2013

Comprehensive

Formulary
(Complete list of covered drugs)

UnitedHealthcare® Group Medicare Advantage Plan

Inside
• Drug tiers and drug payment stages
• Requirements and limits

• Complete list of drugs by category
• Index of covered drugs

Please read: This document contains information about the drugs covered
by this plan.
Note to existing members: This complete list of drugs has changed since last year.
Please review this document to make sure it still contains the drugs you take.

00013509G, 11
Y0066_120911_110211

About this complete drug list
This is a complete list of prescription drugs that are covered by the UnitedHealthcare® Group
Medicare Advantage Plan, insured through UnitedHealthcare, for the 2013 plan year. It is called the
Comprehensive Formulary (drug list) and includes all of the drugs covered by the plan.
For your drug to be covered by the plan, it must be included in the complete drug list. In most cases, your
prescription must also be filled at one of our more than 65,000 network pharmacies. To find out if your
drug is covered:
1. See if your drug is included in this complete drug list.
2. Visit the plan website at www.UHCRetiree.com. You can use online tools to look up your drugs.
The information is updated on a regular basis.
3. Call Customer Service at the number located on the back of your ID card. Customer Service can
look up your drugs and let you know if they are covered.

For more information
Please take the time to review your Evidence of Coverage and any other 2013 plan materials you have
received. These materials give more detailed information about your drug coverage in the plan.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1‑800‑MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call
1‑877‑486‑2048. Or visit www.medicare.gov.

Questions?

Online tools

If you have questions, we’re here to help.

Visit www.UHCRetiree.com to 

all Customer Service at the number
C
located on the back of your ID card. 
Or visit www.UHCRetiree.com

• Look up your drugs and see what you
could save with lower-cost drugs
• View your cost and benefits summary
• Track your payment status and
claims history

2013 Complete drug list
The plan is designed to help you manage your prescription drug costs. An important part of this is giving
you choices so you and your doctor can choose the best course of treatment for you.
A formulary is a list of the drugs covered by a Medicare Advantage prescription drug plan in
consultation with a team of health care providers, which represents the prescription therapies believed
to be a necessary part of a quality treatment program. The plan will generally cover the drugs listed
in the formulary as long as the drug is medically necessary, the prescription is filled at a plan network
pharmacy and other plan rules are followed. For more information on how to fill your prescriptions,
please review your Evidence of Coverage.
With your doctor’s help, you can use this drug list as a tool to choose the drugs that work best for you
and to find lower-cost drugs if needed.

Using the drug list
There are two ways to find your prescription drugs in this complete drug list:
1. Alphabetical list (index): Turn to the “Index of covered drugs” section, which begins on page 62,
to see the list of drug names in alphabetical order.
2. Medical condition: Turn to the “Covered drugs by category” section, which begins on page 8,
to look for drug names based on your medical conditions. For example, if you want to find
drugs used to treat high cholesterol, go to the “Cardiovascular Drugs” category and look under
“Cholesterol Control Drugs.”

Is it a generic or brand name drug?
The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain
type (for example, Simvastatin).

More information about your drug
Some drugs have requirements or limits. Please see the “Requirements and limits” section on page 4 for
more information on drugs you may use.
This document is a complete list of covered drugs. If your drug is not included in this drug list, the
plan may still cover it. Contact Customer Service to ask if it’s covered, or go to www.UHCRetiree.com
to look it up online. If you learn that the plan does not cover your drug, you have two options:
1. Y 
ou can ask Customer Service for a list of similar drugs that are covered by the plan. When you
receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered
by the plan.
2. Y 
ou can ask the plan to make an exception and cover your drug. See the “Coverage decisions”
section on page 5 for information about how to request an exception.

1

Drug tiers and drug payment stages
The amount you pay for a covered drug will depend on:
• Your drug payment stage. The plan has different stages of drug coverage. When you fill a
prescription, the amount you pay depends on the stage you’re in.
• The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier may have a
different copay or coinsurance amount. The chart below shows the differences between the tiers.
For more information about drug payment stages and copay or coinsurance amounts for each tier,
please refer to the plan’s Evidence of Coverage (EOC).

If you qualify for extra help
If you qualify for extra help for your prescription drugs, your copays and coinsurance may be lower.
Members who qualify for extra help will receive the “Evidence of Coverage Rider for People Who Get
Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to find out what your costs are.
You can also contact Customer Service.

Drug Tier

Includes

Tier 1:
Preferred generic

Most generic drugs.

Tier 2:
Preferred brand

Many common brand name drugs, called preferred brands, and
some higher-cost generic drugs.

Tier 3:
Non-preferred brand

Non-preferred generic and non-preferred brand name drugs.

Tier 4:
Specialty tier

Unique and/or very high‑cost drugs.

2

whether preferred or non-preferred. For the best coverage. The administration fee likely will be lower at a network pharmacy than at your doctor’s office. the plan recommends that you get vaccines at a network pharmacy if your state allows it. call Customer Service at the number located on the back of your ID card. Vaccines The plan covers a number of Part D vaccines.Generic drugs The plan covers both brand name and generic drugs. If you get your vaccines at your doctor’s office. may be covered by Medicare Part B (doctor and outpatient health care). The Food and Drug Administration (FDA) requires a generic drug to have the same active ingredient as the brand name drug. Our coverage may include the cost of both the vaccine medication and the administration of the vaccine shot. Some vaccines. Using generic drugs. may save you money on your copays or coinsurance and may help you stay out of the coverage gap if you have one. To make sure a recommended vaccine is covered. 3 . like those for the flu and pneumonia. you will pay the entire cost of the vaccine and administration fee to your doctor. Please see your Evidence of Coverage for more information about vaccines and their costs.

The codes and what they mean are shown below. Drugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. B/D Medicare Part B or Part D LA Limited access PA Prior authorization ST Step therapy Depending on how this drug is used. For more information about requirements and limits. If your drug has any requirements or limits. the plan may not cover the drug. it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). These drugs may require extra handling. provider coordination or patient education that can’t be done at a network pharmacy. You and your doctor may ask the plan for an exception to the requirement and/or limit for your drug. you may be responsible for paying the full cost of the drug. If you don’t get approval. you or your doctor can ask the plan to cover this drug. Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare. The plan requires you or your doctor to get prior authorization for certain drugs. You may be required to try one or more of these other drugs before the plan will cover your drug.Requirements and limits Some of the plan’s drugs have requirements or limits to help ensure safe. See the “Coverage decisions” section on the next page or your Evidence of Coverage to learn more. lower-cost drugs that treat the same medical condition as this drug. effective and affordable use. call Customer Service at the number located on the back of your ID card. there will be a code(s) in the “Requirements & Limits” column of the drug list starting on page 8. There are effective. If you do not get prior approval from the plan for a drug with a requirement or limit. 4 . If you have already tried other drugs or your doctor thinks they are not right for you. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare.

the lower-tiered drug or additional utilization restrictions would not be effective in treating your condition and/or would cause you to have adverse medical effects. the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary. • You can ask the plan to waive coverage restrictions or limits on your drug (utilization exception). the plan will consider your request and respond with a coverage decision (coverage determination). you will receive a decision within 24 hours after the plan receives your prescriber’s or prescribing physician’s supporting statement. How to request an exception You can ask the plan to make an exception to the coverage rules. if we grant your request to cover a drug that is not in the plan’s formulary. process. or fast. See your Evidence of Coverage for more information. Receiving a coverage decision Generally. This would lower the amount you must pay for your drug. decision if you or your doctor believe your health requires it. When you are requesting a formulary. Please note. When you do. you can ask the plan to cover it at the cost‑sharing amount that applies to drugs in the preferred tier/lowest tier subject to the tiering exception process tier instead. the plan will make a coverage decision within 72 hours after receiving your prescribing physician’s statement. you may not ask us to provide a higher level of coverage for the drug. • Asking for an exception to the plan’s coverage rules. Tiering exceptions are not available for drugs in the specialty tier. There are several types of exceptions that you can ask the plan to make. Asking for a coverage decision You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling Customer Service at the number located on the back of your ID card. If your drug is in the non‑preferred tier/the highest tier subject to the tiering exceptions Generally. tiering or utilization restriction exception. You can request an expedited. If the plan agrees to a fast decision. • You can ask the plan to provide a higher level of coverage for your drug (tier exception).Coverage decisions At times you may need to ask for drug coverage that’s not normally provided by the plan. Examples of coverage decisions you may ask for include: • Asking the plan to pay you back for the cost of a drug you bought at an out‑of‑network pharmacy. 5 . your prescriber or physician should submit a statement supporting your request. • You can ask the plan to cover your drug even if it is not on the formulary (formulary exception).

will not affect members who are currently taking the drug. the plan will immediately remove the drug from the drug list and inform affected members. It is important that you have continued access for the remainder of the coverage year to the list of drugs that were available when you chose the plan. • Moves a drug to a lower-cost tier. members may receive a special mailing. • Moves a drug to a higher-cost tier. less expensive generic equivalent drug becomes available (for example. members may see information in the Explanation of Benefits statement. Generally. such as removing a drug from the drug list. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. I f the FDA declares a drug to be unsafe or the drug’s manufacturer removes the drug from the market. the plan will inform affected members at least 60 days before the change or at the time the member requests a refill of the drug. • Changes the requirements or limits for a drug. If a drug moves to a higher‑cost tier or undergoes some other change. or when new information about the safety or effectiveness of a drug is released. If there are changes to the drug list outside of regular or necessary updates. drug list changes may be necessary for safety or other reasons. • Removes a drug. If there are changes to the drug list such as regular or necessary updates. From time to time. member newsletters or other member mailings. Other types of changes. the brand name drug moves to a higher tier and the less expensive drug is on the lower tier). the plan will not remove the drug from the drug list or move a drug to a higher tier during the 2013 coverage year except when a new. The drug list may change throughout the year when the plan: • Adds a new drug. except for cases in which you can save additional money or your safety is a concern.Drug list changes The plan recognizes that drug list stability is very important to you. at which time the member will receive a 60-day supply of the drug. The plan website also has updated information. That is why the plan tries to make as few changes to the drug list as possible during the plan year. if you are taking a drug on the 2013 drug list that was covered at the beginning of the year. 6 .

Or visit www. 7 . even if you have been a member of the plan less than 90 days. you may be taking drugs that are not on the formulary. the plan will cover a 31-day emergency supply of the drug (unless your prescription is for fewer days) while you request a formulary exception.gov. 7 days a week.medicare. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers. like a hospital discharge or a change in your level of care. Other transitions You may have an unplanned transition. If this happens and your doctor prescribes a drug that’s not on the drug list. Or visit www. please review your Evidence of Coverage and other plan materials.Transition supply process New or continuing members As a new or continuing member in the plan. You may ask for a one-time emergency supply of up to 31 days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception. If you have questions. For example. The plan will also cover one or more refills for the first 90 days of your membership. the plan will not pay for these drugs. the plan will allow you to refill your prescription until we have provided you with a 91-day transition supply of the drug consistent with dispensing increment (unless your prescription is for fewer days). please call Customer Service at the number located on the back of your ID card. For each of your drugs that is not on the formulary. after the first 90 days of your plan membership. the plan may cover your drug in certain cases during the first 90 days you are a member of the plan.com If you have general questions about Medicare prescription drug coverage. you may need prior authorization before you can fill your prescription. or request a formulary exception so that the plan will cover the drug you take. For more information For more detailed information about the plan’s prescription drug coverage. or if your ability to get your drugs is limited. you are required to use the plan’s exception process.UHCRetiree. 24 hours a day. please call Medicare at 1‑800‑MEDICARE (1-800-633-4227). While you talk to your doctor to determine the right course of action for you. or if it’s difficult for you to get your drugs. After your first 30-day supply. Or you may be taking a drug that is on the formulary but your ability to get it is limited. Long-term care facility residents If you’re a resident of a long-term care facility. the plan will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. If you need a drug that’s not on the drug list or if you have limited ability to get your drugs but you are past the first 90 days of your plan membership. TTY/TDD users should call 1‑877‑486‑2048.

com or call Customer Service at the number located on the back of your ID card. turn to the “Index of covered drugs” section that begins on page 62. 600mg Tablet. Tablet) Etodolac ER Feldene Fenoprofen Calcium Flector Flurbiprofen Ibuprofen (Suspension. Inflammation and Muscle and Joint Conditions Analgesics. If you have trouble finding your drug in the list.Covered drugs by category This Comprehensive Formulary (drug list) below provides coverage information about the drugs covered by the plan. It is current as of January 1. 400mg Tablet. Simvastatin). The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example. The information in the Requirements & Limits column tells you if the plan has any special requirements for coverage of your drug. for additional help.UHCRetiree. please visit www. 2013. Drug Name Drug Requirements Tier  & Limits Drug Name Diflunisal Duexis EC-Naprosyn Etodolac (200mg Capsule. 800mg Tablet) Indocin (Suspension) Indomethacin (Capsule) Indomethacin ER Ketoprofen Ketoprofen ER Ketorolac Tromethamine (Tablet) Analgesics — Drugs to Treat Pain. Crestor) and generic drugs are listed in plain type (for example. If your prescription is not in this complete formulary. Other — Miscellaneous Analgesics Gralise 3 ST Gralise Starter 3 ST Nonsteroidal Anti-Inflammatory Drugs — Pain/Anti-Inflammatory Drugs Anaprox 3 Anaprox DS 3 Arthrotec 3 Cambia 3 Cataflam 3 Celebrex 2 Clinoril 3 Daypro 3 Diclofenac Potassium 1 Diclofenac Sodium DR 1 Diclofenac Sodium ER 1 Drug Requirements Tier  & Limits 1 3 3 ST 1 1 3 1 3 1 1 3 2 2 2 2 2 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 8 .

50mg Capsule Extended Release 24 Hour. 3 ST 50mcg/Hr Patch 72 Hour) 9 Drug Requirements Tier  & Limits 4 2 2 2 3 4 2 2 3 2 2 2 ST . Tablet) Morphine Sulfate ER Ketorolac Tromethamine (15mg/ml Injection. 60mg Capsule Extended Release 24 Hour. 30mg Capsule Extended Release 24 Hour. 2 PA 30mg/ml Injection) Meclofenamate Sodium 2 Mefenamic Acid 2 Meloxicam 1 Mobic 3 Nabumetone 2 Nalfon 3 Naprelan (750mg Tablet Extended 3 Release 24 Hour) Naprosyn 3 Naproxen 1 Naproxen DR 1 Naproxen Sodium (275mg 1 Tablet. Long-Acting — Opioid Pain Relievers Astramorph 2 Avinza 2 Dolophine 3 Dolophine HCl 3 Duragesic (12mcg/Hr Patch 72 Hour. 20mg Capsule Extended Release 24 Hour. 10mg Capsule Extended Release 24 Hour. 25mcg/ Hr Patch 72 Hour. 550mg Tablet) Oxaprozin 1 Oxycodone/Ibuprofen 2 Piroxicam 2 Ponstel 3 Sprix 3 PA Sulindac 1 Tolmetin Sodium 2 Treximet 3 ST Voltaren-XR 3 Zipsor 3 ST Opioid Analgesics. 75mcg/ Hr Patch 72 Hour) Duramorph Exalgo Fentanyl (Patch) Kadian (100mg Capsule Extended Release 24 Hour. 80mg Capsule Extended Release 24 Hour) Kadian (200mg Capsule Extended Release 24 Hour) Levorphanol Tartrate Methadone HCl (Concentrate. Tablet) Methadone HCl (Injection) Methadose (Tablet) Morphine Sulfate (Oral Solution.Drug Name Drug Requirements Tier  & Limits Drug Name Duragesic (100mcg/Hr Patch 72 Hour. Oral Solution.

15mg Tablet Extended Release 12 Hour. 600mcg Tablet Sublingual. 800mcg Tablet Sublingual) Acetaminophen/Caffeine/ Dihydrocodeine Bitartrate Acetaminophen/Codeine Actiq Butalbital/Aspirin/ Caffeine/Codeine Butorphanol Tartrate Capital/Codeine Carisoprodol/Aspirin/ Codeine Co-Gesic Codeine Sulfate (Tablet) Demerol (50mg/ml Injection) Demerol (Tablet) Dilaudid Dilaudid-5 Dilaudid-HP (10mg/ml Injection) Endocet Endodan Fentanyl Citrate Oral Transmucosal Fentora Fiorinal/Codeine Hycet Drug Requirements Tier  & Limits 2 1 4 PA 2 2 3 3 2 1 3 3 3 3 ST 3 2 1 4 PA 4 3 3 PA Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 10 . 400mcg Tablet 4 PA Sublingual. 3 30mg Tablet Extended Release 12 Hour.Drug Name Drug Requirements Tier  & Limits Drug Name MS Contin (100mg Tablet Extended Release 12 Hour. 300mcg Tablet Sublingual. Short-Acting — Opioid Pain Relievers Abstral (100mcg Tablet 3 PA Sublingual) Abstral (200mcg Tablet Sublingual. 60mg Tablet Extended Release 12 Hour) MS Contin (200mg Tablet Extended 4 Release 12 Hour) Nucynta ER 2 Opana ER 2 (Crush Resistant) Oxycontin 2 Oxymorphone HCl ER 2 Ryzolt 3 ST Tramadol HCl ER (Tablet Extended Release 3 24 Hour) Ultram ER 3 Opioid Analgesics.

5mg Tablet) Oxycodone/ Acetaminophen Oxycodone/Aspirin Oxymorphone HCl Pentazocine/ Acetaminophen Pentazocine/Naloxone HCl Percocet Percodan Reprexain Roxicet (500mg. Tablet) Lazanda Lorcet Lortab Magnacet Maxidone Meperidine HCl (100mg/ml Injection. 500mg. 300mg. 660mg. 300mg. 7. 10mg Tablet. 2. 300mg. 5mg Tablet) Roxicet (Oral Solution) Roxicodone Stagesic Synalgos-DC Talwin Tramadol HCl Tramadol HCl/ Acetaminophen Tylenol/Codeine Tylox Ultracet Ultram Vicodin Vicodin ES Vicodin HP Vicoprofen Xodol (300mg.5mg Tablet.5mg Tablet. 25mg/ml Injection. 7. Concentrate. 300mg.5mg Tablet. 325mg. 325mg. 10mg Tablet. Tablet) Nalbuphine HCl Norco Nucynta Onsolis Opana (Tablet) Oxecta Drug Requirements Tier  & Limits Oxycodone HCl (Capsule. 7. 5mg Tablet. 325mg. 30mg Tablet. 5mg Tablet.5mg Tablet. 500mg.Drug Name Hydrocodone/ Acetaminophen (Oral Solution.5mg Tablet. 10mg Tablet. 500mg. 5mg Tablet. 500mg. 7. 650mg.5mg Tablet) Hydrocodone/Ibuprofen Hydromorphone HCl (500mg/50ml Injection. 7. 650mg.5mg Tablet) Zamicet Zydone 2 2 2 3 3 3 3 3 PA 3 3 ST 2 3 3 4 3 3 PA PA Drug Name PA 11 Drug Requirements Tier  & Limits 2 2 1 2 3 ST 3 3 3 3 ST 2 3 3 2 3 3 1 1 3 3 3 3 3 3 3 3 3 3 3 . 750mg. 10mg Tablet. 15mg Tablet. 10mg Tablet. 750mg. 7. 10mg Tablet. 50mg/ml Injection) Meperidine HCl (Oral Solution. 10mg Tablet.

1% Injection) Lidocaine HCl (Gel) Lidocaine Viscous Lidocaine/Prilocaine (Cream) Lidoderm Synera Xylocaine (External Solution) Xylocaine (1% Injection) 3 2 B/D B/D 2 2 B/D 2 2 2 B/D 2 3 B/D 3 3 Drug Requirements Tier  & Limits B/D Anti-Inflammatory Agents Nonsteroidal Anti-Inflammatory Drugs — Pain/Anti-Inflammatory Drugs Naprelan (375mg Tablet Extended Release 24 Hour.9% Injection) Gentamicin Sulfate/ NaCl (0.6mg/ml.5% Injection.9mg/ml. 0.Drug Name Drug Requirements Tier  & Limits Drug Name Gentamicin Sulfate (Cream. 1 Ophthalmic Solution) Gentamicin Sulfate/NaCl (1.9% 2 Injection.9% Injection. 1mg/ml. 0. 1. 0. 0. Injection. Other — Antibiotics Altabax 3 Baciim 1 Anesthetics — Drugs for Numbing Local Anesthetics Emla Lidocaine (Ointment) Lidocaine HCl (External Solution) Lidocaine HCl (0.8mg/ml.9% Injection) Kanamycin Sulfate 2 Neomycin Sulfate 1 Neomycin/Polymyxin B 2 Sulfates Paromomycin Sulfate 2 Streptomycin Sulfate 3 Tobi 4 B/D Tobramycin Sulfate 1 (Ophthalmic Solution) Tobramycin Sulfate (10mg/ml Injection.1% Ointment. 2 50mg/ml Injection) Gentak (Ointment) 1 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 12 . 1 1. 3 500mg Tablet Extended Release 24 Hour) Antibacterials — Drugs to Treat Bacterial Infections Aminoglycosides — Antibiotics Amikacin Sulfate (500mg/2ml Injection.9% Injection) Isotonic Gentamicin 1 (0. 0.4mg/ml.2mg/ml. 2 80mg/2ml Injection) Tobramycin Sulfate/ 2 Sodium Chloride Tobrex (Ointment) 2 Tobrex 3 (Ophthalmic Solution) Antibacterials. 0.9% Injection. 0.

Ophthalmic Ointment) Bacitracin/Polymyxin B Bactroban Bactroban Nasal Chloramphenicol Sodium Succinate Cleocin Cleocin Galaxy Cleocin in D5W Cleocin Phosphate (900mg/6ml Injection) Clindamycin HCl (150mg Capsule. 25mg Capsule) Methenamine Hippurate MetroCream MetroGel MetroGel-Vaginal Metrolotion Metronidazole Drug Requirements Tier  & Limits Metronidazole in NaCl 0. 500mg Injection) Vancomycin HCl (125mg Capsule) 1 1 3 3 2 3 3 3 3 1 1 2 3 3 ST 3 4 3 3 3 3 3 3 Drug Name B/D 3 2 3 3 3 3 2 13 Drug Requirements Tier  & Limits 2 1 3 1 1 1 3 2 2 2 3 2 3 3 3 3 1 1 3 4 1 1 1 3 4 PA 2 B/D 4 PA .79% Metronidazole Vaginal Monurol Mupirocin Neomycin/Bacitracin/ Polymyxin Neomycin/Polymyxin/ Gramicidin Neosporin Nitrofurantoin Nitrofurantoin Macrocrystalline (50mg Capsule) Nitrofurantoin Monohydrate Phisohex Polymyxin B Sulfate Polytrim Prevpac Primsol Silvadene Silver Sulfadiazine SSD Sulfamylon Synercid Thermazene Trimethoprim Trimethoprim Sulfate/ Polymyxin B Sulfate Tygacil Vancocin HCl Vancomycin HCl (1000mg Injection.Drug Name Bacitracin (Injection. Ointment) Cubicin Flagyl Flagyl ER Furadantin Hiprex Lincocin Macrobid Macrodantin (100mg Capsule. 10gm Injection. 300mg Capsule) Clindamycin Phosphate (Cream) Clindamycin Phosphate Add-Vantage Colistimethate Sodium Coly-Mycin M Cortisporin (Cream.

5% Injection. 500mg Injection) Cefdinir 2 Cefepime (1gm Injection. 2gm 2 Injection. 6gm Injection) Ceftazidime/Dextrose 2 Ceftin 3 Drug Requirements Tier  & Limits Ceftriaxone Sodium 2 Cefuroxime Axetil (Tablet) 1 Cefuroxime Sodium (1. Cephalosporins — Antibiotics Cedax (Capsule) 3 Cefaclor 1 Cefaclor ER 1 Cefadroxil 1 Cefazolin Sodium (10gm Injection. 1gm 2 Injection. 2 2gm Injection) Cefotaxime Sodium (10gm Injection. 6gm Injection) Keflex (250mg Capsule. 2gm Injection.5gm Injection. 3 500mg Capsule) Rocephin 3 (500mg Injection) Spectracef 3 Suprax 2 Teflaro 3 Zinacef 3 Zinacef in Iso-Osmotic 3 Dextrose Zinacef in Iso-Osmotic 3 Diluent Beta-Lactam. 5% Injection. 750mg Injection) Cephalexin 1 Claforan 3 Fortaz (1gm/50ml. Other — Antibiotics Azactam 2 (2gm Injection) Azactam in Iso-Osmotic 3 Dextrose Aztreonam (1gm Injection) 2 Cayston 4 Cefotetan 3 PA Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 14 . 2 1gm. 5% Injection. 3 2gm/50ml. 2gm Injection) Cefoxitin Sodium/ 2 Dextrose Cefoxitin Sodium 2 Cefpodoxime Proxetil 2 Cefprozil 2 Ceftazidime (1gm Injection. 1gm Injection.5gm Injection. 1 7.Drug Name Drug Requirements Tier  & Limits Drug Name Vancomycin HCl 4 PA (250mg Capsule) Vandazole 1 Vibativ (250mg Injection) 3 Xifaxan (200mg Tablet) 3 Xifaxan (550mg Tablet) 4 Zyvox 4 PA Beta-Lactam.

Penicillins — Antibiotics Amoxicillin 1 Amoxicillin/Potassium 1 Clavulanate Amoxicillin/Potassium 1 Clavulanate ER Ampicillin 2 Ampicillin Sodium (10gm Injection. 3gm Injection) Unasyn (2gm.S. 0.E.375gm/50ml Injection) Macrolides — Antibiotics Akne-Mycin Azasite Azithromycin (500mg Injection. 0.5gm Injection) Timentin (0. 125mg 2 Injection. 1gm Injection) Penicillin G Potassium 3 (5mu Injection) Drug Name Penicillin G Potassium in Iso-Osmotic Dextrose Penicillin G Procaine Penicillin G Sodium Penicillin V Potassium Pfizerpen-G (20mu Injection) Piperacillin Sodium/ Tazobactam Sodium (3gm. Granules Ery Ery-Tab Eryped 15 Drug Requirements Tier  & Limits 2 3 3 1 3 2 3 3 3 3 3 2 1 3 3 3 2 2 4 1 2 1 2 2 PA .E.Drug Name Drug Requirements Tier  & Limits Doribax 3 (500mg Injection) Imipenem/Cilastatin 2 Invanz 3 Meropenem 2 (500mg Injection) Merrem 3 (500mg Injection) Primaxin 3 Beta-Lactam.375gm Injection.375gm Injection.S. 5%. 4gm. 5gm Injection. 400 E. Suspension Reconstituted. 2gm/50ml. 1gm Injection) Nallpen/Dextrose 3 (1gm/50ml Injection) Oxacillin Sodium (10gm 3 Injection.1gm.25gm/50ml Injection. 0. 3gm/50ml. Tablet) Biaxin Biaxin XL Biaxin XL PAC Clarithromycin Clarithromycin ER Dificid E. 2gm. 0. 5%. 0. 2 1gm Injection) Bactocill in Dextrose 3 (1gm/50ml Injection) Bactocill in Dextrose 4 (2gm/50ml Injection) Bicillin C-R 3 Bicillin L-A 3 Dicloxacillin Sodium 1 Moxatag 3 Nafcillin Sodium (10gm 2 Injection. 1gm Injection) Ampicillin-Sulbactam (10gm. 1gm Injection) Unasyn Bulk Pack Zosyn (3gm.

3 Oral Solution. Tablet) Zithromax Tri-Pak Zithromax Z-Pak Zmax Quinolones — Antibiotics Avelox (Tablet) Avelox (Injection) Avelox ABC Pack Besivance Ciloxan Cipro Cipro HC Cipro IV (200mg/100ml. 5% Injection) Ciprodex Ciprofloxacin (400mg/40ml Injection) Ciprofloxacin ER Ciprofloxacin HCl Factive Drug Requirements Tier  & Limits Drug Name Levaquin (5%. 750mg/150ml Injection. Ointment) Erythromycin Base Erythromycin Ethylsuccinate Ketek PCE Zithromax (Injection. Tablet) Levofloxacin 2 Levofloxacin in D5W (5%. Gel.Drug Name Erythrocin Lactobionate (500mg Injection) Erythrocin Stearate Erythromycin (External Solution. 2 500mg/100ml Injection) Moxeza 2 Noroxin 3 Ocuflox 3 Ofloxacin 2 Vigamox 2 Zymaxid 2 Sulfonamides — Antibiotics Bactrim 3 Bactrim DS 3 Bleph-10 3 Septra DS 3 Sodium Sulfacetamide 1 (Ophthalmic Solution) Sulfacetamide Sodium 1 (Ointment) Sulfadiazine 2 Sulfamethoxazole/ 1 Trimethoprim Sulfamethoxazole/ 1 Trimethoprim DS Tetracyclines — Antibiotics Demeclocycline HCl 2 Doryx 3 Doxycycline 2 (75mg Capsule) 3 3 1 1 1 3 3 Drug Requirements Tier  & Limits PA 3 3 3 3 2 3 2 2 3 3 3 3 2 1 2 1 3 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 16 . Suspension Reconstituted.

75mg Tablet) Dynacin Minocin (Capsule) Minocycline HCl (Capsule) Minocycline HCl (Tablet) Minocycline HCl ER Monodox Oracea Solodyn Tetracycline HCl Vibramycin Drug Requirements Tier  & Limits Drug Name Drug Requirements Tier  & Limits Calcium Channel Modifying Agents — Seizure Control Drugs Celontin 3 Ethosuximide 2 Lyrica 2 Zarontin 3 Zonegran 3 Zonisamide 1 Gamma-Aminobutyric Acid (GABA) Augmenting Agents — Seizure Control Drugs Clonazepam 1 Clonazepam ODT 3 Clorazepate Dipotassium 1 Depacon 3 Depakene 3 Depakote 3 Depakote ER 3 Depakote Sprinkles 3 Diazepam (Gel) 3 Divalproex Sodium 1 Divalproex Sodium DR 1 Divalproex Sodium ER 1 Gabapentin 1 Gabitril 3 Horizant 3 ST Klonopin 3 Mysoline 3 Neurontin 3 Onfi 3 PA Primidone 1 Sabril 4 PA Stavzor 3 Tranxene T 3 Valproate Sodium 2 (100mg/ml injection) Valproic Acid 1 2 3 2 3 3 1 3 3 3 3 3 1 3 Anticonvulsants — Drugs to Treat Seizures Anticonvulsants. 50mg Tablet.Drug Name Doxycycline Hyclate (Capsule. 16.2mg Tablet.4mg 1 PA Tablet. Tablet) Keppra XR 3 Levetiracetam (500mg/5ml Injection. Tablet) Levetiracetam ER 2 Phenobarbital (Elixir. Other — Seizure Control Drugs Keppra 3 (Oral Solution. 32. 97.8mg Tablet. 64. 100mg Tablet Delayed Release. 75mg Tablet Delayed Release) Doxycycline Hyclate (150mg Tablet Delayed Release) Doxycycline Monohydrate (150mg Tablet. 30mg Tablet. Tablet. Injection.2mg Tablet) Potiga 3 17 . 1 Oral Solution.

Other Ergoloid Mesylates 2 Cholinesterase Inhibitors — Alzheimer’s Disease and Dementia Drugs Aricept (23mg Tablet) 2 Aricept (10mg Tablet. 100mg Tablet Extended Release 24 Hour. Tablet) Vimpat (Injection) Drug Requirements Tier  & Limits 2 3 2 2 2 3 2 2 3 1 1 1 1 2 2 3 3 3 PA Antidementia Agents — Drugs to Treat Alzheimer’s Disease and Dementia Antidementia Agents. 25mg Tablet Extended Release 24 Hour.Drug Name Drug Requirements Tier  & Limits Drug Name Glutamate Reducing Agents — Seizure Control Drugs Felbamate (Tablet) 3 Felbamate (Suspension) 4 Felbatol (Tablet) 3 Felbatol (Suspension) 4 Lamictal (Tablet) 3 Lamictal Chewable 3 Dispersible Lamictal ODT (Tablet 3 Dispersible) Lamictal Starter Kit 3 Lamictal XR (Kit. 200mg Tablet Extended Release 24 Hour. 3 5mg Tablet) Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 18 . 50mg Tablet Extended Release 24 Hour) Lamotrigine (Tablet) 1 Lamotrigine 2 (Tablet Chewable) Topamax 3 Topamax Sprinkle 3 Topiramate 1 Sodium Channel Agents — Seizure Control Drugs Banzel 3 Carbamazepine 2 Carbamazepine ER (Capsule Extended Release 12 Hour) Carbatrol Dilantin Dilantin Infatabs Epitol Equetro Fosphenytoin Sodium (100mg pe/2ml Injection) Oxcarbazepine Peganone Phenytek Phenytoin Phenytoin Sodium Phenytoin Sodium Extended Tegretol Tegretol-XR Trileptal Vimpat (Oral Solution. 250mg Tablet Extended 3 Release 24 Hour.

Oral Solution.Drug Name Drug Requirements Tier  & Limits Aricept ODT 3 Donepezil HCl 1 Exelon 3 (Capsule. 1 20mg Tablet) Fluvoxamine Maleate 1 Lexapro 3 Luvox CR 3 Paroxetine HCl 1 Paroxetine HCl ER 3 Paxil 3 Paxil CR 3 Pexeva 3 Pristiq 3 PA Prozac 3 Prozac Weekly 3 Sarafem 3 ST Sertraline HCl (Tablet) 1 Antidepressants — Drugs to Treat Depression Antidepressants. 1 45mg Tablet Dispersible) Nefazodone HCl 1 Oleptro 3 Remeron 3 Remeron Soltab 3 Trazodone HCl 1 Wellbutrin 3 Wellbutrin SR 3 Wellbutrin XL 3 19 . 10mg Tablet. Other — Antidepressants Aplenzin 3 Budeprion SR 1 Bupropion HCl 1 Bupropion HCl SR 1 Bupropion XL 1 Maprotiline HCl 1 Mirtazapine 1 Mirtazapine ODT (30mg Tablet Dispersible. Oral Solution) Exelon (Patch 24 Hour) 3 ST Galantamine Hydrobromide 2 Razadyne 3 Razadyne ER 3 Rivastigmine Tartrate 2 N-methyl-D-aspartate (NMDA) Receptor Antagonists — Alzheimer’s Disease and Dementia Drugs Namenda 2 Namenda Titration Pak 2 Drug Name Drug Requirements Tier  & Limits Monoamine Oxidase Inhibitors — Antidepressants Emsam 3 ST Marplan 3 Nardil 2 Parnate 3 Phenelzine Sulfate 1 Selegiline HCl 2 Tranylcypromine Sulfate 2 Zelapar 3 Serotonin/Norepinephrine Reuptake Inhibitors — Antidepressants Celexa 3 Citalopram Hydrobromide 1 (Tablet) Citalopram Hydrobromide 2 (Oral Solution) Cymbalta 2 Effexor XR 3 Escitalopram Oxalate 1 Fluoxetine DR 3 Fluoxetine HCl (Capsule.

Deterrents. and Toxicologic Agents — Drugs for Overdose or Deterrents Alcohol Deterrents/Anti-Craving — Antidotes/Deterrents/Protectants Antabuse 2 Campral 3 Disulfiram 2 Naltrexone HCl 2 Revia 3 Vivitrol 4 Opioid Antagonists — Antidotes/ Deterrents/Protectants Buprenex 3 Buprenorphine HCl 2 Butrans 3 PA Naloxone HCl 2 (1mg/ml Injection) Suboxone 3 Smoking Cessation Agents — Deterrents Buproban 1 Chantix 3 Chantix Pak 3 Nicotrol Inhaler 3 Nicotrol NS 2 Zyban 3 ST ST Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 20 . 37.5mg Tablet Extended 3 Release 24 Hour.Drug Name Drug Requirements Tier  & Limits Sertraline HCl 2 (Concentrate) Venlafaxine HCl 2 Venlafaxine HCl ER (Capsule Extended 1 Release 24 Hour) Venlafaxine HCl ER (225mg Tablet Extended 3 Release 24 Hour) Venlafaxine HCl ER (150mg Tablet Extended Release 24 Hour. 75mg Tablet Extended Release 24 Hour) Viibryd 3 Zoloft 3 Tricyclics — Antidepressants Amitriptyline HCl 1 Amoxapine 1 Anafranil 3 Clomipramine HCl 1 Desipramine HCl 2 Doxepin HCl 1 Imipramine HCl 1 Imipramine Pamoate 2 Norpramin 3 Nortriptyline HCl 1 Pamelor 4 Perphenazine/Amitriptyline 1 Protriptyline HCl 2 Drug Name Surmontil Tofranil Tofranil-PM Trimipramine Maleate Vivactil Drug Requirements Tier  & Limits 3 3 3 2 3 Antidotes.

4 B/D. Troche) Clotrimazole/ Betamethasone 1 Dipropionate Diflucan 3 Econazole Nitrate 1 Eraxis (100mg Injection) 4 Ertaczo 3 Exelderm 3 Extina 3 Fluconazole 1 Fluconazole in Dextrose (56mg/ml. PA B/D Antifungals — Drugs to Treat Fungal Infections Antifungals — Fungal Infection Drugs Abelcet 4 B/D AmBisome 4 B/D Amphotec 3 B/D (50mg Injection) Amphotericin B 2 B/D Ancobon 4 Cancidas 4 Ciclopirox 2 Ciclopirox Nail Lacquer 2 Ciclopirox Olamine 2 Clotrimazole (External Cream. Tablet) Drug Requirements Tier  & Limits 4 4 3 ST B/D.1mg/ml Injection. 1 400mg/200ml Injection) Flucytosine 4 Gris-Peg 3 Griseofulvin Microsize 2 Itraconazole 2 PA 21 . Other — Nausea and Vomiting Drugs Antivert 3 Meclizine HCl 1 Tigan 3 PA Trimethobenzamide HCl 3 PA (Capsule) Emetogenic Therapy Adjuncts — Nausea and Vomiting Drugs Aloxi 3 Anzemet (Injection) 3 Anzemet (50mg Tablet) 3 B/D Anzemet (100mg Tablet) 4 B/D Cesamet 4 B/D. 1 External Solution. PA Capsule.5mg Capsule) 3 B/D.Drug Name Drug Requirements Tier  & Limits Drug Name Zofran (Injection) Zofran ODT Zuplenz Antiemetics — Drugs to Treat Nausea and Vomiting Antiemetics. PA Dronabinol (2. 5mg Capsule) Dronabinol (10mg Capsule) 4 B/D. 2 1mg/ml Injection) Granisetron HCl (Tablet) 2 B/D Granisol 2 B/D Marinol (2.5mg 2 B/D. PA (Oral Solution. PA Marinol (10mg Capsule. PA Emend (Capsule) 2 B/D. PA 5mg Capsule) Ondansetron HCl (Tablet) 1 B/D Ondansetron HCl 2 (4mg/2ml Injection) Ondansetron HCl 2 B/D (Oral Solution) Ondansetron ODT 1 B/D Sancuso 4 Zofran 4 B/D. PA Granisetron HCl (0.

Suspension. Tablet) Nystatin/Triamcinolone Nystop Oxistat Pedi-Dri Sporanox (Oral Solution) Sporanox (Capsule) Sporanox Pulsepak Terazol Terbinafine HCl (Tablet) Terconazole (0.Drug Name Ketoconazole (Cream. Suppository) Vfend (Suspension Reconstituted) Vfend (Tablet) Drug Requirements Tier  & Limits Drug Name Vfend IV Voriconazole (Tablet) Zazole (Cream) 1 3 3 3 3 3 3 1 4 3 2 3 4 1 Antigout Agents — Gout Drugs Allopurinol (Tablet) 1 Allopurinol Sodium 1 (Injection) Aloprim 3 Colcrys 2 Probenecid 1 Probenecid/Colchicine 1 Uloric 2 Zyloprim 3 ST Antimigraine Agents — Drugs to Treat Migraines Ergot Alkaloids — Migraine Drugs Dihydroergotamine 2 Mesylate Ergotamine Tartrate/ 2 Caffeine Migergot 2 Migranal 3 Serotonin (5-HT) 1b/1d Receptor Agonists — Migraine Drugs Amerge 3 Axert 3 Frova 3 Imitrex 3 Imitrex Statdose Refill 3 Maxalt 2 PA PA PA 1 4 4 3 4 1 Antigout Agents — Drugs to Treat Gout 1 1 1 3 1 3 4 3 3 1 Drug Requirements Tier  & Limits ST ST ST Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 22 . Ointment. Gel) Natacyn Nizoral Noxafil Nyamyc Nystatin (Cream. Tablet) Loprox Loprox Shampoo Lotrisone Mentax Miconazole 3 Mycamine Naftin (1% Cream. Shampoo. Tablet) Ketoconazole (Foam) Lamisil (Packet. 100000unit/gm Powder.4% Cream.

Drug Name Maxalt-MLT Naratriptan HCl Relpax Sumatriptan Succinate (Tablet) Sumatriptan Succinate (6mg/0. 5mg Capsule) Thalomid 4 PA Antiestrogens/Modifiers — Chemotherapy Agents Emcyt 3 PA Fareston 3 Faslodex 4 Tamoxifen Citrate 1 1 2 3 3 Drug Name ST ST Antimyasthenic Agents — Drugs to Treat Myasthenia Gravis Parasympathomimetics — Myasthenia Gravis Drugs Mestinon 3 Mestinon Timespan 3 Mytelase 3 Pyridostigmine Bromide 1 Regonol 1 Antimycobacterials — Drugs to Treat Infections Antimycobacterials. 25mg 4 PA.5ml Injection) Zomig Zomig ZMT Drug Requirements Tier  & Limits 2 1 3 Drug Requirements Tier  & Limits Antineoplastics — Drugs to Treat Cancer ST Alkylating Agents — Chemotherapy Agents Alkeran (Injection) 3 BiCNU 3 Busulfex 4 CeeNU 3 Cyclophosphamide (Tablet) 2 B/D Dacarbazine 2 (200mg Injection) Hexalen 4 PA Ifex (3gm Injection) 3 Ifosfamide (1gm Injection) 2 Leukeran 2 Matulane 4 Melphalan HCl 4 Mustargen 4 Thiotepa 3 Treanda 4 PA (100mg Injection) Zanosar 4 Antiangiogenic Agents — Chemotherapy Agents Caprelsa 4 PA Revlimid (10mg Capsule. LA Capsule. Other — Miscellaneous Anti-Infectives Dapsone 2 Mycobutin 3 Antituberculars — Tuberculosis Drugs Capastat Sulfate 3 Ethambutol HCl 2 Isoniazid 2 Paser 3 Priftin 3 Rifadin 3 Rifamate 3 Rifampin (Capsule) 2 Rifampin (Injection) 3 Rifater 3 Seromycin 3 Trecator 3 23 . 15mg Capsule.

Other — Chemotherapy Agents Abraxane 4 PA Adriamycin 2 B/D (2mg/ml Injection) Alimta (500mg Injection) 4 PA Amifostine 4 Arranon Bleomycin Sulfate (30unit Injection) Camptosar (100mg/5ml Injection) Carboplatin (150mg/15ml Injection) Cerubidine Cisplatin (100mg/100ml Injection) Cosmegen Dacogen Daunorubicin HCl (5mg/ml Injection) Dexrazoxane (500mg Injection) Docefrez Docetaxel (80mg/4ml Injection.5mg Injection) 4 Fluorouracil 2 B/D (500mg/10ml Injection) Folotyn 4 PA (40mg/2ml Injection) Gemcitabine HCl 4 (1gm Injection) Gemzar (1gm Injection) 4 Hydrea 3 Hydroxyurea 1 Mercaptopurine 2 Nipent 4 ST Pentostatin 4 Purinethol 3 Tabloid 3 PA Antineoplastics. 80mg/8ml Injection) Doxil Doxorubicin HCl (2mg/ml Injection) Ellence (200mg/100ml Injection) Eloxatin (100mg/20ml Injection) Elspar Epirubicin HCl (50mg/25ml Injection) Erivedge Ethyol Drug Requirements Tier  & Limits 4 2 B/D 3 ST 2 3 2 3 4 1 4 PA 4 4 4 B/D 2 B/D 4 ST 4 3 2 4 4 PA ST Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 24 .Drug Name Drug Requirements Tier  & Limits Drug Name Antimetabolites — Chemotherapy Agents Cladribine 2 B/D Clolar 4 Cytarabine 2 B/D (500mg Injection) Cytarabine Aqueous 1 B/D (20mg/ml Injection) Cytarabine Aqueous 2 B/D (100mg/ml Injection) Droxia 3 Elitek (1.

350mg Injection. Tablet) Menest Mesna Mesnex Mitomycin (20mg Injection) Mitoxantrone HCl Ontak Oxaliplatin (100mg/20ml Injection) Paclitaxel (300mg/50ml Injection) Picato Proleukin Sylatron Taxotere (80mg/4ml Injection) Trisenox Velcade Vidaza Vinblastine Sulfate (10mg Injection) Drug Requirements Tier  & Limits Drug Name Vincasar PFS 2 B/D Vincristine Sulfate 2 B/D Vinorelbine Tartrate 2 (50mg/5ml Injection) Zinecard 4 PA (250mg Injection) Zolinza 4 PA Zytiga 4 PA Aromatase Inhibitors.Drug Name Fludarabine Phosphate (50mg Injection) Fusilev Halaven Idamycin PFS (20mg/20ml Injection) Idarubicin HCl (10mg/10ml Injection) Irinotecan (100mg/5ml Injection) Istodax Ixempra Kit (45mg Injection) Jakafi Jevtana Leucovorin Calcium (100mg Injection. 3rd Generation — Chemotherapy Agents Anastrozole 1 Arimidex 3 Aromasin 3 Exemestane 2 Femara 3 Letrozole 1 Enzyme Inhibitors — Chemotherapy Agents Etopophos 4 Etoposide (Injection) 2 Hycamtin (Injection) 4 Toposar 2 Topotecan HCl 4 (4mg Injection) Molecular Target Inhibitors — Chemotherapy Agents Afinitor 4 PA Gleevec 4 PA Inlyta 4 PA Nexavar 4 PA Sprycel 4 PA Sutent 4 PA Tarceva 4 PA Tasigna 4 PA Tykerb 4 PA Votrient 4 PA Xalkori 4 PA Zelboraf 4 PA 4 4 4 PA 4 ST 4 2 4 PA 4 4 4 PA PA 2 2 2 3 2 2 4 PA PA 4 2 3 4 4 PA PA 4 3 4 4 PA PA PA 2 B/D Drug Requirements Tier  & Limits 25 .

100mg Tablet) Chloroquine Phosphate 2 Coartem 3 Daraprim 2 Anticholinergics — Parkinson’s Disease Drugs Benztropine Mesylate 1 Cogentin 3 Trihexyphenidyl HCl 1 Antiparkinson Agents — Parkinson’s Disease Drugs Comtan 2 Tasmar 4 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 26 .Drug Name Drug Requirements Tier  & Limits Drug Name Drug Requirements Tier  & Limits Monoclonal Antibodies — Chemotherapy Agents Arzerra 4 PA Avastin 4 PA (100mg/4ml Injection) Campath 4 PA Erbitux 4 PA (100mg/50ml Injection) Herceptin 4 PA Rituxan 4 PA Vectibix 4 PA (100mg/5ml Injection) Yervoy 4 PA (50mg/10ml Injection) Retinoids — Chemotherapy Agents Panretin 4 PA Targretin 4 PA Tretinoin (Capsule) 4 Hydroxychloroquine Sulfate 1 Malarone 3 Mefloquine HCl 1 Mepron 4 Nebupent 3 B/D Pentam 300 3 Plaquenil 3 Primaquine Phosphate 3 Qualaquin 3 PA Pediculicides/Scabicides — Scabies and Lice Drugs Eurax 3 Lindane 2 Malathion 2 Ovide 3 Permethrin (Cream) 1 Ulesfia 3 Antiparasitics — Drugs to Treat Parasitic Infections Antiparkinson Agents — Drugs to Treat Parkinson’s Disease Anthelmintics — Worm Infection Drugs Albenza 2 Biltricide 2 Stromectol 2 Antiprotozoals — Protozoal Infection Drugs Alinia 3 Atovaquone/Proguanil HCl 2 (250mg.

5ml Injection) Invega Sustenna (117mg/0.75ml Injection.25ml Injection. 4 156mg/ml Injection. 3 78mg/0.Drug Name Drug Requirements Tier  & Limits Dopamine Agonists — Parkinson’s Disease Drugs Apokyn 4 Bromocriptine Mesylate 2 Mirapex 3 Mirapex ER 3 Parlodel 3 Pramipexole 2 Dihydrochloride Requip 3 Requip XL 3 Ropinirole ER 3 Ropinirole HCl 1 Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors — Parkinson’s Disease Drugs Carbidopa/Levodopa 1 Carbidopa/Levodopa ER 1 Carbidopa/ 1 Levodopa ODT Lodosyn 3 Parcopa 3 Sinemet 3 Sinemet CR 3 Stalevo 2 Monoamine Oxidase B (MAO-B) Inhibitors — Parkinson’s Disease Drugs Azilect 2 Eldepryl 3 Drug Name Drug Requirements Tier  & Limits Haldol 3 Haldol Decanoate 3 Haloperidol 1 Haloperidol Decanoate 1 Haloperidol Lactate 1 Loxapine Succinate 1 Loxitane 3 Orap 2 Perphenazine 1 Prochlorperazine 1 Prochlorperazine Edisylate 2 Prochlorperazine Maleate 1 Thioridazine HCl 2 Thiothixene 1 Trifluoperazine HCl 1 2nd Generation/Atypical — Mood Disorder Drugs Abilify 3 Abilify Discmelt 3 Fanapt 3 ST Fanapt Titration Pack 3 ST Geodon 3 Invega 3 ST Invega Sustenna (39mg/0. 234mg/1.5ml Injection) Latuda 3 Olanzapine 2 Olanzapine ODT 2 Quetiapine Fumarate 1 Risperdal 3 Antipsychotics — Drugs to Treat Mood Disorders 1st Generation/Typical — Mood Disorder Drugs Chlorpromazine HCl 1 Compro 1 Fluphenazine Decanoate 2 Fluphenazine HCl 1 27 .

50mcg/ml Injection) Gablofen (40000mcg/20ml Injection) Lioresal Intrathecal (0. Non-nucleoside Reverse Transcriptase Inhibitors — HIV Drugs Atripla 4 Complera 4 Edurant 4 Intelence (100mg Tablet. PA 2 B/D. PA 4 B/D. PA 1 3 3 Antivirals — Drugs to Treat Viral Infections Anti-Cytomegalovirus (CMV) Agents — Miscellaneous Antiviral Drugs Cytovene 3 B/D Foscarnet Sodium 2 B/D Ganciclovir (Capsule) 3 Ganciclovir (Injection) 3 B/D Valcyte 4 Vistide 4 Zirgan 3 Anti-HIV Agents. 4 50mg Injection) Risperdal M-Tab 3 Risperidone (Tablet) 1 Risperidone (Oral Solution) 2 Risperidone ODT 2 Saphris 2 Seroquel 3 Seroquel XR 2 Ziprasidone HCl (Capsule) 3 Zyprexa 3 Zyprexa Zydis 3 Treatment-Resistant — Mood Disorder Drugs Clozapine 2 Clozaril 3 Fazaclo 2 Gablofen (10000mcg/20ml Injection. 4 200mg Tablet) Antispasticity Agents — Drugs to Treat Spasms Antispasticity Agents — Muscle Spasm Drugs Baclofen 1 Dantrium 3 Dantrolene Sodium 2 (Capsule) Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 28 . 10mg/20ml Injection) Lioresal Intrathecal (10mg/5ml Injection) Tizanidine HCl (Tablet) Tizanidine HCl (Capsule) Zanaflex Drug Requirements Tier  & Limits 2 B/D. 3 25mg Injection) Risperdal Consta (37. PA 4 B/D.5mg Injection.Drug Name Drug Requirements Tier  & Limits Drug Name Risperdal Consta (12.5mg Injection.05mg/ml Injection.

300mg Capsule) Viracept 4 Anti-Influenza Agents — Flu Drugs Amantadine HCl 1 Relenza Diskhaler 3 Rimantadine HCl 1 Tamiflu 2 Antihepatitis Agents — Hepatitis Drugs Baraclude 3 (Oral Solution) Baraclude (Tablet) 4 Copegus 4 PA Hepsera 4 Incivek 4 PA Infergen 4 PA (15mcg/0. Protease Inhibitors — HIV Drugs Aptivus 4 Crixivan 2 Invirase (Capsule) 3 Invirase (Tablet) 4 Kaletra 3 (100mg. Nucleoside and Nucleotide Reverse Transcriptase Inhibitors — HIV Drugs Combivir 4 Didanosine 2 Emtriva 3 Epivir (Oral Solution) 2 Epivir (Tablet) 3 Epivir HBV 2 Epzicom 4 Lamivudine 2 Lamivudine/Zidovudine 4 Retrovir 3 Retrovir IV Infusion 3 Stavudine (Capsule) 2 Trizivir 4 Truvada 4 Videx EC 3 Videx Pediatric 3 (2gm Oral Solution) Viread 4 Zerit 3 Ziagen 3 Zidovudine 2 Anti-HIV Agents. 4 600mg Tablet) Reyataz 2 (100mg Capsule) Reyataz (150mg Capsule. 3 75mg Tablet) Prezista (400mg Tablet. 4 200mg.Drug Name Drug Requirements Tier  & Limits Drug Name Drug Requirements Tier  & Limits Anti-HIV Agents. 25mg Tablet) Kaletra (Oral Solution. 4 200mg Capsule.5ml Injection) Nevirapine (Tablet) 2 Rescriptor 3 Sustiva 3 Viramune (Tablet) 2 Viramune (Suspension) 3 Viramune XR 2 Anti-HIV Agents. Other — HIV Drugs Fuzeon 4 Isentress 4 Selzentry 4 29 . 50mg Tablet) Lexiva (Suspension) 3 Lexiva (Tablet) 4 Norvir 3 Prezista (150mg Tablet.

5mg Tablet Extended 3 Release 24 Hour) Alprazolam Intensol 3 Alprazolam ODT 3 Alprazolam XR (1mg Tablet Extended Release 24 Hour.5ml Injection) Peg-Intron Redipen 4 PA Pegasys 4 PA Pegasys Proclick 4 PA (135mcg/0. 6000000unit/ ml Injection) Intron-A 4 PA (5mu/0. 3mg Tablet Extended Release 24 Hour) Ativan (Tablet) 3 Buspirone HCl 1 Chlordiazepoxide HCl 1 Chlordiazepoxide/ 1 Amitriptyline Diazepam 1 (Oral Solution.2ml Injection.2ml Injection) Intron-A W/Diluent 4 PA (10mu Injection) Peg-Intron 4 PA (50mcg/0. 4 PA 600mg Tablet) Ribavirin 2 PA Tyzeka 4 Victrelis 4 PA Antiherpetic Agents — Herpes Drugs Acyclovir 1 Acyclovir Sodium 1 B/D (500mg Injection) Denavir 3 Famciclovir 2 Famvir 3 Trifluridine 2 Valacyclovir HCl 2 Valtrex Viroptic Xerese Zovirax Drug Requirements Tier  & Limits 2 3 3 3 Anxiolytics — Drugs to Treat Anxiety Anxiolytics. 3mu/0. 2mg Tablet Extended 3 Release 24 Hour.2ml 3 PA Injection.Drug Name Drug Requirements Tier  & Limits Drug Name Intron-A (10mu/0. 200mg Tablet) Ribasphere (400mg Tablet.5ml Injection) Rebetol (Oral Solution) 3 PA Rebetol (Capsule) 4 PA Ribapak (Tablet) 4 PA Ribasphere 2 PA (Capsule. Tablet) Diazepam Intensol 1 Estazolam 3 Lorazepam (Tablet) 1 Lorazepam Intensol 1 Meprobamate 3 PA Niravam 3 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 30 . Other — Anxiety Drugs Alprazolam 1 Alprazolam ER (0.

Drug Name Oxazepam Valium Xanax Xanax XR Drug Requirements Tier  & Limits Drug Name Glucophage Glucophage XR Glucotrol Glucotrol XL Glucovance (2. 500mg Tablet) Glumetza (500mg Tablet Extended Release 24 Hour) Glyburide Glyburide Micronized Glyburide/Metformin HCl Glynase Glyset Janumet Janumet XR Januvia Jentadueto Juvisync Kombiglyze XR Metformin HCl Metformin HCl ER (500mg Tablet Extended Release 24 Hour.5mg. 750mg Tablet Extended Release 24 Hour) Nateglinide Onglyza Prandimet Prandin Precose Riomet Starlix Symlinpen 120 Symlinpen 60 Tolazamide Tolbutamide 3 3 3 3 Bipolar Agents — Drugs to Treat Mood Disorders Bipolar Agents — Mood Disorder Drugs Symbyax 3 Mood Stabilizers — Mood Disorder Drugs Lithium Carbonate 1 Lithium Carbonate ER 1 Lithium Citrate 1 Lithobid 2 Blood Glucose Regulators — Drugs to Regulate Blood Sugar Antidiabetic Agents — Diabetic Drugs Acarbose 1 Actoplus Met 2 Actoplus Met XR 3 Actos 2 Amaryl 3 Avandamet 3 PA Avandaryl 3 PA Avandia 3 PA Bydureon 3 Byetta 2 Chlorpropamide 3 ST Cycloset 3 PA Diabeta 3 Duetact 2 Fortamet 3 ST Glimepiride 1 Glipizide 1 Glipizide ER 1 Glipizide/Metformin HCl 1 31 Drug Requirements Tier  & Limits 3 3 3 3 3 3 1 1 1 3 3 2 3 2 3 3 2 1 ST ST ST 1 2 2 3 3 3 3 3 3 3 1 1 PA PA . 500mg Tablet. 5mg.

75%/ 3 Dextrose 10% Clinimix E 2.2% KCl 0.075%/D5W/ NaCl 0.5%/ 2 Sodium Chloride 0.9% Normosol-R in D5W Potassium Chloride 0.45% Dextrose 10% 2 Flex Container Dextrose 10%/ 2 NaCl 0.15%/D5W/ NaCl 0.45% Viaflex Potassium Chloride 0.3%/D5W/ NaCl 0.2% 2 Dextrose 5%/ 2 NaCl 0.3%/D5W/ NaCl 0.45% Dextrose 5% 2 Dextrose 5%/NaCl 0.15%/D5W/LR KCl 0.15%/D5W/NaCl 0.9% Glucagen Hypokit Glucagon Emergency Kit Ionosol-B/Dextrose 5% Ionosol-MB/ Dextrose 5% KCl 0.33% Dextrose 5%/ NaCl 0.45% KCl 0.9% KCl 0.Drug Name Drug Requirements Tier  & Limits Tradjenta 3 Victoza 2 Glycemic Agents — Diabetic Drugs Clinimix 4.225% Drug Name ST Dextrose 5%/ NaCl 0.45% KCl 0.225% KCl 0.15%/D5W/ NaCl 0.15%/D5W/ NaCl 0.75%/ 3 Dextrose 5% Clinimix E 4.45% Proglycem B/D B/D B/D B/D B/D B/D B/D B/D B/D Drug Requirements Tier  & Limits 2 2 2 3 2 3 3 2 2 2 2 2 2 2 2 2 2 2 3 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 32 .2% Dextrose 2.15%/D5W/ NaCl 0.25%/ 3 Dextrose 5% Clinimix E 5%/ 3 Dextrose 15% Clinimix E 5%/ 3 Dextrose 25% Dextrose 10%/ 2 NaCl 0.33% Potassium Chloride 0.25%/ 3 Dextrose 20% Clinimix 5%/ 3 Dextrose 15% Clinimix 5%/ 3 Dextrose 20% Clinimix E 2.25%/ 3 Dextrose 25% Clinimix E 4.22%/D5W/ NaCl 0.45% Dextrose 5%/NaCl 0.

5mg/0.8ml Injection. 7500unit/0.8ml Injection) Enoxaparin Sodium (100mg/ml Injection.4ml Injection. 80mg/0. 40mg/0.72ml Injection.5mg/0. 7.2ml Injection) Fragmin (10000unit/ml Injection. 0. 40unit/ml Injection) Heparin Sodium/NaCl (100unit/ml.3ml Injection) Heparin Sodium (10000unit/ml Injection.5ml Injection) Fondaparinux Sodium (10mg/0. 40mg/0.45% Injection) Heparin Sodium/ NaCl 0. 150mg/ml Injection) 33 Drug Requirements Tier  & Limits 3 4 3 4 2 2 2 2 1 3 .45% Injection. 3 60mg/0.9% Injection) Arixtra 3 (2.9% Premix Jantoven Lovenox (300mg/3ml Injection. 18000unt/0. 30mg/0. 4 120mg/0. 15000unit/0.8ml Injection.4ml Injection.5mg/0.Drug Name Insulins — Diabetic Drugs Humalog (Vial) Humalog Kwikpen Humulin (Vial) Humulin Pen Lantus Lantus Solostar Levemir Levemir Flexpen Novolin (Vial) Novolog (Vial) Novolog Flexpen Drug Requirements Tier  & Limits Drug Name Fondaparinux Sodium (2.3ml Injection. 12500unit/0.4ml Injection. 7.6ml Injection) Coumadin (Tablet) 2 Coumadin (Injection) 3 Enoxaparin Sodium (30mg/0. 5000unit/0.8ml Injection.6ml Injection.6ml Injection) Fragmin (25000unit/ml Injection. 1000unit/ml Injection. 50unit/ml. 4 5mg/0.5mg/0. 4 0.4ml Injection) 2 2 2 2 2 2 2 2 2 2 2 Blood Products/Modifiers/Volume Expanders — Drugs to Treat Blood Disorders Anticoagulants — Blood Thinners Argatroban 4 (100mg/ml Injection) Argatroban (125mg/125ml.3ml Injection. 2500unit/0. 5000unit/ml Injection) Heparin Sodium/D5W (5%. 5mg/0.2ml Injection. 0. 20000unit/ml Injection.5ml Injection) Arixtra (10mg/0.5ml Injection.6ml Injection.

300mcg/ml Injection. 25mcg/ml Injection. 3 B/D. 4 300mcg/0. PA B/D. PA B/D.4ml Injection. 40mcg/ml Injection. 100mcg/ml Injection. PA 40000unit/ml Injection) Promacta 4 PA Blood Products/Modifiers/Volume Expanders Cinryze 4 PA Coagulants — Blood Clotting Drugs Cyklokapron 2 Tranexamic Acid 2 Platelet Modifying Agents — Platelet Modifying Drugs Aggrenox 2 Brilinta 3 PA Cilostazol 1 Clopidogrel 1 Dipyridamole (Tablet) 1 PA Effient 3 PA Persantine 3 PA Plavix 3 Pletal 3 Ticlopidine HCl 2 PA PA B/D. PA PA PA PA PA Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 34 .3ml Injection. 4 B/D. 3 40mcg/0. 25mcg/0. 2000unit/ml Injection.4ml Injection.6ml Injection) Procrit (10000unit/ml Injection.3ml Injection.8ml 4 PA Injection. 80mg/0.5ml Injection.8ml Injection.8ml Injection) Pradaxa 2 Warfarin Sodium 1 Xarelto 2 Blood Formation Modifiers — Blood Formation Drugs Agrylin 3 Anagrelide Hydrochloride 1 Aranesp Albumin Free (100mcg/0. 120mg/0.42ml Injection. 480mcg/0. 480mcg/1. 60mcg/ml Injection) Aranesp Albumin Free (150mcg/0. 4000unit/ml Injection) Procrit (20000unit/ml Injection. 60mg/0. 60mcg/0. PA 3000unit/ml Injection.6ml Injection. 200mcg/ml Injection. 200mcg/0.5ml Injection. 500mcg/ml Injection) Epogen 3 Leukine 4 Mozobil 4 Neulasta 4 Neumega 2 Drug Name Drug Requirements Tier  & Limits Neupogen (300mcg/0. 4 150mg/ml Injection.Drug Name Drug Requirements Tier  & Limits Lovenox (100mg/ml Injection.6ml Injection.

Drug Name

Drug Requirements
Tier 
& Limits

Drug Name

Drug Requirements
Tier 
& Limits

Eprosartan Mesylate
3
Hyzaar
3
Irbesartan
1
Irbesartan/
1
Hydrochlorothiazide
Losartan Potassium
1
Losartan Potassium/
1
Hydrochlorothiazide
Micardis
3
Micardis HCT
3
Teveten
3
Teveten HCT
3
ST
Angiotensin-Converting Enzyme (ACE)
Inhibitors — Blood Pressure Drugs
Accupril
3
Accuretic
3
Aceon
3
Altace
3
Benazepril HCl
1
Benazepril HCl/
1
Hydrochlorothiazide
Captopril
1
Captopril/
1
Hydrochlorothiazide
Enalapril Maleate
1
Enalapril Maleate/
1
Hydrochlorothiazide
Fosinopril Sodium
1
Fosinopril Sodium/
1
Hydrochlorothiazide
Lisinopril
1
Lisinopril/
1
Hydrochlorothiazide
Lotensin
3
Lotensin HCT
3
Mavik
3
Moexipril HCl
2

Cardiovascular Agents — Drugs to Treat
Heart and Circulation Conditions
Alpha-Adrenergic Agonists —
Blood Pressure Drugs
Catapres
3
Catapres-TTS
3
Clonidine HCl (Tablet)
1
Clonidine HCl
2
(Patch Weekly)
Clorpres
3
Guanfacine HCl
1
Methyldopa
1
Methyldopa/
1
Hydrochlorothiazide
Methyldopate HCl
1
Midodrine HCl
2
Tenex
3
Alpha-Adrenergic Blocking Agents —
Blood Pressure Drugs
Cardura XL
3
Dibenzyline
3
Minipress
3
Prazosin HCl
1
Reserpine
1
Angiotensin II Receptor Antagonists —
Blood Pressure Drugs
Atacand
3
ST
Atacand HCT
3
ST
Avalide
3
Avapro
3
Benicar
2
Benicar HCT
2
Cozaar
3
Diovan
2
Diovan HCT
2
Edarbi
3
Edarbyclor
3

35

Drug Name

Drug Requirements
Tier 
& Limits

Drug Name

Moexipril/
2
Hydrochlorothiazide
Perindopril Erbumine
1
Prinivil
3
Prinzide
3
Quinapril HCl
1
Quinapril/
1
Hydrochlorothiazide
Ramipril
1
Tarka
3
Trandolapril
1
Uniretic
3
Univasc
3
Vaseretic
3
Vasotec
3
Zestoretic
3
Zestril
3
Antiarrhythmics — Heart Regulation Drugs
Amiodarone HCl (50mg/ml
1
Injection, Tablet)
Betapace (120mg Tablet,
3
160mg Tablet)
Betapace AF
3
(80mg Tablet)
Cordarone
3
Disopyramide Phosphate
1
Flecainide Acetate
1
Mexiletine HCl
1
Multaq
2
Norpace
3
Norpace CR
3

Drug Requirements
Tier 
& Limits

Pacerone (200mg Tablet)
1
Pacerone (100mg Tablet,
3
400mg Tablet)
Procainamide HCl
2
Propafenone HCl
1
Propafenone HCl ER
2
Quinidine Gluconate
3
Quinidine Gluconate ER
1
Quinidine Sulfate
1
Quinidine Sulfate ER
1
Rythmol
3
Rythmol SR
3
Sorine
1
Sotalol HCl (Tablet)
1
Sotalol HCl (Injection)
2
Tikosyn
3
Beta-Adrenergic Blocking Agents —
Blood Pressure Drugs
Acebutolol HCl
1
Atenolol
1
Atenolol/Chlorthalidone
1
Betaxolol HCl
1
(20mg Tablet)
Bisoprolol Fumarate
1
Bisoprolol Fumarate/
1
Hydrochlorothiazide
Bystolic
2
Carvedilol
1
Coreg
3
Coreg CR
3
ST
Corgard
3

Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug
PA = Prior authorization
ST = Step therapy

36

Drug Name

Drug Requirements
Tier 
& Limits

Drug Name

Corzide
3
Inderal LA
3
Innopran XL
3
Labetalol HCl
1
Levatol
3
Lopressor
3
Lopressor HCT
3
Metoprolol Succinate ER
2
Metoprolol Tartrate (Tablet) 1
Metoprolol Tartrate
2
(Injection)
Metoprolol/
2
Hydrochlorothiazide
Nadolol
2
Nadolol/
2
Bendroflumethiazide
Pindolol
1
Propranolol HCl
1
Propranolol HCl ER
1
Propranolol/
1
Hydrochlorothiazide
Sectral
3
Tenoretic
3
Tenormin
3
Timolol Maleate (Tablet)
1
Toprol XL
3
Trandate (100mg Tablet,
3
200mg Tablet)
Zebeta
3
Ziac
3
Calcium Channel Blocking Agents —
Blood Pressure Drugs
Adalat CC
3
Afeditab CR
1
Amlodipine Besylate
1
Amlodipine Besylate/
3
Benazepril HCl

Azor
Caduet
Calan
Calan SR
Cardizem
Cardizem CD
Cardizem LA
Cartia XT
Covera-HS
Dilacor XR
Dilt-CD
(120mg Capsule Extended
Release 24 Hour,
300mg Capsule Extended
Release 24 Hour)
Dilt-XR
(180mg Capsule Extended
Release 24 Hour,
240mg Capsule Extended
Release 24 Hour)
Diltiazem CD
(120mg Capsule Extended
Release 24 Hour,
240mg Capsule Extended
Release 24 Hour,
300mg Capsule Extended
Release 24 Hour)
Diltiazem HCl (100mg
Injection, 50mg/10ml
Injection, Tablet)
Diltiazem HCl ER
(Capsule Extended
Release 12 Hour,
180mg Capsule Extended
Release 24 Hour,
360mg Capsule Extended
Release 24 Hour)
Dynacirc CR
Exforge
Exforge HCT

37

Drug Requirements
Tier 
& Limits
2
3
3
3
3
3
3
1
3
3

1

1

1

1

1

3
2
2

ST

Drug Name
Felodipine ER
Isradipine
Lotrel
Matzim LA
Nicardipine HCl
Nifediac CC
(90mg Tablet Extended
Release 24 Hour)
Nifedical XL
Nifedipine (Capsule)
Nifedipine ER
Nimodipine
Nisoldipine
Nisoldipine ER
Norvasc
Procardia
Procardia XL
Sular
Taztia XT
Tiazac
Tribenzor
Twynsta
Verapamil HCl (Tablet)
Verapamil HCl (Injection)
Verapamil HCl ER (Tablet
Extended Release)
Verapamil HCl ER
(Capsule Extended
Release 24 Hour)
Verelan
Verelan PM

Drug Requirements
Tier 
& Limits

Drug Name

Cardiovascular Agents, Other —
Miscellaneous Cardiac Drugs
Amturnide
3
ST
Demser
4
Digoxin
1
Lanoxin (0.25mg/ml
2
Injection, Tablet)
Lanoxin
3
(0.1mg/ml Injection)
Pentoxifylline ER
1
Ranexa
2
ST
Tekamlo
3
ST
Tekturna
2
ST
Tekturna HCT
2
ST
Trental
3
Valturna
3
ST
Diuretics, Carbonic Anhydrase Inhibitors —
Cardiac Drugs
Acetazolamide Sodium
2
Diuretics, Loop — Cardiac Drugs
Bumetanide
1
Demadex (10mg Tablet,
20mg Tablet,
3
5mg Tablet)
Edecrin
3
Furosemide
1
Lasix
3
Torsemide (20mg/2ml
1
Injection, Tablet)

2
2
3
3
1
1
1
2
1
3
2
2
3
3
3
3
1
3
2
3
1
2

Drug Requirements
Tier 
& Limits

ST

1
2
3
3

Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug
PA = Prior authorization
ST = Step therapy

38

40mg Tablet Extended Release 24 Hour. 40mg Tablet Extended Release 24 Hour. Tablet) 39 . 20mg Tablet Extended Release 24 Hour) Simvastatin 1 Zocor 3 Dyslipidemics. Other — Miscellaneous Cholesterol Control Drugs Cholestyramine Light 1 (Packet) Colestid 3 (Granules. 500mg.Drug Name Drug Requirements Tier  & Limits Diuretics. Thiazide — Cardiac Drugs Chlorothiazide 1 Chlorothiazide Sodium 1 Chlorthalidone (25mg 1 Tablet. 500mg. 50mg Tablet) Diuril 3 Diuril IV 3 Hydrochlorothiazide 1 Indapamide 1 Methyclothiazide 1 Metolazone 1 Microzide 3 Thalitone 3 Dyslipidemics. Potassium-Sparing — Cardiac Drugs Aldactazide 3 Aldactone 3 Amiloride HCl 1 Amiloride/ 1 Hydrochlorothiazide Dyazide 3 Dyrenium 3 Eplerenone 2 Inspra 3 Maxzide 3 Spironolactone 1 Spironolactone/ 1 Hydrochlorothiazide Triamterene/ 1 Hydrochlorothiazide Diuretics. 750mg. HMG CoA Reductase Inhibitors — Cholesterol Control Drugs Advicor 3 ST Altoprev 3 ST Atorvastatin Calcium 1 Crestor 2 Fluvastatin 3 ST Lescol 3 ST Lescol XL 3 ST Lipitor 3 Livalo 3 Lovastatin 1 Mevacor 3 Pravachol 3 Pravastatin Sodium 1 Simcor (1000mg. 20mg Tablet Extended Release 3 ST 24 Hour. Fibric Acid Derivatives — Cholesterol Control Drugs Antara 2 Fenofibrate 1 Fenofibrate Micronized 1 Fenoglide 3 ST Fibricor 3 ST Drug Name Drug Requirements Tier  & Limits Gemfibrozil 1 Lipofen 3 ST Lofibra 3 Lopid 3 Tricor 2 Trilipix 2 Dyslipidemics.

Non-amphetamines — ADHD Drugs Concerta 3 Daytrana 3 Dexmethylphenidate HCl 2 Focalin 3 Focalin XR 3 Intuniv 3 Kapvay 3 Metadate CD 3 Metadate ER 1 Methylin 3 Methylphenidate HCl 2 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 40 .Drug Name Drug Requirements Tier  & Limits Drug Name Colestipol HCl (Tablet) 1 Colestipol HCl (Granules) 2 Lovaza 3 Niaspan 2 Prevalite (Powder) 1 Questran (Packet) 3 Vytorin 3 Welchol 2 Zetia 2 Vasodilators. Amphetamines — ADHD Drugs Adderall XR 3 Amphetamine/ Dextroamphetamine 2 (Tablet) Desoxyn 3 Dexedrine 3 Dextroamphetamine 1 Sulfate (5mg Tablet) Dextroamphetamine 2 Sulfate (10mg Tablet) Dextroamphetamine 2 Sulfate ER Methamphetamine HCl 2 Vyvanse 3 Attention Deficit Hyperactivity Disorder Agents. Direct-Acting Arterial — Chest Pain Drugs Hydralazine HCl 1 Minoxidil (Tablet) 1 Vasodilators. Patch) Nitrolingual Pumpspray 3 Nitromist 3 Nitrostat 2 Rectiv 3 Drug Requirements Tier  & Limits Central Nervous System Agents — Drugs to Treat Nerve Conditions Attention Deficit Hyperactivity Disorder Agents. Direct-Acting Arterial/ Venous — Chest Pain Drugs Dilatrate SR 3 Isordil Titradose 3 Isosorbide Dinitrate 1 Isosorbide Dinitrate ER 1 Isosorbide Mononitrate 1 (20mg Tablet) Isosorbide Mononitrate ER 1 Minitran 1 Monoket 3 Nitro-Bid 3 Nitroglycerin 1 (Injection.

1% Gel) Condylox (Gel) 3 Differin 3 Dovonex 3 Dovonex Scalp 3 Efudex 3 Elidel 3 ST Epiduo 3 ST Erythromycin/ 1 Benzoyl Peroxide Evoclin 3 1 3 4 1 2 3 1 Drug Requirements Tier  & Limits Dermatological Agents — Drugs to Treat Skin Conditions Dental And Oral Agents — Drugs to Treat Mouth and Throat Conditions Dental and Oral Agents Chlorhexidine Gluconate Oral Rinse Evoxac Kepivance Periogard Pilocarpine HCl (Tablet) Salagen Triamcinolone in Orabase Drug Name ST 41 . Swab) Clindamycin/Benzoyl 2 Peroxide (5%. Other — Miscellaneous Central Nervous System Drugs Butalbital/Acetaminophen/ 2 Caffeine/Codeine Fioricet/Codeine 3 Nuedexta 2 PA Rilutek 2 Xenazine 4 PA Fibromyalgia Agents — Fibromyalgia Drugs Savella 2 Savella Titration Pack 2 Multiple Sclerosis Agents — Multiple Sclerosis Drugs Ampyra 4 PA Copaxone 4 PA Gilenya 4 PA Dermatological Agents — Skin Agents 8-MOP 3 Acanya 3 ST Aczone 3 Adapalene 2 Aldara 3 Amevive 4 PA Ammonium Lactate 1 Amnesteem 2 Atralin 3 PA Avita (Cream) 1 PA Avita (Gel) 2 PA Azelex 3 Benzamycin 3 Calcipotriene 2 Carac 3 Claravis 2 Cleocin-T 3 Clindacin PAC 3 Clindagel 3 Clindamycin Phosphate (External Solution. Foam. Lotion. 2 Gel.Drug Name Drug Requirements Tier  & Limits Methylphenidate HCl ER (20mg Tablet Extended 1 Release) Methylphenidate HCl ER (Capsule Extended 2 Release 24 Hour) Ritalin 3 Ritalin LA 3 Ritalin SR 3 Strattera 3 ST Central Nervous System.

Drug Name Finacea Fluoroplex Fluorouracil (Cream) Imiquimod Klaron LAC-Hydrin Laclotion Oxsoralen Oxsoralen Ultra Pennsaid Podofilox Protopic Regranex Retin-A Retin-A Micro Santyl Selenium Sulfide (Lotion) Solaraze Soriatane Sorilux Stelara Sulfacetamide Sodium (Suspension) Taclonex Taclonex Scalp Tazorac Tretin-X (Kit) Tretinoin (Cream. Gel) Uvadex Vectical Veltin Drug Requirements Tier  & Limits 2 3 2 3 3 3 1 3 4 3 2 3 4 3 3 3 1 3 4 3 4 Drug Name Veregen Voltaren (Gel) Ziana Zonalon Zyclara 3 2 3 3 2 PA Enzyme Replacements/Modifiers — Drugs to Treat Enzyme Deficiency PA PA Enzyme Replacements/Modifiers — Enzyme Replacement/Modifying Drugs Adagen 4 Aldurazyme 4 Buphenyl 4 Carbaglu 4 Cerezyme 4 PA (200unit Injection) Creon 2 Cystadane 4 Cystagon 3 Elaprase 4 Fabrazyme 4 (35mg Injection) Kuvan 4 Lumizyme 4 Myozyme 4 Naglazyme 4 Orfadin 4 Pancreaze 3 Sucraid 4 Vpriv 4 PA Zavesca 4 Zenpep 2 ST PA PA PA PA PA 2 3 3 3 3 2 3 3 3 Drug Requirements Tier  & Limits PA PA PA PA Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 42 .

1mg/ml Injection) Bentyl 3 PA Cantil 3 Cuvposa 3 Dicyclomine HCl (Capsule.6ml Injection) Urso 3 Ursodiol 2 Histamine2 (H2) Blocking Agents — Ulcer and Stomach Acid Drugs Axid (Oral Solution) 3 Cimetidine 1 Cimetidine HCl 1 Famotidine (Injection.05mg/ml Injection.72gm. 1 PA 0. Syrup. Other — Miscellaneous Gastrointestinal Drugs Actigall 3 Cromolyn Sodium 2 (Concentrate) Diphenoxylate/Atropine 1 PA Gastrocrom 3 Halflytely Bowel Prep/ 2 Flavor Packs Lomotil 3 Loperamide HCl (Capsule) 1 Metoclopramide HCl 1 Metozolv ODT 3 ST Motofen 3 OsmoPrep 3 43 . 40mg Tablet) Famotidine Premixed 2 Nizatidine 1 Pepcid 3 Ranitidine HCl (Capsule. Tablet) Zantac 3 Irritable Bowel Syndrome Agents — Bowel Treatment Drugs Amitiza 2 ST Lotronex 4 PA Laxatives — Bowel Treatment Drugs Colyte-Flavor Packs (240gm. 150mg/6ml 1 Injection. 22. 2. 20mg Tablet. 1 PA Oral Solution.Drug Name Drug Requirements Tier  & Limits Drug Name Drug Requirements Tier  & Limits Pylera 3 Reglan 3 Relistor 3 PA (12mg/0. 3 6. Gastrointestinal — Bowel Treatment Drugs Atropine Sulfate (0.98gm. 5.72gm Oral Solution) Enulose 1 Gavilyte-C 1 Gavilyte-G 1 Gavilyte-N/Flavor Pack 1 Golytely 3 Lactulose 1 MoviPrep 3 Gastrointestinal Agents — Drugs to Treat Bowel. Tablet) Glycopyrrolate 2 Helidac 3 Methscopolamine Bromide 2 Pamine 3 Pamine Forte 3 Propantheline Bromide 1 Robinul (Tablet) 3 Robinul Forte 3 Gastrointestinal Agents. Suspension 1 Reconstituted.84gm. Intestine and Stomach Conditions Antispasmodics.

Drug Name Drug Requirements Tier  & Limits Drug Name Nulytely/Flavor Packs 2 Polyethylene Glycol 3350 1 (Powder) Suprep Bowel Prep 3 Trilyte 1 Protectants — Ulcer and Stomach Acid Drugs Carafate 3 Cytotec 3 Misoprostol 1 (200mcg Tablet) Sucralfate 1 Proton Pump Inhibitors — Ulcer and Stomach Acid Drugs Aciphex 3 ST Dexilant 3 Lansoprazole 3 ST Nexium 2 Nexium I.V. Urinary — Bladder Control Drugs Detrol 3 ST Detrol LA 3 ST Ditropan XL 3 Enablex 3 ST Flavoxate HCl 2 Gelnique (10% Gel) 2 Oxybutynin Chloride 1 Oxybutynin Chloride ER 2 Oxytrol 2 Sanctura 3 Sanctura XR 3 Toviaz 2 ST Trospium Chloride 2 Vesicare 2 Benign Prostatic Hypertrophy Agents — Prostate Enlargement Drugs Alfuzosin HCl ER 2 Avodart 2 Cardura 3 Doxazosin Mesylate 1 Finasteride (Tablet) 1 Flomax 3 Jalyn 3 ST Proscar 3 Rapaflo 2 Tamsulosin HCl 1 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 44 . Genital and Kidney Conditions Antispasmodics. 3 ST Tablet Delayed Release) Vimovo 2 Zegerid 3 ST Drug Requirements Tier  & Limits Genitourinary Agents — Drugs to Treat Bladder. 3 Omeprazole (Capsule 1 Delayed Release) Omeprazole/Sodium 2 Bicarbonate Pantoprazole Sodium 1 Prevacid 3 ST Prevacid Solutab 3 ST Prilosec (Capsule 3 ST Delayed Release) Protonix (Injection) 3 Protonix (Packet.

5mg Tablet. Lotion. Genital. Stimulant/ Replacement/Modifying (Adrenal) — Drugs to Regulate Hormones Glucocorticoids/Mineralocorticoids — Anti-Inflammatory Drugs A-Hydrocort 2 Aclovate 3 Ala Scalp 3 Ala-Cort 2 Alclometasone 1 Dipropionate Amcinonide 1 Anusol-HC (Cream) 3 Augmented Betamethasone 1 Dipropionate (Cream. Tablet) Dexamethasone Intensol Dexamethasone Sodium Phosphate (4mg/ml Injection) Dexpak 13 Day Diflorasone Diacetate Diprolene Diprolene AF Elocon Flo-Pred Fludrocortisone Acetate Hormonal Agents. Other — Miscellaneous Bladder. Shampoo) Clobetasol Propionate (Foam) Clobetasol Propionate E Clobex Cloderm Pump Cordran Cordran Tape Cortef Cortifoam Cortisone Acetate Cutivate Depo-Medrol Derma-Smoothe/FS Dermatop Desonate Desonide Desowen (Cream. Ointment. 0.Drug Name Drug Requirements Tier  & Limits Terazosin HCl 1 Uroxatral 3 Genitourinary Agents. Lotion) Desoximetasone (Cream.25% Ointment) Dexamethasone (Elixir. and Kidney Conditions Drugs Bethanechol Chloride 1 Cialis (2. Gel. Gel. Lotion. 3 PA 5mg Tablet) Elmiron 3 Urecholine 3 Phosphate Binders — Phosphate-Removing Agents Fosrenol 4 Renagel 2 ST Renvela 2 Drug Name Clobetasol Propionate (External Solution. Ointment) Betamethasone 1 Dipropionate Betamethasone Valerate 1 Capex 3 Carmol-HC 3 Celestone 3 45 Drug Requirements Tier  & Limits 1 2 1 3 3 3 3 3 3 1 3 3 3 3 3 1 3 2 1 1 1 3 1 3 3 3 3 1 .

5% Cream. 2gm Injection. 4mg Tablet. 0. 2. Gel. Ointment) Fluocinolone Acetonide Body Oil Fluocinonide (External Solution. Ointment) Halobetasol Propionate Halog Hydrocortisone (1% Cream. Ointment) Locoid Lipocream Lokara Luxiq Medrol (16mg Tablet. 8mg Tablet) Medrol Dosepak Methylprednisolone (Tablet) Methylprednisolone Acetate (Injection) Methylprednisolone Dose Pack Drug Requirements Tier  & Limits Drug Name Methylprednisolone Sodium Succinate (Injection) Millipred (Oral Solution) Mometasone Furoate Olux-E Orapred Orapred ODT (15mg Tablet Dispersible. 250mg Injection) Solu-Medrol (125mg Injection.5% Lotion. External Solution. 500mg Injection) Temovate Topicort (Cream.5% Ointment. Lotion.Drug Name Fluocinolone Acetonide (Cream. 32mg Tablet. 1% Ointment.25% Ointment) Triamcinolone Acetonide (Cream. Gel. 2. Lotion. 2. 40mg Injection. Tablet) Hydrocortisone Valerate Kenalog Locoid (External Solution. 30mg Tablet Dispersible) Pandel Prednicarbate Prednisolone Sodium Phosphate (Oral Solution) Prednisone Prednisone Intensol Proctocream HC Solu-Cortef (100mg Injection. Ointment) Triderm U-Cort Ultravate 1 1 1 1 1 2 3 2 2 3 3 3 1 3 3 3 1 2 1 Drug Requirements Tier  & Limits 2 3 1 3 3 3 3 1 1 1 1 2 3 3 3 3 1 1 1 3 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 46 . Lotion. Ointment) Fluocinonide-E Fluticasone Propionate (Cream.

Drug Name Vanos Verdeso Veripred 20 Westcort Drug Requirements Tier  & Limits Drug Name Omnitrope (5.5mg Tablet) Oxandrolone (10mg Tablet) 4 PA Androgens — Hormone Replacement/ Modifying Drugs Androgel 2 (50mg/5gm Gel) Androgel Pump 2 (1. 0. Stimulant/ Replacement/Modifying (Pituitary) — Drugs to Regulate Hormones Hormonal Agents. Tablet) DDAVP (Injection) 4 ST Desmopressin Acetate 2 Egrifta 4 PA Genotropin 4 PA Genotropin Miniquick 3 PA (0.6mg Injection.4mg Injection.8mg Injection) Pregnyl W/Diluent Benzyl Alcohol/NaCl Saizen Serostim Stimate Tev-Tropin Zorbtive 3 3 3 3 Hormonal Agents. 4 PA 1. Stimulant/Replacement/ Modifying (Pituitary) — Hormone Replacement/Modifying Drugs Chorionic Gonadotropin 2 PA DDAVP 3 (Nasal Solution.8mg Injection.62% Gel) Androxy 2 Axiron 3 PA Danazol 2 Delatestryl 3 Depo-Testosterone 3 Fortesta 3 PA Methitest 3 Striant 3 PA Testim 3 PA Testosterone Cypionate 2 Testosterone Enanthate 2 Testred 3 47 .5ml Injection.4mg Injection.5ml Injection) Drug Requirements Tier  & Limits 4 PA 2 PA 4 4 3 3 4 PA PA PA PA Hormonal Agents. 1. 2mg Injection) Humatrope 4 PA Increlex 4 PA Norditropin Flexpro 4 PA Norditropin Nordiflex 4 PA Pen Nutropin 4 PA Nutropin AQ 4 PA Omnitrope (10mg/1.2mg Injection) Genotropin Miniquick (0.8mg Injection. 1. 1. 1mg Injection. 0. 3 PA 5mg/1. Stimulant/ Replacement/Modifying (Sex Hormones/Modifiers) — Drugs to Regulate Hormones Anabolic Steroids — Hormone Replacement/Modifying Drugs Oxandrolone 2 PA (2.6mg Injection.2mg Injection.

0.5mg Tablet) Estring Estropipate Estrostep Fe Evamist Femcon Fe Femhrt 1/5 Femhrt Low Dose Femring Femtrace Gianvi Introvale Jinteli Junel Junel Fe Kariva Kelnor Leena Lessina Levora Lo Loestrin Fe Lo/Ovral Loestrin Fe (20mcg. 75mg. 1mg Tablet) Apri 1 Aranelle 1 Aviane 1 Balziva 1 Beyaz 3 Brevicon 3 Briellyn 1 Cenestin 3 Climara 3 Climara Pro 3 Combipatch 3 Cryselle 1 Cyclafem 1/35 1 Cyclafem 7/7/7 1 Cyclessa 3 Delestrogen 3 Depo-Estradiol 3 Desogen 3 Divigel (1mg/gm Gel) 3 Elestrin 3 Emoquette 1 Enjuvia 2 Enpresse 1 Estrace Estradiol Estradiol Valerate Estradiol/Norethindrone Acetate (1mg. 1mg Tablet) LoSeasonique Low-Ogestrel Drug Requirements Tier  & Limits 3 1 2 1 3 1 3 3 3 3 3 3 3 1 1 1 1 1 1 1 1 1 1 3 3 3 3 1 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 48 .5mg.Drug Name Drug Requirements Tier  & Limits Drug Name Estrogens — Hormone Replacement/ Modifying Drugs Activella 3 Alora 3 Amethia 1 Amethyst 1 Angeliq 3 (0.

1mg Tablet) Nortrel Nuvaring Ocella Ogestrel Orsythia Ortho Evra Ortho Tri-Cyclen Ortho Tri-Cyclen Lo Ortho-Cept Ortho-Cyclen Ortho-Novum 7/7/7 Ovcon-35 Ovcon-50 28 Portia Prefest Premarin (Cream. Tablet) Premarin (Injection) Premphase Prempro Previfem Quasense Reclipsen Safyral Drug Requirements Tier  & Limits Drug Name Drug Requirements Tier  & Limits Seasonale 3 Seasonique 3 Sprintec 1 Sronyx 1 Tri-Legest Fe 1 Tri-Norinyl 3 Tri-Previfem 1 Tri-Sprintec 1 Trinessa 1 Trivora 1 Vagifem 3 Velivet 1 Vestura 1 Vivelle-Dot 2 Yasmin 3 Yaz 3 Zeosa 1 Zovia 1 Progesterone — Hormone Replacement/ Modifying Drugs Ella 3 Progestins — Hormone Replacement/ Modifying Drugs Aygestin 3 Camila 1 Crinone 3 Depo-Provera 3 Depo-SubQ Provera 104 3 Endometrin 3 Errin 1 Jolivette 1 Medroxyprogesterone 1 Acetate Megace ES 3 Megace Oral 3 Megestrol Acetate 1 1 3 1 3 1 1 3 1 1 3 3 1 2 1 1 1 3 3 3 3 3 3 3 3 1 3 2 3 2 2 1 1 1 3 49 .Drug Name Lutera Lybrel Marlissa Menostar Microgestin Microgestin Fe Modicon Mononessa Necon Nordette Norinyl (35mcg.

Suppressant (Pituitary) — Drugs to Regulate Hormones Hormonal Agents. 200mcg Tablet. 50mcg Tablet. Suppressant (Parathyroid) — Hormone Suppressants Sensipar (30mg Tablet) 2 Sensipar (60mg Tablet. Stimulant/ Replacement/Modifying (Thyroid) — Drugs to Replace Thyroid Hormones Hormonal Agents. 75mcg Tablet. 125mcg Tablet. Suppressant (Parathyroid) — Drugs to Regulate Hormones Hormonal Agents. Suppressant (Adrenal) — Drugs to Regulate Hormones Hormonal Agents. 300mcg Tablet. 175mcg Tablet. 4 90mg Tablet) Hormonal Agents. Stimulant/Replacement/ Modifying (Thyroid) — Thyroid Replacement Drugs Cytomel 3 Levothroid 2 Levothyroxine Sodium 1 (Tablet) Levoxyl 2 Liothyronine Sodium 1 Synthroid 2 Tirosint 3 Hormonal Agents. 25mcg Tablet. Suppressant (Pituitary) — Hormone Suppressants Cabergoline 2 Eligard 3 Firmagon 3 PA (80mg Injection) Firmagon 4 PA (120mg Injection) Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 50 . 150mcg Tablet. 112mcg Tablet. 88mcg Tablet) Next Choice 1 Nor-QD 3 Nora-BE 1 Norethindrone Acetate 1 Ortho Micronor 3 Progesterone (Capsule) 1 Prometrium 3 Provera 3 Selective Estrogen Receptor Modifying Agents — Hormone Replacement/ Modifying Drugs Evista 2 Drug Requirements Tier  & Limits 1 Hormonal Agents.Drug Name Drug Requirements Tier  & Limits Drug Name Unithroid (100mcg Tablet. Suppressant (Adrenal) — Hormone Suppressants Lysodren 2 Hormonal Agents.

75mg Injection) Lupron Depot (22. 45mg Injection. 500mcg/ml Injection) Sandostatin Sandostatin LAR Depot Somatuline Depot Somavert Synarel Trelstar Depot Trelstar LA Trelstar Mixject Drug Requirements Tier  & Limits 2 Drug Name Drug Requirements Tier  & Limits Hormonal Agents.25mg Injection – 3 Month) Lupron Depot-PED (11. 15mg Injection – 1 Month) Octreotide Acetate (100mcg/ml Injection.5mg Injection. Suppressant (Sex Hormones/Modifiers) — Drugs to Regulate Hormones Antiandrogens — Hormone Suppressants Bicalutamide 1 Casodex 3 Flutamide 2 Nilandron 3 51 .Drug Name Leuprolide Acetate Lupron Depot (3. PA Cellcept (Suspension 4 B/D. Suppressant (Thyroid) — Drugs to Suppress Thyroid Hormones 3 Antithyroid Agents — Thyroid Suppressing Drugs Methimazole 1 Propylthiouracil 1 Tapazole 3 4 3 Immunological Agents — Drugs that Stimulate or Suppress the Immune System 4 3 PA 4 PA 4 4 4 4 4 4 4 4 PA PA PA PA PA Immune Suppressants — Immune System Drugs Azasan 3 Azathioprine 1 Azathioprine Sodium 2 Benlysta 4 PA (120mg Injection) Cellcept (Capsule) 3 B/D. Tablet) Cellcept Intravenous 3 B/D.5mg Injection) Lupron Depot-PED (11. 50mcg/ml Injection) Octreotide Acetate (1000mcg/ml Injection. PA Reconstituted. PA Cimzia 4 PA Cyclosporine 2 B/D Cyclosporine Modified 1 B/D (100mg Capsule) Cyclosporine Modified (50mg Capsule. 30mg Injection. 2 B/D Oral Solution) Enbrel 4 PA Gengraf 2 B/D Humira 4 PA Humira Starter Kit 4 PA Imuran 3 Kineret 4 PA Methotrexate (Tablet) 1 Hormonal Agents. 7.25mg Injection – 1 Month. 200mcg/ml Injection.

PA 4 B/D.5mg Capsule. PA (10gm/200ml Injection) Gamunex-C 4 B/D. 1mg Tablet.5mg Tablet.25mg Tablet) Zortress (0. 0. Passive — Immune System Drugs Atgam 4 B/D Carimune Nanofiltered 4 B/D. PA B/D. PA Gammaplex 4 B/D.Drug Name Methotrexate Sodium (25mg/ml Injection) Methotrexate Sodium (1gm Injection) Mycophenolate Mofetil Myfortic (180mg Tablet Delayed Release) Myfortic (360mg Tablet Delayed Release) Neoral Nulojix Orencia Prograf (0. 1mg Capsule) Tacrolimus (5mg Capsule) Torisel Trexall Zortress (0.75mg Tablet) Drug Requirements Tier  & Limits Drug Name Immunizing Agents. PA 4 4 3 3 B/D. PA Drug Requirements Tier  & Limits Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 52 . PA PA 3 B/D. 2mg Tablet) Remicade Rheumatrex Sandimmune Simponi Tacrolimus (0. PA (3gm Injection) Gammagard Liquid 4 B/D. PA 3 B/D 4 B/D 3 4 4 B/D B/D. PA (1gm/5ml Injection) Privigen 4 B/D. PA 4 B/D.5mg Tablet) Rapamune (Oral Solution. 1mg Capsule.5mg Capsule. PA (20gm/200ml Injection) Thymoglobulin 4 B/D Immunomodulators — Immune System Drugs Actemra 4 PA (200mg/10ml Injection) Actimmune 4 Arava 3 Arcalyst 4 PA Avonex 4 PA Betaseron 4 PA Extavia 3 PA Ilaris 4 PA Leflunomide 1 Rebif 4 PA Rebif Titration Pack 4 PA Ridaura 3 Simulect 4 B/D (20mg Injection) 1 2 2 B/D. Injection) Prograf (5mg Capsule) Rapamune (0. PA 3 B/D 4 B/D 4 3 3 4 PA B/D PA 2 B/D. PA (1gm/10ml Injection) Hizentra 4 B/D.

5ml Injection) Tysabri Vaccines ActHIB Adacel Boostrix Cervarix Comvax Daptacel Decavac Engerix-B Gardasil Havrix Infanrix IPOL Ixiaro M-M-R II Menactra MenomuneA/C/Y/W-135 Menveo Pedvax HIB ProQuad Rabavert Recombivax HB (10mcg/ml Injection. LA Drug Requirements Tier  & Limits 2 3 Inflammatory Bowel Disease Agents — Drugs to Treat Inflammatory Bowel Disease Aminosalicylates — Inflammatory Bowel Disease Drugs Apriso 2 Asacol 3 Asacol HD 3 PA Balsalazide Disodium 2 Canasa 2 Colazal 3 Dipentum 3 Lialda 3 Mesalamine (Kit) 2 Pentasa 3 sfRowasa 4 Glucocorticoids — Inflammatory Bowel Disease Drugs Budesonide (Capsule Extended 2 Release 24 Hour) Colocort 2 Entocort EC 3 Hydrocortisone (Enema) 2 Millipred (Tablet) 3 Sulfonamides — Inflammatory Bowel Disease Drugs Azulfidine 3 Azulfidine EN-Tabs 3 Sulfasalazine (Tablet) 1 Sulfazine EC 1 B/D 2 2 2 2 2 2 Drug Name B/D 2 2 2 2 2 2 53 . 40mcg/ml Injection) RotaTeq Tetanus/Diphtheria Toxoids-Adsorbed Adult Twinrix Typhim Vi Vaqta (25unit/0.5ml Injection) Varivax Drug Requirements Tier  & Limits YF-Vax Zostavax 4 4 2 2 2 3 2 2 2 2 2 2 2 2 2 2 2 PA.Drug Name Synagis (50mg/0.

20% Injection) Lactated Ringers Irrigation 2 Levocarnitine 2 Liposyn III (1.2%.5%. 1.Drug Name Drug Requirements Tier  & Limits Drug Name Rocaltrol Skelid Xgeva Zemplar Zometa Metabolic Bone Disease Agents — Drugs to Treat Bone Conditions Metabolic Bone Disease Agents — Osteoporosis (Bone Loss) Drugs Actonel 3 Alendronate Sodium 1 Atelvia 3 Boniva (Tablet) 3 Boniva (Injection) 3 B/D Calcijex 3 B/D Calcitonin-Salmon 2 Calcitriol (Capsule. PA Fortical 2 Fosamax (70mg Tablet) 3 Fosamax Plus D 3 ST Hectorol 2 B/D Ibandronate Sodium 2 Miacalcin 3 (Nasal Solution) Miacalcin (Injection) 3 B/D. 20% Injection) Methergine 2 Methylergonovine Maleate 1 (Tablet) Physiolyte 3 Physiosol Irrigation 3 Ringers Irrigation 2 PA B/D PA PA B/D B/D B/D B/D Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 54 . 1 B/D Injection.5%. PA Pamidronate Disodium (30mg/10ml Injection.25%. 2 B/D 90mg/10ml Injection) Pamidronate Disodium 3 B/D (6mg/ml Injection) Prolia 3 PA Reclast 3 PA Drug Requirements Tier  & Limits 3 3 4 2 4 B/D PA B/D Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Alcohol Preps (Pad) 1 Botox (100unit Injection) 3 Carnitor 3 Ferriprox 4 Firazyr 4 Fomepizole 4 Gauze Pads 2 Insulin Syringes. 2.7%. Oral Solution) Didronel 3 Etidronate Disodium 2 Forteo 3 B/D. 30% Injection) Intralipid 3 (2. 10% Injection.2%. 2 Needles Intralipid 3 (1. 3 2.

Drug Name Sodium Chloride 0. Other — Miscellaneous Eye Drugs AK-Con 1 Alcaine 3 Mydriacyl 3 Proparacaine HCl 1 Restasis 2 Tropicamide 1 Ophthalmic Anti-Allergy Agents — Allergy. Infection and Inflammation Drugs Acular 2 Acular LS 2 Acuvail 3 PA Alrex 2 55 Drug Requirements Tier  & Limits 2 2 3 2 1 1 2 2 1 2 2 3 2 2 3 3 1 1 1 2 3 3 3 2 2 2 1 .P. Infection and Inflammation Drugs Alocril 3 Alomide 3 Azelastine HCl 2 (Ophthalmic Solution) Bepreve 3 Cromolyn Sodium 1 (Ophthalmic Solution) Elestat 3 Emadine 3 Epinastine HCl 2 Lastacaft 2 Optivar 3 ST Pataday 3 Patanol 2 Ophthalmic Anti-Inflammatories — Allergy.P.9% (Irrigation Solution) Sterile Water Irrigation Xeomin (50unit Injection) Drug Requirements Tier  & Limits Blephamide Blephamide S. Prednisolone Acetate 1 2 3 Drug Name PA Ophthalmic Agents — Drugs to Treat Eye Conditions Ophthalmic Agents.O. Bromday Bromfenac Dexamethasone Sodium Phosphate (Ophthalmic Solution) Diclofenac Sodium (Ophthalmic Solution) Durezol Flarex Flurbiprofen Sodium FML FML Forte FML Liquifilm Ketorolac Tromethamine (Ophthalmic Solution) Lotemax Maxidex Maxitrol Neomycin/Polymyxin/ Bacitracin/Hydrocortisone Neomycin/Polymyxin/ Dexamethasone Neomycin/Polymyxin/ Hydrocortisone (Ophthalmic Suspension) Nevanac Ocufen Omnipred Pred Forte Pred Mild Pred-G Pred-G S.O.

1 Ophthalmic Solution) Timoptic Ocudose 3 Timoptic-XE 3 Trusopt 3 Ophthalmic Prostaglandin and Prostamide Analogs — Glaucoma Drugs Latanoprost 1 Lumigan 2 Travatan Z 2 Xalatan 3 ST Zioptan 3 ST Otic Agents — Drugs to Treat Ear Conditions Otic Agents — Ear Drugs Acetasol HC Acetic Acid 2 1 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 56 .Drug Name Drug Requirements Tier  & Limits Drug Name Prednisolone Sodium Phosphate 1 (Ophthalmic Solution) Sulfacetamide Sodium/ Prednisolone Sodium 1 Phosphate Tobradex (Ointment) 2 Tobradex (Suspension) 3 Tobradex ST 3 Tobramycin/ 2 Dexamethasone Vexol 3 Voltaren (Ophthalmic 3 Solution) Zylet 2 Ophthalmic Antiglaucoma Agents — Glaucoma Drugs Acetazolamide 1 Acetazolamide ER 2 Alphagan P 2 Apraclonidine 2 Azopt 2 Betagan 3 Betaxolol HCl 1 (Ophthalmic Solution) Betimol 3 Betoptic-S 3 Brimonidine Tartrate 1 Carteolol HCl 1 Combigan 2 Cosopt 3 Diamox 3 Drug Requirements Tier  & Limits Dorzolamide HCl 1 Dorzolamide HCl/ 1 Timolol Maleate Iopidine 3 Isopto Carpine 3 Istalol 3 Levobunolol HCl (0.5% 1 Ophthalmic Solution) Methazolamide 1 Metipranolol 1 Optipranolol 3 Phospholine Iodide 2 Pilopine HS 2 Timolol Maleate (Gel Forming Solution.

Suspension) Cortisporin-TC Dermotic Fluocinolone Acetonide (Otic Oil) Hydrocortisone/ Acetic Acid Neomycin/Polymyxin/ Hydrocortisone (Solution. 2 50mg Suppository) Semprex-D 3 3 3 3 2 1 2 1 Respiratory Tract Agents — Drugs to Treat Allergies. Cough. Injection) Hydroxyzine HCl 1 Hydroxyzine Pamoate 1 Levocetirizine 3 Dihydrochloride (Tablet) Levocetirizine Dihydrochloride 3 (Oral Solution) Palgic 3 Patanase 2 Phenadoz 2 Phenergan 3 Promethazine HCl 2 Promethazine VC 2 Promethegan (25mg Suppository.68mg Tablet) Cyproheptadine HCl 3 Diphenhydramine HCl 3 (50mg Capsule.025% Nasal Solution) Fluticasone Propionate 1 (Nasal Suspension) Nasacort AQ 3 Nasonex 2 Omnaris 3 Pulmicort 3 B/D Pulmicort Flexhaler 2 Qnasl 3 57 ST ST ST ST . Inhaled Corticosteroids — Asthma/Lung Drugs Advair Diskus 2 Advair HFA 2 Alvesco 3 ST Asmanex 3 Beconase AQ 3 Budesonide (Suspension) 2 B/D Dulera 3 Flonase 3 Flovent Diskus 2 Flovent HFA 2 Flunisolide 1 (0.Drug Name Coly-Mycin S Cortisporin (Solution. 2. Cold and Lung Conditions Anti-Inflammatories. Suspension) Drug Requirements Tier  & Limits Drug Name Drug Requirements Tier  & Limits QVAR 2 Rhinocort Aqua 3 Symbicort 2 Triamcinolone Acetonide 2 (Inhaler) Veramyst 3 Antihistamines — Allergy Drugs Astelin 3 Astepro 2 Azelastine HCl 2 (Nasal Spray) Carbinoxamine Maleate 1 Cetirizine HCl (Syrup) 1 Clarinex 3 Clarinex Reditabs 3 Clarinex-D 3 Clemastine Fumarate 2 (Syrup.

450mg Tablet Extended Release 12 Hour.Drug Name Drug Requirements Tier  & Limits Drug Name Vistaril 3 Xyzal (Tablet) 3 Xyzal (Oral Solution) 3 ST Antileukotrienes — Asthma/Lung Drugs Accolate 3 Singulair 2 Zafirlukast 1 Zyflo 3 ST Zyflo CR 3 ST Bronchodilators. Anticholinergic — Asthma/Lung Drugs Atrovent 3 Atrovent HFA 3 Combivent 2 Duoneb 3 B/D Ipratropium Bromide 1 (Nasal Solution) Ipratropium Bromide 1 B/D (Inhalation Solution) Ipratropium Bromide/ 1 B/D Albuterol Sulfate Spiriva Handihaler 2 Bronchodilators. 300mg Tablet 1 Extended Release 12 Hour. Phosphodiesterase Inhibitors (Xanthines) — Asthma/Lung Drugs Aminophylline 1 Elixophyllin 2 Lufyllin 3 Drug Requirements Tier  & Limits Theophylline ER (100mg Tablet Extended Release 12 Hour. ST Maxair Autohaler 3 Metaproterenol Sulfate 1 Perforomist 3 B/D Proair HFA 2 Proventil HFA 3 ST Serevent Diskus 2 ST Terbutaline Sulfate (Tablet) 1 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 58 . 200mg Tablet Extended Release 12 Hour. Tablet) Albuterol Sulfate 1 B/D (Nebulization Solution) Albuterol Sulfate ER 1 Arcapta Neohaler 3 ST Brovana 3 B/D Epinephrine HCl 2 (0.1mg/ml Injection) Epipen 2 Foradil Aerolizer 2 ST Levalbuterol 3 B/D. Sympathomimetic — Asthma/Lung Drugs Accuneb 3 B/D Albuterol Sulfate 1 (Syrup. Tablet Extended Release 24 Hour) Bronchodilators.

5mg 3 Capsule. Inflammation. 30mg Capsule) Temazepam (22. 10mg Tablet) Zolpidem Tartrate ER 3 ST Zolpimist 3 ST Sleep Disorders. 5mg Tablet) Sedatives/Hypnotics — Drugs for Sedation and Sleep GABA Receptor Modulators — Sedation and Sleep Drugs Ambien 3 ST Ambien CR 3 ST 59 . LA Terbutaline Sulfate 3 (Injection) Twinject 3 Ventolin HFA 3 ST Xopenex 3 B/D. ST Xopenex HFA 3 ST Mast Cell Stabilizers — Asthma/Lung Drugs Cromolyn Sodium 2 B/D (Nebulization Solution) Pulmonary Antihypertensives — Asthma/ Lung Drugs Adcirca 4 PA Letairis 4 Remodulin 4 B/D. PA Inhalation Solution) Respiratory Tract Agents.5mg Capsule) Triazolam 3 Zaleplon 1 Zolpidem Tartrate 1 (5mg Tablet. PA Revatio 4 PA Tracleer 4 LA Ventavis (10mcg/ml 4 B/D. Other — Asthma/Lung Drugs Acetylcysteine 1 B/D Aralast NP 4 PA (400mg Injection) Daliresp 3 PA Glassia 4 PA Kalydeco 4 PA Prolastin-C 4 PA Pulmozyme 4 B/D Tyzine 2 Xolair 4 PA Zemaira 4 PA Skeletal Muscle Relaxants — Drugs to Treat Pain.Drug Name Drug Requirements Tier  & Limits Drug Name Drug Requirements Tier  & Limits Edluar 3 ST Flurazepam HCl 3 Halcion 3 Intermezzo 3 ST Lunesta 2 Restoril 3 Sonata 3 ST Temazepam (15mg 1 Capsule. Other — Miscellaneous Sedation and Sleep Drugs Butisol Sodium 3 PA Nuvigil 3 PA Provigil 3 PA Rozerem 3 Silenor 3 ST Xyrem 2 PA. 7. and Muscle and Joint Conditions Skeletal Muscle Relaxants — Pain/Swelling Management Drugs Amrix 3 ST Carisoprodol 2 (350mg Tablet) Carisoprodol/Aspirin 3 Chlorzoxazone 2 Cyclobenzaprine HCl 3 (10mg Tablet.

Drug Name Cyclobenzaprine HCl (7. Mineral and Body Fluid Deficiencies Electrolyte/Mineral Modifiers — Vitamin.5%/ 2 B/D Electrolytes Aminosyn II 3 B/D Aminosyn II 8.25%/ 3 B/D Dextrose 25% Clinimix 4.25%/ 3 B/D Dextrose 5% Clinimix 5%/ 3 B/D Dextrose 25% Clinimix E 5%/ 3 B/D Dextrose 20% Clinisol SF 15% 2 B/D Dextrose 5%/ 2 Lactated Ringers Dextrose 5%/Potassium 2 Chloride 0. 4 500mg Tablet Soluble) Kayexalate 3 Kionex (Powder) 2 Samsca 4 PA Sodium Fluoride (Tablet) 1 Sodium Lactate 1 Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy 60 .5mg Tablet) Cyclobenzaprine HCl ER Fexmid Methocarbamol Orphenadrine Citrate Orphenadrine Citrate ER Orphenadrine Compound DS Orphenadrine/Aspirin/ Caffeine Parafon Forte DSC Skelaxin Soma Drug Requirements Tier  & Limits 3 ST 3 3 2 3 2 ST ST Drug Name Drug Requirements Tier  & Limits Sodium Polystyrene 2 Sulfonate (Suspension) Syprine 3 Electrolyte/Mineral Replacement — Vitamin.15% Eliphos 2 2 2 3 3 3 Therapeutic Nutrients/Minerals/ Electrolytes — Drugs to Treat Vitamin.5%/ 2 B/D Electrolytes Aminosyn M 3 B/D Aminosyn-HBC 3 B/D Aminosyn-PF 3 B/D Calcium Acetate (Capsule) 2 Clinimix 2.75%/ 3 B/D Dextrose 5% Clinimix 4. Mineral and Body Fluid Deficiency Drugs Aminosyn 8. Mineral and Body Fluid Deficiency Drugs Ammonium Chloride 3 Chemet 3 Depen Titratabs 3 Exjade 3 (125mg Tablet Soluble) Exjade (250mg Tablet Soluble.25%/ 3 B/D Dextrose 10% Clinimix 4.

9% Potassium Chloride 0. 5% Injection) Sodium Chloride 0.4meq/ml Injection. 10meq/50ml Injection. 10meq Tablet 1 Extended Release.5% Injection) Hepatamine Hepatasol Isolyte-H/Dextrose 5% Isolyte-M/Dextrose 5% Isolyte-P/Dextrose 5% Isolyte-S Isolyte-S/Dextrose 5% K-Tabs Klor-Con 10 Klor-Con 8 Klor-Con M15 Klor-Con M20 Lactated Ringers Magnesium Sulfate (50% Injection) Nephramine Normosol-M in D5W Normosol-R Phoslo Phoslyra Plasma-Lyte Plasma-Lyte/D5W (16meq/L. 30meq/100ml Injection) Potassium Chloride 0. 40meq/L.5meq/ml 1 Injection.3%/ 2 D5W/Viaflex Potassium Chloride ER (Capsule Extended Release. 40meq/L Injection) Potassium Chloride (0.9% Injection.9% Potassium Chloride 0. 2meq/ml Injection. 10meq/100ml Injection. 20meq Tablet Extended Release) Premasol (6% Injection) 3 B/D Premasol (10% Injection) 3 B/D Procalamine 3 B/D Prosol 3 B/D Ringers Injection 2 Sodium Chloride (0. 2.45% Viaflex Drug Requirements Tier  & Limits 3 B/D 3 B/D 2 3 3 2 3 3 3 3 1 1 2 1 2 B/D B/D Drug Requirements Tier  & Limits Potassium Chloride 2 0. Mineral and Body Fluid Deficiency Drugs Niacor 1 Prenatal Vitamins 1 2 3 2 3 2 3 3 Drug Name B/D ST 3 2 2 61 .Drug Name Freamine III 3% Freamine III (8.224%/Dextrose 5% 2 Viaflex Potassium Chloride 2 0.15%/NaCl 0. 3meq/L. 3% Injection. 5%. 13meq/L.15%/NaCl 0.45% 1 Viaflex (Injection) TPN Electrolytes 2 Travasol 3 B/D Trophamine 3 B/D Vitamins — Vitamin.3%/NaCl 0.

....................... 22 Alora......... 55 Aceon........... 56 Acetasol HC.. 52 Albuterol Sulfate..... 12 Actemra............................. 57 Aloprim.............................................................................................. 29 Actimmune.......................................... 30 Acanya.................... 22 Allopurinol Sodium....................................................... 30 Acetazolamide........................ 43 Albenza.... 56 Advicor.............. 57 Actigall........................................ 53 Alkeran........................................................ 23 Accuneb.. 59 Alomide......................................................... 41 Alinia................... 10 Albuterol Sulfate ER......................... 58 Ambien..... 39 Altace..... 57 Alphagan P.................................................. 24 Acarbose.................................. 55 Aciphex.... 48 Alcaine.. 56 Afeditab CR.... 55 Actonel.................... 10 Advair HFA....... 37 Allopurinol.................................................................................................................................... 45 Altoprev............... 58 Amaryl........................... 54 Alclometasone Dipropionate................................ 38 Aggrenox.... 21 Actos............ 48 Aloxi.................................................................................................................... 22 Accuretic.... 59 AmBisome..........................45 62 Ambien CR......... 40 Adriamycin................... 30 Acetazolamide ER................................ 10 Advair Diskus.......... 58 Adacel...... 54 Actoplus Met XR............................................................................................................. 30 Alfuzosin HCl ER.............................................................................................. 56 Agrylin.......................................................................................................... 41 Acyclovir Sodium................. 24 Acetaminophen/Caffeine/ Dihydrocodeine Bitartrate.......................................... 55 Aclovate........................................ 39 Abilify Discmelt....................... 41 Alendronate Sodium................ 27 Acular.............................. 25 Acetazolamide Sodium................................... 37 Alprazolam ER............................................ 31 Alcohol Preps............................................... 52 Ala-Cort.... 35 Adapalene.................................... 31 Aczone..... 21 ........................................ 41 Actoplus Met............................ 31 Actiq............................. 31 Aldactazide.................................................................... 45 Alprazolam XR........ 24 Acuvail.................................. 45 ActHIB.......................... 42 Abstral.............................. 55 Acebutolol HCl.............. 15 Altabax............. 58 Adagen....... 59 Activella. 35 Adalat CC. 54 Alimta........................................... 35 Alvesco. 10 Acyclovir....................................................................... 53 Ala Scalp....... 36 Adcirca..................................................... 39 Alprazolam...................... 26 Amantadine HCl............................................................................................................... 42 Accupril.......................... 26 Accolate................ 55 Aldurazyme..............Index of covered drugs 8-MOP................................. 39 Abelcet..................................................... 34 Acetylcysteine.................... 30 Alprazolam ODT......................... 35 Adderall XR....................................................................................................................................... 56 Afinitor............................................................... 44 AK-Con...... 41 Alocril............ 27 Acular LS...... 55 Aldactone........ 21 Acetaminophen/Codeine........................................... 30 Acetic Acid.................... 34 Alprazolam Intensol............. 45 Akne-Mycin............ 30 Alrex.............. 31 Abilify...................................................... 59 A-Hydrocort.................... 55 Abraxane.. 44 A Aldara.

............................60 Aminosyn-HBC.......... 58 Avandaryl......................................... 41 Amrix........... 47 Astepro.... 40 Amphotec................................................ 9 Androxy....................................................................... 25 Asmanex.................................................................................................................. 15 Aralast NP....... 34 Arcalyst..................................................... 21 Ativan.......................................................................................... 8 Asacol................. 48 Ampyra............................................................ 41 Apri.................................................................................... 43 Amitriptyline HCl........ 45 Atgam...................................... 53 Anaprox DS. 35 Angeliq........................ 12 Anafranil......... 48 Atacand HCT.................. 39 Apokyn.. 48 Ampicillin-Sulbactam....................... 20 Amlodipine Besylate..... 60 Apraclonidine......... 20 Atelvia........ 36 Antivert.. 19 Atorvastatin Calcium..................... 24 Amikacin Sulfate......................................... 53 Anastrozole.......................... 52 Amphetamine/ Dextroamphetamine........................... 15 Arava... 57 Androgel Pump.... 52 Avalide....... 39 Anagrelide Hydrochloride............................ 58 Amoxicillin/Potassium Clavulanate.... 58 Aminosyn 8..........................Amcinonide.... 30 Amlodipine Besylate/ Benazepril HCl...... 31 Avapro........... 36 Amitiza.... 8 Asacol HD............................................................................................................... 45 Amphotericin B............ 37 Androgel............................... 52 Anzemet.............. 39 Anaprox............................................... 29 Atrovent............................... 41 Apriso................................................ 57 Ancobon................................... 41 Arixtra............................................. 60 Aminosyn M........................................................ 36 Anusol-HC................................................ 35 Avandamet............ 21 Astelin.................. 35 Antabuse....... 21 Aricept.......................... 43 Amoxapine................. 48 Atripla.............. 59 Atrovent HFA......................................... 60 Aminosyn II..... 22 Ampicillin........................................................................................................ 21 Aranesp Albumin Free..................... 20 Arthrotec....... 48 Augmented Betamethasone Dipropionate.............................. 8 Amiloride HCl............................................................ 39 Atenolol.................... 60 Aminosyn II 8................... 26 Ammonium Chloride........... 28 Amnesteem....... 58 Amoxicillin.............. 37 Aplenzin..................................... 18 Amerge.................. 34 Arzerra................... 20 Aptivus............... 24 Amturnide...................... 25 Amethyst................ 26 Amiloride/ Hydrochlorothiazide.................................... 47 Atacand................ 57 Aminophylline...........................................5%/ Electrolytes.................... 15 Aranelle...................................................... 15 Aricept ODT. 21 Atenolol/Chlorthalidone.................................. 60 Amiodarone HCl. 59 Aromasin..........5%/Electrolytes............................................ 19 Amethia................................................................... 54 Antara......................................... 60 Aminosyn-PF................ 35 63 .................................................... 45 Amoxicillin/Potassium Clavulanate ER................................................................................................................... 53 Atropine Sulfate.... 25 Amifostine. 47 Astramorph. 27 Atovaquone/Proguanil HCl................. 38 Arranon........ 15 Arimidex............................. 31 Argatroban.. 33 Amevive................................................................... 33 Avandia............................................... 56 Atralin......................................... 41 Ammonium Lactate.................. 31 Arcapta Neohaler............................

............................................................................................................................................................................. 53 Bisoprolol Fumarate.. 36 Bumetanide............................ 55 Azelastine HCl........................................................................................ 51 Benztropine Mesylate......................... 15 Avelox ABC Pack......................................................... 37 Betapace AF..................................... 35 Blephamide...................... 57 Bleph-10........................... 41 Brilinta.............. 52 Axert........... 56 Bromocriptine Mesylate.. 56 Buproban.............................. 20 B Betimol....... 57 Besivance................. 52 Buphenyl... 58 Azithromycin.......... 15 Baclofen... 51 Bentyl.......................... 15 Bupropion XL................................. 55 Bromday.......... 54 Azasan...................................55............ 51 Busulfex.............................. 26 Brimonidine Tartrate............................................................................................................................. 47 Aygestin........ 22 Axid....... 48 64 Buspirone HCl..... 16 Bactrim DS....... 15 Benzamycin....................... 55 Benazepril HCl/ Hydrochlorothiazide............................................... 42 Azulfidine....... 48 Bactroban Nasal.............. 34 Azathioprine........ 15 Bicalutamide.................................................... 38 Aztreonam.............. 19 Bacitracin............... 16 Benazepril HCl. 24 Beconase AQ.. 51 Bepreve................. 30 .............................................................................. 13 Biltricide................. 19 Bacitracin/Polymyxin B................................ 55 Blephamide S.................................................................... 36....... 56 Buprenex...................... 15 Avelox...................... 56 Azathioprine Sodium........ 20 Azulfidine EN-Tabs.................................... 56 Betapace............................................................. 28 Biaxin XL........................O........................ 20 Baciim....................... 48 Bisoprolol Fumarate/ Hydrochlorothiazide.... 45 Budeprion SR.. 43 Axiron.................. 55 Azelex........................................................................................... 16 Bromfenac......................... 19 Azopt. 43 Briellyn............ 48 Bupropion HCl SR................................................ 18 Avodart.................................................... 44 Avonex.............................................................................. 54 Benicar...................P.. 14 Baraclude..... 45 Buprenorphine HCl.............. 36 Avita............... 23 Benlysta........ 26 Bactrim............................... 14 Betaseron............. 51 Brevicon....................................... 48 Azasite................... 26 Avinza.................................. 16 Bactroban....................................................................... 53.............................. 35 Boostrix. 36 Budesonide........ 53 Azactam in Iso-Osmotic Dextrose........................ 15 Biaxin XL PAC................ 13 Biaxin............. 35 Boniva................. 27 Betamethasone Dipropionate..................................................................................... 16 Bicillin L-A................................... 9 Balsalazide Disodium............... 41 Betagan............................................. 36 Banzel............................................... 57 Azor........... 13 BiCNU............................. 53 Bethanechol Chloride.................................... 15 Betamethasone Valerate........................................... 16 Bicillin C-R..... 13 Beyaz...... 14 Benicar HCT...........................Avastin........................... 41 Balziva........................ 27 Azilect............................. 35 Botox........................................................................................ 29 Bleomycin Sulfate..........................................................45 Brovana.. 49 Azactam............... 23 Aviane.............................. 12 Betoptic-S........................ 19 Bactocill in Dextrose...... 56 Bupropion HCl............. 53 Betaxolol HCl...........................

.... 48 Carteolol HCl.................................. 10 Butisol Sodium...................................... 51 Carmol-HC................ 20 Bydureon......... 37 Calan......... 20 Camptosar....................................... 21 Cantil........................................................................................... 50 Caduet..................... 14 Carbidopa/Levodopa ER... 54 Calcipotriene...................... 31 Bystolic........................ 43 Capastat Sulfate................................................................................................. 24 Canasa.......................................... 14 Cardizem CD............................................. 44 Cefazolin Sodium............................... 18 Cefotetan............................................... 54 Cenestin...................... 8 Camila... 10 Cellcept Intravenous............................................................................................ 20 Cedax........................... 14 Carbidopa/Levodopa ODT............................................ 53 Cancidas....................... 14 Carbamazepine................................ 26 Campral......... 14 Cartia XT.................... 14 Carbamazepine ER................................. 14 Cardizem........................ 14 Carbaglu............... 41 Calcitonin-Salmon............................ 14 Carboplatin.......................... 31 Byetta.................. 14 65 ............................................ 18 Cefepime........................... 59 Butorphanol Tartrate......... 42 Carvedilol...... 14 Carafate. 27 Cefoxitin Sodium.................................................................................................. 45 Capital/Codeine................... 59 Celestone..................... 37 Calcijex.............. 49 Campath... 41 Butalbital/Aspirin/ Caffeine/Codeine....................................... 37 Ceftazidime/Dextrose........ 35 Cefuroxime Sodium............................................. 14 Chemet.. 24 Casodex....................... 60 Cambia........... 10 Butrans.................. 45 Celontin................... 23 Chloramphenicol Sodium Cefaclor.................................. 17 Carnitor................................................................. 14 Succinate................................... 19 Carisoprodol/Aspirin/ Cellcept............... 59 Celexa....... 14 Carimune Nanofiltered.........................................Butalbital/Acetaminophen/ Caffeine/Codeine....... 37 Calan SR.... 37 Ceftin..... 37 Ceftriaxone Sodium......................... 27 Cefpodoxime Proxetil............................. 42 Cefdinir...... 8 Carisoprodol... 13 Cefaclor ER................... 24 Ceftazidime.......................................................... 35 Carac.............................................................. 14 Cardura XL....... 23 Capex................................................... 36 C Cabergoline............. 21 Catapres................................................... 45 Carisoprodol/Aspirin.................................................... 36 Cerubidine.. 35 Captopril/ Hydrochlorothiazide.................... 51 Cervarix............................................................. 14 Cardizem LA....................................... 14 Carbinoxamine Maleate.............................................. 60 CeeNU................................................ 57 Catapres-TTS....................... 8 Cesamet.................. 14 Carbatrol................ 44 Cefuroxime Axetil.......... 14 Cardura........................... 41 Cefadroxil... 27 Cefoxitin Sodium/Dextrose............................................................................................... 51 Codeine............. 57 Cefprozil............................ 52 Celebrex............................................ 23 Captopril......... 10 Caprelsa........................................ 35 Chantix......................................................................... 54 Calcium Acetate. 18 Cefotaxime Sodium................................ 37 Cerezyme........................................................ 14 Carbidopa/Levodopa........ 14 Chantix Pak... 20 Cayston.... 53 Cataflam..... 35 Cetirizine HCl... 54 Calcitriol..................................................................... 56 Cephalexin........................

........... 57 Chlorhexidine Gluconate Clarinex Reditabs.... 48 Chorionic Gonadotropin.....75%/ Dextrose 10%.... 32 Clinisol SF 15%............... 16 Cipro HC.................. 35 Clotrimazole. 60 Clinimix 4......................25%/ Dextrose 10%........................ 51 Clopidogrel. 10 Clinimix E 2.............. 32 Clinimix E 5%/ Dextrose 15%.........................................Chlordiazepoxide/ Claravis................................... 32 Colcrys....25%/ Dextrose 25%..... 39 Cleocin Phosphate................................................... 35 Cimzia.................. 41 Cilostazol................. 41 Amitriptyline.............. 45 Clolar. 48 Cialis.................................................................................................... 13 Chlorpropamide........... 26 Clinimix 5%/Dextrose 25%..................................... 17 Clonazepam ODT.................................................................. 45 Clobex.................................. 24 Citalopram Hydrobromide.... 16 Clindamycin Phosphate....................................................................................... 43 Add-Vantage......................... 45 Clindacin PAC.25%/ Dextrose 20%.. 15 Chlorothiazide... 32 Clinimix E 5%/ Dextrose 20%. 60 Coartem................. 8 Clobetasol Propionate........................................ 10 Clinimix 5%/Dextrose 20%........... 16 Ciprofloxacin HCl..... 32 Clinimix E 4................ 39 Cleocin....................................................................... 28 Clinimix 4................ 13 Chlorpromazine HCl..................................... 16 Ciprodex................. 60 Clinimix 4....... 41 Cholestyramine Light.............. 13 Chlorzoxazone.. 24 Clomipramine HCl...................................................... 28 Clozaril....... 32 Clozapine........ 20 Clonazepam.......... 34 Clindamycin HCl........... 34 Cipro.. 34 Cinryze....... 19 Cladribine................. 32 Clinimix E 4.............................. 21 Benzoyl Peroxide.......... 39 Climara........ 15 Chloroquine Phosphate........... 13 Ciloxan...................... 57 Chlordiazepoxide HCl...................... 13 Chlorthalidone.......... 13.............. 16 Ciprofloxacin......................25%/ Dextrose 25%................ 16 Cisplatin... 16 Cipro IV..... 27 Cleocin Galaxy................................... 45 Cloderm Pump....... 59 Cleocin-T................................ 53 Dextrose 5%.......... 60 Clinoril.................. 24 Claforan...... 47 Climara Pro................ 41 Cimetidine.................... 17 Clorpres................................................................................................................. 41 Ciclopirox....................................................................................... 21 Clinimix 4.... 57 Chlorothiazide Sodium.. 26 Clarithromycin ER... 43 Clindamycin Phosphate Cimetidine HCl............ 13 Clonidine HCl........ 60 Clinimix E 2................................................................ 41 Ciclopirox Nail Lacquer......................................... 26 Clinimix 5%/Dextrose 15%........................................25%/ Dextrose 5%.............................................................................................. 22 66 .. 32 Cogentin........ 60 Co-Gesic........... 21 Clotrimazole/Betamethasone Dipropionate........................... 31 Cleocin in D5W....... 45 Clobetasol Propionate E.............75%/ Dextrose 5%.. 30 Clarinex-D...... 57 Oral Rinse............. 21 Clindamycin/ Ciclopirox Olamine... 30 Clarinex........25%/ Dextrose 5%.......................................... 17 Clorazepate Dipotassium............................. 32 Codeine Sulfate......... 16 Ciprofloxacin ER........... 21 Clindagel.............. 60 Clinimix E 5%/ Dextrose 25%.... 41 Clarithromycin......75%/ Colazal............................................................................................................................................................................................. 14 Clinimix 2......................................................... 39 Clemastine Fumarate....

......... 47 Colestipol HCl...... 24 Depo-Medrol.................. 17 Coreg.................................... 55.................................. 34 Depakote.................... 17 Cordran... 42 Depen Titratabs................................................................. 45 Cytarabine Aqueous.... 45 Cymbalta............................................................... 44 Depo-Testosterone....................... 29 Daraprim.... 13................ 53 Complera................. 36 Cyproheptadine HCl........... 29 Cyclosporine............ 56 Cryselle. 41 Cyclophosphamide..................................... 43 Decavac.. 48 Cortef...43.......... 38 Comvax........ 37 Danazol... 20 Coumadin......... 47 Cortisporin-TC... 57 Cytotec.............. 10 Condylox......................................................... 30 Copegus......... 53 Crestor............ 17 Coreg CR.... 16 Concerta......... 17 Cordran Tape...................................................... 13 Crinone.............................. 24 Desipramine HCl................................. 60 Corgard........................... 59 Desmopressin Acetate..................................... 28 Colistimethate Sodium....................... 45 Corzide........... 23 Dermotic........... 42 Dantrolene Sodium............................ 33 Daliresp................................... 48 Demadex.......... 57 Depakote Sprinkles....... 58 Cutivate.............................. 48 Delestrogen......... 57 Cosopt.......... 43 Cromolyn Sodium....... 13 Daytrana.................................. 47 Combivir.................................................... 48 Comtan... 60 Demeclocycline HCl..........................Colestid............... 23 Coly-Mycin M....... 51 Depakene............................................................................................................................................................................... 40 Cyclobenzaprine HCl ER................. 49 Daptacel. 56 Dacogen................. 39 Covera-HS................................................. 49 Cortisporin......................................... 47 67 ..................................................................................................... 24 Combigan........ 60 Demerol.................................................................................................................................................................................................................. 53 Coly-Mycin S........ 26 Cyclessa... 40 Combivent......................... 35 Dantrium.......... 36 Cystadane.................................................. 40 Cozaar........... 49 Cortisone Acetate......................... 53 Cyclobenzaprine HCl............. 57 Crixivan........................... 36 Cyclosporine Modified.............. 23 Demser.. 24 Dacarbazine............... 48 Daypro............... 50 Depo-SubQ Provera 104... 28 Cyclafem 1/35.. 19 Depakote ER.................................................................................... 13 Creon..................................... 59........................................................... 45 Cortifoam......................................... 39 Dapsone.............................................................................. 57 Cytovene.................. 45 Cytomel.... 38 Copaxone..................... 27 Cyclafem 7/7/7....................................... 47 Compro.......................................... 8 Combipatch............................ 51 Depacon. 59 Daunorubicin HCl....................................................................................................... 48 Delatestryl................................................. 37 D Dermatop....................... 31 Denavir............................. 45 Cosmegen.......... 17 Cordarone................... 29 Cuvposa...... 45 Cyklokapron................. 24 Depo-Provera...... 48 Cubicin.............................................................................................. 28 Derma-Smoothe/FS............................ 26 Colyte-Flavor Packs......................... 36 Cystagon.............. 41 Cycloset........................................................................................... 42 Depo-Estradiol............... 28 Colocort................................................ 45 DDAVP................... 45 Cytarabine.............................

.................................... 40 Dorzolamide HCl/ Timolol Maleate.... 41 Dextrose 5%/NaCl 0....... 38 Dolophine HCl...... 32 Dilt-XR.... 16 Doxycycline Hyclate................ 17 Didronel...... 60 Diltiazem HCl... 43 Desowen............. 24 Doxorubicin HCl......... 29 Divalproex Sodium..... 44 Dexmethylphenidate HCl.. 53 Desonate... 45 Dexrazoxane...........................................................2%... 40 Dexilant....................33%....................................... 17 Doxycycline Monohydrate..................................... 32 Dilaudid-5.... 32 Dilaudid-HP..... 8 Disulfiram..... 45 Desoxyn................... 9 Digoxin............. 15 Divigel....Desogen............................................ 18 Dorzolamide HCl...................... 16 Dilantin Infatabs........................................................................................................................................................ 9 Dihydroergotamine Mesylate............ 37 Dextrose 10%/NaCl 0..................................5%/ Sodium Chloride 0.................................................. 10 Dovonex Scalp........................ 30 Diphenoxylate/Atropine........................ 43 Diuril IV.................................... 45 Diazepam Intensol............. 10 Dextrose 5%/NaCl 0................................... 8 Ditropan XL.................................. 32 Diovan HCT.................. 55 Disopyramide Phosphate.............. 40 Dexpak 13 Day............................................................. 32 Dilt-CD............................. 44 Diclofenac Sodium..............................22 Dextrose 2..... 32 Diovan....... 39 Dexamethasone Sodium Phosphate....... 56 Dextrose 5%/NaCl 0.. 19 Doribax.................... 36 Detrol LA.......................................................... 40 Didanosine...9%.......... 32 Dilaudid......... 8 Dipyridamole................................................ 37 Diltiazem HCl ER.................................. 45 Docefrez.....................................45%..................................... 35 Dextrose 10%/NaCl 0............... 39 Dexedrine....................................................45%......... 41 Divalproex Sodium ER......................................... 32 Diltiazem CD.... 31 Dipentum............................................................. 45 Desoximetasone..... 45 Dicloxacillin Sodium....... 24 Diflunisal........ 37 Dextrose 5%........... 8 Dolophine.......................................... 54 Divalproex Sodium DR. 17 Dificid...........................................17...2%............. 10 Dovonex.. 45 Dibenzyline... 24 Doxycycline....... 55 Dicyclomine HCl.................................................... 32 Dilacor XR...................................... 48 Diflorasone Diacetate......... 57 Desonide...... 35 68 Doxazosin Mesylate.... 37 Dextrose 5%/Potassium Chloride 0............................................ 20 Dexamethasone................... 32 Dilantin................ 48 Diabeta.................................225%....... 17 Dronabinol........ 45 Diamox.... 44 Doxepin HCl........ 15 Diuril................ 40 Dextroamphetamine Sulfate ER............. 24 Diflucan... 45...............................15%...... 45 Diazepam................................... 41 Dextrose 5%/NaCl 0......................................................... 20 Doxil.....45%.................................. 40 Diclofenac Potassium.......... 56 Dextrose 5%/ Lactated Ringers... 60 Donepezil HCl...... 37 Dextrose 5%/NaCl 0........... 35 Diprolene AF............. 24 Dextroamphetamine Sulfate............................................. 21 ............................................. 18 Doryx................................ 15 Dilatrate SR............. 17 Differin........................................................................ 45 Diclofenac Sodium ER....... 44 Dexamethasone Intensol.......... 37 Dextrose 10% Flex Container.. 30 Diprolene.... 56 Diphenhydramine HCl................. 44 Diclofenac Sodium DR............................................................. 21 Docetaxel.................. 34 Detrol........................

. 10 E................. 37 Emla. 49 Eplerenone.............................................................. 26 Dyazide....S..... 35 Enalapril Maleate/ Hydrochlorothiazide...................... 18 Dynacin.................................................................. 28 Endodan................. 24 Elixophyllin................................................................................. 57 Elmiron................................................................. 48 Estradiol....................... 400.............................................................................................................................. 15 Endometrin................................................................ 45 Eprosartan Mesylate........E............ 55 Erbitux.....S. 24 Epogen. 16 Erythrocin Stearate....... 21 Eryped................................ 53 Effexor XR................ 15 Engerix-B. 48 Estradiol/Norethindrone Acetate.......................................................... 48 Estropipate.. 48 Estrostep Fe................................................................................ 42 Enulose................ 21 Dynacirc CR................ 38 Enbrel............................................. 45 Epzicom..... 48 Epinephrine HCl........ 59 Endocet.................................................... 21 Durezol................. 29 Econazole Nitrate. 41 Elestat.................................................... 23 .......................................................... 27 Epiduo..... 48 Effient........................................... 49 EC-Naprosyn..................... 16 Erythromycin/ Benzoyl Peroxide....................... 29 Duragesic.. 19 Estazolam.................... 53 Elaprase................................................................................................... 60 Epitol... 48 Estring.............................................. 24 Equetro................E......................................... 58 Epivir HBV.............................. 17 Emend................... 35 Enalapril Maleate........................................................ 21 Enablex................ 47 Entocort EC..... 39 Emcyt.......... 50 Epirubicin HCl. 9 Eloxatin.............. 16 Erythromycin............................. 41 Enpresse........ 8 Ellence....................................................................... 48 Estradiol Valerate........... 29 Duetact................. 58 Elocon...................................................................... 34 Enoxaparin Sodium......... 39 Emoquette....................... 43 Eldepryl............................ 15 Ery-Tab................... 55 Elestrin................Droxia................................................................ 33 Efudex.................................................................... 39 Duexis.............................................................................................................................. 49 E.......................................... 19 Enjuvia.. 55 Epinastine HCl........................................................... 18 Duramorph........ 48 Ethambutol HCl........................................ 23 Ergoloid Mesylates............ 58 Eligard.................................................................................... 19 Errin. 15 E Edarbi........................... 44 Ery... 24 Emsam........................................................ 10 Edurant............................. 34 Dulera................................ 24 Eraxis..................... 55 Emadine........................................................................................................... 48 Egrifta......................................... 51 Edluar.... 16 Erythromycin Base... 41 Epipen............................ 24 Epivir.................... 9 Elspar........... 12 Ergotamine Tartrate/ Caffeine.... 22 Dyrenium... 41 Erythromycin Ethylsuccinate........................................ 8 Emtriva......... 30 Estrace........ 35 Duoneb.................... 35 Edecrin.................................... 18 Elitek........ 31 Ella.................16 Escitalopram Oxalate...... 15 Erythrocin Lactobionate.................................................................................................. 48 Erivedge.. 29 69 Ertaczo...................... 58 Elidel............................... 24 Eliphos..................... 35 Edarbyclor............................. Granules.......................................................................................................

..................................... 36 Focalin XR......... 41 Flutamide............... 25 Exforge.... 27 Fibricor........... 55 FML Liquifilm.............................................................................. 54 Fluvastatin............................................. 43 Famvir...................... 19 Ferriprox........................ 21 Exelon......................................... 13 FML............................. 39 Firmagon... 30 Famotidine.......................................................... 45 Foradil Aerolizer. 39 Fluocinolone Acetonide Body Oil... 27 Fanapt Titration Pack....................................... 26 Femring.............. 25 Etoposide................... 10 Fluticasone Propionate............. 8 Finasteride.......... 55 Flagyl ER... 8 Femara.................. 37 Exforge HCT. 19 Exemestane.......................... 30 Fanapt................................... 46 Exelderm...................... 25 Femhrt Low Dose...................... 57 Etidronate Disodium............... 48 Flunisolide................ 57 Firazyr.............. 46.................................. 46 Evoclin... 21 Etopophos.... 55 Flavoxate HCl....................................................... 23 Fazaclo........................ 42 Fentanyl Citrate Oral Transmucosal...... 40 Flecainide Acetate....................................................... 44 Focalin...................................................... 41 Fenofibrate Micronized..... 21 Etodolac ER..................................... 38 Fluconazole.............. 57 Ethyol....... 39 Fluocinonide........ 51 Fiorinal/Codeine..................... 37 Exjade........................................................ 54 Flonase.. 41 Fenoglide..................................... 48 Flucytosine.................. 19 Flagyl... 44 Fomepizole...... 10 Fluoxetine DR....................................................... 43 Famotidine Premixed....................................Ethosuximide............................................................ 48 Fludarabine Phosphate........................................................... 57 Fondaparinux Sodium...... 42 Fluorouracil........................ 17 Felbatol................................................................................... 52 Extina.................................................................. 50 Fenofibrate...................... 27 Fexmid.................................................................................................. 8 Fluocinonide-E...................................................................................... 8 Folotyn........ 50 Fluvoxamine Maleate............. 18 Fentanyl................................... 57 Evista.................... 45 Eurax.............. 25 Fluconazole in Dextrose.............. 16 Famciclovir..................................................... 54 Felodipine ER................... 13 FML Forte.................. 9 Fenoprofen Calcium.............. 27 Fareston... 60 Fluphenazine HCl............................ 8 Femcon Fe............................................. 24 Feldene........... 59 Finacea................................ 55 Fioricet/Codeine................. 39 Evoxac...................................... 48 Fluocinolone Acetonide......................... 57 Evamist.......................... 18 Flovent Diskus......................................................................................................................... 42 Factive.... 19 Fentora............................................................. 33 Flo-Pred............................................................................. 46 Exalgo................................................................... 28 Felbamate............... 10 Fluoxetine HCl.......... 44 Flurbiprofen Sodium............ 21 Etodolac........................ 23 Faslodex.......... 42 Flurbiprofen..... 46........................ 48 Fludrocortisone Acetate.................. 39 Flurazepam HCl.............. 25 Femhrt 1/5................................................................... 9 Fluoroplex......... 24 Flomax............................................................................................. 21 F Fabrazyme... 58 70 .................................................................................... 60 Extavia..... 55 Flarex...................... 54 Fluphenazine Decanoate.... 24.............................................. 40 Flector..... 8 Flovent HFA.. 48 Femtrace............

........................................................................ 12 Fosrenol................... 54 Gablofen.............................. 32 Gabitril.................... 52 Glucotrol XL................... 35 Genotropin Miniquick.................................... 27 Haloperidol Lactate............ 28 Glyburide....................... 21 Fosamax........ 47 Gemcitabine HCl......... 33 Heparin Sodium/ NaCl 0........................................... 54 Gemfibrozil................................................................................... 31 G H Halaven........................................ 24 Gralise Starter...... 22 Gleevec.................... 38 Glipizide............................................. 61 Hepatasol........................ 21 Fosamax Plus D................................. 31 Galantamine Hydrobromide........................................................... 31 Hepsera....... 54 Glycopyrrolate........................................................................Fortamet........................................................................................ 43 Forteo........ 43 Glyset.... 23 71 Herceptin................... 31 Furosemide.................................. 39 Granisetron HCl................... 31 Hectorol.............. 12 Hydrochlorothiazide..... 47 Gris-Peg......19 Glucotrol............................................... 31 Fuzeon............................... 31 Hexalen.......................... 33 Gammagard Liquid............ 8 Fortesta... 43 Golytely................ 31 Fusilev........ 31 Fortaz........................ 47 Guanfacine HCl............................................ 52 Glucovance........................ 31 Gavilyte-G....................................... 33 Gianvi..................... 43 Gavilyte-C............. 33 Gamunex-C................ 46 Halog.................................................. 44 Gralise....................... 54 Gelnique................... 46 Haloperidol................ 43 Halobetasol Propionate.. 18 Gentamicin Sulfate/NaCl............... 28 Glucophage XR....................................... 13 Glimepiride...................................................... 25 Halcion.......9% Premix..................... 13 ..................................... 48 Freamine III...... 27 Haloperidol Decanoate.................................. 21 Foscarnet Sodium........ 33 Hepatamine......... 12 Fosphenytoin Sodium......... 25 Furadantin. 59 Frova......................................... 31 Gastrocrom..................................................................... 43 Heparin Sodium/D5W...................... 27 Halflytely Bowel Prep/ Flavor Packs.. 35 Gentamicin Sulfate........................................... 54 Gemzar....................... 61 Glassia.............................. 52 Glumetza....................................................... 29 Gauze Pads................................ 27 Haldol Decanoate............................................................................ 32 Havrix............... 27 Glucagen Hypokit.......................................................................................... 31 Heparin Sodium/NaCl.. 14 Gavilyte-N/Flavor Pack................. 43 Glynase.................. 24 Granisol......... 17 Glucagon Emergency Kit....................................... 53 Glyburide/Metformin HCl................ 51 Griseofulvin Microsize................. 27 Fragmin. 31 Gammaplex........ 28 Genotropin.............................................. 25 Glipizide ER.................................................................. 21 Fosinopril Sodium......... 26 Hiprex........................... 8 Fortical.................................... 53 Gabapentin..... 61 Gardasil................................................................................... 31 Helidac....................... 31 Heparin Sodium............................... 41 Freamine III 3%....... 59 Haldol......................................... 35 Fosinopril Sodium/ Gentak.................................... 54 Gengraf............ 29 Glipizide/Metformin HCl.... 17 Glucophage................................. 61 Gilenya......................... 31 Ganciclovir.................................... 45 Geodon.. 43 Glyburide Micronized.........................

............................. 27 Idarubicin HCl.............. 8 Isoniazid........ 25 Hycet....... 27 Idamycin PFS.................................................................................................. 40 Inspra......... 17 Imipramine HCl................................ 61 Indomethacin ER................... 25 Invirase.......................... 57 Hyzaar................................................................................ 58 Humalog......... 56 Humatrope...... 11 Hydrocortisone................Hizentra............ 26 Hydroxyurea........................................... 24 Hydroxyzine HCl.... 20 Ipratropium Bromide................................................................................ 24 Hydrochlorothiazide.... 33 Humulin Pen.............. 29 Isordil Titradose....... 54 Imitrex.......................... 35 Imitrex Statdose Refill..... 40 Intelence........ 37 Isosorbide Dinitrate ER............... 25 Jalyn................................ 29 Ifex.............................................................................. 51 Humira Starter Kit.................................................. 31 ... 23 Ionosol-B/Dextrose 5%.... Needles......... 61 Indomethacin...................... 47 Humira.......................... 23 Ionosol-MB/Dextrose 5%........... 40 Hydrea.................................... 15 Ibuprofen...................... 40 Ixiaro........... 40 Insulin Syringes.. 40 Inlyta..................................................................... 23 Infanrix...... 12 Intermezzo............................................ 57 Hydrocortisone Valerate..... 39 Hydrocodone/ Acetaminophen..................................................................... 8 Invega.......................................... 44 Jantoven........................................... 30 Istodax.............................. 53 Hydrocortisone/Acetic Acid..... 53 Invanz............... 39 Isosorbide Mononitrate................................. 11 Hydrocodone/Ibuprofen....................... 37 Isolyte-P/Dextrose 5%........................................... 10 Hydralazine HCl............ 58 Imiquimod........................................................ 29 Isentress................................. 54 Isosorbide Mononitrate ER... 46 Hydromorphone HCl................................................................... 33 Imipramine Pamoate................................... 25 Isosorbide Dinitrate.................... 57 Hydroxyzine Pamoate.............................. 52 Imipenem/Cilastatin....... 61 Indapamide..................................... 39 Isolyte-M/Dextrose 5%................ 21 Introvale......... 48 Ixempra Kit...................... 61 Indocin........ 33 Janumet........................ 31 Januvia................................................................... 8 Isolyte-S............ 25 Intuniv....... 33 Ibandronate Sodium... 32 Ifosfamide.................................................... 56 Intron-A............................. 59 Isradipine.............................................. 25 Incivek................. 54 Istalol.. 15 IPOL.... 25 Invega Sustenna........................... 61 Inderal LA........................................................... 40 Innopran XL.................................................. 28 Isotonic Gentamicin...................... 52 Iopidine............................................. 8 Isolyte-S/Dextrose 5%................................................................................. 25 Intron-A W/Diluent... 20 Ipratropium Bromide/ Albuterol Sulfate............ 51 Humulin........................................................................ 11 Hydroxychloroquine Sulfate........................ 22 Irbesartan/ Hydrochlorothiazide............................ 46......... 31 Janumet XR........... 51 Irinotecan................. 56 Infergen................... 22 Irbesartan.................................................. 53 Horizant................................... 53 Isopto Carpine. 42 Humalog Kwikpen...... 32 Ilaris............. 33 Hycamtin......... 38 Intralipid......................... 35 I 72 J Jakafi...................................... 29 Increlex........ 35 Imuran....................... 30 Itraconazole....... 47 Isolyte-H/Dextrose 5%..

............. 61 Levaquin..... 37 KCl 0..................... 38 Ketoprofen ER....................15%/D5W/ Levetiracetam.. 16 KCl 0........... 18 Keppra.................... 54 Levatol............................ 52 Junel Fe....................................... 60 Laclotion.................... 9 Levothroid....... 19 Lexiva......... 48 Klor-Con 10......................................... 48 Lamivudine..................................................................................... 58 KCl 0.......... 51 Kayexalate................................... 40 Labetalol HCl....... 16 Levora.............................................. 48 LAC-Hydrin........ 17 NaCl 0.225%........32 Lactated Ringers Irrigation......... 32 Lactulose...................................... 29 Lialda............ 39 Juvisync........ 31 Letairis............. 22 Kelnor.................... 48 Levorphanol Tartrate..........................................................15%/D5W/NaCl 0.......................................32 Lamictal................ 60 Latuda..................................... 33 Ketoprofen...................................................................................................................... 48 Klaron........... 32 Lactated Ringers.............. 56 KCl 0.......................... 25 Kanamycin Sulfate.................................... 34 Kariva........................................................... 31 Klor-Con M15..........................Jentadueto........................................... 23 Kapvay............................. 29 K-Tabs......................................... 9 Kombiglyze XR..................... 41 Lamotrigine....................................................................................................... 33 KCl 0... 18 Levobunolol HCl.. 17 Lanoxin....................................................... 49 Klonopin........................................................................................................................................................ 17 Leena....................................... 31 Kineret.............9%..... 9. 59 Kaletra............................... 42 Leucovorin Calcium....3%/D5W/NaCl 0. 44 Ketek................... 61 Lessina.................15%/D5W/LR........................... 61 Letrozole........ 42 Leuprolide Acetate...................................... 8 Lastacaft..... 51 Latanoprost........ 50 Lexapro...................... 39 K Klor-Con M20........................................................ 38 Keppra XR................8.............2%.......................................15%/D5W/NaCl 0......... 55 Ketorolac Tromethamine...... 27 Jinteli................... 33 Ketoconazole......45%.......................................................................... 17 Lansoprazole..... 50 Levoxyl...... 46 Lamivudine/Zidovudine.......................... 32 Lamictal Chewable Dispersible........... 11 Jolivette............ 55 Levocarnitine........................................ 17 Levetiracetam ER. 37 Leukine........................... 33 KCl 0............ 29 Kenalog.. 32 Lamictal XR............ 29 Kepivance............. 16 Lantus.... 18 Levemir Flexpen.........9%.................... 54 73 Levocetirizine Dihydrochloride...............075%/D5W/ Lamictal Starter Kit.................................................................. 59 Kuvan.... 61 Lescol XL... 12 L Leukeran.. 48 Kadian.................... 48 Klor-Con 8........................ 57 Levofloxacin................................ 14 Lamisil........................................... 53 ........... 18 Keflex....................................................... 50 Levothyroxine Sodium......... 42 Lazanda............ 22 Lantus Solostar....... 8 Lasix....................................................................................................3%/D5W/NaCl 0............... 18 NaCl 0....................... 56 Jevtana.........45%............................................ 16 Levofloxacin in D5W....... 42 Levalbuterol...... 32 Lamictal ODT............................... 18 KCl 0.............. 48 Junel. 43 Levemir...................................... 25 Kalydeco.......... 25 Kionex........................... 61 Leflunomide..... 61 Lescol....................................................................................................................

.................... . 19 LoSeasonique......................... 19 Lotensin HCT......................................... 35 Lotronex.............. 27 Maxitrol......................... 28 Maprotiline HCl................. 51 Medroxyprogesterone Lo Loestrin Fe................ 37 Lysodren.... 54 Matulane........................................................................... ................................... 31 Lovenox........................................ 26 Losartan Potassium/ Malathion................... 19 Mefloquine HCl............................................... 38 Lotrisone.................................................................................................................... 43 Luvox CR............... 46 Lupron Depot................ 48 Liothyronine Sodium................................................. 43 Maxair Autohaler........................................................................................ ....................................... 43 Lutera......................... 37 Lyrica............................................................ 48 Lumizyme.......... 58 Lithium Carbonate....... 35 Matzim LA...................... 13 Lidocaine Viscous....... 30 Macrobid....................... 56 Meclofenamate Sodium.... 49 Mefenamic Acid..... 22 M Lidocaine HCl.............. 26 Hydrochlorothiazide... 55 Lipitor.............. 12 Lorcet................................................................... 31 Lovastatin....... 51 Acetate... 22 Lisinopril/ Mavik.. 17 Megestrol Acetate........................................ 38 Lisinopril......................................................... 22 Lithium Carbonate ER........ 50 Marinol................ 39 Marplan............................................................................................................ 26 Luxiq........................................................................................................................................... 27 Lumigan.............................................................. 11 Lidoderm...................... 33..................................................... 48 Lupron Depot-PED........................................................ 21 Lotemax................... 40 Maxalt-MLT...................................... 31 Low-Ogestrel.....Lidocaine.................. 35 Malarone................ 49 Lotensin.. 49 Lopressor HCT. 30 Macrodantin.. 11 Livalo.... 35 Lioresal Intrathecal....................... 49 Megace Oral.... 39 Locoid Lipocream............................. 55 Lithobid........................................................... 48 Maxidone....... 59 Medrol Dosepak........................................... 11 Magnacet.... 34 Maxidex......... 46 Lufyllin...... 35 Hydrochlorothiazide.............................................................................. 12 Lorazepam................... 49 Lopressor.......... 39 Lunesta..................................... 27 Maxzide............. 46 Lofibra........ 35 Liposyn III......... 23 74 ........... 39 Marlissa........................ 23 Lithium Citrate............... 61 Lincocin............ 23 Lotrel..... 55 Locoid................. 58 Meclizine HCl..... 9 Loestrin Fe.......................................... 49 Lomotil........ ................................................ 21 Lodosyn................................. 46 Lokara.................................................... 50 Meloxicam..................... 31 Lovaza.......................................... 9 Loprox............................................... 48 Loperamide HCl.................... 46 Loxitane................... 39 Maxalt............ 9 Lo/Ovral....................................... 11 Magnesium Sulfate... 12 Lortab...................... 42 Medrol......... 49 Lopid.............. 35 Lipofen......... 12 Lorazepam Intensol..... 13 Lidocaine/Prilocaine.......................... 46 Megace ES...................................................................................................................................................... 39 Loxapine Succinate....................... 12 Loprox Shampoo.. 26 Lindane. 22 Melphalan HCl.................................................................. 39 Lybrel............ 13 Losartan Potassium..................................

............. 13 Metronidazole.. 17 Misoprostol............................... 46 Microzide......................... 9 MetroCream.......................................................................... 35 Motofen....................... 40 MetroGel-Vaginal....... 40 Metoprolol/ Hydrochlorothiazide............................................ 36 Monurol....................................................... 13 Mobic................. 9 Methadose....................... 25 Metformin HCl..................................................................... 23 Metolazone............ 40 Merrem..................................................................................... 44 Monodox.... 49 Mentax.................... 60 Methotrexate................................. 23 Metoclopramide HCl....................................... 49 Menomune-A/C/Y/W-135..... 31 Metozolv ODT.. 39 Miconazole 3.......... 35 Methazolamide....... 26 Mercaptopurine............ 13 Monoket.... 49 Mexiletine HCl................................................................................................................................... 25 Metipranolol..................................................... 13 Moexipril HCl........................ 25 Metformin HCl ER.................................... 46 Metronidazole Vaginal......... 9 MetroGel............... 22 Migranal............... 54 Metronidazole in NaCl 0........ 53 Minipress............................ 37 Metaproterenol Sulfate............................... 35 Minitran............. 56 Mirapex....................... 46.............................................. 17 Mevacor....................................................... 22 Menveo........... 13 Miacalcin..... 40 Methylphenidate HCl.......................................................................... 19 Metadate ER.................................. 19 Metadate CD..... 39 Mononessa........... 37 Mitomycin. 9 Micardis... 53 Methyclothiazide................................. 58 Metoprolol Succinate ER.......... 35 Methylergonovine Maleate.......... 47 Methocarbamol........................................Menactra................................... 41 Methylprednisolone..... 40 Mirtazapine ODT.................. 43 M-M-R II......... 24 Meropenem.................................. 43 Minocycline HCl ER... 39 Mirtazapine.. 25 Methyldopa... 13 Modicon................ 54 Methylin............... 35 Morphine Sulfate ER.................................................................... 53 Meperidine HCl....................... 13 Mometasone Furoate................. 53 Methyldopa/ Hydrochlorothiazide......................... 51 Methitest............. 54 Morphine Sulfate.. 43 Mirapex ER..... 9 Micardis HCT.................................... 53 Methimazole..................................................................... 17 Methylprednisolone Dose Pack......................... 30 Mepron........ 22 Millipred....................................................... 51 Methotrexate Sodium................................ 15 Mesalamine............ 43 75 ........ 11 Meprobamate.... 27 Mestinon Timespan............. 39 Midodrine HCl................................................. 13 Moexipril/ Hydrochlorothiazide... 46 Minoxidil................. 35 Microgestin..................................................... 46 Minocycline HCl...................... 49 Methamphetamine HCl........................................... 52 Methscopolamine Bromide............................. 27 Mestinon...... 13 Methenamine Hippurate.......... 49 Menostar.................. 53 Methadone HCl..... 15 Methyldopate HCl.......... 40 Minocin............................................................... 40 Mesnex.. 25 Methylprednisolone Sodium Succinate........................ 56 Metrolotion............................. 31 Metoprolol Tartrate...................... 22 Menest................................................................... 37 Mitoxantrone HCl... 35 Microgestin Fe.......... 40 Methylphenidate HCl ER.............. 36 Methergine... 17 Mesna............. 35 Migergot.................................................... 46 Methylprednisolone Acetate...79%.................................

........................ 19 Namenda Titration Pak...................................... 22 Naglazyme..................... 38 Mycobutin............... 17 Nordette.. 61 Moxeza.................. 22 Nebupent..... 36 Nasonex.... 57 Nicotrol Inhaler............................V............................................................................ 13 Natacyn........................................ 38 Nipent........................................................................ 9 Nallpen/Dextrose............... 15 Naftin........................... 11 Neurontin.... 13 Myfortic............................................................................................................................................... 51 Mydriacyl.............. 12 Nitrolingual Pumpspray....... 12 Naprosyn.......... 49 Nifedipine ER....................................................................................................................................................... 23 Nateglinide................. 47 Nevirapine.................................. 61 Nizatidine................. 47 Nexavar. 23 Necon............ 50 Neupogen............ 52 Nimodipine............. 30 Bacitracin/Hydrocortisone.................................................. 9 Nadolol........... 55 Neomycin/Bacitracin/ Polymyxin............. 40 Neosporin............................. 40 Nephramine............................................................................................................. 9 Next Choice................. 57 Nicotrol NS..... 44 Norinyl............................................................ 25 Norethindrone Acetate. 34 Norco.............................. 43 Neulasta........... 13 Neomycin/Polymyxin/ Nitrofurantoin Monohydrate........ 55 Nitrofurantoin..... 20 Mupirocin... 13 Macrocrystalline............ 40 Neomycin Sulfate........................ 61 76 ..................... 13 Neomycin/Polymyxin/ Nitrofurantoin Gramicidin......................... 38 Mustargen..................................................................................................... 34 Nardil........... 34 Nizoral.............. 49 Nevanac...................................... 50 Moxatag........................... 57 Nitroglycerin.......... 22 Nifediac CC................................... 11 Nalfon................................. 20 Multaq.............. 29 Norditropin Nordiflex Pen................ 19 Naprelan..... 34 Nora-BE.......................................... 17 Nisoldipine................ 38 Neomycin/Polymyxin B Mytelase............................................. 31 Nifedical XL......... 20 Naltrexone HCl.................................................... 9.................... 15 Naproxen Sodium......................................................... 23 Sulfates.................................. 52 Nitromist......... 37 Nafcillin Sodium...............................................................................55...... 38 N Nabumetone.. 20 Namenda............13 Hydrocortisone.................. 26 Nifedipine............................ 40 Neoral................................................................................... 24 Neomycin/Polymyxin/ Myozyme........ 23 Niaspan...... 12 Nisoldipine ER........... 10 Nasacort AQ................................................................ 55 Norditropin Flexpro... 19 Nilandron.............. 42 Niravam............. 19 Nicardipine HCl.................. 42 Nalbuphine HCl...... 37 Nadolol/ Bendroflumethiazide..... 40 Mozobil............. 38 Mycophenolate Mofetil...... 43 Naproxen DR......... 40 Neomycin/Polymyxin/ Dexamethasone.................. 52 Nefazodone HCl........................ 50 Nexium.................. 38 MS Contin................... 22 Neumega.....55 Mysoline.... 9 Niacor........... 9 Naproxen................. 9 Nitro-Bid................................................................................................................................................. 13 Nitrostat.................................. 38 Mycamine................................................................................ 49 Nexium I............MoviPrep............................................... 15 Naloxone HCl........... 44 Normosol-M in D5W................................ 16 Naratriptan HCl...........................

....... 9 Orfadin.................................................. 19 Ortho-Novum 7/7/7................................................................................. 49 Omnipred............ 22 Opana ER............. .......................... ...................... 31 Onsolis............................ 16 Olanzapine ODT........................ 44 Nortrel................... 55 Norvasc......... 47 Norvir...................... 56 Nulytely/Flavor Packs.......................................... 20 Ovcon-50 28........ 27 Ortho Evra................................... 49 Ortho-Cyclen..... 41 Oxistat........................ 61 Ogestrel................................................ 46 Nyamyc............. 60 Oxytrol............................... .... 60 Ocella................. 52 Oxsoralen.. 60 Oxymorphone HCl ER........... 44 Orap... ....................... 60 Ocufen........................ 20 Omeprazole...................................... 22 Oxycodone HCl................................. 10 Orphenadrine/Aspirin/ Nystop..................................................... 49 Oxycodone/Acetaminophen....... 47 Oxybutynin Chloride ER............... 11 Orapred.. 21 Novolog......................... 22 Oxycontin............. 51 Orphenadrine Compound DS......... 26 Omnitrope...... 22 Oxazepam..... ..................................................................... 10 Oxecta.............. 16 Orsythia....................................................... 25 Nucynta ER................................................. 10 O Orphenadrine Citrate......................................... 46 Ortho Tri-Cyclen.................................................................. 42 Nystatin/Triamcinolone...................... 11 Nucynta. 44 Ortho Tri-Cyclen Lo.......................................................... 55 P Ocuflox.................. 33 Oxaprozin........ 49 Orphenadrine Citrate ER...... 11 Orencia....................... 15 Ondansetron HCl.................... 11 Nuedexta....... 18 Ontak......... 27 Ortho Micronor.................... 44 Oxsoralen Ultra............................... 33 Oxandrolone...................................................... 50 Norpace.... 11 Caffeine. 52 Nystatin............. 46 Nuvigil. 31 Noxafil.............. 36 Olux-E.................................... ............. ............. ..... 49 Palgic........................... .......................... 36 Oleptro......................... 9 Onglyza................................................................................................ 49 Nor-QD................................................................. 16 Ortho-Cept............. 49 Ovcon-35............ 11 Opana...... 57 77 Pacerone............................. 49 Noroxin.... 43 Bicarbonate........ ............................................................................ 59 Oxycodone/Aspirin................ 27 Nuvaring......................... 42 Optipranolol................... 50 Omeprazole/Sodium OsmoPrep............. 25 Ondansetron ODT........... 42 Optivar........... 49 Norpramin.................. 49 Omnaris..................... 57 Nortriptyline HCl..................................................... 17 Nutropin AQ....... 32 Olanzapine...... 11 Orapred ODT..................................................................................... ......... 49 Norpace CR............................ 22 Oxycodone/Ibuprofen.................................................................................................. 21 Novolin..... 44 Oracea.......................... 44 Octreotide Acetate............. 49 Normosol-R in D5W............... 47 Oxybutynin Chloride.... 47 Onfi................................................................ 49 Paclitaxel.............. 11 Oxcarbazepine......... 29 Oxacillin Sodium...................................................... 25 Ofloxacin.......................Normosol-R............................... 38 Ovide....................................................................................................... ....................... 22 Oxymorphone HCl................................................................. 10 Nulojix... 36 ................ 33 Oxaliplatin.................... 17 Novolog Flexpen............................................................. 55 Nutropin.....

.......................................................... 15 Phoslyra........ 9 Plaquenil............. 15 Physiosol Irrigation........ 11 Plavix............................................................................................................................ 27 Paser............. 61 Phospholine Iodide.. 43 Pancreaze...................................................11 Piperacillin Sodium/ Tazobactam Sodium......... 49 Potassium Chloride................................ 57 Pexeva......................................... 55 Persantine.......... 15 Picato.224%/ Dextrose 5% Viaflex........................................................ 20 Pennsaid........ 18 Peganone......... 61 Potassium Chloride 0................... 60 Percocet.............. 13 Piroxicam................................22%/ D5W/NaCl 0......................................3%/ NaCl 0......................................15%/ D5W/NaCl 0................9%......................................... 61 Potiga......... 42 Pilocarpine HCl....... 41 Pamidronate Disodium................. 46 Pentostatin.. 26 Pentoxifylline ER... 61 Perforomist.. 11 Pandel.........Pamelor................................................................ 61 Potassium Chloride 0.................................... 19 Patanol............................................ 53 Phenytek........ 34 Parnate..... 18 Pegasys............ 26 Plasma-Lyte.............. 34 Permethrin..................... 44 Parlodel....... 36 Podofilox......................... 18 Pegasys Proclick.................... 23 Perphenazine/Amitriptyline......45% Viaflex........... 25 Penicillin V Potassium...45% Viaflex.................... 61 Potassium Chloride 0.................... 19 Phenadoz. 15 Paxil................................................... 19 Perphenazine........................... 58 Pletal........................... 61 Potassium Chloride 0.................................................................... 19 Perindopril Erbumine........ 30 Phenytoin Sodium....... 32 Potassium Chloride 0....................... 22 Phenobarbital. 30 Phenytoin Sodium Extended...18 Peg-Intron............ 13 Peg-Intron Redipen........................... 38 Pantoprazole Sodium............................................................ 61 Plasma-Lyte/D5W.................... 56 Penicillin G Potassium in Iso-Osmotic Dextrose..... 15 Physiolyte.... 19 Phenelzine Sulfate...........................15%/ D5W/NaCl 0..... 61 Potassium Chloride ER..9%.... 30 Phoslo. 19 PCE....................... 32 Potassium Chloride 0.................................. 26 Pilopine HS..... 13 Ponstel................................... 55 Pfizerpen-G.............................15%/ NaCl 0..... 54 Penicillin G Procaine................................ 42 Pentazocine/Acetaminophen..................................... 15 78 Polytrim.................................................... 26 Polymyxin B Sulfate........ 11 Parcopa............. 15 Pentazocine/Naloxone HCl.............. 56 Pamine........... 34 Patanase........................................................................................................................... 44 Pepcid........... 19 Paroxetine HCl ER....................... 41 Polyethylene Glycol 3350..................... 54 Penicillin G Sodium...45%................... 57 Paxil CR..... 18 Phenytoin................ 37 Pamine Forte.............................................. 20 Pataday.................................................... 54 Pentam 300................................. 32 Potassium Chloride 0.................................................. 43 Pentasa................................................................15%/ NaCl 0...... 57 Pedi-Dri........ 61 Potassium Chloride 0...................................................... 43 Parafon Forte DSC........ 27 Paroxetine HCl. 12 Periogard....3%/ D5W/Viaflex............................ 42 Paromomycin Sulfate..................................... 53 Pindolol.............. 30 Phisohex....... 17 Pedvax HIB.......33%...... 24 Panretin.............................. 17 Pradaxa............................ 61 Penicillin G Potassium................................................. 34 ...................... 9 Portia.......................................................................... 16 Phenergan............ 27 Percodan..............................

........................ 27 Prednisone...... 39 Prinzide................................................................. 46 Prochlorperazine Maleate.... 38 Prednisolone Sodium Prochlorperazine.................................................................. 55 Probenecid/Colchicine.................................................................... 57 ........ 49 Proctocream HC. 38 Prazosin HCl............ 44 Promethazine HCl......... 57 Previfem. 23 Q Qnasl.......................................... 17 Propranolol HCl ER................. 59 Premphase............................... 57 Prevalite................ 55 Primaquine Phosphate.............Pramipexole Dihydrochloride... 43 Prilosec.. 61 Promacta.................. 43 Pyridostigmine Bromide............... 35 Precose........................................................................................... 27 Quinapril HCl............. 54 Prenatal Vitamins. 37 Prandimet...................................... 59 Purinethol... 44 Proparacaine HCl........................................ 36 Propranolol/ Hydrochlorothiazide................. 22 Protonix..................................... 56 Prochlorperazine Edisylate................... 47 Proglycem....................... 46............. 44 Pred-G........ 32 Premarin....................................................................................... 57 Pulmozyme................ 36 Prezista................... 49 Questran..................... 58 Prosol................................................ 36 Quinapril/ Hydrochlorothiazide.................................................................................................................... 57 Qualaquin............................ 49 Prolia....................................................... 46 Procrit........................... 36 Quinidine Gluconate............. 19 Propylthiouracil.................................................................................. 20 Proventil HFA..P...... 34 Prefest............................. 46 Pregnyl W/Diluent Benzyl Progesterone... 36 Priftin.......................................... 36 QVAR. 55 Procainamide HCl................................ 31 Prednisolone Acetate................................ 36 Quinidine Sulfate.........O......................................... 44 Pred Forte........................ 44 Promethazine VC......................................................... 40 Promethegan..................................................... 37 Pravachol......... 57 Pulmicort Flexhaler................................... 61 Prolastin-C....... 19 Pulmicort.................. 27 Prednisone Intensol............................................ 31 Prinivil............................................. 26 Quasense.............................................................................................................. 40 Quetiapine Fumarate......... 36 Quinidine Gluconate ER....... 53 Privigen.............................................................................. 36 Pravastatin Sodium............. 51 ProQuad........................................ 36 Pred Mild. 59 Prozac......27 Primidone... 50 Prevpac...... 61 Probenecid................................................ 27 Phosphate.............................................. 13 Propafenone HCl........... 29 Propafenone HCl ER................................... 24 Pylera........................................................ 15 79 Protriptyline HCl.................... 49 Prometrium............................................. 23 Propantheline Bromide............................ 57 Prevacid Solutab......................................... 50 Alcohol/NaCl..... 42 Pred-G S......... 19 Prozac Weekly...... 50 Provigil........... 37 Primaxin.......................... 61 Prednicarbate... 52 Premasol.. 13 Prandin........................ 55 Procalamine............................. 52 Proscar.................. 34 Prevacid. 55 Proair HFA................................. 49 Prograf................................................ 46 Procardia............. 36 Quinidine Sulfate ER.................. 26 Propranolol HCl......................... 39 Pristiq......................................... 22 Protopic..... 58 Provera.................... 55 Procardia XL. 31 Primsol.... 49 Proleukin.................................... 25 Prempro..............

............................................................ 59 Robinul................................................................................................ 52 Rhinocort Aqua.... 27 Rapaflo...................................................... 27 Requip XL.................................... 53 Ridaura.................................................................................... 44 Rimantadine HCl..................... 23 Regranex. 30 Ryzolt. 23 Safyral........................ 37 Rivastigmine Tartrate.. 17 Rifadin.................. 52 Sabril............ 28 Santyl......................... 35 Restasis...................... 26 Sectral...................................................................................................................................................... 31 Sandostatin....... 54 Sandimmune.................................................................................. 60 Rilutek.......... 14 Ranitidine HCl.... 55 Rifamate...................................... 43 Ramipril............................... 42 Rocaltrol.............................. 11 Razadyne ER. 20 RotaTeq...................................................... 41 Ritalin......................................... 51 Risperdal Consta...................... 29 Sanctura XR.............................................. 51 Risperdal....................... 19 80 ............. 19 Remicade. 49 Ritalin SR................................................. 53 Razadyne............. 42 Risperdal M-Tab.................................... 41 Seasonale................... 29 Reserpine... 47 Rifampin................................... 36 Reclast........................................... 27 Rapamune............. 52 Remodulin................................... 28 Saphris......... 23 Saizen................................................... 54 Ribasphere................................................................................................... 41 Rifater............................................................................. 53 Retin-A............................................... 59 Rebif....................................................... 42 Robinul Forte..... 19 Remeron Soltab. 29 Rocephin................................................................. 43 Rabavert....................................................... 40 Reglan.............................................................. 29 Relistor... 30 Rheumatrex.................................................................. 23 Samsca...... 49 Rectiv...................... 36 Rebif Titration Pack................................... 44 Revatio..... 23 Remeron.................... 43 Regonol..................................... 57 Rythmol......... 23 Salagen....... 27 Rescriptor............... 43 Relpax.. 38 Retrovir. 11 Rebetol.. 28 Risperidone........ 27 Sandostatin LAR Depot.................................. 21 Ringers Irrigation.......................................... 19 Revlimid.................................................................................................................... 43 Retrovir IV Infusion............... 61 Sancuso. 19 Reyataz................................ 11 Requip........................................... 29 Roxicodone...................................... 29 Ropinirole ER...... 59 Renagel.. 30 S Recombivax HB.......... 36 Retin-A Micro................ 41 Savella Titration Pack............................ 44 Ringers Injection........................ 41 Ritalin LA............................................................................. 45 Renvela................................ 30 Rythmol SR........................ 52 Rozerem..... 41 Seasonique......................................... 41 Sanctura...... 10 Reclipsen........................................................................................................... 52 Revia............................................................. 52 Ribapak...................................................R Restoril................................................... 19 Risperidone ODT... 49 Rituxan........ 28 Savella.............. 54 Ranexa........................................... 19 Selegiline HCl.......................... 52 Riomet......... 23 Roxicet.............. 45 Reprexain........... 49 Ribavirin................................ 42 Relenza Diskhaler...... 28 Sarafem................................................................ 59 Ropinirole HCl......................................

............... 50 ..................................... 52 Sprintec.................. 27 SSD.................................................... 39 Sulfasalazine...........9%......... 49 Suprax............................ 57 Symbyax............................................................ 16 Sonata............ 39 Sulindac.................................................... 59 Serevent Diskus............. 23 Sorilux...................... 16 Solaraze..................... 17 Stelara... 36 Seroquel XR.................................................................................. 60 Stimate................................................. 28 Sorine.. 54 Starlix.................................................. 31 Skelid............................................................................ 12 Sodium Sulfacetamide.......................... 56 Seromycin..................................................................... 57 Somatuline Depot....................... 28 Sotalol HCl................................................. 20 Simvastatin................... 14 Simulect..................... 39 Sporanox Pulsepak.... 31 Sodium Chloride 0...........................................60 Streptomycin Sulfate..................... 38 Semprex-D................................................................ 25 Synalgos-DC.......................................... 47 Synera.............. 16 Sulfazine EC................................................. 22 Sumatriptan Succinate.............. 46 Sucralfate................................... 29 Symlinpen 120............................................................ 60 Suprep Bowel Prep....... 52 Sprix......................................................................... 13 Sylatron........ 20 Solu-Cortef...................................... 61 Viaflex............................................. 27 Sronyx.................................................. 11 Skelaxin......... 14 Sertraline HCl................................................. 42 81 Synthroid................ 58 Soriatane..............................Selenium Sulfide............................. 59 Silvadene............ 9 Surmontil.......... 51 Sulfacetamide Sodium......................................................................................................................... 44 Sutent.................................................................................................. 51 Sodium Lactate................................ 42 Sodium Chloride 0......... 42 Sulfacetamide Sodium/ Prednisolone Sodium Phosphate...... 31 Stavudine.................................. 13 Spironolactone....... 36 Serostim............ 25 Sinemet........ 23 Simcor......................................................... 42 Seroquel.. 11 Synarel........... 13 Sulfadiazine....... 42 Sensipar..... 16 Sulfamethoxazole/ Trimethoprim.... 29 Sinemet CR....................................... 53 Sodium Chloride...........45% Synagis..................... 61 Sterile Water Irrigation........... 27 Symbicort................... 26 Solodyn....................................... 53 sfRowasa......... 39 Sprycel............. 47 Syprine.......................................................................... 13 Silver Sulfadiazine......................................................... 53 Spironolactone/ Hydrochlorothiazide....................... 12 Strattera.... 44 Selzentry....................................................... 51 Septra DS... 16 Sulfamethoxazole/ Trimethoprim DS........ 60 Sular. 41 Synercid.... 60 Stalevo.............. 29 Soma...................................................................... 58 Sulfamylon.............................................. 31 Symlinpen 60.. 55 Stavzor.................................................................. 42 Striant................................... 19.. 47 Spectracef.......................... 42 Solu-Medrol................... 50 Somavert.................................................. 55 Sodium Fluoride................. 22 Simponi..................... 49 Sustiva....................................................................................... 58 Stagesic.... 17 Suboxone..................... 25 Singulair............. 16.... 13 Sodium Polystyrene Sulfonate.......................... 20 Spiriva Handihaler...... 60 Stromectol. 53 Silenor... 9 Sporanox........................................................... 46 Sucraid....

..................................... 17 Tizanidine HCl....... 19 Tobi..... 51 Sodium Chloride......................................................... 56 Tobradex ST................................. 44 Thiothixene.............................. 24 Testosterone Cypionate......................... 12 Travasol...........................................................37............................. 15 Tramadol HCl ER........................ 11 Tamiflu.... 42 Taztia XT.................................................................. 47 Tobrex............ 44 Tapazole....................................... 61 Thymoglobulin............................... 56 Trandolapril........................................ 50 Tranxene T....................... 37 Terazol........... 20 Taclonex.......... 36 Timoptic-XE..... 23 Tamsulosin HCl.... 32 Ticlopidine HCl............. 19 Tobramycin/Dexamethasone................ 36 Acetaminophen........ 27 TPN Electrolytes............ 25 Tasmar...... 18 Thalitone........................................................................................... 51 82 ........................ 42 Testred............................ 58....................................... 52 Tolbutamide.......................... 59 Tiazac.. 31 Tetanus/Diphtheria Toxoids-Adsorbed Adult................................... 35 Topicort........................................... 34 Tramadol HCl.......................... 37 Timoptic Ocudose................................................................... 56 Travatan Z.......................... 26 Taxotere..... 18 Tekamlo............... 27 Torsemide....................... 37 Tenormin............. 47 Tofranil...................... 38 Thiotepa......... 59 Temovate.......................................... 21 Tramadol HCl/ Tikosyn..................... 25 Theophylline ER................. 56 Tranexamic Acid.......... 25 Thalomid............................................................. 18 Teveten HCT...................................... 23 Toviaz................. 22 Terbutaline Sulfate............................... 38 Tekturna......... 12 Tabloid................................................... 10 Timolol Maleate.......... 14 Tegretol.................. 23 Tobramycin Sulfate/ Trelstar Depot......................... 26 Tarka............................................ 11 Tigan........ 25 Tazorac............................... 13 Torisel............................................. 22 Terazosin HCl................... 46 Tev-Tropin..56 Treanda.............. 47 Topiramate........................... 37 Thermazene....... 42 Testosterone Enanthate.. 56 Trandate................................................................................ 38 Tradjenta....................... 52 Thioridazine HCl............................ 35 Tenoretic............................................................... 47 Tofranil-PM................. 18 Tegretol-XR.... 25 Targretin.............................................. 51 Tarceva....................................... 20 Taclonex Scalp.... 61 Tobradex................................. 22 Teveten.......... 31 Tacrolimus... 38 Temazepam...... 56 Trazodone HCl..................................... 46 Tenex......... 35 Topamax Sprinkle............ 39 Toposar............................ 28 Tranylcypromine Sulfate.......................................................................................................... 23 Tobramycin Sulfate.............. 45 Terbinafine HCl.......... 38 Tekturna HCT.................. 38 Teflaro................................................ 12 Trelstar LA........................................................ 53 Tolmetin Sodium..... 12 Trecator........ 47 Tolazamide. 36 Tasigna................................................................................. 18 Talwin..........................T Testim...................... 59 Terconazole............................ 34 Tirosint...................................... 52 Tracleer................................................... 23 Topotecan HCl....................................................................... 58 Toprol XL........................................................................................................... 11 Timentin.................... 17 Topamax.. 29 Tamoxifen Citrate.................................. 9 Tetracycline HCl.............................................................................

........................... 20 Trinessa.............. 47 Trimethoprim....................................................................................... 13 Typhim Vi......................................................................................................................................................................................................... 38 Trusopt.......................................... 41 Triamterene/ Hydrochlorothiazide.......... 39 Triazolam............................... 11 Valturna..... 36 Ventolin HFA...... 38 Trophamine....................................................... 42 Unasyn........................... 18 Trilipix..................................46.. 46 Trifluoperazine HCl................. 13 Unasyn Bulk Pack.................................. 39 Triderm.................... 10 Velivet.................................. 51 Trospium Chloride......... 36 Uloric......... 42 Trizivir......................................................................... 21 Twinject.......... 15 Trimipramine Maleate........................................ 45 Verapamil HCl.......... 15 Trimethoprim Sulfate/ Polymyxin B Sulfate................... 26 Tri-Legest Fe. 20 Uniretic............................. 59 Tribenzor.................................. 49 Trileptal..................................... 43 Verdeso............................................................................. 30 Tretinoin... 38 Tri-Sprintec.... 36 Venlafaxine HCl........................... 57 Verapamil HCl ER............................................... 49 Truvada...... 38 Tricor................. 53 Vandazole.................................... 29 Valacyclovir HCl.................. 49 Ursodiol.... 44 Trental.... 27 Trifluridine.............. 13 Valproic Acid............. 42 Verelan............ 42 Ultram............. 56 Vagifem.... 52 Treximet................. 53 U-Cort........................................................... 59 Vaqta........ 44 Trimethobenzamide HCl................................. 59 Veramyst......................................................................... 38 Tropicamide... 46 Veltin........ 11 Vectical...... 11 Vancocin HCl............................................ 29 Uvadex.................... 49 Unithroid.......... 45 Trisenox.. 31 Twynsta......................................................................... 49 Urecholine................................. 28 Twinrix. 55 Veripred 20.......................... 59 Valcyte........................ 14 Tysabri....................... 26... 47 Veregen................. 61 Verelan PM............................................ 17 Tygacil............................................. 49 Ultravate.................... 49 Univasc..... 39 Trilyte......................................................................................................... 30 Tylenol/Codeine...................... 53 Valium..................... 14 Tyzeka...... 43 Trivora............................................................................ 38 Tylox.......... 26 Ultracet................................ 38 Valproate Sodium .... 25 Uroxatral............ 36 Ulesfia.. 20 Ventavis.. 22 Vectibix....................... 30 Trihexyphenidyl HCl................ 49 Urso................................V Trelstar Mixject...................................................................... 13 83 Venlafaxine HCl ER.. 53 U Varivax............. 17 Tykerb........................................................................................................................ 38 .................................................................. 25 Ultram ER............................................ 42 Trexall............................................................... 42 Tretin-X............................. 13....................... 46 Vaseretic............ 50 Tri-Norinyl..................................................... 30 Vanos............................................................. 59 Tri-Previfem........................... 26 Vasotec....................................................... 9 Triamcinolone Acetonide............... 53 Vancomycin HCl................... 11 Velcade........................................................................ 47 Tyzine................................ 57 Triamcinolone in Orabase............................................... 25 Valtrex........

................................................... 14 Zinacef in Iso-Osmotic Dextrose........ 49 Vfend......... 44 Xanax................................................................ 25 Vinorelbine Tartrate.................................................................................................. 14 Vivitrol.................. 59 Zetia............... 29 Xylocaine... 26 Vfend IV.............. 19 Xanax XR.................. 56 Zebeta.................. 20 Vivelle-Dot........... 11 Welchol................................................. 42..... 29 Viramune................... 22 Xalatan............... 42 Xyrem............ 20 84 .......................................................................... 30 Zeosa. 11 Zanaflex........................... 18 Vinblastine Sulfate............... 11 Zestril....................................................... 28 Vivactil........ 49 Zafirlukast. 53 Vibativ...................... 41 Zemplar................ 40 Vicoprofen.......................................................... 31 Zelapar......................................... 25 Vincristine Sulfate.. 17 Vyvanse........... 17 Westcort............................................................................ 58 Zinacef........... 30 Vistaril................................................ 25 Vincasar PFS........................... 42 Xerese................................................................. 40 Z Vicodin......................................................... 25 Yervoy.......... 42 X Zazole.......................Vesicare................................................. 54 Zerit....... 19 Zanosar............................................................................ 25 Zegerid........................................................................... 23 Zaleplon................................... 22 Votrient............. 19 Vidaza............................... 36 Xolair................. 58 Vistide......................................................... 19 Victrelis.................................. 47 Zavesca.............................................. 59 Zidovudine................ 56 Voriconazole...... 43 Zarontin.......................................................................................... 55 Zenpep................................................................... 59 Ziagen.............. 37 Xalkori......... 59 Xenazine.............................................................................................................................................. 9 Yasmin..................................................... 34 Vicodin HP......................................................... 58 Zantac.............................................. 11 W Vicodin ES.... 49 Vexol...................................... 36 Xodol. 29 Videx Pediatric............................................................ 42 YF-Vax.................. 12 Ziana.......................................................... 22 Vpriv............... 25 Viracept........................................... 20 Vimovo.. 29 Viramune XR........................ 32 Wellbutrin SR................................ 28 Wellbutrin....... 29 Vigamox................................................................ 29 Viroptic.. 29 Xifaxan..................................... 49 Xgeva............. 11 Zamicet....... 16 Viibryd................................................................ 31 Zelboraf....................................... 14 Zestoretic.......... 40 Xopenex...................... 59 Victoza............................... 34 Zemaira.................................................................... 29 Xyzal...................................................................... 25 Videx EC............. 25 Xarelto................................................ 30 Wellbutrin XL................ 54 Xeomin.......................................................................... 37 Xopenex HFA....................... 44 Voltaren............. 11 Warfarin Sodium........... 14 Vytorin................... 22 Yaz........................................................... 49 Voltaren-XR......................................... 56 Y Vestura.................................. 29 Viread............................................ 40 Vibramycin............ 59 Ziac.................. 44 Vimpat..................................................................................

23 Zonalon........ 49 Zovirax........ 59 Zolpidem Tartrate ER............................ 25 Zithromax Tri-Pak................ 23 Zomig ZMT........................................ 14 Zithromax Z-Pak................................. 59 Zometa.............................. 28 Zithromax... 42 Zydone........................................................................... 9 Zyprexa............... 42 Zonegran................................................................. 20 Zyclara....................................................... 54 Zomig............................................................................................................................................................ 53 Zosyn........ 17 Zonisamide.........Zinacef in Iso-Osmotic Zyflo........................ 17 Zorbtive.......................... 20 Zolpidem Tartrate................................................................... 47 Zortress.......................................................................................... 58 Diluent.................................................... 16 Zmax....................... 52 Zostavax....... 59 Zolpimist........................................................... 21 Zyban....................... 15 Zovia............. 28 Zymaxid........................................ 21 Zolinza...................................................................................... 28 Zirgan............... 21 Zofran ODT. 25 Zylet............. 30 Zuplenz............... 16 Zyvox................................. 56 Zyloprim......................................... 16 Zytiga................ 28 Zyprexa Zydis........................................ 58 Zinecard.............................................. 56 Zioptan.................... 25 Zoloft........................................................... 22 Ziprasidone HCl.................. 16 Zipsor............. 39 Zofran.... 14 Zyflo CR................................ 11 85 ...... 16 Zocor.....

Or visit www. pharmacy network. a Medicare Advantage organization with a Medicare contract. 2013. updated information. It was updated August 2012. Benefits. Beneficiaries must use network pharmacies to access their prescription drug benefit. 2014. formulary. Call Customer Service for complete. Please contact our Customer Service at the number located on the back of your ID card. Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates.UHCRetiree.This complete formulary (drug list) is effective January 1.  lease contact our Customer Service at the number located P on the back of your ID card.com This information is available for free in other languages. premium and/or copayments/coinsurance may change on January 1. Changes may have been made to this list after it was printed. UHEX13MP3398969_000 .

Sign up to vote on this title
UsefulNot useful