Providence Health Insurance Marketplace Formulary

Providence prescription drug coverage Providence Health Plan wants to help you to make the most of your prescription drug coverage. That’s why we strive to provide you with the information you need to make smart decisions about medications. Know more, save more

We encourage you to be knowledgeable about your prescription drug benefits. Information is available on your benefit summary, in your member handbook and on the Providence Health Plan website. When you require a prescription, be sure to let your doctor know cost matters to you. Choosing a generic when possible can help manage your costs. Retail pharmacies

You have access to more than 25,000 participating pharmacies nationwide at discounted rates. Search the provider directory to locate participating pharmacies near you. Maintenance drugs

Maintenance medications are those typically prescribed to treat long-term or chronic conditions, such as diabetes, high blood pressure and high cholesterol. A 90-day supply of maintenance medication is available through participating mail-order pharmacies, as well as through preferred retail pharmacies. Your 90-day supply copay or coinsurance applies. Not all covered prescription drugs are available in a 90-day supply. Learn more about mail-order pharmacies and preferred retail pharmacies. Specialty drugs

Specialty drugs are prescriptions that require special delivery, handling, administration and monitoring by your pharmacist. These drugs are listed in the Providence formulary with a status of “Specialty,” and are available through Providence Specialty Pharmacy Services. Learn more about specialty drugs. Generic drugs

Making the switch from brand to generic medication can save you money. Generic drugs, which are available only after the brand-name patent expires: • •

Have the same active ingredient formula as the brand-name drug and Are tested by the Food and Drug Administration (FDA) to be as safe and effective as the brand-name drug.

There are two types of generic drugs: •

Generic equivalent - A generic equivalent is a generic drug that has the same active

ingredient, dosage form and strength as its brand-name counterpart. The FDA assures i

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sameness between brand-name and generic equivalent products. Generic equivalents are an important option to brand-name prescription drugs because they cost less. Example: Zocor®, a brand-name drug commonly used to treat high cholesterol, is now available in generic form under the name simvastatin. Zocor® and simvastatin are identical drugs – the only difference is that one costs more than the other. •

Generic alternative - A generic alternative is a generic drug used to treat the same

condition as a brand-name drug. It is not, however, the exact same medication as the brandname drug. According to clinical evidence, a generic alternative can be expected to treat the same condition as well as the brand-name option. Example: Simvastatin, the generic form of Zocor®, may be prescribed instead of Crestor® in the treatment of high cholesterol. Generic alternatives are an important option for prescription drugs for which there is no generic available. Visit the Consumer Reports Best-Buy Drug website for more information regarding safe and effective drug treatment options. The Providence formulary

Your prescription drug plan provides coverage for medications listed on the Providence formulary. Developed in collaboration with Providence Health Plans, physicians and pharmacists, the formulary includes FDA-approved prescription generic, brand-name and specialty medications. The formulary can help you and your physician choose effective, quality medications that minimize your out-ofpocket expense. Search the formulary

There are two ways to search the formulary. They include: 1. By medical condition category (e.g., drugs used to treat heart conditions are listed under the category, Cardiovascular Agents); and 2. By index (provides an alphabetical listing of drugs included in the formulary). Formulary updates

The formulary is updated every two months. Providence’s Oregon Regional Pharmacy and Therapeutics committee (comprised of doctors and pharmacists who practice in the communities we serve) continuously reviews the latest evidence to identify opportunities to promote safe, effective and affordable drug therapy. Generally, the formulary status of a drug covered by your Providence Health Plan prescription drug coverage will not change during the year unless: • • •

The medication becomes available in generic form; There are safety or effectiveness concerns raised about the prescription drug; or The Pharmacy and Therapeutics committee determines that changes to the formulary would be in the best overall interest of Providence Health Plan members. ii

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If a change to the formulary results in a reduction of benefits or an increase in member copay, affected individuals are notified in writing. Formulary brand-name drugs

The Providence formulary includes prescription drugs that are proven safe, effective and that offer value. Refer to your benefit summary for your brand-name drug copay or coinsurance amount. Remember, even if a generic equivalent is not yet available, safe and effective generic alternatives may be available to treat most common conditions. Using these options can provide cost savings. Non-approved drugs

Your prescription drug benefit covers only FDA-approved prescription drugs. It is possible for medications to be on the market without FDA approval. The FDA is taking action to ensure these drugs become approved or are removed from the market. In the meantime, many remain on pharmacy shelves. If the drug you are taking is not FDA approved, know that there are likely approved prescription drugs available to treat your condition. We encourage you to discuss alternative medications with your doctor. Should you and your doctor determine that there is no covered alternative and you choose to continue to take a medication that is not FDA approved, your health plan will not cover that expense. More information regarding medications that are not FDA approved can be found on our website, in the related article and in the FAQ document, which includes links to the FDA website. You may also call the Providence Health Plan pharmacy team for more information and to discuss potential alternatives. Prior authorization

Prior authorization is a process to review a prescription drug for coverage before it is dispensed. The prior authorization process is initiated by the prescribing medical provider. Many factors – including the potential for serious health risks, FDA-approved indications and costeffectiveness – are considered before making the decision to require prior authorization of a prescription medication. A limited number of medications require prior authorization review; any medications requiring prior authorization are indicated as such in the Providence formulary. Keep in mind, the formulary may contain other suitable options. You and your doctor may wish to discuss the possibility of changing your prescription to an effective formulary alternative. Otherwise, your doctor may submit a prior authorization request on your behalf. Formulary exceptions

There may be times that you require a medication that is not on the Providence formulary. If you currently take a prescription drug that is not on the formulary, contact customer service to confirm that drug is not covered. If the prescription drug is not covered, your doctor may request a formulary exception. iii

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Step therapy

Step therapy is a form of prior authorization. Its purpose is to confirm if drugs generally considered "first-line" therapy based on clinical evidence already have been tried. If they have, the drug requiring prior authorization will automatically be approved. In the event these drugs are not tried first, cannot be tried first or the individual’s prescription medication history is not part of Providence Health Plan claims history, prior authorization is required. Quantity limit

For certain drugs, Providence Health Plan limits the amount of the drug covered for a specified time frame [e.g., Providence Health Plan provides two inhalers per 30 days for Proair® or Proventil® HFA (albuterol HFA)]. Quantity limits are in place to ensure safe and appropriate use of a drug. Answers to frequently asked questions

Learn more about your prescription drug coverage by reviewing answers to frequently asked questions.

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Providence Health Insurance Marketplace Formulary [To help find a drug see the back of the document for an alphabetical listing]

Drug Name

Status*

Requirements/Limits

Analgesics alagesic lq

Generic

butalbital/acetaminophen

Generic

butalbital/acetaminophen/caffeine (capsule, tablet)

Generic

butalbital/aspirin/caffeine

Generic

capacet

Generic

tencon 50-325 mg tablet

Generic

vanatol lq

Generic

Nonsteroidal Anti-inflammatory Drugs CAMBIA

Non-Preferred Brand

PA, QL (9 PER 30 DAYS)

celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule)

Generic

PA, QL (2 PER DAY)

celecoxib 400 mg capsule

Generic

PA, QL (1 PER DAY)

comfort pac-ibuprofen

Generic

diclofenac potassium

Generic

diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er 24h)

Generic

diclofenac sodium/misoprostol 75 mg200 tab ir dr

Generic

diflunisal

Generic

etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tablet, 500 mg tab er 24h, 600 mg tab er 24h)

Generic

fenoprofen calcium 600 mg tablet

Generic

FLECTOR

Non-Preferred Brand

flurbiprofen (50 mg tablet, 100 mg tablet)

Generic

PA

PA

*Specialty medications are only available through the Providence specialty network. See introduction. PA - Prior Authorization, QL - Quantity Limits, ST - Step Therapy, LA- Limited Access 5

LAST UPDATE 11/2015


Drug Name

Status*

ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet)

Generic

ibuprofen/oxycodone hcl

Generic

indomethacin (25 mg capsule, 50 mg capsule, 75 mg capsule er)

Generic

ketoprofen (50 mg capsule, 75 mg capsule, 200 mg cap24h pel)

Generic

ketorolac tromethamine 10 mg tablet

Generic

meclofenamate sodium (50 mg capsule, 100 mg capsule)

Generic

mefenamic acid 250 mg capsule

Generic

meloxicam (7.5 mg tablet, 7.5 mg/5ml oral susp, 15 mg tablet)

Generic

nabumetone (500 mg tablet, 750 mg tablet)

Generic

naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg tablet)

Generic

naproxen sodium (275 mg tablet, 550 mg tablet)

Generic

oxaprozin

Generic

piroxicam (10 mg capsule, 20 mg capsule)

Generic

sulindac (150 mg tablet, 200 mg tablet)

Generic

tolmetin sodium

Generic

Requirements/Limits

Opioid Analgesics, Long-acting BUTRANS

Non-Preferred Brand


fentanyl (12 mcg/hr patch td72, 25mcg/hr patch td72)

Generic

QL (15 PER 30 DAYS)

fentanyl (75mcg/hr patch td72, 100 mcg/hr patch td72)

Generic

QL (5 PER 30 DAYS)

fentanyl 50mcg/hr patch td72

Generic

QL (10 PER 30 DAYS)


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

fentanyl citrate (200 mcg lozenge hd, 400 mcg lozenge hd, 600 mcg lozenge hd, 800 mcg lozenge hd, 1200 mcg lozenge hd, 1600 mcg lozenge hd)

Generic

PA, QL (4 PER DAY)

hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mg tab er 24h, 32 mg tab er 24h)

Generic

PA, QL (1 PER DAY)

levorphanol tartrate 2 mg tablet

Generic

methadone hcl (5 ml solution, 10 ml solution)

Generic

QL (20 ML PER DAY)

methadone hcl 10 mg tablet

Generic

QL (120 PER 30 DAYS)

methadone hcl 10 mg/ml oral conc

Generic

QL (4 ML PER DAY)

methadone hcl 40 mg tablet sol

Generic

QL (30 PER 30 DAYS)

methadone hcl 5 mg tablet

Generic


methadone intensol

Generic

QL (4 ML PER DAY)

methadose 40 mg tablet dispr

Generic

QL (30 PER 30 DAYS)

morphine sulfate (20 mg cap er pel, 30 mg cap er pel, 30 mg tablet er, 80 mg cap er pel, 100 mg cap er pel, 100 mg tablet er, 200 mg tablet er)

Generic

QL (1 PER DAY)

morphine sulfate (50 mg cap er pel, 60 mg cap er pel, 60 mg tablet er)

Generic

QL (2 PER DAY)

morphine sulfate 15 mg tablet er

Generic

QL (3 PER DAY)

NUCYNTA ER

Non-Preferred Brand


OPANA ER

Non-Preferred Brand

PA, QL (2 PER DAY)

oxycodone hcl (10 mg tab er 12h, 20 mg tab er 12h)

Non-Preferred Brand

PA, QL (3 PER DAY)

oxycodone hcl 40 mg tab er 12h

Non-Preferred Brand

PA, QL (2 PER DAY)

oxycodone hcl 80 mg tab er 12h

Non-Preferred Brand

PA, QL (1 PER DAY)

OXYCONTIN 15 MG TABLET

Non-Preferred Brand

PA, QL (3 PER DAY)


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits


Non-Preferred Brand

PA, QL (2 PER DAY)


Non-Preferred Brand

PA, QL (1 PER DAY)

oxymorphone hcl (30 mg tab er 12h, 40 mg tab er 12h)

Generic

PA, QL (1 PER DAY)

oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mg tab er 12h, 15 mg tab er 12h, 20 mg tab er 12h)

Generic

PA, QL (2 PER DAY)

tramadol hcl (100 mg tbmp 24hr, 100 mg tab er 24h, 200 mg tbmp 24hr, 200 mg tab er 24h, 300 mg tab er 24h, 300 mg tbmp 24hr)

Generic

Opioid Analgesics, Short-acting acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg/12.5 solution, 300mg-30mg tablet, 300mg60mg tablet, 300mg-15mg tablet)

Generic

PA (PA for ages 5 and under)

ascomp with codeine

Generic


ASTRAMORPH-PF 1 MG/ML AMPUL

Medical

butalbit/acetamin/caff/codeine 50-32530 capsule

Generic

butorphanol tartrate 10 mg/ml spray

Generic

co-gesic

Generic

codeine phosphate/butalbital/aspirin/caffeine

Generic


codeine phosphate/carisoprodol/aspirin

Generic


codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg tablet)

Generic


dhcodeine bt/acetaminophn/caff 32713-60 tablet

Generic

endocet (10-325 mg tablet, 10-650 mg tablet)

Generic

endocet (2.5-325 mg tablet, 5-325 tablet, 7.5-325 mg tablet, 7.5-500 mg tablet)

Generic

QL (2.5 ML PER 30 DAYS)

QL (8 PER DAY)


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

endodan

Generic

hydrocodone bitartrate/acetaminophen (2.5-167/5 solution, 2.5-500 mg tablet, 5 mg-325mg tablet, 5 mg-500mg tablet, 5-334mg/10 solution, 7.5500/15 solution, 7.5-750mg tablet, 7.5325/15 solution, 7.5-325mg tablet, 7.5650 mg tablet, 7.5-500mg tablet, 10660mg tablet, 10-750mg tablet, 10mg650mg tablet, 10mg-500mg tablet, 10mg-325mg tablet)

Generic

hydrocodone/ibuprofen

Generic

hydromorphone hcl 1 mg/ml liquid

Generic

QL (10 ML PER DAY)

hydromorphone hcl 2 mg tablet

Generic


hydromorphone hcl 3 mg supp.rect

Generic


Generic



Generic


ibudone 5-200 mg tablet

Generic

INFUMORPH

Medical

lorcet

Generic

lorcet hd

Generic

lorcet plus 7.5-325 mg tablet

Generic

lortab (5-325 mg tablet, 5-500 tablet, 7.5-325 mg tablet, 10-325 mg tablet)

Generic

meperidine hcl (50 mg tablet, 100 mg tablet)

Generic

meperitab

Generic

morphine sulfate (10 ml solution, 20 ml solution)

Generic

morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 20 mg supp.rect, 30 mg supp.rect)

Generic

morphine sulfate 100 mg/5ml solution

Generic

QL (5 ML PER DAY)

morphine sulfate 15 mg tablet

Generic

QL (8 PER DAY)

QL (30 ML PER DAY)


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

morphine sulfate 30 mg tablet

Generic

QL (4 PER DAY)

morphine sulfate 5 mg/ml vial

Medical

morphine sulfate/pf (1 mg/ml vial, 30 mg/30ml pca vial, 150mg/30ml pca vial)

Medical

NUCYNTA

Non-Preferred Brand

PA

oxycodone hcl (20 mg/ml oral conc, 20 mg tablet)

Generic

QL (4 PER DAY)

oxycodone hcl (5 mg capsule, 5 mg tablet)

Generic

QL (10 PER DAY)

oxycodone hcl 10 mg tablet

Generic

QL (8 PER DAY)


Generic

QL (5 PER DAY)


Generic

oxycodone hcl 5 mg/5 ml solution

Generic

QL (50 ML PER DAY)

oxycodone hcl/acetaminophen (10mg650mg tablet, 10mg-325mg tablet)

Generic

QL (8 PER DAY)

oxycodone hcl/acetaminophen (2.5325mg tablet, 5 mg-500mg capsule, 5 mg-325mg tablet, 7.5-325mg tablet, 7.5-500mg tablet)

Generic

oxycodone hcl/aspirin

Generic

oxymorphone hcl 10 mg tablet

Generic

PA, QL (4 PER DAY)

oxymorphone hcl 5 mg tablet

Generic

PA, QL (8 PER DAY)

reprexain 10-200 mg tablet

Generic

ROXICET 5-325 ORAL SOLUTION

Non-Preferred Brand

roxicet 5-325 tablet

Generic

stagesic

Generic

tramadol hcl 50 mg tablet

Generic

tramadol hcl/acetaminophen

Generic

VITUZ

Non-Preferred Brand

QL (8 PER DAY)


LAST UPDATE 11/2015


Drug Name

Status*

xylon 10

Generic

Requirements/Limits

Anesthetics Local Anesthetics glydo

Generic

lidocaine 5 % oint. (g)

Generic

lidocaine 5%(700mg) adh. patch

Generic

lidocaine hcl (2 % solution, 2 % jel/pf app, 2 % jel (ml), 4 % solution, 40 mg/ml solution)

Generic

lidocaine/prilocaine (2.5 %-2.5% cream (g), 2.5 %-2.5% kit)

Generic

NAROPIN (0.2% 400 MG/200 ML BTL, 2 MG/ML INFUSION BTL, 5 MG/ML INFUSION BTL, 200 MG/100 ML INF BTL)

Medical

proparacaine hcl 0.5 % drops

Generic

relador pak

Generic

relador pak plus

Generic

SYNERA

Medical


Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium

Generic

depade

Generic

disulfiram (250 mg tablet, 500 mg tablet)

Generic

naltrexone hcl 50 mg tablet

Generic

revia

Generic

VIVITROL

Medical


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

buprenorphine hcl (2 mg tab subl, 8 mg tab subl)

Generic

QL (90 PER 30 DAYS)

buprenorphine hcl/naloxone hcl

Generic

QL (90 PER 30 DAYS)

naloxone hcl (0.4 mg/ml vial, 0.4 mg/ml syringe, 1 mg/ml syringe)

Medical

SUBOXONE

Non-Preferred Brand

Opioid Antagonists

QL (90 PER 30 DAYS)

Smoking Cessation Agents BUPROBAN

Preventive

CHANTIX

Preventive

Anti-inflammatory Agents Glucocorticoids alclometasone dipropionate

Generic

amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g))

Generic

anusol-hc 2.5% cream

Generic

apexicon e

Generic

betamethasone dipropionate (0.05 % lotion, 0.05 % gel (gram), 0.05 % cream (g), 0.05 % oint. (g))

Generic

betamethasone dipropionate/propylene glycol (0.05 % cream (g), 0.05 % oint. (g), 0.05 % lotion)

Generic

betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g))

Generic

clobetasol propionate (0.05 % solution, 0.05 % lotion, 0.05 % shampoo, 0.05 % cream (g), 0.05 % foam, 0.05 % oint. (g), 0.05 % gel (gram))

Generic

clobetasol propionate/emollient base

Generic

clocortolone pivalate

Non-Preferred Brand


LAST UPDATE 11/2015


Drug Name

Status*

clodan 0.05% shampoo

Generic

CLODERM

Non-Preferred Brand

CORDRAN (4 CM TAPE LARGE, 4 CM TAPE SMALL)

Non-Preferred Brand

cormax

Generic

cortisone acetate 25 mg tablet

Generic

CORTISPORIN CREAM

Non-Preferred Brand

desonide (0.05 % lotion, 0.05 % cream (g), 0.05 % oint. (g))

Generic

desoximetasone

Generic

diflorasone diacetate

Generic

fludrocortisone acetate 0.1 mg tablet

Generic

fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.01 % solution, 0.025 % oint. (g), 0.025 % cream (g))

Generic

fluocinolone acetonide/shower cap

Generic

fluocinonide (0.05 % gel (gram), 0.05 % solution, 0.05 % cream (g), 0.05 % oint. (g))

Generic

fluocinonide/emollient base

Generic

fluticasone propionate (0.005 % oint. (g), 0.05 % lotion, 0.05 % cream (g))

Generic

halobetasol propionate

Generic

HALOG 0.1% CREAM

Non-Preferred Brand

hydrocortisone (2.5 % lotion, 2.5 % cream (g), 2.5 % oint. (g))

Generic

hydrocortisone butyrate 0.1 % cream (g)

Generic

methylprednisolone

Generic

millipred 5 mg tablet

Generic

Requirements/Limits


LAST UPDATE 11/2015


Drug Name

Status*

millipred dp

Generic

neomycin sulfate/polymyxin b sulfate/hydrocortisone (drops susp, solution)

Generic

nystatin/triamcinolone acetonide

Generic

oralone

Generic

prednisolone 15 mg/5 ml solution

Generic

prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 15 mg tab rapdis, 15 mg/5 ml solution, 30 mg tab rapdis)

Generic

prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg tab ds pk, 10 mg tablet, 10 mg tab ds pk, 20 mg tablet, 50 mg tablet)

Generic

prednisone intensol

Generic

procto-pak

Generic

proctocream-hc

Generic

psorcon

Generic

TEXACORT

Non-Preferred Brand

triamcinolone acetonide (0.025 % cream (g), 0.025 % oint. (g), 0.025 % lotion, 0.1 % lotion, 0.1 % oint. (g), 0.1 % cream (g), 0.1 % paste (g), 0.5 % oint. (g), 0.5 % cream (g))

Generic

triderm

Generic

Requirements/Limits

Antibacterials Aminoglycosides amikacin sulfate (500 mg/2ml vial, 1000mg/4ml vial)

Medical

garamycin 0.3% eye drops

Generic

gentak

Generic


LAST UPDATE 11/2015


Drug Name

Status*

gentamicin in nacl, iso-osm 120mg/0.1l piggyback

Medical

gentamicin sulfate (0.1 % oint. (g), 0.1 % cream (g), 0.3 % oint. (g), 0.3 % drops)

Generic

gentamicin sulfate (20 mg/2 ml vial, 40 mg/ml vial)

Medical

gentamicin sulfate/pf

Medical

neomycin sulfate 500 mg tablet

Generic

paromomycin sulfate 250 mg capsule

Generic

streptomycin sulfate 1 g vial

Medical

TOBI PODHALER

Specialty

TOBRADEX EYE OINTMENT

Non-Preferred Brand

tobramycin 0.3 % drops

Generic

tobramycin in 0.225 % sodium chloride

Specialty

tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial)

Medical

tobramycin sulfate/sodium chloride

Medical

Requirements/Limits

LA

Antibacterials, Other acetasol hc

Generic

acetic acid 2 % solution

Generic

acetic acid/aluminum acetate

Generic

acetic acid/hydrocortisone

Generic

ALTABAX

Non-Preferred Brand

BACIIM

Medical

bacitracin 500 unit/g oint. (g)

Generic

bacitracin 50000 unit vial

Medical

chlorhexidine gluconate 0.12 % mouthwash

Generic

PA


LAST UPDATE 11/2015


Drug Name

Status*

CLEOCIN 600 MG-D5W-GALAXY

Medical

CLEOCIN PHOS 150 MG/ML VIAL

Medical

clindacin etz 1% pledget

Generic

clindacin p

Generic

clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg capsule)

Generic

clindamycin palmitate hcl

Generic

clindamycin phosphate (1 % foam, 1 % lotion, 1 % gel (gram), 1 % med. swab, 1 % solution, 2 % cream/appl)

Generic

clindamycin phosphate (300 mg/2ml vial port, 600 mg/4ml vial port)

Medical

CUBICIN

Medical

cycloserine 250 mg capsule

Generic

erythromycin ethylsuccinate/sulfisoxazole acetyl

Generic

LINCOCIN

Medical

linezolid 600 mg tablet

Non-Preferred Brand

methenamine hippurate

Generic

methenamine mandelate 1 g tablet

Generic

metronidazole (0.75 % gel (gram), 0.75 % cream (g), 0.75 % gel w/appl, 0.75 % lotion, 250 mg tablet, 375 mg capsule, 500 mg tablet)

Generic

metronidazole in sodium chloride

Medical

MONUROL

Pref. Brand

mupirocin 2 % oint. (g)

Generic

mupirocin calcium

Generic

nitrofurantoin 25 mg/5 ml oral susp

Generic

nitrofurantoin macrocrystal (25 mg capsule, 50 mg capsule, 100 mg capsule)

Generic

Requirements/Limits


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

nitrofurantoin monohydrate/macrocrystals

Generic

paroex

Generic

periogard

Generic

polymyxin b sulfate

Medical

PRIMSOL

Non-Preferred Brand

rosadan (0.75% gel, 0.75% cream)

Generic

SIVEXTRO 200 MG VIAL

Medical

SULFAMYLON 8.5% CREAM

Non-Preferred Brand

tinidazole (250 mg tablet, 500 mg tablet)

Generic

trimethoprim 100 mg tablet

Generic

TYGACIL

Medical

vancomycin hcl (1 g vial, 5 g vial, 10 g vial, 500 mg vial, 500 mg vial port)

Medical

vancomycin hcl (125 mg capsule, 250 mg capsule)

Generic

vancomycin hcl/dextrose 5 % in water

Medical

vandazole

Generic

VIBATIV

Medical

vitazol

Generic

XIFAXAN 200 MG TABLET

Non-Preferred Brand


XIFAXAN 550 MG TABLET

Non-Preferred Brand


ZYVOX (100 MG/5 ML SUSPENSION, 600 MG TABLET)

Non-Preferred Brand

ZYVOX (200 MG/100 ML IV SOLN, 600 MG/300 ML IV SOLN)

Medical

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Beta-lactam, Cephalosporins cefaclor (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg capsule, 375 mg/5ml susp recon, 500 mg tab er 12h, 500 mg capsule)

Generic

cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon)

Generic

cefazolin sodium

Medical

cefazolin sodium/dextrose, iso-osmotic (1 ml froz.piggy, 1 ml piggyback)

Medical

cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule)

Generic

cefditoren pivoxil 400 mg tablet

Generic

cefepime hcl

Medical

cefixime

Generic

cefotaxime sodium

Medical

cefotetan disod/dextrose,iso 1 g/50 ml piggyback

Medical

cefotetan disodium

Medical

cefoxitin sodium

Medical

cefoxitin sodium/dextrose, iso-osmotic

Medical

cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet)

Generic

cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet)

Generic

ceftazidime (1 g vial, 2 g vial, 6 g vial)

Medical

ceftibuten (180 mg/5ml susp recon, 400 mg capsule)

Generic

CEFTIN 125 MG/5 ML ORAL SUSP

Non-Preferred Brand

CEFTIN 250 MG/5 ML ORAL SUSP

Pref. Brand


LAST UPDATE 11/2015


Drug Name

Status*

ceftriaxone sodium (1 g vial, 1 g vial port, 2 g vial port, 2 g vial, 10 g vial, 250 mg vial, 500 mg vial)

Medical

ceftriaxone sodium/dextrose, isoosmotic (1 ml piggyback, 1 ml froz.piggy, 2 ml froz.piggy, 2 ml piggyback)

Medical

cefuroxime axetil

Generic

cefuroxime sodium

Medical

cefuroxime sodium/dextrose,iso 1.5g/50ml piggyback

Medical

cephalexin (125 mg/5ml susp recon, 250 mg tablet, 250 mg capsule, 250 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 750 mg capsule)

Generic

FORTAZ IN ISO-OSMOTIC DEXTROSE

Medical

SUPRAX (400 MG TABLET, 400 MG CAPSULE)

Non-Preferred Brand

TAZICEF

Medical

TEFLARO

Medical

Requirements/Limits

Beta-lactam, Other aztreonam

Medical

DORIBAX 500 MG VIAL

Medical

imipenem/cilastatin sodium

Medical

INVANZ 1 GM VIAL

Medical

meropenem

Medical

PRIMAXIN 500 MG VIAL

Medical

Beta-lactam, Penicillins amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

amoxicillin/potassium clavulanate (20028.5mg tab chew, 200-28.5/5 susp recon, 250-125 mg tablet, 250-62.5/5 susp recon, 400-57mg tab chew, 40057mg/5 susp recon, 500-125 mg tablet, 600-42.9/5 susp recon, 875-125 mg tablet, 1000-62.5 tab er 12h)

Generic

ampicillin sodium

Medical

ampicillin sodium/sulbactam sodium (1.5 g vial, 3 g vial, 15 g vial)

Medical

ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule)

Generic

dicloxacillin sodium

Generic

MOXATAG

Non-Preferred Brand

nafcillin in dextrose, iso-osmotic

Medical

nafcillin sodium (1 g vial, 1 g vial port, 2 g vial, 10 g vial)

Medical

oxacillin sodium

Medical

oxacillin sodium/dextrose, iso-osmotic

Medical

penicillin g potassium 20mm unit vial

Generic

penicillin g procaine

Medical

penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet)

Generic

pfizerpen 20 million unit vial

Generic

piperacillin sodium/tazobactam sodium (2.25 g vial port, 2.25 g vial, 3.375 g vial, 3.375 g vial port, 4.5 g vial, 40.5 g vial)

Medical

TIMENTIN (3.1 GM/100 ML ISO, 3.1 GM VIAL, 31 GM BULK VIAL)

Medical

Requirements/Limits

Macrolides AZASITE

Non-Preferred Brand


LAST UPDATE 11/2015


Drug Name

Status*

azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mg tablet)

Generic

clarithromycin (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet)

Generic

DIFICID

Specialty

E.E.S. 200

Pref. Brand

ery

Generic

ERY-TAB

Non-Preferred Brand

erygel

Generic

ERYPED 200

Pref. Brand

ERYTHROCIN STEARATE

Non-Preferred Brand

erythromycin base (5 mg/g oint. (g), 250 mg tablet, 250 mg capsule dr, 500 mg tablet)

Generic

erythromycin base/ethyl alcohol (2 % med. swab, 2 % solution, 2 % gel (gram))

Generic

erythromycin ethylsuccinate 400 mg tablet

Generic

KETEK 300 MG TABLET

Pref. Brand

Requirements/Limits

PA

Quinolones BESIVANCE

Non-Preferred Brand

ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet)

Generic

ciprofloxacin/ciprofloxacin hcl

Generic

FACTIVE

Non-Preferred Brand

gatifloxacin

Generic


LAST UPDATE 11/2015


Drug Name

Status*

levofloxacin (0.5 % drops, 250mg/10ml solution, 250 mg tablet, 500 mg tablet, 750 mg tablet)

Generic

moxifloxacin hcl (100 % powder, 400 mg tablet)

Generic

NOROXIN

Non-Preferred Brand

ofloxacin (0.3 % drops, 200 mg tablet, 300 mg tablet, 400 mg tablet)

Generic

VIGAMOX

Non-Preferred Brand

Requirements/Limits

Sulfonamides bleph-10

Generic

silver sulfadiazine 1 % cream (g)

Generic

sulfacetamide sodium (10 % drops, 10 % suspension)

Generic

sulfadiazine 500 mg tablet

Generic

sulfamethoxazole/trimethoprim (20040mg/5 oral susp, 400mg-80mg tablet, 800-160/20 oral susp, 800-160 mg tablet)

Generic

sulfamide

Generic

Tetracyclines avidoxy

Generic

demeclocycline hcl

Generic

doxycycline hyclate (20 mg tablet, 50 mg capsule, 100 mg capsule, 100 mg tablet)

Generic

doxycycline monohydrate (50 mg capsule, 50 mg tablet, 75 mg tablet, 100 mg tablet, 100 mg capsule, 150 mg tablet)

Generic

dynacin (50 mg tablet, 100 mg tablet)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

minocycline hcl (50 mg tablet, 50 mg capsule, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet)

Generic

mondoxyne nl (nl 50 mg capsule, nl 100 mg capsule)

Generic

morgidox 100 mg capsule

Generic

tetracycline hcl (250 mg capsule, 500 mg capsule)

Generic

Requirements/Limits

Anticonvulsants Anticonvulsants, Other acetazolamide (125 mg tablet, 250 mg tablet)

Generic

levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg/5ml solution, 500 mg tablet, 750 mg tab er 24h, 750 mg tablet, 1000 mg tablet)

Generic

POTIGA

Non-Preferred Brand

primidone (50 mg tablet, 250 mg tablet)

Generic

Calcium Channel Modifying Agents CELONTIN

Non-Preferred Brand

ethosuximide (250 mg/5ml solution, 250 mg capsule)

Generic

LYRICA (20 MG/ML ORAL SOLUTION, 25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300 MG CAPSULE)

Non-Preferred Brand

zonisamide (25 mg capsule, 50 mg capsule, 100 mg capsule)

Generic

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT

Non-Preferred Brand

diazepam (5-7.5-10mg kit, 12.5-15-20 kit)

Generic

diazepam 2.5 mg kit

Non-Preferred Brand

divalproex sodium

Generic

gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 400 mg capsule, 600 mg tablet, 800 mg tablet)

Generic

GABITRIL (12 MG TABLET, 16 MG TABLET)

Non-Preferred Brand

ONFI (5 MG TABLET, 10 MG TABLET, 20 MG TABLET)

Non-Preferred Brand


ONFI 2.5 MG/ML SUSPENSION

Non-Preferred Brand

PA

phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet)

Generic

SABRIL

Non-Preferred Brand

LA

STAVZOR

Non-Preferred Brand

PA

tiagabine hcl

Generic

valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution, 500mg/10ml solution)

Generic

valproic acid (as sodium salt) 500 mg/5ml vial

Medical

valproic acid 250 mg capsule

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp)

Generic

lamotrigine (5 mg tb chw dsp, 25 mg tablet, 25mg (35) tab ds pk, 25 mg tb chw dsp, 100 mg tablet, 150 mg tablet, 200 mg tablet)

Generic

topiragen

Generic

topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)

Generic

topiramate (25 mg cap spr 24, 50 mg cap spr 24, 100 mg cap spr 24, 150 mg cap spr 24, 200 mg cap spr 24)

Generic

PA

Sodium Channel Agents APTIOM

Non-Preferred Brand

BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET)

Non-Preferred Brand

carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg tablet, 200 mg tab er 12h, 200 mg cpmp 12hr, 300 mg cpmp 12hr, 400 mg tab er 12h)

Generic

DILANTIN 30 MG CAPSULE

Pref. Brand

epitol

Generic

fosphenytoin sodium

Medical

oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet)

Generic

PEGANONE

Non-Preferred Brand

phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp)

Generic

phenytoin sodium extended

Generic

PA


LAST UPDATE 11/2015


Drug Name

Status*

VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)

Non-Preferred Brand

Requirements/Limits

Antidementia Agents Antidementia Agents, Other ergoloid mesylates 1 mg tablet

Generic

Cholinesterase Inhibitors donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tablet, 10 mg tab rapdis)

Generic

donepezil hcl 23 mg tablet

Generic

EXELON 2 MG/ML ORAL SOLUTION

Non-Preferred Brand

galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet, 12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel)

Generic

rivastigmine

Generic

rivastigmine tartrate

Generic


QL (60 PER 30 DAYS)

N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (5 mg tablet, 10 mg tablet)

Generic

QL (2 PER DAY)

memantine hcl 10 mg/5 ml solution

Generic

QL (300 ML PER 30 DAYS)

memantine hcl 5 mg-10 mg tab ds pk

Generic

Antidepressants Antidepressants, Other ABILIFY 9.7 MG/1.3 ML VIAL

Medical

APLENZIN ER 174 MG TABLET

Non-Preferred Brand

aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)

Generic

PA


LAST UPDATE 11/2015


Drug Name

Status*

aripiprazole (10 mg tab rapdis, 15 mg tab rapdis)

Pref. Brand

budeprion sr

Generic

bupropion hcl (75 mg tablet, 100 mg tablet er, 100 mg tablet, 150 mg tab er 24h, 150 mg tablet er, 200 mg tablet er, 300 mg tab er 24h)

Generic

maprotiline hcl

Generic

mirtazapine (7.5 mg tablet, 15 mg tablet, 15 mg tab rapdis, 30 mg tablet, 30 mg tab rapdis, 45 mg tablet, 45 mg tab rapdis)

Generic

nefazodone hcl

Generic

olanzapine/fluoxetine hcl

Generic

perphenazine/amitriptyline hcl

Generic

trazodone hcl (50 mg tablet, 100 mg tablet, 150 mg tablet, 300 mg tablet)

Generic

VIIBRYD

Non-Preferred Brand

Requirements/Limits

PA

Monoamine Oxidase Inhibitors EMSAM

Non-Preferred Brand

MARPLAN

Non-Preferred Brand

phenelzine sulfate 15 mg tablet

Generic

tranylcypromine sulfate

Generic

Serotonin/Norepinephrine Reuptake Inhibitors citalopram hydrobromide (10 mg tablet, 10 mg/5 ml solution, 20 mg tablet, 40 mg tablet)

Generic

desvenlafaxine

Non-Preferred Brand


desvenlafaxine fumarate

Non-Preferred Brand



LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

duloxetine hcl (20 mg capsule dr, 30 mg capsule dr)

Generic

QL (60 PER 30 DAYS)

duloxetine hcl 60 mg capsule dr

Generic

QL (30 PER 30 DAYS)

escitalopram oxalate (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 20 mg tablet)

Generic

fluoxetine hcl (10 mg tablet, 10 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 20 mg capsule, 40 mg capsule, 60 mg tablet, 90 mg capsule dr)

Generic

fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

KHEDEZLA

Non-Preferred Brand

paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet)

Generic

paroxetine hcl (25 mg tab er 24h, 37.5 mg tab er 24h)

Generic

PAXIL 10 MG/5 ML SUSPENSION

Non-Preferred Brand

PEXEVA

Non-Preferred Brand

PA

PRISTIQ ER

Non-Preferred Brand


sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tab er 24, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 24h, 75 mg tab er 24, 75 mg tablet, 100 mg tablet, 150 mg cap er 24h, 150 mg tab er 24)

Generic

venlafaxine hcl 225 mg tab er 24

Non-Preferred Brand


PA

QL (30 PER 30 DAYS)


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Tricyclics amitriptyline hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet)

Generic

amoxapine

Generic

clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule)

Generic

desipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet)

Generic

doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule)

Generic

imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet)

Generic

imipramine pamoate

Generic

nortriptyline hcl (10 mg/5 ml solution, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule)

Generic

protriptyline hcl

Generic

trimipramine maleate

Generic

Antiemetics Antiemetics, Other ALOXI

Medical

chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)

Generic

compro

Generic

DICLEGIS

Non-Preferred Brand

diphenhydramine hcl (50 mg/ml vial, 50 mg/ml syringe)

Medical

QL (60 PER 30 DAYS)


LAST UPDATE 11/2015


Drug Name

Status*

hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet)

Generic

hydroxyzine pamoate (25 mg capsule, 50 mg capsule, 100 mg capsule)

Generic

metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10ml solution)

Generic

perphenazine (2 mg tablet, 4 mg tablet, 8 mg tablet, 16 mg tablet)

Generic

phenadoz

Generic

prochlorperazine

Generic

prochlorperazine maleate (5 mg tablet, 10 mg tablet)

Generic

promethazine hcl (6.25mg/5ml syrup, 12.5 mg supp.rect, 12.5 mg tablet, 25 mg tablet, 25 mg supp.rect, 50 mg supp.rect, 50 mg tablet)

Generic

promethegan

Generic

TRANSDERM-SCOP

Non-Preferred Brand

trimethobenzamide hcl 300 mg capsule

Generic

Requirements/Limits

Emetogenic Therapy Adjuncts ANZEMET (50 MG TABLET, 100 MG TABLET)

Non-Preferred Brand


CESAMET

Non-Preferred Brand


dronabinol

Generic


EMEND 125 MG CAPSULE

Pref. Brand

QL (2 PER 30 DAYS)

EMEND 40 MG CAPSULE

Pref. Brand

QL (8 PER 30 DAYS)

EMEND 80 MG CAPSULE

Pref. Brand

QL (4 PER 30 DAYS)

EMEND TRIFOLD PACK

Pref. Brand

QL (6 PER 30 DAYS)

granisetron hcl 1 mg tablet

Generic


ondansetron 8 mg tab rapdis

Generic


LAST UPDATE 11/2015


Drug Name

Status*

ondansetron hcl (4 mg/5 ml solution, 4 mg tablet, 8 mg tablet, 24 mg tablet)

Generic

ondansetron odt

Generic

SANCUSO

Non-Preferred Brand

Requirements/Limits


Antifungals ABELCET

Medical

AMBISOME

Medical

amphotericin b 50 mg vial

Medical

CANCIDAS

Medical

ciclodan 0.77% cream

Generic

ciclopirox (0.77 % gel (gram), 1 % shampoo)

Generic

ciclopirox olamine (0.77 % cream (g), 0.77 % suspension)

Generic

ciclopirox/vitamin e mixed/nail lacquer remover, non-acet

Generic

clotrimazole 10 mg troche

Generic

econazole nitrate 1 % cream (g)

Generic

ERAXIS (WATER DILUENT)

Medical

ERTACZO

Non-Preferred Brand

EXELDERM (1% CREAM, 1% SOLUTION)

Non-Preferred Brand

fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)

Generic

flucytosine (250 mg capsule, 500 mg capsule)

Generic

griseofulvin ultramicrosize

Generic

griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

itraconazole 100 mg capsule

Generic

PA

ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo)

Generic

ketodan 2% foam

Generic

LAMISIL (125 MG GRANULES PACKET, 187.5 MG GRANULES PACK)

Non-Preferred Brand

miconazole nitrate 200 mg supp.vag

Generic

MYCAMINE

Medical

naftifine hcl

Non-Preferred Brand

NAFTIN (1% GEL, 1% CREAM)

Non-Preferred Brand

NATACYN

Non-Preferred Brand

NOXAFIL 40 MG/ML SUSPENSION

Non-Preferred Brand

nyamyc

Generic

nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, 100000/ml oral susp, 100000/g powder, 100000/g cream (g), 100000/g oint. (g))

Generic

nystop

Generic

ORAVIG

Non-Preferred Brand

OXISTAT (1% CREAM, 1% LOTION)

Non-Preferred Brand

pedi-dri

Generic

SPORANOX 10 MG/ML SOLUTION

Pref. Brand

terbinafine hcl 250 mg tablet

Generic

terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag)

Generic

voriconazole (50 mg tablet, 200 mg tablet, 200 mg/5ml susp recon)

Generic

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Antigout Agents allopurinol (100 mg tablet, 300 mg tablet)

Generic

colchicine 0.6 mg tablet

Pref. Brand

colchicine/probenecid

Generic

COLCRYS

Pref. Brand

probenecid

Generic

ULORIC

Non-Preferred Brand

QL (60 PER 30 DAYS) QL (60 PER 30 DAYS) PA

Antimigraine Agents Ergot Alkaloids cafergot

Generic

dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial)

Generic

dihydroergotamine mesylate 0.5mg/spry spray/pump

Non-Preferred Brand

ERGOMAR

Non-Preferred Brand

ergotamine tartrate/caffeine

Generic

migergot

Generic

MIGRANAL

Non-Preferred Brand


Medical

PA


Prophylactic BOTOX

Serotonin (5-HT) 1b/1d Receptor Agonists almotriptan malate

Non-Preferred Brand

QL (12 PER 30 DAYS)

FROVA

Non-Preferred Brand

QL (9 PER 30 DAYS)


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

naratriptan hcl

Generic

QL (9 PER 30 DAYS)

RELPAX

Non-Preferred Brand

QL (12 PER 30 DAYS)

rizatriptan benzoate

Generic

QL (9 PER 30 DAYS)

sumatriptan (5 mg spray, 20 mg spray)

Generic

QL (6 PER 30 DAYS)

sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

QL (9 PER 30 DAYS)

sumatriptan succinate (4 cartridge, 6 pen injctr, 6 syringe, 6 cartridge, 6 vial)

Generic


sumatriptan succinate 4 mg/0.5ml pen injctr

Generic


zolmitriptan (2.5 mg tab rapdis, 2.5 mg tablet)

Generic

QL (12 PER 30 DAYS)

zolmitriptan (5 mg tab rapdis, 5 mg tablet)

Generic

QL (9 PER 30 DAYS)

ZOMIG 2.5 MG NASAL SPRAY

Non-Preferred Brand

QL (12 PER 30 DAYS)

ZOMIG 5 MG NASAL SPRAY

Non-Preferred Brand

QL (6 PER 30 DAYS)

Antimyasthenic Agents Parasympathomimetics guanidine hcl

Generic

MESTINON 60 MG/5 ML SYRUP

Non-Preferred Brand

pyridostigmine bromide (60 mg tablet, 180 mg tablet er)

Generic

Antimycobacterials Antimycobacterials, Other dapsone (25 mg tablet, 100 mg tablet)

Generic

rifabutin

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Antituberculars CAPASTAT SULFATE

Medical

ethambutol hcl

Generic

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet)

Generic

PASER

Non-Preferred Brand

PRIFTIN

Non-Preferred Brand

pyrazinamide

Generic

RIFAMATE

Non-Preferred Brand

rifampin (150 mg capsule, 300 mg capsule)

Generic

RIFATER

Non-Preferred Brand

SIRTURO

Specialty

TRECATOR

Pref. Brand

LA

Antineoplastics Alkylating Agents ALKERAN 2 MG TABLET

Pref. Brand

BUSULFEX

Medical

CEENU

Non-Preferred Brand

CYCLOPHOSPHAMIDE CAPSULES

Non-Preferred Brand

cyclophosphamide tablets

Generic

GLEOSTINE

Non-Preferred Brand

LEUKERAN

Pref. Brand

lomustine

Non-Preferred Brand

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

MATULANE

Specialty

melphalan hcl

Medical

PA

temozolomide

Specialty

PA

VALCHLOR

Specialty

LA

ZANOSAR

Medical

Antiangiogenic Agents POMALYST

Specialty

PA

REVLIMID

Specialty

PA, LA

THALOMID

Specialty

Antiestrogens/Modifiers EMCYT

Specialty

FARESTON

Non-Preferred Brand

SOLTAMOX

Non-Preferred Brand

tamoxifen citrate (10 mg tablet, 20 mg tablet)

Generic

Antimetabolites ADRUCIL

Medical

capecitabine

Specialty

DACOGEN

Medical

DROXIA

Non-Preferred Brand

fludarabine phosphate 50 mg/2 ml vial

Medical

fluorouracil (1 g/20 ml vial, 2.5 g/50ml vial, 5 g/100 ml vial, 500mg/10ml vial)

Medical

hydroxyurea 500 mg capsule

Generic

mercaptopurine 50 mg tablet

Generic

methotrexate sodium (2.5 mg tablet, 25 mg/ml vial)

Generic

PA


LAST UPDATE 11/2015


Drug Name

Status*

methotrexate sodium/pf (1 g vial, 25 mg/ml vial)

Generic

PURIXAN

Non-Preferred Brand

RHEUMATREX

Non-Preferred Brand

TABLOID

Pref. Brand

VIDAZA

Medical

Requirements/Limits

PA

Antineoplastics, Other amifostine crystalline

Medical

ELSPAR

Medical

FARYDAK

Specialty

flutamide

Generic

HEXALEN

Specialty

imiquimod 5 % cream pack

Generic

INTRON A (6 MILLION UNIT/ML VL, 10 MILLION UNIT/ML, 10 MILLION UNITS VIL, 18 MILLION UNITS VIL, 50 MILLION UNITS VIL)

Specialty

leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet)

Generic

MESNEX 400 MG TABLET

Pref. Brand

mitoxantrone hcl

Medical

SYLATRON

Specialty

PA

SYLATRON 4-PACK

Specialty

PA

SYNRIBO

Specialty

PA

TRELSTAR 11.25 MG SYRINGE

Medical

ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM PUMP, 3.75% CREAM)

Non-Preferred Brand


PA

Aromatase Inhibitors, 3rd Generation anastrozole 1 mg tablet

Generic


LAST UPDATE 11/2015


Drug Name

Status*

exemestane

Generic

letrozole 2.5 mg tablet

Generic

Requirements/Limits

Enzyme Inhibitors BOSULIF

Specialty

PA

ETOPOPHOS

Medical

etoposide 20 mg/ml vial

Medical

GILOTRIF

Specialty

PA

HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE)

Specialty

PA

HYCAMTIN 4 MG VIAL

Medical

PA

IMBRUVICA

Specialty

PA

INLYTA

Specialty

PA, LA

JAKAFI

Specialty

PA, LA

LYNPARZA

Specialty

PA, LA

MEKINIST

Specialty

PA

TAFINLAR

Specialty

PA

TOPOSAR

Medical

VOTRIENT

Specialty

PA

ZELBORAF

Specialty

PA

ZYTIGA

Specialty

PA

AFINITOR

Specialty

PA

AFINITOR DISPERZ

Specialty

PA

CAPRELSA

Specialty

PA

COMETRIQ

Specialty

PA, LA

ERIVEDGE

Specialty

PA

GLEEVEC

Specialty

PA

IBRANCE

Specialty

PA

Molecular Target Inhibitors


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

ICLUSIG

Specialty

PA

LENVIMA

Specialty

PA, LA

NEXAVAR

Specialty

PA

SPRYCEL

Specialty

PA

STIVARGA

Specialty

PA

SUTENT

Specialty

PA

TARCEVA

Specialty

PA

TASIGNA

Specialty

PA

TORISEL

Medical

PA

TYKERB

Specialty

PA

vandetanib

Specialty

PA

XALKORI

Specialty

PA, LA

ZOLINZA

Specialty

PA

ZYDELIG

Specialty


ZYKADIA

Specialty

PA

ARZERRA

Medical

PA

PROLIA

Medical

PA

RITUXAN

Medical

PA

XGEVA

Medical

PA

YERVOY

Medical

PA

bexarotene

Specialty

PA

PANRETIN

Specialty

TARGRETIN 1% GEL

Specialty

PA

tretinoin 10 mg capsule

Generic

PA

Monoclonal Antibodies

Retinoids


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Antiparasitics Anthelmintics ALBENZA

Pref. Brand

BILTRICIDE

Non-Preferred Brand

ivermectin 3 mg tablet

Generic

SOOLANTRA

Non-Preferred Brand

ST, QL (30 GM PER 30 DAYS)

Antiprotozoals ALINIA 100 MG/5 ML SUSPENSION

Non-Preferred Brand

ALINIA 500 MG TABLET

Pref. Brand

atovaquone

Specialty

PA

chloroquine phosphate (250 mg tablet, 500 mg tablet)

Generic

PA

COARTEM

Non-Preferred Brand

PA

DARAPRIM

Non-Preferred Brand

PA

hydroxychloroquine sulfate 200 mg tablet

Generic

mefloquine hcl

Generic

PA

primaquine phosphate

Generic

PA

Pediculicides/Scabicides elimite

Generic

EURAX 10% CREAM

Non-Preferred Brand

lindane

Generic

malathion

Generic

permethrin 5 % cream (g)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

SKLICE

Non-Preferred Brand

ULESFIA

Non-Preferred Brand

Requirements/Limits

Antiparkinson Agents Anticholinergics benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet)

Generic

trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg tablet)

Generic

Antiparkinson Agents, Other amantadine hcl (50 mg/5 ml solution, 100 mg tablet, 100 mg capsule)

Generic

carbidopa/levodopa/entacapone

Generic

entacapone

Generic

tolcapone

Generic

Dopamine Agonists APOKYN

Specialty

bromocriptine mesylate (2.5 mg tablet, 5 mg capsule)

Generic

pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet)

Generic

ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet)

Generic

PA, LA

Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa 25 mg tablet

Generic

carbidopa/levodopa

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Monoamine Oxidase B (MAO-B) Inhibitors AZILECT

Pref. Brand

selegiline hcl (5 mg tablet, 5 mg capsule)

Generic

ZELAPAR

Non-Preferred Brand

Antipsychotics 1st Generation/Typical fluphenazine hcl (1 mg tablet, 2.5 mg/5ml elixir, 2.5 mg tablet, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet)

Generic

haloperidol (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet)

Generic

haloperidol lactate 2 mg/ml oral conc

Generic

loxapine succinate

Generic

pimozide

Generic

thioridazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

thiothixene

Generic

trifluoperazine hcl

Generic

2nd Generation/Atypical FANAPT

Non-Preferred Brand

LATUDA

Non-Preferred Brand

olanzapine (2.5 mg tablet, 5 mg tablet, 5 mg tab rapdis, 7.5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 20 mg tab rapdis)

Generic

paliperidone

Generic



LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

quetiapine fumarate

Generic

RISPERDAL CONSTA 12.5 MG SYR

Medical

risperidone (0.25 mg tablet, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg/ml solution, 1 mg tablet, 2 mg tablet, 2 mg tab rapdis, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)

Generic

SAPHRIS

Non-Preferred Brand

PA

SEROQUEL XR

Non-Preferred Brand

PA

ziprasidone hcl

Generic

Treatment-Resistant clozapine (12.5 mg tab rapdis, 25 mg tablet, 25 mg tab rapdis, 50 mg tablet, 100 mg tablet, 100 mg tab rapdis, 200 mg tablet)

Generic

clozapine (150 mg tab rapdis, 200 mg tab rapdis)

Non-Preferred Brand

VERSACLOZ

Non-Preferred Brand

Antispasticity Agents baclofen (10 mg tablet, 20 mg tablet)

Generic

dantrolene sodium (25 mg capsule, 50 mg capsule, 100 mg capsule)

Generic

MYRBETRIQ

Non-Preferred Brand

tizanidine hcl (2 mg tablet, 4 mg tablet)

Generic

XEOMIN

Medical

PA

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Antivirals Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors EDURANT

Pref. Brand

INTELENCE

Pref. Brand

nevirapine (200 mg tablet, 400 mg tab er 24h)

Generic

RESCRIPTOR

Pref. Brand

SUSTIVA

Pref. Brand

VIRAMUNE XR 100 MG TABLET

Pref. Brand

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir sulfate

Generic

abacavir sulfate/lamivudine/zidovudine

Generic

COMPLERA

Pref. Brand

didanosine

Generic

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)

Pref. Brand

EPZICOM

Pref. Brand

lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet)

Generic

lamivudine/zidovudine

Generic

stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule)

Generic

TRUVADA

Pref. Brand

VIDEX

Pref. Brand

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER)

Pref. Brand

ZIAGEN 20 MG/ML SOLUTION

Pref. Brand

zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Anti-HIV Agents, Other ATRIPLA

Pref. Brand

FUZEON

Non-Preferred Brand

ISENTRESS (100 MG POWDER PACKET, 400 MG TABLET)

Pref. Brand

SELZENTRY

Pref. Brand

STRIBILD

Pref. Brand

TIVICAY

Non-Preferred Brand

TRIUMEQ

Pref. Brand

TYBOST

Pref. Brand

VITEKTA

Non-Preferred Brand

Anti-HIV Agents, Protease Inhibitors APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE)

Pref. Brand

CRIXIVAN

Pref. Brand

EVOTAZ

Non-Preferred Brand

INVIRASE

Pref. Brand

KALETRA (100-25 MG TABLET, 200-50 MG TABLET, 400-100/5 ML ORAL SOLU)

Pref. Brand

LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET)

Pref. Brand

NORVIR (100 MG TABLET, 100 MG SOFTGEL CAP)

Pref. Brand

NORVIR 80 MG/ML SOLUTION

Non-Preferred Brand

PREZCOBIX

Specialty

PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET)

Pref. Brand


LAST UPDATE 11/2015


Drug Name

Status*

REYATAZ

Pref. Brand

VIRACEPT

Pref. Brand

Requirements/Limits

Anti-cytomegalovirus (CMV) Agents foscarnet sodium

Medical

VALCYTE 50 MG/ML SOLUTION

Specialty

valganciclovir hcl

Generic

VISTIDE

Medical

ZIRGAN

Pref. Brand


Anti-influenza Agents RELENZA

Pref. Brand

rimantadine hcl

Generic

TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75 MG CAPSULE)

Pref. Brand

Antihepatitis Agents adefovir dipivoxil

Specialty

BARACLUDE 0.05 MG/ML SOLUTION

Specialty

entecavir

Specialty

EPIVIR HBV 25 MG/5 ML SOLN

Pref. Brand

HARVONI

Specialty

INCIVEK

Specialty

INFERGEN

Specialty

lamivudine 100 mg tablet

Generic

MODERIBA

Specialty

OLYSIO

Specialty

PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML SYRINGE)

Specialty

PEGASYS PROCLICK

Specialty

PEGINTRON

Specialty

QL (30 PER 30 DAYS)




LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

PEGINTRON REDIPEN

Specialty

REBETOL 40 MG/ML SOLUTION

Specialty

RIBAPAK

Specialty

RIBASPHERE

Specialty

RIBASPHERE RIBAPAK

Specialty

RIBATAB

Specialty

ribavirin (200 mg capsule, 200 mg tablet, 400 mg tablet, 600 mg tablet)

Specialty

SOVALDI

Specialty


TYZEKA

Specialty

QL (30 PER 30 DAYS)

VICTRELIS

Specialty

PA

VIEKIRA PAK

Specialty


Antiherpetic Agents acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet)

Generic

DENAVIR

Non-Preferred Brand

famciclovir

Generic

trifluridine 1 % drops

Generic

valacyclovir hcl (500 mg tablet, 1000 mg tablet)

Generic

PA

Anxiolytics Anxiolytics, Other alprazolam (0.25 mg tablet, 0.5 mg tab er 24h, 0.5 mg tablet, 1 mg tablet, 1 mg tab er 24h, 2 mg tablet, 2 mg tab er 24h, 3 mg tab er 24h)

Generic

buspirone hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 30 mg tablet)

Generic

chlordiazepoxide hcl

Generic


LAST UPDATE 11/2015


Drug Name

Status*

clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tablet, 0.5 mg tab rapdis, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet)

Generic

clorazepate dipotassium

Generic

diazepam (2 mg tablet, 5 mg/5 ml solution, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet)

Generic

lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc)

Generic

lorazepam intensol

Generic

meprobamate 400 mg tablet

Generic

oxazepam

Generic

Requirements/Limits

Bipolar Agents Mood Stabilizers lithium carbonate (150 mg capsule, 300 mg tablet er, 300 mg tablet, 300 mg capsule, 450 mg tablet er, 600 mg capsule)

Generic

lithium citrate

Generic

Blood Glucose Regulators Antidiabetic Agents acarbose

Generic

ACTOPLUS MET XR

Pref. Brand

BYDUREON

Pref. Brand

ST

BYDUREON PEN

Pref. Brand

ST

BYETTA

Pref. Brand

ST

chlorpropamide

Generic

CYCLOSET

Non-Preferred Brand


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

FARXIGA

Non-Preferred Brand

PA

glimepiride

Generic

glipizide (2.5 mg tab er 24, 5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 10 mg tablet)

Generic

glipizide/metformin hcl

Generic

glyburide

Generic

glyburide,micronized

Generic

glyburide/metformin hcl

Generic

GLYSET

Non-Preferred Brand

GLYXAMBI

Non-Preferred Brand

PA

INVOKAMET

Non-Preferred Brand

PA

INVOKANA

Non-Preferred Brand

PA

JANUMET

Non-Preferred Brand

PA

JANUMET XR

Non-Preferred Brand

PA

JANUVIA

Non-Preferred Brand

PA

JARDIANCE

Non-Preferred Brand

PA

JENTADUETO

Non-Preferred Brand

PA

KAZANO

Non-Preferred Brand

PA

KOMBIGLYZE XR

Non-Preferred Brand

PA

metformin hcl (500 mg tablet, 500 mg tab er 24h, 750 mg tab er 24h, 850 mg tablet, 1000 mg tablet)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

nateglinide

Generic

NESINA

Non-Preferred Brand

PA

ONGLYZA

Non-Preferred Brand

PA

OSENI

Non-Preferred Brand

PA

pioglitazone hcl

Generic

pioglitazone hcl/glimepiride

Generic

pioglitazone hcl/metformin hcl

Generic

repaglinide (1 mg tablet, 2 mg tablet)

Generic

RIOMET

Non-Preferred Brand

SYMLINPEN 120

Non-Preferred Brand

PA

SYMLINPEN 60

Non-Preferred Brand

PA

tolazamide

Generic

tolbutamide

Generic

TRADJENTA

Non-Preferred Brand

PA

VICTOZA 2-PAK

Pref. Brand

ST

VICTOZA 3-PAK

Pref. Brand

ST

WELCHOL

Non-Preferred Brand

PA

XIGDUO XR

Non-Preferred Brand

PA

Glycemic Agents GLUCAGEN 1MG HYPOKIT

Pref. Brand

GLUCAGON EMERGENCY KIT

Pref. Brand

PROGLYCEM

Non-Preferred Brand


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Insulins APIDRA

Pref. Brand

APIDRA SOLOSTAR

Pref. Brand

HUMALOG

Pref. Brand

HUMALOG KWIKPEN U-100

Pref. Brand


Pref. Brand

HUMALOG MIX 50-50

Pref. Brand

HUMALOG MIX 50-50 KWIKPEN

Pref. Brand

HUMALOG MIX 75-25

Pref. Brand


Pref. Brand

HUMULIN 70-30 (PEN, VIAL)

Pref. Brand

HUMULIN 70/30 KWIKPEN

Pref. Brand

HUMULIN N (N 100 PEN, N 100 VIAL)

Pref. Brand

HUMULIN N KWIKPEN

Pref. Brand

HUMULIN R 100 UNITS/ML VIAL

Pref. Brand

LANTUS

Pref. Brand

LANTUS SOLOSTAR

Pref. Brand

LEVEMIR

Pref. Brand

LEVEMIR FLEXPEN

Pref. Brand

LEVEMIR FLEXTOUCH

Pref. Brand

NOVOLIN 70-30 100 UNIT/ML VIAL

Pref. Brand

NOVOLIN N 100 UNITS/ML VIAL

Pref. Brand

NOVOLIN R 100 UNITS/ML VIAL

Pref. Brand

NOVOLOG

Pref. Brand

NOVOLOG FLEXPEN

Pref. Brand

NOVOLOG MIX 70-30

Pref. Brand

NOVOLOG MIX 70-30 FLEXPEN

Pref. Brand

TOUJEO SOLOSTAR

Pref. Brand


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Blood Products/Modifiers/ Volume Expanders Anticoagulants ELIQUIS

Pref. Brand

enoxaparin sodium

Generic

fondaparinux sodium

Generic

FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR, 10,000 UNITS/ML SYRING, 12,500 UNITS/0.5 ML, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML, 25,000 UNITS/ML VIAL, 95,000 UNITS/3.8 ML VL)

Specialty

heparin sodium,porcine (100/ml vial, 1000/ml vial, 5000/ml vial, 5000/ml(1) cartridge, 10000/ml vial, 20000/ml vial)

Medical

heparin sodium,porcine in 0.45 % sodium chloride

Medical

heparin sodium,porcine in 0.9 % sodium chloride/pf

Medical

heparin sodium,porcine/dextrose 5 % in water

Medical

heparin sodium,porcine/pf (100/ml (1) vial, 1000/ml vial, 5000/0.5ml syringe, 5000/0.5ml vial)

Medical

jantoven

Generic

PRADAXA

Pref. Brand

SAVAYSA

Non-Preferred Brand

warfarin sodium (1 mg tablet, 2 mg tablet, 2.5 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet, 6 mg tablet, 7.5 mg tablet, 10 mg tablet)

Generic

XARELTO

Pref. Brand


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Blood Formation Modifiers anagrelide hcl

Generic

ARANESP

Specialty

PA

EPOGEN

Specialty

PA

GRANIX

Specialty

LEUKINE (250 MCG VIAL, 500 MCG/ML VIAL)

Specialty

MOZOBIL

Medical

NEULASTA

Specialty

NEUMEGA

Specialty

NEUPOGEN

Specialty

PROCRIT

Specialty

PA

PROMACTA

Specialty

PA

Coagulants tranexamic acid 1000 mg/10 vial

Medical

tranexamic acid 650 mg tablet

Generic

Platelet Modifying Agents AGGRENOX

Pref. Brand

aspirin/dipyridamole

Pref. Brand

BRILINTA 90 MG TABLET

Pref. Brand

cilostazol

Generic

clopidogrel bisulfate 75 mg tablet

Generic

dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet)

Generic

EFFIENT

Pref. Brand

ticlopidine hcl

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Cardiovascular Agents Alpha-adrenergic Agonists clonidine

Generic

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet)

Generic

guanfacine hcl (1 mg tablet, 2 mg tablet)

Generic

methyldopa

Generic

methyldopate hcl

Medical

midodrine hcl

Generic

Alpha-adrenergic Blocking Agents doxazosin mesylate (1 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet)

Generic

phenoxybenzamine hcl 10 mg capsule

Generic

prazosin hcl (1 mg capsule, 2 mg capsule, 5 mg capsule)

Generic

terazosin hcl

Generic

Angiotensin II Receptor Antagonists BENICAR

Non-Preferred Brand

candesartan cilexetil

Generic

EDARBI

Non-Preferred Brand

irbesartan

Generic

losartan potassium

Generic

telmisartan

Generic

valsartan

Generic

PA

PA

PA

Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

enalapril maleate (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet)

Generic

EPANED

Non-Preferred Brand

fosinopril sodium

Generic

lisinopril (2.5 mg tablet, 5 mg tablet, 10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet)

Generic

moexipril hcl

Generic

perindopril erbumine

Generic

quinapril hcl

Generic

ramipril

Generic

trandolapril

Generic

Requirements/Limits

Antiarrhythmics amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet)

Generic

atropine sulfate (0.05mg/ml syringe, 0.1 mg/ml syringe)

Medical

disopyramide phosphate

Generic

flecainide acetate

Generic

lidocaine hcl/pf 100 mg/5ml syringe

Medical

mexiletine hcl (150 mg capsule, 200 mg capsule, 250 mg capsule)

Generic

MULTAQ

Pref. Brand

NORPACE CR

Pref. Brand

pacerone 200 mg tablet

Generic

procainamide hcl (100 mg/ml vial, 500 mg/ml vial)

Medical

propafenone hcl

Generic

quinidine gluconate 324 mg tablet er

Generic


LAST UPDATE 11/2015


Drug Name

Status*

quinidine sulfate (200 mg tablet, 300 mg tablet er, 300 mg tablet)

Generic

sorine

Generic

sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet)

Generic

TIKOSYN

Pref. Brand

verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet)

Generic

Requirements/Limits

Beta-adrenergic Blocking Agents acebutolol hcl (200 mg capsule, 400 mg capsule)

Generic

atenolol (25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

betaxolol hcl (10 mg tablet, 20 mg tablet)

Generic

bisoprolol fumarate

Generic

BYSTOLIC

Non-Preferred Brand

carvedilol

Generic

COREG CR

Non-Preferred Brand

labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet)

Generic

LEVATOL

Non-Preferred Brand

metoprolol succinate

Generic

metoprolol tartrate (25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

nadolol (20 mg tablet, 40 mg tablet, 80 mg tablet)

Generic

pindolol

Generic

PA


LAST UPDATE 11/2015


Drug Name

Status*

propranolol hcl (10 mg tablet, 20 mg/5 ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg tablet, 80 mg cap sa 24h, 120 mg cap sa 24h, 160 mg cap sa 24h)

Generic

timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet)

Generic

Requirements/Limits

Calcium Channel Blocking Agents afeditab cr

Generic

amlodipine besylate (2.5 mg tablet, 5 mg tablet, 10 mg tablet)

Generic

CARDIZEM LA 120 MG TABLET

Non-Preferred Brand

cartia xt

Generic

dilt-cd

Generic

dilt-xr

Generic

diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h, 90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120 mg capsule er, 120 mg tablet, 180 mg cap er 24h, 180 mg tab er 24h, 180 mg capsule er, 180 mg cap er deg, 240 mg tab er 24h, 240 mg cap er deg, 240 mg cap er 24h, 240 mg capsule er, 300 mg capsule er, 300 mg tab er 24h, 300 mg cap er 24h, 360 mg cap er 24h, 360 mg capsule er, 360 mg tab er 24h, 420mg tab er 24h, 420mg capsule er)

Generic

diltzac er

Generic

felodipine

Generic

isradipine

Generic

matzim la

Generic

nicardipine hcl (20 mg capsule, 30 mg capsule)

Generic

nifediac cc

Generic


LAST UPDATE 11/2015


Drug Name

Status*

nifedical xl

Generic

nifedipine (30 mg tab er 24, 30 mg tablet er, 60 mg tablet er, 60 mg tab er 24, 90 mg tab er 24, 90 mg tablet er)

Generic

nimodipine 30 mg capsule

Generic

nisoldipine

Generic

taztia xt

Generic

verapamil hcl (100 mg cap24h pct, 120 mg tablet er, 120 mg cap24h pel, 180 mg tablet er, 180 mg cap24h pel, 200 mg cap24h pct, 240 mg cap24h pel, 240 mg tablet er, 300 mg cap24h pct, 360 mg cap24h pel)

Generic

Requirements/Limits

Cardiovascular Agents, Other amiloride hcl/hydrochlorothiazide

Generic

amlodipine besylate/atorvastatin calcium

Generic

amlodipine besylate/benazepril hcl

Generic

amlodipine besylate/valsartan

Generic

atenolol/chlorthalidone

Generic

benazepril hcl/hydrochlorothiazide

Generic

bisoprolol fumarate/hydrochlorothiazide

Generic

captopril/hydrochlorothiazide

Generic

digitek

Generic

digox

Generic

digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet)

Generic

EDARBYCLOR

Non-Preferred Brand

enalapril maleate/hydrochlorothiazide

Generic

fosinopril sodium/hydrochlorothiazide

Generic

irbesartan/hydrochlorothiazide

Generic

PA


LAST UPDATE 11/2015


Drug Name

Status*

lisinopril/hydrochlorothiazide

Generic

losartan potassium/hydrochlorothiazide

Generic

methyldopa/hydrochlorothiazide

Generic

metoprolol tartrate/hydrochlorothiazide

Generic

moexipril hcl/hydrochlorothiazide

Generic

nadolol/bendroflumethiazide

Generic

pentoxifylline 400 mg tablet er

Generic

propranolol hcl/hydrochlorothiazide

Generic

quinapril hcl/hydrochlorothiazide

Generic

RANEXA

Pref. Brand

spironolactone/hydrochlorothiazide

Generic

TEKTURNA

Non-Preferred Brand

telmisartan/hydrochlorothiazide

Non-Preferred Brand

triamterene/hydrochlorothiazide (37.525 mg capsule, 37.5-25 mg tablet, 75 mg-50mg tablet)

Generic

valsartan/hydrochlorothiazide

Generic

Requirements/Limits

PA

Diuretics, Carbonic Anhydrase Inhibitors acetazolamide 500 mg capsule er

Generic

methazolamide (25 mg tablet, 50 mg tablet)

Generic

Diuretics, Loop bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet)

Generic

EDECRIN

Non-Preferred Brand

furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 80 mg tablet)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

torsemide (5 mg tablet, 10 mg tablet, 20 mg tablet, 100 mg tablet)

Generic

Requirements/Limits

Diuretics, Potassium-sparing amiloride hcl

Generic

DYRENIUM

Pref. Brand

eplerenone

Generic

spironolactone (25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

Diuretics, Thiazide chlorothiazide

Generic

chlorthalidone

Generic

hydrochlorothiazide (12.5 mg capsule, 12.5 mg tablet, 25 mg tablet, 50 mg tablet)

Generic

indapamide

Generic

methyclothiazide

Generic

metolazone

Generic

Dyslipidemics, Fibric Acid Derivatives fenofibrate (54 mg tablet, 160 mg tablet)

Generic

fenofibrate nanocrystallized

Generic

fenofibrate,micronized (67 mg capsule, 134mg capsule, 200 mg capsule)

Generic

fenofibric acid

Generic

fenofibric acid (choline)

Generic

gemfibrozil 600 mg tablet

Generic

lofibra

Generic

Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium

Generic

CRESTOR

Pref. Brand


LAST UPDATE 11/2015


Drug Name

Status*

fluvastatin sodium (20 mg capsule, 40 mg capsule)

Generic

LIVALO

Non-Preferred Brand

lovastatin

Generic

pravastatin sodium

Generic

simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet)

Generic

simvastatin 40 mg tablet

Generic

Requirements/Limits

PA

QL (30 PER 30 DAYS)

Dyslipidemics, Other cholestyramine (with sugar) (4 g powder, 4 g powd pack)

Generic

cholestyramine/aspartame (4 g powd pack, 4 g powder)

Generic

COLESTID FLAVORED GRANULES

Non-Preferred Brand

colestid granules

Generic

colestipol hcl (1 g tablet, 5 g packet, 5 g granules)

Generic

JUXTAPID

Specialty

PA, LA

KYNAMRO

Specialty

PA, LA

niacin (500 mg tab er 24h, 750 mg tab er 24h, 1000 mg tab er 24h)

Generic

PA

niacor

Generic

omega-3 acid ethyl esters

Generic

prevalite (packet, powder)

Generic

ZETIA

Non-Preferred Brand

PA PA

Vasodilators, Direct-acting Arterial hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet)

Generic

minoxidil (2.5 mg tablet, 10 mg tablet)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

RECTIV

Pref. Brand

Requirements/Limits

Vasodilators, Direct-acting Arterial/Venous DILATRATE-SR

Non-Preferred Brand

isochron

Generic

isosorbide dinitrate

Generic

isosorbide mononitrate

Generic

minitran

Generic

NITRO-BID

Pref. Brand

NITRO-DUR (0.3 PATCH, 0.8 PATCH)

Pref. Brand

nitro-time

Generic

nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24, 0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er, 400mcg/spr spray)

Generic

NITROSTAT (0.3 MG TABLET, 0.6 MG TABLET)

Pref. Brand

NITROSTAT 0.4 MG TABLET SL

Non-Preferred Brand

Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (5 mg cap er 24h, 10 mg cap er 24h, 15 mg cap er 24h, 25 mg cap er 24h, 30 mg cap er 24h)

Generic

dextroamphetamine sulfsaccharate/amphetamine sulfaspartate (5 mg tablet, 7.5 mg tablet, 10 mg tablet, 12.5 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)

Generic

QL (30 PER 30 DAYS)


LAST UPDATE 11/2015


Drug Name

Status*

dextroamphetamine sulfate (5 mg tablet, 5 mg capsule er, 10 mg tablet, 10 mg capsule er, 15 mg capsule er)

Generic

dextroamphetamine/amphetamine 20 mg cap er 24h

Generic

methamphetamine hcl

Generic

VYVANSE

Non-Preferred Brand

zenzedi (5 mg tablet, 10 mg tablet)

Generic

Requirements/Limits

QL (60 PER 30 DAYS)

QL (30 PER 30 DAYS)

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines clonidine hcl 0.1 mg tab er 12h

Generic


DAYTRANA

Non-Preferred Brand

QL (30 PER 30 DAYS)

dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet)

Generic

guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er 24h, 4 mg tab er 24h)

Generic


metadate er

Generic

QL (90 PER 30 DAYS)

methylphenidate hcl (10 mg cpbp 3070, 18 mg tab er 24, 20 mg cpbp 30-70, 27 mg tab er 24, 30 mg cpbp 30-70, 40 mg cpbp 30-70, 50 mg cpbp 30-70, 60 mg cpbp 30-70)

Generic

QL (30 PER 30 DAYS)

methylphenidate hcl (2.5 mg tab chew, 5 mg tablet, 5 mg/5 ml solution, 5 mg tab chew, 10 mg tablet, 10 mg tablet er, 10 mg/5 ml solution, 10 mg tab chew, 20 mg tablet, 20 mg cpbp 50-50, 30 mg cpbp 50-50, 36 mg tab er 24, 40 mg cpbp 50-50, 54 mg tab er 24)

Generic

methylphenidate hcl 20 mg tablet er

Generic

QL (90 PER 30 DAYS)

RITALIN LA (10 MG CAPSULE, 60 MG CAPSULE)

Non-Preferred Brand

QL (30 PER 30 DAYS)

STRATTERA

Non-Preferred Brand



LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

BETASERON

Specialty


cevimeline hcl

Generic

EXTAVIA

Specialty


GILENYA

Specialty


HORIZANT

Non-Preferred Brand


NUEDEXTA

Non-Preferred Brand

PA

riluzole

Generic

tetrabenazine

Specialty

PA, LA

SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET)

Non-Preferred Brand


SAVELLA TITRATION PACK

Non-Preferred Brand


AMPYRA

Specialty

PA, LA, QL (60 PER 30 DAYS)

AUBAGIO

Specialty


AVONEX (SYR 30 MCG, SYR 30 MCG KT)

Specialty

AVONEX ADMINISTRATION PACK

Specialty

AVONEX PEN

Specialty

COPAXONE 20 MG/ML SYRINGE

Specialty


COPAXONE 40 MG/ML SYRINGE

Specialty


GLATOPA

Specialty


PLEGRIDY

Specialty


PLEGRIDY PEN

Specialty


REBIF (22 ML SYRINGE, 44 ML SYRINGE)

Specialty


REBIF REBIDOSE (22 ML, 44 ML)

Specialty


Central Nervous System Agents, Other

Fibromyalgia Agents

Multiple Sclerosis Agents


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

REBIF REBIDOSE TITRATION PACK

Specialty


REBIF TITRATION PACK

Specialty


TECFIDERA

Specialty

QL (60 PER 30 DAYS)

TYSABRI

Medical

PA

Dental and Oral Agents KEPIVANCE

Medical

pilocarpine hcl (5 mg tablet, 7.5 mg tablet)

Generic

Dermatological Agents ONEXTON

Non-Preferred Brand

PA

8-MOP

Specialty

ABSORICA (25 MG CAPSULE, 35 MG CAPSULE)

Non-Preferred Brand

ACANYA

Non-Preferred Brand

acitretin

Generic

adapalene (0.1 % gel (gram), 0.1 % cream (g))

Generic

adapalene (0.3 % gel (gram), 0.3 % gel w/pump)

Non-Preferred Brand

amnesteem

Generic

avita 0.025% cream

Generic

AZELEX

Non-Preferred Brand

PA

BENZACLIN (GEL 35G PUMP, GEL 50G PUMP)

Non-Preferred Brand

PA

BENZAMYCINPAK

Non-Preferred Brand

calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 % solution)

Generic

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

calcipotriene/betamethasone dipropionate

Generic

PA, QL (120 GM PER 30 DAYS)

calcitrene

Generic

calcitriol 3 mcg/g oint. (g)

Generic

CARAC

Non-Preferred Brand

claravis

Generic

clindamycin phosphate/benzoyl peroxide

Generic

clotrimazole/betamethasone dipropionate (1 %-0.05 % lotion, 1 %0.05 % cream (g))

Generic

CONDYLOX 0.5% GEL

Non-Preferred Brand

CORTISPORIN OINTMENT

Non-Preferred Brand

cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg/ml solution)

Generic

diclofenac sodium 3 % gel (gram)

Generic

DIFFERIN 0.3% GEL

Non-Preferred Brand

ELIDEL

Non-Preferred Brand

PA

EPIDUO

Non-Preferred Brand

PA

EPIDUO FORTE

Non-Preferred Brand

PA

erythromycin base/benzoyl peroxide

Generic

FINACEA

Pref. Brand

FLUOROPLEX

Pref. Brand

fluorouracil (2 % solution, 5 % solution, 5 % cream (g))

Generic

fluorouracil 0.5 % cream (g)

Non-Preferred Brand


PA

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

gengraf (25 mg capsule, 100 mg/ml solution, 100 mg capsule)

Generic

hypercare

Generic

methoxsalen, rapid

Specialty

mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution)

Generic

myorisan

Generic

neuac gel

Generic

OXSORALEN

Non-Preferred Brand

PHISOHEX

Non-Preferred Brand

PICATO

Non-Preferred Brand

podofilox 0.5 % solution

Generic

prednicarbate

Generic

PRUDOXIN

Non-Preferred Brand

refissa

Generic

REGRANEX

Specialty

PA

SANTYL

Pref. Brand

QL (30 GM PER 30 DAYS)

selenium sulfide 2.5 % suspension

Generic

spinosad

Generic

PA

STELARA 45 MG/0.5 ML SYRINGE

Specialty


STELARA 90 MG/ML SYRINGE

Specialty


TACLONEX 0.005%-0.064% SUSPENS

Non-Preferred Brand


tacrolimus (0.03 % oint. (g), 0.1 % oint. (g))

Generic

PA

TAZORAC

Pref. Brand

tretinoin (0.01 % gel (gram), 0.025 % gel (gram), 0.025 % cream (g), 0.05 % cream (g), 0.1 % cream (g))

Generic


LAST UPDATE 11/2015


Drug Name

Status*

tretinoin/emollient base

Generic

trianex

Generic

UVADEX

Medical

VELTIN

Non-Preferred Brand

VEREGEN

Non-Preferred Brand

VOLTAREN

Pref. Brand

zenatane

Generic

ZIANA

Non-Preferred Brand

ZONALON

Non-Preferred Brand

Requirements/Limits

PA

PA

Enzyme Replacement/ Modifiers ADAGEN

Specialty

ALDURAZYME

Medical

BUPHENYL 500 MG TABLET

Specialty

CARBAGLU

Specialty

CERDELGA

Specialty

CEREZYME 400 UNITS VIAL

Medical

CREON

Pref. Brand

CYSTADANE

Non-Preferred Brand

ELAPRASE

Medical

ELELYSO

Medical

FABRAZYME

Medical

KUVAN

Specialty

PA, LA

MYOZYME

Medical

PA

NAGLAZYME

Medical

PA

ORFADIN

Specialty


LAST UPDATE 11/2015


Drug Name

Status*

pancrelipase 5,000

Generic

RAVICTI

Specialty

sodium phenylbutyrate 0.94 g/g powder

Specialty

SUCRAID

Specialty

VPRIV

Medical

ZAVESCA

Specialty

ZENPEP (DR 3,000 CAPSULE, DR 10,000 CAPSULE, DR 15,000 CAPSULE, DR 20,000 CAPSULE, DR 25,000 CAPSULE, DR 40,000 CAPSULE)

Pref. Brand

Requirements/Limits LA

Gastrointestinal Agents Antispasmodics, Gastrointestinal CANTIL

Non-Preferred Brand

CUVPOSA

Non-Preferred Brand

dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet)

Generic

glycopyrrolate (1 mg tablet, 2 mg tablet)

Generic

methscopolamine bromide (2.5 mg tablet, 5 mg tablet)

Generic

PA

Gastrointestinal Agents, Other APRISO

Pref. Brand

ASACOL HD

Pref. Brand

CANASA

Pref. Brand

CHENODAL

Specialty

PA, LA

CHOLBAM

Specialty

PA, LA

DELZICOL

Pref. Brand

diphenoxylate hcl/atropine sulfate (2.5.025mg tablet, 2.5-.025/5 liquid)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

FULYZAQ

Non-Preferred Brand

PA

GATTEX

Specialty

PA

lansoprazole/amoxicillin trihydrate/clarithromycin

Generic

LIALDA

Pref. Brand

mesalamine 4 g/60 ml enema

Generic

mesalamine with cleansing wipes

Generic

MOTOFEN

Non-Preferred Brand

MOVANTIK

Non-Preferred Brand

PENTASA

Pref. Brand

PROCTOFOAM-HC

Non-Preferred Brand

propantheline bromide 15 mg tablet

Generic

PYLERA

Pref. Brand

RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML KIT, 12 MG/0.6 ML VIAL, 12 MG/0.6 ML SYRINGE)

Non-Preferred Brand

sulfasalazine (500 mg tablet, 500 mg tablet dr)

Generic

sulfazine

Generic

sulfazine ec

Generic

ursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet)

Generic


PA

Histamine2 (H2) Receptor Antagonists cimetidine (300 mg tablet, 400 mg tablet, 800 mg tablet)

Generic

cimetidine hcl

Generic

famotidine (40mg/5ml oral susp, 40 mg tablet)

Generic

nizatidine (150mg/10ml solution, 150 mg capsule, 300 mg capsule)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

ranitidine hcl (15 mg/ml syrup, 300 mg tablet, 300 mg capsule)

Generic

Requirements/Limits

Irritable Bowel Syndrome Agents alosetron hcl

Generic

PA

AMITIZA

Non-Preferred Brand

PA

Laxatives constulose

Generic

enulose

Generic

gavilyte-c

Generic

gavilyte-g

Generic

gavilyte-n

Generic

generlac

Generic

GOLYTELY PACKET

Pref. Brand

lactulose

Generic

MOVIPREP

Non-Preferred Brand

NULYTELY WITH FLAVOR PACKS

Non-Preferred Brand

peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl

Generic

sodium chloride/sodium bicarbonate/potassium chloride/peg

Generic

SUPREP

Non-Preferred Brand

trilyte with flavor packets

Generic

Protectants CARAFATE 1 GM/10 ML SUSP

Non-Preferred Brand

misoprostol (100 mcg tablet, 200 mcg tablet)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

sucralfate 1 g tablet

Generic

Requirements/Limits

Proton Pump Inhibitors DEXILANT

Non-Preferred Brand


esomeprazole magnesium

Generic


lansoprazole 30 mg capsule dr

Generic

NEXIUM (DR 20 MG PACKET, DR 40 MG PACKET)

Non-Preferred Brand

omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule dr)

Generic

pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr)

Generic

PROTONIX 40 MG SUSPENSION

Non-Preferred Brand

rabeprazole sodium

Generic


Genitourinary Agents Antispasmodics, Urinary ENABLEX

Non-Preferred Brand

PA

flavoxate hcl

Generic

oxybutynin chloride (5 mg/5 ml syrup, 5 mg tablet, 5 mg tab er 24, 10 mg tab er 24, 15 mg tab er 24)

Generic

OXYTROL

Pref. Brand

tolterodine tartrate

Generic

TOVIAZ

Non-Preferred Brand

trospium chloride 20 mg tablet

Generic

trospium chloride 60 mg cap er 24h

Generic

PA

VESICARE

Non-Preferred Brand

PA

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Benign Prostatic Hypertrophy Agents alfuzosin hcl

Generic

CIALIS 5 MG TABLET

Non-Preferred Brand


dutasteride

Generic

PA

finasteride 5 mg tablet

Generic

RAPAFLO

Non-Preferred Brand

tamsulosin hcl

Generic

PA

Genitourinary Agents, Other bethanechol chloride (5 mg tablet, 10 mg tablet, 25 mg tablet, 50 mg tablet)

Generic

CUPRIMINE

Non-Preferred Brand

CYSTAGON

Specialty

DEPEN

Pref. Brand

ELMIRON

Non-Preferred Brand

methylergonovine maleate 0.2 mg tablet

Generic

PROCYSBI

Specialty

THIOLA

Pref. Brand

QL (90 PER 30 DAYS)

PA, LA

Phosphate Binders AURYXIA

Non-Preferred Brand

calcium acetate 667 mg capsule

Generic

FOSRENOL

Non-Preferred Brand

PHOSLYRA

Non-Preferred Brand

RENAGEL

Pref. Brand

PA

PA

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

RENVELA

Pref. Brand

PA

sevelamer carbonate

Pref. Brand

PA

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Glucocorticoids/Mineralocorticoids betamethasone acetate/betamethasone sodium phosphate

Medical

budesonide 3 mg capdr - er

Generic

dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)

Generic

dexamethasone sod phosphate 0.1 % drops

Generic

diclofenac sodium 0.1 % drops

Generic

DUREZOL

Non-Preferred Brand

EPIFOAM

Pref. Brand

FLAREX

Non-Preferred Brand

FLOVENT DISKUS

Pref. Brand

FLOVENT HFA

Pref. Brand

fluocinolone acetonide oil

Generic

fluorometholone

Generic

fluticasone propionate 50 mcg spray susp

Generic

FML FORTE

Non-Preferred Brand

FML S.O.P.

Pref. Brand

hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet)

Generic

hydrocortisone butyrate (0.1 % oint. (g), 0.1 % solution)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

hydrocortisone valerate

Generic

hydrocortisone/mineral oil/petrolatum,white

Generic

MAXIDEX

Non-Preferred Brand

methylprednisolone acetate 80 mg/ml vial

Medical

prednisolone acetate

Generic

triamcinolone acetonide 55 mcg spray

Generic

VERAMYST

Non-Preferred Brand

Requirements/Limits

PA

Hormonal Agents, Stimulant/Replacement/Modifying (Other) MYALEPT

Specialty

PA

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet, 10/spray spray/pump)

Generic

PA

desmopressin acetate (ampul, vial)

Medical

PA

desmopressin acetate (nonrefrigerated)

Generic

PA

EGRIFTA

Specialty

PA

GENOTROPIN 5 MG CARTRIDGE

Specialty

PA

H.P. ACTHAR

Specialty

PA

HUMATROPE

Specialty

PA

INCRELEX

Specialty

PA, LA

NORDITROPIN 5 MG/1.5 ML CRTG

Specialty

PA

NUTROPIN 10 MG VIAL

Specialty

PA

NUTROPIN AQ (20 MG/2ML PEN CART, PEN CARTRIDGE)

Specialty

PA

NUTROPIN AQ NUSPIN

Specialty

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG)

Specialty

PA

SAIZEN 8.8 MG CLICK.EASY CARTG

Specialty

PA

SEROSTIM 4 MG VIAL

Specialty

PA

STIMATE

Pref. Brand

ZOMACTON 10 MG VIAL

Specialty

PA

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids ANADROL-50

Specialty

oxandrolone (2.5 mg tablet, 10 mg tablet)

Generic

Androgens ANDRODERM

Pref. Brand

PA

ANDROGEL

Pref. Brand

PA

androxy

Generic

danazol (50 mg capsule, 100 mg capsule, 200 mg capsule)

Generic

METHITEST

Non-Preferred Brand

methyltestosterone 10 mg capsule

Generic

testosterone cypionate (100 mg/ml vial, 200 mg/ml vial)

Generic

testosterone enanthate 200 mg/ml vial

Generic

Estrogens ALTAVERA

Preventive

ALYACEN

Preventive

AMETHIA

Preventive

AMETHIA LO

Preventive

AMETHYST

Preventive


LAST UPDATE 11/2015


Drug Name

Status*

APRI

Preventive

ARANELLE

Preventive

ASHLYNA

Preventive

AUBRA

Preventive

AVIANE

Preventive

AZURETTE

Preventive

BALZIVA

Preventive

BRIELLYN

Preventive

CAMRESE

Preventive

CAMRESE LO

Preventive

CAZIANT

Preventive

CENESTIN (0.625 MG TABLET, 1.25 MG TABLET)

Non-Preferred Brand

CHATEAL

Preventive

COMBIPATCH

Non-Preferred Brand

CRYSELLE

Preventive

CYCLAFEM

Preventive

CYRED

Preventive

DASETTA

Preventive

DAYSEE

Preventive

DELYLA

Preventive

desogestrel-ethinyl estradiol

Preventive

desogestrel-ethinyl estradiol/ethinyl estradiol

Preventive

DUAVEE

Non-Preferred Brand

ELINEST

Preventive

EMOQUETTE

Preventive

ENJUVIA (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET)

Non-Preferred Brand

Requirements/Limits


LAST UPDATE 11/2015


Drug Name

Status*

ENPRESSE

Preventive

ENSKYCE

Preventive

ESTARYLLA

Preventive

ESTRACE 0.01% CREAM

Pref. Brand

estradiol (.025mg/24h patch tdsw, .025mg/24h patch tdwk, .0375mg/24 patch tdwk, .0375mg/24 patch tdsw, 0.05mg/24h patch tdsw, 0.05mg/24h patch tdwk, 0.06mg/24h patch tdwk, .075mg/24h patch tdwk, .075mg/24h patch tdsw, 0.1mg/24hr patch tdwk, 0.1mg/24hr patch tdsw, 0.5 mg tablet, 1 mg tablet, 2 mg tablet)

Generic

estradiol/norethindrone acetate

Generic

ESTRING

Pref. Brand

estropipate

Generic

ethinyl estradiol/drospirenone

Preventive

FALMINA

Preventive

GIANVI

Preventive

GILDAGIA

Preventive

GILDESS

Preventive

GILDESS 24 FE

Preventive

GILDESS FE

Preventive

INTROVALE

Preventive

jinteli

Generic

JOLESSA

Preventive

JULEBER

Preventive

JUNEL

Preventive

JUNEL FE

Preventive

JUNEL FE 24

Preventive

KARIVA

Preventive

KELNOR 1-35

Preventive

Requirements/Limits


LAST UPDATE 11/2015


Drug Name

Status*

KIMIDESS

Preventive

KURVELO

Preventive

LARIN

Preventive

LARIN 24 FE

Preventive

LARIN FE

Preventive

LEENA

Preventive

LESSINA

Preventive

LEVONEST

Preventive

levonorgestrel-ethinyl estradiol

Preventive

levonorgestrel/ethinyl estradiol and ethinyl estradiol

Preventive

LEVORA-28

Preventive

LOMEDIA 24 FE

Preventive

LOPREEZA

Non-Preferred Brand

LORYNA

Preventive

LOW-OGESTREL

Preventive

LUTERA

Preventive

MARLISSA

Preventive

MENEST

Non-Preferred Brand

MICROGESTIN

Preventive

MICROGESTIN FE

Preventive

mimvey

Generic

mimvey lo

Generic

MONO-LINYAH

Preventive

MONONESSA

Preventive

MYZILRA

Preventive

NECON

Preventive

NIKKI

Preventive

Requirements/Limits


LAST UPDATE 11/2015


Drug Name

Status*

norethindrone ac-eth estradiol 1mg20mcg tablet

Preventive

norethindrone ac-eth estradiol 1mg5mcg tablet

Generic

norethindrone acetate-ethinyl estradiol/ferrous fumarate

Preventive

norgestimate-ethinyl estradiol

Preventive

NORTREL

Preventive

NUVARING

Preventive

OCELLA

Preventive

OGESTREL

Preventive

ORSYTHIA

Preventive

ORTHO TRI-CYCLEN LO

Preventive

PHILITH

Preventive

PIMTREA

Preventive

PIRMELLA

Preventive

PORTIA

Preventive

PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET)

Non-Preferred Brand

PREMARIN VAGINAL CREAM-APPL

Pref. Brand

PREMPHASE

Non-Preferred Brand

PREMPRO

Non-Preferred Brand

PREVIFEM

Preventive

QUASENSE

Preventive

RECLIPSEN

Preventive

setlakin

Generic

SPRINTEC

Preventive

SRONYX

Preventive

Requirements/Limits


LAST UPDATE 11/2015


Drug Name

Status*

SYEDA

Preventive

TARINA FE

Preventive

TILIA FE

Preventive

TRI-ESTARYLLA

Preventive

TRI-LEGEST FE

Preventive

TRI-LINYAH

Preventive

TRI-PREVIFEM

Preventive

TRI-SPRINTEC

Preventive

TRINESSA

Preventive

TRIVORA-28

Preventive

VAGIFEM

Pref. Brand

VELIVET

Preventive

VESTURA

Preventive

VIORELE

Preventive

VYFEMLA

Preventive

WERA

Preventive

WYMZYA FE

Preventive

XULANE

Preventive

ZARAH

Preventive

ZENCHENT

Preventive

ZENCHENT FE

Preventive

ZEOSA

Preventive

ZOVIA 1-35E

Preventive

ZOVIA 1-50E

Preventive

Requirements/Limits

Progestins CAMILA

Preventive

CRINONE 4% GEL

Non-Preferred Brand

DEBLITANE

Preventive

PA


LAST UPDATE 11/2015


Drug Name

Status*

DEPO-SUBQ PROVERA 104

Preventive

ELLA

Preventive

ENDOMETRIN

Non-Preferred Brand

ERRIN

Preventive

HEATHER

Preventive

JENCYCLA

Preventive

JOLIVETTE

Preventive

levonorgestrel 0.75 mg tablet

Preventive

LYZA

Preventive

medroxyprogesterone acetate (150 mg/ml vial, 150 mg/ml syringe)

Preventive

medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet)

Generic

megestrol acetate (20 mg tablet, 40 mg tablet, 400mg/10ml oral susp)

Generic

NORA-BE

Preventive

norethindrone 0.35 mg tablet

Preventive

norethindrone acetate 5 mg tablet

Generic

NORLYROC

Preventive

progesterone,micronized (100 mg capsule, 200 mg capsule)

Generic

SHAROBEL

Preventive

Requirements/Limits

PA

Selective Estrogen Receptor Modifying Agents raloxifene hcl

Generic

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) ARMOUR THYROID (15 MG TABLET, 120 MG TABLET, 180 MG TABLET, 240 MG TABLET, 300 MG TABLET)

Non-Preferred Brand


LAST UPDATE 11/2015


Drug Name

Status*

levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175mcg tablet, 200 mcg tablet, 300 mcg tablet)

Generic

levoxyl

Generic

liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet)

Generic

NATPARA

Specialty

THYROLAR-1

Non-Preferred Brand

THYROLAR-1/2

Non-Preferred Brand

THYROLAR-1/4

Non-Preferred Brand

THYROLAR-2

Non-Preferred Brand

THYROLAR-3

Non-Preferred Brand

unithroid (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet)

Generic

Requirements/Limits


Hormonal Agents, Suppressant (Adrenal) LYSODREN

Pref. Brand

SIGNIFOR

Specialty

PA, LA

Hormonal Agents, Suppressant (Parathyroid) calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution)

Generic

calcitriol 1 mcg/ml ampul

Medical

paricalcitol (1 mcg capsule, 2 mcg capsule, 4mcg capsule)

Generic

ST


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

SENSIPAR (30 MG TABLET, 60 MG TABLET)

Specialty

QL (60 PER 30 DAYS)

SENSIPAR 90 MG TABLET

Specialty


ZEMPLAR (2 MCG/ML VIAL, 5 MCG/ML VIAL, 10 MCG/2 ML VIAL)

Medical

ST

Hormonal Agents, Suppressant (Pituitary) cabergoline

Generic

ELIGARD

Medical

FIRMAGON

Medical

leuprolide acetate 1 mg/0.2ml kit

Specialty

PA

LUPRON DEPOT-PED (7.5 MG KIT, 11.25 MG KIT, 15 MG KIT)

Medical

PA

octreotide acetate

Specialty

PA

SOMATULINE DEPOT (60 MG/0.2 ML, 90 MG/0.3 ML)

Medical

PA

SOMAVERT

Specialty

PA, LA

SYNAREL

Specialty

PA

PA

Hormonal Agents, Suppressant (Sex Hormones/Modifiers) Antiandrogens bicalutamide

Generic

NILANDRON

Pref. Brand

XTANDI

Specialty

PA

Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole (5 mg tablet, 10 mg tablet)

Generic

propylthiouracil 50 mg tablet

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

BERINERT

Specialty


CINRYZE

Medical

PA

KALBITOR

Medical

PA

Immunological Agents Angioedema (HAE) Agents

Immune Suppressants ASTAGRAF XL

Non-Preferred Brand

ATGAM

Medical

azathioprine 50 mg tablet

Generic

azathioprine sodium

Medical

BENLYSTA

Medical

CELLCEPT 500 MG VIAL

Medical

CIMZIA (200 MG/ML STARTER KIT, 200 MG/ML SYRINGE KIT)

Specialty


CIMZIA 200 MG VIAL KIT

Medical

PA

cyclosporine (25 mg capsule, 100 mg capsule)

Generic

cyclosporine (250 vial, 250 ampul)

Medical

cyclosporine, modified 100 mg capsule

Generic

ENBREL (50 MG/ML SYRINGE, 50 MG/ML SURECLICK SYR)

Specialty


ENBREL 25 MG KIT

Specialty

QL (8 PER 28 DAYS)

ENBREL 25 MG/0.5 ML SYRINGE

Specialty


ENTYVIO

Medical

PA

hecoria

Generic

HUMIRA (10 MG/0.2 ML SYRINGE, 20 MG/0.4 ML SYRINGE)

Specialty

QL (2 PER 28 DAYS)

HUMIRA 40 MG/0.8 ML SYRINGE

Specialty

QL (1 PER 28 DAYS)

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

HUMIRA PEDIATRIC CROHN'S

Specialty

QL (1 PER 28 DAYS)

HUMIRA PEN

Specialty

QL (1 PER 28 DAYS)

HUMIRA PEN CROHN'S-UC-HS

Specialty

QL (1 PER 28 DAYS)

HUMIRA PEN PSORIASIS

Specialty

QL (1 PER 28 DAYS)

KINERET

Specialty

PA, QL (0.67 ML PER DAY)

mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet)

Generic

mycophenolate sodium

Generic

NULOJIX

Medical

ORENCIA 250 MG VIAL

Medical

PROGRAF 5 MG/ML AMPULE

Medical

RAPAMUNE 1 MG/ML ORAL SOLN

Non-Preferred Brand

REMICADE

Medical

RESTASIS

Pref. Brand

SANDIMMUNE 100 MG/ML SOLN

Non-Preferred Brand

SIMPONI (100 MG/ML PEN INJECTOR, 100 MG/ML SYRINGE)

Specialty


SIMPONI (50 ML SYRINGE, 50 ML PEN INJEC)

Specialty


SIMPONI ARIA

Medical

SIMULECT

Medical

sirolimus (0.5 mg tablet, 1 mg tablet, 2 mg tablet)

Generic

tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule)

Generic

ZORTRESS

Specialty

PA

QL (60 PER 30 DAYS)

Immunizing Agents, Passive BIVIGAM

Medical

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

CARIMUNE NF NANOFILTERED

Medical

PA

FLEBOGAMMA DIF

Medical

PA

GAMASTAN S-D

Medical

PA

GAMMAGARD LIQUID

Medical

PA

GAMMAGARD S-D

Medical

PA

GAMMAKED

Medical

PA

GAMMAPLEX

Medical

PA

GAMUNEX

Medical

PA

GAMUNEX-C

Medical

PA

HIZENTRA

Medical

PA

HYQVIA

Specialty

PA

OCTAGAM

Medical

PA

PRIVIGEN

Medical

PA

THYMOGLOBULIN

Medical

PA

ACTEMRA (80 MG/4 ML VIAL, 200 MG/10 ML VIAL, 400 MG/20 ML VIAL)

Medical

PA

ACTIMMUNE

Specialty

PA

FIRAZYR

Specialty

PA, QL (9 ML PER 30 DAYS)

leflunomide

Generic

OTEZLA (28 DAY PACK, PACK)

Specialty

PA

OTEZLA 30 MG TABLET

Specialty

PA, QL (2 PER DAY)

RIDAURA

Specialty

Immunomodulators

Inflammatory Bowel Disease Agents Aminosalicylates balsalazide disodium

Generic

DIPENTUM

Pref. Brand


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Glucocorticoids colocort

Generic

hydrocortisone 100mg/60ml enema

Generic

proctosol-hc

Generic

proctozone-hc

Generic

UCERIS 9 MG ER TABLET

Non-Preferred Brand

PA

MISCELLANEOUS THERAPEUTIC AGENTS hydroxyprogesterone caproate

Generic

Metabolic Bone Disease Agents alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70 mg/75ml solution, 70 mg tablet)

Generic

calcitonin,salmon,synthetic

Generic

doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule)

Generic

etidronate disodium

Generic

FORTEO

Specialty

fortical

Generic

FOSAMAX PLUS D

Non-Preferred Brand

PA

HECTOROL (2 MCG/ML VIAL, 4 MCG/2 ML VIAL)

Medical

ST

ibandronate sodium 150 mg tablet

Generic

ibandronate sodium 3 mg/3 ml syringe

Medical

MIACALCIN (200 UNIT/ML VIAL, 400 UNIT/2 ML VIAL)

Non-Preferred Brand

OMONTYS

Medical

pamidronate disodium (30 mg vial, 30mg/10ml vial, 60 mg/10ml vial, 90 mg vial, 90 mg/10ml vial)

Medical

ST

PA

PA


LAST UPDATE 11/2015


Drug Name

Status*

risedronate sodium

Generic

zoledronic acid/mannitol&water 5 mg/100ml infus. btl

Medical

ZOMETA

Medical

Requirements/Limits

Miscellaneous Diabetes Testing Supplies ACCU-CHECK (METERS & TEST STRIPS)

DME Benefit

QL

LIFESCAN (METERS & TEST STRIPS)

DME Benefit

QL

NOVOFINE NEEDLES

DME Benefit

QL

Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost

Generic

latanoprost 0.005 % drops

Generic

LUMIGAN

Pref. Brand

TRAVATAN Z

Pref. Brand

travoprost (benzalkonium)

Generic

ST, QL (2.5 ML PER 30 DAYS) ST, QL (2.5 ML PER 30 DAYS)

Ophthalmic Agents, Other ak-poly-bac

Generic

bacitracin/polymyxin b sulfate 50010k/g oint. (g)

Generic

BLEPHAMIDE

Pref. Brand

BLEPHAMIDE S.O.P.

Non-Preferred Brand

CYSTARAN

Specialty

LACRISERT

Non-Preferred Brand

naphazoline hcl

Generic

neo-polycin

Generic

PA, LA, QL (60 ML PER 30 DAYS)


LAST UPDATE 11/2015


Drug Name

Status*

neo-polycin hc

Generic

neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone

Generic

neomycin sulfate/bacitracin/polymyxin b

Generic

neomycin sulfate/polymyxin b sulfate/gramicidin d

Generic

neomycin/polymyxin b sulf/hc 3.5-10k10 drops susp

Generic

neomycin/polymyxin b sulfate/dexamethasone (0.1 % drops susp, 3.5-10k-.1 oint. (g))

Generic

neosporin eye drops

Generic

polycin

Generic

polymyxin b sulfate/trimethoprim

Generic

sulfacetamide sodium 10 % oint. (g)

Generic

sulfacetamide sodium/prednisolone sodium phosphate

Generic

tobramycin/dexamethasone

Generic

tropicamide (0.5 % drops, 1 % drops)

Generic

ZYLET

Non-Preferred Brand

Requirements/Limits

Ophthalmic Anti-allergy Agents ALOCRIL

Non-Preferred Brand

ALOMIDE

Non-Preferred Brand

azelastine hcl 0.05 % drops

Generic

BEPREVE

Non-Preferred Brand

cromolyn sodium 4 % drops

Generic

EMADINE

Non-Preferred Brand

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

epinastine hcl

Generic

LASTACAFT

Non-Preferred Brand

PA

PATADAY

Non-Preferred Brand

PA

PATANOL

Non-Preferred Brand

PA

Ophthalmic Anti-inflammatories ALREX

Non-Preferred Brand

bromfenac sodium

Generic

flurbiprofen sodium

Generic

ketorolac tromethamine (0.4 % drops, 0.5 % drops)

Generic

LOTEMAX (0.5% EYE DROPS, 0.5% OPHTHALMIC GEL, 0.5% EYE OINTMENT)

Non-Preferred Brand

NEVANAC

Non-Preferred Brand

prednisolone sod phosphate 1 % drops

Generic

VEXOL

Pref. Brand

Ophthalmic Antiglaucoma Agents ALPHAGAN P 0.1% DROPS

Pref. Brand

apraclonidine hcl

Generic

AZOPT

Non-Preferred Brand

betaxolol hcl 0.5 % drops

Generic

BETIMOL

Non-Preferred Brand

BETOPTIC S

Pref. Brand

brimonidine tartrate (0.15 % drops, 0.2 % drops)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

carteolol hcl

Generic

COMBIGAN

Non-Preferred Brand

dorzolamide hcl

Generic

dorzolamide hcl/timolol maleate

Generic

ISTALOL

Non-Preferred Brand

levobunolol hcl

Generic

metipranolol

Generic

PHOSPHOLINE IODIDE

Non-Preferred Brand

pilocarpine hcl (1 % drops, 2 % drops, 4 % drops)

Generic

PILOPINE HS

Non-Preferred Brand

timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % drops, 0.5 % sol-gel)

Generic

ZIOPTAN

Non-Preferred Brand

Requirements/Limits PA

Otic Agents CIPRO HC

Pref. Brand

CIPRODEX

Pref. Brand

ciprofloxacin hcl 0.2 % droperette

Generic

COLY-MYCIN S

Non-Preferred Brand

CORTISPORIN-TC

Non-Preferred Brand

Respiratory Tract Agents Anti-inflammatories, Inhaled Corticosteroids AEROSPAN

Non-Preferred Brand


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

ALVESCO

Pref. Brand

ARNUITY ELLIPTA

Pref. Brand

ASMANEX

Pref. Brand

ASMANEX HFA

Pref. Brand

BREO ELLIPTA 100-25 MCG INH

Pref. Brand

budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb, 32mcg spray/pump)

Generic

flunisolide (25 mcg spray, 29mcg spray)

Generic

NASONEX

Non-Preferred Brand


OMNARIS

Non-Preferred Brand

PA

PULMICORT FLEXHALER

Pref. Brand

QVAR

Pref. Brand

ZETONNA

Non-Preferred Brand

PA

Antihistamines arbinoxa (4 mg tablet, 4 mg/5 ml liquid)

Generic

azelastine hcl 137 mcg spray/pump

Generic

carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid)

Generic

clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet)

Generic

cyproheptadine hcl (2 mg/5 ml syrup, 4 mg tablet)

Generic

desloratadine 5 mg tablet

Generic

levocetirizine dihydrochloride (2.5 mg/5ml solution, 5 mg tablet)

Generic

olopatadine hcl

Generic

palgic (4 mg/5 ml liquid, 4 mg tablet)

Generic

PA

PA


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

Antileukotrienes montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mg tablet)

Generic

zafirlukast

Generic

ZYFLO CR

Non-Preferred Brand

PA

Bronchodilators, Anticholinergic ATROVENT HFA

Pref. Brand

INCRUSE ELLIPTA

Pref. Brand

ipratropium bromide (0.2 mg/ml solution, 21 mcg spray, 42mcg spray)

Generic

SPIRIVA

Pref. Brand

SPIRIVA RESPIMAT

Pref. Brand

QL (30 PER 30 DAYS)

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) aminophylline (250mg/10ml vial, 250mg/10ml ampul, 500mg/20ml vial, 500mg/20ml ampul)

Medical

LUFYLLIN

Non-Preferred Brand

theochron

Generic

theophylline anhydrous (100 mg tab er 12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tablet er, 450 mg tab er 12h, 600 mg tablet er)

Generic

Bronchodilators, Sympathomimetic ADVAIR DISKUS

Pref. Brand

ADVAIR HFA

Pref. Brand

albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg/5 ml syrup, 2 mg tablet, 2.5 mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 4 mg tab er 12h, 4 mg tablet, 5 mg/ml solution, 8 mg tab er 12h)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

ANORO ELLIPTA

Pref. Brand

ARCAPTA NEOHALER

Non-Preferred Brand

BREO ELLIPTA 200-25 MCG INH

Pref. Brand

BROVANA

Specialty

COMBIVENT

Pref. Brand

COMBIVENT RESPIMAT

Pref. Brand

EPIPEN 2-PAK

Pref. Brand

EPIPEN JR 2-PAK

Pref. Brand

FORADIL

Pref. Brand

ipratropium bromide/albuterol sulfate

Generic

levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb, 1.25mg/0.5 vialneb, 1.25mg/3ml vial-neb)

Generic

MAXAIR AUTOHALER

Non-Preferred Brand

metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet)

Generic

PERFOROMIST

Pref. Brand

proair hfa

Generic


proair respiclick

Generic

QL (2 PER 30 DAYS)

SEREVENT DISKUS

Pref. Brand

SYMBICORT

Pref. Brand

terbutaline sulfate (2.5 mg tablet, 5 mg tablet)

Generic

ventolin hfa

Generic

XOPENEX HFA

Non-Preferred Brand

QL (30 PER 30 DAYS)

QL (120 ML PER 30 DAYS) QL (4 GM PER 30 DAYS)


Mast Cell Stabilizers cromolyn sodium (20 mg/ml oral conc, 20 mg/2 ml ampul-neb)

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

ADCIRCA

Specialty


ADEMPAS

Specialty

PA

epoprostenol sodium (glycine)

Medical

PA, LA

LETAIRIS

Specialty

PA

OPSUMIT

Specialty

PA, LA

ORENITRAM ER

Specialty

PA, LA

REMODULIN

Medical

PA, LA

REVATIO 10 MG/12.5 ML VIAL

Medical

PA

REVATIO 10 MG/ML ORAL SUSP

Specialty

PA

sildenafil citrate 20 mg tablet

Specialty


TRACLEER

Specialty

PA, LA

TYVASO

Medical

PA, LA

VELETRI

Medical

PA, LA

VENTAVIS

Specialty

PA

Pulmonary Antihypertensives

Respiratory Tract Agents, Other acetylcysteine (100 mg/ml vial, 200 mg/ml vial)

Generic

ambitussin ac

Generic


ARALAST NP

Medical

PA

benzonatate

Generic

cheratussin ac

Generic


cheratussin dac

Generic


DALIRESP

Specialty

PA

ESBRIET

Specialty

PA, LA

GLASSIA

Medical

PA

GRASTEK

Non-Preferred Brand

PA

guaiatussin ac

Generic



LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

guaifenesin ac

Generic


guaifenesin dac

Generic


guaifenesin/codeine phosphate 10010mg/5 liquid

Generic


hydrocodone bit/homatrop me-br 5-1.5 mg/5 syrup

Generic

hydromet

Generic

HYPER-SAL 3.5% VIAL

Non-Preferred Brand

iophen-c nr

Generic


KALYDECO

Specialty


lortuss ex

Generic


OFEV

Specialty

PA

ORALAIR

Non-Preferred Brand

PA, LA

phenylephrine hcl/promethazine hcl

Generic

PROLASTIN C

Medical

PA

promethazine hcl/codeine

Generic


promethazine hcl/dextromethorphan hbr

Generic

promethazine/phenylephrine hcl/codeine

Generic

pulmosal

Generic

PULMOZYME

Specialty

RAGWITEK

Non-Preferred Brand

sodium chloride for inhalation 7 % vialneb

Generic

tusnel c

Generic

TYZINE

Non-Preferred Brand

virtussin ac

Generic


PA




LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

virtussin dac

Generic


ZEMAIRA

Medical

PA

Skeletal Muscle Relaxants carisoprodol (250 mg tablet, 350 mg tablet)

Generic

carisoprodol/aspirin

Generic

chlorzoxazone

Generic

cyclobenzaprine hcl (5 mg tablet, 7.5 mg tablet, 10 mg tablet)

Generic

metaxalone 800 mg tablet

Generic

methocarbamol (500 mg tablet, 750 mg tablet)

Generic

orphenadrine citrate 100 mg tablet er

Generic

orphenadrine/aspirin/caffeine 50-77060 tablet

Generic

Sleep Disorder Agents GABA Receptor Modulators estazolam

Generic

eszopiclone

Generic

flurazepam hcl

Generic

temazepam

Generic

triazolam

Generic

zaleplon

Generic

QL (30 PER 30 DAYS)

zolpidem tartrate (5 mg tablet, 10 mg tablet)

Generic

QL (30 PER 30 DAYS)

modafinil

Generic


NUVIGIL (150 MG TABLET, 200 MG TABLET, 250 MG TABLET)

Non-Preferred Brand


QL (30 PER 30 DAYS)

Sleep Disorders, Other


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

NUVIGIL 50 MG TABLET

Non-Preferred Brand


ROZEREM

Non-Preferred Brand


XYREM

Specialty

PA, LA, QL (540 ML PER 30 DAYS)

Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/Mineral Modifiers CHEMET

Non-Preferred Brand

EXJADE

Specialty

FERRIPROX

Specialty

kionex (15 gm/60 ml suspension, powder)

Generic

levocarnitine (with sugar)

Generic

levocarnitine 330 mg tablet

Generic

marlexate

Generic

SAMSCA

Specialty

sodium polystyrene sulfonate (15 g/60 ml oral susp, 30g/120ml enema, 50g/200ml enema, powder)

Generic

sps 15 gm/60 ml suspension

Generic

SYPRINE

Non-Preferred Brand

Electrolyte/Mineral Replacement 0.9 % sodium chloride (0.9 % 0.9 % IV SOLN, 0.9 % 0.9 % SYRINGE, 0.9 % 0.9 % VIAL)

Medical

ammonium chloride 5 meq/ml vial

Medical

bacteriostatic sodium chloride

Medical

cyanocobalamin (vitamin b-12) 1000mcg/ml vial

Generic


LAST UPDATE 11/2015


Drug Name

Status*

Requirements/Limits

ergocalciferol (vitamin d2) 50000 unit capsule

Generic

fluoride/iron/vitamins a,c,and d

Preventive

ISOLYTE S

Medical

klor-con 10

Generic

KLOR-CON 8

Non-Preferred Brand

klor-con m10

Generic

klor-con m15

Generic

klor-con m20

Generic

klor-con sprinkle

Generic

magnesium sulfate (4 syringe, 4 vial)

Medical

magnesium sulfate in sterile water

Medical

magnesium sulfate/dextrose 5 % in water

Medical

MONOJECT 0.9% SODIUM CHLORIDE

Medical

MONOJECT PREFILL 0.9% FLUSH

Medical

MONOJECT PREFILL 0.9% NA SYR

Medical

NIVA-PLUS

Preventive

NORMOSOL-R

Medical

PA

NORMOSOL-R PH 7.4

Medical

PA

OSMOPREP

Non-Preferred Brand

pediatric multivitamin combination no.2/sodium fluoride

Preventive

pediatric multivitamins no.82 with sodium fluoride

Preventive

PHYSIOLYTE

Medical

PHYSIOSOL

Medical

PLASMA-LYTE 148

Medical

PA

PLASMA-LYTE A PH 7.4

Medical

PA

PA


LAST UPDATE 11/2015


Drug Name

Status*

PNV-VP-U

Preventive

potassium chloride (2 meq/ml vial, 2 meq/ml iv soln, 10meq/0.1l piggyback, 10meq/50ml piggyback, 20meq/50ml piggyback, 20meq/0.1l piggyback, 30meq/0.1l piggyback, 40meq/0.1l piggyback)

Medical

potassium chloride (8 capsule er, 8 tablet er, 10 tab er prt, 10 tablet er, 10 capsule er, 20 tablet er, 20 tab er prt)

Generic

potassium chloride in 0.45 % sodium chloride

Medical


Medical

potassium citrate (5 tablet er, 10 tablet er)

Generic

prenatal vits with calcium #72/ferrous fumarate/folic acid

Preventive


Preventive

prenatal vits without calc no5/ferrous fumarate/folic acid

Preventive

PREPLUS

Preventive

PROCALAMINE

Medical

QUFLORA (0.25 MG/ML DROP, 0.5 MG/ML DROP)

Preventive

ringers solution irrig soln

Medical

sodium chloride 0.45 %

Medical

sodium chloride 2.5 meq/ml vial

Medical

sodium chloride 3 %

Medical

sodium chloride 5 %

Medical

SYREX

Medical

TL FOLATE

Preventive

TRIVEEN-U

Preventive

Requirements/Limits


LAST UPDATE 11/2015


Drug Name

Status*

VIRT NATE

Preventive

virt-nate

Generic

VOL-NATE

Preventive

Requirements/Limits


LAST UPDATE 11/2015

Alphabetical Listing

0 0.9 % sodium chloride

99

8 8-MOP

65

A

AGGRENOX

53

ak-poly-bac

89

alagesic lq

5

ALBENZA

40

albuterol sulfate

94

alclometasone dipropionate

12

ALDURAZYME

68

alendronate sodium

88

abacavir sulfate

44

alfuzosin hcl

73

abacavir sulfate/lamivudine/zidovudine

44

ALINIA

40

ABELCET

31

ALKERAN

35

ABILIFY

26

allopurinol

33

ABSORICA

65

almotriptan malate

33

acamprosate calcium

11

ALOCRIL

90

ACANYA

65

ALOMIDE

90

acarbose

48

alosetron hcl

71

acebutolol hcl

56

ALOXI

29

ALPHAGAN P

91

alprazolam

47

ALREX

91

acetaminophen with codeine phosphate acetasol hc acetazolamide

8 15 23,59

acetic acid

15

ALTABAX

15

acetic acid/aluminum acetate

15

ALTAVERA

76

acetic acid/hydrocortisone

15

ALVESCO

93

acetylcysteine

96

ALYACEN

76

acitretin

65

amantadine hcl

41

ACTEMRA

87

AMBISOME

31

ACTIMMUNE

87

ambitussin ac

96

ACTOPLUS MET XR

48

amcinonide

12

acyclovir

47

AMETHIA

76

ADAGEN

68

AMETHIA LO

76

adapalene

65

AMETHYST

76

ADCIRCA

96

amifostine crystalline

37

adefovir dipivoxil

46

amikacin sulfate

14

ADEMPAS

96

amiloride hcl

60

ADRUCIL

36

amiloride hcl/hydrochlorothiazide

58

ADVAIR DISKUS

94

aminophylline

94

ADVAIR HFA

94

amiodarone hcl

55

AEROSPAN

92

AMITIZA

71

afeditab cr

57

amitriptyline hcl

29

AFINITOR

38

amlodipine besylate

57

AFINITOR DISPERZ

38

amlodipine besylate/atorvastatin calcium

58

103

amlodipine besylate/benazepril hcl

58

ascomp with codeine

amlodipine besylate/valsartan

58

ASHLYNA

77

ammonium chloride

99

ASMANEX

93

amnesteem

65

ASMANEX HFA

93

amoxapine

29

aspirin/dipyridamole

53

amoxicillin

19

ASTAGRAF XL

85

amoxicillin/potassium clavulanate

20

ASTRAMORPH-PF

amphotericin b

31

atenolol

56

ampicillin sodium

20

atenolol/chlorthalidone

58

ampicillin sodium/sulbactam sodium

20

ATGAM

85

ampicillin trihydrate

20

atorvastatin calcium

60

AMPYRA

64

atovaquone

40

ANADROL-50

76

ATRIPLA

45

anagrelide hcl

53

atropine sulfate

55

anastrozole

37

ATROVENT HFA

94

ANDRODERM

76

AUBAGIO

64

ANDROGEL

76

AUBRA

77

androxy

76

AURYXIA

73

ANORO ELLIPTA

95

AVIANE

77

anusol-hc

12

avidoxy

22

ANZEMET

30

avita

65

apexicon e

12

AVONEX

64

APIDRA

51

AVONEX ADMINISTRATION PACK

64

APIDRA SOLOSTAR

51

AVONEX PEN

64

APLENZIN

26

AZASITE

20

APOKYN

41

azathioprine

85

apraclonidine hcl

91

azathioprine sodium

85

APRI

77

azelastine hcl

APRISO

69

AZELEX

65

APTIOM

25

AZILECT

42

APTIVUS

45

azithromycin

21

ARALAST NP

96

AZOPT

91

ARANELLE

77

aztreonam

19

ARANESP

53

AZURETTE

77

arbinoxa

93

ARCAPTA NEOHALER

95

aripiprazole

26,27

8

8

90,93

B BACIIM

15

ARMOUR THYROID

82

bacitracin

15

ARNUITY ELLIPTA

93

bacitracin/polymyxin b sulfate

89

ARZERRA

39

baclofen

43

ASACOL HD

69

bacteriostatic sodium chloride

99

104

balsalazide disodium

87

brimonidine tartrate

91

BALZIVA

77

bromfenac sodium

91

BANZEL

25

bromocriptine mesylate

41

BARACLUDE

46

BROVANA

95

benazepril hcl

54

budeprion sr

27

benazepril hcl/hydrochlorothiazide

58

budesonide

74,93

BENICAR

54

bumetanide

59

BENLYSTA

85

BUPHENYL

68

BENZACLIN

65

buprenorphine hcl

12

BENZAMYCINPAK

65

buprenorphine hcl/naloxone hcl

12

benzonatate

96

BUPROBAN

12

benztropine mesylate

41

bupropion hcl

27

BEPREVE

90

buspirone hcl

47

BERINERT

85

BUSULFEX

35

BESIVANCE

21

butalbital/acetaminophen

5

butalbital/acetaminophen/caffeine

5

betamethasone acetate/betamethasone sodium phosphate

74

butalbital/acetaminophen/caffeine/codeine phosphate 8

betamethasone dipropionate

12

butalbital/aspirin/caffeine

5

betamethasone dipropionate/propylene glycol

12

butorphanol tartrate

8

betamethasone valerate

12

BUTRANS

6

BETASERON

64

BYDUREON

48

BYDUREON PEN

48

betaxolol hcl

56,91

bethanechol chloride

73

BYETTA

48

BETIMOL

91

BYSTOLIC

56

BETOPTIC S

91

bexarotene

39

C

bicalutamide

84

cabergoline

84

BILTRICIDE

40

cafergot

33

bimatoprost

89

calcipotriene

65

bisoprolol fumarate

56

calcipotriene/betamethasone dipropionate

66

bisoprolol fumarate/hydrochlorothiazide

58

calcitonin,salmon,synthetic

88

BIVIGAM

86

calcitrene

66

bleph-10

22

calcitriol

BLEPHAMIDE

89

calcium acetate

BLEPHAMIDE S.O.P.

89

CAMBIA

5

blood sugar diagnostic

89

CAMILA

81

BOSULIF

38

CAMRESE

77

BOTOX

33

CAMRESE LO

77

CANASA

69

BREO ELLIPTA

93,95

66,83 73

BRIELLYN

77

CANCIDAS

31

BRILINTA

53

candesartan cilexetil

54

105

CANTIL

69

capacet

5

CEFTIN

18

ceftriaxone sodium

19

CAPASTAT SULFATE

35

ceftriaxone sodium/dextrose, iso-osmotic

19

capecitabine

36

cefuroxime axetil

19

CAPRELSA

38

cefuroxime sodium

19

captopril

55

cefuroxime sodium/dextrose, iso-osmotic

19

captopril/hydrochlorothiazide

58

celecoxib

CARAC

66

CELLCEPT

85

CARAFATE

71

CELONTIN

23

CARBAGLU

68

CENESTIN

77

carbamazepine

25

cephalexin

19

carbidopa

41

CERDELGA

68

carbidopa/levodopa

41

CEREZYME

68

carbidopa/levodopa/entacapone

41

CESAMET

30

carbinoxamine maleate

93

cevimeline hcl

64

CARDIZEM LA

57

CHANTIX

12

CARIMUNE NF NANOFILTERED

87

CHATEAL

77

carisoprodol

98

CHEMET

99

carisoprodol/aspirin

98

CHENODAL

69

carteolol hcl

92

cheratussin ac

96

cartia xt

57

cheratussin dac

96

carvedilol

56

chlordiazepoxide hcl

47

CAZIANT

77

chlorhexidine gluconate

15

CEENU

35

chloroquine phosphate

40

cefaclor

18

chlorothiazide

60

cefadroxil

18

chlorpromazine hcl

29

cefazolin sodium

18

chlorpropamide

48

cefazolin sodium/dextrose, iso-osmotic

18

chlorthalidone

60

cefdinir

18

chlorzoxazone

98

cefditoren pivoxil

18

CHOLBAM

69

cefepime hcl

18

cholestyramine (with sugar)

61

cefixime

18

cholestyramine/aspartame

61

cefotaxime sodium

18

CIALIS

73

cefotetan disodium

18

ciclodan

31

cefotetan disodium/dextrose, iso-osmotic

18

ciclopirox

31

cefoxitin sodium

18

ciclopirox olamine

31

cefoxitin sodium/dextrose, iso-osmotic

18

ciclopirox/vitamin e mixed/nail lacquer remover, non-

cefpodoxime proxetil

18

acet

31

cefprozil

18

cilostazol

53

ceftazidime

18

cimetidine

70

ceftibuten

18

cimetidine hcl

70

106

5

CIMZIA

85

colestid

61

CINRYZE

85

colestipol hcl

61

CIPRO HC

92

colocort

88

CIPRODEX

92

COLY-MYCIN S

92

COMBIGAN

92

ciprofloxacin hcl

21,92

ciprofloxacin/ciprofloxacin hcl

21

COMBIPATCH

77

citalopram hydrobromide

27

COMBIVENT

95

claravis

66

COMBIVENT RESPIMAT

95

clarithromycin

21

COMETRIQ

38

clemastine fumarate

93

comfort pac-ibuprofen

CLEOCIN PHOSPHATE

16

COMPLERA

44

CLEOCIN PHOSPHATE IN D5W

16

compro

29

clindacin etz

16

CONDYLOX

66

clindacin p

16

constulose

71

clindamycin hcl

16

COPAXONE

64

clindamycin palmitate hcl

16

CORDRAN

13

clindamycin phosphate

16

COREG CR

56

clindamycin phosphate/benzoyl peroxide

66

cormax

13

clobetasol propionate

12

cortisone acetate

13

clobetasol propionate/emollient base

12

CORTISPORIN

clocortolone pivalate

12

CORTISPORIN-TC

92

clodan

13

CREON

68

CLODERM

13

CRESTOR

60

clomipramine hcl

29

CRINONE

81

clonazepam

48

CRIXIVAN

45

clonidine

54

cromolyn sodium

clonidine hcl

54,63

5

13,66

90,95

CRYSELLE

77

clopidogrel bisulfate

53

CUBICIN

16

clorazepate dipotassium

48

CUPRIMINE

73

clotrimazole

31

CUVPOSA

69

clotrimazole/betamethasone dipropionate

66

cyanocobalamin (vitamin b-12)

99

clozapine

43

CYCLAFEM

77

co-gesic

8

cyclobenzaprine hcl

98

CYCLOPHOSPHAMIDE CAPSULES

35

COARTEM

40

codeine phosphate/butalbital/aspirin/caffeine

8

cyclophosphamide tablets

35

codeine phosphate/carisoprodol/aspirin

8

cycloserine

16

codeine sulfate

8

CYCLOSET

48

colchicine

33

cyclosporine

85

colchicine/probenecid

33

cyclosporine, modified

COLCRYS

33

cyproheptadine hcl

93

COLESTID

61

CYRED

77

107

66,85

CYSTADANE

68

DICLEGIS

CYSTAGON

73

diclofenac potassium

CYSTARAN

89

diclofenac sodium

29 5 5,66,74

diclofenac sodium/misoprostol

D

5

dicloxacillin sodium

20

DACOGEN

36

dicyclomine hcl

69

DALIRESP

96

didanosine

44

danazol

76

DIFFERIN

66

dantrolene sodium

43

DIFICID

21

dapsone

34

diflorasone diacetate

13

DARAPRIM

40

diflunisal

DASETTA

77

digitek

58

DAYSEE

77

digox

58

DAYTRANA

63

digoxin

58

DEBLITANE

81

dihydrocodeine bitartrate/acetaminophen/caffeine

DELYLA

77

dihydroergotamine mesylate

33

DELZICOL

69

DILANTIN

25

demeclocycline hcl

22

DILATRATE-SR

62

DENAVIR

47

dilt-cd

57

depade

11

dilt-xr

57

DEPEN

73

diltiazem hcl

57

DEPO-SUBQ PROVERA 104

82

diltzac er

57

desipramine hcl

29

DIPENTUM

87

desloratadine

93

diphenhydramine hcl

29

desmopressin acetate

75

diphenoxylate hcl/atropine sulfate

69

desmopressin acetate (non-refrigerated)

75

dipyridamole

53

desogestrel-ethinyl estradiol

77

disopyramide phosphate

55

desogestrel-ethinyl estradiol/ethinyl estradiol

77

disulfiram

11

desonide

13

divalproex sodium

24

desoximetasone

13

donepezil hcl

26

desvenlafaxine

27

DORIBAX

19

desvenlafaxine fumarate

27

dorzolamide hcl

92

dexamethasone

74

dorzolamide hcl/timolol maleate

92

dexamethasone sod phosphate

74

doxazosin mesylate

54

DEXILANT

72

doxepin hcl

29

dexmethylphenidate hcl

63

doxercalciferol

88

dextroamphetamine sulf-saccharate/amphetamine sulf-

doxycycline hyclate

22

aspartate

doxycycline monohydrate

22

62,63

5

8

dextroamphetamine sulfate

63

dronabinol

30

DIASTAT

24

DROXIA

36

diazepam

24,48

DUAVEE

77

108

duloxetine hcl

28

ENSKYCE

78

DUREZOL

74

entacapone

41

dutasteride

73

entecavir

46

dynacin

22

ENTYVIO

85

DYRENIUM

60

enulose

71

EPANED

55

EPIDUO

66

E E.E.S. 200

21

EPIDUO FORTE

66

econazole nitrate

31

EPIFOAM

74

EDARBI

54

epinastine hcl

91

EDARBYCLOR

58

EPIPEN 2-PAK

95

EDECRIN

59

EPIPEN JR 2-PAK

95

EDURANT

44

epitol

25

EFFIENT

53

EPIVIR HBV

46

EGRIFTA

75

eplerenone

60

ELAPRASE

68

EPOGEN

53

ELELYSO

68

epoprostenol sodium (glycine)

96

ELIDEL

66

EPZICOM

44

ELIGARD

84

ERAXIS (WATER DILUENT)

31

elimite

40

ergocalciferol (vitamin d2)

ELINEST

77

ergoloid mesylates

26

ELIQUIS

52

ERGOMAR

33

ELLA

82

ergotamine tartrate/caffeine

33

ELMIRON

73

ERIVEDGE

38

ELSPAR

37

ERRIN

82

EMADINE

90

ERTACZO

31

EMCYT

36

ery

21

EMEND

30

ERY-TAB

21

EMOQUETTE

77

erygel

21

EMSAM

27

ERYPED 200

21

EMTRIVA

44

ERYTHROCIN STEARATE

21

ENABLEX

72

erythromycin base

21

enalapril maleate

55

erythromycin base/benzoyl peroxide

66

enalapril maleate/hydrochlorothiazide

58

erythromycin base/ethyl alcohol

21

ENBREL

85

erythromycin ethylsuccinate

21

endocet

8

erythromycin ethylsuccinate/sulfisoxazole acetyl

16

endodan

9

ESBRIET

96

100

ENDOMETRIN

82

escitalopram oxalate

28

ENJUVIA

77

esomeprazole magnesium

72

enoxaparin sodium

52

ESTARYLLA

78

ENPRESSE

78

estazolam

98

109

ESTRACE

78

FERRIPROX

99

estradiol

78

FINACEA

66

estradiol/norethindrone acetate

78

finasteride

73

ESTRING

78

FIRAZYR

87

estropipate

78

FIRMAGON

84

eszopiclone

98

FLAREX

74

ethambutol hcl

35

flavoxate hcl

72

ethinyl estradiol/drospirenone

78

FLEBOGAMMA DIF

87

ethosuximide

23

flecainide acetate

55

etidronate disodium

88

FLECTOR

etodolac

5

5

FLOVENT DISKUS

74

ETOPOPHOS

38

FLOVENT HFA

74

etoposide

38

fluconazole

31

EURAX

40

flucytosine

31

EVOTAZ

45

fludarabine phosphate

36

EXELDERM

31

fludrocortisone acetate

13

EXELON

26

flunisolide

93

exemestane

38

fluocinolone acetonide

13

EXJADE

99

fluocinolone acetonide oil

74

EXTAVIA

64

fluocinolone acetonide/shower cap

13

fluocinonide

13

fluocinonide/emollient base

13

F FABRAZYME

68

fluoride/iron/vitamins a,c,and d

100

FACTIVE

21

fluorometholone

74

FALMINA

78

FLUOROPLEX

66

famciclovir

47

fluorouracil

famotidine

70

fluoxetine hcl

28

FANAPT

42

fluphenazine hcl

42

FARESTON

36

flurazepam hcl

98

FARXIGA

49

flurbiprofen

FARYDAK

37

flurbiprofen sodium

91

felbamate

25

flutamide

37

felodipine

57

fluticasone propionate

fenofibrate

60

fluvastatin sodium

61

fenofibrate nanocrystallized

60

fluvoxamine maleate

28

fenofibrate,micronized

60

FML FORTE

74

fenofibric acid

60

FML S.O.P.

74

fenofibric acid (choline)

60

fondaparinux sodium

52

36,66

5

13,74

fenoprofen calcium

5

FORADIL

95

fentanyl

6

FORTAZ IN ISO-OSMOTIC DEXTROSE

19

fentanyl citrate

7

FORTEO

88

110

fortical

88

GILDESS 24 FE

78

FOSAMAX PLUS D

88

GILDESS FE

78

foscarnet sodium

46

GILENYA

64

fosinopril sodium

55

GILOTRIF

38

fosinopril sodium/hydrochlorothiazide

58

GLASSIA

96

fosphenytoin sodium

25

GLATOPA

64

FOSRENOL

73

GLEEVEC

38

FRAGMIN

52

GLEOSTINE

35

FROVA

33

glimepiride

49

FULYZAQ

70

glipizide

49

furosemide

59

glipizide/metformin hcl

49

FUZEON

45

GLUCAGEN 1MG HYPOKIT

50

GLUCAGON EMERGENCY KIT

50

glyburide

49

G gabapentin

24

glyburide,micronized

49

GABITRIL

24

glyburide/metformin hcl

49

galantamine hbr

26

glycopyrrolate

69

GAMASTAN S-D

87

glydo

11

GAMMAGARD LIQUID

87

GLYSET

49

GAMMAGARD S-D

87

GLYXAMBI

49

GAMMAKED

87

GOLYTELY

71

GAMMAPLEX

87

granisetron hcl

30

GAMUNEX

87

GRANIX

53

GAMUNEX-C

87

GRASTEK

96

garamycin

14

griseofulvin ultramicrosize

31

gatifloxacin

21

griseofulvin, microsize

31

GATTEX

70

guaiatussin ac

96

gavilyte-c

71

guaifenesin ac

97

gavilyte-g

71

guaifenesin dac

97

gavilyte-n

71

guaifenesin/codeine phosphate

97

gemfibrozil

60

guanfacine hcl

generlac

71

guanidine hcl

gengraf

67

GENOTROPIN

75

H

gentak

14

H.P. ACTHAR

75

gentamicin sulfate

15

halobetasol propionate

13

gentamicin sulfate in sodium chloride, iso-osmotic

15

HALOG

13

gentamicin sulfate/pf

15

haloperidol

42

GIANVI

78

haloperidol lactate

42

GILDAGIA

78

HARVONI

46

GILDESS

78

HEATHER

82

111

54,63 34

hecoria

85

hydroxyprogesterone caproate

88

HECTOROL

88

hydroxyurea

36

heparin sodium,porcine

52

hydroxyzine hcl

30

heparin sodium,porcine in 0.45 % sodium chloride

52

hydroxyzine pamoate

30

heparin sodium,porcine in 0.9 % sodium chloride/pf 52

HYPER-SAL

97

heparin sodium,porcine/dextrose 5 % in water

52

hypercare

67

heparin sodium,porcine/pf

52

HYQVIA

87

HEXALEN

37

HIZENTRA

87

I

HORIZANT

64

ibandronate sodium

88

HUMALOG

51

IBRANCE

38


51

ibudone

9


51

ibuprofen

6

HUMALOG MIX 50-50

51

ibuprofen/oxycodone hcl

6


51

ICLUSIG

39

HUMALOG MIX 75-25

51

IMBRUVICA

38


51

imipenem/cilastatin sodium

19

HUMATROPE

75

imipramine hcl

29

HUMIRA

85

imipramine pamoate

29

HUMIRA PEDIATRIC CROHN'S

86

imiquimod

37

HUMIRA PEN

86

INCIVEK

46

HUMIRA PEN CROHN'S-UC-HS

86

INCRELEX

75

HUMIRA PEN PSORIASIS

86

INCRUSE ELLIPTA

94

HUMULIN 70-30

51

indapamide

60

HUMULIN 70/30 KWIKPEN

51

indomethacin

HUMULIN N

51

INFERGEN

HUMULIN N KWIKPEN

51

INFUMORPH

HUMULIN R

51

INLYTA

38

HYCAMTIN

38

INTELENCE

44

hydralazine hcl

61

INTRON A

37

hydrochlorothiazide

60

INTROVALE

78

INVANZ

19

hydrocodone bitartrate/homatropine methylbromide 97

INVIRASE

45

hydrocodone/ibuprofen

INVOKAMET

49

13,74,88

INVOKANA

49

hydrocortisone butyrate

13,74

iophen-c nr

97

hydrocortisone valerate

75

ipratropium bromide

94

hydrocortisone/mineral oil/petrolatum,white

75

ipratropium bromide/albuterol sulfate

95

hydromet

97

irbesartan

54

hydromorphone hcl

7,9

irbesartan/hydrochlorothiazide

58

hydroxychloroquine sulfate

40

ISENTRESS

45

hydrocodone bitartrate/acetaminophen

hydrocortisone

9 9

112

6 46 9

isochron

62

KHEDEZLA

28

100

KIMIDESS

79

isoniazid

35

KINERET

86

isosorbide dinitrate

62

kionex

99

isosorbide mononitrate

62

klor-con 10

100

isradipine

57

KLOR-CON 8

100

ISTALOL

92

klor-con m10

100

itraconazole

32

klor-con m15

100

ivermectin

40

klor-con m20

100

klor-con sprinkle

100

ISOLYTE S

J

KOMBIGLYZE XR

49

JAKAFI

38

KURVELO

79

jantoven

52

KUVAN

68

JANUMET

49

KYNAMRO

61

JANUMET XR

49

JANUVIA

49

L

JARDIANCE

49

labetalol hcl

56

JENCYCLA

82

LACRISERT

89

JENTADUETO

49

lactulose

71

jinteli

78

LAMISIL

32

JOLESSA

78

lamivudine

JOLIVETTE

82

lamivudine/zidovudine

44

JULEBER

78

lamotrigine

25

JUNEL

78

lansoprazole

72

JUNEL FE

78

lansoprazole/amoxicillin trihydrate/clarithromycin

70

JUNEL FE 24

78

LANTUS

51

JUXTAPID

61

LANTUS SOLOSTAR

51

LARIN

79

LARIN 24 FE

79

K

44,46

KALBITOR

85

LARIN FE

79

KALETRA

45

LASTACAFT

91

KALYDECO

97

latanoprost

89

KARIVA

78

LATUDA

42

KAZANO

49

LEENA

79

KELNOR 1-35

78

leflunomide

87

KEPIVANCE

65

LENVIMA

39

KETEK

21

LESSINA

79

ketoconazole

32

LETAIRIS

96

ketodan

32

letrozole

38

leucovorin calcium

37

LEUKERAN

35

ketoprofen ketorolac tromethamine

6 6,91

113

LEUKINE

53

lorazepam intensol

leuprolide acetate

84

lorcet

9

levalbuterol hcl

95

lorcet hd

9

LEVATOL

56

lorcet plus

9

LEVEMIR

51

lortab

9

LEVEMIR FLEXPEN

51

lortuss ex

97

LEVEMIR FLEXTOUCH

51

LORYNA

79

levetiracetam

23

losartan potassium

54

levobunolol hcl

92

losartan potassium/hydrochlorothiazide

59

levocarnitine

99

LOTEMAX

91

levocarnitine (with sugar)

99

lovastatin

61

levocetirizine dihydrochloride

93

LOW-OGESTREL

79

levofloxacin

22

loxapine succinate

42

LEVONEST

79

LUFYLLIN

94

levonorgestrel

82

LUMIGAN

89

levonorgestrel-ethinyl estradiol

79

LUPRON DEPOT-PED

84

levonorgestrel/ethinyl estradiol and ethinyl estradiol 79

LUTERA

79

LEVORA-28

LYNPARZA

38

LYRICA

23

levorphanol tartrate

79 7

48

levothyroxine sodium

83

LYSODREN

83

levoxyl

83

LYZA

82

LEXIVA

45

LIALDA

70

M

lidocaine

11

magnesium sulfate

100

lidocaine hcl

11

magnesium sulfate in sterile water

100

lidocaine hcl/pf

55

magnesium sulfate/dextrose 5 % in water

100

lidocaine/prilocaine

11

malathion

40

LINCOCIN

16

maprotiline hcl

27

lindane

40

marlexate

99

linezolid

16

MARLISSA

79

liothyronine sodium

83

MARPLAN

27

lisinopril

55

MATULANE

36

lisinopril/hydrochlorothiazide

59

matzim la

57

lithium carbonate

48

MAXAIR AUTOHALER

95

lithium citrate

48

MAXIDEX

75

LIVALO

61

meclofenamate sodium

lofibra

60

medroxyprogesterone acetate

LOMEDIA 24 FE

79

mefenamic acid

6

lomustine

35

mefloquine hcl

40

LOPREEZA

79

megestrol acetate

82

lorazepam

48

MEKINIST

38

114

6 82

meloxicam

6

metoclopramide hcl

30

melphalan hcl

36

metolazone

60

memantine hcl

26

metoprolol succinate

56

MENEST

79

metoprolol tartrate

56

meperidine hcl

9

metoprolol tartrate/hydrochlorothiazide

59

meperitab

9

metronidazole

16

meprobamate

48

metronidazole in sodium chloride

16

mercaptopurine

36

mexiletine hcl

55

meropenem

19

MIACALCIN

88

mesalamine

70

miconazole nitrate

32

mesalamine with cleansing wipes

70

MICROGESTIN

79

MESNEX

37

MICROGESTIN FE

79

MESTINON

34

midodrine hcl

54

metadate er

63

migergot

33

metaproterenol sulfate

95

MIGRANAL

33

metaxalone

98

millipred

13

metformin hcl

49

millipred dp

14

methadone hcl

7

mimvey

79

methadone intensol

7

mimvey lo

79

methadose

7

minitran

62

methamphetamine hcl

63

minocycline hcl

23

methazolamide

59

minoxidil

61

methenamine hippurate

16

mirtazapine

27

methenamine mandelate

16

misoprostol

71

methimazole

84

mitoxantrone hcl

37

METHITEST

76

modafinil

98

methocarbamol

98

MODERIBA

46

methotrexate sodium

36

moexipril hcl

55

methotrexate sodium/pf

37

moexipril hcl/hydrochlorothiazide

59

methoxsalen, rapid

67

mometasone furoate

67

methscopolamine bromide

69

mondoxyne nl

23

methyclothiazide

60

MONO-LINYAH

79

methyldopa

54

MONOJECT 0.9% SODIUM CHLORIDE

100

methyldopa/hydrochlorothiazide

59

MONOJECT PREFILL

100

methyldopate hcl

54

MONOJECT PREFILL ADVANCED

100

methylergonovine maleate

73

MONONESSA

79

methylphenidate hcl

63

montelukast sodium

94

methylprednisolone

13

MONUROL

16

methylprednisolone acetate

75

morgidox

23

methyltestosterone

76

morphine sulfate

metipranolol

92

morphine sulfate/pf

115

7,9,10 10

MOTOFEN

70

neo-polycin hc

90

MOVANTIK

70

neomycin sulfate

15

MOVIPREP

71

neomycin sulfate/bacitracin zinc/polymyxin

MOXATAG

20

b/hydrocortisone

90

moxifloxacin hcl

22

neomycin sulfate/bacitracin/polymyxin b

90

MOZOBIL

53

neomycin sulfate/polymyxin b sulfate/gramicidin d

90

MULTAQ

55

neomycin sulfate/polymyxin b

mupirocin

16

sulfate/hydrocortisone

mupirocin calcium

16

neomycin/polymyxin b sulfate/dexamethasone

90

MYALEPT

75

neosporin

90

MYCAMINE

32

NESINA

50

mycophenolate mofetil

86

neuac

67

mycophenolate sodium

86

NEULASTA

53

myorisan

67

NEUMEGA

53

MYOZYME

68

NEUPOGEN

53

MYRBETRIQ

43

NEVANAC

91

MYZILRA

79

nevirapine

44

NEXAVAR

39

NEXIUM

72

6

niacin

61

nadolol

56

niacor

61

nadolol/bendroflumethiazide

59

nicardipine hcl

57

nafcillin in dextrose, iso-osmotic

20

nifediac cc

57

nafcillin sodium

20

nifedical xl

58

naftifine hcl

32

nifedipine

58

NAFTIN

32

NIKKI

79

NAGLAZYME

68

NILANDRON

84

naloxone hcl

12

nimodipine

58

naltrexone hcl

11

nisoldipine

58

naphazoline hcl

89

NITRO-BID

62

naproxen

6

NITRO-DUR

62

naproxen sodium

6

nitro-time

62

N nabumetone

14,90

naratriptan hcl

34

nitrofurantoin

16

NAROPIN

11

nitrofurantoin macrocrystal

16

NASONEX

93

nitrofurantoin monohydrate/macrocrystals

17

NATACYN

32

nitroglycerin

62

nateglinide

50

NITROSTAT

62

NATPARA

83

NIVA-PLUS

100

NECON

79

nizatidine

70

nefazodone hcl

27

NORA-BE

82

neo-polycin

89

NORDITROPIN

75

116

norethindrone

82

OFEV

97

norethindrone acetate

82

ofloxacin

22

norethindrone acetate-ethinyl estradiol

80

OGESTREL

80

olanzapine

42

norethindrone acetate-ethinyl estradiol/ferrous fumarate

80

olanzapine/fluoxetine hcl

27

norgestimate-ethinyl estradiol

80

olopatadine hcl

93

NORLYROC

82

OLYSIO

46

NORMOSOL-R

100

omega-3 acid ethyl esters

61

NORMOSOL-R PH 7.4

100

omeprazole

72

NOROXIN

22

OMNARIS

93

NORPACE CR

55

OMNITROPE

76

NORTREL

80

OMONTYS

88

nortriptyline hcl

29

ondansetron

30

NORVIR

45

ondansetron hcl

31

NOVOLIN 70-30

51

ondansetron odt

31

NOVOLIN N

51

ONEXTON

65

NOVOLIN R

51

ONFI

24

NOVOLOG

51

ONGLYZA

50

NOVOLOG FLEXPEN

51

OPANA ER

7

NOVOLOG MIX 70-30

51

OPSUMIT

96

NOVOLOG MIX 70-30 FLEXPEN

51

ORALAIR

97

NOXAFIL

32

oralone

14

NUCYNTA

10

ORAVIG

32

ORENCIA

86

NUCYNTA ER

7

NUEDEXTA

64

ORENITRAM ER

96

NULOJIX

86

ORFADIN

68

NULYTELY WITH FLAVOR PACKS

71

orphenadrine citrate

98

NUTROPIN

75

orphenadrine citrate/aspirin/caffeine

98

NUTROPIN AQ

75

ORSYTHIA

80

NUTROPIN AQ NUSPIN

75

ORTHO TRI-CYCLEN LO

80

NUVARING

80

OSENI

50

NUVIGIL

98,99

OSMOPREP

100

nyamyc

32

OTEZLA

87

nystatin

32

oxacillin sodium

20

nystatin/triamcinolone acetonide

14

oxacillin sodium/dextrose, iso-osmotic

20

nystop

32

oxandrolone

76

O

oxaprozin

6

oxazepam

48

OCELLA

80

oxcarbazepine

25

OCTAGAM

87

OXISTAT

32

octreotide acetate

84

OXSORALEN

67

117

oxybutynin chloride oxycodone hcl

72 7,10

perindopril erbumine

55

periogard

17

oxycodone hcl/acetaminophen

10

permethrin

40

oxycodone hcl/aspirin

10

perphenazine

30

OXYCONTIN

7,8

perphenazine/amitriptyline hcl

27

8,10

PEXEVA

28

72

pfizerpen

20

phenadoz

30

phenelzine sulfate

27

oxymorphone hcl OXYTROL

P pacerone

55

phenobarbital

24

palgic

93

phenoxybenzamine hcl

54

paliperidone

42

phenylephrine hcl/promethazine hcl

97

pamidronate disodium

88

phenytoin

25

pancrelipase 5,000

69

phenytoin sodium extended

25

PANRETIN

39

PHILITH

80

pantoprazole sodium

72

PHISOHEX

67

paricalcitol

83

PHOSLYRA

73

paroex

17

PHOSPHOLINE IODIDE

92

paromomycin sulfate

15

PHYSIOLYTE

100

paroxetine hcl

28

PHYSIOSOL

100

PASER

35

PICATO

PATADAY

91

pilocarpine hcl

65,92

PATANOL

91

PILOPINE HS

92

PAXIL

28

pimozide

42

pedi-dri

32

PIMTREA

80

pindolol

56

pediatric multivitamin combination no.2/sodium

67

fluoride

100

pioglitazone hcl

50

pediatric multivitamins no.82 with sodium fluoride

100

pioglitazone hcl/glimepiride

50

pioglitazone hcl/metformin hcl

50

peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl

71

piperacillin sodium/tazobactam sodium

20

PEGANONE

25

PIRMELLA

80

PEGASYS

46

piroxicam

PEGASYS PROCLICK

46

PLASMA-LYTE 148

100

PEGINTRON

46

PLASMA-LYTE A PH 7.4

100

PEGINTRON REDIPEN

47

PLEGRIDY

64

penicillin g potassium

20

PLEGRIDY PEN

64

penicillin g procaine

20

PNV-VP-U

penicillin v potassium

20

podofilox

67

PENTASA

70

polycin

90

pentoxifylline

59

polymyxin b sulfate

17

PERFOROMIST

95

polymyxin b sulfate/trimethoprim

90

118

6

101

POMALYST

36

procainamide hcl

55

PORTIA

80

PROCALAMINE

101

potassium chloride

101

prochlorperazine

30


101

prochlorperazine maleate

30


101

PROCRIT

53

potassium citrate

101

procto-pak

14

POTIGA

23

proctocream-hc

14

PRADAXA

52

PROCTOFOAM-HC

70

pramipexole di-hcl

41

proctosol-hc

88

pravastatin sodium

61

proctozone-hc

88

prazosin hcl

54

PROCYSBI

73

prednicarbate

67

progesterone,micronized

82

prednisolone

14

PROGLYCEM

50

prednisolone acetate

75

PROGRAF

86

PROLASTIN C

97

prednisolone sod phosphate

14,91

prednisone

14

PROLIA

39

prednisone intensol

14

PROMACTA

53

PREMARIN

80

promethazine hcl

30

PREMPHASE

80

promethazine hcl/codeine

97

PREMPRO

80

promethazine hcl/dextromethorphan hbr

97

promethazine/phenylephrine hcl/codeine

97

promethegan

30

propafenone hcl

55

propantheline bromide

70

proparacaine hcl

11


101


101

prenatal vits without calc no5/ferrous fumarate/folic acid

101

propranolol hcl

57

PREPLUS

101

propranolol hcl/hydrochlorothiazide

59

prevalite

61

propylthiouracil

84

PREVIFEM

80

PROTONIX

72

PREZCOBIX

45

protriptyline hcl

29

PREZISTA

45

PRUDOXIN

67

PRIFTIN

35

psorcon

14

primaquine phosphate

40

PULMICORT FLEXHALER

93

PRIMAXIN

19

pulmosal

97

primidone

23

PULMOZYME

97

PRIMSOL

17

PURIXAN

37

PRISTIQ ER

28

PYLERA

70

PRIVIGEN

87

pyrazinamide

35

proair hfa

95

pyridostigmine bromide

34

proair respiclick

95

probenecid

33

119

Q

REVATIO

96

revia

11

QUASENSE

80

REVLIMID

36

quetiapine fumarate

43

REYATAZ

46

RHEUMATREX

37

QUFLORA

101

quinapril hcl

55

RIBAPAK

47

quinapril hcl/hydrochlorothiazide

59

RIBASPHERE

47

quinidine gluconate

55

RIBASPHERE RIBAPAK

47

quinidine sulfate

56

RIBATAB

47

QVAR

93

ribavirin

47

RIDAURA

87

rifabutin

34

R rabeprazole sodium

72

RIFAMATE

35

RAGWITEK

97

rifampin

35

raloxifene hcl

82

RIFATER

35

ramipril

55

riluzole

64

RANEXA

59

rimantadine hcl

46

ranitidine hcl

71

ringers solution

101

RAPAFLO

73

RIOMET

50

RAPAMUNE

86

risedronate sodium

89

RAVICTI

69

RISPERDAL CONSTA

43

REBETOL

47

risperidone

43

REBIF

64,65

RITALIN LA

63

REBIF REBIDOSE

64,65

RITUXAN

39

RECLIPSEN

80

rivastigmine

26

RECTIV

62

rivastigmine tartrate

26

refissa

67

rizatriptan benzoate

34

REGRANEX

67

ropinirole hcl

41

relador pak

11

rosadan

17

relador pak plus

11

ROXICET

10

RELENZA

46

roxicet

10

RELISTOR

70

ROZEREM

99

RELPAX

34

REMICADE

86

S

REMODULIN

96

SABRIL

24

RENAGEL

73

SAIZEN

76

RENVELA

74

SAMSCA

99

repaglinide

50

SANCUSO

31

reprexain

10

SANDIMMUNE

86

RESCRIPTOR

44

SANTYL

67

RESTASIS

86

SAPHRIS

43

120

SAVAYSA

52

SPIRIVA

94

SAVELLA

64

SPIRIVA RESPIMAT

94

selegiline hcl

42

spironolactone

60

selenium sulfide

67

spironolactone/hydrochlorothiazide

59

SELZENTRY

45

SPORANOX

32

SENSIPAR

84

SPRINTEC

80

SEREVENT DISKUS

95

SPRYCEL

39

SEROQUEL XR

43

sps

99

SEROSTIM

76

SRONYX

80

sertraline hcl

28

stagesic

10

setlakin

80

stavudine

44

sevelamer carbonate

74

STAVZOR

24

SHAROBEL

82

STELARA

67

SIGNIFOR

83

STIMATE

76

sildenafil citrate

96

STIVARGA

39

silver sulfadiazine

22

STRATTERA

63

SIMPONI

86

streptomycin sulfate

15

SIMPONI ARIA

86

STRIBILD

45

SIMULECT

86

SUBOXONE

12

simvastatin

61

SUCRAID

69

sirolimus

86

sucralfate

72

SIRTURO

35

sulfacetamide sodium

SIVEXTRO

17

sulfacetamide sodium/prednisolone sodium

SKLICE

41

phosphate

90

22,90

sodium chloride

101

sulfadiazine

22

sodium chloride 0.45 %

101

sulfamethoxazole/trimethoprim

22

sodium chloride 3 %

101

sulfamide

22

sodium chloride 5 %

101

SULFAMYLON

17

sulfasalazine

70

sulfazine

70 70

sodium chloride for inhalation

97

sodium chloride/sodium bicarbonate/potassium chloride/peg

71

sulfazine ec

sodium phenylbutyrate

69

sulindac

sodium polystyrene sulfonate

99

sumatriptan

34

SOLTAMOX

36

sumatriptan succinate

34

SOMATULINE DEPOT

84

SUPRAX

19

SOMAVERT

84

SUPREP

71

SOOLANTRA

40

SUSTIVA

44

sorine

56

SUTENT

39

sotalol hcl

56

SYEDA

81

SOVALDI

47

SYLATRON

37

spinosad

67

SYLATRON 4-PACK

37

121

6

SYMBICORT

95

THALOMID

36

SYMLINPEN 120

50

theochron

94

SYMLINPEN 60

50

theophylline anhydrous

94

SYNAREL

84

THIOLA

73

SYNERA

11

thioridazine hcl

42

SYNRIBO

37

thiothixene

42

SYPRINE

99

THYMOGLOBULIN

87

THYROLAR-1

83

THYROLAR-1/2

83

THYROLAR-1/4

83

SYREX

101

T TABLOID

37

THYROLAR-2

83

TACLONEX

67

THYROLAR-3

83

tiagabine hcl

24

tacrolimus

67,86

TAFINLAR

38

ticlopidine hcl

53

TAMIFLU

46

TIKOSYN

56

tamoxifen citrate

36

TILIA FE

81

tamsulosin hcl

73

TIMENTIN

20

TARCEVA

39

timolol maleate

TARGRETIN

39

tinidazole

17

TARINA FE

81

TIVICAY

45

TASIGNA

39

tizanidine hcl

43

TAZICEF

19

TL FOLATE

101

TAZORAC

67

TOBI PODHALER

15

taztia xt

58

TOBRADEX

15

TECFIDERA

65

tobramycin

15

TEFLARO

19

tobramycin in 0.225 % sodium chloride

15

TEKTURNA

59

tobramycin sulfate

15

telmisartan

54

tobramycin sulfate/sodium chloride

15

telmisartan/hydrochlorothiazide

59

tobramycin/dexamethasone

90

temazepam

98

tolazamide

50

temozolomide

36

tolbutamide

50

tolcapone

41

tencon

5

57,92

terazosin hcl

54

tolmetin sodium

terbinafine hcl

32

tolterodine tartrate

72

terbutaline sulfate

95

topiragen

25

terconazole

32

topiramate

25

testosterone cypionate

76

TOPOSAR

38

testosterone enanthate

76

TORISEL

39

tetrabenazine

64

torsemide

60

tetracycline hcl

23

TOUJEO SOLOSTAR

51

TEXACORT

14

TOVIAZ

72

122

6

TRACLEER

96

TYGACIL

17

TRADJENTA

50

TYKERB

39

8,10

TYSABRI

65

tramadol hcl/acetaminophen

10

TYVASO

96

trandolapril

55

TYZEKA

47

tranexamic acid

53

TYZINE

97

TRANSDERM-SCOP

30

tranylcypromine sulfate

27

U

TRAVATAN Z

89

UCERIS

88

travoprost (benzalkonium)

89

ULESFIA

41

trazodone hcl

27

ULORIC

33

TRECATOR

35

unithroid

83

TRELSTAR

37

ursodiol

70

UVADEX

68

tramadol hcl

tretinoin

39,67

tretinoin/emollient base

68

TRI-ESTARYLLA

81

V

TRI-LEGEST FE

81

VAGIFEM

81

TRI-LINYAH

81

valacyclovir hcl

47

TRI-PREVIFEM

81

VALCHLOR

36

TRI-SPRINTEC

81

VALCYTE

46

valganciclovir hcl

46

triamcinolone acetonide

14,75

triamterene/hydrochlorothiazide

59

valproic acid

24

trianex

68

valproic acid (as sodium salt) (valproate sodium)

24

triazolam

98

valsartan

54

triderm

14

valsartan/hydrochlorothiazide

59

trifluoperazine hcl

42

vanatol lq

trifluridine

47

vancomycin hcl

17

trihexyphenidyl hcl

41

vancomycin hcl/dextrose 5 % in water

17

trilyte with flavor packets

71

vandazole

17

trimethobenzamide hcl

30

vandetanib

39

trimethoprim

17

VELETRI

96

trimipramine maleate

29

VELIVET

81

TRINESSA

81

VELTIN

68

TRIUMEQ

45

venlafaxine hcl

28

5

TRIVEEN-U

101

VENTAVIS

96

TRIVORA-28

81

ventolin hfa

95

tropicamide

90

VERAMYST

75

trospium chloride

72

verapamil hcl

TRUVADA

44

VEREGEN

68

tusnel c

97

VERSACLOZ

43

TYBOST

45

VESICARE

72

123

56,58

VESTURA

81

XARELTO

52

VEXOL

91

XEOMIN

43

VIBATIV

17

XGEVA

39

VICTOZA 2-PAK

50

XIFAXAN

17

VICTOZA 3-PAK

50

XIGDUO XR

50

VICTRELIS

47

XOPENEX HFA

95

VIDAZA

37

XTANDI

84

VIDEX

44

XULANE

81

VIEKIRA PAK

47

xylon 10

11

VIGAMOX

22

XYREM

99

VIIBRYD

27

VIMPAT

26

Y

VIORELE

81

YERVOY

VIRACEPT

46

VIRAMUNE XR

44

Z

VIREAD

44

zafirlukast

94

39

VIRT NATE

102

zaleplon

98

virt-nate

102

ZANOSAR

36

virtussin ac

97

ZARAH

81

virtussin dac

98

ZAVESCA

69

VISTIDE

46

ZELAPAR

42

vitazol

17

ZELBORAF

38

VITEKTA

45

ZEMAIRA

98

VITUZ

10

ZEMPLAR

84

VIVITROL

11

zenatane

68

VOL-NATE

102

ZENCHENT

81

VOLTAREN

68

ZENCHENT FE

81

voriconazole

32

ZENPEP

69

VOTRIENT

38

zenzedi

63

VPRIV

69

ZEOSA

81

VYFEMLA

81

ZETIA

61

VYVANSE

63

ZETONNA

93

ZIAGEN

44

ZIANA

68

W warfarin sodium

52

zidovudine

44

WELCHOL

50

ZIOPTAN

92

WERA

81

ziprasidone hcl

43

WYMZYA FE

81

ZIRGAN

46

zoledronic acid in mannitol & water for injection

89

ZOLINZA

39

zolmitriptan

34

X XALKORI

39

124

zolpidem tartrate

98

ZOMACTON

76

ZOMETA

89

ZOMIG

34

ZONALON

68

zonisamide

23

ZORTRESS

86

ZOVIA 1-35E

81

ZOVIA 1-50E

81

ZYCLARA

37

ZYDELIG

39

ZYFLO CR

94

ZYKADIA

39

ZYLET

90

ZYTIGA

38

ZYVOX

17

125

Category Listing Analgesics Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Anti-inflammatory Agents Antibacterials Anticonvulsants Antidementia Agents Antidepressants Antiemetics Antifungals Antigout Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics Antiparasitics Antiparkinson Agents Antipsychotics Antispasticity Agents Antivirals Anxiolytics Bipolar Agents Blood Glucose Regulators Blood Products/Modifiers/ Volume Expanders Cardiovascular Agents Central Nervous System Agents Dental and Oral Agents Dermatological Agents Enzyme Replacement/ Modifiers Gastrointestinal Agents Genitourinary Agents Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/Replacement/Modifying (Other) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Sex Hormones/Modifiers) Hormonal Agents, Suppressant (Thyroid) Immunological Agents Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Miscellaneous

126

5 11 11 12 14 23 26 26 29 31 33 33 34 34 35 40 41 42 43 44 47 48 48 52 54 62 65 65 68 69 72 74 75 75 76 82 83 83 84 84 84 85 87 88 89

MISCELLANEOUS THERAPEUTIC AGENTS Ophthalmic Agents Otic Agents Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Therapeutic Nutrients/ Minerals/ Electrolytes

88 89 92 92 98 98 99

127