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Express Scripts Medicare (PDP)

2019 Formulary

(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION

ABOUT THE DRUGS WE COVER IN THIS PLAN

Formulary ID Number: 19155, Version 13

This formulary was updated on 7/25/2019. For more recent information or other questions,
please contact Express Scripts Medicare® (PDP) Customer Service at 1.800.758.4574;
New York State residents: 1.800.758.4570 or, for TTY users, 1.800.716.3231, 24 hours a day,
7 days a week, or visit express-scripts.com.

Note to existing members: This formulary has changed since last year. Please review this document
to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Medco Containment Life
Insurance Company and Medco Containment Insurance Company of New York (for members located in
New York State only). When it refers to “plan” or “our plan,” it means Express Scripts Medicare.

This document includes a list of the drugs (formulary) for our plan, which is current as of
July 25, 2019. For an updated formulary, please contact us. Our contact information, along
with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network and/or copayments/coinsurance may change on January 1, 2020, and from
time to time during the year.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame
al 1.800.758.4574; para residentes del estado de New York: 1.800.758.4570 (TTY: 1.800.716.3231).

Y0046_F00SNR9A_C CRP1804_0167 F00SNR9CW1

What is the Express Scripts Medicare Formulary?
A formulary is a list of covered drugs selected by Express Scripts Medicare in consultation with a team
of healthcare providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program. Express Scripts Medicare will generally cover the drugs listed in our
formulary as long as the drug is medically necessary, the prescription is filled at an Express Scripts
Medicare network pharmacy, and other plan rules are followed. For more information on how to fill
your prescriptions, please review your Evidence of Coverage.

Can the formulary (drug list) change?

Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new,
less expensive generic drug becomes available, when new information about the safety or effectiveness of
a drug is released, or the drug is removed from the market. (See bullets below for more information on
changes that affect members currently taking the drug.). Other types of formulary changes, such as
removing a drug from our formulary, will not affect members who are currently taking the drug. It will
remain available at the same cost-sharing for those members taking it for the remainder of the coverage
year. Below are changes to the drug list that will also affect members currently taking a drug:
• New generic drugs. We may immediately remove a brand-name drug on our Drug List if we are
replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and
with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to
keep the brand-name drug on our Drug List, but immediately move it to a different cost-sharing
tier or add new restrictions. If you are currently taking that brand-name drug, we may not tell
you in advance before we make that change, but we will later provide you with information
about the specific change(s) we have made.
o If we make such a change, you or your prescriber can ask us to make an exception and
continue to cover the brand-name drug for you. The notice we provide you will also
include information on the steps you may take to request an exception, and you can also
find information in the section below entitled “How do I request an exception to the
Express Scripts Medicare Formulary?”

• Drugs removed from the market. If the Food and Drug Administration deems a drug on our
formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will
immediately remove the drug from our formulary and provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. For
instance, we may add a generic drug that is not new to market to replace a brand-name drug
currently on the formulary or add new restrictions to the brand-name drug or move it to a different
cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs
from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a
drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change
at least 30 days before the change becomes effective, or at the time the member requests a refill of
the drug, at which time the member will receive a 30-day supply of the drug.

The enclosed formulary is current as of July 25, 2019. To get updated information about the drugs
covered by Express Scripts Medicare, please contact us. Our contact information appears on the
front and back cover pages. If there are additional changes made to the formulary that affect you
and are not mentioned above, you will be notified in writing of these changes within a reasonable
period of time from when the changes are made.
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How do I use the formulary?
There are two ways to find your drug within the formulary:

Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending
on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category “Cardiovascular, Hypertension/Lipids.” If you know what
your drug is used for, look for the category name in the list that begins on page 1. Then look under
the category name for your drug.

Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
begins on page 81. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and
find your drug. Next to your drug, you will see the page number where you can find coverage
information. Turn to the page listed in the Index and find the name of your drug in the first column
of the list.

What are generic drugs?

Express Scripts Medicare covers both brand-name drugs and generic drugs. A generic drug is approved
by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs
cost less than brand-name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:

• Prior Authorization: Express Scripts Medicare requires you or your physician to get

prior authorization for certain drugs. This means that you will need to get approval from

Express Scripts Medicare before you fill your prescriptions. If you don’t get approval,

Express Scripts Medicare may not cover the drug.

• Quantity Limits: For certain drugs, Express Scripts Medicare limits the amount of the drug
that Express Scripts Medicare will cover. For example, Express Scripts Medicare provides
two inhalers (17 grams) for a 1-month supply per prescription for PROAIR® HFA. This may be
in addition to a standard 1-month or 3-month supply.

• Step Therapy: In some cases, Express Scripts Medicare 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, Express Scripts Medicare may not cover
Drug B unless you try Drug A first. If Drug A does not work for you, Express Scripts Medicare
will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 1. You can also get more information about the restrictions applied to specific covered
drugs by visiting our website. We have posted online documents that explain our prior authorization and
step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with
the date we last updated the formulary, appears on the front and back cover pages.

iii

You can ask Express Scripts Medicare to make an exception to these restrictions or limits or for a list
of other, similar drugs that may treat your health condition. See the section “How do I request an
exception to the Express Scripts Medicare Formulary?” on page iv for information about how to
request an exception.

What if my drug is not on the formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact
Customer Service and ask if your drug is covered.

If you learn that Express Scripts Medicare does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Express Scripts
Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a
similar drug that is covered by Express Scripts Medicare.

• You can ask Express Scripts Medicare to make an exception and cover your drug. See below for
information about how to request an exception.

How do I request an exception to the Express Scripts Medicare Formulary?

You can ask Express Scripts Medicare to make an exception to our coverage rules. There are several
types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide
the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the
specialty tier. If approved, this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, Express Scripts Medicare limits the amount of the drug that we will cover. If your drug
has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Express Scripts Medicare will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not
be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you request a formulary, tiering or utilization restriction exception, you
should submit a statement from your prescriber or physician supporting your request. Generally, we
must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request
an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by
waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision
no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

iv

What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example,
you may need a prior authorization from us before you can fill your prescription. You should talk to
your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary
exception so that we will cover the drug you take. While you talk to your doctor to determine the right
course of action for you, we may cover your drug in certain cases during the first 90 days you are a
member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to
provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay
for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary, or if
your ability to get your drugs is limited but you are past the first 90 days of membership in our plan, we
will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

Other times when we will cover a temporary 30-day transition supply (or less, if you have a prescription
written for fewer days) include:
• When you leave a long-term care facility
• When you are discharged from a hospital
• When you leave a skilled nursing facility
• When you cancel hospice care
• When you are discharged from a psychiatric hospital with a medication regimen that is

highly individualized

If you are entering a long-term care facility, we will cover a 31-day transition supply.

The plan will send you a letter within 3 business days of your filling a temporary transition supply,
notifying you that this was a temporary supply and explaining your options.

For more information

For more detailed information about your Express Scripts Medicare prescription drug coverage,
please review your Evidence of Coverage and other plan materials.

If you have questions about Express Scripts Medicare, please contact us. Our contact information,
along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at
1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users should call
1.877.486.2048. Or, visit http://www.medicare.gov.

Express Scripts Medicare’s Formulary

The formulary that begins on page 1 provides coverage information about the drugs covered by
Express Scripts Medicare. If you have trouble finding your drug in the list, turn to the Index that
begins on page 81.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., JANUMET®)
and generic drugs are listed in lowercase italics (e.g., omeprazole).

The information in the Requirements/Limits column tells you if Express Scripts Medicare has any
special requirements for coverage of your drug.

B/D PA: Part B or Part D Prior Authorization. This drug may be covered under Medicare Part B or
Part D depending upon the circumstances. Information may need to be submitted describing the use and
setting of the drug to make the determination.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information, consult your Pharmacy Directory or call Customer Service at 1.800.758.4574 (New York
State residents: 1.800.758.4570), 24 hours a day, 7 days a week. TTY users, call 1.800.716.3231.

MO: Mail-Order Drug. This prescription drug is available through our home delivery pharmacy service,
as well as through our retail network pharmacies. Consider using mail order for your long-term
medications (the kind you take regularly, such as high blood pressure medications). Retail network
pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).

PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain
drugs. This means that you will need to get approval before you fill your prescription. If you don’t get
approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the plan requires you to first try a certain drug 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.

Your costs
The amount you pay for a covered drug will depend on:
• Your coverage stage. Express Scripts Medicare has different stages of coverage. In each stage,
the amount you pay for a drug may change.
• The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a
different copayment or coinsurance amount. The “Drug Tiers” chart on the following page explains
what types of drugs are included in each tier and shows how costs may change with each tier.

The Evidence of Coverage has more information about the plan’s coverage stages and lists the
copayment and coinsurance amounts for each tier.

vi

If you qualify for Extra Help
If you qualify for Extra Help for your prescription drugs, your copayments and coinsurance may be
lower. Please refer to the “Evidence of Coverage Rider for People Who Get Extra Help Paying for
Prescription Drugs (LIS Rider)” to find out what your costs are or you may contact Customer Service
for more information.

Drug Tiers
Tier Description
Tier 1: This tier includes commonly prescribed generic drugs. Use Tier 1 drugs for the
Preferred lowest copayments.
Generic Drugs
Tier 2: This tier includes generic drugs. Use Tier 2 drugs to keep your copayments low.
Generic Drugs
Tier 3: This tier includes preferred brand-name drugs as well as some generic drugs.
Preferred Drugs in this tier will generally have lower copayments than non-preferred drugs.
Brand Drugs
Tier 4: This tier includes non-preferred brand-name drugs as well as some generic
Non-Preferred drugs. There may be lower-cost alternatives for you. Ask your doctor if
Drugs switching to a lower-cost generic or preferred brand drug may be right for you.
Drugs in this tier are limited to up to a 30-day supply from either your local retail
network pharmacy or from our network home delivery service.
Tier 5: This tier includes very high-cost brand-name and generic drugs. To learn more
Specialty about medications in this tier, you may contact a pharmacist at the numbers
Tier Drugs listed on the front and back covers of this document. Drugs in this tier are limited
to up to a 30-day supply from either your local retail network pharmacy or from
our network home delivery service.

Key
The abbreviations listed below may appear on the following pages in the Requirements/Limits column
that tells you if there are any special requirements for coverage of your drug. You can find information
on what the symbols and abbreviations on these tables mean by going to page vi.
B/D PA: Part B or Part D Prior Authorization
LA: Limited Availability
MO: Mail-Order Drug
PA: Prior Authorization
QL: Quantity Limit
ST: Step Therapy

vii

 Table of Contents
ANTI - INFECTIVES........................................ 3

ANTINEOPLASTIC /

IMMUNOSUPPRESSANT DRUGS...............15

AUTONOMIC / CNS DRUGS,

NEUROLOGY / PSYCH................................. 26

CARDIOVASCULAR, HYPERTENSION /

LIPIDS............................................................. 40

DERMATOLOGICALS/TOPICAL

THERAPY ........................................................47

DIAGNOSTICS / MISCELLANEOUS

AGENTS .......................................................... 51

EAR, NOSE / THROAT MEDICATIONS......53

ENDOCRINE/DIABETES...............................54

GASTROENTEROLOGY............................... 60

IMMUNOLOGY, VACCINES /

BIOTECHNOLOGY....................................... 63

MUSCULOSKELETAL /

RHEUMATOLOGY ........................................ 65

OBSTETRICS / GYNECOLOGY................... 67

OPHTHALMOLOGY..................................... 69

RESPIRATORY AND ALLERGY.................. 71

UROLOGICALS..............................................75

VITAMINS, HEMATINICS /

ELECTROLYTES........................................... 76

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
ANTI - itraconazole oral 3 MO; QL
capsule (120 per 30
INFECTIVES
days)
ANTIFUNGAL itraconazole oral 3 MO
AGENTS solution
ABELCET 5 B/D PA; ketoconazole oral 2 MO
MO MYCAMINE 5 MO
AMBISOME 5 B/D PA; NOXAFIL ORAL 5 MO; QL
MO SUSPENSION (840 per 30
amphotericin b 4 B/D PA; days)
MO NOXAFIL ORAL 5 MO; QL
caspofungin 5 B/D PA TABLET,DELAY (93 per 28
clotrimazole mucous 3 MO ED RELEASE days)
membrane (DR/EC)
CRESEMBA 5 nystatin oral 2 MO
INTRAVENOUS suspension
CRESEMBA 5 MO nystatin oral tablet 2 MO
ORAL SPORANOX 5 MO
fluconazole in 4 ORAL
dextrose(iso-o) SOLUTION
fluconazole in nacl 4 MO terbinafine hcl oral 2 MO
(iso-osm) voriconazole 4 MO
intravenous intravenous
piggyback 200 voriconazole oral 5 MO
mg/100 ml
ANTIVIRALS
fluconazole in nacl 4
(iso-osm) abacavir oral 3 MO; QL
intravenous solution (900 per 30
piggyback 400 days)
mg/200 ml abacavir oral tablet 3 MO; QL
fluconazole oral 3 MO (60 per 30
suspension for days)
reconstitution abacavir-lamivudine 5 MO; QL
fluconazole oral 2 MO (30 per 30
tablet days)
flucytosine 5 MO abacavir- 5 MO; QL
lamivudine- (60 per 30
griseofulvin 4 MO
zidovudine days)
microsize
acyclovir oral 2 MO
griseofulvin 4 MO
capsule
ultramicrosize

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
acyclovir oral 3 MO CRIXIVAN 4 MO; QL
suspension 200 mg/5 ORAL CAPSULE (90 per 30
ml 200 MG days)
acyclovir oral tablet 2 MO CRIXIVAN 4 MO; QL
acyclovir sodium 4 B/D PA ORAL CAPSULE (180 per 30
intravenous recon 400 MG days)
soln 500 mg DELSTRIGO 4 MO
acyclovir sodium 4 B/D PA; DESCOVY 5 MO; QL
intravenous solution MO (30 per 30
amantadine hcl oral 4 MO days)
capsule didanosine oral 3 QL (30 per
amantadine hcl oral 2 MO capsule,delayed 30 days)
solution release(dr/ec) 200
mg
amantadine hcl oral 4 MO
tablet didanosine oral 3 MO; QL
capsule,delayed (30 per 30
APTIVUS ORAL 4 MO; QL
release(dr/ec) 250 days)
CAPSULE (120 per 30
mg, 400 mg
days)
DOVATO 5 MO
APTIVUS ORAL 4 QL (300 per
SOLUTION 30 days) EDURANT 4 MO; QL
(60 per 30
atazanavir oral 5 MO; QL
days)
capsule 150 mg, 300 (30 per 30
mg days) efavirenz oral 5 MO; QL
capsule 200 mg (120 per 30
atazanavir oral 5 MO; QL
days)
capsule 200 mg (60 per 30
days) efavirenz oral 3 MO; QL
capsule 50 mg (180 per 30
ATRIPLA 5 MO; QL
days)
(30 per 30
days) efavirenz oral tablet 5 MO; QL
(30 per 30
BARACLUDE 5 MO; QL
days)
ORAL (600 per 30
SOLUTION days) EMTRIVA ORAL 3 MO; QL
CAPSULE (30 per 30
BIKTARVY 4 MO
days)
cidofovir 4 B/D PA;
EMTRIVA ORAL 3 MO; QL
MO
SOLUTION (720 per 30
CIMDUO 4 MO days)
COMPLERA 4 MO; QL entecavir 5 MO; QL
(30 per 30 (30 per 30
days) days)

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
4
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
EPCLUSA 5 PA; MO; ISENTRESS 5 MO; QL
QL (28 per ORAL TABLET (120 per 30
28 days) days)
EPIVIR HBV 3 MO ISENTRESS 5 MO; QL
ORAL ORAL (180 per 30
SOLUTION TABLET,CHEWA days)
EVOTAZ 4 MO; QL BLE 100 MG
(30 per 30 ISENTRESS 3 MO; QL
days) ORAL (180 per 30
famciclovir oral 4 MO; QL TABLET,CHEWA days)
tablet 125 mg, 250 (60 per 30 BLE 25 MG
mg days) JULUCA 4 MO
famciclovir oral 4 MO; QL KALETRA ORAL 3 MO; QL
tablet 500 mg (21 per 30 TABLET 100-25 (300 per 30
days) MG days)
fosamprenavir 5 MO; QL KALETRA ORAL 5 MO; QL
(120 per 30 TABLET 200-50 (180 per 30
days) MG days)
FUZEON 4 MO; QL lamivudine oral 3 MO; QL
SUBCUTANEOU (60 per 30 solution (900 per 30
S RECON SOLN days) days)
ganciclovir sodium 4 B/D PA; lamivudine oral 2 MO; QL
MO tablet 100 mg (90 per 30
GENVOYA 5 MO; QL days)
(30 per 30 lamivudine oral 3 MO; QL
days) tablet 150 mg (60 per 30
INTELENCE 5 MO; QL days)
ORAL TABLET (120 per 30 lamivudine oral 3 MO; QL
100 MG days) tablet 300 mg (30 per 30
INTELENCE 5 MO; QL days)
ORAL TABLET (60 per 30 lamivudine- 3 MO; QL
200 MG days) zidovudine (60 per 30
INTELENCE 3 MO; QL days)
ORAL TABLET (180 per 30 LEXIVA ORAL 3 MO; QL
25 MG days) SUSPENSION (1680 per
INVIRASE ORAL 5 MO; QL 30 days)
TABLET (120 per 30 lopinavir-ritonavir 5 MO
days) moderiba 4 MO
ISENTRESS HD 4 MO nevirapine oral 3 QL (1200
ISENTRESS 5 MO; QL suspension per 30 days)
ORAL POWDER (60 per 30
IN PACKET days)

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
nevirapine oral 3 MO; QL PREZISTA ORAL 5 MO; QL
tablet (60 per 30 TABLET 600 MG (60 per 30
days) days)
nevirapine oral 4 MO; QL PREZISTA ORAL 3 MO; QL
tablet extended (90 per 30 TABLET 75 MG (480 per 30
release 24 hr 100 mg days) days)
nevirapine oral 4 MO; QL PREZISTA ORAL 5 MO; QL
tablet extended (30 per 30 TABLET 800 MG (30 per 30
release 24 hr 400 mg days) days)
NORVIR ORAL 3 MO REBETOL ORAL 5 MO
POWDER IN SOLUTION
PACKET RELENZA 3 MO; QL
NORVIR ORAL 3 MO; QL DISKHALER (60 per 180
SOLUTION (450 per 30 days)
days) RESCRIPTOR 4 MO; QL
ODEFSEY 5 MO; QL ORAL TABLET (180 per 30
(30 per 30 days)
days) RETROVIR 3 MO
oseltamivir oral 3 MO; QL INTRAVENOUS
capsule 30 mg (168 per REYATAZ ORAL 5 MO; QL
365 days) POWDER IN (240 per 30
oseltamivir oral 3 MO; QL PACKET days)
capsule 45 mg, 75 (84 per 365 ribavirin oral 3 MO
mg days) capsule
oseltamivir oral 3 MO; QL ribavirin oral tablet 3 MO
suspension for (1080 per 200 mg
reconstitution 365 days)
rimantadine 4 MO
PIFELTRO 4 MO
ritonavir 3 MO; QL
PREVYMIS 5 (360 per 30
INTRAVENOUS days)
PREVYMIS 5 MO; QL SELZENTRY 4 MO
ORAL (30 per 30 ORAL
days) SOLUTION
PREZCOBIX 4 MO; QL SELZENTRY 5 MO; QL
(30 per 30 ORAL TABLET (60 per 30
days) 150 MG, 75 MG days)
PREZISTA ORAL 5 MO; QL SELZENTRY 3 MO; QL
SUSPENSION (360 per 30 ORAL TABLET (120 per 30
days) 25 MG days)
PREZISTA ORAL 3 MO; QL SELZENTRY 5 MO; QL
TABLET 150 MG (120 per 30 ORAL TABLET (120 per 30
days) 300 MG days)

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
6
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
stavudine oral 4 MO; QL VIDEX EC ORAL 4 MO; QL
capsule (60 per 30 CAPSULE,DELA (90 per 30
days) YED days)
STRIBILD 4 MO; QL RELEASE(DR/EC
(30 per 30 ) 125 MG
days) VIRACEPT 4 MO; QL
SYMFI 4 MO ORAL TABLET (270 per 30
250 MG days)
SYMFI LO 4 MO
VIRACEPT 4 MO; QL
SYMTUZA 4 MO
ORAL TABLET (120 per 30
SYNAGIS 5 MO; LA 625 MG days)
tenofovir disoproxil 5 MO; QL VIRAMUNE 4 MO; QL
fumarate (30 per 30 ORAL (1200 per
days) SUSPENSION 30 days)
TIVICAY ORAL 3 MO; QL VIREAD ORAL 5 MO; QL
TABLET 10 MG (60 per 30 POWDER (225 per 30
days) days)
TIVICAY ORAL 5 MO; QL VIREAD ORAL 5 MO; QL
TABLET 25 MG, (60 per 30 TABLET 150 MG, (30 per 30
50 MG days) 200 MG, 250 MG days)
TRIUMEQ 4 MO; QL ZEPATIER 5 PA; MO;
(30 per 30 QL (28 per
days) 28 days)
TROGARZO 5 MO; LA zidovudine oral 3 MO; QL
TRUVADA 5 MO; QL capsule (180 per 30
(30 per 30 days)
days) zidovudine oral 3 MO; QL
valacyclovir oral 4 MO; QL syrup (1800 per
tablet 1 gram (120 per 30 30 days)
days) zidovudine oral 2 MO; QL
valacyclovir oral 4 MO; QL tablet (60 per 30
tablet 500 mg (60 per 30 days)
days) CEPHALOSPO
valganciclovir 5 MO RINS
VEMLIDY 5 MO cefaclor oral capsule 3 MO
VIDEX 2 GRAM 4 MO; QL cefadroxil oral 2 MO
PEDIATRIC (1200 per capsule
30 days)
cefadroxil oral 4 MO
VIDEX 4 GRAM 4 MO; QL suspension for
PEDIATRIC (1200 per reconstitution 250
30 days) mg/5 ml, 500 mg/5
ml

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
7
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
cefadroxil oral 4 MO cefoxitin 4 MO
tablet intravenous recon
cefazolin in dextrose 4 MO soln 1 gram, 2 gram
(iso-os) intravenous cefoxitin 4
piggyback 1 intravenous recon
gram/50 ml soln 10 gram
cefazolin in dextrose 2 MO CEFTAZIDIME 4
(iso-os) intravenous IN D5W
piggyback 2 ceftazidime injection 4 MO
gram/50 ml recon soln 1 gram, 2
cefazolin injection 4 MO gram
recon soln 1 gram, ceftazidime injection 4
500 mg recon soln 6 gram
cefazolin injection 4 ceftriaxone in 4 MO
recon soln 10 gram, dextrose,iso-os
100 gram, 20 gram,
ceftriaxone injection 4 MO
300 g
recon soln 1 gram, 2
cefazolin 4 gram, 250 mg, 500
intravenous mg
cefdinir oral capsule 2 MO ceftriaxone injection 4
cefdinir oral 3 MO recon soln 10 gram
suspension for CEFTRIAXONE 4
reconstitution INJECTION
CEFEPIME IN 4 MO RECON SOLN
DEXTROSE 5 % 100 GRAM
cefepime in 4 ceftriaxone 4 MO
dextrose,iso-osm intravenous
intravenous cefuroxime axetil 2 MO
piggyback 1 oral tablet
gram/50 ml
cefuroxime sodium 4 MO
cefepime in 4 MO injection recon soln
dextrose,iso-osm 750 mg
intravenous
cefuroxime sodium 4 MO
piggyback 2
intravenous recon
gram/100 ml
soln 1.5 gram
cefepime injection 4 MO
cefuroxime sodium 4
cefixime 4 MO intravenous recon
cefotaxime injection 4 soln 7.5 gram
recon soln 1 gram, cephalexin oral 2 MO
500 mg capsule 250 mg, 500
cefoxitin in 4 mg
dextrose, iso-osm

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8

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
cephalexin oral 2 MO erythrocin (as 4 MO
suspension for stearate) oral tablet
reconstitution 250 mg
SUPRAX ORAL 4 MO ERYTHROCIN 3 MO
CAPSULE INTRAVENOUS
SUPRAX ORAL 4 RECON SOLN
SUSPENSION 500 MG
FOR erythromycin 4 MO
RECONSTITUTI ethylsuccinate oral
ON 500 MG/5 ML suspension for
TEFLARO 4 MO reconstitution
ERYTHROMYC erythromycin 4 MO
INS / OTHER ethylsuccinate oral
tablet
MACROLIDES
erythromycin oral 3 MO
azithromycin 4 MO capsule,delayed
intravenous release(dr/ec)
azithromycin oral 2 MO erythromycin oral 4 MO
packet tablet
azithromycin oral 4 MO MISCELLANEO
suspension for
US
reconstitution
ANTIINFECTIV
azithromycin oral 2 MO ES
tablet 250 mg, 250
mg (6 pack), 500 albendazole 5 MO; QL
mg, 600 mg (120 per 30
days)
azithromycin oral 2
tablet 500 mg (3 ALBENZA 5 MO; QL
pack) (120 per 30
days)
clarithromycin oral 2 MO
suspension for ALINIA ORAL 3 MO; QL
reconstitution 125 SUSPENSION (360 per 30
mg/5 ml FOR days)
RECONSTITUTI
clarithromycin oral 4 MO
ON
suspension for
reconstitution 250 ALINIA ORAL 5 MO; QL
mg/5 ml TABLET (14 per 30
days)
clarithromycin oral 4 MO
tablet amikacin injection 4 MO
solution 1,000 mg/4
clarithromycin oral 4 MO
ml, 500 mg/2 ml
tablet extended
release 24 hr ARIKAYCE 5 PA; MO;
LA

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9
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
atovaquone 5 MO clindamycin 4
atovaquone- 3 MO phosphate
proguanil oral tablet intravenous solution
250-100 mg 300 mg/2 ml, 900
mg/6 ml
atovaquone- 2 MO
proguanil oral tablet clindamycin 4 MO
62.5-25 mg phosphate
intravenous solution
aztreonam 3 MO
600 mg/4 ml
BENZNIDAZOLE 3
COARTEM 3 MO; QL
BILTRICIDE 5 MO (24 per 30
CAPASTAT 4 days)
CAYSTON 5 PA; MO; colistin 4 MO
LA; QL (84 (colistimethate na)
per 28 days) dapsone oral 3 MO
chloramphenicol sod 4 DAPTOMYCIN 3
succinate INTRAVENOUS
chloroquine 2 MO RECON SOLN
phosphate oral 350 MG
tablet 250 mg daptomycin 5 MO
chloroquine 4 MO intravenous recon
phosphate oral soln 500 mg
tablet 500 mg DARAPRIM 5 PA; MO
cleocin intravenous 2 EMVERM 5 MO
solution 300 mg/2
ethambutol oral 2 MO
ml
tablet 100 mg
clindamycin hcl 2 MO
ethambutol oral 4 MO
CLINDAMYCIN 4 tablet 400 mg
IN 0.9 % SOD
gentamicin in nacl 4 MO
CHLOR
(iso-osm)
clindamycin in 5 % 4 MO intravenous
dextrose piggyback 100
clindamycin 2 MO mg/100 ml
palmitate hcl GENTAMICIN IN 2 MO
clindamycin 2 MO NACL (ISO-OSM)
pediatric INTRAVENOUS
clindamycin 4 MO PIGGYBACK 100
phosphate injection MG/50 ML

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10

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
GENTAMICIN IN 2 MEROPENEM- 4 MO
NACL (ISO-OSM) 0.9% SODIUM
INTRAVENOUS CHLORIDE
PIGGYBACK 120 INTRAVENOUS
MG/100 ML PIGGYBACK 1
gentamicin in nacl 2 MO GRAM/50 ML
(iso-osm) MEROPENEM- 4
intravenous 0.9% SODIUM
piggyback 60 mg/50 CHLORIDE
ml, 80 mg/50 ml INTRAVENOUS
gentamicin in nacl 2 PIGGYBACK 500
(iso-osm) MG/50 ML
intravenous metro i.v. 2 MO
piggyback 80 metronidazole in 2 MO
mg/100 ml nacl (iso-os)
gentamicin injection 2 MO metronidazole oral 2 MO
gentamicin sulfate 2 MO NEBUPENT 3 B/D PA;
(ped) (pf) MO; QL (1
hydroxychloroquine 3 MO per 28 days)
imipenem-cilastatin 4 MO neomycin 2 MO
IMPAVIDO 5 MO paromomycin 4 MO
isoniazid oral 4 MO PASER 3 MO
solution PENTAM 4 MO
isoniazid oral tablet 2 MO pentamidine 3
ivermectin 3 MO praziquantel 3 MO
linezolid in dextrose 4 PRIFTIN 3 MO
5%
PRIMAQUINE 3 MO
linezolid oral 5 MO; QL
pyrazinamide 4 MO
suspension for (1800 per
reconstitution 30 days) quinine sulfate 3 PA; MO;
QL (42 per
linezolid oral tablet 5 MO; QL
30 days)
(60 per 30
days) rifabutin 4 MO
linezolid-0.9% 4 rifampin 2 MO
sodium chloride intravenous
mefloquine 2 MO rifampin oral 4 MO
meropenem 4 MO SIRTURO 5 PA; MO;
LA
STREPTOMYCIN 3 MO
SYNERCID 5
tigecycline 5

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11
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
tobramycin in 0.225 5 B/D PA; vancomycin 4 MO
% nacl MO; QL intravenous recon
(280 per 28 soln 10 gram, 500
days) mg, 750 mg
tobramycin sulfate 4 VANCOMYCIN 4
injection recon soln INTRAVENOUS
tobramycin sulfate 2 MO RECON SOLN
injection solution 10 250 MG
mg/ml vancomycin oral 3 MO; QL
tobramycin sulfate 4 MO capsule 125 mg (120 per 30
injection solution 40 days)
mg/ml vancomycin oral 5 MO; QL
TRECATOR 3 MO capsule 250 mg (240 per 30
days)
VANCOMYCIN 4
IN 0.9 % SODIUM VIBATIV 5
CHL INTRAVENOUS
INTRAVENOUS RECON SOLN
PIGGYBACK 750 MG
VANCOMYCIN 4 MO XIFAXAN ORAL 4 PA; MO;
IN DEXTROSE 5 TABLET 200 MG QL (9 per
% 30 days)
INTRAVENOUS XIFAXAN ORAL 4 PA; MO;
PIGGYBACK 1 TABLET 550 MG QL (90 per
GRAM/200 ML 30 days)
VANCOMYCIN 4 PENICILLINS
IN DEXTROSE 5
amoxicillin oral 2 MO
%
capsule
INTRAVENOUS
PIGGYBACK 500 amoxicillin oral 2 MO
MG/100 ML, 750 suspension for
MG/150 ML reconstitution
VANCOMYCIN 4 amoxicillin oral 2 MO
INJECTION tablet
vancomycin 2 MO amoxicillin oral 2 MO
intravenous recon tablet,chewable 125
soln 1,000 mg, 5 mg, 250 mg
gram amoxicillin-pot 2 MO

VANCOMYCIN 2 clavulanate oral

INTRAVENOUS suspension for
RECON SOLN reconstitution 200-
1.25 GRAM, 1.5 28.5 mg/5 ml, 600-
GRAM 42.9 mg/5 ml

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12
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
amoxicillin-pot 3 MO AUGMENTIN 5 MO
clavulanate oral ORAL
suspension for SUSPENSION
reconstitution 250- FOR
62.5 mg/5 ml, 400- RECONSTITUTI
57 mg/5 ml ON 125-31.25
amoxicillin-pot 2 MO MG/5 ML
clavulanate oral dicloxacillin 2 MO
tablet nafcillin in dextrose 4 MO
amoxicillin-pot 4 MO iso-osm intravenous
clavulanate oral piggyback 2
tablet extended gram/100 ml
release 12 hr nafcillin injection 5 MO
amoxicillin-pot 2 MO recon soln 10 gram
clavulanate oral nafcillin injection 4 MO
tablet,chewable recon soln 2 gram
ampicillin oral 2 MO nafcillin intravenous 4 MO
capsule 500 mg recon soln 2 gram
ampicillin sodium 4 MO penicillin g 4 MO
injection potassium
ampicillin sodium 4 penicillin g procaine 2 MO
intravenous intramuscular
ampicillin- 4 MO syringe 1.2 million
sulbactam injection unit/2 ml
recon soln 1.5 gram, penicillin g procaine 2
3 gram intramuscular
ampicillin- 4 syringe 600,000
sulbactam injection unit/ml
recon soln 15 gram penicillin g sodium 4 MO
ampicillin- 4 penicillin v 2 MO
sulbactam potassium
intravenous recon
pfizerpen-g 4
soln 1.5 gram
PIPERACILLIN- 4 MO
ampicillin- 4 MO
TAZOBACTAM
sulbactam
INTRAVENOUS
intravenous recon
RECON SOLN
soln 3 gram
13.5 GRAM
piperacillin- 3 MO
tazobactam
intravenous recon
soln 2.25 gram,
3.375 gram

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13
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
piperacillin- 4 MO sulfamethoxazole- 4 MO
tazobactam trimethoprim
intravenous recon intravenous
soln 4.5 gram, 40.5 sulfamethoxazole- 2 MO
gram trimethoprim oral
ZOSYN IN 3 MO sulfatrim 2 MO
DEXTROSE (ISO-
OSM)
TETRACYCLIN
INTRAVENOUS ES
PIGGYBACK 4.5 demeclocycline 4 MO
GRAM/100 ML doxy-100 4 MO
QUINOLONES doxycycline hyclate 4
ciprofloxacin 4 intravenous
ciprofloxacin hcl 2 MO doxycycline hyclate 2 MO
oral oral capsule
ciprofloxacin in 5 % 4 MO doxycycline hyclate 2 MO
dextrose oral tablet
levofloxacin in d5w 4 doxycycline 4 MO
intravenous monohydrate oral
piggyback 250 capsule 100 mg, 50
mg/50 ml mg, 75 mg
levofloxacin in d5w 4 MO doxycycline 4 MO
intravenous monohydrate oral
piggyback 500 suspension for
mg/100 ml reconstitution
levofloxacin in d5w 3 MO doxycycline 4 MO
intravenous monohydrate oral
piggyback 750 tablet
mg/150 ml minocycline oral 2 MO
levofloxacin 4 MO capsule
intravenous minocycline oral 4 MO
levofloxacin oral 4 MO tablet
solution mondoxyne nl 4 MO
levofloxacin oral 2 MO morgidox 2 MO
tablet okebo oral capsule 4 MO
SULFA'S / 75 mg
RELATED tetracycline 2 MO
AGENTS URINARY
sulfadiazine 4 MO TRACT
AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
14
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
methenamine 4 MO mesna 4 B/D PA;
hippurate MO
methenamine 3 MO MESNEX ORAL 5 MO
mandelate VISTOGARD 5 MO
nitrofurantoin 3 MO XGEVA 5 B/D PA;
nitrofurantoin 3 MO MO; QL
macrocrystal oral (1.7 per 28
capsule 100 mg, 25 days)
mg ANTINEOPLAS
nitrofurantoin 2 MO TIC /
macrocrystal oral IMMUNOSUPP
capsule 50 mg RESSANT
nitrofurantoin 4 MO DRUGS
monohyd/m-cryst
abiraterone 4 PA; MO;
trimethoprim 2 MO QL (120 per
ANTINEOPL 30 days)
ASTIC / ABRAXANE 5 B/D PA;
IMMUNOSUP MO
PRESSANT adriamycin 3 B/D PA
intravenous recon
DRUGS soln 10 mg
ADJUNCTIVE ADRIAMYCIN 4 B/D PA
AGENTS INTRAVENOUS
RECON SOLN 50
KEPIVANCE 5 MO
MG
KHAPZORY 4 B/D PA
adriamycin 3 B/D PA
leucovorin calcium 2 B/D PA; intravenous solution
injection recon soln MO
adrucil intravenous 4 B/D PA
100 mg, 200 mg,
solution 2.5 gram/50
350 mg, 50 mg
ml
leucovorin calcium 2 B/D PA
adrucil intravenous 4 B/D PA;
injection recon soln
solution 5 gram/100 MO
500 mg
ml, 500 mg/10 ml
leucovorin calcium 2 MO
AFINITOR 5 PA; MO;
oral
QL (30 per
levoleucovorin 3 B/D PA 30 days)
calcium intravenous
AFINITOR 5 PA; MO;
recon soln 50 mg
DISPERZ ORAL QL (150 per
levoleucovorin 4 B/D PA TABLET FOR 30 days)
calcium intravenous SUSPENSION 2
solution MG

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
15
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
AFINITOR 5 PA; MO; azathioprine sodium 3 B/D PA
DISPERZ ORAL QL (90 per BALVERSA 5 PA; MO
TABLET FOR 30 days)
BAVENCIO 5 B/D PA;
SUSPENSION 3
MO; LA
MG
BELEODAQ 5 B/D PA;
AFINITOR 5 PA; MO;
MO
DISPERZ ORAL QL (60 per
TABLET FOR 30 days) BENDEKA 4 B/D PA;
SUSPENSION 5 MO
MG BESPONSA 5 B/D PA;
ALECENSA 4 PA; MO; MO; LA
QL (240 per bexarotene 5 PA; MO
30 days) bicalutamide 2 MO
ALIMTA 5 B/D PA; BICNU 4 B/D PA;
MO MO
ALIQOPA 4 B/D PA; bleomycin 4 B/D PA;
MO; LA MO
ALKERAN 3 B/D PA; BLINCYTO 5 B/D PA;
MO INTRAVENOUS MO
ALUNBRIG 4 PA; MO; KIT
ORAL TABLET QL (30 per BORTEZOMIB 4 B/D PA;
180 MG 30 days) MO
ALUNBRIG 4 PA; MO; BOSULIF ORAL 5 PA; MO;
ORAL TABLET QL (60 per TABLET 100 MG QL (90 per
30 MG, 90 MG 30 days) 30 days)
ALUNBRIG 4 PA; MO; BOSULIF ORAL 5 PA; MO;
ORAL QL (30 per TABLET 400 MG, QL (30 per
TABLETS,DOSE 30 days) 500 MG 30 days)
PACK
BRAFTOVI 4 PA; MO;
anastrozole 2 MO ORAL CAPSULE LA; QL
ARRANON 3 B/D PA 50 MG (120 per 30
ARSENIC 4 B/D PA days)
TRIOXIDE BRAFTOVI 4 PA; MO;
ARZERRA 5 B/D PA; ORAL CAPSULE LA; QL
MO 75 MG (180 per 30
days)
AVASTIN 3 B/D PA;
MO busulfan 5 B/D PA
azacitidine 5 B/D PA; BUSULFEX 4 B/D PA
MO CABOMETYX 4 PA; MO;
azathioprine 2 B/D PA; ORAL TABLET LA; QL (30
MO 20 MG, 60 MG per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
16
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
CABOMETYX 4 PA; MO; COTELLIC 4 PA; MO;
ORAL TABLET LA; QL (60 LA; QL (63
40 MG per 30 days) per 28 days)
CALQUENCE 4 PA; MO; cyclophosphamide 3 B/D PA;
LA; QL (60 intravenous MO
per 30 days) cyclophosphamide 3 B/D PA;
CAPRELSA 5 PA; LA; oral capsule MO
ORAL TABLET QL (60 per cyclosporine 4 B/D PA
100 MG 30 days) intravenous
CAPRELSA 5 PA; MO; cyclosporine 3 B/D PA;
ORAL TABLET LA; QL (30 modified MO
300 MG per 30 days)
cyclosporine oral 3 B/D PA;
carboplatin 4 B/D PA; capsule MO
intravenous solution MO
CYRAMZA 5 B/D PA;
carmustine 3 B/D PA; MO
MO
cytarabine 4 B/D PA;
CELLCEPT 3 B/D PA; MO
INTRAVENOUS MO
cytarabine (pf) 2 B/D PA;
cisplatin intravenous 3 B/D PA; injection solution MO
solution MO 100 mg/5 ml (20
cladribine 4 B/D PA; mg/ml)
MO cytarabine (pf) 4 B/D PA;
clofarabine 3 B/D PA injection solution 2 MO
CLOLAR 4 B/D PA gram/20 ml (100
mg/ml)
COMETRIQ 5 PA; MO;
ORAL CAPSULE QL (56 per cytarabine (pf) 4 B/D PA
100 MG/DAY(80 28 days) injection solution 20
MG X1-20 MG mg/ml
X1) dacarbazine 2 B/D PA;
COMETRIQ 5 PA; MO; MO
ORAL CAPSULE QL (112 per dactinomycin 3 B/D PA
140 MG/DAY(80 28 days) DARZALEX 3 B/D PA;
MG X1-20 MG MO; LA
X3)
daunorubicin 2 B/D PA
COMETRIQ 5 PA; MO; intravenous solution
ORAL CAPSULE QL (84 per
DAURISMO 4 PA; MO
60 MG/DAY (20 28 days)
MG X 3/DAY) decitabine 5 B/D PA;
MO
COPIKTRA 4 PA; MO;
LA

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
docetaxel 3 B/D PA erlotinib oral tablet 5 PA; MO;
intravenous solution 100 mg, 150 mg QL (30 per
160 mg/16 ml (10 30 days)
mg/ml), 20 mg/2 ml erlotinib oral tablet 5 PA; MO;
(10 mg/ml) 25 mg QL (60 per
docetaxel 3 B/D PA; 30 days)
intravenous solution MO ERWINAZE 5 B/D PA;
160 mg/8 ml (20 MO
mg/ml), 20 mg/ml
ETOPOPHOS 4 B/D PA;
(1 ml), 80 mg/4 ml
MO
(20 mg/ml), 80
mg/8 ml (10 mg/ml) etoposide 2 B/D PA;
intravenous MO
DOCETAXEL 3 B/D PA
INTRAVENOUS exemestane 3 MO
SOLUTION 20 FARESTON 5 MO
MG/ML FARYDAK 5 PA; MO;
doxorubicin 2 B/D PA ORAL CAPSULE QL (12 per
intravenous recon 10 MG 21 days)
soln 10 mg FARYDAK 5 PA; MO;
doxorubicin 2 B/D PA; ORAL CAPSULE QL (6 per
intravenous recon MO 15 MG, 20 MG 21 days)
soln 50 mg FASLODEX 5 B/D PA;
doxorubicin 2 B/D PA; MO
intravenous solution MO FIRMAGON KIT 4 B/D PA;
doxorubicin, peg- 5 B/D PA; W DILUENT MO
liposomal MO SYRINGE
DROXIA 3 MO floxuridine 4 B/D PA
ELLENCE 4 B/D PA; fludarabine 3 B/D PA;
MO intravenous recon MO
EMCYT 4 MO soln
EMPLICITI 4 B/D PA; fludarabine 3 B/D PA
MO intravenous solution
epirubicin 4 B/D PA; fluorouracil 2 B/D PA;
intravenous solution MO intravenous solution MO
1 gram/20 ml, 500
ERBITUX 5 B/D PA;
mg/10 ml
MO
fluorouracil 4 B/D PA;
ERIVEDGE 5 PA; MO;
intravenous solution MO
QL (30 per
2.5 gram/50 ml, 5
30 days)
gram/100 ml
ERLEADA 5 PA; MO
flutamide 4 MO

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
18
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
FOLOTYN 5 B/D PA; hydroxyurea 2 MO
MO IBRANCE 5 PA; MO;
fulvestrant 5 B/D PA; QL (21 per
MO 28 days)
GAZYVA 5 B/D PA; ICLUSIG ORAL 5 PA; MO;
MO TABLET 15 MG QL (60 per
gemcitabine 3 B/D PA; 30 days)
intravenous recon MO ICLUSIG ORAL 5 PA; MO;
soln 1 gram, 200 mg TABLET 45 MG QL (30 per
gemcitabine 3 B/D PA 30 days)
intravenous recon idarubicin 4 B/D PA
soln 2 gram IDHIFA 5 PA; MO;
gemcitabine 3 B/D PA; LA; QL (30
intravenous solution MO per 30 days)
1 gram/26.3 ml (38 ifosfamide 4 B/D PA;
mg/ml), 200 intravenous recon MO
mg/5.26 ml (38 soln
mg/ml)
ifosfamide 4 B/D PA;
GEMCITABINE 3 B/D PA intravenous solution MO
INTRAVENOUS 1 gram/20 ml
SOLUTION 100
ifosfamide 4 B/D PA
MG/ML
intravenous solution
gemcitabine 3 B/D PA 3 gram/60 ml
intravenous solution
imatinib oral tablet 5 PA; MO;
2 gram/52.6 ml (38
100 mg QL (180 per
mg/ml)
30 days)
gengraf oral capsule 4 B/D PA;
imatinib oral tablet 5 PA; MO;
100 mg, 25 mg MO
400 mg QL (60 per
gengraf oral 4 B/D PA; 30 days)
solution MO
IMBRUVICA 5 PA; MO;
GILOTRIF 5 PA; MO; ORAL CAPSULE QL (120 per
QL (30 per 140 MG 30 days)
30 days)
IMBRUVICA 5 PA; MO;
GLEOSTINE 3 MO ORAL CAPSULE QL (240 per
HALAVEN 3 B/D PA; 70 MG 30 days)
MO IMBRUVICA 5 PA; MO;
HERCEPTIN 5 B/D PA; ORAL TABLET QL (120 per
HYLECTA MO 140 MG 30 days)
HERCEPTIN 5 B/D PA; IMBRUVICA 5 PA; MO;
INTRAVENOUS MO ORAL TABLET QL (60 per
RECON SOLN 280 MG 30 days)
150 MG

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
IMBRUVICA 5 PA; MO; KISQALI 4 PA; MO;
ORAL TABLET QL (40 per FEMARA CO- QL (49 per
420 MG 30 days) PACK ORAL 28 days)
IMBRUVICA 5 PA; MO; TABLET 200
ORAL TABLET QL (30 per MG/DAY(200 MG
560 MG 30 days) X 1)-2.5 MG
IMFINZI 4 B/D PA; KISQALI 4 PA; MO;
MO; LA FEMARA CO- QL (70 per
PACK ORAL 28 days)
INFUGEM 4 B/D PA
TABLET 400
INLYTA ORAL 5 PA; MO; MG/DAY(200 MG
TABLET 1 MG QL (180 per X 2)-2.5 MG
30 days)
KISQALI 4 PA; MO;
INLYTA ORAL 5 PA; MO; FEMARA CO- QL (91 per
TABLET 5 MG QL (120 per PACK ORAL 28 days)
30 days) TABLET 600
IRESSA 4 PA; MO; MG/DAY(200 MG
QL (30 per X 3)-2.5 MG
30 days) KISQALI ORAL 4 PA; MO;
irinotecan 4 B/D PA; TABLET 200 QL (21 per
intravenous solution MO MG/DAY (200 28 days)
100 mg/5 ml, 40 MG X 1)
mg/2 ml KISQALI ORAL 4 PA; MO;
irinotecan 4 B/D PA TABLET 400 QL (42 per
intravenous solution MG/DAY (200 28 days)
500 mg/25 ml MG X 2)
ISTODAX 5 B/D PA; KISQALI ORAL 4 PA; MO;
MO TABLET 600 QL (63 per
IXEMPRA 5 B/D PA; MG/DAY (200 28 days)
MO MG X 3)
JAKAFI 5 PA; MO; KYPROLIS 5 B/D PA;
QL (60 per MO
30 days) LARTRUVO 5 B/D PA;
JEVTANA 4 B/D PA; MO; LA
MO LENVIMA ORAL 5 PA; MO;
KADCYLA 5 PA; MO CAPSULE 10 QL (30 per
MG/DAY (10 MG 30 days)
KEYTRUDA 5 PA; MO
X 1), 12 MG/DAY
INTRAVENOUS
(4 MG X 3), 4 MG
SOLUTION

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
LENVIMA ORAL 5 PA; MO; LYNPARZA 4 PA; MO;
CAPSULE 14 QL (60 per ORAL TABLET QL (120 per
MG/DAY(10 MG 30 days) 30 days)
X 1-4 MG X 1), 20 LYSODREN 3 MO
MG/DAY (10 MG
MARQIBO 5 B/D PA;
X 2), 8 MG/DAY
MO
(4 MG X 2)
MATULANE 5 MO
LENVIMA ORAL 5 PA; MO;
CAPSULE 18 QL (90 per megestrol oral 4 PA
MG/DAY (10 MG 30 days) suspension 400
X 1-4 MG X2), 24 mg/10 ml (10 ml)
MG/DAY(10 MG megestrol oral 4 PA; MO
X 2-4 MG X 1) suspension 400
letrozole 2 MO mg/10 ml (40
mg/ml), 625 mg/5
LEUKERAN 3 MO
ml
leuprolide 4 MO
megestrol oral 4 PA; MO
subcutaneous kit
tablet
LIBTAYO 5 PA; MO;
MEKINIST 5 PA; MO;
LA
ORAL TABLET QL (90 per
LONSURF ORAL 5 PA; MO; 0.5 MG 30 days)
TABLET 15-6.14 QL (100 per
MEKINIST 5 PA; MO;
MG 28 days)
ORAL TABLET 2 QL (30 per
LONSURF ORAL 5 PA; MO; MG 30 days)
TABLET 20-8.19 QL (80 per
MEKTOVI 4 PA; MO;
MG 28 days)
LA; QL
LORBRENA 5 PA; MO (180 per 30
LUMOXITI 4 PA; MO; days)
LA melphalan 3 B/D PA;
LUPRON DEPOT 5 PA; MO MO
LUPRON DEPOT 5 PA; MO melphalan hcl 3 B/D PA
(3 MONTH) mercaptopurine 2 MO
LUPRON DEPOT 5 PA; MO methotrexate 3 B/D PA;
(4 MONTH) sodium MO
LUPRON DEPOT 5 PA; MO methotrexate 3 B/D PA
(6 MONTH) sodium (pf)
LUPRON 5 PA; MO injection recon soln
DEPOT-PED methotrexate 3 B/D PA;
LUPRON 5 PA; MO sodium (pf) MO
DEPOT-PED (3 injection solution
MONTH) mitomycin 4 B/D PA;
intravenous MO

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21
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
mitoxantrone 2 B/D PA; NULOJIX 5 B/D PA;
MO MO
mycophenolate 3 B/D PA octreotide acetate 5 PA; MO
mofetil hcl injection solution
mycophenolate 2 B/D PA; 1,000 mcg/ml, 500
mofetil oral capsule MO mcg/ml
mycophenolate 5 B/D PA; octreotide acetate 3 PA; MO
mofetil oral MO injection solution
suspension for 100 mcg/ml, 200
reconstitution mcg/ml, 50 mcg/ml
mycophenolate 2 B/D PA; octreotide acetate 5 PA; MO
mofetil oral tablet MO injection syringe 100
mcg/ml (1 ml), 500
mycophenolate 2 B/D PA;
mcg/ml (1 ml)
sodium oral MO
tablet,delayed octreotide acetate 3 PA; MO
release (dr/ec) 180 injection syringe 50
mg mcg/ml (1 ml)
mycophenolate 3 B/D PA; ODOMZO 5 PA; MO;
sodium oral MO LA; QL (30
tablet,delayed per 30 days)
release (dr/ec) 360 ONCASPAR 5 B/D PA;
mg MO
MYLOTARG 4 B/D PA; ONIVYDE 5 B/D PA;
MO; LA MO
NERLYNX 5 PA; MO; OPDIVO 5 PA; MO
LA oxaliplatin 4 B/D PA;
NEXAVAR 5 PA; MO; intravenous recon MO
LA; QL soln 100 mg
(120 per 30 oxaliplatin 4 B/D PA
days) intravenous recon
nilutamide 5 MO soln 50 mg
NINLARO ORAL 5 PA; MO; oxaliplatin 4 B/D PA;
CAPSULE 2.3 MG QL (6 per intravenous solution MO
28 days) paclitaxel 4 B/D PA;
NINLARO ORAL 5 PA; MO; MO
CAPSULE 3 MG QL (4 per PERJETA 5 B/D PA;
28 days) MO
NINLARO ORAL 5 PA; MO; POMALYST 5 PA; MO;
CAPSULE 4 MG QL (3 per LA; QL (21
28 days) per 28 days)
NIPENT 4 B/D PA; PORTRAZZA 4 B/D PA;
MO MO

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
22
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
POTELIGEO 5 PA; MO sirolimus oral 5 B/D PA;
PROGRAF 3 B/D PA; solution MO
INTRAVENOUS MO sirolimus oral tablet 2 B/D PA;
PROGRAF ORAL 3 B/D PA; 0.5 mg MO
GRANULES IN MO sirolimus oral tablet 3 B/D PA;
PACKET 1 mg MO
PURIXAN 5
sirolimus oral tablet 5 B/D PA;
RAPAMUNE 5 B/D PA; 2 mg MO
ORAL MO SOLTAMOX 4 MO
SOLUTION SOMATULINE 5 PA; MO
REVLIMID 4 PA; MO; DEPOT
LA; QL (28 SPRYCEL ORAL 5 PA; MO;
per 28 days) TABLET 100 MG, QL (30 per
RITUXAN 5 PA; MO
140 MG, 50 MG, 30 days)
RITUXAN 4 PA; MO
80 MG
HYCELA
SPRYCEL ORAL 5 PA; MO;
ROMIDEPSIN 4 B/D PA
TABLET 20 MG QL (90 per
30 days)
RUBRACA 5 PA; MO;
ORAL TABLET LA; QL SPRYCEL ORAL 5 PA; MO;
200 MG, 300 MG (120 per 30 TABLET 70 MG QL (60 per
days) 30 days)
RUBRACA 5 PA; MO; STIVARGA 5 PA; MO;
ORAL TABLET LA; QL QL (84 per
250 MG (150 per 30 28 days)
days) SUTENT 5 PA; MO;
RYDAPT 5 PA; MO; QL (30 per
QL (240 per 30 days)
30 days) SYLVANT 5 B/D PA;
SANDIMMUNE 3 B/D PA; MO
ORAL MO SYNRIBO 4 B/D PA;
SOLUTION MO
SIGNIFOR 5 PA; MO TABLOID 3 MO

SIMULECT 3 B/D PA tacrolimus oral 3 B/D PA;

INTRAVENOUS MO
RECON SOLN 10 TAFINLAR 5 PA; MO;
MG QL (120 per
SIMULECT 3 B/D PA; 30 days)
INTRAVENOUS MO TAGRISSO 5 PA; MO;
RECON SOLN 20 LA; QL (30
MG per 30 days)
TALZENNA 4 PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
23
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
tamoxifen 2 MO TREANDA 4 B/D PA;
TARCEVA ORAL 5 PA; MO; INTRAVENOUS MO
TABLET 100 MG, QL (30 per RECON SOLN
150 MG 30 days) TRELSTAR 5 B/D PA;
TARCEVA ORAL 5 PA; MO; INTRAMUSCUL MO
TABLET 25 MG QL (60 per AR SUSPENSION
30 days) FOR
RECONSTITUTI
TARGRETIN 5 PA; MO
ON
TOPICAL
tretinoin 5 MO
TASIGNA ORAL 5 PA; MO;
(chemotherapy)
CAPSULE 150 QL (112 per
MG, 200 MG 28 days) TRISENOX 4 B/D PA;
INTRAVENOUS MO
TASIGNA ORAL 5 PA; MO
SOLUTION 2
CAPSULE 50 MG
MG/ML
TECENTRIQ 5 B/D PA;
TYKERB 5 PA; MO;
MO; LA
LA; QL
TEMODAR 5 B/D PA; (180 per 30
INTRAVENOUS MO days)
temsirolimus 5 B/D PA; UNITUXIN 5 B/D PA;
MO MO
THALOMID 5 PA; MO; valrubicin 3 B/D PA
ORAL CAPSULE QL (30 per
VALSTAR 4 B/D PA;
100 MG, 50 MG 30 days)
MO
THALOMID 5 PA; MO;
VANTAS 4 B/D PA;
ORAL CAPSULE QL (60 per
MO
150 MG, 200 MG 30 days)
VECTIBIX 5 B/D PA;
thiotepa 5 B/D PA;
MO
MO
VELCADE 5 B/D PA;
TIBSOVO 5 PA; MO
MO
toposar 4 B/D PA;
VENCLEXTA 4 PA; MO;
MO
ORAL TABLET LA; QL (60
topotecan 4 B/D PA 10 MG per 30 days)
intravenous recon
VENCLEXTA 4 PA; MO;
soln
ORAL TABLET LA; QL
topotecan 4 B/D PA; 100 MG (120 per 30
intravenous solution MO days)
toremifene 5 MO VENCLEXTA 4 PA; MO;
TORISEL 5 B/D PA; ORAL TABLET LA; QL (30
MO 50 MG per 30 days)

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
VENCLEXTA 4 PA; MO; YONSA 5 PA; MO;
STARTING LA; QL (42 QL (120 per
PACK per 28 days) 30 days)
VERZENIO 4 PA; MO; ZALTRAP 4 B/D PA;
LA; QL (60 MO
per 30 days) ZANOSAR 4 B/D PA;
vinblastine 2 B/D PA; MO
intravenous solution MO ZEJULA 5 PA; MO;
vincristine 2 B/D PA; LA; QL (90
MO per 30 days)
vinorelbine 3 B/D PA; ZELBORAF 4 PA; MO;
MO QL (240 per
VITRAKVI 4 PA; MO; 30 days)
LA ZOLADEX 4 B/D PA;
VIZIMPRO 4 PA; MO; MO
QL (30 per ZOLINZA 5 MO; QL
30 days) (120 per 30
VOTRIENT 5 PA; MO; days)
QL (120 per ZORTRESS 5 B/D PA;
30 days) ORAL TABLET MO; QL
VYXEOS 5 B/D PA; 0.25 MG, 0.75 MG (60 per 30
MO days)
XALKORI 4 PA; MO; ZORTRESS 5 B/D PA;
QL (60 per ORAL TABLET MO; QL
30 days) 0.5 MG (120 per 30
days)
XATMEP 4 B/D PA;
MO ZORTRESS 5 B/D PA;
ORAL TABLET 1 MO
XERMELO 5 PA; MO;
MG
LA; QL (90
per 30 days) ZYDELIG 4 PA; MO;
QL (60 per
XOSPATA 4 PA; MO;
30 days)
LA
ZYKADIA 5 PA; MO;
XTANDI 4 PA; MO;
QL (150 per
QL (120 per
30 days)
30 days)
ZYTIGA ORAL 4 PA; MO;
YERVOY 3 B/D PA;
TABLET 250 MG QL (120 per
MO
30 days)
YONDELIS 5 B/D PA;
ZYTIGA ORAL 5 PA; MO;
MO
TABLET 500 MG QL (60 per
30 days)

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25
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
AUTONOMIC clobazam oral 3 PA; MO;
suspension QL (480 per
/ CNS DRUGS,
30 days)
NEUROLOGY
clobazam oral tablet 3 PA; MO;
/ PSYCH QL (60 per
ANTICONVULS 30 days)
ANTS clonazepam oral 2 PA; MO;
tablet 0.5 mg, 1 mg QL (90 per
APTIOM ORAL 4 MO; QL
30 days)
TABLET 200 MG (180 per 30
days) clonazepam oral 2 PA; MO;
tablet 2 mg QL (300 per
APTIOM ORAL 4 MO; QL
30 days)
TABLET 400 MG (90 per 30
days) clonazepam oral 3 PA; MO;
tablet,disintegrating QL (90 per
APTIOM ORAL 4 MO; QL
0.125 mg, 0.25 mg, 30 days)
TABLET 600 MG, (60 per 30
0.5 mg, 1 mg
800 MG days)
clonazepam oral 3 PA; MO;
BANZEL 5 PA; MO
tablet,disintegrating QL (300 per
BRIVIACT 4 2 mg 30 days)
INTRAVENOUS
DIASTAT 4 MO
BRIVIACT ORAL 4 MO; QL
DIASTAT 4 MO
SOLUTION (600 per 30
ACUDIAL
days)
diazepam rectal 2 MO
BRIVIACT ORAL 4 MO; QL
TABLET (60 per 30 DILANTIN 30 4 MO
days) MG
carbamazepine oral 4 MO divalproex oral 4 MO
capsule, er capsule, delayed rel
multiphase 12 hr sprinkle
carbamazepine oral 4 MO divalproex oral 4 MO
suspension 100 mg/5 tablet extended
ml release 24 hr
carbamazepine oral 4 MO divalproex oral 2 MO
tablet tablet,delayed
release (dr/ec)
carbamazepine oral 4 MO
tablet extended EPIDIOLEX 5 PA; MO;
release 12 hr LA
carbamazepine oral 2 MO epitol 2 MO
tablet,chewable ethosuximide 4 MO
CELONTIN 3 MO felbamate 4 MO
ORAL CAPSULE fosphenytoin 2 MO
300 MG

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26

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
FYCOMPA 4 PA; MO; lamotrigine oral 2 MO
ORAL QL (720 per tablet, chewable
SUSPENSION 30 days) dispersible
FYCOMPA 4 PA; MO; lamotrigine oral 3 MO
ORAL TABLET QL (30 per tablets,dose pack
10 MG, 12 MG, 8 30 days) levetiracetam in 3
MG nacl (iso-os)
FYCOMPA 4 PA; MO; intravenous
ORAL TABLET 2 QL (180 per piggyback 1,000
MG 30 days) mg/100 ml, 1,500
FYCOMPA 4 PA; MO; mg/100 ml
ORAL TABLET 4 QL (90 per levetiracetam in 3 MO
MG 30 days) nacl (iso-os)
FYCOMPA 4 PA; MO; intravenous
ORAL TABLET 6 QL (60 per piggyback 500
MG 30 days) mg/100 ml
gabapentin oral 2 PA; MO; levetiracetam 3 MO
capsule 100 mg QL (1080 intravenous
per 30 days) levetiracetam oral 3 MO
gabapentin oral 2 PA; MO; solution 100 mg/ml
capsule 300 mg QL (360 per levetiracetam oral 3
30 days) solution 500 mg/5
gabapentin oral 2 PA; MO; ml (5 ml)
capsule 400 mg QL (270 per levetiracetam oral 2 MO
30 days) tablet
gabapentin oral 4 PA; MO; LYRICA ORAL 3 PA; MO;
solution 250 mg/5 QL (2160 CAPSULE 100 QL (90 per
ml per 30 days) MG, 150 MG, 200 30 days)
gabapentin oral 4 PA; QL MG, 25 MG, 50
solution 250 mg/5 (2160 per MG, 75 MG
ml (5 ml), 300 mg/6 30 days) LYRICA ORAL 3 PA; MO;
ml (6 ml) CAPSULE 225 QL (60 per
gabapentin oral 2 PA; MO; MG, 300 MG 30 days)
tablet 600 mg QL (180 per LYRICA ORAL 3 PA; MO;
30 days) SOLUTION QL (900 per
gabapentin oral 2 PA; MO; 30 days)
tablet 800 mg QL (120 per ONFI ORAL 5 PA; MO;
30 days) SUSPENSION QL (480 per
lamotrigine oral 2 MO 30 days)
tablet ONFI ORAL 5 PA; MO;
TABLET 10 MG, QL (60 per
20 MG 30 days)

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27
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
oxcarbazepine oral 3 MO subvenite starter 3 MO
suspension (orange) kit
oxcarbazepine oral 2 MO SYMPAZAN 4 PA; MO;
tablet QL (60 per
PEGANONE 4 MO 30 days)
phenobarbital oral 3 PA; MO; tiagabine 4 MO
elixir QL (1500 topiramate oral 3 PA; MO
per 30 days) capsule, sprinkle
phenobarbital oral 2 PA; MO; topiramate oral 3 PA; MO
tablet QL (120 per tablet
30 days) valproate sodium 2 MO
phenobarbital 3 MO valproic acid 2 MO
sodium injection
valproic acid (as 2 MO
solution 130 mg/ml
sodium salt) oral
phenobarbital 3 solution 250 mg/5
sodium injection ml
solution 65 mg/ml
valproic acid (as 2
phenytoin oral 2 sodium salt) oral
suspension 100 mg/4 solution 250 mg/5
ml ml (5 ml), 500
phenytoin oral 2 MO mg/10 ml (10 ml)
suspension 125 mg/5 vigabatrin oral 3 PA; MO;
ml powder in packet LA; QL
phenytoin oral 2 MO (180 per 30
tablet,chewable days)
phenytoin sodium 2 MO vigabatrin oral 5 PA; MO;
extended tablet LA; QL
phenytoin sodium 2 MO (180 per 30
intravenous solution days)
primidone 2 MO vigadrone 3 PA; MO;
LA; QL
roweepra 2 MO
(180 per 30
SABRIL ORAL 5 PA; MO; days)
TABLET LA; QL
VIMPAT 4
(180 per 30
INTRAVENOUS
days)
VIMPAT ORAL 4 MO; QL
SPRITAM 4 MO
SOLUTION (1200 per
subvenite 3 MO 30 days)
subvenite starter 3 MO VIMPAT ORAL 4 MO; QL
(blue) kit TABLET (60 per 30
subvenite starter 3 MO days)
(green) kit zonisamide 3 PA; MO

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28
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
ANTIPARKINS rizatriptan 4 MO; QL
ONISM (36 per 28
AGENTS days)
sumatriptan nasal 4 MO; QL
APOKYN 5 PA; MO;
spray,non-aerosol (18 per 28
LA; QL (60
20 mg/actuation days)
per 30 days)
sumatriptan nasal 4 MO; QL
benztropine 4 MO
spray,non-aerosol 5 (36 per 28
injection
mg/actuation days)
benztropine oral 3 PA; MO
sumatriptan 2 MO; QL
bromocriptine 4 MO succinate oral (18 per 28
carbidopa 5 MO days)
carbidopa-levodopa 2 MO sumatriptan 3 MO; QL (8
oral tablet succinate per 28 days)
carbidopa-levodopa 2 MO subcutaneous
oral tablet extended cartridge
release sumatriptan 3 MO; QL (8
carbidopa-levodopa 4 MO succinate per 28 days)
oral subcutaneous pen
tablet,disintegrating injector
carbidopa-levodopa- 4 MO sumatriptan 3 MO; QL (8
entacapone succinate per 28 days)
subcutaneous
entacapone 3 MO
solution
NEUPRO 4 MO
sumatriptan 3 MO; QL (8
pramipexole oral 2 MO succinate per 28 days)
tablet subcutaneous
rasagiline 3 MO syringe 6 mg/0.5 ml
ropinirole oral 2 MO MISCELLANEO
tablet US
selegiline hcl 2 MO NEUROLOGICA
MIGRAINE / L THERAPY
CLUSTER AMPYRA 5 PA; MO;
HEADACHE LA; QL (60
THERAPY per 30 days)
dihydroergotamine 2 MO dalfampridine 5 PA; MO;
injection QL (60 per
30 days)
ergotamine-caffeine 3 MO
donepezil oral tablet 2 MO; QL
migergot 4 MO
10 mg (69 per 30
days)

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29
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
donepezil oral tablet 2 MO; QL MEMANTINE 3 PA; MO;
5 mg (30 per 30 ORAL QL (98 per
days) TABLETS,DOSE 28 days)
donepezil oral 2 MO; QL PACK
tablet,disintegrating (69 per 30 NAMENDA 3 PA; MO
10 mg days) TITRATION PAK
donepezil oral 2 MO; QL NAMZARIC 3 PA; MO
tablet,disintegrating (30 per 30 NUEDEXTA 3 PA; MO
5 mg days)
OCREVUS 5 PA; MO;
FIRDAPSE 5 PA; MO; LA
LA
RADICAVA 5 PA; MO
galantamine oral 3 MO; QL
rivastigmine 3 MO
capsule,ext rel. (30 per 30
pellets 24 hr days) rivastigmine tartrate 4 MO; QL
(60 per 30
galantamine oral 4 MO; QL
days)
solution (200 per 30
days) TECFIDERA 5 PA; MO;
LA
galantamine oral 4 MO; QL
tablet (60 per 30 tetrabenazine oral 5 PA; MO;
days) tablet 12.5 mg QL (240 per
30 days)
glatiramer 5 PA; MO;
subcutaneous QL (30 per tetrabenazine oral 5 PA; MO;
syringe 20 mg/ml 30 days) tablet 25 mg QL (120 per
30 days)
glatiramer 5 PA; MO;
subcutaneous QL (12 per TYSABRI 5 PA; MO;
syringe 40 mg/ml 28 days) LA
glatopa 5 PA; MO; MUSCLE
subcutaneous QL (30 per RELAXANTS /
syringe 20 mg/ml 30 days) ANTISPASMOD
glatopa 5 PA; MO; IC THERAPY
subcutaneous QL (12 per baclofen oral tablet 2 MO
syringe 40 mg/ml 28 days) 10 mg, 20 mg
LEMTRADA 5 PA; MO cyclobenzaprine 4 PA; MO
memantine oral 3 PA; MO oral tablet
capsule,sprinkle,er dantrolene 4 MO
24hr
LIORESAL 5 B/D PA;
memantine oral 3 PA; MO; INTRATHECAL MO
solution QL (300 per SOLUTION 2,000
30 days) MCG/ML
memantine oral 3 PA; MO;
tablet QL (60 per
30 days)

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30

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
LIORESAL 3 B/D PA acetaminophen- 2 MO; QL
INTRATHECAL codeine oral tablet (360 per 30
SOLUTION 50 300-15 mg, 300-30 days)
MCG/ML mg
LIORESAL 3 B/D PA; acetaminophen- 2 MO; QL
INTRATHECAL MO codeine oral tablet (180 per 30
SOLUTION 500 300-60 mg days)
MCG/ML buprenorphine hcl 4 MO
MESTINON 5 MO injection solution
ORAL SYRUP buprenorphine hcl 4
neostigmine 3 MO injection syringe
methylsulfate buprenorphine hcl 3 PA; MO
intravenous solution sublingual
0.5 mg/ml
buprenorphine 3 PA; MO;
neostigmine 3 transdermal patch QL (4 per
methylsulfate weekly 10 mcg/hour, 28 days)
intravenous solution 15 mcg/hour, 20
1 mg/ml mcg/hour, 5
pyridostigmine 3 MO mcg/hour
bromide oral syrup BUTRANS 4 PA; MO;
pyridostigmine 3 MO TRANSDERMAL QL (8 per
bromide oral tablet PATCH WEEKLY 28 days)
60 mg 7.5 MCG/HOUR
pyridostigmine 3 MO codeine sulfate oral 4 MO; QL
bromide oral tablet tablet (180 per 30
extended release days)
regonol 3 duramorph (pf) 4 MO; QL
revonto 3 injection solution (4000 per
0.5 mg/ml 30 days)
tizanidine oral 2 MO
tablet duramorph (pf) 4 QL (2000
injection solution 1 per 30 days)
NARCOTIC mg/ml
ANALGESICS
endocet oral tablet 4 MO; QL
acetaminophen- 2 QL (4500 10-325 mg, 2.5-325 (360 per 30
codeine oral solution per 30 days) mg, 5-325 mg, 7.5- days)
120 mg-12 mg /5 ml 325 mg
(5 ml), 300 mg-30 fentanyl citrate (pf) 3 MO; QL
mg /12.5 ml injection solution (400 per 30
acetaminophen- 2 MO; QL days)
codeine oral solution (4500 per
120-12 mg/5 ml 30 days)

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
fentanyl citrate (pf) 3 QL (400 per HYDROMORPH 4 QL (600 per
intravenous syringe 30 days) ONE (PF) 30 days)
100 mcg/2 ml (50 INJECTION
mcg/ml) SOLUTION 4
fentanyl citrate 5 PA; MO; MG/ML
buccal lozenge on a QL (120 per hydromorphone 4 QL (2400
handle 30 days) injection solution 1 per 30 days)
fentanyl 3 PA; MO; mg/ml
transdermal patch QL (10 per hydromorphone 4 MO; QL
72 hour 100 mcg/hr, 30 days) injection solution 2 (1200 per
12 mcg/hr, 25 mg/ml 30 days)
mcg/hr, 50 mcg/hr, hydromorphone 4 MO; QL
75 mcg/hr injection solution 4 (600 per 30
hydrocodone- 4 QL (5550 mg/ml days)
acetaminophen oral per 30 days) hydromorphone 4 MO; QL
solution 10-325 injection syringe 1 (2400 per
mg/15 ml(15 ml) mg/ml 30 days)
hydrocodone- 4 MO; QL hydromorphone 4 QL (1200
acetaminophen oral (5550 per injection syringe 2 per 30 days)
solution 7.5-325 30 days) mg/ml
mg/15 ml
hydromorphone oral 2 MO; QL
hydrocodone- 4 MO; QL liquid (2400 per
acetaminophen oral (360 per 30 30 days)
tablet 10-325 mg, 5- days)
hydromorphone oral 4 MO; QL
325 mg, 7.5-325 mg
tablet (180 per 30
hydrocodone- 4 MO; QL days)
ibuprofen oral tablet (50 per 30
methadone injection 4 QL (150 per
7.5-200 mg days)
solution 30 days)
HYDROMORPH 4 QL (2400
methadone intensol 4 PA; MO;
ONE (PF) per 30 days)
QL (90 per
INJECTION
30 days)
SOLUTION 1
MG/ML methadone oral 4 PA; MO;
concentrate QL (90 per
hydromorphone 4 MO; QL
30 days)
(pf) injection (240 per 30
solution 10 (mg/ml) days) methadone oral 4 PA; MO;
(5 ml), 10 mg/ml solution 10 mg/5 ml QL (600 per
30 days)
hydromorphone 4 QL (1200
(pf) injection per 30 days) methadone oral 4 PA; MO;
solution 2 mg/ml solution 5 mg/5 ml QL (1200
per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
32
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
methadone oral 2 PA; MO; morphine injection 4 MO; QL
tablet 10 mg QL (120 per syringe 4 mg/ml (500 per 30
30 days) days)
methadone oral 2 PA; MO; morphine 4 MO; QL
tablet 5 mg QL (240 per intravenous solution (200 per 30
30 days) 10 mg/ml days)
methadose oral 3 PA; MO; MORPHINE 4 MO; QL
concentrate QL (90 per INTRAVENOUS (500 per 30
30 days) SOLUTION 4 days)
morphine (pf) 4 QL (4000 MG/ML
injection solution per 30 days) morphine 4 QL (1000
0.5 mg/ml intravenous syringe per 30 days)
morphine (pf) 4 MO; QL 2 mg/ml
injection solution 1 (2000 per morphine 4 QL (500 per
mg/ml 30 days) intravenous syringe 30 days)
morphine (pf) 4 B/D PA; 4 mg/ml
intravenous patient MO; QL morphine oral 4 MO; QL
control.analgesia (400 per 30 solution (900 per 30
soln 150 mg/30 ml days) days)
morphine (pf) 4 B/D PA; morphine oral tablet 2 MO; QL
intravenous patient QL (2000 (180 per 30
control.analgesia per 30 days) days)
soln 30 mg/30 ml morphine oral tablet 3 PA; MO;
morphine 4 MO; QL extended release QL (120 per
concentrate oral (900 per 30 30 days)
solution days) oxycodone oral 4 MO; QL
MORPHINE 4 QL (200 per capsule (360 per 30
INJECTION 30 days) days)
SOLUTION 10 oxycodone oral 4 MO; QL
MG/ML concentrate (180 per 30
MORPHINE 4 QL (1000 days)
INJECTION per 30 days) oxycodone oral 4 MO; QL
SOLUTION 2 solution (1200 per
MG/ML 30 days)
MORPHINE 4 QL (500 per OXYCODONE 4 QL (180 per
INJECTION 30 days) ORAL SYRINGE 30 days)
SOLUTION 4
oxycodone oral 4 MO; QL
MG/ML
tablet 10 mg, 15 mg, (180 per 30
morphine injection 4 MO; QL 20 mg, 30 mg days)
syringe 2 mg/ml (1000 per
oxycodone oral 4 MO; QL
30 days)
tablet 5 mg (360 per 30
days)

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
33
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
oxycodone- 2 MO; QL ibuprofen oral 2 MO
acetaminophen oral (360 per 30 suspension
tablet 10-325 mg, days) ibuprofen oral tablet 2 MO
2.5-325 mg, 5-325 400 mg, 600 mg,
mg, 7.5-325 mg 800 mg
oxycodone-aspirin 4 MO; QL meloxicam oral 1 MO; QL
(360 per 30 tablet (30 per 30
days) days)
oxymorphone oral 3 PA; MO; naloxone 2 MO
tablet extended QL (90 per
naltrexone 2 MO
release 12 hr 30 days)
naproxen oral 2 MO
NON- suspension
NARCOTIC
naproxen oral tablet 1 MO
ANALGESICS
NARCAN NASAL 3 MO
buprenorphine- 2 MO; QL SPRAY,NON-
naloxone sublingual (60 per 30 AEROSOL 4
film 12-3 mg days) MG/ACTUATION
buprenorphine- 2 MO; QL oxaprozin 4 MO
naloxone sublingual (360 per 30
salsalate 3 MO
film 2-0.5 mg days)
SUBOXONE 3 MO; QL
buprenorphine- 2 MO; QL
SUBLINGUAL (60 per 30
naloxone sublingual (90 per 30
FILM 12-3 MG days)
film 4-1 mg, 8-2 mg days)
SUBOXONE 3 MO; QL
butorphanol tartrate 2 MO; QL
SUBLINGUAL (360 per 30
nasal (10 per 28
FILM 2-0.5 MG days)
days)
SUBOXONE 3 MO; QL
celecoxib 3 MO; QL
SUBLINGUAL (90 per 30
(60 per 30
FILM 4-1 MG, 8-2 days)
days)
MG
diclofenac sodium 2 MO; QL
sulindac 2 MO
topical drops (300 per 28
days) tolmetin oral tablet 4 MO
200 mg
diclofenac sodium 2 MO; QL
topical gel 1 % (1000 per tramadol oral tablet 2 MO; QL
28 days) (240 per 30
days)
diflunisal 4 MO
VIVITROL 5 MO
etodolac oral 2 MO
capsule PSYCHOTHER
etodolac oral tablet 2 MO APEUTIC
ibu 1 MO
DRUGS

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
34
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
ABILIFY 4 MO; QL (1 clorazepate 4 PA; MO;
MAINTENA per 28 days) dipotassium oral QL (180 per
ADASUVE 4 LA tablet 15 mg 30 days)
amitriptyline 2 PA; MO clorazepate 4 PA; MO;
dipotassium oral QL (90 per
amoxapine 2 MO
tablet 3.75 mg 30 days)
aripiprazole oral 5 PA; MO
clorazepate 4 PA; MO;
solution
dipotassium oral QL (360 per
aripiprazole oral 3 PA; MO; tablet 7.5 mg 30 days)
tablet QL (30 per
clozapine oral tablet 3 MO
30 days)
clozapine oral 4
aripiprazole oral 5 PA; MO;
tablet,disintegrating
tablet,disintegrating QL (60 per
100 mg, 12.5 mg, 25
30 days)
mg
atomoxetine oral 3 MO; QL
desipramine 4 MO
capsule 10 mg, 18 (60 per 30
mg, 25 mg, 40 mg days) desvenlafaxine 3 MO; QL
succinate (30 per 30
atomoxetine oral 3 MO; QL
days)
capsule 100 mg, 60 (30 per 30
mg, 80 mg days) dextroamphetamine 4 MO
oral capsule,
bupropion hcl oral 2 MO; QL
extended release
tablet (180 per 30
days) dextroamphetamine 4 MO
oral solution
bupropion hcl oral 2 MO; QL
tablet extended (90 per 30 dextroamphetamine 2 MO
release 24 hr 150 mg days) oral tablet
bupropion hcl oral 2 MO; QL dextroamphetamine 3 MO; QL
tablet extended (30 per 30 -amphetamine oral (30 per 30
release 24 hr 300 mg days) capsule,extended days)
release 24hr 10 mg,
bupropion hcl oral 3 MO; QL
15 mg
tablet sustained- (60 per 30
release 12 hr days) dextroamphetamine 3 MO; QL
-amphetamine oral (60 per 30
buspirone 2 MO
capsule,extended days)
chlorpromazine 4 MO release 24hr 20 mg,
citalopram oral 2 MO 25 mg, 30 mg, 5 mg
solution diazepam injection 2 PA
citalopram oral 1 MO; QL solution
tablet (30 per 30 diazepam injection 2 PA; MO
days) syringe
clomipramine 4 PA; MO diazepam intensol 2 PA; MO;
QL (240 per
30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
35
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
diazepam oral 2 PA; MO; FETZIMA ORAL 4 ST; MO;
concentrate QL (240 per CAPSULE,EXTE QL (30 per
30 days) NDED RELEASE 30 days)
diazepam oral 2 PA; MO; 24 HR
solution 5 mg/5 ml QL (1200 fluoxetine oral 1 MO; QL
(1 mg/ml) per 30 days) capsule 10 mg (30 per 30
diazepam oral tablet 2 PA; MO; days)
QL (120 per fluoxetine oral 1 MO
30 days) capsule 20 mg
doxepin oral 4 PA; MO fluoxetine oral 1 MO; QL
duloxetine oral 3 MO; QL capsule 40 mg (60 per 30
capsule,delayed (60 per 30 days)
release(dr/ec) 20 days) fluoxetine oral 2 MO
mg, 30 mg, 60 mg solution
duloxetine oral 3 MO; QL fluoxetine oral 2 MO; QL
capsule,delayed (90 per 30 tablet 10 mg (30 per 30
release(dr/ec) 40 days) days)
mg fluoxetine oral 2 MO
EMSAM 4 MO; QL tablet 20 mg, 60 mg
(30 per 30 fluphenazine 4 MO
days) decanoate
escitalopram 4 MO; QL fluphenazine hcl 4 MO
oxalate oral solution (600 per 30 injection
days)
fluphenazine hcl 2 MO
escitalopram 2 MO; QL oral concentrate
oxalate oral tablet (30 per 30
fluphenazine hcl 4 MO
days)
oral elixir
FANAPT ORAL 4 PA; MO;
fluphenazine hcl 2 MO
TABLET QL (60 per
oral tablet
30 days)
fluvoxamine oral 4 MO; QL
FANAPT ORAL 4 PA; MO;
tablet 100 mg (90 per 30
TABLETS,DOSE QL (8 per
days)
PACK 28 days)
fluvoxamine oral 4 MO; QL
FAZACLO ORAL 4
tablet 25 mg (30 per 30
TABLET,DISINT
days)
EGRATING 150
MG, 200 MG fluvoxamine oral 4 MO; QL
tablet 50 mg (60 per 30
FETZIMA ORAL 4 ST; MO;
days)
CAPSULE,EXT QL (28 per
REL 24HR DOSE 28 days) GEODON 4 MO; QL
PACK INTRAMUSCUL (60 per 30
AR days)

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36
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
haloperidol 2 MO INVEGA 4 MO; QL
haloperidol 4 MO TRINZA (0.88 per 28
decanoate INTRAMUSCUL days)
AR SYRINGE 273
haloperidol lactate 2 MO
MG/0.875 ML
injection
INVEGA 4 MO; QL
haloperidol lactate 2
TRINZA (1.32 per 28
intramuscular
INTRAMUSCUL days)
haloperidol lactate 2 MO AR SYRINGE 410
oral MG/1.315 ML
HETLIOZ 5 PA; MO; INVEGA 4 MO; QL
QL (30 per TRINZA (1.76 per 28
30 days) INTRAMUSCUL days)
imipramine hcl 4 PA; MO AR SYRINGE 546
INVEGA 4 MO; QL MG/1.75 ML
SUSTENNA (0.75 per 28 INVEGA 4 MO; QL
INTRAMUSCUL days) TRINZA (2.63 per 28
AR SYRINGE 117 INTRAMUSCUL days)
MG/0.75 ML AR SYRINGE 819
INVEGA 4 MO; QL (1 MG/2.625 ML
SUSTENNA per 28 days) LATUDA ORAL 4 PA; MO;
INTRAMUSCUL TABLET 120 MG, QL (30 per
AR SYRINGE 156 20 MG, 40 MG, 60 30 days)
MG/ML MG
INVEGA 4 MO; QL LATUDA ORAL 4 PA; MO;
SUSTENNA (1.5 per 28 TABLET 80 MG QL (60 per
INTRAMUSCUL days) 30 days)
AR SYRINGE 234 lithium carbonate 2 MO
MG/1.5 ML
lithium citrate oral 2 MO
INVEGA 4 MO; QL solution 8 meq/5 ml
SUSTENNA (0.25 per 28
lorazepam injection 4 PA; MO
INTRAMUSCUL days)
solution
AR SYRINGE 39
MG/0.25 ML lorazepam injection 4 PA
syringe
INVEGA 4 MO; QL
SUSTENNA (0.5 per 28 lorazepam intensol 3 PA; MO;
INTRAMUSCUL days) QL (150 per
AR SYRINGE 78 30 days)
MG/0.5 ML lorazepam oral 3 PA; MO;
concentrate QL (150 per
30 days)

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37
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
lorazepam oral 2 PA; MO; NUPLAZID 4 PA; MO;
tablet 0.5 mg, 1 mg QL (90 per ORAL TABLET QL (30 per
30 days) 10 MG 30 days)
lorazepam oral 2 PA; MO; olanzapine 4 MO; QL
tablet 2 mg QL (150 per intramuscular (30 per 30
30 days) days)
loxapine succinate 2 MO olanzapine oral 3 PA; MO;
maprotiline 2 MO tablet QL (30 per
30 days)
MARPLAN 3 MO; QL
(180 per 30 olanzapine oral 4 PA; MO;
days) tablet,disintegrating QL (30 per
30 days)
methylphenidate hcl 3 MO
oral capsule, er paliperidone oral 4 PA; MO;
biphasic 30-70 tablet extended QL (30 per
release 24hr 1.5 mg, 30 days)
methylphenidate hcl 4 MO
3 mg
oral capsule,er
biphasic 50-50 paliperidone oral 4 PA; MO;
tablet extended QL (60 per
methylphenidate hcl 4 MO; QL
release 24hr 6 mg 30 days)
oral solution 10 (900 per 30
mg/5 ml days) paliperidone oral 5 PA; MO;
tablet extended QL (30 per
methylphenidate hcl 4 MO; QL
release 24hr 9 mg 30 days)
oral solution 5 mg/5 (1800 per
ml 30 days) paroxetine hcl oral 1 MO; QL
tablet 10 mg, 20 mg, (30 per 30
methylphenidate hcl 2 MO; QL
40 mg days)
oral tablet (90 per 30
days) paroxetine hcl oral 1 MO; QL
tablet 30 mg (60 per 30
mirtazapine 2 MO; QL
days)
(30 per 30
days) PAXIL ORAL 4 MO; QL
SUSPENSION (900 per 30
modafinil oral tablet 3 PA; MO;
days)
100 mg QL (30 per
30 days) perphenazine 4 MO
modafinil oral tablet 3 PA; MO; PERSERIS 4 MO; QL (1
200 mg QL (60 per per 28 days)
30 days) phenelzine 2 MO
molindone 3 pimozide 4 MO
nefazodone 4 MO protriptyline 4 MO
nortriptyline 2 MO quetiapine oral 2 PA; MO;
NUPLAZID 4 PA; MO; tablet 100 mg, 200 QL (90 per
ORAL CAPSULE QL (30 per mg, 25 mg, 50 mg 30 days)
30 days)

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38

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
quetiapine oral 2 PA; MO; sertraline oral tablet 1 MO; QL
tablet 300 mg, 400 QL (60 per 100 mg, 50 mg (60 per 30
mg 30 days) days)
quetiapine oral 4 PA; MO; sertraline oral tablet 1 MO; QL
tablet extended QL (30 per 25 mg (30 per 30
release 24 hr 150 30 days) days)
mg, 200 mg thioridazine 4 MO
quetiapine oral 4 PA; MO; thiothixene 4 MO
tablet extended QL (60 per
tranylcypromine 4 MO
release 24 hr 300 30 days)
mg, 400 mg, 50 mg trazodone 2 MO
REXULTI 4 PA; MO; trifluoperazine 2 MO
QL (30 per trimipramine 4 PA; MO
30 days) TRINTELLIX 4 MO; QL
RISPERDAL 4 MO; QL (2 (30 per 30
CONSTA per 28 days) days)
risperidone oral 4 MO venlafaxine oral 2 MO; QL
solution capsule,extended (30 per 30
risperidone oral 2 PA; MO; release 24hr 150 days)
tablet 0.25 mg, 0.5 QL (60 per mg, 37.5 mg
mg, 1 mg, 2 mg, 3 30 days) venlafaxine oral 2 MO; QL
mg capsule,extended (90 per 30
risperidone oral 2 PA; MO; release 24hr 75 mg days)
tablet 4 mg QL (120 per venlafaxine oral 2 MO; QL
30 days) tablet (90 per 30
risperidone oral 4 PA; MO; days)
tablet,disintegrating QL (60 per VERSACLOZ 5
0.25 mg, 0.5 mg, 1 30 days) VIIBRYD ORAL 3 MO; QL
mg, 2 mg, 3 mg TABLET (30 per 30
risperidone oral 4 PA; MO; days)
tablet,disintegrating QL (120 per VIIBRYD ORAL 3 MO; QL
4 mg 30 days) TABLETS,DOSE (30 per 180
ROZEREM 3 MO; QL PACK 10 MG (7)- days)
(30 per 30 20 MG (23)
days) VRAYLAR ORAL 4 PA; MO;
SAPHRIS 4 PA; MO; CAPSULE QL (30 per
QL (60 per 30 days)
30 days) VRAYLAR ORAL 4 PA; MO;
sertraline oral 4 MO CAPSULE,DOSE QL (7 per
concentrate PACK 30 days)

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
XYREM 5 PA; MO; dofetilide 3 MO
LA; QL flecainide 2 MO
(540 per 30
lidocaine (pf) 2 MO
days)
intravenous solution
ziprasidone hcl 4 PA; MO;
lidocaine (pf) 2
QL (60 per
intravenous syringe
30 days)
mexiletine 2 MO
zolpidem oral tablet 2 ST; MO;
QL (30 per MULTAQ 4 MO
30 days) pacerone oral tablet 4 MO
ZYPREXA 4 PA; MO; 100 mg
RELPREVV QL (2 per pacerone oral tablet 2 MO
INTRAMUSCUL 28 days) 200 mg
AR SUSPENSION propafenone oral 4 MO
FOR capsule,extended
RECONSTITUTI release 12 hr
ON 210 MG, 300
propafenone oral 2 MO
MG
tablet 150 mg, 225
ZYPREXA 4 PA; MO; mg
RELPREVV QL (1 per
propafenone oral 4 MO
INTRAMUSCUL 28 days)
tablet 300 mg
AR SUSPENSION
FOR quinidine gluconate 4 MO
RECONSTITUTI oral
ON 405 MG quinidine sulfate 2 MO
CARDIOVAS oral tablet
CULAR, sorine oral tablet 2 MO
120 mg, 160 mg, 80
HYPERTENSI mg
ON / LIPIDS sorine oral tablet 2
ANTIARRHYTH 240 mg
MIC AGENTS sotalol af 2 MO
adenosine 3 sotalol oral tablet 2 MO
120 mg, 160 mg, 80
amiodarone 2 B/D PA;
mg
intravenous solution MO
sotalol oral tablet 4 MO
amiodarone 2 B/D PA
240 mg
intravenous syringe
SOTYLIZE 3 MO
amiodarone oral 2 MO
tablet 100 mg, 200 ANTIHYPERTE
mg NSIVE
amiodarone oral 4 MO THERAPY
tablet 400 mg acebutolol 2 MO

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
40
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
amiloride 3 MO DEMSER 4 PA; MO
amiloride- 2 MO diltiazem hcl 4
hydrochlorothiazide intravenous
amlodipine 1 MO diltiazem hcl oral 3 MO
amlodipine- 4 MO capsule,ext.rel 24h
benazepril degradable 180 mg
atenolol 1 MO diltiazem hcl oral 2 MO
capsule,ext.rel 24h
atenolol- 2 MO
degradable 240 mg
chlorthalidone
diltiazem hcl oral 3 MO
benazepril 1 MO
capsule,extended
benazepril- 2 MO release 12 hr
hydrochlorothiazide
diltiazem hcl oral 2 MO
BIDIL 3 MO capsule,extended
bisoprolol fumarate 2 MO release 24 hr 120
bisoprolol- 1 MO mg, 240 mg, 300 mg
hydrochlorothiazide diltiazem hcl oral 3 MO
bumetanide 4 MO capsule,extended
injection release 24 hr 180
mg, 360 mg, 420 mg
bumetanide oral 2 MO
diltiazem hcl oral 2 MO
candesartan oral 3 MO; QL
capsule,extended
tablet 16 mg, 4 mg, (60 per 30
release 24hr 120
8 mg days)
mg, 240 mg, 300 mg
candesartan oral 3 MO; QL
diltiazem hcl oral 3 MO
tablet 32 mg (30 per 30
capsule,extended
days)
release 24hr 180
cartia xt oral 2 MO mg, 360 mg
capsule,extended
diltiazem hcl oral 2 MO
release 24hr 120
tablet
mg, 180 mg, 240 mg
diltiazem hcl oral 3 MO
cartia xt oral 3 MO
tablet extended
capsule,extended
release 24 hr
release 24hr 300 mg
dilt-xr 2 MO
carvedilol 1 MO
doxazosin oral 2 MO; QL
chlorothiazide 2 MO
tablet 1 mg, 2 mg, 4 (30 per 30
chlorthalidone oral 2 MO mg days)
tablet 25 mg, 50 mg
doxazosin oral 2 MO; QL
clonidine 4 MO; QL (4 tablet 8 mg (60 per 30
per 28 days) days)
clonidine hcl oral 2 MO enalapril maleate 2 MO
tablet

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
enalaprilat 3 metoprolol 2 MO
intravenous solution succinate
enalapril- 2 MO metoprolol ta- 4 MO
hydrochlorothiazide hydrochlorothiaz
eplerenone 4 MO metoprolol tartrate 2 MO
epoprostenol 3 B/D PA; intravenous solution
(glycine) MO metoprolol tartrate 1 MO
felodipine 4 MO oral
furosemide injection 4 MO minoxidil oral 2 MO
furosemide oral 2 MO nifedipine oral 3 MO
solution 10 mg/ml, tablet extended
40 mg/5 ml (8 release
mg/ml) nifedipine oral 3 MO
furosemide oral 1 MO tablet extended
tablet release 24hr
hydralazine 4 MO nimodipine 4 MO
injection olmesartan 2 MO
hydralazine oral 2 MO olmesartan- 2 MO
hydrochlorothiazide 1 MO hydrochlorothiazide
indapamide 2 MO osmitrol 15 % 3
labetalol 2 osmitrol 20 % 3
intravenous syringe phentolamine 3
20 mg/4 ml (5 injection recon soln
mg/ml) pindolol 4 MO
labetalol oral 2 MO prazosin 2 MO
lisinopril 1 MO propranolol 2
lisinopril- 1 MO intravenous
hydrochlorothiazide propranolol oral 4 MO
losartan 2 MO; QL capsule,extended
(30 per 30 release 24 hr
days) propranolol oral 2 MO
losartan- 2 MO; QL solution
hydrochlorothiazide (30 per 30 propranolol oral 2 MO
days) tablet
mannitol 20 % 3 propranolol- 4 MO
mannitol 25 % 3 MO hydrochlorothiazid
intravenous solution REMODULIN 5 PA; MO;
methyclothiazide 4 MO LA
methyldopa 4 MO RESECTISOL 3
metolazone 2 MO

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
42
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
SODIUM 3 verapamil oral 2 MO
EDECRIN tablet extended
spironolactone oral 2 MO release
tablet 100 mg, 50 COAGULATION
mg THERAPY
spironolactone oral 1 MO AMICAR 3 MO
tablet 25 mg
aminocaproic acid 3 MO
spironolacton- 2 MO intravenous
hydrochlorothiaz
aminocaproic acid 3 MO
terazosin oral 2 MO; QL oral tablet
capsule 1 mg, 2 mg, (30 per 30
5 mg days) BRILINTA 4 MO; QL
(60 per 30
terazosin oral 2 MO; QL days)
capsule 10 mg (60 per 30
days) CABLIVI 5 PA; MO;
INJECTION KIT LA
timolol maleate oral 4 MO
CEPROTIN 3 MO
torsemide oral 2 MO (BLUE BAR)
treprostinil sodium 5 PA; MO; CEPROTIN 3 MO
LA (GREEN BAR)
triamterene- 2 MO cilostazol 2 MO
hydrochlorothiazid
clopidogrel oral 4 MO
UPTRAVI 5 PA; MO; tablet 300 mg
LA
clopidogrel oral 2 MO
valsartan 4 MO; QL tablet 75 mg
(30 per 30
days) dipyridamole oral 4 MO
valsartan- 4 MO; QL DOPTELET (10 5 PA; MO;
hydrochlorothiazide (30 per 30 TAB PACK) LA
days) DOPTELET (15 5 PA; MO;
verapamil 2 MO TAB PACK) LA
intravenous solution ELIQUIS 3 MO
verapamil 2 enoxaparin 4 MO
intravenous syringe subcutaneous
verapamil oral 2 MO solution
capsule, 24 hr er enoxaparin 4 MO; QL
pellet ct subcutaneous (28 per 28
verapamil oral 2 MO syringe 100 mg/ml, days)
capsule,ext rel. 150 mg/ml
pellets 24 hr
verapamil oral 1 MO
tablet

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
enoxaparin 4 MO; QL HEPARIN(PORCI 4
subcutaneous (22.4 per 28 NE) IN 0.45%
syringe 120 mg/0.8 days) NACL
ml, 80 mg/0.8 ml INTRAVENOUS
enoxaparin 4 MO; QL PARENTERAL
subcutaneous (16.8 per 28 SOLUTION 12,500
syringe 30 mg/0.3 days) UNIT/250 ML
ml, 60 mg/0.6 ml heparin(porcine) in 4 MO
enoxaparin 4 MO; QL 0.45% nacl
subcutaneous (11.2 per 28 intravenous
syringe 40 mg/0.4 days) parenteral solution
ml 25,000 unit/250 ml,
25,000 unit/500 ml
fondaparinux 5 MO
subcutaneous heparin, porcine 4 MO
syringe 10 mg/0.8 (pf) injection
ml, 5 mg/0.4 ml, 7.5 solution 1,000
mg/0.6 ml unit/ml
fondaparinux 3 MO heparin, porcine 3 MO
subcutaneous (pf) injection
syringe 2.5 mg/0.5 solution 5,000
ml unit/0.5 ml
heparin (porcine) in 4 heparin, porcine 3 MO
5 % dex intravenous (pf) injection
parenteral solution syringe
20,000 unit/500 ml HEPARIN, 3
(40 unit/ml) PORCINE (PF)
heparin (porcine) in 4 MO SUBCUTANEOU
5 % dex intravenous S
parenteral solution jantoven 1 MO
25,000 unit/250 NPLATE 5 MO
ml(100 unit/ml),
pentoxifylline 2 MO
25,000 unit/500 ml
(50 unit/ml) PRADAXA 4 MO
heparin (porcine) in 3 prasugrel 3 MO
nacl (pf) PROMACTA 5 PA; MO;
heparin (porcine) 4 MO ORAL POWDER LA; QL (30
injection cartridge IN PACKET per 30 days)
heparin (porcine) 3 MO PROMACTA 5 PA; MO;
injection solution ORAL TABLET LA; QL (30
12.5 MG, 25 MG, per 30 days)
heparin (porcine) 4 MO
50 MG
injection syringe
5,000 unit/ml

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
PROMACTA 5 PA; MO; fenofibrate 3 MO; QL
ORAL TABLET LA; QL (60 micronized oral (60 per 30
75 MG per 30 days) capsule 67 mg days)
warfarin 1 MO fenofibrate 3 MO; QL
XARELTO ORAL 3 MO; QL nanocrystallized (30 per 30
TABLET 10 MG (35 per 30 oral tablet 145 mg days)
days) fenofibrate 3 MO; QL
XARELTO ORAL 3 MO; QL nanocrystallized (60 per 30
TABLET 15 MG, (60 per 30 oral tablet 48 mg days)
2.5 MG days) fenofibrate oral 2 MO; QL
XARELTO ORAL 3 MO; QL tablet 160 mg (30 per 30
TABLET 20 MG (30 per 30 days)
days) fenofibrate oral 2 MO; QL
XARELTO ORAL 3 MO; QL tablet 54 mg (60 per 30
TABLETS,DOSE (51 per 30 days)
PACK days) fluvastatin oral 4 MO; QL
LIPID/CHOLES capsule 20 mg (30 per 30
TEROL days)
LOWERING fluvastatin oral 4 MO; QL
AGENTS capsule 40 mg (60 per 30
days)
atorvastatin 1 MO; QL
gemfibrozil 2 MO; QL
(30 per 30
(60 per 30
days)
days)
cholestyramine 3 MO
niacin oral tablet 3 MO
(with sugar)
500 mg
cholestyramine light 3 MO
niacin oral tablet 4 MO
colesevelam oral 3 MO extended release 24
powder in packet hr
colesevelam oral 4 MO PRALUENT 5 PA; MO;
tablet SUBCUTANEOU QL (2 per
ezetimibe 3 MO; QL S PEN INJECTOR 28 days)
(30 per 30 150 MG/ML
days) PRALUENT 5 PA; MO;
ezetimibe- 3 MO; QL SUBCUTANEOU QL (4 per
simvastatin (30 per 30 S PEN INJECTOR 28 days)
days) 75 MG/ML
fenofibrate 3 MO; QL pravastatin 2 MO; QL
micronized oral (30 per 30 (30 per 30
capsule 134 mg, 200 days) days)
mg prevalite 3 MO

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
45
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
REPATHA 5 PA; MO; digoxin oral tablet 2 MO
QL (3 per 250 mcg
28 days) dobutamine 3 B/D PA
REPATHA 5 PA; MO; dobutamine in d5w 3 B/D PA;
PUSHTRONEX QL (3.5 per intravenous MO
28 days) parenteral solution
REPATHA 5 PA; MO; 1,000 mg/250 ml
SURECLICK QL (3 per (4,000 mcg/ml),
28 days) 250 mg/250 ml (1
rosuvastatin 2 MO; QL mg/ml)
(30 per 30 dobutamine in d5w 3 B/D PA
days) intravenous
simvastatin 1 MO; QL parenteral solution
(30 per 30 500 mg/250 ml
days) (2,000 mcg/ml)
VASCEPA 3 MO dopamine in 5 % 3 B/D PA
dextrose
WELCHOL 4 MO
intravenous solution
ORAL POWDER
200 mg/250 ml (800
IN PACKET
mcg/ml), 400
MISCELLANEO mg/250 ml (1,600
US mcg/ml), 400
CARDIOVASCU mg/500 ml (800
LAR AGENTS mcg/ml), 800
mg/500 ml (1,600
CORLANOR 3 PA; MO;
mcg/ml)
QL (60 per
30 days) dopamine in 5 % 3 B/D PA;
dextrose MO
digitek oral tablet 3 MO; QL
intravenous solution
125 mcg (30 per 30
800 mg/250 ml
days)
(3,200 mcg/ml)
digitek oral tablet 3 MO
dopamine 3 B/D PA
250 mcg
intravenous solution
digox oral tablet 2 MO; QL 200 mg/5 ml (40
125 mcg (30 per 30 mg/ml)
days)
dopamine 3 B/D PA;
digox oral tablet 2 MO intravenous solution MO
250 mcg 400 mg/10 ml (40
digoxin oral solution 2 MO mg/ml)
50 mcg/ml ENTRESTO 3 MO; QL
digoxin oral tablet 2 MO; QL (60 per 30
125 mcg (30 per 30 days)
days)

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46

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
LANOXIN ORAL 3 MO nitroglycerin 2 MO
TABLET 187.5 transdermal patch
MCG, 62.5 MCG 24 hour
LANOXIN 3 nitroglycerin 2 MO
PEDIATRIC translingual
milrinone 3 B/D PA; spray,non-aerosol
MO DERMATOL
milrinone in 5 % 3 B/D PA; OGICALS/TO
dextrose MO PICAL
RANEXA 4 MO; QL THERAPY
(60 per 30
days) ANTIPSORIATI
ranolazine 3 MO; QL C/
(60 per 30 ANTISEBORRH
days) EIC
NITRATES acitretin 4 MO
ISORDIL 4 MO calcipotriene scalp 3 MO; QL
isosorbide dinitrate 4 MO (120 per 30
oral tablet 10 mg, days)
20 mg, 5 mg calcipotriene topical 4 MO; QL
isosorbide dinitrate 2 MO (120 per 30
oral tablet 30 mg days)
isosorbide dinitrate 4 calcitrene 4 MO; QL
oral tablet extended (120 per 30
release days)
isosorbide 2 MO selenium sulfide 2 MO
mononitrate topical lotion
nitro-bid 2 MO SKYRIZI 5 PA; MO;
SUBCUTANEOU QL (1 per
nitroglycerin in 5 % 3 B/D PA
S SYRINGE KIT 28 days)
dextrose
intravenous solution MISCELLANEO
100 mg/250 ml (400 US
mcg/ml), 50 mg/250 DERMATOLOG
ml (200 mcg/ml) ICALS
nitroglycerin in 5 % 3 B/D PA; ammonium lactate 2 MO
dextrose MO
DUPIXENT 5 PA; MO
intravenous solution
25 mg/250 ml (100 fluorouracil topical 4 MO
mcg/ml) cream 5 %
nitroglycerin 2 MO fluorouracil topical 4 MO
sublingual solution

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47
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
glydo 2 MO; QL lidocaine viscous 2 MO
(60 per 30 lidocaine-prilocaine 4 MO; QL
days) topical cream (30 per 30
imiquimod topical 3 MO days)
cream in packet methoxsalen 5 MO
lidocaine (pf) 4 MO PANRETIN 4 MO
injection solution 10
podofilox 4 MO
mg/ml (1 %), 5
mg/ml (0.5 %) REGRANEX 5 MO
lidocaine (pf) 2 SANTYL 3 MO
injection solution 15 silver sulfadiazine 2 MO
mg/ml (1.5 %) ssd 2 MO
lidocaine (pf) 2 MO tacrolimus topical 3 PA; MO;
injection solution 20 QL (100 per
mg/ml (2 %), 40 30 days)
mg/ml (4 %)
UVADEX 4 B/D PA
lidocaine hcl 2 MO
VALCHLOR 5 PA; MO
injection solution 10
mg/ml (1 %) THERAPY FOR
lidocaine hcl 4 MO ACNE
injection solution 20 adapalene-benzoyl 3 PA; MO
mg/ml (2 %) peroxide
lidocaine hcl 1 MO claravis 4 MO
injection solution 5 clindamycin 4 MO
mg/ml (0.5 %) phosphate topical
lidocaine hcl 2 MO gel
laryngotracheal clindamycin 4 MO
lidocaine hcl mucous 2 MO; QL phosphate topical
membrane jelly (60 per 30 lotion
days) clindamycin 2 MO
lidocaine hcl mucous 2 MO; QL phosphate topical
membrane jelly in (60 per 30 solution
applicator days) clindamycin 2 MO
lidocaine hcl mucous 2 MO phosphate topical
membrane solution swab
4 % (40 mg/ml) clindamycin-benzoyl 4 MO
lidocaine topical 2 PA; MO; peroxide
adhesive QL (90 per dapsone topical 3 MO
patch,medicated 30 days)
ery pads 4 MO
lidocaine topical 4 MO; QL
ointment (36 per 30 erythromycin with 2 MO
days) ethanol

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48

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
erythromycin- 4 MO ciclopirox topical 4 MO; QL
benzoyl peroxide cream (90 per 28
isotretinoin 3 days)
metronidazole 4 MO ciclopirox topical 4 MO; QL
topical cream gel (45 per 28
days)
metronidazole 4 MO
topical gel 0.75 % ciclopirox topical 4 MO; QL
shampoo (120 per 28
metronidazole 2 MO
days)
topical gel 1 %
ciclopirox topical 2 MO
metronidazole 2 MO
solution
topical gel with
pump ciclopirox topical 4 MO; QL
suspension (60 per 28
metronidazole 4 MO
days)
topical lotion
clotrimazole topical 2 MO; QL
rosadan topical 4 MO
cream (45 per 28
cream
days)
rosadan topical gel 4 MO
clotrimazole topical 2 MO; QL
tazarotene 3 PA; MO solution (30 per 28
TAZORAC 3 PA; MO days)
TOPICAL clotrimazole- 4 MO; QL
CREAM 0.05 % betamethasone (45 per 28
TAZORAC 3 PA; MO topical cream days)
TOPICAL GEL clotrimazole- 4 MO; QL
tretinoin topical 3 PA; MO betamethasone (60 per 28
TOPICAL topical lotion days)
ANTIBACTERIA econazole 4 MO; QL
LS (85 per 28
days)
gentamicin topical 2 MO
ketoconazole topical 2 MO; QL
mafenide acetate 2 MO cream (60 per 28
mupirocin 2 MO days)
sulfacetamide 4 MO ketoconazole topical 2 MO; QL
sodium (acne) shampoo (120 per 28
SULFAMYLON 3 MO days)
TOPICAL naftifine topical 3 MO; QL
CREAM cream (60 per 28
TOPICAL days)
ANTIFUNGALS naftifine topical gel 3 MO
nyamyc 4 MO

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49
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
nystatin topical 2 MO; QL betamethasone 2 MO
cream (30 per 28 valerate topical
days) ointment
nystatin topical 2 MO; QL betamethasone, 2 MO
ointment (30 per 28 augmented topical
days) cream
nystatin topical 2 MO betamethasone, 4 MO
powder augmented topical
nystatin- 4 MO; QL gel
triamcinolone (60 per 28 betamethasone, 4 MO
days) augmented topical
nystop 4 MO lotion
TOPICAL betamethasone, 4 MO
ANTIVIRALS augmented topical
ointment
acyclovir topical 4 PA; MO; clobetasol scalp 2 MO; QL
ointment QL (30 per (100 per 28
30 days) days)
DENAVIR 3 MO clobetasol topical 2 MO; QL
TOPICAL cream (120 per 28
CORTICOSTER days)
OIDS clobetasol topical 2 MO; QL
alclometasone 4 MO gel (120 per 28
topical cream days)
alclometasone 2 MO clobetasol topical 4 MO; QL
topical ointment ointment (120 per 28
days)
amcinonide topical 4 MO
cream clobetasol-emollient 2 MO; QL
topical cream (120 per 28
amcinonide topical 4 MO
days)
lotion
desonide 4 MO
amcinonide topical 4
ointment desoximetasone 4 MO
beser 3 diflorasone 4 MO
betamethasone 4 MO fluocinolone 4 MO
dipropionate fluocinolone and 4 MO
betamethasone 2 MO shower cap
valerate topical fluocinonide topical 2 MO; QL
cream cream 0.05 % (120 per 30
betamethasone 4 MO days)
valerate topical
lotion

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50

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
fluocinonide topical 2 MO; QL prednicarbate 4 MO
gel (120 per 30 triamcinolone 2 MO
days) acetonide topical
fluocinonide topical 2 MO; QL cream
ointment (120 per 30 triamcinolone 2 MO
days) acetonide topical
fluocinonide topical 4 MO; QL lotion
solution (120 per 30 triamcinolone 2 MO
days) acetonide topical
fluocinonide-e 2 MO; QL ointment 0.025 %,
(120 per 30 0.1 %, 0.5 %
days) triderm topical 2 MO
fluocinonide- 2 MO; QL cream
emollient (120 per 30 TOPICAL
days) SCABICIDES /
fluticasone 2 MO PEDICULICIDE
propionate topical S
cream
lindane topical 4 MO
fluticasone 2 MO
shampoo
propionate topical
ointment malathion 4 MO
halobetasol 4 MO NATROBA 4 MO
propionate topical permethrin topical 3 MO
cream cream
halobetasol 4 MO DIAGNOSTIC
propionate topical
S/
ointment
MISCELLAN
hydrocortisone 2 MO
topical cream 1 %, EOUS
2.5 %
­ AGENTS
hydrocortisone 4 MO
ANTIDOTES
topical lotion 2.5 %
acetylcysteine 3 MO
hydrocortisone 2 MO
intravenous
topical ointment 1
%, 2.5 % MISCELLANEO
hydrocortisone 2 MO US AGENTS
valerate topical acamprosate 4 MO
cream alendronate oral 2 MO; QL
hydrocortisone 4 MO tablet 40 mg (30 per 30
valerate topical days)
ointment anagrelide oral 2 MO
mometasone topical 2 MO capsule 0.5 mg

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51
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
anagrelide oral 3 MO levocarnitine (with 4 MO
capsule 1 mg sugar)
caffeine citrate oral 3 MO levocarnitine oral 4 MO
CARBAGLU 5 PA; MO; tablet
LA midodrine oral 4 MO
CHEMET 3 PA; MO tablet 10 mg, 5 mg
d10 %-0.45 % 3 midodrine oral 2 MO
sodium chloride tablet 2.5 mg
d2.5 %-0.45 % 3 NORTHERA 5 PA; MO;
sodium chloride ORAL CAPSULE QL (90 per
100 MG, 200 MG 30 days)
d5 % and 0.9 % 3 MO
sodium chloride NORTHERA 5 PA; MO;
ORAL CAPSULE QL (180 per
d5 %-0.45 % sodium 3 MO
300 MG 30 days)
chloride
ORFADIN ORAL 5 LA
deferasirox 5 PA; MO
CAPSULE 10 MG,
dextrose 10 % and 3 2 MG, 5 MG
0.2 % nacl
ORFADIN ORAL 5 MO; LA
dextrose 10 % in 3 MO CAPSULE 20 MG
water (d10w)
ORFADIN ORAL 5 MO; LA
dextrose 5 % in 3 MO SUSPENSION
water (d5w)
pilocarpine hcl oral 3 MO
dextrose 5 %- 4 MO
PROLASTIN-C 5 PA; LA
lactated ringers
INTRAVENOUS
dextrose 5%-0.2 % 3 RECON SOLN
sod chloride
PROLASTIN-C 5 PA; MO;
dextrose 5%-0.3 % 3 INTRAVENOUS LA
sod.chloride SOLUTION
dextrose with 3 RAVICTI 5 MO
sodium chloride
REVCOVI 5 PA; MO;
disulfiram 4 MO LA
EXJADE 5 PA; MO; riluzole 3 MO
LA
sevelamer carbonate 5 MO
FERRIPROX 5 PA; MO oral powder in
ORAL TABLET packet
INCRELEX 5 PA; MO; sevelamer carbonate 3 MO; QL
LA oral tablet (540 per 30
kionex (with 4 MO days)
sorbitol) sodium chloride 0.9 4 MO
lanthanum 3 MO % intravenous

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52

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
sodium chloride 2 MO NICOTROL 4 MO
irrigation NICOTROL NS 4 MO
sodium polystyrene 4 MO
EAR, NOSE /
sulfonate oral
THROAT
sodium polystyrene 4
sulfonate rectal MEDICATIO
enema 30 gram/120 NS
ml
MISCELLANEO
SODIUM 4 US AGENTS
POLYSTYRENE
SULFONATE azelastine nasal 4 MO; QL
RECTAL ENEMA aerosol,spray (60 per 30
50 GRAM/200 ML days)
SOLIRIS 5 PA; MO
azelastine nasal 2 MO; QL
spray,non-aerosol (60 per 30
sps (with sorbitol) 3 MO
days)
oral
chlorhexidine 2 MO
sps (with sorbitol) 3
gluconate mucous
rectal
membrane
trientine 5 PA; MO;
denta 5000 plus 3 MO
QL (240 per
30 days) dentagel 3 MO
VELTASSA 3 MO fluoride (sodium) 3
dental gel
XIAFLEX 5 MO
ipratropium 2 MO; QL
XURIDEN 5 MO
bromide nasal (30 per 30
zoledronic acid- 3 PA; MO days)
mannitol-water
oralone 4 MO
intravenous
piggyback 5 mg/100 paroex oral rinse 2 MO
ml periogard 2 MO
SMOKING sf 3 MO
DETERRENTS sf 5000 plus 3 MO
bupropion hcl 3 MO; QL sodium fluoride 3
(smoking deter) (60 per 30 5000 plus
days) triamcinolone 4 MO
CHANTIX 3 MO acetonide dental
CHANTIX 3 MO MISCELLANEO
CONTINUING US OTIC
MONTH BOX PREPARATION
CHANTIX 3 MO S
STARTING
MONTH BOX

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53
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
acetic acid otic 3 MO hidex 3
(ear) hydrocortisone oral 2 MO
ciprofloxacin hcl 3 MO methylprednisolone 2 MO
otic (ear) acetate
flac otic oil 4 methylprednisolone 2 B/D PA;
fluocinolone 4 MO oral tablet MO
acetonide oil methylprednisolone 2 MO
hydrocortisone- 4 MO oral tablets,dose
acetic acid pack
ofloxacin otic (ear) 2 MO methylprednisolone 4 MO
OTIC STEROID sodium succ
/ ANTIBIOTIC injection recon soln
125 mg
CIPRODEX 3 MO methylprednisolone 2 MO
CORTISPORIN- 3 MO sodium succ
TC injection recon soln
neomycin- 2 MO 40 mg
polymyxin-hc otic methylprednisolone 4 MO
(ear) sodium succ
ENDOCRINE/ intravenous
DIABETES prednisolone oral 2 MO
solution 15 mg/5 ml
ADRENAL prednisolone sodium 2 MO
HORMONES phosphate oral
cortisone 2 MO solution 10 mg/5 ml,
decadron oral elixir 3 MO 15 mg/5 ml (3
mg/ml), 20 mg/5 ml
decadron oral tablet 3 (4 mg/ml), 25 mg/5
DEPO-MEDROL 3 MO ml (5 mg/ml), 5 mg
dexamethasone 2 MO base/5 ml (6.7 mg/5
dexamethasone 2 MO ml)
intensol prednisone intensol 4 B/D PA;
dexamethasone 2 MO MO
sodium phos (pf) prednisone oral 2 MO
dexamethasone 4 MO solution
sodium phosphate prednisone oral 2 B/D PA;
injection solution tablet MO
dexamethasone 2 MO prednisone oral 2 MO
sodium phosphate tablets,dose pack
injection syringe
fludrocortisone 2 MO

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54

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
SOLU-CORTEF 3 MO BYETTA 4 PA; MO;
(PF) INJECTION SUBCUTANEOU QL (1.2 per
RECON SOLN S PEN INJECTOR 30 days)
1,000 MG/8 ML, 5 MCG/DOSE (250
250 MG/2 ML, 500 MCG/ML) 1.2 ML
MG/4 ML CYCLOSET 4 MO; QL
triamcinolone 2 MO (180 per 30
acetonide injection days)
ANTITHYROID GAUZE PADS 2 3 MO
AGENTS X2
methimazole oral 2 MO glimepiride oral 1 MO; QL
tablet 10 mg, 5 mg tablet 1 mg (240 per 30
days)
propylthiouracil 2 MO
glimepiride oral 1 MO; QL
DIABETES tablet 2 mg (120 per 30
THERAPY days)
acarbose oral tablet 2 MO; QL glimepiride oral 1 MO; QL
100 mg (90 per 30 tablet 4 mg (60 per 30
days) days)
acarbose oral tablet 2 MO; QL glipizide oral tablet 1 MO; QL
25 mg (360 per 30 10 mg (120 per 30
days) days)
acarbose oral tablet 2 MO; QL glipizide oral tablet 1 MO; QL
50 mg (180 per 30 5 mg (240 per 30
days) days)
alcohol pads 2 MO glipizide oral tablet 2 MO; QL
BYDUREON 3 PA; MO; extended release (60 per 30
BCISE QL (4 per 24hr 10 mg days)
28 days) glipizide oral tablet 2 MO; QL
BYDUREON 3 PA; MO; extended release (240 per 30
SUBCUTANEOU QL (4 per 24hr 2.5 mg days)
S PEN INJECTOR 28 days) glipizide oral tablet 2 MO; QL
BYETTA 4 PA; MO; extended release (120 per 30
SUBCUTANEOU QL (2.4 per 24hr 5 mg days)
S PEN INJECTOR 30 days) GLUCAGEN 3 MO
10 HYPOKIT
MCG/DOSE(250 GLUCAGON 3 MO
MCG/ML) 2.4 ML EMERGENCY
KIT (HUMAN)

HUMALOG 3 MO
JUNIOR
KWIKPEN U-100

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55
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
HUMALOG 3 MO INSULIN 3 MO
KWIKPEN SYRINGE (DISP)
INSULIN U-100 0.3 ML, 1
SUBCUTANEOU ML, 1/2 ML
S INSULIN PEN JANUMET 3 MO; QL
100 UNIT/ML (60 per 30
HUMALOG MIX 3 MO days)
50-50 INSULN U- JANUVIA 3 MO; QL
100 (30 per 30
HUMALOG MIX 3 MO days)
50-50 KWIKPEN JARDIANCE 3 MO; QL
HUMALOG MIX 3 MO (30 per 30
75-25 KWIKPEN days)
HUMALOG MIX 3 MO LANTUS 3 MO
75-25(U- SOLOSTAR U-100
100)INSULN INSULIN
HUMALOG U- 3 MO LANTUS U-100 3 MO
100 INSULIN INSULIN
HUMULIN 70/30 3 MO LEVEMIR 4 ST; MO
U-100 INSULIN FLEXTOUCH U-
HUMULIN 70/30 3 MO 100 INSULN
U-100 KWIKPEN LEVEMIR U-100 4 ST; MO
HUMULIN N 3 MO INSULIN
NPH INSULIN metformin oral 1 MO; QL
KWIKPEN tablet 1,000 mg (75 per 30
HUMULIN N 3 MO days)
NPH U-100 metformin oral 1 MO; QL
INSULIN tablet 500 mg (150 per 30
HUMULIN R 3 MO days)
REGULAR U-100 metformin oral 1 MO; QL
INSULN tablet 850 mg (90 per 30
HUMULIN R U- 4 MO days)
500 (CONC) metformin oral 2 MO; QL
INSULIN tablet extended (120 per 30
HUMULIN R U- 4 MO release 24 hr 500 mg days)
500 (CONC) metformin oral 2 MO; QL
KWIKPEN tablet extended (75 per 30
INSULIN PEN 3 MO release 24 hr 750 mg days)
NEEDLE NEEDLES, 3 MO
INSULIN
DISP.,SAFETY

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56
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
NOVOLOG 4 ST; MO SYNJARDY 3 MO; QL
FLEXPEN U-100 ORAL TABLET 5- (120 per 30
INSULIN 500 MG days)
NOVOLOG MIX 4 ST; MO SYNJARDY XR 3 MO; QL
70-30 U-100 ORAL TABLET, (60 per 30
INSULN IR - ER, days)
NOVOLOG MIX 4 ST; MO BIPHASIC 24HR
70-30FLEXPEN 10-1,000 MG, 12.5-
U-100 1,000 MG, 5-1,000
MG
NOVOLOG 4 ST; MO
PENFILL U-100 SYNJARDY XR 3 MO; QL
INSULIN ORAL TABLET, (30 per 30
IR - ER, days)
NOVOLOG U-100 4 ST; MO
BIPHASIC 24HR
INSULIN
25-1,000 MG
ASPART
TOUJEO MAX U- 3 MO
ONGLYZA 4 ST; MO;
300 SOLOSTAR
QL (30 per
30 days) TOUJEO 3 MO
SOLOSTAR U-300
pioglitazone 2 MO; QL
INSULIN
(30 per 30
days) MISCELLANEO
PROGLYCEM 5 MO US HORMONES
repaglinide oral 2 MO; QL ALDURAZYME 5 MO
tablet 0.5 mg (960 per 30 ANADROL-50 4 PA; MO
days) ANDROGEL 3 PA; MO;
repaglinide oral 2 MO; QL TRANSDERMAL QL (150 per
tablet 1 mg (480 per 30 GEL IN 30 days)
days) METERED-DOSE
repaglinide oral 2 MO; QL PUMP 20.25
tablet 2 mg (240 per 30 MG/1.25 GRAM
days) (1.62 %)
SYMLINPEN 120 5 PA; MO; ANDROGEL 3 PA; MO;
QL (10.8 TRANSDERMAL QL (37.5
per 30 days) GEL IN PACKET per 30 days)
SYMLINPEN 60 5 PA; MO; 1.62 % (20.25
QL (6 per MG/1.25 GRAM)
30 days) ANDROGEL 3 PA; MO;
SYNJARDY 3 MO; QL TRANSDERMAL QL (150 per
ORAL TABLET (60 per 30 GEL IN PACKET 30 days)
12.5-1,000 MG, days) 1.62 % (40.5
12.5-500 MG, 5- MG/2.5 GRAM)
1,000 MG cabergoline 4 MO

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57
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
calcitonin (salmon) 4 MO ELAPRASE 5 MO
calcitriol 2 MO FABRAZYME 5 MO
intravenous solution KANUMA 5 MO
1 mcg/ml
KORLYM 5 PA; MO;
calcitriol oral 2 MO QL (120 per
capsule 0.25 mcg 30 days)
calcitriol oral 3 MO KUVAN 5 PA; MO
capsule 0.5 mcg
LUMIZYME 4 MO
calcitriol oral 3 MO
MEPSEVII 5 MO
solution
methyltestosterone 5 MO
CERDELGA 5 MO
oral capsule
CEREZYME 5 MO
MIACALCIN 4 MO
INTRAVENOUS
INJECTION
RECON SOLN
400 UNIT MYALEPT 5 PA; MO;
LA
CHORIONIC 3 PA; MO
GONADOTROPI NAGLAZYME 5 MO; LA
N, HUMAN NATPARA 5 PA; MO;
INTRAMUSCUL LA; QL (2
AR per 28 days)
cinacalcet oral 3 MO; QL oxandrolone oral 5 PA; MO;
tablet 30 mg (60 per 30 tablet 10 mg QL (60 per
days) 30 days)
cinacalcet oral 4 MO; QL oxandrolone oral 3 PA; MO;
tablet 60 mg (60 per 30 tablet 2.5 mg QL (120 per
days) 30 days)
cinacalcet oral 4 MO; QL PALYNZIQ 5 PA; MO;
tablet 90 mg (120 per 30 SUBCUTANEOU LA; QL (15
days) S SYRINGE 10 per 30 days)
CRYSVITA 5 PA; MO; MG/0.5 ML
LA PALYNZIQ 5 PA; MO;
danazol 4 MO SUBCUTANEOU LA; QL (4
S SYRINGE 2.5 per 30 days)
DDAVP NASAL 3 MO
MG/0.5 ML
SOLUTION
PALYNZIQ 5 PA; MO;
desmopressin 3 MO
SUBCUTANEOU LA; QL (60
injection
S SYRINGE 20 per 30 days)
desmopressin nasal 3 MO MG/ML
spray with pump
PARICALCITOL 4
desmopressin nasal 3 MO HEMODIALYSIS
spray,non-aerosol PORT
desmopressin oral 3 MO INJECTION

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
paricalcitol 4 testosterone 3 PA; MO;
intravenous solution transdermal gel in QL (300 per
2 mcg/ml packet 1 % (25 30 days)
paricalcitol 4 MO mg/2.5gram)
intravenous solution testosterone 3 PA; MO;
5 mcg/ml transdermal gel in QL (37.5
paricalcitol oral 4 MO; QL packet 1.62 % per 30 days)
capsule 1 mcg, 2 (30 per 30 (20.25 mg/1.25
mcg days) gram)
paricalcitol oral 4 MO; QL testosterone 3 PA; MO;
capsule 4 mcg (60 per 30 transdermal gel in QL (150 per
days) packet 1.62 % (40.5 30 days)
mg/2.5 gram)
SAMSCA ORAL 5 PA; MO;
TABLET 15 MG QL (30 per VIMIZIM 5 MO; LA
30 days) zoledronic acid 3 B/D PA;
SAMSCA ORAL 5 PA; MO; intravenous solution MO
TABLET 30 MG QL (60 per zoledronic acid- 3 B/D PA
30 days) mannitol-water
SENSIPAR ORAL 4 MO; QL intravenous
TABLET 30 MG, (60 per 30 piggyback 4 mg/100
60 MG days) ml
SENSIPAR ORAL 4 MO; QL ZOLEDRONIC 3 B/D PA;
TABLET 90 MG (120 per 30 AC-MANNITOL- MO
days) 0.9NACL
SOMAVERT 5 PA; MO; THYROID
QL (30 per HORMONES
30 days) levothyroxine oral 2 MO
STIMATE 5 MO levoxyl oral tablet 3 MO
STRENSIQ 4 MO; LA 100 mcg, 112 mcg,
SYNAREL 4 MO 125 mcg, 137 mcg,
testosterone 2 PA; MO 150 mcg, 175 mcg,
cypionate 200 mcg, 25 mcg, 50
mcg, 75 mcg, 88
testosterone 4 PA; MO mcg
enanthate
liothyronine oral 2 MO
testosterone 3 PA; MO;
transdermal gel in QL (150 per unithroid 3 MO
metered-dose pump 30 days) GASTROENT
20.25 mg/1.25 gram EROLOGY
(1.62 %)

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
ANTIDIARRHE APRISO 3 MO
ALS / balsalazide 4 MO
ANTISPASMOD budesonide oral 5 MO
ICS CANASA 4 MO
atropine injection 4 MO CHENODAL 5 PA; LA
solution 0.4 mg/ml
CHOLBAM 5 PA; MO
atropine injection 4 ORAL CAPSULE
syringe 0.05 mg/ml 250 MG
atropine injection 2 MO CHOLBAM 5 PA; MO;
syringe 0.1 mg/ml ORAL CAPSULE QL (120 per
dicyclomine oral 2 MO 50 MG 30 days)
capsule compro 4 MO
dicyclomine oral 2 MO constulose 2 MO
solution
CORTIFOAM 3 MO
dicyclomine oral 2 MO
CREON 3 MO
tablet
cromolyn oral 4 MO
glycopyrrolate 4 MO
injection CYSTADANE 5
glycopyrrolate oral 2 MO DELZICOL 4 MO
tablet 1 mg ORAL CAPSULE
(WITH DEL REL
glycopyrrolate oral 4
TABLETS)
tablet 1.5 mg
dronabinol 4 B/D PA;
glycopyrrolate oral 4 MO
MO; QL
tablet 2 mg
(60 per 30
loperamide oral 2 MO days)
capsule
EMEND 3 MO
opium tincture 3 MO (FOSAPREPITAN
paregoric 3 MO T)
MISCELLANEO EMEND ORAL 3 B/D PA;
US SUSPENSION MO
GASTROINTES FOR
TINAL AGENTS RECONSTITUTI
ON
alosetron 5 MO
ENTYVIO 5 PA; MO
ALOXI 4 MO
enulose 2 MO
AMITIZA 3 MO; QL
GATTEX 30-VIAL 5 PA; MO
(60 per 30
days) GATTEX ONE- 5 PA; MO
VIAL
aprepitant 3 B/D PA;
MO gavilyte-c 2 MO
gavilyte-g 2 MO

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
60
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
gavilyte-n 2 MO ondansetron hcl oral 3 B/D PA;
generlac 2 MO solution MO; QL
(450 per 30
hydrocortisone 3 MO
days)
rectal
ondansetron hcl oral 2 B/D PA
hydrocortisone 2 MO
tablet 24 mg
topical cream with
perineal applicator ondansetron hcl oral 2 B/D PA;
tablet 4 mg, 8 mg MO
lactulose oral 2 MO
solution palonosetron 4 MO
intravenous solution
meclizine oral tablet 2 MO
0.25 mg/5 ml
12.5 mg, 25 mg
peg 3350- 2 MO
mesalamine oral 3 MO
electrolytes oral
capsule (with del rel
recon soln 236-
tablets)
22.74-6.74 -5.86
mesalamine oral 3 MO gram
tablet,delayed
peg 3350- 2
release (dr/ec) 1.2
electrolytes oral
gram
recon soln 240-
mesalamine rectal 3 MO 22.72-6.72 -5.84
mesalamine with 3 MO gram
cleansing wipe peg-electrolyte 2
metoclopramide hcl 2 MO PENTASA 4 MO
injection solution
polyethylene glycol 3 MO
metoclopramide hcl 2 3350
injection syringe
prochlorperazine 4 MO
metoclopramide hcl 2 MO
prochlorperazine 2 MO
oral solution
edisylate
metoclopramide hcl 2 MO
prochlorperazine 2 MO
oral tablet
maleate oral
OCALIVA 5 PA; MO;
procto-med hc 2 MO
LA; QL (30
per 30 days) procto-pak 2 MO
ondansetron 2 B/D PA; proctosol hc topical 2 MO
MO proctozone-hc 2 MO
ondansetron hcl 3 MO RECTIV 3 MO
(pf) injection RELISTOR 5 PA; MO
solution SUBCUTANEOU
ondansetron hcl 3 MO S SOLUTION
intravenous RELISTOR 5 PA; MO
SUBCUTANEOU
S SYRINGE

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
61
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
REMICADE 5 PA; MO famotidine (pf)- 2 MO
scopolamine base 3 MO; QL nacl (iso-os)
(10 per 30 famotidine 2 MO
days) intravenous solution
SUCRAID 5 MO famotidine oral 4 MO
sulfasalazine 2 MO suspension
trilyte with flavor 2 MO famotidine oral 2 MO
packets tablet 20 mg, 40 mg
ursodiol oral capsule 2 MO misoprostol 2 MO
ursodiol oral tablet 3 MO omeprazole oral 2 MO; QL
capsule,delayed (30 per 30
VIOKACE ORAL 3 MO
release(dr/ec) 10 days)
TABLET 10,440-
mg, 20 mg
39,150- 39,150
UNIT omeprazole oral 2 MO; QL
capsule,delayed (60 per 30
VIOKACE ORAL 5 MO
release(dr/ec) 40 days)
TABLET 20,880-
mg
78,300- 78,300
UNIT pantoprazole oral 2 MO; QL
tablet,delayed (30 per 30
ULCER release (dr/ec) 20 days)
THERAPY mg
DEXILANT 4 MO; QL pantoprazole oral 2 MO; QL
(30 per 30 tablet,delayed (60 per 30
days) release (dr/ec) 40 days)
esomeprazole 3 MO; QL mg
magnesium oral (30 per 30 PRILOSEC ORAL 4 MO
capsule,delayed days) SUSP,DELAYED
release(dr/ec) 20 RELEASE FOR
mg RECON
esomeprazole 3 MO ranitidine hcl oral 2 MO
magnesium oral capsule
capsule,delayed ranitidine hcl oral 3 MO
release(dr/ec) 40 syrup
mg
ranitidine hcl oral 1 MO
esomeprazole 4 tablet 150 mg, 300
sodium intravenous mg
recon soln 20 mg
sucralfate oral 2 MO
esomeprazole 4 MO tablet
sodium intravenous
recon soln 40 mg
famotidine (pf) 2 MO

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
IMMUNOLO PEGASYS 5 PA; MO;
SUBCUTANEOU QL (2 per
GY,
S SYRINGE 28 days)
VACCINES /
PEGINTRON 5 PA; MO;
BIOTECHNO SUBCUTANEOU QL (4 per
LOGY S KIT 50 MCG/0.5 28 days)
ML
BIOTECHNOLO
GY DRUGS PROCRIT 3 PA; MO
INJECTION
ACTIMMUNE 5 B/D PA; SOLUTION 10,000
MO UNIT/ML, 2,000
ARCALYST 5 PA; MO UNIT/ML, 20,000
BETASERON 5 PA; MO; UNIT/2 ML, 3,000
SUBCUTANEOU QL (15 per UNIT/ML, 4,000
S KIT 28 days) UNIT/ML
ILARIS (PF) 5 PA; MO; PROCRIT 5 PA; MO
SUBCUTANEOU LA INJECTION
S SOLUTION SOLUTION 20,000
UNIT/ML, 40,000
INTRON A 5 B/D PA;
UNIT/ML
INJECTION MO
PROLEUKIN 4 B/D PA;
MOZOBIL 5 B/D PA;
MO
MO
REBIF (WITH 5 PA; MO;
NEULASTA 4 PA; MO
ALBUMIN) QL (6 per
NEUPOGEN 5 PA; MO 28 days)
NORDITROPIN 5 PA; MO REBIF 5 PA; MO;
FLEXPRO REBIDOSE QL (6 per
SUBCUTANEOU SUBCUTANEOU 28 days)
S PEN INJECTOR S PEN INJECTOR
10 MG/1.5 ML (6.7 22 MCG/0.5 ML,
MG/ML), 15 44 MCG/0.5 ML
MG/1.5 ML (10
REBIF 5 PA; MO;
MG/ML), 5
REBIDOSE QL (4.2 per
MG/1.5 ML (3.3
SUBCUTANEOU 180 days)
MG/ML)
S PEN INJECTOR
PEGASYS 5 PA; MO; 8.8MCG/0.2ML-22
PROCLICK QL (2 per MCG/0.5ML (6)
SUBCUTANEOU 28 days)
REBIF 5 PA; MO;
S PEN INJECTOR
TITRATION QL (4.2 per
180 MCG/0.5 ML
PACK 180 days)
PEGASYS 5 PA; MO;
SYLATRON 5 PA; MO
SUBCUTANEOU QL (4 per
S SOLUTION 28 days)

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
VACCINES / HIBERIX (PF) 3 MO
MISCELLANEO HIZENTRA 5 B/D PA;
US MO
IMMUNOLOGI HYPERHEP B 3
CALS S/D
ACTHIB (PF) 3 MO INTRAMUSCUL
AR SOLUTION
ADACEL(TDAP 3 MO 220 UNIT/ML
ADOLESN/ADUL
T)(PF) HYPERHEP B 3 MO
S/D
BCG VACCINE, 3 MO INTRAMUSCUL
LIVE (PF) AR SOLUTION
BEXSERO 3 MO 220 UNIT/ML (5
BOOSTRIX TDAP 3 MO ML)
BOTOX 4 PA; MO HYPERHEP B 3
DAPTACEL 3 MO S/D
(DTAP INTRAMUSCUL
PEDIATRIC) (PF) AR SYRINGE
ENGERIX-B (PF) 3 B/D PA; HYPERHEP B S- 3
MO D NEONATAL
ENGERIX-B 3 B/D PA; IMOVAX RABIES 4 MO
PEDIATRIC (PF) MO VACCINE (PF)
INTRAMUSCUL INFANRIX 3 MO
AR SYRINGE (DTAP) (PF)
GAMASTAN 3 MO IPOL 3 MO
GAMASTAN S/D 3 MO IXIARO (PF) 4 MO
GARDASIL 9 (PF) 4 MO KINRIX (PF) 3
GRASTEK 3 PA; MO INTRAMUSCUL
AR SUSPENSION
HAVRIX (PF) 3 MO
INTRAMUSCUL KINRIX (PF) 3 MO
AR SUSPENSION INTRAMUSCUL
AR SYRINGE
HAVRIX (PF) 3 MO
INTRAMUSCUL MENACTRA (PF) 3 MO
AR SYRINGE INTRAMUSCUL
1,440 ELISA AR SOLUTION
UNIT/ML MENVEO A-C-Y- 3 MO
HAVRIX (PF) 3 W-135-DIP (PF)
INTRAMUSCUL M-M-R II (PF) 3 MO
AR SYRINGE 720 PEDIARIX (PF) 3 MO
ELISA UNIT/0.5 PEDVAX HIB 3 MO
ML (PF)

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
64
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
PENTACEL (PF) 3 MO TYPHIM VI 3 MO
PRIVIGEN 5 PA; MO INTRAMUSCUL
AR SYRINGE
PROQUAD (PF) 3 MO
VAQTA (PF) 3 MO
QUADRACEL 3 MO
(PF) VARIVAX (PF) 3 MO
RABAVERT (PF) 3 MO VARIZIG 5 MO
INTRAMUSCUL
RAGWITEK 3 MO
AR SOLUTION
RECOMBIVAX 3 B/D PA;
YF-VAX (PF) 3 MO
HB (PF) MO
INTRAMUSCUL ZOSTAVAX (PF) 4 MO
AR SUSPENSION MUSCULOSK
RECOMBIVAX 3 B/D PA; ELETAL /
HB (PF) MO RHEUMATO
INTRAMUSCUL
AR SYRINGE 10 LOGY
MCG/ML GOUT
RECOMBIVAX 3 B/D PA THERAPY
HB (PF)
allopurinol 1 MO
INTRAMUSCUL
AR SYRINGE 5 COLCRYS 3 MO; QL
MCG/0.5 ML (120 per 30
days)
ROTARIX 3
KRYSTEXXA 5 MO
ROTATEQ 3 MO
VACCINE probenecid 2 MO
SHINGRIX (PF) 4 MO probenecid- 2 MO
colchicine
STAMARIL (PF) 3
ULORIC 3 MO
TDVAX 3 MO
TENIVAC (PF) 3 MO OSTEOPOROSI
S THERAPY
TETANUS,DIPH 3 MO
THERIA TOX alendronate oral 2 MO; QL
PED(PF) tablet 10 mg, 5 mg (30 per 30
TICE BCG 3 B/D PA; days)
MO alendronate oral 2 MO; QL (4
TRUMENBA 3 MO tablet 35 mg, 70 mg per 28 days)
TWINRIX (PF) 3 MO ibandronate oral 3 MO; QL (1
INTRAMUSCUL per 30 days)
AR SYRINGE PROLIA 4 PA; MO;
TYPHIM VI 3 QL (1 per
INTRAMUSCUL 30 days)
AR SOLUTION

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
65
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
raloxifene 3 MO; QL HUMIRA 5 PA; MO;
(30 per 30 PEDIATRIC QL (6 per
days) CROHNS START 180 days)
risedronate oral 3 MO; QL (4 SUBCUTANEOU
tablet 35 mg, 35 mg per 28 days) S SYRINGE KIT
(12 pack), 35 mg (4 40 MG/0.8 ML (6
pack) PACK)
TYMLOS 5 PA; MO; HUMIRA PEN 5 PA; MO;
QL (1.56 QL (4 per
per 30 days) 28 days)
OTHER HUMIRA PEN 5 PA; MO;
RHEUMATOLO CROHNS-UC-HS QL (6 per
START 180 days)
GICALS
HUMIRA PEN 5 PA; MO;
BENLYSTA 5 PA; MO PSOR-UVEITS- QL (4 per
DEPEN 5 MO ADOL HS 180 days)
TITRATABS HUMIRA 5 PA; MO;
ENBREL MINI 5 PA; MO; SUBCUTANEOU QL (2 per
QL (8 per S SYRINGE KIT 28 days)
28 days) 10 MG/0.2 ML, 20
ENBREL 5 PA; MO; MG/0.4 ML
SUBCUTANEOU QL (16 per HUMIRA 5 PA; MO;
S RECON SOLN 28 days) SUBCUTANEOU QL (4 per
ENBREL 5 PA; MO; S SYRINGE KIT 28 days)
SUBCUTANEOU QL (16 per 40 MG/0.8 ML
S SYRINGE 25 28 days) HUMIRA(CF) 5 PA; MO;
MG/0.5ML (0.51) PEDI CROHNS QL (3 per
ENBREL 5 PA; MO; STARTER 180 days)
SUBCUTANEOU QL (8 per SUBCUTANEOU
S SYRINGE 50 28 days) S SYRINGE KIT
MG/ML (0.98 ML) 80 MG/0.8 ML
ENBREL 5 PA; MO; HUMIRA(CF) 5 PA; MO;
SURECLICK QL (8 per PEDI CROHNS QL (2 per
28 days) STARTER 180 days)
SUBCUTANEOU
HUMIRA 5 PA; MO;
S SYRINGE KIT
PEDIATRIC QL (3 per
80 MG/0.8 ML-40
CROHNS START 180 days)
MG/0.4 ML
SUBCUTANEOU
S SYRINGE KIT HUMIRA(CF) 5 PA; MO;
40 MG/0.8 ML PEN CROHNS- QL (3 per
UC-HS 180 days)

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66
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
HUMIRA(CF) 5 PA; MO; estradiol valerate 2 MO
PEN PSOR-UV- QL (3 per intramuscular oil 20
ADOL HS 180 days) mg/ml, 40 mg/ml
HUMIRA(CF) 5 PA; MO; estradiol- 3 PA; MO
PEN QL (4 per norethindrone acet
SUBCUTANEOU 28 days) heather 3 MO
S PEN INJECTOR
hydroxyprogesteron 5 MO
KIT 40 MG/0.4
e caproate
ML
incassia 3 MO
HUMIRA(CF) 5 PA; MO;
SUBCUTANEOU QL (2 per jencycla 3 MO
S SYRINGE KIT 28 days) medroxyprogesteron 3 MO
10 MG/0.1 ML, 20 e intramuscular
MG/0.2 ML medroxyprogesteron 2 MO
HUMIRA(CF) 5 PA; MO; e oral
SUBCUTANEOU QL (4 per norethindrone 2 MO
S SYRINGE KIT 28 days) (contraceptive)
40 MG/0.4 ML
norethindrone 4 MO
leflunomide 2 MO; QL acetate
(30 per 30
norethindrone ac- 4 PA; MO
days)
eth estradiol oral
ORENCIA 5 PA; MO tablet 0.5-2.5 mg-
ORENCIA 5 PA; MO mcg
CLICKJECT norlyda 3 MO
penicillamine 5 MO PREMARIN 3 MO
OBSTETRICS ORAL
/ tulana 3 MO
GYNECOLOG yuvafem 3 MO
Y MISCELLANEO
US OB/GYN
ESTROGENS /
PROGESTINS clindamycin 2 MO
phosphate vaginal
estradiol oral 4 PA; MO
metronidazole 2 MO
estradiol 2 PA; MO; vaginal
transdermal patch QL (4 per
MIRENA 3 MO; LA
weekly 28 days)
NEXPLANON 3 MO
estradiol vaginal 2 MO
cream terconazole vaginal 2 MO
cream
estradiol vaginal 3 MO
tablet terconazole vaginal 4 MO
suppository

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
67
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
tranexamic acid 3 MO fayosim 4 MO
oral femynor 4 MO
vandazole 2 MO hailey 24 fe 4 MO
ORAL isibloom 4 MO
CONTRACEPTI jasmiel (28) 4
VES / RELATED
juleber 4 MO
AGENTS
junel 1.5/30 (21) 4 MO
afirmelle 4
junel 1/20 (21) 4 MO
alyacen 1/35 (28) 4 MO
junel fe 1.5/30 (28) 4 MO
amethia lo 4 MO
junel fe 1/20 (28) 4 MO
aubra 4 MO
junel fe 24 4 MO
aubra eq 4 MO
kaitlib fe 4 MO
aurovela 1.5/30 4
kalliga 4
(21)
kelnor 1/35 (28) 4 MO
aurovela 1/20 (21) 4
kelnor 1-50 4 MO
aurovela 24 fe 4
l norgest/e.estradiol- 4 MO
aurovela fe 1.5/30 4
e.estrad oral
(28)
tablets,dose pack,3
aurovela fe 1-20 4 month 0.15 mg-20
(28) mcg/ 0.15 mg-25
ayuna 4 mcg, 0.15 mg-30
bekyree (28) 4 MO mcg (84)/10 mcg
(7)
blisovi 24 fe 4 MO
larissia 4 MO
blisovi fe 1.5/30 4 MO
(28) levonorgestrel- 4 MO
ethinyl estrad oral
blisovi fe 1/20 (28) 4 MO
tablet 0.1-20 mg-
camrese lo 4 MO mcg, 90-20 mcg
caziant (28) 4 MO (28)
chateal eq (28) 4 MO levonorgestrel- 4 MO
delyla (28) 4 ethinyl estrad oral
tablets,dose pack,3
drospirenone- 4 MO
month
e.estradiol-lm.fa
levonorg-eth estrad 4 MO
drospirenone-ethinyl 4 MO
triphasic
estradiol
lillow (28) 4 MO
emoquette 4 MO
low-ogestrel (28) 4 MO
estarylla 4 MO
lo-zumandimine 4
ethynodiol diac-eth 4
(28)
estradiol
melodetta 24 fe 4 MO

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
68
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
mibelas 24 fe 4 MO tri-vylibra lo 4 MO
microgestin 1.5/30 4 MO tydemy 4 MO
(21) vienva 4 MO
microgestin 1/20 4 MO vylibra 4 MO
(21)
zarah 4 MO
microgestin fe 4
zumandimine (28) 4
1.5/30 (28)
microgestin fe 1/20 4 MO
OXYTOCICS
(28) methylergonovine 5 MO
mili 4 MO oral
noreth-ethinyl 4 MO OPHTHALM
estradiol-iron OLOGY
norethindrone ac- 4 MO
ANTIBIOTICS
eth estradiol oral
tablet 1-20 mg-mcg ak-poly-bac 2 MO
norethindrone- 4 MO bacitracin 4 MO
e.estradiol-iron oral ophthalmic (eye)
tablet 1 mg-20 mcg bacitracin- 2 MO
(24)/75 mg (4) polymyxin b
norethindrone- 4 MO ophthalmic (eye)
e.estradiol-iron oral ciprofloxacin hcl 2 MO
tablet,chewable ophthalmic (eye)
norgestimate-ethinyl 4 MO erythromycin 2 MO
estradiol ophthalmic (eye)
ocella 4 MO gatifloxacin 2 MO
ogestrel (28) 4 MO gentak ophthalmic 2 MO
previfem 4 MO (eye) ointment
rivelsa 4 MO gentamicin 2 MO
setlakin 4 MO ophthalmic (eye)
drops
simliya (28) 4
moxifloxacin 3 MO
simpesse 4
ophthalmic (eye)
sprintec (28) 4 MO
NATACYN 3 MO
syeda 4 MO
neomycin- 4 MO
tarina 24 fe 4 bacitracin-
tri-lo-mili 4 polymyxin
tri-lo-sprintec 4 MO neomycin- 2 MO
tri-mili 4 MO polymyxin-
gramicidin
tri-sprintec (28) 4 MO
neo-polycin 4 MO
tri-vylibra 4 MO

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
polycin 2 MO JETREA (PF) 5 MO; LA
polymyxin b sulf- 2 MO INTRAVITREAL
trimethoprim SOLUTION 0.125
MG/0.1 ML (1.25
tobramycin 2 MO
MG/ML)
ANTIVIRALS LUCENTIS 5 MO
trifluridine 3 MO OXERVATE 5 PA; MO
ZIRGAN 4 MO PHOSPHOLINE 4 MO
BETA- IODIDE
BLOCKERS pilocarpine hcl 3 MO
betaxolol 4 MO ophthalmic (eye)
ophthalmic (eye) drops 1 %, 2 %, 4 %
BETIMOL 4 MO RESTASIS 3 MO; QL
(60 per 30
carteolol ­ 2 MO days)
levobunolol 2 MO RESTASIS 3 MO; QL (6
ophthalmic (eye) MULTIDOSE per 30 days)
drops 0.5 %
sulfacetamide 2 MO
timolol maleate 1 MO sodium ophthalmic
ophthalmic (eye) (eye) drops
drops
sulfacetamide 4 MO
timolol maleate 2 MO sodium ophthalmic
ophthalmic (eye) (eye) ointment
drops, once daily
NON-
timolol maleate 2 MO
STEROIDAL
ophthalmic (eye)
gel forming solution ANTI-
INFLAMMATO
MISCELLANEO
RY AGENTS
US
OPHTHALMOL diclofenac sodium 2 MO
OGICS ophthalmic (eye)
ketorolac 2 MO
azelastine 4 MO
ophthalmic (eye)
ophthalmic (eye)
ORAL DRUGS
cromolyn 2 MO
ophthalmic (eye) FOR
GLAUCOMA
CYSTARAN 5 PA; MO
epinastine ­ 4 MO acetazolamide oral 3 MO
capsule, extended
EYLEA 5 MO release
acetazolamide oral 2 MO
tablet

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
70
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
methazolamide 4 MO loteprednol 3
OTHER etabonate
GLAUCOMA OZURDEX 5 MO
DRUGS prednisolone acetate 3 MO
AZOPT 4 MO prednisolone sodium 4 MO
phosphate
COMBIGAN 3 MO
ophthalmic (eye)
COSOPT (PF) 4 MO
SYMPATHOMI
dorzolamide 2 MO
METICS
dorzolamide-timolol 4 MO
ALPHAGAN P 3 MO
dorzolamide-timolol 3 MO OPHTHALMIC
(pf) ophthalmic (EYE) DROPS 0.1
(eye) dropperette %
latanoprost 2 MO apraclonidine 4 MO
LUMIGAN 3 MO brimonidine 4 MO
OPHTHALMIC ophthalmic (eye)
(EYE) DROPS drops 0.15 %
0.01 %
brimonidine 2 MO
TRAVATAN Z 3 MO ophthalmic (eye)
STEROID- drops 0.2 %
ANTIBIOTIC RESPIRATOR
COMBINATION
S
Y AND
ALLERGY
neomycin- 4 MO
bacitracin-poly-hc ANTIHISTAMI
neomycin- 2 MO NE /
polymyxin b- ANTIALLERGE
dexameth NIC AGENTS
neomycin- 4 MO adrenalin injection 2 MO
polymyxin-hc solution 1 mg/ml
ophthalmic (eye) cetirizine oral 2 MO
neo-polycin hc 4 MO solution 1 mg/ml
tobramycin- 3 MO dexchlorpheniramin 3
dexamethasone e maleate oral syrup
STEROIDS diphenhydramine 2 MO
hcl injection solution
dexamethasone 2 MO
50 mg/ml
sodium phosphate
ophthalmic (eye) diphenhydramine 2 MO
hcl injection syringe
fluorometholone 4 MO

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
71
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
diphenhydramine 2 ADVAIR HFA 4 MO; QL
hcl oral elixir (12 per 30
EPINEPHRINE 3 MO; QL (4 days)
INJECTION per 30 days) albuterol sulfate 2 B/D PA;
AUTO- inhalation solution MO
INJECTOR 0.15 for nebulization
MG/0.15 ML, 0.15 albuterol sulfate 2 MO
MG/0.3 ML, 0.3 oral syrup
MG/0.3 ML
albuterol sulfate 4 MO
epinephrine injection 3 MO; QL (4 oral tablet
auto-injector 0.3 per 30 days)
alyq 5 PA; QL (60
mg/0.3 ml
per 30 days)
EPIPEN 3 MO; QL (4
ambrisentan 5 PA; MO;
per 30 days)
LA; QL (30
EPIPEN 2-PAK 3 MO; QL (4 per 30 days)
per 30 days)
ATROVENT HFA 4 MO; QL
EPIPEN JR 3 MO; QL (4 (25.8 per 30
per 30 days) days)
EPIPEN JR 2-PAK 3 MO; QL (4 BEVESPI 3 MO; QL
per 30 days) AEROSPHERE (10.7 per 30
hydroxyzine hcl oral 2 PA; MO days)
tablet budesonide 3 B/D PA;
levocetirizine oral 4 MO inhalation MO
solution suspension for
levocetirizine oral 2 MO; QL nebulization 0.25
tablet (30 per 30 mg/2 ml, 0.5 mg/2
days) ml
PULMONARY budesonide 4 B/D PA;
AGENTS inhalation MO
suspension for
acetylcysteine 2 B/D PA; nebulization 1 mg/2
MO ml
ADCIRCA 5 PA; MO; CINRYZE 5 PA; MO;
QL (60 per QL (20 per
30 days) 30 days)
ADEMPAS 5 PA; MO; COMBIVENT 4 MO; QL (8
LA; QL (90 RESPIMAT per 30 days)
per 30 days) cromolyn inhalation 2 B/D PA;
ADVAIR DISKUS 4 MO; QL MO
(60 per 30 DALIRESP ORAL 4 PA; MO
days) TABLET 250
MCG

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72
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
DALIRESP ORAL 4 PA; MO; FLOVENT HFA 3 MO; QL
TABLET 500 QL (30 per AEROSOL (10.6 per 30
MCG 30 days) INHALER 44 days)
ESBRIET ORAL 5 PA; MO; MCG/ACTUATIO
CAPSULE QL (270 per N
30 days) flunisolide nasal 2 MO; QL
ESBRIET ORAL 5 PA; MO; spray,non-aerosol (50 per 30
TABLET 267 MG QL (270 per 25 mcg (0.025 %) days)
30 days) fluticasone 2 MO; QL
ESBRIET ORAL 5 PA; MO; propionate nasal (16 per 30
TABLET 801 MG QL (90 per days)
30 days) ipratropium 2 B/D PA;
FASENRA 5 PA; MO bromide inhalation MO
FIRAZYR 5 PA; MO; KALYDECO 5 PA; MO
QL (270 per ORAL
30 days) GRANULES IN
PACKET 25 MG
FLOVENT 3 MO; QL
DISKUS (60 per 30 KALYDECO 5 PA; MO;
INHALATION days) ORAL QL (56 per
BLISTER WITH GRANULES IN 28 days)
DEVICE 100 PACKET 50 MG,
MCG/ACTUATIO 75 MG
N, 50 KALYDECO 5 PA; MO;
MCG/ACTUATIO ORAL TABLET QL (60 per
N 30 days)
FLOVENT 3 MO; QL LETAIRIS 5 PA; MO;
DISKUS (240 per 30 LA; QL (30
INHALATION days) per 30 days)
BLISTER WITH mometasone nasal 4 MO; QL
DEVICE 250 (34 per 30
MCG/ACTUATIO days)
N
montelukast oral 3 MO; QL
FLOVENT HFA 3 MO; QL granules in packet (30 per 30
AEROSOL (12 per 30 days)
INHALER 110 days)
montelukast oral 2 MO; QL
MCG/ACTUATIO
tablet (30 per 30
N
days)
FLOVENT HFA 3 MO; QL
montelukast oral 2 MO; QL
AEROSOL (24 per 30
tablet,chewable (30 per 30
INHALER 220 days)
days)
MCG/ACTUATIO
N

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

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
OFEV 4 PA; MO; SYMBICORT 3 MO; QL
QL (60 per (10.2 per 30
30 days) days)
ORKAMBI ORAL 5 PA; MO; SYMDEKO 5 PA; MO;
GRANULES IN QL (56 per ORAL TABLETS, QL (56 per
PACKET 28 days) SEQUENTIAL 28 days)
ORKAMBI ORAL 5 PA; MO; 100-150 MG (D)/
TABLET QL (112 per 150 MG (N)
28 days) SYMDEKO 5 PA; MO
PERFOROMIST 3 B/D PA; ORAL TABLETS,
MO; QL SEQUENTIAL 50-
(120 per 30 75 MG (D)/ 75 MG
days) (N)
PROAIR HFA 3 MO; QL tadalafil 5 PA; MO;
(17 per 30 (pulmonary arterial QL (60 per
days) hypertension) oral 30 days)
tablet 20 mg
PROAIR 3 MO; QL (2
RESPICLICK per 30 days) terbutaline oral 4 MO
PULMOZYME 5 B/D PA; terbutaline 5 MO
MO; QL subcutaneous
(150 per 30 theophylline in 3
days) dextrose 5 %
SEREVENT 3 MO; QL intravenous
DISKUS (60 per 30 parenteral solution
days) 400 mg/500 ml
sildenafil 5 PA; MO theophylline oral 2 MO
(pulmonary arterial tablet extended
hypertension) oral release 12 hr
suspension for theophylline oral 2 MO
reconstitution 10 tablet extended
mg/ml release 24 hr
sildenafil 2 PA; MO; TUDORZA 3 MO; QL (1
(pulmonary arterial QL (90 per PRESSAIR per 30 days)
hypertension) oral 30 days) TYVASO 5 B/D PA;
tablet 20 mg MO
SPIRIVA 3 MO; QL (4 TYVASO 5 B/D PA
RESPIMAT per 30 days) INSTITUTIONAL
SPIRIVA WITH 3 MO; QL START KIT
HANDIHALER (90 per 90 TYVASO REFILL 5 B/D PA;
days) KIT MO
TYVASO 5 B/D PA;
STARTER KIT MO

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
74
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
XOLAIR 5 PA; MO; TOVIAZ 4 MO; QL
SUBCUTANEOU LA; QL (6 (30 per 30
S RECON SOLN per 28 days) days)
XOLAIR 5 PA; MO; VESICARE 4 MO

SUBCUTANEOU LA; QL (6 BENIGN

S SYRINGE 150 per 28 days) PROSTATIC
MG/ML
HYPERPLASIA(
XOLAIR 5 PA; MO; BPH) THERAPY
SUBCUTANEOU LA; QL (5
S SYRINGE 75 per 28 days) alfuzosin 2 MO
MG/0.5 ML dutasteride 4 MO
zafirlukast 4 MO; QL finasteride oral 2 MO; QL
(60 per 30 tablet 5 mg (30 per 30
days) days)
UROLOGICA tamsulosin 2 MO; QL
LS (60 per 30
days)
ANTICHOLINE MISCELLANEO
RGICS / US
ANTISPASMOD UROLOGICALS
ICS
bethanechol chloride 4 MO
darifenacin 4 MO oral tablet 10 mg,
MYRBETRIQ 4 MO 25 mg, 50 mg
oxybutynin chloride 2 MO bethanechol chloride 2 MO
oral syrup oral tablet 5 mg
oxybutynin chloride 2 MO CYSTAGON 3 MO; LA
oral tablet ELMIRON 3 MO
oxybutynin chloride 3 MO; QL K-PHOS NO 2 3 MO
oral tablet extended (30 per 30
K-PHOS 3 MO
release 24hr 10 mg, days)
ORIGINAL
5 mg
potassium citrate 4 MO
oxybutynin chloride 3 MO; QL
oral tablet extended (60 per 30 RENACIDIN 3 MO
release 24hr 15 mg days) IRRIGATION
SOLUTION 1980.6
solifenacin 4 MO
MG-59.4 MG-
tolterodine oral 2 MO 980.4MG/30ML
capsule,extended
release 24hr
tolterodine oral 4 MO
tablet

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
75

 Drug Name Drug Requiremen Drug Name Drug Requiremen

Tier ts/Limits Tier ts/Limits
VITAMINS, klor-con sprinkle 3 MO
oral capsule,
HEMATINICS
extended release 8
/ meq
ELECTROLY klor-con/ef 3 MO
TES lactated ringers 4 MO
BLOOD intravenous
DERIVATIVES MAGNESIUM 3
SULFATE IN
albumin, human 25 3
D5W
%
INTRAVENOUS
albuminar 25 % 3 MO PIGGYBACK 1
alburx (human) 25 3 MO GRAM/100 ML
% magnesium sulfate 3
alburx (human) 5 3 in water intravenous
% parenteral solution
albutein 25 % 3 magnesium sulfate 3
albutein 5 % 3 in water intravenous
piggyback 2
buminate 5 % 3
gram/50 ml (4 %),
plasbumin 25 % 3 MO 4 gram/50 ml (8 %)
plasbumin 5 % 3 magnesium sulfate 3 MO
ELECTROLYTE in water intravenous
S piggyback 4
gram/100 ml (4 %)
calcium acetate oral 3 MO
capsule magnesium sulfate 2 MO
injection solution
calcium acetate oral 3 MO
tablet 667 mg magnesium sulfate 2
injection syringe
calcium gluconate 3 MO
intravenous NORMOSOL-R 3 MO
effer-k oral tablet, 3 MO NORMOSOL-R 3
effervescent 25 meq IN 5 %
DEXTROSE
klor-con 2 MO
potassium acetate 3
klor-con 10 2 MO intravenous solution
klor-con 8 2 MO 2 meq/ml
klor-con m10 2 MO potassium chlorid- 2
klor-con m15 2 MO d5-0.45%nacl
klor-con m20 2 MO intravenous
parenteral solution
10 meq/l, 30 meq/l,
40 meq/l

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76
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
potassium chlorid- 2 MO potassium chloride 3 MO
d5-0.45%nacl intravenous
intravenous potassium chloride 2 MO
parenteral solution oral capsule,
20 meq/l extended release
potassium chloride 2 potassium chloride 3 MO
in 0.9%nacl oral liquid
intravenous
potassium chloride 2 MO
parenteral solution
oral packet
20 meq/l, 40 meq/l
potassium chloride 2 MO
potassium chloride 2
oral tablet extended
in 5 % dex
release
intravenous
parenteral solution potassium chloride 2 MO
20 meq/l, 30 meq/l, oral tablet,er
40 meq/l particles/crystals
potassium chloride 2 MO potassium chloride- 3
in lr-d5 intravenous 0.45 % nacl
parenteral solution potassium chloride- 2 MO
20 meq/l d5-0.2%nacl
potassium chloride 2 intravenous
in lr-d5 intravenous parenteral solution
parenteral solution 20 meq/l
40 meq/l potassium chloride- 2
potassium chloride 3 MO d5-0.2%nacl
in water intravenous intravenous
piggyback 10 parenteral solution
meq/100 ml 30 meq/l, 40 meq/l
potassium chloride 2 MO potassium chloride- 2
in water intravenous d5-0.3%nacl
piggyback 10 intravenous
meq/50 ml parenteral solution
20 meq/l
potassium chloride 3
in water intravenous potassium chloride- 2 MO
piggyback 20 d5-0.9%nacl
meq/100 ml, 40 intravenous
meq/100 ml parenteral solution
20 meq/l
potassium chloride 2
in water intravenous potassium chloride- 2
piggyback 20 d5-0.9%nacl
meq/50 ml, 30 intravenous
meq/100 ml parenteral solution
40 meq/l

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77
 Drug Name Drug Requiremen Drug Name Drug Requiremen
Tier ts/Limits Tier ts/Limits
potassium 3 AMINOSYN 8.5 3 B/D PA
phosphate m-/d- %-
basic ELECTROLYTES
ringer's intravenous 4 AMINOSYN II 10 3 B/D PA
sodium acetate 3 %
sodium bicarbonate 3 MO AMINOSYN II 15 3 B/D PA
intravenous solution %
1 meq/ml (8.4 %) AMINOSYN II 8.5 3 B/D PA
sodium bicarbonate 3 MO %
intravenous syringe AMINOSYN II 8.5 3 B/D PA
10 meq/10 ml (8.4 %-
%), 7.5 % (0.9 ELECTROLYTES
meq/ml) AMINOSYN M 3 B/D PA
sodium bicarbonate 3 3.5 %
intravenous syringe AMINOSYN-HBC 3 B/D PA
8.4 % (1 meq/ml) 7%
sodium chloride 0.45 4 MO AMINOSYN-PF 3 B/D PA
% intravenous 10 %
parenteral solution
AMINOSYN-PF 7 3 B/D PA
sodium chloride 0.45 2 % (SULFITE-
% intravenous FREE)
piggyback
AMINOSYN-RF 3 B/D PA
sodium chloride 3 % 4 MO 5.2 %
sodium chloride 5 % 4 MO electrolyte-48 in 3
sodium chloride 4 MO d5w
intravenous FREAMINE HBC 3 B/D PA
parenteral solution 6.9 %
2.5 meq/ml
freamine iii 10 % 3 B/D PA
sodium chloride 2 MO
HEPATAMINE 3 B/D PA
intravenous
8%
parenteral solution 4
meq/ml intralipid 4 B/D PA
intravenous
sodium phosphate 3 MO
emulsion 20 %
MISCELLANEO INTRALIPID 3 B/D PA
US NUTRITION INTRAVENOUS
PRODUCTS EMULSION 30 %
AMINOSYN 10 % 3 B/D PA IONOSOL-MB IN 3
AMINOSYN 7 % 3 B/D PA D5W
WITH ISOLYTE S PH 7.4 3
ELECTROLYTES ISOLYTE-P IN 5 3
AMINOSYN 8.5 % 3 B/D PA % DEXTROSE

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78
 Drug Name Drug Requiremen
Tier ts/Limits
ISOLYTE-S 3
NEPHRAMINE 3 B/D PA
5.4 %
NORMOSOL-R 3
PH 7.4
plenamine 3 B/D PA
premasol 10 % 2 B/D PA;
MO
PREMASOL 6 % 3 B/D PA
travasol 10 % 4 B/D PA;
MO
TROPHAMINE 3 B/D PA;
10 % MO
TROPHAMINE 3 B/D PA
6%
VITAMINS /
HEMATINICS
fluoride (sodium) 2 MO
oral tablet
fluoride (sodium) 2 MO
oral tablet,chewable
1 mg (2.2 mg sod.
fluoride)
prenatal vitamin 1 MO
oral tablet

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79

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
80
Index
abacavir................................... 3
ALDURAZYME.................. 57
amoxapine.............................. 35

abacavir-lamivudine ................. 3
ALECENSA ..........................16
amoxicillin ............................. 12

abacavir-lamivudine- alendronate ....................... 51, 65

amoxicillin-pot clavulanate12, 13

zidovudine ................................ 3
alfuzosin ................................. 75
amphotericin b ......................... 3

ABELCET .............................. 3
ALIMTA ............................... 16
ampicillin ............................... 13

ABILIFY MAINTENA ........ 35

ALINIA .................................. 9
ampicillin sodium .................... 13

abiraterone ............................. 15
ALIQOPA ............................. 16
ampicillin-sulbactam ............... 13

ABRAXANE ........................ 15
ALKERAN ........................... 16
AMPYRA ............................. 29

acamprosate ........................... 51
allopurinol .............................. 65
ANADROL-50 ......................57

acarbose ................................. 55
alosetron ................................ 60
anagrelide ......................... 51, 52

acebutolol ............................... 40
ALOXI .................................. 60
anastrozole ............................. 16

acetaminophen-codeine ........... 31
ALPHAGAN P ..................... 71
ANDROGEL ........................ 57

acetazolamide .........................70
ALUNBRIG ......................... 16
APOKYN ..............................29

acetic acid .............................. 54

alyacen 1/35 (28) ................... 68
apraclonidine .......................... 71

acetylcysteine ................... 51, 72

alyq ........................................ 72
aprepitant ............................... 60

acitretin ..................................47
amantadine hcl ......................... 4
APRISO ................................ 60

ACTHIB (PF) ....................... 64

AMBISOME ........................... 3
APTIOM ............................... 26

ACTIMMUNE ..................... 63
ambrisentan ............................72
APTIVUS ................................4

acyclovir ......................... 3, 4, 50
amcinonide ............................. 50
ARCALYST ......................... 63

acyclovir sodium ....................... 4

amethia lo .............................. 68
ARIKAYCE ........................... 9

ADACEL(TDAP
AMICAR .............................. 43
aripiprazole ............................ 35

ADOLESN/ADULT)(PF) .... 64
amikacin .................................. 9
ARRANON .......................... 16

adapalene-benzoyl peroxide .... 48

amiloride ................................ 41
ARSENIC TRIOXIDE ......... 16

ADASUVE ........................... 35
amiloride-hydrochlorothiazide 41
ARZERRA ........................... 16

ADCIRCA ............................ 72
aminocaproic acid ...................43
atazanavir ................................ 4

ADEMPAS ........................... 72
AMINOSYN 10 % ................ 78
atenolol .................................. 41

adenosine ............................... 40
AMINOSYN 7 % WITH
atenolol-chlorthalidone ........... 41

adrenalin ................................ 71
ELECTROLYTES ................ 78
atomoxetine ........................... 35

adriamycin ............................. 15
AMINOSYN 8.5 % ............... 78
atorvastatin ............................ 45

ADRIAMYCIN .................... 15
AMINOSYN 8.5 %- atovaquone ............................. 10

adrucil .................................... 15
ELECTROLYTES ................ 78
atovaquone-proguanil ............. 10

ADVAIR DISKUS ............... 72

AMINOSYN II 10 % ............ 78
ATRIPLA ............................... 4

ADVAIR HFA ..................... 72

AMINOSYN II 15 % ............ 78
atropine .................................. 60

AFINITOR ........................... 15
AMINOSYN II 8.5 % ........... 78
ATROVENT HFA ............... 72

AFINITOR DISPERZ .... 15, 16

AMINOSYN II 8.5 %- aubra ......................................68

afirmelle ................................. 68
ELECTROLYTES ................ 78
aubra eq ................................. 68

ak-poly-bac ............................ 69
AMINOSYN M 3.5 % .......... 78
AUGMENTIN ..................... 13

albendazole .............................. 9
AMINOSYN-HBC 7% ......... 78
aurovela 1.5/30 (21) ............... 68

ALBENZA .............................. 9
AMINOSYN-PF 10 % .......... 78
aurovela 1/20 (21) ..................68

albumin, human 25 % ............. 76

AMINOSYN-PF 7 %
aurovela 24 fe ......................... 68

albuminar 25 % ...................... 76
(SULFITE-FREE) ................ 78
aurovela fe 1.5/30 (28) ........... 68

alburx (human) 25 % ............. 76

AMINOSYN-RF 5.2 % .........78
aurovela fe 1-20 (28) ..............68

alburx (human) 5 % ............... 76

amiodarone ............................ 40
AVASTIN ............................. 16

albutein 25 % ..........................76
AMITIZA ............................. 60
ayuna ..................................... 68

albutein 5 % ........................... 76
amitriptyline ........................... 35
azacitidine .............................. 16

albuterol sulfate ...................... 72

amlodipine .............................. 41
azathioprine ........................... 16

alclometasone ......................... 50
amlodipine-benazepril ............. 41
azathioprine sodium ................ 16

alcohol pads ........................... 55

ammonium lactate .................. 47
azelastine .......................... 53, 70

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
81

azithromycin............................ 9
BOTOX................................. 64
carvedilol ................................41

AZOPT ..................................71
BRAFTOVI .......................... 16
caspofungin .............................. 3

aztreonam .............................. 10
BRILINTA ........................... 43
CAYSTON ............................ 10

bacitracin ............................... 69
brimonidine ............................ 71
caziant (28) ........................... 68

bacitracin-polymyxin b ........... 69
BRIVIACT ............................26
cefaclor .................................... 7

baclofen ..................................30
bromocriptine ......................... 29
cefadroxil ............................. 7, 8

balsalazide ............................. 60
budesonide ........................ 60, 72
cefazolin...................................8

BALVERSA .......................... 16
bumetanide ............................. 41
cefazolin in dextrose (iso-os) ... 8

BANZEL ............................... 26
buminate 5 % ..........................76
cefdinir ..................................... 8

BARACLUDE ........................4
buprenorphine .........................31
cefepime ................................... 8

BAVENCIO .......................... 16
buprenorphine hcl ................... 31
CEFEPIME IN

BCG VACCINE, LIVE (PF).64

buprenorphine-naloxone ......... 34
DEXTROSE 5 % .................... 8

bekyree (28) .......................... 68

bupropion hcl .......................... 35
cefepime in dextrose,iso-osm .... 8

BELEODAQ ......................... 16
bupropion hcl (smoking
cefixime ................................... 8

benazepril ............................... 41
deter) ..................................... 53
cefotaxime ............................... 8

benazepril- buspirone ................................ 35

cefoxitin ................................... 8

hydrochlorothiazide ................ 41
busulfan ................................. 16
cefoxitin in dextrose, iso-osm ....8

BENDEKA ........................... 16
BUSULFEX ..........................16
ceftazidime ............................... 8

BENLYSTA .......................... 66
butorphanol tartrate ............... 34
CEFTAZIDIME IN D5W ...... 8

BENZNIDAZOLE ............... 10
BUTRANS ............................ 31
ceftriaxone ............................... 8

benztropine ............................. 29
BYDUREON ........................ 55
CEFTRIAXONE .................... 8

beser ...................................... 50
BYDUREON BCISE ............ 55
ceftriaxone in dextrose,iso-os ... 8

BESPONSA .......................... 16
BYETTA ............................... 55
cefuroxime axetil ..................... 8

betamethasone dipropionate .... 50

cabergoline ............................. 57
cefuroxime sodium ................... 8

betamethasone valerate ...........50

CABLIVI .............................. 43
celecoxib ................................ 34

betamethasone, augmented ..... 50

CABOMETYX ................ 16, 17
CELLCEPT

BETASERON ....................... 63
caffeine citrate ....................... 52
INTRAVENOUS .................. 17

betaxolol ................................ 70
calcipotriene ........................... 47
CELONTIN .......................... 26

bethanechol chloride ............... 75

calcitonin (salmon) ................ 58
cephalexin ............................ 8, 9

BETIMOL .............................70
calcitrene ................................47
CEPROTIN (BLUE BAR) ....43

BEVESPI AEROSPHERE .... 72

calcitriol ................................. 58
CEPROTIN (GREEN BAR) 43

bexarotene ............................. 16
calcium acetate ....................... 76
CERDELGA .........................58

BEXSERO ............................ 64
calcium gluconate ................... 76
CEREZYME .........................58

bicalutamide ........................... 16
CALQUENCE ...................... 17
cetirizine ................................ 71

BICNU .................................. 16
camrese lo .............................. 68
CHANTIX ............................ 53

BIDIL ....................................41
CANASA .............................. 60
CHANTIX CONTINUING

BIKTARVY ............................ 4
candesartan ............................ 41
MONTH BOX ...................... 53

BILTRICIDE ........................ 10
CAPASTAT .......................... 10
CHANTIX STARTING

bisoprolol fumarate ................ 41

CAPRELSA .......................... 17
MONTH BOX ...................... 53

bisoprolol-
CARBAGLU ........................ 52
chateal eq (28) ....................... 68

hydrochlorothiazide ................ 41
carbamazepine ........................26
CHEMET .............................. 52

bleomycin ............................... 16
carbidopa ............................... 29
CHENODAL ........................ 60

BLINCYTO .......................... 16
carbidopa-levodopa .................29
chloramphenicol sod succinate 10

blisovi 24 fe ............................ 68
carbidopa-levodopa- chlorhexidine gluconate .......... 53

blisovi fe 1.5/30 (28) .............. 68

entacapone ............................. 29
chloroquine phosphate ............ 10

blisovi fe 1/20 (28) ................. 68

carboplatin ............................. 17
chlorothiazide ......................... 41

BOOSTRIX TDAP ............... 64

carmustine .............................. 17
chlorpromazine ....................... 35

BORTEZOMIB .................... 16
carteolol ................................. 70
chlorthalidone .........................41

BOSULIF .............................. 16
cartia xt ................................. 41
CHOLBAM .......................... 60

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
82

cholestyramine (with sugar)... 45

COMBIVENT RESPIMAT..72
DAURISMO ......................... 17

cholestyramine light ................45

COMETRIQ ......................... 17
DDAVP .................................58

CHORIONIC
COMPLERA .......................... 4
decadron ................................ 54

GONADOTROPIN,
compro ................................... 60
decitabine ............................... 17

HUMAN ............................... 58
constulose ............................... 60
deferasirox ............................. 52

ciclopirox ............................... 49
COPIKTRA .......................... 17
DELSTRIGO ..........................4

cidofovir ................................... 4
CORLANOR ........................ 46
delyla (28) ............................. 68

cilostazol ................................ 43
CORTIFOAM ...................... 60
DELZICOL ...........................60

CIMDUO ................................4
cortisone .................................54
demeclocycline ....................... 14

cinacalcet ............................... 58
CORTISPORIN-TC ............. 54
DEMSER .............................. 41

CINRYZE ............................. 72
COSOPT (PF) ....................... 71
DENAVIR ............................ 50

CIPRODEX .......................... 54
COTELLIC ........................... 17
denta 5000 plus ....................... 53

ciprofloxacin .......................... 14
CREON .................................60
dentagel ..................................53

ciprofloxacin hcl ..........14, 54, 69

CRESEMBA ........................... 3
DEPEN TITRATABS .......... 66

ciprofloxacin in 5 % dextrose..14
CRIXIVAN ............................ 4
DEPO-MEDROL ................. 54

cisplatin ..................................17
cromolyn ..................... 60, 70, 72
DESCOVY .............................. 4

citalopram .............................. 35
CRYSVITA ...........................58
desipramine ............................ 35

cladribine ............................... 17
cyclobenzaprine ...................... 30
desmopressin .......................... 58

claravis ...................................48
cyclophosphamide ................... 17
desonide ................................. 50

clarithromycin .......................... 9
CYCLOSET .......................... 55
desoximetasone ...................... 50

cleocin .................................... 10
cyclosporine ........................... 17
desvenlafaxine succinate ......... 35

clindamycin hcl ....................... 10

cyclosporine modified ............. 17
dexamethasone ....................... 54

CLINDAMYCIN IN 0.9 %
CYRAMZA .......................... 17
dexamethasone intensol .......... 54

SOD CHLOR ........................ 10

CYSTADANE ...................... 60
dexamethasone sodium phos

clindamycin in 5 % dextrose ....10

CYSTAGON .........................75
(pf) ........................................54

clindamycin palmitate hcl ....... 10

CYSTARAN ......................... 70
dexamethasone sodium

clindamycin pediatric .............. 10

cytarabine .............................. 17
phosphate ......................... 54, 71

clindamycin phosphate.10, 48, 67

cytarabine (pf) .......................17
dexchlorpheniramine maleate . 71

clindamycin-benzoyl peroxide. 48
d10 %-0.45 % sodium chloride 52
DEXILANT .......................... 62

clobazam ................................ 26
d2.5 %-0.45 % sodium
dextroamphetamine ................ 35

clobetasol ............................... 50
chloride .................................. 52
dextroamphetamine-
clobetasol-emollient ................ 50
d5 % and 0.9 % sodium
amphetamine .......................... 35

clofarabine ............................. 17
chloride .................................. 52
dextrose 10 % and 0.2 % nacl . 52

CLOLAR .............................. 17
d5 %-0.45 % sodium chloride .. 52
dextrose 10 % in water

clomipramine .......................... 35
dacarbazine ............................ 17
(d10w) ................................... 52

clonazepam ............................ 26
dactinomycin .......................... 17
dextrose 5 % in water (d5w) ...52

clonidine ................................. 41
dalfampridine ......................... 29
dextrose 5 %-lactated ringers .. 52

clonidine hcl ........................... 41

DALIRESP ..................... 72, 73
dextrose 5%-0.2 % sod

clopidogrel ............................. 43
danazol ...................................58
chloride .................................. 52

clorazepate dipotassium .......... 35

dantrolene .............................. 30
dextrose 5%-0.3 %

clotrimazole ........................ 3, 49
dapsone ............................ 10, 48
sod.chloride ............................ 52

clotrimazole-betamethasone ....49
DAPTACEL (DTAP
dextrose with sodium chloride . 52

clozapine ................................ 35
PEDIATRIC) (PF) ................ 64
DIASTAT ............................. 26

COARTEM ...........................10
DAPTOMYCIN ................... 10
DIASTAT ACUDIAL .......... 26

codeine sulfate ........................ 31

daptomycin .............................10
diazepam ..................... 26, 35, 36

COLCRYS ............................ 65
DARAPRIM ......................... 10
diazepam intensol ................... 35

colesevelam ............................ 45
darifenacin ............................. 75
diclofenac sodium ..............34, 70

colistin (colistimethate na) ..... 10

DARZALEX .........................17
dicloxacillin ............................ 13

COMBIGAN ........................ 71
daunorubicin ...........................17
dicyclomine ............................ 60

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
83

didanosine................................ 4
ELAPRASE.......................... 58
ERWINAZE......................... 18

diflorasone ............................. 50
electrolyte-48 in d5w ...............78
ery pads ..................................48

diflunisal ................................ 34
ELIQUIS ............................... 43
ERYTHROCIN ...................... 9

digitek .................................... 46
ELLENCE ............................ 18
erythrocin (as stearate) ........... 9

digox ...................................... 46
ELMIRON ............................ 75
erythromycin ...................... 9, 69

digoxin ................................... 46
EMCYT ................................ 18
erythromycin ethylsuccinate ..... 9

dihydroergotamine ..................29
EMEND ................................ 60
erythromycin with ethanol ...... 48

DILANTIN 30 MG .............. 26
EMEND
erythromycin-benzoyl

diltiazem hcl ........................... 41

(FOSAPREPITANT) ............ 60
peroxide ................................. 49

dilt-xr .....................................41
emoquette ............................... 68
ESBRIET .............................. 73

diphenhydramine hcl ......... 71, 72

EMPLICITI .......................... 18
escitalopram oxalate .............. 36

dipyridamole .......................... 43
EMSAM ................................ 36
esomeprazole magnesium ........ 62

disulfiram ............................... 52
EMTRIVA .............................. 4
esomeprazole sodium .............. 62

divalproex .............................. 26
EMVERM ............................. 10
estarylla ................................. 68

dobutamine .............................46
enalapril maleate .................... 41
estradiol ................................. 67

dobutamine in d5w .................. 46

enalaprilat .............................. 42
estradiol valerate .................... 67

docetaxel ................................ 18
enalapril-hydrochlorothiazide . 42
estradiol-norethindrone acet ... 67

DOCETAXEL ...................... 18
ENBREL ............................... 66
ethambutol ............................. 10

dofetilide ................................ 40
ENBREL MINI .................... 66
ethosuximide .......................... 26

donepezil ...........................29, 30
ENBREL SURECLICK ....... 66
ethynodiol diac-eth estradiol ... 68

dopamine ................................ 46
endocet ................................... 31
etodolac ..................................34

dopamine in 5 % dextrose ....... 46

ENGERIX-B (PF) ................ 64
ETOPOPHOS ....................... 18

DOPTELET (10 TAB

ENGERIX-B PEDIATRIC
etoposide ................................ 18

PACK) .................................. 43
(PF) ....................................... 64
EVOTAZ ................................ 5

DOPTELET (15 TAB

enoxaparin ........................43, 44
exemestane ............................. 18

PACK) .................................. 43
entacapone ............................. 29
EXJADE ............................... 52

dorzolamide ............................ 71
entecavir .................................. 4
EYLEA ................................. 70

dorzolamide-timolol ................ 71
ENTRESTO .......................... 46
ezetimibe ................................ 45

dorzolamide-timolol (pf) ........ 71

ENTYVIO ............................. 60
ezetimibe-simvastatin ............. 45

DOVATO ................................4
enulose ................................... 60
FABRAZYME ..................... 58

doxazosin ............................... 41
EPCLUSA .............................. 5
famciclovir ............................... 5

doxepin .................................. 36
EPIDIOLEX ......................... 26
famotidine .............................. 62

doxorubicin ............................ 18
epinastine ............................... 70
famotidine (pf) ...................... 62

doxorubicin, peg-liposomal ..... 18

EPINEPHRINE .................... 72
famotidine (pf)-nacl (iso-os) .62

doxy-100 ................................ 14
epinephrine ............................. 72
FANAPT .............................. 36

doxycycline hyclate ................ 14

EPIPEN .................................72
FARESTON ......................... 18

doxycycline monohydrate ....... 14

EPIPEN 2-PAK .................... 72
FARYDAK .......................... 18

dronabinol .............................. 60
EPIPEN JR ........................... 72
FASENRA ............................ 73

drospirenone-e.estradiol-lm.fa .68
EPIPEN JR 2-PAK ............... 72
FASLODEX ......................... 18

drospirenone-ethinyl estradiol . 68
epirubicin ............................... 18
fayosim .................................. 68

DROXIA ...............................18
epitol ...................................... 26
FAZACLO ............................ 36

duloxetine .............................. 36
EPIVIR HBV .......................... 5
felbamate ............................... 26

DUPIXENT .......................... 47
eplerenone .............................. 42
felodipine ................................42

duramorph (pf) ...................... 31

epoprostenol (glycine) ............42
femynor .................................. 68

dutasteride ............................. 75
ERBITUX ............................. 18
fenofibrate .............................. 45

econazole ................................49
ergotamine-caffeine ................ 29
fenofibrate micronized ............ 45

EDURANT ............................ 4
ERIVEDGE .......................... 18
fenofibrate nanocrystallized .... 45

efavirenz .................................. 4
ERLEADA ........................... 18
fentanyl .................................. 32

effer-k .................................... 76
erlotinib ..................................18
fentanyl citrate ....................... 32

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

fentanyl citrate (pf).......... 31, 32

GAMASTAN S/D.................64
heparin (porcine) in 5 % dex .. 44

FERRIPROX ........................52
ganciclovir sodium .................... 5
heparin (porcine) in nacl (pf) 44

FETZIMA .............................36
GARDASIL 9 (PF) ............... 64
HEPARIN(PORCINE) IN

finasteride .............................. 75
gatifloxacin ............................ 69
0.45% NACL ......................... 44

FIRAZYR ............................. 73
GATTEX 30-VIAL ............... 60
heparin(porcine) in 0.45%

FIRDAPSE ........................... 30
GATTEX ONE-VIAL .......... 60
nacl ........................................ 44

FIRMAGON KIT W
GAUZE PAD ....................... 55
heparin, porcine (pf) .............. 44

DILUENT SYRINGE .......... 18

gavilyte-c ................................60
HEPARIN, PORCINE (PF) . 44

flac otic oil ............................. 54

gavilyte-g ............................... 60
HEPATAMINE 8% .............. 78

flecainide ................................ 40
gavilyte-n ............................... 61
HERCEPTIN ........................ 19

FLOVENT DISKUS ............ 73

GAZYVA .............................. 19
HERCEPTIN HYLECTA .... 19

FLOVENT HFA ................... 73

gemcitabine ............................ 19
HETLIOZ ............................. 37

floxuridine .............................. 18
GEMCITABINE .................. 19
HIBERIX (PF) ...................... 64

fluconazole ............................... 3
gemfibrozil ............................. 45
hidex ...................................... 54

fluconazole in dextrose(iso-o) .. 3
generlac ..................................61
HIZENTRA .......................... 64

fluconazole in nacl (iso-osm) .... 3

gengraf ................................... 19
HUMALOG JUNIOR

flucytosine ................................ 3
gentak .................................... 69
KWIKPEN U-100 ................. 55

fludarabine ............................. 18
gentamicin .................. 11, 49, 69
HUMALOG KWIKPEN

fludrocortisone ....................... 54
gentamicin in nacl (iso-osm) INSULIN .............................. 56

flunisolide ............................... 73
......................................... 10, 11
HUMALOG MIX 50-50

fluocinolone ............................ 50
GENTAMICIN IN NACL
INSULN U-100 .....................56

fluocinolone acetonide oil ........ 54

(ISO-OSM) ...................... 10, 11
HUMALOG MIX 50-50

fluocinolone and shower cap ....50

gentamicin sulfate (ped) (pf). 11
KWIKPEN ........................... 56

fluocinonide ...................... 50, 51

GENVOYA ............................ 5
HUMALOG MIX 75-25

fluocinonide-e ......................... 51
GEODON ............................. 36
KWIKPEN ........................... 56

fluocinonide-emollient .............51
GILOTRIF ........................... 19
HUMALOG MIX 75-25(U-
fluoride (sodium) ..............53, 79
glatiramer .............................. 30
100)INSULN .........................56

fluorometholone ..................... 71
glatopa ................................... 30
HUMALOG U-100

fluorouracil ....................... 18, 47

GLEOSTINE ........................ 19
INSULIN .............................. 56

fluoxetine ............................... 36
glimepiride ............................. 55
HUMIRA ..............................66

fluphenazine decanoate ........... 36

glipizide ..................................55
HUMIRA PEDIATRIC

fluphenazine hcl ...................... 36

GLUCAGEN HYPOKIT ..... 55
CROHNS START ................ 66

flutamide ................................ 18
GLUCAGON
HUMIRA PEN ..................... 66

fluticasone propionate ....... 51, 73

EMERGENCY KIT
HUMIRA PEN CROHNS-
fluvastatin .............................. 45
(HUMAN) ............................ 55
UC-HS START ..................... 66

fluvoxamine ............................ 36
glycopyrrolate ........................ 60
HUMIRA PEN PSOR-
FOLOTYN ........................... 19
glydo ...................................... 48
UVEITS-ADOL HS .............. 66

fondaparinux .......................... 44
GRASTEK ............................ 64
HUMIRA(CF) ...................... 67

fosamprenavir .......................... 5
griseofulvin microsize ............... 3
HUMIRA(CF) PEDI

fosphenytoin ........................... 26
griseofulvin ultramicrosize ........ 3
CROHNS STARTER ........... 66

FREAMINE HBC 6.9 % .......78

hailey 24 fe ............................. 68
HUMIRA(CF) PEN ............. 67

freamine iii 10 % .................... 78

HALAVEN ........................... 19
HUMIRA(CF) PEN

fulvestrant .............................. 19
halobetasol propionate ............ 51
CROHNS-UC-HS ................. 66

furosemide .............................. 42
haloperidol ............................. 37
HUMIRA(CF) PEN PSOR-
FUZEON ................................ 5
haloperidol decanoate ............. 37
UV-ADOL HS ...................... 67

FYCOMPA ........................... 27
haloperidol lactate .................. 37
HUMULIN 70/30 U-100

gabapentin ..............................27
HAVRIX (PF) ....................... 64
INSULIN .............................. 56

galantamine ............................30
heather ................................... 67
HUMULIN 70/30 U-100

GAMASTAN ........................64
heparin (porcine) ................... 44
KWIKPEN ........................... 56

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

HUMULIN N NPH
INFANRIX (DTAP) (PF).... 64
junel fe 1/20 (28)................... 68

INSULIN KWIKPEN.......... 56
INFUGEM ........................... 20
junel fe 24 ............................... 68

HUMULIN N NPH U-100

INLYTA ............................... 20
KADCYLA ........................... 20

INSULIN .............................. 56
INSULIN PEN NEEDLE .... 56
kaitlib fe ................................. 68

HUMULIN R REGULAR
INSULIN SYRINGE
KALETRA ............................. 5

U-100 INSULN .....................56

(DISP) U-100 ........................ 56
kalliga .................................... 68

HUMULIN R U-500
INTELENCE .......................... 5
KALYDECO ........................ 73

(CONC) INSULIN ............... 56

intralipid ................................ 78
KANUMA ............................ 58

HUMULIN R U-500
INTRALIPID ....................... 78
kelnor 1/35 (28) ..................... 68

(CONC) KWIKPEN ............. 56

INTRON A ........................... 63
kelnor 1-50 ............................. 68

hydralazine ............................. 42
INVEGA SUSTENNA ......... 37
KEPIVANCE ........................15

hydrochlorothiazide ................ 42
INVEGA TRINZA ............... 37
ketoconazole ....................... 3, 49

hydrocodone-acetaminophen ... 32
INVIRASE ............................. 5
ketorolac ................................ 70

hydrocodone-ibuprofen ........... 32
IONOSOL-MB IN D5W ....... 78
KEYTRUDA ........................ 20

hydrocortisone ............ 51, 54, 61

IPOL ..................................... 64
KHAPZORY ........................ 15

hydrocortisone valerate ...........51

ipratropium bromide ......... 53, 73
KINRIX (PF) ........................ 64

hydrocortisone-acetic acid ...... 54

IRESSA ................................. 20
kionex (with sorbitol) ............ 52

hydromorphone ...................... 32
irinotecan ............................... 20
KISQALI .............................. 20

HYDROMORPHONE (PF) . 32
ISENTRESS ........................... 5
KISQALI FEMARA CO-
hydromorphone (pf) ............... 32
ISENTRESS HD .................... 5
PACK ....................................20

hydroxychloroquine ................ 11
isibloom ..................................68
klor-con ..................................76

hydroxyprogesterone
ISOLYTE S PH 7.4 ............... 78
klor-con 10 ............................. 76

caproate ................................. 67
ISOLYTE-P IN 5 %
klor-con 8 ............................... 76

hydroxyurea ........................... 19
DEXTROSE ......................... 78
klor-con m10 .......................... 76

hydroxyzine hcl ...................... 72

ISOLYTE-S ...........................79
klor-con m15 .......................... 76

HYPERHEP B S/D ............... 64

isoniazid ................................. 11
klor-con m20 .......................... 76

HYPERHEP B S-D
ISORDIL .............................. 47
klor-con sprinkle .....................76

NEONATAL ........................ 64
isosorbide dinitrate ................. 47
klor-con/ef .............................. 76

ibandronate ............................ 65
isosorbide mononitrate ............ 47
KORLYM ............................. 58

IBRANCE ............................. 19
isotretinoin ............................. 49
K-PHOS NO 2 ...................... 75

ibu .......................................... 34
ISTODAX ............................. 20
K-PHOS ORIGINAL ........... 75

ibuprofen ................................ 34
itraconazole ............................. 3
KRYSTEXXA ...................... 65

ICLUSIG .............................. 19
ivermectin ...............................11
KUVAN ................................ 58

idarubicin ............................... 19
IXEMPRA ............................ 20
KYPROLIS ........................... 20

IDHIFA ................................ 19
IXIARO (PF) ........................ 64
l norgest/e.estradiol-e.estrad ... 68

ifosfamide .............................. 19
JAKAFI ................................ 20
labetalol ................................. 42

ILARIS (PF) ......................... 63

jantoven ..................................44
lactated ringers ....................... 76

imatinib .................................. 19
JANUMET ........................... 56
lactulose ................................. 61

IMBRUVICA .................. 19, 20

JANUVIA ............................. 56
lamivudine ................................ 5

IMFINZI .............................. 20
JARDIANCE ........................56
lamivudine-zidovudine .............. 5

imipenem-cilastatin ................ 11
jasmiel (28) ........................... 68
lamotrigine ............................. 27

imipramine hcl ........................ 37

jencycla .................................. 67
LANOXIN ............................ 47

imiquimod .............................. 48
JETREA (PF) ........................70
LANOXIN PEDIATRIC ......47

IMOVAX RABIES
JEVTANA ............................ 20
lanthanum .............................. 52

VACCINE (PF) .....................64

juleber .................................... 68
LANTUS SOLOSTAR U-
IMPAVIDO .......................... 11
JULUCA .................................5
100 INSULIN ....................... 56

incassia .................................. 67
junel 1.5/30 (21) .................... 68
LANTUS U-100 INSULIN .. 56

INCRELEX .......................... 52
junel 1/20 (21) ....................... 68
larissia ................................... 68

indapamide ............................. 42
junel fe 1.5/30 (28) ................. 68
LARTRUVO ........................ 20

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
86

latanoprost............................. 71
lorazepam intensol .................. 37
MENACTRA (PF)............... 64

LATUDA .............................. 37
LORBRENA .........................21
MENVEO A-C-Y-W-135-
leflunomide ............................. 67
losartan .................................. 42
DIP (PF) ................................64

LEMTRADA ........................ 30
losartan-hydrochlorothiazide .. 42
MEPSEVII ............................ 58

LENVIMA ...................... 20, 21

loteprednol etabonate ............. 71
mercaptopurine .......................21

LETAIRIS ............................ 73
low-ogestrel (28) ....................68
meropenem ............................. 11

letrozole ................................. 21
loxapine succinate .................. 38
MEROPENEM-0.9%

leucovorin calcium .................. 15

lo-zumandimine (28) .............. 68
SODIUM CHLORIDE ......... 11

LEUKERAN ........................ 21
LUCENTIS ........................... 70
mesalamine ............................ 61

leuprolide ............................... 21
LUMIGAN ........................... 71
mesalamine with cleansing

LEVEMIR FLEXTOUCH
LUMIZYME ........................ 58
wipe ....................................... 61

U-100 INSULN .....................56

LUMOXITI .......................... 21
mesna ..................................... 15

LEVEMIR U-100 INSULIN 56

LUPRON DEPOT ................ 21
MESNEX .............................. 15

levetiracetam .......................... 27
LUPRON DEPOT (3
MESTINON ......................... 31

levetiracetam in nacl (iso-os) . 27

MONTH) .............................. 21
metformin .............................. 56

levobunolol ............................. 70
LUPRON DEPOT (4
methadone ........................ 32, 33

levocarnitine ........................... 52
MONTH) .............................. 21
methadone intensol ................. 32

levocarnitine (with sugar) ...... 52

LUPRON DEPOT (6
methadose .............................. 33

levocetirizine .......................... 72
MONTH) .............................. 21
methazolamide ....................... 71

levofloxacin ............................ 14
LUPRON DEPOT-PED ....... 21
methenamine hippurate ........... 15

levofloxacin in d5w ................. 14

LUPRON DEPOT-PED (3
methenamine mandelate ..........15

levoleucovorin calcium ............ 15

MONTH) .............................. 21
methimazole ........................... 55

levonorgestrel-ethinyl estrad ... 68

LYNPARZA ......................... 21
methotrexate sodium .............. 21

levonorg-eth estrad triphasic ... 68

LYRICA ............................... 27
methotrexate sodium (pf) .......21

levothyroxine ..........................59
LYSODREN ......................... 21
methoxsalen ........................... 48

levoxyl ................................... 59
mafenide acetate .....................49
methyclothiazide .....................42

LEXIVA ..................................5
magnesium sulfate .................. 76
methyldopa .............................42

LIBTAYO ............................. 21
MAGNESIUM SULFATE
methylergonovine ................... 69

lidocaine ................................. 48
IN D5W ................................ 76
methylphenidate hcl ................ 38

lidocaine (pf) ................... 40, 48

magnesium sulfate in water ..... 76
methylprednisolone ................. 54

lidocaine hcl ........................... 48

malathion ............................... 51
methylprednisolone acetate ..... 54

lidocaine viscous ..................... 48

mannitol 20 % ........................ 42
methylprednisolone sodium

lidocaine-prilocaine ................ 48
mannitol 25 % ........................ 42
succ ........................................ 54

lillow (28) .............................. 68

maprotiline ............................. 38
methyltestosterone .................. 58

lindane ................................... 51
MARPLAN .......................... 38
metoclopramide hcl .................61

linezolid ..................................11
MARQIBO ........................... 21
metolazone ............................. 42

linezolid in dextrose 5% .......... 11

MATULANE ........................21
metoprolol succinate ............... 42

linezolid-0.9% sodium
meclizine ................................ 61
metoprolol ta-
chloride .................................. 11
medroxyprogesterone ............. 67
hydrochlorothiaz .................... 42

LIORESAL ..................... 30, 31

mefloquine .............................. 11
metoprolol tartrate ................. 42

liothyronine ............................ 59
megestrol ................................21
metro i.v. ................................ 11

lisinopril ................................. 42
MEKINIST ........................... 21
metronidazole ..............11, 49, 67

lisinopril-hydrochlorothiazide . 42
MEKTOVI ............................ 21
metronidazole in nacl (iso-os) 11

lithium carbonate ....................37

melodetta 24 fe ....................... 68
mexiletine ...............................40

lithium citrate ......................... 37

meloxicam .............................. 34
MIACALCIN ....................... 58

LONSURF ............................ 21
melphalan ............................... 21
mibelas 24 fe .......................... 69

loperamide ............................. 60
melphalan hcl ......................... 21
microgestin 1.5/30 (21) .......... 69

lopinavir-ritonavir .................... 5
memantine .............................. 30
microgestin 1/20 (21) ............. 69

lorazepam ......................... 37, 38

MEMANTINE ..................... 30
microgestin fe 1.5/30 (28) ...... 69

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

microgestin fe 1/20 (28)......... 69

NATROBA ........................... 51
norlyda................................... 67

midodrine ............................... 52
NEBUPENT ......................... 11
NORMOSOL-R .................... 76

migergot ................................. 29
NEEDLES, INSULIN
NORMOSOL-R IN 5 %

mili .........................................69
DISP.,SAFETY .....................56
DEXTROSE ......................... 76

milrinone ................................ 47
nefazodone ............................. 38
NORMOSOL-R PH 7.4 ........ 79

milrinone in 5 % dextrose ....... 47

neomycin ................................ 11
NORTHERA ........................ 52

minocycline ............................ 14
neomycin-bacitracin-poly-hc ... 71
nortriptyline ........................... 38

minoxidil ................................ 42
neomycin-bacitracin- NORVIR .................................6

MIRENA .............................. 67
polymyxin .............................. 69
NOVOLOG FLEXPEN U-
mirtazapine ............................ 38
neomycin-polymyxin b- 100 INSULIN ....................... 57

misoprostol ............................. 62
dexameth ............................... 71
NOVOLOG MIX 70-30 U-
mitomycin .............................. 21
neomycin-polymyxin- 100 INSULN ......................... 57

mitoxantrone .......................... 22
gramicidin .............................. 69
NOVOLOG MIX 70-
M-M-R II (PF) ...................... 64
neomycin-polymyxin-hc .... 54, 71
30FLEXPEN U-100 .............. 57

modafinil ................................ 38
neo-polycin ............................. 69
NOVOLOG PENFILL U-
moderiba .................................. 5
neo-polycin hc ........................ 71
100 INSULIN ....................... 57

molindone ............................... 38
neostigmine methylsulfate ....... 31
NOVOLOG U-100

mometasone ...................... 51, 73

NEPHRAMINE 5.4 % .......... 79
INSULIN ASPART .............. 57

mondoxyne nl ......................... 14
NERLYNX ........................... 22
NOXAFIL .............................. 3

montelukast ............................ 73
NEULASTA ......................... 63
NPLATE ............................... 44

morgidox ................................ 14
NEUPOGEN ........................ 63
NUEDEXTA ........................ 30

MORPHINE ......................... 33
NEUPRO .............................. 29
NULOJIX ............................. 22

morphine ................................ 33
nevirapine ............................. 5, 6
NUPLAZID .......................... 38

morphine (pf) ........................ 33

NEXAVAR ........................... 22
nyamyc ...................................49

morphine concentrate ............. 33

NEXPLANON ......................67
nystatin .............................. 3, 50

moxifloxacin .......................... 69
niacin ..................................... 45
nystatin-triamcinolone ............ 50

MOZOBIL ............................ 63
NICOTROL .......................... 53
nystop .................................... 50

MULTAQ ............................. 40
NICOTROL NS .................... 53
OCALIVA ............................. 61

mupirocin ............................... 49
nifedipine ................................42
ocella ..................................... 69

MYALEPT ........................... 58
nilutamide .............................. 22
OCREVUS ............................ 30

MYCAMINE .......................... 3
nimodipine .............................. 42
octreotide acetate ................... 22

mycophenolate mofetil ............ 22

NINLARO ............................ 22
ODEFSEY .............................. 6

mycophenolate mofetil hcl ...... 22

NIPENT ................................ 22
ODOMZO ............................. 22

mycophenolate sodium ............ 22

nitro-bid ................................. 47
OFEV .................................... 74

MYLOTARG ....................... 22
nitrofurantoin ......................... 15
ofloxacin ................................ 54

MYRBETRIQ .......................75
nitrofurantoin macrocrystal .... 15
ogestrel (28) .......................... 69

nafcillin .................................. 13
nitrofurantoin monohyd/m- okebo ..................................... 14

nafcillin in dextrose iso-osm .... 13

cryst ....................................... 15
olanzapine .............................. 38

naftifine ..................................49
nitroglycerin ........................... 47
olmesartan ............................. 42

NAGLAZYME ..................... 58
nitroglycerin in 5 % dextrose .. 47
olmesartan-
naloxone ................................ 34
NORDITROPIN
hydrochlorothiazide ................ 42

naltrexone .............................. 34
FLEXPRO ............................ 63
omeprazole ............................. 62

NAMENDA TITRATION
noreth-ethinyl estradiol-iron ... 69
ONCASPAR ......................... 22

PAK ...................................... 30
norethindrone (contraceptive) 67
ondansetron ............................ 61

NAMZARIC .........................30
norethindrone acetate ............. 67
ondansetron hcl ...................... 61

naproxen ................................ 34
norethindrone ac-eth estradiol
­ ondansetron hcl (pf) ............... 61

NARCAN ............................. 34
......................................... 67, 69
ONFI .....................................27

NATACYN ........................... 69
norethindrone-e.estradiol-iron . 69
ONGLYZA ........................... 57

NATPARA ........................... 58
norgestimate-ethinyl estradiol . 69
ONIVYDE ............................ 22

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

OPDIVO............................... 22
penicillin v potassium.............. 13
potassium chloride-0.45 %

opium tincture ........................ 60

PENTACEL (PF) .................. 65
nacl ........................................ 77

oralone ................................... 53
PENTAM .............................. 11
potassium chloride-d5-
ORENCIA ............................ 67
pentamidine ............................ 11
0.2%nacl ................................ 77

ORENCIA CLICKJECT ...... 67

PENTASA ............................ 61
potassium chloride-d5-
ORFADIN ............................ 52
pentoxifylline ......................... 44
0.3%nacl ................................ 77

ORKAMBI ........................... 74
PERFOROMIST .................. 74
potassium chloride-d5-
oseltamivir ............................... 6
periogard ................................ 53
0.9%nacl ................................ 77

osmitrol 15 % ......................... 42
PERJETA ............................. 22
potassium citrate .................... 75

osmitrol 20 % ......................... 42
permethrin .............................. 51
potassium phosphate m-/d-
oxaliplatin .............................. 22
perphenazine .......................... 38
basic ....................................... 78

oxandrolone ........................... 58
PERSERIS ............................ 38
POTELIGEO ........................ 23

oxaprozin ............................... 34
pfizerpen-g ............................. 13
PRADAXA ........................... 44

oxcarbazepine ........................ 28
phenelzine ...............................38
PRALUENT PEN ................ 45

OXERVATE ......................... 70
phenobarbital ......................... 28
pramipexole ........................... 29

oxybutynin chloride ................ 75

phenobarbital sodium ..............28
prasugrel ................................ 44

oxycodone .............................. 33
phentolamine .......................... 42
pravastatin ............................. 45

OXYCODONE ..................... 33
phenytoin ............................... 28
praziquantel ........................... 11

oxycodone-acetaminophen ...... 34
phenytoin sodium .................... 28
prazosin ..................................42

oxycodone-aspirin .................. 34
phenytoin sodium extended ..... 28
prednicarbate ......................... 51

oxymorphone ..........................34
PHOSPHOLINE IODIDE ....70
prednisolone ........................... 54

OZURDEX ........................... 71
PIFELTRO ............................. 6
prednisolone acetate ............... 71

pacerone ................................. 40
pilocarpine hcl .................. 52, 70
prednisolone sodium

paclitaxel ............................... 22
pimozide ................................. 38
phosphate ......................... 54, 71

paliperidone ............................ 38
pindolol .................................. 42
prednisone .............................. 54

palonosetron ........................... 61
pioglitazone ............................ 57
prednisone intensol ................. 54

PALYNZIQ .......................... 58
PIPERACILLIN- PREMARIN ......................... 67

PANRETIN .......................... 48
TAZOBACTAM ................... 13
premasol 10 % ........................ 79

pantoprazole ...........................62
piperacillin-tazobactam ..... 13, 14
PREMASOL 6 % .................. 79

paregoric ................................ 60
plasbumin 25 % ...................... 76
prenatal vitamin oral tablet ..... 79

PARICALCITOL ................. 58
plasbumin 5 % ........................ 76
prevalite ................................. 45

paricalcitol ............................. 59
plenamine ............................... 79
previfem ................................. 69

paroex oral rinse .................... 53

podofilox ................................ 48
PREVYMIS ............................ 6

paromomycin ..........................11
polycin ................................... 70
PREZCOBIX .......................... 6

paroxetine hcl ......................... 38

polyethylene glycol 3350 ......... 61
PREZISTA ............................. 6

PASER .................................. 11
polymyxin b sulf- PRIFTIN .............................. 11

PAXIL ...................................38
trimethoprim .......................... 70
PRILOSEC ........................... 62

PEDIARIX (PF) ................... 64

POMALYST ......................... 22
PRIMAQUINE .....................11

PEDVAX HIB (PF) .............. 64

PORTRAZZA .......................22
primidone ............................... 28

peg 3350-electrolytes .............. 61

potassium acetate ................... 76
PRIVIGEN ........................... 65

PEGANONE ........................ 28
potassium chlorid-d5- PROAIR HFA ...................... 74

PEGASYS ............................. 63
0.45%nacl ......................... 76, 77
PROAIR RESPICLICK ....... 74

PEGASYS PROCLICK ........ 63

potassium chloride .................. 77
probenecid .............................. 65

peg-electrolyte ........................ 61
potassium chloride in
probenecid-colchicine .............. 65

PEGINTRON ....................... 63
0.9%nacl ................................ 77
prochlorperazine ..................... 61

penicillamine .......................... 67
potassium chloride in 5 % dex . 77
prochlorperazine edisylate ...... 61

penicillin g potassium ..............13

potassium chloride in lr-d5 ...... 77
prochlorperazine maleate oral . 61

penicillin g procaine ................ 13

potassium chloride in water ..... 77
PROCRIT ............................. 63

penicillin g sodium .................. 13

procto-med hc ......................... 61

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
89

procto-pak.............................. 61
REPATHA ............................ 46
SELZENTRY ......................... 6

proctosol hc ............................ 61
REPATHA
SENSIPAR ........................... 59

proctozone-hc ......................... 61
PUSHTRONEX ....................46
SEREVENT DISKUS .......... 74

PROGLYCEM ..................... 57
REPATHA SURECLICK .... 46
sertraline ................................ 39

PROGRAF ........................... 23
RESCRIPTOR ........................6
setlakin .................................. 69

PROLASTIN-C .................... 52
RESECTISOL ....................... 42
sevelamer carbonate ............... 52

PROLEUKIN ....................... 63
RESTASIS ............................ 70
sf ............................................ 53

PROLIA ................................ 65
RESTASIS MULTIDOSE .... 70
sf 5000 plus ............................ 53

PROMACTA .................. 44, 45

RETROVIR ............................ 6
SHINGRIX (PF) ...................65

propafenone ............................40
REVCOVI ............................. 52
SIGNIFOR ........................... 23

propranolol .............................42
REVLIMID .......................... 23
sildenafil (pulmonary arterial

propranolol- revonto ................................... 31

hypertension) ......................... 74

hydrochlorothiazid ..................42
REXULTI ............................. 39
silver sulfadiazine ................... 48

propylthiouracil ...................... 55
REYATAZ ............................. 6
simliya (28) ........................... 69

PROQUAD (PF) ...................65

ribavirin ................................... 6
simpesse ................................. 69

protriptyline ........................... 38
rifabutin ................................. 11
SIMULECT .......................... 23

PULMOZYME ..................... 74
rifampin ................................. 11
simvastatin ............................. 46

PURIXAN ............................ 23
riluzole ................................... 52
sirolimus .................................23

pyrazinamide .......................... 11
rimantadine .............................. 6
SIRTURO ............................. 11

pyridostigmine bromide .......... 31

ringer's ................................... 78
SKYRIZI .............................. 47

QUADRACEL (PF) ............. 65

risedronate ............................. 66
sodium acetate ........................ 78

quetiapine ......................... 38, 39

RISPERDAL CONSTA ....... 39
sodium bicarbonate ................. 78

quinidine gluconate ................. 40

risperidone ............................. 39
sodium chloride ................. 53, 78

quinidine sulfate ..................... 40

ritonavir ................................... 6
sodium chloride 0.45 % ........... 78

quinine sulfate ........................ 11

RITUXAN ............................ 23
sodium chloride 0.9 % ............. 52

RABAVERT (PF) ................. 65

RITUXAN HYCELA ........... 23
sodium chloride 3 % ................ 78

RADICAVA ......................... 30
rivastigmine ............................ 30
sodium chloride 5 % ................ 78

RAGWITEK .........................65
rivastigmine tartrate ............... 30
SODIUM EDECRIN ........... 43

raloxifene ............................... 66
rivelsa .................................... 69
sodium fluoride 5000 plus ....... 53

RANEXA ............................. 47
rizatriptan .............................. 29
sodium phosphate ................... 78

ranitidine hcl .......................... 62

ROMIDEPSIN ..................... 23
sodium polystyrene sulfonate .. 53

ranolazine .............................. 47
ropinirole ................................29
SODIUM POLYSTYRENE

RAPAMUNE ....................... 23
rosadan .................................. 49
SULFONATE ....................... 53

rasagiline ................................29
rosuvastatin ............................ 46
solifenacin .............................. 75

RAVICTI .............................. 52
ROTARIX ............................ 65
SOLIRIS ............................... 53

REBETOL .............................. 6
ROTATEQ VACCINE ......... 65
SOLTAMOX ........................ 23

REBIF (WITH ALBUMIN) . 63

roweepra ................................ 28
SOLU-CORTEF (PF) ........... 55

REBIF REBIDOSE .............. 63

ROZEREM ........................... 39
SOMATULINE DEPOT ...... 23

REBIF TITRATION PACK 63

RUBRACA ........................... 23
SOMAVERT .........................59

RECOMBIVAX HB (PF) ..... 65

RYDAPT .............................. 23
sorine ..................................... 40

RECTIV ................................ 61
SABRIL ................................ 28
sotalol .................................... 40

regonol ................................... 31
salsalate ................................. 34
sotalol af ................................ 40

REGRANEX ........................ 48
SAMSCA .............................. 59
SOTYLIZE ........................... 40

RELENZA DISKHALER ......6

SANDIMMUNE .................. 23
SPIRIVA RESPIMAT .......... 74

RELISTOR ........................... 61
SANTYL ............................... 48
SPIRIVA WITH

REMICADE ......................... 62
SAPHRIS .............................. 39
HANDIHALER ................... 74

REMODULIN ......................42
scopolamine base .................... 62
spironolactone ........................ 43

RENACIDIN ........................75
selegiline hcl ........................... 29
spironolacton-
repaglinide ............................. 57
selenium sulfide ...................... 47
hydrochlorothiaz .................... 43

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
90

SPORANOX........................... 3
SYNRIBO ............................. 23
tobramycin ............................. 70

sprintec (28) .......................... 69

TABLOID ............................. 23
tobramycin in 0.225 % nacl ..... 12

SPRITAM ............................. 28
tacrolimus ......................... 23, 48
tobramycin sulfate .................. 12

SPRYCEL ............................. 23
tadalafil (pulmonary arterial
tobramycin-dexamethasone .... 71

sps (with sorbitol) .................. 53

hypertension) oral tablet 20
tolmetin .................................. 34

ssd .......................................... 48
mg .......................................... 74
tolterodine .............................. 75

STAMARIL (PF) .................. 65

TAFINLAR .......................... 23
topiramate .............................. 28

stavudine .................................. 7
TAGRISSO ........................... 23
toposar ................................... 24

STIMATE ............................. 59
TALZENNA ......................... 23
topotecan ............................... 24

STIVARGA .......................... 23
tamoxifen ............................... 24
toremifene .............................. 24

STRENSIQ ........................... 59
tamsulosin .............................. 75
TORISEL .............................. 24

STREPTOMYCIN ............... 11
TARCEVA ............................24
torsemide ................................43

STRIBILD .............................. 7
TARGRETIN ....................... 24
TOUJEO MAX U-300

SUBOXONE ......................... 34
tarina 24 fe ............................. 69
SOLOSTAR .......................... 57

subvenite ................................ 28
TASIGNA ............................. 24
TOUJEO SOLOSTAR U-
subvenite starter (blue) kit ..... 28
tazarotene .............................. 49
300 INSULIN ....................... 57

subvenite starter (green) kit ... 28

TAZORAC ........................... 49
TOVIAZ ................................ 75

subvenite starter (orange) kit . 28

TDVAX .................................65
tramadol ................................ 34

SUCRAID ............................ 62
TECENTRIQ ........................ 24
tranexamic acid ...................... 68

sucralfate ............................... 62
TECFIDERA ........................ 30
tranylcypromine ..................... 39

sulfacetamide sodium .............. 70

TEFLARO .............................. 9
travasol 10 % ..........................79

sulfacetamide sodium (acne) .. 49

TEMODAR .......................... 24
TRAVATAN Z ..................... 71

sulfadiazine ............................ 14
temsirolimus ........................... 24
trazodone ............................... 39

sulfamethoxazole- TENIVAC (PF) ..................... 65

TREANDA ........................... 24

trimethoprim .......................... 14
tenofovir disoproxil fumarate ....7
TRECATOR ......................... 12

SULFAMYLON ................... 49
terazosin .................................43
TRELSTAR .......................... 24

sulfasalazine ........................... 62
terbinafine hcl .......................... 3
treprostinil sodium .................. 43

sulfatrim .................................14
terbutaline .............................. 74
tretinoin (chemotherapy) ....... 24

sulindac .................................. 34
terconazole ............................. 67
tretinoin topical ...................... 49

sumatriptan ............................ 29
testosterone ............................ 59
triamcinolone acetonide
sumatriptan succinate ............. 29
testosterone cypionate ............ 59
................................... 51, 53, 55

SUPRAX ................................ 9
testosterone enanthate ............ 59
triamterene-
SUTENT ............................... 23
TETANUS,DIPHTHERIA
hydrochlorothiazid ..................43

syeda ...................................... 69
TOX PED(PF) ...................... 65
triderm ................................... 51

SYLATRON ......................... 63
tetrabenazine .......................... 30
trientine ..................................53

SYLVANT ............................ 23
tetracycline ............................ 14
trifluoperazine ........................ 39

SYMBICORT ....................... 74
THALOMID .........................24
trifluridine .............................. 70

SYMDEKO .......................... 74
theophylline ............................ 74
tri-lo-mili ................................69

SYMFI .................................... 7
theophylline in dextrose 5 % ... 74
tri-lo-sprintec ......................... 69

SYMFI LO ..............................7
thioridazine ............................ 39
trilyte with flavor packets ....... 62

SYMLINPEN 120 ................. 57

thiotepa .................................. 24
trimethoprim .......................... 15

SYMLINPEN 60 ...................57
thiothixene ............................. 39
tri-mili .................................... 69

SYMPAZAN ........................ 28
tiagabine ................................ 28
trimipramine .......................... 39

SYMTUZA ............................. 7
TIBSOVO .............................. 24
TRINTELLIX ...................... 39

SYNAGIS ............................... 7
TICE BCG ............................ 65
TRISENOX .......................... 24

SYNAREL ............................ 59
tigecycline .............................. 11
tri-sprintec (28) ..................... 69

SYNERCID .......................... 11
timolol maleate ................. 43, 70
TRIUMEQ ............................. 7

SYNJARDY ......................... 57
TIVICAY ................................ 7
tri-vylibra ............................... 69

SYNJARDY XR ................... 57
tizanidine ................................31
tri-vylibra lo ........................... 69

You can find information on what the symbols and abbreviations on this table mean by going to page vii.
91

TROGARZO.......................... 7 VELTASSA...........................53 XTANDI............................... 25

TROPHAMINE 10 % ........... 79 VEMLIDY .............................. 7 XURIDEN ............................ 53
TROPHAMINE 6% .............. 79 VENCLEXTA ...................... 24 XYREM ................................ 40
TRUMENBA ........................65 VENCLEXTA STARTING
YERVOY .............................. 25
TRUVADA ............................ 7 PACK ....................................25 YF-VAX (PF) ....................... 65
TUDORZA PRESSAIR ....... 74 venlafaxine ............................. 39 YONDELIS .......................... 25
tulana ..................................... 67 verapamil ............................... 43 YONSA ................................. 25
TWINRIX (PF) .....................65 VERSACLOZ ....................... 39 yuvafem ..................................67
tydemy ................................... 69 VERZENIO .......................... 25 zafirlukast .............................. 75
TYKERB .............................. 24 VESICARE ........................... 75 ZALTRAP ............................ 25
TYMLOS .............................. 66 VIBATIV .............................. 12 ZANOSAR ........................... 25
TYPHIM VI .......................... 65 VIDEX 2 GRAM
zarah ...................................... 69
TYSABRI ............................. 30 PEDIATRIC ........................... 7 ZEJULA ............................... 25
TYVASO ............................... 74 VIDEX 4 GRAM
ZELBORAF ..........................25
TYVASO
PEDIATRIC ........................... 7 ZEPATIER ............................. 7
INSTITUTIONAL START
VIDEX EC .............................. 7 zidovudine ................................ 7
KIT ....................................... 74 vienva ..................................... 69 ziprasidone hcl ........................ 40
TYVASO REFILL KIT ........ 74 vigabatrin ............................... 28 ZIRGAN ............................... 70
TYVASO STARTER KIT .... 74 vigadrone ............................... 28 ZOLADEX ........................... 25
ULORIC ............................... 65 VIIBRYD .............................. 39 zoledronic acid ....................... 59
unithroid ................................ 59 VIMIZIM .............................. 59 zoledronic acid-mannitol-
UNITUXIN .......................... 24 VIMPAT ............................... 28 water ................................ 53, 59
UPTRAVI ............................. 43 vinblastine .............................. 25 ZOLEDRONIC AC-
ursodiol .................................. 62 vincristine ............................... 25 MANNITOL-0.9NACL ........ 59
UVADEX ............................. 48 vinorelbine .............................. 25 ZOLINZA ............................. 25
valacyclovir .............................. 7 VIOKACE ............................ 62 zolpidem ................................. 40
VALCHLOR .........................48 VIRACEPT ............................. 7 zonisamide ............................. 28
valganciclovir ........................... 7 VIRAMUNE .......................... 7 ZORTRESS .......................... 25
valproate sodium .................... 28 VIREAD ................................. 7 ZOSTAVAX (PF) ................. 65
valproic acid ........................... 28 VISTOGARD ....................... 15 ZOSYN IN DEXTROSE

valproic acid (as sodium salt) . 28 VITRAKVI ........................... 25 (ISO-OSM) ............................ 14

valrubicin ............................... 24 VIVITROL ............................34 zumandimine (28) .................. 69
valsartan ................................ 43 VIZIMPRO ........................... 25 ZYDELIG ............................. 25
valsartan-hydrochlorothiazide . 43 voriconazole ............................. 3 ZYKADIA ............................ 25
VALSTAR ............................ 24 VOTRIENT .......................... 25 ZYPREXA RELPREVV ...... 40
VANCOMYCIN ................... 12 VRAYLAR ........................... 39 ZYTIGA ............................... 25
vancomycin ............................ 12 vylibra .................................... 69
VANCOMYCIN IN 0.9 %
VYXEOS ............................... 25
SODIUM CHL ..................... 12 warfarin ................................. 45
VANCOMYCIN IN
WELCHOL ........................... 46
DEXTROSE 5 % ................... 12 XALKORI ............................ 25
vandazole ............................... 68 XARELTO ............................45
VANTAS .............................. 24 XATMEP .............................. 25
VAQTA (PF) ......................... 65 XERMELO ........................... 25
VARIVAX (PF) .................... 65 XGEVA .................................15
VARIZIG .............................. 65 XIAFLEX ............................. 53
VASCEPA ............................. 46 XIFAXAN ............................ 12
VECTIBIX ............................ 24 XOLAIR ............................... 75
VELCADE ............................ 24 XOSPATA ............................ 25
You can find information on what the symbols and abbreviations on this table mean by going to page vii.
92
This formulary was updated on 7/25/2019. For more recent information or other questions, please

contact Express Scripts Medicare Customer Service at 1.800.758.4574; New York State residents:

1.800.758.4570 or, for TTY users, 1.800.716.3231, 24 hours a day, 7 days a week,

or visit express-scripts.com.

Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract.

Enrollment in Express Scripts Medicare depends on contract renewal.

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