED) . . . . . . . . . . . . . . 25
HUMULIN R U-500 KWIKPEN. . . . . . 25
hydralazine hcl . . . . . . . . . . . . . . . . . . . 30
hydrochlorothiazide . . . . . . . . . . . . . . . 30
hydrocodone/acetaminophen
tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg . . . . . . . . . . . . . . . . . 8
hydrocodone bitartrate/
acetaminophen oral soln
325mg/15ml; 7.5mg/15ml . . . . . . . . . . . . 8
hydrocodone bitartrate/
acetaminophen tabs 300mg; 10mg,
300mg; 5mg, 300mg; 7.5mg. . . . . . . . . . 8
hydrocodone bitartrate/
acetaminophen tabs 325mg; 2.5mg. . . 8
hydrocodone/ibuprofen tabs
5mg; 200mg, 7.5mg; 200mg. . . . . . . . . . 8
hydrocodone/ibuprofen tabs
10mg; 200mg . . . . . . . . . . . . . . . . . . . . . . . 8
hydrocortisone/acetic acid . . . . . . . . 44
hydrocortisone butyrate . . . . . . . . . . . 35
hydrocortisone crea 1%, 2.5%. . . . . . 35
hydrocortisone enem . . . . . . . . . . . . . . 42
hydrocortisone lotn 2.5%. . . . . . . . . . . 35
hydrocortisone oint 1%, 2.5% . . . . . . 35
hydrocortisone tabs . . . . . . . . . . . . . . . 35
hydrocortisone valerate . . . . . . . . . . . 36
hydromorphone hcl dosette . . . . . . . . . 8
hydromorphone hcl inj 1mg/ml,
2mg/ml, 4mg/ml, 500mg/50ml . . . . . . . . 8
hydromorphone hcl liqd . . . . . . . . . . . . . 8
hydromorphone hcl supp . . . . . . . . . . . . 8
hydromorphone hcl tabs . . . . . . . . . . . . . 8
hydroxychloroquine sulfate . . . . . . . . 21
hydroxyprogesterone caproate . . . . 39
hydroxyurea . . . . . . . . . . . . . . . . . . . . . 18
HYOLEV MB . . . . . . . . . . . . . . . . . . . . . 34
hyoscyamine sulfate elix . . . . . . . . . . . 33
hyoscyamine sulfate odt . . . . . . . . . . 33
hyoscyamine sulfate subl . . . . . . . . . . 33
hyoscyamine sulfate tabs . . . . . . . . . . 33
hyoscyamine sulfate tbdp . . . . . . . . . . 33
hyosyne . . . . . . . . . . . . . . . . . . . . . . . . . 33
hyperlyte-cr . . . . . . . . . . . . . . . . . . . . . . 47
INFANRIX . . . . . . . . . . . . . . . . . . . . . . . 41
INFUMORPH 200 . . . . . . . . . . . . . . . . . . 7
INFUMORPH 500 . . . . . . . . . . . . . . . . . . 7
INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . 20
INNOPRAN XL . . . . . . . . . . . . . . . . . . . 28
INTELENCE TABS 25MG. . . . . . . . . . 23
INTELENCE TABS
100MG, 200MG . . . . . . . . . . . . . . . . . . . 23
INTRALIPID . . . . . . . . . . . . . . . . . . . . . 49
INTRON A . . . . . . . . . . . . . . . . . . . . . . . 23
INTRON A W/DILUENT . . . . . . . . . . . 23
introvale . . . . . . . . . . . . . . . . . . . . . . . . . 37
INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . 12
INVEGA SUSTENNA INJ
39MG/0.25ML, 78MG/0.5ML . . . . . . . 22
INVEGA SUSTENNA INJ
117MG/0.75ML, 156MG/ML,
234MG/1.5ML. . . . . . . . . . . . . . . . . . . . . 22
INVEGA TB24 1.5MG, 3MG. . . . . . . . 22
INVEGA TB24 6MG . . . . . . . . . . . . . . . 22
INVEGA TB24 9MG . . . . . . . . . . . . . . . 22
INVEGA TRINZA . . . . . . . . . . . . . . . . . 22
INVIRASE CAPS . . . . . . . . . . . . . . . . . 24
INVIRASE TABS . . . . . . . . . . . . . . . . . . 24
INVOKAMET . . . . . . . . . . . . . . . . . . . . . 25
INVOKANA . . . . . . . . . . . . . . . . . . . . . . 25
IONOSOL-B/DEXTROSE 5% . . . . . 47
IONOSOL-MB/DEXTROSE 5%. . . . . 47
IOPIDINE
OPHTHALMIC SOLN 1% . . . . . . . . . . 44
IPOL INACTIVATED IPV . . . . . . . . . . 41
ipratropium bromide/
albuterol sulfate . . . . . . . . . . . . . . . . . . 44
ipratropium bromide
inhalation soln . . . . . . . . . . . . . . . . . . . . 44
ipratropium bromide nasal soln . . . . 44
irbesartan . . . . . . . . . . . . . . . . . . . . . . . . 27
irbesartan/hydrochlorothiazide. . . . . . 27
IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . 20
irinotecan . . . . . . . . . . . . . . . . . . . . . . . . 19
ISENTRESS CHEW . . . . . . . . . . . . . . . 23
I
ibandronate sodium . . . . . . . . . . . . . . 42
IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . 19
ibudone tabs 5mg; 200mg. . . . . . . . . . . . 8
ibuprofen lysine . . . . . . . . . . . . . . . . . . . . 7
ibuprofen susp . . . . . . . . . . . . . . . . . . . . . . 7
ibuprofen tabs
400mg, 600mg, 800mg . . . . . . . . . . . . . . 7
ICLUSIG . . . . . . . . . . . . . . . . . . . . . . . . . 20
idarubicin hcl . . . . . . . . . . . . . . . . . . . . . 19
ifosfamide . . . . . . . . . . . . . . . . . . . . . . . 18
ILARIS . . . . . . . . . . . . . . . . . . . . . . . . . . 41
ilotycin . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
imatinib mesylate . . . . . . . . . . . . . . . . . 20
IMBRUVICA . . . . . . . . . . . . . . . . . . . . . 20
imipenem/cilastatin . . . . . . . . . . . . . . . 12
imipramine hcl . . . . . . . . . . . . . . . . . . . 16
imipramine pamoate . . . . . . . . . . . . . . 16
imiquimod . . . . . . . . . . . . . . . . . . . . . . . 32
IMOVAX RABIES (H.D.C.V.) . . . . . . 41
indapamide . . . . . . . . . . . . . . . . . . . . . . 30
60
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
ISENTRESS PACK . . . . . . . . . . . . . . . 23
ISENTRESS TABS . . . . . . . . . . . . . . . . 23
ISOLYTE-P/DEXTROSE 5% . . . . . . 47
ISOLYTE-S . . . . . . . . . . . . . . . . . . . . . . 47
ISOLYTE-S PH 7.4 . . . . . . . . . . . . . . . 47
isoniazid . . . . . . . . . . . . . . . . . . . . . . . . . 18
isopto carpine . . . . . . . . . . . . . . . . . . . . 44
isosorbide dinitrate er . . . . . . . . . . . . . 30
isosorbide dinitrate tabs . . . . . . . . . . . 30
isosorbide mononitrate . . . . . . . . . . . 30
isosorbide mononitrate er . . . . . . . . . 30
isotonic gentamicin inj
0.8mg/ml; 0.9%. . . . . . . . . . . . . . . . . . . . 10
isradipine . . . . . . . . . . . . . . . . . . . . . . . . 29
ISTALOL . . . . . . . . . . . . . . . . . . . . . . . . . 44
ISTODAX . . . . . . . . . . . . . . . . . . . . . . . . 19
ISUPREL . . . . . . . . . . . . . . . . . . . . . . . . 45
itraconazole . . . . . . . . . . . . . . . . . . . . . . 16
ivermectin . . . . . . . . . . . . . . . . . . . . . . . 20
IXEMPRA KIT . . . . . . . . . . . . . . . . . . . . 19
IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . 41
JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . 19
jinteli . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
jolivette . . . . . . . . . . . . . . . . . . . . . . . . . . 39
juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . 37
junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . 37
junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 37
junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 37
junel fe 24 . . . . . . . . . . . . . . . . . . . . . . . 37
JUXTAPID . . . . . . . . . . . . . . . . . . . . . . . 30
ketoconazole tabs . . . . . . . . . . . . . . . . . 16
ketoprofen . . . . . . . . . . . . . . . . . . . . . . . . . 7
ketoprofen er . . . . . . . . . . . . . . . . . . . . . . . 7
ketorolac tromethamine
ophthalmic soln . . . . . . . . . . . . . . . . . . . 43
KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . 20
kimidess . . . . . . . . . . . . . . . . . . . . . . . . . 37
KINERET . . . . . . . . . . . . . . . . . . . . . . . . 40
KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . 41
kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . 48
KLOR-CON 8 . . . . . . . . . . . . . . . . . . . . 48
KLOR-CON 10 . . . . . . . . . . . . . . . . . . . 48
klor-con/25 . . . . . . . . . . . . . . . . . . . . . . . 48
klor-con m10 . . . . . . . . . . . . . . . . . . . . . 48
klor-con m15 . . . . . . . . . . . . . . . . . . . . . 48
klor-con m20 . . . . . . . . . . . . . . . . . . . . . 48
klor-con sprinkle . . . . . . . . . . . . . . . . . . 48
KORLYM . . . . . . . . . . . . . . . . . . . . . . . . 42
K-PHOS . . . . . . . . . . . . . . . . . . . . . . . . . 48
K-PHOS NO 2 . . . . . . . . . . . . . . . . . . . 48
KRISTALOSE . . . . . . . . . . . . . . . . . . . . 34
k-sol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
K-TAB TBCR 10MEQ, 20MEQ . . . . . 48
kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . 37
KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . 33
k-vescent tbef . . . . . . . . . . . . . . . . . . . . 48
KYNAMRO . . . . . . . . . . . . . . . . . . . . . . 30
J
JADENU . . . . . . . . . . . . . . . . . . . . . . . . . 46
JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . 20
JALYN . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
jantoven . . . . . . . . . . . . . . . . . . . . . . . . . 26
JANUMET . . . . . . . . . . . . . . . . . . . . . . . 25
JANUMET XR TB24
1000MG; 50MG, 500MG; 50MG. . . . 25
JANUMET XR TB24
1000MG; 100MG. . . . . . . . . . . . . . . . . . 25
JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . 25
jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . 39
JENTADUETO . . . . . . . . . . . . . . . . . . . 25
JENTADUETO XR TB24
2.5MG; 1000MG. . . . . . . . . . . . . . . . . . . 25
JENTADUETO XR TB24
5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 25
jevantique lo . . . . . . . . . . . . . . . . . . . . . 37
K
KABIVEN . . . . . . . . . . . . . . . . . . . . . . . . 49
KADCYLA . . . . . . . . . . . . . . . . . . . . . . . 20
kaitlib fe . . . . . . . . . . . . . . . . . . . . . . . . . 37
KALBITOR . . . . . . . . . . . . . . . . . . . . . . . 40
KALETRA ORAL SOLN . . . . . . . . . . . 24
KALETRA TABS 100MG; 25MG. . . . 24
KALETRA TABS 200MG; 50MG. . . . 24
KALYDECO . . . . . . . . . . . . . . . . . . . . . . 45
kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
KCL 0.3%/D5W/LR IV LAC RING . . . 48
KCL 0.3%/D5W/NACL 0.9% . . . . . . 48
KCL 0.3%/D5W/NACL 0.45% . . . . . 48
KCL 0.15%/D5W/LR . . . . . . . . . . . . . . 48
KCL 0.15%/D5W/NACL 0.2% . . . . . 48
KCL 0.15%/D5W/ NACL 0.3% . . . . . 48
KCL 0.15%/D5W/NACL 0.9% . . . . . 48
KCL 0.15%/D5W/NACL 0.45% . . . . 48
KCL 0.15%/D5W/NACL 0.225% . . . 48
KCL 0.075%/D5W/NACL 0.45% . . . 48
k-effervescent . . . . . . . . . . . . . . . . . . . . 48
kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . 37
KENALOG . . . . . . . . . . . . . . . . . . . . . . . 36
KEPIVANCE . . . . . . . . . . . . . . . . . . . . . 31
KETEK . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ketoconazole crea . . . . . . . . . . . . . . . . 16
ketoconazole sham . . . . . . . . . . . . . . . 16
61
L
labetalol hcl . . . . . . . . . . . . . . . . . . . . . . 28
LACRISERT . . . . . . . . . . . . . . . . . . . . . 43
LACTATED RINGERS
DEXTROSE 5% VIAFLEX . . . . . . . . 48
LACTATED RINGERS
IRRIGATION . . . . . . . . . . . . . . . . . . . . . 42
LACTATED RINGERS VIAFLEX. . . . 48
lactulose . . . . . . . . . . . . . . . . . . . . . . . . . 34
lamivudine . . . . . . . . . . . . . . . . . . . . . . . 23
lamivudine . . . . . . . . . . . . . . . . . . . . . . . 23
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
lamivudine/zidovudine . . . . . . . . . . . . 23
lamotrigine . . . . . . . . . . . . . . . . . . . . . . . 14
lamotrigine er . . . . . . . . . . . . . . . . . . . . 14
lamotrigine odt . . . . . . . . . . . . . . . . . . . 14
LANOXIN PEDIATRIC . . . . . . . . . . . . 29
LANOXIN TABS 62.5MCG . . . . . . . . . 29
LANOXIN TABS 187.5MCG. . . . . . . . 29
lansoprazole . . . . . . . . . . . . . . . . . . . . . 34
lansoprazole/amoxicillin/
clarithromycin . . . . . . . . . . . . . . . . . . . . 10
LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . 25
LANTUS SOLOSTAR . . . . . . . . . . . . . 26
larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 37
larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . 37
larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 37
larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 37
latanoprost . . . . . . . . . . . . . . . . . . . . . . . 42
latrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
LATUDA TABS 80MG. . . . . . . . . . . . . . 22
LATUDA TABS
120MG, 20MG, 40MG, 60MG . . . . . . 22
layolis fe . . . . . . . . . . . . . . . . . . . . . . . . . 37
LAZANDA . . . . . . . . . . . . . . . . . . . . . . . . . 8
leena . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
leflunomide . . . . . . . . . . . . . . . . . . . . . . 41
LENVIMA 8 MG DAILY DOSE . . . . . 20
LENVIMA 10 MG DAILY DOSE . . . . 20
LENVIMA 14 MG DAILY DOSE . . . . 20
LENVIMA 18 MG DAILY DOSE . . . . 20
LENVIMA 20 MG DAILY DOSE . . . . 20
LENVIMA 24 MG DAILY DOSE . . . . 20
LESCOL XL . . . . . . . . . . . . . . . . . . . . . . 30
lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . 45
letrozole . . . . . . . . . . . . . . . . . . . . . . . . . 19
leucovorin calcium . . . . . . . . . . . . . . . . 19
LEUKERAN . . . . . . . . . . . . . . . . . . . . . . 18
LEUKINE INJ 250MCG . . . . . . . . . . . . 27
leuprolide acetate . . . . . . . . . . . . . . . . 39
levalbuterol . . . . . . . . . . . . . . . . . . . . . . 45
levalbuterol hcl . . . . . . . . . . . . . . . . . . . 45
LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . 26
LEVEMIR FLEXTOUCH . . . . . . . . . . 26
levetiracetam . . . . . . . . . . . . . . . . . . . . 13
levetiracetam er . . . . . . . . . . . . . . . . . . 13
levobunolol hcl . . . . . . . . . . . . . . . . . . . 44
levocarnitine . . . . . . . . . . . . . . . . . . . . . 42
levocetirizine dihydrochloride
oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 44
levocetirizine dihydrochloride tabs. . . 44
levofloxacin in d5w . . . . . . . . . . . . . . . 13
levofloxacin inj . . . . . . . . . . . . . . . . . . . . 13
levofloxacin ophthalmic soln . . . . . . . 13
levofloxacin oral soln . . . . . . . . . . . . . . 13
levofloxacin tabs . . . . . . . . . . . . . . . . . . 13
levoleucovorin calcium . . . . . . . . . . . . 19
levoleucovorin inj 250mg/25ml . . . . . 19
levonest . . . . . . . . . . . . . . . . . . . . . . . . . 38
levonorgestrel and
ethinyl estradiol . . . . . . . . . . . . . . . . . . 38
levonorgestrel/ethinyl estradiol . . . . . 38
levora 0.15/30-28 . . . . . . . . . . . . . . . . . 38
levorphanol tartrate . . . . . . . . . . . . . . . . . 7
levothyroxine sodium inj . . . . . . . . . . . 39
levothyroxine sodium tabs . . . . . . . . . 39
LEVOXYL . . . . . . . . . . . . . . . . . . . . . . . . 39
LEVULAN KERASTICK . . . . . . . . . . . 32
LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 24
LEXIVA TABS . . . . . . . . . . . . . . . . . . . . . 24
LIALDA . . . . . . . . . . . . . . . . . . . . . . . . . . 42
lidocaine hcl external soln . . . . . . . . . . . 9
lidocaine hcl gel . . . . . . . . . . . . . . . . . . . . . 9
lidocaine hcl inj
0.5%, 1%, 1.5%, 2%, 4%. . . . . . . . . . . . . 9
lidocaine hcl inj 10mg/ml, 20mg/ml . . 28
lidocaine hcl jelly . . . . . . . . . . . . . . . . . . . 9
lidocaine hcl mouth/throat soln . . . . . . . 9
lidocaine hcl viscous . . . . . . . . . . . . . . . . 9
lidocaine oint . . . . . . . . . . . . . . . . . . . . . . . 9
lidocaine/prilocaine crea . . . . . . . . . . . . . 9
lidocaine ptch . . . . . . . . . . . . . . . . . . . . . . . 9
lidocaine viscous . . . . . . . . . . . . . . . . . . . 9
LINCOCIN . . . . . . . . . . . . . . . . . . . . . . . 10
lincomycin hcl . . . . . . . . . . . . . . . . . . . . 10
lindane . . . . . . . . . . . . . . . . . . . . . . . . . . 21
linezolid inj 600mg/300ml . . . . . . . . . . 10
linezolid susr . . . . . . . . . . . . . . . . . . . . . 10
linezolid tabs . . . . . . . . . . . . . . . . . . . . . 10
LINZESS . . . . . . . . . . . . . . . . . . . . . . . . 34
liothyronine sodium . . . . . . . . . . . . . . . 39
lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . 28
lisinopril/hydrochlorothiazide . . . . . . . 28
lithium . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
lithium carbonate . . . . . . . . . . . . . . . . . 25
lithium carbonate er . . . . . . . . . . . . . . 25
LITHOSTAT . . . . . . . . . . . . . . . . . . . . . . 35
lokara . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
lomedia 24 fe . . . . . . . . . . . . . . . . . . . . 38
LONSURF TABS 6.14MG; 15MG . . . 18
LONSURF TABS 8.19MG; 20MG . . . 18
loperamide hcl caps . . . . . . . . . . . . . . . 33
lopreeza . . . . . . . . . . . . . . . . . . . . . . . . . 38
lorazepam conc . . . . . . . . . . . . . . . . . . . 24
lorazepam inj
20mg/10ml, 2mg/ml, 4mg/ml . . . . . . . 24
lorazepam intensol . . . . . . . . . . . . . . . 24
lorazepam tabs . . . . . . . . . . . . . . . . . . . 25
lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
lorcet plus tabs 325mg; 7.5mg. . . . . . . . 8
lortab tabs . . . . . . . . . . . . . . . . . . . . . . . . . . 8
loryna . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
losartan potassium/
hydrochlorothiazide tabs
12.5mg; 50mg. . . . . . . . . . . . . . . . . . . . . 27
losartan potassium/
hydrochlorothiazide tabs
12.5mg; 100mg, 25mg; 100mg . . . . . 27
losartan potassium tabs 25mg. . . . . . 27
losartan potassium tabs 50mg. . . . . . 27
losartan potassium tabs 100mg. . . . . 27
62
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . 43
lovastatin tabs 10mg, 20mg . . . . . . . . 30
lovastatin tabs 40mg. . . . . . . . . . . . . . . 30
low-ogestrel . . . . . . . . . . . . . . . . . . . . . . 38
loxapine succinate . . . . . . . . . . . . . . . . 21
ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . 42
LUMIZYME . . . . . . . . . . . . . . . . . . . . . . 33
LUPRON DEPOT . . . . . . . . . . . . . . . . 40
LUPRON DEPOT-PED . . . . . . . . . . . 40
lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
LYNPARZA . . . . . . . . . . . . . . . . . . . . . . 19
LYRICA CAPS 100MG, 150MG,
200MG, 25MG, 50MG, 75MG . . . . . . 14
LYRICA CAPS 225MG, 300MG. . . . . 14
LYRICA ORAL SOLN . . . . . . . . . . . . . . 14
LYSODREN . . . . . . . . . . . . . . . . . . . . . . 39
lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
MEGACE ES . . . . . . . . . . . . . . . . . . . . 39
megestrol acetate . . . . . . . . . . . . . . . . 39
MEKINIST . . . . . . . . . . . . . . . . . . . . . . . 20
meloxicam . . . . . . . . . . . . . . . . . . . . . . . . . 7
melphalan hydrochloride . . . . . . . . . . 18
memantine hcl tabs 5mg. . . . . . . . . . . 14
memantine hcl tabs 10mg. . . . . . . . . . 14
memantine hcl titration pak . . . . . . . . 14
memantine hydrochloride . . . . . . . . . 15
MENACTRA . . . . . . . . . . . . . . . . . . . . . 41
MENEST . . . . . . . . . . . . . . . . . . . . . . . . 38
MENHIBRIX . . . . . . . . . . . . . . . . . . . . . 41
MENOMUNE-A/C/Y/W-135 . . . . . . . 41
MENOSTAR . . . . . . . . . . . . . . . . . . . . . 38
MENVEO . . . . . . . . . . . . . . . . . . . . . . . . 41
mercaptopurine . . . . . . . . . . . . . . . . . . 18
meropenem . . . . . . . . . . . . . . . . . . . . . . 12
MERREM . . . . . . . . . . . . . . . . . . . . . . . . 12
mesalamine . . . . . . . . . . . . . . . . . . . . . . 42
mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
MESNEX TABS . . . . . . . . . . . . . . . . . . . 19
MESTINON SYRP . . . . . . . . . . . . . . . . 17
MESTINON TIMESPAN . . . . . . . . . . . 18
metadate er . . . . . . . . . . . . . . . . . . . . . . 31
metaproterenol sulfate . . . . . . . . . . . . 45
metformin hcl . . . . . . . . . . . . . . . . . . . . 25
metformin hcl er . . . . . . . . . . . . . . . . . . 25
methadone hcl conc . . . . . . . . . . . . . . . . . 7
methadone hcl inj . . . . . . . . . . . . . . . . . . . 7
methadone hcl intensol . . . . . . . . . . . . . 7
methadone hcl oral soln 5mg/5ml. . . . . 7
methadone hcl oral soln 10mg/5ml . . . . 7
methadone hcl tabs . . . . . . . . . . . . . . . . . 7
methadone hcl tbso . . . . . . . . . . . . . . . . . 7
methadose conc . . . . . . . . . . . . . . . . . . . . 7
methadose sugar-free . . . . . . . . . . . . . . 7
methadose tbso . . . . . . . . . . . . . . . . . . . . . 8
methamphetamine hcl . . . . . . . . . . . . 31
methazolamide . . . . . . . . . . . . . . . . . . . 44
methenamine hippurate . . . . . . . . . . . 10
methenamine mandelate . . . . . . . . . . 10
methimazole . . . . . . . . . . . . . . . . . . . . . 40
methitest . . . . . . . . . . . . . . . . . . . . . . . . . 36
methotrexate . . . . . . . . . . . . . . . . . . . . . 40
methotrexate sodium inj
1gm, 1gm/40ml, 250mg/10ml. . . . . . . 40
methoxsalen . . . . . . . . . . . . . . . . . . . . . 32
methscopolamine bromide . . . . . . . . 33
methyclothiazide . . . . . . . . . . . . . . . . . 30
methylergonovine maleate . . . . . . . . 42
METHYLIN CHEW . . . . . . . . . . . . . . . . 31
methylphenidate hcl . . . . . . . . . . . . . . 31
methylphenidate hcl cd . . . . . . . . . . . 31
methylphenidate hcl er cp24
20mg, 40mg. . . . . . . . . . . . . . . . . . . . . . . 31
methylphenidate hcl er tb24 . . . . . . . 31
methylphenidate hcl er tbcr 10mg. . . 31
methylphenidate hcl er tbcr 20mg. . . 31
methylphenidate hydrochloride . . . . 31
methylprednisolone . . . . . . . . . . . . . . . 36
methylprednisolone acetate . . . . . . . 36
methylprednisolone dose pack . . . . 36
methylprednisolone
sodiumsuccinate inj 125mg, 40mg. . . 36
methylprednisolone
sodiumsuccinate inj 1000mg . . . . . . . 36
metipranolol . . . . . . . . . . . . . . . . . . . . . . 44
metoclopramide hcl . . . . . . . . . . . . . . . 33
metolazone . . . . . . . . . . . . . . . . . . . . . . 30
metoprolol/hydrochlorothiazide . . . . 28
metoprolol succinate er tb24
100mg, 25mg, 50mg. . . . . . . . . . . . . . . 28
metoprolol succinate er tb24
200mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
metoprolol tartrate . . . . . . . . . . . . . . . . 28
METRO IV . . . . . . . . . . . . . . . . . . . . . . . 10
metronidazole caps . . . . . . . . . . . . . . . 10
metronidazole crea . . . . . . . . . . . . . . . . 10
metronidazole gel . . . . . . . . . . . . . . . . . 10
metronidazole inj . . . . . . . . . . . . . . . . . . 10
metronidazole in nacl 0.79% . . . . . . 10
M
magnesium sulfate in d5w inj
5%; 10mg/ml. . . . . . . . . . . . . . . . . . . . . . 48
magnesium sulfate inj . . . . . . . . . . . . . 48
MAKENA . . . . . . . . . . . . . . . . . . . . . . . . 39
malathion . . . . . . . . . . . . . . . . . . . . . . . . 21
maprotiline hcl . . . . . . . . . . . . . . . . . . . 15
margesic . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
marlissa . . . . . . . . . . . . . . . . . . . . . . . . . 38
MARPLAN . . . . . . . . . . . . . . . . . . . . . . . 15
MARQIBO . . . . . . . . . . . . . . . . . . . . . . . 19
marten-tab . . . . . . . . . . . . . . . . . . . . . . . . . 7
MATULANE . . . . . . . . . . . . . . . . . . . . . . 18
matzim la . . . . . . . . . . . . . . . . . . . . . . . . 29
MAXIDEX . . . . . . . . . . . . . . . . . . . . . . . . 43
MAXIPIME . . . . . . . . . . . . . . . . . . . . . . . . 11
meclizine hcl tabs . . . . . . . . . . . . . . . . . 16
meclofenamate sodium . . . . . . . . . . . . . 7
MEDROL TABS 2MG. . . . . . . . . . . . . . 36
medroxyprogesterone acetate . . . . . 39
mefloquine hcl . . . . . . . . . . . . . . . . . . . 21
63
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
metronidazole lotn . . . . . . . . . . . . . . . . 10
metronidazole tabs . . . . . . . . . . . . . . . . 10
metronidazole vaginal . . . . . . . . . . . . 10
mexiletine hcl . . . . . . . . . . . . . . . . . . . . 28
MIACALCIN INJ . . . . . . . . . . . . . . . . . . 42
miconazole 3 . . . . . . . . . . . . . . . . . . . . . 16
microgestin 1.5/30 . . . . . . . . . . . . . . . . 38
microgestin 1/20 . . . . . . . . . . . . . . . . . 38
microgestin fe . . . . . . . . . . . . . . . . . . . . 38
microgestin fe 1.5/30 . . . . . . . . . . . . . 38
midodrine hcl . . . . . . . . . . . . . . . . . . . . 27
migergot . . . . . . . . . . . . . . . . . . . . . . . . . 17
miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
MIGRANAL . . . . . . . . . . . . . . . . . . . . . . 17
mimvey . . . . . . . . . . . . . . . . . . . . . . . . . . 38
mimvey lo . . . . . . . . . . . . . . . . . . . . . . . . 38
minitran . . . . . . . . . . . . . . . . . . . . . . . . . . 30
minocycline hcl . . . . . . . . . . . . . . . . . . . 13
minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . 30
mirtazapine . . . . . . . . . . . . . . . . . . . . . . 15
mirtazapine odt . . . . . . . . . . . . . . . . . . . 15
misoprostol . . . . . . . . . . . . . . . . . . . . . . 34
mitomycin . . . . . . . . . . . . . . . . . . . . . . . . 19
mitoxantrone hcl . . . . . . . . . . . . . . . . . 19
M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . 41
modafinil tabs 100mg. . . . . . . . . . . . . . 46
modafinil tabs 200mg. . . . . . . . . . . . . . 46
moderiba 800 dose pack . . . . . . . . . . 23
moderiba 1200 dose pack . . . . . . . . 23
moderiba misc . . . . . . . . . . . . . . . . . . . . 23
moderiba tabs . . . . . . . . . . . . . . . . . . . . 23
moexipril hcl . . . . . . . . . . . . . . . . . . . . . 28
moexipril/hydrochlorothiazide . . . . . 28
molindone hydrochloride . . . . . . . . . . 22
mometasone furoate crea . . . . . . . . . 36
mometasone furoate external soln. . . 36
mometasone furoate oint . . . . . . . . . . 36
mondoxyne nl . . . . . . . . . . . . . . . . . . . . 13
mono-linyah . . . . . . . . . . . . . . . . . . . . . . 38
mononessa . . . . . . . . . . . . . . . . . . . . . . 38
montelukast sodium . . . . . . . . . . . . . . 44
MONUROL . . . . . . . . . . . . . . . . . . . . . . 10
morphine sulfate add-vantage . . . . . . . 8
morphine sulfate er cp24 . . . . . . . . . . . . 8
morphine sulfate er tbcr . . . . . . . . . . . . . 8
morphine sulfate inj 0.5mg/ml,
10mg/0.7ml, 1mg/ml. . . . . . . . . . . . . . . . . 8
morphine sulfate inj 10mg/ml,
150mg/30ml, 15mg/ml, 1mg/ml,
25mg/ml, 2mg/ml, 4mg/ml,
50mg/ml, 5mg/ml, 8mg/ml. . . . . . . . . . . . 8
morphine sulfate oral soln
10mg/5ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 8
morphine sulfate oral soln
20mg/5ml. . . . . . . . . . . . . . . . . . . . . . . . . . . 8
morphine sulfate oral soln
100mg/5ml. . . . . . . . . . . . . . . . . . . . . . . . . . 8
morphine sulfate supp . . . . . . . . . . . . . . . 8
morphine sulfate tabs . . . . . . . . . . . . . . . 9
MOTOFEN . . . . . . . . . . . . . . . . . . . . . . . 33
MOVIPREP . . . . . . . . . . . . . . . . . . . . . . 34
MOXEZA . . . . . . . . . . . . . . . . . . . . . . . . 13
moxifloxacin hcl inj . . . . . . . . . . . . . . . . 13
moxifloxacin hcl tabs . . . . . . . . . . . . . . 13
MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . 48
MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . 28
multi vitamin/fluoride . . . . . . . . . . . . . . 49
multivitamin/fluoride chew
60mg; 400unit; 4.5mcg; 0.3mg;
13.5mg; 1.05mg; 1.2mg; 0; 0.25mg;
1.05mg; 15unit; 2500unit. . . . . . . . . . . 49
multi-vitamin/fluoride oral soln
35mg/ml; 400unit/ml; 2mcg/ml;
5unit/ml; 8mg/ml; 0.4mg/ml;
0.6mg/ml; 0.25mg/ml; 0.5mg/ml;
1500unit/ml, 35mg/ml; 400unit/ml;
2mcg/ml; 5unit/ml; 8mg/ml;
0.4mg/ml; 0.6mg/ml; 0.5mg/ml;
0.5mg/ml; 1500unit/ml . . . . . . . . . . . . . 49
multivitamin with fluoride . . . . . . . . . . 49
multi-vit/fluoride . . . . . . . . . . . . . . . . . . 49
multi-vit/iron/fluoride oral soln
35mg/ml; 400unit/ml; 10mg/ml;
8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.25mg/ml; 0.5mg/ml; 5unit/ml;
1500unit/ml . . . . . . . . . . . . . . . . . . . . . . . 49
mult-vitamin/fluoride . . . . . . . . . . . . . . 49
mupirocin . . . . . . . . . . . . . . . . . . . . . . . . 10
MUSTARGEN . . . . . . . . . . . . . . . . . . . . 18
mvc-fluoride . . . . . . . . . . . . . . . . . . . . . . 49
MYCAMINE . . . . . . . . . . . . . . . . . . . . . . 17
mycophenolate mofetil . . . . . . . . . . . . 40
mycophenolic acid dr . . . . . . . . . . . . . 40
MYFORTIC . . . . . . . . . . . . . . . . . . . . . . 40
myorisan . . . . . . . . . . . . . . . . . . . . . . . . . 32
MYRBETRIQ . . . . . . . . . . . . . . . . . . . . 34
myzilra . . . . . . . . . . . . . . . . . . . . . . . . . . 38
64
N
nabumetone . . . . . . . . . . . . . . . . . . . . . . . 7
nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . 28
nadolol/bendroflumethiazide . . . . . . 28
NAFCILLIN . . . . . . . . . . . . . . . . . . . . . . 12
nafcillin sodium . . . . . . . . . . . . . . . . . . . 12
naftifine hcl . . . . . . . . . . . . . . . . . . . . . . 17
naftifine hydrochloride . . . . . . . . . . . . 17
NAFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 17
NAGLAZYME . . . . . . . . . . . . . . . . . . . . 33
nalbuphine hcl . . . . . . . . . . . . . . . . . . . . . 9
naloxone hcl . . . . . . . . . . . . . . . . . . . . . . . 9
naltrexone hcl . . . . . . . . . . . . . . . . . . . . . . 9
NAMENDA ORAL SOLN . . . . . . . . . . 15
NAMENDA TABS 5MG. . . . . . . . . . . . . 15
NAMENDA TABS 10MG . . . . . . . . . . . 15
NAMENDA TITRATION PAK . . . . . . 15
NAMENDA XR . . . . . . . . . . . . . . . . . . . 15
NAMENDA XR TITRATION PACK. . . 15
naphazoline hcl . . . . . . . . . . . . . . . . . . 43
naproxen . . . . . . . . . . . . . . . . . . . . . . . . . . 7
naproxen dr . . . . . . . . . . . . . . . . . . . . . . . . 7
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
naproxen sodium tabs
275mg, 550mg . . . . . . . . . . . . . . . . . . . . . . 7
naratriptan hcl . . . . . . . . . . . . . . . . . . . . 17
NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . . 9
NATACYN . . . . . . . . . . . . . . . . . . . . . . . 17
nateglinide . . . . . . . . . . . . . . . . . . . . . . . 25
NATPARA . . . . . . . . . . . . . . . . . . . . . . . . 42
NEBUPENT . . . . . . . . . . . . . . . . . . . . . . 21
necon 0.5/35-28 . . . . . . . . . . . . . . . . . . 38
necon 1/35 . . . . . . . . . . . . . . . . . . . . . . . 38
necon 1/50-28 . . . . . . . . . . . . . . . . . . . . 38
necon 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 38
necon 10/11-28 . . . . . . . . . . . . . . . . . . . 38
nefazodone hcl . . . . . . . . . . . . . . . . . . . 15
neomycin/bacitracin/polymyxin . . . . 10
neomycin/polymyxin/
bacitracin/hydrocortisone . . . . . . . . . 10
neomycin/polymyxin b sulfates . . . . . 10
neomycin/polymyxin/
dexamethasone . . . . . . . . . . . . . . . . . . 43
neomycin/polymyxin/gramicidin. . . . . 10
neomycin/polymyxin/hc . . . . . . . . . . . 44
neomycin/polymyxin/
hydrocortisone . . . . . . . . . . . . . . . . . . . 10
neomycin/polymyxin/
hydrocortisone . . . . . . . . . . . . . . . . . . . 44
neomycin sulfate . . . . . . . . . . . . . . . . . 10
NEOPROFEN . . . . . . . . . . . . . . . . . . . . . . 7
NEORAL . . . . . . . . . . . . . . . . . . . . . . . . . 40
NEPHRAMINE . . . . . . . . . . . . . . . . . . . 48
neuac . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
NEULASTA . . . . . . . . . . . . . . . . . . . . . . 27
NEUPOGEN . . . . . . . . . . . . . . . . . . . . . 27
NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . 21
NEVANAC . . . . . . . . . . . . . . . . . . . . . . . 43
nevirapine . . . . . . . . . . . . . . . . . . . . . . . 23
nevirapine er . . . . . . . . . . . . . . . . . . . . . 23
NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . 20
niacin er tbcr 500mg. . . . . . . . . . . . . . . 30
niacin er tbcr 1000mg, 750mg. . . . . . 30
niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
nicardipine hcl . . . . . . . . . . . . . . . . . . . . 29
NICOTROL INHALER . . . . . . . . . . . . . . 9
NICOTROL NS . . . . . . . . . . . . . . . . . . . . . 9
nifedical xl . . . . . . . . . . . . . . . . . . . . . . . 29
nifedipine er . . . . . . . . . . . . . . . . . . . . . . 29
nikki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
NILANDRON . . . . . . . . . . . . . . . . . . . . . 18
nimodipine . . . . . . . . . . . . . . . . . . . . . . . 29
NINLARO . . . . . . . . . . . . . . . . . . . . . . . . 19
NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . 18
nisoldipine er . . . . . . . . . . . . . . . . . . . . . 29
nisoldipine tb24 17mg,
20mg, 34mg, 40mg, 8.5mg. . . . . . . . . 29
nisoldipine tb24 30mg. . . . . . . . . . . . . . 29
NITRO-BID . . . . . . . . . . . . . . . . . . . . . . 30
NITRO-DUR PT24
0.3MG/HR, 0.8MG/HR. . . . . . . . . . . . . 30
nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 11
nitrofurantoin macrocrystals
caps 100mg, 50mg . . . . . . . . . . . . . . . . . 11
nitrofurantoin monohydrate . . . . . . . . . 11
nitrofurantoin monohydrate/
macrocrystals . . . . . . . . . . . . . . . . . . . . . 11
nitroglycerin . . . . . . . . . . . . . . . . . . . . . . 30
nitroglycerin lingual
translingual soln . . . . . . . . . . . . . . . . . . 30
nitroglycerin transdermal . . . . . . . . . . 30
NITROSTAT . . . . . . . . . . . . . . . . . . . . . 30
nizatidine caps . . . . . . . . . . . . . . . . . . . . 33
nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . 39
norethindrone . . . . . . . . . . . . . . . . . . . . 39
norethindrone acetate . . . . . . . . . . . . 39
norethindrone acetate/ethinyl
estradiol/ferrous fumarate . . . . . . . . . 38
norethindrone acetate/ethinyl
estradiol tabs 2.5mcg; 0.5mg,
5mcg; 1mg. . . . . . . . . . . . . . . . . . . . . . . . 38
norethindrone acetate/ethinyl
estradiol tabs 20mcg; 1mg . . . . . . . . . 38
norethindrone & ethinyl
estradiol ferrous fumarate . . . . . . . . . 38
norgestimate/ethinyl estradiol . . . . . 38
norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . 39
NORMOSOL-M IN D5W . . . . . . . . . . 48
NORMOSOL -R . . . . . . . . . . . . . . . . . . 48
NORMOSOL-R . . . . . . . . . . . . . . . . . . 48
NORMOSOL-R IN D5W . . . . . . . . . . 48
NORTHERA . . . . . . . . . . . . . . . . . . . . . 29
nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . 38
nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . 38
nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . 38
nortriptyline hcl . . . . . . . . . . . . . . . . . . . 16
NORVIR . . . . . . . . . . . . . . . . . . . . . . . . . 24
NOVOFINE 30GX8MM . . . . . . . . . . . 42
NOVOFINE 31 . . . . . . . . . . . . . . . . . . . 42
NOVOFINE 32GX6MM . . . . . . . . . . . 42
NOVOFINE AUTOCOVER
30GX8MM . . . . . . . . . . . . . . . . . . . . . . . 42
NOVOLIN 70/30 . . . . . . . . . . . . . . . . . . 26
NOVOLIN 70/30 RELION . . . . . . . . . 26
NOVOLIN N . . . . . . . . . . . . . . . . . . . . . 26
NOVOLIN N RELION . . . . . . . . . . . . . 26
NOVOLIN R . . . . . . . . . . . . . . . . . . . . . 26
NOVOLIN R INNOLET . . . . . . . . . . . . 26
NOVOLIN R RELION . . . . . . . . . . . . . 26
NOVOLOG . . . . . . . . . . . . . . . . . . . . . . 26
NOVOLOG FLEXPEN . . . . . . . . . . . . 26
NOVOLOG MIX 70/30 . . . . . . . . . . . . 26
NOVOLOG MIX 70/30
PREFILLED FLEXPEN . . . . . . . . . . . 26
NOVOLOG PENFILL . . . . . . . . . . . . . 26
NOVOTWIST 30GX8MM . . . . . . . . . 42
NOVOTWIST 32GX5MM . . . . . . . . . 42
NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 17
NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 17
NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . 31
nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . 40
NULYTELY/FLAVOR PACKS . . . . . . 34
NUPLAZID . . . . . . . . . . . . . . . . . . . . . . . 22
NUTRILIPID . . . . . . . . . . . . . . . . . . . . . 49
65
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
NUTRILYTE INJ 2.03MEQ/ML;
0.25MEQ/ML; 1.68MEQ/ML;
0.25MEQ/ML; 0.4MEQ/ML;
2.03MEQ/ML; 1.25MEQ . . . . . . . . . . . 48
NUVARING . . . . . . . . . . . . . . . . . . . . . . 38
NUVIGIL . . . . . . . . . . . . . . . . . . . . . . . . . 46
nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . 17
NYMALIZE . . . . . . . . . . . . . . . . . . . . . . . 29
nystatin crea . . . . . . . . . . . . . . . . . . . . . . 17
nystatin oint . . . . . . . . . . . . . . . . . . . . . . 17
nystatin powd 100000unit/gm . . . . . . 17
nystatin susp . . . . . . . . . . . . . . . . . . . . . 17
nystatin tabs . . . . . . . . . . . . . . . . . . . . . . 17
nystatin/triamcinolone . . . . . . . . . . . . 17
nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
olanzapine/fluoxetine . . . . . . . . . . . . . 15
olanzapine inj . . . . . . . . . . . . . . . . . . . . . 22
olanzapine odt . . . . . . . . . . . . . . . . . . . 22
olanzapine tabs 2.5mg. . . . . . . . . . . . . 22
olanzapine tabs 10mg,
15mg, 20mg, 5mg, 7.5mg. . . . . . . . . . 22
olopatadine hcl ophthalmic soln . . . . 43
OLYSIO . . . . . . . . . . . . . . . . . . . . . . . . . 23
omega-3-acid ethyl esters . . . . . . . . 30
omeprazole cpdr . . . . . . . . . . . . . . . . . . 34
omeprazole/sodium
bicarbonate caps . . . . . . . . . . . . . . . . . 34
omeprazole/sodium
bicarbonate pack . . . . . . . . . . . . . . . . . 34
ONCASPAR . . . . . . . . . . . . . . . . . . . . . 19
ondansetron hcl inj
40mg/20ml, 4mg/2ml . . . . . . . . . . . . . . 16
ondansetron hcl oral soln . . . . . . . . . . 16
ondansetron hcl tabs 4mg, 8mg . . . . 16
ondansetron hcl tabs 24mg . . . . . . . . 16
ondansetron odt . . . . . . . . . . . . . . . . . . 16
ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 14
ONFI TABS 10MG. . . . . . . . . . . . . . . . . 14
ONFI TABS 20MG. . . . . . . . . . . . . . . . . 14
OPANA ER (CRUSH RESISTANT)
T12A 10MG, 15MG, 20MG,
30MG, 5MG, 7.5MG. . . . . . . . . . . . . . . . . 8
OPANA ER (CRUSH RESISTANT)
T12A 40MG. . . . . . . . . . . . . . . . . . . . . . . . . 8
OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . 20
OPIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
OPIUM TINCTURE . . . . . . . . . . . . . . . . . 9
OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . 45
ORACEA . . . . . . . . . . . . . . . . . . . . . . . . 32
oralone . . . . . . . . . . . . . . . . . . . . . . . . . . 31
ORAP . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ORENCIA INJ 250MG . . . . . . . . . . . . . 40
ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . 33
orphenadrine citrate er . . . . . . . . . . . . 46
orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . 38
ORTHO TRI-CYCLEN LO . . . . . . . . . 38
oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . 33
OSMOPREP . . . . . . . . . . . . . . . . . . . . . 33
oxacillin sodium . . . . . . . . . . . . . . . . . . 12
oxaliplatin . . . . . . . . . . . . . . . . . . . . . . . . 19
oxandrolone . . . . . . . . . . . . . . . . . . . . . 36
oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . . 7
oxazepam . . . . . . . . . . . . . . . . . . . . . . . 25
oxcarbazepine . . . . . . . . . . . . . . . . . . . 14
oxiconazole nitrate . . . . . . . . . . . . . . . 17
OXISTAT . . . . . . . . . . . . . . . . . . . . . . . . 17
OXSORALEN . . . . . . . . . . . . . . . . . . . . 32
OXTELLAR XR . . . . . . . . . . . . . . . . . . 14
oxybutynin chloride . . . . . . . . . . . . . . . 34
oxybutynin chloride er tb24 5mg. . . . 34
oxybutynin chloride er tb24
10mg, 15mg. . . . . . . . . . . . . . . . . . . . . . . 34
oxycodone/acetaminophen
oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
oxycodone/acetaminophen tabs
325mg; 10mg, 325mg; 2.5mg,
325mg; 5mg, 325mg; 7.5mg. . . . . . . . . . 9
oxycodone/aspirin . . . . . . . . . . . . . . . . . . 9
oxycodone hcl caps . . . . . . . . . . . . . . . . . 9
oxycodone hcl conc . . . . . . . . . . . . . . . . . 9
oxycodone hcl oral soln . . . . . . . . . . . . . 9
oxycodone hcl tabs . . . . . . . . . . . . . . . . . 9
oxycodone/ibuprofen . . . . . . . . . . . . . . . 9
oxymorphone hydrochloride . . . . . . . . . 9
oxymorphone hydrochloride er . . . . . . 8
Needles and Syringes
bd eclipse syringe/1ml/30gx1/2” . . . 49
bd insulin syringe safetyglide/
1ml/29g x 1/2” . . . . . . . . . . . . . . . . . . . . 49
bd insulin syringe ultrafine/
0.3ml/31g x 5/16” . . . . . . . . . . . . . . . . . 49
bd insulin syringe ultrafine/
0.5ml/30g x 1/2” . . . . . . . . . . . . . . . . . . 49
bd insulin syringe ultrafine/
1ml/31g x 5/16” . . . . . . . . . . . . . . . . . . 49
bd pen needle/ultrafine/
29g x 12.7mm . . . . . . . . . . . . . . . . . . . . 49
O
ocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
OCTAGAM INJ 10GM/100ML,
1GM/20ML, 20GM/200ML,
2GM/20ML, 5GM/50ML. . . . . . . . . . . . 41
octreotide acetate inj 100mcg/ml,
200mcg/ml, 50mcg/ml . . . . . . . . . . . . . 40
octreotide acetate inj
1000mcg/ml, 500mcg/ml. . . . . . . . . . . 40
ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . 23
ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . 19
ofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . 13
ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . 38
66
P
pacerone . . . . . . . . . . . . . . . . . . . . . . . . 28
paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . 19
paliperidone er tb24 1.5mg, 3mg . . . 22
paliperidone er tb24 6mg. . . . . . . . . . . 22
paliperidone er tb24 9mg. . . . . . . . . . . 22
pamidronate disodium . . . . . . . . . . . . 42
PANDEL . . . . . . . . . . . . . . . . . . . . . . . . . 36
PANRETIN . . . . . . . . . . . . . . . . . . . . . . . 20
pantoprazole sodium inj . . . . . . . . . . . 34
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
pantoprazole sodium tbec . . . . . . . . . 34
PAREGORIC . . . . . . . . . . . . . . . . . . . . . 33
paricalcitol . . . . . . . . . . . . . . . . . . . . . . . 42
paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
paromomycin sulfate . . . . . . . . . . . . . 10
paroxetine hcl tabs 10mg . . . . . . . . . . 15
paroxetine hcl tabs
20mg, 30mg, 40mg. . . . . . . . . . . . . . . . 15
PASER . . . . . . . . . . . . . . . . . . . . . . . . . . 18
PATADAY . . . . . . . . . . . . . . . . . . . . . . . . 43
PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 15
PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . 43
PCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . 41
PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . 41
peg 3350/electrolytes . . . . . . . . . . . . . 34
peg-3350/electrolytes . . . . . . . . . . . . . 34
peg-3350/nacl/na bicarbonate/kcl. . . 34
PEGANONE . . . . . . . . . . . . . . . . . . . . . 14
PEGINTRON . . . . . . . . . . . . . . . . . . . . 23
PEG-INTRON REDIPEN . . . . . . . . . . 23
PEG-INTRON REDIPEN PAK 4 . . . . 23
penicillin g potassium in
iso-osmotic dextrose . . . . . . . . . . . . . . 12
penicillin g potassium inj
20000000unit, 5000000unit . . . . . . . . 12
penicillin g procaine . . . . . . . . . . . . . . 12
penicillin g sodium . . . . . . . . . . . . . . . . 12
penicillin v potassium . . . . . . . . . . . . . 12
PENTACEL . . . . . . . . . . . . . . . . . . . . . . 41
PENTAM 300 . . . . . . . . . . . . . . . . . . . . 21
PENTASA . . . . . . . . . . . . . . . . . . . . . . . . 42
pentoxifylline er . . . . . . . . . . . . . . . . . . 29
PERFOROMIST . . . . . . . . . . . . . . . . . . 45
PERIKABIVEN . . . . . . . . . . . . . . . . . . . 49
perindopril erbumine . . . . . . . . . . . . . . 28
periogard . . . . . . . . . . . . . . . . . . . . . . . . 31
PERJETA . . . . . . . . . . . . . . . . . . . . . . . . 20
permethrin . . . . . . . . . . . . . . . . . . . . . . . 21
perphenazine . . . . . . . . . . . . . . . . . . . . 21
perphenazine/amitriptyline . . . . . . . . 16
pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . 12
phenadoz . . . . . . . . . . . . . . . . . . . . . . . . 16
phenazopyridine hcl . . . . . . . . . . . . . . 35
phenelzine sulfate . . . . . . . . . . . . . . . . 15
phenergan supp . . . . . . . . . . . . . . . . . . 16
phenobarbital . . . . . . . . . . . . . . . . . . . . 14
phenoxybenzamine hydrochloride. . . 27
phenylephrine hcl
ophthalmic soln 10%, 2.5% . . . . . . . . 43
PHENYTEK . . . . . . . . . . . . . . . . . . . . . . 14
phenytoin . . . . . . . . . . . . . . . . . . . . . . . . 14
phenytoin sodium . . . . . . . . . . . . . . . . 14
phenytoin sodium extended . . . . . . . 14
PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . 35
phospha 250 neutral . . . . . . . . . . . . . . 48
phosphasal . . . . . . . . . . . . . . . . . . . . . . 34
PHOSPHOLINE IODIDE . . . . . . . . . . 44
PHOTOFRIN . . . . . . . . . . . . . . . . . . . . . 19
PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . 42
PHYSIOSOL IRRIGATION . . . . . . . . 42
pilocarpine hcl . . . . . . . . . . . . . . . . . . . . 32
pilocarpine hcl . . . . . . . . . . . . . . . . . . . . 44
pilocarpine hydrochloride . . . . . . . . . 32
pimozide . . . . . . . . . . . . . . . . . . . . . . . . . 21
pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . 38
pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . 28
pioglitazone hcl . . . . . . . . . . . . . . . . . . 25
pioglitazone hcl-glimepiride . . . . . . . 25
pioglitazone hcl/metformin hcl . . . . . . 25
piperacillin sodium/
tazobactam sodium . . . . . . . . . . . . . . . 12
piperacillin sodium/
tazobactam sodium . . . . . . . . . . . . . . . 12
piperacillin/tazobactam . . . . . . . . . . . 12
pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . 38
piroxicam . . . . . . . . . . . . . . . . . . . . . . . . . . 7
PLASMA-LYTE-56/D5W . . . . . . . . . . 48
PLASMA-LYTE-148 . . . . . . . . . . . . . . 48
PLASMA-LYTE A . . . . . . . . . . . . . . . . . 48
PLENAMINE . . . . . . . . . . . . . . . . . . . . . 48
podocon 25 in benzoin tincture . . . . . 32
podofilox . . . . . . . . . . . . . . . . . . . . . . . . . 32
polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
polyethylene glycol 3350 . . . . . . . . . . 34
polymyxin b sulfate . . . . . . . . . . . . . . . . 11
polymyxin b sulfate/
trimethoprim sulfate . . . . . . . . . . . . . . . 11
POMALYST . . . . . . . . . . . . . . . . . . . . . . 18
portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . 38
PORTRAZZA . . . . . . . . . . . . . . . . . . . . 19
POTASSIUM CHLORIDE
0.3%/D5W . . . . . . . . . . . . . . . . . . . . . . . 48
POTASSIUM CHLORIDE
0.3%/ NACL 0.9% . . . . . . . . . . . . . . . . 48
POTASSIUM CHLORIDE
0.15% D5W/NACL 0.33% . . . . . . . . . 48
POTASSIUM CHLORIDE
0.15% D5W/NACL 0.45% . . . . . . . . . 48
POTASSIUM CHLORIDE 0.15%
D5W/NACL 0.45% VIAFLEX . . . . . 48
POTASSIUM CHLORIDE
0.15% NACL 0.9% . . . . . . . . . . . . . . . 48
POTASSIUM CHLORIDE
0.15%/NACL 0.9% . . . . . . . . . . . . . . . 48
POTASSIUM CHLORIDE
0.15% /NACL 0.45% VIAFLEX . . . . 48
POTASSIUM CHLORIDE 0.15%
W/NACL 0.9% VIAFLEX . . . . . . . . . . 48
POTASSIUM CHLORIDE
0.22% D5W/NACL 0.45% . . . . . . . . . 48
potassium chloride cr . . . . . . . . . . . . . 48
potassium chloride er . . . . . . . . . . . . . 48
potassium chloride inj
0.4meq/ml, 10meq/100ml,
10meq/50ml, 20meq/100ml,
2meq/ml, 40meq/100ml. . . . . . . . . . . . 48
potassium chloride oral soln . . . . . . . 48
potassium chloride pack . . . . . . . . . . . 48
potassium chloride sr . . . . . . . . . . . . . 48
potassium citrate/citric acid . . . . . . . 48
potassium citrate-citric
acid crystals . . . . . . . . . . . . . . . . . . . . . 48
67
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
potassium citrate er . . . . . . . . . . . . . . 48
POTIGA TABS 50MG. . . . . . . . . . . . . . 13
POTIGA TABS
200MG, 300MG, 400MG. . . . . . . . . . . 13
PRADAXA . . . . . . . . . . . . . . . . . . . . . . . 26
pramipexole dihydrochloride . . . . . . 21
pramipexole dihydrochloride er . . . . 21
pravastatin sodium tabs
10mg, 20mg. . . . . . . . . . . . . . . . . . . . . . . 30
pravastatin sodium tabs 40mg. . . . . . 30
pravastatin sodium tabs 80mg. . . . . . 30
prazosin hcl . . . . . . . . . . . . . . . . . . . . . . 27
PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . 43
PRED-G S.O.P. . . . . . . . . . . . . . . . . . . 43
PRED MILD . . . . . . . . . . . . . . . . . . . . . . 43
prednicarbate . . . . . . . . . . . . . . . . . . . . 36
prednisolone acetate . . . . . . . . . . . . . 43
prednisolone oral soln . . . . . . . . . . . . . 36
prednisolone sodium phosphate. . . . 36
prednisolone sodium phosphate. . . . 43
prednisone . . . . . . . . . . . . . . . . . . . . . . . 36
prednisone intensol . . . . . . . . . . . . . . . 36
PREFEST . . . . . . . . . . . . . . . . . . . . . . . 38
PREMARIN CREA . . . . . . . . . . . . . . . . 38
PREMARIN INJ . . . . . . . . . . . . . . . . . . . 38
PREMARIN TABS . . . . . . . . . . . . . . . . 38
PREMASOL . . . . . . . . . . . . . . . . . . . . . 49
premium lidocaine . . . . . . . . . . . . . . . . . . 9
PREMPHASE . . . . . . . . . . . . . . . . . . . . 38
PREMPRO . . . . . . . . . . . . . . . . . . . . . . 38
prevalite . . . . . . . . . . . . . . . . . . . . . . . . . 30
previfem . . . . . . . . . . . . . . . . . . . . . . . . . 38
PREZCOBIX . . . . . . . . . . . . . . . . . . . . . 24
PREZISTA SUSP . . . . . . . . . . . . . . . . . 24
PREZISTA TABS 150MG, 75MG . . . 24
PREZISTA TABS 600MG, 800MG. . . . 24
PRIALT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
PRIMAQUINE PHOSPHATE . . . . . . 21
PRIMAXIN IV . . . . . . . . . . . . . . . . . . . . 12
PRIMAXIN IV ADD-VANTAGE . . . . . 12
primidone . . . . . . . . . . . . . . . . . . . . . . . . 14
PRIMSOL . . . . . . . . . . . . . . . . . . . . . . . . . 11
PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . 15
PRIVIGEN . . . . . . . . . . . . . . . . . . . . . . . 41
PROAIR HFA . . . . . . . . . . . . . . . . . . . . 45
PROAIR RESPICLICK . . . . . . . . . . . . 45
probenecid . . . . . . . . . . . . . . . . . . . . . . . 17
probenecid/colchicine . . . . . . . . . . . . . 17
procainamide hcl . . . . . . . . . . . . . . . . . 28
PROCALAMINE . . . . . . . . . . . . . . . . . . 49
prochlorperazine . . . . . . . . . . . . . . . . . 21
prochlorperazine edisylate . . . . . . . . 21
prochlorperazine maleate . . . . . . . . . 21
PROCRIT INJ
10000UNIT/ML, 2000UNIT/ML,
3000UNIT/ML, 4000UNIT/ML . . . . . . 27
PROCRIT INJ
20000UNIT/ML, 40000UNIT/ML. . . . 27
procto-med hc . . . . . . . . . . . . . . . . . . . . 36
procto-pak . . . . . . . . . . . . . . . . . . . . . . . 36
proctosol hc . . . . . . . . . . . . . . . . . . . . . . 36
proctozone-hc . . . . . . . . . . . . . . . . . . . . 36
PROCYSBI . . . . . . . . . . . . . . . . . . . . . . 43
progesterone . . . . . . . . . . . . . . . . . . . . . 39
PROGLYCEM . . . . . . . . . . . . . . . . . . . . 25
PROGRAF CAPS 0.5MG, 1MG . . . . 40
PROGRAF CAPS 5MG. . . . . . . . . . . . 40
PROGRAF INJ . . . . . . . . . . . . . . . . . . . 40
PROLASTIN-C . . . . . . . . . . . . . . . . . . . 45
PROLEUKIN . . . . . . . . . . . . . . . . . . . . . 19
PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . 42
PROMACTA TABS
12.5MG, 25MG, 50MG. . . . . . . . . . . . . 27
promethazine hcl . . . . . . . . . . . . . . . . . 16
promethazine hcl . . . . . . . . . . . . . . . . . 44
promethazine hcl plain . . . . . . . . . . . . 16
promethazine vc plain . . . . . . . . . . . . 45
promethegan . . . . . . . . . . . . . . . . . . . . . 16
propafenone hcl . . . . . . . . . . . . . . . . . . 28
propafenone hcl er . . . . . . . . . . . . . . . 28
propantheline bromide . . . . . . . . . . . . 33
proparacaine hcl . . . . . . . . . . . . . . . . . 43
propranolol hcl . . . . . . . . . . . . . . . . . . . 28
propranolol hcl er . . . . . . . . . . . . . . . . . 28
propranolol/hydrochlorothiazide . . . . 28
propylthiouracil . . . . . . . . . . . . . . . . . . . 40
PROQUAD . . . . . . . . . . . . . . . . . . . . . . 41
PROSOL . . . . . . . . . . . . . . . . . . . . . . . . 49
protriptyline hcl . . . . . . . . . . . . . . . . . . . 16
PROVENTIL HFA . . . . . . . . . . . . . . . . 45
PRUDOXIN . . . . . . . . . . . . . . . . . . . . . . 32
PULMICORT FLEXHALER . . . . . . . . 44
PULMICORT SUSP 1MG/2ML . . . . . 44
PULMOZYME . . . . . . . . . . . . . . . . . . . . 45
PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . 18
pyrazinamide . . . . . . . . . . . . . . . . . . . . 18
pyridostigmine bromide . . . . . . . . . . . 18
68
Q
QUADRACEL . . . . . . . . . . . . . . . . . . . . 41
quasense . . . . . . . . . . . . . . . . . . . . . . . . 38
quetiapine fumarate . . . . . . . . . . . . . . 22
quinapril hcl . . . . . . . . . . . . . . . . . . . . . . 28
quinapril/hydrochlorothiazide . . . . . . 28
quinidine gluconate . . . . . . . . . . . . . . . 28
quinidine gluconate cr . . . . . . . . . . . . 28
quinidine gluconate er . . . . . . . . . . . . 28
quinidine sulfate . . . . . . . . . . . . . . . . . . 28
quinine sulfate . . . . . . . . . . . . . . . . . . . 21
QVAR . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
R
RABAVERT . . . . . . . . . . . . . . . . . . . . . . 41
rabeprazole sodium . . . . . . . . . . . . . . 34
raloxifene hydrochloride . . . . . . . . . . 39
ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . 28
RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . 29
ranitidine hcl . . . . . . . . . . . . . . . . . . . . . 33
RAPAMUNE ORAL SOLN . . . . . . . . . 40
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
RAPAMUNE TABS 0.5MG . . . . . . . . . 40
RAPAMUNE TABS 1MG, 2MG . . . . . 40
RAVICTI . . . . . . . . . . . . . . . . . . . . . . . . . 33
rea lo 39 . . . . . . . . . . . . . . . . . . . . . . . . . 32
rea lo 40 crea . . . . . . . . . . . . . . . . . . . . . 32
REBETOL ORAL SOLN . . . . . . . . . . . 23
REBIF . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
REBIF REBIDOSE . . . . . . . . . . . . . . . 31
REBIF REBIDOSE
TITRATION PACK . . . . . . . . . . . . . . . . 31
REBIF TITRATION PACK . . . . . . . . . 31
reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . 38
RECOMBIVAX HB . . . . . . . . . . . . . . . 41
RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . 30
REGRANEX . . . . . . . . . . . . . . . . . . . . . 32
RELAGARD . . . . . . . . . . . . . . . . . . . . . . 11
RELENZA DISKHALER . . . . . . . . . . . 24
RELISTOR . . . . . . . . . . . . . . . . . . . . . . . 33
RELPAX TABS 20MG. . . . . . . . . . . . . . 17
RELPAX TABS 40MG. . . . . . . . . . . . . . 17
remeven . . . . . . . . . . . . . . . . . . . . . . . . . 32
REMICADE . . . . . . . . . . . . . . . . . . . . . . 40
REMODULIN . . . . . . . . . . . . . . . . . . . . 45
RENVELA . . . . . . . . . . . . . . . . . . . . . . . 35
repaglinide . . . . . . . . . . . . . . . . . . . . . . . 25
reprexain tabs 10mg; 200mg. . . . . . . . . 9
RESCRIPTOR . . . . . . . . . . . . . . . . . . . 23
RESTASIS . . . . . . . . . . . . . . . . . . . . . . . 43
RETROVIR IV INFUSION . . . . . . . . . 24
REVLIMID . . . . . . . . . . . . . . . . . . . . . . . 18
REXULTI . . . . . . . . . . . . . . . . . . . . . . . . 22
REYATAZ . . . . . . . . . . . . . . . . . . . . . . . . 24
RHEUMATREX . . . . . . . . . . . . . . . . . . 40
ribasphere caps . . . . . . . . . . . . . . . . . . . 23
ribasphere ribapak . . . . . . . . . . . . . . . 23
ribasphere tabs 200mg, 400mg. . . . . 23
ribasphere tabs 600mg . . . . . . . . . . . . 23
ribavirin . . . . . . . . . . . . . . . . . . . . . . . . . . 23
RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . 41
rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . 18
RIFAMATE . . . . . . . . . . . . . . . . . . . . . . . 18
rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . 18
RIFATER . . . . . . . . . . . . . . . . . . . . . . . . 18
riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . 31
rimantadine hcl . . . . . . . . . . . . . . . . . . . 24
RINGERS INJECTION . . . . . . . . . . . . 49
RINGERS IRRIGATION . . . . . . . . . . 42
RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . 25
risedronate sodium tabs 150mg . . . . 42
RISPERDAL CONSTA INJ
12.5MG, 25MG. . . . . . . . . . . . . . . . . . . . 22
RISPERDAL CONSTA INJ
37.5MG, 50MG. . . . . . . . . . . . . . . . . . . . 22
risperidone m-tab tbdp
0.5mg, 2mg . . . . . . . . . . . . . . . . . . . . . . . 22
risperidone odt tbdp 0.25mg,
0.5mg, 1mg, 2mg, 3mg . . . . . . . . . . . . 22
risperidone odt tbdp 4mg. . . . . . . . . . . 22
risperidone oral soln . . . . . . . . . . . . . . 22
risperidone tabs 0.25mg,
0.5mg, 1mg, 2mg, 3mg . . . . . . . . . . . . 22
risperidone tabs 4mg . . . . . . . . . . . . . . 22
RITUXAN INJ 500MG/50ML. . . . . . . . 20
rivastigmine tartrate . . . . . . . . . . . . . . 14
rivastigmine transdermal system. . . . 14
rizatriptan benzoate . . . . . . . . . . . . . . 17
rizatriptan benzoate odt . . . . . . . . . . . 17
ropinirole er . . . . . . . . . . . . . . . . . . . . . . 21
ropinirole hcl . . . . . . . . . . . . . . . . . . . . . 21
rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . 41
ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . 41
roweepra . . . . . . . . . . . . . . . . . . . . . . . . 13
roxicet oral soln . . . . . . . . . . . . . . . . . . . . . 9
roxicet tabs . . . . . . . . . . . . . . . . . . . . . . . . . 9
ROZEREM . . . . . . . . . . . . . . . . . . . . . . . 46
SAIZEN . . . . . . . . . . . . . . . . . . . . . . . . . . 36
SAIZEN CLICK.EASY . . . . . . . . . . . . 36
salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
SAMSCA TABS 15MG. . . . . . . . . . . . . 46
SAMSCA TABS 30MG. . . . . . . . . . . . . 46
SANCUSO . . . . . . . . . . . . . . . . . . . . . . . 16
SANDIMMUNE . . . . . . . . . . . . . . . . . . . 40
SANDOSTATIN LAR DEPOT . . . . . . 40
SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . 32
SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . 22
SAVELLA . . . . . . . . . . . . . . . . . . . . . . . . 31
SAVELLA TITRATION PACK . . . . . . 31
selegiline hcl . . . . . . . . . . . . . . . . . . . . . 21
selenium sulfide . . . . . . . . . . . . . . . . . . 32
SELZENTRY . . . . . . . . . . . . . . . . . . . . . 24
SEMPREX-D . . . . . . . . . . . . . . . . . . . . 44
SENSIPAR TABS 30MG . . . . . . . . . . . 39
SENSIPAR TABS 60MG . . . . . . . . . . . 39
SENSIPAR TABS 90MG . . . . . . . . . . . 39
SEREVENT DISKUS . . . . . . . . . . . . . 45
SEROQUEL XR TB24
150MG, 200MG . . . . . . . . . . . . . . . . . . . 22
SEROQUEL XR TB24
300MG, 400MG, 50MG. . . . . . . . . . . . 22
SEROSTIM . . . . . . . . . . . . . . . . . . . . . . 36
sertraline hcl conc . . . . . . . . . . . . . . . . . 15
sertraline hcl tabs 25mg. . . . . . . . . . . . 15
sertraline hcl tabs 50mg. . . . . . . . . . . . 15
sertraline hcl tabs 100mg . . . . . . . . . . 15
setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . 38
sf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
sf 5000 plus . . . . . . . . . . . . . . . . . . . . . . 49
sharobel . . . . . . . . . . . . . . . . . . . . . . . . . 39
SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . 40
sildenafil tabs . . . . . . . . . . . . . . . . . . . . . 45
SILENOR . . . . . . . . . . . . . . . . . . . . . . . . 46
SILVER NITRATE
EXTERNAL SOLN . . . . . . . . . . . . . . . . . 11
silver sulfadiazine . . . . . . . . . . . . . . . . . 11
SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . 44
S
SABRIL PACK . . . . . . . . . . . . . . . . . . . . 14
SABRIL TABS . . . . . . . . . . . . . . . . . . . . 14
69
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
SIMULECT . . . . . . . . . . . . . . . . . . . . . . 41
simvastatin tabs 10mg, 5mg. . . . . . . . 30
simvastatin tabs
20mg, 40mg, 80mg. . . . . . . . . . . . . . . . 30
sirolimus . . . . . . . . . . . . . . . . . . . . . . . . . 40
SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . 18
SKLICE . . . . . . . . . . . . . . . . . . . . . . . . . . 21
sodium bicarbonate inj . . . . . . . . . . . . 46
sodium bicarbonate partial fill . . . . . 46
sodium chloride 0.9% . . . . . . . . . . . . . 42
sodium chloride 0.45% viaflex . . . . . 49
sodium chloride bacteriostatic . . . . . 49
sodium chloride bacteriostatic/
benzyl alcohol . . . . . . . . . . . . . . . . . . . . 49
sodium chloride inj . . . . . . . . . . . . . . . . 49
SODIUM EDECRIN . . . . . . . . . . . . . . 29
sodium fluoride chew 0.5mg, 1mg. . . 49
sodium fluoride oral soln . . . . . . . . . . . 49
sodium fluoride tabs . . . . . . . . . . . . . . . 49
SODIUM LACTATE INJ 5MEQ/ML . . 46
sodium phenylbutyrate . . . . . . . . . . . . 33
sodium polystyrene
sulfonate powd . . . . . . . . . . . . . . . . . . . 46
sodium polystyrene sulfonate
susp 15gm/60ml, 30gm/120ml. . . . . . 46
sodium sulfacetamide
ophthalmic soln . . . . . . . . . . . . . . . . . . . 13
SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . 18
SOLU-CORTEF . . . . . . . . . . . . . . . . . . 36
SOLU-MEDROL INJ 2GM. . . . . . . . . . 36
SOLU-MEDROL INJ 500MG . . . . . . . 36
SOMATULINE DEPOT . . . . . . . . . . . 40
SOMAVERT . . . . . . . . . . . . . . . . . . . . . 40
sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . 28
sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . 28
SOVALDI . . . . . . . . . . . . . . . . . . . . . . . . 23
SPECTRACEF TABS 400MG . . . . . . . 11
SPIRIVA HANDIHALER . . . . . . . . . . . 44
SPIRIVA RESPIMAT . . . . . . . . . . . . . . 44
spironolactone . . . . . . . . . . . . . . . . . . . 30
spironolactone/
hydrochlorothiazide . . . . . . . . . . . . . . . 30
SPORANOX ORAL SOLN . . . . . . . . . 17
sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . 38
SPRITAM . . . . . . . . . . . . . . . . . . . . . . . . 13
SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . 20
sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
ssd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
stavudine . . . . . . . . . . . . . . . . . . . . . . . . 24
sterile water irrigation . . . . . . . . . . . . . 42
STIOLTO RESPIMAT . . . . . . . . . . . . . 45
STIVARGA . . . . . . . . . . . . . . . . . . . . . . . 20
STRATTERA CAPS
10MG, 18MG, 25MG, 40MG . . . . . . . 31
STRATTERA CAPS
100MG, 60MG, 80MG . . . . . . . . . . . . . 31
streptomycin sulfate . . . . . . . . . . . . . . 10
STRIANT . . . . . . . . . . . . . . . . . . . . . . . . 36
STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . 23
STRIVERDI RESPIMAT . . . . . . . . . . 45
SUBOXONE . . . . . . . . . . . . . . . . . . . . . . . 9
SUCRAID . . . . . . . . . . . . . . . . . . . . . . . . 33
sucralfate . . . . . . . . . . . . . . . . . . . . . . . . 34
sulfacetamide sodium oint . . . . . . . . . 13
sulfacetamide sodium/
prednisolone sodium phosphate. . . . 13
sulfacetamide sodium susp . . . . . . . . 13
sulfadiazine . . . . . . . . . . . . . . . . . . . . . . 13
sulfamethoxazole/trimethoprim . . . . . 13
sulfamethoxazole/trimethoprim ds. . . 13
SULFAMYLON . . . . . . . . . . . . . . . . . . . . 11
sulfasalazine . . . . . . . . . . . . . . . . . . . . . 42
sulfatrim pediatric . . . . . . . . . . . . . . . . 13
sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
sumatriptan . . . . . . . . . . . . . . . . . . . . . . 17
sumatriptan succinate inj . . . . . . . . . . 17
sumatriptan succinate refill . . . . . . . . 17
sumatriptan succinate tabs . . . . . . . . 17
SUPRAX CAPS . . . . . . . . . . . . . . . . . . . 12
SUPRAX CHEW . . . . . . . . . . . . . . . . . . 12
SUPRAX SUSR 500MG/5ML. . . . . . . 12
SUPREP BOWEL PREP . . . . . . . . . . 34
SURMONTIL . . . . . . . . . . . . . . . . . . . . . 16
SUSTIVA CAPS 50MG. . . . . . . . . . . . . 23
SUSTIVA CAPS 200MG . . . . . . . . . . . 23
SUSTIVA TABS . . . . . . . . . . . . . . . . . . . 23
SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . 20
SYLATRON . . . . . . . . . . . . . . . . . . . . . . 19
symax-sl . . . . . . . . . . . . . . . . . . . . . . . . . 33
SYMBICORT . . . . . . . . . . . . . . . . . . . . . 44
SYMLINPEN 60 . . . . . . . . . . . . . . . . . . 25
SYMLINPEN 120 . . . . . . . . . . . . . . . . . 25
SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . 41
SYNALGOS-DC . . . . . . . . . . . . . . . . . . . . 9
SYNAREL . . . . . . . . . . . . . . . . . . . . . . . 40
SYNERA . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 11
SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . 19
SYNTHROID . . . . . . . . . . . . . . . . . . . . . 39
SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . 46
70
T
TABLOID . . . . . . . . . . . . . . . . . . . . . . . . 19
tacrolimus caps . . . . . . . . . . . . . . . . . . . 40
TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . 20
TAGRISSO . . . . . . . . . . . . . . . . . . . . . . 20
TALWIN . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
TAMIFLU CAPS 30MG . . . . . . . . . . . . 24
TAMIFLU CAPS 45MG . . . . . . . . . . . . 24
TAMIFLU CAPS 75MG . . . . . . . . . . . . 24
TAMIFLU SUSR . . . . . . . . . . . . . . . . . . 24
tamoxifen citrate . . . . . . . . . . . . . . . . . 18
tamsulosin hcl . . . . . . . . . . . . . . . . . . . . 35
TARCEVA . . . . . . . . . . . . . . . . . . . . . . . . 20
TARGRETIN . . . . . . . . . . . . . . . . . . . . . 20
tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . 38
TASIGNA . . . . . . . . . . . . . . . . . . . . . . . . 20
tazicef . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
TAZORAC . . . . . . . . . . . . . . . . . . . . . . . 32
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
taztia xt . . . . . . . . . . . . . . . . . . . . . . . . . . 29
TECENTRIQ . . . . . . . . . . . . . . . . . . . . . 20
TEFLARO . . . . . . . . . . . . . . . . . . . . . . . 12
TEGRETOL-XR TB12 100MG. . . . . . 14
TEKTURNA . . . . . . . . . . . . . . . . . . . . . . 29
TEKTURNA HCT . . . . . . . . . . . . . . . . . 29
telmisartan . . . . . . . . . . . . . . . . . . . . . . . 27
telmisartan/amlodipine . . . . . . . . . . . . 27
telmisartan/hydrochlorothiazide. . . . . 27
temazepam . . . . . . . . . . . . . . . . . . . . . . 46
tencon tabs 325mg; 50mg. . . . . . . . . . . . 7
teniposide . . . . . . . . . . . . . . . . . . . . . . . 19
TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . 41
terazosin hcl . . . . . . . . . . . . . . . . . . . . . 35
terbinafine hcl tabs . . . . . . . . . . . . . . . . 17
terbutaline sulfate . . . . . . . . . . . . . . . . 45
terconazole . . . . . . . . . . . . . . . . . . . . . . 17
TESTIM . . . . . . . . . . . . . . . . . . . . . . . . . 36
testosterone cypionate . . . . . . . . . . . . 36
testosterone enanthate . . . . . . . . . . . 36
testosterone gel 25mg/2.5gm. . . . . . . 36
testosterone pump . . . . . . . . . . . . . . . 36
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED . . . . . . . . . . . 41
tetrabenazine . . . . . . . . . . . . . . . . . . . . 31
tetracycline hcl . . . . . . . . . . . . . . . . . . . 13
TEXACORT . . . . . . . . . . . . . . . . . . . . . . 36
THALOMID . . . . . . . . . . . . . . . . . . . . . . 18
THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . 45
theochron . . . . . . . . . . . . . . . . . . . . . . . . 45
theophylline . . . . . . . . . . . . . . . . . . . . . . 45
theophylline cr . . . . . . . . . . . . . . . . . . . 45
theophylline/d5w inj 5%; 0.8mg/ml. . . 45
theophylline er . . . . . . . . . . . . . . . . . . . 45
THERACYS . . . . . . . . . . . . . . . . . . . . . . 19
thioridazine hcl . . . . . . . . . . . . . . . . . . . 21
thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . 18
thiothixene . . . . . . . . . . . . . . . . . . . . . . . 21
THYMOGLOBULIN . . . . . . . . . . . . . . . 41
THYROLAR-1 . . . . . . . . . . . . . . . . . . . . 39
THYROLAR-1/2 . . . . . . . . . . . . . . . . . . 39
THYROLAR-1/4 . . . . . . . . . . . . . . . . . . 39
THYROLAR-2 . . . . . . . . . . . . . . . . . . . . 39
THYROLAR-3 . . . . . . . . . . . . . . . . . . . . 39
tiagabine hydrochloride . . . . . . . . . . . 14
TICE BCG . . . . . . . . . . . . . . . . . . . . . . . 19
TIKOSYN . . . . . . . . . . . . . . . . . . . . . . . . 28
timolol maleate . . . . . . . . . . . . . . . . . . . 29
timolol maleate . . . . . . . . . . . . . . . . . . . 44
timolol maleate ophthalmic
gel forming . . . . . . . . . . . . . . . . . . . . . . . 44
tinidazole . . . . . . . . . . . . . . . . . . . . . . . . 21
TIVICAY TABS 10MG, 25MG. . . . . . . 23
TIVICAY TABS 50MG. . . . . . . . . . . . . . 23
tizanidine hcl . . . . . . . . . . . . . . . . . . . . . 22
tl-fluorivite . . . . . . . . . . . . . . . . . . . . . . . 49
TOBI PODHALER . . . . . . . . . . . . . . . . 45
TOBRADEX OINT . . . . . . . . . . . . . . . . 43
tobramycin . . . . . . . . . . . . . . . . . . . . . . . 45
tobramycin/dexamethasone . . . . . . . 43
tobramycin sulfate . . . . . . . . . . . . . . . . 10
TOBREX OINT . . . . . . . . . . . . . . . . . . . 10
tolcapone . . . . . . . . . . . . . . . . . . . . . . . . 21
tolmetin sodium . . . . . . . . . . . . . . . . . . . . 7
tolterodine tartrate . . . . . . . . . . . . . . . . 34
tolterodine tartrate er . . . . . . . . . . . . . 34
topiramate . . . . . . . . . . . . . . . . . . . . . . . 14
toposar . . . . . . . . . . . . . . . . . . . . . . . . . . 20
topotecan hcl . . . . . . . . . . . . . . . . . . . . 20
TORISEL . . . . . . . . . . . . . . . . . . . . . . . . 40
torsemide . . . . . . . . . . . . . . . . . . . . . . . . 29
TOUJEO SOLOSTAR . . . . . . . . . . . . 26
TPN ELECTROLYTES . . . . . . . . . . . . 49
TRACLEER . . . . . . . . . . . . . . . . . . . . . . 45
TRADJENTA . . . . . . . . . . . . . . . . . . . . . 25
tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . . 9
tramadol hcl er tb24 . . . . . . . . . . . . . . . . . 8
tramadol hydrochloride/
acetaminophen . . . . . . . . . . . . . . . . . . . . . 9
trandolapril . . . . . . . . . . . . . . . . . . . . . . . 28
trandolapril/verapamil hcl er
tbcr 1mg; 240mg, 2mg; 180mg,
2mg; 240mg. . . . . . . . . . . . . . . . . . . . . . . 28
trandolapril/verapamil hcl er
tbcr 4mg; 240mg . . . . . . . . . . . . . . . . . . 28
trandolapril/verapamil hcl tbcr
1mg; 240mg, 2mg; 180mg,
2mg; 240mg. . . . . . . . . . . . . . . . . . . . . . . 28
trandolapril/verapamil hcl tbcr
4mg; 240mg. . . . . . . . . . . . . . . . . . . . . . . 28
tranexamic acid inj . . . . . . . . . . . . . . . . 27
tranexamic acid tabs . . . . . . . . . . . . . . 27
TRANSDERM-SCOP . . . . . . . . . . . . . 16
tranylcypromine sulfate . . . . . . . . . . . 15
TRAVASOL . . . . . . . . . . . . . . . . . . . . . . 49
TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . 42
travoprost . . . . . . . . . . . . . . . . . . . . . . . . 42
trazodone hcl . . . . . . . . . . . . . . . . . . . . 15
TREANDA . . . . . . . . . . . . . . . . . . . . . . . 18
TRECATOR . . . . . . . . . . . . . . . . . . . . . . 18
TRELSTAR INJ 3.75MG . . . . . . . . . . . 40
TRELSTAR INJ 11.25MG . . . . . . . . . . 40
TRELSTAR MIXJECT INJ
3.75MG. . . . . . . . . . . . . . . . . . . . . . . . . . . 40
TRELSTAR MIXJECT INJ
11.25MG. . . . . . . . . . . . . . . . . . . . . . . . . . 40
TRELSTAR MIXJECT INJ
22.5MG. . . . . . . . . . . . . . . . . . . . . . . . . . . 40
TRESIBA FLEXTOUCH . . . . . . . . . . . 26
tretinoin caps . . . . . . . . . . . . . . . . . . . . . 20
tretinoin crea . . . . . . . . . . . . . . . . . . . . . 32
tretinoin gel 0.01%, 0.025% . . . . . . . . 32
tretinoin microsphere . . . . . . . . . . . . . 32
tretinoin microsphere pump . . . . . . . 32
TREXALL . . . . . . . . . . . . . . . . . . . . . . . . 40
triamcinolone acetonide aers . . . . . . 36
triamcinolone acetonide crea . . . . . . 36
triamcinolone acetonide lotn . . . . . . . 36
triamcinolone acetonide oint . . . . . . . 36
triamcinolone acetonide pste . . . . . . 32
triamcinolone in orabase . . . . . . . . . . 32
triamterene/hydrochlorothiazide . . . . 30
71
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
trianex . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
triderm . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . 38
trifluoperazine hcl . . . . . . . . . . . . . . . . 21
trifluridine . . . . . . . . . . . . . . . . . . . . . . . . 24
TRIGLIDE . . . . . . . . . . . . . . . . . . . . . . . 30
trihexyphenidyl hcl . . . . . . . . . . . . . . . . 21
tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . 38
tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . 38
tri-lo-estarylla . . . . . . . . . . . . . . . . . . . . 38
tri-lo-marzia . . . . . . . . . . . . . . . . . . . . . . 38
tri-lo-sprintec . . . . . . . . . . . . . . . . . . . . . 38
trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
trimethoprim . . . . . . . . . . . . . . . . . . . . . . 11
trimethoprim sulfate/
polymyxin b sulfate . . . . . . . . . . . . . . . . 11
trimipramine maleate . . . . . . . . . . . . . 16
trinessa . . . . . . . . . . . . . . . . . . . . . . . . . . 38
trinessa lo . . . . . . . . . . . . . . . . . . . . . . . 38
TRINTELLIX . . . . . . . . . . . . . . . . . . . . . 15
triple-vitamin/fluoride . . . . . . . . . . . . . 49
tri-previfem . . . . . . . . . . . . . . . . . . . . . . . 38
TRISENOX . . . . . . . . . . . . . . . . . . . . . . 19
tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . 38
TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . 24
tri-vitamin/fluoride . . . . . . . . . . . . . . . . 49
tri-vit/fluoride . . . . . . . . . . . . . . . . . . . . . 49
tri-vit/fluoride/iron . . . . . . . . . . . . . . . . . 49
trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . 38
TROPHAMINE . . . . . . . . . . . . . . . . . . . 49
tropicamide . . . . . . . . . . . . . . . . . . . . . . 43
trospium chloride . . . . . . . . . . . . . . . . . 34
trospium chloride er . . . . . . . . . . . . . . 34
TRULICITY . . . . . . . . . . . . . . . . . . . . . . 25
TRUMENBA . . . . . . . . . . . . . . . . . . . . . 41
TRUVADA . . . . . . . . . . . . . . . . . . . . . . . 24
TUDORZA PRESSAIR . . . . . . . . . . . . 45
TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . 41
TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . 24
TYGACIL . . . . . . . . . . . . . . . . . . . . . . . . . 11
TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . 20
TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . 41
TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . 31
TYVASO . . . . . . . . . . . . . . . . . . . . . . . . . 45
TYZEKA . . . . . . . . . . . . . . . . . . . . . . . . . 23
TYZINE PEDIATRIC
NASAL DROPS . . . . . . . . . . . . . . . . . . 45
valproate sodium . . . . . . . . . . . . . . . . . 14
valproic acid . . . . . . . . . . . . . . . . . . . . . 14
valsartan/hydrochlorothiazide . . . . . 27
valsartan tabs
160mg, 40mg, 80mg. . . . . . . . . . . . . . . 27
valsartan tabs 320mg. . . . . . . . . . . . . . 27
vancomycin . . . . . . . . . . . . . . . . . . . . . . . 11
vancomycin hcl caps 125mg . . . . . . . . 11
vancomycin hcl caps 250mg . . . . . . . . 11
vancomycin hcl in dextrose . . . . . . . . 11
vancomycin hcl inj 0.9%;
1gm/200ml, 1000mg, 10gm,
500mg, 750mg . . . . . . . . . . . . . . . . . . . . . 11
vancomycin hcl inj 5000mg. . . . . . . . . . 11
vandazole . . . . . . . . . . . . . . . . . . . . . . . . 11
VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . 41
VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . 41
VARIZIG INJ 125UNIT/1.2ML . . . . . . 42
VASCEPA . . . . . . . . . . . . . . . . . . . . . . . . 30
VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . 20
VELCADE . . . . . . . . . . . . . . . . . . . . . . . 19
velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
VELPHORO . . . . . . . . . . . . . . . . . . . . . 35
VELTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 32
VENCLEXTA STARTING PACK . . . . 19
VENCLEXTA TABS 10MG . . . . . . . . . 19
VENCLEXTA TABS 50MG . . . . . . . . . 19
VENCLEXTA TABS 100MG . . . . . . . . 19
venlafaxine hcl . . . . . . . . . . . . . . . . . . . 15
venlafaxine hcl er cp24 75mg . . . . . . 15
venlafaxine hcl er cp24
150mg, 37.5mg. . . . . . . . . . . . . . . . . . . . 15
VENLAFAXINE HCL ER
TB24 75MG. . . . . . . . . . . . . . . . . . . . . . . 15
VENLAFAXINE HCL ER
TB24 150MG, 225MG, 37.5MG. . . . . 15
VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . 45
verapamil hcl . . . . . . . . . . . . . . . . . . . . . 29
verapamil hcl er . . . . . . . . . . . . . . . . . . 29
verapamil hcl sr cp24 . . . . . . . . . . . . . . 29
VERDESO . . . . . . . . . . . . . . . . . . . . . . . 36
U
ULORIC . . . . . . . . . . . . . . . . . . . . . . . . . 17
umecta . . . . . . . . . . . . . . . . . . . . . . . . . . 32
umecta mousse . . . . . . . . . . . . . . . . . . 32
UNASYN . . . . . . . . . . . . . . . . . . . . . . . . 12
UNASYN BULK PACK . . . . . . . . . . . . 12
UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . 20
uramit mb . . . . . . . . . . . . . . . . . . . . . . . . 34
urea 40% nail film . . . . . . . . . . . . . . . . 32
urea crea
39%, 40%, 45%, 47%, 50% . . . . . . . . 32
urea gel . . . . . . . . . . . . . . . . . . . . . . . . . . 32
urea nail gel . . . . . . . . . . . . . . . . . . . . . . 32
urea susp . . . . . . . . . . . . . . . . . . . . . . . . 32
URELLE . . . . . . . . . . . . . . . . . . . . . . . . . 34
uribel . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
urin d/s . . . . . . . . . . . . . . . . . . . . . . . . . . 34
ur n-c . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
URO-L . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
uro-mp . . . . . . . . . . . . . . . . . . . . . . . . . . 34
ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . 33
ustell . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
utira-c . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
UVADEX . . . . . . . . . . . . . . . . . . . . . . . . . 32
V
VAGIFEM . . . . . . . . . . . . . . . . . . . . . . . . 38
valacyclovir hcl . . . . . . . . . . . . . . . . . . . 24
VALCHLOR . . . . . . . . . . . . . . . . . . . . . . 18
VALCYTE ORAL SOLN . . . . . . . . . . . 23
valganciclovir . . . . . . . . . . . . . . . . . . . . 23
72
Covered Drugs Index
DRUGPAGE
DRUGPAGE
DRUGPAGE
VERSACLOZ . . . . . . . . . . . . . . . . . . . . 22
VESICARE . . . . . . . . . . . . . . . . . . . . . . 34
vestura . . . . . . . . . . . . . . . . . . . . . . . . . . 38
VEXOL . . . . . . . . . . . . . . . . . . . . . . . . . . 43
V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . 42
V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . 42
V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . 42
VIBATIV . . . . . . . . . . . . . . . . . . . . . . . . . . 11
VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . 25
VIDEX PEDIATRIC . . . . . . . . . . . . . . . 24
vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . 13
VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . 15
VIIBRYD STARTER PACK . . . . . . . . 15
VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 14
VIMPAT ORAL SOLN . . . . . . . . . . . . . 14
VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 14
vinblastine sulfate . . . . . . . . . . . . . . . . 19
vincasar pfs . . . . . . . . . . . . . . . . . . . . . . 19
vincristine sulfate . . . . . . . . . . . . . . . . . 19
vinorelbine tartrate . . . . . . . . . . . . . . . 19
viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
VIRACEPT . . . . . . . . . . . . . . . . . . . . . . . 24
VIRAMUNE XR TB24 100MG . . . . . . 23
VIRAZOLE . . . . . . . . . . . . . . . . . . . . . . . 45
VIREAD . . . . . . . . . . . . . . . . . . . . . . . . . 24
virt-phos 250 neutral . . . . . . . . . . . . . . 49
virtrate-2 . . . . . . . . . . . . . . . . . . . . . . . . . 49
virtrate-k . . . . . . . . . . . . . . . . . . . . . . . . . 49
vitamins a/c/d/fluoride . . . . . . . . . . . . 49
VITEKTA . . . . . . . . . . . . . . . . . . . . . . . . . 23
VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . . 9
VOLTAREN GEL . . . . . . . . . . . . . . . . . . 32
voriconazole inj . . . . . . . . . . . . . . . . . . . 17
voriconazole susr . . . . . . . . . . . . . . . . . 17
voriconazole tabs . . . . . . . . . . . . . . . . . 17
VOTRIENT . . . . . . . . . . . . . . . . . . . . . . 20
VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . 49
VPRIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 22
VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 22
vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . 39
VYTORIN . . . . . . . . . . . . . . . . . . . . . . . . 30
ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . 18
ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . 27
ZAVESCA . . . . . . . . . . . . . . . . . . . . . . . . 33
zazole crea . . . . . . . . . . . . . . . . . . . . . . . 17
zebutal caps
325mg; 50mg; 40mg. . . . . . . . . . . . . . . . . 7
ZEGERID PACK . . . . . . . . . . . . . . . . . . 34
ZELAPAR . . . . . . . . . . . . . . . . . . . . . . . . 21
ZELBORAF . . . . . . . . . . . . . . . . . . . . . . 20
ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . 46
zenatane . . . . . . . . . . . . . . . . . . . . . . . . 32
zenchent . . . . . . . . . . . . . . . . . . . . . . . . . 39
zenchent fe . . . . . . . . . . . . . . . . . . . . . . 39
ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . 33
ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
ZIAGEN ORAL SOLN . . . . . . . . . . . . . 24
ZIANA . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
zidovudine . . . . . . . . . . . . . . . . . . . . . . . 24
ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . 43
ziprasidone hcl . . . . . . . . . . . . . . . . . . . 22
ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . 23
ZMAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
ZOLADEX . . . . . . . . . . . . . . . . . . . . . . . 40
zoledronic acid . . . . . . . . . . . . . . . . . . . 42
ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . 19
zolmitriptan odt tbdp 2.5mg . . . . . . . . 17
zolmitriptan odt tbdp 5mg . . . . . . . . . . 17
zolmitriptan tabs 2.5mg . . . . . . . . . . . . 17
zolmitriptan tabs 5mg. . . . . . . . . . . . . . 17
zolpidem tartrate tabs . . . . . . . . . . . . . 46
ZONALON . . . . . . . . . . . . . . . . . . . . . . . 32
zonisamide . . . . . . . . . . . . . . . . . . . . . . 14
ZORBTIVE . . . . . . . . . . . . . . . . . . . . . . . 36
ZORTRESS TABS
0.5MG, 0.75MG . . . . . . . . . . . . . . . . . . . 40
ZORTRESS TABS 0.25MG . . . . . . . . 40
ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . 42
ZOSYN . . . . . . . . . . . . . . . . . . . . . . . . . . 12
zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . 39
zovia 1/50e . . . . . . . . . . . . . . . . . . . . . . 39
W
warfarin sodium . . . . . . . . . . . . . . . . . . 26
WELCHOL . . . . . . . . . . . . . . . . . . . . . . . 30
wymzya fe . . . . . . . . . . . . . . . . . . . . . . . 39
X
XALKORI . . . . . . . . . . . . . . . . . . . . . . . . 20
XARELTO STARTER PACK . . . . . . . 26
XARELTO TABS 10MG, 20MG. . . . . 26
XARELTO TABS 15MG . . . . . . . . . . . . 26
XENAZINE . . . . . . . . . . . . . . . . . . . . . . . 31
XEOMIN . . . . . . . . . . . . . . . . . . . . . . . . . 22
XEOMIN . . . . . . . . . . . . . . . . . . . . . . . . . 42
XERAC AC . . . . . . . . . . . . . . . . . . . . . . 32
XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . 42
XIAFLEX . . . . . . . . . . . . . . . . . . . . . . . . 33
XIFAXAN TABS 200MG. . . . . . . . . . . . . 11
XIFAXAN TABS 550MG. . . . . . . . . . . . . 11
XOLAIR . . . . . . . . . . . . . . . . . . . . . . . . . 45
XOPENEX HFA . . . . . . . . . . . . . . . . . . 45
XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . 18
xulane . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
xylon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Y
YERVOY . . . . . . . . . . . . . . . . . . . . . . . . 20
YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . 42
YONDELIS . . . . . . . . . . . . . . . . . . . . . . 18
Z
zafirlukast . . . . . . . . . . . . . . . . . . . . . . . . 44
zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . 46
ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . 20
73
Covered Drugs Index
DRUGPAGE
DRUGPAGE
ZOVIRAX CREA . . . . . . . . . . . . . . . . . . 24
ZYCLARA . . . . . . . . . . . . . . . . . . . . . . . 32
ZYCLARA PUMP . . . . . . . . . . . . . . . . . 32
ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . 20
ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . 20
ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ZYPREXA RELPREVV INJ
210MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
ZYPREXA RELPREVV INJ
300MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
ZYPREXA RELPREVV INJ
405MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
ZYTIGA . . . . . . . . . . . . . . . . . . . . . . . . . . 18
ZYVOX SUSR . . . . . . . . . . . . . . . . . . . . . 11
74
DRUGPAGE
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