Covered Drugs

Transcrição

Covered Drugs

Anthem MediBlue Plus (HMO)
2016 Formulary (List of Covered Drugs)
Please read: This document contains
information about the drugs we cover
in this plan.
This formulary was updated on August 1, 2016. For more recent information or other questions, please
contact Anthem MediBlue Plus (HMO) Customer Service at 1-888-346-0095 or, for TTY users, 711, 8 a.m.
to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14,
and Monday to Friday (except holidays) from February 15 through September 30, or visit www.anthem.com.
Y0114_16_24724_U_112 CMS Accepted 6/18/2016
54169MUSENMUB _112 H1394_003
Core_16293_CG6_v15_1609_1
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
Anthem Blue Cross and Blue Shield. When it refers to “plan” or “our
plan,” it means Anthem MediBlue Plus (HMO).
This document includes a list of the drugs (formulary) for our plan which
is current as of September 1, 2016. For an updated formulary, please
contact us. Our contact information, along with the date we last updated
the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug
benefit. Benefits, formulary, pharmacy network, and/or copayments/
coinsurance may change on January 1, 2017 and from time to time during
the year.
The Formulary, pharmacy network, and/or provider network may change
at any time. You will receive notice when necessary.
Effective Date September 1, 2016
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What is the Anthem MediBlue Plus
(HMO) formulary?
How do I use the formulary?
There are two ways to find your drug within the formulary:
A formulary is a list of covered drugs selected by our plan
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. Our plan
will generally cover the drugs listed in our formulary as long
as the drug is medically necessary, the prescription is filled
at a plan network pharmacy, and other plan rules are
followed. For more information on how to fill your
prescriptions, please review your Evidence of Coverage.
Medical Condition
The formulary begins on page 8. 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 Medications.” If you
know what your drug is used for, look for the category name
in the list that begins on page 8. Then look under the
category name for your drug.
Can the formulary (drug list) change?
Alphabetical Listing
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 forumulary 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 you are not sure what category to look under, you should
look for your drug in the Index that begins on page 60.
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?
Our plan 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.
If we remove drugs from our formulary, or add prior
authorization, quantity limits and/or step-therapy
restrictions on a drug or move a drug to a higher
cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective,
or at the time the member requests a refill of the drug, at
which time the member will receive a 60-day supply of the
drug. If the Food and Drug Administration (FDA) deems
a drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market, we will
immediately remove the drug from our formulary and
provide notice to members who take the drug. The enclosed
formulary is current as of September 1, 2016. To get
updated information about the drugs covered by our plan,
please contact us. Our contact information appears on the
front and back cover pages. If any other type of approved
formulary change (nonmaintenance change) is made during
the year, we will notify you by sending you a list of these
changes, or by sending you an updated formulary.
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: Our plan requires you or your
physician to get prior authorization for certain drugs. This
means that you will need to get approval from our plan
before you fill your prescriptions. If you don't get approval,
our plan may not cover the drug.
Quantity Limits: For certain drugs, our plan limits the
amount of the drug that our plan will cover. For example,
our plan provides 30 tablets per prescription for irbesartan
75mg tablets. This may be in addition to a standard
one-month or three-month supply.
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Step Therapy: In some cases, our plan requires you to first How do I request an exception to the
try certain drugs to treat your medical condition before we
will cover another drug for that condition. For example, if Anthem MediBlue Plus (HMO)'s
Drug A and Drug B both treat your medical condition, our formulary?
plan may not cover Drug B unless you try Drug A first. If You can ask our plan to make an exception to our coverage
rules. There are several types of exceptions that you can ask
Drug A does not work for you, our plan will then cover
us to make:
Drug B.
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
predetermined cost-sharing level, and you would not be
able to ask us to provide the drug at a lower cost-sharing
level.
You can find out if your drug has any additional
requirements or limits by looking in the formulary that
begins on page 8. You can also get more information about
the restrictions applied to specific covered drugs by visiting
our website. We have posted online documents that explain
our prior authorization and step therapy restrictions. You
may also ask us to send you a copy. Our contact
information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You can ask us to cover a formulary drug at a lower
cost-sharing level if this drug is not on the specialty tier.
If approved this would lower the amount you must pay for
your drug.
You can ask our plan to make an exception to these
restrictions or limits or for a list of other, similar drugs that
may treat your health condition. See the section, “How do
I request an exception to the Anthem MediBlue Plus
(HMO)'s formulary?” on page 4 for information about
how to request an exception.
You can ask us to waive coverage restrictions or limits
on your drug. For example, for certain drugs, our plan
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, our plan will only approve your request for an
exception if the alternative drugs included on the plan’s
If your drug is not included in this formulary (list of covered
formulary, the lower cost-sharing drug or additional
drugs), you should first contact Customer Service and ask
utilization restrictions would not be as effective in treating
if your drug is covered.
your condition and/or would cause you to have adverse
medical effects.
If you learn that our plan does not cover your drug, you
have two options:
You should contact us to ask us for an initial coverage
You can ask Customer Service for a list of similar drugs that decision for a formulary, tiering or utilization restriction
are covered by our plan. When you receive the list, show it exception. When you request a formulary, tiering or
to your doctor and ask him or her to prescribe a similar drug utilization restriction exception, you should submit a
statement from your prescriber or physician supporting
that is covered by our plan.
your request. Generally, we must make our decision within
You can ask our plan to make an exception and cover your 72 hours of getting your prescriber’s supporting statement.
You can request an expedited (fast) exception if you or your
drug. See below for information about how to request an
doctor believe that your health could be seriously harmed
exception.
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 if my drug is not on the formulary?
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What do I do before I can talk to my
doctor about changing my drugs or
requesting an exception?
For more information
For more detailed information about our plan prescription
drug coverage, please review your Evidence of Coverage and
other plan materials.
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.
If you have questions about our plan, 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.
Our plan’s formulary
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.
The formulary on page 8 provides coverage information
about some of the drugs covered by our plan. If you have
trouble finding your drug in the list, turn to the Index that
begins on page 60.
The first column of the chart lists the drug name.
Brand-name drugs are capitalized (e.g., CRESTOR) and
generic drugs are listed in lowercase italics (e.g., atenolol).
If you are a resident of a long-term-care facility, we will
allow you to refill your prescription until we have provided
you with a 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.
The information in the Requirements/Limits column tells
you if our plan has any special requirements for coverage of
your drug.
QLL - Quantity Limits: Restricts the frequency, amount
or dosage of medication for which you can obtain benefits
each time you get a prescription filled (most often set on a
monthly basis).
PAR - Prior Authorization: The process of obtaining
approval for certain prescriptions before benefits will be
approved. You, your doctor or other network provider will
During the time when you are getting a temporary supply need to request prior authorization before you fill the
of a drug, you should talk to your prescriber or prescribing prescription.
physician to decide what to do when your supply runs out.
ST - Step Therapy: The process of first trying a certain
You can call Customer Service to ask for a list of covered
drug or drugs to determine if that drug or those drugs will
drugs that treat the same medical condition. This list can
help your doctor find a covered drug that might work for treat your medical condition before your plan will cover
you while you pursue a formulary exception. Please refer to another drug for that condition.
the Evidence of Coverage for more information about
B/D - Part B vs. Part D: This drug may be covered under
exceptions.
either your Part D prescripton drug benefits or as a Part B
drug under your medical benefits, as determined by
Medicare.
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LA - Limited Access: This prescription may be available
only at certain pharmacies. For more information, consult
your Pharmacy Directory or call Customer Service at
1-888-346-0095, 8 a.m. to 8 p.m., seven days a week (except
Thanksgiving and Christmas) from October 1 through
February 14, and Monday to Friday (except holidays) from
February 15 through September 30. TTY/TDD users should
call 711.
INJ - Injectable: The drug is available in injectable form.
MO - Mail Orders: Prescription drugs available through
mail order.
CG – Coverage Gap: We provide additional coverage of
this prescription drug in the coverage gap. Please refer to
your Evidence of Coverage for more information about this
coverage.
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Cost-sharing for a one-month supply of a covered Part D prescription drug
during the Initial Coverage Stage:
Cost-Sharing Tier 1: Preferred Generic
Network Pharmacy with preferred cost-sharing (30-day supply)
or Mail-Order Pharmacy** (30-day supply)
$4.00
Network Pharmacy with standard cost-sharing (30-day supply)
or Long-Term-Care Pharmacy (34-day supply)
$9.00
Cost-Sharing Tier 2: Generic
$8.00
$13.00
Cost-Sharing Tier 3: Preferred Brand
$42.00
$47.00
Cost-Sharing Tier 4: Nonpreferred Brand
$95.00
$100.00
Cost-Sharing Tier 5: Specialty Tier*
33%
33%
Cost-Sharing Tier 6: Select Care Drugs
$0.00
$0.00
Please refer to our Evidence of Coverage for more information for cost sharing.
Network Pharmacy with preferred cost-sharing – A network pharmacy that offers covered drugs to members of our plan
that may have lower cost-sharing levels than other network pharmacies with standard cost-sharing.
* A long-term supply is not available for drugs in the Tier 5: Specialty Tier
** Mail-Order Pharmacy – Mail-order service allows you to order a 30–90-day supply of drugs. The drugs available through
our plan’s mail-order service are marked as “mail-order” drugs in our drug list.
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Covered Medications by Therapeutic Category
Legend
Generic drugs are shown in lower-case italics (e.g. atenolol)
Brand-name drugs are shown in capital letters (e.g. CRESTOR)
QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits
each time you get a prescription filled (most often set on a monthly basis).
PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved.
You, your doctor or other network provider will need to request prior authorization before you fill the prescription.
ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat
your medical condition before your plan will cover another drug for that condition.
B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B
drug under your medical benefits, as determined by Medicare.
LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your
Pharmacy Directory or call Customer Service 1-888-346-0095, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving
and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through
September 30 TTY/TDD users should call 711.
INJ - Injectable: The drug is available in injectable form.
MO - Mail Order: Prescription drugs available through mail order.
CG – Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your
Evidence of Coverage for more information about this coverage.
Drug Name
Anti - Infectives
abacavir
abacavir-lamivudinezidovudine
ABELCET
acyclovir oral capsule
acyclovir oral suspension 200
mg/5 ml
acyclovir oral tablet
acyclovir sodium intravenous
solution
adefovir
ALBENZA
ALINIA ORAL
SUSPENSION FOR
RECONSTITUTION
ALINIA ORAL TABLET
amantadine hcl oral capsule
amantadine hcl oral tablet
AMBISOME
amikacin injection solution 1,
000 mg/4 ml, 500 mg/2 ml
amoxicillin oral capsule
Drug Requirements/
Tier Limits
4
5
2
4
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
B/D PAR; MO
MO
MO
2
4
MO
B/D PAR; MO
5
4
4
MO
MO
MO; QLL (180 per
3 days)
4
3
3
5
4
MO
MO
MO
B/D PAR; MO
MO
1
MO
5
Drug Name
amoxicillin oral suspension for
reconstitution
amoxicillin oral tablet
amoxicillin oral tablet,chewable
125 mg, 250 mg
amoxicillin-pot clavulanate oral
suspension for reconstitution
200-28.5 mg/5 ml, 400-57
mg/5 ml, 600-42.9 mg/5 ml
250-62.5 mg/5 ml
tablet 250-125 mg
tablet 500-125 mg, 875-125
mg
tablet extended release 12 hr
tablet,chewable
amphotericin b
ampicillin oral capsule
Drug Requirements/
Tier Limits
1
MO
1
2
MO
MO
3
MO
4
MO
3
MO
2
MO
4
MO
3
MO
4
1
B/D PAR; MO
MO
You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page 8.
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8
Drug Name
ampicillin oral suspension for
reconstitution
ampicillin sodium injection
ampicillin sodium intravenous
ampicillin-sulbactam injection
recon soln 1.5 gram, 3 gram
ampicillin-sulbactam injection
recon soln 15 gram
ampicillin-sulbactam
intravenous recon soln 1.5 gram
ampicillin-sulbactam
intravenous recon soln 3 gram
APTIVUS ORAL CAPSULE
Drug Requirements/
Tier Limits
2
MO
4
4
4
MO
MO
4
4
4
MO
5
MO; QLL (120 per
30 days)
QLL (390 per 30
days)
PAR; MO
MO
MO; QLL (30 per
30 days)
MO
APTIVUS ORAL
SOLUTION
atovaquone
atovaquone-proguanil
ATRIPLA
5
azithromycin intravenous recon
soln 500 mg
azithromycin intravenous recon
soln 500 mg (2 mg/ml)
azithromycin oral packet
azithromycin oral suspension
for reconstitution 100 mg/5 ml
azithromycin oral suspension
azithromycin oral tablet
aztreonam
BARACLUDE ORAL
SOLUTION
BICILLIN C-R
BICILLIN L-A
CANCIDAS
CAPASTAT
CAYSTON
cefaclor oral capsule
cefaclor oral suspension for
reconstitution 125 mg/5 ml
cefaclor oral suspension for
reconstitution 250 mg/5 ml,
375 mg/5 ml
cefaclor oral tablet extended
release 12 hr
4
5
4
5
4
2
4
2
2
4
5
4
4
5
4
5
3
2
2
3
MO
MO
MO
MO
MO
PAR; MO
MO
MO
B/D PAR; MO
PAR; MO; LA
MO
MO
MO
Drug Name
cefadroxil oral capsule
cefadroxil oral suspension for
reconstitution 250 mg/5 ml,
500 mg/5 ml
cefadroxil oral tablet
cefazolin in dextrose (iso-os)
intravenous piggyback 1 gram/
50 ml, 2 gram/50 ml
cefazolin injection recon soln 1
gram, 500 mg
cefazolin injection recon soln
10 gram, 100 gram, 20 gram,
300 g
cefazolin intravenous
cefdinir oral capsule
cefdinir oral suspension for
reconstitution
cefepime
cefepime in dextrose,iso-osm
50 ml
cefepime in dextrose,iso-osm
100 ml
cefotaxime injection recon soln
1 gram, 2 gram, 500 mg
cefotaxime injection recon soln
10 gram
cefotetan
cefoxitin in dextrose, iso-osm
cefoxitin intravenous recon soln
1 gram
cefoxitin intravenous recon soln
10 gram, 2 gram
cefpodoxime oral suspension for
reconstitution
cefpodoxime oral tablet 100 mg
cefpodoxime oral tablet 200 mg
cefprozil oral suspension for
reconstitution
cefprozil oral tablet 250 mg
cefprozil oral tablet 500 mg
CEFTAZIDIME IN D5W
ceftazidime injection recon soln
1 gram, 2 gram
Drug Requirements/
Tier Limits
2
3
MO
MO
4
4
MO
MO
4
MO
4
4
2
4
MO
MO
4
4
MO
4
MO
4
4
MO
4
4
4
MO
4
4
MO
3
4
3
MO
MO
MO
2
3
4
4
MO
MO
MO
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9
Drug Name
ceftazidime injection recon soln
6 gram
ceftriaxone in dextrose,iso-os
ceftriaxone injection recon soln
1 gram, 2 gram, 250 mg, 500
mg
ceftriaxone injection recon soln
10 gram, 100 gram
ceftriaxone intravenous
cefuroxime axetil oral tablet
250 mg
cefuroxime axetil oral tablet
500 mg
cefuroxime sodium injection
recon soln 1.5 gram, 750 mg
cefuroxime sodium intravenous
vial
cephalexin oral capsule 250 mg,
500 mg
cephalexin oral suspension for
reconstitution
cephalexin oral tablet
chloramphenicol sod succinate
chloroquine phosphate oral
tablet 250 mg
chloroquine phosphate oral
tablet 500 mg
cidofovir
ciprofloxacin (mixture) oral
tablet, er multiphase 24 hr 1,
000 mg
ciprofloxacin (mixture) oral
tablet, er multiphase 24 hr 500
mg
ciprofloxacin hcl oral tablet
ciprofloxacin in 5 % dextrose
ciprofloxacin lactate
intravenous solution 200 mg/
20 ml
ciprofloxacin lactate
40 ml
ciprofloxacin oral suspension
clarithromycin oral suspension
Drug Requirements/
Tier Limits
4
4
4
MO
MO
4
4
1
MO
MO
2
MO
4
MO
4
1
MO
2
MO
1
4
4
MO
3
MO
MO
5
3
B/D PAR; MO
MO; QLL (14 per 2
days)
2
MO; QLL (3 per 2
days)
2
4
4
MO
MO
MO
4
4
2
MO
Drug Name
Drug Requirements/
Tier Limits
clarithromycin oral suspension
clarithromycin oral tablet
clarithromycin oral tablet
extended release 24 hr
clindamycin hcl oral capsule
clindamycin in 5 % dextrose
clindamycin phosphate injection
clindamycin phosphate
intravenous solution 300 mg/2
ml, 900 mg/6 ml
clindamycin phosphate
ml
clotrimazole mucous membrane
COARTEM
colistin (colistimethate na)
COMPLERA
4
MO
3
3
MO
MO; QLL (28 per 2
days)
MO
MO
MO
CRIXIVAN ORAL
CAPSULE 200 MG
CRIXIVAN ORAL
CAPSULE 400 MG
CUBICIN
DAKLINZA ORAL
TABLET 30 MG, 60 MG
DAKLINZA ORAL
TABLET 90 MG
DAPSONE
DARAPRIM
demeclocycline
DESCOVY
4
dicloxacillin
didanosine oral capsule,delayed
release(dr/ec) 125 mg
DIFICID
DORIBAX
DOXY-100
doxycycline hyclate intravenous
2
3
2
4
4
4
4
MO
3
4
4
5
MO
MO
MO
MO; QLL (30 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
MO
PAR; MO; QLL (30
per 30 days)
PAR; QLL (30 per
30 days)
MO
MO
MO
QLL (30 per 30
days)
MO
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
PAR; MO
4
5
5
5
3
3
4
5
4
3
4
5
4
4
4
MO
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10
Drug Name
Drug Requirements/
Tier Limits
doxycycline hyclate oral capsule
doxycycline hyclate oral tablet
100 mg, 50 mg
doxycycline hyclate oral tablet
20 mg
doxycycline monohydrate oral
tablet 100 mg
doxycycline monohydrate oral
tablet 150 mg, 50 mg, 75 mg
e.e.s. 400 oral tablet
EDURANT
4
4
EMTRIVA ORAL CAPSULE
4
EMTRIVA ORAL
SOLUTION
entecavir
EPIVIR HBV ORAL
SOLUTION
EPIVIR ORAL SOLUTION
4
EPZICOM
5
ery-tab oral tablet,delayed
release (dr/ec) 250 mg, 333 mg
erythrocin (as stearate) oral
tablet 250 mg
ERYTHROCIN
INTRAVENOUS RECON
SOLN 500 MG
erythromycin ethylsuccinate oral
tablet
erythromycin oral capsule,
delayed release(dr/ec)
erythromycin oral tablet
ethambutol
EVOTAZ
3
MO; QLL (960 per
30 days)
MO; QLL (30 per
30 days)
MO
3
MO
famciclovir oral tablet 125 mg,
250 mg
famciclovir oral tablet 500 mg
3
fluconazole in dextrose(iso-o)
FLUCONAZOLE IN NACL
(ISO-OSM)
INTRAVENOUS
4
4
MO
MO
3
MO
2
MO
4
MO
3
5
5
3
4
MO
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (870 per
30 days)
PAR; MO
MO
4
3
MO
2
MO
4
4
5
MO
MO
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (21 per 7
days)
4
Drug Name
PIGGYBACK 100 MG/50
ML
fluconazole in nacl (iso-osm)
intravenous piggyback 200 mg/
100 ml
fluconazole in nacl (iso-osm)
200 ml
fluconazole oral suspension for
reconstitution 10 mg/ml
fluconazole oral suspension for
reconstitution 40 mg/ml
fluconazole oral tablet 100 mg
fluconazole oral tablet 150 mg,
50 mg
fluconazole oral tablet 200 mg
flucytosine
foscarnet
FUZEON
SUBCUTANEOUS RECON
SOLN
ganciclovir sodium
gentamicin in nacl (iso-osm)
100 ml, 60 mg/50 ml
GENTAMICIN IN NACL
(ISO-OSM)
INTRAVENOUS
PIGGYBACK 100 MG/50
ML, 120 MG/100 ML
gentamicin in nacl (iso-osm)
50 ml, 80 mg/100 ml, 80 mg/
50 ml, 90 mg/100 ml
gentamicin injection
gentamicin sulfate (ped) (pf)
gentamicin sulfate (pf)
10 ml
gentamicin sulfate (pf)
ml, 80 mg/8 ml
GENVOYA
Drug Requirements/
Tier Limits
4
MO
4
3
MO
4
MO
3
2
MO
MO
4
5
3
5
MO
MO
B/D PAR
MO; QLL (60 per
30 days)
4
4
MO
MO
4
4
4
4
4
MO
MO
MO
4
5
MO; QLL (30 per
30 days)
Core_16293_CG6_v15_1609_1
11
Drug Name
GRIS-PEG
(ULTRAMICROSIZE)
ORAL TABLET 250 MG
griseofulvin microsize oral
suspension
griseofulvin ultramicrosize
HARVONI
Drug Requirements/
Tier Limits
4
4
4
5
MO
hydroxychloroquine oral
imipenem-cilastatin
intravenous recon soln 250 mg
imipenem-cilastatin
intravenous recon soln 500 mg
INTELENCE ORAL
TABLET 100 MG
INTELENCE ORAL
TABLET 200 MG
INTELENCE ORAL
TABLET 25 MG
INVANZ 1 GM ADDVANTAGE VIAL
INVIRASE ORAL
CAPSULE
INVIRASE ORAL TABLET
2
3
4
MO
ISENTRESS ORAL
POWDER IN PACKET
ISENTRESS ORAL
TABLET
ISENTRESS ORAL
TABLET,CHEWABLE 100
MG
ISENTRESS ORAL
TABLET,CHEWABLE 25
MG
isoniazid injection
isoniazid oral solution
isoniazid oral tablet 100 mg
isoniazid oral tablet 300 mg
itraconazole
ivermectin oral
KALETRA ORAL
SOLUTION
KALETRA ORAL TABLET
100-25 MG
4
5
4
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (480 per
30 days)
4
5
5
5
5
3
4
4
1
2
4
3
4
5
Drug Requirements/
Tier Limits
KALETRA ORAL TABLET
200-50 MG
KETEK
5
ketoconazole oral
LAMISIL ORAL TABLET
3
4
lamivudine oral solution
4
lamivudine oral tablet 100 mg
4
4
4
lamivudine-zidovudine
5
levofloxacin in d5w intravenous
piggyback 250 mg/50 ml
levofloxacin in d5w intravenous
piggyback 500 mg/100 ml, 750
mg/150 ml
levofloxacin oral tablet
4
LEXIVA ORAL
SUSPENSION
LEXIVA ORAL TABLET
4
LINCOCIN
lincomycin injection
linezolid intravenous
linezolid oral suspension for
reconstitution
linezolid oral tablet
4
4
5
5
linezolid-0.9% sodium chloride
MALARONE
mefloquine
meropenem
methenamine hippurate
methenamine mandelate
metro i.v.
metronidazole in nacl (iso-os)
metronidazole oral capsule
metronidazole oral tablet
minocycline oral capsule 100
mg, 50 mg
5
4
3
4
4
2
4
4
4
2
2
3
MO
MO
PAR; MO; QLL (28
per 28 days)
MO
MO
5
Drug Name
MO; QLL (300 per
30 days)
MO; QLL (120 per
30 days)
MO
MO; QLL (120 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (720 per
30 days)
MO
MO
MO
PAR; MO
MO
MO; QLL (480 per
30 days)
MO; QLL (300 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (20 per 2
days)
MO
MO; QLL (30 per
30 days)
MO; QLL (900 per
30 days)
MO
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
4
MO
2
MO; QLL (14 per 2
days)
MO; QLL (1800 per
30 days)
MO; QLL (120 per
30 days)
MO
5
5
PAR; MO; QLL
(1800 per 2 days)
PAR; MO; QLL (28
per 2 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Core_16293_CG6_v15_1609_1
12
Drug Name
Drug Requirements/
Tier Limits
minocycline oral capsule 75 mg
minocycline oral tablet
moxifloxacin
3
4
3
MYCAMINE
nafcillin in dextrose iso-osm
50 ml
nafcillin in dextrose iso-osm
100 ml
nafcillin injection
nafcillin intravenous recon soln
1 gram
NAFCILLIN
INTRAVENOUS RECON
SOLN 2 GRAM
NEBUPENT
neomycin
nevirapine oral suspension
5
4
nevirapine oral tablet
3
nevirapine oral tablet extended
release 24 hr 100 mg
nevirapine oral tablet extended
nitrofurantoin macrocrystal oral
capsule 100 mg, 50 mg
nitrofurantoin monohyd/mcryst
NORVIR ORAL CAPSULE
4
4
5
5
5
3
2
4
4
4
4
4
NORVIR ORAL
SOLUTION
NORVIR ORAL TABLET
4
NOXAFIL ORAL
SUSPENSION
nystatin oral suspension
nystatin oral tablet
ODEFSEY
5
ofloxacin oral tablet 400 mg
OLYSIO
3
5
3
2
2
5
Drug Name
oxacillin in dextrose(iso-osm)
50 ml
oxacillin in dextrose(iso-osm)
50 ml
oxacillin injection
oxacillin intravenous
paromomycin
MO
PASER
PENICILLIN G POT IN
MO
DEXTROSE
penicillin g potassium
MO
penicillin g procaine
intramuscular syringe 1.2
MO
million unit/2 ml
penicillin g procaine
intramuscular syringe 600,000
B/D PAR; MO
unit/ml
MO
MO; QLL (1200 per penicillin g sodium
penicillin v potassium oral
30 days)
recon soln
MO; QLL (60 per
30 days)
tablet 250 mg
MO
tablet 500 mg
MO; QLL (30 per
30 days)
PENTAM
pfizerpen-g
PAR; MO
piperacillin-tazobactam
PAR; MO
polymyxin b sulfate
PREZCOBIX
MO; QLL (360 per
30 days)
PREZISTA ORAL
MO; QLL (480 per SUSPENSION
30 days)
PREZISTA ORAL TABLET
MO; QLL (360 per 150 MG
30 days)
PAR; MO; QLL
600 MG, 800 MG
(630 per 30 days)
MO
75 MG
MO
PRIFTIN
QLL (30 per 30
PRIMAQUINE
days)
pyrazinamide
MO
RELENZA DISKHALER
PAR; MO
MO
MO
MO; QLL (21 per 2
days)
MO
Drug Requirements/
Tier Limits
4
5
MO
5
5
4
4
4
MO
5
4
MO
MO
MO
MO
4
4
1
MO
MO
1
MO
2
MO
4
4
4
4
5
MO
5
4
5
4
4
3
4
3
MO
MO
MO; QLL (30 per
30 days)
MO; QLL (420 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (300 per
30 days)
MO
MO
MO
MO; QLL (60 per
180 days)
Core_16293_CG6_v15_1609_1
13
Drug Name
Drug Requirements/
Tier Limits
RESCRIPTOR ORAL
TABLET
RESCRIPTOR ORAL
TABLET, DISPERSIBLE
RETROVIR
INTRAVENOUS
REYATAZ ORAL CAPSULE
150 MG, 200 MG
REYATAZ ORAL CAPSULE
300 MG
REYATAZ ORAL POWDER
IN PACKET
ribasphere oral capsule
ribasphere oral tablet 200 mg
ribavirin oral capsule
ribavirin oral tablet 200 mg
rifabutin
rifampin
RIFATER
rimantadine
SELZENTRY
4
SIRTURO
SOVALDI
stavudine oral capsule 15 mg
5
5
3
4
3
4
4
5
5
4
4
4
4
3
4
4
4
4
5
4
stavudine oral recon soln
3
STREPTOMYCIN
INTRAMUSCULAR
STRIBILD
STROMECTOL
sulfadiazine oral
sulfamethoxazole-trimethoprim
intravenous
oral suspension
oral tablet
4
5
Drug Name
Drug Requirements/
Tier Limits
MO; QLL (180 per
30 days)
MO; QLL (360 per
30 days)
MO
SUSTIVA ORAL CAPSULE
200 MG
SUSTIVA ORAL CAPSULE
50 MG
SUSTIVA ORAL TABLET
4
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (240 per
30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO; QLL (120 per
30 days)
PAR; MO; LA
PAR; MO
MO; QLL (120 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (2400 per
30 days)
MO
SYNAGIS
SYNERCID
TAMIFLU
TECHNIVIE
5
5
3
5
TEFLARO INTRAVENOUS
RECON SOLN 400 MG
TEFLARO INTRAVENOUS
RECON SOLN 600 MG
terbinafine hcl oral
4
MO
PAR; MO; QLL (56
per 28 days)
MO
5
MO
2
tetracycline
tinidazole oral tablet 250 mg
tinidazole oral tablet 500 mg
TIVICAY ORAL TABLET
10 MG
TIVICAY ORAL TABLET
25 MG
TIVICAY ORAL TABLET
50 MG
tobramycin in 0.225 % nacl
4
2
4
4
MO; QLL (30 per
30 days)
MO
MO
MO
QLL (60 per 30
days)
QLL (60 per 30
days)
MO; QLL (60 per
30 days)
B/D PAR; MO;
QLL (280 per 28
days)
tobramycin sulfate injection
recon soln
tobramycin sulfate injection
solution
TRECATOR
trimethoprim
TRIUMEQ
4
TRUVADA ORAL TABLET
100-150 MG, 133-200 MG,
167-250 MG
TRUVADA ORAL TABLET
200-300 MG
TYBOST
5
TYGACIL
TYZEKA
5
5
3
4
4
MO; QLL (30 per
30 days)
MO
MO
MO
2
MO
1
MO
4
5
5
5
5
MO; QLL (120 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (30 per
30 days)
PAR; MO; LA
4
MO
4
2
5
MO
MO
MO; QLL (30 per
30 days)
QLL (30 per 30
days)
5
3
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO
PAR; MO
Core_16293_CG6_v15_1609_1
14
Drug Name
Drug Requirements/
Tier Limits
valacyclovir
3
valganciclovir
VANCOMYCIN IN 0.9%
SODIUM CL
INTRAVENOUS
PIGGYBACK 500 MG/100
ML, 750 MG/150 ML
VANCOMYCIN IN
DEXTROSE 5 %
INTRAVENOUS
PIGGYBACK 1 GRAM/200
ML
VANCOMYCIN IN
DEXTROSE 5 %
INTRAVENOUS
PIGGYBACK 500 MG/100
ML, 750 MG/150 ML
vancomycin intravenous
vancomycin oral capsule 125
mg
vancomycin oral capsule 250
mg
VIDEX 2 GRAM
PEDIATRIC
VIDEX 4 GRAM
PEDIATRIC
VIEKIRA PAK
VIRACEPT ORAL TABLET
250 MG
VIRACEPT ORAL TABLET
625 MG
VIRAMUNE XR ORAL
TABLET EXTENDED
RELEASE 24 HR 100 MG
VIRAZOLE
VIREAD ORAL POWDER
5
4
VIREAD ORAL TABLET
150 MG, 250 MG, 300 MG
VIREAD ORAL TABLET
200 MG
VITEKTA
5
voriconazole intravenous
4
4
MO; QLL (30 per 2
days)
MO
MO
Drug Name
Drug Requirements/
Tier Limits
voriconazole oral suspension for
reconstitution
voriconazole oral tablet 200 mg
5
voriconazole oral tablet 50 mg
5
ZEPATIER
5
ZIAGEN ORAL
SOLUTION
zidovudine oral capsule
4
zidovudine oral syrup
3
zidovudine oral tablet
3
5
4
4
4
5
5
4
4
5
5
5
4
5
5
4
5
PAR; MO; QLL
(300 per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (30
per 30 days)
MO; QLL (960 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (1920 per
30 days)
MO; QLL (60 per
30 days)
MO
ZITHROMAX ORAL
4
PACKET
MO
ZITHROMAX ORAL
4 MO
PAR; MO; QLL (40 TABLET 250 MG
per 2 days)
ZITHROMAX Z-PAK
4 MO
PAR; MO; QLL (80 ZMAX
3 MO
per 2 days)
ZYVOX INTRAVENOUS
5
MO; QLL (1200 per PARENTERAL SOLUTION
30 days)
200 MG/100 ML
MO; QLL (1200 per ZYVOX INTRAVENOUS
5 MO
30 days)
PARENTERAL SOLUTION
PAR; MO
600 MG/300 ML
MO; QLL (300 per ZYVOX ORAL
5 PAR; MO; QLL
30 days)
SUSPENSION FOR
(1800 per 2 days)
MO; QLL (120 per RECONSTITUTION
30 days)
Antineoplastic / Immunosuppressant Drugs
MO
ABRAXANE
5 MO
adrucil intravenous solution 2.5 4
gram/50 ml
PAR; MO
adrucil intravenous solution 5
4 MO
MO; QLL (240 per gram/100 ml, 500 mg/10 ml
30 days)
AFINITOR
5 PAR; MO
MO; QLL (30 per
AFINITOR DISPERZ
5 PAR; MO
30 days)
ALECENSA
5 MO
MO; QLL (30 per
ALIMTA
5 PAR; MO
30 days)
ALKERAN ORAL
4 B/D PAR; MO
MO; QLL (30 per
amifostine crystalline
5 PAR; MO
30 days)
anastrozole
3 MO; QLL (30 per
MO
30 days)
ARRANON
4
Core_16293_CG6_v15_1609_1
15
Drug Name
ARZERRA
AVASTIN
azacitidine
azathioprine
azathioprine sodium
BELEODAQ
BENDEKA
bexarotene
bicalutamide
BICNU
bleomycin
BLINCYTO
BOSULIF ORAL TABLET
100 MG
BOSULIF ORAL TABLET
500 MG
BUSULFEX
CABOMETYX ORAL
TABLET 20 MG
CABOMETYX ORAL
TABLET 40 MG, 60 MG
CAPRELSA ORAL TABLET
100 MG
CAPRELSA ORAL TABLET
300 MG
carboplatin intravenous
solution
CELLCEPT
INTRAVENOUS
cisplatin
cladribine
CLOLAR
COMETRIQ ORAL
CAPSULE 100 MG/DAY(80
MG X1-20 MG X1)
COMETRIQ ORAL
MG X1-20 MG X3)
COMETRIQ ORAL
CAPSULE 60 MG/DAY (20
MG X 3/DAY)
COSMEGEN
COTELLIC
cyclophosphamide oral capsule
cyclosporine intravenous
Drug Requirements/
Tier Limits
5
5
5
2
4
5
5
5
3
4
4
5
5
5
4
5
5
5
5
4
4
4
5
5
5
5
5
5
5
4
4
Drug Name
cyclosporine modified
cyclosporine oral capsule
CYRAMZA
cytarabine
cytarabine (pf) injection
solution 100 mg/5 ml (20 mg/
ml), 2 gram/20 ml (100 mg/
ml)
cytarabine (pf) injection
solution 20 mg/ml
dacarbazine
DARZALEX
daunorubicin intravenous
solution
decitabine
dexrazoxane hcl intravenous
recon soln 250 mg
PAR; LA; QLL (90 dexrazoxane hcl intravenous
recon soln 500 mg
per 30 days)
PAR; LA; QLL (30 DOCEFREZ
INTRAVENOUS RECON
per 30 days)
PAR; MO; LA; QLL SOLN 20 MG
DOCETAXEL
(90 per 30 days)
PAR; MO; LA; QLL INTRAVENOUS
SOLUTION 10 MG/ML
(30 per 30 days)
docetaxel intravenous solution
MO
160 mg/16 ml (10 mg/ml), 160
mg/8 ml (20 mg/ml), 20 mg/2
B/D PAR; MO
ml (10 mg/ml)
docetaxel intravenous solution
MO
20 mg/ml (1 ml), 80 mg/4 ml
MO
(20 mg/ml), 80 mg/8 ml (10
MO
PAR; MO; QLL (56 mg/ml)
doxorubicin intravenous recon
per 28 days)
soln
doxorubicin intravenous
PAR; MO; QLL
solution
(112 per 28 days)
ELITEK
PAR; MO; QLL (84 EMCYT
EMPLICITI
per 28 days)
ENVARSUS XR
epirubicin intravenous solution
MO
PAR; MO; LA; QLL 200 mg/100 ml
epirubicin intravenous solution
(90 per 30 days)
50 mg/25 ml
B/D PAR; MO
ERBITUX
B/D PAR
PAR; MO
PAR; MO
PAR; MO
B/D PAR; MO
B/D PAR
PAR; MO
MO
PAR; MO
MO
MO
MO
PAR; MO
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (30
per 30 days)
Drug Requirements/
Tier Limits
4
4
5
4
4
B/D PAR; MO
B/D PAR; MO
PAR; MO
MO
MO
4
4
5
4
MO
MO; LA
5
5
MO
5
MO
5
5
5
5
MO
4
4
MO
5
5
5
4
4
PAR; MO
MO
B/D PAR; MO
B/D PAR; MO
4
MO
5
PAR; MO
Core_16293_CG6_v15_1609_1
16
Drug Name
Drug Requirements/
Tier Limits
ERIVEDGE
5
ERWINAZE
ETOPOPHOS
etoposide intravenous
EVOMELA
exemestane
5
5
3
5
4
FARESTON
5
FARYDAK ORAL
CAPSULE 10 MG
FARYDAK ORAL
CAPSULE 15 MG, 20 MG
FASLODEX
FIRMAGON KIT W
DILUENT SYRINGE
SUBCUTANEOUS RECON
SOLN 120 MG
FIRMAGON KIT W
DILUENT SYRINGE
SUBCUTANEOUS RECON
SOLN 80 MG
fludarabine intravenous recon
soln
fludarabine intravenous
solution
fluorouracil intravenous
flutamide
FOLOTYN
FUSILEV
GAZYVA
gemcitabine intravenous recon
soln 1 gram, 200 mg
gemcitabine intravenous recon
soln 2 gram
gemcitabine intravenous
solution 1 gram/26.3 ml (38
mg/ml), 200 mg/5.26 ml (38
mg/ml)
gemcitabine intravenous
solution 2 gram/52.6 ml (38
mg/ml)
gengraf oral capsule 100 mg,
25 mg
gengraf oral capsule 50 mg
5
5
5
5
PAR; MO; QLL (30
per 30 days)
PAR; MO
MO
MO
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL (30
per 30 days)
PAR; MO
PAR; MO
4
PAR; MO
4
MO
4
4
4
5
5
5
5
MO
MO
MO
MO
PAR; MO
MO
5
5
MO
5
4
B/D PAR; MO
4
B/D PAR
Drug Name
Drug Requirements/
Tier Limits
gengraf oral solution
GILOTRIF
4
5
GLEEVEC ORAL TABLET
100 MG
GLEEVEC ORAL TABLET
400 MG
GLEOSTINE
HALAVEN
HERCEPTIN
HEXALEN
hydroxyurea
IBRANCE
5
ICLUSIG ORAL TABLET
15 MG
ICLUSIG ORAL TABLET
45 MG
idarubicin
IFEX
ifosfamide intravenous recon
soln
ifosfamide intravenous solution
imatinib oral tablet 100 mg
5
imatinib oral tablet 400 mg
5
IMBRUVICA
5
INLYTA ORAL TABLET 1
MG
INLYTA ORAL TABLET 5
MG
IRESSA
irinotecan intravenous solution
100 mg/5 ml, 40 mg/2 ml
irinotecan intravenous solution
500 mg/25 ml
ISTODAX
IXEMPRA
JAKAFI ORAL TABLET 10
MG
MG
MG
5
5
4
5
5
5
2
5
5
5
4
4
4
5
5
5
4
B/D PAR; MO
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL (60
per 30 days)
MO
PAR; MO
PAR; MO
MO
MO
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL (30
per 30 days)
MO
MO
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL
(120 per 30 days)
MO
MO
4
5
5
5
5
5
PAR; MO
MO
PAR; MO; QLL
(150 per 30 days)
PAR; MO; QLL
(100 per 30 days)
PAR; MO; QLL (75
per 30 days)
Core_16293_CG6_v15_1609_1
17
Drug Name
Drug Requirements/
Tier Limits
MG
MG
JEVTANA
KADCYLA
KEYTRUDA
LENVIMA ORAL
MG X 1/DAY)
LENVIMA ORAL
MG X 1-4 MG X 1), 20 MG/
DAY (10 MG X 2)
LENVIMA ORAL
MG X 1-4 MG X2)
LENVIMA ORAL
MG X 2-4 MG X 1)
LENVIMA ORAL
CAPSULE 8 MG/DAY (4
MG X 2), 8 MG/DAY (4
MG X 2) (60 PACK)
letrozole
5
leucovorin calcium injection
recon soln 100 mg, 200 mg,
350 mg, 50 mg
leucovorin calcium injection
recon soln 500 mg
leucovorin calcium oral tablet
10 mg, 25 mg
leucovorin calcium oral tablet
15 mg, 5 mg
LEUKERAN
leuprolide subcutaneous kit
LONSURF
LUPRON DEPOT
INTRAMUSCULAR
SYRINGE KIT 3.75 MG
LUPRON DEPOT
INTRAMUSCULAR
SYRINGE KIT 7.5 MG
4
5
5
5
5
5
5
5
5
5
3
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL
(300 per 30 days)
MO
PAR; MO
PAR; MO
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; QLL (90 per
30 days)
PAR; MO; QLL (90
per 30 days)
PAR; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO
4
4
MO
2
MO
4
4
5
5
MO
PAR; MO
PAR; MO
PAR; MO; QLL (1
per 28 days)
5
Drug Name
Drug Requirements/
Tier Limits
LUPRON DEPOT-PED
INTRAMUSCULAR KIT
7.5 MG (PED)
LYNPARZA
5
PAR; MO; QLL (1
per 28 days)
5
LYSODREN
MATULANE
megestrol oral suspension 400
mg/10 ml (10 ml), 800 mg/20
ml (20 ml)
megestrol oral suspension 400
mg/10 ml (40 mg/ml)
megestrol oral tablet
MEKINIST ORAL TABLET
0.5 MG
MEKINIST ORAL TABLET
2 MG
melphalan hcl
mercaptopurine
mesna
MESNEX ORAL
methotrexate sodium (pf)
injection recon soln
methotrexate sodium (pf)
injection solution
methotrexate sodium injection
methotrexate sodium oral
mitomycin
mitoxantrone
MUSTARGEN
mycophenolate mofetil oral
capsule
tablet
NEXAVAR
3
5
4
PAR; MO; QLL
(480 per 30 days)
MO
MO
PAR
4
PAR; MO
3
5
PAR; MO
PAR; QLL (90 per
30 days)
PAR; QLL (30 per
30 days)
NILANDRON
5
NINLARO
5
NIPENT
NULOJIX
5
5
5
3
3
4
5
4
MO
MO
MO
4
MO
4
2
5
3
4
3
MO
MO
MO
MO
MO
B/D PAR; MO
5
B/D PAR; MO
3
B/D PAR; MO
5
PAR; MO; LA; QLL
(120 per 30 days)
MO; QLL (30 per
30 days)
PAR; MO; QLL (3
per 28 days)
MO
PAR; MO
PAR; MO
Core_16293_CG6_v15_1609_1
18
Drug Name
Drug Requirements/
Tier Limits
octreotide acetate injection
solution 1,000 mcg/ml, 500
mcg/ml
solution 100 mcg/ml, 200 mcg/
ml, 50 mcg/ml
syringe 100 mcg/ml (1 ml), 50
mcg/ml (1 ml)
syringe 500 mcg/ml (1 ml)
ODOMZO
5
ONCASPAR
OPDIVO
oxaliplatin intravenous recon
soln 100 mg
oxaliplatin intravenous recon
soln 50 mg
oxaliplatin intravenous solution
paclitaxel
PERJETA
POMALYST ORAL
CAPSULE 1 MG
POMALYST ORAL
CAPSULE 2 MG
POMALYST ORAL
CAPSULE 3 MG, 4 MG
PORTRAZZA
PROGRAF
INTRAVENOUS
PURIXAN
RAPAMUNE ORAL
SOLUTION
REVLIMID ORAL
CAPSULE 10 MG
REVLIMID ORAL
CAPSULE 15 MG, 2.5 MG,
20 MG, 25 MG
REVLIMID ORAL
CAPSULE 5 MG
RITUXAN
SANDOSTATIN LAR
DEPOT
INTRAMUSCULAR
5
5
5
4
4
5
5
5
5
4
5
5
5
5
5
4
5
5
5
5
5
5
5
Drug Name
SUSPENSION,EXTENDED
REL RECON
SIGNIFOR
PAR; MO
SIMULECT
INTRAVENOUS RECON
SOLN 10 MG
PAR; MO
SIMULECT
INTRAVENOUS RECON
SOLN 20 MG
PAR; MO
sirolimus
SOLTAMOX
PAR; MO; LA; QLL SOMATULINE DEPOT
(30 per 30 days)
SPRYCEL
PAR; MO
PAR; MO
STIVARGA
MO
SUTENT ORAL CAPSULE
12.5 MG
SUTENT ORAL CAPSULE
MO
25 MG, 37.5 MG, 50 MG
MO
SYNRIBO
PAR; MO
TABLOID
PAR; MO; QLL
tacrolimus oral capsule 0.5 mg,
(120 per 30 days)
1 mg
PAR; MO; QLL (60 tacrolimus oral capsule 5 mg
per 30 days)
TAFINLAR
PAR; MO; QLL (30
per 30 days)
TAGRISSO ORAL TABLET
MO
40 MG
B/D PAR; MO
TAGRISSO ORAL TABLET
80 MG
PAR; MO
tamoxifen
B/D PAR; MO
TARCEVA ORAL TABLET
100 MG, 150 MG
PAR; MO; LA; QLL TARCEVA ORAL TABLET
(60 per 30 days)
25 MG
PAR; MO; LA; QLL TARGRETIN
(30 per 30 days)
TASIGNA
Drug Requirements/
Tier Limits
PAR; MO
PAR; MO; LA; QLL
(150 per 30 days)
PAR; MO
PAR; MO
TAXOTERE
INTRAVENOUS
SOLUTION 20 MG/ML (1
ML), 80 MG/4 ML (20 MG/
ML)
TECENTRIQ
5
5
MO
B/D PAR
5
B/D PAR; MO
4
4
5
5
B/D PAR; MO
MO
PAR; MO
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (90
per 30 days)
PAR; MO; QLL (30
per 30 days)
PAR; MO
MO
B/D PAR; MO
5
5
5
5
4
4
5
5
5
5
2
5
5
5
5
5
5
B/D PAR; MO
PAR; QLL (120 per
30 days)
PAR; MO; LA; QLL
(60 per 30 days)
PAR; MO; LA; QLL
(30 per 30 days)
MO
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (90
per 30 days)
PAR; MO
PAR; MO; QLL
(120 per 30 days)
MO
LA; QLL (20 per 21
days)
Core_16293_CG6_v15_1609_1
19
Drug Name
Drug Requirements/
Tier Limits
THALOMID ORAL
THALOMID ORAL
thiotepa
toposar
topotecan intravenous recon
soln
topotecan intravenous solution
TORISEL
TREANDA
INTRAVENOUS RECON
SOLN
TRELSTAR
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION
TRELSTAR
INTRAMUSCULAR
SYRINGE 11.25 MG/2 ML,
3.75 MG/2 ML
TRELSTAR
INTRAMUSCULAR
SYRINGE 22.5 MG/2 ML
tretinoin (chemotherapy) oral
capsule
TRISENOX
TYKERB
5
UNITUXIN
VECTIBIX
VELCADE
VENCLEXTA ORAL
TABLET 10 MG
VENCLEXTA ORAL
TABLET 100 MG
VENCLEXTA ORAL
TABLET 50 MG
VENCLEXTA STARTING
PACK
vinblastine intravenous solution
VINCASAR PFS
INTRAVENOUS
SOLUTION 1 MG/ML
vincasar pfs intravenous
solution 2 mg/2 ml
5
5
5
4
5
4
4
5
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (60
per 30 days)
MO
MO
5
5
5
MO
MO
MO
5
MO; QLL (1 per
168 days)
5
5
5
5
5
5
4
5
4
4
4
Drug Name
Drug Requirements/
Tier Limits
vincristine
vinorelbine
VOTRIENT
4
4
5
XALKORI
5
XGEVA
5
XTANDI
5
YERVOY
YONDELIS
ZALTRAP
ZANOSAR
ZELBORAF
5
5
5
4
5
ZOLINZA
5
ZORTRESS ORAL TABLET
0.25 MG
ZORTRESS ORAL TABLET
0.5 MG, 0.75 MG
ZYDELIG
4
MO
MO
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL (1.7
per 28 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO
MO
PAR; MO
MO
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL
(120 per 30 days)
B/D PAR; MO
5
B/D PAR; MO
MO
MO; QLL (1 per
168 days)
5
PAR; MO; QLL (60
per 30 days)
MO
ZYKADIA
5 PAR; MO; QLL
(150 per 30 days)
MO
ZYTIGA
5 PAR; MO; QLL
PAR; MO; LA; QLL
(120 per 30 days)
(180 per 30 days)
Autonomic / Cns Drugs, Neurology / Psych
MO
ABILIFY MAINTENA
5 MO; QLL (1 per 28
PAR; MO
days)
PAR; MO
acetaminophen-codeine oral
3 QLL (4500 per 30
PAR; LA; QLL (60 solution 120 mg-12 mg /5 ml
days)
per 30 days)
(5 ml), 240 mg-24 mg /10 ml
PAR; LA; QLL (120 (10 ml), 300 mg-30 mg /12.5
per 30 days)
ml
PAR; LA; QLL (30 acetaminophen-codeine oral
3 MO; QLL (4500 per
per 30 days)
solution 120-12 mg/5 ml
30 days)
PAR; LA; QLL (42 acetaminophen-codeine oral
3 MO; QLL (390 per
per 365 days)
tablet 300-15 mg
30 days)
MO
3 MO; QLL (360 per
tablet 300-30 mg
30 days)
3 MO; QLL (180 per
tablet 300-60 mg
30 days)
MO
ADASUVE
4
Core_16293_CG6_v15_1609_1
20
Drug Name
Drug Requirements/
Tier Limits
alprazolam oral tablet
3
amitriptyline
amoxapine oral tablet 100 mg,
50 mg
amoxapine oral tablet 150 mg,
25 mg
AMPYRA
4
3
APOKYN
APTIOM ORAL TABLET
200 MG, 400 MG, 600 MG
APTIOM ORAL TABLET
800 MG
aripiprazole oral solution
5
5
2
5
4
5
aripiprazole oral tablet 10 mg
5
5
5
aripiprazole oral tablet 20 mg,
30 mg
5
aripiprazole oral tablet,
disintegrating 10 mg
aripiprazole oral tablet,
ARISTADA
INTRAMUSCULAR
SUSPENSION,EXTENDED
REL SYRING 441 MG/1.6
ML
ARISTADA
INTRAMUSCULAR
SUSPENSION,EXTENDED
ML
ARISTADA
INTRAMUSCULAR
SUSPENSION,EXTENDED
ML
AZILECT
5
5
5
5
5
5
3
Drug Name
Drug Requirements/
Tier Limits
baclofen
BANZEL ORAL
SUSPENSION
BANZEL ORAL TABLET
200 MG
MO
BANZEL ORAL TABLET
400 MG
PAR; MO; LA; QLL benztropine injection
(60 per 30 days)
benztropine oral
PAR; MO; LA
BRIVIACT
ST; MO
INTRAVENOUS
BRIVIACT ORAL
ST; MO
SOLUTION
BRIVIACT ORAL TABLET
30 days)
MO; QLL (90 per
100 MG, 75 MG
30 days)
MO; QLL (60 per
25 MG
30 days)
30 days)
bromocriptine
MO; QLL (30 per
buprenorphine hcl injection
30 days)
solution
MO; QLL (180 per buprenorphine hcl injection
30 days)
syringe
MO; QLL (90 per
buprenorphine hcl sublingual
30 days)
tablet 2 mg
MO; QLL (60 per
buprenorphine hcl sublingual
30 days)
tablet 8 mg
PAR; MO; QLL (1.6 buprenorphine-naloxone
per 30 days)
sublingual tablet 2-0.5 mg
buprenorphine-naloxone
sublingual tablet 8-2 mg
bupropion hcl oral tablet 100
PAR; MO; QLL (2.4 mg
per 30 days)
bupropion hcl oral tablet 75 mg
2
5
bupropion hcl oral tablet
extended release 100 mg
PAR; MO; QLL (3.2 bupropion hcl oral tablet
per 30 days)
extended release 150 mg, 200
mg
extended release 24 hr 150 mg
MO
3
MO; QLL (90 per
30 days)
PAR; MO
MO
4
5
4
3
4
5
5
5
5
5
4
4
4
4
4
4
4
4
3
3
3
MO
PAR; MO; QLL
(2400 per 30 days)
PAR; MO; QLL
(480 per 30 days)
PAR; MO; QLL
(240 per 30 days)
PAR; MO
PAR; MO
PAR
PAR; QLL (600 per
30 days)
PAR; QLL (600 per
30 days)
PAR; QLL (60 per
30 days)
PAR; QLL (240 per
30 days)
PAR; QLL (120 per
30 days)
MO
MO; QLL (150 per
30 days)
QLL (150 per 30
days)
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL
(360 per 30 days)
PAR; MO; QLL (90
per 30 days)
MO; QLL (135 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (90 per
30 days)
Core_16293_CG6_v15_1609_1
21
Drug Name
Drug Requirements/
Tier Limits
buspirone oral tablet 10 mg, 15
mg, 5 mg
buspirone oral tablet 30 mg,
7.5 mg
butorphanol tartrate injection
solution 1 mg/ml
butorphanol tartrate injection
solution 2 mg/ml
butorphanol tartrate nasal
3
carbamazepine oral capsule, er
multiphase 12 hr
carbamazepine oral suspension
100 mg/5 ml
carbamazepine oral suspension
200 mg/10 ml
carbamazepine oral tablet
extended release 12 hr 200 mg,
400 mg
carbamazepine oral tablet,
chewable
carbidopa-levodopa oral tablet
extended release 25-100 mg
extended release 50-200 mg
carbidopa-levodopa oral tablet,
disintegrating
CELONTIN ORAL
CAPSULE 300 MG
chlorpromazine
citalopram oral solution
citalopram oral tablet 10 mg
2
Drug Name
Drug Requirements/
Tier Limits
clonazepam oral tablet 0.5 mg
2
2
MO; QLL (45 per
30 days)
MO
clonazepam oral tablet 1 mg
2
4
MO
clonazepam oral tablet 2 mg
3
4
4
MO
clonazepam oral tablet,
disintegrating 0.125 mg
disintegrating 1 mg
disintegrating 2 mg
clorazepate dipotassium
4
4
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (5 per 28
days)
MO
clozapine oral tablet 100 mg
3
3
2
4
4
4
2
4
4
MO
4
4
4
4
3
MO
2
MO
2
3
3
MO
MO
clozapine oral tablet,
COPAXONE
SUBCUTANEOUS
SYRINGE 20 MG/ML
COPAXONE
SUBCUTANEOUS
SYRINGE 40 MG/ML
cyclobenzaprine oral tablet
dantrolene
desipramine oral
4
4
MO
4
MO
4
4
4
1
1
clomipramine
4
MO
PAR; MO
MO; QLL (600 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
PAR; MO
4
4
4
4
5
PAR; MO; QLL
(1200 per 30 days)
PAR; MO; QLL
(600 per 30 days)
PAR; MO; QLL
(300 per 30 days)
PAR; MO; QLL
(4800 per 30 days)
PAR; MO; QLL
(2400 per 30 days)
PAR; MO; QLL
(1200 per 30 days)
PAR; MO; QLL
(600 per 30 days)
PAR; MO; QLL
(300 per 30 days)
MO; QLL (120 per
30 days)
MO; QLL (270 per
30 days)
MO; QLL (135 per
30 days)
MO; QLL (1080 per
30 days)
MO; QLL (540 per
30 days)
QLL (270 per 30
days)
QLL (2160 per 30
days)
QLL (180 per 30
days)
QLL (135 per 30
days)
QLL (1080 per 30
days)
PAR; MO; QLL (30
per 30 days)
5
PAR; MO; QLL (12
per 28 days)
4
4
4
PAR; MO
MO
MO
Core_16293_CG6_v15_1609_1
22
Drug Name
Drug Requirements/
Tier Limits
desvenlafaxine fumarate oral
tablet extended release 24hr
100 mg
desvenlafaxine fumarate oral
tablet extended release 24hr 50
mg
DESVENLAFAXINE ORAL
TABLET EXTENDED
DESVENLAFAXINE ORAL
TABLET EXTENDED
RELEASE 24 HR 50 MG
desvenlafaxine oral tablet
extended release 24hr 100 mg
desvenlafaxine oral tablet
dextroamphetamine oral tablet
10 mg
dextroamphetamine oral tablet
5 mg
dextroamphetamineamphetamine oral tablet 10
mg, 12.5 mg, 15 mg, 20 mg, 5
mg, 7.5 mg
dextroamphetamineamphetamine oral tablet 30 mg
diazepam intensol
4
diazepam oral concentrate
4
diazepam oral solution 5 mg/5
ml (1 mg/ml)
diazepam oral solution 5 mg/5
ml (1 mg/ml, 5 ml)
diazepam oral tablet 10 mg
3
3
3
diazepam rectal kit 12.5-1517.5-20 mg
diazepam rectal kit 2.5 mg, 57.5-10 mg
diclofenac potassium
4
4
4
2
MO
3
MO
2
MO
3
QLL (1000 per 30
days)
MO
MO
MO
MO
4
4
2
MO
3
MO
1
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL
(1200 per 30 days)
PAR; QLL (1200
per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL
(600 per 30 days)
PAR; MO; QLL
(240 per 30 days)
MO
divalproex oral capsule, sprinkle
divalproex oral tablet extended
release 24 hr
divalproex oral tablet,delayed
release (dr/ec) 125 mg, 250 mg
divalproex oral tablet,delayed
release (dr/ec) 500 mg
donepezil oral tablet 10 mg, 5
mg
donepezil oral tablet,
disintegrating
doxepin oral
duloxetine oral capsule,delayed
duramorph (pf) injection
solution 0.5 mg/ml
duramorph (pf) injection
solution 1 mg/ml
EMSAM
QLL (30 per 30
days)
MO
MO
MO; QLL (2 per 2
days)
MO
endocet oral tablet 10-325 mg,
7.5-325 mg
endocet oral tablet 5-325 mg
4
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
PAR; MO
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (180 per
30 days)
QLL (180 per 30
days)
PAR; MO; QLL (30
per 30 days)
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (240 per
30 days)
4
QLL (120 per 30
days)
QLL (240 per 30
days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
PAR; MO; QLL (90
per 30 days)
4
4
3
3
4
3
3
4
2
Drug Requirements/
Tier Limits
diclofenac sodium oral tablet
diclofenac sodium oral tablet,
delayed release (dr/ec) 25 mg
diclofenac sodium oral tablet,
delayed release (dr/ec) 50 mg,
75 mg
diclofenac sodium topical gel 1
%
diflunisal
dihydroergotamine injection
DILANTIN INFATABS
DILANTIN ORAL
CAPSULE 30 MG
diskets
MO; QLL (120 per
30 days)
4
4
Drug Name
3
5
3
3
3
1
4
4
4
3
4
4
4
5
3
Core_16293_CG6_v15_1609_1
23
Drug Name
entacapone
epitol
EQUETRO ORAL
CAPSULE, ER
MULTIPHASE 12 HR 100
MG
EQUETRO ORAL
CAPSULE, ER
MG
EQUETRO ORAL
CAPSULE, ER
MG
ergoloid
escitalopram oxalate oral
solution
escitalopram oxalate oral tablet
10 mg
20 mg
5 mg
ethosuximide oral capsule
ethosuximide oral solution
etodolac oral capsule
etodolac oral tablet
etodolac oral tablet extended
release 24 hr
EXELON ORAL CAPSULE
1.5 MG, 4.5 MG
FANAPT ORAL TABLET 1
MG
FANAPT ORAL TABLET
10 MG
FANAPT ORAL TABLET
12 MG
MG
MG
MG
MG
Drug Requirements/
Tier Limits
4
1
4
MO
MO
MO; QLL (480 per
30 days)
4
MO; QLL (240 per
30 days)
4
MO; QLL (180 per
30 days)
4
4
PAR; MO
MO; QLL (600 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (120 per
30 days)
MO
MO
MO
MO
MO
3
3
3
4
3
3
2
3
4
4
5
4
4
4
4
4
MO; QLL (60 per
30 days)
ST; MO; QLL (720
per 30 days)
ST; QLL (72 per 30
days)
ST; MO; QLL (60
per 30 days)
ST; MO; QLL (360
per 30 days)
ST; MO; QLL (180
per 30 days)
ST; MO; QLL (120
per 30 days)
ST; MO; QLL (90
per 30 days)
Drug Name
Drug Requirements/
Tier Limits
FANAPT ORAL TABLETS,
DOSE PACK
felbamate oral suspension
felbamate oral tablet 400 mg
felbamate oral tablet 600 mg
FELBATOL ORAL TABLET
400 MG
fenoprofen oral tablet
fentanyl citrate
4
fentanyl transdermal patch 72
hour 100 mcg/hr, 12 mcg/hr,
25 mcg/hr, 50 mcg/hr, 75 mcg/
hr
FETZIMA ORAL
CAPSULE,EXT REL 24HR
DOSE PACK
FETZIMA ORAL
CAPSULE,EXTENDED
RELEASE 24 HR 120 MG,
80 MG
FETZIMA ORAL
CAPSULE,EXTENDED
RELEASE 24 HR 20 MG
FETZIMA ORAL
CAPSULE,EXTENDED
RELEASE 24 HR 40 MG
fluoxetine oral capsule 10 mg
4
2
2
fluoxetine oral solution
2
fluoxetine oral tablet 10 mg
2
fluoxetine oral tablet 20 mg
3
fluphenazine decanoate
fluphenazine hcl injection
fluphenazine hcl oral
flurbiprofen
fluvoxamine oral tablet 100 mg
4
4
2
2
3
5
4
5
4
4
5
ST; MO; QLL (16
per 365 days)
MO
MO
MO
MO
MO
PAR; MO; QLL
(120 per 30 days)
ST; MO; QLL (15
per 30 days)
4
PAR; MO; QLL (56
per 365 days)
4
PAR; MO; QLL (30
per 30 days)
4
PAR; MO; QLL
(180 per 30 days)
4
PAR; MO; QLL (90
per 30 days)
2
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (600 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO
MO
MO
MO
MO; QLL (90 per
30 days)
Core_16293_CG6_v15_1609_1
24
Drug Name
Drug Requirements/
Tier Limits
3
3
fosphenytoin
FYCOMPA ORAL
SUSPENSION
FYCOMPA ORAL TABLET
10 MG, 12 MG
FYCOMPA ORAL TABLET
2 MG
FYCOMPA ORAL TABLET
4 MG
FYCOMPA ORAL TABLET
6 MG
FYCOMPA ORAL TABLET
8 MG
gabapentin oral capsule 100 mg
4
4
4
4
4
4
4
2
2
3
gabapentin oral solution 250
mg/5 ml
gabapentin oral solution 250
mg/5 ml (5 ml), 300 mg/6 ml
(6 ml)
gabapentin oral tablet 600 mg
4
4
GABITRIL ORAL TABLET
12 MG
GABITRIL ORAL TABLET
16 MG
galantamine oral capsule,ext
rel. pellets 24 hr
galantamine oral solution
4
MO; QLL (180 per
30 days)
MO; QLL (135 per
30 days)
MO
5
MO
galantamine oral tablet
4
GEODON
INTRAMUSCULAR
GILENYA
4
gabapentin oral tablet 800 mg
4
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
MO
QLL (720 per 30
days)
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (45 per
30 days)
MO; QLL (1080 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (270 per
30 days)
MO; QLL (2160 per
30 days)
QLL (2160 per 30
days)
4
4
3
5
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (60 per
30 days)
MO
PAR; MO; QLL (30
per 30 days)
Drug Name
Drug Requirements/
Tier Limits
GLATOPA
5
guanfacine oral tablet extended
release 24 hr
guanidine
haloperidol
haloperidol decanoate
haloperidol lactate injection
haloperidol lactate oral
HETLIOZ
4
hydrocodone-acetaminophen
oral solution 2.5-167 mg/5 ml
oral solution 7.5-325 mg/15 ml
oral tablet 10-325 mg, 5-325
mg, 7.5-325 mg
hydrocodone-ibuprofen oral
tablet 10-200 mg, 5-200 mg,
7.5-200 mg
hydromorphone (pf) injection
solution 1 mg/ml
solution 10 mg/ml
solution 4 mg/ml
hydromorphone injection
solution
syringe 1 mg/ml
syringe 2 mg/ml
syringe 4 mg/ml
hydromorphone oral tablet 2
mg, 4 mg
hydromorphone oral tablet 8
mg
ibuprofen oral suspension
ibuprofen oral tablet 400 mg,
600 mg, 800 mg
ibuprofen-oxycodone
3
imipramine hcl
4
4
2
4
4
2
5
4
3
3
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (30
per 30 days)
MO
MO
MO
MO
MO
PAR; MO; QLL (30
per 30 days)
QLL (2700 per 30
days)
MO; QLL (2700 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (480 per
30 days)
4
4
4
4
MO; QLL (120 per
30 days)
MO
MO; QLL (180 per
30 days)
4
4
4
3
4
1
1
4
QLL (180 per 30
days)
MO
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
MO
MO
MO; QLL (28 per 2
days)
PAR; MO
Core_16293_CG6_v15_1609_1
25
Drug Name
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 1.5 MG
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 3 MG
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 6 MG
INVEGA ORAL TABLET
EXTENDED RELEASE
24HR 9 MG
INVEGA SUSTENNA
INTRAMUSCULAR
SYRINGE 117 MG/0.75
ML, 156 MG/ML, 234 MG/
1.5 ML, 78 MG/0.5 ML
INVEGA SUSTENNA
INTRAMUSCULAR
SYRINGE 39 MG/0.25 ML
INVEGA TRINZA
INTRAMUSCULAR
SYRINGE 273 MG/0.875
ML
INVEGA TRINZA
INTRAMUSCULAR
ML
INVEGA TRINZA
INTRAMUSCULAR
SYRINGE 546 MG/1.75 ML
INVEGA TRINZA
INTRAMUSCULAR
ML
KHEDEZLA ORAL
TABLET EXTENDED
RELEASE 24HR 100 MG
KHEDEZLA ORAL
TABLET EXTENDED
RELEASE 24HR 50 MG
lamotrigine oral tablet 100 mg,
150 mg, 200 mg
lamotrigine oral tablet 25 mg
lamotrigine oral tablet,
chewable dispersible
Drug Requirements/
Tier Limits
5
5
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
5
MO; QLL (60 per
30 days)
5
MO; QLL (30 per
30 days)
5
MO; QLL (2 per 28
days)
4
MO; QLL (2 per 28
days)
5
MO; QLL (0.875
per 90 days)
5
5
5
4
MO; QLL (1.315
per 90 days)
MO; QLL (1.75 per
90 days)
MO; QLL (2.625
per 90 days)
MO; QLL (120 per
30 days)
4
MO; QLL (240 per
30 days)
3
MO
2
3
MO
MO
Drug Name
Drug Requirements/
Tier Limits
LATUDA ORAL TABLET
120 MG
LATUDA ORAL TABLET
20 MG
LATUDA ORAL TABLET
40 MG
LATUDA ORAL TABLET
60 MG
LATUDA ORAL TABLET
80 MG
levetiracetam in nacl (iso-os)
intravenous piggyback 1,000
mg/100 ml, 1,500 mg/100 ml
levetiracetam in nacl (iso-os)
100 ml
levetiracetam intravenous
levetiracetam oral solution 100
mg/ml
levetiracetam oral solution 500
mg/5 ml (5 ml)
levetiracetam oral tablet 1,000
mg
levetiracetam oral tablet 250
mg, 500 mg, 750 mg
levetiracetam oral tablet
levetiracetam oral tablet
lithium carbonate oral capsule
150 mg, 300 mg
lithium carbonate oral capsule
600 mg
lithium carbonate oral tablet
lithium carbonate oral tablet
extended release
lithium citrate oral solution 8
meq/5 ml
lorazepam oral tablet
5
loxapine succinate oral capsule
10 mg, 5 mg
loxapine succinate oral capsule
25 mg, 50 mg
LYRICA ORAL CAPSULE
100 MG
4
4
4
5
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (75
per 30 days)
PAR; MO; QLL (60
per 30 days)
4
4
MO
4
4
MO
MO
4
4
MO
3
MO
4
1
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO
2
MO
2
2
MO
MO
2
MO
3
3
MO; QLL (90 per
30 days)
MO
4
MO
4
PAR; MO; QLL
(180 per 30 days)
4
Core_16293_CG6_v15_1609_1
26
Drug Name
Drug Requirements/
Tier Limits
LYRICA ORAL CAPSULE
150 MG
LYRICA ORAL CAPSULE
200 MG
LYRICA ORAL CAPSULE
225 MG, 300 MG
LYRICA ORAL CAPSULE
25 MG
LYRICA ORAL CAPSULE
50 MG
LYRICA ORAL CAPSULE
75 MG
LYRICA ORAL SOLUTION
4
maprotiline oral tablet 25 mg
4
4
MARPLAN
meclofenamate oral
meloxicam oral suspension
4
4
4
3
meloxicam oral tablet
1
memantine oral solution
memantine oral tablet 10 mg
4
4
4
4
4
4
3
3
memantine oral tablet 5 mg
3
MESTINON ORAL SYRUP
MESTINON TIMESPAN
methadone intensol
4
4
3
methadone oral concentrate
3
methadone oral solution 10 mg/
5 ml
methadone oral solution 5 mg/
5 ml
methadone oral tablet 10 mg
3
methadone oral tablet 5 mg
3
4
3
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (90
per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL
(720 per 30 days)
PAR; MO; QLL
(360 per 30 days)
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL
(900 per 30 days)
MO; QLL (270 per
30 days)
MO; QLL (135 per
30 days)
MO
MO
MO
MO; QLL (300 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (300 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (90 per
30 days)
MO
MO
MO; QLL (180 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (900 per
30 days)
MO; QLL (1800 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (360 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
methadone oral tablet,soluble
3
methadose oral concentrate
3
methadose oral tablet,soluble
3
methylphenidate oral tablet
3
MIRAPEX ORAL TABLET
0.25 MG, 0.75 MG
mirtazapine oral tablet 15 mg
4
2
2
mirtazapine oral tablet 7.5 mg
3
mirtazapine oral tablet,
modafinil oral tablet 100 mg
4
modafinil oral tablet 200 mg
5
molindone
morphine (pf) injection solution
0.5 mg/ml
morphine (pf) injection solution
1 mg/ml
morphine (pf) intravenous
patient control.analgesia soln
150 mg/30 ml
morphine (pf) intravenous
patient control.analgesia soln
30 mg/30 ml
morphine concentrate oral
solution
morphine intravenous cartridge
4
4
morphine intravenous solution
10 mg/ml, 50 mg/ml
4
2
3
3
4
4
4
QLL (30 per 30
days)
MO; QLL (180 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (90 per
30 days)
MO
MO; QLL (90 per
30 days)
MO; QLL (45 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (45 per
30 days)
MO; QLL (30 per
30 days)
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (60
per 30 days)
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
4
QLL (180 per 30
days)
3
MO; QLL (270 per
30 days)
QLL (120 per 30
days)
MO; QLL (120 per
30 days)
4
Core_16293_CG6_v15_1609_1
27
Drug Name
100 mg/4 ml, 25 mg/ml, 250
mg/10 ml
4 mg/ml, 8 mg/ml
morphine intravenous syringe
2 mg/ml, 4 mg/ml
morphine oral solution 10 mg/
5 ml
morphine oral solution 20 mg/
5 ml (4 mg/ml)
morphine oral tablet 15 mg
Drug Requirements/
Tier Limits
4
4
QLL (120 per 30
days)
4
4
MO; QLL (180 per
30 days)
QLL (120 per 30
days)
MO; QLL (2700 per
30 days)
MO; QLL (1350 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (180 per
30 days)
MO
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO
MO
2
MO
4
3
3
3
morphine oral tablet 30 mg
3
morphine oral tablet extended
release 100 mg, 30 mg, 60 mg
release 15 mg
release 200 mg
morphine rectal
4
nabumetone
nalbuphine injection solution
10 mg/ml
nalbuphine injection solution
20 mg/ml
naloxone injection solution
naloxone injection syringe 0.4
mg/ml
naloxone injection syringe 1 mg/
ml
naltrexone
NAMENDA ORAL
SOLUTION
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR
DOSE PACK
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER
24HR
NAMZARIC
naproxen oral suspension
naproxen oral tablet
2
4
3
4
3
4
2
3
3
3
3
2
1
MO
MO; QLL (300 per
30 days)
MO; QLL (56 per
365 days)
MO; QLL (30 per
30 days)
MO
MO
MO
Drug Name
Drug Requirements/
Tier Limits
naproxen oral tablet,delayed
release (dr/ec)
naproxen sodium oral tablet
275 mg, 550 mg
naratriptan
1
MO
1
MO
4
nefazodone oral tablet 100 mg
3
4
3
3
4
NEUPRO
3
nortriptyline oral capsule
nortriptyline oral solution
NUEDEXTA
2
4
3
NUPLAZID
5
olanzapine intramuscular
4
olanzapine oral tablet 10 mg
3
3
olanzapine oral tablet 2.5 mg
3
3
3
olanzapine oral tablet 7.5 mg
3
olanzapine oral tablet,
disintegrating 5 mg
4
MO; QLL (9 per 30
days)
MO; QLL (180 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (72 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (30 per
30 days)
MO
MO
MO; QLL (60 per
30 days)
PAR; LA; QLL (60
per 30 days)
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (40 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (80 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (40 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (120 per
30 days)
4
5
4
Core_16293_CG6_v15_1609_1
28
Drug Name
Drug Requirements/
Tier Limits
ONFI ORAL SUSPENSION
4
ONFI ORAL TABLET 10
MG
ONFI ORAL TABLET 20
MG
ORAP
oxaprozin
oxazepam
4
oxcarbazepine oral suspension
oxcarbazepine oral tablet 150
mg, 300 mg
oxcarbazepine oral tablet 600
mg
oxycodone oral capsule
4
3
oxycodone oral concentrate
4
oxycodone oral solution
4
oxycodone oral tablet 10 mg, 5
mg
oxycodone oral tablet 15 mg
3
oxycodone oral tablet 20 mg,
30 mg
oxycodone-acetaminophen oral
solution
tablet 10-325 mg, 2.5-325 mg,
7.5-325 mg
tablet 5-325 mg
oxycodone-aspirin
4
paliperidone oral tablet
extended release 24hr 1.5 mg
paroxetine hcl oral tablet 10 mg
5
4
4
4
PAR; MO; QLL
(480 per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL (60
per 30 days)
MO
MO
PAR; MO; QLL
(120 per 30 days)
MO
MO
4
MO
4
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (1800 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (540 per
30 days)
MO; QLL (180 per
30 days)
QLL (1800 per 30
days)
MO; QLL (360 per
30 days)
4
3
4
3
4
4
4
4
4
2
MO; QLL (360 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
2
2
2
paroxetine hcl oral tablet
extended release 24 hr 12.5 mg
extended release 24 hr 37.5 mg
PAXIL ORAL
SUSPENSION
PEGANONE
perphenazine
phenelzine
phenobarbital oral elixir
4
phenobarbital oral tablet 100
mg
phenobarbital oral tablet 15 mg
4
phenobarbital oral tablet 16.2
mg
4
mg
4
mg
mg
PHENYTEK
phenytoin oral suspension 100
mg/4 ml
phenytoin oral suspension 125
mg/5 ml
phenytoin oral tablet,chewable
phenytoin sodium extended
phenytoin sodium intravenous
solution
phenytoin sodium intravenous
syringe
4
4
4
4
4
4
3
4
4
4
4
4
4
3
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (45 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (900 per
30 days)
MO
MO
MO
PAR; MO; QLL
(3000 per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL
(800 per 30 days)
PAR; MO; QLL
(741 per 30 days)
PAR; MO; QLL
(400 per 30 days)
PAR; MO; QLL
(370 per 30 days)
PAR; MO; QLL
(200 per 30 days)
PAR; MO; QLL
(185 per 30 days)
PAR; MO; QLL
(123 per 30 days)
MO
3
MO
3
3
4
MO
MO
MO
4
Core_16293_CG6_v15_1609_1
29
Drug Name
Drug Requirements/
Tier Limits
pimozide
piroxicam
POTIGA ORAL TABLET
200 MG
POTIGA ORAL TABLET
300 MG, 400 MG
POTIGA ORAL TABLET
50 MG
pramipexole oral tablet
primidone
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24
HR 100 MG
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24
HR 25 MG
PRISTIQ ORAL TABLET
EXTENDED RELEASE 24
HR 50 MG
protriptyline
pyridostigmine bromide oral
tablet
quetiapine oral tablet 100 mg
3
3
4
3
3
3
3
3
RAZADYNE ORAL
TABLET 4 MG
regonol
REQUIP ORAL TABLET 1
MG, 4 MG, 5 MG
REXULTI ORAL TABLET
0.25 MG, 0.5 MG, 1 MG, 2
MG
REXULTI ORAL TABLET
3 MG, 4 MG
RISPERDAL CONSTA
INTRAMUSCULAR
4
5
4
2
3
4
4
4
MO
MO
MO; QLL (90 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (270 per
30 days)
MO
MO
MO; QLL (120 per
30 days)
MO; QLL (480 per
30 days)
MO; QLL (240 per
30 days)
Drug Name
SYRINGE 12.5 MG/2 ML,
25 MG/2 ML
RISPERDAL CONSTA
INTRAMUSCULAR
SYRINGE 37.5 MG/2 ML
RISPERDAL CONSTA
INTRAMUSCULAR
SYRINGE 50 MG/2 ML
risperidone oral solution
Drug Requirements/
Tier Limits
5
MO; QLL (2 per 28
days)
5
MO
3
MO; QLL (480 per
30 days)
MO; QLL (1920 per
30 days)
MO; QLL (960 per
30 days)
MO; QLL (480 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (150 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (1920 per
30 days)
MO; QLL (960 per
30 days)
MO; QLL (480 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (150 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
MO
MO
risperidone oral tablet 0.25 mg
2
risperidone oral tablet 0.5 mg
2
risperidone oral tablet 1 mg
2
2
2
4
3
MO
MO
2
3
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (960 per
30 days)
MO; QLL (80 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (480 per
30 days)
MO
risperidone oral tablet,
disintegrating 1 mg
disintegrating 2 mg
disintegrating 3 mg
disintegrating 4 mg
rivastigmine tartrate
4
ropinirole oral tablet
ropinirole oral tablet extended
release 24 hr
roweepra
ROZEREM
2
4
SABRIL ORAL POWDER
IN PACKET
SABRIL ORAL TABLET
4
4
4
5
5
4
MO
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL (30
per 30 days)
MO; QLL (2 per 28
days)
4
4
4
4
4
4
3
3
5
MO; QLL (30 per
30 days)
PAR; MO; LA; QLL
(180 per 30 days)
PAR; MO; LA; QLL
(180 per 30 days)
Core_16293_CG6_v15_1609_1
30
Drug Name
Drug Requirements/
Tier Limits
SAPHRIS (BLACK
CHERRY) SUBLINGUAL
TABLET 10 MG
SAPHRIS (BLACK
CHERRY) SUBLINGUAL
TABLET 2.5 MG
SAPHRIS (BLACK
CHERRY) SUBLINGUAL
TABLET 5 MG
selegiline hcl
SEROQUEL XR ORAL
TABLET EXTENDED
SEROQUEL XR ORAL
TABLET EXTENDED
SEROQUEL XR ORAL
TABLET EXTENDED
SEROQUEL XR ORAL
TABLET EXTENDED
SEROQUEL XR ORAL
TABLET EXTENDED
RELEASE 24 HR 50 MG
sertraline oral concentrate
4
MO; QLL (60 per
30 days)
4
MO; QLL (240 per
30 days)
4
MO; QLL (120 per
30 days)
3
4
MO
PAR; MO; QLL
(150 per 30 days)
sertraline oral tablet 100 mg
2
2
2
SINEMET CR ORAL
TABLET EXTENDED
RELEASE 25-100 MG
SPRITAM ORAL TABLET
FOR SUSPENSION 1,000
MG, 250 MG, 500 MG
SPRITAM ORAL TABLET
FOR SUSPENSION 750
MG
STRATTERA ORAL
CAPSULE 10 MG, 18 MG,
25 MG, 40 MG
4
4
PAR; MO; QLL
(120 per 30 days)
4
PAR; MO; QLL (80
per 30 days)
5
PAR; MO; QLL (60
per 30 days)
4
PAR; MO; QLL
(480 per 30 days)
4
MO; QLL (300 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO
4
PAR; QLL (60 per
30 days)
4
PAR; QLL (120 per
30 days)
4
PAR; MO; QLL (60
per 30 days)
Drug Name
Drug Requirements/
Tier Limits
STRATTERA ORAL
CAPSULE 100 MG, 60 MG,
80 MG
SUBOXONE
SUBLINGUAL FILM 12-3
MG
SUBOXONE
SUBLINGUAL FILM 2-0.5
MG
SUBOXONE
SUBLINGUAL FILM 4-1
MG
SUBOXONE
SUBLINGUAL FILM 8-2
MG
sulindac oral tablet 150 mg
sulindac oral tablet 200 mg
sumatriptan
4
PAR; MO; QLL (30
per 30 days)
4
PAR; MO; QLL (60
per 30 days)
4
PAR; MO; QLL
(360 per 30 days)
4
PAR; MO; QLL
(180 per 30 days)
4
PAR; MO; QLL (90
per 30 days)
1
2
4
sumatriptan succinate oral
2
sumatriptan succinate
subcutaneous cartridge
subcutaneous pen injector
subcutaneous solution
subcutaneous syringe 6 mg/0.5
ml
SURMONTIL
SYMBYAX ORAL CAPSULE
12-25 MG, 12-50 MG, 6-50
MG
SYMBYAX ORAL CAPSULE
3-25 MG
TECFIDERA
tetrabenazine oral tablet 12.5
mg
tetrabenazine oral tablet 25 mg
4
MO
MO
MO; QLL (12 per
30 days)
MO; QLL (9 per 30
days)
MO; QLL (4 per 30
days)
MO; QLL (4 per 30
days)
MO; QLL (4 per 30
days)
QLL (4 per 30 days)
thioridazine
thiothixene
tiagabine
tizanidine oral tablet
tolcapone
4
2
4
2
5
4
4
4
4
4
PAR; MO
MO; QLL (30 per
30 days)
4
MO; QLL (90 per
30 days)
PAR; MO
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO
MO
MO
MO
MO
5
5
5
Core_16293_CG6_v15_1609_1
31
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
topiramate oral capsule,
sprinkle
topiramate oral tablet 100 mg
4
PAR; MO
venlafaxine oral tablet 25 mg
3
2
venlafaxine oral tablet 37.5 mg
3
3
4
2
3
2
3
tramadol-acetaminophen
4
4
2
4
1
3
MO
MO
MO
venlafaxine oral tablet extended
release 24hr 150 mg
VENLAFAXINE ORAL
TABLET EXTENDED
RELEASE 24HR 225 MG
release 24hr 37.5 mg
release 24hr 75 mg
VERSACLOZ
4
tramadol oral tablet
PAR; MO; QLL
(480 per 30 days)
PAR; MO; QLL
(240 per 30 days)
PAR; MO; QLL
(1920 per 30 days)
PAR; MO; QLL
(960 per 30 days)
MO; QLL (240 per
30 days)
MO; QLL (240 per
30 days)
MO
MO
4
4
MO
4
ST; QLL (60 per 30
days)
ST; QLL (30 per 30
days)
ST; QLL (120 per
30 days)
PAR; MO; LA
MO
MO
MO
VIIBRYD ORAL TABLET
10 MG
VIIBRYD ORAL TABLET
20 MG
VIIBRYD ORAL TABLET
40 MG
VIIBRYD ORAL TABLETS,
DOSE PACK 10 MG (7)- 20
MG (23)
VIMPAT INTRAVENOUS
VIMPAT ORAL
SOLUTION
VIMPAT ORAL TABLET
100 MG
VIMPAT ORAL TABLET
150 MG
VIMPAT ORAL TABLET
200 MG
VIMPAT ORAL TABLET
50 MG
VOLTAREN TOPICAL
GEL 1 %
VRAYLAR ORAL CAPSULE
1.5 MG
VRAYLAR ORAL CAPSULE
3 MG, 4.5 MG, 6 MG
4
tranylcypromine
trazodone oral tablet 100 mg,
150 mg
trazodone oral tablet 300 mg
trazodone oral tablet 50 mg
trifluoperazine oral tablet 1 mg,
2 mg
trifluoperazine oral tablet 10
mg, 5 mg
TRINTELLIX ORAL
TABLET 10 MG
TRINTELLIX ORAL
TABLET 20 MG
TRINTELLIX ORAL
TABLET 5 MG
TYSABRI
valproate sodium
valproic acid
valproic acid (as sodium salt)
oral solution 250 mg/5 ml
valproic acid (as sodium salt)
oral solution 250 mg/5 ml (5
ml), 500 mg/10 ml (10 ml)
venlafaxine oral capsule,
extended release 24hr 37.5 mg
4
4
5
4
3
2
2
3
2
3
4
MO; QLL (60 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (113 per
30 days)
4
4
4
5
4
4
4
4
4
4
4
4
3
4
5
MO; QLL (450 per
30 days)
MO; QLL (300 per
30 days)
MO; QLL (225 per
30 days)
MO; QLL (150 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (180 per
30 days)
MO; QLL (90 per
30 days)
QLL (600 per 30
days)
ST; MO; QLL (120
per 30 days)
ST; MO; QLL (60
per 30 days)
ST; MO; QLL (30
per 30 days)
ST; MO; QLL (30
per 30 days)
QLL (1200 per 30
days)
MO; QLL (1200 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (80 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (1000 per
30 days)
PAR; QLL (30 per
30 days)
PAR; QLL (30 per
30 days)
Core_16293_CG6_v15_1609_1
32
Drug Name
VRAYLAR ORAL
CAPSULE,DOSE PACK
XENAZINE ORAL TABLET
12.5 MG
XENAZINE ORAL TABLET
25 MG
XYREM
zaleplon oral capsule 10 mg
Drug Requirements/
Tier Limits
4
5
5
5
3
zaleplon oral capsule 5 mg
3
ZARONTIN ORAL
CAPSULE
zenzedi oral tablet 10 mg
4
zenzedi oral tablet 5 mg
4
ziprasidone hcl oral capsule 20
mg
mg
mg, 80 mg
zolpidem oral
4
4
4
4
4
PAR; QLL (7 per
365 days)
PAR; MO; LA; QLL
(240 per 30 days)
PAR; MO; LA; QLL
(120 per 30 days)
PAR; MO; LA; QLL
(540 per 30 days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; QLL (30
per 30 days)
MO
PAR; MO; QLL
(180 per 30 days)
PAR; MO; QLL (90
per 30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
PAR; MO; QLL (30
per 30 days)
MO
zonisamide oral capsule 100
3
mg, 50 mg
zonisamide oral capsule 25 mg 2 MO
ZYPREXA RELPREVV
5 PAR; QLL (2 per 28
INTRAMUSCULAR
days)
SUSPENSION FOR
RECONSTITUTION 210
MG, 405 MG
ZYPREXA RELPREVV
5 PAR; MO; QLL (2
INTRAMUSCULAR
per 28 days)
SUSPENSION FOR
RECONSTITUTION 300
MG
Cardiovascular, Hypertension / Lipids
ACCUPRIL
4 MO
ACCURETIC ORAL
4 MO
TABLET 20-12.5 MG, 20-25
MG
acebutolol
2 MO
ADALAT CC
4 MO
Drug Name
Drug Requirements/
Tier Limits
afeditab cr
AGGRENOX
2
4
ALDACTAZIDE ORAL
TABLET 25-25 MG
ALTACE ORAL CAPSULE
10 MG, 2.5 MG, 5 MG
ALTOPREV
4
MO
ST; MO; QLL (60
per 30 days)
MO
4
MO
4
amiloride
amiloride-hydrochlorothiazide
amiodarone intravenous
solution
amiodarone intravenous syringe
amiodarone oral tablet 100 mg,
200 mg
amiodarone oral tablet 400 mg
amlodipine besylate oral tablet
10 mg, 2.5 mg
amlodipine besylate oral tablet
5 mg
amlodipine-atorvastatin
3
2
4
PAR; MO; QLL (30
per 30 days)
MO
MO
B/D PAR; MO
4
2
B/D PAR
MO
4
1
amlodipine-benazepril oral
capsule 10-20 mg, 10-40 mg,
2.5-10 mg, 5-20 mg, 5-40 mg
amlodipine-benazepril oral
capsule 5-10 mg
amlodipine-valsartan
3
MO
MO; QLL (30 per
30 days)
MO; QLL (45 per
30 days)
MO; QLL (30 per
30 days)
MO
2
MO
4
amlodipine-valsartan-hcthiazid
4
aspirin-dipyridamole
3
ATACAND HCT ORAL
TABLET 16-12.5 MG
ATACAND HCT ORAL
TABLET 32-12.5 MG, 32-25
MG
ATACAND ORAL TABLET
16 MG, 4 MG, 8 MG
ATACAND ORAL TABLET
32 MG
atenolol
atenolol-chlorthalidone
4
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
ST; MO; QLL (60
per 30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
1
3
4
4
4
1
1
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO
MO
Core_16293_CG6_v15_1609_1
33
Drug Name
Drug Requirements/
Tier Limits
atorvastatin
6
AVALIDE ORAL TABLET
150-12.5 MG
AVALIDE ORAL TABLET
300-12.5 MG
AVAPRO
4
AZOR
3
benazepril
benazepril-hydrochlorothiazide
oral tablet 10-12.5 mg, 2012.5 mg, 5-6.25 mg
benazepril-hydrochlorothiazide
oral tablet 20-25 mg
BENICAR HCT
6
2
MO; CG; QLL (30
per 30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; CG
MO
1
MO
BENICAR ORAL TABLET
20 MG, 40 MG
BENICAR ORAL TABLET
5 MG
betaxolol oral
BIDIL
3
4
4
3
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
BRILINTA
2
1
3
bumetanide injection
bumetanide oral tablet 0.5 mg,
1 mg
bumetanide oral tablet 2 mg
BYSTOLIC
CALAN ORAL TABLET
120 MG
CALAN SR ORAL TABLET
EXTENDED RELEASE 120
MG
candesartan oral tablet 16 mg,
4 mg, 8 mg
candesartan oral tablet 32 mg
4
2
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO
MO; QLL (180 per
30 days)
MO
MO
MO; QLL (60 per
30 days)
MO
MO
3
3
4
MO
MO
MO
4
MO
candesartan-hydrochlorothiazid
oral tablet 16-12.5 mg
3
3
2
3
3
4
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
candesartan-hydrochlorothiazid
oral tablet 32-12.5 mg, 32-25
mg
captopril oral tablet 100 mg,
25 mg, 50 mg
captopril oral tablet 12.5 mg
captopril-hydrochlorothiazide
mg, 50-25 mg
captopril-hydrochlorothiazide
CARDIZEM LA ORAL
TABLET EXTENDED
RELEASE 24 HR 180 MG,
240 MG, 420 MG
cartia xt
carvedilol
chlorothiazide oral tablet 250
mg
chlorothiazide oral tablet 500
mg
chlorothiazide sodium
chlorthalidone oral tablet 25
mg, 50 mg
cholestyramine (with sugar)
cholestyramine light
cilostazol
clonidine hcl oral tablet
clonidine transdermal patch
3
MO; QLL (30 per
30 days)
2
MO
1
2
MO
MO
1
MO
4
MO
2
1
1
MO
MO
MO
2
MO
4
2
MO
MO
2
2
2
2
4
clopidogrel oral tablet 300 mg
4
clopidogrel oral tablet 75 mg
2
colestipol
COREG CR
CORZIDE ORAL TABLET
40-5 MG
COUMADIN ORAL
COZAAR ORAL TABLET
100 MG
COZAAR ORAL TABLET
25 MG, 50 MG
CRESTOR
2
4
4
MO
MO
MO
MO
MO; QLL (4 per 28
days)
MO; QLL (1 per 30
days)
MO; QLL (30 per
30 days)
MO
ST; MO
MO
DEMSER
4
4
4
4
3
MO
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO
Core_16293_CG6_v15_1609_1
34
Drug Name
DIGITEK ORAL TABLET
125 MCG
DIGOX ORAL TABLET
125 MCG
digoxin oral solution 50 mcg/ml
digoxin oral tablet 125 mcg
dilt-xr
diltiazem hcl intravenous
diltiazem hcl oral capsule,
extended release 120 mg, 180
mg, 240 mg, 300 mg
diltiazem hcl oral capsule,ext
release degradable
extended release 24hr 120 mg,
180 mg, 240 mg, 300 mg
diltiazem hcl oral tablet
DIOVAN HCT
Drug Requirements/
Tier Limits
3
MO
3
MO
3
3
2
4
2
MO
MO
MO
Drug Name
Drug Requirements/
Tier Limits
enoxaparin subcutaneous
syringe 30 mg/0.3 ml
eplerenone
eprosartan
4
EXFORGE
4
4
MO
EXFORGE HCT
4
3
MO
3
2
MO
2
MO
3
MO
4
MO
2
MO
3
MO; QLL (30 per
30 days)
4
MO
3
MO
1
4
MO
MO; QLL (30 per
30 days)
felodipine oral tablet extended
release 24 hr 10 mg
felodipine oral tablet extended
release 24 hr 2.5 mg, 5 mg
fenofibrate micronized oral
capsule 130 mg
capsule 134 mg, 200 mg, 67
mg
capsule 43 mg
fenofibrate nanocrystallized 48
mg, 145 mg
fenofibrate oral tablet 160 mg
MO; QLL (8.4 per
30 days)
MO; QLL (11.2 per
30 days)
MO; QLL (16.8 per
30 days)
MO
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO
3
MO
3
fenofibrate oral tablet 54 mg
2
fenofibric acid (choline) dr
capsules
flecainide oral tablet 100 mg,
50 mg
flecainide oral tablet 150 mg
fluvastatin oral capsule 20 mg
3
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO
3
MO
4
3
fluvastatin oral capsule 40 mg
4
fondaparinux subcutaneous
syringe 2.5 mg/0.5 ml
syringe 5 mg/0.4 ml
5
MO
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (24 per
30 days)
MO; QLL (15 per
30 days)
MO; QLL (12 per
30 days)
dofetilide
doxazosin
DYAZIDE
EFFIENT
4
2
4
3
ELIQUIS ORAL TABLET
2.5 MG
ELIQUIS ORAL TABLET 5
MG
enalapril maleate
enalapril-hydrochlorothiazide
solution
syringe 100 mg/ml, 150 mg/ml
syringe 120 mg/0.8 ml, 80 mg/
0.8 ml
3
3
6
6
5
5
5
4
4
4
3
MO
MO
MO
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (74 per
30 days)
MO; CG
MO; CG
MO; QLL (84 per
30 days)
MO; QLL (28 per
30 days)
MO; QLL (22.4 per
30 days)
4
5
Core_16293_CG6_v15_1609_1
35
Drug Name
syringe 7.5 mg/0.6 ml
fosinopril
fosinopril-hydrochlorothiazide
fosinopril-hydrochlorothiazide
furosemide injection
furosemide oral solution 10 mg/
ml
furosemide oral solution 40 mg/
5 ml (8 mg/ml)
furosemide oral tablet
gemfibrozil oral
heparin (porcine) in 5 % dex
intravenous parenteral solution
12,500 unit/250 ml
20,000 unit/500 ml (40 unit/
ml)
25,000 unit/250 ml(100 unit/
ml), 25,000 unit/500 ml (50
unit/ml)
heparin (porcine) in nacl (pf)
1,000 unit/500 ml, 2,000
unit/1,000 ml
heparin (porcine) injection
cartridge
heparin (porcine) injection
solution
heparin(porcine) in 0.45% nacl
12,500 unit/250 ml
25,000 unit/250 ml
25,000 unit/500 ml
heparin, porcine (pf) injection
solution
hydralazine injection
Drug Requirements/
Tier Limits
5
1
3
MO; QLL (18 per
30 days)
MO
MO
2
MO
4
2
MO
MO
1
MO
1
2
4
MO
MO
B/D PAR
4
4
4
MO
B/D PAR
4
B/D PAR; MO
4
B/D PAR; MO
4
B/D PAR
4
4
Drug Name
Drug Requirements/
Tier Limits
hydralazine oral
hydrochlorothiazide
HYZAAR
2
1
4
indapamide
irbesartan
1
1
irbesartan-hydrochlorothiazide
irbesartan-hydrochlorothiazide
isosorbide dinitrate oral tablet
10 mg, 20 mg, 5 mg
30 mg
extended release
isosorbide mononitrate
isradipine
jantoven oral tablet 1 mg, 10
mg, 2.5 mg, 3 mg, 4 mg, 5 mg,
6 mg, 7.5 mg
jantoven oral tablet 2 mg
JUXTAPID
labetalol intravenous solution
labetalol oral tablet 100 mg,
200 mg
labetalol oral tablet 300 mg
LANOXIN ORAL TABLET
125 MCG, 62.5 MCG
LESCOL
2
LIPITOR ORAL TABLET
10 MG
lisinopril
lisinopril-hydrochlorothiazide
LOFIBRA ORAL CAPSULE
200 MG
LOPID
losartan oral tablet 100 mg
4
losartan oral tablet 25 mg, 50
mg
losartan-hydrochlorothiazide
6
4
MO
MO
MO; QLL (30 per
30 days)
MO
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO
3
MO
4
MO
2
3
1
MO
MO
MO
2
5
4
2
MO
PAR; MO; LA
MO
MO
3
3
MO
MO
4
MO; QLL (60 per
30 days)
MO
3
6
6
4
4
6
B/D PAR; MO
4
MO
4
MO
6
MO; CG
MO; CG
MO; QLL (30 per
30 days)
MO
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (30
per 30 days)
Core_16293_CG6_v15_1609_1
36
Drug Name
Drug Requirements/
Tier Limits
LOTENSIN ORAL TABLET
20 MG, 40 MG
lovastatin oral tablet 10 mg, 20
mg
lovastatin oral tablet 40 mg
4
MO
6
MAVIK ORAL TABLET 1
MG, 2 MG
MAXZIDE
MAXZIDE-25MG
methyclothiazide
metolazone oral tablet 10 mg,
5 mg
metolazone oral tablet 2.5 mg
metoprolol succinate oral tablet
25 mg, 50 mg
metoprolol succinate oral tablet
metoprolol ta-hydrochlorothiaz
mg
metoprolol ta-hydrochlorothiaz
metoprolol tartrate intravenous
solution
metoprolol tartrate intravenous
syringe
metoprolol tartrate oral tablet
100 mg, 25 mg, 50 mg
metoprolol tartrate oral tablet
37.5 mg, 75 mg
mexiletine oral capsule 150 mg,
250 mg
mexiletine oral capsule 200 mg
MICARDIS HCT ORAL
TABLET 40-12.5 MG, 80-25
MG
MICARDIS HCT ORAL
TABLET 80-12.5 MG
MICARDIS ORAL TABLET
20 MG, 40 MG
MICARDIS ORAL TABLET
80 MG
MICROZIDE
4
MO; CG; QLL (30
per 30 days)
MO; CG; QLL (60
per 30 days)
MO
6
4
4
3
3
MO
MO
MO
MO
2
2
MO
MO
3
MO
3
MO
2
MO
4
MO
4
1
MO
1
3
MO
4
4
MO
MO; QLL (30 per
30 days)
4
4
4
4
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO
Drug Name
Drug Requirements/
Tier Limits
MINIPRESS ORAL
CAPSULE 2 MG
minoxidil oral
moexipril
moexipril-hydrochlorothiazide
MULTAQ
4
MO
2
2
2
3
nadolol oral tablet 20 mg, 40
mg
nadolol oral tablet 80 mg
nadolol-bendroflumethiazide
niacin oral tablet extended
release 24 hr 1,000 mg, 750
mg
niacin oral tablet extended
NIACOR
nicardipine intravenous
solution
nicardipine oral
nifedical xl
nifedipine oral tablet extended
release 24hr 30 mg, 60 mg
release 24hr 90 mg
release 30 mg, 60 mg
release 90 mg
nimodipine
nitroglycerin intravenous
nitroglycerin transdermal patch
24 hour
NITROSTAT
NORPACE
NORVASC ORAL TABLET
10 MG, 2.5 MG
NORVASC ORAL TABLET
5 MG
omega-3 acid ethyl esters
pacerone oral tablet 100 mg,
400 mg
pacerone oral tablet 200 mg
pentoxifylline
perindopril erbumine
pindolol oral tablet 10 mg
3
MO
MO
MO
MO; QLL (60 per
30 days)
MO
4
3
4
MO
MO
MO; QLL (60 per
30 days)
4
3
4
MO; QLL (30 per
30 days)
MO
MO
2
2
2
MO
MO
MO
3
MO
2
MO
3
MO
4
4
2
MO
B/D PAR
MO
3
4
4
3
4
MO
PAR; MO
MO; QLL (30 per
30 days)
MO; QLL (45 per
30 days)
PAR; MO
MO
2
2
2
3
MO
MO
MO
MO
4
Core_16293_CG6_v15_1609_1
37
Drug Name
Drug Requirements/
Tier Limits
pindolol oral tablet 5 mg
PRADAXA
2
4
PRALUENT PEN
5
PRALUENT SYRINGE
5
PRAVACHOL ORAL
TABLET 20 MG
pravastatin oral tablet 10 mg,
20 mg, 40 mg
pravastatin oral tablet 80 mg
4
prazosin oral capsule 1 mg, 2
mg
prazosin oral capsule 5 mg
prevalite
PRINIVIL ORAL TABLET
10 MG, 20 MG, 5 MG
procainamide injection solution
100 mg/ml
procainamide injection solution
500 mg/ml
PROCARDIA
PROCARDIA XL ORAL
TABLET EXTENDED
RELEASE 24HR 30 MG
PROMACTA ORAL
TABLET 12.5 MG, 25 MG,
75 MG
PROMACTA ORAL
TABLET 50 MG
propafenone oral tablet 150
mg, 225 mg
propafenone oral tablet 300 mg
propranolol intravenous
propranolol oral capsule,
160 mg
propranolol oral capsule,
80 mg
propranolol oral solution
propranolol oral tablet 10 mg,
20 mg, 40 mg, 80 mg
propranolol oral tablet 60 mg
2
MO; CG; QLL (30
per 30 days)
MO; QLL (30 per
30 days)
MO
3
2
4
MO
MO
MO
6
1
MO
MO; QLL (60 per
30 days)
PAR; MO; QLL (2
per 28 days)
PAR; MO; QLL (2
per 28 days)
MO
Drug Name
propranolol-hydrochlorothiazid
quinapril oral tablet 10 mg, 5
mg
quinapril oral tablet 20 mg, 40
mg
quinapril-hydrochlorothiazide
quinidine sulfate oral tablet
ramipril
RANEXA
REPATHA SURECLICK
2
1
MO
MO
2
MO
2
2
1
3
5
REPATHA SYRINGE
5
reserpine oral tablet 0.1 mg
rosuvastatin
1
3
simvastatin
6
2
MO
MO
MO
MO
PAR; MO; QLL (3
per 28 days)
PAR; MO; QLL (3
per 28 days)
PAR; MO
QLL (30 per 30
days)
MO; CG; QLL (30
per 30 days)
MO
2
1
2
MO
MO
1
2
MO
MO
1
3
3
MO
MO
MO
2
MO
4
MO
2
MO
3
MO
4
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
2
1
sorine oral tablet 120 mg, 160
MO
mg
sorine oral tablet 240 mg
sorine oral tablet 80 mg
sotalol af oral tablet 120 mg,
PAR; MO
160 mg
MO
sotalol af oral tablet 80 mg
sotalol oral tablet 120 mg, 160
mg, 240 mg
PAR; MO; LA; QLL sotalol oral tablet 80 mg
(30 per 30 days)
spironolacton-hydrochlorothiaz
spironolactone oral tablet 100
PAR; MO; LA; QLL mg
(60 per 30 days)
spironolactone oral tablet 25
MO
mg, 50 mg
SULAR ORAL TABLET
MO
EXTENDED RELEASE 24
HR 17 MG
MO
taztia xt oral capsule, extended
release 120 mg, 180 mg, 240
mg, 360 mg
MO
taztia xt oral capsule, extended
release 300 mg
TEKTURNA
MO
MO
TEKTURNA HCT
2
MO
4
4
4
4
5
5
3
4
4
3
2
Drug Requirements/
Tier Limits
4
Core_16293_CG6_v15_1609_1
38
Drug Name
Drug Requirements/
Tier Limits
telmisartan oral tablet 20 mg,
40 mg
telmisartan oral tablet 80 mg
4
telmisartan-hydrochlorothiazid
oral tablet 40-12.5 mg, 80-25
mg
telmisartan-hydrochlorothiazid
TENORETIC 100
TENORETIC 50
terazosin
TIAZAC
TIKOSYN
timolol maleate oral tablet 10
mg, 5 mg
timolol maleate oral tablet 20
mg
torsemide oral tablet 10 mg, 5
mg
torsemide oral tablet 100 mg,
20 mg
trandolapril
tranexamic acid intravenous
triamterene-hydrochlorothiazid
oral capsule 37.5-25 mg
triamterene-hydrochlorothiazid
oral tablet
TRIBENZOR
4
TRICOR ORAL TABLET
48 MG
TRILIPIX ORAL CAPSULE,
DELAYED RELEASE(DR/
EC) 45 MG
TWYNSTA ORAL TABLET
40-10 MG, 40-5 MG, 80-5
MG
valsartan oral tablet 160 mg
valsartan oral tablet 320 mg
4
valsartan oral tablet 40 mg, 80
mg
valsartan-hydrochlorothiazide
oral tablet 160-12.5 mg, 160-
4
Drug Name
Drug Requirements/
Tier Limits
4
4
1
4
4
2
MO; QLL (60 per
30 days)
MO
MO
MO
MO
MO
MO
3
MO
2
MO
3
MO
1
3
1
MO
MO
MO
1
MO
3
4
MO; QLL (30 per
30 days)
MO
4
MO
4
MO; QLL (30 per
30 days)
25 mg, 320-12.5 mg, 80-12.5
mg
valsartan-hydrochlorothiazide
VASCEPA
VASERETIC
VASOTEC ORAL TABLET
2.5 MG
VECAMYL
verapamil intravenous solution
verapamil intravenous syringe
verapamil oral capsule, 24 hr
er pellet ct
verapamil oral capsule,ext rel.
pellets 24 hr 120 mg, 180 mg,
240 mg
verapamil oral capsule,ext rel.
pellets 24 hr 360 mg
verapamil oral tablet
verapamil oral tablet extended
release 120 mg, 120 mg (24
hours)
verapamil oral tablet extended
release 180 mg, 240 mg
warfarin
WELCHOL
XARELTO ORAL TABLET
10 MG, 20 MG
XARELTO ORAL TABLET
15 MG
XARELTO ORAL
TABLETS,DOSE PACK
ZESTORETIC
ZESTRIL ORAL TABLET
10 MG, 20 MG, 40 MG, 5
MG
ZETIA
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (30 per
30 days)
ZIAC ORAL TABLET 104
6.25 MG, 5-6.25 MG
ZOCOR ORAL TABLET 10 4 MO
MG, 5 MG
Dermatologicals/Topical Therapy
acitretin
5 MO
acyclovir topical
4 MO; QLL (30 per
30 days)
4
4
4
2
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
3
4
4
4
4
4
4
3
MO; QLL (30 per
30 days)
MO
MO
MO
MO
MO
2
MO
3
MO
1
2
MO
MO
1
MO
1
3
3
MO
MO
MO; QLL (30 per
30 days)
MO; QLL (42 per
30 days)
MO; QLL (102 per
365 days)
MO
MO
3
3
4
4
4
MO; QLL (30 per
30 days)
MO
Core_16293_CG6_v15_1609_1
39
Drug Name
Drug Requirements/
Tier Limits
adapalene topical gel 0.1 %
alclometasone topical cream
alclometasone topical ointment
amcinonide
ammonium lactate
betamethasone dipropionate
topical cream
topical lotion
topical ointment
betamethasone valerate topical
cream
lotion
ointment
betamethasone, augmented
topical cream
topical gel
topical lotion
topical ointment
calcipotriene scalp
4
4
3
4
2
4
MO
MO
MO
MO
MO
MO
3
MO
4
MO
2
MO
4
MO
3
MO
3
MO
4
MO
4
MO
4
MO
calcipotriene topical
4
ciclodan topical cream
ciclodan topical solution
ciclopirox topical cream
ciclopirox topical gel
ciclopirox topical shampoo
ciclopirox topical solution
ciclopirox topical suspension
claravis oral capsule 10 mg, 20
mg, 40 mg
claravis oral capsule 30 mg
clindamycin phosphate topical
gel
lotion
solution
3
3
3
4
4
2
3
4
MO; QLL (60 per
30 days)
MO; QLL (120 per
30 days)
MO
PAR; MO
MO
MO
MO
PAR; MO
MO
MO
5
3
MO
MO
3
MO
3
MO
4
Drug Name
Drug Requirements/
Tier Limits
swab
clindamycin-benzoyl peroxide
topical gel
clobetasol scalp
clobetasol topical cream
clobetasol topical foam
clobetasol topical gel
clobetasol topical lotion
clobetasol topical ointment
clobetasol topical shampoo
clobetasol-emollient topical
cream
clobetasol-emollient topical
foam
CLOBEX TOPICAL
LOTION
clotrimazole topical cream
clotrimazole topical solution
clotrimazole-betamethasone
topical cream
clotrimazole-betamethasone
topical lotion
cormax scalp
DENAVIR
2
MO
4
MO
2
2
4
2
4
3
4
3
MO
MO
MO
MO
MO
MO
MO
MO
4
MO
4
MO
3
2
3
MO
MO
MO
4
MO
DERMATOP TOPICAL
OINTMENT
desonide
desoximetasone topical cream
desoximetasone topical gel
desoximetasone topical ointment
0.25 %
diflorasone
DIPROLENE AF
econazole topical
ELIDEL
4
MO; QLL (5 per 2
days)
MO
4
4
4
4
MO
MO
MO
MO
4
4
2
4
ELOCON TOPICAL
SOLUTION
ery pads
erythromycin with ethanol
erythromycin-benzoyl peroxide
fluocinolone topical cream
fluocinolone topical ointment
4
MO
MO
MO
PAR; MO; QLL
(100 per 90 days)
MO
3
2
3
4
4
MO
MO
MO
MO
MO
2
3
Core_16293_CG6_v15_1609_1
40
Drug Name
fluocinolone topical solution
fluocinonide topical cream 0.05
%
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
fluocinonide-e
fluorouracil topical cream 5 %
fluorouracil topical solution
fluticasone topical cream
fluticasone topical lotion
fluticasone topical ointment
gentamicin topical
halobetasol propionate
hydrocortisone butyrate topical
cream
ointment
solution
hydrocortisone topical cream 1
%
hydrocortisone topical cream
2.5 %
hydrocortisone topical lotion 2.5
%
hydrocortisone topical ointment
1%
hydrocortisone topical ointment
2.5 %
hydrocortisone valerate
hydrocortisone-min oil-wht pet
imiquimod
ketoconazole topical cream
ketoconazole topical shampoo
lidocaine hcl laryngotracheal
lidocaine hcl mucous membrane
lidocaine hcl urethral
lidocaine topical adhesive patch,
medicated
lidocaine topical ointment
lidocaine viscous
lidocaine-prilocaine topical
cream
lindane topical shampoo
Drug Requirements/
Tier Limits
4
2
MO
MO
3
3
4
3
4
4
3
4
3
3
4
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
MO
2
MO
1
MO
2
MO
3
MO
1
MO
2
MO
4
2
4
3
2
2
2
2
4
4
2
4
MO
MO
MO
MO
MO
MO
MO
MO
PAR; MO; QLL (90
per 30 days)
MO
MO
MO
4
MO
Drug Name
Drug Requirements/
Tier Limits
malathion
methoxsalen rapid
metronidazole topical cream
metronidazole topical gel 0.75
%
metronidazole topical lotion
mometasone topical
mupirocin calcium
mupirocin topical ointment
myorisan oral capsule 10 mg,
20 mg, 40 mg
nyamyc
nystatin topical cream
nystatin topical ointment
nystatin topical powder
nystatin-triamcinolone
nystop
PANRETIN
permethrin topical cream
PICATO
podofilox
prednicarbate
rosadan topical cream
rosadan topical gel
SANTYL
4
5
4
3
MO
PAR; MO
MO
MO
4
2
4
2
4
MO
MO
MO
MO
MO
3
2
3
3
4
3
5
3
4
4
4
2
2
4
selenium sulfide topical lotion
SILVADENE
silver sulfadiazine
ssd
sulfacetamide sodium (acne)
TAZORAC
TEMOVATE TOPICAL
CREAM
TEMOVATE TOPICAL
OINTMENT
tretinoin topical cream
2
3
2
2
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO; QLL (30 per
30 days)
MO
MO
MO
MO
MO
PAR; MO
MO
4
MO
3
tretinoin topical gel 0.01 %,
0.025 %
triamcinolone acetonide topical
cream 0.025 %
triamcinolone acetonide topical
cream 0.1 %, 0.5 %
3
1
MO; QLL (45 per
30 days)
MO; QLL (45 per
30 days)
MO
2
MO
Core_16293_CG6_v15_1609_1
41
Drug Name
Drug Requirements/
Tier Limits
triamcinolone acetonide topical 3 MO
lotion 0.025 %
lotion 0.1 %
ointment 0.025 %, 0.1 %, 0.5
%
trianex
2 MO
triderm topical cream
1 MO
UVADEX
4
VALCHLOR
5 MO
zenatane oral capsule 10 mg,
4 MO
20 mg, 40 mg
ZENATANE ORAL
3 MO
CAPSULE 30 MG
Diagnostics / Miscellaneous Agents
acamprosate
4 MO
acetic acid irrigation
2 MO
acetylcysteine intravenous
2 MO
ADAGEN
5 MO
alendronate oral tablet 40 mg
6 MO; CG; QLL (30
per 30 days)
anagrelide
3 MO
ARALAST NP
5 PAR; MO; LA
BUPHENYL ORAL
5 PAR; MO
TABLET
buproban
2 QLL (60 per 30
days)
CARBAGLU
5 PAR; MO; LA
CHANTIX
4 PAR; MO; QLL (60
per 30 days)
CHANTIX CONTINUING 4 PAR; MO; QLL (56
MONTH BOX
per 28 days)
CHANTIX STARTING
4 PAR; MO; QLL
MONTH BOX
(106 per 365 days)
CLINIMIX 4.25%/D5W
4 B/D PAR
SULFIT FREE
CLINIMIX E 2.75%/D10W 4 B/D PAR
SUL FREE
CLINIMIX E 2.75%/D5W
4 B/D PAR
SULF FREE
d10 %-0.45 % sodium
4
chloride
d2.5 %-0.45 % sodium
4
chloride
Drug Name
Drug Requirements/
Tier Limits
d5 % and 0.9 % sodium
chloride
d5 %-0.45 % sodium chloride
dextrose 10 % and 0.2 % nacl
dextrose 10 % in water (d10w)
dextrose 5 %-lactated ringers
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
intravenous syringe
dextrose with sodium chloride
disulfiram
etidronate disodium oral tablet
200 mg
etidronate disodium oral tablet
400 mg
EXJADE
INCRELEX
kionex
lactated ringers irrigation
levocarnitine (with sugar)
levocarnitine intravenous
levocarnitine oral tablet
midodrine
neomycin-polymyxin b gu
NICOTROL NS
4
MO
4
4
4
4
4
4
4
4
4
4
4
MO
ORFADIN ORAL
CAPSULE
PHYSIOLYTE
PHYSIOSOL IRRIGATION
pilocarpine hcl oral
PROLASTIN-C
RAVICTI
5
RENVELA ORAL
POWDER IN PACKET 0.8
GRAM
5
MO
MO
MO
MO
4
4
4
4
3
MO
2
MO
5
5
3
4
3
4
3
4
4
3
PAR; MO; LA
PAR; MO; LA
MO
MO
B/D PAR; MO
B/D PAR; MO
MO
MO
MO
MO; QLL (120 per
30 days)
LA
4
4
4
5
5
MO
MO
MO
PAR; LA
PAR; MO; QLL
(525 per 30 days)
MO; QLL (180 per
30 days)
Core_16293_CG6_v15_1609_1
42
Drug Name
RENVELA ORAL
POWDER IN PACKET 2.4
GRAM
RENVELA ORAL TABLET
riluzole
ringers irrigation
risedronate oral tablet 30 mg
Drug Requirements/
Tier Limits
5
MO; QLL (90 per
30 days)
3
MO; QLL (270 per
30 days)
MO
MO
ST; MO; QLL (30
per 30 days)
MO
4
4
4
sodium chloride 0.9 %
4
intravenous
sodium chloride irrigation
4
sodium phenylbutyrate
5
sodium polystyrene (sorb free)
4
sodium polystyrene sulfonate
4
oral powder
4
oral suspension
4
rectal
sps oral
4
sps rectal
4
SYPRINE
5
THIOLA
5
water for irrigation, sterile
4
Ear, Nose / Throat Medications
acetasol hc
4
acetic acid otic
3
acetic acid-aluminum acetate
2
azelastine nasal
4
chlorhexidine gluconate mucous
membrane
CIPRODEX
denta 5000 plus
dentagel
fluocinolone acetonide oil otic
hydrocortisone-acetic acid
ipratropium bromide nasal
1
neomycin-polymyxin-hc otic
ofloxacin otic
paroex oral rinse
periogard
sf 5000 plus
2
2
1
1
2
3
2
2
4
4
2
MO
PAR; MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO; QLL (30 per
25 days)
MO
MO
MO
MO
MO
MO
MO; QLL (30 per
30 days)
MO
MO
MO
MO
MO
Drug Name
Drug Requirements/
Tier Limits
triamcinolone acetonide dental
TYZINE NASAL DROPS
0.05 %
Endocrine/Diabetes
acarbose oral tablet 100 mg
4
4
MO
MO
3
3
3
ACTHAR H.P.
ACTOPLUS MET XR
ORAL TABLET, ER
MULTIPHASE 24 HR 15-1,
000 MG
ACTOPLUS MET XR
ORAL TABLET, ER
000 MG
alcohol pads
ALDURAZYME
AMARYL ORAL TABLET 1
MG
MG
MG
ANDROGEL
TRANSDERMAL GEL IN
METERED-DOSE PUMP
20.25 MG/1.25 GRAM (1.62
%)
ANDROGEL
TRANSDERMAL GEL IN
PACKET 1.62 % (20.25
MG/1.25 GRAM)
ANDROGEL
TRANSDERMAL GEL IN
PACKET 1.62 % (40.5 MG/
2.5 GRAM)
androxy
BYDUREON
5
4
MO; QLL (90 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
PAR; MO
MO; QLL (60 per
30 days)
BYETTA
SUBCUTANEOUS PEN
INJECTOR 10 MCG/
3
4
MO; QLL (45 per
30 days)
1
5
4
MO
PAR; MO
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
PAR; MO; QLL
(150 per 30 days)
4
4
3
3
PAR; MO; QLL
(112.5 per 30 days)
3
PAR; MO; QLL
(150 per 30 days)
4
3
PAR; MO
MO; QLL (4 per 28
days)
MO; QLL (2.4 per
30 days)
Core_16293_CG6_v15_1609_1
43
Drug Name
DOSE(250 MCG/ML) 2.4
ML
BYETTA
SUBCUTANEOUS PEN
INJECTOR 5 MCG/DOSE
(250 MCG/ML) 1.2 ML
cabergoline
calcitonin (salmon)
calcitriol intravenous solution
1 mcg/ml
calcitriol oral capsule
calcitriol oral solution
CEREZYME
INTRAVENOUS RECON
SOLN 400 UNIT
cortisone
CYCLOSET
CYTOMEL
danazol oral
desmopressin injection
desmopressin nasal aerosol,spray
desmopressin nasal solution
desmopressin nasal spray,nonaerosol
desmopressin oral
dexamethasone oral elixir
0.5mg/ml
dexamethasone oral solution
0.5mg/ml
dexamethasone oral tablet 0.5
mg, 1.5 mg
dexamethasone oral tablet 0.75
mg, 1 mg, 4 mg, 6 mg
dexamethasone oral tablet 2 mg
dexamethasone sodium phos (pf)
dexamethasone sodium
phosphate injection
doxercalciferol intravenous
DUETACT ORAL TABLET
30-4 MG
ELAPRASE
FABRAZYME
fludrocortisone
Drug Requirements/
Tier Limits
3
3
3
4
2
3
5
4
4
MO; QLL (1.2 per
30 days)
MO
MO; QLL (4 per 30
days)
MO
B/D PAR; MO
B/D PAR; MO
PAR; MO
4
3
5
4
3
4
MO
ST; MO; QLL (180
per 30 days)
MO
MO
MO
MO
MO
MO
4
4
MO
MO
4
1
2
MO
MO
MO
3
4
4
MO
MO
MO
4
4
B/D PAR
MO; QLL (30 per
30 days)
PAR; MO
PAR; MO
MO
5
5
3
Drug Name
Drug Requirements/
Tier Limits
fortical
3
gauze pads 2 x 2
1
glimepiride oral tablet 1 mg
6
6
6
glipizide oral tablet 10 mg
6
glipizide oral tablet 5 mg
6
glipizide oral tablet extended
release 24hr 10 mg
release 24hr 2.5 mg
release 24hr 5 mg
glipizide-metformin oral tablet
2.5-250 mg
glipizide-metformin oral tablet
2.5-500 mg, 5-500 mg
GLUCAGEN HYPOKIT
GLUCAGON
EMERGENCY KIT
(HUMAN)
GLUCOPHAGE ORAL
TABLET 1,000 MG
GLUCOPHAGE ORAL
TABLET 500 MG
GLUCOPHAGE ORAL
TABLET 850 MG
GLUCOPHAGE XR ORAL
TABLET EXTENDED
GLUCOPHAGE XR ORAL
TABLET EXTENDED
GLUCOTROL ORAL
TABLET 10 MG
GLUCOTROL ORAL
TABLET 5 MG
1
6
6
2
3
3
4
4
4
4
4
MO; QLL (4 per 30
days)
MO; QLL (200 per
30 days)
MO; CG; QLL (240
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (60
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (240
per 30 days)
MO; QLL (60 per
30 days)
MO; CG; QLL (240
per 30 days)
MO; CG; QLL (120
per 30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO
MO
MO; QLL (76 per
30 days)
MO; QLL (153 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (120 per
30 days)
4
MO; QLL (80 per
30 days)
4
MO; QLL (120 per
30 days)
MO; QLL (240 per
30 days)
4
Core_16293_CG6_v15_1609_1
44
Drug Name
Drug Requirements/
Tier Limits
GLUCOTROL XL ORAL
TABLET EXTENDED
RELEASE 24HR 10 MG
GLUCOTROL XL ORAL
TABLET EXTENDED
RELEASE 24HR 2.5 MG
GLUCOTROL XL ORAL
TABLET EXTENDED
RELEASE 24HR 5 MG
GLUCOVANCE
4
MO; QLL (60 per
30 days)
4
MO; QLL (240 per
30 days)
GLUMETZA ORAL
TABLET,ER
GAST.RETENTION 24 HR
1,000 MG
GLUMETZA ORAL
TABLET,ER
GAST.RETENTION 24 HR
500 MG
HUMALOG
HUMALOG KWIKPEN
HUMALOG MIX 50-50
HUMALOG MIX 50-50
KWIKPEN
HUMALOG MIX 75-25
HUMALOG MIX 75-25
KWIKPEN
HUMAPEN LUXURA HD
4
HUMULIN 70/30
HUMULIN 70/30
KWIKPEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN R
HUMULIN R U-500
(CONC) KWIKPEN
HUMULIN R U-500
(CONCENTRATED)
hydrocortisone oral tablet 10
mg, 5 mg
hydrocortisone oral tablet 20
mg
insulin pen needle
3
3
4
MO; QLL (120 per
30 days)
4
PAR; MO; QLL
(120 per 30 days)
MO; QLL (60 per
30 days)
4
3
3
3
3
3
3
3
3
3
3
3
MO; QLL (120 per
30 days)
MO
MO
MO
MO
MO
MO
MO; QLL (200 per
30 days)
MO
MO
MO
MO
MO
3
MO
3
MO
2
MO
3
MO; QLL (200 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
INSULIN SYRINGE (DISP)
U-100 0.3 ML, 1 ML, 1/2
ML
JANUMET
3
MO; QLL (200 per
30 days)
3
JANUMET XR ORAL
TABLET, ER
MULTIPHASE 24 HR 1001,000 MG
JANUMET XR ORAL
TABLET, ER
000 MG, 50-500 MG
JANUVIA ORAL TABLET
100 MG
JANUVIA ORAL TABLET
25 MG
JANUVIA ORAL TABLET
50 MG
JARDIANCE
3
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
JENTADUETO
3
KORLYM
KUVAN ORAL TABLET,
SOLUBLE
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
levothyroxine oral
levoxyl oral tablet 100 mcg,
112 mcg, 125 mcg, 137 mcg,
150 mcg, 175 mcg, 200 mcg,
25 mcg, 50 mcg, 75 mcg, 88
mcg
liothyronine intravenous
liothyronine oral tablet 25 mcg,
5 mcg
liothyronine oral tablet 50 mcg
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
6
metformin oral tablet 850 mg
6
3
MO; QLL (60 per
30 days)
3
5
5
MO; QLL (30 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
PAR; MO; QLL (30
per 30 days)
MO; QLL (60 per
30 days)
PAR; MO
PAR; MO
3
3
3
3
1
2
MO
MO
MO
MO
MO
MO
5
3
MO
MO
4
6
MO
MO; CG; QLL (76
per 30 days)
MO; CG; QLL (153
per 30 days)
MO; CG; QLL (90
per 30 days)
3
3
4
Core_16293_CG6_v15_1609_1
45
Drug Name
Drug Requirements/
Tier Limits
metformin oral tablet extended
release 24hr 1,000 mg
release 24hr 500 mg
metformin oral tablet,er
gast.retention 24 hr 1,000 mg
metformin oral tablet,er
gast.retention 24 hr 500 mg
methimazole oral tablet 10 mg
methimazole oral tablet 5 mg
methylprednisolone acetate
methylprednisolone oral tablet
16 mg, 4 mg, 8 mg
methylprednisolone oral tablet
32 mg
methylprednisolone oral tablets,
dose pack
methylprednisolone sodium succ
injection recon soln 125 mg, 40
mg
methylprednisolone sodium succ
intravenous
MIACALCIN INJECTION
MIACALCIN NASAL
6
MYOZYME
NAGLAZYME
nateglinide oral tablet 120 mg
5
5
4
Drug Requirements/
Tier Limits
pamidronate intravenous recon
soln
pamidronate intravenous
ml), 90 mg/10 ml (9 mg/ml)
pamidronate intravenous
ml)
paricalcitol oral capsule 1 mcg,
2 mcg
paricalcitol oral capsule 4 mcg
pioglitazone oral tablet 15 mg
4
MO
4
MO
4
B/D PAR; MO
4
B/D PAR; MO
5
2
3
2
4
4
MO; CG; QLL (120
per 30 days)
MO; CG; QLL (80
per 30 days)
MO; QLL (75 per
30 days)
MO; CG; QLL (150
per 30 days)
MO; QLL (60 per
30 days)
MO; QLL (120 per
30 days)
MO
MO
MO
MO
2
2
3
MO
pioglitazone-glimepiride
4
3
MO
pioglitazone-metformin
4
4
MO
3
B/D PAR; MO
MO; QLL (90 per
30 days)
MO; QLL (45 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (90 per
30 days)
MO; QLL (360 per
30 days)
MO; QLL (180 per
30 days)
MO
3
MO
4
MO
4
MO
4
3
2
1
MO
MO
MO
MO
1
MO
5
3
MO
MO
6
4
6
4
4
4
4
4
nateglinide oral tablet 60 mg
4
NATPARA
5
needles, insulin disp.,safety
3
NOVOPEN ECHO
3
oxandrolone oral tablet 10 mg
5
oxandrolone oral tablet 2.5 mg
Drug Name
3
PRECOSE ORAL TABLET
100 MG
PRECOSE ORAL TABLET
25 MG
MO
PRECOSE ORAL TABLET
50 MG
B/D PAR; MO
MO; QLL (4 per 30 prednisolone oral solution 15
mg/5 ml
days)
prednisolone sodium phosphate
PAR; MO
oral solution 15 mg/5 ml (3
PAR; MO; LA
mg/ml)
MO; QLL (90 per
30 days)
MO; QLL (180 per oral solution 5 mg base/5 ml
(6.7 mg/5 ml)
30 days)
PAR; MO; LA; QLL prednisolone sodium phosphate
oral tablet,disintegrating
(2 per 28 days)
MO; QLL (200 per prednisone intensol
prednisone oral solution
30 days)
MO; QLL (200 per prednisone oral tablet 1 mg
prednisone oral tablet 10 mg,
30 days)
PAR; MO; QLL (60 2.5 mg, 20 mg, 5 mg, 50 mg
prednisone oral tablets,dose
per 30 days)
pack
PAR; MO; QLL
PROGLYCEM
(120 per 30 days)
propylthiouracil
4
4
4
Core_16293_CG6_v15_1609_1
46
Drug Name
Drug Requirements/
Tier Limits
repaglinide oral tablet 0.5 mg
4
repaglinide oral tablet 1 mg
4
repaglinide oral tablet 2 mg
4
SAMSCA ORAL TABLET
15 MG
SAMSCA ORAL TABLET
30 MG
SENSIPAR ORAL TABLET
30 MG
60 MG
90 MG
SOMAVERT
STIMATE
SYMLINPEN 120
5
SYMLINPEN 60
4
SYNAREL
SYNJARDY
5
4
SYNTHROID
TANZEUM
5
3
5
5
5
4
5
4
4
TAPAZOLE
testosterone cypionate
testosterone enanthate
testosterone transdermal gel
4
4
4
3
testosterone transdermal gel in
metered-dose pump 1.25 gram/
actuation (1 %)
metered-dose pump 10 mg/0.5
gram /actuation
packet 1 % (25 mg/2.5gram)
packet 1 % (50 mg/5 gram)
tolazamide oral tablet 250 mg
3
3
3
3
2
MO; QLL (960 per
30 days)
MO; QLL (480 per
30 days)
MO; QLL (240 per
30 days)
PAR; MO; QLL (30
per 30 days)
PAR; MO; QLL (60
per 30 days)
MO; QLL (60 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (120 per
30 days)
PAR; MO
MO
PAR; MO; QLL (11
per 30 days)
PAR; MO; QLL (6
per 30 days)
PAR; MO
PAR; MO; QLL (60
per 30 days)
MO
MO; QLL (4 per 28
days)
MO
MO
MO
PAR; MO; QLL
(300 per 30 days)
PAR; MO; QLL
(300 per 30 days)
PAR; MO; QLL
(120 per 30 days)
PAR; MO; QLL
(225 per 30 days)
PAR; MO; QLL
(300 per 30 days)
MO; QLL (120 per
30 days)
Drug Name
Drug Requirements/
Tier Limits
tolazamide oral tablet 500 mg
2
tolbutamide
3
TOUJEO SOLOSTAR
TRADJENTA
3
3
triamcinolone acetonide
injection suspension 10 mg/ml
triamcinolone acetonide
injection suspension 40 mg/ml
TRULICITY
4
unithroid
VICTOZA 2-PAK
1
3
VICTOZA 3-PAK
3
VPRIV
ZAVESCA
zoledronic acid intravenous
recon soln 4 mg
zoledronic acid intravenous
solution 4 mg/5 ml
ZOMETA INTRAVENOUS
SOLUTION 4 MG/100 ML
Gastroenterology
alosetron
5
5
5
MO; QLL (2 per 28
days)
MO
MO; QLL (9 per 30
days)
MO; QLL (9 per 30
days)
PAR; MO
PAR; MO; LA
PAR
5
PAR; MO
5
PAR; MO
5
APRISO
ASACOL HD
atropine injection syringe 0.05
mg/ml, 0.1 mg/ml
balsalazide
budesonide oral
CIMZIA
3
3
4
PAR; MO; QLL (60
per 30 days)
MO
MO
CIMZIA POWDER FOR
RECONST
CIMZIA STARTER KIT
5
compro
constulose
CREON ORAL CAPSULE,
DELAYED RELEASE(DR/
EC) 12,000-38,000 -60,000
4
3
3
MO; QLL (60 per
30 days)
MO; QLL (180 per
30 days)
MO
MO; QLL (30 per
30 days)
MO
4
4
4
5
5
5
MO
MO
PAR; MO; QLL (6
per 28 days)
PAR; MO; QLL (6
per 28 days)
PAR; MO; QLL (6
per 28 days)
PAR; MO
MO
MO
Core_16293_CG6_v15_1609_1
47
Drug Name
UNIT, 24,000-76,000 -120,
000 UNIT, 3,000-9,500- 15,
000 UNIT, 6,000-19,000 30,000 UNIT
CREON ORAL CAPSULE,
DELAYED RELEASE(DR/
EC) 36,000-114,000- 180,
000 UNIT
cromolyn oral
CYSTADANE
DELZICOL ORAL
CAPSULE,DELAYED
RELEASE(DR/EC)
DEXILANT
Drug Requirements/
Tier Limits
5
MO
4
5
3
MO
MO
MO
4
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
DIPENTUM
diphenoxylate-atropine oral
liquid
diphenoxylate-atropine oral
tablet
dronabinol oral capsule 10 mg
2
4
2
5
1
ST; MO; QLL (30
per 30 days)
MO
MO
MO
MO
MO
3
MO
5
dronabinol oral capsule 2.5 mg,
5 mg
4
EMEND ORAL CAPSULE
125 MG
EMEND ORAL CAPSULE
40 MG
EMEND ORAL CAPSULE
80 MG
3
EMEND ORAL CAPSULE,
DOSE PACK
3
enulose
esomeprazole sodium
intravenous
famotidine (pf)
famotidine (pf)-nacl (iso-os)
famotidine intravenous
famotidine oral suspension
2
4
B/D PAR; MO;
QLL (120 per 30
days)
B/D PAR; MO;
QLL (120 per 30
days)
B/D PAR; MO;
QLL (5 per 30 days)
B/D PAR; MO;
QLL (1 per 2 days)
B/D PAR; MO;
QLL (10 per 30
days)
B/D PAR; MO;
QLL (15 per 30
days)
MO
3
3
4
4
4
4
MO
MO
MO
Drug Name
famotidine oral tablet 20 mg,
40 mg
GATTEX 30-VIAL
GATTEX ONE-VIAL
gavilyte-c
gavilyte-g
gavilyte-n
generlac
glycopyrrolate injection
glycopyrrolate oral tablet
hydrocortisone rectal cream 2.5
%
hydrocortisone rectal enema
lactulose
lansoprazole oral capsule,
delayed release(dr/ec)
LIALDA
LINZESS
loperamide oral capsule
meclizine oral tablet 12.5 mg,
25 mg
mesalamine rectal
mesalamine with cleansing wipe
methscopolamine oral
metoclopramide hcl injection
solution
metoclopramide hcl injection
syringe
metoclopramide hcl oral
solution
metoclopramide hcl oral tablet
misoprostol oral tablet 100 mcg
misoprostol oral tablet 200 mcg
MOVIPREP
nizatidine oral capsule 150 mg
nizatidine oral capsule 300 mg
omeprazole oral capsule,delayed
release(dr/ec) 10 mg, 40 mg
omeprazole oral capsule,delayed
ondansetron hcl (pf) injection
solution
ondansetron hcl (pf) injection
syringe
ondansetron hcl intravenous
Drug Requirements/
Tier Limits
2
MO
5
5
2
2
2
3
4
4
1
MO
MO
MO
MO
MO
MO
MO
MO
4
2
4
3
3
3
2
MO
MO
MO; QLL (30 per
30 days)
MO
MO
MO
MO
3
4
4
4
MO
MO
MO
MO
4
2
MO
2
3
4
4
3
4
2
MO
MO
MO
MO
MO
MO
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO
3
4
4
4
MO
Core_16293_CG6_v15_1609_1
48
Drug Name
Drug Requirements/
Tier Limits
ondansetron hcl oral tablet 4
mg, 8 mg
3
ondansetron oral tablet,
disintegrating 4 mg
4
ondansetron oral tablet,
disintegrating 8 mg
3
opium tincture
OSMOPREP
pantoprazole intravenous
pantoprazole oral
2
4
4
2
paregoric
peg 3350-electrolytes oral recon
soln 236-22.74-6.74 -5.86
gram
peg 3350-electrolytes oral recon
soln 240-22.72-6.72 -5.84
gram
peg-electrolyte soln
PENTASA
polyethylene glycol 3350 oral
prochlorperazine
prochlorperazine edisylate
injection solution 10 mg/2 ml
(5 mg/ml)
prochlorperazine maleate oral
procto-pak
proctosol hc
proctozone-hc
propantheline
ranitidine hcl injection
ranitidine hcl oral syrup
ranitidine hcl oral tablet 150
mg, 300 mg
RELISTOR
SUBCUTANEOUS
SOLUTION
RELISTOR
SUBCUTANEOUS
SYRINGE
REMICADE
SUCRAID
sucralfate oral tablet
2
2
B/D PAR; MO;
QLL (90 per 30
days)
B/D PAR; MO;
QLL (90 per 30
days)
B/D PAR; MO;
QLL (90 per 30
days)
MO
MO
MO
MO; QLL (30 per
30 days)
MO
MO
2
2
3
2
4
4
MO
MO
PAR; MO
PAR; MO
2
2
2
1
4
4
4
2
PAR; MO
MO
MO
MO
MO
MO
MO
MO
4
PAR; MO
5
PAR; MO
5
5
2
PAR; MO
MO
MO
Drug Name
Drug Requirements/
Tier Limits
sulfasalazine
2 MO
SUPREP BOWEL PREP KIT 3 MO
trilyte with flavor packets
2 MO
UCERIS ORAL
5 MO
ursodiol
4 MO
Immunology, Vaccines / Biotechnology
ACTHIB (PF)
3 MO
ACTIMMUNE
5 PAR; MO
ADACEL(TDAP
3 MO
ADOLESN/ADULT)(PF)
ARANESP (IN
5 PAR; MO
POLYSORBATE)
INJECTION SOLUTION
100 MCG/ML, 200 MCG/
ML, 300 MCG/ML
ARANESP (IN
4 PAR; MO
POLYSORBATE)
INJECTION SOLUTION
25 MCG/ML, 40 MCG/ML,
60 MCG/ML
ARANESP (IN
4 PAR; MO
POLYSORBATE)
INJECTION SYRINGE 10
MCG/0.4 ML, 25 MCG/
0.42 ML, 40 MCG/0.4 ML,
60 MCG/0.3 ML
ARANESP (IN
5 PAR; MO
POLYSORBATE)
INJECTION SYRINGE 100
MCG/0.5 ML, 150 MCG/
0.3 ML, 200 MCG/0.4 ML,
300 MCG/0.6 ML, 500
MCG/ML
ARCALYST
5 PAR; MO
AVONEX (WITH
5 PAR; MO; QLL (4
ALBUMIN)
per 28 days)
AVONEX
5 PAR; MO; QLL (4
INTRAMUSCULAR PEN
per 28 days)
INJECTOR KIT
AVONEX
5 PAR; MO; QLL (4
INTRAMUSCULAR
per 28 days)
SYRINGE
AVONEX
5 PAR; MO; QLL (4
INTRAMUSCULAR
per 28 days)
SYRINGE KIT
BCG VACCINE, LIVE (PF) 4 MO
Core_16293_CG6_v15_1609_1
49
Drug Name
BETASERON
SUBCUTANEOUS KIT
BEXSERO (PF)
BIVIGAM
BOOSTRIX TDAP
BOTOX
CARIMUNE NF
NANOFILTERED
INTRAVENOUS RECON
SOLN 12 GRAM, 6 GRAM
CERVARIX VACCINE (PF)
DAPTACEL (DTAP
PEDIATRIC) (PF)
DYSPORT
ENGERIX-B (PF)
ENGERIX-B PEDIATRIC
(PF)
EXTAVIA
SUBCUTANEOUS KIT
EXTAVIA
SUBCUTANEOUS RECON
SOLN
fomepizole
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAGARD S-D (IGA
< 1 MCG/ML)
GAMUNEX-C
GARDASIL (PF)
GARDASIL 9 (PF)
HAVRIX (PF)
INTRAMUSCULAR
SUSPENSION
HAVRIX (PF)
INTRAMUSCULAR
SYRINGE 1,440 ELISA
UNIT/ML
HAVRIX (PF)
INTRAMUSCULAR
SYRINGE 720 ELISA
UNIT/0.5 ML
HIBERIX (PF)
ILARIS (PF)
IMOVAX RABIES
VACCINE (PF)
INFANRIX (DTAP) (PF)
Drug Requirements/
Tier Limits
5
PAR; MO
3
5
3
4
5
MO
PAR; MO
MO
PAR; MO
PAR; MO
3
3
MO
MO
4
3
3
PAR; MO
B/D PAR; MO
B/D PAR; MO
5
PAR; MO
5
PAR
5
3
5
5
MO
PAR; MO
PAR; MO
PAR; MO
5
3
3
3
PAR; MO
MO
MO
MO
3
MO
3
3
5
3
PAR; MO; LA
MO
3
MO
Drug Name
Drug Requirements/
Tier Limits
INTRON A INJECTION
IPOL INJECTION
SUSPENSION
IXIARO (PF)
M-M-R II (PF)
MENACTRA (PF)
INTRAMUSCULAR
SOLUTION
MENOMUNE - A/C/Y/W135
MENOMUNE - A/C/Y/W135 (PF)
MENVEO A-C-Y-W-135DIP (PF)
NEUPOGEN
NORDITROPIN FLEXPRO
OCTAGAM
OMNITROPE
PEDVAX HIB (PF)
PEGINTRON
SUBCUTANEOUS KIT 120
MCG/0.5 ML, 50 MCG/0.5
ML, 80 MCG/0.5 ML
PLEGRIDY
5
3
PAR; MO
MO
3
3
3
MO
MO
MO
PRIVIGEN
PROCRIT INJECTION
SOLUTION 10,000 UNIT/
ML, 2,000 UNIT/ML, 20,
000 UNIT/2 ML, 3,000
UNIT/ML, 4,000 UNIT/ML
PROCRIT INJECTION
SOLUTION 20,000 UNIT/
ML, 40,000 UNIT/ML
PROLEUKIN
PROQUAD (PF)
QUADRACEL (PF)
RABAVERT (PF)
REBIF (WITH ALBUMIN)
REBIF REBIDOSE
REBIF TITRATION PACK
RECOMBIVAX HB (PF)
INTRAMUSCULAR
SUSPENSION
5
4
3
3
MO
3
MO
5
5
5
5
3
5
PAR; MO
PAR; MO
PAR; MO
PAR; MO
MO
PAR; MO
5
PAR; MO; QLL (1
per 28 days)
PAR; MO
PAR; MO; QLL (12
per 28 days)
5
PAR; MO; QLL (12
per 28 days)
5
3
3
4
5
5
5
3
MO
MO
MO
PAR; MO
PAR; MO
PAR; MO
B/D PAR; MO
Core_16293_CG6_v15_1609_1
50
Drug Name
Drug Requirements/
Tier Limits
RECOMBIVAX HB (PF)
3
INTRAMUSCULAR
SYRINGE 10 MCG/ML
RECOMBIVAX HB (PF)
3
INTRAMUSCULAR
SYRINGE 5 MCG/0.5 ML
ROTARIX
3
ROTATEQ VACCINE
3
SYLATRON
5
tetanus,diphtheria tox ped(pf)
3
TETANUS-DIPHTHERIA
3
TOXOIDS-TD
THYMOGLOBULIN
5
TICE BCG
4
TRUMENBA
3
TWINRIX (PF)
3
TYPHIM VI
3
INTRAMUSCULAR
SOLUTION
TYPHIM VI
3
INTRAMUSCULAR
SYRINGE
VAQTA (PF)
3
INTRAMUSCULAR
SUSPENSION
VAQTA (PF)
3
INTRAMUSCULAR
SYRINGE
VARIVAX (PF)
3
VARIZIG
3
XEOMIN
4
INTRAMUSCULAR
RECON SOLN 100 UNIT,
50 UNIT
XEOMIN
5
INTRAMUSCULAR
RECON SOLN 200 UNIT
YF-VAX (PF)
3
ZOSTAVAX (PF)
3
Musculoskeletal / Rheumatology
ACTEMRA
5
INTRAVENOUS VIAL
alendronate oral solution
3
alendronate oral tablet 10 mg,
5 mg
6
MO
MO
PAR; MO
MO
MO
B/D PAR
MO
MO
MO
MO
MO
MO
PAR; MO
PAR; MO
MO
MO
PAR; MO
MO; QLL (300 per
28 days)
MO; CG; QLL (30
per 30 days)
Drug Name
Drug Requirements/
Tier Limits
alendronate oral tablet 35 mg,
70 mg
allopurinol
aloprim
BENLYSTA
BONIVA INTRAVENOUS
colchicine-probenecid
COLCRYS
DEPEN TITRATABS
ENBREL
SUBCUTANEOUS RECON
SOLN
ENBREL
SUBCUTANEOUS
SYRINGE 25 MG/0.5ML
(0.51)
ENBREL
SUBCUTANEOUS
SYRINGE 50 MG/ML (0.98
ML)
ENBREL SURECLICK
6
FORTEO
5
FOSAMAX ORAL TABLET
70 MG
FOSAMAX PLUS D
4
HUMIRA PEDIATRIC
CROHN'S START
HUMIRA PEN
5
HUMIRA PEN CROHN'SUC-HS START
HUMIRA PEN PSORIASIS
STARTER
HUMIRA
SUBCUTANEOUS
SYRINGE KIT 10 MG/0.2
ML, 20 MG/0.4 ML
HUMIRA
SUBCUTANEOUS
SYRINGE KIT 40 MG/0.8
ML
ibandronate intravenous
solution
5
1
4
5
4
3
3
5
5
MO; CG; QLL (4
per 28 days)
MO
PAR; MO
B/D PAR; MO
MO
MO
MO
PAR; MO; QLL (8
per 28 days)
5
PAR; MO; QLL
(4.08 per 28 days)
5
PAR; MO; QLL (8
per 28 days)
5
PAR; MO; QLL (8
per 28 days)
PAR; MO; QLL (3
per 28 days)
ST; MO; QLL (4
per 28 days)
ST; MO; QLL (4
per 28 days)
PAR; MO; QLL (4.8
per 365 days)
PAR; MO; QLL (3.2
per 28 days)
PAR; MO; QLL (9.6
per 365 days)
PAR; MO; QLL (3.2
per 28 days)
PAR; MO; QLL (2
per 28 days)
4
5
5
5
5
PAR; MO; QLL (3.2
per 28 days)
4
B/D PAR; MO
Core_16293_CG6_v15_1609_1
51
Drug Name
Drug Requirements/
Tier Limits
ibandronate intravenous syringe
ibandronate oral
4
4
KINERET
5
leflunomide oral tablet 10 mg
leflunomide oral tablet 20 mg
ORENCIA
4
3
5
ORENCIA (WITH
MALTOSE)
probenecid
PROLIA
5
raloxifene
3
RIDAURA
4
4
risedronate oral tablet 35 mg,
35 mg (12 pack), 35 mg (4
pack)
4
risedronate oral tablet,delayed
release (dr/ec)
SAVELLA ORAL TABLET
100 MG
SAVELLA ORAL TABLET
12.5 MG
SAVELLA ORAL TABLET
25 MG
SAVELLA ORAL TABLET
50 MG
SAVELLA ORAL TABLETS,
DOSE PACK
SIMPONI
4
ULORIC
Obstetrics / Gynecology
altavera (28)
ALYACEN 1/35 (28)
ALYACEN 7/7/7 (28)
amethia 0.15 mg-30 mcg (84)/
10 mcg (7)
amethyst
3
ST; MO; QLL (30
per 30 days)
MO; QLL (4 per 28
days)
MO; QLL (60 per
30 days)
MO; QLL (480 per
30 days)
MO; QLL (240 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (110 per
365 days)
PAR; MO; QLL (1
per 28 days)
ST; MO
4
4
4
4
MO
MO
MO
MO
4
MO
3
4
4
3
3
3
3
3
5
MO
MO; QLL (1 per 28
days)
PAR; MO; QLL (28
per 28 days)
MO
MO
PAR; MO; QLL (4
per 28 days)
PAR; MO
MO
PAR; MO; QLL (2
per 365 days)
MO; QLL (30 per
30 days)
MO
ST; MO; QLL (1
per 28 days)
ST; MO; QLL (4
per 28 days)
Drug Name
Drug Requirements/
Tier Limits
apri
aranelle (28)
aviane
azurette (28)
balziva (28)
blisovi fe 1.5/30 (28)
briellyn
camila
CAZIANT (28)
clindamycin phosphate vaginal
cryselle (28)
cyclafem 1/35 (28)
cyclafem 7/7/7 (28)
dasetta 1/35 (28)
dasetta 7/7/7 (28)
delestrogen
depo-estradiol
drospirenone-ethinyl estradiol
elinest
ELLA
emoquette
enpresse
errin
estarylla
ESTRACE VAGINAL
estradiol oral
estradiol transdermal patch
semiweekly
estradiol transdermal patch
weekly
estradiol valerate intramuscular
oil 20 mg/ml, 40 mg/ml
ESTRING
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
4
4
3
4
4
4
4
4
1
4
falmina (28)
FEMRING
4
4
gildagia
gildess 1.5/30 (21)
gildess 1/20 (21)
GILDESS FE 1.5/30 (28)
GILDESS FE 1/20 (28)
heather
introvale
jolessa
4
4
4
4
4
4
4
4
4
4
4
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
PAR; MO
PAR; MO; QLL (8
per 28 days)
PAR; MO; QLL (4
per 28 days)
MO
MO; QLL (1 per 90
days)
MO
MO; QLL (1 per 90
days)
MO
MO
MO
MO
MO
MO
MO
MO
Core_16293_CG6_v15_1609_1
52
Drug Name
jolivette
junel 1.5/30 (21)
junel 1/20 (21)
junel fe 1.5/30 (28)
junel fe 1/20 (28)
kariva (28)
kelnor 1/35 (28)
LARIN 1/20 (21)
LARIN FE 1.5/30 (28)
LARIN FE 1/20 (28)
leena 28
lessina
levonest (28)
levonorg-eth estrad triphasic
levonorgestrel-ethinyl estrad oral
tablet 0.1-20 mg-mcg, 0.150.03 mg
tablet 90-20 mcg
tablets,dose pack,3 month
levora-28
loryna (28)
low-ogestrel (28)
lutera (28)
lyza
marlissa
medroxyprogesterone
intramuscular
medroxyprogesterone oral
MENEST
methylergonovine oral
metronidazole vaginal
miconazole-3 vaginal
suppository
MICROGESTIN 1.5/30 (21)
MICROGESTIN 1/20 (21)
MICROGESTIN FE 1.5/30
(28)
MICROGESTIN FE 1/20
(28)
mono-linyah
mononessa (28)
MYZILRA
necon 0.5/35 (28)
Drug Requirements/
Tier Limits
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
4
MO
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
1
4
4
2
4
4
4
4
MO
PAR; MO
MO
MO
MO; QLL (6 per 30
days)
MO
MO
MO
4
MO
4
4
4
4
MO
MO
MO
MO
Drug Name
necon 1/35 (28)
necon 1/50 (28)
necon 10/11 (28)
necon 7/7/7 (28)
NOR-QD
nora-be
norethindrone (contraceptive)
norethindrone acetate
norgestimate-ethinyl estradiol
oral tablet 0.18/0.215/0.25
mg-35 mcg (28), 0.25-35 mgmcg
nortrel 0.5/35 (28)
nortrel 1/35 (21)
nortrel 1/35 (28)
nortrel 7/7/7 (28)
ocella
ogestrel (28)
orsythia
ORTHO MICRONOR
philith
PIMTREA (28)
pirmella oral tablet 1-35 mgmcg
portia
PREMARIN ORAL
PREMARIN VAGINAL
PREMPRO
previfem
progesterone micronized
quasense
reclipsen (28)
sprintec (28)
sronyx
syeda
terconazole vaginal cream
terconazole vaginal suppository
TILIA FE
tranexamic acid oral
tri-estarylla
tri-legest fe
tri-linyah
tri-previfem (28)
tri-sprintec (28)
trinessa (28)
Drug Requirements/
Tier Limits
4
4
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
4
4
4
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
3
3
4
4
3
4
4
4
4
4
3
4
4
4
4
4
4
4
4
4
MO
PAR; MO
MO
PAR; MO
MO
ST; MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Core_16293_CG6_v15_1609_1
53
Drug Name
trivora (28)
vandazole
velivet triphasic regimen (28)
vestura (28)
viorele (28)
VYFEMLA (28)
XULANE
ZARAH
zenchent (28)
ZENCHENT FE
zovia 1/35e (28)
zovia 1/50e (28)
Ophthalmology
acetazolamide oral capsule,
extended release
acetazolamide oral tablet 125
mg
acetazolamide oral tablet 250
mg
acetazolamide sodium
ALPHAGAN P
OPHTHALMIC DROPS 0.1
%
ALPHAGAN P
OPHTHALMIC DROPS
0.15 %
apraclonidine
atropine ophthalmic drops
azelastine ophthalmic
AZOPT
bacitracin ophthalmic
bacitracin-polymyxin b
ophthalmic
BESIVANCE
BETAGAN OPHTHALMIC
DROPS 0.5 %
betaxolol ophthalmic
BETIMOL
BETOPTIC S
bimatoprost
BLEPHAMIDE S.O.P.
brimonidine ophthalmic drops
0.15 %
brimonidine ophthalmic drops
0.2 %
Drug Requirements/
Tier Limits
4
2
4
4
4
4
4
4
4
4
4
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
MO
2
MO
3
MO
4
3
MO
MO
4
MO
3
2
3
4
4
3
MO
MO
MO
MO
MO
MO
4
4
MO
MO
4
4
4
3
4
3
MO
MO
MO
MO
MO
MO
2
MO
Drug Name
carteolol
ciprofloxacin hcl ophthalmic
COMBIGAN
COSOPT
cromolyn ophthalmic
dexamethasone sodium
phosphate ophthalmic
diclofenac sodium ophthalmic
dorzolamide
dorzolamide-timolol
DUREZOL
erythromycin ophthalmic
fluorometholone
flurbiprofen sodium
gentak ophthalmic ointment
gentamicin ophthalmic
ILEVRO
IOPIDINE OPHTHALMIC
DROPS
ISOPTO CARPINE
ketorolac ophthalmic
LACRISERT
latanoprost
levobunolol ophthalmic drops
0.5 %
levofloxacin ophthalmic
LUMIGAN OPHTHALMIC
DROPS 0.01 %
methazolamide oral
metipranolol
MOXEZA
naphazoline
neo-polycin
neo-polycin hc
neomycin-bacitracin-poly-hc
neomycin-bacitracin-polymyxin
neomycin-polymyxin bdexameth
neomycin-polymyxingramicidin
neomycin-polymyxin-hc
ophthalmic
NEVANAC
ofloxacin ophthalmic
PATADAY
Drug Requirements/
Tier Limits
2
2
3
4
2
2
MO
MO
MO
MO
MO
MO
2
3
2
3
2
2
1
2
2
3
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
2
3
2
2
MO
MO
MO
MO
MO
4
3
MO
MO
4
3
3
1
2
2
3
3
2
MO
3
MO
3
MO
3
2
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
Core_16293_CG6_v15_1609_1
54
Drug Name
PAZEO
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic
drops 1 %, 2 %
pilocarpine hcl ophthalmic
drops 4 %
polycin
polymyxin b sulf-trimethoprim
prednisolone acetate
ophthalmic
RESTASIS
SIMBRINZA
sulfacetamide sodium
ophthalmic drops
sulfacetamide sodium
ophthalmic ointment
sulfacetamide-prednisolone
timolol maleate ophthalmic
drops
timolol maleate ophthalmic gel
forming solution
TIMOPTIC OCUDOSE
(PF) OPHTHALMIC
DROPPERETTE 0.25 %
TIMOPTIC
OPHTHALMIC DROPS
0.25 %
TIMOPTIC-XE
TOBRADEX
OPHTHALMIC
OINTMENT
TOBRADEX ST
tobramycin
tobramycin-dexamethasone
TRAVATAN Z
trifluridine
VIGAMOX
XALATAN
ZIRGAN
Respiratory And Allergy
acetylcysteine solution 100 mg/
ml (10 %)
acetylcysteine solution 200 mg/
ml (20 %)
ADEMPAS
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
3
4
3
MO
MO
MO
ADVAIR DISKUS
3
ADVAIR HFA
3
4
MO
AEROSPAN
4
2
1
2
2
3
4
2
MO
MO
MO
3
MO
2
1
MO
MO
albuterol sulfate inhalation
solution for nebulization 0.63
mg/3 ml, 1.25 mg/3 ml
mg /3 ml (0.083 %)
mg/0.5 ml, 5 mg/ml
albuterol sulfate oral syrup
albuterol sulfate oral tablet
aminophylline intravenous
ANORO ELLIPTA
3
MO
MO
MO
ARNUITY ELLIPTA
3
ASMANEX HFA
3
ASMANEX TWISTHALER
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 110 MCG (30
DOSES)
ASMANEX TWISTHALER
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 110 MCG (7
DOSES), 220 MCG (14
DOSES)
ASMANEX TWISTHALER
INHALATION AEROSOL
POWDR BREATH
ACTIVATED 220 MCG
(120 DOSES), 220 MCG (30
DOSES), 220 MCG (60
DOSES)
3
3
4
4
MO
MO
2
4
3
MO; QLL (60 per
30 days)
MO; QLL (12 per
30 days)
QLL (18 per 30
days)
B/D PAR; MO;
QLL (360 per 30
days)
B/D PAR; MO;
QLL (360 per 30
days)
B/D PAR; MO;
QLL (60 per 30
days)
MO
MO
MO
4
MO
2
2
4
3
MO
4
3
MO
MO
3
2
3
3
4
3
4
4
MO
MO
MO
MO
MO
MO
MO
MO
2
B/D PAR; MO
3
B/D PAR; MO
5
PAR; MO; LA
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (13 per
30 days)
MO; QLL (0.14 per
30 days)
3
3
MO; QLL (0.24 per
30 days)
Core_16293_CG6_v15_1609_1
55
Drug Name
Drug Requirements/
Tier Limits
ATROVENT HFA
4
BREO ELLIPTA
3
cetirizine oral solution 1 mg/ml
2
CINRYZE
clemastine oral tablet 2.68 mg
COMBIVENT RESPIMAT
5
4
4
cromolyn inhalation
2
DALIRESP
4
desloratadine oral tablet
3
desloratadine oral tablet,
disintegrating
diphenhydramine hcl injection
solution 50 mg/ml
diphenhydramine hcl injection
syringe
DULERA
2
ELIXOPHYLLIN ORAL
ELIXIR 80 MG/15 ML
epinephrine injection autoinjector
epinephrine injection syringe
0.1 mg/ml
EPIPEN 2-PAK
3
EPIPEN JR 2-PAK
4
ESBRIET
5
FIRAZYR
FLOVENT DISKUS
INHALATION BLISTER
WITH DEVICE 100 MCG/
ACTUATION
FLOVENT DISKUS
INHALATION BLISTER
WITH DEVICE 250 MCG/
4
4
3
4
4
4
5
3
3
MO; QLL (26 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (300 per
30 days)
PAR; MO
PAR; MO
MO; QLL (8 per 30
days)
B/D PAR; MO;
QLL (240 per 30
days)
PAR; MO; QLL (30
per 30 days)
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
PAR; MO
PAR; MO
MO; QLL (13 per
30 days)
MO
MO; QLL (2 per 2
days)
MO
MO; QLL (2 per 2
days)
MO; QLL (2 per 2
days)
PAR; QLL (270 per
30 days)
PAR; MO
MO; QLL (60 per
30 days)
MO; QLL (240 per
30 days)
Drug Name
ACTUATION, 50 MCG/
ACTUATION
FLOVENT HFA
INHALATION HFA
AEROSOL INHALER 110
MCG/ACTUATION
FLOVENT HFA
INHALATION HFA
AEROSOL INHALER 220
MCG/ACTUATION
FLOVENT HFA
INHALATION HFA
AEROSOL INHALER 44
MCG/ACTUATION
flunisolide nasal spray,nonaerosol 25 mcg (0.025 %)
fluticasone nasal
Drug Requirements/
Tier Limits
3
MO; QLL (12 per
30 days)
3
MO; QLL (24 per
30 days)
3
MO; QLL (11 per
30 days)
2
MO; QLL (75 per
30 days)
MO; QLL (16 per
30 days)
MO; QLL (60 per
30 days)
B/D PAR; MO
1
FORADIL AEROLIZER
3
ipratropium bromide
inhalation
ipratropium-albuterol
3
KALYDECO ORAL
TABLET
LETAIRIS
5
levalbuterol hcl inhalation
mg/3 ml, 1.25 mg/0.5 ml, 1.25
mg/3 ml
levalbuterol hcl inhalation
mg/3 ml
levocetirizine oral tablet
4
mometasone nasal
3
montelukast oral granules in
packet
montelukast oral tablet
4
montelukast oral tablet,
chewable
4
2
5
4
3
3
B/D PAR; MO;
QLL (540 per 30
days)
PAR; MO; QLL (60
per 30 days)
PAR; MO; LA; QLL
(30 per 30 days)
B/D PAR; MO;
QLL (270 per 30
days)
B/D PAR; MO;
QLL (540 per 30
days)
MO; QLL (30 per
30 days)
QLL (17 per 30
days)
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (30 per
30 days)
Core_16293_CG6_v15_1609_1
56
Drug Name
Drug Requirements/
Tier Limits
NASONEX
3
OFEV ORAL CAPSULE 150
MG
PERFOROMIST
5
PROAIR HFA
3
PROAIR RESPICLICK
3
promethazine injection solution
promethazine oral tablet 12.5
mg, 25 mg
PULMOZYME
QVAR INHALATION
AEROSOL 40 MCG/
ACTUATION
QVAR INHALATION
AEROSOL 80 MCG/
ACTUATION
SEREVENT DISKUS
4
4
sildenafil oral
5
SPIRIVA RESPIMAT
3
SPIRIVA WITH
HANDIHALER
STIOLTO RESPIMAT
3
SYMBICORT
4
4
MO; QLL (17 per
30 days)
PAR; MO; QLL (60
per 30 days)
B/D PAR; MO;
QLL (120 per 30
days)
MO; QLL (18 per
30 days)
MO; QLL (2 per 30
days)
PAR; MO
PAR; MO
5
3
B/D PAR; MO
MO; QLL (9 per 30
days)
3
MO; QLL (18 per
30 days)
3
MO; QLL (60 per
30 days)
PAR; MO; QLL (90
per 30 days)
MO; QLL (4 per 30
days)
MO; QLL (30 per
30 days)
MO; QLL (4 per 30
days)
PAR; MO; QLL (11
per 30 days)
MO
3
terbutaline oral
theophylline oral elixir
theophylline oral solution
theophylline oral tablet
extended release
theophylline oral tablet
TRACLEER
3
2
2
2
VENTAVIS
VENTOLIN HFA
5
3
2
5
Drug Name
Drug Requirements/
Tier Limits
XOLAIR
5
XOPENEX HFA
4
XYZAL ORAL TABLET
4
zafirlukast
4
Urologicals
alfuzosin
AMMONIUM CHLORIDE
bethanechol chloride oral tablet
10 mg, 25 mg, 5 mg
bethanechol chloride oral tablet
50 mg
CIALIS ORAL TABLET 2.5
MG, 5 MG
CYSTAGON
cytra k crystals
finasteride oral tablet 5 mg
flavoxate
MYRBETRIQ
PAR; MO; LA; QLL
(6 per 28 days)
MO; QLL (45 per
30 days)
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
2
4
3
MO
4
MO
4
PAR; MO; QLL (30
per 30 days)
MO; LA
MO
MO
MO
MO; QLL (30 per
30 days)
MO; QLL (600 per
30 days)
MO; QLL (120 per
30 days)
MO; QLL (60 per
30 days)
3
2
2
4
4
oxybutynin chloride oral syrup
2
oxybutynin chloride oral tablet
2
extended release 24hr 10 mg,
15 mg
potassium citrate oral tablet
extended release 10 meq (1,080
mg)
potassium citrate oral tablet
MO
extended release 5 meq (540
mg)
MO
sodium citrate-citric acid
tamsulosin
PAR; MO; LA; QLL tolterodine oral capsule,
(60 per 30 days)
extended release 24hr
PAR; MO
tolterodine oral tablet
MO; QLL (36 per
30 days)
TOVIAZ
3
3
MO
4
MO; QLL (30 per
30 days)
MO
3
MO
2
2
4
MO
MO
MO; QLL (30 per
30 days)
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
4
4
Core_16293_CG6_v15_1609_1
57
Drug Name
Drug Requirements/
Tier Limits
trospium oral tablet
4
VESICARE
4
MO; QLL (60 per
30 days)
MO; QLL (30 per
30 days)
Vitamins, Hematinics / Electrolytes
AMINOSYN 10 %
4 B/D PAR
AMINOSYN 7 % WITH
4 B/D PAR
ELECTROLYTES
AMINOSYN 8.5 %
4 B/D PAR
AMINOSYN 8.5 %4 B/D PAR
ELECTROLYTES
AMINOSYN II 10 %
4 B/D PAR
AMINOSYN II 15 %
4 B/D PAR
AMINOSYN II 7 %
4 B/D PAR
AMINOSYN II 8.5 %
4 B/D PAR
AMINOSYN II 8.5 %4 B/D PAR
ELECTROLYTES
AMINOSYN M 3.5 %
4 B/D PAR
AMINOSYN-HBC 7%
4 B/D PAR
AMINOSYN-PF 10 %
4 B/D PAR
AMINOSYN-PF 7 %
4 B/D PAR
(SULFITE-FREE)
AMINOSYN-RF 5.2 %
4 B/D PAR
calcium acetate oral capsule
2 MO
CLINIMIX 5%/D15W
4 B/D PAR
SULFITE FREE
CLINIMIX 5%/D25W
4 B/D PAR
SULFITE-FREE
CLINIMIX 2.75%/D5W
4 B/D PAR
SULFIT FREE
CLINIMIX 4.25%-D20W
4 B/D PAR
SULF-FREE
CLINIMIX 4.25%-D25W
4 B/D PAR
SULF-FREE
CLINIMIX 4.25%/D10W
4 B/D PAR
SULF FREE
CLINIMIX 5%4 B/D PAR
D20W(SULFITE-FREE)
SUL FREE
SUL FREE
CLINIMIX E 4.25%/D5W
4 B/D PAR
SULF FREE
CLINIMIX E 5%/D15W
4 B/D PAR
SULFIT FREE
Drug Name
CLINIMIX E 5%/D20W
SULFIT FREE
CLINIMIX E 5%/D25W
SULFIT FREE
dextrose-kcl-nacl
fluoritab oral tablet,chewable
1 mg fluoride (2.2 mg)
freamine iii 10 %
HEPATAMINE 8%
intralipid intravenous emulsion
20 %
INTRALIPID
INTRAVENOUS
EMULSION 30 %
IONOSOL-B IN D5W
IONOSOL-MB IN D5W
ISOLYTE S PH 7.4
ISOLYTE-P IN 5 %
DEXTROSE
ISOLYTE-S
k-effervescent
k-tab oral tablet extended
release 8 meq
klor-con 10
klor-con 8
klor-con m10
klor-con m15
klor-con m20
klor-con/ef
lactated ringers intravenous
ludent fluoride
magnesium sulfate in water
50 ml (4 %), 4 gram/50 ml (8
%)
100 ml (4 %)
magnesium sulfate injection
solution
magnesium sulfate injection
syringe
NEPHRAMINE 5.4 %
Drug Requirements/
Tier Limits
4
B/D PAR
4
B/D PAR
4
2
MO
MO
4
4
4
B/D PAR
B/D PAR
B/D PAR; MO
4
B/D PAR
4
4
4
4
4
1
2
2
2
2
2
2
1
4
2
4
MO
MO
MO
MO
MO
MO
MO
MO
MO
4
4
MO
4
MO
4
4
B/D PAR
Core_16293_CG6_v15_1609_1
58
Drug Name
NORMOSOL-M IN 5 %
DEXTROSE
NORMOSOL-R
NORMOSOL-R IN 5 %
DEXTROSE
NORMOSOL-R PH 7.4
phospha 250 neutral
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN 5 %
DEXTROSE
potassium bicarb and chloride
potassium bicarb-citric acid
potassium chlorid-d50.45%nacl intravenous
parenteral solution 10 meq/l,
30 meq/l, 40 meq/l
potassium chlorid-d50.45%nacl intravenous
parenteral solution 20 meq/l
potassium chloride in 0.9%nacl
20 meq/l, 40 meq/l
potassium chloride in 5 % dex
20 meq/l, 30 meq/l, 40 meq/l
potassium chloride in lr-d5
20 meq/l
potassium chloride in lr-d5
40 meq/l
potassium chloride intravenous
piggyback 10 meq/100 ml, 20
meq/100 ml, 30 meq/100 ml
potassium chloride intravenous
piggyback 10 meq/50 ml
potassium chloride oral capsule,
extended release
potassium chloride oral liquid
potassium chloride oral tablet
extended release
potassium chloride oral tablet,
er particles/crystals
potassium chloride-0.45 % nacl
Drug Requirements/
Tier Limits
4
4
4
4
2
4
4
4
2
1
4
4
MO
MO
MO
MO
4
4
4
MO
4
4
4
MO
2
MO
1
2
MO
MO
2
MO
Drug Name
potassium chloride-d50.2%nacl intravenous
parenteral solution 30 meq/l,
40 meq/l
premasol 10 %
PREMASOL 6 %
prenatal vitamin oral tablet
PROCALAMINE 3%
PROSOL 20 %
ringers intravenous
sodium bicarbonate intravenous
solution
sodium bicarbonate intravenous
syringe 4.2 % (0.5 meq/ml),
7.5 % (0.9 meq/ml)
SODIUM BICARBONATE
INTRAVENOUS SYRINGE
8.4 % (1 MEQ/ML)
intravenous piggyback
sodium chloride 3 %
sodium chloride 5 %
sodium chloride intravenous
sodium fluoride oral tablet
sodium fluoride oral tablet,
chewable
sodium lactate intravenous
travasol 10 %
TROPHAMINE 10 %
TROPHAMINE 6%
Drug Requirements/
Tier Limits
4
MO
4
4
4
MO
4
4
4
2
4
4
4
4
B/D PAR; MO
B/D PAR
MO
B/D PAR
B/D PAR; MO
MO
4
4
4
MO
4
4
4
4
2
2
4
4
4
4
MO
MO
MO
MO
B/D PAR; MO
B/D PAR; MO
B/D PAR
4
Core_16293_CG6_v15_1609_1
59
Index of Drugs:
Legend
Generic drugs are shown in lowercase italic (e.g., atenolol).
Brand-name drugs are shown in capital letters (e.g., CRESTOR).
The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and
generic drugs are listed. 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.
Drug Name
Page
ACTIMMUNE......................................................49
ACTOPLUS MET XR ORAL TABLET, ER
MULTIPHASE 24 HR 15-1,000 MG.................43
ACTOPLUS MET XR ORAL TABLET, ER
MULTIPHASE 24 HR 30-1,000 MG.................43
acyclovir oral capsule...................................................8
acyclovir oral suspension 200 mg/5 ml..........................8
acyclovir oral tablet.....................................................8
acyclovir sodium intravenous solution...........................8
acyclovir topical........................................................39
ADACEL(TDAP ADOLESN/ADULT)(PF)..........49
ADAGEN...............................................................42
ADALAT CC.........................................................33
adapalene topical gel 0.1 %.......................................40
ADASUVE.............................................................20
adefovir......................................................................8
ADEMPAS.............................................................55
adrucil intravenous solution 2.5 gram/50 ml..............15
adrucil intravenous solution 5 gram/100 ml, 500 mg/
10 ml....................................................................15
ADVAIR DISKUS..................................................55
ADVAIR HFA........................................................55
AEROSPAN...........................................................55
afeditab cr................................................................33
AFINITOR.............................................................15
AFINITOR DISPERZ............................................15
AGGRENOX.........................................................33
ALBENZA................................................................8
albuterol sulfate inhalation solution for nebulization
0.63 mg/3 ml, 1.25 mg/3 ml..................................55
2.5 mg /3 ml (0.083 %)........................................55
2.5 mg/0.5 ml, 5 mg/ml.........................................55
albuterol sulfate oral syrup.........................................55
albuterol sulfate oral tablet........................................55
abacavir.....................................................................8
abacavir-lamivudine-zidovudine.................................8
ABELCET................................................................8
ABILIFY MAINTENA...........................................20
ABRAXANE...........................................................15
acamprosate..............................................................42
acarbose oral tablet 100 mg.......................................43
acarbose oral tablet 25 mg.........................................43
acarbose oral tablet 50 mg.........................................43
ACCUPRIL............................................................33
ACCURETIC ORAL TABLET 20-12.5 MG, 2025 MG.................................................................33
acebutolol.................................................................33
acetaminophen-codeine oral solution 120 mg-12 mg
/5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300
mg-30 mg /12.5 ml...............................................20
acetaminophen-codeine oral solution 120-12 mg/5
ml.........................................................................20
acetaminophen-codeine oral tablet 300-15 mg............20
acetasol hc................................................................43
acetazolamide oral capsule, extended release................54
acetazolamide oral tablet 125 mg..............................54
acetazolamide oral tablet 250 mg..............................54
acetazolamide sodium...............................................54
acetic acid irrigation.................................................42
acetic acid otic..........................................................43
acetic acid-aluminum acetate....................................43
acetylcysteine intravenous..........................................42
acetylcysteine solution 100 mg/ml (10 %)...................55
acetylcysteine solution 200 mg/ml (20 %)...................55
acitretin...................................................................39
ACTEMRA INTRAVENOUS VIAL.....................51
ACTHAR H.P........................................................43
ACTHIB (PF).........................................................49
Core_16293_CG6_v15_1609_1
60
albuterol sulfate oral tablet extended release 12 hr 4
mg........................................................................55
albuterol sulfate oral tablet extended release 12 hr 8
mg........................................................................55
alclometasone topical cream.......................................40
alclometasone topical ointment..................................40
alcohol pads..............................................................43
ALDACTAZIDE ORAL TABLET 25-25 MG.......33
ALDURAZYME.....................................................43
ALECENSA............................................................15
alendronate oral solution...........................................51
alendronate oral tablet 10 mg, 5 mg..........................51
alendronate oral tablet 35 mg, 70 mg........................51
alendronate oral tablet 40 mg....................................42
alfuzosin..................................................................57
ALIMTA.................................................................15
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION...........................................8
ALINIA ORAL TABLET.........................................8
ALKERAN ORAL..................................................15
allopurinol...............................................................51
aloprim....................................................................51
alosetron...................................................................47
ALPHAGAN P OPHTHALMIC DROPS 0.1
%.........................................................................54
ALPHAGAN P OPHTHALMIC DROPS 0.15
%.........................................................................54
alprazolam oral tablet...............................................21
ALTACE ORAL CAPSULE 10 MG, 2.5 MG, 5
MG......................................................................33
altavera (28)............................................................52
ALTOPREV...........................................................33
ALYACEN 1/35 (28)..............................................52
ALYACEN 7/7/7 (28).............................................52
amantadine hcl oral capsule........................................8
amantadine hcl oral tablet..........................................8
AMARYL ORAL TABLET 1 MG..........................43
AMBISOME............................................................8
amcinonide..............................................................40
amethia 0.15 mg-30 mcg (84)/10 mcg (7).................52
amethyst...................................................................52
amifostine crystalline.................................................15
amikacin injection solution 1,000 mg/4 ml, 500 mg/
2 ml........................................................................8
amiloride.................................................................33
amiloride-hydrochlorothiazide...................................33
Core_16293_CG6_v15_1609_1
aminophylline intravenous........................................55
AMINOSYN 10 %.................................................58
AMINOSYN 7 % WITH ELECTROLYTES........58
AMINOSYN 8.5 %................................................58
AMINOSYN 8.5 %-ELECTROLYTES.................58
AMINOSYN II 10 %.............................................58
AMINOSYN II 15 %.............................................58
AMINOSYN II 7 %...............................................58
AMINOSYN II 8.5 %............................................58
AMINOSYN II 8.5 %-ELECTROLYTES.............58
AMINOSYN M 3.5 %...........................................58
AMINOSYN-HBC 7%..........................................58
AMINOSYN-PF 10 %...........................................58
AMINOSYN-PF 7 % (SULFITE-FREE)...............58
AMINOSYN-RF 5.2 %..........................................58
amiodarone intravenous solution...............................33
amiodarone intravenous syringe.................................33
amiodarone oral tablet 100 mg, 200 mg....................33
amiodarone oral tablet 400 mg..................................33
amitriptyline............................................................21
amlodipine besylate oral tablet 10 mg, 2.5 mg............33
amlodipine besylate oral tablet 5 mg..........................33
amlodipine-atorvastatin............................................33
amlodipine-benazepril oral capsule 10-20 mg, 10-40
mg, 2.5-10 mg, 5-20 mg, 5-40 mg.........................33
amlodipine-benazepril oral capsule 5-10 mg...............33
amlodipine-valsartan................................................33
amlodipine-valsartan-hcthiazid.................................33
AMMONIUM CHLORIDE..................................57
ammonium lactate....................................................40
amoxapine oral tablet 100 mg, 50 mg........................21
amoxapine oral tablet 150 mg, 25 mg........................21
amoxicillin oral capsule...............................................8
amoxicillin oral suspension for reconstitution................8
amoxicillin oral tablet.................................................8
amoxicillin oral tablet,chewable 125 mg, 250 mg.........8
amoxicillin-pot clavulanate oral suspension for
reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml,
600-42.9 mg/5 ml...................................................8
amoxicillin-pot clavulanate oral suspension for
reconstitution 250-62.5 mg/5 ml..............................8
amoxicillin-pot clavulanate oral tablet 250-125
mg..........................................................................8
amoxicillin-pot clavulanate oral tablet 500-125 mg,
875-125 mg............................................................8
amoxicillin-pot clavulanate oral tablet extended release
12 hr......................................................................8
amoxicillin-pot clavulanate oral tablet,chewable...........8
61
ARCALYST............................................................49
aripiprazole oral solution...........................................21
aripiprazole oral tablet 10 mg...................................21
aripiprazole oral tablet 15 mg...................................21
aripiprazole oral tablet 2 mg.....................................21
aripiprazole oral tablet 20 mg, 30 mg........................21
aripiprazole oral tablet 5 mg.....................................21
aripiprazole oral tablet,disintegrating 10 mg..............21
aripiprazole oral tablet,disintegrating 15 mg..............21
ARISTADA INTRAMUSCULAR SUSPENSION,
EXTENDED REL SYRING 441 MG/1.6
ML.......................................................................21
ML.......................................................................21
ML.......................................................................21
ARNUITY ELLIPTA..............................................55
ARRANON............................................................15
ARZERRA..............................................................16
ASACOL HD.........................................................47
ASMANEX HFA....................................................55
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED
110 MCG (30 DOSES).......................................55
110 MCG (7 DOSES), 220 MCG (14
DOSES)...............................................................55
220 MCG (120 DOSES), 220 MCG (30
DOSES), 220 MCG (60 DOSES).......................55
aspirin-dipyridamole.................................................33
ATACAND HCT ORAL TABLET 16-12.5
MG......................................................................33
ATACAND HCT ORAL TABLET 32-12.5 MG,
32-25 MG............................................................33
ATACAND ORAL TABLET 16 MG, 4 MG, 8
MG......................................................................33
ATACAND ORAL TABLET 32 MG.....................33
atenolol....................................................................33
atenolol-chlorthalidone..............................................33
atorvastatin..............................................................34
atovaquone.................................................................9
atovaquone-proguanil.................................................9
ATRIPLA..................................................................9
amphotericin b...........................................................8
ampicillin oral capsule................................................8
ampicillin oral suspension for reconstitution..................9
ampicillin sodium injection.........................................9
ampicillin sodium intravenous.....................................9
ampicillin-sulbactam injection recon soln 1.5 gram, 3
gram.......................................................................9
ampicillin-sulbactam injection recon soln 15 gram........9
ampicillin-sulbactam intravenous recon soln 1.5
gram.......................................................................9
ampicillin-sulbactam intravenous recon soln 3
gram.......................................................................9
AMPYRA................................................................21
anagrelide................................................................42
anastrozole...............................................................15
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 20.25 MG/1.25
GRAM (1.62 %)..................................................43
PACKET 1.62 % (20.25 MG/1.25 GRAM)........43
PACKET 1.62 % (40.5 MG/2.5 GRAM)............43
androxy....................................................................43
ANORO ELLIPTA................................................55
APOKYN................................................................21
apraclonidine...........................................................54
apri.........................................................................52
APRISO..................................................................47
APTIOM ORAL TABLET 200 MG, 400 MG, 600
MG......................................................................21
APTIOM ORAL TABLET 800 MG......................21
APTIVUS ORAL CAPSULE....................................9
APTIVUS ORAL SOLUTION................................9
ARALAST NP........................................................42
aranelle (28)............................................................52
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION 100 MCG/ML, 200 MCG/ML,
300 MCG/ML.....................................................49
SOLUTION 25 MCG/ML, 40 MCG/ML, 60
MCG/ML............................................................49
SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML,
40 MCG/0.4 ML, 60 MCG/0.3 ML...................49
SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3
ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500
MCG/ML............................................................49
Core_16293_CG6_v15_1609_1
62
atropine injection syringe 0.05 mg/ml, 0.1 mg/ml.......47
atropine ophthalmic drops.........................................54
ATROVENT HFA.................................................56
AVALIDE ORAL TABLET 150-12.5 MG.............34
AVALIDE ORAL TABLET 300-12.5 MG.............34
AVAPRO................................................................34
AVASTIN...............................................................16
aviane......................................................................52
AVONEX (WITH ALBUMIN).............................49
AVONEX INTRAMUSCULAR PEN INJECTOR
KIT......................................................................49
AVONEX INTRAMUSCULAR SYRINGE...........49
AVONEX INTRAMUSCULAR SYRINGE
KIT......................................................................49
azacitidine...............................................................16
azathioprine.............................................................16
azathioprine sodium.................................................16
azelastine nasal.........................................................43
azelastine ophthalmic................................................54
AZILECT...............................................................21
azithromycin intravenous recon soln 500 mg................9
azithromycin intravenous recon soln 500 mg (2 mg/
ml).........................................................................9
azithromycin oral packet.............................................9
azithromycin oral suspension for reconstitution 100
mg/5 ml..................................................................9
azithromycin oral suspension for reconstitution 200
mg/5 ml..................................................................9
azithromycin oral tablet..............................................9
AZOPT..................................................................54
AZOR.....................................................................34
aztreonam..................................................................9
azurette (28)............................................................52
bacitracin ophthalmic...............................................54
bacitracin-polymyxin b ophthalmic............................54
baclofen...................................................................21
balsalazide...............................................................47
balziva (28).............................................................52
BANZEL ORAL SUSPENSION............................21
BANZEL ORAL TABLET 200 MG.......................21
BANZEL ORAL TABLET 400 MG.......................21
BARACLUDE ORAL SOLUTION.........................9
BCG VACCINE, LIVE (PF)..................................49
BELEODAQ..........................................................16
benazepril................................................................34
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 5-6.25 mg...................................34
Core_16293_CG6_v15_1609_1
benazepril-hydrochlorothiazide oral tablet 20-25
mg........................................................................34
BENDEKA.............................................................16
BENICAR HCT.....................................................34
BENICAR ORAL TABLET 20 MG, 40 MG.........34
BENICAR ORAL TABLET 5 MG.........................34
BENLYSTA............................................................51
benztropine injection................................................21
benztropine oral.......................................................21
BESIVANCE..........................................................54
BETAGAN OPHTHALMIC DROPS 0.5 %.........54
betamethasone dipropionate topical cream..................40
betamethasone dipropionate topical lotion..................40
betamethasone dipropionate topical ointment.............40
betamethasone valerate topical cream.........................40
betamethasone valerate topical lotion.........................40
betamethasone valerate topical ointment.....................40
betamethasone, augmented topical cream....................40
betamethasone, augmented topical gel........................40
betamethasone, augmented topical lotion....................40
betamethasone, augmented topical ointment...............40
BETASERON SUBCUTANEOUS KIT................50
betaxolol ophthalmic.................................................54
betaxolol oral............................................................34
bethanechol chloride oral tablet 10 mg, 25 mg, 5
mg........................................................................57
bethanechol chloride oral tablet 50 mg.......................57
BETIMOL..............................................................54
BETOPTIC S.........................................................54
bexarotene................................................................16
BEXSERO (PF)......................................................50
bicalutamide............................................................16
BICILLIN C-R.........................................................9
BICILLIN L-A..........................................................9
BICNU...................................................................16
BIDIL.....................................................................34
bimatoprost..............................................................54
bisoprolol fumarate...................................................34
bisoprolol-hydrochlorothiazide...................................34
BIVIGAM...............................................................50
bleomycin.................................................................16
BLEPHAMIDE S.O.P............................................54
BLINCYTO...........................................................16
blisovi fe 1.5/30 (28)................................................52
BONIVA INTRAVENOUS...................................51
BOOSTRIX TDAP................................................50
BOSULIF ORAL TABLET 100 MG.....................16
BOSULIF ORAL TABLET 500 MG.....................16
63
BOTOX..................................................................50
BREO ELLIPTA.....................................................56
briellyn....................................................................52
BRILINTA.............................................................34
brimonidine ophthalmic drops 0.15 %......................54
brimonidine ophthalmic drops 0.2 %........................54
BRIVIACT INTRAVENOUS................................21
BRIVIACT ORAL SOLUTION............................21
BRIVIACT ORAL TABLET 10 MG.....................21
BRIVIACT ORAL TABLET 100 MG, 75 MG......21
bromocriptine...........................................................21
budesonide oral.........................................................47
bumetanide injection................................................34
bumetanide oral tablet 0.5 mg, 1 mg.........................34
bumetanide oral tablet 2 mg......................................34
BUPHENYL ORAL TABLET...............................42
buprenorphine hcl injection solution..........................21
buprenorphine hcl injection syringe............................21
buprenorphine hcl sublingual tablet 2 mg...................21
buprenorphine hcl sublingual tablet 8 mg...................21
buprenorphine-naloxone sublingual tablet 2-0.5
mg........................................................................21
buprenorphine-naloxone sublingual tablet 8-2 mg......21
buproban.................................................................42
bupropion hcl oral tablet 100 mg...............................21
bupropion hcl oral tablet 75 mg.................................21
bupropion hcl oral tablet extended release 100 mg.......21
bupropion hcl oral tablet extended release 150 mg, 200
mg........................................................................21
bupropion hcl oral tablet extended release 24 hr 150
mg........................................................................21
bupropion hcl oral tablet extended release 24 hr 300
mg........................................................................22
buspirone oral tablet 10 mg, 15 mg, 5 mg..................22
buspirone oral tablet 30 mg, 7.5 mg..........................22
BUSULFEX............................................................16
butorphanol tartrate injection solution 1 mg/ml..........22
butorphanol tartrate injection solution 2 mg/ml..........22
butorphanol tartrate nasal.........................................22
BYDUREON.........................................................43
BYETTA SUBCUTANEOUS PEN INJECTOR
10 MCG/DOSE(250 MCG/ML) 2.4 ML....43–
4
4
BYETTA SUBCUTANEOUS PEN INJECTOR
5 MCG/DOSE (250 MCG/ML) 1.2 ML............44
BYSTOLIC.............................................................34
Core_16293_CG6_v15_1609_1
cabergoline...............................................................44
CABOMETYX ORAL TABLET 20 MG...............16
CABOMETYX ORAL TABLET 40 MG, 60
MG......................................................................16
CALAN ORAL TABLET 120 MG.........................34
CALAN SR ORAL TABLET EXTENDED
RELEASE 120 MG..............................................34
calcipotriene scalp.....................................................40
calcipotriene topical..................................................40
calcitonin (salmon)...................................................44
calcitriol intravenous solution 1 mcg/ml.....................44
calcitriol oral capsule.................................................44
calcitriol oral solution...............................................44
calcium acetate oral capsule.......................................58
camila......................................................................52
CANCIDAS.............................................................9
candesartan oral tablet 16 mg, 4 mg, 8 mg.................34
candesartan oral tablet 32 mg....................................34
candesartan-hydrochlorothiazid oral tablet 16-12.5
mg........................................................................34
candesartan-hydrochlorothiazid oral tablet 32-12.5
mg, 32-25 mg.......................................................34
CAPASTAT..............................................................9
CAPRELSA ORAL TABLET 100 MG...................16
CAPRELSA ORAL TABLET 300 MG...................16
captopril oral tablet 100 mg, 25 mg, 50 mg...............34
captopril oral tablet 12.5 mg.....................................34
captopril-hydrochlorothiazide oral tablet 25-15 mg,
50-15 mg, 50-25 mg.............................................34
captopril-hydrochlorothiazide oral tablet 25-25
mg........................................................................34
CARBAGLU...........................................................42
carbamazepine oral capsule, er multiphase 12 hr........22
carbamazepine oral suspension 100 mg/5 ml..............22
carbamazepine oral suspension 200 mg/10 ml............22
carbamazepine oral tablet.........................................22
carbamazepine oral tablet extended release 12 hr 100
mg........................................................................22
carbamazepine oral tablet extended release 12 hr 200
mg, 400 mg...........................................................22
carbamazepine oral tablet,chewable...........................22
carbidopa-levodopa oral tablet...................................22
carbidopa-levodopa oral tablet extended release 25100 mg.................................................................22
carbidopa-levodopa oral tablet extended release 50200 mg.................................................................22
carbidopa-levodopa oral tablet,disintegrating..............22
carboplatin intravenous solution................................16
64
CARDIZEM LA ORAL TABLET EXTENDED
RELEASE 24 HR 180 MG, 240 MG, 420
MG......................................................................34
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 12 GRAM,
6 GRAM..............................................................50
carteolol...................................................................54
cartia xt...................................................................34
carvedilol.................................................................34
CAYSTON...............................................................9
CAZIANT (28)......................................................52
cefaclor oral capsule.....................................................9
cefaclor oral suspension for reconstitution 125 mg/5
ml...........................................................................9
cefaclor oral suspension for reconstitution 250 mg/5
ml, 375 mg/5 ml.....................................................9
cefaclor oral tablet extended release 12 hr.....................9
cefadroxil oral capsule.................................................9
cefadroxil oral suspension for reconstitution 250 mg/5
ml, 500 mg/5 ml.....................................................9
cefadroxil oral tablet...................................................9
cefazolin in dextrose (iso-os) intravenous piggyback 1
gram/50 ml, 2 gram/50 ml.......................................9
cefazolin injection recon soln 1 gram, 500 mg..............9
cefazolin injection recon soln 10 gram, 100 gram, 20
gram, 300 g............................................................9
cefazolin intravenous..................................................9
cefdinir oral capsule....................................................9
cefdinir oral suspension for reconstitution.....................9
cefepime.....................................................................9
cefepime in dextrose,iso-osm intravenous piggyback 1
gram/50 ml.............................................................9
cefepime in dextrose,iso-osm intravenous piggyback 2
gram/100 ml...........................................................9
cefotaxime injection recon soln 1 gram, 2 gram, 500
mg..........................................................................9
cefotaxime injection recon soln 10 gram.......................9
cefotetan.....................................................................9
cefoxitin in dextrose, iso-osm........................................9
cefoxitin intravenous recon soln 1 gram........................9
cefoxitin intravenous recon soln 10 gram, 2 gram.........9
cefpodoxime oral suspension for reconstitution...............9
cefpodoxime oral tablet 100 mg...................................9
cefpodoxime oral tablet 200 mg...................................9
cefprozil oral suspension for reconstitution....................9
cefprozil oral tablet 250 mg.........................................9
cefprozil oral tablet 500 mg.........................................9
CEFTAZIDIME IN D5W.......................................9
Core_16293_CG6_v15_1609_1
ceftazidime injection recon soln 1 gram, 2 gram...........9
ceftazidime injection recon soln 6 gram......................10
ceftriaxone in dextrose,iso-os......................................10
ceftriaxone injection recon soln 1 gram, 2 gram, 250
mg, 500 mg...........................................................10
ceftriaxone injection recon soln 10 gram, 100
gram.....................................................................10
ceftriaxone intravenous..............................................10
cefuroxime axetil oral tablet 250 mg..........................10
cefuroxime axetil oral tablet 500 mg..........................10
cefuroxime sodium injection recon soln 1.5 gram, 750
mg........................................................................10
cefuroxime sodium intravenous vial...........................10
CELLCEPT INTRAVENOUS...............................16
CELONTIN ORAL CAPSULE 300 MG...............22
cephalexin oral capsule 250 mg, 500 mg....................10
cephalexin oral suspension for reconstitution...............10
cephalexin oral tablet................................................10
CEREZYME INTRAVENOUS RECON SOLN
400 UNIT...........................................................44
CERVARIX VACCINE (PF)..................................50
cetirizine oral solution 1 mg/ml.................................56
CHANTIX.............................................................42
CHANTIX CONTINUING MONTH BOX........42
CHANTIX STARTING MONTH BOX...............42
chloramphenicol sod succinate....................................10
chlorhexidine gluconate mucous membrane.................43
chloroquine phosphate oral tablet 250 mg..................10
chloroquine phosphate oral tablet 500 mg..................10
chlorothiazide oral tablet 250 mg..............................34
chlorothiazide oral tablet 500 mg..............................34
chlorothiazide sodium...............................................34
chlorpromazine.........................................................22
chlorthalidone oral tablet 25 mg, 50 mg.....................34
cholestyramine (with sugar).......................................34
cholestyramine light..................................................34
CIALIS ORAL TABLET 2.5 MG, 5 MG...............57
ciclodan topical cream...............................................40
ciclodan topical solution............................................40
ciclopirox topical cream.............................................40
ciclopirox topical gel..................................................40
ciclopirox topical shampoo.........................................40
ciclopirox topical solution..........................................40
ciclopirox topical suspension.......................................40
cidofovir...................................................................10
cilostazol..................................................................34
CIMZIA.................................................................47
CIMZIA POWDER FOR RECONST...................47
65
CIMZIA STARTER KIT.......................................47
CINRYZE..............................................................56
CIPRODEX...........................................................43
ciprofloxacin (mixture) oral tablet, er multiphase 24
hr 1,000 mg..........................................................10
ciprofloxacin (mixture) oral tablet, er multiphase 24
hr 500 mg.............................................................10
ciprofloxacin hcl ophthalmic......................................54
ciprofloxacin hcl oral tablet.......................................10
ciprofloxacin in 5 % dextrose.....................................10
ciprofloxacin lactate intravenous solution 200 mg/20
ml.........................................................................10
ciprofloxacin lactate intravenous solution 400 mg/40
ml.........................................................................10
ciprofloxacin oral suspension......................................10
cisplatin...................................................................16
citalopram oral solution............................................22
citalopram oral tablet 10 mg.....................................22
cladribine.................................................................16
claravis oral capsule 10 mg, 20 mg, 40 mg.................40
claravis oral capsule 30 mg........................................40
clarithromycin oral suspension for reconstitution 125
mg/5 ml................................................................10
clarithromycin oral suspension for reconstitution 250
mg/5 ml................................................................10
clarithromycin oral tablet..........................................10
clarithromycin oral tablet extended release 24 hr.........10
clemastine oral tablet 2.68 mg...................................56
clindamycin hcl oral capsule......................................10
clindamycin in 5 % dextrose.....................................10
clindamycin phosphate injection................................10
clindamycin phosphate intravenous solution 300 mg/
2 ml, 900 mg/6 ml................................................10
clindamycin phosphate intravenous solution 600 mg/
4 ml......................................................................10
clindamycin phosphate topical gel...............................40
clindamycin phosphate topical lotion..........................40
clindamycin phosphate topical solution.......................40
clindamycin phosphate topical swab...........................40
clindamycin phosphate vaginal..................................52
clindamycin-benzoyl peroxide topical gel....................40
CLINIMIX 2.75%/D5W SULFIT FREE...............58
CLINIMIX 4.25%-D20W SULF-FREE................58
CLINIMIX 4.25%-D25W SULF-FREE................58
CLINIMIX 4.25%/D10W SULF FREE.................58
CLINIMIX 4.25%/D5W SULFIT FREE...............42
Core_16293_CG6_v15_1609_1
CLINIMIX 5%-D20W(SULFITE-FREE)..............58
CLINIMIX 5%/D15W SULFITE FREE...............58
CLINIMIX 5%/D25W SULFITE-FREE...............58
CLINIMIX E 2.75%/D10W SUL FREE................42
CLINIMIX E 2.75%/D5W SULF FREE...............42
CLINIMIX E 4.25%/D5W SULF FREE...............58
CLINIMIX E 5%/D15W SULFIT FREE..............58
clobetasol scalp..........................................................40
clobetasol topical cream.............................................40
clobetasol topical foam...............................................40
clobetasol topical gel..................................................40
clobetasol topical lotion.............................................40
clobetasol topical ointment.........................................40
clobetasol topical shampoo.........................................40
clobetasol-emollient topical cream..............................40
clobetasol-emollient topical foam................................40
CLOBEX TOPICAL LOTION.............................40
CLOLAR................................................................16
clomipramine...........................................................22
clonazepam oral tablet 0.5 mg...................................22
clonazepam oral tablet 1 mg......................................22
clonazepam oral tablet 2 mg......................................22
clonazepam oral tablet,disintegrating 0.125 mg..........22
clonazepam oral tablet,disintegrating 0.25 mg............22
clonazepam oral tablet,disintegrating 0.5 mg..............22
clonazepam oral tablet,disintegrating 1 mg.................22
clonazepam oral tablet,disintegrating 2 mg.................22
clonidine hcl oral tablet.............................................34
clonidine transdermal patch......................................34
clopidogrel oral tablet 300 mg...................................34
clopidogrel oral tablet 75 mg.....................................34
clorazepate dipotassium.............................................22
clotrimazole mucous membrane.................................10
clotrimazole topical cream.........................................40
clotrimazole topical solution......................................40
clotrimazole-betamethasone topical cream..................40
clotrimazole-betamethasone topical lotion...................40
clozapine oral tablet 100 mg.....................................22
clozapine oral tablet 200 mg.....................................22
clozapine oral tablet 25 mg.......................................22
clozapine oral tablet 50 mg.......................................22
clozapine oral tablet,disintegrating 100 mg................22
clozapine oral tablet,disintegrating 12.5 mg...............22
66
clozapine oral tablet,disintegrating 25 mg..................22
COARTEM............................................................10
colchicine-probenecid................................................51
COLCRYS..............................................................51
colestipol..................................................................34
colistin (colistimethate na).........................................10
COMBIGAN..........................................................54
COMBIVENT RESPIMAT...................................56
COMETRIQ ORAL CAPSULE 100 MG/DAY(80
MG X1-20 MG X1).............................................16
COMETRIQ ORAL CAPSULE 140 MG/DAY(80
MG X1-20 MG X3).............................................16
COMETRIQ ORAL CAPSULE 60 MG/DAY (20
MG X 3/DAY).....................................................16
COMPLERA..........................................................10
compro.....................................................................47
constulose.................................................................47
COPAXONE SUBCUTANEOUS SYRINGE 20
MG/ML...............................................................22
COPAXONE SUBCUTANEOUS SYRINGE 40
MG/ML...............................................................22
COREG CR...........................................................34
cormax scalp.............................................................40
cortisone...................................................................44
CORZIDE ORAL TABLET 40-5 MG..................34
COSMEGEN.........................................................16
COSOPT................................................................54
COTELLIC............................................................16
COUMADIN ORAL.............................................34
COZAAR ORAL TABLET 100 MG......................34
COZAAR ORAL TABLET 25 MG, 50 MG..........34
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000 -60,000
UNIT, 24,000-76,000 -120,000 UNIT, 3,0009,500- 15,000 UNIT, 6,000-19,000 -30,000
UNIT............................................................47–48
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 36,000-114,000- 180,000
UNIT..................................................................48
CRESTOR.............................................................34
CRIXIVAN ORAL CAPSULE 200 MG................10
CRIXIVAN ORAL CAPSULE 400 MG................10
cromolyn inhalation..................................................56
cromolyn ophthalmic.................................................54
cromolyn oral...........................................................48
cryselle (28)..............................................................52
CUBICIN...............................................................10
Core_16293_CG6_v15_1609_1
cyclafem 1/35 (28)....................................................52
cyclafem 7/7/7 (28)...................................................52
cyclobenzaprine oral tablet........................................22
cyclophosphamide oral capsule....................................16
CYCLOSET...........................................................44
cyclosporine intravenous............................................16
cyclosporine modified................................................16
cyclosporine oral capsule............................................16
CYRAMZA.............................................................16
CYSTADANE........................................................48
CYSTAGON..........................................................57
cytarabine................................................................16
cytarabine (pf) injection solution 100 mg/5 ml (20
mg/ml), 2 gram/20 ml (100 mg/ml).......................16
cytarabine (pf) injection solution 20 mg/ml................16
CYTOMEL............................................................44
cytra k crystals..........................................................57
d10 %-0.45 % sodium chloride................................42
d2.5 %-0.45 % sodium chloride...............................42
d5 % and 0.9 % sodium chloride..............................42
d5 %-0.45 % sodium chloride..................................42
dacarbazine..............................................................16
DAKLINZA ORAL TABLET 30 MG, 60 MG......10
DAKLINZA ORAL TABLET 90 MG....................10
DALIRESP.............................................................56
danazol oral.............................................................44
dantrolene................................................................22
DAPSONE.............................................................10
DAPTACEL (DTAP PEDIATRIC) (PF)...............50
DARAPRIM...........................................................10
DARZALEX...........................................................16
dasetta 1/35 (28)......................................................52
dasetta 7/7/7 (28).....................................................52
daunorubicin intravenous solution.............................16
decitabine................................................................16
delestrogen................................................................52
DELZICOL ORAL CAPSULE,DELAYED
RELEASE(DR/EC)..............................................48
demeclocycline..........................................................10
DEMSER................................................................34
DENAVIR..............................................................40
denta 5000 plus.......................................................43
dentagel...................................................................43
DEPEN TITRATABS............................................51
depo-estradiol...........................................................52
DERMATOP TOPICAL OINTMENT................40
DESCOVY.............................................................10
desipramine oral.......................................................22
67
desloratadine oral tablet............................................56
desloratadine oral tablet,disintegrating.......................56
desmopressin injection...............................................44
desmopressin nasal aerosol,spray.................................44
desmopressin nasal solution........................................44
desmopressin nasal spray,non-aerosol..........................44
desmopressin oral......................................................44
desonide...................................................................40
desoximetasone topical cream.....................................40
desoximetasone topical gel..........................................40
desoximetasone topical ointment 0.25 %....................40
desvenlafaxine fumarate oral tablet extended release
24hr 100 mg.........................................................23
desvenlafaxine fumarate oral tablet extended release
24hr 50 mg...........................................................23
DESVENLAFAXINE ORAL TABLET
EXTENDED RELEASE 24 HR 100 MG...........23
DESVENLAFAXINE ORAL TABLET
EXTENDED RELEASE 24 HR 50 MG.............23
desvenlafaxine oral tablet extended release 24hr 100
mg........................................................................23
desvenlafaxine oral tablet extended release 24hr 50
mg........................................................................23
dexamethasone oral elixir 0.5mg/ml...........................44
dexamethasone oral solution 0.5mg/ml.......................44
dexamethasone oral tablet 0.5 mg, 1.5 mg..................44
dexamethasone oral tablet 0.75 mg, 1 mg, 4 mg, 6
mg........................................................................44
dexamethasone oral tablet 2 mg.................................44
dexamethasone sodium phos (pf)................................44
dexamethasone sodium phosphate injection.................44
dexamethasone sodium phosphate ophthalmic.............54
DEXILANT............................................................48
dexrazoxane hcl intravenous recon soln 250 mg..........16
dexrazoxane hcl intravenous recon soln 500 mg..........16
dextroamphetamine oral tablet 10 mg........................23
dextroamphetamine oral tablet 5 mg..........................23
dextroamphetamine-amphetamine oral tablet 10 mg,
12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg...................23
dextroamphetamine-amphetamine oral tablet 30
mg........................................................................23
dextrose 10 % and 0.2 % nacl..................................42
dextrose 10 % in water (d10w).................................42
dextrose 5 % in water (d5w).....................................42
dextrose 5 %-lactated ringers.....................................42
Core_16293_CG6_v15_1609_1
dextrose 5%-0.2 % sod chloride.................................42
dextrose 5%-0.3 % sod.chloride.................................42
dextrose 50 % in water (d50w) intravenous parenteral
solution.................................................................42
dextrose 50 % in water (d50w) intravenous
syringe...................................................................42
dextrose with sodium chloride....................................42
dextrose-kcl-nacl.......................................................58
diazepam intensol.....................................................23
diazepam oral concentrate.........................................23
diazepam oral solution 5 mg/5 ml (1 mg/ml)..............23
diazepam oral solution 5 mg/5 ml (1 mg/ml, 5
ml).......................................................................23
diazepam oral tablet 10 mg.......................................23
diazepam oral tablet 2 mg.........................................23
diazepam oral tablet 5 mg.........................................23
diazepam rectal kit 12.5-15-17.5-20 mg...................23
diazepam rectal kit 2.5 mg, 5-7.5-10 mg...................23
diclofenac potassium..................................................23
diclofenac sodium ophthalmic....................................54
diclofenac sodium oral tablet extended release 24
hr.........................................................................23
diclofenac sodium oral tablet,delayed release (dr/ec) 25
mg........................................................................23
diclofenac sodium oral tablet,delayed release (dr/ec) 50
mg, 75 mg.............................................................23
diclofenac sodium topical gel 1 %..............................23
dicloxacillin..............................................................10
dicyclomine oral capsule............................................48
dicyclomine oral solution...........................................48
dicyclomine oral tablet..............................................48
didanosine oral capsule,delayed release(dr/ec) 125
mg........................................................................10
mg........................................................................10
mg........................................................................10
mg........................................................................10
DIFICID................................................................10
diflorasone................................................................40
diflunisal..................................................................23
DIGITEK ORAL TABLET 125 MCG..................35
DIGOX ORAL TABLET 125 MCG......................35
digoxin oral solution 50 mcg/ml.................................35
digoxin oral tablet 125 mcg.......................................35
dihydroergotamine injection......................................23
68
DILANTIN INFATABS........................................23
DILANTIN ORAL CAPSULE 30 MG..................23
dilt-xr......................................................................35
diltiazem hcl intravenous..........................................35
diltiazem hcl oral capsule, extended release 120 mg,
180 mg, 240 mg, 300 mg......................................35
diltiazem hcl oral capsule, extended release 360
mg........................................................................35
diltiazem hcl oral capsule, extended release 420
mg........................................................................35
diltiazem hcl oral capsule,ext release degradable..........35
diltiazem hcl oral capsule,extended release 12 hr.........35
diltiazem hcl oral capsule,extended release 24hr 120
mg, 180 mg, 240 mg, 300 mg................................35
diltiazem hcl oral capsule,extended release 24hr 360
mg........................................................................35
diltiazem hcl oral tablet............................................35
DIOVAN HCT......................................................35
DIPENTUM..........................................................48
diphenhydramine hcl injection solution 50 mg/ml.......56
diphenhydramine hcl injection syringe........................56
diphenoxylate-atropine oral liquid.............................48
diphenoxylate-atropine oral tablet..............................48
DIPROLENE AF...................................................40
diskets......................................................................23
disulfiram................................................................42
divalproex oral capsule, sprinkle.................................23
divalproex oral tablet extended release 24 hr...............23
divalproex oral tablet,delayed release (dr/ec) 125 mg,
250 mg.................................................................23
divalproex oral tablet,delayed release (dr/ec) 500
mg........................................................................23
DOCEFREZ INTRAVENOUS RECON SOLN
20 MG.................................................................16
DOCETAXEL INTRAVENOUS SOLUTION 10
MG/ML...............................................................16
docetaxel intravenous solution 160 mg/16 ml (10 mg/
ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/
ml).......................................................................16
docetaxel intravenous solution 20 mg/ml (1 ml), 80
mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml).........16
dofetilide..................................................................35
donepezil oral tablet 10 mg, 5 mg..............................23
donepezil oral tablet,disintegrating.............................23
DORIBAX..............................................................10
dorzolamide.............................................................54
dorzolamide-timolol..................................................54
doxazosin.................................................................35
Core_16293_CG6_v15_1609_1
doxepin oral.............................................................23
doxercalciferol intravenous........................................44
doxorubicin intravenous recon soln............................16
doxorubicin intravenous solution...............................16
DOXY-100.............................................................10
doxycycline hyclate intravenous..................................10
doxycycline hyclate oral capsule..................................11
doxycycline hyclate oral tablet 100 mg, 50 mg............11
doxycycline hyclate oral tablet 20 mg..........................11
doxycycline monohydrate oral tablet 100 mg...............11
doxycycline monohydrate oral tablet 150 mg, 50 mg,
75 mg...................................................................11
dronabinol oral capsule 10 mg...................................48
dronabinol oral capsule 2.5 mg, 5 mg........................48
drospirenone-ethinyl estradiol....................................52
DUETACT ORAL TABLET 30-4 MG.................44
DULERA................................................................56
duloxetine oral capsule,delayed release(dr/ec) 20
mg........................................................................23
mg........................................................................23
mg........................................................................23
mg........................................................................23
duramorph (pf) injection solution 0.5 mg/ml..............23
duramorph (pf) injection solution 1 mg/ml.................23
DUREZOL.............................................................54
DYAZIDE..............................................................35
DYSPORT..............................................................50
e.e.s. 400 oral tablet..................................................11
econazole topical.......................................................40
EDURANT............................................................11
EFFIENT...............................................................35
ELAPRASE.............................................................44
ELIDEL..................................................................40
elinest......................................................................52
ELIQUIS ORAL TABLET 2.5 MG.......................35
ELIQUIS ORAL TABLET 5 MG..........................35
ELITEK..................................................................16
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15
ML.......................................................................56
ELLA......................................................................52
ELOCON TOPICAL SOLUTION.......................40
EMCYT..................................................................16
EMEND ORAL CAPSULE 125 MG.....................48
EMEND ORAL CAPSULE 40 MG.......................48
EMEND ORAL CAPSULE 80 MG.......................48
69
EMEND ORAL CAPSULE,DOSE PACK.............48
emoquette.................................................................52
EMPLICITI............................................................16
EMSAM.................................................................23
EMTRIVA ORAL CAPSULE................................11
EMTRIVA ORAL SOLUTION.............................11
enalapril maleate......................................................35
enalapril-hydrochlorothiazide....................................35
ENBREL SUBCUTANEOUS RECON
SOLN..................................................................51
ENBREL SUBCUTANEOUS SYRINGE 25 MG/
0.5ML (0.51).......................................................51
ENBREL SUBCUTANEOUS SYRINGE 50 MG/
ML (0.98 ML).....................................................51
ENBREL SURECLICK..........................................51
endocet oral tablet 10-325 mg, 7.5-325 mg...............23
endocet oral tablet 5-325 mg.....................................23
ENGERIX-B (PF)...................................................50
ENGERIX-B PEDIATRIC (PF).............................50
enoxaparin subcutaneous solution..............................35
enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/
ml.........................................................................35
enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80
mg/0.8 ml.............................................................35
enoxaparin subcutaneous syringe 30 mg/0.3 ml...........35
enoxaparin subcutaneous syringe 40 mg/0.4 ml..........35
enoxaparin subcutaneous syringe 60 mg/0.6 ml...........35
enpresse....................................................................52
entacapone...............................................................24
entecavir..................................................................11
enulose.....................................................................48
ENVARSUS XR.....................................................16
epinephrine injection auto-injector.............................56
epinephrine injection syringe 0.1 mg/ml.....................56
EPIPEN 2-PAK......................................................56
EPIPEN JR 2-PAK.................................................56
epirubicin intravenous solution 200 mg/100 ml.........16
epirubicin intravenous solution 50 mg/25 ml.............16
epitol.......................................................................24
EPIVIR HBV ORAL SOLUTION.........................11
EPIVIR ORAL SOLUTION..................................11
eplerenone................................................................35
eprosartan................................................................35
EPZICOM.............................................................11
EQUETRO ORAL CAPSULE, ER MULTIPHASE
12 HR 100 MG...................................................24
12 HR 200 MG...................................................24
Core_16293_CG6_v15_1609_1
12 HR 300 MG...................................................24
ERBITUX...............................................................16
ergoloid....................................................................24
ERIVEDGE............................................................17
errin........................................................................52
ERWINAZE...........................................................17
ery pads....................................................................40
ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333
mg........................................................................11
erythrocin (as stearate) oral tablet 250 mg..................11
ERYTHROCIN INTRAVENOUS RECON
SOLN 500 MG...................................................11
erythromycin ethylsuccinate oral tablet.......................11
erythromycin ophthalmic...........................................54
erythromycin oral capsule,delayed release(dr/ec)...........11
erythromycin oral tablet............................................11
erythromycin with ethanol.........................................40
erythromycin-benzoyl peroxide...................................40
ESBRIET................................................................56
escitalopram oxalate oral solution...............................24
escitalopram oxalate oral tablet 10 mg.......................24
escitalopram oxalate oral tablet 20 mg.......................24
escitalopram oxalate oral tablet 5 mg.........................24
esomeprazole sodium intravenous...............................48
estarylla....................................................................52
ESTRACE VAGINAL............................................52
estradiol oral............................................................52
estradiol transdermal patch semiweekly......................52
estradiol transdermal patch weekly.............................52
estradiol valerate intramuscular oil 20 mg/ml, 40 mg/
ml.........................................................................52
ESTRING...............................................................52
ethambutol...............................................................11
ethosuximide oral capsule..........................................24
ethosuximide oral solution.........................................24
etidronate disodium oral tablet 200 mg......................42
etidronate disodium oral tablet 400 mg......................42
etodolac oral capsule..................................................24
etodolac oral tablet....................................................24
etodolac oral tablet extended release 24 hr..................24
ETOPOPHOS.......................................................17
etoposide intravenous................................................17
EVOMELA.............................................................17
EVOTAZ................................................................11
EXELON ORAL CAPSULE 1.5 MG, 4.5 MG......24
exemestane...............................................................17
EXFORGE.............................................................35
70
EXFORGE HCT....................................................35
EXJADE.................................................................42
EXTAVIA SUBCUTANEOUS KIT......................50
EXTAVIA SUBCUTANEOUS RECON
SOLN..................................................................50
FABRAZYME.........................................................44
falmina (28)............................................................52
famciclovir oral tablet 125 mg, 250 mg.....................11
famciclovir oral tablet 500 mg...................................11
famotidine (pf).........................................................48
famotidine (pf)-nacl (iso-os)......................................48
famotidine intravenous.............................................48
famotidine oral suspension.........................................48
famotidine oral tablet 20 mg, 40 mg..........................48
FANAPT ORAL TABLET 1 MG...........................24
FANAPT ORAL TABLET 10 MG.........................24
FANAPT ORAL TABLET 12 MG.........................24
FANAPT ORAL TABLETS,DOSE PACK............24
FARESTON...........................................................17
FARYDAK ORAL CAPSULE 10 MG....................17
FARYDAK ORAL CAPSULE 15 MG, 20 MG......17
FASLODEX...........................................................17
felbamate oral suspension..........................................24
felbamate oral tablet 400 mg.....................................24
felbamate oral tablet 600 mg.....................................24
FELBATOL ORAL TABLET 400 MG..................24
felodipine oral tablet extended release 24 hr 10
mg........................................................................35
felodipine oral tablet extended release 24 hr 2.5 mg,
5 mg.....................................................................35
FEMRING.............................................................52
fenofibrate micronized oral capsule 130 mg................35
fenofibrate micronized oral capsule 134 mg, 200 mg,
67 mg...................................................................35
fenofibrate micronized oral capsule 43 mg..................35
fenofibrate nanocrystallized 48 mg, 145 mg...............35
fenofibrate oral tablet 160 mg...................................35
fenofibrate oral tablet 54 mg.....................................35
fenofibric acid (choline) dr capsules............................35
fenoprofen oral tablet................................................24
fentanyl citrate.........................................................24
fentanyl transdermal patch 72 hour 100 mcg/hr, 12
mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr...............24
Core_16293_CG6_v15_1609_1
FETZIMA ORAL CAPSULE,EXT REL 24HR
DOSE PACK.......................................................24
FETZIMA ORAL CAPSULE,EXTENDED
RELEASE 24 HR 120 MG, 80 MG....................24
RELEASE 24 HR 20 MG....................................24
RELEASE 24 HR 40 MG....................................24
finasteride oral tablet 5 mg........................................57
FIRAZYR...............................................................56
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 120
MG......................................................................17
FIRMAGON KIT W DILUENT SYRINGE
SUBCUTANEOUS RECON SOLN 80
MG......................................................................17
flavoxate..................................................................57
flecainide oral tablet 100 mg, 50 mg..........................35
flecainide oral tablet 150 mg.....................................35
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION.......56
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 250 MCG/ACTUATION, 50
MCG/ACTUATION..........................................56
FLOVENT HFA INHALATION HFA AEROSOL
INHALER 110 MCG/ACTUATION.................56
INHALER 220 MCG/ACTUATION.................56
INHALER 44 MCG/ACTUATION...................56
fluconazole in dextrose(iso-o).....................................11
FLUCONAZOLE IN NACL (ISO-OSM)
INTRAVENOUS PIGGYBACK 100 MG/50
ML.......................................................................11
fluconazole in nacl (iso-osm) intravenous piggyback
200 mg/100 ml.....................................................11
fluconazole in nacl (iso-osm) intravenous piggyback
400 mg/200 ml.....................................................11
fluconazole oral suspension for reconstitution 10 mg/
ml.........................................................................11
fluconazole oral suspension for reconstitution 40 mg/
ml.........................................................................11
fluconazole oral tablet 100 mg...................................11
fluconazole oral tablet 150 mg, 50 mg.......................11
fluconazole oral tablet 200 mg...................................11
flucytosine................................................................11
fludarabine intravenous recon soln.............................17
fludarabine intravenous solution................................17
71
FOSAMAX ORAL TABLET 70 MG.....................51
FOSAMAX PLUS D...............................................51
foscarnet...................................................................11
fosinopril..................................................................36
fosinopril-hydrochlorothiazide oral tablet 10-12.5
mg........................................................................36
fosinopril-hydrochlorothiazide oral tablet 20-12.5
mg........................................................................36
fosphenytoin.............................................................25
freamine iii 10 %.....................................................58
furosemide injection..................................................36
furosemide oral solution 10 mg/ml.............................36
furosemide oral solution 40 mg/5 ml (8 mg/ml)..........36
furosemide oral tablet................................................36
FUSILEV................................................................17
FUZEON SUBCUTANEOUS RECON
SOLN..................................................................11
FYCOMPA ORAL SUSPENSION........................25
FYCOMPA ORAL TABLET 10 MG, 12 MG.......25
FYCOMPA ORAL TABLET 2 MG.......................25
gabapentin oral capsule 100 mg.................................25
gabapentin oral solution 250 mg/5 ml........................25
gabapentin oral solution 250 mg/5 ml (5 ml), 300
mg/6 ml (6 ml)......................................................25
gabapentin oral tablet 600 mg...................................25
gabapentin oral tablet 800 mg...................................25
GABITRIL ORAL TABLET 12 MG......................25
GABITRIL ORAL TABLET 16 MG......................25
galantamine oral capsule,ext rel. pellets 24 hr.............25
galantamine oral solution..........................................25
galantamine oral tablet.............................................25
GAMASTAN S/D..................................................50
GAMMAGARD LIQUID......................................50
GAMMAGARD S-D (IGA < 1 MCG/ML).......50
GAMUNEX-C.......................................................50
ganciclovir sodium....................................................11
GARDASIL (PF)....................................................50
GARDASIL 9 (PF).................................................50
GATTEX 30-VIAL.................................................48
GATTEX ONE-VIAL............................................48
gauze pads 2 x 2.......................................................44
gavilyte-c..................................................................48
gavilyte-g..................................................................48
fludrocortisone..........................................................44
flunisolide nasal spray,non-aerosol 25 mcg (0.025
%)........................................................................56
fluocinolone acetonide oil otic....................................43
fluocinolone topical cream.........................................40
fluocinolone topical ointment.....................................40
fluocinolone topical solution......................................41
fluocinonide topical cream 0.05 %............................41
fluocinonide topical gel..............................................41
fluocinonide topical ointment....................................41
fluocinonide topical solution......................................41
fluocinonide-e...........................................................41
fluoritab oral tablet,chewable 1 mg fluoride (2.2
mg).......................................................................58
fluorometholone........................................................54
fluorouracil intravenous............................................17
fluorouracil topical cream 5 %..................................41
fluorouracil topical solution.......................................41
fluoxetine oral capsule 10 mg.....................................24
fluoxetine oral solution..............................................24
fluoxetine oral tablet 10 mg.......................................24
fluoxetine oral tablet 20 mg.......................................24
fluphenazine decanoate.............................................24
fluphenazine hcl injection..........................................24
fluphenazine hcl oral.................................................24
flurbiprofen..............................................................24
flurbiprofen sodium..................................................54
flutamide.................................................................17
fluticasone nasal.......................................................56
fluticasone topical cream...........................................41
fluticasone topical lotion............................................41
fluticasone topical ointment.......................................41
fluvastatin oral capsule 20 mg...................................35
fluvastatin oral capsule 40 mg...................................35
fluvoxamine oral tablet 100 mg.................................24
fluvoxamine oral tablet 25 mg...................................25
fluvoxamine oral tablet 50 mg...................................25
FOLOTYN.............................................................17
fomepizole................................................................50
fondaparinux subcutaneous syringe 10 mg/0.8 ml.......35
fondaparinux subcutaneous syringe 2.5 mg/0.5 ml......35
fondaparinux subcutaneous syringe 5 mg/0.4 ml.........35
fondaparinux subcutaneous syringe 7.5 mg/0.6 ml......36
FORADIL AEROLIZER........................................56
FORTEO...............................................................51
fortical.....................................................................44
Core_16293_CG6_v15_1609_1
72
gavilyte-n.................................................................48
GAZYVA................................................................17
gemcitabine intravenous recon soln 1 gram, 200
mg........................................................................17
gemcitabine intravenous recon soln 2 gram.................17
gemcitabine intravenous solution 1 gram/26.3 ml (38
mg/ml), 200 mg/5.26 ml (38 mg/ml)......................17
gemcitabine intravenous solution 2 gram/52.6 ml (38
mg/ml)..................................................................17
gemfibrozil oral........................................................36
generlac....................................................................48
gengraf oral capsule 100 mg, 25 mg...........................17
gengraf oral capsule 50 mg........................................17
gengraf oral solution..................................................17
gentak ophthalmic ointment......................................54
gentamicin in nacl (iso-osm) intravenous piggyback
100 mg/100 ml, 60 mg/50 ml................................11
GENTAMICIN IN NACL (ISO-OSM)
ML, 120 MG/100 ML.........................................11
gentamicin in nacl (iso-osm) intravenous piggyback
70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/
100 ml..................................................................11
gentamicin injection.................................................11
gentamicin ophthalmic..............................................54
gentamicin sulfate (ped) (pf)......................................11
gentamicin sulfate (pf) intravenous solution 100 mg/
10 ml....................................................................11
gentamicin sulfate (pf) intravenous solution 60 mg/6
ml, 80 mg/8 ml.....................................................11
gentamicin topical....................................................41
GENVOYA............................................................11
GEODON INTRAMUSCULAR...........................25
gildagia....................................................................52
gildess 1.5/30 (21)....................................................52
gildess 1/20 (21).......................................................52
GILDESS FE 1.5/30 (28).......................................52
GILDESS FE 1/20 (28)..........................................52
GILENYA...............................................................25
GILOTRIF.............................................................17
GLATOPA.............................................................25
GLEEVEC ORAL TABLET 100 MG....................17
GLEEVEC ORAL TABLET 400 MG....................17
GLEOSTINE.........................................................17
glimepiride oral tablet 1 mg......................................44
glipizide oral tablet 10 mg........................................44
Core_16293_CG6_v15_1609_1
glipizide oral tablet 5 mg..........................................44
glipizide oral tablet extended release 24hr 10 mg........44
glipizide oral tablet extended release 24hr 2.5 mg.......44
glipizide oral tablet extended release 24hr 5 mg..........44
glipizide-metformin oral tablet 2.5-250 mg...............44
glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg........................................................................44
GLUCAGEN HYPOKIT.......................................44
GLUCAGON EMERGENCY KIT
(HUMAN)..........................................................44
GLUCOPHAGE ORAL TABLET 1,000 MG.......44
GLUCOPHAGE ORAL TABLET 500 MG..........44
GLUCOPHAGE ORAL TABLET 850 MG..........44
GLUCOPHAGE XR ORAL TABLET
GLUCOPHAGE XR ORAL TABLET
GLUCOTROL ORAL TABLET 10 MG...............44
GLUCOTROL ORAL TABLET 5 MG.................44
GLUCOTROL XL ORAL TABLET EXTENDED
RELEASE 24HR 10 MG.....................................45
RELEASE 24HR 2.5 MG....................................45
RELEASE 24HR 5 MG.......................................45
GLUCOVANCE....................................................45
GLUMETZA ORAL TABLET,ER
GAST.RETENTION 24 HR 1,000 MG.............45
GLUMETZA ORAL TABLET,ER
GAST.RETENTION 24 HR 500 MG................45
glycopyrrolate injection..............................................48
glycopyrrolate oral tablet............................................48
GRIS-PEG (ULTRAMICROSIZE) ORAL
TABLET 250 MG...............................................12
griseofulvin microsize oral suspension.........................12
griseofulvin ultramicrosize.........................................12
guanfacine oral tablet extended release 24 hr..............25
guanidine.................................................................25
HALAVEN.............................................................17
halobetasol propionate...............................................41
haloperidol...............................................................25
haloperidol decanoate................................................25
haloperidol lactate injection.......................................25
haloperidol lactate oral..............................................25
HARVONI.............................................................12
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION....................................................50
73
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,
440 ELISA UNIT/ML.........................................50
HAVRIX (PF) INTRAMUSCULAR SYRINGE
720 ELISA UNIT/0.5 ML...................................50
heather.....................................................................52
heparin (porcine) in 5 % dex intravenous parenteral
solution 12,500 unit/250 ml..................................36
solution 20,000 unit/500 ml (40 unit/ml)..............36
solution 25,000 unit/250 ml(100 unit/ml), 25,000
unit/500 ml (50 unit/ml).......................................36
heparin (porcine) in nacl (pf) intravenous parenteral
solution 1,000 unit/500 ml, 2,000 unit/1,000
ml.........................................................................36
heparin (porcine) injection cartridge..........................36
heparin (porcine) injection solution............................36
heparin(porcine) in 0.45% nacl intravenous parenteral
solution 12,500 unit/250 ml..................................36
solution 25,000 unit/250 ml..................................36
solution 25,000 unit/500 ml..................................36
heparin, porcine (pf) injection solution.......................36
HEPATAMINE 8%...............................................58
HERCEPTIN.........................................................17
HETLIOZ..............................................................25
HEXALEN.............................................................17
HIBERIX (PF)........................................................50
HUMALOG...........................................................45
HUMALOG KWIKPEN........................................45
HUMALOG MIX 50-50........................................45
HUMALOG MIX 50-50 KWIKPEN.....................45
HUMALOG MIX 75-25........................................45
HUMALOG MIX 75-25 KWIKPEN.....................45
HUMAPEN LUXURA HD...................................45
HUMIRA PEDIATRIC CROHN'S START.........51
HUMIRA PEN.......................................................51
HUMIRA PEN CROHN'S-UC-HS START.........51
HUMIRA PEN PSORIASIS STARTER................51
HUMIRA SUBCUTANEOUS SYRINGE KIT 10
MG/0.2 ML, 20 MG/0.4 ML..............................51
HUMIRA SUBCUTANEOUS SYRINGE KIT 40
MG/0.8 ML.........................................................51
HUMULIN 70/30..................................................45
HUMULIN 70/30 KWIKPEN..............................45
HUMULIN N........................................................45
HUMULIN N KWIKPEN.....................................45
Core_16293_CG6_v15_1609_1
HUMULIN R........................................................45
HUMULIN R U-500 (CONC) KWIKPEN..........45
HUMULIN R U-500 (CONCENTRATED)........45
hydralazine injection................................................36
hydralazine oral.......................................................36
hydrochlorothiazide..................................................36
hydrocodone-acetaminophen oral solution 2.5-167 mg/
5 ml......................................................................25
hydrocodone-acetaminophen oral solution 7.5-325 mg/
15 ml....................................................................25
hydrocodone-acetaminophen oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg..........................................25
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200
mg, 7.5-200 mg....................................................25
hydrocortisone butyrate topical cream.........................41
hydrocortisone butyrate topical ointment....................41
hydrocortisone butyrate topical solution......................41
hydrocortisone oral tablet 10 mg, 5 mg.......................45
hydrocortisone oral tablet 20 mg................................45
hydrocortisone rectal cream 2.5 %.............................48
hydrocortisone rectal enema.......................................48
hydrocortisone topical cream 1 %...............................41
hydrocortisone topical cream 2.5 %............................41
hydrocortisone topical lotion 2.5 %............................41
hydrocortisone topical ointment 1 %..........................41
hydrocortisone topical ointment 2.5 %.......................41
hydrocortisone valerate..............................................41
hydrocortisone-acetic acid..........................................43
hydrocortisone-min oil-wht pet..................................41
hydromorphone (pf) injection solution 1 mg/ml...........25
hydromorphone (pf) injection solution 10 mg/ml.........25
hydromorphone (pf) injection solution 4 mg/ml...........25
hydromorphone injection solution..............................25
hydromorphone injection syringe 1 mg/ml...................25
hydromorphone oral tablet 2 mg, 4 mg.......................25
hydromorphone oral tablet 8 mg................................25
hydroxychloroquine oral............................................12
hydroxyurea..............................................................17
HYZAAR................................................................36
ibandronate intravenous solution...............................51
ibandronate intravenous syringe.................................52
ibandronate oral.......................................................52
IBRANCE..............................................................17
ibuprofen oral suspension...........................................25
ibuprofen oral tablet 400 mg, 600 mg, 800 mg..........25
ibuprofen-oxycodone.................................................25
74
ICLUSIG ORAL TABLET 15 MG........................17
ICLUSIG ORAL TABLET 45 MG........................17
idarubicin................................................................17
IFEX.......................................................................17
ifosfamide intravenous recon soln...............................17
ifosfamide intravenous solution..................................17
ILARIS (PF)............................................................50
ILEVRO.................................................................54
imatinib oral tablet 100 mg......................................17
imatinib oral tablet 400 mg......................................17
IMBRUVICA.........................................................17
imipenem-cilastatin intravenous recon soln 250
mg........................................................................12
imipenem-cilastatin intravenous recon soln 500
mg........................................................................12
imipramine hcl.........................................................25
imiquimod...............................................................41
IMOVAX RABIES VACCINE (PF).......................50
INCRELEX............................................................42
indapamide..............................................................36
INFANRIX (DTAP) (PF).......................................50
INLYTA ORAL TABLET 1 MG............................17
INLYTA ORAL TABLET 5 MG............................17
insulin pen needle.....................................................45
INSULIN SYRINGE (DISP) U-100 0.3 ML, 1
ML, 1/2 ML........................................................45
INTELENCE ORAL TABLET 100 MG...............12
INTELENCE ORAL TABLET 200 MG...............12
INTELENCE ORAL TABLET 25 MG.................12
intralipid intravenous emulsion 20 %........................58
INTRALIPID INTRAVENOUS EMULSION 30
%.........................................................................58
INTRON A INJECTION......................................50
introvale..................................................................52
INVANZ 1 GM ADD-VANTAGE VIAL..............12
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 1.5 MG....................................26
RELEASE 24HR 3 MG.......................................26
RELEASE 24HR 6 MG.......................................26
RELEASE 24HR 9 MG.......................................26
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234
MG/1.5 ML, 78 MG/0.5 ML..............................26
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 39 MG/0.25 ML................................26
Core_16293_CG6_v15_1609_1
INVEGA TRINZA INTRAMUSCULAR
SYRINGE 273 MG/0.875 ML............................26
SYRINGE 410 MG/1.315 ML............................26
SYRINGE 546 MG/1.75 ML..............................26
SYRINGE 819 MG/2.625 ML............................26
INVIRASE ORAL CAPSULE................................12
INVIRASE ORAL TABLET..................................12
IONOSOL-B IN D5W..........................................58
IONOSOL-MB IN D5W.......................................58
IOPIDINE OPHTHALMIC DROPS...................54
IPOL INJECTION SUSPENSION.......................50
ipratropium bromide inhalation................................56
ipratropium bromide nasal........................................43
ipratropium-albuterol...............................................56
irbesartan.................................................................36
irbesartan-hydrochlorothiazide oral tablet 150-12.5
mg........................................................................36
irbesartan-hydrochlorothiazide oral tablet 300-12.5
mg........................................................................36
IRESSA...................................................................17
irinotecan intravenous solution 100 mg/5 ml, 40 mg/
2 ml......................................................................17
irinotecan intravenous solution 500 mg/25 ml............17
ISENTRESS ORAL POWDER IN PACKET........12
ISENTRESS ORAL TABLET................................12
ISENTRESS ORAL TABLET,CHEWABLE 100
MG......................................................................12
ISENTRESS ORAL TABLET,CHEWABLE 25
MG......................................................................12
ISOLYTE S PH 7.4................................................58
ISOLYTE-P IN 5 % DEXTROSE.........................58
ISOLYTE-S............................................................58
isoniazid injection....................................................12
isoniazid oral solution...............................................12
isoniazid oral tablet 100 mg......................................12
isoniazid oral tablet 300 mg......................................12
ISOPTO CARPINE...............................................54
isosorbide dinitrate oral tablet 10 mg, 20 mg, 5
mg........................................................................36
isosorbide dinitrate oral tablet 30 mg.........................36
isosorbide dinitrate oral tablet extended release...........36
isosorbide mononitrate..............................................36
isradipine.................................................................36
ISTODAX..............................................................17
itraconazole..............................................................12
75
KHEDEZLA ORAL TABLET EXTENDED
RELEASE 24HR 50 MG.....................................26
KINERET..............................................................52
kionex......................................................................42
klor-con 10..............................................................58
klor-con 8................................................................58
klor-con m10............................................................58
klor-con m15............................................................58
klor-con m20............................................................58
klor-con/ef................................................................58
KORLYM...............................................................45
KUVAN ORAL TABLET,SOLUBLE....................45
labetalol intravenous solution....................................36
labetalol oral tablet 100 mg, 200 mg.........................36
labetalol oral tablet 300 mg.......................................36
LACRISERT...........................................................54
lactated ringers intravenous.......................................58
lactated ringers irrigation..........................................42
lactulose...................................................................48
LAMISIL ORAL TABLET.....................................12
lamivudine oral solution...........................................12
lamivudine oral tablet 100 mg..................................12
lamivudine-zidovudine.............................................12
lamotrigine oral tablet 100 mg, 150 mg, 200 mg.......26
lamotrigine oral tablet 25 mg....................................26
lamotrigine oral tablet, chewable dispersible...............26
LANOXIN ORAL TABLET 125 MCG, 62.5
MCG...................................................................36
lansoprazole oral capsule,delayed release(dr/ec)............48
LANTUS................................................................45
LANTUS SOLOSTAR...........................................45
LARIN 1/20 (21)....................................................53
LARIN FE 1.5/30 (28)...........................................53
LARIN FE 1/20 (28)..............................................53
latanoprost...............................................................54
LATUDA ORAL TABLET 120 MG......................26
LATUDA ORAL TABLET 20 MG........................26
leena 28...................................................................53
leflunomide oral tablet 10 mg....................................52
leflunomide oral tablet 20 mg....................................52
LENVIMA ORAL CAPSULE 10 MG/DAY (10
MG X 1/DAY).....................................................18
ivermectin oral.........................................................12
IXEMPRA..............................................................17
IXIARO (PF)..........................................................50
JAKAFI ORAL TABLET 10 MG...........................17
JAKAFI ORAL TABLET 5 MG.............................18
jantoven oral tablet 1 mg, 10 mg, 2.5 mg, 3 mg, 4
mg, 5 mg, 6 mg, 7.5 mg.........................................36
jantoven oral tablet 2 mg..........................................36
JANUMET.............................................................45
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG...............45
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 50-1,000 MG, 50-500
MG......................................................................45
JANUVIA ORAL TABLET 100 MG.....................45
JANUVIA ORAL TABLET 25 MG.......................45
JANUVIA ORAL TABLET 50 MG.......................45
JARDIANCE..........................................................45
JENTADUETO.....................................................45
JEVTANA..............................................................18
jolessa.......................................................................52
jolivette....................................................................53
junel 1.5/30 (21)......................................................53
junel 1/20 (21).........................................................53
junel fe 1.5/30 (28)..................................................53
junel fe 1/20 (28).....................................................53
JUXTAPID.............................................................36
k-effervescent............................................................58
k-tab oral tablet extended release 8 meq.....................58
KADCYLA.............................................................18
KALETRA ORAL SOLUTION.............................12
KALETRA ORAL TABLET 100-25 MG...............12
KALETRA ORAL TABLET 200-50 MG...............12
KALYDECO ORAL TABLET...............................56
kariva (28)..............................................................53
kelnor 1/35 (28).......................................................53
KETEK...................................................................12
ketoconazole oral......................................................12
ketoconazole topical cream.........................................41
ketoconazole topical shampoo.....................................41
ketorolac ophthalmic.................................................54
KEYTRUDA..........................................................18
KHEDEZLA ORAL TABLET EXTENDED
RELEASE 24HR 100 MG...................................26
Core_16293_CG6_v15_1609_1
76
LENVIMA ORAL CAPSULE 14 MG/DAY(10
MG X 1-4 MG X 1), 20 MG/DAY (10 MG X
2).........................................................................18
LENVIMA ORAL CAPSULE 18 MG/DAY (10
MG X 1-4 MG X2)..............................................18
LENVIMA ORAL CAPSULE 24 MG/DAY(10
MG X 2-4 MG X 1).............................................18
LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG
X 2), 8 MG/DAY (4 MG X 2) (60 PACK)..........18
LESCOL.................................................................36
lessina......................................................................53
LETAIRIS...............................................................56
letrozole...................................................................18
leucovorin calcium injection recon soln 100 mg, 200
mg, 350 mg, 50 mg...............................................18
leucovorin calcium injection recon soln 500 mg..........18
leucovorin calcium oral tablet 10 mg, 25 mg..............18
leucovorin calcium oral tablet 15 mg, 5 mg................18
LEUKERAN...........................................................18
leuprolide subcutaneous kit........................................18
levalbuterol hcl inhalation solution for nebulization
0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml........56
levalbuterol hcl inhalation solution for nebulization
0.63 mg/3 ml........................................................56
LEVEMIR..............................................................45
LEVEMIR FLEXTOUCH.....................................45
levetiracetam in nacl (iso-os) intravenous piggyback 1,
000 mg/100 ml, 1,500 mg/100 ml.........................26
levetiracetam in nacl (iso-os) intravenous piggyback
500 mg/100 ml.....................................................26
levetiracetam intravenous..........................................26
levetiracetam oral solution 100 mg/ml.......................26
levetiracetam oral solution 500 mg/5 ml (5 ml)..........26
levetiracetam oral tablet 1,000 mg.............................26
levetiracetam oral tablet 250 mg, 500 mg, 750
mg........................................................................26
levetiracetam oral tablet extended release 24 hr 500
mg........................................................................26
levetiracetam oral tablet extended release 24 hr 750
mg........................................................................26
levobunolol ophthalmic drops 0.5 %..........................54
levocarnitine (with sugar)..........................................42
levocarnitine intravenous..........................................42
levocarnitine oral tablet.............................................42
levocetirizine oral tablet............................................56
levofloxacin in d5w intravenous piggyback 250 mg/50
ml.........................................................................12
Core_16293_CG6_v15_1609_1
levofloxacin in d5w intravenous piggyback 500 mg/
100 ml, 750 mg/150 ml........................................12
levofloxacin ophthalmic.............................................54
levofloxacin oral tablet..............................................12
levonest (28).............................................................53
levonorg-eth estrad triphasic......................................53
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg,
0.15-0.03 mg........................................................53
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg......53
levonorgestrel-ethinyl estrad oral tablets,dose pack,3
month...................................................................53
levora-28.................................................................53
levothyroxine oral.....................................................45
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137
mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg,
75 mcg, 88 mcg.....................................................45
LEXIVA ORAL SUSPENSION.............................12
LEXIVA ORAL TABLET.......................................12
LIALDA..................................................................48
lidocaine hcl laryngotracheal......................................41
lidocaine hcl mucous membrane.................................41
lidocaine hcl urethral................................................41
lidocaine topical adhesive patch,medicated.................41
lidocaine topical ointment.........................................41
lidocaine viscous.......................................................41
lidocaine-prilocaine topical cream..............................41
LINCOCIN............................................................12
lincomycin injection..................................................12
lindane topical shampoo............................................41
linezolid intravenous.................................................12
linezolid oral suspension for reconstitution..................12
linezolid oral tablet...................................................12
linezolid-0.9% sodium chloride.................................12
LINZESS................................................................48
liothyronine intravenous............................................45
liothyronine oral tablet 25 mcg, 5 mcg.......................45
liothyronine oral tablet 50 mcg..................................45
LIPITOR ORAL TABLET 10 MG........................36
lisinopril..................................................................36
lisinopril-hydrochlorothiazide....................................36
lithium carbonate oral capsule 150 mg, 300 mg.........26
lithium carbonate oral capsule 600 mg.......................26
lithium carbonate oral tablet.....................................26
lithium carbonate oral tablet extended release.............26
lithium citrate oral solution 8 meq/5 ml.....................26
LOFIBRA ORAL CAPSULE 200 MG...................36
LONSURF.............................................................18
loperamide oral capsule.............................................48
77
LOPID...................................................................36
lorazepam oral tablet................................................26
loryna (28)...............................................................53
losartan oral tablet 100 mg.......................................36
losartan oral tablet 25 mg, 50 mg..............................36
losartan-hydrochlorothiazide.....................................36
LOTENSIN ORAL TABLET 20 MG, 40 MG......37
lovastatin oral tablet 10 mg, 20 mg...........................37
lovastatin oral tablet 40 mg.......................................37
low-ogestrel (28).......................................................53
loxapine succinate oral capsule 10 mg, 5 mg...............26
loxapine succinate oral capsule 25 mg, 50 mg.............26
ludent fluoride..........................................................58
LUMIGAN OPHTHALMIC DROPS 0.01 %......54
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 3.75 MG.....................................18
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 7.5 MG.......................................18
LUPRON DEPOT-PED INTRAMUSCULAR
KIT 7.5 MG (PED).............................................18
lutera (28)...............................................................53
LYNPARZA............................................................18
LYRICA ORAL CAPSULE 100 MG......................26
LYRICA ORAL CAPSULE 225 MG, 300 MG......27
LYRICA ORAL CAPSULE 25 MG........................27
LYRICA ORAL SOLUTION.................................27
LYSODREN...........................................................18
lyza..........................................................................53
M-M-R II (PF).......................................................50
magnesium sulfate in water intravenous parenteral
solution.................................................................58
magnesium sulfate in water intravenous piggyback 2
gram/50 ml (4 %), 4 gram/50 ml (8 %)................58
magnesium sulfate in water intravenous piggyback 4
gram/100 ml (4 %)...............................................58
magnesium sulfate injection solution..........................58
magnesium sulfate injection syringe............................58
MALARONE.........................................................12
malathion................................................................41
maprotiline oral tablet 25 mg....................................27
marlissa...................................................................53
MARPLAN.............................................................27
Core_16293_CG6_v15_1609_1
MATULANE..........................................................18
MAVIK ORAL TABLET 1 MG, 2 MG.................37
MAXZIDE.............................................................37
MAXZIDE-25MG..................................................37
meclizine oral tablet 12.5 mg, 25 mg.........................48
meclofenamate oral...................................................27
medroxyprogesterone intramuscular............................53
medroxyprogesterone oral...........................................53
mefloquine...............................................................12
megestrol oral suspension 400 mg/10 ml (10 ml), 800
mg/20 ml (20 ml)..................................................18
megestrol oral suspension 400 mg/10 ml (40 mg/
ml).......................................................................18
megestrol oral tablet..................................................18
MEKINIST ORAL TABLET 0.5 MG....................18
MEKINIST ORAL TABLET 2 MG.......................18
meloxicam oral suspension.........................................27
meloxicam oral tablet................................................27
melphalan hcl...........................................................18
memantine oral solution............................................27
memantine oral tablet 10 mg....................................27
memantine oral tablet 5 mg......................................27
MENACTRA (PF) INTRAMUSCULAR
SOLUTION........................................................50
MENEST...............................................................53
MENOMUNE - A/C/Y/W-135.............................50
MENOMUNE - A/C/Y/W-135 (PF).....................50
MENVEO A-C-Y-W-135-DIP (PF).......................50
mercaptopurine.........................................................18
meropenem...............................................................12
mesalamine rectal.....................................................48
mesalamine with cleansing wipe................................48
mesna......................................................................18
MESNEX ORAL....................................................18
MESTINON ORAL SYRUP..................................27
MESTINON TIMESPAN.....................................27
metformin oral tablet 1,000 mg.................................45
metformin oral tablet 500 mg....................................45
metformin oral tablet 850 mg....................................45
metformin oral tablet extended release 24 hr 500
mg........................................................................46
metformin oral tablet extended release 24 hr 750
mg........................................................................46
metformin oral tablet extended release 24hr 1,000
mg........................................................................46
metformin oral tablet extended release 24hr 500
mg........................................................................46
78
metformin oral tablet,er gast.retention 24 hr 1,000
mg........................................................................46
metformin oral tablet,er gast.retention 24 hr 500
mg........................................................................46
methadone intensol...................................................27
methadone oral concentrate.......................................27
methadone oral solution 10 mg/5 ml..........................27
methadone oral solution 5 mg/5 ml............................27
methadone oral tablet 10 mg.....................................27
methadone oral tablet 5 mg.......................................27
methadone oral tablet,soluble.....................................27
methadose oral concentrate........................................27
methadose oral tablet,soluble......................................27
methazolamide oral..................................................54
methenamine hippurate............................................12
methenamine mandelate...........................................12
methimazole oral tablet 10 mg..................................46
methimazole oral tablet 5 mg....................................46
methotrexate sodium (pf) injection recon soln..............18
methotrexate sodium (pf) injection solution................18
methotrexate sodium injection...................................18
methotrexate sodium oral..........................................18
methoxsalen rapid.....................................................41
methscopolamine oral................................................48
methyclothiazide.......................................................37
methylergonovine oral...............................................53
methylphenidate oral tablet.......................................27
methylprednisolone acetate.........................................46
methylprednisolone oral tablet 16 mg, 4 mg, 8 mg......46
methylprednisolone oral tablet 32 mg.........................46
methylprednisolone oral tablets,dose pack....................46
methylprednisolone sodium succ injection recon soln
125 mg, 40 mg......................................................46
methylprednisolone sodium succ intravenous...............46
metipranolol.............................................................54
metoclopramide hcl injection solution.........................48
metoclopramide hcl injection syringe..........................48
metoclopramide hcl oral solution................................48
metoclopramide hcl oral tablet...................................48
metolazone oral tablet 10 mg, 5 mg...........................37
metolazone oral tablet 2.5 mg....................................37
metoprolol succinate oral tablet extended release 24 hr
100 mg, 25 mg, 50 mg..........................................37
metoprolol succinate oral tablet extended release 24 hr
200 mg.................................................................37
metoprolol ta-hydrochlorothiaz oral tablet 100-25 mg,
100-50 mg............................................................37
Core_16293_CG6_v15_1609_1
metoprolol ta-hydrochlorothiaz oral tablet 50-25
mg........................................................................37
metoprolol tartrate intravenous solution.....................37
metoprolol tartrate intravenous syringe.......................37
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg........................................................................37
metoprolol tartrate oral tablet 37.5 mg, 75 mg...........37
metro i.v..................................................................12
metronidazole in nacl (iso-os)....................................12
metronidazole oral capsule.........................................12
metronidazole oral tablet...........................................12
metronidazole topical cream......................................41
metronidazole topical gel 0.75 %...............................41
metronidazole topical lotion......................................41
metronidazole vaginal...............................................53
mexiletine oral capsule 150 mg, 250 mg....................37
mexiletine oral capsule 200 mg..................................37
MIACALCIN INJECTION...................................46
MIACALCIN NASAL............................................46
MICARDIS HCT ORAL TABLET 40-12.5 MG,
80-25 MG............................................................37
MICARDIS HCT ORAL TABLET 80-12.5
MG......................................................................37
MICARDIS ORAL TABLET 20 MG, 40 MG.......37
MICARDIS ORAL TABLET 80 MG....................37
miconazole-3 vaginal suppository...............................53
MICROGESTIN 1.5/30 (21).................................53
MICROGESTIN 1/20 (21)....................................53
MICROGESTIN FE 1.5/30 (28)...........................53
MICROGESTIN FE 1/20 (28)..............................53
MICROZIDE.........................................................37
midodrine................................................................42
MINIPRESS ORAL CAPSULE 2 MG...................37
minocycline oral capsule 100 mg, 50 mg....................12
minocycline oral capsule 75 mg..................................13
minocycline oral tablet..............................................13
minoxidil oral..........................................................37
MIRAPEX ORAL TABLET 0.25 MG, 0.75
MG......................................................................27
mirtazapine oral tablet 15 mg...................................27
mirtazapine oral tablet 7.5 mg..................................27
mirtazapine oral tablet,disintegrating 15 mg..............27
misoprostol oral tablet 100 mcg.................................48
misoprostol oral tablet 200 mcg.................................48
79
mitomycin................................................................18
mitoxantrone............................................................18
modafinil oral tablet 100 mg.....................................27
modafinil oral tablet 200 mg.....................................27
moexipril..................................................................37
moexipril-hydrochlorothiazide...................................37
molindone................................................................27
mometasone nasal.....................................................56
mometasone topical...................................................41
mono-linyah.............................................................53
mononessa (28).........................................................53
montelukast oral granules in packet............................56
montelukast oral tablet..............................................56
montelukast oral tablet,chewable...............................56
morphine (pf) injection solution 0.5 mg/ml................27
morphine (pf) injection solution 1 mg/ml...................27
morphine (pf) intravenous patient control.analgesia
soln 150 mg/30 ml................................................27
morphine (pf) intravenous patient control.analgesia
soln 30 mg/30 ml..................................................27
morphine concentrate oral solution.............................27
morphine intravenous cartridge.................................27
morphine intravenous solution 10 mg/ml, 50 mg/
ml.........................................................................27
morphine intravenous solution 100 mg/4 ml, 25 mg/
ml, 250 mg/10 ml.................................................28
morphine intravenous solution 4 mg/ml, 8 mg/ml.......28
morphine intravenous syringe 2 mg/ml, 4 mg/ml.........28
morphine oral solution 10 mg/5 ml............................28
morphine oral solution 20 mg/5 ml (4 mg/ml)............28
morphine oral tablet 15 mg.......................................28
morphine oral tablet 30 mg.......................................28
morphine oral tablet extended release 100 mg, 30 mg,
60 mg...................................................................28
morphine oral tablet extended release 15 mg...............28
morphine oral tablet extended release 200 mg.............28
morphine rectal........................................................28
MOVIPREP...........................................................48
MOXEZA...............................................................54
moxifloxacin.............................................................13
MULTAQ..............................................................37
mupirocin calcium....................................................41
mupirocin topical ointment.......................................41
MUSTARGEN.......................................................18
MYCAMINE..........................................................13
mycophenolate mofetil oral capsule.............................18
mycophenolate mofetil oral suspension for
reconstitution........................................................18
Core_16293_CG6_v15_1609_1
mycophenolate mofetil oral tablet...............................18
myorisan oral capsule 10 mg, 20 mg, 40 mg...............41
MYOZYME............................................................46
MYRBETRIQ........................................................57
MYZILRA..............................................................53
nabumetone.............................................................28
nadolol oral tablet 20 mg, 40 mg...............................37
nadolol oral tablet 80 mg..........................................37
nadolol-bendroflumethiazide.....................................37
nafcillin in dextrose iso-osm intravenous piggyback 1
gram/50 ml...........................................................13
nafcillin in dextrose iso-osm intravenous piggyback 2
gram/100 ml.........................................................13
nafcillin injection.....................................................13
nafcillin intravenous recon soln 1 gram......................13
NAFCILLIN INTRAVENOUS RECON SOLN
2 GRAM..............................................................13
NAGLAZYME.......................................................46
nalbuphine injection solution 10 mg/ml.....................28
nalbuphine injection solution 20 mg/ml.....................28
naloxone injection solution........................................28
naloxone injection syringe 0.4 mg/ml.........................28
naloxone injection syringe 1 mg/ml............................28
naltrexone................................................................28
NAMENDA ORAL SOLUTION..........................28
NAMENDA XR ORAL CAP,SPRINKLE,ER
24HR DOSE PACK............................................28
NAMENDA XR ORAL CAPSULE,SPRINKLE,
ER 24HR.............................................................28
NAMZARIC..........................................................28
naphazoline..............................................................54
naproxen oral suspension...........................................28
naproxen oral tablet..................................................28
naproxen oral tablet,delayed release (dr/ec).................28
naproxen sodium oral tablet 275 mg, 550 mg............28
naratriptan..............................................................28
NASONEX.............................................................57
nateglinide oral tablet 120 mg...................................46
nateglinide oral tablet 60 mg.....................................46
NATPARA.............................................................46
NEBUPENT..........................................................13
necon 0.5/35 (28).....................................................53
necon 1/35 (28)........................................................53
necon 1/50 (28)........................................................53
necon 10/11 (28)......................................................53
necon 7/7/7 (28).......................................................53
needles, insulin disp.,safety........................................46
nefazodone oral tablet 100 mg...................................28
80
NITROSTAT.........................................................37
nizatidine oral capsule 150 mg..................................48
nizatidine oral capsule 300 mg..................................48
NOR-QD...............................................................53
nora-be....................................................................53
NORDITROPIN FLEXPRO.................................50
norethindrone (contraceptive)....................................53
norethindrone acetate................................................53
norgestimate-ethinyl estradiol oral tablet 0.18/0.215/
0.25 mg-35 mcg (28), 0.25-35 mg-mcg..................53
NORMOSOL-M IN 5 % DEXTROSE.................59
NORMOSOL-R.....................................................59
NORMOSOL-R IN 5 % DEXTROSE..................59
NORMOSOL-R PH 7.4........................................59
NORPACE.............................................................37
nortrel 0.5/35 (28)...................................................53
nortrel 1/35 (21)......................................................53
nortrel 1/35 (28)......................................................53
nortrel 7/7/7 (28).....................................................53
nortriptyline oral capsule...........................................28
nortriptyline oral solution..........................................28
NORVASC ORAL TABLET 10 MG, 2.5 MG......37
NORVASC ORAL TABLET 5 MG.......................37
NORVIR ORAL CAPSULE...................................13
NORVIR ORAL SOLUTION...............................13
NORVIR ORAL TABLET.....................................13
NOVOPEN ECHO...............................................46
NOXAFIL ORAL SUSPENSION..........................13
NUEDEXTA..........................................................28
NULOJIX...............................................................18
NUPLAZID...........................................................28
nyamyc.....................................................................41
nystatin oral suspension.............................................13
nystatin oral tablet....................................................13
nystatin topical cream...............................................41
nystatin topical ointment...........................................41
nystatin topical powder.............................................41
nystatin-triamcinolone..............................................41
nystop......................................................................41
ocella.......................................................................53
OCTAGAM...........................................................50
octreotide acetate injection solution 1,000 mcg/ml, 500
mcg/ml..................................................................19
octreotide acetate injection solution 100 mcg/ml, 200
mcg/ml, 50 mcg/ml................................................19
octreotide acetate injection syringe 100 mcg/ml (1 ml),
50 mcg/ml (1 ml)..................................................19
nefazodone oral tablet 50 mg.....................................28
neo-polycin...............................................................54
neo-polycin hc...........................................................54
neomycin..................................................................13
neomycin-bacitracin-poly-hc......................................54
neomycin-bacitracin-polymyxin.................................54
neomycin-polymyxin b gu..........................................42
neomycin-polymyxin b-dexameth...............................54
neomycin-polymyxin-gramicidin................................54
neomycin-polymyxin-hc ophthalmic...........................54
neomycin-polymyxin-hc otic.......................................43
NEPHRAMINE 5.4 %...........................................58
NEUPOGEN.........................................................50
NEUPRO...............................................................28
NEVANAC............................................................54
nevirapine oral suspension.........................................13
nevirapine oral tablet................................................13
nevirapine oral tablet extended release 24 hr 100
mg........................................................................13
nevirapine oral tablet extended release 24 hr 400
mg........................................................................13
NEXAVAR.............................................................18
niacin oral tablet extended release 24 hr 1,000 mg,
750 mg.................................................................37
niacin oral tablet extended release 24 hr 500 mg........37
NIACOR................................................................37
nicardipine intravenous solution................................37
nicardipine oral........................................................37
NICOTROL NS....................................................42
nifedical xl...............................................................37
nifedipine oral tablet extended release 24hr 30 mg, 60
mg........................................................................37
nifedipine oral tablet extended release 24hr 90 mg......37
nifedipine oral tablet extended release 30 mg, 60
mg........................................................................37
nifedipine oral tablet extended release 90 mg..............37
NILANDRON.......................................................18
nimodipine...............................................................37
NINLARO.............................................................18
NIPENT.................................................................18
nitrofurantoin macrocrystal oral capsule 100 mg, 50
mg........................................................................13
nitrofurantoin monohyd/m-cryst................................13
nitroglycerin intravenous...........................................37
nitroglycerin transdermal patch 24 hour.....................37
Core_16293_CG6_v15_1609_1
81
octreotide acetate injection syringe 500 mcg/ml (1
ml).......................................................................19
ODEFSEY..............................................................13
ODOMZO.............................................................19
OFEV ORAL CAPSULE 150 MG.........................57
ofloxacin ophthalmic.................................................54
ofloxacin oral tablet 400 mg......................................13
ofloxacin otic............................................................43
ogestrel (28).............................................................53
olanzapine intramuscular..........................................28
olanzapine oral tablet 10 mg.....................................28
olanzapine oral tablet 2.5 mg....................................28
olanzapine oral tablet 5 mg.......................................28
olanzapine oral tablet 7.5 mg....................................28
olanzapine oral tablet,disintegrating 10 mg................28
olanzapine oral tablet,disintegrating 5 mg..................28
OLYSIO.................................................................13
omega-3 acid ethyl esters............................................37
omeprazole oral capsule,delayed release(dr/ec) 10 mg,
40 mg...................................................................48
omeprazole oral capsule,delayed release(dr/ec) 20
mg........................................................................48
OMNITROPE.......................................................50
ONCASPAR...........................................................19
ondansetron hcl (pf) injection solution........................48
ondansetron hcl (pf) injection syringe.........................48
ondansetron hcl intravenous......................................48
ondansetron hcl oral tablet 4 mg, 8 mg......................49
ondansetron oral tablet,disintegrating 4 mg................49
ondansetron oral tablet,disintegrating 8 mg................49
ONFI ORAL SUSPENSION.................................29
ONFI ORAL TABLET 10 MG..............................29
ONFI ORAL TABLET 20 MG..............................29
OPDIVO................................................................19
opium tincture..........................................................49
ORAP.....................................................................29
ORENCIA..............................................................52
ORENCIA (WITH MALTOSE)............................52
ORFADIN ORAL CAPSULE................................42
orsythia....................................................................53
ORTHO MICRONOR.........................................53
OSMOPREP..........................................................49
oxacillin in dextrose(iso-osm) intravenous piggyback 1
gram/50 ml...........................................................13
Core_16293_CG6_v15_1609_1
oxacillin in dextrose(iso-osm) intravenous piggyback 2
gram/50 ml...........................................................13
oxacillin injection.....................................................13
oxacillin intravenous.................................................13
oxaliplatin intravenous recon soln 100 mg..................19
oxaliplatin intravenous recon soln 50 mg....................19
oxaliplatin intravenous solution.................................19
oxandrolone oral tablet 10 mg...................................46
oxandrolone oral tablet 2.5 mg..................................46
oxaprozin.................................................................29
oxazepam.................................................................29
oxcarbazepine oral suspension....................................29
oxcarbazepine oral tablet 150 mg, 300 mg.................29
oxcarbazepine oral tablet 600 mg..............................29
oxybutynin chloride oral syrup...................................57
oxybutynin chloride oral tablet...................................57
oxybutynin chloride oral tablet extended release 24hr
10 mg, 15 mg........................................................57
oxybutynin chloride oral tablet extended release 24hr
5 mg.....................................................................57
oxycodone oral capsule...............................................29
oxycodone oral concentrate.........................................29
oxycodone oral solution..............................................29
oxycodone oral tablet 10 mg, 5 mg.............................29
oxycodone oral tablet 15 mg......................................29
oxycodone oral tablet 20 mg, 30 mg...........................29
oxycodone-acetaminophen oral solution......................29
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5325 mg, 7.5-325 mg.............................................29
oxycodone-acetaminophen oral tablet 5-325 mg..........29
oxycodone-aspirin.....................................................29
pacerone oral tablet 100 mg, 400 mg.........................37
pacerone oral tablet 200 mg......................................37
paclitaxel..................................................................19
paliperidone oral tablet extended release 24hr 1.5
mg........................................................................29
paliperidone oral tablet extended release 24hr 3
mg........................................................................29
mg........................................................................29
mg........................................................................29
pamidronate intravenous recon soln...........................46
pamidronate intravenous solution 30 mg/10 ml (3 mg/
ml), 90 mg/10 ml (9 mg/ml)..................................46
pamidronate intravenous solution 60 mg/10 ml (6 mg/
ml).......................................................................46
PANRETIN............................................................41
82
pantoprazole intravenous..........................................49
pantoprazole oral......................................................49
paregoric..................................................................49
paricalcitol oral capsule 1 mcg, 2 mcg........................46
paricalcitol oral capsule 4 mcg...................................46
paroex oral rinse.......................................................43
paromomycin............................................................13
paroxetine hcl oral tablet 10 mg.................................29
paroxetine hcl oral tablet 40 mg................................29
paroxetine hcl oral tablet extended release 24 hr 12.5
mg........................................................................29
paroxetine hcl oral tablet extended release 24 hr 25
mg........................................................................29
paroxetine hcl oral tablet extended release 24 hr 37.5
mg........................................................................29
PASER....................................................................13
PATADAY..............................................................54
PAXIL ORAL SUSPENSION................................29
PAZEO...................................................................55
PEDVAX HIB (PF)................................................50
peg 3350-electrolytes oral recon soln 236-22.74-6.74
-5.86 gram............................................................49
peg 3350-electrolytes oral recon soln 240-22.72-6.72
-5.84 gram............................................................49
peg-electrolyte soln.....................................................49
PEGANONE..........................................................29
PEGINTRON SUBCUTANEOUS KIT 120
MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5
ML.......................................................................50
PENICILLIN G POT IN DEXTROSE.................13
penicillin g potassium................................................13
penicillin g procaine intramuscular syringe 1.2 million
unit/2 ml..............................................................13
penicillin g procaine intramuscular syringe 600,000
unit/ml.................................................................13
penicillin g sodium....................................................13
penicillin v potassium oral recon soln.........................13
penicillin v potassium oral tablet 250 mg...................13
penicillin v potassium oral tablet 500 mg...................13
PENTAM...............................................................13
PENTASA..............................................................49
pentoxifylline............................................................37
PERFOROMIST....................................................57
perindopril erbumine................................................37
periogard..................................................................43
PERJETA................................................................19
Core_16293_CG6_v15_1609_1
permethrin topical cream...........................................41
perphenazine............................................................29
pfizerpen-g...............................................................13
phenelzine................................................................29
phenobarbital oral elixir............................................29
phenobarbital oral tablet 100 mg..............................29
phenobarbital oral tablet 15 mg................................29
phenobarbital oral tablet 16.2 mg.............................29
PHENYTEK...........................................................29
phenytoin oral suspension 100 mg/4 ml......................29
phenytoin oral suspension 125 mg/5 ml......................29
phenytoin oral tablet,chewable...................................29
phenytoin sodium extended........................................29
phenytoin sodium intravenous solution.......................29
phenytoin sodium intravenous syringe........................29
philith......................................................................53
phospha 250 neutral.................................................59
PHOSPHOLINE IODIDE....................................55
PHYSIOLYTE........................................................42
PHYSIOSOL IRRIGATION.................................42
PICATO.................................................................41
pilocarpine hcl ophthalmic drops 1 %, 2 %................55
pilocarpine hcl ophthalmic drops 4 %........................55
pilocarpine hcl oral...................................................42
pimozide..................................................................30
PIMTREA (28).......................................................53
pindolol oral tablet 10 mg.........................................37
pindolol oral tablet 5 mg...........................................38
pioglitazone oral tablet 15 mg...................................46
pioglitazone-glimepiride............................................46
pioglitazone-metformin.............................................46
piperacillin-tazobactam............................................13
pirmella oral tablet 1-35 mg-mcg..............................53
piroxicam.................................................................30
PLASMA-LYTE 148...............................................59
PLASMA-LYTE A..................................................59
PLASMA-LYTE-56 IN 5 % DEXTROSE..............59
PLEGRIDY............................................................50
podofilox..................................................................41
polycin.....................................................................55
polyethylene glycol 3350 oral.....................................49
83
PRADAXA..............................................................38
PRALUENT PEN..................................................38
PRALUENT SYRINGE.........................................38
pramipexole oral tablet..............................................30
PRAVACHOL ORAL TABLET 20 MG................38
pravastatin oral tablet 10 mg, 20 mg, 40 mg.............38
pravastatin oral tablet 80 mg....................................38
prazosin oral capsule 1 mg, 2 mg...............................38
prazosin oral capsule 5 mg.........................................38
PRECOSE ORAL TABLET 100 MG....................46
PRECOSE ORAL TABLET 25 MG......................46
PRECOSE ORAL TABLET 50 MG......................46
prednicarbate...........................................................41
prednisolone acetate..................................................55
prednisolone oral solution 15 mg/5 ml........................46
prednisolone sodium phosphate ophthalmic.................55
prednisolone sodium phosphate oral solution 15 mg/5
ml (3 mg/ml).........................................................46
prednisolone sodium phosphate oral solution 5 mg base/
5 ml (6.7 mg/5 ml)................................................46
prednisolone sodium phosphate oral tablet,
disintegrating........................................................46
prednisone intensol....................................................46
prednisone oral solution.............................................46
prednisone oral tablet 1 mg.......................................46
prednisone oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg,
50 mg...................................................................46
prednisone oral tablets,dose pack................................46
PREMARIN ORAL................................................53
PREMARIN VAGINAL.........................................53
premasol 10 %.........................................................59
PREMASOL 6 %....................................................59
PREMPRO.............................................................53
prenatal vitamin oral tablet......................................59
prevalite...................................................................38
previfem...................................................................53
PREZCOBIX..........................................................13
PREZISTA ORAL SUSPENSION.........................13
PREZISTA ORAL TABLET 150 MG....................13
PREZISTA ORAL TABLET 600 MG, 800
MG......................................................................13
PREZISTA ORAL TABLET 75 MG......................13
PRIFTIN................................................................13
PRIMAQUINE......................................................13
primidone................................................................30
PRINIVIL ORAL TABLET 10 MG, 20 MG, 5
MG......................................................................38
polymyxin b sulf-trimethoprim...................................55
polymyxin b sulfate...................................................13
POMALYST ORAL CAPSULE 1 MG...................19
POMALYST ORAL CAPSULE 2 MG...................19
POMALYST ORAL CAPSULE 3 MG, 4 MG.......19
portia.......................................................................53
PORTRAZZA........................................................19
potassium bicarb and chloride...................................59
potassium bicarb-citric acid.......................................59
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 10 meq/l, 30 meq/l, 40 meq/
l............................................................................59
potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 20 meq/l...................................59
potassium chloride in 0.9%nacl intravenous parenteral
solution 20 meq/l, 40 meq/l....................................59
potassium chloride in 5 % dex intravenous parenteral
solution 20 meq/l, 30 meq/l, 40 meq/l.....................59
potassium chloride in lr-d5 intravenous parenteral
solution 20 meq/l...................................................59
potassium chloride in lr-d5 intravenous parenteral
solution 40 meq/l...................................................59
potassium chloride intravenous piggyback 10 meq/100
ml, 20 meq/100 ml, 30 meq/100 ml......................59
potassium chloride intravenous piggyback 10 meq/50
ml.........................................................................59
potassium chloride oral capsule, extended release.........59
potassium chloride oral liquid....................................59
potassium chloride oral tablet extended release............59
potassium chloride oral tablet,er particles/crystals.........59
potassium chloride-0.45 % nacl.................................59
potassium chloride-d5-0.2%nacl intravenous
parenteral solution 30 meq/l, 40 meq/l....................59
potassium citrate oral tablet extended release 10 meq
(1,080 mg)...........................................................57
potassium citrate oral tablet extended release 5 meq
(540 mg)..............................................................57
POTIGA ORAL TABLET 200 MG.......................30
POTIGA ORAL TABLET 300 MG, 400 MG.......30
POTIGA ORAL TABLET 50 MG.........................30
Core_16293_CG6_v15_1609_1
84
PRISTIQ ORAL TABLET EXTENDED
RELEASE 24 HR 100 MG..................................30
RELEASE 24 HR 25 MG....................................30
RELEASE 24 HR 50 MG....................................30
PRIVIGEN.............................................................50
PROAIR HFA........................................................57
PROAIR RESPICLICK..........................................57
probenecid................................................................52
procainamide injection solution 100 mg/ml................38
procainamide injection solution 500 mg/ml................38
PROCALAMINE 3%.............................................59
PROCARDIA.........................................................38
PROCARDIA XL ORAL TABLET EXTENDED
RELEASE 24HR 30 MG.....................................38
prochlorperazine.......................................................49
prochlorperazine edisylate injection solution 10 mg/2
ml (5 mg/ml).........................................................49
prochlorperazine maleate oral....................................49
PROCRIT INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2
ML, 3,000 UNIT/ML, 4,000 UNIT/ML............50
PROCRIT INJECTION SOLUTION 20,000
UNIT/ML, 40,000 UNIT/ML............................50
procto-pak................................................................49
proctosol hc...............................................................49
proctozone-hc...........................................................49
progesterone micronized............................................53
PROGLYCEM.......................................................46
PROGRAF INTRAVENOUS................................19
PROLASTIN-C......................................................42
PROLEUKIN.........................................................50
PROLIA.................................................................52
PROMACTA ORAL TABLET 12.5 MG, 25 MG,
75 MG.................................................................38
PROMACTA ORAL TABLET 50 MG..................38
promethazine injection solution.................................57
promethazine oral tablet 12.5 mg, 25 mg...................57
propafenone oral tablet 150 mg, 225 mg....................38
propafenone oral tablet 300 mg.................................38
propantheline...........................................................49
propranolol intravenous............................................38
propranolol oral capsule,extended release 24 hr 120
mg, 160 mg...........................................................38
propranolol oral capsule,extended release 24 hr 60 mg,
80 mg...................................................................38
propranolol oral solution...........................................38
Core_16293_CG6_v15_1609_1
propranolol oral tablet 10 mg, 20 mg, 40 mg, 80
mg........................................................................38
propranolol oral tablet 60 mg....................................38
propranolol-hydrochlorothiazid..................................38
propylthiouracil........................................................46
PROQUAD (PF)....................................................50
PROSOL 20 %.......................................................59
protriptyline.............................................................30
PULMOZYME......................................................57
PURIXAN..............................................................19
pyrazinamide...........................................................13
pyridostigmine bromide oral tablet.............................30
QUADRACEL (PF)...............................................50
quasense...................................................................53
quetiapine oral tablet 100 mg...................................30
quetiapine oral tablet 25 mg.....................................30
quetiapine oral tablet 50 mg.....................................30
quinapril oral tablet 10 mg, 5 mg..............................38
quinapril oral tablet 20 mg, 40 mg............................38
quinapril-hydrochlorothiazide...................................38
quinidine sulfate oral tablet.......................................38
QVAR INHALATION AEROSOL 40 MCG/
ACTUATION.....................................................57
QVAR INHALATION AEROSOL 80 MCG/
ACTUATION.....................................................57
RABAVERT (PF)...................................................50
raloxifene.................................................................52
ramipril...................................................................38
RANEXA................................................................38
ranitidine hcl injection..............................................49
ranitidine hcl oral syrup............................................49
ranitidine hcl oral tablet 150 mg, 300 mg.................49
RAPAMUNE ORAL SOLUTION.........................19
RAVICTI................................................................42
RAZADYNE ORAL TABLET 4 MG.....................30
REBIF (WITH ALBUMIN)...................................50
REBIF REBIDOSE................................................50
REBIF TITRATION PACK..................................50
reclipsen (28)............................................................53
RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION....................................................50
SYRINGE 10 MCG/ML.....................................51
SYRINGE 5 MCG/0.5 ML.................................51
85
regonol.....................................................................30
RELENZA DISKHALER.......................................13
RELISTOR SUBCUTANEOUS SOLUTION......49
RELISTOR SUBCUTANEOUS SYRINGE..........49
REMICADE...........................................................49
RENVELA ORAL POWDER IN PACKET 0.8
GRAM.................................................................42
RENVELA ORAL POWDER IN PACKET 2.4
GRAM.................................................................43
RENVELA ORAL TABLET...................................43
repaglinide oral tablet 0.5 mg....................................47
repaglinide oral tablet 1 mg.......................................47
repaglinide oral tablet 2 mg.......................................47
REPATHA SURECLICK.......................................38
REPATHA SYRINGE............................................38
REQUIP ORAL TABLET 1 MG, 4 MG, 5
MG......................................................................30
RESCRIPTOR ORAL TABLET............................14
RESCRIPTOR ORAL TABLET,
DISPERSIBLE.....................................................14
reserpine oral tablet 0.1 mg.......................................38
RESTASIS..............................................................55
RETROVIR INTRAVENOUS..............................14
REVLIMID ORAL CAPSULE 10 MG..................19
REVLIMID ORAL CAPSULE 15 MG, 2.5 MG,
20 MG, 25 MG...................................................19
REVLIMID ORAL CAPSULE 5 MG....................19
REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1
MG, 2 MG..........................................................30
REXULTI ORAL TABLET 3 MG, 4 MG.............30
REYATAZ ORAL CAPSULE 150 MG, 200
MG......................................................................14
REYATAZ ORAL CAPSULE 300 MG..................14
REYATAZ ORAL POWDER IN PACKET...........14
ribasphere oral capsule..............................................14
ribasphere oral tablet 200 mg....................................14
ribavirin oral capsule................................................14
ribavirin oral tablet 200 mg......................................14
RIDAURA..............................................................52
rifabutin..................................................................14
rifampin..................................................................14
RIFATER...............................................................14
riluzole....................................................................43
rimantadine.............................................................14
ringers intravenous....................................................59
ringers irrigation.......................................................43
risedronate oral tablet 150 mg...................................52
risedronate oral tablet 30 mg.....................................43
Core_16293_CG6_v15_1609_1
risedronate oral tablet 35 mg, 35 mg (12 pack), 35
mg (4 pack)...........................................................52
risedronate oral tablet 5 mg.......................................52
risedronate oral tablet,delayed release (dr/ec)...............52
RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 12.5 MG/2 ML, 25 MG/2 ML..........30
SYRINGE 37.5 MG/2 ML..................................30
SYRINGE 50 MG/2 ML.....................................30
risperidone oral solution............................................30
risperidone oral tablet 0.25 mg..................................30
risperidone oral tablet 0.5 mg....................................30
risperidone oral tablet 1 mg.......................................30
risperidone oral tablet,disintegrating 0.25 mg.............30
risperidone oral tablet,disintegrating 0.5 mg...............30
risperidone oral tablet,disintegrating 1 mg..................30
RITUXAN..............................................................19
rivastigmine tartrate.................................................30
ropinirole oral tablet.................................................30
ropinirole oral tablet extended release 24 hr................30
rosadan topical cream...............................................41
rosadan topical gel....................................................41
rosuvastatin..............................................................38
ROTARIX..............................................................51
ROTATEQ VACCINE..........................................51
roweepra..................................................................30
ROZEREM............................................................30
SABRIL ORAL POWDER IN PACKET...............30
SABRIL ORAL TABLET.......................................30
SAMSCA ORAL TABLET 15 MG........................47
SAMSCA ORAL TABLET 30 MG........................47
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR SUSPENSION,
EXTENDED REL RECON................................19
SANTYL.................................................................41
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 10 MG.................................................31
TABLET 2.5 MG................................................31
TABLET 5 MG...................................................31
86
SAVELLA ORAL TABLET 100 MG.....................52
SAVELLA ORAL TABLET 12.5 MG....................52
SAVELLA ORAL TABLET 25 MG.......................52
SAVELLA ORAL TABLET 50 MG.......................52
SAVELLA ORAL TABLETS,DOSE PACK...........52
selegiline hcl.............................................................31
selenium sulfide topical lotion....................................41
SELZENTRY.........................................................14
SENSIPAR ORAL TABLET 30 MG......................47
SEREVENT DISKUS............................................57
SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR 150 MG..................................31
RELEASE 24 HR 200 MG..................................31
RELEASE 24 HR 300 MG..................................31
RELEASE 24 HR 400 MG..................................31
RELEASE 24 HR 50 MG....................................31
sertraline oral concentrate..........................................31
sertraline oral tablet 100 mg.....................................31
sertraline oral tablet 25 mg.......................................31
sertraline oral tablet 50 mg.......................................31
sf 5000 plus..............................................................43
SIGNIFOR.............................................................19
sildenafil oral...........................................................57
SILVADENE..........................................................41
silver sulfadiazine.....................................................41
SIMBRINZA..........................................................55
SIMPONI...............................................................52
SIMULECT INTRAVENOUS RECON SOLN
10 MG.................................................................19
SIMULECT INTRAVENOUS RECON SOLN
20 MG.................................................................19
simvastatin...............................................................38
SINEMET CR ORAL TABLET EXTENDED
RELEASE 25-100 MG........................................31
sirolimus..................................................................19
SIRTURO..............................................................14
sodium bicarbonate intravenous solution....................59
sodium bicarbonate intravenous syringe 4.2 % (0.5
meq/ml), 7.5 % (0.9 meq/ml)................................59
SODIUM BICARBONATE INTRAVENOUS
SYRINGE 8.4 % (1 MEQ/ML)...........................59
Core_16293_CG6_v15_1609_1
sodium chloride 0.45 % intravenous parenteral
solution.................................................................59
sodium chloride 0.45 % intravenous piggyback..........59
sodium chloride 0.9 % intravenous............................43
sodium chloride 3 %.................................................59
sodium chloride 5 %.................................................59
sodium chloride intravenous......................................59
sodium chloride irrigation.........................................43
sodium citrate-citric acid...........................................57
sodium fluoride oral tablet.........................................59
sodium fluoride oral tablet,chewable..........................59
sodium lactate intravenous........................................59
sodium phenylbutyrate..............................................43
sodium polystyrene (sorb free).....................................43
sodium polystyrene sulfonate oral powder....................43
sodium polystyrene sulfonate oral suspension...............43
sodium polystyrene sulfonate rectal.............................43
SOLTAMOX..........................................................19
SOMATULINE DEPOT.......................................19
SOMAVERT..........................................................47
sorine oral tablet 120 mg, 160 mg.............................38
sorine oral tablet 240 mg..........................................38
sorine oral tablet 80 mg............................................38
sotalol af oral tablet 120 mg, 160 mg.........................38
sotalol af oral tablet 80 mg........................................38
sotalol oral tablet 120 mg, 160 mg, 240 mg...............38
sotalol oral tablet 80 mg............................................38
SOVALDI..............................................................14
SPIRIVA RESPIMAT.............................................57
SPIRIVA WITH HANDIHALER..........................57
spironolacton-hydrochlorothiaz..................................38
spironolactone oral tablet 100 mg..............................38
spironolactone oral tablet 25 mg, 50 mg.....................38
sprintec (28).............................................................53
SPRITAM ORAL TABLET FOR SUSPENSION
1,000 MG, 250 MG, 500 MG.............................31
SPRITAM ORAL TABLET FOR SUSPENSION
750 MG...............................................................31
SPRYCEL...............................................................19
sps oral.....................................................................43
sps rectal...................................................................43
sronyx......................................................................53
ssd............................................................................41
stavudine oral capsule 15 mg.....................................14
stavudine oral recon soln...........................................14
87
STIMATE..............................................................47
STIOLTO RESPIMAT..........................................57
STIVARGA............................................................19
STRATTERA ORAL CAPSULE 10 MG, 18 MG,
25 MG, 40 MG...................................................31
STRATTERA ORAL CAPSULE 100 MG, 60 MG,
80 MG.................................................................31
STREPTOMYCIN INTRAMUSCULAR..............14
STRIBILD..............................................................14
STROMECTOL....................................................14
SUBOXONE SUBLINGUAL FILM 12-3 MG......31
SUBOXONE SUBLINGUAL FILM 2-0.5
MG......................................................................31
SUBOXONE SUBLINGUAL FILM 4-1 MG........31
SUBOXONE SUBLINGUAL FILM 8-2 MG........31
SUCRAID..............................................................49
sucralfate oral tablet..................................................49
SULAR ORAL TABLET EXTENDED RELEASE
24 HR 17 MG.....................................................38
sulfacetamide sodium (acne)......................................41
sulfacetamide sodium ophthalmic drops......................55
sulfacetamide sodium ophthalmic ointment................55
sulfacetamide-prednisolone........................................55
sulfadiazine oral.......................................................14
sulfamethoxazole-trimethoprim intravenous...............14
sulfamethoxazole-trimethoprim oral suspension...........14
sulfamethoxazole-trimethoprim oral tablet..................14
sulfasalazine.............................................................49
sulindac oral tablet 150 mg.......................................31
sulindac oral tablet 200 mg.......................................31
sumatriptan.............................................................31
sumatriptan succinate oral.........................................31
sumatriptan succinate subcutaneous cartridge.............31
sumatriptan succinate subcutaneous pen injector.........31
sumatriptan succinate subcutaneous solution...............31
sumatriptan succinate subcutaneous syringe 6 mg/0.5
ml.........................................................................31
SUPREP BOWEL PREP KIT................................49
SURMONTIL........................................................31
SUSTIVA ORAL CAPSULE 200 MG...................14
SUSTIVA ORAL CAPSULE 50 MG.....................14
SUSTIVA ORAL TABLET....................................14
SUTENT ORAL CAPSULE 12.5 MG...................19
SUTENT ORAL CAPSULE 25 MG, 37.5 MG,
50 MG.................................................................19
syeda........................................................................53
SYLATRON...........................................................51
SYMBICORT.........................................................57
Core_16293_CG6_v15_1609_1
SYMBYAX ORAL CAPSULE 12-25 MG, 12-50
MG, 6-50 MG.....................................................31
SYMBYAX ORAL CAPSULE 3-25 MG................31
SYMLINPEN 120..................................................47
SYMLINPEN 60....................................................47
SYNAGIS...............................................................14
SYNAREL..............................................................47
SYNERCID............................................................14
SYNJARDY............................................................47
SYNRIBO...............................................................19
SYNTHROID........................................................47
SYPRINE................................................................43
TABLOID..............................................................19
tacrolimus oral capsule 0.5 mg, 1 mg.........................19
tacrolimus oral capsule 5 mg......................................19
TAFINLAR............................................................19
TAGRISSO ORAL TABLET 40 MG.....................19
TAGRISSO ORAL TABLET 80 MG.....................19
TAMIFLU..............................................................14
tamoxifen.................................................................19
tamsulosin................................................................57
TANZEUM............................................................47
TAPAZOLE...........................................................47
TARCEVA ORAL TABLET 100 MG, 150
MG......................................................................19
TARCEVA ORAL TABLET 25 MG......................19
TARGRETIN.........................................................19
TASIGNA..............................................................19
TAXOTERE INTRAVENOUS SOLUTION 20
MG/ML (1 ML), 80 MG/4 ML (20 MG/
ML).....................................................................19
TAZORAC.............................................................41
taztia xt oral capsule, extended release 120 mg, 180
mg, 240 mg, 360 mg.............................................38
taztia xt oral capsule, extended release 300 mg............38
TECENTRIQ.........................................................19
TECFIDERA..........................................................31
TECHNIVIE..........................................................14
TEFLARO INTRAVENOUS RECON SOLN 400
MG......................................................................14
TEFLARO INTRAVENOUS RECON SOLN 600
MG......................................................................14
TEKTURNA..........................................................38
TEKTURNA HCT................................................38
telmisartan oral tablet 20 mg, 40 mg.........................39
telmisartan oral tablet 80 mg....................................39
telmisartan-hydrochlorothiazid oral tablet 40-12.5
mg, 80-25 mg.......................................................39
88
telmisartan-hydrochlorothiazid oral tablet 80-12.5
mg........................................................................39
TEMOVATE TOPICAL CREAM.........................41
TEMOVATE TOPICAL OINTMENT.................41
TENORETIC 100..................................................39
TENORETIC 50....................................................39
terazosin..................................................................39
terbinafine hcl oral...................................................14
terbutaline oral.........................................................57
terconazole vaginal cream..........................................53
terconazole vaginal suppository..................................53
testosterone cypionate.................................................47
testosterone enanthate................................................47
testosterone transdermal gel........................................47
testosterone transdermal gel in metered-dose pump 1.25
gram/ actuation (1 %)...........................................47
testosterone transdermal gel in metered-dose pump 10
mg/0.5 gram /actuation..........................................47
testosterone transdermal gel in packet 1 % (25 mg/
2.5gram)...............................................................47
testosterone transdermal gel in packet 1 % (50 mg/5
gram)....................................................................47
tetanus,diphtheria tox ped(pf)....................................51
TETANUS-DIPHTHERIA TOXOIDS-TD.........51
tetrabenazine oral tablet 12.5 mg..............................31
tetrabenazine oral tablet 25 mg.................................31
tetracycline...............................................................14
THALOMID ORAL CAPSULE 100 MG, 50
MG......................................................................20
THALOMID ORAL CAPSULE 150 MG, 200
MG......................................................................20
theophylline oral elixir..............................................57
theophylline oral solution...........................................57
theophylline oral tablet extended release......................57
theophylline oral tablet extended release 12 hr............57
THIOLA................................................................43
thioridazine.............................................................31
thiotepa....................................................................20
thiothixene...............................................................31
THYMOGLOBULIN............................................51
tiagabine..................................................................31
TIAZAC.................................................................39
TICE BCG.............................................................51
TIKOSYN..............................................................39
TILIA FE................................................................53
timolol maleate ophthalmic drops...............................55
timolol maleate ophthalmic gel forming solution.........55
timolol maleate oral tablet 10 mg, 5 mg.....................39
Core_16293_CG6_v15_1609_1
timolol maleate oral tablet 20 mg..............................39
TIMOPTIC OCUDOSE (PF) OPHTHALMIC
DROPPERETTE 0.25 %....................................55
TIMOPTIC OPHTHALMIC DROPS 0.25
%.........................................................................55
TIMOPTIC-XE......................................................55
tinidazole oral tablet 250 mg....................................14
tinidazole oral tablet 500 mg....................................14
TIVICAY ORAL TABLET 10 MG........................14
tizanidine oral tablet................................................31
TOBRADEX OPHTHALMIC OINTMENT.......55
TOBRADEX ST.....................................................55
tobramycin...............................................................55
tobramycin in 0.225 % nacl.....................................14
tobramycin sulfate injection recon soln.......................14
tobramycin sulfate injection solution..........................14
tobramycin-dexamethasone........................................55
tolazamide oral tablet 250 mg...................................47
tolazamide oral tablet 500 mg...................................47
tolbutamide..............................................................47
tolcapone..................................................................31
tolterodine oral capsule,extended release 24hr.............57
tolterodine oral tablet................................................57
topiramate oral capsule, sprinkle................................32
topiramate oral tablet 100 mg...................................32
topiramate oral tablet 200 mg...................................32
topiramate oral tablet 25 mg.....................................32
topiramate oral tablet 50 mg.....................................32
toposar.....................................................................20
topotecan intravenous recon soln................................20
topotecan intravenous solution...................................20
TORISEL...............................................................20
torsemide oral tablet 10 mg, 5 mg..............................39
torsemide oral tablet 100 mg, 20 mg..........................39
TOUJEO SOLOSTAR...........................................47
TOVIAZ.................................................................57
TRACLEER............................................................57
TRADJENTA.........................................................47
tramadol oral tablet..................................................32
tramadol-acetaminophen...........................................32
trandolapril..............................................................39
tranexamic acid intravenous......................................39
tranexamic acid oral.................................................53
tranylcypromine........................................................32
travasol 10 %...........................................................59
TRAVATAN Z.......................................................55
89
TRINTELLIX ORAL TABLET 20 MG.................32
TRINTELLIX ORAL TABLET 5 MG...................32
TRISENOX............................................................20
TRIUMEQ.............................................................14
trivora (28)..............................................................54
TROPHAMINE 10 %...........................................59
TROPHAMINE 6%..............................................59
trospium oral tablet..................................................58
TRULICITY...........................................................47
TRUMENBA.........................................................51
TRUVADA ORAL TABLET 100-150 MG, 133200 MG, 167-250 MG........................................14
TRUVADA ORAL TABLET 200-300 MG...........14
TWINRIX (PF)......................................................51
TWYNSTA ORAL TABLET 40-10 MG, 40-5
MG, 80-5 MG.....................................................39
TYBOST................................................................14
TYGACIL...............................................................14
TYKERB.................................................................20
TYPHIM VI INTRAMUSCULAR
SOLUTION........................................................51
TYPHIM VI INTRAMUSCULAR SYRINGE.......51
TYSABRI................................................................32
TYZEKA................................................................14
TYZINE NASAL DROPS 0.05 %.........................43
UCERIS ORAL......................................................49
ULORIC................................................................52
unithroid.................................................................47
UNITUXIN...........................................................20
ursodiol....................................................................49
UVADEX...............................................................42
valacyclovir..............................................................15
VALCHLOR..........................................................42
valganciclovir...........................................................15
valproate sodium......................................................32
valproic acid.............................................................32
valproic acid (as sodium salt) oral solution 250 mg/5
ml.........................................................................32
valproic acid (as sodium salt) oral solution 250 mg/5
ml (5 ml), 500 mg/10 ml (10 ml)..........................32
valsartan oral tablet 160 mg.....................................39
valsartan oral tablet 320 mg.....................................39
valsartan oral tablet 40 mg, 80 mg............................39
valsartan-hydrochlorothiazide oral tablet 160-12.5
mg, 160-25 mg, 320-12.5 mg, 80-12.5 mg............39
valsartan-hydrochlorothiazide oral tablet 320-25
mg........................................................................39
trazodone oral tablet 100 mg, 150 mg.......................32
trazodone oral tablet 300 mg.....................................32
trazodone oral tablet 50 mg.......................................32
TREANDA INTRAVENOUS RECON
SOLN..................................................................20
TRECATOR..........................................................14
TRELSTAR INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION................................20
TRELSTAR INTRAMUSCULAR SYRINGE
11.25 MG/2 ML, 3.75 MG/2 ML.......................20
TRELSTAR INTRAMUSCULAR SYRINGE 22.5
MG/2 ML............................................................20
tretinoin (chemotherapy) oral capsule.........................20
tretinoin topical cream..............................................41
tretinoin topical gel 0.01 %, 0.025 %.......................41
tri-estarylla...............................................................53
tri-legest fe................................................................53
tri-linyah.................................................................53
tri-previfem (28)......................................................53
tri-sprintec (28)........................................................53
triamcinolone acetonide dental..................................43
triamcinolone acetonide injection suspension 10 mg/
ml.........................................................................47
triamcinolone acetonide injection suspension 40 mg/
ml.........................................................................47
triamcinolone acetonide topical cream 0.025 %.........41
triamcinolone acetonide topical cream 0.1 %, 0.5
%.........................................................................41
triamcinolone acetonide topical lotion 0.025 %..........42
triamcinolone acetonide topical lotion 0.1 %..............42
triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %........................................................42
triamterene-hydrochlorothiazid oral capsule 37.5-25
mg........................................................................39
triamterene-hydrochlorothiazid oral tablet..................39
trianex.....................................................................42
TRIBENZOR.........................................................39
TRICOR ORAL TABLET 48 MG.........................39
triderm topical cream................................................42
trifluoperazine oral tablet 1 mg, 2 mg........................32
trifluoperazine oral tablet 10 mg, 5 mg......................32
trifluridine...............................................................55
TRILIPIX ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 45 MG.................................39
trilyte with flavor packets..........................................49
trimethoprim............................................................14
trinessa (28).............................................................53
TRINTELLIX ORAL TABLET 10 MG.................32
Core_16293_CG6_v15_1609_1
90
VANCOMYCIN IN 0.9% SODIUM CL
ML, 750 MG/150 ML.........................................15
VANCOMYCIN IN DEXTROSE 5 %
INTRAVENOUS PIGGYBACK 1 GRAM/200
ML.......................................................................15
VANCOMYCIN IN DEXTROSE 5 %
ML, 750 MG/150 ML.........................................15
vancomycin intravenous............................................15
vancomycin oral capsule 125 mg................................15
vancomycin oral capsule 250 mg................................15
vandazole.................................................................54
VAQTA (PF) INTRAMUSCULAR
SUSPENSION....................................................51
VAQTA (PF) INTRAMUSCULAR SYRINGE......51
VARIVAX (PF).......................................................51
VARIZIG...............................................................51
VASCEPA...............................................................39
VASERETIC..........................................................39
VASOTEC ORAL TABLET 2.5 MG.....................39
VECAMYL.............................................................39
VECTIBIX.............................................................20
VELCADE..............................................................20
velivet triphasic regimen (28)....................................54
VENCLEXTA ORAL TABLET 10 MG................20
VENCLEXTA ORAL TABLET 100 MG..............20
VENCLEXTA ORAL TABLET 50 MG................20
VENCLEXTA STARTING PACK........................20
venlafaxine oral capsule,extended release 24hr 150
mg........................................................................32
venlafaxine oral capsule,extended release 24hr 37.5
mg........................................................................32
venlafaxine oral capsule,extended release 24hr 75
mg........................................................................32
venlafaxine oral tablet 100 mg..................................32
venlafaxine oral tablet 25 mg....................................32
venlafaxine oral tablet 37.5 mg.................................32
venlafaxine oral tablet extended release 24hr 150
mg........................................................................32
VENLAFAXINE ORAL TABLET EXTENDED
RELEASE 24HR 225 MG...................................32
venlafaxine oral tablet extended release 24hr 37.5
mg........................................................................32
venlafaxine oral tablet extended release 24hr 75
mg........................................................................32
Core_16293_CG6_v15_1609_1
VENTAVIS............................................................57
VENTOLIN HFA..................................................57
verapamil intravenous solution..................................39
verapamil intravenous syringe....................................39
verapamil oral capsule, 24 hr er pellet ct....................39
verapamil oral capsule,ext rel. pellets 24 hr 120 mg,
180 mg, 240 mg....................................................39
verapamil oral capsule,ext rel. pellets 24 hr 360
mg........................................................................39
verapamil oral tablet.................................................39
verapamil oral tablet extended release 120 mg, 120
mg (24 hours)........................................................39
verapamil oral tablet extended release 180 mg, 240
mg........................................................................39
VERSACLOZ.........................................................32
VESICARE.............................................................58
vestura (28)..............................................................54
VICTOZA 2-PAK..................................................47
VICTOZA 3-PAK..................................................47
VIDEX 2 GRAM PEDIATRIC..............................15
VIDEX 4 GRAM PEDIATRIC..............................15
VIEKIRA PAK........................................................15
VIGAMOX.............................................................55
VIIBRYD ORAL TABLET 10 MG........................32
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG
(7)- 20 MG (23)..................................................32
VIMPAT INTRAVENOUS...................................32
VIMPAT ORAL SOLUTION...............................32
VIMPAT ORAL TABLET 100 MG.......................32
VIMPAT ORAL TABLET 50 MG.........................32
vinblastine intravenous solution.................................20
VINCASAR PFS INTRAVENOUS SOLUTION
1 MG/ML............................................................20
vincasar pfs intravenous solution 2 mg/2 ml...............20
vincristine................................................................20
vinorelbine...............................................................20
viorele (28)..............................................................54
VIRACEPT ORAL TABLET 250 MG...................15
VIRACEPT ORAL TABLET 625 MG...................15
VIRAMUNE XR ORAL TABLET EXTENDED
RELEASE 24 HR 100 MG..................................15
VIRAZOLE............................................................15
VIREAD ORAL POWDER...................................15
91
VIREAD ORAL TABLET 150 MG, 250 MG, 300
MG......................................................................15
VIREAD ORAL TABLET 200 MG.......................15
VITEKTA...............................................................15
VOLTAREN TOPICAL GEL 1 %........................32
voriconazole intravenous...........................................15
voriconazole oral suspension for reconstitution............15
voriconazole oral tablet 200 mg.................................15
voriconazole oral tablet 50 mg...................................15
VOTRIENT...........................................................20
VPRIV....................................................................47
VRAYLAR ORAL CAPSULE 1.5 MG...................32
VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG, 6
MG......................................................................32
VRAYLAR ORAL CAPSULE,DOSE PACK..........33
VYFEMLA (28)......................................................54
warfarin..................................................................39
water for irrigation, sterile.........................................43
WELCHOL............................................................39
XALATAN.............................................................55
XALKORI..............................................................20
XARELTO ORAL TABLET 10 MG, 20 MG........39
XARELTO ORAL TABLET 15 MG......................39
XARELTO ORAL TABLETS,DOSE PACK..........39
XENAZINE ORAL TABLET 12.5 MG.................33
XENAZINE ORAL TABLET 25 MG....................33
XEOMIN INTRAMUSCULAR RECON SOLN
100 UNIT, 50 UNIT..........................................51
XEOMIN INTRAMUSCULAR RECON SOLN
200 UNIT...........................................................51
XGEVA..................................................................20
XOLAIR.................................................................57
XOPENEX HFA....................................................57
XTANDI................................................................20
XULANE................................................................54
XYREM..................................................................33
XYZAL ORAL TABLET........................................57
YERVOY................................................................20
YF-VAX (PF)..........................................................51
YONDELIS............................................................20
zafirlukast................................................................57
zaleplon oral capsule 10 mg.......................................33
zaleplon oral capsule 5 mg.........................................33
ZALTRAP..............................................................20
ZANOSAR.............................................................20
ZARAH..................................................................54
ZARONTIN ORAL CAPSULE.............................33
ZAVESCA..............................................................47
Core_16293_CG6_v15_1609_1
ZELBORAF............................................................20
zenatane oral capsule 10 mg, 20 mg, 40 mg...............42
ZENATANE ORAL CAPSULE 30 MG................42
zenchent (28)...........................................................54
ZENCHENT FE....................................................54
zenzedi oral tablet 10 mg..........................................33
zenzedi oral tablet 5 mg............................................33
ZEPATIER.............................................................15
ZESTORETIC.......................................................39
ZESTRIL ORAL TABLET 10 MG, 20 MG, 40
MG, 5 MG..........................................................39
ZETIA....................................................................39
ZIAC ORAL TABLET 10-6.25 MG, 5-6.25
MG......................................................................39
ZIAGEN ORAL SOLUTION................................15
zidovudine oral capsule.............................................15
zidovudine oral syrup................................................15
zidovudine oral tablet...............................................15
ziprasidone hcl oral capsule 20 mg.............................33
ziprasidone hcl oral capsule 40 mg.............................33
ziprasidone hcl oral capsule 60 mg, 80 mg..................33
ZIRGAN................................................................55
ZITHROMAX ORAL PACKET............................15
ZITHROMAX ORAL TABLET 250 MG.............15
ZITHROMAX Z-PAK...........................................15
ZMAX....................................................................15
ZOCOR ORAL TABLET 10 MG, 5 MG..............39
zoledronic acid intravenous recon soln 4 mg...............47
zoledronic acid intravenous solution 4 mg/5 ml..........47
ZOLINZA..............................................................20
zolpidem oral...........................................................33
ZOMETA INTRAVENOUS SOLUTION 4 MG/
100 ML................................................................47
zonisamide oral capsule 100 mg, 50 mg.....................33
zonisamide oral capsule 25 mg..................................33
ZORTRESS ORAL TABLET 0.25 MG.................20
ZORTRESS ORAL TABLET 0.5 MG, 0.75
MG......................................................................20
ZOSTAVAX (PF)...................................................51
zovia 1/35e (28).......................................................54
zovia 1/50e (28).......................................................54
ZYDELIG...............................................................20
ZYKADIA..............................................................20
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 210
MG, 405 MG......................................................33
92
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 300
MG......................................................................33
ZYTIGA.................................................................20
ZYVOX INTRAVENOUS PARENTERAL
SOLUTION 200 MG/100 ML...........................15
Core_16293_CG6_v15_1609_1
ZYVOX INTRAVENOUS PARENTERAL
SOLUTION 600 MG/300 ML...........................15
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION.........................................15
93
Anthem Blue Cross and Blue Shield is an HMO plan with a Medicare contract. Enrollment in Anthem Blue
Cross and Blue Shield depends on contract renewal.
Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc.
HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross and Blue Shield
Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and
Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
This information is available for free in other languages. Please contact our customer service number
at 1-888-346-0095 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving
and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from
February 15 through September 30
Spanish (US):
Esta información está disponible sin cargo en otros idiomas. Póngase en contacto con el
Servicio de Atención al Cliente llamando al número 1-888-346-0095 o, para los usuarios
de TTY, 711, de 8 a. m. a 8 p. m., los 7 días de la semana (excepto en el Día de Acción de
Gracias y Navidad) desde el 1° de octubre hasta el 14 de febrero, y de lunes a viernes
(excepto feriados) del 15 de febrero hasta el 30 de septiembre.
This formulary was updated on August 1, 2016. For more recent information or other questions, please
contact Anthem MediBlue Plus (HMO) Customer Service at 1-888-346-0095 or, for TTY users, 711, 8 a.m. to
8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and
Monday to Friday (except holidays) from February 15 through September 30, or visit www.anthem.com.
54169MUSENMUB _112 H1394_003
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API PRODUCT LIST

Product Catalog - Aurobindo Pharma USA

List of Formulary Drugs

Covered Drugs

HVPA Rx Cost Comparison: Oral Contraceptives January 2005