Formulary (List of Covered Drugs) UCare Choices and Fairview UCare Choices This formulary may change throughout the year. Please visit ucare.org or call UCare Customer Services for the most current information. UCare Customer Services UCare Choices members: -877-903-0070 toll free Fairview UCare Choices members: -877-903-0069 toll free TTY: -800-688-534 toll free 8 a.m. 6 p.m., Monday through Friday UC FVC_0067 IA (00607) Last updated 0/07 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THESE PLANS.
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What is the UCare formulary? The UCare formulary is a list of generic and brand drugs that are covered by this plan(s). To be covered, the drug must be on our formulary. The most current list of covered drugs can be found on the UCare Choices formulary search tool at ucare.org. To be covered, you must use a network pharmacy to fill your prescription. The Provider Directory includes in-network pharmacies. You can also visit ucare.org for the most current information. Over-the-counter (OTC) drugs are not covered by this plan(s). For more information on OTC drugs, please see your Contract/Evidence of Coverage. Can the formulary change? Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. How do I use the formulary? In the formulary, brand name drugs are capitalized (e.g. CELEBREX) and generic drugs are listed in lowercase italics (e.g. fenofibrate). UCare covers both brand name drugs and generic drugs. A generic drug is approved by the U.S. Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs, but work just as well and are equally as safe as the branded product. How to find prescription drugs in the formulary? There are two ways to find your prescription drugs in the formulary. You can search by type of drug or by alphabetical listing. Search by Type of Drug Drugs listed by drug type begin on page. The drugs in this formulary are grouped into drug types depending on the medical conditions they are used to treat. Search by Alphabetical Listing If you are not sure what class to look under, you can look for your drug in the Index. The Index gives an alphabetical list of all of the drugs included in the formulary. Both brand name and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information within the formulary. Tiers and limitations for prescription drugs The numbers in the Tier column on the prescription drug formulary indicate the cost share for the medication. Tier indicates drugs that are primarily generic drugs and have a Tier copay. Tier indicates drugs that are primarily brand name or specialty and have a Tier drug coinsurance. Tier 3 indicates drugs that may be eligible for a zero dollar copay if they are part of the Essential Health Benefit-Preventative Medication list. For more detailed information about copays and coinsurance, please review your Contract/Evidence of Coverage. i
The abbreviations/symbols in the Limitations (Notes) column on the formulary tell you if UCare has any special requirements or limits on coverage for that drug. Use the key below to help understand the meaning of each abbreviation/symbol. PA = Prior authorization Some drugs require you or your provider to get approval from us before you fill your prescription. If you do not get approval, we may not cover the drug. ST = Step therapy Even though this drug is on the formulary, we may require you to try one or more alternative drugs on the formulary before this drug will be covered. QL = Quantity limits For some covered drugs, we limit the amount of the drug you can have. We may limit how much of a drug you get each time the prescription is filled. SP = Specialty drugs Fairview Specialty Pharmacy is the exclusive network provider of specialty drugs for UCare Choices and Fairview UCare Choices members. Specialty drugs are costly injectable or oral drugs that often require special handling or monitoring by a trained pharmacist. Your medication and any needed supplies will be shipped to your home, work, or doctor s office. You can also contact Fairview Specialty Pharmacy and arrange to pick up your medication at one of their retail locations. A Fairview pharmacist is available any time of day if you have an urgent need related to your specialty medication. If you use a specialty medication, please have your physician send your prescription to Fairview Specialty Pharmacy via e-prescribing and select FAIRVIEW MAIL ORDER/SPECIALTY PHARMACY or fax it to -866-347-4939. You can also have your current pharmacy transfer the prescription to Fairview Specialty Pharmacy. For any questions, please contact Fairview at 6-67-560. PV (Tier 3) = May be considered a Preventive Medication with a zero copay. Eligible Preventive Medication with no Copay Aspirin For prevention or cardiovascular events Men: 45 to 79 years old Women: 55 to 79 years old Aspirin (for pregnant women who are at risk for preeclampsia) Oral Fluoride Folic Acid Immunizations Tobacco Cessation Vitamin D Women under 55 years old Children ages 6 months to 6 years Women under 5 years old Recommended ages per the Advisory Committee on Immunization Practices Men and women age 8 and older who use tobacco products. Prescription products have $0 copay in pharmacy. OTC products available through smoking cessation program. Men and women age 65 and older who are at increased risks of falls Bowel Preps Men and women between the ages of 49 and 76 - limit per 365 days Breast Cancer Prevention High risk women age 35 and older with no previous diagnosis of breast cancer. Member must contact ESI for copay override. Contraceptives Women under 5 years old: Please see EOC/Contract/SBC Statins Low-to Moderate-Dose Statins Adults 40-75 years ii
What if my drug is not on the formulary? If your drug is not included in this formulary, you should first contact UCare Customer Services and confirm that your drug is not covered. If you learn that UCare does not cover your drug, you can: Ask your doctor to prescribe a similar drug that is covered by UCare. Ask UCare to make an exception to cover your drug. Requesting a formulary or drug restriction exception You or your doctor can ask UCare to make an exception to cover a nonformulary drug or an exception to a drug restriction. Contact Customer Services at the number listed on the front cover for information on how to request an exception. We generally require you to submit a statement from your doctor supporting your request. For more information For more detailed information about your UCare prescription drug coverage, please review your Contract/ Evidence of Coverage and other plan materials. If you have questions, please call the UCare Customer Services number on the front cover or visit ucare.org. This information is available in other forms to people with disabilities by calling: 6-676-0070 (voice) or toll free at -877-903-0070 (voice), 6-676-680 (TTY) or toll free at -800-688-534 (TTY); or through the Minnesota Relay at 7 or toll free direct access at -800-67-359 (TTY, Voice, ASCII, Hearing Carry Over), or -877-67-3848 (speech-to-speech relay service). iii
List of Covered Drugs Drug Name Tier Limitations (Notes) ANTIHISTAMINE DRUGS carbinoxamine maleate oral liquid 4 /5 ml carbinoxamine maleate oral tablet 4 cetirizine oral solution /ml clemastine oral tablet.68 cyproheptadine oral syrup /5 ml cyproheptadine oral tablet 4 desloratadine oral tablet 5 QL desloratadine oral tablet,disintegrating.5, 5 QL diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl oral capsule 50 hydroxyzine hcl intramuscular solution 5 /ml hydroxyzine hcl oral solution 0 /5 ml hydroxyzine hcl oral tablet 0, 5, 50 hydroxyzine pamoate oral capsule 00, 5, 50 levocetirizine oral solution.5 /5 ml QL levocetirizine oral tablet 5 QL meclizine oral tablet.5, 5 promethazine injection solution 5 /ml, 50 /ml promethazine oral syrup 6.5 /5 ml promethazine oral tablet.5, 5, 50 promethazine rectal suppository.5, 5 ANTI-INFECTIVE AGENTS abacavir oral tablet 300 abacavir-lamivudine oral tablet 600-300 Effective: January, 08
abacavir-lamivudine-zidovudine oral tablet 300-50-300 acyclovir oral capsule 00 acyclovir oral suspension 00 /5 ml acyclovir oral tablet 400, 800 acyclovir sodium intravenous recon soln,000, 500 adefovir oral tablet 0 SP ALBENZA ORAL TABLET 00 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML amantadine hcl oral capsule 00 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 00 AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amikacin injection solution,000 /4 ml, 500 / ml amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50 amoxicillin-pot clavulanate oral suspension for reconstitution 00-8.5 /5 ml, 50-6.5 /5 ml, 400-57 /5 ml, 600-4.9 /5 ml amoxicillin-pot clavulanate oral tablet 50-5, 500-5, 875-5 amoxicillin-pot clavulanate oral tablet extended release hr,000-6.5 amoxicillin-pot clavulanate oral tablet,chewable 00-8.5, 400-57 amphotericin b injection recon soln 50 ampicillin oral capsule 50, 500 ampicillin oral suspension for reconstitution 5 /5 ml, 50 /5 ml Effective: January, 08
ampicillin sodium injection recon soln gram, 0 gram, 5, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln.5 gram, 5 gram ampicillin-sulbactam intravenous recon soln.5 gram, 3 gram APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLUTION 00 MG/ML atovaquone oral suspension 750 /5 ml atovaquone-proguanil oral tablet 50-00, 6.5-5 ATRIPLA ORAL TABLET 600-00-300 MG AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, GRAM/50 ML azithromycin intravenous recon soln 500 azithromycin oral suspension for reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50, 500, 600 aztreonam injection recon soln gram, gram bacitracin intramuscular recon soln 50,000 unit BARACLUDE ORAL SOLUTION 0.05 MG/ML SP BILTRICIDE ORAL TABLET 600 MG CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG CAPASTAT INJECTION RECON SOLN GRAM CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML SP; QL cefaclor oral capsule 50, 500 cefaclor oral tablet extended release hr 500 cefadroxil oral capsule 500 Effective: January, 08 3
cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, gram/50 ml cefazolin injection recon soln gram, 0 gram, 00 gram, 0 gram, 300 g, 500 cefazolin intravenous recon soln gram cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefepime injection recon soln gram, gram cefotaxime injection recon soln gram, 0 gram, gram, 500 cefotetan injection recon soln gram, gram cefotetan intravenous recon soln 0 gram cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml, gram/50 ml cefoxitin intravenous recon soln gram, 0 gram, gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram, gram, 6 gram ceftriaxone in dextrose,iso-os intravenous piggyback gram/50 ml, gram/50 ml ceftriaxone injection recon soln gram, 0 gram, gram, 50, 500 ceftriaxone intravenous recon soln gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln.5 gram, 750 Effective: January, 08 4
cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 50, 500 cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 chloramphenicol sod succinate intravenous recon soln gram chloroquine phosphate oral tablet 50, 500 cidofovir intravenous solution 75 /ml cipro oral suspension,microcapsule recon 50 /5 ml CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 50 MG/5 ML ciprofloxacin (mixture) oral tablet, er multiphase 4 hr,000, 500 ciprofloxacin hcl oral tablet 00, 50, 500, 750 ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml ciprofloxacin oral suspension,microcapsule recon 50 /5 ml, 500 /5 ml clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 clindamycin hcl oral capsule 50, 300, 75 clindamycin phosphate injection solution 50 /ml clindamycin phosphate intravenous solution 300 / ml, 600 /4 ml, 900 /6 ml COARTEM ORAL TABLET 0-0 MG colistin (colistimethate na) injection recon soln 50 COMPLERA ORAL TABLET 00-5-300 MG Effective: January, 08 5
CRIXIVAN ORAL CAPSULE 00 MG dapsone oral tablet 00, 5 DAPTOMYCIN INTRAVENOUS RECON SOLN 500 MG demeclocycline oral tablet 50, 300 DESCOVY ORAL TABLET 00-5 MG dicloxacillin oral capsule 50, 500 didanosine oral capsule,delayed release(dr/ec) 5, 00, 50, 400 DIFICID ORAL TABLET 00 MG doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon soln 00 doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00 doxycycline hyclate oral tablet,delayed release (dr/ec) 00, 50, 75 doxycycline monohydrate oral capsule 00, 50, 50, 75 doxycycline monohydrate oral tablet 50, 50, 75 E.E.S. 400 ORAL TABLET 400 MG EDURANT ORAL TABLET 5 MG EMTRIVA ORAL CAPSULE 00 MG EMTRIVA ORAL SOLUTION 0 MG/ML entecavir oral tablet 0.5, SP EPCLUSA ORAL TABLET 400-00 MG PA; SP ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 50 MG, 333 MG ERYTHROCIN (AS STEARATE) ORAL TABLET 50 MG ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG, 500 MG erythromycin ethylsuccinate oral tablet 400 erythromycin oral tablet 50, 500 Effective: January, 08 6
ethambutol oral tablet 00, 400 EVOTAZ ORAL TABLET 300-50 MG famciclovir oral tablet 5, 50, 500 QL fluconazole in dextrose(iso-o) intravenous piggyback 00 /00 ml, 400 /00 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 /00 ml fluconazole oral suspension for reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 00, 50 fluconazole oral tablet 50 QL flucytosine oral capsule 50, 500 foscarnet intravenous solution 4 /ml ganciclovir sodium intravenous recon soln 500 SP gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin in nacl (iso-osm) intravenous piggyback 0 /00 ml gentamicin injection solution 0 / ml, 40 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 60 /6 ml GENVOYA ORAL TABLET 50-50-00-0 MG griseofulvin microsize oral suspension 5 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 5, 50 HEPSERA ORAL TABLET 0 MG SP hydroxychloroquine oral tablet 00 Effective: January, 08 7
imipenem-cilastatin intravenous recon soln 50, 500 INTELENCE ORAL TABLET 00 MG, 00 MG, 5 MG INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( SP ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML SP INVIRASE ORAL CAPSULE 00 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 5 MG isoniazid injection solution 00 /ml isoniazid oral solution 50 /5 ml isoniazid oral tablet 00, 300 itraconazole oral capsule 00 QL ivermectin oral tablet 3 KALETRA ORAL TABLET 00-5 MG, 00-50 MG ketoconazole oral tablet 00 lamivudine oral solution 0 /ml lamivudine oral tablet 00, 50, 300 lamivudine-zidovudine oral tablet 50-300 levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50, 500, 750 LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG Effective: January, 08 8
linezolid intravenous parenteral solution 600 /300 ml linezolid oral suspension for reconstitution 00 /5 ml linezolid oral tablet 600 linezolid-0.9% sodium chloride intravenous parenteral solution 600 /300 ml lopinavir-ritonavir oral solution 400-00 /5 ml mefloquine oral tablet 50 meropenem intravenous recon soln gram, 500 methenamine hippurate oral tablet gram METRO I.V. INTRAVENOUS PIGGYBACK 500 MG/00 ML metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml metronidazole oral capsule 375 metronidazole oral tablet 50, 500 minocycline oral capsule 00, 50, 75 minocycline oral tablet 00, 50, 75 MYCAMINE INTRAVENOUS RECON SOLN 00 MG, 50 MG nafcillin injection recon soln gram, 0 gram, gram nafcillin intravenous recon soln gram, gram neomycin oral tablet 500 nevirapine oral suspension 50 /5 ml nevirapine oral tablet 00 nitrofurantoin macrocrystal oral capsule 00, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 nitrofurantoin oral suspension 5 /5 ml NORVIR ORAL CAPSULE 00 MG Effective: January, 08 9
NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG NOXAFIL ORAL SUSPENSION 00 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit ODEFSEY ORAL TABLET 00-5-5 MG oseltamivir oral capsule 30, 45, 75 oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, gram/50 ml oxacillin injection recon soln gram, 0 gram, gram oxacillin intravenous recon soln gram, gram paromomycin oral capsule 50 PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 35 MCG/0.5 ML SP; QL PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML SP; QL PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 0 MCG/0.5 ML, 50 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SP; QL PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe. million unit/ ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 SP; QL Effective: January, 08 0
piperacillin-tazobactam intravenous recon soln.5 gram, 3.375 gram, 4.5 gram, 40.5 gram polymyxin b sulfate injection recon soln 500,000 unit PREZCOBIX ORAL TABLET 800-50 MG- MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 400 MG, 600 MG, 75 MG, 800 MG PRIFTIN ORAL TABLET 50 MG PYLERA ORAL CAPSULE 40-5-5 MG pyrazinamide oral tablet 500 quinidine gluconate injection solution 80 /ml quinidine gluconate oral tablet extended release 34 quinidine sulfate oral tablet 00, 300 quinidine sulfate oral tablet extended release 300 quinine sulfate oral capsule 34 RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION QL RESCRIPTOR ORAL TABLET 00 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML REYATAZ ORAL CAPSULE 50 MG, 00 MG, 300 MG ribavirin oral capsule 00 SP ribavirin oral tablet 00 SP rifabutin oral capsule 50 rifampin intravenous recon soln 600 rifampin oral capsule 50, 300 RIFATER ORAL TABLET 50-0-300 MG rimantadine oral tablet 00 Effective: January, 08
SELZENTRY ORAL SOLUTION 0 MG/ML SELZENTRY ORAL TABLET 50 MG, 5 MG, 300 MG, 75 MG stavudine oral capsule 5, 0, 30, 40 stavudine oral recon soln /ml streptomycin intramuscular recon soln gram STRIBILD ORAL TABLET 50-50-00-300 MG STROMECTOL ORAL TABLET 3 MG sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution 400-80 /5 ml sulfamethoxazole-trimethoprim oral suspension 00-40 /5 ml sulfamethoxazole-trimethoprim oral tablet 400-80, 800-60 sulfasalazine oral tablet 500 sulfasalazine oral tablet,delayed release (dr/ec) 500 SUSTIVA ORAL CAPSULE 00 MG, 50 MG SUSTIVA ORAL TABLET 600 MG SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SP SYNAGIS INTRAMUSCULAR SOLUTION 00 MG/ML, 50 MG/0.5 ML SP SYNERCID INTRAVENOUS RECON SOLN 500 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML terbinafine hcl oral tablet 50 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 tinidazole oral tablet 50, 500 TIVICAY ORAL TABLET 0 MG, 5 MG, 50 MG Effective: January, 08
tobramycin in 0.5 % nacl inhalation solution for nebulization 300 /5 ml SP; QL tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 0 /ml, 40 /ml TRECATOR ORAL TABLET 50 MG trimethoprim oral tablet 00 TRIUMEQ ORAL TABLET 600-50-300 MG TRUVADA ORAL TABLET 00-300 MG TYZEKA ORAL TABLET 600 MG valacyclovir oral tablet gram, 500 QL VALGANCICLOVIR ORAL RECON SOLN 50 MG/ML valganciclovir oral tablet 450 vancomycin intravenous recon soln,000, 0 gram, 5 gram, 500, 750 vancomycin oral capsule 5, 50 VEMLIDY ORAL TABLET 5 MG SP VIRACEPT ORAL TABLET 50 MG, 65 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) SP VIREAD ORAL TABLET 50 MG, 00 MG, 50 MG, 300 MG SP VITEKTA ORAL TABLET 50 MG, 85 MG voriconazole intravenous solution 00 voriconazole oral suspension for reconstitution 00 /5 ml (40 /ml) PA voriconazole oral tablet 00, 50 PA ZEPATIER ORAL TABLET 50-00 MG ZIAGEN ORAL SOLUTION 0 MG/ML zidovudine oral capsule 00 zidovudine oral syrup 0 /ml zidovudine oral tablet 300 PA; SP; QL (84 EA per 84 days) Effective: January, 08 3
ANTINEOPLASTIC AGENTS AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG, 7.5 MG PA; SP ALECENSA ORAL CAPSULE 50 MG PA; SP; QL (40 EA per 30 days) ALIMTA INTRAVENOUS RECON SOLN 00 MG, 500 MG SP ALUNBRIG ORAL TABLET 30 MG PA anastrozole oral tablet AVASTIN INTRAVENOUS SOLUTION 5 MG/ML SP azacitidine injection recon soln 00 SP BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG bicalutamide oral tablet 50 BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 00 MG PA; SP BOSULIF ORAL TABLET 500 MG PA; SP; QL (30 EA per 30 days) CABOMETYX ORAL TABLET 0 MG, 40 MG, 60 MG PA capecitabine oral tablet 50, 500 SP CAPRELSA ORAL TABLET 00 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 MG/DAY(80 MG X-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) PA; SP PA; SP; QL (90 EA per 30 days) PA; SP; QL (30 EA per 30 days) COTELLIC ORAL TABLET 0 MG PA; QL (63 EA per 8 days) CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 50 MG CYCLOPHOSPHAMIDE ORAL TABLET 5 MG, 50 MG CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML Effective: January, 08 4
DOCETAXEL INTRAVENOUS SOLUTION 0 MG/ML, 40 MG/7 ML (0 MG/ML), 60 MG/6 ML (0 MG/ML), 60 MG/8 ML (0 MG/ML), 0 MG/ ML (0 MG/ML), 0 MG/ML ( ML), 80 MG/4 ML (0 MG/ML), 80 MG/8 ML (0 MG/ML) docetaxel intravenous solution 0 /ml EMCYT ORAL CAPSULE 40 MG ERIVEDGE ORAL CAPSULE 50 MG PA; SP; QL (30 EA per 30 days) exemestane oral tablet 5 FARYDAK ORAL CAPSULE 0 MG PA; QL ( EA per days) FARYDAK ORAL CAPSULE 5 MG, 0 MG PA; QL (6 EA per days) FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML SP flutamide oral capsule 5 GILOTRIF ORAL TABLET 0 MG PA; SP; QL; QL (60 EA per 30 days) GILOTRIF ORAL TABLET 30 MG PA; SP; QL; QL (40 EA per 30 days) GILOTRIF ORAL TABLET 40 MG PA; SP; QL; QL (30 EA per 30 days) HALAVEN INTRAVENOUS SOLUTION MG/ ML (0.5 MG/ML) SP HEXALEN ORAL CAPSULE 50 MG HYCAMTIN ORAL CAPSULE 0.5 MG, MG SP hydroxyurea oral capsule 500 IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG PA; QL ( EA per 8 days) imatinib oral tablet 00 PA; SP imatinib oral tablet 400 PA; SP; QL (60 EA per 30 days) IMBRUVICA ORAL CAPSULE 40 MG PA; QL (0 EA per 30 days) IMFINZI INTRAVENOUS SOLUTION 50 MG/ML SP INLYTA ORAL TABLET MG, 5 MG PA; SP Effective: January, 08 5
INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML IRESSA ORAL TABLET 50 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG KADCYLA INTRAVENOUS RECON SOLN 00 MG, 60 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X), 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (4 MG X ), 8 MG/DAY (4 MG X ) (60 PACK) SP SP PA; SP PA; SP PA letrozole oral tablet.5 LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit /0. ml SP lomustine oral capsule 0, 00, 40 LONSURF ORAL TABLET 5-6.4 MG, 0-8.9 MG PA LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 PA; SP MG,.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG PA; SP LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG PA; SP LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG PA; SP LUPRON DEPOT-PED INTRAMUSCULAR KIT.5 MG, 5 MG, 7.5 MG (PED) PA; SP LYNPARZA ORAL CAPSULE 50 MG PA; SP Effective: January, 08 6 PA; SP; QL (30 EA per 30 days)
LYNPARZA ORAL TABLET 00 MG, 50 MG PA; SP LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG SP megestrol oral suspension 400 /0 ml (0 ml), 400 /0 ml (40 /ml) PA megestrol oral tablet 0, 40 PA MEKINIST ORAL TABLET 0.5 MG PA; SP; QL (0 EA per 30 days) MEKINIST ORAL TABLET MG PA; SP; QL (30 EA per 30 days) melphalan oral tablet mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln gram methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 mitoxantrone intravenous concentrate /ml SP MYLERAN ORAL TABLET MG NEXAVAR ORAL TABLET 00 MG PA; SP; QL (0 EA per 30 days) nilutamide oral tablet 50 NINLARO ORAL CAPSULE.3 MG PA; SP; QL (6 EA per 8 days) NINLARO ORAL CAPSULE 3 MG PA; SP; QL (4 EA per 8 days) NINLARO ORAL CAPSULE 4 MG PA; SP; QL (3 EA per 8 days) OPDIVO INTRAVENOUS SOLUTION 00 MG/0 ML, 40 MG/4 ML POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG SP PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT SP REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG PA; SP RITUXAN HYCELA SUBCUTANEOUS SOLUTION 400 MG/.7 ML (0 MG/ML), 600 MG/3.4 ML (0 MG/ML) PA Effective: January, 08 7
RUBRACA ORAL TABLET 00 MG, 50 MG, 300 MG PA RYDAPT ORAL CAPSULE 5 MG PA; SP SPRYCEL ORAL TABLET 00 MG, 0 MG, 50 MG, 80 MG PA; SP SPRYCEL ORAL TABLET 40 MG PA; SP; QL (30 EA per 30 days) SPRYCEL ORAL TABLET 70 MG PA; SP; QL (60 EA per 30 days) STIVARGA ORAL TABLET 40 MG PA; SP SUTENT ORAL CAPSULE.5 MG, 5 MG, 50 MG PA; SP SUTENT ORAL CAPSULE 37.5 MG PA SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SP SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG SP TAFINLAR ORAL CAPSULE 50 MG PA; SP; QL; QL (80 EA per 30 days) TAFINLAR ORAL CAPSULE 75 MG PA; SP; QL; QL (0 EA per 30 days) TAGRISSO ORAL TABLET 40 MG PA; QL (60 EA per 30 days) TAGRISSO ORAL TABLET 80 MG PA; QL (30 EA per 30 days) tamoxifen oral tablet 0, 0 TARCEVA ORAL TABLET 00 MG, 5 MG PA; SP TARCEVA ORAL TABLET 50 MG PA; SP; QL (30 EA per 30 days) TASIGNA ORAL CAPSULE 50 MG PA; SP TASIGNA ORAL CAPSULE 00 MG PA; SP; QL ( EA per 8 days) TECENTRIQ INTRAVENOUS SOLUTION,00 MG/0 ML (60 MG/ML) SP temozolomide oral capsule 00, 40, 80, 0, 50, 5 SP topotecan intravenous recon soln 4 TOPOTECAN INTRAVENOUS SOLUTION 4 MG/4 ML ( MG/ML) Effective: January, 08 8
TRELSTAR DEPOT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 3.75 MG TRELSTAR INTRAMUSCULAR SYRINGE.5 MG/ ML,.5 MG/ ML SP TRELSTAR LA INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 MG tretinoin (chemotherapy) oral capsule 0 TYKERB ORAL TABLET 50 MG PA; SP; QL (80 EA per 30 days) UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VECTIBIX INTRAVENOUS SOLUTION 00 MG/5 ML (0 MG/ML), 400 MG/0 ML (0 SP MG/ML) VELCADE INJECTION RECON SOLN 3.5 MG SP VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG PA VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 PA; QL (4 EA per 80 days) MG VOTRIENT ORAL TABLET 00 MG PA; SP; QL (0 EA per 30 days) XALKORI ORAL CAPSULE 00 MG, 50 MG PA; SP XTANDI ORAL CAPSULE 40 MG PA; SP; QL (0 EA per 30 days) YONDELIS INTRAVENOUS RECON SOLN MG PA ZALTRAP INTRAVENOUS SOLUTION 00 MG/4 ML (5 MG/ML), 00 MG/8 ML (5 SP MG/ML) ZEJULA ORAL CAPSULE 00 MG PA ZELBORAF ORAL TABLET 40 MG PA; SP; QL (40 EA per 30 days) ZOLINZA ORAL CAPSULE 00 MG SP ZYDELIG ORAL TABLET 00 MG, 50 MG PA Effective: January, 08 9
ZYKADIA ORAL CAPSULE 50 MG PA; SP; QL (50 EA per 30 days) ZYTIGA ORAL TABLET 50 MG PA; SP; QL (0 EA per 30 days) ZYTIGA ORAL TABLET 500 MG PA; SP ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES ACTHIB (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION LF-(.5-5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE LF-(.5-5-3-5 MCG)-5LF/0.5 ML AFLURIA 05-06 (PF) INTRAMUSCULAR SYRINGE 45 MCG (5 MCG X 3)/0.5 ML AFLURIA 05-06 INTRAMUSCULAR SUSPENSION 45 MCG (5 MCG X 3)/0.5 ML AFLURIA 06-07 (PF) INTRAMUSCULAR SYRINGE 45 MCG (5 MCG X 3)/0.5 ML AFLURIA 06-07 INTRAMUSCULAR SUSPENSION 45 MCG (5 MCG X 3)/0.5 ML AFLURIA QUAD 06-07 (PF) INTRAMUSCULAR SYRINGE 60 MCG/0.5 ML AFLURIA QUAD 06-07 INTRAMUSCULAR SUSPENSION 60 MCG/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR 3 SP; PV RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-5 MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION.5-8-5 LF-MCG-LF/0.5ML Effective: January, 08 0
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE.5-8-5 LF-MCG-LF/0.5ML CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN GRAM, 6 GRAM CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE 0-0 MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 5-0-5 LF-MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 0 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML EZ FLU 06-7 (AFLURIA) (PF) INTRAMUSCULAR SYRINGE KIT 45 MCG (5 MCG X 3)/0.5 ML EZ FLU 06-7 (FLUVIRIN) (PF) INTRAMUSCULAR SYRINGE KIT 45 MCG (5 MCG X 3)/0.5 ML FLUAD 06-07 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE 45 MCG (5 MCG X 3)/0.5 ML FLUARIX QUAD 06-07 (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG X 4)/0.5 ML FLUBLOK 06-07 (PF) INTRAMUSCULAR SOLUTION 35 MCG (45 MCG X 3)/0.5 ML FLUCELVAX QUAD 06-07 (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG X 4)/0.5 ML PA; SP Effective: January, 08
FLULAVAL QUAD 06-07 (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG X 4)/0.5 ML FLULAVAL QUAD 06-07 INTRAMUSCULAR SUSPENSION 60 MCG (5 MCG X 4)/0.5 ML FLUMIST QUAD 05-06 NASAL NASAL SPRAY SYRINGE 0EXP6.5-7.5 FF UNIT/0. ML FLUVIRIN 06-07 (PF) INTRAMUSCULAR SYRINGE 45 MCG (5 MCG X 3)/0.5 ML FLUVIRIN 06-07 INTRAMUSCULAR SUSPENSION 45 MCG (5 MCG X 3)/0.5 ML FLUZONE HIGH-DOSE 06-7 (PF) INTRAMUSCULAR SYRINGE 80 MCG/0.5 ML FLUZONE QUAD 06-07 (PF) INTRAMUSCULAR SUSPENSION 60 MCG (5 MCG X 4)/0.5 ML FLUZONE QUAD 06-07 (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG X 4)/0.5 ML FLUZONE QUAD 06-07 INTRAMUSCULAR SUSPENSION 60 MCG (5 MCG X 4)/0.5 ML FLUZONE QUAD PEDI 06-7 (PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.5 ML GAMASTAN S/D INTRAMUSCULAR SOLUTION 5-8 % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 0 % GARDASIL (PF) INTRAMUSCULAR SUSPENSION 0-40-40-0 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SYRINGE 0-40-40-0 MCG/0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION,440 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML Effective: January, 08 PV PV PV PV SP PA; SP
HAVRIX (PF) INTRAMUSCULAR SYRINGE,440 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML HYQVIA SUBCUTANEOUS SOLUTION 0 GRAM /00 ML (0 %),.5 GRAM /5 ML (0 %), 0 GRAM /00 ML (0 %), 30 GRAM /300 ML (0 %), 5 GRAM /50 ML (0 %) IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 5-58-0 LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 5-58-0 LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION 40-8-3 UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 5 LF-58 MCG-0 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN 5-.5 MCG/0.5 ML MENOMUNE - A/C/Y/W-35 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENOMUNE - A/C/Y/W-35 SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-35-DIP (PF) INTRAMUSCULAR KIT 0-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN,000-,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 0 MCG-5LF-5 MCG-0LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 5 LF UNIT-0 MCG-5 LF/0.5 ML PA; SP Effective: January, 08 3
PNEUMOVAX 3 INJECTION SOLUTION 5 MCG/0.5 ML PNEUMOVAX 3 INJECTION SYRINGE 5 MCG/0.5 ML PREVNAR 3 (PF) INTRAMUSCULAR SYRINGE 0.5 ML PRIVIGEN INTRAVENOUS SOLUTION 0 % PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0EXP3-4.3-3- 3.99 TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 0EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION ML STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,000 UNIT/0.5 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5- LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-5 LF UNIT/0.5 ML tetanus-diphtheria toxoids-td intramuscular suspension - lf unit/0.5 ml TRUMENBA INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML PA; SP 3 Effective: January, 08 4
TWINRIX (PF) INTRAMUSCULAR SUSPENSION 70 ELISA UNIT -0 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 70 ELISA UNIT -0 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 5 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 5 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 5 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,350 UNIT/0.5 ML VARIZIG INTRAMUSCULAR RECON SOLN 5 UNIT VAXCHORA ACTIVE COMPONENT ORAL SUSPENSION FOR RECONSTITUTION 4X0EXP8 TO X 0EXP9 CF UNIT VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X0EXP8 TO X 0EXP9 CF UNIT VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 3 BILLION UNIT VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC) BILLION UNIT 3 YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 9,400 UNIT/0.65 ML AUTONOMIC DRUGS acebutolol oral capsule 00, 400 albuterol sulfate inhalation solution for nebulization 0.63 /3 ml,.5 /3 ml,.5 /3 ml (0.083 %), 5 /ml albuterol sulfate oral syrup /5 ml albuterol sulfate oral tablet, 4 Effective: January, 08 5
albuterol sulfate oral tablet extended release hr 4, 8 alfuzosin oral tablet extended release 4 hr 0 ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 6.5-5 MCG/ACTUATION atenolol oral tablet 00, 5, 50 atenolol-chlorthalidone oral tablet 00-5, 50-5 atropine injection solution 0.4 /ml, /ml atropine injection syringe 0.05 /ml, 0. /ml ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION QL baclofen oral tablet 0, 0 benztropine injection solution / ml benztropine oral tablet 0.5,, betaxolol oral tablet 0, 0 bethanechol chloride oral tablet 0, 5, 5, 50 bisoprolol fumarate oral tablet 0, 5 bisoprolol-hydrochlorothiazide oral tablet 0-6.5,.5-6.5, 5-6.5 BROVANA INHALATION SOLUTION FOR NEBULIZATION 5 MCG/ ML carvedilol oral tablet.5, 5, 3.5, 6.5 cevimeline oral capsule 30 CHANTIX CONTINUING MONTH BOX ORAL TABLET MG 3 CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) chlorzoxazone oral tablet 500 clonidine hcl oral tablet 0., 0., 0.3 Effective: January, 08 6
clonidine transdermal patch weekly 0. /4 hr, 0. /4 hr, 0.3 /4 hr QL CLORPRES ORAL TABLET 0.-5 MG, 0.- 5 MG COMBIVENT RESPIMAT INHALATION MIST 0-00 MCG/ACTUATION QL COREG CR ORAL CAPSULE, ER MULTIPHASE 4 HR 0 MG, 0 MG, 40 MG, 80 MG cyclobenzaprine oral tablet 0, 5, 7.5 dantrolene oral capsule 00, 5, 50 dicyclomine oral capsule 0 dicyclomine oral solution 0 /5 ml dicyclomine oral tablet 0 dihydroergotamine injection solution /ml diphenoxylate-atropine oral liquid.5-0.05 /5 ml diphenoxylate-atropine oral tablet.5-0.05 donepezil oral tablet 0, 5 donepezil oral tablet,disintegrating 0, 5 doxazosin oral tablet,, 4 QL doxazosin oral tablet 8 DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION, 00-5 QL MCG/ACTUATION DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT, 500 UNIT PA; SP EPINEPHRINE INJECTION AUTO- INJECTOR 0.5 MG/0.5 ML, 0.5 MG/0.3 ML, 0.3 MG/0.3 ML epinephrine injection solution /ml, /ml ( ml) epinephrine injection syringe 0. /ml EPIPEN -PAK INJECTION AUTO- INJECTOR 0.3 MG/0.3 ML QL Effective: January, 08 7
EPIPEN INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML EPIPEN JR -PAK INJECTION AUTO- INJECTOR 0.5 MG/0.3 ML QL EPIPEN JR INJECTION AUTO-INJECTOR 0.5 MG/0.3 ML ergoloid oral tablet FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE QL MCG galantamine oral capsule,ext rel. pellets 4 hr 6, 4, 8 galantamine oral solution 4 /ml galantamine oral tablet, 4, 8 glycopyrrolate injection solution 0. /ml glycopyrrolate oral tablet, guanidine oral tablet 5 ipratropium bromide inhalation solution 0.0 % labetalol intravenous solution 5 /ml labetalol oral tablet 00, 00, 300 metaproterenol oral syrup 0 /5 ml metaproterenol oral tablet 0, 0 methocarbamol oral tablet 500, 750 methscopolamine oral tablet.5, 5 methyldopa oral tablet 50, 500 methyldopa-hydrochlorothiazide oral tablet 50-5, 50-5 methyldopate intravenous solution 50 /5 ml metoprolol succinate oral tablet extended release 4 hr 00, 00, 5, 50 metoprolol ta-hydrochlorothiaz oral tablet 00-5, 00-50, 50-5 metoprolol tartrate intravenous solution 5 /5 ml metoprolol tartrate oral tablet 00, 5, 50 Effective: January, 08 8
midodrine oral tablet 0,.5, 5 NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 0 MG/ML orphenadrine citrate injection solution 30 /ml pilocarpine hcl oral tablet 5, 7.5 pindolol oral tablet 0, 5 prazosin oral capsule,, 5 propranolol intravenous solution /ml propranolol oral capsule,extended release 4 hr 0, 60, 60, 80 propranolol oral solution 0 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 0, 0, 40, 60, 80 propranolol-hydrochlorothiazid oral tablet 40-5, 80-5 pyridostigmine bromide oral tablet 60 REGONOL INJECTION SOLUTION 5 MG/ML rivastigmine tartrate oral capsule.5, 3, 4.5, 6 rivastigmine transdermal patch 4 hour 3.3 /4 hour, 4.6 /4 hr, 9.5 /4 hr sotalol oral tablet 0, 60, 40, 80 SPIRIVA RESPIMAT INHALATION MIST.5 MCG/ACTUATION,.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 QL MCG SYMBICORT INHALATION HFA AEROSOL INHALER 60-4.5 MCG/ACTUATION, 80-4.5 QL MCG/ACTUATION tamsulosin oral capsule,extended release 4hr 0.4 Effective: January, 08 9
terazosin oral capsule, 0,, 5 QL terbutaline oral tablet.5, 5 terbutaline subcutaneous solution /ml timolol maleate oral tablet 0, 0, 5 tizanidine oral capsule, 4, 6 tizanidine oral tablet, 4 trihexyphenidyl oral elixir 0.4 /ml trihexyphenidyl oral tablet, 5 VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION XEOMIN INTRAMUSCULAR RECON SOLN 00 UNIT, 00 UNIT, 50 UNIT PA; SP BLOOD FORMATION, COAGULATION, THROMBOSIS anagrelide oral capsule 0.5, ARANESP (IN POLYSORBATE) INJECTION SOLUTION 00 MCG/ML, 50 MCG/0.75 ML, 00 MCG/ML, 5 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML PA; SP ARANESP (IN POLYSORBATE) INJECTION SYRINGE 0 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 00 MCG/0.5 ML, 50 MCG/0.3 ML, 00 MCG/0.4 ML, 5 MCG/0.4 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML SP PA; SP argatroban in 0.9 % sod chlor intravenous parenteral solution 50 /50 ml ( /ml) argatroban in 0.9 % sod chlor intravenous solution /ml argatroban in nacl (iso-os) intravenous solution 50 /50 ml ( /ml) argatroban intravenous solution 00 /ml aspirin oral tablet 35 aspirin oral tablet,delayed release (dr/ec) 35 Effective: January, 08 30
aspirin-dipyridamole oral capsule, er multiphase hr 5-00 BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00, 50 clopidogrel oral tablet 300 clopidogrel oral tablet 75 desmopressin injection solution 4 mcg/ml desmopressin nasal spray,non-aerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0., 0. dipyridamole oral tablet 5, 50, 75 enoxaparin subcutaneous solution 300 /3 ml SP enoxaparin subcutaneous syringe 00 /ml, 0 /0.8 ml, 50 /ml, 30 /0.3 SP ml, 40 /0.4 ml, 60 /0.6 ml, 80 /0.8 ml enteric coated aspirin oral tablet,delayed release (dr/ec) 8 EPOGEN INJECTION SOLUTION 0,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PA; SP fondaparinux subcutaneous syringe 0 /0.8 ml,.5 /0.5 ml, 5 /0.4 ml, 7.5 /0.6 ml FRAGMIN SUBCUTANEOUS SOLUTION 5,000 ANTI-XA UNIT/ML FRAGMIN SUBCUTANEOUS SYRINGE 0,000 ANTI-XA UNIT/ML,,500 ANTI-XA UNIT/0.5 ML, 5,000 ANTI-XA UNIT/0.6 ML, 8,000 ANTI-XA UNIT/0.7 ML,,500 ANTI- XA UNIT/0. ML, 5,000 ANTI-XA UNIT/0. ML, 7,500 ANTI-XA UNIT/0.3 ML heparin (porcine) in 5 % dex intravenous parenteral solution 0,000 unit/500 ml (40 unit/ml), 5,000 unit/50 ml(00 unit/ml), 5,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/,000 ml SP SP SP Effective: January, 08 3
heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 0,000 unit/ml heparin, porcine (pf) injection solution,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml IXINITY INTRAVENOUS RECON SOLN,000 UNIT,,500 UNIT,,000 UNIT, 50 UNIT, 3,000 UNIT, 500 UNIT JANTOVEN ORAL TABLET MG, 0 MG, MG,.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG LEUKINE INJECTION RECON SOLN 50 MCG MOZOBIL SUBCUTANEOUS SOLUTION 4 MG/. ML (0 MG/ML) multi-vit with fluoride-iron oral drops 0.5 fluoride -0 iron/ml NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML NOVOEIGHT INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,500 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE pentoxifylline oral tablet extended release 400 PRENATAL VITAMIN WITH MINERALS ORAL TABLET 8 MG IRON- 800 MCG PROCRIT INJECTION SOLUTION 0,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML Effective: January, 08 3 SP SP SP PA; SP; QL PA; SP PA; SP PA; SP PA PA; SP
PROMACTA ORAL TABLET.5 MG, 5 MG, 50 MG, 75 MG PA; SP ticlopidine oral tablet 50 tranexamic acid intravenous solution,000 /0 ml (00 /ml) tranexamic acid oral tablet 650 TRI-VIT WITH FLUORIDE AND IRON ORAL DROPS 0.5-0 MG/ML warfarin oral tablet, 0,,.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 0 MG, 5 MG, 0 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (4)- 0 MG (9) ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PA; SP CARDIOVASCULAR DRUGS acebutolol oral capsule 00, 400 acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 5, 50 acetazolamide sodium injection recon soln 500 ADCIRCA ORAL TABLET 0 MG PA; SP amiloride oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 amiodarone intravenous solution 50 /ml amiodarone oral tablet 00, 400 amlodipine oral tablet 0,.5, 5 amlodipine-benazepril oral capsule 0-0, 0-40,.5-0, 5-0, 5-0, 5-40 aspirin-dipyridamole oral capsule, er multiphase hr 5-00 atenolol oral tablet 00, 5, 50 atenolol-chlorthalidone oral tablet 00-5, 50-5 Effective: January, 08 33
atorvastatin oral tablet 0, 0 3 ST; QL atorvastatin oral tablet 40, 80 ST; QL benazepril oral tablet 0, 0, 40, 5 benazepril-hydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5, 5-6.5 betaxolol oral tablet 0, 0 bisoprolol fumarate oral tablet 0, 5 bisoprolol-hydrochlorothiazide oral tablet 0-6.5,.5-6.5, 5-6.5 bumetanide injection solution 0.5 /ml bumetanide oral tablet 0.5,, captopril oral tablet 00,.5, 5, 50 captopril-hydrochlorothiazide oral tablet 5-5, 5-5, 50-5, 50-5 carvedilol oral tablet.5, 5, 3.5, 6.5 chlorothiazide oral tablet 50, 500 chlorothiazide sodium intravenous recon soln 500 chlorthalidone oral tablet 5, 50 CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM cilostazol oral tablet 00, 50 clonidine hcl oral tablet 0., 0., 0.3 clonidine transdermal patch weekly 0. /4 hr, 0. /4 hr, 0.3 /4 hr QL CLORPRES ORAL TABLET 0.-5 MG, 0.- 5 MG colestipol oral packet 5 gram colestipol oral tablet gram COREG CR ORAL CAPSULE, ER MULTIPHASE 4 HR 0 MG, 0 MG, 40 MG, 80 MG Effective: January, 08 34
CORLANOR ORAL TABLET 5 MG, 7.5 MG PA digoxin injection solution 50 mcg/ml digoxin injection syringe 50 mcg/ml digoxin oral solution 50 mcg/ml digoxin oral tablet 5 mcg, 50 mcg DILANTIN ORAL CAPSULE 30 MG diltiazem hcl intravenous recon soln 00 diltiazem hcl intravenous solution 5 /ml diltiazem hcl oral capsule,ext.rel 4h degradable 0, 80, 40 diltiazem hcl oral capsule,ext.rel 4h degradable 40 diltiazem hcl oral capsule,extended release hr 0, 60, 90 diltiazem hcl oral capsule,extended release 4 hr 0, 80, 40, 300, 360, 40 diltiazem hcl oral capsule,extended release 4hr 0, 80, 40, 300, 360 diltiazem hcl oral tablet 0, 30, 60, 90 diltiazem hcl oral tablet extended release 4 hr 80, 40, 300, 360, 40 dilt-xr oral capsule,ext.rel 4h degradable 0, 80, 40 dipyridamole oral tablet 5, 50, 75 disopyramide phosphate oral capsule 00, 50 dofetilide oral capsule 5 mcg, 50 mcg, 500 mcg doxazosin oral tablet,, 4 QL doxazosin oral tablet 8 enalapril maleate oral tablet 0,.5, 0, 5 enalapril-hydrochlorothiazide oral tablet 0-5, 5-.5 Effective: January, 08 35
ENTRESTO ORAL TABLET 4-6 MG, 49-5 MG, 97-03 MG ENTRESTO ORAL TABLET 4-6 MG, 49-5 MG, 97-03 MG PA eplerenone oral tablet 5, 50 ezetimibe oral tablet 0 felodipine oral tablet extended release 4 hr 0,.5, 5 fenofibrate micronized oral capsule 30, 34, 00, 43, 67 fenofibrate nanocrystallized oral tablet 45, 48 fenofibrate oral tablet 60, 54 fenofibric acid (choline) oral capsule,delayed release(dr/ec) 35, 45 flecainide oral tablet 00, 50, 50 fosinopril oral tablet 0, 0, 40 fosinopril-hydrochlorothiazide oral tablet 0-.5, 0-.5 furosemide injection solution 0 /ml furosemide oral solution 0 /ml, 40 /5 ml (8 /ml) furosemide oral tablet 0, 40, 80 gemfibrozil oral tablet 600 guanfacine oral tablet, guanfacine oral tablet extended release 4 hr,, 3, 4 hydralazine injection solution 0 /ml hydralazine oral tablet 0, 00, 5, 50 hydrochlorothiazide oral capsule.5 hydrochlorothiazide oral tablet.5, 5, 50 indapamide oral tablet.5,.5 irbesartan oral tablet 50, 300, 75 irbesartan-hydrochlorothiazide oral tablet 50-.5, 300-.5 Effective: January, 08 36