Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan) List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Member Services: 1-855-878-1784 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time TXDMKT-0060-15 09.15 www.myamerigroup.com/txmmp Y0005_H8786_15_23464_R CMS Approved 02/26/2015 Formulary ID: 15336 Version: 12 Issued 09/01/2015
Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan) 2015 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan). Amerigroup STAR+PLUS MMP is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year. You can always check Amerigroup STAR+PLUS MMP s up-to-date List of Covered Drugs online at www.myamerigroup.com/txmmp. Limitations, co-payments and restrictions may apply. For more information, call Amerigroup STAR+PLUS MMP Member Services or read the Amerigroup STAR+PLUS MMP Member Handbook. Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can ask for this information in other formats, such as audio, Braille or large print. Call 1-855-878-1784 (TTY 711). The call is free. You can get this information for free in other languages. Call 1-855-878-1784 (TTY 711). The call is free.? If you have questions, please call Amerigroup STAR+PLUS MMP at 1-855-878-1784 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit www.myamerigroup.com/txmmp. Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT-0060-15 1
Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 10 are the drugs covered by Amerigroup STAR+PLUS MMP. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. Amerigroup STAR+PLUS MMP will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at an Amerigroup STAR+PLUS MMP network pharmacy. Amerigroup STAR+PLUS MMP may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at www.myamerigroup.com/txmmp or call Member Services at 1-855-878-1784 (TTY 711). 2. Does the Drug List ever change? Yes. Amerigroup STAR+PLUS MMP may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Amerigroup STAR+PLUS MMP before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)? If you have questions, please call Amerigroup STAR+PLUS MMP at 1-855-878-1784 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit www.myamerigroup.com/txmmp. Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT-0060-15 2
(For more information on these drug rules, see page 3.) We will tell you when a Medicare Part D drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a Medicare Part D drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check Amerigroup STAR+PLUS MMP s up-to-date Drug List online at www.myamerigroup.com/txmmp. You can also call Member Services to check the current Drug List at 1-855-878-1784 (TTY 711). 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a Medicare Part D drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. You will get a letter in the mail letting you know about the change. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Please contact your prescribing doctor as soon as you get the letter. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Amerigroup STAR+PLUS MMP before you fill your prescription. If you don t get approval, Amerigroup STAR+PLUS MMP may not cover the drug. Quantity limits: Sometimes Amerigroup STAR+PLUS MMP limits the amount of a drug you can get. Step therapy: Sometimes Amerigroup STAR+PLUS MMP requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second.? If you have questions, please call Amerigroup STAR+PLUS MMP at 1-855-878-1784 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit www.myamerigroup.com/txmmp. Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT-0060-15 3
You can find out if your drug has any additional requirements or limits by looking in the tables on pages 10-124. You can also get more information by visiting our website at www.myamerigroup.com/txmmp. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Amerigroup STAR+PLUS MMP member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 10 has a column labeled Necessary actions, restrictions, or limits in use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it on page 125, then look for the name of your drug in the list.? If you have questions, please call Amerigroup STAR+PLUS MMP at 1-855-878-1784 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit www.myamerigroup.com/txmmp. Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT-0060-15 4
To search by medical condition, find the section labeled List of drugs by medical condition on page 10. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at 1-855-878-1784 (TTY 711) and ask about it. If you learn that Amerigroup STAR+PLUS MMP will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new Amerigroup STAR+PLUS MMP member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Amerigroup STAR+PLUS MMP. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by Amerigroup STAR+PLUS MMP, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the 90 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. We will cover a temporary 30-day supply of your drug to cover level-of-care changes. 11. Can you ask for an exception to cover your drug?? If you have questions, please call Amerigroup STAR+PLUS MMP at 1-855-878-1784 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit www.myamerigroup.com/txmmp. Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT-0060-15 5
Yes. You can ask Amerigroup STAR+PLUS MMP to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, Amerigroup STAR+PLUS MMP may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call your service coordinator. Your service coordinator will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same active ingredients as brand-name drugs. They usually cost less than the brand-name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). Amerigroup STAR+PLUS MMP covers both brand-name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. Amerigroup STAR+PLUS MMP covers some OTC drugs when they are written as prescriptions by your provider. You can read the Amerigroup STAR+PLUS MMP Drug List to see what OTC drugs are covered.? If you have questions, please call Amerigroup STAR+PLUS MMP at 1-855-878-1784 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit www.myamerigroup.com/txmmp. Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT-0060-15 6
16. Does Amerigroup STAR+PLUS MMP cover OTC non-drug products? Amerigroup STAR+PLUS MMP covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the Amerigroup STAR+PLUS MMP Drug List to see what OTC non-drug products are covered. 17. What is your copay? You can read the Amerigroup STAR+PLUS MMP Drug List to learn about the copay for each drug. Amerigroup STAR+PLUS MMP members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. Copays are listed by tiers. Tiers are groups of drugs with the same copay. Tier 1 drugs have the lowest copay. They are Medicare preferred brand-name and generic drugs. The copay will be from $0 to $2.65 depending on your level of Medicaid eligibility. Tier 2 drugs have a medium copay. They are Medicare non-preferred brand-name and generic drugs. The copay will be from $0 to $6.60 depending on your level of Medicaid eligibility. Tier 3 and Tier 4 drugs do not have a copay. List of Covered Drugs The list of covered drugs below gives you information about the drugs covered by Amerigroup STAR+PLUS MMP. If you have trouble finding your drug in the list, turn to the Index that begins on page 125. The first column of the chart lists the name of the drug. Brand-name drugs are capitalized (e.g., ABELCET ) and generic drugs are listed in lower-case italics (e.g., fluconazole). The information in the necessary actions, restrictions, or limits in use column tells you if Amerigroup STAR+PLUS MMP has any rules for covering your drug. Note: The asterisk (*) next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees with our decision, you can? If you have questions, please call Amerigroup STAR+PLUS MMP at 1-855-878-1784 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit www.myamerigroup.com/txmmp. Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT-0060-15 7
appeal. To ask for instructions on how to appeal, call Member Services at 1-855-878-1784 (TTY 711). You can also read the Member Handbook to learn how to appeal a decision. Here are the meanings of the codes used in the Necessary actions, restrictions, or limits in use column: B/D: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Member Services. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Member Services. MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PAR: Prior Authorization required. The plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QLL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.? If you have questions, please call Amerigroup STAR+PLUS MMP at 1-855-878-1784 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. For more information, visit www.myamerigroup.com/txmmp. Y0005_H8786_15_22941_T_012 CMS Approved 02/19/2015 TXDMKT-0060-15 8
List of drugs by medical condition Name of Drug ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET $0-$6.60 (Tier 2) B/D PAR; MO AMBISOME $0-$6.60 (Tier 2) B/D PAR; MO amphotericin b $0-$6.60 (Tier 2) B/D PAR; MO CANCIDAS $0-$6.60 (Tier 2) B/D PAR; MO clotrimazole mucous membrane $0-$6.60 (Tier 2) MO ERAXIS(WATER DILUENT) $0-$6.60 (Tier 2) PAR; MO fluconazole $0-$6.60 (Tier 2) MO fluconazole in dextrose(iso-o) $0-$6.60 (Tier 2) fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) flucytosine $0-$6.60 (Tier 2) MO griseofulvin microsize oral suspension $0-$6.60 (Tier 2) MO griseofulvin ultramicrosize $0-$6.60 (Tier 2) MO itraconazole $0-$6.60 (Tier 2) PAR; MO ketoconazole oral $0-$6.60 (Tier 2) MO NOXAFIL ORAL SUSPENSION $0-$6.60 (Tier 2) PAR; MO; QLL (630 per 30 days) nystatin oral suspension $0-$6.60 (Tier 2) MO nystatin oral tablet $0-$6.60 (Tier 2) MO terbinafine hcl oral $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) voriconazole intravenous $0-$6.60 (Tier 2) MO voriconazole oral suspension for reconstitution $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) voriconazole oral tablet 200 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) voriconazole oral tablet 50 mg $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) 9
ANTIVIRALS abacavir $0-$6.60 (Tier 2) MO abacavir-lamivudine-zidovudine $0-$6.60 (Tier 2) MO acyclovir oral capsule $0-$6.60 (Tier 2) MO acyclovir oral suspension 200 mg/5 ml $0-$6.60 (Tier 2) MO acyclovir oral tablet $0-$6.60 (Tier 2) MO acyclovir sodium intravenous recon soln 500 mg $0-$6.60 (Tier 2) B/D PAR acyclovir sodium intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO adefovir $0-$6.60 (Tier 2) MO amantadine hcl oral capsule $0-$6.60 (Tier 2) MO amantadine hcl oral tablet $0-$6.60 (Tier 2) MO APTIVUS ORAL CAPSULE $0-$6.60 (Tier 2) MO APTIVUS ORAL SOLUTION $0-$6.60 (Tier 2) ATRIPLA $0-$6.60 (Tier 2) MO BARACLUDE $0-$6.60 (Tier 2) PAR; MO cidofovir $0-$6.60 (Tier 2) B/D PAR; MO COMPLERA $0-$6.60 (Tier 2) MO CRIXIVAN ORAL CAPSULE 200 MG, 400 MG $0-$6.60 (Tier 2) MO didanosine $0-$6.60 (Tier 2) MO EDURANT $0-$6.60 (Tier 2) MO EMTRIVA $0-$6.60 (Tier 2) MO entecavir $0-$6.60 (Tier 2) PAR; MO EPIVIR HBV ORAL SOLUTION $0-$6.60 (Tier 2) MO EPIVIR ORAL SOLUTION $0-$6.60 (Tier 2) MO EPZICOM $0-$6.60 (Tier 2) MO EVOTAZ $0-$6.60 (Tier 2) MO famciclovir oral tablet 125 mg, 250 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) famciclovir oral tablet 500 mg $0-$6.60 (Tier 2) MO; QLL (21 per 7 days) foscarnet $0-$6.60 (Tier 2) B/D PAR; MO FUZEON SUBCUTANEOUS RECON SOLN $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) 10
ganciclovir sodium $0-$6.60 (Tier 2) MO HARVONI $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 28 days) INTELENCE ORAL TABLET 100 MG, 200 MG $0-$6.60 (Tier 2) MO INTELENCE ORAL TABLET 25 MG $0-$6.60 (Tier 2) INVIRASE $0-$6.60 (Tier 2) MO ISENTRESS $0-$6.60 (Tier 2) MO KALETRA $0-$6.60 (Tier 2) MO lamivudine $0-$6.60 (Tier 2) MO lamivudine-zidovudine $0-$6.60 (Tier 2) MO LEXIVA $0-$6.60 (Tier 2) MO nevirapine $0-$6.60 (Tier 2) MO NORVIR $0-$6.60 (Tier 2) MO OLYSIO $0-$6.60 (Tier 2) PAR; MO PREZCOBIX $0-$6.60 (Tier 2) MO PREZISTA ORAL SUSPENSION $0-$6.60 (Tier 2) MO PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG $0-$6.60 (Tier 2) MO RELENZA DISKHALER $0-$6.60 (Tier 2) MO; QLL (60 per 180 days) RESCRIPTOR $0-$6.60 (Tier 2) MO RETROVIR INTRAVENOUS $0-$6.60 (Tier 2) MO REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG $0-$6.60 (Tier 2) MO REYATAZ ORAL POWDER IN PACKET $0-$6.60 (Tier 2) MO ribasphere oral capsule $0-$6.60 (Tier 2) PAR; MO ribasphere oral tablet 200 mg $0-$6.60 (Tier 2) PAR; MO ribavirin oral capsule $0-$6.60 (Tier 2) PAR; MO ribavirin oral tablet 200 mg $0-$6.60 (Tier 2) PAR; MO rimantadine $0-$6.60 (Tier 2) MO SELZENTRY $0-$6.60 (Tier 2) MO SOVALDI $0-$6.60 (Tier 2) PAR; MO 11
stavudine $0-$6.60 (Tier 2) MO STRIBILD $0-$6.60 (Tier 2) MO SUSTIVA $0-$6.60 (Tier 2) MO SYNAGIS $0-$6.60 (Tier 2) PAR; MO; LA TAMIFLU ORAL CAPSULE 30 MG $0-$6.60 (Tier 2) MO; QLL (84 per 1 day) TAMIFLU ORAL CAPSULE 45 MG $0-$6.60 (Tier 2) MO; QLL (42 per 1 day) TAMIFLU ORAL CAPSULE 75 MG $0-$6.60 (Tier 2) MO; QLL (56 per 365 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TIVICAY $0-$6.60 (Tier 2) MO TRIUMEQ $0-$6.60 (Tier 2) MO TRIZIVIR $0-$6.60 (Tier 2) MO TRUVADA $0-$6.60 (Tier 2) MO TYBOST $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) MO; QLL (360 per 180 days) TYZEKA $0-$6.60 (Tier 2) PAR; MO valacyclovir $0-$6.60 (Tier 2) MO; QLL (30 per 1 day) VALCYTE ORAL TABLET $0-$6.60 (Tier 2) MO valganciclovir $0-$6.60 (Tier 2) MO VIDEX 2 GRAM PEDIATRIC $0-$6.60 (Tier 2) MO VIDEX 4 GRAM PEDIATRIC $0-$6.60 (Tier 2) MO VIEKIRA PAK $0-$6.60 (Tier 2) PAR; MO VIRACEPT ORAL TABLET $0-$6.60 (Tier 2) MO VIRAMUNE XR $0-$6.60 (Tier 2) MO VIRAZOLE $0-$6.60 (Tier 2) PAR; MO VIREAD ORAL POWDER $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) VIREAD ORAL TABLET $0-$6.60 (Tier 2) MO VITEKTA $0-$6.60 (Tier 2) MO ZIAGEN ORAL SOLUTION $0-$6.60 (Tier 2) MO zidovudine $0-$6.60 (Tier 2) MO CEPHALOSPORINS 12
cefaclor oral capsule $0-$6.60 (Tier 2) MO cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml $0-$6.60 (Tier 2) MO cefaclor oral tablet extended release 12 hr $0-$6.60 (Tier 2) MO cefadroxil oral capsule $0-$6.60 (Tier 2) MO cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml $0-$6.60 (Tier 2) MO cefadroxil oral tablet $0-$6.60 (Tier 2) MO cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml $0-$6.60 (Tier 2) MO cefazolin injection recon soln 1 gram, 500 mg $0-$6.60 (Tier 2) MO cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g $0-$6.60 (Tier 2) cefazolin intravenous $0-$6.60 (Tier 2) cefdinir $0-$6.60 (Tier 2) MO cefepime $0-$6.60 (Tier 2) MO cefoxitin in dextrose, iso-osm $0-$6.60 (Tier 2) cefoxitin intravenous recon soln 1 gram $0-$6.60 (Tier 2) MO cefoxitin intravenous recon soln 10 gram, 2 gram $0-$6.60 (Tier 2) cefpodoxime $0-$6.60 (Tier 2) MO cefprozil $0-$6.60 (Tier 2) MO ceftazidime injection recon soln 1 gram, 2 gram $0-$6.60 (Tier 2) MO ceftazidime injection recon soln 6 gram $0-$6.60 (Tier 2) ceftriaxone in dextrose,iso-os $0-$6.60 (Tier 2) MO ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg $0-$6.60 (Tier 2) MO ceftriaxone injection recon soln 10 gram $0-$6.60 (Tier 2) ceftriaxone intravenous recon soln $0-$6.60 (Tier 2) MO cefuroxime axetil oral tablet $0-$6.60 (Tier 2) MO cefuroxime sodium injection recon soln 1.5 gram, 750 mg $0-$6.60 (Tier 2) MO cefuroxime sodium intravenous $0-$6.60 (Tier 2) 13
cephalexin oral capsule 250 mg, 500 mg $0-$2.65 (Tier 1) MO cephalexin oral suspension for reconstitution $0-$2.65 (Tier 1) MO cephalexin oral tablet $0-$2.65 (Tier 1) MO TEFLARO $0-$6.60 (Tier 2) MO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous $0-$6.60 (Tier 2) MO azithromycin oral suspension for reconstitution $0-$6.60 (Tier 2) MO azithromycin oral tablet $0-$6.60 (Tier 2) MO clarithromycin oral suspension for reconstitution $0-$6.60 (Tier 2) MO clarithromycin oral tablet $0-$6.60 (Tier 2) MO clarithromycin oral tablet extended release 24 hr $0-$6.60 (Tier 2) MO; QLL (28 per 1 day) ery-tab $0-$6.60 (Tier 2) MO erythrocin (as stearate) oral tablet 250 mg $0-$6.60 (Tier 2) MO ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG $0-$6.60 (Tier 2) erythromycin ethylsuccinate oral tablet $0-$6.60 (Tier 2) MO erythromycin oral tablet $0-$6.60 (Tier 2) MO MISCELLANEOUS ANTIINFECTIVES ALBENZA $0-$6.60 (Tier 2) MO ALINIA ORAL SUSPENSION FOR RECONSTITUTION $0-$6.60 (Tier 2) MO; QLL (180 per 3 days) ALINIA ORAL TABLET $0-$6.60 (Tier 2) MO amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml $0-$6.60 (Tier 2) MO atovaquone $0-$6.60 (Tier 2) PAR; MO atovaquone-proguanil $0-$6.60 (Tier 2) MO AZACTAM IN DEXTROSE (ISO-OSM) $0-$6.60 (Tier 2) aztreonam $0-$6.60 (Tier 2) MO baciim $0-$6.60 (Tier 2) BILTRICIDE $0-$6.60 (Tier 2) MO CAPASTAT $0-$6.60 (Tier 2) 14
CAYSTON $0-$6.60 (Tier 2) PAR; MO; LA chloramphenicol sod succinate $0-$6.60 (Tier 2) chloroquine phosphate oral $0-$6.60 (Tier 2) MO clindamycin hcl $0-$6.60 (Tier 2) MO clindamycin phosphate injection $0-$6.60 (Tier 2) MO clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO colistin (colistimethate na) $0-$6.60 (Tier 2) MO DAPSONE $0-$6.60 (Tier 2) MO DARAPRIM $0-$6.60 (Tier 2) MO ethambutol $0-$6.60 (Tier 2) MO gentamicin injection $0-$6.60 (Tier 2) MO gentamicin sulfate (ped) (pf) $0-$6.60 (Tier 2) MO gentamicin sulfate (pf) intravenous solution 100 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) hydroxychloroquine oral $0-$2.65 (Tier 1) MO imipenem-cilastatin $0-$6.60 (Tier 2) MO INVANZ INJECTION $0-$6.60 (Tier 2) MO isoniazid oral $0-$2.65 (Tier 1) MO ivermectin oral $0-$6.60 (Tier 2) MO linezolid intravenous $0-$6.60 (Tier 2) linezolid oral $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 1 day) linezolid-0.9% sodium chloride $0-$6.60 (Tier 2) mefloquine $0-$6.60 (Tier 2) MO MEPRON $0-$6.60 (Tier 2) PAR; MO 15
meropenem $0-$6.60 (Tier 2) MO metro i.v. $0-$6.60 (Tier 2) MO metronidazole in nacl (iso-os) $0-$6.60 (Tier 2) MO metronidazole oral $0-$6.60 (Tier 2) MO MYCOBUTIN $0-$6.60 (Tier 2) MO NEBUPENT $0-$6.60 (Tier 2) B/D PAR; MO neomycin $0-$6.60 (Tier 2) MO paromomycin $0-$6.60 (Tier 2) MO PASER $0-$6.60 (Tier 2) MO PENTAM $0-$6.60 (Tier 2) MO PRIFTIN $0-$6.60 (Tier 2) MO PRIMAQUINE $0-$6.60 (Tier 2) MO pyrazinamide $0-$6.60 (Tier 2) MO rifabutin $0-$6.60 (Tier 2) MO rifampin intravenous $0-$6.60 (Tier 2) MO rifampin oral $0-$6.60 (Tier 2) MO RIFATER $0-$6.60 (Tier 2) MO STREPTOMYCIN INTRAMUSCULAR $0-$6.60 (Tier 2) MO STROMECTOL $0-$6.60 (Tier 2) MO SYNERCID $0-$6.60 (Tier 2) tobramycin in 0.225 % nacl $0-$6.60 (Tier 2) B/D PAR; MO; QLL (280 per 28 days) tobramycin sulfate injection recon soln $0-$6.60 (Tier 2) tobramycin sulfate injection solution $0-$6.60 (Tier 2) MO TRECATOR $0-$6.60 (Tier 2) MO TYGACIL $0-$6.60 (Tier 2) MO XIFAXAN ORAL TABLET 550 MG $0-$6.60 (Tier 2) MO ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO 16
ZYVOX ORAL SUSPENSION FOR RECONSTITUTION $0-$6.60 (Tier 2) PAR; MO; QLL (1800 per 1 day) ZYVOX ORAL TABLET $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 1 day) PENICILLINS amoxicillin oral capsule $0-$2.65 (Tier 1) MO amoxicillin oral suspension for reconstitution $0-$2.65 (Tier 1) MO amoxicillin oral tablet $0-$2.65 (Tier 1) MO amoxicillin oral tablet,chewable 125 mg, 250 mg $0-$2.65 (Tier 1) MO amoxicillin-pot clavulanate $0-$6.60 (Tier 2) MO ampicillin $0-$6.60 (Tier 2) MO ampicillin sodium injection $0-$6.60 (Tier 2) MO ampicillin sodium intravenous $0-$6.60 (Tier 2) ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram $0-$6.60 (Tier 2) MO ampicillin-sulbactam injection recon soln 15 gram $0-$6.60 (Tier 2) ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO BICILLIN C-R $0-$6.60 (Tier 2) MO BICILLIN L-A $0-$6.60 (Tier 2) MO dicloxacillin $0-$6.60 (Tier 2) MO nafcillin injection $0-$6.60 (Tier 2) MO nafcillin intravenous recon soln 2 gram $0-$6.60 (Tier 2) MO oxacillin injection $0-$6.60 (Tier 2) MO oxacillin intravenous $0-$6.60 (Tier 2) PENICILLIN G POT IN DEXTROSE $0-$6.60 (Tier 2) penicillin g potassium $0-$6.60 (Tier 2) MO penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) 17
penicillin g sodium $0-$6.60 (Tier 2) MO penicillin v potassium $0-$6.60 (Tier 2) MO piperacillin-tazobactam $0-$6.60 (Tier 2) MO QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg $0-$2.65 (Tier 1) MO; QLL (14 per 1 day) $0-$2.65 (Tier 1) MO; QLL (3 per 1 day) ciprofloxacin hcl oral tablet $0-$2.65 (Tier 1) MO ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml $0-$2.65 (Tier 1) MO $0-$2.65 (Tier 1) levofloxacin intravenous $0-$6.60 (Tier 2) MO levofloxacin oral tablet $0-$6.60 (Tier 2) MO; QLL (14 per 1 day) moxifloxacin $0-$6.60 (Tier 2) MO; QLL (21 per 1 day) ofloxacin oral tablet 300 mg, 400 mg $0-$6.60 (Tier 2) SULFA'S / RELATED AGENTS sulfadiazine oral $0-$6.60 (Tier 2) MO sulfamethoxazole-trimethoprim $0-$2.65 (Tier 1) MO TETRACYCLINES demeclocycline oral $0-$6.60 (Tier 2) MO DOXY-100 $0-$6.60 (Tier 2) MO doxycycline hyclate intravenous $0-$6.60 (Tier 2) doxycycline hyclate oral capsule $0-$6.60 (Tier 2) MO doxycycline hyclate oral tablet 100 mg, 20 mg $0-$6.60 (Tier 2) MO doxycycline hyclate oral tablet 50 mg $0-$6.60 (Tier 2) doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) MO doxycycline monohydrate oral capsule 75 mg $0-$6.60 (Tier 2) MO; QLL (60 per 1 day) 18
doxycycline monohydrate oral tablet $0-$6.60 (Tier 2) MO minocycline oral capsule $0-$6.60 (Tier 2) MO minocycline oral tablet $0-$6.60 (Tier 2) MO tetracycline $0-$6.60 (Tier 2) MO URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 50 MG $0-$6.60 (Tier 2) PAR; MO methenamine hippurate $0-$6.60 (Tier 2) MO nitrofurantoin macrocrystal oral capsule 50 mg $0-$6.60 (Tier 2) PAR; MO trimethoprim $0-$6.60 (Tier 2) MO VANCOMYCIN VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/200 ML VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 500 MG/100 ML $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR VANCOMYCIN IN DEXTROSE ISO-OSM $0-$6.60 (Tier 2) B/D PAR vancomycin intravenous $0-$6.60 (Tier 2) B/D PAR; MO VANCOMYCIN INTRAVENOUS 750 MG $0-$6.60 (Tier 2) B/D PAR; MO vancomycin oral capsule 125 mg $0-$6.60 (Tier 2) PAR; MO; QLL (40 per 1 day) vancomycin oral capsule 250 mg $0-$6.60 (Tier 2) PAR; MO; QLL (80 per 1 day) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline $0-$6.60 (Tier 2) PAR; MO dexrazoxane hcl intravenous recon soln 250 mg $0-$6.60 (Tier 2) B/D PAR dexrazoxane hcl intravenous recon soln 500 mg $0-$6.60 (Tier 2) B/D PAR; MO ELITEK $0-$6.60 (Tier 2) PAR FUSILEV $0-$6.60 (Tier 2) B/D PAR; MO KEPIVANCE $0-$6.60 (Tier 2) leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg $0-$6.60 (Tier 2) B/D PAR; MO leucovorin calcium injection recon soln 500 mg $0-$6.60 (Tier 2) B/D PAR 19
leucovorin calcium oral $0-$6.60 (Tier 2) MO mesna $0-$6.60 (Tier 2) B/D PAR; MO MESNEX ORAL $0-$6.60 (Tier 2) MO XGEVA $0-$6.60 (Tier 2) PAR; MO; QLL (1.7 per 28 days) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE $0-$6.60 (Tier 2) B/D PAR; MO AFINITOR $0-$6.60 (Tier 2) PAR; MO AFINITOR DISPERZ $0-$6.60 (Tier 2) PAR; MO ALIMTA $0-$6.60 (Tier 2) PAR; MO anastrozole $0-$6.60 (Tier 2) MO ARRANON $0-$6.60 (Tier 2) B/D PAR ARZERRA $0-$6.60 (Tier 2) B/D PAR; MO ASTAGRAF XL $0-$6.60 (Tier 2) B/D PAR; MO AVASTIN $0-$6.60 (Tier 2) PAR; MO azacitidine $0-$6.60 (Tier 2) PAR; MO azathioprine $0-$6.60 (Tier 2) B/D PAR; MO BELEODAQ $0-$6.60 (Tier 2) PAR; MO bexarotene $0-$6.60 (Tier 2) PAR; MO bicalutamide $0-$6.60 (Tier 2) MO BICNU $0-$6.60 (Tier 2) B/D PAR; MO bleomycin $0-$6.60 (Tier 2) B/D PAR; MO BLINCYTO $0-$6.60 (Tier 2) PAR; MO BOSULIF $0-$6.60 (Tier 2) PAR; MO BUSULFEX $0-$6.60 (Tier 2) B/D PAR CAPRELSA $0-$6.60 (Tier 2) PAR; MO; LA carboplatin intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO CELLCEPT INTRAVENOUS $0-$6.60 (Tier 2) B/D PAR; MO CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION $0-$6.60 (Tier 2) B/D PAR; MO cisplatin $0-$6.60 (Tier 2) B/D PAR; MO 20
cladribine $0-$6.60 (Tier 2) B/D PAR; MO CLOLAR $0-$6.60 (Tier 2) B/D PAR; MO COMETRIQ $0-$6.60 (Tier 2) PAR; MO COSMEGEN $0-$6.60 (Tier 2) B/D PAR; MO cyclophosphamide oral capsule $0-$6.60 (Tier 2) B/D PAR; MO cyclosporine intravenous $0-$6.60 (Tier 2) B/D PAR cyclosporine modified $0-$6.60 (Tier 2) B/D PAR; MO cyclosporine oral capsule $0-$6.60 (Tier 2) B/D PAR; MO CYRAMZA $0-$6.60 (Tier 2) PAR; MO cytarabine $0-$6.60 (Tier 2) B/D PAR; MO cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) $0-$6.60 (Tier 2) B/D PAR; MO cytarabine (pf) injection solution 20 mg/ml $0-$6.60 (Tier 2) B/D PAR dacarbazine $0-$6.60 (Tier 2) B/D PAR; MO daunorubicin intravenous solution $0-$6.60 (Tier 2) B/D PAR DAUNOXOME $0-$6.60 (Tier 2) B/D PAR; MO decitabine $0-$6.60 (Tier 2) B/D PAR; MO DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ml, 140 mg/7 ml (20 mg/ml), 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO DOXIL $0-$6.60 (Tier 2) B/D PAR; MO doxorubicin intravenous recon soln $0-$6.60 (Tier 2) B/D PAR doxorubicin intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO DROXIA $0-$6.60 (Tier 2) MO EMCYT $0-$6.60 (Tier 2) MO epirubicin intravenous solution 200 mg/100 ml $0-$6.60 (Tier 2) B/D PAR epirubicin intravenous solution 50 mg/25 ml $0-$6.60 (Tier 2) B/D PAR; MO 21
ERBITUX $0-$6.60 (Tier 2) PAR; MO ERIVEDGE $0-$6.60 (Tier 2) PAR; MO ERWINAZE $0-$6.60 (Tier 2) B/D PAR; MO ETOPOPHOS $0-$6.60 (Tier 2) B/D PAR; MO etoposide intravenous $0-$6.60 (Tier 2) B/D PAR; MO exemestane $0-$6.60 (Tier 2) MO FARESTON $0-$6.60 (Tier 2) MO FARYDAK ORAL CAPSULE 10 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) FARYDAK ORAL CAPSULE 15 MG, 20 MG $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) FASLODEX $0-$6.60 (Tier 2) PAR; MO FIRMAGON KIT W DILUENT SYRINGE $0-$6.60 (Tier 2) B/D PAR; MO fludarabine intravenous recon soln $0-$6.60 (Tier 2) B/D PAR; MO fludarabine intravenous solution $0-$6.60 (Tier 2) B/D PAR fluorouracil intravenous $0-$6.60 (Tier 2) B/D PAR; MO flutamide $0-$6.60 (Tier 2) MO FOLOTYN $0-$6.60 (Tier 2) B/D PAR; MO GAZYVA $0-$6.60 (Tier 2) PAR; MO gemcitabine intravenous recon soln 1 gram, 200 mg $0-$6.60 (Tier 2) B/D PAR; MO gemcitabine intravenous recon soln 2 gram $0-$6.60 (Tier 2) B/D PAR gemcitabine intravenous solution $0-$6.60 (Tier 2) B/D PAR gengraf $0-$6.60 (Tier 2) B/D PAR; MO GILOTRIF $0-$6.60 (Tier 2) PAR; MO GLEEVEC $0-$6.60 (Tier 2) PAR; MO GLEOSTINE $0-$6.60 (Tier 2) MO HALAVEN $0-$6.60 (Tier 2) PAR; MO HERCEPTIN $0-$6.60 (Tier 2) PAR; MO HEXALEN $0-$6.60 (Tier 2) MO hydroxyurea $0-$6.60 (Tier 2) MO IBRANCE $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) 22
ICLUSIG $0-$6.60 (Tier 2) PAR; MO idarubicin $0-$6.60 (Tier 2) B/D PAR IFEX $0-$6.60 (Tier 2) B/D PAR; MO ifosfamide intravenous recon soln 1 gram $0-$6.60 (Tier 2) B/D PAR; MO ifosfamide intravenous recon soln 3 gram $0-$6.60 (Tier 2) B/D PAR ifosfamide intravenous solution $0-$6.60 (Tier 2) B/D PAR IMBRUVICA $0-$6.60 (Tier 2) PAR; MO INLYTA $0-$6.60 (Tier 2) PAR; MO irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml $0-$6.60 (Tier 2) B/D PAR; MO irinotecan intravenous solution 500 mg/25 ml $0-$6.60 (Tier 2) B/D PAR ISTODAX $0-$6.60 (Tier 2) PAR; MO IXEMPRA $0-$6.60 (Tier 2) B/D PAR; MO JAKAFI $0-$6.60 (Tier 2) PAR; MO JEVTANA $0-$6.60 (Tier 2) B/D PAR; MO KADCYLA $0-$6.60 (Tier 2) PAR; MO KEYTRUDA $0-$6.60 (Tier 2) PAR; MO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY) LENVIMA ORAL CAPSULE 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY) LENVIMA ORAL CAPSULE 24 MG (10 MG[2] -4 MG[1])/DAY letrozole $0-$6.60 (Tier 2) MO LEUKERAN $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) leuprolide $0-$6.60 (Tier 2) PAR; MO LOMUSTINE $0-$6.60 (Tier 2) MO LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) $0-$6.60 (Tier 2) PAR; MO $0-$6.60 (Tier 2) PAR; MO LYNPARZA $0-$6.60 (Tier 2) PAR; MO; QLL (480 per 30 days) 23
LYSODREN $0-$6.60 (Tier 2) MO MATULANE $0-$6.60 (Tier 2) MO megestrol oral suspension 400 mg/10 ml (10 ml) $0-$6.60 (Tier 2) PAR megestrol oral suspension 400 mg/10 ml (40 mg/ml) $0-$6.60 (Tier 2) PAR; MO megestrol oral tablet $0-$6.60 (Tier 2) PAR; MO MEKINIST $0-$6.60 (Tier 2) PAR; MO melphalan hcl $0-$6.60 (Tier 2) B/D PAR mercaptopurine $0-$6.60 (Tier 2) MO methotrexate sodium $0-$6.60 (Tier 2) MO methotrexate sodium (pf) injection recon soln $0-$6.60 (Tier 2) methotrexate sodium (pf) injection solution $0-$6.60 (Tier 2) MO mitomycin $0-$6.60 (Tier 2) B/D PAR; MO mitoxantrone $0-$6.60 (Tier 2) MO MUSTARGEN $0-$6.60 (Tier 2) B/D PAR; MO mycophenolate mofetil $0-$6.60 (Tier 2) B/D PAR; MO mycophenolate sodium $0-$6.60 (Tier 2) B/D PAR; MO NEXAVAR $0-$6.60 (Tier 2) PAR; MO; LA; QLL (120 per 30 days) NILANDRON $0-$6.60 (Tier 2) MO NIPENT $0-$6.60 (Tier 2) B/D PAR; MO NULOJIX $0-$6.60 (Tier 2) B/D PAR; MO octreotide acetate $0-$6.60 (Tier 2) PAR; MO ONCASPAR $0-$6.60 (Tier 2) B/D PAR; MO OPDIVO $0-$6.60 (Tier 2) PAR; MO oxaliplatin intravenous recon soln 100 mg $0-$6.60 (Tier 2) B/D PAR; MO oxaliplatin intravenous recon soln 50 mg $0-$6.60 (Tier 2) B/D PAR oxaliplatin intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO paclitaxel $0-$6.60 (Tier 2) B/D PAR; MO PERJETA $0-$6.60 (Tier 2) PAR; MO 24
POMALYST $0-$6.60 (Tier 2) PAR; MO PROGRAF INTRAVENOUS $0-$6.60 (Tier 2) B/D PAR; MO PURIXAN $0-$6.60 (Tier 2) PAR; MO RAPAMUNE $0-$6.60 (Tier 2) B/D PAR; MO REVLIMID ORAL CAPSULE 10 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (30 per 30 days) REVLIMID ORAL CAPSULE 5 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (150 per 30 days) RITUXAN $0-$6.60 (Tier 2) PAR; MO SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO sirolimus $0-$6.60 (Tier 2) B/D PAR; MO SOLTAMOX $0-$6.60 (Tier 2) MO SOMATULINE DEPOT $0-$6.60 (Tier 2) MO SPRYCEL $0-$6.60 (Tier 2) PAR; MO STIVARGA $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) SUTENT $0-$6.60 (Tier 2) PAR; MO SYNRIBO $0-$6.60 (Tier 2) PAR; MO TABLOID $0-$6.60 (Tier 2) MO tacrolimus oral $0-$6.60 (Tier 2) B/D PAR; MO TAFINLAR $0-$6.60 (Tier 2) PAR; MO tamoxifen $0-$6.60 (Tier 2) MO TARCEVA $0-$6.60 (Tier 2) PAR; MO TARGRETIN $0-$6.60 (Tier 2) PAR; MO TASIGNA $0-$6.60 (Tier 2) PAR; MO THALOMID ORAL CAPSULE 100 MG, 50 MG $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) THALOMID ORAL CAPSULE 150 MG, 200 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) toposar $0-$6.60 (Tier 2) B/D PAR; MO 25
topotecan $0-$6.60 (Tier 2) B/D PAR; MO TORISEL $0-$6.60 (Tier 2) B/D PAR; MO TREANDA $0-$6.60 (Tier 2) B/D PAR; MO TRELSTAR $0-$6.60 (Tier 2) MO TRELSTAR DEPOT $0-$6.60 (Tier 2) TRELSTAR LA $0-$6.60 (Tier 2) tretinoin (chemotherapy) $0-$6.60 (Tier 2) MO TREXALL $0-$6.60 (Tier 2) MO TRISENOX $0-$6.60 (Tier 2) B/D PAR; MO TYKERB $0-$6.60 (Tier 2) PAR; MO; LA VECTIBIX $0-$6.60 (Tier 2) PAR; MO VELCADE $0-$6.60 (Tier 2) PAR; MO vinblastine intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO vincasar pfs intravenous solution 1 mg/ml $0-$6.60 (Tier 2) B/D PAR vincasar pfs intravenous solution 2 mg/2 ml $0-$6.60 (Tier 2) B/D PAR; MO vincristine $0-$6.60 (Tier 2) B/D PAR; MO vinorelbine $0-$6.60 (Tier 2) B/D PAR; MO VOTRIENT $0-$6.60 (Tier 2) PAR; MO XALKORI $0-$6.60 (Tier 2) PAR; MO XTANDI $0-$6.60 (Tier 2) PAR; MO YERVOY $0-$6.60 (Tier 2) PAR; MO ZALTRAP $0-$6.60 (Tier 2) PAR; MO ZANOSAR $0-$6.60 (Tier 2) B/D PAR; MO ZELBORAF $0-$6.60 (Tier 2) PAR; MO ZOLINZA $0-$6.60 (Tier 2) PAR; MO ZORTRESS $0-$6.60 (Tier 2) B/D PAR; MO ZYDELIG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) ZYKADIA $0-$6.60 (Tier 2) PAR; MO ZYTIGA $0-$6.60 (Tier 2) PAR; MO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH 26
ANTICONVULSANTS APTIOM $0-$6.60 (Tier 2) ST; MO BANZEL ORAL SUSPENSION $0-$6.60 (Tier 2) PAR; MO; QLL (2400 per 30 days) BANZEL ORAL TABLET 200 MG $0-$6.60 (Tier 2) PAR; MO; QLL (480 per 30 days) BANZEL ORAL TABLET 400 MG $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) carbamazepine oral capsule, er multiphase 12 hr $0-$6.60 (Tier 2) MO carbamazepine oral suspension 100 mg/5 ml $0-$6.60 (Tier 2) MO carbamazepine oral tablet $0-$6.60 (Tier 2) MO carbamazepine oral tablet extended release 12 hr $0-$6.60 (Tier 2) MO carbamazepine oral tablet,chewable $0-$6.60 (Tier 2) MO CELONTIN ORAL CAPSULE 300 MG $0-$6.60 (Tier 2) MO clonazepam oral tablet 0.5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet 1 mg $0-$6.60 (Tier 2) PAR; MO; QLL (600 per 30 days) clonazepam oral tablet 2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) clonazepam oral tablet,disintegrating 0.125 mg $0-$6.60 (Tier 2) PAR; MO; QLL (4800 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg $0-$6.60 (Tier 2) PAR; MO; QLL (2400 per 30 days) clonazepam oral tablet,disintegrating 0.5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet,disintegrating 1 mg $0-$6.60 (Tier 2) PAR; MO; QLL (600 per 30 days) clonazepam oral tablet,disintegrating 2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) diazepam rectal $0-$6.60 (Tier 2) MO; QLL (2 per 1 day) DILANTIN CAPSULES $0-$6.60 (Tier 2) MO DILANTIN EXTENDED CAPSULES $0-$6.60 (Tier 2) MO DILANTIN INFATABS $0-$6.60 (Tier 2) MO divalproex $0-$6.60 (Tier 2) MO epitol $0-$6.60 (Tier 2) MO EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG $0-$6.60 (Tier 2) MO; QLL (480 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) 27
ethosuximide $0-$6.60 (Tier 2) MO felbamate $0-$6.60 (Tier 2) MO fosphenytoin $0-$6.60 (Tier 2) B/D PAR; MO FYCOMPA ORAL TABLET 10 MG, 12 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) FYCOMPA ORAL TABLET 2 MG $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) FYCOMPA ORAL TABLET 4 MG $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) FYCOMPA ORAL TABLET 6 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) FYCOMPA ORAL TABLET 8 MG $0-$6.60 (Tier 2) MO; QLL (45 per 30 days) gabapentin oral capsule 100 mg $0-$6.60 (Tier 2) MO; QLL (1080 per 30 days) gabapentin oral capsule 300 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) gabapentin oral capsule 400 mg $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) gabapentin oral solution 250 mg/5 ml $0-$6.60 (Tier 2) MO; QLL (2160 per 30 days) gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) $0-$6.60 (Tier 2) QLL (2160 per 30 days) gabapentin oral tablet 600 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) gabapentin oral tablet 800 mg $0-$6.60 (Tier 2) MO; QLL (135 per 30 days) GABITRIL $0-$6.60 (Tier 2) MO lamotrigine oral tablet $0-$6.60 (Tier 2) MO lamotrigine oral tablet, chewable dispersible $0-$6.60 (Tier 2) MO levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO levetiracetam intravenous $0-$6.60 (Tier 2) B/D PAR; MO levetiracetam oral solution 100 mg/ml $0-$6.60 (Tier 2) MO levetiracetam oral solution 500 mg/5 ml (5 ml) $0-$6.60 (Tier 2) levetiracetam oral tablet $0-$6.60 (Tier 2) MO levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) 28
LYRICA ORAL CAPSULE 100 MG $0-$6.60 (Tier 2) PAR; MO; QLL (180 per 30 days) LYRICA ORAL CAPSULE 150 MG $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 200 MG $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) LYRICA ORAL CAPSULE 225 MG, 300 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) LYRICA ORAL CAPSULE 25 MG $0-$6.60 (Tier 2) PAR; MO; QLL (720 per 30 days) LYRICA ORAL CAPSULE 50 MG $0-$6.60 (Tier 2) PAR; MO; QLL (360 per 30 days) LYRICA ORAL CAPSULE 75 MG $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) LYRICA ORAL SOLUTION $0-$6.60 (Tier 2) PAR; MO; QLL (900 per 30 days) ONFI ORAL SUSPENSION $0-$6.60 (Tier 2) PAR; MO; QLL (480 per 30 days) ONFI ORAL TABLET 10 MG $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) ONFI ORAL TABLET 20 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) oxcarbazepine $0-$6.60 (Tier 2) MO OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG $0-$6.60 (Tier 2) MO; QLL (480 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) PEGANONE $0-$6.60 (Tier 2) MO phenobarbital oral elixir $0-$6.60 (Tier 2) PAR; MO; QLL (3000 per 30 days) phenobarbital oral tablet 100 mg $0-$6.60 (Tier 2) PAR; QLL (120 per 30 days) phenobarbital oral tablet 15 mg $0-$6.60 (Tier 2) PAR; MO; QLL (800 per 30 days) phenobarbital oral tablet 16.2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (741 per 30 days) phenobarbital oral tablet 30 mg $0-$6.60 (Tier 2) PAR; MO; QLL (400 per 30 days) phenobarbital oral tablet 32.4 mg $0-$6.60 (Tier 2) PAR; MO; QLL (370 per 30 days) phenobarbital oral tablet 60 mg $0-$6.60 (Tier 2) PAR; MO; QLL (200 per 30 days) phenobarbital oral tablet 64.8 mg $0-$6.60 (Tier 2) PAR; MO; QLL (185 per 30 days) phenobarbital oral tablet 97.2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (123 per 30 days) phenytoin oral suspension 100 mg/4 ml $0-$6.60 (Tier 2) phenytoin oral suspension 125 mg/5 ml $0-$6.60 (Tier 2) MO phenytoin oral tablet,chewable $0-$6.60 (Tier 2) MO 29
phenytoin sodium extended $0-$6.60 (Tier 2) MO phenytoin sodium intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO phenytoin sodium intravenous syringe $0-$6.60 (Tier 2) B/D PAR POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) POTIGA ORAL TABLET 50 MG $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) primidone $0-$6.60 (Tier 2) MO SABRIL $0-$6.60 (Tier 2) PAR; MO; LA; QLL (180 per 30 days) tiagabine $0-$6.60 (Tier 2) MO topiramate oral capsule, sprinkle $0-$6.60 (Tier 2) PAR; MO topiramate oral tablet $0-$6.60 (Tier 2) PAR; MO valproate sodium $0-$6.60 (Tier 2) B/D PAR; MO valproic acid $0-$6.60 (Tier 2) MO valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) VIMPAT INTRAVENOUS $0-$6.60 (Tier 2) B/D PAR; QLL (1200 per 30 days) VIMPAT ORAL SOLUTION $0-$6.60 (Tier 2) MO; QLL (1200 per 30 days) VIMPAT ORAL TABLET 100 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) VIMPAT ORAL TABLET 150 MG $0-$6.60 (Tier 2) MO; QLL (80 per 30 days) VIMPAT ORAL TABLET 200 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) VIMPAT ORAL TABLET 50 MG $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) zonisamide $0-$6.60 (Tier 2) MO ANTIPARKINSONISM AGENTS APOKYN $0-$6.60 (Tier 2) PAR; MO; LA AZILECT $0-$6.60 (Tier 2) MO benztropine oral $0-$6.60 (Tier 2) PAR; MO bromocriptine $0-$6.60 (Tier 2) MO carbidopa-levodopa $0-$6.60 (Tier 2) MO 30
entacapone $0-$6.60 (Tier 2) MO NEUPRO $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) pramipexole oral tablet $0-$6.60 (Tier 2) MO ropinirole oral tablet $0-$6.60 (Tier 2) MO selegiline hcl $0-$6.60 (Tier 2) MO TASMAR ORAL TABLET 100 MG $0-$6.60 (Tier 2) MO tolcapone $0-$6.60 (Tier 2) MO MIGRAINE / CLUSTER HEADACHE THERAPY ERGOMAR $0-$6.60 (Tier 2) MO MIGRANAL $0-$6.60 (Tier 2) MO; QLL (8 per 28 days) rizatriptan $0-$6.60 (Tier 2) MO; QLL (12 per 30 days) sumatriptan succinate oral $0-$6.60 (Tier 2) MO; QLL (9 per 30 days) sumatriptan succinate subcutaneous cartridge $0-$6.60 (Tier 2) MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous pen injector $0-$6.60 (Tier 2) MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous solution $0-$6.60 (Tier 2) MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml $0-$6.60 (Tier 2) QLL (4 per 30 days) zolmitriptan $0-$6.60 (Tier 2) MO; QLL (9 per 30 days) ZOMIG NASAL $0-$6.60 (Tier 2) MO; QLL (6 per 30 days) MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA $0-$6.60 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (12 per 28 days) donepezil oral tablet 10 mg, 5 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) donepezil oral tablet,disintegrating $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) EXELON TRANSDERMAL $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) galantamine oral capsule,ext rel. pellets 24 hr $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) galantamine oral solution $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) galantamine oral tablet $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) 31
GILENYA $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) GLATOPA $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) NAMENDA ORAL SOLUTION $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) NAMENDA ORAL TABLET 10 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) NAMENDA ORAL TABLET 5 MG $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) NAMENDA TITRATION PAK $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 365 days) $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) NUEDEXTA $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) rivastigmine tartrate $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) TECFIDERA $0-$6.60 (Tier 2) PAR; MO TYSABRI $0-$6.60 (Tier 2) MO; LA XENAZINE ORAL TABLET 12.5 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (240 per 30 days) XENAZINE ORAL TABLET 25 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (120 per 30 days) MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen $0-$6.60 (Tier 2) MO cyclobenzaprine oral tablet $0-$6.60 (Tier 2) PAR; MO dantrolene $0-$6.60 (Tier 2) MO MESTINON ORAL SYRUP $0-$6.60 (Tier 2) MO MESTINON TIMESPAN $0-$6.60 (Tier 2) MO pyridostigmine bromide $0-$6.60 (Tier 2) MO tizanidine oral tablet $0-$6.60 (Tier 2) MO NARCOTIC ANALGESICS ABSTRAL $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml $0-$6.60 (Tier 2) QLL (4500 per 30 days) 32
acetaminophen-codeine oral solution 120-12 mg/5 ml $0-$6.60 (Tier 2) MO; QLL (4500 per 30 days) acetaminophen-codeine oral tablet 300-15 mg $0-$6.60 (Tier 2) MO; QLL (390 per 30 days) acetaminophen-codeine oral tablet 300-30 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) acetaminophen-codeine oral tablet 300-60 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) ACTIQ $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) AVINZA ORAL CAPSULE, ER MULTIPHASE 24 HR 75 MG buprenorphine hcl injection syringe $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) buprenorphine hcl sublingual tablet 2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) buprenorphine hcl sublingual tablet 8 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) butalbital compound w/codeine $0-$6.60 (Tier 2) PAR; MO duramorph (pf) injection solution 0.5 mg/ml $0-$6.60 (Tier 2) B/D PAR; MO duramorph (pf) injection solution 1 mg/ml $0-$6.60 (Tier 2) B/D PAR endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) fentanyl citrate $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr $0-$6.60 (Tier 2) ST; MO; QLL (15 per 30 days) FENTORA $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) hydrocodone-acetaminophen oral solution 2.5-167 mg/5 ml hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg $0-$6.60 (Tier 2) QLL (2700 per 30 days) $0-$6.60 (Tier 2) MO; QLL (2700 per 30 days) $0-$6.60 (Tier 2) MO; QLL (390 per 30 days) $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) hydrocodone-ibuprofen $0-$6.60 (Tier 2) MO; QLL (480 per 30 days) hydromorphone oral tablet 2 mg, 4 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) hydromorphone oral tablet 8 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) LAZANDA $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) 33
levorphanol tartrate $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) methadone injection $0-$6.60 (Tier 2) methadone intensol $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) methadone oral concentrate $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) methadone oral solution 10 mg/5 ml $0-$6.60 (Tier 2) MO; QLL (900 per 30 days) methadone oral solution 5 mg/5 ml $0-$6.60 (Tier 2) MO; QLL (1800 per 30 days) methadone oral tablet 10 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) methadone oral tablet 5 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) methadose oral concentrate $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) morphine (pf) injection solution 0.5 mg/ml $0-$6.60 (Tier 2) B/D PAR morphine (pf) injection solution 1 mg/ml $0-$6.60 (Tier 2) B/D PAR; MO morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) morphine concentrate oral solution $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) morphine intravenous cartridge $0-$6.60 (Tier 2) MORPHINE INTRAVENOUS CARTRIDGE $0-$6.60 (Tier 2) morphine intravenous pt controlled analgesia syring morphine intravenous solution 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) morphine intravenous solution 50 mg/ml $0-$6.60 (Tier 2) MO morphine intravenous syringe 2 mg/ml, 4 mg/ml $0-$6.60 (Tier 2) morphine oral capsule, er multiphase 24 hr 120 mg, 75 mg, 90 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) morphine oral solution 20 mg/5 ml $0-$6.60 (Tier 2) MO; QLL (1350 per 30 days) morphine oral tablet 15 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) 34
morphine oral tablet 30 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) morphine oral tablet extended release 200 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) oxycodone oral capsule $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) oxycodone oral concentrate $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) oxycodone oral tablet 10 mg, 5 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) oxycodone oral tablet 15 mg $0-$6.60 (Tier 2) MO; QLL (540 per 30 days) oxycodone oral tablet 20 mg, 30 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) oxycodone-aspirin $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) ROXICET ORAL SOLUTION $0-$6.60 (Tier 2) MO; QLL (1800 per 30 days) SUBSYS $0-$6.60 (Tier 2) PAR; MO; LA; QLL (120 per 30 days) NON-NARCOTIC ANALGESICS acephen rectal suppository 120 mg, 650 mg $0 (Tier 4) MO; [*] acephen rectal suppository 325 mg $0 (Tier 4) [*] aceta-gesic $0 (Tier 4) [*] acetaminophen oral tablet 325 mg $0 (Tier 4) MO; [*] added strength pain reliever $0 (Tier 4) [*] all day pain relief $0 (Tier 4) [*] all day relief $0 (Tier 4) MO; [*] arthritis pain relief (acetam) $0 (Tier 4) [*] aspirin low-strength $0 (Tier 4) [*] aspirin oral tablet 325 mg $0 (Tier 4) MO; [*] aspirin oral tablet,chewable $0 (Tier 4) MO; [*] aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg $0 (Tier 4) MO; [*] aspir-low $0 (Tier 4) MO; [*] 35
buprenorphine-naloxone sublingual tablet 2-0.5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (360 per 30 days) buprenorphine-naloxone sublingual tablet 8-2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) butorphanol tartrate injection $0-$6.60 (Tier 2) MO butorphanol tartrate nasal $0-$6.60 (Tier 2) MO; QLL (5 per 28 days) child ibuprofen $0 (Tier 4) [*] children's aspirin $0 (Tier 4) MO; [*] children's ibuprofen $0 (Tier 4) MO; [*] children's mapap $0 (Tier 4) [*] children's medi-profen $0 (Tier 4) [*] children's medi-tabs suspension $0 (Tier 4) [*] children's pain & fever relief $0 (Tier 4) MO; [*] children's pain relief oral suspension $0 (Tier 4) [*] children's pain reliever oral suspension $0 (Tier 4) [*] children's pain reliever oral tablet,disintegrating $0 (Tier 4) [*] children's q-pap $0 (Tier 4) MO; [*] children's silapap $0 (Tier 4) [*] diclofenac potassium $0-$6.60 (Tier 2) MO diclofenac sodium oral $0-$6.60 (Tier 2) MO diflunisal $0-$6.60 (Tier 2) MO diphenhydramine-acetaminophen $0 (Tier 4) [*] ed-apap $0 (Tier 4) [*] effervescent pain relief oral tablet, effervescent 325-1,916-1,000 mg $0 (Tier 4) [*] enteric coated aspirin $0 (Tier 4) [*] etodolac oral capsule 200 mg $0-$6.60 (Tier 2) MO etodolac oral tablet $0-$6.60 (Tier 2) MO etodolac oral tablet extended release 24 hr $0-$6.60 (Tier 2) MO ex-strength medi-tabs pm $0 (Tier 4) [*] fenoprofen oral tablet $0-$6.60 (Tier 2) MO 36
flurbiprofen $0-$6.60 (Tier 2) MO headache formula added str $0 (Tier 4) [*] headache relief (asa-acet-caf) $0 (Tier 4) [*] HISTAFLEX $0 (Tier 4) [*] ibu-drops $0 (Tier 4) [*] ibuprofen jr strength $0 (Tier 4) [*] ibuprofen oral capsule $0 (Tier 4) [*] ibuprofen oral suspension $0-$6.60 (Tier 2) MO ibuprofen oral tablet 200 mg $0 (Tier 4) MO; [*] ibuprofen oral tablet 400 mg, 600 mg, 800 mg $0-$6.60 (Tier 2) MO infants ibu-drops $0 (Tier 4) [*] infant's ibuprofen $0 (Tier 4) [*] junior mapap $0 (Tier 4) MO; [*] lite coat aspirin $0 (Tier 4) [*] mapap (acetaminophen) oral capsule $0 (Tier 4) MO; [*] mapap (acetaminophen) oral elixir $0 (Tier 4) MO; [*] mapap (acetaminophen) oral liquid $0 (Tier 4) MO; [*] mapap (acetaminophen) oral suspension $0 (Tier 4) [*] mapap (acetaminophen) oral tablet $0 (Tier 4) MO; [*] mapap (acetaminophen) oral tablet,chewable $0 (Tier 4) MO; [*] mapap arthritis pain $0 (Tier 4) MO; [*] mapap extra strength $0 (Tier 4) MO; [*] mapap pm $0 (Tier 4) MO; [*] meclofenamate oral $0-$6.60 (Tier 2) MO medi-profen $0 (Tier 4) [*] medi-tabs oral tablet 325 mg $0 (Tier 4) [*] meloxicam oral suspension $0-$6.60 (Tier 2) MO; QLL (300 per 30 days) meloxicam oral tablet $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) menstrual relief $0 (Tier 4) [*] migraine formula $0 (Tier 4) [*] 37
nabumetone $0-$6.60 (Tier 2) MO nalbuphine injection $0-$6.60 (Tier 2) MO naloxone injection solution $0-$6.60 (Tier 2) MO naloxone injection syringe 0.4 mg/ml $0-$6.60 (Tier 2) naloxone injection syringe 1 mg/ml $0-$6.60 (Tier 2) MO naltrexone oral $0-$6.60 (Tier 2) MO naproxen $0-$6.60 (Tier 2) MO naproxen sodium oral tablet 220 mg $0 (Tier 4) MO; [*] naproxen sodium oral tablet 275 mg, 550 mg $0-$6.60 (Tier 2) MO non-aspirin pain relief oral tablet 500 mg $0 (Tier 4) [*] non-aspirin pm $0 (Tier 4) [*] oxaprozin $0-$6.60 (Tier 2) MO pain & fever $0 (Tier 4) MO; [*] pain relief oral tablet 500 mg $0 (Tier 4) [*] pain reliever extra strength $0 (Tier 4) [*] pain reliever oral tablet $0 (Tier 4) [*] pain reliever pm ex-strength $0 (Tier 4) [*] piroxicam $0-$6.60 (Tier 2) MO q-pap extra strength $0 (Tier 4) MO; [*] q-pap oral drops $0 (Tier 4) MO; [*] q-pap oral liquid $0 (Tier 4) MO; [*] q-pap oral tablet 325 mg $0 (Tier 4) [*] q-pap oral tablet 500 mg $0 (Tier 4) MO; [*] silapap $0 (Tier 4) [*] SUBOXONE SUBLINGUAL FILM 12-3 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) SUBOXONE SUBLINGUAL FILM 2-0.5 MG $0-$6.60 (Tier 2) PAR; MO; QLL (360 per 30 days) SUBOXONE SUBLINGUAL FILM 4-1 MG $0-$6.60 (Tier 2) PAR; MO; QLL (180 per 30 days) SUBOXONE SUBLINGUAL FILM 8-2 MG $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) sulindac oral $0-$6.60 (Tier 2) MO tolmetin $0-$6.60 (Tier 2) MO 38
tramadol oral tablet $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) tramadol-acetaminophen $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) VOLTAREN GEL TOPICAL GEL 1 % $0-$6.60 (Tier 2) MO; QLL (1000 per 30 days) PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING $0-$6.60 (Tier 2) MO; QLL (1 per 28 days) $0-$6.60 (Tier 2) QLL (1 per 28 days) ABILIFY ORAL TABLET 10 MG $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) ABILIFY ORAL TABLET 15 MG, 20 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) ABILIFY ORAL TABLET 2 MG $0-$6.60 (Tier 2) MO; QLL (450 per 30 days) ABILIFY ORAL TABLET 30 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) ABILIFY ORAL TABLET 5 MG $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) ADASUVE $0-$6.60 (Tier 2) alprazolam oral tablet $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) amitriptyline $0-$6.60 (Tier 2) PAR; MO amoxapine $0-$6.60 (Tier 2) MO amphetamine salt combo oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) amphetamine salt combo oral tablet 30 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) aripiprazole oral tablet 10 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) aripiprazole oral tablet 15 mg, 20 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) aripiprazole oral tablet 2 mg $0-$6.60 (Tier 2) MO; QLL (450 per 30 days) aripiprazole oral tablet 30 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) aripiprazole oral tablet 5 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) BRINTELLIX ORAL TABLET 10 MG $0-$6.60 (Tier 2) ST; MO; QLL (60 per 30 days) BRINTELLIX ORAL TABLET 20 MG $0-$6.60 (Tier 2) ST; MO; QLL (30 per 30 days) BRINTELLIX ORAL TABLET 5 MG $0-$6.60 (Tier 2) ST; MO; QLL (120 per 30 days) bupropion hcl oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (135 per 30 days) bupropion hcl oral tablet 75 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) bupropion hcl oral tablet extended release 100 mg $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) 39
bupropion hcl oral tablet extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) $0-$6.60 (Tier 2) MO; QLL (45 per 30 days) buspirone $0-$6.60 (Tier 2) MO chlorpromazine $0-$6.60 (Tier 2) PAR; MO citalopram oral solution $0-$2.65 (Tier 1) MO; QLL (600 per 30 days) citalopram oral tablet 10 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) citalopram oral tablet 20 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) citalopram oral tablet 40 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) clomipramine $0-$6.60 (Tier 2) PAR; MO clorazepate dipotassium $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) clozapine oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) clozapine oral tablet 200 mg $0-$6.60 (Tier 2) QLL (135 per 30 days) clozapine oral tablet 25 mg $0-$6.60 (Tier 2) MO; QLL (1080 per 30 days) clozapine oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (540 per 30 days) clozapine oral tablet,disintegrating 100 mg $0-$6.60 (Tier 2) QLL (270 per 30 days) clozapine oral tablet,disintegrating 12.5 mg $0-$6.60 (Tier 2) QLL (2160 per 30 days) clozapine oral tablet,disintegrating 150 mg $0-$6.60 (Tier 2) QLL (180 per 30 days) clozapine oral tablet,disintegrating 200 mg $0-$6.60 (Tier 2) QLL (135 per 30 days) clozapine oral tablet,disintegrating 25 mg $0-$6.60 (Tier 2) QLL (1080 per 30 days) desipramine oral $0-$6.60 (Tier 2) MO DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) 40
DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG dextroamphetamine oral capsule, extended release 10 mg, 5 mg dextroamphetamine oral capsule, extended release 15 mg $0-$6.60 (Tier 2) QLL (120 per 30 days) $0-$6.60 (Tier 2) QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) dextroamphetamine oral tablet 10 mg $0-$6.60 (Tier 2) PAR; MO; QLL (180 per 30 days) dextroamphetamine oral tablet 5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) diazepam injection solution $0-$6.60 (Tier 2) diazepam injection syringe $0-$6.60 (Tier 2) MO diazepam intensol $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) diazepam oral concentrate $0-$6.60 (Tier 2) PAR; QLL (240 per 30 days) diazepam oral solution 5 mg/5 ml $0-$6.60 (Tier 2) MO; QLL (1200 per 30 days) diazepam oral tablet 10 mg $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) diazepam oral tablet 2 mg $0-$6.60 (Tier 2) PAR; MO; QLL (600 per 30 days) diazepam oral tablet 5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) doxepin oral $0-$6.60 (Tier 2) PAR; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) EMSAM $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) ergoloid $0-$6.60 (Tier 2) PAR; MO escitalopram oxalate oral solution $0-$2.65 (Tier 1) MO; QLL (600 per 30 days) escitalopram oxalate oral tablet 10 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) escitalopram oxalate oral tablet 20 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) 41
escitalopram oxalate oral tablet 5 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) FANAPT ORAL TABLET 1 MG $0-$6.60 (Tier 2) MO; QLL (720 per 30 days) FANAPT ORAL TABLET 10 MG $0-$6.60 (Tier 2) MO; QLL (72 per 30 days) FANAPT ORAL TABLET 12 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) FANAPT ORAL TABLET 2 MG $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) FANAPT ORAL TABLET 4 MG $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) FANAPT ORAL TABLET 6 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) FANAPT ORAL TABLET 8 MG $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) FANAPT ORAL TABLETS,DOSE PACK $0-$6.60 (Tier 2) MO; QLL (8 per 30 days) FAZACLO ORAL TABLET,DISINTEGRATING 100 MG FAZACLO ORAL TABLET,DISINTEGRATING 12.5 MG FAZACLO ORAL TABLET,DISINTEGRATING 150 MG FAZACLO ORAL TABLET,DISINTEGRATING 200 MG FAZACLO ORAL TABLET,DISINTEGRATING 25 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG $0-$6.60 (Tier 2) QLL (270 per 30 days) $0-$6.60 (Tier 2) QLL (2160 per 30 days) $0-$6.60 (Tier 2) QLL (180 per 30 days) $0-$6.60 (Tier 2) QLL (135 per 30 days) $0-$6.60 (Tier 2) QLL (1080 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 365 days) $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (180 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) fluoxetine oral capsule 10 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) fluoxetine oral capsule 20 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) fluoxetine oral capsule 40 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) fluoxetine oral solution $0-$2.65 (Tier 1) MO; QLL (600 per 30 days) fluoxetine oral tablet 10 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) fluoxetine oral tablet 20 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) 42
fluphenazine decanoate $0-$6.60 (Tier 2) MO fluphenazine hcl $0-$6.60 (Tier 2) MO fluvoxamine oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) fluvoxamine oral tablet 25 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) fluvoxamine oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) GEODON INTRAMUSCULAR $0-$6.60 (Tier 2) MO guanfacine oral tablet extended release 24 hr $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) guanidine $0-$6.60 (Tier 2) MO haloperidol $0-$6.60 (Tier 2) MO haloperidol decanoate $0-$6.60 (Tier 2) MO haloperidol lactate $0-$6.60 (Tier 2) MO imipramine hcl $0-$6.60 (Tier 2) PAR; MO INTUNIV ER $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (40 per 30 days) INVEGA SUSTENNA $0-$6.60 (Tier 2) MO; QLL (2 per 28 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG $0-$6.60 (Tier 2) MO; QLL (0.875 per 90 days) $0-$6.60 (Tier 2) MO; QLL (1.315 per 90 days) $0-$6.60 (Tier 2) MO; QLL (1.75 per 90 days) $0-$6.60 (Tier 2) MO; QLL (2.625 per 90 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) 43
KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) LATUDA ORAL TABLET 120 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) LATUDA ORAL TABLET 20 MG $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) LATUDA ORAL TABLET 40 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) LATUDA ORAL TABLET 60 MG $0-$6.60 (Tier 2) MO; QLL (75 per 30 days) LATUDA ORAL TABLET 80 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) lithium carbonate $0-$6.60 (Tier 2) MO lithium citrate oral solution 8 meq/5 ml $0-$6.60 (Tier 2) MO lorazepam oral tablet $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) loxapine succinate $0-$6.60 (Tier 2) MO maprotiline oral tablet 25 mg $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) maprotiline oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (135 per 30 days) maprotiline oral tablet 75 mg $0-$6.60 (Tier 2) MO MARPLAN $0-$6.60 (Tier 2) MO medi-sleep $0 (Tier 4) [*] methylphenidate oral tablet $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) mirtazapine oral tablet 15 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) mirtazapine oral tablet 30 mg $0-$6.60 (Tier 2) MO; QLL (45 per 30 days) mirtazapine oral tablet 45 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) mirtazapine oral tablet 7.5 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) mirtazapine oral tablet,disintegrating 15 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) mirtazapine oral tablet,disintegrating 30 mg $0-$6.60 (Tier 2) MO; QLL (45 per 30 days) mirtazapine oral tablet,disintegrating 45 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) modafinil oral tablet 100 mg $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) modafinil oral tablet 200 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) nefazodone oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) nefazodone oral tablet 150 mg $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) nefazodone oral tablet 200 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) nefazodone oral tablet 250 mg $0-$6.60 (Tier 2) MO; QLL (72 per 30 days) 44
nefazodone oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) nortriptyline $0-$6.60 (Tier 2) MO olanzapine intramuscular $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) olanzapine oral tablet 10 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) olanzapine oral tablet 15 mg $0-$6.60 (Tier 2) MO; QLL (40 per 30 days) olanzapine oral tablet 2.5 mg $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) olanzapine oral tablet 20 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) olanzapine oral tablet 5 mg $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) olanzapine oral tablet 7.5 mg $0-$6.60 (Tier 2) MO; QLL (80 per 30 days) olanzapine oral tablet,disintegrating 10 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) olanzapine oral tablet,disintegrating 15 mg $0-$6.60 (Tier 2) MO; QLL (40 per 30 days) olanzapine oral tablet,disintegrating 20 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) olanzapine oral tablet,disintegrating 5 mg $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) ORAP $0-$6.60 (Tier 2) MO paroxetine hcl oral tablet 10 mg $0-$2.65 (Tier 1) MO; QLL (180 per 30 days) paroxetine hcl oral tablet 20 mg $0-$2.65 (Tier 1) MO; QLL (90 per 30 days) paroxetine hcl oral tablet 30 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) paroxetine hcl oral tablet 40 mg $0-$2.65 (Tier 1) MO; QLL (45 per 30 days) paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg $0-$2.65 (Tier 1) MO; QLL (180 per 30 days) $0-$2.65 (Tier 1) MO; QLL (90 per 30 days) $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) PAXIL ORAL SUSPENSION $0-$6.60 (Tier 2) MO; QLL (900 per 30 days) perphenazine $0-$6.60 (Tier 2) MO phenelzine $0-$6.60 (Tier 2) MO PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (480 per 30 days) 45
PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG protriptyline $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) PAR; MO; QLL (240 per 30 days) quetiapine oral tablet 100 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) quetiapine oral tablet 200 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) quetiapine oral tablet 25 mg $0-$2.65 (Tier 1) MO; QLL (960 per 30 days) quetiapine oral tablet 300 mg $0-$2.65 (Tier 1) MO; QLL (80 per 30 days) quetiapine oral tablet 400 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) quetiapine oral tablet 50 mg $0-$2.65 (Tier 1) MO; QLL (480 per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML $0-$6.60 (Tier 2) MO; QLL (2 per 28 days) $0-$6.60 (Tier 2) MO risperidone oral solution $0-$2.65 (Tier 1) MO; QLL (480 per 30 days) risperidone oral tablet 0.25 mg $0-$2.65 (Tier 1) MO; QLL (1920 per 30 days) risperidone oral tablet 0.5 mg $0-$2.65 (Tier 1) MO; QLL (960 per 30 days) risperidone oral tablet 1 mg $0-$2.65 (Tier 1) MO; QLL (480 per 30 days) risperidone oral tablet 2 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) risperidone oral tablet 3 mg $0-$2.65 (Tier 1) MO; QLL (160 per 30 days) risperidone oral tablet 4 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) risperidone oral tablet,disintegrating 0.25 mg $0-$2.65 (Tier 1) MO; QLL (1920 per 30 days) risperidone oral tablet,disintegrating 0.5 mg $0-$2.65 (Tier 1) MO; QLL (960 per 30 days) risperidone oral tablet,disintegrating 1 mg $0-$2.65 (Tier 1) MO; QLL (480 per 30 days) risperidone oral tablet,disintegrating 2 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) risperidone oral tablet,disintegrating 3 mg $0-$2.65 (Tier 1) MO; QLL (160 per 30 days) risperidone oral tablet,disintegrating 4 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) ROZEREM $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) 46
SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (160 per 30 days) $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) $0-$6.60 (Tier 2) MO; QLL (80 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (480 per 30 days) sertraline oral concentrate $0-$2.65 (Tier 1) MO; QLL (300 per 30 days) sertraline oral tablet 100 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) sertraline oral tablet 25 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) sertraline oral tablet 50 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) sleep aid (doxylamine) $0 (Tier 4) [*] STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) SURMONTIL $0-$6.60 (Tier 2) PAR; MO temazepam oral capsule 15 mg, 22.5 mg, 30 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) thioridazine $0-$6.60 (Tier 2) PAR; MO thiothixene $0-$6.60 (Tier 2) MO tranylcypromine $0-$6.60 (Tier 2) MO trazodone $0-$6.60 (Tier 2) MO trifluoperazine $0-$6.60 (Tier 2) MO venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) 47
venlafaxine oral capsule,extended release 24hr 75 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) venlafaxine oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (113 per 30 days) venlafaxine oral tablet 25 mg $0-$6.60 (Tier 2) MO; QLL (450 per 30 days) venlafaxine oral tablet 37.5 mg $0-$6.60 (Tier 2) MO; QLL (300 per 30 days) venlafaxine oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (225 per 30 days) venlafaxine oral tablet 75 mg $0-$6.60 (Tier 2) MO; QLL (150 per 30 days) venlafaxine oral tablet extended release 24hr 150 mg VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 MG venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) VERSACLOZ $0-$6.60 (Tier 2) LA; QLL (600 per 30 days) VIIBRYD ORAL TABLET 10 MG $0-$6.60 (Tier 2) ST; MO; QLL (120 per 30 days) VIIBRYD ORAL TABLET 20 MG $0-$6.60 (Tier 2) ST; MO; QLL (60 per 30 days) VIIBRYD ORAL TABLET 40 MG $0-$6.60 (Tier 2) ST; MO; QLL (30 per 30 days) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16) $0-$6.60 (Tier 2) ST; MO; QLL (30 per 30 days) XYREM $0-$6.60 (Tier 2) PAR; MO; LA; QLL (540 per 30 days) zaleplon oral capsule 10 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) zaleplon oral capsule 5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) zenzedi oral tablet 10 mg $0-$6.60 (Tier 2) PAR; MO; QLL (180 per 30 days) zenzedi oral tablet 5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) ziprasidone hcl oral capsule 20 mg $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) ziprasidone hcl oral capsule 40 mg $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) ziprasidone hcl oral capsule 60 mg, 80 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) zolpidem oral tablet $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) 48
ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG $0-$6.60 (Tier 2) LA $0-$6.60 (Tier 2) MO; LA CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO amiodarone intravenous syringe $0-$6.60 (Tier 2) B/D PAR amiodarone oral $0-$6.60 (Tier 2) MO flecainide $0-$6.60 (Tier 2) MO lidocaine (pf) intravenous solution $0-$6.60 (Tier 2) MO lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %), 50 mg/5 ml (1 %) $0-$6.60 (Tier 2) mexiletine $0-$6.60 (Tier 2) MO MULTAQ $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) pacerone oral tablet 100 mg, 200 mg, 400 mg $0-$6.60 (Tier 2) MO procainamide injection solution 100 mg/ml $0-$6.60 (Tier 2) MO procainamide injection solution 500 mg/ml $0-$6.60 (Tier 2) propafenone oral tablet $0-$6.60 (Tier 2) MO quinidine sulfate tablets oral tablet 200 mg, 300 mg $0-$6.60 (Tier 2) MO sorine oral tablet 120 mg, 160 mg, 80 mg $0-$6.60 (Tier 2) MO sorine oral tablet 240 mg $0-$6.60 (Tier 2) sotalol af $0-$6.60 (Tier 2) MO sotalol oral $0-$6.60 (Tier 2) MO TIKOSYN $0-$6.60 (Tier 2) MO ANTIHYPERTENSIVE THERAPY acebutolol oral $0-$2.65 (Tier 1) MO afeditab cr $0-$6.60 (Tier 2) MO 49
amiloride oral $0-$6.60 (Tier 2) MO amiloride-hydrochlorothiazide $0-$6.60 (Tier 2) MO amlodipine oral tablet 10 mg, 2.5 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) amlodipine oral tablet 5 mg $0-$2.65 (Tier 1) MO; QLL (45 per 30 days) amlodipine-benazepril $0-$2.65 (Tier 1) MO amlodipine-valsartan $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) amlodipine-valsartan-hcthiazid $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) atenolol $0-$2.65 (Tier 1) MO atenolol-chlorthalidone $0-$2.65 (Tier 1) MO AZOR $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) benazepril $0-$2.65 (Tier 1) MO benazepril-hydrochlorothiazide $0-$2.65 (Tier 1) MO betaxolol oral $0-$6.60 (Tier 2) MO bisoprolol fumarate $0-$6.60 (Tier 2) MO bisoprolol-hydrochlorothiazide $0-$6.60 (Tier 2) MO bumetanide $0-$6.60 (Tier 2) MO BYSTOLIC $0-$6.60 (Tier 2) MO candesartan oral tablet 16 mg, 4 mg, 8 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) candesartan oral tablet 32 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) candesartan-hydrochlorothiazid oral tablet 16-12.5 mg candesartan-hydrochlorothiazid oral tablet 32-12.5 mg, 32-25 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) captopril $0-$2.65 (Tier 1) MO captopril-hydrochlorothiazide $0-$2.65 (Tier 1) MO cartia xt $0-$6.60 (Tier 2) MO carvedilol $0-$2.65 (Tier 1) MO chlorothiazide $0-$6.60 (Tier 2) MO chlorothiazide sodium $0-$6.60 (Tier 2) MO chlorthalidone oral tablet 25 mg, 50 mg $0-$6.60 (Tier 2) MO 50
clonidine hcl oral tablet $0-$2.65 (Tier 1) MO clonidine patches $0-$6.60 (Tier 2) MO; QLL (4 per 28 days) COREG CR $0-$6.60 (Tier 2) ST; MO DEMSER $0-$6.60 (Tier 2) MO diltiazem hcl intravenous $0-$6.60 (Tier 2) diltiazem hcl oral capsule, extended release $0-$6.60 (Tier 2) MO diltiazem hcl oral capsule,ext release degradable $0-$6.60 (Tier 2) MO diltiazem hcl oral capsule,extended release 12 hr $0-$6.60 (Tier 2) MO diltiazem hcl oral capsule,extended release 24hr $0-$6.60 (Tier 2) MO diltiazem hcl oral tablet $0-$6.60 (Tier 2) MO diltiazem hcl oral tablet extended release 24 hr 180 mg, 300 mg, 420 mg diltiazem hcl oral tablet extended release 24 hr 240 mg, 360 mg $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO dilt-xr $0-$6.60 (Tier 2) MO doxazosin $0-$6.60 (Tier 2) MO enalapril maleate $0-$2.65 (Tier 1) MO enalapril-hydrochlorothiazide $0-$2.65 (Tier 1) MO eplerenone $0-$6.60 (Tier 2) MO eprosartan $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) felodipine $0-$6.60 (Tier 2) MO fosinopril $0-$2.65 (Tier 1) MO fosinopril-hydrochlorothiazide $0-$2.65 (Tier 1) MO furosemide injection $0-$6.60 (Tier 2) MO furosemide oral solution 10 mg/ml, 40 mg/5 ml $0-$2.65 (Tier 1) MO furosemide oral tablet $0-$2.65 (Tier 1) MO hydralazine $0-$6.60 (Tier 2) MO hydrochlorothiazide $0-$2.65 (Tier 1) MO indapamide $0-$2.65 (Tier 1) MO irbesartan $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) 51
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) isradipine $0-$6.60 (Tier 2) MO labetalol intravenous solution $0-$6.60 (Tier 2) MO labetalol oral $0-$6.60 (Tier 2) MO lisinopril $0-$2.65 (Tier 1) MO lisinopril-hydrochlorothiazide $0-$2.65 (Tier 1) MO losartan oral tablet 100 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) losartan oral tablet 25 mg, 50 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) losartan-hydrochlorothiazide $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) methyclothiazide $0-$6.60 (Tier 2) MO metolazone $0-$2.65 (Tier 1) MO metoprolol succinate $0-$6.60 (Tier 2) MO metoprolol ta-hydrochlorothiaz $0-$6.60 (Tier 2) MO metoprolol tartrate intravenous solution $0-$6.60 (Tier 2) MO metoprolol tartrate intravenous syringe $0-$6.60 (Tier 2) metoprolol tartrate oral $0-$2.65 (Tier 1) MO minoxidil oral $0-$6.60 (Tier 2) MO moexipril $0-$2.65 (Tier 1) MO moexipril-hydrochlorothiazide $0-$2.65 (Tier 1) MO nadolol $0-$2.65 (Tier 1) MO nadolol-bendroflumethiazide $0-$6.60 (Tier 2) MO nicardipine $0-$6.60 (Tier 2) MO nifedical xl $0-$6.60 (Tier 2) MO nifedipine oral tablet extended release $0-$6.60 (Tier 2) MO nifedipine oral tablet extended release 24hr $0-$6.60 (Tier 2) MO nimodipine $0-$6.60 (Tier 2) MO perindopril erbumine $0-$2.65 (Tier 1) MO 52
pindolol $0-$6.60 (Tier 2) MO prazosin oral $0-$6.60 (Tier 2) MO propranolol intravenous $0-$6.60 (Tier 2) propranolol oral $0-$6.60 (Tier 2) MO propranolol-hydrochlorothiazid $0-$6.60 (Tier 2) MO quinapril $0-$2.65 (Tier 1) MO quinapril-hydrochlorothiazide $0-$2.65 (Tier 1) MO ramipril $0-$2.65 (Tier 1) MO spironolactone $0-$2.65 (Tier 1) MO spironolacton-hydrochlorothiaz $0-$2.65 (Tier 1) MO taztia xt $0-$6.60 (Tier 2) MO TEKTURNA $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) TEKTURNA HCT $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) telmisartan oral tablet 20 mg, 40 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) telmisartan oral tablet 80 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) telmisartan-amlodipine $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) terazosin $0-$2.65 (Tier 1) MO timolol maleate oral $0-$6.60 (Tier 2) MO torsemide oral $0-$2.65 (Tier 1) MO trandolapril $0-$2.65 (Tier 1) MO triamterene-hydrochlorothiazid oral capsule 37.5-25 mg $0-$2.65 (Tier 1) MO triamterene-hydrochlorothiazid oral tablet $0-$2.65 (Tier 1) MO TRIBENZOR $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) valsartan oral tablet 160 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) valsartan oral tablet 320 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) valsartan oral tablet 40 mg, 80 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) 53
valsartan-hydrochlorothiazide $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) verapamil intravenous solution $0-$6.60 (Tier 2) MO verapamil intravenous syringe $0-$6.60 (Tier 2) verapamil oral $0-$6.60 (Tier 2) MO CARDIAC GLYCOSIDES DIGITEK ORAL TABLET 125 MCG $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) digox oral tablet 125 mcg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) digoxin oral solution 50 mcg/ml $0-$6.60 (Tier 2) MO digoxin oral tablet 125 mcg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) LANOXIN ORAL TABLET 125 MCG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) LANOXIN ORAL TABLET 62.5 MCG $0-$6.60 (Tier 2) MO COAGULATION THERAPY AGGRENOX $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) aspirin-dipyridamole $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) BRILINTA $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) cilostazol $0-$6.60 (Tier 2) MO clopidogrel oral tablet 300 mg $0-$6.60 (Tier 2) MO; QLL (1 per 30 days) clopidogrel oral tablet 75 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) COUMADIN ORAL $0-$6.60 (Tier 2) MO EFFIENT $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) ELIQUIS $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) enoxaparin subcutaneous solution $0-$6.60 (Tier 2) MO; QLL (84 per 30 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml $0-$6.60 (Tier 2) MO; QLL (28 per 30 days) $0-$6.60 (Tier 2) MO; QLL (22.4 per 30 days) enoxaparin subcutaneous syringe 30 mg/0.3 ml $0-$6.60 (Tier 2) MO; QLL (8.4 per 30 days) enoxaparin subcutaneous syringe 40 mg/0.4 ml $0-$6.60 (Tier 2) MO; QLL (11.2 per 30 days) enoxaparin subcutaneous syringe 60 mg/0.6 ml $0-$6.60 (Tier 2) MO; QLL (16.8 per 30 days) fondaparinux subcutaneous syringe 10 mg/0.8 ml $0-$6.60 (Tier 2) MO; QLL (24 per 30 days) 54
fondaparinux subcutaneous syringe 2.5 mg/0.5 ml $0-$6.60 (Tier 2) MO; QLL (15 per 30 days) fondaparinux subcutaneous syringe 5 mg/0.4 ml $0-$6.60 (Tier 2) MO; QLL (12 per 30 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml $0-$6.60 (Tier 2) MO; QLL (18 per 30 days) FRAGMIN SUBCUTANEOUS SOLUTION $0-$6.60 (Tier 2) ST; MO FRAGMIN SUBCUTANEOUS SYRINGE $0-$6.60 (Tier 2) ST; MO heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 25,000 unit/250 ml(100 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR heparin (porcine) injection cartridge $0-$6.60 (Tier 2) B/D PAR; MO heparin (porcine) injection solution $0-$6.60 (Tier 2) B/D PAR; MO HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR heparin, porcine (pf) injection $0-$6.60 (Tier 2) B/D PAR; MO jantoven $0-$2.65 (Tier 1) MO MEPHYTON $0 (Tier 3) MO; [*] pentoxifylline $0-$6.60 (Tier 2) MO PRADAXA $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (30 per 30 days) PROMACTA ORAL TABLET 50 MG $0-$6.60 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) tranexamic acid intravenous $0-$6.60 (Tier 2) MO vitamin k1 injection $0 (Tier 3) MO; [*] warfarin $0-$2.65 (Tier 1) MO 55
XARELTO ORAL TABLET 10 MG, 20 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) XARELTO ORAL TABLET 15 MG $0-$6.60 (Tier 2) MO; QLL (42 per 30 days) XARELTO ORAL TABLETS,DOSE PACK $0-$6.60 (Tier 2) MO; QLL (51 per 365 days) LIPID/CHOLESTEROL LOWERING AGENTS amlodipine-atorvastatin $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) atorvastatin $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) cholestyramine (with sugar) $0-$6.60 (Tier 2) MO cholestyramine light $0-$6.60 (Tier 2) MO colestipol $0-$6.60 (Tier 2) MO CRESTOR $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) fenofibrate nanocrystallized $0-$6.60 (Tier 2) MO fenofibrate oral tablet 160 mg, 54 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) gemfibrozil oral $0-$6.60 (Tier 2) MO lovastatin oral tablet 10 mg, 20 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) lovastatin oral tablet 40 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) niacin oral capsule, extended release 250 mg $0 (Tier 4) MO; [*] niacin oral tablet 100 mg, 50 mg, 500 mg $0 (Tier 4) MO; [*] niacin oral tablet extended release 24 hr 1,000 mg, 750 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) niacin oral tablet extended release 24 hr 500 mg $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) niacin oral tablet extended release 250 mg, 500 mg $0 (Tier 4) MO; [*] NIACOR $0-$2.65 (Tier 1) MO omega-3 acid ethyl esters $0-$6.60 (Tier 2) PAR; MO pravastatin $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) prevalite $0-$6.60 (Tier 2) MO simvastatin $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) SLO-NIACIN ORAL TABLET EXTENDED RELEASE 250 MG $0 (Tier 4) MO; [*] 56
slo-niacin oral tablet extended release 500 mg $0 (Tier 4) MO; [*] WELCHOL $0-$6.60 (Tier 2) MO ZETIA $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA $0-$6.60 (Tier 2) PAR; MO VECAMYL $0-$6.60 (Tier 2) NITRATES isosorbide dinitrate oral $0-$6.60 (Tier 2) MO isosorbide mononitrate $0-$6.60 (Tier 2) MO nitro-bid $0-$6.60 (Tier 2) MO nitroglycerin intravenous $0-$6.60 (Tier 2) B/D PAR nitroglycerin transdermal patch 24 hour $0-$6.60 (Tier 2) MO NITROSTAT $0-$2.65 (Tier 1) MO DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin $0-$6.60 (Tier 2) MO calcipotriene topical cream $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) calcipotriene topical ointment $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) calcipotriene topical solution $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) selenium sulfide topical suspension $0-$6.60 (Tier 2) MO BURN THERAPY silver sulfadiazine $0-$6.60 (Tier 2) MO ssd $0-$6.60 (Tier 2) MO MISCELLANEOUS DERMATOLOGICALS ALOE VERA TOPICAL CREAM $0 (Tier 4) MO; [*] ALOE VERA TOPICAL GEL $0 (Tier 4) MO; [*] ALOE VERA TOPICAL LIQUID $0 (Tier 4) [*] ALOE VERA TOPICAL LOTION $0 (Tier 4) [*] ammonium lactate topical $0-$6.60 (Tier 2) MO 57
anti-itch (diphenhydramine) topical aerosol,spray $0 (Tier 4) [*] anti-itch(diphenhyd) with zinc topical cream 2-0.1 % $0 (Tier 4) [*] dermabase $0 (Tier 4) MO; [*] diclofenac sodium topical gel $0-$6.60 (Tier 2) PAR; MO; QLL (100 per 30 days) DR. SMITH'S DIAPER $0 (Tier 4) MO; [*] DR. SMITH'S DIAPER RASH $0 (Tier 4) [*] DR. SMITH'S RASH-SKIN TOPICAL AEROSOL,SPRAY $0 (Tier 4) [*] ELIDEL $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 1 day) fluorouracil topical cream 5 % $0-$6.60 (Tier 2) MO fluorouracil topical solution $0-$6.60 (Tier 2) MO imiquimod $0-$6.60 (Tier 2) MO ITCH-X TOPICAL GEL $0 (Tier 4) MO; [*] MEDICATED BODY POWDER TOPICAL POWDER 0.15 % $0 (Tier 4) [*] methoxsalen rapid $0-$6.60 (Tier 2) PAR; MO METHYL SALICYLATE-ALOE VERA $0 (Tier 4) MO; [*] mobisyl $0 (Tier 4) MO; [*] OXSORALEN $0-$6.60 (Tier 2) MO PANRETIN $0-$6.60 (Tier 2) MO podofilox $0-$6.60 (Tier 2) MO PROPYLENE GLYCOL $0 (Tier 4) MO; [*] PROTOPIC $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 1 day) SARNA ANTI-ITCH $0 (Tier 4) MO; [*] tacrolimus topical $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 1 day) THERA-GESIC TOPICAL CREAM 15-1 % $0 (Tier 4) MO; [*] trixaicin $0 (Tier 4) MO; [*] TRIXAICIN HP $0 (Tier 4) MO; [*] U-CORT $0-$6.60 (Tier 2) MO UVADEX $0-$6.60 (Tier 2) 58
VALCHLOR $0-$6.60 (Tier 2) MO vits a and d-white pet-lanolin topical ointment $0 (Tier 4) MO; [*] white petrolatum topical ointment $0 (Tier 4) MO; [*] zinc oxide topical ointment 20 % $0 (Tier 4) MO; [*] THERAPY FOR ACNE ACNE MEDICATION TOPICAL GEL $0 (Tier 4) MO; [*] ACNE MEDICATION TOPICAL LOTION 10 % $0 (Tier 4) MO; [*] adapalene topical gel 0.3 % $0-$6.60 (Tier 2) MO adapalene topical gel with pump $0-$6.60 (Tier 2) MO amnesteem $0-$6.60 (Tier 2) MO benzoyl peroxide topical foam $0 (Tier 4) [*] benzoyl peroxide topical gel 10 %, 2.5 %, 5 % $0 (Tier 4) MO; [*] clindamycin phosphate topical $0-$6.60 (Tier 2) MO DIFFERIN TOPICAL GEL 0.3 % $0-$6.60 (Tier 2) MO DIFFERIN TOPICAL GEL WITH PUMP $0-$6.60 (Tier 2) MO ery pads $0-$6.60 (Tier 2) MO erythromycin with ethanol $0-$6.60 (Tier 2) MO erythromycin-benzoyl peroxide $0-$6.60 (Tier 2) MO metronidazole topical cream $0-$6.60 (Tier 2) MO metronidazole topical gel 0.75 % $0-$6.60 (Tier 2) MO metronidazole topical lotion $0-$6.60 (Tier 2) MO rosadan topical cream $0-$6.60 (Tier 2) MO TAZORAC $0-$6.60 (Tier 2) PAR; MO tretinoin topical $0-$6.60 (Tier 2) MO; QLL (45 per 30 days) TRETIN-X CREAM KIT $0-$6.60 (Tier 2) MO TOPICAL ANESTHETICS caldyphen topical lotion 1-8 % $0 (Tier 4) [*] dibucaine $0 (Tier 4) MO; [*] lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) $0-$6.60 (Tier 2) MO 59
lidocaine (pf) injection solution 15 mg/ml (1.5 %) $0-$6.60 (Tier 2) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) $0-$6.60 (Tier 2) MO lidocaine hcl laryngotracheal $0-$6.60 (Tier 2) MO lidocaine hcl mucous membrane gel $0-$6.60 (Tier 2) MO lidocaine hcl mucous membrane jelly in applicator $0-$6.60 (Tier 2) MO lidocaine hcl mucous membrane solution 2 % $0-$6.60 (Tier 2) lidocaine hcl mucous membrane solution 4 % (40 mg/ml) $0-$6.60 (Tier 2) MO lidocaine hcl urethral $0-$6.60 (Tier 2) lidocaine topical adhesive patch,medicated $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) LIDOCAINE TOPICAL CREAM $0 (Tier 4) [*] lidocaine topical ointment $0-$6.60 (Tier 2) MO lidocaine viscous $0-$6.60 (Tier 2) MO lidocaine-prilocaine $0-$6.60 (Tier 2) MO TOPICAL ANTIBACTERIALS bacitracin topical ointment $0 (Tier 4) MO; [*] bacitracin zinc topical ointment $0 (Tier 4) MO; [*] gentamicin topical $0-$6.60 (Tier 2) MO mupirocin ointment $0-$6.60 (Tier 2) MO povidone-iodine topical ointment $0 (Tier 4) MO; [*] povidone-iodine topical solution 10 % $0 (Tier 4) [*] sulfacetamide sodium (acne) $0-$6.60 (Tier 2) MO SULFAMYLON TOPICAL CREAM $0-$6.60 (Tier 2) MO triple antibiotic plus $0 (Tier 4) [*] triple antibiotic topical ointment $0 (Tier 4) MO; [*] TOPICAL ANTIFUNGALS antifungal (tolnaftate) topical powder $0 (Tier 4) MO; [*] antifungal cream $0 (Tier 4) [*] antifungal spray $0 (Tier 4) [*] 60
ciclodan topical solution $0-$6.60 (Tier 2) PAR; MO ciclopirox topical cream $0-$6.60 (Tier 2) MO ciclopirox topical gel $0-$6.60 (Tier 2) MO ciclopirox topical shampoo $0-$6.60 (Tier 2) MO ciclopirox topical solution $0-$6.60 (Tier 2) PAR; MO ciclopirox topical suspension $0-$6.60 (Tier 2) MO clotrim antifungal $0 (Tier 4) [*] clotrimazole 1% cream $0 (Tier 4) [*] clotrimazole topical $0-$6.60 (Tier 2) MO clotrimazole-betamethasone $0-$6.60 (Tier 2) MO econazole topical $0-$6.60 (Tier 2) MO fungoid tincture topical tincture $0 (Tier 4) MO; [*] ketoconazole topical $0-$6.60 (Tier 2) MO miconazole nitrate topical cream $0 (Tier 4) MO; [*] nystatin topical $0-$6.60 (Tier 2) MO nystatin-triamcinolone $0-$6.60 (Tier 2) MO nystop $0-$6.60 (Tier 2) MO terbinafine hcl topical $0 (Tier 4) MO; [*] tolnaftate topical cream $0 (Tier 4) [*] tolnaftate topical powder $0 (Tier 4) [*] zeasorb (miconazole) $0 (Tier 4) MO; [*] TOPICAL ANTIVIRALS acyclovir topical $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) DENAVIR $0-$6.60 (Tier 2) MO; QLL (5 per 1 day) TOPICAL CORTICOSTEROIDS ala-cort topical cream $0-$6.60 (Tier 2) MO alclometasone $0-$6.60 (Tier 2) MO amcinonide $0-$6.60 (Tier 2) MO betamethasone dipropionate $0-$6.60 (Tier 2) MO betamethasone valerate topical cream $0-$6.60 (Tier 2) MO 61
betamethasone valerate topical lotion $0-$6.60 (Tier 2) MO betamethasone valerate topical ointment $0-$6.60 (Tier 2) MO betamethasone, augmented $0-$6.60 (Tier 2) MO CAPEX $0-$6.60 (Tier 2) MO clobetasol topical cream $0-$6.60 (Tier 2) MO clobetasol topical foam $0-$6.60 (Tier 2) MO clobetasol topical gel $0-$6.60 (Tier 2) MO clobetasol topical ointment $0-$6.60 (Tier 2) MO clobetasol topical solution $0-$6.60 (Tier 2) MO clobetasol-emollient topical cream $0-$6.60 (Tier 2) MO cormax topical solution $0-$6.60 (Tier 2) MO desonide $0-$6.60 (Tier 2) MO desoximetasone $0-$6.60 (Tier 2) MO diflorasone $0-$6.60 (Tier 2) MO fluocinolone $0-$6.60 (Tier 2) MO fluocinolone-shower cap $0-$6.60 (Tier 2) MO fluocinonide topical cream 0.05 % $0-$6.60 (Tier 2) MO fluocinonide topical gel $0-$6.60 (Tier 2) MO fluocinonide topical ointment $0-$6.60 (Tier 2) MO fluocinonide topical solution $0-$6.60 (Tier 2) MO fluocinonide-e $0-$6.60 (Tier 2) MO fluticasone topical $0-$6.60 (Tier 2) MO halobetasol propionate $0-$6.60 (Tier 2) MO HALOG $0-$6.60 (Tier 2) MO hydro skin topical cream $0 (Tier 4) [*] hydro skin topical lotion $0 (Tier 4) MO; [*] hydrocortisone topical cream 0.5 % $0 (Tier 4) MO; [*] hydrocortisone topical cream 1 %, 2.5 % $0-$6.60 (Tier 2) MO hydrocortisone topical lotion 2.5 % $0-$6.60 (Tier 2) MO hydrocortisone topical ointment 0.5 % $0 (Tier 4) MO; [*] 62
hydrocortisone topical ointment 1 %, 2.5 % $0-$6.60 (Tier 2) MO hydrocortisone valerate $0-$6.60 (Tier 2) MO hydrocortisone-min oil-wht pet $0-$6.60 (Tier 2) MO mometasone $0-$6.60 (Tier 2) MO triamcinolone acetonide topical cream $0-$6.60 (Tier 2) MO triamcinolone acetonide topical lotion $0-$6.60 (Tier 2) MO triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % $0-$6.60 (Tier 2) MO trianex $0-$6.60 (Tier 2) MO triderm topical cream $0-$6.60 (Tier 2) MO TOPICAL ENZYMES SANTYL $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) TOPICAL SCABICIDES / PEDICULICIDES lindane $0-$6.60 (Tier 2) MO permethrin topical cream $0-$6.60 (Tier 2) MO permethrin topical liquid $0 (Tier 4) MO; [*] DIAGNOSTICS / MISCELLANEOUS AGENTS ANTIDOTES acetylcysteine intravenous $0-$6.60 (Tier 2) B/D PAR; MO IRRIGATING SOLUTIONS lactated ringers irrigation $0-$6.60 (Tier 2) B/D PAR; MO neomycin-polymyxin b gu $0-$6.60 (Tier 2) MO ringers irrigation $0-$6.60 (Tier 2) B/D PAR; MO MISCELLANEOUS AGENTS ADAGEN $0-$6.60 (Tier 2) MO alendronate oral tablet 40 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) anagrelide $0-$6.60 (Tier 2) MO ARALAST NP $0-$6.60 (Tier 2) PAR; MO; LA BUPHENYL ORAL TABLET $0-$6.60 (Tier 2) PAR; MO CALCIUM WITH BORON $0 (Tier 4) [*] 63
cevimeline $0-$6.60 (Tier 2) MO CLINIMIX 4.25%/D5W SULFIT FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 2.75%/D10W SUL FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 2.75%/D5W SULF FREE $0-$6.60 (Tier 2) B/D PAR d10 % & 0.45 % sodium chloride $0-$6.60 (Tier 2) B/D PAR d2.5 %-0.45 % sodium chloride $0-$6.60 (Tier 2) B/D PAR d5 % and 0.9 % sodium chloride $0-$6.60 (Tier 2) B/D PAR; MO d5 %-0.45 % sodium chloride $0-$6.60 (Tier 2) B/D PAR; MO dextrose 10 % and 0.2 % nacl $0-$6.60 (Tier 2) B/D PAR dextrose 10 % in water (d10w) intravenous parenteral solution $0-$6.60 (Tier 2) B/D PAR; MO dextrose 25 % in water (d25w) $0-$6.60 (Tier 2) B/D PAR dextrose 30 % in water (d30w) $0-$6.60 (Tier 2) B/D PAR dextrose 40 % in water (d40w) $0-$6.60 (Tier 2) B/D PAR dextrose 5 % in water (d5w) $0-$6.60 (Tier 2) B/D PAR; MO dextrose 5 %-lactated ringers $0-$6.60 (Tier 2) B/D PAR; MO dextrose 5%-0.2 % sod chloride $0-$6.60 (Tier 2) B/D PAR dextrose 5%-0.3 % sod.chloride $0-$6.60 (Tier 2) B/D PAR dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR dextrose 70 % in water (d70w) $0-$6.60 (Tier 2) B/D PAR; MO dextrose with sodium chloride $0-$6.60 (Tier 2) B/D PAR disulfiram $0-$6.60 (Tier 2) MO EXJADE $0-$6.60 (Tier 2) PAR; MO; LA GLUTOSE 15 $0 (Tier 4) MO; [*] GLUTOSE 45 $0 (Tier 4) MO; [*] INCRELEX $0-$6.60 (Tier 2) PAR; MO; LA levocarnitine (with sugar) $0-$6.60 (Tier 2) B/D PAR; MO levocarnitine oral tablet $0-$6.60 (Tier 2) B/D PAR; MO 64
midodrine $0-$6.60 (Tier 2) MO ORFADIN $0-$6.60 (Tier 2) LA pilocarpine hcl oral $0-$6.60 (Tier 2) MO RENAGEL $0-$6.60 (Tier 2) ST; MO RENVELA ORAL POWDER IN PACKET 0.8 GRAM RENVELA ORAL POWDER IN PACKET 2.4 GRAM $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) RENVELA ORAL TABLET $0-$6.60 (Tier 2) MO; QLL (270 per 30 days) riluzole $0-$6.60 (Tier 2) MO sodium chloride 0.9 % intravenous $0-$6.60 (Tier 2) MO sodium chloride irrigation $0-$6.60 (Tier 2) MO sodium polystyrene (sorb free) $0-$6.60 (Tier 2) sodium polystyrene sulfonate oral powder $0-$6.60 (Tier 2) MO sodium polystyrene sulfonate oral suspension $0-$6.60 (Tier 2) sodium polystyrene sulfonate rectal $0-$6.60 (Tier 2) SODIUM POLYSTYRENE SULFONATE RECTAL $0-$6.60 (Tier 2) sps oral $0-$6.60 (Tier 2) MO sps rectal $0-$6.60 (Tier 2) SUSPENDOL-S $0 (Tier 4) MO; [*] SYPRINE $0-$6.60 (Tier 2) MO water for irrigation, sterile $0-$6.60 (Tier 2) B/D PAR; MO ZEMAIRA $0-$6.60 (Tier 2) PAR; MO; LA MISCELLANEOUS DEVICES aquabase $0 (Tier 4) MO; [*] FATTIBASE $0 (Tier 4) MO; [*] polybase $0 (Tier 4) MO; [*] NEUTRACEUTICALS central vite $0 (Tier 4) [*] complete premium vitamin $0 (Tier 4) [*] 65
spectravite performance $0 (Tier 4) [*] SMOKING DETERRENTS buproban $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) CHANTIX $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) CHANTIX CONTINUING MONTH BOX $0-$6.60 (Tier 2) PAR; MO; QLL (56 per 28 days) CHANTIX STARTING MONTH BOX $0-$6.60 (Tier 2) PAR; MO; QLL (53 per 365 days) NICODERM CQ $0 (Tier 4) MO; [*]; QLL (30 per 30 days) nicorelief buccal gum $0 (Tier 4) MO; [*] NICORETTE BUCCAL GUM $0 (Tier 4) MO; [*] NICORETTE BUCCAL LOZENGE $0 (Tier 4) MO; [*]; QLL (20 per 1 day) nicotine (polacrilex) buccal gum $0 (Tier 4) MO; [*] nicotine (polacrilex) buccal lozenge $0 (Tier 4) MO; [*]; QLL (20 per 1 day) nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr $0 (Tier 4) MO; [*]; QLL (30 per 30 days) NICOTROL NS $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal $0-$6.60 (Tier 2) MO; QLL (30 per 25 days) chlorhexidine gluconate mucous membrane $0-$6.60 (Tier 2) MO deep sea nasal $0 (Tier 4) [*] ENTSOL NASAL GEL $0 (Tier 4) [*] ipratropium bromide nasal $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) nasal decongestant (oxymetazl) $0 (Tier 4) [*] nasal spray (oxymetazoline) $0 (Tier 4) [*] nasal spray 12 hour nasal spray,non-aerosol $0 (Tier 4) [*] nasal spray long acting $0 (Tier 4) [*] nose drops $0 (Tier 4) [*] nrs nasal relief $0 (Tier 4) [*] paroex oral rinse $0-$6.60 (Tier 2) MO periogard $0-$6.60 (Tier 2) MO 66
triamcinolone acetonide dental $0-$6.60 (Tier 2) MO TYZINE NASAL DROPS 0.05 % $0-$6.60 (Tier 2) MO MISCELLANEOUS OTIC PREPARATIONS acetic acid otic $0-$6.60 (Tier 2) MO acetic acid-aluminum acetate $0-$6.60 (Tier 2) MO ear drops (carbamide peroxide) $0 (Tier 4) [*] ear wax removal system otic drops $0 (Tier 4) [*] ear wax treatment $0 (Tier 4) [*] fluocinolone acetonide oil $0-$6.60 (Tier 2) MO hydrocortisone-acetic acid $0-$6.60 (Tier 2) MO ofloxacin otic $0-$6.60 (Tier 2) MO OTIC STEROID / ANTIBIOTIC CIPRODEX $0-$6.60 (Tier 2) MO COLY-MYCIN S $0-$6.60 (Tier 2) MO neomycin-polymyxin-hc otic $0-$6.60 (Tier 2) MO ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P. $0-$6.60 (Tier 2) PAR; MO cortisone $0-$6.60 (Tier 2) MO dexamethasone $0-$6.60 (Tier 2) MO dexamethasone sodium phos (pf) $0-$6.60 (Tier 2) MO dexamethasone sodium phosphate injection $0-$6.60 (Tier 2) MO fludrocortisone $0-$6.60 (Tier 2) MO hydrocortisone oral $0-$6.60 (Tier 2) MO methylprednisolone acetate $0-$6.60 (Tier 2) MO methylprednisolone sodium succ injection recon soln 125 mg, 40 mg $0-$6.60 (Tier 2) MO methylprednisolone sodium succ intravenous $0-$6.60 (Tier 2) MO methylprednisolone tablets $0-$6.60 (Tier 2) MO prednisolone oral solution 15 mg/5 ml $0-$6.60 (Tier 2) MO 67
prednisolone sodium phosphate oral solution 15 mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) MO prednisone intensol $0-$6.60 (Tier 2) MO prednisone oral solution $0-$6.60 (Tier 2) MO prednisone oral tablet $0-$2.65 (Tier 1) MO prednisone oral tablets,dose pack $0-$2.65 (Tier 1) MO triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml ANTITHYROID AGENTS $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) IOSAT $0 (Tier 4) [*] methimazole oral tablet 10 mg, 5 mg $0-$6.60 (Tier 2) MO propylthiouracil $0-$6.60 (Tier 2) MO THYROSAFE $0 (Tier 4) [*] DIABETES THERAPY acarbose oral tablet 100 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) acarbose oral tablet 25 mg $0-$6.60 (Tier 2) MO; QLL (360 per 30 days) acarbose oral tablet 50 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) alcohol pads $0-$2.65 (Tier 1) BYDUREON $0-$6.60 (Tier 2) MO; QLL (4 per 28 days) BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML $0-$6.60 (Tier 2) MO; QLL (2.4 per 30 days) $0-$6.60 (Tier 2) MO; QLL (1.2 per 30 days) CYCLOSET $0-$6.60 (Tier 2) ST; MO; QLL (180 per 30 days) GAUZE PADS 2 X 2 $0-$2.65 (Tier 1) QLL (200 per 30 days) glimepiride oral tablet 1 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) glimepiride oral tablet 2 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) glimepiride oral tablet 4 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) 68
glipizide oral tablet 10 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) glipizide oral tablet 5 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) glipizide oral tablet extended release 24hr 10 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) glipizide oral tablet extended release 24hr 2.5 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) glipizide oral tablet extended release 24hr 5 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) glipizide-metformin oral tablet 2.5-250 mg $0-$2.65 (Tier 1) MO; QLL (240 per 30 days) glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) GLUCAGEN HYPOKIT $0-$6.60 (Tier 2) MO GLUCAGON EMERGENCY KIT (HUMAN) $0-$6.60 (Tier 2) MO HUMALOG KWIKPEN $0-$6.60 (Tier 2) MO HUMALOG MIX 50-50 $0-$6.60 (Tier 2) MO HUMALOG MIX 50-50 KWIKPEN $0-$6.60 (Tier 2) MO HUMALOG MIX 75-25 $0-$6.60 (Tier 2) MO HUMALOG MIX 75-25 KWIKPEN $0-$6.60 (Tier 2) MO HUMALOG SUBCUTANEOUS CARTRIDGE $0-$6.60 (Tier 2) MO HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML (PREFILLED SYRINGE) $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) HUMULIN 70/30 $0-$6.60 (Tier 2) MO HUMULIN 70/30 KWIKPEN $0-$6.60 (Tier 2) MO HUMULIN N $0-$6.60 (Tier 2) MO HUMULIN N KWIKPEN $0-$6.60 (Tier 2) MO HUMULIN R $0-$6.60 (Tier 2) MO HUMULIN R U-500 "CONCENTRATED" $0-$6.60 (Tier 2) MO INSULIN PEN NEEDLE $0-$2.65 (Tier 1) MO; QLL (200 per 30 days) INSULIN SYRINGE (DISP) U-100 0.3 ML $0-$2.65 (Tier 1) MO; QLL (200 per 30 days) INSULIN SYRINGE (DISP) U-100 1 ML $0-$2.65 (Tier 1) QLL (200 per 30 days) INSULIN SYRINGE (DISP) U-100 1/2 ML $0-$2.65 (Tier 1) QLL (200 per 30 days) JANUMET $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) 69
JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) JANUVIA ORAL TABLET 100 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) JANUVIA ORAL TABLET 25 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) JANUVIA ORAL TABLET 50 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) JENTADUETO $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) LANTUS $0-$6.60 (Tier 2) MO LANTUS SOLOSTAR $0-$6.60 (Tier 2) MO LEVEMIR $0-$6.60 (Tier 2) MO LEVEMIR FLEXTOUCH $0-$6.60 (Tier 2) MO metformin oral tablet 1,000 mg $0-$2.65 (Tier 1) MO; QLL (76 per 30 days) metformin oral tablet 500 mg $0-$2.65 (Tier 1) MO; QLL (153 per 30 days) metformin oral tablet 850 mg $0-$2.65 (Tier 1) MO; QLL (90 per 30 days) metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg metformin oral tablet extended release 24hr 500 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) $0-$2.65 (Tier 1) MO; QLL (80 per 30 days) $0-$2.65 (Tier 1) MO; QLL (75 per 30 days) $0-$2.65 (Tier 1) MO; QLL (150 per 30 days) nateglinide oral tablet 120 mg $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) nateglinide oral tablet 60 mg $0-$6.60 (Tier 2) MO; QLL (180 per 30 days) NEEDLES, INSULIN DISP.,SAFETY $0-$2.65 (Tier 1) QLL (200 per 30 days) ONGLYZA ORAL TABLET 2.5 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) ONGLYZA ORAL TABLET 5 MG $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) 70
pioglitazone oral tablet 15 mg $0-$2.65 (Tier 1) MO; QLL (90 per 30 days) pioglitazone oral tablet 30 mg $0-$2.65 (Tier 1) MO; QLL (45 per 30 days) pioglitazone oral tablet 45 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) pioglitazone-glimepiride $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) pioglitazone-metformin $0-$6.60 (Tier 2) MO; QLL (90 per 30 days) PRANDIMET $0-$6.60 (Tier 2) MO; QLL (150 per 30 days) PROGLYCEM $0-$6.60 (Tier 2) MO SYMLINPEN 120 $0-$6.60 (Tier 2) PAR; MO; QLL (11 per 30 days) SYMLINPEN 60 $0-$6.60 (Tier 2) PAR; MO; QLL (6 per 30 days) TANZEUM $0-$6.60 (Tier 2) MO; QLL (4 per 28 days) tolazamide oral tablet 250 mg $0-$2.65 (Tier 1) MO; QLL (120 per 30 days) tolazamide oral tablet 500 mg $0-$2.65 (Tier 1) MO; QLL (60 per 30 days) tolbutamide $0-$2.65 (Tier 1) MO; QLL (180 per 30 days) TOUJEO SOLOSTAR $0-$6.60 (Tier 2) MO TRADJENTA $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) TRULICITY $0-$6.60 (Tier 2) MO; QLL (2 per 28 days) VICTOZA 2-PAK $0-$6.60 (Tier 2) MO; QLL (9 per 30 days) VICTOZA 3-PAK $0-$6.60 (Tier 2) MO; QLL (9 per 30 days) MISCELLANEOUS HORMONES ALDURAZYME $0-$6.60 (Tier 2) PAR; MO ANDRODERM $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (150 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) 71
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) androxy $0-$6.60 (Tier 2) PAR; MO cabergoline $0-$6.60 (Tier 2) MO calcitonin (salmon) $0-$6.60 (Tier 2) MO; QLL (4 per 30 days) calcitriol intravenous solution 1 mcg/ml $0-$6.60 (Tier 2) B/D PAR; MO calcitriol oral $0-$6.60 (Tier 2) B/D PAR; MO CEREZYME INTRAVENOUS RECON SOLN 400 UNIT $0-$6.60 (Tier 2) PAR; MO danazol oral $0-$6.60 (Tier 2) MO desmopressin injection $0-$6.60 (Tier 2) MO desmopressin nasal $0-$6.60 (Tier 2) MO desmopressin oral $0-$6.60 (Tier 2) MO doxercalciferol intravenous $0-$6.60 (Tier 2) B/D PAR doxercalciferol oral $0-$6.60 (Tier 2) B/D PAR; MO ELAPRASE $0-$6.60 (Tier 2) PAR; MO FABRAZYME $0-$6.60 (Tier 2) PAR; MO HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML (1 ML) HECTOROL INTRAVENOUS SOLUTION 4 MCG/2 ML $0-$6.60 (Tier 2) PAR $0-$6.60 (Tier 2) PAR; MO HECTOROL ORAL $0-$6.60 (Tier 2) PAR; MO KUVAN ORAL TABLET,SOLUBLE $0-$6.60 (Tier 2) PAR; MO MYOZYME $0-$6.60 (Tier 2) PAR; MO NAGLAZYME $0-$6.60 (Tier 2) PAR; MO; LA oxandrolone oral tablet 10 mg $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) oxandrolone oral tablet 2.5 mg $0-$6.60 (Tier 2) PAR; MO; QLL (120 per 30 days) pamidronate $0-$6.60 (Tier 2) B/D PAR; MO paricalcitol oral $0-$6.60 (Tier 2) B/D PAR; MO SENSIPAR ORAL TABLET 30 MG, 60 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) SENSIPAR ORAL TABLET 90 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) 72
SOMAVERT $0-$6.60 (Tier 2) PAR; MO; LA STIMATE $0-$6.60 (Tier 2) MO SYNAREL $0-$6.60 (Tier 2) PAR; MO TESTIM $0-$6.60 (Tier 2) PAR; MO; QLL (300 per 30 days) testosterone cypionate $0-$6.60 (Tier 2) MO testosterone enanthate $0-$6.60 (Tier 2) MO ZAVESCA $0-$6.60 (Tier 2) PAR; MO; LA ZEMPLAR INTRAVENOUS $0-$6.60 (Tier 2) B/D PAR; MO zoledronic acid intravenous recon soln $0-$6.60 (Tier 2) PAR zoledronic acid intravenous solution $0-$6.60 (Tier 2) PAR; MO ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML THYROID HORMONES $0-$6.60 (Tier 2) PAR; MO levothyroxine oral $0-$6.60 (Tier 2) MO levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg $0-$6.60 (Tier 2) MO liothyronine oral $0-$6.60 (Tier 2) MO SYNTHROID $0-$6.60 (Tier 2) MO unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS $0-$6.60 (Tier 2) MO anti-diarrheal (loperamide) oral tablet $0 (Tier 4) MO; [*] atropine injection syringe 0.05 mg/ml, 0.1 mg/ml $0-$6.60 (Tier 2) bismatrol oral suspension 262 mg/15 ml $0 (Tier 4) MO; [*] bismatrol oral suspension 525 mg/15 ml $0 (Tier 4) [*] bismatrol oral tablet,chewable $0 (Tier 4) [*] dicyclomine oral capsule $0-$6.60 (Tier 2) MO dicyclomine oral solution $0-$6.60 (Tier 2) MO 73
dicyclomine oral tablet $0-$6.60 (Tier 2) MO diphenoxylate-atropine $0-$6.60 (Tier 2) MO glycopyrrolate oral $0-$6.60 (Tier 2) MO kao-tin (bismuth subsalicylat) $0 (Tier 4) [*] loperamide oral capsule $0-$6.60 (Tier 2) MO loperamide oral liquid 1 mg/5 ml $0 (Tier 4) MO; [*] loperamide oral liquid 1 mg/7.5 ml $0 (Tier 4) [*] medi-bismuth $0 (Tier 4) [*] opium tincture oral tincture $0-$6.60 (Tier 2) MO peptic relief oral tablet,chewable $0 (Tier 4) [*] pink bismuth maximum strength $0 (Tier 4) [*] pink bismuth oral suspension 262 mg/15 ml $0 (Tier 4) [*] pink bismuth oral tablet,chewable $0 (Tier 4) MO; [*] stomach relief max strength $0 (Tier 4) [*] stomach relief oral suspension 262 mg/15 ml $0 (Tier 4) [*] stomach relief oral tablet,chewable $0 (Tier 4) [*] MISCELLANEOUS GASTROINTESTINAL AGENTS acid gone antacid $0 (Tier 4) [*] actidose/sorbitol oral suspension 50 gram/240 ml $0 (Tier 4) [*] almacone oral suspension $0 (Tier 4) [*] almacone-2 $0 (Tier 4) [*] alosetron $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) aluminum hydroxide gel oral suspension 320 mg/5 ml $0 (Tier 4) MO; [*] AMITIZA $0-$6.60 (Tier 2) MO antacid anti-gas oral suspension $0 (Tier 4) [*] antacid extra-strength oral suspension 200-200-20 mg/5 ml $0 (Tier 4) [*] antacid oral suspension $0 (Tier 4) [*] antacid plus anti-gas oral suspension 200-200-20 mg/5 ml $0 (Tier 4) [*] 74
antacid tablet $0 (Tier 4) [*] antacid with simethicone oral suspension $0 (Tier 4) [*] antacid-simethicone ds $0 (Tier 4) [*] anti-nausea liquid $0 (Tier 4) [*] anu-med $0 (Tier 4) MO; [*] APRISO $0-$6.60 (Tier 2) MO ASACOL HD $0-$6.60 (Tier 2) MO balsalazide $0-$6.60 (Tier 2) MO bisac-evac $0 (Tier 4) MO; [*] bisacodyl oral $0 (Tier 4) MO; [*] bisacodyl rectal $0 (Tier 4) MO; [*] biscolax $0 (Tier 4) MO; [*] budesonide oral $0-$6.60 (Tier 2) MO CANASA $0-$6.60 (Tier 2) MO CIMZIA $0-$6.60 (Tier 2) PAR; MO; QLL (6 per 28 days) CIMZIA POWDER FOR RECONST $0-$6.60 (Tier 2) PAR; MO; QLL (6 per 28 days) CIMZIA STARTER KIT $0-$6.60 (Tier 2) PAR; MO; QLL (6 per 28 days) COLACE ORAL CAPSULE 100 MG $0 (Tier 4) MO; [*] colocort $0-$6.60 (Tier 2) MO compro $0-$6.60 (Tier 2) PAR; MO constulose $0-$6.60 (Tier 2) MO CREON $0-$6.60 (Tier 2) MO CYSTADANE $0-$6.60 (Tier 2) MO DELZICOL $0-$6.60 (Tier 2) MO dimenhydrinate oral $0 (Tier 4) MO; [*] diocto oral liquid $0 (Tier 4) [*] diocto oral syrup $0 (Tier 4) MO; [*] DIPENTUM $0-$6.60 (Tier 2) MO doc-q-lace oral capsule $0 (Tier 4) MO; [*] doc-q-lax $0 (Tier 4) MO; [*] 75
docu $0 (Tier 4) MO; [*] docusate calcium $0 (Tier 4) MO; [*] docusate sodium oral capsule $0 (Tier 4) MO; [*] DOCUSOL $0 (Tier 4) [*] DOCUSOL KIDS $0 (Tier 4) [*] DOCUSOL PLUS $0 (Tier 4) [*] dok oral capsule 100 mg $0 (Tier 4) MO; [*] dok oral capsule 250 mg $0 (Tier 4) [*] dok oral tablet $0 (Tier 4) MO; [*] dok plus $0 (Tier 4) [*] dronabinol $0-$6.60 (Tier 2) B/D PAR; MO; QLL (120 per 30 days) EMEND ORAL CAPSULE 125 MG $0-$6.60 (Tier 2) B/D PAR; MO; QLL (4 per 30 days) EMEND ORAL CAPSULE 40 MG $0-$6.60 (Tier 2) B/D PAR; MO; QLL (1 per 1 day) EMEND ORAL CAPSULE 80 MG $0-$6.60 (Tier 2) B/D PAR; MO; QLL (8 per 30 days) EMEND ORAL CAPSULE,DOSE PACK $0-$6.60 (Tier 2) B/D PAR; MO; QLL (12 per 30 days) enema rectal enema 19-7 gram/118 ml $0 (Tier 4) [*] ENEMEEZ $0 (Tier 4) MO; [*] ENEMEEZ PLUS $0 (Tier 4) MO; [*] enulose $0-$6.60 (Tier 2) MO fiber (calcium polycarbophil) $0 (Tier 4) MO; [*] fiber laxative (ca polycarbo) $0 (Tier 4) [*] fiber laxative (psyllium husk) $0 (Tier 4) [*] fiber oral powder $0 (Tier 4) [*] fiber smooth $0 (Tier 4) [*] fiber smooth (sucrose) $0 (Tier 4) [*] fiber-lax $0 (Tier 4) MO; [*] FLEET PEDIATRIC $0 (Tier 4) MO; [*] formula em solution $0 (Tier 4) [*] gas relief oral capsule $0 (Tier 4) [*] 76
gas relief oral tablet,chewable $0 (Tier 4) MO; [*] gavilyte-c $0-$6.60 (Tier 2) MO gavilyte-g $0-$6.60 (Tier 2) MO gavilyte-n $0-$6.60 (Tier 2) MO generlac $0-$6.60 (Tier 2) MO gentle laxative oral $0 (Tier 4) [*] hemorrhoidal rectal ointment $0 (Tier 4) MO; [*] hydrocortisone rectal enema $0-$6.60 (Tier 2) MO infants gas relief $0 (Tier 4) [*] kao-tin (docusate calcium) $0 (Tier 4) [*] konsyl (sugar) oral powder 3.4 gram/12 gram $0 (Tier 4) MO; [*] konsyl sugar-free oral powder $0 (Tier 4) MO; [*] lactulose $0-$6.60 (Tier 2) MO laxative maximum strength $0 (Tier 4) [*] laxative-senna $0 (Tier 4) [*] LIALDA $0-$6.60 (Tier 2) MO LINZESS $0-$6.60 (Tier 2) MO liquid antacid oral suspension 200-200-20 mg/5 ml $0 (Tier 4) [*] LOTRONEX $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) magnesium oral tablet 250 mg $0 (Tier 4) [*] MAGTAB $0 (Tier 4) MO; [*] MAJOR-PREP HEMORRHOIDAL RECTAL OINTMENT 0.25-14-74.9 % $0 (Tier 4) [*] masanti double strength $0 (Tier 4) [*] meclizine oral tablet 12.5 mg, 25 mg $0-$6.60 (Tier 2) MO meclizine oral tablet,chewable $0 (Tier 4) MO; [*] medi-natural $0 (Tier 4) [*] mesalamine rectal $0-$6.60 (Tier 2) MO mesalamine with cleansing wipe $0-$6.60 (Tier 2) MO 77
metoclopramide hcl injection solution $0-$6.60 (Tier 2) MO metoclopramide hcl injection syringe $0-$6.60 (Tier 2) metoclopramide hcl oral solution $0-$6.60 (Tier 2) MO metoclopramide hcl oral tablet $0-$6.60 (Tier 2) MO mi-acid gas relief $0 (Tier 4) [*] mi-acid oral suspension $0 (Tier 4) MO; [*] milk of magnesia $0 (Tier 4) MO; [*] milk of magnesia concentrated $0 (Tier 4) MO; [*] mineral oil laxative $0 (Tier 4) MO; [*] mintox maximum strength $0 (Tier 4) MO; [*] mytab gas $0 (Tier 4) [*] mytab gas maximum strength $0 (Tier 4) [*] natural fiber laxative oral powder 3.4 gram/7 gram $0 (Tier 4) [*] natural fiber laxative therapy $0 (Tier 4) [*] ondansetron hcl (pf) injection solution $0-$6.60 (Tier 2) MO ondansetron hcl (pf) injection syringe $0-$6.60 (Tier 2) ondansetron hcl intravenous solution $0-$6.60 (Tier 2) MO ondansetron hcl oral solution $0-$6.60 (Tier 2) B/D PAR; MO; QLL (450 per 30 days) ondansetron hcl oral tablet 24 mg $0-$6.60 (Tier 2) B/D PAR; QLL (30 per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg $0-$6.60 (Tier 2) B/D PAR; MO; QLL (90 per 30 days) ondansetron odt $0-$6.60 (Tier 2) B/D PAR; MO; QLL (90 per 30 days) peg 3350-electrolytes oral recon soln 236-22.74-6.74-5.86 gram peg 3350-electrolytes oral recon soln 240-22.72-6.72-5.84 gram $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) peg3350 $0 (Tier 4) [*] peg-3350 with flavor packs $0-$6.60 (Tier 2) peg-electrolyte soln $0-$6.60 (Tier 2) PENTASA $0-$6.60 (Tier 2) MO 78
polyethylene glycol 3350 oral $0-$6.60 (Tier 2) MO prochlorperazine edisylate $0-$6.60 (Tier 2) PAR; MO prochlorperazine maleate oral $0-$6.60 (Tier 2) PAR; MO prochlorperazine maleate rectal $0-$6.60 (Tier 2) PAR; MO procto-pak $0-$6.60 (Tier 2) MO proctosol hc $0-$6.60 (Tier 2) MO proctozone-hc $0-$6.60 (Tier 2) MO reguloid oral capsule $0 (Tier 4) [*] RELISTOR SUBCUTANEOUS SOLUTION $0-$6.60 (Tier 2) PAR; MO RELISTOR SUBCUTANEOUS SYRINGE $0-$6.60 (Tier 2) PAR; MO REMICADE $0-$6.60 (Tier 2) PAR; MO RULOX $0 (Tier 4) [*] sani-supp (adult) $0 (Tier 4) MO; [*] sani-supp (infant) $0 (Tier 4) MO; [*] senexon $0 (Tier 4) MO; [*] senna lax $0 (Tier 4) MO; [*] senna oral syrup 8.8 mg/5 ml $0 (Tier 4) MO; [*] senna oral tablet $0 (Tier 4) [*] senna plus $0 (Tier 4) MO; [*] senna with docusate sodium $0 (Tier 4) [*] senna-gen $0 (Tier 4) MO; [*] SENNALAX-S $0 (Tier 4) MO; [*] senna-s $0 (Tier 4) MO; [*] silace oral liquid $0 (Tier 4) MO; [*] silace oral syrup $0 (Tier 4) [*] simethicone oral capsule 180 mg $0 (Tier 4) [*] simethicone oral drops,suspension $0 (Tier 4) MO; [*] simethicone oral tablet,chewable 125 mg $0 (Tier 4) [*] sodium bicarbonate oral tablet 650 mg $0 (Tier 4) MO; [*] stool softener oral capsule 100 mg $0 (Tier 4) [*] 79
stool softener-laxative $0 (Tier 4) [*] sulfasalazine $0-$6.60 (Tier 2) MO sulfazine $0-$6.60 (Tier 2) MO sulfazine ec $0-$6.60 (Tier 2) MO travel sickness $0 (Tier 4) [*] travel sickness (meclizine) $0 (Tier 4) MO; [*] ursodiol $0-$6.60 (Tier 2) MO ULCER THERAPY acid reducer (famotidine) oral tablet 20 mg $0 (Tier 4) [*] DEXILANT $0-$6.60 (Tier 2) ST; MO; QLL (30 per 30 days) famotidine (pf) $0-$6.60 (Tier 2) MO famotidine (pf)-nacl (iso-os) $0-$6.60 (Tier 2) famotidine intravenous $0-$6.60 (Tier 2) MO famotidine oral suspension $0-$6.60 (Tier 2) MO famotidine oral tablet 10 mg $0 (Tier 4) MO; [*] famotidine oral tablet 20 mg, 40 mg $0-$6.60 (Tier 2) MO heartburn relief 24 hour (lansoprazole) oral capsule,delayed release(dr/ec) 15 mg $0 (Tier 4) [*]; QLL (30 per 30 days) lansoprazole oral capsule,delayed release(dr/ec) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) misoprostol $0-$6.60 (Tier 2) MO omeprazole oral capsule,delayed release(dr/ec) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) omeprazole oral tablet,delayed release (dr/ec) $0 (Tier 4) MO; [*] pantoprazole oral $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) PRILOSEC OTC $0 (Tier 4) MO; [*] ranitidine hcl injection $0-$6.60 (Tier 2) MO ranitidine hcl oral syrup $0-$6.60 (Tier 2) MO ranitidine hcl oral tablet 150 mg, 300 mg $0-$6.60 (Tier 2) MO ranitidine hcl oral tablet 75 mg $0 (Tier 4) MO; [*] sucralfate oral tablet $0-$6.60 (Tier 2) MO ZEGERID OTC $0 (Tier 4) MO; [*] 80
IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE $0-$6.60 (Tier 2) PAR; MO ARANESP (IN POLYSORBATE) $0-$6.60 (Tier 2) PAR; MO ARCALYST $0-$6.60 (Tier 2) PAR; MO AVONEX (WITH ALBUMIN) $0-$6.60 (Tier 2) PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR PEN INJECTOR KIT $0-$6.60 (Tier 2) PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR SYRINGE $0-$6.60 (Tier 2) PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR SYRINGE KIT $0-$6.60 (Tier 2) PAR; MO; QLL (4 per 28 days) EXTAVIA SUBCUTANEOUS KIT $0-$6.60 (Tier 2) PAR; MO EXTAVIA SUBCUTANEOUS RECON SOLN $0-$6.60 (Tier 2) PAR GENOTROPIN $0-$6.60 (Tier 2) PAR; MO GENOTROPIN MINIQUICK $0-$6.60 (Tier 2) PAR; MO HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT) $0-$6.60 (Tier 2) PAR; MO ILARIS (PF) $0-$6.60 (Tier 2) PAR; MO; LA INTRON A INJECTION $0-$6.60 (Tier 2) PAR; MO LEUKINE INJECTION RECON SOLN $0-$6.60 (Tier 2) PAR; MO MOZOBIL $0-$6.60 (Tier 2) PAR; MO NEULASTA SUBCUTANEOUS SYRINGE $0-$6.60 (Tier 2) PAR; MO; QLL (2 per 28 days) NEUMEGA $0-$6.60 (Tier 2) PAR; MO; QLL (21 per 21 days) NEUPOGEN $0-$6.60 (Tier 2) PAR; MO NORDITROPIN FLEXPRO $0-$6.60 (Tier 2) PAR; MO NORDITROPIN NORDIFLEX $0-$6.60 (Tier 2) PAR; MO PEGASYS $0-$6.60 (Tier 2) PAR; MO PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML $0-$6.60 (Tier 2) PAR; MO PEGINTRON $0-$6.60 (Tier 2) PAR; MO PEGINTRON REDIPEN $0-$6.60 (Tier 2) PAR; MO PROCRIT $0-$6.60 (Tier 2) PAR; MO; QLL (12 per 28 days) 81
PROLEUKIN $0-$6.60 (Tier 2) B/D PAR; MO REBIF (WITH ALBUMIN) $0-$6.60 (Tier 2) PAR; MO REBIF REBIDOSE $0-$6.60 (Tier 2) PAR; MO REBIF TITRATION PACK $0-$6.60 (Tier 2) PAR; MO SYLATRON $0-$6.60 (Tier 2) PAR; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) $0-$2.65 (Tier 1) MO ADACEL(TDAP ADOLESN/ADULT)(PF) $0-$2.65 (Tier 1) MO ATGAM $0-$6.60 (Tier 2) B/D PAR BCG VACCINE, LIVE (PF) $0-$6.60 (Tier 2) BEXSERO (PF) $0-$6.60 (Tier 2) BOOSTRIX TDAP $0-$2.65 (Tier 1) MO CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM $0-$6.60 (Tier 2) PAR; MO CERVARIX VACCINE (PF) $0-$2.65 (Tier 1) MO COMVAX (PF) $0-$2.65 (Tier 1) MO DAPTACEL (DTAP PEDIATRIC) (PF) $0-$2.65 (Tier 1) MO ENGERIX-B (PF) $0-$2.65 (Tier 1) B/D PAR; MO ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE $0-$2.65 (Tier 1) B/D PAR; MO $0-$2.65 (Tier 1) B/D PAR GAMASTAN S/D $0-$6.60 (Tier 2) PAR; MO GAMMAGARD LIQUID $0-$6.60 (Tier 2) PAR; MO GAMMAGARD S-D (IGA < 1 MCG/ML) $0-$6.60 (Tier 2) PAR; MO GAMMAPLEX $0-$6.60 (Tier 2) PAR; MO GAMUNEX-C $0-$6.60 (Tier 2) PAR; MO GARDASIL (PF) $0-$6.60 (Tier 2) MO GARDASIL 9 (PF) $0-$6.60 (Tier 2) MO 82
HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML $0-$2.65 (Tier 1) MO $0-$2.65 (Tier 1) MO $0-$2.65 (Tier 1) IMOVAX RABIES VACCINE (PF) $0-$6.60 (Tier 2) MO INFANRIX (DTAP) (PF) $0-$6.60 (Tier 2) MO IPOL $0-$2.65 (Tier 1) MO IXIARO (PF) $0-$6.60 (Tier 2) MO MENACTRA (PF) INTRAMUSCULAR SOLUTION $0-$6.60 (Tier 2) MO MENOMUNE - A/C/Y/W-135 $0-$6.60 (Tier 2) MENOMUNE - A/C/Y/W-135 (PF) $0-$6.60 (Tier 2) MO MENVEO A-C-Y-W-135-DIP (PF) $0-$6.60 (Tier 2) MO M-M-R II (PF) $0-$2.65 (Tier 1) MO PEDVAX HIB (PF) $0-$2.65 (Tier 1) MO PROQUAD (PF) $0-$6.60 (Tier 2) QUADRACEL (PF) $0-$6.60 (Tier 2) RABAVERT (PF) $0-$6.60 (Tier 2) MO RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML $0-$2.65 (Tier 1) B/D PAR; MO $0-$2.65 (Tier 1) B/D PAR; MO $0-$2.65 (Tier 1) B/D PAR ROTARIX $0-$6.60 (Tier 2) ROTATEQ VACCINE $0-$2.65 (Tier 1) MO tetanus toxoid,adsorbed (pf) $0-$2.65 (Tier 1) MO TETANUS,DIPHTHERIA TOX PED(PF) $0-$6.60 (Tier 2) MO TETANUS-DIPHTHERIA TOXOIDS-TD $0-$2.65 (Tier 1) MO THYMOGLOBULIN $0-$6.60 (Tier 2) B/D PAR 83
TICE BCG $0-$6.60 (Tier 2) MO TRUMENBA $0-$6.60 (Tier 2) TWINRIX (PF) $0-$2.65 (Tier 1) MO TYPHIM VI INTRAMUSCULAR SOLUTION $0-$6.60 (Tier 2) TYPHIM VI INTRAMUSCULAR SYRINGE $0-$6.60 (Tier 2) MO VAQTA (PF) INTRAMUSCULAR SUSPENSION $0-$6.60 (Tier 2) MO VAQTA (PF) INTRAMUSCULAR SYRINGE $0-$6.60 (Tier 2) VARIVAX (PF) $0-$6.60 (Tier 2) MO VARIZIG INTRAMUSCULAR RECON SOLN $0-$6.60 (Tier 2) MO VARIZIG INTRAMUSCULAR SOLUTION $0-$6.60 (Tier 2) YF-VAX (PF) $0-$6.60 (Tier 2) MO ZOSTAVAX (PF) $0-$6.60 (Tier 2) MO MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol $0-$2.65 (Tier 1) MO colchicine-probenecid $0-$6.60 (Tier 2) MO COLCRYS $0-$6.60 (Tier 2) MO probenecid $0-$6.60 (Tier 2) MO ULORIC $0-$6.60 (Tier 2) ST; MO OSTEOPOROSIS THERAPY alendronate oral solution $0-$6.60 (Tier 2) MO; QLL (300 per 28 days) alendronate oral tablet 10 mg, 5 mg $0-$2.65 (Tier 1) MO; QLL (30 per 30 days) alendronate oral tablet 35 mg, 70 mg $0-$2.65 (Tier 1) MO; QLL (4 per 28 days) BONIVA INTRAVENOUS $0-$6.60 (Tier 2) B/D PAR; MO EVISTA $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) FORTEO $0-$6.60 (Tier 2) PAR; MO; QLL (3 per 28 days) ibandronate intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO ibandronate intravenous syringe $0-$6.60 (Tier 2) MO ibandronate oral $0-$6.60 (Tier 2) MO; QLL (1 per 28 days) 84
PROLIA $0-$6.60 (Tier 2) PAR; MO; QLL (2 per 365 days) raloxifene $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) OTHER RHEUMATOLOGICALS ACTEMRA INTRAVENOUS $0-$6.60 (Tier 2) PAR; MO DEPEN TITRATABS $0-$6.60 (Tier 2) MO ENBREL SUBCUTANEOUS RECON SOLN $0-$6.60 (Tier 2) PAR; MO; QLL (8 per 28 days) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) $0-$6.60 (Tier 2) PAR; MO; QLL (4.08 per 28 days) $0-$6.60 (Tier 2) PAR; MO; QLL (8 per 28 days) ENBREL SURECLICK $0-$6.60 (Tier 2) PAR; MO; QLL (8 per 28 days) HUMIRA CROHN'S DIS START PCK $0-$6.60 (Tier 2) PAR; MO; QLL (4.8 per 365 days) HUMIRA PED CROHN'S STARTER PK $0-$6.60 (Tier 2) PAR; MO; QLL (4.8 per 365 days) HUMIRA PEN $0-$6.60 (Tier 2) PAR; MO; QLL (3.2 per 28 days) HUMIRA PSORIASIS STARTER PACK $0-$6.60 (Tier 2) PAR; MO; QLL (3.2 per 28 days) HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML $0-$6.60 (Tier 2) PAR; MO; QLL (2 per 28 days) $0-$6.60 (Tier 2) PAR; MO; QLL (3.2 per 28 days) KINERET $0-$6.60 (Tier 2) PAR; MO; QLL (28 per 28 days) leflunomide $0-$6.60 (Tier 2) MO RIDAURA $0-$6.60 (Tier 2) MO SAVELLA ORAL TABLET 100 MG $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) SAVELLA ORAL TABLET 12.5 MG $0-$6.60 (Tier 2) MO; QLL (480 per 30 days) SAVELLA ORAL TABLET 25 MG $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) SAVELLA ORAL TABLET 50 MG $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) SAVELLA ORAL TABLETS,DOSE PACK $0-$6.60 (Tier 2) MO; QLL (1 per 365 days) SIMPONI $0-$6.60 (Tier 2) PAR; MO; QLL (1 per 28 days) OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila $0-$6.60 (Tier 2) MO 85
DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML $0-$6.60 (Tier 2) MO errin $0-$6.60 (Tier 2) MO ESTRACE VAGINAL $0-$6.60 (Tier 2) MO estradiol oral $0-$6.60 (Tier 2) PAR; MO estradiol transdermal patch weekly $0-$6.60 (Tier 2) PAR; MO; QLL (4 per 28 days) ESTRING $0-$6.60 (Tier 2) MO; QLL (1 per 90 days) lyza $0-$6.60 (Tier 2) MO medroxyprogesterone $0-$6.60 (Tier 2) MO MENEST $0-$6.60 (Tier 2) PAR; MO nora-be $0-$6.60 (Tier 2) MO norethindrone (contraceptive) $0-$6.60 (Tier 2) MO norethindrone acetate $0-$6.60 (Tier 2) MO PREMARIN ORAL $0-$6.60 (Tier 2) MO PREMARIN VAGINAL $0-$6.60 (Tier 2) MO progesterone micronized $0-$6.60 (Tier 2) ST; MO VAGIFEM $0-$6.60 (Tier 2) MO MISCELLANEOUS OB/GYN clindamycin phosphate vaginal $0-$6.60 (Tier 2) MO clotrimazole vaginal cream $0 (Tier 4) MO; [*] metronidazole vaginal $0-$6.60 (Tier 2) MO miconazole 7 $0 (Tier 4) MO; [*] miconazole nitrate vaginal cream $0 (Tier 4) MO; [*] miconazole nitrate vaginal suppository $0 (Tier 4) [*] miconazole-3 vaginal suppository $0-$6.60 (Tier 2) MO; QLL (6 per 30 days) NUVARING $0-$6.60 (Tier 2) MO ORTHO EVRA $0-$6.60 (Tier 2) MO terconazole $0-$6.60 (Tier 2) MO tioconazole-1 $0 (Tier 4) [*] tranexamic acid oral $0-$6.60 (Tier 2) MO 86
XULANE $0-$6.60 (Tier 2) MO zazole vaginal cream 0.4 % $0-$6.60 (Tier 2) ORAL CONTRACEPTIVES / RELATED AGENTS altavera (28) $0-$6.60 (Tier 2) MO alyacen 1/35 (28) $0-$6.60 (Tier 2) MO alyacen 7/7/7 (28) $0-$6.60 (Tier 2) MO apri $0-$6.60 (Tier 2) MO aranelle (28) $0-$6.60 (Tier 2) MO aviane $0-$6.60 (Tier 2) MO azurette (28) $0-$6.60 (Tier 2) MO caziant (28) $0-$6.60 (Tier 2) MO cryselle (28) $0-$6.60 (Tier 2) MO drospirenone-ethinyl estradiol $0-$6.60 (Tier 2) MO econtra ez $0 (Tier 4) [*] elinest $0-$6.60 (Tier 2) MO ELLA $0-$6.60 (Tier 2) MO enpresse $0-$6.60 (Tier 2) MO fallback solo $0 (Tier 4) [*] falmina (28) $0-$6.60 (Tier 2) MO gildagia $0-$6.60 (Tier 2) MO gildess fe $0-$6.60 (Tier 2) MO junel 1.5/30 (21) $0-$6.60 (Tier 2) MO junel 1/20 (21) $0-$6.60 (Tier 2) MO junel fe 1.5/30 (28) $0-$6.60 (Tier 2) MO junel fe 1/20 (28) $0-$6.60 (Tier 2) MO kariva (28) $0-$6.60 (Tier 2) MO kelnor 1/35 (28) $0-$6.60 (Tier 2) MO lessina $0-$6.60 (Tier 2) MO levonest (28) $0-$6.60 (Tier 2) MO 87
levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) MO low-ogestrel (28) $0-$6.60 (Tier 2) MO lutera (28) $0-$6.60 (Tier 2) MO marlissa $0-$6.60 (Tier 2) MO microgestin 1.5/30 (21) $0-$6.60 (Tier 2) MO microgestin 1/20 (21) $0-$6.60 (Tier 2) MO microgestin fe 1.5/30 (28) $0-$6.60 (Tier 2) MO microgestin fe 1/20 (28) $0-$6.60 (Tier 2) MO mono-linyah $0-$6.60 (Tier 2) MO mononessa (28) $0-$6.60 (Tier 2) MO my way $0 (Tier 4) [*] myzilra $0-$6.60 (Tier 2) MO necon 0.5/35 (28) $0-$6.60 (Tier 2) MO necon 1/35 (28) $0-$6.60 (Tier 2) MO necon 1/50 (28) $0-$6.60 (Tier 2) MO necon 10/11 (28) $0-$6.60 (Tier 2) MO necon 7/7/7 (28) $0-$6.60 (Tier 2) MO next choice one dose $0 (Tier 4) [*] norgestimate-ethinyl estradiol $0-$6.60 (Tier 2) MO nortrel 0.5/35 (28) $0-$6.60 (Tier 2) MO nortrel 1/35 (21) $0-$6.60 (Tier 2) MO nortrel 1/35 (28) $0-$6.60 (Tier 2) MO nortrel 7/7/7 (28) $0-$6.60 (Tier 2) MO ocella $0-$6.60 (Tier 2) MO ogestrel (28) $0-$6.60 (Tier 2) MO opcicon one-step $0 (Tier 4) [*] PLAN B ONE-STEP $0 (Tier 4) MO; [*] 88
portia $0-$6.60 (Tier 2) MO previfem $0-$6.60 (Tier 2) MO reclipsen (28) $0-$6.60 (Tier 2) MO sprintec (28) $0-$6.60 (Tier 2) MO syeda $0-$6.60 (Tier 2) MO tri-previfem (28) $0-$6.60 (Tier 2) MO tri-sprintec (28) $0-$6.60 (Tier 2) MO trivora (28) $0-$6.60 (Tier 2) MO velivet triphasic regimen (28) $0-$6.60 (Tier 2) MO viorele (28) $0-$6.60 (Tier 2) MO zarah $0-$6.60 (Tier 2) MO zenchent (28) $0-$6.60 (Tier 2) MO zovia 1/35e (28) $0-$6.60 (Tier 2) MO zovia 1/50e (28) $0-$6.60 (Tier 2) MO OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac $0-$6.60 (Tier 2) MO bacitracin ophthalmic $0-$6.60 (Tier 2) MO bacitracin-polymyxin b ophthalmic $0-$6.60 (Tier 2) MO ciprofloxacin hcl ophthalmic $0-$2.65 (Tier 1) MO erythromycin ophthalmic $0-$6.60 (Tier 2) MO gentak ophthalmic ointment $0-$6.60 (Tier 2) MO gentamicin ophthalmic $0-$6.60 (Tier 2) MO NATACYN $0-$6.60 (Tier 2) MO neomycin-bacitracin-polymyxin $0-$6.60 (Tier 2) MO neomycin-polymyxin-gramicidin $0-$6.60 (Tier 2) MO neo-polycin $0-$6.60 (Tier 2) ofloxacin ophthalmic $0-$6.60 (Tier 2) MO polycin $0-$6.60 (Tier 2) polymyxin b sulf-trimethoprim $0-$6.60 (Tier 2) MO 89
tobramycin $0-$6.60 (Tier 2) MO VIGAMOX $0-$6.60 (Tier 2) MO ANTIVIRALS trifluridine $0-$6.60 (Tier 2) MO ZIRGAN $0-$6.60 (Tier 2) MO BETA-BLOCKERS betaxolol ophthalmic $0-$6.60 (Tier 2) MO carteolol $0-$6.60 (Tier 2) MO levobunolol ophthalmic drops 0.5 % $0-$6.60 (Tier 2) MO metipranolol $0-$6.60 (Tier 2) MO timolol maleate ophthalmic $0-$6.60 (Tier 2) MO TIMOPTIC OCUDOSE (PF) $0-$6.60 (Tier 2) MO CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE $0-$6.60 (Tier 2) MO CYCLOPLEGIC MYDRIATICS tropicamide ophthalmic $0-$6.60 (Tier 2) MO MISCELLANEOUS OPHTHALMOLOGICS akwa tears $0 (Tier 4) MO; [*] akwa tears (polyvinyl alcohol) $0 (Tier 4) MO; [*] artificial tears (petro/min) $0 (Tier 4) MO; [*] artificial tears (polyvin alc) $0 (Tier 4) MO; [*] azelastine ophthalmic $0-$6.60 (Tier 2) MO cromolyn ophthalmic $0-$6.60 (Tier 2) MO FRESHKOTE $0 (Tier 4) MO; [*] ISOPTO TEARS $0 (Tier 4) MO; [*] lubricating plus $0 (Tier 4) [*] lubrifresh pm $0 (Tier 4) [*] MURO 128 OPHTHALMIC DROPS $0 (Tier 4) MO; [*] natural balance $0 (Tier 4) MO; [*] nature's tears $0 (Tier 4) [*] 90
PATADAY $0-$6.60 (Tier 2) MO PATANOL $0-$6.60 (Tier 2) MO PAZEO $0-$6.60 (Tier 2) MO puralube $0 (Tier 4) MO; [*] REFRESH CELLUVISC $0 (Tier 4) MO; [*] REFRESH LACRI-LUBE $0 (Tier 4) MO; [*] REFRESH PLUS $0 (Tier 4) MO; [*] RESTASIS $0-$6.60 (Tier 2) MO sodium chloride ophthalmic $0 (Tier 4) MO; [*] NON-STEROIDAL ANTI-INFLAMMATORY AGENTS flurbiprofen sodium $0-$6.60 (Tier 2) MO ILEVRO $0-$6.60 (Tier 2) MO ketorolac ophthalmic $0-$6.60 (Tier 2) MO NEVANAC $0-$6.60 (Tier 2) MO ORAL DRUGS FOR GLAUCOMA acetazolamide oral $0-$6.60 (Tier 2) MO acetazolamide sodium $0-$6.60 (Tier 2) MO methazolamide oral $0-$6.60 (Tier 2) MO OTHER GLAUCOMA DRUGS AZOPT $0-$6.60 (Tier 2) MO bimatoprost $0-$6.60 (Tier 2) MO COMBIGAN $0-$6.60 (Tier 2) MO dorzolamide $0-$6.60 (Tier 2) MO dorzolamide-timolol $0-$6.60 (Tier 2) MO latanoprost $0-$6.60 (Tier 2) MO LUMIGAN OPHTHALMIC DROPS 0.01 % $0-$6.60 (Tier 2) MO TRAVATAN Z $0-$6.60 (Tier 2) MO; QLL (5 per 30 days) travoprost (benzalkonium) $0-$6.60 (Tier 2) MO STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc $0-$6.60 (Tier 2) MO 91
neomycin-polymyxin b-dexameth $0-$6.60 (Tier 2) MO neomycin-polymyxin-hc ophthalmic $0-$6.60 (Tier 2) MO neo-polycin hc $0-$6.60 (Tier 2) tobramycin-dexamethasone $0-$6.60 (Tier 2) MO STEROIDS dexamethasone sodium phosphate ophthalmic $0-$6.60 (Tier 2) MO fluorometholone $0-$6.60 (Tier 2) MO prednisolone acetate $0-$6.60 (Tier 2) MO prednisolone sodium phosphate ophthalmic $0-$6.60 (Tier 2) MO STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE S.O.P. $0-$6.60 (Tier 2) MO sulfacetamide-prednisolone $0-$6.60 (Tier 2) MO SULFONAMIDES sulfacetamide sodium ophthalmic drops $0-$6.60 (Tier 2) MO SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % $0-$6.60 (Tier 2) MO apraclonidine $0-$6.60 (Tier 2) MO brimonidine $0-$6.60 (Tier 2) MO VASOCONSTRICTOR DECONGESTANTS eye drops (tetrahydrozoline) $0 (Tier 4) [*] naphazoline $0-$6.60 (Tier 2) MO opti-clear $0 (Tier 4) [*] RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS 12 hour decongestant $0 (Tier 4) [*] adult tussin chest congestion $0 (Tier 4) [*] ALA-HIST DM $0 (Tier 4) MO; [*] ala-hist ir $0 (Tier 4) MO; [*] ALA-HIST PE $0 (Tier 4) MO; [*] 92
alavert d-12 allergy-sinus $0 (Tier 4) MO; [*] ALDEX GS $0 (Tier 4) [*] all day allergy (cetirizine) oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) all day allergy (cetirizine) oral tablet,chewable 10 mg $0 (Tier 4) MO; [*] all day allergy-d $0 (Tier 4) MO; [*] ALLER-CHLOR ORAL SYRUP $0 (Tier 4) [*] aller-chlor oral tablet $0 (Tier 4) MO; [*] allergy (chlorpheniramine) $0 (Tier 4) MO; [*] allergy 4-hour $0 (Tier 4) [*] allergy relief (clemastine) $0 (Tier 4) MO; [*] allergy relief (loratadine) oral solution $0 (Tier 4) [*] allergy relief (loratadine) oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) allergy relief (loratadine) oral tablet,disintegrating allergy relief d-24 $0 (Tier 4) [*] allergy relief(diphenhydramin) oral liquid $0 (Tier 4) [*] allerhist-1 $0 (Tier 4) [*] $0 (Tier 4) [*]; QLL (30 per 30 days) allfen dm $0 (Tier 4) MO; [*] ALL-NITE COLD-FLU ORAL LIQUID 6.25-15- 325 MG/15 ML $0 (Tier 4) [*] ap-hist dm $0 (Tier 4) [*] aprodine $0 (Tier 4) MO; [*] arbinoxa $0-$6.60 (Tier 2) PAR; MO banophen allergy $0 (Tier 4) MO; [*] banophen oral capsule 25 mg $0 (Tier 4) MO; [*] banophen oral capsule 50 mg $0 (Tier 4) [*] banophen oral liquid $0 (Tier 4) MO; [*] benzonatate oral capsule 100 mg, 200 mg $0 (Tier 3) MO; [*] bp 8 cough $0 (Tier 4) [*] BROMFED DM $0 (Tier 3) MO; [*] 93
brompheniramine-pseudoeph-dm oral syrup $0 (Tier 3) MO; [*] brotapp $0 (Tier 4) MO; [*] brotapp dm $0 (Tier 4) [*] cetirizine oral solution 1 mg/ml $0 (Tier 4) MO; [*]; QLL (300 per 30 days) cetirizine oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) cetirizine oral tablet,chewable $0 (Tier 4) MO; [*] cetirizine-pseudoephedrine $0 (Tier 4) MO; [*] cheratussin ac $0 (Tier 4) MO; [*] cheratussin dac $0 (Tier 4) MO; [*] chest congestion relief oral tablet $0 (Tier 4) [*] chest congestion relief pe $0 (Tier 4) [*] child delsym cough+chest dm $0 (Tier 4) [*] CHILD DELSYM COUGH+COLD $0 (Tier 4) [*] child mucinex chest congestion $0 (Tier 4) [*] CHILD MUCINEX CONGESTION-COUGH $0 (Tier 4) [*] CHILD MUCINEX M-S COLD DAY-NTE $0 (Tier 4) [*] CHILD MUCINEX STUFFY NOSE-COLD $0 (Tier 4) MO; [*] children's allergy (diphenhyd) oral liquid $0 (Tier 4) [*] children's cetirizine oral solution $0 (Tier 4) [*]; QLL (300 per 30 days) children's cetirizine oral tablet,chewable $0 (Tier 4) MO; [*] CHILDREN'S CLARITIN ORAL TABLET,CHEWABLE $0 (Tier 4) MO; [*] children's cold & cough dm $0 (Tier 4) [*] CHILDREN'S MUCINEX COLD-FEVER $0 (Tier 4) [*] children's mucinex cough $0 (Tier 4) [*] CHILDREN'S MUCINEX MULTI-SYMP $0 (Tier 4) [*] CHILDREN'S MUCINEX NIGHT TIME $0 (Tier 4) [*] children's silfedrine $0 (Tier 4) [*] child's all day allergy(cetir) $0 (Tier 4) [*]; QLL (300 per 30 days) CHLO TUSS $0 (Tier 4) MO; [*] 94
CHLO TUSS EX $0 (Tier 4) [*] chlorpheniramine maleate oral tablet $0 (Tier 4) [*] chlorpheniramine maleate oral tablet extended release $0 (Tier 4) MO; [*] CLARITIN-D 12 HOUR $0 (Tier 4) MO; [*] clemastine oral tablet 2.68 mg $0-$6.60 (Tier 2) PAR; MO codeine-guaifenesin $0 (Tier 4) MO; [*] complete allergy medicine oral capsule $0 (Tier 4) [*] complete allergy oral liquid $0 (Tier 4) [*] CONGESTION RELIEF (IBUPROF-PE) $0 (Tier 4) [*] cough dm er $0 (Tier 4) [*] cough syrup dm $0 (Tier 4) [*] cough-sore throat night $0 (Tier 4) [*] cpm-pseudoephed-hydrocodone $0 (Tier 3) MO; [*] DALLERGY (CHLORPHENIRAMINE-PE) ORAL DROPS 1-2.5 MG/ML DALLERGY (DEXBROMPHENIRAMN-PE) ORAL TABLET $0 (Tier 4) [*] $0 (Tier 4) MO; [*] dayhist allergy $0 (Tier 4) [*] DAYTIME COLD & FLU RELIEF ORAL CAPSULE 5-10-325 MG $0 (Tier 4) [*] daytime liquid capsules $0 (Tier 4) [*] DECONEX DMX $0 (Tier 4) MO; [*] DECONEX IR $0 (Tier 4) MO; [*] DELSYM 12 HOUR $0 (Tier 4) MO; [*] delsym cough+chest congest dm $0 (Tier 4) [*] DELSYM COUGH+COLD DAYTIME $0 (Tier 4) [*] DELSYM COUGH+COLD NIGHTTIME $0 (Tier 4) [*] dextromethorphan polistirex $0 (Tier 4) [*] dimaphen (pe) $0 (Tier 4) [*] dimaphen dm $0 (Tier 4) MO; [*] 95
diphenhist oral liquid $0 (Tier 4) MO; [*] diphenhist oral tablet 25 mg $0 (Tier 4) MO; [*] diphenhydramine hcl injection solution 50 mg/ml $0-$6.60 (Tier 2) PAR; MO diphenhydramine hcl injection syringe $0-$6.60 (Tier 2) PAR; MO diphenhydramine hcl oral capsule $0 (Tier 4) MO; [*] DURAFLU $0 (Tier 4) MO; [*] ed a-hist $0 (Tier 4) MO; [*] ed a-hist dm oral liquid $0 (Tier 4) MO; [*] ED A-HIST DM ORAL TABLET $0 (Tier 4) [*] ed a-hist pse $0 (Tier 4) [*] ed bron gp $0 (Tier 4) [*] ED CHLORPED D $0 (Tier 4) [*] ed chlorped jr $0 (Tier 4) [*] ED-CHLORPED $0 (Tier 4) [*] ed-chlortan $0 (Tier 4) MO; [*] endacof - dm $0 (Tier 4) [*] endacof-c $0 (Tier 4) MO; [*] epinephrine injection solution 1 mg/ml (1:1,000) $0-$6.60 (Tier 2) MO epinephrine injection syringe 0.1 mg/ml (1:10,000) $0-$6.60 (Tier 2) MO EPIPEN 2-PAK $0-$6.60 (Tier 2) MO; QLL (2 per 1 day) EPIPEN JR 2-PAK $0-$6.60 (Tier 2) MO; QLL (2 per 1 day) FEXOFENADINE ORAL SUSPENSION $0 (Tier 4) [*] fexofenadine oral tablet 180 mg, 60 mg $0 (Tier 4) MO; [*] guaiatussin ac $0 (Tier 4) [*] guaifenesin ac $0 (Tier 4) [*] guaifenesin oral liquid $0 (Tier 4) [*] guaifenesin oral tablet extended release 12hr $0 (Tier 4) MO; [*] HISTEX (TRIPROLIDINE) $0 (Tier 4) [*] HISTEX DM $0 (Tier 4) [*] HISTEX PD $0 (Tier 4) [*] 96
HISTEX PE $0 (Tier 4) [*] hydrocodone-chlorpheniramine $0 (Tier 3) MO; [*] hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml $0 (Tier 3) MO; [*] hydrocodone-homatropine oral tablet $0 (Tier 3) MO; [*] hydromet $0 (Tier 3) MO; [*] iophen c-nr $0 (Tier 4) MO; [*] iophen dm-nr $0 (Tier 4) MO; [*] iophen-nr $0 (Tier 4) MO; [*] J-MAX $0 (Tier 4) MO; [*] J-TAN D PD $0 (Tier 4) MO; [*] J-TAN PD $0 (Tier 4) MO; [*] kidkare cough/cold $0 (Tier 4) [*] levocetirizine oral tablet $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) LODRANE D $0 (Tier 4) MO; [*] lohist - d $0 (Tier 4) MO; [*] lohist peb dm $0 (Tier 4) [*] lohist-dm $0 (Tier 3) MO; [*] lorata-dine d $0 (Tier 4) [*] loratadine oral solution $0 (Tier 4) MO; [*] loratadine oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) loratadine oral tablet,disintegrating $0 (Tier 4) MO; [*]; QLL (30 per 30 days) loratadine-d $0 (Tier 4) MO; [*] LORTUSS DM $0 (Tier 4) MO; [*] lortuss ex oral syrup $0 (Tier 4) [*] LORTUSS LQ $0 (Tier 4) [*] mapap cold formula $0 (Tier 4) [*] mapap sinus max strength (pe) $0 (Tier 4) [*] maxiphen $0 (Tier 4) MO; [*] MAXIPHEN DM $0 (Tier 4) [*] 97
medi-phedryl $0 (Tier 4) [*] medi-tussin dm diabetic $0 (Tier 4) [*] M-END DMX $0 (Tier 4) [*] M-END MAX D $0 (Tier 4) MO; [*] mucaphed $0 (Tier 4) [*] MUCINEX $0 (Tier 4) MO; [*] MUCINEX COLD & SINUS $0 (Tier 4) [*] MUCINEX COLD-FLU & SORE THROAT $0 (Tier 4) [*] MUCINEX COUGH MINI-MELTS $0 (Tier 4) MO; [*] mucinex d $0 (Tier 4) MO; [*] mucinex d maximum strength $0 (Tier 4) MO; [*] mucinex dm $0 (Tier 4) MO; [*] MUCINEX FAST-MAX COLD-FLU-THRT ORAL TABLET $0 (Tier 4) [*] MUCINEX FAST-MAX COLD-SINUS $0 (Tier 4) [*] MUCINEX FAST-MAX CONGEST-COUGH ORAL LIQUID MUCINEX FAST-MAX CONGEST-COUGH ORAL TABLET MUCINEX FAST-MAX DAY-NITE CONG ORAL TABLETS, SEQUENTIAL $0 (Tier 4) MO; [*] $0 (Tier 4) [*] $0 (Tier 4) [*] mucinex fast-max dm max $0 (Tier 4) [*] MUCINEX FAST-MAX NITE COLD-FLU $0 (Tier 4) [*] MUCINEX FAST-MAX SEVERE COLD ORAL LIQUID MUCINEX FST-MX DY-NT CLD (DPH) ORAL LIQUID, SEQUENTIAL MUCINEX MINI-MELTS ORAL GRANULES IN PACKET 100 MG $0 (Tier 4) [*] $0 (Tier 4) [*] $0 (Tier 4) MO; [*] MUCINEX SINUS-MAX D-N (DIPHEN) $0 (Tier 4) [*] MUCINEX SINUS-MAX PRESSUR-PAIN ORAL TABLET $0 (Tier 4) [*] 98
MUCINEX SINUS-MAX SEV CONGESTN ORAL TABLET $0 (Tier 4) [*] mucus relief er oral tablet extended release 12hr $0 (Tier 4) [*] mucus relief oral tablet 400 mg $0 (Tier 4) MO; [*] mucus relief sinus $0 (Tier 4) [*] nasal decongestant (pe) oral tablet 10 mg $0 (Tier 4) [*] nasal decongestant (pseudoeph) oral tablet $0 (Tier 4) [*] NASOPEN PE $0 (Tier 4) [*] nighttime cough $0 (Tier 4) [*] nighttime sleep aid (diphen) oral tablet $0 (Tier 4) [*] NINJACOF $0 (Tier 4) [*] NINJACOF-A $0 (Tier 4) [*] NINJACOF-XG $0 (Tier 4) [*] NITE TIME COLD-FLU RELIEF ORAL CAPSULE $0 (Tier 4) [*] NIVA-HIST DM $0 (Tier 4) MO; [*] NIVANEX DMX $0 (Tier 4) MO; [*] nohist-dm $0 (Tier 4) [*] nohist-lq $0 (Tier 4) [*] non-drowsy allergy $0 (Tier 4) [*]; QLL (30 per 30 days) NOREL AD $0 (Tier 4) MO; [*] organ-i nr $0 (Tier 4) MO; [*] PAIN RELIEF SINUS PE $0 (Tier 4) [*] PEDIATEX TDM $0 (Tier 4) [*] pediatric cough & cold oral liquid 1-15-5 mg/5 ml $0 (Tier 4) [*] phenylhistine dh $0 (Tier 4) MO; [*] POLY HIST PD $0 (Tier 4) [*] POLY-HIST DM (THONZYLAMINE) $0 (Tier 4) [*] poly-tussin $0 (Tier 4) [*] poly-tussin d $0 (Tier 4) [*] 99
POLY-VENT DM ORAL TABLET 60-20-380 MG $0 (Tier 4) [*] POLY-VENT IR ORAL TABLET 60-380 MG $0 (Tier 4) MO; [*] PRO-CHLO $0 (Tier 4) [*] PRO-CLEAR AC $0 (Tier 4) MO; [*] promethazine injection solution $0-$6.60 (Tier 2) PAR; MO promethazine vc-codeine $0 (Tier 3) MO; [*] promethazine-codeine $0 (Tier 3) MO; [*] promethazine-dm $0 (Tier 3) MO; [*] promethegan rectal suppository 12.5 mg $0-$6.60 (Tier 2) PAR; MO pseudoephedrine hcl oral liquid $0 (Tier 4) MO; [*] pseudoephedrine hcl oral tablet 30 mg $0 (Tier 4) MO; [*] PYRILAMINE-PHENYLEPHRINE ORAL TABLET $0 (Tier 4) [*] q-dryl oral capsule $0 (Tier 4) [*] q-dryl oral liquid $0 (Tier 4) MO; [*] q-tussin $0 (Tier 4) [*] q-tussin dm $0 (Tier 4) [*] quenalin $0 (Tier 4) [*] RESCON $0 (Tier 4) [*] RESCON-DM $0 (Tier 4) MO; [*] rescon-gg $0 (Tier 4) MO; [*] RESPAIRE-30 $0 (Tier 4) MO; [*] restfully sleep $0 (Tier 4) [*] REZIRA $0 (Tier 3) MO; [*] robafen $0 (Tier 4) MO; [*] robafen cf oral liquid $0 (Tier 4) [*] robafen dm $0 (Tier 4) MO; [*] robafen dm cough $0 (Tier 4) [*] RU-HIST D $0 (Tier 4) MO; [*] 100
RYMED (DEXCHLORPHENIRAMINE-PE) $0 (Tier 4) MO; [*] rynex dm $0 (Tier 4) [*] rynex pe $0 (Tier 4) [*] rynex pse $0 (Tier 4) [*] siladryl sa $0 (Tier 4) [*] silphen cough $0 (Tier 4) [*] siltussin dm das $0 (Tier 4) [*] siltussin sa $0 (Tier 4) MO; [*] siltussin-dm $0 (Tier 4) [*] SORE THROAT & COUGH LOZENGE $0 (Tier 4) [*] STAHIST AD ORAL LIQUID $0 (Tier 4) [*] STAHIST AD ORAL TABLET $0 (Tier 4) MO; [*] sudogest $0 (Tier 4) MO; [*] sudogest 12-hour $0 (Tier 4) MO; [*] sudogest pe $0 (Tier 4) MO; [*] sudogest sinus & allergy $0 (Tier 4) [*] suphedrine pe $0 (Tier 4) [*] tussin dm oral liquid $0 (Tier 4) [*] tussin dm oral syrup 10-100 mg/5 ml $0 (Tier 4) [*] tussin expectorant $0 (Tier 4) [*] tussin oral liquid $0 (Tier 4) [*] TUSSIONEX PENNKINETIC ER $0 (Tier 3) MO; [*] VANACOF $0 (Tier 4) MO; [*] VANACOF DM $0 (Tier 4) [*] VANACOF-8 $0 (Tier 4) [*] VANAHIST PD $0 (Tier 4) [*] virtussin ac $0 (Tier 4) MO; [*] VITUZ $0 (Tier 3) MO; [*] ZONATUSS $0 (Tier 3) MO; [*] ZUTRIPRO $0 (Tier 3) MO; [*] 101
PULMONARY AGENTS acetylcysteine solution $0-$6.60 (Tier 2) B/D PAR; MO ADVAIR DISKUS $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) ADVAIR HFA $0-$6.60 (Tier 2) MO; QLL (12 per 30 days) AEROSPAN $0-$6.60 (Tier 2) MO; QLL (18 per 30 days) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup $0-$2.65 (Tier 1) MO albuterol sulfate oral tablet $0-$6.60 (Tier 2) MO albuterol sulfate oral tablet extended release 12 hr $0-$6.60 (Tier 2) MO $0-$2.65 (Tier 1) B/D PAR; MO; QLL (360 per 30 days) $0-$2.65 (Tier 1) B/D PAR; MO; QLL (60 per 30 days) ANORO ELLIPTA $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) ARNUITY ELLIPTA $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) ASMANEX HFA $0-$6.60 (Tier 2) MO; QLL (13 per 30 days) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) $0-$6.60 (Tier 2) MO; QLL (0.14 per 30 days) $0-$6.60 (Tier 2) $0-$6.60 (Tier 2) MO; QLL (0.24 per 30 days) ATROVENT HFA $0-$6.60 (Tier 2) MO; QLL (26 per 30 days) BREO ELLIPTA $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) COMBIVENT RESPIMAT $0-$6.60 (Tier 2) MO; QLL (8 per 30 days) cromolyn inhalation $0-$6.60 (Tier 2) B/D PAR; MO; QLL (240 per 30 days) cromolyn nasal $0 (Tier 4) MO; [*] DALIRESP $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) 102
DULERA $0-$6.60 (Tier 2) MO; QLL (13 per 30 days) FIRAZYR $0-$6.60 (Tier 2) PAR; MO FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (240 per 30 days) $0-$6.60 (Tier 2) MO; QLL (12 per 30 days) $0-$6.60 (Tier 2) MO; QLL (24 per 30 days) $0-$6.60 (Tier 2) MO; QLL (11 per 30 days) $0-$6.60 (Tier 2) MO; QLL (75 per 30 days) fluticasone nasal $0-$6.60 (Tier 2) MO; QLL (16 per 30 days) FORADIL AEROLIZER $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) ipratropium bromide inhalation $0-$6.60 (Tier 2) B/D PAR; MO ipratropium-albuterol $0-$6.60 (Tier 2) B/D PAR; MO; QLL (540 per 30 days) KALYDECO ORAL TABLET $0-$6.60 (Tier 2) PAR; MO; QLL (60 per 30 days) LETAIRIS $0-$6.60 (Tier 2) PAR; MO; LA; QLL (30 per 30 days) levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml metaproterenol oral $0-$6.60 (Tier 2) MO $0-$6.60 (Tier 2) B/D PAR; MO; QLL (270 per 30 days) $0-$6.60 (Tier 2) B/D PAR; MO; QLL (540 per 30 days) montelukast $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) NASONEX $0-$6.60 (Tier 2) MO; QLL (17 per 30 days) PERFOROMIST $0-$6.60 (Tier 2) B/D PAR; MO; QLL (120 per 30 days) PROAIR HFA $0-$6.60 (Tier 2) MO; QLL (18 per 30 days) PULMOZYME $0-$6.60 (Tier 2) B/D PAR; MO 103
QVAR INHALATION AEROSOL 40 MCG/ACTUATION QVAR INHALATION AEROSOL 80 MCG/ACTUATION $0-$6.60 (Tier 2) MO; QLL (9 per 30 days) $0-$6.60 (Tier 2) MO; QLL (18 per 30 days) S2 RACEPINEPHRINE $0 (Tier 4) MO; [*] SEREVENT DISKUS $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) sildenafil oral $0-$6.60 (Tier 2) PAR; MO; QLL (90 per 30 days) SPIRIVA RESPIMAT $0-$6.60 (Tier 2) MO; QLL (4 per 30 days) SPIRIVA WITH HANDIHALER $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) terbutaline oral $0-$6.60 (Tier 2) MO terbutaline subcutaneous $0-$6.60 (Tier 2) MO theophylline oral tablet extended release $0-$6.60 (Tier 2) MO theophylline oral tablet extended release 12 hr $0-$6.60 (Tier 2) MO TRACLEER $0-$6.60 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) VENTAVIS $0-$6.60 (Tier 2) PAR; MO XOLAIR $0-$6.60 (Tier 2) PAR; MO; LA; QLL (6 per 28 days) zafirlukast $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS oxybutynin chloride oral syrup $0-$6.60 (Tier 2) MO; QLL (600 per 30 days) oxybutynin chloride oral tablet $0-$6.60 (Tier 2) MO; QLL (120 per 30 days) oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) tolterodine oral capsule,extended release 24hr $0-$6.60 (Tier 2) MO; QLL (30 per 30 days) tolterodine oral tablet $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) trospium oral tablet $0-$6.60 (Tier 2) MO; QLL (60 per 30 days) BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin $0-$6.60 (Tier 2) MO finasteride oral tablet 5 mg $0-$6.60 (Tier 2) MO 104
tamsulosin $0-$6.60 (Tier 2) MO CHOLINERGIC STIMULANTS bethanechol chloride $0-$6.60 (Tier 2) MO MISCELLANEOUS UROLOGICALS CIALIS ORAL TABLET 2.5 MG, 5 MG $0-$6.60 (Tier 2) PAR; MO; QLL (30 per 30 days) CYSTAGON $0-$6.60 (Tier 2) MO; LA potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) URINARY ANESTHETICS $0-$6.60 (Tier 2) MO azo-tabs $0 (Tier 4) [*] VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES antacid ext str (calcium carb) $0 (Tier 4) [*] antacid extra-strength oral tablet,chewable 200 mg calcium (500 mg), 300 mg (750 mg) antacid oral tablet,chewable 200 mg calcium (500 mg) $0 (Tier 4) [*] $0 (Tier 4) [*] CALCET CREAMY BITES $0 (Tier 4) MO; [*] calci-chew $0 (Tier 4) MO; [*] calcitrate $0 (Tier 4) MO; [*] CALCITRATE-VITAMIN D $0 (Tier 4) MO; [*] calcium 500 + d oral tablet 500 mg(1,250mg) -200 unit $0 (Tier 4) MO; [*] calcium 500 oral tablet $0 (Tier 4) [*] calcium 500 with d $0 (Tier 4) MO; [*] calcium 600 $0 (Tier 4) [*] calcium 600 + d(3) oral tablet 600 mg(1,500mg) - 200 unit, 600 mg(1,500mg) -400 unit $0 (Tier 4) MO; [*] calcium acetate oral capsule $0-$2.65 (Tier 1) MO calcium antacid oral tablet,chewable 200 mg calcium (500 mg) $0 (Tier 4) MO; [*] 105
calcium antacid oral tablet,chewable 300 mg (750 mg) $0 (Tier 4) [*] calcium carbonate oral suspension $0 (Tier 4) MO; [*] calcium carbonate oral tablet 260 mg calcium (648 mg), 500 mg calcium (1,250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet 650 mg calcium (1,625 mg) calcium carbonate oral tablet,chewable 500 mg calcium (1,250 mg) calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit calcium carbonate-vitamin d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit CALCIUM CARBONATE-VITAMIN D3 ORAL TABLET 600 MG(1,500MG) -800 UNIT calcium carbonate-vitamin d3 oral tablet,chewable $0 (Tier 4) MO; [*] $0 (Tier 4) [*] $0 (Tier 4) [*] $0 (Tier 4) [*] $0 (Tier 4) MO; [*] $0 (Tier 4) MO; [*] $0 (Tier 4) MO; [*] calcium citrate + d with mag $0 (Tier 4) [*] calcium citrate oral tablet 200 mg (950 mg) $0 (Tier 4) [*] calcium citrate-vitamin d3 oral tablet 200-125 mgunit calcium citrate-vitamin d3 oral tablet 315-200 mgunit, 315-250 mg-unit $0 (Tier 4) [*] $0 (Tier 4) MO; [*] calcium gluconate oral tablet 45 mg (500 mg) $0 (Tier 4) MO; [*] calcium with vitamin d $0 (Tier 4) [*] CALCIUM-MAGNESIUM $0 (Tier 4) [*] calcium-magnesium-zinc oral tablet, 333-133-5 mg $0 (Tier 4) [*] cal-gest antacid $0 (Tier 4) MO; [*] CALTRATE 600 + D $0 (Tier 4) MO; [*] chelated zinc $0 (Tier 4) MO; [*] 106
citrus calcium oral tablet 315-250 mg-unit $0 (Tier 4) MO; [*] dextrose-kcl-nacl $0-$6.60 (Tier 2) B/D PAR ENFAMIL ENFALYTE $0 (Tier 4) [*] hi-cal plus vit d $0 (Tier 4) [*] klor-con 10 $0-$6.60 (Tier 2) MO klor-con 8 $0-$6.60 (Tier 2) MO klor-con m10 $0-$6.60 (Tier 2) MO klor-con m15 $0-$6.60 (Tier 2) MO klor-con m20 $0-$6.60 (Tier 2) MO K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ $0-$6.60 (Tier 2) lactated ringers intravenous $0-$6.60 (Tier 2) B/D PAR; MO laxative dietary supplement $0 (Tier 4) [*] mag-delay $0 (Tier 4) MO; [*] MAGNESIUM (OXIDE/AA CHELATE) $0 (Tier 4) MO; [*] MAGNESIUM AMINO ACID CHELATE ORAL TABLET 27 MG MAGNESIUM GLUCONATE ORAL TABLET 30 MG (550 MG) $0 (Tier 4) [*] $0 (Tier 4) [*] MAGNESIUM ORAL TABLET 30 MG $0 (Tier 4) [*] magnesium oxide oral capsule 500 mg $0 (Tier 4) [*] magnesium oxide oral tablet 400 mg, 420 mg, 500 mg $0 (Tier 4) MO; [*] magnesium sulfate in water $0-$6.60 (Tier 2) magnesium sulfate injection solution $0-$6.60 (Tier 2) MO magnesium sulfate injection syringe $0-$6.60 (Tier 2) MG-PLUS-PROTEIN $0 (Tier 4) MO; [*] MONOCAL $0 (Tier 4) MO; [*] NORMOSOL-R $0-$6.60 (Tier 2) B/D PAR NORMOSOL-R IN 5 % DEXTROSE $0-$6.60 (Tier 2) B/D PAR oral electrolytes $0 (Tier 4) [*] 107
oralyte $0 (Tier 4) [*] ORAZINC $0 (Tier 4) MO; [*] OS-CAL 500 + D3 ORAL TABLET $0 (Tier 4) MO; [*] OSTEO-PORETICAL $0 (Tier 4) MO; [*] oysco 500/d oral tablet $0 (Tier 4) MO; [*] oysco d $0 (Tier 4) MO; [*] oysco-500 $0 (Tier 4) MO; [*] oyst-cal-500 $0 (Tier 4) MO; [*] oyster shell + d3 $0 (Tier 4) [*] oyster shell calcium $0 (Tier 4) MO; [*] oyster shell calcium & mag $0 (Tier 4) [*] oyster shell calcium 500 $0 (Tier 4) MO; [*] oyster shell calcium-vit d3 oral tablet 250-125 mgunit, 500 mg(1,250mg) -400 unit $0 (Tier 4) MO; [*] PEDIALYTE ADVANCED CARE $0 (Tier 4) [*] pedialyte freezer pops $0 (Tier 4) [*] pedialyte oral solution $0 (Tier 4) MO; [*] pedialyte singles $0 (Tier 4) [*] pediatric electrolyte oral solution $0 (Tier 4) [*] pediatric freezer pops $0 (Tier 4) [*] potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR 108
potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous piggyback 10 meq/50 ml $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO potassium chloride intravenous solution $0-$6.60 (Tier 2) B/D PAR; MO potassium chloride oral capsule, extended release $0-$6.60 (Tier 2) MO potassium chloride oral tablet extended release $0-$6.60 (Tier 2) MO potassium chloride oral tablet,er particles/crystals $0-$6.60 (Tier 2) MO potassium chloride-0.45 % nacl $0-$6.60 (Tier 2) B/D PAR potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR $0-$6.60 (Tier 2) B/D PAR; MO $0-$6.60 (Tier 2) B/D PAR ringers intravenous $0-$6.60 (Tier 2) B/D PAR selenium oral tablet 100 mcg, 50 mcg $0 (Tier 4) MO; [*] selenium oral tablet 200 mcg $0 (Tier 4) [*] selenium oral tablet,delayed release (dr/ec) $0 (Tier 4) MO; [*] SLOW-MAG $0 (Tier 4) MO; [*] sodium chloride 0.45 % intravenous parenteral solution $0-$6.60 (Tier 2) MO sodium chloride 0.45 % intravenous piggyback $0-$6.60 (Tier 2) sodium chloride 3 % $0-$6.60 (Tier 2) MO sodium chloride 5 % $0-$6.60 (Tier 2) sodium chloride intravenous $0-$6.60 (Tier 2) B/D PAR; MO super calcium $0 (Tier 4) [*] TPN ELECTROLYTES $0-$6.60 (Tier 2) B/D PAR 109
zinc $0 (Tier 4) [*] zinc gluconate oral lozenge 10 mg $0 (Tier 4) [*] zinc gluconate oral tablet 100 mg $0 (Tier 4) [*] zinc gluconate oral tablet 50 mg $0 (Tier 4) MO; [*] zinc sulfate oral capsule $0 (Tier 4) MO; [*] zinc sulfate oral tablet $0 (Tier 4) [*] ZINC-15 $0 (Tier 4) MO; [*] zinc-220 $0 (Tier 4) [*] MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 8.5 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN 8.5 %-ELECTROLYTES $0-$6.60 (Tier 2) B/D PAR AMINOSYN II 10 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN II 7 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN II 8.5 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN II 8.5 %-ELECTROLYTES $0-$6.60 (Tier 2) B/D PAR AMINOSYN M 3.5 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN-HBC 7% $0-$6.60 (Tier 2) B/D PAR AMINOSYN-PF 10 % $0-$6.60 (Tier 2) B/D PAR AMINOSYN-PF 7 % (SULFITE-FREE) $0-$6.60 (Tier 2) B/D PAR CALCIUM CITRATE MALATE-VIT D3 $0 (Tier 4) [*] CLINIMIX 5%/D15W SULFITE FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 5%/D25W SULFITE-FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 2.75%/D5W SULFIT FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 4.25%/D10W SULF FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 4.25%-D20W SULF-FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 4.25%-D25W SULF-FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX 5%-D20W(SULFITE-FREE) $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 4.25%/D10W SUL FREE $0-$6.60 (Tier 2) CLINIMIX E 4.25%/D25W SUL FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 4.25%/D5W SULF FREE $0-$6.60 (Tier 2) B/D PAR 110
CLINIMIX E 5%/D15W SULFIT FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 5%/D20W SULFIT FREE $0-$6.60 (Tier 2) B/D PAR CLINIMIX E 5%/D25W SULFIT FREE $0-$6.60 (Tier 2) B/D PAR CLINISOL SF 15 % $0-$6.60 (Tier 2) B/D PAR; MO FORTAVIT $0 (Tier 3) [*] freamine iii 10 % $0-$6.60 (Tier 2) B/D PAR HEPATAMINE 8% $0-$6.60 (Tier 2) B/D PAR intralipid intravenous emulsion 20 % $0-$6.60 (Tier 2) B/D PAR; MO ISOLYTE-P IN 5 % DEXTROSE $0-$6.60 (Tier 2) B/D PAR NORMOSOL-M IN 5 % DEXTROSE $0-$6.60 (Tier 2) B/D PAR NORMOSOL-R PH 7.4 $0-$6.60 (Tier 2) B/D PAR PLASMA-LYTE 148 $0-$6.60 (Tier 2) B/D PAR PLASMA-LYTE-56 IN 5 % DEXTROSE $0-$6.60 (Tier 2) B/D PAR travasol 10 % $0-$6.60 (Tier 2) B/D PAR; MO TROPHAMINE 10 % $0-$6.60 (Tier 2) B/D PAR; MO TROPHAMINE 6% $0-$6.60 (Tier 2) B/D PAR VITAMINS / HEMATINICS ABANEU-SL $0 (Tier 4) [*] acerola c-500 $0 (Tier 4) [*] actical $0 (Tier 4) MO; [*] adults 50+ daily formula $0 (Tier 4) [*] adults' daily formula $0 (Tier 4) [*] ALBA-LYBE $0 (Tier 4) [*] animal shape vitamins $0 (Tier 4) [*] apatate forte $0 (Tier 4) [*] APETEX $0 (Tier 4) [*] APETIGEN $0 (Tier 4) [*] apetigen plus oral liquid $0 (Tier 4) [*] APETIGEN PLUS ORAL TABLET $0 (Tier 4) MO; [*] AQUADEKS $0 (Tier 4) MO; [*] 111
aquasol e $0 (Tier 4) MO; [*] ascorbic acid oral tablet $0 (Tier 4) [*] ascorbic acid oral tablet extended release 1,000 mg ascorbic acid oral tablet extended release 1,500 mg $0 (Tier 4) MO; [*] $0 (Tier 4) [*] ascorbic acid oral tablet,chewable $0 (Tier 4) [*] b complex 1 $0 (Tier 4) MO; [*] B COMPLEX W-VIT C $0 (Tier 4) [*] b complex-vitamin b12 $0 (Tier 4) MO; [*] bal b-100 $0 (Tier 4) [*] bal b-50 $0 (Tier 4) [*] balance b-100 $0 (Tier 4) [*] balance b-50 $0 (Tier 4) [*] balanced b-100 oral tablet 0.4 mg, 100 mg $0 (Tier 4) [*] balanced b-150 $0 (Tier 4) [*] balanced b-50 oral tablet $0 (Tier 4) [*] b-complex oral tablet $0 (Tier 4) [*] b-complex with vitamin c oral capsule $0 (Tier 4) MO; [*] b-complex with vitamin c oral tablet $0 (Tier 4) MO; [*] b-complex with vitamin c oral tablet extended release $0 (Tier 4) [*] bee-zee $0 (Tier 4) [*] beta carotene oral capsule 25,000 unit $0 (Tier 4) MO; [*] BIOCAL $0 (Tier 4) [*] biosupp $0 (Tier 4) [*] biotin oral capsule 2,500 mcg, 5 mg $0 (Tier 4) MO; [*] biotin oral tablet 1 mg, 300 mcg $0 (Tier 4) MO; [*] biovol $0 (Tier 4) [*] C 1000-BIOFLAVONOIDS-ROSE HIPS $0 (Tier 4) [*] c complex $0 (Tier 4) [*] 112
c-500 oral tablet,chewable $0 (Tier 4) [*] CALCET PETITES $0 (Tier 4) MO; [*] calcium 600 + minerals oral tablet 600 mg calcium- 200 unit calcium 600 with vitamin d3 oral capsule 600 mg(1,500mg) -400 unit $0 (Tier 4) [*] $0 (Tier 4) [*] CALCIUM CARB-MAG OX-ZINC GLUC $0 (Tier 4) [*] calcium carbonate-vit d3-min $0 (Tier 4) [*] calcium plus $0 (Tier 4) [*] calcium soft chew oral tablet,chewable 500-200- 40 mg-unit-mcg $0 (Tier 4) [*] calcium-magnesium-copper-zinc $0 (Tier 4) [*] calcium-vitamin d3-vitamin k oral tablet,chewable 500-200-40 mg-unit-mcg $0 (Tier 4) [*] calvite p&d $0 (Tier 4) [*] centamin $0 (Tier 4) [*] centavite a-z complete-mineral $0 (Tier 4) [*] central vite with lutein $0 (Tier 4) [*] central-vite cardio $0 (Tier 4) [*] CENTRAL-VITE ENERGY $0 (Tier 4) [*] central-vite men's under 50 $0 (Tier 4) [*] central-vite oral tablet 18-400 mg-mcg $0 (Tier 4) [*] central-vite select $0 (Tier 4) [*] central-vite senior $0 (Tier 4) [*] CENTRAL-VITE WOMEN'S MATURE $0 (Tier 4) [*] central-vite women's under 50 $0 (Tier 4) [*] CENTRUM COMPLETE $0 (Tier 4) MO; [*] CENTRUM KIDS $0 (Tier 4) MO; [*] CENTRUM MEN $0 (Tier 4) [*] CENTRUM ORAL LIQUID $0 (Tier 4) MO; [*] CENTRUM ORAL TABLET,CHEWABLE $0 (Tier 4) [*] 113
CENTRUM SILVER ORAL TABLET $0 (Tier 4) MO; [*] CENTRUM SILVER WOMEN $0 (Tier 4) MO; [*] CENTRUM SPECIALIST HEART $0 (Tier 4) MO; [*] CENTRUM ULTRA MEN'S $0 (Tier 4) [*] century adults 50+ $0 (Tier 4) [*] century cardio $0 (Tier 4) [*] century oral tablet 18-400 mg-mcg $0 (Tier 4) [*] CENTURY ULTIMATE MEN'S ORAL TABLET 8 MG IRON- 200 MCG-600 MCG $0 (Tier 4) [*] century ultimate women's $0 (Tier 4) [*] cerovite $0 (Tier 4) MO; [*] cerovite advanced formula $0 (Tier 4) MO; [*] cerovite jr $0 (Tier 4) [*] certavite with lutein $0 (Tier 4) [*] certavite-antioxid (iron gluc) oral liquid 9 mg iron/15 ml $0 (Tier 4) MO; [*] certavite-antioxidant $0 (Tier 4) MO; [*] chewable-vite $0 (Tier 4) MO; [*] chewable-vite with iron $0 (Tier 4) [*] child vitamin with minerals $0 (Tier 4) [*] children's chewable complete oral tablet,chewable $0 (Tier 4) [*] children's chewable vitamin $0 (Tier 4) [*] children's chewables $0 (Tier 4) [*] children's chewables extra c $0 (Tier 4) [*] children's chewables with iron $0 (Tier 4) [*] children's iron $0 (Tier 4) [*] childs chew vite $0 (Tier 4) [*] child's chewable vitamins/iron $0 (Tier 4) [*] child's vitamin with iron $0 (Tier 4) [*] child's vitamin with vitamin c $0 (Tier 4) [*] 114
childs/iron $0 (Tier 4) MO; [*] cholecalciferol (vitamin d3) oral drops 400 unit/ml $0 (Tier 4) MO; [*] compete $0 (Tier 4) [*] complete multivitamin oral tablet $0 (Tier 4) [*] complete multivitamin-mineral oral tablet $0 (Tier 4) [*] complete oral tablet $0 (Tier 4) [*] complete senior oral tablet 0.4-300-250 mg-mcgmcg $0 (Tier 4) MO; [*] complex b-100 oral tablet extended release $0 (Tier 4) MO; [*] CORAL CALCIUM ORAL CAPSULE 185-50- 100 MG-MG-UNIT, 200-100-100 MG-MG-UNIT $0 (Tier 4) [*] corvita $0 (Tier 3) MO; [*] CORVITE $0 (Tier 3) MO; [*] CORVITE FREE $0 (Tier 3) MO; [*] cyanocobalamin (vitamin b-12) oral liquid $0 (Tier 4) [*] cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg, 500 mcg cyanocobalamin (vitamin b-12) oral tablet extended release $0 (Tier 4) [*] $0 (Tier 4) [*] daily energy $0 (Tier 4) [*] daily multiple for men $0 (Tier 4) [*] daily multiple for men 50+ $0 (Tier 4) [*] DAILY MULTIPLE FOR WOMEN $0 (Tier 4) [*] daily multiple for women 50+ $0 (Tier 4) [*] daily multiple oral tablet $0 (Tier 4) [*] DAILY MULTIPLE ORAL TABLET 400-120 MCG-MG $0 (Tier 4) [*] daily multiple vitamins/iron $0 (Tier 4) [*] daily multivitamin-minerals $0 (Tier 4) [*] daily vitamin with iron $0 (Tier 4) [*] daily vitamin with iron and ca $0 (Tier 4) [*] 115
daily vites/iron $0 (Tier 4) MO; [*] daily-vite $0 (Tier 4) MO; [*] dialyvite 800 $0 (Tier 4) MO; [*] DIALYVITE 800 WITH IRON $0 (Tier 3) MO; [*] DIALYVITE 800 WITH ZINC 15 $0 (Tier 4) MO; [*] DIALYVITE 800 WITH ZINC 50 $0 (Tier 4) MO; [*] dino-life $0 (Tier 4) [*] dino-life with extra c $0 (Tier 4) [*] dino-life with iron-zinc $0 (Tier 4) [*] DRISDOL ORAL CAPSULE $0 (Tier 3) MO; [*] duofer $0 (Tier 4) [*] ECEE PLUS $0 (Tier 4) MO; [*] ENLYTE (FERROUS GLYCINE) $0 (Tier 3) MO; [*] ergocalciferol (vitamin d2) oral capsule $0 (Tier 3) MO; [*] ergocalciferol (vitamin d2) oral drops $0 (Tier 4) MO; [*] ezfe 200 $0 (Tier 4) MO; [*] fe c $0 (Tier 4) MO; [*] ferate oral tablet 240 mg (27 mg iron) $0 (Tier 4) MO; [*] FERGON $0 (Tier 4) MO; [*] FER-IN-SOL $0 (Tier 4) MO; [*] fer-iron $0 (Tier 4) [*] ferosul oral solution $0 (Tier 4) [*] ferosul oral tablet $0 (Tier 4) MO; [*] ferretts $0 (Tier 4) MO; [*] FERRETTS IPS $0 (Tier 4) MO; [*] ferrex 150 $0 (Tier 4) MO; [*] FERRIMIN 150 $0 (Tier 4) MO; [*] ferrocite $0 (Tier 4) MO; [*] ferro-time $0 (Tier 4) MO; [*] ferrous fumarate oral tablet 324 mg (106 mg iron) $0 (Tier 4) MO; [*] 116
ferrous gluconate oral tablet 236 mg (27 mg iron) $0 (Tier 4) [*] ferrous gluconate oral tablet 240 mg (27 mg iron), 324 mg (37.5 mg iron), 324 mg (38 mg iron), 325 mg (36 mg iron) $0 (Tier 4) MO; [*] ferrous sulfate oral drops $0 (Tier 4) MO; [*] ferrous sulfate oral liquid $0 (Tier 4) MO; [*] ferrous sulfate oral solution $0 (Tier 4) MO; [*] ferrous sulfate oral tablet 325 mg (65 mg iron) $0 (Tier 4) MO; [*] FERROUS SULFATE ORAL TABLET EXTENDED RELEASE $0 (Tier 4) MO; [*] ferrous sulfate oral tablet,delayed release (dr/ec) $0 (Tier 4) MO; [*] ferrousul $0 (Tier 4) [*] fluoritab oral tablet,chewable 1 mg fluoride (2.2 mg) $0-$6.60 (Tier 2) MO folbee ar $0 (Tier 4) MO; [*] folic acid injection $0 (Tier 3) MO; [*] folic acid oral tablet 1 mg $0 (Tier 3) MO; [*] FOLIC ACID-VIT B6-VIT B12 ORAL TABLET 0.5-5-0.2 MG $0 (Tier 4) [*] folitab $0 (Tier 4) MO; [*] foltabs 800 $0 (Tier 4) MO; [*] fosfree $0 (Tier 4) MO; [*] fruity vitamin $0 (Tier 4) [*] full spectrum b-vitamin c $0 (Tier 4) [*] gummy dinos oral tablet,chewable 200 mcg $0 (Tier 4) [*] gummy swirls $0 (Tier 4) [*] hair vitamins $0 (Tier 4) [*] hair,skin & nails oral tablet $0 (Tier 4) [*] HARD NAIL $0 (Tier 4) [*] HEMOCYTE $0 (Tier 4) MO; [*] high potency iron $0 (Tier 4) [*] 117
honey bears $0 (Tier 4) [*] honey bears with iron-zinc $0 (Tier 4) [*] I.L.X. B-12 $0 (Tier 4) MO; [*] ICAPS $0 (Tier 4) MO; [*] ICAPS AREDS ORAL TABLET,DELAYED RELEASE (DR/EC) $0 (Tier 4) MO; [*] ICAPS MV $0 (Tier 4) MO; [*] icaps plus $0 (Tier 4) [*] ICAR ORAL SUSPENSION $0 (Tier 4) MO; [*] ICAR-C $0 (Tier 4) MO; [*] iferex 150 $0 (Tier 4) MO; [*] INTEGRA $0 (Tier 4) MO; [*] iron (ferrous sulfate) $0 (Tier 4) [*] iron high potency $0 (Tier 4) [*] iron oral tablet 325 mg (65 mg iron) $0 (Tier 4) [*] iron oral tablet extended release 159 mg (45 mg iron) $0 (Tier 4) [*] iron-vitamin c $0 (Tier 4) MO; [*] LIFE-PACK MEN'S $0 (Tier 4) [*] LIFE-PACK WOMEN'S $0 (Tier 4) [*] little animals $0 (Tier 4) [*] little animals-iron oral tablet,chewable $0 (Tier 4) [*] lysiplex plus oral liquid $0 (Tier 4) MO; [*] macuvite eye care $0 (Tier 4) [*] MEDTYCHOLL-B COMPLEX-LIVER $0 (Tier 4) [*] mega multi for women $0 (Tier 4) [*] mega multiple/chelated mineral $0 (Tier 4) [*] mega multivitamin for men $0 (Tier 4) [*] mega multivitamin with mineral oral tablet 13.5-200-250 mg-mcg-mcg $0 (Tier 4) [*] men's 50+ daily formula $0 (Tier 4) [*] 118
men's multi-vitamin $0 (Tier 4) [*] MERIBIN $0 (Tier 4) MO; [*] MULTICHEW $0 (Tier 3) MO; [*] multi-day $0 (Tier 4) [*] multi-delyn $0 (Tier 4) MO; [*] multi-delyn with iron $0 (Tier 4) [*] multilex $0 (Tier 4) MO; [*] multilex-t&m $0 (Tier 4) MO; [*] multiple vitamin-minerals $0 (Tier 4) [*] multiple vitamins $0 (Tier 4) [*] multi-vitamin hp/minerals $0 (Tier 4) [*] multivitamin oral tablet $0 (Tier 4) MO; [*] multivitamin with iron $0 (Tier 4) [*] multivitamin with minerals oral tablet $0 (Tier 4) MO; [*] multi-vitamins with iron $0 (Tier 4) [*] myferon 150 $0 (Tier 4) MO; [*] my-vitalife $0 (Tier 4) [*] NEPHROCAPS $0 (Tier 4) MO; [*] nephronex $0 (Tier 4) [*] nephronex-sl $0 (Tier 4) MO; [*] NEPHRO-VITE $0 (Tier 4) MO; [*] NOVAFERRUM 125 $0 (Tier 4) [*] NOVAFERRUM 50 $0 (Tier 4) [*] NOVAFERRUM ORAL DROPS $0 (Tier 4) [*] NU-IRON $0 (Tier 4) MO; [*] NUTRICAP $0 (Tier 3) [*] NUTRIVIT $0 (Tier 4) [*] once daily $0 (Tier 4) [*] ONCOVITE $0 (Tier 4) MO; [*] one daily energy oral tablet $0 (Tier 4) [*] 119
one daily essential oral tablet, 0.4 mg $0 (Tier 4) [*] one daily maximum $0 (Tier 4) [*] ONE DAILY MEN'S 50+ $0 (Tier 4) [*] one daily multi-vit w-mineral $0 (Tier 4) [*] one daily multivitamin oral tablet $0 (Tier 4) [*] one daily oral tablet $0 (Tier 4) [*] one daily plus iron $0 (Tier 4) [*] one daily with iron $0 (Tier 4) [*] ONE DAILY WOMEN 50 PLUS $0 (Tier 4) [*] one daily women's oral tablet 27-0.4 mg $0 (Tier 4) [*] one-tablet-daily $0 (Tier 4) [*] oyster shell calcium with d $0 (Tier 4) [*] oyster shell calcium-vit d3 oral tablet 500 mg(1,250mg) -200 unit $0 (Tier 4) MO; [*] pantothenic acid $0 (Tier 4) MO; [*] PERIDIN-C $0 (Tier 4) MO; [*] poly-iron $0 (Tier 4) MO; [*] polysaccharide iron complex $0 (Tier 4) [*] poly-vita $0 (Tier 4) [*] poly-vita (iron) $0 (Tier 4) [*] poly-vitamin $0 (Tier 4) [*] poly-vitamin with iron oral drops 1,500 unit-400 unit-10 mg/ml $0 (Tier 4) [*] polyvitamin/iron $0 (Tier 4) [*] poly-vitamins $0 (Tier 4) [*] PRENATAL VITAMIN ORAL TABLET $0-$6.60 (Tier 2) PREVENT $0 (Tier 4) [*] PRO FE $0 (Tier 4) MO; [*] PROFERRIN ES $0 (Tier 4) MO; [*] prosight $0 (Tier 4) [*] 120
PROTECT IRON $0 (Tier 3) [*] pyridoxine oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 4) [*] RABANO YODADO $0 (Tier 4) [*] rena-vite $0 (Tier 4) MO; [*] riboflavin (vitamin b2) oral tablet 100 mg $0 (Tier 4) [*] risacal-d $0 (Tier 4) MO; [*] sentry oral tablet 18-500-300-250 mg-mcg-mcgmcg $0 (Tier 4) [*] sentry senior oral tablet 500-300-250 mcg $0 (Tier 4) [*] SIDEROL ORAL TABLET $0 (Tier 4) MO; [*] slow release iron oral tablet extended release 143 mg (45 mg iron), 159 mg (45 mg iron), 47.5 mg iron $0 (Tier 4) [*] sodium fluoride oral tablet $0-$6.60 (Tier 2) sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg) $0-$6.60 (Tier 2) MO soft chews calcium $0 (Tier 4) [*] spectravite adult 50+ oral tablet $0 (Tier 4) [*] spectravite advanced formula $0 (Tier 4) [*] spectravite men's $0 (Tier 4) [*] spectravite senior oral tablet 500-300-250 mcg $0 (Tier 4) [*] spectravite ultra women $0 (Tier 4) [*] spectravite ultra women's sr $0 (Tier 4) [*] strawberry c $0 (Tier 4) [*] stress formula $0 (Tier 4) [*] stress formula 600 c $0 (Tier 4) [*] stress formula advanced $0 (Tier 4) [*] STRESS FORMULA ENERGY $0 (Tier 4) [*] stress formula with iron $0 (Tier 4) MO; [*] stress formula with iron(sulf) $0 (Tier 4) [*] stress formula with zinc $0 (Tier 4) MO; [*] 121
STROVITE FORTE $0 (Tier 3) MO; [*] STROVITE ONE $0 (Tier 3) MO; [*] SUPER B COMPLEX + C $0 (Tier 4) [*] super b complex-vitamin c $0 (Tier 4) [*] super b/c $0 (Tier 4) [*] super b-50 complex $0 (Tier 4) [*] super multiple oral tablet $0 (Tier 4) [*] super multivitamin $0 (Tier 4) [*] super thera vite m $0 (Tier 4) [*] superplex-t $0 (Tier 4) [*] SUPERVITE (EC) $0 (Tier 3) MO; [*] support $0 (Tier 4) MO; [*] SUPPORT-500 $0 (Tier 3) MO; [*] tab a vite oral tablet 18-0.4 mg $0 (Tier 4) MO; [*] tab-a-vite $0 (Tier 4) MO; [*] tab-a-vite/iron $0 (Tier 4) MO; [*] tab-a-vite-minerals $0 (Tier 4) [*] TANDEM DUAL ACTION $0 (Tier 4) MO; [*] thera $0 (Tier 4) [*] thera-m oral tablet $0 (Tier 4) [*] therapeutic liquid $0 (Tier 4) [*] therapeutic m + beta-carotene $0 (Tier 4) [*] therapeutic-m oral tablet 9 mg iron-400 mcg $0 (Tier 4) [*] therapeutic-m vitamin/minerals oral tablet 27-0.4 mg $0 (Tier 4) [*] thera-tabs $0 (Tier 4) [*] theratrum complete with lutein $0 (Tier 4) [*] thiamine hcl oral tablet 100 mg $0 (Tier 4) [*] thiamine hcl oral tablet 250 mg $0 (Tier 4) MO; [*] total b/c $0 (Tier 4) [*] 122
totalday multiple $0 (Tier 4) [*] TRI-VI-SOL $0 (Tier 4) MO; [*] tri-vita $0 (Tier 4) [*] tri-vitamin $0 (Tier 4) MO; [*] ultra b-100 complex oral tablet $0 (Tier 4) [*] v-c forte $0 (Tier 3) MO; [*] vic-forte $0 (Tier 3) [*] VITA-BEE WITH C $0 (Tier 4) MO; [*] vitamin a oral capsule 10,000 unit $0 (Tier 4) MO; [*] vitamin a oral capsule 8,000 unit $0 (Tier 4) [*] vitamin b complex $0 (Tier 4) [*] vitamin b complex with c $0 (Tier 4) [*] vitamin b-1 $0 (Tier 4) MO; [*] vitamin b-100 complex $0 (Tier 4) [*] vitamin b-12 oral tablet $0 (Tier 4) MO; [*] vitamin b-12 oral tablet extended release 1,000 mcg vitamin b-12 oral tablet extended release 2,000 mcg $0 (Tier 4) MO; [*] $0 (Tier 4) [*] vitamin b-12 sublingual tablet 2,500 mcg $0 (Tier 4) MO; [*] vitamin b-2 oral tablet 100 mg, 25 mg $0 (Tier 4) MO; [*] vitamin b-6 oral tablet 100 mg, 25 mg, 50 mg $0 (Tier 4) MO; [*] vitamin b-6 oral tablet 200 mg $0 (Tier 4) [*] vitamin c cough drops $0 (Tier 4) [*] vitamin c drops $0 (Tier 4) [*] vitamin c oral capsule, extended release $0 (Tier 4) MO; [*] vitamin c oral lozenge $0 (Tier 4) [*] VITAMIN C ORAL POWDER EFFERVESCENT IN PACKET $0 (Tier 4) [*] vitamin c oral syrup $0 (Tier 4) MO; [*] vitamin c oral tablet 1,000 mg, 250 mg, 500 mg $0 (Tier 4) MO; [*] 123
vitamin c oral tablet extended release 1,000 mg $0 (Tier 4) [*] vitamin c oral tablet extended release 500 mg $0 (Tier 4) MO; [*] vitamin c oral tablet,chewable 250 mg, 500 mg $0 (Tier 4) MO; [*] vitamin c with rose hips oral tablet $0 (Tier 4) MO; [*] vitamin c with rose hips oral tablet extended release 1,000 mg $0 (Tier 4) [*] vitamin d2 $0 (Tier 3) MO; [*] vitamin e (dl, acetate) oral capsule 400 unit $0 (Tier 4) MO; [*] vitamin e acetate $0 (Tier 4) [*] vitamin e mixed oral capsule $0 (Tier 4) [*] vitamin e oral capsule 1,000 unit, 100 unit, 200 unit, 400 unit $0 (Tier 4) MO; [*] vitamin e oral capsule 600 unit $0 (Tier 4) [*] VITAMIN E ORAL DROPS 100 UNIT/0.25 ML $0 (Tier 4) [*] vitamin e oral drops 50 unit/ml $0 (Tier 4) [*] vitamins & minerals $0 (Tier 4) [*] vitamins a and d $0 (Tier 4) [*] vitamins b complex oral capsule $0 (Tier 4) MO; [*] vitamins for hair oral tablet $0 (Tier 4) [*] wee care $0 (Tier 4) [*] WHOLE SOURCE MULTI-VITAMINS $0 (Tier 4) [*] women's daily formula oral tablet 18 mg iron-400 mcg-500 mg ca $0 (Tier 4) [*] ZINC (WITH A & C) LOZENGES $0 (Tier 4) [*] zinc sulfate-vitamin c $0 (Tier 4) [*] zoo chews $0 (Tier 4) [*] zoo friends complete $0 (Tier 4) [*] zoo friends oral tablet,chewable 15 mg, 300 mcg $0 (Tier 4) [*] zoo friends original $0 (Tier 4) [*] 124
Index 1 12 hour decongestant... 92 A abacavir... 10 abacavir-lamivudine-zidovudine.. 10 ABANEU-SL... 111 ABELCET... 9 ABILIFY... 39 ABILIFY MAINTENA... 39 ABRAXANE... 20 ABSTRAL... 32 acarbose... 68 acebutolol... 49 acephen... 35 acerola c-500... 111 aceta-gesic... 35 acetaminophen... 35 acetaminophen-codeine... 32, 33 acetazolamide... 91 acetazolamide sodium... 91 acetic acid... 67 acetic acid-aluminum acetate... 67 acetylcysteine... 63, 102 acid gone antacid... 74 acid reducer (famotidine)... 80 acitretin... 57 ACNE MEDICATION... 59 ACTEMRA... 85 ACTHAR H.P.... 67 ACTHIB (PF)... 82 actical... 111 actidose/sorbitol... 74 ACTIMMUNE... 81 ACTIQ... 33 acyclovir... 10, 61 acyclovir sodium... 10 ADACEL(TDAP ADOLESN/ADULT)(PF)... 82 ADAGEN... 63 adapalene... 59 ADASUVE... 39 added strength pain reliever... 35 adefovir... 10 adult tussin chest congestion... 92 adults 50+ daily formula... 111 adults' daily formula... 111 ADVAIR DISKUS... 102 ADVAIR HFA... 102 AEROSPAN... 102 afeditab cr... 49 AFINITOR... 20 AFINITOR DISPERZ... 20 AGGRENOX... 54 ak-poly-bac... 89 akwa tears... 90 akwa tears (polyvinyl alcohol)... 90 ala-cort... 61 ALA-HIST DM... 92 ala-hist ir... 92 ALA-HIST PE... 92 alavert d-12 allergy-sinus... 93 ALBA-LYBE... 111 ALBENZA... 14 albuterol sulfate... 102 alclometasone... 61 alcohol pads... 68 ALDEX GS... 93 ALDURAZYME... 71 alendronate... 63, 84 alfuzosin... 104 ALIMTA... 20 ALINIA... 14 all day allergy (cetirizine)... 93 all day allergy-d... 93 all day pain relief... 35 all day relief... 35 aller-chlor... 93 ALLER-CHLOR... 93 allergy (chlorpheniramine)... 93 allergy 4-hour... 93 allergy relief (clemastine)... 93 allergy relief (loratadine)... 93 allergy relief d-24... 93 allergy relief(diphenhydramin)... 93 allerhist-1... 93 allfen dm... 93 ALL-NITE COLD-FLU... 93 allopurinol... 84 almacone... 74 almacone-2... 74 ALOE VERA... 57 alosetron... 74 ALPHAGAN P... 92 alprazolam... 39 altavera (28)... 87 aluminum hydroxide gel... 74 alyacen 1/35 (28)... 87 alyacen 7/7/7 (28)... 87 amantadine hcl... 10 AMBISOME... 9 amcinonide... 61 amifostine crystalline... 19 amikacin... 14 amiloride... 50 amiloride-hydrochlorothiazide... 50 AMINOSYN 8.5 %... 110 AMINOSYN 8.5 %-ELECTROLYTES110 AMINOSYN II 10 %... 110 AMINOSYN II 7 %... 110 AMINOSYN II 8.5 %... 110 AMINOSYN II 8.5 %- ELECTROLYTES... 110 AMINOSYN M 3.5 %... 110 AMINOSYN-HBC 7%... 110 AMINOSYN-PF 10 %... 110 AMINOSYN-PF 7 % (SULFITE-FREE)110 amiodarone... 49 AMITIZA... 74 amitriptyline... 39 amlodipine... 50 amlodipine-atorvastatin... 56 amlodipine-benazepril... 50 amlodipine-valsartan... 50 amlodipine-valsartan-hcthiazid... 50 ammonium lactate... 57 amnesteem... 59 amoxapine... 39 amoxicillin... 17 amoxicillin-pot clavulanate... 17 amphetamine salt combo... 39 amphotericin b... 9 ampicillin... 17 ampicillin sodium... 17 ampicillin-sulbactam... 17 AMPYRA... 31 anagrelide... 63 anastrozole... 20 ANDRODERM... 71 ANDROGEL... 71, 72 androxy... 72 animal shape vitamins... 111 ANORO ELLIPTA... 102 antacid... 74, 105 125
antacid anti-gas... 74 antacid ext str (calcium carb)... 105 antacid extra-strength... 74, 105 antacid plus anti-gas... 74 antacid tablet... 75 antacid with simethicone... 75 antacid-simethicone ds... 75 anti-diarrheal (loperamide)... 73 antifungal (tolnaftate)... 60 antifungal cream... 60 antifungal spray... 60 anti-itch (diphenhydramine)... 58 anti-itch(diphenhyd) with zinc... 58 anti-nausea liquid... 75 anu-med... 75 apatate forte... 111 APETEX... 111 APETIGEN... 111 apetigen plus... 111 APETIGEN PLUS... 111 ap-hist dm... 93 APOKYN... 30 apraclonidine... 92 apri... 87 APRISO... 75 aprodine... 93 APTIOM... 27 APTIVUS... 10 aquabase... 65 AQUADEKS... 111 aquasol e... 112 ARALAST NP... 63 aranelle (28)... 87 ARANESP (IN POLYSORBATE)... 81 arbinoxa... 93 ARCALYST... 81 aripiprazole... 39 ARNUITY ELLIPTA... 102 ARRANON... 20 arthritis pain relief (acetam)... 35 artificial tears (petro/min)... 90 artificial tears (polyvin alc)... 90 ARZERRA... 20 ASACOL HD... 75 ascorbic acid... 112 ASMANEX HFA... 102 ASMANEX TWISTHALER... 102 aspirin... 35 aspirin low-strength... 35 aspirin-dipyridamole... 54 aspir-low... 35 ASTAGRAF XL... 20 atenolol... 50 atenolol-chlorthalidone... 50 ATGAM... 82 atorvastatin... 56 atovaquone... 14 atovaquone-proguanil... 14 ATRIPLA... 10 atropine... 73 ATROVENT HFA... 102 AVASTIN... 20 aviane... 87 AVINZA... 33 AVONEX... 81 AVONEX (WITH ALBUMIN)... 81 azacitidine... 20 AZACTAM IN DEXTROSE (ISO- OSM)... 14 azathioprine... 20 azelastine... 66, 90 AZILECT... 30 azithromycin... 14 AZOPT... 91 AZOR... 50 azo-tabs... 105 aztreonam... 14 azurette (28)... 87 B b complex 1... 112 B COMPLEX W-VIT C... 112 b complex-vitamin b12... 112 baciim... 14 bacitracin... 60, 89 bacitracin zinc... 60 bacitracin-polymyxin b... 89 baclofen... 32 bal b-100... 112 bal b-50... 112 balance b-100... 112 balance b-50... 112 balanced b-100... 112 balanced b-150... 112 balanced b-50... 112 balsalazide... 75 banophen... 93 banophen allergy... 93 BANZEL... 27 BARACLUDE... 10 BCG VACCINE, LIVE (PF)... 82 b-complex... 112 b-complex with vitamin c... 112 bee-zee... 112 BELEODAQ... 20 benazepril... 50 benazepril-hydrochlorothiazide... 50 benzonatate... 93 benzoyl peroxide... 59 benztropine... 30 beta carotene... 112 betamethasone dipropionate... 61 betamethasone valerate... 61, 62 betamethasone, augmented... 62 betaxolol... 50, 90 bethanechol chloride... 105 bexarotene... 20 BEXSERO (PF)... 82 bicalutamide... 20 BICILLIN C-R... 17 BICILLIN L-A... 17 BICNU... 20 BILTRICIDE... 14 bimatoprost... 91 BIOCAL... 112 biosupp... 112 biotin... 112 biovol... 112 bisac-evac... 75 bisacodyl... 75 biscolax... 75 bismatrol... 73 bisoprolol fumarate... 50 bisoprolol-hydrochlorothiazide... 50 bleomycin... 20 BLEPHAMIDE S.O.P.... 92 BLINCYTO... 20 BONIVA... 84 BOOSTRIX TDAP... 82 BOSULIF... 20 bp 8 cough... 93 BREO ELLIPTA... 102 BRILINTA... 54 brimonidine... 92 BRINTELLIX... 39 BROMFED DM... 93 bromocriptine... 30 brompheniramine-pseudoeph-dm94 brotapp... 94 brotapp dm... 94 budesonide... 75 126
bumetanide... 50 BUPHENYL... 63 buprenorphine hcl... 33 buprenorphine-naloxone... 36 buproban... 66 bupropion hcl... 39, 40 buspirone... 40 BUSULFEX... 20 butalbital compound w/codeine.. 33 butorphanol tartrate... 36 BYDUREON... 68 BYETTA... 68 BYSTOLIC... 50 C C 1000-BIOFLAVONOIDS-ROSE HIPS... 112 c complex... 112 c-500... 113 cabergoline... 72 CALCET CREAMY BITES... 105 CALCET PETITES... 113 calci-chew... 105 calcipotriene... 57 calcitonin (salmon)... 72 calcitrate... 105 CALCITRATE-VITAMIN D... 105 calcitriol... 72 calcium 500... 105 calcium 500 + d... 105 calcium 500 with d... 105 calcium 600... 105 calcium 600 + d(3)... 105 calcium 600 + minerals... 113 calcium 600 with vitamin d3... 113 calcium acetate... 105 calcium antacid... 105, 106 CALCIUM CARB-MAG OX-ZINC GLUC... 113 calcium carbonate... 106 calcium carbonate-vit d3-min... 113 calcium carbonate-vitamin d3... 106 CALCIUM CARBONATE-VITAMIN D3... 106 calcium citrate... 106 calcium citrate + d with mag... 106 CALCIUM CITRATE MALATE-VIT D3... 110 calcium citrate-vitamin d3... 106 calcium gluconate... 106 calcium plus... 113 calcium soft chew... 113 CALCIUM WITH BORON... 63 calcium with vitamin d... 106 CALCIUM-MAGNESIUM... 106 calcium-magnesium-copper-zinc 113 calcium-magnesium-zinc... 106 calcium-vitamin d3-vitamin k... 113 caldyphen... 59 cal-gest antacid... 106 CALTRATE 600 + D... 106 calvite p&d... 113 camila... 85 CANASA... 75 CANCIDAS... 9 candesartan... 50 candesartan-hydrochlorothiazid.. 50 CAPASTAT... 14 CAPEX... 62 CAPRELSA... 20 captopril... 50 captopril-hydrochlorothiazide... 50 carbamazepine... 27 carbidopa-levodopa... 30 carboplatin... 20 CARIMUNE NF NANOFILTERED... 82 carteolol... 90 cartia xt... 50 carvedilol... 50 CAYSTON... 15 caziant (28)... 87 cefaclor... 13 cefadroxil... 13 cefazolin... 13 cefazolin in dextrose (iso-os)... 13 cefdinir... 13 cefepime... 13 cefoxitin... 13 cefoxitin in dextrose, iso-osm... 13 cefpodoxime... 13 cefprozil... 13 ceftazidime... 13 ceftriaxone... 13 ceftriaxone in dextrose,iso-os... 13 cefuroxime axetil... 13 cefuroxime sodium... 13 CELLCEPT... 20 CELLCEPT INTRAVENOUS... 20 CELONTIN... 27 centamin... 113 centavite a-z complete-mineral. 113 central vite... 65 central vite with lutein... 113 central-vite... 113 central-vite cardio... 113 CENTRAL-VITE ENERGY... 113 central-vite men's under 50... 113 central-vite select... 113 central-vite senior... 113 CENTRAL-VITE WOMEN'S MATURE... 113 central-vite women's under 50.. 113 CENTRUM... 113 CENTRUM COMPLETE... 113 CENTRUM KIDS... 113 CENTRUM MEN... 113 CENTRUM SILVER... 114 CENTRUM SILVER WOMEN... 114 CENTRUM SPECIALIST HEART... 114 CENTRUM ULTRA MEN'S... 114 century... 114 century adults 50+... 114 century cardio... 114 CENTURY ULTIMATE MEN'S... 114 century ultimate women's... 114 cephalexin... 14 CEREZYME... 72 cerovite... 114 cerovite advanced formula... 114 cerovite jr... 114 certavite with lutein... 114 certavite-antioxid (iron gluc)... 114 certavite-antioxidant... 114 CERVARIX VACCINE (PF)... 82 cetirizine... 94 cetirizine-pseudoephedrine... 94 cevimeline... 64 CHANTIX... 66 CHANTIX CONTINUING MONTH BOX... 66 CHANTIX STARTING MONTH BOX. 66 chelated zinc... 106 cheratussin ac... 94 cheratussin dac... 94 chest congestion relief... 94 chest congestion relief pe... 94 chewable-vite... 114 chewable-vite with iron... 114 child delsym cough+chest dm... 94 CHILD DELSYM COUGH+COLD... 94 child ibuprofen... 36 127
child mucinex chest congestion... 94 CHILD MUCINEX CONGESTION- COUGH... 94 CHILD MUCINEX M-S COLD DAY- NTE... 94 CHILD MUCINEX STUFFY NOSE- COLD... 94 child vitamin with minerals... 114 children's allergy (diphenhyd)... 94 children's aspirin... 36 children's cetirizine... 94 children's chewable complete... 114 children's chewable vitamin... 114 children's chewables... 114 children's chewables extra c... 114 children's chewables with iron... 114 CHILDREN'S CLARITIN... 94 children's cold & cough dm... 94 children's ibuprofen... 36 children's iron... 114 children's mapap... 36 children's medi-profen... 36 children's medi-tabs suspension.. 36 CHILDREN'S MUCINEX COLD- FEVER... 94 children's mucinex cough... 94 CHILDREN'S MUCINEX MULTI- SYMP... 94 CHILDREN'S MUCINEX NIGHT TIME... 94 children's pain & fever relief... 36 children's pain relief... 36 children's pain reliever... 36 children's q-pap... 36 children's silapap... 36 children's silfedrine... 94 child's all day allergy(cetir)... 94 childs chew vite... 114 child's chewable vitamins/iron.. 114 child's vitamin with iron... 114 child's vitamin with vitamin c... 114 childs/iron... 115 CHLO TUSS... 94 CHLO TUSS EX... 95 chloramphenicol sod succinate... 15 chlorhexidine gluconate... 66 chloroquine phosphate... 15 chlorothiazide... 50 chlorothiazide sodium... 50 chlorpheniramine maleate... 95 chlorpromazine... 40 chlorthalidone... 50 cholecalciferol (vitamin d3)... 115 cholestyramine (with sugar)... 56 cholestyramine light... 56 CIALIS... 105 ciclodan... 61 ciclopirox... 61 cidofovir... 10 cilostazol... 54 CIMZIA... 75 CIMZIA POWDER FOR RECONST.. 75 CIMZIA STARTER KIT... 75 CIPRODEX... 67 ciprofloxacin (mixture)... 18 ciprofloxacin hcl... 18, 89 ciprofloxacin lactate... 18 cisplatin... 20 citalopram... 40 citrus calcium... 107 cladribine... 21 clarithromycin... 14 CLARITIN-D 12 HOUR... 95 clemastine... 95 clindamycin hcl... 15 clindamycin phosphate...15, 59, 86 CLINIMIX 5%/D15W SULFITE FREE... 110 CLINIMIX 5%/D25W SULFITE- FREE... 110 CLINIMIX 2.75%/D5W SULFIT FREE... 110 CLINIMIX 4.25%/D10W SULF FREE110 CLINIMIX 4.25%/D5W SULFIT FREE... 64 CLINIMIX 4.25%-D20W SULF-FREE110 CLINIMIX 4.25%-D25W SULF-FREE110 CLINIMIX 5%-D20W(SULFITE- FREE)... 110 CLINIMIX E 2.75%/D10W SUL FREE... 64 CLINIMIX E 2.75%/D5W SULF FREE... 64 CLINIMIX E 4.25%/D10W SUL FREE... 110 CLINIMIX E 4.25%/D25W SUL FREE... 110 CLINIMIX E 4.25%/D5W SULF FREE... 110 CLINIMIX E 5%/D15W SULFIT FREE... 111 CLINIMIX E 5%/D20W SULFIT FREE... 111 CLINIMIX E 5%/D25W SULFIT FREE... 111 CLINISOL SF 15 %... 111 clobetasol... 62 clobetasol-emollient... 62 CLOLAR... 21 clomipramine... 40 clonazepam... 27 clonidine hcl... 51 clonidine patches... 51 clopidogrel... 54 clorazepate dipotassium... 40 clotrim antifungal... 61 clotrimazole... 9, 61, 86 clotrimazole 1% cream... 61 clotrimazole-betamethasone... 61 clozapine... 40 codeine-guaifenesin... 95 COLACE... 75 colchicine-probenecid... 84 COLCRYS... 84 colestipol... 56 colistin (colistimethate na)... 15 colocort... 75 COLY-MYCIN S... 67 COMBIGAN... 91 COMBIVENT RESPIMAT... 102 COMETRIQ... 21 compete... 115 COMPLERA... 10 complete... 115 complete allergy... 95 complete allergy medicine... 95 complete multivitamin... 115 complete multivitamin-mineral.. 115 complete premium vitamin... 65 complete senior... 115 complex b-100... 115 compro... 75 COMVAX (PF)... 82 CONGESTION RELIEF (IBUPROF- PE)... 95 constulose... 75 COPAXONE 20 MG/ML... 31 CORAL CALCIUM... 115 COREG CR... 51 128
cormax... 62 cortisone... 67 corvita... 115 CORVITE... 115 CORVITE FREE... 115 COSMEGEN... 21 cough dm er... 95 cough syrup dm... 95 cough-sore throat night... 95 COUMADIN... 54 cpm-pseudoephed-hydrocodone. 95 CREON... 75 CRESTOR... 56 CRIXIVAN... 10 cromolyn... 90, 102 cryselle (28)... 87 cyanocobalamin (vitamin b-12).. 115 cyclobenzaprine... 32 cyclophosphamide... 21 CYCLOSET... 68 cyclosporine... 21 cyclosporine modified... 21 CYRAMZA... 21 CYSTADANE... 75 CYSTAGON... 105 cytarabine... 21 cytarabine (pf)... 21 D d10 % & 0.45 % sodium chloride. 64 d2.5 %-0.45 % sodium chloride... 64 d5 % and 0.9 % sodium chloride.. 64 d5 %-0.45 % sodium chloride... 64 dacarbazine... 21 daily energy... 115 daily multiple... 115 DAILY MULTIPLE... 115 daily multiple for men... 115 daily multiple for men 50+... 115 DAILY MULTIPLE FOR WOMEN... 115 daily multiple for women 50+... 115 daily multiple vitamins/iron... 115 daily multivitamin-minerals... 115 daily vitamin with iron... 115 daily vitamin with iron and ca... 115 daily vites/iron... 116 daily-vite... 116 DALIRESP... 102 DALLERGY (CHLORPHENIRAMINE- PE)... 95 DALLERGY (DEXBROMPHENIRAMN-PE)... 95 danazol... 72 dantrolene... 32 DAPSONE... 15 DAPTACEL (DTAP PEDIATRIC) (PF) 82 DARAPRIM... 15 daunorubicin... 21 DAUNOXOME... 21 dayhist allergy... 95 DAYTIME COLD & FLU RELIEF (PE) 95 daytime liquid capsules... 95 decitabine... 21 DECONEX DMX... 95 DECONEX IR... 95 deep sea nasal... 66 DELSYM 12 HOUR... 95 delsym cough+chest congest dm. 95 DELSYM COUGH+COLD DAYTIME 95 DELSYM COUGH+COLD NIGHTTIME... 95 DELZICOL... 75 demeclocycline... 18 DEMSER... 51 DENAVIR... 61 DEPEN TITRATABS... 85 DEPO-PROVERA 400 MG/ML... 86 dermabase... 58 desipramine... 40 desmopressin... 72 desonide... 62 desoximetasone... 62 DESVENLAFAXINE... 40, 41 DESVENLAFAXINE FUMARATE... 40 dexamethasone... 67 dexamethasone sodium phos (pf) 67 dexamethasone sodium phosphate... 67, 92 DEXILANT... 80 dexrazoxane hcl... 19 dextroamphetamine... 41 dextromethorphan polistirex... 95 dextrose 10 % and 0.2 % nacl... 64 dextrose 10 % in water (d10w)... 64 dextrose 25 % in water (d25w)... 64 dextrose 30 % in water (d30w)... 64 dextrose 40 % in water (d40w)... 64 dextrose 5 % in water (d5w)... 64 dextrose 5 %-lactated ringers... 64 dextrose 5%-0.2 % sod chloride... 64 dextrose 5%-0.3 % sod.chloride... 64 dextrose 50 % in water (d50w)... 64 dextrose 70 % in water (d70w)... 64 dextrose with sodium chloride... 64 dextrose-kcl-nacl... 107 dialyvite 800... 116 DIALYVITE 800 WITH IRON... 116 DIALYVITE 800 WITH ZINC 15... 116 DIALYVITE 800 WITH ZINC 50... 116 diazepam... 27, 41 diazepam intensol... 41 dibucaine... 59 diclofenac potassium... 36 diclofenac sodium... 36, 58 dicloxacillin... 17 dicyclomine... 73, 74 didanosine... 10 DIFFERIN... 59 diflorasone... 62 diflunisal... 36 DIGITEK... 54 digox... 54 digoxin... 54 DILANTIN CAPSULES... 27 DILANTIN EXTENDED CAPSULES... 27 DILANTIN INFATABS... 27 diltiazem hcl... 51 dilt-xr... 51 dimaphen (pe)... 95 dimaphen dm... 95 dimenhydrinate... 75 dino-life... 116 dino-life with extra c... 116 dino-life with iron-zinc... 116 diocto... 75 DIPENTUM... 75 diphenhist... 96 diphenhydramine hcl... 96 diphenhydramineacetaminophen... 36 diphenoxylate-atropine... 74 disulfiram... 64 divalproex... 27 DOCEFREZ... 21 docetaxel... 21 doc-q-lace... 75 doc-q-lax... 75 docu... 76 docusate calcium... 76 docusate sodium... 76 129
DOCUSOL... 76 DOCUSOL KIDS... 76 DOCUSOL PLUS... 76 dok... 76 dok plus... 76 donepezil... 31 dorzolamide... 91 dorzolamide-timolol... 91 doxazosin... 51 doxepin... 41 doxercalciferol... 72 DOXIL... 21 doxorubicin... 21 DOXY-100... 18 doxycycline hyclate... 18 doxycycline monohydrate... 18, 19 DR. SMITH'S DIAPER... 58 DR. SMITH'S DIAPER RASH... 58 DR. SMITH'S RASH-SKIN... 58 DRISDOL... 116 dronabinol... 76 drospirenone-ethinyl estradiol... 87 DROXIA... 21 DULERA... 103 duloxetine... 41 duofer... 116 DURAFLU... 96 duramorph (pf)... 33 E ear drops (carbamide peroxide)... 67 ear wax removal system... 67 ear wax treatment... 67 ECEE PLUS... 116 econazole... 61 econtra ez... 87 ed a-hist... 96 ed a-hist dm... 96 ED A-HIST DM... 96 ed a-hist pse... 96 ed bron gp... 96 ED CHLORPED D... 96 ed chlorped jr... 96 ed-apap... 36 ED-CHLORPED... 96 ed-chlortan... 96 EDURANT... 10 effervescent pain relief... 36 EFFIENT... 54 ELAPRASE... 72 ELIDEL... 58 elinest... 87 ELIQUIS... 54 ELITEK... 19 ELLA... 87 EMCYT... 21 EMEND... 76 EMSAM... 41 EMTRIVA... 10 enalapril maleate... 51 enalapril-hydrochlorothiazide... 51 ENBREL... 85 ENBREL SURECLICK... 85 endacof - dm... 96 endacof-c... 96 endocet... 33 enema... 76 ENEMEEZ... 76 ENEMEEZ PLUS... 76 ENFAMIL ENFALYTE... 107 ENGERIX-B (PF)... 82 ENGERIX-B PEDIATRIC (PF)... 82 ENLYTE (FERROUS GLYCINE)... 116 enoxaparin... 54 enpresse... 87 entacapone... 31 entecavir... 10 enteric coated aspirin... 36 ENTSOL... 66 enulose... 76 epinephrine... 96 EPIPEN 2-PAK... 96 EPIPEN JR 2-PAK... 96 epirubicin... 21 epitol... 27 EPIVIR... 10 EPIVIR HBV... 10 eplerenone... 51 eprosartan... 51 EPZICOM... 10 EQUETRO... 27 ERAXIS(WATER DILUENT)... 9 ERBITUX... 22 ergocalciferol (vitamin d2)... 116 ergoloid... 41 ERGOMAR... 31 ERIVEDGE... 22 errin... 86 ERWINAZE... 22 ery pads... 59 ery-tab... 14 ERYTHROCIN... 14 erythrocin (as stearate)... 14 erythromycin... 14, 89 erythromycin ethylsuccinate... 14 erythromycin with ethanol... 59 erythromycin-benzoyl peroxide... 59 escitalopram oxalate... 41, 42 ESTRACE... 86 estradiol... 86 ESTRING... 86 ethambutol... 15 ethosuximide... 28 etodolac... 36 ETOPOPHOS... 22 etoposide... 22 EVISTA... 84 EVOTAZ... 10 EXELON... 31 exemestane... 22 EXJADE... 64 ex-strength medi-tabs pm... 36 EXTAVIA... 81 eye drops (tetrahydrozoline)... 92 ezfe 200... 116 F FABRAZYME... 72 fallback solo... 87 falmina (28)... 87 famciclovir... 10 famotidine... 80 famotidine (pf)... 80 famotidine (pf)-nacl (iso-os)... 80 FANAPT... 42 FARESTON... 22 FARYDAK... 22 FASLODEX... 22 FATTIBASE... 65 FAZACLO... 42 fe c... 116 felbamate... 28 felodipine... 51 fenofibrate... 56 fenofibrate micronized... 56 fenofibrate nanocrystallized... 56 fenoprofen... 36 fentanyl... 33 fentanyl citrate... 33 FENTORA... 33 ferate... 116 FERGON... 116 130
FER-IN-SOL... 116 fer-iron... 116 ferosul... 116 ferretts... 116 FERRETTS IPS... 116 ferrex 150... 116 FERRIMIN 150... 116 ferrocite... 116 ferro-time... 116 ferrous fumarate... 116 ferrous gluconate... 117 ferrous sulfate... 117 FERROUS SULFATE... 117 ferrousul... 117 FETZIMA... 42 fexofenadine... 96 FEXOFENADINE... 96 fiber... 76 fiber (calcium polycarbophil)... 76 fiber laxative (ca polycarbo)... 76 fiber laxative (psyllium husk)... 76 fiber smooth... 76 fiber smooth (sucrose)... 76 fiber-lax... 76 finasteride... 104 FIRAZYR... 103 FIRMAGON KIT W DILUENT SYRINGE... 22 flecainide... 49 FLEET PEDIATRIC... 76 FLOVENT DISKUS... 103 FLOVENT HFA... 103 fluconazole... 9 fluconazole in dextrose(iso-o)... 9 fluconazole in nacl (iso-osm)... 9 flucytosine... 9 fludarabine... 22 fludrocortisone... 67 flunisolide... 103 fluocinolone... 62 fluocinolone acetonide oil... 67 fluocinolone-shower cap... 62 fluocinonide... 62 fluocinonide-e... 62 fluoritab... 117 fluorometholone... 92 fluorouracil... 22, 58 fluoxetine... 42 fluphenazine decanoate... 43 fluphenazine hcl... 43 flurbiprofen... 37 flurbiprofen sodium... 91 flutamide... 22 fluticasone... 62, 103 fluvoxamine... 43 folbee ar... 117 folic acid... 117 FOLIC ACID-VIT B6-VIT B12... 117 folitab... 117 FOLOTYN... 22 foltabs 800... 117 fondaparinux... 54, 55 FORADIL AEROLIZER... 103 formula em solution... 76 FORTAVIT... 111 FORTEO... 84 foscarnet... 10 fosfree... 117 fosinopril... 51 fosinopril-hydrochlorothiazide... 51 fosphenytoin... 28 FRAGMIN... 55 freamine iii 10 %... 111 FRESHKOTE... 90 fruity vitamin... 117 full spectrum b-vitamin c... 117 fungoid tincture... 61 furosemide... 51 FUSILEV... 19 FUZEON... 10 FYCOMPA... 28 G gabapentin... 28 GABITRIL... 28 galantamine... 31 GAMASTAN S/D... 82 GAMMAGARD LIQUID... 82 GAMMAGARD S-D (IGA < 1 MCG/ML)... 82 GAMMAPLEX... 82 GAMUNEX-C... 82 ganciclovir sodium... 11 GARDASIL (PF)... 82 GARDASIL 9 (PF)... 82 gas relief... 76, 77 GAUZE PADS 2 X 2... 68 gavilyte-c... 77 gavilyte-g... 77 gavilyte-n... 77 GAZYVA... 22 gemcitabine... 22 gemfibrozil... 56 generlac... 77 gengraf... 22 GENOTROPIN... 81 GENOTROPIN MINIQUICK... 81 gentak... 89 gentamicin... 15, 60, 89 gentamicin sulfate (ped) (pf)... 15 gentamicin sulfate (pf)... 15 GENTAMICIN SULFATE (PF)... 15 gentle laxative... 77 GEODON... 43 gildagia... 87 gildess fe... 87 GILENYA... 32 GILOTRIF... 22 GLATOPA... 32 GLEEVEC... 22 GLEOSTINE... 22 glimepiride... 68 glipizide... 69 glipizide-metformin... 69 GLUCAGEN HYPOKIT... 69 GLUCAGON EMERGENCY KIT (HUMAN)... 69 GLUTOSE 15... 64 GLUTOSE 45... 64 glycopyrrolate... 74 griseofulvin microsize... 9 griseofulvin ultramicrosize... 9 guaiatussin ac... 96 guaifenesin... 96 guaifenesin ac... 96 guanfacine... 43 guanidine... 43 gummy dinos... 117 gummy swirls... 117 H hair vitamins... 117 hair,skin & nails... 117 HALAVEN... 22 halobetasol propionate... 62 HALOG... 62 haloperidol... 43 haloperidol decanoate... 43 haloperidol lactate... 43 HARD NAIL... 117 HARVONI... 11 HAVRIX (PF)... 83 131
headache formula added str... 37 headache relief (asa-acet-caf)... 37 heartburn relief 24 hour (lansoprazole)... 80 HECTOROL... 72 HEMOCYTE... 117 hemorrhoidal... 77 heparin (porcine)... 55 heparin (porcine) in 5 % dex... 55 heparin (porcine) in nacl (pf)... 55 heparin(porcine) in 0.45% nacl... 55 HEPARIN(PORCINE) IN 0.45% NACL... 55 heparin, porcine (pf)... 55 HEPATAMINE 8%... 111 HERCEPTIN... 22 HEXALEN... 22 hi-cal plus vit d... 107 high potency iron... 117 HISTAFLEX... 37 HISTEX (TRIPROLIDINE)... 96 HISTEX DM... 96 HISTEX PD... 96 HISTEX PE... 97 honey bears... 118 honey bears with iron-zinc... 118 HUMALOG... 69 HUMALOG KWIKPEN... 69 HUMALOG MIX 50-50... 69 HUMALOG MIX 50-50 KWIKPEN.. 69 HUMALOG MIX 75-25... 69 HUMALOG MIX 75-25 KWIKPEN.. 69 HUMATROPE... 81 HUMIRA... 85 HUMIRA CROHN'S DIS START PCK 85 HUMIRA PED CROHN'S STARTER PK... 85 HUMIRA PEN... 85 HUMIRA PSORIASIS STARTER PACK... 85 HUMULIN 70/30... 69 HUMULIN 70/30 KWIKPEN... 69 HUMULIN N... 69 HUMULIN N KWIKPEN... 69 HUMULIN R... 69 HUMULIN R U-500... 69 hydralazine... 51 hydro skin... 62 hydrochlorothiazide... 51 hydrocodone-acetaminophen... 33 hydrocodone-chlorpheniramine.. 97 hydrocodone-homatropine... 97 hydrocodone-ibuprofen... 33 hydrocortisone... 62, 63, 67, 77 hydrocortisone valerate... 63 hydrocortisone-acetic acid... 67 hydrocortisone-min oil-wht pet... 63 hydromet... 97 hydromorphone... 33 hydroxychloroquine... 15 hydroxyurea... 22 I I.L.X. B-12... 118 ibandronate... 84 IBRANCE... 22 ibu-drops... 37 ibuprofen... 37 ibuprofen jr strength... 37 ICAPS... 118 ICAPS AREDS... 118 ICAPS MV... 118 icaps plus... 118 ICAR... 118 ICAR-C... 118 ICLUSIG... 23 idarubicin... 23 iferex 150... 118 IFEX... 23 ifosfamide... 23 ILARIS (PF)... 81 ILEVRO... 91 IMBRUVICA... 23 imipenem-cilastatin... 15 imipramine hcl... 43 imiquimod... 58 IMOVAX RABIES VACCINE (PF)... 83 INCRELEX... 64 indapamide... 51 INFANRIX (DTAP) (PF)... 83 infants gas relief... 77 infants ibu-drops... 37 infant's ibuprofen... 37 INLYTA... 23 INSULIN PEN NEEDLE... 69 INSULIN SYRINGE (DISP) U-100 0.3 ML... 69 INSULIN SYRINGE (DISP) U-100 1 ML... 69 INSULIN SYRINGE (DISP) U-100 1/2 ML... 69 INTEGRA... 118 INTELENCE... 11 intralipid... 111 INTRON A... 81 INTUNIV ER... 43 INVANZ... 15 INVEGA... 43 INVEGA SUSTENNA... 43 INVEGA TRINZA... 43 INVIRASE... 11 iophen c-nr... 97 iophen dm-nr... 97 iophen-nr... 97 IOSAT... 68 IPOL... 83 ipratropium bromide... 66, 103 ipratropium-albuterol... 103 irbesartan... 51 irbesartan-hydrochlorothiazide... 52 irinotecan... 23 iron... 118 iron (ferrous sulfate)... 118 iron high potency... 118 iron-vitamin c... 118 ISENTRESS... 11 ISOLYTE-P IN 5 % DEXTROSE... 111 isoniazid... 15 ISOPTO TEARS... 90 isosorbide dinitrate... 57 isosorbide mononitrate... 57 isradipine... 52 ISTODAX... 23 ITCH-X... 58 itraconazole... 9 ivermectin... 15 IXEMPRA... 23 IXIARO (PF)... 83 J JAKAFI... 23 jantoven... 55 JANUMET... 69 JANUMET XR... 70 JANUVIA... 70 JENTADUETO... 70 JEVTANA... 23 J-MAX... 97 J-TAN D PD... 97 J-TAN PD... 97 junel 1.5/30 (21)... 87 junel 1/20 (21)... 87 132
junel fe 1.5/30 (28)... 87 junel fe 1/20 (28)... 87 junior mapap... 37 K KADCYLA... 23 KALETRA... 11 KALYDECO... 103 kao-tin (bismuth subsalicylat)... 74 kao-tin (docusate calcium)... 77 kariva (28)... 87 kelnor 1/35 (28)... 87 KEPIVANCE... 19 ketoconazole... 9, 61 ketorolac... 91 KEYTRUDA... 23 KHEDEZLA... 43, 44 kidkare cough/cold... 97 KINERET... 85 klor-con 10... 107 klor-con 8... 107 klor-con m10... 107 klor-con m15... 107 klor-con m20... 107 KOMBIGLYZE XR... 70 konsyl (sugar)... 77 konsyl sugar-free... 77 K-TAB... 107 KUVAN... 72 L labetalol... 52 lactated ringers... 63, 107 lactulose... 77 lamivudine... 11 lamivudine-zidovudine... 11 lamotrigine... 28 LANOXIN... 54 lansoprazole... 80 LANTUS... 70 LANTUS SOLOSTAR... 70 latanoprost... 91 LATUDA... 44 laxative dietary supplement... 107 laxative maximum strength... 77 laxative-senna... 77 LAZANDA... 33 leflunomide... 85 LENVIMA... 23 lessina... 87 LETAIRIS... 103 letrozole... 23 leucovorin calcium... 19, 20 LEUKERAN... 23 LEUKINE... 81 leuprolide... 23 levalbuterol hcl... 103 LEVEMIR... 70 LEVEMIR FLEXTOUCH... 70 levetiracetam... 28 levetiracetam in nacl (iso-os)... 28 levobunolol... 90 levocarnitine... 64 levocarnitine (with sugar)... 64 levocetirizine... 97 levofloxacin... 18 levonest (28)... 87 levonorgestrel-ethinyl estrad... 88 levorphanol tartrate... 34 levothyroxine... 73 levoxyl... 73 LEXIVA... 11 LIALDA... 77 lidocaine... 60 LIDOCAINE... 60 lidocaine (pf)...49, 59, 60 lidocaine hcl... 60 lidocaine viscous... 60 lidocaine-prilocaine... 60 LIFE-PACK MEN'S... 118 LIFE-PACK WOMEN'S... 118 lindane... 63 linezolid... 15 linezolid-0.9% sodium chloride... 15 LINZESS... 77 liothyronine... 73 liquid antacid... 77 lisinopril... 52 lisinopril-hydrochlorothiazide... 52 lite coat aspirin... 37 lithium carbonate... 44 lithium citrate... 44 little animals... 118 little animals-iron... 118 LODRANE D... 97 lohist - d... 97 lohist peb dm... 97 lohist-dm... 97 LOMUSTINE... 23 loperamide... 74 loratadine... 97 lorata-dine d... 97 loratadine-d... 97 lorazepam... 44 LORTUSS DM... 97 lortuss ex... 97 LORTUSS LQ... 97 losartan... 52 losartan-hydrochlorothiazide... 52 LOTRONEX... 77 lovastatin... 56 low-ogestrel (28)... 88 loxapine succinate... 44 lubricating plus... 90 lubrifresh pm... 90 LUMIGAN... 91 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG.. 23 LUPRON DEPOT-PED... 23 lutera (28)... 88 LYNPARZA... 23 LYRICA... 29 lysiplex plus... 118 LYSODREN... 24 lyza... 86 M MACRODANTIN... 19 macuvite eye care... 118 mag-delay... 107 magnesium... 77 MAGNESIUM... 107 MAGNESIUM (OXIDE/AA CHELATE)... 107 MAGNESIUM AMINO ACID CHELATE... 107 MAGNESIUM GLUCONATE... 107 magnesium oxide... 107 magnesium sulfate... 107 magnesium sulfate in water... 107 MAGTAB... 77 MAJOR-PREP HEMORRHOIDAL... 77 mapap (acetaminophen)... 37 mapap arthritis pain... 37 mapap cold formula... 97 mapap extra strength... 37 mapap pm... 37 mapap sinus max strength (pe)... 97 maprotiline... 44 marlissa... 88 MARPLAN... 44 masanti double strength... 77 MATULANE... 24 133
maxiphen... 97 MAXIPHEN DM... 97 meclizine... 77 meclofenamate... 37 medi-bismuth... 74 MEDICATED BODY POWDER... 58 medi-natural... 77 medi-phedryl... 98 medi-profen... 37 medi-sleep... 44 medi-tabs... 37 medi-tussin dm diabetic... 98 medroxyprogesterone... 86 MEDTYCHOLL-B COMPLEX-LIVER118 mefloquine... 15 mega multi for women... 118 mega multiple/chelated mineral 118 mega multivitamin for men... 118 mega multivitamin with mineral 118 megestrol... 24 MEKINIST... 24 meloxicam... 37 melphalan hcl... 24 MENACTRA (PF)... 83 M-END DMX... 98 M-END MAX D... 98 MENEST... 86 MENOMUNE - A/C/Y/W-135... 83 MENOMUNE - A/C/Y/W-135 (PF). 83 men's 50+ daily formula... 118 men's multi-vitamin... 119 menstrual relief... 37 MENVEO A-C-Y-W-135-DIP (PF)... 83 MEPHYTON... 55 MEPRON... 15 mercaptopurine... 24 MERIBIN... 119 meropenem... 16 mesalamine... 77 mesalamine with cleansing wipe. 77 mesna... 20 MESNEX... 20 MESTINON... 32 MESTINON TIMESPAN... 32 metaproterenol... 103 metformin... 70 methadone... 34 methadone intensol... 34 methadose... 34 methazolamide... 91 methenamine hippurate... 19 methimazole... 68 methotrexate sodium... 24 methotrexate sodium (pf)... 24 methoxsalen rapid... 58 methyclothiazide... 52 METHYL SALICYLATE-ALOE VERA. 58 methylphenidate... 44 methylprednisolone acetate... 67 methylprednisolone sodium succ 67 methylprednisolone tablets... 67 metipranolol... 90 metoclopramide hcl... 78 metolazone... 52 metoprolol succinate... 52 metoprolol ta-hydrochlorothiaz.. 52 metoprolol tartrate... 52 metro i.v.... 16 metronidazole...16, 59, 86 metronidazole in nacl (iso-os)... 16 mexiletine... 49 MG-PLUS-PROTEIN... 107 mi-acid... 78 mi-acid gas relief... 78 miconazole 7... 86 miconazole nitrate... 61, 86 miconazole-3... 86 microgestin 1.5/30 (21)... 88 microgestin 1/20 (21)... 88 microgestin fe 1.5/30 (28)... 88 microgestin fe 1/20 (28)... 88 midodrine... 65 migraine formula... 37 MIGRANAL... 31 milk of magnesia... 78 milk of magnesia concentrated... 78 mineral oil laxative... 78 minocycline... 19 minoxidil... 52 mintox maximum strength... 78 mirtazapine... 44 misoprostol... 80 mitomycin... 24 mitoxantrone... 24 M-M-R II (PF)... 83 mobisyl... 58 modafinil... 44 moexipril... 52 moexipril-hydrochlorothiazide... 52 mometasone... 63 MONOCAL... 107 mono-linyah... 88 mononessa (28)... 88 montelukast... 103 morphine... 34, 35 MORPHINE... 34 morphine (pf)... 34 morphine concentrate... 34 moxifloxacin... 18 MOZOBIL... 81 mucaphed... 98 MUCINEX... 98 MUCINEX COLD & SINUS... 98 MUCINEX COLD-FLU & SORE THROAT... 98 MUCINEX COUGH MINI-MELTS... 98 mucinex d... 98 mucinex d maximum strength... 98 mucinex dm... 98 MUCINEX FAST-MAX COLD-FLU- THRT... 98 MUCINEX FAST-MAX COLD-SINUS 98 MUCINEX FAST-MAX CONGEST- COUGH... 98 MUCINEX FAST-MAX DAY-NITE CONG... 98 mucinex fast-max dm max... 98 MUCINEX FAST-MAX NITE COLD- FLU... 98 MUCINEX FAST-MAX SEVERE COLD... 98 MUCINEX FST-MX DY-NT CLD (DPH)... 98 MUCINEX MINI-MELTS... 98 MUCINEX SINUS-MAX D-N (DIPHEN)... 98 MUCINEX SINUS-MAX PRESSUR- PAIN... 98 MUCINEX SINUS-MAX SEV CONGESTN... 99 mucus relief... 99 mucus relief er... 99 mucus relief sinus... 99 MULTAQ... 49 MULTICHEW... 119 multi-day... 119 multi-delyn... 119 multi-delyn with iron... 119 multilex... 119 multilex-t&m... 119 134
multiple vitamin-minerals... 119 multiple vitamins... 119 multivitamin... 119 multi-vitamin hp/minerals... 119 multivitamin with iron... 119 multivitamin with minerals... 119 multi-vitamins with iron... 119 mupirocin ointment... 60 MURO 128... 90 MUSTARGEN... 24 my way... 88 MYCOBUTIN... 16 mycophenolate mofetil... 24 mycophenolate sodium... 24 myferon 150... 119 MYOZYME... 72 mytab gas... 78 mytab gas maximum strength... 78 my-vitalife... 119 myzilra... 88 N nabumetone... 38 nadolol... 52 nadolol-bendroflumethiazide... 52 nafcillin... 17 NAGLAZYME... 72 nalbuphine... 38 naloxone... 38 naltrexone... 38 NAMENDA... 32 NAMENDA TITRATION PAK... 32 NAMENDA XR... 32 naphazoline... 92 naproxen... 38 naproxen sodium... 38 nasal decongestant (oxymetazl).. 66 nasal decongestant (pe)... 99 nasal decongestant (pseudoeph). 99 nasal spray (oxymetazoline)... 66 nasal spray 12 hour... 66 nasal spray long acting... 66 NASONEX... 103 NASOPEN PE... 99 NATACYN... 89 nateglinide... 70 natural balance... 90 natural fiber laxative... 78 natural fiber laxative therapy... 78 nature's tears... 90 NEBUPENT... 16 necon 0.5/35 (28)... 88 necon 1/35 (28)... 88 necon 1/50 (28)... 88 necon 10/11 (28)... 88 necon 7/7/7 (28)... 88 NEEDLES, INSULIN DISP.,SAFETY.. 70 nefazodone... 44, 45 neomycin... 16 neomycin-bacitracin-poly-hc... 91 neomycin-bacitracin-polymyxin.. 89 neomycin-polymyxin b gu... 63 neomycin-polymyxin b-dexameth 92 neomycin-polymyxin-gramicidin. 89 neomycin-polymyxin-hc... 67, 92 neo-polycin... 89 neo-polycin hc... 92 NEPHROCAPS... 119 nephronex... 119 nephronex-sl... 119 NEPHRO-VITE... 119 NEULASTA... 81 NEUMEGA... 81 NEUPOGEN... 81 NEUPRO... 31 NEVANAC... 91 nevirapine... 11 NEXAVAR... 24 next choice one dose... 88 niacin... 56 NIACOR... 56 nicardipine... 52 NICODERM CQ... 66 nicorelief... 66 NICORETTE... 66 nicotine... 66 nicotine (polacrilex)... 66 NICOTROL NS... 66 nifedical xl... 52 nifedipine... 52 nighttime cough... 99 nighttime sleep aid (diphen)... 99 NILANDRON... 24 nimodipine... 52 NINJACOF... 99 NINJACOF-A... 99 NINJACOF-XG... 99 NIPENT... 24 NITE TIME COLD-FLU RELIEF... 99 nitro-bid... 57 nitrofurantoin macrocrystal... 19 nitroglycerin... 57 NITROSTAT... 57 NIVA-HIST DM... 99 NIVANEX DMX... 99 nohist-dm... 99 nohist-lq... 99 non-aspirin pain relief... 38 non-aspirin pm... 38 non-drowsy allergy... 99 nora-be... 86 NORDITROPIN FLEXPRO... 81 NORDITROPIN NORDIFLEX... 81 NOREL AD... 99 norethindrone (contraceptive)... 86 norethindrone acetate... 86 norgestimate-ethinyl estradiol... 88 NORMOSOL-M IN 5 % DEXTROSE111 NORMOSOL-R... 107 NORMOSOL-R IN 5 % DEXTROSE 107 NORMOSOL-R PH 7.4... 111 nortrel 0.5/35 (28)... 88 nortrel 1/35 (21)... 88 nortrel 1/35 (28)... 88 nortrel 7/7/7 (28)... 88 nortriptyline... 45 NORVIR... 11 nose drops... 66 NOVAFERRUM... 119 NOVAFERRUM 125... 119 NOVAFERRUM 50... 119 NOXAFIL... 9 nrs nasal relief... 66 NUEDEXTA... 32 NU-IRON... 119 NULOJIX... 24 NUTRICAP... 119 NUTRIVIT... 119 NUVARING... 86 nystatin... 9, 61 nystatin-triamcinolone... 61 nystop... 61 O ocella... 88 octreotide acetate... 24 ofloxacin... 18, 67, 89 ogestrel (28)... 88 olanzapine... 45 OLYSIO... 11 omega-3 acid ethyl esters... 56 omeprazole... 80 135
ONCASPAR... 24 once daily... 119 ONCOVITE... 119 ondansetron hcl... 78 ondansetron hcl (pf)... 78 ondansetron odt... 78 one daily... 120 one daily energy... 119 one daily essential... 120 one daily maximum... 120 ONE DAILY MEN'S 50+... 120 one daily multi-vit w-mineral... 120 one daily multivitamin... 120 one daily plus iron... 120 one daily with iron... 120 ONE DAILY WOMEN 50 PLUS... 120 one daily women's... 120 one-tablet-daily... 120 ONFI... 29 ONGLYZA... 70 opcicon one-step... 88 OPDIVO... 24 opium tincture... 74 opti-clear... 92 oral electrolytes... 107 oralyte... 108 ORAP... 45 ORAZINC... 108 ORFADIN... 65 organ-i nr... 99 ORTHO EVRA... 86 OS-CAL 500 + D3... 108 OSTEO-PORETICAL... 108 oxacillin... 17 oxaliplatin... 24 oxandrolone... 72 oxaprozin... 38 oxcarbazepine... 29 OXSORALEN... 58 OXTELLAR XR... 29 oxybutynin chloride... 104 oxycodone... 35 oxycodone-acetaminophen... 35 oxycodone-aspirin... 35 oysco 500/d... 108 oysco d... 108 oysco-500... 108 oyst-cal-500... 108 oyster shell + d3... 108 oyster shell calcium... 108 oyster shell calcium & mag... 108 oyster shell calcium 500... 108 oyster shell calcium with d... 120 oyster shell calcium-vit d3. 108, 120 P pacerone... 49 paclitaxel... 24 pain & fever... 38 pain relief... 38 PAIN RELIEF SINUS PE... 99 pain reliever... 38 pain reliever extra strength... 38 pain reliever pm ex-strength... 38 pamidronate... 72 PANRETIN... 58 pantoprazole... 80 pantothenic acid... 120 paricalcitol... 72 paroex oral rinse... 66 paromomycin... 16 paroxetine hcl... 45 PASER... 16 PATADAY... 91 PATANOL... 91 PAXIL... 45 PAZEO... 91 pedialyte... 108 PEDIALYTE ADVANCED CARE... 108 pedialyte freezer pops... 108 pedialyte singles... 108 PEDIATEX TDM... 99 pediatric cough & cold... 99 pediatric electrolyte... 108 pediatric freezer pops... 108 PEDVAX HIB (PF)... 83 peg 3350-electrolytes... 78 peg3350... 78 peg-3350 with flavor packs... 78 PEGANONE... 29 PEGASYS... 81 PEGASYS PROCLICK... 81 peg-electrolyte soln... 78 PEGINTRON... 81 PEGINTRON REDIPEN... 81 PENICILLIN G POT IN DEXTROSE.. 17 penicillin g potassium... 17 penicillin g procaine... 17 penicillin g sodium... 18 penicillin v potassium... 18 PENTAM... 16 PENTASA... 78 pentoxifylline... 55 peptic relief... 74 PERFOROMIST... 103 PERIDIN-C... 120 perindopril erbumine... 52 periogard... 66 PERJETA... 24 permethrin... 63 perphenazine... 45 phenelzine... 45 phenobarbital... 29 phenylhistine dh... 99 phenytoin... 29 phenytoin sodium... 30 phenytoin sodium extended... 30 PHOSPHOLINE IODIDE... 90 pilocarpine hcl... 65 pindolol... 53 pink bismuth... 74 pink bismuth maximum strength. 74 pioglitazone... 71 pioglitazone-glimepiride... 71 pioglitazone-metformin... 71 piperacillin-tazobactam... 18 piroxicam... 38 PLAN B ONE-STEP... 88 PLASMA-LYTE 148... 111 PLASMA-LYTE-56 IN 5 % DEXTROSE... 111 podofilox... 58 POLY HIST PD... 99 polybase... 65 polycin... 89 polyethylene glycol 3350... 79 POLY-HIST DM (THONZYLAMINE). 99 poly-iron... 120 polymyxin b sulf-trimethoprim... 89 polysaccharide iron complex... 120 poly-tussin... 99 poly-tussin d... 99 POLY-VENT DM... 100 POLY-VENT IR... 100 poly-vita... 120 poly-vita (iron)... 120 poly-vitamin... 120 poly-vitamin with iron... 120 polyvitamin/iron... 120 poly-vitamins... 120 POMALYST... 25 136
portia... 89 potassium chlorid-d5-0.45%nacl 108 potassium chloride... 109 potassium chloride in 0.9%nacl. 108 potassium chloride in 5 % dex... 108 potassium chloride in lr-d5... 108 potassium chloride-0.45 % nacl. 109 potassium chloride-d5-0.2%nacl 109 potassium chloride-d5-0.3%nacl 109 potassium chloride-d5-0.9%nacl 109 potassium citrate... 105 POTIGA... 30 povidone-iodine... 60 PRADAXA... 55 pramipexole... 31 PRANDIMET... 71 pravastatin... 56 prazosin... 53 prednisolone... 67 prednisolone acetate... 92 prednisolone sodium phosphate68, 92 prednisone... 68 prednisone intensol... 68 PREMARIN... 86 PRENATAL VITAMIN ORAL TABLET120 prevalite... 56 PREVENT... 120 previfem... 89 PREZCOBIX... 11 PREZISTA... 11 PRIFTIN... 16 PRILOSEC OTC... 80 PRIMAQUINE... 16 primidone... 30 PRISTIQ... 45, 46 PRO FE... 120 PROAIR HFA... 103 probenecid... 84 procainamide... 49 PRO-CHLO... 100 prochlorperazine edisylate... 79 prochlorperazine maleate... 79 prochlorperazine maleate rectal.. 79 PRO-CLEAR AC... 100 PROCRIT... 81 procto-pak... 79 proctosol hc... 79 proctozone-hc... 79 PROFERRIN ES... 120 progesterone micronized... 86 PROGLYCEM... 71 PROGRAF... 25 PROLEUKIN... 82 PROLIA... 85 PROMACTA... 55 promethazine... 100 promethazine vc-codeine... 100 promethazine-codeine... 100 promethazine-dm... 100 promethegan... 100 propafenone... 49 propranolol... 53 propranolol-hydrochlorothiazid.. 53 PROPYLENE GLYCOL... 58 propylthiouracil... 68 PROQUAD (PF)... 83 prosight... 120 PROTECT IRON... 121 PROTOPIC... 58 protriptyline... 46 pseudoephedrine hcl... 100 PULMOZYME... 103 puralube... 91 PURIXAN... 25 pyrazinamide... 16 pyridostigmine bromide... 32 pyridoxine... 121 PYRILAMINE-PHENYLEPHRINE... 100 Q q-dryl... 100 q-pap... 38 q-pap extra strength... 38 q-tussin... 100 q-tussin dm... 100 QUADRACEL (PF)... 83 quenalin... 100 quetiapine... 46 quinapril... 53 quinapril-hydrochlorothiazide... 53 quinidine sulfate tablets... 49 QVAR... 104 R RABANO YODADO... 121 RABAVERT (PF)... 83 raloxifene... 85 ramipril... 53 RANEXA... 57 ranitidine hcl... 80 RAPAMUNE... 25 REBIF (WITH ALBUMIN)... 82 REBIF REBIDOSE... 82 REBIF TITRATION PACK... 82 reclipsen (28)... 89 RECOMBIVAX HB (PF)... 83 REFRESH CELLUVISC... 91 REFRESH LACRI-LUBE... 91 REFRESH PLUS... 91 reguloid... 79 RELENZA DISKHALER... 11 RELISTOR... 79 REMICADE... 79 RENAGEL... 65 rena-vite... 121 RENVELA... 65 RESCON... 100 RESCON-DM... 100 rescon-gg... 100 RESCRIPTOR... 11 RESPAIRE-30... 100 RESTASIS... 91 restfully sleep... 100 RETROVIR... 11 REVLIMID... 25 REYATAZ... 11 REZIRA... 100 ribasphere... 11 ribavirin... 11 riboflavin (vitamin b2)... 121 RIDAURA... 85 rifabutin... 16 rifampin... 16 RIFATER... 16 riluzole... 65 rimantadine... 11 ringers... 63, 109 risacal-d... 121 RISPERDAL CONSTA... 46 risperidone... 46 RITUXAN... 25 rivastigmine tartrate... 32 rizatriptan... 31 robafen... 100 robafen cf... 100 robafen dm... 100 robafen dm cough... 100 ropinirole... 31 rosadan... 59 ROTARIX... 83 ROTATEQ VACCINE... 83 ROXICET... 35 137
ROZEREM... 46 RU-HIST D... 100 RULOX... 79 RYMED (DEXCHLORPHENIRAMINE-PE)101 rynex dm... 101 rynex pe... 101 rynex pse... 101 S S2 RACEPINEPHRINE... 104 SABRIL... 30 sani-supp (adult)... 79 sani-supp (infant)... 79 SANTYL... 63 SAPHRIS (BLACK CHERRY)... 46, 47 SARNA ANTI-ITCH... 58 SAVELLA... 85 selegiline hcl... 31 selenium... 109 selenium sulfide... 57 SELZENTRY... 11 senexon... 79 senna... 79 senna lax... 79 senna plus... 79 senna with docusate sodium... 79 senna-gen... 79 SENNALAX-S... 79 senna-s... 79 SENSIPAR... 72 sentry... 121 sentry senior... 121 SEREVENT DISKUS... 104 SEROQUEL XR... 47 sertraline... 47 SIDEROL... 121 silace... 79 siladryl sa... 101 silapap... 38 sildenafil... 104 silphen cough... 101 siltussin dm das... 101 siltussin sa... 101 siltussin-dm... 101 silver sulfadiazine... 57 simethicone... 79 SIMPONI... 85 SIMULECT... 25 simvastatin... 56 sirolimus... 25 sleep aid (doxylamine)... 47 slo-niacin... 57 SLO-NIACIN... 56 slow release iron... 121 SLOW-MAG... 109 sodium bicarbonate... 79 sodium chloride... 65, 91, 109 sodium chloride 0.45 %... 109 sodium chloride 0.9 %... 65 sodium chloride 3 %... 109 sodium chloride 5 %... 109 sodium fluoride... 121 sodium polystyrene (sorb free)... 65 sodium polystyrene sulfonate... 65 SODIUM POLYSTYRENE SULFONATE... 65 soft chews calcium... 121 SOLTAMOX... 25 SOMATULINE DEPOT... 25 SOMAVERT... 73 SORE THROAT & COUGH LOZENGE... 101 sorine... 49 sotalol... 49 sotalol af... 49 SOVALDI... 11 spectravite adult 50+... 121 spectravite advanced formula... 121 spectravite men's... 121 spectravite performance... 66 spectravite senior... 121 spectravite ultra women... 121 spectravite ultra women's sr... 121 SPIRIVA RESPIMAT... 104 SPIRIVA WITH HANDIHALER... 104 spironolactone... 53 spironolacton-hydrochlorothiaz.. 53 sprintec (28)... 89 SPRYCEL... 25 sps... 65 ssd... 57 STAHIST AD... 101 stavudine... 12 STIMATE... 73 STIVARGA... 25 stomach relief... 74 stomach relief max strength... 74 stool softener... 79 stool softener-laxative... 80 STRATTERA... 47 strawberry c... 121 STREPTOMYCIN... 16 stress formula... 121 stress formula 600 c... 121 stress formula advanced... 121 STRESS FORMULA ENERGY... 121 stress formula with iron... 121 stress formula with iron(sulf)... 121 stress formula with zinc... 121 STRIBILD... 12 STROMECTOL... 16 STROVITE FORTE... 122 STROVITE ONE... 122 SUBOXONE... 38 SUBSYS... 35 sucralfate... 80 sudogest... 101 sudogest 12-hour... 101 sudogest pe... 101 sudogest sinus & allergy... 101 sulfacetamide sodium... 92 sulfacetamide sodium (acne)... 60 sulfacetamide-prednisolone... 92 sulfadiazine... 18 sulfamethoxazole-trimethoprim.. 18 SULFAMYLON... 60 sulfasalazine... 80 sulfazine... 80 sulfazine ec... 80 sulindac... 38 sumatriptan succinate... 31 SUPER B COMPLEX + C... 122 super b complex-vitamin c... 122 super b/c... 122 super b-50 complex... 122 super calcium... 109 super multiple... 122 super multivitamin... 122 super thera vite m... 122 superplex-t... 122 SUPERVITE (EC)... 122 suphedrine pe... 101 support... 122 SUPPORT-500... 122 SURMONTIL... 47 SUSPENDOL-S... 65 SUSTIVA... 12 SUTENT... 25 syeda... 89 SYLATRON... 82 138
SYMLINPEN 120... 71 SYMLINPEN 60... 71 SYNAGIS... 12 SYNAREL... 73 SYNERCID... 16 SYNRIBO... 25 SYNTHROID... 73 SYPRINE... 65 T tab a vite... 122 tab-a-vite... 122 tab-a-vite/iron... 122 tab-a-vite-minerals... 122 TABLOID... 25 tacrolimus... 25, 58 TAFINLAR... 25 TAMIFLU... 12 tamoxifen... 25 tamsulosin... 105 TANDEM DUAL ACTION... 122 TANZEUM... 71 TARCEVA... 25 TARGRETIN... 25 TASIGNA... 25 TASMAR... 31 TAZORAC... 59 taztia xt... 53 TECFIDERA... 32 TEFLARO... 14 TEKTURNA... 53 TEKTURNA HCT... 53 telmisartan... 53 telmisartan-amlodipine... 53 telmisartan-hydrochlorothiazid... 53 temazepam... 47 terazosin... 53 terbinafine hcl... 9, 61 terbutaline... 104 terconazole... 86 TESTIM... 73 testosterone cypionate... 73 testosterone enanthate... 73 tetanus toxoid,adsorbed (pf)... 83 TETANUS,DIPHTHERIA TOX PED(PF)... 83 TETANUS-DIPHTHERIA TOXOIDS- TD... 83 tetracycline... 19 THALOMID... 25 theophylline... 104 thera... 122 THERA-GESIC... 58 thera-m... 122 therapeutic liquid... 122 therapeutic m + beta-carotene.. 122 therapeutic-m... 122 therapeutic-m vitamin/minerals 122 thera-tabs... 122 theratrum complete with lutein 122 thiamine hcl... 122 thioridazine... 47 thiothixene... 47 THYMOGLOBULIN... 83 THYROSAFE... 68 tiagabine... 30 TICE BCG... 84 TIKOSYN... 49 timolol maleate... 53, 90 TIMOPTIC OCUDOSE (PF)... 90 tioconazole-1... 86 TIVICAY... 12 tizanidine... 32 tobramycin... 90 tobramycin in 0.225 % nacl... 16 tobramycin sulfate... 16 tobramycin-dexamethasone... 92 tolazamide... 71 tolbutamide... 71 tolcapone... 31 tolmetin... 38 tolnaftate... 61 tolterodine... 104 topiramate... 30 toposar... 25 topotecan... 26 TORISEL... 26 torsemide... 53 total b/c... 122 totalday multiple... 123 TOUJEO SOLOSTAR... 71 TPN ELECTROLYTES... 109 TRACLEER... 104 TRADJENTA... 71 tramadol... 39 tramadol-acetaminophen... 39 trandolapril... 53 tranexamic acid... 55, 86 tranylcypromine... 47 travasol 10 %... 111 TRAVATAN Z... 91 travel sickness... 80 travel sickness (meclizine)... 80 travoprost (benzalkonium)... 91 trazodone... 47 TREANDA... 26 TRECATOR... 16 TRELSTAR... 26 TRELSTAR DEPOT... 26 TRELSTAR LA... 26 tretinoin... 59 tretinoin (chemotherapy)... 26 TRETIN-X CREAM KIT... 59 TREXALL... 26 triamcinolone acetonide.. 63, 67, 68 triamterene-hydrochlorothiazid... 53 trianex... 63 TRIBENZOR... 53 triderm... 63 trifluoperazine... 47 trifluridine... 90 trimethoprim... 19 triple antibiotic... 60 triple antibiotic plus... 60 tri-previfem (28)... 89 TRISENOX... 26 tri-sprintec (28)... 89 TRIUMEQ... 12 TRI-VI-SOL... 123 tri-vita... 123 tri-vitamin... 123 trivora (28)... 89 trixaicin... 58 TRIXAICIN HP... 58 TRIZIVIR... 12 TROPHAMINE 10 %... 111 TROPHAMINE 6%... 111 tropicamide... 90 trospium... 104 TRULICITY... 71 TRUMENBA... 84 TRUVADA... 12 tussin... 101 tussin dm... 101 tussin expectorant... 101 TUSSIONEX PENNKINETIC ER... 101 TWINRIX (PF)... 84 TYBOST... 12 TYGACIL... 16 TYKERB... 26 TYPHIM VI... 84 139
TYSABRI... 32 TYZEKA... 12 TYZINE... 67 U U-CORT... 58 ULORIC... 84 ultra b-100 complex... 123 unithroid... 73 ursodiol... 80 UVADEX... 58 V VAGIFEM... 86 valacyclovir... 12 VALCHLOR... 59 VALCYTE... 12 valganciclovir... 12 valproate sodium... 30 valproic acid... 30 valproic acid (as sodium salt)... 30 valsartan... 53 valsartan-hydrochlorothiazide... 54 VANACOF... 101 VANACOF DM... 101 VANACOF-8... 101 VANAHIST PD... 101 vancomycin... 19 VANCOMYCIN... 19 VANCOMYCIN IN D5W... 19 VANCOMYCIN IN DEXTROSE ISO- OSM... 19 VAQTA (PF)... 84 VARIVAX (PF)... 84 VARIZIG... 84 v-c forte... 123 VECAMYL... 57 VECTIBIX... 26 VELCADE... 26 velivet triphasic regimen (28)... 89 venlafaxine... 47, 48 VENLAFAXINE... 48 VENTAVIS... 104 verapamil... 54 VERSACLOZ... 48 vic-forte... 123 VICTOZA 2-PAK... 71 VICTOZA 3-PAK... 71 VIDEX 2 GRAM PEDIATRIC... 12 VIDEX 4 GRAM PEDIATRIC... 12 VIEKIRA PAK... 12 VIGAMOX... 90 VIIBRYD... 48 VIMPAT... 30 vinblastine... 26 vincasar pfs... 26 vincristine... 26 vinorelbine... 26 viorele (28)... 89 VIRACEPT... 12 VIRAMUNE XR... 12 VIRAZOLE... 12 VIREAD... 12 virtussin ac... 101 VITA-BEE WITH C... 123 vitamin a... 123 vitamin b complex... 123 vitamin b complex with c... 123 vitamin b-1... 123 vitamin b-100 complex... 123 vitamin b-12... 123 vitamin b-2... 123 vitamin b-6... 123 vitamin c... 123, 124 VITAMIN C... 123 vitamin c cough drops... 123 vitamin c drops... 123 vitamin c with rose hips... 124 vitamin d2... 124 vitamin e... 124 VITAMIN E... 124 vitamin e (dl, acetate)... 124 vitamin e acetate... 124 vitamin e mixed... 124 vitamin k1... 55 vitamins & minerals... 124 vitamins a and d... 124 vitamins b complex... 124 vitamins for hair... 124 VITEKTA... 12 vits a and d-white pet-lanolin... 59 VITUZ... 101 VOLTAREN GEL... 39 voriconazole... 9 VOTRIENT... 26 W warfarin... 55 water for irrigation, sterile... 65 wee care... 124 WELCHOL... 57 white petrolatum... 59 WHOLE SOURCE MULTI- VITAMINS... 124 women's daily formula... 124 X XALKORI... 26 XARELTO... 56 XENAZINE... 32 XGEVA... 20 XIFAXAN... 16 XOLAIR... 104 XTANDI... 26 XULANE... 87 XYREM... 48 Y YERVOY... 26 YF-VAX (PF)... 84 Z zafirlukast... 104 zaleplon... 48 ZALTRAP... 26 ZANOSAR... 26 zarah... 89 ZAVESCA... 73 zazole... 87 zeasorb (miconazole)... 61 ZEGERID OTC... 80 ZELBORAF... 26 ZEMAIRA... 65 ZEMPLAR... 73 zenchent (28)... 89 zenzedi... 48 ZETIA... 57 ZIAGEN... 12 zidovudine... 12 zinc... 110 ZINC (WITH A & C) LOZENGES... 124 zinc gluconate... 110 zinc oxide... 59 zinc sulfate... 110 zinc sulfate-vitamin c... 124 ZINC-15... 110 zinc-220... 110 ziprasidone hcl... 48 ZIRGAN... 90 zoledronic acid... 73 ZOLINZA... 26 zolmitriptan... 31 zolpidem... 48 ZOMETA... 73 ZOMIG... 31 140
ZONATUSS... 101 zonisamide... 30 zoo chews... 124 zoo friends... 124 zoo friends complete... 124 zoo friends original... 124 ZORTRESS... 26 ZOSTAVAX (PF)... 84 zovia 1/35e (28)... 89 zovia 1/50e (28)... 89 ZUTRIPRO... 101 ZYDELIG... 26 ZYKADIA... 26 ZYPREXA RELPREVV... 49 ZYTIGA... 26 ZYVOX... 16, 17 141
Have questions? Call us toll free at 1-855-878-1784 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. Or visit www.myamerigroup.com/txmmp. Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or co-pays may change on January 1 of each year. Limitations, co-pays and restrictions may apply. For more information, call Amerigroup STAR+PLUS MMP Member Services or read the Amerigroup STAR+PLUS MMP Member Handbook. Co-pays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can get this information for free in other languages. Call us at 1-855-878-1784 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. local time. The call is free. Usted puede obtener esta información gratuitamente en otros idiomas. Llame al 1-855-878-1784 (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratuita. You can get this information for free in other formats, such as large print, braille, or audio. Call us at 1-855-878-1784 (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. local time. The call is free. Y0005_H8786_15_23464_R CMS Approved 02/26/2015 Formulary ID: 15336 Version: 12 Issued 09/01/2015