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GuildNet Gold

Medicare Advantage Prescription Drug Plan

Formulary 2017

This formulary was updated on 09/01/2017 For more recent information or other questions, please contact
the Plan at 1-800-815-0000 or, for TTY users, 711. Hours are Monday through Sunday, 8am to 8pm or visit
www. guildnetny.org.
17312v15
H6864_GN479_2017 Formulary_Accepted

GuildNet Gold HMO-SNP Plan
2017 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS
WE COVER IN THIS PLAN

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 GuildNet. When
it refers to “plan” or “our plan,” it means GuildNet Gold.
This document includes list of the drugs (formulary) for our plan which is current as of
09/01/2017. 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, 2018, and from tim
e to tim
e during the year.
GuildNet Gold is a HMO SNP plan with a Medicare and New York State Medicaid
contract. Enrollment in GuildNet Gold depends upon contract renewal.
You must continue to pay your Medicare Part B premium. If you have full Medicaid
coverage, the State Medicaid plan pays the Medicare Part B premium for you.
The beneﬁt information provided is a brief summary, not a complete description of
beneﬁts. For more information, contact the plan.
Limitations, copayments, and restrictions may apply.
The Formulary and pharmacy network may change at any time. You will receive notice
when necessary.

i

2017 GUILDNET GOLD HMO-SNP PLAN
FORMULARY
This information is available for free in other languages. Please contact our customer
service number at 1-800-815-0000, from 8am to 8pm, Monday through Sunday.
TTY users should call 711, from 8am to 8pm, Monday through Sunday for additional
information.
Esta información está disponible en otros idiomas a gratis. Por favor llame a Servicios a
los miembros. Por favor llame a Servicios a los miembros, al 1-800-815-0000 por
información adicional. (Los usuarios de TTY deben llamar al 711). Se atiende de lunes a
domingo, de 8am a 8pm Servicios a los Miembros tienen los servicios gratuitos de
intérprete de idioma disponibles para altavoces de no-inglés.

ii

2017 GUILDNET GOLD HMO-SNP PLAN
FORMULARY
What is the GuildNet Gold Formulary?
A formulary is a list of covered drugs selected by GuildNet Gold 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. GuildNet Gold will generally cover the
drugs listed in our formulary as long as the drug is medically necessary, the prescription is
ﬁlled at a GuildNet Gold network pharmacy, and other plan rules are followed. For more
information on how to ﬁll your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2017 formulary that was covered at the
beginning of the year, we will not discontinue or reduce coverage of the drug during the
2017 coverage year except when a new, less expensive generic drug becomes available or
when new adverse information about the safety or eﬀectiveness of a drug is released.
Other types of formulary changes, such as removing a drug from our formulary, will not
aﬀect members who are currently taking the drug. It will remain available at the same
cost-sharing for those members taking it for the remainder of the coverage year. We feel it
is important that you have continued access for the remainder of the coverage year to the
formulary drugs that were available when you chose our plan, except for cases in which
you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/
or step therapy restrictions on a drug, we must notify aﬀected members of the change at
least 60 days before the change becomes eﬀective, or at the time the member requests a
reﬁll of the drug, at which time the member will receive a 60-day supply of the drug. If
the Food and Drug Administration deems a drug on our formulary to be unsafe or the
drug’s manufacturer removes the drug from the market, we will immediately remove the
drug from our formulary and provide notice to members who take the drug. The
enclosed formulary is current as of 09/01/2017. To get updated information about the
drugs covered by GuildNet Gold, please contact us. Our contact information appears on
the front and back cover pages.
In the event of a mid-year non-maintenance formulary change, the change is added to a
comprehensive list of changes that have been made since the formulary was printed. The
list of changes is included with the formulary booklet that is mailed to new members
with their welcome kit. Existing members can view the updated formulary by visiting us
on the web at www.guildnetny.org. The formulary that is posted on our website is
updated monthly. Members may also request a copy of the list of changes by calling
Customer Service. Our contact information appears on the front and back cover pages.

iii

2017 GUILDNET GOLD HMO-SNP PLAN
FORMULARY
How do I use the Formulary?
There are two ways to ﬁnd your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example,
drugs used to treat a heart condition are listed under the category, “Cardiovascular
Hypertensive/Lipids”. If you know what your drug is used for, look for the category
name in the list that begins on page 1. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the
Index that begins on page 89. 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?
GuildNet Gold covers both brand name drugs and generic drugs. A generic drug is
approved by the FDA as having the same active ingredient as the brand name drug.
Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These
requirements and limits may include:
t Prior Authorization: GuildNet Gold requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from
GuildNet Gold before you ﬁll your prescriptions. If you don’t get approval, GuildNet
Gold may not cover the drug.
t Quantity Limits: For certain drugs, GuildNet Gold limits the amount of the drug
that GuildNet Gold will cover. For example, GuildNet Gold provides 30 tablets per
prescription for Januvia. This may be in addition to a standard one-month or threemonth supply.
t Step Therapy: In some cases, GuildNet Gold requires you to ﬁrst try certain drugs to
treat your medical condition before we will cover another drug for that condition.
For example, if Drug A and Drug B both treat your medical condition, GuildNet
Gold may not cover Drug B unless you try Drug A ﬁrst. If Drug A does not work for
you, GuildNet Gold will then cover Drug B.
You can ﬁnd out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 1. You can also get more information about the
restrictions applied to speciﬁc covered drugs by visiting our Web site. We have posted on
iv

2017 GUILDNET GOLD HMO-SNP PLAN
FORMULARY
line documents that explain our prior authorization restriction or step therapy restriction
or 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 GuildNet Gold 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 GuildNet Gold’s HMO-SNP Plan?” on page iv for
information about how to request an exception.

What are over-the counter (OTC) drugs?
OTC drugs are non-prescription drugs that are not normally covered by a Medicare
Prescription Drug Plan. GuildNet Gold pays for certain OTC drugs. (Examples of OTC
covered drugs are: aspirin, acetaminophen, Advil, antacids, allergy and cold medications,
anti-biotic creams, laxatives, nicotine patches and gum, and vitamins.) GuildNet Gold
will provide these OTC drugs at no cost to you. The cost to GuildNet Gold of these
OTC drugs will not count toward your total Part D drug costs (that is, the amount you
pay does not count for the coverage gap.

What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should ﬁrst
contact Member Services and ask if your drug is covered.
If you learn that GuildNet Gold does not cover your drug, you have two options:
t You can ask Member Services for a list of similar drugs that are covered by GuildNet
Gold. When you receive the list, show it to your doctor and ask him or her to
prescribe a similar drug that is covered by GuildNet Gold.
t You can ask GuildNet Gold to make an exception and cover your drug. See below for
information about how to request an exception.

How do I request an exception to the GuildNet Gold’s
Formulary?
You can ask GuildNet Gold to make an exception to our coverage rules. There are several
types of exceptions that you can ask us to make.
t You can ask us to cover a drug even if it is not on our formulary. If approved, this
drug will be covered at a pre-determined cost-sharing level, and you would not be
able to ask us to provide the drug at a lower cost-sharing level.
t You can ask us to waive coverage restrictions or limits on your drug. For example, for
certain drugs, GuildNet Gold 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, GuildNet Gold will only approve your request for an exception if the
alternative drugs included on the plan’s formulary, the lower cost-sharing drug or

v

2017 GUILDNET GOLD HMO-SNP PLAN
FORMULARY
additional utilization restrictions would not be as eﬀective in treating your condition
and/or would cause you to have adverse medical eﬀects.
You should contact us to ask us for an initial coverage decision for a formulary, or
utilization restriction exception. When you request a formulary or utilization
restriction exception you should submit a statement from your prescriber or
physician supporting your request. Generally, we must make our decision within
72 hours of getting your prescriber’s supporting statement. You can request an expedited
(fast) exception if you or your doctor believe that your health could be seriously harmed
by waiting up to 72 hours for a decision. If your request to expedite is granted, we must
give you a decision no later than 24 hours after we get a supporting statement from your
doctor or other prescriber.

What do I do before I can talk to my doctor about
changing my drugs or requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our
formulary. Or, you may be taking a drug that is on our formulary but your ability to get
it is limited. For example, you may need a prior authorization from us before you can ﬁll
your prescription. You should talk to your doctor to decide if you should switch to an
appropriate drug that we cover or request a formulary exception so that we will cover the
drug you take. While you talk to your doctor to determine the right course of action for
you, we may cover your drug in certain cases during the ﬁrst 90 days you are a member
of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is
limited, we will cover a temporary 30-day supply (unless you have a prescription written
for fewer days) when you go to a network pharmacy. After your ﬁrst 30-day supply, we
will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to reﬁll your
prescription until we have provided you with 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.
If you are a current member in our plan and you experience a change in the level of care,
such as an admission or discharge from the long-term care facility, you will be allowed an
“early” reﬁll of your medications, as needed, to assist with your transition to your new
level of care.

vi

2017 GUILDNET GOLD HMO-SNP PLAN
FORMULARY
For more information
For more detailed information about your GuildNet Gold prescription drug coverage,
please review your Evidence of Coverage and other plan materials.
If you have questions about GuildNet Gold, 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.

GuildNet Gold’s Formulary
The formulary that begins on page 1 provides coverage information about the drugs
covered by GuildNet Gold. If you have trouble ﬁnding your drug in the list, turn to the
Index that begins on page 89.
The ﬁrst column of the chart lists the drug name. Brand name drugs are capitalized
(e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g.,
levothyroxine).

vii

2017 GUILDNET GOLD HMO-SNP PLAN
FORMULARY
Below is a list of abbreviations that may appear on the following pages in the Requirements/
Limits column that tells you if there are any special requirements for coverage of your drug.
List of Abbreviations
B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon
the circumstances. Information may need to be submitted describing the use and setting of the
drug to make the determination.
LA: Limited Availability. This prescription may be available only at certain pharmacies.
For more information, please call Customer Service at 1-877-344-7364, Monday to
Sunday, 8:00 am to 8:00 pm, (TTY users should call 711).
MO: Mail-Order Drug. This prescription drug is available through our mail-order
service, as well as through our retail network pharmacies. Consider using mail order for
your long-term (maintenance) medications (such as high blood pressure medications).
Retail network pharmacies may be more appropriate for short- term prescriptions (such
as antibiotics).
PA: Prior Authorization. The plan requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval before you
ﬁll your prescriptions. If you don’t get approval, we may not cover the drug.
QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we
will cover.
ST: Step Therapy. In some cases, the plan requires you to ﬁrst try certain drugs to treat your
medical condition before we will cover another drug for that condition. For example, if
Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you
try Drug A ﬁrst. If Drug A does not work for you, we will then cover Drug B.
NEDS: Non-extended day supply. For certain drugs, the plan limits the days’ supply we will
cover to one month at a time.

viii

GuildNet Gold HMO SNP complies with applicable Federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, or sex. GuildNet Gold does not exclude
people or treat them differently because of race, color, national origin, age, disability, or sex.
GuildNet Gold:
 Provides free aids and services to people with disabilities to communicate effectively with us,
such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats,
other formats)
 Provides free language services to people whose primary language is not English, such as:
○ Qualified interpreters
○ Information written in other languages
If you need these services, contact GuildNet Gold at 1-800-815-0000, TTY 711, Monday through
Sunday, 8am to 8pm.
If you believe that GuildNet Gold has failed to provide these services or discriminated in another way on
the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Bruce
Mastalinski, Chief Compliance Officer, 15 West 65th St New York, NY, 212-769-6212, Fax 646-8748222, mastalinskib@lighthouseguild.org. You can file a grievance in person or by mail, fax, or email. If
you need help filing a grievance, Bruce Mastalinski is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-815-0000 (TTY: 711).

GNG_GN477_OCR Notice

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-815-0000（TTY：
711）。
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 1-800-815-0000 (телетайп: 711).
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800815-0000 (TTY: 711).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800815-0000 (TTY: 711)번으로 전화해 주십시오.
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica
gratuiti. Chiamare il numero 1-800-815-0000 (TTY: 711).

1- ‫ רופט‬.‫ זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל‬,‫ אויב איר רעדט אידיש‬:‫אויפמערקזאם‬
.1-800-815-0000 (TTY: 711)
ΐϠ ҝ ͵ ჈ Έι যিদ আপিন বাংলা, কথা বলেত পােরন, তাহেল িনঃখরচায় ভাষা সহায়তা
পিরেষবা ͫ Ή ΐѐ আেছ। έΊ ΚΈ ͵ ჈ Έ 1-800-815-0000 (TTY: 711)।
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod
numer 1-800-815-0000 (TTY: 711).
‫ )رﻗﻢ ھﺎﺗﻒ‬800-815-0000-1 ‫ اﺗﺼﻞ ﺑﺮﻗﻢ‬.‫ ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن‬،‫ إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ‬:‫ﻣﻠﺤﻮظﺔ‬
.(711 :‫اﻟﺼﻢ واﻟﺒﻜﻢ‬
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés
gratuitement. Appelez le 1-800-815-0000 (ATS : 711).
1- ‫ ﺗﻮ آپ ﮐﻮ زﺑﺎن ﮐﯽ ﻣﺪد ﮐﯽ ﺧﺪﻣﺎت ﻣﻔﺖ ﻣﯿﮟ دﺳﺘﯿﺎب ﮨﯿﮟ ۔ ﮐﺎل ﮐﺮﯾﮟ‬،‫ اﮔﺮ آپ اردو ﺑﻮﻟﺘﮯ ﮨﯿﮟ‬:‫ﺧﺒﺮدار‬
800-815-0000 (TTY: 711).
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa
wika nang walang bayad. Tumawag sa 1-800-815-0000 (TTY: 711).
ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι
οποίες παρέχονται δωρεάν. Καλέστε 1-800-815-0000 (TTY: 711).
KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë.
Telefononi në 1-800-815-0000 (TTY: 711).
2

Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column
that tells you if there are any special requirements for coverage of your drug.
List of Abbreviations
*: The * next to a drug means the drug is not a “Part D drug.” These drugs have different rules for appeals.
An appeal is a formal way of asking for a review of and change to a coverage decision if you think there was
a mistake. For example, GuildNet or your Interdisciplinary Team (IDT) might decide that a drug that you
want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other
prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call the
GuildNet Gold Plus FIDA Plan at 1-800-815-0000; TTY/TDD 1-800-662-1220 or the Independent Consumer
Advocacy Network (ICAN) at 1-844-614-8800. You can also read the Participant Handbook to learn how to
appeal a decision.
B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the
circumstances. Information may need to be submitted describing the use and setting of the drug to make the
determination.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information, please call Customer Service.
MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through
our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such
as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term
prescriptions (such as antibiotics).
NEDS: For certain drugs, the plan limits the days’ supply we will cover to one month at a time.
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.
This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we
may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat
your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for
you, we will then cover Drug B.

If you have questions, please call GuildNet Gold Plus FIDA at 1-800-815-0000, Monday through Sunday
between 8 am and 8 pm. TTY/TDD, please call 1-800-662-1220. The call is free. For more information, visit
www.guildnetny.org.
1

Drug Name

Drug Tier

Requirements/Limits

ANTI - INFECTIVES
ANTIFUNGAL AGENTS
ABELCET INTRAVENOUS SUSPENSION

4

B/D PA; MO

AMBISOME INTRAVENOUS SUSPENSION
FOR RECONSTITUTION

4

B/D PA; MO

amphotericin b injection recon soln

2

B/D PA; MO

CANCIDAS INTRAVENOUS RECON SOLN

5

B/D PA; MO

clotrimazole mucous membrane troche

2

MO

fluconazole in dextrose(iso-osm) intravenous
piggyback

2

B/D PA

fluconazole in nacl (iso-osm) intravenous
piggyback 200 mg/100 ml

2

B/D PA; MO

fluconazole in nacl (iso-osm) intravenous
piggyback 400 mg/200 ml

2

B/D PA

fluconazole oral suspension for reconstitution

2

MO

fluconazole oral tablet

2

MO

flucytosine oral capsule

2

MO

griseofulvin microsize oral suspension

2

MO

griseofulvin microsize oral tablet

2

MO

griseofulvin ultramicrosize oral tablet

2

MO

itraconazole oral capsule

2

MO; QL (120 per 30 days)

ketoconazole oral tablet

2

MO

NOXAFIL ORAL SUSPENSION

5

MO

nystatin oral suspension

2

MO

nystatin oral tablet

2

MO

terbinafine hcl oral tablet

2

MO; QL (90 per 365 days)

voriconazole intravenous solution

2

B/D PA; MO

voriconazole oral suspension for reconstitution

5

MO

voriconazole oral tablet 200 mg

5

MO

voriconazole oral tablet 50 mg

2

MO

abacavir oral tablet

2

MO

abacavir-lamivudine oral tablet

5

MO

abacavir-lamivudine-zidovudine oral tablet

5

MO

acyclovir oral capsule

2

MO

ANTIVIRALS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
1

Drug Name

Drug Tier

Requirements/Limits

acyclovir oral suspension 200 mg/5 ml

2

MO

acyclovir oral tablet

2

MO

acyclovir sodium intravenous recon soln 500 mg

2

B/D PA

acyclovir sodium intravenous solution

2

B/D PA; MO

adefovir oral tablet

5

MO

amantadine hcl oral capsule

2

MO

amantadine hcl oral solution

2

MO

amantadine hcl oral tablet

2

MO

APTIVUS ORAL CAPSULE

3

MO

APTIVUS ORAL SOLUTION

3

ATRIPLA ORAL TABLET

5

MO

BARACLUDE ORAL SOLUTION

3

MO

CIDOFOVIR INTRAVENOUS SOLUTION

3

B/D PA; MO

COMPLERA ORAL TABLET

5

MO

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

3

MO

DESCOVY ORAL TABLET

5

MO

didanosine oral capsule,delayed release(dr/ec)
125 mg

2

didanosine oral capsule,delayed release(dr/ec)
200 mg, 250 mg, 400 mg

2

MO

EDURANT ORAL TABLET

4

MO

EMTRIVA ORAL CAPSULE

3

MO

EMTRIVA ORAL SOLUTION

3

MO

entecavir oral tablet

5

MO

EPCLUSA ORAL TABLET

5

PA; MO; QL (28 per 28 days)

EPIVIR HBV ORAL SOLUTION

4

MO

EPZICOM ORAL TABLET

3

MO

EVOTAZ ORAL TABLET

5

MO

famciclovir oral tablet 125 mg

2

MO; QL (21 per 10 days)

famciclovir oral tablet 250 mg

2

MO; QL (60 per 30 days)

famciclovir oral tablet 500 mg

2

MO; QL (21 per 7 days)

foscarnet intravenous solution

2

FUZEON SUBCUTANEOUS RECON SOLN

5

MO

ganciclovir sodium intravenous recon soln

2

B/D PA; MO

GENVOYA ORAL TABLET

5

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2

Drug Name

Drug Tier

Requirements/Limits

HARVONI ORAL TABLET

5

PA; MO; QL (28 per 28 days); NEDS

INTELENCE ORAL TABLET 100 MG, 25 MG

3

MO

INTELENCE ORAL TABLET 200 MG

5

MO

INVIRASE ORAL CAPSULE

5

MO

INVIRASE ORAL TABLET

5

MO

ISENTRESS ORAL POWDER IN PACKET

3

MO

ISENTRESS ORAL TABLET

3

MO

ISENTRESS ORAL TABLET,CHEWABLE

3

MO

KALETRA ORAL SOLUTION

5

MO

KALETRA ORAL TABLET 100-25 MG

3

MO

KALETRA ORAL TABLET 200-50 MG

5

MO

lamivudine oral solution

2

MO

lamivudine oral tablet

2

MO

lamivudine-zidovudine oral tablet

4

MO

LEXIVA ORAL SUSPENSION

3

MO

LEXIVA ORAL TABLET

3

MO

lopinavir-ritonavir oral solution

4

MO

nevirapine oral suspension

2

MO

nevirapine oral tablet

2

MO

nevirapine oral tablet extended release 24 hr

2

MO

NORVIR ORAL CAPSULE

3

MO

NORVIR ORAL SOLUTION

3

MO

NORVIR ORAL TABLET

3

MO

ODEFSEY ORAL TABLET

5

MO

oseltamivir oral capsule 30 mg

2

MO; QL (84 per 180 days)

oseltamivir oral capsule 45 mg, 75 mg

2

MO; QL (42 per 180 days)

PREZCOBIX ORAL TABLET

5

MO

PREZISTA ORAL SUSPENSION

5

MO

PREZISTA ORAL TABLET 150 MG, 75 MG

3

MO

PREZISTA ORAL TABLET 600 MG, 800 MG

5

MO

RELENZA DISKHALER INHALATION
BLISTER WITH DEVICE

4

MO; QL (60 per 180 days)

RESCRIPTOR ORAL TABLET

3

MO

RESCRIPTOR ORAL TABLET, DISPERSIBLE

3

MO

RETROVIR INTRAVENOUS SOLUTION

3

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
3

Drug Name

Drug Tier

Requirements/Limits

REYATAZ ORAL CAPSULE 150 MG, 200 MG,
300 MG

3

MO

REYATAZ ORAL POWDER IN PACKET

3

MO

ribavirin oral capsule

2

PA; MO

ribavirin oral tablet 200 mg

2

PA; MO

rimantadine oral tablet

2

MO

SELZENTRY ORAL SOLUTION

4

MO

SELZENTRY ORAL TABLET 150 MG, 300 MG

5

MO

SELZENTRY ORAL TABLET 25 MG, 75 MG

4

MO

SOVALDI ORAL TABLET

5

PA; MO; QL (30 per 30 days); NEDS

stavudine oral capsule

2

MO

STRIBILD ORAL TABLET

5

MO

SUSTIVA ORAL CAPSULE

3

MO

SUSTIVA ORAL TABLET

3

MO

SYNAGIS INTRAMUSCULAR SOLUTION 100
MG/ML

5

PA; MO

SYNAGIS INTRAMUSCULAR SOLUTION 50
MG/0.5 ML

5

PA; MO; LA

TIVICAY ORAL TABLET 10 MG

4

MO

TIVICAY ORAL TABLET 25 MG, 50 MG

5

MO

TRIUMEQ ORAL TABLET

5

MO

TRUVADA ORAL TABLET

5

MO

TYBOST ORAL TABLET

3

MO

valacyclovir oral tablet

2

MO; QL (30 per 30 days)

VALCYTE ORAL RECON SOLN

5

MO

valganciclovir oral recon soln

5

MO

valganciclovir oral tablet

5

MO

VIDEX 2 GRAM PEDIATRIC ORAL RECON
SOLN

3

MO

VIDEX 4 GRAM PEDIATRIC ORAL RECON
SOLN

3

MO

VIRACEPT ORAL TABLET

3

MO

VIRAMUNE XR ORAL TABLET EXTENDED
RELEASE 24 HR 100 MG

4

MO

VIRAZOLE INHALATION RECON SOLN

5

B/D PA; MO

VIREAD ORAL POWDER

3

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
4

Drug Name

Drug Tier

Requirements/Limits

VIREAD ORAL TABLET

3

MO

ZERIT ORAL RECON SOLN

4

MO

ZIAGEN ORAL SOLUTION

3

MO

zidovudine oral capsule

2

MO

zidovudine oral syrup

2

MO

zidovudine oral tablet

2

MO

cefaclor oral capsule

2

MO

cefaclor oral tablet extended release 12 hr

2

MO

cefadroxil oral capsule

2

MO

cefadroxil oral suspension for reconstitution 250
mg/5 ml, 500 mg/5 ml

2

MO

cefadroxil oral tablet

2

MO

cefazolin in dextrose (iso-osm) intravenous
piggyback 1 gram/50 ml, 2 gram/50 ml

2

B/D PA; MO

cefazolin injection recon soln 1 gram, 500 mg

2

B/D PA; MO

cefazolin injection recon soln 10 gram, 100 gram,
20 gram, 300 g

2

B/D PA

cefazolin intravenous recon soln

2

B/D PA

cefdinir oral capsule

2

MO

cefdinir oral suspension for reconstitution

2

MO

CEFEPIME IN DEXTROSE 5 %
INTRAVENOUS PIGGYBACK

2

B/D PA; MO

cefepime in dextrose,(iso-osm) intravenous
piggyback 1 gram/50 ml

2

B/D PA

cefepime in dextrose,(iso-osm) intravenous
piggyback 2 gram/100 ml

2

B/D PA; MO

cefepime injection recon soln

2

B/D PA; MO

cefixime oral suspension for reconstitution

2

MO

cefotaxime injection recon soln 1 gram, 2 gram,
500 mg

2

cefotaxime injection recon soln 10 gram

2

CEFOTETAN IN DEXTROSE, (ISO-OSM)
INTRAVENOUS PIGGYBACK

2

cefotetan injection recon soln

2

cefotetan intravenous recon soln

2

CEPHALOSPORINS

B/D PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
5

Drug Name

Drug Tier

Requirements/Limits

cefoxitin in dextrose, (iso-osm) intravenous
piggyback

2

B/D PA

cefoxitin intravenous recon soln 1 gram, 2 gram

2

B/D PA; MO

cefoxitin intravenous recon soln 10 gram

2

B/D PA

cefpodoxime oral suspension for reconstitution

2

MO

cefpodoxime oral tablet

2

MO

cefprozil oral suspension for reconstitution

2

MO

cefprozil oral tablet

2

MO

CEFTAZIDIME IN D5W INTRAVENOUS
PIGGYBACK

2

ceftazidime injection recon soln 1 gram, 2 gram

2

ceftazidime injection recon soln 6 gram

2

ceftriaxone in dextrose,(iso-osm) intravenous
piggyback 1 gram/50 ml

2

MO

ceftriaxone in dextrose,(iso-osm) intravenous
piggyback 2 gram/50 ml

2

B/D PA; MO

ceftriaxone injection recon soln 1 gram

2

MO

ceftriaxone injection recon soln 10 gram

2

CEFTRIAXONE INJECTION RECON SOLN
100 GRAM

2

ceftriaxone injection recon soln 2 gram, 250 mg,
500 mg

2

B/D PA; MO

ceftriaxone intravenous recon soln 1 gram

2

MO

ceftriaxone intravenous recon soln 2 gram

2

B/D PA; MO

cefuroxime axetil oral tablet

2

MO

cefuroxime sodium injection recon soln 750 mg

2

B/D PA; MO

cefuroxime sodium intravenous recon soln 1.5
gram

2

B/D PA; MO

cefuroxime sodium intravenous recon soln 7.5
gram

2

B/D PA

cephalexin oral capsule

2

MO

cephalexin oral suspension for reconstitution

2

MO

cephalexin oral tablet

2

MO

SUPRAX ORAL CAPSULE

4

MO

SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION 500 MG/5 ML

4

SUPRAX ORAL TABLET,CHEWABLE

4

MO

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
6

Drug Name
TEFLARO INTRAVENOUS RECON SOLN

Drug Tier

Requirements/Limits

4

B/D PA; MO

azithromycin intravenous recon soln

2

B/D PA; MO

azithromycin oral packet

2

MO

azithromycin oral suspension for reconstitution

2

MO

azithromycin oral tablet

2

MO

clarithromycin oral suspension for reconstitution

2

MO

clarithromycin oral tablet

2

MO

clarithromycin oral tablet extended release 24 hr

2

MO

e.e.s. 400 oral tablet

2

MO

ERYPED 200 ORAL SUSPENSION FOR
RECONSTITUTION

3

MO

erythrocin (as stearate) oral tablet 250 mg

2

MO

ERYTHROCIN INTRAVENOUS RECON SOLN
500 MG

3

B/D PA; MO; NEDS

erythromycin ethylsuccinate oral suspension for
reconstitution

2

MO

erythromycin ethylsuccinate oral tablet

2

MO

erythromycin oral capsule,delayed release(dr/ec)

2

MO

erythromycin oral tablet

2

MO

ALBENZA ORAL TABLET

4

MO

ALINIA ORAL SUSPENSION FOR
RECONSTITUTION

4

MO; QL (180 per 30 days)

ALINIA ORAL TABLET

4

MO; QL (12 per 30 days)

amikacin injection solution 1,000 mg/4 ml, 500
mg/2 ml

2

B/D PA; MO

atovaquone oral suspension

5

MO

atovaquone-proguanil oral tablet

2

MO

aztreonam injection recon soln

2

MO

baciim intramuscular recon soln

2

bacitracin intramuscular recon soln

2

MO

CAPASTAT INJECTION RECON SOLN

4

B/D PA

CAYSTON INHALATION SOLUTION FOR
NEBULIZATION

5

MO; QL (84 per 28 days)

ERYTHROMYCINS / OTHER MACROLIDES

MISCELLANEOUS ANTIINFECTIVES

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
7

Drug Name

Drug Tier

Requirements/Limits

chloramphenicol sod succinate intravenous recon
soln

2

B/D PA

chloroquine phosphate oral tablet

2

MO

clindamycin hcl oral capsule

2

MO

clindamycin palmitate hcl oral recon soln

2

MO

clindamycin pediatric oral recon soln

2

MO

clindamycin phosphate injection solution

2

B/D PA; MO

clindamycin phosphate intravenous solution 300
mg/2 ml, 900 mg/6 ml

2

B/D PA

clindamycin phosphate intravenous solution 600
mg/4 ml

2

B/D PA; MO

COARTEM ORAL TABLET

4

MO

COLISTIN (COLISTIMETHATE NA)
INJECTION RECON SOLN

4

B/D PA; MO

CUBICIN INTRAVENOUS RECON SOLN

5

MO

CUBICIN RF INTRAVENOUS RECON SOLN

5

CYCLOSERINE ORAL CAPSULE

2

MO

DAPSONE ORAL TABLET

4

MO

daptomycin intravenous recon soln

5

MO

DARAPRIM ORAL TABLET

5

PA; MO; NEDS

ethambutol oral tablet

2

MO

gentamicin in nacl (iso-osm) intravenous
piggyback 100 mg/100 ml, 80 mg/50 ml

2

MO

GENTAMICIN IN NACL (ISO-OSM)
INTRAVENOUS PIGGYBACK 100 MG/50 ML,
120 MG/100 ML

2

gentamicin in nacl (iso-osm) intravenous
piggyback 60 mg/50 ml, 70 mg/50 ml, 90 mg/100
ml

2

GENTAMICIN IN NACL (ISO-OSM)
INTRAVENOUS PIGGYBACK 80 MG/100 ML

4

gentamicin injection solution 40 mg/ml

2

B/D PA; MO

hydroxychloroquine oral tablet

2

MO

imipenem-cilastatin intravenous recon soln

2

B/D PA; MO

INVANZ INJECTION RECON SOLN

4

B/D PA; MO

INVANZ INTRAVENOUS RECON SOLN

4

B/D PA

isoniazid injection solution

2

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
8

Drug Name

Drug Tier

Requirements/Limits

isoniazid oral solution

2

MO

isoniazid oral tablet

2

MO

ivermectin oral tablet

2

MO

linezolid intravenous parenteral solution

5

PA

linezolid oral suspension for reconstitution

4

PA; MO

linezolid oral tablet

5

PA; MO

linezolid-0.9% sodium chloride intravenous
parenteral solution

5

PA

mefloquine oral tablet

2

MO

meropenem intravenous recon soln

2

B/D PA; MO

MEROPENEM-0.9% SODIUM CHLORIDE
INTRAVENOUS PIGGYBACK

2

B/D PA

metro i.v. intravenous piggyback

2

MO

metronidazole in nacl (iso-osm) intravenous
piggyback

2

MO

metronidazole oral capsule

2

MO

metronidazole oral tablet

2

MO

NEBUPENT INHALATION RECON SOLN

4

B/D PA; MO

neomycin oral tablet

2

MO

paromomycin oral capsule

2

MO

PASER ORAL GRANULES DR FOR SUSP IN
PACKET

4

MO

PENTAM INJECTION RECON SOLN

4

B/D PA; MO

polymyxin b sulfate injection recon soln

2

MO

PRIFTIN ORAL TABLET

4

MO

PRIMAQUINE ORAL TABLET

4

MO

pyrazinamide oral tablet

2

MO

quinine sulfate oral capsule

2

PA; MO

rifabutin oral capsule

2

MO

rifampin intravenous recon soln

2

B/D PA; MO

rifampin oral capsule

2

MO

SIRTURO ORAL TABLET

5

MO; LA

STREPTOMYCIN INTRAMUSCULAR RECON
SOLN

4

B/D PA; MO

SYNERCID INTRAVENOUS RECON SOLN

4

B/D PA

tinidazole oral tablet

2

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
9

Drug Name

Drug Tier

Requirements/Limits

TOBI PODHALER INHALATION CAPSULE

5

QL (224 per 28 days)

TOBI PODHALER INHALATION CAPSULE,
W/INHALATION DEVICE

5

MO; QL (224 per 28 days)

tobramycin in 0.225 % nacl inhalation solution for
nebulization

5

B/D PA; MO

tobramycin sulfate injection recon soln

2

B/D PA

tobramycin sulfate injection solution

2

B/D PA; MO

TRECATOR ORAL TABLET

4

MO

TYGACIL INTRAVENOUS RECON SOLN

4

MO

XIFAXAN ORAL TABLET 550 MG

5

MO

amoxicillin oral capsule

2

MO

amoxicillin oral suspension for reconstitution

2

MO

amoxicillin oral tablet

2

MO

amoxicillin oral tablet,chewable 125 mg, 250 mg

2

MO

amoxicillin-pot clavulanate oral suspension for
reconstitution

2

MO

amoxicillin-pot clavulanate oral tablet

2

MO

amoxicillin-pot clavulanate oral tablet extended
release 12 hr

2

MO

amoxicillin-pot clavulanate oral tablet,chewable

2

MO

ampicillin oral capsule

2

MO

ampicillin oral suspension for reconstitution

2

MO

ampicillin sodium injection recon soln

2

B/D PA; MO

ampicillin sodium intravenous recon soln

2

B/D PA

ampicillin-sulbactam injection recon soln 1.5
gram

2

MO

ampicillin-sulbactam injection recon soln 15 gram

2

B/D PA

ampicillin-sulbactam injection recon soln 3 gram

2

B/D PA; MO

BICILLIN C-R INTRAMUSCULAR SYRINGE

4

MO

BICILLIN L-A INTRAMUSCULAR SYRINGE

4

MO

dicloxacillin oral capsule

2

MO

nafcillin in dextrose (iso-osm) intravenous
piggyback 1 gram/50 ml

2

B/D PA

nafcillin in dextrose (iso-osm) intravenous
piggyback 2 gram/100 ml

2

B/D PA; MO

PENICILLINS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
10

Drug Name

Drug Tier

Requirements/Limits

nafcillin injection recon soln 1 gram, 2 gram

2

B/D PA; MO

nafcillin injection recon soln 10 gram

5

B/D PA; MO

nafcillin intravenous recon soln

2

B/D PA; MO

oxacillin in dextrose (iso-osm) intravenous
piggyback 1 gram/50 ml

2

oxacillin in dextrose (iso-osm) intravenous
piggyback 2 gram/50 ml

5

MO

oxacillin injection recon soln 1 gram

2

B/D PA

oxacillin injection recon soln 10 gram

5

oxacillin injection recon soln 2 gram

2

MO

oxacillin intravenous recon soln 1 gram

2

B/D PA

oxacillin intravenous recon soln 2 gram

2

penicillin g potassium injection recon soln

2

B/D PA; MO

penicillin g procaine intramuscular syringe 1.2
million unit/2 ml

2

MO

penicillin g procaine intramuscular syringe
600,000 unit/ml

2

B/D PA

penicillin g sodium injection recon soln

2

B/D PA; MO

penicillin v potassium oral recon soln

2

MO

penicillin v potassium oral tablet

2

MO

PIPERACILLIN-TAZOBACTAM
INTRAVENOUS RECON SOLN 13.5 GRAM

2

B/D PA

piperacillin-tazobactam intravenous recon soln
2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

2

B/D PA; MO

AVELOX IN NACL (ISO-OSM)
INTRAVENOUS PIGGYBACK

4

B/D PA; MO

ciprofloxacin (mixture) oral tablet, er multiphase
24 hr

2

MO

ciprofloxacin hcl oral tablet

2

MO

ciprofloxacin lactate intravenous solution 200
mg/20 ml

2

B/D PA; MO

ciprofloxacin lactate intravenous solution 400
mg/40 ml

2

B/D PA

ciprofloxacin oral suspension,microcapsule recon

2

levofloxacin in d5w intravenous piggyback 250
mg/50 ml

2

QUINOLONES

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
11

Drug Name

Drug Tier

Requirements/Limits

levofloxacin in d5w intravenous piggyback 500
mg/100 ml, 750 mg/150 ml

2

MO

levofloxacin intravenous solution

2

B/D PA; MO

levofloxacin oral solution

2

MO

levofloxacin oral tablet

2

MO

moxifloxacin oral tablet

2

MO

ofloxacin oral tablet 300 mg

2

ofloxacin oral tablet 400 mg

2

MO

sulfadiazine oral tablet

2

MO

sulfamethoxazole-trimethoprim intravenous
solution

2

B/D PA; MO

sulfamethoxazole-trimethoprim oral suspension

2

MO

sulfamethoxazole-trimethoprim oral tablet

2

MO

demeclocycline oral tablet

2

MO

doxy-100 intravenous recon soln

2

MO; NEDS

doxycycline hyclate oral capsule

2

MO

doxycycline hyclate oral tablet 100 mg, 20 mg

2

MO

doxycycline hyclate oral tablet,delayed release
(dr/ec)

2

MO

doxycycline monohydrate oral capsule

2

MO

doxycycline monohydrate oral tablet

2

MO

minocycline oral capsule

2

MO

minocycline oral tablet

2

MO

minocycline oral tablet extended release 24 hr

2

MO

morgidox oral capsule 100 mg

2

MO

morgidox oral capsule 50 mg

2

ORACEA ORAL CAPSULE,IR - DELAY
REL,BIPHASE

4

MO

tetracycline oral capsule

2

MO

methenamine hippurate oral tablet

2

MO

methenamine mandelate oral tablet 1 gram

2

MO

nitrofurantoin macrocrystal oral capsule

2

MO

SULFA'S / RELATED AGENTS

TETRACYCLINES

URINARY TRACT AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
12

Drug Name

Drug Tier

Requirements/Limits

nitrofurantoin monohyd/m-cryst oral capsule

2

MO

trimethoprim oral tablet

2

MO

VANCOMYCIN IN 0.9% SODIUM CL
INTRAVENOUS PIGGYBACK

2

B/D PA

VANCOMYCIN IN DEXTROSE 5 %
INTRAVENOUS PIGGYBACK 1 GRAM/200
ML

2

B/D PA; MO

VANCOMYCIN IN DEXTROSE 5 %
INTRAVENOUS PIGGYBACK 500 MG/100
ML, 750 MG/150 ML

2

B/D PA

VANCOMYCIN INJECTION RECON SOLN

2

B/D PA

vancomycin intravenous recon soln 1,000 mg, 10
gram, 5 gram, 500 mg

2

B/D PA; MO

VANCOMYCIN INTRAVENOUS RECON
SOLN 750 MG

2

B/D PA; MO

vancomycin oral capsule

5

MO

VANCOMYCIN

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
amifostine crystalline intravenous recon soln

5

B/D PA; MO

dexrazoxane hcl intravenous recon soln 250 mg

2

B/D PA

dexrazoxane hcl intravenous recon soln 500 mg

2

B/D PA; MO

ELITEK INTRAVENOUS RECON SOLN

5

B/D PA; MO

leucovorin calcium injection recon soln 100 mg,
200 mg, 350 mg, 50 mg

2

B/D PA; MO

leucovorin calcium injection recon soln 500 mg

2

B/D PA

leucovorin calcium oral tablet

2

MO

levoleucovorin intravenous recon soln 50 mg

4

B/D PA

LEVOLEUCOVORIN INTRAVENOUS
SOLUTION

4

B/D PA

mesna intravenous solution

2

B/D PA; MO

MESNEX ORAL TABLET

5

MO

XGEVA SUBCUTANEOUS SOLUTION

5

B/D PA; MO

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ABRAXANE INTRAVENOUS SUSPENSION
FOR RECONSTITUTION

4

B/D PA; MO

adriamycin intravenous solution

2

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
13

Drug Name

Drug Tier

Requirements/Limits

adrucil intravenous solution 2.5 gram/50 ml

2

B/D PA

adrucil intravenous solution 5 gram/100 ml, 500
mg/10 ml

2

B/D PA; MO

AFINITOR DISPERZ ORAL TABLET FOR
SUSPENSION

5

PA; MO; NEDS

AFINITOR ORAL TABLET

5

PA; MO; NEDS

ALECENSA ORAL CAPSULE

5

PA; MO

ALIMTA INTRAVENOUS RECON SOLN

5

B/D PA; MO

ALUNBRIG ORAL TABLET

5

PA; MO; LA; QL (180 per 30 days)

anastrozole oral tablet

2

MO

ASTAGRAF XL ORAL CAPSULE,EXTENDED
RELEASE 24HR

4

B/D PA; MO

AVASTIN INTRAVENOUS SOLUTION

5

B/D PA; MO

azacitidine injection recon soln

5

MO

AZASAN ORAL TABLET

3

B/D PA; MO

azathioprine oral tablet

2

B/D PA; MO

azathioprine sodium injection recon soln

2

B/D PA

BAVENCIO INTRAVENOUS SOLUTION

5

PA; MO; LA

BELEODAQ INTRAVENOUS RECON SOLN

5

B/D PA; MO

BENDEKA INTRAVENOUS SOLUTION

5

PA; MO

bexarotene oral capsule

5

PA; MO

bicalutamide oral tablet

2

MO

BICNU INTRAVENOUS RECON SOLN

3

B/D PA; MO

bleomycin injection recon soln

2

B/D PA; MO

BOSULIF ORAL TABLET

5

PA; MO; NEDS

BUSULFEX INTRAVENOUS SOLUTION

3

B/D PA

CABOMETYX ORAL TABLET

5

PA; MO; LA

CAPRELSA ORAL TABLET

5

MO

carboplatin intravenous solution

2

B/D PA; MO

CELLCEPT INTRAVENOUS RECON SOLN

4

B/D PA; MO

CELLCEPT ORAL SUSPENSION FOR
RECONSTITUTION

4

B/D PA; MO

cisplatin intravenous solution

2

B/D PA; MO

cladribine intravenous solution

2

B/D PA; MO

clofarabine intravenous solution

5

B/D PA

COMETRIQ ORAL CAPSULE

5

PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
14

Drug Name

Drug Tier

Requirements/Limits

COTELLIC ORAL TABLET

5

PA; MO; LA

CYCLOPHOSPHAMIDE ORAL CAPSULE

4

B/D PA; MO

cyclosporine intravenous solution

2

B/D PA

cyclosporine modified oral capsule

2

B/D PA; MO

cyclosporine modified oral solution

2

B/D PA; MO

cyclosporine oral capsule

2

B/D PA; MO

CYRAMZA INTRAVENOUS SOLUTION

5

PA; MO

cytarabine (pf) injection solution 100 mg/5 ml (20
mg/ml)

2

B/D PA; MO

cytarabine (pf) injection solution 20 mg/ml

2

B/D PA

cytarabine injection solution

2

B/D PA; MO

dacarbazine intravenous recon soln

2

B/D PA; MO

DARZALEX INTRAVENOUS SOLUTION

3

PA; MO; LA

daunorubicin intravenous solution

2

B/D PA

decitabine intravenous recon soln

5

B/D PA; MO

doxorubicin intravenous recon soln

2

B/D PA

doxorubicin intravenous solution

2

B/D PA; MO

doxorubicin, peg-liposomal intravenous
suspension

5

B/D PA; MO

DROXIA ORAL CAPSULE

3

MO

ELIGARD (3 MONTH) SUBCUTANEOUS
SYRINGE

3

PA; MO

ELIGARD (4 MONTH) SUBCUTANEOUS
SYRINGE

3

PA; MO

ELIGARD (6 MONTH) SUBCUTANEOUS
SYRINGE

3

PA; MO

ELIGARD SUBCUTANEOUS SYRINGE

3

PA; MO

EMCYT ORAL CAPSULE

3

MO

EMPLICITI INTRAVENOUS RECON SOLN

5

PA; MO

ENVARSUS XR ORAL TABLET EXTENDED
RELEASE 24 HR

4

B/D PA; MO

epirubicin intravenous solution

4

B/D PA; MO

ERIVEDGE ORAL CAPSULE

3

PA; MO

ERWINAZE INJECTION RECON SOLN

5

PA; MO

etoposide intravenous solution

2

B/D PA; MO

exemestane oral tablet

2

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
15

Drug Name

Drug Tier

Requirements/Limits

FARESTON ORAL TABLET

3

MO

FARYDAK ORAL CAPSULE

5

PA; MO

FASLODEX INTRAMUSCULAR SYRINGE

5

B/D PA; MO

FLUDARABINE INTRAVENOUS RECON
SOLN

4

B/D PA; MO

fludarabine intravenous solution

4

B/D PA

fluorouracil intravenous solution

2

B/D PA; MO

flutamide oral capsule

2

MO

GAZYVA INTRAVENOUS SOLUTION

5

B/D PA; MO

gemcitabine intravenous recon soln 1 gram, 200
mg

5

B/D PA; MO

gemcitabine intravenous recon soln 2 gram

5

B/D PA

gemcitabine intravenous solution 1 gram/26.3 ml
(38 mg/ml), 200 mg/5.26 ml (38 mg/ml)

5

B/D PA; MO

gemcitabine intravenous solution 2 gram/52.6 ml
(38 mg/ml)

5

B/D PA

gengraf oral capsule

2

B/D PA; MO

gengraf oral solution

2

B/D PA; MO

GILOTRIF ORAL TABLET

5

PA; MO

GLEEVEC ORAL TABLET 100 MG

5

PA; MO

GLEEVEC ORAL TABLET 400 MG

5

PA; MO; QL (60 per 30 days)

GLEOSTINE ORAL CAPSULE

4

MO

HERCEPTIN INTRAVENOUS RECON SOLN

5

B/D PA; MO

HEXALEN ORAL CAPSULE

5

MO

hydroxyurea oral capsule

2

MO

IBRANCE ORAL CAPSULE

5

PA; MO; QL (21 per 28 days)

ICLUSIG ORAL TABLET 15 MG

5

PA

ICLUSIG ORAL TABLET 45 MG

5

PA; MO

idarubicin intravenous solution

2

B/D PA

IFOSFAMIDE INTRAVENOUS RECON SOLN
1 GRAM

3

B/D PA; MO

ifosfamide intravenous recon soln 3 gram

3

B/D PA; MO

ifosfamide intravenous solution

3

B/D PA

imatinib oral tablet 100 mg

5

PA; MO

imatinib oral tablet 400 mg

5

PA; MO; QL (60 per 30 days)

IMBRUVICA ORAL CAPSULE

5

PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
16

Drug Name

Drug Tier

Requirements/Limits

IMFINZI INTRAVENOUS SOLUTION

5

PA; MO; LA

INLYTA ORAL TABLET

4

PA; MO

IRESSA ORAL TABLET

5

PA; MO

irinotecan intravenous solution 100 mg/5 ml, 40
mg/2 ml

2

B/D PA; MO

irinotecan intravenous solution 500 mg/25 ml

2

B/D PA

ISTODAX INTRAVENOUS RECON SOLN

5

B/D PA; MO

JAKAFI ORAL TABLET 10 MG, 15 MG, 20
MG, 5 MG

5

PA; MO

JAKAFI ORAL TABLET 25 MG

5

PA; MO; QL (60 per 30 days)

KADCYLA INTRAVENOUS RECON SOLN 100
MG

5

PA; MO; NEDS

KADCYLA INTRAVENOUS RECON SOLN 160
MG

5

PA; MO

KEYTRUDA INTRAVENOUS RECON SOLN

5

PA; MO

KEYTRUDA INTRAVENOUS SOLUTION

5

PA; MO

KISQALI FEMARA CO-PACK ORAL TABLET
200 MG/DAY(200 MG X 1)-2.5 MG

5

PA; MO; QL (49 per 30 days)

KISQALI FEMARA CO-PACK ORAL TABLET
400 MG/DAY(200 MG X 2)-2.5 MG

5

PA; MO; QL (70 per 30 days)

KISQALI FEMARA CO-PACK ORAL TABLET
600 MG/DAY(200 MG X 3)-2.5 MG

5

PA; MO; QL (91 per 30 days)

KISQALI ORAL TABLET 200 MG/DAY (200
MG X 1)

5

PA; MO; QL (21 per 28 days)

KISQALI ORAL TABLET 400 MG/DAY (200
MG X 2)

5

PA; MO; QL (42 per 28 days)

KISQALI ORAL TABLET 600 MG/DAY (200
MG X 3)

5

PA; MO; QL (63 per 28 days)

KYPROLIS INTRAVENOUS RECON SOLN

5

PA; MO

LARTRUVO INTRAVENOUS SOLUTION

5

PA; MO

LENVIMA ORAL CAPSULE

5

PA; MO

letrozole oral tablet

2

MO

LEUKERAN ORAL TABLET

3

MO

leuprolide subcutaneous kit

2

MO

LONSURF ORAL TABLET

5

PA; MO

LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT

5

PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
17

Drug Name

Drug Tier

Requirements/Limits

LUPRON DEPOT (4 MONTH)
INTRAMUSCULAR SYRINGE KIT

5

PA; MO

LUPRON DEPOT (6 MONTH)
INTRAMUSCULAR SYRINGE KIT

5

PA; MO

LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 3.75 MG

3

PA; MO

LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 7.5 MG

5

PA; MO

LUPRON DEPOT-PED (3 MONTH)
INTRAMUSCULAR SYRINGE KIT

5

PA; MO

LUPRON DEPOT-PED INTRAMUSCULAR KIT

5

PA; MO

LYNPARZA ORAL CAPSULE

5

PA; MO

LYSODREN ORAL TABLET

3

MO

MATULANE ORAL CAPSULE

5

MO

megestrol oral suspension 400 mg/10 ml (10 ml)

4

PA

megestrol oral suspension 400 mg/10 ml (40
mg/ml), 625 mg/5 ml

4

PA; MO

megestrol oral tablet

2

PA; MO

MEKINIST ORAL TABLET

5

PA; MO

melphalan hcl intravenous recon soln

2

B/D PA

mercaptopurine oral tablet

2

MO

methotrexate sodium (pf) injection recon soln

2

B/D PA

methotrexate sodium (pf) injection solution

2

B/D PA; MO

methotrexate sodium injection solution

2

B/D PA; MO

methotrexate sodium oral tablet

2

B/D PA; MO

mitomycin intravenous recon soln

2

B/D PA; MO

mitoxantrone intravenous concentrate

2

B/D PA; MO

MUSTARGEN INJECTION RECON SOLN

3

B/D PA; MO

mycophenolate mofetil hcl intravenous recon soln

4

B/D PA

mycophenolate mofetil oral capsule

2

B/D PA; MO

mycophenolate mofetil oral suspension for
reconstitution

2

B/D PA; MO

mycophenolate mofetil oral tablet

2

B/D PA; MO

mycophenolate sodium oral tablet,delayed release
(dr/ec)

2

B/D PA; MO

NEORAL ORAL CAPSULE

4

B/D PA; MO

NEORAL ORAL SOLUTION

4

B/D PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
18

Drug Name

Drug Tier

Requirements/Limits

NEXAVAR ORAL TABLET

5

PA; MO

NILANDRON ORAL TABLET

3

MO

nilutamide oral tablet

2

MO

NINLARO ORAL CAPSULE

5

PA; MO

NULOJIX INTRAVENOUS RECON SOLN

5

B/D PA; MO

octreotide acetate injection solution 1,000 mcg/ml,
500 mcg/ml

5

PA; MO

octreotide acetate injection solution 100 mcg/ml,
200 mcg/ml, 50 mcg/ml

2

PA; MO

octreotide acetate injection syringe 100 mcg/ml (1
ml), 50 mcg/ml (1 ml)

2

PA; MO

octreotide acetate injection syringe 500 mcg/ml (1
ml)

5

PA; MO

ODOMZO ORAL CAPSULE

5

PA; MO; LA

ONCASPAR INJECTION SOLUTION

5

PA; MO

OPDIVO INTRAVENOUS SOLUTION

5

PA; MO

oxaliplatin intravenous recon soln 100 mg

4

B/D PA; MO

oxaliplatin intravenous recon soln 50 mg

4

B/D PA

OXALIPLATIN INTRAVENOUS SOLUTION
100 MG/20 ML

4

B/D PA; MO

oxaliplatin intravenous solution 50 mg/10 ml (5
mg/ml)

4

B/D PA; MO

PACLITAXEL INTRAVENOUS
CONCENTRATE

3

B/D PA; MO

PERJETA INTRAVENOUS SOLUTION

5

PA; MO

POMALYST ORAL CAPSULE

5

PA; MO

PORTRAZZA INTRAVENOUS SOLUTION

5

PA; MO

PURIXAN ORAL SUSPENSION

4

MO

RAPAMUNE ORAL SOLUTION

3

B/D PA; MO

RAPAMUNE ORAL TABLET

4

B/D PA; MO

REVLIMID ORAL CAPSULE

5

PA; MO; LA

RITUXAN INTRAVENOUS CONCENTRATE

5

PA; MO

RUBRACA ORAL TABLET 200 MG, 300 MG

5

PA; MO; LA; QL (120 per 30 days)

RUBRACA ORAL TABLET 250 MG

5

PA; MO; QL (124 per 30 days);
NEDS

RYDAPT ORAL CAPSULE

5

PA; MO

SANDIMMUNE ORAL CAPSULE

4

B/D PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
19

Drug Name

Drug Tier

Requirements/Limits

SANDIMMUNE ORAL SOLUTION

4

B/D PA; MO

SANDOSTATIN LAR DEPOT
INTRAMUSCULAR SUSPENSION,EXTENDED
REL RECON

5

PA; MO

SIGNIFOR SUBCUTANEOUS SOLUTION

5

PA; MO

SIMULECT INTRAVENOUS RECON SOLN 10
MG

3

B/D PA

SIMULECT INTRAVENOUS RECON SOLN 20
MG

3

B/D PA; MO

sirolimus oral tablet

2

B/D PA; MO

SOLTAMOX ORAL SOLUTION

4

MO

SOMATULINE DEPOT SUBCUTANEOUS
SYRINGE

5

B/D PA; MO

SPRYCEL ORAL TABLET 100 MG, 140 MG, 80
MG

5

PA; MO; QL (30 per 30 days); NEDS

SPRYCEL ORAL TABLET 20 MG, 50 MG

5

PA; MO; NEDS

SPRYCEL ORAL TABLET 70 MG

5

PA; MO; QL (60 per 30 days); NEDS

STIVARGA ORAL TABLET

5

PA; MO

SUTENT ORAL CAPSULE

5

PA; MO

SYNRIBO SUBCUTANEOUS RECON SOLN

5

B/D PA; MO

TABLOID ORAL TABLET

3

MO

tacrolimus oral capsule 0.5 mg, 1 mg

2

B/D PA; MO

tacrolimus oral capsule 5 mg

4

B/D PA; MO

TAFINLAR ORAL CAPSULE

5

PA; MO; NEDS

TAGRISSO ORAL TABLET

5

PA; MO; LA

tamoxifen oral tablet

2

MO

TARCEVA ORAL TABLET 100 MG, 25 MG

5

PA; MO; NEDS

TARCEVA ORAL TABLET 150 MG

5

PA; MO; QL (30 per 30 days); NEDS

TARGRETIN TOPICAL GEL

5

MO

TASIGNA ORAL CAPSULE

5

PA; MO

TECENTRIQ INTRAVENOUS SOLUTION

5

PA; MO; LA

THALOMID ORAL CAPSULE

5

PA; MO

thiotepa injection recon soln

5

PA; MO

toposar intravenous solution

2

B/D PA; MO

topotecan intravenous recon soln

5

B/D PA

topotecan intravenous solution

5

B/D PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
20

Drug Name

Drug Tier

Requirements/Limits

TREANDA INTRAVENOUS RECON SOLN

5

B/D PA; MO

TRELSTAR INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 11.25 MG, 3.75 MG

3

B/D PA; MO

TRELSTAR INTRAMUSCULAR SUSPENSION
FOR RECONSTITUTION 22.5 MG

5

B/D PA; MO

TRELSTAR INTRAMUSCULAR SYRINGE
11.25 MG/2 ML, 3.75 MG/2 ML

3

B/D PA; MO

TRELSTAR INTRAMUSCULAR SYRINGE 22.5
MG/2 ML

5

B/D PA; MO

tretinoin (chemotherapy) oral capsule

5

MO

TRISENOX INTRAVENOUS SOLUTION

3

B/D PA; MO

TYKERB ORAL TABLET

5

PA; MO; NEDS

VELCADE INJECTION RECON SOLN

5

B/D PA; MO

VENCLEXTA ORAL TABLET 10 MG, 50 MG

4

PA; MO; LA

VENCLEXTA ORAL TABLET 100 MG

5

PA; MO; LA

VENCLEXTA STARTING PACK ORAL
TABLETS,DOSE PACK

5

PA; MO; LA

VINBLASTINE INTRAVENOUS SOLUTION

3

B/D PA; MO

vincasar pfs intravenous solution 1 mg/ml

2

B/D PA

vincasar pfs intravenous solution 2 mg/2 ml

2

B/D PA; MO

vincristine intravenous solution

2

B/D PA; MO

vinorelbine intravenous solution

2

B/D PA; MO

VOTRIENT ORAL TABLET

5

PA; MO; NEDS

XALKORI ORAL CAPSULE

5

PA; MO

XATMEP ORAL SOLUTION

5

PA

XERMELO ORAL TABLET

5

PA; MO; LA; QL (84 per 28 days)

XTANDI ORAL CAPSULE

5

PA; MO; QL (120 per 30 days)

YERVOY INTRAVENOUS SOLUTION

5

PA; MO

YONDELIS INTRAVENOUS RECON SOLN

5

PA; MO

ZALTRAP INTRAVENOUS SOLUTION

5

PA; MO

ZEJULA ORAL CAPSULE

5

PA; MO; LA; QL (90 per 30 days)

ZELBORAF ORAL TABLET

5

PA; MO; NEDS

ZOLINZA ORAL CAPSULE

5

MO

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG

3

B/D PA; MO

ZORTRESS ORAL TABLET 0.75 MG

5

B/D PA; MO

ZYDELIG ORAL TABLET

5

PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
21

Drug Name

Drug Tier

Requirements/Limits

ZYKADIA ORAL CAPSULE

5

PA; MO; QL (150 per 30 days)

ZYTIGA ORAL TABLET

5

MO; NEDS

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH
ANTICONVULSANTS
APTIOM ORAL TABLET

4

PA; MO

BANZEL ORAL SUSPENSION

4

MO

BANZEL ORAL TABLET

4

PA; MO

BRIVIACT INTRAVENOUS SOLUTION

4

PA

BRIVIACT ORAL SOLUTION

5

PA; MO

BRIVIACT ORAL TABLET

5

PA; MO

carbamazepine oral capsule, er multiphase 12 hr

2

MO

carbamazepine oral suspension 100 mg/5 ml

2

MO

carbamazepine oral tablet

1

MO

carbamazepine oral tablet extended release 12 hr

2

MO

carbamazepine oral tablet,chewable

1

MO

CELONTIN ORAL CAPSULE 300 MG

4

MO

clonazepam oral tablet

2

MO

clonazepam oral tablet,disintegrating

2

PA; MO

DIASTAT RECTAL KIT

4

PA; MO

DILANTIN 30 MG ORAL CAPSULE

4

MO

divalproex oral capsule, delayed release sprinkle

2

MO

divalproex oral tablet extended release 24 hr

2

MO

divalproex oral tablet,delayed release (dr/ec)

2

MO

epitol oral tablet

1

MO

ethosuximide oral capsule

2

MO

ethosuximide oral solution

2

MO

felbamate oral suspension

2

MO

felbamate oral tablet

2

MO

fosphenytoin injection solution

2

B/D PA; MO

FYCOMPA ORAL SUSPENSION

4

PA; MO

FYCOMPA ORAL TABLET

4

PA; MO

gabapentin oral capsule

2

MO

gabapentin oral solution 250 mg/5 ml

2

MO

gabapentin oral solution 250 mg/5 ml (5 ml), 300
2
mg/6 ml (6 ml)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
22

Drug Name

Drug Tier

Requirements/Limits

gabapentin oral tablet 600 mg, 800 mg

2

MO

GABITRIL ORAL TABLET 12 MG, 16 MG

4

MO

lamotrigine oral tablet

2

MO

lamotrigine oral tablet disintegrating, dose pk

2

MO

lamotrigine oral tablet extended release 24hr

2

MO

lamotrigine oral tablet, chewable dispersible

2

MO

lamotrigine oral tablet,disintegrating

2

MO

levetiracetam in nacl (iso-osm) intravenous
piggyback 1,000 mg/100 ml, 1,500 mg/100 ml

2

levetiracetam in nacl (iso-osm) intravenous
piggyback 500 mg/100 ml

2

MO

levetiracetam intravenous solution

2

B/D PA; MO

levetiracetam oral solution 100 mg/ml

2

MO

levetiracetam oral solution 500 mg/5 ml (5 ml)

2

levetiracetam oral tablet

2

MO

levetiracetam oral tablet extended release 24 hr

2

MO

LYRICA ORAL CAPSULE

3

MO

LYRICA ORAL SOLUTION

3

MO

ONFI ORAL SUSPENSION

4

PA; MO

ONFI ORAL TABLET 10 MG, 20 MG

4

PA; MO

oxcarbazepine oral suspension

2

MO

oxcarbazepine oral tablet

2

MO

PEGANONE ORAL TABLET

4

MO

phenobarbital oral elixir

2

PA; MO

phenobarbital oral tablet

2

PA; MO

PHENYTEK ORAL CAPSULE

3

MO

phenytoin oral suspension 100 mg/4 ml

2

phenytoin oral suspension 125 mg/5 ml

2

MO

phenytoin oral tablet,chewable

2

MO

phenytoin sodium extended oral capsule

2

MO

phenytoin sodium intravenous solution

2

B/D PA; MO

phenytoin sodium intravenous syringe

2

B/D PA

primidone oral tablet

2

MO

ROWEEPRA ORAL TABLET 1,000 MG, 750
MG

4

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
23

Drug Name

Drug Tier

Requirements/Limits

ROWEEPRA ORAL TABLET 500 MG

4

MO

SABRIL ORAL POWDER IN PACKET

5

PA; MO

SABRIL ORAL TABLET

5

PA; MO

SPRITAM ORAL TABLET FOR SUSPENSION

4

MO

TEGRETOL XR ORAL TABLET EXTENDED
RELEASE 12 HR 100 MG

4

MO

tiagabine oral tablet

2

MO

topiramate oral capsule, sprinkle

2

PA; MO

TOPIRAMATE ORAL
CAPSULE,SPRINKLE,ER 24HR

3

PA; MO

topiramate oral tablet

2

PA; MO

valproate sodium intravenous solution

2

B/D PA; MO

valproic acid (as sodium salt) oral solution 250
mg/5 ml

2

MO

valproic acid (as sodium salt) oral solution 250
mg/5 ml (5 ml), 500 mg/10 ml (10 ml)

2

valproic acid oral capsule

2

MO

VIMPAT INTRAVENOUS SOLUTION

4

PA

VIMPAT ORAL SOLUTION

4

PA; MO

VIMPAT ORAL TABLET

4

PA; MO

zonisamide oral capsule

2

PA; MO

APOKYN SUBCUTANEOUS CARTRIDGE

5

PA; MO

AZILECT ORAL TABLET

4

MO

benztropine injection solution

2

B/D PA; MO

benztropine oral tablet

2

PA; MO

bromocriptine oral capsule

2

MO

bromocriptine oral tablet

2

MO

carbidopa oral tablet

2

MO

carbidopa-levodopa oral tablet

2

MO

carbidopa-levodopa oral tablet extended release

2

MO

carbidopa-levodopa oral tablet,disintegrating

2

MO

carbidopa-levodopa-entacapone oral tablet

2

MO

entacapone oral tablet

2

MO

NEUPRO TRANSDERMAL PATCH 24 HOUR

4

PA; MO

pramipexole oral tablet

2

MO

ANTIPARKINSONISM AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
24

Drug Name

Drug Tier

Requirements/Limits

pramipexole oral tablet extended release 24 hr

2

MO

rasagiline oral tablet

4

MO

ropinirole oral tablet

2

MO

ropinirole oral tablet extended release 24 hr

2

MO

selegiline hcl oral capsule

2

MO

selegiline hcl oral tablet

2

MO

tolcapone oral tablet

2

MO

trihexyphenidyl oral elixir

2

PA; MO

trihexyphenidyl oral tablet

2

PA; MO

dihydroergotamine injection solution

2

MO

dihydroergotamine nasal spray,non-aerosol

4

MO

migergot rectal suppository

2

MO

naratriptan oral tablet

2

MO; QL (18 per 28 days)

rizatriptan oral tablet

2

MO; QL (36 per 30 days)

rizatriptan oral tablet,disintegrating

2

MO; QL (36 per 30 days)

sumatriptan nasal spray,non-aerosol

2

MO

sumatriptan succinate oral tablet

2

MO; QL (9 per 30 days)

sumatriptan succinate subcutaneous cartridge

2

MO; QL (10 per 30 days)

sumatriptan succinate subcutaneous pen injector

2

MO; QL (10 per 30 days)

sumatriptan succinate subcutaneous solution

2

MO; QL (10 per 30 days)

sumatriptan succinate subcutaneous syringe 6
mg/0.5 ml

2

MO; QL (10 per 30 days)

zolmitriptan oral tablet

2

MO; QL (12 per 30 days)

zolmitriptan oral tablet,disintegrating

2

MO; QL (12 per 30 days)

AMPYRA ORAL TABLET EXTENDED
RELEASE 12 HR

5

PA; MO; NEDS

AUBAGIO ORAL TABLET

5

PA; MO

COPAXONE SUBCUTANEOUS SYRINGE

5

PA; MO

donepezil oral tablet

2

MO; QL (30 per 30 days)

donepezil oral tablet,disintegrating

2

MO; QL (30 per 30 days)

galantamine oral capsule,ext rel. pellets 24 hr

2

MO; QL (30 per 30 days)

galantamine oral solution

2

MO

galantamine oral tablet

2

MO

MIGRAINE / CLUSTER HEADACHE THERAPY

MISCELLANEOUS NEUROLOGICAL THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
25

Drug Name

Drug Tier

Requirements/Limits

GILENYA ORAL CAPSULE

5

MO

glatopa subcutaneous syringe

5

PA; MO

KEVEYIS ORAL TABLET

5

PA; MO

memantine oral solution

2

PA; MO

memantine oral tablet

2

PA; MO

memantine oral tablets,dose pack

2

PA; MO

NAMENDA ORAL TABLET

4

PA; MO

NAMENDA TITRATION PAK ORAL
TABLETS,DOSE PACK

4

PA; MO

NAMENDA XR ORAL CAP,SPRINKLE,ER
24HR DOSE PACK

3

PA; MO

NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR

3

PA; MO

NUEDEXTA ORAL CAPSULE

3

MO

rivastigmine tartrate oral capsule 1.5 mg

2

MO; QL (240 per 30 days)

rivastigmine tartrate oral capsule 3 mg

2

MO; QL (120 per 30 days)

rivastigmine tartrate oral capsule 4.5 mg, 6 mg

2

MO; QL (60 per 30 days)

rivastigmine transdermal patch 24 hour

2

MO; QL (30 per 30 days)

TECFIDERA ORAL CAPSULE,DELAYED
RELEASE(DR/EC)

5

MO

tetrabenazine oral tablet

5

PA; MO

TYSABRI INTRAVENOUS SOLUTION

5

PA; MO

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY
baclofen oral tablet

2

MO

cyclobenzaprine oral tablet

2

PA; MO

dantrolene oral capsule

2

MO

meprobamate oral tablet

2

PA; MO

MESTINON ORAL SYRUP

3

MO

metaxalone oral tablet

2

PA; MO

pyridostigmine bromide oral tablet

2

MO

pyridostigmine bromide oral tablet extended
release

2

MO

regonol injection solution

3

B/D PA

tizanidine oral capsule

2

MO

tizanidine oral tablet

2

MO

NARCOTIC ANALGESICS
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
26

Drug Name

Drug Tier

Requirements/Limits

acetaminophen-codeine oral solution 120 mg-12
mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml

2

QL (4500 per 30 days)

acetaminophen-codeine oral solution 120-12 mg/5
ml

2

MO; QL (4500 per 30 days)

acetaminophen-codeine oral tablet 300-15 mg,
300-30 mg

2

MO; QL (360 per 30 days)

acetaminophen-codeine oral tablet 300-60 mg

2

MO; QL (180 per 30 days)

buprenorphine hcl injection solution

2

B/D PA; MO; QL (267 per 30 days)

buprenorphine hcl injection syringe

2

B/D PA; QL (267 per 30 days)

buprenorphine hcl sublingual tablet

2

MO

butalbital-acetaminop-caf-cod oral capsule 50300-40-30 mg

4

PA; MO; QL (360 per 30 days)

butalbital-acetaminop-caf-cod oral capsule 50325-40-30 mg

2

PA; MO; QL (360 per 30 days)

butalbital-acetaminophen oral tablet 50-325 mg

4

MO; QL (360 per 30 days)

butalbital-acetaminophen-caff oral capsule

4

MO; QL (360 per 30 days)

butalbital-acetaminophen-caff oral tablet 50-32540 mg

4

MO; QL (360 per 30 days)

butalbital-aspirin-caffeine oral capsule

4

MO

codeine sulfate oral tablet

2

MO; QL (180 per 30 days)

diskets oral tablet,soluble

2

QL (30 per 30 days)

DURAMORPH (PF) INJECTION SOLUTION
0.5 MG/ML

4

B/D PA; MO; QL (4000 per 30 days)

DURAMORPH (PF) INJECTION SOLUTION 1
MG/ML

4

B/D PA; QL (2000 per 30 days)

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325
mg, 7.5-325 mg

2

MO; QL (360 per 30 days)

fentanyl citrate buccal lozenge on a handle 1,200
mcg

5

PA; MO; QL (39 per 30 days)

fentanyl citrate buccal lozenge on a handle 1,600
mcg

5

PA; MO; QL (29 per 30 days)

fentanyl citrate buccal lozenge on a handle 200
mcg

5

PA; MO; QL (120 per 30 days)

fentanyl citrate buccal lozenge on a handle 400
mcg

5

PA; MO; QL (116 per 30 days)

fentanyl citrate buccal lozenge on a handle 600
mcg

5

PA; MO; QL (77 per 30 days)

fentanyl citrate buccal lozenge on a handle 800
mcg

5

PA; MO; QL (58 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
27

Drug Name

Drug Tier

Requirements/Limits

fentanyl transdermal patch 72 hour 100 mcg/hr

2

MO; QL (9 per 30 days)

fentanyl transdermal patch 72 hour 12 mcg/hr, 25
mcg/hr, 50 mcg/hr, 75 mcg/hr

2

MO; QL (10 per 30 days)

hydrocodone-acetaminophen oral solution 7.5-325
mg/15 ml

2

MO; QL (5550 per 30 days)

hydrocodone-acetaminophen oral tablet 10-300
mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg,
7.5-300 mg, 7.5-325 mg

2

MO; QL (360 per 30 days)

hydrocodone-ibuprofen oral tablet 10-200 mg, 5200 mg, 7.5-200 mg

2

MO; QL (50 per 30 days)

hydromorphone (pf) injection solution

2

B/D PA; MO; QL (120 per 30 days)

hydromorphone injection solution 1 mg/ml

2

B/D PA; QL (300 per 30 days)

hydromorphone injection solution 2 mg/ml

2

B/D PA; MO; QL (150 per 30 days)

hydromorphone injection solution 4 mg/ml

2

B/D PA; MO; QL (75 per 30 days)

hydromorphone oral liquid

2

MO; QL (1500 per 30 days)

hydromorphone oral tablet

2

MO; QL (180 per 30 days)

ibuprofen-oxycodone oral tablet

2

MO; QL (28 per 30 days)

KADIAN ORAL CAPSULE,EXTEND.RELEASE
PELLETS 200 MG

4

MO; QL (60 per 30 days)

levorphanol tartrate oral tablet

2

MO; QL (120 per 30 days)

methadone injection solution

2

B/D PA; QL (160 per 30 days)

methadone intensol oral concentrate

2

MO; QL (120 per 30 days)

methadone oral concentrate

2

MO; QL (120 per 30 days)

methadone oral solution 10 mg/5 ml

2

MO; QL (600 per 30 days)

methadone oral solution 5 mg/5 ml

2

MO; QL (1200 per 30 days)

methadone oral tablet 10 mg

2

MO; QL (120 per 30 days)

methadone oral tablet 5 mg

2

MO; QL (240 per 30 days)

methadone oral tablet,soluble

2

QL (30 per 30 days)

methadose oral concentrate

2

MO; QL (120 per 30 days)

methadose oral tablet,soluble

2

MO; QL (30 per 30 days)

morphine (pf) injection solution 0.5 mg/ml

2

B/D PA; QL (2400 per 30 days)

morphine (pf) injection solution 1 mg/ml

2

B/D PA; MO; QL (1200 per 30 days)

morphine concentrate oral solution

2

MO; QL (300 per 30 days)

morphine intravenous cartridge 10 mg/ml

2

B/D PA; QL (200 per 30 days)

MORPHINE INTRAVENOUS CARTRIDGE 8
MG/ML

2

B/D PA; QL (250 per 30 days)

morphine intravenous syringe 10 mg/ml
2
B/D PA; QL (200 per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
28

Drug Name

Drug Tier

Requirements/Limits

morphine intravenous syringe 8 mg/ml

2

B/D PA; QL (250 per 30 days)

morphine oral capsule, er multiphase 24 hr 120
mg

2

MO; QL (50 per 30 days)

morphine oral capsule, er multiphase 24 hr 30 mg,
45 mg, 60 mg, 75 mg, 90 mg

2

MO; QL (60 per 30 days)

morphine oral capsule,extend.release pellets

2

MO; QL (60 per 30 days)

morphine oral solution

2

MO; QL (900 per 30 days)

morphine oral tablet

2

MO; QL (180 per 30 days)

morphine oral tablet extended release 100 mg

2

MO; QL (60 per 30 days)

morphine oral tablet extended release 15 mg, 30
mg, 60 mg

2

MO; QL (90 per 30 days)

morphine oral tablet extended release 200 mg

2

MO; QL (30 per 30 days)

oxycodone oral capsule

2

MO; QL (360 per 30 days)

oxycodone oral concentrate

2

MO; QL (180 per 30 days)

oxycodone oral solution

2

MO; QL (1200 per 30 days)

OXYCODONE ORAL SYRINGE

2

QL (360 per 30 days)

oxycodone oral tablet 10 mg, 15 mg, 20 mg

2

MO; QL (180 per 30 days)

oxycodone oral tablet 30 mg

2

MO; QL (134 per 30 days)

oxycodone oral tablet 5 mg

2

MO; QL (360 per 30 days)

oxycodone-acetaminophen oral solution

2

QL (800 per 30 days)

oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg

2

MO; QL (360 per 30 days)

oxycodone-aspirin oral tablet

2

MO; QL (360 per 30 days)

oxymorphone oral tablet 10 mg

2

MO; QL (200 per 30 days)

oxymorphone oral tablet 5 mg

2

MO; QL (180 per 30 days)

oxymorphone oral tablet extended release 12 hr 10
mg, 15 mg, 20 mg, 5 mg, 7.5 mg

2

MO; QL (90 per 30 days)

oxymorphone oral tablet extended release 12 hr 30
mg

2

MO; QL (67 per 30 days)

oxymorphone oral tablet extended release 12 hr 40
mg

2

MO; QL (50 per 30 days)

reprexain oral tablet 2.5-200 mg

2

QL (50 per 30 days)

zamicet oral solution

2

QL (5550 per 30 days)

buprenorphine-naloxone sublingual tablet

2

MO; QL (90 per 30 days)

butorphanol tartrate injection solution 1 mg/ml

2

MO; QL (720 per 30 days)

NON-NARCOTIC ANALGESICS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
29

Drug Name

Drug Tier

Requirements/Limits

butorphanol tartrate injection solution 2 mg/ml

2

MO; QL (360 per 30 days)

butorphanol tartrate nasal spray,non-aerosol

2

MO; QL (5 per 30 days)

celecoxib oral capsule

2

MO

diclofenac potassium oral tablet

2

MO

diclofenac sodium oral tablet extended release 24
hr

2

MO

diclofenac sodium oral tablet,delayed release
(dr/ec)

2

MO

diclofenac sodium topical drops

2

MO

diclofenac sodium topical gel 1 %

2

MO

diclofenac-misoprostol oral tablet,ir,delayed
release,biphasic

2

MO

diflunisal oral tablet

2

MO

etodolac oral capsule

2

MO

etodolac oral tablet

2

MO

etodolac oral tablet extended release 24 hr

2

MO

fenoprofen oral tablet

2

MO

flurbiprofen oral tablet

2

MO

ibuprofen oral suspension

2

MO

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

MO

indomethacin oral capsule

2

MO

indomethacin oral capsule, extended release

2

MO

ketoprofen oral capsule

2

MO

ketoprofen oral capsule,ext rel. pellets 24 hr 200
mg

2

MO

meclofenamate oral capsule

2

MO

mefenamic acid oral capsule

2

MO

meloxicam oral suspension

2

MO

meloxicam oral tablet

1

MO

nabumetone oral tablet

2

MO

nalbuphine injection solution 10 mg/ml

2

B/D PA; MO; QL (200 per 30 days)

nalbuphine injection solution 20 mg/ml

2

B/D PA; MO; QL (100 per 30 days)

naloxone injection solution

2

MO

naloxone injection syringe

2

MO

naltrexone oral tablet

2

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
30

Drug Name

Drug Tier

Requirements/Limits

NAPRELAN CR ORAL TABLET, ER
MULTIPHASE 24 HR 750 MG

4

MO

naproxen oral suspension

2

MO

naproxen oral tablet

1

MO

naproxen oral tablet,delayed release (dr/ec)

1

MO

naproxen sodium oral tablet 275 mg, 550 mg

2

MO

naproxen sodium oral tablet, er multiphase 24 hr
375 mg

2

MO

NARCAN NASAL SPRAY,NON-AEROSOL 4
MG/ACTUATION

4

MO

NUCYNTA ER ORAL TABLET EXTENDED
RELEASE 12 HR

3

MO

NUCYNTA ORAL TABLET

3

MO

oxaprozin oral tablet

2

MO

piroxicam oral capsule

2

MO

SUBOXONE SUBLINGUAL FILM 12-3 MG

4

MO; QL (60 per 30 days)

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 41 MG, 8-2 MG

4

MO; QL (90 per 30 days)

sulindac oral tablet

2

MO

tolmetin oral capsule

2

MO

tolmetin oral tablet

2

MO

tramadol oral tablet

2

MO; QL (240 per 30 days)

tramadol oral tablet extended release 24 hr

2

MO; QL (30 per 30 days)

tramadol oral tablet, er multiphase 24 hr

2

MO; QL (30 per 30 days)

tramadol-acetaminophen oral tablet

2

MO; QL (240 per 30 days)

VIVITROL INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON

4

MO

VOLTAREN GEL TOPICAL GEL 1 %

3

ST; MO

ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON 300
MG

5

B/D PA; MO

ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON 400
MG

5

MO

ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION,EXTENDED REL SYRING

5

MO

ABILIFY ORAL TABLET 10 MG

4

MO; QL (90 per 30 days)

PSYCHOTHERAPEUTIC DRUGS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
31

Drug Name

Drug Tier

Requirements/Limits

ABILIFY ORAL TABLET 15 MG

4

MO; QL (60 per 30 days)

ABILIFY ORAL TABLET 2 MG

4

MO; QL (450 per 30 days)

ABILIFY ORAL TABLET 20 MG

5

MO; QL (60 per 30 days)

ABILIFY ORAL TABLET 30 MG

5

MO; QL (30 per 30 days)

ABILIFY ORAL TABLET 5 MG

4

MO; QL (180 per 30 days)

alprazolam oral tablet

2

MO

alprazolam oral tablet extended release 24 hr

2

PA; MO

alprazolam oral tablet,disintegrating

2

MO

amitriptyline oral tablet

2

PA; MO

amoxapine oral tablet

2

MO

aripiprazole oral solution

4

MO

aripiprazole oral tablet 10 mg

4

MO; QL (90 per 30 days)

aripiprazole oral tablet 15 mg, 20 mg

4

MO; QL (60 per 30 days)

aripiprazole oral tablet 2 mg

4

MO; QL (450 per 30 days)

aripiprazole oral tablet 30 mg

4

MO; QL (30 per 30 days)

aripiprazole oral tablet 5 mg

4

MO; QL (180 per 30 days)

aripiprazole oral tablet,disintegrating 10 mg

2

MO; QL (90 per 30 days)

aripiprazole oral tablet,disintegrating 15 mg

2

MO; QL (60 per 30 days)

ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED RELEASE
SYRINGE 1,064 MG/3.9 ML

5

ARISTADA INTRAMUSCULAR
SUSPENSION,EXTENDED RELEASE
SYRINGE 441 MG/1.6 ML, 662 MG/2.4 ML, 882
MG/3.2 ML

5

MO

atomoxetine oral capsule

2

MO

BRISDELLE ORAL CAPSULE

4

MO

bupropion hcl oral tablet

2

MO

bupropion hcl oral tablet extended release 12 hr

2

MO

bupropion hcl oral tablet extended release 24 hr

2

MO

buspirone oral tablet

2

MO

chlorpromazine injection solution

2

MO

chlorpromazine oral tablet

2

MO

citalopram oral solution

2

MO

citalopram oral tablet

1

MO

clomipramine oral capsule

2

PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
32

Drug Name

Drug Tier

Requirements/Limits

clonidine hcl oral tablet extended release 12 hr

2

MO

clorazepate dipotassium oral tablet

2

PA; MO

clozapine oral tablet

2

MO

clozapine oral tablet,disintegrating 100 mg, 12.5
mg, 25 mg

2

CLOZAPINE ORAL
TABLET,DISINTEGRATING 150 MG, 200 MG

4

desipramine oral tablet

2

MO

desvenlafaxine succinate oral tablet extended
release 24 hr

2

MO

dexmethylphenidate oral capsule,er biphasic 5050 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg

2

MO

dexmethylphenidate oral tablet

2

MO

dextroamphetamine oral capsule, extended release

2

MO

dextroamphetamine oral tablet

2

MO

dextroamphetamine-amphetamine oral
capsule,extended release 24hr

2

MO

dextroamphetamine-amphetamine oral tablet

2

MO

diazepam intensol oral concentrate

2

PA; MO

diazepam oral concentrate

2

PA; MO

diazepam oral solution 5 mg/5 ml (1 mg/ml)

2

PA; MO

diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 ml)

2

PA

diazepam oral tablet

2

PA; MO

doxepin oral capsule

2

PA; MO

doxepin oral concentrate

2

PA; MO

duloxetine oral capsule,delayed release(dr/ec)

2

MO

EMSAM TRANSDERMAL PATCH 24 HOUR

4

MO

ergoloid oral tablet

2

PA; MO

escitalopram oxalate oral solution

2

MO

escitalopram oxalate oral tablet

2

MO

eszopiclone oral tablet

2

MO; QL (30 per 30 days)

FANAPT ORAL TABLET

4

MO; QL (60 per 30 days)

FANAPT ORAL TABLETS,DOSE PACK

4

MO; QL (8 per 28 days)

FAZACLO ORAL TABLET,DISINTEGRATING
150 MG, 200 MG

4

FETZIMA ORAL CAPSULE,EXT REL 24HR
4
MO; QL (30 per 30 days)
DOSE PACK
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
33

Drug Name

Drug Tier

Requirements/Limits

FETZIMA ORAL CAPSULE,EXTENDED
RELEASE 24 HR

4

MO; QL (30 per 30 days)

fluoxetine oral capsule

2

MO

fluoxetine oral capsule,delayed release(dr/ec)

2

MO

fluoxetine oral solution

2

MO

fluoxetine oral tablet 10 mg, 20 mg

2

MO

FLUOXETINE ORAL TABLET 60 MG

4

MO

fluphenazine decanoate injection solution

2

B/D PA; MO

fluphenazine hcl injection solution

2

B/D PA; MO

fluphenazine hcl oral concentrate

2

MO

fluphenazine hcl oral elixir

2

MO

fluphenazine hcl oral tablet

2

MO

fluvoxamine oral capsule,extended release 24hr

2

MO

fluvoxamine oral tablet

2

MO

FORFIVO XL ORAL TABLET EXTENDED
RELEASE 24 HR

4

MO

GEODON INTRAMUSCULAR RECON SOLN

4

B/D PA; MO

guanfacine oral tablet extended release 24 hr

2

MO

guanidine oral tablet

2

MO

haloperidol decanoate intramuscular solution

2

B/D PA; MO

haloperidol lactate injection solution

2

B/D PA; MO

haloperidol lactate oral concentrate

2

MO

haloperidol oral tablet

2

MO

HETLIOZ ORAL CAPSULE

5

PA; MO; QL (30 per 30 days)

imipramine hcl oral tablet

2

PA; MO

imipramine pamoate oral capsule

2

PA; MO

INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234
MG/1.5 ML

5

MO

INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 39 MG/0.25 ML, 78 MG/0.5 ML

4

MO

INVEGA TRINZA INTRAMUSCULAR
SYRINGE

5

MO

IRENKA ORAL CAPSULE,DELAYED
RELEASE(DR/EC)

4

MO

KHEDEZLA ORAL TABLET EXTENDED
RELEASE 24HR

4

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
34

Drug Name

Drug Tier

Requirements/Limits

LATUDA ORAL TABLET

4

MO

lithium carbonate oral capsule

1

MO

lithium carbonate oral tablet

1

MO

lithium carbonate oral tablet extended release

1

MO

lithium citrate oral solution 8 meq/5 ml

2

MO

lorazepam intensol oral concentrate

2

PA; MO

lorazepam oral concentrate

2

PA; MO

lorazepam oral tablet

2

PA; MO

loxapine succinate oral capsule

2

MO

maprotiline oral tablet

2

MO

MARPLAN ORAL TABLET

4

MO

metadate er oral tablet extended release

2

MO

methamphetamine oral tablet

2

PA; MO

methylphenidate hcl oral capsule, er biphasic 3070

2

MO

methylphenidate hcl oral capsule,er biphasic 5050 20 mg, 30 mg, 40 mg

2

MO

methylphenidate hcl oral solution

2

MO

methylphenidate hcl oral tablet

2

MO

methylphenidate hcl oral tablet extended release

2

MO

methylphenidate hcl oral tablet extended release
24hr 18 mg

2

MO

mirtazapine oral tablet

2

MO

mirtazapine oral tablet,disintegrating

2

MO

modafinil oral tablet

2

PA; MO

nefazodone oral tablet

2

MO

nortriptyline oral capsule

2

MO

nortriptyline oral solution

2

MO

NUPLAZID ORAL TABLET

5

PA; MO; QL (60 per 30 days)

olanzapine intramuscular recon soln

2

MO

olanzapine oral tablet

2

MO

olanzapine oral tablet,disintegrating

2

MO

olanzapine-fluoxetine oral capsule

2

MO

oxazepam oral capsule

2

PA; MO

paliperidone oral tablet extended release 24hr 1.5
mg, 3 mg, 9 mg

5

MO; QL (30 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
35

Drug Name

Drug Tier

Requirements/Limits

paliperidone oral tablet extended release 24hr 6
mg

5

MO; QL (60 per 30 days)

paroxetine hcl oral tablet

1

MO

paroxetine hcl oral tablet extended release 24 hr

2

MO

PAXIL ORAL SUSPENSION

4

MO

perphenazine oral tablet

2

MO

perphenazine-amitriptyline oral tablet

2

PA; MO

phenelzine oral tablet

2

MO

pimozide oral tablet

2

MO

PRISTIQ ORAL TABLET EXTENDED
RELEASE 24 HR

4

MO

protriptyline oral tablet

2

MO

quetiapine oral tablet

2

MO

quetiapine oral tablet extended release 24 hr

4

MO

REXULTI ORAL TABLET

5

MO

RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 12.5 MG/2 ML, 25 MG/2 ML

3

B/D PA; MO

RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 37.5 MG/2 ML, 50 MG/2 ML

5

B/D PA; MO

risperidone oral solution

2

MO

risperidone oral tablet

2

MO

risperidone oral tablet,disintegrating

2

MO

ROZEREM ORAL TABLET

4

MO; QL (30 per 30 days)

SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 10 MG, 5 MG

4

MO; QL (60 per 30 days)

SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET 2.5 MG

4

MO

SEROQUEL XR ORAL TABLET EXTENDED
RELEASE 24 HR

4

MO

sertraline oral concentrate

2

MO

sertraline oral tablet

1

MO

STRATTERA ORAL CAPSULE

3

MO

SURMONTIL ORAL CAPSULE

4

PA; MO

temazepam oral capsule

2

PA; MO

thioridazine oral tablet

2

PA; MO

thiothixene oral capsule

1

MO

tranylcypromine oral tablet
2
MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
36

Drug Name

Drug Tier

Requirements/Limits

trazodone oral tablet

2

MO

trifluoperazine oral tablet

2

MO

trimipramine oral capsule

2

PA; MO

TRINTELLIX ORAL TABLET

4

MO

venlafaxine oral capsule,extended release 24hr

2

MO

venlafaxine oral tablet

2

MO

venlafaxine oral tablet extended release 24hr 150
mg, 37.5 mg, 75 mg

2

MO

VENLAFAXINE ORAL TABLET EXTENDED
RELEASE 24HR 225 MG

4

MO

VERSACLOZ ORAL SUSPENSION

5

VIIBRYD ORAL TABLET

3

MO

VIIBRYD ORAL TABLETS,DOSE PACK 10
MG (7)- 20 MG (23)

3

MO; QL (30 per 30 days)

VRAYLAR ORAL CAPSULE 1.5 MG

5

MO; QL (120 per 30 days)

VRAYLAR ORAL CAPSULE 3 MG

5

MO; QL (60 per 30 days)

VRAYLAR ORAL CAPSULE 4.5 MG

5

MO; QL (40 per 30 days)

VRAYLAR ORAL CAPSULE 6 MG

5

MO; QL (30 per 30 days)

VRAYLAR ORAL CAPSULE,DOSE PACK

4

MO; QL (7 per 30 days)

XYREM ORAL SOLUTION

5

MO; LA

ziprasidone hcl oral capsule

2

MO

zolpidem oral tablet

2

MO; QL (90 per 365 days)

zolpidem oral tablet,ext release multiphase

2

MO; QL (30 per 30 days)

ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 210
MG, 405 MG

4

B/D PA

ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 300
MG

4

B/D PA; MO

CARDIOVASCULAR, HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone intravenous solution

2

B/D PA; MO

amiodarone intravenous syringe

2

amiodarone oral tablet

2

MO

dofetilide oral capsule

2

MO

flecainide oral tablet

2

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
37

Drug Name

Drug Tier

Requirements/Limits

lidocaine (pf) intravenous solution

2

B/D PA; MO

mexiletine oral capsule

2

MO

MULTAQ ORAL TABLET

3

MO

pacerone oral tablet 100 mg, 200 mg, 400 mg

2

MO

procainamide injection solution 100 mg/ml

2

MO

procainamide injection solution 500 mg/ml

2

propafenone oral capsule,extended release 12 hr

2

MO

propafenone oral tablet

2

MO

quinidine gluconate injection solution

2

MO

quinidine gluconate oral tablet extended release

2

MO

quinidine sulfate oral tablet

2

MO

sorine oral tablet 120 mg, 160 mg, 80 mg

2

MO

sorine oral tablet 240 mg

2

sotalol af oral tablet

2

MO

sotalol oral tablet

2

MO

TIKOSYN ORAL CAPSULE

3

MO

acebutolol oral capsule

2

MO

afeditab cr oral tablet extended release

2

MO

amiloride oral tablet

2

MO

amiloride-hydrochlorothiazide oral tablet

1

MO

amlodipine oral tablet

1

MO

amlodipine-benazepril oral capsule

2

MO

amlodipine-olmesartan oral tablet

2

MO

amlodipine-valsartan oral tablet

2

MO

amlodipine-valsartan-hydrochlorothiazide oral
tablet

2

MO

atenolol oral tablet

1

MO

atenolol-chlorthalidone oral tablet

1

MO

benazepril oral tablet

1

MO

benazepril-hydrochlorothiazide oral tablet

2

MO

BENICAR HCT ORAL TABLET

4

ST; MO; QL (30 per 30 days)

BENICAR ORAL TABLET

4

ST; MO; QL (30 per 30 days)

betaxolol oral tablet

2

MO

bisoprolol fumarate oral tablet

2

MO

ANTIHYPERTENSIVE THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
38

Drug Name

Drug Tier

Requirements/Limits

bisoprolol-hydrochlorothiazide oral tablet

2

MO

bumetanide injection solution

2

MO

bumetanide oral tablet

2

MO

BYSTOLIC ORAL TABLET

3

MO

candesartan oral tablet

2

MO

candesartan-hydrochlorothiazide oral tablet

2

MO

captopril oral tablet

1

MO

captopril-hydrochlorothiazide oral tablet

2

MO

cartia xt oral capsule,extended release 24hr

2

MO

carvedilol oral tablet

1

MO

chlorothiazide oral tablet

1

MO

chlorothiazide sodium intravenous recon soln

2

MO

chlorthalidone oral tablet 25 mg, 50 mg

2

MO

clonidine hcl oral tablet

1

MO

clonidine transdermal patch weekly

2

MO

COREG CR ORAL CAPSULE, ER
MULTIPHASE 24 HR

4

ST; MO

DEMSER ORAL CAPSULE

5

PA; MO

diltiazem hcl intravenous recon soln

2

B/D PA

diltiazem hcl intravenous solution

2

B/D PA

diltiazem hcl oral capsule, extended release

2

MO

diltiazem hcl oral capsule,ext release degradable

2

MO

diltiazem hcl oral capsule,extended release 12 hr

2

MO

diltiazem hcl oral capsule,extended release 24hr

2

MO

diltiazem hcl oral tablet

2

MO

diltiazem hcl oral tablet extended release 24 hr

2

MO

dilt-xr oral capsule,ext release degradable

2

MO

doxazosin oral tablet

1

MO

enalapril maleate oral tablet

2

MO

enalapril-hydrochlorothiazide oral tablet

2

MO

eplerenone oral tablet

2

MO

eprosartan oral tablet

2

MO

felodipine oral tablet extended release 24 hr

1

MO

fosinopril oral tablet

2

MO

fosinopril-hydrochlorothiazide oral tablet

2

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
39

Drug Name

Drug Tier

Requirements/Limits

furosemide injection solution

1

B/D PA; MO

furosemide injection syringe

2

B/D PA; MO

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8
mg/ml)

1

MO

furosemide oral tablet

1

MO

hydralazine injection solution

2

B/D PA; MO

hydralazine oral tablet

2

MO

hydrochlorothiazide oral capsule

1

MO

hydrochlorothiazide oral tablet

1

MO

indapamide oral tablet

1

MO

irbesartan oral tablet

2

MO

irbesartan-hydrochlorothiazide oral tablet

2

MO

isradipine oral capsule

2

MO

labetalol intravenous solution

2

B/D PA; MO

labetalol intravenous syringe 20 mg/4 ml (5
mg/ml)

2

B/D PA

labetalol oral tablet

2

MO

lisinopril oral tablet

1

MO

lisinopril-hydrochlorothiazide oral tablet

1

MO

losartan oral tablet

1

MO

losartan-hydrochlorothiazide oral tablet

1

MO

matzim la oral tablet extended release 24 hr

2

MO

methyclothiazide oral tablet

2

MO

methyldopa-hydrochlorothiazide oral tablet

2

PA; MO

metolazone oral tablet

2

MO

metoprolol succinate oral tablet extended release
24 hr

2

MO

metoprolol tartrate intravenous solution

1

B/D PA; MO; NEDS

metoprolol tartrate intravenous syringe

1

B/D PA; NEDS

metoprolol tartrate oral tablet

1

MO

metoprolol tartrate-hydrochlorothiazide oral
tablet

2

MO

minoxidil oral tablet

2

MO

moexipril oral tablet

2

MO

moexipril-hydrochlorothiazide oral tablet

2

MO

nadolol oral tablet

2

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
40

Drug Name

Drug Tier

Requirements/Limits

nadolol-bendroflumethiazide oral tablet

2

MO

nicardipine intravenous solution

2

MO

nicardipine oral capsule

2

MO

nifedipine oral tablet extended release

2

MO

nifedipine oral tablet extended release 24hr

2

MO

nimodipine oral capsule

1

MO

olmesartan oral tablet

2

MO; QL (30 per 30 days)

olmesartan-amlodipine-hydrochlorothiazide oral
tablet

2

MO

olmesartan-hydrochlorothiazide oral tablet

2

MO; QL (30 per 30 days)

perindopril erbumine oral tablet

2

MO

phenoxybenzamine oral capsule

5

PA; MO

pindolol oral tablet

2

MO

prazosin oral capsule

2

MO

propranolol intravenous solution

2

B/D PA

propranolol oral capsule,extended release 24 hr

2

MO

propranolol oral solution

2

MO

propranolol oral tablet

2

MO

propranolol-hydrochlorothiazide oral tablet

2

MO

quinapril oral tablet

2

MO

quinapril-hydrochlorothiazide oral tablet

2

MO

ramipril oral capsule

1

MO

REMODULIN INJECTION SOLUTION

5

B/D PA; MO

spironolactone oral tablet

2

MO

spironolactone-hydrochlorothiazide oral tablet

2

MO

taztia xt oral capsule, extended release

2

MO

TEKTURNA HCT ORAL TABLET

3

MO

TEKTURNA ORAL TABLET

3

MO

telmisartan oral tablet

2

MO

telmisartan-hydrochlorothiazide oral tablet

2

MO

terazosin oral capsule

1

MO

timolol maleate oral tablet

2

MO

torsemide oral tablet

2

MO

trandolapril oral tablet

2

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
41

Drug Name

Drug Tier

Requirements/Limits

trandolapril-verapamil oral tablet, ir - er, biphasic
24hr

2

MO

triamterene-hydrochlorothiazide oral capsule

2

MO

triamterene-hydrochlorothiazide oral tablet

2

MO

UPTRAVI ORAL TABLET

5

PA; MO; QL (60 per 30 days)

UPTRAVI ORAL TABLETS,DOSE PACK

5

PA; MO

valsartan oral tablet

2

MO

valsartan-hydrochlorothiazide oral tablet

2

MO

verapamil intravenous solution

1

B/D PA; MO

verapamil intravenous syringe

2

B/D PA

verapamil oral capsule, 24 hr er pellet ct

2

MO

verapamil oral capsule,ext rel. pellets 24 hr

2

MO

verapamil oral tablet

1

MO

verapamil oral tablet extended release

2

MO

digitek oral tablet

1

PA; MO

digox oral tablet

1

MO

digoxin injection solution

2

PA; MO

digoxin oral solution 50 mcg/ml

2

PA; MO

digoxin oral tablet

1

PA; MO

LANOXIN ORAL TABLET

4

MO

AGGRENOX ORAL CAPSULE, ER
MULTIPHASE 12 HR

4

MO

aspirin-dipyridamole oral capsule, er multiphase
12 hr

2

MO

BRILINTA ORAL TABLET

3

MO

cilostazol oral tablet

2

MO

clopidogrel oral tablet 300 mg

2

MO; QL (1 per 30 days)

clopidogrel oral tablet 75 mg

2

MO

COUMADIN ORAL TABLET

3

MO

EFFIENT ORAL TABLET

3

MO

ELIQUIS ORAL TABLET

3

MO

enoxaparin subcutaneous solution

4

MO; QL (180 per 30 days); NEDS

enoxaparin subcutaneous syringe 100 mg/ml

4

MO; QL (60 per 30 days); NEDS

CARDIAC GLYCOSIDES

COAGULATION THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
42

Drug Name

Drug Tier

Requirements/Limits

enoxaparin subcutaneous syringe 120 mg/0.8 ml,
80 mg/0.8 ml

4

MO; QL (48 per 30 days); NEDS

enoxaparin subcutaneous syringe 150 mg/ml

5

MO; QL (60 per 30 days); NEDS

enoxaparin subcutaneous syringe 30 mg/0.3 ml

4

MO; QL (18 per 30 days); NEDS

enoxaparin subcutaneous syringe 40 mg/0.4 ml

4

MO; QL (24 per 30 days); NEDS

enoxaparin subcutaneous syringe 60 mg/0.6 ml

4

MO; QL (36 per 30 days); NEDS

fondaparinux subcutaneous syringe 10 mg/0.8 ml

5

MO; QL (24 per 30 days)

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

4

MO; QL (15 per 30 days)

fondaparinux subcutaneous syringe 5 mg/0.4 ml

5

MO; QL (12 per 30 days)

fondaparinux subcutaneous syringe 7.5 mg/0.6 ml

5

MO; QL (18 per 30 days)

FRAGMIN SUBCUTANEOUS SOLUTION

4

MO; QL (30 per 30 days)

FRAGMIN SUBCUTANEOUS SYRINGE 10,000
ANTI-XA UNIT/ML

5

MO; QL (30 per 30 days)

FRAGMIN SUBCUTANEOUS SYRINGE 12,500
ANTI-XA UNIT/0.5 ML

5

MO; QL (15 per 30 days)

FRAGMIN SUBCUTANEOUS SYRINGE 15,000
ANTI-XA UNIT/0.6 ML

5

MO; QL (18 per 30 days)

FRAGMIN SUBCUTANEOUS SYRINGE 18,000
ANTI-XA UNIT/0.72 ML

5

MO; QL (21.6 per 30 days)

FRAGMIN SUBCUTANEOUS SYRINGE 2,500
ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA
UNIT/0.2 ML

4

MO; QL (6 per 30 days)

FRAGMIN SUBCUTANEOUS SYRINGE 7,500
ANTI-XA UNIT/0.3 ML

5

MO; QL (9 per 30 days)

heparin (porcine) in 5 % dex intravenous
parenteral solution 12,500 unit/250 ml, 20,000
unit/500 ml (40 unit/ml)

2

B/D PA

heparin (porcine) in 5 % dex intravenous
parenteral solution 25,000 unit/250 ml(100
unit/ml), 25,000 unit/500 ml (50 unit/ml)

2

B/D PA; MO

heparin (porcine) in nacl (pf) intravenous
parenteral solution

2

B/D PA

heparin (porcine) injection cartridge

2

B/D PA; MO

heparin (porcine) injection solution

2

B/D PA; MO

HEPARIN(PORCINE) IN 0.45% NACL
INTRAVENOUS PARENTERAL SOLUTION
12,500 UNIT/250 ML

2

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
43

Drug Name

Drug Tier

Requirements/Limits

heparin(porcine) in 0.45% nacl intravenous
parenteral solution 25,000 unit/250 ml, 25,000
unit/500 ml

2

B/D PA; MO

heparin, porcine (pf) injection solution

2

B/D PA; MO

heparin, porcine (pf) injection syringe

2

B/D PA; MO

jantoven oral tablet

1

MO

pentoxifylline oral tablet extended release

2

MO

PRADAXA ORAL CAPSULE

4

MO

PROMACTA ORAL TABLET

5

PA; MO

tranexamic acid intravenous solution

2

B/D PA; MO

warfarin oral tablet

1

MO

XARELTO ORAL TABLET

3

MO

XARELTO ORAL TABLETS,DOSE PACK

3

MO

amlodipine-atorvastatin oral tablet

2

MO

atorvastatin oral tablet

1

MO

cholestyramine (with sugar) oral powder

2

MO

cholestyramine (with sugar) oral powder in packet

2

MO

cholestyramine light oral powder

2

MO

cholestyramine light oral powder in packet

2

MO

colestipol oral granules

2

MO

colestipol oral packet

2

MO

colestipol oral tablet

2

MO

CRESTOR ORAL TABLET

4

ST; MO; QL (30 per 30 days)

ezetimibe oral tablet

2

MO; QL (30 per 30 days)

ezetimibe-simvastatin oral tablet

2

MO

fenofibrate micronized oral capsule

2

MO

fenofibrate nanocrystallized oral tablet

2

MO

fenofibrate oral tablet 160 mg, 54 mg

2

MO

fenofibric acid (choline) oral capsule,delayed
release(dr/ec)

2

MO

fenofibric acid oral tablet

2

MO

fluvastatin oral capsule

2

MO

fluvastatin oral tablet extended release 24 hr

2

MO

gemfibrozil oral tablet

1

MO

LIPID/CHOLESTEROL LOWERING AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
44

Drug Name

Drug Tier

Requirements/Limits

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5
MG

5

PA; MO; LA

JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60
MG

5

PA; MO

KYNAMRO SUBCUTANEOUS SYRINGE

5

PA; MO

lovastatin oral tablet

1

MO

niacin oral tablet extended release 24 hr

2

MO

omega-3 acid ethyl esters oral capsule

2

MO

PRALUENT SUBCUTANEOUS PEN
INJECTOR 150 MG/ML

5

PA; MO; QL (2 per 28 days)

PRALUENT SUBCUTANEOUS PEN
INJECTOR 75 MG/ML

5

PA; MO; QL (4 per 28 days)

pravastatin oral tablet

1

MO

prevalite oral powder

2

MO

prevalite oral powder in packet

2

MO

REPATHA PUSHTRONEX SUBCUTANEOUS
WEARABLE INJECTOR

5

PA; MO; QL (1 per 30 days)

REPATHA SURECLICK SUBCUTANEOUS
PEN INJECTOR

5

PA; MO; QL (3 per 28 days)

REPATHA SUBCUTANEOUS SYRINGE

5

PA; MO; QL (3 per 28 days)

rosuvastatin oral tablet

2

MO

simvastatin oral tablet

1

MO

VYTORIN 10-10 ORAL TABLET

3

MO

VYTORIN 10-20 ORAL TABLET

3

MO

VYTORIN 10-40 ORAL TABLET

3

MO

VYTORIN 10-80 ORAL TABLET

3

MO

WELCHOL ORAL POWDER IN PACKET

3

MO

WELCHOL ORAL TABLET

3

MO

ZETIA ORAL TABLET

4

MO; QL (30 per 30 days)

ENTRESTO ORAL TABLET

3

MO

RANEXA ORAL TABLET EXTENDED
RELEASE 12 HR

3

MO

VECAMYL ORAL TABLET

4

MISCELLANEOUS CARDIOVASCULAR AGENTS

NITRATES
ISORDIL ORAL TABLET

3

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
45

Drug Name

Drug Tier

Requirements/Limits

isosorbide dinitrate oral tablet

2

MO

isosorbide dinitrate oral tablet extended release

2

MO

isosorbide mononitrate oral tablet

1

MO

isosorbide mononitrate oral tablet extended
release 24 hr

1

MO

nitro-bid transdermal ointment

2

MO

nitroglycerin intravenous solution

2

B/D PA

nitroglycerin sublingual tablet

2

MO

nitroglycerin transdermal patch 24 hour

2

MO

nitroglycerin translingual aerosol,spray

2

MO

nitroglycerin translingual spray,non-aerosol

2

MO

NITROSTAT SUBLINGUAL TABLET

3

MO

DERMATOLOGICALS/TOPICAL THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
acitretin oral capsule 10 mg

4

MO

acitretin oral capsule 17.5 mg, 25 mg

5

MO; NEDS

calcipotriene scalp solution

2

MO

calcipotriene topical cream

2

MO

calcipotriene topical ointment

2

MO

calcipotriene-betamethasone topical ointment

4

MO

calcitrene topical ointment

4

MO

calcitriol topical ointment

2

MO

selenium sulfide topical lotion

2

MO

silver sulfadiazine topical cream

2

MO

ssd topical cream

2

MO

thermazene topical cream

2

BURN THERAPY

MISCELLANEOUS DERMATOLOGICALS
ammonium lactate topical cream

2

MO

ammonium lactate topical lotion

2

MO

CARAC TOPICAL CREAM

3

MO

diclofenac sodium topical gel 3 %

5

PA; MO

ELIDEL TOPICAL CREAM

4

ST; MO

FLUOROURACIL TOPICAL CREAM 0.5 %

4

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
46

Drug Name

Drug Tier

Requirements/Limits

fluorouracil topical cream 5 %

2

MO

fluorouracil topical solution

2

MO

imiquimod topical cream in packet

2

MO

methoxsalen oral capsule,liqd-filled,rapid rel

2

MO

PANRETIN TOPICAL GEL

5

MO

podofilox topical solution

2

MO

REGRANEX TOPICAL GEL

5

MO; QL (30 per 30 days)

tacrolimus topical ointment

4

MO

VALCHLOR TOPICAL GEL

5

MO

ZYCLARA TOPICAL CREAM IN METEREDDOSE PUMP

4

MO

ZYCLARA TOPICAL CREAM IN PACKET

4

MO

adapalene topical cream

2

PA; MO

adapalene topical gel

2

PA; MO

adapalene topical gel with pump

2

PA; MO

amnesteem oral capsule 10 mg, 40 mg

2

MO

amnesteem oral capsule 20 mg

2

claravis oral capsule 10 mg, 20 mg, 40 mg

2

MO

claravis oral capsule 30 mg

4

MO

clindamycin phosphate topical foam

2

MO

clindamycin phosphate topical gel

2

MO

clindamycin phosphate topical lotion

2

MO

clindamycin phosphate topical solution

2

MO

clindamycin phosphate topical swab

2

MO

clindamycin-benzoyl peroxide topical gel

2

MO

clindamycin-benzoyl peroxide topical gel with
pump

2

MO

ery pads topical swab

2

MO

erythromycin with ethanol topical gel

2

MO

erythromycin with ethanol topical solution

2

MO

erythromycin with ethanol topical swab

2

MO

erythromycin-benzoyl peroxide topical gel

2

MO

metronidazole topical cream

2

MO

metronidazole topical gel

2

MO

THERAPY FOR ACNE

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
47

Drug Name

Drug Tier

Requirements/Limits

metronidazole topical gel with pump

2

MO

metronidazole topical lotion

2

MO

rosadan topical cream

2

MO

rosadan topical gel

2

MO

tazarotene topical cream

4

MO

TAZORAC TOPICAL CREAM

4

MO

TAZORAC TOPICAL GEL

4

MO

tretinoin microspheres topical gel

2

PA; MO

tretinoin microspheres topical gel with pump

2

PA; MO

tretinoin topical cream

2

PA; MO

tretinoin topical gel

2

PA; MO

lidocaine (pf) injection solution 10 mg/ml (1 %),
20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)

2

B/D PA; MO

lidocaine (pf) injection solution 15 mg/ml (1.5 %)

2

B/D PA

lidocaine hcl injection solution

2

B/D PA; MO

lidocaine hcl laryngotracheal solution

2

MO

lidocaine hcl mucous membrane jelly

2

MO

lidocaine hcl mucous membrane jelly in applicator

2

MO

lidocaine hcl mucous membrane solution 4 % (40
mg/ml)

2

MO

lidocaine hcl urethral gel

2

MO

lidocaine topical adhesive patch,medicated

2

PA; MO

lidocaine topical ointment

2

MO

lidocaine viscous mucous membrane solution

2

MO

lidocaine-prilocaine topical cream

2

MO

gentamicin topical cream

2

MO

gentamicin topical ointment

2

MO

mupirocin calcium topical cream

2

MO

mupirocin topical ointment

2

MO

sulfacetamide sodium (acne) topical suspension

2

MO

SULFAMYLON TOPICAL CREAM

4

MO

2

MO

TOPICAL ANESTHETICS

TOPICAL ANTIBACTERIALS

TOPICAL ANTIFUNGALS
ciclodan topical cream

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
48

Drug Name

Drug Tier

Requirements/Limits

ciclodan topical solution

2

MO

ciclopirox topical cream

2

MO

ciclopirox topical gel

2

MO

ciclopirox topical shampoo

2

MO

ciclopirox topical solution

2

MO

ciclopirox topical suspension

2

MO

clotrimazole topical cream

2

MO

clotrimazole topical solution

2

MO

clotrimazole-betamethasone topical cream

2

MO

clotrimazole-betamethasone topical lotion

2

MO

econazole topical cream

2

MO

ketoconazole topical cream

2

MO

ketoconazole topical foam

2

MO

ketoconazole topical shampoo

2

MO

nyamyc topical powder

2

MO

nystatin topical cream

2

MO

nystatin topical ointment

2

MO

nystatin topical powder

2

MO

nystatin-triamcinolone topical cream

2

MO

nystatin-triamcinolone topical ointment

2

MO

nystop topical powder

2

MO

acyclovir topical ointment

2

MO

DENAVIR TOPICAL CREAM

3

MO

ala-cort topical cream

2

MO

alclometasone topical cream

2

MO

alclometasone topical ointment

2

MO

amcinonide topical cream

2

MO

amcinonide topical lotion

2

MO

amcinonide topical ointment

2

MO

betamethasone dipropionate topical cream

2

MO

betamethasone dipropionate topical lotion

2

MO

betamethasone dipropionate topical ointment

2

MO

TOPICAL ANTIVIRALS

TOPICAL CORTICOSTEROIDS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
49

Drug Name

Drug Tier

Requirements/Limits

betamethasone valerate topical cream

2

MO

betamethasone valerate topical foam

2

MO

betamethasone valerate topical lotion

2

MO

betamethasone valerate topical ointment

2

MO

betamethasone, augmented topical cream

2

MO

betamethasone, augmented topical gel

2

MO

betamethasone, augmented topical lotion

2

MO

betamethasone, augmented topical ointment

2

MO

clobetasol scalp solution

2

MO

clobetasol topical cream

2

MO

clobetasol topical foam

2

MO

clobetasol topical gel

2

MO

clobetasol topical lotion

2

MO

clobetasol topical ointment

2

MO

clobetasol topical shampoo

2

MO

clobetasol-emollient topical cream

2

MO

clobetasol-emollient topical foam

2

MO

cormax scalp solution

2

desonide topical cream

2

MO

desonide topical lotion

2

MO

desonide topical ointment

2

MO

desoximetasone topical cream

2

MO

desoximetasone topical gel

2

MO

desoximetasone topical ointment

2

MO

diflorasone topical cream

2

MO

diflorasone topical ointment

2

MO

fluocinolone and shower cap scalp oil

2

MO

fluocinolone topical cream

2

MO

fluocinolone topical oil

2

MO

fluocinolone topical ointment

2

MO

fluocinolone topical solution

2

MO

fluocinonide topical cream

2

MO

fluocinonide topical gel

2

MO

fluocinonide topical ointment

2

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
50

Drug Name

Drug Tier

Requirements/Limits

fluocinonide topical solution

2

MO

fluocinonide-e topical cream

2

MO

fluocinonide-emollient topical cream

2

fluticasone topical cream

2

MO

fluticasone topical lotion

2

MO

fluticasone topical ointment

2

MO

halobetasol propionate topical cream

2

MO

halobetasol propionate topical ointment

2

MO

hydrocortisone butyrate topical cream

2

MO

hydrocortisone butyrate topical ointment

2

MO

hydrocortisone butyrate topical solution

2

MO

hydrocortisone butyr-emollient topical cream

2

MO

hydrocortisone topical cream 1 %, 2.5 %

2

MO

hydrocortisone topical lotion 2.5 %

2

MO

hydrocortisone topical ointment 1 %, 2.5 %

2

MO

hydrocortisone valerate topical cream

2

MO

hydrocortisone valerate topical ointment

2

MO

hydrocortisone-min oil-wht pet topical ointment

2

MO

mometasone topical cream

2

MO

mometasone topical ointment

2

MO

mometasone topical solution

2

MO

prednicarbate topical cream

2

MO

prednicarbate topical ointment

2

MO

triamcinolone acetonide topical aerosol

2

MO

triamcinolone acetonide topical cream

2

MO

triamcinolone acetonide topical lotion

2

MO

triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %

2

MO

trianex topical ointment

2

MO

triderm topical cream

2

MO

3

MO

lindane topical shampoo

2

MO

malathion topical lotion

2

MO

TOPICAL ENZYMES
SANTYL TOPICAL OINTMENT

TOPICAL SCABICIDES / PEDICULICIDES

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
51

Drug Name
permethrin topical cream

Drug Tier
2

Requirements/Limits
MO

DIAGNOSTICS / MISCELLANEOUS AGENTS
IRRIGATING SOLUTIONS
lactated ringers irrigation solution

2

MO

neomycin-polymyxin b gu irrigation solution

2

MO

acamprosate oral tablet,delayed release (dr/ec)

2

MO

ADAGEN INTRAMUSCULAR SOLUTION

5

B/D PA; MO

alendronate oral tablet 40 mg

1

MO; QL (30 per 30 days)

anagrelide oral capsule

2

MO

ARALAST NP INTRAVENOUS RECON SOLN

5

B/D PA; MO

AURYXIA ORAL TABLET

5

MO

CARBAGLU ORAL TABLET, DISPERSIBLE

5

PA; MO; LA

cevimeline oral capsule

2

MO

CHEMET ORAL CAPSULE

3

MO

CLINIMIX 4.25%/D5W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX E 2.75%/D10W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX E 2.75%/D5W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

d10 %-0.45 % sodium chloride intravenous
parenteral solution

2

d2.5 %-0.45 % sodium chloride intravenous
parenteral solution

2

B/D PA

d5 % and 0.9 % sodium chloride intravenous
parenteral solution

2

B/D PA; MO

d5 %-0.45 % sodium chloride intravenous
parenteral solution

2

B/D PA; MO

dextrose 10 % and 0.2 % nacl intravenous
parenteral solution

2

B/D PA

dextrose 10 % in water (d10w) intravenous
parenteral solution

2

B/D PA; MO

dextrose 20 % in water (d20w) intravenous
parenteral solution

2

B/D PA

dextrose 25 % in water (d25w) intravenous
syringe

2

B/D PA

MISCELLANEOUS AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
52

Drug Name

Drug Tier

Requirements/Limits

dextrose 30 % in water (d30w) intravenous
parenteral solution

2

B/D PA

dextrose 40 % in water (d40w) intravenous
parenteral solution

2

B/D PA

dextrose 5 % in water (d5w) intravenous
parenteral solution

2

B/D PA; MO

dextrose 5 % in water (d5w) intravenous
piggyback

2

B/D PA; MO

dextrose 5 %-lactated ringers intravenous
parenteral solution

2

B/D PA; MO

dextrose 5%-0.2 % sod chloride intravenous
parenteral solution

2

B/D PA

dextrose 5%-0.3 % sod.chloride intravenous
parenteral solution

2

B/D PA

dextrose 50 % in water (d50w) intravenous
parenteral solution

2

B/D PA; MO

dextrose 50 % in water (d50w) intravenous
syringe

2

B/D PA

dextrose 70 % in water (d70w) intravenous
parenteral solution

2

B/D PA; MO

dextrose with sodium chloride intravenous
parenteral solution

2

B/D PA

disulfiram oral tablet

2

MO

etidronate disodium oral tablet

2

MO

EXJADE ORAL TABLET, DISPERSIBLE 125
MG

4

MO

EXJADE ORAL TABLET, DISPERSIBLE 250
MG, 500 MG

5

MO

FERRIPROX ORAL TABLET

5

PA; MO

FOSRENOL ORAL POWDER IN PACKET

3

MO

FOSRENOL ORAL TABLET,CHEWABLE

3

MO

INCRELEX SUBCUTANEOUS SOLUTION

5

B/D PA; MO

kionex (with sorbitol) oral suspension

4

MO

KIONEX ORAL POWDER

4

MO

levocarnitine (with sugar) oral solution

2

B/D PA; MO

levocarnitine oral tablet

2

B/D PA; MO

midodrine oral tablet

2

MO

NORTHERA ORAL CAPSULE

5

PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
53

Drug Name

Drug Tier

Requirements/Limits

pilocarpine hcl oral tablet

2

MO

RAVICTI ORAL LIQUID

5

PA; MO

RENVELA ORAL POWDER IN PACKET

3

MO

RENVELA ORAL TABLET

3

MO

riluzole oral tablet

2

MO

risedronate oral tablet 30 mg

2

MO

sevelamer carbonate oral powder in packet

2

MO

sevelamer carbonate oral tablet

2

MO

sodium chloride 0.9 % intravenous parenteral
solution

2

MO

sodium chloride 0.9 % intravenous piggyback

2

MO

sodium chloride irrigation solution

2

MO

sodium polystyrene (sorb free) oral suspension

2

MO

sodium polystyrene sulfonate oral powder

2

MO

sodium polystyrene sulfonate oral suspension

2

MO

sodium polystyrene sulfonate rectal enema 30
gram/120 ml

2

SODIUM POLYSTYRENE SULFONATE
RECTAL ENEMA 50 GRAM/200 ML

2

sps (with sorbitol) oral suspension

2

sps (with sorbitol) rectal enema

2

SYPRINE ORAL CAPSULE

3

MO

zoledronic acid-mannitol-water intravenous
piggyback

2

PA; MO

bupropion hcl (smoking deter) oral tablet extended
release 12 hr

2

MO

CHANTIX CONTINUING MONTH BOX ORAL
TABLET

4

MO

CHANTIX ORAL TABLET

4

MO

CHANTIX STARTING MONTH BOX ORAL
TABLETS,DOSE PACK

4

MO

NICOTROL INHALATION CARTRIDGE

3

MO

NICOTROL NS NASAL SPRAY,NONAEROSOL

3

MO

MO

SMOKING DETERRENTS

EAR, NOSE / THROAT MEDICATIONS
MISCELLANEOUS AGENTS
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
54

Drug Name

Drug Tier

Requirements/Limits

azelastine nasal spray, aerosol

2

MO; QL (60 per 30 days)

azelastine nasal spray,non-aerosol

2

MO; QL (60 per 30 days)

chlorhexidine gluconate mucous membrane
mouthwash

2

MO

denta 5000 plus dental cream

2

MO

dentagel dental gel

2

MO

ipratropium bromide nasal spray,non-aerosol 0.03
%

2

MO; QL (60 per 30 days)

ipratropium bromide nasal spray,non-aerosol 0.06
%

2

MO; QL (30 per 30 days)

olopatadine nasal spray,non-aerosol

2

MO; QL (30.5 per 30 days)

oralone dental paste

2

MO

paroex oral rinse mucous membrane mouthwash

2

MO

periogard mucous membrane mouthwash

2

MO

sf 5000 plus dental cream

2

MO

sf dental gel

2

MO

triamcinolone acetonide dental paste

2

MO

acetasol hc otic drops

2

MO

acetic acid otic solution

2

MO

acetic acid-aluminum acetate otic drops

2

MO

fluocinolone acetonide oil otic drops

2

MO

hydrocortisone-acetic acid otic drops

2

MO

ofloxacin otic drops

2

MO

neomycin-polymyxin-hc otic drops,suspension

2

MO

neomycin-polymyxin-hc otic solution

2

MO

ACTHAR H.P. INJECTION GEL

5

PA; MO

a-hydrocort injection recon soln

3

B/D PA; MO

cortisone oral tablet

2

MO

dexamethasone intensol oral drops

2

MO

dexamethasone oral elixir

2

MO

dexamethasone oral solution

2

MO

MISCELLANEOUS OTIC PREPARATIONS

OTIC STEROID / ANTIBIOTIC

ENDOCRINE/DIABETES
ADRENAL HORMONES

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
55

Drug Name

Drug Tier

Requirements/Limits

dexamethasone oral tablet

2

MO

dexamethasone sodium phos (pf) injection solution

2

B/D PA; MO

dexamethasone sodium phosphate injection
solution

2

B/D PA; MO

dexamethasone sodium phosphate injection
syringe

2

B/D PA; MO

fludrocortisone oral tablet

2

MO

hydrocortisone oral tablet

2

MO

KENALOG INJECTION SUSPENSION

4

MO

methylprednisolone acetate injection suspension

2

B/D PA; MO

methylprednisolone oral tablet

2

MO

methylprednisolone oral tablets,dose pack

2

MO

methylprednisolone sodium succ injection recon
soln 125 mg, 40 mg

2

B/D PA; MO

methylprednisolone sodium succ intravenous
recon soln

2

B/D PA; MO

millipred oral tablet

2

MO

prednisolone oral solution 15 mg/5 ml

2

MO

prednisolone sodium phosphate oral solution 10
mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4
mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7
mg/5 ml)

2

MO

prednisolone sodium phosphate oral
tablet,disintegrating

2

MO

prednisone intensol oral concentrate

2

MO

prednisone oral solution

2

MO

prednisone oral tablet

1

MO

prednisone oral tablets,dose pack

1

MO

SOLU-CORTEF (PF) INJECTION RECON
SOLN

3

B/D PA; MO

SOLU-CORTEF INJECTION RECON SOLN

3

B/D PA; MO

triamcinolone acetonide injection suspension 10
mg/ml

2

MO

triamcinolone acetonide injection suspension 40
mg/ml

2

veripred 20 oral solution

2

MO

2

MO

ANTITHYROID AGENTS
methimazole oral tablet 10 mg, 5 mg

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
56

Drug Name
propylthiouracil oral tablet

Drug Tier

Requirements/Limits

2

MO

acarbose oral tablet

2

MO

ACTOPLUS MET XR ORAL TABLET, ER
MULTIPHASE 24 HR 15-1,000 MG

4

ST; MO; QL (60 per 30 days)

ACTOPLUS MET XR ORAL TABLET, ER
MULTIPHASE 24 HR 30-1,000 MG

4

ST; MO; QL (30 per 30 days)

ALCOHOL PADS TOPICAL PADS,
MEDICATED

3

MO

BYDUREON SUBCUTANEOUS PEN
INJECTOR

3

MO

BYDUREON SUBCUTANEOUS
SUSPENSION,EXTENDED REL RECON

3

MO

BYETTA SUBCUTANEOUS PEN INJECTOR

3

MO

CYCLOSET ORAL TABLET

4

ST; MO

FARXIGA ORAL TABLET

3

MO

GAUZE PADS 2 X 2

3

MO

glimepiride oral tablet

1

MO

glipizide oral tablet

1

MO

glipizide oral tablet extended release 24hr

1

MO

glipizide-metformin oral tablet 2.5-250 mg

2

MO; QL (240 per 30 days)

glipizide-metformin oral tablet 2.5-500 mg, 5-500
mg

2

MO; QL (120 per 30 days)

GLUCAGEN HYPOKIT INJECTION RECON
SOLN

3

MO

GLUCAGON EMERGENCY KIT (HUMAN)
INJECTION KIT

3

MO

glyburide micronized oral tablet

2

ST; MO

glyburide oral tablet

2

ST; MO

glyburide-metformin oral tablet

2

ST; MO

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS
INSULIN PEN

3

MO

HUMULIN 70/30 SUBCUTANEOUS
SUSPENSION

3

MO

HUMULIN N KWIKPEN SUBCUTANEOUS
INSULIN PEN

3

MO

HUMULIN N SUBCUTANEOUS SUSPENSION

3

MO

HUMULIN R U-100 INJECTION SOLUTION

3

MO

DIABETES THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
57

Drug Name

Drug Tier

Requirements/Limits

HUMULIN R U-500 (CONC) KWIKPEN
SUBCUTANEOUS INSULIN PEN

3

MO

HUMULIN R U-500 (CONCENTRATED)
SUBCUTANEOUS SOLUTION

3

MO

INSULIN PEN NEEDLE

3

MO

INSULIN SYRINGE (DISP) U-100 0.3 ML, 1
ML, 1/2 ML

3

MO

JANUMET ORAL TABLET

3

MO; QL (60 per 30 days)

JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR

3

MO; QL (60 per 30 days)

JANUVIA ORAL TABLET

3

MO; QL (30 per 30 days)

JARDIANCE ORAL TABLET

3

MO

KOMBIGLYZE XR ORAL TABLET, ER
MULTIPHASE 24 HR

3

MO; QL (30 per 30 days)

LEVEMIR FLEXTOUCH SUBCUTANEOUS
INSULIN PEN

3

MO

LEVEMIR SUBCUTANEOUS SOLUTION

3

MO

metformin oral tablet

1

MO

metformin oral tablet extended release 24 hr

1

MO

metformin oral tablet extended release (osm) 24hr
1,000 mg

1

MO

metformin oral tablet,er gast.retention 24 hr

1

MO

nateglinide oral tablet

2

MO

NEEDLES, INSULIN DISP.,SAFETY

3

MO

NOVOFINE NEEDLE

3

MO

NOVOLIN 70/30 SUBCUTANEOUS
SUSPENSION

3

MO

NOVOLIN N SUBCUTANEOUS SUSPENSION

3

MO

NOVOLIN R INJECTION SOLUTION

3

MO

NOVOLOG FLEXPEN SUBCUTANEOUS
INSULIN PEN

3

MO

NOVOLOG MIX 70-30 FLEXPEN
SUBCUTANEOUS INSULIN PEN

3

MO

NOVOLOG MIX 70-30 SUBCUTANEOUS
SOLUTION

3

MO

NOVOLOG PENFILL SUBCUTANEOUS
CARTRIDGE

3

MO

NOVOLOG SUBCUTANEOUS SOLUTION

3

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
58

Drug Name

Drug Tier

Requirements/Limits

NOVOTWIST NEEDLE

3

MO

ONGLYZA ORAL TABLET

3

MO; QL (30 per 30 days)

pioglitazone oral tablet

2

MO

pioglitazone-glimepiride oral tablet

2

MO; QL (30 per 30 days)

pioglitazone-metformin oral tablet

2

MO; QL (90 per 30 days)

PROGLYCEM ORAL SUSPENSION

4

MO

repaglinide oral tablet 0.5 mg

2

MO; QL (930 per 30 days)

repaglinide oral tablet 1 mg

2

MO; QL (480 per 30 days)

repaglinide oral tablet 2 mg

2

MO; QL (240 per 30 days)

repaglinide-metformin oral tablet

2

MO

SYMLINPEN 120 SUBCUTANEOUS PEN
INJECTOR

3

MO

SYMLINPEN 60 SUBCUTANEOUS PEN
INJECTOR

3

MO

SYNJARDY ORAL TABLET

3

MO

SYNJARDY XR ORAL TABLET, IR - ER,
BIPHASIC 24HR

3

MO

tolazamide oral tablet

2

MO

tolbutamide oral tablet

1

MO

TRESIBA FLEXTOUCH U-100
SUBCUTANEOUS INSULIN PEN

3

MO

TRESIBA FLEXTOUCH U-200
SUBCUTANEOUS INSULIN PEN

3

MO

VICTOZA 2-PAK SUBCUTANEOUS PEN
INJECTOR

3

MO

VICTOZA 3-PAK SUBCUTANEOUS PEN
INJECTOR

3

MO

XIGDUO XR ORAL TABLET, IR - ER,
BIPHASIC 24HR

3

MO

ALDURAZYME INTRAVENOUS SOLUTION

5

B/D PA; MO

ANADROL-50 ORAL TABLET

4

PA; MO

ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 20.25 MG/1.25 GRAM
(1.62 %)

3

MO

ANDROGEL TRANSDERMAL GEL IN
PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62
% (40.5 MG/2.5 GRAM)

3

MO

MISCELLANEOUS HORMONES

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
59

Drug Name

Drug Tier

Requirements/Limits

ANDROID ORAL CAPSULE

4

MO

androxy oral tablet

3

MO

cabergoline oral tablet

2

MO; QL (20 per 30 days)

calcitonin (salmon) nasal spray,non-aerosol

2

MO

calcitriol intravenous solution 1 mcg/ml

2

B/D PA; MO

calcitriol oral capsule

2

B/D PA; MO

calcitriol oral solution

2

B/D PA; MO

CEREZYME INTRAVENOUS RECON SOLN
400 UNIT

5

B/D PA; MO

CHORIONIC GONADOTROPIN, HUMAN
INTRAMUSCULAR RECON SOLN

4

PA; MO

danazol oral capsule

2

MO

desmopressin injection solution

2

MO

desmopressin nasal aerosol,spray

2

MO

desmopressin nasal solution

2

desmopressin nasal spray,non-aerosol

2

MO

desmopressin oral tablet

2

MO

ELAPRASE INTRAVENOUS SOLUTION

5

B/D PA; MO

ELELYSO INTRAVENOUS RECON SOLN

5

B/D PA; MO

FABRAZYME INTRAVENOUS RECON SOLN

5

PA; MO

KORLYM ORAL TABLET

5

PA; MO

KUVAN ORAL TABLET,SOLUBLE

5

PA; MO

methyltestosterone oral capsule

2

MO

MIACALCIN INJECTION SOLUTION

3

B/D PA; MO

NAGLAZYME INTRAVENOUS SOLUTION

5

B/D PA; MO

NATPARA SUBCUTANEOUS CARTRIDGE

5

PA; MO

NOVAREL INTRAMUSCULAR RECON SOLN

4

PA; MO

oxandrolone oral tablet 10 mg

5

MO

oxandrolone oral tablet 2.5 mg

2

MO

pamidronate intravenous recon soln

2

B/D PA; MO

pamidronate intravenous solution

2

B/D PA; MO

paricalcitol oral capsule

2

B/D PA; MO

PREGNYL INTRAMUSCULAR RECON SOLN

4

PA; MO

SAMSCA ORAL TABLET 15 MG

5

PA; MO; QL (30 per 30 days); NEDS

SAMSCA ORAL TABLET 30 MG

5

PA; MO; QL (60 per 30 days); NEDS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
60

Drug Name

Drug Tier

Requirements/Limits

SENSIPAR ORAL TABLET 30 MG

3

MO

SENSIPAR ORAL TABLET 60 MG, 90 MG

5

MO

SOMAVERT SUBCUTANEOUS RECON SOLN

5

B/D PA; MO

SYNAREL NASAL SPRAY,NON-AEROSOL

3

MO

testosterone cypionate intramuscular oil

2

B/D PA; MO

testosterone enanthate intramuscular oil

2

B/D PA; MO

VPRIV INTRAVENOUS RECON SOLN

5

B/D PA; MO

ZAVESCA ORAL CAPSULE

5

MO

ZEMPLAR INTRAVENOUS SOLUTION

3

B/D PA; MO

zoledronic acid intravenous recon soln

2

B/D PA

zoledronic acid intravenous solution

2

B/D PA; MO

ZOMETA INTRAVENOUS PIGGYBACK

5

B/D PA; MO

LEVOTHYROXINE INTRAVENOUS RECON
SOLN 100 MCG

3

MO

levothyroxine oral tablet

1

MO

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

2

MO

liothyronine intravenous solution

2

MO

liothyronine oral tablet

2

MO

SYNTHROID ORAL TABLET

4

MO

unithroid oral tablet

1

MO

THYROID HORMONES

GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
atropine injection syringe 0.05 mg/ml, 0.1 mg/ml

2

dicyclomine oral capsule

2

MO

dicyclomine oral solution

2

MO

dicyclomine oral tablet

2

MO

glycopyrrolate injection solution

2

MO

glycopyrrolate oral tablet

2

MO

loperamide oral capsule

2

MO

methscopolamine oral tablet

2

MO

MISCELLANEOUS GASTROINTESTINAL AGENTS
alosetron oral tablet

5

PA; MO; QL (60 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
61

Drug Name

Drug Tier

Requirements/Limits

AMITIZA ORAL CAPSULE

3

MO; QL (60 per 30 days)

aprepitant oral capsule

4

B/D PA; MO

aprepitant oral capsule,dose pack

4

B/D PA; MO

APRISO ORAL CAPSULE,EXTENDED
RELEASE 24HR

3

MO

balsalazide oral capsule

2

MO

budesonide oral capsule,delayed,extend.release

5

MO

CANASA RECTAL SUPPOSITORY

3

MO

CHOLBAM ORAL CAPSULE

5

PA; MO

CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT

5

B/D PA; ST; MO

CIMZIA STARTER KIT SUBCUTANEOUS
SYRINGE KIT

5

ST; MO

CIMZIA SUBCUTANEOUS SYRINGE KIT

5

ST; MO

compro rectal suppository

2

MO

constulose oral solution

2

MO

CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC)

4

MO

cromolyn oral concentrate

2

MO

CYSTADANE ORAL POWDER

5

MO

DELZICOL ORAL CAPSULE (WITH DEL REL
TABLETS)

4

MO

DIPENTUM ORAL CAPSULE

4

MO

dronabinol oral capsule

4

B/D PA; MO

EMEND ORAL SUSPENSION FOR
RECONSTITUTION

4

B/D PA

enulose oral solution

2

MO

GATTEX 30-VIAL SUBCUTANEOUS KIT

5

PA; MO

GATTEX ONE-VIAL SUBCUTANEOUS KIT

5

PA; MO

gavilyte-c oral recon soln

2

MO

gavilyte-g oral recon soln

2

MO

gavilyte-n oral recon soln

2

MO

generlac oral solution

2

MO

granisetron (pf) intravenous solution

2

B/D PA; MO

granisetron hcl intravenous solution

2

B/D PA; MO

granisetron hcl oral tablet

2

B/D PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
62

Drug Name

Drug Tier

Requirements/Limits

hydrocortisone rectal enema

2

MO

hydrocortisone topical cream with perineal
applicator 1 %

2

hydrocortisone topical cream with perineal
applicator 2.5 %

2

MO

lactulose oral solution

2

MO

LIALDA ORAL TABLET,DELAYED RELEASE
(DR/EC)

3

MO

LINZESS ORAL CAPSULE 145 MCG, 290 MCG

3

MO; QL (30 per 30 days)

LINZESS ORAL CAPSULE 72 MCG

3

MO

meclizine oral tablet 12.5 mg, 25 mg

2

MO

mesalamine rectal enema

2

MO

mesalamine with cleansing wipe rectal enema kit

2

MO

metoclopramide hcl injection solution

2

B/D PA; MO

metoclopramide hcl injection syringe

2

B/D PA

metoclopramide hcl oral solution

2

MO

metoclopramide hcl oral tablet

1

MO

MOVANTIK ORAL TABLET

3

MO

MOVIPREP ORAL POWDER IN PACKET

3

MO

ondansetron hcl (pf) injection solution

2

B/D PA; MO

ondansetron hcl (pf) injection syringe

2

B/D PA; MO

ondansetron hcl intravenous solution

2

B/D PA; MO

ondansetron hcl oral solution

2

B/D PA; MO

ondansetron hcl oral tablet 24 mg

2

B/D PA

ondansetron hcl oral tablet 4 mg, 8 mg

2

B/D PA; MO

ondansetron oral tablet,disintegrating

2

B/D PA; MO

PANCREAZE ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT,
16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850
UNIT, 21,000-54,700- 83,900 UNIT, 4,20014,200- 24,600 UNIT

4

MO

peg 3350-electrolytes oral recon soln 236-22.746.74 -5.86 gram

1

MO

peg 3350-electrolytes oral recon soln 240-22.726.72 -5.84 gram

1

peg-electrolyte oral recon soln

1

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
63

Drug Name

Drug Tier

Requirements/Limits

PENTASA ORAL CAPSULE, EXTENDED
RELEASE

4

MO

polyethylene glycol 3350 oral powder

2

MO

polyethylene glycol 3350 oral powder in packet

2

MO

prochlorperazine edisylate injection solution 10
mg/2 ml (5 mg/ml)

2

MO

prochlorperazine maleate oral tablet

1

MO

prochlorperazine rectal suppository

2

MO

procto-pak topical cream with perineal applicator

2

MO

proctosol hc topical cream with perineal
applicator

2

MO

proctozone-hc topical cream with perineal
applicator

2

MO

RELISTOR SUBCUTANEOUS SOLUTION

5

MO

RELISTOR SUBCUTANEOUS SYRINGE

5

MO

REMICADE INTRAVENOUS RECON SOLN

5

PA; MO

SANCUSO TRANSDERMAL PATCH WEEKLY

3

B/D PA; MO; QL (2 per 15 days)

sulfasalazine oral tablet

2

MO

sulfasalazine oral tablet,delayed release (dr/ec)

2

MO

TRANSDERM-SCOP TRANSDERMAL PATCH
3 DAY

4

MO; QL (10 per 30 days)

trilyte with flavor packets oral recon soln

2

MO

ursodiol oral capsule

2

MO

ursodiol oral tablet

2

MO

VARUBI ORAL TABLET

4

B/D PA; MO

ZENPEP ORAL CAPSULE,DELAYED
RELEASE(DR/EC)

3

MO

amoxicil-clarithromy-lansopraz oral combo pack

2

MO

CARAFATE ORAL SUSPENSION

3

MO

cimetidine hcl oral solution

2

MO

cimetidine oral tablet

2

MO

DEXILANT ORAL CAPSULE,BIPHASE
DELAYED RELEASE

3

MO

esomeprazole sodium intravenous recon soln

2

B/D PA

famotidine (pf) intravenous solution

2

B/D PA; MO

ULCER THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
64

Drug Name

Drug Tier

Requirements/Limits

famotidine (pf)-nacl (iso-osm) intravenous
piggyback

2

B/D PA; MO

famotidine intravenous solution

2

B/D PA; MO

famotidine oral suspension

2

MO

famotidine oral tablet 20 mg, 40 mg

1

MO

lansoprazole oral capsule,delayed release(dr/ec)

2

MO

misoprostol oral tablet

2

MO

nizatidine oral capsule

2

MO

nizatidine oral solution

2

MO

omeprazole oral capsule,delayed release(dr/ec)

2

MO

pantoprazole oral tablet,delayed release (dr/ec)

2

MO

ranitidine hcl injection solution

2

B/D PA; MO

ranitidine hcl oral capsule

2

MO

ranitidine hcl oral syrup

2

MO

ranitidine hcl oral tablet 150 mg, 300 mg

2

MO

sucralfate oral tablet

2

MO

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ACTIMMUNE SUBCUTANEOUS SOLUTION

5

PA; MO

ARCALYST SUBCUTANEOUS RECON SOLN

5

PA; MO

AVONEX (WITH ALBUMIN)
INTRAMUSCULAR KIT

5

PA; MO; QL (4 per 28 days)

AVONEX INTRAMUSCULAR PEN INJECTOR
KIT

5

PA; MO; QL (4 per 28 days)

AVONEX INTRAMUSCULAR SYRINGE KIT

5

PA; MO; QL (4 per 28 days)

EGRIFTA SUBCUTANEOUS RECON SOLN 1
MG

5

PA; MO

EGRIFTA SUBCUTANEOUS RECON SOLN 2
MG

5

PA

EXTAVIA SUBCUTANEOUS KIT

5

PA; MO; QL (15 per 30 days)

EXTAVIA SUBCUTANEOUS RECON SOLN

5

PA; QL (15 per 30 days)

ILARIS (PF) SUBCUTANEOUS RECON SOLN

5

PA; MO; LA

INTRON A INJECTION RECON SOLN 10
MILLION UNIT (1 ML), 50 MILLION UNIT (1
ML)

5

B/D PA; MO

INTRON A INJECTION RECON SOLN 18
MILLION UNIT (1 ML)

4

B/D PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
65

Drug Name

Drug Tier

Requirements/Limits

INTRON A INJECTION SOLUTION

5

B/D PA; MO

LEUKINE INJECTION RECON SOLN

5

PA; MO

MOZOBIL SUBCUTANEOUS SOLUTION

5

B/D PA; MO

NEUPOGEN INJECTION SOLUTION

5

PA; MO

NEUPOGEN INJECTION SYRINGE

5

PA; MO

NORDITROPIN FLEXPRO SUBCUTANEOUS
PEN INJECTOR

5

PA; MO

PEGASYS SUBCUTANEOUS SOLUTION

5

PA; MO; QL (4 per 28 days)

PEGASYS SUBCUTANEOUS SYRINGE

5

PA; MO; QL (2 per 28 days)

PEGINTRON REDIPEN SUBCUTANEOUS
PEN INJECTOR KIT 120 MCG/0.5 ML

5

PA; QL (5 per 30 days)

PEGINTRON SUBCUTANEOUS KIT 50
MCG/0.5 ML

5

PA; MO; QL (5 per 30 days)

PROCRIT INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML,
3,000 UNIT/ML, 4,000 UNIT/ML

3

PA; MO; QL (24 per 30 days)

PROCRIT INJECTION SOLUTION 20,000
UNIT/ML

5

PA; MO; QL (24 per 30 days)

PROCRIT INJECTION SOLUTION 40,000
UNIT/ML

5

PA; MO; QL (6 per 30 days)

PROLEUKIN INTRAVENOUS RECON SOLN

5

B/D PA; MO

REBIF (WITH ALBUMIN) SUBCUTANEOUS
SYRINGE

5

PA; MO; QL (6 per 28 days)

REBIF REBIDOSE SUBCUTANEOUS PEN
INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML

5

PA; MO; QL (6 per 28 days)

REBIF REBIDOSE SUBCUTANEOUS PEN
INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)

5

PA; MO; QL (4.2 per 180 days)

REBIF TITRATION PACK SUBCUTANEOUS
SYRINGE

5

PA; MO; QL (6 per 28 days)

SYLATRON SUBCUTANEOUS KIT

5

PA; MO

VACCINES / MISCELLANEOUS IMMUNOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON
SOLN

3

MO

ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SUSPENSION

3

MO

ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE

3

MO

BCG VACCINE, LIVE (PF) PERCUTANEOUS
SUSPENSION FOR RECONSTITUTION

4

B/D PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
66

Drug Name

Drug Tier

Requirements/Limits

BEXSERO INTRAMUSCULAR SYRINGE

4

MO

BOOSTRIX TDAP INTRAMUSCULAR
SUSPENSION

3

MO

BOOSTRIX TDAP INTRAMUSCULAR
SYRINGE

3

MO

DAPTACEL (DTAP PEDIATRIC) (PF)
INTRAMUSCULAR SUSPENSION

3

MO

ENGERIX-B (PF) INTRAMUSCULAR
SUSPENSION

3

B/D PA; MO

ENGERIX-B (PF) INTRAMUSCULAR
SYRINGE

3

B/D PA; MO

ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SUSPENSION

3

B/D PA; MO

ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SYRINGE

3

B/D PA; MO

fomepizole intravenous solution

2

B/D PA; MO

GAMMAGARD LIQUID INJECTION
SOLUTION

5

PA; MO

GAMMAGARD S-D (IGA < 1 MCG/ML)
INTRAVENOUS RECON SOLN

5

B/D PA; MO

GAMUNEX-C INJECTION SOLUTION

3

PA; MO

GARDASIL (PF) INTRAMUSCULAR
SUSPENSION

3

MO

GARDASIL 9 (PF) INTRAMUSCULAR
SUSPENSION

3

MO

GARDASIL 9 (PF) INTRAMUSCULAR
SYRINGE

3

MO

HAVRIX (PF) INTRAMUSCULAR
SUSPENSION

3

MO

HAVRIX (PF) INTRAMUSCULAR SYRINGE
1,440 ELISA UNIT/ML

3

MO

HAVRIX (PF) INTRAMUSCULAR SYRINGE
720 ELISA UNIT/0.5 ML

3

HIBERIX (PF) INTRAMUSCULAR RECON
SOLN

3

HYPERRAB S/D (PF) INTRAMUSCULAR
SOLUTION

4

IMOGAM RABIES-HT (PF)
INTRAMUSCULAR SOLUTION

4

MO

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
67

Drug Name

Drug Tier

Requirements/Limits

IMOVAX RABIES VACCINE (PF)
INTRAMUSCULAR RECON SOLN

4

MO

INFANRIX (DTAP) (PF) INTRAMUSCULAR
SUSPENSION

3

MO

INFANRIX (DTAP) (PF) INTRAMUSCULAR
SYRINGE

3

MO

IPOL INJECTION SUSPENSION

3

MO

IXIARO (PF) INTRAMUSCULAR SYRINGE

3

MO

KINRIX (PF) INTRAMUSCULAR
SUSPENSION

3

KINRIX (PF) INTRAMUSCULAR SYRINGE

3

MO

MENACTRA (PF) INTRAMUSCULAR
SOLUTION

3

MO

MENHIBRIX (PF) INTRAMUSCULAR RECON
SOLN

3

MENOMUNE - A/C/Y/W-135 (PF)
SUBCUTANEOUS RECON SOLN

3

MENOMUNE - A/C/Y/W-135
SUBCUTANEOUS RECON SOLN

3

MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT

3

MO

M-M-R II (PF) SUBCUTANEOUS RECON
SOLN

3

MO

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

3

MO

PEDVAX HIB (PF) INTRAMUSCULAR
SOLUTION

3

MO

PENTACEL ACTHIB COMPONENT (PF)
INTRAMUSCULAR RECON SOLN

3

PROQUAD (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION

3

QUADRACEL (PF) INTRAMUSCULAR
SUSPENSION

3

RABAVERT (PF) INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION

3

MO

RECOMBIVAX HB (PF) INTRAMUSCULAR
SUSPENSION

3

B/D PA; MO

RECOMBIVAX HB (PF) INTRAMUSCULAR
SYRINGE 10 MCG/ML

3

B/D PA; MO

RECOMBIVAX HB (PF) INTRAMUSCULAR
SYRINGE 5 MCG/0.5 ML

3

B/D PA

MO

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
68

Drug Name

Drug Tier

Requirements/Limits

ROTARIX ORAL SUSPENSION FOR
RECONSTITUTION

4

ROTATEQ VACCINE ORAL SOLUTION

3

STAMARIL (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION

3

TENIVAC (PF) INTRAMUSCULAR
SUSPENSION

4

B/D PA; MO

TENIVAC (PF) INTRAMUSCULAR SYRINGE

4

MO

TETANUS,DIPHTHERIA TOX PED(PF)
INTRAMUSCULAR SUSPENSION

4

MO

TETANUS-DIPHTHERIA TOXOIDS-TD
INTRAMUSCULAR SUSPENSION

4

B/D PA; MO

TRUMENBA INTRAMUSCULAR SYRINGE

3

MO

TWINRIX (PF) INTRAMUSCULAR
SUSPENSION

3

B/D PA; MO

TWINRIX (PF) INTRAMUSCULAR SYRINGE

3

B/D PA; MO

TYPHIM VI INTRAMUSCULAR SOLUTION

3

TYPHIM VI INTRAMUSCULAR SYRINGE

3

MO

VAQTA (PF) INTRAMUSCULAR
SUSPENSION

3

MO

VAQTA (PF) INTRAMUSCULAR SYRINGE

3

MO

VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION

3

MO

VARIZIG INTRAMUSCULAR SOLUTION

4

MO

YF-VAX (PF) SUBCUTANEOUS SUSPENSION
FOR RECONSTITUTION

3

MO

ZOSTAVAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION

3

MO; QL (1 per 365 days)

MO

MUSCULOSKELETAL / RHEUMATOLOGY
GOUT THERAPY
allopurinol oral tablet

1

MO

allopurinol sodium intravenous recon soln

2

B/D PA

COLCRYS ORAL TABLET

3

MO

probenecid oral tablet

2

MO

probenecid-colchicine oral tablet

2

MO

ULORIC ORAL TABLET

3

MO

OSTEOPOROSIS THERAPY
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
69

Drug Name

Drug Tier

Requirements/Limits

alendronate oral solution

1

MO; QL (375 per 30 days)

alendronate oral tablet 10 mg, 5 mg

1

MO; QL (30 per 30 days)

alendronate oral tablet 35 mg, 70 mg

1

MO; QL (5 per 30 days)

FORTEO SUBCUTANEOUS PEN INJECTOR

5

MO; QL (2.4 per 28 days)

ibandronate oral tablet

2

MO; QL (1 per 30 days)

PROLIA SUBCUTANEOUS SYRINGE

4

PA; MO

raloxifene oral tablet

2

MO

risedronate oral tablet

2

MO

risedronate oral tablet,delayed release (dr/ec)

2

MO

ACTEMRA INTRAVENOUS SOLUTION

5

B/D PA; ST; MO

BENLYSTA INTRAVENOUS RECON SOLN

4

B/D PA; MO

CUPRIMINE ORAL CAPSULE

5

MO

DEPEN TITRATABS ORAL TABLET

4

PA; MO

ENBREL SUBCUTANEOUS RECON SOLN

5

MO; QL (8 per 28 days)

ENBREL SUBCUTANEOUS SYRINGE 25
MG/0.5ML (0.51)

5

MO; QL (4 per 28 days)

ENBREL SUBCUTANEOUS SYRINGE 50
MG/ML (0.98 ML)

5

MO; QL (8 per 28 days)

ENBREL SURECLICK SUBCUTANEOUS PEN
INJECTOR

5

MO; QL (8 per 28 days)

HUMIRA PEDIATRIC CROHN'S START
SUBCUTANEOUS SYRINGE KIT 40 MG/0.8
ML

5

MO; QL (3 per 28 days)

HUMIRA PEDIATRIC CROHN'S START
SUBCUTANEOUS SYRINGE KIT 40 MG/0.8
ML (6 PACK)

5

MO; QL (6 per 28 days)

HUMIRA PEN CROHN'S-UC-HS START
SUBCUTANEOUS INJECTOR KIT

5

MO; QL (6 per 180 days)

HUMIRA PEN PSORIASIS-UVEITIS
SUBCUTANEOUS INJECTOR KIT

5

MO; QL (6 per 180 days)

HUMIRA PEN SUBCUTANEOUS INJECTOR
KIT

5

MO; QL (4 per 28 days)

HUMIRA SUBCUTANEOUS SYRINGE KIT 10
MG/0.2 ML

5

MO; QL (2 per 28 days)

HUMIRA SUBCUTANEOUS SYRINGE KIT 20
MG/0.4 ML, 40 MG/0.8 ML

5

MO; QL (4 per 28 days)

leflunomide oral tablet

2

MO; QL (30 per 30 days)

OTHER RHEUMATOLOGICALS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
70

Drug Name

Drug Tier

Requirements/Limits

SAVELLA ORAL TABLET

3

MO; QL (60 per 30 days)

SAVELLA ORAL TABLETS,DOSE PACK

3

MO; QL (60 per 30 days)

XELJANZ ORAL TABLET

5

ST; MO

XELJANZ XR ORAL TABLET EXTENDED
RELEASE 24 HR

5

ST; MO

camila oral tablet

2

MO

COMBIPATCH TRANSDERMAL PATCH
SEMIWEEKLY

4

MO

CRINONE VAGINAL GEL

4

PA; MO

DELESTROGEN INTRAMUSCULAR OIL 10
MG/ML

4

MO

DEPO-PROVERA INTRAMUSCULAR
SOLUTION

3

B/D PA; MO

DEPO-SUBQ PROVERA 104
SUBCUTANEOUS SYRINGE

4

MO

errin oral tablet

2

MO

ESTRACE VAGINAL CREAM

4

MO

estradiol oral tablet

2

PA; MO

estradiol transdermal patch semiweekly

2

MO

estradiol transdermal patch weekly

2

MO

estradiol valerate intramuscular oil 20 mg/ml, 40
mg/ml

2

MO

heather oral tablet

2

MO

hydroxyprogesterone caproate intramuscular oil

4

PA; MO

jencycla oral tablet

2

MO

JINTELI ORAL TABLET

4

MO

jolivette oral tablet

2

MO

lyza oral tablet

2

MO

medroxyprogesterone intramuscular suspension

2

MO; QL (1 per 90 days)

medroxyprogesterone intramuscular syringe

2

MO; QL (1 per 90 days)

medroxyprogesterone oral tablet

2

MO

norethindrone (contraceptive) oral tablet

2

MO

norethindrone acetate oral tablet

2

MO

PREMARIN INJECTION RECON SOLN

4

B/D PA; MO

OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
71

Drug Name

Drug Tier

Requirements/Limits

PREMARIN VAGINAL CREAM

4

MO

progesterone micronized oral capsule

2

MO

CLEOCIN VAGINAL SUPPOSITORY

4

MO

clindamycin phosphate vaginal cream

2

MO

metronidazole vaginal gel

2

MO

miconazole-3 vaginal suppository

2

MO; QL (3 per 3 days)

NUVARING VAGINAL RING

4

MO

terconazole vaginal cream

2

MO

terconazole vaginal suppository

2

MO; QL (3 per 3 days)

tranexamic acid oral tablet

2

MO

vandazole vaginal gel

2

MO

altavera (28) oral tablet

2

MO

alyacen 1/35 (28) oral tablet

2

MO

alyacen 7/7/7 (28) oral tablet

2

MO

amethia lo oral tablets,dose pack,3 month

2

MO

amethia oral tablets,dose pack,3 month

2

MO

amethyst oral tablet

2

MO

apri oral tablet

2

MO

aranelle (28) oral tablet

2

MO

ashlyna oral tablets,dose pack,3 month

2

MO

aubra oral tablet

2

MO

aviane oral tablet

2

MO

azurette (28) oral tablet

2

MO

balziva (28) oral tablet

2

MO

blisovi 24 fe oral tablet

2

MO

blisovi fe 1.5/30 (28) oral tablet

2

MO

blisovi fe 1/20 (28) oral tablet

2

MO

briellyn oral tablet

2

MO

camrese lo oral tablets,dose pack,3 month

2

MO

camrese oral tablets,dose pack,3 month

2

MO

caziant (28) oral tablet

2

MO

chateal oral tablet

2

MO

MISCELLANEOUS OB/GYN

ORAL CONTRACEPTIVES / RELATED AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
72

Drug Name

Drug Tier

Requirements/Limits

cryselle (28) oral tablet

2

MO

cyclafem 1/35 (28) oral tablet

2

MO

cyclafem 7/7/7 (28) oral tablet

2

MO

dasetta 1/35 (28) oral tablet

2

MO

dasetta 7/7/7 (28) oral tablet

2

MO

daysee oral tablets,dose pack,3 month

2

MO

desog-e.estradiol/e.estradiol oral tablet

2

MO

drospirenone-e.estradiol-lm.fa oral tablet

2

MO

drospirenone-ethinyl estradiol oral tablet

2

MO

elinest oral tablet

2

MO

ELLA ORAL TABLET

3

emoquette oral tablet

2

MO

enpresse oral tablet

2

MO

enskyce oral tablet

2

MO

estarylla oral tablet

2

MO

falmina (28) oral tablet

2

MO

gianvi (28) oral tablet

2

MO

introvale oral tablets,dose pack,3 month

2

MO

jolessa oral tablets,dose pack,3 month

2

MO

junel 1.5/30 (21) oral tablet

2

MO

junel 1/20 (21) oral tablet

2

MO

junel fe 1.5/30 (28) oral tablet

2

MO

junel fe 1/20 (28) oral tablet

2

MO

junel fe 24 oral tablet

2

MO

kariva (28) oral tablet

2

MO

kelnor 1/35 (28) oral tablet

2

MO

kimidess (28) oral tablet

2

MO

kurvelo oral tablet

2

MO

l norgest/e.estradiol-e.estrad oral tablets,dose
pack,3 month

2

MO

larissia oral tablet

2

MO

layolis fe oral tablet,chewable

2

MO

lessina oral tablet

2

MO

levonest (28) oral tablet

2

MO

levonorgestrel-ethinyl estrad oral tablet

2

MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
73

Drug Name

Drug Tier

Requirements/Limits

levonorgestrel-ethinyl estrad oral tablets,dose
pack,3 month

2

MO

levonorg-eth estrad triphasic oral tablet

2

MO

levora-28 oral tablet

2

MO

loryna (28) oral tablet

2

MO

low-ogestrel (28) oral tablet

2

MO

lutera (28) oral tablet

2

MO

marlissa oral tablet

2

MO

microgestin 1.5/30 (21) oral tablet

2

MO

microgestin 1/20 (21) oral tablet

2

MO

microgestin fe 1.5/30 (28) oral tablet

2

MO

microgestin fe 1/20 (28) oral tablet

2

MO

mono-linyah oral tablet

2

MO

mononessa (28) oral tablet

2

MO

my way oral tablet

2

myzilra oral tablet

2

MO

necon 0.5/35 (28) oral tablet

2

MO

necon 1/50 (28) oral tablet

2

MO

necon 10/11 (28) oral tablet

2

necon 7/7/7 (28) oral tablet

2

next choice one dose oral tablet

2

nikki (28) oral tablet

2

noreth-ethinyl estradiol-iron oral tablet,chewable
0.4mg-35mcg(21) and 75 mg (7)

2

noreth-ethinyl estradiol-iron oral tablet,chewable
0.8mg-25mcg(24) and 75 mg (4)

2

MO

norgestimate-ethinyl estradiol oral tablet

2

MO

nortrel 0.5/35 (28) oral tablet

2

MO

nortrel 1/35 (21) oral tablet

2

MO

nortrel 1/35 (28) oral tablet

2

MO

nortrel 7/7/7 (28) oral tablet

2

MO

ocella oral tablet

2

MO

ogestrel (28) oral tablet

2

MO

orsythia oral tablet

2

MO

philith oral tablet

2

MO

MO
MO

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
74

Drug Name

Drug Tier

Requirements/Limits

pimtrea (28) oral tablet

2

MO

pirmella oral tablet

2

MO

portia oral tablet

2

MO

previfem oral tablet

2

MO

quasense oral tablets,dose pack,3 month

2

MO

rajani oral tablet

2

MO

reclipsen (28) oral tablet

2

MO

sprintec (28) oral tablet

2

MO

sronyx oral tablet

2

MO

syeda oral tablet

2

MO

tilia fe oral tablet

2

MO

tri-estarylla oral tablet

2

MO

tri-legest fe oral tablet

2

MO

tri-linyah oral tablet

2

MO

trinessa (28) oral tablet

2

MO

tri-previfem (28) oral tablet

2

MO

tri-sprintec (28) oral tablet

2

MO

trivora (28) oral tablet

2

MO

velivet triphasic regimen (28) oral tablet

2

MO

vestura (28) oral tablet

2

MO

viorele (28) oral tablet

2

MO

wera (28) oral tablet

2

MO

wymzya fe oral tablet,chewable

2

MO

zarah oral tablet

2

MO

zenchent (28) oral tablet

2

MO

zenchent fe oral tablet,chewable

2

MO

zovia 1/35e (28) oral tablet

2

MO

zovia 1/50e (28) oral tablet

2

MO

2

B/D PA; MO

3

MO

OXYTOCICS
METHYLERGONOVINE INJECTION
SOLUTION

OPHTHALMOLOGY
ANTIBIOTICS
AZASITE OPHTHALMIC DROPS

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75

Drug Name

Drug Tier

Requirements/Limits

bacitracin ophthalmic ointment

2

MO

bacitracin-polymyxin b ophthalmic ointment

2

MO

CILOXAN OPHTHALMIC OINTMENT

4

MO

ciprofloxacin hcl ophthalmic drops

2

MO

erythromycin ophthalmic ointment

2

MO

gatifloxacin ophthalmic drops

2

MO

gentak ophthalmic ointment

1

MO

gentamicin ophthalmic drops

1

MO

gentamicin ophthalmic ointment

2

MO

levofloxacin ophthalmic drops

2

MO

moxifloxacin ophthalmic drops

2

MO

NATACYN OPHTHALMIC
DROPS,SUSPENSION

3

MO

neomycin-bacitracin-polymyxin ophthalmic
ointment

2

MO

neomycin-polymyxin-gramicidin ophthalmic drops

2

MO

neo-polycin ophthalmic ointment

2

MO

ofloxacin ophthalmic drops

2

MO

polycin ophthalmic ointment

2

MO

polymyxin b sulf-trimethoprim ophthalmic drops

1

MO

tobramycin ophthalmic drops

1

MO

TOBREX OPHTHALMIC OINTMENT

3

MO

VIGAMOX OPHTHALMIC DROPS

3

MO

trifluridine ophthalmic drops

2

MO

ZIRGAN OPHTHALMIC GEL

4

MO

betaxolol ophthalmic drops

2

MO

BETIMOL OPHTHALMIC DROPS

4

MO

BETOPTIC S OPHTHALMIC
DROPS,SUSPENSION

3

MO

carteolol ophthalmic drops

1

MO

levobunolol ophthalmic drops 0.5 %

1

MO

metipranolol ophthalmic drops

2

timolol maleate ophthalmic drops

1

ANTIVIRALS

BETA-BLOCKERS

MO

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76

Drug Name
timolol maleate ophthalmic gel forming solution

Drug Tier

Requirements/Limits

2

MO

3

MO

2

MO

azelastine ophthalmic drops

2

MO

cromolyn ophthalmic drops

2

MO

CYSTARAN OPHTHALMIC DROPS

4

MO

epinastine ophthalmic drops

2

MO

LASTACAFT OPHTHALMIC DROPS

3

MO

olopatadine ophthalmic drops

2

MO

PATADAY OPHTHALMIC DROPS

4

ST; MO

PAZEO OPHTHALMIC DROPS

3

MO

RESTASIS MULTIDOSE OPHTHALMIC
DROPS

3

MO; QL (11 per 30 days)

RESTASIS OPHTHALMIC DROPPERETTE

3

MO; QL (60 per 30 days)

CHOLINESTERASE INHIBITOR MIOTICS
PHOSPHOLINE IODIDE OPHTHALMIC
DROPS

DIRECT ACTING MIOTICS
pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 %

MISCELLANEOUS OPHTHALMOLOGICS

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
bromfenac ophthalmic drops

2

MO

diclofenac sodium ophthalmic drops

2

MO

flurbiprofen sodium ophthalmic drops

2

MO

ILEVRO OPHTHALMIC DROPS,SUSPENSION

3

MO

ketorolac ophthalmic drops

2

MO

acetazolamide oral capsule, extended release

2

MO

acetazolamide oral tablet

2

MO

acetazolamide sodium injection recon soln

2

MO

methazolamide oral tablet

2

MO

AZOPT OPHTHALMIC DROPS,SUSPENSION

3

MO

COMBIGAN OPHTHALMIC DROPS

3

MO

dorzolamide ophthalmic drops

2

MO

dorzolamide-timolol ophthalmic drops

2

MO

latanoprost ophthalmic drops

2

MO

ORAL DRUGS FOR GLAUCOMA

OTHER GLAUCOMA DRUGS

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77

Drug Name

Drug Tier

Requirements/Limits

LUMIGAN OPHTHALMIC DROPS 0.01 %

3

MO; QL (2.5 per 30 days)

SIMBRINZA OPHTHALMIC
DROPS,SUSPENSION

3

MO

TRAVATAN Z OPHTHALMIC DROPS

3

MO; QL (2.5 per 30 days)

neomycin-bacitracin-poly-hc ophthalmic ointment

2

MO

neomycin-polymyxin b-dexameth ophthalmic
drops,suspension

1

MO

neomycin-polymyxin b-dexameth ophthalmic
ointment

1

MO

neomycin-polymyxin-hc ophthalmic
drops,suspension

2

MO

neo-polycin hc ophthalmic ointment

2

MO

TOBRADEX ST OPHTHALMIC
DROPS,SUSPENSION

3

MO

tobramycin-dexamethasone ophthalmic
drops,suspension

2

MO

dexamethasone sodium phosphate ophthalmic
drops

2

MO

DUREZOL OPHTHALMIC DROPS

3

MO

fluorometholone ophthalmic drops,suspension

2

MO

FML S.O.P. OPHTHALMIC OINTMENT

3

MO

prednisolone acetate ophthalmic drops,suspension

2

MO

prednisolone sodium phosphate ophthalmic drops

2

MO

BLEPHAMIDE S.O.P. OPHTHALMIC
OINTMENT

3

MO

sulfacetamide-prednisolone ophthalmic drops

2

MO

sulfacetamide sodium ophthalmic drops

1

MO

sulfacetamide sodium ophthalmic ointment

2

MO

ALPHAGAN P OPHTHALMIC DROPS 0.1 %

3

MO

apraclonidine ophthalmic drops

2

MO

brimonidine ophthalmic drops

2

MO

STEROID-ANTIBIOTIC COMBINATIONS

STEROIDS

STEROID-SULFONAMIDE COMBINATIONS

SULFONAMIDES

SYMPATHOMIMETICS

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78

Drug Name

Drug Tier

Requirements/Limits

RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC AGENTS
cetirizine oral solution 1 mg/ml

2

MO

clemastine oral tablet 2.68 mg

2

PA; MO

cyproheptadine oral syrup

2

PA; MO

cyproheptadine oral tablet

2

PA; MO

desloratadine oral tablet

2

MO

desloratadine oral tablet,disintegrating

2

MO

diphenhydramine hcl injection solution 50 mg/ml

2

B/D PA; MO

diphenhydramine hcl injection syringe

2

B/D PA; MO

EPINEPHRINE INJECTION AUTO-INJECTOR
0.15 MG/0.3 ML, 0.3 MG/0.3 ML

3

MO; QL (4 per 2 days)

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

3

MO; QL (4 per 2 days)

EPIPEN JR 2-PAK INJECTION AUTOINJECTOR

3

MO; QL (4 per 2 days)

hydroxyzine hcl intramuscular solution

2

B/D PA; MO

hydroxyzine hcl oral solution 10 mg/5 ml

4

MO

hydroxyzine hcl oral tablet

4

MO

levocetirizine oral solution

2

MO

levocetirizine oral tablet

2

MO; QL (30 per 30 days)

promethazine oral tablet

2

PA; MO

acetylcysteine solution

2

B/D PA; MO

ADCIRCA ORAL TABLET

5

PA; MO; QL (60 per 30 days)

ADEMPAS ORAL TABLET

5

PA; MO; LA

ADVAIR DISKUS INHALATION BLISTER
WITH DEVICE

3

MO; QL (60 per 30 days)

ADVAIR HFA AEROSOL INHALER

3

MO; QL (24 per 30 days)

albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3
ml (0.083 %)

2

B/D PA; MO; QL (360 per 30 days)

albuterol sulfate inhalation solution for
nebulization 2.5 mg/0.5 ml, 5 mg/ml

2

B/D PA; MO; QL (60 per 30 days)

albuterol sulfate oral syrup

2

MO

albuterol sulfate oral tablet

2

MO

albuterol sulfate oral tablet extended release 12 hr

2

MO

PULMONARY AGENTS

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79

Drug Name

Drug Tier

Requirements/Limits

ANORO ELLIPTA INHALATION BLISTER
WITH DEVICE

3

MO

ARNUITY ELLIPTA INHALATION BLISTER
WITH DEVICE

3

MO

ASMANEX HFA AEROSOL INHALER

3

MO; QL (26 per 30 days)

ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (30 DOSES), 220 MCG (120 DOSES), 220
MCG (30 DOSES), 220 MCG (60 DOSES)

3

MO; QL (2 per 30 days)

ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED 110
MCG (7 DOSES), 220 MCG (14 DOSES)

3

QL (2 per 30 days)

ATROVENT HFA AEROSOL INHALER

3

MO; QL (26 per 30 days)

BREO ELLIPTA INHALATION BLISTER
WITH DEVICE

3

MO

budesonide inhalation suspension for nebulization
0.25 mg/2 ml, 0.5 mg/2 ml

2

B/D PA; MO; QL (120 per 30 days)

budesonide inhalation suspension for nebulization
1 mg/2 ml

2

B/D PA; MO

budesonide nasal spray,non-aerosol

2

MO

CINRYZE INTRAVENOUS RECON SOLN

5

PA; MO

COMBIVENT RESPIMAT INHALATION MIST

3

MO; QL (8 per 30 days)

cromolyn inhalation solution for nebulization

2

B/D PA; MO; QL (240 per 30 days)

DALIRESP ORAL TABLET

4

MO

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML

3

MO

ESBRIET ORAL CAPSULE

5

PA; MO

ESBRIET ORAL TABLET

5

PA; MO

FIRAZYR SUBCUTANEOUS SYRINGE

5

PA; MO

FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION, 50
MCG/ACTUATION

3

MO; QL (120 per 30 days)

FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 250 MCG/ACTUATION

3

MO; QL (300 per 30 days)

FLOVENT HFA AEROSOL INHALER 110
MCG/ACTUATION

3

MO; QL (12 per 30 days)

FLOVENT HFA AEROSOL INHALER 220
MCG/ACTUATION

3

MO; QL (36 per 30 days)

FLOVENT HFA AEROSOL INHALER 44
MCG/ACTUATION

3

MO; QL (21 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
80

Drug Name

Drug Tier

Requirements/Limits

flunisolide nasal spray,non-aerosol 25 mcg (0.025
%)

2

MO; QL (50 per 30 days)

fluticasone nasal spray,suspension

2

MO; QL (16 per 30 days)

ipratropium bromide inhalation solution

2

B/D PA; MO; QL (315 per 30 days)

ipratropium-albuterol inhalation solution for
nebulization

2

B/D PA; MO; QL (540 per 30 days)

KALYDECO ORAL GRANULES IN PACKET

5

PA; MO; QL (60 per 30 days)

KALYDECO ORAL TABLET

5

PA; MO; QL (60 per 30 days)

LETAIRIS ORAL TABLET

5

PA; MO; QL (30 per 30 days)

levalbuterol hcl inhalation solution for
nebulization 0.31 mg/3 ml, 0.63 mg/3 ml

2

B/D PA; MO

levalbuterol hcl inhalation solution for
nebulization 1.25 mg/0.5 ml, 1.25 mg/3 ml

2

B/D PA; MO; QL (90 per 30 days)

metaproterenol oral syrup

2

MO

metaproterenol oral tablet

2

MO

mometasone nasal spray,non-aerosol

2

MO; QL (51 per 30 days)

montelukast oral granules in packet

2

MO

montelukast oral tablet

2

MO

montelukast oral tablet,chewable

2

MO

NASONEX NASAL SPRAY,NON-AEROSOL

4

ST; MO; QL (51 per 30 days)

OFEV ORAL CAPSULE

5

PA; MO; QL (60 per 30 days)

OPSUMIT ORAL TABLET

5

PA; MO; LA

ORKAMBI ORAL TABLET

5

PA; MO

PERFOROMIST INHALATION SOLUTION
FOR NEBULIZATION

4

B/D PA; MO; QL (120 per 30 days)

PROAIR HFA AEROSOL INHALER

3

MO; QL (18 per 30 days)

PROAIR RESPICLICK INHALATION
AEROSOL POWDR BREATH ACTIVATED

3

MO

PULMOZYME INHALATION SOLUTION

5

B/D PA; MO

SEREVENT DISKUS INHALATION BLISTER
WITH DEVICE

3

MO; QL (120 per 30 days)

sildenafil oral tablet

2

PA; MO; QL (90 per 30 days)

SYMBICORT HFA AEROSOL INHALER

3

MO; QL (20 per 30 days)

terbutaline oral tablet

2

MO

terbutaline subcutaneous solution

2

MO

theophylline oral elixir

2

theophylline oral solution
2
MO
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81

Drug Name

Drug Tier

Requirements/Limits

theophylline oral tablet extended release 12 hr

2

MO

theophylline oral tablet extended release 24 hr

2

MO

triamcinolone acetonide nasal spray, aerosol

2

MO; QL (17 per 30 days)

TUDORZA PRESSAIR INHALATION
AEROSOL POWDR BREATH ACTIVATED

3

MO

TYVASO INHALATION SOLUTION FOR
NEBULIZATION

5

PA; MO

TYVASO INSTITUTIONAL START KIT
INHALATION SOLUTION FOR
NEBULIZATION

5

B/D PA

TYVASO REFILL KIT INHALATION
SOLUTION FOR NEBULIZATION

5

B/D PA; MO

TYVASO STARTER KIT INHALATION
SOLUTION FOR NEBULIZATION

5

B/D PA; MO

VENTOLIN HFA AEROSOL INHALER

3

MO; QL (54 per 30 days)

XOLAIR SUBCUTANEOUS RECON SOLN

5

PA; MO; QL (6 per 28 days)

zafirlukast oral tablet

2

MO

darifenacin oral tablet extended release 24 hr

2

MO

ENABLEX ORAL TABLET EXTENDED
RELEASE 24 HR

4

ST; MO

flavoxate oral tablet

2

MO

GELNIQUE TRANSDERMAL GEL IN
METERED-DOSE PUMP 100 MG/GRAM (10
%)

3

MO

GELNIQUE TRANSDERMAL GEL IN PACKET

3

ST; MO

MYRBETRIQ ORAL TABLET EXTENDED
RELEASE 24 HR

3

MO

oxybutynin chloride oral syrup

2

MO

oxybutynin chloride oral tablet

2

MO

oxybutynin chloride oral tablet extended release
24hr

2

MO

tolterodine oral capsule,extended release 24hr

2

MO

tolterodine oral tablet

2

MO

trospium oral capsule,extended release 24hr

2

MO

trospium oral tablet

2

MO

UROLOGICALS
ANTICHOLINERGICS / ANTISPASMODICS

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82

Drug Name
VESICARE ORAL TABLET

Drug Tier
3

Requirements/Limits
MO

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY
alfuzosin oral tablet extended release 24 hr

2

MO

dutasteride oral capsule

2

MO

dutasteride-tamsulosin oral capsule, er multiphase
24 hr

2

MO

finasteride oral tablet 5 mg

2

MO

tamsulosin oral capsule,extended release 24hr

2

MO

2

MO

CIALIS ORAL TABLET 2.5 MG, 5 MG

4

PA; MO; QL (30 per 30 days)

CYSTAGON ORAL CAPSULE

3

MO

ELMIRON ORAL CAPSULE

4

MO

potassium citrate oral tablet extended release

2

MO

CHOLINERGIC STIMULANTS
bethanechol chloride oral tablet

MISCELLANEOUS UROLOGICALS

VITAMINS, HEMATINICS / ELECTROLYTES
ELECTROLYTES
calcium acetate oral capsule

2

MO

calcium acetate oral tablet 667 mg

2

MO

dextrose-kcl-nacl intravenous solution

2

B/D PA; MO

eliphos oral tablet

2

MO

klor-con 10 oral tablet extended release

2

MO

klor-con 8 oral tablet extended release

2

MO

klor-con m10 oral tablet,er particles/crystals

2

MO

klor-con m15 oral tablet,er particles/crystals

2

MO

klor-con m20 oral tablet,er particles/crystals

2

MO

klor-con oral packet

2

MO

klor-con sprinkle oral capsule, extended release

2

MO

k-tab oral tablet extended release 8 meq

2

MO

lactated ringers intravenous parenteral solution

2

MO

magnesium sulfate injection solution

2

B/D PA; MO

magnesium sulfate injection syringe

2

B/D PA

NORMOSOL-R IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

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83

Drug Name

Drug Tier

Requirements/Limits

NORMOSOL-R INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

potassium bicarb and chloride oral tablet,
effervescent

2

MO

potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 10 meq/l, 30 meq/l, 40 meq/l

2

B/D PA

potassium chlorid-d5-0.45%nacl intravenous
parenteral solution 20 meq/l

2

B/D PA; MO

potassium chloride in 0.9%nacl intravenous
parenteral solution 20 meq/l, 40 meq/l

2

B/D PA

potassium chloride in 5 % dex intravenous
parenteral solution 20 meq/l, 30 meq/l, 40 meq/l

2

B/D PA

potassium chloride in lr-d5 intravenous parenteral
solution 20 meq/l

2

B/D PA; MO

potassium chloride in lr-d5 intravenous parenteral
solution 40 meq/l

2

B/D PA

potassium chloride intravenous piggyback 10
meq/100 ml, 10 meq/50 ml

2

MO

potassium chloride intravenous piggyback 20
meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40
meq/100 ml

2

potassium chloride intravenous solution

2

MO

potassium chloride oral capsule, extended release

2

MO

potassium chloride oral liquid

2

MO

potassium chloride oral packet

2

MO

potassium chloride oral tablet extended release

2

MO

potassium chloride oral tablet,er particles/crystals

2

MO

potassium chloride-0.45 % nacl intravenous
parenteral solution

2

potassium chloride-d5-0.2%nacl intravenous
parenteral solution 20 meq/l

2

B/D PA; MO

potassium chloride-d5-0.2%nacl intravenous
parenteral solution 30 meq/l, 40 meq/l

2

B/D PA

potassium chloride-d5-0.3%nacl intravenous
parenteral solution 20 meq/l

2

B/D PA

potassium chloride-d5-0.9%nacl intravenous
parenteral solution 20 meq/l

2

B/D PA; MO

potassium chloride-d5-0.9%nacl intravenous
parenteral solution 40 meq/l

2

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
84

Drug Name

Drug Tier

Requirements/Limits

ringer's intravenous parenteral solution

2

B/D PA

sodium chloride 0.45 % intravenous parenteral
solution

2

MO

sodium chloride 0.45 % intravenous piggyback

2

sodium chloride 3 % intravenous parenteral
solution

2

sodium chloride 5 % intravenous parenteral
solution

2

sodium chloride intravenous parenteral solution

2

sodium lactate intravenous solution

2

MO

MO

MISCELLANEOUS NUTRITION PRODUCTS
amino acids 15 % intravenous parenteral solution

2

B/D PA

AMINOSYN 10 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

AMINOSYN 8.5 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

AMINOSYN 8.5 %-ELECTROLYTES
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

AMINOSYN II 10 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

AMINOSYN II 15 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

AMINOSYN II 7 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

AMINOSYN II 8.5 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

AMINOSYN II 8.5 %-ELECTROLYTES
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

AMINOSYN M 3.5 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

AMINOSYN-HBC 7% INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

AMINOSYN-PF 10 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

AMINOSYN-PF 7 % SULFITE-FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

AMINOSYN-RF 5.2 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
85

Drug Name

Drug Tier

Requirements/Limits

CLINIMIX 5%/D15W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX 5%/D25W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX 2.75%/D5W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX 4.25%/D10W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX 4.25%-D20W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX 4.25%-D25W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX 5%-D20W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX E 4.25%/D10W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX E 4.25%/D25W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX E 4.25%/D5W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX E 5%/D15W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX E 5%/D20W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

CLINIMIX E 5%/D25W SULFITE FREE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

electrolyte-48 in d5w intravenous parenteral
solution

2

B/D PA

HEPATAMINE 8% INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

INTRALIPID INTRAVENOUS EMULSION 20
%, 30 %

4

B/D PA

IONOSOL-B IN D5W INTRAVENOUS
PARENTERAL SOLUTION

4

IONOSOL-MB IN D5W INTRAVENOUS
PARENTERAL SOLUTION

4

ISOLYTE S PH 7.4 INTRAVENOUS
PARENTERAL SOLUTION

4

ISOLYTE-P IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL SOLUTION

4

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86

Drug Name

Drug Tier

Requirements/Limits

ISOLYTE-S INTRAVENOUS PARENTERAL
SOLUTION

4

NEPHRAMINE 5.4 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

NORMOSOL-M IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL SOLUTION

4

B/D PA

NORMOSOL-R PH 7.4 INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

PLASMA-LYTE 148 INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

PLASMA-LYTE A INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

premasol 10 % intravenous parenteral solution

4

B/D PA; MO

PREMASOL 6 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

PROCALAMINE 3% INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

PROSOL 20 % INTRAVENOUS PARENTERAL
SOLUTION

4

B/D PA; MO

travasol 10 % intravenous parenteral solution

4

B/D PA; MO

TROPHAMINE 10 % INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA; MO

TROPHAMINE 6% INTRAVENOUS
PARENTERAL SOLUTION

4

B/D PA

fluor-a-day (with xylitol) oral tablet,chewable 0.25
mg f (0.55 mg)-236.79mg

2

MO

fluoride (sodium) oral drops

2

MO

fluoride (sodium) oral tablet

2

MO

fluoride (sodium) oral tablet,chewable 0.25
mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium
fluorid)

2

MO

fluoritab oral tablet,chewable 0.5 mg (1.1 mg
sodium fluorid)

2

MO

ludent fluoride oral tablet,chewable 0.25 mg(0.55
mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

2

MO

multi-vit with fluoride-iron oral drops

2

MO

multi-vitamin with fluoride oral drops

2

MO

multivitamin with fluoride oral tablet,chewable

2

MO

VITAMINS / HEMATINICS

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
87

Drug Name

Drug Tier

Requirements/Limits

multivitamins with fluoride oral tablet,chewable

2

MO

mvc-fluoride oral tablet,chewable

2

MO

prenatal vitamin oral tablet

2

MO

triple vitamin with fluoride oral drops

2

tri-vit with fluoride and iron oral drops

2

MO

tri-vitamin with fluoride oral drops

2

MO

vitamins a,c,d and fluoride oral drops

2

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
88

Index
ALECENSA ......................... 14
amlodipine-valsartan ............38
A
abacavir .................................. 1
alendronate ............... 52, 69, 70
amlodipine-valsartanabacavir-lamivudine ............... 1
alfuzosin ............................... 83
hydrochlorothiazide ..........38
abacavir-lamivudineALIMTA .............................. 14
ammonium lactate ................46
zidovudine .......................... 1
ALINIA .................................. 7
amnesteem ............................47
ABELCET .............................. 1
allopurinol ............................ 69
amoxapine.............................32
ABILIFY ........................ 31, 32
allopurinol sodium................ 69
amoxicil-clarithromy-lansopraz
ABILIFY MAINTENA ........ 31
alosetron ............................... 61
..........................................64
ABRAXANE ........................ 13
ALPHAGAN P ..................... 78
amoxicillin ............................10
acamprosate .......................... 52
alprazolam ............................ 32
amoxicillin-pot clavulanate ..10
acarbose ................................ 57
altavera (28) .......................... 72
amphotericin b ........................1
acebutolol ............................. 38
ALUNBRIG ......................... 14
ampicillin ..............................10
acetaminophen-codeine ........ 27
alyacen 1/35 (28) .................. 72
ampicillin sodium .................10
acetasol hc ............................ 55
alyacen 7/7/7 (28) ................. 72
ampicillin-sulbactam ............10
acetazolamide ....................... 77
amantadine hcl ........................ 2
AMPYRA .............................25
acetazolamide sodium .......... 77
AMBISOME .......................... 1
ANADROL-50 .....................59
acetic acid ............................. 55
amcinonide ........................... 49
anagrelide .............................52
acetic acid-aluminum acetate55
amethia ................................. 72
anastrozole ............................14
acetylcysteine ....................... 79
amethia lo ............................. 72
ANDROGEL ........................59
acitretin ................................. 46
amethyst................................ 72
ANDROID ............................59
ACTEMRA .......................... 70
amifostine crystalline ........... 13
androxy .................................60
ACTHAR H.P. ..................... 55
amikacin ................................. 7
ANORO ELLIPTA ...............80
ACTHIB (PF) ....................... 66
amiloride............................... 38
APOKYN .............................24
ACTIMMUNE ..................... 65
amiloride-hydrochlorothiazide
apraclonidine ........................78
ACTOPLUS MET XR ......... 57
.......................................... 38
aprepitant ..............................62
acyclovir ....................... 1, 2, 49
amino acids 15 % ................. 85
apri ........................................72
acyclovir sodium .................... 2
AMINOSYN 10 % ............... 85
APRISO ................................ 62
ADACEL(TDAP
AMINOSYN 8.5 % .............. 85
APTIOM ...............................22
ADOLESN/ADULT)(PF) 66
AMINOSYN 8.5 %APTIVUS ...............................2
ADAGEN ............................. 52
ELECTROLYTES............ 85
ARALAST NP......................52
adapalene .............................. 47
AMINOSYN II 10 % ........... 85
aranelle (28) ..........................72
ADCIRCA ............................ 79
AMINOSYN II 15 % ........... 85
ARCALYST .........................65
adefovir................................... 2
AMINOSYN II 7 % ............. 85
aripiprazole ...........................32
ADEMPAS ........................... 79
AMINOSYN II 8.5 % .......... 85
ARISTADA ..........................32
adriamycin ............................ 13
AMINOSYN II 8.5 %ARNUITY ELLIPTA ...........80
adrucil ................................... 14
ELECTROLYTES............ 85
ashlyna ..................................72
ADVAIR DISKUS ............... 79
AMINOSYN M 3.5 %.......... 85
ASMANEX HFA .................80
ADVAIR HFA ..................... 79
AMINOSYN-HBC 7%......... 85
ASMANEX TWISTHALER 80
afeditab cr ............................. 38
AMINOSYN-PF 10 % ......... 85
aspirin-dipyridamole.............42
AFINITOR ........................... 14
AMINOSYN-PF 7 %
ASTAGRAF XL ...................14
AFINITOR DISPERZ .......... 14
SULFITE-FREE ............... 85
atenolol .................................38
AGGRENOX ....................... 42
AMINOSYN-RF 5.2 % ........ 85
atenolol-chlorthalidone .........38
a-hydrocort ........................... 55
amiodarone ........................... 37
atomoxetine ..........................32
ala-cort .................................. 49
AMITIZA ............................. 61
atorvastatin ...........................44
ALBENZA ............................. 7
amitriptyline ......................... 32
atovaquone ..............................7
albuterol sulfate .................... 79
amlodipine ............................ 38
atovaquone-proguanil .............7
alclometasone ....................... 49
amlodipine-atorvastatin ........ 44
ATRIPLA ...............................2
ALCOHOL PADS................ 57
amlodipine-benazepril .......... 38
atropine .................................61
ALDURAZYME .................. 59
amlodipine-olmesartan ......... 38
ATROVENT HFA................80
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
89

AUBAGIO ........................... 25
BICILLIN C-R ..................... 10
camrese lo .............................72
aubra ..................................... 72
BICILLIN L-A ..................... 10
CANASA ..............................62
AURYXIA ........................... 52
BICNU.................................. 14
CANCIDAS ............................1
AVASTIN ............................ 14
bisoprolol fumarate............... 38
candesartan ...........................39
AVELOX IN NACL (ISObisoprolol-hydrochlorothiazide
candesartanOSM) ................................ 11
.......................................... 39
hydrochlorothiazide ..........39
aviane ................................... 72
bleomycin ............................. 14
CAPASTAT ...........................7
AVONEX ............................. 65
BLEPHAMIDE S.O.P. ......... 78
CAPRELSA ..........................14
AVONEX (WITH ALBUMIN)
blisovi 24 fe .......................... 72
captopril ................................ 39
.......................................... 65
blisovi fe 1.5/30 (28) ............ 72
captopril-hydrochlorothiazide
azacitidine............................. 14
blisovi fe 1/20 (28) ............... 72
..........................................39
AZASAN.............................. 14
BOOSTRIX TDAP............... 67
CARAC ................................ 46
AZASITE ............................. 75
BOSULIF ............................. 14
CARAFATE .........................64
azathioprine .......................... 14
BREO ELLIPTA .................. 80
CARBAGLU ........................52
azathioprine sodium ............. 14
briellyn.................................. 72
carbamazepine ......................22
azelastine ........................ 55, 77
BRILINTA ........................... 42
carbidopa ..............................24
AZILECT ............................. 24
brimonidine .......................... 78
carbidopa-levodopa ..............24
azithromycin ........................... 7
BRISDELLE ........................ 32
carbidopa-levodopaAZOPT ................................. 77
BRIVIACT ........................... 22
entacapone ........................24
aztreonam ............................... 7
bromfenac ............................. 77
carboplatin ............................14
azurette (28).......................... 72
bromocriptine ....................... 24
carteolol ................................ 76
budesonide ...................... 62, 80
cartia xt .................................39
B
baciim ..................................... 7
bumetanide ........................... 39
carvedilol ..............................39
bacitracin .......................... 7, 75
buprenorphine hcl ................. 27
CAYSTON .............................7
bacitracin-polymyxin b ........ 75
buprenorphine-naloxone....... 29
caziant (28) ...........................72
baclofen ................................ 26
bupropion hcl ........................ 32
cefaclor ...................................5
balsalazide ............................ 62
bupropion hcl (smoking deter)
cefadroxil ................................5
balziva (28)........................... 72
.......................................... 54
cefazolin .................................5
BANZEL .............................. 22
buspirone .............................. 32
cefazolin in dextrose (iso-osm)
BARACLUDE ....................... 2
BUSULFEX ......................... 14
............................................5
BAVENCIO ......................... 14
butalbital-acetaminop-caf-cod
cefdinir ....................................5
BCG VACCINE, LIVE (PF) 66
.......................................... 27
cefepime .................................5
BELEODAQ ........................ 14
butalbital-acetaminophen ..... 27
CEFEPIME IN DEXTROSE 5
benazepril ............................. 38
butalbital-acetaminophen-caff
% .........................................5
benazepril-hydrochlorothiazide
.......................................... 27
cefepime in dextrose,(iso-osm)
.......................................... 38
butalbital-aspirin-caffeine .... 27
............................................5
BENDEKA ........................... 14
butorphanol tartrate ........ 29, 30
cefixime ..................................5
BENICAR ............................ 38
BYDUREON ........................ 57
cefotaxime ..............................5
BENICAR HCT ................... 38
BYETTA .............................. 57
cefotetan .................................5
BENLYSTA ......................... 70
BYSTOLIC .......................... 39
CEFOTETAN IN
benztropine ........................... 24
DEXTROSE, (ISO-OSM) ..5
C
betamethasone dipropionate . 49
cabergoline ........................... 60
cefoxitin ..................................6
betamethasone valerate ........ 50
CABOMETYX ..................... 14
cefoxitin in dextrose, (iso-osm)
betamethasone, augmented... 50
calcipotriene ......................... 46
............................................6
betaxolol ......................... 38, 76
calcipotriene-betamethasone 46
cefpodoxime ...........................6
bethanechol chloride ............ 83
calcitonin (salmon) ............... 60
cefprozil ..................................6
BETIMOL ............................ 76
calcitrene .............................. 46
ceftazidime .............................6
BETOPTIC S........................ 76
calcitriol .......................... 46, 60
CEFTAZIDIME IN D5W.......6
bexarotene ............................ 14
calcium acetate ..................... 83
ceftriaxone ..............................6
BEXSERO ............................ 66
camila ................................... 71
CEFTRIAXONE ....................6
bicalutamide ......................... 14
camrese ................................. 72
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
90

ceftriaxone in dextrose,(isocisplatin ................................ 14
clonidine ...............................39
osm) .................................... 6
citalopram ............................. 32
clonidine hcl ...................33, 39
cefuroxime axetil .................... 6
cladribine .............................. 14
clopidogrel ............................42
cefuroxime sodium ................. 6
claravis.................................. 47
clorazepate dipotassium........33
celecoxib............................... 30
clarithromycin ........................ 7
clotrimazole ......................1, 49
CELLCEPT .......................... 14
clemastine ............................. 79
clotrimazole-betamethasone .49
CELLCEPT INTRAVENOUS
CLEOCIN ............................. 72
clozapine ...............................33
.......................................... 14
clindamycin hcl ...................... 8
CLOZAPINE ........................33
CELONTIN .......................... 22
clindamycin palmitate hcl ...... 8
COARTEM.............................8
cephalexin............................... 6
clindamycin pediatric ............. 8
codeine sulfate ......................27
CEREZYME ........................ 60
clindamycin phosphate .... 8, 47,
COLCRYS ............................69
cetirizine ............................... 79
72
colestipol...............................44
cevimeline ............................ 52
clindamycin-benzoyl peroxide
COLISTIN
CHANTIX ............................ 54
.......................................... 47
(COLISTIMETHATE NA) 8
CHANTIX CONTINUING
CLINIMIX 5%/D15W
COMBIGAN ........................77
MONTH BOX .................. 54
SULFITE FREE ............... 86
COMBIPATCH ....................71
CHANTIX STARTING
CLINIMIX 5%/D25W
COMBIVENT RESPIMAT..80
MONTH BOX .................. 54
SULFITE-FREE ............... 86
COMETRIQ .........................14
chateal................................... 72
CLINIMIX 2.75%/D5W
COMPLERA ..........................2
CHEMET ............................. 52
SULFITE FREE ............... 86
compro ..................................62
chloramphenicol sod succinate
CLINIMIX 4.25%/D10W
constulose .............................62
............................................ 8
SULFITE FREE ............... 86
COPAXONE ........................25
chlorhexidine gluconate ....... 55
CLINIMIX 4.25%/D5W
COREG CR ..........................39
chloroquine phosphate............ 8
SULFITE FREE ............... 52
cormax ..................................50
chlorothiazide ....................... 39
CLINIMIX 4.25%-D20W
cortisone ...............................55
chlorothiazide sodium .......... 39
SULFITE-FREE ............... 86
COTELLIC ...........................15
chlorpromazine ..................... 32
CLINIMIX 4.25%-D25W
COUMADIN ........................42
chlorthalidone ....................... 39
SULFITE-FREE ............... 86
CREON.................................62
CHOLBAM .......................... 62
CLINIMIX 5%-D20W
CRESTOR ............................44
cholestyramine (with sugar) . 44
SULFITE-FREE ............... 86
CRINONE ............................71
cholestyramine light ............. 44
CLINIMIX E 2.75%/D10W
CRIXIVAN.............................2
CHORIONIC
SULFITE FREE ............... 52
cromolyn ...................62, 77, 80
GONADOTROPIN,
CLINIMIX E 2.75%/D5W
cryselle (28) ..........................72
HUMAN ........................... 60
SULFITE FREE ............... 52
CUBICIN ................................8
CIALIS ................................. 83
CLINIMIX E 4.25%/D10W
CUBICIN RF ..........................8
ciclodan .......................... 48, 49
SULFITE FREE ............... 86
CUPRIMINE ........................70
ciclopirox .............................. 49
CLINIMIX E 4.25%/D25W
cyclafem 1/35 (28) ................72
CIDOFOVIR .......................... 2
SULFITE FREE ............... 86
cyclafem 7/7/7 (28)...............73
cilostazol............................... 42
CLINIMIX E 4.25%/D5W
cyclobenzaprine ....................26
CILOXAN ............................ 76
SULFITE FREE ............... 86
CYCLOPHOSPHAMIDE ....15
cimetidine ............................. 64
CLINIMIX E 5%/D15W
CYCLOSERINE.....................8
cimetidine hcl ....................... 64
SULFITE FREE ............... 86
CYCLOSET .........................57
CIMZIA ................................ 62
CLINIMIX E 5%/D20W
cyclosporine ..........................15
CIMZIA POWDER FOR
SULFITE FREE ............... 86
cyclosporine modified ..........15
RECONST........................ 62
CLINIMIX E 5%/D25W
cyproheptadine .....................79
CIMZIA STARTER KIT ..... 62
SULFITE FREE ............... 86
CYRAMZA ..........................15
CINRYZE............................. 80
clobetasol .............................. 50
CYSTADANE ......................62
ciprofloxacin......................... 11
clobetasol-emollient ............. 50
CYSTAGON ........................83
ciprofloxacin (mixture) ........ 11
clofarabine ............................ 14
CYSTARAN.........................77
ciprofloxacin hcl ............. 11, 76
clomipramine ........................ 32
cytarabine .............................15
ciprofloxacin lactate ............. 11
clonazepam ........................... 22
cytarabine (pf) ......................15
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
91

dexmethylphenidate.............. 33
disulfiram ..............................53
D
d10 %-0.45 % sodium chloride
dexrazoxane hcl .................... 13
divalproex .............................22
.......................................... 52
dextroamphetamine .............. 33
dofetilide ...............................37
d2.5 %-0.45 % sodium
dextroamphetaminedonepezil...............................25
chloride ............................. 52
amphetamine .................... 33
dorzolamide ..........................77
d5 % and 0.9 % sodium
dextrose 10 % and 0.2 % nacl
dorzolamide-timolol .............77
chloride ............................. 52
.......................................... 52
doxazosin ..............................39
d5 %-0.45 % sodium chloride
dextrose 10 % in water (d10w)
doxepin .................................33
.......................................... 52
.......................................... 52
doxorubicin ...........................15
dacarbazine ........................... 15
dextrose 20 % in water (d20w)
doxorubicin, peg-liposomal ..15
DALIRESP ........................... 80
.......................................... 52
doxy-100 ...............................12
danazol ................................. 60
dextrose 25 % in water (d25w)
doxycycline hyclate ..............12
dantrolene ............................. 26
.......................................... 52
doxycycline monohydrate ....12
DAPSONE ............................. 8
dextrose 30 % in water (d30w)
dronabinol .............................62
DAPTACEL (DTAP
.......................................... 53
drospirenone-e.estradiol-lm.fa
PEDIATRIC) (PF)............ 67
dextrose 40 % in water (d40w)
..........................................73
daptomycin ............................. 8
.......................................... 53
drospirenone-ethinyl estradiol
DARAPRIM ........................... 8
dextrose 5 % in water (d5w). 53
..........................................73
darifenacin ............................ 82
dextrose 5 %-lactated ringers53
DROXIA...............................15
DARZALEX ........................ 15
dextrose 5%-0.2 % sod
duloxetine .............................33
dasetta 1/35 (28) ................... 73
chloride ............................. 53
DURAMORPH (PF) ............27
dasetta 7/7/7 (28) .................. 73
dextrose 5%-0.3 %
DUREZOL ...........................78
daunorubicin ......................... 15
sod.chloride ...................... 53
dutasteride.............................83
daysee ................................... 73
dextrose 50 % in water (d50w)
dutasteride-tamsulosin ..........83
decitabine ............................. 15
.......................................... 53
E
DELESTROGEN ................. 71
dextrose 70 % in water (d70w)
e.e.s. 400 .................................7
DELZICOL .......................... 62
.......................................... 53
econazole ..............................49
demeclocycline ..................... 12
dextrose with sodium chloride
EDURANT .............................2
DEMSER.............................. 39
.......................................... 53
EFFIENT ..............................42
DENAVIR ............................ 49
dextrose-kcl-nacl .................. 83
EGRIFTA .............................65
denta 5000 plus..................... 55
DIASTAT ............................. 22
ELAPRASE ..........................60
dentagel ................................ 55
diazepam ............................... 33
electrolyte-48 in d5w ............86
DEPEN TITRATABS .......... 70
diazepam intensol ................. 33
ELELYSO ............................60
DEPO-PROVERA ............... 71
diclofenac potassium ............ 30
ELIDEL ................................ 46
DEPO-SUBQ PROVERA 104
diclofenac sodium..... 30, 46, 77
ELIGARD.............................15
.......................................... 71
diclofenac-misoprostol ......... 30
ELIGARD (3 MONTH) .......15
DESCOVY ............................. 2
dicloxacillin .......................... 10
ELIGARD (4 MONTH) .......15
desipramine .......................... 33
dicyclomine .......................... 61
ELIGARD (6 MONTH) .......15
desloratadine......................... 79
didanosine............................... 2
elinest ....................................73
desmopressin ........................ 60
diflorasone ............................ 50
eliphos...................................83
desog-e.estradiol/e.estradiol . 73
diflunisal ............................... 30
ELIQUIS...............................42
desonide................................ 50
digitek ................................... 42
ELITEK ................................ 13
desoximetasone .................... 50
digox ..................................... 42
ELIXOPHYLLIN .................80
desvenlafaxine succinate ...... 33
digoxin .................................. 42
ELLA ....................................73
dexamethasone ............... 55, 56
dihydroergotamine................ 25
ELMIRON ............................83
dexamethasone intensol........ 55
DILANTIN 30 MG .............. 22
EMCYT ................................ 15
dexamethasone sodium phos
diltiazem hcl ......................... 39
EMEND ................................ 62
(pf) .................................... 56
dilt-xr .................................... 39
emoquette .............................73
dexamethasone sodium
DIPENTUM ......................... 62
EMPLICITI ..........................15
phosphate.................... 56, 78
diphenhydramine hcl ............ 79
EMSAM ...............................33
DEXILANT .......................... 64
diskets ................................... 27
EMTRIVA ..............................2
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
92

ENABLEX ........................... 82
ethosuximide ........................ 22
fluocinolone ..........................50
enalapril maleate .................. 39
etidronate disodium .............. 53
fluocinolone acetonide oil ....55
enalapril-hydrochlorothiazide
etodolac ................................ 30
fluocinolone and shower cap 50
.......................................... 39
etoposide............................... 15
fluocinonide ....................50, 51
ENBREL .............................. 70
EVOTAZ ................................ 2
fluocinonide-e .......................51
ENBREL SURECLICK ....... 70
exemestane ........................... 15
fluocinonide-emollient .........51
endocet ................................. 27
EXJADE ............................... 53
fluor-a-day (with xylitol) ......87
ENGERIX-B (PF) ................ 67
EXTAVIA ............................ 65
fluoride (sodium) ..................87
ENGERIX-B PEDIATRIC
ezetimibe .............................. 44
fluoritab ................................ 87
(PF) ................................... 67
ezetimibe-simvastatin ........... 44
fluorometholone ...................78
enoxaparin ...................... 42, 43
fluorouracil .....................16, 47
F
enpresse ................................ 73
FABRAZYME ..................... 60
FLUOROURACIL ...............46
enskyce ................................. 73
falmina (28) .......................... 73
fluoxetine ..............................34
entacapone ............................ 24
famciclovir.............................. 2
FLUOXETINE .....................34
entecavir ................................. 2
famotidine............................. 65
fluphenazine decanoate ........34
ENTRESTO ......................... 45
famotidine (pf) ...................... 64
fluphenazine hcl....................34
enulose.................................. 62
famotidine (pf)-nacl (iso-osm)
flurbiprofen ...........................30
ENVARSUS XR .................. 15
.......................................... 64
flurbiprofen sodium ..............77
EPCLUSA .............................. 2
FANAPT .............................. 33
flutamide ...............................16
epinastine.............................. 77
FARESTON ......................... 16
fluticasone.......................51, 81
EPINEPHRINE .................... 79
FARXIGA ............................ 57
fluvastatin .............................44
EPIPEN 2-PAK .................... 79
FARYDAK ........................... 16
fluvoxamine ..........................34
EPIPEN JR 2-PAK ............... 79
FASLODEX ......................... 16
FML S.O.P............................78
epirubicin .............................. 15
FAZACLO............................ 33
fomepizole ............................67
epitol ..................................... 22
felbamate .............................. 22
fondaparinux .........................43
EPIVIR HBV.......................... 2
felodipine .............................. 39
FORFIVO XL .......................34
eplerenone ............................ 39
fenofibrate ............................ 44
FORTEO...............................70
eprosartan ............................. 39
fenofibrate micronized ......... 44
foscarnet .................................2
EPZICOM .............................. 2
fenofibrate nanocrystallized . 44
fosinopril...............................39
ergoloid................................. 33
fenofibric acid....................... 44
fosinopril-hydrochlorothiazide
ERIVEDGE .......................... 15
fenofibric acid (choline) ....... 44
..........................................39
errin ...................................... 71
fenoprofen ............................ 30
fosphenytoin .........................22
ERWINAZE ......................... 15
fentanyl ................................. 28
FOSRENOL .........................53
ery pads ................................ 47
fentanyl citrate ...................... 27
FRAGMIN ............................43
ERYPED 200 ......................... 7
FERRIPROX ........................ 53
furosemide ............................40
ERYTHROCIN ...................... 7
FETZIMA ....................... 33, 34
FUZEON ................................2
erythrocin (as stearate) ........... 7
finasteride ............................. 83
FYCOMPA ...........................22
erythromycin .................... 7, 76
FIRAZYR ............................. 80
G
erythromycin ethylsuccinate .. 7
flavoxate ............................... 82
gabapentin.......................22, 23
erythromycin with ethanol ... 47
flecainide .............................. 37
GABITRIL ...........................23
erythromycin-benzoyl peroxide
FLOVENT DISKUS ............ 80
galantamine...........................25
.......................................... 47
FLOVENT HFA ................... 80
GAMMAGARD LIQUID ....67
ESBRIET .............................. 80
fluconazole ............................. 1
GAMMAGARD S-D (IGA < 1
escitalopram oxalate ............. 33
fluconazole in dextrose(isoMCG/ML).........................67
esomeprazole sodium ........... 64
osm) .................................... 1
GAMUNEX-C ......................67
estarylla ................................ 73
fluconazole in nacl (iso-osm) . 1
ganciclovir sodium .................2
ESTRACE ............................ 71
flucytosine .............................. 1
GARDASIL (PF) ..................67
estradiol ................................ 71
fludarabine ............................ 16
GARDASIL 9 (PF) ...............67
estradiol valerate .................. 71
FLUDARABINE .................. 16
gatifloxacin ...........................76
eszopiclone ........................... 33
fludrocortisone...................... 56
GATTEX 30-VIAL ..............62
ethambutol .............................. 8
flunisolide ............................. 81
GATTEX ONE-VIAL ..........62
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
93

GAUZE PAD ....................... 57
gavilyte-c .............................. 62
gavilyte-g.............................. 62
gavilyte-n .............................. 62
GAZYVA ............................. 16
GELNIQUE .......................... 82
gemcitabine .......................... 16
gemfibrozil ........................... 44
generlac ................................ 62
gengraf .................................. 16
gentak ................................... 76
gentamicin .................. 8, 48, 76
gentamicin in nacl (iso-osm) .. 8
GENTAMICIN IN NACL
(ISO-OSM) ......................... 8
GENVOYA ............................ 2
GEODON ............................. 34
gianvi (28) ............................ 73
GILENYA ............................ 26
GILOTRIF ............................ 16
glatopa .................................. 26
GLEEVEC ............................ 16
GLEOSTINE ........................ 16
glimepiride ........................... 57
glipizide ................................ 57
glipizide-metformin .............. 57
GLUCAGEN HYPOKIT ..... 57
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 57
glyburide............................... 57
glyburide micronized............ 57
glyburide-metformin ............ 57
glycopyrrolate....................... 61
granisetron (pf) ..................... 62
granisetron hcl ...................... 62
griseofulvin microsize ............ 1
griseofulvin ultramicrosize..... 1
guanfacine ............................ 34
guanidine .............................. 34
H
halobetasol propionate.......... 51
haloperidol ............................ 34
haloperidol decanoate ........... 34
haloperidol lactate ................ 34
HARVONI ............................. 3
HAVRIX (PF) ...................... 67
heather .................................. 71
heparin (porcine) .................. 43
heparin (porcine) in 5 % dex 43
heparin (porcine) in nacl (pf) 43

heparin(porcine) in 0.45% nacl
ibuprofen...............................30
.......................................... 44
ibuprofen-oxycodone ............28
HEPARIN(PORCINE) IN
ICLUSIG ..............................16
0.45% NACL .................... 43
idarubicin ..............................16
heparin, porcine (pf) ............. 44
ifosfamide .............................16
HEPATAMINE 8% .............. 86
IFOSFAMIDE ......................16
HERCEPTIN ........................ 16
ILARIS (PF) .........................65
HETLIOZ ............................. 34
ILEVRO ...............................77
HEXALEN ........................... 16
imatinib .................................16
HIBERIX (PF) ...................... 67
IMBRUVICA .......................16
HUMIRA .............................. 70
IMFINZI ...............................17
HUMIRA PEDIATRIC
imipenem-cilastatin ................8
CROHN'S START ........... 70
imipramine hcl ......................34
HUMIRA PEN ..................... 70
imipramine pamoate .............34
HUMIRA PEN CROHN'Simiquimod.............................47
UC-HS START ................ 70
IMOGAM RABIES-HT (PF)
HUMIRA PEN PSORIASIS..........................................67
UVEITIS .......................... 70
IMOVAX RABIES VACCINE
HUMULIN 70/30 ................. 57
(PF) ...................................67
HUMULIN 70/30 KWIKPEN
INCRELEX ..........................53
.......................................... 57
indapamide ...........................40
HUMULIN N ....................... 57
indomethacin ........................30
HUMULIN N KWIKPEN .... 57
INFANRIX (DTAP) (PF) .....68
HUMULIN R U-100 ............ 57
INLYTA ...............................17
HUMULIN R U-500 (CONC)
INSULIN PEN NEEDLE .....58
KWIKPEN........................ 58
INSULIN SYRINGE (DISP)
HUMULIN R U-500
U-100 ................................ 58
(CONCENTRATED) ....... 58
INTELENCE ..........................3
hydralazine ........................... 40
INTRALIPID ........................86
hydrochlorothiazide .............. 40
INTRON A ...........................65
hydrocodone-acetaminophen 28
introvale ................................ 73
hydrocodone-ibuprofen ........ 28
INVANZ .................................8
hydrocortisone .... 51, 56, 62, 63
INVEGA SUSTENNA .........34
hydrocortisone butyrate ........ 51
INVEGA TRINZA ...............34
hydrocortisone butyr-emollient
INVIRASE .............................3
.......................................... 51
IONOSOL-B IN D5W ..........86
hydrocortisone valerate ........ 51
IONOSOL-MB IN D5W ......86
hydrocortisone-acetic acid .... 55
IPOL .....................................68
hydrocortisone-min oil-wht pet
ipratropium bromide .......55, 81
.......................................... 51
ipratropium-albuterol ............81
hydromorphone .................... 28
irbesartan ..............................40
hydromorphone (pf) ............. 28
irbesartan-hydrochlorothiazide
hydroxychloroquine................ 8
..........................................40
hydroxyprogesterone caproate
IRENKA ...............................34
.......................................... 71
IRESSA ................................ 17
hydroxyurea .......................... 16
irinotecan ..............................17
hydroxyzine hcl .................... 79
ISENTRESS ...........................3
HYPERRAB S/D (PF) ......... 67
ISOLYTE S PH 7.4 ..............86
ISOLYTE-P IN 5 %
I
ibandronate ........................... 70
DEXTROSE .....................86
IBRANCE ............................ 16
ISOLYTE-S ..........................87
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
94

isoniazid ............................. 8, 9
klor-con m15 ........................ 83
levonorg-eth estrad triphasic 74
ISORDIL .............................. 45
klor-con m20 ........................ 83
levora-28 ...............................74
isosorbide dinitrate ............... 46
klor-con sprinkle................... 83
levorphanol tartrate ...............28
isosorbide mononitrate ......... 46
KOMBIGLYZE XR ............. 58
levothyroxine ........................61
isradipine .............................. 40
KORLYM ............................. 60
LEVOTHYROXINE ............61
ISTODAX ............................ 17
k-tab ...................................... 83
levoxyl ..................................61
itraconazole ............................ 1
kurvelo .................................. 73
LEXIVA .................................3
ivermectin ............................... 9
KUVAN................................ 60
LIALDA ...............................63
IXIARO (PF) ........................ 68
KYNAMRO ......................... 45
lidocaine ...............................48
KYPROLIS .......................... 17
lidocaine (pf) ..................38, 48
J
JAKAFI ................................ 17
lidocaine hcl..........................48
L
jantoven ................................ 44
l norgest/e.estradiol-e.estrad . 73
lidocaine viscous ..................48
JANUMET ........................... 58
labetalol ................................ 40
lidocaine-prilocaine ..............48
JANUMET XR..................... 58
lactated ringers ............... 52, 83
lindane ..................................51
JANUVIA............................. 58
lactulose ................................ 63
linezolid ..................................9
JARDIANCE ........................ 58
lamivudine .............................. 3
linezolid-0.9% sodium chloride
jencycla................................. 71
lamivudine-zidovudine ........... 3
............................................9
JINTELI ............................... 71
lamotrigine............................ 23
LINZESS ..............................63
jolessa ................................... 73
LANOXIN ............................ 42
liothyronine...........................61
jolivette ................................. 71
lansoprazole .......................... 65
lisinopril ................................ 40
junel 1.5/30 (21) ................... 73
larissia................................... 73
lisinopril-hydrochlorothiazide
junel 1/20 (21) ...................... 73
LARTRUVO ........................ 17
..........................................40
junel fe 1.5/30 (28) ............... 73
LASTACAFT ....................... 77
lithium carbonate ..................35
junel fe 1/20 (28) .................. 73
latanoprost ............................ 77
lithium citrate........................35
junel fe 24 ............................. 73
LATUDA.............................. 35
LONSURF ............................17
JUXTAPID ........................... 45
layolis fe ............................... 73
loperamide ............................61
leflunomide........................... 70
lopinavir-ritonavir...................3
K
KADCYLA .......................... 17
LENVIMA............................ 17
lorazepam .............................35
KADIAN .............................. 28
lessina ................................... 73
lorazepam intensol ................35
KALETRA ............................. 3
LETAIRIS ............................ 81
loryna (28) ............................74
KALYDECO ........................ 81
letrozole ................................ 17
losartan .................................40
kariva (28) ............................ 73
leucovorin calcium ............... 13
losartan-hydrochlorothiazide 40
kelnor 1/35 (28) .................... 73
LEUKERAN ........................ 17
lovastatin...............................45
KENALOG........................... 56
LEUKINE ............................. 66
low-ogestrel (28) ..................74
ketoconazole ..................... 1, 49
leuprolide .............................. 17
loxapine succinate ................35
ketoprofen............................. 30
levalbuterol hcl ..................... 81
ludent fluoride ......................87
ketorolac ............................... 77
LEVEMIR ............................ 58
LUMIGAN ...........................77
KEVEYIS ............................. 26
LEVEMIR FLEXTOUCH ... 58
LUPRON DEPOT ................18
KEYTRUDA ........................ 17
levetiracetam ........................ 23
LUPRON DEPOT (3
KHEDEZLA......................... 34
levetiracetam in nacl (iso-osm)
MONTH) ..........................17
kimidess (28) ........................ 73
.......................................... 23
LUPRON DEPOT (4
KINRIX (PF) ........................ 68
levobunolol ........................... 76
MONTH) ..........................18
KIONEX............................... 53
levocarnitine ......................... 53
LUPRON DEPOT (6
kionex (with sorbitol) ........... 53
levocarnitine (with sugar) ..... 53
MONTH) ..........................18
KISQALI .............................. 17
levocetirizine ........................ 79
LUPRON DEPOT-PED .......18
KISQALI FEMARA COlevofloxacin .................... 12, 76
LUPRON DEPOT-PED (3
PACK ............................... 17
levofloxacin in d5w ........ 11, 12
MONTH) ..........................18
klor-con ................................ 83
levoleucovorin ...................... 13
lutera (28) .............................74
klor-con 10 ........................... 83
LEVOLEUCOVORIN ......... 13
LYNPARZA .........................18
klor-con 8 ............................. 83
levonest (28) ......................... 73
LYRICA ...............................23
klor-con m10 ........................ 83
levonorgestrel-ethinyl estrad 73
LYSODREN .........................18
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
95

lyza ....................................... 71
methotrexate sodium (pf) ..... 18
MORPHINE .........................28
methoxsalen .......................... 47
morphine (pf) ........................28
M
magnesium sulfate ................ 83
methscopolamine .................. 61
morphine concentrate ...........28
malathion .............................. 51
methyclothiazide .................. 40
MOVANTIK ........................63
maprotiline ........................... 35
methyldopaMOVIPREP ..........................63
marlissa................................. 74
hydrochlorothiazide .......... 40
moxifloxacin ...................12, 76
MARPLAN .......................... 35
METHYLERGONOVINE ... 75
MOZOBIL ............................66
MATULANE ....................... 18
methylphenidate hcl ............. 35
MULTAQ .............................38
matzim la .............................. 40
methylprednisolone .............. 56
multi-vit with fluoride-iron...87
meclizine .............................. 63
methylprednisolone acetate .. 56
multivitamin with fluoride ....87
meclofenamate ..................... 30
methylprednisolone sodium
multi-vitamin with fluoride ..87
medroxyprogesterone ........... 71
succ ................................... 56
multivitamins with fluoride ..88
mefenamic acid .................... 30
methyltestosterone ................ 60
mupirocin ..............................48
mefloquine.............................. 9
metipranolol.......................... 76
mupirocin calcium ................48
megestrol .............................. 18
metoclopramide hcl .............. 63
MUSTARGEN .....................18
MEKINIST ........................... 18
metolazone............................ 40
mvc-fluoride .........................88
meloxicam ............................ 30
metoprolol succinate............. 40
my way .................................74
melphalan hcl ....................... 18
metoprolol tartrate ................ 40
mycophenolate mofetil .........18
memantine ............................ 26
metoprolol tartratemycophenolate mofetil hcl ...18
MENACTRA (PF) ............... 68
hydrochlorothiazide .......... 40
mycophenolate sodium .........18
MENHIBRIX (PF) ............... 68
metro i.v.................................. 9
MYRBETRIQ.......................82
MENOMUNE - A/C/Y/W-135
metronidazole ....... 9, 47, 48, 72
myzilra ..................................74
.......................................... 68
metronidazole in nacl (isoN
MENOMUNE - A/C/Y/W-135
osm) .................................... 9
nabumetone...........................30
(PF) ................................... 68
mexiletine ............................. 38
nadolol ..................................40
MENVEO A-C-Y-W-135-DIP
MIACALCIN ....................... 60
nadolol-bendroflumethiazide 41
(PF) ................................... 68
miconazole-3 ........................ 72
nafcillin .................................11
meprobamate ........................ 26
microgestin 1.5/30 (21) ........ 74
nafcillin in dextrose (iso-osm)
mercaptopurine ..................... 18
microgestin 1/20 (21) ........... 74
..........................................10
meropenem ............................. 9
microgestin fe 1.5/30 (28) .... 74
NAGLAZYME .....................60
MEROPENEM-0.9%
microgestin fe 1/20 (28) ....... 74
nalbuphine ............................30
SODIUM CHLORIDE ....... 9
midodrine.............................. 53
naloxone ...............................30
mesalamine ........................... 63
migergot................................ 25
naltrexone .............................30
mesalamine with cleansing
millipred ............................... 56
NAMENDA ..........................26
wipe .................................. 63
minocycline .......................... 12
NAMENDA TITRATION
mesna.................................... 13
minoxidil .............................. 40
PAK ..................................26
MESNEX ............................. 13
mirtazapine ........................... 35
NAMENDA XR ...................26
MESTINON ......................... 26
misoprostol ........................... 65
NAPRELAN CR ..................31
metadate er ........................... 35
mitomycin ............................. 18
naproxen ...............................31
metaproterenol ...................... 81
mitoxantrone......................... 18
naproxen sodium ..................31
metaxalone ........................... 26
M-M-R II (PF) ...................... 68
naratriptan .............................25
metformin ............................. 58
modafinil .............................. 35
NARCAN .............................31
methadone ............................ 28
moexipril .............................. 40
NASONEX ...........................81
methadone intensol ............... 28
moexipril-hydrochlorothiazide
NATACYN...........................76
methadose ............................. 28
.......................................... 40
nateglinide ............................58
methamphetamine ................ 35
mometasone .................... 51, 81
NATPARA ...........................60
methazolamide ..................... 77
mono-linyah.......................... 74
NEBUPENT ...........................9
methenamine hippurate ........ 12
mononessa (28)..................... 74
necon 0.5/35 (28) ..................74
methenamine mandelate ....... 12
montelukast .......................... 81
necon 1/50 (28) .....................74
methimazole ......................... 56
morgidox .............................. 12
necon 10/11 (28) ...................74
methotrexate sodium ............ 18
morphine......................... 28, 29
necon 7/7/7 (28) ....................74
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
96

NEEDLES, INSULIN
NORMOSOL-R PH 7.4 ....... 87
ondansetron hcl .....................63
DISP.,SAFETY ................ 58
NORTHERA ........................ 53
ondansetron hcl (pf) ..............63
nefazodone ........................... 35
nortrel 0.5/35 (28)................. 74
ONFI .....................................23
neomycin ................................ 9
nortrel 1/35 (21).................... 74
ONGLYZA ...........................59
neomycin-bacitracin-poly-hc 78
nortrel 1/35 (28).................... 74
OPDIVO ...............................19
neomycin-bacitracinnortrel 7/7/7 (28) .................. 74
OPSUMIT.............................81
polymyxin......................... 76
nortriptyline .......................... 35
ORACEA ..............................12
neomycin-polymyxin b gu ... 52
NORVIR ................................. 3
oralone ..................................55
neomycin-polymyxin bNOVAREL ........................... 60
ORKAMBI ...........................81
dexameth .......................... 78
NOVOFINE.......................... 58
orsythia .................................74
neomycin-polymyxinNOVOLIN 70/30 .................. 58
oseltamivir ..............................3
gramicidin......................... 76
NOVOLIN N ........................ 58
oxacillin ................................ 11
neomycin-polymyxin-hc 55, 78
NOVOLIN R ........................ 58
oxacillin in dextrose(iso-osm)
neo-polycin ........................... 76
NOVOLOG .......................... 58
..........................................11
neo-polycin hc ...................... 78
NOVOLOG FLEXPEN ........ 58
oxaliplatin .............................19
NEORAL.............................. 18
NOVOLOG MIX 70-30 ....... 58
OXALIPLATIN ...................19
NEPHRAMINE 5.4 % ......... 87
NOVOLOG MIX 70-30
oxandrolone ..........................60
NEUPOGEN ........................ 66
FLEXPEN ........................ 58
oxaprozin ..............................31
NEUPRO .............................. 24
NOVOLOG PENFILL ......... 58
oxazepam ..............................35
nevirapine ............................... 3
NOVOTWIST ...................... 58
oxcarbazepine .......................23
NEXAVAR .......................... 19
NOXAFIL .............................. 1
oxybutynin chloride ..............82
next choice one dose ............ 74
NUCYNTA .......................... 31
oxycodone.............................29
niacin .................................... 45
NUCYNTA ER .................... 31
OXYCODONE .....................29
nicardipine ............................ 41
NUEDEXTA ........................ 26
oxycodone-acetaminophen ...29
NICOTROL.......................... 54
NULOJIX ............................. 19
oxycodone-aspirin ................29
NICOTROL NS.................... 54
NUPLAZID .......................... 35
oxymorphone ........................29
nifedipine.............................. 41
NUVARING ......................... 72
P
nikki (28) .............................. 74
nyamyc ................................. 49
pacerone ................................ 38
NILANDRON ...................... 19
nystatin ............................. 1, 49
PACLITAXEL .....................19
nilutamide ............................. 19
nystatin-triamcinolone .......... 49
paliperidone ....................35, 36
nimodipine............................ 41
nystop ................................... 49
pamidronate ..........................60
NINLARO ............................ 19
PANCREAZE.......................63
O
nitro-bid ................................ 46
ocella .................................... 74
PANRETIN ..........................47
nitrofurantoin macrocrystal .. 12
octreotide acetate .................. 19
pantoprazole .........................65
nitrofurantoin monohyd/mODEFSEY .............................. 3
paricalcitol ............................60
cryst .................................. 13
ODOMZO ............................ 19
paroex oral rinse ...................55
nitroglycerin ......................... 46
OFEV.................................... 81
paromomycin ..........................9
NITROSTAT........................ 46
ofloxacin ................... 12, 55, 76
paroxetine hcl .......................36
nizatidine .............................. 65
ogestrel (28) .......................... 74
PASER ....................................9
NORDITROPIN FLEXPRO 66
olanzapine............................. 35
PATADAY ...........................77
noreth-ethinyl estradiol-iron. 74
olanzapine-fluoxetine ........... 35
PAXIL ..................................36
norethindrone (contraceptive)
olmesartan ............................ 41
PAZEO .................................77
.......................................... 71
olmesartan-amlodipinePEDIARIX (PF) ...................68
norethindrone acetate ........... 71
hydrochlorothiazide .......... 41
PEDVAX HIB (PF) ..............68
norgestimate-ethinyl estradiol
olmesartanpeg 3350-electrolytes............63
.......................................... 74
hydrochlorothiazide .......... 41
PEGANONE.........................23
NORMOSOL-M IN 5 %
olopatadine ..................... 55, 77
PEGASYS ............................66
DEXTROSE ..................... 87
omega-3 acid ethyl esters ..... 45
peg-electrolyte soln ..............63
NORMOSOL-R ................... 84
omeprazole ........................... 65
PEGINTRON .......................66
NORMOSOL-R IN 5 %
ONCASPAR......................... 19
PEGINTRON REDIPEN......66
DEXTROSE ..................... 83
ondansetron .......................... 63
penicillin g potassium ...........11
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
97

penicillin g procaine ............. 11
potassium chloride................ 84
procto-pak .............................64
penicillin g sodium ............... 11
potassium chloride in 0.9%nacl
proctosol hc ..........................64
penicillin v potassium........... 11
.......................................... 84
proctozone-hc .......................64
PENTACEL ACTHIB
potassium chloride in 5 % dex
progesterone micronized ......71
COMPONENT (PF) ......... 68
.......................................... 84
PROGLYCEM .....................59
PENTAM ............................... 9
potassium chloride in lr-d5 ... 84
PROLEUKIN .......................66
PENTASA ............................ 63
potassium chloride-0.45 % nacl
PROLIA ................................ 70
pentoxifylline ....................... 44
.......................................... 84
PROMACTA ........................44
PERFOROMIST .................. 81
potassium chloride-d5promethazine ........................79
perindopril erbumine ............ 41
0.2%nacl ........................... 84
propafenone ..........................38
periogard............................... 55
potassium chloride-d5propranolol ...........................41
PERJETA ............................. 19
0.3%nacl ........................... 84
propranololpermethrin ............................ 52
potassium chloride-d5hydrochlorothiazide ..........41
perphenazine......................... 36
0.9%nacl ........................... 84
propylthiouracil ....................57
perphenazine-amitriptyline... 36
potassium citrate ................... 83
PROQUAD (PF) ...................68
phenelzine............................. 36
PRADAXA ........................... 44
PROSOL 20 % .....................87
phenobarbital ........................ 23
PRALUENT PEN................. 45
protriptyline ..........................36
phenoxybenzamine ............... 41
pramipexole .................... 24, 25
PULMOZYME .....................81
PHENYTEK ......................... 23
pravastatin ............................ 45
PURIXAN ............................19
phenytoin .............................. 23
prazosin ................................ 41
pyrazinamide ..........................9
phenytoin sodium ................. 23
prednicarbate ........................ 51
pyridostigmine bromide........26
phenytoin sodium extended .. 23
prednisolone ......................... 56
Q
philith ................................... 74
prednisolone acetate ............. 78
QUADRACEL (PF) .............68
PHOSPHOLINE IODIDE .... 77
prednisolone sodium phosphate
quasense ................................ 75
pilocarpine hcl ................ 54, 77
.................................... 56, 78
quetiapine .............................36
pimozide ............................... 36
prednisone ............................ 56
quinapril ................................ 41
pimtrea (28) .......................... 74
prednisone intensol ............... 56
quinapril-hydrochlorothiazide
pindolol................................. 41
PREGNYL............................ 60
..........................................41
pioglitazone .......................... 59
PREMARIN ......................... 71
quinidine gluconate ..............38
pioglitazone-glimepiride ...... 59
premasol 10 % ...................... 87
quinidine sulfate ...................38
pioglitazone-metformin ........ 59
PREMASOL 6 % ................. 87
quinine sulfate ........................9
piperacillin-tazobactam ........ 11
prenatal vitamin oral tablet ... 88
R
PIPERACILLINprevalite ................................ 45
RABAVERT (PF) ................68
TAZOBACTAM .............. 11
previfem................................ 75
rajani .....................................75
pirmella................................. 74
PREZCOBIX .......................... 3
raloxifene ..............................70
piroxicam.............................. 31
PREZISTA ............................. 3
ramipril .................................41
PLASMA-LYTE 148 ........... 87
PRIFTIN ................................. 9
RANEXA .............................45
PLASMA-LYTE A .............. 87
PRIMAQUINE ....................... 9
ranitidine hcl .........................65
podofilox .............................. 47
primidone.............................. 23
RAPAMUNE ........................19
polycin .................................. 76
PRISTIQ ............................... 36
rasagiline...............................25
polyethylene glycol 3350 ..... 64
PROAIR HFA ...................... 81
RAVICTI ..............................54
polymyxin b sulfate ................ 9
PROAIR RESPICLICK ....... 81
REBIF (WITH ALBUMIN) .66
polymyxin b sulf-trimethoprim
probenecid ............................ 69
REBIF REBIDOSE ..............66
.......................................... 76
probenecid-colchicine .......... 69
REBIF TITRATION PACK .66
POMALYST ........................ 19
procainamide ........................ 38
reclipsen (28) ........................75
portia..................................... 75
PROCALAMINE 3% ........... 87
RECOMBIVAX HB (PF).....68
PORTRAZZA ...................... 19
prochlorperazine ................... 64
regonol ..................................26
potassium bicarb and chloride
prochlorperazine edisylate .... 64
REGRANEX ........................47
.......................................... 84
prochlorperazine maleate oral
RELENZA DISKHALER ......3
potassium chlorid-d5.......................................... 64
RELISTOR ...........................64
0.45%nacl ......................... 84
PROCRIT ............................. 66
REMICADE .........................64
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
98

REMODULIN ...................... 41
SENSIPAR ..................... 60, 61
SUBOXONE ........................31
RENVELA ........................... 54
SEREVENT DISKUS .......... 81
sucralfate...............................65
repaglinide ............................ 59
SEROQUEL XR................... 36
sulfacetamide sodium ...........78
repaglinide-metformin .......... 59
sertraline ............................... 36
sulfacetamide sodium (acne) 48
REPATHA PUSHTRONEX 45
sevelamer carbonate ............. 54
sulfacetamide-prednisolone ..78
REPATHA SURECLICK .... 45
sf 55
sulfadiazine ...........................12
REPATHA SYRINGE ......... 45
sf 5000 plus .......................... 55
sulfamethoxazole-trimethoprim
reprexain ............................... 29
SIGNIFOR............................ 20
..........................................12
RESCRIPTOR ........................ 3
sildenafil ............................... 81
SULFAMYLON ...................48
RESTASIS ........................... 77
silver sulfadiazine ................. 46
sulfasalazine .........................64
RESTASIS MULTIDOSE ... 77
SIMBRINZA ........................ 78
sulindac .................................31
RETROVIR ............................ 3
SIMULECT .......................... 20
sumatriptan ...........................25
REVLIMID .......................... 19
simvastatin ............................ 45
sumatriptan succinate ...........25
REXULTI ............................. 36
sirolimus ............................... 20
SUPRAX ................................6
REYATAZ ............................. 4
SIRTURO ............................... 9
SURMONTIL .......................36
ribavirin .................................. 4
sodium chloride .............. 54, 85
SUSTIVA ...............................4
rifabutin .................................. 9
sodium chloride 0.45 % ........ 85
SUTENT ...............................20
rifampin .................................. 9
sodium chloride 0.9 % .......... 54
syeda .....................................75
riluzole.................................. 54
sodium chloride 3 % ............. 85
SYLATRON .........................66
rimantadine ............................. 4
sodium chloride 5 % ............. 85
SYMBICORT .......................81
ringer's .................................. 85
sodium lactate intravenous ... 85
SYMLINPEN 120 ................59
risedronate ...................... 54, 70
sodium polystyrene (sorb free)
SYMLINPEN 60 ..................59
RISPERDAL CONSTA ....... 36
.......................................... 54
SYNAGIS ...............................4
risperidone ............................ 36
sodium polystyrene sulfonate
SYNAREL ............................61
RITUXAN ............................ 19
.......................................... 54
SYNERCID ............................9
rivastigmine .......................... 26
SODIUM POLYSTYRENE
SYNJARDY .........................59
rivastigmine tartrate.............. 26
SULFONATE ................... 54
SYNJARDY XR ...................59
rizatriptan ............................. 25
SOLTAMOX ........................ 20
SYNRIBO.............................20
ropinirole .............................. 25
SOLU-CORTEF ................... 56
SYNTHROID .......................61
rosadan ................................. 48
SOLU-CORTEF (PF) ........... 56
SYPRINE .............................54
rosuvastatin........................... 45
SOMATULINE DEPOT ...... 20
T
ROTARIX ............................ 68
SOMAVERT ........................ 61
TABLOID.............................20
ROTATEQ VACCINE ........ 69
sorine .................................... 38
tacrolimus .......................20, 47
ROWEEPRA .................. 23, 24
sotalol ................................... 38
TAFINLAR ..........................20
ROZEREM ........................... 36
sotalol af ............................... 38
TAGRISSO...........................20
RUBRACA........................... 19
SOVALDI .............................. 4
tamoxifen ..............................20
RYDAPT .............................. 19
spironolactone ...................... 41
tamsulosin .............................83
spironolactoneTARCEVA ...........................20
S
SABRIL................................ 24
hydrochlorothiazide .......... 41
TARGRETIN .......................20
SAMSCA ............................. 60
sprintec (28) .......................... 75
TASIGNA.............................20
SANCUSO ........................... 64
SPRITAM ............................. 24
tazarotene ..............................48
SANDIMMUNE ............ 19, 20
SPRYCEL ............................ 20
TAZORAC ...........................48
SANDOSTATIN LAR
sps (with sorbitol) ................. 54
taztia xt .................................41
DEPOT ............................. 20
sronyx ................................... 75
TECENTRIQ ........................20
SANTYL .............................. 51
ssd ......................................... 46
TECFIDERA ........................26
SAPHRIS (BLACK
STAMARIL (PF) ................. 69
TEFLARO ..............................7
CHERRY) ........................ 36
stavudine................................. 4
TEGRETOL XR ...................24
SAVELLA ............................ 70
STIVARGA .......................... 20
TEKTURNA.........................41
selegiline hcl ......................... 25
STRATTERA ....................... 36
TEKTURNA HCT................41
selenium sulfide.................... 46
STREPTOMYCIN ................. 9
telmisartan ............................41
SELZENTRY ......................... 4
STRIBILD .............................. 4
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
99

telmisartanTRANSDERM-SCOP .......... 64
TYSABRI .............................26
hydrochlorothiazide .......... 41
tranylcypromine.................... 36
TYVASO ..............................82
temazepam ............................ 36
travasol 10 % ........................ 87
TYVASO INSTITUTIONAL
TENIVAC (PF) .................... 69
TRAVATAN Z..................... 78
START KIT ......................82
terazosin ............................... 41
trazodone .............................. 37
TYVASO REFILL KIT ........82
terbinafine hcl ......................... 1
TREANDA ........................... 21
TYVASO STARTER KIT ...82
terbutaline ............................. 81
TRECATOR ......................... 10
U
terconazole ........................... 72
TRELSTAR .......................... 21
ULORIC ...............................69
testosterone cypionate .......... 61
TRESIBA FLEXTOUCH Uunithroid ...............................61
testosterone enanthate .......... 61
100 .................................... 59
UPTRAVI .............................42
TETANUS,DIPHTHERIA
TRESIBA FLEXTOUCH Uursodiol .................................64
TOX PED(PF) .................. 69
200 .................................... 59
V
TETANUS-DIPHTHERIA
tretinoin (chemotherapy) ...... 21
valacyclovir ............................4
TOXOIDS-TD.................. 69
tretinoin microspheres .......... 48
VALCHLOR ........................47
tetrabenazine......................... 26
tretinoin topical..................... 48
VALCYTE .............................4
tetracycline ........................... 12
triamcinolone acetonide 51, 55,
valganciclovir .........................4
THALOMID......................... 20
56, 82
valproate sodium ..................24
theophylline .................... 81, 82
triamterenevalproic acid .........................24
thermazene ........................... 46
hydrochlorothiazide .......... 42
valproic acid (as sodium salt)
thioridazine ........................... 36
trianex ................................... 51
..........................................24
thiotepa ................................. 20
triderm .................................. 51
valsartan ................................ 42
thiothixene ............................ 36
tri-estarylla............................ 75
valsartan-hydrochlorothiazide
tiagabine ............................... 24
trifluoperazine ...................... 37
..........................................42
TIKOSYN ............................ 38
trifluridine............................. 76
vancomycin...........................13
tilia fe.................................... 75
trihexyphenidyl ..................... 25
VANCOMYCIN...................13
timolol maleate ............... 41, 76
tri-legest fe ............................ 75
VANCOMYCIN IN 0.9%
tinidazole ................................ 9
tri-linyah ............................... 75
SODIUM CL ....................13
TIVICAY ............................... 4
trilyte with flavor packets ..... 64
VANCOMYCIN IN
tizanidine .............................. 26
trimethoprim ......................... 13
DEXTROSE 5 % ..............13
TOBI PODHALER .............. 10
trimipramine ......................... 37
vandazole ..............................72
TOBRADEX ST .................. 78
trinessa (28) .......................... 75
VAQTA (PF) ........................69
tobramycin ............................ 76
TRINTELLIX ....................... 37
VARIVAX (PF)....................69
tobramycin in 0.225 % nacl . 10
triple vitamin with fluoride... 88
VARIZIG ..............................69
tobramycin sulfate ................ 10
tri-previfem (28) ................... 75
VARUBI ...............................64
tobramycin-dexamethasone.. 78
TRISENOX .......................... 21
VECAMYL ..........................45
TOBREX .............................. 76
tri-sprintec (28) ..................... 75
VELCADE ...........................21
tolazamide ............................ 59
TRIUMEQ .............................. 4
velivet triphasic regimen (28)
tolbutamide ........................... 59
tri-vit with fluoride and iron . 88
..........................................75
tolcapone .............................. 25
tri-vitamin with fluoride ....... 88
VENCLEXTA ......................21
tolmetin................................. 31
trivora (28) ............................ 75
VENCLEXTA STARTING
tolterodine............................. 82
TROPHAMINE 10 % .......... 87
PACK ...............................21
topiramate ............................. 24
TROPHAMINE 6% ............. 87
venlafaxine ...........................37
TOPIRAMATE .................... 24
trospium ................................ 82
VENLAFAXINE ..................37
toposar .................................. 20
TRUMENBA........................ 69
VENTOLIN HFA .................82
topotecan .............................. 20
TRUVADA ............................ 4
verapamil ..............................42
torsemide .............................. 41
TUDORZA PRESSAIR ....... 82
veripred 20 ............................56
tramadol ................................ 31
TWINRIX (PF)..................... 69
VERSACLOZ.......................37
tramadol-acetaminophen ...... 31
TYBOST ................................ 4
VESICARE...........................83
trandolapril ........................... 41
TYGACIL ............................ 10
vestura (28) ...........................75
trandolapril-verapamil .......... 42
TYKERB .............................. 21
VICTOZA 2-PAK ................59
tranexamic acid .............. 44, 72
TYPHIM VI ......................... 69
VICTOZA 3-PAK ................59
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
100

VIDEX 2 GRAM PEDIATRIC
............................................ 4
VIDEX 4 GRAM PEDIATRIC
............................................ 4
VIGAMOX........................... 76
VIIBRYD ............................. 37
VIMPAT............................... 24
VINBLASTINE ................... 21
vincasar pfs ........................... 21
vincristine ............................. 21
vinorelbine............................ 21
viorele (28) ........................... 75
VIRACEPT ............................ 4
VIRAMUNE XR .................... 4
VIRAZOLE ............................ 4
VIREAD ............................. 4, 5
vitamins a,c,d and fluoride ... 88
VIVITROL ........................... 31
VOLTAREN GEL................ 31
voriconazole ........................... 1
VOTRIENT .......................... 21
VPRIV .................................. 61
VRAYLAR........................... 37
VYTORIN 10-10.................. 45
VYTORIN 10-20.................. 45
VYTORIN 10-40.................. 45
VYTORIN 10-80.................. 45
W
warfarin ................................ 44

WELCHOL .......................... 45
wera (28)............................... 75
wymzya fe ............................ 75
X
XALKORI ............................ 21
XARELTO ........................... 44
XATMEP.............................. 21
XELJANZ ............................ 71
XELJANZ XR ...................... 71
XERMELO ........................... 21
XGEVA ................................ 13
XIFAXAN ............................ 10
XIGDUO XR ........................ 59
XOLAIR ............................... 82
XTANDI............................... 21
XYREM................................ 37
Y
YERVOY ............................. 21
YF-VAX (PF) ....................... 69
YONDELIS .......................... 21
Z
zafirlukast ............................. 82
ZALTRAP ............................ 21
zamicet.................................. 29
zarah ..................................... 75
ZAVESCA............................ 61
ZEJULA ............................... 21
ZELBORAF ......................... 21
ZEMPLAR ........................... 61

zenchent (28) ........................75
zenchent fe ............................75
ZENPEP ...............................64
ZERIT .....................................5
ZETIA...................................45
ZIAGEN .................................5
zidovudine ..............................5
ziprasidone hcl ......................37
ZIRGAN ...............................76
zoledronic acid......................61
zoledronic acid-mannitol-water
..........................................54
ZOLINZA .............................21
zolmitriptan...........................25
zolpidem ...............................37
ZOMETA .............................61
zonisamide ............................24
ZORTRESS ..........................21
ZOSTAVAX (PF) ................69
zovia 1/35e (28) ....................75
zovia 1/50e (28) ....................75
ZYCLARA ...........................47
ZYDELIG .............................21
ZYKADIA ............................22
ZYPREXA RELPREVV ......37
ZYTIGA ...............................22

You can find information on what the symbols and abbreviations on this table mean by going to page vi.
101

This formulary was updated on 09/01/2017. For more recent information or other questions, please contact
the Plan at 1-800-815-0000 or, for TTY users, 711, hours are Monday through Sunday, 8am to 8pm or visit
www.guildnetny.org.

15 West 65th Street
New York, NY 10023-6601
Monday – Sunday, 8 am – 8 pm
800-815-0000
TTY: 711
www.guildnetny.org
GN_Gold_Formulary_cover2017_EN.indd 2

86-8641 – 17

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