Get documents about "5_tier_group_drug_list_1_
Document Sample
Updated: January 1st, 2013
What is the Drug List? has expired on a brand name drug, the FDA permits
new manufacturers to create an equivalent of the
Also called a “formulary” by doctors and
brand name drug and make it available to the
pharmacists, the Drug List is an extensive list of
public. Generally, more than one manufacturer will
safe and effective, FDA-approved, brand name and
create generic versions, although often the same
generic prescription drugs used to treat the most
pharmaceutical firm that produces the brand name
common medical conditions.
drug also makes the generic version. This prompts
The Health First Health Plans Pharmacy and competitive pricing of the generic version and
Therapeutics Committee (P&T), a panel of usually results in a less expensive drug.
physicians and pharmacists, developed our Drug
List and updates it regularly. The list includes
The Drug List is subject to change
quality drugs available to you at reasonable cost. In order to continue to offer a safe and cost effective
Only those medications that have successfully selection of prescription drugs, Health First
passed federally required clinical testing and periodically makes changes to the Drug List. These
evaluation and have been proven effective are changes may include removing medications, adding
included. The Pharmacy and Therapeutics restrictions, and/or covering a drug at a higher tier.
Committee reviews and evaluates all available The following list represents some of the most
literature about a drug when updating the list. common scenarios in which changes to drug
coverage will occur:
About tiers
Throughout the year, new medications are
Most covered prescription drugs will be categorized
approved by the FDA. It is the policy of Health
into one of five tiers. The cost of drugs varies
First Health Plans that new drugs will be
widely, even though several different medications
excluded for 6 months from the date of FDA
may be used to treat the same condition. What you
approval, during which time the Health First
pay for the prescription depends upon what tier the
Pharmacy and Therapeutics Committee can
drug is listed in. Health First Health Plans offers
review the drug for safety and efficacy.
many benefit plans that can vary in coverage for
each tier. Details about your specific benefit for The Drug List may change when a medication is
each tier are included in the Health First Health withdrawn from the market due to safety reasons
Plans Summary of Benefits. or if it becomes available over-the-counter
(OTC). At the time that a medication on the
Tier 1 — Preferred Generic Drugs Health First Drug List becomes available OTC, it
Tier 2 — Non-Preferred Generic Drugs may be excluded from coverage from that point
Tier 3 — Preferred Brand Name Drugs forward.
Tier 4 — Non-Preferred Brand Name Drugs When a brand-name prescription drug loses its
Tier 5 — Specialty Drugs (must obtain from patent and the equivalent generic form is added
HFFP or Circles of Care Pharmacy) to the Drug List, the brand-name drug may be
moved to the highest non-specialty drug tier,
Generic drugs are prescription drugs that are which is generally Tier 4 or removed from the
identified by their chemical name. When the patent formulary.
1
2
This formulary is current as of January 1, 2013. To Use Tier 1 generic medications whenever
get updated information about the drugs we cover, possible
please visit our Web site at
Generic drugs are the chemical equivalent of
www.healthfirsthealthplans.org or call Customer
brand-name drugs, and are just as effective in most
Service at 1-800-716-7737. Our hours are: Monday
cases. If you take generic drugs you will generally
through Friday, 8am–8pm, and Saturday, 8am–
pay less, so talk to your doctor about switching to a
Noon. TTY/TDD users should call the Florida
generic equivalent of any brand-name you are
Relay Center at 1-800-955-8771 during the same
taking if it is appropriate. In addition, many of our
business hours.
prescription drug riders include a $2 copayment for
Are there any restrictions on my Tier 1 generic drugs ensuring affordable access to
coverage? many commonly prescribed medications. Please
see the list of drugs below to determine which
Some covered drugs may have additional
drugs are included in Tier 1.
requirements or limits on coverage. These
requirements and limits may include: See if your prescription pills can be split in half
Prior Authorization: Health First requires you For some medications, pills may be available in
and/or your physician to get prior authorization different strengths but still have the same price. If
for certain drugs. This means that you will need you need one of these select medications, your
to get approval from us before you fill your doctor may be able to write your prescription so
prescriptions. In order for the plan to pay for that you can get your pills at double strength, but
these drugs, the physician ordering the half of the number of pills you’d normally need,
prescription is required to submit all medical and you’d only pay half of the regular price. Then
information to Health First Health Plans you’d split them in half, so you’d get the proper
documenting the medical necessity. These drugs dose – saving up to 50 percent of the cost! The
are identified in the Drug List. drugs that may be eligible for the Pill-Splitting
program are marked with the symbol (1/2) on the
Step Therapy: In some cases, Health First requires drug list, so review this information with your
you to first try certain drugs to treat your medical doctor if your drug qualifies.
condition before we will cover another drug for
that condition. For example, if Drug A and Drug B What if my drug is not on the Formulary?
both treat your medical condition, we may not If your drug is not included in this formulary, you
cover drug B unless you try Drug A first. If Drug A should first contact Customer Service and confirm
does not work for you, we will then cover Drug B. that your drug is not covered. If you learn that Health
Please see the reference table on page 9 for a First Health Plans does not cover your drug, you have
complete listing of the drugs which currently two options:
require step therapy.
You can ask Customer Service for a list of similar
Quantity Limits: For certain drugs, Health First drugs that are covered by Health First Health
Health Plans limits the amount of the drug that Plans. When you receive the list, show it to your
Health First Health Plans will cover. For example, doctor and ask him or her to prescribe a similar
Health First Health Plans provides 30 tablets per drug that is covered by Health First Health Plans.
prescription for Pradaxa. This may be in addition You can ask Health First Health Plans to make an
to a standard one month or three month supply. exception and cover your drug. See below for
How can I make the most of my information about how to request an exception.
prescription drug benefit? If Health First Health Plans approves you or your
physician’s request for an exception to the Health
Prescription drug costs continue to rise every year and
First Health Plans formulary the approved drug
can represent a significant part of your healthcare
will be covered at the Tier 4 cost share. If the cost
expenses. Health First Health Plans can help you pay
of the medication is greater than $500 per month
for your medications by sharing the cost with you and
it will be covered at the T5 or Specialty Tier.
providing substantial discounts for medications you
purchase. To help you manage your drug costs, here Excluded drugs
are some money-saving tips to consider:
3
Health First Health Plans does not provide coverage
for all drugs. In addition to the drugs marked
Injectables (except insulin, Imitrex, and those
“excluded” in this drug list, newly FDA approved
requiring prior authorization)
drugs are not covered unless the P & T Committee
in its sole discretion approves these drugs for Multivitamins and nutritional supplements
coverage. Health First Health Plans will (except prescription pre-natal vitamins)
automatically exclude a particular drug if a generic
Nicotine products
version becomes available and an entire class of
drugs if a particular drug within that class becomes Nonprescriptive supplies or substances
available over the counter. Oral and topical antifungals for onychomycosis
The following are NOT covered by (such as Lamisil, Sporanox, and Penlac)
HFHP: Over-the-counter (OTC) medications (such as
Compounded drugs Lotrimin, Zantac 75, Pepcid AC or their generic
formulations), or any drug for which a similar
Cosmetics or any drugs used for cosmetic over-the-counter version is available
purposes (such as Retin-A, Rogaine, Topical
Minoxidil, and Vaniqa) All new drugs approved by the FDA will be
excluded from the preferred drug list/formulary
Diabetic supplies, blood glucose monitors and unless HFHP’s Pharmacy and Therapeutics
test strips other than those manufactured by Committee, in its sole discretion, decides to
Abbott under the product name Freestyle, waive this exclusion for a particular drug.
Precision, and test strips®
Sleeping agents (such as Sonata and Lunesta)
Erectile dysfunction drugs (such as Viagra)
Support garments
Infertility drugs (such as Clomid) and abortive
drugs such as Plan B and RU486 Syringes, needles, or other disposable supplies
(except those used with insulin)
For information about a specific drug not listed, please contact Customer Service. Health First Health Plans
Customer Service is available Monday–Friday, 8am–8pm, and Saturday, 8am–Noon. TTY is available during the same
hours.
Phone (321) 434-5665 TDD/TTY relay (800) 955-8771
Toll free (800) 716-7737 E-mail hfhpinfo@health-first.org
4
Health First Health Plans Formulary
The formulary that begins on the next page provides coverage information about some of the drugs covered by
Health First Health Plans. If you have trouble finding your drug in the list, turn to the Index that begins on page
73. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PRADAXA) and
generic drugs are listed in lower-case italics (e.g., lisinopril).
The information in the Requirements/Limits column tells you if Health First Health Plans has any special
requirements for coverage of your drug.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information
consult your Pharmacy Directory or call Customer Service at the numbers listed above.
PA: Prior Authorization. Health First Health Plans requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval from Health First Health Plans before you fill your
prescriptions. If you don't get approval, Health First Health Plans may not cover the drug.
QL: Quantity Limit may also be listed. (For example, “30/30 days” would mean your coverage of this drug is
limited to 30 pills every 30 days.) Prescriptions written for more than the suggested Quantity Limits will only
be honored up to the listed amount.
ST: Step Therapy. In some cases, Health First Health Plans 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, Health First Health Plans may not cover drug B unless you try Drug A first.
If Drug A does not work for you, Health First Health Plans will then cover Drug B.
1/2: You may be able to split these pills in half. Begin by asking your doctor if pill-splitting is right for you. If
so, ask your doctor to write your prescription for half the number of pills and double the strength you normally
need. For example, instead of 30 pills of 20 mg, you’d get a prescription for 15 pills of 40 mg. Then you (or the
pharmacy) can split them in half for the correct dose. This way, you save 50 percent of the cost. Call our
Customer Service Department for details.
MD: Maintenance Drug. You may be taking these drugs on a long-term basis. Maintenance medications are
generally those used to treat chronic conditions and long-term conditions.
5
Step Therapy Reference Table
Step 2 Drugs Step Therapy Criteria Step 1 Drugs
AXERT Before using AXERT, you must first try the following Step 1 drug: sumatriptan
FROVA Before using FROVA, you must first try the following Step 1 drug: sumatriptan
LYRICA Before using LYRICA, you must first try the following Step 1 drug: gabapentin
MAXALT & Before using MAXALT or MAXALT MLT, you must first try the sumatriptan
MAXALT following Step 1 drug:
MLT
RELPAX Before using RELPAX, you must first try the following Step 1 drug: sumatriptan
TREXIMET Before using TREXIMET, you must first try the following Step 1 drug: sumatriptan
ULORIC Before using ULORIC, you must first try the following Step 1 drug: allopurinol
ZOMIG Before using ZOMIG you must first try the following Step 1 drug: sumatriptan
6
Contraceptive coverage for new employer groups and employer groups
renewing August 1st, 2012 and thereafter
Beginning August 1st, 2012, members of new and renewing employer group plans subject to preventive care
provisions of the Affordable Care Act are eligible to receive the following prescription contraceptives with no cost
share
NECON 0.5/35-28
NECON 1/35-28
NORTREL 0.5/35 (28)
NORTREL 1/35 (21)
NORTREL 1/35 (28)
CYCLAFEM 1/35
ALYACEN 1/35
LOW-OGESTREL
CRYSELLE-28
NORGESTREL/ETHINYL ESTRADIOL
NECON 7/7/7
NORTREL 7/7/7
CYCLAFEM 7/7/7
ALYACEN 7/7/7
TRI-SPRINTEC
TRINESSA
TRI-PREVIFEM
NORGESTIMATE/ETHINYL ESTRADIOL
If you have any questions regarding your eligibility for preventive contraceptive coverage, please contact your
employer or HFHP’s Customer Service Department at 321-434-5665 or 1-800-716-7737. Our Customer Service
hours are: Monday through Friday, 8am–8pm, and Saturday, 8am–Noon. TTY/TDD users should call the Florida
Relay Center at 1-800-955-8771 during the same business hours.
7
Table of Contents
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS ....................................................................9
AMINOGLYCOSIDES .........................................................................................................................................9
ANALGESICS - ANTI-INFLAMMATORY ......................................................................................................10
ANALGESICS - NONNARCOTIC.....................................................................................................................11
ANALGESICS - OPIOID ....................................................................................................................................11
ANDROGENS-ANABOLIC ...............................................................................................................................13
ANORECTAL AGENTS.....................................................................................................................................13
ANTHELMINTICS .............................................................................................................................................14
ANTIANGINAL AGENTS .................................................................................................................................14
ANTIANXIETY AGENTS..................................................................................................................................14
ANTIARRHYTHMICS .......................................................................................................................................15
ANTIASTHMATIC AND BRONCHODILATOR AGENTS.............................................................................15
ANTICOAGULANTS .........................................................................................................................................17
ANTICONVULSANTS .......................................................................................................................................17
ANTIDEPRESSANTS.........................................................................................................................................19
ANTIDIABETICS ...............................................................................................................................................21
ANTIDIARRHEALS ...........................................................................................................................................23
ANTIDOTES .......................................................................................................................................................23
ANTIEMETICS ...................................................................................................................................................23
ANTIFUNGALS..................................................................................................................................................24
ANTIHISTAMINES ............................................................................................................................................24
ANTIHYPERLIPIDEMICS .................................................................................................................................24
ANTIHYPERTENSIVES ....................................................................................................................................25
ANTI-INFECTIVE AGENTS - MISC.................................................................................................................28
ANTIMALARIALS .............................................................................................................................................28
ANTIMYASTHENIC AGENTS .........................................................................................................................29
ANTIMYCOBACTERIAL AGENTS .................................................................................................................29
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES................................................................................29
ANTIPARKINSON AGENTS.............................................................................................................................30
ANTIPSYCHOTICS/ANTIMANIC AGENTS ...................................................................................................31
ANTIVIRALS......................................................................................................................................................32
ASSORTED CLASSES.......................................................................................................................................35
BETA BLOCKERS .............................................................................................................................................35
CALCIUM CHANNEL BLOCKERS..................................................................................................................36
CARDIOTONICS ................................................................................................................................................37
CARDIOVASCULAR AGENTS - MISC. ..........................................................................................................37
CEPHALOSPORINS...........................................................................................................................................37
CHEMICALS.......................................................................................................................................................38
CONTRACEPTIVES...........................................................................................................................................38
CORTICOSTEROIDS .........................................................................................................................................41
COUGH/COLD/ALLERGY................................................................................................................................42
DERMATOLOGICALS ......................................................................................................................................43
DIGESTIVE AIDS...............................................................................................................................................50
DIURETICS.........................................................................................................................................................50
ENDOCRINE AND METABOLIC AGENTS - MISC. ......................................................................................51
ESTROGENS ......................................................................................................................................................52
FLUOROQUINOLONES ....................................................................................................................................53
8
GASTROINTESTINAL AGENTS - MISC.........................................................................................................54
GENITOURINARY AGENTS - MISCELLANEOUS........................................................................................54
GOUT AGENTS..................................................................................................................................................55
HEMATOLOGICAL AGENTS - MISC. ............................................................................................................55
HEMATOPOIETIC AGENTS.............................................................................................................................56
HEMOSTATICS..................................................................................................................................................56
HYPNOTICS .......................................................................................................................................................56
LAXATIVES .......................................................................................................................................................57
MACROLIDES....................................................................................................................................................57
MIGRAINE PRODUCTS....................................................................................................................................58
MINERALS & ELECTROLYTES ......................................................................................................................59
MOUTH/THROAT/DENTAL AGENTS............................................................................................................59
MULTIVITAMINS..............................................................................................................................................60
MUSCULOSKELETAL THERAPY AGENTS..................................................................................................62
NASAL AGENTS - SYSTEMIC AND TOPICAL .............................................................................................62
OPHTHALMIC AGENTS...................................................................................................................................63
OTIC AGENTS....................................................................................................................................................66
OXYTOCICS.......................................................................................................................................................67
PENICILLINS......................................................................................................................................................67
PHARMACEUTICAL ADJUVANTS ................................................................................................................67
PROGESTINS .....................................................................................................................................................68
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. ..........................................................68
RESPIRATORY AGENTS - MISC.....................................................................................................................69
SULFONAMIDES ...............................................................................................................................................69
TETRACYCLINES .............................................................................................................................................69
THYROID AGENTS ...........................................................................................................................................69
ULCER DRUGS ..................................................................................................................................................70
URINARY ANTI-INFECTIVES .........................................................................................................................71
URINARY ANTISPASMODICS ........................................................................................................................71
VAGINAL PRODUCTS......................................................................................................................................72
VASOPRESSORS ...............................................................................................................................................72
VITAMINS ..........................................................................................................................................................72
Index.....................................................................................................................................................................73
9
Drug Name Tier Notes
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
Adhd Agent - Selective Alpha Adrenergic Agonists
INTUNIV T3 QL (31 per 31 Day(s))
Adhd Agent - Selective Norepinephrine Reuptake Inhibitor
STRATTERA T3
Amphetamine Mixtures
ADDERALL XR T3
amphetamine-dextroamphetamine oral tablet 10 MG, 12.5 MG,
T2
15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG
Amphetamines
dextroamphetamine sulfate oral tablet 10 MG, 5 MG T2
dextroamphetamine sulfate er T2
VYVANSE T3
Stimulants - Misc.
DAYTRANA T4
dexmethylphenidate hcl T2
FOCALIN XR T3
METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML T2
METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5
T2
MG
methylphenidate hcl oral capsule extended release 24 hour 20
T2
MG, 30 MG, 40 MG
methylphenidate hcl oral solution 10 MG/5ML, 5 MG/5ML T2
methylphenidate hcl oral tablet 10 MG, 20 MG, 5 MG T2
methylphenidate hcl oral tablet extendedrelease 10 MG, 18 MG,
T2
27 MG, 36 MG, 54 MG
methylphenidate hcl er T2
NUVIGIL ORAL TABLET 150 MG, 50 MG T4 PA; QL (31 per 31 Day(s))
PROVIGIL ORAL TABLET 200 MG T4 PA; QL (31 per 31 Day(s))
PROVIGIL ORAL TABLET 100 MG T4 PA; QL (62 per 31 Day(s))
AMINOGLYCOSIDES
Aminoglycosides
neomycin sulfate oral tablet 500 MG T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
10
Drug Name Tier Notes
paromomycin sulfate oral capsule 250 MG T2
ANALGESICS - ANTI-INFLAMMATORY
Anti-Tnf-Alpha - Monoclonoal Antibodies
HUMIRA SUBCUTANEOUS KIT 40 MG/0.8ML T5 PA; QL (2.4 per 31 Day(s))
HUMIRA SUBCUTANEOUS KIT 20 MG/0.4ML T5 PA; QL (4.8 per 31 Day(s))
HUMIRA PEN-CROHNS STARTER T5 PA; QL (2.4 per 31 Day(s))
Cyclooxygenase 2 (Cox-2) Inhibitors
CELEBREX T4 ST; QL (62 per 31 Day(s))
Gold Compounds
RIDAURA T3
Nonsteroidal Anti-Inflammatory Agents (Nsaids)
diclofenac sodium oral tablet delayed release 25 MG, 50 MG, 75
T2
MG
diclofenac sodium er T2
etodolac oral capsule 200 MG, 300 MG T2
etodolac oral tablet 400 MG, 500 MG T2
etodolac er oral tablet extended release 24 hr 500 MG, 600 MG T2
flurbiprofen oral tablet 100 MG, 50 MG T2
IBU T1
indomethacin oral capsule 25 MG, 50 MG T2
ketoprofen oral capsule 50 MG, 75 MG T2
ketorolac tromethamine oral tablet 10 MG T2
mefenamic acid oral capsule 250 MG T2
meloxicam oral tablet 15 MG, 7.5 MG T2
nabumetone oral tablet 500 MG, 750 MG T2
NAPROSYN ORAL TABLET 375 MG T1
naproxen oral tablet 250 MG, 375 MG, 500 MG T1
naproxen dr oral tablet delayed release 500 MG T1
naproxen sodium oral tablet 275 MG, 550 MG T1
oxaprozin T2
piroxicam oral capsule 10 MG, 20 MG T2
SPRIX T4
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
11
Drug Name Tier Notes
sulindac oral tablet 150 MG, 200 MG T2
Pyrimidine Synthesis Inhibitors
leflunomide T2 QL (31 per 31 Day(s))
Soluble Tumor Necrosis Factor Receptor Agents
ENBREL SUBCUTANEOUS SOLUTION 50 MG/ML T5 PA; QL (4 per 31 Day(s))
ENBREL SUBCUTANEOUS KIT T5 PA; QL (8 per 31 Day(s))
ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML T5 PA; QL (8 per 31 Day(s))
ANALGESICS - NONNARCOTIC
Analgesics-Sedatives
BUPAP T2
butalbital-acetaminophen T2
butalbital-apap-caffeine oral capsule 50-325-40 MG T2
butalbital-apap-caffeine oral tablet 50-325-40 MG T2
butalbital-aspirin-caffeine T2
Salicylates
diflunisal oral tablet 500 MG T3
ANALGESICS - OPIOID
Codeine Combinations
acetaminophen-codeine T2
acetaminophen-codeine #2 T2 QL (248 per 31 Day(s))
acetaminophen-codeine #3 T2 QL (248 per 31 Day(s))
acetaminophen-codeine #4 T2 QL (248 per 31 Day(s))
butalbital-apap-caff-cod T2
Dihydrocodeine Combinations
TREZIX T4
Hydrocodone Combinations
CO-GESIC T2 QL (248 per 31 Day(s))
hydrocodone-acetaminophen oral solution 7.5-325 MG/15ML,
T2
7.5-500 MG/15ML
hydrocodone-acetaminophen oral tablet 10-660 MG, 10-750 MG,
T2 QL (155 per 31 Day(s))
7.5-750 MG
hydrocodone-acetaminophen oral tablet 10-650 MG, 7.5-650 MG T2 QL (186 per 31 Day(s))
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
12
Drug Name Tier Notes
hydrocodone-acetaminophen oral tablet 10-325 MG, 10-500 MG,
T2 QL (248 per 31 Day(s))
2.5-500 MG, 5-500 MG, 7.5-325 MG, 7.5-500 MG
hydrocodone-acetaminophen oral tablet 10-300 MG, 5-300 MG,
T2 QL (403 per 31 Day(s))
7.5-300 MG
hydrocodone-ibuprofen oral tablet 7.5-200 MG T2 QL (155 per 31 Day(s))
REPREXAIN ORAL TABLET 5-200 MG T2 QL (155 per 31 Day(s))
Opioid Agonists
AVINZA T4
codeine sulfate oral tablet 15 MG, 30 MG, 60 MG T2 QL (248 per 31 Day(s))
fentanyl T2 QL (10 per 31 Day(s))
hydromorphone hcl oral liquid† 1 MG/ML T2
hydromorphone hcl oral tablet 2 MG, 4 MG, 8 MG T2 QL (248 per 31 Day(s))
methadone hcl oral tablet 10 MG, 5 MG T2 QL (248 per 31 Day(s))
morphine sulfate oral capsule extended release 24 hour 100 MG,
T2
20 MG, 30 MG, 50 MG, 60 MG, 80 MG
morphine sulfate oral solution 10 MG/5ML, 20 MG/5ML T2
morphine sulfate oral tablet 15 MG, 30 MG T2 QL (248 per 31 Day(s))
morphine sulfate er oral tablet extended release 12 hr 200 MG T2 QL (62 per 31 Day(s))
morphine sulfate er oral tablet extended release 12 hr 100 MG,
T2 QL (93 per 31 Day(s))
15 MG, 30 MG, 60 MG
OPANA ER ORAL TABLET EXTENDED RELEASE 12 HR 10
T3
MG, 20 MG, 30 MG, 40 MG, 5 MG
oxycodone hcl oral tablet 10 MG, 20 MG, 5 MG T2 QL (248 per 31 Day(s))
oxycodone hcl oral solution 5 MG/5ML T4
ROXICODONE ORAL TABLET 15 MG, 30 MG T2 QL (248 per 31 Day(s))
tramadol hcl oral tablet 50 MG T2 QL (372 per 31 Day(s))
Opioid Combinations
oxycodone-acetaminophen oral tablet 10-650 MG T2 QL (186 per 31 Day(s))
oxycodone-acetaminophen oral capsule T2 QL (248 per 31 Day(s))
oxycodone-acetaminophen oral tablet 10-325 MG, 2.5-325 MG,
T2 QL (248 per 31 Day(s))
5-325 MG, 7.5-325 MG, 7.5-500 MG
oxycodone-aspirin T2
oxycodone-ibuprofen T2 QL (155 per 31 Day(s))
Opioid Partial Agonists
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
13
Drug Name Tier Notes
buprenorphine hcl sublingual tablet sublingual 2 MG, 8 MG T2
BUTRANS T4
pentazocine-naloxone hcl T2
SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 8-2 MG T3
Pentazocine Combinations
pentazocine-acetaminophen T2
Tramadol Combinations
tramadol-acetaminophen T2
ANDROGENS-ANABOLIC
Androgens
ANDROGEL TRANSDERMAL GEL 25 MG/2.5GM T3
ANDROGEL TRANSDERMAL GEL 50 MG/5GM T3 QL (300 per 31 Day(s))
ANDROGEL PUMP TRANSDERMAL GEL 1.25 GM/ACT
T3
(1%)
ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT
T3 QL (300 per 31 Day(s))
(1.62%)
danazol oral capsule 100 MG, 200 MG, 50 MG T2
FORTESTA T4
TESTIM T4
testosterone cypionate intramuscular oil 100 MG/ML, 200
T2
MG/ML
testosterone enanthate intramuscular oil 200 MG/ML T2
ANORECTAL AGENTS
Intrarectal Steroids
CORTIFOAM T4
hydrocortisone re enema 100 MG/60ML T2
Rectal Anesthetic/Steroids
ANALPRAM ADVANCED T4
hydrocortisone ace-pramoxine re cream 1-1 %, 2.5-1 % T2
lidocaine-hydrocortisone ace re cream 3-0.5 % T2
lidocaine-hydrocortisone ace re gel 2.8-0.55 % T2
lidocaine-hydrocortisone ace re kit 2-2 %, 3-0.5 %, 3-1 %, 3-2.5
T2
%
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
14
Drug Name Tier Notes
PROCORT T3
PROCTOFOAM HC T3
Rectal Steroids
hemorrhoidal-hc T2
hydrocortisone acetate re suppository 30 MG T2
PROCTOCREAM HC T2
PROCTO-PAK T2
PROCTOSOL HC T2
PROCTOZONE-HC T2
ANTHELMINTICS
Anthelmintics
ALBENZA T3
STROMECTOL T3
ANTIANGINAL AGENTS
Antianginals-Other
RANEXA T4
Nitrates
isosorbide dinitrate T1
isosorbide dinitrate er T1
isosorbide mononitrate T2
isosorbide mononitrate er T2
MINITRAN T2
NITRO-BID T3
nitroglycerin transdermal patch 24 hr 0.1 MG/HR, 0.2 MG/HR,
T2
0.4 MG/HR, 0.6 MG/HR
NITROLINGUAL T4
NITROSTAT T3
ANTIANXIETY AGENTS
Antianxiety Agents - Misc.
buspirone hcl oral tablet 10 MG, 15 MG, 30 MG, 5 MG, 7.5 MG T2
hydroxyzine hcl intramuscular solution 25 MG/ML, 50 MG/ML T2
hydroxyzine hcl oral syrup 10 MG/5ML T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
15
Drug Name Tier Notes
hydroxyzine hcl oral tablet 10 MG, 25 MG, 50 MG T2
hydroxyzine pamoate oral capsule 100 MG, 25 MG T2
meprobamate T2
Benzodiazepines
alprazolam oral tablet 0.25 MG, 0.5 MG, 1 MG, 2 MG T2
alprazolam er T2
chlordiazepoxide hcl T2
clorazepate dipotassium T2 PA
diazepam oral solution 1 MG/ML T2
diazepam oral tablet 10 MG, 2 MG, 5 MG T2
DIAZEPAM INTENSOL T4 PA
lorazepam oral concentrate 2 MG/ML T2
lorazepam oral tablet 0.5 MG, 1 MG, 2 MG T2
ANTIARRHYTHMICS
Antiarrhythmics Type I-A
disopyramide phosphate oral capsule 100 MG, 150 MG T2
quinidine gluconate er T2
quinidine sulfate T2
quinidine sulfate er T3
Antiarrhythmics Type I-C
flecainide acetate T2
propafenone hcl T2
Antiarrhythmics Type Iii
amiodarone hcl oral tablet 200 MG, 400 MG T2
MULTAQ T3
PACERONE T3
TIKOSYN T3
ANTIASTHMATIC AND BRONCHODILATOR AGENTS
5-Lipoxygenase Inhibitors
ZYFLO CR T4 QL (124 per 31 Day(s))
Adrenergic Combinations
ADVAIR DISKUS T3 QL (62 per 31 Day(s))
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
16
Drug Name Tier Notes
ADVAIR HFA T3 QL (12 per 31 Day(s))
COMBIVENT T3
COMBIVENT RESPIMAT T3
DULERA T3 QL (13 per 31 Day(s))
ipratropium-albuterol T2
SYMBICORT INHALATION AEROSOL† 160-4.5 MCG/ACT T4 QL (10.2 per 31 Day(s))
SYMBICORT INHALATION AEROSOL† 80-4.5 MCG/ACT T4 QL (13.8 per 31 Day(s))
Anti-Ige Monoclonal Antibodies
XOLAIR T5 PA
Beta Adrenergics
albuterol sulfate inhalation nebulization solution (2.5 MG/3ML)
T2
0.083%, (5 MG/ML) 0.5%, 0.63 MG/3ML, 1.25 MG/3ML
albuterol sulfate oral syrup 2 MG/5ML T2
albuterol sulfate oral tablet 2 MG, 4 MG T2
FORADIL AEROLIZER T4
levalbuterol hcl inhalation nebulization solution 0.31 MG/3ML,
T2
0.63 MG/3ML, 1.25 MG/0.5ML, 1.25 MG/3ML
MAXAIR AUTOHALER T3
metaproterenol sulfate oral syrup 10 MG/5ML T2
metaproterenol sulfate oral tablet 10 MG, 20 MG T3
SEREVENT DISKUS T3 QL (62 per 31 Day(s))
terbutaline sulfate oral tablet 2.5 MG, 5 MG T2
VENTOLIN HFA T3 QL (36 per 31 Day(s))
Bronchodilators - Anticholinergics
ATROVENT HFA T4 QL (26 per 31 Day(s))
ipratropium bromide inhalation solution 0.02 % T2
SPIRIVA HANDIHALER T3 QL (31 per 31 Day(s))
Leukotriene Receptor Antagonists
montelukast sodium oral tablet 10 MG T2
montelukast sodium oral tablet chewable 4 MG, 5 MG T2
zafirlukast T2 QL (31 per 31 Day(s))
Mixed Adrenergics
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
17
Drug Name Tier Notes
epinephrine hcl T4
Steroid Inhalants
budesonide inhalation suspension 0.25 MG/2ML, 0.5 MG/2ML T2
FLOVENT DISKUS T3 QL (124 per 31 Day(s))
FLOVENT HFA T3 QL (24 per 31 Day(s))
PULMICORT T3
PULMICORT FLEXHALER T3
Xanthines
theophylline er T2
ANTICOAGULANTS
Coumarin Anticoagulants
COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3
T3
MG, 4 MG, 5 MG, 6 MG, 7.5 MG
JANTOVEN T3
warfarin sodium oral tablet 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG,
T2
4 MG, 5 MG, 6 MG, 7.5 MG
Direct Factor Xa Inhibitors
XARELTO ORAL TABLET 10 MG T3 QL (31 per 31 Day(s))
Heparins And Heparinoid-Like Agents
heparin sodium (porcine) injection solution 1000 UNIT/ML,
T2
10000 UNIT/ML, 20000 UNIT/ML, 5000 UNIT/ML
Low Molecular Weight Heparins
enoxaparin sodium T5 PA; QL (31 per 31 Day(s))
Synthetic Heparinoid-Like Agents
fondaparinux sodium T5 PA
Thrombin Inhibitors - Selective Direct & Reversible
PRADAXA T3
ANTICONVULSANTS
Anticonvulsants - Benzodiazepines
clonazepam oral tablet 0.5 MG, 1 MG, 2 MG T2
clonazepam oral tablet dispersible 0.125 MG, 0.25 MG, 0.5 MG,
T2
1 MG, 2 MG
diazepam re gel 10 MG, 2.5 MG, 20 MG T4
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
18
Drug Name Tier Notes
Anticonvulsants - Misc.
carbamazepine oral capsule extended release 12 hour 100 MG,
T2
200 MG, 300 MG
carbamazepine oral suspension 100 MG/5ML T2
carbamazepine oral tablet 200 MG T2
carbamazepine oral tablet chewable 100 MG T2
carbamazepine oral tablet extended release 12 hr 200 MG, 400
T2
MG
EPITOL T2
gabapentin oral tablet 800 MG T2 QL (140 per 31 Day(s))
gabapentin oral tablet 600 MG T2 QL (186 per 31 Day(s))
gabapentin oral solution 250 MG/5ML T2 QL (2232 per 31 Day(s))
gabapentin oral capsule 400 MG T2 QL (279 per 31 Day(s))
gabapentin oral capsule 100 MG, 300 MG T2 QL (372 per 31 Day(s))
lamotrigine oral tablet 100 MG, 150 MG, 200 MG, 25 MG T2
lamotrigine oral tablet chewable 25 MG, 5 MG T2
levetiracetam oral solution 100 MG/ML T2
levetiracetam oral tablet extended release 24 hr 750 MG T2 QL (124 per 31 Day(s))
levetiracetam oral tablet extended release 24 hr 500 MG T2 QL (186 per 31 Day(s))
levetiracetam oral tablet 250 MG, 500 MG, 750 MG T2 QL (62 per 31 Day(s))
levetiracetam oral tablet 1000 MG T2 QL (93 per 31 Day(s))
LYRICA ORAL CAPSULE 225 MG, 300 MG T4 ST; QL (62 per 31 Day(s))
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG,
T4 ST; QL (93 per 31 Day(s))
50 MG, 75 MG
oxcarbazepine T2
primidone oral tablet 250 MG, 50 MG T2
topiramate oral capsule sprinkle 15 MG, 25 MG T2
topiramate oral tablet 100 MG, 200 MG, 25 MG, 50 MG T2
VIMPAT ORAL SOLUTION 10 MG/ML T4 PA; QL (1240 per 31 Day(s))
VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG T4 PA; QL (62 per 31 Day(s))
zonisamide T2
Gaba Modulators
GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG T4
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
19
Drug Name Tier Notes
GABITRIL ORAL TABLET 4 MG T4 QL (124 per 31 Day(s))
Hydantoins
DILANTIN T4
DILANTIN INFATABS T4
PEGANONE T4
PHENYTEK T4
phenytoin oral suspension 125 MG/5ML T2
phenytoin sodium extended T2
Succinimides
ethosuximide oral capsule 250 MG T2
ethosuximide oral solution 250 MG/5ML T2
Valproic Acid
DEPAKOTE T4
DEPAKOTE ER T4
DEPAKOTE SPRINKLES T4
divalproex sodium T2
valproic acid oral capsule 250 MG T2
valproic acid oral syrup 250 MG/5ML T2
ANTIDEPRESSANTS
Alpha-2 Receptor Antagonists (Tetracyclics)
mirtazapine oral tablet 30 MG, 45 MG T2 QL (31 per 31 Day(s))
mirtazapine oral tablet dispersible T2 QL (31 per 31 Day(s))
mirtazapine oral tablet 15 MG, 7.5 MG T2 QL (93 per 31 Day(s))
Antidepressants - Misc.
BUDEPRION SR T2 QL (62 per 31 Day(s))
bupropion hcl oral tablet 100 MG, 75 MG T2
bupropion hcl er (sr) T2 QL (62 per 31 Day(s))
bupropion hcl er (xl) T2 QL (31 per 31 Day(s))
maprotiline hcl T3
WELLBUTRIN T4
WELLBUTRIN SR T4
WELLBUTRIN XL T4
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
20
Drug Name Tier Notes
Modified Cyclics
nefazodone hcl oral tablet 100 MG, 150 MG, 250 MG, 50 MG T2 QL (62 per 31 Day(s))
nefazodone hcl oral tablet 200 MG T2 QL (93 per 31 Day(s))
trazodone hcl oral tablet 100 MG, 150 MG, 50 MG T2
VIIBRYD T4 QL (31 per 31 Day(s))
Selective Serotonin Reuptake Inhibitors (Ssris)
citalopram hydrobromide T2
escitalopram oxalate T2
fluoxetine hcl oral solution 20 MG/5ML T1
fluoxetine hcl oral capsule 10 MG, 20 MG T1 QL (93 per 31 Day(s))
fluvoxamine maleate T2
paroxetine hcl oral tablet 10 MG, 20 MG, 30 MG, 40 MG T2
paroxetine hcl oral tablet extended release 24 hr 12.5 MG, 25
T2
MG, 37.5 MG
PEXEVA T4
sertraline hcl oral concentrate 20 MG/ML T2
sertraline hcl oral tablet 100 MG, 25 MG, 50 MG T2 QL (62 per 31 Day(s))
Serotonin-Norepinephrine Reuptake Inhibitors (Snris)
CYMBALTA ORAL CAPSULE DELAYED RELEASE
T3 QL (31 per 31 Day(s))
PARTICLES 60 MG
CYMBALTA ORAL CAPSULE DELAYED RELEASE
T3 QL (62 per 31 Day(s))
PARTICLES 20 MG, 30 MG
PRISTIQ T3 QL (31 per 31 Day(s))
venlafaxine hcl oral capsule extended release 24 hour 150 MG T2 QL (31 per 31 Day(s))
venlafaxine hcl oral tablet extended release 24 hr 150 MG, 225
T2 QL (31 per 31 Day(s))
MG
venlafaxine hcl oral capsule extended release 24 hour 37.5 MG,
T2 QL (93 per 31 Day(s))
75 MG
venlafaxine hcl oral tablet T2 QL (93 per 31 Day(s))
venlafaxine hcl oral tablet extended release 24 hr 37.5 MG, 75
T2 QL (93 per 31 Day(s))
MG
Tricyclic Agents
amitriptyline hcl oral tablet 10 MG, 100 MG, 150 MG, 25 MG, 50
T2
MG, 75 MG
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
21
Drug Name Tier Notes
amoxapine T3
clomipramine hcl oral capsule 25 MG, 50 MG, 75 MG T2
desipramine hcl oral tablet 10 MG, 100 MG, 150 MG, 25 MG, 50
T2
MG, 75 MG
doxepin hcl oral capsule 10 MG, 100 MG, 150 MG, 25 MG, 50
T2
MG, 75 MG
doxepin hcl oral concentrate 10 MG/ML T2
imipramine hcl oral tablet 10 MG, 25 MG, 50 MG T2
nortriptyline hcl oral capsule 10 MG, 25 MG, 50 MG, 75 MG T2
protriptyline hcl T2
SURMONTIL T4
TOFRANIL-PM T4
VIVACTIL T4
ANTIDIABETICS
Alpha-Glucosidase Inhibitors
acarbose T2 QL (93 per 31 Day(s))
Antidiabetic - Amylin Analogs
SYMLIN T3
SYMLINPEN 120 T3
SYMLINPEN 60 T3
Biguanides
metformin hcl oral tablet 1000 MG T1 QL (1000 per 31 Day(s))
metformin hcl oral tablet 500 MG T1 QL (155 per 31 Day(s))
metformin hcl oral tablet 850 MG T1 QL (93 per 31 Day(s))
metformin hcl er oral tablet extended release 24 hr 500 MG T2 QL (124 per 31 Day(s))
metformin hcl er oral tablet extended release 24 hr 750 MG T2 QL (62 per 31 Day(s))
Diabetic Other
GLUCAGEN T4
GLUCAGEN HYPOKIT T3
Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors
TRADJENTA T3
Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
22
Drug Name Tier Notes
JENTADUETO T3
Dopamine Receptor Agonists - Ergot Derivatives
CYCLOSET T4
Human Insulin
LANTUS T3 QL (35 per 31 Day(s))
LANTUS SOLOSTAR T3 QL (35 per 31 Day(s))
LEVEMIR T3 QL (35 per 31 Day(s))
LEVEMIR FLEXPEN T3 QL (35 per 31 Day(s))
NOVOLOG T3 QL (35 per 31 Day(s))
NOVOLOG FLEXPEN T3
NOVOLOG MIX 70/30 T3 QL (35 per 31 Day(s))
NOVOLOG MIX 70/30 FLEXPEN T3 QL (35 per 31 Day(s))
NOVOLOG PENFILL T3
Incretin Mimetic Agents (Glp-1 Receptor Agonists)
BYDUREON T3
BYETTA 10 MCG PEN T3 QL (4.8 per 31 Day(s))
BYETTA 5 MCG PEN T3 QL (4.8 per 31 Day(s))
Meglitinide Analogues
nateglinide T2 QL (93 per 31 Day(s))
PRANDIN T3
Sulfonylurea-Biguanide Combinations
glipizide-metformin hcl oral tablet 2.5-500 MG, 5-500 MG T2 QL (124 per 31 Day(s))
glipizide-metformin hcl oral tablet 2.5-250 MG T2 QL (248 per 31 Day(s))
glyburide-metformin oral tablet 2.5-500 MG, 5-500 MG T2 QL (124 per 31 Day(s))
glyburide-metformin oral tablet 1.25-250 MG T2 QL (248 per 31 Day(s))
Sulfonylurea-Thiazolidinedione Combinations
DUETACT T3 QL (31 per 31 Day(s))
Sulfonylureas
glimepiride oral tablet 2 MG T2 QL (124 per 31 Day(s))
glimepiride oral tablet 1 MG T2 QL (248 per 31 Day(s))
glimepiride oral tablet 4 MG T2 QL (62 per 31 Day(s))
glipizide oral tablet 10 MG T1 QL (124 per 31 Day(s))
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
23
Drug Name Tier Notes
glipizide oral tablet 5 MG T1 QL (248 per 31 Day(s))
glipizide er oral tablet extended release 24 hr 5 MG T2 QL (124 per 31 Day(s))
glipizide er oral tablet extended release 24 hr 2.5 MG T2 QL (248 per 31 Day(s))
glipizide er oral tablet extended release 24 hr 10 MG T2 QL (62 per 31 Day(s))
glyburide oral tablet 2.5 MG T2 QL (248 per 31 Day(s))
glyburide oral tablet 1.25 MG T2 QL (496 per 31 Day(s))
glyburide oral tablet 5 MG T2 QL (62 per 31 Day(s))
glyburide micronized oral tablet 1.5 MG, 3 MG T2 QL (124 per 31 Day(s))
glyburide micronized oral tablet 6 MG T2 QL (62 per 31 Day(s))
Thiazolidinedione-Biguanide Combinations
ACTOPLUS MET T4 QL (93 per 31 Day(s))
ACTOPLUS MET XR T4
pioglitazone hcl-metformin hcl T2
Thiazolidinediones
pioglitazone hcl T2
ANTIDIARRHEALS
Antiperistaltic Agents
diphenatol T2
diphenoxylate-atropine oral liquid† 2.5-0.025 MG/5ML T2
loperamide hcl oral capsule 2 MG T2
ANTIDOTES
Opioid Antagonists
naltrexone hcl oral tablet 50 MG T2
ANTIEMETICS
5-Ht3 Receptor Antagonists
ondansetron T2
ondansetron hcl oral solution 4 MG/5ML T2
ondansetron hcl oral tablet 24 MG T2 QL (31 per 31 Day(s))
ondansetron hcl oral tablet 4 MG, 8 MG T2 QL (62 per 31 Day(s))
Antiemetics - Anticholinergic
meclizine hcl T2
trimethobenzamide hcl oral capsule 300 MG T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
24
Drug Name Tier Notes
Antiemetics - Miscellaneous
dronabinol T5 QL (62 per 31 Day(s))
Substance P/Neurokinin 1 (Nk1) Receptor Antagonists
EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125 MG, 80
T4 PA; QL (62 per 31 Day(s))
MG
ANTIFUNGALS
Antifungals
ANCOBON T3
GRIFULVIN V T3
griseofulvin microsize oral suspension 125 MG/5ML T2
GRIS-PEG T4
nystatin oral tablet 500000 UNIT T2
terbinafine hcl oral tablet 250 MG T2 QL (31 per 31 Day(s))
Imidazoles
ketoconazole oral tablet 200 MG T2
Triazoles
fluconazole oral suspension reconstituted 10 MG/ML, 40 MG/ML T2
fluconazole oral tablet 100 MG, 150 MG, 200 MG, 50 MG T2
itraconazole oral capsule 100 MG T3 PA
ANTIHISTAMINES
Antihistamines - Non-Sedating
levocetirizine dihydrochloride oral solution 2.5 MG/5ML T2
levocetirizine dihydrochloride oral tablet 5 MG T2
Antihistamines - Phenothiazines
promethazine hcl oral tablet 12.5 MG, 25 MG T1
promethazine hcl injection solution 25 MG/ML T2
promethazine hcl oral syrup 6.25 MG/5ML T2
promethazine hcl oral tablet 50 MG T2
promethazine hcl re suppository 12.5 MG, 25 MG T2
PROMETHEGAN T2
ANTIHYPERLIPIDEMICS
Antihyperlipidemics - Misc.
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
25
Drug Name Tier Notes
LOVAZA T3
Bile Acid Sequestrants
cholestyramine oral packet 4 GM T1
cholestyramine oral powder 4 GM/DOSE T1
cholestyramine light T1
colestipol hcl oral granules 5 GM T2
colestipol hcl oral tablet 1 GM T2
PREVALITE T1
Fibric Acid Derivatives
fenofibrate T2
fenofibrate micronized T2
FENOGLIDE T3
gemfibrozil oral tablet 600 MG T2
TRICOR T3
TRILIPIX T3
Hmg Coa Reductase Inhibitors
atorvastatin calcium T2 QL (31 per 31 Day(s))
CRESTOR T4 QL (31 per 31 Day(s))
fluvastatin sodium T2
lovastatin T1
pravastatin sodium T2 QL (31 per 31 Day(s))
simvastatin oral tablet 10 MG, 20 MG, 40 MG, 5 MG, 80 MG T2 QL (31 per 31 Day(s))
Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb
VYTORIN T3
Intestinal Cholesterol Absorption Inhibitors
ZETIA T3
Nicotinic Acid Derivatives
NIASPAN T3
ANTIHYPERTENSIVES
Ace Inhibitor & Calcium Channel Blocker Combinations
amlodipine besy-benazepril hcl oral capsule 10-40 MG, 5-40 MG T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
26
Drug Name Tier Notes
amlodipine besy-benazepril hcl oral capsule 10-20 MG, 2.5-10
T2 QL (31 per 31 Day(s))
MG, 5-10 MG, 5-20 MG
Ace Inhibitors & Thiazide/Thiazide-Like
benazepril-hydrochlorothiazide T2
captopril-hydrochlorothiazide T1
enalapril-hydrochlorothiazide T2
fosinopril sodium-hctz T2
lisinopril-hydrochlorothiazide T1
moexipril-hydrochlorothiazide T2
quinapril-hydrochlorothiazide T2
Ace Inhibitors
benazepril hcl oral tablet 10 MG, 20 MG, 40 MG, 5 MG T2
captopril oral tablet 100 MG, 12.5 MG, 25 MG, 50 MG T1
enalapril maleate oral tablet 10 MG, 2.5 MG, 20 MG, 5 MG T1
fosinopril sodium T2
lisinopril oral tablet 10 MG, 20 MG, 30 MG, 40 MG, 5 MG T1
moexipril hcl T2
quinapril hcl T2
ramipril T2
trandolapril T2
Adrenolytics-Central & Thiazide/Thiazide-Like Comb
methyldopa-hydrochlorothiazide T2
Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides
EXFORGE HCT T3
TRIBENZOR T3
Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb
AZOR T3
EXFORGE T3
Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like
ATACAND HCT T4
BENICAR HCT T3
DIOVAN HCT T3
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
27
Drug Name Tier Notes
irbesartan-hydrochlorothiazide T2
losartan potassium-hctz T2
MICARDIS HCT T4
Angiotensin Ii Receptor Antagonists
ATACAND T4
BENICAR T3
DIOVAN T3
irbesartan T2
losartan potassium T2
MICARDIS T4
Antiadrenergics - Centrally Acting
clonidine hcl oral tablet 0.1 MG, 0.2 MG, 0.3 MG T2
clonidine hcl transdermal patch weekly 0.1 MG/24HR, 0.2
T2
MG/24HR, 0.3 MG/24HR
guanfacine hcl oral tablet 1 MG, 2 MG T2
methyldopa T2
Antiadrenergics - Peripherally Acting
doxazosin mesylate T2
prazosin hcl T2
terazosin hcl T2
Beta Blocker & Diuretic Combinations
atenolol-chlorthalidone T1
bisoprolol-hydrochlorothiazide T2
metoprolol-hydrochlorothiazide T2
propranolol-hctz T2
Direct Renin Inhibitors & Calcium Channel Blocker Comb
TEKAMLO T3
Direct Renin Inhibitors & Thiazide/Thiazide-Like Comb
TEKTURNA HCT T3
Direct Renin Inhibitors
TEKTURNA T3
Direct Renin Inhibitors-Ca Channel Blocker-Thiazide Comb
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
28
Drug Name Tier Notes
AMTURNIDE T3
Selective Aldosterone Receptor Antagonists (Saras)
eplerenone T2
Vasodilators
hydralazine hcl oral tablet 10 MG, 100 MG, 25 MG, 50 MG T2
minoxidil oral tablet 10 MG, 2.5 MG T2
ANTI-INFECTIVE AGENTS - MISC.
Anti-Infective Agents - Misc.
metronidazole oral capsule 375 MG T2
metronidazole oral tablet 250 MG, 500 MG T2
trimethoprim oral tablet 100 MG T2
vancomycin hcl oral capsule 125 MG, 250 MG T5 PA
XIFAXAN T4 PA; QL (62 per 31 Day(s))
Anti-Infective Misc. - Combinations
sulfamethoxazole-tmp ds T1
sulfamethoxazole-trimethoprim intravenous solution 400-80
T1
MG/5ML
sulfamethoxazole-trimethoprim oral suspension 200-40 MG/5ML T1
sulfamethoxazole-trimethoprim oral tablet 400-80 MG T1
Leprostatics
dapsone oral tablet 100 MG, 25 MG T3
Lincosamides
clindamycin hcl oral capsule 150 MG, 300 MG, 75 MG T2
clindamycin palmitate hcl T2
Oxazolidinones
ZYVOX ORAL SUSPENSION RECONSTITUTED 100
T5 PA
MG/5ML
ZYVOX ORAL TABLET 600 MG T5 PA
Polymyxins
polymyxin b sulfate injection solution reconstituted 500000 UNIT T2
ANTIMALARIALS
Antimalarial Combinations
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
29
Drug Name Tier Notes
atovaquone-proguanil hcl T2
Antimalarials
chloroquine phosphate oral tablet 250 MG, 500 MG T2
DARAPRIM T3
hydroxychloroquine sulfate oral tablet 200 MG T2
mefloquine hcl T2
primaquine phosphate oral tablet 26.3 MG T3
QUALAQUIN T3
ANTIMYASTHENIC AGENTS
Antimyasthenic Agents
pyridostigmine bromide oral tablet 60 MG T2
ANTIMYCOBACTERIAL AGENTS
Antimycobacterial Agents
ethambutol hcl oral tablet 100 MG, 400 MG T2
isoniazid oral syrup 50 MG/5ML T2
isoniazid oral tablet 100 MG, 300 MG T2
MYCOBUTIN T4
PRIFTIN T3
rifampin oral capsule 150 MG, 300 MG T2
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
Androgen Biosynthesis Inhibitors
ZYTIGA T5 PA
Antiandrogens
bicalutamide T2
Antiestrogens
tamoxifen citrate oral tablet 10 MG, 20 MG T2
Antimetabolites
mercaptopurine oral tablet 50 MG T2
methotrexate oral tablet 2.5 MG T2
methotrexate sodium injection solution 25 MG/ML T2
XELODA T5 PA
Antineoplastic - Tyrosine Kinase Inhibitors
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
30
Drug Name Tier Notes
GLEEVEC T5 PA
TYKERB T5 PA
Antineoplastics Misc.
hydroxyurea oral capsule 500 MG T2
Aromatase Inhibitors
anastrozole oral tablet 1 MG T2
exemestane T2
letrozole T2
Folic Acid Antagonists Rescue Agents
leucovorin calcium oral tablet 10 MG, 15 MG, 25 MG, 5 MG T4
Imidazotetrazines
TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, 20
T5 PA
MG, 250 MG, 5 MG
Lhrh Analogs
LUPRON DEPOT T5 PA
Progestins-Antineoplastic
megestrol acetate oral suspension 40 MG/ML T2
megestrol acetate oral tablet 20 MG, 40 MG T2
ANTIPARKINSON AGENTS
Antiparkinson Anticholinergics
benztropine mesylate oral tablet 0.5 MG, 1 MG, 2 MG T2
trihexyphenidyl hcl T2
Antiparkinson Dopaminergics
amantadine hcl oral capsule 100 MG T2
amantadine hcl oral tablet 100 MG T2
bromocriptine mesylate oral capsule 5 MG T2
bromocriptine mesylate oral tablet 2.5 MG T2
Antiparkinson Monoamine Oxidase Inhibitors
AZILECT T4
selegiline hcl oral tablet 5 MG T2
Decarboxylase Inhibitors
LODOSYN T4
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
31
Drug Name Tier Notes
Levodopa Combinations
carbidopa-levodopa oral tablet 10-100 MG, 25-100 MG, 25-250
T2
MG
carbidopa-levodopa er T2
STALEVO 100 T3
STALEVO 125 T3
STALEVO 150 T3
STALEVO 200 T3
STALEVO 50 T3
STALEVO 75 T3
Nonergoline Dopamine Receptor Agonists
pramipexole dihydrochloride T2
REQUIP XL T4
ropinirole hcl T2
ANTIPSYCHOTICS/ANTIMANIC AGENTS
Antimanic Agents
lithium carbonate oral capsule 150 MG, 300 MG, 600 MG T2
lithium carbonate oral tablet 300 MG T2
lithium carbonate oral tablet extendedrelease 450 MG T2
lithium citrate oral syrup 8 MEQ/5ML T2
Antipsychotics - Misc.
LATUDA T4
ziprasidone hcl T2 QL (62 per 31 Day(s))
Benzisoxazoles
risperidone T2
Butyrophenones
haloperidol oral tablet 0.5 MG, 1 MG, 10 MG, 2 MG, 20 MG, 5
T2
MG
haloperidol lactate oral concentrate 2 MG/ML T2
Dibenzo-Oxepino Pyrroles
SAPHRIS T4
Dibenzodiazepines
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
32
Drug Name Tier Notes
clozapine T2
Dibenzothiazepines
quetiapine fumarate T2 QL (62 per 31 Day(s))
SEROQUEL XR T4
Dibenzoxazepines
loxapine succinate oral capsule 10 MG, 25 MG, 5 MG, 50 MG T2
Phenothiazines
chlorpromazine hcl oral tablet 10 MG, 100 MG, 200 MG, 25 MG,
T2
50 MG
COMPRO T2
fluphenazine hcl oral tablet 1 MG, 10 MG, 2.5 MG, 5 MG T2
fluphenazine hcl oral elixir 2.5 MG/5ML T3
perphenazine T2
prochlorperazine T2
prochlorperazine edisylate injection solution 5 MG/ML T2
prochlorperazine maleate oral tablet 10 MG, 5 MG T2
thioridazine hcl oral tablet 10 MG, 100 MG, 25 MG, 50 MG T2
trifluoperazine hcl T2
Quinolinone Derivatives
ABILIFY INTRAMUSCULAR T4
ABILIFY ORAL SOLUTION T4
ABILIFY ORAL TABLET T4 QL (31 per 31 Day(s))
ABILIFY DISCMELT T4 QL (62 per 31 Day(s))
Thienbenzodiazepines
olanzapine oral tablet 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5
T2
MG
olanzapine oral tablet dispersible 10 MG, 15 MG, 20 MG, 5 MG T2
Thioxanthenes
thiothixene T2
ANTIVIRALS
Antiretroviral Combinations
ATRIPLA T5 QL (31 per 31 Day(s))
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
33
Drug Name Tier Notes
COMBIVIR T3
COMPLERA T4
EPZICOM T4
KALETRA T4
lamivudine-zidovudine T2
TRIZIVIR T4
TRUVADA T4
Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)
SELZENTRY T4 QL (124 per 31 Day(s))
Antiretrovirals - Integrase Inhibitors
ISENTRESS T4 QL (62 per 31 Day(s))
Antiretrovirals - Protease Inhibitors
APTIVUS T4
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG T4
INVIRASE T4
LEXIVA T4
NORVIR T4
PREZISTA T5
REYATAZ T4
VIRACEPT ORAL TABLET 250 MG, 625 MG T4
Antiretrovirals - Rti-Non-Nucleoside Analogues
EDURANT T4
INTELENCE ORAL TABLET 25 MG T4
INTELENCE ORAL TABLET 100 MG T4 QL (124 per 31 Day(s))
INTELENCE ORAL TABLET 200 MG T4 QL (62 per 31 Day(s))
RESCRIPTOR T4
SUSTIVA T4
VIRAMUNE T3
VIRAMUNE XR T4
Antiretrovirals - Rti-Nucleoside Analogues-Purines
didanosine T2
VIDEX ORAL SOLUTION RECONSTITUTED 2 GM T3
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
34
Drug Name Tier Notes
VIDEX EC T3
ZIAGEN T4
Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines
EMTRIVA T4
EPIVIR T3
EPIVIR HBV T3
lamivudine T2
Antiretrovirals - Rti-Nucleoside Analogues-Thymidines
RETROVIR ORAL CAPSULE 100 MG T4
RETROVIR ORAL SYRUP 50 MG/5ML T4
stavudine oral capsule 15 MG, 20 MG, 30 MG, 40 MG T2
ZERIT T3
zidovudine T2
Antiretrovirals - Rti-Nucleotide Analogues
VIREAD T4
Cmv Agents
VALCYTE T4
Hepatitis B Agents
BARACLUDE T4
HEPSERA T4
TYZEKA T3
Hepatitis C Agents
INCIVEK T5 PA
PEGASYS T5 PA
PEGASYS PROCLICK T5 PA
ribavirin oral capsule 200 MG T1
ribavirin oral tablet 200 MG T1
Herpes Agents - Purine Analogues
acyclovir oral capsule 200 MG T2
acyclovir oral suspension 200 MG/5ML T2
acyclovir oral tablet 400 MG, 800 MG T2
valacyclovir hcl oral tablet 1 GM, 500 MG T2 QL (93 per 31 Day(s))
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
35
Drug Name Tier Notes
Herpes Agents - Thymidine Analogues
famciclovir T2
Influenza Agents
rimantadine hcl T2
Neuraminidase Inhibitors
TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG T4
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML T4
ASSORTED CLASSES
Chelating Agents
SYPRINE T4
Cyclosporine Analogs
cyclosporine oral capsule 100 MG, 25 MG T2
cyclosporine modified T2
GENGRAF T2
Immunomodulators For Myelodysplastic Syndromes
REVLIMID T5 PA
Inosine Monophosphate Dehydrogenase Inhibitors
mycophenolate mofetil T2
Irrigation Solutions
sterile water for irrigation T2
Macrolide Immunosuppressants
HECORIA T2
PROGRAF ORAL CAPSULE 1 MG T2
RAPAMUNE T3
tacrolimus oral capsule 0.5 MG, 5 MG T2
Potassium Removing Resins
kalexate T2
KIONEX ORAL SUSPENSION 15 GM/60ML T2
Purine Analogs
azathioprine oral tablet 50 MG T2
BETA BLOCKERS
Alpha-Beta Blockers
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
36
Drug Name Tier Notes
carvedilol T2
COREG CR T3
labetalol hcl oral tablet 100 MG, 200 MG, 300 MG T2
Beta Blockers Cardio-Selective
acebutolol hcl oral capsule 200 MG, 400 MG T2
atenolol oral tablet 100 MG, 25 MG, 50 MG T1
betaxolol hcl oral tablet 20 MG T2
bisoprolol fumarate T2
BYSTOLIC T3
metoprolol succinate oral tablet extended release 24 hr 100 MG,
T2 QL (62 per 31 Day(s))
200 MG, 25 MG, 50 MG
metoprolol tartrate oral tablet 100 MG, 25 MG, 50 MG T1
TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR
T4
200 MG, 25 MG, 50 MG
Beta Blockers Non-Selective
INNOPRAN XL T4
nadolol oral tablet 20 MG, 40 MG, 80 MG T2
propranolol hcl oral tablet 10 MG, 20 MG, 40 MG, 60 MG, 80
T2
MG
propranolol hcl oral solution 20 MG/5ML, 40 MG/5ML T3
propranolol hcl er T2
sotalol hcl oral tablet 120 MG, 160 MG, 240 MG, 80 MG T2
timolol maleate oral tablet 10 MG, 20 MG, 5 MG T2
CALCIUM CHANNEL BLOCKERS
Calcium Channel Blockers
AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HR
T2
60 MG
amlodipine besylate oral tablet 10 MG, 2.5 MG, 5 MG T2
CARDIZEM CD T4
CARDIZEM LA T4
CARTIA XT T4
diltiazem hcl oral tablet 120 MG, 30 MG, 60 MG, 90 MG T2
diltiazem hcl coated beads T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
37
Drug Name Tier Notes
diltiazem hcl cr oral capsule extended release 12 hour 120 MG,
T2
60 MG, 90 MG
diltiazem hcl cr oral capsule extended release 24 hour 180 MG T2
diltiazem hcl er beads oral capsule extended release 24 hour 120
T2
MG, 180 MG, 240 MG, 300 MG, 360 MG
felodipine oral tablet extended release 24 hr 10 MG, 2.5 MG T2
nicardipine hcl oral capsule 20 MG, 30 MG T2
NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR
T2
90 MG
NIFEDICAL XL T2
nifedipine oral capsule 10 MG, 20 MG T2
nifedipine er T2
nimodipine oral capsule 30 MG T2 MD
nisoldipine T2
PLENDIL T2
verapamil hcl oral tablet 120 MG, 40 MG, 80 MG T2
verapamil hcl er oral capsule extended release 24 hour 100 MG,
T2
120 MG, 180 MG, 200 MG, 240 MG, 300 MG, 360 MG
verapamil hcl er oral tablet extendedrelease 180 MG, 240 MG T2
CARDIOTONICS
Cardiac Glycosides
digoxin oral tablet 0.125 MG, 0.25 MG T2
digoxin oral solution 0.05 MG/ML T3
CARDIOVASCULAR AGENTS - MISC.
Pulmonary Hypertension - Endothelin Receptor Antagonists
LETAIRIS T5 PA
TRACLEER T5 PA
Pulmonary Hypertension - Phosphodiesterase Inhibitors
REVATIO ORAL TABLET 20 MG T5 MD
CEPHALOSPORINS
Cephalosporins - 1St Generation
cefadroxil T2
cephalexin oral capsule 250 MG, 500 MG T1
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
38
Drug Name Tier Notes
cephalexin oral suspension reconstituted 125 MG/5ML, 250
T1
MG/5ML
Cephalosporins - 2Nd Generation
cefaclor oral capsule 250 MG, 500 MG T2
cefaclor er T2
cefprozil T2
CEFTIN ORAL SUSPENSION RECONSTITUTED 125
T3
MG/5ML, 250 MG/5ML
cefuroxime axetil oral tablet 250 MG, 500 MG T2
Cephalosporins - 3Rd Generation
cefdinir T2
cefpodoxime proxetil oral tablet 100 MG, 200 MG T2
SUPRAX T4
CHEMICALS
Bulk Chemicals - Hy's
hydroxyprogesterone caproate T4
CONTRACEPTIVES
Biphasic Contraceptives - Oral
AZURETTE T2
KARIVA T2
LO LOESTRIN FE T4
viorele T2
Combination Contraceptives - Oral
ALTAVERA T2
APRI T2
AVIANE T2
BALZIVA T2
BEYAZ T3
briellyn T2
CRYSELLE-28 T2
CYCLAFEM 1/35 T1
EMOQUETTE T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
39
Drug Name Tier Notes
GENERESS FE T4
GILDESS FE 1.5/30 T2
GILDESS FE 1/20 T2
JUNEL 1.5/30 T2
JUNEL 1/20 T2
JUNEL FE 1.5/30 T2
JUNEL FE 1/20 T2
KELNOR 1/35 T2
LESSINA-28 T2
LEVORA 0.15/30 (28) T2
LOESTRIN 24 FE T4
LOESTRIN FE 1.5/30 T4
LOESTRIN FE 1/20 T4
LOW-OGESTREL T2
LUTERA T2
MICROGESTIN 1.5/30 T2
MICROGESTIN 1/20 T2
MICROGESTIN FE 1.5/30 T2
MICROGESTIN FE 1/20 T2
MONONESSA T2
NECON 0.5/35 (28) T1
NECON 1/35 (28) T2
NECON 1/50 (28) T3
norgestimate-eth estradiol T1
NORTREL 0.5/35 (28) T2
ORSYTHIA T2
PORTIA-28 T2
PREVIFEM T2
RECLIPSEN T2
SAFYRAL T3
SPRINTEC 28 T2
SRONYX T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
40
Drug Name Tier Notes
VESTURA T2
WYMZYA FE T2
YASMIN 28 T2
YAZ T2
ZENCHENT T2
ZENCHENT FE T2
ZEOSA T2
ZOVIA 1/35E (28) T2
ZOVIA 1/50E (28) T2
Combination Contraceptives - Transdermal
ORTHO EVRA T4
Combination Contraceptives - Vaginal
NUVARING T4
Continuous Contraceptives - Oral
AMETHYST T2
Emergency Contraceptives
ELLA T3
NEXT CHOICE T2
Extended-Cycle Contraceptives - Oral
AMETHIA T3
AMETHIA LO T3
CAMRESE T3
CAMRESE LO T3
INTROVALE T2
JOLESSA T2
levonorgest-eth estrad 91-day T3
LOSEASONIQUE T3
QUASENSE T2
SEASONIQUE T3
Four Phase Contraceptives - Oral
NATAZIA T3
Progestin Contraceptives - Injectable
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
41
Drug Name Tier Notes
medroxyprogesterone acetate intramuscular suspension 150
T2
MG/ML
Progestin Contraceptives - Oral
CAMILA T2
ERRIN T2
HEATHER T2
JOLIVETTE T2
NORA-BE T2
norethindrone oral tablet 0.35 MG T2
Triphasic Contraceptives - Oral
CYCLAFEM 7/7/7 T1
ENPRESSE-28 T2
LEENA T2
MYZILRA T2
NECON 7/7/7 T2
norgestim-eth estrad triphasic T1
NORTREL 7/7/7 T1
TILIA FE T2
TRI-LEGEST FE T2
TRINESSA (28) T1
TRI-PREVIFEM T1
TRI-SPRINTEC T2
TRIVORA (28) T2
VELIVET T2
CORTICOSTEROIDS
Glucocorticosteroids
budesonide oral capsule extended release 24 hour 3 MG T2
cortisone acetate oral tablet 25 MG T2
dexamethasone oral tablet 0.5 MG, 0.75 MG, 1 MG, 1.5 MG, 2
T2
MG, 4 MG, 6 MG
dexamethasone oral elixir 0.5 MG/5ML T3
dexamethasone oral solution 0.5 MG/5ML T3
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
42
Drug Name Tier Notes
dexamethasone sodium phosphate injection solution 4 MG/ML T2
hydrocortisone oral tablet 10 MG, 20 MG, 5 MG T2
methylprednisolone oral tablet 16 MG, 32 MG, 4 MG, 8 MG T2
methylprednisolone acetate injection suspension 40 MG/ML, 80
T2
MG/ML
MILLIPRED DP T3
ORAPRED ODT T3
prednisolone oral syrup 15 MG/5ML T2
prednisolone sodium phosphate oral solution 15 MG/5ML, 6.7 (5
T2
Base) MG/5ML
prednisone oral tablet 1 MG, 10 MG, 2.5 MG, 20 MG, 5 MG, 50
T1
MG
prednisone oral solution 5 MG/5ML T2
PREDNISONE INTENSOL T2
Mineralocorticoids
fludrocortisone acetate oral tablet 0.1 MG T2
COUGH/COLD/ALLERGY
Antitussive - Nonnarcotic
benzonatate T2
Antitussive - Opioid
hydrocodone-homatropine T2
hydromet T2
TUSSIGON T2
Decongestant & Antihistamine
promethazine vc T2
Misc. Respiratory Inhalants
sodium chloride inhalation nebulization solution 10 %, 3 %, 7 % T2
Mucolytics
acetylcysteine inhalation solution 10 %, 20 % T2
Non-Narc Antitussive-Antihistamine
promethazine-dm T2
Non-Narc Antitussive-Decongestant-Antihistamine
BROMFED DM T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
43
Drug Name Tier Notes
Opioid Antitussive-Decongestant-Antihistamine
promethazine vc/codeine T2
DERMATOLOGICALS
Acne Antibiotics
AKNE-MYCIN T4
CLINDAGEL T4
clindamycin phosphate external foam 1 % T2
clindamycin phosphate external gel 1 % T2
clindamycin phosphate external lotion 1 % T2
clindamycin phosphate external solution 1 % T2
clindamycin phosphate external swab 1 % T2
ery T2
erythromycin external gel 2 % T2
erythromycin external pad 2 % T2
erythromycin external solution 2 % T2
Acne Combinations
ACANYA T4
AVAR LS CLEANSER T4
AVAR-E GREEN T2
AVAR-E LS T4
BENZAMYCIN T4
BENZAMYCINPAK T4
benzoyl peroxide-erythromycin T2
clindamycin phos-benzoyl perox T2
EPIDUO T4
PRASCION T2
PRASCION FC T4
PRASCION RA T2
ROSANIL CLEANSER T2
sulfacetamide sodium-sulfur external cream 10-5 % T2
sulfacetamide sodium-sulfur external emulsion 10-5 % T2
sulfacetamide sodium-sulfur external foam 10-5 % T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
44
Drug Name Tier Notes
sulfacetamide sodium-sulfur external lotion 10-5 % T2
sulfacetamide sodium-sulfur external suspension 10-5 % T2
sulfacetamide-sulfur in urea T2
VELTIN T4
ZIANA T4
Acne Products
acne medication-5 T2
adapalene T2
AMNESTEEM ORAL CAPSULE 20 MG, 40 MG T4
ATRALIN T4
benzoyl peroxide external foam 5.3 % T2
benzoyl peroxide external liquid† 10 %, 5 % T2
benzoyl peroxide short contact T2
benzoyl peroxide wash external liquid† 7 % T2
CLARAVIS T4
isotretinoin T4
RETIN-A MICRO T3
RETIN-A MICRO PUMP T3
se bpo wash T3
tretinoin external cream 0.025 %, 0.05 %, 0.1 % T2
tretinoin external gel 0.01 %, 0.025 % T2
Agents For External Genital And Perianal Warts
VEREGEN T3
Anti-Inflammatory Agents - Topical
VOLTAREN TRANSDERMAL GEL 1 % T3
Antibiotics - Topical
ALTABAX T3
BACTROBAN EXTERNAL CREAM 2 % T3
gentamicin sulfate external cream 0.1 % T2
gentamicin sulfate external ointment 0.1 % T2
mupirocin external ointment 2 % T2
Antifungals - Topical Combinations
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
45
Drug Name Tier Notes
clotrimazole-betamethasone T2
hydrocortisone-iodoquinol T2
nystatin-triamcinolone external cream 100000-0.1 UNIT/GM-% T2
VUSION T4
Antifungals - Topical
ciclopirox T2
ciclopirox olamine external cream 0.77 % T2
ciclopirox olamine external suspension 0.77 % T2
MENTAX T3
NAFTIN T4
nystatin external cream 100000 UNIT/GM T2
nystatin external ointment 100000 UNIT/GM T2
nystatin external powder 100000 UNIT/GM T2
NYSTOP T2
Antineoplastic Antimetabolites - Topical
CARAC T4
FLUOROPLEX T3
fluorouracil external cream 5 % T2
fluorouracil external solution 2 %, 5 % T2
Antipsoriatics - Systemic
OXSORALEN ULTRA T5
SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG T5 PA
Antipsoriatics
calcipotriene T2
TAZORAC T4
Antiseborrheic Combinations
PROMISEB T4
selenium sulf-pyrithione-urea T4
Antiseborrheic Products
OVACE PLUS EXTERNAL SHAMPOO 10 % T4
OVACE PLUS WASH EXTERNAL GEL 10 % T4
SEB-PREV WASH T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
46
Drug Name Tier Notes
selenium sulfide external lotion 2.5 % T2
sulfacetamide sodium external liquid† 10 % T2
Antivirals - Topical
DENAVIR T3
ZOVIRAX EXTERNAL CREAM 5 % T4 QL (15 per 31 Day(s))
ZOVIRAX EXTERNAL OINTMENT 5 % T4 QL (60 per 31 Day(s))
Burn Products
SILVADENE T2
silver sulfadiazine external cream 1 % T2
SSD T2
THERMAZENE T2
Corticosteroids - Topical
alclometasone dipropionate external cream 0.05 % T2
amcinonide external cream 0.1 % T2
betamethasone dipropionate external cream 0.05 % T2
betamethasone dipropionate external lotion 0.05 % T2
betamethasone dipropionate external ointment 0.05 % T2
betamethasone dipropionate aug T2
betamethasone valerate external cream 0.1 % T2
betamethasone valerate external lotion 0.1 % T2
betamethasone valerate external ointment 0.1 % T2
CAPEX T3
clobetasol propionate external cream 0.05 % T2
clobetasol propionate external foam 0.05 % T2
clobetasol propionate external gel 0.05 % T2
clobetasol propionate external lotion 0.05 % T2
clobetasol propionate external ointment 0.05 % T2
clobetasol propionate external shampoo 0.05 % T2
clobetasol propionate external solution 0.05 % T2
clobetasol propionate e T2
CORDRAN T4
CORDRAN SP T4
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
47
Drug Name Tier Notes
DERMA-SMOOTHE/FS BODY T4
DERMA-SMOOTHE/FS SCALP T4
desonide external cream 0.05 % T2
desonide external lotion 0.05 % T2
desonide external ointment 0.05 % T2
desoximetasone external cream 0.05 %, 0.25 % T2
desoximetasone external gel 0.05 % T2
desoximetasone external ointment 0.25 % T2
diflorasone diacetate external cream 0.05 % T4
fluocinolone acetonide external cream 0.01 % T2
fluocinolone acetonide external solution 0.01 % T2
fluocinolone acetonide body T2
fluocinolone acetonide scalp T2
fluocinonide external cream 0.05 % T2
fluocinonide external gel 0.05 % T2
fluocinonide external ointment 0.05 % T2
fluocinonide external solution 0.05 % T2
fluocinonide-e T2
fluticasone propionate external cream 0.05 % T2
fluticasone propionate external ointment 0.005 % T2
halobetasol propionate T2
hydrocortisone T2
hydrocortisone external cream 2.5 % T2
hydrocortisone external lotion 2.5 % T2
hydrocortisone external ointment 2.5 % T2
hydrocortisone butyrate T2
hydrocortisone valerate T2
KENALOG EXTERNAL AEROSOL, SOLUTION T4
LOCOID EXTERNAL LOTION 0.1 % T4
LOCOID LIPOCREAM T3
LUXIQ T4
mometasone furoate external cream 0.1 % T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
48
Drug Name Tier Notes
mometasone furoate external ointment 0.1 % T2
mometasone furoate external solution 0.1 % T2
OLUX-E T4
triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % T2
triamcinolone acetonide external lotion 0.025 %, 0.1 % T2
triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % T2
Emollient/Keratolytic Agents
REMEVEN T2
urea external cream 39 %, 40 %, 45 %, 50 % T2
urea external gel 40 % T2
urea external lotion 40 %, 45 % T2
urea nail external gel 45 % T2
urea nail film T2
X-VIATE EXTERNAL CREAM 40 % T2
Emollient/Keratolytic Combinations
urea hydrating T2
Emollients
ammonium lactate T2
ELETONE T4
HPR T4
HPR PLUS T4
HYLATOPIC T4
HYLATOPIC PLUS T4
Enzymes - Topical
SANTYL T4
Imidazole-Related Antifungals - Topical
clotrimazole T2
econazole nitrate external cream 1 % T2
ketoconazole external cream 2 % T2
ketoconazole external shampoo 2 % T2
Immunomodulators Imidazoquinolinamines - Topical
imiquimod external cream 5 % T5
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
49
Drug Name Tier Notes
Keratolytic/Antimitotic Agents
CONDYLOX T4
podofilox T2
salicylic acid external cream 6 % T2
salicylic acid external foam 6 % T2
salicylic acid external gel 6 % T2
salicylic acid external lotion 6 % T2
salicylic acid external shampoo 6 % T2
Local Anesthetics - Topical
lidocaine external ointment 5 % T2
lidocaine hcl external cream 3 % T2
lidocaine hcl external gel 2 % T2
lidocaine hcl external lotion 3 % T2
lidocaine hcl external solution 4 % T2
LIDODERM T4 QL (93 per 31 Day(s))
Macrolide Immunosuppressants - Topical
ELIDEL T3
PROTOPIC T3 PA
Misc. Dermatological Products
TETRIX T4
tl-cermide T4
Misc. Topical
HYPERCARE T2
Pigmenting Agents
OXSORALEN T3
Rosacea Agents
FINACEA T4
METROGEL EXTERNAL GEL 1 % T4
metronidazole external cream 0.75 % T2
metronidazole external gel 0.75 % T2
metronidazole external lotion 0.75 % T2
Scabicides & Pediculicides
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
50
Drug Name Tier Notes
EURAX EXTERNAL LOTION 10 % T4
lindane T2
malathion T2
OVIDE T3
permethrin external cream 5 % T2
ULESFIA T4
Steroid-Local Anesthetic Combinations
CORTANE-B EXTERNAL LOTION 10-10-1 MG/ML T4
EPIFOAM T4
hydrocortisone ace-pramoxine external cream 2.5-1 % T2
lidocaine-hydrocortisone ace external cream 3-0.5 % T2
PRAMOSONE EXTERNAL LOTION 1-1 %, 1-2.5 % T4
Topical Anesthetic Combinations
lidocaine-prilocaine external cream 2.5-2.5 % T2
Topical Steroid Combinations
hydrocortisone acetate-aloe external gel 2 % T2
TACLONEX T4
Wound Care - Growth Factor Agents
REGRANEX T4 PA
Wound Dressings
PRUTECT T3
DIGESTIVE AIDS
Digestive Enzymes
CREON T4
SUCRAID T5
DIURETICS
Carbonic Anhydrase Inhibitors
acetazolamide oral tablet 125 MG, 250 MG T2
acetazolamide sodium T3
methazolamide oral tablet 25 MG, 50 MG T2
Diuretic Combinations
amiloride-hydrochlorothiazide T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
51
Drug Name Tier Notes
spironolactone-hctz T2
triamterene-hctz oral capsule 37.5-25 MG T2
triamterene-hctz oral tablet 37.5-25 MG, 75-50 MG T2
Loop Diuretics
bumetanide oral tablet 0.5 MG, 1 MG, 2 MG T2
furosemide oral solution 10 MG/ML, 8 MG/ML T1
furosemide oral tablet 20 MG, 40 MG, 80 MG T1
torsemide oral tablet 10 MG, 100 MG, 20 MG, 5 MG T2
Potassium Sparing Diuretics
amiloride hcl oral tablet 5 MG T3
DYRENIUM T4
spironolactone oral tablet 100 MG, 25 MG, 50 MG T2
Thiazides And Thiazide-Like Diuretics
chlorothiazide T2
chlorthalidone T2
hydrochlorothiazide oral capsule 12.5 MG T1
hydrochlorothiazide oral tablet 12.5 MG, 25 MG, 50 MG T1
indapamide T2
metolazone T2
ENDOCRINE AND METABOLIC AGENTS - MISC.
Bisphosphonates
ACTONEL ORAL TABLET 150 MG T4 QL (1 per 31 Day(s))
ACTONEL ORAL TABLET 30 MG, 5 MG T4 QL (31 per 31 Day(s))
ACTONEL ORAL TABLET 35 MG T4 QL (4 per 28 Day(s))
alendronate sodium oral tablet 10 MG, 40 MG, 5 MG T2 QL (31 per 31 Day(s))
alendronate sodium oral tablet 35 MG, 70 MG T2 QL (4 per 28 Day(s))
ATELVIA T4
ibandronate sodium T2
Calcimimetic Agents
SENSIPAR T4
Calcitonins
calcitonin (salmon) T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
52
Drug Name Tier Notes
Carnitine Replenisher - Agents
levocarnitine oral tablet 330 MG T2
Dopamine Receptor Agonists
cabergoline T2
Growth Hormones
NORDITROPIN FLEXPRO T5 PA
NORDITROPIN NORDIFLEX PEN SUBCUTANEOUS
T5 PA
SOLUTION 30 MG/3ML
SEROSTIM SUBCUTANEOUS SOLUTION
T5 PA
RECONSTITUTED 4 MG, 5 MG, 6 MG
Hyperparathyroid Treatment - Vitamin D Analogs
calcitriol oral capsule 0.25 MCG, 0.5 MCG T2
calcitriol oral solution 1 MCG/ML T2
Lhrh/Gnrh Agonist Analog Pituitary Suppressants
LUPRON DEPOT-PED T5 PA
Parathyroid Hormone And Derivatives
FORTEO T5 PA; QL (2.4 per 31 Day(s))
Rank Ligand (Rankl) Inhibitors
PROLIA T5 PA
Selective Estrogen Receptor Modulators (Serms)
EVISTA T3 QL (31 per 31 Day(s))
Selective Vasopressin V2-Receptor Antagonists
SAMSCA T5 PA
Somatostatic Agents
SANDOSTATIN LAR DEPOT T5 PA
SOMATULINE DEPOT T5 PA
Vasopressin
desmopressin ace spray refrig T2
desmopressin acetate oral tablet 0.1 MG, 0.2 MG T2
ESTROGENS
Estrogen & Androgen
est estrogens-methyltest T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
53
Drug Name Tier Notes
est estrogens-methyltest hs T2
Estrogen & Progestin
CLIMARA PRO T4
COMBIPATCH T3
estradiol-norethindrone acet T2
FEMHRT LOW DOSE T3
JINTELI T3
MIMVEY T2
PREMPHASE T3
PREMPRO T3
Estrogens
CENESTIN T3
DEPO-ESTRADIOL T3
DIVIGEL T4
ENJUVIA T3
estradiol oral tablet 0.5 MG, 1 MG, 2 MG T2
estradiol transdermal patch weekly 0.025 MG/24HR, 0.0375
MG/24HR, 0.05 MG/24HR, 0.06 MG/24HR, 0.075 MG/24HR, 0.1 T2
MG/24HR
ESTROGEL T4
estropipate oral tablet 0.75 MG, 1.5 MG, 3 MG T2
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9
T3 QL (31 per 31 Day(s))
MG, 1.25 MG
VIVELLE-DOT T3
FLUOROQUINOLONES
Fluoroquinolones
CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML
T4
(5%), 500 MG/5ML (10%)
ciprofloxacin hcl oral tablet 100 MG, 250 MG, 500 MG, 750 MG T2
ciprofloxacin-ciproflox hcl T2
levofloxacin oral solution 25 MG/ML T2
levofloxacin oral tablet 250 MG, 500 MG, 750 MG T2
ofloxacin T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
54
Drug Name Tier Notes
GASTROINTESTINAL AGENTS - MISC.
Gallstone Solubilizing Agents
ursodiol oral capsule 300 MG T2
ursodiol oral tablet 250 MG, 500 MG T2
Gastrointestinal Chloride Channel Activators
AMITIZA T3 QL (62 per 31 Day(s))
Gastrointestinal Stimulants
metoclopramide hcl oral solution 10 MG/10ML T2
metoclopramide hcl oral tablet 10 MG, 5 MG T2
Ibs Agent - Selective 5-Ht3 Receptor Antagonists
LOTRONEX T3 PA; QL (62 per 31 Day(s))
Inflammatory Bowel Agents
APRISO T3 QL (124 per 31 Day(s))
ASACOL T3 QL (372 per 31 Day(s))
ASACOL HD T3
balsalazide disodium T2
CANASA T4
LIALDA T3
mesalamine re enema 4 GM T2
mesalamine-cleanser T2
PENTASA T4
sulfasalazine oral tablet 500 MG T2
SULFAZINE T2
SULFAZINE EC T2
Intestinal Acidifiers
enulose T2
generlac T2
Phosphate Binder Agents
calcium acetate oral capsule 667 MG T2
RENAGEL T3
RENVELA ORAL TABLET 800 MG T4
GENITOURINARY AGENTS - MISCELLANEOUS
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
55
Drug Name Tier Notes
5-Alpha Reductase Inhibitors
AVODART T3 QL (31 per 31 Day(s))
finasteride oral tablet 5 MG T2
Alpha 1-Adrenoceptor Antagonists
tamsulosin hcl T2
Citrates
cytra-2 T2
CYTRA-3 T4
potassium citrate oral tablet extendedrelease 10 MEQ (1080
T2
MG), 5 MEQ (540 MG)
tricitrates T4
Genitourinary Irrigants
sodium chloride irrigation solution 0.9 % T2
Interstitial Cystitis Agents
ELMIRON T3
Prostatic Hypertrophy Agent Combinations
JALYN T3 QL (31 per 31 Day(s))
Urinary Analgesics
phenazopyridine hcl oral tablet 100 MG, 200 MG T2
GOUT AGENTS
Gout Agent Combinations
colchicine-probenecid T2
Gout Agents
allopurinol oral tablet 100 MG, 300 MG T2
COLCRYS T3
ULORIC T3 ST
Uricosurics
probenecid T2
HEMATOLOGICAL AGENTS - MISC.
Cyclopentyltriazolopyrimidine (Cptp) Derivatives
BRILINTA T4
Hematorheologic Agents
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
56
Drug Name Tier Notes
pentoxifylline er T2
Phosphodiesterase Iii Inhibitors
cilostazol T2
Platelet Aggregation Inhibitor Combinations
AGGRENOX T3 QL (62 per 31 Day(s))
Platelet Aggregation Inhibitors
dipyridamole oral tablet 25 MG, 50 MG, 75 MG T2
Quinazoline Agents
anagrelide hcl T2
Thienopyridine Derivatives
clopidogrel bisulfate oral tablet 75 MG T2 QL (31 per 31 Day(s))
EFFIENT T3
ticlopidine hcl T2
HEMATOPOIETIC AGENTS
Cytotoxic Agents
DROXIA T3
Erythropoietins
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000
T5 PA; QL (12 per 31 Day(s))
UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML
PROCRIT INJECTION SOLUTION 40000 UNIT/ML T5 PA; QL (6 per 31 Day(s))
HEMOSTATICS
Hemostatics - Systemic
LYSTEDA T4
HYPNOTICS
Barbiturate Hypnotics
phenobarbital oral elixir 20 MG/5ML T2
phenobarbital oral tablet 100 MG, 15 MG, 16.2 MG, 30 MG, 32.4
T2
MG, 60 MG, 64.8 MG, 97.2 MG
Benzodiazepine Hypnotics
estazolam T2
flurazepam hcl T2
temazepam T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
57
Drug Name Tier Notes
triazolam T2
Non-Benzodiazepine - Gaba-Receptor Modulators
zaleplon T2 QL (31 per 31 Day(s))
zolpidem tartrate T2 QL (31 per 31 Day(s))
LAXATIVES
Bowel Evacuant Combinations
COLYTE WITH FLAVOR PACKS ORAL SOLUTION
T3
RECONSTITUTED 227.1 GM
GAVILYTE-C T2
GAVILYTE-G T2
GAVILYTE-N WITH FLAVOR PACK T2
GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM T3
HALFLYTELY WITH FLAVOR PACKS T4
MOVIPREP T4
peg 3350/electrolytes oral solution reconstituted 240 GM T2
peg 3350-kcl-na bicarb-nacl T2
peg-3350/electrolytes T2
SUPREP BOWEL PREP T4
TRILYTE T2
Laxatives - Miscellaneous
KRISTALOSE T3
lactulose oral solution 10 GM/15ML T2
Saline Laxative Mixtures
OSMOPREP T3
MACROLIDES
Azithromycin
azithromycin oral packet 1 GM T2
azithromycin oral suspension reconstituted 100 MG/5ML, 200
T2
MG/5ML
azithromycin oral tablet 250 MG, 500 MG, 600 MG T2
ZMAX T3
Clarithromycin
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
58
Drug Name Tier Notes
clarithromycin oral suspension reconstituted 125 MG/5ML, 250
T2
MG/5ML
clarithromycin oral tablet 250 MG, 500 MG T2
clarithromycin er T2
Erythromycins
E.E.S. 400 T2
E.E.S. GRANULES T3
ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG T2
ERY-TAB ORAL TABLET DELAYED RELEASE 333 MG, 500
T3
MG
ERYTHROCIN STEARATE ORAL TABLET 250 MG T4
erythromycin base oral tablet 500 MG T2
MIGRAINE PRODUCTS
Ergot Combinations
ergotamine-caffeine T2
Migraine Combinations
EPIDRIN T2
isometheptene-apap-dichloral T2
Migraine Products
MIGRANAL T4
Selective Serotonin Agonist-Nsaid Combinations
TREXIMET T3 ST; QL (12 per 31 Day(s))
Selective Serotonin Agonists 5-Ht(1)
AXERT T4 ST
FROVA T4 ST
MAXALT T3 ST; QL (12 per 31 Day(s))
MAXALT-MLT T3 ST; QL (12 per 31 Day(s))
RELPAX T4 ST
sumatriptan T2
sumatriptan succinate oral tablet 100 MG, 25 MG, 50 MG T2 QL (12 per 31 Day(s))
sumatriptan succinate subcutaneous solution 6 MG/0.5ML T4 QL (8 per 31 Day(s))
ZOMIG T4 ST
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
59
Drug Name Tier Notes
ZOMIG ZMT T4 ST
MINERALS & ELECTROLYTES
Fluoride
LUDENT T2
sodium fluoride oral solution 1.1 (0.5 F) MG/ML T2
sodium fluoride oral tablet 2.2 (1 F) MG T2
sodium fluoride oral tablet chewable 0.55 (0.25 F) MG, 1.1 (0.5
T2
F) MG, 2.2 (1 F) MG
Phosphate
PHOSPHA 250 NEUTRAL T2
Potassium
KLOR-CON T2
KLOR-CON 10 T2
KLOR-CON M10 T2
KLOR-CON M15 T2
KLOR-CON M20 T2
K-TABS T2
potassium chloride oral liquid† 20 MEQ/15ML (10%), 40
T2
MEQ/15ML (20%)
potassium chloride cr oral capsule extended release 8 MEQ T2
potassium chloride cr oral tablet extendedrelease 10 MEQ, 8
T2
MEQ
potassium chloride crys cr oral tablet extendedrelease 20 MEQ T2
Sodium
sodium chloride injection solution 0.9 % T2
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral - Combinations
FIRST-MOUTHWASH BLM T3
Anesthetics Topical Oral
lidocaine viscous T2
Anti-Infective Combinations - Throat
FIRST-BXN MOUTHWASH T3
Anti-Infectives - Throat
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
60
Drug Name Tier Notes
clotrimazole mouth/throat troche 10 MG T2
nystatin mouth/throat suspension 100000 UNIT/ML T2
Antiseptics - Mouth/Throat
chlorhexidine gluconate mouth/throat solution 0.12 % T2
Dental Products - Combinations
PREVIDENT 5000 ENAMEL PROTECT T4
PREVIDENT 5000 SENSITIVE T4
Fluoride Dental Products
DENTA 5000 PLUS T2
DENTAGEL T2
neutral sodium fluoride T2
PREVIDENT T4
PREVIDENT 5000 BOOSTER T4
PREVIDENT 5000 DRY MOUTH T4
PREVIDENT 5000 PLUS T4
sf T2
sf 5000 plus T2
stannous fluoride mouth/throat concentrate 0.63 % T2
Saliva Stimulants
pilocarpine hcl oral tablet 5 MG, 7.5 MG T2
Steroids - Mouth/Throat
triamcinolone acetonide mouth/throat paste 0.1 % T2
MULTIVITAMINS
Iron W/ Vitamins
VITAFOL ORAL TABLET T3
Prenatal Mv & Min W/Fe-Fa
CONCEPT DHA T3
FOLIVANE-OB T3
hemenatal ob T3
hemenatal ob + dha T3
NESTABS T3
NESTABS DHA T3
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
61
Drug Name Tier Notes
nutri-tab ob T3
nutri-tab ob + dha T3
PREFERA OB ORAL TABLET 28-6-1 MG T3
PREFERA OB + DHA ORAL MISC 28-6-1 & 203 MG T3
prenaplus T4
PRENATABS RX T4
PRENATAL 19 T3
prenatal plus T4
prenatal plus/iron T4
PRENATE ELITE ORAL TABLET 26-0.6-0.4 MG T3
PRENATE ESSENTIAL ORAL CAPSULE 29-0.6-0.4-340 MG T3
SELECT-OB T3
TARON-C DHA T3
TRIVEEN-ONE T3
TRIVEEN-U T3
ultimatecare one T4
ultimatecare one nf T4
VINATE CARE T3
virt-pn T3
VITAFOL-OB T3
ZATEAN-PN T3
ZATEAN-PN PLUS T3
Prenatal Mv & Min W/Fe-Fa-Dha
CITRANATAL 90 DHA ORAL MISC 90-1 & 300 MG T3
CITRANATAL DHA T3
FOLIVANE-PRX DHA NF T3
NEXA SELECT T3
pnv-dha T3
PREFERAOB ONE T3
prenaissance T3
PRENATE DHA ORAL CAPSULE 28-0.6-0.4-300 MG T3
PRENATE MINI T3
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
62
Drug Name Tier Notes
PRENEXA ORAL CAPSULE 27-1.25-300 MG T3
PREQUE 10 ORAL TABLET 15-25-0.5-50 MG T3
SELECT-OB+DHA T3
tl-select T3
TRIVEEN-PRX RNF T3
virt-pn dha T3
VITAFOL-ONE T3
VITAMEDMD ONE RX/QUATREFOLIC T3
ZATEAN-CH T3
ZATEAN-PN DHA T3
Prenatal Vitamins
VITAMEDMD REDICHEW RX T3
vp-ggr-b6 prenatal T3
MUSCULOSKELETAL THERAPY AGENTS
Central Muscle Relaxants
baclofen oral tablet 10 MG, 20 MG T2
chlorzoxazone T2
cyclobenzaprine hcl oral tablet 10 MG, 5 MG, 7.5 MG T2
methocarbamol oral tablet 500 MG, 750 MG T2
orphenadrine citrate er T2
tizanidine hcl oral capsule 2 MG, 4 MG, 6 MG T2
tizanidine hcl oral tablet 2 MG, 4 MG T2
Direct Muscle Relaxants
dantrolene sodium oral capsule 100 MG, 25 MG, 50 MG T2
NASAL AGENTS - SYSTEMIC AND TOPICAL
Nasal Antibiotics
BACTROBAN NASAL T3
Nasal Anticholinergics
ipratropium bromide nasal solution 0.03 %, 0.06 % T2
Nasal Antihistamines
ASTEPRO NASAL SOLUTION 0.15 % T3
azelastine hcl T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
63
Drug Name Tier Notes
PATANASE T4
Nasal Steroids
BECONASE AQ T4
flunisolide nasal solution 0.025 % T2 QL (50 per 31 Day(s))
fluticasone propionate nasal suspension 50 MCG/ACT T2 QL (16 per 31 Day(s))
NASONEX T4
RHINOCORT AQUA T4
triamcinolone acetonide nasal inhaler 55 MCG/ACT T2
VERAMYST T3 QL (10 per 31 Day(s))
OPHTHALMIC AGENTS
Beta-Blockers - Ophthalmic Combinations
COMBIGAN T3 QL (10 per 31 Day(s))
COSOPT PF T4
dorzolamide hcl-timolol mal T2
Beta-Blockers - Ophthalmic
betaxolol hcl ophthalmic solution 0.5 % T3
BETIMOL T3
BETOPTIC-S T3
carteolol hcl T2
ISTALOL T4
levobunolol hcl T2
metipranolol T2
timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % T2
timolol maleate ophthalmic solution 0.25 %, 0.5 % T2
Cycloplegic Mydriatics
atropine sulfate ophthalmic solution 1 % T2
cyclopentolate hcl ophthalmic solution 1 %, 2 % T2
ISOPTO HOMATROPINE T4
ISOPTO HYOSCINE T3
tropicamide ophthalmic solution 0.5 %, 1 % T3
Miotics - Cholinesterase Inhibitors
PHOSPHOLINE IODIDE T3
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
64
Drug Name Tier Notes
Miotics - Direct Acting
PILOPINE HS T3
Ophthalmic Anti-Infective Combinations
ak-poly-bac T2
bacitracin-polymyxin b T2
neomycin-polymyxin-gramicidin T2
polymyxin b-trimethoprim T2
triple antibiotic ophthalmic ointment 5-400-10000 T2
Ophthalmic Antiallergic
azelastine hcl T2
BEPREVE T4
cromolyn sodium ophthalmic solution 4 % T2
epinastine hcl T3
LASTACAFT T4 QL (6 per 31 Day(s))
PATADAY T3 QL (10 per 31 Day(s))
PATANOL T3
Ophthalmic Antibiotics
AZASITE T4
bacitracin ophthalmic ointment 500 UNIT/GM T2
CILOXAN OPHTHALMIC OINTMENT 0.3 % T3
ciprofloxacin hcl ophthalmic solution 0.3 % T2
erythromycin ophthalmic ointment 5 MG/GM T2
gentamicin sulfate ophthalmic ointment 0.3 % T2
gentamicin sulfate ophthalmic solution 0.3 % T2
levofloxacin ophthalmic solution 0.5 % T2
MOXEZA T3
ofloxacin T2
tobramycin sulfate ophthalmic solution 0.3 % T2
VIGAMOX T3
ZYMAXID T3
Ophthalmic Antifungal
NATACYN T3
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
65
Drug Name Tier Notes
Ophthalmic Antivirals
trifluridine ophthalmic solution 1 % T2
ZIRGAN T4
Ophthalmic Carbonic Anhydrase Inhibitors
AZOPT T3 QL (15 per 31 Day(s))
dorzolamide hcl T2
Ophthalmic Immunomodulators
RESTASIS T3
Ophthalmic Local Anesthetics
proparacaine hcl ophthalmic solution 0.5 % T3
Ophthalmic Nonsteroidal Anti-Inflammatory Agents
ACULAR T4 QL (10 per 31 Day(s))
ACULAR LS T4 QL (10 per 31 Day(s))
bromfenac sodium T3
diclofenac sodium ophthalmic solution 0.1 % T2
flurbiprofen sodium T2
ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % T2
NEVANAC T3
Ophthalmic Selective Alpha Adrenergic Agonists
ALPHAGAN P T3 QL (15 per 31 Day(s))
apraclonidine hcl T2
brimonidine tartrate T2
Ophthalmic Steroid Combinations
bacitra-neomycin-polymyxin-hc T2
BLEPHAMIDE S.O.P. T3
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-
T2
0.1
neomycin-polymyxin-hc ophthalmic suspension 5-10000-1 T2
TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % T3
TOBRADEX ST T3
tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % T2
triple antibiotic ophthalmic ointment 0.35-10000-0.1 T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
66
Drug Name Tier Notes
ZYLET T4
Ophthalmic Steroids
ALREX T3
dexamethasone sodium phosphate ophthalmic solution 0.1 % T2
DUREZOL T3
fluorometholone ophthalmic suspension 0.1 % T2
FML T4
LOTEMAX OPHTHALMIC SUSPENSION 0.5 % T3
prednisolone acetate ophthalmic suspension 1 % T2
Ophthalmic Sulfonamides
sulfacetamide sodium ophthalmic solution 10 % T2
Prostaglandins - Ophthalmic
latanoprost T2
LUMIGAN T3 QL (5 per 31 Day(s))
TRAVATAN Z T3 QL (5 per 31 Day(s))
ZIOPTAN T4
OTIC AGENTS
Otic Agents - Miscellaneous
acetic acid otic solution 2 % T2
Otic Analgesic Combinations
antipyrine-benzocaine otic solution 5.4-1.4 % T2
aurax T2
oticin T2
Otic Anti-Infectives
ofloxacin T2
Otic Steroid-Anti-Infective Combinations
CIPRO HC T3
CIPRODEX T3
COLY-MYCIN S T3
CORTISPORIN OTIC SOLUTION 3.5-10000-1 T3
CORTISPORIN-TC T3
neomycin-polymyxin-hc otic solution 3.5-10000-1 T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
67
Drug Name Tier Notes
neomycin-polymyxin-hc otic suspension 3.5-10000-1 T2
Otic Steroids
ACETASOL HC T2
DERMOTIC T4
fluocinolone acetonide otic oil 0.01 % T2
OXYTOCICS
Oxytocics
methylergonovine maleate oral tablet 0.2 MG T2
PENICILLINS
Aminopenicillins
amoxicillin oral capsule 250 MG, 500 MG T1
amoxicillin oral suspension reconstituted 125 MG/5ML, 200
T1
MG/5ML, 250 MG/5ML, 400 MG/5ML
amoxicillin oral tablet 500 MG, 875 MG T1
amoxicillin oral tablet chewable 125 MG, 250 MG T1
ampicillin oral capsule 250 MG, 500 MG T2
ampicillin oral suspension reconstituted 250 MG/5ML T3
Natural Penicillins
penicillin v potassium T2
PFIZERPEN-G T2
Penicillin Combinations
amoxicillin-pot clavulanate oral suspension reconstituted 200-
28.5 MG/5ML, 250-62.5 MG/5ML, 400-57 MG/5ML, 600-42.9 T2
MG/5ML
amoxicillin-pot clavulanate oral tablet 250-125 MG, 500-125 MG T2
amoxicillin-pot clavulanate oral tablet chewable 200-28.5 MG,
T2
400-57 MG
amoxicillin-pot clavulanate oral tablet extended release 12 hr
T2
1000-62.5 MG
Penicillinase-Resistant Penicillins
dicloxacillin sodium T2
PHARMACEUTICAL ADJUVANTS
Semi Solid Vehicles
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
68
Drug Name Tier Notes
polyethylene glycol 3350 T2
PROGESTINS
Progestins
medroxyprogesterone acetate oral tablet 10 MG, 2.5 MG, 5 MG T2
MEGACE ES T4
norethindrone acetate oral tablet 5 MG T2
progesterone intramuscular oil 50 MG/ML T2
progesterone micronized oral capsule 100 MG, 200 MG T2
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
Alcohol Deterrents
disulfiram oral tablet 250 MG, 500 MG T2
Benzodiazepines & Tricyclic Agents
chlordiazepoxide-amitriptyline T2
Cholinomimetics - Ache Inhibitors
donepezil hcl T2 QL (31 per 31 Day(s))
galantamine hydrobromide oral capsule extended release 24 hour T2 QL (31 per 31 Day(s))
galantamine hydrobromide oral tablet T2 QL (62 per 31 Day(s))
galantamine hydrobromide oral solution T2 QL (620 per 31 Day(s))
rivastigmine tartrate T2 QL (62 per 31 Day(s))
Fibromyalgia Agent - Snris
SAVELLA T3
SAVELLA TITRATION PACK T3
Multiple Sclerosis Agents - Interferons
BETASERON T5 PA; QL (15 per 365 Day(s))
Multiple Sclerosis Agents
COPAXONE T5 PA
N-Methyl-D-Aspartate (Nmda) Receptor Antagonists
NAMENDA ORAL SOLUTION T4 QL (320 per 31 Day(s))
NAMENDA ORAL TABLET T4 QL (62 per 31 Day(s))
NAMENDA TITRATION PAK T4
Phenothiazines & Tricyclic Agents
perphenazine-amitriptyline T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
69
Drug Name Tier Notes
Psychotherapeutic And Neurological Agents - Misc.
ergoloid mesylates oral tablet 1 MG T2
Smoking Deterrents
CHANTIX ORAL TABLET 0.5 MG T3 QL (340 per 365 Day(s))
CHANTIX CONTINUING MONTH PAK ORAL TABLET 1
T3 QL (340 per 365 Day(s))
MG
CHANTIX STARTING MONTH PAK T3 QL (106 per 365 Day(s))
Sphingosine 1-Phosphate (S1p) Receptor Modulators
GILENYA T5 PA
Thienbenzodiazepines & Ssris
olanzapine-fluoxetine hcl T2
RESPIRATORY AGENTS - MISC.
Hydrolytic Enzymes
PULMOZYME T5 PA; QL (155 per 31 Day(s))
SULFONAMIDES
Sulfonamides
sulfadiazine oral tablet 500 MG T3
TETRACYCLINES
Tetracyclines
doxycycline hyclate oral capsule 100 MG, 50 MG T2
doxycycline hyclate oral tablet 100 MG T2
minocycline hcl oral capsule 100 MG, 50 MG, 75 MG T2
minocycline hcl oral tablet 100 MG, 50 MG, 75 MG T2
tetracycline hcl oral capsule 250 MG, 500 MG T2
THYROID AGENTS
Antithyroid Agents
methimazole oral tablet 10 MG, 5 MG T2
propylthiouracil oral tablet 50 MG T2
Thyroid Hormones
ARMOUR THYROID T2
LEVOTHROID T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
70
Drug Name Tier Notes
levothyroxine sodium oral tablet 100 MCG, 112 MCG, 125 MCG,
137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, T2
50 MCG, 75 MCG, 88 MCG
LEVOXYL ORAL TABLET 112 MCG, 125 MCG, 137 MCG,
150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 T2
MCG
liothyronine sodium oral tablet 25 MCG, 5 MCG, 50 MCG T2
NATURE-THROID T2
np thyroid T2
SYNTHROID ORAL TABLET 112 MCG, 137 MCG, 175 MCG,
T3
200 MCG, 300 MCG, 75 MCG, 88 MCG
UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG,
150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, T2
75 MCG, 88 MCG
ULCER DRUGS
Anticholinergic Combinations
belladonna alk-phenobarbital T2
clidinium-chlordiazepoxide T2
DONNATAL T4
quadrapax T2
Antispasmodics
dicyclomine hcl oral capsule 10 MG T2
dicyclomine hcl oral solution 10 MG/5ML T2
dicyclomine hcl oral tablet 20 MG T2
Belladonna Alkaloids
hyoscyamine sulfate oral elixir 0.125 MG/5ML T2
hyoscyamine sulfate oral solution 0.125 MG/ML T2
hyoscyamine sulfate oral tablet 0.125 MG T2
hyoscyamine sulfate oral tablet dispersible 0.125 MG T2
hyoscyamine sulfate er T2
oscimin sr T2
H-2 Antagonists
cimetidine T2
cimetidine oral tablet 300 MG, 400 MG, 800 MG T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
71
Drug Name Tier Notes
cimetidine hcl oral solution 300 MG/5ML T2
famotidine oral suspension reconstituted 40 MG/5ML T2
famotidine oral tablet 20 MG, 40 MG T2
nizatidine T2
ranitidine hcl oral capsule 150 MG, 300 MG T2
ranitidine hcl oral syrup 75 MG/5ML T2
ranitidine hcl oral tablet 300 MG T2
Misc. Anti-Ulcer
sucralfate oral suspension 1 GM/10ML T2
sucralfate oral tablet 1 GM T2
Proton Pump Inhibitors
DEXILANT T3 QL (62 per 31 Day(s))
omeprazole oral capsule delayed release 10 MG, 20 MG, 40 MG T2
pantoprazole sodium T2
Quaternary Anticholinergics
glycopyrrolate oral tablet 1 MG, 2 MG T2
methscopolamine bromide oral tablet 2.5 MG, 5 MG T2
propantheline bromide oral tablet 15 MG T3
Ulcer Drugs - Prostaglandins
misoprostol T2
URINARY ANTI-INFECTIVES
Urinary Anti-Infectives
MACROBID T2
nitrofurantoin T2
nitrofurantoin macrocrystal oral capsule 100 MG, 50 MG T2
URINARY ANTISPASMODICS
Urinary Antispasmodics
bethanechol chloride oral tablet 10 MG, 25 MG, 5 MG, 50 MG T2
flavoxate hcl T2
oxybutynin chloride oral tablet 5 MG T1
oxybutynin chloride er oral tablet extended release 24 hr 10 MG,
T2
15 MG
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
72
Drug Name Tier Notes
TOVIAZ T3 QL (31 per 31 Day(s))
VESICARE T3 QL (31 per 31 Day(s))
VAGINAL PRODUCTS
Imidazole-Related Antifungals
terconazole T2
Vaginal Anti-Infectives
CLEOCIN VAGINAL SUPPOSITORY 100 MG T3
clindamycin phosphate vaginal cream 2 % T2
METROGEL-VAGINAL T2
metronidazole vaginal gel 0.75 % T2
VANDAZOLE T2
Vaginal Estrogens
ESTRACE VAGINAL CREAM 0.1 MG/GM T3
PREMARIN VAGINAL CREAM 0.625 MG/GM T3
VAGIFEM VAGINAL TABLET 10 MCG T3
VASOPRESSORS
Anaphylaxis Therapy Agents
EPIPEN 2-PAK T3
EPIPEN JR 2-PAK T3
Vasopressors
midodrine hcl T2
VITAMINS
Vitamin B-3
NIACOR T2
PA = Prior Authorization required | ST = Step Therapy required | QL = Quantity Limit applies
SP = Medication must be obtained through a specialty pharmacy | MD=Medication is a maintenance medication
(1/2) = Certain strengths may be eligible for the Pill-Splitting program. Call Customer Service for details.
73
Index
Abilify ............................................................. 32 Amitiza............................................................ 54
Abilify Discmelt.............................................. 32 Amitriptyline HCl ........................................... 20
Acanya ............................................................ 43 Amlodipine Besy-Benazepril HCl ............ 25, 26
Acarbose ......................................................... 21 AmLODIPine Besylate ................................... 36
Acebutolol HCl ............................................... 36 Ammonium Lactate......................................... 48
Acetaminophen-Codeine................................. 11 Amnesteem ..................................................... 44
Acetaminophen-Codeine #2............................ 11 Amoxapine...................................................... 21
Acetaminophen-Codeine #3............................ 11 Amoxicillin ..................................................... 67
Acetaminophen-Codeine #4............................ 11 Amoxicillin-Pot Clavulanate .......................... 67
Acetasol HC .................................................... 67 Amphetamine-Dextroamphetamine .................. 9
AcetaZOLAMIDE........................................... 50 Ampicillin ....................................................... 67
AcetaZOLAMIDE Sodium ............................. 50 Amturnide ....................................................... 28
Acetic Acid ..................................................... 66 Anagrelide HCl ............................................... 56
Acetylcysteine ................................................. 42 Analpram Advanced ....................................... 13
Acne Medication-5.......................................... 44 Anastrozole ..................................................... 30
Actonel............................................................ 51 Ancobon.......................................................... 24
Actoplus Met................................................... 23 AndroGel......................................................... 13
Actoplus met XR............................................. 23 AndroGel Pump .............................................. 13
Acular.............................................................. 65 Antipyrine-Benzocaine ................................... 66
Acular LS ........................................................ 65 Apraclonidine HCl .......................................... 65
Acyclovir......................................................... 34 Apri ................................................................. 38
Adapalene ....................................................... 44 Apriso.............................................................. 54
Adderall XR ...................................................... 9 Aptivus............................................................ 33
Advair Diskus ................................................. 15 Armour Thyroid .............................................. 69
Advair HFA .................................................... 16 Asacol ............................................................. 54
Afeditab CR .................................................... 36 Asacol HD....................................................... 54
Aggrenox......................................................... 56 Astepro............................................................ 62
Akne-Mycin .................................................... 43 Atacand ........................................................... 27
AK-Poly-Bac................................................... 64 Atacand HCT .................................................. 26
Albenza ........................................................... 14 Atelvia............................................................. 51
Albuterol Sulfate............................................. 16 Atenolol........................................................... 36
Alclometasone Dipropionate .......................... 46 Atenolol-Chlorthalidone ................................. 27
Alendronate Sodium ....................................... 51 Atorvastatin Calcium ...................................... 25
Allopurinol...................................................... 55 Atovaquone-Proguanil HCl ............................ 29
Alphagan P...................................................... 65 Atralin ............................................................. 44
ALPRAZolam ................................................. 15 Atripla ............................................................. 32
ALPRAZolam ER ........................................... 15 Atropine Sulfate .............................................. 63
Alrex ............................................................... 66 Atrovent HFA ................................................. 16
Altabax............................................................ 44 Aurax............................................................... 66
Altavera........................................................... 38 Avar LS Cleanser ............................................ 43
Amantadine HCl ............................................. 30 Avar-e Green................................................... 43
Amcinonide..................................................... 46 Avar-e LS ........................................................ 43
Amethia........................................................... 40 Aviane ............................................................. 38
Amethia Lo ..................................................... 40 AVINza ........................................................... 12
Amethyst ......................................................... 40 Avodart ........................................................... 55
AMILoride HCl............................................... 51 Axert ............................................................... 58
Amiloride-Hydrochlorothiazide...................... 50 AzaSite............................................................ 64
Amiodarone HCl............................................. 15 AzaTHIOprine ................................................ 35
74
Azelastine HCl .......................................... 62, 64 Budesonide................................................ 17, 41
Azilect ............................................................. 30 Bumetanide ..................................................... 51
Azithromycin .................................................. 57 Bupap .............................................................. 11
Azopt............................................................... 65 Buprenorphine HCl ......................................... 13
Azor................................................................. 26 BuPROPion HCl ............................................. 19
Azurette........................................................... 38 BuPROPion HCl ER (SR) .............................. 19
Bacitracin ........................................................ 64 BuPROPion HCl ER (XL) .............................. 19
Bacitracin-Polymyxin B.................................. 64 BusPIRone HCl............................................... 14
Bacitra-Neomycin-Polymyxin-HC.................. 65 Butalbital-Acetaminophen .............................. 11
Baclofen .......................................................... 62 Butalbital-APAP-Caff-Cod............................. 11
Bactroban ........................................................ 44 Butalbital-APAP-Caffeine .............................. 11
Bactroban Nasal .............................................. 62 Butalbital-Aspirin-Caffeine ............................ 11
Balsalazide Disodium ..................................... 54 Butrans ............................................................ 13
Balziva ............................................................ 38 Bydureon......................................................... 22
Baraclude ........................................................ 34 Byetta 10 MCG Pen ........................................ 22
Beconase AQ................................................... 63 Byetta 5 MCG Pen .......................................... 22
Belladonna Alk-Phenobarbital........................ 70 Bystolic ........................................................... 36
Benazepril HCl................................................ 26 Cabergoline ..................................................... 52
Benazepril-Hydrochlorothiazide ..................... 26 Calcipotriene ................................................... 45
Benicar ............................................................ 27 Calcitonin (Salmon) ........................................ 51
Benicar HCT ................................................... 26 Calcitriol ......................................................... 52
Benzamycin..................................................... 43 Calcium Acetate.............................................. 54
BenzamycinPak............................................... 43 Camila ............................................................. 41
Benzonatate..................................................... 42 Camrese........................................................... 40
Benzoyl Peroxide ............................................ 44 Camrese Lo ..................................................... 40
Benzoyl Peroxide Short Contact ..................... 44 Canasa ............................................................. 54
Benzoyl Peroxide Wash .................................. 44 Capex .............................................................. 46
Benzoyl Peroxide-Erythromycin..................... 43 Captopril ......................................................... 26
Benztropine Mesylate ..................................... 30 Captopril-Hydrochlorothiazide ....................... 26
Bepreve ........................................................... 64 Carac ............................................................... 45
Betamethasone Dipropionate .......................... 46 CarBAMazepine ............................................. 18
Betamethasone Dipropionate Aug .................. 46 Carbidopa-Levodopa....................................... 31
Betamethasone Valerate.................................. 46 Carbidopa-Levodopa ER................................. 31
Betaseron......................................................... 68 Cardizem CD .................................................. 36
Betaxolol HCl ........................................... 36, 63 Cardizem LA................................................... 36
Bethanechol Chloride...................................... 71 Carteolol HCl .................................................. 63
Betimol............................................................ 63 Cartia XT ........................................................ 36
Betoptic-S ....................................................... 63 Carvedilol........................................................ 36
Beyaz............................................................... 38 Cefaclor........................................................... 38
Bicalutamide ................................................... 29 Cefaclor ER..................................................... 38
Bisoprolol Fumarate........................................ 36 Cefadroxil ....................................................... 37
Bisoprolol-Hydrochlorothiazide ..................... 27 Cefdinir ........................................................... 38
Blephamide S.O.P........................................... 65 Cefpodoxime Proxetil ..................................... 38
Briellyn............................................................ 38 Cefprozil ......................................................... 38
Brilinta ............................................................ 55 Ceftin............................................................... 38
Brimonidine Tartrate....................................... 65 Cefuroxime Axetil .......................................... 38
Bromfed DM................................................... 42 CeleBREX....................................................... 10
Bromfenac Sodium ......................................... 65 Cenestin........................................................... 53
Bromocriptine Mesylate.................................. 30 Cephalexin ................................................ 37, 38
Budeprion SR.................................................. 19 Chantix............................................................ 69
75
Chantix Continuing Month Pak ...................... 69 Colcrys ............................................................ 55
Chantix Starting Month Pak ........................... 69 Colestipol HCl ................................................ 25
ChlordiazePOXIDE HCl................................. 15 Coly-Mycin S .................................................. 66
Chlordiazepoxide-Amitriptyline ..................... 68 Colyte with Flavor Packs ................................ 57
Chlorhexidine Gluconate ................................ 60 Combigan........................................................ 63
Chloroquine Phosphate ................................... 29 CombiPatch..................................................... 53
Chlorothiazide................................................. 51 Combivent....................................................... 16
ChlorproMAZINE HCl ................................... 32 Combivent Respimat....................................... 16
Chlorthalidone................................................. 51 Combivir ......................................................... 33
Chlorzoxazone ................................................ 62 Complera......................................................... 33
Cholestyramine ............................................... 25 Compro ........................................................... 32
Cholestyramine Light...................................... 25 Concept DHA.................................................. 60
Ciclopirox ....................................................... 45 Condylox......................................................... 49
Ciclopirox Olamine......................................... 45 Copaxone ........................................................ 68
Cilostazol ........................................................ 56 Cordran ........................................................... 46
Ciloxan............................................................ 64 Cordran SP ...................................................... 46
Cimetidine....................................................... 70 Coreg CR ........................................................ 36
Cimetidine HCl ............................................... 71 Cortane-B........................................................ 50
Cipro ............................................................... 53 Cortifoam ........................................................ 13
Cipro HC......................................................... 66 Cortisone Acetate............................................ 41
Ciprodex.......................................................... 66 Cortisporin ...................................................... 66
Ciprofloxacin HCl..................................... 53, 64 Cortisporin-TC................................................ 66
Ciprofloxacin-Ciproflox HCl.......................... 53 Cosopt PF........................................................ 63
Citalopram Hydrobromide .............................. 20 Coumadin........................................................ 17
CitraNatal 90 DHA ......................................... 61 Creon............................................................... 50
CitraNatal DHA .............................................. 61 Crestor............................................................. 25
Claravis ........................................................... 44 Crixivan .......................................................... 33
Clarithromycin ................................................ 58 Cromolyn Sodium ........................................... 64
Clarithromycin ER .......................................... 58 Cryselle-28 ...................................................... 38
Cleocin ............................................................ 72 Cyclafem 1/35 ................................................. 38
Clidinium-Chlordiazepoxide .......................... 70 Cyclafem 7/7/7................................................ 41
Climara Pro ..................................................... 53 Cyclobenzaprine HCl...................................... 62
Clindagel ......................................................... 43 Cyclopentolate HCl......................................... 63
Clindamycin HCl ............................................ 28 Cycloset........................................................... 22
Clindamycin Palmitate HCl ............................ 28 CycloSPORINE .............................................. 35
Clindamycin Phos-Benzoyl Perox .................. 43 CycloSPORINE Modified............................... 35
Clindamycin Phosphate............................. 43, 72 Cymbalta ......................................................... 20
Clobetasol Propionate ..................................... 46 Cytra-2 ............................................................ 55
Clobetasol Propionate E.................................. 46 Cytra-3 ............................................................ 55
ClomiPRAMINE HCl..................................... 21 Danazol ........................................................... 13
ClonazePAM................................................... 17 Dantrolene Sodium ......................................... 62
CloNIDine HCl ............................................... 27 Dapsone........................................................... 28
Clopidogrel Bisulfate ...................................... 56 Daraprim ......................................................... 29
Clorazepate Dipotassium ................................ 15 Daytrana ............................................................ 9
Clotrimazole.............................................. 48, 60 Denavir............................................................ 46
Clotrimazole-Betamethasone .......................... 45 Denta 5000 Plus .............................................. 60
CloZAPine ...................................................... 32 DentaGel ......................................................... 60
Codeine Sulfate............................................... 12 Depakote ......................................................... 19
Co-Gesic ......................................................... 11 Depakote ER ................................................... 19
Colchicine-Probenecid.................................... 55 Depakote Sprinkles ......................................... 19
76
Depo-Estradiol ................................................ 53 Dulera.............................................................. 16
Derma-Smoothe/FS Body............................... 47 Durezol............................................................ 66
Derma-Smoothe/FS Scalp............................... 47 Dyrenium ........................................................ 51
DermOtic......................................................... 67 E.E.S. 400 ....................................................... 58
Desipramine HCl ............................................ 21 E.E.S. Granules ............................................... 58
Desmopressin Ace Spray Refrig ..................... 52 Econazole Nitrate............................................ 48
Desmopressin Acetate..................................... 52 Edurant............................................................ 33
Desonide ......................................................... 47 Effient ............................................................. 56
Desoximetasone .............................................. 47 Eletone ............................................................ 48
Dexamethasone ............................................... 41 Elidel ............................................................... 49
Dexamethasone Sodium Phosphate .......... 42, 66 Ella .................................................................. 40
Dexilant........................................................... 71 Elmiron ........................................................... 55
Dexmethylphenidate HCl.................................. 9 Emend ............................................................. 24
Dextroamphetamine Sulfate.............................. 9 Emoquette ....................................................... 38
Dextroamphetamine Sulfate ER ....................... 9 Emtriva............................................................ 34
Diazepam .................................................. 15, 17 Enalapril Maleate ............................................ 26
Diazepam Intensol........................................... 15 Enalapril-Hydrochlorothiazide........................ 26
Diclofenac Sodium.................................... 10, 65 Enbrel.............................................................. 11
Diclofenac Sodium ER ................................... 10 Enjuvia ............................................................ 53
Dicloxacillin Sodium ...................................... 67 Enoxaparin Sodium......................................... 17
Dicyclomine HCl ............................................ 70 Enpresse-28..................................................... 41
Didanosine ...................................................... 33 Enulose............................................................ 54
Diflorasone Diacetate...................................... 47 Epidrin............................................................. 58
Diflunisal......................................................... 11 Epiduo ............................................................. 43
Digoxin ........................................................... 37 Epifoam........................................................... 50
Dilantin ........................................................... 19 Epinastine HCl ................................................ 64
Dilantin Infatabs.............................................. 19 EPINEPHrine HCl .......................................... 17
Diltiazem HCl ................................................. 36 EpiPen 2-Pak................................................... 72
Diltiazem HCl Coated Beads .......................... 36 EpiPen Jr 2-Pak............................................... 72
Diltiazem HCl CR........................................... 37 Epitol............................................................... 18
Diltiazem HCl ER Beads ................................ 37 Epivir............................................................... 34
Diovan............................................................. 27 Epivir HBV ..................................................... 34
Diovan HCT.................................................... 26 Eplerenone ...................................................... 28
Diphenatol....................................................... 23 Epzicom .......................................................... 33
Diphenoxylate-Atropine.................................. 23 Ergoloid Mesylates ......................................... 69
Dipyridamole .................................................. 56 Ergotamine-Caffeine....................................... 58
Disopyramide Phosphate................................. 15 Errin ................................................................ 41
Disulfiram ....................................................... 68 Ery................................................................... 43
Divalproex Sodium ......................................... 19 Ery-Tab ........................................................... 58
Divigel............................................................. 53 Erythrocin Stearate.......................................... 58
Donepezil HCl ................................................ 68 Erythromycin............................................. 43, 64
Donnatal.......................................................... 70 Erythromycin Base.......................................... 58
Dorzolamide HCl ............................................ 65 Escitalopram Oxalate ...................................... 20
Dorzolamide HCl-Timolol Mal ...................... 63 Est Estrogens-Methyltest ................................ 52
Doxazosin Mesylate........................................ 27 Est Estrogens-Methyltest HS .......................... 53
Doxepin HCl ................................................... 21 Estazolam........................................................ 56
Doxycycline Hyclate ....................................... 69 Estrace............................................................. 72
Dronabinol ...................................................... 24 Estradiol .......................................................... 53
Droxia ............................................................. 56 Estradiol-Norethindrone Acet ......................... 53
Duetact ............................................................ 22 Estrogel ........................................................... 53
77
Estropipate ...................................................... 53 Foradil Aerolizer............................................. 16
Ethambutol HCl .............................................. 29 Forteo .............................................................. 52
Ethosuximide .................................................. 19 Fortesta............................................................ 13
Etodolac .......................................................... 10 Fosinopril Sodium........................................... 26
Etodolac ER .................................................... 10 Fosinopril Sodium-HCTZ............................... 26
Eurax ............................................................... 50 Frova ............................................................... 58
Evista............................................................... 52 Furosemide...................................................... 51
Exemestane ..................................................... 30 Gabapentin ...................................................... 18
Exforge............................................................ 26 Gabitril ...................................................... 18, 19
Exforge HCT................................................... 26 Galantamine Hydrobromide............................ 68
Famciclovir ..................................................... 35 GaviLyte-C...................................................... 57
Famotidine ...................................................... 71 GaviLyte-G ..................................................... 57
Felodipine ....................................................... 37 GaviLyte-N with Flavor Pack ......................... 57
Femhrt Low Dose............................................ 53 Gemfibrozil ..................................................... 25
Fenofibrate ...................................................... 25 Generess FE .................................................... 39
Fenofibrate Micronized................................... 25 Generlac .......................................................... 54
Fenoglide......................................................... 25 Gengraf............................................................ 35
FentaNYL........................................................ 12 Gentamicin Sulfate.................................... 44, 64
Finacea ............................................................ 49 Gildess FE 1.5/30............................................ 39
Finasteride....................................................... 55 Gildess FE 1/20............................................... 39
First-BXN Mouthwash.................................... 59 Gilenya ............................................................ 69
First-Mouthwash BLM ................................... 59 Gleevec ........................................................... 30
FlavoxATE HCl .............................................. 71 Glimepiride ..................................................... 22
Flecainide Acetate........................................... 15 GlipiZIDE ................................................. 22, 23
Flovent Diskus ................................................ 17 GlipiZIDE ER ................................................. 23
Flovent HFA ................................................... 17 GlipiZIDE-MetFORMIN HCl ........................ 22
Fluconazole ..................................................... 24 GlucaGen ........................................................ 21
Fludrocortisone Acetate .................................. 42 GlucaGen HypoKit ......................................... 21
Flunisolide....................................................... 63 GlyBURIDE.................................................... 23
Fluocinolone Acetonide ............................ 47, 67 GlyBURIDE Micronized ................................ 23
Fluocinolone Acetonide Body......................... 47 GlyBURIDE-MetFORMIN............................. 22
Fluocinolone Acetonide Scalp ........................ 47 Glycopyrrolate................................................. 71
Fluocinonide ................................................... 47 Golytely........................................................... 57
Fluocinonide-E................................................ 47 Grifulvin V...................................................... 24
Fluorometholone ............................................. 66 Griseofulvin Microsize ................................... 24
Fluoroplex ....................................................... 45 Gris-PEG......................................................... 24
Fluorouracil..................................................... 45 GuanFACINE HCl.......................................... 27
FLUoxetine HCl.............................................. 20 HalfLytely with Flavor Packs ......................... 57
FluPHENAZine HCl ....................................... 32 Halobetasol Propionate ................................... 47
Flurazepam HCl .............................................. 56 Haloperidol ..................................................... 31
Flurbiprofen .................................................... 10 Haloperidol Lactate......................................... 31
Flurbiprofen Sodium....................................... 65 Heather............................................................ 41
Fluticasone Propionate.............................. 47, 63 Hecoria............................................................ 35
Fluvastatin Sodium ......................................... 25 HemeNatal OB................................................ 60
FluvoxaMINE Maleate ................................... 20 HemeNatal OB + DHA ................................... 60
FML ................................................................ 66 Hemorrhoidal-HC ........................................... 14
Focalin XR ........................................................ 9 Heparin Sodium (Porcine) .............................. 17
Folivane-OB.................................................... 60 Hepsera ........................................................... 34
Folivane-PRx DHA NF................................... 61 HPR................................................................. 48
Fondaparinux Sodium..................................... 17 HPR Plus......................................................... 48
78
Humira ............................................................ 10 Isosorbide Mononitrate ER ............................. 14
Humira Pen-Crohns Starter............................. 10 ISOtretinoin..................................................... 44
HydrALAZINE HCl........................................ 28 Istalol............................................................... 63
Hydrochlorothiazide........................................ 51 Itraconazole..................................................... 24
Hydrocodone-Acetaminophen .................. 11, 12 Jalyn ................................................................ 55
Hydrocodone-Homatropine............................. 42 Jantoven .......................................................... 17
Hydrocodone-Ibuprofen .................................. 12 Jentadueto ....................................................... 22
Hydrocortisone.................................... 13, 42, 47 Jinteli............................................................... 53
Hydrocortisone Ace-Pramoxine................ 13, 50 Jolessa ............................................................. 40
Hydrocortisone Acetate................................... 14 Jolivette ........................................................... 41
Hydrocortisone Acetate-Aloe.......................... 50 Junel 1.5/30 ..................................................... 39
Hydrocortisone Butyrate ................................. 47 Junel 1/20 ........................................................ 39
Hydrocortisone Valerate ................................. 47 Junel FE 1.5/30 ............................................... 39
Hydrocortisone-Iodoquinol ............................. 45 Junel FE 1/20 .................................................. 39
Hydromet ........................................................ 42 Kaletra............................................................. 33
HYDROmorphone HCl .................................. 12 Kalexate .......................................................... 35
Hydroxychloroquine Sulfate ........................... 29 Kariva.............................................................. 38
Hydroxyprogesterone Caproate....................... 38 Kelnor 1/35 ..................................................... 39
Hydroxyurea.................................................... 30 Kenalog ........................................................... 47
HydrOXYzine HCl ................................... 14, 15 Ketoconazole............................................. 24, 48
HydrOXYzine Pamoate .................................. 15 Ketoprofen ...................................................... 10
Hylatopic......................................................... 48 Ketorolac Tromethamine .......................... 10, 65
Hylatopic Plus ................................................. 48 Kionex............................................................. 35
Hyoscyamine Sulfate ...................................... 70 Klor-Con ......................................................... 59
Hyoscyamine Sulfate ER ................................ 70 Klor-Con 10 .................................................... 59
Hypercare ........................................................ 49 Klor-Con M10................................................. 59
Ibandronate Sodium ........................................ 51 Klor-Con M15................................................. 59
IBU.................................................................. 10 Klor-Con M20................................................. 59
Imipramine HCl .............................................. 21 Kristalose ........................................................ 57
Imiquimod....................................................... 48 K-Tabs............................................................. 59
Incivek............................................................. 34 Labetalol HCl.................................................. 36
Indapamide...................................................... 51 Lactulose ......................................................... 57
Indomethacin................................................... 10 LamiVUDine................................................... 34
InnoPran XL.................................................... 36 Lamivudine-Zidovudine.................................. 33
Intelence .......................................................... 33 LamoTRIgine .................................................. 18
Introvale .......................................................... 40 Lantus.............................................................. 22
Intuniv ............................................................... 9 Lantus SoloStar............................................... 22
Invirase............................................................ 33 Lastacaft .......................................................... 64
Ipratropium Bromide................................. 16, 62 Latanoprost...................................................... 66
Ipratropium-Albuterol..................................... 16 Latuda.............................................................. 31
Irbesartan......................................................... 27 Leena............................................................... 41
Irbesartan-Hydrochlorothiazide ...................... 27 Leflunomide .................................................... 11
Isentress........................................................... 33 Lessina-28 ....................................................... 39
Isometheptene-APAP-Dichloral ..................... 58 Letairis ............................................................ 37
Isoniazid.......................................................... 29 Letrozole ......................................................... 30
Isopto Homatropine......................................... 63 Leucovorin Calcium........................................ 30
Isopto Hyoscine............................................... 63 Levalbuterol HCl............................................. 16
Isosorbide Dinitrate......................................... 14 Levemir ........................................................... 22
Isosorbide Dinitrate ER................................... 14 Levemir FlexPen ............................................. 22
Isosorbide Mononitrate ................................... 14 LevETIRAcetam ............................................. 18
79
Levobunolol HCl ............................................ 63 Malathion ........................................................ 50
LevOCARNitine ............................................. 52 Maprotiline HCl .............................................. 19
Levocetirizine Dihydrochloride ...................... 24 Maxair Autohaler ............................................ 16
Levofloxacin ............................................. 53, 64 Maxalt ............................................................. 58
Levonorgest-Eth Estrad 91-Day...................... 40 Maxalt-MLT ................................................... 58
Levora 0.15/30 (28)......................................... 39 Meclizine HCl................................................. 23
Levothroid....................................................... 69 MedroxyPROGESTERone Acetate .......... 41, 68
Levothyroxine Sodium.................................... 70 Mefenamic Acid.............................................. 10
Levoxyl ........................................................... 70 Mefloquine HCl .............................................. 29
Lexiva ............................................................. 33 Megace ES ...................................................... 68
Lialda .............................................................. 54 Megestrol Acetate ........................................... 30
Lidocaine......................................................... 49 Meloxicam ...................................................... 10
Lidocaine HCl ................................................. 49 Mentax ............................................................ 45
Lidocaine Viscous........................................... 59 Meprobamate .................................................. 15
Lidocaine-Hydrocortisone Ace ................. 13, 50 Mercaptopurine ............................................... 29
Lidocaine-Prilocaine ....................................... 50 Mesalamine ..................................................... 54
Lidoderm......................................................... 49 Mesalamine-Cleanser...................................... 54
Lindane............................................................ 50 Metaproterenol Sulfate.................................... 16
Liothyronine Sodium ...................................... 70 MetFORMIN HCl ........................................... 21
Lisinopril......................................................... 26 MetFORMIN HCl ER..................................... 21
Lisinopril-Hydrochlorothiazide....................... 26 Methadone HCl............................................... 12
Lithium Carbonate .......................................... 31 Methazolamide................................................ 50
Lithium Citrate................................................ 31 Methimazole ................................................... 69
Lo Loestrin Fe ................................................. 38 Methocarbamol ............................................... 62
Locoid ............................................................. 47 Methotrexate ................................................... 29
Locoid Lipocream ........................................... 47 Methotrexate Sodium...................................... 29
Lodosyn........................................................... 30 Methscopolamine Bromide ............................. 71
Loestrin 24 Fe ................................................. 39 Methyldopa ..................................................... 27
Loestrin Fe 1.5/30 ........................................... 39 Methyldopa-Hydrochlorothiazide ................... 26
Loestrin Fe 1/20 .............................................. 39 Methylergonovine Maleate ............................. 67
Loperamide HCl.............................................. 23 Methylin ............................................................ 9
LORazepam .................................................... 15 Methylphenidate HCl........................................ 9
Losartan Potassium ......................................... 27 Methylphenidate HCl ER.................................. 9
Losartan Potassium-HCTZ ............................. 27 MethylPREDNISolone.................................... 42
LoSeasonique .................................................. 40 MethylPREDNISolone Acetate ...................... 42
Lotemax .......................................................... 66 Metipranolol.................................................... 63
Lotronex .......................................................... 54 Metoclopramide HCl ...................................... 54
Lovastatin........................................................ 25 Metolazone...................................................... 51
Lovaza............................................................. 25 Metoprolol Succinate ...................................... 36
Low-Ogestrel .................................................. 39 Metoprolol Tartrate ......................................... 36
Loxapine Succinate ......................................... 32 Metoprolol-Hydrochlorothiazide .................... 27
Ludent ............................................................. 59 Metrogel .......................................................... 49
Lumigan .......................................................... 66 MetroGel-Vaginal ........................................... 72
Lupron Depot .................................................. 30 MetroNIDAZOLE............................... 28, 49, 72
Lupron Depot-Ped........................................... 52 Micardis .......................................................... 27
Lutera .............................................................. 39 Micardis HCT ................................................. 27
Luxiq ............................................................... 47 Microgestin 1.5/30 .......................................... 39
Lyrica .............................................................. 18 Microgestin 1/20 ............................................. 39
Lysteda ............................................................ 56 Microgestin FE 1.5/30 .................................... 39
Macrobid ......................................................... 71 Microgestin FE 1/20 ....................................... 39
80
Midodrine HCl ................................................ 72 Nevanac........................................................... 65
Migranal .......................................................... 58 Nexa Select ..................................................... 61
Millipred DP ................................................... 42 Next Choice .................................................... 40
Mimvey ........................................................... 53 Niacor.............................................................. 72
Minitran........................................................... 14 Niaspan ........................................................... 25
Minocycline HCl............................................. 69 NiCARdipine HCl........................................... 37
Minoxidil ........................................................ 28 Nifediac CC .................................................... 37
Mirtazapine ..................................................... 19 Nifedical XL ................................................... 37
Misoprostol ..................................................... 71 NIFEdipine...................................................... 37
Moexipril HCl................................................. 26 NIFEdipine ER................................................ 37
Moexipril-Hydrochlorothiazide ...................... 26 NiMODipine ................................................... 37
Mometasone Furoate................................. 47, 48 Nisoldipine...................................................... 37
MonoNessa ..................................................... 39 Nitro-Bid ......................................................... 14
Montelukast Sodium ....................................... 16 Nitrofurantoin ................................................. 71
Morphine Sulfate ............................................ 12 Nitrofurantoin Macrocrystal............................ 71
Morphine Sulfate ER ...................................... 12 Nitroglycerin ................................................... 14
MoviPrep......................................................... 57 Nitrolingual ..................................................... 14
Moxeza............................................................ 64 Nitrostat........................................................... 14
Multaq ............................................................. 15 Nizatidine........................................................ 71
Mupirocin........................................................ 44 Nora-BE .......................................................... 41
Mycobutin ....................................................... 29 Norditropin FlexPro ........................................ 52
Mycophenolate Mofetil................................... 35 Norditropin NordiFlex Pen ............................. 52
Myzilra ............................................................ 41 Norethindrone ................................................. 41
Nabumetone .................................................... 10 Norethindrone Acetate .................................... 68
Nadolol............................................................ 36 Norgestimate-Eth Estradiol............................. 39
Naftin .............................................................. 45 Norgestim-Eth Estrad Triphasic...................... 41
Naltrexone HCl ............................................... 23 Nortrel 0.5/35 (28) .......................................... 39
Namenda ......................................................... 68 Nortrel 7/7/7.................................................... 41
Namenda Titration Pak ................................... 68 Nortriptyline HCl ............................................ 21
Naprosyn ......................................................... 10 Norvir.............................................................. 33
Naproxen......................................................... 10 NovoLOG........................................................ 22
Naproxen DR .................................................. 10 NovoLOG FlexPen ......................................... 22
Naproxen Sodium ........................................... 10 NovoLOG Mix 70/30...................................... 22
Nasonex........................................................... 63 NovoLOG Mix 70/30 FlexPen........................ 22
Natacyn ........................................................... 64 NovoLOG PenFill ........................................... 22
Natazia ............................................................ 40 NP Thyroid...................................................... 70
Nateglinide...................................................... 22 Nutri-Tab OB .................................................. 61
Nature-Throid ................................................. 70 Nutri-Tab OB + DHA ..................................... 61
Necon 0.5/35 (28) ........................................... 39 NuvaRing ........................................................ 40
Necon 1/35 (28) .............................................. 39 Nuvigil .............................................................. 9
Necon 1/50 (28) .............................................. 39 Nystatin ............................................... 24, 45, 60
Necon 7/7/7..................................................... 41 Nystatin-Triamcinolone .................................. 45
Nefazodone HCl.............................................. 20 Nystop ............................................................. 45
Neomycin Sulfate.............................................. 9 Ofloxacin............................................. 53, 64, 66
Neomycin-Polymyxin-Dexameth.................... 65 OLANZapine .................................................. 32
Neomycin-Polymyxin-Gramicidin.................. 64 OLANZapine-FLUoxetine HCl ...................... 69
Neomycin-Polymyxin-HC .................. 65, 66, 67 Olux-E............................................................. 48
Nestabs............................................................ 60 Omeprazole ..................................................... 71
Nestabs DHA .................................................. 60 Ondansetron .................................................... 23
Neutral Sodium Fluoride................................. 60 Ondansetron HCl ............................................ 23
81
Opana ER ........................................................ 12 Phospholine Iodide.......................................... 63
Orapred ODT .................................................. 42 Pilocarpine HCl............................................... 60
Orphenadrine Citrate ER................................. 62 Pilopine HS ..................................................... 64
Orsythia........................................................... 39 Pioglitazone HCl............................................. 23
Ortho Evra....................................................... 40 Pioglitazone HCl-Metformin HCl................... 23
Oscimin SR ..................................................... 70 Piroxicam ........................................................ 10
OsmoPrep........................................................ 57 Plendil ............................................................. 37
Oticin............................................................... 66 PNV-DHA....................................................... 61
Ovace Plus ...................................................... 45 Podofilox......................................................... 49
Ovace Plus Wash ............................................ 45 Polyethylene Glycol 3350 ............................... 68
Ovide............................................................... 50 Polymyxin B Sulfate ....................................... 28
Oxaprozin........................................................ 10 Polymyxin B-Trimethoprim............................ 64
OXcarbazepine................................................ 18 Portia-28.......................................................... 39
Oxsoralen ........................................................ 49 Potassium Chloride ......................................... 59
Oxsoralen Ultra............................................... 45 Potassium Chloride CR................................... 59
Oxybutynin Chloride....................................... 71 Potassium Chloride Crys CR .......................... 59
Oxybutynin Chloride ER ................................ 71 Potassium Citrate ............................................ 55
OxyCODONE HCl ......................................... 12 Pradaxa............................................................ 17
Oxycodone-Acetaminophen............................ 12 Pramipexole Dihydrochloride ......................... 31
Oxycodone-Aspirin......................................... 12 Pramosone....................................................... 50
Oxycodone-Ibuprofen ..................................... 12 Prandin ............................................................ 22
Pacerone .......................................................... 15 Prascion........................................................... 43
Pantoprazole Sodium ...................................... 71 Prascion FC..................................................... 43
Paromomycin Sulfate...................................... 10 Prascion RA .................................................... 43
PARoxetine HCl ............................................. 20 Pravastatin Sodium ......................................... 25
Pataday............................................................ 64 Prazosin HCl ................................................... 27
Patanase........................................................... 63 PrednisoLONE ................................................ 42
Patanol............................................................. 64 PrednisoLONE Acetate................................... 66
PEG 3350/Electrolytes.................................... 57 PrednisoLONE Sodium Phosphate ................. 42
PEG 3350-KCl-Na Bicarb-NaCl..................... 57 PredniSONE.................................................... 42
PEG-3350/Electrolytes.................................... 57 PredniSONE Intensol...................................... 42
Peganone ......................................................... 19 Prefera OB....................................................... 61
Pegasys............................................................ 34 Prefera OB + DHA.......................................... 61
Pegasys ProClick............................................. 34 PreferaOB One................................................ 61
Penicillin V Potassium.................................... 67 Premarin.................................................... 53, 72
Pentasa ............................................................ 54 Premphase ....................................................... 53
Pentazocine-Acetaminophen........................... 13 Prempro........................................................... 53
Pentazocine-Naloxone HCl............................. 13 Prenaissance .................................................... 61
Pentoxifylline ER............................................ 56 PrenaPlus......................................................... 61
Permethrin....................................................... 50 Prenatabs Rx ................................................... 61
Perphenazine ................................................... 32 Prenatal 19 ...................................................... 61
Perphenazine-Amitriptyline ............................ 68 Prenatal Plus.................................................... 61
Pexeva ............................................................. 20 Prenatal Plus/Iron............................................ 61
Pfizerpen-G ..................................................... 67 Prenate DHA................................................... 61
Phenazopyridine HCl ...................................... 55 Prenate Elite .................................................... 61
PHENobarbital................................................ 56 Prenate Essential ............................................. 61
Phenytek.......................................................... 19 Prenate Mini.................................................... 61
Phenytoin ........................................................ 19 PreNexa........................................................... 62
Phenytoin Sodium Extended........................... 19 PreQue 10........................................................ 62
Phospha 250 Neutral ....................................... 59 Prevalite .......................................................... 25
82
PreviDent ........................................................ 60 Quasense ......................................................... 40
PreviDent 5000 Booster.................................. 60 QUEtiapine Fumarate ..................................... 32
PreviDent 5000 Dry Mouth............................. 60 Quinapril HCl.................................................. 26
PreviDent 5000 Enamel Protect...................... 60 Quinapril-Hydrochlorothiazide ....................... 26
PreviDent 5000 Plus ....................................... 60 QuiNIDine Gluconate ER ............................... 15
PreviDent 5000 Sensitive................................ 60 QuiNIDine Sulfate .......................................... 15
Previfem.......................................................... 39 QuiNIDine Sulfate ER .................................... 15
Prezista............................................................ 33 Ramipril .......................................................... 26
Priftin .............................................................. 29 Ranexa............................................................. 14
Primaquine Phosphate..................................... 29 Ranitidine HCl ................................................ 71
Primidone........................................................ 18 Rapamune ....................................................... 35
Pristiq .............................................................. 20 Reclipsen......................................................... 39
Probenecid....................................................... 55 Regranex ......................................................... 50
Prochlorperazine ............................................. 32 Relpax ............................................................. 58
Prochlorperazine Edisylate ............................. 32 Remeven ......................................................... 48
Prochlorperazine Maleate ............................... 32 Renagel ........................................................... 54
ProCort............................................................ 14 Renvela ........................................................... 54
Procrit.............................................................. 56 Reprexain ........................................................ 12
Proctocream HC.............................................. 14 Requip XL....................................................... 31
Proctofoam HC ............................................... 14 Rescriptor........................................................ 33
Procto-Pak....................................................... 14 Restasis ........................................................... 65
Proctosol HC................................................... 14 Retin-A Micro................................................. 44
Proctozone-HC................................................ 14 Retin-A Micro Pump....................................... 44
Progesterone.................................................... 68 Retrovir ........................................................... 34
Progesterone Micronized ................................ 68 Revatio ............................................................ 37
Prograf............................................................. 35 Revlimid.......................................................... 35
Prolia ............................................................... 52 Reyataz............................................................ 33
Promethazine HCl........................................... 24 Rhinocort Aqua............................................... 63
Promethazine VC ............................................ 42 Ribavirin ......................................................... 34
Promethazine VC/Codeine.............................. 43 Ridaura............................................................ 10
Promethazine-DM........................................... 42 Rifampin ......................................................... 29
Promethegan ................................................... 24 Rimantadine HCl ............................................ 35
Promiseb ......................................................... 45 RisperiDONE.................................................. 31
Propafenone HCl............................................. 15 Rivastigmine Tartrate...................................... 68
Propantheline Bromide ................................... 71 ROPINIRole HCl ............................................ 31
Proparacaine HCl ............................................ 65 Rosanil Cleanser ............................................. 43
Propranolol HCl .............................................. 36 Roxicodone ..................................................... 12
Propranolol HCl ER........................................ 36 Safyral ............................................................. 39
Propranolol-HCTZ.......................................... 27 Salicylic Acid.................................................. 49
Propylthiouracil............................................... 69 Samsca ............................................................ 52
Protopic ........................................................... 49 SandoSTATIN LAR Depot............................. 52
Protriptyline HCl............................................. 21 Santyl .............................................................. 48
Provigil.............................................................. 9 Saphris............................................................. 31
PruTect............................................................ 50 Savella............................................................. 68
Pulmicort......................................................... 17 Savella Titration Pack ..................................... 68
Pulmicort Flexhaler......................................... 17 SE BPO Wash ................................................. 44
Pulmozyme ..................................................... 69 Seasonique ...................................................... 40
Pyridostigmine Bromide ................................. 29 Seb-Prev Wash................................................ 45
Quadrapax ....................................................... 70 Select-OB........................................................ 61
Qualaquin........................................................ 29 Select-OB+DHA ............................................. 62
83
Selegiline HCl................................................. 30 SUMAtriptan................................................... 58
Selenium Sulfide............................................. 46 SUMAtriptan Succinate .................................. 58
Selenium Sulf-Pyrithione-Urea....................... 45 Suprax ............................................................. 38
Selzentry.......................................................... 33 Suprep Bowel Prep ......................................... 57
Sensipar........................................................... 51 Surmontil ........................................................ 21
Serevent Diskus .............................................. 16 Sustiva............................................................. 33
SEROquel XR................................................. 32 Symbicort ........................................................ 16
Serostim .......................................................... 52 Symlin ............................................................. 21
Sertraline HCl ................................................. 20 SymlinPen 120 ................................................ 21
SF .................................................................... 60 SymlinPen 60 .................................................. 21
SF 5000 Plus ................................................... 60 Synthroid......................................................... 70
Silvadene......................................................... 46 Syprine ............................................................ 35
Silver Sulfadiazine .......................................... 46 Taclonex.......................................................... 50
Simvastatin...................................................... 25 Tacrolimus ...................................................... 35
Sodium Chloride ................................. 42, 55, 59 Tamiflu............................................................ 35
Sodium Fluoride.............................................. 59 Tamoxifen Citrate ........................................... 29
Somatuline Depot............................................ 52 Tamsulosin HCl .............................................. 55
Soriatane ......................................................... 45 Taron-C DHA ................................................. 61
Sotalol HCl ..................................................... 36 Tazorac............................................................ 45
Spiriva HandiHaler ......................................... 16 Tekamlo .......................................................... 27
Spironolactone ................................................ 51 Tekturna .......................................................... 27
Spironolactone-HCTZ..................................... 51 Tekturna HCT ................................................. 27
Sprintec 28 ...................................................... 39 Temazepam ..................................................... 56
Sprix................................................................ 10 Temodar .......................................................... 30
Sronyx ............................................................. 39 Terazosin HCl ................................................. 27
SSD ................................................................. 46 Terbinafine HCl .............................................. 24
Stalevo 100...................................................... 31 Terbutaline Sulfate.......................................... 16
Stalevo 125...................................................... 31 Terconazole..................................................... 72
Stalevo 150...................................................... 31 Testim ............................................................. 13
Stalevo 200...................................................... 31 Testosterone Cypionate................................... 13
Stalevo 50........................................................ 31 Testosterone Enanthate ................................... 13
Stalevo 75........................................................ 31 Tetracycline HCl ............................................. 69
Stannous Fluoride ........................................... 60 Tetrix............................................................... 49
Stavudine......................................................... 34 Theophylline ER ............................................. 17
Sterile Water for Irrigation.............................. 35 Thermazene..................................................... 46
Strattera ............................................................. 9 Thioridazine HCl ............................................ 32
Stromectol ....................................................... 14 Thiothixene ..................................................... 32
Suboxone ........................................................ 13 Ticlopidine HCl .............................................. 56
Sucraid ............................................................ 50 Tikosyn............................................................ 15
Sucralfate ........................................................ 71 Tilia Fe ............................................................ 41
Sulfacetamide Sodium .............................. 46, 66 Timolol Maleate........................................ 36, 63
Sulfacetamide Sodium-Sulfur................... 43, 44 TiZANidine HCl ............................................. 62
Sulfacetamide-Sulfur in Urea.......................... 44 TL-Cermide..................................................... 49
SulfADIAZINE ............................................... 69 TL-Select......................................................... 62
Sulfamethoxazole-TMP DS ............................ 28 TobraDex ........................................................ 65
Sulfamethoxazole-Trimethoprim.................... 28 TobraDex ST................................................... 65
SulfaSALAzine ............................................... 54 Tobramycin Sulfate......................................... 64
Sulfazine ......................................................... 54 Tobramycin-Dexamethasone .......................... 65
Sulfazine EC ................................................... 54 Tofranil-PM .................................................... 21
Sulindac........................................................... 11 Topiramate ...................................................... 18
84
Toprol XL ....................................................... 36 Ursodiol........................................................... 54
Torsemide ....................................................... 51 Vagifem........................................................... 72
Toviaz ............................................................. 72 ValACYclovir HCl ......................................... 34
Tracleer ........................................................... 37 Valcyte ............................................................ 34
Tradjenta ......................................................... 21 Valproic Acid.................................................. 19
TraMADol HCl............................................... 12 Vancomycin HCl............................................. 28
Tramadol-Acetaminophen .............................. 13 Vandazole ....................................................... 72
Trandolapril..................................................... 26 Velivet............................................................. 41
Travatan Z....................................................... 66 Veltin............................................................... 44
TraZODone HCl ............................................. 20 Venlafaxine HCl ............................................. 20
Tretinoin.......................................................... 44 Ventolin HFA.................................................. 16
Treximet.......................................................... 58 Veramyst ......................................................... 63
Trezix .............................................................. 11 Verapamil HCl ................................................ 37
Triamcinolone Acetonide.................... 48, 60, 63 Verapamil HCl ER.......................................... 37
Triamterene-HCTZ ......................................... 51 Veregen ........................................................... 44
Triazolam ........................................................ 57 VESIcare ......................................................... 72
Tribenzor......................................................... 26 Vestura ............................................................ 40
Tricitrates ........................................................ 55 Videx............................................................... 33
Tricor............................................................... 25 Videx EC......................................................... 34
Trifluoperazine HCl ........................................ 32 Vigamox.......................................................... 64
Trifluridine...................................................... 65 Viibryd ............................................................ 20
Trihexyphenidyl HCl ...................................... 30 Vimpat............................................................. 18
Tri-Legest Fe................................................... 41 Vinate Care ..................................................... 61
Trilipix ............................................................ 25 Viorele............................................................. 38
TriLyte............................................................. 57 Viracept........................................................... 33
Trimethobenzamide HCl................................. 23 Viramune......................................................... 33
Trimethoprim .................................................. 28 Viramune XR .................................................. 33
TriNessa (28) .................................................. 41 Viread.............................................................. 34
Triple Antibiotic........................................ 64, 65 Virt-PN............................................................ 61
Tri-Previfem.................................................... 41 Virt-PN DHA .................................................. 62
Tri-Sprintec ..................................................... 41 Vitafol ............................................................. 60
Triveen-One .................................................... 61 Vitafol-OB ...................................................... 61
Triveen-PRx RNF ........................................... 62 Vitafol-One ..................................................... 62
Triveen-U ........................................................ 61 VitaMedMD One Rx/Quatrefolic ................... 62
Trivora (28)..................................................... 41 VitaMedMD RediChew Rx ............................ 62
Trizivir ............................................................ 33 Vivactil............................................................ 21
Tropicamide .................................................... 63 Vivelle-Dot ..................................................... 53
Truvada ........................................................... 33 Voltaren........................................................... 44
Tussigon.......................................................... 42 VP-GGR-B6 Prenatal...................................... 62
Tykerb ............................................................. 30 Vusion ............................................................. 45
Tyzeka............................................................. 34 Vytorin ............................................................ 25
Ulesfia ............................................................. 50 Vyvanse............................................................. 9
Uloric .............................................................. 55 Warfarin Sodium............................................. 17
UltimateCare ONE.......................................... 61 Wellbutrin ....................................................... 19
UltimateCare ONE NF.................................... 61 Wellbutrin SR ................................................. 19
Unithroid ......................................................... 70 Wellbutrin XL................................................. 19
Urea................................................................. 48 Wymzya Fe ..................................................... 40
Urea Hydrating................................................ 48 Xarelto............................................................. 17
Urea Nail ......................................................... 48 Xeloda ............................................................. 29
Urea Nail Film ................................................ 48 Xifaxan............................................................ 28
85
Xolair .............................................................. 16 Zidovudine ...................................................... 34
X-Viate............................................................ 48 Zioptan ............................................................ 66
Yasmin 28 ....................................................... 40 Ziprasidone HCl.............................................. 31
YAZ ................................................................ 40 Zirgan .............................................................. 65
Zafirlukast ....................................................... 16 Zmax ............................................................... 57
Zaleplon .......................................................... 57 Zolpidem Tartrate ........................................... 57
Zatean-CH....................................................... 62 Zomig.............................................................. 58
Zatean-Pn ........................................................ 61 Zomig ZMT..................................................... 59
Zatean-Pn DHA............................................... 62 Zonisamide...................................................... 18
Zatean-Pn Plus ................................................ 61 Zovia 1/35E (28) ............................................. 40
Zenchent.......................................................... 40 Zovia 1/50E (28) ............................................. 40
Zenchent FE .................................................... 40 Zovirax............................................................ 46
Zeosa ............................................................... 40 Zyflo CR ......................................................... 15
Zerit................................................................. 34 Zylet ................................................................ 66
Zetia ................................................................ 25 Zymaxid .......................................................... 64
Ziagen.............................................................. 34 Zytiga .............................................................. 29
Ziana ............................................................... 44 Zyvox .............................................................. 28
