C 075849

First Health Part D Premier (PDP)
2013 Formulary
(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER
IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document
to make sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1,
2014.
A Medicare approved Part D sponsor.
This document may be available for free in other alternative formats. Please call 1-866-865-0662
(TTY/TDD users only: 711 Telecommunications Relay Services), 24 hours a day, seven (7) days a
week, if you need plan information in another format.
This information is available for free in other languages. Please contact our customer service number
at: 1-866-865-0662, 24 hours a day, seven (7) days a week. (TTY/TDD users please call 711
Telecommunications Relay Services).
Este documento puede estar disponible de forma gratuita en formatos alternativos. Por favor llame al
1-866-865-0662 (Los usuarios de TTY / TDD solamente: 711 Servicios de Retransmisin de
Telecomunicaciones) 24 horas al da, 7 das a la semana si usted necesita informacin en otro
formato.
Esta informacin est disponible de forma gratuita en otros idiomas. Por favor, pngase en contacto
con nuestro nmero de servicio al cliente al 1-866-865-0662, 24 horas al da, 7 das a la semana.
TTY / TDD llame al 711 Servicios de Retransmisin de Telecomunicaciones.
Y0022_PDPCCP_2013_1085_1531_FINAL_PRE approved 07/2012

Formulary ID 13442, Ver. 5
Last Updated 08/15/2012
FOR-13-PRE
What is the First Health Part D Premier Formulary?
A formulary is a list of covered drugs selected by First Health Part D Premier in consultation with a team
of health care providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program. First Health Part D Premier will generally cover the drugs listed in our
formulary as long as the drug is medically necessary, the prescription is filled at a First Health Part D
Premier network pharmacy, and other plan rules are followed. For more information on how to fill your
prescriptions, please review your Evidence of Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a
new, less expensive generic drug becomes available or when new adverse information about the safety
or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from
our formulary, will not affect members who are currently taking the drug unless the drug is removed from
the market for safety concerns. It will remain available at the same cost-sharing for those members
taking it for the remainder of the coverage year. We feel it is important that you have continued access
for the remainder of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of
the change at least 60 days before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug
Administration (FDA) deems a drug on our formulary to be unsafe or the drugs manufacturer removes
the drug from the market, we will immediately remove the drug from our formulary and provide notice to
members who take the drug. The enclosed formulary is current as of 08/15/2012. To get updated
information about the drugs covered by First Health Part D Premier, please visit our Web site at:
First Health Part D Premier, www.FHDFormulary.coventry-medicare.com
or call Customer Service at:
First Health Part D Premier, 1-866-865-0662, 24 hours a day, 7 days a week. TTY/TDD users should call
711 Telecommunications Relay Services.
In the event of a (non-routine) mid-year formulary change such as moving a preferred formulary drug to a
non-preferred formulary tier, adding an additional requirement or limit to a drug, removing a dosage form,
or exchanging one drug for therapeutic alternative by adding or deleting a drug or changing a tier as a
result of a therapeutic alternative, we will notify you by providing you with a written notice of the (non
routine) formulary change. Please visit our website or refer to your monthly Explanation of Benefits
(EOB) for the (non-routine) formulary change. In addition, we will also update our online searchable
formulary.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page B-1. The drugs in this formulary are grouped into categories depending on
the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for,
look for the category name in the list that begins on page number B-1. Then look under the category
name for your drug.
A-2
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page Index-1. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
First Health Part D Premier covers both brand name drugs and generic drugs. A generic drug is
approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic
drugs cost less than brand name drugs.
What are compounded drugs?
Compounded drugs are composed of two or more ingredients and they require a prescription from a
physician. In addition, compounded drugs are prepared by a pharmacist who mixes the various
ingredients to customize the drug to meet your individual medical needs. Compounded drugs often have
the same active ingredients as generic prescription drugs and brand name drugs, but they are different in
(a) strength, (b) inactive ingredients such as preservatives, dyes, sugars and other inactive ingredients
found in regular prescription drugs, and (c) form.
The Plan only covers the compounds when one or more of the ingredients in the compounded drug are
recognized by Medicare to be Part D drug eligible products. The plan only covers up to a 30-day supply
at a time because compounded drugs do not have an extended expiration date as compared to
commercially manufactured medications. The member's cost share for a compounded drug is based on
a variety of factors. (1) During the initial coverage phase of the benefit, the member's cost share is
determined by the formulary tier placement of the highest tier of any of the individual ingredients in the
compound. (2) When in the coverage gap or catastrophic phase of the benefit, the member's cost share
is based off the benefit design and the individual drugs in the compound. (see the Annual Notice of
Changes/Evidence of Coverage for benefit details). Regardless of the benefit phase, drug restrictions on
the individual ingredients may apply (see below).
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
Prior Authorization: First Health Part D Premier requires you or your physician to get prior authorization
for certain drugs. This means that you will need to get approval from First Health Part D Premier before
you fill your prescriptions. If you dont get approval, First Health Part D Premier may not cover the drug.
Quantity Limits: For certain drugs, First Health Part D Premier limits the amount of the drug that First
Health Part D Premier will cover. For example, First Health Part D Premier has no more than 2 inhalers
per prescription for ProAir HFA per 30 days. In the formulary drug list you will see this displayed as
PROAIR HFA INHALER QL 2 inhalers 30DY.
Step Therapy: In some cases, First Health Part D Premier requires you to first try certain drugs to treat
your medical condition before we will cover another drug for that condition. For example, if Drug A and
Drug B both treat your medical condition, First Health Part D Premier may not cover Drug B unless you
try Drug A first. If Drug A does not work for you, First Health Part D Premier will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page B-1. You can also get more information about the restrictions applied to specific covered
drugs by visiting our web site at:
First Health Part D Premier, www.FHDFormulary.coventry-medicare.com.
A-3
You can ask First Health Part D Premier to make an exception to these restrictions or limits. See the
section, How do I request an exception to the First Health Part D Premiers formulary? on page A-5 for
information about how to request an exception.
Are all drugs on this formulary provided for a long term extended 90-day
supply?
First Health Part D Premier only provides a long term extended day supply (up to 90-days) for those
drugs listed in this formulary with an abbreviation of 90D in the Drug Notes column of the formulary. If
the drug you need does not have a 90D listed in the Drug Notes column of the formulary, First Health
Part D Premier will not provide coverage for an extended day supply. Drugs that do not have a 90D in
the Drug Notes column can be covered as follows:
Drugs will be covered only up to a 30 day supply per fill by default when there is no quantity limit noted.
Drugs that are typically limited to a 30 day supply include FDA controlled substances and high cost
agents.
Drugs with a quantity limit noted will be covered up to a 30 day supply per fill, unless otherwise noted in
the day supply of the quantity limit note. Drugs that are typically limited to less than a 30 day supply
include select medications used for pain and some antibiotics since typically these are only needed for a
short term use to treat the medical issue. An example of a drug that is limited to less than 30 days per
prescription is vancomycin (brand name Vancocin) 125mg tablets which has a quantity limit noted as 56
capsules per 14 days in the formulary drug list.
For more information on how to read this formulary, please see How To Read The Drug List on page
A-7.
What are over-the-counter (OTC) drugs?
OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug
Plan. However, First Health Part D Premier covers the OTCs listed in the chart below as part of Step
Therapy and when a prescription is written by your doctor or other prescriber. We provide a 30 day
supply for all members and a 31-day supply for members in long-term care. Your copayment is $0 for
these covered OTCs regardless of where you are in the various stages of your prescription drug benefit.
The cost of these covered OTC drugs will not count toward your total drug costs. All OTCs have quantity
limits.
Drug Name
Loratadine
Loratadine
Loratadine
Loratadine and Pseudoephedrine Sulfate
Loratadine and Pseudoephedrine Sulfate
Cetirizine
Cetirizine
Cetirizine
Cetirizine
Cetirizine
Cetirizine HCL and Pseudoephedrine
Hydrochloride
Type
Tablets
Dissolve Tablets
Syrup
12 Hour Tablets
24 Hour Tablets
Tablets
Tablets
Chewable Tablets
Chewable Tablets
Syrup
12 Hour Tablets
Strength
10mg
10mg
5mg/5 ml
5mg/120mg
10mg/240mg
5mg
10 mg
5mg
10 mg
1 mg/ml
5 mg/120 mg
A-4
What if my drug is not on the Formulary?
If your drug, drug strength or drugs dosage form (examples of dosage forms include but are not limited
to an extended release tablet, suspension, or an injection) is not included in this formulary, you should
first contact Customer Service and confirm that your drug, drug strength or dosage form is not covered.
There may be times when a single strength or dosage form is not posted on the formulary. If you have
coverage questions, please contact Customer Service.
If you learn that First Health Part D Premier does not cover your drug, you have two options:
You can ask Customer Service for a list of similar drugs that are covered by First Health Part D Premier.
When you receive the list, show it to your doctor or other prescriber and ask him or her to prescribe a
similar drug that is covered by First Health Part D Premier. If you prefer you can also take this printed
formulary document to your next doctor or other prescribers appointment to ask your doctor or other
prescriber if another drug on the formulary list could be used for your condition.
You can ask First Health Part D Premier to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to the First Health Part D Premiers

Formulary?
You can ask First Health Part D Premier to make an exception to our coverage rules. There are several
types of exceptions that you can ask us to make.
You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, First
Health Part D Premier limits the amount of the drug that we will cover. If your drug has a quantity limit,
you can ask us to waive the limit and cover more.
You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our NonPreferred Brand Drugs Tier, the highest tier subject to the tiering exceptions process, you can ask us to
cover it at the cost-sharing amount that applies to drugs in the Preferred Brand Tier, the lowest tier
subject to the tiering exceptions process instead. This would lower the amount you must pay for your
drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask
us to provide a higher level of coverage for the drug.
Generally, First Health Part D Premier will only approve your request for an exception if the alternative
drug is included on the plans formulary, the lower-tiered drug or additional utilization restrictions would
not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you are requesting a formulary, tiering or utilization restriction
exception you should submit a statement from your doctor or other prescriber supporting your
request. Generally, we must make our decision within 72 hours of getting your doctor or other
prescribers supporting statement. You can request an expedited (fast) exception if you or your doctor or
other prescriber believe that your health could be seriously harmed by waiting up to 72 hours for a
decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after
we get your doctor or other prescribers supporting statement.
A-5
What do I do before I can talk to my doctor about changing my drugs or

requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or,
you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you
may need a prior authorization from us before you can fill your prescription. You should talk to your
doctor or other prescriber to decide if you should switch to an appropriate drug that we cover or request a
formulary exception so that we will cover the drug you take. While you talk to your doctor or other
prescriber to determine the right course of action for you, we may cover your drug in certain cases during
the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have a prescription written for less than 30 days, in which
case, we will allow multiple fills to provide up to a total of 30 days of the drugs) when you go to a network
pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a
member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with a 91-day transition supply (unless you have a prescription written for fewer days). We
will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you
need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the
first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless
you have a prescription for fewer days) while you pursue a formulary exception.
For current members who are changing from one treatment setting to another, for example entering a
long-term care facility from a hospital or being discharged from a hospital to home, the member and
provider will need to utilize our exception and appeals process should the drugs not be on our formulary.
Members entering or being discharged from a long-term care facility will be allowed a one time
emergency supply of a 31-day supply for medications which the member has not already received a
transition supply. In addition, the dispensing pharmacist will be able to override early refill edits, where
appropriate, for members entering or being discharged from a long-term care facility where beneficiaries
are not allowed to take their previously filled medications with them to their new location.
For more information
For more detailed information about your First Health Part D Premier prescription drug coverage, please
review your Evidence of Coverage and other plan materials.
If you have questions about First Health Part D Premier, please call Customer Service at:
First Health Part D Premier, 1-866-865-0662, 24 hours a day, 7 days a week. TTY/TDD users should call
711 Telecommunications Relay Services.
Or visit First Health Part D Premier, www.FHDFormulary.coventry-medicare.com.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800
MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486
2048. Or, visit www.medicare.gov.
First Health Part D Premiers Formulary
The formulary that begins on page B-1 provides coverage information about some of the drugs covered
by First Health Part D Premier (the plan). If you have trouble finding your drug in the list, turn to the
Index that begins on page Index-1.
A-6
How to Read the Drug List
The formulary drug list that begins on page B-1 is set up like a table to make it easy to read. The column
headers look as follows:
Drug Name
Drug Notes
C
D
Plan Name and Plan Type

Tier
Plan Notes
A. The first column of the chart is the Drug Name. This column will list out the names of drugs. Brand
name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g.,
warfarin).
B. The second column is called Drug Notes. This column will list the requirements that apply to that
drug in all cases where the drug is covered on the plans formulary.
C. The remaining columns are specific to the plan you are enrolled in. The Plan Name and Type will
appear on top of the Tier and Plan Notes columns. Please refer to the cover of your Evidence of
Coverage or your Membership Identification Card for the name of your plan.
D. The Tier column defines the type of drug and the copayment and/or coinsurance level. Please refer
to Explanation of Cost-Sharing Tiers on page A-8 for an explanation of the cost-share tiers and the
levels of coverage. In addition, please refer to Chapter 4, What you pay for your Part D prescription
drugs" in your Evidence of Coverage for the exact amounts you pay for the drugs in each cost-sharing
tier.
E. The Plan Notes column defines the special requirements that apply to the drug on your plans
formulary where the note is listed. The requirements under Plan Notes are in addition to those listed
under Drug Notes.
DRUG NOTES
The following list contains an explanation of the abbreviations you will see in the Drug Notes column.
These are the special requirements that apply to the drug in all cases where the drug is covered on the
formulary.
Medicare Part B v. Medicare Part D | B v D
This drug requires a prior authorization to
determine if this drug may be covered under
Medicare Part B or Part D depending upon the
circumstances. Information may need to be
submitted describing the use of the drug, how the
drug is going to be purchased, and where the drug
will be administered to make the determination.
A-7
Quantity Limits | QL
The plan will only cover a certain amount of these
drugs for one copay/coinsurance or over a defined
number of days. For example, a drug that is
covered up to one tablet per day will be displayed
as 30 QY 30 DY which means a quantity of 30
tablets will be covered per 30 day supply. These
limits may be in place to ensure safe and efficient
use of a drug. If your doctor or other prescriber
prescribes more than this amount or thinks the limit
is not right for your situation, you or your doctor or
other prescriber can ask the plan to cover the
additional quantity.
High Risk Medications | HRM

The plan recognizes that there are certain
medications that are considered high risk
medications. These may be inappropriate in elderly
patients and could cause harmful side effects. We
encourage you to speak with your doctor or other
prescriber if you are prescribed one of these
medications to see if there may be other
alternatives available to you.
90-day Long-Term Supply | 90D

The plan provides a long-term (extended day)
supply up to 90 days of these drugs.
PLAN NOTES
The following list contains an explanation of the abbreviations you will see in the Plan Notes column.
These are the special requirements that apply to the drug on your plans formulary where the note is
listed.
Prior Authorization | PA
Non-Formulary | NF
You or your doctor or other prescriber must provide
This drug is a non-formulary drug. The plan
additional information to the plan before the plan will
does not include this drug on its formulary.
cover this drug. The plan uses this information to help
You or your doctor or other prescriber may
ensure the drug is covered appropriately for Medicarerequest an exception. Your doctor or other
eligible health conditions. In some cases you may be
prescriber will need to provide a supporting
asked to try another drug on the formulary before the
statement for an exception.
plan covers the drug you are requesting. If you do not
get approval, your drug may not be covered by the plan,
and you would be responsible for the full cost.
Step Therapy | ST
There are effective, clinically proven lower-cost alternatives to this drug that treat the same health
condition. The plan may require that you try an alternative drug for your health condition before the plan
will cover the drug you are requesting. If you have already tried other drugs or your doctor or other
prescriber thinks other drugs are not right for your situation, you or your doctor or other prescriber can
ask the plan to cover these drugs by request, as an exception through the process described on
page A-3 .
Explanation of Cost-Sharing Tiers
Every drug on the formulary is in one of 3 cost-sharing tiers. When you review the drug list that appears
on page B-1, the column called Tier will show whether the drug is on Tier 1, 2 or 3. In general, the
higher the cost-sharing tier, the higher your cost for the drug. Here is how the plan defines its cost-sha
ring tiers:
Three (3) Tier Plans - First Health Part D Premier

Tier 1 Preferred Generic Drugs
Preferred Generic drugs offer the lowest out-of-pocket cost to you. You and your doctor or other
prescriber should decide if Tier 1 medications are right for your treatment.
Tier 2 - Preferred Brand Drugs
Preferred Brand drugs are offered at a lower cost-share than Non-Preferred Brand and Non-Preferred
Generic drugs. You might consider having your doctor or other prescriber review the formulary list of Tier
2 drugs as an alternative to the Non-Preferred Brand drugs on Tier 3.
Tier 3 - Non-Preferred Brand Drugs
The drugs on this tier include the plans Non-Preferred Brand and Non-Preferred Generic drugs. The
cost of these drugs are usually higher than Tier 1 and Tier 2 drugs. By discussing your prescription
A-8
needs with your doctor or other prescriber and sharing a copy of this formulary, you and your doctor or
other prescriber may find equally effective alternatives and lower-cost brands on Tier 2 and lower cost
generics on Tier 1. If you, along with your doctor or other prescriber request a formulary exception for a
non-formulary drug (a drug that is not on our drug list) and your request is approved, the non-formulary
drug will be treated as a Tier 3 drug and you will be responsible for paying the cost of the non-formulary
drug as if it were on Tier 3.
Where Can I Find the Actual Costs Associated With The Cost-Share Tiers?
Please refer to Chapter 4, What you pay for your Part D prescription drugs" in your Evidence of
Coverage for the exact amounts you pay for the drugs in each cost-sharing tier.
If you are in a program that helps pay for your drugs, we mail an insert, called the Evidence of Coverage
Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider), that tells you about your
drug coverage. This Rider also lists the amount you pay for drugs in each cost-sharing tier. You can also
contact Customer Service at the telephone numbers on the cover of this formulary to find out what your
costs are in this situation.
Network Pharmacies
We have over 65,000 pharmacies in our network across the United States and the District of Columbia.
That means you can have your covered prescription drugs filled at any network pharmacy in the area
even if you are traveling for business or leisure. A listing of all our network pharmacies is provided in our
Pharmacy Directory and on our website at http://PharmacyLocator.coventry-medicare.com.
Limited Distribution of Some Drugs
Some drugs may be subject to limited distribution or restricted access. This means that a drug may only
be available at certain pharmacies. These pharmacies dispense drugs that are restricted by the FDA to
certain locations or that require special handling, provider coordination, or education on their use. (Note:
This scenario should happen rarely.)
If you are having difficulty finding a network pharmacy to fill a medication that is limited to select
pharmacies by the FDA, please contact Customer Service at the telephone numbers provided on the
cover of this formulary.
Drugs Packaged to Provide an Extended Day Supply
Some drugs are packaged by the manufacturer to provide greater than a 30-day supply, such as
medroxyprogesterone acetate injection. In these cases you may be responsible for paying multiple
copayments for a single prescription when filling a packaged drug that would normally provide greater
than a 30-day supply. For more information please call the toll-free Customer Service number located on
the cover.
Early Refills
We have guidelines regarding refilling your prescription too early. These guidelines are designed for your
safety and to minimize the excessive use, waste and stockpiling of prescription medications. In general,
the plan does not cover early refills. If you try to fill a prescription several days (for example more than 7
days early following a 30 day fill) too early your refill can be delayed because of your drug supply on
hand. If you have filled a routine prescription a few days early each month you can accumulate an extra
supply of your prescription. We track the prescriptions you fill routinely over a 6 month timeframe to
determine if an excessive amount of the prescription is being accumulated. If accumulation occurs your
prescription refill can be delayed. We delay the refill because we are concerned both with members
unable to fill their medication but also in situations where the member has an excessive amount of their
drug on hand based on how the physician wrote the prescription.
A-9
To avoid having a refill delayed, you may want to use these guidelines. Please note these are simply
guidelines.
For a 30-day retail prescription, order a refill when you have no more than a seven (7)-day supply left.
(For a 30-day mail order prescription, you may order the refill a few days earlier, to ensure you receive
the refill before the medication on hand is used.)
For a 90-day retail or mail order prescription, request the refill when you have no more than a 14-day
supply remaining.
The determination of whether your prescription is filled too early is based on a number of factors such as:
The original prescription from your doctor or other prescriber, including his/her instructions for dosage;
Refills you have purchased of the same prescription drug previously; and
How much of the prescription drug you still should have on-hand based on your previous refills and your
doctor or other prescribers instructions on dosage.
If you order a refill at a network pharmacy too soon, you will be asked to wait until the allowable refill
date. If you order the refill through our mail order service too soon, the mail-order service may hold the
refill until the allowable date.
If you are told that it is too soon to fill your prescription but are out of medication (or almost out of
medication) because of a change in how your doctor or other prescriber told you to take the drug, you will
need to have your doctor or other prescriber provide a new prescription with the new directions to your
pharmacy.
What do I do if I need to get my prescription filled before I have used most of

the supply I have at home because I am going on a trip?
If you are in need of filling a prescription early due to domestic travel, remember that this plan has
network pharmacies in every state for your convenience. You can transfer your prescription, in
compliance with state laws, to a network pharmacy when travelling domestically or you can present your
prescription insurance card and a new prescription to the new pharmacy when you are due for your next
fill. When planning for either domestic or international travel please make sure you take advantage of
extended day supply options for drugs eligible for 90 day fills; this may provide you a supply of your
drugs to last for your entire trip. However, if you are traveling to an international destination for an
extended period of time and have exhausted other options including 90 day fills, please have your
pharmacy contact our Customer Service for assistance. Please see page A-1 of this formulary on how to
contact Customer Service.
Vaccines
Your prescription drug benefit covers vaccines for meningitis, shingles, diphtheria, tetanus and more.
Some vaccines, like those for the flu and pneumonia, are covered by Medicare Part B. The cost for
vaccines depends on where you have it administered.
For the best coverage, we recommend that you get vaccines at a network pharmacy, if your state allows
it. The administration fee (the service cost that the healthcare professional charges for giving the
vaccine) will likely be lower, so it could save you money. Please refer to your Evidence of Coverage for
description on other coverage methods for vaccines and information on how these vaccines are paid for.
If you dont see the vaccine you need listed in the drug list, call Customer Service at the telephone
numbers provided on page A-1 of this formulary. They can see if the vaccine is covered and send you a
reimbursement form if you need one.
A-10
Mail Order
We are pleased to offer Mail-Order services to all of our members. Our mail-order service, in general, is
designed for those medications that members may take on an ongoing basis. It is a great way to
purchase and receive your medications. You can obtain up to a 90-day supply of those drugs identified
on the formulary drug list with a 90D through mail order.
Please note that the actual quantity and/or days' supply may vary for each prescription. Your doctor or
other prescriber's instructions on how to take the medication, state and federal dispensing guidelines, or
how the medication is packaged may impact the quantity and/or days' supply you can receive. When
switching from your local pharmacy to mail order, please make sure you have an adequate supply of
your prescriptions on hand prior to sending your next fill request to the mail order pharmacy.
What is the timeframe for Mail-Order?
First-time orders will usually be delivered within 8 to 11 days after your order is received.
Refills usually arrive in less time. Refills ordered online are usually delivered within 5 to 8 days after your
order is received.
New and renewal prescriptions faxed from your doctor or other prescriber will usually be delivered in 5 to
8 days.
How are medications shipped?

Most medications are shipped via the U.S. Postal Service at no cost to you. Medications containing
certain controlled substances are shipped United Parcel Service (UPS). If necessary, you can request
express shipping for an additional fee.
What if I need to speak with a pharmacist?
Our registered pharmacists are available 24 hours a day, seven days a week to answer any questions
about your medications. Please call Customer Service at the telephone numbers listed on page A-1 of
this formulary.
How much do I pay for mail order?
The amount you pay for covered drugs through our mail order service may be lower than if you purchase
them at a network pharmacy. Please refer to Chapter 4, What you pay for your Part D prescription
drugs" in your Evidence of Coverage for your cost-shares for drugs purchased through Mail Order.
Cancelling your order
Should you wish to cancel your order, you must call Customer Service immediately at the toll-free
numbers shown on the back of your Member ID card. You can only cancel an order before your
medication is dispensed. If you do not call and request to cancel your order, your medication will be
shipped to you and you will be charged the applicable co-payment/coinsurance. Please also note that
medications properly dispensed and shipped cannot be returned to the mail-order pharmacy for a refund
or credit, unless the shipment was due to our error. This policy is based in part on federal and state laws
regarding the proper dispensing of prescription medications.
For additional information about our mail order cancellation policy, please contact Customer Service at
the telephone number on the back of your member ID card.
Can I return my medication for a refund or credit?
Medications properly dispensed and shipped cannot be returned for a refund or credit unless the
shipment was due to our error. This policy is based in part on federal and state laws regarding the proper
dispensing of prescription medications. Exceptions are granted when the plan has made an error. In
those cases, we may request that you return the medication to us (we will pay for the shipping), so we
can properly dispose of the medication and refund or credit you for the charge that you have incurred.
A-11
What should I do with my expired or unused medication?

Please contact Customer Service for general instructions on how to dispose of your expired or unused
medication.
Working with your doctor or other prescriber
If we receive a prescription directly from your doctor or other prescriber, we will work with your doctor or
other prescriber to fill your prescription. In some cases, we may contact your doctor or other prescriber if
we have questions about your prescription before it is filled and shipped to you. To ensure that you are
properly informed of any changes to your prescription that your doctor or other prescriber may make, we
ask that you contact your doctor or other prescriber before your prescription is filled and shipped to you
to learn if there were any changes to your prescription that you may not agree with. If your medication
has been shipped, we will not be able to accept it if you return it to us. We cannot accept the return of
properly dispensed prescription medications for credit or refund.
Generic Substitution
If your doctor or other prescriber writes a prescription for a brand drug, we may substitute it for a generic
drug where appropriate and in compliance with state law. For example, if your doctor or other prescriber
writes a prescription for a brand drug (and a generic equivalent is available) but did not indicate
"dispense as written," or "brand only," we may dispense the generic equivalent drug instead, if permitted
to do so. Please also refer to Chapter 3, Using the plan's coverage for your Part D prescription drugs,"
Section 4.2, "What kinds of restrictions?" in your Evidence of Coverage for additional information.
Payment Options Available
You can pay by credit card, personal check, electronic funds transfer, or money order. Please do not
send cash. If you would like to pay by credit card, there are two methods of setting up your account
using a credit card:
One Time Use If your order is over $100.00 and you did not include your payment with your order, the
Mail Order pharmacy will contact you by telephone and request your payment before your order is
shipped. If you choose to use a credit card, the credit card will be used for this payment only, unless you
have given us permission to bill future orders to your credit card.
Auto Bill Under this option, all medication orders under $350.00 will be automatically charged to your
credit card before they are shipped to you if you are set up for automatic refills. The Mail Order pharmacy
will contact you and request your approval for orders over $350.00. Please note that shipment will be
delayed until the Mail Order service has received your approval for the payment of your order.
Handling of mail order claims that are close to the end of the benefit year
Unless you have notified us otherwise, mail order requests received towards the end of the benefit year
will be processed for the current benefit year and your TrOOP and drug spend amounts will be applied to
your current benefit year. If you would like us to process your request for the upcoming benefit year,
instead of the current benefit year, you must notify us in writing of your request and we will place your
prescription on hold for a future date not greater than 90 days from the date of your request.
My Online Services
My Online Services is a secure web-based tool with features that allow you to view, track and store
personal health information. Through My Online Services, you may find a pharmacy near you, track your
current medications and prescription history, track your claims and authorizations, access your health
benefit information, research clinical and health-related information, request an ID card, update your
address and more.
A-12
To register for My Online Services, you must be an enrolled member and the registration process is
easy. Go to www.FirstHealthPartD.com and click on My Online Services located at the top of the screen.
You will need your member ID number (found on the back of your card), your zip code, your date of birth
and your e-mail address.
A-13
Are you wondering why our network

pharmacies automatically give you the generic
version of a brand drug?
Here is the answer!

The Food and Drug Administration (FDA) makes sure that all generic drugs are safe and effective.
Every generic drug is put through a rigorous, multi-step approval process by the FDA. From quality
and performance to manufacturing and labeling, everything must meet FDAs high standards. The
FDA makes it tough to become a generic drug in America, so you can rest assured that generics are
safe, effective and a lower cost option to brand name drugs.
If you are currently taking brand name drugs, talk to your doctor or other prescriber to see if there are
generic equivalents available for you. Not only will you find they are safe and just as effective as brand
drugs, but your cost-shares will be much lower.
Visit www.fda.gov/cder or call 1-888-INFO-FDA (463-6332) to learn more.
A-14
Drug Name
Analgesics
Nonsteroidal Anti-inflammatory Drugs
FLECTOR 1.3% PATCH QL-60 PATCH 30 DY
oxycodone/ibuprofen 5mg/400mg tab QL-28 QY 7 DY
Opioid Analgesics, Long-acting
EXALGO 12MG TAB QL-150 QY 30 DY
fentanyl 100mcg/hr patch QL-15 PATCHES 30 DY
fentanyl 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr patch
QL-10 PATCHES 30 DY
KADIAN 10MG, 20MG, 30MG, 50MG, 60MG, 80MG,
100MG, 200MG CAP,24HR QL-60 QY 30 DY
methadone 10mg/ml conc oral
METHADONE 10MG/ML VIAL
methadone 5mg & 10mg tab QL-240 QY 30 DY
METHADONE 5MG/5ML, 10MG/5ML ORAL SOLN
methadose 10mg tab QL-240 QY 30 DY
morphine sulfate 20mg, 30mg, 50mg, 60mg, 80mg,
100mg cap, 24hr QL-60 QY 30 DY
morphine sulfate er 15mg, 30mg, 60mg, 100mg, 200mg
tab QL-120 QY 30 DY
OPANA ER 40MG TAB QL-60 QY 30 DY
OPANA ER 5MG, 10MG, 20MG, 30MG TAB QL-60 QY
30 DY
oxymorphone hcl er 7.5mg, 15mg QL-60 QY 30 DY
Opioid Analgesics, Short-acting
apap/caffeine/dihydrocodeine 32mg/713mg/60mg tab
QL-150 QY 30 DY
apap/codeine 120-12mg/5ml elixir QL-4950ML 30 DY
apap/codeine 300mg/15mg; 300mg/30mg; 300mg/60mg
tab QL-390 QY 30 DY
butalbital/apap/caffeine/codeine
50mg/325mg/40mg/30mg cap QL-180 QY 30 DY
butorphanol tart 10mg/ml aero
CAPITAL/CODEINE 120MG-12MG/5ML SUSP QL4950ML 30 DY
codeine sulfate 15mg, 30mg, 60mg tab
duramorph 0.5mg/ml; 1mg/ml ampul
endocet 325mg/5mg tab QL-360 QY 30 DY
endocet 325mg/7.5mg & 325mg/10mg tab QL-360 QY
30 DY
endocet 500mg/7.5mg tab QL-240 QY 30 DY
endocet 650mg/10mg tab QL-180 QY 30 DY
endodan 325mg/4.835mg tab QL-360 QY 30 DY
B-1
Drug
Notes

Tier
Plan Notes
90D; QL
QL
3
3
QL
QL
QL
QL
2
2
2
3
QL
QL
QL
QL
1
2
1
2
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
3
3
QL
QL
3
1
1
QL
QL
QL
QL
3
3
3
Drug Name
fentanyl cit 200mcg, 400mcg, 600mcg, 800mcg,
1200mcg, 1600mcg oral buccal lpop QL-120 QY 30 DY
hydrocodone bit/apap 10mg/750mg tab QL-150 QY 30
DY
hydrocodone/apap 5mg/325mg; 7.5mg/325mg;
10mg/325mg tab QL-360 QY 30 DY
hydrocodone/apap 5mg/500mg; 7.5mg/500mg;
hydrocodone/apap 7.5mg-500mg/15ml soln oral QL3600ML 30 DY
hydrocodone/apap 7.5mg/650mg; 10mg/650mg;
hydrocodone/apap 7.5mg/750mg tab QL-150 QY 30 DY
hydrocodone/apap-hs 2.5mg/500mg tab QL-240 QY 30
DY
hydrocodone/ibuprofen 7.5mg/200mg tab
hydromorphone 1mg/ml, 2mg/ml syringe
hydromorphone 1mg/ml, 4mg/ml, 10mg/ml ampule
hydromorphone 2mg, 4mg, 8mg tab
levorphanol tartrate 2mg tab
morphine sulfate 0.5mg/ml; 1mg/ml; 5mg/ml vial
morphine sulfate 10mg/5ml; 20mg/5ml; 100mg/5ml soln
oral
morphine sulfate 15mg & 30mg tab QL-240 QY 30 DY
morphine sulfate 5mg, 10mg, 20mg, 30mg supp rectal
nalbuphine 10mg/ml; 20mg/ml vial
oxycodone 10mg, 20mg, 30mg tab QL-180 QY 30 DY
oxycodone 20mg/ml conc oral
oxycodone 5mg & 15mg tab QL-360 QY 30 DY
oxycodone/apap 10mg/650mg tab QL-180 QY 30 DY
oxycodone/apap 2.5mg/325mg; 7.5mg/325mg;
oxycodone/apap 5mg/325mg tab QL-360 QY 30 DY
oxycodone/apap 5mg/500mg cap QL-240 QY 30 DY
oxycodone/apap 7.5mg/500mg tab QL-240 QY 30 DY
oxycodone/aspirin 4.5mg/325mg; 4.835mg/325mg tab
QL-360 QY 30 DY
roxicet 325;5mg tab QL-360 QY 30 DY
roxicet 325mg/5ml;5mg/5ml oral soln QL-1800 QY 30
DY
stagesic 5mg/500mg cap QL-240 QY 30 DY
tramadol 50mg tab
tramadol/apap 37.5mg/325mg tab QL-240 QY 30 DY
Anesthetics
Local Anesthetics
lidocaine 2% jelly
Drug
Notes

Tier
Plan Notes
QL
QL
QL
QL
QL
QL
QL
QL
PA
3
1
1
1
3
1
1
QL
QL
QL
1
1
3
1
1
1
3
QL
QL
QL
QL
1
1
3
QL
QL
QL
QL
90D
90D; QL
1
1
3
QL
B-2
Drug Name
lidocaine 20mg/ml viscous soln
lidocaine 40mg/ml soln
lidocaine 5% oint
lidocaine 5mg/ml, 10mg/ml vial
lidocaine/prilocaine 2.5%/2.5% cream
LIDODERM 5% PATCH QL-90 PATCHES 30 DY
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
CAMPRAL 333MG TAB QL-180 QY 30 DY
depade 50mg tab
disulfiram 250mg, 500mg tab
naltrexone 50mg tab
Opioid Antagonists
naloxone 0.4mg/ml; 1mg/ml syringe
SUBOXONE 2MG/0.5MG, 8MG/2MG FILM, SUBL QL90 QY 30 DY
Smoking Cessation Agents
buproban 150mg tab
CHANTIX 0.5MG(11)-1MG(42) DOSE PACK QL-53 QY
30 DY
CHANTIX 0.5MG, 1MG TAB QL-60 QY 30 DY
NICOTROL NS 10MG/ML SPRAY QL-4 BOTTLES 30
DY
Anti-inflammatory Agents
Nonsteroidal Anti-inflammatory Drugs
CELEBREX 100MG CAP QL-30 QY 30 DY
CELEBREX 50MG, 200MG, 400MG CAP QL-60 QY 30
DY
diclofenac 75mg tab
diclofenac ec 25mg, 50mg tab
diclofenac potassium 50mg tab
diclofenac xr 100mg tab
diflunisal 500mg tab
etodolac 200mg, 300mg cap
etodolac 400mg, 500mg tab
etodolac er 400mg, 500mg, 600mg tab
fenoprofen calcium 600mg tab
flurbiprofen 50mg, 100mg tab
ibuprofen 400mg, 600mg, 800mg tab
INDOCIN 25MG/5ML SUSPENSION
indomethacin 25mg, 50mg cap
indomethacin er 75mg cap
ketoprofen 50mg, 75mg cap
B-3
Drug
Notes
90D
90D; QL
QL
90D

Tier
Plan Notes
1
1
1
1
1
2
3
1
1
1
1
QL
PA
90D
QL
PA
QL
PA
QL
90D; QL
ST
90D; QL
ST
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
1
1
1
3
3
1
1
3
1
1
1
3
1
3
1
Drug Name
ketoprofen er 200mg cap
ketorolac trometh 15mg/ml vial QL-20 VIALS 5 DY
meclofenamate 50mg, 100mg cap
meloxicam 7.5mg, 15mg tab
meloxicam 7.5mg/5ml suspension
nabumetone 500mg, 750mg tab
NALFON 200MG, 400MG CAP
naproxen 125mg/5ml oral suspension
naproxen 275mg, 550mg tab
naproxen dr 375mg, 500mg tabec
naproxen tab 250mg, 375mg, 500mg tab
oxaprozin 600mg tab
piroxicam 10mg & 20mg caps
sulindac 150mg, 200mg tabs
tolmetin 200mg, 600mg tabs
tolmetin 400mg cap
Antibacterials
Aminoglycosides
amikacin sulfate 100mg/2ml, 500mg/2ml vial
gentamicin sulfate 40mg/ml vial
gentamicin sulfate 80mg/8ml vial
gentamicin/0.9% sod chl iv
isotonic gentamicin 60mg/100ml; 80mg/100ml iv
neomycin sulfate 500mg tab
paromomycin sulfate 250mg cap
tobramycin sulfate 10mg/ml, 80mg/2ml vial
TOBRAMYCIN/SODIUM CHLORIDE 60MG/50ML,
80MG/100ML IV
Antibacterials, Other
alcohol preps pads
baciim 50000 unit vial
chloramphenicol succ 1g vial
CLEOCIN 75MG CAP
clindamycin 150mg, 300mg cap
clindamycin 75mg/5ml pediatric granules
clindamycin phos 600mg/4ml vial
colistimethate 150mg vial
CUBICIN 500MG VIAL
methenamine hippurate 1g tab
metronidazole 250mg, 500mg tab
metronidazole 375mg cap
metronidazole 500mg/0.1l iv
Drug
Notes
90D
QL
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D

Tier
Plan Notes
3
1
1
1
1
1
3
1
1
1
1
1
1
1
3
3
3
1
1
1
1
1
1
3
3
90D
BvD
BvD
90D
1
3
1
1
1
3
1
3
3
3
1
1
1
PA
PA
B-4
Drug Name
Drug
Notes
MONUROL 3G PACKET
nitrofurantoin 25mg/5ml suspension
nitrofurantoin macrocrystalline 50mg cap
nitrofurantoin monohydrate 100mg cap
PRIMSOL 50MG/5ML SOLN ORAL
trimethoprim 100mg tab
TYGACIL 50MG VIAL
vancomycin 125mg cap QL-56 QY 14 DY
vancomycin 1GM, 10GM vial
vancomycin 250mg cap QL-40 QY 10 DY
vancomycin dextrose 500mg iv
VANCOMYCIN DEXTROSE 750MG/0.15L IV
ZYVOX 100MG/5ML ORAL SUSR QL-900ML 14 DY
ZYVOX 600MG TAB QL-28 QY 14 DY
ZYVOX 600MG/300ML IV
Beta-lactam, Cephalosporins
CEDAX 400MG CAP
CEDAX 90MG/5ML SUSPENSION
cefaclor 250mg, 500mg cap
cefaclor er 500mg tab
cefadroxil 1g tab
cefadroxil 250mg/5ml, 500mg/5ml suspension
cefadroxil 500mg cap
cefazolin 1g/50ml iv
cefazolin 500mg, 1g, 10g vial
cefdinir 125mg/5ml, 250mg/5ml suspension
cefdinir 300mg cap
cefditoren pivoxil 200mg, 400mg tab
cefepime 1g, 2g vial
CEFEPIME 1G/50ML, 2G/100ML IV
cefotaxime 500mg, 1g, 2g, 10g vial
CEFOTETAN 1G, 2G, 10G VIAL
CEFOTETAN/DEXTROSE 1G/50ML, 2G/50ML IV
cefoxitin 1g, 2g, 10g vial
CEFOXITIN 1G/50ML, 2G/50ML IV
cefpodoxime proxetil 100mg, 200mg tab
cefpodoxime proxetil 50mg/5ml, 100mg/5ml suspension
cefprozil 125mg/5ml, 250mg/5ml suspension
cefprozil 250mg, 500mg tab
cefprozil 250mg, 500mg tab
B-5
90D;
HRM
90D;
HRM
90D;
HRM
90D
QL
BvD
QL
BvD
BvD
QL
QL

Tier
Plan Notes
3
3
PA
PA
PA
3
1
3
3
1
3
1
1
3
3
3
PA
PA
PA
PA
PA
PA
PA
PA
PA
3
3
1
1
1
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Drug Name
ceftazidime 500mg, 1g, 2g, 6g vial
CEFTAZIDIME/DEXTROSE 1G/50ML-5%; 2G/50ML-5%
IV
ceftriaxone 250mg, 500mg, 10g vial
ceftriaxone/dextrose 1g, 2g iv
cefuroxime 750mg, 1.5g vial
cefuroxime 750mg, 1.5g, 7.5g vial
cefuroxime axetil 125mg/5ml suspension
cefuroxime axetil 250mg, 500mg tab
CEFUROXIME/DEXTROSE 750MG/50ML, 1.5G/50ML
IV
cephalexin 125mg/5ml, 250mg/5ml suspension
cephalexin 250mg, 500mg cap
cephalexin 250mg, 500mg tab
SUPRAX 100MG/5ML & 200MG/5ML SUSPENSION
SUPRAX 400MG TAB
TEFLARO 400MG, 600MG VIAL
Beta-lactam, Other
aztreonam 1g, 2g vial
imipenem/cilastatin 250mg/250mg; 500mg/500mg iv vial
INVANZ 1G VIAL
meropenem 500mg vial
Beta-lactam, Penicillins
amoxicillin 125mg, 200mg, 250mg chew
amoxicillin 125mg/5ml; 200mg/5ml; 250mg/5ml;
400mg/5ml suspension
amoxicillin 250mg, 500mg cap
amoxicillin 500mg, 875mg tab
amoxicillin/clav pota 1000mg/62.5mg er tab
amoxicillin/clav pota 200mg/28.5mg/5ml;
250mg/62.5mg/5ml; 400mg/57mg/5ml;
600mg/42.9mg/5ml susp
amoxicillin/clav pota 200mg/28.5mg; 400mg/57mg chew
amoxicillin/clav pota 250mg/125mg; 500mg/125mg;
875mg/125mg tab
ampicillin 125mg, 1g, 10g vial
ampicillin 125mg/5ml; 250mg/5ml suspension
ampicillin 250mg, 500mg cap
ampicillin-sulbactam 1.5g, 3g, 15g vial
dicloxacillin 250mg, 500mg cap
MOXATAG 775MG TAB QL-10 QY 10 DY
nafcillin 1g, 10g vial
OXACILLIN 1G, 2G IV
OXACILLIN 1G, 2G, 10G VIAL
Drug
Notes

Tier
Plan Notes
3
3
3
3
3
3
1
1
3
1
1
1
3
3
3
1
3
3
3
1
1
1
1
3
3
3
3
QL
1
1
1
3
1
3
3
3
3
B-6
Drug Name
penicillin g 5mm unit vial
penicillin g potassium 5mm unit, 20mm unit vial
PENICILLIN G PROCAINE 1.2MM UNIT SYRINGE
penicillin v potassium 125mg/5ml; 250mg/5ml
suspension
penicillin v potassium 250mg, 500mg tab
pfizerpen-g 20 mm unit vial
piperacillin/tazobactam 2gm/0.25gm, 2gm/0.375gm,
4gm/0.5gm vials
TIMENTIN 3.1GM, 31GM VIALS
TIMENTIN 3.1GM/0.1L IV
Macrolides
azithromycin 100mg/5ml, 200mg/5ml suspension
azithromycin 250mg, 500mg, 600mg tab
azithromycin 500mg vial
clarithromycin 125mg/5ml, 250mg/5ml suspension
clarithromycin 250mg, 500mg tab
clarithromycin er 500mg tab QL-28 QY 14 DY
E.E.S. 200MG/5MLGRANULES
e.e.s. 400 400mg tab
ery-tab 250mg, 333mg tab
ery-tab 500mg tbec
ERYPED 200MG/5ML; 400MG/5ML SUSPENSION
ERYTHROCIN LACTOBIONATE 500MG VIAL
erythrocin stearate 250mg tab
erythromycin base 250mg, 500mg tab
erythromycin ethylsuccinate 400mg tab
erythromycin/sulfisoxazole 200mg-600mg/5ml
suspension
KETEK 300MG, 400MG TAB QL-20 QY 10 DY
PCE 333MG, 500MG TAB
Quinolones
AVELOX 400MG ABC PACK QL-30 QY 30 DY
AVELOX 400MG TAB QL-30 QY 30 DY
AVELOX 400MG/.25ML IV
CIPRO 250MG/5ML, 500MG/5ML SUSPENSION
ciprofloxacin 100mg, 250mg, 500mg, 750mg tab
ciprofloxacin 400mg/40ml vial
ciprofloxacin er 1000mg tab QL-14 QY 30 DY
ciprofloxacin er 500mg tab QL-28 QY 30 DY
levofloxacin 250mg, 500mg, 750mg tab QL-30 QY 30
DY
ofloxacin 200mg, 300mg, 400mg tab
B-7
Drug
Notes

Tier
Plan Notes
3
3
3
1
1
3
3
3
3
QL
1
1
1
1
1
1
2
1
2
2
2
3
1
1
1
1
QL
3
2
QL
QL
QL
QL
3
3
3
3
1
1
1
1
QL
1
1
Drug Name
Sulfonamides
sulfadiazine 500mg tab
sulfamethoxazole/trimethoprim 200mg-40mg/5ml
suspension
sulfamethoxazole/trimethoprim 400mg/80mg tab
sulfamethoxazole/trimethoprim 800mg-16mg/ml vial
sulfamethoxazole/trimethoprim ds 800mg/160mg tab
Tetracyclines
demeclocycline 150mg, 300mg tab
doxycycline hyclate 100mg tab
doxycycline hyclate 100mg vial
doxycycline hyclate 50mg, 100mg cap
doxycycline monohydrate 150mg cap
doxycycline monohydrate 50mg, 75mg tab
minocycline 50mg, 75mg, 100mg cap
tetracycline 250mg, 500mg caps
VIBRAMYCIN 50MG/5ML SYRUP
Anticonvulsants
Anticonvulsants, Other
levetiracetam 100mg/ml soln oral
levetiracetam 250mg, 500mg tab QL-180 QY 30 DY
levetiracetam 500mg/5ml vial
levetiracetam 750mg, 1000mg tab
phenobarbial elixir 10mg/5ml
phenobarbital 97.2mg & 100mg tabs QL-60 QY 30 DY
phenobarbital tab 15mg, 16.2mg, 32.4mg, 50mg,
64.8mg QL-120 QY 30 DY
phenobarbital tab 30mg QL-180 QY 30 DY
POTIGA 50MG, 200MG, 300MG, 400MG TABS QL-90
QY 30 DY
Calcium Channel Modifying Agents
CELONTIN 300MG CAP
ethosuximide 250mg cap
ethosuximide 250mg/5ml syrup
LYRICA 225MG, 300MG CAP QL-60 QY 30 DY
LYRICA 25MG, 50MG, 75MG, 100MG, 150MG, 200MG
CAP QL-90 QY 30 DY
zonisamide 25mg, 50mg, 100mg cap
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clonazepam 0.5mg & 1mg tab QL-150 QY 30 DY
clonazepam 2mg tab QL-300 QY 30 DY
clonazepam odt 0.125mg, 0.25mg, 0.5mg, 1mg tabs QL150 QY 30 DY
Drug
Notes

Tier
Plan Notes
90D
90D
90D
1
1
1
90D
3
1
1
1
3
3
1
1
3
90D
90D; QL
1
1
1
1
1
PA
PA
PA
PA
90D; QL
PA
90D
90D
90D
QL
3
1
1
3
PA
QL
PA
90D
QL
QL
1
1
QL
90D
HRM
HRM;
QL
HRM;
QL
HRM;
QL
B-8
Drug Name
clonazepam odt 2mg tab QL-300 QY 30 DY
clorazepate dipotassium 3.75mg, 7.5mg, 15mg, tabs QL180 QY 30 DY
diazepam 1mg/ml soln QL-1200ML QY 30 DY
diazepam 2mg, 5mg, 10mg tab QL-120 QY 30 DY
diazepm 2.5mg, 10mg, 20mg gel
divalproex 125mg sprink cap
divalproex 125mg, 250mg, 500mg tabec
divalproex er 250mg, 500mg tab24
gabapentin 100mg, 300mg, 400mg cap
gabapentin 250mg/5ml soln oral
gabapentin 600mg, 800mg tab
GABITRIL 12MG TAB QL-120 QY 30 DY
ONFI 5MG, 10MG, 20MG QL-60 QY 30 DY
primidone 50mg & 250mg tabs
SABRIL 500MG PACKET
SABRIL 500MG TAB
valproate 500mg/5ml vial
valproic acid 250mg cap
valproic acid 250mg/5ml syrup
Glutamate Reducing Agents
felbamate 400mg, 600mg tab
felbamate 600mg/5ml susp
lamotrigine 100mg tab QL-90 QY 30 DY
lamotrigine 25mg, 150mg, 200mg tab
lamotrigine 5mg, 25mg chew tab
topiramate 15mg, 25mg cap, sprinkle
topiramate 25mg, 200mg tabs
topiramate 50mg, 100mg tabs QL-90 QY 30 DY
Sodium Channel Agents
BANZEL 200MG, 400MG TAB QL-240 QY 30 DY
BANZEL 40 MG/ML SUSP QL-2400ML 30 DY
carbamazepine 100mg chew
carbamazepine 200mg tab
carbamazepine 200mg/10ml suspension
carbamazepine er 100mg, 200mg, 300mg cp12
carbamazepine er 200mg, 400mg tab
CARBATROL 100MG, 200MG, 300MG CAP
B-9
Drug
Notes
QL
QL
HRM;
QL
HRM;
QL
HRM
90D
90D
90D
90D
90D
90D
90D; QL
90D; QL
90D; QL
90D; QL
QL
90D

Tier
Plan Notes
3
1
1
PA
PA
PA
90D
90D
3
1
1
1
1
1
1
3
3
3
3
3
1
3
3
1
1
1
90D
90D
90D; QL
90D
90D
90D
90D
90D; QL
1
1
1
1
1
3
1
1
QL
90D; QL
90D
90D
90D
90D
90D
90D
3
3
1
1
1
3
3
3
PA
PA
PA
PA
PA
Drug Name
DILANTIN 125MG/5ML SUSPENSION
DILANTIN 30MG, 100MG CAP
DILANTIN 50MG INFATAB
epitol 200mg tab
oxcarbazepine 150mg, 300mg, 600mg tab
PEGANONE 250MG TAB
PHENYTEK 200MG & 300MG CAPS
phenytoin 125mg/5ml suspension
phenytoin 50mg/ml ampul
phenytoin er 100mg, 200mg, 300mg caps
TEGRETOL 100MG CHEW
TEGRETOL 100MG/5ML SUSPENSION
TEGRETOL 200MG TAB
TEGRETOL-XR 100MG, 200MG, 400MG TABS
TRILEPTAL 300MG/5ML ORAL SUSP
VIMPAT 10MG/ML SOLN ORAL
VIMPAT 200MG/20ML VIAL
VIMPAT 50MG, 100MG, 150MG, 200MG TABS QL-60
QY 30 DY
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates 1mg tab
Cholinesterase Inhibitors
donepezil 5mg, 10mg tab QL-30 QY 30 DY
donepezil odt 5mg, 10mg tab QL-30 QY 30 DY
EXELON 2MG/ML SOLN ORAL QL-180ML 30 DY
EXELON 4.6MG/24HR, 9.5MG/24/HR PATCH QL-30
PATCHES 30 DY
galantamine 4mg, 8mg, 12mg tab QL-60 QY 30 DY
galantamine 4mg/ml soln oral QL-200ML 30 DY
galantamine 8mg, 16mg, 24mg cap 24hr QL-30 QY 30
DY
rivastigmine 1.5mg, 3mg, 4.5mg, 6mg caps QL-60 QY
30 DY
N-methyl-D-aspartate (NMDA) Receptor Antagonist
NAMENDA 10MG/5ML SOLN ORAL QL-360ML 30 DY
NAMENDA 5MG, 10MG TAB QL-60 QY 30 DY
NAMENDA 5MG/10MG TITR PAK TAB QL-1 PACK 28
DY
Antidepressants
Antidepressants, Other
budeprion sr 100mg, 150mg tab
budeprion xl 150mg, 300mg tab QL-30 QY 30 DY
Drug
Notes
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D

Tier
Plan Notes
3
3
3
1
1
3
3
1
1
1
3
3
3
3
3
3
3
90D; QL
90D;
HRM
90D; QL
90D; QL
90D; QL
1
1
2
90D; QL
90D; QL
90D; QL
3
3
90D; QL
90D; QL
90D; QL
90D; QL
2
2
QL
90D
90D; QL
1
1
B-10
Drug Name
bupropion 75mg, 100mg tab
bupropion sr 100mg, 150mg, 200mg tab
bupropion xl 150mg, 300mg tab QL-30 QY 30 DY
maprotiline 25mg, 50mg, 75mg tab
mirtazapine 7.5mg, 15mg, 30mg, 45mg tab
mirtazapine odt 15mg, 30mg, 45mg tab QL-30 QY 30
DY
nefazodone 50mg, 100mg, 150mg, 200mg, 250mg tab
SYMBYAX 3MG/25MG, 6MG/25MG, 6MG/50MG,
12MG/25MG, 12MG/50MG CAPS QL-30 QY 30 DY
trazodone 50mg, 100mg, 150mg, 300mg tabs
Monoamine Oxidase Inhibitors
EMSAM 12MG 24HR PATCH QL-30 PATCH 30 DY
MARPLAN 10MG TAB
phenelzine 15mg tab
tranylcypromine sulfate 10mg tab
Serotonin/Norepinephrine Reuptake Inhibitors
citalopram 10mg, 20mg, 40mg tab
citalopram 10mg/5ml soln oral
CYMBALTA 20MG, 60MG CAP QL-60 QY 30 DY
CYMBALTA 30MG CAP QL-90 QY 30 DY
escitalopram oxalate 5mg, 10mg, 20mg tab QL-45 QY
30 DY
escitalopram oxalate 5mg/5ml oral soln QL-600ML 30
DY
fluoxetine 10mg, 20mg tab
fluoxetine 10mg, 20mg, 40mg cap
fluoxetine 20mg/5ml soln oral
fluoxetine 90mg wkly cap QL-4 QY 28 DY
fluvoxamine 25mg, 50mg, 100mg tab
paroxetine 10mg, 20mg, 30mg, 40mg tab
paroxetine er 12.5mg, 25mg tab QL-90 QY 30 DY
paroxetine er 37.5mg tab QL-60 QY 30 DY
PAXIL 10MG/5ML SUSP
PRISTIQ 50MG & 100MG TABS QL-30 QY 30 DY
sertraline 20mg/ml conc oral
sertraline 25mg, 50mg, 100mg tabs
venlafaxine er 150mg cap QL-90 QY 30 DY
venlafaxine er 150mg tab QL-90 QY 30 DY
venlafaxine er 37.5mg, 75mg caps QL-30 QY 30 DY
venlafaxine er 37.5mg, 75MG, 225mg tabs QL-30 QY 30
DY
B-11
Drug
Notes
90D
90D
90D; QL
90D
90D

Tier
Plan Notes
1
1
1
1
1
90D; QL
90D
90D; QL
90D
90D; QL
90D; QL
90D; QL
90D
90D
90D
3
3
3
3
1
1
90D
90D
90D; QL
90D; QL
1
1
3
3
90D; QL
90D; QL
90D
90D
90D
90D; QL
90D
90D
90D; QL
90D; QL
90D
90D; QL
90D
90D
90D; QL
90D; QL
90D; QL
1
1
1
3
1
1
3
3
3
3
1
1
1
3
1
90D; QL
PA
ST
ST
ST
PA
PA
ST
ST
ST
ST
Drug Name
venlafaxine ir 25mg, 37.5mg, 50mg, 75mg, 100mg tabs
VIIBRYD 10MG, 20MG, 40MG TABS QL-30 QY 30 DY
VIIBRYD KIT QL-1 KIT 365 DY
Tricyclics
amitriptyline 10mg, 25mg, 50mg, 75mg, 100mg, 150mg
tab
amoxapine 25mg, 50mg, 100mg, 150mg tab
clomipramine 25mg, 50mg, 75mg cap
desipramine 10mg, 25mg, 50mg, 75mg, 100mg 150mg
tab
doxepin 10mg, 25mg, 50mg, 75mg, 100mg, 150mg cap
doxepin 10mg/ml conc oral
imipramine 10mg, 25mg, 50mg tab
nortriptyline 10mg, 25mg, 50mg, 75mg cap
perphenazine/amitriptyline 2mg/10mg, 2mg/25mg,
4mg/10mg; 4mg/25mg, 4mg/50mg tab
protriptyline 5mg & 10mg tabs
trimipramine maleate 25mg, 50mg, 100mg caps
Antiemetics
Antiemetics, Other
compro 25mg suppository
meclizine 12.5mg, 25mg tab
phenadoz 12.5mg, 25mg suppository
prochlorperazine 25mg supp rectal
prochlorperazine 5mg & 10mg tabs
prochlorperazine edisylate 5mg/ml vial
promethazine 12.5mg & 25mg supp rectal
promethazine 25mg/ml syringe
promethazine 50mg/ml vial
promethegan 25mg & 50mg supp rectal
trimethobenzamide 300mg cap
Drug
Notes
90D
90D; QL
90D; QL

Tier
Plan Notes
1
2
2
90D
90D
90D
1
1
90D
90D
90D
90D
90D
1
1
1
1
90D
90D
90D
3
3
90D
HRM
HRM
90D;
HRM
1
1
1
1
1
1
1
1
1
1
3
Emetogenic Therapy Adjuncts

dronabinol 2.5mg, 5mg, 10mg cap QL-60 QY 30 DY
EMEND 125MG, 80MG CAP TRIFLD QL-6 QY 30 DY
EMEND 40MG CAP QL-1 QY 30 DY
EMEND 80MG, 125MG CAP QL-6 QY 30 DY
granisetron 1mg tab QL-30 QY 30 DY
ondansetron 4mg/2ml vial
ondansetron ir 4mg, 8mg tab
SANCUSO 3.1MG/24HR PATCH QL-4 PATCH 28 DY
B v D;
QL
B v D;
QL
QL
B v D;
QL
B v D;
QL
QL
PA
PA
3
3
PA
PA
3
1
3
PA
B-12
Drug Name
Antifungals
Antifungals
AMPHOTERICIN B 50MG SOLN
CANCIDAS 50MG, 70MG VIAL
ciclopirox 0.77% lotion
ciclopirox 8% nail lacquer soln
ciclopirox olamine 0.77% cream
clotrimazole 1% topical soln
clotrimazole 10mg troche
clotrimazole/betameth diprop 1%/0.05% cream
clotrimazole/betameth diprop 1%/0.05% lotion
econazole nitrate 1% cream
EXELDERM 1% CREAM
EXELDERM 1% SOLN NON-ORAL
fluconazole 10mg/ml, 40mg/ml suspension
fluconazole 50mg, 100mg, 150mg, 200mg tab
fluconazole in dextrose 400mg/0.2l iv
FLUCONAZOLE IN NACL 100MG/50ML
flucytosine 250mg, 500mg cap
GRIFULVIN V 500MG TAB
GRIS-PEG 125MG, 250MG TAB
griseofulvin 125mg/5ml micro susp
itraconazole 100mg cap
ketoconazole 2% cream
ketoconazole 2% shampoo
ketoconazole 200mg tab
MENTAX 1% CREAM
NAFTIN 1% CREAM
NAFTIN 1%GEL
NOXAFIL 200MG/5ML ORAL SUSP QL-630ML 30 DY
nyamyc powder 100000unit/g
nystatin 100000unit/g cream
nystatin 100000unit/g oint
nystatin 100000unit/g powder
nystatin 100000unit/ml oral susp
nystatin 500000 tab
nystatin/triamcinolone 100000unit/g-1% cream
nystatin/triamcinolone 100000unit/g-1% oint
nystop 100000unit/g powder
pedi-dri 100000/g powder
SPORANOX 10MG/ML SOLN ORAL
terbinafine 250mg tab QL-30 QY 30 DY
B-13
Drug
Notes
QL
QL

Tier
Plan Notes
1
3
3
3
3
1
3
3
3
1
3
3
1
1
1
1
3
2
3
1
3
1
1
3
3
3
3
3
3
1
1
3
1
1
1
1
3
3
3
1
PA
PA
PA
PA
Drug Name
VFEND 200MG/5ML SUSPENSION
voriconazole 50mg, 200mg tab QL-60 QY 30 DY
Antigout Agents
Antigout Agents
allopurinol 100mg, 300mg tab
COLCRYS 0.6MG TAB QL-120 QY 30 DY
probenecid 500mg tab
probenecid/colchicine 0.5mg/500mg tab
Antimigraine Agents
Ergot Alkaloids
dihydroergotamine mesylate 1mg/ml ampul
ERGOMAR 2MG TAB, SUBL
ergotamine tartrate/caffeine 1mg/100mg tab
migergot 2mg/100mg supp rectal
MIGRANAL 0.5MG/SPRY QL-8 VIALS 28 DY
Serotonin (5-HT) 1b/1d Receptor Agonists
AXERT 6.25MG, 12.5MG TAB QL-8 QY 30 DY
FROVA 2.5MG TAB QL-12 QY 30 DY
MAXALT 5MG, 10MG TAB QL-12 QY 30 DY
MAXALT-MLT 5MG, 10MG TAB QL-12 QY 30 DY
naratriptan 1mg, 2.5mg tab QL-9 QY 30 DY
RELPAX 20MG, 40MG TABS QL-9 QY 30 DY
sumatriptan 25mg, 50mg, 100mg tabs QL-9 QY 30 DY
sumatriptan 4mg/0.5ml, 6mg/0.5ml inj QL-8 INJ 30 DY
sumatriptan 5mg, 20mg spray QL-8 SPRAY UNITS 30
DY
ZOMIG 2.5MG, 5MG TAB QL-6 QY 30 DY
ZOMIG 5MG NASAL SPR QL-6 SPRAY UNITS 30 DY
ZOMIG ZMT 2.5MG, 5MG TAB QL-6 QY 30 DY
Antimyasthenic Agents
Parasympathomimetics
GUANIDINE 125MG TAB
MESTINON 60MG/5ML SYRUP
MESTINON TIMESPAN 180MG TAB, SR
MYTELASE 10MG TAB
pyridostigmine bromide 60mg tab
Antimycobacterials
Antimycobacterials, Other
DAPSONE 25MG, 100MG TAB
MYCOBUTIN 150MG CAP
Antituberculars
CAPASTAT SULFATE 1G VIAL
Drug
Notes
QL

Tier
Plan Notes
3
PA
3
PA
90D
90D; QL
90D
90D
1
2
1
1
QL
3
3
1
3
3
QL
QL
QL
QL
QL
QL
QL
QL
3
3
2
2
3
3
3
3
QL
QL
QL
QL
3
3
3
90D
90D
90D
90D
90D
2
3
3
3
1
ST
ST
ST
ST
ST
ST
ST
2
3
3
B-14
Drug Name
ethambutol 100mg, 400mg tab
isonarif 150mg/300mg cap
isoniazid 100mg, 300mg tab
isoniazid 50mg/5ml syrup
PASER 4G PACKET
PRIFTIN 150MG TAB
pyrazinamide 500mg tab
rifampin 150mg & 300mg caps
rifampin 600mg vial
RIFATER 50MG/120MG/300MG TAB
SEROMYCIN 250MG CAP
TRECATOR 250MG TAB
Antineoplastics
Alkylating Agents
CEENU 10MG, 40MG, 100MG CAP
cyclophosphamide 25mg, 50mg tab
HEXALEN 50MG CAP
LEUKERAN 2MG TAB
MATULANE 50MG CAP
thiotepa 15mg vial
Antiangiogenic Agents
CAPRELSA 100MG TAB QL-60 QY 30 DY
CAPRELSA 300MG TAB QL-30 QY 30 DY
REVLIMID 2.5MG, 5MG, 10MG, 15MG, 25MG CAPS
QL-30 QY 30 DY
THALOMID 200MG CAPS QL-56 QY 28 DY
THALOMID 50MG, 100MG, 150MG CAPS QL-28 QY 28
DY
VANDETANIB 100MG TAB QL-60 QY 30 DY
VANDETANIB 300MG TAB QL-30 QY 30 DY
Antiestrogens/Modifiers
EMCYT 140MG CAP
FARESTON 60MG TAB
FASLODEX 250MG/5ML SYRINGE
tamoxifen citrate 10mg, 20mg tabs
Antimetabolites
ALIMTA 100MG, 500MG VIAL
DROXIA 200MG, 300MG, 400MG CAP
ELITEK 1.5MG VIAL
fluorouracil 500mg/10ml vial
gemcitabine 200mg, 1g, 2g vial
GEMCITABINE 200MG/5.26ML; 1G/26.3ML; 2G/52.6ML
VIAL
B-15
Drug
Notes
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
BvD

Tier
Plan Notes
1
1
1
1
3
3
1
1
1
3
3
3
2
1
3
2
3
3
PA
QL
QL
2
2
PA
PA
QL
PA
QL
PA
QL
PA
QL
QL
2
2
PA
PA
90D
90D
2
2
3
1
PA
3
2
3
1
3
PA
PA
PA
PA
Drug Name
GEMCITABINE 200MG/5.26ML; 1G/26.3ML; 2G/52.6ML
VIAL
hydroxyurea 500mg cap
mercaptopurine 50mg tab
TABLOID 40MG TAB
Antineoplastics, Other
amifostine 500mg vial
bleomycin sulfate 30 unit vial
cisplatin 1mg/ml inj
DACOGEN 50MG VIAL
DOCEFREZ 20MG, 80MG VIAL
DOCETAXEL 20MG/2ML; 80MG/8ML; 160MG/16ML
VIAL
docetaxel 80mg/4ml vial
ERIVEDGE CAP 150MG QL-30 QY 30 DY
IXEMPRA KIT 45MG VIAL
JAKAFI 5MG, 10MG, 15MG, 20MG, 25MG TAB QL-60
QY 30 DY
leucovorin calcium 100mg, 350mg soln
leucovorin calcium 5mg, 10mg, 15mg, 25mg tab
mesna 100mg/ml vial
MESNEX 400MG TAB
mitoxantrone 2mg/ml vial
paclitaxel 6mg/ml vial
SYLATRON 296MCG, 444MCG, 888MCG KIT QL-4 QY
28 DY
TAXOTERE FNL 80MG/8ML VIAL
TRISENOX 10MG/10ML AMPUL
VELCADE 3.5MG VIAL
VIDAZA 100MG VIAL
ZOLINZA 100MG CAP QL-120 QY 30 DY
ZYTIGA 250MG TAB QL-120 QY 30 DY
Aromatase Inhibitors, 3rd Generation
anastrozole 1mg tab QL-30 QY 30 DY
exemestane 25mg tab
letrozole 2.5mg tab QL-30 QY 30 DY
Enzyme Inhibitors
etoposide 20mg/ml soln
topotecan hcl 4mg solr
Molecular Target Inhibitors
AFINITOR 2.5MG, 5MG, 10MG TAB QL-30 QY 30 DY
AFINITOR 7.5MG TAB QL-30 QY 30 DY
GLEEVEC 100MG TAB QL-90 QY 30 DY
Drug
Notes

Tier
Plan Notes
3
90D
PA
1
1
2
3
3
1
3
3
PA
PA
PA
PA
QL
3
3
3
PA
PA
PA
QL
PA
1
1
1
3
1
3
PA
PA
QL
PA
QL
QL
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
90D; QL
90D
90D; QL
1
3
1
QL
QL
QL
3
1
PA
PA
2
3
3
PA
PA
PA
B-16
Drug Name
GLEEVEC 400MG TAB QL-60 QY 30 DY
INLYTA 1MG TAB 1MG QL-240 QY 30 DY
INLYTA 5MG TAB 5MG QL-120 QY 30 DY
IRESSA 250MG TAB QL-30 QY 30 DY
NEXAVAR 200MG TAB QL-120 QY 30 DY
SPRYCEL 100MG, 140MG TABS QL-30 QY 30 DY
SPRYCEL 20MG, 50MG, 70MG, 80MG TABS QL-60 QY
30 DY
SUTENT 12.5MG, 25MG, 50MG CAPS QL-30 QY 30
DY
TARCEVA 100MG, 150MG TABS QL-30 QY 30 DY
TARCEVA 25MG TAB QL-60 QY 30 DY
TASIGNA 150MG, 200MG CAPS QL-120 QY 30 DY
TYKERB 250MG TAB QL-180 QY 30 DY
VOTRIENT 200MG TAB QL-120 QY 30 DY
XALKORI 200MG, 250MG CAP QL-60 QY 30 DY
ZELBORAF 240MG TAB QL-240 QY 30 DY
Monoclonal Antibodies
AVASTIN 25MG/ML VIAL
CAMPATH 30MG/ML VIAL
HERCEPTIN 440MG VIAL
RITUXAN 10MG/ML VIAL
YERVOY 50MG/10ML, 200MG/40ML SOLN
Retinoids
PANRETIN 0.1% GEL
TARGRETIN 1% GEL QL-60GM 30 DY
TARGRETIN 75MG CAP
tretinoin 10mg cap
Antiparasitics
Anthelmintics
ALBENZA 200MG TAB
BILTRICIDE 600MG TAB
STROMECTOL 3MG TAB
Antiprotozoals
ALINIA 100MG/5ML SUSPENSION
ALINIA 500MG TAB
chloroquine 250mg, 500mg tab
DARAPRIM 25MG TAB
hydroxychloroquine sulfate 200mg tab
mefloquine 250mg tab
MEPRON 750MG/5ML SUSPENSION
NEBUPENT 300MG VIAL
B-17
Drug
Notes
QL
QL
QL
QL
QL
QL

Tier
Plan Notes
3
PA
3
PA
3
PA
3
3
PA
3
PA
QL
PA
QL
PA
QL
QL
QL
QL
QL
QL
QL
3
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
PA
3
3
3
2
3
PA
PA
PA
PA
PA
2
3
3
1
PA
PA
PA
BvD
QL
3
3
2
90D
90D
BvD
3
3
1
2
1
1
3
2
PA
PA
Drug Name
Drug
Notes
PRIMAQUINE PHOSPHATE 26.3MG TAB

QUALAQUIN 324MG CAP QL-80 QY 365 DY
QL
Pediculicides/Scabicides
acticin 5% cream
EURAX 10% CREAM
EURAX 10% LOTION
LINDANE 1% LOTN QL-60ML 30 DY
QL
lindane 1% shamp QL-60ML 30 DY
QL
malathion 0.5% lotion
permethrin 5% cream
ULESFIA 5% LOTION
Antiparkinson Agents
Anticholinergics
benztropin 1mg/ml soln
benztropine 0.5mg, 1mg, 2mg tab
90D
trihexyphenidyl 2mg, 5mg tabs
90D
trihexyphenidyl 2mg/5ml elixir
90D
Antiparkinson Agents, Other
COMTAN 200MG TAB
90D
TASMAR 100MG TAB
90D
Dopamine Agonists
APOKYN CARTRIDGE 10MG/ML
bromocriptine 2.5mg tab
90D
bromocriptine 5mg cap
90D
pramipexole 0.125mg, 0.25mg, 0.5mg, 0.75mg, 1mg,
90D; QL
1.5mg tabs QL-90 QY 30 DY
ropinirole 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg
90D
tabs
Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors
carbidopa/levodopa 10mg/100mg; 25mg/100mg;
90D
25mg/250mg tab
carbidopa/levodopa cr 25mg/100mg tab
90D
carbidopa/levodopa odt 10mg/100mg; 25mg/100mg;
90D
25mg/250mg tab
carbidopa/levodopa sr 50mg/200mg tab
90D
LODOSYN 25MG TAB
90D
STALEVO 50, 75, 100, 125, 150, 200 TABS
90D
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT 0.5MG, 1MG TAB QL-30 QY 30 DY
90D; QL
selegiline 5mg cap
90D
selegiline 5mg tab
90D

Tier
Plan Notes
3
3
PA
1
3
3
1
1
3
1
3
1
1
1
1
2
3
3
3
3
PA
1
1
1
1
1
1
3
3
3
1
1
ST
B-18
Drug Name
chlorpromazine 10mg, 25mg, 50mg, 100mg, 200mg tab
chlorpromazine 25mg/ml ampul
fluphenazine 1mg, 2.5mg, 5mg, 10mg tab
fluphenazine 2.5mg/5ml elixir
fluphenazine 2.5mg/ml vial
fluphenazine 5mg/ml conc oral
fluphenazine decanoate 25mg/ml vial
haloperidol 0.5mg, 1mg, 2mg, 5mg, 10mg, 20mg tabs
haloperidol 2mg/ml conc oral
haloperidol decanoate 50mg/ml, 100mg/ml vial
haloperidol lactate 5mg/ml vial
loxapine succinate 5mg, 10mg, 25mg, 50mg cap
ORAP 1MG, 2MG TAB
perphenazine 2mg, 4mg, 8mg, 16mg tab
thioridazine 10mg, 25mg, 50mg, 100mg tabs
thiothixene 1mg, 2mg, 5mg, 10mg caps
trifluoperazine 1mg, 2mg, 5mg, 10mg tabs
2nd Generation/Atypical
ABILIFY 10MG, 15MG DISCMELT TAB QL-60 QY 30
DY
ABILIFY 1MG/ML SOLN ORAL QL-900ML 30 DY
ABILIFY 2MG, 5MG, 10MG, 15MG, 20MG, 30MG TAB
QL-30 QY 30 DY
ABILIFY 9.75MG/1.3 VIAL
FANAPT 1MG, 2MG, 4MG, 6MG, 8MG, 10MG, 12MG
TAB QL-60 QY 30 DY
FANAPT 1MG/2MG/4MG/6MG TITR PACK QL-1 PACK
365 DY
GEODON 20MG VIAL QL-60ML 30 DY
INVEGA 1.5MG, 3MG, 9MG TAB24 QL-30 QY 30 DY
INVEGA 6MG TAB24 QL-60 QY 30 DY
INVEGA SUST 39MG/0.25ML; 78MG/0.5ML;
117MG/0.75ML; 156MG/ML; 234MG/1.5ML VIAL QL-1
INJ 28 DY
LATUDA 20MG, 40MG, 80MG TAB QL-30 QY 30 DY
olanzapine 10mg vial
olanzapine 15mg, 20mg tab QL-60 QY 30 DY
olanzapine 2.5mg, 5mg, 7.5mg, 10mg tab QL-30 QY 30
DY
olanzapine odt 15mg, 20mg tbdp QL-60 QY 30 DY
olanzapine odt 5mg, 10mg tbdp QL-30 QY 30 DY
quetiapine fumarate 25mg, 50mg, 100mg, 200mg,
300mg tabs QL-90 QY 30 DY
quetiapine fumarate 400mg tab QL-60 QY 30 DY
B-19
Drug
Notes
90D
90D
90D
90D
90D
90D
90D
90D
90D;
HRM
90D
90D

Tier
Plan Notes
1
1
1
1
1
1
1
1
1
3
1
1
3
1
1
1
1
90D; QL
90D; QL
90D; QL
PA
3
90D; QL
PA
QL
PA
QL
90D; QL
90D; QL
3
3
3
PA
PA
QL
90D; QL
90D; QL
3
1
1
90D; QL
90D; QL
90D; QL
3
3
90D; QL
90D; QL
Drug Name
Drug
Notes
RISPERDAL CONSTA 12.5MG/2ML, 25MG/2ML,

QL
37.5MG/2ML, 50MG/2ML QL-2 INJ 28 DY
risperidone 0.25mg, 0.5mg, 3mg tabs QL-90 QY 30 DY
90D; QL
risperidone 1mg, 2mg tabs QL-60 QY 30 DY
90D; QL
risperidone 1mg/ml soln oral
90D
risperidone 4mg tab QL-120 QY 30 DY
90D; QL
risperidone odt 0.25mg, 0.5mg, 3mg QL-90 QY 30 DY
90D; QL
risperidone odt 1mg & 2mg QL-60 QY 30 DY
90D; QL
risperidone odt 4mg QL-120 QY 30 DY
90D; QL
SAPHRIS 5MG, 10MG SUBL QL-60 QY 30 DY
QL
SEROQUEL XR 150MG, 200MG TABS QL-30 QY 30
90D; QL
DY
SEROQUEL XR 50MG, 300MG, 400MG TABS QL-60
90D; QL
QY 30 DY
ziprasidone hcl 20mg, 40mg, 60mg, 80mg cap QL-60
90D; QL
QY 30 DY
ZYPREXA RELPREVV 210MG, 300MG QL-2 INJ 28 DY
QL
ZYPREXA RELPREVV 405MG QL-1 INJ 28 DY
QL
Treatment-Resistant
clozapine 25mg, 50mg, 100mg, 200mg tab
90D
FAZACLO 12.5MG, 25MG, 100MG, 150MG, 200MG
90D
ODT TAB
Antispasticity Agents
Antispasticity Agents
baclofen 10mg, 20mg tab
90D
dantrolene 25mg, 50mg, 100mg cap
90D
tizanidine2mg, 4mg tabs
90D
Antivirals
Anti-cytomegalovirus (CMV) Agents
foscarnet 24mg/ml inj
ganciclovir 250mg, 500mg cap
VALCYTE 450mg TAB
ZIRGAN 0.15% GEL QL-5 QY 30 DY
QL
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors
COMPLERA 300MG TAB QL-30 QY 30 DY
QL
EDURANT 25MG TAB QL-30 QY 30 DY
QL
INTELENCE 100MG TAB QL-120 QY 30 DY
QL
INTELENCE 200MG TAB QL-60 QY 30 DY
QL
nevirapine 200mg tab
RESCRIPTOR 100MG & 200MG TABS
SUSTIVA 50MG & 200MG CAPS
SUSTIVA 600MG TAB
VIRAMUNE 50MG/5ML SUSPENSION
VIRAMUNE XR 400MG TAB

Tier
Plan Notes
3
1
1
1
1
3
3
3
3
2
2
3
3
3
PA
PA
1
3
1
3
1
3
1
3
3
PA
3
3
3
3
3
2
3
3
3
3
B-20

Tier
Plan Notes
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors
ATRIPLA 600MG/200MG TAB QL-30 QY 30 DY
QL
3
didanosine 125mg, 200mg, 250mg, 400mg cap
3
EMTRIVA 10MG/ML SOLN ORAL
3
EMTRIVA 200MG CAP
3
EPIVIR 10MG/ML SOLN ORAL
3
EPZICOM 600MG/300MG TAB
3
lamivudine 150mg, 300mg tab
3
lamivudine/zidovudine 150mg/300mg tab
3
RETROVIR 10MG/ML IV
3
stavudine 15mg, 20mg, 30mg, 40mg caps
1
TRIZIVIR 150MG/300MG TAB
3
TRUVADA 200MG/300MG TAB QL-30 QY 30 DY
QL
3
VIDEX PEDIATRIC 10MG/ML SOLN ORAL
3
VIREAD 150MG, 200MG, 250MG, 300MG TAB
3
VIREAD 40MG/GM POWDER
3
ZERIT 1MG/ML SOLR
3
ZIAGEN 20MG/ML SOLN ORAL
3
ZIAGEN 300MG TAB
3
zidovudine 100mg cap
1
zidovudine 10mg/ml syrup
1
zidovudine 300mg tab
1
Anti-HIV Agents, Other
FUZEON 90MG KIT QL-60 VIALS 30 DY
QL
3
ISENTRESS 400MG TAB QL-60 QY 30 DY
QL
3
SELZENTRY 150MG TAB QL-60 QY 30 DY
QL
2
SELZENTRY 300MG TAB QL-120 QY 30 DY
QL
2
Anti-HIV Agents, Protease Inhibitors
APTIVUS 100MG/ML SOLN ORAL
3
APTIVUS 250MG CAP
3
CRIXIVAN 100MG, 200MG, 400MG CAP
2
INVIRASE 200MG CAP
3
INVIRASE 500MG TAB
3
KALETRA 100MG/25MG TAB QL-300 QY 30 DY
QL
3
KALETRA 200MG/50MG TAB QL-120 QY 30 DY
QL
3
KALETRA 400MG-100MG/5ML ORAL SOLN QL-375ML
QL
3
30 DY
LEXIVA 50MG/ML SUSPENSION
3
LEXIVA 700MG TAB
3
NORVIR 100MG CAP
3
NORVIR 100MG TAB
3
NORVIR 80MG/ML SOLN ORAL
3
Drug Name
B-21
Drug
Notes
Drug Name
PREZISTA 150MG TAB
PREZISTA 400MG TAB
PREZISTA 600MG TAB
PREZISTA 75MG TAB
REYATAZ 100MG CAP
REYATAZ 150MG CAP
REYATAZ 200MG CAP
REYATAZ 300MG CAP
VIRACEPT 250MG, 625MG TAB
Anti-influenza Agents
amantadine 100mg tab
amantadine 100mg cap
RELENZA 5MG DISKHALER QL-120 DOSES 365 DY
rimantadine 100mg tab
TAMIFLU 30MG & 45MG CAP
TAMIFLU 6MG/ML, 12MG/ML SUSPENSION
TAMIFLU CAP 75MG QL-56 QY 365 DY
Antihepatitis Agents
BARACLUDE 0.05MG/ML SOLN ORAL QL-630ML 30
DY
BARACLUDE 0.5MG, 1MG TAB QL-30 QY 30 DY
EPIVIR HBV 100MG TAB
EPIVIR HBV 25MG/5ML SOLN ORAL
HEPSERA 10MG TAB QL-30 QY 30 DY
INCIVEK 375MG TAB QL-180 QY 30 DY
INTRON-A 10 MU INJ
INTRON-A 10MU/0.2ML INJ
INTRON-A 6000000U/ML INJ
PEGASYS 180MCG/0.5ML KIT QL-1 KIT 28 DY
PEGASYS PROCLICK 135MCG/0.5ML QL-4 PENS 28
DY
PEGASYS PROCLICK 180MCG/0.5ML QL-4 PENS 28
DY
ribasphere cap 200mg
ribasphere tab 200mg
ribavirin cap 200mg
ribavirin tab 200mg
TYZEKA 600MG TAB QL-30 QY 30 DY
Antiherpetic Agents
acyclovir 200mg cap
acyclovir 200mg/5ml susp
Drug
Notes
90D
90D
QL

Tier
Plan Notes
3
3
3
3
3
3
3
3
3
QL
1
1
3
1
3
3
3
QL
QL
QL
3
2
2
2
3
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
PA
QL
PA
QL
PA
PA
PA
PA
PA
QL
3
3
3
3
3
90D
90D
1
1
QL
QL
B-22
Drug Name
acyclovir 400mg, 800mg tab
acyclovir sodium 500mg solr
DENAVIR 1% CREAM QL-2GM 30 DY
famciclovir 125mg, 250mg, 500mg tab QL-60 QY 30 DY
valacyclovir 1000mg tab QL-30 QY 30 DY
valacyclovir 500mg tab QL-42 QY 30 DY
ZOVIRAX 5% OINT QL-30GM 30 DY
Anxiolytics
Anxiolytics, Other
alprazolam 0.25mg, 0.5mg, 1mg, 2mg tab QL-150 QY
30 DY
buspirone 5mg, 7.5mg, 10mg, 15mg, 30mg tab
chlordiazepoxide/amitriptyline 12.5mg/5mg, 25mg/10mg
tab
lorazepam 0.5mg, 1mg, 2mg tab QL-90 QY 30 DY
lorazepam intensol 2mg/ml soln oral
oxazepam cap 10mg, 15mg, 30mg QL-120 QY 30 DY
Bipolar Agents
Mood Stabilizers
EQUETRO 100MG, 200MG, 300MG CAP
lithium carbonate 150mg, 300mg, 600mg cap
lithium carbonate 300mg tab
lithium carbonate er 300mg, 450mg tab
lithium citrate 8meq/5ml soln oral
LITHOBID 300MG TAB, SR
Blood Glucose Regulators
Antidiabetic Agents
acarbose 25mg, 50mg, 100mg tab
ACTOS 15MG, 30MG, 45MG TAB QL-30 QY 30 DY
BYETTA 5MCG/0.02ML, 10MCG/0.04ML PEN QL-1
PEN 30 DY
glimepiride 1mg, 2mg, 4mg tab
glipizide 5mg, 10mg tab
glipizide er 2.5mg tab
glipizide xl 5mg, 10mg tab
glipizide/metformin 2.5mg/250mg; 2.5mg/500mg;
5mg/500mg tab
glyburide 1.25mg, 2.5mg, 5mg tab
glyburide 1.5mg, 3mg, 6mg micronized tab
glyburide/metformin 1.25mg/250mg; 2.5mg/500mg;
5mg/500mg tab
JANUMET 50MG/500MG; 50MG/1000MG TAB QL-60
QY 30 DY
JANUMET XR 1000MG/50MG TAB QL-60 QY 30 DY
B-23
Drug
Notes
90D
QL
90D; QL
90D; QL
90D; QL
QL

Tier
Plan Notes
1
1
2
3
3
ST
3
ST
3
QL
90D
HRM
QL
QL
1
1
1
90D
90D
90D
90D
90D
90D
3
1
1
1
1
3
90D
90D; QL
1
3
90D; QL
90D
90D
90D
90D
1
1
1
1
90D
90D
90D
3
3
90D
90D; QL
ST
90D; QL
ST
PA
Drug Name
JANUMET XR 500MG/50MG; 1000MG/100MG TAB QL30 QY 30 DY
JANUVIA 25MG, 50MG, 100MG TAB QL-30 QY 30 DY
KOMBIGLYZE XR 2.5MG/1000MG TAB QL-60 QY 30
DY
KOMBIGLYZE XR 5MG/500MG; 5MG/1000MG TAB QL30 QY 30 DY
metformin 500mg, 850mg, 1000mg tab
metformin er 500mg, 750mg tab (generic
GLUCOPHAGE XR)
nateglinide 60mg, 120mg tab QL-90 QY 30 DY
ONGLYZA 2.5MG, 5MG TAB QL-30 QY 30 DY
PRANDIN TAB 0.5MG & 1MG QL-120 QY 30 DY
PRANDIN TAB 2MG QL-240 QY 30 DY
RIOMET 500MG/5ML SOLN ORAL
SYMLINPEN 120 1000MCG/ML QL-4 PENS 30 DY
SYMLINPEN 60 1000MCG/ML QL-8 PENS 30 DY
tolazamide 250mg, 500mg tabs
tolbutamide 500mg tab
VICTOZA 18MG/3ML SOLN QL-3 PENS 30 DY
Glycemic Agents
CLINIMIX E/DEXTROSE 2.75% IV
CLINIMIX E/DEXTROSE 4.25% IV
dextrose 10% flex container
DEXTROSE 10%/NACL 0.2% IV
DEXTROSE 10%/NACL 0.45% IV
dextrose 2.5%/nacl 0.45% iv
dextrose 5% iv
dextrose 5%/nacl 0.2% iv
GLUCAGEN 1MG HYPOKIT QL-2 INJ 1 DY
GLUCAGON 1MG EMERG KIT QL-1 INJ 1 DY
kcl/d5w/nacl 10MEQ/L; 20MEQ/L; 30MEQ/L; 40MEQ/L
iv
potassium chloride/d5w/nacl iv 10meq/l, 20meq/l,
30meq/l
PROGLYCEM 50MG/ML SUSPENSION
Insulins
LANTUS 100UNIT/ML VIAL
LANTUS SOLOSTAR 100UNIT/ML
LEVEMIR 100UNIT/ML FLEXPEN
LEVEMIR 100UNIT/ML VIAL
Drug
Notes

Tier
Plan Notes
90D; QL
ST
90D; QL
ST
90D; QL
ST
90D; QL
ST
90D
90D
90D; QL
90D; QL
90D; QL
90D; QL
90D
90D; QL
90D; QL
90D
90D
90D; QL
3
2
3
3
3
3
3
1
1
2
BvD
BvD
3
3
1
1
1
1
1
1
1
1
1
2
2
QL
QL
ST
PA
PA
ST
PA
PA
1
1
90D
90D
90D
90D
90D
2
2
2
2
B-24
Drug Name
NOVOLIN 70/30 VIAL
NOVOLIN N 100UNIT/ML VIAL
NOVOLIN R 100UNIT/ML VIAL
NOVOLOG 100UNIT/ML FLEXPEN
NOVOLOG 100UNIT/ML VIAL
NOVOLOG MIX 70/30 FLEXPEN
NOVOLOG MIX 70/30 VIAL
Blood Products/Modifiers/Volume Expanders
Anticoagulants
COUMADIN 1MG, 2MG, 2.5MG, 3MG, 4MG, 5MG,
6MG, 7.5MG, 10MG TAB
enoxaparin 100mg/ml syringe
enoxaparin 30mg/0.3ml; 40mg/0.4ml; 60mg/0.6ml;
80mg/0.8ml; 120mg/0.8ml; 150mg/ml syringe
fondaparinux sodium 2.5mg/0.5ml; 5mg/0.4ml;
7.5mg/0.6ml; 10mg/0.8ml syringe
heparin sod 10000unit/5ml; 25000unit/10ml vial
heparin sod 1000unit/ml; 5000unit/ml; 10000unit/ml;
20000unit/ml vial
heparin/d5w 20000UNIT/500ml; 25000unit/250ml;
25000/500ml iv
heparin/nacl 1000unit/500ml; 2000unit/1000ml iv
jantoven 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg,
7.5mg, 10mg tab
PRADAXA 75MG & 150MG CAPS QL-60 QY 30 DY
warfarin 1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg,
7.5mg, 10mg tabs
XARELTO 10MG, 15MG, 20MG TAB QL-30 QY 30 DY
Blood Formation Modifiers
anagrelide 0.5mg, 1mg cap
LEUKINE 250MCG VIAL
LEUKINE 500MCG/ML VIAL
NEUMEGA 5MG VIAL
NEUPOGEN 300MCG/0.5ML; 480MCG/0.8ML;
480MCG/1.6ML INJ
PROCRIT VIAL 10000U QL-12ML 28 DY
PROMACTA 12.5MG, 25MG, 50MG, 75MG TABS QL30 QY 30 DY
Blood Products/Modifiers/Volume Expanders
CINRYZE 500 UNIT VIAL QL-20 VIALS 30 DY
B-25
Drug
Notes
90D
90D
90D
90D
90D
90D
90D
90D

Tier
Plan Notes
2
2
2
2
2
2
2
3
3
PA
PA
PA
1
1
1
1
90D
90D; QL
90D
QL
90D
1
3
3
2
PA
PA
PA
PA
QL
QL
QL
QL
QL
QL
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
QL
PA
QL
PA
Drug Name
Coagulants
CYKLOKAPRON 100MG/ML AMPUL
Platelet Modifying Agents
AGGRENOX 25MG/200MG CAP QL-60 QY 30 DY
BRILINTA 90MG TAB QL-60 QY 30 DY
cilostazol 50mg, 100mg tab
clopidogrel 300mg tab QL-1 QY 365 DY
clopidogrel 75mg tab QL-30 QY 30 DY
EFFIENT 5MG, 10MG TAB QL-30 QY 30 DY
ticlopidine 250mg tab
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine 0.1mg, 0.2mg, 0.3mg tab
clorpres 0.1mg/15mg, 0.2mg/15mg tab
CLORPRES 0.3MG/15MG TAB
guanfacine 1mg, 2mg tab
methyldopa 250mg, 500mg tab
methyldopa/hctz 250mg/15mg tab
methyldopa/hctz 250mg/25mg tab
midodrine 2.5mg, 5mg, 10mg tab
Alpha-adrenergic Blocking Agents
DIBENZYLINE 10MG CAP
prazosin 1mg, 2mg, 5mg caps
reserpine 0.1mg & 0.25mg tabs
Angiotensin II Receptor Antagonists
ATACAND 4MG, 8MG, 16MG, 32MG TAB QL-30 QY 30
DY
ATACAND HCT 16MG/12.5MG; 32MG/12.5MG;
32MG/25MG TAB QL-30 QY 30 DY
BENICAR 5MG, 20MG, 40MG TAB QL-30 QY 30 DY
BENICAR HCT 20MG/12.5MG; 40MG/12.5MG;
eprosartan mesylate 600mg tab QL-30 QY 30 DY
irbesartan 75mg, 150mg, 300mg tab QL-30 QY 30 DY
irbesartan/hydrochlorothiazide 12.5mg/150mg tab QL-30
QY 30 DY
irbesartan/hydrochlorothiazide 12.5mg/300mg tab QL-30
QY 30 DY
losartan pot/hctz 50mg/12.5mg; 100mg/12.5mg;
losartan potassium 100mg tab QL-30 QY 30 DY
losartan potassium 25mg, 50mg tab QL-60 QY 30 DY
MICARDIS 20MG, 40MG, 80MG TAB QL-30 QY 30 DY
MICARDIS HCT 40MG/12.5MG; 80MG/12.5MG;
Drug
Notes

Tier
Plan Notes
2
90D; QL
90D; QL
90D
QL
90D; QL
90D; QL
90D
2
3
1
1
1
3
1
90D
90D
90D
90D
90D
90D
90D
90D
1
3
3
1
1
1
1
3
90D
90D
90D
3
1
1
90D; QL
ST
90D; QL
ST
90D; QL
ST
90D; QL
ST
90D; QL
90D; QL
1
1
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
1
1
2
90D; QL
B-26
Drug Name
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril 5mg, 10mg, 20mg, 40mg tab
benazepril/hctz 5mg/6.25mg; 10mg/12.5mg;
20mg/12.5mg; 20mg/25mg tab
captopril 12.5mg, 25mg, 50mg, 100mg tab
captopril/hctz 25mg/15mg; 25mg/25mg; 50mg/15mg;
50mg/25mg tab
enalapril 2.5mg, 5mg, 10mg, 20mg tab
enalapril/hctz 5mg/12.5mg, 10mg/25mg tab
fosinopril 10mg, 20mg, 40mg tab
fosinopril/hctz 10mg/12.5mg; 20mg/12.5mg tab
lisinopril 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg tab
lisinopril 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg tab
lisinopril/hctz 10mg/12.5mg; 20mg/12.5mg; 20mg/25mg
tab
moexipril 7.5mg, 15mg tab
moexipril/hctz 7.5mg/12.5mg; 15mg/12.5mg;
15mg/25mg tab
perindopril 2mg, 4mg tab QL-30 QY 30 DY
perindopril 8mg tab QL-60 QY 30 DY
quinapril 5mg, 10mg, 20mg, 40mg tabs
quinapril/hydrochlorothiazide 10/12.5mg, 20/12.5mg,
20/25mg tabs
ramipril 1.25mg, 2.5mg, 5mg, 10mg caps
trandolapril 1mg, 2mg, 4mg tabs
Antiarrhythmics
amiodarone 200mg, 400mg tab
disopyramide phosphate 100mg, 150mg cap
flecainide 50mg, 100mg, 150mg tab
mexiletine 150mg, 200mg, 250mg cap
MULTAQ 400MG TAB QL-60 QY 30 DY
NORPACE CR 100MG, 150MG CAP
pacerone 100mg tab
pacerone 200mg tab
procainamide 100mg/ml & 500mg/ml vials
propafenone 150mg, 225mg, 300mg tabs
propafenone hcl er 225mg, 325mg, 425mg caps
quinidine gluconate cr 324mg tab
quinidine sulfate 200mg & 300mg tabs
quinidine sulfate er 300mg tab
sorine 80mg, 120mg, 160mg, 240mg tabs
sotalol 80mg, 120mg, 160mg, 240mg tabs
TIKOSYN 125MCG, 250MCG, 500MCG CAPS
B-27
Drug
Notes

Tier
Plan Notes
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
1
1
1
1
1
1
90D
90D
90D
90D; QL
90D; QL
90D
1
1
1
90D
90D
90D
1
1
90D
90D
90D
90D
90D; QL
90D
90D
90D
1
1
1
1
3
3
3
1
1
1
3
1
1
1
1
1
3
90D
90D
90D
90D
90D
90D
90D
90D
Drug Name
acebutolol 200mg, 400mg cap
atenolol 25mg; 50mg; 100mg tab
atenolol/chlorthalidone 50mg/25mg; 100mg/25mg tab
betaxolol 10mg, 20mg tab
bisoprolol 5mg, 10mg tab
bisoprolol/hctz 2.5mg/6.25mg; 5mg/6.25mg;
10mg/6.25mg tab
BYSTOLIC 2.5MG, 5MG, 10MG TAB QL-30 QY 30 DY
BYSTOLIC 20MG TAB QL-60 QY 30 DY
carvedilol 3.125mg, 6.25mg, 12.5mg, 25mg tab
COREG CR 10MG, 20MG, 40MG, 80MG CAP QL-30
QY 30 DY
INNOPRAN XL 120MG CAP24 QL-60 QY 30 DY
INNOPRAN XL 80MG CAP24 QL-30 QY 30 DY
labetalol 100mg, 200mg, 300mg tab
labetalol 5mg/ml vial
LEVATOL 20MG TAB
metoprolol succinate er 25mg, 50mg, 100mg, 200mg tab
metoprolol tartrate 25mg, 50mg, 100mg tab
metoprolol tartrate 5mg/5ml vial
metoprolol/hctz 50mg/25mg; 100mg/25mg; 100mg/50mg
tab
nadolol 20mg, 40mg, 80mg tab
nadolol/bendroflumethiazide 40mg/5mg; 80mg/5mg tab
pindolol 5mg & 10mg tabs
propranolol 10mg, 20mg, 40mg, 60mg, 80mg tabs
propranolol 1mg/ml vial
propranolol 20mg/5ml & 40mg/5ml soln oral
propranolol er 60mg, 80mg, 120MG, 160mg caps
propranolol/hctz 40mg/25mg & 80mg/25mg tabs
timolol 5mg, 10mg, 20mg tabs
Calcium Channel Blocking Agents
afeditab 30mg, 60mg cr tab
amlodipine 2.5mg, 5mg, 10mg tab
amlodipine besylate/atorvastatin calcium 2.5mg/10mg;
2.5mg/20mg; 2.5mg/40mg; 5mg/10mg; 5mg/20mg;
5mg/40mg; 5mg/80mg; 10mg/10mg; 10mg/20mg;
10mg/40mg; 10mg/80mg tab QL-30 QY 30 DY
amlodipine/benazepril 2.5mg/10mg; 5mg/10mg;
5mg/20mg; 5mg/40mg; 10mg/20mg; 10mg/40mg cap
QL-30 QY 30 DY
cartia xt 120mg, 180mg, 240mg, 300mg cap
COVERA-HS 180MG, 240MG TAB
dilt-cd 120mg, 180mg, 300mg cap
Drug
Notes
90D
90D
90D
90D
90D

Tier
Plan Notes
1
1
1
1
1
90D
90D; QL
90D; QL
90D
2
2
1
90D; QL
90D; QL
90D; QL
90D
3
3
1
1
3
1
1
1
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
1
3
1
1
1
1
3
1
1
90D
90D
1
1
90D; QL
90D; QL
90D
90D
90D
1
3
1
B-28
Drug Name
dilt-xr 180mg, 240mg cap
diltiazem 30mg, 60mg, 90mg, 120mg tab
diltiazem 5mg/ml vial
diltiazem cd 120mg, 240mg, 300mg, 360mg cap
diltiazem er 180mg, 300mg, 360mg, 420mg tab24 QL-30
QY 30 DY
diltiazem er 240mg tab24 QL-60 QY 30 DY
diltiazem er 420mg cap24
diltiazem er 60mg, 90mg, 120mg cap12
diltiazem hcl er 180mg, 360mg cap
diltzac 120mg, 180mg, 240mg, 300mg, 360mg cap
DYNACIRC CR 5MG, 10MG TAB
felodipine er 2.5mg, 5mg, 10mg tab
isradipine 2.5mg, 5mg cap
nicardipine 20mg, 30mg cap
nifediac cc 30mg, 60mg, 90mg tab, sr
nifedical xl 30mg tab
nifedical xl 60mg tab
nifedipine er 30mg, 60mg, 90mg tab
nimodipine 30mg cap
nisoldipine 25.5mg, 30mg tab QL-60 QY 30 DY
nisoldipine 8.5mg, 17mg, 20mg, 34mg, 40mg tab QL-30
QY 30 DY
taztia xt 120mg, 180mg, 240mg, 300mg, 360mg caps
TWYNSTA 5MG/ 40MG, 5MG/80MG, 10MG/40MG,
10MG/80MG TABS QL-30 QY 30 DY
verapamil 2.5mg/ml ampul
verapamil hcl 40mg, 80mg, 120mg tabs
verapamil hcl er 100mg, 120mg, 180mg, 200mg, 240mg,
300mg cap,24hr
verapamil hcl er 120mg, 180mg, 240mg tabs
verapamil hcl sr 360mg cap,24hr
Cardiovascular Agents, Other
DEMSER 250MG CAP
digoxin 125mcg, 250mcg tab
digoxin 250mcg/ml ampul
digoxin 50mcg/ml soln oral
LANOXIN 125MCG, 250MCG TAB
pentoxifylline er 400mg tab
RANEXA 500MG & 1000MG TABS QL-60 QY 30 DY
Diuretics, Carbonic Anhydrase Inhibitors
acetazolamide 125mg, 250mg tab
acetazolamide 500mg cap
B-29
Drug
Notes
90D
90D
90D

Tier
Plan Notes
1
1
1
1
90D; QL
90D; QL
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D; QL
3
1
1
1
1
3
3
3
1
1
1
1
1
3
3
90D; QL
90D
90D; QL
90D
1
1
90D
90D
90D
1
1
90D
90D
90D
90D; QL
3
1
1
1
3
1
3
90D
90D
1
1
90D
ST
Drug Name
Diuretics, Loop
bumetanide 0.25mg/ml vial
bumetanide 0.5mg, 1mg, 2mg tab
EDECRIN 25MG TAB
furosemide 10mg/ml soln oral
furosemide 10mg/ml vial
furosemide 20mg, 40mg, 80mg tab
furosemide 40mg/5ml soln oral
torsemide 5mg, 10mg, 20mg, 100mg tabs
Diuretics, Potassium-sparing
amiloride 5mg tab
amiloride/hctz 5mg/50mg tab
DYRENIUM 50MG, 100MG CAP
eplerenone 25mg, 50mg tab
spironolactone /hctz 25mg/25mg tab
spironolactone 25mg, 50mg, 100mg tabs
triamterene/hctz 37.5mg/25mg; 75mg/50mg cap
triamterene/hctz 37.5mg/25mg; 75mg/50mg tab
Diuretics, Thiazide
chlorothiazide 250mg, 500mg tab
chlorthalidone 25mg, 50mg tab
hydrochlorothiazide 12.5mg cap
hydrochlorothiazide 12.5mg, 25mg, 50mg tab
indapamide 1.25mg, 2.5mg tab
methyclothiazide 5mg tab
metolazone 2.5mg, 5mg, 10mg tab
THALITONE 15MG TAB
Dyslipidemics, Fibric Acid Derivatives
ANTARA 43MG, 130MG CAP QL-30 QY 30 DY
fenofibrate 54mg, 160mg tab
fenofibrate 67mg, 134mg, 200mg micronized cap
FENOGLIDE 40MG, 120MG TAB QL-30 QY 30 DY
gemfibrozil 600mg tab
LIPOFEN 150MG CAP QL-30 QY 30 DY
LIPOFEN 50MG CAP QL-90 QY 30 DY
TRICOR 48MG, 145MG TABS QL-30 QY 30 DY
TRIGLIDE 50MG, 160MG TABS QL-30 QY 30 DY
TRILIPIX 45MG, 135MG CAPS QL-30 QY 30 DY
Dyslipidemics, HMG CoA Reductase Inhibitors
ADVICOR 500MG/20MG, 1000MG/40MG TAB QL-30
QY 30 DY
Drug
Notes

Tier
Plan Notes
90D
90D
90D
1
1
3
1
1
1
1
1
90D
90D
90D
90D
90D
90D
90D
90D
90D
1
1
3
3
3
1
1
1
1
90D
90D
90D
90D
90D
90D
90D
90D
1
1
1
1
1
1
1
3
90D; QL
90D
90D
90D; QL
90D
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
2
1
1
3
1
2
2
3
3
3
90D; QL
90D
90D
90D
B-30
Drug Name
ADVICOR 750MG/20MG, 1000MG/20MG TAB QL-60
QY 30 DY
ALTOPREV 20MG, 40MG, 60MG TAB QL-30 QY 30 DY
atorvastatin calcium 10mg, 20mg, 40mg, 80mg tab QL30 QY 30 DY
CRESTOR 5MG, 10MG, 20MG, 40MG TAB QL-30 QY
30 DY
fluvastatin sodium 20mg cap QL-30 QY 30 DY
fluvastatin sodium 40mg cap QL-60 QY 30 DY
LIVALO 1MG, 2MG, 4MG TAB QL-30 QY 30 DY
lovastatin 10mg, 20mg, 40mg tab
pravastatin 10mg, 20mg, 40mg, 80mg tabs
simvastatin 5mg, 10mg, 20mg, 40mg tabs
simvastatin tab 80mg
Dyslipidemics, Other
cholestyramine 4g light packet
cholestyramine 4g light powder
cholestyramine 4g packet
cholestyramine 4g powder
colestipol 1g tab
colestipol 5g granules
colestipol 5g packet
LOVAZA 1G CAP QL-120 QY 30 DY
NIASPAN 500MG TABCR QL-30 QY 30 DY
NIASPAN 750MG, 1000MG TABCR QL-60 QY 30 DY
prevalite 4gm packet
prevalite 4gm powder
VYTORIN TAB 10/10MG, 10/20MG, 10/40MG TABS
QL-30 QY 30 DY
VYTORIN TAB 10/80MG TABS QL-30 QY 30 DY
WELCHOL 3.75GM PACK QL-30 PACK 30 DY
WELCHOL 625MG TAB QL-180 QY 30 DY
ZETIA 10MG TAB QL-30 QY 30 DY
Vasodilators, Direct-acting Arterial/Venous
DILATRATE SR 40MG CAP
isosorbide dinitrate 2.5mg, 5mg tab, subl
isosorbide dinitrate 5mg, 10mg, 20mg, 30mg tab
isosorbide dinitrate er 40mg tab
isosorbide mononitrate 10mg, 20mg tab
isosorbide mononitrate er 30mg, 60mg, 120mg tab
NITRO-BID 2% OINT
nitroglycerin 0.1mg/hr; 0.2mg/hr; 0.4mg/hr; 0.6mg/hr
patch
nitroglycerin 0.4mg/dose pumpspray
B-31
Drug
Notes

Tier
Plan Notes
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
90D
90D
90D
90D
3
3
3
1
1
1
1
90D
90D
90D
90D
90D
90D
90D
90D; QL
90D; QL
90D; QL
90D
90D
1
1
1
1
3
3
3
2
2
2
1
1
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
2
3
3
3
90D
90D
90D
90D
90D
90D
90D
3
1
1
1
1
1
2
90D
90D
ST
PA
PA
Drug Name
Drug
Notes
nitroglycerin 50mg/10ml vial

NITROMIST 0.4MG/DOSE SPRAY
90D
NITROSTAT 0.3MG, 0.4MG, 0.6MG TAB, SUBL
90D
Vasodilators, Direct-acting Arterial
hydralazine 10mg, 25mg, 50mg, 100mg tab
90D
hydralazine 20mg/ml vial
minoxidil 2.5mg, 10mg tab
90D
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine salt combo 1.25mg tab
HRM
HRM
HRM
HRM
HRM
amphetamine salt combo 5mg tab
HRM
HRM
amphetamine/dextroamphetamine er 10mg cap QL-30
HRM;
QY 30 DY
QL
HRM;
QY 30 DY
QL
HRM;
QY 30 DY
QL
HRM;
QY 30 DY
QL
HRM;
QY 30 DY
QL
HRM;
QY 30 DY
QL
dextroamphetamine sulfate 5mg, 10mg tab
HRM
dextroamphetamine sulfate er 5mg, 10mg, 15mg cap,
HRM
24hr
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines
CONCERTA TAB 18MG, 27MG, 54MG QL-30 QY 30
HRM;
DY
QL
HRM;
CONCERTA TAB 36MG QL-60 QY 30 DY
QL
dexmethylphenidate 2.5mg, 5mg, 10mg tab
HRM
INTUNIV 1MG, 2MG, 3MG, 4MG TB24 QL-30 QY 30 DY 90D; QL
METADATE CD 10MG, 20MG, 30MG, 40MG, 50MG,
HRM;
60MG CAP QL-30 QY 30 DY
QL
metadate er 20mg tab
HRM
methylphenidate 5mg, 10mg, 20mg tab
HRM
methylphenidate hcl er 18mg, 27mg, 54mg tab QL-30
HRM;
QY 30 DY
QL
methylphenidate hcl er 20mg, 40mg cap QL-30 QY 30
HRM;
DY
QL

Tier
Plan Notes
1
3
2
1
1
1
1
1
1
1
1
1
1
3
ST
ST
ST
ST
ST
ST
1
3
ST
ST
ST
1
3
PA
ST
1
1
3
ST
ST
B-32
Drug Name
methylphenidate hcl er 30mg cap QL-60 QY 30 DY
methylphenidate hcl er 36mg tab QL-60 QY 30 DY
methylphenidate sr 20mg tab
RITALIN LA 10MG CAPS QL-30 QY 30 DY
Central Nervous System Agents
ascomp/codeine 30mg/50mg/325mg cap
Central Nervous System, Other
RILUTEK 50MG TAB
XENAZINE 12.5MG TAB QL-90 QY 30 DY
XENAZINE 25MG TAB QL-120 QY 30 DY
Fibromyalgia Agents
SAVELLA 12.5MG, 25MG, 50MG, 100MG TABS QL-60
QY 30 DY
SAVELLA TITRATION PACK QL-1 PACK PER 365
DAYS
Multiple Sclerosis Agents
AMPYRA 10MG TAB QL-60 QY 30 DY
COPAXONE 20MG KIT QL-30 INJ 30 DY
Dental and Oral Agents
Dental and Oral Agents
chlorhexidine gluconate 0.12% oral rinse
EVOXAC 30MG CAP
periogard 0.12% mouthwash
pilocarpine 5mg & 7.5mg tabs
triamcinolone in orabase 0.1%paste
Dermatological Agents
Dermatological Agents
8-MOP 10MG CAP
AKNE-MYCIN 2% OINT
alclometasone dipropionate 0.05% cream
alclometasone dipropionate 0.05% oint
ALTABAX 1% OINT QL-15GM 30 DY
amcinonide 0.1% cream
amcinonide 0.1% lotion
amcinonide 0.1% oint
ammonium lactate 12% cream
ammonium lactate 12% lotion
amnesteem 10mg, 20mg, 40mg cap
apexicon e 0.05% cream
augmented betameth dip 0.05% cream
B-33
Drug
Notes
HRM;
QL
HRM;
QL
HRM
HRM;
QL

Tier
Plan Notes
3
ST
ST
1
3
ST
QL
QL
2
3
3
90D; QL
QL
QL
QL
3
3
90D
90D
90D
90D
90D
QL
90D
90D
90D
90D
90D
90D
90D
1
3
2
1
3
1
2
3
1
1
3
1
1
1
1
1
3
3
1
PA
PA
PA
PA
PA
Drug Name
augmented betameth dip 0.05% gel
augmented betameth dip 0.05% lotion
augmented betameth dip 0.05% oint
AZELEX 20% CREAM
beta-val 0.1% cream
beta-val 0.1% lotion
beta-val 0.1% oint
betamethasone diprop 0.05% cream
betamethasone diprop 0.05% lotion
betamethasone diprop 0.05% oint
calcipotriene 0.005% soln non-oral
CAPEX 0.01% SHAMPOO
CARAC 0.5% CREAM
claravis 10mg, 20mg, 30mg, 40mg cap
clindamycin phos 1% lotion
clindamycin phos 1% gel
clindamycin phos 1% soln
clindamycin phos 1% swab
clindamycin/benzoyl peroxide gel 1%- 5%
clobetasol propionate 0.05% gel
clobetasol propionate 0.05% oint
clobetasol propionate 0.05% soln
clobetasol propionate e 0.05% cream
CLODERM 0.1% CREAM
CONDYLOX 0.5% GEL
CORDRAN 0.05% LOTION
CORDRAN 4MCG/SQ CM TAPE
CORDRAN SP 0.05% CREAM
desonide 0.05% cream
desonide 0.05% lotion
desonide 0.05% oint
desoximetasone 0.05% gel
desoximetasone 0.05%, 0.25% cream
desoximetasone 0.25% oint
diflorasone diacet 0.05% cream
diflorasone diacet 0.05% oint
ELIDEL 1% CREAM QL-30GM 30 DY
ery 2% swab
erythromycin 2% gel
erythromycin 2% soln
erythromycin/benzoyl 3%/ 5% peroxide gel
FINACEA 15% GEL
Drug
Notes
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D; QL
90D

Tier
Plan Notes
1
1
1
3
1
1
1
1
1
1
3
3
3
3
1
1
1
1
3
1
1
1
1
3
3
3
3
3
1
1
1
3
3
3
3
3
3
ST
1
1
1
3
3
B-34
Drug Name
FINACEA PLUS 15% KIT
fluocinolone acetonide 0.01% body oil
fluocinolone acetonide 0.01% scalp oil
fluocinolone acetonide 0.01% soln
fluocinolone acetonide 0.01%, 0.025% cream
fluocinolone acetonide 0.025% oint
fluocinonide 0.05% emollient base cream
fluocinonide 0.05% gel
fluocinonide 0.05% oint
fluocinonide 0.05% soln non-oral
FLUOROPLEX 1% CREAM
fluorouracil 2%, 5% soln
fluorouracil 5% cream
fluticasone propionate 0.005% oint
fluticasone propionate 0.05% cream
gauze pads 2"x2" bandage
gentamicin sulfate 0.1% cream
gentamicin sulfate 0.1% oint
halobetasol propionate 0.05% cream
halobetasol propionate 0.05% oint
HALOG 0.1% CREAM
HALOG 0.1% OINT
hydrocortisone 2.5% cream
hydrocortisone 2.5% lotion
hydrocortisone 2.5% oint
hydrocortisone butyrate 0.1% cream
hydrocortisone butyrate 0.1% oint
hydrocortisone butyrate 0.1% soln
hydrocortisone in absorbase 1% oint
hydrocortisone valerate 0.2% cream
hydrocortisone valerate 0.2% oint
imiquimod 5% cream QL-12 PACK 30 DY
KENALOG 0.147MG/G AERO
laclotion 12% lotion
metronidazole 0.75% cream
metronidazole 0.75% gel
metronidazole 0.75% lotion
mometasone furoate 0.1% cream
mometasone furoate 0.1% oint
mometasone furoate 0.1% soln
mupirocin 2% oint
NORITATE 1% CREAM
B-35
Drug
Notes
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
QL
90D
90D
90D
90D
90D
90D
90D
90D
90D

Tier
Plan Notes
3
1
1
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
3
3
3
3
1
1
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1
1
1
3
Drug Name
OXSORALEN 1% LOTION
OXSORALEN ULTRA 10MG CAP
PENNSAID 1.5% DROPS QL-450ML 30 DAYS
PICATO 0.015% GEL QL-3 TUBES 30 DY
PICATO 0.05% GEL QL-2 TUBES 30 DY
podofilox 0.5% soln
prednicarbate 0.1% cream
prednicarbate 0.1% oint
PROTOPIC 0.03% & 0.1% OINT QL-30GM 30 DY
REGRANEX 0.01% GEL QL-15GM 30 DY
SANTYL 250UNIT/GM OINT
scalacort 2% lotion
silver sulfadiazine 1% cream
sodium sulfacetamide 10% susp
SORIATANE 10MG, 17.5MG, 25MG CAPS QL-60 QY
30 DY
sotret 10mg, 20mg, 30mg, 40mg caps
ssd 1% cream
SULFAMYLON 50G PACKET
SULFAMYLON 8.5% CREAM
TACLONEX 0.064%; 0.005% OINT QL-400 QY 28 DY
TAZORAC 0.05%, 0.1% CREAM QL-30GM 30 DY
TAZORAC 0.05%, 0.1% GEL QL-30GM 30 DY
TEXACORT 2.5% SOLN NON-ORAL
thermazene 1% cream
tretinoin 0.025%, 0.01% gels
tretinoin 0.025%, 0.05%, 0.1% creams
triamcinolone acetonide 0.025%, 0.1% lotions
triamcinolone acetonide 0.025%, 0.1%, 0.5% creams
triamcinolone acetonide 0.025%, 0.1%, 0.5% oints
triderm 0.1% cream
VEREGEN 15% OINT QL-15GM 30 DY
VOLTAREN 1%GMEL QL-1000GM 30 DY
ZONALON 5% CREAM QL-45GM 30 DY
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN 250 UNIT/1 VIAL
ALDURAZYME 2.9MG/5ML VIAL
BUPHENYL 500MG TAB
CEREDASE 80 UNIT/ML VIAL
CEREZYME 200 UNIT, 400 UNIT VIAL
CREON 120000UNIT/24000UNIT/76000UNIT CAP
Drug
Notes
QL
90D; QL
90D; QL
90D
90D
90D; QL
QL
90D
QL

Tier
Plan Notes
2
3
2
3
3
1
1
1
3
ST
3
PA
3
1
1
1
3
90D
90D
90D
90D
90D
90D
QL
QL
QL
3
1
3
3
3
3
3
3
1
1
1
1
1
1
1
3
3
3
90D
3
3
3
3
3
2
QL
QL
QL
90D
PA
PA
PA
PA
PA
B-36
Drug Name
CYSTADANE POWDER
CYSTAGON 50MG, 150MG CAP
ELAPRASE 6MG/3MLVIAL
ELELYSO 200UNIT SOLR
FABRAZYME 35MG VIAL
KUVAN 100MG TAB
NAGLAZYME 5MG/5ML VIAL
ORFADIN 2MG, 5MG, 10MG CAP
SUCRAID 85000UNIT/ML SOLN
ZAVESCA 100MG CAP
ZENPEP 10000UNIT/34000UNIT/55000UNIT CAP QL120 QY 30 DY
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
CANTIL 25MG TAB
dicyclomine 10mg cap
dicyclomine 10mg/5ml syrup
dicyclomine 20mg tab
glycopyrrolate 0.2mg/ml vial
glycopyrrolate 1mg, 2mg tab
methscopolamine bromide 2.5mg, 5mg tab
propantheline bromide 15mg tab
Gastrointestinal Agents, Other
CORTIFOAM 10%
cromolyn sodium 20mg/ml soln oral
diphenoxylate/atropine 2.5mg-0.025mg/5ml liquid
diphenoxylate/atropine 2.5mg/0.025mg tab
HALFLYTELY 5MG/210G/0.74G/2.86G/5.6G BOWEL
PREP KIT/FLAVOR PACKS QL-1 KIT QY 30 DY
B-37
Drug
Notes
90D
90D
90D
90D

Tier
Plan Notes
2
2
2
3
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
90D
90D;
HRM
90D;
HRM
90D;
HRM
90D
90D
90D;
HRM
PA
PA
PA
3
3
3
1
90D
HRM
HRM
2
1
1
1
QL
Drug Name
loperamide 2mg cap
metoclopramide 5mg, 10mg tab
metoclopramide 5mg/5ml soln oral
metoclopramide 5mg/ml vial
MOTOFEN 0.025MG/1MG TAB
OSMOPREP 1.5G TAB
proctosol hc 2.5% cream
proctozone-hc 2.5% cream
RELISTOR 12MG/0.6ML SOLN
ursodiol cap 300mg
ursodiol tab 250mg, 500mg
VISICOL 1.5GM TAB
Histamine2 (H2) receptor Antagonists
cimetidine 150mg/ml vial
cimetidine 200mg, 300mg, 400mg, 800mg tab
cimetidine 300mg/5ml soln oral
famotidine 20mg, 40mg tab
famotidine 20mg/2ml vial
famotidine 20mg/50ml iv
famotidine 40mg/5ml suspension
nizatadine 150mg/10ml oral soln
nizatidine 150mg, 300mg cap
ranitidine 150mg & 300mg caps
ranitidine 150mg & 300mg tabs
ranitidine 15mg/ml syrup
ranitidine 25mg/ml vial
Irritable Bowel Syndrome Agents
AMITIZA 8MG, 24MG CAP QL-60 QY 30 DY
LOTRONEX 0.5MG, 1MG TAB QL-60 QY 30 DY
Laxatives
constulose 10g/15ml soln oral
enulose 10g/15ml soln oral
gavilyte-c 240g/2.98g/6.72g/5.84g/22.72g soln oral QL-1
KIT QY 30 DY
gavilyte-g 236g/2.97g/6.74g/5.86g/22.74g soln oral QL-1
KIT QY 30 DY
gavilyte-n 420g/1.48g/5.72g/11.2g QL-1 KIT QY 30 DY
generlac 10g/15ml soln oral
GOLYTELY 236G/2.97G/6.74G/5.86G/22.74G QL-1 KIT
QY 30 DY
lactulose 10g/15ml soln oral
MOVIPREP 4.7G/100G/1.015G/5.9G/2.691G/7.5G QL-1
KIT QY 30 DY
Drug
Notes
90D
90D
90D
HRM
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D

Tier
Plan Notes
1
1
1
1
3
3
1
1
3
PA
1
3
3
1
1
1
1
1
3
3
3
3
1
1
3
1
90D; QL
QL
3
2
90D
90D
1
1
QL
QL
QL
90D
1
1
QL
90D
QL
PA
PA
B-38
Drug Name
NULYTELY 420G QL-1 KIT QY 30 DY
peg 3350 240g/2.98g/6.72g/5.84g/22.72g QL-1 KIT QY
30 DY
polyethylene glycol 3350 powder
SUPREP BOWL PREP QL-1 KIT QY 30 DY
trilyte 420gm soln oral QL-1 KIT QY 30 DY
Protectants
misoprostol 100mcg, 200mcg tab
sucralfate 1g tab
Proton Pump Inhibitors
lansoprazole 15mg, 30mg capr QL-30 QY 30 DY
NEXIUM 10MG, 20MG, 40MG PACK QL-30 PACK 30
DY
NEXIUM 20MG, 40MG CAP QL-30 QY 30 DY
NEXIUM 20MG, 40MG IV
omeprazole 10mg cap QL-30 QY 30 DY
omeprazole 20mg cap
omeprazole 40mg cap QL-60 QY 30 DY
pantoprazole 20mg tab QL-30 QY 30 DY
pantoprazole 40mg tab QL-60 QY 30 DY
VIMOVO 20MG/375MG, 20MG/500MG TABS QL-60 QY
30 DY
Genitourinary Agents
Antispasmodics, Urinary
ENABLEX 7.5MG, 15MG TAB QL-30 QY 30 DY
flavoxate 100mg tab
GELNIQUE 10% GEL QL-30 PACK 30 DY
oxybutynin 5mg tab
oxybutynin 5mg/5ml syrup
oxybutynin er 15mg tab QL-60 QY 30 DY
oxybutynin er 5mg, 10mg tab QL-30 QY 30 DY
OXYTROL 3.9MG/24HR PATCH QL-8 PATCHES 28 DY
SANCTURA XR 60MG CAP QL-30 QY 30 DY
trospium 20mg tab QL-60 QY 30 DY
VESICARE 5MG, 10MG TABS QL-30 QY 30 DY
Benign Prostatic Hypertrophy Agents
alfuzosin hcl 10mg er tab QL-30 QY 30 DY
AVODART 0.5MG CAP QL-30 QY 30 DY
doxazosin mesylate 1mg, 2mg, 4mg, 8mg tab
finasteride 5mg tab
JALYN 0.5MG/0.4MG CAP QL-30 QY 30 DY
RAPAFLO 4MG & 8MG CAPS QL-30 QY 30 DY
tamsulosin 0.4mg cap QL-60 QY 30 DY
B-39
Drug
Notes
QL

Tier
Plan Notes
2
QL
QL
QL
1
3
1
90D
90D
1
1
90D; QL
90D; QL
90D; QL
90D; QL
90D
90D; QL
90D; QL
90D; QL
2
2
1
1
1
1
1
90D; QL
90D; QL
90D
90D; QL
90D
90D
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
3
3
3
1
1
3
3
3
2
1
2
90D; QL
90D; QL
90D
90D
90D; QL
90D; QL
90D; QL
1
2
1
1
2
3
1
ST
ST
ST
ST
Drug Name
Drug
Notes
terazosin 1mg, 2mg, 5mg, 10mg caps

90D
Genitourinary Agents, Other
bethanechol 5mg, 10mg, 25mg, 50mg tab
90D
CLEOCIN 100MG VAGINAL SUPP
clindamycin phos 2% cream
ELMIRON 100MG CAP
metronidazole vaginal gel 0.75%
terconazole 0.4%, 0.8% cream
terconazole 80mg vaginal supp
vandazole 0.75% gel
zazole 0.4% cream
Phosphate Binders
calcium acet 667mg cap
90D
eliphos 667mg tab
90D
FOSRENOL 1000MG CHEW QL-120 QY 30 DY
90D; QL
FOSRENOL 500MG & 750MG CHEW QL-180 QY 30
90D; QL
DY
PHOSLYRA SOLN 667MG/5ML
90D
RENVELA 2.4GM PACK QL-90 QY 30 DY
90D; QL
RENVELA 800MG TAB
90D
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
Glucocorticoids/Mineralocorticoids
a-hydrocort 100mg solr
a-methapred 40mg/ml, 125mg/2ml vial
CELESTONE 0.6MG/5ML SOLN ORAL
90D
cortisone acet 25mg tab
90D
dexamethasone 0.5mg, 0.75mg, 1mg, 1.5mg, 2mg, 4mg,
90D
6mg tab
dexamethasone 0.5mg/5ml elixir
90D
dexamethasone intensol 0.5mg/.5ml drops
90D
dexamethasone sod phos 4mg/ml vial
fludrocortisone 0.1mg tab
90D
hydrocortisone 5mg, 10mg, 20mg tab
90D
methylprednisolone 4mg tab
90D
methylprednisolone 4mg, 8mg, 16mg, 32mg tab
90D
methylprednisolone acet 40mg/ml, 80mg/ml vial
methylprednisolone sod succ 40mg, 125mg, 1000mg
vial
millipred 5mg tab
90D
prednisolone 5mg/5ml syrup
90D
prednisolone sod phos 15mg/5ml soln oral
90D
prednisone 1mg, 2.5mg, 5mg, 10mg, 20mg, 50mg tabs
90D
prednisone 5mg/5ml soln oral
90D

Tier
Plan Notes
1
3
3
1
2
1
1
1
1
1
3
1
3
3
3
2
2
1
3
3
1
1
1
1
1
1
1
1
1
1
3
3
1
1
1
1
B-40
Drug Name
Drug
Notes

Tier
Plan Notes
1
prednisone intensol 5mg/ml conc oral

90D
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin acet 0.01% nasal aerosol
90D
1
desmopressin acet 0.1mg, 0.2mg tab
90D
1
desmopressin acet 0.1mg/ml nasal soln
90D
1
desmopressin acet 4mcg/ml vial
1
INCRELEX 10MG/ML VIAL
3
OMNITROPE 10MG/1.5ML CARTRIDGE
3
OMNITROPE 5.8MG VIAL
3
OMNITROPE 5MG/1.5ML VIAL
3
SEROSTIM 4MG, 5MG, 6MG VIALS
3
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
Anabolic Steroids
ANADROL-50 50MG TAB
2
oxandrolone 10mg tab QL-60 QY 30 DY
QL
1
oxandrolone 2.5mg tab QL-120 QY 30 DY
QL
1
Androgens
ANDROGEL 50MG 1% GEL
2
ANDROGEL PUMP 1.25G 1% GEL
2
ANDROGEL PUMP 20.25MG 1.62% GEL
2
androxy 10mg tab
1
danazol 50mg, 100mg, 200mg cap
3
testosterone cypionate 100mg/ml, 200mg/ml vial
3
testosterone enanthate 200mg/ml vial
3
TESTRED 10MG CAP
HRM
3
Estrogens
ALORA 0.025MG/24H, 0.05MG/24H, 0.075MG/24H,
90D; QL
3
0.1MG/24HR PATCH QL-8 PATCHES 28 DY
amethyst 20mcg/90mcg tab
90D
3
ANGELIQ 1MG/0.5MG TAB
90D
3
apri 0.15mg/0.03mg tab
90D
3
aranelle 7-9-5 tab
90D
3
aviane tab 0.1mg/0.02mg tab
90D
3
balziva 0.4mg/0.035mg tab
90D
3
briellyn 0.4mg/0.035mg tab
90D
3
cesia tab
90D
1
CLIMARA PRO 0.045MG/0.015MG PTWK QL-4 PATCH
90D; QL
3
28 DY
COMBIPATCH 0.05MG/0.14MG, 0.05MG/0.25MG
90D; QL
3
PATCH QL-8 PATCHES 28 DY
cryselle-28 0.3mg/0.03mg tab
90D
3
DEPO-ESTRADIOL 5MG/ML VIAL
3
B-41
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug Name
DIVIGEL 1MG (0.1%) GEL QL-30GM 30 DY
emoquette 0.15mg/30mcg tab
enpresse-28 0.03mg-0.05mg/0.03mg-0.125mg/0.04mg0.075mg tab
ESTRACE 0.01% CREAM
estradiol 0.025mg/24hr; 0.0375mg/24hr; 0.05mg/24hr;
0.06mg/24hr; 0.075mg/24hr; 0.1mg/24hr patch
estradiol 0.5mg, 1mg, 2mg tab
estradiol/norethindrone 0.5mg/ 0.1mg tab
estradiol/norethindrone 1mg/0.5mg tab
ESTRING 7.5MCG/24HR RING QL-1 RING 90 DY
EVAMIST 1.53MG/ SPRAY QL-2 BOTTLES 30 DY
FEMHRT LOW DOSE 0.5MG/2.5MCG TAB
FEMRING 0.05MG/24HR, 0.1MG/24HR RING QL-1
RING 84 DY
FEMTRACE 0.45MG, 0.9MG, 1.8MG TAB
gianvi 0.02mg/3mg tab
jinteli 1mg/5mcg
junel 1mg/20mcg; 1.5mg/30mcg tab
junel fe 1mg/20mcg; 1.5mg/30mcg tab
kariva 21-5 tab
kelnor 1/35 1mg/35mcg tab
leena 7-9-5 tab
lessina-28 0.1mg/20mcg tab
levora 0.15mg/30mcg tab
LO LOESTRIN FE 1MG/75MG/10MCG TAB
LOESTRIN 24 FE 1MG/75MG/20MCG TAB
low-ogestrel 0.3mg/30mcg tab
lutera 0.1mg/20mcg tab
MENOSTAR 14MCG/24HR PATCH QL-4 PATCHES 28
DY
microgestin 1.5mg/30mcg tab
microgestin 1mg/20mcg tab
microgestin fe 1.5mg/30mcg tab
microgestin fe 1mg/20mcg tab
mononessa 0.25mg/35mcg tab
necon 0.5/35-28 0.5mg/35mcg tab
necon 1/35-28 1mg/35mcg tab
necon 10/11-28 tab
necon 7/7/7 tab
nortrel 0.5mg/35mcg; 1mg/35mcg tab
nortrel tab
Drug
Notes
90D; QL
90D

Tier
Plan Notes
3
3
90D
90D
90D
90D
90D
90D
90D; QL
QL
90D
1
3
3
3
3
3
90D; QL
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
3
3
3
1
1
3
3
3
3
3
3
3
3
3
90D; QL
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
1
1
1
1
3
3
3
3
3
3
3
3
B-42
Drug Name
ocella 0.03mg/3mg tab
ogestrel 0.5mg/50mcg tab
ORTHO EVRA PATCH 150MCG-20MCG/24HR QL-3
PATCH 28 DY
portia-28 tab
PREFEST TAB
PREMARIN 0.625MG/GM CREAM
previfem 0.25mg/35mcg tab
reclipsen 0.15mg/30mcg tab
solia 0.15mg/30mcg tab
sprintec 28 tab
sronyx 0.1mg/20mcg tab
tri-legest fe tab
tri-previfem tab
tri-sprintec tab
trinessa tab
trivora-28 tab
VAGIFEM 10mcg TAB
velivet tab
vestura tab 3mg/0.02mg
VIVELLE-DOT 0.025MG/24HR, 0.0375MG/24HR,
0.075MG/24HR, 0.05MG/24HR, 0.1MG/24HR
PATCHES QL-8 PATCHES 28 DY
zeosa 0.4mg/35mcg tab
zovia 1mg/35mcg, 1mg/50mcg tab
Progestins
amethia tab
camila 0.35mg tab
camrese lo tab
camrese tab
CRINONE 8% GEL
errin 0.35mg tab
introvale 0.15mg/0.03mg tab
jolivette 0.35mg tab
marlissa 0.03mg/0.15mg tab
medroxyprogesterone acet 150mg/ml vial QL-1ML 90
DY
medroxyprogesterone acet 2.5mg, 5mg, 10mg tab
next choice 0.75mg tab
nora-be 0.35mg tab
norethindrone acet 5mg tab
progesterone 100mg & 200mg caps
quasense 0.03mg/0.15mg tab
B-43
Drug
Notes
90D
90D

Tier
Plan Notes
3
3
90D; QL
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
90D
3
3
2
3
3
3
3
3
3
1
1
1
3
3
1
3
90D; QL
90D
90D
3
3
90D
90D
90D
90D
90D
90D
90D
90D
3
1
3
3
3
1
3
1
3
90D; QL
90D
1
1
1
1
1
3
90D
90D
90D
90D
Drug Name
Drug
Notes
Selective Estrogen Receptor Modifying Agents

EVISTA 60MG TAB QL-30 QY 30 DY
90D; QL
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothroid 25mcg, 50mcg, 75mcg, 88mcg, 100mcg,
112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg,
90D
300mcg tab
levothyroxine 25mcg, 50mcg, 75mcg, 88mcg, 100mcg,
112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg,
90D
300mcg tab
levoxyl 25mcg, 50mcg, 75mcg, 88mcg, 100mcg,
112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg
90D
tab
liothyronine 5mcg, 25mcg, 50mcg tab
90D
SYNTHROID 25MCG, 50MCG, 75MCG, 88MCG,
100MCG, 112MCG, 125MCG, 137MCG, 150MCG,
90D
175MCG, 200MCG, 300MCG TABS
THYROLAR 15MG, 30MG, 60MG, 120MG, 180MG
90D
TABS
TIROSINT 13MCG, 25MCG, 50MCG, 75MCG, 88MCG,
100MCG, 112MCG, 125MCG, 137MCG, 150MCG
90D; QL
CAPS QL-30 QY 30 DY
unithroid 25mcg, 50mcg, 75mcg, 88mcg 100mcg,
112mcg, 125mg, 137mcg 150mcg, 175mcg, 200mcg,
90D
300mcg tabs
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN 500MG TAB
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR 30MG & 60MG TAB QL-60 QY 30 DY
QL
SENSIPAR 90MG TAB QL-120 QY 30 DY
QL
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline 0.5mg tab
90D
leuprolide acet 1mg/0.2ml kit
LUPRON DEPOT 3.75MG, 7.5MG, 11.25MG, 22.5MG,
30MG, 45MG KIT
LUPRON DEPOT-PED 11.25MG, 15MG, 30MG KIT
octreotide 50mcg/ml; 100mcg/ml; 200mcg/ml;
500mcg/ml; 1000mcg/ml inj
SOMATULINE DEPOT 120MG/0.5ML QL-1 INJ 28 DY
QL
SOMATULINE DEPOT 60MG/0.2ML SOLN QL-1 INJ 28
QL
DY
SOMATULINE DEPOT 90MG/0.3ML SOLN QL-1 INJ 28
QL
DY
SOMAVERT 10MG, 15MG, 20MG VIALS
SYNAREL AERO 2MG/ML

Tier
Plan Notes
2
1
1
1
1
3
3
2
1
2
2
PA
PA
3
3
PA
PA
PA
PA
PA
PA
PA
3
2
PA
PA
B-44
Drug Name
Drug
Notes
TRELSTAR DEPOT 3.75MG SUSR QL-1 VIAL 28 DY

QL
TRELSTAR LA 11.25MG SUSR QL-1 VIAL 84 DY
QL
TRELSTAR MIXJECT 22.5MG QL-1 VIAL 168 DY
QL
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Antiandrogens
bicalutamide 50mg tab QL-30 QY 30 DY
90D; QL
flutamide 125mg cap
90D
NILANDRON 150MG TAB
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole 5mg, 10mg tab
90D
propylthiouracil 50mg tab
90D
Immunological Agents
Immune Suppressants
azathioprine 100mg soln
azathioprine 50mg tab
90D
BENLYSTA 120MG, 400MG SOLN
CELLCEPT 200MG/ML SUSPENSION
BvD
cyclosporine 25mg, 100mg cap
BvD
cyclosporine modified 100mg/ml soln oral
BvD
cyclosporine modified 50mg, 100mg cap
BvD
ENBREL 25MG KIT QL-16 INJ 30 DY
QL
ENBREL 25MG/0.5ML SOLN QL-16 SYRINGE 30 DY
QL
ENBREL 50MG/ML SOLN QL-8 SYRINGE 28 DY
QL
ENBREL PEN 50MG/ML SOLN QL-8 SYRINGE 28 DY
QL
gengraf 100mg/ml soln oral
BvD
gengraf 25mg, 100mg cap
BvD
HUMIRA 20MG/0.4ML KIT QL-2 SYRINGE 30 DY
QL
HUMIRA 40MG/0.8ML KIT QL-6 SYRINGE 30 DY
QL
HUMIRA PEN 40MG/0.8ML QL-6 SYRINGE 30 DY
QL
methotrexate 25mg/ml vial
methotrexatemg tab
90D
mycophenolate mofetil 250mg cap
BvD
mycophenolate mofetil 500mg tab
BvD
NEORAL 100MG/ML SOLN ORAL
BvD
NEORAL 25MG, 100MG CAP
BvD
NULOJIX 250MG
ORENCIA 125MG/1ML SYRINGE QL-4 QY 28 DY
QL
ORENCIA 250MG VIAL
RAPAMUNE 0.5MG TAB
BvD
RAPAMUNE 1MG TAB
BvD
RAPAMUNE 1MG/ML ORAL SOLN
BvD
B-45

Tier
Plan Notes
3
3
3
1
1
3
1
1
1
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
3
3
3
3
3
3
3
3
3
3
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug Name
RAPAMUNE 2MG TAB
REMICADE 100MG VIAL
SANDIMMUNE 100MG/ML SOLN ORAL
SANDIMMUNE 25MG & 100MG CAPS
tacrolimus 0.5mg cap
tacrolimus 1mg cap
tacrolimus 5mg cap
ZORTRESS 0.25MG, 0.5MG, 0.75MG TAB
Immunizing Agents, Passive
gammagard liquid 10% vial
GAMMAGARD S/D 2.5G, 5G, 10G VIAL
GAMMAPLEX 5% SOLN
Immunomodulators
ACTIMMUNE 2MM/0.5ML VIAL
ARCALYST 220MG VIAL QL-8 VIALS 30 DY
AVONEX 30MCG QL-4 INJ 30 DY
AVONEX 30MCG/0.5ML KIT QL-4 INJ 30 DY
BETASERON 0.3MG KIT QL-15 SYRINGE 30 DY
EXTAVIA 0.3MG KIT QL-15 SYRINGE 30 DY
ILARIS 180MG VIAL QL-1 VIAL QY 56 DY
leflunomide 10mg, 20mg tab
REBIF 22MCG/0.5ML, 44MCG/0.5ML SYRINGE QL-12
INJ 28 DY
REBIF TITRATION PACK SYRINGE QL-12 INJ 28 DY
RIDAURA 3MG CAP
Vaccines
ACTHIB 10MCG/0.5 VIAL
ADACEL 2-2.5-5MGC/.5ML VIAL
BOOSTRIX 18.5MCG-0.5ML/2.5LF-0.5ML/5LF-0.5ML
SYRINGE
BOOSTRIX 18.5MCG-0.5ML/2.5LF-0.5ML/5LF-0.5ML
VIAL
CERVARIX 0.5ML SYRINGE
COMVAX 5MCG-7.5MCG/0.5ML VIAL
DAPTACEL 10MCG-15LF-5LF/0.5ML VIAL
DECAVAC 5LFU/2LFU SYRINGE
DIPTHERIA/TETANUS TOXOID PEDIATRIC 6.7LFU5LFU/0.5ML INJ
ENGERIX-B 10MCG/0.5ML INJ
ENGERIX-B 20MCG/ML INJ
GARDASIL 0.5ML VIAL
HAVRIX 1440ELU/ML INJ
HAVRIX 720ELU/0.5ML INJ
Drug
Notes
BvD
BvD
BvD
BvD
BvD
BvD
BvD

Tier
Plan Notes
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
3
PA
BvD
BvD
BvD
3
3
2
PA
PA
PA
QL
QL
QL
QL
QL
QL
90D
3
3
3
3
3
3
3
1
PA
PA
PA
PA
PA
PA
QL
PA
QL
90D
3
3
PA
3
3
3
3
3
3
3
2
2
BvD
BvD
2
2
3
3
3
PA
PA
B-46
Drug Name
IMOVAX RABIES 2.5 UNIT INJ
INFANRIX 25LFU-58MCG-10LFU/0.5ML VIAL
IPOL 40-8-32/0.5ML VIAL
IXIARO 6MCG/0.5ML SUSP
JE-VAX VIAL
KINRIX 25-25-10 SYRINGE QL-1 INJ 365 DY
M-M-R II 12500/0.5 VIAL
MENACTRA 4MCG/0.5ML VIAL
MENOMUNE-A/C/Y/W-135 50MCG VIAL
MENVEO 10-5/0.5ML VIAL
PEDIARIX 58MCG-25LFU-10MCG-10LFU/0.5ML VIAL
PEDVAX HIB 7.5MCG/0.5ML VIAL
PENTACEL 48MCG-15LFU-5LFU/0.5ML KIT QL-3 INJ
30 DY
PROQUAD VIAL
RABAVERT 2.5 UNIT KIT
RECOMBIVAX HB 10MCG/ML & 40MCG/ML VIALS
ROTARIX SUSPENSION
ROTATEQ SUSPENSION
TENIVAC 2LFU/5LFU SYRINGE
TENIVAC 2LFU/5LFU VIAL
TETANUS TOXOID ADSORBED 5LF/0.5ML VIAL
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED
2LF/0.5MLVIAL
TRIHIBIT 46.8MCG/6.7LFU/5LFU KIT
TRIPEDIA 6.7LFU-0.5ML/46.8MCG-0.5ML/8LFU/0.5ML
VIAL
TWINRIX VIAL
TYPHIM VI 25MCG/0.5ML VIAL
VAQTA 25UNIT/0.5ML VIAL
VARIVAX 1350UNIT VIAL
YF-VAX VIAL
ZOSTAVAX 19400UNIT VIAL QL-1 INJ 365 DY
Inflammatory Bowel Disease Agents
Aminosalicylates
APRISO 0.375G CAP QL-120 QY 30 DY
ASACOL 400MG TAB
ASACOL HD 800MG TAB
balsalazide 750mg cap
CANASA 1000MG SUPP RECTAL
DIPENTUM 250MG CAP
LIALDA 1.2G TAB QL-120 QY 30 DY
mesalamine 4g/60ml enema
B-47
Drug
Notes
QL
QL
BvD

Tier
Plan Notes
3
2
2
3
3
3
2
3
2
3
3
3
3
3
3
3
2
2
2
2
2
2
3
3
QL
3
3
3
2
2
3
90D; QL
90D
90D
90D
90D
90D
90D; QL
90D
2
2
2
3
2
3
3
1
PA
Drug Name
PENTASA 250MG, 500MG CAP
Glucocorticoids
budesonide ec 3mg cap
hydrocortisone 100mg/60ml enema
Sulfonamides
sulfasalazine 500mg tab
sulfazine ec 500mg tab
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL 150MG TAB QL-1 QY 30 DY
ACTONEL 35MG TAB QL-4 QY 28 DY
ACTONEL 5MG, 30MG TAB QL-30 QY 30 DY
alendronate 5mg, 10mg, 35mg, 40mg, 70mg tab
BONIVA 3MG/3ML SOLN QL-3ML 90 DY
calcitonin-salmon 200 unit/dose aero
calcitriol 0.25mcg, 0.5mcg cap
calcitriol 1mcg/ml ampul
calcitriol 1mcg/ml soln oral
etidronate 200mg, 400mg tab
FORTEO 20MCG/DOSE QL-1 PEN 28 DY
fortical 200unit/dose nasal soln
HECTOROL 0.5MCG, 1MCG, 2.5MCG CAP
ibandronate sodium 150mg tab QL-1 QY 30 DY
pamidronate 30mg/10ml; 60mg/10ml; 90mg/10ml vial
PROLIA 60MG/ML SOLN QL-1 QY 180 DY
SKELID 200MG TAB
ZEMPLAR 1MCG, 2MCG, 4MCG CAP QL-30 QY 30 DY
ZOMETA 4MG/100ML SOLN
ZOMETA 4MG/5ML VIAL
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
fomepizole 1g/ml vial
INSULIN PEN NEEDLE
INSULIN SAFETY SYRINGE
INSULIN SYRINGE
intralipid 20% emulsion
INTRALIPID 30% EMULSION
levocarnitine 330mg tab
LIPOSYN II 10%, 20% EMUL
Drug
Notes
90D

Tier
Plan Notes
3
90D
3
3
90D
90D
1
1
90D; QL
90D; QL
QL
90D
B v D;
QL
90D
90D; B v
D
BvD
90D; B v
D
90D
QL
90D
BvD
90D; B v
D; QL
BvD
QL
90D
B v D;
QL
3
3
3
1
ST
ST
ST
PA
90D
90D
90D
BvD
BvD
90D
BvD
1
1
PA
PA
PA
3
3
1
3
PA
PA
PA
3
3
3
PA
PA
PA
3
3
PA
PA
3
2
3
2
3
3
3
3
PA
PA
PA
PA
B-48
Drug Name
LIPOSYN III 10%, 20% EMUL
LIPOSYN III 30% VIAL
MEGACE ES 625MG/5ML ORAL SUSP QL-150ML 30
DY
megestrol acet 20mg, 40mg tab
megestrol acet 400mg/10ml suspension
methylergonovine maleate 0.2mg tab
sodium chloride 0.9%irrigation
VORAXAZE 1000UNIT SOLR
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost 0.005% QL-2.5ML 30 DY
LUMIGAN 0.01%, 0.03% QL-5ML 30 DY
TRAVATAN Z 0.004% QL-5ML 30 DY
Ophthalmic Agents, Other
AZASITE 1% DROPS QL-2.5ML 14 DY
bacitracin 500 unit/g oint
bacitracin/polymyxin b 500/10k/g oint
BESIVANCE 0.6% SUSP QL-5ML 30 DY
CILOXAN 0.3% OINT
ciprofloxacin 0.3% drops
erythromycin 5mg/g oint
gentak 0.3%oint
gentamicin sulfate 0.3% opht drops
LACRISERT 5MG INSERT
levofloxacin 0.5% drops
MOXEZA 0.5% DROPS QL-3ML 30 DY
NATACYN 5% SUSPENSION
neomycin /bacitracin /hydrocortisone 3.5-10k-1 oint
neomycin /bacitracin /polymyxin 3.5mg-400 oint
neomycin /polymyxin /gramicidin 1.75mg-10k drops
ofloxacin 0.3% opht soln
RESTASIS 0.05% QL-64 VIALS 30 DY
romycin 5mg/gm oint
sodium sulfacetamide ophth 10% drops
sodium sulfacetamide ophth 10% oint
tobramycin sulfate 0.3% ophth drops
TOBREX 0.3% OPHTH OINT
trifluridine 1% drops
trimethoprim sulf/poly b sulfate 10000units1ml/0.1%drops
tropicamide 0.5%, 1% drops
B-49
Drug
Notes
BvD
BvD

Tier
Plan Notes
3
PA
3
PA
90D; QL
90D
90D
1
1
3
1
3
90D; QL
90D; QL
90D; QL
1
2
3
QL
3
1
1
3
3
1
1
1
1
3
3
3
2
1
1
1
3
3
1
1
3
1
3
3
QL
QL
90D; QL
1
90D
PA
Drug Name
VIGAMOX 0.5% DROPS QL-3ML 30 DY
ZYMAXID 0.5% DROPS QL-2.5ML 30 DY
Ophthalmic Anti-allergy Agents
ak-con 0.1% drops
ALOCRIL 2% DROPS QL-10ML 30 DY
ALOMIDE 0.1% DROPS
azelastine 0.05% drops
BEPREVE 1.5% DROPS QL-10ML 30 DY
cromolyn 4% drops
EMADINE 0.05% DROPS
epinastine 0.05% drops
LASTACAFT 0.25% DROPS QL-3ML 30 DY
PATADAY 0.2% DROPS QL-2.5ML 30 DY
PATANOL 0.1% DROPS QL-5ML 30 DY
Ophthalmic Anti-inflammatories
ACUVAIL 0.45% OPHTH DROPS QL-60 VIALS 30 DY
ALREX 0.2% SUSP QL-15ML 30 DY
BLEPHAMIDE 10%/0.2% SUSPENSION
BLEPHAMIDE S.O.P. 10%/0.2% OINT
BROMDAY 0.09% OPHTHALMIC SOLN QL-1.7ML QY
30 DY
bromfenac 0.09% ophthalmic soln QL-3ML 30 DY
dexamethasone sod phos 0.1% drops
diclofenac 0.1% drops
DUREZOL 0.05% DROPS
FLAREX 0.1% SUSPENSION
fluorometholone 0.1% suspension
flurbiprofen 0.03% drops
FML 0.1% OINT
FML FORTE 0.25% SUSPENSION
ketorolac trometh 0.4%, 0.5% ophth soln QL-10ML 30
DY
LOTEMAX 0.5% OINTMENT
LOTEMAX 0.5% SUSPENSION
MAXIDEX 0.1% SUSPENSION
neomycin /poly/hydrocort 3.5-10k-10 opht susp
neomycin /polymyxin /dexameth 0.1% suspension
neomycin /polymyxin /dexameth 3.5-10k-.1 oint
NEVANAC 0.1% SUSP QL-3ML 30 DY
poly-dex 0.1%/2.5mg-gm/1000unit-gm oint
PRED MILD 0.12% SUSPENSION
PRED-G 0.3%/1% SUSPENSION
Drug
Notes
QL
QL
QL
90D; QL
90D
90D
90D; QL
90D; QL
90D; QL

Tier
Plan Notes
3
3
1
3
3
3
3
1
3
3
3
3
3
QL
QL
3
2
3
3
QL
QL
3
1
1
3
3
1
1
3
3
QL
QL
2
2
2
1
1
1
3
1
2
2
B-50
Drug Name
PRED-G S.O.P. 0.3%/0.6% OINT
prednisolone acet 1% ophth susp
prednisolone sod phos 1% ophth drops
sulfacetamide/predn sod phosp 10%/0.25% drops
TOBRADEX 0.3%/0.1% OINT
TOBRADEX ST 0.05%/0.3% SUSP
tobramycin/dexamethasone 0.3%/0.1% susp
VEXOL 1% SUSPENSION
ZYLET 0.3%/0.5% SUSPENSION
Ophthalmic Antiglaucoma Agents
ALPHAGAN P 0.1%, 0.15% OPHTH DROPS QL-10ML
30 DY
apraclonidine 0.5% drops
AZOPT 1% SUSPENSION
betaxolol 0.5% drops
BETIMOL 0.25%, 0.5% DROPS
BETOPTIC-S 0.25% SUSPENSION
brimonidine tart 0.15% ophth drops
brimonidine tart 0.2% ophth drops
carteolol 1% drops
COMBIGAN 0.2%/ 0.5% DROPS QL-10ML 30 DY
dorzolamide 2% drops
dorzolamide/timolol 2%/0.5% drops QL-10ML 30 DY
ISTALOL 0.5% DROPS
levobunolol 0.25%, 0.5% drops
methazolamide 25mg, 50mg tab
metipranolol 0.3% drops
PHOSPHOLINE IODIDE 0.125% DROPS
PILOPINE HS 4% GEL
timolol 0.25%, 0.5% drops
timolol drops 0.25%, 0.5% gel
Otic Agents
Otic Agents
acetic acid 2% soln
CIPRO HC 0.2%-1% SUSPENSION
CIPRODEX 0.3%-0.1% SUSPENSION
COLY-MYCIN S 3.3MG-3MG-10MG-0.5MG/ML
SUSPENSION
CORTISPORIN-TC 3.3MG-3MG-10MG-0.5MG/ML
DROPS
fluocinolone acetonide 0.01% drops
neomycin /poly/hydrocort 3.5-10k-1 otic susp
neomycin /polymyxin /hc 3.5-10k-1 otic soln
B-51
Drug
Notes

Tier
Plan Notes
2
1
1
1
3
3
3
3
2
90D; QL
90D
90D
90D
90D
90D
90D
90D
90D
90D; QL
90D
90D; QL
90D
90D
90D
90D
90D
90D
90D
90D
3
3
1
3
3
3
1
1
2
1
3
3
1
1
1
2
2
1
3
1
3
2
3
3
1
1
1
Drug Name
ofloxacin 0.3% otic soln
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR 100/50MCG, 250/50MCG, 500/50MCG
DISKUS QL-1 DISKUS 30 DY
ADVAIR 45/21MCG, 115/21MCG, 230/21MCG HFA QL1 INHALER 30 DY
ALVESCO 80MCG, 160MCG HFA QL-2 INHALERS 30
DY
ASMANEX 110MCG(30); 220MCG(30); 220MCG(60);
220MCG(120) INHALER QL-1 INHALER 30 DY
BECONASE AQ 42MCG QL-2 BOTTLES 30 DY
budesonide 0.25mg/2ml, 0.5mg/2ml neb QL-60 VIALS
30 DY
DULERA HFA 100MCG/5MCG; 200MCG/5MCG
INHALER QL-1 INHALER 30 DY
FLOVENT 50MCG, 100MCG, 250MCG DISKUS QL-1
DISKUS 30 DY
FLOVENT HFA 44MCG, 110MCG, 220MCG INHALER
QL-2 INHALERS 30 DY
flunisolide 25mcg aero
fluticasone propionate 50mcg spray
NASONEX 50MCG QL-2 BOTTLES 30 DY
OMNARIS 50MCG QL-1 BOTTLE 30 DY
QVAR 40MCG & 80MCG INHALERS QL-2 INHALERS
30 DY
RHINOCORT AQUA 32MCG QL-2 BOTTLES 30 DY
SYMBICORT 80MCG, 160MCG AERO QL-1 INHALER
30 DY
triamcinolone acetonide 55mcg/act inhaler QL-2
BOTTLES 30 DY
Antihistamines
ASTEPRO 205.5MCG QL-1 BOTTLE 25 DY
azelastine 137mcg nasal spray
carbinoxamine 4mg tab
carbinoxamine 4mg/5ml liquid
clemastine 0.67mg/5ml syrup
clemastine 2.68mg tab
dexchlorpheniramine 2mg/5ml syrup
hydroxyzine 25mg/ml, 50mg/ml vial
levocetirizine dihydrochloride 5mg tab QL-30 QY 30 DY
PATANASE 0.6% QL-1 BOTTLE 25 DY
SEMPREX-D 8MG/60MG CAP
Antileukotrienes
SINGULAIR 10MG TAB QL-30 QY 30 DY
Drug
Notes

Tier
Plan Notes
3
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
B v D;
QL
ST
PA
90D; QL
90D; QL
90D; QL
90D
90D
90D; QL
90D; QL
1
1
2
3
90D; QL
90D; QL
90D; QL
90D; QL
90D; QL
90D
90D
90D
90D
90D
90D;
HRM
HRM
90D; QL
90D; QL
90D
3
3
1
1
1
1
90D; QL
ST
1
1
3
3
3
ST
B-52
Drug Name
SINGULAIR 4MG & 5MG CHEWABLE TABS QL-30 QY
30 DY
SINGULAIR 4MG PACKET QL-30 QY 30 DY
zafirlukast 10mg, 20mg tab QL-60 QY 30 DY
Bronchodilators, Anticholinergic
ATROVENT HFA 17MCG QL-2 INHALERS 30 DY
COMBIVENT 18MCG/103MCG INHALER QL-2
INHALERS 30 DY
ipratropium bromide 0.2mg/ml soln, neb
ipratropium bromide 21mcg, 42mcg nasal soln
ipratropium bromide/albuterol sulfate 0.5mg-3mg/3ml
neb
SPIRIVA 18MCG HANDIHALER CAP QL-30 QY 30 DY
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
aminophylline 250mg/10ml vial
ELIXOPHYLLIN 80MG/15ML ELIXIR
THEO-24 100MG, 200MG, 400MG CAPS QL-30 QY 30
DY
THEO-24 300MG CAP QL-60 QY 30 DY
theochron 100mg, 200mg, 300mg tabs
theophylline er 100mg, 200mg, 300mg, 450mg tabs
theophylline er 400mg, 600mg tab, sr
Bronchodilators, Sympathomimetic
albuterol sulf 0.083% neb
albuterol sulf 0.5% neb
albuterol sulf 0.63mg/3ml, 1.25mg/3ml neb
albuterol sulf 2mg, 4mg tab
albuterol sulf 2mg/5ml syrup
albuterol sulf 4mg, 8mg er tab
ARCAPTA NEOHALER 75MCG QL-30 QY 30 DY
BROVANA 15MCG/2ML NEB QL-60 VIALS 30 DY
epinephrine 0.1mg/ml syringe
EPIPEN 0.3MG/0.3ML QL-2 INJ 30 DY
EPIPEN-JR 0.15MG/0.3ML QL-2 INJ 30 DY
FORADIL 12MCG AERO CAP QL-60 QY 30 DY
levalbuterol 1.25mg/0.5ml neb QL-90 VIALS 30 DY
metaproterenol sulfate 10mg, 20mg tab
metaproterenol sulfate 10mg/5ml syrup
PERFOROMIST 20MCG/2ML NEB QL-60 VIALS 30 DY
PROAIR HFA 90MCG INHALER QL-2 INHALERS 30
DY
PROVENTIL HFA 90MCG QL-2 INHALERS 30 DY
B-53
Drug
Notes

Tier
Plan Notes
90D; QL
90D; QL
90D; QL
2
3
90D; QL
90D; QL
BvD
90D
1
1
PA
BvD
PA
90D; QL
90D
1
3
90D; QL
90D; QL
90D
90D
90D
3
1
1
1
BvD
BvD
BvD
90D
90D
90D
90D; QL
B v D;
QL
1
1
1
1
1
1
3
PA
PA
PA
PA
QL
QL
90D; QL
B v D;
QL
90D
90D
B v D;
QL
1
3
3
2
3
PA
1
1
3
90D; QL
90D; QL
PA
ST
Drug Name
SEREVENT DISKUS 50MCG QL-1 DISKUS 30 DY
terbutaline sulfate 2.5mg, 5mg tab
TWINJECT 0.15MG/0.15ML, 0.3MG/0.3ML
VENTOLIN HFA 90MCG QL-2 INHALERS 30 DY
XOPENEX HFA 45MCG QL-2 INHALERS 30 DY
Mast Cell Stabilizers
cromolyn 20mg/2ml neb
Pulmonary Antihypertensives
ADCIRCA 20MG TAB QL-60 QY 30 DY
TRACLEER 62.5MG, 125MG TAB QL-60 QY 30 DY
VENTAVIS 10MCG/ML, 20MCG/ML AMPUL
Respiratory Tract Agents, Other
acetylcysteine 100mg/ml, 200mg/ml vial
ARALAST NP 500MG VIAL
DALIRESP 500MCG QL-30 QY 30 DY
PROLASTIN 500MG & 1000MG VIALS
PROLASTIN-C 1000MG VIAL
PULMOZYME 1MG/ML SOLN NON-ORAL
TOBI 300MG/5ML VIAL, NEB QL-56 VIALS 28 DY
TYZINE 0.1% DROPS
TYZINE PEDIATRIC 0.05% NASAL DROPS
XOLAIR 150MG VIAL
Sleep Disorder Agents
GABA Receptor Modulators
LUNESTA 1MG, 2MG, 3MG TAB QL-30 QY 30 DY
temazepam 15mg, 30mg caps QL-30 QY 30 DY
triazolam 0.125mg, 0.25mg tabs QL-60 QY 30 DY
zaleplon 5mg, 10mg cap QL-30 QY 30 DY
zolpidem tartrate 5mg, 10mg tab
Sleep Disorders, Other
NUVIGIL 50MG, 150MG, 250MG TAB QL-30 QY 30 DY
SILENOR 3MG, 6MG TABS QL-30 QY 30 DY
XYREM 500MG/ML SOLN ORAL QL-540ML 30 DY
Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
CUPRIMINE 250MG CAP
DEPEN TITRATABS 250MG TAB
EXJADE 125MG, 250MG, 500MG TAB
kionex powder
SAMSCA 15MG TAB QL-30 QY 30 DY
SAMSCA 30MG TAB QL-60 QY 30 DY
Drug
Notes
90D; QL
90D
90D; QL
90D; QL

Tier
Plan Notes
3
1
2
2
3
BvD
PA
QL
QL
2
3
3
PA
PA
PA
BvD
1
3
2
3
3
3
PA
PA
PA
3
3
3
PA
90D; QL
BvD
B v D;
QL
QL
QL
QL
QL
3
1
1
3
1
QL
QL
QL
3
3
3
90D
90D
2
2
3
1
3
3
QL
QL
PA
PA
PA
PA
PA
PA
PA
B-54
Drug Name
sodium polystyrene sulfonate powder
SYPRINE 250MG CAP
Electrolyte/Mineral Replacement
AMINOSYN 10% IV
AMINOSYN 3.5% IV
AMINOSYN 7% IV
AMINOSYN 8.5% IV
AMINOSYN II 10% IV
AMINOSYN II 15% IV
AMINOSYN II 4.25% IV
AMINOSYN II 5% IV
AMINOSYN II 7% IV
AMINOSYN II 8.5% IV
AMINOSYN M 3.5% IV
AMINOSYN-HBC 7% IV
AMINOSYN-HF 8% IV
AMINOSYN-PF 10% IV
AMINOSYN-PF 7% IV
CLINIMIX/DEXTROSE 2.75% IV
CLINISOL SF 15% IV
DEXTROSE 5%/ELECTROLYTE #48 VIAFLEX
FREAMINE HBC 6.9% IV
FREAMINE III 3% IV
FREAMINE III 8.5% IV
HEPATAMINE 8% IV
HEPATASOL 8% IV
K-TAB 10 MEQ TAB, SR
klor-con 20 meq packet
klor-con 8 meq, 10 meq tab, sr
klor-con m 15 meq, 20 meq tab, sr
LACTATED RINGERS IV
magnesium sulfate 4 meq/ml syringe
NEPHRAMINE 5.4% IV
nutrilyte ii 1.475meq-0.225meq/1.75meq-0.25meq1meq-1.75meq/ml vial
potassium chloride 0.15%/d5w iv 20meq/l
potassium chloride 2meq/ml vial
potassium chloride er 8meq & 10meq cap, cr
potassium chloride er 8meq, 10meq, 20meq tab, sr
potassium chloride iv 10meq/0.1l, 10meq/50ml,
20meq/50ml, 30meq/0.1l
potassium chloride/ nacl iv 20meq/l & 40meq/l
B-55
Drug
Notes
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
BvD
90D
90D
90D
90D
BvD

Tier
Plan Notes
1
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
3
3
3
3
3
3
1
1
1
1
1
3
3
90D
90D
1
1
1
1
1
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
Drug Name
potassium chloride/d5w iv 30meq/l & 40meq/l
potassium citrate er 5meq & 10meq tabs
premasol iv 6% & 10%
PROCALAMINE 3% IV
PROSOL 20% IV
ringers inj iv
sodium chloride 0.45% & 0.9% iv
sodium fluoride 1mg tab
TPN ELECTROLYTE 35MEQ/20MEQ/5MEQ FTV
travasol 10% iv
TROPHAMINE 6%, 10% IV
Glycemic Agents
CLINIMIX E/DEXTROSE 5% IV
CLINIMIX/DEXTROSE 4.25% IV
CLINIMIX/DEXTROSE 5% IV
kcl/d5w/lr 20MEQ/L; 40MEQ/L iv
Vitamins
NIACOR 500MG TAB
prenatab
Drug
Notes
90D
BvD
BvD
BvD
90D
BvD
BvD

Tier
Plan Notes
1
1
3
PA
3
PA
3
PA
1
1
1
3
3
PA
3
PA
BvD
BvD
BvD
3
3
3
1
90D
90D
2
1
PA
PA
PA
PA
B-56
First Health Part D Premier

Formulary Index
Drug Name
Page
8
8-MOP 10MG CAP ............. 33
A
ABILIFY 10MG, 15MG
DISCMELT TAB QL-60 QY
30 DY.............................. 19
ABILIFY 1MG/ML SOLN
ORAL QL-900ML 30 DY . 19
ABILIFY 2MG, 5MG, 10MG,
15MG, 20MG, 30MG TAB
QL-30 QY 30 DY ............. 19
ABILIFY 9.75MG/1.3 VIAL .. 19
acarbose 25mg, 50mg, 100mg
tab .................................. 23
acebutolol 200mg, 400mg cap
....................................... 28
acetazolamide 125mg, 250mg
tab .................................. 29
acetazolamide 500mg cap .. 29
acetic acid 2% soln ............. 51
acetylcysteine 100mg/ml,
200mg/ml vial .................. 54
ACTHIB 10MCG/0.5 VIAL ... 46
acticin 5% cream ................ 18
ACTIMMUNE 2MM/0.5ML
VIAL ................................ 46
ACTONEL 150MG TAB QL-1
QY 30 DY ....................... 48
ACTONEL 35MG TAB QL-4
QY 28 DY ....................... 48
ACTONEL 5MG, 30MG TAB
QL-30 QY 30 DY ............. 48
ACTOS 15MG, 30MG, 45MG
TAB QL-30 QY 30 DY ..... 23
ACUVAIL 0.45% OPHTH
DROPS QL-60 VIALS 30
DY .................................. 50
acyclovir 200mg cap ........... 22
acyclovir 200mg/5ml susp ... 22
acyclovir 400mg, 800mg tab23
acyclovir sodium 500mg solr
....................................... 23
ADACEL 2-2.5-5MGC/.5ML
VIAL ................................ 46
ADAGEN 250 UNIT/1 VIAL . 36
Index-1
Drug Name
Page
ADCIRCA 20MG TAB QL-60

QY 30 DY ....................... 54
ADVAIR 100/50MCG,
250/50MCG, 500/50MCG
DISKUS QL-1 DISKUS 30
DY .................................. 52
ADVAIR 45/21MCG,
115/21MCG, 230/21MCG
HFA QL-1 INHALER 30 DY
....................................... 52
ADVICOR 500MG/20MG,
1000MG/40MG TAB QL-30
QY 30 DY ....................... 30
ADVICOR 750MG/20MG,
QY 30 DY ....................... 31
afeditab 30mg, 60mg cr tab 28
AFINITOR 2.5MG, 5MG,
10MG TAB QL-30 QY 30
DY .................................. 16
AFINITOR 7.5MG TAB QL-30
QY 30 DY ....................... 16
AGGRENOX 25MG/200MG
CAP QL-60 QY 30 DY .... 26
a-hydrocort 100mg solr ...... 40
ak-con 0.1% drops ............. 50
AKNE-MYCIN 2% OINT ..... 33
ALBENZA 200MG TAB ...... 17
albuterol sulf 0.083% neb ... 53
albuterol sulf 0.5% neb ....... 53
albuterol sulf 0.63mg/3ml,
1.25mg/3ml neb ............. 53
albuterol sulf 2mg, 4mg tab 53
albuterol sulf 2mg/5ml syrup53
albuterol sulf 4mg, 8mg er tab
....................................... 53
alclometasone dipropionate
0.05% cream .................. 33
alclometasone dipropionate
0.05% oint ...................... 33
alcohol preps pads ............... 4
ALDURAZYME 2.9MG/5ML
VIAL ............................... 36
alendronate 5mg, 10mg,
35mg, 40mg, 70mg tab .. 48
alfuzosin hcl 10mg er tab QL30 QY 30 DY .................. 39
ALIMTA 100MG, 500MG VIAL
....................................... 15
Drug Name
Page
ALINIA 100MG/5ML
SUSPENSION ................ 17
ALINIA 500MG TAB ........... 17
allopurinol 100mg, 300mg tab
....................................... 14
ALOCRIL 2% DROPS QL10ML 30 DY.................... 50
ALOMIDE 0.1% DROPS..... 50
ALORA 0.025MG/24H,
0.05MG/24H,
0.075MG/24H,
0.1MG/24HR PATCH QL-8
PATCHES 28 DY ............ 41
ALPHAGAN P 0.1%, 0.15%
OPHTH DROPS QL-10ML
30 DY ............................. 51
alprazolam 0.25mg, 0.5mg,
1mg, 2mg tab QL-150 QY
30 DY ............................. 23
ALREX 0.2% SUSP QL-15ML
30 DY ............................. 50
ALTABAX 1% OINT QL-15GM
30 DY ............................. 33
ALTOPREV 20MG, 40MG,
DY .................................. 31
ALVESCO 80MCG, 160MCG
HFA QL-2 INHALERS 30
DY .................................. 52
amantadine 100mg tab ...... 22
amantadine 100mg cap ...... 22
amcinonide 0.1% cream ..... 33
amcinonide 0.1% lotion....... 33
amcinonide 0.1% oint ......... 33
a-methapred 40mg/ml,
125mg/2ml vial ............... 40
amethia tab......................... 43
amethyst 20mcg/90mcg tab 41
amifostine 500mg vial ......... 16
amikacin sulfate 100mg/2ml,
500mg/2ml vial ................. 4
amiloride 5mg tab ............... 30
amiloride/hctz 5mg/50mg tab
....................................... 30
aminophylline 250mg/10ml
vial .................................. 53
AMINOSYN 10% IV ............ 55
AMINOSYN 3.5% IV ........... 55
AMINOSYN 7% IV .............. 55

Formulary Index
Drug Name
Page
AMINOSYN 8.5% IV ........... 55

AMINOSYN II 10% IV ......... 55
AMINOSYN II 15% IV ......... 55
AMINOSYN II 4.25% IV ...... 55
AMINOSYN II 5% IV ........... 55
AMINOSYN II 7% IV ........... 55
AMINOSYN II 8.5% IV ........ 55
AMINOSYN M 3.5% IV ....... 55
AMINOSYN-HBC 7% IV ..... 55
AMINOSYN-HF 8% IV ........ 55
AMINOSYN-PF 10% IV ...... 55
AMINOSYN-PF 7% IV ........ 55
amiodarone 200mg, 400mg
tab .................................. 27
AMITIZA 8MG, 24MG CAP
QL-60 QY 30 DY ............. 38
amitriptyline 10mg, 25mg,
50mg, 75mg, 100mg,
150mg tab ....................... 12
amlodipine 2.5mg, 5mg, 10mg
tab .................................. 28
amlodipine/benazepril
2.5mg/10mg 5mg/10mg
5mg/20mg 5mg/40mg
10mg/20mg 10mg/40mg
cap QL-30 QY 30 DY ...... 28
ammonium lactate 12% cream
....................................... 33
ammonium lactate 12% lotion
....................................... 33
amnesteem 10mg, 20mg,
40mg cap ........................ 33
amoxapine 25mg, 50mg,
100mg, 150mg tab .......... 12
amoxicillin 125mg, 200mg,
250mg chew ..................... 6
amoxicillin 125mg/5ml
200mg/5ml 250mg/5ml
400mg/5ml suspension ..... 6
amoxicillin 250mg, 500mg cap
......................................... 6
amoxicillin 500mg, 875mg tab
......................................... 6
amoxicillin/clav pota
1000mg/62.5mg er tab ...... 6
200mg/28.5mg
400mg/57mg chew............ 6
200mg/28.5mg/5ml
250mg/62.5mg/5ml
Drug Name
Page
400mg/57mg/5ml
600mg/42.9mg/5ml susp .. 6
250mg/125mg
500mg/125mg
875mg/125mg tab ............ 6
amphetamine salt combo
1.25mg tab ..................... 32
1.875mg tab ................... 32
2.5mg tab ....................... 32
3.125mg tab ................... 32
3.75mg tab ..................... 32
amphetamine salt combo 5mg
tab .................................. 32
7.5mg tab ....................... 32
amphetamine/dextroampheta
mine er 10mg cap QL-30
QY 30 DY ....................... 32
QY 30 DY ....................... 32
QY 30 DY ....................... 32
QY 30 DY ....................... 32
QY 30 DY ....................... 32
mine er 5mg cap QL-30 QY
30 DY ............................. 32
AMPHOTERICIN B 50MG
SOLN ............................. 13
ampicillin 125mg, 1g, 10g vial
......................................... 6
ampicillin 125mg/5ml
250mg/5ml suspension .... 6
ampicillin 250mg, 500mg cap 6
ampicillin-sulbactam 1.5g, 3g,
15g vial ............................. 6
AMPYRA 10MG TAB QL-60
QY 30 DY ....................... 33
ANADROL-50 50MG TAB .. 41
anagrelide 0.5mg, 1mg cap 25
Drug Name
Page
anastrozole 1mg tab QL-30

QY 30 DY ....................... 16
ANDROGEL 50MG 1% GEL
....................................... 41
ANDROGEL PUMP 1.25G 1%
GEL ................................ 41
ANDROGEL PUMP 20.25MG
1.62% GEL ..................... 41
androxy 10mg tab ............... 41
ANGELIQ 1MG/0.5MG TAB 41
ANTARA 43MG, 130MG CAP
QL-30 QY 30 DY ............ 30
apap/caffeine/dihydrocodeine
32mg/713mg/60mg tab QL150 QY 30 DY .................. 1
apap/codeine 120-12mg/5ml
elixir QL-4950ML 30 DY.... 1
apap/codeine 300mg/15mg
300mg/30mg 300mg/60mg
tab QL-390 QY 30 DY....... 1
apexicon e 0.05% cream .... 33
APOKYN CARTRIDGE
10MG/ML ........................ 18
apraclonidine 0.5% drops ... 51
apri 0.15mg/0.03mg tab ...... 41
APRISO 0.375G CAP QL-120
QY 30 DY ....................... 47
APTIVUS 100MG/ML SOLN
ORAL.............................. 21
APTIVUS 250MG CAP ....... 21
ARALAST NP 500MG VIAL 54
aranelle 7-9-5 tab ............... 41
ARCALYST 220MG VIAL QL8 VIALS 30 DY ............... 46
ARCAPTA NEOHALER
75MCG QL-30 QY 30 DY 53
ASACOL 400MG TAB ........ 47
ASACOL HD 800MG TAB .. 47
ascomp/codeine
30mg/50mg/325mg cap .. 33
ASMANEX 110MCG(30)
220MCG(30) 220MCG(60)
220MCG(120) INHALER
QL-1 INHALER 30 DY .... 52
ASTEPRO 205.5MCG QL-1
BOTTLE 25 DY............... 52
ATACAND 4MG, 8MG, 16MG,
DY .................................. 26
ATACAND HCT
16MG/12.5MG
32MG/12.5MG
Index-2

Formulary Index
Drug Name
Page
32MG/25MG TAB QL-30

QY 30 DY ....................... 26
atenolol 25mg 50mg 100mg
tab .................................. 28
atenolol/chlorthalidone
50mg/25mg 100mg/25mg
tab .................................. 28
atorvastatin calcium 10mg,
20mg, 40mg, 80mg tab QL30 QY 30 DY................... 31
ATRIPLA 600MG/200MG TAB
QL-30 QY 30 DY ............. 21
ATROVENT HFA 17MCG QL2 INHALERS 30 DY ........ 53
augmented betameth dip
0.05% cream................... 33
0.05% gel ........................ 34
0.05% lotion .................... 34
0.05% oint ....................... 34
AVASTIN 25MG/ML VIAL ... 17
AVELOX 400MG ABC PACK
QL-30 QY 30 DY ............... 7
AVELOX 400MG TAB QL-30
QY 30 DY ......................... 7
AVELOX 400MG/.25ML IV ... 7
aviane tab 0.1mg/0.02mg tab
....................................... 41
AVODART 0.5MG CAP QL-30
QY 30 DY ....................... 39
AVONEX 30MCG QL-4 INJ 30
DY .................................. 46
AVONEX 30MCG/0.5ML KIT
QL-4 INJ 30 DY .............. 46
AXERT 6.25MG, 12.5MG TAB
QL-8 QY 30 DY............... 14
AZASITE 1% DROPS QL2.5ML 14 DY ................... 49
azathioprine 100mg soln ..... 45
azathioprine 50mg tab ........ 45
azelastine 0.05% drops....... 50
azelastine 137mcg nasal
spray ............................... 52
AZELEX 20% CREAM ........ 34
AZILECT 0.5MG, 1MG TAB
QL-30 QY 30 DY ............. 18
azithromycin 100mg/5ml,
Index-3
Drug Name
Page
azithromycin 250mg, 500mg,

600mg tab ........................ 7
azithromycin 500mg vial ....... 7
AZOPT 1% SUSPENSION. 51
aztreonam 1g, 2g vial ........... 6
B
baciim 50000 unit vial ........... 4
bacitracin 500 unit/g oint .... 49
bacitracin/polymyxin b
500/10k/g oint................. 49
baclofen 10mg, 20mg tab ... 20
balsalazide 750mg cap....... 47
balziva 0.4mg/0.035mg tab 41
BANZEL 200MG, 400MG TAB
QL-240 QY 30 DY ............ 9
BANZEL 40 MG/ML SUSP
QL-2400ML 30 DY ........... 9
BARACLUDE 0.05MG/ML
SOLN ORAL QL-630ML 30
DY .................................. 22
BARACLUDE 0.5MG, 1MG
TAB QL-30 QY 30 DY .... 22
BECONASE AQ 42MCG QL-2
BOTTLES 30 DY ............ 52
benazepril 5mg, 10mg, 20mg,
40mg tab ........................ 27
benazepril/hctz 5mg/6.25mg
10mg/12.5mg
20mg/12.5mg 20mg/25mg
tab .................................. 27
BENICAR 5MG, 20MG, 40MG
TAB QL-30 QY 30 DY .... 26
BENICAR HCT 20MG/12.5MG
40MG/12.5MG
40MG/25MG TAB QL-30
QY 30 DY ....................... 26
BENLYSTA 120MG, 400MG
SOLN ............................. 45
benztropin 1mg/ml soln ...... 18
benztropine 0.5mg, 1mg, 2mg
tab .................................. 18
BEPREVE 1.5% DROPS QL10ML 30 DY ................... 50
BESIVANCE 0.6% SUSP QL5ML 30 DY ..................... 49
betamethasone diprop 0.05%
cream ............................. 34
lotion .............................. 34
Drug Name
Page

oint ................................. 34
BETASERON 0.3MG KIT QL15 SYRINGE 30 DY........ 46
beta-val 0.1% cream........... 34
beta-val 0.1% lotion ............ 34
beta-val 0.1% oint ............... 34
betaxolol 0.5% drops .......... 51
betaxolol 10mg, 20mg tab .. 28
bethanechol 5mg, 10mg,
25mg, 50mg tab .............. 40
BETIMOL 0.25%, 0.5%
DROPS........................... 51
BETOPTIC-S 0.25%
SUSPENSION ................ 51
bicalutamide 50mg tab QL-30
QY 30 DY ....................... 45
BILTRICIDE 600MG TAB ... 17
bisoprolol 5mg, 10mg tab ... 28
bisoprolol/hctz 2.5mg/6.25mg
5mg/6.25mg 10mg/6.25mg
tab .................................. 28
bleomycin sulfate 30 unit vial
....................................... 16
BLEPHAMIDE 10%/0.2%
SUSPENSION ................ 50
BLEPHAMIDE S.O.P.
10%/0.2% OINT .............. 50
BONIVA 3MG/3ML SOLN QL3ML 90 DY ..................... 48
BOOSTRIX 18.5MCG0.5ML/2.5LF-0.5ML/5LF0.5ML SYRINGE ............ 46
BOOSTRIX 18.5MCG0.5ML/2.5LF-0.5ML/5LF0.5ML VIAL ..................... 46
briellyn 0.4mg/0.035mg tab 41
BRILINTA 90MG TAB QL-60
QY 30 DY ....................... 26
brimonidine tart 0.15% ophth
drops .............................. 51
brimonidine tart 0.2% ophth
drops .............................. 51
BROMDAY 0.09%
OPHTHALMIC SOLN QL1.7ML QY 30 DY ............ 50
bromfenac 0.09% ophthalmic
soln QL-3ML 30 DY ........ 50
bromocriptine 2.5mg tab ..... 18
bromocriptine 5mg cap ....... 18

Formulary Index
Drug Name
Page
BROVANA 15MCG/2ML NEB

QL-60 VIALS 30 DY ........ 53
budeprion sr 100mg, 150mg
tab .................................. 10
budeprion xl 150mg, 300mg
tab QL-30 QY 30 DY ....... 10
budesonide 0.25mg/2ml,
0.5mg/2ml neb QL-60
VIALS 30 DY................... 52
budesonide ec 3mg cap ...... 48
bumetanide 0.25mg/ml vial . 30
bumetanide 0.5mg, 1mg, 2mg
tab .................................. 30
BUPHENYL 500MG TAB .... 36
buproban 150mg tab ............. 3
bupropion 75mg, 100mg tab11
bupropion sr 100mg, 150mg,
200mg tab ....................... 11
bupropion xl 150mg, 300mg
tab QL-30 QY 30 DY ....... 11
buspirone 5mg, 7.5mg, 10mg,
15mg, 30mg tab .............. 23
butalbital/apap/caffeine/codein
e 50mg/325mg/40mg/30mg
cap QL-180 QY 30 DY ...... 1
butorphanol tart 10mg/ml aero
......................................... 1
BYETTA 5MCG/0.02ML,
10MCG/0.04ML PEN QL-1
PEN 30 DY ..................... 23
BYSTOLIC 2.5MG, 5MG,
DY .................................. 28
BYSTOLIC 20MG TAB QL-60
QY 30 DY ....................... 28
C
cabergoline 0.5mg tab ........ 44
calcipotriene 0.005% soln
non-oral .......................... 34
calcitonin-salmon 200
unit/dose aero ................. 48
calcitriol 0.25mcg, 0.5mcg cap
....................................... 48
calcitriol 1mcg/ml ampul...... 48
calcitriol 1mcg/ml soln oral .. 48
calcium acet 667mg cap ..... 40
camila 0.35mg tab .............. 43
CAMPATH 30MG/ML VIAL . 17
CAMPRAL 333MG TAB QL180 QY 30 DY................... 3
Drug Name
Page
camrese lo tab ................... 43

camrese tab ....................... 43
CANASA 1000MG SUPP
RECTAL ......................... 47
CANCIDAS 50MG, 70MG
VIAL ............................... 13
CANTIL 25MG TAB............ 37
CAPASTAT SULFATE 1G
VIAL ............................... 14
CAPEX 0.01% SHAMPOO . 34
CAPITAL/CODEINE 120MG12MG/5ML SUSP QL4950ML 30 DY ................. 1
CAPRELSA 100MG TAB QL60 QY 30 DY .................. 15
CAPRELSA 300MG TAB QL30 QY 30 DY .................. 15
captopril 12.5mg, 25mg,
50mg, 100mg tab ........... 27
captopril/hctz 25mg/15mg
25mg/25mg 50mg/15mg
50mg/25mg tab .............. 27
CARAC 0.5% CREAM........ 34
carbamazepine 100mg chew 9
carbamazepine 200mg tab ... 9
carbamazepine 200mg/10ml
suspension ....................... 9
carbamazepine er 100mg,
200mg, 300mg cp12......... 9
carbamazepine er 200mg,
400mg tab ........................ 9
CARBATROL 100MG,
200MG, 300MG CAP ....... 9
carbidopa/levodopa
10mg/100mg 25mg/100mg
25mg/250mg tab ............ 18
carbidopa/levodopa cr
25mg/100mg tab ............ 18
carbidopa/levodopa odt
10mg/100mg 25mg/100mg
25mg/250mg tab ............ 18
carbidopa/levodopa sr
50mg/200mg tab ............ 18
carbinoxamine 4mg tab ...... 52
carbinoxamine 4mg/5ml liquid
....................................... 52
carteolol 1% drops ............. 51
cartia xt 120mg, 180mg,
240mg, 300mg cap......... 28
carvedilol 3.125mg, 6.25mg,
12.5mg, 25mg tab .......... 28
CEDAX 400MG CAP ............ 5
Drug Name
Page
CEDAX 90MG/5ML
SUSPENSION .................. 5
CEENU 10MG, 40MG, 100MG
CAP ................................ 15
cefaclor 250mg, 500mg cap . 5
cefaclor er 500mg tab ........... 5
cefadroxil 1g tab ................... 5
cefadroxil 250mg/5ml,
cefadroxil 500mg cap ........... 5
cefazolin 1g/50ml iv .............. 5
cefazolin 500mg, 1g, 10g vial 5
cefdinir 125mg/5ml,
cefdinir 300mg cap ............... 5
cefditoren pivoxil 200mg,
400mg tab ........................ 5
cefepime 1g, 2g vial .............. 5
CEFEPIME 1G/50ML,
2G/100ML IV .................... 5
cefotaxime 500mg, 1g, 2g,
10g vial ............................. 5
CEFOTETAN 1G, 2G, 10G
VIAL ................................. 5
CEFOTETAN/DEXTROSE
1G/50ML, 2G/50ML IV ...... 5
cefoxitin 1g, 2g, 10g vial ....... 5
CEFOXITIN 1G/50ML,
2G/50ML IV ...................... 5
cefpodoxime proxetil 100mg,
200mg tab ........................ 5
cefpodoxime proxetil
50mg/5ml, 100mg/5ml
suspension ....................... 5
cefprozil 125mg/5ml,
cefprozil 250mg, 500mg tab 5
cefprozil 250mg, 500mg tab . 5
ceftazidime 500mg, 1g, 2g, 6g
vial .................................... 6
CEFTAZIDIME/DEXTROSE
1G/50ML-5% 2G/50ML-5%
IV ...................................... 6
ceftriaxone 250mg, 500mg,
10g vial ............................. 6
ceftriaxone/dextrose 1g, 2g iv6
cefuroxime 750mg, 1.5g vial . 6
cefuroxime 750mg, 1.5g, 7.5g
vial .................................... 6
cefuroxime axetil 125mg/5ml
suspension ....................... 6
Index-4

Formulary Index
Drug Name
Page
cefuroxime axetil 250mg,

500mg tab ......................... 6
CEFUROXIME/DEXTROSE
750MG/50ML, 1.5G/50ML
IV ...................................... 6
CELEBREX 100MG CAP QL30 QY 30 DY..................... 3
CELEBREX 50MG, 200MG,
400MG CAP QL-60 QY 30
DY .................................... 3
CELESTONE 0.6MG/5ML
SOLN ORAL ................... 40
CELLCEPT 200MG/ML
SUSPENSION ................ 45
CELONTIN 300MG CAP....... 8
cephalexin 125mg/5ml,
cephalexin 250mg, 500mg cap
......................................... 6
cephalexin 250mg, 500mg tab
......................................... 6
CEREDASE 80 UNIT/ML VIAL
....................................... 36
CEREZYME 200 UNIT, 400
UNIT VIAL....................... 36
CERVARIX 0.5ML SYRINGE
....................................... 46
cesia tab ............................. 41
CHANTIX 0.5MG(11)1MG(42) DOSE PACK QL53 QY 30 DY..................... 3
CHANTIX 0.5MG, 1MG TAB
QL-60 QY 30 DY ............... 3
chloramphenicol succ 1g vial 4
chlordiazepoxide/amitriptyline
12.5mg/5mg, 25mg/10mg
tab .................................. 23
chlorhexidine gluconate 0.12%
oral rinse ......................... 33
chloroquine 250mg, 500mg
tab .................................. 17
chlorothiazide 250mg, 500mg
tab .................................. 30
chlorpromazine 10mg, 25mg,
50mg, 100mg, 200mg tab19
chlorpromazine 25mg/ml
ampul .............................. 19
chlorthalidone 25mg, 50mg
tab .................................. 30
cholestyramine 4g light packet
....................................... 31
Index-5
Drug Name
Page
cholestyramine 4g light
powder ........................... 31
cholestyramine 4g packet ... 31
cholestyramine 4g powder . 31
ciclopirox 0.77% lotion........ 13
ciclopirox 8% nail lacquer soln
....................................... 13
ciclopirox olamine 0.77%
cream ............................. 13
cilostazol 50mg, 100mg tab 26
CILOXAN 0.3% OINT ......... 49
cimetidine 150mg/ml vial .... 38
cimetidine 200mg, 300mg,
400mg, 800mg tab ......... 38
cimetidine 300mg/5ml soln
oral ................................. 38
CINRYZE 500 UNIT VIAL QL20 VIALS 30 DY ............. 25
CIPRO 250MG/5ML,
500MG/5ML SUSPENSION
......................................... 7
CIPRO HC 0.2%-1%
SUSPENSION................ 51
CIPRODEX 0.3%-0.1%
SUSPENSION................ 51
ciprofloxacin 0.3% drops .... 49
ciprofloxacin 100mg, 250mg,
500mg, 750mg tab ........... 7
ciprofloxacin 400mg/40ml vial
......................................... 7
ciprofloxacin er 1000mg tab
QL-14 QY 30 DY .............. 7
ciprofloxacin er 500mg tab
QL-28 QY 30 DY .............. 7
cisplatin 1mg/ml inj ............. 16
citalopram 10mg, 20mg, 40mg
tab .................................. 11
citalopram 10mg/5ml soln oral
....................................... 11
claravis 10mg, 20mg, 30mg,
40mg cap ....................... 34
clarithromycin 125mg/5ml,
250mg/5ml suspension .... 7
clarithromycin 250mg, 500mg
tab .................................... 7
clarithromycin er 500mg tab
QL-28 QY 14 DY .............. 7
clemastine 0.67mg/5ml syrup
....................................... 52
clemastine 2.68mg tab ....... 52
Drug Name
Page
CLEOCIN 100MG VAGINAL

SUPP.............................. 40
CLEOCIN 75MG CAP .......... 4
CLIMARA PRO
0.045MG/0.015MG PTWK
QL-4 PATCH 28 DY........ 41
clindamycin 150mg, 300mg
cap ................................... 4
clindamycin 75mg/5ml
pediatric granules ............. 4
clindamycin phos 1% lotion 34
clindamycin phos 1% gel .... 34
clindamycin phos 1% soln .. 34
clindamycin phos 1% swab . 34
clindamycin phos 2% cream40
clindamycin phos 600mg/4ml
vial .................................... 4
clindamycin/benzoyl peroxide
gel 1%- 5% ..................... 34
CLINIMIX E/DEXTROSE
2.75% IV ......................... 24
CLINIMIX E/DEXTROSE
4.25% IV ......................... 24
CLINIMIX E/DEXTROSE 5%
IV .................................... 56
CLINIMIX/DEXTROSE 2.75%
IV .................................... 55
CLINIMIX/DEXTROSE 4.25%
IV .................................... 56
CLINIMIX/DEXTROSE 5% IV
....................................... 56
CLINISOL SF 15% IV ......... 55
clobetasol propionate 0.05%
gel .................................. 34
oint ................................. 34
soln ................................. 34
clobetasol propionate e 0.05%
cream ............................. 34
CLODERM 0.1% CREAM... 34
clomipramine 25mg, 50mg,
75mg cap........................ 12
clonazepam 0.5mg & 1mg tab
QL-150 QY 30 DY............. 8
clonazepam 2mg tab QL-300
QY 30 DY ......................... 8
clonazepam odt 0.125mg,
0.25mg, 0.5mg, 1mg tabs
QL-150 QY 30 DY............. 8

Formulary Index
Drug Name
Page
clonazepam odt 2mg tab QL300 QY 30 DY................... 9

clonidine 0.1mg, 0.2mg,
0.3mg tab ........................ 26
clopidogrel 300mg tab QL-1
QY 365 DY...................... 26
clopidogrel 75mg tab QL-30
QY 30 DY ....................... 26
clorazepate dipotassium
3.75mg, 7.5mg, 15mg, tabs
QL-180 QY 30 DY ............. 9
clorpres 0.1mg/15mg,
0.2mg/15mg tab .............. 26
CLORPRES 0.3MG/15MG
TAB................................. 26
clotrimazole 1% topical soln 13
clotrimazole 10mg troche .... 13
clotrimazole/betameth diprop
1%/0.05% cream............. 13
clotrimazole/betameth diprop
1%/0.05% lotion .............. 13
clozapine 25mg, 50mg,
100mg, 200mg tab .......... 20
codeine sulfate 15mg, 30mg,
60mg tab ........................... 1
COLCRYS 0.6MG TAB QL120 QY 30 DY................. 14
colestipol 1g tab .................. 31
colestipol 5g granules ......... 31
colestipol 5g packet ............ 31
colistimethate 150mg vial ...... 4
COLY-MYCIN S 3.3MG-3MG10MG-0.5MG/ML
SUSPENSION ................ 51
COMBIGAN 0.2%/ 0.5%
DROPS QL-10ML 30 DY 51
COMBIPATCH
0.05MG/0.14MG,
0.05MG/0.25MG PATCH
QL-8 PATCHES 28 DY ... 41
COMBIVENT
18MCG/103MCG INHALER
QL-2 INHALERS 30 DY .. 53
COMPLERA 300MG TAB QL30 QY 30 DY................... 20
compro 25mg suppository ... 12
COMTAN 200MG TAB........ 18
COMVAX 5MCG7.5MCG/0.5ML VIAL ....... 46
CONCERTA TAB 18MG,
27MG, 54MG QL-30 QY 30
DY .................................. 32
Drug Name
Page
CONCERTA TAB 36MG QL60 QY 30 DY .................. 32

CONDYLOX 0.5% GEL ...... 34
constulose 10g/15ml soln oral
....................................... 38
COPAXONE 20MG KIT QL-30
INJ 30 DY ....................... 33
CORDRAN 0.05% LOTION 34
CORDRAN 4MCG/SQ CM
TAPE.............................. 34
CORDRAN SP 0.05%
CREAM .......................... 34
COREG CR 10MG, 20MG,
40MG, 80MG CAP QL-30
QY 30 DY ....................... 28
CORTIFOAM 10% ............. 37
cortisone acet 25mg tab ..... 40
CORTISPORIN-TC 3.3MG3MG-10MG-0.5MG/ML
DROPS .......................... 51
COUMADIN 1MG, 2MG,
2.5MG, 3MG, 4MG, 5MG,
6MG, 7.5MG, 10MG TAB 25
COVERA-HS 180MG, 240MG
TAB ................................ 28
CREON
120000UNIT/24000UNIT/76
000UNIT CAP ................ 36
CREON
15000UNIT/3000UNIT/9500
UNIT CAP ...................... 37
CREON
30000UNIT/6000UNIT/1900
0UNIT CAP .................... 37
CREON
60000UNIT/12000UNIT/380
00UNIT CAP .................. 37
CRESTOR 5MG, 10MG,
20MG, 40MG TAB QL-30
QY 30 DY ....................... 31
CRINONE 8% GEL ............ 43
CRIXIVAN 100MG, 200MG,
400MG CAP ................... 21
cromolyn 20mg/2ml neb ..... 54
cromolyn 4% drops ............ 50
cromolyn sodium 20mg/ml
soln oral ......................... 37
cryselle-28 0.3mg/0.03mg tab
....................................... 41
CUBICIN 500MG VIAL ......... 4
CUPRIMINE 250MG CAP .. 54
Drug Name
Page
cyclophosphamide 25mg,
50mg tab ........................ 15
cyclosporine 25mg, 100mg
cap ................................. 45
cyclosporine modified
100mg/ml soln oral ......... 45
cyclosporine modified 50mg,
100mg cap ...................... 45
CYKLOKAPRON 100MG/ML
AMPUL ........................... 26
CYMBALTA 20MG, 60MG
CAP QL-60 QY 30 DY .... 11
CYMBALTA 30MG CAP QL90 QY 30 DY .................. 11
CYSTADANE POWDER..... 37
CYSTAGON 50MG, 150MG
CAP ................................ 37
D
DACOGEN 50MG VIAL ...... 16
DALIRESP 500MCG QL-30
QY 30 DY ....................... 54
danazol 50mg, 100mg, 200mg
cap ................................. 41
dantrolene 25mg, 50mg,
100mg cap ...................... 20
DAPSONE 25MG, 100MG
TAB ................................ 14
DAPTACEL 10MCG-15LF5LF/0.5ML VIAL .............. 46
DARAPRIM 25MG TAB ...... 17
DECAVAC 5LFU/2LFU
SYRINGE ....................... 46
demeclocycline 150mg,
300mg tab ........................ 8
DEMSER 250MG CAP ....... 29
DENAVIR 1% CREAM QL2GM 30 DY ..................... 23
depade 50mg tab.................. 3
DEPEN TITRATABS 250MG
TAB ................................ 54
DEPO-ESTRADIOL 5MG/ML
VIAL ............................... 41
desipramine 10mg, 25mg,
50mg, 75mg, 100mg 150mg
tab .................................. 12
desmopressin acet 0.01%
nasal aerosol .................. 41
desmopressin acet 0.1mg,
0.2mg tab ....................... 41
Index-6

Formulary Index
Drug Name
Page
desmopressin acet 0.1mg/ml

nasal soln ....................... 41
desmopressin acet 4mcg/ml
vial .................................. 41
desonide 0.05% cream ....... 34
desonide 0.05% lotion......... 34
desonide 0.05% oint ........... 34
desoximetasone 0.05% gel . 34
desoximetasone 0.05%,
0.25% cream................... 34
desoximetasone 0.25% oint 34
dexamethasone 0.5mg,
0.75mg, 1mg, 1.5mg, 2mg,
4mg, 6mg tab .................. 40
dexamethasone 0.5mg/5ml
elixir ................................ 40
dexamethasone intensol
0.5mg/.5ml drops ............ 40
dexamethasone sod phos
0.1% drops...................... 50
dexamethasone sod phos
4mg/ml vial...................... 40
dexchlorpheniramine 2mg/5ml
syrup ............................... 52
dexmethylphenidate 2.5mg,
5mg, 10mg tab ................ 32
dextroamphetamine sulfate
5mg, 10mg tab ................ 32
dextroamphetamine sulfate er
5mg, 10mg, 15mg cap, 24hr
....................................... 32
dextrose 10% flex container 24
DEXTROSE 10%/NACL 0.2%
IV .................................... 24
DEXTROSE 10%/NACL
0.45% IV ......................... 24
dextrose 2.5%/nacl 0.45% iv
....................................... 24
dextrose 5% iv .................... 24
DEXTROSE
5%/ELECTROLYTE #48
VIAFLEX ......................... 55
dextrose 5%/nacl 0.2% iv .... 24
dextrose 5%/nacl 0.33% iv .. 24
dextrose 5%/nacl 0.45% iv .. 24
dextrose 5%/nacl 0.9% iv .... 24
diazepam 1mg/ml soln QL1200ML QY 30 DY ............ 9
diazepam 2mg, 5mg, 10mg
tab QL-120 QY 30 DY ....... 9
Index-7
Drug Name
Page
diazepm 2.5mg, 10mg, 20mg

gel .................................... 9
DIBENZYLINE 10MG CAP . 26
diclofenac 0.1% drops ........ 50
diclofenac 75mg tab ............. 3
diclofenac ec 25mg, 50mg tab
......................................... 3
diclofenac potassium 50mg
tab .................................... 3
diclofenac xr 100mg tab ....... 3
dicloxacillin 250mg, 500mg
cap ................................... 6
dicyclomine 10mg cap ........ 37
dicyclomine 10mg/5ml syrup
....................................... 37
dicyclomine 20mg tab ........ 37
didanosine 125mg, 200mg,
250mg, 400mg cap......... 21
diflorasone diacet 0.05%
cream ............................. 34
diflorasone diacet 0.05% oint
....................................... 34
diflunisal 500mg tab ............. 3
digoxin 125mcg, 250mcg tab
....................................... 29
digoxin 250mcg/ml ampul ... 29
digoxin 50mcg/ml soln oral . 29
dihydroergotamine mesylate
1mg/ml ampul................. 14
DILANTIN 125MG/5ML
SUSPENSION................ 10
DILANTIN 30MG, 100MG
CAP................................ 10
DILANTIN 50MG INFATAB 10
DILATRATE SR 40MG CAP31
dilt-cd 120mg, 180mg, 300mg
cap ................................. 28
diltiazem 30mg, 60mg, 90mg,
120mg tab ...................... 29
diltiazem 5mg/ml vial .......... 29
diltiazem cd 120mg, 240mg,
300mg, 360mg cap......... 29
diltiazem er 180mg, 300mg,
360mg, 420mg tab24 QL-30
QY 30 DY ....................... 29
diltiazem er 240mg tab24 QL60 QY 30 DY .................. 29
diltiazem er 420mg cap24 .. 29
diltiazem er 60mg, 90mg,
120mg cap12 ................. 29
Drug Name
Page
diltiazem hcl er 180mg, 360mg

cap ................................. 29
dilt-xr 180mg, 240mg cap ... 29
diltzac 120mg, 180mg,
240mg, 300mg, 360mg cap
....................................... 29
DIPENTUM 250MG CAP .... 47
diphenoxylate/atropine
2.5mg/0.025mg tab ......... 37
diphenoxylate/atropine 2.5mg0.025mg/5ml liquid.......... 37
DIPTHERIA/TETANUS
TOXOID PEDIATRIC
6.7LFU-5LFU/0.5ML INJ . 46
disopyramide phosphate
100mg, 150mg cap ......... 27
disulfiram 250mg, 500mg tab 3
divalproex 125mg sprink cap 9
divalproex 125mg, 250mg,
500mg tabec ..................... 9
divalproex er 250mg, 500mg
tab24 ................................ 9
DIVIGEL 1MG (0.1%) GEL
QL-30GM 30 DY ............. 42
DOCEFREZ 20MG, 80MG
VIAL ............................... 16
DOCETAXEL 20MG/2ML
80MG/8ML 160MG/16ML
VIAL ............................... 16
docetaxel 80mg/4ml vial ..... 16
donepezil 5mg, 10mg tab QL30 QY 30 DY .................. 10
donepezil odt 5mg, 10mg tab
QL-30 QY 30 DY ............ 10
dorzolamide 2% drops ........ 51
dorzolamide/timolol 2%/0.5%
drops QL-10ML 30 DY .... 51
doxazosin mesylate 1mg,
2mg, 4mg, 8mg tab ......... 39
doxepin 10mg, 25mg, 50mg,
75mg, 100mg, 150mg cap
....................................... 12
doxepin 10mg/ml conc oral . 12
......................................... 8
doxycycline hyclate 100mg
vial .................................... 8
....................................... 33
doxycycline hyclate 50mg,
100mg cap ........................ 8

Formulary Index
Drug Name
Page
doxycycline monohydrate
150mg cap ........................ 8
doxycycline monohydrate
50mg, 75mg tab ................ 8
dronabinol 2.5mg, 5mg, 10mg
cap QL-60 QY 30 DY ...... 12
DROXIA 200MG, 300MG,
400MG CAP.................... 15
DULERA HFA
100MCG/5MCG
200MCG/5MCG INHALER
QL-1 INHALER 30 DY .... 52
duramorph 0.5mg/ml 1mg/ml
ampul ................................ 1
DUREZOL 0.05% DROPS .. 50
DYNACIRC CR 5MG, 10MG
TAB................................. 29
DYRENIUM 50MG, 100MG
CAP ................................ 30
E
E.E.S.
200MG/5MLGRANULES... 7
e.e.s. 400 400mg tab ............ 7
econazole nitrate 1% cream 13
EDECRIN 25MG TAB ......... 30
EDURANT 25MG TAB QL-30
QY 30 DY ....................... 20
EFFIENT 5MG, 10MG TAB
QL-30 QY 30 DY ............. 26
ELAPRASE 6MG/3MLVIAL 37
ELELYSO 200UNIT SOLR . 37
ELIDEL 1% CREAM QL30GM 30 DY ................... 34
eliphos 667mg tab .............. 40
ELITEK 1.5MG VIAL ........... 15
ELIXOPHYLLIN 80MG/15ML
ELIXIR ............................ 53
ELMIRON 100MG CAP ...... 40
EMADINE 0.05% DROPS ... 50
EMCYT 140MG CAP .......... 15
EMEND 125MG, 80MG CAP
TRIFLD QL-6 QY 30 DY . 12
EMEND 40MG CAP QL-1 QY
30 DY.............................. 12
EMEND 80MG, 125MG CAP
QL-6 QY 30 DY............... 12
emoquette 0.15mg/30mcg tab
....................................... 42
EMSAM 12MG 24HR PATCH
QL-30 PATCH 30 DY ...... 11
Drug Name
Page

QL-30 PATCH 30 DY ..... 11
QL-30 PATCH 30 DY ..... 11
EMTRIVA 10MG/ML SOLN
ORAL ............................. 21
EMTRIVA 200MG CAP ...... 21
ENABLEX 7.5MG, 15MG TAB
QL-30 QY 30 DY ............ 39
enalapril 2.5mg, 5mg, 10mg,
20mg tab ........................ 27
enalapril/hctz 5mg/12.5mg,
10mg/25mg tab .............. 27
ENBREL 25MG KIT QL-16
INJ 30 DY ....................... 45
ENBREL 25MG/0.5ML SOLN
QL-16 SYRINGE 30 DY . 45
ENBREL 50MG/ML SOLN QL8 SYRINGE 28 DY ......... 45
ENBREL PEN 50MG/ML
SOLN QL-8 SYRINGE 28
DY .................................. 45
endocet 325mg/5mg tab QL360 QY 30 DY .................. 1
endocet 325mg/7.5mg &
325mg/10mg tab QL-360
QY 30 DY ......................... 1
endocet 500mg/7.5mg tab QL240 QY 30 DY .................. 1
endocet 650mg/10mg tab QL180 QY 30 DY .................. 1
endodan 325mg/4.835mg tab
QL-360 QY 30 DY ............ 1
ENGERIX-B 10MCG/0.5ML
INJ ................................. 46
ENGERIX-B 20MCG/ML INJ
....................................... 46
enoxaparin 100mg/ml syringe
....................................... 25
enoxaparin 30mg/0.3ml
40mg/0.4ml 60mg/0.6ml
80mg/0.8ml 120mg/0.8ml
150mg/ml syringe ........... 25
enpresse-28 0.03mg0.05mg/0.03mg0.125mg/0.04mg-0.075mg
tab .................................. 42
enulose 10g/15ml soln oral 38
epinastine 0.05% drops ...... 50
epinephrine 0.1mg/ml syringe
....................................... 53
Drug Name
Page
EPIPEN 0.3MG/0.3ML QL-2

INJ 30 DY ....................... 53
EPIPEN-JR 0.15MG/0.3ML
QL-2 INJ 30 DY .............. 53
epitol 200mg tab ................. 10
EPIVIR 10MG/ML SOLN
ORAL.............................. 21
EPIVIR HBV 100MG TAB ... 22
EPIVIR HBV 25MG/5ML
SOLN ORAL ................... 22
....................................... 30
eplerenone 25mg, 50mg tab30
eprosartan mesylate 600mg
tab QL-30 QY 30 DY....... 26
EPZICOM 600MG/300MG
TAB ................................ 21
EQUETRO 100MG, 200MG,
300MG CAP ................... 23
ergoloid mesylates 1mg tab 10
ERGOMAR 2MG TAB, SUBL
....................................... 14
ergotamine tartrate/caffeine
1mg/100mg tab............... 14
ERIVEDGE CAP 150MG QL30 QY 30 DY .................. 16
errin 0.35mg tab ................. 43
ery 2% swab ....................... 34
ERYPED 200MG/5ML
......................................... 7
ery-tab 250mg, 333mg tab .... 7
ery-tab 500mg tbec............... 7
ERYTHROCIN
LACTOBIONATE 500MG
VIAL ................................. 7
erythrocin stearate 250mg tab
......................................... 7
erythromycin 2% gel ........... 34
erythromycin 2% soln ......... 34
erythromycin 5mg/g oint ..... 49
erythromycin base 250mg,
500mg tab ........................ 7
erythromycin ethylsuccinate
400mg tab ........................ 7
erythromycin/benzoyl 3%/ 5%
peroxide gel .................... 34
erythromycin/sulfisoxazole
200mg-600mg/5ml
suspension ....................... 7
Index-8

Formulary Index
Drug Name
Page
escitalopram oxalate 5mg,

30 DY.............................. 11
escitalopram oxalate 5mg/5ml
oral soln QL-600ML 30 DY
....................................... 11
ESTRACE 0.01% CREAM .. 42
estradiol 0.025mg/24hr
0.0375mg/24hr
0.05mg/24hr 0.06mg/24hr
0.075mg/24hr 0.1mg/24hr
patch ............................... 42
estradiol 0.5mg, 1mg, 2mg tab
....................................... 42
estradiol/norethindrone 0.5mg/
0.1mg tab ........................ 42
estradiol/norethindrone
1mg/0.5mg tab ................ 42
ESTRING 7.5MCG/24HR
RING QL-1 RING 90 DY . 42
ethambutol 100mg, 400mg tab
....................................... 15
ethosuximide 250mg cap ...... 8
ethosuximide 250mg/5ml
syrup ................................. 8
etidronate 200mg, 400mg tab
....................................... 48
etodolac 200mg, 300mg cap . 3
etodolac 400mg, 500mg tab.. 3
etodolac er 400mg, 500mg,
600mg tab ......................... 3
etoposide 20mg/ml soln ...... 16
EURAX 10% CREAM ......... 18
EURAX 10% LOTION ......... 18
EVAMIST 1.53MG/ SPRAY
QL-2 BOTTLES 30 DY .... 42
EVISTA 60MG TAB QL-30 QY
30 DY.............................. 44
EVOXAC 30MG CAP .......... 33
EXALGO 12MG TAB QL-150
QY 30 DY ......................... 1
QY 30 DY ......................... 1
QY 30 DY ......................... 1
EXELDERM 1% CREAM .... 13
EXELDERM 1% SOLN NONORAL .............................. 13
EXELON 2MG/ML SOLN
Index-9
Drug Name
Page
EXELON 4.6MG/24HR,
9.5MG/24/HR PATCH QL30 PATCHES 30 DY ...... 10
exemestane 25mg tab ........ 16
EXJADE 125MG, 250MG,
500MG TAB ................... 54
EXTAVIA 0.3MG KIT QL-15
SYRINGE 30 DY ............ 46
F
FABRAZYME 35MG VIAL .. 37
famciclovir 125mg, 250mg,
500mg tab QL-60 QY 30
DY .................................. 23
famotidine 20mg, 40mg tab 38
famotidine 20mg/2ml vial .... 38
famotidine 20mg/50ml iv .... 38
famotidine 40mg/5ml
suspension ..................... 38
FANAPT 1MG, 2MG, 4MG,
6MG, 8MG, 10MG, 12MG
TAB QL-60 QY 30 DY .... 19
FANAPT
1MG/2MG/4MG/6MG TITR
PACK QL-1 PACK 365 DY
....................................... 19
FARESTON 60MG TAB ..... 15
FASLODEX 250MG/5ML
SYRINGE ....................... 15
FAZACLO 12.5MG, 25MG,
100MG, 150MG, 200MG
ODT TAB ....................... 20
felbamate 400mg, 600mg tab9
felbamate 600mg/5ml susp .. 9
felodipine er 2.5mg, 5mg,
10mg tab ........................ 29
FEMHRT LOW DOSE
0.5MG/2.5MCG TAB ...... 42
FEMRING 0.05MG/24HR,
0.1MG/24HR RING QL-1
RING 84 DY ................... 42
FEMTRACE 0.45MG, 0.9MG,
1.8MG TAB .................... 42
fenofibrate 54mg, 160mg tab
....................................... 30
fenofibrate 67mg, 134mg,
200mg micronized cap ... 30
FENOGLIDE 40MG, 120MG
TAB QL-30 QY 30 DY .... 30
fenoprofen calcium 600mg tab
......................................... 3
Drug Name
Page
fentanyl 100mcg/hr patch QL15 PATCHES 30 DY ......... 1

fentanyl 12mcg/hr, 25mcg/hr,
50mcg/hr, 75mcg/hr patch
QL-10 PATCHES 30 DY ... 1
fentanyl cit 200mcg, 400mcg,
600mcg, 800mcg,
1200mcg, 1600mcg oral
buccal lpop QL-120 QY 30
DY .................................... 2
FINACEA 15% GEL............ 34
FINACEA PLUS 15% KIT ... 35
finasteride 5mg tab ............. 39
FLAREX 0.1% SUSPENSION
....................................... 50
flavoxate 100mg tab ........... 39
flecainide 50mg, 100mg,
150mg tab ...................... 27
FLECTOR 1.3% PATCH QL60 PATCH 30 DY.............. 1
FLOVENT 50MCG, 100MCG,
250MCG DISKUS QL-1
DISKUS 30 DY ............... 52
FLOVENT HFA 44MCG,
110MCG, 220MCG
INHALER QL-2 INHALERS
30 DY ............................. 52
fluconazole 10mg/ml, 40mg/ml
suspension ..................... 13
fluconazole 50mg, 100mg,
150mg, 200mg tab .......... 13
fluconazole in dextrose
400mg/0.2l iv .................. 13
FLUCONAZOLE IN NACL
100MG/50ML .................. 13
flucytosine 250mg, 500mg cap
....................................... 13
fludrocortisone 0.1mg tab ... 40
flunisolide 25mcg aero ........ 52
fluocinolone acetonide 0.01%
body oil ........................... 35
drops .............................. 51
scalp oil .......................... 35
soln ................................. 35
fluocinolone acetonide 0.01%,
0.025% cream ................ 35
oint ................................. 35

Formulary Index
Drug Name
Page
fluocinonide 0.05% emollient

base cream ..................... 35
fluocinonide 0.05% gel ........ 35
fluocinonide 0.05% oint ....... 35
fluocinonide 0.05% soln nonoral ................................. 35
fluorometholone 0.1%
suspension...................... 50
FLUOROPLEX 1% CREAM 35
fluorouracil 2%, 5% soln ..... 35
fluorouracil 5% cream ......... 35
fluorouracil 500mg/10ml vial 15
fluoxetine 10mg, 20mg tab .. 11
fluoxetine 10mg, 20mg, 40mg
cap .................................. 11
fluoxetine 20mg/5ml soln oral
....................................... 11
fluoxetine 90mg wkly cap QL4 QY 28 DY..................... 11
fluphenazine 1mg, 2.5mg,
5mg, 10mg tab ................ 19
fluphenazine 2.5mg/5ml elixir
....................................... 19
fluphenazine 2.5mg/ml vial . 19
fluphenazine 5mg/ml conc oral
....................................... 19
fluphenazine decanoate
25mg/ml vial.................... 19
flurbiprofen 0.03% drops ..... 50
flurbiprofen 50mg, 100mg tab3
flutamide 125mg cap .......... 45
fluticasone propionate 0.005%
oint .................................. 35
fluticasone propionate 0.05%
cream.............................. 35
fluticasone propionate 50mcg
spray ............................... 52
fluvastatin sodium 20mg cap
QL-30 QY 30 DY ............. 31
fluvastatin sodium 40mg cap
QL-60 QY 30 DY ............. 31
fluvoxamine 25mg, 50mg,
100mg tab ....................... 11
FML 0.1% OINT .................. 50
FML FORTE 0.25%
SUSPENSION ................ 50
fomepizole 1g/ml vial .......... 48
fondaparinux sodium
2.5mg/0.5ml 5mg/0.4ml
7.5mg/0.6ml 10mg/0.8ml
syringe ............................ 25
Drug Name
Page
FORADIL 12MCG AERO CAP

QL-60 QY 30 DY ............ 53
FORTEO 20MCG/DOSE QL-1
PEN 28 DY ..................... 48
fortical 200unit/dose nasal
soln ................................ 48
foscarnet 24mg/ml inj ......... 20
fosinopril 10mg, 20mg, 40mg
tab .................................. 27
fosinopril/hctz 10mg/12.5mg
20mg/12.5mg tab ........... 27
FOSRENOL 1000MG CHEW
QL-120 QY 30 DY .......... 40
FOSRENOL 500MG & 750MG
CHEW QL-180 QY 30 DY
....................................... 40
FREAMINE HBC 6.9% IV... 55
FREAMINE III 3% IV .......... 55
FREAMINE III 8.5% IV ....... 55
FROVA 2.5MG TAB QL-12
QY 30 DY ....................... 14
furosemide 10mg/ml soln oral
....................................... 30
furosemide 10mg/ml vial .... 30
furosemide 20mg, 40mg,
80mg tab ........................ 30
furosemide 40mg/5ml soln
oral ................................. 30
FUZEON 90MG KIT QL-60
VIALS 30 DY .................. 21
G
gabapentin 100mg, 300mg,
400mg cap ....................... 9
gabapentin 250mg/5ml soln
oral ................................... 9
gabapentin 600mg, 800mg tab
......................................... 9
GABITRIL 12MG TAB QL-120
QY 30 DY ......................... 9
QY 30 DY ......................... 9
QY 30 DY ......................... 9
QY 30 DY ......................... 9
galantamine 4mg, 8mg, 12mg
tab QL-60 QY 30 DY ...... 10
galantamine 4mg/ml soln oral
QL-200ML 30 DY ........... 10
Drug Name
Page
galantamine 8mg, 16mg,

24mg cap 24hr QL-30 QY
30 DY ............................. 10
gammagard liquid 10% vial . 46
GAMMAGARD S/D 2.5G, 5G,
10G VIAL ........................ 46
GAMMAPLEX 5% SOLN .... 46
ganciclovir 250mg, 500mg cap
....................................... 20
GARDASIL 0.5ML VIAL ...... 46
gauze pads 2 ...................... 35
gavilyte-c
240g/2.98g/6.72g/5.84g/22.
72g soln oral QL-1 KIT QY
30 DY ............................. 38
gavilyte-g
236g/2.97g/6.74g/5.86g/22.
74g soln oral QL-1 KIT QY
30 DY ............................. 38
gavilyte-n
420g/1.48g/5.72g/11.2g QL1 KIT QY 30 DY .............. 38
GELNIQUE 10% GEL QL-30
PACK 30 DY ................... 39
gemcitabine 200mg, 1g, 2g
vial .................................. 15
GEMCITABINE
200MG/5.26ML 1G/26.3ML
2G/52.6ML VIAL ............ 15
GEMCITABINE
200MG/5.26ML 1G/26.3ML
2G/52.6ML VIAL ............. 16
gemfibrozil 600mg tab ........ 30
generlac 10g/15ml soln oral 38
gengraf 100mg/ml soln oral 45
gengraf 25mg, 100mg cap .. 45
gentak 0.3%oint .................. 49
gentamicin sulfate 0.1%
cream ............................. 35
gentamicin sulfate 0.1% oint35
gentamicin sulfate 0.3% opht
drops .............................. 49
gentamicin sulfate 40mg/ml
vial .................................... 4
gentamicin sulfate 80mg/8ml
vial .................................... 4
gentamicin/0.9% sod chl iv ... 4
GEODON 20MG VIAL QL60ML 30 DY.................... 19
gianvi 0.02mg/3mg tab ....... 42
GLEEVEC 100MG TAB QL-90
QY 30 DY ....................... 16
Index-10

Formulary Index
Drug Name
Page
GLEEVEC 400MG TAB QL-60

QY 30 DY ....................... 17
glimepiride 1mg, 2mg, 4mg
tab .................................. 23
glipizide 5mg, 10mg tab ...... 23
glipizide er 2.5mg tab .......... 23
glipizide xl 5mg, 10mg tab .. 23
glipizide/metformin
2.5mg/250mg
2.5mg/500mg 5mg/500mg
tab .................................. 23
GLUCAGEN 1MG HYPOKIT
QL-2 INJ 1 DY ................ 24
GLUCAGON 1MG EMERG
KIT QL-1 INJ 1 DY .......... 24
glyburide 1.25mg, 2.5mg, 5mg
tab .................................. 23
glyburide 1.5mg, 3mg, 6mg
micronized tab ................ 23
glyburide/metformin
1.25mg/250mg
2.5mg/500mg 5mg/500mg
tab .................................. 23
glycopyrrolate 0.2mg/ml vial 37
glycopyrrolate 1mg, 2mg tab
....................................... 37
GOLYTELY
236G/2.97G/6.74G/5.86G/2
2.74G QL-1 KIT QY 30 DY
....................................... 38
granisetron 1mg tab QL-30
QY 30 DY ....................... 12
GRIFULVIN V 500MG TAB . 13
griseofulvin 125mg/5ml micro
susp ................................ 13
GRIS-PEG 125MG, 250MG
TAB................................. 13
guanfacine 1mg, 2mg tab ... 26
GUANIDINE 125MG TAB ... 14
H
HALFLYTELY
5MG/210G/0.74G/2.86G/5.
6G BOWEL PREP
KIT/FLAVOR PACKS QL-1
KIT QY 30 DY ................. 37
halobetasol propionate 0.05%
cream.............................. 35
halobetasol propionate 0.05%
oint .................................. 35
HALOG 0.1% CREAM ........ 35
Index-11
Drug Name
Page
HALOG 0.1% OINT ............ 35

haloperidol 0.5mg, 1mg, 2mg,
5mg, 10mg, 20mg tabs ... 19
haloperidol 2mg/ml conc oral
....................................... 19
haloperidol decanoate
50mg/ml, 100mg/ml vial.. 19
haloperidol lactate 5mg/ml vial
....................................... 19
HAVRIX 1440ELU/ML INJ .. 46
HAVRIX 720ELU/0.5ML INJ46
HECTOROL 0.5MCG, 1MCG,
2.5MCG CAP ................. 48
heparin sod 10000unit/5ml
25000unit/10ml vial ........ 25
heparin sod 1000unit/ml
5000unit/ml 10000unit/ml
20000unit/ml vial ............ 25
heparin/d5w
20000UNIT/500ml
25000unit/250ml
25000/500ml iv ............... 25
heparin/nacl 1000unit/500ml
2000unit/1000ml iv ......... 25
HEPATAMINE 8% IV ......... 55
HEPATASOL 8% IV .......... 55
HEPSERA 10MG TAB QL-30
QY 30 DY ....................... 22
HERCEPTIN 440MG VIAL . 17
HEXALEN 50MG CAP ....... 15
HUMIRA 20MG/0.4ML KIT
QL-2 SYRINGE 30 DY ... 45
HUMIRA 40MG/0.8ML KIT
HUMIRA PEN 40MG/0.8ML
hydralazine 10mg, 25mg,
50mg, 100mg tab ........... 32
hydralazine 20mg/ml vial .... 32
hydrochlorothiazide 12.5mg
cap ................................. 30
hydrochlorothiazide 12.5mg,
25mg, 50mg tab ............. 30
hydrocodone bit/apap
QY 30 DY ......................... 2
hydrocodone/apap
5mg/325mg 7.5mg/325mg
QY 30 DY ......................... 2
Drug Name
Page
hydrocodone/apap
5mg/500mg 7.5mg/500mg
QY 30 DY ......................... 2
hydrocodone/apap
7.5mg/650mg 10mg/650mg
QY 30 DY ......................... 2
hydrocodone/apap
7.5mg/750mg tab QL-150
QY 30 DY ......................... 2
hydrocodone/apap 7.5mg500mg/15ml soln oral QL3600ML 30 DY .................. 2
hydrocodone/apap-hs
QY 30 DY ......................... 2
hydrocodone/ibuprofen
7.5mg/200mg tab .............. 2
hydrocortisone 100mg/60ml
enema ............................ 48
hydrocortisone 2.5% cream 35
hydrocortisone 2.5% lotion . 35
hydrocortisone 2.5% oint .... 35
hydrocortisone 5mg, 10mg,
20mg tab ........................ 40
hydrocortisone butyrate 0.1%
cream ............................. 35
oint ................................. 35
soln ................................. 35
hydrocortisone in absorbase
1% oint ........................... 35
hydrocortisone valerate 0.2%
cream ............................. 35
hydrocortisone valerate 0.2%
oint ................................. 35
hydromorphone 1mg/ml,
2mg/ml syringe ................. 2
hydromorphone 1mg/ml,
4mg/ml, 10mg/ml ampule.. 2
hydromorphone 2mg, 4mg,
8mg tab ............................ 2
hydroxychloroquine sulfate
200mg tab ...................... 17
hydroxyurea 500mg cap ..... 16
hydroxyzine 25mg/ml,
50mg/ml vial ................... 52

Formulary Index
Drug Name
Page
I
ibandronate sodium 150mg
tab QL-1 QY 30 DY ......... 48
ibuprofen 400mg, 600mg,
800mg tab ......................... 3
ILARIS 180MG VIAL QL-1
VIAL QY 56 DY ............... 46
imipenem/cilastatin
250mg/250mg
500mg/500mg iv vial ......... 6
imipramine 10mg, 25mg,
50mg tab ......................... 12
imiquimod 5% cream QL-12
PACK 30 DY ................... 35
IMOVAX RABIES 2.5 UNIT
INJ .................................. 47
INCIVEK 375MG TAB QL-180
QY 30 DY ....................... 22
INCRELEX 10MG/ML VIAL 41
indapamide 1.25mg, 2.5mg
tab .................................. 30
INDOCIN 25MG/5ML
SUSPENSION .................. 3
indomethacin 25mg, 50mg
cap .................................... 3
indomethacin er 75mg cap .... 3
INFANRIX 25LFU-58MCG10LFU/0.5ML VIAL ......... 47
INLYTA 1MG TAB 1MG QL240 QY 30 DY................. 17
INLYTA 5MG TAB 5MG QL120 QY 30 DY................. 17
INNOPRAN XL 120MG
CAP24 QL-60 QY 30 DY. 28
INNOPRAN XL 80MG CAP24
QL-30 QY 30 DY ............. 28
INSULIN PEN NEEDLE ...... 48
INSULIN SAFETY SYRINGE
....................................... 48
INSULIN SYRINGE ............ 48
INTELENCE 100MG TAB QL120 QY 30 DY................. 20
INTELENCE 200MG TAB QL60 QY 30 DY................... 20
intralipid 20% emulsion ....... 48
INTRALIPID 30% EMULSION
....................................... 48
INTRON-A 10 MU INJ......... 22
....................................... 22
INTRON-A 3MU/0.2ML INJ . 22
Drug Name
Page
INTRON-A 5MU/0.2ML INJ 22

INTRON-A 6000000U/ML INJ
....................................... 22
introvale 0.15mg/0.03mg tab
....................................... 43
INTUNIV 1MG, 2MG, 3MG,
4MG TB24 QL-30 QY 30
DY .................................. 32
INVANZ 1G VIAL ................. 6
INVEGA 1.5MG, 3MG, 9MG
TAB24 QL-30 QY 30 DY 19
INVEGA 6MG TAB24 QL-60
QY 30 DY ....................... 19
INVEGA SUST 39MG/0.25ML
78MG/0.5ML
117MG/0.75ML 156MG/ML
234MG/1.5ML VIAL QL-1
INJ 28 DY ....................... 19
INVIRASE 200MG CAP ..... 21
INVIRASE 500MG TAB ...... 21
IPOL 40-8-32/0.5ML VIAL .. 47
ipratropium bromide 0.2mg/ml
soln, neb ........................ 53
ipratropium bromide 21mcg,
42mcg nasal soln ........... 53
ipratropium bromide/albuterol
sulfate 0.5mg-3mg/3ml neb
....................................... 53
irbesartan 75mg, 150mg,
DY .................................. 26
irbesartan/hydrochlorothiazide
QY 30 DY ....................... 26
irbesartan/hydrochlorothiazide
QY 30 DY ....................... 26
IRESSA 250MG TAB QL-30
QY 30 DY ....................... 17
ISENTRESS 400MG TAB QL60 QY 30 DY .................. 21
isonarif 150mg/300mg cap . 15
isoniazid 100mg, 300mg tab15
isoniazid 50mg/5ml syrup ... 15
isosorbide dinitrate 2.5mg,
5mg tab, subl.................. 31
isosorbide dinitrate 5mg,
10mg, 20mg, 30mg tab .. 31
isosorbide dinitrate er 40mg
tab .................................. 31
isosorbide mononitrate 10mg,
20mg tab ........................ 31
Drug Name
Page
isosorbide mononitrate er
30mg, 60mg, 120mg tab . 31
isotonic gentamicin
60mg/100ml 80mg/100ml
iv....................................... 4
isradipine 2.5mg, 5mg cap .. 29
ISTALOL 0.5% DROPS ...... 51
itraconazole 100mg cap...... 13
IXEMPRA KIT 45MG VIAL . 16
IXIARO 6MCG/0.5ML SUSP
....................................... 47
J
JAKAFI 5MG, 10MG, 15MG,
QY 30 DY ....................... 16
JALYN 0.5MG/0.4MG CAP
QL-30 QY 30 DY ............ 39
jantoven 1mg, 2mg, 2.5mg,
3mg, 4mg, 5mg, 6mg,
7.5mg, 10mg tab ............. 25
JANUMET 50MG/500MG
QY 30 DY ....................... 23
JANUMET XR 1000MG/50MG
TAB QL-60 QY 30 DY..... 23
JANUMET XR 500MG/50MG
1000MG/100MG TAB QL30 QY 30 DY .................. 24
JANUVIA 25MG, 50MG,
DY .................................. 24
JE-VAX VIAL ...................... 47
jinteli 1mg/5mcg.................. 42
jolivette 0.35mg tab ............ 43
junel 1mg/20mcg
1.5mg/30mcg tab ............ 42
junel fe 1mg/20mcg
1.5mg/30mcg tab ............ 42
K
KADIAN 10MG, 20MG, 30MG,
50MG, 60MG, 80MG,
100MG, 200MG CAP,24HR
QL-60 QY 30 DY .............. 1
KALETRA 100MG/25MG TAB
QL-300 QY 30 DY........... 21
KALETRA 200MG/50MG TAB
QL-120 QY 30 DY........... 21
Index-12

Formulary Index
Drug Name
Page
KALETRA 400MG100MG/5ML ORAL SOLN

QL-375ML 30 DY ............ 21
kariva 21-5 tab .................... 42
kcl/d5w/lr 20MEQ/L 40MEQ/L
iv ..................................... 56
kcl/d5w/nacl 10MEQ/L
20MEQ/L 30MEQ/L
40MEQ/L iv ..................... 24
kelnor 1/35 1mg/35mcg tab 42
KENALOG 0.147MG/G AERO
....................................... 35
KETEK 300MG, 400MG TAB
QL-20 QY 10 DY ............... 7
ketoconazole 2% cream...... 13
ketoconazole 2% shampoo . 13
ketoconazole 200mg tab ..... 13
ketoprofen 50mg, 75mg cap . 3
ketoprofen er 200mg cap ...... 4
ketorolac trometh 0.4%, 0.5%
ophth soln QL-10ML 30 DY
....................................... 50
ketorolac trometh 15mg/ml vial
QL-20 VIALS 5 DY ............ 4
KINRIX 25-25-10 SYRINGE
QL-1 INJ 365 DY............. 47
kionex powder .................... 54
klor-con 20 meq packet....... 55
klor-con 8 meq, 10 meq tab, sr
....................................... 55
klor-con m 15 meq, 20 meq
tab, sr.............................. 55
KOMBIGLYZE XR
2.5MG/1000MG TAB QL-60
QY 30 DY ....................... 24
KOMBIGLYZE XR
5MG/500MG
QY 30 DY ....................... 24
K-TAB 10 MEQ TAB, SR .... 55
KUVAN 100MG TAB ........... 37
L
labetalol 100mg, 200mg,
300mg tab ....................... 28
labetalol 5mg/ml vial ........... 28
laclotion 12% lotion ............. 35
LACRISERT 5MG INSERT . 49
LACTATED RINGERS IV ... 55
lactulose 10g/15ml soln oral 38
Index-13
Drug Name
Page
lamivudine 150mg, 300mg tab

....................................... 21
lamivudine/zidovudine
150mg/300mg tab .......... 21
lamotrigine 100mg tab QL-90
QY 30 DY ......................... 9
lamotrigine 25mg, 150mg,
200mg tab ........................ 9
lamotrigine 5mg, 25mg chew
tab .................................... 9
LANOXIN 125MCG, 250MCG
TAB ................................ 29
lansoprazole 15mg, 30mg
capr QL-30 QY 30 DY .... 39
LANTUS 100UNIT/ML VIAL 24
LANTUS SOLOSTAR
100UNIT/ML ................... 24
LASTACAFT 0.25% DROPS
QL-3ML 30 DY ............... 50
latanoprost 0.005% QL-2.5ML
30 DY ............................. 49
LATUDA 20MG, 40MG, 80MG
TAB QL-30 QY 30 DY .... 19
leena 7-9-5 tab ................... 42
leflunomide 10mg, 20mg tab
....................................... 46
lessina-28 0.1mg/20mcg tab
....................................... 42
letrozole 2.5mg tab QL-30 QY
30 DY ............................. 16
leucovorin calcium 100mg,
350mg soln..................... 16
leucovorin calcium 5mg,
10mg, 15mg, 25mg tab .. 16
LEUKERAN 2MG TAB ....... 15
LEUKINE 250MCG VIAL .... 25
LEUKINE 500MCG/ML VIAL
....................................... 25
leuprolide acet 1mg/0.2ml kit
....................................... 44
levalbuterol 1.25mg/0.5ml neb
QL-90 VIALS 30 DY ....... 53
LEVATOL 20MG TAB ........ 28
LEVEMIR 100UNIT/ML
FLEXPEN ....................... 24
LEVEMIR 100UNIT/ML VIAL
....................................... 24
levetiracetam 100mg/ml soln
oral ................................... 8
levetiracetam 250mg, 500mg
tab QL-180 QY 30 DY ...... 8
Drug Name
Page
levetiracetam 500mg/5ml vial 8

levetiracetam 750mg, 1000mg
tab .................................... 8
levobunolol 0.25%, 0.5%
drops .............................. 51
levocarnitine 330mg tab...... 48
levocetirizine dihydrochloride
5mg tab QL-30 QY 30 DY
....................................... 52
levofloxacin 0.5% drops ...... 49
levofloxacin 250mg, 500mg,
DY .................................... 7
levora 0.15mg/30mcg tab ... 42
levorphanol tartrate 2mg tab . 2
levothroid 25mcg, 50mcg,
75mcg, 88mcg, 100mcg,
112mcg, 125mcg, 137mcg,
150mcg, 175mcg, 200mcg,
300mcg tab ..................... 44
levothyroxine 25mcg, 50mcg,
112mcg, 125mcg, 137mcg,
150mcg, 175mcg, 200mcg,
300mcg tab ..................... 44
levoxyl 25mcg, 50mcg,
112mcg, 125mcg, 137mcg,
150mcg, 175mcg, 200mcg
tab .................................. 44
LEXIVA 50MG/ML
SUSPENSION ................ 21
LEXIVA 700MG TAB .......... 21
LIALDA 1.2G TAB QL-120 QY
30 DY ............................. 47
lidocaine 2% jelly .................. 2
lidocaine 20mg/ml viscous
soln ................................... 3
lidocaine 40mg/ml soln ......... 3
lidocaine 5% oint .................. 3
lidocaine 5mg/ml, 10mg/ml
vial .................................... 3
lidocaine/prilocaine 2.5%/2.5%
cream ............................... 3
LIDODERM 5% PATCH QL90 PATCHES 30 DY ......... 3
LINDANE 1% LOTN QL-60ML
30 DY ............................. 18
lindane 1% shamp QL-60ML
30 DY ............................. 18

Formulary Index
Drug Name
Page
liothyronine 5mcg, 25mcg,

50mcg tab ....................... 44
LIPOFEN 150MG CAP QL-30
QY 30 DY ....................... 30
LIPOFEN 50MG CAP QL-90
QY 30 DY ....................... 30
LIPOSYN II 10%, 20% EMUL
....................................... 48
LIPOSYN III 10%, 20% EMUL
....................................... 49
LIPOSYN III 30% VIAL ....... 49
lisinopril 2.5mg, 5mg, 10mg,
20mg, 30mg, 40mg tab .. 27
lisinopril 2.5mg, 5mg, 10mg,
20mg, 30mg, 40mg tab ... 27
lisinopril/hctz 10mg/12.5mg
20mg/12.5mg 20mg/25mg
tab .................................. 27
lithium carbonate 150mg,
300mg, 600mg cap ......... 23
lithium carbonate 300mg tab
....................................... 23
lithium carbonate er 300mg,
450mg tab ....................... 23
lithium citrate 8meq/5ml soln
oral ................................. 23
LITHOBID 300MG TAB, SR 23
LIVALO 1MG, 2MG, 4MG TAB
QL-30 QY 30 DY ............. 31
LO LOESTRIN FE
1MG/75MG/10MCG TAB 42
LODOSYN 25MG TAB........ 18
LOESTRIN 24 FE
1MG/75MG/20MCG TAB 42
loperamide 2mg cap ........... 38
lorazepam 0.5mg, 1mg, 2mg
tab QL-90 QY 30 DY ....... 23
lorazepam intensol 2mg/ml
soln oral .......................... 23
losartan pot/hctz
50mg/12.5mg
100mg/12.5mg
100mg/25mg tab QL-30 QY
30 DY.............................. 26
losartan potassium 100mg tab
QL-30 QY 30 DY ............. 26
losartan potassium 25mg,
....................................... 26
LOTEMAX 0.5% OINTMENT
....................................... 50
Drug Name
Page
LOTEMAX 0.5%
SUSPENSION................ 50
LOTRONEX 0.5MG, 1MG
TAB QL-60 QY 30 DY .... 38
lovastatin 10mg, 20mg, 40mg
tab .................................. 31
LOVAZA 1G CAP QL-120 QY
30 DY ............................. 31
low-ogestrel 0.3mg/30mcg tab
....................................... 42
loxapine succinate 5mg,
10mg, 25mg, 50mg cap .. 19
LUMIGAN 0.01%, 0.03% QL5ML 30 DY ..................... 49
LUNESTA 1MG, 2MG, 3MG
TAB QL-30 QY 30 DY .... 54
LUPRON DEPOT 3.75MG,
7.5MG, 11.25MG, 22.5MG,
30MG, 45MG KIT ........... 44
LUPRON DEPOT-PED
11.25MG, 15MG, 30MG KIT
....................................... 44
lutera 0.1mg/20mcg tab...... 42
LYRICA 225MG, 300MG CAP
QL-60 QY 30 DY .............. 8
LYRICA 25MG, 50MG, 75MG,
100MG, 150MG, 200MG
CAP QL-90 QY 30 DY ...... 8
LYSODREN 500MG TAB ... 44
M
magnesium sulfate 4 meq/ml
syringe ........................... 55
malathion 0.5% lotion ......... 18
maprotiline 25mg, 50mg,
75mg tab ........................ 11
marlissa 0.03mg/0.15mg tab
....................................... 43
MARPLAN 10MG TAB ....... 11
MATULANE 50MG CAP..... 15
MAXALT 5MG, 10MG TAB
QL-12 QY 30 DY ............ 14
MAXALT-MLT 5MG, 10MG
TAB QL-12 QY 30 DY .... 14
MAXIDEX 0.1%
SUSPENSION................ 50
meclizine 12.5mg, 25mg tab12
meclofenamate 50mg, 100mg
cap ................................... 4
Drug Name
Page
medroxyprogesterone acet
150mg/ml vial QL-1ML 90
DY .................................. 43
medroxyprogesterone acet
2.5mg, 5mg, 10mg tab .... 43
mefloquine 250mg tab ........ 17
MEGACE ES 625MG/5ML
ORAL SUSP QL-150ML 30
DY .................................. 49
megestrol acet 20mg, 40mg
tab .................................. 49
megestrol acet 400mg/10ml
suspension ..................... 49
meloxicam 7.5mg, 15mg tab . 4
meloxicam 7.5mg/5ml
suspension ....................... 4
MENACTRA 4MCG/0.5ML
VIAL ............................... 47
MENOMUNE-A/C/Y/W-135
50MCG VIAL .................. 47
MENOSTAR 14MCG/24HR
PATCH QL-4 PATCHES 28
DY .................................. 42
MENTAX 1% CREAM ........ 13
MENVEO 10-5/0.5ML VIAL 47
MEPRON 750MG/5ML
SUSPENSION ................ 17
mercaptopurine 50mg tab ... 16
meropenem 500mg vial ........ 6
mesalamine 4g/60ml enema
....................................... 47
mesna 100mg/ml vial .......... 16
MESNEX 400MG TAB ........ 16
MESTINON 60MG/5ML
SYRUP ........................... 14
MESTINON TIMESPAN
180MG TAB, SR ............. 14
METADATE CD 10MG,
20MG, 30MG, 40MG,
50MG, 60MG CAP QL-30
QY 30 DY ....................... 32
metadate er 20mg tab ........ 32
metaproterenol sulfate 10mg,
20mg tab ........................ 53
metaproterenol sulfate
10mg/5ml syrup .............. 53
metformin 500mg, 850mg,
1000mg tab..................... 24
metformin er 500mg, 750mg
tab (generic
GLUCOPHAGE XR) ....... 24
Index-14

Formulary Index
Drug Name
Page
methadone 10mg/ml conc oral

......................................... 1
METHADONE 10MG/ML VIAL
......................................... 1
methadone 5mg & 10mg tab
QL-240 QY 30 DY ............. 1
METHADONE 5MG/5ML,
10MG/5ML ORAL SOLN ... 1
methadose 10mg tab QL-240
QY 30 DY ......................... 1
methazolamide 25mg, 50mg
tab .................................. 51
methenamine hippurate 1g tab
......................................... 4
methimazole 5mg, 10mg tab
....................................... 45
methotrexate 25mg/ml vial .. 45
methotrexatemg tab ............ 45
methscopolamine bromide
2.5mg, 5mg tab ............... 37
methyclothiazide 5mg tab ... 30
methyldopa 250mg, 500mg
tab .................................. 26
methyldopa/hctz 250mg/15mg
tab .................................. 26
methyldopa/hctz 250mg/25mg
tab .................................. 26
methylergonovine maleate
0.2mg tab ........................ 49
methylphenidate 5mg, 10mg,
20mg tab ......................... 32
methylphenidate hcl er 18mg,
30 DY.............................. 32
methylphenidate hcl er 20mg,
40mg cap QL-30 QY 30 DY
....................................... 32
methylphenidate hcl er 30mg
cap QL-60 QY 30 DY ...... 33
methylphenidate hcl er 36mg
tab QL-60 QY 30 DY ....... 33
methylphenidate sr 20mg tab
....................................... 33
methylprednisolone 4mg tab
....................................... 40
methylprednisolone 4mg,
8mg, 16mg, 32mg tab ..... 40
methylprednisolone acet
40mg/ml, 80mg/ml vial .... 40
Index-15
Drug Name
Page
methylprednisolone sod succ

40mg, 125mg, 1000mg vial
....................................... 40
metipranolol 0.3% drops..... 51
metoclopramide 5mg, 10mg
tab .................................. 38
metoclopramide 5mg/5ml soln
oral ................................. 38
metoclopramide 5mg/ml vial 38
metolazone 2.5mg, 5mg,
10mg tab ........................ 30
metoprolol succinate er 25mg,
50mg, 100mg, 200mg tab28
metoprolol tartrate 25mg,
50mg, 100mg tab ........... 28
metoprolol tartrate 5mg/5ml
vial ................................. 28
metoprolol/hctz 50mg/25mg
100mg/25mg 100mg/50mg
tab .................................. 28
metronidazole 0.75% cream 35
metronidazole 0.75% gel .... 35
metronidazole 0.75% lotion 35
metronidazole 250mg, 500mg
tab .................................... 4
metronidazole 375mg cap .... 4
metronidazole 500mg/0.1l iv 4
metronidazole vaginal gel
0.75% ............................. 40
mexiletine 150mg, 200mg,
250mg cap ..................... 27
MICARDIS 20MG, 40MG,
DY .................................. 26
MICARDIS HCT
40MG/12.5MG
80MG/12.5MG
80MG/25MG TAB QL-30
QY 30 DY ....................... 26
microgestin 1.5mg/30mcg tab
....................................... 42
microgestin 1mg/20mcg tab 42
microgestin fe 1.5mg/30mcg
tab .................................. 42
microgestin fe 1mg/20mcg tab
....................................... 42
midodrine 2.5mg, 5mg, 10mg
tab .................................. 26
migergot 2mg/100mg supp
rectal .............................. 14
Drug Name
Page
MIGRANAL 0.5MG/SPRY QL8 VIALS 28 DY ............... 14

millipred 5mg tab ................ 40
minocycline 50mg, 75mg,
100mg cap ........................ 8
minoxidil 2.5mg, 10mg tab .. 32
mirtazapine 7.5mg, 15mg,
30mg, 45mg tab .............. 11
mirtazapine odt 15mg, 30mg,
....................................... 11
misoprostol 100mcg, 200mcg
tab .................................. 39
mitoxantrone 2mg/ml vial .... 16
M-M-R II 12500/0.5 VIAL .... 47
moexipril 7.5mg, 15mg tab . 27
moexipril/hctz 7.5mg/12.5mg
15mg/12.5mg 15mg/25mg
tab .................................. 27
mometasone furoate 0.1%
cream ............................. 35
mometasone furoate 0.1% oint
....................................... 35
mometasone furoate 0.1%
soln ................................. 35
mononessa 0.25mg/35mcg
tab .................................. 42
MONUROL 3G PACKET ...... 5
morphine sulfate 0.5mg/ml
1mg/ml 5mg/ml vial .......... 2
morphine sulfate 10mg/5ml
20mg/5ml 100mg/5ml soln
oral ................................... 2
morphine sulfate 15mg &
DY .................................... 2
morphine sulfate 20mg, 30mg,
50mg, 60mg, 80mg, 100mg
cap, 24hr QL-60 QY 30 DY
......................................... 1
morphine sulfate 5mg, 10mg,
20mg, 30mg supp rectal ... 2
morphine sulfate er 15mg,
30mg, 60mg, 100mg,
DY .................................... 1
MOTOFEN 0.025MG/1MG
TAB ................................ 38
MOVIPREP
4.7G/100G/1.015G/5.9G/2.

Formulary Index
Drug Name
Page
691G/7.5G QL-1 KIT QY 30

DY .................................. 38
MOXATAG 775MG TAB QL10 QY 10 DY..................... 6
MOXEZA 0.5% DROPS QL3ML 30 DY ...................... 49
MULTAQ 400MG TAB QL-60
QY 30 DY ....................... 27
mupirocin 2% oint ............... 35
MYCOBUTIN 150MG CAP . 14
mycophenolate mofetil 250mg
cap .................................. 45
mycophenolate mofetil 500mg
tab .................................. 45
MYTELASE 10MG TAB ...... 14
N
nabumetone 500mg, 750mg
tab .................................... 4
nadolol 20mg, 40mg, 80mg
tab .................................. 28
nadolol/bendroflumethiazide
40mg/5mg 80mg/5mg tab
....................................... 28
nafcillin 1g, 10g vial .............. 6
NAFTIN 1% CREAM ........... 13
NAFTIN 1%GEL ................. 13
NAGLAZYME 5MG/5ML VIAL
....................................... 37
nalbuphine 10mg/ml 20mg/ml
vial .................................... 2
NALFON 200MG, 400MG
CAP .................................. 4
naloxone 0.4mg/ml 1mg/ml
syringe .............................. 3
naltrexone 50mg tab ............. 3
NAMENDA 10MG/5ML SOLN
NAMENDA 5MG, 10MG TAB
QL-60 QY 30 DY ............. 10
NAMENDA 5MG/10MG TITR
PAK TAB QL-1 PACK 28
DY .................................. 10
naproxen 125mg/5ml oral
suspension........................ 4
naproxen 275mg, 550mg tab 4
naproxen dr 375mg, 500mg
tabec ................................. 4
naproxen tab 250mg, 375mg,
500mg tab ......................... 4
Drug Name
Page
naratriptan 1mg, 2.5mg tab

QL-9 QY 30 DY .............. 14
NASONEX 50MCG QL-2
BOTTLES 30 DY ............ 52
NATACYN 5% SUSPENSION
....................................... 49
nateglinide 60mg, 120mg tab
QL-90 QY 30 DY ............ 24
NEBUPENT 300MG VIAL .. 17
necon 0.5/35-28 0.5mg/35mcg
tab .................................. 42
....................................... 42
....................................... 42
necon 10/11-28 tab ............ 42
necon 7/7/7 tab .................. 42
nefazodone 50mg, 100mg,
150mg, 200mg, 250mg tab
....................................... 11
neomycin /bacitracin
/hydrocortisone 3.5-10k-1
oint ................................. 49
neomycin /bacitracin
/polymyxin 3.5mg-400 oint
....................................... 49
neomycin /poly/hydrocort 3.510k-1 otic susp ............... 51
neomycin /poly/hydrocort 3.510k-10 opht susp ............ 50
neomycin /polymyxin
/dexameth 0.1%
suspension ..................... 50
neomycin /polymyxin
/dexameth 3.5-10k-.1 oint 50
neomycin /polymyxin
/gramicidin 1.75mg-10k
drops .............................. 49
neomycin /polymyxin /hc 3.510k-1 otic soln ................ 51
neomycin sulfate 500mg tab. 4
NEORAL 100MG/ML SOLN
ORAL ............................. 45
NEORAL 25MG, 100MG CAP
....................................... 45
NEPHRAMINE 5.4% IV ...... 55
NEUMEGA 5MG VIAL........ 25
NEUPOGEN 300MCG/0.5ML
480MCG/0.8ML
480MCG/1.6ML INJ........ 25
NEVANAC 0.1% SUSP QL3ML 30 DY ..................... 50
Drug Name
Page
nevirapine 200mg tab ......... 20

NEXAVAR 200MG TAB QL120 QY 30 DY ................ 17
NEXIUM 10MG, 20MG, 40MG
PACK QL-30 PACK 30 DY
....................................... 39
NEXIUM 20MG, 40MG CAP
QL-30 QY 30 DY ............ 39
NEXIUM 20MG, 40MG IV ... 39
next choice 0.75mg tab....... 43
NIACOR 500MG TAB ......... 56
NIASPAN 500MG TABCR QL30 QY 30 DY .................. 31
NIASPAN 750MG, 1000MG
TABCR QL-60 QY 30 DY 31
nicardipine 20mg, 30mg cap
....................................... 29
NICOTROL NS 10MG/ML
SPRAY QL-4 BOTTLES 30
DY .................................... 3
nifediac cc 30mg, 60mg, 90mg
tab, sr ............................. 29
nifedical xl 30mg tab ........... 29
nifedical xl 60mg tab ........... 29
nifedipine er 30mg, 60mg,
90mg tab ........................ 29
NILANDRON 150MG TAB .. 45
nimodipine 30mg cap ......... 29
nisoldipine 25.5mg, 30mg tab
QL-60 QY 30 DY ............ 29
nisoldipine 8.5mg, 17mg,
20mg, 34mg, 40mg tab QL30 QY 30 DY .................. 29
NITRO-BID 2% OINT ......... 31
nitrofurantoin 25mg/5ml
suspension ....................... 5
nitrofurantoin macrocrystalline
50mg cap.......................... 5
nitrofurantoin monohydrate
100mg cap ........................ 5
nitroglycerin 0.1mg/hr
0.2mg/hr 0.4mg/hr
0.6mg/hr patch................ 31
nitroglycerin 0.4mg/dose
pumpspray ...................... 31
nitroglycerin 50mg/10ml vial 32
NITROMIST 0.4MG/DOSE
SPRAY ........................... 32
NITROSTAT 0.3MG, 0.4MG,
0.6MG TAB, SUBL.......... 32
nizatadine 150mg/10ml oral
soln ................................. 38
Index-16

Formulary Index
Drug Name
Page
nizatidine 150mg, 300mg cap

....................................... 38
nora-be 0.35mg tab ............ 43
norethindrone acet 5mg tab 43
NORITATE 1% CREAM...... 35
NORPACE CR 100MG,
150MG CAP.................... 27
nortrel 0.5mg/35mcg
1mg/35mcg tab ............... 42
nortrel tab ........................... 42
nortriptyline 10mg, 25mg,
50mg, 75mg cap ............. 12
NORVIR 100MG CAP ......... 21
NORVIR 100MG TAB ......... 21
NORVIR 80MG/ML SOLN
ORAL .............................. 21
NOVOLIN 70/30 VIAL ......... 25
NOVOLIN N 100UNIT/ML
VIAL ................................ 25
NOVOLIN R 100UNIT/ML
VIAL ................................ 25
NOVOLOG 100UNIT/ML
FLEXPEN ....................... 25
NOVOLOG 100UNIT/ML VIAL
....................................... 25
NOVOLOG MIX 70/30
FLEXPEN ....................... 25
NOVOLOG MIX 70/30 VIAL 25
NOXAFIL 200MG/5ML ORAL
SUSP QL-630ML 30 DY . 13
NULOJIX 250MG ................ 45
NULYTELY 420G QL-1 KIT
QY 30 DY ....................... 39
nutrilyte ii 1.475meq0.225meq/1.75meq0.25meq-1meq-1.75meq/ml
vial .................................. 55
NUVIGIL 50MG, 150MG,
DY .................................. 54
nyamyc powder 100000unit/g
....................................... 13
nystatin 100000unit/g cream
....................................... 13
nystatin 100000unit/g oint ... 13
nystatin 100000unit/g powder
....................................... 13
nystatin 100000unit/ml oral
susp ................................ 13
nystatin 500000 tab ............ 13
Index-17
Drug Name
Page
nystatin/triamcinolone
100000unit/g-1% cream . 13
nystatin/triamcinolone
100000unit/g-1% oint ..... 13
nystop 100000unit/g powder
....................................... 13
O
ocella 0.03mg/3mg tab ....... 43
octreotide 50mcg/ml
100mcg/ml 200mcg/ml
500mcg/ml 1000mcg/ml inj
....................................... 44
ofloxacin 0.3% opht soln .... 49
ofloxacin 0.3% otic soln ...... 52
ofloxacin 200mg, 300mg,
400mg tab ........................ 7
ogestrel 0.5mg/50mcg tab .. 43
olanzapine 10mg vial ......... 19
olanzapine 15mg, 20mg tab
QL-60 QY 30 DY ............ 19
olanzapine 2.5mg, 5mg,
7.5mg, 10mg tab QL-30 QY
30 DY ............................. 19
olanzapine odt 15mg, 20mg
tbdp QL-60 QY 30 DY .... 19
olanzapine odt 5mg, 10mg
tbdp QL-30 QY 30 DY .... 19
omeprazole 10mg cap QL-30
QY 30 DY ....................... 39
omeprazole 20mg cap ........ 39
omeprazole 40mg cap QL-60
QY 30 DY ....................... 39
OMNARIS 50MCG QL-1
BOTTLE 30 DY .............. 52
OMNITROPE 10MG/1.5ML
CARTRIDGE .................. 41
OMNITROPE 5.8MG VIAL . 41
OMNITROPE 5MG/1.5ML
VIAL ............................... 41
ondansetron 4mg/2ml vial .. 12
ondansetron ir 4mg, 8mg tab
....................................... 12
ONFI 5MG, 10MG, 20MG QL60 QY 30 DY .................... 9
ONGLYZA 2.5MG, 5MG TAB
QL-30 QY 30 DY ............ 24
OPANA ER 40MG TAB QL-60
QY 30 DY ......................... 1
Drug Name
Page
OPANA ER 5MG, 10MG,

QY 30 DY ......................... 1
ORAP 1MG, 2MG TAB ....... 19
ORENCIA 125MG/1ML
SYRINGE QL-4 QY 28 DY
....................................... 45
ORENCIA 250MG VIAL ...... 45
ORFADIN 2MG, 5MG, 10MG
CAP ................................ 37
ORTHO EVRA PATCH
150MCG-20MCG/24HR
QL-3 PATCH 28 DY........ 43
OSMOPREP 1.5G TAB ...... 38
OXACILLIN 1G, 2G IV .......... 6
OXACILLIN 1G, 2G, 10G VIAL
......................................... 6
oxandrolone 10mg tab QL-60
QY 30 DY ....................... 41
oxandrolone 2.5mg tab QL120 QY 30 DY ................ 41
oxaprozin 600mg tab ............ 4
oxazepam cap 10mg, 15mg,
30mg QL-120 QY 30 DY . 23
oxcarbazepine 150mg,
300mg, 600mg tab .......... 10
OXSORALEN 1% LOTION . 36
OXSORALEN ULTRA 10MG
CAP ................................ 36
oxybutynin 5mg tab ............ 39
oxybutynin 5mg/5ml syrup .. 39
oxybutynin er 15mg tab QL-60
QY 30 DY ....................... 39
oxybutynin er 5mg, 10mg tab
QL-30 QY 30 DY ............ 39
oxycodone 10mg, 20mg,
DY .................................... 2
oxycodone 20mg/ml conc oral
......................................... 2
oxycodone 5mg & 15mg tab
QL-360 QY 30 DY............. 2
oxycodone/apap 10mg/650mg
tab QL-180 QY 30 DY....... 2
oxycodone/apap
2.5mg/325mg
7.5mg/325mg 10mg/325mg
tab QL-360 QY 30 DY....... 2
tab QL-360 QY 30 DY....... 2

Formulary Index
Drug Name
Page
cap QL-240 QY 30 DY ...... 2
oxycodone/apap
QY 30 DY ......................... 2
oxycodone/aspirin
4.5mg/325mg
4.835mg/325mg tab QL-360
QY 30 DY ......................... 2
oxycodone/ibuprofen
5mg/400mg tab QL-28 QY
7 DY.................................. 1
oxymorphone hcl er 7.5mg,
15mg QL-60 QY 30 DY ..... 1
OXYTROL 3.9MG/24HR
PATCH QL-8 PATCHES 28
DY .................................. 39
P
pacerone 100mg tab ........... 27
pacerone 200mg tab ........... 27
paclitaxel 6mg/ml vial .......... 16
pamidronate 30mg/10ml
60mg/10ml 90mg/10ml vial
....................................... 48
PANRETIN 0.1% GEL ........ 17
pantoprazole 20mg tab QL-30
QY 30 DY ....................... 39
pantoprazole 40mg tab QL-60
QY 30 DY ....................... 39
paromomycin sulfate 250mg
cap .................................... 4
paroxetine 10mg, 20mg,
30mg, 40mg tab .............. 11
paroxetine er 12.5mg, 25mg
tab QL-90 QY 30 DY ....... 11
paroxetine er 37.5mg tab QL60 QY 30 DY................... 11
PASER 4G PACKET .......... 15
PATADAY 0.2% DROPS QL2.5ML 30 DY ................... 50
PATANASE 0.6% QL-1
BOTTLE 25 DY ............... 52
PATANOL 0.1% DROPS QL5ML 30 DY ...................... 50
PAXIL 10MG/5ML SUSP .... 11
PCE 333MG, 500MG TAB .... 7
PEDIARIX 58MCG-25LFU10MCG-10LFU/0.5ML VIAL
....................................... 47
pedi-dri 100000/g powder ... 13
Drug Name
Page
PEDVAX HIB 7.5MCG/0.5ML

VIAL ............................... 47
peg 3350
240g/2.98g/6.72g/5.84g/22.
72g QL-1 KIT QY 30 DY . 39
PEGANONE 250MG TAB .. 10
PEGASYS 180MCG/0.5ML
KIT QL-1 KIT 28 DY ....... 22
PEGASYS PROCLICK
135MCG/0.5ML QL-4
PENS 28 DY .................. 22
PEGASYS PROCLICK
180MCG/0.5ML QL-4
PENS 28 DY .................. 22
penicillin g 5mm unit vial ...... 7
penicillin g potassium 5mm
unit, 20mm unit vial .......... 7
PENICILLIN G PROCAINE
1.2MM UNIT SYRINGE .... 7
penicillin v potassium
125mg/5ml 250mg/5ml
suspension ....................... 7
penicillin v potassium 250mg,
500mg tab ........................ 7
PENNSAID 1.5% DROPS QL450ML 30 DAYS ............ 36
PENTACEL 48MCG-15LFU5LFU/0.5ML KIT QL-3 INJ
30 DY ............................. 47
PENTASA 250MG, 500MG
CAP................................ 48
pentoxifylline er 400mg tab 29
PERFOROMIST 20MCG/2ML
NEB QL-60 VIALS 30 DY 53
perindopril 2mg, 4mg tab QL30 QY 30 DY .................. 27
perindopril 8mg tab QL-60 QY
30 DY ............................. 27
periogard 0.12% mouthwash
....................................... 33
permethrin 5% cream ......... 18
perphenazine 2mg, 4mg, 8mg,
16mg tab ........................ 19
perphenazine/amitriptyline
2mg/10mg, 2mg/25mg,
4mg/10mg 4mg/25mg,
4mg/50mg tab ................ 12
pfizerpen-g 20 mm unit vial .. 7
phenadoz 12.5mg, 25mg
suppository ..................... 12
phenelzine 15mg tab .......... 11
phenobarbial elixir 10mg/5ml 8
Drug Name
Page
phenobarbital 97.2mg &

100mg tabs QL-60 QY 30
DY .................................... 8
phenobarbital tab 15mg,
16.2mg, 32.4mg, 50mg,
64.8mg QL-120 QY 30 DY
......................................... 8
phenobarbital tab 30mg QL180 QY 30 DY .................. 8
PHENYTEK 200MG & 300MG
CAPS.............................. 10
phenytoin 125mg/5ml
suspension ..................... 10
phenytoin 50mg/ml ampul ... 10
phenytoin er 100mg, 200mg,
300mg caps .................... 10
PHOSLYRA SOLN
667MG/5ML .................... 40
PHOSPHOLINE IODIDE
0.125% DROPS .............. 51
PICATO 0.015% GEL QL-3
TUBES 30 DY................. 36
PICATO 0.05% GEL QL-2
TUBES 30 DY................. 36
pilocarpine 5mg & 7.5mg tabs
....................................... 33
PILOPINE HS 4% GEL ....... 51
pindolol 5mg & 10mg tabs .. 28
piperacillin/tazobactam
2gm/0.25gm, 2gm/0.375gm,
4gm/0.5gm vials ............... 7
piroxicam 10mg & 20mg caps
......................................... 4
podofilox 0.5% soln ............ 36
poly-dex 0.1%/2.5mggm/1000unit-gm oint ....... 50
polyethylene glycol 3350
powder............................ 39
portia-28 tab ....................... 43
potassium chloride 0.15%/d5w
iv 20meq/l ....................... 55
potassium chloride 2meq/ml
vial .................................. 55
potassium chloride er 8meq &
10meq cap, cr ................. 55
potassium chloride er 8meq,
10meq, 20meq tab, sr ..... 55
potassium chloride iv
10meq/0.1l, 10meq/50ml,
20meq/50ml, 30meq/0.1l 55
potassium chloride/ nacl iv
20meq/l & 40meq/l .......... 55
Index-18

Formulary Index
Drug Name
Page
potassium chloride/d5w iv
30meq/l & 40meq/l .......... 56
potassium chloride/d5w/nacl iv
10meq/l, 20meq/l, 30meq/l
....................................... 24
potassium citrate er 5meq &
10meq tabs ..................... 56
POTIGA 50MG, 200MG,
300MG, 400MG TABS QL90 QY 30 DY..................... 8
PRADAXA 75MG & 150MG
CAPS QL-60 QY 30 DY .. 25
pramipexole 0.125mg,
0.25mg, 0.5mg, 0.75mg,
1mg, 1.5mg tabs QL-90 QY
30 DY.............................. 18
PRANDIN TAB 0.5MG & 1MG
QL-120 QY 30 DY ........... 24
PRANDIN TAB 2MG QL-240
QY 30 DY ....................... 24
pravastatin 10mg, 20mg,
40mg, 80mg tabs ............ 31
prazosin 1mg, 2mg, 5mg caps
....................................... 26
PRED MILD 0.12%
SUSPENSION ................ 50
PRED-G 0.3%/1%
SUSPENSION ................ 50
PRED-G S.O.P. 0.3%/0.6%
OINT ............................... 51
prednicarbate 0.1% cream .. 36
prednicarbate 0.1% oint ...... 36
prednisolone 5mg/5ml syrup
....................................... 40
prednisolone acet 1% ophth
susp ................................ 51
prednisolone sod phos 1%
ophth drops ..................... 51
prednisolone sod phos
15mg/5ml soln oral.......... 40
prednisone 1mg, 2.5mg, 5mg,
10mg, 20mg, 50mg tabs . 40
prednisone 5mg/5ml soln oral
....................................... 40
prednisone intensol 5mg/ml
conc oral ......................... 41
PREFEST TAB ................... 43
PREMARIN 0.625MG/GM
CREAM........................... 43
premasol iv 6% & 10% ........ 56
prenatab ............................. 56
Index-19
Drug Name
Page
prevalite 4gm packet .......... 31

prevalite 4gm powder ......... 31
previfem 0.25mg/35mcg tab 43
PREZISTA 150MG TAB ..... 22
PREZISTA 75MG TAB ....... 22
PRIFTIN 150MG TAB......... 15
PRIMAQUINE PHOSPHATE
26.3MG TAB .................. 18
primidone 50mg & 250mg tabs
......................................... 9
PRIMSOL 50MG/5ML SOLN
ORAL ............................... 5
PRISTIQ 50MG & 100MG
TABS QL-30 QY 30 DY .. 11
PROAIR HFA 90MCG
INHALER QL-2 INHALERS
30 DY ............................. 53
probenecid 500mg tab........ 14
probenecid/colchicine
0.5mg/500mg tab ........... 14
procainamide 100mg/ml &
500mg/ml vials ............... 27
PROCALAMINE 3% IV....... 56
prochlorperazine 25mg supp
rectal .............................. 12
prochlorperazine 5mg & 10mg
tabs ................................ 12
prochlorperazine edisylate
5mg/ml vial ..................... 12
PROCRIT VIAL 10000U QL12ML 28 DY ................... 25
PROCRIT VIAL 40000U QL8ML 28 DY ..................... 25
proctosol hc 2.5% cream .... 38
proctozone-hc 2.5% cream 38
progesterone 100mg & 200mg
caps ............................... 43
PROGLYCEM 50MG/ML
SUSPENSION................ 24
PROLASTIN 500MG &
1000MG VIALS .............. 54
Drug Name
Page
PROLASTIN-C 1000MG VIAL

....................................... 54
PROLIA 60MG/ML SOLN QL1 QY 180 DY .................. 48
PROMACTA 12.5MG, 25MG,
50MG, 75MG TABS QL-30
QY 30 DY ....................... 25
promethazine 12.5mg & 25mg
supp rectal ...................... 12
promethazine 25mg/ml
syringe ............................ 12
promethazine 50mg/ml vial . 12
promethegan 25mg & 50mg
supp rectal ...................... 12
propafenone 150mg, 225mg,
300mg tabs ..................... 27
propafenone hcl er 225mg,
325mg, 425mg caps ....... 27
propantheline bromide 15mg
tab .................................. 37
propranolol 10mg, 20mg,
40mg, 60mg, 80mg tabs . 28
propranolol 1mg/ml vial....... 28
propranolol 20mg/5ml &
40mg/5ml soln oral ......... 28
propranolol er 60mg, 80mg,
120MG, 160mg caps ...... 28
propranolol/hctz 40mg/25mg &
80mg/25mg tabs ............. 28
propylthiouracil 50mg tab.... 45
PROQUAD VIAL................. 47
PROSOL 20% IV ................ 56
PROTOPIC 0.03% & 0.1%
OINT QL-30GM 30 DY ... 36
protriptyline 5mg & 10mg tabs
....................................... 12
PROVENTIL HFA 90MCG QL2 INHALERS 30 DY ........ 53
PULMOZYME 1MG/ML SOLN
NON-ORAL..................... 54
pyrazinamide 500mg tab .... 15
pyridostigmine bromide 60mg
tab .................................. 14
Q
QUALAQUIN 324MG CAP
QL-80 QY 365 DY........... 18
quasense 0.03mg/0.15mg tab
....................................... 43
quetiapine fumarate 25mg,
50mg, 100mg, 200mg,

Formulary Index
Drug Name
Page

DY .................................. 19
quetiapine fumarate 400mg
tab QL-60 QY 30 DY ....... 19
quinapril 5mg, 10mg, 20mg,
40mg tabs ....................... 27
quinapril/hydrochlorothiazide
10/12.5mg, 20/12.5mg,
20/25mg tabs .................. 27
quinidine gluconate cr 324mg
tab .................................. 27
quinidine sulfate 200mg &
300mg tabs ..................... 27
quinidine sulfate er 300mg tab
....................................... 27
QVAR 40MCG & 80MCG
INHALERS QL-2
INHALERS 30 DY ........... 52
R
RABAVERT 2.5 UNIT KIT ... 47
ramipril 1.25mg, 2.5mg, 5mg,
10mg caps ...................... 27
RANEXA 500MG & 1000MG
TABS QL-60 QY 30 DY... 29
ranitidine 150mg & 300mg
caps ................................ 38
ranitidine 150mg & 300mg
tabs ................................. 38
ranitidine 15mg/ml syrup ..... 38
ranitidine 25mg/ml vial ........ 38
RAPAFLO 4MG & 8MG CAPS
QL-30 QY 30 DY ............. 39
RAPAMUNE 0.5MG TAB .... 45
RAPAMUNE 1MG TAB ....... 45
RAPAMUNE 1MG/ML ORAL
SOLN .............................. 45
RAPAMUNE 2MG TAB ....... 46
REBIF 22MCG/0.5ML,
44MCG/0.5ML SYRINGE
QL-12 INJ 28 DY............. 46
REBIF TITRATION PACK
SYRINGE QL-12 INJ 28 DY
....................................... 46
reclipsen 0.15mg/30mcg tab
....................................... 43
RECOMBIVAX HB
10MCG/ML & 40MCG/ML
VIALS ............................. 47
REGRANEX 0.01% GEL QL15GM 30 DY ................... 36
Drug Name
Page
RELENZA 5MG DISKHALER

QL-120 DOSES 365 DY . 22
RELISTOR 12MG/0.6ML
SOLN ............................. 38
RELPAX 20MG, 40MG TABS
QL-9 QY 30 DY .............. 14
REMICADE 100MG VIAL ... 46
RENVELA 2.4GM PACK QL90 QY 30 DY .................. 40
RENVELA 800MG TAB ...... 40
RESCRIPTOR 100MG &
200MG TABS ................. 20
reserpine 0.1mg & 0.25mg
tabs ................................ 26
RESTASIS 0.05% QL-64
VIALS 30 DY .................. 49
RETROVIR 10MG/ML IV.... 21
REVLIMID 2.5MG, 5MG,
10MG, 15MG, 25MG CAPS
QL-30 QY 30 DY ............ 15
REYATAZ 100MG CAP...... 22
RHINOCORT AQUA 32MCG
QL-2 BOTTLES 30 DY ... 52
ribasphere cap 200mg........ 22
ribasphere tab 200mg ........ 22
ribavirin cap 200mg ............ 22
ribavirin tab 200mg............. 22
RIDAURA 3MG CAP .......... 46
rifampin 150mg & 300mg caps
....................................... 15
rifampin 600mg vial ............ 15
RIFATER
50MG/120MG/300MG TAB
....................................... 15
RILUTEK 50MG TAB ......... 33
rimantadine 100mg tab....... 22
ringers inj iv ........................ 56
RIOMET 500MG/5ML SOLN
ORAL ............................. 24
RISPERDAL CONSTA
12.5MG/2ML, 25MG/2ML,
37.5MG/2ML, 50MG/2ML
QL-2 INJ 28 DY .............. 20
risperidone 0.25mg, 0.5mg,
....................................... 20
risperidone 1mg, 2mg tabs
QL-60 QY 30 DY ............ 20
Drug Name
Page
risperidone 1mg/ml soln oral

....................................... 20
risperidone 4mg tab QL-120
QY 30 DY ....................... 20
risperidone odt 0.25mg,
0.5mg, 3mg QL-90 QY 30
DY .................................. 20
risperidone odt 1mg & 2mg
QL-60 QY 30 DY ............ 20
risperidone odt 4mg QL-120
QY 30 DY ....................... 20
RITALIN LA 10MG CAPS QL30 QY 30 DY .................. 33
RITUXAN 10MG/ML VIAL .. 17
rivastigmine 1.5mg, 3mg,
4.5mg, 6mg caps QL-60 QY
30 DY ............................. 10
romycin 5mg/gm oint .......... 49
ropinirole 0.25mg, 0.5mg,
1mg, 2mg, 3mg, 4mg, 5mg
tabs ................................ 18
ROTARIX SUSPENSION ... 47
ROTATEQ SUSPENSION .. 47
roxicet 325 5mg tab QL-360
QY 30 DY ......................... 2
roxicet 325mg/5ml 5mg/5ml
oral soln QL-1800 QY 30
DY .................................... 2
S
SABRIL 500MG PACKET ..... 9
SABRIL 500MG TAB ............ 9
SAMSCA 15MG TAB QL-30
QY 30 DY ....................... 54
SAMSCA 30MG TAB QL-60
QY 30 DY ....................... 54
SANCTURA XR 60MG CAP
QL-30 QY 30 DY ............ 39
SANCUSO 3.1MG/24HR
PATCH QL-4 PATCH 28
DY .................................. 12
SANDIMMUNE 100MG/ML
SOLN ORAL ................... 46
SANDIMMUNE 25MG &
100MG CAPS ................. 46
SANTYL 250UNIT/GM OINT
....................................... 36
SAPHRIS 5MG, 10MG SUBL
QL-60 QY 30 DY ............ 20
Index-20

Formulary Index
Drug Name
Page
SAVELLA 12.5MG, 25MG,

QY 30 DY ....................... 33
SAVELLA TITRATION PACK
QL-1 PACK PER 365 DAYS
....................................... 33
scalacort 2% lotion.............. 36
selegiline 5mg cap .............. 18
selegiline 5mg tab ............... 18
SELZENTRY 150MG TAB QL60 QY 30 DY................... 21
SELZENTRY 300MG TAB QL120 QY 30 DY................. 21
SEMPREX-D 8MG/60MG
CAP ................................ 52
SENSIPAR 30MG & 60MG
TAB QL-60 QY 30 DY ..... 44
SENSIPAR 90MG TAB QL120 QY 30 DY................. 44
SEREVENT DISKUS 50MCG
QL-1 DISKUS 30 DY....... 54
SEROMYCIN 250MG CAP . 15
SEROQUEL XR 150MG,
200MG TABS QL-30 QY 30
DY .................................. 20
SEROQUEL XR 50MG,
300MG, 400MG TABS QL60 QY 30 DY................... 20
SEROSTIM 4MG, 5MG, 6MG
VIALS ............................. 41
sertraline 20mg/ml conc oral
....................................... 11
sertraline 25mg, 50mg, 100mg
tabs ................................. 11
SILENOR 3MG, 6MG TABS
QL-30 QY 30 DY ............. 54
silver sulfadiazine 1% cream
....................................... 36
simvastatin 5mg, 10mg, 20mg,
40mg tabs ....................... 31
simvastatin tab 80mg .......... 31
SINGULAIR 10MG TAB QL30 QY 30 DY................... 52
SINGULAIR 4MG & 5MG
CHEWABLE TABS QL-30
QY 30 DY ....................... 53
SINGULAIR 4MG PACKET
QL-30 QY 30 DY ............. 53
SKELID 200MG TAB .......... 48
sodium chloride
0.9%irrigation .................. 49
Index-21
Drug Name
Page
sodium chloride 0.45% & 0.9%

iv .................................... 56
sodium fluoride 1mg tab ..... 56
sodium polystyrene sulfonate
powder ........................... 55
sodium sulfacetamide 10%
susp ............................... 36
sodium sulfacetamide ophth
10% drops ...................... 49
sodium sulfacetamide ophth
10% oint ......................... 49
solia 0.15mg/30mcg tab ..... 43
SOMATULINE DEPOT
120MG/0.5ML QL-1 INJ 28
DY .................................. 44
SOMATULINE DEPOT
60MG/0.2ML SOLN QL-1
INJ 28 DY ....................... 44
SOMATULINE DEPOT
90MG/0.3ML SOLN QL-1
INJ 28 DY ....................... 44
SOMAVERT 10MG, 15MG,
20MG VIALS .................. 44
SORIATANE 10MG, 17.5MG,
25MG CAPS QL-60 QY 30
DY .................................. 36
sorine 80mg, 120mg, 160mg,
240mg tabs .................... 27
sotalol 80mg, 120mg, 160mg,
240mg tabs .................... 27
sotret 10mg, 20mg, 30mg,
40mg caps...................... 36
SPIRIVA 18MCG
HANDIHALER CAP QL-30
QY 30 DY ....................... 53
spironolactone /hctz
25mg/25mg tab .............. 30
spironolactone 25mg, 50mg,
100mg tabs .................... 30
SPORANOX 10MG/ML SOLN
ORAL ............................. 13
sprintec 28 tab ................... 43
SPRYCEL 100MG, 140MG
SPRYCEL 20MG, 50MG,
QY 30 DY ....................... 17
sronyx 0.1mg/20mcg tab .... 43
ssd 1% cream .................... 36
stagesic 5mg/500mg cap QL240 QY 30 DY .................. 2
Drug Name
Page
STALEVO 50, 75, 100, 125,

150, 200 TABS ............... 18
stavudine 15mg, 20mg, 30mg,
40mg caps ...................... 21
STROMECTOL 3MG TAB .. 17
SUBOXONE 2MG/0.5MG,
8MG/2MG FILM, SUBL QL90 QY 30 DY .................... 3
SUCRAID 85000UNIT/ML
SOLN.............................. 37
sucralfate 1g tab ................. 39
sulfacetamide/predn sod
phosp 10%/0.25% drops . 51
sulfadiazine 500mg tab ......... 8
sulfamethoxazole/trimethoprim
200mg-40mg/5ml
suspension ....................... 8
400mg/80mg tab ............... 8
800mg-16mg/ml vial ......... 8
ds 800mg/160mg tab ........ 8
SULFAMYLON 50G PACKET
....................................... 36
SULFAMYLON 8.5% CREAM
....................................... 36
sulfasalazine 500mg tab ..... 48
sulfazine ec 500mg tab ...... 48
sulindac 150mg, 200mg tabs 4
sumatriptan 25mg, 50mg,
....................................... 14
sumatriptan 4mg/0.5ml,
6mg/0.5ml inj QL-8 INJ 30
DY .................................. 14
sumatriptan 5mg, 20mg spray
QL-8 SPRAY UNITS 30 DY
....................................... 14
SUPRAX 100MG/5ML &
......................................... 6
SUPRAX 400MG TAB .......... 6
SUPREP BOWL PREP QL-1
KIT QY 30 DY ................. 39
SUSTIVA 50MG & 200MG
CAPS.............................. 20
SUSTIVA 600MG TAB........ 20
SUTENT 12.5MG, 25MG,
DY .................................. 17

Formulary Index
Drug Name
Page
SYLATRON 296MCG,
444MCG, 888MCG KIT QL4 QY 28 DY..................... 16
SYMBICORT 80MCG,
160MCG AERO QL-1
INHALER 30 DY ............. 52
SYMBYAX 3MG/25MG,
6MG/25MG, 6MG/50MG,
12MG/25MG, 12MG/50MG
CAPS QL-30 QY 30 DY .. 11
SYMLINPEN 120
1000MCG/ML QL-4 PENS
30 DY.............................. 24
SYMLINPEN 60
1000MCG/ML QL-8 PENS
30 DY.............................. 24
SYNAREL AERO 2MG/ML . 44
SYNTHROID 25MCG,
50MCG, 75MCG, 88MCG,
100MCG, 112MCG,
125MCG, 137MCG,
150MCG, 175MCG,
200MCG, 300MCG TABS
....................................... 44
SYPRINE 250MG CAP ....... 55
T
TABLOID 40MG TAB .......... 16
TACLONEX 0.064% 0.005%
OINT QL-400 QY 28 DY . 36
tacrolimus 0.5mg cap .......... 46
tacrolimus 1mg cap............. 46
tacrolimus 5mg cap............. 46
TAMIFLU 30MG & 45MG CAP
....................................... 22
TAMIFLU 6MG/ML, 12MG/ML
SUSPENSION ................ 22
TAMIFLU CAP 75MG QL-56
QY 365 DY...................... 22
tamoxifen citrate 10mg, 20mg
tabs ................................. 15
tamsulosin 0.4mg cap QL-60
QY 30 DY ....................... 39
TARCEVA 100MG, 150MG
TABS QL-30 QY 30 DY... 17
TARCEVA 25MG TAB QL-60
QY 30 DY ....................... 17
TARGRETIN 1% GEL QL60GM 30 DY ................... 17
TARGRETIN 75MG CAP .... 17
Drug Name
Page
TASIGNA 150MG, 200MG

CAPS QL-120 QY 30 DY 17
TASMAR 100MG TAB........ 18
TAXOTERE FNL 80MG/8ML
VIAL ............................... 16
TAZORAC 0.05%, 0.1%
CREAM QL-30GM 30 DY 36
TAZORAC 0.05%, 0.1% GEL
QL-30GM 30 DY ............ 36
taztia xt 120mg, 180mg,
240mg, 300mg, 360mg
caps ............................... 29
TEFLARO 400MG, 600MG
VIAL ................................. 6
TEGRETOL 100MG CHEW 10
TEGRETOL 100MG/5ML
SUSPENSION................ 10
TEGRETOL 200MG TAB ... 10
TEGRETOL-XR 100MG,
200MG, 400MG TABS ... 10
temazepam 15mg, 30mg caps
QL-30 QY 30 DY ............ 54
TENIVAC 2LFU/5LFU
SYRINGE ....................... 47
TENIVAC 2LFU/5LFU VIAL 47
terazosin 1mg, 2mg, 5mg,
10mg caps...................... 40
terbinafine 250mg tab QL-30
QY 30 DY ....................... 13
terbutaline sulfate 2.5mg, 5mg
tab .................................. 54
terconazole 0.4%, 0.8% cream
....................................... 40
terconazole 80mg vaginal
supp ............................... 40
testosterone cypionate
100mg/ml, 200mg/ml vial 41
testosterone enanthate
200mg/ml vial ................. 41
TESTRED 10MG CAP ....... 41
TETANUS TOXOID
ADSORBED 5LF/0.5ML
VIAL ............................... 47
TETANUS/DIPHTHERIA
TOXOIDS-ADSORBED
2LF/0.5MLVIAL .............. 47
tetracycline 250mg, 500mg
caps ................................. 8
TEXACORT 2.5% SOLN
NON-ORAL .................... 36
THALITONE 15MG TAB .... 30
Drug Name
Page
THALOMID 200MG CAPS

QL-56 QY 28 DY ............ 15
THALOMID 50MG, 100MG,
DY .................................. 15
THEO-24 100MG, 200MG,
DY .................................. 53
THEO-24 300MG CAP QL-60
QY 30 DY ....................... 53
theochron 100mg, 200mg,
300mg tabs ..................... 53
theophylline er 100mg,
200mg, 300mg, 450mg tabs
....................................... 53
theophylline er 400mg, 600mg
tab, sr ............................. 53
thermazene 1% cream........ 36
thioridazine 10mg, 25mg,
50mg, 100mg tabs .......... 19
thiotepa 15mg vial .............. 15
thiothixene 1mg, 2mg, 5mg,
10mg caps ...................... 19
THYROLAR 15MG, 30MG,
60MG, 120MG, 180MG
TABS .............................. 44
ticlopidine 250mg tab ......... 26
TIKOSYN 125MCG, 250MCG,
500MCG CAPS .............. 27
TIMENTIN 3.1GM, 31GM
VIALS ............................... 7
TIMENTIN 3.1GM/0.1L IV..... 7
timolol 0.25%, 0.5% drops .. 51
timolol 5mg, 10mg, 20mg tabs
....................................... 28
timolol drops 0.25%, 0.5% gel
....................................... 51
TIROSINT 13MCG, 25MCG,
50MCG, 75MCG, 88MCG,
100MCG, 112MCG,
125MCG, 137MCG,
150MCG CAPS QL-30 QY
30 DY ............................. 44
tizanidine2mg, 4mg tabs ..... 20
TOBI 300MG/5ML VIAL, NEB
QL-56 VIALS 28 DY........ 54
TOBRADEX 0.3%/0.1% OINT
....................................... 51
TOBRADEX ST 0.05%/0.3%
SUSP.............................. 51
tobramycin sulfate 0.3% ophth
drops .............................. 49
Index-22

Formulary Index
Drug Name
Page
tobramycin sulfate 10mg/ml,

80mg/2ml vial .................... 4
tobramycin/dexamethasone
0.3%/0.1% susp .............. 51
TOBRAMYCIN/SODIUM
CHLORIDE 60MG/50ML,
80MG/100ML IV ................ 4
TOBREX 0.3% OPHTH OINT
....................................... 49
tolazamide 250mg, 500mg
tabs ................................. 24
tolbutamide 500mg tab ....... 24
tolmetin 200mg, 600mg tabs . 4
tolmetin 400mg cap .............. 4
topiramate 15mg, 25mg cap,
sprinkle ............................. 9
......................................... 9
QL-90 QY 30 DY ............... 9
topotecan hcl 4mg solr ........ 16
torsemide 5mg, 10mg, 20mg,
100mg tabs ..................... 30
TPN ELECTROLYTE
35MEQ/20MEQ/5MEQ FTV
....................................... 56
TRACLEER 62.5MG, 125MG
TAB QL-60 QY 30 DY ..... 54
tramadol 50mg tab ................ 2
tramadol/apap 37.5mg/325mg
tab QL-240 QY 30 DY ....... 2
trandolapril 1mg, 2mg, 4mg
tabs ................................. 27
tranylcypromine sulfate 10mg
tab .................................. 11
travasol 10% iv ................... 56
TRAVATAN Z 0.004% QL5ML 30 DY ...................... 49
trazodone 50mg, 100mg,
150mg, 300mg tabs ........ 11
TRECATOR 250MG TAB ... 15
TRELSTAR DEPOT 3.75MG
SUSR QL-1 VIAL 28 DY . 45
TRELSTAR LA 11.25MG
SUSR QL-1 VIAL 84 DY . 45
TRELSTAR MIXJECT 22.5MG
QL-1 VIAL 168 DY .......... 45
tretinoin 0.025%, 0.01% gels
....................................... 36
tretinoin 0.025%, 0.05%, 0.1%
creams ............................ 36
Index-23
Drug Name
Page
tretinoin 10mg cap.............. 17

triamcinolone acetonide
0.025%, 0.1% lotions...... 36
0.025%, 0.1%, 0.5%
creams ........................... 36
0.025%, 0.1%, 0.5% oints
....................................... 36
55mcg/act inhaler QL-2
BOTTLES 30 DY ............ 52
triamcinolone in orabase
0.1%paste ...................... 33
triamterene/hctz 37.5mg/25mg
75mg/50mg cap ............. 30
triamterene/hctz 37.5mg/25mg
75mg/50mg tab .............. 30
triazolam 0.125mg, 0.25mg
tabs QL-60 QY 30 DY .... 54
TRICOR 48MG, 145MG TABS
QL-30 QY 30 DY ............ 30
triderm 0.1% cream ............ 36
trifluoperazine 1mg, 2mg,
5mg, 10mg tabs ............. 19
trifluridine 1% drops ........... 49
TRIGLIDE 50MG, 160MG
trihexyphenidyl 2mg, 5mg tabs
....................................... 18
trihexyphenidyl 2mg/5ml elixir
....................................... 18
TRIHIBIT
46.8MCG/6.7LFU/5LFU KIT
....................................... 47
tri-legest fe tab ................... 43
TRILEPTAL 300MG/5ML
ORAL SUSP................... 10
TRILIPIX 45MG, 135MG
CAPS QL-30 QY 30 DY.. 30
trilyte 420gm soln oral QL-1
KIT QY 30 DY ................ 39
trimethobenzamide 300mg
cap ................................. 12
trimethoprim 100mg tab ....... 5
trimethoprim sulf/poly b sulfate
10000units-1ml/0.1%drops
....................................... 49
trimipramine maleate 25mg,
50mg, 100mg caps ......... 12
trinessa tab ........................ 43
Drug Name
Page
TRIPEDIA 6.7LFU0.5ML/46.8MCG0.5ML/8LFU/0.5ML VIAL 47

tri-previfem tab ................... 43
TRISENOX 10MG/10ML
AMPUL ........................... 16
tri-sprintec tab..................... 43
trivora-28 tab ...................... 43
TRIZIVIR 150MG/300MG TAB
....................................... 21
TROPHAMINE 6%, 10% IV 56
tropicamide 0.5%, 1% drops49
trospium 20mg tab QL-60 QY
30 DY ............................. 39
TRUVADA 200MG/300MG
TAB QL-30 QY 30 DY..... 21
TWINJECT 0.15MG/0.15ML,
0.3MG/0.3ML .................. 54
TWINRIX VIAL ................... 47
TWYNSTA 5MG/ 40MG,
5MG/80MG, 10MG/40MG,
10MG/80MG TABS QL-30
QY 30 DY ....................... 29
TYGACIL 50MG VIAL ........... 5
TYKERB 250MG TAB QL-180
QY 30 DY ....................... 17
TYPHIM VI 25MCG/0.5ML
VIAL ............................... 47
TYZEKA 600MG TAB QL-30
QY 30 DY ....................... 22
TYZINE 0.1% DROPS ........ 54
TYZINE PEDIATRIC 0.05%
NASAL DROPS .............. 54
U
ULESFIA 5% LOTION ........ 18
unithroid 25mcg, 50mcg,
75mcg, 88mcg 100mcg,
112mcg, 125mg, 137mcg
150mcg, 175mcg, 200mcg,
300mcg tabs ................... 44
ursodiol cap 300mg ............ 38
ursodiol tab 250mg, 500mg 38
V
VAGIFEM 10mcg TAB ........ 43
valacyclovir 1000mg tab QL30 QY 30 DY .................. 23
valacyclovir 500mg tab QL-42
QY 30 DY ....................... 23

Formulary Index
Drug Name
Page
VALCYTE 450mg TAB........ 20

valproate 500mg/5ml vial ...... 9
valproic acid 250mg cap ....... 9
valproic acid 250mg/5ml syrup
......................................... 9
vancomycin 125mg cap QL-56
QY 14 DY ......................... 5
vancomycin 1GM, 10GM vial 5
vancomycin 250mg cap QL-40
QY 10 DY ......................... 5
vancomycin dextrose 500mg
iv ....................................... 5
VANCOMYCIN DEXTROSE
750MG/0.15L IV ................ 5
vandazole 0.75% gel .......... 40
VANDETANIB 100MG TAB
QL-60 QY 30 DY ............. 15
VANDETANIB 300MG TAB
QL-30 QY 30 DY ............. 15
VAQTA 25UNIT/0.5ML VIAL
....................................... 47
VARIVAX 1350UNIT VIAL .. 47
VELCADE 3.5MG VIAL....... 16
velivet tab ........................... 43
venlafaxine er 150mg cap QL90 QY 30 DY................... 11
venlafaxine er 150mg tab QL90 QY 30 DY................... 11
venlafaxine er 37.5mg, 75mg
caps QL-30 QY 30 DY .... 11
venlafaxine er 37.5mg, 75MG,
DY .................................. 11
venlafaxine ir 25mg, 37.5mg,
50mg, 75mg, 100mg tabs 12
VENTAVIS 10MCG/ML,
20MCG/ML AMPUL ........ 54
VENTOLIN HFA 90MCG QL-2
INHALERS 30 DY ........... 54
verapamil 2.5mg/ml ampul .. 29
verapamil hcl 40mg, 80mg,
120mg tabs ..................... 29
verapamil hcl er 100mg,
120mg, 180mg, 200mg,
240mg, 300mg cap,24hr . 29
verapamil hcl er 120mg,
180mg, 240mg tabs ........ 29
verapamil hcl sr 360mg
cap,24hr.......................... 29
VEREGEN 15% OINT QL15GM 30 DY ................... 36
Drug Name
Page
VESICARE 5MG, 10MG

vestura tab 3mg/0.02mg..... 43
VEXOL 1% SUSPENSION. 51
VFEND 200MG/5ML
SUSPENSION................ 14
VIBRAMYCIN 50MG/5ML
SYRUP ............................. 8
VICTOZA 18MG/3ML SOLN
QL-3 PENS 30 DY.......... 24
VIDAZA 100MG VIAL ......... 16
VIDEX PEDIATRIC 10MG/ML
SOLN ORAL................... 21
VIGAMOX 0.5% DROPS QL3ML 30 DY ..................... 50
VIIBRYD 10MG, 20MG, 40MG
VIIBRYD KIT QL-1 KIT 365
DY .................................. 12
VIMOVO 20MG/375MG,
20MG/500MG TABS QL-60
QY 30 DY ....................... 39
VIMPAT 10MG/ML SOLN
ORAL ............................. 10
VIMPAT 200MG/20ML VIAL10
VIMPAT 50MG, 100MG,
150MG, 200MG TABS QL60 QY 30 DY .................. 10
VIRACEPT 250MG, 625MG
TAB ................................ 22
VIRAMUNE 50MG/5ML
SUSPENSION................ 20
VIRAMUNE XR 400MG TAB
....................................... 20
VIREAD 150MG, 200MG,
250MG, 300MG TAB ...... 21
VIREAD 40MG/GM POWDER
....................................... 21
VISICOL 1.5GM TAB ......... 38
VIVELLE-DOT
0.025MG/24HR,
0.0375MG/24HR,
0.075MG/24HR,
0.05MG/24HR,
0.1MG/24HR PATCHES
QL-8 PATCHES 28 DY .. 43
VOLTAREN 1%GMEL QL1000GM 30 DY .............. 36
VORAXAZE 1000UNIT SOLR
....................................... 49
voriconazole 50mg, 200mg
tab QL-60 QY 30 DY ...... 14
Drug Name
Page
VOTRIENT 200MG TAB QL120 QY 30 DY ................ 17

VYTORIN TAB 10/10MG,
10/20MG, 10/40MG TABS
QL-30 QY 30 DY ............ 31
VYTORIN TAB 10/80MG
W
warfarin 1mg, 2mg, 2.5mg,
3mg, 4mg, 5mg, 6mg,
7.5mg, 10mg tabs .......... 25
WELCHOL 3.75GM PACK
QL-30 PACK 30 DY ........ 31
WELCHOL 625MG TAB QL180 QY 30 DY ................ 31
X
XALKORI 200MG, 250MG
CAP QL-60 QY 30 DY .... 17
XARELTO 10MG, 15MG,
DY .................................. 25
XENAZINE 12.5MG TAB QL90 QY 30 DY .................. 33
XENAZINE 25MG TAB QL120 QY 30 DY ................ 33
XOLAIR 150MG VIAL ......... 54
XOPENEX HFA 45MCG QL-2
INHALERS 30 DY ........... 54
XYREM 500MG/ML SOLN
Y
YERVOY 50MG/10ML,
200MG/40ML SOLN ....... 17
YF-VAX VIAL...................... 47
Z
zafirlukast 10mg, 20mg tab
QL-60 QY 30 DY ............ 53
zaleplon 5mg, 10mg cap QL30 QY 30 DY .................. 54
ZAVESCA 100MG CAP ...... 37
zazole 0.4% cream ............. 40
ZELBORAF 240MG TAB QL240 QY 30 DY ................ 17
Index-24

Formulary Index
Drug Name
Page
ZEMPLAR 1MCG, 2MCG,

4MCG CAP QL-30 QY 30
DY .................................. 48
ZENPEP
10000UNIT/34000UNIT/550
00UNIT CAP QL-120 QY 30
DY .................................. 37
ZENPEP
136000UNIT/25000UNIT/85
000UNIT CAP QL-120 QY
30 DY.............................. 37
ZENPEP
15000UNIT/51000UNIT/820
DY .................................. 37
ZENPEP
16000UNIT/3000UNIT/1000
DY .................................. 37
ZENPEP
20000UNIT/68000UNIT/109
000UNIT CAP QL-120 QY
30 DY.............................. 37
ZENPEP
5000UNIT/17000UNIT/2700
DY .................................. 37
zeosa 0.4mg/35mcg tab...... 43
Index-25
Drug Name
Page
ZERIT 1MG/ML SOLR ....... 21

ZETIA 10MG TAB QL-30 QY
30 DY ............................. 31
ZIAGEN 20MG/ML SOLN
ORAL ............................. 21
ZIAGEN 300MG TAB ......... 21
zidovudine 100mg cap ....... 21
zidovudine 10mg/ml syrup .. 21
zidovudine 300mg tab ........ 21
ziprasidone hcl 20mg, 40mg,
60mg, 80mg cap QL-60 QY
30 DY ............................. 20
ZIRGAN 0.15% GEL QL-5 QY
30 DY ............................. 20
ZOLINZA 100MG CAP QL120 QY 30 DY ................ 16
zolpidem tartrate 5mg, 10mg
tab .................................. 54
ZOMETA 4MG/100ML SOLN
....................................... 48
ZOMETA 4MG/5ML VIAL ... 48
ZOMIG 2.5MG, 5MG TAB QL6 QY 30 DY .................... 14
ZOMIG 5MG NASAL SPR QL6 SPRAY UNITS 30 DY.. 14
ZOMIG ZMT 2.5MG, 5MG
TAB QL-6 QY 30 DY ...... 14
Drug Name
Page
ZONALON 5% CREAM QL45GM 30 DY ................... 36

zonisamide 25mg, 50mg,
100mg cap ........................ 8
ZORTRESS 0.25MG, 0.5MG,
0.75MG TAB ................... 46
ZOSTAVAX 19400UNIT VIAL
QL-1 INJ 365 DY ............ 47
zovia 1mg/35mcg, 1mg/50mcg
tab .................................. 43
ZOVIRAX 5% OINT QL-30GM
30 DY ............................. 23
ZYLET 0.3%/0.5%
SUSPENSION ................ 51
ZYMAXID 0.5% DROPS QL2.5ML 30 DY................... 50
ZYPREXA RELPREVV
210MG, 300MG QL-2 INJ
28 DY ............................. 20
ZYPREXA RELPREVV
405MG QL-1 INJ 28 DY .. 20
ZYTIGA 250MG TAB QL-120
QY 30 DY ....................... 16
ZYVOX 100MG/5ML ORAL
SUSR QL-900ML 14 DY ... 5
ZYVOX 600MG TAB QL-28
QY 14 DY ......................... 5
ZYVOX 600MG/300ML IV .... 5

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First Health Part D Premier (PDP)

(List of Covered Drugs)

Y0022_PDPCCP_2013_1085_1531_FINAL_PRE approved 07/2012

What is the First Health Part D Premier Formulary?

Can the Formulary change?

How do I use the Formulary?

What are generic drugs?

What are compounded drugs?

Are there any restrictions on my coverage?

What are over-the-counter (OTC) drugs?

What if my drug is not on the Formulary?

How do I request an exception to the First Health Part D Premiers

What do I do before I can talk to my doctor about changing my drugs or

For more information

First Health Part D Premiers Formulary

How to Read the Drug List

Plan Name and Plan Type

High Risk Medications | HRM

90-day Long-Term Supply | 90D

Explanation of Cost-Sharing Tiers

Three (3) Tier Plans - First Health Part D Premier

Limited Distribution of Some Drugs

Drugs Packaged to Provide an Extended Day Supply

the refill before the medication on hand is used.)

doctor or other prescribers instructions on dosage.

refill until the allowable date.

What do I do if I need to get my prescription filled before I have used most of

How are medications shipped?

What should I do with my expired or unused medication?

Are you wondering why our network

Here is the answer!

Visit www.fda.gov/cder or call 1-888-INFO-FDA (463-6332) to learn more.

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

Emetogenic Therapy Adjuncts

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

PRIMAQUINE PHOSPHATE 26.3MG TAB

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

RISPERDAL CONSTA 12.5MG/2ML, 25MG/2ML,

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)

First Health Part D Premier (PDP)