2016 Formulary List of Covered Drugs Premera Blue Cross Medicare Advantage (HMO) Premera Blue Cross Medicare Advantage Plus (HMO) Premera Blue Cross Medicare Advantage (HMO-POS) premera.com/ma Version 18 PLEASE READ: This document contains information about the drugs we cover in this plan. Customer Service Premera Blue Cross Medicare Advantage PO Box 4196, Portland, OR 97208-4196 Call toll free 888-850-8526 (TTY: 711). Representatives are available between 8 a.m. and 8 p.m., 7 days a week.
Premera Blue Cross Medicare Advantage (HMO), Premera Blue Cross Medicare Advantage Plus (HMO) and Premera Blue Cross Medicare Advantage (HMO-POS) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID: 00016004, Version: 18 This formulary was updated on 07/01/2016. We have made no changes to this formulary since 07/01/2016. For more recent information or other questions, please contact Premera Blue Cross Medicare Advantage Plans Customer Service at 888-850-8526 or, for TTY users, 711, seven days a week between 8 a.m. and 8 p.m., or visit premera.com/ma. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Premera Blue Cross. When it refers to plan or our plan, it means Premera Blue Cross Medicare Advantage Plans. This document includes a list of the drugs (formulary) for our plan which is current as of 07/2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. The Formulary may change at any time. You will receive notice when necessary. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. i
What is the Premera Blue Cross Medicare Advantage (HMO), Premera Blue Cross Medicare Advantage Plus (HMO) and Premera Blue Cross Medicare Advantage (HMO-POS) Formulary? A formulary is a list of covered drugs selected by Premera Blue Cross Medicare Advantage Plans 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. Premera Blue Cross Medicare Advantage Plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Premera Blue Cross Medicare Advantage Plans network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of July 1, 2016. To get updated information about the drugs covered by Premera Blue Cross Medicare Advantage Plans, please contact us. Our contact information appears on the front and back cover pages. If we make any mid-year non-maintenance changes to the Premera Blue Cross Medicare Advantage Plans formulary, we will mail you a copy of the formulary changes via errata sheets to ensure that you have a complete and updated formulary. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you ii
know what your drug is used for, look for the category name in the list that begins on page 116. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 95. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Premera Blue Cross Medicare Advantage Plans covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Premera Blue Cross Medicare Advantage Plans requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Premera Blue Cross Medicare Advantage Plans before you fill your prescriptions. If you don t get approval, Premera Blue Cross Medicare Advantage Plans may not cover the drug. Quantity Limits: For certain drugs, Premera Blue Cross Medicare Advantage Plans limits the amount of the drug that Premera Blue Cross Medicare Advantage Plans will cover. For example, Premera Blue Cross Medicare Advantage Plans provides 9 tablets/30 days per prescription for sumatriptan tablets. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Premera Blue Cross Medicare Advantage Plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Premera Blue Cross Medicare Advantage Plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Premera Blue Cross Medicare Advantage Plans will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. iii
You can ask Premera Blue Cross Medicare Advantage Plans to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to Premera Blue Cross Medicare Advantage Plans formulary? on page iv for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Premera Blue Cross Medicare Advantage Plans does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Premera Blue Cross Medicare Advantage Plans. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Premera Blue Cross Medicare Advantage Plans. You can ask Premera Blue Cross Medicare Advantage Plans to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to Premera Blue Cross Medicare Advantage (HMO), Premera Blue Cross Medicare Advantage Plus (HMO) and Premera Blue Cross Medicare Advantage (HMO-POS) s Formulary? You can ask Premera Blue Cross Medicare Advantage Plans to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Premera Blue Cross Medicare Advantage Plans limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Premera Blue Cross Medicare Advantage Plans will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting iv
your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 90-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 90-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 102-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Level of care change: For members transitioning from a SNF to LTC: SNF to Home (Retail): LTC- LTC: Hospital to Home (Retail): Day Supply 31 day supply 30 day supply 31 day supply 30 day supply For more information For more detailed information about your Premera Blue Cross Medicare Advantage Plans prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Premera Blue Cross Medicare Advantage Plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. v
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877 486-2048. Or, visit http://www.medicare.gov. Premera Blue Cross Medicare Advantage Plans Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Premera Blue Cross Medicare Advantage Plans. If you have trouble finding your drug in the list, turn to the Index that begins on page 95. The first column of the chart lists the drug name. name drugs are capitalized (e.g., JANUVIA ) and generic drugs are listed in lower-case italics (e.g., simvastatin). The second column of the chart lists the Drug Tier. The Drug Tier name lets you know the amount you will pay at the pharmacy. The information in the Requirements/Limits column tells you if Premera Blue Cross Medicare Advantage Plans has any special requirements for coverage of your drug. vi
Initial Coverage Level for a 30-Day Supply at a Pharmacy with Preferred Cost Sharing* Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6 Plans Preferred Generic Preferred Non- Injectable Specialty Generic Preferred ** ** Premera Blue Cross Medicare Advantage (HMO) Premera Blue Cross Medicare Advantage Plus (HMO) Premera Blue Cross Medicare Advantage (HMO-POS) $4.00 copayment $4.00 copayment $4.00 copayment $12.00 copayment $12.00 copayment $12.00 copayment $45.00 copayment $45.00 copayment $45.00 copayment $100.00 copayment $100.00 copayment $100.00 copayment 25% coinsurance 33% coinsurance 25% coinsurance 25% coinsurance 33% coinsurance 25% coinsurance *Table shows initial coverage level for a 30-day supply. Coverage level shown does not reflect deductibles, gap coverage, catastrophic benefit coverage, or mail order pharmacy cost shares. Please refer to your 2016 Summary of Benefits or Evidence of Coverage for details. **Tier 5 (Injectable) and Tier 6 (Specialty) drugs are limited to a maximum of 1-month (30 day) supply per prescription fill or refill. Initial Coverage Level for a 30-Day Supply at a Pharmacy with Standard Cost Sharing* Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6 Plans Preferred Generic Preferred Non- Injectable Specialty Generic Preferred ** ** Premera Blue Cross Medicare Advantage (HMO) Premera Blue Cross Medicare Advantage Plus (HMO) Premera Blue Cross Medicare Advantage (HMO-POS) $12.00 copayment $12.00 copayment $12.00 copayment $20.00 copayment $20.00 copayment $20.00 copayment $45.00 copayment $45.00 copayment $45.00 copayment $100.00 copayment $100.00 copayment $100.00 copayment 25% coinsurance 33% coinsurance 25% coinsurance 25% coinsurance 33% coinsurance 25% coinsurance *Table shows initial coverage level for a 30-day supply. Coverage level shown does not reflect deductibles, gap coverage, catastrophic benefit coverage, or mail order pharmacy cost shares. Please refer to your 2016 Summary of Benefits or Evidence of Coverage for details. **Tier 5 (Injectable) and Tier 6 (Specialty) drugs are limited to a maximum of 1-month (30 day) supply per prescription fill or refill. vii
The following abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA QL ST Prior Authorization Restriction Quantity Limit Restriction Step Therapy Restriction You (or your physician) are required to get prior authorization from Premera Blue Cross Medicare Advantage Plans before you fill your prescription for this drug. Without prior approval, Premera Blue Cross Medicare Advantage Plans may not cover this drug. Premera Blue Cross Medicare Advantage Plans limits the amount of this drug that is covered per prescription, or within a specific time frame. Before Premera Blue Cross Medicare Advantage Plans will provide coverage for this drug, you must first try another drug to treat your medical condition. This drug may only be covered if the other drug does not work for you. Other Special Requirements for Coverage LA Limited Access Drug This prescription is limited to certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Customer Service at 888-850-8526, daily between 8 a.m. and 8 p.m., seven days a week. TTY/TDD users should call 711. viii
Analgesics Analgesics alagesic lq PA FOR 65 YEARS AND OLDER butalbital/acetaminophen PA FOR 65 YEARS AND OLDER butalbital/acetaminophen/caffeine (50-300-40 capsule, 50-325-40 tablet, 50-325-40 capsule) butalbital/aspirin/caffeine 50-325-40 capsule PA FOR 65 YEARS AND OLDER PA FOR 65 YEARS AND OLDER capacet PA FOR 65 YEARS AND OLDER fioricet PA FOR 65 YEARS AND OLDER tencon 50-325 mg tablet PA FOR 65 YEARS AND OLDER vanatol lq PA FOR 65 YEARS AND OLDER Nonsteroidal Anti-inflammatory Drugs celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule) QL (2 PER 1 DAYS) celecoxib 400 mg capsule QL (1 PER 1 DAYS) diclofenac potassium diclofenac sodium (1 % gel (gram), 25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er 24h) diflunisal etodolac fenoprofen calcium 600 mg tablet flurbiprofen ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) ketoprofen 200 mg cap24h pel QL (1 PER 1 DAYS) ketoprofen 50 mg capsule QL (6 PER 1 DAYS) ketoprofen 75 mg capsule QL (4 PER 1 DAYS) 1
meclofenamate sodium meloxicam (7.5 mg tablet, 7.5 mg/5ml oral susp, 15 mg tablet) nabumetone naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg tablet) naproxen sodium (275 mg tablet, 550 mg tablet) piroxicam sulindac tolmetin sodium VOLTAREN Opioid Analgesics, Long-acting ASTRAMORPH-PF (1 MG/ML AMPUL, 1 MG/2 ML AMPULE) fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72, 50mcg/hr patch td72, 75mcg/hr patch td72, 100 mcg/hr patch td72) QL (15 PER 30 DAYS OVER TIME) fentanyl citrate PA, QL (4 PER 1 DAYS) levorphanol tartrate methadone hcl (5 mg/5 ml solution, 10 mg/5 ml solution) methadone hcl 10 mg tablet QL (4 PER 1 DAYS) methadone hcl 10 mg/ml vial methadone hcl 5 mg tablet QL (8 PER 1 DAYS) morphine sulfate (30 mg cap er pel, 30 mg tablet er) morphine sulfate (50 mg cap er pel, 60 mg cap er pel, 60 mg tablet er) morphine sulfate (80 mg cap er pel, 100 mg cap er pel, 100 mg tablet er) QL (4 PER 1 DAYS) QL (2 PER 1 DAYS) QL (1 PER 1 DAYS) 2
morphine sulfate 10 mg/5 ml solution morphine sulfate 15 mg tablet er QL (8 PER 1 DAYS) morphine sulfate 20 mg cap er pel QL (6 PER 1 DAYS) OXYCODONE HCL (10 MG TAB ER 12H, 15 MG TAB ER 12H, 20 MG TAB ER 12H, 30 MG TAB ER 12H, 40 MG TAB ER 12H, 60 MG TAB ER 12H) 3-Preferred QL (2 PER 1 DAYS) OXYCODONE HCL 80 MG TAB ER 12H 3-Preferred QL (4 PER 1 DAYS) OXYCONTIN (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40 MG TABLET, 60 MG TABLET) 3-Preferred QL (2 PER 1 DAYS) OXYCONTIN 80 MG TABLET 3-Preferred QL (4 PER 1 DAYS) tramadol hcl (100 mg tbmp 24hr, 100 mg tab er 24h, 200 mg tbmp 24hr, 200 mg tab er 24h, 300 mg tab er 24h, 300 mg tbmp 24hr) Opioid Analgesics, Short-acting acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg/12.5 solution, 300mg-30mg tablet, 300mg- 60mg tablet, 300mg-15mg tablet) QL (1 PER 1 DAYS) ascomp with codeine PA FOR 65 YEARS AND OLDER butalbit/acetamin/caff/codeine 50-325- 30 capsule butorphanol tartrate (1 mg/ml vial, 2 mg/ml vial) butorphanol tartrate 10 mg/ml spray codeine phosphate/butalbital/aspirin/caffeine endocet (2.5-325 mg tablet, 5-325 tablet, 7.5-325 mg tablet) PA FOR 65 YEARS AND OLDER PA FOR 65 YEARS AND OLDER endocet 10-325 mg tablet QL (8 PER 1 DAYS) endodan 3
hydrocodone bitartrate/acetaminophen (2.5-167/5 solution, 2.5-108/5 solution, 5 mg-325mg tablet, 5-217mg/10 solution, 7.5-325/15 solution, 7.5-325mg tablet, 10mg-325mg tablet) hydromorphone hcl (1 mg/ml liquid, 2 mg tablet) hydromorphone hcl 4 mg tablet QL (8 PER 1 DAYS) hydromorphone hcl 8 mg tablet QL (4 PER 1 DAYS) hydromorphone hcl/pf (10 mg/ml ampul, 10 mg/ml vial) LAZANDA lorcet lorcet hd lorcet plus 7.5-325 mg tablet lortab (5-325 mg tablet, 7.5-325 mg tablet, 10-325 mg tablet) morphine sulfate (2 mg/ml cartridge, 2 mg/ml syringe, 4 mg/ml syringe, 4 mg/ml cartridge) morphine sulfate 100 mg/5ml solution QL (6 ML PER 1 DAYS) morphine sulfate 15 mg tablet QL (8 PER 1 DAYS) morphine sulfate 20 mg/5 ml solution morphine sulfate 30 mg tablet QL (4 PER 1 DAYS) morphine sulfate/pf (0.5 mg/ml vial, 1 mg/ml vial) oxycodone hcl (5 mg/5 ml solution, 5 mg capsule, 5 mg tablet) oxycodone hcl 10 mg tablet QL (8 PER 1 DAYS) oxycodone hcl 15 mg tablet QL (6 PER 1 DAYS) oxycodone hcl 20 mg tablet QL (4 PER 1 DAYS) oxycodone hcl 30 mg tablet QL (3 PER 1 DAYS) PA 4
oxycodone hcl/acetaminophen (2.5-325mg tablet, 5 mg-325mg tablet, 7.5-325mg tablet) oxycodone hcl/acetaminophen 10mg- 325mg tablet QL (8 PER 1 DAYS) oxycodone hcl/aspirin oxymorphone hcl 10 mg tablet PA, QL (4 PER 1 DAYS) oxymorphone hcl 5 mg tablet PA, QL (8 PER 1 DAYS) ROXICET 5-325 ORAL SOLUTION roxicet 5-325 tablet 3-Preferred tramadol hcl 50 mg tablet QL (8 PER 1 DAYS) tramadol hcl/acetaminophen QL (10 PER 1 DAYS) Anesthetics Local Anesthetics dermacinrx prizopak PA TO CONFIRM PART D COVERAGE glydo lidocaine 5 % adh. patch PA, QL (3 PER 1 DAYS) lidocaine 5 % oint. (g) PA TO CONFIRM PART D COVERAGE lidocaine hcl (2 % solution, 2 % jel/pf app, 2 % jel (ml), 40 mg/ml solution) lidocaine hcl (5 mg/ml vial, 20 mg/ml vial) lidocaine hcl/pf (5 mg/ml vial, 20 mg/ml ampul luer, 20 mg/ml ampul, 20 mg/ml vial) lidocaine/prilocaine (2.5 %-2.5% cream (g), 2.5 %-2.5% kit) PA TO CONFIRM PART D COVERAGE relador pak PA TO CONFIRM PART D COVERAGE relador pak plus PA TO CONFIRM PART D COVERAGE 5
Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium disulfiram Opioid Dependence Treatments buprenorphine hcl (0.3 mg/ml vial, 0.3 mg/ml syringe) buprenorphine hcl (2 mg tab subl, 8 mg tab subl) QL (3 ML PER 1 DAYS) buprenorphine hcl/naloxone hcl PA, QL (3 PER 1 DAYS) naltrexone hcl revia Opioid Reversal Agents naloxone hcl NARCAN Smoking Cessation Agents CHANTIX NICOTROL NICOTROL NS Antibacterials Aminoglycosides garamycin 0.3% eye drops gentak gentamicin sulfate (0.1 % oint. (g), 0.1 % cream (g), 0.3 % oint. (g), 0.3 % drops) 3-Preferred QL (2 PER 365 DAYS OVER TIME) 6
gentamicin sulfate (20 mg/2 ml vial, 40 mg/ml vial) gentamicin sulfate/pf neomycin sulfate paromomycin sulfate streptomycin sulfate TOBRADEX EYE OINTMENT tobramycin tobramycin in 0.225 % sodium chloride PA TO CONFIRM PART D COVERAGE tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial) Antibacterials, Other acetic acid 2 % solution AVYCAZ BACIIM bacitracin 500 unit/g oint. (g) bacitracin 50000 unit vial chloramphenicol sod succ clindacin etz 1% pledget clindacin p clindamycin hcl clindamycin palmitate hcl clindamycin phosphate (1 % foam, 1 % lotion, 1 % gel (gram), 1 % med. swab, 1 % solution, 2 % cream/appl) clindamycin phosphate (150 mg/ml vial, 300 mg/2ml vial port, 600 mg/4ml vial port, 900mg/6ml vial port) clindamycin phosphate/dextrose 5 % in water colistin (as colistimethate sodium) 7
CUBICIN DALVANCE PA LINEZOLID (100 MG/5ML SUSP RECON, 600MG/300 IV SOLN, 600 MG TABLET) LINEZOLID IN 0.9 % SODIUM CHLORIDE methenamine hippurate methenamine mandelate 1 g tablet metronidazole (0.75 % gel (gram), 0.75 % cream (g), 0.75 % gel w/appl, 0.75 % lotion, 250 mg tablet, 375 mg capsule, 500 mg tablet) metronidazole in sodium chloride MONUROL mupirocin 2% ointment nitrofurantoin nitrofurantoin macrocrystal (50 mg capsule, 100 mg capsule) nitrofurantoin monohydrate/macrocrystals ORBACTIV PA rosadan (0.75% gel, 0.75% cream) SIVEXTRO PA SYNERCID tinidazole trimethoprim TYGACIL vancomycin hcl (1 g vial, 1 g vial port, 5 g vial, 10 g vial, 500 mg vial, 500 mg vial port, 750 mg vial port, 750 mg vial) vancomycin hcl (125 mg capsule, 250 mg capsule) vancomycin hcl/dextrose 5 % in water 8
vancomycin in 0.9 % sodium chloride (vancomycin/0.9 % 750mg/.15l froz.piggy, vancomycin/0.9 % 500mg/0.1l froz.piggy) vancomycin in dextrose, iso-osmotic vandazole vitazol XIFAXAN 200 MG TABLET 3-Preferred PA, QL (3 PER 1 DAYS) XIFAXAN 550 MG TABLET 3-Preferred PA, QL (2 PER 1 DAYS) ZYVOX 100 MG/5 ML SUSPENSION Beta-lactam, Cephalosporins CEDAX (90 MG/5 ML SUSPENSION, 180 MG/5 ML SUSPENSION, 400 MG CAPSULE) cefaclor (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg capsule, 375 mg/5ml susp recon, 500 mg capsule) cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon) cefazolin sodium cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) cefepime hcl cefepime hcl/dextrose 5 % in water cefotaxime sodium cefotetan disodium cefoxitin sodium cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet) cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet) 9
ceftazidime ceftibuten (180 mg/5ml susp recon, 400 mg capsule) CEFTIN 250 MG/5 ML ORAL SUSP ceftriaxone sodium ceftriaxone sodium/dextrose, isoosmotic (1 g/50 ml piggyback, 1 g/50 ml froz.piggy, 2 g/50 ml froz.piggy, 2 g/50 ml piggyback) cefuroxime axetil cefuroxime sodium cefuroxime sodium/dextrose, isoosmotic cephalexin (125 mg/5ml susp recon, 250 mg tablet, 250 mg capsule, 250 mg/5ml susp recon, 500 mg tablet, 500 mg capsule) TAZICEF (1 GRAM VIAL, 2 GRAM VIAL, 2 GM ADD-VANTAGE, 6 GRAM VIAL) ZERBAXA Beta-lactam, Other aztreonam DORIBAX 500 MG VIAL imipenem/cilastatin sodium INVANZ 1 GM VIAL meropenem meropenem in 0.9 % sodium chloride 10
Beta-lactam, Penicillins amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet) amoxicillin/potassium clavulanate (200-28.5mg tab chew, 200-28.5/5 susp recon, 250-125 mg tablet, 250-62.5/5 susp recon, 400-57mg tab chew, 400-57mg/5 susp recon, 500-125 mg tablet, 600-42.9/5 susp recon, 875-125 mg tablet, 1000-62.5 tab er 12h) ampicillin sodium ampicillin sodium/sulbactam sodium ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule) BICILLIN C-R BICILLIN L-A dicloxacillin sodium nafcillin sodium (1 g vial, 2 g vial, 10 g vial) oxacillin sodium oxacillin sodium/dextrose, iso-osmotic penicillin g potassium penicillin g procaine 1.2mm/2 ml syringe penicillin g sodium penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) PFIZERPEN piperacillin sodium/tazobactam sodium 11
TIMENTIN (3.1 GM/100 ML ISO, 3.1 GM VIAL, 31 GM BULK VIAL) Macrolides AZASITE azithromycin (100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mg tablet) azithromycin (500 mg vial port, 500 mg vial) clarithromycin (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet) E.E.S. 200 e.e.s. 400 ery ERY-TAB erygel ERYPED 200 ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500 MG ADDVNT VL) ERYTHROCIN STEARATE erythromycin base (5 mg/g oint. (g), 250 mg tablet, 500 mg tablet) erythromycin base/ethyl alcohol (2 % med. swab, 2 % solution, 2 % gel (gram)) erythromycin ethylsuccinate Quinolones AVELOX IV ciprofloxacin hcl (0.2 % droperette, 0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet) 3-Preferred 3-Preferred 3-Preferred 3-Preferred 12
ciprofloxacin lactate ciprofloxacin lactate/dextrose 5 % in water ciprofloxacin/ciprofloxacin hcl gatifloxacin levofloxacin (0.5 % drops, 250mg/10ml solution, 250 mg tablet, 500 mg tablet, 500mg/20ml solution, 750 mg tablet) levofloxacin 25 mg/ml vial levofloxacin/dextrose 5 % in water moxifloxacin hcl moxifloxacin hcl in sodium acetate and sulfate,water,iso-osm ofloxacin (0.3 % drops, 300 mg tablet, 400 mg tablet) VIGAMOX Sulfonamides bleph-10 silver sulfadiazine sulfacetamide sodium (10 % drops, 10 % suspension, 10 % oint. (g)) sulfadiazine sulfamethoxazole/trimethoprim (200-40mg/5 oral susp, 400mg-80mg tablet, 800-160/20 oral susp, 800-160 mg tablet) sulfamethoxazole/trimethoprim 80-16mg/ml vial sulfamide Tetracyclines avidoxy demeclocycline hcl 3-Preferred 13
DOXY 100 doxycycline hyclate (20 mg tablet, 50 mg capsule, 100 mg capsule, 100 mg tablet) doxycycline hyclate 100 mg vial doxycycline monohydrate (50 mg capsule, 50 mg tablet, 75 mg tablet, 100 mg tablet, 100 mg capsule, 150 mg tablet) dynacin (50 mg tablet, 100 mg tablet) minocycline hcl (50 mg tablet, 50 mg capsule, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet) mondoxyne nl (nl 50 mg capsule, nl 100 mg capsule) morgidox 100 mg capsule tetracycline hcl Anticonvulsants Anticonvulsants, Other levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg/5ml solution, 500 mg tablet, 750 mg tab er 24h, 750 mg tablet, 1000 mg tablet) levetiracetam 500 mg/5ml vial levetiracetam in sodium chloride, isoosmotic POTIGA roweepra SPRITAM PA FOR NEW STARTS ONLY 14
Calcium Channel Modifying Agents CELONTIN ethosuximide (250 mg/5ml solution, 250 mg capsule) LYRICA (20 MG/ML ORAL SOLUTION, 25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE) zonisamide 3-Preferred Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam PA FOR NEW STARTS ONLY AND FOR 65 YEARS AND OLDER clorazepate dipotassium PA FOR NEW STARTS ONLY AND FOR 65 YEARS AND OLDER DIASTAT diazepam (2 mg tablet, 5 mg/5 ml solution, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) DIAZEPAM (2.5 MG KIT, 5-7.5-10MG KIT, 12.5-15-20 KIT) divalproex sodium gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300 mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet) GABITRIL (12 MG TABLET, 16 MG TABLET) ONFI (10 MG TABLET, 20 MG TABLET) ONFI 2.5 MG/ML SUSPENSION 3-Preferred 3-Preferred PA FOR NEW STARTS ONLY AND FOR 65 YEARS AND OLDER PA FOR NEW STARTS ONLY, QL (2 PER 1 DAYS) PA FOR NEW STARTS ONLY 15
phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet) PA FOR NEW STARTS ONLY AND FOR 65 YEARS AND OLDER primidone SABRIL LA tiagabine hcl valproic acid valproic acid (as sodium salt) (valproate sodium) (salt) 250 mg/5ml solution, salt) 500mg/10ml solution) valproic acid (as sodium salt) 500 mg/5ml vial Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) FYCOMPA LAMICTAL (BLUE) LAMICTAL (GREEN) LAMICTAL (ORANGE) LAMICTAL XR (BLUE) LAMICTAL XR (GREEN) LAMICTAL XR (ORANGE) PA FOR NEW STARTS ONLY 16
lamotrigine (5 mg tb chw dsp, 25 mg tablet, 25 mg tab er 24, 25mg (35) tab ds pk, 25 mg tb chw dsp, 50 mg tab er 24, 100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200 mg tablet, 200 mg tab er 24, 250 mg tab er 24, 300 mg tab er 24) topiragen topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) topiramate (25 mg cap spr 24, 50 mg cap spr 24, 100 mg cap spr 24, 150 mg cap spr 24, 200 mg cap spr 24) Sodium Channel Agents APTIOM BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) carbamazepine (100 mg tab er 12h, 100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg tablet, 200 mg tab er 12h, 200 mg cpmp 12hr, 300 mg cpmp 12hr, 400 mg tab er 12h) DILANTIN 30 MG CAPSULE epitol fosphenytoin sodium oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) PEGANONE phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) phenytoin sodium (50 mg/ml vial, 50 mg/ml ampul) PA FOR NEW STARTS ONLY PA FOR NEW STARTS ONLY 17
phenytoin sodium extended VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET) VIMPAT 200 MG/20 ML VIAL PA TO CONFIRM PART D COVERAGE Antidementia Agents Cholinesterase Inhibitors donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tablet, 10 mg tab rapdis) donepezil hcl 23 mg tablet PA EXELON (4.6 MG/24HR PATCH, 9.5 MG/24HR PATCH, 13.3 MG/24HR PATCH) galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet, 12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel) QL (1 PER 1 DAYS) rivastigmine QL (1 PER 1 DAYS) rivastigmine tartrate QL (2 PER 1 DAYS) N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (5 mg tablet, 10 mg tablet) QL (2 PER 1 DAYS) memantine hcl 2 mg/ml solution QL (12 ML PER 1 DAYS) memantine hcl 5 mg-10 mg tab ds pk NAMENDA (5 MG TABLET, 10 MG TABLET) 3-Preferred QL (2 PER 1 DAYS) NAMENDA 2 MG/ML SOLUTION 3-Preferred QL (12 ML PER 1 DAYS) NAMENDA 5-10 MG TITRATION PK NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE) NAMENDA XR TITRATION PACK 3-Preferred PA, QL (1 PER 1 DAYS) PA 18
Antidepressants Antidepressants, Other ABILIFY 1 MG/ML SOLUTION ABILIFY 9.7 MG/1.3 ML VIAL ABILIFY DISCMELT aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) ARIPIPRAZOLE (10 MG TAB RAPDIS, 15 MG TAB RAPDIS) budeprion sr buproban bupropion hcl maprotiline hcl mirtazapine odt (15 mg, 45 mg, 30 mg) mirtazapine tablet (15 mg, 45 mg, 7.5 mg, 30mg) olanzapine/fluoxetine hcl REXULTI trazodone hcl Monoamine Oxidase Inhibitors EMSAM MARPLAN phenelzine sulfate tranylcypromine sulfate 3-Preferred 3-Preferred 3-Preferred PA FOR NEW STARTS ONLY SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor BRINTELLIX PA FOR NEW STARTS ONLY 19
citalopram hydrobromide (10 mg tablet, 10 mg/5 ml solution, 20 mg tablet, 40 mg tablet) DESVENLAFAXINE duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 60 mg capsule dr) escitalopram oxalate (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 20 mg tablet) FETZIMA fluoxetine hcl (10 mg tablet, 10 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 20 mg capsule, 40 mg capsule, 60 mg tablet, 90 mg capsule dr) fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet) KHEDEZLA nefazodone hcl paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) PAXIL 10 MG/5 ML SUSPENSION PRISTIQ ER sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet) TRINTELLIX venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tab er 24, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 24h, 75 mg tab er 24, 75 mg tablet, 100 mg tablet, 150 mg cap er 24h, 150 mg tab er 24) PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS) QL (2 PER 1 DAYS) PA FOR NEW STARTS ONLY PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS) PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS) PA FOR NEW STARTS ONLY 20
VENLAFAXINE HCL 225 MG TAB ER 24 VIIBRYD Tricyclics amitriptyline hcl amoxapine clomipramine hcl desipramine hcl doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule) imipramine hcl imipramine pamoate nortriptyline hcl (10 mg/5 ml solution, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) protriptyline hcl SURMONTIL trimipramine maleate Antidotes Chemotherapy Antidote Agent MESNEX 400 MG TABLET Antiemetics Antiemetics, Other chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) 3-Preferred QL (1 PER 1 DAYS) PA FOR NEW STARTS ONLY 21
chlorpromazine hcl 25 mg/ml ampul compro diphenhydramine hcl 50 mg/ml vial meclizine hcl (12.5 mg tablet, 25 mg tablet) metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet) metoclopramide hcl 5 mg/ml vial perphenazine prochlorperazine prochlorperazine edisylate prochlorperazine maleate Emetogenic Therapy Adjuncts dronabinol PA EMEND 125 MG CAPSULE EMEND 80 MG CAPSULE EMEND TRIPACK QL (2 PER 30 DAYS OVER TIME) QL (4 PER 30 DAYS OVER TIME) QL (6 PER 30 DAYS OVER TIME) granisetron hcl 1 mg tablet QL (8 PER 30 DAYS OVER TIME) ondansetron ondansetron hcl (4 mg/5 ml solution, 4 mg tablet, 8 mg tablet, 24 mg tablet) ondansetron hcl 2 mg/ml vial ondansetron hcl/pf Antifungals Antifungals ABELCET AMBISOME 22
amphotericin b CANCIDAS ciclodan (0.77% cream, 8% solution) ciclopirox (0.77 % gel (gram), 1 % shampoo, 8 % solution) ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) clotrimazole (1 % cream (g), 1 % solution, 10 mg troche) econazole nitrate fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet) fluconazole in dextrose, iso-osmotic fluconazole in sodium chloride, isoosmotic FLUCYTOSINE griseofulvin ultramicrosize griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) itraconazole ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo) ketodan 2% foam miconazole nitrate 200 mg supp.vag NATACYN NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) nyamyc 23
nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, 100000/ml oral susp, 100000/g powder, 100000/g cream (g), 100000/g oint. (g)) nystatin/triamcinolone acetonide nystop pedi-dri terbinafine hcl 250 mg tablet terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) voriconazole (50 mg tablet, 200 mg tablet, 200 mg/5ml susp recon) voriconazole 200 mg vial Antigout Agents Antigout Agents allopurinol COLCHICINE 0.6 MG TABLET 3-Preferred QL (2 PER 1 DAYS) colchicine/probenecid COLCRYS 3-Preferred QL (2 PER 1 DAYS) probenecid ULORIC Antimigraine Agents PA Ergot Alkaloids cafergot dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY SPRAY/PUMP QL (21 ML PER 30 DAYS OVER TIME) 24
ergotamine tartrate/caffeine migergot MIGRANAL QL (21 ML PER 30 DAYS OVER TIME) Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl QL (9 PER 30 DAYS OVER TIME) rizatriptan benzoate (10 mg tablet, 10 mg tab rapdis) rizatriptan benzoate (5 mg tablet, 5 mg tab rapdis) sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet) sumatriptan succinate (4 mg/0.5ml pen injctr, 4 mg/0.5ml cartridge) sumatriptan succinate (6 mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml cartridge, 6 mg/0.5ml vial) QL (12 PER 30 DAYS OVER TIME) QL (9 PER 30 DAYS OVER TIME) QL (9 ML PER 30 DAYS OVER TIME) QL (2 ML PER 30 DAYS OVER TIME) QL (4 ML PER 30 DAYS OVER TIME) zolmitriptan ST, QL (9 PER 30 DAYS OVER TIME) Antimyasthenic Agents Parasympathomimetics guanidine hcl MESTINON (60 MG/5 ML SYRUP, 180 MG TIMESPAN) pyridostigmine bromide 3-Preferred Antimycobacterials Antimycobacterials, Other dapsone rifabutin 25
Antituberculars CAPASTAT SULFATE cycloserine ethambutol hcl isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) isoniazid 100 mg/ml vial PASER PRIFTIN pyrazinamide rifampin (150 mg capsule, 300 mg capsule) rifampin 600 mg vial RIFATER SIRTURO LA TRECATOR Antineoplastics Alkylating Agents CEENU CYCLOPHOSPHAMIDE CAPSULES (25 MG, 50 MG) GLEOSTINE HEXALEN LEUKERAN LOMUSTINE 3-Preferred 3-Preferred PA TO CONFIRM PART D COVERAGE 26
MATULANE Antiandrogens bicalutamide flutamide NILANDRON XTANDI PA FOR NEW STARTS ONLY, LA ZYTIGA PA FOR NEW STARTS ONLY Antiangiogenic Agents POMALYST PA FOR NEW STARTS ONLY REVLIMID PA FOR NEW STARTS ONLY, LA THALOMID Antiestrogens/Modifiers EMCYT FARESTON SOLTAMOX tamoxifen citrate Antimetabolites ADRUCIL DROXIA fluorouracil (1 g/20 ml vial, 2.5 g/50ml vial, 5 g/100 ml vial, 500mg/10ml vial) hydroxyurea mercaptopurine PURIXAN TABLOID 27
Antineoplastics, Other ALIMTA amifostine crystalline AZACITIDINE PA FOR NEW STARTS ONLY bleomycin sulfate ELITEK FARYDAK PA FOR NEW STARTS ONLY, QL (6 PER 21 DAYS OVER TIME) FASLODEX PA FOR NEW STARTS ONLY IXEMPRA PA FOR NEW STARTS ONLY leucovorin calcium (10 mg/ml vial, 50 mg vial, 100 mg vial, 200 mg vial, 350 mg vial, 500mg/50ml vial, 500 mg vial) leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet) LONSURF 15 MG-6.14 MG TABLET PA FOR NEW STARTS ONLY, QL (100 PER 28 DAYS OVER TIME) LONSURF 20 MG-8.19 MG TABLET PA FOR NEW STARTS ONLY, QL (80 PER 28 DAYS OVER TIME) mitoxantrone hcl PROLEUKIN SYNRIBO PA FOR NEW STARTS ONLY TRISENOX VALCHLOR LA VELCADE PA FOR NEW STARTS ONLY ZOLINZA PA FOR NEW STARTS ONLY Aromatase Inhibitors, 3rd Generation anastrozole exemestane letrozole 28
Enzyme Inhibitors etoposide 20 mg/ml vial IBRANCE PA FOR NEW STARTS ONLY, QL (21 PER 30 DAYS OVER TIME) LYNPARZA PA FOR NEW STARTS ONLY, LA TOPOSAR Molecular Target Inhibitors AFINITOR PA FOR NEW STARTS ONLY AFINITOR DISPERZ PA FOR NEW STARTS ONLY ALECENSA PA FOR NEW STARTS ONLY BOSULIF PA FOR NEW STARTS ONLY CAPRELSA PA FOR NEW STARTS ONLY COMETRIQ PA FOR NEW STARTS ONLY COTELLIC QL (63 PER 28 DAYS OVER TIME) ERIVEDGE PA FOR NEW STARTS ONLY, LA GILOTRIF PA FOR NEW STARTS ONLY, LA GLEEVEC PA FOR NEW STARTS ONLY ICLUSIG PA FOR NEW STARTS ONLY IMATINIB MESYLATE PA FOR NEW STARTS ONLY IMBRUVICA PA FOR NEW STARTS ONLY INLYTA PA FOR NEW STARTS ONLY, LA IRESSA PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS) JAKAFI PA FOR NEW STARTS ONLY, LA LENVIMA (10 MG DAILY, 14 MG DAILY, 20 MG DAILY, 24 MG DAILY) PA FOR NEW STARTS ONLY, LA MEKINIST PA FOR NEW STARTS ONLY NEXAVAR PA FOR NEW STARTS ONLY NINLARO PA FOR NEW STARTS ONLY 29
ODOMZO PA FOR NEW STARTS ONLY SPRYCEL PA FOR NEW STARTS ONLY STIVARGA PA FOR NEW STARTS ONLY SUTENT PA FOR NEW STARTS ONLY TAFINLAR PA FOR NEW STARTS ONLY TAGRISSO PA FOR NEW STARTS ONLY TARCEVA PA FOR NEW STARTS ONLY TASIGNA PA FOR NEW STARTS ONLY TYKERB PA FOR NEW STARTS ONLY VENCLEXTA (10 MG TABLET, 50 MG TABLET) PA FOR NEW STARTS ONLY VENCLEXTA 100 MG TABLET PA FOR NEW STARTS ONLY VENCLEXTA STARTING PACK PA FOR NEW STARTS ONLY VOTRIENT PA FOR NEW STARTS ONLY XALKORI PA FOR NEW STARTS ONLY, LA ZELBORAF PA FOR NEW STARTS ONLY ZYDELIG PA FOR NEW STARTS ONLY, QL (2 PER 1 DAYS) ZYKADIA PA FOR NEW STARTS ONLY Monoclonal Antibodies AVASTIN PA FOR NEW STARTS ONLY RITUXAN PA FOR NEW STARTS ONLY SYLVANT PA FOR NEW STARTS ONLY Retinoids BEXAROTENE PA FOR NEW STARTS ONLY PANRETIN TARGRETIN (1% GEL, 75 MG SOFTGEL, 75 MG CAPSULE) PA FOR NEW STARTS ONLY TRETINOIN 10 MG CAPSULE PA FOR NEW STARTS ONLY 30
Antiparasitics Anthelmintics ALBENZA ivermectin STROMECTOL Antiprotozoals ALINIA 100 MG/5 ML SUSPENSION ALINIA 500 MG TABLET ATOVAQUONE chloroquine phosphate COARTEM DARAPRIM hydroxychloroquine sulfate mefloquine hcl NEBUPENT PENTAM 300 primaquine phosphate Pediculicides/Scabicides lindane permethrin 5 % cream (g) ULESFIA 3-Preferred 3-Preferred PA TO CONFIRM PART D COVERAGE 31
Antiparkinson Agents Anticholinergics benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg tablet) Antiparkinson Agents, Other amantadine hcl (50 mg/5 ml solution, 100 mg tablet, 100 mg capsule) carbidopa/levodopa/entacapone entacapone Dopamine Agonists APOKYN PA, LA bromocriptine mesylate pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors carbidopa carbidopa/levodopa Monoamine Oxidase B (MAO-B) Inhibitors AZILECT selegiline hcl Antipsychotics 3-Preferred 1st Generation/Typical fluphenazine decanoate 32
fluphenazine hcl (1 mg tablet, 2.5 mg/5ml elixir, 2.5 mg tablet, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet) fluphenazine hcl 2.5 mg/ml vial haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet) haloperidol decanoate haloperidol lactate (5 mg/ml vial, 5 mg/ml ampul) haloperidol lactate 2 mg/ml oral conc loxapine succinate molindone hcl ORAP perphenazine/amitriptyline hcl pimozide thioridazine hcl PA FOR NEW STARTS ONLY AND FOR 65 YEARS AND OLDER thiothixene trifluoperazine hcl 2nd Generation/Atypical ABILIFY MAINTENA FANAPT GEODON 20 MG/ML VIAL QL (6 PER 30 DAYS OVER TIME) INVEGA INVEGA SUSTENNA 117 MG/0.75 ML QL (0.75 ML PER 30 DAYS OVER TIME) INVEGA SUSTENNA 156 MG/ML SYRG QL (1 ML PER 30 DAYS OVER TIME) INVEGA SUSTENNA 234 MG/1.5 ML QL (1.5 ML PER 30 DAYS OVER TIME) INVEGA SUSTENNA 39 MG/0.25 ML QL (0.25 ML PER 30 DAYS OVER TIME) 33
INVEGA SUSTENNA 78 MG/0.5 ML QL (0.5 ML PER 30 DAYS OVER TIME) INVEGA TRINZA LATUDA olanzapine (2.5 mg tablet, 5 mg tablet, 5 mg tab rapdis, 7.5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 20 mg tab rapdis) olanzapine 10 mg vial paliperidone quetiapine fumarate PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS) RISPERDAL CONSTA QL (4 PER 30 DAYS OVER TIME) risperidone (0.25 mg tablet, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg/ml solution, 1 mg tablet, 2 mg tablet, 2 mg tab rapdis, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet) SAPHRIS SEROQUEL XR VRAYLAR ziprasidone hcl ZYPREXA RELPREVV 3-Preferred PA FOR NEW STARTS ONLY PA FOR NEW STARTS ONLY Treatment-Resistant CLOZAPINE (12.5 MG TAB RAPDIS, 25 MG TAB RAPDIS, 100 MG TAB RAPDIS, 150 MG TAB RAPDIS, 200 MG TAB RAPDIS) clozapine (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet) FAZACLO 34
VERSACLOZ Antispasticity Agents Antispasticity Agents baclofen dantrolene sodium tizanidine hcl (2 mg tablet, 4 mg tablet) Antivirals Anti-HIV Agents, Integrase Inhibitors (INSTI) ATRIPLA GENVOYA ISENTRESS (100 MG TABLET CHEW, 400 MG TABLET) ISENTRESS (25 MG TABLET CHEW, 100 MG POWDER PACKET) STRIBILD TIVICAY VITEKTA 3-Preferred Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA EDURANT INTELENCE (100 MG TABLET, 200 MG TABLET) INTELENCE 25 MG TABLET nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h) ODEFSEY RESCRIPTOR 3-Preferred 3-Preferred 35
SUSTIVA VIRAMUNE XR 100 MG TABLET 3-Preferred 3-Preferred Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir sulfate abacavir sulfate/lamivudine/zidovudine DESCOVY didanosine EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) EPZICOM lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet) lamivudine/zidovudine RETROVIR 200 MG/20 ML VIAL stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule) TRUVADA 200 MG-300 MG TABLET VIDEX VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER) ZIAGEN 20 MG/ML SOLUTION zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) 3-Preferred 3-Preferred 3-Preferred Anti-HIV Agents, Other FUZEON SELZENTRY TRIUMEQ TYBOST 3-Preferred 36
Anti-HIV Agents, Protease Inhibitors APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) CRIXIVAN EVOTAZ INVIRASE KALETRA (200-50 MG TABLET, 400-100/5 ML ORAL SOLU) KALETRA 100-25 MG TABLET LEXIVA 50 MG/ML SUSPENSION LEXIVA 700 MG TABLET NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100 MG SOFTGEL CAP) PREZCOBIX PREZISTA (100 MG/ML SUSPENSION, 600 MG TABLET, 800 MG TABLET) PREZISTA (75 MG TABLET, 150 MG TABLET) REYATAZ (50 MG POWDER PACKET, 150 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE) VIRACEPT Anti-cytomegalovirus (CMV) Agents foscarnet sodium ganciclovir sodium VALCYTE 50 MG/ML SOLUTION VALGANCICLOVIR HCL ZIRGAN Anti-hepatitis B (HBV) Agents ADEFOVIR DIPIVOXIL BARACLUDE 0.05 MG/ML SOLUTION 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 37
ENTECAVIR EPIVIR HBV 25 MG/5 ML SOLN lamivudine 100 mg tablet TYZEKA 3-Preferred Anti-hepatitis B (HBV) Agents/Anti-hepatitis C (HCV) Agents INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL) PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML SYRINGE) PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN SYLATRON PA FOR NEW STARTS ONLY SYLATRON 4-PACK PA FOR NEW STARTS ONLY Anti-hepatitis C (HCV) Agents DAKLINZA (30 MG TABLET, 60 MG TABLET) PA, QL (1 PER 1 DAYS) HARVONI PA, QL (1 PER 1 DAYS) moderiba (200 mg tablet, 400-400 mg dosepack, 600-600 mg dosepack, 600-400 mg dosepack) OLYSIO PA REBETOL 40 MG/ML SOLUTION ribasphere (200 mg tablet, 200 mg capsule, 400 mg tablet) RIBASPHERE 600 MG TABLET ribavirin (200 mg capsule, 200 mg tablet, 400 mg tablet) SOVALDI PA TECHNIVIE PA, QL (2 PER 1 DAYS) 38
VIEKIRA PAK PA, QL (4 PER 1 DAYS) Anti-influenza Agents RELENZA rimantadine hcl TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE) Antiherpetic Agents acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) acyclovir sodium (50 mg/ml vial, 500 mg vial, 1000 mg vial) famciclovir trifluridine valacyclovir hcl Antivirals, Other SYNAGIS 3-Preferred 3-Preferred Anxiolytics Anxiolytics, Other buspirone hcl Benzodiazepines lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc) lorazepam intensol oxazepam Bipolar Agents Mood Stabilizers lithium carbonate 39
lithium citrate Blood Glucose Regulators Antidiabetic Agents acarbose ALOGLIPTIN BENZOATE ALOGLIPTIN BENZOATE/METFORMIN HCL ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL BYDUREON BYDUREON PEN BYETTA CYCLOSET FARXIGA glimepiride glipizide (2.5 mg tab er 24, 5 mg tab er 24, 10 mg tab er 24) glipizide (5 mg tablet, 10 mg tablet) glipizide/metformin hcl GLYXAMBI INVOKAMET INVOKANA JANUMET JANUMET XR 3-Preferred 3-Preferred 3-Preferred 1-Preferred Generic PA PA PA PA PA PA PA PA PA 40
JANUVIA JARDIANCE JENTADUETO KAZANO KOMBIGLYZE XR metformin hcl (500 mg tablet, 850 mg tablet, 1000 mg tablet) metformin hcl 500 mg osm-tab er 24 metformin hcl 500 mg tab er 24h (generic for glucophage xr) metformin hcl 750 mg tab er 24h nateglinide NESINA ONGLYZA OSENI pioglitazone hcl pioglitazone hcl/glimepiride pioglitazone hcl/metformin hcl RIOMET 1-Preferred Generic SYMLINPEN 120 PA, QL (10.8 ML PER 30 DAYS OVER TIME) SYMLINPEN 60 PA, QL (6 ML PER 30 DAYS OVER TIME) SYNJARDY tolbutamide PA PA PA PA PA PA PA PA PA 41
TRADJENTA VICTOZA 2-PAK 3-Preferred QL (9 ML PER 30 DAYS OVER TIME) VICTOZA 3-PAK 3-Preferred QL (9 ML PER 30 DAYS OVER TIME) WELCHOL XIGDUO XR Glycemic Agents GLUCAGON EMERGENCY KIT 3-Preferred QL (2 PER 30 DAYS OVER TIME) PROGLYCEM PA PA PA Insulins HUMALOG HUMALOG KWIKPEN U-100 HUMALOG KWIKPEN U-200 HUMALOG MIX 50-50 HUMALOG MIX 50-50 KWIKPEN HUMALOG MIX 75-25 HUMALOG MIX 75-25 KWIKPEN HUMULIN 70-30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXPEN LEVEMIR FLEXTOUCH 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 42
TOUJEO SOLOSTAR TRESIBA FLEXTOUCH U-100 TRESIBA FLEXTOUCH U-200 3-Preferred 3-Preferred 3-Preferred Blood Products/Modifiers/Volume Expanders Anticoagulants ELIQUIS ENOXAPARIN SODIUM (100 MG/ML SYRINGE, 150 MG/ML SYRINGE) ENOXAPARIN SODIUM 120MG/.8ML SYRINGE 3-Preferred QL (60 ML PER 30 DAYS OVER TIME) QL (48 ML PER 30 DAYS OVER TIME) enoxaparin sodium 30mg/0.3ml syringe QL (18 ML PER 30 DAYS OVER TIME) enoxaparin sodium 40mg/0.4ml syringe QL (24 ML PER 30 DAYS OVER TIME) enoxaparin sodium 60mg/0.6ml syringe QL (36 ML PER 30 DAYS OVER TIME) enoxaparin sodium 80mg/0.8ml syringe QL (48 ML PER 30 DAYS OVER TIME) FONDAPARINUX SODIUM 10MG/0.8ML SYRINGE fondaparinux sodium 2.5 mg/0.5 syringe FONDAPARINUX SODIUM 5MG/0.4ML SYRINGE FONDAPARINUX SODIUM 7.5MG/0.6 SYRINGE FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR) FRAGMIN (25,000 UNITS/ML VIAL, 95,000 UNITS/3.8 ML VL) QL (24 ML PER 30 DAYS OVER TIME) QL (15 ML PER 30 DAYS OVER TIME) QL (12 ML PER 30 DAYS OVER TIME) QL (18 ML PER 30 DAYS OVER TIME) QL (6 ML PER 30 DAYS OVER TIME) QL (30.4 ML PER 30 DAYS OVER TIME) FRAGMIN 10,000 UNITS/ML SYRING QL (30 ML PER 30 DAYS OVER TIME) FRAGMIN 12,500 UNITS/0.5 ML QL (15 ML PER 30 DAYS OVER TIME) FRAGMIN 15,000 UNITS/0.6 ML QL (18 ML PER 30 DAYS OVER TIME) FRAGMIN 18,000 UNITS/0.72 ML QL (21.6 ML PER 30 DAYS OVER TIME) FRAGMIN 7,500 UNITS/0.3 ML SYR QL (9 ML PER 30 DAYS OVER TIME) 43
heparin sodium,porcine (1000/ml vial, 5000/ml vial, 5000/ml(1) cartridge, 10000/ml vial, 20000/ml vial) heparin sodium,porcine in 0.45 % sodium chloride heparin sodium,porcine/dextrose 5 % in water heparin sodium,porcine/pf (1000/ml vial, 5000/0.5ml vial) jantoven PRADAXA SAVAYSA warfarin sodium XARELTO Blood Formation Modifiers anagrelide hcl ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 40 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 ML SYRINGE) ARANESP (100 MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 150 MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 MCG/1 ML SYRINGE) EPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL, 20,000 UNITS/ML VIAL) GRANIX LEUKINE 250 MCG VIAL 3-Preferred PA PA PA 44
NEULASTA QL (1.2 ML PER 28 DAYS OVER TIME) NEUMEGA NEUPOGEN PROCRIT (2,000 VIAL, 3,000 VIAL, 4,000 VIAL, 10,000 VIAL) PROCRIT (20,000 VIAL, 40,000 VIAL) PA PROMACTA PA PA Coagulants tranexamic acid (1000 mg/10 vial, 1000 mg/10 ampul) tranexamic acid 650 mg tablet Platelet Modifying Agents AGGRENOX ASPIRIN/DIPYRIDAMOLE BRILINTA cilostazol clopidogrel bisulfate 75 mg tablet EFFIENT 3-Preferred 3-Preferred 3-Preferred 3-Preferred Cardiovascular Agents Alpha-adrenergic Agonists clonidine clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) midodrine hcl Alpha-adrenergic Blocking Agents doxazosin mesylate PHENOXYBENZAMINE HCL prazosin hcl 1-Preferred Generic 45
terazosin hcl Angiotensin II Receptor Antagonists candesartan cilexetil eprosartan mesylate irbesartan irbesartan/hydrochlorothiazide losartan potassium losartan potassium/hydrochlorothiazide telmisartan telmisartan/hydrochlorothiazide valsartan valsartan/hydrochlorothiazide 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl benazepril hcl/hydrochlorothiazide captopril captopril/hydrochlorothiazide enalapril maleate enalapril maleate/hydrochlorothiazide EPANED fosinopril sodium fosinopril sodium/hydrochlorothiazide 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic 46
lisinopril lisinopril/hydrochlorothiazide moexipril hcl moexipril hcl/hydrochlorothiazide perindopril erbumine quinapril hcl quinapril hcl/hydrochlorothiazide ramipril trandolapril Antiarrhythmics amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) disopyramide phosphate dofetilide flecainide acetate mexiletine hcl MULTAQ NORPACE CR pacerone 200 mg tablet procainamide hcl propafenone hcl quinidine gluconate 324 mg tablet er quinidine gluconate 80 mg/ml vial quinidine sulfate (200 mg tablet, 300 mg tablet) sorine 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic 3-Preferred 47
sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet) TIKOSYN Beta-adrenergic Blocking Agents acebutolol hcl atenolol atenolol/chlorthalidone betaxolol hcl (10 mg tablet, 20 mg tablet) bisoprolol fumarate bisoprolol fumarate/hydrochlorothiazide BYSTOLIC carvedilol COREG CR labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) labetalol hcl 5 mg/ml vial LEVATOL metoprolol succinate metoprolol tartrate (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet) metoprolol tartrate (5 mg/5 ml syringe, 5 mg/5 ml ampul, 5 mg/5 ml vial) metoprolol tartrate/hydrochlorothiazide 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic PA 48
nadolol pindolol propranolol hcl (10 mg tablet, 20 mg/5 ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 60 mg tablet, 80 mg tablet) propranolol hcl (60 mg cap sa 24h, 80 mg cap sa 24h, 120 mg cap sa 24h, 160 mg cap sa 24h) propranolol hcl 1 mg/ml vial propranolol hcl/hydrochlorothiazide timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) Calcium Channel Blocking Agents afeditab cr amlodipine besylate amlodipine besylate/atorvastatin calcium amlodipine besylate/benazepril hcl amlodipine besylate/valsartan CARDIZEM LA 120 MG TABLET cartia xt dilt-cd dilt-xr diltiazem hcl (30 mg tablet, 60 mg tablet, 90 mg tablet, 120 mg tablet) diltiazem hcl (5 mg/ml vial, 100 mg vial port) 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic 49
diltiazem hcl (60 mg cap er 12h, 90 mg cap er 12h, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120 mg capsule er, 180 mg cap er 24h, 180 mg tab er 24h, 180 mg capsule er, 180 mg cap er deg, 240 mg tab er 24h, 240 mg cap er deg, 240 mg cap er 24h, 240 mg capsule er, 300 mg capsule er, 300 mg tab er 24h, 300 mg cap er 24h, 360 mg cap er 24h, 360 mg capsule er, 360 mg tab er 24h, 420 mg tab er 24h, 420 mg capsule er) felodipine isradipine matzim la nicardipine hcl (20 mg capsule, 30 mg capsule) nifediac cc nifedical xl nifedipine (30 mg tab er 24, 30 mg tablet er, 60 mg tablet er, 60 mg tab er 24, 90 mg tab er 24, 90 mg tablet er) nimodipine nisoldipine taztia xt verapamil hcl (100 mg cap24h pct, 120 mg tablet er, 120 mg cap24h pel, 180 mg tablet er, 180 mg cap24h pel, 200 mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 360 mg cap24h pel) verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet) Cardiovascular Agents, Other CORLANOR DEMSER 1-Preferred Generic PA 50
digitek digox digoxin (250 mcg/ml ampul, 250 mcg/ml syringe) digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) ENTRESTO 3-Preferred PA NORTHERA PA, LA pentoxifylline RANEXA Diuretics, Carbonic Anhydrase Inhibitors acetazolamide acetazolamide sodium methazolamide neptazane 25 mg tablet 3-Preferred Diuretics, Loop bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) EDECRIN furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 80 mg tablet) furosemide (10 mg/ml syringe, 10 mg/ml vial) torsemide (5 mg tablet, 10 mg tablet, 20 mg tablet, 100 mg tablet) Diuretics, Potassium-sparing amiloride hcl amiloride hcl/hydrochlorothiazide DYRENIUM 1-Preferred Generic 51
eplerenone spironolactone spironolactone/hydrochlorothiazide triamterene/hydrochlorothiazide (37.5-25 mg capsule, 37.5-25 mg tablet, 75 mg-50mg tablet) Diuretics, Thiazide chlorothiazide chlorthalidone hydrochlorothiazide indapamide metolazone Dyslipidemics, Fibric Acid Derivatives fenofibrate (54 mg tablet, 160 mg tablet) fenofibrate nanocrystallized fenofibrate,micronized (67 mg capsule, 134mg capsule, 200 mg capsule) fenofibric acid (choline) gemfibrozil lofibra 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic 1-Preferred Generic Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium CRESTOR fluvastatin sodium (20 mg capsule, 40 mg capsule) lovastatin 1-Preferred Generic 3-Preferred 52
pravastatin sodium rosuvastatin calcium simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet) simvastatin 40 mg tablet 1-Preferred Generic 1-Preferred Generic simvastatin 80 mg tablet PA Dyslipidemics, Other cholestyramine (with sugar) (sugar) 4 g powder, sugar) 4 g powd pack) cholestyramine/aspartame (4 g powd pack, 4 g powder) colestipol hcl (1 g tablet, 5 g packet, 5 g granules) JUXTAPID PA, LA KYNAMRO PA, LA PRALUENT PEN PA PRALUENT SYRINGE PA prevalite (packet, powder) REPATHA SURECLICK PA REPATHA SYRINGE PA VASCEPA ZETIA QL (1 PER 1 DAYS) PA PA Vasodilators, Direct-acting Arterial hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) minoxidil Vasodilators, Direct-acting Arterial/Venous isochron 53
isosorbide dinitrate (5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet er) isosorbide mononitrate minitran NITRO-DUR (0.3 PATCH, 0.8 PATCH) nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24, 0.6mg/hr patch td24, 400mcg/spr spray) NITROSTAT 1-Preferred Generic 3-Preferred 3-Preferred Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (5 mg cap er 24h, 10 mg cap er 24h, 15 mg cap er 24h, 25 mg cap er 24h, 30 mg cap er 24h) dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 12.5 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) dextroamphetamine sulfate (5 mg tablet, 5 mg capsule er, 10 mg tablet, 10 mg capsule er, 15 mg capsule er) dextroamphetamine/amphetamine 20 mg cap er 24h VYVANSE PA FOR 65 YEARS AND OLDER, QL (1 PER 1 DAYS) PA FOR 65 YEARS AND OLDER PA FOR 65 YEARS AND OLDER PA FOR 65 YEARS AND OLDER, QL (2 PER 1 DAYS) PA FOR 65 YEARS AND OLDER, QL (1 PER 1 DAYS) zenzedi (5 mg tablet, 10 mg tablet) PA FOR 65 YEARS AND OLDER Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines clonidine hcl 0.1 mg tab er 12h PA DAYTRANA PA, QL (1 PER 1 DAYS) 54
dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet) PA FOR 65 YEARS AND OLDER metadate er PA FOR 65 YEARS AND OLDER methylphenidate hcl (10 mg cpbp 30-70, 18 mg tab er 24, 20 mg cpbp 30-70, 20 mg cpbp 50-50, 27 mg tab er 24, 40 mg cpbp 30-70, 40 mg cpbp 50-50, 50 mg cpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70) methylphenidate hcl (30 mg cpbp 50-50, 30 mg cpbp 30-70, 36 mg tab er 24) methylphenidate hcl (5 mg tablet, 10 mg tablet, 10 mg tablet er, 20 mg tablet er, 20 mg tablet) RITALIN LA (10 MG CAPSULE, 60 MG CAPSULE) STRATTERA PA FOR 65 YEARS AND OLDER, QL (1 PER 1 DAYS) PA FOR 65 YEARS AND OLDER, QL (2 PER 1 DAYS) PA FOR 65 YEARS AND OLDER PA FOR 65 YEARS AND OLDER, QL (1 PER 1 DAYS) QL (1 PER 1 DAYS) Central Nervous System, Other HETLIOZ PA, LA, QL (1 PER 1 DAYS) NUEDEXTA 3-Preferred PA riluzole TETRABENAZINE PA XENAZINE PA, LA Fibromyalgia Agents SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET) 3-Preferred QL (2 PER 1 DAYS) SAVELLA TITRATION PACK 3-Preferred QL (55 PER 28 DAYS OVER TIME) Multiple Sclerosis Agents AMPYRA PA, LA, QL (2 PER 1 DAYS) AUBAGIO PA, QL (1 PER 1 DAYS) AVONEX (SYR 30 MCG, SYR 30 MCG KT) 55
AVONEX ADMINISTRATION PACK AVONEX PEN BETASERON PA, QL (15 PER 30 DAYS OVER TIME) COPAXONE 20 MG/ML SYRINGE QL (1 ML PER 1 DAYS) COPAXONE 40 MG/ML SYRINGE QL (12 ML PER 28 DAYS OVER TIME) EXTAVIA PA, QL (15 PER 30 DAYS OVER TIME) GILENYA PA, QL (1 PER 1 DAYS) GLATOPA QL (1 ML PER 1 DAYS) PLEGRIDY QL (1 ML PER 28 DAYS OVER TIME) PLEGRIDY PEN QL (1 ML PER 28 DAYS OVER TIME) REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 ML SYRINGE) REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) QL (6 ML PER 30 DAYS OVER TIME) QL (6 ML PER 30 DAYS OVER TIME) REBIF REBIDOSE TITRATION PACK QL (4.2 ML PER 30 DAYS OVER TIME) REBIF TITRATION PACK QL (4.2 ML PER 30 DAYS OVER TIME) TECFIDERA QL (2 PER 1 DAYS) TYSABRI PA Dental and Oral Agents Dental and Oral Agents chlorhexidine gluconate 0.12 % mouthwash denta 5000 plus dentagel fluoridex daily defense oralone paroex periogard pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 56
prevident 1.1% gel PREVIDENT 5000 PREVIDENT 5000 BOOSTER PLUS PREVIDENT 5000 PLUS sf sf 5000 plus sodium fluoride 0.2 % solution triamcinolone acetonide 0.1 % paste (g) 3-Preferred 3-Preferred 3-Preferred Dermatological Agents Dermatological Agents absorica 30 mg capsule acitretin adapalene (0.1 % gel (gram), 0.1 % cream (g)) ammonium lactate amnesteem avita 0.025% cream calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 % solution) calcitrene CARAC claravis clotrimazole/betamethasone dipropionate (1 %-0.05 % lotion, 1 %- 0.05 % cream (g)) ELIDEL EPIFOAM erythromycin base/benzoyl peroxide 3-Preferred PA 57
fluorouracil (2 % solution, 5 % solution, 5 % cream (g)) FLUOROURACIL 0.5 % CREAM (G) imiquimod METHOXSALEN, RAPID myorisan 3-Preferred OTEZLA (28 DAY PACK, PACK) PA OTEZLA 30 MG TABLET PA, QL (2 PER 1 DAYS) PICATO podofilox PROCTOFOAM-HC REGRANEX SANTYL selenium sulfide 2.5 % lotion STELARA tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) TAZORAC TOLAK tretinoin (0.01 % gel (gram), 0.025 % gel (gram), 0.025 % cream (g), 0.05 % cream (g), 0.1 % cream (g)) zenatane Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers 3-Preferred 3-Preferred ADAGEN LA ALDURAZYME PA QL (30 GM PER 30 DAYS OVER TIME) PA 58
CARBAGLU CERDELGA CEREZYME CREON CYSTADANE CYSTAGON 3-Preferred CYSTARAN PA, LA, QL (60 ML PER 30 DAYS OVER TIME) ELAPRASE ELELYSO FABRAZYME KUVAN PA, LA LUMIZYME PA MYOZYME PA NAGLAZYME PA ORFADIN (2 MG CAPSULE, 5 MG CAPSULE, 10 MG CAPSULE) pancrelipase 5,000 PROCYSBI PA, LA RAVICTI LA SODIUM PHENYLBUTYRATE STRENSIQ PA, LA SUCRAID LA ZAVESCA LA ZENPEP 3-Preferred LA LA 59
Gastrointestinal Agents Antispasmodics, Gastrointestinal glycopyrrolate (1 mg tablet, 2 mg tablet) glycopyrrolate 0.2 mg/ml vial methscopolamine bromide Gastrointestinal Agents, Other CHENODAL PA CHOLBAM PA FULYZAQ GATTEX PA, LA lansoprazole/amoxicillin trihydrate/clarithromycin loperamide hcl 2 mg capsule MOVANTIK PYLERA RELISTOR 12 MG/0.6 ML (KIT, SYRINGE, VIAL) RELISTOR 8 MG/0.4 ML SYRINGE ursodiol Histamine2 (H2) Receptor Antagonists cimetidine cimetidine hcl famotidine (20 mg tablet, 40mg/5ml oral susp, 40 mg tablet) famotidine in sodium chloride, isoosmotic/pf QL (1 PER 1 DAYS) PA, QL (18 PER 30 DAYS OVER TIME) PA, QL (12 ML PER 30 DAYS OVER TIME) 60
nizatidine (150mg/10ml solution, 150 mg capsule, 300 mg capsule) ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet, 300 mg tablet, 300 mg capsule) ranitidine hcl (25 mg/ml vial, 50 mg/2 ml vial) Irritable Bowel Syndrome Agents alosetron hcl AMITIZA Laxatives constulose enulose gavilyte-c gavilyte-g gavilyte-n generlac lactulose MOVIPREP peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl polyethylene glycol 3350 (3350 17g powd pack, 3350 17g/dose powder) sodium chloride/sodium bicarbonate/potassium chloride/peg SUPREP trilyte with flavor packets Protectants CARAFATE 1 GM/10 ML SUSP 3-Preferred 61
misoprostol sucralfate Proton Pump Inhibitors lansoprazole QL (2 PER 1 DAYS) omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule dr) pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) pantoprazole sodium 40 mg vial PROTONIX 40 MG SUSPENSION PROTONIX IV rabeprazole sodium Genitourinary Agents 3-Preferred QL (2 PER 1 DAYS) QL (2 PER 1 DAYS) Antispasmodics, Urinary flavoxate hcl MYRBETRIQ oxybutynin chloride (5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 15 mg tab er 24) OXYTROL tolterodine tartrate (1 mg tablet, 2 mg tablet) tolterodine tartrate (2 mg cap er 24h, 4 mg cap er 24h) trospium chloride 20 mg tablet VESICARE Benign Prostatic Hypertrophy Agents alfuzosin hcl dutasteride 3-Preferred 3-Preferred QL (1 PER 1 DAYS) 62
finasteride tamsulosin hcl Genitourinary Agents, Other bethanechol chloride CUPRIMINE DEPEN ELMIRON methylergonovine maleate 0.2 mg tablet Phosphate Binders AURYXIA calcium acetate (667 mg capsule, 667 mg tablet) eliphos FOSRENOL RENVELA SEVELAMER CARBONATE 3-Preferred 3-Preferred 3-Preferred 3-Preferred PA Hormonal Agents, Stimulant/Replacement/ Modifying (Parathyroid) Hormonal Agents, Stimulant/Replacement/ Modifying (Parathyroid) NATPARA PA, LA, QL (28 PER 28 DAYS OVER TIME) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) alclometasone dipropionate amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) anusol-hc 63
betamethasone dipropionate (0.05 % lotion, 0.05 % cream (g), 0.05 % oint. (g)) betamethasone dipropionate/propylene glycol (0.05 % cream (g), 0.05 % oint. (g), 0.05 % lotion) betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) budesonide 3 mg capdr - er clobetasol propionate (0.05 % solution, 0.05 % lotion, 0.05 % shampoo, 0.05 % cream (g), 0.05 % foam, 0.05 % oint. (g), 0.05 % gel (gram)) clobetasol propionate/emoll 0.05 % cream (g) clodan colocort cormax cortisone acetate desonide (0.05 % lotion, 0.05 % cream (g), 0.05 % oint. (g)) desoximetasone dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet) dexamethasone sod phosphate (4 mg/ml vial, 10 mg/ml vial) dexamethasone sodium phosphate/pf diflorasone diacetate fludrocortisone acetate fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.01 % solution, 0.025 % oint. (g), 0.025 % cream (g)) fluocinolone acetonide oil 64
fluocinolone acetonide/shower cap fluocinonide (0.05 % gel (gram), 0.05 % solution, 0.05 % cream (g), 0.05 % oint. (g)) fluocinonide/emollient base fluticasone propionate (0.005 % oint. (g), 0.05 % lotion, 0.05 % cream (g)) halobetasol propionate hydrocortisone (1 % oint. (g), 1 % cream (g), 2.5 % lotion, 2.5 % cream (g), 2.5 % oint. (g), 2.5 % cream/appl, 5 mg tablet, 10 mg tablet, 20 mg tablet, 100mg/60ml enema) hydrocortisone butyrate (0.1 % oint. (g), 0.1 % solution, 0.1 % cream (g)) hydrocortisone valerate hydrocortisone/mineral oil/petrolatum,white methylprednisolone methylprednisolone acetate methylprednisolone sodium succinate millipred 5 mg tablet millipred dp mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) prednisolone prednisolone sod phosphate (5 mg/5 ml solution, 15 mg/5 ml solution, 25 mg/5 ml solution) prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg tab ds pk, 10 mg tablet, 10 mg tab ds pk, 20 mg tablet, 50 mg tablet) prednisone intensol procto-med hc 65
proctocream-hc proctosol-hc proctozone-hc psorcon triamcinolone acetonide (0.025 % cream (g), 0.025 % oint. (g), 0.025 % lotion, 0.1 % lotion, 0.1 % oint. (g), 0.1 % cream (g), 0.5 % oint. (g), 0.5 % cream (g), 55 mcg spray) triderm UCERIS 9 MG ER TABLET PA Hormonal Agents, Stimulant/Replacement/Modifying (Other) Hormonal Agents, Stimulant/Replacement/Modifying (Other) MYALEPT PA Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet, 10/spray spray/pump) desmopressin acetate (4mcg/ml ampul, 4mcg/ml vial) desmopressin acetate (nonrefrigerated) EGRIFTA PA INCRELEX PA, LA OMNITROPE (5 MG/1.5 ML, 10 MG/1.5 ML) OMNITROPE 5.8 MG VIAL PA STIMATE PA 66
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids oxandrolone Androgens ANDRODERM 3-Preferred PA ANDROGEL 3-Preferred PA ANDROXY danazol testosterone (1.25 g(1%) gel md pmp, 25mg(1%) gel packet, 50 mg (1%) gel (gram), 50 mg (1%) gel packet) testosterone cypionate testosterone enanthate PA Estrogens altavera alyacen amethyst apri aranelle aubra aviane azurette balziva bekyree blisovi 24 fe blisovi fe briellyn 67
caziant chateal cryselle cyclafem cyred dasetta delyla desogestrel-ethinyl estradiol desogestrel-ethinyl estradiol/ethinyl estradiol elinest emoquette enpresse enskyce estarylla ESTRACE 0.01% CREAM estradiol estradiol valerate (20 mg/ml vial, 40 mg/ml vial) estradiol/norethindrone acetate ESTRING estropipate ethinyl estradiol/drospirenone falmina fyavolv gianvi gildagia gildess gildess 24 fe 3-Preferred 3-Preferred 68
gildess fe introvale jevantique lo jinteli jolessa juleber junel junel fe junel fe 24 kariva kelnor 1-35 kimidess kurvelo larin larin 24 fe larin fe leena lessina levonest levonorgestrel-ethinyl estradiol levora-28 lomedia 24 fe lopreeza loryna low-ogestrel lutera marlissa MENEST 69
microgestin microgestin fe mimvey mimvey lo mircette mono-linyah mononessa myzilra necon nikki norethindrone acetate-ethinyl estradiol norethindrone acetate-ethinyl estradiol/ferrous fumarate norgestimate-ethinyl estradiol nortrel ocella ogestrel orsythia philith pimtrea pirmella portia PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET) PREMARIN 25 MG VIAL PREMARIN VAGINAL CREAM-APPL PREMPHASE PREMPRO 3-Preferred QL (1 PER 1 DAYS) 70
previfem quasense reclipsen setlakin sprintec sronyx syeda tarina fe tri-estarylla tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec tri-previfem tri-sprintec trinessa trinessa lo trivora-28 VAGIFEM 3-Preferred velivet vestura vienva viorele vyfemla wera xulane zarah zenchent zovia 1-35e 71
zovia 1-50e Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers), Other DUAVEE Progesterone Agonists/Antagonists ELLA Progestins camila deblitane DEPO-SUBQ PROVERA 104 errin heather jencycla jolivette lyza medroxyprogesterone acetate (150 mg/ml vial, 150 mg/ml syringe) medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) megestrol acetate (20 mg tablet, 40 mg tablet, 400mg/10ml oral susp) nora-be norethindrone norethindrone acetate norlyroc progesterone,micronized sharobel 72
Selective Estrogen Receptor Modifying Agents raloxifene hcl Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175mcg tablet, 200 mcg tablet, 300 mcg tablet) levothyroxine sodium 100 mcg vial levoxyl liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet) liothyronine sodium 10 mcg/ml vial SYNTHROID unithroid Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) KORLYM PA LYSODREN Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Parathyroid) 3-Preferred SENSIPAR 30 MG TABLET 3-Preferred QL (2 PER 1 DAYS) SENSIPAR 60 MG TABLET QL (2 PER 1 DAYS) SENSIPAR 90 MG TABLET QL (4 PER 1 DAYS) 73
Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline ELIGARD leuprolide acetate LUPANETA PACK LUPRON DEPOT LUPRON DEPOT-PED octreotide acetate (50 mcg/ml vial, 50 mcg/ml ampul, 100 mcg/ml ampul, 100 mcg/ml vial, 200 mcg/ml vial, 500 mcg/ml ampul, 500 mcg/ml vial, 1000mcg/ml vial) SIGNIFOR PA, LA SOMATULINE DEPOT SOMAVERT PA, LA Hormonal Agents, Suppressant (Thyroid) PA Antithyroid Agents methimazole propylthiouracil Immunological Agents Angioedema (HAE) Agents CINRYZE PA, LA FIRAZYR PA, QL (9 ML PER 30 DAYS OVER TIME) Immune Suppressants ASTAGRAF XL PA TO CONFIRM PART D COVERAGE 74
azathioprine PA TO CONFIRM PART D COVERAGE azathioprine sodium PA TO CONFIRM PART D COVERAGE BENLYSTA PA CELLCEPT 200 MG/ML ORAL SUSP PA TO CONFIRM PART D COVERAGE cyclosporine (25 mg capsule, 100 mg capsule) cyclosporine (250 mg/5ml vial, 250 mg/5ml ampul) cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg/ml solution, 100 mg capsule) ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML SYRINGE, 50 MG/ML SURECLICK SYR) gengraf (25 mg capsule, 100 mg/ml solution, 100 mg capsule) GRASTEK PA TO CONFIRM PART D COVERAGE PA TO CONFIRM PART D COVERAGE PA TO CONFIRM PART D COVERAGE PA TO CONFIRM PART D COVERAGE hecoria PA TO CONFIRM PART D COVERAGE HUMIRA HUMIRA PEDIATRIC CROHN'S HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS HUMIRA PEN PSORIASIS methotrexate sodium 2.5 mg tablet methotrexate sodium 25 mg/ml vial methotrexate sodium/pf (1 g vial, 25 mg/ml vial) mycophenolate mofetil (250 mg capsule, 500 mg tablet) MYCOPHENOLATE MOFETIL 200 MG/ML SUSP RECON PA PA TO CONFIRM PART D COVERAGE PA TO CONFIRM PART D COVERAGE mycophenolate sodium PA TO CONFIRM PART D COVERAGE 75
NULOJIX PA TO CONFIRM PART D COVERAGE ORALAIR PROGRAF 5 MG/ML AMPULE PA TO CONFIRM PART D COVERAGE RAGWITEK RAPAMUNE 1 MG/ML ORAL SOLN REMICADE SIMPONI SIMPONI ARIA PA PA PA TO CONFIRM PART D COVERAGE sirolimus PA TO CONFIRM PART D COVERAGE tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) ZORTRESS (0.5 MG TABLET, 0.75 MG TABLET) ZORTRESS 0.25 MG TABLET Immunizing Agents, Passive BIVIGAM PA CARIMUNE NF NANOFILTERED PA FLEBOGAMMA DIF 10% VIAL PA GAMMAGARD LIQUID PA GAMMAGARD S-D PA GAMMAKED PA GAMMAPLEX PA GAMUNEX PA GAMUNEX-C PA PRIVIGEN PA THYMOGLOBULIN PA TO CONFIRM PART D COVERAGE PA TO CONFIRM PART D COVERAGE, QL (2 PER 1 DAYS) PA TO CONFIRM PART D COVERAGE, QL (2 PER 1 DAYS) 76
Immunomodulators ACTIMMUNE PA FOR NEW STARTS ONLY, LA ARCALYST PA, LA ILARIS PA, LA leflunomide Vaccines ACTHIB ADACEL TDAP bcg live bcg vaccine, live/pf BEXSERO BOOSTRIX TDAP CERVARIX PA COMVAX DAPTACEL DTAP ENGERIX-B ADULT PA TO CONFIRM PART D COVERAGE ENGERIX-B PEDIATRIC-ADOLESCENT PA TO CONFIRM PART D COVERAGE GARDASIL PA GARDASIL 9 PA HAVRIX HIBERIX IMOVAX RABIES VACCINE INFANRIX DTAP VIAL IPOL IXIARO M-M-R II VACCINE MENACTRA MENHIBRIX 77
MENOMUNE-A-C-Y-W-135 MENVEO A-C-Y-W-135-DIP PEDVAXHIB PENTACEL ACTHIB COMPONENT PENTACEL DTAP-IPV COMPONENT PROQUAD QUADRACEL DTAP-IPV RABAVERT RECOMBIVAX HB (5 MCG/0.5 ML SYR, 10 MCG/ML SYR) RECOMBIVAX HB (5 MCG/0.5 ML VL, 10 MCG/ML VIAL, 40 MCG/ML VIAL) ROTARIX ROTATEQ TENIVAC SYRINGE tetanus and diphtheria toxoids, adult tetanus toxoid, adsorbed/pf tetanus,diphtheria toxoid ped/pf TRUMENBA TWINRIX TYPHIM VI VAQTA VARIVAX VACCINE YF-VAX ZOSTAVAX 3-Preferred PA TO CONFIRM PART D COVERAGE Inflammatory Bowel Disease Agents Aminosalicylates APRISO 3-Preferred 78
ASACOL HD balsalazide disodium CANASA DELZICOL LIALDA mesalamine mesalamine with cleansing wipes PENTASA Sulfonamides sulfasalazine 3-Preferred 3-Preferred Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70 mg/75ml solution, 70 mg tablet) BINOSTO calcitonin,salmon,synthetic calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) PA TO CONFIRM PART D COVERAGE calcitriol 1 mcg/ml ampul PA TO CONFIRM PART D COVERAGE doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule) doxercalciferol (4mcg/2ml ampul, 4mcg/2ml vial) etidronate disodium FORTEO PA ibandronate sodium (3 mg/3 ml syringe, 3 mg/3 ml vial) PA TO CONFIRM PART D COVERAGE, ST PA TO CONFIRM PART D COVERAGE 79
ibandronate sodium 150 mg tablet MIACALCIN (200 UNIT/ML VIAL, 400 UNIT/2 ML VIAL) pamidronate disodium (30 mg vial, 30mg/10ml vial, 60 mg/10ml vial, 90 mg vial, 90 mg/10ml vial) paricalcitol (1 mcg capsule, 2 mcg capsule, 4mcg capsule) paricalcitol (2 mcg/ml vial, 5 mcg/ml vial) PROLIA PA risedronate sodium PA PA TO CONFIRM PART D COVERAGE, ST PA TO CONFIRM PART D COVERAGE XGEVA PA FOR NEW STARTS ONLY ZEMPLAR (2 MCG/ML VIAL, 5 MCG/ML VIAL, 10 MCG/2 ML VIAL) zoledronic acid (4 mg/5 ml vial, 4 mg vial) PA TO CONFIRM PART D COVERAGE PA TO CONFIRM PART D COVERAGE ZOMETA 4 MG/100 ML INJECTION PA TO CONFIRM PART D COVERAGE Miscellaneous Miscellaneous alcohol antiseptic pads gauze bandage 2" x 2" bandage insulin syringe (disp syrin) needles, insulin disposable needles, insulin disposable, safety 80
pen needle, diabetic (pen 29 g x1/2" dis needle, pen 29g x 3/8" dis needle, pen 31 g x1/4" dis needle, pen 31 gx3/16" dis needle, pen 31 g x1/6" dis needle, pen 31 gx5/16" dis needle, pen 32 gx5/16" dis needle, pen 32 gx3/16" dis needle, pen 32 gx 1/4" dis needle, pen 32gx 5/32" dis needle, pen 32 gx 1/5" dis needle, pen 33 g x1/4" dis needle) pen needle, diabetic disposable, safety RENACIDIN IRRIGATION SOLN syringe with needle, insulin, safety, 1 ml syringe with needle,disposable,insulin 81
syringe with needle,disposable,insulin 1 ml (syringe needle,insulin,1ml 30gx 5/16" disp syrin, syringe needle,insulin,1ml 30gx3/8" disp syrin, syringe needle,insulin,1ml 27gx5/8" disp syrin, syringe needle,insulin,1ml 30gx1/2" disp syrin, syringe needle,insulin,1ml disp syrin, syringe needle,insulin,1ml 27gx1/2" disp syrin, syringe needle,insulin,1ml 29gx7/16" disp syrin, syringe needle,insulin,1ml 28gx1/2" disp syrin, syringe needle,insulin,1ml 31 gx5/16" disp syrin, syringe needle,insulin,1ml 30 gauge disp syrin, syringe needle,insulin,1ml 25gx5/8" disp syrin, syringe needle,insulin,1ml 29 g x1/2" disp syrin, syringe needle,insulin,1ml 29 gauge disp syrin, syringe needle,insulin,1ml 31gx3/8" disp syrin, syringe needle,insulin,1ml 31 g x1/4" disp syrin, syringe needle,insulin,1ml 28 gauge disp syrin) syringe with needle,insulin 0.3 ml (half unit mark) (0.3 ml 30gx 5/16" disp syrin, 0.3 ml 31 g x1/4" disp syrin, 0.3 ml 31 gx5/16" disp syrin, 0.3 ml 29 g x1/2" disp syrin) syringe with needle,insulin disposable,0.3 ml syringe with needle,insulin disposable,0.5 ml 82
syringe with needle,insulin,0.3 ml (syring-needl,disp,insul,0.3 ml 29 g x1/2" disp syrin, syringneedl,disp,insul,0.3 ml 31 gx5/16" disp syrin, syring-needl,disp,insul,0.3 ml 30gx3/8" disp syrin, syringneedl,disp,insul,0.3 ml 30gx 5/16" disp syrin, syring-needl,disp,insul,0.3 ml 30gx1/2" disp syrin, syringneedl,disp,insul,0.3 ml 31gx3/8" disp syrin, syring-needl,disp,insul,0.3 ml 30 gauge disp syrin, syringneedl,disp,insul,0.3 ml 29 gauge disp syrin, syring-needl,disp,insul,0.3 ml 31 g x1/4" disp syrin) syringe with needle,insulin,0.5 ml (syringe-needle,insulin,0.5 ml 31 gx5/16" disp syrin, syringeneedle,insulin,0.5 ml 31 g x1/4" disp syrin) Ophthalmic Agents Ophthalmic Agents, Other ak-poly-bac bacitracin/polymyxin b sulfate 500-10k/g oint. (g) BLEPHAMIDE BLEPHAMIDE S.O.P. LACRISERT naphazoline hcl neo-polycin neo-polycin hc neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone neomycin sulfate/bacitracin/polymyxin b 3-Preferred 3-Preferred 83
neomycin sulfate/polymyxin b sulfate/gramicidin d neomycin/polymyxin b sulf/hc 3.5-10k- 10 drops susp neomycin/polymyxin b sulfate/dexamethasone (0.1 % drops susp, 3.5-10k-.1 oint. (g)) neosporin eye drops polycin polymyxin b sulfate/trimethoprim RESTASIS sulfacetamide sodium/prednisolone sodium phosphate tobramycin/dexamethasone tropicamide ZYLET Ophthalmic Anti-allergy Agents azelastine hcl 0.05 % drops cromolyn sodium 4 % drops epinastine hcl olopatadine hcl 0.1 % drops Ophthalmic Anti-inflammatories ALREX bromfenac sodium dexamethasone sod phosphate 0.1 % drops diclofenac sodium 0.1 % drops FLAREX fluorometholone flurbiprofen sodium 3-Preferred 3-Preferred 3-Preferred QL (2 PER 1 DAYS) 84
FML FORTE FML S.O.P. ketorolac tromethamine (0.4 % drops, 0.5 % drops) LOTEMAX (0.5% EYE DROPS, 0.5% OPHTHALMIC GEL, 0.5% EYE OINTMENT) prednisolone acetate prednisolone sod phosphate 1 % drops VEXOL Ophthalmic Antiglaucoma Agents ALPHAGAN P 0.1% DROPS AZOPT betaxolol hcl 0.5 % drops BETIMOL brimonidine tartrate carteolol hcl dorzolamide hcl dorzolamide hcl/timolol maleate ISOPTO CARPINE ISTALOL levobunolol hcl metipranolol pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) timolol maleate drops (0.25, 0.5) timolol maleate sol-gel (0.25, 0.5) TRAVATAN Z 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred 85
Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost QL (5 ML PER 30 DAYS OVER TIME) latanoprost LUMIGAN 3-Preferred QL (2.5 ML PER 30 DAYS OVER TIME) Otic Agents Otic Agents acetasol hc acetic acid/hydrocortisone CIPRO HC CIPRODEX neomycin sulfate/polymyxin b sulfate/hydrocortisone (3.5-10k-1 solution, 3.5-10k-1 drops susp) vosol hc 3-Preferred 3-Preferred Respiratory Tract/Pulmonary Agents Anti-inflammatories, Inhaled Corticosteroids ARNUITY ELLIPTA ASMANEX ASMANEX HFA budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb) budesonide 32mcg spray/pump FLOVENT DISKUS FLOVENT HFA flunisolide 25 mcg spray fluticasone propionate 50 mcg spray susp 3-Preferred 3-Preferred 3-Preferred 3-Preferred 3-Preferred PA TO CONFIRM PART D COVERAGE 86
MOMETASONE FUROATE 50 MCG SPRAY/PUMP NASONEX QVAR Antihistamines azelastine hcl 137 mcg spray/pump clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet) cyproheptadine hcl (2 mg/5 ml syrup, 4 mg/10 ml syrup, 4 mg tablet) levocetirizine dihydrochloride (2.5 mg/5ml solution, 5 mg tablet) Antileukotrienes montelukast sodium zafirlukast 3-Preferred Bronchodilators, Anticholinergic ATROVENT HFA 3-Preferred COMBIVENT RESPIMAT 3-Preferred QL (4 GM PER 30 DAYS OVER TIME) INCRUSE ELLIPTA ipratropium bromide (21 mcg spray, 42 mcg spray) ipratropium bromide 0.2 mg/ml solution 3-Preferred PA TO CONFIRM PART D COVERAGE ipratropium bromide/albuterol sulfate PA TO CONFIRM PART D COVERAGE SPIRIVA SPIRIVA RESPIMAT 3-Preferred 3-Preferred Bronchodilators, Sympathomimetic ADRENACLICK 87
albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2.5 mg/3ml vialneb, 2.5 mg/0.5 vial-neb, 5 mg/ml solution) albuterol sulfate (2 mg/5 ml syrup, 2 mg tablet, 4 mg tab er 12h, 4 mg tablet, 8 mg tab er 12h) PA TO CONFIRM PART D COVERAGE EPINEPHRINE 0.15/0.15 AUTO INJCT EPIPEN 2-PAK EPIPEN JR 2-PAK FORADIL metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet) 3-Preferred 3-Preferred 3-Preferred proair hfa QL (17 GM PER 30 DAYS OVER TIME) proair respiclick QL (2 PER 30 DAYS OVER TIME) PROVENTIL HFA SEREVENT DISKUS terbutaline sulfate (2.5 mg tablet, 5 mg tablet) 3-Preferred QL (13.4 GM PER 30 DAYS OVER TIME) ventolin hfa QL (36 GM PER 30 DAYS OVER TIME) XOPENEX HFA Cystic Fibrosis Agents CAYSTON LA KALYDECO PA, QL (2 PER 1 DAYS) ORKAMBI PA, LA, QL (4 PER 1 DAYS) TOBI PODHALER Mast Cell Stabilizers cromolyn sodium 20 mg/2 ml ampulneb cromolyn sodium 20 mg/ml oral conc PA TO CONFIRM PART D COVERAGE 88
Phosphodiesterase Inhibitors, Airways Disease aminophylline DALIRESP theochron theophylline anhydrous (100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tablet er, 450 mg tab er 12h, 600 mg tablet er) PA Pulmonary Antihypertensives ADCIRCA PA, QL (2 PER 1 DAYS) ADEMPAS PA LETAIRIS PA OPSUMIT PA, LA ORENITRAM ER (ER 0.125 MG TABLET, ER 0.25 MG TABLET) ORENITRAM ER (ER 1 MG TABLET, ER 2.5 MG TABLET) REVATIO 10 MG/ML ORAL SUSP PA SILDENAFIL 10 MG/12.5 ML VIAL PA PA, LA PA, LA sildenafil citrate 20 mg tablet PA, QL (3 PER 1 DAYS) TRACLEER PA, LA VENTAVIS PA, LA Respiratory Tract Agents, Other acetylcysteine PA TO CONFIRM PART D COVERAGE ADVAIR DISKUS ADVAIR HFA AEROSPAN ANORO ELLIPTA 3-Preferred 3-Preferred 3-Preferred ARALAST NP PA 89
BREO ELLIPTA DULERA 3-Preferred ESBRIET PA, LA GLASSIA PA OFEV PA PROLASTIN C PA, LA PULMOZYME PA TO CONFIRM PART D COVERAGE SYMBICORT TYZINE 0.1% NOSE DROPS 3-Preferred XOLAIR PA ZEMAIRA PA, LA Skeletal Muscle Relaxants Skeletal Muscle Relaxants cyclobenzaprine hcl PA FOR 65 YEARS AND OLDER methocarbamol (500 mg tablet, 750 mg tablet) Sleep Disorder Agents GABA Receptor Modulators PA FOR 65 YEARS AND OLDER eszopiclone QL (1 PER 1 DAYS) temazepam (15 mg capsule, 30 mg capsule) zaleplon QL (1 PER 1 DAYS) zolpidem tartrate (5 mg tablet, 10 mg tablet) QL (1 PER 1 DAYS) Sleep Disorders, Other ARMODAFINIL (150 MG TABLET, 200 MG TABLET, 250 MG TABLET) PA, QL (1 PER 1 DAYS) 90
ARMODAFINIL 50 MG TABLET PA, QL (2 PER 1 DAYS) modafinil PA, QL (1 PER 1 DAYS) NUVIGIL (150 MG TABLET, 200 MG TABLET, 250 MG TABLET) NUVIGIL 50 MG TABLET PA, QL (1 PER 1 DAYS) PA, QL (2 PER 1 DAYS) XYREM PA, LA, QL (18 ML PER 1 DAYS) Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Modifiers EXJADE LA JADENU kionex (15 gm/60 ml suspension, powder) SAMSCA sodium polystyrene sulfonate (15 g/60 ml oral susp, 30g/120ml enema, 50g/200ml enema, powder) sps 15 gm/60 ml suspension SYPRINE Electrolyte/Mineral Replacement 0.9 % sodium chloride AMINOSYN II 15% IV SOLUTION PA TO CONFIRM PART D COVERAGE dextrose 10 % in water dextrose 2.5 % and 0.45 % sodium chloride dextrose 5 % and 0.2 % sodium chloride dextrose 5 % and 0.3 % sodium chloride dextrose 5 % and 0.45 % sodium chloride 91
dextrose 5 % and 0.9 % sodium chloride dextrose 5 % in lactated ringers dextrose 5 % in water fluor-a-day (0.25 mg tab chew, 0.5 mg tab chew, 1 mg tablet chew) fluoritab (0.5 mg tablet chew, 1 mg tablet chew) focalgin-b folbecal INTRALIPID PA TO CONFIRM PART D COVERAGE k-sol k-tab er klor-con 10 klor-con 8 klor-con m10 klor-con m15 klor-con m20 klor-con sprinkle kosher prenatal plus iron levocarnitine (with sugar) PA TO CONFIRM PART D COVERAGE levocarnitine 200 mg/ml vial PA TO CONFIRM PART D COVERAGE levocarnitine 330 mg tablet PA TO CONFIRM PART D COVERAGE LIPOSYN II PA TO CONFIRM PART D COVERAGE LIPOSYN III (20% IV, 30% IV) PA TO CONFIRM PART D COVERAGE ludent fluoride magnesium sulfate 4 meq/ml vial NUTRILIPID PA TO CONFIRM PART D COVERAGE NUTRILYTE II 92
potassium chloride (2 meq/ml vial, 2 meq/ml iv soln, 10meq/0.1l piggyback, 10meq/50ml piggyback, 20meq/50ml piggyback, 20meq/0.1l piggyback, 30meq/0.1l piggyback, 40meq/0.1l piggyback) potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq tab er prt, 10 meq tablet er, 10 meq capsule er, 20meq/15ml liquid, 20 meq tablet er, 20 meq tab er prt, 40meq/15ml liquid) potassium chloride in dextrose 5 % and 0.9 % sodium chloride potassium chloride in dextrose 5 %-0.45 % sodium chloride (chloride/d5-0.45nacl 10 iv soln, chloride/d5-0.45nacl 20 iv soln, chloride/d5-0.45nacl 30 iv soln) potassium chloride in lactated ringers and 5 % dextrose potassium chloride/d5-0.2%nacl 20 meq/l iv soln potassium citrate prenaissance next prenaissance next-b prenatal plus iron tablet prenatal plus tablet prenatal vitamins tablet ringers solution,lactated iv soln sodium chloride irrigating solution sodium fluoride (0.25(0.55) tab chew, 0.5(1.1)mg tab chew, 1mg(2.2mg) tab chew) thrivite 19 thrivite rx tl folate 93
TPN ELECTROLYTES virt nate virt-care one virt-nate virt-vite gt vol-plus tablet vp-ggr-b6 zingiber 94
Alphabetical Listing 0 0.9 % sodium chloride 91 A abacavir sulfate 36 abacavir sulfate/lamivudine/zidovudine 36 ABELCET 22 ABILIFY 19 ABILIFY DISCMELT 19 ABILIFY MAINTENA 33 absorica 57 acamprosate calcium 6 acarbose 40 acebutolol hcl 48 acetaminophen with codeine phosphate 3 acetasol hc 86 acetazolamide 51 acetazolamide sodium 51 acetic acid 7 acetic acid/hydrocortisone 86 acetylcysteine 89 acitretin 57 ACTHIB 77 ACTIMMUNE 77 acyclovir 39 acyclovir sodium 39 ADACEL TDAP 77 ADAGEN 58 adapalene 57 ADCIRCA 89 ADEFOVIR DIPIVOXIL 37 ADEMPAS 89 ADRENACLICK 87 ADRUCIL 27 ADVAIR DISKUS 89 ADVAIR HFA 89 AEROSPAN 89 afeditab cr 49 AFINITOR 29 AFINITOR DISPERZ 29 AGGRENOX 45 ak-poly-bac 83 alagesic lq 1 ALBENZA 31 albuterol sulfate 88 alclometasone dipropionate 63 alcohol antiseptic pads 80 ALDURAZYME 58 ALECENSA 29 alendronate sodium 79 alfuzosin hcl 62 ALIMTA 28 ALINIA 31 allopurinol 24 ALOGLIPTIN BENZOATE 40 ALOGLIPTIN BENZOATE/METFORMIN HCL 40 ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 40 alosetron hcl 61 ALPHAGAN P 85 ALREX 84 altavera 67 alyacen 67 amantadine hcl 32 AMBISOME 22 amcinonide 63 amethyst 67 amifostine crystalline 28 amiloride hcl 51 amiloride hcl/hydrochlorothiazide 51 aminophylline 89 AMINOSYN II 91 amiodarone hcl 47 AMITIZA 61 amitriptyline hcl 21 amlodipine besylate 49 amlodipine besylate/atorvastatin calcium 49 amlodipine besylate/benazepril hcl 49 amlodipine besylate/valsartan 49 ammonium lactate 57 amnesteem 57 amoxapine 21 95
amoxicillin 11 amoxicillin/potassium clavulanate 11 amphotericin b 23 ampicillin sodium 11 ampicillin sodium/sulbactam sodium 11 ampicillin trihydrate 11 AMPYRA 55 anagrelide hcl 44 anastrozole 28 ANDRODERM 67 ANDROGEL 67 ANDROXY 67 ANORO ELLIPTA 89 anusol-hc 63 APOKYN 32 apri 67 APRISO 78 APTIOM 17 APTIVUS 37 ARALAST NP 89 aranelle 67 ARANESP 44 ARCALYST 77 aripiprazole 19 ARIPIPRAZOLE 19 ARMODAFINIL 90,91 ARNUITY ELLIPTA 86 ASACOL HD 79 ascomp with codeine 3 ASMANEX 86 ASMANEX HFA 86 ASPIRIN/DIPYRIDAMOLE 45 ASTAGRAF XL 74 ASTRAMORPH-PF 2 atenolol 48 atenolol/chlorthalidone 48 atorvastatin calcium 52 ATOVAQUONE 31 ATRIPLA 35 ATROVENT HFA 87 AUBAGIO 55 aubra 67 AURYXIA 63 AVASTIN 30 AVELOX IV 12 aviane 67 avidoxy 13 avita 57 AVONEX 55 AVONEX ADMINISTRATION PACK 56 AVONEX PEN 56 AVYCAZ 7 AZACITIDINE 28 AZASITE 12 azathioprine 75 azathioprine sodium 75 azelastine hcl 84,87 AZILECT 32 azithromycin 12 AZOPT 85 aztreonam 10 azurette 67 B BACIIM 7 bacitracin 7 bacitracin/polymyxin b sulfate 83 baclofen 35 balsalazide disodium 79 balziva 67 BANZEL 17 BARACLUDE 37 bcg live 77 bcg vaccine, live/pf 77 bekyree 67 benazepril hcl 46 benazepril hcl/hydrochlorothiazide 46 BENLYSTA 75 benztropine mesylate 32 betamethasone dipropionate 64 betamethasone dipropionate/propylene glycol 64 betamethasone valerate 64 96
BETASERON 56 betaxolol hcl 48,85 bethanechol chloride 63 BETIMOL 85 BEXAROTENE 30 BEXSERO 77 bicalutamide 27 BICILLIN C-R 11 BICILLIN L-A 11 bimatoprost 86 BINOSTO 79 bisoprolol fumarate 48 bisoprolol fumarate/hydrochlorothiazide 48 BIVIGAM 76 bleomycin sulfate 28 bleph-10 13 BLEPHAMIDE 83 BLEPHAMIDE S.O.P. 83 blisovi 24 fe 67 blisovi fe 67 BOOSTRIX TDAP 77 BOSULIF 29 BREO ELLIPTA 90 briellyn 67 BRILINTA 45 brimonidine tartrate 85 BRINTELLIX 19 bromfenac sodium 84 bromocriptine mesylate 32 budeprion sr 19 budesonide 64,86 bumetanide 51 buprenorphine hcl 6 buprenorphine hcl/naloxone hcl 6 buproban 19 bupropion hcl 19 buspirone hcl 39 butalbital/acetaminophen 1 butalbital/acetaminophen/caffeine 1 butalbital/acetaminophen/caffeine/codeine phosphate 3 butalbital/aspirin/caffeine 1 butorphanol tartrate 3 BYDUREON 40 BYDUREON PEN 40 BYETTA 40 BYSTOLIC 48 C cabergoline 74 cafergot 24 calcipotriene 57 calcitonin,salmon,synthetic 79 calcitrene 57 calcitriol 79 calcium acetate 63 camila 72 CANASA 79 CANCIDAS 23 candesartan cilexetil 46 capacet 1 CAPASTAT SULFATE 26 CAPRELSA 29 captopril 46 captopril/hydrochlorothiazide 46 CARAC 57 CARAFATE 61 CARBAGLU 59 carbamazepine 17 carbidopa 32 carbidopa/levodopa 32 carbidopa/levodopa/entacapone 32 CARDIZEM LA 49 CARIMUNE NF NANOFILTERED 76 carteolol hcl 85 cartia xt 49 carvedilol 48 CAYSTON 88 caziant 68 CEDAX 9 CEENU 26 cefaclor 9 cefadroxil 9 97
cefazolin sodium 9 cefdinir 9 cefepime hcl 9 cefepime hcl/dextrose 5 % in water 9 cefotaxime sodium 9 cefotetan disodium 9 cefoxitin sodium 9 cefpodoxime proxetil 9 cefprozil 9 ceftazidime 10 ceftibuten 10 CEFTIN 10 ceftriaxone sodium 10 ceftriaxone sodium/dextrose, iso-osmotic 10 cefuroxime axetil 10 cefuroxime sodium 10 cefuroxime sodium/dextrose, iso-osmotic 10 celecoxib 1 CELLCEPT 75 CELONTIN 15 cephalexin 10 CERDELGA 59 CEREZYME 59 CERVARIX 77 CHANTIX 6 chateal 68 CHENODAL 60 chloramphenicol sod succ 7 chlorhexidine gluconate 56 chloroquine phosphate 31 chlorothiazide 52 chlorpromazine hcl 21,22 chlorthalidone 52 CHOLBAM 60 cholestyramine (with sugar) 53 cholestyramine/aspartame 53 ciclodan 23 ciclopirox 23 ciclopirox olamine 23 cilostazol 45 cimetidine 60 cimetidine hcl 60 CINRYZE 74 CIPRO HC 86 CIPRODEX 86 ciprofloxacin hcl 12 ciprofloxacin lactate 13 ciprofloxacin lactate/dextrose 5 % in water 13 ciprofloxacin/ciprofloxacin hcl 13 citalopram hydrobromide 20 claravis 57 clarithromycin 12 clemastine fumarate 87 clindacin etz 7 clindacin p 7 clindamycin hcl 7 clindamycin palmitate hcl 7 clindamycin phosphate 7 clindamycin phosphate/dextrose 5 % in water 7 clobetasol propionate 64 clobetasol propionate/emollient base 64 clodan 64 clomipramine hcl 21 clonazepam 15 clonidine 45 clonidine hcl 45,54 clopidogrel bisulfate 45 clorazepate dipotassium 15 clotrimazole 23 clotrimazole/betamethasone dipropionate 57 CLOZAPINE 34 clozapine 34 COARTEM 31 codeine phosphate/butalbital/aspirin/caffeine 3 COLCHICINE 24 colchicine/probenecid 24 COLCRYS 24 colestipol hcl 53 colistin (as colistimethate sodium) 7 colocort 64 COMBIVENT RESPIMAT 87 COMETRIQ 29 98
COMPLERA 35 compro 22 COMVAX 77 constulose 61 COPAXONE 56 COREG CR 48 CORLANOR 50 cormax 64 cortisone acetate 64 COTELLIC 29 CREON 59 CRESTOR 52 CRIXIVAN 37 cromolyn sodium 84,88 cryselle 68 CUBICIN 8 CUPRIMINE 63 cyclafem 68 cyclobenzaprine hcl 90 CYCLOPHOSPHAMIDE CAPSULES (25 MG, 50 MG) 26 cycloserine 26 CYCLOSET 40 cyclosporine 75 cyclosporine, modified 75 cyproheptadine hcl 87 cyred 68 CYSTADANE 59 CYSTAGON 59 CYSTARAN 59 D DAKLINZA 38 DALIRESP 89 DALVANCE 8 danazol 67 dantrolene sodium 35 dapsone 25 DAPTACEL DTAP 77 DARAPRIM 31 dasetta 68 DAYTRANA 54 deblitane 72 delyla 68 DELZICOL 79 demeclocycline hcl 13 DEMSER 50 denta 5000 plus 56 dentagel 56 DEPEN 63 DEPO-SUBQ PROVERA 104 72 dermacinrx prizopak 5 DESCOVY 36 desipramine hcl 21 desmopressin acetate 66 desmopressin acetate (non-refrigerated) 66 desogestrel-ethinyl estradiol 68 desogestrel-ethinyl estradiol/ethinyl estradiol 68 desonide 64 desoximetasone 64 DESVENLAFAXINE 20 dexamethasone 64 dexamethasone sod phosphate 64,84 dexamethasone sodium phosphate/pf 64 dexmethylphenidate hcl 55 dextroamphetamine sulf-saccharate/amphetamine sulfaspartate 54 dextroamphetamine sulfate 54 dextrose 10 % in water 91 dextrose 2.5 % and 0.45 % sodium chloride 91 dextrose 5 % and 0.2 % sodium chloride 91 dextrose 5 % and 0.3 % sodium chloride 91 dextrose 5 % and 0.45 % sodium chloride 91 dextrose 5 % and 0.9 % sodium chloride 92 dextrose 5 % in lactated ringers 92 dextrose 5 % in water 92 DIASTAT 15 diazepam 15 DIAZEPAM 15 diclofenac potassium 1 diclofenac sodium 1,84 dicloxacillin sodium 11 99
didanosine 36 diflorasone diacetate 64 diflunisal 1 digitek 51 digox 51 digoxin 51 dihydroergotamine mesylate 24 DIHYDROERGOTAMINE MESYLATE 24 DILANTIN 17 dilt-cd 49 dilt-xr 49 diltiazem hcl 49,50 diphenhydramine hcl 22 disopyramide phosphate 47 disulfiram 6 divalproex sodium 15 dofetilide 47 donepezil hcl 18 DORIBAX 10 dorzolamide hcl 85 dorzolamide hcl/timolol maleate 85 doxazosin mesylate 45 doxepin hcl 21 doxercalciferol 79 DOXY 100 14 doxycycline hyclate 14 doxycycline monohydrate 14 dronabinol 22 DROXIA 27 DUAVEE 72 DULERA 90 duloxetine hcl 20 dutasteride 62 dynacin 14 DYRENIUM 51 E E.E.S. 200 12 e.e.s. 400 12 econazole nitrate 23 EDECRIN 51 EDURANT 35 EFFIENT 45 EGRIFTA 66 ELAPRASE 59 ELELYSO 59 ELIDEL 57 ELIGARD 74 elinest 68 eliphos 63 ELIQUIS 43 ELITEK 28 ELLA 72 ELMIRON 63 EMCYT 27 EMEND 22 emoquette 68 EMSAM 19 EMTRIVA 36 enalapril maleate 46 enalapril maleate/hydrochlorothiazide 46 ENBREL 75 endocet 3 endodan 3 ENGERIX-B ADULT 77 ENGERIX-B PEDIATRIC-ADOLESCENT 77 ENOXAPARIN SODIUM 43 enoxaparin sodium 43 enpresse 68 enskyce 68 entacapone 32 ENTECAVIR 38 ENTRESTO 51 enulose 61 EPANED 46 EPIFOAM 57 epinastine hcl 84 EPINEPHRINE 88 EPIPEN 2-PAK 88 EPIPEN JR 2-PAK 88 epitol 17 EPIVIR HBV 38 100
eplerenone 52 EPOGEN 44 eprosartan mesylate 46 EPZICOM 36 ergotamine tartrate/caffeine 25 ERIVEDGE 29 errin 72 ery 12 ERY-TAB 12 erygel 12 ERYPED 200 12 ERYTHROCIN LACTOBIONATE 12 ERYTHROCIN STEARATE 12 erythromycin base 12 erythromycin base/benzoyl peroxide 57 erythromycin base/ethyl alcohol 12 erythromycin ethylsuccinate 12 ESBRIET 90 escitalopram oxalate 20 estarylla 68 ESTRACE 68 estradiol 68 estradiol valerate 68 estradiol/norethindrone acetate 68 ESTRING 68 estropipate 68 eszopiclone 90 ethambutol hcl 26 ethinyl estradiol/drospirenone 68 ethosuximide 15 etidronate disodium 79 etodolac 1 etoposide 29 EVOTAZ 37 EXELON 18 exemestane 28 EXJADE 91 EXTAVIA 56 F FABRAZYME 59 falmina 68 famciclovir 39 famotidine 60 famotidine in sodium chloride, iso-osmotic/pf 60 FANAPT 33 FARESTON 27 FARXIGA 40 FARYDAK 28 FASLODEX 28 FAZACLO 34 felbamate 16 felodipine 50 fenofibrate 52 fenofibrate nanocrystallized 52 fenofibrate,micronized 52 fenofibric acid (choline) 52 fenoprofen calcium 1 fentanyl 2 fentanyl citrate 2 FETZIMA 20 finasteride 63 fioricet 1 FIRAZYR 74 FLAREX 84 flavoxate hcl 62 FLEBOGAMMA DIF 76 flecainide acetate 47 FLOVENT DISKUS 86 FLOVENT HFA 86 fluconazole 23 fluconazole in dextrose, iso-osmotic 23 fluconazole in sodium chloride, iso-osmotic 23 FLUCYTOSINE 23 fludrocortisone acetate 64 flunisolide 86 fluocinolone acetonide 64 fluocinolone acetonide oil 64 fluocinolone acetonide/shower cap 65 fluocinonide 65 fluocinonide/emollient base 65 fluor-a-day 92 101
fluoridex daily defense 56 fluoritab 92 fluorometholone 84 fluorouracil 27,58 FLUOROURACIL 58 fluoxetine hcl 20 fluphenazine decanoate 32 fluphenazine hcl 33 flurbiprofen 1 flurbiprofen sodium 84 flutamide 27 fluticasone propionate 65,86 fluvastatin sodium 52 fluvoxamine maleate 20 FML FORTE 85 FML S.O.P. 85 focalgin-b 92 folbecal 92 FONDAPARINUX SODIUM 43 fondaparinux sodium 43 FORADIL 88 FORTEO 79 foscarnet sodium 37 fosinopril sodium 46 fosinopril sodium/hydrochlorothiazide 46 fosphenytoin sodium 17 FOSRENOL 63 FRAGMIN 43 FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR) 43 FULYZAQ 60 furosemide 51 FUZEON 36 fyavolv 68 FYCOMPA 16 G gabapentin 15 GABITRIL 15 galantamine hbr 18 GAMMAGARD LIQUID 76 GAMMAGARD S-D 76 GAMMAKED 76 GAMMAPLEX 76 GAMUNEX 76 GAMUNEX-C 76 ganciclovir sodium 37 garamycin 6 GARDASIL 77 GARDASIL 9 77 gatifloxacin 13 GATTEX 60 gauze bandage 80 gavilyte-c 61 gavilyte-g 61 gavilyte-n 61 gemfibrozil 52 generlac 61 gengraf 75 gentak 6 gentamicin sulfate 6,7 gentamicin sulfate/pf 7 GENVOYA 35 GEODON 33 gianvi 68 gildagia 68 gildess 68 gildess 24 fe 68 gildess fe 69 GILENYA 56 GILOTRIF 29 GLASSIA 90 GLATOPA 56 GLEEVEC 29 GLEOSTINE 26 glimepiride 40 glipizide 40 glipizide/metformin hcl 40 GLUCAGON EMERGENCY KIT 42 glycopyrrolate 60 glydo 5 GLYXAMBI 40 102
granisetron hcl 22 GRANIX 44 GRASTEK 75 griseofulvin ultramicrosize 23 griseofulvin, microsize 23 guanidine hcl 25 H halobetasol propionate 65 haloperidol 33 haloperidol decanoate 33 haloperidol lactate 33 HARVONI 38 HAVRIX 77 heather 72 hecoria 75 heparin sodium,porcine 44 heparin sodium,porcine in 0.45 % sodium chloride 44 heparin sodium,porcine/dextrose 5 % in water 44 heparin sodium,porcine/pf 44 HETLIOZ 55 HEXALEN 26 HIBERIX 77 HUMALOG 42 HUMALOG KWIKPEN U-100 42 HUMALOG KWIKPEN U-200 42 HUMALOG MIX 50-50 42 HUMALOG MIX 50-50 KWIKPEN 42 HUMALOG MIX 75-25 42 HUMALOG MIX 75-25 KWIKPEN 42 HUMIRA 75 HUMIRA PEDIATRIC CROHN'S 75 HUMIRA PEN 75 HUMIRA PEN CROHN'S-UC-HS 75 HUMIRA PEN PSORIASIS 75 HUMULIN 70-30 42 HUMULIN 70/30 KWIKPEN 42 HUMULIN N 42 HUMULIN N KWIKPEN 42 HUMULIN R 42 hydralazine hcl 53 hydrochlorothiazide 52 hydrocodone bitartrate/acetaminophen 4 hydrocortisone 65 hydrocortisone butyrate 65 hydrocortisone valerate 65 hydrocortisone/mineral oil/petrolatum,white 65 hydromorphone hcl 4 hydromorphone hcl/pf 4 hydroxychloroquine sulfate 31 hydroxyurea 27 I ibandronate sodium 79,80 IBRANCE 29 ibuprofen 1 ICLUSIG 29 ILARIS 77 IMATINIB MESYLATE 29 IMBRUVICA 29 imipenem/cilastatin sodium 10 imipramine hcl 21 imipramine pamoate 21 imiquimod 58 IMOVAX RABIES VACCINE 77 INCRELEX 66 INCRUSE ELLIPTA 87 indapamide 52 INFANRIX DTAP 77 INLYTA 29 insulin syringe (disp syrin) 80 INTELENCE 35 INTRALIPID 92 INTRON A 38 introvale 69 INVANZ 10 INVEGA 33 INVEGA SUSTENNA 33,34 INVEGA TRINZA 34 INVIRASE 37 INVOKAMET 40 INVOKANA 40 103
IPOL 77 ipratropium bromide 87 ipratropium bromide/albuterol sulfate 87 irbesartan 46 irbesartan/hydrochlorothiazide 46 IRESSA 29 ISENTRESS 35 isochron 53 isoniazid 26 ISOPTO CARPINE 85 isosorbide dinitrate 54 isosorbide mononitrate 54 isradipine 50 ISTALOL 85 itraconazole 23 ivermectin 31 IXEMPRA 28 IXIARO 77 J JADENU 91 JAKAFI 29 jantoven 44 JANUMET 40 JANUMET XR 40 JANUVIA 41 JARDIANCE 41 jencycla 72 JENTADUETO 41 jevantique lo 69 jinteli 69 jolessa 69 jolivette 72 juleber 69 junel 69 junel fe 69 junel fe 24 69 JUXTAPID 53 K k-sol 92 k-tab er 92 KALETRA 37 KALYDECO 88 kariva 69 KAZANO 41 kelnor 1-35 69 ketoconazole 23 ketodan 23 ketoprofen 1 ketorolac tromethamine 85 KHEDEZLA 20 kimidess 69 kionex 91 klor-con 10 92 klor-con 8 92 klor-con m10 92 klor-con m15 92 klor-con m20 92 klor-con sprinkle 92 KOMBIGLYZE XR 41 KORLYM 73 kosher prenatal plus iron 92 kurvelo 69 KUVAN 59 KYNAMRO 53 L labetalol hcl 48 LACRISERT 83 lactulose 61 LAMICTAL (BLUE) 16 LAMICTAL (GREEN) 16 LAMICTAL (ORANGE) 16 LAMICTAL XR (BLUE) 16 LAMICTAL XR (GREEN) 16 LAMICTAL XR (ORANGE) 16 lamivudine 36,38 lamivudine/zidovudine 36 lamotrigine 17 lansoprazole 62 lansoprazole/amoxicillin trihydrate/clarithromycin 60 104
LANTUS 42 LANTUS SOLOSTAR 42 larin 69 larin 24 fe 69 larin fe 69 latanoprost 86 LATUDA 34 LAZANDA 4 leena 69 leflunomide 77 LENVIMA 29 lessina 69 LETAIRIS 89 letrozole 28 leucovorin calcium 28 LEUKERAN 26 LEUKINE 44 leuprolide acetate 74 LEVATOL 48 LEVEMIR 42 LEVEMIR FLEXPEN 42 LEVEMIR FLEXTOUCH 42 levetiracetam 14 levetiracetam in sodium chloride, iso-osmotic 14 levobunolol hcl 85 levocarnitine 92 levocarnitine (with sugar) 92 levocetirizine dihydrochloride 87 levofloxacin 13 levofloxacin/dextrose 5 % in water 13 levonest 69 levonorgestrel-ethinyl estradiol 69 levora-28 69 levorphanol tartrate 2 levothyroxine sodium 73 levoxyl 73 LEXIVA 37 LIALDA 79 lidocaine 5 lidocaine hcl 5 lidocaine hcl/pf 5 lidocaine/prilocaine 5 lindane 31 LINEZOLID 8 LINEZOLID IN 0.9 % SODIUM CHLORIDE 8 liothyronine sodium 73 LIPOSYN II 92 LIPOSYN III 92 lisinopril 47 lisinopril/hydrochlorothiazide 47 lithium carbonate 39 lithium citrate 40 lofibra 52 lomedia 24 fe 69 LOMUSTINE 26 LONSURF 28 loperamide hcl 60 lopreeza 69 lorazepam 39 lorazepam intensol 39 lorcet 4 lorcet hd 4 lorcet plus 4 lortab 4 loryna 69 losartan potassium 46 losartan potassium/hydrochlorothiazide 46 LOTEMAX 85 lovastatin 52 low-ogestrel 69 loxapine succinate 33 ludent fluoride 92 LUMIGAN 86 LUMIZYME 59 LUPANETA PACK 74 LUPRON DEPOT 74 LUPRON DEPOT-PED 74 lutera 69 LYNPARZA 29 LYRICA 15 LYSODREN 73 lyza 72 105
M M-M-R II VACCINE 77 magnesium sulfate 92 maprotiline hcl 19 marlissa 69 MARPLAN 19 MATULANE 27 matzim la 50 meclizine hcl 22 meclofenamate sodium 2 medroxyprogesterone acetate 72 mefloquine hcl 31 megestrol acetate 72 MEKINIST 29 meloxicam 2 memantine hcl 18 MENACTRA 77 MENEST 69 MENHIBRIX 77 MENOMUNE-A-C-Y-W-135 78 MENVEO A-C-Y-W-135-DIP 78 mercaptopurine 27 meropenem 10 meropenem in 0.9 % sodium chloride 10 mesalamine 79 mesalamine with cleansing wipes 79 MESNEX 21 MESTINON 25 metadate er 55 metaproterenol sulfate 88 metformin hcl 41 metformin hcl 500 mg osm-tab er 24 41 metformin hcl 500 mg tab er 24h (generic for glucophage xr) 41 methadone hcl 2 methazolamide 51 methenamine hippurate 8 methenamine mandelate 8 methimazole 74 methocarbamol 90 methotrexate sodium 75 methotrexate sodium/pf 75 METHOXSALEN, RAPID 58 methscopolamine bromide 60 methylergonovine maleate 63 methylphenidate hcl 55 methylprednisolone 65 methylprednisolone acetate 65 methylprednisolone sodium succinate 65 metipranolol 85 metoclopramide hcl 22 metolazone 52 metoprolol succinate 48 metoprolol tartrate 48 metoprolol tartrate/hydrochlorothiazide 48 metronidazole 8 metronidazole in sodium chloride 8 mexiletine hcl 47 MIACALCIN 80 miconazole nitrate 23 microgestin 70 microgestin fe 70 midodrine hcl 45 migergot 25 MIGRANAL 25 millipred 65 millipred dp 65 mimvey 70 mimvey lo 70 minitran 54 minocycline hcl 14 minoxidil 53 mircette 70 mirtazapine odt (15 mg, 45 mg, 30 mg) 19 mirtazapine tablet (15 mg, 45 mg, 7.5 mg, 30mg) 19 misoprostol 62 mitoxantrone hcl 28 modafinil 91 moderiba 38 moexipril hcl 47 moexipril hcl/hydrochlorothiazide 47 106
molindone hcl 33 mometasone furoate 65 MOMETASONE FUROATE 87 mondoxyne nl 14 mono-linyah 70 mononessa 70 montelukast sodium 87 MONUROL 8 morgidox 14 morphine sulfate 2,3,4 morphine sulfate/pf 4 MOVANTIK 60 MOVIPREP 61 moxifloxacin hcl 13 moxifloxacin hcl in sodium acetate and sulfate,water,iso-osm 13 MULTAQ 47 mupirocin 2% ointment 8 MYALEPT 66 mycophenolate mofetil 75 MYCOPHENOLATE MOFETIL 75 mycophenolate sodium 75 myorisan 58 MYOZYME 59 MYRBETRIQ 62 myzilra 70 N nabumetone 2 nadolol 49 nafcillin sodium 11 NAGLAZYME 59 naloxone hcl 6 naltrexone hcl 6 NAMENDA 18 NAMENDA XR 18 naphazoline hcl 83 naproxen 2 naproxen sodium 2 naratriptan hcl 25 NARCAN 6 NASONEX 87 NATACYN 23 nateglinide 41 NATPARA 63 NEBUPENT 31 necon 70 needles, insulin disposable 80 needles, insulin disposable, safety 80 nefazodone hcl 20 neo-polycin 83 neo-polycin hc 83 neomycin sulfate 7 neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone 83 neomycin sulfate/bacitracin/polymyxin b 83 neomycin sulfate/polymyxin b sulfate/gramicidin d 84 neomycin sulfate/polymyxin b sulfate/hydrocortisone 84,86 neomycin/polymyxin b sulfate/dexamethasone 84 neosporin 84 neptazane 51 NESINA 41 NEULASTA 45 NEUMEGA 45 NEUPOGEN 45 nevirapine 35 NEXAVAR 29 nicardipine hcl 50 NICOTROL 6 NICOTROL NS 6 nifediac cc 50 nifedical xl 50 nifedipine 50 nikki 70 NILANDRON 27 nimodipine 50 NINLARO 29 nisoldipine 50 NITRO-DUR 54 nitrofurantoin 8 nitrofurantoin macrocrystal 8 107
nitrofurantoin monohydrate/macrocrystals 8 nitroglycerin 54 NITROSTAT 54 nizatidine 61 nora-be 72 norethindrone 72 norethindrone acetate 72 norethindrone acetate-ethinyl estradiol 70 norethindrone acetate-ethinyl estradiol/ferrous fumarate 70 norgestimate-ethinyl estradiol 70 norlyroc 72 NORPACE CR 47 NORTHERA 51 nortrel 70 nortriptyline hcl 21 NORVIR 37 NOXAFIL 23 NUEDEXTA 55 NULOJIX 76 NUTRILIPID 92 NUTRILYTE II 92 NUVIGIL 91 nyamyc 23 nystatin 24 nystatin/triamcinolone acetonide 24 nystop 24 O ocella 70 octreotide acetate 74 ODEFSEY 35 ODOMZO 30 OFEV 90 ofloxacin 13 ogestrel 70 olanzapine 34 olanzapine/fluoxetine hcl 19 olopatadine hcl 84 OLYSIO 38 omeprazole 62 OMNITROPE 66 ondansetron 22 ondansetron hcl 22 ondansetron hcl/pf 22 ONFI 15 ONGLYZA 41 OPSUMIT 89 ORALAIR 76 oralone 56 ORAP 33 ORBACTIV 8 ORENITRAM ER 89 ORFADIN 59 ORKAMBI 88 orsythia 70 OSENI 41 OTEZLA 58 oxacillin sodium 11 oxacillin sodium/dextrose, iso-osmotic 11 oxandrolone 67 oxazepam 39 oxcarbazepine 17 oxybutynin chloride 62 OXYCODONE HCL 3 oxycodone hcl 4 oxycodone hcl/acetaminophen 5 oxycodone hcl/aspirin 5 OXYCONTIN 3 oxymorphone hcl 5 OXYTROL 62 P pacerone 47 paliperidone 34 pamidronate disodium 80 pancrelipase 5,000 59 PANRETIN 30 pantoprazole sodium 62 paricalcitol 80 paroex 56 paromomycin sulfate 7 108
paroxetine hcl 20 PASER 26 PAXIL 20 pedi-dri 24 PEDVAXHIB 78 peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl 61 PEGANONE 17 PEGASYS 38 PEGASYS PROCLICK 38 PEGINTRON 38 PEGINTRON REDIPEN 38 pen needle, diabetic 81 pen needle, diabetic disposable, safety 81 penicillin g potassium 11 penicillin g procaine 11 penicillin g sodium 11 penicillin v potassium 11 PENTACEL ACTHIB COMPONENT 78 PENTACEL DTAP-IPV COMPONENT 78 PENTAM 300 31 PENTASA 79 pentoxifylline 51 perindopril erbumine 47 periogard 56 permethrin 31 perphenazine 22 perphenazine/amitriptyline hcl 33 PFIZERPEN 11 phenelzine sulfate 19 phenobarbital 16 PHENOXYBENZAMINE HCL 45 phenytoin 17 phenytoin sodium 17 phenytoin sodium extended 18 philith 70 PICATO 58 pilocarpine hcl 56,85 pimozide 33 pimtrea 70 pindolol 49 pioglitazone hcl 41 pioglitazone hcl/glimepiride 41 pioglitazone hcl/metformin hcl 41 piperacillin sodium/tazobactam sodium 11 pirmella 70 piroxicam 2 PLEGRIDY 56 PLEGRIDY PEN 56 podofilox 58 polycin 84 polyethylene glycol 3350 61 polymyxin b sulfate/trimethoprim 84 POMALYST 27 portia 70 potassium chloride 93 potassium chloride in dextrose 5 % and 0.9 % sodium chloride 93 potassium chloride in dextrose 5 %-0.2 % sodium chloride 93 potassium chloride in dextrose 5 %-0.45 % sodium chloride 93 potassium chloride in lactated ringers and 5 % dextrose 93 potassium citrate 93 POTIGA 14 PRADAXA 44 PRALUENT PEN 53 PRALUENT SYRINGE 53 pramipexole di-hcl 32 pravastatin sodium 53 prazosin hcl 45 prednisolone 65 prednisolone acetate 85 prednisolone sod phosphate 65,85 prednisone 65 prednisone intensol 65 PREMARIN 70 PREMPHASE 70 PREMPRO 70 prenaissance next 93 prenaissance next-b 93 109
prenatal plus iron tablet 93 prenatal plus tablet 93 prenatal vitamins tablet 93 prevalite 53 prevident 57 PREVIDENT 57 PREVIDENT 5000 57 PREVIDENT 5000 PLUS 57 previfem 71 PREZCOBIX 37 PREZISTA 37 PRIFTIN 26 primaquine phosphate 31 primidone 16 PRISTIQ ER 20 PRIVIGEN 76 proair hfa 88 proair respiclick 88 probenecid 24 procainamide hcl 47 prochlorperazine 22 prochlorperazine edisylate 22 prochlorperazine maleate 22 PROCRIT 45 procto-med hc 65 proctocream-hc 66 PROCTOFOAM-HC 58 proctosol-hc 66 proctozone-hc 66 PROCYSBI 59 progesterone,micronized 72 PROGLYCEM 42 PROGRAF 76 PROLASTIN C 90 PROLEUKIN 28 PROLIA 80 PROMACTA 45 propafenone hcl 47 propranolol hcl 49 propranolol hcl/hydrochlorothiazide 49 propylthiouracil 74 PROQUAD 78 PROTONIX 62 PROTONIX IV 62 protriptyline hcl 21 PROVENTIL HFA 88 psorcon 66 PULMOZYME 90 PURIXAN 27 PYLERA 60 pyrazinamide 26 pyridostigmine bromide 25 Q QUADRACEL DTAP-IPV 78 quasense 71 quetiapine fumarate 34 quinapril hcl 47 quinapril hcl/hydrochlorothiazide 47 quinidine gluconate 47 quinidine sulfate 47 QVAR 87 R RABAVERT 78 rabeprazole sodium 62 RAGWITEK 76 raloxifene hcl 73 ramipril 47 RANEXA 51 ranitidine hcl 61 RAPAMUNE 76 RAVICTI 59 REBETOL 38 REBIF 56 REBIF REBIDOSE 56 reclipsen 71 RECOMBIVAX HB 78 REGRANEX 58 relador pak 5 relador pak plus 5 RELENZA 39 110
RELISTOR 60 RELISTOR 12 MG/0.6 ML (KIT, SYRINGE, VIAL) 60 REMICADE 76 RENACIDIN 81 RENVELA 63 REPATHA SURECLICK 53 REPATHA SYRINGE 53 RESCRIPTOR 35 RESTASIS 84 RETROVIR 36 REVATIO 89 revia 6 REVLIMID 27 REXULTI 19 REYATAZ 37 ribasphere 38 RIBASPHERE 38 ribavirin 38 rifabutin 25 rifampin 26 RIFATER 26 riluzole 55 rimantadine hcl 39 ringers solution,lactated 93 RIOMET 41 risedronate sodium 80 RISPERDAL CONSTA 34 risperidone 34 RITALIN LA 55 RITUXAN 30 rivastigmine 18 rivastigmine tartrate 18 rizatriptan benzoate 25 ropinirole hcl 32 rosadan 8 rosuvastatin calcium 53 ROTARIX 78 ROTATEQ 78 roweepra 14 ROXICET 5 roxicet 5 S SABRIL 16 SAMSCA 91 SANTYL 58 SAPHRIS 34 SAVAYSA 44 SAVELLA 55 selegiline hcl 32 selenium sulfide 58 SELZENTRY 36 SENSIPAR 73 SEREVENT DISKUS 88 SEROQUEL XR 34 sertraline hcl 20 setlakin 71 SEVELAMER CARBONATE 63 sf 57 sf 5000 plus 57 sharobel 72 SIGNIFOR 74 SILDENAFIL 10 MG/12.5 ML VIAL 89 sildenafil citrate 89 silver sulfadiazine 13 SIMPONI 76 SIMPONI ARIA 76 simvastatin 53 sirolimus 76 SIRTURO 26 SIVEXTRO 8 sodium chloride irrigating solution 93 sodium chloride/sodium bicarbonate/potassium chloride/peg 61 sodium fluoride 57,93 SODIUM PHENYLBUTYRATE 59 sodium polystyrene sulfonate 91 SOLTAMOX 27 SOMATULINE DEPOT 74 SOMAVERT 74 sorine 47 sotalol hcl 48 111
SOVALDI 38 SPIRIVA 87 SPIRIVA RESPIMAT 87 spironolactone 52 spironolactone/hydrochlorothiazide 52 sprintec 71 SPRITAM 14 SPRYCEL 30 sps 91 sronyx 71 stavudine 36 STELARA 58 STIMATE 66 STIVARGA 30 STRATTERA 55 STRENSIQ 59 streptomycin sulfate 7 STRIBILD 35 STROMECTOL 31 SUCRAID 59 sucralfate 62 sulfacetamide sodium 13 sulfacetamide sodium/prednisolone sodium phosphate 84 sulfadiazine 13 sulfamethoxazole/trimethoprim 13 sulfamide 13 sulfasalazine 79 sulindac 2 sumatriptan succinate 25 SUPREP 61 SURMONTIL 21 SUSTIVA 36 SUTENT 30 syeda 71 SYLATRON 38 SYLATRON 4-PACK 38 SYLVANT 30 SYMBICORT 90 SYMLINPEN 120 41 SYMLINPEN 60 41 SYNAGIS 39 SYNERCID 8 SYNJARDY 41 SYNRIBO 28 SYNTHROID 73 SYPRINE 91 syringe with needle, insulin, safety, 1 ml 81 syringe with needle,disposable,insulin 81 syringe with needle,disposable,insulin 1 ml 82 syringe with needle,insulin 0.3 ml (half unit mark) 82 syringe with needle,insulin disposable,0.3 ml 82 syringe with needle,insulin disposable,0.5 ml 82 syringe with needle,insulin,0.3 ml 83 syringe with needle,insulin,0.5 ml 83 T TABLOID 27 tacrolimus 58,76 TAFINLAR 30 TAGRISSO 30 TAMIFLU 39 tamoxifen citrate 27 tamsulosin hcl 63 TARCEVA 30 TARGRETIN 30 tarina fe 71 TASIGNA 30 TAZICEF 10 TAZORAC 58 taztia xt 50 TECFIDERA 56 TECHNIVIE 38 telmisartan 46 telmisartan/hydrochlorothiazide 46 temazepam 90 tencon 1 TENIVAC 78 terazosin hcl 46 terbinafine hcl 24 terbutaline sulfate 88 terconazole 24 112
testosterone 67 testosterone cypionate 67 testosterone enanthate 67 tetanus and diphtheria toxoids, adult 78 tetanus toxoid, adsorbed/pf 78 tetanus,diphtheria toxoid ped/pf 78 TETRABENAZINE 55 tetracycline hcl 14 THALOMID 27 theochron 89 theophylline anhydrous 89 thioridazine hcl 33 thiothixene 33 thrivite 19 93 thrivite rx 93 THYMOGLOBULIN 76 tiagabine hcl 16 TIKOSYN 48 TIMENTIN 12 timolol maleate 49 timolol maleate drops (0.25, 0.5) 85 timolol maleate sol-gel (0.25, 0.5) 85 tinidazole 8 TIVICAY 35 tizanidine hcl 35 tl folate 93 TOBI PODHALER 88 TOBRADEX 7 tobramycin 7 tobramycin in 0.225 % sodium chloride 7 tobramycin sulfate 7 tobramycin/dexamethasone 84 TOLAK 58 tolbutamide 41 tolmetin sodium 2 tolterodine tartrate 62 topiragen 17 topiramate 17 TOPOSAR 29 torsemide 51 TOUJEO SOLOSTAR 43 TPN ELECTROLYTES 94 TRACLEER 89 TRADJENTA 42 tramadol hcl 3,5 tramadol hcl/acetaminophen 5 trandolapril 47 tranexamic acid 45 tranylcypromine sulfate 19 TRAVATAN Z 85 trazodone hcl 19 TRECATOR 26 TRESIBA FLEXTOUCH U-100 43 TRESIBA FLEXTOUCH U-200 43 TRETINOIN 30 tretinoin 58 tri-estarylla 71 tri-linyah 71 tri-lo-estarylla 71 tri-lo-marzia 71 tri-lo-sprintec 71 tri-previfem 71 tri-sprintec 71 triamcinolone acetonide 57,66 triamterene/hydrochlorothiazide 52 triderm 66 trifluoperazine hcl 33 trifluridine 39 trihexyphenidyl hcl 32 trilyte with flavor packets 61 trimethoprim 8 trimipramine maleate 21 trinessa 71 trinessa lo 71 TRINTELLIX 20 TRISENOX 28 TRIUMEQ 36 trivora-28 71 tropicamide 84 trospium chloride 62 TRUMENBA 78 TRUVADA 36 113
TWINRIX 78 TYBOST 36 TYGACIL 8 TYKERB 30 TYPHIM VI 78 TYSABRI 56 TYZEKA 38 TYZINE 90 U UCERIS 66 ULESFIA 31 ULORIC 24 unithroid 73 ursodiol 60 V VAGIFEM 71 valacyclovir hcl 39 VALCHLOR 28 VALCYTE 37 VALGANCICLOVIR HCL 37 valproic acid 16 valproic acid (as sodium salt) (valproate sodium) 16 valsartan 46 valsartan/hydrochlorothiazide 46 vanatol lq 1 vancomycin hcl 8 vancomycin hcl/dextrose 5 % in water 8 vancomycin in 0.9 % sodium chloride 9 vancomycin in dextrose, iso-osmotic 9 vandazole 9 VAQTA 78 VARIVAX VACCINE 78 VASCEPA 53 VELCADE 28 velivet 71 VENCLEXTA 30 VENCLEXTA STARTING PACK 30 venlafaxine hcl 20 VENLAFAXINE HCL 21 VENTAVIS 89 ventolin hfa 88 verapamil hcl 50 VERSACLOZ 35 VESICARE 62 vestura 71 VEXOL 85 VICTOZA 2-PAK 42 VICTOZA 3-PAK 42 VIDEX 36 VIEKIRA PAK 39 vienva 71 VIGAMOX 13 VIIBRYD 21 VIMPAT 18 viorele 71 VIRACEPT 37 VIRAMUNE XR 36 VIREAD 36 virt nate 94 virt-care one 94 virt-nate 94 virt-vite gt 94 vitazol 9 VITEKTA 35 vol-plus tablet 94 VOLTAREN 2 voriconazole 24 vosol hc 86 VOTRIENT 30 vp-ggr-b6 94 VRAYLAR 34 vyfemla 71 VYVANSE 54 W warfarin sodium 44 WELCHOL 42 wera 71 114
X XALKORI 30 XARELTO 44 XENAZINE 55 XGEVA 80 XIFAXAN 9 XIGDUO XR 42 XOLAIR 90 XOPENEX HFA 88 XTANDI 27 xulane 71 XYREM 91 zonisamide 15 ZORTRESS 76 ZOSTAVAX 78 zovia 1-35e 71 zovia 1-50e 72 ZYDELIG 30 ZYKADIA 30 ZYLET 84 ZYPREXA RELPREVV 34 ZYTIGA 27 ZYVOX 9 Y YF-VAX 78 Z zafirlukast 87 zaleplon 90 zarah 71 ZAVESCA 59 ZELBORAF 30 ZEMAIRA 90 ZEMPLAR 80 zenatane 58 zenchent 71 ZENPEP 59 zenzedi 54 ZERBAXA 10 ZETIA 53 ZIAGEN 36 zidovudine 36 zingiber 94 ziprasidone hcl 34 ZIRGAN 37 zoledronic acid 80 ZOLINZA 28 zolmitriptan 25 zolpidem tartrate 90 ZOMETA 80 115
Category Listing Analgesics 1 Anesthetics 5 Anti-Addiction/Substance Abuse Treatment Agents 6 Antibacterials 6 Anticonvulsants 14 Antidementia Agents 18 Antidepressants 19 Antidotes 21 Antiemetics 21 Antifungals 22 Antigout Agents 24 Antimigraine Agents 24 Antimyasthenic Agents 25 Antimycobacterials 25 Antineoplastics 26 Antiparasitics 31 Antiparkinson Agents 32 Antipsychotics 32 Antispasticity Agents 35 Antivirals 35 Anxiolytics 39 Bipolar Agents 39 Blood Glucose Regulators 40 Blood Products/Modifiers/Volume Expanders 43 Cardiovascular Agents 45 Central Nervous System Agents 54 Dental and Oral Agents 56 Dermatological Agents 57 Enzyme Replacement/Modifiers 58 Gastrointestinal Agents 60 Genitourinary Agents 62 Hormonal Agents, Stimulant/Replacement/ Modifying (Parathyroid) 63 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) 63 Hormonal Agents, Stimulant/Replacement/Modifying (Other) 66 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) 66 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) 67 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) 73 Hormonal Agents, Suppressant (Adrenal) 73 Hormonal Agents, Suppressant (Parathyroid) 73 Hormonal Agents, Suppressant (Pituitary) 74 Hormonal Agents, Suppressant (Thyroid) 74 Immunological Agents 74 Inflammatory Bowel Disease Agents 78 Metabolic Bone Disease Agents 79 Miscellaneous 80 116
Ophthalmic Agents 83 Otic Agents 86 Respiratory Tract/Pulmonary Agents 86 Skeletal Muscle Relaxants 90 Sleep Disorder Agents 90 Therapeutic Nutrients/Minerals/Electrolytes 91 117
Customer Service Premera Blue Cross Medicare Advantage PO Box 4196 Portland, OR 97208-4196 Call toll free 888-850-8526 (TTY: 711) Representatives are available between 8 a.m. and 8 p.m., 7 days a week. premera.com/ma 24/7 Nurse Line Call 855-339-8123. Free and confidential. Version 18 Premera Blue Cross is an HMO and HMO-POS plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal. The Formulary may change at any time. You will receive notice when necessary. H7245_2016RXF_Accepted 027877 (06-2016)