First UA Medicare Group Part D Formulary

2013 Comprehensive Formulary(List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THEDRUGS WE COVER IN THIS PLANNote to existing members: This formulary has changed since last year.Please review this document to make sure that it still contains the drugsyou take.Beneficiaries must use network pharmacies to access their prescriptiondrug benefit. Benefits, formulary, pharmacy network, premium and/orcopayments/coinsurance may change on January 1, 2014.First UA Medicare Group Part D is a Medicare Approved Part D Sponsor.This information is available in a different format, including large print andSpanish large print. Please call Customer Service at 1‐866‐412-8499 if youneed plan information in another format or language.Y0063_13CFORM_GRP_NY B NA104 Last Updated 09/01/2013FID 13125 v.15

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What is the First UA Medicare Group Part D Formulary?A formulary is a list of covered drugs selected by First UA Medicare Group Part D Prescription Drug Coverage(PDP) in consultation with a team of health care providers, which represents the prescription therapiesbelieved to be a necessary part of a quality treatment program. First UA Medicare Group Part D will generallycover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at aFirst UA Medicare Group Part D network pharmacy, and other plan rules are followed. For more informationon 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, wewill not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new, lessexpensive generic drug becomes available, when new adverse information about the safety or effectivenessof a drug is released, or when Medicare determines that a drug should no longer be covered. Other types offormulary changes, such as removing a drug from our formulary, will not generally affect members who arecurrently taking the drug. It will remain available at the same cost-sharing for those members taking it for theremainder of the coverage year. We feel it is important that you have continued access for the remainder ofthe coverage year to the formulary drugs that were available when you chose our plan, except for cases inwhich you can save additional money or we can ensure your safety.If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapyrestrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members ofthe change at least 60 days before the change becomes effective, or at the time the member requests arefill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and DrugAdministration deems a drug on our formulary to be unsafe, the drug’s manufacturer removes the drug fromthe market, or when Medicare determines that a drug should no longer be covered we will immediatelyremove the drug from our formulary and provide notice to members who take the drug. The enclosedformulary is current as of 09/01/2013. To get updated information about the drugs covered by First UAMedicare Group Part D, please visit our Web site at http://www.firstuagrouppartd.com or call Customer Serviceat 1-866-412-8499, weekdays from 8:00am to 8:00pm Eastern. TTY/TDD users should call 1-866-524-4172.In order to keep your formulary current, we will update the page on which the affected drug(s) is listed andsend you a copy to keep with your formulary.How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 2. The drugs in this formulary are grouped into categories dependingon the type of medical conditions that they are used to treat. For example, drugs used to treat a heartcondition are listed under the category, “Cardiovascular/Hypertensive/Lipids”. If you know what your drugis used for, look for the category name in the list that begins on page 2. Then look under the categoryname for your drug.Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins onpage 38. The Index provides an alphabetical list of all of the drugs included in this document. Both brandname drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to yourdrug, you will see the page number where you can find coverage information. Turn to the page listed inthe Index and find the name of your drug in the first column of the list.What are generic drugs?First UA Medicare Group Part D covers both brand name drugs and generic drugs. A generic drug isapproved by the FDA as having the same active ingredient as the brand name drug. Generally, genericdrugs cost less than brand name drugs.i

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limitsmay include:• Prior Authorization: First UA Medicare Group Part D requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from First UA MedicareGroup Part D before you fill your prescriptions. If you don’t get approval, First UA Medicare Group Part Dmay not cover the drug.• Quantity Limits: For certain drugs, First UA Medicare Group Part D limits the amount of the drug thatFirst UA Medicare Group Part D will cover. For example, First UA Medicare Group Part D provides 34 pillsper prescription for Zetia. This may be in addition to a standard one month or three month supply.• Step Therapy: In some cases, First UA Medicare Group Part D requires you to first try certain drugs totreat your medical condition before we will cover another drug for that condition. For example, if DrugA and Drug B both treat your medical condition, First UA Medicare Group Part D may not cover drug Bunless you try Drug A first. If Drug A does not work for you, First UA Medicare Group Part D will thencover Drug B.You can find out if your drug has any additional requirements or limits by looking in the formulary thatbegins on page 2. You can also get more information about the restrictions applied to specific covered drugsby visiting our Web site at http://www.firstuagrouppartd.com.You can ask First UA Medicare Group Part D to make an exception to these restrictions or limits. See thesection, “How do I request an exception to the First UA Medicare Group Part D formulary?” on page ii forinformation about how to request an exception.What if my drug is not on the Formulary?If your drug is not included in this formulary, you should first contact Customer Service and confirm that yourdrug is not covered. If you learn that First UA Medicare Group Part D does not cover your drug, you have twooptions:• You can ask Customer Service for a list of similar drugs that are covered by First UA Medicare Group PartD. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that iscovered by First UA Medicare Group Part D.• You can ask First UA Medicare Group Part D to make an exception and cover your drug. See below forinformation about how to request an exception.How do I request an exception to the First UA Medicare Group Part D Formulary?You can ask First UA Medicare Group Part D to make an exception to our coverage rules. There are severaltypes 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, FirstUA Medicare Group Part D limits the amount of the drug that we will cover. If your drug has a quantitylimit, 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 ournon-Enhanced tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in theEnhanced tier instead. This would lower the amount you must pay for your drug. Please note, if wegrant your request to cover a drug that is not on our formulary, you may not ask us to provide a higherlevel of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugsthat are in the specialty drug tier.Generally, First UA Medicare Group Part D will only approve your request for an exception if the alternativedrugs included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would notbe as effective in treating your condition and/or would cause you to have adverse medical effects.ii

La siguiente es una lista de abreviaturas que pueden aparecer en las siguientes páginas en la columna Notaspara indicarle si su medicamento está sujeto a algún requisito especial de cobertura.Lista de abreviaturas (del inglés)B/D: Este medicamento recetado podría estar cubierto bajo Medicare Parte B o Parte D, dependiendo de lascircunstancias. Puede ser necesario que se presente información que describa la utilización y lascircunstancias en las que se administrará el medicamento, para que se pueda tomar una determinación.LA: Disponibilidad limitada. Este medicamento recetado puede estar disponible solamente en ciertasfarmacias. Para obtener más información, llame al servicio de Atención al cliente.MO: Medicamento obtenido por correo. Este medicamento recetado está disponible a través de nuestroservicio de pedido por correo, así como en las farmacias minoristas de nuestra red. Considere utilizar elservicio de farmacia por correo para obtener sus medicamentos de uso continuo, o de mantenimiento (porejemplo, los medicamentos para la presión sanguínea elevada). Las farmacias minoristas de la red pueden sermás adecuadas para obtener medicamentos de uso a corto plazo (por ejemplo, los antibióticos).PA: Autorización previa. El Plan requiere que usted o su médico obtengan autorización previa para obtenerciertos medicamentos. Esto significa que deberá obtener aprobación antes de que se surtan sus recetas. Si noobtiene aprobación, podríamos no cubrir el medicamento.QL: Límite de cantidad. En el caso de ciertos medicamentos, el Plan limita la cantidad del medicamento quecubriremos.ST: Terapia de paso. En algunos casos, el Plan requiere que primero pruebe ciertos medicamentos para eltratamiento de su afección médica antes de que podamos cubrir otro medicamento para tratar esa afección.Por ejemplo, si puede utilizarse tanto un medicamento A como un medicamento B en el tratamiento de lamisma afección médica, es posible que no cubramos el medicamento B a menos que usted pruebe primero elmedicamento A. Si el medicamento A no le produce mejoras, cubriremos el medicamento B.2 E8

Commonly Prescribed TherapeuticDrug Categorie s(Categorías de productos farmacoterapéuticos que serecetan comúnmente)ANTI - INFECTIVESANTIFUNGAL AGENTSDrug Name(Nombre del medicamento)Require-Drug Tier ments/(Nivel de Limitsmedicamento) (Requisitos/Limites)2 B/D PA MOamphotericin bANCOBON 3 MOclotrimazole troc 2 MOERAXIS INJ 100MG 3 MOfluconazole 1 MOfluconazole in dextrose inj 256mg/ml; 400mg/200mlflucytosine 2 MOGRIS-PEG 4 MOgriseofulvin microsize 2 MOgriseofulvin ultramicrosize 2 MOitraconazole 2 MOketoconazole 2 MONOXAFIL 3 MOnystatin susp 2 MOnystatin tabs 2 MOSPORANOX ORAL SOLN 3 MOterbinafine hcl tabs 2 MOVFEND IV 3 MOVFEND SUSR 3 MOvoriconazole 2 MOANTIVIRALSabacavir 2 QL(180 per90 days)MOacyclovir 2 MOacyclovir sodium inj 500mg 2 MOamantadine hcl 2 MOAPTIVUS CAPS 5 QL(360 per90 days)MOAPTIVUS ORAL SOLN 5 QL(950 per90 days)Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)ATRIPLA 5 QL(90 per90 days)MOBARACLUDE ORAL SOLN 3 QL(1890per 90 days)MOBARACLUDE TABS 3 QL(90 per90 days)MOCIDOFOVIR 5COMPLERA 5 QL(90 per90 days)MOCRIXIVAN 3 MOdidanosine 2 QL(90 per90 days)MOEDURANT 5 QL(90 per90 days)MOEMTRIVA CAPS 3 QL(90 per90 days)MOEMTRIVA ORAL SOLN 3 QL(2210per 90 days)MOEPIVIR HBV 3 MOEPIVIR ORAL SOLN 3 QL(2880per 90 days)MOEPZICOM 5 QL(90 per90 days)MOfamciclovir 2 MOfoscarnet sodium2 B/D PA MOFUZEON 5 QL(180 per90 days)MOganciclovir 2 MOHEPSERA 5 QL(90 per90 days)MO3

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)INCIVEK 5 PA QL(504per 84 days)MOINTELENCE TABS 200MG 5 QL(180 per90 days)MOINTELENCE TABS 100MG 5 QL(360 per90 days)MOINVIRASE CAPS 4 QL(900 per90 days)MOINVIRASE TABS 5 QL(360 per90 days)MOISENTRESS CHEW 100MG 5 QL(540 per90 days)MOISENTRESS CHEW 25MG 3 QL(540 per90 days)ISENTRESS TABS 5 QL(360 per90 days)MOKALETRA ORAL SOLN 5 QL(1280per 90 days)MOKALETRA TABS 200MG;50MGKALETRA TABS 100MG;25MG5 QL(360 per90 days)MO3 QL(900 per90 days)MOlamivudine tabs 300mg 2 QL(90 per90 days)MOlamivudine tabs 150mg 2 QL(180 per90 days)MOlamivudine/zidovudine 2 QL(180 per90 days)MOLEXIVA SUSP 3 QL(5175per 90 days)MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)LEXIVA TABS 5 QL(360 per90 days)MOnevirapine tabs 2 QL(180 per90 days)MONORVIR CAPS 3 QL(1080per 90 days)MONORVIR ORAL SOLN 3 QL(1440per 90 days)MONORVIR TABS 3 QL(1080per 90 days)MOPREZISTA SUSP 5 MOPREZISTA TABS 800MG 5 MOPREZISTA TABS 400MG,600MG5 QL(180 per90 days)MOPREZISTA TABS 150MG 3 QL(540 per90 days)MOPREZISTA TABS 75MG 3 QL(900 per90 days)MOREBETOL ORAL SOLN 3 PA MORELENZA DISKHALER 3 QL(300 per365 days)MORESCRIPTOR TABS 200MG 4 QL(540 per90 days)MORESCRIPTOR TABS 100MG 4 QL(1080per 90 days)MORETROVIR IV INFUSION 3 MOREYATAZ CAPS 300MG 3 QL(90 per90 days)MOREYATAZ CAPS 150MG,200MG3 QL(180 per90 days)MO4

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)REYATAZ CAPS 100MG 3 QL(360 per90 days)MOribapak tabs 5 PA MOribasphere caps 2 PA MOribasphere tabs 400mg 2 PAribasphere tabs 200mg 2 PA MOribasphere tabs 600mg 5 PA MOribavirin 2 PA MOrimantadine hcl 2 MOSELZENTRY TABS 150MG 5 QL(180 per90 days)MOSELZENTRY TABS 300MG 5 QL(360 per90 days)MOstavudine caps 2 QL(180 per90 days)MOstavudine oral soln 2 QL(7200per 90 days)MOSTRIBILD 5 QL(90 per90 days)MOSUSTIVA CAPS 200MG 3 QL(360 per90 days)MOSUSTIVA CAPS 50MG 3 QL(630 per90 days)MOSUSTIVA TABS 3 QL(90 per90 days)MOTAMIFLU CAPS 45MG, 75MG 3 QL(60 per365 days)MOTAMIFLU CAPS 30MG 3 QL(120 per365 days)MOTAMIFLU SUSR 3 QL(720 per365 days)MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)TRIZIVIR 5 QL(180 per90 days)MOTRUVADA 5 QL(90 per90 days)MOTYZEKA 5 MOvalacyclovir hcl tabs 1000mg 2 QL(100 per90 days)MOvalacyclovir hcl tabs 500mg 2 QL(200 per90 days)MOVALCYTE 5 MOVICTRELIS 5 PAQL(1008per 84 days)MOVIDEX PEDIATRIC ORALSOLN 2GM3 QL(3600per 90 days)MOVIRACEPT TABS 625MG 5 QL(360 per90 days)MOVIRACEPT TABS 250MG 5 QL(900 per90 days)MOVIRAMUNE SUSP 3 QL(3600per 90 days)MOVIRAMUNE XR TB24 100MG 3VIRAMUNE XR TB24 400MG 3 MOVIRAZOLE 5 MOVIREAD POWD 3 QL(720 per90 days)MOVIREAD TABS 3 QL(90 per90 days)MOZERIT ORAL SOLN 4 QL(7200per 90 days)MO5

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)ZIAGEN ORAL SOLN 3 QL(2880per 90 days)MOZIAGEN TABS 3 QL(180 per90 days)MOzidovudine caps 2 QL(540 per90 days)MOzidovudine syrp 2 QL(5520per 90 days)MOzidovudine tabs 2 QL(180 per90 days)MOCEPHALOSPORINScefaclor caps 2 MOcefadroxil 2 MOcefazolin sodium inj 10gm, 1gm; 25%, 500mgcefazolin sodium inj 1gm 2 MOcefdinir 2 MOcefepime inj 2gm 2cefepime inj 1gm 2 MOcefotaxime sodium inj 1gm 2cefotaxime sodium inj 10gm, 2gm 2 MOcefoxitin sodium inj 10gm, 2gm 2cefoxitin sodium inj 1gm 2 MOcefpodoxime proxetil 2 MOceftazidime inj 1gm, 6gm 2ceftazidime inj 2gm 2 MOceftriaxone sodium 2 MOcefuroxime axetil tabs 2 MOcefuroxime sodium inj 7.5gm 2cefuroxime sodium inj 1.5gm, 2 MO750mgcephalexin caps 250mg, 500mg 1 MOcephalexin susr 1 MOcephalexin tabs 1 MOFORTAZ INJ 1GM/50ML; 5%,2GM/50ML; 5%, 6GM3Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)SUPRAX CAPS 4SUPRAX SUSR 500MG/5ML 4SUPRAX SUSR 100MG/5ML, 4 MO200MG/5MLSUPRAX TABS 4 MOTEFLARO 3 MOZINACEF IN ISO-OSMOTIC 3DEXTROSEZINACEF IN ISO-OSMOTIC 3DILUENTERYTHROMYCINS / OTHERMACROLIDESazithromycin inj 500mg 2 MOazithromycin susr 2 MOazithromycin tabs 2 MOclarithromycin 2 MOclarithromycin er 2 MODIFICID 3 QL(60 per90 days)MOe.e.s. 400 2 MOE.E.S. GRANULES 3 MOERY-TAB TBEC 500MG 3 MOery-tab tbec 250mg, 333mg 2 MOERYTHROCIN3LACTOBIONATE INJ 500MGerythrocin stearate 2 MOerythromycin base 2 MOerythromycin ethylsuccinate 2 MOZMAX 3 MOMISCELLANEOUS ANTIINFECTIVESALBENZA 3 MOALINIA 3 MOamikacin sulfate inj 1gm/4ml, 2 MO50mg/mlatovaquone/proguanil hcl tabs 2 MO250mg; 100mgAZACTAM IN ISO-OSMOTIC 3DEXTROSEAZACTAM INJ 2GM 3 MOaztreonam inj 1gm 2 MO6

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)BILTRICIDE 3 MOCAPASTAT SULFATE 4CAYSTON 5 LA MOchloroquine phosphate 2 MOCLEOCIN IN D5W 3CLEOCIN PEDIATRIC 3 MOGRANULESclindamycin hcl 2 MOclindamycin phosphate addvantage2 MOclindamycin phosphate in d5w inj 2300mg/50ml; 5%, 600mg/50ml;5%clindamycin phosphate in d5w inj 2 MO900mg/50ml; 5%COARTEM 3 MOcolistimethate sodium 2 MOCUBICIN3 B/D PA MODAPSONE 3 MODARAPRIM 3 MOethambutol hcl 2 MOgentamicin sulfate inj 2 MOgentamicin sulfate/0.9% sodium 2chloride inj 0.9mg/ml; 0.9%,1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%,1mg/ml; 0.9%hydroxychloroquine sulfate 2 MOimipenem/cilastatin 2 MOisoniazid syrp 2 MOisoniazid tabs 1 MOisotonic gentamicin inj 0.8mg/ml; 20.9%, 1.2mg/ml; 0.9%KETEK 3 QL(20 per30 days)MOMALARONE 3 MOmefloquine hcl 2 MOMEPRON 5 MOmeropenem inj 500mg 2 MOmetronidazole caps 2 MOmetronidazole in nacl 0.79% 2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)metronidazole tabs 2 MOMYCOBUTIN 3 MONEBUPENT3 B/D PA MOneomycin sulfate tabs 2 MOparomomycin sulfate 2 MOPASER 3 MOPRIMAQUINE PHOSPHATE 3 MOpyrazinamide 2 MOQUALAQUIN 3 MOquinine sulfate 2 MOrifampin 2 MOSEROMYCIN 3 MOSIRTURO 5 LASTREPTOMYCIN SULFATE 3 MOSTROMECTOL 3 MOtinidazole 2 QL(60 per90 days)MOTOBI5 B/D PA MOtobramycin sulfate inj 10mg/ml, 2 MO80mg/2mltobramycin sulfate/sodium 2chloride inj 0.9%; 1.2mg/mltobramycin sulfate/sodium 2 MOchloride inj 0.9%; 0.8mg/mlTRECATOR 3 MOTYGACIL 3 MOXIFAXAN TABS 200MG 3 QL(9 per 30days) MOXIFAXAN TABS 550MG 3 QL(180 per90 days)MOZYVOX INJ 3 MOZYVOX SUSR 3 QL(1800per 30 days)MOZYVOX TABS 3 QL(56 per30 days)MOPENICILLINSamoxicillin 1 MO7

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)amoxicillin/clavulanate potassium 2 MOchewamoxicillin/clavulanate potassium 2 MOeramoxicillin/clavulanate potassium 2 MOsusr 250mg/5ml; 62.5mg/5ml,400mg/5ml; 57mg/5ml,600mg/5ml; 42.9mg/5mlamoxicillin/clavulanate potassium 2 MOtabs 250mg; 125mgamoxicillin/potassium clavulanate 2 MOsusr 200mg/5ml; 28.5mg/5mlamoxicillin/potassium clavulanate 2 MOtabsampicillin 2 MOampicillin sodium inj 1gm 2ampicillin sodium inj 10gm, 2 MO125mgampicillin-sulbactam inj 10gm; 25gmampicillin-sulbactam inj 2gm; 2 MO1gmBICILLIN C-R 3 MOBICILLIN L-A 3 MOdicloxacillin sodium 2 MOnafcillin sodium inj 10gm, 1gm 2 MOnallpen/dextrose 2PENICILLIN G POTASSIUM IN 3ISO-OSMOTIC DEXTROSE INJ0; 40000UNIT/ML, 0;60000UNIT/MLpenicillin g potassium inj 5mu 2 MOpenicillin g procaine 2 MOpenicillin g sodium 2 MOpenicillin v potassium 1 MOpfizerpen-g inj 20mu 2 MOpiperacillin sodium/tazobactam 2 MOsodium inj 3gm; 0.375gm, 4gm;0.5gmZOSYN INJ 5%; 2GM/50ML; 30.25GM/50MLZOSYN INJ 5%; 3GM/50ML;0.375GM/50ML3 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)QUINOLONESAVELOX 3 MOAVELOX ABC PACK 3 MOCIPRO I.V.-IN D5W INJ 3200MG/100ML; 5%ciprofloxacin hcl 1 MOciprofloxacin i.v.-in d5w inj 2 MO200mg/100ml; 5%ciprofloxacin inj 400mg/40ml 1levofloxacin 2 MOlevofloxacin in d5w inj 5%; 2500mg/100mlNOROXIN 4 MOofloxacin 2 MOSULFA'S / RELATED AGENTSsulfadiazine 2 MOsulfamethoxazole/trimethoprim 1 MOsulfamethoxazole/trimethoprim ds 1 MOTETRACYCLINESdemeclocycline hcl 3 MOdoxycycline caps 75mg 2 MOdoxycycline hyclate caps 1 MOdoxycycline hyclate dr 1 MOdoxycycline hyclate inj 1 MOdoxycycline hyclate tabs 1 MOdoxycycline monohydrate tabs 2 MO150mg, 50mg, 75mgdoxycycline susr 2 MOminocycline hcl 2 MOminocycline hcl er 2 MOtetracycline hcl 1 MOVIBRAMYCIN SUSR 3 MOVIBRAMYCIN SYRP 3 MOURINARY TRACT AGENTSMACRODANTIN CAPS 25MG 3 MOmethenamine hippurate 2 MOnitrofurantoin 2 MOnitrofurantoin macrocrystalline 2 MOcaps 50mgnitrofurantoin monohydrate 2 MO8

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)PRIMSOL 4 MOtrimethoprim 2 MOVANCOMYCINvancomycin hcl caps 2 MOvancomycin hcl inj 500mg 2 B/D PAvancomycin hcl inj 1000mg, 10gm2 B/D PA MOVIBATIV INJ 250MG 3ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSADJUNCTIVE AGENTSamifostine 5 MOdexrazoxane inj 500mg 2 MOELITEK INJ 1.5MG 5FUSILEV 5 MOleucovorin calcium inj 100mg, 2 MO350mgleucovorin calcium tabs 2 MOmesna 2 MOMESNEX TABS 3 MOXGEVA 5 PA QL(8.5per 90 days)MOZINECARD INJ 250MG 3 MOANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSABRAXANE 4 MOadriamycin inj 2mg/ml 2 MOAFINITOR TABS 10MG, 7.5MG 5 PA QL(180per 90 days)MOAFINITOR TABS 2.5MG, 5MG 5 PA QL(270per 90 days)MOALIMTA INJ 500MG 4 MOALKERAN INJ 4anastrozole 2 MOARRANON 4ARZERRA INJ 100MG/5ML 3 MOAVASTIN INJ 100MG/4ML 4 MOazathioprine2 B/D PA MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)azathioprine sodium 2 MObicalutamide 2 MOBICNU 4 MObleomycin sulfate inj 30unit 2 MOBOSULIF TABS 500MG 5 PA QL(90per 90 days)MOBOSULIF TABS 100MG 5 PA QL(360per 90 days)MOBUSULFEX 3CAMPATH 4 MOCAPRELSA TABS 300MG 5 QL(90 per90 days)MOCAPRELSA TABS 100MG 5 QL(180 per90 days)MOcarboplatin inj 150mg/15ml 2 MOCEENU 3 MOCELLCEPT INTRAVENOUS 3CELLCEPT SUSR3 B/D PA MOcisplatin inj 100mg/100ml 2 MOcladribine 2 MOCLOLAR 4 MOCOMETRIQ 5 PA MOCOSMEGEN 4 MOcyclophosphamide tabs2 B/D PA MOcyclosporine caps2 B/D PA MOcyclosporine inj 2cyclosporine modified2 B/D PA MOcytarabine aqueous 2 MOcytarabine inj 500mg 2 MOdacarbazine inj 200mg 2 MODACOGEN 3 MOdaunorubicin hcl inj 5mg/ml 2DOCEFREZ 5docetaxel inj 80mg/8ml 2docetaxel inj 80mg/4ml 2 MODOXIL 3 MO9

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)doxorubicin hcl inj 2mg/ml 2 MODROXIA 3 MOELLENCE INJ 200MG/100ML 4 MOELOXATIN INJ 100MG/20ML 4 MOELSPAR 4 MOEMCYT 3 MOepirubicin hcl inj 50mg/25ml 2ERBITUX INJ 100MG/50ML 4 MOERIVEDGE 5 PA MOETOPOPHOS 4 MOetoposide inj 2 MOexemestane 2 MOFARESTON 4 MOFASLODEX 5 MOFIRMAGON INJ 120MG 5 QL(240 per84 days)MOFIRMAGON INJ 80MG 3 QL(240 per84 days)MOfludarabine phosphate inj 50mg 2 MOfluorouracil inj 2.5gm/50ml 2 MOflutamide 2 MOgemcitabine hcl inj 1gm 5 MOgengraf2 B/D PA MOGLEEVEC 5 MOHALAVEN 5 MOHERCEPTIN 4 MOHEXALEN 5 MOhydroxyurea 2 MOICLUSIG 5 PA MOidarubicin hcl inj 10mg/10ml 2IFEX INJ 3GM 4 MOifosfamide inj 1gm 2 MOINLYTA 5 PA MOirinotecan inj 100mg/5ml 5 MOISTODAX 3 MOIXEMPRA KIT INJ 45MG 5 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)JAKAFI 5 PA QL(180per 90 days)MOJEVTANA 5 MOKADCYLA INJ 100MG 5 MOletrozole 2 MOLEUKERAN 3 MOleuprolide acetate 2 MOLUPRON DEPOT INJ 3.75MG 3 MOLUPRON DEPOT INJ 22.5MG, 5 MO30MG, 45MG, 7.5MGLUPRON DEPOT-PED INJ 5 MO11.25MG, 15MGLYSODREN 3 MOMATULANE 5 MOMEGACE ES 3 QL(150 per30 days)MOmegestrol acetate 2 MOMEKINIST TABS 2MG 5 PA QL(30per 30 days)MOMEKINIST TABS 0.5MG 5 PA QL(120per 30 days)MOmelphalan hydrochloride 2mercaptopurine 2 MOmethotrexate2 B/D PA MOmethotrexate sodium inj 25mg/ml 2 MOMETHOTREXATE SODIUM 4INJ 1GMmitomycin inj 20mg 2 MOmitoxantrone hcl 2 MOMUSTARGEN 4 MOmycophenolate mofetil2 B/D PA MOMYFORTIC3 B/D PA MONEORAL3 B/D PA MONEXAVAR 5 LA PAQL(360 per90 days)MO10

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)NILANDRON 4 QL(120 per90 days)MONIPENT 4 MONULOJIX 5 MOoctreotide acetate inj5 MO1000mcg/ml, 500mcg/mloctreotide acetate inj 100mcg/ml, 2 MO200mcg/ml, 50mcg/mlONTAK 4oxaliplatin inj 100mg/20ml 5 MOpaclitaxel inj 300mg/50ml 2 MOpentostatin 2 MOPERJETA 5 PA MOPOMALYST 5 MOPROGRAF INJ 3 MORAPAMUNE3 B/D PA MOREVLIMID CAPS 25MG 5 LA QL(21per 28 days)MOREVLIMID CAPS 10MG,15MG, 5MG5 LA QL(30per 30 days)MORHEUMATREX 4 MORITUXAN 3 PA MOSANDIMMUNE CAPS3 B/D PA MOSANDIMMUNE INJ 3 MOSANDIMMUNE ORAL SOLN 3 B/D PA MOSANDOSTATIN LAR DEPOT 4 MOSIGNIFOR 5 PA MOSIMULECT INJ 20MG 3 MOSOLTAMOX 3SOMATULINE DEPOT 5 MOSPRYCEL TABS 140MG,50MG, 70MG, 80MG5 QL(90 per90 days)MOSPRYCEL TABS 100MG, 20MG 5 QL(180 per90 days)MOSTIVARGA 5 PA QL(252per 90 days)MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)SUTENT CAPS 25MG, 50MG 5 PA QL(90per 90 days)MOSUTENT CAPS 12.5MG 5 PA QL(270per 90 days)MOSYNRIBO 5 PA MOTABLOID 3 MOtacrolimus2 B/D PA MOTAFINLAR CAPS 75MG 5 PA QL(124per 31 days)MOTAFINLAR CAPS 50MG 5 PA QL(186per 31 days)MOtamoxifen citrate 2 MOTARCEVA TABS 100MG,150MG5 PA QL(90per 90 days)MOTARCEVA TABS 25MG 5 PA QL(180per 90 days)MOTARGRETIN 3 MOTASIGNA 5 QL(336 per84 days)MOTAXOTERE INJ 80MG/4ML 5 MOTHALOMID 5 PA MOthiotepa 2 MOtoposar 2 MOtopotecan hcl inj 4mg 2 MOTORISEL 5 PA MOTREANDA INJ 100MG 5 MOTRELSTAR DEPOT MIXJECT 4 MOTRELSTAR LA MIXJECT 4 MOTRELSTAR MIXJECT 4 MOtretinoin 2 MOTRISENOX 3 MOTYKERB 5 LA QL(540per 90 days)MOVECTIBIX INJ 100MG/5ML 5 MO11

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)VELCADE 4 MOVIDAZA 5 QL(4200per 90 days)MOvinblastine sulfate inj 10mg 2vincasar pfs 2 MOvincristine sulfate 2 MOvinorelbine tartrate inj 50mg/5ml 2 MOVOTRIENT 5 QL(360 per90 days)MOXALKORI 5 PA QL(180per 90 days)MOXTANDI 5 PA QL(360per 90 days)MOYERVOY INJ 50MG/10ML 5 PA MOZALTRAP INJ 100MG/4ML 5 PA MOZANOSAR 4 MOZELBORAF 5 PA QL(720per 90 days)MOZOLINZA 5 QL(360 per90 days)MOZORTRESS TABS 0.5MG,0.75MGZORTRESS TABS 0.25MG5 B/D PA MO3 B/D PA MOZYTIGA 5 PA QL(360per 90 days)MOAUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCHANTICONVULSANTSBANZEL 3 MOcarbamazepine 2 MOcarbamazepine er 1 MOCARBATROL 3 MOCELONTIN 3 MOclonazepam 2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)clonazepam odt 2 MOdiazepam gel 2 MODILANTIN CAPS 30MG 3 MODILANTIN INFATABS 3 MOdivalproex sodium 2 MOdivalproex sodium dr 2 MOdivalproex sodium er 2 MOepitol 1 MOethosuximide 2 MOfelbamate 2 MOFELBATOL 3 MOfosphenytoin sodium inj 100mg 2 MOpe/2mlgabapentin 2 MOGABITRIL 3 MOLAMICTAL ODT TBDP 3 MOLAMICTAL STARTER/NOT 3 MOTAKING CARBAMAZEPINELAMICTAL3 MOSTARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATELAMICTAL3 MOSTARTER/TAKINGVALPROATELAMICTAL XR 3 MOlamotrigine 2 MOlamotrigine er 2 MOlevetiracetam er 2 MOlevetiracetam inj 500mg/5ml 2 MOlevetiracetam oral soln 2 MOlevetiracetam tabs 2 MOLYRICA CAPS 225MG, 300MG 3 QL(180 per90 days)MOLYRICA CAPS 100MG, 150MG,200MG, 25MG, 50MG, 75MG3 QL(270 per90 days)MOLYRICA ORAL SOLN 3 QL(2880per 90 days)MO12

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)ONFI 3 MOoxcarbazepine 2 MOPEGANONE 3 MOphenobarbital 2 PA MOphenytoin 2 MOphenytoin sodium 2phenytoin sodium extended 2 MOPOTIGA 4 MOprimidone 2 MOSABRIL 3 MOTEGRETOL-XR TB12 100MG 3 MOtiagabine hydrochloride 2 MOtopiramate 2 MOTRILEPTAL SUSP 4 MOvalproate sodium 2 MOvalproic acid 2 MOVIMPAT INJ 3VIMPAT ORAL SOLN 3 MOVIMPAT TABS 3 MOzonisamide 2 MOANTIPARKINSONISM AGENTSAPOKYN 3 LA MOAZILECT 3 MObenztropine mesylate inj 1benztropine mesylate tabs 1 MObromocriptine mesylate 2 MOcarbidopa/levodopa 2 MOcarbidopa/levodopa er 2 MOcarbidopa/levodopa odt 2 MOCOMTAN 3 MOentacapone 2 MOLODOSYN 3 MOMIRAPEX ER 3 MOpramipexole dihydrochloride 2 MOropinirole er 2 MOropinirole hcl 2 MOselegiline hcl 2 MOSTALEVO 100 3 MOSTALEVO 125 3 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)STALEVO 150 3 MOSTALEVO 200 3 MOSTALEVO 50 3 MOSTALEVO 75 3 MOtrihexyphenidyl hcl 1 MOZELAPAR 3 MOMIGRAINE / CLUSTER HEADACHETHERAPYdihydroergotamine mesylate inj 2 MOmigergot 2 MOMIGRANAL 4 QL(24 per90 days)MOnaratriptan hcl tabs 2.5mg 2 QL(24 per90 days)MOnaratriptan hcl tabs 1mg 2 QL(36 per90 days)MORELPAX 3 QL(36 per90 days)MOrizatriptan benzoate 2 QL(54 per90 days)MOsumatriptan succinate inj6mg/0.5ml2 QL(12 per90 days)MOsumatriptan succinate tabs 100mg 2 QL(27 per90 days)MOsumatriptan succinate tabs 25mg,50mg2 QL(54 per90 days)MOMISCELLANEOUS NEUROLOGICALTHERAPYARICEPT TABS 23MG 3 QL(90 per90 days)MOCOPAXONE 5 PA QL(90per 90 days)MO13

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)donepezil hcl tabs 10mg, 5mg 2 QL(90 per90 days)MOdonepezil hcl tbdp 2 QL(90 per90 days)MOEXELON ORAL SOLN 3 MOEXELON PT24 3 QL(90 per90 days)MOgalantamine hydrobromide cp24 2 QL(90 per90 days)MOgalantamine hydrobromide oral 2 MOsolngalantamine hydrobromide tabs 2 QL(180 per90 days)MOGILENYA 5 PA QL(28per 28 days)MOMYTELASE 3 MONAMENDA ORAL SOLN 3 MONAMENDA TABS 10MG 3 QL(180 per90 days)MONAMENDA TABS 5MG 3 QL(270 per90 days)MONAMENDA TITRATION PAK 3 MONAMENDA XR 3 MONAMENDA XR TITRATION 3 MOPACKNUEDEXTA 3 QL(180 per90 days)MOrivastigmine tartrate 2 QL(180 per90 days)MOTECFIDERA 5 PA MOTECFIDERA STARTER PACK 5 PA MOXENAZINE 5 LA MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)MUSCLE RELAXANTS /ANTISPASMODIC THERAPYbaclofen 2 MOcyclobenzaprine hcl tabs 10mg, 2 MO5mgdantrolene sodium caps 2 MOLIORESAL INTRATHECAL INJ 3 B/D PA0.05MG/MLLIORESAL INTRATHECAL INJ 3 B/D PA MO10MG/20ML, 10MG/5MLMESTINON SYRP 3 MOMESTINON TIMESPAN 3 MOpyridostigmine bromide 2 MOregonol 2tizanidine hcl 2 MONARCOTIC ANALGESICSacetaminophen/codeine #3 2 MOacetaminophen/codeine oral soln 2acetaminophen/codeine tabs 2 MOascomp/codeine 2 MOBUPRENEX 3 MObuprenorphine hcl inj 2buprenorphine hcl subl 2 MOBUTRANS 3 MOcodeine sulfate tabs 2 MODILAUDID INJ 3 MODILAUDID-5 3 MODILAUDID-HP INJ 10MG/ML 3duramorph 2 MOendocet tabs 650mg; 10mg 2 QL(540 per90 days)MOendocet tabs 500mg; 7.5mg 2 QL(720 per90 days)MOendocet tabs 325mg; 10mg,325mg; 5mg, 325mg; 7.5mg2 QL(1080per 90 days)EXALGO TB24 12MG, 16MG,8MGMO3 MO14

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)fentanyl 2 QL(30 per90 days)MOfentanyl citrate oral transmucosallpop 200mcgfentanyl citrate oral transmucosallpop 1200mcg, 1600mcg, 400mcg,600mcg, 800mcghydrocodonebitartrate/acetaminophen oralsolnhydrocodonebitartrate/acetaminophen tabs300mg; 10mg, 300mg; 5mg,300mg; 7.5mg, 750mg; 10mghydrocodone/acetaminophen oralsolnhydrocodone/acetaminophen tabs750mg; 7.5mghydrocodone/acetaminophen tabs650mg; 10mg, 650mg; 7.5mg,660mg; 10mghydrocodone/acetaminophen tabs500mg; 10mg, 500mg; 2.5mg,500mg; 5mg, 500mg; 7.5mghydrocodone/acetaminophen tabs325mg; 10mg, 325mg; 5mg,325mg; 7.5mghydrocodone/ibuprofen tabs7.5mg; 200mghydromorphone hcl inj2 PA QL(360per 90 days)MO5 PA QL(360per 90 days)MO2 MO2 MO2 QL(3600per 30 days)MO2 QL(450 per90 days)MO2 QL(540 per90 days)MO2 QL(720 per90 days)MO2 QL(1080per 90 days)MO2 MO500mg/50mlhydromorphone hcl tabs 2 MOLAZANDA 5 LA PAQL(31 per90 days)MOlevorphanol tartrate 2 MOmethadone hcl conc 2 MOmethadone hcl inj 2methadone hcl oral soln 2 MO3Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)methadone hcl tabs 2 MOmethadose tabs 2 MOmorphine sulfate er 2 MOmorphine sulfate oral soln 2 MOmorphine sulfate tabs 2 MOONSOLIS FILM 1200MCG,400MCG, 600MCG, 800MCG3 PA QL(360per 90 days)MOONSOLIS FILM 200MCG 3 PA QL(720per 90 days)MOOPANA ER (CRUSHRESISTANT)3 QL(540 per90 days)MOoxycodone hcl caps 2 QL(1080per 90 days)MOoxycodone hcl conc 2 QL(1800per 90 days)MOoxycodone hcl oral soln 2 QL(3600per 90 days)MOoxycodone hcl tabs 10mg, 15mg,20mg, 30mg2 QL(540 per90 days)MOoxycodone hcl tabs 5mg 2 QL(1080per 90 days)MOoxycodone/acetaminophen caps 2 QL(720 per90 days)MOoxycodone/acetaminophen tabs650mg; 10mgoxycodone/acetaminophen tabs500mg; 7.5mgoxycodone/acetaminophen tabs325mg; 10mg, 325mg; 2.5mg,325mg; 5mg, 325mg; 7.5mg2 QL(540 per90 days)MO2 QL(720 per90 days)MO2 QL(1080per 90 days)MOoxycodone/aspirin 2 MO15

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)OXYCONTIN 3 QL(540 per90 days)MOoxymorphone hydrochloride 2 MOoxymorphone hydrochloride er 2 MOtb12 15mg, 7.5mgreprexain tabs 10mg; 200mg 2 MOROXICET ORAL SOLN 3 QL(5580per 90 days)MOstagesic 2 QL(720 per90 days)MOvicodin 2 MOvicodin es 2 MOvicodin hp 2 MONON-NARCOTIC ANALGESICSARTHROTEC 50 4 MOARTHROTEC 75 4 MObuprenorphine hcl/naloxone hcl 2 MObutorphanol tartrate nasal soln 2 PA QL(30per 90 days)MOCELEBREX 4 QL(180 per90 days)MOdiclofenac potassium 2 MOdiclofenac sodium dr 2 MOdiclofenac sodium er 2 MOdiclofenac sodium/misoprostol 2 MOdiflunisal 2 MOetodolac 2 MOetodolac er 2 MOfenoprofen calcium 2 MOFLECTOR 4 MOflurbiprofen 2 MOibuprofen susp 1 MOibuprofen tabs 400mg, 600mg, 1 MO800mgindomethacin caps 2 MOindomethacin er 2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)ketoprofen 2 MOketoprofen er 2 MOmeclofenamate sodium 2 MOmefenamic acid 2 MOmeloxicam 1 MOnabumetone 2 MOnaloxone hcl inj 1mg/ml 2 MOnaltrexone hcl 2 MOnaproxen 1 MOnaproxen dr 1 MOnaproxen sodium tabs 275mg, 2 MO550mgNUCYNTA 3 QL(541 per90 days)MONUCYNTA ER 3 QL(180 per90 days)MOoxaprozin 2 MOPENNSAID 3 MOpiroxicam 2 MOSUBOXONE 3 MOsulindac 2 MOtolmetin sodium 2 MOtramadol hcl 2 QL(720 per90 days)MOtramadol hcl er tb24 3 QL(90 per90 days)MOVIMOVO 3 QL(180 per90 days)MOVOLTAREN GEL 3 MOPSYCHOTHERAPEUTIC DRUGSABILIFY DISCMELT TBDP15MG4 QL(180 per90 days)ABILIFY DISCMELT TBDP10MGMO4 QL(270 per90 days)MOABILIFY INJ 4 MO16

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)ABILIFY MAINTENA INJ 5 MO300MGABILIFY ORAL SOLN 4 MOABILIFY TABS 20MG, 2MG,30MG, 5MG4 QL(90 per90 days)MOABILIFY TABS 15MG 4 QL(180 per90 days)MOABILIFY TABS 10MG 4 QL(270 per90 days)MOamitriptyline hcl 1 MOamoxapine 2 MObudeprion sr 2 QL(180 per90 days)MObupropion hcl 2 MObupropion hcl sr 2 QL(180 per90 days)MObupropion hcl xl tb24 300mg 2 QL(90 per90 days)MObupropion hcl xl tb24 150mg 2 QL(270 per90 days)MObuspirone hcl 2 MOchlordiazepoxide/amitriptyline 2 MOchlorpromazine hcl inj 2 MOchlorpromazine hcl tabs 2 MOcitalopram hydrobromide oralsolncitalopram hydrobromide tabs40mgcitalopram hydrobromide tabs10mgcitalopram hydrobromide tabs20mg1 MO1 QL(90 per90 days)MO1 QL(180 per90 days)MO1 QL(270 per90 days)MOclomipramine hcl 2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)clorazepate dipotassium 2 MOclozapine 2CYMBALTA CPEP 60MG 3 QL(180 per90 days)MOCYMBALTA CPEP 30MG 3 QL(360 per90 days)MOCYMBALTA CPEP 20MG 3 QL(540 per90 days)MOdesipramine hcl 2 MOdextroamphetamine sulfate er 2 PA MOdextroamphetamine sulfate tabs 2 PA MOdiazepam intensol 2 MOdiazepam oral soln 2 MOdiazepam tabs 2 MOdoxepin hcl 1 MOEMSAM 4 QL(90 per90 days)MOescitalopram oxalate oral soln 2 QL(1920per 90 days)MOescitalopram oxalate tabs 2 QL(90 per90 days)MOFANAPT TABS 1MG, 2MG,4MGFANAPT TABS 10MG, 12MG,6MG, 8MG4 QL(90 per90 days)MO4 QL(180 per90 days)MOFANAPT TITRATION PACK 4 MOFAZACLO 4fluoxetine dr 2 QL(12 per90 days)MOfluoxetine hcl caps 40mg 1 QL(180 per90 days)MO17

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)fluoxetine hcl caps 20mg 1 QL(360 per90 days)MOfluoxetine hcl caps 10mg 1 QL(720 per90 days)MOfluoxetine hcl oral soln 1 MOfluoxetine hcl tabs 20mg 1 QL(360 per90 days)MOfluoxetine hcl tabs 10mg 1 QL(720 per90 days)MOfluphenazine decanoate 2 MOfluphenazine hcl conc 2fluphenazine hcl elix 2 MOfluphenazine hcl inj 2 MOfluphenazine hcl tabs 2 MOfluvoxamine maleate 2 QL(270 per90 days)MOfluvoxamine maleate er cp24150mgfluvoxamine maleate er cp24100mg2 QL(180 per90 days)MO2 QL(270 per90 days)MOFOCALIN XR 3 PA MOFORFIVO XL 4 QL(90 per90 days)MOGEODON INJ 4 MOHALDOL 3 MOHALDOL DECANOATE 100 3 MOHALDOL DECANOATE 50 3 MOhaloperidol 2 MOhaloperidol decanoate 2 MOhaloperidol lactate 2 MOimipramine hcl 2 MOimipramine pamoate 3 MOINTUNIV 4 MODrug Name(Nombre del medicamento)INVEGA SUSTENNA INJ39MG/0.25MLINVEGA SUSTENNA INJ78MG/0.5MLINVEGA SUSTENNA INJ117MG/0.75MLINVEGA SUSTENNA INJ156MG/MLINVEGA SUSTENNA INJ234MG/1.5MLINVEGA TB24 1.5MG, 3MG,9MGDrug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)3 QL(0.75 per90 days)MO3 QL(1.5 per90 days)MO3 QL(2.25 per90 days)MO3 QL(3 per 90days) MO3 QL(4.5 per90 days)MO4 QL(90 per90 days)MOINVEGA TB24 6MG 4 QL(180 per90 days)MOLATUDA TABS 120MG 3 QL(90 per90 days)MOLATUDA TABS 80MG 3 QL(180 per90 days)MOLATUDA TABS 40MG 3 QL(360 per90 days)MOLATUDA TABS 20MG 3 QL(720 per90 days)MOlithium carbonate 2 MOlithium carbonate er 2 MOlithium citrate 2 MOlorazepam intensol 2 MOlorazepam tabs 2 MOloxapine succinate 2 MOLUNESTA 4 QL(90 per90 days)MOmaprotiline hcl 2 MOMARPLAN 3 MO18

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)METADATE CD CPCR 20MG, 4 PA MO30MG, 40MG, 50MG, 60MGmethylphenidate hcl 2 PA MOmethylphenidate hcl cd cpcr 2 PA MO50mg, 60mgmethylphenidate hcl er cp24 2 PA MOmethylphenidate hydrochloride 2 PA MOmirtazapine 2 QL(90 per90 days)MOmirtazapine odt tbdp 30mg, 45mg 2 QL(90 per90 days)MOmodafinil 2 PA QL(90per 90 days)MOnefazodone hcl 2 QL(180 per90 days)MOnortriptyline hcl caps 1 MOolanzapine inj 2 MOolanzapine odt 2 QL(90 per90 days)MOolanzapine tabs 2 QL(90 per90 days)MOolanzapine/fluoxetine 2 QL(90 per90 days)MOORAP 3 MOparoxetine hcl er tb24 12.5mg,37.5mg2 QL(180 per90 days)MOparoxetine hcl er tb24 25mg 2 QL(270 per90 days)MOparoxetine hcl tabs 20mg, 40mg 2 QL(90 per90 days)MOparoxetine hcl tabs 10mg, 30mg 2 QL(180 per90 days)MOPAXIL SUSP 3 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)perphenazine 2 MOphenelzine sulfate 2 MOPRISTIQ 3 QL(90 per90 days)MOprocentra 2 PA MOprotriptyline hcl 2 MOPROVIGIL 3 PA QL(90per 90 days)MOquetiapine fumarate tabs 25mg,300mg, 400mgquetiapine fumarate tabs 100mg,200mg, 50mg2 QL(180 per90 days)MO2 QL(270 per90 days)MORISPERDAL CONSTA 3 QL(12 per84 days)MOrisperidone odt 2 QL(180 per90 days)MOrisperidone oral soln 2 MOrisperidone tabs 2 QL(180 per90 days)MORITALIN LA 4 PA MOSAPHRIS 3 QL(180 per90 days)MOSEROQUEL XR TB24 150MG,300MG, 400MGSEROQUEL XR TB24 200MG,50MG3 QL(180 per90 days)MO3 QL(270 per90 days)MOsertraline hcl conc 2 MOsertraline hcl tabs 100mg, 25mg 2 QL(180 per90 days)MOsertraline hcl tabs 50mg 2 QL(270 per90 days)MO19

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)SILENOR 4 QL(90 per90 days)MOSTRATTERA 3 MOSYMBYAX 4 QL(90 per90 days)MOtemazepam 2 MOthioridazine hcl 2 MOthiothixene 2 MOtranylcypromine sulfate 2 MOtrazodone hcl 1 MOtrifluoperazine hcl 2 MOtrimipramine maleate 2 MOvenlafaxine hcl er cp24 150mg,37.5mg2 QL(90 per90 days)MOvenlafaxine hcl er cp24 75mg 2 QL(270 per90 days)MOvenlafaxine hcl tabs 100mg,25mg, 37.5mg2 QL(270 per90 days)MOvenlafaxine hcl tabs 75mg 2 QL(450 per90 days)MOvenlafaxine hcl tabs 50mg 2 QL(675 per90 days)MOVIIBRYD KIT 3 QL(30 per365 days)MOVIIBRYD TABS 3 QL(90 per90 days)MOXYREM 5 PA MOzaleplon caps 5mg 2 QL(90 per90 days)MOzaleplon caps 10mg 2 QL(180 per90 days)MOzenzedi tabs 2.5mg, 7.5mg 2 PADrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)zenzedi tabs 10mg, 5mg 2 PA MOziprasidone hcl 2 QL(180 per90 days)MOzolpidem tartrate 2 QL(90 per90 days)MOzolpidem tartrate er 2 QL(90 per90 days)MOCARDIOVASCULAR,HYPERTENSION / LIPIDSANTIARRHYTHMIC AGENTSamiodarone hcl inj 50mg/ml 2 MOamiodarone hcl tabs 2 MOdisopyramide phosphate 2 MOflecainide acetate 2 MOmexiletine hcl 2 MOMULTAQ 3 MONORPACE CR 3 MOpacerone tabs 100mg, 200mg 2 MOprocainamide hcl inj 500mg/ml 2procainamide hcl inj 100mg/ml 2 MOpropafenone hcl 2 MOpropafenone hcl er 2 MOquinidine gluconate cr 2 MOquinidine sulfate 2 MOquinidine sulfate er 2 MOsorine 2 MOsotalol hcl (af) tabs 120mg 2 MOsotalol hcl tabs 160mg, 240mg, 2 MO80mgTIKOSYN 4 MOANTIHYPERTENSIVE THERAPYacebutolol hcl 2 MOafeditab cr 2 MOamiloride hcl 2 MOamiloride/hydrochlorothiazide 1 MOamlodipine besylate 2 MO20

Drug Name(Nombre del medicamento)amlodipine besylate/benazeprilhclamlodipine besylate/benazeprilhydrochlorideDrug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)2 QL(90 per90 days)MO2 QL(90 per90 days)MOAMTURNIDE 3 QL(90 per90 days)MOatenolol 1 MOatenolol/chlorthalidone 1 MOAZOR 3 QL(90 per90 days)MObenazepril hcl 1 MObenazeprilhcl/hydrochlorothiazide tabs20mg; 12.5mg, 20mg; 25mgbenazeprilhcl/hydrochlorothiazide tabs10mg; 12.5mgbenazeprilhcl/hydrochlorothiazide tabs5mg; 6.25mg2 QL(360 per90 days)MO2 QL(720 per90 days)MO2 QL(1440per 90 days)MOBENICAR HCT 3 QL(90 per90 days)MOBENICAR TABS 20MG, 40MG 3 QL(90 per90 days)MOBENICAR TABS 5MG 3 QL(180 per90 days)MObetaxolol hcl 2 MOBIDIL 3 QL(540 per90 days)MObisoprolol fumarate 2 MObisoprolol1 MOfumarate/hydrochlorothiazidebumetanide 1 MOBYSTOLIC 3 MOcandesartancilexetil/hydrochlorothiazide2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)captopril 1 MOcaptopril/hydrochlorothiazidetabs 25mg; 15mg, 25mg; 25mg,50mg; 15mg2 QL(90 per90 days)MOcaptopril/hydrochlorothiazidetabs 50mg; 25mg2 QL(270 per90 days)MOcartia xt 2 MOcarvedilol 2 MOchlorothiazide 1 MOchlorothiazide sodium 2 MOchlorthalidone tabs 25mg, 50mg 1 MOclonidine hcl ptwk 2 MOclonidine hcl tabs 1 MOCOREG CR 3 MODEMSER 3 MODIBENZYLINE 4 MOdilt-cd cp24 120mg, 300mg 2 MOdilt-xr cp24 180mg, 240mg 2 MOdiltiazem cd cp24 120mg, 240mg, 2 MO300mgdiltiazem hcl er cp12 2 MOdiltiazem hcl er cp24 180mg, 2 MO360mg, 420mgdiltiazem hcl inj 100mg,250mg/10mldiltiazem hcl tabs 2 MODIOVAN 3 MOdoxazosin mesylate 1 QL(180 per90 days)MOEDECRIN 3 MOenalapril maleate 1 MOenalaprilmaleate/hydrochlorothiazide tabs5mg; 12.5mg2 QL(90 per90 days)MOenalaprilmaleate/hydrochlorothiazide tabs10mg; 25mg2 QL(180 per90 days)MOeplerenone 2 MO21

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)eprosartan mesylate 2 QL(90 per90 days)MOEXFORGE 3 QL(90 per90 days)MOEXFORGE HCT 3 QL(90 per90 days)MOfelodipine er 2 MOfosinopril sodium 2 MOfosinoprilsodium/hydrochlorothiazide tabs10mg; 12.5mgfosinoprilsodium/hydrochlorothiazide tabs2 QL(90 per90 days)MO2 QL(360 per90 days)MO20mg; 12.5mgfurosemide 1 MOguanfacine hcl 2 MOhydralazine hcl 2 MOhydrochlorothiazide 1 MOindapamide 1 MOirbesartan 2 QL(90 per90 days)MOirbesartan/hydrochlorothiazide 2 QL(90 per90 days)MOisradipine 2 MOlabetalol hcl 2 MOlisinopril 1 MOlisinopril/hydrochlorothiazidetabs 12.5mg; 10mg, 12.5mg;20mglisinopril/hydrochlorothiazidetabs 25mg; 20mg1 QL(90 per90 days)MO1 QL(360 per90 days)MOlosartan potassium tabs 100mg 2 QL(90 per90 days)MOlosartan potassium tabs 25mg,50mg2 QL(180 per90 days)MODrug Name(Nombre del medicamento)losartanpotassium/hydrochlorothiazidetabs 12.5mg; 100mg, 25mg;100mglosartanpotassium/hydrochlorothiazideDrug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)2 QL(90 per90 days)MO2 QL(180 per90 days)MOtabs 12.5mg; 50mgmatzim la 2 MOmethyclothiazide 2 MOmetolazone 2 MOmetoprolol succinate er 2 MOmetoprolol tartrate inj 2metoprolol tartrate tabs 1 MOmetoprolol/hydrochlorothiazide 2 MOMICARDIS HCT 3 QL(90 per90 days)MOMICARDIS TABS 20MG, 40MG 3 QL(90 per90 days)MOMICARDIS TABS 80MG 3 QL(180 per90 days)MOminoxidil tabs 2 MOmoexipril hcl 2 MOmoexipril/hydrochlorothiazidetabs 12.5mg; 15mg, 12.5mg;7.5mgmoexipril/hydrochlorothiazidetabs 25mg; 15mg2 QL(90 per90 days)MO2 QL(180 per90 days)MOnadolol 2 MOnadolol/bendroflumethiazide 2 MOnicardipine hcl caps 2 MOnifediac cc tb24 90mg 2 MOnifedical xl 2 MOnifedipine 2 MOnifedipine er 2 MOnimodipine 2 MOnisoldipine 2 MOnisoldipine er 2 MOperindopril erbumine 2 MO22

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)pindolol 2 MOprazosin hcl 2 QL(360 per90 days)MOpropranolol hcl er 2 MOpropranolol hcl inj 2propranolol hcl oral soln 2 MOpropranolol hcl tabs 2 MOpropranolol/hydrochlorothiazide 2 MOquinapril hcl 2 MOquinapril/hydrochlorothiazide 2 QL(90 per90 days)MOramipril 2 MOREMODULIN 5 PA MOreserpine 2 MOspironolactone 1 MOspironolactone/hydrochlorothiazi 2 MOdetaztia xt 2 MOTEKAMLO 3 QL(90 per90 days)MOTEKTURNA 3 QL(90 per90 days)MOTEKTURNA HCT 3 QL(90 per90 days)MOterazosin hcl 1 QL(180 per90 days)MOtimolol maleate 2 MOtorsemide tabs 2 MOtrandolapril 2 MOtriamterene/hydrochlorothiazide 1 MOTRIBENZOR 3 QL(90 per90 days)MOTWYNSTA 3 QL(90 per90 days)MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)valsartan/hydrochlorothiazide 2 QL(90 per90 days)MOverapamil hcl er 2 MOverapamil hcl inj 2verapamil hcl sr cp24 360mg 2 MOverapamil hcl tabs 2 MOCARDIAC GLYCOSIDESdigoxin 1 MOLANOXIN 3 MOLANOXIN PEDIATRIC 3COAGULATION THERAPYAGGRENOX 3 MOBRILINTA 3 MOcilostazol 2 MOclopidogrel 2 MOCYKLOKAPRON 3 MOEFFIENT 3 MOELIQUIS 3 MOenoxaparin sodium inj2 MO300mg/3ml, 30mg/0.3ml,40mg/0.4ml, 60mg/0.6ml,80mg/0.8mlenoxaparin sodium inj 100mg/ml, 5 MO120mg/0.8ml, 150mg/mlfondaparinux sodium 2 MOFRAGMIN 3 MOheparin sodium inj 10000unit/ml, 2 MO1000unit/ml, 20000unit/ml,5000unit/mlheparin sodium/d5w inj 5%; 240unit/mlheparin sodium/nacl 0.45% 2heparin sodium/sodium chloride 20.9% premixjantoven 1 MOLOVENOX INJ 300MG/3ML 3 MOpentoxifylline er 2 MOPRADAXA 3 MO23

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)PROMACTA 5 LA PAQL(90 per90 days)MOticlopidine hcl 2 MOwarfarin sodium 1 MOXARELTO 3 MOLIPID/CHOLESTEROL LOWERINGAGENTSatorvastatin calcium 2 QL(90 per90 days)MOcholestyramine light pack 2 MOcolestipol hcl 2 MOCRESTOR 3 QL(90 per90 days)MOfenofibrate 2 MOfenofibrate micronized 2 MOfluvastatin 2 QL(90 per90 days)MOgemfibrozil 2 MOJUXTAPID 5 LA MOLIPOFEN 3 MOlovastatin tabs 10mg 1 QL(90 per90 days)MOlovastatin tabs 20mg, 40mg 1 QL(180 per90 days)MOLOVAZA 3 MONIASPAN 3 MOpravastatin sodium tabs 10mg,20mg, 80mg2 QL(90 per90 days)MOpravastatin sodium tabs 40mg 2 QL(180 per90 days)MOprevalite powd 2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)simvastatin 2 QL(90 per90 days)MOTRILIPIX 3 MOVASCEPA 3 MOWELCHOL 3 MOZETIA 3 QL(90 per90 days)MOMISCELLANEOUS CARDIOVASCULARAGENTSRANEXA 3 MONITRATESisosorbide dinitrate 1 MOisosorbide dinitrate er 1 MOisosorbide mononitrate 2 MOisosorbide mononitrate er 2 MOnitro-bid 2 MONITRO-DUR PT24 0.3MG/HR, 3 MO0.8MG/HRnitroglycerin inj 2 B/D PAnitroglycerin pt24 2 MOnitroglycerin transdermal pt240.1mg/hr2 MONITROLINGUAL PUMPSPRAY 3 MONITROSTAT 3 MODERMATOLOGICALS/TOPICALTHERAPYANTIPSORIATIC / ANTISEBORRHEICcalcipotriene 2 MOselenium sulfide lotn 2 MOSORIATANE 3 MOBURN THERAPYsilver sulfadiazine 2 MOssd 2 MOMISCELLANEOUS DERMATOLOGICALS8-MOP 3 MOammonium lactate 2 MOCARAC 3 MO24

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)CARMOL-HC 3 MOCONDYLOX GEL 3 MOELIDEL 4 MOFLUOROPLEX 3 MOfluorouracil crea 2 MOfluorouracil external soln 2 MOimiquimod 2 MOlaclotion 2 MOOXSORALEN ULTRA 5 MOPANRETIN 3 MOpodofilox 2 MOPROTOPIC 4 MOprudoxin 2 MOREGRANEX 3 PA MOSOLARAZE 4 MOUVADEX 4VEREGEN 4 MOTHERAPY FOR ACNEadapalene 2 MOamnesteem 2 MOavita crea 2 MOAZELEX 3 MOclaravis caps 10mg, 20mg, 40mg 3 MOclaravis caps 30mg 5 MOclindamycin phosphate external 2 MOsolnclindamycin phosphate foam 2 MOclindamycin phosphate gel 2 MOclindamycin phosphate lotn 2 MOclindamycin phosphate swab 2 MOclindamycin/benzoyl peroxide gel 2 MO5%; 1%DIFFERIN GEL 0.3% 3 MODIFFERIN LOTN 3 MOery 2 MOerythromycin external soln 2 MOerythromycin gel 2 MOerythromycin/benzoyl peroxide 2 MOFINACEA 3 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)METROGEL 3 MOmetronidazole crea 2 MOmetronidazole gel 0.75% 2 MOmetronidazole lotn 2 MOmyorisan 2 MOTAZORAC 3 MOtretinoin 2 MOTOPICAL ANESTHETICSlidocaine hcl external soln 2 MOlidocaine hcl inj 0.5%, 1% 2 MOlidocaine hcl jelly 2 MOlidocaine oint 2 MOlidocaine viscous 2 MOlidocaine/prilocaine crea 2 MOLIDODERM 3 PA MOTOPICAL ANTIBACTERIALSALTABAX 3 MOBACTROBAN CREA 3 MOgentamicin sulfate crea 1 MOgentamicin sulfate oint 0.1% 1 MOmafenide acetate 2mupirocin 2 MOPHISOHEX 3 MOsulfacetamide sodium susp 2 MOSULFAMYLON 3 MOTOPICAL ANTIFUNGALSciclopirox 2 MOciclopirox nail lacquer 2 MOciclopirox olamine 2 MOclotrimazole external crea 2 MOclotrimazole external soln 2 MOclotrimazole/betamethasone 2 MOdipropionateeconazole nitrate 2 MOketoconazole 2 MOketodan kit 2 MONAFTIN CREA 1% 3 MONAFTIN GEL 1% 3 MOnyamyc 2 MO25

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)nystatin crea 2 MOnystatin oint 2 MOnystatin powd 100000unit/gm 2 MOnystatin/triamcinolone 2 MOnystop 2 MOpedi-dri 2 MOTOPICAL ANTIVIRALSacyclovir 2 MODENAVIR 3 MOZOVIRAX CREA 4 MOZOVIRAX OINT 4 MOTOPICAL CORTICOSTEROIDSala cort 1 MOalclometasone dipropionate 2 MOamcinonide 2 MOaugmented betamethasone 2 MOdipropionatebetamethasone dipropionate 2 MObetamethasone valerate 1 MOCAPEX 3 MOclobetasol propionate e 2 MOclobetasol propionate external 2 MOsolnclobetasol propionate foam 2 MOclobetasol propionate gel 2 MOclobetasol propionate lotn 2 MOclobetasol propionate oint 2 MOclobetasol propionate sham 2 MOCORDRAN TAPE 3 MODERMA-SMOOTHE/FS BODY 3 MOOILdesonide 2 MOdesoximetasone 2 MOdiflorasone diacetate 2 MOfluocinolone acetonide 2 MOfluocinolone acetonide body 1 MOfluocinonide external soln 2 MOfluocinonide gel 2 MOfluocinonide oint 2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)fluocinonide-e 2 MOfluticasone propionate 2 MOhalobetasol propionate 2 MOhydrocortisone butyrate 2 MOhydrocortisone crea 1%, 2.5% 2 MOhydrocortisone lotn 2.5% 2 MOhydrocortisone oint 1%, 2.5% 2 MOhydrocortisone valerate 2 MOLOCOID LOTN 3 MOLUXIQ 3 MOmometasone furoate crea 2 MOmometasone furoate external soln 2 MOmometasone furoate oint 2 MOPANDEL 3 MOprednicarbate 2 MOtriamcinolone acetonide crea 2 MOtriamcinolone acetonide lotn 2 MOtriamcinolone acetonide oint 2 MOtriderm 2 MOTOPICAL ENZYMESSANTYL 3 MOTOPICAL SCABICIDES / PEDICULICIDESEURAX 3 MOlindane 2 QL(1800per 365days) MOmalathion 2 MOpermethrin crea 2 MOSKLICE 3 MOspinosad 2 QL(720 per90 days)MOULESFIA 4 MODIAGNOSTICS / MISCELLANEOUSAGENTSMISCELLANEOUS AGENTSACTONEL TABS 30MG 4 PA QL(60per 120days) MO26

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)ADAGEN 5 LA MOalendronate sodium tabs 40mg 2 QL(180 per365 days)MOanagrelide hydrochloride 2 MOANTABUSE TABS 250MG 3 MOARALAST NP INJ 400MG 5 LA MOBUPHENYL 3 MOCAMPRAL 3 QL(540 per90 days)MOCARBAGLU 5 LA MOcevimeline hcl 2 MOCHEMET 3 MOCLINIMIX 4.25%/DEXTROSE 35%dextrose 10%/nacl 0.45% 2dextrose 10% flex container 2dextrose 10%/nacl 0.2% 2dextrose 2.5%/sodium chloride 20.45%dextrose 5% 2 MOdextrose 5%/lactated ringers 2 MOdextrose 5%/nacl 0.2% 2dextrose 5%/nacl 0.225% 2dextrose 5%/nacl 0.33% 2dextrose 5%/nacl 0.45% 2 MOdextrose 5%/nacl 0.9% 2 MOdisulfiram 2 MOetidronate disodium 2 MOEVOXAC 3 MOEXJADE TBSO 125MG 3 LA MOEXJADE TBSO 250MG, 500MG 5 LA MOFOSRENOL 3 MOINCRELEX 5 LA PA MOkionex powd 2 MOlevocarnitine oral soln2 B/D PA MOlevocarnitine tabs2 B/D PA MOmidodrine hcl 2 MOORFADIN 5 LA MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)pilocarpine hcl tabs 2 MOpilocarpine hydrochloride 2 MOPROLASTIN-C 5 LA MORAVICTI 5 MORECLAST 4 MORENVELA 3 MORILUTEK 5 MOriluzole 2 MOSKELID 4 PA QL(180per 90 days)MOsodium chloride 0.9% 2 MOsodium chloride inj 0.9% 2 MOsodium phenylbutyrate 2 MOsodium polystyrene sulfonate susp 2 MO15gm/60mlSYPRINE 3 MOzoledronic acid inj 5mg/100ml 2 MOSMOKING DETERRENTSbuproban 2 PA QL(180per 90 days)MOCHANTIX 3 PA QL(168per 90 days)MOCHANTIX STARTING MONTHPAK3 PA MONICOTROL INHALER 4 PAQL(1008per 90 days)MONICOTROL NS 4 PA QL(120per 90 days)MOEAR, NOSE / THROATMEDICATIONSMISCELLANEOUS AGENTSASTEPRO 3 MOazelastine hcl 2 MOBACTROBAN NASAL 3 MO27

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)chlorhexidine gluconate oral 1 MOrinseipratropium bromide nasal soln 2 MOperiogard 1 MOtriamcinolone in orabase 1 MOTYZINE 3 MOTYZINE PEDIATRIC NASAL 3 MODROPSMISCELLANEOUS OTICPREPARATIONSacetasol hc 2 MOacetic acid otic soln 2 MODERMOTIC 3 MOfluocinolone acetonide 2 MOhydrocortisone/acetic acid 2 MOofloxacin 2 MOOTIC STEROID / ANTIBIOTICCIPRO HC 4 MOCIPRODEX 3 MOCOLY-MYCIN S 3 MOCORTISPORIN-TC 3 MOneomycin/polymyxin/hc 2 MOneomycin/polymyxin/hydrocortisone otic susp2 MOENDOCRINE/DIABETESADRENAL HORMONESa-hydrocort 2 MOACTHAR HP 5 PA MOcortisone acetate 2 MODEPO-MEDROL 3 MOdexamethasone elix 2 MOdexamethasone intensol 2 MOdexamethasone sodium phosphate 2 MOinj 4mg/mldexamethasone tabs 0.5mg, 2 MO0.75mg, 1.5mg, 4mg, 6mgdexamethasone tabs 1mg, 2mg 1 MOfludrocortisone acetate 2 MOhydrocortisone tabs 2 MOmethylprednisolone2 B/D PA MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)methylprednisolone acetate 2 MOmethylprednisolone dose pack 2 MOmethylprednisolonesodiumsuccinate inj 125mg, 1gm,40mg2 MOprednisolone sodium phosphate 2 B/D PAoral soln 25mg/5mlprednisolone sodium phosphate 2 B/D PA MOoral soln 15mg/5ml, 5mg/5mlprednisone1 B/D PA MOprednisone intensol1 B/D PA MOSOLU-CORTEF INJ 100MG, 3 MO250MGSOLU-MEDROL INJ 2GM 3SOLU-MEDROL INJ 125MG, 3 MO40MG, 500MGANTITHYROID AGENTSmethimazole 2 MOpropylthiouracil 2 MODIABETES THERAPYacarbose 2 QL(270 per90 days)MOACTOPLUS MET 3 QL(270 per90 days)MOACTOS 3 QL(90 per90 days)MOalcohol preps pads 2 MOAPIDRA 4 QL(180 per90 days)MOAPIDRA SOLOSTAR 4 QL(180 per90 days)MOAVANDAMET 3 QL(180 per90 days)MOAVANDARYL TABS 2MG;8MG, 4MG; 4MG, 4MG; 8MG3 QL(90 per90 days)MO28

Drug Name(Nombre del medicamento)AVANDARYL TABS 1MG;4MG, 2MG; 4MGDrug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)3 QL(180 per90 days)MOAVANDIA TABS 8MG 3 QL(90 per90 days)MOAVANDIA TABS 2MG, 4MG 3 QL(180 per90 days)MOBYDUREON 3 MOBYETTA 3 MODUETACT 3 QL(90 per90 days)MOGAUZE PADS 2"X2" 3 MOglimepiride tabs 1mg, 2mg 1 QL(90 per90 days)MOglimepiride tabs 4mg 1 QL(180 per90 days)MOglipizide er tb24 2.5mg, 5mg 2 QL(90 per90 days)MOglipizide er tb24 10mg 2 QL(180 per90 days)MOglipizide tabs 10mg 1 QL(360 per90 days)MOglipizide tabs 5mg 1 QL(720 per90 days)MOglipizide/metformin hcl 2 QL(360 per90 days)MOGLUCAGEN HYPOKIT 3 MOGLUCAGON EMERGENCY 3 MOKITglyburide micronized 1 QL(180 per90 days)MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)glyburide tabs 1.25mg, 2.5mg 2 QL(180 per90 days)MOglyburide tabs 5mg 2 QL(360 per90 days)MOglyburide/metformin hcl tabs1.25mg; 250mg, 2.5mg; 500mgglyburide/metformin hcl tabs5mg; 500mg2 QL(180 per90 days)MO2 QL(360 per90 days)MOHUMALOG 3 QL(60 per30 days)MOHUMALOG KWIKPEN 3 QL(60 per30 days)MOHUMALOG MIX 50/50 3 QL(60 per30 days)MOHUMALOG MIX 50/50KWIKPEN3 QL(60 per30 days)MOHUMALOG MIX 75/25 3 QL(60 per30 days)MOHUMALOG MIX 75/25KWIKPEN3 QL(60 per30 days)MOHUMULIN 70/30 3 QL(60 per30 days)MOHUMULIN 70/30 PEN 3 QL(60 per30 days)MOHUMULIN N 3 QL(60 per30 days)MOHUMULIN N U-100 PEN 3 QL(60 per30 days)MOHUMULIN R 3 QL(60 per30 days)MO29

Drug Name(Nombre del medicamento)HUMULIN R U-500(CONCENTRATED)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)3 QL(60 per30 days)MOINSULIN PEN NEEDLE 3 MOINSULIN SYRINGE (DISP) U- 3 MO100 0.3 MLINSULIN SYRINGE (DISP) U- 3 MO100 1 MLINSULIN SYRINGE (DISP) U- 3 MO100 1/2 MLINVOKANA TABS 300MG 3 QL(90 per90 days)MOINVOKANA TABS 100MG 3 QL(270 per90 days)MOJANUMET 3 QL(180 per90 days)MOJANUMET XR TB24 1000MG;100MGJANUMET XR TB24 1000MG;50MG, 500MG; 50MG3 QL(90 per90 days)MO3 QL(180 per90 days)MOJANUVIA 3 QL(90 per90 days)MOJENTADUETO 3 QL(180 per90 days)MOJUVISYNC TABS 10MG;50MG, 20MG; 50MG, 40MG;50MGJUVISYNC TABS 10MG;100MG, 20MG; 100MG, 40MG;100MGKOMBIGLYZE XR TB241000MG; 5MG, 500MG; 5MGKOMBIGLYZE XR TB241000MG; 2.5MG3 MO3 QL(90 per90 days)MO3 QL(90 per90 days)MO3 QL(180 per90 days)MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)LANTUS 3 QL(30 per30 days)MOLANTUS SOLOSTAR 3 QL(30 per30 days)MOLEVEMIR 3 QL(90 per90 days)MOLEVEMIR FLEXPEN 3 QL(90 per90 days)MOmetformin hcl er tb24 1000mg 1 QL(180 per90 days)MOmetformin hcl er tb24 750mg 1 QL(270 per90 days)MOmetformin hcl er tb24 500mg 1 QL(450 per90 days)MOmetformin hcl tabs 1000mg 1 QL(180 per90 days)MOmetformin hcl tabs 850mg 1 QL(270 per90 days)MOmetformin hcl tabs 500mg 1 QL(450 per90 days)MOnateglinide 2 QL(270 per90 days)MONEEDLES, INSULIN DISP., 3 MOSAFETYNOVOLOG 3 QL(60 per30 days)MONOVOLOG FLEXPEN 3 QL(60 per30 days)MONOVOLOG MIX 70/30 3 QL(60 per30 days)MO30

Drug Name(Nombre del medicamento)NOVOLOG MIX 70/30PREFILLED FLEXPENDrug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)3 QL(60 per30 days)MOONGLYZA 3 QL(90 per90 days)MOpioglitazone hcl 2 QL(90 per90 days)MOpioglitazone hcl-glimepiride 2 QL(90 per90 days)MOpioglitazone hcl/metformin hcl 2 QL(270 per90 days)MOPRANDIN TABS 0.5MG, 1MG 3 QL(360 per90 days)MOPRANDIN TABS 2MG 3 QL(720 per90 days)MOPROGLYCEM 3 MOSYMLINPEN 120 4 QL(33 per90 days)MOSYMLINPEN 60 4 QL(33 per90 days)MOtolazamide 2 MOtolbutamide 2 MOTRADJENTA 3 QL(90 per90 days)MOVICTOZA 3 MOMISCELLANEOUS HORMONESALDURAZYME 5 LA MOANDRODERM 3 PA MOANDROGEL GEL 50MG/5GM 3 PA MOANDROGEL PUMP GEL 1.62% 3 PA MOANDROID 3 PA MOandroxy 3 PA MOcabergoline 2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)calcitonin-salmon 2 QL(12 per90 days)MOcalcitriol caps2 B/D PA MOcalcitriol inj2 B/D PA MOcalcitriol oral soln2 B/D PA MOCEREZYME INJ 200UNIT 5 LA MOdanazol 2 MOdesmopressin acetate 2 MOFABRAZYME INJ 35MG 5 LA MOfortical 2 QL(12 per90 days)MOKUVAN 5 LA MONAGLAZYME 5 LA MOoxandrolone tabs 10mg 5 PA MOoxandrolone tabs 2.5mg 3 PA MOSAMSCA TABS 30MG 5 QL(730 per365 days)MOSAMSCA TABS 15MG 5 QL(1460per 365days) MOSENSIPAR TABS 60MG, 90MG 5 MOSENSIPAR TABS 30MG 3 MOSOMAVERT 3 PA MOSTIMATE 3 MOSYNAREL 4 MOtestosterone cypionate 2 PA MOtestosterone enanthate 2 PA MOZAVESCA 3 LA MOZEMPLAR3 B/D PA MOzoledronic acid inj 4mg/5ml 2 QL(30 per90 days)MOZOMETA INJ 4MG/5ML 5 QL(30 per90 days)MOTHYROID HORMONESlevothyroxine sodium tabs 1 MOlevoxyl 2 MO31

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)liothyronine sodium tabs 2 MOunithroid tabs 100mcg, 112mcg,125mcg, 150mcg, 175mcg,200mcg, 25mcg, 300mcg, 50mcg,75mcg, 88mcg1 MOGASTROENTEROLOGYANTIDIARRHEALS / ANTISPASMODICSatropine sulfate inj 0.05mg/ml, 20.1mg/mldicyclomine hcl caps 2 MOdicyclomine hcl oral soln 2 MOglycopyrrolate inj 4mg/20ml 2 MOglycopyrrolate tabs 2 MOloperamide hcl caps 2 MOpropantheline bromide 2 MOMISCELLANEOUS GASTROINTESTINALAGENTSAMITIZA 3 MOAPRISO 3 MOASACOL 3 MOASACOL HD 3 MObalsalazide disodium 2 MObudesonide cp24 2 MOCANASA 3 MOCIMZIA 5 PA QL(6per 28 days)MOcompro 2 MOconstulose 1 MOCORTIFOAM 3 MOCREON 3 MOcromolyn sodium conc 2 MOCYSTADANE 3 MODELZICOL 3 MODIPENTUM 4 MOdronabinol2 B/D PA MOEMEND CAPS 40MG 3 B/D PAQL(3 per 90days) MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)EMEND CAPS 125MG 3 B/D PAQL(6 per 90days) MOEMEND CAPS 3 B/D PAQL(18 per90 days)MOEMEND CAPS 80MG 3 B/D PAQL(24 per90 days)MOENTOCORT EC 3 MOenulose 2 MOGASTROCROM 3 MOgavilyte-c 2 QL(4000per 30 days)MOgavilyte-g 2 QL(4000per 30 days)MOgavilyte-n/flavor pack 2 QL(4000per 30 days)MOgenerlac 1 MOgranisetron hcl inj 0.1mg/ml,1mg/ml2 QL(42 per90 days)MOgranisetron hcl tabs 2 B/D PAQL(180 per90 days)MOHALFLYTELY BOWELPREP/FLAVOR PACKS3 QL(6 per 90days) MOhydrocortisone enem 2 MOlactulose 2 MOLIALDA 3 MOLINZESS 3 MOLOTRONEX 3 QL(180 per90 days)MOmeclizine hcl tabs 2 MOmetoclopramide hcl 1 MO32

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)MOVIPREP 4 QL(6 per 90days) MOondansetron hcl inj 4mg/2ml 2 MOondansetron hcl oral soln 2 B/D PA MOondansetron hcl tabs 24mg 2 B/D PAQL(21 per90 days)ondansetron hcl tabs 4mg, 8mg 2 B/D PAQL(135 per90 days)MOondansetron odt 2 B/D PAQL(135 per90 days)MOPENTASA 3 MOpolyethylene glycol 3350 powd 2 MOprochlorperazine 2 MOprochlorperazine edisylate 2 MOprochlorperazine maleate 1 MOprocto-pak 1 MOproctozone-hc 1 MORECTIV 3 MORELISTOR INJ 12MG/0.6ML 3 MOREMICADE 5 PA MOSANCUSO 3 QL(6 per 90days) MOSUCRAID 5 MOsulfasalazine tabs 2 MOsulfazine ec 2 MOSUPREP BOWEL PREP 3 MOTRANSDERM-SCOP 3 MOtrilyte 2 QL(4000per 30 days)MOUCERIS 5 MOursodiol 2 MOZENPEP 3 MOULCER THERAPYcarafate susp 2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)DEXILANT 4 QL(90 per90 days) STMOfamotidine inj 1 MOfamotidine premixed 2famotidine susr 1 MOfamotidine tabs 20mg, 40mg 1 MOlansoprazole 2 QL(180 per90 days)MOmisoprostol 2 MONEXIUM 3 QL(90 per90 days)MONEXIUM I.V. INJ 20MG 3NEXIUM I.V. INJ 40MG 3 MOnizatidine 2 MOomeprazole cpdr 40mg 2 QL(90 per90 days)MOomeprazole cpdr 10mg, 20mg 2 QL(180 per90 days)MOomeprazole/sodium bicarbonate 2 QL(90 per90 days)MOpantoprazole sodium inj 2pantoprazole sodium tbec 2 QL(180 per90 days)MOPREVPAC 4 MOPYLERA 3 MOranitidine hcl caps 1 MOranitidine hcl syrp 1 MOranitidine hcl tabs 150mg, 300mg 1 MOsucralfate 2 MOZANTAC INJ 50MG/50ML;0.45%IMMUNOLOGY, VACCINES /BIOTECHNOLOGYBIOTECHNOLOGY DRUGS3 MO33

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)ACTIMMUNE 5 LA MOARANESP ALBUMIN FREE 3 PA QL(3INJ 500MCG/MLper 90 days)ARANESP ALBUMIN FREEINJ 150MCG/0.3MLARANESP ALBUMIN FREEINJ 200MCG/0.4MLARANESP ALBUMIN FREEINJ 100MCG/0.5MLARANESP ALBUMIN FREEINJ 300MCG/0.6ML,60MCG/0.3MLARANESP ALBUMIN FREEINJ 40MCG/0.4MLARANESP ALBUMIN FREEINJ 25MCG/0.42MLARANESP ALBUMIN FREEINJ 100MCG/ML, 200MCG/ML,300MCG/MLARANESP ALBUMIN FREEINJ 25MCG/ML, 40MCG/ML,MO3 PA QL(3.6per 90 days)MO3 PA QL(4.8per 90 days)MO3 PA QL(6per 90 days)MO3 PA QL(7.2per 90 days)MO3 PA QL(9.6per 90 days)MO3 PAQL(10.08per 90 days)MO3 PA QL(12per 90 days)MO3 PA QL(24per 90 days)MO60MCG/MLARCALYST 5 LA MOAVONEX 5 PA QL(12per 90 days)MOBETASERON 5 PA QL(45per 90 days)MOEPOGEN INJ 20000UNIT/ML,2000UNIT/ML, 3000UNIT/ML,4000UNIT/ML4 PA QL(36per 90 days)MOEPOGEN INJ 10000UNIT/ML 4 PA QL(72per 90 days)MOINTRON-A INJ 10MU/0.2ML 4 PAINTRON-A INJ 3MU/0.2ML 3 PADrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)INTRON-A INJ3 PA MO6000000UNIT/MLINTRON-A INJ 5MU/0.2ML 5 PAINTRON-A W/DILUENT INJ 5 PA MO10MULEUKINE 5 PA MOMOZOBIL 5 QL(4.8 per90 days)MONEULASTA 4 PA QL(3.6per 90 days)MONEUMEGA 5 PA QL(63per 90 days)MONEUPOGEN INJ300MCG/0.5MLNEUPOGEN INJ480MCG/0.8ML5 PA QL(21per 90 days)MO5 PA QL(33.6per 90 days)MONEUPOGEN INJ480MCG/1.6ML5 PA QL(67.2per 90 days)MONORDITROPIN FLEXPRO 5 PA MONORDITROPIN NORDIFLEX 5 PA MOPENOMNITROPE INJ 5MG/1.5ML 4 PA MOPEG-INTRON INJ50MCG/0.5ML5 PA QL(12per 90 days)MOPEG-INTRON REDIPEN 5 PA QL(12per 90 days)MOPEGASYS INJ 180MCG/0.5ML 5 PA QL(6per 90 days)MOPEGASYS INJ 180MCG/ML 5 PA QL(12per 90 days)MOPEGASYS PROCLICK INJ135MCG/0.5ML5 PA QL(12per 90 days)MO34

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)PROCRIT INJ 40000UNIT/ML 3 PA QL(18per 90 days)MOPROCRIT INJ 10000UNIT/ML,20000UNIT/ML, 2000UNIT/ML,3000UNIT/ML, 4000UNIT/ML3 PA QL(36per 90 days)MOPROLEUKIN 5 MOREBIF 5 PA QL(18per 90 days)MOREBIF TITRATION PACK 5 PA MOSYLATRON INJ 888MCG 5 PA QL(8per 90 days)MOSYLATRON INJ 296MCG,444MCG5 PA QL(12per 90 days)MOVACCINES / MISCELLANEOUSIMMUNOLOGICALSACTHIB 3ADACEL 3 MOBOOSTRIX 3 MOCERVARIX 3 PA MOCOMVAX 3 MODAPTACEL 3 MODECAVAC 3 MOENGERIX-B INJ 10MCG/0.5ML 3 B/D PAENGERIX-B INJ 20MCG/ML 3 B/D PA MOGARDASIL 3 PA MOHAVRIX INJ 720ELU/0.5ML 3HAVRIX INJ 1440ELU/ML 3 MOIMOVAX RABIES (H.D.C.V.) 3 MOINFANRIX 3IPOL INACTIVATED IPV 3 MOIXIARO 3 MOM-M-R II W/DILUENT 10 3 MODOSEMENACTRA 3 MOMENOMUNE-A/C/Y/W-135 3 MOMENVEO 3 MOPEDVAX HIB 3 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)PRIVIGEN INJ 20GM/200ML 5 PA MOPROQUAD 3RABAVERT 3 MORECOMBIVAX HB INJ 3 B/D PA MO10MCG/ML, 40MCG/MLROTATEQ 3tetanus toxoid adsorbed 2 MOTETANUS/DIPHTHERIATOXOIDS-ADSORBED ADULT3 MOTHYMOGLOBULIN 3TWINRIX 3 MOTYPHIM VI 3VAQTA INJ 25UNIT/0.5ML 3 MOVARIVAX 3 MOYF-VAX 3 MOZOSTAVAX 3 PA MOMUSCULOSKELETAL /RHEUMATOLOGYGOUT THERAPYallopurinol 1 MOCOLCRYS 3 QL(360 per90 days)MOprobenecid 2 MOprobenecid/colchicine 2 MOULORIC 3 MOOSTEOPOROSIS THERAPYACTONEL TABS 150MG 4 QL(3 per 90days) MOACTONEL TABS 35MG 4 QL(12 per90 days)MOACTONEL TABS 5MG 4 QL(90 per90 days)MOalendronate sodium oral soln 2 MOalendronate sodium tabs 35mg,70mg2 QL(12 per90 days)MO35

Drug Name(Nombre del medicamento)alendronate sodium tabs 10mg,5mgDrug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)2 QL(90 per90 days)MOATELVIA 3 QL(12 per90 days)MOEVISTA 3 QL(90 per90 days)MOFORTEO 3 QL(7.2 per90 days)MOibandronate sodium 2 MOPROLIA 4 ST MOOTHER RHEUMATOLOGICALSDEPEN TITRATABS 3 MOENBREL 5 PA QL(600per 90 days)MOHUMIRA INJ 20MG/0.4ML 5 PA QL(2.4per 90 days)MOHUMIRA INJ 40MG/0.8ML 5 PA QL(4.8per 90 days)MOHUMIRA PEN-CROHNS 5 PA MODISEASESTARTERleflunomide tabs 10mg 2 QL(90 per90 days)MOleflunomide tabs 20mg 2 QL(102 per90 days)MOORENCIA INJ 125MG/ML 5 PA QL(12per 90 days)MORIDAURA 4 MOSAVELLA 3 QL(180 per90 days)MOSAVELLA TITRATION PACK 3 MOSIMPONI INJ 50MG/0.5ML 5 PA QL(1per 30 days)MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)XELJANZ 5 PA MOOBSTETRICS / GYNECOLOGYESTROGENS / PROGESTINSALORA 3 MOcamila 2 MOCLIMARA PRO 3 MOCOMBIPATCH 3 MOCRINONE GEL 4% 3 MOCRINONE GEL 8% 3 PA MODELESTROGEN INJ 10MG/ML 4 MODEPO-PROVERA 3 MODEPO-SUBQ PROVERA 104 4 MODIVIGEL GEL 1MG/GM 3 MOerrin 2 MOESTRACE CREA 3 MOestradiol 1 MOestradiol valerate 2 MOestradiol/norethindrone acetate 2 MOESTRING 4 QL(1 per 90days) MOestropipate 1 MOjinteli 2 MOjolivette 2 MOmedroxyprogesterone acetate 1 MOMENEST 4 MOnora-be 2 MOnorethindrone acetate 2 MOPREFEST 4 MOPREMARIN CREA 3 MOPREMARIN TABS 3 MOPREMPHASE 3 MOPREMPRO 3 MOprogesterone caps 2 MOVAGIFEM 3 MOVIVELLE-DOT 3 MOMISCELLANEOUS OB/GYNCLEOCIN SUPP 3 MOclindamycin phosphate crea 2 MOGYNAZOLE-1 3 MO36

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)LYSTEDA 4 QL(120 per90 days)MOmetronidazole vaginal 2 MOmiconazole 3 2 MONUVARING 4 MOORTHO EVRA 4 MOterconazole 2 MOtranexamic acid tabs 2 QL(120 per90 days)MOvandazole 2 MOzazole crea 0.4% 2ORAL CONTRACEPTIVES / RELATEDAGENTSamethia 2 MOamethyst 2 MOapri 2 MOaranelle 2 MOaviane 2 MObalziva 2 MObriellyn 2 MOcryselle-28 2 MOcyclafem 1/35 2 MOcyclafem 7/7/7 2 MOdrospirenone/ethinyl estradiol 2 MOELLA 3 MOemoquette 2 MOenpresse-28 2 MOgianvi 2 MOgildagia 2 MOintrovale 2 MOjunel 1.5/30 2 MOjunel 1/20 2 MOjunel fe 1.5/30 2 MOjunel fe 1/20 2 MOkariva 2 MOkelnor 1/35 2 MOleena 2 MOlessina 2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)levonest 2 MOlevonorgestrel/ethinyl estradiol 2 MOtabs 0.03mg; 0.15mglevora 0.15/30-28 2 MOloryna 2 MOlow-ogestrel 2 MOlutera 2 MOmarlissa 2 MOmicrogestin 1.5/30 2 MOmicrogestin 1/20 2 MOmicrogestin fe 2 MOmicrogestin fe 1.5/30 2 MOmononessa 2 MOnecon 0.5/35-28 2 MOnecon 1/35 2 MOnecon 10/11-28 2 MOnecon 7/7/7 2 MOnortrel 0.5/35 (28) 2 MOnortrel 1/35 2 MOnortrel 7/7/7 2 MOocella 2 MOogestrel 2 MOorsythia 2 MOportia-28 2 MOprevifem 2 MOquasense 2 MOreclipsen 2 MOsprintec 28 2 MOsronyx 2 MOtri-legest fe 2 MOtri-previfem 2 MOtri-sprintec 2 MOtrinessa 2 MOtrivora-28 2 MOvelivet 2 MOvestura 2 MOzenchent fe 2 MOzeosa 2 MOzovia 1/35e 2 MO37

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)zovia 1/50e 2 MOOXYTOCICSMETHERGINE 3 MOmethylergonovine maleate tabs 2 MOOPHTHALMOLOGYANTIBIOTICSAZASITE 3 MObacitracin ophthalmic oint 2 MObacitracin/polymyxin b 2 MOBESIVANCE 3 MOCILOXAN OINT 3 MOciprofloxacin hcl 1 MOerythromycin oint 2 MOgentak oint 2 MOgentamicin sulfate ophthalmic 1 MOsolnlevofloxacin 2 MOMOXEZA 3 MONATACYN 3 MOneomycin/bacitracin/polymyxin 2 MOneomycin/polymyxin/gramicidin 2 MOofloxacin 2 MOtobramycin sulfate ophthalmic 1 MOsolnTOBREX OINT 3 MOtrimethoprim sulfate/polymyxin b 2 MOsulfateVIGAMOX 3 MOZYMAXID 3 MOANTIVIRALStrifluridine 2 MOZIRGAN 4 MOBETA-BLOCKERSbetaxolol hcl 2 MOBETOPTIC-S 3 MOcarteolol hcl 2 MOISTALOL 3 MOlevobunolol hcl ophthalmic soln0.5%2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)metipranolol 2 MOtimolol maleate 2 MOtimolol maleate ophthalmic gel 2 MOformingTIMOPTIC OCUDOSE 3 MODIRECT ACTING MIOTICSPILOPINE HS 3 MOMISCELLANEOUS OPHTHALMOLOGICSALOCRIL 4 MOazelastine hcl 2 MOBEPREVE 3 MOcromolyn sodium ophthalmic soln 2 MOCYSTARAN 5 MOepinastine hcl 2 MOLACRISERT 3 MOLASTACAFT 3 MOPATADAY 3 MOPATANOL 3 MORESTASIS 3 MONON-STEROIDAL ANTI-INFLAMMATORY AGENTSACUVAIL 3 MOBROMDAY 3 MObromfenac 2 MOdiclofenac sodium 2 MOflurbiprofen sodium 2 MOILEVRO 3 MOketorolac tromethamine2 MOophthalmic solnNEVANAC 3 MOPROLENSA 3 MOORAL DRUGS FOR GLAUCOMAacetazolamide 2 MOacetazolamide er 2 MOacetazolamide sodium 2methazolamide 2 MOOTHER GLAUCOMA DRUGSAZOPT 3 MOCOMBIGAN 3 MO38

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)dorzolamide hcl 2 MOdorzolamide hcl/timolol maleate 2 MOlatanoprost 2 MOLUMIGAN 3 MOTRAVATAN Z 3 MOtravoprost 2 MOSTEROID-ANTIBIOTIC COMBINATIONSneomycin/polymyxin/bacitracin/h 2 MOydrocortisoneneomycin/polymyxin/dexamethaso 2 MOneneomycin/polymyxin/hydrocortiso 2 MOne ophthalmic suspTOBRADEX OINT 3 MOTOBRADEX ST 3 MOtobramycin/dexamethasone 2 MOZYLET 3 MOSTEROID-SULFONAMIDECOMBINATIONSBLEPHAMIDE 4 MOBLEPHAMIDE S.O.P. 4 MOsulfacetamide2 MOsodium/prednisolone sodiumphosphateSTEROIDSALREX 3 MOdexamethasone sodium phosphate 2 MOophthalmic solnDUREZOL 3 MOFML 3 MOFML FORTE 3 MOLOTEMAX 3 MOprednisolone acetate 2 MOprednisolone sodium phosphate 2 MOophthalmic solnSULFONAMIDESBLEPH-10 3 MOsodium sulfacetamide ophthalmic 2 MOsolnsulfacetamide sodium oint 2 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)SYMPATHOMIMETICSALPHAGAN P 3 MOapraclonidine 2 MObrimonidine tartrate 2 MOIOPIDINE OPHTHALMICSOLN 1%4 MOVASOCONSTRICTOR DECONGESTANTSnaphazoline hcl 1 MORESPIRATORY AND ALLERGYANTIHISTAMINE / ANTIALLERGENICAGENTScarbinoxamine maleate 2 MOcetirizine hcl syrp 2 MOclemastine fumarate syrp 2 MOclemastine fumarate tabs 2.68mg 2 MOdesloratadine 2 MOdesloratadine odt 2 MOepinephrine hcl inj 0.1mg/ml 2 MOEPIPEN 2-PAK 3 MOEPIPEN-JR 2-PAK 3 MOhydroxyzine hcl 2 MOlevocetirizine dihydrochloride 2 MOoral solnlevocetirizine dihydrochloridetabs2 QL(90 per90 days)MOpalgic liqd 2 MOphenadoz 2 MOpromethazine hcl inj 25mg/ml 2promethazine hcl inj 50mg/ml 2 MOpromethazine hcl supp 2 MOpromethazine hcl syrp 2 MOpromethazine hcl tabs 2 MOpromethegan supp 25mg, 50mg 2 MOTWINJECT 3 MOPULMONARY AGENTSacetylcysteine inhalation soln 2 B/D PA MOADVAIR DISKUS 3 QL(180 per90 days)MO39

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)ADVAIR HFA 3 QL(36 per90 days)MOalbuterol sulfate er 2 MOalbuterol sulfate nebu2 B/D PA MOalbuterol sulfate syrp 2 MOalbuterol sulfate tabs 2 MOALVESCO 4 QL(37 per90 days)MOARCAPTA NEOHALER 4 QL(90 per90 days)MOASMANEX 120 METEREDDOSES3 QL(3 per 90days) MOASMANEX 14 METEREDDOSES3 QL(3 per 90days) MOASMANEX 30 METEREDDOSES3 QL(3 per 90days) MOASMANEX 60 METEREDDOSES3 QL(3 per 90days) MOATROVENT HFA 3 QL(77.4 per90 days)MObudesonide susp2 B/D PA MOCINRYZE 5 LA PAQL(60 per90 days)MOCOMBIVENT 3 QL(88.2 per90 days)MOCOMBIVENT RESPIMAT 3 QL(20 per90 days)MOcromolyn sodium nebu2 B/D PA MODALIRESP 3 QL(90 per90 days)MODULERA 4 QL(39 per90 days)MOELIXOPHYLLIN 4 MOFIRAZYR 5 MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)FLOVENT DISKUS 3 QL(360 per90 days)MOFLOVENT HFA 3 QL(72 per90 days)MOflunisolide nasal soln 0.025% 2 MOfluticasone propionate 2 MOFORADIL AEROLIZER 3 QL(180 per90 days)MOipratropium bromide inhalation 2 B/D PA MOsolnipratropium bromide/albuterol 2 B/D PA MOsulfateKALYDECO 5 PA QL(180per 90 days)MOLETAIRIS 5 LA PAQL(90 per90 days)MOlevalbuterol2 B/D PA MOlevalbuterol hcl nebu 0.31mg/3ml, 2 B/D PA MO0.63mg/3mlmetaproterenol sulfate 2 MOmontelukast sodium 2 QL(90 per90 days)MONASONEX 3 MOPERFOROMIST3 B/D PA MOPROAIR HFA 3 QL(51 per90 days)MOPULMICORT SUSP 1MG/2ML 3 B/D PA MOPULMOZYME5 B/D PA MOQVAR 3 QL(53 per90 days)MOREVATIO INJ 5 QL(3375per 90 days)MO40

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)REVATIO TABS 5 PA QL(270per 90 days)MOSEREVENT DISKUS 3 QL(180 per90 days)MOsildenafil citrate 2 PA QL(270per 90 days)MOSINGULAIR 3 QL(90 per90 days)MOSPIRIVA HANDIHALER 3 QL(90 per90 days)MOSYMBICORT 3 QL(30.6 per90 days)MOterbutaline sulfate 2 MOtheophylline cr 2 MOtheophylline er tb12 300mg, 2 MO450mgtheophylline er tb24 2 MOTRACLEER 5 LA PAQL(180 per90 days)MOtriamcinolone acetonide inha 2 MOTYVASO5 B/D PA MOVENTOLIN HFA 3 QL(108 per90 days)MOXOLAIR 5 PA QL(7.2per 30 days)MOzafirlukast 2 QL(180 per90 days)MOZYFLO 4 QL(360 per90 days)MOZYFLO CR 4 QL(360 per90 days)MODrug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)UROLOGICALSANTICHOLINERGICS /ANTISPASMODICSDETROL LA 3 QL(90 per90 days)MOENABLEX 3 QL(90 per90 days)MOflavoxate hcl 2 MOGELNIQUE GEL 10% 3 QL(90 per90 days)MOGELNIQUE GEL 3% 3 QL(276 per90 days)MOMYRBETRIQ 3 QL(90 per90 days)MOoxybutynin chloride er tb24 5mg 2 QL(90 per90 days)oxybutynin chloride er tb24 10mg,15mgMO2 QL(180 per90 days)MOoxybutynin chloride syrp 1 MOoxybutynin chloride tabs 1 QL(360 per90 days)MOOXYTROL 3 QL(32 per90 days)MOtolterodine tartrate 2 QL(180 per90 days)MOTOVIAZ 3 QL(90 per90 days)MOtrospium chloride 2 QL(180 per90 days)MOtrospium chloride er 2 QL(90 per90 days)MO41

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)VESICARE 3 QL(90 per90 days)MOBENIGN PROSTATICHYPERPLASIA(BPH) THERAPYalfuzosin hcl er 2 QL(90 per90 days)MOAVODART 3 QL(90 per90 days)MOfinasteride tabs 5mg 2 QL(90 per90 days)MOJALYN 3 QL(90 per90 days)MORAPAFLO 3 QL(90 per90 days)MOtamsulosin hcl 2 QL(180 per90 days)MOUROXATRAL 3 QL(90 per90 days)MOCHOLINERGIC STIMULANTSbethanechol chloride 2 MOMISCELLANEOUS UROLOGICALSCIALIS TABS 2.5MG, 5MG 3 PA MOCYSTAGON 3 LA MOELMIRON 3 MOpotassium citrate tbcr 2 MOVITAMINS, HEMATINICS /ELECTROLYTESELECTROLYTEScalcium acetate caps 2 MOdextrose 5%/potassium chloride 20.15%eliphos 2 MOK-TABS 4 MOkcl 0.075%/d5w/nacl 0.45% 2Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)kcl 0.15%/d5w/lr 2 MOkcl 0.15%/d5w/nacl 0.2% 2 MOkcl 0.15%/d5w/nacl 0.225% 2 MOkcl 0.15%/d5w/nacl 0.9% 2kcl 0.3%/d5w/nacl 0.45% 2kcl 0.3%/d5w/nacl 0.9% 2klor-con 10 2 MOklor-con 8 2 MOKLOR-CON M15 4 MOklor-con m20 2 MOlactated ringers viaflex 2 MOmagnesium sulfate inj 50% 2 MONORMOSOL-R IN D5W 3PHOSLYRA 3 MOpotassium chloride 0.15% /nacl 20.45% viaflexpotassium chloride 0.15% 2d5w/nacl 0.33%potassium chloride 0.15% 2 MOd5w/nacl 0.45% viaflexpotassium chloride 0.15% nacl 20.9%potassium chloride 0.22% 2d5w/nacl 0.45%potassium chloride20.224%/dextrose 5% viaflexpotassium chloride 0.3%/ nacl 20.9%potassium chloride 0.3%/d5w 2potassium chloride er cpcr 2 MOpotassium chloride er tbcr 10meq, 2 MO20meqpotassium chloride inj 0.4meq/ml, 210meq/100ml, 10meq/50ml,30meq/100mlpotassium chloride inj 2meq/ml 2 MOringers injection 2sodium chloride 0.45% viaflex 2 MOsodium chloride inj 5% 2sodium chloride inj 2.5meq/ml,3%2 MO42

Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)Requirements/Limits(Requisitos/Limites)MISCELLANEOUS NUTRITIONPRODUCTSAMINOSYN II 3AMINOSYN II38.5%/ELECTROLYTESAMINOSYN-HBC 3AMINOSYN-PF 3AMINOSYN-PF 7% 3CLINIMIX 2.75%/DEXTROSE 35%CLINIMIX 4.25%/DEXTROSE 310%CLINIMIX 4.25%/DEXTROSE 320%CLINIMIX 4.25%/DEXTROSE 325%CLINIMIX 5%/DEXTROSE 15% 3CLINIMIX 5%/DEXTROSE 20% 3CLINIMIX 5%/DEXTROSE 25% 3CLINISOL SF 15% 3 MOFREAMINE III INJ 72MEQ/L; 3 MO600MG/100ML; 810MG/100ML;3MEQ/L; 14MG/100ML;1190MG/100ML;240MG/100ML; 590MG/100ML;770MG/100ML; 620MG/100ML;450MG/100ML; 480MG/100ML;10MMOLE/L; 115MG/100ML;950MG/100ML; 500MG/100ML;10MEQ/L; 340MG/100ML;130MG/100ML; 560MG/100MLHEPATAMINE 3HEPATASOL 3INTRALIPID INJ 1.7%; 30% 3intralipid inj 2.25%; 20% 2 MOIONOSOL-B/DEXTROSE 5% 3IONOSOL-MB/DEXTROSE 5% 3ISOLYTE-H/DEXTROSE 5% 3ISOLYTE-P/DEXTROSE 5% 3ISOLYTE-S 3ISOLYTE-S/DEXTROSE 5% 3liposyn iii inj 1.2%; 2.5%; 10% 2Drug Name(Nombre del medicamento)Drug Tier(Nivel demedicamento)NEPHRAMINE 3NORMOSOL-R 3PLASMA-LYTE A 3PLASMA-LYTE-148 3PLASMA-LYTE-56/D5W 3PREMASOL INJ 56MEQ/L; 3320MG/100ML; 730MG/100ML;190MG/100ML; 3MEQ/L;20MG/100ML; 300MG/100ML;220MG/100ML; 290MG/100ML;490MG/100ML; 840MG/100ML;490MG/100ML; 200MG/100ML;290MG/100ML; 410MG/100ML;230MG/100ML; 5MEQ/L;15MG/100ML; 250MG/100ML;120MG/100ML; 140MG/100ML;470MG/100MLpremasol inj 52meq/l;21760mg/100ml; 880mg/100ml;34meq/l; 1760mg/100ml;372mg/100ml; 406mg/100ml;526mg/100ml; 492mg/100ml;492mg/100ml; 526mg/100ml;356mg/100ml; 356mg/100ml;390mg/100ml; 34mg/100ml;152mg/100mltravasol 3TROPHAMINE 3VITAMINS / HEMATINICSprenatabs obn 1sodium fluoride tabs 2Requirements/Limits(Requisitos/Limites)43

Index of Drugs8 8-MOP..................................................................24A abacavir .................................................................3ABILIFY........................................................16, 17ABILIFY DISCMELT.........................................16ABILIFY MAINTENA .......................................17ABRAXANE .........................................................9acarbose...............................................................28acebutolol hcl.......................................................20acetaminophen/codeine........................................14acetaminophen/codeine #3...................................14acetasol hc ...........................................................28acetazolamide ......................................................38acetazolamide er ..................................................38acetazolamide sodium..........................................38acetic acid ............................................................28acetylcysteine .......................................................39ACTHAR HP .......................................................28ACTHIB...............................................................35ACTIMMUNE.....................................................34ACTONEL.....................................................26, 35ACTOPLUS MET ...............................................28ACTOS ................................................................28ACUVAIL............................................................38acyclovir...........................................................3, 26acyclovir sodium ....................................................3ADACEL .............................................................35ADAGEN.............................................................27adapalene.............................................................25adriamycin .............................................................9ADVAIR DISKUS...............................................39ADVAIR HFA .....................................................40afeditab cr ............................................................20AFINITOR.............................................................9AGGRENOX .......................................................23a-hydrocort ..........................................................28ala cort .................................................................26ALBENZA.............................................................6albuterol sulfate ...................................................40albuterol sulfate er...............................................40alclometasone dipropionate ................................26alcohol preps .......................................................28ALDURAZYME .................................................31alendronate sodium .................................27, 35, 36alfuzosin hcl er.....................................................42ALIMTA................................................................9ALINIA .................................................................6ALKERAN ............................................................9allopurinol ...........................................................35ALOCRIL............................................................38ALORA ...............................................................36ALPHAGAN P ....................................................39ALREX................................................................39ALTABAX ..........................................................25ALVESCO...........................................................40amantadine hcl ......................................................3amcinonide...........................................................26amethia ................................................................37amethyst ...............................................................37amifostine...............................................................9amikacin sulfate.....................................................6amiloride hcl........................................................20amiloride/hydrochlorothiazide ............................20AMINOSYN II ....................................................43AMINOSYN II 8.5%/ELECTROLYTES ...........43AMINOSYN-HBC ..............................................43AMINOSYN-PF..................................................43AMINOSYN-PF 7%............................................43amiodarone hcl ....................................................20AMITIZA ............................................................32amitriptyline hcl...................................................17amlodipine besylate .............................................20amlodipine besylate/benazepril hcl .....................21amlodipine besylate/benazepril hydrochloride ...21ammonium lactate................................................24amnesteem ...........................................................25amoxapine............................................................17amoxicillin .............................................................7amoxicillin/clavulanate potassium ........................8amoxicillin/clavulanate potassium er....................8amoxicillin/potassium clavulanate ........................8amphotericin b.......................................................344

ampicillin ...............................................................8ampicillin sodium...................................................8ampicillin-sulbactam..............................................8AMTURNIDE......................................................21anagrelide hydrochloride.....................................27anastrozole.............................................................9ANCOBON............................................................3ANDRODERM....................................................31ANDROGEL........................................................31ANDROGEL PUMP............................................31ANDROID ...........................................................31androxy ................................................................31ANTABUSE ........................................................27APIDRA...............................................................28APIDRA SOLOSTAR .........................................28APOKYN.............................................................13apraclonidine .......................................................39apri.......................................................................37APRISO ...............................................................32APTIVUS...............................................................3ARALAST NP .....................................................27aranelle ................................................................37ARANESP ALBUMIN FREE.............................34ARCALYST ........................................................34ARCAPTA NEOHALER ....................................40ARICEPT.............................................................13ARRANON............................................................9ARTHROTEC 50.................................................16ARTHROTEC 75.................................................16ARZERRA.............................................................9ASACOL..............................................................32ASACOL HD.......................................................32ascomp/codeine....................................................14ASMANEX 120 METERED DOSES .................40ASMANEX 14 METERED DOSES ...................40ASMANEX 30 METERED DOSES ...................40ASMANEX 60 METERED DOSES ...................40ASTEPRO............................................................27ATELVIA ............................................................36atenolol ................................................................21atenolol/chlorthalidone........................................21atorvastatin calcium.............................................24atovaquone/proguanil hcl ......................................6ATRIPLA ..............................................................3atropine sulfate ....................................................32ATROVENT HFA...............................................40augmented betamethasone dipropionate .............26AVANDAMET ...................................................28AVANDARYL..............................................28, 29AVANDIA...........................................................29AVASTIN..............................................................9AVELOX...............................................................8AVELOX ABC PACK..........................................8aviane...................................................................37avita .....................................................................25AVODART..........................................................42AVONEX ............................................................34AZACTAM ...........................................................6AZACTAM IN ISO-OSMOTIC DEXTROSE......6AZASITE.............................................................38azathioprine ...........................................................9azathioprine sodium ..............................................9azelastine hcl .................................................27, 38AZELEX..............................................................25AZILECT.............................................................13azithromycin ..........................................................6AZOPT ................................................................38AZOR ..................................................................21aztreonam ..............................................................6B bacitracin.............................................................38bacitracin/polymyxin b ........................................38baclofen ...............................................................14BACTROBAN.....................................................25BACTROBAN NASAL ......................................27balsalazide disodium ...........................................32balziva..................................................................37BANZEL .............................................................12BARACLUDE.......................................................3benazepril hcl ......................................................21benazepril hcl/hydrochlorothiazide.....................21BENICAR............................................................21BENICAR HCT...................................................21benztropine mesylate ...........................................13BEPREVE ...........................................................3845

BESIVANCE .......................................................38betamethasone dipropionate................................26betamethasone valerate .......................................26BETASERON ......................................................34betaxolol hcl...................................................21, 38bethanechol chloride............................................42BETOPTIC-S.......................................................38bicalutamide...........................................................9BICILLIN C-R.......................................................8BICILLIN L-A.......................................................8BICNU ...................................................................9BIDIL...................................................................21BILTRICIDE .........................................................7bisoprolol fumarate..............................................21bisoprolol fumarate/hydrochlorothiazide ............21bleomycin sulfate ...................................................9BLEPH-10............................................................39BLEPHAMIDE....................................................39BLEPHAMIDE S.O.P. ........................................39BOOSTRIX..........................................................35BOSULIF...............................................................9briellyn .................................................................37BRILINTA...........................................................23brimonidine tartrate.............................................39BROMDAY .........................................................38bromfenac ............................................................38bromocriptine mesylate........................................13budeprion sr .........................................................17budesonide .....................................................32, 40bumetanide...........................................................21BUPHENYL ........................................................27BUPRENEX ........................................................14buprenorphine hcl................................................14buprenorphine hcl/naloxone hcl ..........................16buproban ..............................................................27bupropion hcl .......................................................17bupropion hcl sr...................................................17bupropion hcl xl ...................................................17buspirone hcl........................................................17BUSULFEX...........................................................9butorphanol tartrate.............................................16BUTRANS...........................................................14BYDUREON .......................................................29BYETTA .............................................................29BYSTOLIC..........................................................21C cabergoline ..........................................................31calcipotriene ........................................................24calcitonin-salmon ................................................31calcitriol...............................................................31calcium acetate ....................................................42camila ..................................................................36CAMPATH............................................................9CAMPRAL..........................................................27CANASA.............................................................32candesartan cilexetil/hydrochlorothiazide ..........21CAPASTAT SULFATE ........................................7CAPEX ................................................................26CAPRELSA...........................................................9captopril...............................................................21captopril/hydrochlorothiazide .............................21CARAC ...............................................................24carafate................................................................33CARBAGLU .......................................................27carbamazepine.....................................................12carbamazepine er ................................................12CARBATROL .....................................................12carbidopa/levodopa .............................................13carbidopa/levodopa er.........................................13carbidopa/levodopa odt.......................................13carbinoxamine maleate........................................39carboplatin.............................................................9CARMOL-HC .....................................................25carteolol hcl.........................................................38cartia xt................................................................21carvedilol .............................................................21CAYSTON ............................................................7CEENU..................................................................9cefaclor ..................................................................6cefadroxil ...............................................................6cefazolin sodium ....................................................6cefdinir...................................................................6cefepime .................................................................6cefotaxime sodium .................................................6cefoxitin sodium.....................................................646

cefpodoxime proxetil..............................................6ceftazidime .............................................................6ceftriaxone sodium .................................................6cefuroxime axetil....................................................6cefuroxime sodium .................................................6CELEBREX.........................................................16CELLCEPT............................................................9CELLCEPT INTRAVENOUS ..............................9CELONTIN..........................................................12cephalexin ..............................................................6CEREZYME ........................................................31CERVARIX .........................................................35cetirizine hcl.........................................................39cevimeline hcl.......................................................27CHANTIX............................................................27CHANTIX STARTING MONTH PAK ..............27CHEMET .............................................................27chlordiazepoxide/amitriptyline ............................17chlorhexidine gluconate oral rinse ......................28chloroquine phosphate...........................................7chlorothiazide ......................................................21chlorothiazide sodium..........................................21chlorpromazine hcl ..............................................17chlorthalidone ......................................................21cholestyramine light.............................................24CIALIS.................................................................42ciclopirox .............................................................25ciclopirox nail lacquer.........................................25ciclopirox olamine ...............................................25CIDOFOVIR..........................................................3cilostazol ..............................................................23CILOXAN............................................................38CIMZIA ...............................................................32CINRYZE ............................................................40CIPRO HC ...........................................................28CIPRO I.V.-IN D5W .............................................8CIPRODEX..........................................................28ciprofloxacin ..........................................................8ciprofloxacin hcl ..............................................8, 38ciprofloxacin i.v.-in d5w ........................................8cisplatin..................................................................9citalopram hydrobromide ....................................17cladribine ...............................................................9claravis ................................................................25clarithromycin .......................................................6clarithromycin er ...................................................6clemastine fumarate.............................................39CLEOCIN............................................................36CLEOCIN IN D5W ...............................................7CLEOCIN PEDIATRIC GRANULES..................7CLIMARA PRO ..................................................36clindamycin hcl......................................................7clindamycin phosphate ..................................25, 36clindamycin phosphate add-vantage .....................7clindamycin phosphate in d5w ..............................7clindamycin/benzoyl peroxide .............................25CLINIMIX 2.75%/DEXTROSE 5% ...................43CLINIMIX 4.25%/DEXTROSE 10% .................43CLINIMIX 4.25%/DEXTROSE 20% .................43CLINIMIX 4.25%/DEXTROSE 25% .................43CLINIMIX 4.25%/DEXTROSE 5% ...................27CLINIMIX 5%/DEXTROSE 15% ......................43CLINIMIX 5%/DEXTROSE 20% ......................43CLINIMIX 5%/DEXTROSE 25% ......................43CLINISOL SF 15% .............................................43clobetasol propionate ..........................................26clobetasol propionate e .......................................26CLOLAR ...............................................................9clomipramine hcl .................................................17clonazepam ..........................................................12clonazepam odt ....................................................12clonidine hcl ........................................................21clopidogrel...........................................................23clorazepate dipotassium ......................................17clotrimazole .....................................................3, 25clotrimazole/betamethasone dipropionate ..........25clozapine..............................................................17COARTEM............................................................7codeine sulfate .....................................................14COLCRYS...........................................................35colestipol hcl........................................................24colistimethate sodium ............................................7COLY-MYCIN S ................................................28COMBIGAN .......................................................38COMBIPATCH ...................................................36COMBIVENT .....................................................4047

COMBIVENT RESPIMAT .................................40COMETRIQ...........................................................9COMPLERA..........................................................3compro .................................................................32COMTAN ............................................................13COMVAX............................................................35CONDYLOX .......................................................25constulose.............................................................32COPAXONE........................................................13CORDRAN TAPE ...............................................26COREG CR..........................................................21CORTIFOAM ......................................................32cortisone acetate ..................................................28CORTISPORIN-TC.............................................28COSMEGEN..........................................................9CREON ................................................................32CRESTOR............................................................24CRINONE............................................................36CRIXIVAN ............................................................3cromolyn sodium......................................32, 38, 40cryselle-28............................................................37CUBICIN ...............................................................7cyclafem 1/35 .......................................................37cyclafem 7/7/7 ......................................................37cyclobenzaprine hcl .............................................14cyclophosphamide..................................................9cyclosporine ...........................................................9cyclosporine modified ............................................9CYKLOKAPRON ...............................................23CYMBALTA .......................................................17CYSTADANE .....................................................32CYSTAGON........................................................42CYSTARAN ........................................................38cytarabine ..............................................................9cytarabine aqueous ................................................9D dacarbazine............................................................9DACOGEN ............................................................9DALIRESP ..........................................................40danazol.................................................................31dantrolene sodium................................................14DAPSONE .............................................................7DAPTACEL ........................................................35DARAPRIM ..........................................................7daunorubicin hcl....................................................9DECAVAC..........................................................35DELESTROGEN.................................................36DELZICOL..........................................................32demeclocycline hcl.................................................8DEMSER .............................................................21DENAVIR ...........................................................26DEPEN TITRATABS .........................................36DEPO-MEDROL.................................................28DEPO-PROVERA...............................................36DEPO-SUBQ PROVERA 104 ............................36DERMA-SMOOTHE/FS BODY OIL.................26DERMOTIC ........................................................28desipramine hcl....................................................17desloratadine .......................................................39desloratadine odt .................................................39desmopressin acetate...........................................31desonide ...............................................................26desoximetasone....................................................26DETROL LA .......................................................41dexamethasone.....................................................28dexamethasone intensol.......................................28dexamethasone sodium phosphate.................28, 39DEXILANT .........................................................33dexrazoxane ...........................................................9dextroamphetamine sulfate..................................17dextroamphetamine sulfate er .............................17dextrose 10%/nacl 0.45% ...................................27dextrose 10% flex container ................................27dextrose 10%/nacl 0.2% ......................................27dextrose 2.5%/sodium chloride 0.45% ................27dextrose 5% .........................................................27dextrose 5%/lactated ringers...............................27dextrose 5%/nacl 0.2% ........................................27dextrose 5%/nacl 0.225% ....................................27dextrose 5%/nacl 0.33% ......................................27dextrose 5%/nacl 0.45% ......................................27dextrose 5%/nacl 0.9% ........................................27dextrose 5%/potassium chloride 0.15% ..............42diazepam........................................................12, 17diazepam intensol ................................................1748

DIBENZYLINE...................................................21diclofenac potassium............................................16diclofenac sodium ................................................38diclofenac sodium dr............................................16diclofenac sodium er ............................................16diclofenac sodium/misoprostol ............................16dicloxacillin sodium ...............................................8dicyclomine hcl ....................................................32didanosine ..............................................................3DIFFERIN............................................................25DIFICID.................................................................6diflorasone diacetate............................................26diflunisal ..............................................................16digoxin..................................................................23dihydroergotamine mesylate................................13DILANTIN ..........................................................12DILANTIN INFATABS......................................12DILAUDID ..........................................................14DILAUDID-5.......................................................14DILAUDID-HP....................................................14dilt-cd ...................................................................21diltiazem cd ..........................................................21diltiazem hcl .........................................................21diltiazem hcl er.....................................................21dilt-xr....................................................................21DIOVAN..............................................................21DIPENTUM.........................................................32disopyramide phosphate ......................................20disulfiram .............................................................27divalproex sodium................................................12divalproex sodium dr ...........................................12divalproex sodium er............................................12DIVIGEL .............................................................36DOCEFREZ...........................................................9docetaxel ................................................................9donepezil hcl ........................................................14dorzolamide hcl....................................................39dorzolamide hcl/timolol maleate..........................39doxazosin mesylate...............................................21doxepin hcl ...........................................................17DOXIL ...................................................................9doxorubicin hcl ....................................................10doxycycline.............................................................8doxycycline hyclate................................................8doxycycline hyclate dr ...........................................8doxycycline monohydrate ......................................8dronabinol ...........................................................32drospirenone/ethinyl estradiol.............................37DROXIA..............................................................10DUETACT...........................................................29DULERA .............................................................40duramorph ...........................................................14DUREZOL...........................................................39E e.e.s. 400 ................................................................6E.E.S. GRANULES...............................................6econazole nitrate..................................................25EDECRIN............................................................21EDURANT ............................................................3EFFIENT .............................................................23ELIDEL ...............................................................25eliphos..................................................................42ELIQUIS..............................................................23ELITEK .................................................................9ELIXOPHYLLIN ................................................40ELLA ...................................................................37ELLENCE ...........................................................10ELMIRON ...........................................................42ELOXATIN .........................................................10ELSPAR ..............................................................10EMCYT ...............................................................10EMEND ...............................................................32emoquette.............................................................37EMSAM...............................................................17EMTRIVA .............................................................3ENABLEX...........................................................41enalapril maleate.................................................21enalapril maleate/hydrochlorothiazide ...............21ENBREL..............................................................36endocet.................................................................14ENGERIX-B........................................................35enoxaparin sodium ..............................................23enpresse-28..........................................................37entacapone...........................................................13ENTOCORT EC..................................................3249

enulose .................................................................32epinastine hcl .......................................................38epinephrine hcl.....................................................39EPIPEN 2-PAK....................................................39EPIPEN-JR 2-PAK ..............................................39epirubicin hcl .......................................................10epitol ....................................................................12EPIVIR...................................................................3EPIVIR HBV .........................................................3eplerenone............................................................21EPOGEN..............................................................34eprosartan mesylate .............................................22EPZICOM ..............................................................3ERAXIS .................................................................3ERBITUX ............................................................10ERIVEDGE..........................................................10errin......................................................................36ery ........................................................................25ERY-TAB ..............................................................6ERYTHROCIN LACTOBIONATE......................6erythrocin stearate .................................................6erythromycin ..................................................25, 38erythromycin base..................................................6erythromycin ethylsuccinate ..................................6erythromycin/benzoyl peroxide............................25escitalopram oxalate............................................17ESTRACE............................................................36estradiol ...............................................................36estradiol valerate .................................................36estradiol/norethindrone acetate...........................36ESTRING.............................................................36estropipate............................................................36ethambutol hcl........................................................7ethosuximide ........................................................12etidronate disodium .............................................27etodolac................................................................16etodolac er ...........................................................16ETOPOPHOS ......................................................10etoposide ..............................................................10EURAX................................................................26EVISTA ...............................................................36EVOXAC.............................................................27EXALGO .............................................................14EXELON .............................................................14exemestane...........................................................10EXFORGE...........................................................22EXFORGE HCT..................................................22EXJADE ..............................................................27F FABRAZYME.....................................................31famciclovir .............................................................3famotidine ............................................................33famotidine premixed ............................................33FANAPT..............................................................17FANAPT TITRATION PACK............................17FARESTON.........................................................10FASLODEX ........................................................10FAZACLO...........................................................17felbamate .............................................................12FELBATOL.........................................................12felodipine er.........................................................22fenofibrate............................................................24fenofibrate micronized.........................................24fenoprofen calcium ..............................................16fentanyl ................................................................15fentanyl citrate oral transmucosal.......................15FINACEA............................................................25finasteride ............................................................42FIRAZYR ............................................................40FIRMAGON........................................................10flavoxate hcl.........................................................41flecainide acetate.................................................20FLECTOR ...........................................................16FLOVENT DISKUS............................................40FLOVENT HFA ..................................................40fluconazole.............................................................3fluconazole in dextrose ..........................................3flucytosine..............................................................3fludarabine phosphate .........................................10fludrocortisone acetate ........................................28flunisolide ............................................................40fluocinolone acetonide...................................26, 28fluocinolone acetonide body................................26fluocinonide .........................................................26fluocinonide-e ......................................................2650

FLUOROPLEX....................................................25fluorouracil ....................................................10, 25fluoxetine dr .........................................................17fluoxetine hcl..................................................17, 18fluphenazine decanoate........................................18fluphenazine hcl ...................................................18flurbiprofen ..........................................................16flurbiprofen sodium..............................................38flutamide ..............................................................10fluticasone propionate ...................................26, 40fluvastatin.............................................................24fluvoxamine maleate ............................................18fluvoxamine maleate er ........................................18FML .....................................................................39FML FORTE........................................................39FOCALIN XR......................................................18fondaparinux sodium ...........................................23FORADIL AEROLIZER .....................................40FORFIVO XL ......................................................18FORTAZ ................................................................6FORTEO ..............................................................36fortical..................................................................31foscarnet sodium ....................................................3fosinopril sodium .................................................22fosinopril sodium/hydrochlorothiazide................22fosphenytoin sodium.............................................12FOSRENOL.........................................................27FRAGMIN ...........................................................23FREAMINE III ....................................................43furosemide............................................................22FUSILEV ...............................................................9FUZEON................................................................3G gabapentin............................................................12GABITRIL...........................................................12galantamine hydrobromide..................................14ganciclovir .............................................................3GARDASIL .........................................................35GASTROCROM..................................................32GAUZE PADS 2..................................................29gavilyte-c..............................................................32gavilyte-g..............................................................32gavilyte-n/flavor pack ..........................................32GELNIQUE .........................................................41gemcitabine hcl....................................................10gemfibrozil ...........................................................24generlac ...............................................................32gengraf.................................................................10gentak...................................................................38gentamicin sulfate......................................7, 25, 38gentamicin sulfate/0.9% sodium chloride .............7GEODON ............................................................18gianvi ...................................................................37gildagia................................................................37GILENYA ...........................................................14GLEEVEC ...........................................................10glimepiride...........................................................29glipizide ...............................................................29glipizide er ...........................................................29glipizide/metformin hcl ........................................29GLUCAGEN HYPOKIT.....................................29GLUCAGON EMERGENCY KIT .....................29glyburide..............................................................29glyburide micronized ...........................................29glyburide/metformin hcl ......................................29glycopyrrolate......................................................32granisetron hcl.....................................................32griseofulvin microsize............................................3griseofulvin ultramicrosize ....................................3GRIS-PEG .............................................................3guanfacine hcl......................................................22GYNAZOLE-1 ....................................................36H HALAVEN..........................................................10HALDOL.............................................................18HALDOL DECANOATE 100 ............................18HALDOL DECANOATE 50 ..............................18HALFLYTELY BOWEL PREP/FLAVORPACKS ............................................................32halobetasol propionate ........................................26haloperidol...........................................................18haloperidol decanoate .........................................18haloperidol lactate...............................................18HAVRIX..............................................................3551

heparin sodium.....................................................23heparin sodium/d5w.............................................23heparin sodium/nacl 0.45% .................................23heparin sodium/sodium chloride 0.9% premix ....23HEPATAMINE....................................................43HEPATASOL ......................................................43HEPSERA..............................................................3HERCEPTIN........................................................10HEXALEN...........................................................10HUMALOG .........................................................29HUMALOG KWIKPEN......................................29HUMALOG MIX 50/50 ......................................29HUMALOG MIX 50/50 KWIKPEN...................29HUMALOG MIX 75/25 ......................................29HUMALOG MIX 75/25 KWIKPEN...................29HUMIRA .............................................................36HUMIRA PEN-CROHNS DISEASESTARTER 36HUMULIN 70/30.................................................29HUMULIN 70/30 PEN ........................................29HUMULIN N.......................................................29HUMULIN N U-100 PEN ...................................29HUMULIN R .......................................................29HUMULIN R U-500 (CONCENTRATED)........30hydralazine hcl.....................................................22hydrochlorothiazide .............................................22hydrocodone bitartrate/acetaminophen...............15hydrocodone/acetaminophen ...............................15hydrocodone/ibuprofen ........................................15hydrocortisone .........................................26, 28, 32hydrocortisone butyrate .......................................26hydrocortisone valerate .......................................26hydrocortisone/acetic acid...................................28hydromorphone hcl ..............................................15hydroxychloroquine sulfate....................................7hydroxyurea .........................................................10hydroxyzine hcl ....................................................39I ibandronate sodium .............................................36ibuprofen ..............................................................16ICLUSIG..............................................................10idarubicin hcl .......................................................10IFEX.....................................................................10ifosfamide.............................................................10ILEVRO...............................................................38imipenem/cilastatin................................................7imipramine hcl.....................................................18imipramine pamoate ............................................18imiquimod ............................................................25IMOVAX RABIES (H.D.C.V.)...........................35INCIVEK...............................................................4INCRELEX .........................................................27indapamide ..........................................................22indomethacin .......................................................16indomethacin er ...................................................16INFANRIX ..........................................................35INLYTA ..............................................................10INSULIN PEN NEEDLE ....................................30INSULIN SYRINGE (DISP) U-100 0.3 ML ......30INSULIN SYRINGE (DISP) U-100 1 ML .........30INSULIN SYRINGE (DISP) U-100 1/2 ML ......30INTELENCE .........................................................4INTRALIPID.......................................................43INTRON-A..........................................................34INTRON-A W/DILUENT...................................34introvale...............................................................37INTUNIV.............................................................18INVEGA..............................................................18INVEGA SUSTENNA ........................................18INVIRASE.............................................................4INVOKANA........................................................30IONOSOL-B/DEXTROSE 5% ...........................43IONOSOL-MB/DEXTROSE 5%........................43IOPIDINE............................................................39IPOL INACTIVATED IPV.................................35ipratropium bromide......................................28, 40ipratropium bromide/albuterol sulfate ................40irbesartan.............................................................22irbesartan/hydrochlorothiazide ...........................22irinotecan.............................................................10ISENTRESS ..........................................................4ISOLYTE-H/DEXTROSE 5% ............................43ISOLYTE-P/DEXTROSE 5%.............................43ISOLYTE-S .........................................................43ISOLYTE-S/DEXTROSE 5%.............................43isoniazid.................................................................752

isosorbide dinitrate ..............................................24isosorbide dinitrate er..........................................24isosorbide mononitrate ........................................24isosorbide mononitrate er ....................................24isotonic gentamicin ................................................7isradipine .............................................................22ISTALOL.............................................................38ISTODAX ............................................................10itraconazole............................................................3IXEMPRA KIT....................................................10IXIARO................................................................35J JAKAFI................................................................10JALYN.................................................................42jantoven................................................................23JANUMET...........................................................30JANUMET XR ....................................................30JANUVIA ............................................................30JENTADUETO....................................................30JEVTANA............................................................10jinteli ....................................................................36jolivette.................................................................36junel 1.5/30 ..........................................................37junel 1/20 .............................................................37junel fe 1.5/30.......................................................37junel fe 1/20..........................................................37JUVISYNC ..........................................................30JUXTAPID ..........................................................24K KADCYLA ..........................................................10KALETRA.............................................................4KALYDECO........................................................40kariva ...................................................................37kcl 0.075%/d5w/nacl 0.45% ................................42kcl 0.15%/d5w/lr ..................................................42kcl 0.15%/d5w/nacl 0.2% ....................................42kcl 0.15%/d5w/nacl 0.225% ................................42kcl 0.15%/d5w/nacl 0.9% ....................................42kcl 0.3%/d5w/nacl 0.45% ....................................42kcl 0.3%/d5w/nacl 0.9% ......................................42kelnor 1/35 ...........................................................37KETEK ..................................................................7ketoconazole ....................................................3, 25ketodan kit............................................................25ketoprofen ............................................................16ketoprofen er........................................................16ketorolac tromethamine.......................................38kionex...................................................................27klor-con 10...........................................................42klor-con 8.............................................................42KLOR-CON M15 ................................................42klor-con m20........................................................42KOMBIGLYZE XR ............................................30K-TABS...............................................................42KUVAN...............................................................31L labetalol hcl .........................................................22laclotion ...............................................................25LACRISERT .......................................................38lactated ringers viaflex ........................................42lactulose...............................................................32LAMICTAL ODT ...............................................12LAMICTAL STARTER/NOT TAKINGCARBAMAZEPINE .......................................12LAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOT TAKINGVALPROATE .................................................12LAMICTAL STARTER/TAKING VALPROATE.........................................................................12LAMICTAL XR ..................................................12lamivudine .............................................................4lamivudine/zidovudine ...........................................4lamotrigine...........................................................12lamotrigine er ......................................................12LANOXIN ...........................................................23LANOXIN PEDIATRIC .....................................23lansoprazole.........................................................33LANTUS .............................................................30LANTUS SOLOSTAR........................................30LASTACAFT ......................................................38latanoprost...........................................................39LATUDA.............................................................18LAZANDA..........................................................15leena.....................................................................3753

leflunomide...........................................................36lessina ..................................................................37LETAIRIS............................................................40letrozole................................................................10leucovorin calcium.................................................9LEUKERAN ........................................................10LEUKINE ............................................................34leuprolide acetate.................................................10levalbuterol ..........................................................40levalbuterol hcl ....................................................40LEVEMIR............................................................30LEVEMIR FLEXPEN .........................................30levetiracetam........................................................12levetiracetam er ...................................................12levobunolol hcl.....................................................38levocarnitine ........................................................27levocetirizine dihydrochloride .............................39levofloxacin ......................................................8, 38levofloxacin in d5w ................................................8levonest ................................................................37levonorgestrel/ethinyl estradiol ...........................37levora 0.15/30-28.................................................37levorphanol tartrate .............................................15levothyroxine sodium ...........................................31levoxyl ..................................................................31LEXIVA.................................................................4LIALDA...............................................................32lidocaine...............................................................25lidocaine hcl.........................................................25lidocaine hcl jelly.................................................25lidocaine viscous..................................................25lidocaine/prilocaine .............................................25LIDODERM ........................................................25lindane..................................................................26LINZESS..............................................................32LIORESAL INTRATHECAL .............................14liothyronine sodium .............................................32LIPOFEN .............................................................24liposyn iii..............................................................43lisinopril...............................................................22lisinopril/hydrochlorothiazide .............................22lithium carbonate .................................................18lithium carbonate er.............................................18lithium citrate ......................................................18LOCOID ..............................................................26LODOSYN ..........................................................13loperamide hcl .....................................................32lorazepam ............................................................18lorazepam intensol...............................................18loryna...................................................................37losartan potassium...............................................22losartan potassium/hydrochlorothiazide .............22LOTEMAX..........................................................39LOTRONEX........................................................32lovastatin .............................................................24LOVAZA.............................................................24LOVENOX..........................................................23low-ogestrel .........................................................37loxapine succinate ...............................................18LUMIGAN ..........................................................39LUNESTA ...........................................................18LUPRON DEPOT ...............................................10LUPRON DEPOT-PED ......................................10lutera....................................................................37LUXIQ.................................................................26LYRICA ..............................................................12LYSODREN........................................................10LYSTEDA ...........................................................37M MACRODANTIN .................................................8mafenide acetate ..................................................25magnesium sulfate ...............................................42MALARONE.........................................................7malathion .............................................................26maprotiline hcl.....................................................18marlissa ...............................................................37MARPLAN..........................................................18MATULANE.......................................................10matzim la..............................................................22meclizine hcl ........................................................32meclofenamate sodium ........................................16medroxyprogesterone acetate..............................36mefenamic acid ....................................................16mefloquine hcl........................................................7MEGACE ES.......................................................1054

megestrol acetate .................................................10MEKINIST ..........................................................10meloxicam ............................................................16melphalan hydrochloride .....................................10MENACTRA .......................................................35MENEST..............................................................36MENOMUNE-A/C/Y/W-135..............................35MENVEO ............................................................35MEPRON...............................................................7mercaptopurine ....................................................10meropenem.............................................................7mesna .....................................................................9MESNEX ...............................................................9MESTINON.........................................................14MESTINON TIMESPAN....................................14METADATE CD .................................................19metaproterenol sulfate .........................................40metformin hcl .......................................................30metformin hcl er...................................................30methadone hcl ......................................................15methadose ............................................................15methazolamide .....................................................38methenamine hippurate..........................................8METHERGINE....................................................38methimazole .........................................................28methotrexate.........................................................10methotrexate sodium ............................................10methyclothiazide ..................................................22methylergonovine maleate ...................................38methylphenidate hcl .............................................19methylphenidate hcl cd ........................................19methylphenidate hcl er.........................................19methylphenidate hydrochloride ...........................19methylprednisolone ..............................................28methylprednisolone acetate .................................28methylprednisolone dose pack .............................28methylprednisolone sodiumsuccinate ..................28metipranolol.........................................................38metoclopramide hcl..............................................32metolazone ...........................................................22metoprolol succinate er........................................22metoprolol tartrate...............................................22metoprolol/hydrochlorothiazide ..........................22METROGEL .......................................................25metronidazole ..................................................7, 25metronidazole in nacl 0.79% .................................7metronidazole vaginal .........................................37mexiletine hcl.......................................................20MICARDIS..........................................................22MICARDIS HCT.................................................22miconazole 3 ........................................................37microgestin 1.5/30 ...............................................37microgestin 1/20 ..................................................37microgestin fe ......................................................37microgestin fe 1.5/30 ...........................................37midodrine hcl.......................................................27migergot...............................................................13MIGRANAL........................................................13minocycline hcl ......................................................8minocycline hcl er..................................................8minoxidil ..............................................................22MIRAPEX ER .....................................................13mirtazapine ..........................................................19mirtazapine odt ....................................................19misoprostol ..........................................................33mitomycin.............................................................10mitoxantrone hcl ..................................................10M-M-R II W/DILUENT 10 DOSE .....................35modafinil..............................................................19moexipril hcl ........................................................22moexipril/hydrochlorothiazide ............................22mometasone furoate.............................................26mononessa ...........................................................37montelukast sodium .............................................40morphine sulfate ..................................................15morphine sulfate er..............................................15MOVIPREP .........................................................33MOXEZA ............................................................38MOZOBIL ...........................................................34MULTAQ ............................................................20mupirocin.............................................................25MUSTARGEN ....................................................10MYCOBUTIN .......................................................7mycophenolate mofetil.........................................10MYFORTIC.........................................................10myorisan ..............................................................2555

MYRBETRIQ ......................................................41MYTELASE ........................................................14N nabumetone ..........................................................16nadolol .................................................................22nadolol/bendroflumethiazide ...............................22nafcillin sodium......................................................8NAFTIN...............................................................25NAGLAZYME ....................................................31nallpen/dextrose.....................................................8naloxone hcl .........................................................16naltrexone hcl.......................................................16NAMENDA .........................................................14NAMENDA TITRATION PAK..........................14NAMENDA XR...................................................14NAMENDA XR TITRATION PACK.................14naphazoline hcl ....................................................39naproxen ..............................................................16naproxen dr..........................................................16naproxen sodium..................................................16naratriptan hcl .....................................................13NASONEX ..........................................................40NATACYN ..........................................................38nateglinide............................................................30NEBUPENT...........................................................7necon 0.5/35-28....................................................37necon 1/35............................................................37necon 10/11-28.....................................................37necon 7/7/7...........................................................37NEEDLES, INSULIN DISP., SAFETY ..............30nefazodone hcl .....................................................19neomycin sulfate.....................................................7neomycin/bacitracin/polymyxin ...........................38neomycin/polymyxin/bacitracin/hydrocortisone..39neomycin/polymyxin/dexamethasone...................39neomycin/polymyxin/gramicidin ..........................38neomycin/polymyxin/hc........................................28neomycin/polymyxin/hydrocortisone .............28, 39NEORAL .............................................................10NEPHRAMINE ...................................................43NEULASTA ........................................................34NEUMEGA..........................................................34NEUPOGEN........................................................34NEVANAC..........................................................38nevirapine ..............................................................4NEXAVAR..........................................................10NEXIUM .............................................................33NEXIUM I.V. ......................................................33NIASPAN............................................................24nicardipine hcl.....................................................22NICOTROL INHALER ......................................27NICOTROL NS...................................................27nifediac cc............................................................22nifedical xl ...........................................................22nifedipine .............................................................22nifedipine er.........................................................22NILANDRON .....................................................11nimodipine ...........................................................22NIPENT ...............................................................11nisoldipine ...........................................................22nisoldipine er .......................................................22nitro-bid ...............................................................24NITRO-DUR .......................................................24nitrofurantoin.........................................................8nitrofurantoin macrocrystalline ............................8nitrofurantoin monohydrate ..................................8nitroglycerin ........................................................24nitroglycerin transdermal....................................24NITROLINGUAL PUMPSPRAY ......................24NITROSTAT .......................................................24nizatidine .............................................................33nora-be.................................................................36NORDITROPIN FLEXPRO ...............................34NORDITROPIN NORDIFLEX PEN..................34norethindrone acetate..........................................36NORMOSOL-R...................................................43NORMOSOL-R IN D5W....................................42NOROXIN.............................................................8NORPACE CR ....................................................20nortrel 0.5/35 (28) ...............................................37nortrel 1/35 ..........................................................37nortrel 7/7/7.........................................................37nortriptyline hcl ...................................................19NORVIR................................................................4NOVOLOG .........................................................3056

NOVOLOG FLEXPEN .......................................30NOVOLOG MIX 70/30.......................................30NOVOLOG MIX 70/30 PREFILLED FLEXPEN..........................................................................31NOXAFIL ..............................................................3NUCYNTA ..........................................................16NUCYNTA ER....................................................16NUEDEXTA........................................................14NULOJIX.............................................................11NUVARING ........................................................37nyamyc .................................................................25nystatin.............................................................3, 26nystatin/triamcinolone .........................................26nystop ...................................................................26O ocella....................................................................37octreotide acetate.................................................11ofloxacin.....................................................8, 28, 38ogestrel.................................................................37olanzapine ............................................................19olanzapine odt......................................................19olanzapine/fluoxetine ...........................................19omeprazole...........................................................33omeprazole/sodium bicarbonate..........................33OMNITROPE ......................................................34ondansetron hcl....................................................33ondansetron odt ...................................................33ONFI ....................................................................13ONGLYZA ..........................................................31ONSOLIS.............................................................15ONTAK................................................................11OPANA ER (CRUSH RESISTANT) ..................15ORAP...................................................................19ORENCIA............................................................36ORFADIN............................................................27orsythia ................................................................37ORTHO EVRA....................................................37oxaliplatin ............................................................11oxandrolone .........................................................31oxaprozin..............................................................16oxcarbazepine ......................................................13OXSORALEN ULTRA .......................................25oxybutynin chloride .............................................41oxybutynin chloride er .........................................41oxycodone hcl ......................................................15oxycodone/acetaminophen...................................15oxycodone/aspirin................................................15OXYCONTIN .....................................................16oxymorphone hydrochloride................................16oxymorphone hydrochloride er ...........................16OXYTROL ..........................................................41P pacerone ..............................................................20paclitaxel .............................................................11palgic ...................................................................39PANDEL .............................................................26PANRETIN .........................................................25pantoprazole sodium............................................33paromomycin sulfate..............................................7paroxetine hcl ......................................................19paroxetine hcl er..................................................19PASER...................................................................7PATADAY ..........................................................38PATANOL...........................................................38PAXIL .................................................................19pedi-dri ................................................................26PEDVAX HIB .....................................................35PEGANONE........................................................13PEGASYS ...........................................................34PEGASYS PROCLICK.......................................34PEG-INTRON .....................................................34PEG-INTRON REDIPEN ...................................34penicillin g potassium............................................8PENICILLIN G POTASSIUM IN ISO-OSMOTICDEXTROSE ......................................................8penicillin g procaine..............................................8penicillin g sodium.................................................8penicillin v potassium ............................................8PENNSAID .........................................................16PENTASA ...........................................................33pentostatin ...........................................................11pentoxifylline er ...................................................23PERFOROMIST..................................................40perindopril erbumine...........................................2257

periogard..............................................................28PERJETA.............................................................11permethrin............................................................26perphenazine ........................................................19pfizerpen-g .............................................................8phenadoz ..............................................................39phenelzine sulfate.................................................19phenobarbital.......................................................13phenytoin..............................................................13phenytoin sodium .................................................13phenytoin sodium extended ..................................13PHISOHEX..........................................................25PHOSLYRA ........................................................42pilocarpine hcl .....................................................27pilocarpine hydrochloride ...................................27PILOPINE HS......................................................38pindolol ................................................................23pioglitazone hcl....................................................31pioglitazone hcl/metformin hcl ............................31pioglitazone hcl-glimepiride ................................31piperacillin sodium/tazobactam sodium ................8piroxicam .............................................................16PLASMA-LYTE A..............................................43PLASMA-LYTE-148 ..........................................43PLASMA-LYTE-56/D5W...................................43podofilox ..............................................................25polyethylene glycol 3350......................................33POMALYST ........................................................11portia-28 ..............................................................37potassium chloride ...............................................42potassium chloride 0.15% /nacl 0.45% viaflex....42potassium chloride 0.15% d5w/nacl 0.33%.........42potassium chloride 0.15% d5w/nacl 0.45% viaflex..........................................................................42potassium chloride 0.15% nacl 0.9% ..................42potassium chloride 0.22% d5w/nacl 0.45%.........42potassium chloride 0.224%/dextrose 5% viaflex .42potassium chloride 0.3%/ nacl 0.9% ...................42potassium chloride 0.3%/d5w..............................42potassium chloride er...........................................42potassium citrate..................................................42POTIGA...............................................................13PRADAXA ..........................................................23pramipexole dihydrochloride ..............................13PRANDIN ...........................................................31pravastatin sodium ..............................................24prazosin hcl..........................................................23prednicarbate.......................................................26prednisolone acetate............................................39prednisolone sodium phosphate ....................28, 39prednisone ...........................................................28prednisone intensol..............................................28PREFEST.............................................................36PREMARIN.........................................................36PREMASOL........................................................43PREMPHASE......................................................36PREMPRO...........................................................36prenatabs obn ......................................................43prevalite ...............................................................24previfem ...............................................................37PREVPAC ...........................................................33PREZISTA.............................................................4PRIMAQUINE PHOSPHATE ..............................7primidone.............................................................13PRIMSOL..............................................................9PRISTIQ ..............................................................19PRIVIGEN...........................................................35PROAIR HFA......................................................40probenecid ...........................................................35probenecid/colchicine..........................................35procainamide hcl .................................................20procentra .............................................................19prochlorperazine .................................................33prochlorperazine edisylate ..................................33prochlorperazine maleate....................................33PROCRIT ............................................................35procto-pak............................................................33proctozone-hc ......................................................33progesterone ........................................................36PROGLYCEM.....................................................31PROGRAF...........................................................11PROLASTIN-C ...................................................27PROLENSA.........................................................38PROLEUKIN.......................................................35PROLIA...............................................................36PROMACTA .......................................................2458

promethazine hcl..................................................39promethegan ........................................................39propafenone hcl ...................................................20propafenone hcl er ...............................................20propantheline bromide.........................................32propranolol hcl ....................................................23propranolol hcl er ................................................23propranolol/hydrochlorothiazide.........................23propylthiouracil ...................................................28PROQUAD ..........................................................35PROTOPIC ..........................................................25protriptyline hcl ...................................................19PROVIGIL...........................................................19prudoxin ...............................................................25PULMICORT ......................................................40PULMOZYME ....................................................40PYLERA ..............................................................33pyrazinamide..........................................................7pyridostigmine bromide .......................................14Q QUALAQUIN........................................................7quasense...............................................................37quetiapine fumarate .............................................19quinapril hcl.........................................................23quinapril/hydrochlorothiazide .............................23quinidine gluconate cr .........................................20quinidine sulfate...................................................20quinidine sulfate er ..............................................20quinine sulfate........................................................7QVAR ..................................................................40R RABAVERT ........................................................35ramipril ................................................................23RANEXA.............................................................24ranitidine hcl........................................................33RAPAFLO ...........................................................42RAPAMUNE .......................................................11RAVICTI .............................................................27REBETOL..............................................................4REBIF ..................................................................35REBIF TITRATION PACK ................................35RECLAST............................................................27reclipsen...............................................................37RECOMBIVAX HB............................................35RECTIV...............................................................33regonol.................................................................14REGRANEX .......................................................25RELENZA DISKHALER .....................................4RELISTOR ..........................................................33RELPAX..............................................................13REMICADE ........................................................33REMODULIN .....................................................23RENVELA...........................................................27reprexain..............................................................16RESCRIPTOR .......................................................4reserpine ..............................................................23RESTASIS...........................................................38RETROVIR IV INFUSION ..................................4REVATIO......................................................40, 41REVLIMID..........................................................11REYATAZ.........................................................4, 5RHEUMATREX .................................................11ribapak...................................................................5ribasphere..............................................................5ribavirin .................................................................5RIDAURA ...........................................................36rifampin .................................................................7RILUTEK ............................................................27riluzole .................................................................27rimantadine hcl......................................................5ringers injection...................................................42RISPERDAL CONSTA ......................................19risperidone...........................................................19risperidone odt.....................................................19RITALIN LA.......................................................19RITUXAN ...........................................................11rivastigmine tartrate ............................................14rizatriptan benzoate.............................................13ropinirole er.........................................................13ropinirole hcl .......................................................13ROTATEQ...........................................................35ROXICET............................................................16S SABRIL ...............................................................1359

SAMSCA .............................................................31SANCUSO...........................................................33SANDIMMUNE ..................................................11SANDOSTATIN LAR DEPOT...........................11SANTYL..............................................................26SAPHRIS .............................................................19SAVELLA ...........................................................36SAVELLA TITRATION PACK .........................36selegiline hcl ........................................................13selenium sulfide....................................................24SELZENTRY.........................................................5SENSIPAR...........................................................31SEREVENT DISKUS..........................................41SEROMYCIN ........................................................7SEROQUEL XR ..................................................19sertraline hcl ........................................................19SIGNIFOR ...........................................................11sildenafil citrate ...................................................41SILENOR.............................................................20silver sulfadiazine ................................................24SIMPONI .............................................................36SIMULECT..........................................................11simvastatin ...........................................................24SINGULAIR ........................................................41SIRTURO ..............................................................7SKELID ...............................................................27SKLICE................................................................26sodium chloride..............................................27, 42sodium chloride 0.45% viaflex.............................42sodium chloride 0.9% ..........................................27sodium fluoride ....................................................43sodium phenylbutyrate .........................................27sodium polystyrene sulfonate...............................27sodium sulfacetamide...........................................39SOLARAZE.........................................................25SOLTAMOX .......................................................11SOLU-CORTEF ..................................................28SOLU-MEDROL.................................................28SOMATULINE DEPOT......................................11SOMAVERT........................................................31SORIATANE.......................................................24sorine....................................................................20sotalol hcl.............................................................20sotalol hcl (af)......................................................20spinosad ...............................................................26SPIRIVA HANDIHALER ..................................41spironolactone .....................................................23spironolactone/hydrochlorothiazide....................23SPORANOX..........................................................3sprintec 28 ...........................................................37SPRYCEL............................................................11sronyx...................................................................37ssd ........................................................................24stagesic ................................................................16STALEVO 100 ....................................................13STALEVO 125 ....................................................13STALEVO 150 ....................................................13STALEVO 200 ....................................................13STALEVO 50 ......................................................13STALEVO 75 ......................................................13stavudine................................................................5STIMATE............................................................31STIVARGA .........................................................11STRATTERA ......................................................20STREPTOMYCIN SULFATE ..............................7STRIBILD .............................................................5STROMECTOL.....................................................7SUBOXONE .......................................................16SUCRAID............................................................33sucralfate .............................................................33sulfacetamide sodium ....................................25, 39sulfacetamide sodium/prednisolone sodiumphosphate.........................................................39sulfadiazine............................................................8sulfamethoxazole/trimethoprim .............................8sulfamethoxazole/trimethoprim ds.........................8SULFAMYLON..................................................25sulfasalazine ........................................................33sulfazine ec ..........................................................33sulindac................................................................16sumatriptan succinate..........................................13SUPRAX ...............................................................6SUPREP BOWEL PREP.....................................33SUSTIVA ..............................................................5SUTENT..............................................................11SYLATRON........................................................3560

SYMBICORT ......................................................41SYMBYAX..........................................................20SYMLINPEN 120................................................31SYMLINPEN 60..................................................31SYNAREL ...........................................................31SYNRIBO ............................................................11SYPRINE.............................................................27T TABLOID ............................................................11tacrolimus ............................................................11TAFINLAR..........................................................11TAMIFLU..............................................................5tamoxifen citrate ..................................................11tamsulosin hcl ......................................................42TARCEVA...........................................................11TARGRETIN.......................................................11TASIGNA ............................................................11TAXOTERE ........................................................11TAZORAC...........................................................25taztia xt.................................................................23TECFIDERA........................................................14TECFIDERA STARTER PACK .........................14TEFLARO..............................................................6TEGRETOL-XR ..................................................13TEKAMLO ..........................................................23TEKTURNA ........................................................23TEKTURNA HCT ...............................................23temazepam............................................................20terazosin hcl .........................................................23terbinafine hcl ........................................................3terbutaline sulfate ................................................41terconazole...........................................................37testosterone cypionate..........................................31testosterone enanthate .........................................31tetanus toxoid adsorbed .......................................35TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT .....................................35tetracycline hcl.......................................................8THALOMID ........................................................11theophylline cr .....................................................41theophylline er .....................................................41thioridazine hcl ....................................................20thiotepa ................................................................11thiothixene ...........................................................20THYMOGLOBULIN ..........................................35tiagabine hydrochloride ......................................13ticlopidine hcl ......................................................24TIKOSYN............................................................20timolol maleate ..............................................23, 38timolol maleate ophthalmic gel forming..............38TIMOPTIC OCUDOSE ......................................38tinidazole ...............................................................7tizanidine hcl........................................................14TOBI......................................................................7TOBRADEX .......................................................39TOBRADEX ST..................................................39tobramycin sulfate ...........................................7, 38tobramycin sulfate/sodium chloride ......................7tobramycin/dexamethasone .................................39TOBREX .............................................................38tolazamide............................................................31tolbutamide ..........................................................31tolmetin sodium....................................................16tolterodine tartrate ..............................................41topiramate............................................................13toposar .................................................................11topotecan hcl........................................................11TORISEL.............................................................11torsemide .............................................................23TOVIAZ ..............................................................41TRACLEER.........................................................41TRADJENTA ......................................................31tramadol hcl.........................................................16tramadol hcl er ....................................................16trandolapril..........................................................23tranexamic acid ...................................................37TRANSDERM-SCOP .........................................33tranylcypromine sulfate .......................................20travasol ................................................................43TRAVATAN Z....................................................39travoprost.............................................................39trazodone hcl .......................................................20TREANDA ..........................................................11TRECATOR ..........................................................7TRELSTAR DEPOT MIXJECT .........................1161

TRELSTAR LA MIXJECT .................................11TRELSTAR MIXJECT .......................................11tretinoin..........................................................11, 25triamcinolone acetonide.................................26, 41triamcinolone in orabase .....................................28triamterene/hydrochlorothiazide .........................23TRIBENZOR .......................................................23triderm..................................................................26trifluoperazine hcl................................................20trifluridine ............................................................38trihexyphenidyl hcl...............................................13tri-legest fe ...........................................................37TRILEPTAL ........................................................13TRILIPIX.............................................................24trilyte ....................................................................33trimethoprim ..........................................................9trimethoprim sulfate/polymyxin b sulfate.............38trimipramine maleate...........................................20trinessa.................................................................37tri-previfem ..........................................................37TRISENOX..........................................................11tri-sprintec............................................................37trivora-28 .............................................................37TRIZIVIR ..............................................................5TROPHAMINE ...................................................43trospium chloride .................................................41trospium chloride er.............................................41TRUVADA ............................................................5TWINJECT ..........................................................39TWINRIX ............................................................35TWYNSTA ..........................................................23TYGACIL ..............................................................7TYKERB..............................................................11TYPHIM VI .........................................................35TYVASO .............................................................41TYZEKA................................................................5TYZINE ...............................................................28TYZINE PEDIATRIC NASAL DROPS .............28U UCERIS ...............................................................33ULESFIA .............................................................26ULORIC...............................................................35unithroid ..............................................................32UROXATRAL.....................................................42ursodiol................................................................33UVADEX ............................................................25V VAGIFEM ...........................................................36valacyclovir hcl......................................................5VALCYTE.............................................................5valproate sodium .................................................13valproic acid ........................................................13valsartan/hydrochlorothiazide.............................23vancomycin hcl ......................................................9vandazole .............................................................37VAQTA ...............................................................35VARIVAX...........................................................35VASCEPA ...........................................................24VECTIBIX...........................................................11VELCADE...........................................................12velivet...................................................................37venlafaxine hcl.....................................................20venlafaxine hcl er.................................................20VENTOLIN HFA ................................................41verapamil hcl .......................................................23verapamil hcl er...................................................23verapamil hcl sr ...................................................23VEREGEN...........................................................25VESICARE..........................................................42vestura .................................................................37VFEND..................................................................3VFEND IV.............................................................3VIBATIV...............................................................9VIBRAMYCIN .....................................................8vicodin .................................................................16vicodin es .............................................................16vicodin hp ............................................................16VICTOZA............................................................31VICTRELIS...........................................................5VIDAZA..............................................................12VIDEX PEDIATRIC.............................................5VIGAMOX..........................................................38VIIBRYD.............................................................20VIMOVO.............................................................1662

VIMPAT ..............................................................13vinblastine sulfate ................................................12vincasar pfs ..........................................................12vincristine sulfate .................................................12vinorelbine tartrate ..............................................12VIRACEPT ............................................................5VIRAMUNE ..........................................................5VIRAMUNE XR ...................................................5VIRAZOLE............................................................5VIREAD ................................................................5VIVELLE-DOT ...................................................36VOLTAREN ........................................................16voriconazole...........................................................3VOTRIENT..........................................................12W warfarin sodium ...................................................24WELCHOL ..........................................................24X XALKORI............................................................12XARELTO...........................................................24XELJANZ ............................................................36XENAZINE .........................................................14XGEVA..................................................................9XIFAXAN..............................................................7XOLAIR ..............................................................41XTANDI ..............................................................12XYREM ...............................................................20Y YERVOY.............................................................12YF-VAX ..............................................................35Z zafirlukast.............................................................41zaleplon ................................................................20ZALTRAP............................................................12ZANOSAR...........................................................12ZANTAC .............................................................33ZAVESCA...........................................................31zazole ...................................................................37ZELAPAR ...........................................................13ZELBORAF.........................................................12ZEMPLAR...........................................................31zenchent fe ...........................................................37ZENPEP...............................................................33zenzedi .................................................................20zeosa ....................................................................37ZERIT....................................................................5ZETIA..................................................................24ZIAGEN ................................................................6zidovudine..............................................................6ZINACEF IN ISO-OSMOTIC DEXTROSE ........6ZINACEF IN ISO-OSMOTIC DILUENT ............6ZINECARD ...........................................................9ziprasidone hcl.....................................................20ZIRGAN ..............................................................38ZMAX ...................................................................6zoledronic acid ..............................................27, 31ZOLINZA............................................................12zolpidem tartrate..................................................20zolpidem tartrate er .............................................20ZOMETA.............................................................31zonisamide ...........................................................13ZORTRESS .........................................................12ZOSTAVAX........................................................35ZOSYN..................................................................8zovia 1/35e...........................................................37zovia 1/50e...........................................................38ZOVIRAX ...........................................................26ZYFLO ................................................................41ZYFLO CR ..........................................................41ZYLET.................................................................39ZYMAXID ..........................................................38ZYTIGA ..............................................................12ZYVOX .................................................................763