Mercy Care Advantage (HMO SNP) Member Services
Call
602‑263‑3000 or 1‑800‑624‑3879
Calls to these numbers are free. 24 hours a day, 7 days a week.
Member Services also has free language interpreter services available for
non‑English speakers.
TTY
711
Calls to this number are free. 24 hours a day, 7 days a week.
Write
Mercy Care Advantage (HMO SNP)
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040
Website www.MercyCareAdvantage.com
This formulary was updated on 12/23/2015. For more recent information or other questions,
please contact Mercy Care Advantage (HMO SNP) Member Services at 602‑263‑3000 or
1‑800‑624‑3879 or, for TTY users, 711, 24 hours a day, 7 days a week, or visit
www.MercyCareAdvantage.com.
Mercy Care Advantage (HMO SNP)
Servicios al Miembro de Mercy Care Advantage (HMO SNP)
Llame 602‑263‑3000 ó 1‑800‑624‑3879
Las llamadas a estos números son gratis. 24 horas al día, 7 días de la semana.
Servicios al Miembro también tiene servicios gratuitos de interpretación de
idiomas disponibles para personas que no hablan inglés.
TTY
711
Las llamadas a este número son gratis. 24 horas al día, 7 días de la semana.
Escriba Mercy Care Advantage (HMO SNP)
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040
Sitio Web www.MercyCareAdvantage.com
Este formulario fue actualizado en 12/23/2015. Para la información más reciente o para otras
preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al
602‑263‑3000 ó al 1‑800‑624‑3879, ó para los usuarios de TTY, al 711, 24 horas al día, 7
días de la semana, ó visite www.MercyCare Advantage.com.
2016 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary ID 00016462, Version 6
This formulary was updated on 12/23/2015. For more recent information or other questions, please contact
Mercy Care Advantage (HMO SNP) Member Services at 602‑263‑3000 or 1‑800‑624‑3879 or, for TTY users,
711, 24 hours a day, 7 days a week, or visit www.MercyCareAdvantage.com.
Mercy Care Advantage (HMO SNP)
Formulario de 2016 (Lista de medicamentos cubiertos)
POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE
CUBRIMOS EN ESTE PLAN
Identificación del Formulario 00016462, Versión 6
Este formulario fue actualizado en 12/23/2015. Para la información más reciente o para otras preguntas, por
favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602‑263‑3000 ó al 1‑800‑624‑3879,
ó para los usuarios de TTY, al 711, 24 horas al día, 7 días de la semana, ó visite www.MercyCareAdvantage.com.
AZ-15-12-21
Mercy Care Advantage (HMO SNP)
2016 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE
DRUGS WE COVER IN THIS PLAN
Formulary ID 00016462, Version 6
This formulary was updated on 12/23/2015. For more recent information or other questions, please contact
Mercy Care Advantage (HMO SNP) Member Services, at 602‑263‑3000 or 1‑800‑624‑3879 or, for TTY users,
711, 24 hours a day, 7 days a week, or visit www.MercyCareAdvantage.com.
Note to existing members: This formulary has changed since last year. Please review this document to make
sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Southwest Catholic Health Network.
When it refers to “plan” or “our plan,” it means Mercy Care Advantage (HMO SNP).
This document includes a list of the drugs (formulary) for our plan which is current as of 12/23/2015. For
an updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to
time during the year. This information is not a complete description of benefits. Contact the plan for more
information. Limitations, copayments, and restrictions may apply.
Mercy Care Advantage (HMO SNP) is a Coordinated Care Plan with a Medicare contract and a contract with
the Arizona Medicaid Program. Enrollment in Mercy Care Advantage depends on contract renewal.
This information is available for free in other languages. Please contact our Member Services number at
602‑263‑3000 or 1‑800‑624‑3879 (TTY 711) for additional information. Hours of operation: 24 hours a
day, 7 days a week. Esta información está disponible gratis en otros idiomas. Por favor comuníquese a nuestro
número de Servicios al Miembro al 602‑263‑3000 o 1‑800‑624‑3879 (TTY 711) para información adicional.
Horas de servicio: 24 horas al día, 7 días a la semana.
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice
when necessary.
H5580_16_010 CMS Accepted
I
II
What is the Mercy Care Advantage
(HMO SNP) Formulary?
A formulary is a list of covered drugs selected by
Mercy Care Advantage (HMO SNP) 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. Mercy Care Advantage (HMO SNP) will
generally cover the drugs listed in our formulary
as long as the drug is medically necessary, the
prescription is filled at a Mercy Care Advantage
(HMO SNP) network pharmacy, and other plan rules
are followed. For more information on how to fill
your prescriptions, please review your Evidence of
Coverage.
Can the Formulary (drug list)
change?
Generally, if you are taking a drug on our 2016
formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage
of the drug during the 2016 coverage year except
when a new, less expensive generic drug becomes
available or when new adverse information about
the safety or effectiveness of a drug is released.
Other types of formulary changes, such as
removing a drug from our formulary, will not affect
members who are currently taking the drug. It
will remain available at the same cost‑sharing for
those members taking it for the remainder of the
coverage year. We feel it is important that you have
continued access for the remainder of the coverage
year to the formulary drugs that were available
when you chose our plan, except for cases in which
you can save additional money or we can ensure
your safety.
If we remove drugs from our formulary, or add prior
authorization, quantity limits and/or step therapy
restrictions on a drug, we must notify affected
members of the change at least 60 days before
the change becomes effective, or at the time the
member requests a refill of the drug, at which time
the member will receive a 60‑day supply of the
drug. If the Food and Drug Administration deems
a drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market,
we will immediately remove the drug from our
formulary and provide notice to members
who take the drug. The enclosed formulary
is current as of 12/23/2015. To get updated
information about the drugs covered by Mercy
Care Advantage (HMO SNP), please contact us. Our
contact information appears on the front and back
cover pages. If we update the formulary during
2016, a notice will be posted on our website at
www.MercyCareAdvantage.com and impacted
members will be notified by mail.
How do I use the Formulary?
There are two ways to find your drug within the
formulary:
Medical Condition
The formulary begins on page 1. The drugs in this
formulary are grouped into categories depending
on the type of medical conditions that they are
used to treat. For example, drugs used to treat
a heart condition are listed under the category,
“Cardiovascular Agents”. If you know what your
drug is used for, look for the category name in the
list that begins on page 1. Then look under the
category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you
should look for your drug in the Index that begins
on page 133. The Index provides an alphabetical list
of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in
the Index. Look in the Index and find your drug.
Next to your drug, you will see the page number
where you can find coverage information. Turn to
the page listed in the Index and find the name of
your drug in the first column of the list.
What are generic drugs?
Mercy Care Advantage (HMO SNP) 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.
III
Are there any restrictions on my
coverage?
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:
• Prior Authorization: Mercy Care Advantage
(HMO SNP) requires you or your physician to get
prior authorization for certain drugs. This means
that you will need to get approval from Mercy
Care Advantage (HMO SNP) before you fill your
prescriptions. If you don’t get approval, Mercy
Care Advantage (HMO SNP) may not cover the
drug.
• Quantity Limits: For certain drugs, Mercy Care
Advantage (HMO SNP) limits the amount of the
drug that Mercy Care Advantage (HMO SNP) will
cover. For example, Mercy Care Advantage (HMO
SNP) provides 30 EA per 30 days per prescription
for simvastatin. This may be in addition to a
standard one‑month or three‑month supply.
• Step Therapy: In some cases, Mercy Care
Advantage (HMO SNP) 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, Mercy Care
Advantage (HMO SNP) may not cover Drug B
unless you try Drug A first. If Drug A does not
work for you, Mercy Care Advantage (HMO SNP)
will then cover Drug B.
You can find out if your drug has any additional
requirements or limits by looking in the formulary
that begins on page 1. You can also get more
information about the restrictions applied to
specific covered drugs by visiting our website. We
have posted online a document that explains our
prior authorization and step therapy restrictions.
You may also ask us to send you a copy. Our contact
information, along with the date we last updated
the formulary, appears on the front and back cover
pages.
You can ask Mercy Care Advantage (HMO SNP)
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,
IV
“How do I request an exception to the Mercy Care
Advantage (HMO SNP)’s formulary?” on page IV for
information about how to request an exception.
What if my drug is not on the
Formulary?
If your drug is not included in this formulary (list of
covered drugs), you should first contact Member
Services and ask if your drug is covered.
If you learn that Mercy Care Advantage (HMO SNP)
does not cover your drug, you have two options:
• You can ask Member Services for a list of similar
drugs that are covered by Mercy Care Advantage
(HMO SNP). When you receive the list, show it
to your doctor and ask him or her to prescribe
a similar drug that is covered by Mercy Care
Advantage (HMO SNP).
• You can ask Mercy Care Advantage (HMO SNP)
to make an exception and cover your drug. See
below for information about how to request an
exception.
How do I request an exception to
the Mercy Care Advantage (HMO
SNP) Formulary?
You can ask Mercy Care Advantage (HMO SNP) to
make an exception to our coverage rules. There are
several types of exceptions that you can ask us to
make.
• You can ask us to cover a drug even if it is not
on our formulary. If approved, this drug will be
covered at a pre‑determined cost‑sharing level,
and you would not be able to ask us to provide
the drug at a lower cost‑sharing level.
• You can ask us to waive coverage restrictions
or limits on your drug. For example, for certain
drugs, Mercy Care Advantage (HMO SNP) limits
the amount of the drug that we will cover. If your
drug has a quantity limit, you can ask us to waive
the limit and cover a greater amount.
Generally, Mercy Care Advantage (HMO SNP) will
only approve your request for an exception if the
alternative drugs included on the plan’s formulary,
or additional utilization restrictions would not be
as effective in treating your condition and/or would
cause you to have adverse medical effects.
You should contact us to ask us for an initial
coverage decision for a formulary, or utilization
restriction exception. When you request a
formulary or utilization restriction exception
you should submit a statement from your
prescriber or physician supporting your request.
Generally, we must make our decision within 72
hours of getting your prescriber’s supporting
statement. You can request an expedited (fast)
exception if you or your doctor believe that your
health could be seriously harmed by waiting up to
72 hours for a decision. If your request to expedite
is granted, we must give you a decision no later
than 24 hours after we get a supporting statement
from your doctor or other prescriber.
What do I do before I can talk to my
doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan
you may be taking drugs that are not on our
formulary. Or, you may be taking a drug that is on
our formulary but your ability to get it is limited.
For example, you may need a prior authorization
from us before you can fill your prescription. You
should talk to your doctor to decide if you should
switch to an appropriate drug that we cover or
request a formulary exception so that we will cover
the drug you take. While you talk to your doctor to
determine the right course of action for you, we
may cover your drug in certain cases during the first
90 days you are a member of our plan.
For each of your drugs that is not on our formulary
or if your ability to get your drugs is limited, we will
cover a temporary 30‑day supply (unless you have a
prescription written for fewer days) when you go to
a network pharmacy. After your first 30‑day supply,
we will not pay for these drugs, even if you have
been a member of the plan less than 90 days.
If you are a resident of a long‑term care facility,
we will allow you to refill your prescription until we
have provided you with 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 member of our plan. If you
need a drug that is not on our formulary or if your
ability to get your drugs is limited, but you are past
the first 90 days of membership in our plan, we
will cover a 31‑day emergency supply of that drug
(unless you have a prescription for fewer days) while
you pursue a formulary exception.
If you are admitted to or discharged from a
long‑term care facility, you will be allowed to refill a
prescription upon admission or discharge.
For more information
For more detailed information about your Mercy
Care Advantage (HMO SNP) prescription drug
coverage, please review your Evidence of Coverage
and other plan materials.
If you have questions about Mercy Care Advantage
(HMO SNP), please contact us. Our contact
information, along with the date we last updated
the formulary, appears on the front and back cover
pages.
If you have general questions about Medicare
prescription drug coverage, please call Medicare
at 1‑800‑MEDICARE (1‑800‑633‑4227)
24 hours a day/7 days a week. TTY users should
call 1‑877‑486‑2048. Or, visit
http://www.medicare.gov.
V
Mercy Care Advantage (HMO SNP)’s Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by Mercy Care
Advantage (HMO SNP). If you have trouble finding your drug in the list, turn to the Index that begins on
page 133.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and
generic drugs are listed in lower‑case italics (e.g., levothyroxine).
The “Drug Tier” column of the chart lists the category of each drug. Your cost sharing amounts depend
on which category the drug is in:
Category
Generic drugs
(including brand drugs treated as generic)
Cost‑sharing amount
All other drugs
$0/$3.60/$7.40 copay
$0/$1.20/$2.95 copay
Your copays may be less, depending on the level of “Extra Help” you are receiving. The Evidence of Coverage
Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider) lists the amount you will pay
for your prescription drugs. You can also call Member Services to find out your cost sharing amount. Phone
numbers for Member Services are on the front and back cover pages.
The information in the Requirements/Limits column tells you if Mercy Care Advantage (HMO SNP) has
any special requirements for coverage of your drug.
Abbreviation
B/D
EA
LA
MO
PA
QL
ST
VI
Requirements/Limits
Covered under Medicare B or D. This prescription drug may be covered under our
medical benefit. For more information, call Member Services at 602‑263‑3000 or
1‑800‑624‑3879, 24 hours a day, 7 days a week. TTY users should call 711.
Each. Medications listed with EA indicates number of pills dispensed.
Limited Access. This prescription may be available only at certain pharmacies. For more
information consult your Pharmacy Directory or call Member Services at 602‑263‑3000
or 1‑800‑624‑3879, 24 hours a day, 7 days a week. TTY users should call 711.
Maintenance. This drug is available through mail‑order.
Prior Authorization. You or your provider need to get approval from our plan before we
will agree to cover the drug.
Quantity Limits. The amount per fill or refill is shown.
Step Therapy. This prescription drug requires that you've tried another drug first, which
did not work for you.
Mercy Care Advantage (HMO SNP)
Formulario para 2016
(Lista de Medicamentos Cubiertos)
POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS
MEDICAMENTOS QUE CUBRIMOS BAJO ESTE PLAN
Identificación del Formulario 00016462, Versión 6
Este formulario fue actualizado en 23 de diciembre 2015. Para la información más reciente o para otras
preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602‑263‑3000
ó al 1‑800‑624‑3879, ó para los usuarios de TTY al 711, 24 horas al día, 7 días de la semana, ó visite
www.MercyCareAdvantage.com.
Nota para los miembros actuales: Este formulario cambió desde el año pasado. Por favor revisen este
documento para asegurarse de que todavía incluya los medicamentos que usted toma.
Cuando esta lista de medicamentos (formulario) se refiere a “nosotros” o a “nuestros”, esto significa
Southwest Catholic Health Network. Cuando se refiere al “plan” o a “nuestro plan”, esto significa Mercy Care
Advantage (HMO SNP).
Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, la cual está actualizada
a la fecha de 23 de diciembre 2015. Para un formulario actualizado, por favor contáctenos. Nuestra
información de contacto, junto con la fecha en la que actualizamos por último el formulario, aparece en la
portada y la contraportada.
Generalmente usted debe usar farmacias de la red para usar su beneficio de medicamentos de prescripción.
Los beneficios, el formulario, la red de farmacias, y/o los copagos/el coseguro pueden cambiar el 1º de
enero de 2017, y de tiempo en tiempo durante el año. Esta información no es una descripción completa
de los beneficios. Comuníquese con el plan para más información. Pueden aplicar limitaciones, copagos, y
restricciones.
Mercy Care Advantage (HMO SNP) es un Plan de Cuidado Coordinado bajo contrato con Medicare y un
contrato con el Programa Medicaid de Arizona. La inscripción en Mercy Care Advantage depende de la
renovación del contrato.
H5580_16_011 CMS Accepted
VII
Esta información está disponible gratuitamente en otros idiomas. Para información adicional, por favor llame
a nuestro número de Servicios al Miembro al 602‑263‑3000 ó al 1‑800‑624‑3879 (TTY al 711). Horas de
servicio: 24 horas al día, 7 días de la semana. This information is available for free in other languages. Please contact
our Member Services number at 602‑263‑3000 or 1‑800‑624‑3879 (TTY: 711) for additional information. Hours of
operation: 24 hours a day, 7 days a week.
El formulario, la red de farmacias, y/o la red de proveedores pueden cambiar en cualquier momento. Usted
recibirá aviso cuando sea necesario.
VIII
¿Qué es el Formulario de Mercy
Care Advantage (HMO SNP)?
Un formulario es una lista de medicamentos
cubiertos seleccionados por Mercy Care
Advantage (HMO SNP) en consulta con un
equipo de proveedores del cuidado de la salud,
el cual representa las terapias de prescripción/
receta que se considera son una parte necesaria
de un programa de tratamiento de calidad.
Generalmente, Mercy Care Advantage (HMO SNP)
cubrirá los medicamentos listados en nuestro
formulario, siempre y cuando el medicamento sea
médicamente necesario, la prescripción/receta sea
surtida en una farmacia de la red de Mercy Care
Advantage (HMO SNP), y se sigan otras reglas del
plan. Para más información sobre cómo surtir sus
prescripciones/recetas, por favor revise su Evidencia
de Cobertura.
¿El Formulario (lista de
medicamentos) puede cambiar?
Generalmente, si usted está tomando un
medicamento que esté en nuestro formulario en
2016 y que estaba cubierto a principios de año,
nosotros no descontinuaremos ni reduciremos
la cobertura del medicamento durante el año de
cobertura 2016, excepto cuando un medicamento
genérico nuevo y menos costoso esté disponible,
o cuando nueva información negativa sobre la
seguridad o efectividad de un medicamento
sea dada a conocer. Otros tipos de cambio en el
formulario, como retirar un medicamento del
formulario, no afectarán a los miembros que
entonces lo estén tomando. Éste seguirá disponible
por el resto del año de cobertura al mismo costo
compartido para los miembros que lo estén
tomando. Nosotros sentimos que es importante
que durante lo que resta del año de cobertura,
usted tenga acceso continuo a los medicamentos
del formulario que estaban disponibles cuando
usted eligió nuestro plan, excepto en casos en los
que usted pueda ahorrar dinero adicional o que
nosotros podamos cerciorarnos de su seguridad.
Si nosotros retiramos medicamentos de nuestro
formulario, agregamos autorización previa, límites
de cantidad y/o restricciones de terapia a pasos en
un medicamento, nosotros debemos notificárselo
a los miembros afectados por el cambio por lo
menos 60 días antes de que el cambio entre en
vigor, ó cuando el miembro pida que se le vuelva
a surtir el medicamento, en cuyo momento, el
miembro recibirá un suministro de 60 días del
medicamento. Si la Administración de Alimentos y
Medicamentos considera que un medicamento en
nuestro formulario no es seguro, o si el fabricante
del medicamento retira el medicamento del
mercado, nosotros inmediatamente retiraremos
el medicamento de nuestro formulario y les
proveeremos un aviso a los miembros que estén
tomando dicho medicamento. El formulario
adjunto ha sido actualizado a la fecha de 23 de
diciembre 2015. Para información actualizada
sobre los medicamentos cubiertos por Mercy Care
Advantage (HMO SNP), por favor comuníquese
con nosotros. Nuestra información de contacto
aparece en la portada y contraportada. Si nosotros
actualizamos el formulario durante 2016, se
publicará un aviso en nuestro sitio web en
www.MercyCareAdvantage.com y aquellos
miembros impactados serán notificados por correo
postal.
¿Cómo uso el Formulario?
Hay dos formas de encontrar su medicamento
dentro del formulario:
Condición Médica
El formulario empieza en la página 1. Los
medicamentos en este formulario están
agrupados en categorías, dependiendo del tipo
de condiciones médicas para cuyo tratamiento de
usan. Por ejemplo, los medicamentos usados para
tratar una condición cardiaca, están listados bajo la
categoría de “Agentes Cardiovasculares”. Si usted
sabe para qué se usa su medicamento, busque el
nombre de la categoría en la lista que empieza en
la página 1. Después busque en esa categoría el
nombre de su medicamento.
Listado Alfabético
Si no está seguro/a bajo qué categoría buscar,
deberá buscar su medicamento en el Índice que
empieza en la página 133. El Índice provee una lista
en orden alfabético de todos los medicamentos
incluidos en este documento. Tanto los
medicamentos de marca como los medicamentos
IX
genéricos están listados en el Índice. Busque en
el Índice y encuentre su medicamento. Junto a su
medicamento, usted encontrará el número de
la página en la que podrá encontrar información
sobre la cobertura. Pase a la página listada en el
Índice y encuentre el nombre de su medicamento
en la primera columna de la lista.
¿Qué son los medicamentos
genéricos?
Mercy Care Advantage (HMO SNP) cubre tanto
a los medicamentos de marca como a los
medicamentos genéricos. Un medicamento
genérico es aprobado por la Administración de
Alimentos y Medicamentos (FDA por sus siglas en
inglés) por contar con el mismo ingrediente activo
que el medicamento de marca. En general, los
medicamentos genéricos cuestan menos que los
medicamentos de marca.
¿Hay alguna restricción en mi
cobertura?
Algunos medicamentos cubiertos pueden contar
con requerimientos adicionales o límites en la
cobertura. Estos requerimientos y límites pueden
incluir:
• Autorización Previa: Mercy Care Advantage
(HMO SNP) requiere que usted o su médico
obtengan autorización previa para ciertos
medicamentos. Esto significa que usted
necesitará obtener la aprobación de Mercy
Care Advantage (HMO SNP) antes de surtir sus
prescripciones/recetas. Si usted no obtiene la
aprobación, Mercy Care Advantage (HMO SNP)
puede no cubrir el costo del medicamento.
• Límites de Cantidades: Para ciertos
medicamentos, Mercy Care Advantage (HMO
SNP) limita la cantidad del medicamento que
Mercy Care Advantage (HMO SNP) cubrirá.
Por ejemplo, Mercy Care Advantage (HMO
SNP) provee 30 píldoras para 30 días por cada
prescripción de Simvastatin. Esto puede ser en
adición al suministro estándar para un mes o tres
meses.
X
• Terapia a Pasos: En algunos casos, Mercy Care
Advantage (HMO SNP) requiere que usted
pruebe primero ciertos medicamentos para
tratar su condición médica antes de cubrir
otro medicamento para esa condición. Por
ejemplo, si el Medicamento A y el Medicamento
B tratan ambos su condición médica, Mercy
Care Advantage (HMO SNP) puede no cubrir
el Medicamento B a menos que usted pruebe
primero el Medicamento A. Si el Medicamento A
no le funciona, entonces Mercy Care Advantage
(HMO SNP) cubrirá el Medicamento B.
Usted puede informarse si hay cualquier
requerimiento o límite adicional para sus
medicamentos consultando el formulario que
empieza en la página 1. También puede obtener
más información sobre las restricciones aplicadas
a medicamentos cubiertos específicos visitando
nuestro sitio web. Nosotros hemos publicado
un documento en línea que explica nuestras
restricciones sobre la autorización previa y la
terapia a pasos. Usted también puede pedirnos que
le enviemos una copia. Nuestra información de
contacto, junto con la fecha en la cual actualizamos
por último el formulario, aparece en la portada y la
contraportada.
Usted puede pedirle a Mercy Care Advantage (HMO
SNP) que haga una excepción a estas restricciones
o límites, o para una lista de otros medicamentos
similares que puedan tratar su condición de salud.
Vea la sección “¿Cómo solicito una excepción al
formulario de Mercy Care Advantage (HMO SNP)?”
en la página XI para información sobre cómo
solicitar una excepción
¿Qué pasa si mi medicamento no
está en el Formulario?
Si su medicamento no está incluido en este
formulario (lista de medicamentos cubiertos),
primero usted debe ponerse en contacto
con Servicios al Miembro y preguntar si su
medicamento está cubierto.
Si usted descubre que Mercy Care Advantage
(HMO SNP) no cubre su medicamento, tiene dos
opciones:
• Usted puede pedir a Servicios al Miembro una
lista de medicamentos similares que estén
cubiertos por Mercy Care Advantage (HMO SNP).
Cuando usted reciba la lista, muéstresela a su
doctor y pídale que le prescriba un medicamento
similar que esté cubierto por Mercy Care
Advantage (HMO SNP).
• Usted puede solicitar que Mercy Care Advantage
(HMO SNP) haga una excepción y cubra su
medicamento. Vea abajo cómo solicitar una
excepción.
¿Cómo solicito una excepción
al Formulario de Mercy Care
Advantage (HMO SNP)?
Usted puede pedir a Mercy Care Advantage (HMO
SNP) que haga una excepción a nuestras normas
de cobertura. Hay varios tipos de excepciones que
usted puede pedir que hagamos.
• Usted nos puede pedir que cubramos un
medicamento, aún si no está en nuestro
formulario. Si es aprobado, dicho medicamento
será cubierto a un nivel de costo compartido
predeterminado, y usted no podrá pedirnos que
le proveamos dicho medicamento a un nivel de
costo compartido más bajo.
• Usted puede pedir que no apliquemos las
restricciones o los límites a la cobertura en
su medicamento. Por ejemplo, para ciertos
medicamentos, Mercy Care Advantage (HMO
SNP) limita la cantidad del medicamento que
nosotros cubriremos. Si sus medicamentos
tienen un límite de cantidad, usted puede
pedirnos que no apliquemos el límite y que
cubramos una cantidad más grande.
Generalmente, Mercy Care Advantage (HMO
SNP) sólo aprobará su solicitud de excepción si los
medicamentos alternos incluidos en el formulario
del plan o las restricciones adicionales para su uso
no serían tan efectivos tratando su condición y/o
podrían ocasionarle efectos médicos adversos.
Usted debería comunicarse con nosotros para
pedirnos una decisión inicial de cobertura para
una excepción al formulario o a la restricción de
uso. Cuando usted solicite una excepción al
formulario o a la restricción de uso, debería
presentar una declaración de su médico o de la
persona emitiendo la prescripción respaldando
su solicitud. Generalmente, nosotros debemos
tomar nuestra decisión dentro de 72 horas después
de recibir la declaración de respaldo de la persona
emitiendo la prescripción. Usted puede solicitar
una excepción expedita (rápida) si usted o su
doctor creen que su salud podría verse seriamente
dañada por esperar 72 horas para una decisión. Si
se le concede su solicitud de excepción expedita,
nosotros debemos darle una decisión no más
tarde de 24 horas después de recibir la declaración
de respaldo de su doctor o de la otra persona
emitiendo la prescripción.
¿Qué hago antes de que pueda
hablar con mi doctor sobre cambiar
mis medicamentos o solicitar una
excepción?
Como miembro nuevo o continuando de nuestro
plan, usted puede estar tomando medicamentos
que no estén en nuestro formulario. O usted
puede estar tomando un medicamento que esté
en nuestro formulario pero su capacidad para
obtenerlo puede ser limitada. Por ejemplo, usted
puede necesitar nuestra autorización previa
antes de poder surtir su prescripción/receta.
Usted debería hablar con su doctor para decidir
si debería cambiar a un medicamento apropiado
que nosotros cubramos, o solicitar una excepción
al formulario para que nosotros cubramos el
medicamento que usted toma. Mientras habla
con su doctor para determinar el curso de acción
apropiado para usted, en ciertos casos, nosotros
podemos cubrir su medicamento durante los
primeros 90 días en los que usted sea miembro de
nuestro plan.
En el caso de cada medicamento que no esté
en nuestro formulario, o si su capacidad para
obtener dicho medicamento es limitada, nosotros
cubriremos un suministro temporal para 30 días
(a menos que a usted se le haya emitido una
XI
prescripción para menos días), cuando usted vaya
a una farmacia de la red. Después de su primer
suministro para 30 días, nosotros ya no pagaremos
por dichos medicamentos, aún si usted ha sido
miembro del plan durante menos de 90 días.
Si usted es residente de una instalación de
cuidado a largo plazo, nosotros permitiremos
que usted vuelva a surtir su prescripción hasta
que le hayamos provisto con un suministro de
transición para 98 días, en forma consistente con
el aumento en el suministro (a menos que a usted
se le haya emitido una prescripción para menos
días). Nosotros cubriremos más de un surtido de
estos medicamentos durante los primeros 90 días
que usted sea miembro de nuestro plan. Si usted
necesita un medicamento que no esté en nuestro
formulario o si su capacidad para obtener sus
medicamentos es limitada, pero ya pasaron los
primeros 90 días como miembro de nuestro plan,
nosotros cubriremos un suministro de emergencia
de dicho medicamento para 31 días (a menos que
a usted se le haya emitido una prescripción para
menos días), mientras usted trata de obtener una
excepción al formulario.
XII
Si se le admite o se le da de alta de una instalación
de cuidado a largo plazo, se le permitirá que se le
surta una prescripción ante su admisión o dada de
alta.
Para más información
Para información más detallada sobre su cobertura
de medicamentos de prescripción/receta de
Mercy Care Advantage (HMO SNP), por favor lea su
Evidencia de Cobertura y otros materiales del plan.
Si tiene preguntas sobre Mercy Care Advantage
(HMO SNP), por favor contáctenos. Nuestra
información de contacto, junto con la fecha en la
que actualizamos por último el formulario, aparece
en la portada y la contraportada.
Si tiene usted preguntas generales sobre la
cobertura de medicamentos de prescripción/
receta de Medicare, por favor llame a Medicare al
1‑800‑MEDICARE (1‑800‑633‑4227) 24 horas al
día, siete días de la semana. Los usuarios de TTY
deben llamar al 1‑877‑486‑2048. Ó visite http://
www.medicare.gov.
Formulario de Mercy Care Advantage (HMO SNP)
El formulario que empieza en la página 1 provee información de cobertura sobre algunos de los
medicamentos cubiertos por Mercy Care Advantage (HMO SNP). Si usted tiene problemas para encontrar su
medicamento en la lista, regrese al Índice que empieza en la página 133.
En la primera columna de la tabla aparece el nombre del medicamento. Los medicamentos de marca
están escritos en mayúsculas (ejem.: SYNTHROID) y los medicamentos genéricos están escritos en cursivas
minúsculas (ejem.: levothyroxine).
La columna del “Nivel del Medicamento” de la tabla lista la categoría de cada medicamento. Sus
cantidades de costo compartido dependen de la categoría en la que se encuentre el medicamento:
Categoría
Medicamentos genéricos (incluyendo
medicamentos de marca tratados como genéricos)
Cantidad de costo compartido
Todo otro medicamento
$0/$3.60/$7.40 de copago
$0/$1.20/$2.95 de copago
Sus copagos pueden ser más bajos, dependiendo del nivel de “Ayuda Extra” que usted esté recibiendo.
La Evidencia de Cobertura para Personas que Reciben Ayuda Extra para el Pago de Sus Medicamentos de
Prescripción (Cláusula LIS) lista la cantidad que usted pagará por sus medicamentos de prescripción. Usted
también puede llamar a Servicios al Miembro para informarse sobre la cantidad de su costo compartido. Los
números telefónicos de Servicios al Miembro están en la portada y la contraportada de este folleto.
La información en la columna de Requerimientos/Límites le indica si Mercy Care Advantage (HMO
SNP) tiene cualquier requerimiento especial para la cobertura de su medicamento.
Abreviación
(en inglés)
B/D
EA
LA
MO
PA
QL
ST
Requerimientos/Límites
Cubierto bajo Medicare B o D. Este medicamento de prescripción puede estar
cubierto bajo nuestro beneficio médico. Para más información, llame a Servicios al
Miembro al 602‑263‑3000 ó al 1‑800‑624‑3879, 24 horas al día, 7 días de la semana.
Los usuarios de TTY deberían llamar al 711.
Each / Cada Uno. Los medicamentos listados con EA indican el número de píldoras
despachadas.
Limited Access / Acceso Limitado. Esta prescripción puede estar disponible sólo en
ciertas farmacias. Para más información consulte su Directorio de Farmacias ó llame a
Servicios al Miembro al 602‑263‑3000 ó al 1‑800‑624‑3879, 24 horas al día, 7 días de
la semana. Los usuarios de TTY deberían llamar al 711.
Maintenance / Mantenimiento. Este medicamento está disponible a través de pedidos
por correo.
Prior Authorization / Autorización Previa. Usted o su proveedor necesitan obtener la
aprobación de nuestro plan antes de que nosotros accedamos a cubrir el medicamento.
Quantity Limits / Límites a la Cantidad. Se muestra la cantidad por suministro o cada
vez que se surta el medicamento.
Step Therapy / Terapia a Pasos. Este medicamento de prescripción requiere que usted
haya probado otro medicamento antes, el cual no le haya funcionado.
XIII
XIV
2016 Formulary (List of Covered Drugs)
Drug Name
Drug Tier
ANALGESICS-DRUGS USED TO TREAT PAIN AND INFLAMMATION
Analgesics
butalbital/acetaminophen/caffeine/codeine caps
Generic
300mg; 50mg; 40mg; 30mg
butalbital/acetaminophen/caffeine/codeine caps
Generic
325mg; 50mg; 40mg; 30mg
butalbital/acetaminophen/caffeine caps 300mg;
Generic
50mg; 40mg
butalbital/acetaminophen/caffeine caps 325mg;
Generic
50mg; 40mg
butalbital/acetaminophen/caffeine tabs 325mg;
Generic
50mg; 40mg
butalbital/aspirin/caffeine/codeine caps 325mg;
Generic
50mg; 40mg; 30mg
butalbital/aspirin/caffeine caps 325mg; 50mg;
Generic
40mg
capacet caps 325mg; 50mg; 40mg
Generic
esgic caps 325mg; 50mg; 40mg
Generic
margesic caps 325mg; 50mg; 40mg
Generic
zebutal caps 325mg; 50mg; 40mg
Generic
Nonsteroidal Anti-inflammatory Drugs
celecoxib caps 100mg
Generic
celecoxib caps 200mg
Generic
celecoxib caps 400mg
Generic
celecoxib caps 50mg
Generic
diclofenac potassium tabs 50mg
Generic
diclofenac sodium dr tbec 25mg
Generic
diclofenac sodium dr tbec 50mg
Generic
diclofenac sodium dr tbec 75mg
Generic
diclofenac sodium er tb24 100mg
Generic
diflunisal tabs 500mg
Generic
etodolac er tb24 400mg
Generic
etodolac er tb24 500mg
Generic
etodolac er tb24 600mg
Generic
etodolac caps 200mg
Generic
etodolac caps 300mg
Generic
Requirements/
Limits
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA
QL (180 EA per 30 days) PA
QL (180 EA per 30 days) PA MO
QL (180 EA per 30 days) PA MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
1
Drug Name
etodolac tabs 400mg
etodolac tabs 500mg
flurbiprofen tabs 100mg
flurbiprofen tabs 50mg
ibuprofen susp 100mg/5ml
ibuprofen tabs 400mg
ibuprofen tabs 600mg
ibuprofen tabs 800mg
ketoprofen er cp24 200mg
ketoprofen caps 50mg
ketoprofen caps 75mg
meclofenamate sodium caps 100mg
meclofenamate sodium caps 50mg
meloxicam susp 7.5mg/5ml
meloxicam tabs 15mg
meloxicam tabs 7.5mg
nabumetone tabs 500mg
nabumetone tabs 750mg
naproxen dr tbec 375mg
naproxen dr tbec 500mg
naproxen sodium tabs 275mg
naproxen sodium tabs 550mg
naproxen susp 125mg/5ml
naproxen tabs 250mg
naproxen tabs 375mg
naproxen tabs 500mg
oxaprozin tabs 600mg
piroxicam caps 10mg
piroxicam caps 20mg
sulindac tabs 150mg
sulindac tabs 200mg
tolmetin sodium caps 400mg
tolmetin sodium tabs 200mg
tolmetin sodium tabs 600mg
VOLTAREN GEL 1%
Opioid Analgesics, Long-acting
fentanyl pt72 100mcg/hr
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (1020 GM per 30 days) MO
Generic
QL (15 EA per 30 days) MO
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
2
Drug Name
fentanyl pt72 12mcg/hr
fentanyl pt72 25mcg/hr
fentanyl pt72 37.5mcg/hr
fentanyl pt72 50mcg/hr
fentanyl pt72 62.5mcg/hr
fentanyl pt72 75mcg/hr
fentanyl pt72 87.5mcg/hr
methadone hcl conc 10mg/ml
methadone hcl inj 10mg/ml
methadone hcl soln 10mg/5ml
methadone hcl soln 5mg/5ml
methadone hcl tabs 10mg
methadone hcl tabs 5mg
methadone hcl tbso 40mg
methadose sugar-free conc 10mg/ml
methadose conc 10mg/ml
methadose tbso 40mg
morphine sulfate er cp24 100mg
morphine sulfate er cp24 10mg
morphine sulfate er cp24 120mg
morphine sulfate er cp24 20mg
morphine sulfate er cp24 30mg
morphine sulfate er cp24 30mg
morphine sulfate er cp24 45mg
morphine sulfate er cp24 50mg
morphine sulfate er cp24 60mg
morphine sulfate er cp24 60mg
morphine sulfate er cp24 75mg
morphine sulfate er cp24 80mg
morphine sulfate er cp24 90mg
morphine sulfate er tbcr 100mg
morphine sulfate er tbcr 15mg
morphine sulfate er tbcr 200mg
morphine sulfate er tbcr 30mg
morphine sulfate er tbcr 60mg
Opioid Analgesics, Short-acting
acetaminophen/codeine #3 tabs 300mg; 30mg
Drug Tier
Requirements/
Limits
QL (15 EA per 30 days) MO
QL (15 EA per 30 days) MO
QL (15 EA per 30 days) MO
QL (15 EA per 30 days) MO
QL (15 EA per 30 days) MO
QL (15 EA per 30 days) MO
QL (15 EA per 30 days) MO
QL (360 ML per 30 days) MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL (3000 ML per 30 days) MO
QL (3000 ML per 30 days) MO
QL (240 EA per 30 days) MO
QL (240 EA per 30 days) MO
QL (90 EA per 30 days)
QL (360 ML per 30 days) MO
QL (360 ML per 30 days) MO
QL (90 EA per 30 days)
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
Generic
QL (390 EA per 30 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
3
Drug Name
acetaminophen/codeine soln 120mg/5ml;
12mg/5ml
acetaminophen/codeine tabs 300mg; 15mg
acetaminophen/codeine tabs 300mg; 60mg
butalbital compound/codeine caps 325mg;
50mg; 40mg; 30mg
codeine sulfate tabs 15mg
codeine sulfate tabs 30mg
codeine sulfate tabs 60mg
duramorph inj 0.5mg/ml
duramorph inj 1mg/ml
endocet tabs 325mg; 10mg
endocet tabs 325mg; 2.5mg
endocet tabs 325mg; 5mg
endocet tabs 325mg; 7.5mg
fentanyl citrate oral transmucosal lpop 1200mcg
fentanyl citrate oral transmucosal lpop 1600mcg
fentanyl citrate oral transmucosal lpop 200mcg
fentanyl citrate oral transmucosal lpop 400mcg
fentanyl citrate oral transmucosal lpop 600mcg
fentanyl citrate oral transmucosal lpop 800mcg
hydrocodone bitartrate/acetaminophen soln
325mg/15ml; 7.5mg/15ml
hydrocodone bitartrate/acetaminophen tabs
300mg; 10mg
hydrocodone bitartrate/acetaminophen tabs
300mg; 5mg
hydrocodone bitartrate/acetaminophen tabs
300mg; 7.5mg
hydrocodone bitartrate/acetaminophen tabs
325mg; 2.5mg
hydrocodone/acetaminophen tabs 325mg;
10mg
hydrocodone/acetaminophen tabs 325mg; 5mg
hydrocodone/acetaminophen tabs 325mg;
7.5mg
hydrocodone/ibuprofen tabs 10mg; 200mg
hydrocodone/ibuprofen tabs 2.5mg; 200mg
hydrocodone/ibuprofen tabs 5mg; 200mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
QL (4500 ML per 30 days) MO
QL (390 EA per 30 days) MO
QL (390 EA per 30 days) MO
QL (180 EA per 30 days) PA
QL (180 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (180 EA per 30 days) MO
B/D
B/D
QL (360 EA per 30 days)
QL (360 EA per 30 days)
QL (360 EA per 30 days)
QL (360 EA per 30 days)
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (5550 ML per 30 days) MO
QL (390 EA per 30 days) MO
QL (390 EA per 30 days) MO
QL (390 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (150 EA per 30 days) MO
QL (150 EA per 30 days) MO
QL (150 EA per 30 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
4
Drug Name
hydrocodone/ibuprofen tabs 7.5mg; 200mg
hydromorphone hcl inj 1mg/ml
hydromorphone hcl inj 2mg/ml
hydromorphone hcl inj 4mg/ml
hydromorphone hcl inj 500mg/50ml
hydromorphone hcl liqd 1mg/ml
hydromorphone hcl tabs 2mg
hydromorphone hcl tabs 4mg
hydromorphone hcl tabs 8mg
ibudone tabs 5mg; 200mg
lorcet hd tabs 325mg; 10mg
lorcet plus tabs 325mg; 7.5mg
lorcet tabs 325mg; 5mg
morphine sulfate inj 0.5mg/ml
morphine sulfate inj 10mg/ml
morphine sulfate inj 10mg/ml
morphine sulfate inj 150mg/30ml
morphine sulfate inj 15mg/ml
morphine sulfate inj 15mg/ml
morphine sulfate inj 1mg/ml
morphine sulfate inj 1mg/ml
morphine sulfate inj 25mg/ml
morphine sulfate inj 2mg/ml
morphine sulfate inj 4mg/ml
morphine sulfate inj 50mg/ml
morphine sulfate inj 5mg/ml
morphine sulfate inj 8mg/ml
morphine sulfate inj 8mg/ml
morphine sulfate soln 100mg/5ml
morphine sulfate soln 10mg/5ml
morphine sulfate soln 20mg/5ml
morphine sulfate tabs 15mg
morphine sulfate tabs 30mg
nalbuphine hcl inj 10mg/ml
nalbuphine hcl inj 20mg/ml
oxycodone hcl caps 5mg
oxycodone hcl conc 100mg/5ml
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
QL (150 EA per 30 days) MO
B/D MO
B/D MO
B/D MO
B/D MO
QL (2400 ML per 30 days) MO
QL (480 EA per 30 days) MO
QL (240 EA per 30 days) MO
QL (240 EA per 30 days) MO
QL (150 EA per 30 days)
QL (360 EA per 30 days)
QL (360 EA per 30 days)
QL (360 EA per 30 days)
B/D
B/D MO
B/D
B/D
B/D MO
B/D
B/D MO
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
QL (180 ML per 30 days) MO
QL (1800 ML per 30 days) MO
QL (1020 ML per 30 days) MO
QL (180 EA per 30 days) MO
QL (180 EA per 30 days) MO
MO
MO
QL (360 EA per 30 days) MO
QL (180 ML per 30 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
5
Drug Name
oxycodone hcl soln 5mg/5ml
oxycodone hcl tabs 10mg
oxycodone hcl tabs 15mg
oxycodone hcl tabs 20mg
oxycodone hcl tabs 30mg
oxycodone hcl tabs 5mg
oxycodone/acetaminophen tabs 325mg; 10mg
oxycodone/acetaminophen tabs 325mg; 2.5mg
oxycodone/acetaminophen tabs 325mg; 5mg
oxycodone/acetaminophen tabs 325mg; 7.5mg
oxycodone/aspirin tabs 325mg; 4.835mg
oxycodone/ibuprofen tabs 400mg; 5mg
ROXICET SOLN 325MG/5ML; 5MG/5ML
roxicet tabs 325mg; 5mg
tramadol hcl tabs 50mg
tramadol hydrochloride/acetaminophen tabs
325mg; 37.5mg
vicodin es tabs 300mg; 7.5mg
vicodin tabs 300mg; 5mg
zamicet soln 325mg/15ml; 10mg/15ml
ANESTHETICS-DRUGS USED FOR NUMBING
Local Anesthetics
glydo gel 2%
lidocaine hcl jelly gel 2%
lidocaine hcl jelly gel 2%
lidocaine hcl jelly gel 2%
lidocaine hcl gel 2%
lidocaine hcl inj 0.5%
lidocaine hcl inj 0.5%
lidocaine hcl inj 1%
lidocaine hcl inj 1%
lidocaine hcl inj 1.5%
lidocaine hcl inj 2%
lidocaine hcl inj 2%
lidocaine hcl inj 4%
lidocaine hcl soln 4%
lidocaine hcl soln 4%
lidocaine viscous soln 2%
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
QL (5400 ML per 30 days) MO
QL (180 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (360 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (1800 ML per 30 days) MO
QL (360 EA per 30 days)
QL (240 EA per 30 days) MO
QL (240 EA per 30 days) MO
QL (390 EA per 30 days)
QL (390 EA per 30 days)
QL (5550 ML per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
6
Drug Name
Drug Tier
lidocaine/prilocaine crea 2.5%; 2.5%
Generic
lidocaine/prilocaine kit 2.5%; 2.5%
Generic
lidocaine oint 5%
Generic
lidocaine ptch 5%
Generic
relador pak plus kit 2.5%; 2.5%
Generic
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
Alcohol Deterrents/Anti-craving
acamprosate calcium dr tbec 333mg
Generic
disulfiram tabs 250mg
Generic
disulfiram tabs 500mg
Generic
naltrexone hcl tabs 50mg
Generic
Opioid Dependence Treatments
buprenorphine hcl/naloxone hcl subl 2mg;
Generic
0.5mg
buprenorphine hcl/naloxone hcl subl 8mg; 2mg
Generic
buprenorphine hcl subl 2mg
Generic
buprenorphine hcl subl 8mg
Generic
SUBOXONE FILM 12MG; 3MG
OTHER
SUBOXONE FILM 2MG; 0.5MG
OTHER
SUBOXONE FILM 4MG; 1MG
OTHER
SUBOXONE FILM 8MG; 2MG
OTHER
Opioid Reversal Agents
EVZIO INJ 0.4MG/0.4ML
OTHER
naloxone hcl inj 0.4mg/ml
Generic
naloxone hcl inj 1mg/ml
Generic
Smoking Cessation Agents
buproban tb12 150mg
Generic
bupropion hcl sr tb12 150mg
Generic
CHANTIX CONTINUING MONTH PAK TABS
OTHER
1MG
CHANTIX STARTING MONTH PAK TABS 0
OTHER
CHANTIX TABS 0.5MG
OTHER
CHANTIX TABS 1MG
OTHER
NICOTROL NS SOLN 10MG/ML
OTHER
ANTIBACTERIALS-DRUGS USED TO TREAT INFECTIONS
Aminoglycosides
amikacin sulfate inj 1gm/4ml
Generic
amikacin sulfate inj 500mg/2ml
Generic
Requirements/
Limits
MO
MO
QL (90 EA per 30 days) PA MO
MO
MO
MO
MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
PA MO
MO
MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (336 EA per 365 days) MO
QL (106 EA per 365 days) MO
QL (336 EA per 365 days) MO
QL (336 EA per 365 days) MO
QL (40 ML per 30 days) MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
7
Drug Name
gentamicin sulfate pediatric inj 10mg/ml
gentamicin sulfate/0.9% sodium chloride inj
0.8mg/ml; 0.9%
gentamicin sulfate/0.9% sodium chloride inj
0.9mg/ml; 0.9%
gentamicin sulfate/0.9% sodium chloride inj
1.2mg/ml; 0.9%
gentamicin sulfate/0.9% sodium chloride inj
1.4mg/ml; 0.9%
gentamicin sulfate/0.9% sodium chloride inj
1.6mg/ml; 0.9%
gentamicin sulfate/0.9% sodium chloride inj
1mg/ml; 0.9%
gentamicin sulfate inj 10mg/ml
gentamicin sulfate inj 40mg/ml
isotonic gentamicin inj 0.8mg/ml; 0.9%
isotonic gentamicin inj 1.2mg/ml; 0.9%
isotonic gentamicin inj 2mg/ml; 0.9%
neomycin sulfate tabs 500mg
paromomycin sulfate caps 250mg
streptomycin sulfate inj 1gm
tobramycin sulfate/sodium chloride inj 0.9%;
0.8mg/ml
tobramycin sulfate inj 1.2gm/30ml
tobramycin sulfate inj 1.2gm
tobramycin sulfate inj 10mg/ml
tobramycin sulfate inj 40mg/ml
tobramycin sulfate inj 40mg/ml
tobramycin sulfate inj 80mg/2ml
Antibacterials, Other
baciim inj 50000unit
bacitracin inj 50000unit
chloramphenicol sodium succinate inj 1gm
clindamax gel 1%
clindamax lotn 1%
clindamycin hcl caps 150mg
clindamycin hcl caps 300mg
clindamycin hcl caps 75mg
Drug Tier
Generic
Generic
Requirements/
Limits
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
8
Drug Name
clindamycin palmitate hcl solr 75mg/5ml
clindamycin phosphate add-vantage inj 150mg/
ml
clindamycin phosphate add-vantage inj 150mg/
ml
clindamycin phosphate in d5w inj 300mg/50ml;
5%
clindamycin phosphate in d5w inj 600mg/50ml;
5%
clindamycin phosphate in d5w inj 900mg/50ml;
5%
clindamycin phosphate crea 2%
clindamycin phosphate inj 150mg/ml
clindamycin phosphate inj 150mg/ml
clindamycin phosphate inj 300mg/2ml
clindamycin phosphate inj 300mg/2ml
clindamycin phosphate inj 300mg/2ml
clindamycin phosphate inj 600mg/4ml
clindamycin phosphate inj 600mg/4ml
clindamycin phosphate inj 600mg/4ml
clindamycin phosphate inj 9000mg/60ml
clindamycin phosphate inj 900mg/6ml
clindamycin phosphate inj 900mg/6ml
clindamycin phosphate inj 900mg/6ml
colistimethate sodium inj 150mg
CUBICIN INJ 500MG
DALVANCE INJ 500MG
linezolid inj 2mg/ml
linezolid tabs 600mg
methenamine hippurate tabs 1gm
METRO IV INJ 500MG/100ML; 0.74%
metronidazole in nacl 0.79% inj 500mg/100ml;
0.79%
metronidazole vaginal gel 0.75%
metronidazole caps 375mg
metronidazole tabs 250mg
metronidazole tabs 500mg
nitrofurantoin macrocrystals caps 100mg
Drug Tier
Generic
Requirements/
Limits
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
OTHER
MO
MO
MO
MO
MO
MO
MO
PA MO
PA
QL (56 EA per 28 days) PA MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
9
Drug Name
nitrofurantoin macrocrystals caps 25mg
nitrofurantoin macrocrystals caps 50mg
nitrofurantoin monohydrate caps 100mg
nitrofurantoin susp 25mg/5ml
SIVEXTRO INJ 200MG
SIVEXTRO TABS 200MG
SYNERCID INJ 350MG; 150MG
tinidazole tabs 250mg
tinidazole tabs 500mg
trimethoprim tabs 100mg
TYGACIL INJ 50MG
vancomycin hcl in dextrose inj 0; 1gm/200ml
vancomycin hcl in dextrose inj 0; 500mg/100ml
vancomycin hcl in dextrose inj 0; 750mg/150ml
vancomycin hcl caps 125mg
vancomycin hcl caps 250mg
vancomycin hcl inj 1000mg
vancomycin hcl inj 10gm
vancomycin hcl inj 5000mg
vancomycin hcl inj 500mg
vancomycin hcl inj 750mg
vandazole gel 0.75%
ZYVOX INJ 2MG/ML
ZYVOX SUSR 100MG/5ML
Beta-lactam, Cephalosporins
cefaclor er tb12 500mg
cefaclor caps 250mg
cefaclor caps 500mg
cefaclor susr 125mg/5ml
cefaclor susr 250mg/5ml
cefaclor susr 375mg/5ml
cefadroxil caps 500mg
cefadroxil susr 250mg/5ml
cefadroxil susr 500mg/5ml
cefadroxil tabs 1gm
cefazolin sodium/dextrose inj 1gm; 4%
cefazolin sodium/dextrose inj 2gm; 3%
Drug Tier
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
MO
MO
PA
QL (1800 ML per 28 days) PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
10
Drug Name
cefazolin sodium inj 100gm
cefazolin sodium inj 10gm
cefazolin sodium inj 1gm
cefazolin sodium inj 1gm
cefazolin sodium inj 1gm; 5%
cefazolin sodium inj 20gm
cefazolin sodium inj 300gm
cefazolin sodium inj 500mg
cefdinir caps 300mg
cefdinir susr 125mg/5ml
cefdinir susr 250mg/5ml
cefditoren pivoxil tabs 200mg
cefditoren pivoxil tabs 400mg
cefepime inj 1gm/50ml
cefepime inj 1gm/50ml; 5%
cefepime inj 1gm
cefepime inj 2gm/100ml
cefepime inj 2gm/50ml; 5%
cefepime inj 2gm
cefixime susr 100mg/5ml
cefixime susr 200mg/5ml
cefotaxime sodium inj 10gm
cefotaxime sodium inj 1gm
cefotaxime sodium inj 2gm
cefotaxime sodium inj 500mg
cefotetan/dextrose inj 1gm; 3.58%
cefotetan/dextrose inj 2gm; 2.08%
cefotetan inj 10gm
cefotetan inj 1gm
cefotetan inj 2gm
cefoxitin sodium inj 10gm
cefoxitin sodium inj 1gm
cefoxitin sodium inj 1gm; 4%
cefoxitin sodium inj 2gm
cefoxitin sodium inj 2gm; 2.2%
cefpodoxime proxetil susr 100mg/5ml
cefpodoxime proxetil susr 50mg/5ml
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
11
Drug Name
cefpodoxime proxetil tabs 100mg
cefpodoxime proxetil tabs 200mg
cefprozil susr 125mg/5ml
cefprozil susr 250mg/5ml
cefprozil tabs 250mg
cefprozil tabs 500mg
ceftazidime/dextrose inj 1gm/50ml; 5%
ceftazidime/dextrose inj 2gm/50ml; 5%
ceftazidime inj 1gm
ceftazidime inj 2gm
ceftazidime inj 6gm
ceftriaxone in iso-osmotic dextrose inj 20mg/ml;
0
ceftriaxone in iso-osmotic dextrose inj 40mg/ml;
0
ceftriaxone sodium inj 10gm
ceftriaxone sodium inj 1gm
ceftriaxone sodium inj 1gm
ceftriaxone sodium inj 250mg
ceftriaxone sodium inj 2gm
ceftriaxone sodium inj 2gm
ceftriaxone sodium inj 500mg
ceftriaxone/dextrose inj 1gm; 3.74%
ceftriaxone/dextrose inj 2gm; 2.22%
cefuroxime axetil tabs 250mg
cefuroxime axetil tabs 500mg
cefuroxime sodium inj 1.5gm
cefuroxime sodium inj 1.5gm
cefuroxime sodium inj 7.5gm
cefuroxime sodium inj 7.5gm
cefuroxime sodium inj 750mg
cefuroxime sodium inj 75gm
cefuroxime/dextrose inj 750mg; 4.1%
cephalexin caps 250mg
cephalexin caps 500mg
cephalexin caps 750mg
cephalexin susr 125mg/5ml
cephalexin susr 250mg/5ml
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
12
Drug Name
cephalexin tabs 250mg
cephalexin tabs 500mg
SUPRAX CAPS 400MG
SUPRAX CHEW 100MG
SUPRAX CHEW 200MG
SUPRAX SUSR 100MG/5ML
SUPRAX SUSR 200MG/5ML
SUPRAX SUSR 500MG/5ML
tazicef inj 1gm
tazicef inj 1gm
tazicef inj 2gm
tazicef inj 2gm
tazicef inj 6gm
TEFLARO INJ 400MG
TEFLARO INJ 600MG
Beta-lactam, Other
aztreonam inj 1gm
aztreonam inj 2gm
imipenem/cilastatin inj 250mg; 250mg
imipenem/cilastatin inj 500mg; 500mg
INVANZ INJ 1GM
INVANZ INJ 1GM
meropenem inj 1gm
meropenem inj 500mg
Beta-lactam, Penicillins
amoxicillin/clavulanate potassium er tb12
1000mg; 62.5mg
amoxicillin/clavulanate potassium chew 200mg;
28.5mg
amoxicillin/clavulanate potassium chew 400mg;
57mg
amoxicillin/clavulanate potassium susr
200mg/5ml; 28.5mg/5ml
amoxicillin/clavulanate potassium susr
250mg/5ml; 62.5mg/5ml
amoxicillin/clavulanate potassium susr
400mg/5ml; 57mg/5ml
Drug Tier
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
13
Drug Name
amoxicillin/clavulanate potassium susr
600mg/5ml; 42.9mg/5ml
amoxicillin/clavulanate potassium tabs 250mg;
125mg
amoxicillin/clavulanate potassium tabs 500mg;
125mg
amoxicillin/clavulanate potassium tabs 875mg;
125mg
amoxicillin caps 250mg
amoxicillin caps 500mg
amoxicillin chew 125mg
amoxicillin chew 250mg
amoxicillin susr 125mg/5ml
amoxicillin susr 200mg/5ml
amoxicillin susr 250mg/5ml
amoxicillin susr 400mg/5ml
amoxicillin tabs 500mg
amoxicillin tabs 875mg
ampicillin sodium inj 10gm
ampicillin sodium inj 10gm
ampicillin sodium inj 125mg
ampicillin sodium inj 1gm
ampicillin sodium inj 1gm
ampicillin sodium inj 250mg
ampicillin sodium inj 2gm
ampicillin sodium inj 2gm
ampicillin sodium inj 500mg
ampicillin-sulbactam inj 10gm; 5gm
ampicillin-sulbactam inj 10gm; 5gm
ampicillin-sulbactam inj 1gm; 0.5gm
ampicillin-sulbactam inj 1gm; 0.5gm
ampicillin-sulbactam inj 1gm; 0.5gm
ampicillin-sulbactam inj 2gm; 1gm
ampicillin-sulbactam inj 2gm; 1gm
ampicillin caps 250mg
ampicillin caps 500mg
ampicillin susr 125mg/5ml
ampicillin susr 250mg/5ml
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
14
Drug Name
BICILLIN L-A INJ 1200000UNIT/2ML
BICILLIN L-A INJ 2400000UNIT/4ML
BICILLIN L-A INJ 600000UNIT/ML
dicloxacillin sodium caps 250mg
dicloxacillin sodium caps 500mg
NALLPEN ISO-OSMOTIC IN DEXTROSE INJ 0;
2GM/100ML
NALLPEN/DEXTROSE INJ 0; 1GM/50ML
oxacillin sodium inj 10gm
oxacillin sodium inj 1gm
oxacillin sodium inj 2gm
penicillin g potassium inj 20000000unit
penicillin g potassium inj 5000000unit
penicillin g procaine inj 600000unit/ml
penicillin g sodium inj 5000000unit
penicillin v potassium solr 125mg/5ml
penicillin v potassium solr 250mg/5ml
penicillin v potassium tabs 250mg
penicillin v potassium tabs 500mg
piperacillin sodium/ tazobactam sodium inj
36gm; 4.5gm
piperacillin sodium/tazobactam sodium inj 2gm;
0.25gm
piperacillin sodium/tazobactam sodium inj 3gm;
0.375gm
piperacillin sodium/tazobactam sodium inj 4gm;
0.5gm
Macrolides
azithromycin inj 500mg
azithromycin inj 500mg
azithromycin pack 1gm
azithromycin susr 100mg/5ml
azithromycin susr 200mg/5ml
azithromycin tabs 250mg
azithromycin tabs 500mg
azithromycin tabs 600mg
clarithromycin susr 125mg/5ml
clarithromycin susr 250mg/5ml
Drug Tier
OTHER
OTHER
OTHER
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
15
Drug Name
clarithromycin tabs 250mg
clarithromycin tabs 500mg
DIFICID TABS 200MG
ERYTHROCIN LACTOBIONATE INJ 500MG
erythromycin base tabs 250mg
erythromycin base tabs 500mg
erythromycin ethylsuccinate tabs 400mg
erythromycin stearate tabs 250mg
erythromycin cpep 250mg
Quinolones
ciprofloxacin er tb24 1000mg; 0
ciprofloxacin er tb24 500mg; 0
ciprofloxacin hcl tabs 100mg
ciprofloxacin hcl tabs 250mg
ciprofloxacin hcl tabs 500mg
ciprofloxacin hcl tabs 750mg
ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%
ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5%
ciprofloxacin inj 200mg/20ml
ciprofloxacin inj 400mg/40ml
ciprofloxacin soln 0.2%
ciprofloxacin susr 250mg/5ml
ciprofloxacin susr 500mg/5ml
levofloxacin in d5w inj 5%; 250mg/50ml
levofloxacin in d5w inj 5%; 500mg/100ml
levofloxacin in d5w inj 5%; 750mg/150ml
levofloxacin inj 25mg/ml
levofloxacin soln 25mg/ml
levofloxacin tabs 250mg
levofloxacin tabs 500mg
levofloxacin tabs 750mg
ofloxacin tabs 400mg
Sulfonamides
sulfadiazine tabs 500mg
sulfamethoxazole/trimethoprim ds tabs 800mg;
160mg
sulfamethoxazole/trimethoprim inj 400mg/5ml;
80mg/5ml
Drug Tier
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
Generic
MO
MO
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
16
Drug Name
Drug Tier
sulfamethoxazole/trimethoprim susp
Generic
200mg/5ml; 40mg/5ml
sulfamethoxazole/trimethoprim tabs 400mg;
Generic
80mg
sulfatrim pediatric susp 200mg/5ml; 40mg/5ml
Generic
Tetracyclines
doxy 100 inj 100mg
Generic
doxycycline hyclate dr tbec 100mg
Generic
doxycycline hyclate dr tbec 150mg
Generic
doxycycline hyclate dr tbec 75mg
Generic
doxycycline hyclate caps 100mg
Generic
doxycycline hyclate caps 50mg
Generic
doxycycline hyclate inj 100mg
Generic
doxycycline hyclate tabs 100mg
Generic
doxycycline hyclate tabs 20mg
Generic
doxycycline monohydrate caps 100mg
Generic
doxycycline monohydrate caps 50mg
Generic
doxycycline monohydrate tabs 100mg
Generic
doxycycline monohydrate tabs 150mg
Generic
doxycycline monohydrate tabs 50mg
Generic
doxycycline monohydrate tabs 50mg
Generic
doxycycline monohydrate tabs 75mg
Generic
doxycycline caps 150mg
Generic
doxycycline caps 75mg
Generic
doxycycline susr 25mg/5ml
Generic
minocycline hcl caps 100mg
Generic
minocycline hcl caps 50mg
Generic
minocycline hcl caps 75mg
Generic
morgidox 1x100mg caps 100mg
Generic
morgidox 2x100mg caps 100mg
Generic
tetracycline hcl caps 250mg
Generic
tetracycline hcl caps 500mg
Generic
ANTICONVULSANTS-DRUGS USED TO TREAT SEIZURES
Anticonvulsants, Other
APTIOM TABS 200MG
OTHER
APTIOM TABS 400MG
OTHER
APTIOM TABS 600MG
OTHER
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
17
Drug Name
APTIOM TABS 800MG
FYCOMPA TABS 10MG
FYCOMPA TABS 12MG
FYCOMPA TABS 2MG
FYCOMPA TABS 4MG
FYCOMPA TABS 6MG
FYCOMPA TABS 8MG
levetiracetam inj 1000mg/100ml;
750mg/100ml
levetiracetam inj 1500mg/100ml;
540mg/100ml
levetiracetam inj 500mg/100ml; 820mg/100ml
levetiracetam inj 500mg/5ml
levetiracetam soln 100mg/ml
levetiracetam tabs 1000mg
levetiracetam tabs 250mg
levetiracetam tabs 500mg
levetiracetam tabs 750mg
POTIGA TABS 200MG
POTIGA TABS 300MG
POTIGA TABS 400MG
POTIGA TABS 50MG
Calcium Channel Modifying Agents
CELONTIN CAPS 300MG
ethosuximide caps 250mg
ethosuximide soln 250mg/5ml
LYRICA CAPS 100MG
LYRICA CAPS 150MG
LYRICA CAPS 200MG
LYRICA CAPS 225MG
LYRICA CAPS 25MG
LYRICA CAPS 300MG
LYRICA CAPS 50MG
LYRICA CAPS 75MG
LYRICA SOLN 20MG/ML
zonisamide caps 100mg
zonisamide caps 25mg
zonisamide caps 50mg
Drug Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
QL (30 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
MO
MO
MO
MO
MO
MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (270 EA per 30 days) MO
OTHER
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
MO
MO
MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (900 ML per 30 days) PA MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
18
Drug Name
Gamma-aminobutyric Acid (GABA) Augmenting
Agents
clonazepam odt tbdp 0.125mg
clonazepam odt tbdp 0.25mg
clonazepam odt tbdp 0.5mg
clonazepam odt tbdp 1mg
clonazepam odt tbdp 2mg
clonazepam tabs 0.5mg
clonazepam tabs 1mg
clonazepam tabs 2mg
diazepam gel 10mg
diazepam gel 2.5mg
diazepam gel 20mg
divalproex sodium dr tbec 125mg
divalproex sodium dr tbec 250mg
divalproex sodium dr tbec 500mg
divalproex sodium er tb24 250mg
divalproex sodium er tb24 500mg
divalproex sodium cpsp 125mg
gabapentin caps 100mg
gabapentin caps 300mg
gabapentin caps 400mg
gabapentin soln 250mg/5ml
gabapentin tabs 600mg
gabapentin tabs 800mg
GABITRIL TABS 12MG
GABITRIL TABS 16MG
ONFI SUSP 2.5MG/ML
ONFI TABS 10MG
ONFI TABS 20MG
phenobarbital elix 20mg/5ml
phenobarbital tabs 100mg
phenobarbital tabs 15mg
phenobarbital tabs 16.2mg
phenobarbital tabs 30mg
phenobarbital tabs 32.4mg
phenobarbital tabs 60mg
phenobarbital tabs 64.8mg
Drug Tier
Requirements/
Limits
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (300 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (300 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (1500 ML per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
19
Drug Name
phenobarbital tabs 97.2mg
primidone tabs 250mg
primidone tabs 50mg
SABRIL PACK 500MG
SABRIL TABS 500MG
tiagabine hydrochloride tabs 2mg
tiagabine hydrochloride tabs 4mg
valproate sodium inj 500mg/5ml
valproic acid caps 250mg
valproic acid syrp 250mg/5ml
Glutamate Reducing Agents
felbamate susp 600mg/5ml
felbamate tabs 400mg
felbamate tabs 600mg
lamotrigine chew 25mg
lamotrigine chew 5mg
lamotrigine tabs 100mg
lamotrigine tabs 150mg
lamotrigine tabs 200mg
lamotrigine tabs 25mg
topiramate cpsp 15mg
topiramate cpsp 25mg
topiramate tabs 100mg
topiramate tabs 200mg
topiramate tabs 25mg
topiramate tabs 50mg
Sodium Channel Agents
BANZEL SUSP 40MG/ML
BANZEL TABS 200MG
BANZEL TABS 400MG
carbamazepine er cp12 100mg
carbamazepine er cp12 200mg
carbamazepine er cp12 300mg
carbamazepine er tb12 200mg
carbamazepine er tb12 400mg
carbamazepine chew 100mg
carbamazepine susp 100mg/5ml
Drug Tier
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
QL (120 EA per 30 days) PA MO
MO
MO
PA LA
PA LA
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
20
Drug Name
Drug Tier
Requirements/
Limits
MO
MO
carbamazepine tabs 200mg
Generic
DILANTIN CAPS 30MG
OTHER
epitol tabs 200mg
Generic
fosphenytoin sodium inj 100mg pe/2ml
Generic
fosphenytoin sodium inj 500mg pe/10ml
Generic
MO
oxcarbazepine susp 300mg/5ml
Generic
MO
oxcarbazepine tabs 150mg
Generic
MO
oxcarbazepine tabs 300mg
Generic
MO
oxcarbazepine tabs 600mg
Generic
MO
PEGANONE TABS 250MG
OTHER
MO
phenytoin sodium extended caps 100mg
Generic
MO
phenytoin sodium extended caps 200mg
Generic
MO
phenytoin sodium extended caps 300mg
Generic
MO
phenytoin sodium inj 50mg/ml
Generic
phenytoin chew 50mg
Generic
MO
phenytoin susp 125mg/5ml
Generic
MO
TEGRETOL-XR TB12 100MG
OTHER
MO
VIMPAT INJ 200MG/20ML
OTHER
VIMPAT SOLN 10MG/ML
OTHER
MO
VIMPAT TABS 100MG
OTHER
QL (60 EA per 30 days) MO
VIMPAT TABS 150MG
OTHER
QL (60 EA per 30 days) MO
VIMPAT TABS 200MG
OTHER
QL (60 EA per 30 days) MO
VIMPAT TABS 50MG
OTHER
QL (180 EA per 30 days) MO
ANTIDEMENTIA AGENTS-DRUGS USED TO TREAT DEMENTIA AND MEMORY LOSS
Antidementia Agents, Other
ergoloid mesylates tabs 1mg
Generic
PA MO
Cholinesterase Inhibitors
donepezil hcl tabs 10mg
Generic
QL (60 EA per 30 days) MO
donepezil hcl tabs 23mg
Generic
QL (30 EA per 30 days) MO
donepezil hcl tabs 5mg
Generic
QL (30 EA per 30 days) MO
donepezil hcl tbdp 10mg
Generic
QL (30 EA per 30 days) MO
donepezil hcl tbdp 5mg
Generic
QL (30 EA per 30 days) MO
EXELON PT24 13.3MG/24HR
OTHER
QL (30 EA per 30 days) MO
EXELON PT24 4.6MG/24HR
OTHER
QL (30 EA per 30 days) MO
EXELON PT24 9.5MG/24HR
OTHER
QL (30 EA per 30 days) MO
galantamine hydrobromide cp24 16mg
Generic
QL (30 EA per 30 days) MO
galantamine hydrobromide cp24 24mg
Generic
QL (30 EA per 30 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
21
Drug Name
Drug Tier
galantamine hydrobromide cp24 8mg
Generic
galantamine hydrobromide soln 4mg/ml
Generic
galantamine hydrobromide tabs 12mg
Generic
galantamine hydrobromide tabs 4mg
Generic
galantamine hydrobromide tabs 8mg
Generic
rivastigmine tartrate caps 1.5mg
Generic
rivastigmine tartrate caps 3mg
Generic
rivastigmine tartrate caps 4.5mg
Generic
rivastigmine tartrate caps 6mg
Generic
rivastigmine transdermal system pt24
Generic
13.3mg/24hr
rivastigmine transdermal system pt24
Generic
4.6mg/24hr
rivastigmine transdermal system pt24
Generic
9.5mg/24hr
N-methyl-D-aspartate (NMDA) Receptor Antag‑
onist
memantine hcl titration pak tabs 0
Generic
memantine hcl tabs 10mg
Generic
memantine hcl tabs 5mg
Generic
memantine hydrochloride soln 2mg/ml
Generic
NAMENDA TITRATION PAK TABS 0
OTHER
NAMENDA XR TITRATION PACK CP24 0
OTHER
NAMENDA XR CP24 14MG
OTHER
NAMENDA XR CP24 21MG
OTHER
NAMENDA XR CP24 28MG
OTHER
NAMENDA XR CP24 7MG
OTHER
NAMENDA SOLN 10MG/5ML
OTHER
NAMENDA TABS 10MG
OTHER
NAMENDA TABS 5MG
OTHER
NAMZARIC CP24 10MG; 14MG
OTHER
NAMZARIC CP24 10MG; 28MG
OTHER
ANTIDEPRESSANTS-DRUGS USED TO TREAT DEPRESSION
Antidepressants, Other
bupropion hcl er tb12 100mg
Generic
bupropion hcl er tb12 150mg
Generic
bupropion hcl er tb12 200mg
Generic
bupropion hcl sr tb12 100mg
Generic
Requirements/
Limits
QL (30 EA per 30 days) MO
QL (200 ML per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (49 EA per 28 days) PA MO
QL (60 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (360 ML per 30 days) PA
QL (49 EA per 28 days) PA MO
QL (30 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (360 ML per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (30 EA per 30 days) PA MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
22
Drug Name
bupropion hcl sr tb12 150mg
bupropion hcl sr tb12 200mg
bupropion hcl xl tb24 150mg
bupropion hcl xl tb24 300mg
bupropion hcl tabs 100mg
bupropion hcl tabs 75mg
mirtazapine odt tbdp 15mg
mirtazapine odt tbdp 30mg
mirtazapine odt tbdp 45mg
mirtazapine tabs 15mg
mirtazapine tabs 30mg
mirtazapine tabs 45mg
mirtazapine tabs 7.5mg
Monoamine Oxidase Inhibitors
EMSAM PT24 12MG/24HR
EMSAM PT24 6MG/24HR
EMSAM PT24 9MG/24HR
MARPLAN TABS 10MG
phenelzine sulfate tabs 15mg
tranylcypromine sulfate tabs 10mg
SSRIs/SNRIs (Selective Serotonin Reuptake In‑
hibitors/Serotonin and Norepinephrine Reuptake
Inhibitor
BRINTELLIX TABS 10MG
BRINTELLIX TABS 20MG
BRINTELLIX TABS 5MG
citalopram hydrobromide soln 10mg/5ml
citalopram hydrobromide tabs 10mg
citalopram hydrobromide tabs 20mg
citalopram hydrobromide tabs 40mg
desvenlafaxine er tb24 100mg
desvenlafaxine er tb24 100mg
desvenlafaxine er tb24 50mg
desvenlafaxine er tb24 50mg
duloxetine hcl cpep 20mg
duloxetine hcl cpep 30mg
duloxetine hcl cpep 60mg
escitalopram oxalate soln 5mg/5ml
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
OTHER
OTHER
OTHER
OTHER
Generic
Generic
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
MO
MO
MO
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (600 ML per 30 days) MO
QL (120 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST
QL (30 EA per 30 days) ST MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (600 ML per 30 days) MO
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
23
Drug Name
escitalopram oxalate tabs 10mg
escitalopram oxalate tabs 20mg
escitalopram oxalate tabs 5mg
FETZIMA TITRATION PACK C4PK 0
FETZIMA CP24 120MG
FETZIMA CP24 20MG
FETZIMA CP24 40MG
FETZIMA CP24 80MG
fluoxetine dr cpdr 90mg
fluoxetine hcl caps 10mg
fluoxetine hcl caps 20mg
fluoxetine hcl caps 40mg
fluoxetine hcl soln 20mg/5ml
fluoxetine hcl tabs 10mg
fluoxetine hcl tabs 20mg
fluoxetine hcl tabs 60mg
fluoxetine caps 10mg
fluoxetine caps 20mg
fluvoxamine maleate tabs 100mg
fluvoxamine maleate tabs 25mg
fluvoxamine maleate tabs 50mg
maprotiline hcl tabs 25mg
maprotiline hcl tabs 50mg
maprotiline hcl tabs 75mg
nefazodone hcl tabs 100mg
nefazodone hcl tabs 150mg
nefazodone hcl tabs 200mg
nefazodone hcl tabs 250mg
nefazodone hcl tabs 50mg
olanzapine/fluoxetine caps 25mg; 12mg
olanzapine/fluoxetine caps 25mg; 3mg
olanzapine/fluoxetine caps 25mg; 6mg
olanzapine/fluoxetine caps 50mg; 12mg
olanzapine/fluoxetine caps 50mg; 6mg
paroxetine hcl tabs 10mg
paroxetine hcl tabs 20mg
paroxetine hcl tabs 30mg
Drug Tier
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
QL (45 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (45 EA per 30 days) MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (4 EA per 28 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
24
Drug Name
paroxetine hcl tabs 40mg
PAXIL SUSP 10MG/5ML
PRISTIQ TB24 25MG
sertraline hcl conc 20mg/ml
sertraline hcl tabs 100mg
sertraline hcl tabs 25mg
sertraline hcl tabs 50mg
trazodone hcl tabs 100mg
trazodone hcl tabs 150mg
trazodone hcl tabs 300mg
trazodone hcl tabs 50mg
venlafaxine hcl er cp24 150mg
venlafaxine hcl er cp24 37.5mg
venlafaxine hcl er cp24 75mg
venlafaxine hcl er tb24 150mg
venlafaxine hcl er tb24 225mg
venlafaxine hcl er tb24 37.5mg
venlafaxine hcl er tb24 75mg
venlafaxine hcl tabs 100mg
venlafaxine hcl tabs 25mg
venlafaxine hcl tabs 37.5mg
venlafaxine hcl tabs 50mg
venlafaxine hcl tabs 75mg
VIIBRYD STARTER PACK KIT 0
VIIBRYD KIT 0
VIIBRYD TABS 10MG
VIIBRYD TABS 20MG
VIIBRYD TABS 40MG
Tricyclics
amitriptyline hcl tabs 100mg
amitriptyline hcl tabs 10mg
amitriptyline hcl tabs 150mg
amitriptyline hcl tabs 25mg
amitriptyline hcl tabs 50mg
amitriptyline hcl tabs 75mg
amoxapine tabs 100mg
amoxapine tabs 150mg
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
MO
MO
QL (120 EA per 30 days) ST MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
QL (60 EA per 365 days)
QL (60 EA per 365 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
MO
MO
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
25
Drug Name
amoxapine tabs 25mg
amoxapine tabs 50mg
clomipramine hcl caps 25mg
clomipramine hcl caps 50mg
clomipramine hcl caps 75mg
desipramine hcl tabs 100mg
desipramine hcl tabs 10mg
desipramine hcl tabs 150mg
desipramine hcl tabs 25mg
desipramine hcl tabs 50mg
desipramine hcl tabs 75mg
doxepin hcl caps 100mg
doxepin hcl caps 10mg
doxepin hcl caps 150mg
doxepin hcl caps 25mg
doxepin hcl caps 50mg
doxepin hcl caps 75mg
doxepin hcl conc 10mg/ml
imipramine hcl tabs 10mg
imipramine hcl tabs 25mg
imipramine hcl tabs 50mg
nortriptyline hcl caps 10mg
nortriptyline hcl caps 25mg
nortriptyline hcl caps 50mg
nortriptyline hcl caps 75mg
nortriptyline hcl soln 10mg/5ml
perphenazine/amitriptyline tabs 10mg; 2mg
perphenazine/amitriptyline tabs 10mg; 4mg
perphenazine/amitriptyline tabs 25mg; 2mg
perphenazine/amitriptyline tabs 25mg; 4mg
perphenazine/amitriptyline tabs 50mg; 4mg
protriptyline hcl tabs 10mg
protriptyline hcl tabs 5mg
SURMONTIL CAPS 100MG
SURMONTIL CAPS 25MG
SURMONTIL CAPS 50MG
trimipramine maleate caps 100mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Requirements/
Limits
MO
MO
PA MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA MO
PA MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
26
Drug Name
Drug Tier
trimipramine maleate caps 25mg
Generic
trimipramine maleate caps 50mg
Generic
ANTIEMETICS-DRUGS FOR NAUSEA AND VOMITING
Antiemetics, Other
meclizine hcl tabs 12.5mg
Generic
meclizine hcl tabs 25mg
Generic
phenadoz supp 12.5mg
Generic
phenadoz supp 25mg
Generic
phenergan supp 12.5mg
Generic
phenergan supp 25mg
Generic
phenergan supp 50mg
Generic
promethazine hcl supp 12.5mg
Generic
promethazine hcl supp 25mg
Generic
promethazine hcl supp 50mg
Generic
promethegan supp 12.5mg
Generic
promethegan supp 25mg
Generic
promethegan supp 50mg
Generic
TRANSDERM-SCOP PT72 1MG/3DAYS
OTHER
Emetogenic Therapy Adjuncts
dronabinol caps 10mg
Generic
dronabinol caps 2.5mg
Generic
dronabinol caps 5mg
Generic
EMEND CAPS 0
OTHER
EMEND CAPS 125MG
OTHER
EMEND CAPS 40MG
OTHER
EMEND CAPS 80MG
OTHER
granisetron hcl tabs 1mg
Generic
ondansetron hcl inj 40mg/20ml
Generic
ondansetron hcl inj 4mg/2ml
Generic
ondansetron hcl soln 4mg/5ml
Generic
ondansetron hcl tabs 24mg
Generic
ondansetron hcl tabs 4mg
Generic
ondansetron hcl tabs 8mg
Generic
ondansetron odt tbdp 4mg
Generic
ondansetron odt tbdp 8mg
Generic
ANTIFUNGALS-DRUGS USED TO TREAT FUNGAL INFECTIONS
Antifungals
Requirements/
Limits
PA MO
PA MO
MO
MO
PA MO
PA
PA
PA
PA
PA MO
PA MO
PA MO
PA
PA
PA MO
MO
QL (60 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (60 EA per 30 days) PA MO
QL (6 EA per 30 days) B/D MO
QL (6 EA per 30 days) B/D MO
QL (1 EA per 30 days) B/D MO
QL (6 EA per 30 days) B/D MO
QL (60 EA per 30 days) B/D MO
MO
MO
QL (900 ML per 30 days) MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
27
Drug Name
ABELCET INJ 5MG/ML
AMBISOME INJ 50MG
amphotericin b inj 50mg
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
ciclodan crea 0.77%
ciclodan soln 8%
ciclopirox nail lacquer soln 8%
ciclopirox olamine crea 0.77%
ciclopirox gel 0.77%
ciclopirox sham 1%
ciclopirox susp 0.77%
clotrimazole/betamethasone dipropionate crea
0.05%; 1%
clotrimazole/betamethasone dipropionate lotn
0.05%; 1%
clotrimazole crea 1%
clotrimazole soln 1%
clotrimazole troc 10mg
econazole nitrate crea 1%
ERAXIS INJ 100MG
ERAXIS INJ 50MG
fluconazole in dextrose inj 56mg/ml;
200mg/100ml
fluconazole in dextrose inj 56mg/ml;
400mg/200ml
fluconazole in nacl inj 100mg/50ml; 0.9%
fluconazole in nacl inj 200mg/100ml; 0.9%
fluconazole in nacl inj 400mg/200ml; 0.9%
fluconazole susr 10mg/ml
fluconazole susr 40mg/ml
fluconazole tabs 100mg
fluconazole tabs 150mg
fluconazole tabs 200mg
fluconazole tabs 50mg
flucytosine caps 250mg
flucytosine caps 500mg
griseofulvin microsize susp 125mg/5ml
Drug Tier
OTHER
OTHER
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Requirements/
Limits
B/D
B/D
B/D MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA
PA
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
28
Drug Name
Drug Tier
griseofulvin microsize tabs 500mg
Generic
griseofulvin ultramicrosize tabs 125mg
Generic
griseofulvin ultramicrosize tabs 250mg
Generic
itraconazole caps 100mg
Generic
ketoconazole crea 2%
Generic
ketoconazole sham 2%
Generic
ketoconazole tabs 200mg
Generic
NOXAFIL INJ 300MG/16.7ML
OTHER
NOXAFIL SUSP 40MG/ML
OTHER
NOXAFIL TBEC 100MG
OTHER
nyamyc powd 100000unit/gm
Generic
nystatin crea 100000unit/gm
Generic
nystatin oint 100000unit/gm
Generic
nystatin powd 100000unit/gm
Generic
nystatin susp 100000unit/ml
Generic
nystatin tabs 500000unit
Generic
nystop powd 100000unit/gm
Generic
SPORANOX SOLN 10MG/ML
OTHER
terbinafine hcl tabs 250mg
Generic
terconazole crea 0.4%
Generic
terconazole crea 0.8%
Generic
terconazole supp 80mg
Generic
voriconazole inj 200mg
Generic
voriconazole susr 40mg/ml
Generic
voriconazole tabs 200mg
Generic
voriconazole tabs 50mg
Generic
zazole supp 80mg
Generic
ANTIGOUT AGENTS- DRUGS USED TO TREAT GOUT
Antigout Agents
allopurinol tabs 100mg
Generic
allopurinol tabs 300mg
Generic
colchicine caps 0.6mg
Generic
colchicine tabs 0.6mg
Generic
COLCRYS TABS 0.6MG
OTHER
probenecid/colchicine tabs 0.5mg; 500mg
Generic
probenecid tabs 500mg
Generic
ANTIMIGRAINE AGENTS- DRUGS USED TO TREAT SEVERE HEADACHES
Requirements/
Limits
MO
MO
MO
PA MO
MO
MO
MO
PA
PA MO
PA MO
MO
MO
MO
MO
MO
MO
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
29
Drug Name
Drug Tier
Requirements/
Limits
Ergot Alkaloids
dihydroergotamine mesylate inj 1mg/ml
Generic
MO
MIGERGOT SUPP 100MG; 2MG
OTHER
QL (20 EA per 28 days) MO
Serotonin (5-HT) 1b/1d Receptor Agonists
naratriptan hcl tabs 1mg
Generic
QL (9 EA per 30 days) MO
naratriptan hcl tabs 2.5mg
Generic
QL (9 EA per 30 days) MO
rizatriptan benzoate odt tbdp 10mg
Generic
QL (12 EA per 30 days) MO
rizatriptan benzoate odt tbdp 5mg
Generic
QL (12 EA per 30 days) MO
rizatriptan benzoate tabs 10mg
Generic
QL (12 EA per 30 days) MO
rizatriptan benzoate tabs 5mg
Generic
QL (12 EA per 30 days) MO
sumatriptan succinate refill inj 4mg/0.5ml
Generic
QL (4 ML per 30 days) MO
sumatriptan succinate refill inj 6mg/0.5ml
Generic
QL (4 ML per 30 days)
sumatriptan succinate inj 4mg/0.5ml
Generic
QL (4 ML per 30 days) MO
sumatriptan succinate inj 6mg/0.5ml
Generic
QL (4 ML per 30 days)
sumatriptan succinate inj 6mg/0.5ml
Generic
QL (4 ML per 30 days) MO
sumatriptan succinate inj 6mg/0.5ml
Generic
QL (4 ML per 30 days) MO
sumatriptan succinate tabs 100mg
Generic
QL (9 EA per 30 days) MO
sumatriptan succinate tabs 25mg
Generic
QL (9 EA per 30 days) MO
sumatriptan succinate tabs 50mg
Generic
QL (9 EA per 30 days) MO
sumatriptan soln 20mg/act
Generic
QL (6 EA per 30 days) MO
sumatriptan soln 5mg/act
Generic
QL (6 EA per 30 days) MO
ANTIMYASTHENIC AGENTS- DRUGS USED TO TREAT MYASTHENIA GRAVIS
Parasympathomimetics
guanidine hcl tabs 125mg
Generic
MESTINON TIMESPAN TBCR 180MG
OTHER
MO
MESTINON SYRP 60MG/5ML
OTHER
MO
pyridostigmine bromide tabs 60mg
Generic
MO
pyridostigmine bromide tbcr 180mg
Generic
MO
ANTIMYCOBACTERIALS- DRUGS USED TO TREAT TUBERCULOSIS
Antimycobacterials, Other
dapsone tabs 100mg
Generic
MO
dapsone tabs 25mg
Generic
MO
rifabutin caps 150mg
Generic
MO
Antituberculars
CAPASTAT SULFATE INJ 1GM
OTHER
cycloserine caps 250mg
Generic
MO
ethambutol hcl tabs 100mg
Generic
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
30
Drug Name
ethambutol hcl tabs 400mg
isoniazid inj 100mg/ml
isoniazid syrp 50mg/5ml
isoniazid tabs 100mg
isoniazid tabs 300mg
PASER PACK 4GM
PRIFTIN TABS 150MG
pyrazinamide tabs 500mg
rifampin caps 150mg
rifampin caps 300mg
rifampin inj 600mg
RIFATER TABS 50MG; 300MG; 120MG
SIRTURO TABS 100MG
TRECATOR TABS 250MG
ANTINEOPLASTICS- DRUGS USED TO TREAT CANCER
Alkylating Agents
ALKERAN TABS 2MG
BUSULFEX INJ 6MG/ML
cyclophosphamide caps 25mg
cyclophosphamide caps 50mg
cyclophosphamide inj 1gm
cyclophosphamide inj 2gm
cyclophosphamide inj 500mg
HEXALEN CAPS 50MG
LEUKERAN TABS 2MG
lomustine caps 100mg
lomustine caps 10mg
lomustine caps 40mg
MATULANE CAPS 50MG
melphalan hydrochloride inj 50mg
MUSTARGEN INJ 10MG
TEMODAR INJ 100MG
thiotepa inj 15mg
TREANDA INJ 100MG
TREANDA INJ 180MG/2ML
TREANDA INJ 25MG
TREANDA INJ 45MG/0.5ML
Drug Tier
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
OTHER
Generic
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (188 EA per 365 days) PA
MO
B/D MO
B/D MO
B/D MO
MO
MO
B/D
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
31
Drug Name
VALCHLOR GEL 0.016%
YONDELIS INJ 1MG
Antiandrogens
bicalutamide tabs 50mg
flutamide caps 125mg
NILANDRON TABS 150MG
XTANDI CAPS 40MG
ZYTIGA TABS 250MG
Antiangiogenic Agents
POMALYST CAPS 1MG
POMALYST CAPS 2MG
POMALYST CAPS 3MG
POMALYST CAPS 4MG
REVLIMID CAPS 10MG
REVLIMID CAPS 15MG
REVLIMID CAPS 2.5MG
REVLIMID CAPS 20MG
REVLIMID CAPS 25MG
REVLIMID CAPS 5MG
THALOMID CAPS 100MG
THALOMID CAPS 150MG
THALOMID CAPS 200MG
THALOMID CAPS 50MG
Antiestrogens/Modifiers
EMCYT CAPS 140MG
FARESTON TABS 60MG
SOLTAMOX SOLN 10MG/5ML
tamoxifen citrate tabs 10mg
tamoxifen citrate tabs 20mg
Antimetabolites
DEPOCYT INJ 50MG/5ML
DROXIA CAPS 200MG
DROXIA CAPS 300MG
DROXIA CAPS 400MG
hydroxyurea caps 500mg
LONSURF TABS 6.14MG; 15MG
LONSURF TABS 8.19MG; 20MG
OTHER
OTHER
Requirements/
Limits
PA
PA
Generic
Generic
OTHER
OTHER
OTHER
MO
MO
MO
QL (120 EA per 30 days) PA LA
QL (120 EA per 30 days) PA
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
QL (21 EA per 28 days) PA LA
QL (21 EA per 28 days) PA LA
QL (21 EA per 28 days) PA LA
QL (21 EA per 28 days) PA LA
QL (30 EA per 30 days) PA LA
QL (30 EA per 30 days) PA LA
QL (30 EA per 30 days) PA LA
QL (30 EA per 30 days) PA LA
QL (30 EA per 30 days) PA LA
QL (30 EA per 30 days) PA LA
QL (28 EA per 28 days) PA
QL (28 EA per 28 days) PA
QL (56 EA per 28 days) PA
QL (28 EA per 28 days) PA
OTHER
OTHER
OTHER
Generic
Generic
MO
MO
PA MO
MO
MO
Drug Tier
OTHER
OTHER
OTHER
OTHER
Generic
OTHER
OTHER
MO
MO
MO
QL (100 EA per 28 days) PA
QL (80 EA per 28 days) PA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
32
Drug Name
mercaptopurine tabs 50mg
PURIXAN SUSP 2000MG/100ML
TABLOID TABS 40MG
Antineoplastics, Other
ABRAXANE INJ 900MG; 100MG
adrucil inj 2.5gm/50ml
adrucil inj 500mg/10ml
adrucil inj 5gm/100ml
ALIMTA INJ 100MG
ALIMTA INJ 500MG
amifostine inj 500mg
ARRANON INJ 5MG/ML
AVASTIN INJ 100MG/4ML
AVASTIN INJ 400MG/16ML
azacitidine inj 100mg
BELEODAQ INJ 500MG
BICNU INJ 100MG
bleomycin sulfate inj 15unit
bleomycin sulfate inj 30unit
carboplatin inj 150mg/15ml
carboplatin inj 450mg/45ml
carboplatin inj 50mg/5ml
carboplatin inj 600mg/60ml
cisplatin inj 100mg/100ml
cisplatin inj 200mg/200ml
cisplatin inj 50mg/50ml
cladribine inj 1mg/ml
CLOLAR INJ 1MG/ML
COSMEGEN INJ 0.5MG
cytarabine aqueous inj 100mg/ml
cytarabine aqueous inj 20mg/ml
cytarabine aqueous inj 20mg/ml
dacarbazine inj 100mg
dacarbazine inj 200mg
daunorubicin hcl inj 5mg/ml
DAUNOXOME INJ 2MG/ML
decitabine inj 50mg
Drug Tier
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Requirements/
Limits
MO
PA
MO
B/D
B/D
B/D
PA
PA
PA
PA
PA
PA LA
B/D
B/D
B/D
B/D
B/D
B/D
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
33
Drug Name
dexrazoxane inj 250mg
dexrazoxane inj 500mg
DOCEFREZ INJ 20MG
DOCEFREZ INJ 80MG
docetaxel inj 140mg/7ml
docetaxel inj 160mg/16ml
docetaxel inj 200mg/20ml
docetaxel inj 20mg/2ml
docetaxel inj 20mg/ml
docetaxel inj 80mg/4ml
docetaxel inj 80mg/8ml
doxorubicin hcl liposome inj 2mg/ml
doxorubicin hcl inj 10mg
doxorubicin hcl inj 2mg/ml
doxorubicin hcl inj 50mg
ELITEK INJ 1.5MG
ELITEK INJ 7.5MG
epirubicin hcl inj 200mg/100ml
epirubicin hcl inj 50mg/25ml
ERBITUX INJ 100MG/50ML
ERBITUX INJ 200MG/100ML
ERWINAZE INJ 10000UNIT
FARYDAK CAPS 10MG
FARYDAK CAPS 15MG
FARYDAK CAPS 20MG
FASLODEX INJ 250MG/5ML
floxuridine inj 0.5gm
fludarabine phosphate inj 50mg/2ml
fludarabine phosphate inj 50mg
fluorouracil inj 1gm/20ml
fluorouracil inj 2.5gm/50ml
fluorouracil inj 5gm/100ml
FOLOTYN INJ 20MG/ML
FOLOTYN INJ 40MG/2ML
FUSILEV INJ 50MG
gemcitabine hcl inj 1gm
gemcitabine hcl inj 200mg
Drug Tier
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Requirements/
Limits
B/D
B/D
B/D
PA
PA
PA
PA
PA
QL (6 EA per 21 days) PA LA
QL (6 EA per 21 days) PA LA
QL (6 EA per 21 days) PA LA
PA
B/D
B/D
B/D
B/D
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
34
Drug Name
gemcitabine hcl inj 2gm
gemcitabine inj 1gm/26.3ml
gemcitabine inj 200mg/5.26ml
gemcitabine inj 2gm/52.6ml
HALAVEN INJ 1MG/2ML
HERCEPTIN INJ 440MG
IBRANCE CAPS 100MG
IBRANCE CAPS 125MG
IBRANCE CAPS 75MG
idarubicin hcl inj 10mg/10ml
idarubicin hcl inj 20mg/20ml
idarubicin hcl inj 5mg/5ml
ifosfamide inj 1gm/20ml
ifosfamide inj 1gm
ifosfamide inj 3gm/60ml
ifosfamide inj 3gm
INTRON A W/DILUENT INJ 10MU
INTRON A W/DILUENT INJ 18MU
INTRON A W/DILUENT INJ 50MU
INTRON A INJ 10MU/ML
INTRON A INJ 6000000UNIT/ML
irinotecan inj 100mg/5ml
irinotecan inj 40mg/2ml
irinotecan inj 500mg/25ml
ISTODAX INJ 10MG
IXEMPRA KIT INJ 15MG
IXEMPRA KIT INJ 45MG
JEVTANA INJ 60MG/1.5ML
KADCYLA INJ 100MG
KADCYLA INJ 160MG
leucovorin calcium inj 100mg
leucovorin calcium inj 200mg
leucovorin calcium inj 350mg
leucovorin calcium inj 500mg
leucovorin calcium inj 50mg
leucovorin calcium tabs 10mg
leucovorin calcium tabs 15mg
Drug Tier
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
PA
PA
QL (21 EA per 28 days) PA LA
QL (21 EA per 28 days) PA LA
QL (21 EA per 28 days) PA LA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
35
Drug Name
leucovorin calcium tabs 25mg
leucovorin calcium tabs 5mg
levoleucovorin calcium inj 175mg/17.5ml
levoleucovorin inj 250mg/25ml
LYNPARZA CAPS 50MG
mesna inj 100mg/ml
MESNEX TABS 400MG
mitomycin inj 20mg
mitomycin inj 40mg
mitomycin inj 5mg
mitoxantrone hcl inj 2mg/ml
mitoxantrone hcl inj 2mg/ml
mitoxantrone hcl inj 2mg/ml
NIPENT INJ 10MG
ODOMZO CAPS 200MG
ONCASPAR INJ 750UNIT/ML
oxaliplatin inj 100mg/20ml
oxaliplatin inj 100mg
oxaliplatin inj 50mg/10ml
oxaliplatin inj 50mg
paclitaxel inj 100mg/16.7ml
paclitaxel inj 150mg/25ml
paclitaxel inj 300mg/50ml
paclitaxel inj 30mg/5ml
PERJETA INJ 420MG/14ML
PROLEUKIN INJ 22000000UNIT
SYLATRON INJ 200MCG
SYLATRON INJ 200MCG
SYLATRON INJ 300MCG
SYLATRON INJ 300MCG
SYLATRON INJ 600MCG
SYNRIBO INJ 3.5MG
THERACYS INJ 81MG/VIAL
TICE BCG INJ 50MG
TRISENOX INJ 10MG/10ML
UVADEX INJ 20MCG/ML
VALSTAR INJ 40MG/ML
Drug Tier
Generic
Generic
Generic
Generic
OTHER
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
MO
MO
QL (448 EA per 28 days) PA
MO
QL (30 EA per 30 days) PA
PA LA
PA LA
PA
PA LA
PA
PA
PA
PA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
36
Drug Name
VECTIBIX INJ 100MG/5ML
VECTIBIX INJ 400MG/20ML
VELCADE INJ 3.5MG
vinblastine sulfate inj 1mg/ml
vincasar pfs inj 1mg/ml
vincristine sulfate inj 1mg/ml
vinorelbine tartrate inj 10mg/ml
vinorelbine tartrate inj 50mg/5ml
YERVOY INJ 200MG/40ML
YERVOY INJ 50MG/10ML
ZALTRAP INJ 100MG/4ML
ZALTRAP INJ 200MG/8ML
ZANOSAR INJ 1GM
ZOLINZA CAPS 100MG
Aromatase Inhibitors, 3rd Generation
anastrozole tabs 1mg
exemestane tabs 25mg
letrozole tabs 2.5mg
Enzyme Inhibitors
etoposide inj 100mg/5ml
etoposide inj 1gm/50ml
etoposide inj 500mg/25ml
toposar inj 100mg/5ml
toposar inj 1gm/50ml
toposar inj 500mg/25ml
topotecan hcl inj 4mg/4ml
topotecan hcl inj 4mg
ZYDELIG TABS 100MG
ZYDELIG TABS 150MG
Molecular Target Inhibitors
AFINITOR DISPERZ TBSO 2MG
AFINITOR DISPERZ TBSO 3MG
AFINITOR DISPERZ TBSO 5MG
AFINITOR TABS 10MG
AFINITOR TABS 2.5MG
AFINITOR TABS 5MG
AFINITOR TABS 7.5MG
Drug Tier
Requirements/
Limits
PA
PA
PA
B/D
B/D
B/D
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
QL (120 EA per 30 days) PA
Generic
Generic
Generic
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
PA
PA
PA
PA LA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
37
Drug Name
BOSULIF TABS 100MG
BOSULIF TABS 500MG
CAPRELSA TABS 100MG
CAPRELSA TABS 300MG
COMETRIQ KIT 0
COMETRIQ KIT 0
COMETRIQ KIT 20MG
ERIVEDGE CAPS 150MG
GILOTRIF TABS 20MG
GILOTRIF TABS 30MG
GILOTRIF TABS 40MG
GLEEVEC TABS 100MG
GLEEVEC TABS 400MG
ICLUSIG TABS 15MG
ICLUSIG TABS 45MG
IMBRUVICA CAPS 140MG
INLYTA TABS 1MG
INLYTA TABS 5MG
JAKAFI TABS 10MG
JAKAFI TABS 15MG
JAKAFI TABS 20MG
JAKAFI TABS 25MG
JAKAFI TABS 5MG
LENVIMA 10MG DAILY DOSE CPPK 10MG
LENVIMA 14MG DAILY DOSE CPPK 0
LENVIMA 20MG DAILY DOSE CPPK 10MG
LENVIMA 24MG DAILY DOSE CPPK 0
MEKINIST TABS 0.5MG
MEKINIST TABS 2MG
NEXAVAR TABS 200MG
SPRYCEL TABS 100MG
SPRYCEL TABS 140MG
SPRYCEL TABS 20MG
SPRYCEL TABS 50MG
SPRYCEL TABS 70MG
SPRYCEL TABS 80MG
STIVARGA TABS 40MG
Drug Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
PA
PA
QL (60 EA per 30 days) PA
QL (30 EA per 30 days) PA
PA
PA
PA
QL (30 EA per 30 days) PA LA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (90 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (240 EA per 30 days) PA LA
QL (120 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
PA
PA
PA
PA
QL (120 EA per 30 days) PA LA
QL (30 EA per 30 days) PA LA
QL (120 EA per 30 days) PA LA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (60 EA per 30 days) PA
QL (120 EA per 30 days) PA LA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
38
Drug Name
SUTENT CAPS 12.5MG
SUTENT CAPS 25MG
SUTENT CAPS 37.5MG
SUTENT CAPS 50MG
TAFINLAR CAPS 50MG
TAFINLAR CAPS 75MG
TARCEVA TABS 100MG
TARCEVA TABS 150MG
TARCEVA TABS 25MG
TASIGNA CAPS 150MG
TASIGNA CAPS 200MG
TORISEL INJ 25MG/ML
TYKERB TABS 250MG
VOTRIENT TABS 200MG
XALKORI CAPS 200MG
XALKORI CAPS 250MG
ZELBORAF TABS 240MG
ZYKADIA CAPS 150MG
Monoclonal Antibodies
ARZERRA INJ 1000MG/50ML
ARZERRA INJ 100MG/5ML
BLINCYTO INJ 35MCG
CYRAMZA INJ 100MG/10ML
CYRAMZA INJ 500MG/50ML
GAZYVA INJ 1000MG/40ML
KEYTRUDA INJ 100MG/4ML
KEYTRUDA INJ 50MG
OPDIVO INJ 100MG/10ML
OPDIVO INJ 40MG/4ML
RITUXAN INJ 100MG/10ML
RITUXAN INJ 500MG/50ML
SYLVANT INJ 100MG
SYLVANT INJ 400MG
Retinoids
bexarotene caps 75mg
PANRETIN GEL 0.1%
TARGRETIN CAPS 75MG
Drug Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
QL (90 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (180 EA per 30 days) PA LA
QL (120 EA per 30 days) PA LA
QL (90 EA per 30 days) PA LA
QL (90 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
QL (120 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (180 EA per 30 days) PA LA
QL (120 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
QL (240 EA per 30 days) PA LA
QL (150 EA per 30 days) PA LA
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
PA LA
PA LA
PA LA
PA
PA
PA LA
PA LA
PA LA
PA LA
PA LA
PA
PA
PA
PA
Generic
OTHER
OTHER
PA
MO
PA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
39
Drug Name
Drug Tier
TARGRETIN GEL 1%
OTHER
tretinoin caps 10mg
Generic
ANTIPARASITICS-DRUGS USED TO TREAT MALARIA AND LICE
Anthelmintics
ALBENZA TABS 200MG
OTHER
ivermectin tabs 3mg
Generic
STROMECTOL TABS 3MG
OTHER
Antiprotozoals
ALINIA SUSR 100MG/5ML
OTHER
ALINIA TABS 500MG
OTHER
atovaquone/proguanil hcl tabs 250mg; 100mg
Generic
atovaquone/proguanil hcl tabs 62.5mg; 25mg
Generic
atovaquone susp 750mg/5ml
Generic
chloroquine phosphate tabs 250mg
Generic
chloroquine phosphate tabs 500mg
Generic
COARTEM TABS 20MG; 120MG
OTHER
DARAPRIM TABS 25MG
OTHER
hydroxychloroquine sulfate tabs 200mg
Generic
mefloquine hcl tabs 250mg
Generic
MEPRON SUSP 750MG/5ML
OTHER
NEBUPENT SOLR 300MG
OTHER
PENTAM 300 INJ 300MG
OTHER
primaquine phosphate tabs 26.3mg
Generic
quinine sulfate caps 324mg
Generic
Pediculicides/Scabicides
lindane lotn 1%
Generic
lindane sham 1%
Generic
malathion lotn 0.5%
Generic
permethrin crea 5%
Generic
ANTIPARKINSON AGENTS- DRUGS USED TO TREAT PARKINSONS DISEASE
Anticholinergics
benztropine mesylate inj 1mg/ml
Generic
benztropine mesylate tabs 0.5mg
Generic
benztropine mesylate tabs 1mg
Generic
benztropine mesylate tabs 2mg
Generic
trihexyphenidyl hcl elix 0.4mg/ml
Generic
trihexyphenidyl hcl tabs 2mg
Generic
Requirements/
Limits
PA
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
MO
MO
MO
MO
MO
MO
PA MO
B/D MO
MO
MO
PA MO
MO
MO
MO
MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
40
Drug Name
trihexyphenidyl hcl tabs 5mg
Antiparkinson Agents, Other
amantadine hcl caps 100mg
amantadine hcl syrp 50mg/5ml
amantadine hcl tabs 100mg
entacapone tabs 200mg
Dopamine Agonists
APOKYN INJ 10MG/ML
bromocriptine mesylate caps 5mg
bromocriptine mesylate tabs 2.5mg
NEUPRO PT24 1MG/24HR
NEUPRO PT24 2MG/24HR
NEUPRO PT24 3MG/24HR
NEUPRO PT24 4MG/24HR
NEUPRO PT24 6MG/24HR
NEUPRO PT24 8MG/24HR
pramipexole dihydrochloride tabs 0.125mg
pramipexole dihydrochloride tabs 0.25mg
pramipexole dihydrochloride tabs 0.5mg
pramipexole dihydrochloride tabs 0.75mg
pramipexole dihydrochloride tabs 1.5mg
pramipexole dihydrochloride tabs 1mg
ropinirole hcl tabs 0.25mg
ropinirole hcl tabs 0.5mg
ropinirole hcl tabs 1mg
ropinirole hcl tabs 2mg
ropinirole hcl tabs 3mg
ropinirole hcl tabs 4mg
ropinirole hcl tabs 5mg
Dopamine Precursors/L- Amino Acid Decarboxy‑
lase Inhibitors
carbidopa/levodopa er tbcr 25mg; 100mg
carbidopa/levodopa er tbcr 50mg; 200mg
carbidopa/levodopa odt tbdp 10mg; 100mg
carbidopa/levodopa odt tbdp 25mg; 100mg
carbidopa/levodopa odt tbdp 25mg; 250mg
carbidopa/levodopa/entacapone tabs 12.5mg;
200mg; 50mg
Generic
Requirements/
Limits
PA MO
Generic
Generic
Generic
Generic
MO
MO
MO
MO
OTHER
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA LA
MO
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
Drug Tier
Generic
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
41
Drug Name
Drug Tier
Requirements/
Limits
MO
carbidopa/levodopa/entacapone tabs 18.75mg;
Generic
200mg; 75mg
carbidopa/levodopa/entacapone tabs 25mg;
MO
Generic
200mg; 100mg
carbidopa/levodopa/entacapone tabs 31.25mg;
MO
Generic
200mg; 125mg
carbidopa/levodopa/entacapone tabs 37.5mg;
MO
Generic
200mg; 150mg
carbidopa/levodopa/entacapone tabs 50mg;
MO
Generic
200mg; 200mg
carbidopa/levodopa tabs 10mg; 100mg
Generic
MO
carbidopa/levodopa tabs 25mg; 100mg
Generic
MO
carbidopa/levodopa tabs 25mg; 250mg
Generic
MO
carbidopa tabs 25mg
Generic
MO
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT TABS 0.5MG
OTHER
QL (30 EA per 30 days) MO
AZILECT TABS 1MG
OTHER
QL (30 EA per 30 days) MO
selegiline hcl caps 5mg
Generic
MO
selegiline hcl tabs 5mg
Generic
MO
ANTIPSYCHOTICS- DRUGS USED TO TREAT PSYCHOSES AND SCHIZOPHRENIA
1st Generation/Typical
ADASUVE AEPB 10MG
OTHER
chlorpromazine hcl inj 25mg/ml
Generic
MO
chlorpromazine hcl inj 50mg/2ml
Generic
MO
chlorpromazine hcl tabs 100mg
Generic
MO
chlorpromazine hcl tabs 10mg
Generic
MO
chlorpromazine hcl tabs 200mg
Generic
MO
chlorpromazine hcl tabs 25mg
Generic
MO
chlorpromazine hcl tabs 50mg
Generic
MO
compazine supp 25mg
Generic
compro supp 25mg
Generic
MO
fluphenazine decanoate inj 25mg/ml
Generic
MO
fluphenazine hcl conc 5mg/ml
Generic
MO
fluphenazine hcl elix 2.5mg/5ml
Generic
MO
fluphenazine hcl inj 2.5mg/ml
Generic
MO
fluphenazine hcl tabs 10mg
Generic
MO
fluphenazine hcl tabs 1mg
Generic
MO
fluphenazine hcl tabs 2.5mg
Generic
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
42
Drug Name
fluphenazine hcl tabs 5mg
haloperidol decanoate inj 100mg/ml
haloperidol decanoate inj 50mg/ml
haloperidol lactate inj 5mg/ml
haloperidol conc 2mg/ml
haloperidol tabs 0.5mg
haloperidol tabs 10mg
haloperidol tabs 1mg
haloperidol tabs 20mg
haloperidol tabs 2mg
haloperidol tabs 5mg
loxapine succinate caps 10mg
loxapine succinate caps 25mg
loxapine succinate caps 50mg
loxapine succinate caps 5mg
ORAP TABS 1MG
ORAP TABS 2MG
perphenazine tabs 16mg
perphenazine tabs 2mg
perphenazine tabs 4mg
perphenazine tabs 8mg
pimozide tabs 1mg
pimozide tabs 2mg
prochlorperazine edisylate inj 5mg/ml
prochlorperazine maleate tabs 10mg
prochlorperazine maleate tabs 5mg
prochlorperazine supp 25mg
thioridazine hcl tabs 100mg
thioridazine hcl tabs 10mg
thioridazine hcl tabs 25mg
thioridazine hcl tabs 50mg
thiothixene caps 10mg
thiothixene caps 1mg
thiothixene caps 2mg
thiothixene caps 5mg
trifluoperazine hcl tabs 10mg
trifluoperazine hcl tabs 1mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
43
Drug Name
trifluoperazine hcl tabs 2mg
trifluoperazine hcl tabs 5mg
2nd Generation/Atypical
ABILIFY DISCMELT TBDP 10MG
ABILIFY DISCMELT TBDP 15MG
ABILIFY MAINTENA INJ 300MG
ABILIFY MAINTENA INJ 300MG
ABILIFY MAINTENA INJ 400MG
ABILIFY INJ 9.75MG/1.3ML
ABILIFY SOLN 1MG/ML
aripiprazole soln 1mg/ml
aripiprazole tabs 10mg
aripiprazole tabs 15mg
aripiprazole tabs 20mg
aripiprazole tabs 2mg
aripiprazole tabs 30mg
aripiprazole tabs 5mg
ARISTADA INJ 441MG/1.6ML
ARISTADA INJ 662MG/2.4ML
ARISTADA INJ 882MG/3.2ML
FANAPT TITRATION PACK TABS 0
FANAPT TABS 10MG
FANAPT TABS 12MG
FANAPT TABS 1MG
FANAPT TABS 2MG
FANAPT TABS 4MG
FANAPT TABS 6MG
FANAPT TABS 8MG
GEODON INJ 20MG
INVEGA SUSTENNA INJ 117MG/0.75ML
INVEGA SUSTENNA INJ 156MG/ML
INVEGA SUSTENNA INJ 234MG/1.5ML
INVEGA SUSTENNA INJ 39MG/0.25ML
INVEGA SUSTENNA INJ 78MG/0.5ML
INVEGA TRINZA INJ 273MG/0.875ML
INVEGA TRINZA INJ 410MG/1.315ML
INVEGA TRINZA INJ 546MG/1.75ML
Generic
Generic
Requirements/
Limits
MO
MO
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
QL (60 EA per 30 days) MO
QL (60 EA per 30 days)
MO
MO
MO
MO
QL (900 ML per 30 days) MO
QL (900 ML per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
PA
PA
PA
QL (16 EA per 365 days) ST
QL (60 EA per 30 days) ST MO
QL (60 EA per 30 days) ST MO
QL (60 EA per 30 days) ST MO
QL (60 EA per 30 days) ST MO
QL (60 EA per 30 days) ST MO
QL (60 EA per 30 days) ST MO
QL (60 EA per 30 days) ST MO
MO
QL (0.75 ML per 28 days) MO
QL (1 ML per 28 days) MO
QL (1.5 ML per 28 days) MO
QL (0.25 ML per 28 days) MO
QL (0.5 ML per 28 days) MO
QL (0.88 ML per 84 days)
QL (1.32 ML per 84 days)
QL (1.75 ML per 84 days)
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
44
Drug Name
INVEGA TRINZA INJ 819MG/2.625ML
INVEGA TB24 1.5MG
INVEGA TB24 3MG
INVEGA TB24 6MG
INVEGA TB24 9MG
LATUDA TABS 120MG
LATUDA TABS 20MG
LATUDA TABS 40MG
LATUDA TABS 60MG
LATUDA TABS 80MG
olanzapine odt tbdp 10mg
olanzapine odt tbdp 15mg
olanzapine odt tbdp 20mg
olanzapine odt tbdp 5mg
olanzapine inj 10mg
olanzapine tabs 10mg
olanzapine tabs 15mg
olanzapine tabs 2.5mg
olanzapine tabs 20mg
olanzapine tabs 5mg
olanzapine tabs 7.5mg
paliperidone er tb24 1.5mg
paliperidone er tb24 3mg
paliperidone er tb24 6mg
paliperidone er tb24 9mg
quetiapine fumarate tabs 100mg
quetiapine fumarate tabs 200mg
quetiapine fumarate tabs 25mg
quetiapine fumarate tabs 300mg
quetiapine fumarate tabs 400mg
quetiapine fumarate tabs 50mg
REXULTI TABS 0.25MG
REXULTI TABS 0.5MG
REXULTI TABS 1MG
REXULTI TABS 2MG
REXULTI TABS 3MG
REXULTI TABS 4MG
Drug Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
QL (2.63 ML per 84 days)
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (60 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
QL (30 EA per 30 days) ST MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
45
Drug Name
RISPERDAL CONSTA INJ 12.5MG
RISPERDAL CONSTA INJ 25MG
RISPERDAL CONSTA INJ 37.5MG
RISPERDAL CONSTA INJ 50MG
risperidone odt tbdp 0.25mg
risperidone odt tbdp 0.5mg
risperidone odt tbdp 1mg
risperidone odt tbdp 2mg
risperidone odt tbdp 3mg
risperidone odt tbdp 4mg
risperidone soln 1mg/ml
risperidone tabs 0.25mg
risperidone tabs 0.5mg
risperidone tabs 1mg
risperidone tabs 2mg
risperidone tabs 3mg
risperidone tabs 4mg
SAPHRIS SUBL 10MG
SAPHRIS SUBL 2.5MG
SAPHRIS SUBL 5MG
ziprasidone hcl caps 20mg
ziprasidone hcl caps 40mg
ziprasidone hcl caps 60mg
ziprasidone hcl caps 80mg
ZYPREXA RELPREVV INJ 210MG
ZYPREXA RELPREVV INJ 300MG
ZYPREXA RELPREVV INJ 405MG
Treatment-Resistant
clozapine odt tbdp 100mg
clozapine odt tbdp 12.5mg
clozapine odt tbdp 150mg
clozapine odt tbdp 200mg
clozapine odt tbdp 25mg
clozapine tabs 100mg
clozapine tabs 200mg
clozapine tabs 25mg
clozapine tabs 50mg
Drug Tier
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Requirements/
Limits
MO
MO
MO
MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (120 EA per 30 days) MO
MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (2 EA per 28 days)
QL (2 EA per 28 days)
QL (1 EA per 28 days)
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
46
Drug Name
Drug Tier
Requirements/
Limits
ST
ST
ST
ST
ST
ST
FAZACLO TBDP 100MG
OTHER
FAZACLO TBDP 12.5MG
OTHER
FAZACLO TBDP 150MG
OTHER
FAZACLO TBDP 200MG
OTHER
FAZACLO TBDP 25MG
OTHER
VERSACLOZ SUSP 50MG/ML
OTHER
ANTISPASTICITY AGENTS - DRUGS USED TO TREAT MUSCLE SPASMS
Antispasticity Agents
baclofen tabs 10mg
Generic
MO
baclofen tabs 20mg
Generic
MO
dantrolene sodium caps 100mg
Generic
MO
dantrolene sodium caps 25mg
Generic
MO
dantrolene sodium caps 50mg
Generic
MO
tizanidine hcl tabs 2mg
Generic
MO
tizanidine hcl tabs 4mg
Generic
MO
ANTIVIRALS- DRUGS USED TO TREAT VIRAL INFECTIONS, HEPATITIS AND HIV/AIDS INFECTIONS
Anti-cytomegalovirus (CMV) Agents
foscarnet sodium inj 24mg/ml
Generic
B/D
ganciclovir inj 500mg
Generic
B/D
VALCYTE SOLR 50MG/ML
OTHER
MO
VALCYTE TABS 450MG
OTHER
MO
valganciclovir tabs 450mg
Generic
MO
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil tabs 10mg
Generic
QL (30 EA per 30 days) MO
BARACLUDE SOLN 0.05MG/ML
OTHER
QL (630 ML per 30 days) MO
BARACLUDE TABS 0.5MG
OTHER
QL (30 EA per 30 days) MO
BARACLUDE TABS 1MG
OTHER
QL (30 EA per 30 days) MO
entecavir tabs 0.5mg
Generic
QL (30 EA per 30 days) MO
entecavir tabs 1mg
Generic
QL (30 EA per 30 days) MO
EPIVIR HBV SOLN 5MG/ML
OTHER
MO
INTRON A INJ 18MU
OTHER
PA LA
INTRON A INJ 50MU
OTHER
PA LA
lamivudine tabs 100mg
Generic
MO
TYZEKA TABS 600MG
OTHER
QL (30 EA per 30 days) MO
Anti-hepatitis C (HCV) Agents
HARVONI TABS 90MG; 400MG
OTHER
QL (30 EA per 30 days) PA
moderiba tabs 200mg
Generic
PA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
47
Drug Name
PEG-INTRON REDIPEN INJ 120MCG/0.5ML
PEG-INTRON REDIPEN INJ 150MCG/0.5ML
PEG-INTRON REDIPEN INJ 50MCG/0.5ML
PEG-INTRON REDIPEN INJ 80MCG/0.5ML
PEG-INTRON INJ 50MCG/0.5ML
PEGINTRON INJ 120MCG/0.5ML
PEGINTRON INJ 150MCG/0.5ML
PEGINTRON INJ 80MCG/0.5ML
ribavirin caps 200mg
ribavirin tabs 200mg
SOVALDI TABS 400MG
Anti-HIV Agents, Integrase Inhibitors (INSTI)
ATRIPLA TABS 600MG; 200MG; 300MG
ISENTRESS CHEW 100MG
ISENTRESS CHEW 25MG
ISENTRESS PACK 100MG
ISENTRESS TABS 400MG
TIVICAY TABS 50MG
VITEKTA TABS 150MG
VITEKTA TABS 85MG
Anti-HIV Agents, Non-nucleoside Reverse Tran‑
scriptase Inhibitors (NNRTI)
COMPLERA TABS 200MG; 25MG; 300MG
EDURANT TABS 25MG
INTELENCE TABS 100MG
INTELENCE TABS 200MG
INTELENCE TABS 25MG
nevirapine er tb24 100mg
nevirapine er tb24 400mg
nevirapine susp 50mg/5ml
nevirapine tabs 200mg
RESCRIPTOR TABS 100MG
RESCRIPTOR TABS 200MG
STRIBILD TABS 150MG; 150MG; 200MG;
300MG
SUSTIVA CAPS 200MG
SUSTIVA CAPS 50MG
SUSTIVA TABS 600MG
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
OTHER
Requirements/
Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL (28 EA per 28 days) PA
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
QL (30 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (300 EA per 30 days)
QL (120 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days)
QL (30 EA per 30 days)
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (180 EA per 30 days)
Drug Tier
OTHER
OTHER
OTHER
OTHER
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
48
Drug Name
VIRAMUNE XR TB24 100MG
VIRAMUNE SUSP 50MG/5ML
Anti-HIV Agents, Nucleoside and Nucleotide Re‑
verse Transcriptase Inhibitors (NRTI)
abacavir sulfate/lamivudine/zidovudine tabs
300mg; 150mg; 300mg
abacavir tabs 300mg
didanosine cpdr 125mg
didanosine cpdr 200mg
didanosine cpdr 250mg
didanosine cpdr 400mg
EMTRIVA CAPS 200MG
EMTRIVA SOLN 10MG/ML
EPIVIR SOLN 10MG/ML
EPZICOM TABS 600MG; 300MG
lamivudine/zidovudine tabs 150mg; 300mg
lamivudine soln 10mg/ml
lamivudine tabs 150mg
lamivudine tabs 300mg
RETROVIR IV INFUSION INJ 10MG/ML
stavudine caps 15mg
stavudine caps 20mg
stavudine caps 30mg
stavudine caps 40mg
stavudine solr 1mg/ml
TRIUMEQ TABS 600MG; 50MG; 300MG
TRUVADA TABS 200MG; 300MG
VIDEX PEDIATRIC SOLR 2GM
VIDEX PEDIATRIC SOLR 4GM
VIREAD POWD 40MG/GM
VIREAD TABS 150MG
VIREAD TABS 200MG
VIREAD TABS 250MG
VIREAD TABS 300MG
ZIAGEN SOLN 20MG/ML
zidovudine caps 100mg
zidovudine syrp 50mg/5ml
zidovudine tabs 300mg
Drug Tier
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
49
Drug Name
Anti-HIV Agents, Other
FUZEON INJ 90MG
SELZENTRY TABS 150MG
SELZENTRY TABS 300MG
TYBOST TABS 150MG
Anti-HIV Agents, Protease Inhibitors
APTIVUS CAPS 250MG
APTIVUS SOLN 100MG/ML
CRIXIVAN CAPS 200MG
CRIXIVAN CAPS 400MG
EVOTAZ TABS 300MG; 150MG
INVIRASE CAPS 200MG
INVIRASE TABS 500MG
KALETRA SOLN 400MG/5ML; 100MG/5ML
KALETRA TABS 100MG; 25MG
KALETRA TABS 200MG; 50MG
LEXIVA SUSP 50MG/ML
LEXIVA TABS 700MG
NORVIR CAPS 100MG
NORVIR SOLN 80MG/ML
NORVIR TABS 100MG
PREZCOBIX TABS 150MG; 800MG
PREZISTA SUSP 100MG/ML
PREZISTA TABS 150MG
PREZISTA TABS 600MG
PREZISTA TABS 75MG
PREZISTA TABS 800MG
REYATAZ CAPS 150MG
REYATAZ CAPS 200MG
REYATAZ CAPS 300MG
REYATAZ PACK 50MG
VIRACEPT TABS 250MG
VIRACEPT TABS 625MG
Anti-influenza Agents
RELENZA DISKHALER AEPB 5MG/BLISTER
rimantadine hcl tabs 100mg
TAMIFLU CAPS 30MG
Drug Tier
Requirements/
Limits
OTHER
OTHER
OTHER
OTHER
QL (60 EA per 30 days)
QL (60 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (30 EA per 30 days) MO
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
MO
OTHER
Generic
OTHER
MO
MO
QL (30 EA per 30 days) MO
MO
MO
QL (390 ML per 30 days) MO
QL (240 EA per 30 days) MO
QL (120 EA per 30 days) MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (120 EA per 365 days) MO
MO
QL (168 EA per 365 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
50
Drug Name
TAMIFLU CAPS 45MG
TAMIFLU CAPS 75MG
TAMIFLU SUSR 6MG/ML
Antiherpetic Agents
acyclovir sodium inj 1000mg
acyclovir sodium inj 500mg
acyclovir sodium inj 50mg/ml
acyclovir caps 200mg
acyclovir oint 5%
acyclovir susp 200mg/5ml
acyclovir tabs 400mg
acyclovir tabs 800mg
DENAVIR CREA 1%
famciclovir tabs 125mg
famciclovir tabs 250mg
famciclovir tabs 500mg
valacyclovir hcl tabs 1000mg
valacyclovir hcl tabs 500mg
Antivirals
VIRAZOLE SOLR 6GM
ANXIOLYTICS- DRUGS USED TO TREAT ANXIETY
Anxiolytics, Other
buspirone hcl tabs 10mg
buspirone hcl tabs 15mg
buspirone hcl tabs 30mg
buspirone hcl tabs 5mg
buspirone hcl tabs 7.5mg
Benzodiazepines
alprazolam tabs 0.25mg
alprazolam tabs 0.5mg
alprazolam tabs 1mg
alprazolam tabs 2mg
clorazepate dipotassium tabs 15mg
clorazepate dipotassium tabs 3.75mg
clorazepate dipotassium tabs 7.5mg
diazepam intensol conc 5mg/ml
diazepam inj 5mg/ml
OTHER
OTHER
OTHER
Requirements/
Limits
QL (84 EA per 365 days) MO
QL (84 EA per 365 days) MO
QL (1080 ML per 365 days) MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
B/D
B/D MO
B/D
MO
MO
MO
MO
MO
MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (90 EA per 30 days) MO
MO
MO
Drug Tier
OTHER
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL (120 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (150 EA per 30 days) MO
QL (150 EA per 30 days) MO
QL (180 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
MO
QL (240 ML per 30 days) PA MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
51
Drug Name
Drug Tier
diazepam soln 1mg/ml
Generic
diazepam tabs 10mg
Generic
diazepam tabs 2mg
Generic
diazepam tabs 5mg
Generic
lorazepam intensol conc 2mg/ml
Generic
lorazepam inj 2mg/ml
Generic
lorazepam inj 4mg/ml
Generic
lorazepam tabs 0.5mg
Generic
lorazepam tabs 1mg
Generic
lorazepam tabs 2mg
Generic
SSRIs/SNRIs (Selective Serotonin Reuptake In‑
hibitors/Serotonin and Norepinephrine Reuptake
Inhibitor
duloxetine hcl cpep 40mg
Generic
BIPOLAR AGENTS- DRUGS USED TO TREAT BIPOLAR DISORDER
Mood Stabilizers
EQUETRO CP12 100MG
OTHER
EQUETRO CP12 200MG
OTHER
EQUETRO CP12 300MG
OTHER
lithium carbonate er tbcr 300mg
Generic
lithium carbonate er tbcr 450mg
Generic
lithium carbonate caps 150mg
Generic
lithium carbonate caps 300mg
Generic
lithium carbonate caps 600mg
Generic
lithium carbonate tabs 300mg
Generic
lithium soln 8meq/5ml
Generic
BLOOD GLUCOSE REGULATORS- DRUGS USED TO TREAT DIABETES
Antidiabetic Agents
acarbose tabs 100mg
Generic
acarbose tabs 25mg
Generic
acarbose tabs 50mg
Generic
glimepiride tabs 1mg
Generic
glimepiride tabs 2mg
Generic
glimepiride tabs 4mg
Generic
glipizide er tb24 10mg
Generic
glipizide er tb24 2.5mg
Generic
glipizide er tb24 5mg
Generic
glipizide xl tb24 10mg
Generic
Requirements/
Limits
QL (1200 ML per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
QL (150 ML per 30 days) MO
QL (120 ML per 30 days) MO
QL (120 ML per 30 days)
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (60 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
52
Drug Name
glipizide xl tb24 2.5mg
glipizide xl tb24 5mg
glipizide/metformin hcl tabs 2.5mg; 250mg
glipizide/metformin hcl tabs 2.5mg; 500mg
glipizide/metformin hcl tabs 5mg; 500mg
glipizide tabs 10mg
glipizide tabs 5mg
glyburide micronized tabs 1.5mg
glyburide micronized tabs 3mg
glyburide micronized tabs 6mg
glyburide/metformin hcl tabs 1.25mg; 250mg
glyburide/metformin hcl tabs 2.5mg; 500mg
glyburide/metformin hcl tabs 5mg; 500mg
glyburide tabs 1.25mg
glyburide tabs 2.5mg
glyburide tabs 5mg
INVOKAMET TABS 150MG; 1000MG
INVOKAMET TABS 150MG; 500MG
INVOKAMET TABS 50MG; 1000MG
INVOKAMET TABS 50MG; 500MG
INVOKANA TABS 100MG
INVOKANA TABS 300MG
JANUMET XR TB24 1000MG; 100MG
JANUMET XR TB24 1000MG; 50MG
JANUMET XR TB24 500MG; 50MG
JANUMET TABS 1000MG; 50MG
JANUMET TABS 500MG; 50MG
JANUVIA TABS 100MG
JANUVIA TABS 25MG
JANUVIA TABS 50MG
JENTADUETO TABS 2.5MG; 1000MG
JENTADUETO TABS 2.5MG; 500MG
JENTADUETO TABS 2.5MG; 850MG
KORLYM TABS 300MG
metformin hcl er tb24 1000mg
metformin hcl er tb24 500mg
metformin hcl er tb24 500mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
QL (120 EA per 30 days) PA
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
53
Drug Name
metformin hcl er tb24 750mg
metformin hcl tabs 1000mg
metformin hcl tabs 500mg
metformin hcl tabs 850mg
nateglinide tabs 120mg
nateglinide tabs 60mg
pioglitazone hcl-glimepiride tabs 2mg; 30mg
pioglitazone hcl-glimepiride tabs 4mg; 30mg
pioglitazone hcl/metformin hcl tabs 500mg;
15mg
pioglitazone hcl/metformin hcl tabs 850mg;
15mg
pioglitazone hcl tabs 15mg
pioglitazone hcl tabs 30mg
pioglitazone hcl tabs 45mg
repaglinide tabs 0.5mg
repaglinide tabs 1mg
repaglinide tabs 2mg
SYMLINPEN 120 INJ 2700MCG/2.7ML
SYMLINPEN 60 INJ 1500MCG/1.5ML
tolazamide tabs 250mg
tolazamide tabs 500mg
tolbutamide tabs 500mg
TRADJENTA TABS 5MG
TRULICITY INJ 0.75MG/0.5ML
TRULICITY INJ 1.5MG/0.5ML
VICTOZA INJ 18MG/3ML
Glycemic Agents
GLUCAGEN DIAGNOSTIC INJ 1MG
GLUCAGEN HYPOKIT INJ 1MG
GLUCAGON EMERGENCY KIT INJ 1MG
PROGLYCEM SUSP 50MG/ML
Insulins
LEVEMIR FLEXTOUCH INJ 100UNIT/ML
LEVEMIR INJ 100UNIT/ML
NOVOLIN 70/30 INJ 30UNIT/ML; 70UNIT/ML
NOVOLIN N INJ 100UNIT/ML
NOVOLIN R INJ 100UNIT/ML
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (90 EA per 30 days) MO
QL (90 EA per 30 days) MO
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (120 EA per 30 days) MO
QL (240 EA per 30 days) MO
QL (10.8 ML per 30 days) MO
QL (6 ML per 30 days) MO
MO
MO
MO
MO
QL (2 ML per 28 days) MO
QL (2 ML per 28 days) MO
QL (9 ML per 30 days) MO
OTHER
OTHER
OTHER
OTHER
QL (4 EA per 30 days) MO
QL (4 EA per 30 days) MO
QL (4 EA per 30 days) MO
MO
OTHER
OTHER
OTHER
OTHER
OTHER
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
54
Drug Name
Drug Tier
Requirements/
Limits
MO
MO
NOVOLOG FLEXPEN INJ 100UNIT/ML
OTHER
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
OTHER
INJ 30UNIT/ML; 70UNIT/ML
NOVOLOG MIX 70/30 INJ 30UNIT/ML;
MO
OTHER
70UNIT/ML
NOVOLOG PENFILL INJ 100UNIT/ML
OTHER
MO
NOVOLOG INJ 100UNIT/ML
OTHER
MO
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS- DRUGS USED TO TREAT BLOOD DISORDERS;
ANTICOAGULANTS/BLOOD THINNERS
Anticoagulants
ELIQUIS TABS 2.5MG
OTHER
QL (60 EA per 30 days) MO
ELIQUIS TABS 5MG
OTHER
QL (60 EA per 30 days) MO
enoxaparin sodium inj 100mg/ml
Generic
MO
enoxaparin sodium inj 120mg/0.8ml
Generic
MO
enoxaparin sodium inj 150mg/ml
Generic
MO
enoxaparin sodium inj 300mg/3ml
Generic
MO
enoxaparin sodium inj 30mg/0.3ml
Generic
MO
enoxaparin sodium inj 40mg/0.4ml
Generic
MO
enoxaparin sodium inj 60mg/0.6ml
Generic
MO
enoxaparin sodium inj 80mg/0.8ml
Generic
MO
fondaparinux sodium inj 10mg/0.8ml
Generic
MO
fondaparinux sodium inj 2.5mg/0.5ml
Generic
MO
fondaparinux sodium inj 5mg/0.4ml
Generic
MO
fondaparinux sodium inj 7.5mg/0.6ml
Generic
MO
heparin sodium/d5w inj 5%; 100unit/ml
Generic
heparin sodium/d5w inj 5%; 40unit/ml
Generic
heparin sodium/d5w inj 5%; 50unit/ml
Generic
heparin sodium/nacl 0.45% inj 100unit/ml;
Generic
0.45%
heparin sodium/nacl 0.45% inj 50unit/ml;
Generic
0.45%
heparin sodium/nacl 0.9% inj 2unit/ml; 0.9%
Generic
heparin sodium/sodium chloride 0.9% premix inj
Generic
2unit/ml; 0.9%
heparin sodium/sodium chloride 0.9% inj 2unit/
Generic
ml; 0.9%
heparin sodium inj 10000unit/ml
Generic
MO
heparin sodium inj 1000unit/ml
Generic
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
55
Drug Name
heparin sodium inj 20000unit/ml
heparin sodium inj 5000unit/0.5ml
heparin sodium inj 5000unit/ml
jantoven tabs 10mg
jantoven tabs 1mg
jantoven tabs 2.5mg
jantoven tabs 2mg
jantoven tabs 3mg
jantoven tabs 4mg
jantoven tabs 5mg
jantoven tabs 6mg
jantoven tabs 7.5mg
PRADAXA CAPS 150MG
PRADAXA CAPS 75MG
SAVAYSA TABS 15MG
SAVAYSA TABS 30MG
SAVAYSA TABS 60MG
warfarin sodium tabs 10mg
warfarin sodium tabs 1mg
warfarin sodium tabs 2.5mg
warfarin sodium tabs 2mg
warfarin sodium tabs 3mg
warfarin sodium tabs 4mg
warfarin sodium tabs 5mg
warfarin sodium tabs 6mg
warfarin sodium tabs 7.5mg
XARELTO STARTER PACK TBPK 0
XARELTO TABS 10MG
XARELTO TABS 15MG
XARELTO TABS 20MG
Blood Formation Modifiers
anagrelide hydrochloride caps 0.5mg
anagrelide hydrochloride caps 1mg
ARANESP ALBUMIN FREE INJ 100MC‑
G/0.5ML
ARANESP ALBUMIN FREE INJ 100MCG/ML
ARANESP ALBUMIN FREE INJ 10MCG/0.4ML
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
Generic
Generic
OTHER
OTHER
OTHER
Requirements/
Limits
MO
MO
MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (51 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
QL (2 ML per 28 days) PA
QL (4 ML per 28 days) PA
QL (3.2 ML per 28 days) PA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
56
Drug Name
ARANESP ALBUMIN FREE INJ 150MC‑
G/0.3ML
ARANESP ALBUMIN FREE INJ 150MC‑
G/0.75ML
ARANESP ALBUMIN FREE INJ 200MC‑
G/0.4ML
ARANESP ALBUMIN FREE INJ 200MCG/ML
ARANESP ALBUMIN FREE INJ 25MC‑
G/0.42ML
ARANESP ALBUMIN FREE INJ 25MCG/ML
ARANESP ALBUMIN FREE INJ 300MC‑
G/0.6ML
ARANESP ALBUMIN FREE INJ 300MCG/ML
ARANESP ALBUMIN FREE INJ 40MCG/0.4ML
ARANESP ALBUMIN FREE INJ 40MCG/ML
ARANESP ALBUMIN FREE INJ 500MCG/ML
ARANESP ALBUMIN FREE INJ 60MCG/0.3ML
ARANESP ALBUMIN FREE INJ 60MCG/ML
LEUKINE INJ 250MCG
NEUMEGA INJ 5MG
NEUPOGEN INJ 300MCG/0.5ML
NEUPOGEN INJ 300MCG/ML
NEUPOGEN INJ 480MCG/0.8ML
NEUPOGEN INJ 480MCG/1.6ML
PROCRIT INJ 10000UNIT/ML
PROCRIT INJ 20000UNIT/ML
PROCRIT INJ 2000UNIT/ML
PROCRIT INJ 3000UNIT/ML
PROCRIT INJ 40000UNIT/ML
PROCRIT INJ 4000UNIT/ML
PROMACTA TABS 12.5MG
PROMACTA TABS 25MG
PROMACTA TABS 50MG
PROMACTA TABS 75MG
Coagulants
tranexamic acid inj 100mg/ml
tranexamic acid tabs 650mg
Platelet Modifying Agents
Drug Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
QL (1.2 ML per 28 days) PA
QL (3 ML per 28 days) PA
QL (1.6 ML per 28 days) PA
QL (4 ML per 28 days) PA
QL (1.68 ML per 28 days) PA
QL (4 ML per 28 days) PA
QL (2.4 ML per 28 days) PA
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
QL (4 ML per 28 days) PA
QL (1.6 ML per 28 days) PA
QL (4 ML per 28 days) PA
QL (1 ML per 21 days) PA
QL (1.2 ML per 28 days) PA
QL (4 ML per 28 days) PA
PA
PA
PA
PA
PA
PA
QL (12 ML per 28 days) PA
QL (12 ML per 28 days) PA
QL (12 ML per 28 days) PA
QL (12 ML per 28 days) PA
QL (8 ML per 28 days) PA
QL (12 ML per 28 days) PA
QL (30 EA per 30 days) PA LA
QL (30 EA per 30 days) PA LA
QL (30 EA per 30 days) PA LA
QL (30 EA per 30 days) PA LA
Generic
Generic
QL (30 EA per 5 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
57
Requirements/
Limits
AGGRENOX CP12 25MG; 200MG
OTHER
QL (60 EA per 30 days) MO
aspirin/dipyridamole cp12 25mg; 200mg
Generic
QL (60 EA per 30 days) MO
BRILINTA TABS 60MG
OTHER
QL (60 EA per 30 days) MO
BRILINTA TABS 90MG
OTHER
QL (60 EA per 30 days) MO
cilostazol tabs 100mg
Generic
MO
cilostazol tabs 50mg
Generic
MO
clopidogrel tabs 300mg
Generic
QL (2 EA per 365 days)
clopidogrel tabs 75mg
Generic
QL (30 EA per 30 days) MO
EFFIENT TABS 10MG
OTHER
QL (30 EA per 30 days) MO
EFFIENT TABS 5MG
OTHER
QL (30 EA per 30 days) MO
ticlopidine hcl tabs 250mg
Generic
PA
CARDIOVASCULAR AGENTS - DRUGS USED TO TREAT HEART AND CIRCULATION CONDITIONS, HIGH
BLOOD PRESSURE, HEART RHYTHM, HIGH CHOLESTEROL
Alpha-adrenergic Agonists
clonidine hcl ptwk 0.1mg/24hr
Generic
QL (8 EA per 28 days) MO
clonidine hcl ptwk 0.2mg/24hr
Generic
QL (8 EA per 28 days) MO
clonidine hcl ptwk 0.3mg/24hr
Generic
QL (8 EA per 28 days) MO
clonidine hcl tabs 0.1mg
Generic
MO
clonidine hcl tabs 0.2mg
Generic
MO
clonidine hcl tabs 0.3mg
Generic
MO
midodrine hcl tabs 10mg
Generic
MO
midodrine hcl tabs 2.5mg
Generic
MO
midodrine hcl tabs 5mg
Generic
MO
Alpha-adrenergic Blocking Agents
doxazosin mesylate tabs 1mg
Generic
MO
doxazosin mesylate tabs 2mg
Generic
MO
doxazosin mesylate tabs 4mg
Generic
MO
doxazosin mesylate tabs 8mg
Generic
MO
prazosin hcl caps 1mg
Generic
MO
prazosin hcl caps 2mg
Generic
MO
prazosin hcl caps 5mg
Generic
MO
terazosin hcl caps 10mg
Generic
MO
terazosin hcl caps 1mg
Generic
MO
terazosin hcl caps 2mg
Generic
MO
terazosin hcl caps 5mg
Generic
MO
Angiotensin II Receptor Antagonists
candesartan cilexetil/hydrochlorothiazide tabs
QL (60 EA per 30 days) MO
Generic
16mg; 12.5mg
Drug Name
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
58
Drug Name
candesartan cilexetil/hydrochlorothiazide tabs
32mg; 12.5mg
candesartan cilexetil/hydrochlorothiazide tabs
32mg; 25mg
candesartan cilexetil tabs 16mg
candesartan cilexetil tabs 32mg
candesartan cilexetil tabs 4mg
candesartan cilexetil tabs 8mg
eprosartan mesylate tabs 600mg
irbesartan/hydrochlorothiazide tabs 12.5mg;
150mg
irbesartan/hydrochlorothiazide tabs 12.5mg;
300mg
irbesartan tabs 150mg
irbesartan tabs 300mg
irbesartan tabs 75mg
losartan potassium/hydrochlorothiazide tabs
12.5mg; 100mg
losartan potassium/hydrochlorothiazide tabs
12.5mg; 50mg
losartan potassium/hydrochlorothiazide tabs
25mg; 100mg
losartan potassium tabs 100mg
losartan potassium tabs 25mg
losartan potassium tabs 50mg
telmisartan/amlodipine tabs 10mg; 40mg
telmisartan/amlodipine tabs 10mg; 80mg
telmisartan/amlodipine tabs 5mg; 40mg
telmisartan/amlodipine tabs 5mg; 80mg
telmisartan/hydrochlorothiazide tabs 12.5mg;
40mg
telmisartan/hydrochlorothiazide tabs 12.5mg;
80mg
telmisartan/hydrochlorothiazide tabs 25mg;
80mg
telmisartan tabs 20mg
telmisartan tabs 40mg
telmisartan tabs 80mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
59
Drug Name
valsartan/hydrochlorothiazide tabs 12.5mg;
160mg
valsartan/hydrochlorothiazide tabs 12.5mg;
320mg
valsartan/hydrochlorothiazide tabs 12.5mg;
80mg
valsartan/hydrochlorothiazide tabs 25mg;
160mg
valsartan/hydrochlorothiazide tabs 25mg;
320mg
valsartan tabs 160mg
valsartan tabs 320mg
valsartan tabs 40mg
valsartan tabs 80mg
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl/hydrochlorothiazide tabs 10mg;
12.5mg
benazepril hcl/hydrochlorothiazide tabs 20mg;
12.5mg
benazepril hcl/hydrochlorothiazide tabs 20mg;
25mg
benazepril hcl/hydrochlorothiazide tabs 5mg;
6.25mg
benazepril hcl tabs 10mg
benazepril hcl tabs 20mg
benazepril hcl tabs 40mg
benazepril hcl tabs 5mg
captopril/hydrochlorothiazide tabs 25mg; 15mg
captopril/hydrochlorothiazide tabs 25mg; 25mg
captopril/hydrochlorothiazide tabs 50mg; 15mg
captopril/hydrochlorothiazide tabs 50mg; 25mg
captopril tabs 100mg
captopril tabs 12.5mg
captopril tabs 25mg
captopril tabs 50mg
enalapril maleate/hydrochlorothiazide tabs
10mg; 25mg
enalapril maleate/hydrochlorothiazide tabs 5mg;
12.5mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
60
Drug Name
enalapril maleate tabs 10mg
enalapril maleate tabs 2.5mg
enalapril maleate tabs 20mg
enalapril maleate tabs 5mg
fosinopril sodium/hydrochlorothiazide tabs
10mg; 12.5mg
fosinopril sodium/hydrochlorothiazide tabs
20mg; 12.5mg
fosinopril sodium tabs 10mg
fosinopril sodium tabs 20mg
fosinopril sodium tabs 40mg
lisinopril/hydrochlorothiazide tabs 12.5mg;
10mg
lisinopril/hydrochlorothiazide tabs 12.5mg;
20mg
lisinopril/hydrochlorothiazide tabs 25mg; 20mg
lisinopril tabs 10mg
lisinopril tabs 2.5mg
lisinopril tabs 20mg
lisinopril tabs 30mg
lisinopril tabs 40mg
lisinopril tabs 5mg
moexipril hcl tabs 15mg
moexipril hcl tabs 7.5mg
moexipril/hydrochlorothiazide tabs 12.5mg;
15mg
moexipril/hydrochlorothiazide tabs 12.5mg;
7.5mg
moexipril/hydrochlorothiazide tabs 25mg; 15mg
perindopril erbumine tabs 2mg
perindopril erbumine tabs 4mg
perindopril erbumine tabs 8mg
quinapril hcl tabs 10mg
quinapril hcl tabs 20mg
quinapril hcl tabs 40mg
quinapril hcl tabs 5mg
quinapril/hydrochlorothiazide tabs 12.5mg;
10mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
61
Drug Name
quinapril/hydrochlorothiazide tabs 12.5mg;
20mg
quinapril/hydrochlorothiazide tabs 25mg; 20mg
ramipril caps 1.25mg
ramipril caps 10mg
ramipril caps 2.5mg
ramipril caps 5mg
trandolapril/verapamil hcl er tbcr 1mg; 240mg
trandolapril/verapamil hcl er tbcr 2mg; 180mg
trandolapril/verapamil hcl er tbcr 2mg; 240mg
trandolapril/verapamil hcl er tbcr 4mg; 240mg
trandolapril/verapamil hcl tbcr 1mg; 240mg
trandolapril/verapamil hcl tbcr 2mg; 180mg
trandolapril/verapamil hcl tbcr 2mg; 240mg
trandolapril/verapamil hcl tbcr 4mg; 240mg
trandolapril tabs 1mg
trandolapril tabs 2mg
trandolapril tabs 4mg
Antiarrhythmics
amiodarone hcl tabs 100mg
amiodarone hcl tabs 200mg
amiodarone hcl tabs 400mg
disopyramide phosphate caps 100mg
disopyramide phosphate caps 150mg
flecainide acetate tabs 100mg
flecainide acetate tabs 150mg
flecainide acetate tabs 50mg
lidocaine hcl inj 10mg/ml
lidocaine hcl inj 20mg/ml
mexiletine hcl caps 150mg
mexiletine hcl caps 200mg
mexiletine hcl caps 250mg
MULTAQ TABS 400MG
pacerone tabs 100mg
pacerone tabs 200mg
pacerone tabs 400mg
propafenone hcl er cp12 225mg
propafenone hcl er cp12 325mg
Drug Tier
Generic
Requirements/
Limits
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
62
Drug Name
propafenone hcl er cp12 425mg
propafenone hcl tabs 150mg
propafenone hcl tabs 225mg
propafenone hcl tabs 300mg
quinidine gluconate cr tbcr 324mg
quinidine gluconate er tbcr 324mg
quinidine sulfate er tbcr 300mg
quinidine sulfate tabs 200mg
quinidine sulfate tabs 300mg
sorine tabs 120mg
sorine tabs 160mg
sorine tabs 240mg
sorine tabs 80mg
sotalol hcl (af) tabs 120mg
sotalol hcl (af) tabs 160mg
sotalol hcl (af) tabs 80mg
sotalol hcl tabs 120mg
sotalol hcl tabs 160mg
sotalol hcl tabs 240mg
sotalol hcl tabs 80mg
TIKOSYN CAPS 125MCG
TIKOSYN CAPS 250MCG
TIKOSYN CAPS 500MCG
Beta-adrenergic Blocking Agents
acebutolol hcl caps 200mg
acebutolol hcl caps 400mg
atenolol/chlorthalidone tabs 100mg; 25mg
atenolol/chlorthalidone tabs 50mg; 25mg
atenolol tabs 100mg
atenolol tabs 25mg
atenolol tabs 50mg
betaxolol hcl tabs 10mg
betaxolol hcl tabs 20mg
bisoprolol fumarate/hydrochlorothiazide tabs
10mg; 6.25mg
bisoprolol fumarate/hydrochlorothiazide tabs
2.5mg; 6.25mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
63
Drug Name
bisoprolol fumarate/hydrochlorothiazide tabs
5mg; 6.25mg
bisoprolol fumarate tabs 10mg
bisoprolol fumarate tabs 5mg
carvedilol tabs 12.5mg
carvedilol tabs 25mg
carvedilol tabs 3.125mg
carvedilol tabs 6.25mg
labetalol hcl inj 5mg/ml
labetalol hcl tabs 100mg
labetalol hcl tabs 200mg
labetalol hcl tabs 300mg
metoprolol succinate er tb24 100mg
metoprolol succinate er tb24 200mg
metoprolol succinate er tb24 25mg
metoprolol succinate er tb24 50mg
metoprolol tartrate inj 1mg/ml
metoprolol tartrate tabs 100mg
metoprolol tartrate tabs 25mg
metoprolol tartrate tabs 50mg
metoprolol/hydrochlorothiazide tabs 25mg;
100mg
metoprolol/hydrochlorothiazide tabs 25mg;
50mg
metoprolol/hydrochlorothiazide tabs 50mg;
100mg
nadolol/bendroflumethiazide tabs 5mg; 40mg
nadolol/bendroflumethiazide tabs 5mg; 80mg
nadolol tabs 20mg
nadolol tabs 40mg
nadolol tabs 80mg
pindolol tabs 10mg
pindolol tabs 5mg
propranolol hcl er cp24 120mg
propranolol hcl er cp24 160mg
propranolol hcl er cp24 60mg
propranolol hcl er cp24 80mg
propranolol hcl inj 1mg/ml
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
64
Drug Name
propranolol hcl soln 20mg/5ml
propranolol hcl soln 40mg/5ml
propranolol hcl tabs 10mg
propranolol hcl tabs 20mg
propranolol hcl tabs 40mg
propranolol hcl tabs 60mg
propranolol hcl tabs 80mg
propranolol/hydrochlorothiazide tabs 25mg;
40mg
propranolol/hydrochlorothiazide tabs 25mg;
80mg
timolol maleate tabs 10mg
timolol maleate tabs 20mg
timolol maleate tabs 5mg
Calcium Channel Blocking Agents
amlodipine besylate/atorvastatin calcium tabs
10mg; 10mg
amlodipine besylate/atorvastatin calcium tabs
10mg; 20mg
amlodipine besylate/atorvastatin calcium tabs
10mg; 40mg
amlodipine besylate/atorvastatin calcium tabs
10mg; 80mg
amlodipine besylate/atorvastatin calcium tabs
2.5mg; 10mg
amlodipine besylate/atorvastatin calcium tabs
2.5mg; 20mg
amlodipine besylate/atorvastatin calcium tabs
2.5mg; 40mg
amlodipine besylate/atorvastatin calcium tabs
5mg; 10mg
amlodipine besylate/atorvastatin calcium tabs
5mg; 20mg
amlodipine besylate/atorvastatin calcium tabs
5mg; 40mg
amlodipine besylate/atorvastatin calcium tabs
5mg; 80mg
amlodipine besylate/benazepril hcl caps 5mg;
40mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
65
Drug Name
amlodipine besylate/benazepril hydrochloride
caps 10mg; 20mg
amlodipine besylate/benazepril hydrochloride
caps 10mg; 40mg
amlodipine besylate/benazepril hydrochloride
caps 2.5mg; 10mg
amlodipine besylate/benazepril hydrochloride
caps 5mg; 10mg
amlodipine besylate/benazepril hydrochloride
caps 5mg; 20mg
amlodipine besylate/valsartan tabs 10mg;
160mg
amlodipine besylate/valsartan tabs 10mg;
320mg
amlodipine besylate/valsartan tabs 5mg; 160mg
amlodipine besylate/valsartan tabs 5mg; 320mg
amlodipine besylate tabs 10mg
amlodipine besylate tabs 2.5mg
amlodipine besylate tabs 5mg
amlodipine/valsartan/hctz tabs 10mg; 12.5mg;
160mg
amlodipine/valsartan/hctz tabs 10mg; 25mg;
160mg
amlodipine/valsartan/hctz tabs 10mg; 25mg;
320mg
amlodipine/valsartan/hctz tabs 5mg; 12.5mg;
160mg
amlodipine/valsartan/hctz tabs 5mg; 25mg;
160mg
cartia xt cp24 120mg
cartia xt cp24 180mg
cartia xt cp24 240mg
cartia xt cp24 300mg
dilt-xr cp24 120mg
dilt-xr cp24 180mg
dilt-xr cp24 240mg
diltiazem cd cp24 120mg
diltiazem cd cp24 180mg
diltiazem cd cp24 180mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
66
Drug Name
diltiazem cd cp24 240mg
diltiazem cd cp24 300mg
diltiazem hcl cd cp24 360mg
diltiazem hcl er cp12 120mg
diltiazem hcl er cp12 60mg
diltiazem hcl er cp12 90mg
diltiazem hcl er cp24 120mg
diltiazem hcl er cp24 120mg
diltiazem hcl er cp24 120mg
diltiazem hcl er cp24 180mg
diltiazem hcl er cp24 180mg
diltiazem hcl er cp24 240mg
diltiazem hcl er cp24 240mg
diltiazem hcl er cp24 240mg
diltiazem hcl er cp24 300mg
diltiazem hcl er cp24 300mg
diltiazem hcl er cp24 360mg
diltiazem hcl er cp24 360mg
diltiazem hcl er cp24 420mg
diltiazem hcl er tb24 180mg
diltiazem hcl er tb24 240mg
diltiazem hcl er tb24 300mg
diltiazem hcl er tb24 360mg
diltiazem hcl er tb24 420mg
diltiazem hcl inj 100mg
diltiazem hcl inj 125mg/25ml
diltiazem hcl inj 25mg/5ml
diltiazem hcl inj 50mg/10ml
diltiazem hcl tabs 120mg
diltiazem hcl tabs 30mg
diltiazem hcl tabs 60mg
diltiazem hcl tabs 90mg
isradipine caps 2.5mg
isradipine caps 5mg
matzim la tb24 180mg
matzim la tb24 240mg
matzim la tb24 300mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
67
Drug Name
matzim la tb24 360mg
matzim la tb24 420mg
nicardipine hcl caps 20mg
nicardipine hcl caps 30mg
nisoldipine er tb24 25.5mg
nisoldipine tb24 17mg
nisoldipine tb24 20mg
nisoldipine tb24 30mg
nisoldipine tb24 34mg
nisoldipine tb24 40mg
nisoldipine tb24 8.5mg
taztia xt cp24 120mg
taztia xt cp24 180mg
taztia xt cp24 240mg
taztia xt cp24 300mg
taztia xt cp24 360mg
verapamil hcl er cp24 100mg
verapamil hcl er cp24 120mg
verapamil hcl er cp24 180mg
verapamil hcl er cp24 200mg
verapamil hcl er cp24 240mg
verapamil hcl er cp24 300mg
verapamil hcl er tbcr 120mg
verapamil hcl er tbcr 180mg
verapamil hcl er tbcr 240mg
verapamil hcl sr cp24 120mg
verapamil hcl sr cp24 180mg
verapamil hcl sr cp24 240mg
verapamil hcl sr cp24 360mg
verapamil hcl sr tbcr 240mg
verapamil hcl inj 2.5mg/ml
verapamil hcl tabs 120mg
verapamil hcl tabs 40mg
verapamil hcl tabs 80mg
Cardiovascular Agents, Other
CORLANOR TABS 5MG
CORLANOR TABS 7.5MG
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
68
Drug Name
digitek tabs 0.125mg
digitek tabs 0.25mg
digoxin inj 0.25mg/ml
digoxin soln 0.05mg/ml
digoxin tabs 125mcg
digoxin tabs 250mcg
digox tabs 125mcg
digox tabs 250mcg
NORTHERA CAPS 100MG
NORTHERA CAPS 200MG
NORTHERA CAPS 300MG
pentoxifylline cr tbcr 400mg
pentoxifylline er tbcr 400mg
RANEXA TB12 1000MG
RANEXA TB12 500MG
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide er cp12 500mg
acetazolamide tabs 125mg
acetazolamide tabs 250mg
methazolamide tabs 25mg
methazolamide tabs 50mg
Diuretics, Loop
bumetanide inj 0.25mg/ml
bumetanide tabs 0.5mg
bumetanide tabs 1mg
bumetanide tabs 2mg
furosemide inj 10mg/ml
furosemide inj 10mg/ml
furosemide soln 10mg/ml
furosemide soln 8mg/ml
furosemide tabs 20mg
furosemide tabs 40mg
furosemide tabs 80mg
torsemide tabs 100mg
torsemide tabs 10mg
torsemide tabs 20mg
torsemide tabs 5mg
Drug Tier
Requirements/
Limits
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
OTHER
OTHER
PA LA
PA LA
PA LA
MO
MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
69
Drug Name
Diuretics, Potassium-sparing
amiloride hcl tabs 5mg
amiloride/hydrochlorothiazide tabs 5mg; 50mg
eplerenone tabs 25mg
eplerenone tabs 50mg
spironolactone/hydrochlorothiazide tabs 25mg;
25mg
spironolactone tabs 100mg
spironolactone tabs 25mg
spironolactone tabs 50mg
triamterene/hydrochlorothiazide caps 25mg;
37.5mg
triamterene/hydrochlorothiazide caps 25mg;
50mg
triamterene/hydrochlorothiazide tabs 25mg;
37.5mg
triamterene/hydrochlorothiazide tabs 50mg;
75mg
Diuretics, Thiazide
chlorothiazide tabs 250mg
chlorothiazide tabs 500mg
chlorthalidone tabs 25mg
chlorthalidone tabs 50mg
hydrochlorothiazide caps 12.5mg
hydrochlorothiazide tabs 12.5mg
hydrochlorothiazide tabs 25mg
hydrochlorothiazide tabs 50mg
indapamide tabs 1.25mg
indapamide tabs 2.5mg
methyclothiazide tabs 5mg
metolazone tabs 10mg
metolazone tabs 2.5mg
metolazone tabs 5mg
Dyslipidemics, Fibric Acid Derivatives
fenofibrate micronized caps 134mg
fenofibrate micronized caps 200mg
fenofibrate micronized caps 67mg
fenofibrate caps 130mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
70
Drug Name
fenofibrate caps 150mg
fenofibrate caps 43mg
fenofibrate caps 50mg
fenofibrate tabs 145mg
fenofibrate tabs 160mg
fenofibrate tabs 48mg
fenofibrate tabs 54mg
fenofibric acid dr cpdr 135mg
fenofibric acid dr cpdr 45mg
fenofibric acid tabs 105mg
fenofibric acid tabs 35mg
gemfibrozil tabs 600mg
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium tabs 10mg
atorvastatin calcium tabs 20mg
atorvastatin calcium tabs 40mg
atorvastatin calcium tabs 80mg
CRESTOR TABS 10MG
CRESTOR TABS 20MG
CRESTOR TABS 40MG
CRESTOR TABS 5MG
fluvastatin sodium er tb24 80mg
fluvastatin caps 20mg
fluvastatin caps 40mg
lovastatin tabs 10mg
lovastatin tabs 20mg
lovastatin tabs 40mg
pravastatin sodium tabs 10mg
pravastatin sodium tabs 20mg
pravastatin sodium tabs 40mg
pravastatin sodium tabs 80mg
simvastatin tabs 10mg
simvastatin tabs 20mg
simvastatin tabs 40mg
simvastatin tabs 5mg
simvastatin tabs 80mg
Dyslipidemics, Other
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
71
Drug Name
cholestyramine light pack 4gm
cholestyramine light powd 4gm/dose
cholestyramine pack 4gm
cholestyramine powd 4gm/dose
colestipol hcl for oral suspension pack 5gm
colestipol hcl gran 5gm
colestipol hcl tabs 1gm
KYNAMRO INJ 200MG/ML
LOVAZA CAPS 375MG; 465MG; 1GM
micronized colestipol hcl tabs 1gm
niacin er tbcr 1000mg
niacin er tbcr 500mg
niacin er tbcr 750mg
omega-3-acid ethyl esters caps 375mg; 465mg;
1gm
prevalite pack 4gm
prevalite powd 4gm/dose
VASCEPA CAPS 1GM
ZETIA TABS 10MG
Vasodilators, Direct-acting Arterial/Venous
isosorbide dinitrate er tbcr 40mg
isosorbide dinitrate tabs 10mg
isosorbide dinitrate tabs 20mg
isosorbide dinitrate tabs 30mg
isosorbide dinitrate tabs 5mg
isosorbide mononitrate er tb24 120mg
isosorbide mononitrate er tb24 30mg
isosorbide mononitrate er tb24 60mg
isosorbide mononitrate tabs 10mg
isosorbide mononitrate tabs 20mg
minitran pt24 0.1mg/hr
minitran pt24 0.2mg/hr
minitran pt24 0.4mg/hr
minitran pt24 0.6mg/hr
nitroglycerin lingual aers 400mcg/spray
nitroglycerin lingual soln 0.4mg/spray
nitroglycerin transdermal pt24 0.1mg/hr
nitroglycerin transdermal pt24 0.2mg/hr
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
PA LA
QL (120 EA per 30 days) ST MO
MO
MO
MO
MO
QL (120 EA per 30 days) MO
Generic
Generic
OTHER
OTHER
MO
MO
MO
QL (30 EA per 30 days) MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
72
Drug Name
Drug Tier
Requirements/
Limits
MO
MO
nitroglycerin transdermal pt24 0.4mg/hr
Generic
nitroglycerin transdermal pt24 0.6mg/hr
Generic
nitroglycerin inj 5mg/ml
Generic
NITROSTAT SUBL 0.3MG
OTHER
MO
NITROSTAT SUBL 0.4MG
OTHER
MO
NITROSTAT SUBL 0.6MG
OTHER
MO
Vasodilators, Direct-acting Arterial
hydralazine hcl inj 20mg/ml
Generic
MO
hydralazine hcl tabs 100mg
Generic
MO
hydralazine hcl tabs 10mg
Generic
MO
hydralazine hcl tabs 25mg
Generic
MO
hydralazine hcl tabs 50mg
Generic
MO
minoxidil tabs 10mg
Generic
MO
minoxidil tabs 2.5mg
Generic
MO
CENTRAL NERVOUS SYSTEM AGENTS- DRUGS USED TO TREAT ADHD, MULTIPLE SCLEROSIS,
CHOREA ASSOCIATED WITH HUNTINGTON DISEASE
Attention Deficit Hyperactivity Disorder Agents,
Amphetamines
amphetamine/dextroamphetamine tabs 1.25mg;
QL (60 EA per 30 days) PA MO
Generic
1.25mg; 1.25mg; 1.25mg
amphetamine/dextroamphetamine tabs
QL (60 EA per 30 days) PA MO
Generic
1.875mg; 1.875mg; 1.875mg; 1.875mg
amphetamine/dextroamphetamine tabs 2.5mg;
QL (60 EA per 30 days) PA MO
Generic
2.5mg; 2.5mg; 2.5mg
amphetamine/dextroamphetamine tabs
QL (60 EA per 30 days) PA MO
Generic
3.125mg; 3.125mg; 3.125mg; 3.125mg
amphetamine/dextroamphetamine tabs 3.75mg;
QL (60 EA per 30 days) PA MO
Generic
3.75mg; 3.75mg; 3.75mg
amphetamine/dextroamphetamine tabs 5mg;
QL (90 EA per 30 days) PA MO
Generic
5mg; 5mg; 5mg
amphetamine/dextroamphetamine tabs 7.5mg;
QL (60 EA per 30 days) PA MO
Generic
7.5mg; 7.5mg; 7.5mg
dextroamphetamine sulfate soln 5mg/5ml
Generic
QL (1800 ML per 30 days) PA MO
dextroamphetamine sulfate tabs 10mg
Generic
QL (180 EA per 30 days) PA MO
dextroamphetamine sulfate tabs 5mg
Generic
QL (180 EA per 30 days) PA MO
Attention Deficit Hyperactivity Disorder Agents,
Non-amphetamines
guanfacine er tb24 1mg
Generic
QL (30 EA per 30 days) MO
guanfacine er tb24 2mg
Generic
QL (30 EA per 30 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
73
Drug Name
guanfacine er tb24 3mg
guanfacine er tb24 4mg
INTUNIV TB24 1MG
INTUNIV TB24 2MG
INTUNIV TB24 3MG
INTUNIV TB24 4MG
metadate er tbcr 20mg
methylphenidate hcl er tbcr 10mg
methylphenidate hcl er tbcr 20mg
methylphenidate hcl sr tbcr 20mg
methylphenidate hcl tabs 10mg
methylphenidate hcl tabs 20mg
methylphenidate hcl tabs 5mg
Central Nervous System, Other
NUEDEXTA CAPS 20MG; 10MG
riluzole tabs 50mg
tetrabenazine tabs 12.5mg
tetrabenazine tabs 25mg
XENAZINE TABS 12.5MG
XENAZINE TABS 25MG
Multiple Sclerosis Agents
AMPYRA TB12 10MG
COPAXONE INJ 20MG/ML
COPAXONE INJ 40MG/ML
EXTAVIA INJ 0.3MG
GILENYA CAPS 0.5MG
glatopa inj 20mg/ml
DENTAL AND ORAL AGENTS
Dental and Oral Agents
chlorhexidine gluconate oral rinse soln 0.12%
clinpro 5000 pste 1.1%
dentagel gel 1.1%
fluoridex daily defense gel 1.1%
oralone pste 0.1%
paroex soln 0.12%
periogard soln 0.12%
phos-flur gel 1.1%
Generic
Generic
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
QL (90 EA per 30 days) PA MO
PA MO
PA MO
PA MO
OTHER
Generic
Generic
Generic
OTHER
OTHER
QL (60 EA per 30 days) MO
MO
QL (90 EA per 30 days) PA
QL (120 EA per 30 days) PA
QL (90 EA per 30 days) PA LA
QL (120 EA per 30 days) PA LA
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
QL (60 EA per 30 days) PA LA
QL (30 ML per 30 days) PA
QL (12 ML per 28 days) PA
QL (15 EA per 30 days) PA
QL (30 EA per 30 days) PA
QL (30 ML per 30 days) PA
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
74
Requirements/
Limits
pilocarpine hcl tabs 7.5mg
Generic
MO
pilocarpine hydrochloride tabs 5mg
Generic
MO
sf gel 1.1%
Generic
MO
triamcinolone acetonide pste 0.1%
Generic
MO
triamcinolone in orabase pste 0.1%
Generic
MO
DERMATOLOGICAL AGENTS- ANTIPSORIATICS, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE,
ACNE, WOUND CARE AGENTS, ANTIBIOTICS
Dermatological Agents
8-MOP CAPS 10MG
OTHER
acitretin caps 10mg
Generic
PA MO
acitretin caps 17.5mg
Generic
PA MO
acitretin caps 25mg
Generic
PA MO
ALTABAX OINT 1%
OTHER
MO
ammonium lactate crea 12%
Generic
MO
ammonium lactate lotn 12%
Generic
MO
amnesteem caps 10mg
Generic
amnesteem caps 20mg
Generic
amnesteem caps 40mg
Generic
avita crea 0.025%
Generic
PA
avita gel 0.025%
Generic
PA MO
calcipotriene crea 0.005%
Generic
MO
calcipotriene oint 0.005%
Generic
MO
calcipotriene soln 0.005%
Generic
MO
calcitrene oint 0.005%
Generic
MO
claravis caps 10mg
Generic
claravis caps 20mg
Generic
CLARAVIS CAPS 30MG
OTHER
claravis caps 40mg
Generic
clindamycin phosphate foam 1%
Generic
MO
clindamycin phosphate gel 1%
Generic
MO
clindamycin phosphate lotn 1%
Generic
MO
clindamycin phosphate soln 1%
Generic
MO
clindamycin phosphate swab 1%
Generic
MO
clindamycin/benzoyl peroxide gel 5%; 1%
Generic
MO
clindamycin/benzoyl peroxide gel 5%; 1.2%
Generic
MO
ELIDEL CREA 1%
OTHER
QL (60 GM per 30 days) ST MO
ery pads 2%
Generic
MO
erythromycin/benzoyl peroxide gel 5%; 3%
Generic
MO
Drug Name
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
75
Drug Name
erythromycin gel 2%
erythromycin pads 2%
erythromycin soln 2%
fluorouracil crea 0.5%
fluorouracil crea 5%
fluorouracil soln 2%
fluorouracil soln 5%
gentamicin sulfate crea 0.1%
gentamicin sulfate oint 0.1%
imiquimod crea 5%
methoxsalen caps 10mg
metronidazole crea 0.75%
metronidazole gel 0.75%
metronidazole gel 1%
metronidazole lotn 0.75%
mupirocin calcium crea 2%
mupirocin crea 2%
mupirocin oint 2%
myorisan caps 10mg
myorisan caps 20mg
myorisan caps 30mg
myorisan caps 40mg
OXSORALEN LOTN 1%
podofilox soln 0.5%
REGRANEX GEL 0.01%
rosadan crea 0.75%
rosadan gel 0.75%
SANTYL OINT 250UNIT/GM
selenium sulfide lotn 2.5%
silver sulfadiazine crea 1%
sodium sulfacetamide lotn 10%
ssd crea 1%
sulfacetamide sodium susp 10%
SULFAMYLON CREA 85MG/GM
TAZORAC CREA 0.05%
TAZORAC CREA 0.1%
TAZORAC GEL 0.05%
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
OTHER
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QL (15 GM per 30 days) PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
76
Drug Name
Drug Tier
Requirements/
Limits
MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
TAZORAC GEL 0.1%
OTHER
tretinoin crea 0.025%
Generic
tretinoin crea 0.05%
Generic
tretinoin crea 0.1%
Generic
tretinoin gel 0.01%
Generic
tretinoin gel 0.025%
Generic
tretinoin gel 0.05%
Generic
zenatane caps 10mg
Generic
zenatane caps 20mg
Generic
ZENATANE CAPS 30MG
OTHER
zenatane caps 40mg
Generic
ZONALON CREA 5%
OTHER
MO
ENZYME REPLACEMENT/MODIFIERS- DRUGS USED TO TREAT ENZYME DEFICIENCIES, PANCREATIC
ENZYMES
Enzyme Replacement/Modifiers
ADAGEN INJ 250UNIT/ML
OTHER
PA
ALDURAZYME INJ 2.9MG/5ML
OTHER
PA LA
BUPHENYL TABS 500MG
OTHER
PA
CARBAGLU TABS 200MG
OTHER
CEREZYME INJ 400UNIT
OTHER
PA LA
CREON CPEP 120000UNIT; 24000UNIT;
MO
OTHER
76000UNIT
CREON CPEP 15000UNIT; 3000UNIT;
MO
OTHER
9500UNIT
CREON CPEP 180000UNIT; 36000UNIT;
MO
OTHER
114000UNIT
CREON CPEP 30000UNIT; 6000UNIT;
MO
OTHER
19000UNIT
CREON CPEP 60000UNIT; 12000UNIT;
MO
OTHER
38000UNIT
CYSTADANE POWD 0
OTHER
CYSTAGON CAPS 150MG
OTHER
PA LA
CYSTAGON CAPS 50MG
OTHER
PA LA
FABRAZYME INJ 35MG
OTHER
PA LA
FABRAZYME INJ 5MG
OTHER
PA LA
KUVAN PACK 100MG
OTHER
PA LA
KUVAN PACK 500MG
OTHER
PA
KUVAN TBSO 100MG
OTHER
PA LA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
77
Drug Name
Drug Tier
Requirements/
Limits
LA
PA LA
PA
PA
PA
MO
LUMIZYME INJ 50MG
OTHER
NAGLAZYME INJ 1MG/ML
OTHER
ORFADIN CAPS 10MG
OTHER
ORFADIN CAPS 2MG
OTHER
ORFADIN CAPS 5MG
OTHER
pancrelipase cpep 27000unit; 5000unit;
Generic
17000unit
RAVICTI LIQD 1.1GM/ML
OTHER
PA LA
sodium phenylbutyrate powd 3gm/tsp
Generic
PA
VPRIV INJ 400UNIT
OTHER
PA
ZAVESCA CAPS 100MG
OTHER
PA
ZENPEP CPEP 109000UNIT; 20000UNIT;
MO
OTHER
68000UNIT
ZENPEP CPEP 136000UNIT; 25000UNIT;
MO
OTHER
85000UNIT
ZENPEP CPEP 16000UNIT; 3000UNIT;
MO
OTHER
10000UNIT
ZENPEP CPEP 218000UNIT; 40000UNIT;
MO
OTHER
136000UNIT
ZENPEP CPEP 27000UNIT; 5000UNIT;
MO
OTHER
17000UNIT
ZENPEP CPEP 55000UNIT; 10000UNIT;
MO
OTHER
34000UNIT
ZENPEP CPEP 82000UNIT; 15000UNIT;
MO
OTHER
51000UNIT
GASTROINTESTINAL- DRUGS USED TO TREAT STOMACH AND INTESTINAL DISORDERS, ANTIDIARRHEAL, LAXATIVES, ULCERS AND STOMACH ACID
Antispasmodics, Gastrointestinal
dicyclomine hcl caps 10mg
Generic
PA MO
dicyclomine hcl soln 10mg/5ml
Generic
PA MO
dicyclomine hcl tabs 20mg
Generic
PA MO
glycopyrrolate inj 0.2mg/ml
Generic
MO
glycopyrrolate inj 0.4mg/2ml
Generic
MO
glycopyrrolate inj 1mg/5ml
Generic
MO
glycopyrrolate inj 4mg/20ml
Generic
MO
glycopyrrolate tabs 1mg
Generic
MO
glycopyrrolate tabs 2mg
Generic
MO
methscopolamine bromide tabs 2.5mg
Generic
MO
methscopolamine bromide tabs 5mg
Generic
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
78
Drug Name
Gastrointestinal Agents, Other
cromolyn sodium conc 100mg/5ml
diphenatol tabs 0.025mg; 2.5mg
diphenoxylate/atropine liqd 0.025mg/5ml;
2.5mg/5ml
diphenoxylate/atropine tabs 0.025mg; 2.5mg
GATTEX INJ 5MG
gavilyte-h kit 5mg; 210gm; 0.74gm; 2.86gm;
5.6gm
loperamide hcl caps 2mg
metoclopramide hcl inj 5mg/ml
metoclopramide hcl soln 5mg/5ml
metoclopramide hcl tabs 10mg
metoclopramide hcl tabs 5mg
RELISTOR INJ 12MG/0.6ML
RELISTOR INJ 12MG/0.6ML
RELISTOR INJ 8MG/0.4ML
ursodiol caps 300mg
ursodiol tabs 250mg
ursodiol tabs 500mg
Histamine2 (H2) receptor Antagonists
cimetidine hcl soln 300mg/5ml
cimetidine tabs 200mg
cimetidine tabs 300mg
cimetidine tabs 400mg
cimetidine tabs 800mg
famotidine premixed inj 0.4mg/ml; 0.9%
famotidine inj 200mg/20ml
famotidine inj 20mg/2ml
famotidine inj 40mg/4ml
famotidine susr 40mg/5ml
famotidine tabs 20mg
famotidine tabs 40mg
ranitidine hcl caps 150mg
ranitidine hcl caps 300mg
ranitidine hcl inj 150mg/6ml
ranitidine hcl inj 50mg/2ml
Drug Tier
Generic
Generic
Generic
Generic
OTHER
Generic
Requirements/
Limits
MO
MO
MO
PA LA
MO
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
MO
MO
MO
MO
MO
PA
PA MO
PA MO
MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
79
Drug Name
ranitidine hcl syrp 15mg/ml
ranitidine hcl tabs 150mg
ranitidine hcl tabs 300mg
Irritable Bowel Syndrome Agents
alosetron hydrochloride tabs 0.5mg
alosetron hydrochloride tabs 1mg
AMITIZA CAPS 24MCG
AMITIZA CAPS 8MCG
LINZESS CAPS 145MCG
LINZESS CAPS 290MCG
Laxatives
constulose soln 10gm/15ml
enulose soln 10gm/15ml
gavilyte-c solr 240gm; 2.98gm; 6.72gm;
5.84gm; 22.72gm
gavilyte-g solr 236gm; 2.97gm; 6.74gm;
5.86gm; 22.74gm
gavilyte-n/flavor pack solr 420gm; 1.48gm;
5.72gm; 11.2gm
generlac soln 10gm/15ml
lactulose soln 10gm/15ml
lactulose soln 10gm/15ml
MOVIPREP SOLR 4.7GM; 100GM; 1.015GM;
5.9GM; 2.691GM; 7.5GM
peg 3350/electrolytes solr 240gm; 2.98gm;
6.72gm; 5.84gm; 22.72gm
peg-3350/electrolytes solr 236gm; 2.97gm;
6.74gm; 5.86gm; 22.74gm
peg-3350/nacl/na bicarbonate/kcl solr 420gm;
1.48gm; 5.72gm; 11.2gm
polyethylene glycol 3350 pack 0
polyethylene glycol 3350 powd 0
PREPOPIK PACK 12GM; 3.5GM; 10MG
SUPREP BOWEL PREP SOLN 1.6GM/180ML;
3.13GM/180ML; 17.5GM/180ML
trilyte solr 420gm; 1.48gm; 5.72gm; 11.2gm
Protectants
misoprostol tabs 100mcg
misoprostol tabs 200mcg
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
Generic
Generic
OTHER
OTHER
OTHER
OTHER
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Generic
MO
Generic
Generic
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
80
Drug Name
sucralfate susp 1gm/10ml
sucralfate tabs 1gm
Proton Pump Inhibitors
esomeprazole magnesium cpdr 20mg
esomeprazole magnesium cpdr 40mg
esomeprazole sodium inj 20mg
esomeprazole sodium inj 40mg
omeprazole cpdr 10mg
omeprazole cpdr 20mg
omeprazole cpdr 40mg
pantoprazole sodium inj 40mg
pantoprazole sodium tbec 20mg
pantoprazole sodium tbec 40mg
GENITOURINARY- VAGINAL ANTI-INFECTIVES
Antispasmodics, Urinary
MYRBETRIQ TB24 25MG
MYRBETRIQ TB24 50MG
oxybutynin chloride er tb24 10mg
oxybutynin chloride er tb24 15mg
oxybutynin chloride er tb24 5mg
oxybutynin chloride syrp 5mg/5ml
oxybutynin chloride tabs 5mg
tolterodine tartrate tabs 1mg
tolterodine tartrate tabs 2mg
VESICARE TABS 10MG
VESICARE TABS 5MG
Benign Prostatic Hypertrophy Agents
dutasteride caps 0.5mg
finasteride tabs 5mg
tamsulosin hcl caps 0.4mg
Genitourinary Agents, Other
bethanechol chloride tabs 10mg
bethanechol chloride tabs 25mg
bethanechol chloride tabs 50mg
bethanechol chloride tabs 5mg
methylergonovine maleate tabs 0.2mg
sodium chloride 0.9% soln 0.9%
Drug Tier
Generic
Generic
Requirements/
Limits
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (600 ML per 30 days) MO
QL (120 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
Generic
Generic
Generic
QL (30 EA per 30 days) MO
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
QL (30 EA per 30 days) MO
MO
QL (60 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
81
Drug Name
Drug Tier
Requirements/
Limits
THIOLA TABS 100MG
OTHER
Phosphate Binders
AURYXIA TABS 210MG
OTHER
MO
calcium acetate caps 667mg
Generic
MO
calcium acetate tabs 667mg
Generic
MO
FOSRENOL CHEW 1000MG
OTHER
MO
FOSRENOL CHEW 500MG
OTHER
MO
FOSRENOL CHEW 750MG
OTHER
MO
FOSRENOL PACK 1000MG
OTHER
FOSRENOL PACK 750MG
OTHER
RENVELA PACK 0.8GM
OTHER
MO
RENVELA PACK 2.4GM
OTHER
MO
RENVELA TABS 800MG
OTHER
MO
VELPHORO CHEW 500MG
OTHER
MO
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)- CORTICOSTEROID
DRUGS THAT CAN BE USED FOR A VARIETY OF CONDITIONS SUCH AS INFLAMMATION
Hormonal Agents, Stimulant/Replacement/Modi‑
fying (Adrenal)
a-hydrocort inj 100mg
Generic
MO
alclometasone dipropionate crea 0.05%
Generic
MO
alclometasone dipropionate oint 0.05%
Generic
MO
amcinonide crea 0.1%
Generic
MO
amcinonide lotn 0.1%
Generic
MO
amcinonide oint 0.1%
Generic
MO
augmented betamethasone dipropionate crea
MO
Generic
0.05%
augmented betamethasone dipropionate gel
MO
Generic
0.05%
augmented betamethasone dipropionate lotn
MO
Generic
0.05%
augmented betamethasone dipropionate oint
MO
Generic
0.05%
baycadron elix 0.5mg/5ml
Generic
betamethasone dipropionate crea 0.05%
Generic
MO
betamethasone dipropionate lotn 0.05%
Generic
MO
betamethasone dipropionate oint 0.05%
Generic
MO
betamethasone valerate crea 0.1%
Generic
MO
betamethasone valerate foam 0.12%
Generic
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
82
Drug Name
betamethasone valerate lotn 0.1%
betamethasone valerate oint 0.1%
budesonide cp24 3mg
clobetasol propionate e crea 0.05%
clobetasol propionate emollient foam 0.05%
clobetasol propionate crea 0.05%
clobetasol propionate foam 0.05%
clobetasol propionate foam 0.05%
clobetasol propionate gel 0.05%
clobetasol propionate liqd 0.05%
clobetasol propionate lotn 0.05%
clobetasol propionate oint 0.05%
clobetasol propionate sham 0.05%
clobetasol propionate soln 0.05%
colocort enem 100mg/60ml
cormax scalp application soln 0.05%
cortisone acetate tabs 25mg
deltasone tabs 20mg
desonide crea 0.05%
desonide lotn 0.05%
desonide oint 0.05%
desoximetasone crea 0.05%
desoximetasone crea 0.25%
desoximetasone gel 0.05%
desoximetasone oint 0.05%
desoximetasone oint 0.25%
DEXAMETHASONE INTENSOL CONC 1MG/
ML
dexamethasone sodium phosphate inj
100mg/10ml
dexamethasone sodium phosphate inj 10mg/ml
dexamethasone sodium phosphate inj 10mg/ml
dexamethasone sodium phosphate inj
120mg/30ml
dexamethasone sodium phosphate inj
20mg/5ml
dexamethasone sodium phosphate inj 4mg/ml
dexamethasone elix 0.5mg/5ml
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
Generic
Generic
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
83
Drug Name
dexamethasone soln 0.5mg/5ml
dexamethasone tabs 0.5mg
dexamethasone tabs 0.75mg
dexamethasone tabs 1.5mg
dexamethasone tabs 1mg
dexamethasone tabs 2mg
dexamethasone tabs 4mg
dexamethasone tabs 6mg
diflorasone diacetate crea 0.05%
diflorasone diacetate oint 0.05%
fludrocortisone acetate tabs 0.1mg
fluocinolone acetonide body oil 0.01%
fluocinolone acetonide scalp oil 0.01%
fluocinolone acetonide crea 0.01%
fluocinolone acetonide crea 0.025%
fluocinolone acetonide oint 0.025%
fluocinolone acetonide soln 0.01%
fluocinonide-e crea 0.05%
fluocinonide crea 0.05%
fluocinonide crea 0.1%
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
fluticasone propionate crea 0.05%
fluticasone propionate lotn 0.05%
fluticasone propionate oint 0.005%
halobetasol propionate crea 0.05%
halobetasol propionate oint 0.05%
hydrocortisone butyrate (lipophilic) crea 0.1%
hydrocortisone butyrate crea 0.1%
hydrocortisone butyrate oint 0.1%
hydrocortisone butyrate soln 0.1%
hydrocortisone in absorbase oint 1%
hydrocortisone valerate crea 0.2%
hydrocortisone valerate oint 0.2%
hydrocortisone crea 1%
hydrocortisone crea 2.5%
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
84
Drug Name
hydrocortisone enem 100mg/60ml
hydrocortisone lotn 2.5%
hydrocortisone oint 1%
hydrocortisone oint 2.5%
hydrocortisone tabs 10mg
hydrocortisone tabs 20mg
hydrocortisone tabs 5mg
methylprednisolone acetate inj 40mg/ml
methylprednisolone acetate inj 80mg/ml
methylprednisolone dose pack tabs 4mg
methylprednisolone sodiumsuccinate inj
1000mg
methylprednisolone sodiumsuccinate inj 125mg
methylprednisolone sodiumsuccinate inj 40mg
methylprednisolone tabs 16mg
methylprednisolone tabs 32mg
methylprednisolone tabs 4mg
methylprednisolone tabs 8mg
MILLIPRED DP TABS 5MG
MILLIPRED SOLN 10MG/5ML
MILLIPRED TABS 5MG
mometasone furoate crea 0.1%
mometasone furoate oint 0.1%
mometasone furoate soln 0.1%
prednicarbate crea 0.1%
prednicarbate oint 0.1%
prednisolone sodium phosphate soln 15mg/5ml
prednisolone sodium phosphate soln 25mg/5ml
prednisolone sodium phosphate soln 5mg/5ml
prednisolone soln 15mg/5ml
prednisolone syrp 15mg/5ml
PREDNISONE INTENSOL CONC 5MG/ML
prednisone soln 5mg/5ml
prednisone tabs 10mg
prednisone tabs 10mg
prednisone tabs 1mg
prednisone tabs 2.5mg
prednisone tabs 20mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
85
Drug Name
Drug Tier
Requirements/
Limits
MO
MO
MO
MO
MO
prednisone tabs 50mg
Generic
prednisone tabs 5mg
Generic
prednisone tabs 5mg
Generic
procto-pak crea 1%
Generic
proctosol hc crea 2.5%
Generic
proctozone-hc crea 2.5%
Generic
proctozone-hc crea 2.5%
Generic
MO
triamcinolone acetonide aers 0.147mg/gm
Generic
MO
triamcinolone acetonide crea 0.025%
Generic
MO
triamcinolone acetonide crea 0.1%
Generic
MO
triamcinolone acetonide crea 0.5%
Generic
MO
triamcinolone acetonide lotn 0.025%
Generic
MO
triamcinolone acetonide lotn 0.1%
Generic
MO
triamcinolone acetonide oint 0.025%
Generic
MO
triamcinolone acetonide oint 0.1%
Generic
MO
triamcinolone acetonide oint 0.5%
Generic
MO
triderm crea 0.1%
Generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)- DRUGS USED TO
REGULATE PITUITARY HORMONES, GROWTH HORMONES
Hormonal Agents, Stimulant/Replacement/Modi‑
fying (Pituitary)
desmopressin acetate inj 4mcg/ml
Generic
MO
desmopressin acetate soln 0.01%
Generic
MO
desmopressin acetate soln 0.01%
Generic
MO
desmopressin acetate soln 0.01%
Generic
MO
desmopressin acetate tabs 0.1mg
Generic
MO
desmopressin acetate tabs 0.2mg
Generic
MO
EGRIFTA INJ 1MG
OTHER
QL (60 EA per 30 days) PA LA
EGRIFTA INJ 2MG
OTHER
QL (30 EA per 30 days) PA LA
INCRELEX INJ 40MG/4ML
OTHER
PA LA
NORDITROPIN FLEXPRO INJ 10MG/1.5ML
OTHER
PA
NORDITROPIN FLEXPRO INJ 15MG/1.5ML
OTHER
PA
NORDITROPIN FLEXPRO INJ 5MG/1.5ML
OTHER
PA
NORDITROPIN NORDIFLEX PEN INJ
PA
OTHER
30MG/3ML
VASOSTRICT INJ 20UNIT/ML
OTHER
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)BIRTH CONTROL, ENDOMETRIOSIS, ESTROGENS, MALE HORMONES
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
86
Drug Name
Anabolic Steroids
ANADROL-50 TABS 50MG
oxandrolone tabs 10mg
oxandrolone tabs 2.5mg
Androgens
ANDROGEL PUMP GEL 1%
ANDROGEL PUMP GEL 1.62%
ANDROGEL GEL 20.25MG/1.25GM
ANDROGEL GEL 25MG/2.5GM
ANDROGEL GEL 40.5MG/2.5GM
ANDROGEL GEL 50MG/5GM
danazol caps 100mg
danazol caps 200mg
danazol caps 50mg
testosterone cypionate inj 100mg/ml
testosterone cypionate inj 200mg/ml
testosterone enanthate inj 200mg/ml
testosterone gel 25mg/2.5gm
Estrogens – Hormonal Replacement
ESTRACE CREA 0.1MG/GM
estradiol pttw 0.025mg/24hr
estradiol pttw 0.0375mg/24hr
estradiol pttw 0.05mg/24hr
estradiol pttw 0.075mg/24hr
estradiol pttw 0.1mg/24hr
estradiol ptwk 0.025mg/24hr
estradiol ptwk 0.05mg/24hr
estradiol ptwk 0.06mg/24hr
estradiol ptwk 0.075mg/24hr
estradiol ptwk 0.1mg/24hr
estradiol ptwk 37.5mcg/24hr
estradiol tabs 0.5mg
estradiol tabs 1mg
estradiol tabs 2mg
MENEST TABS 0.3MG
MENEST TABS 0.625MG
MENEST TABS 1.25MG
Drug Tier
Requirements/
Limits
OTHER
Generic
Generic
MO
QL (60 EA per 30 days) PA MO
QL (120 EA per 30 days) PA MO
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL (300 GM per 30 days) PA MO
PA MO
PA MO
QL (300 GM per 30 days) PA MO
PA MO
QL (300 GM per 30 days) PA MO
MO
MO
MO
PA MO
PA MO
PA MO
QL (300 GM per 30 days) PA MO
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
MO
QL (8 EA per 28 days) PA MO
QL (8 EA per 28 days) PA MO
QL (8 EA per 28 days) PA MO
QL (8 EA per 28 days) PA MO
QL (8 EA per 28 days) PA MO
QL (4 EA per 28 days) PA MO
QL (4 EA per 28 days) PA MO
QL (4 EA per 28 days) PA MO
QL (4 EA per 28 days) PA MO
QL (4 EA per 28 days) PA MO
QL (4 EA per 28 days) PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
87
Drug Name
MENEST TABS 2.5MG
VAGIFEM TABS 10MCG
Estrogens – Birth Control
altavera tabs 0.03mg; 0.15mg
alyacen 1/35 tabs 35mcg; 1mg
alyacen 7/7/7 tabs 0; 0
amethia lo tabs 0; 0
amethia tabs 0; 0
amethyst tabs 20mcg; 90mcg
apri tabs 0.15mg; 30mcg
aranelle tabs 0; 0
ashlyna tabs 0; 0
aubra tabs 20mcg; 0.1mg
aviane tabs 20mcg; 0.1mg
azurette tabs 0; 0
balziva tabs 35mcg; 0.4mg
briellyn tabs 35mcg; 0.4mg
camrese lo tabs 0; 0
camrese tabs 0; 0
caziant tabs 0; 0
chateal tabs 0.03mg; 0.15mg
cryselle-28 tabs 30mcg; 0.3mg
cyclafem 1/35 tabs 35mcg; 1mg
cyclafem 7/7/7 tabs 0; 0
cyred tabs 0.15mg; 30mcg
dasetta 1/35 tabs 35mcg; 1mg
dasetta 7/7/7 tabs 0; 0
daysee tabs 0; 0
delyla tabs 20mcg; 0.1mg
DEPO-ESTRADIOL INJ 5MG/ML
desogestrel/ethinyl estradiol tabs 0.15mg;
30mcg
desogestrel/ethinyl estradiol tabs 0; 0
drospirenone/ethinyl estradiol tabs 3mg; 0.03mg
elinest tabs 30mcg; 0.3mg
emoquette tabs 0.15mg; 30mcg
enpresse-28 tabs 0; 0
enskyce tabs 0.15mg; 30mcg
Drug Tier
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
88
Drug Name
estarylla tabs 35mcg; 0.25mg
estradiol/norethindrone acetate tabs 0.5mg;
0.1mg
estradiol/norethindrone acetate tabs 1mg;
0.5mg
falmina tabs 20mcg; 0.1mg
gianvi tabs 3mg; 0.02mg
gildagia tabs 35mcg; 0.4mg
gildess 1.5/30 tabs 30mcg; 1.5mg
gildess 1/20 tabs 20mcg; 1mg
gildess 24 fe tabs 20mcg; 75mg; 1mg
gildess fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
gildess fe 1/20 tabs 20mcg; 75mg; 1mg
introvale tabs 0.03mg; 0.15mg
JINTELI TABS 5MCG; 1MG
jolessa tabs 0.03mg; 0.15mg
juleber tabs 0.15mg; 30mcg
junel 1.5/30 tabs 30mcg; 1.5mg
junel 1/20 tabs 20mcg; 1mg
junel fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
junel fe 1/20 tabs 20mcg; 75mg; 1mg
junel fe 24 tabs 20mcg; 75mg; 1mg
kariva tabs 0; 0
kelnor 1/35 tabs 35mcg; 1mg
kimidess tabs 0; 0
kurvelo tabs 0.03mg; 0.15mg
larin 1.5/30 tabs 30mcg; 1.5mg
larin 1/20 tabs 20mcg; 1mg
larin 24 fe tabs 20mcg; 75mg; 1mg
larin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg
larin fe 1/20 tabs 20mcg; 75mg; 1mg
layolis fe chew 25mcg; 75mg; 0.8mg
leena tabs 0; 0
lessina tabs 20mcg; 0.1mg
levonest tabs 0; 0
levonorgestrel and ethinyl estradiol tabs 0; 0
levonorgestrel and ethinyl estradiol tabs 20mcg;
90mcg
Drug Tier
Requirements/
Limits
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
PA MO
PA MO
MO
MO
PA MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
89
Drug Name
levonorgestrel/ethinyl estradiol tabs 0.03mg;
0.15mg
levonorgestrel/ethinyl estradiol tabs 0.03mg;
0.15mg
levonorgestrel/ethinyl estradiol tabs 0; 0
levonorgestrel/ethinyl estradiol tabs 20mcg;
0.1mg
levora 0.15/30-28 tabs 30mcg; 0.15mg
lomedia 24 fe tabs 20mcg; 75mg; 1mg
lopreeza tabs 0.5mg; 0.1mg
lopreeza tabs 1mg; 0.5mg
loryna tabs 3mg; 0.02mg
low-ogestrel tabs 30mcg; 0.3mg
lutera tabs 20mcg; 0.1mg
marlissa tabs 0.03mg; 0.15mg
microgestin 1.5/30 tabs 30mcg; 1.5mg
microgestin 1/20 tabs 20mcg; 1mg
microgestin fe 1.5/30 tabs 30mcg; 75mg;
1.5mg
microgestin fe tabs 20mcg; 75mg; 1mg
mimvey lo tabs 0.5mg; 0.1mg
mimvey tabs 1mg; 0.5mg
mono-linyah tabs 35mcg; 0.25mg
mononessa tabs 35mcg; 0.25mg
myzilra tabs 0; 0
necon 0.5/35-28 tabs 35mcg; 0.5mg
necon 1/35 tabs 35mcg; 1mg
NECON 1/50-28 TABS 50MCG; 1MG
NECON 10/11-28 TABS 35MCG; 0
necon 7/7/7 tabs 0; 0
nikki tabs 3mg; 0.02mg
norethindrone & ethinyl estradiol ferrous fumarate chew 25mcg; 75mg; 0.8mg
norethindrone acetate/ethinyl estradiol/ferrous
fumarate tabs 20mcg; 75mg; 1mg
norethindrone acetate/ethinyl estradiol/ferrous
fumarate tabs 20mcg; 75mg; 1mg
norethindrone acetate/ethinyl estradiol tabs
20mcg; 1mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
PA
PA
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
PA MO
PA MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
90
Drug Name
norethindrone acetate/ethinyl estradiol tabs
5mcg; 1mg
norgestimate/ethinyl estradiol tabs 0; 0
norgestimate/ethinyl estradiol tabs 35mcg;
0.25mg
NORINYL 1+50 TABS 50MCG; 1MG
nortrel 0.5/35 (28) tabs 35mcg; 0.5mg
nortrel 1/35 tabs 35mcg; 1mg
nortrel 1/35 tabs 35mcg; 1mg
nortrel 7/7/7 tabs 0; 0
ocella tabs 3mg; 0.03mg
OGESTREL TABS 50MCG; 0.5MG
orsythia tabs 20mcg; 0.1mg
philith tabs 35mcg; 0.4mg
pimtrea tabs 0; 0
pirmella 1/35 tabs 35mcg; 1mg
pirmella 7/7/7 tabs 0; 0
portia-28 tabs 0.03mg; 0.15mg
previfem tabs 35mcg; 0.25mg
quasense tabs 0.03mg; 0.15mg
reclipsen tabs 0.15mg; 30mcg
setlakin tabs 0.03mg; 0.15mg
sprintec 28 tabs 35mcg; 0.25mg
sronyx tabs 20mcg; 0.1mg
syeda tabs 3mg; 0.03mg
tarina fe 1/20 tabs 20mcg; 75mg; 1mg
tilia fe tabs 0; 75mg; 1mg
tri-estarylla tabs 0; 0
tri-legest fe tabs 0; 75mg; 1mg
tri-linyah tabs 0; 0
tri-previfem tabs 0; 0
tri-sprintec tabs 0; 0
trinessa tabs 0; 0
trivora-28 tabs 0; 0
velivet tabs 0; 0
vestura tabs 3mg; 0.02mg
viorele tabs 0; 0
vyfemla tabs 35mcg; 0.4mg
Drug Tier
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
PA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
91
Drug Name
wera tabs 35mcg; 0.5mg
wymzya fe chew 35mcg; 0; 0.4mg
zarah tabs 3mg; 0.03mg
zenchent fe chew 35mcg; 0; 0.4mg
zenchent tabs 35mcg; 0.4mg
zovia 1/35e tabs 35mcg; 1mg
ZOVIA 1/50E TABS 50MCG; 1MG
Progesterone Agonists/Antagonists
ELLA TABS 30MG
Progestins
camila tabs 0.35mg
deblitane tabs 0.35mg
DEPO-PROVERA INJ 400MG/ML
errin tabs 0.35mg
heather tabs 0.35mg
jencycla tabs 0.35mg
jolivette tabs 0.35mg
levonorgestrel tabs 0.75mg
levonorgestrel tabs 1.5mg
lyza tabs 0.35mg
medroxyprogesterone acetate inj 150mg/ml
medroxyprogesterone acetate tabs 10mg
medroxyprogesterone acetate tabs 2.5mg
medroxyprogesterone acetate tabs 5mg
megestrol acetate susp 40mg/ml
megestrol acetate tabs 20mg
megestrol acetate tabs 40mg
nora-be tabs 0.35mg
norethindrone acetate tabs 5mg
norethindrone tabs 0.35mg
norlyroc tabs 0.35mg
progesterone caps 100mg
progesterone caps 200mg
progesterone inj 50mg/ml
sharobel tabs 0.35mg
Selective Estrogen Receptor Modifying Agents
raloxifene hydrochloride tabs 60mg
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Requirements/
Limits
MO
MO
OTHER
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
PA MO
PA MO
PA MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
92
Requirements/
Limits
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) - DRUGS USED TO
REGULATE THYROID LEVELS
Hormonal Agents, Stimulant/Replacement/Modi‑
fying (Thyroid)
levothyroxine sodium inj 100mcg
Generic
MO
levothyroxine sodium inj 200mcg
Generic
MO
levothyroxine sodium inj 500mcg
Generic
MO
levothyroxine sodium tabs 100mcg
Generic
MO
levothyroxine sodium tabs 112mcg
Generic
MO
levothyroxine sodium tabs 125mcg
Generic
MO
levothyroxine sodium tabs 137mcg
Generic
MO
levothyroxine sodium tabs 150mcg
Generic
MO
levothyroxine sodium tabs 175mcg
Generic
MO
levothyroxine sodium tabs 200mcg
Generic
MO
levothyroxine sodium tabs 25mcg
Generic
MO
levothyroxine sodium tabs 300mcg
Generic
MO
levothyroxine sodium tabs 50mcg
Generic
MO
levothyroxine sodium tabs 75mcg
Generic
MO
levothyroxine sodium tabs 88mcg
Generic
MO
levoxyl tabs 100mcg
Generic
MO
levoxyl tabs 112mcg
Generic
MO
levoxyl tabs 125mcg
Generic
MO
levoxyl tabs 137mcg
Generic
MO
levoxyl tabs 150mcg
Generic
MO
levoxyl tabs 175mcg
Generic
MO
levoxyl tabs 200mcg
Generic
MO
levoxyl tabs 25mcg
Generic
MO
levoxyl tabs 50mcg
Generic
MO
levoxyl tabs 75mcg
Generic
MO
levoxyl tabs 88mcg
Generic
MO
liothyronine sodium tabs 25mcg
Generic
MO
liothyronine sodium tabs 50mcg
Generic
MO
liothyronine sodium tabs 5mcg
Generic
MO
SYNTHROID TABS 100MCG
OTHER
MO
SYNTHROID TABS 112MCG
OTHER
MO
SYNTHROID TABS 125MCG
OTHER
MO
SYNTHROID TABS 137MCG
OTHER
MO
SYNTHROID TABS 150MCG
OTHER
MO
Drug Name
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
93
Drug Name
SYNTHROID TABS 175MCG
SYNTHROID TABS 200MCG
SYNTHROID TABS 25MCG
SYNTHROID TABS 300MCG
SYNTHROID TABS 50MCG
SYNTHROID TABS 75MCG
SYNTHROID TABS 88MCG
THYROLAR-1/2 TABS 30MG
THYROLAR-1/4 TABS 15MG
THYROLAR-1 TABS 60MG
THYROLAR-2 TABS 120MG
THYROLAR-3 TABS 180MG
unithroid tabs 100mcg
unithroid tabs 112mcg
unithroid tabs 125mcg
unithroid tabs 137mcg
unithroid tabs 150mcg
unithroid tabs 175mcg
unithroid tabs 200mcg
unithroid tabs 25mcg
unithroid tabs 300mcg
unithroid tabs 50mcg
unithroid tabs 75mcg
unithroid tabs 88mcg
Drug Tier
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
HORMONAL AGENTS, SUPPRESSANT (ADRENAL) - DRUG(S) USED TO TREAT ADRENAL CORTICAL
CANCER
Hormonal Agents, Suppressant (Adrenal)
LYSODREN TABS 500MG
OTHER
MO
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) - DRUGS USED TO TREAT HIGH CALCIUM
LEVELS IN PEOPLE WITH CHRONIC KIDNEY DISEASE
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABS 30MG
OTHER
QL (60 EA per 30 days)
SENSIPAR TABS 60MG
OTHER
QL (60 EA per 30 days)
SENSIPAR TABS 90MG
OTHER
QL (120 EA per 30 days)
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)- DRUGS USED TO TREAT PROSTATE CANCER AND
OTHER CONDITIONS ASSOCIATED WITH AN OVERACTIVE PITUITARY GLAND
Hormonal Agents, Suppressant (Pituitary)
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
94
Drug Name
cabergoline tabs 0.5mg
FIRMAGON INJ 120MG
FIRMAGON INJ 80MG
leuprolide acetate inj 1mg/0.2ml
LUPRON DEPOT-PED INJ 11.25MG
LUPRON DEPOT-PED INJ 11.25MG
LUPRON DEPOT-PED INJ 15MG
LUPRON DEPOT-PED INJ 30MG
LUPRON DEPOT-PED INJ 7.5MG
LUPRON DEPOT INJ 11.25MG
LUPRON DEPOT INJ 22.5MG
LUPRON DEPOT INJ 3.75MG
LUPRON DEPOT INJ 30MG
LUPRON DEPOT INJ 45MG
LUPRON DEPOT INJ 7.5MG
octreotide acetate inj 1000mcg/ml
octreotide acetate inj 100mcg/ml
octreotide acetate inj 200mcg/ml
octreotide acetate inj 500mcg/ml
octreotide acetate inj 50mcg/ml
SIGNIFOR INJ 0.3MG/ML
SIGNIFOR INJ 0.6MG/ML
SIGNIFOR INJ 0.9MG/ML
SOMATULINE DEPOT INJ 120MG/0.5ML
SOMATULINE DEPOT INJ 60MG/0.2ML
SOMATULINE DEPOT INJ 90MG/0.3ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
SOMAVERT INJ 25MG
SOMAVERT INJ 30MG
SYNAREL SOLN 2MG/ML
TRELSTAR MIXJECT INJ 11.25MG
TRELSTAR MIXJECT INJ 22.5MG
TRELSTAR MIXJECT INJ 3.75MG
VANTAS INJ 50MG
ZOLADEX INJ 10.8MG
Drug Tier
Generic
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
MO
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL (60 ML per 30 days) PA
QL (60 ML per 30 days) PA
QL (60 ML per 30 days) PA
QL (0.5 ML per 28 days) PA
QL (0.2 ML per 28 days) PA
QL (0.3 ML per 28 days) PA
PA LA
PA LA
PA LA
PA LA
PA LA
MO
PA
PA
PA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
95
Drug Name
Drug Tier
Requirements/
Limits
ZOLADEX INJ 3.6MG
OTHER
HORMONAL AGENTS, SUPPRESSANT (THYROID) - DRUGS USED TO LOWER THYROID LEVELS
Antithyroid Agents
methimazole tabs 10mg
Generic
MO
methimazole tabs 5mg
Generic
MO
propylthiouracil tabs 50mg
Generic
MO
IMMUNOLOGICAL AGENTS- VACCINES, RHEUMATOID ARTHRITIS , IMMUNOGLOBULINS,
IMMUNOMODULATORS, IMMUNOSUPPRESSANTS
Angioedema (HAE) Agents
CINRYZE INJ 500UNIT
OTHER
PA LA
FIRAZYR INJ 30MG/3ML
OTHER
QL (270 ML per 30 days) PA LA
Immune Suppressants
azathioprine tabs 50mg
Generic
B/D MO
CELLCEPT INTRAVENOUS INJ 500MG
OTHER
PA
CELLCEPT SUSR 200MG/ML
OTHER
PA MO
CIMZIA STARTER KIT INJ 200MG/ML
OTHER
QL (6 EA per 28 days) PA
CIMZIA INJ 200MG/ML
OTHER
QL (6 EA per 28 days) PA
CIMZIA INJ 200MG
OTHER
QL (6 EA per 28 days) PA
cyclosporine modified caps 100mg
Generic
PA MO
cyclosporine modified caps 25mg
Generic
PA MO
cyclosporine modified caps 50mg
Generic
PA MO
cyclosporine modified soln 100mg/ml
Generic
PA MO
cyclosporine caps 100mg
Generic
PA MO
cyclosporine caps 25mg
Generic
PA MO
cyclosporine inj 50mg/ml
Generic
PA
gengraf caps 100mg
Generic
PA
gengraf caps 25mg
Generic
PA
gengraf soln 100mg/ml
Generic
PA MO
hecoria caps 0.5mg
Generic
PA
hecoria caps 1mg
Generic
PA
hecoria caps 5mg
Generic
PA
HUMIRA PEDIATRIC CROHNS DISEASE
QL (6 EA per 28 days) PA
OTHER
STARTER PACK INJ 40MG/0.8ML
HUMIRA PEN-CROHNS DISEASESTARTER INJ
QL (6 EA per 28 days) PA
OTHER
40MG/0.8ML
HUMIRA PEN-PSORIASIS STARTER INJ
QL (6 EA per 28 days) PA
OTHER
40MG/0.8ML
HUMIRA PEN INJ 40MG/0.8ML
OTHER
QL (6 EA per 28 days) PA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
96
Drug Name
HUMIRA INJ 10MG/0.2ML
HUMIRA INJ 20MG/0.4ML
HUMIRA INJ 40MG/0.8ML
methotrexate sodium inj 1gm/40ml
methotrexate sodium inj 1gm
methotrexate sodium inj 25mg/ml
methotrexate tabs 2.5mg
mycophenolate mofetil caps 250mg
mycophenolate mofetil susr 200mg/ml
mycophenolate mofetil tabs 500mg
NULOJIX INJ 250MG
PROGRAF INJ 5MG/ML
RAPAMUNE SOLN 1MG/ML
REMICADE INJ 100MG
SANDIMMUNE SOLN 100MG/ML
SIMULECT INJ 10MG
SIMULECT INJ 20MG
sirolimus tabs 0.5mg
sirolimus tabs 1mg
sirolimus tabs 2mg
tacrolimus caps 0.5mg
tacrolimus caps 1mg
tacrolimus caps 5mg
ZORTRESS TABS 0.25MG
ZORTRESS TABS 0.5MG
ZORTRESS TABS 0.75MG
Immunizing Agents, Passive
ATGAM INJ 50MG/ML
GAMASTAN S/D INJ 0
GAMMAPLEX INJ 10GM/200ML
GAMMAPLEX INJ 2.5GM/50ML
GAMMAPLEX INJ 20GM/400ML
GAMMAPLEX INJ 5GM/100ML
THYMOGLOBULIN INJ 25MG
Immunomodulators
ACTIMMUNE INJ 2000000UNIT/0.5ML
Drug Tier
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Requirements/
Limits
QL (2 EA per 28 days) PA
QL (2 EA per 28 days) PA
QL (6 EA per 28 days) PA
MO
PA MO
PA MO
PA MO
PA
PA
PA MO
PA
PA MO
B/D
B/D
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
PA MO
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
PA
PA
PA
PA LA
PA LA
PA LA
B/D
OTHER
PA LA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
97
Drug Name
ARCALYST INJ 220MG
BENLYSTA INJ 120MG
BENLYSTA INJ 400MG
ILARIS INJ 180MG
leflunomide tabs 10mg
leflunomide tabs 20mg
SYNAGIS INJ 100MG/ML
SYNAGIS INJ 50MG/0.5ML
Vaccines
ACTHIB INJ 0
ADACEL INJ 15.5MCG/0.5ML; 2LF/0.5ML;
5LF/0.5ML
bcg vaccine inj 0
BEXSERO INJ 0
BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML;
5LF/0.5ML
BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML;
5LF/0.5ML
CERVARIX INJ 0
COMVAX INJ 7.5MCG/0.5ML; 5MCG/0.5ML
DAPTACEL INJ 10MCG/0.5ML; 15LF/0.5ML;
5LF/0.5ML
diphtheria/tetanus toxoids adsorbed pediatric inj
25lfu/0.5ml; 5lfu/0.5ml
ENGERIX-B INJ 10MCG/0.5ML
ENGERIX-B INJ 10MCG/0.5ML
ENGERIX-B INJ 20MCG/ML
GARDASIL 9 INJ 0
GARDASIL 9 INJ 0
GARDASIL INJ 0
GARDASIL INJ 0
HAVRIX INJ 1440ELU/ML
HAVRIX INJ 720ELU/0.5ML
HIBERIX INJ 10MCG
IMOVAX RABIES (H.D.C.V.) INJ 2.5UNIT/ML
INFANRIX INJ 58MCG/0.5ML; 25LFU/0.5ML;
10LFU/0.5ML
IPOL INACTIVATED IPV INJ 0
Drug Tier
OTHER
OTHER
OTHER
OTHER
Generic
Generic
OTHER
OTHER
Requirements/
Limits
PA LA
PA
PA
QL (2 EA per 28 days) PA LA
MO
MO
PA
PA
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
B/D
B/D
B/D
B/D
OTHER
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
98
Drug Name
Drug Tier
Requirements/
Limits
IPOL INACTIVATED IPV INJ 0
OTHER
IXIARO INJ 0
OTHER
KINRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 0;
OTHER
10LFU/0.5ML
M-M-R II INJ 0; 0; 0
OTHER
MENACTRA INJ 0
OTHER
MENOMUNE-A/C/Y/W-135 INJ 0
OTHER
MENVEO INJ 0
OTHER
PEDIARIX INJ 58MCG/0.5ML; 25LFU/0.5ML;
OTHER
10MCG/0.5ML; 0; 10LFU/0.5ML
PEDVAX HIB INJ 7.5MCG/0.5ML
OTHER
PENTACEL INJ 48MCG/0.5ML; 15LFU/0.5ML;
OTHER
0; 0; 5LFU/0.5ML
PROQUAD INJ 0; 0; 0; 0
OTHER
QUADRACEL INJ 48MCG/0.5ML;
OTHER
15LFU/0.5ML; 0; 5LFU/0.5ML
RABAVERT INJ 0
OTHER
B/D
RECOMBIVAX HB INJ 10MCG/ML
OTHER
B/D
RECOMBIVAX HB INJ 10MCG/ML
OTHER
B/D
RECOMBIVAX HB INJ 40MCG/ML
OTHER
B/D
RECOMBIVAX HB INJ 5MCG/0.5ML
OTHER
B/D
ROTARIX SUSR 0
OTHER
ROTATEQ SOLN 0
OTHER
TENIVAC INJ 2LFU; 5LFU
OTHER
tetanus/diphtheria toxoids-adsorbed adult inj
Generic
2lf/0.5ml; 2lf/0.5ml
TRUMENBA INJ 0
OTHER
TWINRIX INJ 720ELU/ML; 20MCG/ML
OTHER
TYPHIM VI INJ 25MCG/0.5ML
OTHER
VAQTA INJ 25UNIT/0.5ML
OTHER
VAQTA INJ 50UNIT/ML
OTHER
VARIVAX INJ 1350PFU/0.5ML
OTHER
YF-VAX INJ 0
OTHER
ZOSTAVAX INJ 19400UNT/0.65ML
OTHER
QL (1 EA per 365 days)
INFLAMMATORY BOWEL DISEASE AGENTS DRUGS USED TO MANAGE DISORDERS IN THE COLON
AND/OR INTESTINES
Aminosalicylates
APRISO CP24 0.375GM
OTHER
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
99
Drug Name
Drug Tier
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
ASACOL HD TBEC 800MG
OTHER
balsalazide disodium caps 750mg
Generic
DELZICOL CPDR 400MG
OTHER
LIALDA TBEC 1.2GM
OTHER
mesalamine enem 4gm
Generic
mesalamine kit 4gm
Generic
PENTASA CPCR 250MG
OTHER
PENTASA CPCR 500MG
OTHER
Sulfonamides
sulfasalazine tabs 500mg
Generic
MO
sulfasalazine tbec 500mg
Generic
MO
sulfazine ec tbec 500mg
Generic
sulfazine tabs 500mg
Generic
METABOLIC BONE DISEASE AGENTS- DRUGS USED TO TREAT BONE LOSS
Metabolic Bone Disease Agents
alendronate sodium soln 70mg/75ml
Generic
MO
alendronate sodium tabs 10mg
Generic
QL (30 EA per 30 days) MO
alendronate sodium tabs 35mg
Generic
QL (4 EA per 28 days) MO
alendronate sodium tabs 40mg
Generic
QL (30 EA per 30 days) MO
alendronate sodium tabs 5mg
Generic
QL (30 EA per 30 days) MO
alendronate sodium tabs 70mg
Generic
QL (4 EA per 28 days) MO
calcitonin-salmon soln 200unit/act
Generic
MO
calcitriol caps 0.25mcg
Generic
MO
calcitriol caps 0.5mcg
Generic
MO
calcitriol inj 1mcg/ml
Generic
calcitriol soln 1mcg/ml
Generic
MO
doxercalciferol caps 0.5mcg
Generic
MO
doxercalciferol caps 1mcg
Generic
MO
doxercalciferol caps 2.5mcg
Generic
MO
etidronate disodium tabs 200mg
Generic
MO
etidronate disodium tabs 400mg
Generic
MO
FORTEO INJ 600MCG/2.4ML
OTHER
QL (2.4 ML per 28 days) PA
MIACALCIN INJ 200UNIT/ML
OTHER
MO
pamidronate disodium inj 30mg/10ml
Generic
pamidronate disodium inj 30mg
Generic
pamidronate disodium inj 6mg/ml
Generic
pamidronate disodium inj 90mg/10ml
Generic
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
100
Drug Name
pamidronate disodium inj 90mg
paricalcitol caps 1mcg
paricalcitol caps 2mcg
paricalcitol caps 4mcg
paricalcitol inj 2mcg/ml
paricalcitol inj 5mcg/ml
PROLIA INJ 60MG/ML
risedronate sodium dr tbec 35mg
risedronate sodium tabs 150mg
risedronate sodium tabs 30mg
risedronate sodium tabs 35mg
risedronate sodium tabs 35mg
risedronate sodium tabs 5mg
XGEVA INJ 120MG/1.7ML
zoledronic acid inj 4mg/5ml
zoledronic acid inj 4mg
zoledronic acid inj 5mg/100ml
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
ALCOHOL PREP PADS PADS 70%
GAUZE PADS 2”X2” PADS
INSULIN SYRINGE SAFETYGLIDE/1ML/29G X
1/2” MISC
INSULIN SYRINGE ULTRAFINE/0.3ML/31G X
5/16” MISC
INSULIN SYRINGE ULTRAFINE/0.5ML/30G X
1/2” MISC
INSULIN SYRINGE ULTRAFINE/1ML/31G X
5/16” MISC
NATPARA INJ 100MCG
NATPARA INJ 25MCG
NATPARA INJ 50MCG
NATPARA INJ 75MCG
PEN NEEDLE/ULTRAFINE/29G X 12.7MM
MISC
V-GO 20 KIT
V-GO 30 KIT
V-GO 40 KIT
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
MO
MO
MO
QL (1 ML per 180 days)
QL (4 EA per 28 days) MO
QL (1 EA per 28 days) MO
QL (30 EA per 30 days) MO
QL (12 EA per 84 days) MO
QL (12 EA per 84 days) MO
QL (30 EA per 30 days) MO
PA
MO
MO
MO
MO
MO
MO
QL (2 EA per 28 days) PA
QL (2 EA per 28 days) PA
QL (2 EA per 28 days) PA
QL (2 EA per 28 days) PA
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
101
Requirements/
Limits
OPHTHALMIC AGENTS- DRUGS USED TO TREAT EYE ALLERGIES, INFECTIONS, INFLAMMATION, AND
GLAUCOMA
Ophthalmic Prostaglandin and Prostamide Ana‑
logs
COMBIGAN SOLN 0.2%; 0.5%
OTHER
MO
latanoprost soln 0.005%
Generic
MO
LUMIGAN SOLN 0.01%
OTHER
MO
TRAVATAN Z SOLN 0.004%
OTHER
MO
travoprost soln 0.004%
Generic
MO
Ophthalmic Agents, Other
ak-poly-bac oint 500unit/gm; 10000unit/gm
Generic
atropine sulfate soln 1%
Generic
MO
AZASITE SOLN 1%
OTHER
MO
bacitracin/neomycin/polymyxin oint 400unit/
MO
Generic
gm; 5mg/gm; 10000unit/gm
bacitracin/polymyxin b oint 500unit/gm;
MO
Generic
10000unit/gm
bacitracin oint 500unit/gm
Generic
MO
BESIVANCE SUSP 0.6%
OTHER
MO
ciprofloxacin hcl soln 0.3%
Generic
MO
CYSTARAN SOLN 0.44%
OTHER
QL (60 ML per 28 days)
erythromycin oint 5mg/gm
Generic
MO
gentak oint 0.3%
Generic
MO
gentamicin sulfate oint 0.3%
Generic
MO
gentamicin sulfate soln 0.3%
Generic
MO
levofloxacin soln 0.5%
Generic
MO
MOXEZA SOLN 0.5%
OTHER
MO
naphazoline hcl soln 0.1%
Generic
MO
neo-polycin oint 400unit/gm; 3.5mg/gm;
Generic
10000unit/gm
neomycin/bacitracin/polymyxin oint 400unit/
MO
Generic
gm; 5mg/gm; 10000unit/gm
neomycin/polymyxin/bacitracin/hydrocortisone
MO
Generic
oint 400unit/gm; 1%; 0.5%; 10000unit/gm
neomycin/polymyxin/dexamethasone oint 0.1%;
MO
Generic
3.5mg/gm; 10000unit/gm
neomycin/polymyxin/dexamethasone susp 0.1%;
MO
Generic
3.5mg/ml; 10000unit/ml
Drug Name
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
102
Drug Name
neomycin/polymyxin/gramicidin soln 0.025mg/
ml; 1.75mg/ml; 10000unit/ml
neomycin/polymyxin/hydrocortisone susp 1%;
3.5mg/ml; 10000unit/ml
ofloxacin soln 0.3%
polycin oint 500unit/gm; 10000unit/gm
polymyxin b sulfate/trimethoprim sulfate soln
10000unit/ml; 0.1%
proparacaine hcl soln 0.5%
RESTASIS EMUL 0.05%
sodium sulfacetamide soln 10%
sulfacetamide sodium/prednisolone sodium
phosphate soln 0.23%; 10%
sulfacetamide sodium oint 10%
sulfacetamide sodium soln 10%
TOBRADEX ST SUSP 0.05%; 0.3%
TOBRADEX OINT 0.1%; 0.3%
TOBRADEX SUSP 0.1%; 0.3%
tobramycin sulfate soln 0.3%
tobramycin/dexamethasone susp 0.1%; 0.3%
TOBREX OINT 0.3%
trifluridine soln 1%
trimethoprim sulfate/polymyxin b sulfate soln
10000unit/ml; 0.1%
triple antibiotic oint 400unit/gm; 5mg/gm;
10000unit/gm
VIGAMOX SOLN 0.5%
ZIRGAN GEL 0.15%
Ophthalmic Anti-allergy Agents
azelastine hcl soln 0.05%
cromolyn sodium soln 4%
epinastine hcl soln 0.05%
PATADAY SOLN 0.2%
PATANOL SOLN 0.1%
PAZEO SOLN 0.7%
Ophthalmic Anti-inflammatories
ACUVAIL SOLN 0.45%
dexamethasone sodium phosphate soln 0.1%
Drug Tier
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
OTHER
Generic
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Generic
OTHER
OTHER
MO
MO
Generic
Generic
Generic
OTHER
OTHER
OTHER
MO
MO
MO
MO
MO
MO
OTHER
Generic
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
103
Drug Name
DUREZOL EMUL 0.05%
fluorometholone susp 0.1%
flurbiprofen sodium soln 0.03%
ILEVRO SUSP 0.3%
ketorolac tromethamine soln 0.4%
ketorolac tromethamine soln 0.5%
NEVANAC SUSP 0.1%
prednisolone acetate susp 1%
prednisolone sodium phosphate soln 1%
PROLENSA SOLN 0.07%
Ophthalmic Antiglaucoma Agents
ALPHAGAN P SOLN 0.1%
apraclonidine soln 0.5%
AZOPT SUSP 1%
betaxolol hcl soln 0.5%
BETIMOL SOLN 0.25%
BETIMOL SOLN 0.5%
BETOPTIC-S SUSP 0.25%
brimonidine tartrate soln 0.15%
brimonidine tartrate soln 0.2%
carteolol hcl soln 1%
dorzolamide hcl/timolol maleate soln 22.3mg/
ml; 6.8mg/ml
dorzolamide hcl soln 2%
ISOPTO CARPINE SOLN 1%
ISOPTO CARPINE SOLN 2%
ISOPTO CARPINE SOLN 4%
levobunolol hcl soln 0.25%
levobunolol hcl soln 0.5%
metipranolol soln 0.3%
PHOSPHOLINE IODIDE SOLR 0.125%
pilocarpine hcl soln 1%
pilocarpine hcl soln 2%
pilocarpine hcl soln 4%
SIMBRINZA SUSP 0.2%; 1%
timolol maleate ophthalmic gel forming solg
0.25%
Drug Tier
OTHER
Generic
Generic
OTHER
Generic
Generic
OTHER
Generic
Generic
OTHER
OTHER
Generic
OTHER
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
OTHER
Generic
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
104
Drug Name
Drug Tier
Requirements/
Limits
MO
timolol maleate ophthalmic gel forming solg
Generic
0.5%
timolol maleate soln 0.25%
Generic
MO
timolol maleate soln 0.5%
Generic
MO
OTIC AGENTS- DRUGS USED TO TREAT CONDITIONS OF THE EAR
Otic Agents
acetasol hc soln 2%; 1%
Generic
acetic acid/aluminum acetate soln 2%; 0
Generic
MO
acetic acid soln 2%
Generic
MO
antibiotic ear soln 1%; 3.5mg/ml; 10000unit/ml
Generic
fluocinolone acetonide oil 0.01%
Generic
MO
hydrocortisone/acetic acid soln 2%; 1%
Generic
MO
neomycin/polymyxin/hc soln 1%; 3.5mg/ml;
MO
Generic
10000unit/ml
neomycin/polymyxin/hydrocortisone susp 1%;
MO
Generic
3.5mg/ml; 10000unit/ml
ofloxacin soln 0.3%
Generic
MO
RESPIRATORY TRACT/PULMONARY AGENTS- DRUGS USED TO TREAT ALLERGIES, ASTHMA, COPD,
PULMONARY HYPERTENSION
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS AEPB 100MCG/DOSE;
QL (60 EA per 30 days) MO
OTHER
50MCG/DOSE
ADVAIR DISKUS AEPB 250MCG/DOSE;
QL (60 EA per 30 days) MO
OTHER
50MCG/DOSE
ADVAIR DISKUS AEPB 500MCG/DOSE;
QL (60 EA per 30 days) MO
OTHER
50MCG/DOSE
ADVAIR HFA AERO 115MCG/ACT; 21MCG/
QL (12 GM per 30 days) MO
OTHER
ACT
ADVAIR HFA AERO 230MCG/ACT; 21MCG/
QL (12 GM per 30 days) MO
OTHER
ACT
ADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT
OTHER
QL (12 GM per 30 days) MO
ASMANEX HFA AERO 100MCG/ACT
OTHER
QL (13 GM per 30 days) MO
ASMANEX HFA AERO 200MCG/ACT
OTHER
QL (13 GM per 30 days) MO
ASMANEX TWISTHALER 120 METERED DOS‑
QL (1 EA per 30 days) MO
OTHER
ES AEPB 220MCG/INH
ASMANEX TWISTHALER 14 METERED DOSES
QL (2 EA per 28 days) MO
OTHER
AEPB 220MCG/INH
ASMANEX TWISTHALER 30 METERED DOSES
QL (1 EA per 30 days) MO
OTHER
AEPB 110MCG/INH
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
105
Drug Name
ASMANEX TWISTHALER 30 METERED DOSES
AEPB 220MCG/INH
ASMANEX TWISTHALER 60 METERED DOSES
AEPB 220MCG/INH
ASMANEX TWISTHALER 7 METERED DOSES
AEPB 110MCG/INH
BREO ELLIPTA AEPB 100MCG/INH; 25MCG/
INH
BREO ELLIPTA AEPB 200MCG/INH; 25MCG/
INH
budesonide susp 0.25mg/2ml
budesonide susp 0.5mg/2ml
budesonide susp 1mg/2ml
budesonide susp 32mcg/act
flunisolide soln 0.025%
fluticasone propionate susp 50mcg/act
NASONEX SUSP 50MCG/ACT
QVAR AERS 40MCG/ACT
QVAR AERS 80MCG/ACT
triamcinolone acetonide aero 55mcg/act
Antihistamines
azelastine hcl soln 0.1%
azelastine hcl soln 0.15%
clemastine fumarate syrp 0.67mg/5ml
clemastine fumarate tabs 2.68mg
diphenhydramine hcl inj 50mg/ml
hydroxyzine hcl inj 25mg/ml
hydroxyzine hcl inj 50mg/ml
levocetirizine dihydrochloride soln 2.5mg/5ml
levocetirizine dihydrochloride tabs 5mg
olopatadine hcl soln 0.6%
promethazine hcl tabs 12.5mg
promethazine hcl tabs 25mg
promethazine hcl tabs 50mg
Antileukotrienes
montelukast sodium chew 4mg
montelukast sodium chew 5mg
montelukast sodium pack 4mg
Drug Tier
OTHER
OTHER
OTHER
OTHER
OTHER
Requirements/
Limits
QL (1 EA per 30 days) MO
QL (1 EA per 30 days) MO
QL (4 EA per 28 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
B/D MO
B/D MO
B/D MO
MO
MO
MO
QL (34 GM per 30 days) MO
QL (17.4 GM per 30 days) MO
QL (17.4 GM per 30 days) MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
QL (30 ML per 25 days) MO
MO
PA
PA MO
PA MO
PA MO
PA MO
QL (300 ML per 30 days) MO
QL (30 EA per 30 days) MO
QL (30.5 GM per 30 days) MO
PA MO
PA MO
PA MO
Generic
Generic
Generic
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
QL (30 EA per 30 days) MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
106
Drug Name
montelukast sodium tabs 10mg
zafirlukast tabs 10mg
zafirlukast tabs 20mg
Bronchodilators, Anticholinergic
ANORO ELLIPTA AEPB 62.5MCG/INH;
25MCG/INH
COMBIVENT RESPIMAT AERS 100MCG/ACT;
20MCG/ACT
INCRUSE ELLIPTA AEPB 62.5MCG/INH
ipratropium bromide/albuterol sulfate soln
2.5mg/3ml; 0.5mg/3ml
ipratropium bromide soln 0.02%
ipratropium bromide soln 0.03%
ipratropium bromide soln 0.06%
SPIRIVA HANDIHALER CAPS 18MCG
SPIRIVA RESPIMAT AERS 1.25MCG/ACT
SPIRIVA RESPIMAT AERS 2.5MCG/ACT
Bronchodilators, Sympathomimetic
albuterol sulfate er tb12 4mg
albuterol sulfate er tb12 8mg
albuterol sulfate nebu 0.083%
albuterol sulfate nebu 0.5%
albuterol sulfate nebu 0.63mg/3ml
albuterol sulfate nebu 1.25mg/3ml
albuterol sulfate syrp 2mg/5ml
albuterol sulfate tabs 2mg
albuterol sulfate tabs 4mg
ARCAPTA NEOHALER CAPS 75MCG
EPIPEN 2-PAK INJ 0.3MG/0.3ML
EPIPEN-JR 2-PAK INJ 0.15MG/0.3ML
FORADIL AEROLIZER CAPS 12MCG
levalbuterol hcl nebu 0.31mg/3ml
levalbuterol hcl nebu 0.63mg/3ml
levalbuterol hcl nebu 1.25mg/3ml
levalbuterol nebu 1.25mg/0.5ml
metaproterenol sulfate syrp 10mg/5ml
metaproterenol sulfate tabs 10mg
Drug Tier
Generic
Generic
Generic
OTHER
OTHER
OTHER
Generic
Requirements/
Limits
QL (30 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (60 EA per 30 days) MO
QL (8 GM per 30 days) MO
QL (30 EA per 30 days) MO
B/D MO
Generic
Generic
Generic
OTHER
OTHER
OTHER
B/D MO
MO
MO
QL (30 EA per 30 days) MO
QL (4 GM per 30 days) MO
QL (4 GM per 30 days) MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
OTHER
OTHER
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
B/D MO
B/D MO
B/D MO
B/D MO
MO
MO
MO
QL (30 EA per 30 days) MO
QL (2 EA per 30 days) MO
QL (2 EA per 30 days) MO
QL (60 EA per 30 days) MO
B/D MO
B/D MO
B/D MO
B/D MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
107
Drug Name
metaproterenol sulfate tabs 20mg
PROAIR HFA AERS 108MCG/ACT
PROAIR RESPICLICK AEPB 108MCG/ACT
terbutaline sulfate tabs 2.5mg
terbutaline sulfate tabs 5mg
VENTOLIN HFA AERS 108MCG/ACT
Cystic Fibrosis Agents
CAYSTON SOLR 75MG
KALYDECO PACK 50MG
KALYDECO PACK 75MG
KALYDECO TABS 150MG
ORKAMBI TABS 125MG; 200MG
PULMOZYME SOLN 1MG/ML
TOBI PODHALER CAPS 28MG
tobramycin nebu 300mg/5ml
Mast Cell Stabilizers
cromolyn sodium nebu 20mg/2ml
Phosphodiesterase Inhibitors, Airways Disease
aminophylline inj 25mg/ml
DALIRESP TABS 500MCG
theophylline cr tb12 100mg
theophylline cr tb12 200mg
theophylline er tb12 100mg
theophylline er tb12 200mg
theophylline er tb12 300mg
theophylline er tb12 450mg
theophylline er tb24 400mg
theophylline er tb24 600mg
theophylline elix 80mg/15ml
theophylline soln 80mg/15ml
Pulmonary Antihypertensives
ADEMPAS TABS 0.5MG
ADEMPAS TABS 1.5MG
ADEMPAS TABS 1MG
ADEMPAS TABS 2.5MG
ADEMPAS TABS 2MG
epoprostenol sodium inj 0.5mg
Generic
OTHER
OTHER
Generic
Generic
OTHER
Requirements/
Limits
MO
QL (17 GM per 30 days) MO
QL (2 EA per 30 days) MO
MO
MO
QL (36 GM per 30 days) MO
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
QL (84 ML per 56 days)
QL (56 EA per 28 days) PA
QL (56 EA per 28 days) PA
QL (60 EA per 30 days) PA
QL (112 EA per 28 days) PA
B/D
QL (224 EA per 56 days)
QL (280 ML per 56 days) B/D
Generic
B/D MO
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
QL (30 EA per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
OTHER
OTHER
OTHER
OTHER
OTHER
Generic
QL (90 EA per 30 days) PA LA
QL (90 EA per 30 days) PA LA
QL (90 EA per 30 days) PA LA
QL (90 EA per 30 days) PA LA
QL (90 EA per 30 days) PA LA
PA LA
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
108
Drug Name
Drug Tier
Requirements/
Limits
PA LA
QL (30 EA per 30 days) PA LA
PA LA
PA LA
PA LA
PA LA
QL (90 EA per 30 days) PA
QL (60 EA per 30 days) PA LA
QL (60 EA per 30 days) PA LA
epoprostenol sodium inj 1.5mg
Generic
OPSUMIT TABS 10MG
OTHER
REMODULIN INJ 10MG/ML
OTHER
REMODULIN INJ 1MG/ML
OTHER
REMODULIN INJ 2.5MG/ML
OTHER
REMODULIN INJ 5MG/ML
OTHER
sildenafil tabs 20mg
Generic
TRACLEER TABS 125MG
OTHER
TRACLEER TABS 62.5MG
OTHER
Respiratory Tract Agents, Other
acetylcysteine inj 200mg/ml
Generic
acetylcysteine soln 10%
Generic
B/D MO
acetylcysteine soln 20%
Generic
B/D MO
ESBRIET CAPS 267MG
OTHER
QL (270 EA per 30 days) PA LA
PROLASTIN-C INJ 1000MG
OTHER
PA MO
STIOLTO RESPIMAT AERS 2.5MCG/ACT;
QL (4 GM per 30 days) MO
OTHER
2.5MCG/ACT
TYZINE PEDIATRIC NASAL DROPS SOLN
OTHER
0.05%
XOLAIR INJ 150MG
OTHER
QL (6 EA per 28 days) PA LA
SKELETAL MUSCLE RELAXANTS- DRUGS USED TO TREAT MUSCLE SPASMS
Skeletal Muscle Relaxants
chlorzoxazone tabs 500mg
Generic
QL (180 EA per 30 days) PA MO
cyclobenzaprine hcl tabs 10mg
Generic
QL (90 EA per 30 days) PA MO
cyclobenzaprine hcl tabs 5mg
Generic
QL (90 EA per 30 days) PA MO
cyclobenzaprine hcl tabs 7.5mg
Generic
QL (90 EA per 30 days) PA MO
SLEEP DISORDER AGENTS- DRUGS USED TO TREAT INSOMNIA OR SLEEP DISORDERS
GABA Receptor Modulators
zaleplon caps 10mg
Generic
QL (60 EA per 30 days) PA MO
zaleplon caps 5mg
Generic
QL (30 EA per 30 days) PA MO
zolpidem tartrate tabs 10mg
Generic
QL (30 EA per 30 days) PA MO
zolpidem tartrate tabs 5mg
Generic
QL (30 EA per 30 days) PA MO
Sleep Disorders, Other
HETLIOZ CAPS 20MG
OTHER
QL (30 EA per 30 days) PA
modafinil tabs 100mg
Generic
QL (30 EA per 30 days) PA MO
modafinil tabs 200mg
Generic
QL (60 EA per 30 days) PA MO
ROZEREM TABS 8MG
OTHER
QL (30 EA per 30 days) MO
XYREM SOLN 500MG/ML
OTHER
QL (540 ML per 30 days) PA
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
109
Requirements/
Limits
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES, VITAMINS AND IV NUTRITION
Electrolyte/Mineral Modifiers
CUPRIMINE CAPS 250MG
OTHER
MO
DEPEN TITRATABS TABS 250MG
OTHER
MO
EXJADE TBSO 125MG
OTHER
PA LA
EXJADE TBSO 250MG
OTHER
PA LA
EXJADE TBSO 500MG
OTHER
PA LA
FERRIPROX TABS 500MG
OTHER
PA
fomepizole inj 1gm/ml
Generic
kionex powd 0
Generic
kionex susp 15gm/60ml
Generic
MO
levocarnitine tabs 330mg
Generic
MO
SAMSCA TABS 15MG
OTHER
QL (30 EA per 30 days) PA
SAMSCA TABS 30MG
OTHER
QL (60 EA per 30 days) PA
sodium bicarbonate partial fill inj 4.2%
Generic
MO
sodium bicarbonate inj 8.4%
Generic
MO
sodium polystyrene sulfonate powd 0
Generic
MO
sodium polystyrene sulfonate susp 15gm/60ml
Generic
MO
sodium polystyrene sulfonate susp 30gm/120ml
Generic
sodium polystyrene sulfonate susp 50gm/200ml
Generic
SYPRINE CAPS 250MG
OTHER
MO
Electrolyte/Mineral Replacement
AMINOSYN 7%/ELECTROLYTES INJ
B/D
124MEQ/L; 900MG/100ML; 690MG/100ML;
96MEQ/L; 900MG/100ML; 210MG/100ML;
510MG/100ML; 660MG/100ML;
510MG/100ML; 10MEQ/L; 280MG/100ML;
OTHER
310MG/100ML; 30MMOLE/L; 65MEQ/L;
610MG/100ML; 300MG/100ML; 65MEQ/L;
370MG/100ML; 120MG/100ML;
44MG/100ML; 560MG/100ML
aminosyn 8.5%/electrolytes inj 142meq/l;
B/D
1100mg/100ml; 850mg/100ml;
98meq/l; 1100mg/100ml; 260mg/100ml;
620mg/100ml; 810mg/100ml; 624mg/100ml;
Generic
10meq/l; 340mg/100ml; 380mg/100ml;
30meq/l; 65meq/l; 750mg/100ml;
370mg/100ml; 65meq/l; 460mg/100ml;
150mg/100ml; 44mg/100ml; 680mg/100ml
Drug Name
Drug Tier
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
110
Drug Name
aminosyn ii 8.5%/electrolytes inj 61meq/l;
844mg/100ml; 865mg/100ml; 595mg/100ml;
86meq/l; 627mg/100ml; 425mg/100ml;
255mg/100ml; 561mg/100ml; 850mg/100ml;
893mg/100ml; 10meq/l; 146mg/100ml;
253mg/100ml; 30mmole/l; 66meq/l;
614mg/100ml; 450mg/100ml; 80meq/l;
340mg/100ml; 170mg/100ml; 230mg/100ml;
425mg/100ml
AMINOSYN II INJ 107.6MEQ/L;
1490MG/100ML; 1527MG/100ML;
1050MG/100ML; 1107MG/100ML;
750MG/100ML; 450MG/100ML;
990MG/100ML; 1500MG/100ML;
1575MG/100ML; 258MG/100ML;
447MG/100ML; 1083MG/100ML;
795MG/100ML; 50MEQ/L; 600MG/100ML;
300MG/100ML; 405MG/100ML;
750MG/100ML
AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML;
713MG/100ML; 490MG/100ML;
517MG/100ML; 350MG/100ML;
210MG/100ML; 462MG/100ML;
700MG/100ML; 735MG/100ML;
120MG/100ML; 209MG/100ML;
505MG/100ML; 371MG/100ML; 31.3MEQ/L;
280MG/100ML; 140MG/100ML;
189MG/100ML; 350MG/100ML
AMINOSYN II INJ 61.1MEQ/L; 844MG/100ML;
865MG/100ML; 595MG/100ML;
627MG/100ML; 425MG/100ML;
255MG/100ML; 561MG/100ML;
850MG/100ML; 893MG/100ML;
146MG/100ML; 253MG/100ML;
614MG/100ML; 450MG/100ML; 33.3MEQ/L;
340MG/100ML; 170MG/100ML;
230MG/100ML; 425MG/100ML
Drug Tier
Requirements/
Limits
B/D
Generic
B/D
OTHER
B/D
OTHER
B/D
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
111
Drug Name
AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML;
1018MG/100ML; 700MG/100ML;
738MG/100ML; 500MG/100ML;
300MG/100ML; 660MG/100ML;
1000MG/100ML; 1050MG/100ML;
172MG/100ML; 298MG/100ML;
722MG/100ML; 530MG/100ML; 45.3MEQ/L;
400MG/100ML; 200MG/100ML;
270MG/100ML; 500MG/100ML
AMINOSYN M INJ 65MEQ/L; 448MG/100ML;
343MG/100ML; 40MEQ/L; 448MG/100ML;
105MG/100ML; 252MG/100ML;
329MG/100ML; 252MG/100ML; 3MEQ/L;
140MG/100ML; 154MG/100ML;
3.5MMOLE/L; 13MEQ/L; 300MG/100ML;
147MG/100ML; 40MEQ/L; 182MG/100ML;
56MG/100ML; 31MG/100ML;
280MG/100ML
AMINOSYN-HBC INJ 7.1MEQ/100ML;
660MG/100ML; 507MG/100ML;
4MEQ/100ML; 660MG/100ML;
154MG/100ML; 789MG/100ML;
1576MG/100ML; 265MG/100ML;
206MG/100ML; 1.12GM/100ML;
228MG/100ML; 448MG/100ML;
221MG/100ML; 272MG/100ML;
88MG/100ML; 33MG/100ML;
789MG/100ML
AMINOSYN-PF 7% INJ 32.5MEQ/L;
490MG/100ML; 861MG/100ML;
370MG/100ML; 576MG/100ML;
270MG/100ML; 220MG/100ML;
534MG/100ML; 831MG/100ML;
475MG/100ML; 125MG/100ML;
10.69GM/L; 300MG/100ML; 570MG/100ML;
70GM/L; 347MG/100ML; 50MG/100ML;
360MG/100ML; 125MG/100ML;
44MG/100ML; 452MG/100ML
Drug Tier
Requirements/
Limits
B/D
OTHER
B/D
OTHER
B/D
OTHER
B/D
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
112
Drug Name
AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML;
1227MG/100ML; 527MG/100ML;
820MG/100ML; 385MG/100ML;
312MG/100ML; 760MG/100ML;
1200MG/100ML; 677MG/100ML;
180MG/100ML; 427MG/100ML;
812MG/100ML; 495MG/100ML;
3.4MEQ/L; 70MG/100ML; 512MG/100ML;
180MG/100ML; 44MG/100ML;
673MG/100ML
AMINOSYN-RF INJ 113MEQ/L;
600MG/100ML; 429MG/100ML;
462MG/100ML; 726MG/100ML;
535MG/100ML; 726MG/100ML;
726MG/100ML; 330MG/100ML;
165MG/100ML; 528MG/100ML
AMINOSYN INJ 148MEQ/L; 1280MG/100ML;
980MG/100ML; 1280MG/100ML;
300MG/100ML; 720MG/100ML;
940MG/100ML; 720MG/100ML;
400MG/100ML; 440MG/100ML; 5.4MEQ/L;
860MG/100ML; 420MG/100ML;
520MG/100ML; 160MG/100ML;
44MG/100ML; 800MG/100ML
AMINOSYN INJ 90MEQ/L; 1100MG/100ML;
850MG/100ML; 35MEQ/L; 1100MG/100ML;
260MG/100ML; 620MG/100ML;
810MG/100ML; 624MG/100ML;
340MG/100ML; 380MG/100ML;
5.4MEQ/L; 750MG/100ML; 370MG/100ML;
460MG/100ML; 150MG/100ML;
44MG/100ML; 680MG/100ML
calcium chloride inj 10%
calcium gluconate inj 10%
clinisol sf 15% inj 151meq/l; 2170mg/100ml;
1470mg/100ml; 434mg/100ml;
749mg/100ml; 1040mg/100ml;
894mg/100ml; 749mg/100ml;
1040mg/100ml; 1180mg/100ml;
749mg/100ml; 1040mg/100ml;
894mg/100ml; 592mg/100ml; 749mg/100ml;
250mg/100ml; 39mg/100ml; 960mg/100ml
Drug Tier
Requirements/
Limits
B/D
OTHER
B/D
OTHER
B/D
OTHER
B/D
OTHER
Generic
Generic
B/D
Generic
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
113
Drug Name
dextrose 10%/nacl 0.45% inj 10%; 0.45%
dextrose 5% /electrolyte #48 viaflex inj 24meq/l;
5%; 23meq/l; 3meq/l; 3meq/l; 20meq/l;
25meq/l
dextrose 10% flex container inj 10%
dextrose 10%/nacl 0.2% inj 10%; 0.2%
dextrose 2.5%/sodium chloride 0.45% inj 2.5%;
0.45%
dextrose 20% inj 20%
dextrose 25% inj 250mg/ml
dextrose 30% inj 30%
dextrose 40% inj 40%
dextrose 5%/lactated ringers inj 2.7meq/l;
109meq/l; 5%; 28meq/l; 4meq/l; 130meq/l
dextrose 5%/nacl 0.2% inj 5%; 0.2%
dextrose 5%/nacl 0.225% inj 5%; 0.225%
dextrose 5%/nacl 0.3% inj 5%; 0.3%
dextrose 5%/nacl 0.33% inj 5%; 0.33%
dextrose 5%/nacl 0.45% inj 5%; 0.45%
dextrose 5%/nacl 0.9% inj 5%; 0.9%
dextrose 5%/potassium chloride 0.15% inj 5%;
20meq/l
dextrose 5% inj 5%
dextrose 50% inj 50%
dextrose 70% inj 70%
FLORIVA LIQD 0.25MG/ML; 400UNIT/ML
fluoride chew 1.1mg
fluoride chew 2.2mg
fluoritab chew 0.5mg
fluoritab chew 1mg
fluoritab chew 1mg
FLURA-DROPS SOLN 0.25MG/DROP
hepatamine inj 62meq/l; 770mg/100ml;
600mg/100ml; 3meq/l; 20mg/100ml;
900mg/100ml; 240mg/100ml; 900mg/100ml;
1100mg/100ml; 610mg/100ml;
100mg/100ml; 100mg/100ml; 115mg/100ml;
800mg/100ml; 500mg/100ml; 100mg/100ml;
450mg/100ml; 66mg/100ml; 840mg/100ml
Drug Tier
Requirements/
Limits
Generic
Generic
Generic
Generic
B/D
Generic
Generic
Generic
Generic
Generic
B/D
B/D
B/D
B/D
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
Generic
Generic
Generic
Generic
OTHER
Generic
Generic
Generic
Generic
Generic
OTHER
MO
B/D
B/D
MO
MO
MO
MO
B/D
Generic
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
114
Drug Name
intralipid inj 20gm/100ml
INTRALIPID INJ 30GM/100ML
k-sol soln 10%
k-sol soln 20%
KABIVEN INJ 467MG/100ML;
330MG/100ML; 99MG/100ML;
29MG/100ML; 9.8GM/100ML;
164MG/100ML; 231MG/100ML;
199MG/100ML; 164MG/100ML;
263MG/100ML; 231MG/100ML;
96MG/100ML; 164MG/100ML;
231MG/100ML; 174MG/100ML;
199MG/100ML; 131MG/100ML;
239MG/100ML; 147MG/100ML;
164MG/100ML; 55MG/100ML;
6.7MG/100ML; 213MG/100ML
kcl 0.075%/d5w/nacl 0.45% inj 5%; 10meq/l;
0.45%
kcl 0.15%/d5w/lr inj 3meq/l; 149meq/l; 5%;
28meq/l; 24meq/l; 130meq/l
kcl 0.15%/d5w/nacl 0.2% inj 5%; 20meq/l; 0.2%
kcl 0.15%/d5w/nacl 0.225% inj 5%; 20meq/l;
0.225%
kcl 0.15%/d5w/nacl 0.45% inj 5%; 20meq/l;
0.45%
kcl 0.15%/d5w/nacl 0.9% inj 5%; 20meq/l; 0.9%
kcl 0.3%/d5w/lr iv lac ring inj 3meq/l; 149meq/l;
5%; 28meq/l; 44meq/l; 130meq/l
kcl 0.3%/d5w/nacl 0.45% inj 5%; 40meq/l;
0.45%
kcl 0.3%/d5w/nacl 0.9% inj 5%; 40meq/l; 0.9%
klor-con 10 tbcr 10meq
klor-con 8 tbcr 8meq
klor-con m10 tbcr 10meq
klor-con m20 tbcr 20meq
klor-con sprinkle cpcr 10meq
klor-con sprinkle cpcr 8meq
klor-con/ef tbef 25meq
klor-con pack 20meq
Drug Tier
Generic
OTHER
Generic
Generic
Requirements/
Limits
B/D
B/D
MO
MO
B/D
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
115
Drug Name
lactated ringers dextrose 5% viaflex inj 2.7meq/l;
109meq/l; 5%; 28meq/l; 4meq/l; 130meq/l
lactated ringers viaflex inj 3meq/l; 109meq/l;
28meq/l; 4meq/l; 130meq/l
LIPOSYN III INJ 1.2GM/100ML;
2.5GM/100ML; 10GM/100ML
LIPOSYN III INJ 1.2GM/100ML;
2.5GM/100ML; 20GM/100ML
ludent chew 0.5mg
ludent chew 1mg
magnesium sulfate inj 20gm/500ml
magnesium sulfate inj 4gm/50ml
magnesium sulfate inj 50%
magnesium sulfate inj 50%
NEPHRAMINE INJ 44MEQ/L; 20MG/100ML;
250MG/100ML; 560MG/100ML;
880MG/100ML; 640MG/100ML;
880MG/100ML; 880MG/100ML;
6MEQ/L; 400MG/100ML; 200MG/100ML;
640MG/100ML
PERIKABIVEN INJ 333MG/100ML;
235MG/100ML; 71MG/100ML;
20MG/100ML; 6.8GM/100ML;
116MG/100ML; 164MG/100ML;
141MG/100ML; 116MG/100ML;
164MG/100ML; 187MG/100ML;
68MG/100ML; 116MG/100ML;
164MG/100ML; 124MG/100ML;
141MG/100ML; 94MG/100ML;
170MG/100ML; 105MG/100ML;
116MG/100ML; 40MG/100ML;
4.8MG/100ML; 152MG/100ML
plenamine inj 151meq/l; 2170mg/100ml;
1470mg/100ml; 434mg/100ml;
749mg/100ml; 1040mg/100ml;
894mg/100ml; 749mg/100ml;
1040mg/100ml; 1180mg/100ml;
749mg/100ml; 1040mg/100ml;
894mg/100ml; 592mg/100ml; 749mg/100ml;
250mg/100ml; 39mg/100ml; 960mg/100ml
Drug Tier
Requirements/
Limits
Generic
Generic
OTHER
OTHER
Generic
Generic
Generic
Generic
Generic
Generic
B/D
B/D
MO
MO
MO
MO
B/D
OTHER
B/D
OTHER
B/D
Generic
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
116
Drug Name
potassium chloride 0.15% /nacl 0.45% viaflex inj
20meq/l; 0.45%
potassium chloride 0.15% d5w/nacl 0.33% inj
5%; 20meq/l; 0.33%
potassium chloride 0.15% d5w/nacl 0.45% viaflex inj 5%; 20meq/l; 0.45%
potassium chloride 0.15% d5w/nacl 0.45% inj
5%; 20meq/l; 0.45%
potassium chloride 0.15% nacl 0.9% inj
20meq/l; 0.9%
potassium chloride 0.15%/nacl 0.9% inj
20meq/l; 0.9%
potassium chloride 0.22% d5w/nacl 0.45% inj
5%; 30meq/l; 0.45%
potassium chloride 0.224%d5w/nacl 0.45%
viaflex inj 5%; 30meq/l; 0.45%
potassium chloride 0.3%/ nacl 0.9% inj 40meq/l;
0.9%
potassium chloride 0.3%/d5w inj 5%; 40meq/l
potassium chloride cr tbcr 10meq
potassium chloride cr tbcr 10meq
potassium chloride cr tbcr 20meq
potassium chloride er cpcr 10meq
potassium chloride er cpcr 8meq
potassium chloride er tbcr 10meq
potassium chloride er tbcr 10meq
potassium chloride er tbcr 20meq
potassium chloride er tbcr 20meq
potassium chloride er tbcr 8meq
potassium chloride sr tbcr 8meq
potassium chloride inj 0.4meq/ml
potassium chloride inj 10meq/100ml
potassium chloride inj 10meq/50ml
potassium chloride inj 20meq/100ml
potassium chloride inj 2meq/ml
potassium chloride inj 40meq/100ml
potassium chloride soln 10%
potassium chloride soln 20%
potassium citrate er tbcr 1080mg
Drug Tier
Requirements/
Limits
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
117
Drug Name
potassium citrate er tbcr 15meq
potassium citrate er tbcr 540mg
PREMASOL INJ 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML;
526MG/100ML; 492MG/100ML;
492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML;
390MG/100ML; 34MG/100ML;
152MG/100ML
premasol inj 56meq/l; 320mg/100ml;
730mg/100ml; 190mg/100ml; 3meq/l;
20mg/100ml; 300mg/100ml; 220mg/100ml;
290mg/100ml; 490mg/100ml; 840mg/100ml;
490mg/100ml; 200mg/100ml; 290mg/100ml;
410mg/100ml; 230mg/100ml; 5meq/l;
15mg/100ml; 250mg/100ml; 120mg/100ml;
140mg/100ml; 470mg/100ml
ringers injection inj 4.5meq/l; 156meq/l; 4meq/l;
147meq/l
sodium chloride 0.45% viaflex inj 0.45%
sodium chloride inj 0.9%
sodium chloride inj 2.5meq/ml
sodium chloride inj 3%
sodium chloride inj 5%
sodium fluoride chew 0.5mg
sodium fluoride chew 1.1mg
sodium fluoride chew 1mg
sterile water irrigation soln 0
tpn electrolytes inj 29.5meq/20ml;
4.5meq/20ml; 35meq/20ml; 5meq/20ml;
20meq/20ml; 35meq/20ml
vitamins a/d/c/fluoride soln 35mg/ml; 0.25mg/
ml; 1500unit/ml; 400unit/ml
Vitamins
BAL-CARE DHA MISC 120MG; 2850UNIT;
219MG; 840UNIT; 2MG; 12MCG; 295MG;
0; 1MG; 220MCG; 27MG; 25MG; 20MG;
430MG; 0; 50MG; 4MG; 0; 1.8MG; 3MG;
25MG
Drug Tier
Generic
Generic
Requirements/
Limits
MO
MO
B/D
OTHER
B/D
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
Generic
MO
MO
MO
MO
MO
MO
MO
MO
Generic
Generic
MO
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
118
Drug Name
CALCIUM PNV CAPS 30MG; 102MG; 250MG;
0.625MG; 28MG; 1MG; 25MG; 30UNIT
CITRANATAL 90 DHA MISC 120MG; 159MG;
400UNIT; 2MG; 300MG; 50MG; 0.75MG;
0; 1MG; 90MG; 0; 20MG; 150MCG; 20MG;
3.4MG; 3MG; 30UNIT; 25MG
CITRANATAL ASSURE MISC 120MG; 124MG;
400UNIT; 2MG; 300MG; 50MG; 0.75MG;
0; 1MG; 35MG; 0; 20MG; 150MCG; 25MG;
3.4MG; 3MG; 30UNIT; 25MG
CITRANATAL B-CALM MISC 120MG; 120MG;
400UNIT; 0; 1MG; 20MG; 0; 25MG
CITRANATAL DHA MISC 625MG; 120MG;
0; 124MG; 400UNIT; 2MG; 250MG; 50MG;
0.625MG; 0; 1MG; 27MG; 0; 20MG; 150MCG;
20MG; 3.4MG; 3MG; 30UNIT; 25MG
CITRANATAL RX TABS 120MG; 125MG;
400UNIT; 2MG; 30UNIT; 50MG; 1MG; 27MG;
20MG; 150MCG; 20MG; 3.4MG; 3MG; 25MG
complete natal dha misc 120mg; 0; 200mg;
400unit; 2mg; 12mcg; 200mg; 0; 1mg; 29mg;
0; 25mg; 20mg; 250mg; 25mg; 4mg; 1.8mg;
30mg; 3000unit; 25mg
completenate chew 120mg; 1000unit; 400unit;
12mcg; 29mg; 1mg; 20mg; 10mg; 3mg; 2mg;
11unit
CONCEPT DHA CAPS 25MG; 300MCG; 5MG;
2MG; 12.5MCG; 156MG; 39MG; 53.5MG;
310MG; 1MG; 5MG; 1.8MG; 200MG; 38MG;
25MG; 3MG; 2MG; 10MG
CONCEPT OB CAPS 210MG; 300MCG; 7MG;
800MCG; 10MCG; 130MG; 1MG; 6.9MG;
1.3MG; 20MG; 92.4MG; 25MG; 5MG; 5MG;
18.2MG
ENBRACE HR CAPS 500MCG; 1MG; 50MCG;
0; 0; 13.6MG; 25MCG; 1MG; 2.5MG; 24MG;
5.23MG; 25MCG; 0; 12MCG; 25MCG;
25MCG; 1MG
Drug Tier
OTHER
Requirements/
Limits
MO
MO
OTHER
MO
OTHER
OTHER
MO
MO
OTHER
MO
OTHER
MO
Generic
MO
Generic
MO
OTHER
MO
OTHER
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
119
Drug Name
ESCAVITE D CHEW 100MG; 2500UNIT;
45MCG; 10MG; 600UNIT; 0; 2MG; 0;
400MCG; 6MCG; 6MG; 60MG; 20MG; 2MG;
1.7MG; 0.25MG; 1.5MG; 30UNIT; 15MG
ESCAVITE LQ LIQD 35MG/ML; 400UNIT/
ML; 0.9MCG/ML; 0; 0; 6MG/ML; 8MG/ML;
0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/
ML; 1500UNIT/ML; 7.5UNIT/ML
ESCAVITE CHEW 100MG; 45MCG; 10MG;
400UNIT; 1MG; 9MCG; 7.5MG; 400MCG;
60MG; 20MG; 2MG; 1.7MG; 0.25MG; 1.5MG;
1000UNIT; 30UNIT; 7.5MG
EXTRA-VIRT PLUS DHA CAPS 28MG;
250MCG; 160MG; 800UNIT; 350MG; 55MG;
29MG; 1.25MG; 660MG; 25MG; 30UNIT
FOCALGIN 90 DHA MISC 120MG; 159MG;
400UNIT; 2MG; 300MG; 50MG; 0; 0; 1MG;
90MG; 0; 20MG; 150MCG; 20MG; 3.4MG;
3MG; 30UNIT; 25MG
FOCALGIN CA MISC 120MG; 124MG;
400UNIT; 2MG; 300MG; 50MG; 0; 0; 1MG;
35MG; 0; 20MG; 150MCG; 25MG; 3.4MG;
3MG; 30UNIT; 25MG
FOCALGIN-B TABS 124.23MG; 0; 0; 1.22MG;
42MG; 100MG
FOLCAL DHA CAPS 28MG; 160MG; 400UNIT;
300MG; 55MG; 27MG; 1.25MG; 25MG;
30UNIT
FOLCAPS OMEGA 3 CAPS 25MG; 150MG;
0; 0; 170UNIT; 260MG; 40MG; 7MG; 1MG;
20MG; 30MG; 30MG; 330MG; 25MG;
30UNIT
FOLET DHA THPK 120MG; 0; 400UNIT;
12MCG; 350MG; 50MG; 0; 38MG; 0; 1MG;
30MG; 20MG; 40MG; 3.4MG; 65MCG; 3MG;
2700UNIT; 18UNIT; 10MG
FOLET ONE CAPS 0; 18MG; 250UNIT;
15MCG; 225MG; 25MG; 0; 38MG; 0; 1MG;
15MG; 30MG; 15UNIT; 20MG
Drug Tier
Requirements/
Limits
OTHER
OTHER
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
OTHER
MO
OTHER
MO
OTHER
OTHER
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
120
Drug Name
FOLIVANE-OB CAPS 210MG; 300MCG; 7MG;
800MCG; 10MCG; 130MG; 1MG; 6.9MG;
1.3MG; 20MG; 92.4MG; 25MG; 5MG; 5MG;
18.2MG
FOLIVANE-PRX DHA NF CAPS 25MG;
160MG; 170UNIT; 265MG; 55MG; 30MG;
1.24MG; 25MG; 30UNIT
HEMENATAL OB + DHA MISC 30MCG; 10MG;
400UNIT; 0.8MG; 12MCG; 10UNIT; 200MG;
2.5MG; 1MG; 6MG; 0.5MG; 17MG; 203MG;
28MG; 250MCG; 50MG; 1.6MG; 65MCG;
1.5MG; 4.5MG
HEMENATAL OB TABS 30MCG; 10MG;
400UNIT; 0.8MG; 12MCG; 10UNIT; 1MG;
6MG; 17MG; 28MG; 250MCG; 50MG; 1.6MG;
65MCG; 1.5MG; 4.5MG
inatal advance tabs 120mg; 2700unit; 200mg;
400unit; 2mg; 12mcg; 50mg; 1mg; 90mg;
30mg; 20mg; 20mg; 3.4mg; 3mg; 30unit; 25mg
inatal ultra tabs 120mg; 0; 200mg; 2mg;
12mcg; 50mg; 1mg; 90mg; 20mg; 150mcg;
20mg; 3.4mg; 3mg; 2700unit; 400unit; 30unit;
25mg
mult-vitamin/fluoride chew 60mg; 400unit;
4.5mcg; 0.5mg; 0.3mg; 13.5mg; 1.05mg;
1.2mg; 0; 1.05mg; 2500unit; 15unit
multi vitamin/fluoride chew 60mg; 400unit;
4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg;
1.05mg; 15unit; 2500unit
multi-vit/fluoride soln 35mg/ml; 400unit/
ml; 2mcg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml
multi-vit/iron/fluoride 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
multi-vitamin/fluoride/iron soln 35mg/ml;
400unit/ml; 5unit/ml; 10mg/ml; 8mg/ml;
0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml;
1500unit/ml
Drug Tier
Requirements/
Limits
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
Generic
Generic
MO
Generic
MO
Generic
MO
Generic
MO
Generic
MO
Generic
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
121
Drug Name
multi-vitamin/fluoride soln 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 chew 60mg; 4.5mcg;
0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.25mg;
1.05mg; 2500unit; 400unit; 15unit
multivitamin with fluoride chew 60mg; 4.5mcg;
0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.5mg;
1.05mg; 2500unit; 400unit; 15unit
mvc-fluoride chew 60mg; 400unit; 4.5mcg;
0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.25mg;
1.05mg; 2500unit; 15unit
mvc-fluoride chew 60mg; 400unit; 4.5mcg;
0.3mg; 13.5mg; 1.05mg; 1.2mg; 0.5mg;
1.05mg; 2500unit; 15unit
mvc-fluoride chew 60mg; 400unit; 4.5mcg;
0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg;
2500unit; 15unit
NATACHEW CHEW 120MG; 2700UNIT;
400UNIT; 12MCG; 0; 0; 1MG; 28MG; 20MG;
10MG; 3MG; 0; 2MG; 20UNIT
NATALVIRT 90 DHA MISC 120MG; 160MG;
400UNIT; 2MG; 300MG; 50MG; 0; 0; 1MG;
90MG; 0; 20MG; 150MCG; 20MG; 3.4MG;
3MG; 30UNIT; 25MG
NATALVIRT CA MISC 120MG; 125MG;
400UNIT; 2MG; 300MG; 50MG; 0; 0; 1MG;
35MG; 0; 20MG; 150MCG; 25MG; 3.4MG;
3MG; 30UNIT; 25MG
NATELLE ONE CAPS 30MG; 102MG; 250MG;
0.625MG; 28MG; 1MG; 25MG; 30UNIT
NESTABS DHA MISC 45MG; 155MG;
450UNIT; 55MG; 10MCG; 230MG; 30MG;
32MG; 1000MCG; 100MCG; 50MG; 3MG;
120MG; 3MG; 30UNIT; 10MG
NESTABS TABS 65MG; 155MG; 450UNIT;
55MG; 10MCG; 32MG; 1000MCG; 100MCG;
50MG; 3MG; 120MG; 3MG; 30UNIT; 10MG
NEXA PLUS CAPS 28MG; 0; 250MCG;
660MG; 160MG; 0; 800UNIT; 350MG; 55MG;
29MG; 1.25MG; 25MG; 30UNIT
Drug Tier
Requirements/
Limits
MO
Generic
MO
Generic
MO
Generic
MO
Generic
MO
Generic
MO
Generic
OTHER
MO
OTHER
MO
OTHER
OTHER
MO
MO
OTHER
MO
OTHER
MO
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
122
Drug Name
NIVA-PLUS TABS 120MG; 0; 0; 200MG;
400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG;
10MG; 3MG; 1.84MG; 4000UNIT; 22UNIT;
25MG
O-CAL PRENATAL TABS 70MG; 0; 200MG;
400UNIT; 2MG; 12MCG; 15MG; 1MG;
100MG; 17MG; 150MCG; 12MG; 1.6MG;
1.5MG; 2500UNIT; 30UNIT; 15MG
OB COMPLETE ONE CAPS 200MCG; 70MG;
25MG; 5MG; 1200UNIT; 1MG; 50MCG;
25MG; 300MG; 40MG; 10MG; 476MG;
700MCG; 40MG; 300MCG; 25MG; 10MG;
150MCG; 30MG; 4MG; 2MG; 30UNIT; 15MG
OB COMPLETE PETITE CAPS 125MG;
1000UNIT; 1MG; 15MCG; 0; 5MG; 1MG;
35MG; 200MG; 30MG; 3.4MG; 2MG; 30UNIT;
25MG
OB COMPLETE PREMIER TABS 120MG;
800UNIT; 1MG; 15MCG; 100MG; 15MG;
20MG; 1MG; 30MG; 10MG; 10MG; 3.4MG;
2MG; 2100UNIT; 20UNIT; 10MG
OB COMPLETE/DHA CAPS 125MG; 0; 0;
1000UNIT; 1MG; 15MCG; 0; 0; 10MG; 1MG;
30MG; 200MG; 3.4MG; 2MG; 30UNIT; 25MG
PAIRE OB MISC 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 200MG; 0; 1MG;
6MG; 0; 17MG; 22MG; 175MCG; 50MG;
1.6MG; 65MCG; 1.5MG; 15MG
PNV FERROUS FUMARATE/DOCUSATE/FO‑
LIC ACID TABS 100MG; 1000UNIT; 200MG;
7MG; 400UNIT; 12MCG; 25MG; 29MG; 1MG;
15MG; 20MG; 3MG; 3MG; 30UNIT; 20MG
PNV FOLIC ACID + IRON MULTIVITAMIN TABS
60MG; 50MG; 400UNIT; 4.5MCG; 27MG;
1MG; 13.5MG; 1.05MG; 1.2MG; 1.05MG;
15UNIT; 2500UNIT
PNV OB+DHA MISC 120MG; 125MG;
400UNIT; 2MG; 250MG; 50MG; 0; 0; 1MG;
27MG; 0; 20MG; 0; 150MCG; 20MG; 3.4MG;
3MG; 30UNIT; 25MG
Drug Tier
Requirements/
Limits
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
123
Drug Name
PNV PRENATAL PLUS MULTIVITAMIN TABS
120MG; 0; 200MG; 400UNIT; 2MG; 12MCG;
27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG;
22MG; 4000UNIT; 25MG
PNV TABS 29-1 TABS 120MG; 4000UNIT;
30MCG; 200MG; 7MG; 400UNIT; 3MG;
8MCG; 1MG; 29MG; 100MG; 20MG;
150MCG; 3MG; 3MG; 3MG; 30UNIT; 15MG
PNV-DHA CAPS 85MG; 140MG; 200UNIT;
12MCG; 300MG; 27MG; 400MCG; 600MCG;
45MG; 25MG; 10UNIT
PNV-SELECT TABS 80MG; 2500UNIT;
300MCG; 120MG; 6MG; 400UNIT; 2MG;
12MCG; 27MG; 400MCG; 600MCG; 30MG;
20MG; 150MCG; 20MG; 3.4MG; 3MG;
10UNIT; 15MG
PNV-VP-U CAPS 10MG; 0.8MG; 15MCG;
106.5MG; 1MG; 1.3MG; 30MG; 5MG; 6MG;
200MG; 10MG
poly-vitamin/fluoride chew 60mg; 4.5mcg;
400unit; 0.5mg; 0.3mg; 13.5mg; 1.05mg; 1mg;
1mg; 2500unit; 15mg
poly-vitamin/fluoride soln 35mg/ml; 50mcg/ml;
2mcg/ml; 0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/
ml; 0.6mg/ml; 0.5mg/ml; 1500unit/ml; 400unit/
ml; 5unit/ml
pr natal 400 ec misc 120mg; 3000unit; 200mg;
400unit; 2mg; 12mcg; 275mg; 0; 1mg; 29mg;
25mg; 20mg; 400mg; 25mg; 4mg; 1.8mg; 3mg;
25mg
pr natal 400 misc 120mg; 3000unit; 200mg;
400unit; 2mg; 12mcg; 275mg; 0; 0; 1mg;
29mg; 0; 25mg; 20mg; 400mg; 25mg; 4mg;
1.8mg; 30mg; 25mg
pr natal 430 ec misc 120mg; 3000unit; 200mg;
400unit; 2mg; 12mcg; 295mg; 0; 0; 1mg;
29mg; 0; 25mg; 20mg; 430mg; 25mg; 4mg;
1.8mg; 3mg; 25mg
pr natal 430 misc 120mg; 3000unit; 200mg;
400unit; 2mg; 12mcg; 295mg; 0; 0; 1mg;
29mg; 0; 25mg; 20mg; 430mg; 25mg; 4mg;
1.8mg; 30mg; 25mg
Drug Tier
Requirements/
Limits
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
Generic
Generic
MO
Generic
MO
Generic
MO
Generic
MO
Generic
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
124
Drug Name
PREFERA OB + DHA MISC 30MCG; 10MG;
400UNIT; 0.8MG; 12MCG; 200MG; 2.5MG;
1MG; 6MG; 0.5MG; 17MG; 203MG; 28MG;
250MCG; 50MG; 1.6MG; 65MCG; 1.5MG;
10UNIT; 4.5MG
PREFERA OB TABS 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 1MG; 6MG; 17MG;
28MG; 250MCG; 50MG; 1.6MG; 65MCG;
1.5MG; 4.5MG
PREFERAOB +DHA MISC 30MCG; 10MG;
400UNIT; 0.8MG; 12MCG; 10UNIT; 200MG;
1MG; 6MG; 17MG; 28MG; 250MCG; 50MG;
1.6MG; 65MCG; 1.5MG; 4.5MG
PREFERAOB ONE CAPS 25MG; 30MCG;
10MG; 400UNIT; 12MCG; 200MG; 1MG;
6MG; 17MG; 22MG; 175MCG; 50MG;
10UNIT; 15MG
PRENAISSANCE PLUS CAPS 100MG;
400UNIT; 250MG; 50MG; 1MG; 28MG;
25MG; 30UNIT
PRENAISSANCE CAPS 28MG; 160MG;
800UNIT; 325MG; 55MG; 29MG; 1.25MG;
25MG; 30UNIT
prenatabs fa tabs 120mg; 0; 200mg; 8mcg;
29mg; 1mg; 20mg; 150mcg; 3mg; 3mg; 3mg;
30unit; 4000unit; 400unit; 15mg
prenatabs obn tabs 120mg; 200mg; 400unit;
8mcg; 1mg; 29mg; 20mg; 150mcg; 3mg; 3mg;
3mg; 30unit; 15mg
PRENATA CHEW 120MG; 400UNIT; 12MCG;
29MG; 1MG; 20MG; 10MG; 3MG; 0; 2MG;
11UNIT
prenatal 19 chew 100mg; 1000unit; 200mg;
7mg; 400unit; 12mcg; 29mg; 1mg; 15mg;
20mg; 3mg; 3mg; 30unit; 20mg
prenatal 19 tabs 100mg; 1000unit; 200mg;
7mg; 400unit; 12mcg; 25mg; 29mg; 1mg;
15mg; 20mg; 3mg; 3mg; 30unit; 20mg
Drug Tier
Requirements/
Limits
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
Generic
Generic
MO
OTHER
MO
Generic
MO
Generic
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
125
Drug Name
PRENATAL PLUS IRON TABS 120MG; 0;
200MG; 400UNIT; 2MG; 12MCG; 1MG;
29MG; 20MG; 10MG; 3MG; 1.84MG; 22UNIT;
4000UNIT; 25MG
PRENATAL PLUS IRON TABS 120MG; 0;
200MG; 400UNIT; 2MG; 12MCG; 1MG;
29MG; 20MG; 10MG; 3MG; 1.84MG; 22UNIT;
4000UNIT; 25MG
prenatal plus tabs 120mg; 0; 200mg; 400unit;
2mg; 12mcg; 27mg; 1mg; 20mg; 10mg; 3mg;
1.84mg; 22mg; 4000unit; 25mg
PRENATAL PLUS TABS 120MG; 0; 200MG;
400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG;
10MG; 3MG; 1.84MG; 22MG; 4000UNIT;
25MG
PRENATE AM TABS 200MG; 12MCG;
400MCG; 600MCG; 75MG; 25MG; 500MG
PRENATE DHA CAPS 90MG; 145MG;
220UNIT; 13MCG; 300MG; 28MG; 400MCG;
600MCG; 50MG; 26MG; 10UNIT
PRENATE ELITE TABS 75MG; 2600UNIT;
330MCG; 100MG; 6MG; 450UNIT; 1.5MG;
13MCG; 26MG; 400MCG; 150MCG;
600MCG; 25MG; 21MG; 21MG; 3.5MG; 3MG;
10UNIT; 15MG
PRENATE ESSENTIAL CAPS 600MCG; 90MG;
280MCG; 155MG; 220UNIT; 13MCG;
300MG; 40MG; 18MG; 400MCG; 50MG;
150MCG; 26MG; 10UNIT
PRENATE ESSENTIAL CAPS 90MG; 280MCG;
145MG; 220UNIT; 13MCG; 300MG; 40MG;
29MG; 0; 400MCG; 600MCG; 50MG;
150MCG; 26MG; 10UNIT
PRENATE MINI CAPS 600MCG; 60MG;
280MCG; 80MG; 1000UNIT; 13MCG;
350MG; 0; 400MCG; 18MG; 0; 25MG;
150MCG; 26MG; 10UNIT; 25MG
PRENATE MINI CAPS 60MG; 280MCG;
100MG; 220UNIT; 13MCG; 350MG;
400MCG; 29MG; 600MCG; 25MG; 150MCG;
26MG; 10UNIT; 25MG
Drug Tier
Requirements/
Limits
MO
OTHER
MO
OTHER
Generic
MO
OTHER
OTHER
MO
OTHER
OTHER
MO
OTHER
OTHER
MO
OTHER
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
126
Drug Name
PRENATE PIXIE CAPS 600MCG; 30MG;
75MCG; 500UNIT; 13MCG; 200MG; 10MG;
400MCG; 150MCG; 5MG; 10UNIT; 5MG
PREPLUS TABS 120MG; 0; 200MG; 400UNIT;
2MG; 12MCG; 27MG; 1MG; 20MG; 10MG;
3MG; 1.84MG; 22MG; 4000UNIT; 25MG
PREQUE 10 TABS 30MG; 1250UNIT; 0;
120UNIT; 50MG; 1MG; 1MCG; 15UNIT;
50MG; 25MG; 0.5MG; 15MG; 5MG; 10MG;
1.7MG; 0; 7.5MCG; 1MG; 12.5MG
PRETAB TABS 120MG; 4000UNIT; 200MG;
400UNIT; 8MCG; 29MG; 1MG; 20MG;
150MCG; 3MG; 3MG; 3MG; 30UNIT; 15MG
PROVIDA DHA CAPS 315MG; 300MCG;
30MG; 5MG; 400UNIT; 1MG; 10MCG;
110MG; 16MG; 1.25MG; 30MG; 7MG; 2MG;
16MG; 25MG; 3MG; 2MG; 6MG
PUREFE OB PLUS CAPS 10MG; 0.8MG;
15MCG; 162MG; 1MG; 6.9MG; 1.3MG;
30MG; 115.2MG; 5MG; 6MG; 200MG; 10MG;
18.2MG
QUFLORA PEDIATRIC SOLN 35MG/ML;
400UNIT/ML; 1MG/ML; 2MCG/ML; 35MCG/
ML; 65MCG/ML; 10MG/ML; 0.8MG/ML;
0.4MG/ML; 0.6MG/ML; 0.25MG/ML; 0.5MG/
ML; 1000UNIT/ML; 5UNIT/ML
QUFLORA PEDIATRIC SOLN 45MG/ML;
400UNIT/ML; 1MG/ML; 3MCG/ML; 81MCG/
ML; 150MCG/ML; 12MG/ML; 2MG/ML;
1MG/ML; 1MG/ML; 0.5MG/ML; 1MG/ML;
1100UNIT/ML; 12UNIT/ML
RELNATE DHA CAPS 100MG; 400UNIT; 1MG;
15MCG; 28MG; 1MG; 30MG; 200MG; 20MG;
3MG; 3MG; 30UNIT; 20MG
se-natal 19 chew 1000unit; 100mg; 200mg;
7mg; 400unit; 12mcg; 29mg; 1mg; 15mg;
20mg; 3mg; 3mg; 30unit; 20mg
se-natal 19 tabs 100mg; 1000unit; 200mg;
7mg; 400unit; 12mcg; 25mg; 29mg; 1mg;
15mg; 20mg; 3mg; 3mg; 30unit; 20mg
Drug Tier
Requirements/
Limits
MO
OTHER
MO
OTHER
MO
OTHER
OTHER
OTHER
OTHER
MO
OTHER
OTHER
MO
OTHER
MO
Generic
MO
Generic
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
127
Drug Name
se-tan dha caps 215.12mg; 53.46mg; 15mg;
1mg; 310.1mg; 15mg; 25mg; 20mg
SELECT-OB CHEW 60MG; 0; 400UNIT;
5MCG; 0.4MG; 0.6MG; 25MG; 15MG;
29MG; 2.5MG; 1.8MG; 0; 1.6MG; 30UNIT;
1700UNIT; 15MG
seton et-ec misc 120mg; 3000unit; 200mg;
400unit; 2mg; 12mcg; 295mg; 0; 0; 1mg;
29mg; 0; 25mg; 20mg; 430mg; 25mg; 4mg;
1.8mg; 3mg; 25mg
setonet misc 120mg; 3000unit; 200mg;
400unit; 2mg; 12mcg; 295mg; 0; 0; 1mg;
29mg; 0; 25mg; 20mg; 430mg; 25mg; 4mg;
1.8mg; 30mg; 25mg
TARON-PREX CAPS 25MG; 160MG;
170UNIT; 265MG; 55MG; 30MG; 1.2MG;
25MG; 30UNIT
THRIVITE RX TABS 120MG; 4000UNIT;
30MCG; 200MG; 7MG; 400UNIT; 3MG;
8MCG; 1MG; 29MG; 100MG; 20MG;
150MCG; 3MG; 3MG; 3MG; 30UNIT; 15MG
TL FOLATE TABS 80MG; 4000UNIT; 300MCG;
120MG; 6MG; 400UNIT; 2MG; 12MCG;
27MG; 500MCG; 500MCG; 90MG; 20MG;
150MCG; 20MG; 3.4MG; 3MG; 30UNIT;
15MG
TL-CARE DHA CAPS 60MG; 300MCG;
800UNIT; 2MG; 100MCG; 215MG; 25MG;
45MG; 27MG; 500MG; 1MG; 20MG; 25MG;
3.4MG; 3MG; 30UNIT; 10MG
TL-SELECT CAPS 28MG; 160MG; 800UNIT;
325MG; 55MG; 29MG; 1.25MG; 25MG;
30UNIT
tri-vit/fluoride/iron soln 35mg/ml; 0.25mg/ml;
10mg/ml; 1500unit/ml; 400unit/ml
tri-vit/fluoride soln 35mg/ml; 400unit/ml;
0.25mg/ml; 1500unit/ml
tri-vit/fluoride soln 35mg/ml; 400unit/ml;
0.5mg/ml; 1500unit/ml
tri-vitamin/fluoride soln 35mg/ml; 0.25mg/ml;
1500unit/ml; 400unit/ml
Drug Tier
Generic
Requirements/
Limits
MO
MO
OTHER
MO
Generic
MO
Generic
MO
OTHER
MO
OTHER
OTHER
MO
OTHER
MO
OTHER
Generic
Generic
Generic
Generic
MO
MO
MO
MO
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
128
Drug Name
tri-vitamin/fluoride soln 35mg/ml; 0.5mg/ml;
1500unit/ml; 400unit/ml
triadvance tabs 120mg; 2700unit; 200mg;
400unit; 2mg; 12mcg; 50mg; 1mg; 90mg;
30mg; 20mg; 20mg; 3.4mg; 3mg; 30unit; 25mg
TRICARE PRENATAL COMPLEAT MISC
100MG; 200MG; 400UNIT; 2MG; 12MCG;
135MG; 33.8MG; 27MG; 0; 1MG; 20MG;
71.2MG; 3.1MG; 1.6MG; 1.6MG; 30UNIT;
10MG
TRICARE PRENATAL DHA ONE CAPS 60MG;
300MCG; 800UNIT; 2MG; 100MCG; 215MG;
25MG; 45MG; 27MG; 500MG; 1MG; 20MG;
25MG; 3.4MG; 3MG; 30UNIT; 10MG
tricare tabs 100mg; 200mg; 2mg; 12mcg;
27mg; 1mg; 20mg; 3.1mg; 1.6mg; 1.6mg;
10mcg; 30unit; 10mg
TRINATAL GT TABS 120MG; 2700UNIT;
30MCG; 200MG; 400UNIT; 2MG; 12MCG;
50MG; 1MG; 90MG; 30MG; 20MG; 6MG;
20MG; 3.4MG; 3MG; 10UNIT; 15MG
trinatal rx 1 tabs 80mg; 400unit; 30mcg;
200mg; 400unit; 3mg; 2.5mcg; 60mg; 1mg;
100mg; 17mg; 7mg; 4mg; 1.6mg; 1.5mg;
15unit; 3600unit; 25mg
triple-vitamin/fluoride soln 35mg/ml; 400unit/
ml; 0.25mg/ml; 1500unit/ml
TRISTART DHA CAPS 55MG; 1000UNIT;
14MCG; 200MG; 15MG; 400MCG; 31MG;
30MG; 600MCG; 5MG; 200MCG; 35MG;
1.8MG; 1.3MG; 15UNIT
TRIVEEN-DUO DHA MISC 120MG;
3000UNIT; 200MG; 400UNIT; 2MG; 12MCG;
275MG; 0; 0; 1MG; 29MG; 0; 25MG; 20MG;
400MG; 25MG; 4MG; 1.8MG; 30MG; 25MG
TRIVEEN-PRX RNF CAPS 28MG; 160MG;
400UNIT; 300MG; 55MG; 26MG; 1.2MG;
25MG; 30UNIT
Drug Tier
Generic
Requirements/
Limits
MO
Generic
MO
OTHER
MO
OTHER
MO
Generic
MO
OTHER
MO
Generic
Generic
MO
OTHER
MO
OTHER
MO
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
129
Drug Name
ultimatecare one nf caps 25mg; 300mcg;
100mg; 0; 0; 800unit; 350mg; 50mg; 100mg;
7mg; 1mg; 150mcg; 20mg; 50mg; 50mg;
10mg; 500mg; 50mg; 1.5mg; 15unit; 5mg
VEMAVITE-PRX 2 CAPS 28MG; 160MG;
400UNIT; 300MG; 55MG; 27MG; 1.25MG;
25MG; 30UNIT
VENA-BAL DHA MISC 120MG; 0; 2850UNIT;
219MG; 840UNIT; 2MG; 12MCG; 628MG;
1MG; 220MCG; 27MG; 25MG; 20MG;
430MG; 0; 50MG; 4MG; 0; 1.8MG; 3MG;
25MG
VIRT-ADVANCE TABS 120MG; 2700UNIT;
200MG; 400UNIT; 2MG; 12MCG; 50MG;
1MG; 90MG; 30MG; 20MG; 20MG; 3.4MG;
3MG; 30UNIT; 25MG
VIRT-C DHA CAPS 25MG; 300MCG; 5MG;
2MG; 12.5MCG; 156MG; 39MG; 53.5MG;
310MG; 1MG; 5MG; 1.8MG; 200MG; 38MG;
25MG; 3MG; 2MG; 10MG
VIRT-CARE ONE CAPS 25MG; 150MG; 0;
170UNIT; 260MG; 40MG; 7MG; 1MG; 20MG;
30MG; 30MG; 330MG; 25MG; 30UNIT
VIRT-PN DHA CAPS 85MG; 140MG;
200UNIT; 12MCG; 300MG; 27MG; 400MCG;
600MCG; 45MG; 25MG; 10UNIT
VIRT-PN PLUS CAPS 85MG; 250MCG;
140MG; 200UNIT; 12MCG; 300MG; 40MG;
28MG; 400MCG; 600MCG; 45MG; 340MG;
150MCG; 25MG; 10UNIT
VIRT-PN TABS 80MG; 2500UNIT; 300MCG;
120MG; 6MG; 400UNIT; 2MG; 12MCG;
27MG; 400MCG; 600MCG; 30MG; 20MG;
150MCG; 20MG; 3.4MG; 3MG; 10UNIT;
15MG
VIRT-SELECT CAPS 28MG; 160MG; 800UNIT;
325MG; 55MG; 29MG; 1.25MG; 25MG;
30UNIT
VITAFOL-ONE CAPS 30MG; 0; 1100UNIT;
1000UNIT; 2MG; 12MCG; 200MG; 1MG;
20MG; 15MG; 29MG; 150MCG; 2.5MG;
1.8MG; 1.6MG; 20UNIT; 25MG
Drug Tier
Requirements/
Limits
MO
Generic
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
130
Drug Name
VITAMEDMD ONE RX/QUATREFOLIC CAPS
60MG; 300MCG; 10MG; 400UNIT; 8MCG;
200MG; 30MG; 400MCG; 600MCG; 20MG;
25MG; 1.7MG; 1.5MG; 21UNIT; 7.5MG
VITAMEDMD PLUS RX/QUATRE FOLIC MISC
60MG; 300MCG; 150MG; 10MG; 600UNIT;
2MG; 12MCG; 300MG; 400MCG; 30MG;
600MCG; 20MG; 150MCG; 25MG; 3.4MG;
3MG; 30UNIT; 15MG
vitamins a/c/d/fluoride soln 35mg/ml; 400unit/
ml; 0.25mg/ml; 1500unit/ml
VOL-NATE TABS 120MG; 3000UNIT; 200MG;
400UNIT; 2MG; 12MCG; 28MG; 1MG; 25MG;
20MG; 25MG; 4MG; 1.8MG; 22MG; 25MG
VOL-PLUS TABS 120MG; 0; 200MG;
400UNIT; 2MG; 12MCG; 27MG; 1MG; 20MG;
10MG; 3MG; 1.84MG; 22MG; 4000UNIT;
25MG
VP CH ULTRA CAPS 104MG; 400UNIT;
260MG; 50MG; 0; 1MG; 27MG; 0; 25MG;
30UNIT
VP-CH-PNV CAPS 104MG; 400UNIT;
260MG; 50MG; 0; 1MG; 30MG; 25MG;
30UNIT
VP-HEME OB TABS 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 1MG; 6MG; 17MG;
28MG; 250MCG; 50MG; 1.6MG; 65MCG;
1.5MG; 4.5MG
VP-PNV-DHA CAPS 80MG; 50MG; 400UNIT;
1MG; 12MCG; 200MG; 15.8MG; 28MG; 1MG;
30MG; 20MG; 16MG; 2.2MG; 6MG; 30UNIT;
2500UNIT; 20MG
ZATEAN-CH CAPS 100MG; 400UNIT;
250MG; 50MG; 1MG; 27MG; 25MG; 30UNIT
ZATEAN-PN DHA CAPS 85MG; 140MG;
200UNIT; 12MCG; 300MG; 27MG; 400MCG;
600MCG; 45MG; 25MG; 10UNIT
ZATEAN-PN PLUS CAPS 85MG; 250MCG;
140MG; 200UNIT; 12MCG; 300MG; 40MG;
28MG; 400MCG; 600MCG; 45MG; 340MG;
150MCG; 25MG; 10UNIT
Drug Tier
Requirements/
Limits
MO
OTHER
MO
OTHER
Generic
MO
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
MO
OTHER
OTHER
MO
MO
OTHER
MO
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
131
Drug Name
ZATEAN-PN TABS 80MG; 2500UNIT;
300MCG; 120MG; 6MG; 400UNIT; 2MG;
12MCG; 27MG; 400MCG; 600MCG; 30MG;
20MG; 150MCG; 20MG; 3.4MG; 3MG;
10UNIT; 15MG
Drug Tier
Requirements/
Limits
MO
OTHER
PA – Prior Authorization QL – Quantity Limit ST – Step Therapy MO – Available at Mail Order
B/D – Covered under Medicare B or D LA – Limited Access
01/01/2016
Formulary ID 00016462v6
132
Drug Name
Page Number Drug Name
Page Number
Index of Drugs
8-MOP CAPS 10MG.......................................................75
abacavir sulfate/lamivudine/zidovudine tabs 300mg;
150mg; 300mg.......................................................................49
abacavir tabs 300mg.............................................................49
ABELCET INJ 5MG/ML....................................................28
ABILIFY DISCMELT TBDP 10MG...................................44
ABILIFY DISCMELT TBDP 15MG...................................44
ABILIFY INJ 9.75MG/1.3ML...........................................44
ABILIFY MAINTENA INJ 300MG...................................44
ABILIFY MAINTENA INJ 300MG...................................44
ABILIFY MAINTENA INJ 400MG...................................44
ABILIFY SOLN 1MG/ML.................................................44
ABRAXANE INJ 900MG; 100MG..................................33
acamprosate calcium dr tbec 333mg.................................. 7
acarbose tabs 25mg...............................................................52
acarbose tabs 50mg...............................................................52
acarbose tabs 100mg............................................................52
acebutolol hcl caps 200mg..................................................63
acebutolol hcl caps 400mg..................................................63
acetaminophen/codeine #3 tabs 300mg; 30mg............. 3
acetaminophen/codeine soln 120mg/5ml; 12mg/5ml. 4
acetaminophen/codeine tabs 300mg; 15mg.................... 4
acetaminophen/codeine tabs 300mg; 60mg.................... 4
acetasol hc soln 2%; 1%.....................................................105
acetazolamide er cp12 500mg...........................................69
acetazolamide tabs 125mg..................................................69
acetazolamide tabs 250mg..................................................69
acetic acid/aluminum acetate soln 2%; 0......................105
acetic acid soln 2%..............................................................105
acetylcysteine inj 200mg/ml.............................................109
acetylcysteine soln 10%.....................................................109
acetylcysteine soln 20%.....................................................109
acitretin caps 10mg................................................................75
acitretin caps 17.5mg............................................................75
acitretin caps 25mg................................................................75
ACTHIB INJ 0....................................................................98
ACTIMMUNE INJ 2000000UNIT/0.5ML.....................98
ACUVAIL SOLN 0.45%................................................ 104
acyclovir caps 200mg............................................................51
acyclovir oint 5%.....................................................................51
acyclovir sodium inj 50mg/ml..............................................51
acyclovir sodium inj 500mg.................................................51
acyclovir sodium inj 1000mg..............................................51
acyclovir susp 200mg/5ml...................................................51
acyclovir tabs 400mg.............................................................51
acyclovir tabs 800mg.............................................................51
ADACEL INJ 15.5MCG/0.5ML; 2LF/0.5ML; 5LF/0.5ML
98
ADAGEN INJ 250UNIT/ML.............................................77
ADASUVE AEPB 10MG..................................................42
adefovir dipivoxil tabs 10mg................................................47
ADEMPAS TABS 0.5MG............................................... 108
ADEMPAS TABS 1.5MG............................................... 108
ADEMPAS TABS 1MG.................................................. 109
ADEMPAS TABS 2.5MG............................................... 109
ADEMPAS TABS 2MG.................................................. 109
adrucil inj 2.5gm/50ml.........................................................33
adrucil inj 5gm/100ml..........................................................33
adrucil inj 500mg/10ml........................................................33
ADVAIR DISKUS AEPB 100MCG/DOSE; 50MCG/
DOSE............................................................................... 105
ADVAIR DISKUS AEPB 250MCG/DOSE; 50MCG/
DOSE............................................................................... 105
ADVAIR DISKUS AEPB 500MCG/DOSE; 50MCG/
DOSE............................................................................... 105
ADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT..... 105
ADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT... 105
ADVAIR HFA AERO 230MCG/ACT; 21MCG/ACT... 105
AFINITOR DISPERZ TBSO 2MG....................................37
AFINITOR DISPERZ TBSO 3MG....................................37
AFINITOR DISPERZ TBSO 5MG....................................37
AFINITOR TABS 2.5MG..................................................37
AFINITOR TABS 5MG......................................................37
AFINITOR TABS 7.5MG..................................................37
AFINITOR TABS 10MG...................................................37
AGGRENOX CP12 25MG; 200MG...............................58
a-hydrocort inj 100mg..........................................................82
ak-poly-bac oint 500unit/gm; 10000unit/gm............102
ALBENZA TABS 200MG.................................................40
albuterol sulfate er tb12 4mg...........................................107
albuterol sulfate er tb12 8mg...........................................107
albuterol sulfate nebu 0.5%...............................................107
albuterol sulfate nebu 0.63mg/3ml................................107
albuterol sulfate nebu 0.083%.........................................107
albuterol sulfate nebu 1.25mg/3ml................................107
albuterol sulfate syrp 2mg/5ml........................................107
albuterol sulfate tabs 2mg.................................................107
albuterol sulfate tabs 4mg.................................................107
alclometasone dipropionate crea 0.05%..........................82
alclometasone dipropionate oint 0.05%..........................82
133
Drug Name
Page Number
ALCOHOL PREP PADS PADS 70%............................ 101
ALDURAZYME INJ 2.9MG/5ML....................................77
alendronate sodium soln 70mg/75ml...........................100
alendronate sodium tabs 5mg..........................................100
alendronate sodium tabs 10mg.......................................100
alendronate sodium tabs 35mg.......................................100
alendronate sodium tabs 40mg.......................................100
alendronate sodium tabs 70mg.......................................100
ALIMTA INJ 100MG.........................................................33
ALIMTA INJ 500MG.........................................................33
ALINIA SUSR 100MG/5ML............................................40
ALINIA TABS 500MG......................................................40
ALKERAN TABS 2MG......................................................31
allopurinol tabs 100mg.........................................................29
allopurinol tabs 300mg.........................................................29
alosetron hydrochloride tabs 0.5mg..................................80
alosetron hydrochloride tabs 1mg......................................80
ALPHAGAN P SOLN 0.1%.......................................... 104
alprazolam tabs 0.5mg..........................................................51
alprazolam tabs 0.25mg.......................................................51
alprazolam tabs 1mg.............................................................51
alprazolam tabs 2mg.............................................................51
ALTABAX OINT 1%..........................................................75
altavera tabs 0.03mg; 0.15mg............................................88
alyacen 1/35 tabs 35mcg; 1mg..........................................88
alyacen 7/7/7 tabs 0; 0.........................................................88
amantadine hcl caps 100mg...............................................41
amantadine hcl syrp 50mg/5ml.........................................41
amantadine hcl tabs 100mg................................................41
AMBISOME INJ 50MG....................................................28
amcinonide crea 0.1%...........................................................82
amcinonide lotn 0.1%............................................................82
amcinonide oint 0.1%............................................................82
amethia lo tabs 0; 0................................................................88
amethia tabs 0; 0....................................................................88
amethyst tabs 20mcg; 90mcg.............................................88
amifostine inj 500mg.............................................................33
amikacin sulfate inj 1gm/4ml................................................ 7
amikacin sulfate inj 500mg/2ml........................................... 7
amiloride hcl tabs 5mg..........................................................70
amiloride/hydrochlorothiazide tabs 5mg; 50mg............70
aminophylline inj 25mg/ml...............................................108
AMINOSYN 7%/ELECTROLYTES INJ 124MEQ/L;
900MG/100ML; 690MG/100ML; 96MEQ/L;
900MG/100ML; 210MG/100ML; 510MG/100ML;
660MG/100ML; 510MG/100ML; 10MEQ/L;
280MG/100ML; 310MG/100ML; 30MMOLE/L;
134
Drug Name
Page Number
65MEQ/L; 610MG/100ML; 300MG/100ML;
65MEQ/L; 370MG/100ML; 120MG/100ML;
44MG/100ML; 560MG/100ML................................ 110
aminosyn 8.5%/electrolytes inj 142meq/l;
1100mg/100ml; 850mg/100ml; 98meq/l;
1100mg/100ml; 260mg/100ml; 620mg/100ml;
810mg/100ml; 624mg/100ml; 10meq/l;
340mg/100ml; 380mg/100ml; 30meq/l; 65meq/l;
750mg/100ml; 370mg/100ml; 65meq/l;
460mg/100ml; 150mg/100ml; 44mg/100ml;
680mg/100ml.....................................................................111
AMINOSYN-HBC INJ 7.1MEQ/100ML;
660MG/100ML; 507MG/100ML; 4MEQ/100ML;
660MG/100ML; 154MG/100ML; 789MG/100ML;
1576MG/100ML; 265MG/100ML; 206MG/100ML;
1.12GM/100ML; 228MG/100ML; 448MG/100ML;
221MG/100ML; 272MG/100ML; 88MG/100ML;
33MG/100ML; 789MG/100ML................................ 112
aminosyn ii 8.5%/electrolytes inj 61meq/l;
844mg/100ml; 865mg/100ml; 595mg/100ml;
86meq/l; 627mg/100ml; 425mg/100ml;
255mg/100ml; 561mg/100ml; 850mg/100ml;
893mg/100ml; 10meq/l; 146mg/100ml;
253mg/100ml; 30mmole/l; 66meq/l; 614mg/100ml;
450mg/100ml; 80meq/l; 340mg/100ml;
170mg/100ml; 230mg/100ml; 425mg/100ml.......111
AMINOSYN II INJ 50.3MEQ/L; 695MG/100ML;
713MG/100ML; 490MG/100ML; 517MG/100ML;
350MG/100ML; 210MG/100ML; 462MG/100ML;
700MG/100ML; 735MG/100ML; 120MG/100ML;
209MG/100ML; 505MG/100ML; 371MG/100ML;
31.3MEQ/L; 280MG/100ML; 140MG/100ML;
189MG/100ML; 350MG/100ML............................. 111
AMINOSYN II INJ 61.1MEQ/L; 844MG/100ML;
865MG/100ML; 595MG/100ML; 627MG/100ML;
425MG/100ML; 255MG/100ML; 561MG/100ML;
850MG/100ML; 893MG/100ML; 146MG/100ML;
253MG/100ML; 614MG/100ML; 450MG/100ML;
33.3MEQ/L; 340MG/100ML; 170MG/100ML;
230MG/100ML; 425MG/100ML............................. 112
AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML;
1018MG/100ML; 700MG/100ML; 738MG/100ML;
500MG/100ML; 300MG/100ML; 660MG/100ML;
1000MG/100ML; 1050MG/100ML; 172MG/100ML;
298MG/100ML; 722MG/100ML; 530MG/100ML;
45.3MEQ/L; 400MG/100ML; 200MG/100ML;
270MG/100ML; 500MG/100ML............................. 112
Drug Name
Page Number
AMINOSYN II INJ 107.6MEQ/L; 1490MG/100ML;
1527MG/100ML; 1050MG/100ML;
1107MG/100ML; 750MG/100ML; 450MG/100ML;
990MG/100ML; 1500MG/100ML; 1575MG/100ML;
258MG/100ML; 447MG/100ML; 1083MG/100ML;
795MG/100ML; 50MEQ/L; 600MG/100ML;
300MG/100ML; 405MG/100ML; 750MG/100ML......
111
AMINOSYN INJ 90MEQ/L; 1100MG/100ML;
850MG/100ML; 35MEQ/L; 1100MG/100ML;
260MG/100ML; 620MG/100ML; 810MG/100ML;
624MG/100ML; 340MG/100ML; 380MG/100ML;
5.4MEQ/L; 750MG/100ML; 370MG/100ML;
460MG/100ML; 150MG/100ML; 44MG/100ML;
680MG/100ML............................................................ 113
AMINOSYN INJ 148MEQ/L; 1280MG/100ML;
980MG/100ML; 1280MG/100ML; 300MG/100ML;
720MG/100ML; 940MG/100ML; 720MG/100ML;
400MG/100ML; 440MG/100ML; 5.4MEQ/L;
860MG/100ML; 420MG/100ML; 520MG/100ML;
160MG/100ML; 44MG/100ML; 800MG/100ML.113
AMINOSYN M INJ 65MEQ/L; 448MG/100ML;
343MG/100ML; 40MEQ/L; 448MG/100ML;
105MG/100ML; 252MG/100ML; 329MG/100ML;
252MG/100ML; 3MEQ/L; 140MG/100ML;
154MG/100ML; 3.5MMOLE/L; 13MEQ/L;
300MG/100ML; 147MG/100ML; 40MEQ/L;
182MG/100ML; 56MG/100ML; 31MG/100ML;
280MG/100ML............................................................ 112
AMINOSYN-PF 7% INJ 32.5MEQ/L; 490MG/100ML;
861MG/100ML; 370MG/100ML; 576MG/100ML;
270MG/100ML; 220MG/100ML; 534MG/100ML;
831MG/100ML; 475MG/100ML; 125MG/100ML;
10.69GM/L; 300MG/100ML; 570MG/100ML;
70GM/L; 347MG/100ML; 50MG/100ML;
360MG/100ML; 125MG/100ML; 44MG/100ML;
452MG/100ML............................................................ 113
AMINOSYN-PF INJ 46MEQ/L; 698MG/100ML;
1227MG/100ML; 527MG/100ML; 820MG/100ML;
385MG/100ML; 312MG/100ML; 760MG/100ML;
1200MG/100ML; 677MG/100ML; 180MG/100ML;
427MG/100ML; 812MG/100ML; 495MG/100ML;
3.4MEQ/L; 70MG/100ML; 512MG/100ML;
180MG/100ML; 44MG/100ML; 673MG/100ML.113
AMINOSYN-RF INJ 113MEQ/L; 600MG/100ML;
429MG/100ML; 462MG/100ML; 726MG/100ML;
535MG/100ML; 726MG/100ML; 726MG/100ML;
Drug Name
Page Number
330MG/100ML; 165MG/100ML; 528MG/100ML......
113
amiodarone hcl tabs 100mg................................................62
amiodarone hcl tabs 200mg................................................62
amiodarone hcl tabs 400mg................................................62
AMITIZA CAPS 8MCG....................................................80
AMITIZA CAPS 24MCG..................................................80
amitriptyline hcl tabs 10mg.................................................25
amitriptyline hcl tabs 25mg.................................................25
amitriptyline hcl tabs 50mg.................................................25
amitriptyline hcl tabs 75mg.................................................25
amitriptyline hcl tabs 100mg...............................................25
amitriptyline hcl tabs 150mg...............................................25
amlodipine besylate/atorvastatin calcium tabs 2.5mg;
10mg..........................................................................................65
amlodipine besylate/atorvastatin calcium tabs 2.5mg;
20mg..........................................................................................65
amlodipine besylate/atorvastatin calcium tabs 2.5mg;
40mg..........................................................................................65
amlodipine besylate/atorvastatin calcium tabs 5mg;
10mg..........................................................................................65
amlodipine besylate/atorvastatin calcium tabs 5mg;
20mg..........................................................................................65
amlodipine besylate/atorvastatin calcium tabs 5mg;
40mg..........................................................................................65
amlodipine besylate/atorvastatin calcium tabs 5mg;
80mg..........................................................................................65
amlodipine besylate/atorvastatin calcium tabs 10mg;
10mg..........................................................................................65
amlodipine besylate/atorvastatin calcium tabs 10mg;
20mg..........................................................................................65
amlodipine besylate/atorvastatin calcium tabs 10mg;
40mg..........................................................................................65
amlodipine besylate/atorvastatin calcium tabs 10mg;
80mg..........................................................................................65
amlodipine besylate/benazepril hcl caps 5mg; 40mg...65
amlodipine besylate/benazepril hydrochloride caps
2.5mg; 10mg...........................................................................66
amlodipine besylate/benazepril hydrochloride caps 5mg;
10mg..........................................................................................66
amlodipine besylate/benazepril hydrochloride caps 5mg;
20mg..........................................................................................66
amlodipine besylate/benazepril hydrochloride caps
10mg; 20mg............................................................................66
amlodipine besylate/benazepril hydrochloride caps
10mg; 40mg............................................................................66
amlodipine besylate tabs 2.5mg.........................................66
135
Drug Name
Page Number
amlodipine besylate tabs 5mg.............................................66
amlodipine besylate tabs 10mg..........................................66
amlodipine besylate/valsartan tabs 5mg; 160mg..........66
amlodipine besylate/valsartan tabs 5mg; 320mg..........66
amlodipine besylate/valsartan tabs 10mg; 160mg.......66
amlodipine besylate/valsartan tabs 10mg; 320mg.......66
amlodipine/valsartan/hctz tabs 5mg; 12.5mg; 160mg....
66
amlodipine/valsartan/hctz tabs 5mg; 25mg; 160mg...66
amlodipine/valsartan/hctz tabs 10mg; 12.5mg; 160mg.
66
amlodipine/valsartan/hctz tabs 10mg; 25mg; 160mg.66
amlodipine/valsartan/hctz tabs 10mg; 25mg; 320mg.66
ammonium lactate crea 12%..............................................75
ammonium lactate lotn 12%...............................................75
amnesteem caps 10mg.........................................................75
amnesteem caps 20mg.........................................................75
amnesteem caps 40mg.........................................................75
amoxapine tabs 25mg...........................................................26
amoxapine tabs 50mg...........................................................26
amoxapine tabs 100mg........................................................25
amoxapine tabs 150mg........................................................25
amoxicillin caps 250mg........................................................14
amoxicillin caps 500mg........................................................14
amoxicillin chew 125mg.......................................................14
amoxicillin chew 250mg.......................................................14
amoxicillin/clavulanate potassium chew 200mg; 28.5mg
13
amoxicillin/clavulanate potassium chew 400mg; 57mg...
13
amoxicillin/clavulanate potassium er tb12 1000mg;
62.5mg......................................................................................13
amoxicillin/clavulanate potassium susr 200mg/5ml;
28.5mg/5ml.............................................................................13
amoxicillin/clavulanate potassium susr 250mg/5ml;
62.5mg/5ml.............................................................................13
amoxicillin/clavulanate potassium susr 400mg/5ml;
57mg/5ml.................................................................................13
amoxicillin/clavulanate potassium susr 600mg/5ml;
42.9mg/5ml.............................................................................14
amoxicillin/clavulanate potassium tabs 250mg; 125mg..
14
amoxicillin/clavulanate potassium tabs 500mg; 125mg..
14
amoxicillin/clavulanate potassium tabs 875mg; 125mg..
14
amoxicillin susr 125mg/5ml................................................14
136
Drug Name
Page Number
amoxicillin susr 200mg/5ml................................................14
amoxicillin susr 250mg/5ml................................................14
amoxicillin susr 400mg/5ml................................................14
amoxicillin tabs 500mg.........................................................14
amoxicillin tabs 875mg.........................................................14
amphetamine/dextroamphetamine tabs 1.25mg;
1.25mg; 1.25mg; 1.25mg...................................................73
amphetamine/dextroamphetamine tabs 1.875mg;
1.875mg; 1.875mg; 1.875mg...........................................73
amphetamine/dextroamphetamine tabs 2.5mg; 2.5mg;
2.5mg; 2.5mg..........................................................................73
amphetamine/dextroamphetamine tabs 3.75mg;
3.75mg; 3.75mg; 3.75mg...................................................73
amphetamine/dextroamphetamine tabs 3.125mg;
3.125mg; 3.125mg; 3.125mg...........................................73
amphetamine/dextroamphetamine tabs 5mg; 5mg; 5mg;
5mg.............................................................................................73
amphetamine/dextroamphetamine tabs 7.5mg; 7.5mg;
7.5mg; 7.5mg..........................................................................73
amphotericin b inj 50mg.......................................................28
ampicillin caps 250mg..........................................................14
ampicillin caps 500mg..........................................................14
ampicillin sodium inj 1gm.....................................................14
ampicillin sodium inj 1gm.....................................................14
ampicillin sodium inj 2gm.....................................................14
ampicillin sodium inj 2gm.....................................................14
ampicillin sodium inj 10gm..................................................14
ampicillin sodium inj 10gm..................................................14
ampicillin sodium inj 125mg...............................................14
ampicillin sodium inj 250mg...............................................14
ampicillin sodium inj 500mg...............................................14
ampicillin-sulbactam inj 1gm; 0.5gm...............................14
ampicillin-sulbactam inj 1gm; 0.5gm...............................14
ampicillin-sulbactam inj 1gm; 0.5gm...............................14
ampicillin-sulbactam inj 2gm; 1gm...................................14
ampicillin-sulbactam inj 2gm; 1gm...................................14
ampicillin-sulbactam inj 10gm; 5gm................................14
ampicillin-sulbactam inj 10gm; 5gm................................14
ampicillin susr 125mg/5ml..................................................14
ampicillin susr 250mg/5ml..................................................14
AMPYRA TB12 10MG....................................................74
ANADROL-50 TABS 50MG...........................................87
anagrelide hydrochloride caps 0.5mg...............................56
anagrelide hydrochloride caps 1mg...................................56
anastrozole tabs 1mg.............................................................37
ANDROGEL GEL 20.25MG/1.25GM...........................87
ANDROGEL GEL 25MG/2.5GM...................................87
Drug Name
Page Number
ANDROGEL GEL 40.5MG/2.5GM................................87
ANDROGEL GEL 50MG/5GM.......................................87
ANDROGEL PUMP GEL 1%...........................................87
ANDROGEL PUMP GEL 1.62%.....................................87
ANORO ELLIPTA AEPB 62.5MCG/INH; 25MCG/INH...
107
antibiotic ear soln 1%; 3.5mg/ml; 10000unit/ml.......105
APOKYN INJ 10MG/ML..................................................41
apraclonidine soln 0.5%.....................................................104
APRISO CP24 0.375GM............................................. 100
apri tabs 0.15mg; 30mcg.....................................................88
APTIOM TABS 200MG...................................................17
APTIOM TABS 400MG...................................................17
APTIOM TABS 600MG...................................................17
APTIOM TABS 800MG...................................................18
APTIVUS CAPS 250MG..................................................50
APTIVUS SOLN 100MG/ML..........................................50
aranelle tabs 0; 0.....................................................................88
ARANESP ALBUMIN FREE INJ 10MCG/0.4ML..........56
ARANESP ALBUMIN FREE INJ 25MCG/0.42ML.......57
ARANESP ALBUMIN FREE INJ 25MCG/ML................57
ARANESP ALBUMIN FREE INJ 40MCG/0.4ML..........57
ARANESP ALBUMIN FREE INJ 40MCG/ML................57
ARANESP ALBUMIN FREE INJ 60MCG/0.3ML..........57
ARANESP ALBUMIN FREE INJ 60MCG/ML................57
ARANESP ALBUMIN FREE INJ 100MCG/0.5ML.......56
ARANESP ALBUMIN FREE INJ 100MCG/ML.............56
ARANESP ALBUMIN FREE INJ 150MCG/0.3ML.......57
ARANESP ALBUMIN FREE INJ 150MCG/0.75ML.....57
ARANESP ALBUMIN FREE INJ 200MCG/0.4ML.......57
ARANESP ALBUMIN FREE INJ 200MCG/ML.............57
ARANESP ALBUMIN FREE INJ 300MCG/0.6ML.......57
ARANESP ALBUMIN FREE INJ 300MCG/ML.............57
ARANESP ALBUMIN FREE INJ 500MCG/ML.............57
ARCALYST INJ 220MG....................................................98
ARCAPTA NEOHALER CAPS 75MCG....................... 107
aripiprazole soln 1mg/ml......................................................44
aripiprazole tabs 2mg............................................................44
aripiprazole tabs 5mg............................................................44
aripiprazole tabs 10mg..........................................................44
aripiprazole tabs 15mg..........................................................44
aripiprazole tabs 20mg..........................................................44
aripiprazole tabs 30mg..........................................................44
ARISTADA INJ 441MG/1.6ML.......................................44
ARISTADA INJ 662MG/2.4ML.......................................44
ARISTADA INJ 882MG/3.2ML.......................................44
ARRANON INJ 5MG/ML.................................................33
Drug Name
Page Number
ARZERRA INJ 100MG/5ML...........................................39
ARZERRA INJ 1000MG/50ML......................................39
ASACOL HD TBEC 800MG......................................... 100
ashlyna tabs 0; 0......................................................................88
ASMANEX HFA AERO 100MCG/ACT....................... 105
ASMANEX HFA AERO 200MCG/ACT....................... 105
ASMANEX TWISTHALER 7 METERED DOSES AEPB
110MCG/INH................................................................ 106
ASMANEX TWISTHALER 14 METERED DOSES AEPB
220MCG/INH................................................................ 106
ASMANEX TWISTHALER 30 METERED DOSES AEPB
110MCG/INH................................................................ 106
ASMANEX TWISTHALER 30 METERED DOSES AEPB
220MCG/INH................................................................ 106
ASMANEX TWISTHALER 60 METERED DOSES AEPB
220MCG/INH................................................................ 106
ASMANEX TWISTHALER 120 METERED DOSES AEPB
220MCG/INH................................................................ 105
aspirin/dipyridamole cp12 25mg; 200mg.......................58
atenolol/chlorthalidone tabs 50mg; 25mg......................63
atenolol/chlorthalidone tabs 100mg; 25mg...................63
atenolol tabs 25mg.................................................................63
atenolol tabs 50mg.................................................................63
atenolol tabs 100mg..............................................................63
ATGAM INJ 50MG/ML....................................................97
atorvastatin calcium tabs 10mg.........................................71
atorvastatin calcium tabs 20mg.........................................71
atorvastatin calcium tabs 40mg.........................................71
atorvastatin calcium tabs 80mg.........................................71
atovaquone/proguanil hcl tabs 62.5mg; 25mg..............40
atovaquone/proguanil hcl tabs 250mg; 100mg............40
atovaquone susp 750mg/5ml.............................................40
ATRIPLA TABS 600MG; 200MG; 300MG...................48
atropine sulfate soln 1%.....................................................102
aubra tabs 20mcg; 0.1mg....................................................88
augmented betamethasone dipropionate crea 0.05%.82
augmented betamethasone dipropionate gel 0.05%....82
augmented betamethasone dipropionate lotn 0.05%..82
augmented betamethasone dipropionate oint 0.05%..82
AURYXIA TABS 210MG..................................................82
AVASTIN INJ 100MG/4ML.............................................33
AVASTIN INJ 400MG/16ML..........................................33
aviane tabs 20mcg; 0.1mg...................................................88
avita crea 0.025%...................................................................75
avita gel 0.025%.....................................................................75
azacitidine inj 100mg............................................................33
AZASITE SOLN 1%....................................................... 102
137
Drug Name
Page Number
azathioprine tabs 50mg........................................................96
azelastine hcl soln 0.1%.....................................................106
azelastine hcl soln 0.05%...................................................103
azelastine hcl soln 0.15%...................................................106
AZILECT TABS 0.5MG.....................................................42
AZILECT TABS 1MG........................................................42
azithromycin inj 500mg........................................................15
azithromycin inj 500mg........................................................15
azithromycin pack 1gm.........................................................15
azithromycin susr 100mg/5ml...........................................15
azithromycin susr 200mg/5ml...........................................15
azithromycin tabs 250mg.....................................................15
azithromycin tabs 500mg.....................................................15
azithromycin tabs 600mg.....................................................15
AZOPT SUSP 1%.......................................................... 104
aztreonam inj 1gm..................................................................13
aztreonam inj 2gm..................................................................13
azurette tabs 0; 0.....................................................................88
baciim inj 50000unit............................................................... 8
bacitracin inj 50000unit......................................................... 8
bacitracin/neomycin/polymyxin oint 400unit/gm; 5mg/
gm; 10000unit/gm..............................................................102
bacitracin oint 500unit/gm...............................................102
bacitracin/polymyxin b oint 500unit/gm; 10000unit/gm.
102
baclofen tabs 10mg................................................................47
baclofen tabs 20mg................................................................47
BAL-CARE DHA MISC 120MG; 2850UNIT; 219MG;
840UNIT; 2MG; 12MCG; 295MG; 0; 1MG; 220MCG;
27MG; 25MG; 20MG; 430MG; 0; 50MG; 4MG; 0;
1.8MG; 3MG; 25MG.................................................... 119
balsalazide disodium caps 750mg..................................100
balziva tabs 35mcg; 0.4mg..................................................88
BANZEL SUSP 40MG/ML..............................................20
BANZEL TABS 200MG....................................................20
BANZEL TABS 400MG....................................................20
BARACLUDE SOLN 0.05MG/ML..................................47
BARACLUDE TABS 0.5MG.............................................47
BARACLUDE TABS 1MG................................................47
baycadron elix 0.5mg/5ml...................................................82
bcg vaccine inj 0......................................................................98
BELEODAQ INJ 500MG..................................................33
benazepril hcl/hydrochlorothiazide tabs 5mg; 6.25mg.60
benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg..
60
benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg..
60
138
Drug Name
Page Number
benazepril hcl/hydrochlorothiazide tabs 20mg; 25mg.60
benazepril hcl tabs 5mg.........................................................60
benazepril hcl tabs 10mg......................................................60
benazepril hcl tabs 20mg......................................................60
benazepril hcl tabs 40mg......................................................60
BENLYSTA INJ 120MG....................................................98
BENLYSTA INJ 400MG....................................................98
benztropine mesylate inj 1mg/ml.......................................40
benztropine mesylate tabs 0.5mg......................................40
benztropine mesylate tabs 1mg..........................................40
benztropine mesylate tabs 2mg..........................................40
BESIVANCE SUSP 0.6%............................................... 102
betamethasone dipropionate crea 0.05%........................82
betamethasone dipropionate lotn 0.05%........................82
betamethasone dipropionate oint 0.05%........................82
betamethasone valerate crea 0.1%....................................82
betamethasone valerate foam 0.12%...............................83
betamethasone valerate lotn 0.1%....................................83
betamethasone valerate oint 0.1%....................................83
betaxolol hcl soln 0.5%.......................................................104
betaxolol hcl tabs 10mg........................................................63
betaxolol hcl tabs 20mg........................................................63
bethanechol chloride tabs 5mg...........................................81
bethanechol chloride tabs 10mg........................................81
bethanechol chloride tabs 25mg........................................81
bethanechol chloride tabs 50mg........................................81
BETIMOL SOLN 0.5%.................................................. 104
BETIMOL SOLN 0.25%............................................... 104
BETOPTIC-S SUSP 0.25%.......................................... 104
bexarotene caps 75mg..........................................................39
BEXSERO INJ 0.................................................................98
bicalutamide tabs 50mg.......................................................32
BICILLIN L-A INJ 600000UNIT/ML..............................15
BICILLIN L-A INJ 1200000UNIT/2ML.........................15
BICILLIN L-A INJ 2400000UNIT/4ML.........................15
BICNU INJ 100MG...........................................................33
bisoprolol fumarate/hydrochlorothiazide tabs 2.5mg;
6.25mg......................................................................................63
bisoprolol fumarate/hydrochlorothiazide tabs 5mg;
6.25mg......................................................................................64
bisoprolol fumarate/hydrochlorothiazide tabs 10mg;
6.25mg......................................................................................63
bisoprolol fumarate tabs 5mg.............................................64
bisoprolol fumarate tabs 10mg...........................................64
bleomycin sulfate inj 15unit.................................................33
bleomycin sulfate inj 30unit.................................................33
BLINCYTO INJ 35MCG....................................................39
Drug Name
Page Number
BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML;
5LF/0.5ML........................................................................98
BOOSTRIX INJ 18.5MCG/0.5ML; 2.5LF/0.5ML;
5LF/0.5ML........................................................................98
BOSULIF TABS 100MG...................................................38
BOSULIF TABS 500MG...................................................38
BREO ELLIPTA AEPB 100MCG/INH; 25MCG/INH.106
BREO ELLIPTA AEPB 200MCG/INH; 25MCG/INH.106
briellyn tabs 35mcg; 0.4mg.................................................88
BRILINTA TABS 60MG....................................................58
BRILINTA TABS 90MG....................................................58
brimonidine tartrate soln 0.2%........................................104
brimonidine tartrate soln 0.15%......................................104
BRINTELLIX TABS 5MG..................................................23
BRINTELLIX TABS 10MG................................................23
BRINTELLIX TABS 20MG................................................23
bromocriptine mesylate caps 5mg.....................................41
bromocriptine mesylate tabs 2.5mg..................................41
budesonide cp24 3mg...........................................................83
budesonide susp 0.5mg/2ml............................................106
budesonide susp 0.25mg/2ml.........................................106
budesonide susp 1mg/2ml................................................106
budesonide susp 32mcg/act.............................................106
bumetanide inj 0.25mg/ml...................................................69
bumetanide tabs 0.5mg........................................................69
bumetanide tabs 1mg............................................................69
bumetanide tabs 2mg............................................................69
BUPHENYL TABS 500MG..............................................77
buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg.......... 7
buprenorphine hcl/naloxone hcl subl 8mg; 2mg.............. 7
buprenorphine hcl subl 2mg.................................................. 7
buprenorphine hcl subl 8mg.................................................. 7
buproban tb12 150mg........................................................... 7
bupropion hcl er tb12 100mg.............................................22
bupropion hcl er tb12 150mg.............................................22
bupropion hcl er tb12 200mg.............................................22
bupropion hcl sr tb12 100mg.............................................22
bupropion hcl sr tb12 150mg............................................... 7
bupropion hcl sr tb12 150mg.............................................23
bupropion hcl sr tb12 200mg.............................................23
bupropion hcl tabs 75mg......................................................23
bupropion hcl tabs 100mg...................................................23
bupropion hcl xl tb24 150mg..............................................23
bupropion hcl xl tb24 300mg..............................................23
buspirone hcl tabs 5mg.........................................................51
buspirone hcl tabs 7.5mg.....................................................51
buspirone hcl tabs 10mg......................................................51
Drug Name
Page Number
buspirone hcl tabs 15mg......................................................51
buspirone hcl tabs 30mg......................................................51
BUSULFEX INJ 6MG/ML.................................................31
butalbital/acetaminophen/caffeine caps 300mg; 50mg;
40mg............................................................................................ 1
butalbital/acetaminophen/caffeine caps 325mg; 50mg;
40mg............................................................................................ 1
butalbital/acetaminophen/caffeine/codeine caps 300mg;
50mg; 40mg; 30mg................................................................. 1
butalbital/acetaminophen/caffeine/codeine caps 325mg;
50mg; 40mg; 30mg................................................................. 1
butalbital/acetaminophen/caffeine tabs 325mg; 50mg;
40mg............................................................................................ 1
butalbital/aspirin/caffeine caps 325mg; 50mg; 40mg... 1
butalbital/aspirin/caffeine/codeine caps 325mg; 50mg;
40mg; 30mg.............................................................................. 1
butalbital compound/codeine caps 325mg; 50mg;
40mg; 30mg.............................................................................. 4
cabergoline tabs 0.5mg.........................................................95
calcipotriene crea 0.005%...................................................75
calcipotriene oint 0.005%....................................................75
calcipotriene soln 0.005%....................................................75
calcitonin-salmon soln 200unit/act................................100
calcitrene oint 0.005%..........................................................75
calcitriol caps 0.5mcg.........................................................100
calcitriol caps 0.25mcg......................................................100
calcitriol inj 1mcg/ml...........................................................100
calcitriol soln 1mcg/ml.......................................................100
calcium acetate caps 667mg...............................................82
calcium acetate tabs 667mg................................................82
calcium chloride inj 10%....................................................114
calcium gluconate inj 10%.................................................114
CALCIUM PNV CAPS 30MG; 102MG; 250MG;
0.625MG; 28MG; 1MG; 25MG; 30UNIT................. 119
camila tabs 0.35mg................................................................92
camrese lo tabs 0; 0................................................................88
camrese tabs 0; 0....................................................................88
CANCIDAS INJ 50MG......................................................28
CANCIDAS INJ 70MG......................................................28
candesartan cilexetil/hydrochlorothiazide tabs 16mg;
12.5mg......................................................................................58
candesartan cilexetil/hydrochlorothiazide tabs 32mg;
12.5mg......................................................................................59
candesartan cilexetil/hydrochlorothiazide tabs 32mg;
25mg..........................................................................................59
candesartan cilexetil tabs 4mg............................................59
candesartan cilexetil tabs 8mg............................................59
139
Drug Name
Page Number
candesartan cilexetil tabs 16mg..........................................59
candesartan cilexetil tabs 32mg..........................................59
capacet caps 325mg; 50mg; 40mg.................................... 1
CAPASTAT SULFATE INJ 1GM........................................30
CAPRELSA TABS 100MG...............................................38
CAPRELSA TABS 300MG...............................................38
captopril/hydrochlorothiazide tabs 25mg; 15mg..........60
captopril/hydrochlorothiazide tabs 25mg; 25mg..........60
captopril/hydrochlorothiazide tabs 50mg; 15mg..........60
captopril/hydrochlorothiazide tabs 50mg; 25mg..........60
captopril tabs 12.5mg...........................................................60
captopril tabs 25mg...............................................................60
captopril tabs 50mg...............................................................60
captopril tabs 100mg............................................................60
CARBAGLU TABS 200MG..............................................77
carbamazepine chew 100mg..............................................20
carbamazepine er cp12 100mg.........................................20
carbamazepine er cp12 200mg.........................................20
carbamazepine er cp12 300mg.........................................20
carbamazepine er tb12 200mg..........................................20
carbamazepine er tb12 400mg..........................................20
carbamazepine susp 100mg/5ml......................................20
carbamazepine tabs 200mg................................................21
carbidopa/levodopa/entacapone tabs 12.5mg; 200mg;
50mg..........................................................................................41
carbidopa/levodopa/entacapone tabs 18.75mg; 200mg;
75mg..........................................................................................42
carbidopa/levodopa/entacapone tabs 25mg; 200mg;
100mg.......................................................................................42
carbidopa/levodopa/entacapone tabs 31.25mg; 200mg;
125mg.......................................................................................42
carbidopa/levodopa/entacapone tabs 37.5mg; 200mg;
150mg.......................................................................................42
carbidopa/levodopa/entacapone tabs 50mg; 200mg;
200mg.......................................................................................42
carbidopa/levodopa er tbcr 25mg; 100mg.....................41
carbidopa/levodopa er tbcr 50mg; 200mg.....................41
carbidopa/levodopa odt tbdp 10mg; 100mg.................41
carbidopa/levodopa odt tbdp 25mg; 100mg.................41
carbidopa/levodopa odt tbdp 25mg; 250mg.................41
carbidopa/levodopa tabs 10mg; 100mg.........................42
carbidopa/levodopa tabs 25mg; 100mg.........................42
carbidopa/levodopa tabs 25mg; 250mg.........................42
carbidopa tabs 25mg.............................................................42
carboplatin inj 50mg/5ml....................................................33
carboplatin inj 150mg/15ml...............................................33
carboplatin inj 450mg/45ml...............................................33
140
Drug Name
Page Number
carboplatin inj 600mg/60ml...............................................33
carteolol hcl soln 1%...........................................................104
cartia xt cp24 120mg............................................................66
cartia xt cp24 180mg............................................................66
cartia xt cp24 240mg............................................................66
cartia xt cp24 300mg............................................................66
carvedilol tabs 3.125mg.......................................................64
carvedilol tabs 6.25mg..........................................................64
carvedilol tabs 12.5mg..........................................................64
carvedilol tabs 25mg..............................................................64
CAYSTON SOLR 75MG................................................ 108
caziant tabs 0; 0.......................................................................88
cefaclor caps 250mg.............................................................10
cefaclor caps 500mg.............................................................10
cefaclor er tb12 500mg........................................................10
cefaclor susr 125mg/5ml.....................................................10
cefaclor susr 250mg/5ml.....................................................10
cefaclor susr 375mg/5ml.....................................................10
cefadroxil caps 500mg..........................................................10
cefadroxil susr 250mg/5ml..................................................10
cefadroxil susr 500mg/5ml..................................................10
cefadroxil tabs 1gm................................................................10
cefazolin sodium/dextrose inj 1gm; 4%.............................10
cefazolin sodium/dextrose inj 2gm; 3%.............................10
cefazolin sodium inj 1gm......................................................11
cefazolin sodium inj 1gm......................................................11
cefazolin sodium inj 1gm; 5%..............................................11
cefazolin sodium inj 10gm....................................................11
cefazolin sodium inj 20gm....................................................11
cefazolin sodium inj 100gm.................................................11
cefazolin sodium inj 300gm.................................................11
cefazolin sodium inj 500mg.................................................11
cefdinir caps 300mg..............................................................11
cefdinir susr 125mg/5ml......................................................11
cefdinir susr 250mg/5ml......................................................11
cefditoren pivoxil tabs 200mg.............................................11
cefditoren pivoxil tabs 400mg.............................................11
cefepime inj 1gm.....................................................................11
cefepime inj 1gm/50ml.........................................................11
cefepime inj 1gm/50ml; 5%.................................................11
cefepime inj 2gm.....................................................................11
cefepime inj 2gm/50ml; 5%.................................................11
cefepime inj 2gm/100ml......................................................11
cefixime susr 100mg/5ml.....................................................11
cefixime susr 200mg/5ml.....................................................11
cefotaxime sodium inj 1gm...................................................11
cefotaxime sodium inj 2gm...................................................11
Drug Name
Page Number
cefotaxime sodium inj 10gm................................................11
cefotaxime sodium inj 500mg.............................................11
cefotetan/dextrose inj 1gm; 3.58%....................................11
cefotetan/dextrose inj 2gm; 2.08%....................................11
cefotetan inj 1gm....................................................................11
cefotetan inj 2gm....................................................................11
cefotetan inj 10gm..................................................................11
cefoxitin sodium inj 1gm.......................................................11
cefoxitin sodium inj 1gm; 4%...............................................11
cefoxitin sodium inj 2gm.......................................................11
cefoxitin sodium inj 2gm; 2.2%...........................................11
cefoxitin sodium inj 10gm.....................................................11
cefpodoxime proxetil susr 50mg/5ml................................11
cefpodoxime proxetil susr 100mg/5ml.............................11
cefpodoxime proxetil tabs 100mg......................................12
cefpodoxime proxetil tabs 200mg......................................12
cefprozil susr 125mg/5ml....................................................12
cefprozil susr 250mg/5ml....................................................12
cefprozil tabs 250mg.............................................................12
cefprozil tabs 500mg.............................................................12
ceftazidime/dextrose inj 1gm/50ml; 5%...........................12
ceftazidime/dextrose inj 2gm/50ml; 5%...........................12
ceftazidime inj 1gm................................................................12
ceftazidime inj 2gm................................................................12
ceftazidime inj 6gm................................................................12
ceftriaxone/dextrose inj 1gm; 3.74%.................................12
ceftriaxone/dextrose inj 2gm; 2.22%.................................12
ceftriaxone in iso-osmotic dextrose inj 20mg/ml; 0.......12
ceftriaxone in iso-osmotic dextrose inj 40mg/ml; 0.......12
ceftriaxone sodium inj 1gm..................................................12
ceftriaxone sodium inj 1gm..................................................12
ceftriaxone sodium inj 2gm..................................................12
ceftriaxone sodium inj 2gm..................................................12
ceftriaxone sodium inj 10gm...............................................12
ceftriaxone sodium inj 250mg.............................................12
ceftriaxone sodium inj 500mg.............................................12
cefuroxime axetil tabs 250mg.............................................12
cefuroxime axetil tabs 500mg.............................................12
cefuroxime/dextrose inj 750mg; 4.1%..............................12
cefuroxime sodium inj 1.5gm...............................................12
cefuroxime sodium inj 1.5gm...............................................12
cefuroxime sodium inj 7.5gm...............................................12
cefuroxime sodium inj 7.5gm...............................................12
cefuroxime sodium inj 75gm................................................12
cefuroxime sodium inj 750mg.............................................12
celecoxib caps 50mg................................................................ 1
celecoxib caps 100mg............................................................. 1
Drug Name
Page Number
celecoxib caps 200mg............................................................. 1
celecoxib caps 400mg............................................................. 1
CELLCEPT INTRAVENOUS INJ 500MG.......................96
CELLCEPT SUSR 200MG/ML........................................96
CELONTIN CAPS 300MG..............................................18
cephalexin caps 250mg........................................................12
cephalexin caps 500mg........................................................12
cephalexin caps 750mg........................................................12
cephalexin susr 125mg/5ml................................................12
cephalexin susr 250mg/5ml................................................12
cephalexin tabs 250mg.........................................................13
cephalexin tabs 500mg.........................................................13
CEREZYME INJ 400UNIT................................................77
CERVARIX INJ 0................................................................98
CHANTIX CONTINUING MONTH PAK TABS 1MG...... 7
CHANTIX STARTING MONTH PAK TABS 0................... 7
CHANTIX TABS 0.5MG..................................................... 7
CHANTIX TABS 1MG........................................................ 7
chateal tabs 0.03mg; 0.15mg.............................................88
chloramphenicol sodium succinate inj 1gm....................... 8
chlorhexidine gluconate oral rinse soln 0.12%...............74
chloroquine phosphate tabs 250mg..................................40
chloroquine phosphate tabs 500mg..................................40
chlorothiazide tabs 250mg..................................................70
chlorothiazide tabs 500mg..................................................70
chlorpromazine hcl inj 25mg/ml.........................................42
chlorpromazine hcl inj 50mg/2ml......................................42
chlorpromazine hcl tabs 10mg...........................................42
chlorpromazine hcl tabs 25mg...........................................42
chlorpromazine hcl tabs 50mg...........................................42
chlorpromazine hcl tabs 100mg.........................................42
chlorpromazine hcl tabs 200mg.........................................42
chlorthalidone tabs 25mg....................................................70
chlorthalidone tabs 50mg....................................................70
chlorzoxazone tabs 500mg...............................................109
cholestyramine light pack 4gm...........................................72
cholestyramine light powd 4gm/dose................................72
cholestyramine pack 4gm.....................................................72
cholestyramine powd 4gm/dose.........................................72
ciclodan crea 0.77%...............................................................28
ciclodan soln 8%.....................................................................28
ciclopirox gel 0.77%...............................................................28
ciclopirox nail lacquer soln 8%.............................................28
ciclopirox olamine crea 0.77%............................................28
ciclopirox sham 1%.................................................................28
ciclopirox susp 0.77%............................................................28
cilostazol tabs 50mg..............................................................58
141
Drug Name
Page Number
cilostazol tabs 100mg............................................................58
cimetidine hcl soln 300mg/5ml..........................................79
cimetidine tabs 200mg.........................................................79
cimetidine tabs 300mg.........................................................79
cimetidine tabs 400mg.........................................................79
cimetidine tabs 800mg.........................................................79
CIMZIA INJ 200MG..........................................................96
CIMZIA INJ 200MG/ML..................................................96
CIMZIA STARTER KIT INJ 200MG/ML..........................96
CINRYZE INJ 500UNIT....................................................96
ciprofloxacin er tb24 500mg; 0..........................................16
ciprofloxacin er tb24 1000mg; 0........................................16
ciprofloxacin hcl soln 0.3%................................................102
ciprofloxacin hcl tabs 100mg...............................................16
ciprofloxacin hcl tabs 250mg...............................................16
ciprofloxacin hcl tabs 500mg...............................................16
ciprofloxacin hcl tabs 750mg...............................................16
ciprofloxacin inj 200mg/20ml.............................................16
ciprofloxacin inj 400mg/40ml.............................................16
ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%..............16
ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5%..............16
ciprofloxacin soln 0.2%..........................................................16
ciprofloxacin susr 250mg/5ml............................................16
ciprofloxacin susr 500mg/5ml............................................16
cisplatin inj 50mg/50ml........................................................33
cisplatin inj 100mg/100ml..................................................33
cisplatin inj 200mg/200ml..................................................33
citalopram hydrobromide soln 10mg/5ml.......................23
citalopram hydrobromide tabs 10mg................................23
citalopram hydrobromide tabs 20mg................................23
citalopram hydrobromide tabs 40mg................................23
CITRANATAL 90 DHA MISC 120MG; 159MG;
400UNIT; 2MG; 300MG; 50MG; 0.75MG; 0; 1MG;
90MG; 0; 20MG; 150MCG; 20MG; 3.4MG; 3MG;
30UNIT; 25MG............................................................. 119
CITRANATAL ASSURE MISC 120MG; 124MG;
400UNIT; 2MG; 300MG; 50MG; 0.75MG; 0; 1MG;
35MG; 0; 20MG; 150MCG; 25MG; 3.4MG; 3MG;
30UNIT; 25MG............................................................. 119
CITRANATAL B-CALM MISC 120MG; 120MG;
400UNIT; 0; 1MG; 20MG; 0; 25MG......................... 119
CITRANATAL DHA MISC 625MG; 120MG; 0; 124MG;
400UNIT; 2MG; 250MG; 50MG; 0.625MG; 0; 1MG;
27MG; 0; 20MG; 150MCG; 20MG; 3.4MG; 3MG;
30UNIT; 25MG............................................................. 119
CITRANATAL RX TABS 120MG; 125MG; 400UNIT;
2MG; 30UNIT; 50MG; 1MG; 27MG; 20MG; 150MCG;
142
Drug Name
Page Number
20MG; 3.4MG; 3MG; 25MG...................................... 119
cladribine inj 1mg/ml.............................................................33
claravis caps 10mg.................................................................75
claravis caps 20mg.................................................................75
CLARAVIS CAPS 30MG..................................................75
claravis caps 40mg.................................................................75
clarithromycin susr 125mg/5ml.........................................15
clarithromycin susr 250mg/5ml.........................................15
clarithromycin tabs 250mg..................................................16
clarithromycin tabs 500mg..................................................16
clemastine fumarate syrp 0.67mg/5ml.........................106
clemastine fumarate tabs 2.68mg..................................106
clindamax gel 1%...................................................................... 8
clindamax lotn 1%.................................................................... 8
clindamycin/benzoyl peroxide gel 5%; 1%........................75
clindamycin/benzoyl peroxide gel 5%; 1.2%....................75
clindamycin hcl caps 75mg.................................................... 8
clindamycin hcl caps 150mg................................................. 8
clindamycin hcl caps 300mg................................................. 8
clindamycin palmitate hcl solr 75mg/5ml.......................... 9
clindamycin phosphate add-vantage inj 150mg/ml....... 9
clindamycin phosphate add-vantage inj 150mg/ml....... 9
clindamycin phosphate crea 2%........................................... 9
clindamycin phosphate foam 1%.......................................75
clindamycin phosphate gel 1%............................................75
clindamycin phosphate in d5w inj 300mg/50ml; 5%..... 9
clindamycin phosphate in d5w inj 600mg/50ml; 5%..... 9
clindamycin phosphate in d5w inj 900mg/50ml; 5%..... 9
clindamycin phosphate inj 150mg/ml................................. 9
clindamycin phosphate inj 150mg/ml................................. 9
clindamycin phosphate inj 300mg/2ml.............................. 9
clindamycin phosphate inj 300mg/2ml.............................. 9
clindamycin phosphate inj 300mg/2ml.............................. 9
clindamycin phosphate inj 600mg/4ml.............................. 9
clindamycin phosphate inj 600mg/4ml.............................. 9
clindamycin phosphate inj 600mg/4ml.............................. 9
clindamycin phosphate inj 900mg/6ml.............................. 9
clindamycin phosphate inj 900mg/6ml.............................. 9
clindamycin phosphate inj 900mg/6ml.............................. 9
clindamycin phosphate inj 9000mg/60ml........................ 9
clindamycin phosphate lotn 1%..........................................75
clindamycin phosphate soln 1%..........................................75
clindamycin phosphate swab 1%........................................75
clinisol sf 15% inj 151meq/l; 2170mg/100ml;
1470mg/100ml; 434mg/100ml; 749mg/100ml;
1040mg/100ml; 894mg/100ml; 749mg/100ml;
1040mg/100ml; 1180mg/100ml; 749mg/100ml;
Drug Name
Page Number
1040mg/100ml; 894mg/100ml; 592mg/100ml;
749mg/100ml; 250mg/100ml; 39mg/100ml;
960mg/100ml.....................................................................114
clinpro 5000 pste 1.1%.........................................................74
clobetasol propionate crea 0.05%......................................83
clobetasol propionate e crea 0.05%..................................83
clobetasol propionate emollient foam 0.05%.................83
clobetasol propionate foam 0.05%....................................83
clobetasol propionate foam 0.05%....................................83
clobetasol propionate gel 0.05%........................................83
clobetasol propionate liqd 0.05%.......................................83
clobetasol propionate lotn 0.05%......................................83
clobetasol propionate oint 0.05%......................................83
clobetasol propionate sham 0.05%...................................83
clobetasol propionate soln 0.05%......................................83
CLOLAR INJ 1MG/ML.....................................................33
clomipramine hcl caps 25mg..............................................26
clomipramine hcl caps 50mg..............................................26
clomipramine hcl caps 75mg..............................................26
clonazepam odt tbdp 0.5mg................................................19
clonazepam odt tbdp 0.25mg.............................................19
clonazepam odt tbdp 0.125mg..........................................19
clonazepam odt tbdp 1mg....................................................19
clonazepam odt tbdp 2mg....................................................19
clonazepam tabs 0.5mg........................................................19
clonazepam tabs 1mg............................................................19
clonazepam tabs 2mg............................................................19
clonidine hcl ptwk 0.1mg/24hr...........................................58
clonidine hcl ptwk 0.2mg/24hr...........................................58
clonidine hcl ptwk 0.3mg/24hr...........................................58
clonidine hcl tabs 0.1mg.......................................................58
clonidine hcl tabs 0.2mg.......................................................58
clonidine hcl tabs 0.3mg.......................................................58
clopidogrel tabs 75mg...........................................................58
clopidogrel tabs 300mg........................................................58
clorazepate dipotassium tabs 3.75mg..............................51
clorazepate dipotassium tabs 7.5mg.................................51
clorazepate dipotassium tabs 15mg..................................51
clotrimazole/betamethasone dipropionate crea 0.05%;
1%...............................................................................................28
clotrimazole/betamethasone dipropionate lotn 0.05%;
1%...............................................................................................28
clotrimazole crea 1%..............................................................28
clotrimazole soln 1%..............................................................28
clotrimazole troc 10mg.........................................................28
clozapine odt tbdp 12.5mg..................................................46
clozapine odt tbdp 25mg......................................................46
Drug Name
Page Number
clozapine odt tbdp 100mg...................................................46
clozapine odt tbdp 150mg...................................................46
clozapine odt tbdp 200mg...................................................46
clozapine tabs 25mg..............................................................46
clozapine tabs 50mg..............................................................46
clozapine tabs 100mg...........................................................46
clozapine tabs 200mg...........................................................46
COARTEM TABS 20MG; 120MG..................................40
codeine sulfate tabs 15mg...................................................... 4
codeine sulfate tabs 30mg...................................................... 4
codeine sulfate tabs 60mg...................................................... 4
colchicine caps 0.6mg...........................................................29
colchicine tabs 0.6mg............................................................29
COLCRYS TABS 0.6MG...................................................29
colestipol hcl for oral suspension pack 5gm....................72
colestipol hcl gran 5gm.........................................................72
colestipol hcl tabs 1gm..........................................................72
colistimethate sodium inj 150mg......................................... 9
colocort enem 100mg/60ml...............................................83
COMBIGAN SOLN 0.2%; 0.5%................................. 102
COMBIVENT RESPIMAT AERS 100MCG/ACT;
20MCG/ACT.................................................................. 107
COMETRIQ KIT 0.............................................................38
COMETRIQ KIT 0.............................................................38
COMETRIQ KIT 20MG....................................................38
compazine supp 25mg..........................................................42
COMPLERA TABS 200MG; 25MG; 300MG...............48
complete natal dha misc 120mg; 0; 200mg; 400unit;
2mg; 12mcg; 200mg; 0; 1mg; 29mg; 0; 25mg; 20mg;
250mg; 25mg; 4mg; 1.8mg; 30mg; 3000unit; 25mg.....
120
completenate chew 120mg; 1000unit; 400unit; 12mcg;
29mg; 1mg; 20mg; 10mg; 3mg; 2mg; 11unit............120
compro supp 25mg................................................................42
COMVAX INJ 7.5MCG/0.5ML; 5MCG/0.5ML............98
CONCEPT DHA CAPS 25MG; 300MCG; 5MG; 2MG;
12.5MCG; 156MG; 39MG; 53.5MG; 310MG; 1MG;
5MG; 1.8MG; 200MG; 38MG; 25MG; 3MG; 2MG;
10MG.............................................................................. 120
CONCEPT OB CAPS 210MG; 300MCG; 7MG;
800MCG; 10MCG; 130MG; 1MG; 6.9MG; 1.3MG;
20MG; 92.4MG; 25MG; 5MG; 5MG; 18.2MG........ 120
constulose soln 10gm/15ml................................................80
COPAXONE INJ 20MG/ML.............................................74
COPAXONE INJ 40MG/ML.............................................74
CORLANOR TABS 5MG..................................................68
CORLANOR TABS 7.5MG..............................................68
143
Drug Name
Page Number
cormax scalp application soln 0.05%................................83
cortisone acetate tabs 25mg................................................83
COSMEGEN INJ 0.5MG...................................................33
CREON CPEP 15000UNIT; 3000UNIT; 9500UNIT..77
CREON CPEP 30000UNIT; 6000UNIT; 19000UNIT.77
CREON CPEP 60000UNIT; 12000UNIT; 38000UNIT..
77
CREON CPEP 120000UNIT; 24000UNIT; 76000UNIT
77
CREON CPEP 180000UNIT; 36000UNIT;
114000UNIT....................................................................77
CRESTOR TABS 5MG......................................................71
CRESTOR TABS 10MG....................................................71
CRESTOR TABS 20MG....................................................71
CRESTOR TABS 40MG....................................................71
CRIXIVAN CAPS 200MG................................................50
CRIXIVAN CAPS 400MG................................................50
cromolyn sodium conc 100mg/5ml..................................79
cromolyn sodium nebu 20mg/2ml.................................108
cromolyn sodium soln 4%..................................................103
cryselle-28 tabs 30mcg; 0.3mg..........................................88
CUBICIN INJ 500MG......................................................... 9
CUPRIMINE CAPS 250MG......................................... 110
cyclafem 1/35 tabs 35mcg; 1mg.......................................88
cyclafem 7/7/7 tabs 0; 0.......................................................88
cyclobenzaprine hcl tabs 5mg..........................................109
cyclobenzaprine hcl tabs 7.5mg.......................................109
cyclobenzaprine hcl tabs 10mg........................................109
cyclophosphamide caps 25mg............................................31
cyclophosphamide caps 50mg............................................31
cyclophosphamide inj 1gm..................................................31
cyclophosphamide inj 2gm..................................................31
cyclophosphamide inj 500mg.............................................31
cycloserine caps 250mg.......................................................30
cyclosporine caps 25mg.......................................................96
cyclosporine caps 100mg.....................................................96
cyclosporine inj 50mg/ml.....................................................96
cyclosporine modified caps 25mg......................................96
cyclosporine modified caps 50mg......................................96
cyclosporine modified caps 100mg...................................96
cyclosporine modified soln 100mg/ml..............................96
CYRAMZA INJ 100MG/10ML.......................................39
CYRAMZA INJ 500MG/50ML.......................................39
cyred tabs 0.15mg; 30mcg..................................................88
CYSTADANE POWD 0.....................................................77
CYSTAGON CAPS 50MG...............................................77
CYSTAGON CAPS 150MG.............................................77
144
Drug Name
Page Number
CYSTARAN SOLN 0.44%............................................ 102
cytarabine aqueous inj 20mg/ml........................................33
cytarabine aqueous inj 20mg/ml........................................33
cytarabine aqueous inj 100mg/ml.....................................33
dacarbazine inj 100mg.........................................................33
dacarbazine inj 200mg.........................................................33
DALIRESP TABS 500MCG........................................... 108
DALVANCE INJ 500MG..................................................... 9
danazol caps 50mg................................................................87
danazol caps 100mg..............................................................87
danazol caps 200mg..............................................................87
dantrolene sodium caps 25mg............................................47
dantrolene sodium caps 50mg............................................47
dantrolene sodium caps 100mg.........................................47
dapsone tabs 25mg................................................................30
dapsone tabs 100mg.............................................................30
DAPTACEL INJ 10MCG/0.5ML; 15LF/0.5ML;
5LF/0.5ML........................................................................98
DARAPRIM TABS 25MG.................................................40
dasetta 1/35 tabs 35mcg; 1mg..........................................88
dasetta 7/7/7 tabs 0; 0..........................................................88
daunorubicin hcl inj 5mg/ml................................................33
DAUNOXOME INJ 2MG/ML...........................................33
daysee tabs 0; 0.......................................................................88
deblitane tabs 0.35mg...........................................................92
decitabine inj 50mg................................................................33
deltasone tabs 20mg..............................................................83
delyla tabs 20mcg; 0.1mg....................................................88
DELZICOL CPDR 400MG............................................ 100
DENAVIR CREA 1%.........................................................51
dentagel gel 1.1%...................................................................74
DEPEN TITRATABS TABS 250MG.............................. 110
DEPOCYT INJ 50MG/5ML.............................................32
DEPO-ESTRADIOL INJ 5MG/ML..................................88
DEPO-PROVERA INJ 400MG/ML.................................92
desipramine hcl tabs 10mg..................................................26
desipramine hcl tabs 25mg..................................................26
desipramine hcl tabs 50mg..................................................26
desipramine hcl tabs 75mg..................................................26
desipramine hcl tabs 100mg...............................................26
desipramine hcl tabs 150mg...............................................26
desmopressin acetate inj 4mcg/ml.....................................86
desmopressin acetate soln 0.01%......................................86
desmopressin acetate soln 0.01%......................................86
desmopressin acetate soln 0.01%......................................86
desmopressin acetate tabs 0.1mg......................................86
desmopressin acetate tabs 0.2mg......................................86
Drug Name
Page Number
desogestrel/ethinyl estradiol tabs 0; 0...............................88
desogestrel/ethinyl estradiol tabs 0.15mg; 30mcg.......88
desonide crea 0.05%.............................................................83
desonide lotn 0.05%..............................................................83
desonide oint 0.05%..............................................................83
desoximetasone crea 0.05%................................................83
desoximetasone crea 0.25%................................................83
desoximetasone gel 0.05%...................................................83
desoximetasone oint 0.05%.................................................83
desoximetasone oint 0.25%.................................................83
desvenlafaxine er tb24 50mg..............................................23
desvenlafaxine er tb24 50mg..............................................23
desvenlafaxine er tb24 100mg...........................................23
desvenlafaxine er tb24 100mg...........................................23
dexamethasone elix 0.5mg/5ml..........................................84
DEXAMETHASONE INTENSOL CONC 1MG/ML......83
dexamethasone sodium phosphate inj 4mg/ml..............83
dexamethasone sodium phosphate inj 10mg/ml...........83
dexamethasone sodium phosphate inj 10mg/ml...........83
dexamethasone sodium phosphate inj 20mg/5ml........83
dexamethasone sodium phosphate inj 100mg/10ml...83
dexamethasone sodium phosphate inj 120mg/30ml...83
dexamethasone sodium phosphate soln 0.1%.............104
dexamethasone soln 0.5mg/5ml........................................84
dexamethasone tabs 0.5mg.................................................84
dexamethasone tabs 0.75mg..............................................84
dexamethasone tabs 1.5mg.................................................84
dexamethasone tabs 1mg.....................................................84
dexamethasone tabs 2mg.....................................................84
dexamethasone tabs 4mg.....................................................84
dexamethasone tabs 6mg.....................................................84
dexrazoxane inj 250mg.........................................................34
dexrazoxane inj 500mg.........................................................34
dextroamphetamine sulfate soln 5mg/5ml......................73
dextroamphetamine sulfate tabs 5mg...............................73
dextroamphetamine sulfate tabs 10mg............................73
dextrose 2.5%/sodium chloride 0.45% inj 2.5%; 0.45%..
114
dextrose 5% /electrolyte #48 viaflex inj 24meq/l; 5%;
23meq/l; 3meq/l; 3meq/l; 20meq/l; 25meq/l..............114
dextrose 5% inj 5%..............................................................114
dextrose 5%/lactated ringers inj 2.7meq/l; 109meq/l;
5%; 28meq/l; 4meq/l; 130meq/l.....................................114
dextrose 5%/nacl 0.2% inj 5%; 0.2%..............................114
dextrose 5%/nacl 0.3% inj 5%; 0.3%..............................114
dextrose 5%/nacl 0.9% inj 5%; 0.9%..............................114
dextrose 5%/nacl 0.33% inj 5%; 0.33%........................114
Drug Name
Page Number
dextrose 5%/nacl 0.45% inj 5%; 0.45%........................114
dextrose 5%/nacl 0.225% inj 5%; 0.225%...................114
dextrose 5%/potassium chloride 0.15% inj 5%; 20meq/l.
114
dextrose 10% flex container inj 10%...............................114
dextrose 10%/nacl 0.2% inj 10%; 0.2%........................114
dextrose 10%/nacl 0.45% inj 10%; 0.45%..................114
dextrose 20% inj 20%.........................................................114
dextrose 25% inj 250mg/ml.............................................114
dextrose 30% inj 30%.........................................................114
dextrose 40% inj 40%.........................................................114
dextrose 50% inj 50%.........................................................114
dextrose 70% inj 70%.........................................................114
diazepam gel 2.5mg...............................................................19
diazepam gel 10mg................................................................19
diazepam gel 20mg................................................................19
diazepam inj 5mg/ml.............................................................51
diazepam intensol conc 5mg/ml.........................................51
diazepam soln 1mg/ml..........................................................52
diazepam tabs 2mg................................................................52
diazepam tabs 5mg................................................................52
diazepam tabs 10mg.............................................................52
diclofenac potassium tabs 50mg.......................................... 1
diclofenac sodium dr tbec 25mg.......................................... 1
diclofenac sodium dr tbec 50mg.......................................... 1
diclofenac sodium dr tbec 75mg.......................................... 1
diclofenac sodium er tb24 100mg....................................... 1
dicloxacillin sodium caps 250mg........................................15
dicloxacillin sodium caps 500mg........................................15
dicyclomine hcl caps 10mg..................................................78
dicyclomine hcl soln 10mg/5ml..........................................78
dicyclomine hcl tabs 20mg...................................................78
didanosine cpdr 125mg........................................................49
didanosine cpdr 200mg........................................................49
didanosine cpdr 250mg........................................................49
didanosine cpdr 400mg........................................................49
DIFICID TABS 200MG.....................................................16
diflorasone diacetate crea 0.05%.......................................84
diflorasone diacetate oint 0.05%........................................84
diflunisal tabs 500mg.............................................................. 1
digitek tabs 0.25mg................................................................69
digitek tabs 0.125mg.............................................................69
digoxin inj 0.25mg/ml............................................................69
digoxin soln 0.05mg/ml.........................................................69
digoxin tabs 125mcg..............................................................69
digoxin tabs 250mcg..............................................................69
digox tabs 125mcg.................................................................69
145
Drug Name
Page Number
digox tabs 250mcg.................................................................69
dihydroergotamine mesylate inj 1mg/ml..........................30
DILANTIN CAPS 30MG..................................................21
diltiazem cd cp24 120mg.....................................................66
diltiazem cd cp24 180mg.....................................................66
diltiazem cd cp24 180mg.....................................................66
diltiazem cd cp24 240mg.....................................................67
diltiazem cd cp24 300mg.....................................................67
diltiazem hcl cd cp24 360mg..............................................67
diltiazem hcl er cp12 60mg..................................................67
diltiazem hcl er cp12 90mg..................................................67
diltiazem hcl er cp12 120mg...............................................67
diltiazem hcl er cp24 120mg...............................................67
diltiazem hcl er cp24 120mg...............................................67
diltiazem hcl er cp24 120mg...............................................67
diltiazem hcl er cp24 180mg...............................................67
diltiazem hcl er cp24 180mg...............................................67
diltiazem hcl er cp24 240mg...............................................67
diltiazem hcl er cp24 240mg...............................................67
diltiazem hcl er cp24 240mg...............................................67
diltiazem hcl er cp24 300mg...............................................67
diltiazem hcl er cp24 300mg...............................................67
diltiazem hcl er cp24 360mg...............................................67
diltiazem hcl er cp24 360mg...............................................67
diltiazem hcl er cp24 420mg...............................................67
diltiazem hcl er tb24 180mg...............................................67
diltiazem hcl er tb24 240mg...............................................67
diltiazem hcl er tb24 300mg...............................................67
diltiazem hcl er tb24 360mg...............................................67
diltiazem hcl er tb24 420mg...............................................67
diltiazem hcl inj 25mg/5ml..................................................67
diltiazem hcl inj 50mg/10ml................................................67
diltiazem hcl inj 100mg.........................................................67
diltiazem hcl inj 125mg/25ml.............................................67
diltiazem hcl tabs 30mg........................................................67
diltiazem hcl tabs 60mg........................................................67
diltiazem hcl tabs 90mg........................................................67
diltiazem hcl tabs 120mg.....................................................67
dilt-xr cp24 120mg................................................................66
dilt-xr cp24 180mg................................................................66
dilt-xr cp24 240mg................................................................66
diphenatol tabs 0.025mg; 2.5mg.......................................79
diphenhydramine hcl inj 50mg/ml..................................106
diphenoxylate/atropine liqd 0.025mg/5ml; 2.5mg/5ml...
79
diphenoxylate/atropine tabs 0.025mg; 2.5mg...............79
diphtheria/tetanus toxoids adsorbed pediatric inj
146
Drug Name
Page Number
25lfu/0.5ml; 5lfu/0.5ml.......................................................98
disopyramide phosphate caps 100mg..............................62
disopyramide phosphate caps 150mg..............................62
disulfiram tabs 250mg............................................................ 7
disulfiram tabs 500mg............................................................ 7
divalproex sodium cpsp 125mg..........................................19
divalproex sodium dr tbec 125mg......................................19
divalproex sodium dr tbec 250mg......................................19
divalproex sodium dr tbec 500mg......................................19
divalproex sodium er tb24 250mg.....................................19
divalproex sodium er tb24 500mg.....................................19
DOCEFREZ INJ 20MG.....................................................34
DOCEFREZ INJ 80MG.....................................................34
docetaxel inj 20mg/2ml........................................................34
docetaxel inj 20mg/ml...........................................................34
docetaxel inj 80mg/4ml........................................................34
docetaxel inj 80mg/8ml........................................................34
docetaxel inj 140mg/7ml......................................................34
docetaxel inj 160mg/16ml...................................................34
docetaxel inj 200mg/20ml...................................................34
donepezil hcl tabs 5mg..........................................................21
donepezil hcl tabs 10mg.......................................................21
donepezil hcl tabs 23mg.......................................................21
donepezil hcl tbdp 5mg.........................................................21
donepezil hcl tbdp 10mg.......................................................21
dorzolamide hcl soln 2%....................................................104
dorzolamide hcl/timolol maleate soln 22.3mg/ml;
6.8mg/ml................................................................................104
doxazosin mesylate tabs 1mg..............................................58
doxazosin mesylate tabs 2mg..............................................58
doxazosin mesylate tabs 4mg..............................................58
doxazosin mesylate tabs 8mg..............................................58
doxepin hcl caps 10mg..........................................................26
doxepin hcl caps 25mg..........................................................26
doxepin hcl caps 50mg..........................................................26
doxepin hcl caps 75mg..........................................................26
doxepin hcl caps 100mg.......................................................26
doxepin hcl caps 150mg.......................................................26
doxepin hcl conc 10mg/ml...................................................26
doxercalciferol caps 0.5mcg..............................................100
doxercalciferol caps 1mcg..................................................100
doxercalciferol caps 2.5mcg..............................................100
doxorubicin hcl inj 2mg/ml...................................................34
doxorubicin hcl inj 10mg.......................................................34
doxorubicin hcl inj 50mg.......................................................34
doxorubicin hcl liposome inj 2mg/ml.................................34
doxy 100 inj 100mg...............................................................17
Drug Name
Page Number
doxycycline caps 75mg..........................................................17
doxycycline caps 150mg.......................................................17
doxycycline hyclate caps 50mg...........................................17
doxycycline hyclate caps 100mg.........................................17
doxycycline hyclate dr tbec 75mg.......................................17
doxycycline hyclate dr tbec 100mg....................................17
doxycycline hyclate dr tbec 150mg....................................17
doxycycline hyclate inj 100mg.............................................17
doxycycline hyclate tabs 20mg............................................17
doxycycline hyclate tabs 100mg.........................................17
doxycycline monohydrate caps 50mg...............................17
doxycycline monohydrate caps 100mg............................17
doxycycline monohydrate tabs 50mg................................17
doxycycline monohydrate tabs 50mg................................17
doxycycline monohydrate tabs 75mg................................17
doxycycline monohydrate tabs 100mg.............................17
doxycycline monohydrate tabs 150mg.............................17
doxycycline susr 25mg/5ml.................................................17
dronabinol caps 2.5mg..........................................................27
dronabinol caps 5mg.............................................................27
dronabinol caps 10mg...........................................................27
drospirenone/ethinyl estradiol tabs 3mg; 0.03mg.........88
DROXIA CAPS 200MG....................................................32
DROXIA CAPS 300MG....................................................32
DROXIA CAPS 400MG....................................................32
duloxetine hcl cpep 20mg.....................................................23
duloxetine hcl cpep 30mg.....................................................23
duloxetine hcl cpep 40mg.....................................................52
duloxetine hcl cpep 60mg.....................................................23
duramorph inj 0.5mg/ml........................................................ 4
duramorph inj 1mg/ml............................................................ 4
DUREZOL EMUL 0.05%.............................................. 104
dutasteride caps 0.5mg.........................................................81
econazole nitrate crea 1%.....................................................28
EDURANT TABS 25MG..................................................48
EFFIENT TABS 5MG........................................................58
EFFIENT TABS 10MG......................................................58
EGRIFTA INJ 1MG.............................................................86
EGRIFTA INJ 2MG.............................................................86
ELIDEL CREA 1%.............................................................75
elinest tabs 30mcg; 0.3mg...................................................88
ELIQUIS TABS 2.5MG.....................................................55
ELIQUIS TABS 5MG.........................................................55
ELITEK INJ 1.5MG............................................................34
ELITEK INJ 7.5MG............................................................34
ELLA TABS 30MG............................................................92
EMCYT CAPS 140MG.....................................................32
Drug Name
Page Number
EMEND CAPS 0................................................................27
EMEND CAPS 40MG......................................................27
EMEND CAPS 80MG......................................................27
EMEND CAPS 125MG....................................................27
emoquette tabs 0.15mg; 30mcg........................................88
EMSAM PT24 6MG/24HR.............................................23
EMSAM PT24 9MG/24HR.............................................23
EMSAM PT24 12MG/24HR..........................................23
EMTRIVA CAPS 200MG.................................................49
EMTRIVA SOLN 10MG/ML............................................49
enalapril maleate/hydrochlorothiazide tabs 5mg;
12.5mg......................................................................................60
enalapril maleate/hydrochlorothiazide tabs 10mg; 25mg
60
enalapril maleate tabs 2.5mg..............................................61
enalapril maleate tabs 5mg..................................................61
enalapril maleate tabs 10mg...............................................61
enalapril maleate tabs 20mg...............................................61
ENBRACE HR CAPS 500MCG; 1MG; 50MCG; 0; 0;
13.6MG; 25MCG; 1MG; 2.5MG; 24MG; 5.23MG;
25MCG; 0; 12MCG; 25MCG; 25MCG; 1MG........... 120
endocet tabs 325mg; 2.5mg................................................. 4
endocet tabs 325mg; 5mg..................................................... 4
endocet tabs 325mg; 7.5mg................................................. 4
endocet tabs 325mg; 10mg.................................................. 4
ENGERIX-B INJ 10MCG/0.5ML....................................98
ENGERIX-B INJ 10MCG/0.5ML....................................98
ENGERIX-B INJ 20MCG/ML..........................................98
enoxaparin sodium inj 30mg/0.3ml..................................55
enoxaparin sodium inj 40mg/0.4ml..................................55
enoxaparin sodium inj 60mg/0.6ml..................................55
enoxaparin sodium inj 80mg/0.8ml..................................55
enoxaparin sodium inj 100mg/ml......................................55
enoxaparin sodium inj 120mg/0.8ml................................55
enoxaparin sodium inj 150mg/ml......................................55
enoxaparin sodium inj 300mg/3ml...................................55
enpresse-28 tabs 0; 0............................................................88
enskyce tabs 0.15mg; 30mcg..............................................89
entacapone tabs 200mg.......................................................41
entecavir tabs 0.5mg..............................................................47
entecavir tabs 1mg.................................................................47
enulose soln 10gm/15ml......................................................80
epinastine hcl soln 0.05%..................................................103
EPIPEN 2-PAK INJ 0.3MG/0.3ML.............................. 107
EPIPEN-JR 2-PAK INJ 0.15MG/0.3ML...................... 107
epirubicin hcl inj 50mg/25ml..............................................34
epirubicin hcl inj 200mg/100ml.........................................34
147
Drug Name
Page Number
epitol tabs 200mg...................................................................21
EPIVIR HBV SOLN 5MG/ML..........................................47
EPIVIR SOLN 10MG/ML.................................................49
eplerenone tabs 25mg...........................................................70
eplerenone tabs 50mg...........................................................70
epoprostenol sodium inj 0.5mg........................................109
epoprostenol sodium inj 1.5mg........................................109
eprosartan mesylate tabs 600mg.......................................59
EPZICOM TABS 600MG; 300MG.................................49
EQUETRO CP12 100MG................................................52
EQUETRO CP12 200MG................................................52
EQUETRO CP12 300MG................................................52
ERAXIS INJ 50MG............................................................28
ERAXIS INJ 100MG..........................................................28
ERBITUX INJ 100MG/50ML...........................................34
ERBITUX INJ 200MG/100ML........................................34
ergoloid mesylates tabs 1mg...............................................21
ERIVEDGE CAPS 150MG...............................................38
errin tabs 0.35mg...................................................................92
ERWINAZE INJ 10000UNIT...........................................34
ery pads 2%..............................................................................75
ERYTHROCIN LACTOBIONATE INJ 500MG................16
erythromycin base tabs 250mg..........................................16
erythromycin base tabs 500mg..........................................16
erythromycin/benzoyl peroxide gel 5%; 3%.....................75
erythromycin cpep 250mg...................................................16
erythromycin ethylsuccinate tabs 400mg........................16
erythromycin gel 2%..............................................................76
erythromycin oint 5mg/gm...............................................102
erythromycin pads 2%...........................................................76
erythromycin soln 2%............................................................76
erythromycin stearate tabs 250mg....................................16
ESBRIET CAPS 267MG................................................ 109
ESCAVITE CHEW 100MG; 45MCG; 10MG; 400UNIT;
1MG; 9MCG; 7.5MG; 400MCG; 60MG; 20MG; 2MG;
1.7MG; 0.25MG; 1.5MG; 1000UNIT; 30UNIT; 7.5MG.
120
ESCAVITE D CHEW 100MG; 2500UNIT; 45MCG;
10MG; 600UNIT; 0; 2MG; 0; 400MCG; 6MCG;
6MG; 60MG; 20MG; 2MG; 1.7MG; 0.25MG; 1.5MG;
30UNIT; 15MG............................................................. 120
ESCAVITE LQ LIQD 35MG/ML; 400UNIT/ML;
0.9MCG/ML; 0; 0; 6MG/ML; 8MG/ML; 0.4MG/ML;
0.6MG/ML; 0.25MG/ML; 0.5MG/ML; 1500UNIT/ML;
7.5UNIT/ML................................................................... 120
escitalopram oxalate soln 5mg/5ml...................................23
escitalopram oxalate tabs 5mg............................................24
148
Drug Name
Page Number
escitalopram oxalate tabs 10mg.........................................24
escitalopram oxalate tabs 20mg.........................................24
esgic caps 325mg; 50mg; 40mg.......................................... 1
esomeprazole magnesium cpdr 20mg..............................81
esomeprazole magnesium cpdr 40mg..............................81
esomeprazole sodium inj 20mg..........................................81
esomeprazole sodium inj 40mg..........................................81
estarylla tabs 35mcg; 0.25mg.............................................89
ESTRACE CREA 0.1MG/GM..........................................87
estradiol/norethindrone acetate tabs 0.5mg; 0.1mg....89
estradiol/norethindrone acetate tabs 1mg; 0.5mg........89
estradiol pttw 0.1mg/24hr...................................................87
estradiol pttw 0.05mg/24hr................................................87
estradiol pttw 0.025mg/24hr.............................................87
estradiol pttw 0.075mg/24hr.............................................87
estradiol pttw 0.0375mg/24hr..........................................87
estradiol ptwk 0.1mg/24hr..................................................87
estradiol ptwk 0.05mg/24hr...............................................87
estradiol ptwk 0.06mg/24hr...............................................87
estradiol ptwk 0.025mg/24hr.............................................87
estradiol ptwk 0.075mg/24hr.............................................87
estradiol ptwk 37.5mcg/24hr.............................................87
estradiol tabs 0.5mg...............................................................87
estradiol tabs 1mg..................................................................87
estradiol tabs 2mg..................................................................87
ethambutol hcl tabs 100mg.................................................30
ethambutol hcl tabs 400mg.................................................31
ethosuximide caps 250mg...................................................18
ethosuximide soln 250mg/5ml...........................................18
etidronate disodium tabs 200mg....................................100
etidronate disodium tabs 400mg....................................100
etodolac caps 200mg.............................................................. 1
etodolac caps 300mg.............................................................. 1
etodolac er tb24 400mg......................................................... 1
etodolac er tb24 500mg......................................................... 1
etodolac er tb24 600mg......................................................... 1
etodolac tabs 400mg............................................................... 2
etodolac tabs 500mg............................................................... 2
etoposide inj 1gm/50ml........................................................37
etoposide inj 100mg/5ml.....................................................37
etoposide inj 500mg/25ml..................................................37
EVOTAZ TABS 300MG; 150MG....................................50
EVZIO INJ 0.4MG/0.4ML.................................................. 7
EXELON PT24 4.6MG/24HR.........................................21
EXELON PT24 9.5MG/24HR.........................................21
EXELON PT24 13.3MG/24HR......................................21
exemestane tabs 25mg..........................................................37
Drug Name
Page Number
EXJADE TBSO 125MG................................................. 110
EXJADE TBSO 250MG................................................. 110
EXJADE TBSO 500MG................................................. 110
EXTAVIA INJ 0.3MG.........................................................74
EXTRA-VIRT PLUS DHA CAPS 28MG; 250MCG;
160MG; 800UNIT; 350MG; 55MG; 29MG; 1.25MG;
660MG; 25MG; 30UNIT............................................. 120
FABRAZYME INJ 5MG.....................................................77
FABRAZYME INJ 35MG...................................................77
falmina tabs 20mcg; 0.1mg.................................................89
famciclovir tabs 125mg........................................................51
famciclovir tabs 250mg........................................................51
famciclovir tabs 500mg........................................................51
famotidine inj 20mg/2ml.....................................................79
famotidine inj 40mg/4ml.....................................................79
famotidine inj 200mg/20ml................................................79
famotidine premixed inj 0.4mg/ml; 0.9%.........................79
famotidine susr 40mg/5ml..................................................79
famotidine tabs 20mg...........................................................79
famotidine tabs 40mg...........................................................79
FANAPT TABS 1MG.........................................................44
FANAPT TABS 2MG.........................................................44
FANAPT TABS 4MG.........................................................44
FANAPT TABS 6MG.........................................................44
FANAPT TABS 8MG.........................................................44
FANAPT TABS 10MG......................................................44
FANAPT TABS 12MG......................................................44
FANAPT TITRATION PACK TABS 0...............................44
FARESTON TABS 60MG.................................................32
FARYDAK CAPS 10MG....................................................34
FARYDAK CAPS 15MG....................................................34
FARYDAK CAPS 20MG....................................................34
FASLODEX INJ 250MG/5ML..........................................34
FAZACLO TBDP 12.5MG................................................47
FAZACLO TBDP 25MG...................................................47
FAZACLO TBDP 100MG.................................................47
FAZACLO TBDP 150MG.................................................47
FAZACLO TBDP 200MG.................................................47
felbamate susp 600mg/5ml................................................20
felbamate tabs 400mg..........................................................20
felbamate tabs 600mg..........................................................20
fenofibrate caps 43mg..........................................................71
fenofibrate caps 50mg..........................................................71
fenofibrate caps 130mg........................................................70
fenofibrate caps 150mg........................................................71
fenofibrate micronized caps 67mg.....................................70
fenofibrate micronized caps 134mg..................................70
Drug Name
Page Number
fenofibrate micronized caps 200mg..................................70
fenofibrate tabs 48mg...........................................................71
fenofibrate tabs 54mg...........................................................71
fenofibrate tabs 145mg........................................................71
fenofibrate tabs 160mg........................................................71
fenofibric acid dr cpdr 45mg................................................71
fenofibric acid dr cpdr 135mg.............................................71
fenofibric acid tabs 35mg.....................................................71
fenofibric acid tabs 105mg..................................................71
fentanyl citrate oral transmucosal lpop 200mcg.............. 4
fentanyl citrate oral transmucosal lpop 400mcg.............. 4
fentanyl citrate oral transmucosal lpop 600mcg.............. 4
fentanyl citrate oral transmucosal lpop 800mcg.............. 4
fentanyl citrate oral transmucosal lpop 1200mcg........... 4
fentanyl citrate oral transmucosal lpop 1600mcg........... 4
fentanyl pt72 12mcg/hr.......................................................... 3
fentanyl pt72 25mcg/hr.......................................................... 3
fentanyl pt72 37.5mcg/hr...................................................... 3
fentanyl pt72 50mcg/hr.......................................................... 3
fentanyl pt72 62.5mcg/hr...................................................... 3
fentanyl pt72 75mcg/hr.......................................................... 3
fentanyl pt72 87.5mcg/hr...................................................... 3
fentanyl pt72 100mcg/hr....................................................... 2
FERRIPROX TABS 500MG........................................... 110
FETZIMA CP24 20MG....................................................24
FETZIMA CP24 40MG....................................................24
FETZIMA CP24 80MG....................................................24
FETZIMA CP24 120MG..................................................24
FETZIMA TITRATION PACK C4PK 0.............................24
finasteride tabs 5mg...............................................................81
FIRAZYR INJ 30MG/3ML................................................96
FIRMAGON INJ 80MG....................................................95
FIRMAGON INJ 120MG..................................................95
flecainide acetate tabs 50mg...............................................62
flecainide acetate tabs 100mg............................................62
flecainide acetate tabs 150mg............................................62
FLORIVA LIQD 0.25MG/ML; 400UNIT/ML............. 114
floxuridine inj 0.5gm...............................................................34
fluconazole in dextrose inj 56mg/ml; 200mg/100ml...28
fluconazole in dextrose inj 56mg/ml; 400mg/200ml...28
fluconazole in nacl inj 100mg/50ml; 0.9%......................28
fluconazole in nacl inj 200mg/100ml; 0.9%...................28
fluconazole in nacl inj 400mg/200ml; 0.9%...................28
fluconazole susr 10mg/ml....................................................28
fluconazole susr 40mg/ml....................................................28
fluconazole tabs 50mg..........................................................28
fluconazole tabs 100mg........................................................28
149
Drug Name
Page Number
fluconazole tabs 150mg........................................................28
fluconazole tabs 200mg........................................................28
flucytosine caps 250mg........................................................28
flucytosine caps 500mg........................................................28
fludarabine phosphate inj 50mg.........................................34
fludarabine phosphate inj 50mg/2ml...............................34
fludrocortisone acetate tabs 0.1mg...................................84
flunisolide soln 0.025%......................................................106
fluocinolone acetonide body oil 0.01%.............................84
fluocinolone acetonide crea 0.01%....................................84
fluocinolone acetonide crea 0.025%.................................84
fluocinolone acetonide oil 0.01%....................................105
fluocinolone acetonide oint 0.025%..................................84
fluocinolone acetonide scalp oil 0.01%.............................84
fluocinolone acetonide soln 0.01%....................................84
fluocinonide crea 0.1%..........................................................84
fluocinonide crea 0.05%.......................................................84
fluocinonide-e crea 0.05%...................................................84
fluocinonide gel 0.05%..........................................................84
fluocinonide oint 0.05%........................................................84
fluocinonide soln 0.05%........................................................84
fluoride chew 1.1mg............................................................114
fluoride chew 2.2mg............................................................114
fluoridex daily defense gel 1.1%..........................................74
fluoritab chew 0.5mg..........................................................114
fluoritab chew 1mg..............................................................115
fluoritab chew 1mg..............................................................115
fluorometholone susp 0.1%..............................................104
fluorouracil crea 0.5%............................................................76
fluorouracil crea 5%...............................................................76
fluorouracil inj 1gm/20ml....................................................34
fluorouracil inj 2.5gm/50ml.................................................34
fluorouracil inj 5gm/100ml..................................................34
fluorouracil soln 2%................................................................76
fluorouracil soln 5%................................................................76
fluoxetine caps 10mg.............................................................24
fluoxetine caps 20mg.............................................................24
fluoxetine dr cpdr 90mg........................................................24
fluoxetine hcl caps 10mg......................................................24
fluoxetine hcl caps 20mg......................................................24
fluoxetine hcl caps 40mg......................................................24
fluoxetine hcl soln 20mg/5ml..............................................24
fluoxetine hcl tabs 10mg.......................................................24
fluoxetine hcl tabs 20mg.......................................................24
fluoxetine hcl tabs 60mg.......................................................24
fluphenazine decanoate inj 25mg/ml................................42
fluphenazine hcl conc 5mg/ml............................................42
150
Drug Name
Page Number
fluphenazine hcl elix 2.5mg/5ml.........................................42
fluphenazine hcl inj 2.5mg/ml.............................................42
fluphenazine hcl tabs 1mg....................................................42
fluphenazine hcl tabs 2.5mg................................................42
fluphenazine hcl tabs 5mg....................................................43
fluphenazine hcl tabs 10mg.................................................42
FLURA-DROPS SOLN 0.25MG/DROP..................... 115
flurbiprofen sodium soln 0.03%.......................................104
flurbiprofen tabs 50mg........................................................... 2
flurbiprofen tabs 100mg......................................................... 2
flutamide caps 125mg...........................................................32
fluticasone propionate crea 0.05%....................................84
fluticasone propionate lotn 0.05%.....................................84
fluticasone propionate oint 0.005%..................................84
fluticasone propionate susp 50mcg/act.........................106
fluvastatin caps 20mg............................................................71
fluvastatin caps 40mg............................................................71
fluvastatin sodium er tb24 80mg.......................................71
fluvoxamine maleate tabs 25mg.........................................24
fluvoxamine maleate tabs 50mg.........................................24
fluvoxamine maleate tabs 100mg......................................24
FOCALGIN 90 DHA MISC 120MG; 159MG; 400UNIT;
2MG; 300MG; 50MG; 0; 0; 1MG; 90MG; 0; 20MG;
150MCG; 20MG; 3.4MG; 3MG; 30UNIT; 25MG... 120
FOCALGIN-B TABS 124.23MG; 0; 0; 1.22MG; 42MG;
100MG........................................................................... 121
FOCALGIN CA MISC 120MG; 124MG; 400UNIT;
2MG; 300MG; 50MG; 0; 0; 1MG; 35MG; 0; 20MG;
150MCG; 25MG; 3.4MG; 3MG; 30UNIT; 25MG... 120
FOLCAL DHA CAPS 28MG; 160MG; 400UNIT;
300MG; 55MG; 27MG; 1.25MG; 25MG; 30UNIT.121
FOLCAPS OMEGA 3 CAPS 25MG; 150MG; 0; 0;
170UNIT; 260MG; 40MG; 7MG; 1MG; 20MG; 30MG;
30MG; 330MG; 25MG; 30UNIT................................ 121
FOLET DHA THPK 120MG; 0; 400UNIT; 12MCG;
350MG; 50MG; 0; 38MG; 0; 1MG; 30MG; 20MG;
40MG; 3.4MG; 65MCG; 3MG; 2700UNIT; 18UNIT;
10MG.............................................................................. 121
FOLET ONE CAPS 0; 18MG; 250UNIT; 15MCG;
225MG; 25MG; 0; 38MG; 0; 1MG; 15MG; 30MG;
15UNIT; 20MG............................................................. 121
FOLIVANE-OB CAPS 210MG; 300MCG; 7MG;
800MCG; 10MCG; 130MG; 1MG; 6.9MG; 1.3MG;
20MG; 92.4MG; 25MG; 5MG; 5MG; 18.2MG........ 121
FOLIVANE-PRX DHA NF CAPS 25MG; 160MG;
170UNIT; 265MG; 55MG; 30MG; 1.24MG; 25MG;
30UNIT........................................................................... 121
Drug Name
Page Number
FOLOTYN INJ 20MG/ML................................................34
FOLOTYN INJ 40MG/2ML..............................................34
fomepizole inj 1gm/ml........................................................110
fondaparinux sodium inj 2.5mg/0.5ml.............................55
fondaparinux sodium inj 5mg/0.4ml.................................55
fondaparinux sodium inj 7.5mg/0.6ml.............................55
fondaparinux sodium inj 10mg/0.8ml..............................55
FORADIL AEROLIZER CAPS 12MCG........................ 107
FORTEO INJ 600MCG/2.4ML..................................... 100
foscarnet sodium inj 24mg/ml............................................47
fosinopril sodium/hydrochlorothiazide tabs 10mg;
12.5mg......................................................................................61
fosinopril sodium/hydrochlorothiazide tabs 20mg;
12.5mg......................................................................................61
fosinopril sodium tabs 10mg...............................................61
fosinopril sodium tabs 20mg...............................................61
fosinopril sodium tabs 40mg...............................................61
fosphenytoin sodium inj 100mg pe/2ml..........................21
fosphenytoin sodium inj 500mg pe/10ml........................21
FOSRENOL CHEW 500MG............................................82
FOSRENOL CHEW 750MG............................................82
FOSRENOL CHEW 1000MG.........................................82
FOSRENOL PACK 750MG..............................................82
FOSRENOL PACK 1000MG...........................................82
furosemide inj 10mg/ml........................................................69
furosemide inj 10mg/ml........................................................69
furosemide soln 8mg/ml.......................................................69
furosemide soln 10mg/ml....................................................69
furosemide tabs 20mg..........................................................69
furosemide tabs 40mg..........................................................69
furosemide tabs 80mg..........................................................69
FUSILEV INJ 50MG..........................................................34
FUZEON INJ 90MG..........................................................50
FYCOMPA TABS 2MG.....................................................18
FYCOMPA TABS 4MG.....................................................18
FYCOMPA TABS 6MG.....................................................18
FYCOMPA TABS 8MG.....................................................18
FYCOMPA TABS 10MG...................................................18
FYCOMPA TABS 12MG...................................................18
gabapentin caps 100mg.......................................................19
gabapentin caps 300mg.......................................................19
gabapentin caps 400mg.......................................................19
gabapentin soln 250mg/5ml..............................................19
gabapentin tabs 600mg........................................................19
gabapentin tabs 800mg........................................................19
GABITRIL TABS 12MG....................................................19
GABITRIL TABS 16MG....................................................19
Drug Name
Page Number
galantamine hydrobromide cp24 8mg.............................22
galantamine hydrobromide cp24 16mg..........................21
galantamine hydrobromide cp24 24mg..........................21
galantamine hydrobromide soln 4mg/ml.........................22
galantamine hydrobromide tabs 4mg...............................22
galantamine hydrobromide tabs 8mg...............................22
galantamine hydrobromide tabs 12mg............................22
GAMASTAN S/D INJ 0.....................................................97
GAMMAPLEX INJ 2.5GM/50ML...................................97
GAMMAPLEX INJ 5GM/100ML....................................97
GAMMAPLEX INJ 10GM/200ML.................................97
GAMMAPLEX INJ 20GM/400ML.................................97
ganciclovir inj 500mg............................................................47
GARDASIL 9 INJ 0............................................................98
GARDASIL 9 INJ 0............................................................98
GARDASIL INJ 0................................................................98
GARDASIL INJ 0................................................................98
GATTEX INJ 5MG.............................................................79
GAUZE PADS 2”X2” PADS ......................................... 101
gavilyte-c solr 240gm; 2.98gm; 6.72gm; 5.84gm;
22.72gm...................................................................................80
gavilyte-g solr 236gm; 2.97gm; 6.74gm; 5.86gm;
22.74gm...................................................................................80
gavilyte-h kit 5mg; 210gm; 0.74gm; 2.86gm; 5.6gm.79
gavilyte-n/flavor pack solr 420gm; 1.48gm; 5.72gm;
11.2gm......................................................................................80
GAZYVA INJ 1000MG/40ML.........................................39
gemcitabine hcl inj 1gm........................................................34
gemcitabine hcl inj 2gm........................................................35
gemcitabine hcl inj 200mg...................................................34
gemcitabine inj 1gm/26.3ml...............................................35
gemcitabine inj 2gm/52.6ml...............................................35
gemcitabine inj 200mg/5.26ml..........................................35
gemfibrozil tabs 600mg........................................................71
generlac soln 10gm/15ml....................................................80
gengraf caps 25mg................................................................96
gengraf caps 100mg..............................................................96
gengraf soln 100mg/ml........................................................96
gentak oint 0.3%..................................................................102
gentamicin sulfate/0.9% sodium chloride inj 0.8mg/ml;
0.9%............................................................................................. 8
gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml;
0.9%............................................................................................. 8
gentamicin sulfate/0.9% sodium chloride inj 1.2mg/ml;
0.9%............................................................................................. 8
gentamicin sulfate/0.9% sodium chloride inj 1.4mg/ml;
0.9%............................................................................................. 8
151
Drug Name
Page Number
gentamicin sulfate/0.9% sodium chloride inj 1.6mg/ml;
0.9%............................................................................................. 8
gentamicin sulfate/0.9% sodium chloride inj 1mg/ml;
0.9%............................................................................................. 8
gentamicin sulfate crea 0.1%...............................................76
gentamicin sulfate inj 10mg/ml............................................ 8
gentamicin sulfate inj 40mg/ml............................................ 8
gentamicin sulfate oint 0.1%...............................................76
gentamicin sulfate oint 0.3%............................................102
gentamicin sulfate pediatric inj 10mg/ml........................... 8
gentamicin sulfate soln 0.3%............................................102
GEODON INJ 20MG........................................................44
gianvi tabs 3mg; 0.02mg......................................................89
gildagia tabs 35mcg; 0.4mg................................................89
gildess 1.5/30 tabs 30mcg; 1.5mg....................................89
gildess 1/20 tabs 20mcg; 1mg...........................................89
gildess 24 fe tabs 20mcg; 75mg; 1mg..............................89
gildess fe 1.5/30 tabs 30mcg; 75mg; 1.5mg..................89
gildess fe 1/20 tabs 20mcg; 75mg; 1mg.........................89
GILENYA CAPS 0.5MG...................................................74
GILOTRIF TABS 20MG....................................................38
GILOTRIF TABS 30MG....................................................38
GILOTRIF TABS 40MG....................................................38
glatopa inj 20mg/ml...............................................................74
GLEEVEC TABS 100MG..................................................38
GLEEVEC TABS 400MG..................................................38
glimepiride tabs 1mg.............................................................52
glimepiride tabs 2mg.............................................................52
glimepiride tabs 4mg.............................................................52
glipizide er tb24 2.5mg.........................................................52
glipizide er tb24 5mg.............................................................52
glipizide er tb24 10mg..........................................................52
glipizide/metformin hcl tabs 2.5mg; 250mg...................53
glipizide/metformin hcl tabs 2.5mg; 500mg...................53
glipizide/metformin hcl tabs 5mg; 500mg.......................53
glipizide tabs 5mg...................................................................53
glipizide tabs 10mg................................................................53
glipizide xl tb24 2.5mg..........................................................53
glipizide xl tb24 5mg..............................................................53
glipizide xl tb24 10mg...........................................................52
GLUCAGEN DIAGNOSTIC INJ 1MG.............................54
GLUCAGEN HYPOKIT INJ 1MG.....................................54
GLUCAGON EMERGENCY KIT INJ 1MG......................54
glyburide/metformin hcl tabs 1.25mg; 250mg..............53
glyburide/metformin hcl tabs 2.5mg; 500mg.................53
glyburide/metformin hcl tabs 5mg; 500mg....................53
glyburide micronized tabs 1.5mg.......................................53
152
Drug Name
Page Number
glyburide micronized tabs 3mg...........................................53
glyburide micronized tabs 6mg...........................................53
glyburide tabs 1.25mg...........................................................53
glyburide tabs 2.5mg.............................................................53
glyburide tabs 5mg.................................................................53
glycopyrrolate inj 0.2mg/ml.................................................78
glycopyrrolate inj 0.4mg/2ml..............................................78
glycopyrrolate inj 1mg/5ml..................................................78
glycopyrrolate inj 4mg/20ml...............................................78
glycopyrrolate tabs 1mg........................................................78
glycopyrrolate tabs 2mg........................................................78
glydo gel 2%............................................................................... 6
granisetron hcl tabs 1mg......................................................27
griseofulvin microsize susp 125mg/5ml..........................28
griseofulvin microsize tabs 500mg....................................29
griseofulvin ultramicrosize tabs 125mg...........................29
griseofulvin ultramicrosize tabs 250mg...........................29
guanfacine er tb24 1mg.......................................................73
guanfacine er tb24 2mg.......................................................73
guanfacine er tb24 3mg.......................................................74
guanfacine er tb24 4mg.......................................................74
guanidine hcl tabs 125mg....................................................30
HALAVEN INJ 1MG/2ML................................................35
halobetasol propionate crea 0.05%...................................84
halobetasol propionate oint 0.05%....................................84
haloperidol conc 2mg/ml......................................................43
haloperidol decanoate inj 50mg/ml...................................43
haloperidol decanoate inj 100mg/ml................................43
haloperidol lactate inj 5mg/ml.............................................43
haloperidol tabs 0.5mg.........................................................43
haloperidol tabs 1mg.............................................................43
haloperidol tabs 2mg.............................................................43
haloperidol tabs 5mg.............................................................43
haloperidol tabs 10mg..........................................................43
haloperidol tabs 20mg..........................................................43
HARVONI TABS 90MG; 400MG...................................47
HAVRIX INJ 720ELU/0.5ML...........................................98
HAVRIX INJ 1440ELU/ML...............................................98
heather tabs 0.35mg.............................................................92
hecoria caps 0.5mg................................................................96
hecoria caps 1mg....................................................................96
hecoria caps 5mg....................................................................96
HEMENATAL OB + DHA MISC 30MCG; 10MG;
400UNIT; 0.8MG; 12MCG; 10UNIT; 200MG; 2.5MG;
1MG; 6MG; 0.5MG; 17MG; 203MG; 28MG; 250MCG;
50MG; 1.6MG; 65MCG; 1.5MG; 4.5MG.................. 121
HEMENATAL OB TABS 30MCG; 10MG; 400UNIT;
Drug Name
Page Number
0.8MG; 12MCG; 10UNIT; 1MG; 6MG; 17MG; 28MG;
250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 4.5MG.121
heparin sodium/d5w inj 5%; 40unit/ml............................55
heparin sodium/d5w inj 5%; 50unit/ml............................55
heparin sodium/d5w inj 5%; 100unit/ml.........................55
heparin sodium inj 1000unit/ml.........................................55
heparin sodium inj 5000unit/0.5ml..................................56
heparin sodium inj 5000unit/ml.........................................56
heparin sodium inj 10000unit/ml......................................55
heparin sodium inj 20000unit/ml......................................56
heparin sodium/nacl 0.9% inj 2unit/ml; 0.9%................55
heparin sodium/nacl 0.45% inj 50unit/ml; 0.45%........55
heparin sodium/nacl 0.45% inj 100unit/ml; 0.45%.....55
heparin sodium/sodium chloride 0.9% inj 2unit/ml; 0.9%
55
heparin sodium/sodium chloride 0.9% premix inj 2unit/
ml; 0.9%.....................................................................................55
hepatamine inj 62meq/l; 770mg/100ml;
600mg/100ml; 3meq/l; 20mg/100ml; 900mg/100ml;
240mg/100ml; 900mg/100ml; 1100mg/100ml;
610mg/100ml; 100mg/100ml; 100mg/100ml;
115mg/100ml; 800mg/100ml; 500mg/100ml;
100mg/100ml; 450mg/100ml; 66mg/100ml;
840mg/100ml.....................................................................115
HERCEPTIN INJ 440MG..................................................35
HETLIOZ CAPS 20MG................................................. 109
HEXALEN CAPS 50MG...................................................31
HIBERIX INJ 10MCG........................................................98
HUMIRA INJ 10MG/0.2ML............................................97
HUMIRA INJ 20MG/0.4ML............................................97
HUMIRA INJ 40MG/0.8ML............................................97
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK INJ 40MG/0.8ML..................................................96
HUMIRA PEN-CROHNS DISEASESTARTER INJ
40MG/0.8ML...................................................................96
HUMIRA PEN INJ 40MG/0.8ML...................................97
HUMIRA PEN-PSORIASIS STARTER INJ 40MG/0.8ML.
97
hydralazine hcl inj 20mg/ml.................................................73
hydralazine hcl tabs 10mg....................................................73
hydralazine hcl tabs 25mg....................................................73
hydralazine hcl tabs 50mg....................................................73
hydralazine hcl tabs 100mg.................................................73
hydrochlorothiazide caps 12.5mg......................................70
hydrochlorothiazide tabs 12.5mg......................................70
hydrochlorothiazide tabs 25mg..........................................70
hydrochlorothiazide tabs 50mg..........................................70
Drug Name
Page Number
hydrocodone/acetaminophen tabs 325mg; 5mg............ 4
hydrocodone/acetaminophen tabs 325mg; 7.5mg......... 4
hydrocodone/acetaminophen tabs 325mg; 10mg.......... 4
hydrocodone bitartrate/acetaminophen soln
325mg/15ml; 7.5mg/15ml.................................................. 4
hydrocodone bitartrate/acetaminophen tabs 300mg;
5mg............................................................................................... 4
hydrocodone bitartrate/acetaminophen tabs 300mg;
7.5mg........................................................................................... 4
hydrocodone bitartrate/acetaminophen tabs 300mg;
10mg............................................................................................ 4
hydrocodone bitartrate/acetaminophen tabs 325mg;
2.5mg........................................................................................... 4
hydrocodone/ibuprofen tabs 2.5mg; 200mg.................... 4
hydrocodone/ibuprofen tabs 5mg; 200mg....................... 4
hydrocodone/ibuprofen tabs 7.5mg; 200mg.................... 5
hydrocodone/ibuprofen tabs 10mg; 200mg..................... 4
hydrocortisone/acetic acid soln 2%; 1%........................105
hydrocortisone butyrate crea 0.1%....................................84
hydrocortisone butyrate (lipophilic) crea 0.1%...............84
hydrocortisone butyrate oint 0.1%.....................................84
hydrocortisone butyrate soln 0.1%....................................84
hydrocortisone crea 1%........................................................84
hydrocortisone crea 2.5%.....................................................85
hydrocortisone enem 100mg/60ml..................................85
hydrocortisone in absorbase oint 1%................................84
hydrocortisone lotn 2.5%.....................................................85
hydrocortisone oint 1%.........................................................85
hydrocortisone oint 2.5%.....................................................85
hydrocortisone tabs 5mg......................................................85
hydrocortisone tabs 10mg...................................................85
hydrocortisone tabs 20mg...................................................85
hydrocortisone valerate crea 0.2%.....................................84
hydrocortisone valerate oint 0.2%.....................................84
hydromorphone hcl inj 1mg/ml............................................ 5
hydromorphone hcl inj 2mg/ml............................................ 5
hydromorphone hcl inj 4mg/ml............................................ 5
hydromorphone hcl inj 500mg/50ml................................. 5
hydromorphone hcl liqd 1mg/ml.......................................... 5
hydromorphone hcl tabs 2mg............................................... 5
hydromorphone hcl tabs 4mg............................................... 5
hydromorphone hcl tabs 8mg............................................... 5
hydroxychloroquine sulfate tabs 200mg..........................40
hydroxyurea caps 500mg.....................................................32
hydroxyzine hcl inj 25mg/ml.............................................106
hydroxyzine hcl inj 50mg/ml.............................................106
IBRANCE CAPS 75MG....................................................35
153
Drug Name
Page Number
IBRANCE CAPS 100MG.................................................35
IBRANCE CAPS 125MG.................................................35
ibudone tabs 5mg; 200mg..................................................... 5
ibuprofen susp 100mg/5ml................................................... 2
ibuprofen tabs 400mg............................................................. 2
ibuprofen tabs 600mg............................................................. 2
ibuprofen tabs 800mg............................................................. 2
ICLUSIG TABS 15MG......................................................38
ICLUSIG TABS 45MG......................................................38
idarubicin hcl inj 5mg/5ml...................................................35
idarubicin hcl inj 10mg/10ml..............................................35
idarubicin hcl inj 20mg/20ml..............................................35
ifosfamide inj 1gm..................................................................35
ifosfamide inj 1gm/20ml......................................................35
ifosfamide inj 3gm..................................................................35
ifosfamide inj 3gm/60ml......................................................35
ILARIS INJ 180MG...........................................................98
ILEVRO SUSP 0.3%...................................................... 104
IMBRUVICA CAPS 140MG............................................38
imipenem/cilastatin inj 250mg; 250mg...........................13
imipenem/cilastatin inj 500mg; 500mg...........................13
imipramine hcl tabs 10mg....................................................26
imipramine hcl tabs 25mg....................................................26
imipramine hcl tabs 50mg....................................................26
imiquimod crea 5%.................................................................76
IMOVAX RABIES (H.D.C.V.) INJ 2.5UNIT/ML...............98
inatal advance tabs 120mg; 2700unit; 200mg; 400unit;
2mg; 12mcg; 50mg; 1mg; 90mg; 30mg; 20mg; 20mg;
3.4mg; 3mg; 30unit; 25mg..............................................121
inatal ultra tabs 120mg; 0; 200mg; 2mg; 12mcg; 50mg;
1mg; 90mg; 20mg; 150mcg; 20mg; 3.4mg; 3mg;
2700unit; 400unit; 30unit; 25mg..................................121
INCRELEX INJ 40MG/4ML.............................................86
INCRUSE ELLIPTA AEPB 62.5MCG/INH.................. 107
indapamide tabs 1.25mg......................................................70
indapamide tabs 2.5mg........................................................70
INFANRIX INJ 58MCG/0.5ML; 25LFU/0.5ML;
10LFU/0.5ML...................................................................99
INLYTA TABS 1MG...........................................................38
INLYTA TABS 5MG...........................................................38
INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2”
MISC ............................................................................... 101
INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16”
MISC ............................................................................... 101
INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2”
MISC ............................................................................... 101
INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16”
154
Drug Name
Page Number
MISC ............................................................................... 101
INTELENCE TABS 25MG................................................48
INTELENCE TABS 100MG..............................................48
INTELENCE TABS 200MG..............................................48
intralipid inj 20gm/100ml.................................................115
INTRALIPID INJ 30GM/100ML.................................. 115
INTRON A INJ 10MU/ML...............................................35
INTRON A INJ 18MU.......................................................47
INTRON A INJ 50MU.......................................................47
INTRON A INJ 6000000UNIT/ML................................35
INTRON A W/DILUENT INJ 10MU................................35
INTRON A W/DILUENT INJ 18MU................................35
INTRON A W/DILUENT INJ 50MU................................35
introvale tabs 0.03mg; 0.15mg..........................................89
INTUNIV TB24 1MG.......................................................74
INTUNIV TB24 2MG.......................................................74
INTUNIV TB24 3MG.......................................................74
INTUNIV TB24 4MG.......................................................74
INVANZ INJ 1GM..............................................................13
INVANZ INJ 1GM..............................................................13
INVEGA SUSTENNA INJ 39MG/0.25ML.....................44
INVEGA SUSTENNA INJ 78MG/0.5ML........................44
INVEGA SUSTENNA INJ 117MG/0.75ML...................44
INVEGA SUSTENNA INJ 156MG/ML...........................44
INVEGA SUSTENNA INJ 234MG/1.5ML.....................44
INVEGA TB24 1.5MG.....................................................45
INVEGA TB24 3MG.........................................................45
INVEGA TB24 6MG.........................................................45
INVEGA TB24 9MG.........................................................45
INVEGA TRINZA INJ 273MG/0.875ML.......................44
INVEGA TRINZA INJ 410MG/1.315ML.......................44
INVEGA TRINZA INJ 546MG/1.75ML.........................44
INVEGA TRINZA INJ 819MG/2.625ML.......................45
INVIRASE CAPS 200MG.................................................50
INVIRASE TABS 500MG.................................................50
INVOKAMET TABS 50MG; 500MG..............................53
INVOKAMET TABS 50MG; 1000MG...........................53
INVOKAMET TABS 150MG; 500MG...........................53
INVOKAMET TABS 150MG; 1000MG.........................53
INVOKANA TABS 100MG..............................................53
INVOKANA TABS 300MG..............................................53
IPOL INACTIVATED IPV INJ 0.........................................99
IPOL INACTIVATED IPV INJ 0.........................................99
ipratropium bromide/albuterol sulfate soln 2.5mg/3ml;
0.5mg/3ml.............................................................................107
ipratropium bromide soln 0.02%....................................107
ipratropium bromide soln 0.03%....................................107
Drug Name
Page Number
ipratropium bromide soln 0.06%....................................107
irbesartan/hydrochlorothiazide tabs 12.5mg; 150mg.59
irbesartan/hydrochlorothiazide tabs 12.5mg; 300mg.59
irbesartan tabs 75mg.............................................................59
irbesartan tabs 150mg..........................................................59
irbesartan tabs 300mg..........................................................59
irinotecan inj 40mg/2ml.......................................................35
irinotecan inj 100mg/5ml....................................................35
irinotecan inj 500mg/25ml..................................................35
ISENTRESS CHEW 25MG...............................................48
ISENTRESS CHEW 100MG............................................48
ISENTRESS PACK 100MG..............................................48
ISENTRESS TABS 400MG...............................................48
isoniazid inj 100mg/ml..........................................................31
isoniazid syrp 50mg/5ml......................................................31
isoniazid tabs 100mg.............................................................31
isoniazid tabs 300mg.............................................................31
ISOPTO CARPINE SOLN 1%...................................... 104
ISOPTO CARPINE SOLN 2%...................................... 104
ISOPTO CARPINE SOLN 4%...................................... 104
isosorbide dinitrate er tbcr 40mg.......................................72
isosorbide dinitrate tabs 5mg..............................................72
isosorbide dinitrate tabs 10mg............................................72
isosorbide dinitrate tabs 20mg............................................72
isosorbide dinitrate tabs 30mg............................................72
isosorbide mononitrate er tb24 30mg..............................72
isosorbide mononitrate er tb24 60mg..............................72
isosorbide mononitrate er tb24 120mg...........................72
isosorbide mononitrate tabs 10mg....................................72
isosorbide mononitrate tabs 20mg....................................72
isotonic gentamicin inj 0.8mg/ml; 0.9%............................. 8
isotonic gentamicin inj 1.2mg/ml; 0.9%............................. 8
isotonic gentamicin inj 2mg/ml; 0.9%................................. 8
isradipine caps 2.5mg............................................................67
isradipine caps 5mg................................................................67
ISTODAX INJ 10MG.........................................................35
itraconazole caps 100mg.....................................................29
ivermectin tabs 3mg...............................................................40
IXEMPRA KIT INJ 15MG..................................................35
IXEMPRA KIT INJ 45MG..................................................35
IXIARO INJ 0......................................................................99
JAKAFI TABS 5MG...........................................................38
JAKAFI TABS 10MG.........................................................38
JAKAFI TABS 15MG.........................................................38
JAKAFI TABS 20MG.........................................................38
JAKAFI TABS 25MG.........................................................38
jantoven tabs 1mg..................................................................56
Drug Name
Page Number
jantoven tabs 2.5mg...............................................................56
jantoven tabs 2mg..................................................................56
jantoven tabs 3mg..................................................................56
jantoven tabs 4mg..................................................................56
jantoven tabs 5mg..................................................................56
jantoven tabs 6mg..................................................................56
jantoven tabs 7.5mg...............................................................56
jantoven tabs 10mg................................................................56
JANUMET TABS 500MG; 50MG...................................53
JANUMET TABS 1000MG; 50MG................................53
JANUMET XR TB24 500MG; 50MG.............................53
JANUMET XR TB24 1000MG; 50MG..........................53
JANUMET XR TB24 1000MG; 100MG........................53
JANUVIA TABS 25MG.....................................................53
JANUVIA TABS 50MG.....................................................53
JANUVIA TABS 100MG..................................................53
jencycla tabs 0.35mg.............................................................92
JENTADUETO TABS 2.5MG; 500MG............................53
JENTADUETO TABS 2.5MG; 850MG............................53
JENTADUETO TABS 2.5MG; 1000MG.........................53
JEVTANA INJ 60MG/1.5ML............................................35
JINTELI TABS 5MCG; 1MG.............................................89
jolessa tabs 0.03mg; 0.15mg..............................................89
jolivette tabs 0.35mg.............................................................92
juleber tabs 0.15mg; 30mcg................................................89
junel 1.5/30 tabs 30mcg; 1.5mg........................................89
junel 1/20 tabs 20mcg; 1mg...............................................89
junel fe 1.5/30 tabs 30mcg; 75mg; 1.5mg.....................89
junel fe 1/20 tabs 20mcg; 75mg; 1mg.............................89
junel fe 24 tabs 20mcg; 75mg; 1mg.................................89
KABIVEN INJ 467MG/100ML; 330MG/100ML;
99MG/100ML; 29MG/100ML; 9.8GM/100ML;
164MG/100ML; 231MG/100ML; 199MG/100ML;
164MG/100ML; 263MG/100ML; 231MG/100ML;
96MG/100ML; 164MG/100ML; 231MG/100ML;
174MG/100ML; 199MG/100ML; 131MG/100ML;
239MG/100ML; 147MG/100ML; 164MG/100ML;
55MG/100ML; 6.7MG/100ML; 213MG/100ML.. 115
KADCYLA INJ 100MG.....................................................35
KADCYLA INJ 160MG.....................................................35
KALETRA SOLN 400MG/5ML; 100MG/5ML............50
KALETRA TABS 100MG; 25MG....................................50
KALETRA TABS 200MG; 50MG....................................50
KALYDECO PACK 50MG.............................................. 108
KALYDECO PACK 75MG.............................................. 108
KALYDECO TABS 150MG............................................ 108
kariva tabs 0; 0.........................................................................89
155
Drug Name
Page Number
kcl 0.3%/d5w/lr iv lac ring inj 3meq/l; 149meq/l; 5%;
28meq/l; 44meq/l; 130meq/l..........................................115
kcl 0.3%/d5w/nacl 0.9% inj 5%; 40meq/l; 0.9%.........116
kcl 0.3%/d5w/nacl 0.45% inj 5%; 40meq/l; 0.45%...115
kcl 0.15%/d5w/lr inj 3meq/l; 149meq/l; 5%; 28meq/l;
24meq/l; 130meq/l.............................................................115
kcl 0.15%/d5w/nacl 0.2% inj 5%; 20meq/l; 0.2%......115
kcl 0.15%/d5w/nacl 0.9% inj 5%; 20meq/l; 0.9%......115
kcl 0.15%/d5w/nacl 0.45% inj 5%; 20meq/l; 0.45%.115
kcl 0.15%/d5w/nacl 0.225% inj 5%; 20meq/l; 0.225%...
115
kcl 0.075%/d5w/nacl 0.45% inj 5%; 10meq/l; 0.45%......
115
kelnor 1/35 tabs 35mcg; 1mg............................................89
ketoconazole crea 2%............................................................29
ketoconazole sham 2%..........................................................29
ketoconazole tabs 200mg....................................................29
ketoprofen caps 50mg............................................................. 2
ketoprofen caps 75mg............................................................. 2
ketoprofen er cp24 200mg.................................................... 2
ketorolac tromethamine soln 0.4%.................................104
ketorolac tromethamine soln 0.5%.................................104
KEYTRUDA INJ 50MG.....................................................39
KEYTRUDA INJ 100MG/4ML.........................................39
kimidess tabs 0; 0....................................................................89
KINRIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 0;
10LFU/0.5ML...................................................................99
kionex powd 0.......................................................................110
kionex susp 15gm/60ml....................................................110
klor-con 8 tbcr 8meq..........................................................116
klor-con 10 tbcr 10meq.....................................................116
klor-con/ef tbef 25meq......................................................116
klor-con m10 tbcr 10meq.................................................116
klor-con m20 tbcr 20meq.................................................116
klor-con pack 20meq..........................................................116
klor-con sprinkle cpcr 8meq.............................................116
klor-con sprinkle cpcr 10meq...........................................116
KORLYM TABS 300MG...................................................53
k-sol soln 10%......................................................................115
k-sol soln 20%......................................................................115
kurvelo tabs 0.03mg; 0.15mg.............................................89
KUVAN PACK 100MG.....................................................77
KUVAN PACK 500MG.....................................................77
KUVAN TBSO 100MG.....................................................77
KYNAMRO INJ 200MG/ML............................................72
labetalol hcl inj 5mg/ml.........................................................64
labetalol hcl tabs 100mg......................................................64
156
Drug Name
Page Number
labetalol hcl tabs 200mg......................................................64
labetalol hcl tabs 300mg......................................................64
lactated ringers dextrose 5% viaflex inj 2.7meq/l;
109meq/l; 5%; 28meq/l; 4meq/l; 130meq/l...............116
lactated ringers viaflex inj 3meq/l; 109meq/l; 28meq/l;
4meq/l; 130meq/l...............................................................116
lactulose soln 10gm/15ml...................................................80
lactulose soln 10gm/15ml...................................................80
lamivudine soln 10mg/ml.....................................................49
lamivudine tabs 100mg........................................................47
lamivudine tabs 150mg........................................................49
lamivudine tabs 300mg........................................................49
lamivudine/zidovudine tabs 150mg; 300mg..................49
lamotrigine chew 5mg...........................................................20
lamotrigine chew 25mg........................................................20
lamotrigine tabs 25mg..........................................................20
lamotrigine tabs 100mg.......................................................20
lamotrigine tabs 150mg.......................................................20
lamotrigine tabs 200mg.......................................................20
larin 1.5/30 tabs 30mcg; 1.5mg........................................89
larin 1/20 tabs 20mcg; 1mg................................................89
larin 24 fe tabs 20mcg; 75mg; 1mg..................................89
larin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg......................89
larin fe 1/20 tabs 20mcg; 75mg; 1mg..............................89
latanoprost soln 0.005%...................................................102
LATUDA TABS 20MG......................................................45
LATUDA TABS 40MG......................................................45
LATUDA TABS 60MG......................................................45
LATUDA TABS 80MG......................................................45
LATUDA TABS 120MG...................................................45
layolis fe chew 25mcg; 75mg; 0.8mg................................89
leena tabs 0; 0..........................................................................89
leflunomide tabs 10mg..........................................................98
leflunomide tabs 20mg..........................................................98
LENVIMA 10MG DAILY DOSE CPPK 10MG................38
LENVIMA 14MG DAILY DOSE CPPK 0.........................38
LENVIMA 20MG DAILY DOSE CPPK 10MG................38
LENVIMA 24MG DAILY DOSE CPPK 0.........................38
lessina tabs 20mcg; 0.1mg..................................................89
letrozole tabs 2.5mg...............................................................37
leucovorin calcium inj 50mg................................................35
leucovorin calcium inj 100mg.............................................35
leucovorin calcium inj 200mg.............................................35
leucovorin calcium inj 350mg.............................................35
leucovorin calcium inj 500mg.............................................35
leucovorin calcium tabs 5mg...............................................36
leucovorin calcium tabs 10mg.............................................35
Drug Name
Page Number
leucovorin calcium tabs 15mg.............................................35
leucovorin calcium tabs 25mg.............................................36
LEUKERAN TABS 2MG...................................................31
LEUKINE INJ 250MCG....................................................57
leuprolide acetate inj 1mg/0.2ml........................................95
levalbuterol hcl nebu 0.31mg/3ml..................................107
levalbuterol hcl nebu 0.63mg/3ml..................................107
levalbuterol hcl nebu 1.25mg/3ml..................................108
levalbuterol nebu 1.25mg/0.5ml.....................................108
LEVEMIR FLEXTOUCH INJ 100UNIT/ML.....................54
LEVEMIR INJ 100UNIT/ML.............................................54
levetiracetam inj 500mg/5ml..............................................18
levetiracetam inj 500mg/100ml; 820mg/100ml.........18
levetiracetam inj 1000mg/100ml; 750mg/100ml......18
levetiracetam inj 1500mg/100ml; 540mg/100ml......18
levetiracetam soln 100mg/ml.............................................18
levetiracetam tabs 250mg....................................................18
levetiracetam tabs 500mg....................................................18
levetiracetam tabs 750mg....................................................18
levetiracetam tabs 1000mg.................................................18
levobunolol hcl soln 0.5%..................................................104
levobunolol hcl soln 0.25%...............................................104
levocarnitine tabs 330mg..................................................110
levocetirizine dihydrochloride soln 2.5mg/5ml............106
levocetirizine dihydrochloride tabs 5mg........................106
levofloxacin in d5w inj 5%; 250mg/50ml.........................16
levofloxacin in d5w inj 5%; 500mg/100ml......................16
levofloxacin in d5w inj 5%; 750mg/150ml......................16
levofloxacin inj 25mg/ml.......................................................16
levofloxacin soln 0.5%.........................................................102
levofloxacin soln 25mg/ml....................................................16
levofloxacin tabs 250mg.......................................................16
levofloxacin tabs 500mg.......................................................16
levofloxacin tabs 750mg.......................................................16
levoleucovorin calcium inj 175mg/17.5ml......................36
levoleucovorin inj 250mg/25ml.........................................36
levonest tabs 0; 0.....................................................................89
levonorgestrel and ethinyl estradiol tabs 0; 0..................89
levonorgestrel and ethinyl estradiol tabs 20mcg; 90mcg.
90
levonorgestrel/ethinyl estradiol tabs 0; 0..........................90
levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg.90
levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg.90
levonorgestrel/ethinyl estradiol tabs 20mcg; 0.1mg.....90
levonorgestrel tabs 0.75mg.................................................92
levonorgestrel tabs 1.5mg....................................................92
levora 0.15/30-28 tabs 30mcg; 0.15mg........................90
Drug Name
Page Number
levothyroxine sodium inj 100mcg.......................................93
levothyroxine sodium inj 200mcg.......................................93
levothyroxine sodium inj 500mcg.......................................93
levothyroxine sodium tabs 25mcg......................................93
levothyroxine sodium tabs 50mcg......................................93
levothyroxine sodium tabs 75mcg......................................93
levothyroxine sodium tabs 88mcg......................................93
levothyroxine sodium tabs 100mcg...................................93
levothyroxine sodium tabs 112mcg...................................93
levothyroxine sodium tabs 125mcg...................................93
levothyroxine sodium tabs 137mcg...................................93
levothyroxine sodium tabs 150mcg...................................93
levothyroxine sodium tabs 175mcg...................................93
levothyroxine sodium tabs 200mcg...................................93
levothyroxine sodium tabs 300mcg...................................93
levoxyl tabs 25mcg.................................................................93
levoxyl tabs 50mcg.................................................................93
levoxyl tabs 75mcg.................................................................93
levoxyl tabs 88mcg.................................................................93
levoxyl tabs 100mcg...............................................................93
levoxyl tabs 112mcg...............................................................93
levoxyl tabs 125mcg...............................................................93
levoxyl tabs 137mcg...............................................................93
levoxyl tabs 150mcg...............................................................93
levoxyl tabs 175mcg...............................................................93
levoxyl tabs 200mcg...............................................................93
LEXIVA SUSP 50MG/ML................................................50
LEXIVA TABS 700MG......................................................50
LIALDA TBEC 1.2GM................................................... 100
lidocaine hcl gel 2%.................................................................. 6
lidocaine hcl inj 0.5%............................................................... 6
lidocaine hcl inj 0.5%............................................................... 6
lidocaine hcl inj 1%................................................................... 6
lidocaine hcl inj 1%................................................................... 6
lidocaine hcl inj 1.5%............................................................... 6
lidocaine hcl inj 2%................................................................... 6
lidocaine hcl inj 2%................................................................... 6
lidocaine hcl inj 4%................................................................... 6
lidocaine hcl inj 10mg/ml......................................................62
lidocaine hcl inj 20mg/ml......................................................62
lidocaine hcl jelly gel 2%.......................................................... 6
lidocaine hcl jelly gel 2%.......................................................... 6
lidocaine hcl jelly gel 2%.......................................................... 6
lidocaine hcl soln 4%................................................................ 6
lidocaine hcl soln 4%................................................................ 6
lidocaine oint 5%....................................................................... 7
lidocaine/prilocaine crea 2.5%; 2.5%.................................. 7
157
Drug Name
Page Number
lidocaine/prilocaine kit 2.5%; 2.5%...................................... 7
lidocaine ptch 5%...................................................................... 7
lidocaine viscous soln 2%........................................................ 6
lindane lotn 1%........................................................................40
lindane sham 1%.....................................................................40
linezolid inj 2mg/ml.................................................................. 9
linezolid tabs 600mg................................................................ 9
LINZESS CAPS 145MCG................................................80
LINZESS CAPS 290MCG................................................80
liothyronine sodium tabs 5mcg...........................................93
liothyronine sodium tabs 25mcg........................................93
liothyronine sodium tabs 50mcg........................................93
LIPOSYN III INJ 1.2GM/100ML; 2.5GM/100ML;
10GM/100ML............................................................... 116
LIPOSYN III INJ 1.2GM/100ML; 2.5GM/100ML;
20GM/100ML............................................................... 116
lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg.......61
lisinopril/hydrochlorothiazide tabs 12.5mg; 20mg.......61
lisinopril/hydrochlorothiazide tabs 25mg; 20mg...........61
lisinopril tabs 2.5mg...............................................................61
lisinopril tabs 5mg...................................................................61
lisinopril tabs 10mg................................................................61
lisinopril tabs 20mg................................................................61
lisinopril tabs 30mg................................................................61
lisinopril tabs 40mg................................................................61
lithium carbonate caps 150mg...........................................52
lithium carbonate caps 300mg...........................................52
lithium carbonate caps 600mg...........................................52
lithium carbonate er tbcr 300mg.......................................52
lithium carbonate er tbcr 450mg.......................................52
lithium carbonate tabs 300mg............................................52
lithium soln 8meq/5ml..........................................................52
lomedia 24 fe tabs 20mcg; 75mg; 1mg...........................90
lomustine caps 10mg............................................................31
lomustine caps 40mg............................................................31
lomustine caps 100mg..........................................................31
LONSURF TABS 6.14MG; 15MG..................................32
LONSURF TABS 8.19MG; 20MG..................................32
loperamide hcl caps 2mg......................................................79
lopreeza tabs 0.5mg; 0.1mg................................................90
lopreeza tabs 1mg; 0.5mg....................................................90
lorazepam inj 2mg/ml............................................................52
lorazepam inj 4mg/ml............................................................52
lorazepam intensol conc 2mg/ml........................................52
lorazepam tabs 0.5mg...........................................................52
lorazepam tabs 1mg...............................................................52
lorazepam tabs 2mg...............................................................52
158
Drug Name
Page Number
lorcet hd tabs 325mg; 10mg................................................. 5
lorcet plus tabs 325mg; 7.5mg............................................. 5
lorcet tabs 325mg; 5mg.......................................................... 5
loryna tabs 3mg; 0.02mg.....................................................90
losartan potassium/hydrochlorothiazide tabs 12.5mg;
50mg..........................................................................................59
losartan potassium/hydrochlorothiazide tabs 12.5mg;
100mg.......................................................................................59
losartan potassium/hydrochlorothiazide tabs 25mg;
100mg.......................................................................................59
losartan potassium tabs 25mg............................................59
losartan potassium tabs 50mg............................................59
losartan potassium tabs 100mg.........................................59
lovastatin tabs 10mg..............................................................71
lovastatin tabs 20mg..............................................................71
lovastatin tabs 40mg..............................................................71
LOVAZA CAPS 375MG; 465MG; 1GM........................72
low-ogestrel tabs 30mcg; 0.3mg........................................90
loxapine succinate caps 5mg................................................43
loxapine succinate caps 10mg.............................................43
loxapine succinate caps 25mg.............................................43
loxapine succinate caps 50mg.............................................43
ludent chew 0.5mg..............................................................116
ludent chew 1mg..................................................................116
LUMIGAN SOLN 0.01%.............................................. 102
LUMIZYME INJ 50MG......................................................78
LUPRON DEPOT INJ 3.75MG........................................95
LUPRON DEPOT INJ 7.5MG...........................................95
LUPRON DEPOT INJ 11.25MG......................................95
LUPRON DEPOT INJ 22.5MG........................................95
LUPRON DEPOT INJ 30MG............................................95
LUPRON DEPOT INJ 45MG............................................95
LUPRON DEPOT-PED INJ 7.5MG.................................95
LUPRON DEPOT-PED INJ 11.25MG............................95
LUPRON DEPOT-PED INJ 11.25MG............................95
LUPRON DEPOT-PED INJ 15MG..................................95
LUPRON DEPOT-PED INJ 30MG..................................95
lutera tabs 20mcg; 0.1mg....................................................90
LYNPARZA CAPS 50MG.................................................36
LYRICA CAPS 25MG........................................................18
LYRICA CAPS 50MG........................................................18
LYRICA CAPS 75MG........................................................18
LYRICA CAPS 100MG.....................................................18
LYRICA CAPS 150MG.....................................................18
LYRICA CAPS 200MG.....................................................18
LYRICA CAPS 225MG.....................................................18
LYRICA CAPS 300MG.....................................................18
Drug Name
Page Number
LYRICA SOLN 20MG/ML................................................18
LYSODREN TABS 500MG...............................................94
lyza tabs 0.35mg.....................................................................92
magnesium sulfate inj 4gm/50ml...................................116
magnesium sulfate inj 20gm/500ml..............................116
magnesium sulfate inj 50%...............................................116
magnesium sulfate inj 50%...............................................116
malathion lotn 0.5%..............................................................40
maprotiline hcl tabs 25mg...................................................24
maprotiline hcl tabs 50mg...................................................24
maprotiline hcl tabs 75mg...................................................24
margesic caps 325mg; 50mg; 40mg.................................. 1
marlissa tabs 0.03mg; 0.15mg...........................................90
MARPLAN TABS 10MG..................................................23
MATULANE CAPS 50MG...............................................31
matzim la tb24 180mg.........................................................67
matzim la tb24 240mg.........................................................67
matzim la tb24 300mg.........................................................67
matzim la tb24 360mg.........................................................68
matzim la tb24 420mg.........................................................68
meclizine hcl tabs 12.5mg....................................................27
meclizine hcl tabs 25mg........................................................27
meclofenamate sodium caps 50mg..................................... 2
meclofenamate sodium caps 100mg.................................. 2
medroxyprogesterone acetate inj 150mg/ml..................92
medroxyprogesterone acetate tabs 2.5mg.......................92
medroxyprogesterone acetate tabs 5mg..........................92
medroxyprogesterone acetate tabs 10mg........................92
mefloquine hcl tabs 250mg.................................................40
megestrol acetate susp 40mg/ml.......................................92
megestrol acetate tabs 20mg..............................................92
megestrol acetate tabs 40mg..............................................92
MEKINIST TABS 0.5MG..................................................38
MEKINIST TABS 2MG......................................................38
meloxicam susp 7.5mg/5ml................................................... 2
meloxicam tabs 7.5mg............................................................ 2
meloxicam tabs 15mg............................................................. 2
melphalan hydrochloride inj 50mg....................................31
memantine hcl tabs 5mg......................................................22
memantine hcl tabs 10mg....................................................22
memantine hcl titration pak tabs 0....................................22
memantine hydrochloride soln 2mg/ml............................22
MENACTRA INJ 0.............................................................99
MENEST TABS 0.3MG....................................................87
MENEST TABS 0.625MG...............................................87
MENEST TABS 1.25MG..................................................88
MENEST TABS 2.5MG....................................................88
Drug Name
Page Number
MENOMUNE-A/C/Y/W-135 INJ 0...............................99
MENVEO INJ 0..................................................................99
MEPRON SUSP 750MG/5ML.......................................40
mercaptopurine tabs 50mg.................................................33
meropenem inj 1gm...............................................................13
meropenem inj 500mg.........................................................13
mesalamine enem 4gm......................................................100
mesalamine kit 4gm............................................................100
mesna inj 100mg/ml..............................................................36
MESNEX TABS 400MG...................................................36
MESTINON SYRP 60MG/5ML......................................30
MESTINON TIMESPAN TBCR 180MG.........................30
metadate er tbcr 20mg..........................................................74
metaproterenol sulfate syrp 10mg/5ml.........................108
metaproterenol sulfate tabs 10mg..................................108
metaproterenol sulfate tabs 20mg..................................108
metformin hcl er tb24 500mg............................................53
metformin hcl er tb24 500mg............................................53
metformin hcl er tb24 750mg............................................54
metformin hcl er tb24 1000mg..........................................53
metformin hcl tabs 500mg..................................................54
metformin hcl tabs 850mg..................................................54
metformin hcl tabs 1000mg................................................54
methadone hcl conc 10mg/ml.............................................. 3
methadone hcl inj 10mg/ml................................................... 3
methadone hcl soln 5mg/5ml............................................... 3
methadone hcl soln 10mg/5ml............................................ 3
methadone hcl tabs 5mg........................................................ 3
methadone hcl tabs 10mg..................................................... 3
methadone hcl tbso 40mg..................................................... 3
methadose conc 10mg/ml..................................................... 3
methadose sugar-free conc 10mg/ml................................ 3
methadose tbso 40mg............................................................. 3
methazolamide tabs 25mg..................................................69
methazolamide tabs 50mg..................................................69
methenamine hippurate tabs 1gm....................................... 9
methimazole tabs 5mg..........................................................96
methimazole tabs 10mg.......................................................96
methotrexate sodium inj 1gm..............................................97
methotrexate sodium inj 1gm/40ml..................................97
methotrexate sodium inj 25mg/ml.....................................97
methotrexate tabs 2.5mg......................................................97
methoxsalen caps 10mg.......................................................76
methscopolamine bromide tabs 2.5mg............................78
methscopolamine bromide tabs 5mg................................78
methyclothiazide tabs 5mg..................................................70
methylergonovine maleate tabs 0.2mg............................81
159
Drug Name
Page Number
methylphenidate hcl er tbcr 10mg.....................................74
methylphenidate hcl er tbcr 20mg.....................................74
methylphenidate hcl sr tbcr 20mg.....................................74
methylphenidate hcl tabs 5mg............................................74
methylphenidate hcl tabs 10mg.........................................74
methylphenidate hcl tabs 20mg.........................................74
methylprednisolone acetate inj 40mg/ml.........................85
methylprednisolone acetate inj 80mg/ml.........................85
methylprednisolone dose pack tabs 4mg.........................85
methylprednisolone sodiumsuccinate inj 40mg.............85
methylprednisolone sodiumsuccinate inj 125mg..........85
methylprednisolone sodiumsuccinate inj 1000mg........85
methylprednisolone tabs 4mg.............................................85
methylprednisolone tabs 8mg.............................................85
methylprednisolone tabs 16mg..........................................85
methylprednisolone tabs 32mg..........................................85
metipranolol soln 0.3%......................................................104
metoclopramide hcl inj 5mg/ml..........................................79
metoclopramide hcl soln 5mg/5ml....................................79
metoclopramide hcl tabs 5mg.............................................79
metoclopramide hcl tabs 10mg..........................................79
metolazone tabs 2.5mg.........................................................70
metolazone tabs 5mg.............................................................70
metolazone tabs 10mg..........................................................70
metoprolol/hydrochlorothiazide tabs 25mg; 50mg......64
metoprolol/hydrochlorothiazide tabs 25mg; 100mg...64
metoprolol/hydrochlorothiazide tabs 50mg; 100mg...64
metoprolol succinate er tb24 25mg..................................64
metoprolol succinate er tb24 50mg..................................64
metoprolol succinate er tb24 100mg................................64
metoprolol succinate er tb24 200mg................................64
metoprolol tartrate inj 1mg/ml............................................64
metoprolol tartrate tabs 25mg............................................64
metoprolol tartrate tabs 50mg............................................64
metoprolol tartrate tabs 100mg.........................................64
METRO IV INJ 500MG/100ML; 0.74%.......................... 9
metronidazole caps 375mg................................................... 9
metronidazole crea 0.75%...................................................76
metronidazole gel 0.75%......................................................76
metronidazole gel 1%............................................................76
metronidazole in nacl 0.79% inj 500mg/100ml; 0.79%.9
metronidazole lotn 0.75%....................................................76
metronidazole tabs 250mg.................................................... 9
metronidazole tabs 500mg.................................................... 9
metronidazole vaginal gel 0.75%......................................... 9
mexiletine hcl caps 150mg...................................................62
mexiletine hcl caps 200mg...................................................62
160
Drug Name
Page Number
mexiletine hcl caps 250mg...................................................62
MIACALCIN INJ 200UNIT/ML..................................... 100
microgestin 1.5/30 tabs 30mcg; 1.5mg..........................90
microgestin 1/20 tabs 20mcg; 1mg..................................90
microgestin fe 1.5/30 tabs 30mcg; 75mg; 1.5mg........90
microgestin fe tabs 20mcg; 75mg; 1mg...........................90
micronized colestipol hcl tabs 1gm....................................72
midodrine hcl tabs 2.5mg.....................................................58
midodrine hcl tabs 5mg.........................................................58
midodrine hcl tabs 10mg......................................................58
MIGERGOT SUPP 100MG; 2MG..................................30
MILLIPRED DP TABS 5MG.............................................85
MILLIPRED SOLN 10MG/5ML......................................85
MILLIPRED TABS 5MG....................................................85
mimvey lo tabs 0.5mg; 0.1mg.............................................90
mimvey tabs 1mg; 0.5mg.....................................................90
minitran pt24 0.1mg/hr........................................................72
minitran pt24 0.2mg/hr........................................................72
minitran pt24 0.4mg/hr........................................................72
minitran pt24 0.6mg/hr........................................................72
minocycline hcl caps 50mg..................................................17
minocycline hcl caps 75mg..................................................17
minocycline hcl caps 100mg...............................................17
minoxidil tabs 2.5mg..............................................................73
minoxidil tabs 10mg...............................................................73
mirtazapine odt tbdp 15mg.................................................23
mirtazapine odt tbdp 30mg.................................................23
mirtazapine odt tbdp 45mg.................................................23
mirtazapine tabs 7.5mg........................................................23
mirtazapine tabs 15mg.........................................................23
mirtazapine tabs 30mg.........................................................23
mirtazapine tabs 45mg.........................................................23
misoprostol tabs 100mcg.....................................................80
misoprostol tabs 200mcg.....................................................81
mitomycin inj 5mg..................................................................36
mitomycin inj 20mg...............................................................36
mitomycin inj 40mg...............................................................36
mitoxantrone hcl inj 2mg/ml................................................36
mitoxantrone hcl inj 2mg/ml................................................36
mitoxantrone hcl inj 2mg/ml................................................36
M-M-R II INJ 0; 0; 0.........................................................99
modafinil tabs 100mg........................................................110
modafinil tabs 200mg........................................................110
moderiba tabs 200mg...........................................................47
moexipril hcl tabs 7.5mg.......................................................61
moexipril hcl tabs 15mg........................................................61
moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg.....61
Drug Name
Page Number
moexipril/hydrochlorothiazide tabs 12.5mg; 15mg......61
moexipril/hydrochlorothiazide tabs 25mg; 15mg.........61
mometasone furoate crea 0.1%.........................................85
mometasone furoate oint 0.1%..........................................85
mometasone furoate soln 0.1%..........................................85
mono-linyah tabs 35mcg; 0.25mg....................................90
mononessa tabs 35mcg; 0.25mg.......................................90
montelukast sodium chew 4mg.......................................107
montelukast sodium chew 5mg.......................................107
montelukast sodium pack 4mg........................................107
montelukast sodium tabs 10mg......................................107
morgidox 1x100mg caps 100mg.......................................17
morgidox 2x100mg caps 100mg.......................................17
morphine sulfate er cp24 10mg........................................... 3
morphine sulfate er cp24 20mg........................................... 3
morphine sulfate er cp24 30mg........................................... 3
morphine sulfate er cp24 30mg........................................... 3
morphine sulfate er cp24 45mg........................................... 3
morphine sulfate er cp24 50mg........................................... 3
morphine sulfate er cp24 60mg........................................... 3
morphine sulfate er cp24 60mg........................................... 3
morphine sulfate er cp24 75mg........................................... 3
morphine sulfate er cp24 80mg........................................... 3
morphine sulfate er cp24 90mg........................................... 3
morphine sulfate er cp24 100mg........................................ 3
morphine sulfate er cp24 120mg........................................ 3
morphine sulfate er tbcr 15mg.............................................. 3
morphine sulfate er tbcr 30mg.............................................. 3
morphine sulfate er tbcr 60mg.............................................. 3
morphine sulfate er tbcr 100mg........................................... 3
morphine sulfate er tbcr 200mg........................................... 3
morphine sulfate inj 0.5mg/ml.............................................. 5
morphine sulfate inj 1mg/ml.................................................. 5
morphine sulfate inj 1mg/ml.................................................. 5
morphine sulfate inj 2mg/ml.................................................. 5
morphine sulfate inj 4mg/ml.................................................. 5
morphine sulfate inj 5mg/ml.................................................. 5
morphine sulfate inj 8mg/ml.................................................. 5
morphine sulfate inj 8mg/ml.................................................. 5
morphine sulfate inj 10mg/ml............................................... 5
morphine sulfate inj 10mg/ml............................................... 5
morphine sulfate inj 15mg/ml............................................... 5
morphine sulfate inj 15mg/ml............................................... 5
morphine sulfate inj 25mg/ml............................................... 5
morphine sulfate inj 50mg/ml............................................... 5
morphine sulfate inj 150mg/30ml....................................... 5
morphine sulfate soln 10mg/5ml......................................... 5
Drug Name
Page Number
morphine sulfate soln 20mg/5ml......................................... 5
morphine sulfate soln 100mg/5ml...................................... 5
morphine sulfate tabs 15mg.................................................. 5
morphine sulfate tabs 30mg.................................................. 5
MOVIPREP SOLR 4.7GM; 100GM; 1.015GM; 5.9GM;
2.691GM; 7.5GM............................................................80
MOXEZA SOLN 0.5%................................................... 102
MULTAQ TABS 400MG...................................................62
multi vitamin/fluoride chew 60mg; 400unit; 4.5mcg;
0.3mg; 13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 15unit;
2500unit................................................................................122
multi-vitamin/fluoride/iron soln 35mg/ml; 400unit/
ml; 5unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml;
0.25mg/ml; 0.5mg/ml; 1500unit/ml.............................122
multi-vitamin/fluoride soln 35mg/ml; 400unit/ml; 2mcg/
ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml;
0.5mg/ml; 1500unit/ml.....................................................122
multivitamin with fluoride chew 60mg; 4.5mcg; 0.3mg;
13.5mg; 1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit;
400unit; 15unit....................................................................122
multivitamin with fluoride chew 60mg; 4.5mcg; 0.3mg;
13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg; 2500unit;
400unit; 15unit....................................................................122
multi-vit/fluoride soln 35mg/ml; 400unit/ml; 2mcg/ml;
8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml;
5unit/ml; 1500unit/ml.......................................................122
multi-vit/iron/fluoride 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..................................122
mult-vitamin/fluoride chew 60mg; 400unit; 4.5mcg;
0.5mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 1.05mg;
2500unit; 15unit.................................................................122
mupirocin calcium crea 2%..................................................76
mupirocin crea 2%..................................................................76
mupirocin oint 2%..................................................................76
MUSTARGEN INJ 10MG.................................................31
mvc-fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg;
13.5mg; 1.05mg; 1.2mg; 0.5mg; 1.05mg; 2500unit;
15unit......................................................................................122
mvc-fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg;
13.5mg; 1.05mg; 1.2mg; 0.25mg; 1.05mg; 2500unit;
15unit......................................................................................122
mvc-fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg;
13.5mg; 1.05mg; 1.2mg; 1mg; 1.05mg; 2500unit;
15unit......................................................................................122
mycophenolate mofetil caps 250mg.................................97
mycophenolate mofetil susr 200mg/ml............................97
161
Drug Name
Page Number
mycophenolate mofetil tabs 500mg..................................97
myorisan caps 10mg..............................................................76
myorisan caps 20mg..............................................................76
myorisan caps 30mg..............................................................76
myorisan caps 40mg..............................................................76
MYRBETRIQ TB24 25MG..............................................81
MYRBETRIQ TB24 50MG..............................................81
myzilra tabs 0; 0......................................................................90
nabumetone tabs 500mg....................................................... 2
nabumetone tabs 750mg....................................................... 2
nadolol/bendroflumethiazide tabs 5mg; 40mg..............64
nadolol/bendroflumethiazide tabs 5mg; 80mg..............64
nadolol tabs 20mg..................................................................64
nadolol tabs 40mg..................................................................64
nadolol tabs 80mg..................................................................64
NAGLAZYME INJ 1MG/ML............................................78
nalbuphine hcl inj 10mg/ml................................................... 5
nalbuphine hcl inj 20mg/ml................................................... 5
NALLPEN/DEXTROSE INJ 0; 1GM/50ML...................15
NALLPEN ISO-OSMOTIC IN DEXTROSE INJ 0;
2GM/100ML....................................................................15
naloxone hcl inj 0.4mg/ml....................................................... 7
naloxone hcl inj 1mg/ml.......................................................... 7
naltrexone hcl tabs 50mg....................................................... 7
NAMENDA SOLN 10MG/5ML......................................22
NAMENDA TABS 5MG...................................................22
NAMENDA TABS 10MG.................................................22
NAMENDA TITRATION PAK TABS 0.............................22
NAMENDA XR CP24 7MG.............................................22
NAMENDA XR CP24 14MG...........................................22
NAMENDA XR CP24 21MG...........................................22
NAMENDA XR CP24 28MG...........................................22
NAMENDA XR TITRATION PACK CP24 0....................22
NAMZARIC CP24 10MG; 14MG..................................22
NAMZARIC CP24 10MG; 28MG..................................22
naphazoline hcl soln 0.1%.................................................102
naproxen dr tbec 375mg........................................................ 2
naproxen dr tbec 500mg........................................................ 2
naproxen sodium tabs 275mg............................................... 2
naproxen sodium tabs 550mg............................................... 2
naproxen susp 125mg/5ml.................................................... 2
naproxen tabs 250mg.............................................................. 2
naproxen tabs 375mg.............................................................. 2
naproxen tabs 500mg.............................................................. 2
naratriptan hcl tabs 1mg.......................................................30
naratriptan hcl tabs 2.5mg...................................................30
NASONEX SUSP 50MCG/ACT................................... 106
162
Drug Name
Page Number
NATACHEW CHEW 120MG; 2700UNIT; 400UNIT;
12MCG; 0; 0; 1MG; 28MG; 20MG; 10MG; 3MG; 0;
2MG; 20UNIT................................................................ 122
NATALVIRT 90 DHA MISC 120MG; 160MG; 400UNIT;
2MG; 300MG; 50MG; 0; 0; 1MG; 90MG; 0; 20MG;
150MCG; 20MG; 3.4MG; 3MG; 30UNIT; 25MG... 122
NATALVIRT CA MISC 120MG; 125MG; 400UNIT;
2MG; 300MG; 50MG; 0; 0; 1MG; 35MG; 0; 20MG;
150MCG; 25MG; 3.4MG; 3MG; 30UNIT; 25MG... 123
nateglinide tabs 60mg...........................................................54
nateglinide tabs 120mg........................................................54
NATELLE ONE CAPS 30MG; 102MG; 250MG;
0.625MG; 28MG; 1MG; 25MG; 30UNIT................. 123
NATPARA INJ 25MCG.................................................. 101
NATPARA INJ 50MCG.................................................. 101
NATPARA INJ 75MCG.................................................. 101
NATPARA INJ 100MCG................................................ 101
NEBUPENT SOLR 300MG.............................................40
necon 0.5/35-28 tabs 35mcg; 0.5mg..............................90
necon 1/35 tabs 35mcg; 1mg.............................................90
NECON 1/50-28 TABS 50MCG; 1MG........................90
necon 7/7/7 tabs 0; 0............................................................90
NECON 10/11-28 TABS 35MCG; 0............................90
nefazodone hcl tabs 50mg...................................................24
nefazodone hcl tabs 100mg................................................24
nefazodone hcl tabs 150mg................................................24
nefazodone hcl tabs 200mg................................................24
nefazodone hcl tabs 250mg................................................24
neomycin/bacitracin/polymyxin oint 400unit/gm; 5mg/
gm; 10000unit/gm..............................................................102
neomycin/polymyxin/bacitracin/hydrocortisone oint
400unit/gm; 1%; 0.5%; 10000unit/gm........................102
neomycin/polymyxin/dexamethasone oint 0.1%; 3.5mg/
gm; 10000unit/gm..............................................................103
neomycin/polymyxin/dexamethasone susp 0.1%; 3.5mg/
ml; 10000unit/ml................................................................103
neomycin/polymyxin/gramicidin soln 0.025mg/ml;
1.75mg/ml; 10000unit/ml...............................................103
neomycin/polymyxin/hc soln 1%; 3.5mg/ml; 10000unit/
ml..............................................................................................105
neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/
ml; 10000unit/ml................................................................103
neomycin/polymyxin/hydrocortisone susp 1%; 3.5mg/
ml; 10000unit/ml................................................................105
neomycin sulfate tabs 500mg............................................... 8
neo-polycin oint 400unit/gm; 3.5mg/gm; 10000unit/
gm............................................................................................102
Drug Name
Page Number
NEPHRAMINE INJ 44MEQ/L; 20MG/100ML;
250MG/100ML; 560MG/100ML; 880MG/100ML;
640MG/100ML; 880MG/100ML; 880MG/100ML;
6MEQ/L; 400MG/100ML; 200MG/100ML;
640MG/100ML............................................................ 116
NESTABS DHA MISC 45MG; 155MG; 450UNIT;
55MG; 10MCG; 230MG; 30MG; 32MG; 1000MCG;
100MCG; 50MG; 3MG; 120MG; 3MG; 30UNIT;
10MG.............................................................................. 123
NESTABS TABS 65MG; 155MG; 450UNIT; 55MG;
10MCG; 32MG; 1000MCG; 100MCG; 50MG; 3MG;
120MG; 3MG; 30UNIT; 10MG.................................. 123
NEUMEGA INJ 5MG.........................................................57
NEUPOGEN INJ 300MCG/0.5ML.................................57
NEUPOGEN INJ 300MCG/ML.......................................57
NEUPOGEN INJ 480MCG/0.8ML.................................57
NEUPOGEN INJ 480MCG/1.6ML.................................57
NEUPRO PT24 1MG/24HR...........................................41
NEUPRO PT24 2MG/24HR...........................................41
NEUPRO PT24 3MG/24HR...........................................41
NEUPRO PT24 4MG/24HR...........................................41
NEUPRO PT24 6MG/24HR...........................................41
NEUPRO PT24 8MG/24HR...........................................41
NEVANAC SUSP 0.1%................................................. 104
nevirapine er tb24 100mg...................................................48
nevirapine er tb24 400mg...................................................48
nevirapine susp 50mg/5ml..................................................48
nevirapine tabs 200mg.........................................................48
NEXA PLUS CAPS 28MG; 0; 250MCG; 660MG;
160MG; 0; 800UNIT; 350MG; 55MG; 29MG;
1.25MG; 25MG; 30UNIT............................................ 123
NEXAVAR TABS 200MG.................................................38
niacin er tbcr 500mg.............................................................72
niacin er tbcr 750mg.............................................................72
niacin er tbcr 1000mg...........................................................72
nicardipine hcl caps 20mg....................................................68
nicardipine hcl caps 30mg....................................................68
NICOTROL NS SOLN 10MG/ML.................................... 7
nikki tabs 3mg; 0.02mg........................................................90
NILANDRON TABS 150MG...........................................32
NIPENT INJ 10MG...........................................................36
nisoldipine er tb24 25.5mg..................................................68
nisoldipine tb24 8.5mg.........................................................68
nisoldipine tb24 17mg..........................................................68
nisoldipine tb24 20mg..........................................................68
nisoldipine tb24 30mg..........................................................68
nisoldipine tb24 34mg..........................................................68
Drug Name
Page Number
nisoldipine tb24 40mg..........................................................68
nitrofurantoin macrocrystals caps 25mg.........................10
nitrofurantoin macrocrystals caps 50mg.........................10
nitrofurantoin macrocrystals caps 100mg........................ 9
nitrofurantoin monohydrate caps 100mg.......................10
nitrofurantoin susp 25mg/5ml...........................................10
nitroglycerin inj 5mg/ml........................................................73
nitroglycerin lingual aers 400mcg/spray..........................72
nitroglycerin lingual soln 0.4mg/spray..............................72
nitroglycerin transdermal pt24 0.1mg/hr........................72
nitroglycerin transdermal pt24 0.2mg/hr........................72
nitroglycerin transdermal pt24 0.4mg/hr........................73
nitroglycerin transdermal pt24 0.6mg/hr........................73
NITROSTAT SUBL 0.3MG...............................................73
NITROSTAT SUBL 0.4MG...............................................73
NITROSTAT SUBL 0.6MG...............................................73
NIVA-PLUS TABS 120MG; 0; 0; 200MG; 400UNIT;
2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG;
1.84MG; 4000UNIT; 22UNIT; 25MG....................... 123
nora-be tabs 0.35mg.............................................................92
NORDITROPIN FLEXPRO INJ 5MG/1.5ML.................86
NORDITROPIN FLEXPRO INJ 10MG/1.5ML...............86
NORDITROPIN FLEXPRO INJ 15MG/1.5ML...............86
NORDITROPIN NORDIFLEX PEN INJ 30MG/3ML.....86
norethindrone acetate/ethinyl estradiol/ferrous fumarate
tabs 20mcg; 75mg; 1mg......................................................90
norethindrone acetate/ethinyl estradiol/ferrous fumarate
tabs 20mcg; 75mg; 1mg......................................................91
norethindrone acetate/ethinyl estradiol tabs 5mcg; 1mg.
91
norethindrone acetate/ethinyl estradiol tabs 20mcg;
1mg.............................................................................................91
norethindrone acetate tabs 5mg.........................................92
norethindrone & ethinyl estradiol ferrous fumarate chew
25mcg; 75mg; 0.8mg............................................................90
norethindrone tabs 0.35mg.................................................92
norgestimate/ethinyl estradiol tabs 0; 0............................91
norgestimate/ethinyl estradiol tabs 35mcg; 0.25mg....91
NORINYL 1+50 TABS 50MCG; 1MG...........................91
norlyroc tabs 0.35mg............................................................92
NORTHERA CAPS 100MG............................................69
NORTHERA CAPS 200MG............................................69
NORTHERA CAPS 300MG............................................69
nortrel 0.5/35 (28) tabs 35mcg; 0.5mg...........................91
nortrel 1/35 tabs 35mcg; 1mg...........................................91
nortrel 1/35 tabs 35mcg; 1mg...........................................91
nortrel 7/7/7 tabs 0; 0...........................................................91
163
Drug Name
Page Number
nortriptyline hcl caps 10mg.................................................26
nortriptyline hcl caps 25mg.................................................26
nortriptyline hcl caps 50mg.................................................26
nortriptyline hcl caps 75mg.................................................26
nortriptyline hcl soln 10mg/5ml.........................................26
NORVIR CAPS 100MG...................................................50
NORVIR SOLN 80MG/ML..............................................50
NORVIR TABS 100MG....................................................50
NOVOLIN 70/30 INJ 30UNIT/ML; 70UNIT/ML.........54
NOVOLIN N INJ 100UNIT/ML.......................................54
NOVOLIN R INJ 100UNIT/ML........................................54
NOVOLOG FLEXPEN INJ 100UNIT/ML.......................55
NOVOLOG INJ 100UNIT/ML.........................................55
NOVOLOG MIX 70/30 INJ 30UNIT/ML; 70UNIT/ML.55
NOVOLOG MIX 70/30 PREFILLED FLEXPEN INJ
30UNIT/ML; 70UNIT/ML...............................................55
NOVOLOG PENFILL INJ 100UNIT/ML.........................55
NOXAFIL INJ 300MG/16.7ML......................................29
NOXAFIL SUSP 40MG/ML.............................................29
NOXAFIL TBEC 100MG..................................................29
NUEDEXTA CAPS 20MG; 10MG..................................74
NULOJIX INJ 250MG........................................................97
nyamyc powd 100000unit/gm...........................................29
nystatin crea 100000unit/gm.............................................29
nystatin oint 100000unit/gm..............................................29
nystatin powd 100000unit/gm...........................................29
nystatin susp 100000unit/ml..............................................29
nystatin tabs 500000unit.....................................................29
nystop powd 100000unit/gm.............................................29
OB COMPLETE/DHA CAPS 125MG; 0; 0; 1000UNIT;
1MG; 15MCG; 0; 0; 10MG; 1MG; 30MG; 200MG;
3.4MG; 2MG; 30UNIT; 25MG.................................... 123
OB COMPLETE ONE CAPS 200MCG; 70MG; 25MG;
5MG; 1200UNIT; 1MG; 50MCG; 25MG; 300MG;
40MG; 10MG; 476MG; 700MCG; 40MG; 300MCG;
25MG; 10MG; 150MCG; 30MG; 4MG; 2MG; 30UNIT;
15MG.............................................................................. 123
OB COMPLETE PETITE CAPS 125MG; 1000UNIT;
1MG; 15MCG; 0; 5MG; 1MG; 35MG; 200MG; 30MG;
3.4MG; 2MG; 30UNIT; 25MG.................................... 123
OB COMPLETE PREMIER TABS 120MG; 800UNIT;
1MG; 15MCG; 100MG; 15MG; 20MG; 1MG; 30MG;
10MG; 10MG; 3.4MG; 2MG; 2100UNIT; 20UNIT;
10MG.............................................................................. 123
O-CAL PRENATAL TABS 70MG; 0; 200MG;
400UNIT; 2MG; 12MCG; 15MG; 1MG; 100MG;
17MG; 150MCG; 12MG; 1.6MG; 1.5MG; 2500UNIT;
164
Drug Name
Page Number
30UNIT; 15MG............................................................. 123
ocella tabs 3mg; 0.03mg......................................................91
octreotide acetate inj 50mcg/ml.........................................95
octreotide acetate inj 100mcg/ml......................................95
octreotide acetate inj 200mcg/ml......................................95
octreotide acetate inj 500mcg/ml......................................95
octreotide acetate inj 1000mcg/ml....................................95
ODOMZO CAPS 200MG................................................36
ofloxacin soln 0.3%..............................................................103
ofloxacin soln 0.3%..............................................................105
ofloxacin tabs 400mg............................................................16
OGESTREL TABS 50MCG; 0.5MG................................91
olanzapine/fluoxetine caps 25mg; 3mg............................24
olanzapine/fluoxetine caps 25mg; 6mg............................24
olanzapine/fluoxetine caps 25mg; 12mg.........................24
olanzapine/fluoxetine caps 50mg; 6mg............................24
olanzapine/fluoxetine caps 50mg; 12mg.........................24
olanzapine inj 10mg...............................................................45
olanzapine odt tbdp 5mg......................................................45
olanzapine odt tbdp 10mg...................................................45
olanzapine odt tbdp 15mg...................................................45
olanzapine odt tbdp 20mg...................................................45
olanzapine tabs 2.5mg..........................................................45
olanzapine tabs 5mg..............................................................45
olanzapine tabs 7.5mg..........................................................45
olanzapine tabs 10mg...........................................................45
olanzapine tabs 15mg...........................................................45
olanzapine tabs 20mg...........................................................45
olopatadine hcl soln 0.6%..................................................106
omega-3-acid ethyl esters caps 375mg; 465mg; 1gm.72
omeprazole cpdr 10mg.........................................................81
omeprazole cpdr 20mg.........................................................81
omeprazole cpdr 40mg.........................................................81
ONCASPAR INJ 750UNIT/ML........................................36
ondansetron hcl inj 4mg/2ml..............................................27
ondansetron hcl inj 40mg/20ml.........................................27
ondansetron hcl soln 4mg/5ml...........................................27
ondansetron hcl tabs 4mg....................................................27
ondansetron hcl tabs 8mg....................................................27
ondansetron hcl tabs 24mg.................................................27
ondansetron odt tbdp 4mg..................................................27
ondansetron odt tbdp 8mg..................................................27
ONFI SUSP 2.5MG/ML...................................................19
ONFI TABS 10MG............................................................19
ONFI TABS 20MG............................................................19
OPDIVO INJ 40MG/4ML................................................39
OPDIVO INJ 100MG/10ML...........................................39
Drug Name
Page Number
OPSUMIT TABS 10MG................................................ 109
oralone pste 0.1%...................................................................74
ORAP TABS 1MG.............................................................43
ORAP TABS 2MG.............................................................43
ORFADIN CAPS 2MG......................................................78
ORFADIN CAPS 5MG......................................................78
ORFADIN CAPS 10MG...................................................78
ORKAMBI TABS 125MG; 200MG............................. 108
orsythia tabs 20mcg; 0.1mg................................................91
oxacillin sodium inj 1gm........................................................15
oxacillin sodium inj 2gm........................................................15
oxacillin sodium inj 10gm.....................................................15
oxaliplatin inj 50mg................................................................36
oxaliplatin inj 50mg/10ml....................................................36
oxaliplatin inj 100mg.............................................................36
oxaliplatin inj 100mg/20ml.................................................36
oxandrolone tabs 2.5mg.......................................................87
oxandrolone tabs 10mg........................................................87
oxaprozin tabs 600mg............................................................. 2
oxcarbazepine susp 300mg/5ml........................................21
oxcarbazepine tabs 150mg..................................................21
oxcarbazepine tabs 300mg..................................................21
oxcarbazepine tabs 600mg..................................................21
OXSORALEN LOTN 1%..................................................76
oxybutynin chloride er tb24 5mg........................................81
oxybutynin chloride er tb24 10mg.....................................81
oxybutynin chloride er tb24 15mg.....................................81
oxybutynin chloride syrp 5mg/5ml....................................81
oxybutynin chloride tabs 5mg..............................................81
oxycodone/acetaminophen tabs 325mg; 2.5mg............. 6
oxycodone/acetaminophen tabs 325mg; 5mg................. 6
oxycodone/acetaminophen tabs 325mg; 7.5mg............. 6
oxycodone/acetaminophen tabs 325mg; 10mg.............. 6
oxycodone/aspirin tabs 325mg; 4.835mg......................... 6
oxycodone hcl caps 5mg......................................................... 5
oxycodone hcl conc 100mg/5ml.......................................... 5
oxycodone hcl soln 5mg/5ml................................................. 6
oxycodone hcl tabs 5mg.......................................................... 6
oxycodone hcl tabs 10mg....................................................... 6
oxycodone hcl tabs 15mg....................................................... 6
oxycodone hcl tabs 20mg....................................................... 6
oxycodone hcl tabs 30mg....................................................... 6
oxycodone/ibuprofen tabs 400mg; 5mg............................ 6
pacerone tabs 100mg...........................................................62
pacerone tabs 200mg...........................................................62
pacerone tabs 400mg...........................................................62
paclitaxel inj 30mg/5ml.........................................................36
Drug Name
Page Number
paclitaxel inj 100mg/16.7ml...............................................36
paclitaxel inj 150mg/25ml...................................................36
paclitaxel inj 300mg/50ml...................................................36
PAIRE OB MISC 30MCG; 10MG; 400UNIT; 0.8MG;
12MCG; 10UNIT; 200MG; 0; 1MG; 6MG; 0; 17MG;
22MG; 175MCG; 50MG; 1.6MG; 65MCG; 1.5MG;
15MG.............................................................................. 124
paliperidone er tb24 1.5mg.................................................45
paliperidone er tb24 3mg.....................................................45
paliperidone er tb24 6mg.....................................................45
paliperidone er tb24 9mg.....................................................45
pamidronate disodium inj 6mg/ml..................................101
pamidronate disodium inj 30mg......................................101
pamidronate disodium inj 30mg/10ml..........................100
pamidronate disodium inj 90mg......................................101
pamidronate disodium inj 90mg/10ml..........................101
pancrelipase cpep 27000unit; 5000unit; 17000unit..78
PANRETIN GEL 0.1%......................................................39
pantoprazole sodium inj 40mg............................................81
pantoprazole sodium tbec 20mg........................................81
pantoprazole sodium tbec 40mg........................................81
paricalcitol caps 1mcg........................................................101
paricalcitol caps 2mcg........................................................101
paricalcitol caps 4mcg........................................................101
paricalcitol inj 2mcg/ml......................................................101
paricalcitol inj 5mcg/ml......................................................101
paroex soln 0.12%..................................................................74
paromomycin sulfate caps 250mg....................................... 8
paroxetine hcl tabs 10mg......................................................24
paroxetine hcl tabs 20mg......................................................24
paroxetine hcl tabs 30mg......................................................24
paroxetine hcl tabs 40mg......................................................25
PASER PACK 4GM............................................................31
PATADAY SOLN 0.2%................................................... 103
PATANOL SOLN 0.1%................................................. 103
PAXIL SUSP 10MG/5ML................................................25
PAZEO SOLN 0.7%....................................................... 104
PEDIARIX INJ 58MCG/0.5ML; 25LFU/0.5ML; 10MC‑
G/0.5ML; 0; 10LFU/0.5ML............................................99
PEDVAX HIB INJ 7.5MCG/0.5ML..................................99
peg-3350/electrolytes solr 236gm; 2.97gm; 6.74gm;
5.86gm; 22.74gm..................................................................80
peg 3350/electrolytes solr 240gm; 2.98gm; 6.72gm;
5.84gm; 22.72gm..................................................................80
peg-3350/nacl/na bicarbonate/kcl solr 420gm; 1.48gm;
5.72gm; 11.2gm.....................................................................80
PEGANONE TABS 250MG.............................................21
165
Drug Name
Page Number
PEG-INTRON INJ 50MCG/0.5ML.................................48
PEGINTRON INJ 80MCG/0.5ML...................................48
PEGINTRON INJ 120MCG/0.5ML................................48
PEGINTRON INJ 150MCG/0.5ML................................48
PEG-INTRON REDIPEN INJ 50MCG/0.5ML...............48
PEG-INTRON REDIPEN INJ 80MCG/0.5ML...............48
PEG-INTRON REDIPEN INJ 120MCG/0.5ML.............48
PEG-INTRON REDIPEN INJ 150MCG/0.5ML.............48
penicillin g potassium inj 5000000unit............................15
penicillin g potassium inj 20000000unit.........................15
penicillin g procaine inj 600000unit/ml...........................15
penicillin g sodium inj 5000000unit.................................15
penicillin v potassium solr 125mg/5ml.............................15
penicillin v potassium solr 250mg/5ml.............................15
penicillin v potassium tabs 250mg.....................................15
penicillin v potassium tabs 500mg.....................................15
PEN NEEDLE/ULTRAFINE/29G X 12.7MM MISC .. 101
PENTACEL INJ 48MCG/0.5ML; 15LFU/0.5ML; 0; 0;
5LFU/0.5ML.....................................................................99
PENTAM 300 INJ 300MG...............................................40
PENTASA CPCR 250MG............................................. 100
PENTASA CPCR 500MG............................................. 100
pentoxifylline cr tbcr 400mg................................................69
pentoxifylline er tbcr 400mg................................................69
PERIKABIVEN INJ 333MG/100ML; 235MG/100ML;
71MG/100ML; 20MG/100ML; 6.8GM/100ML;
116MG/100ML; 164MG/100ML; 141MG/100ML;
116MG/100ML; 164MG/100ML; 187MG/100ML;
68MG/100ML; 116MG/100ML; 164MG/100ML;
124MG/100ML; 141MG/100ML; 94MG/100ML;
170MG/100ML; 105MG/100ML; 116MG/100ML;
40MG/100ML; 4.8MG/100ML; 152MG/100ML.. 117
perindopril erbumine tabs 2mg...........................................61
perindopril erbumine tabs 4mg...........................................61
perindopril erbumine tabs 8mg...........................................61
periogard soln 0.12%............................................................74
PERJETA INJ 420MG/14ML...........................................36
permethrin crea 5%................................................................40
perphenazine/amitriptyline tabs 10mg; 2mg..................26
perphenazine/amitriptyline tabs 10mg; 4mg..................26
perphenazine/amitriptyline tabs 25mg; 2mg..................26
perphenazine/amitriptyline tabs 25mg; 4mg..................26
perphenazine/amitriptyline tabs 50mg; 4mg..................26
perphenazine tabs 2mg.........................................................43
perphenazine tabs 4mg.........................................................43
perphenazine tabs 8mg.........................................................43
perphenazine tabs 16mg......................................................43
166
Drug Name
Page Number
phenadoz supp 12.5mg........................................................27
phenadoz supp 25mg............................................................27
phenelzine sulfate tabs 15mg..............................................23
phenergan supp 12.5mg......................................................27
phenergan supp 25mg..........................................................27
phenergan supp 50mg..........................................................27
phenobarbital elix 20mg/5ml..............................................19
phenobarbital tabs 15mg.....................................................19
phenobarbital tabs 16.2mg.................................................19
phenobarbital tabs 30mg.....................................................19
phenobarbital tabs 32.4mg.................................................19
phenobarbital tabs 60mg.....................................................19
phenobarbital tabs 64.8mg.................................................19
phenobarbital tabs 97.2mg.................................................20
phenobarbital tabs 100mg..................................................19
phenytoin chew 50mg...........................................................21
phenytoin sodium extended caps 100mg.........................21
phenytoin sodium extended caps 200mg.........................21
phenytoin sodium extended caps 300mg.........................21
phenytoin sodium inj 50mg/ml...........................................21
phenytoin susp 125mg/5ml................................................21
philith tabs 35mcg; 0.4mg...................................................91
phos-flur gel 1.1%..................................................................74
PHOSPHOLINE IODIDE SOLR 0.125%.................... 104
pilocarpine hcl soln 1%.......................................................104
pilocarpine hcl soln 2%.......................................................104
pilocarpine hcl soln 4%.......................................................104
pilocarpine hcl tabs 7.5mg...................................................75
pilocarpine hydrochloride tabs 5mg..................................75
pimozide tabs 1mg.................................................................43
pimozide tabs 2mg.................................................................43
pimtrea tabs 0; 0.....................................................................91
pindolol tabs 5mg...................................................................64
pindolol tabs 10mg.................................................................64
pioglitazone hcl-glimepiride tabs 2mg; 30mg................54
pioglitazone hcl-glimepiride tabs 4mg; 30mg................54
pioglitazone hcl/metformin hcl tabs 500mg; 15mg......54
pioglitazone hcl/metformin hcl tabs 850mg; 15mg......54
pioglitazone hcl tabs 15mg..................................................54
pioglitazone hcl tabs 30mg..................................................54
pioglitazone hcl tabs 45mg..................................................54
piperacillin sodium/tazobactam sodium inj 2gm; 0.25gm
15
piperacillin sodium/tazobactam sodium inj 3gm;
0.375gm...................................................................................15
piperacillin sodium/tazobactam sodium inj 4gm; 0.5gm..
15
Drug Name
Page Number
piperacillin sodium/ tazobactam sodium inj 36gm;
4.5gm.........................................................................................15
pirmella 1/35 tabs 35mcg; 1mg.........................................91
pirmella 7/7/7 tabs 0; 0........................................................91
piroxicam caps 10mg............................................................... 2
piroxicam caps 20mg............................................................... 2
plenamine inj 151meq/l; 2170mg/100ml;
1470mg/100ml; 434mg/100ml; 749mg/100ml;
1040mg/100ml; 894mg/100ml; 749mg/100ml;
1040mg/100ml; 1180mg/100ml; 749mg/100ml;
1040mg/100ml; 894mg/100ml; 592mg/100ml;
749mg/100ml; 250mg/100ml; 39mg/100ml;
960mg/100ml.....................................................................117
PNV-DHA CAPS 85MG; 140MG; 200UNIT; 12MCG;
300MG; 27MG; 400MCG; 600MCG; 45MG; 25MG;
10UNIT........................................................................... 124
PNV FERROUS FUMARATE/DOCUSATE/FOLIC ACID
TABS 100MG; 1000UNIT; 200MG; 7MG; 400UNIT;
12MCG; 25MG; 29MG; 1MG; 15MG; 20MG; 3MG;
3MG; 30UNIT; 20MG.................................................. 124
PNV FOLIC ACID + IRON MULTIVITAMIN TABS 60MG;
50MG; 400UNIT; 4.5MCG; 27MG; 1MG; 13.5MG;
1.05MG; 1.2MG; 1.05MG; 15UNIT; 2500UNIT..... 124
PNV OB+DHA MISC 120MG; 125MG; 400UNIT;
2MG; 250MG; 50MG; 0; 0; 1MG; 27MG; 0; 20MG; 0;
150MCG; 20MG; 3.4MG; 3MG; 30UNIT; 25MG... 124
PNV PRENATAL PLUS MULTIVITAMIN TABS 120MG;
0; 200MG; 400UNIT; 2MG; 12MCG; 27MG; 1MG;
20MG; 10MG; 3MG; 1.84MG; 22MG; 4000UNIT;
25MG.............................................................................. 124
PNV-SELECT TABS 80MG; 2500UNIT; 300MCG;
120MG; 6MG; 400UNIT; 2MG; 12MCG; 27MG;
400MCG; 600MCG; 30MG; 20MG; 150MCG; 20MG;
3.4MG; 3MG; 10UNIT; 15MG.................................... 124
PNV TABS 29-1 TABS 120MG; 4000UNIT; 30MCG;
200MG; 7MG; 400UNIT; 3MG; 8MCG; 1MG; 29MG;
100MG; 20MG; 150MCG; 3MG; 3MG; 3MG; 30UNIT;
15MG.............................................................................. 124
PNV-VP-U CAPS 10MG; 0.8MG; 15MCG; 106.5MG;
1MG; 1.3MG; 30MG; 5MG; 6MG; 200MG; 10MG.124
podofilox soln 0.5%................................................................76
polycin oint 500unit/gm; 10000unit/gm......................103
polyethylene glycol 3350 pack 0........................................80
polyethylene glycol 3350 powd 0.......................................80
polymyxin b sulfate/trimethoprim sulfate soln
10000unit/ml; 0.1%...........................................................103
poly-vitamin/fluoride chew 60mg; 4.5mcg; 400unit;
Drug Name
Page Number
0.5mg; 0.3mg; 13.5mg; 1.05mg; 1mg; 1mg; 2500unit;
15mg.......................................................................................124
poly-vitamin/fluoride soln 35mg/ml; 50mcg/ml; 2mcg/
ml; 0.25mg/ml; 8mg/ml; 3mg/ml; 0.4mg/ml; 0.6mg/ml;
0.5mg/ml; 1500unit/ml; 400unit/ml; 5unit/ml..........124
POMALYST CAPS 1MG..................................................32
POMALYST CAPS 2MG..................................................32
POMALYST CAPS 3MG..................................................32
POMALYST CAPS 4MG..................................................32
portia-28 tabs 0.03mg; 0.15mg........................................91
potassium chloride 0.3%/d5w inj 5%; 40meq/l...........117
potassium chloride 0.3%/ nacl 0.9% inj 40meq/l; 0.9%...
117
potassium chloride 0.15% d5w/nacl 0.33% inj 5%;
20meq/l; 0.33%...................................................................117
potassium chloride 0.15% d5w/nacl 0.45% inj 5%;
20meq/l; 0.45%...................................................................117
potassium chloride 0.15% d5w/nacl 0.45% viaflex inj
5%; 20meq/l; 0.45%...........................................................117
potassium chloride 0.15% nacl 0.9% inj 20meq/l; 0.9%..
117
potassium chloride 0.15%/nacl 0.9% inj 20meq/l; 0.9%.
117
potassium chloride 0.15% /nacl 0.45% viaflex inj
20meq/l; 0.45%...................................................................117
potassium chloride 0.22% d5w/nacl 0.45% inj 5%;
30meq/l; 0.45%...................................................................117
potassium chloride 0.224%d5w/nacl 0.45% viaflex inj
5%; 30meq/l; 0.45%...........................................................117
potassium chloride cr tbcr 10meq...................................117
potassium chloride cr tbcr 10meq...................................117
potassium chloride cr tbcr 20meq...................................118
potassium chloride er cpcr 8meq.....................................118
potassium chloride er cpcr 10meq..................................118
potassium chloride er tbcr 8meq.....................................118
potassium chloride er tbcr 10meq..................................118
potassium chloride er tbcr 10meq..................................118
potassium chloride er tbcr 20meq..................................118
potassium chloride er tbcr 20meq..................................118
potassium chloride inj 0.4meq/ml...................................118
potassium chloride inj 2meq/ml.......................................118
potassium chloride inj 10meq/50ml..............................118
potassium chloride inj 10meq/100ml...........................118
potassium chloride inj 20meq/100ml...........................118
potassium chloride inj 40meq/100ml...........................118
potassium chloride soln 10%............................................118
potassium chloride soln 20%............................................118
167
Drug Name
Page Number
potassium chloride sr tbcr 8meq......................................118
potassium citrate er tbcr 15meq......................................118
potassium citrate er tbcr 540mg.....................................118
potassium citrate er tbcr 1080mg...................................118
POTIGA TABS 50MG.......................................................18
POTIGA TABS 200MG....................................................18
POTIGA TABS 300MG....................................................18
POTIGA TABS 400MG....................................................18
PRADAXA CAPS 75MG..................................................56
PRADAXA CAPS 150MG...............................................56
pramipexole dihydrochloride tabs 0.5mg.........................41
pramipexole dihydrochloride tabs 0.25mg......................41
pramipexole dihydrochloride tabs 0.75mg......................41
pramipexole dihydrochloride tabs 0.125mg....................41
pramipexole dihydrochloride tabs 1.5mg.........................41
pramipexole dihydrochloride tabs 1mg.............................41
pravastatin sodium tabs 10mg............................................71
pravastatin sodium tabs 20mg............................................71
pravastatin sodium tabs 40mg............................................71
pravastatin sodium tabs 80mg............................................71
prazosin hcl caps 1mg...........................................................58
prazosin hcl caps 2mg...........................................................58
prazosin hcl caps 5mg...........................................................58
prednicarbate crea 0.1%.......................................................85
prednicarbate oint 0.1%.......................................................85
prednisolone acetate susp 1%..........................................104
prednisolone sodium phosphate soln 1%......................104
prednisolone sodium phosphate soln 5mg/5ml.............85
prednisolone sodium phosphate soln 15mg/5ml..........85
prednisolone sodium phosphate soln 25mg/5ml..........85
prednisolone soln 15mg/5ml..............................................85
prednisolone syrp 15mg/5ml..............................................85
PREDNISONE INTENSOL CONC 5MG/ML.................85
prednisone soln 5mg/5ml....................................................85
prednisone tabs 1mg..............................................................85
prednisone tabs 2.5mg..........................................................85
prednisone tabs 5mg..............................................................86
prednisone tabs 5mg..............................................................86
prednisone tabs 10mg...........................................................85
prednisone tabs 10mg...........................................................85
prednisone tabs 20mg...........................................................86
prednisone tabs 50mg...........................................................86
PREFERAOB +DHA MISC 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 200MG; 1MG; 6MG;
17MG; 28MG; 250MCG; 50MG; 1.6MG; 65MCG;
1.5MG; 4.5MG.............................................................. 125
PREFERA OB + DHA MISC 30MCG; 10MG; 400UNIT;
168
Drug Name
Page Number
0.8MG; 12MCG; 200MG; 2.5MG; 1MG; 6MG; 0.5MG;
17MG; 203MG; 28MG; 250MCG; 50MG; 1.6MG;
65MCG; 1.5MG; 10UNIT; 4.5MG............................. 125
PREFERAOB ONE CAPS 25MG; 30MCG; 10MG;
400UNIT; 12MCG; 200MG; 1MG; 6MG; 17MG;
22MG; 175MCG; 50MG; 10UNIT; 15MG............... 125
PREFERA OB TABS 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 1MG; 6MG; 17MG; 28MG;
250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 4.5MG.125
PREMASOL INJ 52MEQ/L; 1760MG/100ML;
880MG/100ML; 34MEQ/L; 1760MG/100ML;
372MG/100ML; 406MG/100ML; 526MG/100ML;
492MG/100ML; 492MG/100ML; 526MG/100ML;
356MG/100ML; 356MG/100ML; 390MG/100ML;
34MG/100ML; 152MG/100ML................................ 118
premasol inj 56meq/l; 320mg/100ml; 730mg/100ml;
190mg/100ml; 3meq/l; 20mg/100ml; 300mg/100ml;
220mg/100ml; 290mg/100ml; 490mg/100ml;
840mg/100ml; 490mg/100ml; 200mg/100ml;
290mg/100ml; 410mg/100ml; 230mg/100ml;
5meq/l; 15mg/100ml; 250mg/100ml; 120mg/100ml;
140mg/100ml; 470mg/100ml......................................118
PRENAISSANCE CAPS 28MG; 160MG; 800UNIT;
325MG; 55MG; 29MG; 1.25MG; 25MG; 30UNIT.125
PRENAISSANCE PLUS CAPS 100MG; 400UNIT;
250MG; 50MG; 1MG; 28MG; 25MG; 30UNIT....... 125
prenatabs fa tabs 120mg; 0; 200mg; 8mcg; 29mg; 1mg;
20mg; 150mcg; 3mg; 3mg; 3mg; 30unit; 4000unit;
400unit; 15mg.....................................................................125
prenatabs obn tabs 120mg; 200mg; 400unit; 8mcg;
1mg; 29mg; 20mg; 150mcg; 3mg; 3mg; 3mg; 30unit;
15mg.......................................................................................126
PRENATA CHEW 120MG; 400UNIT; 12MCG; 29MG;
1MG; 20MG; 10MG; 3MG; 0; 2MG; 11UNIT.......... 126
prenatal 19 chew 100mg; 1000unit; 200mg; 7mg;
400unit; 12mcg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg;
30unit; 20mg........................................................................126
prenatal 19 tabs 100mg; 1000unit; 200mg; 7mg;
400unit; 12mcg; 25mg; 29mg; 1mg; 15mg; 20mg;
3mg; 3mg; 30unit; 20mg..................................................126
PRENATAL PLUS IRON TABS 120MG; 0; 200MG;
400UNIT; 2MG; 12MCG; 1MG; 29MG; 20MG; 10MG;
3MG; 1.84MG; 22UNIT; 4000UNIT; 25MG............ 126
PRENATAL PLUS IRON TABS 120MG; 0; 200MG;
400UNIT; 2MG; 12MCG; 1MG; 29MG; 20MG; 10MG;
3MG; 1.84MG; 22UNIT; 4000UNIT; 25MG............ 126
prenatal plus tabs 120mg; 0; 200mg; 400unit; 2mg;
Drug Name
Page Number
12mcg; 27mg; 1mg; 20mg; 10mg; 3mg; 1.84mg;
22mg; 4000unit; 25mg.....................................................126
PRENATAL PLUS TABS 120MG; 0; 200MG; 400UNIT;
2MG; 12MCG; 27MG; 1MG; 20MG; 10MG; 3MG;
1.84MG; 22MG; 4000UNIT; 25MG.......................... 126
PRENATE AM TABS 200MG; 12MCG; 400MCG;
600MCG; 75MG; 25MG; 500MG............................. 126
PRENATE DHA CAPS 90MG; 145MG; 220UNIT;
13MCG; 300MG; 28MG; 400MCG; 600MCG; 50MG;
26MG; 10UNIT............................................................. 126
PRENATE ELITE TABS 75MG; 2600UNIT; 330MCG;
100MG; 6MG; 450UNIT; 1.5MG; 13MCG; 26MG;
400MCG; 150MCG; 600MCG; 25MG; 21MG; 21MG;
3.5MG; 3MG; 10UNIT; 15MG.................................... 126
PRENATE ESSENTIAL CAPS 90MG; 280MCG;
145MG; 220UNIT; 13MCG; 300MG; 40MG; 29MG; 0;
400MCG; 600MCG; 50MG; 150MCG; 26MG; 10UNIT
127
PRENATE ESSENTIAL CAPS 600MCG; 90MG;
280MCG; 155MG; 220UNIT; 13MCG; 300MG;
40MG; 18MG; 400MCG; 50MG; 150MCG; 26MG;
10UNIT........................................................................... 126
PRENATE MINI CAPS 60MG; 280MCG; 100MG;
220UNIT; 13MCG; 350MG; 400MCG; 29MG;
600MCG; 25MG; 150MCG; 26MG; 10UNIT; 25MG.....
127
PRENATE MINI CAPS 600MCG; 60MG; 280MCG;
80MG; 1000UNIT; 13MCG; 350MG; 0; 400MCG;
18MG; 0; 25MG; 150MCG; 26MG; 10UNIT; 25MG.....
127
PRENATE PIXIE CAPS 600MCG; 30MG; 75MCG;
500UNIT; 13MCG; 200MG; 10MG; 400MCG;
150MCG; 5MG; 10UNIT; 5MG.................................. 127
PREPLUS TABS 120MG; 0; 200MG; 400UNIT; 2MG;
12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG;
22MG; 4000UNIT; 25MG........................................... 127
PREPOPIK PACK 12GM; 3.5GM; 10MG......................80
PREQUE 10 TABS 30MG; 1250UNIT; 0; 120UNIT;
50MG; 1MG; 1MCG; 15UNIT; 50MG; 25MG; 0.5MG;
15MG; 5MG; 10MG; 1.7MG; 0; 7.5MCG; 1MG;
12.5MG.......................................................................... 127
PRETAB TABS 120MG; 4000UNIT; 200MG; 400UNIT;
8MCG; 29MG; 1MG; 20MG; 150MCG; 3MG; 3MG;
3MG; 30UNIT; 15MG.................................................. 127
prevalite pack 4gm..................................................................72
prevalite powd 4gm/dose......................................................72
previfem tabs 35mcg; 0.25mg............................................91
Drug Name
Page Number
PREZCOBIX TABS 150MG; 800MG.............................50
PREZISTA SUSP 100MG/ML.........................................50
PREZISTA TABS 75MG....................................................50
PREZISTA TABS 150MG.................................................50
PREZISTA TABS 600MG.................................................50
PREZISTA TABS 800MG.................................................50
PRIFTIN TABS 150MG....................................................31
primaquine phosphate tabs 26.3mg.................................40
primidone tabs 50mg............................................................20
primidone tabs 250mg..........................................................20
PRISTIQ TB24 25MG......................................................25
pr natal 400 ec misc 120mg; 3000unit; 200mg;
400unit; 2mg; 12mcg; 275mg; 0; 1mg; 29mg; 25mg;
20mg; 400mg; 25mg; 4mg; 1.8mg; 3mg; 25mg.......125
pr natal 400 misc 120mg; 3000unit; 200mg; 400unit;
2mg; 12mcg; 275mg; 0; 0; 1mg; 29mg; 0; 25mg; 20mg;
400mg; 25mg; 4mg; 1.8mg; 30mg; 25mg..................125
pr natal 430 ec misc 120mg; 3000unit; 200mg;
400unit; 2mg; 12mcg; 295mg; 0; 0; 1mg; 29mg; 0;
25mg; 20mg; 430mg; 25mg; 4mg; 1.8mg; 3mg; 25mg.
125
pr natal 430 misc 120mg; 3000unit; 200mg; 400unit;
2mg; 12mcg; 295mg; 0; 0; 1mg; 29mg; 0; 25mg; 20mg;
430mg; 25mg; 4mg; 1.8mg; 30mg; 25mg..................125
PROAIR HFA AERS 108MCG/ACT............................. 108
PROAIR RESPICLICK AEPB 108MCG/ACT............... 108
probenecid/colchicine tabs 0.5mg; 500mg.....................29
probenecid tabs 500mg........................................................29
prochlorperazine edisylate inj 5mg/ml..............................43
prochlorperazine maleate tabs 5mg..................................43
prochlorperazine maleate tabs 10mg...............................43
prochlorperazine supp 25mg..............................................43
PROCRIT INJ 2000UNIT/ML..........................................57
PROCRIT INJ 3000UNIT/ML..........................................57
PROCRIT INJ 4000UNIT/ML..........................................57
PROCRIT INJ 10000UNIT/ML........................................57
PROCRIT INJ 20000UNIT/ML........................................57
PROCRIT INJ 40000UNIT/ML........................................57
procto-pak crea 1%................................................................86
proctosol hc crea 2.5%..........................................................86
proctozone-hc crea 2.5%......................................................86
proctozone-hc crea 2.5%......................................................86
progesterone caps 100mg...................................................92
progesterone caps 200mg...................................................92
progesterone inj 50mg/ml....................................................93
PROGLYCEM SUSP 50MG/ML......................................54
PROGRAF INJ 5MG/ML..................................................97
169
Drug Name
Page Number
PROLASTIN-C INJ 1000MG....................................... 109
PROLENSA SOLN 0.07%............................................ 104
PROLEUKIN INJ 22000000UNIT..................................36
PROLIA INJ 60MG/ML................................................. 101
PROMACTA TABS 12.5MG............................................57
PROMACTA TABS 25MG...............................................57
PROMACTA TABS 50MG...............................................57
PROMACTA TABS 75MG...............................................57
promethazine hcl supp 12.5mg..........................................27
promethazine hcl supp 25mg..............................................27
promethazine hcl supp 50mg..............................................27
promethazine hcl tabs 12.5mg........................................106
promethazine hcl tabs 25mg............................................106
promethazine hcl tabs 50mg............................................106
promethegan supp 12.5mg.................................................27
promethegan supp 25mg.....................................................27
promethegan supp 50mg.....................................................27
propafenone hcl er cp12 225mg........................................62
propafenone hcl er cp12 325mg........................................62
propafenone hcl er cp12 425mg........................................63
propafenone hcl tabs 150mg..............................................63
propafenone hcl tabs 225mg..............................................63
propafenone hcl tabs 300mg..............................................63
proparacaine hcl soln 0.5%...............................................103
propranolol hcl er cp24 60mg............................................64
propranolol hcl er cp24 80mg............................................64
propranolol hcl er cp24 120mg..........................................64
propranolol hcl er cp24 160mg..........................................64
propranolol hcl inj 1mg/ml...................................................64
propranolol hcl soln 20mg/5ml..........................................65
propranolol hcl soln 40mg/5ml..........................................65
propranolol hcl tabs 10mg...................................................65
propranolol hcl tabs 20mg...................................................65
propranolol hcl tabs 40mg...................................................65
propranolol hcl tabs 60mg...................................................65
propranolol hcl tabs 80mg...................................................65
propranolol/hydrochlorothiazide tabs 25mg; 40mg....65
propranolol/hydrochlorothiazide tabs 25mg; 80mg....65
propylthiouracil tabs 50mg..................................................96
PROQUAD INJ 0; 0; 0; 0..................................................99
protriptyline hcl tabs 5mg.....................................................26
protriptyline hcl tabs 10mg..................................................26
PROVIDA DHA CAPS 315MG; 300MCG; 30MG; 5MG;
400UNIT; 1MG; 10MCG; 110MG; 16MG; 1.25MG;
30MG; 7MG; 2MG; 16MG; 25MG; 3MG; 2MG; 6MG...
127
PULMOZYME SOLN 1MG/ML................................... 108
170
Drug Name
Page Number
PUREFE OB PLUS CAPS 10MG; 0.8MG; 15MCG;
162MG; 1MG; 6.9MG; 1.3MG; 30MG; 115.2MG;
5MG; 6MG; 200MG; 10MG; 18.2MG...................... 127
PURIXAN SUSP 2000MG/100ML................................33
pyrazinamide tabs 500mg....................................................31
pyridostigmine bromide tabs 60mg...................................30
pyridostigmine bromide tbcr 180mg................................30
QUADRACEL INJ 48MCG/0.5ML; 15LFU/0.5ML; 0;
5LFU/0.5ML.....................................................................99
quasense tabs 0.03mg; 0.15mg.........................................91
quetiapine fumarate tabs 25mg.........................................45
quetiapine fumarate tabs 50mg.........................................45
quetiapine fumarate tabs 100mg......................................45
quetiapine fumarate tabs 200mg......................................45
quetiapine fumarate tabs 300mg......................................45
quetiapine fumarate tabs 400mg......................................45
QUFLORA PEDIATRIC SOLN 35MG/ML; 400UNIT/
ML; 1MG/ML; 2MCG/ML; 35MCG/ML; 65MCG/
ML; 10MG/ML; 0.8MG/ML; 0.4MG/ML; 0.6MG/ML;
0.25MG/ML; 0.5MG/ML; 1000UNIT/ML; 5UNIT/ML...
127
QUFLORA PEDIATRIC SOLN 45MG/ML; 400UNIT/
ML; 1MG/ML; 3MCG/ML; 81MCG/ML; 150MCG/ML;
12MG/ML; 2MG/ML; 1MG/ML; 1MG/ML; 0.5MG/
ML; 1MG/ML; 1100UNIT/ML; 12UNIT/ML............. 128
quinapril hcl tabs 5mg...........................................................61
quinapril hcl tabs 10mg........................................................61
quinapril hcl tabs 20mg........................................................61
quinapril hcl tabs 40mg........................................................61
quinapril/hydrochlorothiazide tabs 12.5mg; 10mg......61
quinapril/hydrochlorothiazide tabs 12.5mg; 20mg......62
quinapril/hydrochlorothiazide tabs 25mg; 20mg..........62
quinidine gluconate cr tbcr 324mg....................................63
quinidine gluconate er tbcr 324mg....................................63
quinidine sulfate er tbcr 300mg..........................................63
quinidine sulfate tabs 200mg..............................................63
quinidine sulfate tabs 300mg..............................................63
quinine sulfate caps 324mg.................................................40
QVAR AERS 40MCG/ACT............................................ 106
QVAR AERS 80MCG/ACT............................................ 106
RABAVERT INJ 0...............................................................99
raloxifene hydrochloride tabs 60mg..................................93
ramipril caps 1.25mg.............................................................62
ramipril caps 2.5mg...............................................................62
ramipril caps 5mg...................................................................62
ramipril caps 10mg................................................................62
RANEXA TB12 500MG..................................................69
Drug Name
Page Number
RANEXA TB12 1000MG................................................69
ranitidine hcl caps 150mg....................................................79
ranitidine hcl caps 300mg....................................................79
ranitidine hcl inj 50mg/2ml..................................................79
ranitidine hcl inj 150mg/6ml...............................................79
ranitidine hcl syrp 15mg/ml.................................................80
ranitidine hcl tabs 150mg.....................................................80
ranitidine hcl tabs 300mg.....................................................80
RAPAMUNE SOLN 1MG/ML.........................................97
RAVICTI LIQD 1.1GM/ML..............................................78
reclipsen tabs 0.15mg; 30mcg............................................91
RECOMBIVAX HB INJ 5MCG/0.5ML............................99
RECOMBIVAX HB INJ 10MCG/ML................................99
RECOMBIVAX HB INJ 10MCG/ML................................99
RECOMBIVAX HB INJ 40MCG/ML................................99
REGRANEX GEL 0.01%..................................................76
relador pak plus kit 2.5%; 2.5%............................................. 7
RELENZA DISKHALER AEPB 5MG/BLISTER...............50
RELISTOR INJ 8MG/0.4ML.............................................79
RELISTOR INJ 12MG/0.6ML..........................................79
RELISTOR INJ 12MG/0.6ML..........................................79
RELNATE DHA CAPS 100MG; 400UNIT; 1MG;
15MCG; 28MG; 1MG; 30MG; 200MG; 20MG; 3MG;
3MG; 30UNIT; 20MG.................................................. 128
REMICADE INJ 100MG...................................................97
REMODULIN INJ 1MG/ML.......................................... 109
REMODULIN INJ 2.5MG/ML...................................... 109
REMODULIN INJ 5MG/ML.......................................... 109
REMODULIN INJ 10MG/ML....................................... 109
RENVELA PACK 0.8GM..................................................82
RENVELA PACK 2.4GM..................................................82
RENVELA TABS 800MG.................................................82
repaglinide tabs 0.5mg..........................................................54
repaglinide tabs 1mg..............................................................54
repaglinide tabs 2mg..............................................................54
RESCRIPTOR TABS 100MG...........................................48
RESCRIPTOR TABS 200MG...........................................48
RESTASIS EMUL 0.05%............................................... 103
RETROVIR IV INFUSION INJ 10MG/ML.......................49
REVLIMID CAPS 2.5MG.................................................32
REVLIMID CAPS 5MG.....................................................32
REVLIMID CAPS 10MG..................................................32
REVLIMID CAPS 15MG..................................................32
REVLIMID CAPS 20MG..................................................32
REVLIMID CAPS 25MG..................................................32
REXULTI TABS 0.5MG.....................................................45
REXULTI TABS 0.25MG...................................................45
Drug Name
Page Number
REXULTI TABS 1MG.........................................................45
REXULTI TABS 2MG.........................................................45
REXULTI TABS 3MG.........................................................45
REXULTI TABS 4MG.........................................................45
REYATAZ CAPS 150MG..................................................50
REYATAZ CAPS 200MG..................................................50
REYATAZ CAPS 300MG..................................................50
REYATAZ PACK 50MG.....................................................50
ribavirin caps 200mg.............................................................48
ribavirin tabs 200mg.............................................................48
rifabutin caps 150mg............................................................30
rifampin caps 150mg............................................................31
rifampin caps 300mg............................................................31
rifampin inj 600mg................................................................31
RIFATER TABS 50MG; 300MG; 120MG......................31
riluzole tabs 50mg..................................................................74
rimantadine hcl tabs 100mg...............................................50
ringers injection inj 4.5meq/l; 156meq/l; 4meq/l;
147meq/l...............................................................................118
risedronate sodium dr tbec 35mg...................................101
risedronate sodium tabs 5mg...........................................101
risedronate sodium tabs 30mg........................................101
risedronate sodium tabs 35mg........................................101
risedronate sodium tabs 35mg........................................101
risedronate sodium tabs 150mg......................................101
RISPERDAL CONSTA INJ 12.5MG.................................46
RISPERDAL CONSTA INJ 25MG....................................46
RISPERDAL CONSTA INJ 37.5MG.................................46
RISPERDAL CONSTA INJ 50MG....................................46
risperidone odt tbdp 0.5mg.................................................46
risperidone odt tbdp 0.25mg...............................................46
risperidone odt tbdp 1mg.....................................................46
risperidone odt tbdp 2mg.....................................................46
risperidone odt tbdp 3mg.....................................................46
risperidone odt tbdp 4mg.....................................................46
risperidone soln 1mg/ml.......................................................46
risperidone tabs 0.5mg.........................................................46
risperidone tabs 0.25mg.......................................................46
risperidone tabs 1mg.............................................................46
risperidone tabs 2mg.............................................................46
risperidone tabs 3mg.............................................................46
risperidone tabs 4mg.............................................................46
RITUXAN INJ 100MG/10ML..........................................39
RITUXAN INJ 500MG/50ML..........................................39
rivastigmine tartrate caps 1.5mg........................................22
rivastigmine tartrate caps 3mg...........................................22
rivastigmine tartrate caps 4.5mg........................................22
171
Drug Name
Page Number
rivastigmine tartrate caps 6mg...........................................22
rivastigmine transdermal system pt24 4.6mg/24hr.....22
rivastigmine transdermal system pt24 9.5mg/24hr.....22
rivastigmine transdermal system pt24 13.3mg/24hr..22
rizatriptan benzoate odt tbdp 5mg.....................................30
rizatriptan benzoate odt tbdp 10mg..................................30
rizatriptan benzoate tabs 5mg.............................................30
rizatriptan benzoate tabs 10mg..........................................30
ropinirole hcl tabs 0.5mg......................................................41
ropinirole hcl tabs 0.25mg...................................................41
ropinirole hcl tabs 1mg..........................................................41
ropinirole hcl tabs 2mg..........................................................41
ropinirole hcl tabs 3mg..........................................................41
ropinirole hcl tabs 4mg..........................................................41
ropinirole hcl tabs 5mg..........................................................41
rosadan crea 0.75%...............................................................76
rosadan gel 0.75%..................................................................76
ROTARIX SUSR 0..............................................................99
ROTATEQ SOLN 0............................................................99
ROXICET SOLN 325MG/5ML; 5MG/5ML.................... 6
roxicet tabs 325mg; 5mg........................................................ 6
ROZEREM TABS 8MG.................................................. 110
SABRIL PACK 500MG.....................................................20
SABRIL TABS 500MG.....................................................20
SAMSCA TABS 15MG.................................................. 110
SAMSCA TABS 30MG.................................................. 110
SANDIMMUNE SOLN 100MG/ML..............................97
SANTYL OINT 250UNIT/GM.........................................76
SAPHRIS SUBL 2.5MG....................................................46
SAPHRIS SUBL 5MG.......................................................46
SAPHRIS SUBL 10MG.....................................................46
SAVAYSA TABS 15MG....................................................56
SAVAYSA TABS 30MG....................................................56
SAVAYSA TABS 60MG....................................................56
SELECT-OB CHEW 60MG; 0; 400UNIT; 5MCG;
0.4MG; 0.6MG; 25MG; 15MG; 29MG; 2.5MG;
1.8MG; 0; 1.6MG; 30UNIT; 1700UNIT; 15MG...... 128
selegiline hcl caps 5mg..........................................................42
selegiline hcl tabs 5mg...........................................................42
selenium sulfide lotn 2.5%....................................................76
SELZENTRY TABS 150MG..............................................50
SELZENTRY TABS 300MG..............................................50
se-natal 19 chew 1000unit; 100mg; 200mg; 7mg;
400unit; 12mcg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg;
30unit; 20mg........................................................................128
se-natal 19 tabs 100mg; 1000unit; 200mg; 7mg;
400unit; 12mcg; 25mg; 29mg; 1mg; 15mg; 20mg;
172
Drug Name
Page Number
3mg; 3mg; 30unit; 20mg..................................................128
SENSIPAR TABS 30MG...................................................94
SENSIPAR TABS 60MG...................................................94
SENSIPAR TABS 90MG...................................................95
sertraline hcl conc 20mg/ml................................................25
sertraline hcl tabs 25mg........................................................25
sertraline hcl tabs 50mg........................................................25
sertraline hcl tabs 100mg.....................................................25
se-tan dha caps 215.12mg; 53.46mg; 15mg; 1mg;
310.1mg; 15mg; 25mg; 20mg.......................................128
setlakin tabs 0.03mg; 0.15mg............................................91
seton et-ec misc 120mg; 3000unit; 200mg; 400unit;
2mg; 12mcg; 295mg; 0; 0; 1mg; 29mg; 0; 25mg; 20mg;
430mg; 25mg; 4mg; 1.8mg; 3mg; 25mg....................128
setonet misc 120mg; 3000unit; 200mg; 400unit; 2mg;
12mcg; 295mg; 0; 0; 1mg; 29mg; 0; 25mg; 20mg;
430mg; 25mg; 4mg; 1.8mg; 30mg; 25mg..................128
sf gel 1.1%.................................................................................75
sharobel tabs 0.35mg............................................................93
SIGNIFOR INJ 0.3MG/ML...............................................95
SIGNIFOR INJ 0.6MG/ML...............................................95
SIGNIFOR INJ 0.9MG/ML...............................................95
sildenafil tabs 20mg............................................................109
silver sulfadiazine crea 1%....................................................76
SIMBRINZA SUSP 0.2%; 1%...................................... 105
SIMULECT INJ 10MG......................................................97
SIMULECT INJ 20MG......................................................97
simvastatin tabs 5mg.............................................................71
simvastatin tabs 10mg..........................................................71
simvastatin tabs 20mg..........................................................71
simvastatin tabs 40mg..........................................................71
simvastatin tabs 80mg..........................................................71
sirolimus tabs 0.5mg..............................................................97
sirolimus tabs 1mg..................................................................97
sirolimus tabs 2mg..................................................................97
SIRTURO TABS 100MG..................................................31
SIVEXTRO INJ 200MG.....................................................10
SIVEXTRO TABS 200MG................................................10
sodium bicarbonate inj 8.4%............................................110
sodium bicarbonate partial fill inj 4.2%..........................110
sodium chloride 0.9% soln 0.9%........................................82
sodium chloride 0.45% viaflex inj 0.45%......................118
sodium chloride inj 0.9%....................................................119
sodium chloride inj 2.5meq/ml.........................................119
sodium chloride inj 3%.......................................................119
sodium chloride inj 5%.......................................................119
sodium fluoride chew 0.5mg.............................................119
Drug Name
Page Number
sodium fluoride chew 1.1mg.............................................119
sodium fluoride chew 1mg................................................119
sodium phenylbutyrate powd 3gm/tsp.............................78
sodium polystyrene sulfonate powd 0............................110
sodium polystyrene sulfonate susp 15gm/60ml.........110
sodium polystyrene sulfonate susp 30gm/120ml......110
sodium polystyrene sulfonate susp 50gm/200ml......110
sodium sulfacetamide lotn 10%..........................................76
sodium sulfacetamide soln 10%......................................103
SOLTAMOX SOLN 10MG/5ML.....................................32
SOMATULINE DEPOT INJ 60MG/0.2ML.....................95
SOMATULINE DEPOT INJ 90MG/0.3ML.....................95
SOMATULINE DEPOT INJ 120MG/0.5ML..................95
SOMAVERT INJ 10MG....................................................95
SOMAVERT INJ 15MG....................................................95
SOMAVERT INJ 20MG....................................................95
SOMAVERT INJ 25MG....................................................95
SOMAVERT INJ 30MG....................................................95
sorine tabs 80mg....................................................................63
sorine tabs 120mg..................................................................63
sorine tabs 160mg..................................................................63
sorine tabs 240mg..................................................................63
sotalol hcl (af) tabs 80mg.....................................................63
sotalol hcl (af) tabs 120mg...................................................63
sotalol hcl (af) tabs 160mg...................................................63
sotalol hcl tabs 80mg.............................................................63
sotalol hcl tabs 120mg..........................................................63
sotalol hcl tabs 160mg..........................................................63
sotalol hcl tabs 240mg..........................................................63
SOVALDI TABS 400MG..................................................48
SPIRIVA HANDIHALER CAPS 18MCG...................... 107
SPIRIVA RESPIMAT AERS 1.25MCG/ACT................ 107
SPIRIVA RESPIMAT AERS 2.5MCG/ACT................... 107
spironolactone/hydrochlorothiazide tabs 25mg; 25mg....
70
spironolactone tabs 25mg....................................................70
spironolactone tabs 50mg....................................................70
spironolactone tabs 100mg.................................................70
SPORANOX SOLN 10MG/ML.......................................29
sprintec 28 tabs 35mcg; 0.25mg.......................................91
SPRYCEL TABS 20MG.....................................................38
SPRYCEL TABS 50MG.....................................................38
SPRYCEL TABS 70MG.....................................................38
SPRYCEL TABS 80MG.....................................................38
SPRYCEL TABS 100MG..................................................38
SPRYCEL TABS 140MG..................................................38
sronyx tabs 20mcg; 0.1mg...................................................91
Drug Name
Page Number
ssd crea 1%...............................................................................76
stavudine caps 15mg.............................................................49
stavudine caps 20mg.............................................................49
stavudine caps 30mg.............................................................49
stavudine caps 40mg.............................................................49
stavudine solr 1mg/ml...........................................................49
sterile water irrigation soln 0.............................................119
STIOLTO RESPIMAT AERS 2.5MCG/ACT; 2.5MCG/
ACT.................................................................................. 109
STIVARGA TABS 40MG..................................................38
streptomycin sulfate inj 1gm.................................................. 8
STRIBILD TABS 150MG; 150MG; 200MG; 300MG.48
STROMECTOL TABS 3MG..............................................40
SUBOXONE FILM 2MG; 0.5MG...................................... 7
SUBOXONE FILM 4MG; 1MG.......................................... 7
SUBOXONE FILM 8MG; 2MG.......................................... 7
SUBOXONE FILM 12MG; 3MG....................................... 7
sucralfate susp 1gm/10ml...................................................81
sucralfate tabs 1gm................................................................81
sulfacetamide sodium oint 10%.......................................103
sulfacetamide sodium/prednisolone sodium phosphate
soln 0.23%; 10%..................................................................103
sulfacetamide sodium soln 10%......................................103
sulfacetamide sodium susp 10%........................................76
sulfadiazine tabs 500mg.......................................................16
sulfamethoxazole/trimethoprim ds tabs 800mg; 160mg.
16
sulfamethoxazole/trimethoprim inj 400mg/5ml;
80mg/5ml.................................................................................16
sulfamethoxazole/trimethoprim susp 200mg/5ml;
40mg/5ml.................................................................................17
sulfamethoxazole/trimethoprim tabs 400mg; 80mg...17
SULFAMYLON CREA 85MG/GM..................................76
sulfasalazine tabs 500mg..................................................100
sulfasalazine tbec 500mg..................................................100
sulfatrim pediatric susp 200mg/5ml; 40mg/5ml..........17
sulfazine ec tbec 500mg....................................................100
sulfazine tabs 500mg..........................................................100
sulindac tabs 150mg............................................................... 2
sulindac tabs 200mg............................................................... 2
sumatriptan soln 5mg/act....................................................30
sumatriptan soln 20mg/act..................................................30
sumatriptan succinate inj 4mg/0.5ml...............................30
sumatriptan succinate inj 6mg/0.5ml...............................30
sumatriptan succinate inj 6mg/0.5ml...............................30
sumatriptan succinate inj 6mg/0.5ml...............................30
sumatriptan succinate refill inj 4mg/0.5ml......................30
173
Drug Name
Page Number
sumatriptan succinate refill inj 6mg/0.5ml......................30
sumatriptan succinate tabs 25mg......................................30
sumatriptan succinate tabs 50mg......................................30
sumatriptan succinate tabs 100mg...................................30
SUPRAX CAPS 400MG...................................................13
SUPRAX CHEW 100MG.................................................13
SUPRAX CHEW 200MG.................................................13
SUPRAX SUSR 100MG/5ML.........................................13
SUPRAX SUSR 200MG/5ML.........................................13
SUPRAX SUSR 500MG/5ML.........................................13
SUPREP BOWEL PREP SOLN 1.6GM/180ML;
3.13GM/180ML; 17.5GM/180ML..............................80
SURMONTIL CAPS 25MG.............................................26
SURMONTIL CAPS 50MG.............................................26
SURMONTIL CAPS 100MG...........................................26
SUSTIVA CAPS 50MG.....................................................48
SUSTIVA CAPS 200MG..................................................48
SUSTIVA TABS 600MG...................................................48
SUTENT CAPS 12.5MG..................................................39
SUTENT CAPS 25MG.....................................................39
SUTENT CAPS 37.5MG..................................................39
SUTENT CAPS 50MG.....................................................39
syeda tabs 3mg; 0.03mg......................................................91
SYLATRON INJ 200MCG................................................36
SYLATRON INJ 200MCG................................................36
SYLATRON INJ 300MCG................................................36
SYLATRON INJ 300MCG................................................36
SYLATRON INJ 600MCG................................................36
SYLVANT INJ 100MG......................................................39
SYLVANT INJ 400MG......................................................39
SYMLINPEN 60 INJ 1500MCG/1.5ML........................54
SYMLINPEN 120 INJ 2700MCG/2.7ML......................54
SYNAGIS INJ 50MG/0.5ML............................................98
SYNAGIS INJ 100MG/ML...............................................98
SYNAREL SOLN 2MG/ML..............................................95
SYNERCID INJ 350MG; 150MG....................................10
SYNRIBO INJ 3.5MG........................................................36
SYNTHROID TABS 25MCG............................................94
SYNTHROID TABS 50MCG............................................94
SYNTHROID TABS 75MCG............................................94
SYNTHROID TABS 88MCG............................................94
SYNTHROID TABS 100MCG..........................................93
SYNTHROID TABS 112MCG..........................................94
SYNTHROID TABS 125MCG..........................................94
SYNTHROID TABS 137MCG..........................................94
SYNTHROID TABS 150MCG..........................................94
SYNTHROID TABS 175MCG..........................................94
174
Drug Name
Page Number
SYNTHROID TABS 200MCG..........................................94
SYNTHROID TABS 300MCG..........................................94
SYPRINE CAPS 250MG............................................... 110
TABLOID TABS 40MG.....................................................33
tacrolimus caps 0.5mg..........................................................97
tacrolimus caps 1mg..............................................................97
tacrolimus caps 5mg..............................................................97
TAFINLAR CAPS 50MG..................................................39
TAFINLAR CAPS 75MG..................................................39
TAMIFLU CAPS 30MG....................................................50
TAMIFLU CAPS 45MG....................................................51
TAMIFLU CAPS 75MG....................................................51
TAMIFLU SUSR 6MG/ML................................................51
tamoxifen citrate tabs 10mg................................................32
tamoxifen citrate tabs 20mg................................................32
tamsulosin hcl caps 0.4mg...................................................81
TARCEVA TABS 25MG....................................................39
TARCEVA TABS 100MG..................................................39
TARCEVA TABS 150MG..................................................39
TARGRETIN CAPS 75MG...............................................39
TARGRETIN GEL 1%.......................................................40
tarina fe 1/20 tabs 20mcg; 75mg; 1mg...........................91
TARON-PREX CAPS 25MG; 160MG; 170UNIT;
265MG; 55MG; 30MG; 1.2MG; 25MG; 30UNIT... 128
TASIGNA CAPS 150MG.................................................39
TASIGNA CAPS 200MG.................................................39
tazicef inj 1gm..........................................................................13
tazicef inj 1gm..........................................................................13
tazicef inj 2gm..........................................................................13
tazicef inj 2gm..........................................................................13
tazicef inj 6gm..........................................................................13
TAZORAC CREA 0.1%....................................................76
TAZORAC CREA 0.05%..................................................76
TAZORAC GEL 0.1%.......................................................77
TAZORAC GEL 0.05%.....................................................76
taztia xt cp24 120mg............................................................68
taztia xt cp24 180mg............................................................68
taztia xt cp24 240mg............................................................68
taztia xt cp24 300mg............................................................68
taztia xt cp24 360mg............................................................68
TEFLARO INJ 400MG......................................................13
TEFLARO INJ 600MG......................................................13
TEGRETOL-XR TB12 100MG........................................21
telmisartan/amlodipine tabs 5mg; 40mg.........................59
telmisartan/amlodipine tabs 5mg; 80mg.........................59
telmisartan/amlodipine tabs 10mg; 40mg......................59
telmisartan/amlodipine tabs 10mg; 80mg......................59
Drug Name
Page Number
telmisartan/hydrochlorothiazide tabs 12.5mg; 40mg..59
telmisartan/hydrochlorothiazide tabs 12.5mg; 80mg..59
telmisartan/hydrochlorothiazide tabs 25mg; 80mg.....59
telmisartan tabs 20mg..........................................................59
telmisartan tabs 40mg..........................................................59
telmisartan tabs 80mg..........................................................59
TEMODAR INJ 100MG....................................................31
TENIVAC INJ 2LFU; 5LFU...............................................99
terazosin hcl caps 1mg..........................................................58
terazosin hcl caps 2mg..........................................................58
terazosin hcl caps 5mg..........................................................58
terazosin hcl caps 10mg........................................................58
terbinafine hcl tabs 250mg..................................................29
terbutaline sulfate tabs 2.5mg..........................................108
terbutaline sulfate tabs 5mg..............................................108
terconazole crea 0.4%...........................................................29
terconazole crea 0.8%...........................................................29
terconazole supp 80mg.........................................................29
testosterone cypionate inj 100mg/ml................................87
testosterone cypionate inj 200mg/ml................................87
testosterone enanthate inj 200mg/ml...............................87
testosterone gel 25mg/2.5gm.............................................87
tetanus/diphtheria toxoids-adsorbed adult inj 2lf/0.5ml;
2lf/0.5ml...................................................................................99
tetrabenazine tabs 12.5mg..................................................74
tetrabenazine tabs 25mg......................................................74
tetracycline hcl caps 250mg................................................17
tetracycline hcl caps 500mg................................................17
THALOMID CAPS 50MG................................................32
THALOMID CAPS 100MG.............................................32
THALOMID CAPS 150MG.............................................32
THALOMID CAPS 200MG.............................................32
theophylline cr tb12 100mg.............................................108
theophylline cr tb12 200mg.............................................108
theophylline elix 80mg/15ml............................................108
theophylline er tb12 100mg.............................................108
theophylline er tb12 200mg.............................................108
theophylline er tb12 300mg.............................................108
theophylline er tb12 450mg.............................................108
theophylline er tb24 400mg.............................................108
theophylline er tb24 600mg.............................................108
theophylline soln 80mg/15ml..........................................108
THERACYS INJ 81MG/VIAL...........................................36
THIOLA TABS 100MG....................................................82
thioridazine hcl tabs 10mg...................................................43
thioridazine hcl tabs 25mg...................................................43
thioridazine hcl tabs 50mg...................................................43
Drug Name
Page Number
thioridazine hcl tabs 100mg................................................43
thiotepa inj 15mg....................................................................31
thiothixene caps 1mg.............................................................43
thiothixene caps 2mg.............................................................43
thiothixene caps 5mg.............................................................43
thiothixene caps 10mg..........................................................43
THRIVITE RX TABS 120MG; 4000UNIT; 30MCG;
200MG; 7MG; 400UNIT; 3MG; 8MCG; 1MG; 29MG;
100MG; 20MG; 150MCG; 3MG; 3MG; 3MG; 30UNIT;
15MG.............................................................................. 128
THYMOGLOBULIN INJ 25MG.......................................97
THYROLAR-1/2 TABS 30MG........................................94
THYROLAR-1/4 TABS 15MG........................................94
THYROLAR-1 TABS 60MG............................................94
THYROLAR-2 TABS 120MG.........................................94
THYROLAR-3 TABS 180MG.........................................94
tiagabine hydrochloride tabs 2mg......................................20
tiagabine hydrochloride tabs 4mg......................................20
TICE BCG INJ 50MG........................................................36
ticlopidine hcl tabs 250mg...................................................58
TIKOSYN CAPS 125MCG...............................................63
TIKOSYN CAPS 250MCG...............................................63
TIKOSYN CAPS 500MCG...............................................63
tilia fe tabs 0; 75mg; 1mg.....................................................91
timolol maleate ophthalmic gel forming solg 0.5%....105
timolol maleate ophthalmic gel forming solg 0.25%.105
timolol maleate soln 0.5%.................................................105
timolol maleate soln 0.25%..............................................105
timolol maleate tabs 5mg.....................................................65
timolol maleate tabs 10mg..................................................65
timolol maleate tabs 20mg..................................................65
tinidazole tabs 250mg...........................................................10
tinidazole tabs 500mg...........................................................10
TIVICAY TABS 50MG.......................................................48
tizanidine hcl tabs 2mg..........................................................47
tizanidine hcl tabs 4mg..........................................................47
TL-CARE DHA CAPS 60MG; 300MCG; 800UNIT;
2MG; 100MCG; 215MG; 25MG; 45MG; 27MG;
500MG; 1MG; 20MG; 25MG; 3.4MG; 3MG; 30UNIT;
10MG.............................................................................. 129
TL FOLATE TABS 80MG; 4000UNIT; 300MCG;
120MG; 6MG; 400UNIT; 2MG; 12MCG; 27MG;
500MCG; 500MCG; 90MG; 20MG; 150MCG; 20MG;
3.4MG; 3MG; 30UNIT; 15MG.................................... 128
TL-SELECT CAPS 28MG; 160MG; 800UNIT; 325MG;
55MG; 29MG; 1.25MG; 25MG; 30UNIT................. 129
TOBI PODHALER CAPS 28MG.................................. 108
175
Drug Name
Page Number
TOBRADEX OINT 0.1%; 0.3%................................... 103
TOBRADEX ST SUSP 0.05%; 0.3%........................... 103
TOBRADEX SUSP 0.1%; 0.3%................................... 103
tobramycin/dexamethasone susp 0.1%; 0.3%.............103
tobramycin nebu 300mg/5ml..........................................108
tobramycin sulfate inj 1.2gm................................................. 8
tobramycin sulfate inj 1.2gm/30ml..................................... 8
tobramycin sulfate inj 10mg/ml............................................ 8
tobramycin sulfate inj 40mg/ml............................................ 8
tobramycin sulfate inj 40mg/ml............................................ 8
tobramycin sulfate inj 80mg/2ml......................................... 8
tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml.8
tobramycin sulfate soln 0.3%............................................103
TOBREX OINT 0.3%..................................................... 103
tolazamide tabs 250mg........................................................54
tolazamide tabs 500mg........................................................54
tolbutamide tabs 500mg......................................................54
tolmetin sodium caps 400mg................................................ 2
tolmetin sodium tabs 200mg................................................ 2
tolmetin sodium tabs 600mg................................................ 2
tolterodine tartrate tabs 1mg...............................................81
tolterodine tartrate tabs 2mg...............................................81
topiramate cpsp 15mg..........................................................20
topiramate cpsp 25mg..........................................................20
topiramate tabs 25mg...........................................................20
topiramate tabs 50mg...........................................................20
topiramate tabs 100mg........................................................20
topiramate tabs 200mg........................................................20
toposar inj 1gm/50ml............................................................37
toposar inj 100mg/5ml.........................................................37
toposar inj 500mg/25ml......................................................37
topotecan hcl inj 4mg.............................................................37
topotecan hcl inj 4mg/4ml...................................................37
TORISEL INJ 25MG/ML...................................................39
torsemide tabs 5mg................................................................69
torsemide tabs 10mg.............................................................69
torsemide tabs 20mg.............................................................69
torsemide tabs 100mg..........................................................69
tpn electrolytes inj 29.5meq/20ml; 4.5meq/20ml;
35meq/20ml; 5meq/20ml; 20meq/20ml; 35meq/20ml
119
TRACLEER TABS 62.5MG........................................... 109
TRACLEER TABS 125MG............................................ 109
TRADJENTA TABS 5MG..................................................54
tramadol hcl tabs 50mg.......................................................... 6
tramadol hydrochloride/acetaminophen tabs 325mg;
37.5mg........................................................................................ 6
176
Drug Name
Page Number
trandolapril tabs 1mg............................................................62
trandolapril tabs 2mg............................................................62
trandolapril tabs 4mg............................................................62
trandolapril/verapamil hcl er tbcr 1mg; 240mg.............62
trandolapril/verapamil hcl er tbcr 2mg; 180mg.............62
trandolapril/verapamil hcl er tbcr 2mg; 240mg.............62
trandolapril/verapamil hcl er tbcr 4mg; 240mg.............62
trandolapril/verapamil hcl tbcr 1mg; 240mg.................62
trandolapril/verapamil hcl tbcr 2mg; 180mg.................62
trandolapril/verapamil hcl tbcr 2mg; 240mg.................62
trandolapril/verapamil hcl tbcr 4mg; 240mg.................62
tranexamic acid inj 100mg/ml............................................57
tranexamic acid tabs 650mg...............................................57
TRANSDERM-SCOP PT72 1MG/3DAYS.....................27
tranylcypromine sulfate tabs 10mg...................................23
TRAVATAN Z SOLN 0.004%....................................... 102
travoprost soln 0.004%.....................................................102
trazodone hcl tabs 50mg......................................................25
trazodone hcl tabs 100mg...................................................25
trazodone hcl tabs 150mg...................................................25
trazodone hcl tabs 300mg...................................................25
TREANDA INJ 25MG.......................................................31
TREANDA INJ 45MG/0.5ML..........................................31
TREANDA INJ 100MG.....................................................31
TREANDA INJ 180MG/2ML...........................................31
TRECATOR TABS 250MG...............................................31
TRELSTAR MIXJECT INJ 3.75MG...................................96
TRELSTAR MIXJECT INJ 11.25MG.................................95
TRELSTAR MIXJECT INJ 22.5MG...................................95
tretinoin caps 10mg...............................................................40
tretinoin crea 0.1%.................................................................77
tretinoin crea 0.05%..............................................................77
tretinoin crea 0.025%............................................................77
tretinoin gel 0.01%.................................................................77
tretinoin gel 0.05%.................................................................77
tretinoin gel 0.025%..............................................................77
triadvance tabs 120mg; 2700unit; 200mg; 400unit;
2mg; 12mcg; 50mg; 1mg; 90mg; 30mg; 20mg; 20mg;
3.4mg; 3mg; 30unit; 25mg..............................................129
triamcinolone acetonide aero 55mcg/act.....................106
triamcinolone acetonide aers 0.147mg/gm....................86
triamcinolone acetonide crea 0.1%...................................86
triamcinolone acetonide crea 0.5%...................................86
triamcinolone acetonide crea 0.025%..............................86
triamcinolone acetonide lotn 0.1%....................................86
triamcinolone acetonide lotn 0.025%...............................86
triamcinolone acetonide oint 0.1%....................................86
Drug Name
Page Number
triamcinolone acetonide oint 0.5%....................................86
triamcinolone acetonide oint 0.025%...............................86
triamcinolone acetonide pste 0.1%....................................75
triamcinolone in orabase pste 0.1%..................................75
triamterene/hydrochlorothiazide caps 25mg; 37.5mg.70
triamterene/hydrochlorothiazide caps 25mg; 50mg....70
triamterene/hydrochlorothiazide tabs 25mg; 37.5mg.70
triamterene/hydrochlorothiazide tabs 50mg; 75mg....70
TRICARE PRENATAL COMPLEAT MISC 100MG;
200MG; 400UNIT; 2MG; 12MCG; 135MG; 33.8MG;
27MG; 0; 1MG; 20MG; 71.2MG; 3.1MG; 1.6MG;
1.6MG; 30UNIT; 10MG............................................... 129
TRICARE PRENATAL DHA ONE CAPS 60MG;
300MCG; 800UNIT; 2MG; 100MCG; 215MG; 25MG;
45MG; 27MG; 500MG; 1MG; 20MG; 25MG; 3.4MG;
3MG; 30UNIT; 10MG.................................................. 129
tricare tabs 100mg; 200mg; 2mg; 12mcg; 27mg; 1mg;
20mg; 3.1mg; 1.6mg; 1.6mg; 10mcg; 30unit; 10mg.129
triderm crea 0.1%...................................................................86
tri-estarylla tabs 0; 0..............................................................91
trifluoperazine hcl tabs 1mg.................................................43
trifluoperazine hcl tabs 2mg.................................................44
trifluoperazine hcl tabs 5mg.................................................44
trifluoperazine hcl tabs 10mg..............................................43
trifluridine soln 1%...............................................................103
trihexyphenidyl hcl elix 0.4mg/ml.......................................40
trihexyphenidyl hcl tabs 2mg...............................................40
trihexyphenidyl hcl tabs 5mg...............................................41
tri-legest fe tabs 0; 75mg; 1mg...........................................91
tri-linyah tabs 0; 0...................................................................91
trilyte solr 420gm; 1.48gm; 5.72gm; 11.2gm...............80
trimethoprim sulfate/polymyxin b sulfate soln
10000unit/ml; 0.1%...........................................................103
trimethoprim tabs 100mg....................................................10
trimipramine maleate caps 25mg......................................27
trimipramine maleate caps 50mg......................................27
trimipramine maleate caps 100mg...................................26
TRINATAL GT TABS 120MG; 2700UNIT; 30MCG;
200MG; 400UNIT; 2MG; 12MCG; 50MG; 1MG;
90MG; 30MG; 20MG; 6MG; 20MG; 3.4MG; 3MG;
10UNIT; 15MG............................................................. 129
trinatal rx 1 tabs 80mg; 400unit; 30mcg; 200mg;
400unit; 3mg; 2.5mcg; 60mg; 1mg; 100mg; 17mg;
7mg; 4mg; 1.6mg; 1.5mg; 15unit; 3600unit; 25mg.129
trinessa tabs 0; 0.....................................................................91
triple antibiotic oint 400unit/gm; 5mg/gm; 10000unit/
gm............................................................................................103
Drug Name
Page Number
triple-vitamin/fluoride soln 35mg/ml; 400unit/ml;
0.25mg/ml; 1500unit/ml..................................................130
tri-previfem tabs 0; 0.............................................................91
TRISENOX INJ 10MG/10ML..........................................36
tri-sprintec tabs 0; 0...............................................................91
TRISTART DHA CAPS 55MG; 1000UNIT; 14MCG;
200MG; 15MG; 400MCG; 31MG; 30MG; 600MCG;
5MG; 200MCG; 35MG; 1.8MG; 1.3MG; 15UNIT.. 130
TRIUMEQ TABS 600MG; 50MG; 300MG...................49
TRIVEEN-DUO DHA MISC 120MG; 3000UNIT;
200MG; 400UNIT; 2MG; 12MCG; 275MG; 0; 0;
1MG; 29MG; 0; 25MG; 20MG; 400MG; 25MG; 4MG;
1.8MG; 30MG; 25MG.................................................. 130
TRIVEEN-PRX RNF CAPS 28MG; 160MG; 400UNIT;
300MG; 55MG; 26MG; 1.2MG; 25MG; 30UNIT... 130
tri-vitamin/fluoride soln 35mg/ml; 0.5mg/ml; 1500unit/
ml; 400unit/ml......................................................................129
tri-vitamin/fluoride soln 35mg/ml; 0.25mg/ml;
1500unit/ml; 400unit/ml..................................................129
tri-vit/fluoride/iron soln 35mg/ml; 0.25mg/ml; 10mg/
ml; 1500unit/ml; 400unit/ml...........................................129
tri-vit/fluoride soln 35mg/ml; 400unit/ml; 0.5mg/ml;
1500unit/ml..........................................................................129
tri-vit/fluoride soln 35mg/ml; 400unit/ml; 0.25mg/ml;
1500unit/ml..........................................................................129
trivora-28 tabs 0; 0................................................................91
TRULICITY INJ 0.75MG/0.5ML.....................................54
TRULICITY INJ 1.5MG/0.5ML........................................54
TRUMENBA INJ 0.............................................................99
TRUVADA TABS 200MG; 300MG................................49
TWINRIX INJ 720ELU/ML; 20MCG/ML.......................99
TYBOST TABS 150MG....................................................50
TYGACIL INJ 50MG..........................................................10
TYKERB TABS 250MG....................................................39
TYPHIM VI INJ 25MCG/0.5ML......................................99
TYZEKA TABS 600MG....................................................47
TYZINE PEDIATRIC NASAL DROPS SOLN 0.05%.. 109
ultimatecare one nf caps 25mg; 300mcg; 100mg; 0; 0;
800unit; 350mg; 50mg; 100mg; 7mg; 1mg; 150mcg;
20mg; 50mg; 50mg; 10mg; 500mg; 50mg; 1.5mg;
15unit; 5mg...........................................................................130
unithroid tabs 25mcg............................................................94
unithroid tabs 50mcg............................................................94
unithroid tabs 75mcg............................................................94
unithroid tabs 88mcg............................................................94
unithroid tabs 100mcg..........................................................94
unithroid tabs 112mcg..........................................................94
177
Drug Name
Page Number
unithroid tabs 125mcg..........................................................94
unithroid tabs 137mcg..........................................................94
unithroid tabs 150mcg..........................................................94
unithroid tabs 175mcg..........................................................94
unithroid tabs 200mcg..........................................................94
unithroid tabs 300mcg..........................................................94
ursodiol caps 300mg.............................................................79
ursodiol tabs 250mg..............................................................79
ursodiol tabs 500mg..............................................................79
UVADEX INJ 20MCG/ML................................................36
VAGIFEM TABS 10MCG..................................................88
valacyclovir hcl tabs 500mg.................................................51
valacyclovir hcl tabs 1000mg..............................................51
VALCHLOR GEL 0.016%................................................32
VALCYTE SOLR 50MG/ML.............................................47
VALCYTE TABS 450MG..................................................47
valganciclovir tabs 450mg...................................................47
valproate sodium inj 500mg/5ml.......................................20
valproic acid caps 250mg.....................................................20
valproic acid syrp 250mg/5ml............................................20
valsartan/hydrochlorothiazide tabs 12.5mg; 80mg......60
valsartan/hydrochlorothiazide tabs 12.5mg; 160mg...60
valsartan/hydrochlorothiazide tabs 12.5mg; 320mg...60
valsartan/hydrochlorothiazide tabs 25mg; 160mg.......60
valsartan/hydrochlorothiazide tabs 25mg; 320mg.......60
valsartan tabs 40mg..............................................................60
valsartan tabs 80mg..............................................................60
valsartan tabs 160mg............................................................60
valsartan tabs 320mg............................................................60
VALSTAR INJ 40MG/ML.................................................36
vancomycin hcl caps 125mg...............................................10
vancomycin hcl caps 250mg...............................................10
vancomycin hcl in dextrose inj 0; 1gm/200ml................10
vancomycin hcl in dextrose inj 0; 500mg/100ml...........10
vancomycin hcl in dextrose inj 0; 750mg/150ml...........10
vancomycin hcl inj 10gm......................................................10
vancomycin hcl inj 500mg...................................................10
vancomycin hcl inj 750mg...................................................10
vancomycin hcl inj 1000mg.................................................10
vancomycin hcl inj 5000mg.................................................10
vandazole gel 0.75%..............................................................10
VANTAS INJ 50MG...........................................................96
VAQTA INJ 25UNIT/0.5ML.............................................99
VAQTA INJ 50UNIT/ML...................................................99
VARIVAX INJ 1350PFU/0.5ML......................................99
VASCEPA CAPS 1GM......................................................72
VASOSTRICT INJ 20UNIT/ML........................................86
178
Drug Name
Page Number
VECTIBIX INJ 100MG/5ML............................................37
VECTIBIX INJ 400MG/20ML..........................................37
VELCADE INJ 3.5MG.......................................................37
velivet tabs 0; 0........................................................................92
VELPHORO CHEW 500MG...........................................82
VEMAVITE-PRX 2 CAPS 28MG; 160MG; 400UNIT;
300MG; 55MG; 27MG; 1.25MG; 25MG; 30UNIT.130
VENA-BAL DHA MISC 120MG; 0; 2850UNIT;
219MG; 840UNIT; 2MG; 12MCG; 628MG; 1MG;
220MCG; 27MG; 25MG; 20MG; 430MG; 0; 50MG;
4MG; 0; 1.8MG; 3MG; 25MG.................................... 130
venlafaxine hcl er cp24 37.5mg..........................................25
venlafaxine hcl er cp24 75mg.............................................25
venlafaxine hcl er cp24 150mg...........................................25
venlafaxine hcl er tb24 37.5mg..........................................25
venlafaxine hcl er tb24 75mg..............................................25
venlafaxine hcl er tb24 150mg...........................................25
venlafaxine hcl er tb24 225mg...........................................25
venlafaxine hcl tabs 25mg....................................................25
venlafaxine hcl tabs 37.5mg................................................25
venlafaxine hcl tabs 50mg....................................................25
venlafaxine hcl tabs 75mg....................................................25
venlafaxine hcl tabs 100mg.................................................25
VENTOLIN HFA AERS 108MCG/ACT........................ 108
verapamil hcl er cp24 100mg.............................................68
verapamil hcl er cp24 120mg.............................................68
verapamil hcl er cp24 180mg.............................................68
verapamil hcl er cp24 200mg.............................................68
verapamil hcl er cp24 240mg.............................................68
verapamil hcl er cp24 300mg.............................................68
verapamil hcl er tbcr 120mg................................................68
verapamil hcl er tbcr 180mg................................................68
verapamil hcl er tbcr 240mg................................................68
verapamil hcl inj 2.5mg/ml...................................................68
verapamil hcl sr cp24 120mg.............................................68
verapamil hcl sr cp24 180mg.............................................68
verapamil hcl sr cp24 240mg.............................................68
verapamil hcl sr cp24 360mg.............................................68
verapamil hcl sr tbcr 240mg................................................68
verapamil hcl tabs 40mg.......................................................68
verapamil hcl tabs 80mg.......................................................68
verapamil hcl tabs 120mg....................................................68
VERSACLOZ SUSP 50MG/ML.......................................47
VESICARE TABS 5MG.....................................................81
VESICARE TABS 10MG...................................................81
vestura tabs 3mg; 0.02mg...................................................92
V-GO 20 KIT ................................................................. 102
Drug Name
Page Number
V-GO 30 KIT ................................................................. 102
V-GO 40 KIT ................................................................. 102
vicodin es tabs 300mg; 7.5mg.............................................. 6
vicodin tabs 300mg; 5mg....................................................... 6
VICTOZA INJ 18MG/3ML...............................................54
VIDEX PEDIATRIC SOLR 2GM.......................................49
VIDEX PEDIATRIC SOLR 4GM.......................................49
VIGAMOX SOLN 0.5%................................................. 103
VIIBRYD KIT 0...................................................................25
VIIBRYD STARTER PACK KIT 0.......................................25
VIIBRYD TABS 10MG......................................................25
VIIBRYD TABS 20MG......................................................25
VIIBRYD TABS 40MG......................................................25
VIMPAT INJ 200MG/20ML.............................................21
VIMPAT SOLN 10MG/ML...............................................21
VIMPAT TABS 50MG.......................................................21
VIMPAT TABS 100MG.....................................................21
VIMPAT TABS 150MG.....................................................21
VIMPAT TABS 200MG.....................................................21
vinblastine sulfate inj 1mg/ml..............................................37
vincasar pfs inj 1mg/ml.........................................................37
vincristine sulfate inj 1mg/ml...............................................37
vinorelbine tartrate inj 10mg/ml.........................................37
vinorelbine tartrate inj 50mg/5ml......................................37
viorele tabs 0; 0........................................................................92
VIRACEPT TABS 250MG................................................50
VIRACEPT TABS 625MG................................................50
VIRAMUNE SUSP 50MG/5ML......................................49
VIRAMUNE XR TB24 100MG........................................49
VIRAZOLE SOLR 6GM.....................................................51
VIREAD POWD 40MG/GM............................................49
VIREAD TABS 150MG.....................................................49
VIREAD TABS 200MG.....................................................49
VIREAD TABS 250MG.....................................................49
VIREAD TABS 300MG.....................................................49
VIRT-ADVANCE TABS 120MG; 2700UNIT; 200MG;
400UNIT; 2MG; 12MCG; 50MG; 1MG; 90MG; 30MG;
20MG; 20MG; 3.4MG; 3MG; 30UNIT; 25MG........ 130
VIRT-CARE ONE CAPS 25MG; 150MG; 0; 170UNIT;
260MG; 40MG; 7MG; 1MG; 20MG; 30MG; 30MG;
330MG; 25MG; 30UNIT............................................. 130
VIRT-C DHA CAPS 25MG; 300MCG; 5MG; 2MG;
12.5MCG; 156MG; 39MG; 53.5MG; 310MG; 1MG;
5MG; 1.8MG; 200MG; 38MG; 25MG; 3MG; 2MG;
10MG.............................................................................. 130
VIRT-PN DHA CAPS 85MG; 140MG; 200UNIT;
12MCG; 300MG; 27MG; 400MCG; 600MCG; 45MG;
Drug Name
Page Number
25MG; 10UNIT............................................................. 130
VIRT-PN PLUS CAPS 85MG; 250MCG; 140MG;
200UNIT; 12MCG; 300MG; 40MG; 28MG; 400MCG;
600MCG; 45MG; 340MG; 150MCG; 25MG; 10UNIT..
131
VIRT-PN TABS 80MG; 2500UNIT; 300MCG; 120MG;
6MG; 400UNIT; 2MG; 12MCG; 27MG; 400MCG;
600MCG; 30MG; 20MG; 150MCG; 20MG; 3.4MG;
3MG; 10UNIT; 15MG.................................................. 131
VIRT-SELECT CAPS 28MG; 160MG; 800UNIT;
325MG; 55MG; 29MG; 1.25MG; 25MG; 30UNIT.131
VITAFOL-ONE CAPS 30MG; 0; 1100UNIT; 1000UNIT;
2MG; 12MCG; 200MG; 1MG; 20MG; 15MG; 29MG;
150MCG; 2.5MG; 1.8MG; 1.6MG; 20UNIT; 25MG.131
VITAMEDMD ONE RX/QUATREFOLIC CAPS 60MG;
300MCG; 10MG; 400UNIT; 8MCG; 200MG; 30MG;
400MCG; 600MCG; 20MG; 25MG; 1.7MG; 1.5MG;
21UNIT; 7.5MG............................................................ 131
VITAMEDMD PLUS RX/QUATRE FOLIC MISC 60MG;
300MCG; 150MG; 10MG; 600UNIT; 2MG; 12MCG;
300MG; 400MCG; 30MG; 600MCG; 20MG;
150MCG; 25MG; 3.4MG; 3MG; 30UNIT; 15MG... 131
vitamins a/c/d/fluoride soln 35mg/ml; 400unit/ml;
0.25mg/ml; 1500unit/ml..................................................131
vitamins a/d/c/fluoride soln 35mg/ml; 0.25mg/ml;
1500unit/ml; 400unit/ml..................................................119
VITEKTA TABS 85MG......................................................48
VITEKTA TABS 150MG...................................................48
VOL-NATE TABS 120MG; 3000UNIT; 200MG;
400UNIT; 2MG; 12MCG; 28MG; 1MG; 25MG; 20MG;
25MG; 4MG; 1.8MG; 22MG; 25MG......................... 131
VOL-PLUS TABS 120MG; 0; 200MG; 400UNIT; 2MG;
12MCG; 27MG; 1MG; 20MG; 10MG; 3MG; 1.84MG;
22MG; 4000UNIT; 25MG........................................... 131
VOLTAREN GEL 1%........................................................... 2
voriconazole inj 200mg.........................................................29
voriconazole susr 40mg/ml..................................................29
voriconazole tabs 50mg........................................................29
voriconazole tabs 200mg.....................................................29
VOTRIENT TABS 200MG................................................39
VP-CH-PNV CAPS 104MG; 400UNIT; 260MG;
50MG; 0; 1MG; 30MG; 25MG; 30UNIT.................. 131
VP CH ULTRA CAPS 104MG; 400UNIT; 260MG;
50MG; 0; 1MG; 27MG; 0; 25MG; 30UNIT.............. 131
VP-HEME OB TABS 30MCG; 10MG; 400UNIT;
0.8MG; 12MCG; 10UNIT; 1MG; 6MG; 17MG; 28MG;
250MCG; 50MG; 1.6MG; 65MCG; 1.5MG; 4.5MG.132
179
Drug Name
Page Number
VP-PNV-DHA CAPS 80MG; 50MG; 400UNIT; 1MG;
12MCG; 200MG; 15.8MG; 28MG; 1MG; 30MG;
20MG; 16MG; 2.2MG; 6MG; 30UNIT; 2500UNIT;
20MG.............................................................................. 132
VPRIV INJ 400UNIT.........................................................78
vyfemla tabs 35mcg; 0.4mg................................................92
warfarin sodium tabs 1mg....................................................56
warfarin sodium tabs 2.5mg................................................56
warfarin sodium tabs 2mg....................................................56
warfarin sodium tabs 3mg....................................................56
warfarin sodium tabs 4mg....................................................56
warfarin sodium tabs 5mg....................................................56
warfarin sodium tabs 6mg....................................................56
warfarin sodium tabs 7.5mg................................................56
warfarin sodium tabs 10mg.................................................56
wera tabs 35mcg; 0.5mg......................................................92
wymzya fe chew 35mcg; 0; 0.4mg.....................................92
XALKORI CAPS 200MG..................................................39
XALKORI CAPS 250MG..................................................39
XARELTO STARTER PACK TBPK 0.................................56
XARELTO TABS 10MG....................................................56
XARELTO TABS 15MG....................................................56
XARELTO TABS 20MG....................................................56
XENAZINE TABS 12.5MG..............................................74
XENAZINE TABS 25MG..................................................74
XGEVA INJ 120MG/1.7ML.......................................... 101
XOLAIR INJ 150MG...................................................... 109
XTANDI CAPS 40MG......................................................32
XYREM SOLN 500MG/ML.......................................... 110
YERVOY INJ 50MG/10ML...............................................37
YERVOY INJ 200MG/40ML............................................37
YF-VAX INJ 0.....................................................................99
YONDELIS INJ 1MG.........................................................32
zafirlukast tabs 10mg..........................................................107
zafirlukast tabs 20mg..........................................................107
zaleplon caps 5mg...............................................................109
zaleplon caps 10mg............................................................109
ZALTRAP INJ 100MG/4ML............................................37
ZALTRAP INJ 200MG/8ML............................................37
zamicet soln 325mg/15ml; 10mg/15ml........................... 6
ZANOSAR INJ 1GM.........................................................37
zarah tabs 3mg; 0.03mg.......................................................92
ZATEAN-CH CAPS 100MG; 400UNIT; 250MG;
50MG; 1MG; 27MG; 25MG; 30UNIT....................... 132
ZATEAN-PN DHA CAPS 85MG; 140MG; 200UNIT;
12MCG; 300MG; 27MG; 400MCG; 600MCG; 45MG;
25MG; 10UNIT............................................................. 132
180
Drug Name
Page Number
ZATEAN-PN PLUS CAPS 85MG; 250MCG; 140MG;
200UNIT; 12MCG; 300MG; 40MG; 28MG; 400MCG;
600MCG; 45MG; 340MG; 150MCG; 25MG; 10UNIT..
132
ZATEAN-PN TABS 80MG; 2500UNIT; 300MCG;
120MG; 6MG; 400UNIT; 2MG; 12MCG; 27MG;
400MCG; 600MCG; 30MG; 20MG; 150MCG; 20MG;
3.4MG; 3MG; 10UNIT; 15MG.................................... 132
ZAVESCA CAPS 100MG.................................................78
zazole supp 80mg...................................................................29
zebutal caps 325mg; 50mg; 40mg...................................... 1
ZELBORAF TABS 240MG...............................................39
zenatane caps 10mg..............................................................77
zenatane caps 20mg..............................................................77
ZENATANE CAPS 30MG.................................................77
zenatane caps 40mg..............................................................77
zenchent fe chew 35mcg; 0; 0.4mg...................................92
zenchent tabs 35mcg; 0.4mg..............................................92
ZENPEP CPEP 16000UNIT; 3000UNIT; 10000UNIT...
78
ZENPEP CPEP 27000UNIT; 5000UNIT; 17000UNIT...
78
ZENPEP CPEP 55000UNIT; 10000UNIT; 34000UNIT.
78
ZENPEP CPEP 82000UNIT; 15000UNIT; 51000UNIT.
78
ZENPEP CPEP 109000UNIT; 20000UNIT;
68000UNIT.......................................................................78
ZENPEP CPEP 136000UNIT; 25000UNIT;
85000UNIT.......................................................................78
ZENPEP CPEP 218000UNIT; 40000UNIT;
136000UNIT....................................................................78
ZETIA TABS 10MG..........................................................72
ZIAGEN SOLN 20MG/ML..............................................49
zidovudine caps 100mg........................................................49
zidovudine syrp 50mg/5ml..................................................49
zidovudine tabs 300mg.........................................................49
ziprasidone hcl caps 20mg...................................................46
ziprasidone hcl caps 40mg...................................................46
ziprasidone hcl caps 60mg...................................................46
ziprasidone hcl caps 80mg...................................................46
ZIRGAN GEL 0.15%..................................................... 103
ZOLADEX INJ 3.6MG.......................................................96
ZOLADEX INJ 10.8MG....................................................96
zoledronic acid inj 4mg.......................................................101
zoledronic acid inj 4mg/5ml..............................................101
zoledronic acid inj 5mg/100ml........................................101
Drug Name
Page Number Drug Name
ZOLINZA CAPS 100MG.................................................37
zolpidem tartrate tabs 5mg...............................................109
zolpidem tartrate tabs 10mg............................................109
ZONALON CREA 5%......................................................77
zonisamide caps 25mg..........................................................18
zonisamide caps 50mg..........................................................18
zonisamide caps 100mg.......................................................18
ZORTRESS TABS 0.5MG.................................................97
ZORTRESS TABS 0.25MG..............................................97
ZORTRESS TABS 0.75MG..............................................97
ZOSTAVAX INJ 19400UNT/0.65ML.............................99
zovia 1/35e tabs 35mcg; 1mg............................................92
ZOVIA 1/50E TABS 50MCG; 1MG...............................92
ZYDELIG TABS 100MG...................................................37
ZYDELIG TABS 150MG...................................................37
ZYKADIA CAPS 150MG.................................................39
ZYPREXA RELPREVV INJ 210MG..................................46
ZYPREXA RELPREVV INJ 300MG..................................46
ZYPREXA RELPREVV INJ 405MG..................................46
ZYTIGA TABS 250MG.....................................................32
ZYVOX INJ 2MG/ML........................................................10
ZYVOX SUSR 100MG/5ML............................................10
Page Number
181
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182
Mercy Care Advantage (HMO SNP) Member Services
Call
602‑263‑3000 or 1‑800‑624‑3879
Calls to these numbers are free. 24 hours a day, 7 days a week.
Member Services also has free language interpreter services available for
non‑English speakers.
TTY
711
Calls to this number are free. 24 hours a day, 7 days a week.
Write
Mercy Care Advantage (HMO SNP)
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040
Website www.MercyCareAdvantage.com
This formulary was updated on 12/23/2015. For more recent information or other questions,
please contact Mercy Care Advantage (HMO SNP) Member Services at 602‑263‑3000 or
1‑800‑624‑3879 or, for TTY users, 711, 24 hours a day, 7 days a week, or visit
www.MercyCareAdvantage.com.
Mercy Care Advantage (HMO SNP)
Servicios al Miembro de Mercy Care Advantage (HMO SNP)
Llame 602‑263‑3000 ó 1‑800‑624‑3879
Las llamadas a estos números son gratis. 24 horas al día, 7 días de la semana.
Servicios al Miembro también tiene servicios gratuitos de interpretación de
idiomas disponibles para personas que no hablan inglés.
TTY
711
Las llamadas a este número son gratis. 24 horas al día, 7 días de la semana.
Escriba Mercy Care Advantage (HMO SNP)
4350 E. Cotton Center Blvd., Bldg. D
Phoenix, AZ 85040
Sitio Web www.MercyCareAdvantage.com
Este formulario fue actualizado en 12/23/2015. Para la información más reciente o para otras
preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al
602‑263‑3000 ó al 1‑800‑624‑3879, ó para los usuarios de TTY, al 711, 24 horas al día, 7
días de la semana, ó visite www.MercyCare Advantage.com.
2016 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary ID 00016462, Version 6
This formulary was updated on 12/23/2015. For more recent information or other questions, please contact
Mercy Care Advantage (HMO SNP) Member Services at 602‑263‑3000 or 1‑800‑624‑3879 or, for TTY users,
711, 24 hours a day, 7 days a week, or visit www.MercyCareAdvantage.com.
Mercy Care Advantage (HMO SNP)
Formulario de 2016 (Lista de medicamentos cubiertos)
POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE
CUBRIMOS EN ESTE PLAN
Identificación del Formulario 00016462, Versión 6
Este formulario fue actualizado en 12/23/2015. Para la información más reciente o para otras preguntas, por
favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602‑263‑3000 ó al 1‑800‑624‑3879,
ó para los usuarios de TTY, al 711, 24 horas al día, 7 días de la semana, ó visite www.MercyCareAdvantage.com.
AZ-15-12-21