Your Empire MediBlue Freedom (LPPO)
and Senior Rx Plus Plan
2014 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS
PLAN
Your Medicare Prescription Drug benefits and Senior Rx Plus benefits cover the same drug list
(formulary).
This formulary was updated on August 1, 2013. For more recent information or other questions,
please contact us, Empire BlueCross at 1-866-222-0444 or, for TTY users, 711, Monday through
Friday, except holidays from 8 a.m. to 9 p.m. ET, or visit www.empireblue.com.
Note to existing members: This formulary has changed since last year. Please review this document
to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Empire BlueCross . When it refers
to “plan” or “your plan,” it means your 2014 group retiree drug plan.
This document includes a list of the drugs (formulary) for our plan which is current as of January 1,
2014. For an updated formulary, please contact us. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Your formulary and
pharmacy network may change on January 1, 2015. Depending on your former group, employer or
union's renewal date, your benefits, premium or copayments/coinsurance may also change on January
1, 2015. Please refer to your Evidence of Coverage for information specific to your plan.
Our plan has free language interpreter services available to answer questions from non-English speaking
members. Please call the Customer Service number listed above to request interpreter services.
This document may be available in an alternate format, such as large print. Please call the Customer
Service listed above for additional information.
38687MUSENMUB_024
August 1, 2013_Comprehensive_P3TARO_10R
Table of Contents
What is the Empire MediBlue Freedom (LPPO) formulary?.....................2
Can the formulary (Drug List) change?........................................................2
How do I use the formulary?...........................................................................3
What are generic drugs?..................................................................................3
Are there any restrictions on my coverage?...............................................3
What if my drug is not on the formulary?....................................................3
How do I request an exception to the Empire MediBlue Freedom (LPPO)
formulary?...........................................................................................................3
What do I do before I can talk to my doctor about changing my drugs
or requesting an exception?...........................................................................4
For more information.......................................................................................4
Your plan’s formulary........................................................................................4
Select Generics..................................................................................................6
Covered Medications by Therapeutic Category.........................................8
Index of Drugs..................................................................................................87
b+
1
Part D Formulary
What is the Empire MediBlue
Freedom (LPPO) formulary?
Can the formulary (Drug List)
change?
A formulary is a list of covered drugs selected by us in
consultation with a team of health care providers, which
represents the prescription therapies believed to be a
necessary part of a quality treatment program. Your plan
will generally cover the drugs listed in the formulary as long
as the drug is medically necessary, the prescription is filled
at a network pharmacy and other plan rules are followed.
For more information on how to fill your prescriptions,
please review your Evidence of Coverage.
Generally, if you are taking a drug on our 2014 formulary
that was covered at the beginning of the year, we will not
discontinue or reduce coverage of the drug during the 2014
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.
If we remove drugs from our formulary, or add prior
authorization, quantity limits and/or step therapy restrictions
on a drug, or move a drug to a higher cost sharing tier we
If your plan uses a Closed Formulary (Closed Drug List), must notify affected members of the change at least 60 days
you have coverage for most, but not all, Medicare Part D before the change becomes effective, or at the time the
eligible drugs. The drugs on this list are all approved by member requests a refill of the drug, at which time the
the FDA and are selected by the plan with the help of a member will receive a 60-day supply of the drug. If the Food
team of doctors and pharmacists. Not all drugs are on
and Drug Administration deems a drug on our formulary
the Closed Formulary. The drugs covered under your
to be unsafe or the drug’s manufacturer removes the drug
retiree drug coverage are listed in your plan’s Drug List. from the market, we will immediately remove the drug from
If your plan uses an Open Formulary (Open Drug List), our formulary and provide notice to members who take the
you have coverage for all Medicare Part D eligible drugs. drug.
You also have coverage for certain additional drugs not
We evaluate new drugs as they come onto the market. Once
typically covered by Medicare Part D plans. The
we have completed a full evaluation based upon clinical
additional drugs beyond those typically covered by
Medicare are all approved by the FDA and are selected effectiveness and cost relative to other drug therapies, the
drug will be assigned to a drug plan tier or non-formulary
by the plan with the help of a team of doctors and
pharmacists. These drugs are covered by your Senior Rx designation. If your plan uses an Open Formulary you will
have coverage for a new Part D eligible drug designated
Plus supplemental benefits. The drugs covered under
your retiree drug coverage are listed in your plan’s Drug non-formulary following our review. During the period
between the time the drug is first available and our review,
List or your benefit chart.
the drug will not be automatically covered. If your physician
For both types of formularies, some drugs may sometimes feels you should use the new drug, you or your physician
be covered under the medical benefits of your plan rather may request a coverage exception.
than under the drug benefit of your plan. The drugs that
The enclosed formulary is current as of January 1, 2014. If
are sometimes covered under your medical benefits are
any other type of approved formulary change is made during
marked with a B/D in drug list.
the year, we will notify you by sending you a list of these
To find out whether you have a Closed or Open Formulary changes, or by sending you an updated formulary. To get
benefit, please check the benefit chart in the front of your updated information about the drugs covered by your plan,
Evidence of Coverage. For more information on how to fill please contact us. Our contact information appears on the
your prescriptions, please review your Evidence of Coverage. front and back cover pages.
2
Prior Authorization: Your plan requires you or your
provider to get prior authorization for certain drugs. This
means that you will need to get approval from us before
you fill your prescriptions. If you don't get approval, your
plan may not cover the drug.
Quantity Limits: For certain drugs, we limit the amount
of the drug that we will cover. For example, we provide
100 units per ml per prescription for HUMALOG. This
may be in addition to a standard one month or three
month supply.
Step Therapy: In some cases, we require you to first try
certain drugs to treat your medical condition before we
will cover another drug for that condition. For example,
if Drug A and Drug B both treat your medical condition,
we may not cover Drug B unless you try Drug A first. If
Drug A does not work for you, we will then cover Drug
B.
How do I use the formulary?
There are two ways to find your drug within the formulary:
Medical Condition: The formulary begins on page 8.
The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are
used to treat. For example, drugs used to treat a heart
condition are listed under the category, “Cardiovascular
Medication.” If you know what your drug is used for, look
for the category name in the list that begins on page 8.
Then look under the category name for your drug.
Alphabetical Listing: If you are not sure what category to
look under, you should look for your drug in the Index that
begins on page 87. The Index provides an alphabetical list
of all of the drugs included in this document. Both brand
name drugs and generic drugs are listed in the Index. Look
in the Index and find your drug. Next to your drug, you
You can find out if your drug has any additional
will see the page number where you can find coverage
information. Turn to the page listed in the Index and find requirements or limits by looking in the formulary that
begins on page 8. Our contact information, along with
the name of your drug in the first column of the list.
the date we last updated the formulary, appears on the front
and back cover pages.
What are generic drugs?
You can ask us to make an exception to these restrictions
Your plan covers both brand name drugs and generic drugs.
or limits or for a list of other, similar drugs that may treat
A generic drug is approved by the FDA as having the same
your health condition. See the section, “How do I request
active ingredient as the brand name drug. Generally, generic
an exception to the plan’s formulary?” for information about
drugs cost less than brand name drugs.
how to request an exception.
Many plans also cover a small group of $0 copay Select
What if my drug is not on the
Generic drugs. These are drugs which have proven over
time to be especially cost effective options for treating some formulary?
conditions. Your plan offers these drugs at no cost to you
If you learn that access to your drug is limited, for any
when you purchase them at a network pharmacy. You can reason, you have two options:
find the list of $0 copay Select Generic drugs on page 6.
You can ask Customer Service for a list of similar drugs
To find out whether your plan includes this benefit, please
that are covered by your plan. When you receive the list,
check the benefit chart in the front of your Evidence of
show it to your doctor and ask him or her to prescribe a
Coverage.
similar drug that is covered by your plan.
You can ask your plan to make an exception and cover
Are there any restrictions on my
your drug. See below for information about how to
request an exception.
coverage?
Some covered drugs may have additional requirements or
limits on coverage. These requirements and limits may
include:
How do I request an exception to
the Empire MediBlue Freedom
(LPPO) formulary?
You can ask us to make an exception to our coverage rules.
There are several types of exceptions that you can ask us to
make.
3
If your drug plan uses a closed formulary, you can ask us
to cover your drug even if it is not on our formulary. If
approved, this drug will be covered at a pre-determined
cost-sharing level, and you would not be able to ask us
to provide the drug at a lower cost-sharing level.
You can ask us to cover a formulary drug at a lower
cost-sharing level if this drug is not on the specialty tier.
If approved this would lower the amount you must pay
for your drug.
You can ask us to waive coverage restrictions or limits on
your drug. For example, for certain drugs, we limit the
amount of the drug that we will cover. If your drug has
a quantity limit, you can ask us to waive the limit and
cover a greater amount.
While you talk to your doctor to determine the right course
of action for you, we may cover your drug in certain cases
during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if
your ability to get your drugs is limited, we will cover a
temporary 30-day supply (unless you have a prescription
written for fewer days) when you go to a network pharmacy.
After your first 30-day supply, we will not pay for these
drugs, even if you have been a member of the plan less than
90 days.
If you are a resident of a long-term care facility, we will
cover a temporary 98-day transition supply consistent with
dispensing increment (unless you have a prescription written
for fewer days). We will cover more than one refill of these
drugs for the first 90 days you are a member of our plan. If
you need a drug that is not on our formulary or if your
ability to get your drugs is limited, but you are past the first
90 days of membership in our plan, we will cover a: 31-day
emergency supply of that drug (unless you have a
prescription for fewer days) while you pursue a formulary
exception.
Generally, your plan will only approve your request for an
exception if the alternative drugs included on the plan’s
formulary, the lower cost-sharing drug or additional
utilization restrictions would not be as effective in treating
your condition and/or would cause you to have adverse
medical effects.
You should contact us to ask us for an initial coverage
decision for a formulary, tiering or utlization restriction
exception.
For more information
For more detailed information about your
plan's prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
When you request a formulary, tiering or utilization
restriction exception you should submit a statement
from your prescribing provider supporting your request.
Generally, we must make our decision within 72 hours of
getting your provider’s supporting statement. You can
request an expedited (fast) exception if you or your doctor
believe that your health could be seriously harmed by
waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later
than 24 hours after we get a supporting statement from your
prescribing provider.
If you have questions about your plan, please contact us.
Our contact information, along with the date we last
updated this formulary, appears on the front and back cover
pages.
If you have general questions about Medicare prescription
drug coverage, please call Medicare at 1-800-MEDICARE
(1-800-633-4227), 24 hours a day/7 days a week. TTY/
TDD users should call 1-877-486-2048. Or, visit
www.medicare.gov.
What do I do before I can talk to my
doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan, you may be
taking drugs that are not on our formulary. Or, you may
be taking a drug that is on our formulary but your ability
to get it is limited. For example, you may need a prior
authorization from us before you can fill your prescription.
You should talk to your doctor to decide if you should
switch to an appropriate drug that we cover or request a
formulary exception so that we will cover the drug you take.
4
The benefit chart in your Evidence of Coverage will also
tell you if the amount that you pay for covered drugs
The formulary that begins on page 8 provides coverage
information about the drugs covered by your plan. If you changes after the total drug cost paid by you and the plan
have trouble finding your drug in the list, turn to the Index reaches the initial coverage amount of $2,850. Please check
your benefit chart and Evidence of Coverage for complete
that begins on page 87.
details on the cost you must pay for drugs covered by your
The first column of the chart lists the drug name. Brand drug plan.
name drugs are capitalized (e.g., HUMALOG) and generic
The third column tells you if your plan has any special
drugs are listed in lower-case italics (e.g., enalapril).
requirements for coverage of your drug. The formulary chart
legend, located on page 8, contains the list of special
The second column of the chart identifies the tier
placement of each medication covered in your formulary. requirements which can be applied to drugs in your plan.
The legend also gives you a description of the restriction
Many drug plans group drugs based upon cost with the
lowest cost drugs in Tier 1. These are typically generic drugs. and the code used in the drug chart to tell you that the
restriction applies to a specific drug.
To find out what your copayment is for each drug tier,
please check the benefit chart in the front of your Evidence
of Coverage.
Your plan’s formulary
5
Select Generics
(Please check the Benefit Chart in the front of your Evidence of Coverage to find out if your plan offers $0 copay for
Select Generic drugs.)
Drug Name
Drug Name
Cardiovascular
atenolol 25 mg tablet
atenolol 50 mg tablet
atenolol 100 mg tablet
atenolol-chlorthalidone 50-25 tablet
atenolol-chlorthalidone 100-25 tablet
benazepril hcl 5 mg tablet
benazepril hcl 10 mg tablet
benazepril hcl 20 mg tablet
benazepril hcl 40 mg tablet
benazepril-hydrochlorothiazide 5-6.25 mg tablet
benazepril-hydrochlorothiazide 10-12.5 mg tablet
benazepril-hydrochlorothiazide 20-12.5 mg tablet
benazepril-hydrochlorothiazide 20-25 mg tablet
bisoprolol-hydrochlorothiazide 2.5-6.25 mg tablet
bisoprolol-hydrochlorothiazide 5-6.25 mg tablet
bisoprolol-hydrochlorothiazide 10-6.25 mg tablet
captopril 12.5 mg tablet
captopril 25 mg tablet
captopril 50 mg tablet
captopril 100 mg tablet
captopril-hydrochlorothiazide 25-15 mg tablet
captopril-hydrochlorothiazide 25-25 mg tablet
captopril-hydrochlorothiazide 50-15 mg tablet
captopril-hydrochlorothiazide 50-25 mg tablet
chlorthalidone 25 mg tablet
chlorthalidone 50 mg tablet
enalapril maleate 2.5 mg tablet
enalapril maleate 5 mg tablet
enalapril maleate 10 mg tablet
enalapril maleate 20 mg tablet
enalapril-hydrochlorothiazide 5-12.5 mg tablet
enalapril-hydrochlorothiazide 10-25 mg tablet
hydrochlorothiazide 12.5 mg capsule
hydrochlorothiazide 12.5 mg tablet
hydrochlorothiazide 25 mg tablet
hydrochlorothiazide 50 mg tablet
lisinopril 2.5 mg tablet
lisinopril 5 mg tablet
lisinopril 10 mg tablet
lisinopril 20 mg tablet
lisinopril 30 mg tablet
lisinopril 40 mg tablet
lisinopril-hydrochlorothiazide 10-12.5 mg tablet
lisinopril-hydrochlorothiazide 20-12.5 mg tablet
lisinopril-hydrochlorothiazide 20-25 mg tablet
metoprolol 50 mg tablet
metoprolol 100 mg tablet
metoprolol tartrate 25 mg tablet
metoprolol tartrate 50 mg tablet
metoprolol tartrate 100 mg tablet
Cholesterol
lovastatin 10 mg tablet
lovastatin 20 mg tablet
lovastatin 40 mg tablet
pravastatin sodium 10 mg tablet
pravastatin sodium 20 mg tablet
pravastatin sodium 40 mg tablet
pravastatin sodium 80 mg tablet
simvastatin 5 mg tablet
simvastatin 10 mg tablet
simvastatin 20 mg tablet
simvastatin 40 mg tablet
simvastatin 80 mg tablet
Depression
budeprion sr 100 mg tablet
budeprion sr 150 mg tablet
bupropion hcl 75 mg tablet
bupropion hcl 100 mg tablet
bupropion hcl sr 100 mg tablet
bupropion sr 150 mg tablet
bupropion hcl sr 200 mg tablet
citalopram hbr 10 mg tablet
citalopram hbr 20 mg tablet
citalopram hbr 40 mg tablet
fluoxetine hcl 10 mg capsule
fluoxetine hcl 10 mg tablet
fluoxetine hcl 20 mg capsule
fluoxetine hcl 20 mg tablet
fluoxetine hcl 40 mg capsule
mirtazapine 7.5 mg tablet
mirtazapine 15 mg orally disintegrating tablet
mirtazapine 15 mg tablet
6
mirtazapine 30 mg orally disintegrating tablet
mirtazapine 30 mg tablet
mirtazapine 45 mg orally disintegrating tablet
mirtazapine 45 mg tablet
paroxetine hcl 10 mg tablet
paroxetine hcl 20 mg tablet
paroxetine hcl 30 mg tablet
paroxetine hcl 40 mg tablet
Diabetes
glimepiride 1 mg tablet
glimepiride 2 mg tablet
glimepiride 4 mg tablet
glipizide 5 mg tablet
glipizide 10 mg tablet
glipizide er 2.5 mg tablet
glipizide er 5 mg tablet
glipizide er 10 mg tablet
glipizide-metformin 2.5-250 mg
glipizide-metformin 2.5-500 mg
glipizide-metformin 5-500 mg
metformin hcl 500 mg tablet
metformin hcl 850 mg tablet
metformin hcl 1,000 mg tablet
metformin hcl er 500 mg tablet
Osteoperosis
alendronate sodium 5 mg tablet
alendronate sodium 10 mg tablet
alendronate sodium 35 mg tablet
alendronate sodium 40 mg tablet
alendronate sodium 70 mg tablet
Smoking Cessation
buproban 150 mg tablet
bupropion hcl sr 150 mg tablet
7
Covered Medications by Therapeutic Category
Legend
Generic drugs are shown in lowercase italics (e.g. enalapril)
Brand name drugs are shown in capital letters (e.g. LEXAPRO)
QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits
each time you get a prescription filled (most often set on a monthly basis).
PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved.
You, your doctor or other network provider will need to request prior authorization before you fill the prescription.
ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or drugs will treat your
medical condition before your plan will cover another drug for that condition.
B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B
drug under your medical benefits, as determined by Medicare.
LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your
Pharmacy Directory or call Customer Service. The phone numbers are listed on the front and back covers of this booklet.
INJ - Injectable: The drug is available in injectable form.
MO - Mail Order: Prescription drugs available through Mail Order.
[+] Preferred: The symbol [+] in the Drug Name column denotes preferred products.
Part D Eligible
Drug Name
Drug
Tier
Adjunctive Agents
1
amifostine
1
calcium folinate
1
dexrazoxane inj 250mg
1
dexrazoxane inj 500mg
ELITEK
2
ETHYOL
3
FUSILEV
2
KEPIVANCE
3
leucovorin calcium inj 100mg,1
10mg/ml, 200mg, 350mg,
50mg
leucovorin calcium inj 500mg 1
1
leucovorin calcium tabs
1
mesna
MESNEX INJ
2
MESNEX TABS
3
VORAXAZE
3
XGEVA
2
ZINECARD
3
Adrenal Hormones
a-hydrocort
a-methapred
Effective January 1, 2014
1
1
Requirements/
Limits
Drug Name
Drug
Tier
ACTHAR HP
2
ARISTOSPAN INTRA3
PAR MO
ARTICULAR
ARISTOSPAN
3
B/D PAR
INTRALESIONAL
B/D PAR MO
ASMALPRED PLUS
3
3
baycadron
MO
3
betamethasone
sodium
B/D PAR MO
phosphate/betamethasone
acetate
MO
CELESTONE
3
CELESTONE-SOLUSPAN 3
CORTEF
3
1
cortisone
acetate
MO
DEPO-MEDROL
3
MO
1
dexamethasone
1
dexamethasone intensol
MO
1
dexamethasone sodium
PAR QLL(1.7 per 28 phosphate
DEXPAK 10 DAY
3
days) MO
DEXPAK
13
DAY
3
MO
DEXPAK 6 DAY
3
FLO-PRED
3
MO
1
fludrocortisone
acetate
MO
1
hydrocortisone tabs
8
Requirements/
Limits
PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
KENALOG-10
3
KENALOG-40
3
MEDROL
3
MEDROL DOSEPAK
3
1
methylprednisolone
methylprednisolone acetate 1
methylprednisolone dose pack 1
1
methylprednisolone
sodiumsuccinate inj 1000mg,
125mg, 1gm, 40mg
1
methylprednisolone
sodiumsuccinate inj 500mg
1
millipred dp
MILLIPRED ORAL SOLN 3
1
millipred tabs
ORAPRED
3
ORAPRED ODT
3
PEDIAPRED
3
1
prednisolone
prednisolone sodium phosphate1
oral soln 15mg/5ml, 5mg/5ml
prednisolone sodium phosphate3
oral soln 25mg/5ml
1
prednisone
1
prednisone intensol
PRELONE
3
RAYOS
3
SOLU-CORTEF INJ
3
1000MG
SOLU-CORTEF INJ
3
100MG, 250MG, 500MG
SOLU-MEDROL INJ
3
1000MG, 125MG, 40MG,
500MG
SOLU-MEDROL INJ 2GM3
TRIESENCE
3
1
veripred 20
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Antiarrhythmic Agents
amiodarone hcl inj
amiodarone hcl tabs 200mg,
400mg
BETAPACE
BETAPACE AF
CORDARONE
CORVERT
disopyramide phosphate
1
1
B/D PAR MO
MO
3
3
3
3
1
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
flecainide acetate
ibutilide fumarate
lidocaine hcl in d5w
lidocaine hcl inj 10mg/ml
lidocaine hcl inj 20mg/ml
lidocaine hcl inj 20mg/ml
lidocaine hcl/dextrose
mexiletine hcl
MULTAQ
NEXTERONE
NORPACE
NORPACE CR
pacerone
procainamide hcl inj 100mg/
ml
procainamide hcl inj 500mg/
ml
propafenone hcl
propafenone hcl er
quinidine gluconate
quinidine gluconate cr
quinidine gluconate er
quinidine sulfate
quinidine sulfate er
RYTHMOL
RYTHMOL SR
sorine
sotalol hcl
sotalol hcl (af )
SOTALOL
HYDROCHLORIDE
TAMBOCOR
TIKOSYN
XYLOCAINE INJ 20MG/
ML
Drug
Tier
Requirements/
Limits
1
3
3
3
1
3
3
1
3
3
3
3
1
1
MO
MO
MO
MO
MO
MO
B/D PAR
MO
MO
MO
MO
1
1
1
3
1
1
1
1
3
3
1
1
1
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
3
2
3
MO
MO
1
3
1
1
3
3
MO
MO
MO
MO
MO
MO
3
1
1
MO
MO
MO
Antibiotics
ak-poly-bac
AZASITE
bacitracin
bacitracin/polymyxin b
BESIVANCE
BETADINE
OPHTHALMIC PREP
CILOXAN
ciprofloxacin hcl
erythromycin
9
Effective January 1, 2014
Drug Name
Drug
Tier
GARAMYCIN OINT
3
garamycin ophthalmic soln 3
1
gentak
1
gentamicin sulfate
ILOTYCIN
3
levofloxacin ophthalmic soln 1
MOXEZA [+]
2
NATACYN
2
1
neo-polycin
neomycin/bacitracin/polymyxin1
neomycin/polymyxin/bacitracin1
zinc
1
neomycin/polymyxin/
gramicidin
NEOSPORIN
3
OCUFLOX
3
1
ofloxacin
1
polycin
1
polymyxin b sulfate/
trimethoprim sulfate
POLYTRIM
3
3
romycin
tobramycin sulfate ophthalmic 1
soln
TOBREX
3
trimethoprim sulfate/polymyxin1
b sulfate
VIGAMOX [+]
2
ZYMAXID
3
Requirements/
Limits
Drug Name
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
GELNIQUE GEL 3% [+] 2
MYRBETRIQ
3
oxybutynin chloride er tb24
10mg, 15mg
oxybutynin chloride er tb24
5mg
oxybutynin chloride syrp
1
oxybutynin chloride tabs
1
MO
OXYTROL
3
MO
MO
MO
MO
MO
SANCTURA
3
SANCTURA XR
3
MO
MO
MO
tolterodine tartrate tabs 2mg 1
TOVIAZ [+]
2
MO
MO
trospium chloride
1
trospium chloride er
1
VESICARE
3
3
DETROL TABS 1MG
3
DETROL TABS 2MG
3
DITROPAN XL TB24
3
10MG, 15MG
DITROPAN XL TB24 5MG3
ENABLEX
3
1
flavoxate hcl
GELNIQUE GEL 10% [+] 2
Effective January 1, 2014
1
1
tolterodine tartrate tabs 1mg 1
MO
MO
Anticholinergics & Antispasmodics
DETROL LA
Drug
Tier
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
ST MO
QLL(30 per 30 days)
ST MO
QLL(30 per 30 days)
ST MO
MO
QLL(30 per 30 days)
ST MO
10
Requirements/
Limits
QLL(100 per 30
days) ST MO
QLL(30 per 30 days)
ST MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(600 per 30
days) MO
QLL(120 per 30
days) MO
QLL(8 per 28 days)
ST MO
QLL(60 per 30 days)
ST MO
QLL(30 per 30 days)
ST MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
ST MO
QLL(30 per 30 days)
ST MO
Anticonvulsants
BANZEL SUSP
2
BANZEL TABS 200MG
2
BANZEL TABS 400MG
2
1
carbamazepine
1
carbamazepine er
CARBATROL
3
CELONTIN
3
clonazepam odt tbdp 0.125mg1
clonazepam odt tbdp 0.25mg 1
clonazepam odt tbdp 0.5mg 1
QLL(2400 per 30
days) MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
MO
MO
MO
MO
QLL(4800 per 30
days) MO
QLL(2400 per 30
days) MO
QLL(1200 per 30
days) MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
clonazepam odt tbdp 1mg
1
clonazepam odt tbdp 2mg
1
clonazepam tabs 0.5mg
1
clonazepam tabs 1mg
1
QLL(600 per 30
days) MO
QLL(300 per 30
days) MO
QLL(1200 per 30
days) MO
QLL(600 per 30
days) MO
QLL(300 per 30
days) MO
MO
MO
MO
MO
MO
QLL(2 per 1 days)
MO
QLL(2 per 1 days)
MO
QLL(2 per 1 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(180 per 30
days) MO
MO
MO
MO
MO
QLL(1080 per 30
days) MO
QLL(360 per 30
days) MO
QLL(270 per 30
days) MO
QLL(2160 per 30
days) MO
clonazepam tabs 2mg
1
DEPACON
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLES
DIASTAT ACUDIAL
2
3
3
3
3
3
DIASTAT PEDIATRIC
diazepam gel
DILANTIN CAPS 100MG
DILANTIN CAPS 30MG
DILANTIN INFATABS
DILANTIN SUSP
divalproex sodium
divalproex sodium dr
divalproex sodium er
epitol
EQUETRO CP12 100MG
3
1
3
2
2
3
1
1
1
1
3
EQUETRO CP12 200MG 3
EQUETRO CP12 300MG 3
ethosuximide
felbamate
FELBATOL
fosphenytoin sodium
gabapentin caps 100mg
1
1
3
1
1
gabapentin caps 300mg
1
gabapentin caps 400mg
1
gabapentin oral soln
1
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
gabapentin tabs 600mg
1
gabapentin tabs 800mg
1
GABITRIL
GRALISE STARTER
3
3
GRALISE TABS 300MG
3
GRALISE TABS 600MG
3
KLONOPIN TABS 1MG
3
KLONOPIN TABS 2MG
3
LAMICTAL CHEWABLE
DISPERSIBLE
LAMICTAL ODT
LAMICTAL STARTER/
NOT TAKING
CARBAMAZEPINE
LAMICTAL STARTER/
TAKING
CARBAMAZEPINE/NOT
TAKING VALPROATE
LAMICTAL STARTER/
TAKING VALPROATE
LAMICTAL TABS
LAMICTAL XR
lamotrigine
lamotrigine er
levetiracetam er tb24 500mg
3
QLL(180 per 30
days) MO
QLL(135 per 30
days) MO
MO
QLL(78 per 365
days) MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
QLL(180 per 30
days) MO
QLL(120 per 30
days) MO
QLL(1200 per 30
days) MO
QLL(600 per 30
days) MO
QLL(300 per 30
days) MO
MO
3
3
MO
MO
3
MO
3
MO
3
3
1
1
1
MO
MO
MO
MO
QLL(180 per 30
days) MO
QLL(120 per 30
days) MO
MO
MO
MO
KEPPRA
3
KEPPRA XR TB24 500MG 3
KEPPRA XR TB24 750MG 3
KLONOPIN TABS 0.5MG 3
levetiracetam er tb24 750mg 1
levetiracetam inj 500mg/5ml
levetiracetam oral soln
levetiracetam tabs
LUMINAL
11
1
1
1
2
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
LYRICA CAPS 100MG
2
LYRICA CAPS 150MG
2
LYRICA CAPS 200MG
2
LYRICA CAPS 225MG,
300MG
LYRICA CAPS 25MG
2
LYRICA CAPS 50MG
2
LYRICA CAPS 75MG
2
LYRICA ORAL SOLN
2
MYSOLINE
NEURONTIN CAPS
100MG
NEURONTIN CAPS
300MG
NEURONTIN CAPS
400MG
NEURONTIN ORAL
SOLN
NEURONTIN TABS
600MG
NEURONTIN TABS
800MG
ONFI TABS 10MG
3
3
ONFI TABS 20MG
3
ONFI TABS 5MG
3
oxcarbazepine
OXTELLAR XR TB24
150MG
OXTELLAR XR TB24
300MG
OXTELLAR XR TB24
600MG
PEGANONE
phenobarbital elix
1
3
PAR QLL(180 per
30 days) MO
PAR QLL(120 per
30 days) MO
PAR QLL(90 per 30
days) MO
PAR QLL(60 per 30
days) MO
PAR QLL(720 per
30 days) MO
PAR QLL(360 per
30 days) MO
PAR QLL(240 per
30 days) MO
PAR QLL(900 per
30 days) MO
MO
QLL(1080 per 30
days) MO
QLL(360 per 30
days) MO
QLL(270 per 30
days) MO
QLL(2160 per 30
days) MO
QLL(180 per 30
days) MO
QLL(135 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(240 per 30
days) MO
MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
MO
QLL(3000 per 30
days) MO
phenobarbital sodium
1
Effective January 1, 2014
2
3
3
3
3
3
3
3
3
3
1
12
Drug Name
Drug
Tier
Requirements/
Limits
phenobarbital tabs 100mg
1
phenobarbital tabs 15mg
1
phenobarbital tabs 16.2mg
1
phenobarbital tabs 30mg
1
phenobarbital tabs 32.4mg
1
phenobarbital tabs 60mg
1
phenobarbital tabs 64.8mg
1
phenobarbital tabs 97.2mg
1
PHENYTEK
phenytoin
phenytoin infatabs
phenytoin sodium
phenytoin sodium extended
POTIGA TABS 200MG,
300MG, 400MG
POTIGA TABS 50MG
3
1
1
1
1
2
QLL(120 per 30
days) MO
QLL(800 per 30
days) MO
QLL(741 per 30
days) MO
QLL(400 per 30
days) MO
QLL(370 per 30
days) MO
QLL(200 per 30
days) MO
QLL(185 per 30
days) MO
QLL(123 per 30
days) MO
MO
MO
MO
primidone
SABRIL
1
2
STAVZOR
TEGRETOL
TEGRETOL-XR
tiagabine hydrochloride
TOPAMAX SPRINKLE
TOPAMAX TABS 100MG
3
3
3
1
3
3
2
TOPAMAX TABS 200MG 3
TOPAMAX TABS 25MG
3
TOPAMAX TABS 50MG
3
topiragen tabs 100mg
3
topiragen tabs 200mg
3
topiragen tabs 25mg
3
MO
QLL(90 per 30 days)
MO
QLL(270 per 30
days) MO
MO
LA QLL(180 per 30
days) MO
MO
MO
MO
MO
PAR MO
PAR QLL(480 per
30 days) MO
PAR QLL(240 per
30 days) MO
PAR QLL(1920 per
30 days) MO
PAR QLL(960 per
30 days) MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(1920 per 30
days) MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
topiragen tabs 50mg
3
topiramate cpsp
topiramate tabs 100mg
1
1
topiramate tabs 200mg
1
topiramate tabs 25mg
1
topiramate tabs 50mg
1
TRILEPTAL
valproate sodium
valproic acid
VIMPAT INJ
3
1
1
2
VIMPAT ORAL SOLN
2
VIMPAT TABS 100MG
2
VIMPAT TABS 150MG
2
VIMPAT TABS 200MG
2
VIMPAT TABS 50MG
2
ZARONTIN
ZONEGRAN
zonisamide
3
3
1
QLL(960 per 30
days) MO
PAR MO
PAR QLL(480 per
30 days) MO
PAR QLL(240 per
30 days) MO
PAR QLL(1920 per
30 days) MO
PAR QLL(960 per
30 days) MO
MO
MO
MO
QLL(1200 per 30
days)
QLL(1200 per 30
days) MO
QLL(120 per 30
days) MO
QLL(80 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(240 per 30
days) MO
MO
MO
MO
Antidiarrheals & Antispasmodics
atropine sulfate inj 0.05mg/ml,1
0.1mg/ml, 0.8mg/ml
atropine sulfate inj 0.4mg/ml, 1
1mg/ml
BENTYL
3
CANTIL
3
CUVPOSA
3
1
dicyclomine hcl
3
diphenoxylate/atropine
FULYZAQ
3
1
glycopyrrolate
LOMOTIL
3
1
loperamide hcl caps
1
methscopolamine bromide
MOTOFEN
3
1
opium
Comprehensive_P3TARO_10R
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
Requirements/
Limits
opium tincture
PAMINE
PAMINE FORTE
paregoric
propantheline bromide
ROBINUL
ROBINUL FORTE
1
3
3
1
1
3
3
MO
MO
MO
MO
MO
MO
MO
ACETADOTE
3
1
acetylcysteine inj
ATROPEN INJ 0.5MG/ 3
0.7ML, 1MG/0.7ML, 2MG/
0.7ML
PROTOPAM CHLORIDE 3
MO
Antidotes
Antifungal Agents
ABELCET
2
AMBISOME
2
AMPHOTEC INJ 100MG 3
AMPHOTEC INJ 50MG 3
1
amphotericin b
ANCOBON
3
CANCIDAS
2
1
clotrimazole troc
DIFLUCAN
3
ERAXIS
3
1
fluconazole
1
fluconazole in dextrose
1
fluconazole in nacl
1
flucytosine
GRIFULVIN V
3
GRIS-PEG
3
1
griseofulvin microsize
1
griseofulvin ultramicrosize
1
itraconazole
1
ketoconazole tabs
LAMISIL
3
MYCAMINE
2
NOXAFIL
2
1
nystatin
ONMEL
3
ORAVIG
3
SPORANOX CAPS
3
SPORANOX ORAL SOLN 3
SPORANOX PULSEPAK 3
1
terbinafine hcl tabs
TERBINEX
3
13
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR MO
MO
B/D PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PAR MO
MO
MO
MO
MO
MO
MO
MO
PAR MO
MO
PAR MO
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
VFEND IV
VFEND SUSR
VFEND TABS
voriconazole inj
voriconazole tabs
3
2
3
1
1
MO
PAR MO
PAR MO
MO
PAR MO
Drug Name
Drug
Tier
levocetirizine dihydrochloride 1
tabs
3
palgic
3
phenadoz
PHENERGAN INJ 25MG/ 3
ML
Antihistamine & Antiallergenic Agents
PHENERGAN INJ 50MG/ 3
ADRENACLICK
2
QLL(2 per 1 days)
ML
MO
promethazine hcl inj 25mg/ml3
3
MO
adrenalin inj
promethazine hcl inj 50mg/ml3
3
MO
arbinoxa
3
promethazine hcl plain
AUVI-Q
3
QLL(2 per 1 days)
3
promethazine
hcl
supp
MO
3
promethazine hcl syrp
3
MO
carbinoxamine maleate
3
promethazine hcl tabs
1
QLL(300 per 30
cetirizine hcl syrp
3
promethegan
days) MO
3
CLARINEX REDITABS 3
QLL(30 per 30 days) VISTARIL
XYZAL ORAL SOLN
3
MO
CLARINEX SYRP
3
QLL(300 per 30
XYZAL TABS
3
days) MO
CLARINEX TABS
3
QLL(30 per 30 days)
MO
Antihypertensive Therapy
3
MO
clemastine fumarate syrp
ACCUPRIL
3
3
MO
clemastine fumarate tabs
ACCURETIC
3
2.68mg
1
acebutolol hcl
3
MO
cyproheptadine hcl syrp
ACEON
3
1
MO
cyproheptadine hcl tabs
ADALAT CC
3
1
QLL(30 per 30 days) afeditab cr
desloratadine
1
MO
ALDACTAZIDE
3
3
QLL(30 per 30 days) ALDACTONE
desloratadine odt
3
MO
ALTACE
3
MO
dexchlorpheniramine maleate 3
1
amiloride hcl
3
MO
diphenhydramine hcl caps
amiloride/hydrochlorothiazide 1
50mg
amlodipine besylate tabs 10mg,1
3
diphenhydramine hcl elix
2.5mg
1
MO
diphenhydramine hcl inj
amlodipine besylate tabs 5mg 1
1
QLL(2 per 1 days)
epinephrine
MO
amlodipine besylate/benazepril1
1
MO
epinephrine hcl
hcl
EPIPEN 2-PAK
2
QLL(2 per 1 days)
amlodipine besylate/benazepril1
MO
hydrochloride
EPIPEN-JR 2-PAK
2
QLL(2 per 1 days)
AMTURNIDE
3
MO
3
MO
hydroxyzine hcl
ATACAND HCT TABS
3
3
MO
hydroxyzine pamoate
16MG; 12.5MG
QLL(300 per 30
levocetirizine dihydrochloride 3
days) MO
oral soln
Effective January 1, 2014
14
Requirements/
Limits
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(300 per 30
days) MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(45 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
ATACAND HCT TABS
3
32MG; 12.5MG, 32MG;
25MG
ATACAND TABS 16MG, 3
4MG, 8MG
ATACAND TABS 32MG 3
Requirements/
Limits
Drug Name
1
candesartan cilexetil/
hydrochlorothiazide tabs 16mg;
12.5mg
1
candesartan cilexetil/
hydrochlorothiazide tabs 32mg;
12.5mg, 32mg; 25mg
1
captopril
captopril/hydrochlorothiazide 1
CARDENE I.V.
3
CARDENE SR
3
CARDIZEM
3
CARDIZEM CD
3
CARDIZEM LA
3
CARDURA
3
CARDURA XL
3
QLL(30 per 30 days) cartia xt
MO
carvedilol
CATAPRES
QLL(60 per 30 days) CATAPRES-TTS-1
MO
QLL(30 per 30 days) CATAPRES-TTS-2
MO
MO
CATAPRES-TTS-3
MO
QLL(30 per 30 days) chlorothiazide
MO
chlorothiazide sodium
QLL(30 per 30 days) chlorthalidone tabs 25mg,
MO
50mg
QLL(30 per 30 days) CLEVIPREX
MO
clonidine hcl inj
MO
clonidine hcl ptwk
MO
clonidine hcl tabs
MO
clorpres tabs 15mg; 0.1mg,
MO
15mg; 0.2mg
MO
CLORPRES TABS 15MG;
MO
0.3MG
COREG
MO
COREG CR
MO
CORGARD
MO
CORLOPAM
MO
CORZIDE
QLL(60 per 30 days) COZAAR TABS 100MG
MO
QLL(30 per 30 days) COZAAR TABS 25MG,
MO
50MG
QLL(60 per 30 days) DEMADEX
MO
DEMSER
DIBENZYLINE
QLL(30 per 30 days) DILACOR XR
MO
dilt-cd
dilt-xr
MO
diltiazem cd
MO
diltiazem hcl cd
MO
diltiazem hcl cp24
MO
diltiazem hcl er
MO
diltiazem hcl inj
MO
diltiazem hcl tabs
MO
diltzac
MO
DIOVAN HCT
MO
Comprehensive_P3TARO_10R
15
atenolol
atenolol/chlorthalidone
AVALIDE
1
1
3
AVAPRO
3
AZOR
3
1
benazepril hcl
1
benazepril hcl/
hydrochlorothiazide
1
betaxolol hcl
BIDIL [+]
2
1
bisoprolol fumarate
1
bisoprolol fumarate/
hydrochlorothiazide
1
bumetanide
BYSTOLIC [+]
2
CALAN
3
CALAN SR
3
candesartan cilexetil tabs 16mg,1
4mg, 8mg
candesartan cilexetil tabs 32mg1
Drug
Tier
Requirements/
Limits
1
1
3
3
MO
MO
MO
QLL(4 per 28 days)
MO
QLL(4 per 28 days)
MO
QLL(4 per 28 days)
MO
MO
MO
MO
3
3
1
1
1
3
3
1
1
1
QLL(4 per 28 days)
MO
MO
MO
3
MO
3
3
3
3
3
3
MO
ST MO
MO
3
3
3
3
3
1
1
1
1
1
1
1
1
1
3
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
DIOVAN TABS 160MG
2
DIOVAN TABS 320MG
2
DIOVAN TABS 40MG,
80MG
DIURIL
doxazosin mesylate
DURACLON INJ
100MCG/ML
DUTOPROL
DYAZIDE
DYRENIUM
EDARBI
2
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
MO
MO
EDARBYCLOR
3
EDECRIN
enalapril maleate
enalapril maleate/
hydrochlorothiazide
enalaprilat
eplerenone
epoprostenol sodium
eprosartan mesylate
3
1
1
EXFORGE
3
EXFORGE HCT
3
felodipine er
FLOLAN
fosinopril sodium
fosinopril sodium/
hydrochlorothiazide
furosemide
guanfacine hcl
hydralazine hcl
hydrochlorothiazide
HYZAAR
1
3
1
1
indapamide
INDERAL LA
INNOPRAN XL
INSPRA
1
3
3
3
Effective January 1, 2014
3
1
3
3
3
3
3
3
1
3
1
1
3
1
1
3
Drug Name
Drug
Tier
Requirements/
Limits
irbesartan
1
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
irbesartan/hydrochlorothiazide1
ISOPTIN SR
3
1
isradipine
KERLONE
3
1
labetalol hcl
LASIX
3
LEVATOL
3
MO
1
lisinopril
MO
lisinopril/hydrochlorothiazide 1
MO
LOPRESSOR HCT
3
QLL(30 per 30 days) LOPRESSOR INJ
2
MO
LOPRESSOR TABS
3
QLL(30 per 30 days) losartan potassium tabs 100mg1
MO
MO
losartan potassium tabs 25mg, 1
MO
50mg
MO
1
losartan potassium/
hydrochlorothiazide
LOTENSIN
3
MO
LOTENSIN HCT
3
MO
LOTREL
3
QLL(30 per 30 days) mannitol inj 10%, 20%, 5% 3
MO
3
mannitol inj 25%
QLL(30 per 30 days) matzim la
1
MO
MAVIK
3
QLL(30 per 30 days) MAXZIDE
3
MO
MAXZIDE-25
3
MO
1
methyclothiazide
MO
1
methyldopa
MO
methyldopa/hydrochlorothiazide3
MO
3
methyldopate hcl
1
metolazone
MO
1
metoprolol succinate er
MO
1
metoprolol tartrate inj
MO
1
metoprolol tartrate tabs
MO
metoprolol/hydrochlorothiazide1
QLL(30 per 30 days) MICARDIS HCT TABS 2
MO
12.5MG; 40MG, 25MG;
MO
80MG [+]
MO
MICARDIS HCT TABS 2
MO
12.5MG; 80MG [+]
MO
MICARDIS TABS 20MG, 2
40MG [+]
16
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
MICARDIS TABS 80MG [+]2
MICROZIDE
3
MINIPRESS
3
1
minoxidil tabs
1
moexipril hcl
moexipril/hydrochlorothiazide 1
1
nadolol
nadolol/bendroflumethiazide 1
1
nicardipine hcl caps
1
nicardipine hcl inj
1
nifediac cc
1
nifedical xl
3
nifedipine
1
nifedipine er
1
nimodipine
3
nisoldipine
3
nisoldipine er
NORVASC TABS 10MG, 3
2.5MG
NORVASC TABS 5MG
3
OSMITROL VIAFLEX INJ 3
10%
3
osmitrol viaflex inj 20%
1
perindopril erbumine
phentolamine mesylate inj 5mg3
1
pindolol
1
prazosin hcl
PRINIVIL
3
PROCARDIA
3
PROCARDIA XL
3
1
propranolol hcl er
1
propranolol hcl inj
1
propranolol hcl oral soln
1
propranolol hcl tabs
propranolol/hydrochlorothiazide1
1
quinapril hcl
quinapril/hydrochlorothiazide 1
1
ramipril
REMODULIN
2
RESECTISOL
3
1
reserpine tabs 0.1mg
3
reserpine tabs 0.25mg
SECTRAL
3
SODIUM DIURIL
3
Comprehensive_P3TARO_10R
Requirements/
Limits
Drug Name
Drug
Tier
Requirements/
Limits
MO
MO
QLL(60 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
SODIUM EDECRIN
spironolactone
spironolactone/
hydrochlorothiazide
SULAR
TARKA
taztia xt
TEKAMLO
3
1
1
TEKTURNA
3
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(45 per 30 days)
MO
TEKTURNA HCT
3
TENEX
TENORETIC 100
TENORETIC 50
TENORMIN
terazosin hcl
TEVETEN HCT
3
3
3
3
1
3
3
3
1
3
TEVETEN TABS 400MG 3
TEVETEN TABS 600MG 3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
LA PAR MO
MO
MO
MO
MO
TIAZAC
3
1
timolol maleate
TOPROL XL
3
1
torsemide inj 20mg/2ml
TORSEMIDE INJ 50MG/ 1
5ML
1
torsemide tabs
TRANDATE
3
1
trandolapril
triamterene/hydrochlorothiazide1
TRIBENZOR
3
TWYNSTA [+]
2
UNIRETIC
3
UNIVASC
3
valsartan/hydrochlorothiazide 1
VASERETIC
VASOTEC
veletri
verapamil hcl er
17
3
3
3
1
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
verapamil hcl inj
verapamil hcl sr
verapamil hcl tabs
VERELAN
VERELAN PM
ZAROXOLYN
ZEBETA
ZESTORETIC
ZESTRIL
ZIAC
1
1
1
3
3
3
3
3
3
3
Requirements/
Limits
Drug Name
MO
MO
MO
MO
MO
MO
MO
MO
MO
Antineoplastic & Immunosuppressant Drugs
ABRAXANE
2
ADCETRIS
2
adriamycin inj 10mg, 20mg, 2
50mg
1
adriamycin inj 2mg/ml
1
adrucil
AFINITOR
2
AFINITOR DISPERZ
2
ALIMTA
2
ALKERAN INJ
2
ALKERAN TABS
3
1
anastrozole
ARIMIDEX
3
AROMASIN
3
ARRANON
2
ARZERRA
2
AVASTIN
2
AZASAN
3
1
azathioprine
1
azathioprine sodium
1
bicalutamide
BICNU
2
1
bleomycin sulfate
BOSULIF
2
BUSULFEX
2
CAMPTOSAR INJ 100MG/3
5ML, 40MG/2ML
CAMPTOSAR INJ 300MG/3
15ML
CAPRELSA
2
1
carboplatin
CASODEX
3
CEENU
3
CELLCEPT CAPS
3
Effective January 1, 2014
B/D PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
PAR MO
PAR MO
PAR MO
B/D PAR
B/D PAR MO
MO
MO
MO
B/D PAR
B/D PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
MO
B/D PAR MO
B/D PAR MO
PAR MO
B/D PAR
B/D PAR MO
B/D PAR
LA PAR MO
B/D PAR MO
MO
MO
B/D PAR MO
18
Drug
Tier
CELLCEPT
2
INTRAVENOUS
CELLCEPT SUSR
2
CELLCEPT TABS
2
1
cerubidine
1
cisplatin
1
cladribine
CLOLAR
2
COMETRIQ
2
COSMEGEN
2
1
cyclophosphamide tabs
1
cyclosporine caps
1
cyclosporine inj
1
cyclosporine modified caps
100mg, 50mg
1
cyclosporine modified caps
25mg
cyclosporine modified oral soln 1
1
cytarabine
1
cytarabine aqueous
1
dacarbazine inj 100mg
1
dacarbazine inj 200mg
DACOGEN
2
daunorubicin hcl inj 20mg 1
daunorubicin hcl inj 5mg/ml 1
DEPOCYT
3
DOCEFREZ
2
docetaxel inj 160mg/16ml, 1
160mg/8ml, 20mg/0.5ml,
20mg/2ml, 80mg/2ml, 80mg/
8ml
docetaxel inj 20mg/ml, 80mg/ 1
4ml
DOXIL
2
1
doxorubicin hcl
DROXIA
3
ELIGARD
2
ELLENCE
2
ELOXATIN INJ 100MG/ 2
20ML, 50MG/10ML
ELOXATIN INJ 200MG/ 2
40ML
ELSPAR
2
EMCYT
2
1
epirubicin hcl
Requirements/
Limits
B/D PAR
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR
B/D PAR
B/D PAR
B/D PAR MO
B/D PAR MO
B/D PAR MO
MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
MO
B/D PAR
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
ERBITUX INJ 100MG/
2
50ML
ERBITUX INJ 200MG/
2
100ML
ERIVEDGE
2
ERWINAZE
3
ETOPOPHOS
2
1
etoposide inj
1
exemestane
FARESTON
3
FASLODEX
2
FEMARA
3
FIRMAGON
2
1
fludarabine phosphate inj
50mg
1
fludarabine phosphate inj
50mg/2ml
1
fluorouracil inj
1
flutamide
FOLOTYN
2
1
gemcitabine
1
gemcitabine hcl inj 1gm,
200mg
1
gemcitabine hcl inj 2gm
GEMZAR
3
1
gengraf
GLEEVEC
2
HALAVEN
2
1
hecoria
HERCEPTIN
2
HEXALEN
2
HYCAMTIN INJ
3
HYDREA
3
1
hydroxyurea
ICLUSIG
2
IDAMYCIN PFS
2
1
idarubicin hcl
IFEX
2
1
ifosfamide inj 1gm
ifosfamide inj 1gm/20ml, 3gm,1
3gm/60ml
IMURAN
3
INLYTA
2
irinotecan inj 100mg/5ml, 1
40mg/2ml
irinotecan inj 500mg/25ml 1
Comprehensive_P3TARO_10R
Requirements/
Limits
PAR MO
PAR
PAR MO
B/D PAR MO
B/D PAR MO
MO
MO
PAR MO
MO
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR MO
PAR MO
PAR MO
B/D PAR MO
PAR MO
MO
B/D PAR MO
MO
MO
PAR MO
B/D PAR
B/D PAR
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
PAR MO
B/D PAR MO
B/D PAR
Drug Name
Drug
Tier
ISTODAX
2
IXEMPRA KIT
2
JAKAFI
2
JEVTANA
2
KADCYLA
2
KYPROLIS
2
1
letrozole
LEUKERAN
2
1
leuprolide acetate
LUPRON DEPOT INJ
2
11.25MG, 22.5MG,
3.75MG, 7.5MG
LUPRON DEPOT INJ
3
30MG, 45MG
LUPRON DEPOT-PED INJ3
11.25MG, 15MG, 30MG
LUPRON DEPOT-PED INJ2
11.25MG, 7.5MG
LYSODREN
2
MATULANE
2
MEGACE ES
3
MEGACE ORAL
3
1
megestrol acetate
MEKINIST
2
1
melphalan hydrochloride
1
mercaptopurine
1
methotrexate
methotrexate sodium inj 1gm 1
methotrexate sodium inj 25mg/1
ml
1
mitomycin
1
mitoxantrone hcl
MUSTARGEN
2
1
mycophenolate mofetil
MYFORTIC
3
NEORAL
3
NEXAVAR
2
NILANDRON
3
NIPENT
2
NULOJIX
2
1
octreotide acetate
ONTAK
2
oxaliplatin inj 100mg, 50mg 1
oxaliplatin inj 100mg/20ml, 1
50mg/10ml
1
paclitaxel
19
Requirements/
Limits
PAR MO
B/D PAR MO
PAR MO
B/D PAR MO
PAR MO
PAR MO
MO
MO
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
MO
MO
MO
PAR MO
PAR MO
PAR MO
B/D PAR
MO
MO
MO
B/D PAR MO
MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
LA PAR MO
MO
B/D PAR MO
B/D PAR MO
PAR MO
B/D PAR
B/D PAR
B/D PAR MO
B/D PAR MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
pentostatin
PERJETA
POMALYST
PROGRAF CAPS
PROGRAF INJ
PURINETHOL
RAPAMUNE
REVLIMID CAPS 10MG
1
2
2
3
2
3
2
2
B/D PAR MO
PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
MO
B/D PAR MO
LA PAR QLL(60 per
30 days) MO
LA PAR QLL(30 per
30 days) MO
LA PAR MO
LA PAR QLL(150
per 30 days) MO
MO
PAR MO
B/D PAR MO
PAR MO
PAR MO
REVLIMID CAPS 15MG, 2
20MG, 25MG
REVLIMID CAPS 2.5MG 2
REVLIMID CAPS 5MG 2
RHEUMATREX
RITUXAN
SANDIMMUNE
SANDOSTATIN
SANDOSTATIN LAR
DEPOT
SIGNIFOR
SIMULECT INJ 10MG
SIMULECT INJ 20MG
SOLTAMOX
SOMATULINE DEPOT
SPRYCEL
STIVARGA
SUPPRELIN LA
SUTENT
SYNRIBO
TABLOID
tacrolimus
TAFINLAR
tamoxifen citrate
TARCEVA
TARGRETIN CAPS
TARGRETIN GEL
TASIGNA
TAXOTERE
THALOMID
thiotepa
toposar
topotecan hcl inj 4mg
topotecan hcl inj 4mg/4ml
TORISEL
TREANDA INJ 100MG
Effective January 1, 2014
3
2
3
3
2
3
2
2
3
3
2
2
3
2
2
2
1
2
1
2
2
2
2
2
2
1
1
1
1
2
2
Drug Name
MO
B/D PAR
B/D PAR MO
MO
PAR MO
PAR MO
MO
PAR MO
MO
MO
B/D PAR MO
PAR MO
MO
PAR MO
PAR MO
MO
PAR MO
B/D PAR MO
PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR MO
Drug
Tier
TREANDA INJ 25MG
2
TRELSTAR DEPOT
3
TRELSTAR DEPOT
3
MIXJECT
TRELSTAR LA
3
TRELSTAR LA MIXJECT 3
TRELSTAR MIXJECT
3
1
tretinoin caps
TREXALL
3
TRISENOX
2
TYKERB
2
VANTAS
3
VECTIBIX
2
VELCADE
2
VIDAZA
2
vinblastine sulfate inj 10mg 1
vinblastine sulfate inj 1mg/ml 1
1
vincasar pfs
1
vincristine sulfate
1
vinorelbine tartrate
VOTRIENT
2
XALKORI
2
XTANDI
2
YERVOY
2
ZALTRAP
2
ZANOSAR
2
ZELBORAF
2
ZOLADEX
3
ZOLINZA
2
ZORTRESS
2
ZYTIGA
2
Requirements/
Limits
B/D PAR
MO
MO
MO
MO
MO
B/D PAR MO
LA PAR MO
MO
PAR MO
PAR MO
PAR MO
B/D PAR
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
B/D PAR MO
PAR MO
MO
PAR MO
B/D PAR MO
PAR MO
Antiparkinsonism Agents
APOKYN
2
AZILECT [+]
2
1
benztropine mesylate inj
1
benztropine mesylate tabs
1
bromocriptine mesylate
1
carbidopa/levodopa
1
carbidopa/levodopa cr
1
carbidopa/levodopa er
1
carbidopa/levodopa odt
1
carbidopa/levodopa sr
carbidopa/levodopa/entacapone1
COGENTIN
2
COMTAN
3
ELDEPRYL
3
20
LA PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
entacapone
LODOSYN
MIRAPEX
MIRAPEX ER
NEUPRO
1
3
3
3
3
PARCOPA
PARLODEL
pramipexole dihydrochloride
REQUIP
REQUIP XL
ropinirole er
ropinirole hcl
selegiline hcl
SINEMET
SINEMET CR
STALEVO 100
STALEVO 125
STALEVO 150
STALEVO 200
STALEVO 50
STALEVO 75
TASMAR
trihexyphenidyl hcl
ZELAPAR
3
3
1
3
3
1
1
1
3
3
3
3
3
3
3
3
2
3
3
MO
ST MO
ST MO
MO
QLL(30 per 30 days)
MO
ST MO
MO
MO
ST MO
MO
MO
MO
MO
ST MO
ST MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
Requirements/
Limits
STELARA
3
TACLONEX
TERSI FOAM
VECTICAL
3
3
3
ZITHRANOL
ZITHRANOL-RR
3
3
PAR QLL(1 per 28
days) MO
MO
MO
QLL(800 per 28
days) MO
MO
MO
1
1
3
MO
MO
MO
Antithyroid Agents
methimazole
propylthiouracil
TAPAZOLE
Antivirals
1
abacavir
1
acyclovir caps
acyclovir sodium inj 1000mg, 1
50mg/ml
acyclovir sodium inj 500mg 1
1
acyclovir susp
1
acyclovir tabs
1
amantadine hcl caps
3
amantadine hcl syrp
1
amantadine hcl tabs
APTIVUS CAPS
2
APTIVUS ORAL SOLN 2
Antipsoriatic / Antiseborrheic
ATRIPLA
2
1
acitretin
BARACLUDE
2
1
QLL(120 per 30
calcipotriene crea
1
cidofovir
days) MO
COMBIVIR
3
1
QLL(60 per 30 days) COMPLERA
calcipotriene external soln
2
MO
COPEGUS
3
1
QLL(120 per 30
calcipotriene oint
CRIXIVAN
2
days) MO
CYTOVENE
3
1
QLL(120 per 30
calcitrene
1
didanosine
days) MO
EDURANT
2
1
QLL(800 per 28
calcitriol oint
EMTRIVA
2
days) MO
EPIVIR HBV
2
DOVONEX
3
QLL(120 per 30
EPIVIR ORAL SOLN
2
days) MO
EPIVIR TABS
3
1
MO
dritho-creme hp
EPZICOM
2
1
MO
selenium sulfide
famciclovir tabs 125mg, 250mg1
MO
sodium sulfacetamide wash 3
SORIATANE
2
MO
1
famciclovir tabs 500mg
SORILUX
3
QLL(120 per 30
days) MO
FAMVIR TABS 125MG, 3
250MG
Comprehensive_P3TARO_10R
21
MO
MO
B/D PAR
B/D PAR MO
MO
MO
MO
MO
MO
MO
MO
PAR MO
B/D PAR
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(60 per 30 days)
MO
QLL(21 per 7 days)
MO
QLL(60 per 30 days)
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
FAMVIR TABS 500MG
3
FLUMADINE
foscarnet sodium
FOSCAVIR
FUZEON
3
1
3
2
QLL(21 per 7 days)
MO
MO
B/D PAR MO
B/D PAR
QLL(60 per 30 days)
MO
MO
MO
PAR MO
MO
1
ganciclovir
HEPSERA
2
INCIVEK
2
INTELENCE TABS
2
100MG, 200MG
INTELENCE TABS 25MG 2
INVIRASE
2
ISENTRESS CHEW 100MG2
ISENTRESS CHEW 25MG2
ISENTRESS TABS
2
KALETRA ORAL SOLN 3
KALETRA TABS
2
1
lamivudine
1
lamivudine/zidovudine
LEXIVA
2
1
nevirapine
NORVIR
2
PREZISTA SUSP
2
PREZISTA TABS 150MG, 3
75MG
PREZISTA TABS 400MG, 2
600MG, 800MG
REBETOL
2
RELENZA DISKHALER 2
RESCRIPTOR
2
RETROVIR
3
RETROVIR IV INFUSION2
REYATAZ CAPS 100MG 3
REYATAZ CAPS 150MG, 2
200MG, 300MG
1
ribapak
1
ribasphere caps
ribasphere tabs 200mg, 600mg1
1
ribasphere tabs 400mg
RIBATAB
2
1
ribavirin
1
rimantadine hcl
SELZENTRY
2
Effective January 1, 2014
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(60 per 180
days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
22
Drug Name
Drug
Tier
Requirements/
Limits
stavudine
STRIBILD
SUSTIVA
SYNAGIS
TAMIFLU CAPS 30MG
1
2
2
3
2
TAMIFLU CAPS 45MG
2
TAMIFLU CAPS 75MG
2
TAMIFLU SUSR
2
trifluridine
TRIZIVIR
TRUVADA
TYZEKA
valacyclovir hcl
1
2
2
2
1
VALCYTE
VALTREX
2
3
VICTRELIS
VIDEX EC
VIDEX PEDIATRIC
VIRACEPT
VIRAMUNE SUSP
VIRAMUNE TABS
VIRAMUNE XR TB24
100MG
VIRAMUNE XR TB24
400MG
VIRAZOLE
VIREAD
VIROPTIC
VISTIDE
VITRASERT
ZERIT
ZIAGEN ORAL SOLN
ZIAGEN TABS
zidovudine
ZIRGAN [+]
ZOVIRAX CAPS
ZOVIRAX SUSP
ZOVIRAX TABS
2
3
2
2
2
3
2
MO
MO
MO
LA MO
QLL(84 per 1 days)
MO
QLL(42 per 1 days)
MO
QLL(56 per 365
days) MO
QLL(360 per 180
days) MO
MO
MO
MO
PAR MO
QLL(30 per 1 days)
MO
MO
QLL(30 per 1 days)
MO
PAR MO
MO
MO
MO
MO
MO
2
MO
2
2
3
2
3
3
2
3
1
2
3
3
3
PAR MO
MO
MO
B/D PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
Benign Prostatic Hyperplasia (Bph) Therapy
1
2
1
3
2
3
3
1
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
BETAGAN
3
1
betaxolol hcl
BETIMOL
3
BETOPTIC-S
3
1
carteolol hcl
ISTALOL
3
1
levobunolol hcl
1
metipranolol
OPTIPRANOLOL
3
1
timolol maleate
timolol maleate ophthalmic gel1
forming
TIMOPTIC
3
TIMOPTIC OCUDOSE 3
TIMOPTIC-XE
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
alfuzosin hcl er
AVODART [+]
finasteride tabs 5mg
FLOMAX
JALYN [+]
PROSCAR
RAPAFLO
tamsulosin hcl
UROXATRAL
Beta-Blockers
MO
MO
MO
Biotechnology Drugs
ACTIMMUNE
2
ALFERON N
3
ARANESP ALBUMIN FREE2
[+]
ARCALYST
2
AVONEX [+]
2
AVONEX PEN [+]
2
BETASERON
2
EGRIFTA
3
EPOGEN
2
EXTAVIA
2
GENOTROPIN
2
GENOTROPIN
2
MINIQUICK
HUMATROPE
3
HUMATROPE COMBO 3
PACK
ILARIS
2
INFERGEN
2
Comprehensive_P3TARO_10R
PAR MO
MO
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
MO
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
Drug Name
Drug
Tier
Requirements/
Limits
INTRON-A
INTRON-A W/DILUENT
LEUKINE
MOZOBIL
NEULASTA
2
2
2
3
2
NEUMEGA
2
PAR MO
PAR MO
PAR MO
MO
PAR QLL(2 per 28
days) MO
PAR QLL(21 per 21
days) MO
PAR MO
PAR MO
PAR MO
NEUPOGEN
2
NORDITROPIN FLEXPRO3
NORDITROPIN
3
NORDIFLEX PEN
NUTROPIN
3
NUTROPIN AQ
3
NUTROPIN AQ NUSPIN 3
10
NUTROPIN AQ NUSPIN 3
20
NUTROPIN AQ NUSPIN 3
5
NUTROPIN AQ PEN
3
OMNITROPE
3
OMONTYS
3
PEG-INTRON
3
PEG-INTRON REDIPEN 3
PEG-INTRON REDIPEN 3
PAK 4
PEGASYS [+]
2
PEGASYS PROCLICK [+] 2
PROCRIT [+]
2
PROLEUKIN
2
REBIF [+]
2
REBIF REBIDOSE [+]
2
REBIF REBIDOSE
2
TITRATION PACK [+]
REBIF TITRATION PACK 2
[+]
SAIZEN CLICK.EASY
3
SAIZEN INJ 5MG
3
SAIZEN INJ 8.8MG
3
SEROSTIM
3
SYLATRON
2
TEV-TROPIN [+]
2
ZORBTIVE
3
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
B/D PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
MO
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
PAR MO
MO
PAR MO
PAR MO
PAR MO
PAR MO
LA PAR MO
MO
23
Effective January 1, 2014
Drug Name
Drug
Tier
Blood Derivatives
ALBUKED 25
ALBUKED 5
albumin human inj 25%
albuminar-25
albuminar-5
alburx
albutein inj 25%
albutein inj 5%
buminate inj 25%
buminate inj 5%
FLEXBUMIN
human albumin grifols
KEDBUMIN
plasbumin-25
3
3
3
1
3
3
1
1
1
1
3
3
3
3
Burn Therapy
SILVADENE
silver sulfadiazine
ssd
3
1
1
Cardiac Glycosides
digoxin inj
digoxin oral soln
digoxin tabs 0.125mg
3
1
1
1
digoxin tabs 0.25mg
LANOXIN INJ
3
LANOXIN TABS 0.125MG 2
LANOXIN TABS 0.25MG 2
Cephalosporins
CEDAX CAPS
3
CEDAX SUSR 180MG/5ML3
CEDAX SUSR 90MG/5ML 3
1
cefaclor
1
cefaclor er
1
cefadroxil
cefazolin sodium inj 100gm, 1
10gm, 1gm; 5%, 20gm,
300gm, 500mg
1
cefazolin sodium inj 1gm
cefazolin sodium/dextrose inj 1
1gm; 4%
cefazolin sodium/dextrose inj 1
2gm; 3%
1
cefdinir
cefditoren pivoxil tabs 200mg 1
Effective January 1, 2014
Requirements/
Limits
Drug Name
Drug
Tier
cefditoren pivoxil tabs 400mg 1
1
cefepime inj 1gm
cefepime inj 1gm/50ml, 2gm, 1
2gm/100ml
MO
cefotaxime sodium inj 10gm, 1
MO
2gm
cefotaxime sodium inj 1gm, 1
500mg
MO
1
cefotetan
cefoxitin sodium inj 10gm, 1
MO
1gm; 4%, 2gm, 2gm; 2.2%
1
cefoxitin sodium inj 1gm
1
cefpodoxime proxetil
MO
1
cefprozil
1
ceftazidime inj 1gm, 6gm
MO
1
ceftazidime inj 2gm
CEFTAZIDIME/
2
MO
DEXTROSE
MO
CEFTIN
3
MO
1
ceftriaxone in iso-osmotic
dextrose
MO
1
ceftriaxone sodium
MO
1
ceftriaxone/dextrose
QLL(30 per 30 days)
3
cefuroxime axetil susr
MO
1
cefuroxime axetil tabs
MO
cefuroxime sodium inj 1.5gm, 1
MO
750mg
QLL(30 per 30 days)
cefuroxime sodium inj 7.5gm 1
MO
3
cefuroxime/dextrose
MO
1
cephalexin
CLAFORAN INJ 10GM, 2
MO
1GM, 2GM
CLAFORAN INJ 500MG 2
MO
FORTAZ INJ 1GM, 2GM 3
MO
FORTAZ INJ 1GM/50ML; 3
MO
5%, 2GM/50ML; 5%,
MO
500MG, 6GM
KEFLEX
3
MEFOXIN
3
ROCEPHIN
3
MO
SPECTRACEF
3
MO
SUPRAX CAPS
3
SUPRAX CHEW 100MG 3
SUPRAX CHEW 200MG 3
SUPRAX SUSR 100MG/ 3
MO
5ML, 200MG/5ML
24
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
SUPRAX SUSR 500MG/ 3
5ML
SUPRAX TABS
3
TAZICEF INJ 1GM, 2GM, 3
6GM
TEFLARO
3
ZINACEF
3
ZINACEF IN ISO3
OSMOTIC DILUENT
Requirements/
Limits
MO
Drug Name
Drug
Tier
Requirements/
Limits
EFFIENT
3
ELIQUIS
3
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
ST MO
B/D PAR MO
1
enoxaparin sodium
MO
1
fondaparinux sodium
FRAGMIN
2
heparin lock flush inj 100unit/1
ml
heparin lock inj 100unit/ml 1
Cholinergic Stimulants
1
heparin sodium dcu
1
MO
bethanechol chloride
heparin sodium inj 10000unit/1
URECHOLINE
3
MO
ml, 1000unit/ml, 20000unit/
Cholinesterase Inhibitor Miotics
ml, 2000unit/ml, 5000unit/
PHOSPHOLINE IODIDE 3
MO
0.5ml, 5000unit/ml
Coagulation Therapy
heparin sodium inj 2500unit/ 1
AGGRASTAT
3
ml
AGGRENOX [+]
2
QLL(60 per 30 days)
heparin sodium lock flush inj 1
MO
100unit/ml
AMICAR
3
MO
1
heparin sodium/d5w
3
MO
aminocaproic acid inj
1
heparin
sodium/nacl
0.45%
1
MO
aminocaproic acid syrp
heparin sodium/nacl 0.9% 1
AMINOCAPROIC ACID 3
MO
1
heparin sodium/sodium
TABS 1000MG
chloride
0.9%
MO
aminocaproic acid tabs 500mg3
1
heparin sodium/sodium
ANGIOMAX
3
chloride 0.9% premix
ARGATROBAN INJ
3
MO
INTEGRILIN INJ 0.75MG/3
100MG/ML
ML
ARGATROBAN INJ
3
INTEGRILIN INJ 2MG/ML3
125MG/125ML; 0.9%,
IPRIVASK
3
50MG/50ML
1
jantoven
ARIXTRA INJ 10MG/
3
MO
LOVENOX INJ 100MG/ 3
0.8ML, 5MG/0.4ML,
ML, 120MG/0.8ML,
7.5MG/0.6ML
150MG/ML, 60MG/0.6ML,
ARIXTRA INJ 2.5MG/
2
MO
80MG/0.8ML
0.5ML
LOVENOX INJ 300MG/ 2
AVITENE FLOUR
3
BRILINTA
3
QLL(60 per 30 days) 3ML, 30MG/0.3ML, 40MG/
0.4ML
MO
1
pentoxifylline er
1
MO
cilostazol
PERSANTINE
3
1
MO
clopidogrel tabs 300mg
PLAVIX
TABS
300MG
3
1
QLL(30 per 30 days)
clopidogrel tabs 75mg
PLAVIX TABS 75MG
3
MO
COUMADIN
CYKLOKAPRON
dipyridamole tabs
2
2
3
Comprehensive_P3TARO_10R
MO
MO
MO
PLETAL
PRADAXA
25
3
3
B/D PAR MO
B/D PAR MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR
B/D PAR
B/D PAR
B/D PAR
B/D PAR
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
MO
PAR QLL(60 per 30
days) MO
Effective January 1, 2014
Drug Name
PROMACTA
protamine sulfate
REOPRO
THROMBATE III W/10
ML STERILE WATER
THROMBATE III W/20
ML STERILE WATER
ticlopidine hcl
tranexamic acid inj
TRENTAL
warfarin sodium
XARELTO TABS 10MG,
20MG
XARELTO TABS 15MG
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
Requirements/
Limits
2
3
3
3
LA PAR MO
acarbose tabs 50mg
1
MO
ACTOPLUS MET
3
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
ST MO
ST MO
LA QLL(60 per 30
days) MO
ACTOPLUS MET XR TB242
1000MG; 15MG
ACTOPLUS MET XR TB242
1000MG; 30MG
ACTOS TABS 15MG
3
3
3
1
3
1
3
3
MO
MO
MO
PAR QLL(30 per 30
days) MO
PAR QLL(42 per 30
days) MO
Cough & Cold Therapy
CLARINEX-D 12 HOUR 3
CLARINEX-D 24 HOUR 3
promethazine vc
promethazine vc plain
SEMPREX-D
3
3
3
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
Cycloplegic Mydriatics
1
atropine sulfate oint
atropine sulfate ophthalmic soln1
1
atropine-care
CYCLOGYL
3
cyclopentolate hcl ophthalmic 3
soln 1%
cyclopentolate hcl ophthalmic 1
soln 2%
1
homatropaire
1
homatropine hbr
ISOPTO ATROPINE
3
ISOPTO HOMATROPINE3
ISOPTO HYOSCINE
3
3
mydral
MYDRIACYL
3
1
tropicamide
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Diabetes Therapy
acarbose tabs 100mg
1
acarbose tabs 25mg
1
Effective January 1, 2014
QLL(90 per 30 days)
MO
QLL(360 per 30
days) MO
26
ACTOS TABS 30MG
3
ACTOS TABS 45MG
3
alcohol preps pads
AMARYL TABS 1MG
1
3
AMARYL TABS 2MG
3
AMARYL TABS 4MG
3
APIDRA
APIDRA SOLOSTAR
AVANDAMET TABS
1000MG; 2MG, 1000MG;
4MG, 500MG; 4MG
AVANDAMET TABS
500MG; 2MG
AVANDARYL TABS 1MG;
4MG, 2MG; 4MG
AVANDARYL TABS 2MG;
8MG, 4MG; 4MG, 4MG;
8MG
AVANDIA TABS 2MG
3
3
3
AVANDIA TABS 4MG
3
AVANDIA TABS 8MG
3
BYDUREON [+]
2
BYETTA INJ 10MCG/
0.04ML [+]
BYETTA INJ 5MCG/
0.02ML [+]
chlorpropamide
2
3
3
3
3
2
3
LA QLL(120 per 30
days) MO
LA QLL(60 per 30
days) MO
LA QLL(30 per 30
days) MO
LA QLL(120 per 30
days) MO
LA QLL(60 per 30
days) MO
LA QLL(30 per 30
days) MO
PAR QLL(4 per 28
days) MO
PAR QLL(2.4 per 30
days) MO
PAR QLL(1.2 per 30
days) MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
CYCLOSET
3
DIABETA
DUETACT
3
3
QLL(180 per 30
days) MO
PAR MO
QLL(30 per 30 days)
MO
QLL(75 per 30 days)
MO
QLL(150 per 30
days) MO
QLL(200 per 30
days) MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(120 per 30
days) MO
QLL(240 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
MO
MO
MO
FORTAMET TB24
3
1000MG
FORTAMET TB24 500MG3
gauze pads 2"x2"
1
glimepiride tabs 1mg
1
glimepiride tabs 2mg
1
glimepiride tabs 4mg
1
glipizide er tb24 10mg
1
glipizide er tb24 2.5mg
1
glipizide er tb24 5mg
1
glipizide tabs 10mg
1
glipizide tabs 5mg
1
glipizide xl tb24 10mg
1
glipizide xl tb24 2.5mg
1
glipizide xl tb24 5mg
1
glipizide/metformin hcl tabs 1
2.5mg; 250mg
glipizide/metformin hcl tabs 1
2.5mg; 500mg, 5mg; 500mg
GLUCAGEN
2
GLUCAGEN HYPOKIT [+]2
GLUCAGON
2
EMERGENCY KIT
GLUCOPHAGE TABS
3
1000MG
GLUCOPHAGE TABS
3
500MG
GLUCOPHAGE TABS
3
850MG
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
GLUCOPHAGE XR TB24 3
500MG
GLUCOPHAGE XR TB24 3
750MG
GLUCOTROL TABS 10MG3
GLUCOTROL TABS 5MG 3
GLUCOTROL XL TB24 3
10MG
GLUCOTROL XL TB24 3
2.5MG
GLUCOTROL XL TB24 3
5MG
GLUCOVANCE TABS
3
2.5MG; 500MG, 5MG;
500MG
GLUMETZA TB24
3
1000MG
GLUMETZA TB24 500MG3
Requirements/
Limits
QLL(120 per 30
days) MO
QLL(80 per 30 days)
MO
QLL(120 per 30
days) MO
QLL(240 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
PAR MO
glyburide
glyburide micronized
glyburide/metformin hcl tabs
1.25mg; 250mg
glyburide/metformin hcl tabs
2.5mg; 500mg, 5mg; 500mg
GLYNASE
GLYSET TABS 100MG
3
3
3
QLL(60 per 30 days)
MO
QLL(120 per 30
days) MO
PAR MO
PAR MO
MO
3
PAR MO
3
3
GLYSET TABS 25MG
3
GLYSET TABS 50MG
3
PAR MO
QLL(90 per 30 days)
MO
QLL(360 per 30
days) MO
QLL(180 per 30
days) MO
MO
MO
MO
MO
HUMALOG [+]
2
HUMALOG KWIKPEN [+]2
HUMALOG MIX 50/50 [+]2
HUMALOG MIX 50/50 2
KWIKPEN [+]
HUMALOG MIX 75/25 [+]2
HUMALOG MIX 75/25 2
QLL(76 per 30 days) KWIKPEN [+]
MO
HUMAPEN LUXURA HD 2
QLL(153 per 30
HUMAPEN MEMOIR
2
days) MO
HUMULIN 70/30 [+]
2
QLL(90 per 30 days) HUMULIN 70/30 PEN [+] 2
MO
HUMULIN N [+]
2
27
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
HUMULIN N U-100 PEN
[+]
HUMULIN R [+]
HUMULIN R U-500
(CONCENTRATED) [+]
INSULIN PEN NEEDLE
Drug
Tier
Requirements/
Limits
Drug Name
2
MO
metformin hcl er tb24 500mg 1
2
2
MO
MO
metformin hcl er tb24 500mg 1
metformin hcl er tb24 750mg 1
2
INSULIN SYRINGE (DISP)2
U-100 0.3 ML
INSULIN SYRINGE (DISP)2
U-100 1 ML
INSULIN SYRINGE (DISP)2
U-100 1/2 ML
INVOKANA TABS 100MG3
INVOKANA TABS 300MG3
JANUMET [+]
2
JANUMET XR TB24
2
1000MG; 100MG [+]
JANUMET XR TB24
2
1000MG; 50MG, 500MG;
50MG [+]
JANUVIA TABS 100MG [+]2
JANUVIA TABS 25MG [+] 2
JANUVIA TABS 50MG [+] 2
JENTADUETO
3
JUVISYNC [+]
2
KAZANO [+]
2
KOMBIGLYZE XR TB24 2
1000MG; 2.5MG [+]
KOMBIGLYZE XR TB24 2
1000MG; 5MG, 500MG;
5MG [+]
LANTUS [+]
2
LANTUS SOLOSTAR [+] 2
LEVEMIR [+]
2
LEVEMIR FLEXPEN [+] 2
metformin hcl er tb24 1000mg1
Effective January 1, 2014
Drug
Tier
QLL(200 per 30
days) MO
QLL(200 per 30
days) MO
QLL(200 per 30
days) MO
QLL(200 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
metformin hcl tabs 1000mg 1
metformin hcl tabs 500mg
1
metformin hcl tabs 850mg
1
nateglinide tabs 120mg
1
nateglinide tabs 60mg
1
NEEDLES, INSULIN
2
DISP., SAFETY
NESINA TABS 12.5MG [+] 2
NESINA TABS 25MG [+] 2
NESINA TABS 6.25MG [+] 2
NOVOLIN 70/30 [+]
2
NOVOLIN 70/30 RELION2
NOVOLIN N [+]
2
NOVOLIN N RELION
2
NOVOLIN R [+]
2
NOVOLIN R RELION
2
NOVOLOG [+]
2
NOVOLOG FLEXPEN [+] 2
NOVOLOG MIX 70/30 [+]2
NOVOLOG MIX 70/30 2
PREFILLED FLEXPEN [+]
NOVOLOG PENFILL [+] 2
ONGLYZA TABS 2.5MG 2
[+]
ONGLYZA TABS 5MG [+] 2
OSENI TABS 12.5MG;
2
MO
15MG [+]
MO
OSENI TABS 12.5MG;
2
MO
30MG, 12.5MG; 45MG,
MO
25MG; 15MG, 25MG;
QLL(75 per 30 days) 30MG, 25MG; 45MG [+]
MO
28
Requirements/
Limits
QLL(120 per 30
days) MO
QLL(150 per 30
days) MO
QLL(80 per 30 days)
MO
QLL(76 per 30 days)
MO
QLL(153 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(200 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(120 per 30
days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
pioglitazone hcl tabs 15mg
1
pioglitazone hcl tabs 30mg
1
pioglitazone hcl tabs 45mg
1
pioglitazone hcl-glimepiride
1
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(150 per 30
days) MO
QLL(960 per 30
days) MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(360 per 30
days) MO
QLL(180 per 30
days) MO
MO
QLL(480 per 30
days)
QLL(240 per 30
days)
QLL(765 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(180 per 30
days) MO
PAR MO
PAR MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(30 per 30 days)
MO
MO
MO
pioglitazone hcl/metformin hcl 1
PRANDIMET
3
PRANDIN TABS 0.5MG
3
PRANDIN TABS 1MG
3
PRANDIN TABS 2MG
3
PRECOSE TABS 100MG 3
PRECOSE TABS 25MG
3
PRECOSE TABS 50MG
3
PROGLYCEM
repaglinide tabs 1mg
2
1
repaglinide tabs 2mg
1
RIOMET
3
STARLIX TABS 120MG
3
STARLIX TABS 60MG
3
SYMLINPEN 120
SYMLINPEN 60
tolazamide tabs 250mg
2
2
1
tolazamide tabs 500mg
1
tolbutamide
1
TRADJENTA
3
V-GO 20
V-GO 30
3
3
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
V-GO 40
VICTOZA [+]
3
2
MO
PAR QLL(9 per 30
days) MO
3
1
2
MO
MO
MO
1
1
MO
QLL(360 per 30
days) MO
Direct Acting Miotics
ISOPTO CARPINE
pilocarpine hcl
PILOPINE HS
Electrolytes
calcium acetate caps
calcium acetate tabs 667mg
3
calcium chloride
dextrose 5%/potassium chloride1
0.15%
EFFER-K TBEF 0.84GM; 3
1GM, 1.68GM; 2GM
3
effer-k tbef 25meq
1
effervescent pot chloride
1
effervescent potassium
effervescent potassium/chloride 1
3
eliphos
HYPERLYTE-CR
3
1
k-effervescent
1
k-phos neutral
K-TABS
3
1
k-vescent tbef
kcl 0.075%/d5w/nacl 0.45% 1
kcl 0.15%/d5w/ nacl 0.3% 1
1
kcl 0.15%/d5w/lr
kcl 0.15%/d5w/nacl 0.2% 1
kcl 0.15%/d5w/nacl 0.225% 1
kcl 0.15%/d5w/nacl 0.45% 1
kcl 0.15%/d5w/nacl 0.9% 1
kcl 0.3%/d5w/lr iv lac ring 1
kcl 0.3%/d5w/nacl 0.45% 1
1
kcl 0.3%/d5w/nacl 0.9%
3
klor-con
1
klor-con 10
KLOR-CON 25
3
1
klor-con 8
1
klor-con m10
1
klor-con m15
1
klor-con m20
1
klor-con/ef
1
lactated ringers
29
MO
MO
MO
MO
MO
QLL(360 per 30
days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
lactated ringers viaflex
MAGNESIUM SULFATE
IN D5W INJ 5%; 10MG/
ML
magnesium sulfate inj 40mg/
ml, 80mg/ml
magnesium sulfate inj 50%
MICRO-K
NEUT
NORMOSOL -R
NORMOSOL-R IN D5W
nutrilyte
nutrilyte ii
PHOSLO
PHOSLYRA
Drug
Tier
Requirements/
Limits
1
3
MO
1
1
3
3
2
2
3
3
3
3
1
phospha 250 neutral
3
potassium acetate inj
potassium chloride 0.15% /nacl1
0.45% viaflex
potassium chloride 0.15% d5w/1
nacl 0.33%
potassium chloride 0.15% d5w/1
nacl 0.45%
potassium chloride 0.15% d5w/1
nacl 0.45% viaflex
potassium chloride 0.15% nacl1
0.9%
potassium chloride 0.15% w/ 1
nacl 0.9% viaflex
potassium chloride 0.15%/d5w1
potassium chloride 0.15%/nacl1
0.9%
potassium chloride 0.22% d5w/1
nacl 0.45%
potassium chloride 0.224%/ 1
d5w/nacl 0.45%
1
potassium chloride
0.224%d5w/nacl 0.45%
viaflex
potassium chloride 0.3%/ nacl 1
0.9%
potassium chloride 0.3%/d5w 1
potassium chloride 0.3%/nacl 1
0.9%/viaflex
1
potassium chloride cr
Effective January 1, 2014
Drug Name
MO
MO
ST MO
QLL(1892 per 30
days) MO
MO
MO
MO
Drug
Tier
1
potassium chloride er
potassium chloride inj 0.4meq/1
ml, 10meq/100ml, 10meq/
50ml, 20meq/100ml, 20meq/
50ml, 30meq/100ml, 40meq/
100ml
potassium chloride inj 2meq/ml1
1
potassium chloride liqd
potassium chloride oral soln 1
1
potassium chloride sr
1
ringers injection
3
sodium acetate
sodium bicarbonate inj 4.2% 1
sodium bicarbonate inj 7.5%, 1
8.4%
sodium bicarbonate partial fill1
1
sodium chloride 0.45%
sodium chloride 0.45% viaflex1
sodium chloride inj 2.5meq/ml,1
3%, 4meq/ml
1
sodium chloride inj 5%
1
sodium lactate inj
3
sodium phosphate
TPN ELECTROLYTES
2
TPN ELECTROLYTES II 3
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Erythromycins & Other Macrolides
AZITHROMYCIN INJ
1
2.5GM
1
azithromycin inj 500mg
1
azithromycin pack
azithromycin susr 100mg/5ml 1
azithromycin susr 200mg/5ml 1
MO
30
azithromycin tabs 250mg
1
azithromycin tabs 500mg
1
azithromycin tabs 600mg
1
BIAXIN
BIAXIN XL
3
3
BIAXIN XL PAC
3
clarithromycin
1
MO
MO
QLL(15 per 1 days)
MO
QLL(46 per 1 days)
MO
QLL(6 per 1 days)
MO
QLL(3 per 1 days)
MO
QLL(8 per 1 days)
MO
MO
QLL(28 per 1 days)
MO
QLL(28 per 1 days)
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
clarithromycin er
1
DIFICID [+]
e.e.s. 400
E.E.S. GRANULES
e.s.p.
ery-tab tbec 250mg, 333mg
ERY-TAB TBEC 500MG
ERYPED 200
ERYPED 400
ERYTHROCIN
LACTOBIONATE
erythrocin stearate
erythromycin
erythromycin base
erythromycin ethylsuccinate
erythromycin/sulfisoxazole
PCE
ZITHROMAX INJ
ZITHROMAX PACK
ZITHROMAX SUSR
100MG/5ML
ZITHROMAX SUSR
200MG/5ML
ZITHROMAX TABS
250MG
ZITHROMAX TABS
500MG
ZITHROMAX TABS
600MG
ZITHROMAX TRI-PAK
2
3
3
1
1
3
3
3
2
QLL(28 per 1 days)
MO
PAR MO
MO
MO
MO
MO
MO
MO
MO
ZITHROMAX Z-PAK
3
ZMAX
1
1
1
1
1
3
3
3
3
3
3
3
3
3
2
MO
MO
MO
MO
MO
MO
MO
MO
QLL(15 per 1 days)
MO
QLL(46 per 1 days)
MO
QLL(6 per 1 days)
MO
QLL(3 per 1 days)
MO
QLL(8 per 1 days)
MO
QLL(3 per 1 days)
MO
QLL(6 per 1 days)
MO
MO
Estrogens & Progestins
ACTIVELLA
ALORA
3
3
ANGELIQ
AYGESTIN
camila
CENESTIN
CLIMARA
3
3
1
3
3
Comprehensive_P3TARO_10R
PAR MO
PAR QLL(8 per 28
days) MO
MO
MO
MO
MO
PAR QLL(4 per 28
days) MO
Drug Name
Drug
Tier
Requirements/
Limits
CLIMARA PRO
3
COMBIPATCH
3
CRINONE
DELESTROGEN
DEPO-ESTRADIOL
DEPO-PROVERA
DEPO-PROVERA
CONTRACEPTIVE
DEPO-SUBQ PROVERA
104
DIVIGEL
ELESTRIN
ENDOMETRIN
ENJUVIA
errin
ESTRACE CREA
ESTRACE TABS
estradiol ptwk
3
3
2
3
3
PAR QLL(4 per 28
days) MO
QLL(8 per 28 days)
MO
MO
MO
MO
MO
MO
2
MO
3
3
3
3
1
3
3
1
MO
MO
MO
MO
MO
MO
PAR MO
QLL(4 per 28 days)
MO
PAR MO
MO
PAR MO
MO
QLL(1 per 90 days)
MO
MO
MO
MO
MO
QLL(1 per 90 days)
MO
MO
1
estradiol tabs
1
estradiol valerate
estradiol/norethindrone acetate3
ESTRASORB
3
ESTRING
3
ESTROGEL
estropipate
EVAMIST
FEMHRT LOW DOSE
FEMRING
3
3
3
3
3
FIRST-PROGESTERONE 3
VGS 100
COMPOUNDING KIT
FIRST-PROGESTERONE 3
VGS 200
COMPOUNDING KIT
FIRST-PROGESTERONE 3
VGS 25 COMPOUNDING
KIT
FIRST-PROGESTERONE 3
VGS 400
COMPOUNDING KIT
31
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
FIRST-PROGESTERONE 3
VGS 50 COMPOUNDING
KIT
1
heather
3
jinteli
1
jolivette
MAKENA
3
medroxyprogesterone acetate 1
MENEST
3
MENOSTAR
3
mimvey
MINIVELLE
3
3
NOR-QD
nora-be
norethindrone
norethindrone acetate
ORTHO MICRONOR
PREFEST
PREMARIN CREA
PREMARIN INJ
PREMARIN TABS
PREMPHASE
PREMPRO
progesterone caps
progesterone inj
PROMETRIUM
PROVERA
VAGIFEM
VIVELLE-DOT
3
1
1
1
3
3
2
2
3
3
3
1
3
3
3
2
3
Requirements/
Limits
Drug Name
MO
MO
PAR MO
MO
MO
MO
PAR MO
PAR QLL(4 per 28
days) MO
MO
PAR QLL(8 per 28
days) MO
MO
MO
MO
MO
MO
PAR MO
MO
PAR MO
PAR MO
MO
MO
ST MO
MO
ST MO
MO
MO
PAR QLL(8 per 28
days) MO
Gout Therapy
allopurinol
allopurinol sodium
aloprim
COLCRYS
KRYSTEXXA
probenecid
probenecid/colchicine
ULORIC [+]
ZYLOPRIM
1
1
1
2
3
1
1
2
3
MO
Drug
Tier
NEOSPORIN GU
3
IRRIGANT
PHYSIOLYTE
2
PHYSIOSOL IRRIGATION2
PHYSIOSOL IRRIGATION2
PH 7.4
1
ringers irrigation
SORBITOL IRRIGATION 3
SOLN 3.3%
salicylic acid gel
3
Effective January 1, 2014
B/D PAR MO
MO
32
B/D PAR
B/D PAR
B/D PAR
B/D PAR MO
MO
Lipid/Cholesterol Lowering Agents
ADVICOR TB24 20MG; 3
1000MG, 20MG; 750MG
ADVICOR TB24 20MG; 3
500MG, 40MG; 1000MG
ALTOPREV
3
amlodipine besylate/
atorvastatin calcium
ANTARA
atorvastatin calcium
1
CADUET
3
3
1
1
cholestyramine
1
cholestyramine light
COLESTID
3
COLESTID FLAVORED 3
1
colestipol hcl
colestipol hcl for oral suspension1
CRESTOR [+]
2
fenofibrate tabs 54mg
1
fenofibric acid
fenofibric acid dr
FENOGLIDE
3
1
3
Irrigating Solutions
1
lactated ringers irrigation
neomycin/polymyxin b sulfates 1
MO
Keratolytics
1
fenofibrate caps
fenofibrate micronized caps 1
134mg, 200mg
fenofibrate micronized caps 1
67mg
fenofibrate tabs 145mg, 48mg 1
1
fenofibrate tabs 160mg
PAR MO
MO
MO
MO
ST MO
MO
Requirements/
Limits
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
PAR QLL(30 per 30
days) MO
QLL(30 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
ST MO
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
FIBRICOR
fluvastatin
3
1
gemfibrozil
JUXTAPID
KYNAMRO
LESCOL
1
3
3
3
LESCOL XL
3
LIPITOR
3
LIPOFEN [+]
LIVALO
2
3
MO
QLL(60 per 30 days)
MO
MO
LA MO
LA MO
PAR QLL(60 per 30
days) MO
PAR QLL(30 per 30
days) MO
QLL(30 per 30 days)
MO
MO
PAR QLL(30 per 30
days) MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
QLL(60 per 30 days)
MO
LOFIBRA CAPS 134MG, 3
200MG
LOFIBRA CAPS 67MG
3
LOFIBRA TABS 160MG
3
LOFIBRA TABS 54MG
3
LOPID
3
lovastatin tabs 10mg, 20mg 1
lovastatin tabs 40mg
1
LOVAZA [+]
2
MEVACOR TABS 20MG 3
MEVACOR TABS 40MG 3
micronized colestipol hcl
NIACOR
NIASPAN [+]
1
2
2
PRAVACHOL
3
pravastatin sodium
1
prevalite
QUESTRAN
QUESTRAN LIGHT
SIMCOR TB24 1000MG;
20MG, 500MG; 20MG,
750MG; 20MG
1
3
3
3
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
SIMCOR TB24 1000MG; 3
40MG, 500MG; 40MG
1
simvastatin
TRICOR
TRIGLIDE
TRILIPIX [+]
VASCEPA
VYTORIN
3
3
2
3
3
WELCHOL [+]
ZETIA
2
2
ZOCOR
3
Requirements/
Limits
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
PAR QLL(30 per 30
days) MO
MO
PAR QLL(30 per 30
days) MO
QLL(30 per 30 days)
MO
Migraine & Cluster Headache Therapy
ALSUMA
3
AMERGE
3
AXERT
3
CAFERGOT
3
D.H.E. 45
3
dihydroergotamine mesylate inj1
dihydroergotamine mesylate 1
nasal soln
ERGOMAR
2
FROVA
3
IMITREX INJ
3
IMITREX NASAL SOLN
20MG/ACT
IMITREX NASAL SOLN
5MG/ACT
IMITREX STATDOSE
REFILL
IMITREX STATDOSE
SYSTEM
IMITREX TABS
3
MAXALT
2
MAXALT-MLT
2
migergot
1
33
3
3
3
3
QLL(4 per 30 days)
MO
QLL(9 per 30 days)
MO
QLL(9 per 30 days)
MO
MO
MO
MO
QLL(8 per 28 days)
MO
MO
QLL(12 per 30 days)
MO
QLL(4 per 30 days)
MO
QLL(8 per 30 days)
MO
QLL(16 per 30 days)
MO
QLL(4 per 30 days)
MO
QLL(4 per 30 days)
MO
QLL(9 per 30 days)
MO
QLL(12 per 30 days)
MO
QLL(12 per 30 days)
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
MIGRANAL
3
naratriptan hcl
1
RELPAX
3
rizatriptan benzoate
3
rizatriptan benzoate odt
1
QLL(8 per 28 days)
MO
QLL(9 per 30 days)
MO
QLL(9 per 30 days)
MO
QLL(12 per 30 days)
MO
QLL(12 per 30 days)
MO
QLL(8 per 30 days)
MO
QLL(16 per 30 days)
MO
QLL(4 per 30 days)
MO
QLL(4 per 30 days)
MO
QLL(9 per 30 days)
MO
QLL(4 per 30 days)
MO
QLL(9 per 30 days)
MO
QLL(9 per 30 days)
MO
QLL(9 per 30 days)
MO
QLL(6 per 30 days)
MO
QLL(9 per 30 days)
MO
QLL(9 per 30 days)
MO
sumatriptan nasal soln 20mg/ 1
act
sumatriptan nasal soln 5mg/act1
sumatriptan succinate inj
1
sumatriptan succinate refill
1
sumatriptan succinate tabs
1
SUMAVEL DOSEPRO
3
TREXIMET
3
zolmitriptan
1
zolmitriptan odt
1
ZOMIG NASAL SOLN
3
ZOMIG TABS
3
ZOMIG ZMT
3
Miscellaneous Agents
acetic acid 0.25%
ACTONEL TABS 30MG
1
2
ADAGEN
2
AGRYLIN
3
alendronate sodium tabs 40mg1
AMMONUL
3
1
anagrelide hydrochloride
ANTABUSE
2
ARALAST NP INJ 1000MG,2
800MG
Effective January 1, 2014
Drug Name
Drug
Tier
ARALAST NP INJ 400MG,2
500MG
ARESTIN
3
ASCLERA
3
ASTELIN
3
ASTEPRO [+]
2
ATROVENT
3
azelastine hcl nasal soln
1
BACTROBAN NASAL
3
BUPHENYL POWD
3
BUPHENYL TABS
2
3
bupivacaine spinal
CAFCIT
3
3
caffeine citrate inj
3
caffeine citrate oral soln
CAMPRAL
3
CARBAGLU
2
CARNITOR
3
CARNITOR SF
3
CAVIRINSE
3
1
cevimeline hcl
CHEMET
3
chlorhexidine gluconate mouth/1
throat soln
chlorhexidine gluconate oral 1
rinse
CLINIMIX 4.25%/
2
DEXTROSE 5%
CLINIMIX E 2.75%/
2
DEXTROSE 10%
CLINIMIX E 2.75%/
2
MO
DEXTROSE 5%
QLL(30 per 30 days) CONTROLRX CREA
3
ST MO
DEBACTEROL
3
MO
1
denta 5000 plus
MO
1
dentagel
QLL(30 per 30 days) dextrose 10%/nacl 0.45%
1
MO
1
dextrose 2.5%
dextrose 10% flex container 1
MO
DEXTROSE 10% INJ 10% 1
MO
1
dextrose 10% inj 10%
LA MO
1
dextrose 10%/nacl 0.2%
34
Requirements/
Limits
LA MO
MO
QLL(30 per 25 days)
MO
QLL(30 per 25 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 25 days)
MO
MO
PAR MO
PAR MO
MO
MO
LA PAR MO
B/D PAR MO
B/D PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
dextrose 10%/nacl 0.225% 3
dextrose 2.5%/nacl 0.45% 1
dextrose 2.5%/sodium chloride1
0.45%
1
dextrose 25%
1
dextrose 30%
1
dextrose 30% partial fill
1
dextrose 40%
1
dextrose 5%
1
dextrose 5% viaflex
dextrose 5%/lactated ringers 1
1
dextrose 5%/nacl 0.2%
1
dextrose 5%/nacl 0.225%
1
dextrose 5%/nacl 0.3%
1
dextrose 5%/nacl 0.33%
1
dextrose 5%/nacl 0.45%
1
dextrose 5%/nacl 0.9%
3
dextrose 5%/ringers
dextrose 5%/sodium chloride 1
0.2%
dextrose 5%/sodium chloride 1
0.33%
dextrose 5%/sodium chloride 1
0.45%
dextrose 5%/sodium chloride 1
0.9%
1
dextrose 50%
1
dextrose 70%
1
dextrose thermoject system
DIDRONEL
3
1
disulfiram
1
etidronate disodium
EVOXAC
3
EXJADE
2
FERRIPROX
2
3
fluoridex daily defense
FLUORIDEX DAILY
3
DEFENSE SENSITIVITY
RELIEF PSTE
FOSRENOL
3
GEL-KAM ORAL CARE
RINSE
GLASSIA
HEXTEND
INCRELEX
3
2
3
2
Comprehensive_P3TARO_10R
Requirements/
Limits
Drug Name
Drug
Tier
ipratropium bromide nasal soln1
MO
MO
MO
MO
MO
kalexate
KAYEXALATE
kionex
lactated ringers dextrose 5%
viaflex
levocarnitine
LITHOSTAT
MARCAINE SPINAL
midodrine hcl
neutragard advanced
neutral sodium fluoride
NUTRESTORE
oralone
ORFADIN
PANHEMATIN
PATANASE
PERIDEX
perio med
periogard
PHOS-FLUR
MO
pilocarpine hcl
pilocarpine hydrochloride
MO
POLYETHYLENE
GLYCOL 3350-GRX
MO
PREVIDENT
PREVIDENT 5000
BOOSTER
MO
PREVIDENT 5000
MO
BOOSTER PLUS
MO
PREVIDENT 5000 DRY
MO
MOUTH
LA PAR MO
PREVIDENT 5000
PAR MO
ENAMEL PROTECT
MO
PREVIDENT 5000 PLUS
MO
PREVIDENT 5000
SENSITIVE
QLL(90 per 30 days) PREVIDENT FLUORIDE
PROLASTIN-C
ST MO
RAVICTI
RECLAST
RENAGEL
LA MO
RENVELA PACK [+]
LA PAR MO
35
1
3
1
1
1
3
3
1
3
1
3
3
2
3
2
Requirements/
Limits
QLL(30 per 30 days)
MO
MO
MO
MO
MO
B/D PAR MO
MO
3
3
1
3
1
1
1
MO
MO
MO
MO
MO
LA MO
MO
QLL(31 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
3
3
MO
MO
3
MO
3
MO
3
MO
3
3
MO
MO
3
2
3
3
3
2
MO
LA MO
MO
MO
ST MO
QLL(90 per 30 days)
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
RENVELA TABS [+]
2
QLL(270 per 30
days) MO
MO
MO
MO
MO
MO
RILUTEK
3
1
riluzole
SALAGEN
3
1
saline flush
1
saline flush zr/sterile field
SENSORCAINE-MPF
3
SPINAL
3
sf
1
sf 5000 plus
SKELID
3
1
sodium chloride 0.9%
1
sodium chloride 0.9%
sodium chloride bacteriostatic 1
sodium chloride bacteriostatic/ 1
benzyl alcohol
1
sodium chloride flush
1
sodium chloride inj 0.9%
sodium chloride irrigation soln1
1
sodium chloride pab
sodium chloride thermoject 1
system
1
sodium phenylbutyrate
sodium polystyrene sulfonate 1
powd
sodium polystyrene sulfonate 1
susp 15gm/60ml
sodium polystyrene sulfonate 1
susp 30gm/120ml
SOTRADECOL
3
1
sps
stannous fluoride oral rinse 3
1
sterile water irrigation
sterile water irrigation plastic 1
bottle
1
sterile water irrigation w/
hanger
SYPRINE
2
THIOLA
3
triamcinolone acetonide pste 1
1
triamcinolone in orabase
TYZINE
2
TYZINE PEDIATRIC
2
NASAL DROPS
XIAFLEX
3
Effective January 1, 2014
Drug Name
Drug
Tier
ZEMAIRA
2
zoledronic acid inj 5mg/100ml3
Requirements/
Limits
LA MO
MO
Miscellaneous Antiinfectives
ALBENZA
2
ALINIA
3
1
amikacin sulfate
ARALEN
3
1
atovaquone/proguanil hcl
AZACTAM
3
AZACTAM IN ISO2
OSMOTIC DEXTROSE
INJ 1GM; 0
AZACTAM IN ISO3
OSMOTIC DEXTROSE
INJ 2GM; 0
1
aztreonam
1
baciim
1
bacitracin
BILTRICIDE
3
CAPASTAT SULFATE
2
CAYSTON
3
1
chloramphenicol sodium
succinate
1
chloroquine phosphate
CLEOCIN
3
CLEOCIN IN D5W
3
CLEOCIN PEDIATRIC 3
GRANULES
CLEOCIN PHOSPHATE 3
INJ 150MG/ML
CLEOCIN PHOSPHATE 3
INJ 300MG/2ML, 600MG/
4ML, 900MG/6ML, 9GM/
60ML
1
clindamycin hcl
1
clindamycin palmitate hcl
1
clindamycin phosphate
clindamycin phosphate add- 1
vantage
clindamycin phosphate in d5w1
inj 300mg/50ml; 5%, 600mg/
50ml; 5%
clindamycin phosphate in d5w1
inj 900mg/50ml; 5%
1
clindamycin phosphate
pharmacy bulk package
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
36
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
LA MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
COARTEM
2
1
colistimethate sodium
COLY-MYCIN M
2
CUBICIN
2
CYCLOSERINE
3
DAPSONE
2
DARAPRIM
2
DORIBAX
2
1
ethambutol hcl
FLAGYL
3
FLAGYL ER
3
1
gentamicin sulfate
1
gentamicin sulfate/0.9%
sodium chloride
1
gentamicin sulfate/sodium
chloride
hydroxychloroquine sulfate 1
1
imipenem/cilastatin
INVANZ
2
1
isoniazid inj
1
isoniazid syrp
1
isoniazid tabs
isotonic gentamicin inj 0.8mg/1
ml; 0.9%, 1.2mg/ml; 0.9%,
1.6mg/ml; 0.9%, 1mg/ml;
0.9%
ISOTONIC GENTAMICIN2
INJ 2MG/ML; 0.9%
KETEK
2
LINCOCIN
MALARONE
mefloquine hcl
MEPRON
meropenem
MERREM
metro iv
metronidazole
metronidazole in nacl 0.79%
MYAMBUTOL
MYCOBUTIN
NEBUPENT
NEO-FRADIN
neomycin sulfate tabs
paromomycin sulfate
PASER
2
3
1
2
1
3
1
1
1
3
2
2
3
1
1
2
Comprehensive_P3TARO_10R
Requirements/
Limits
MO
MO
MO
B/D PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(20 per 1 days)
MO
MO
MO
MO
PAR MO
MO
MO
MO
MO
MO
MO
MO
B/D PAR MO
MO
MO
MO
MO
Drug
Tier
Requirements/
Limits
PENTAM 300
PLAQUENIL
polymyxin b sulfate
PRIFTIN
PRIMAQUINE
PHOSPHATE
PRIMAXIN IV
PRIMAXIN IV ADDVANTAGE
pyrazinamide
QUALAQUIN
quinine sulfate
RIFADIN CAPS
RIFADIN INJ
RIFAMATE
rifampin
RIFATER
RIMSO-50
SEROMYCIN
SIRTURO
STREPTOMYCIN
SULFATE
STROMECTOL
SYNERCID
TINDAMAX
tinidazole
TOBI
TOBI PODHALER
tobramycin sulfate inj 1.2gm
tobramycin sulfate inj 1.2gm/
30ml, 10mg/ml, 40mg/ml,
80mg/2ml
tobramycin sulfate/sodium
chloride inj 0.9%; 0.8mg/ml
tobramycin sulfate/sodium
chloride inj 0.9%; 1.2mg/ml
TRECATOR
TYGACIL
XIFAXAN
ZYVOX INJ
ZYVOX SUSR
2
3
1
2
2
MO
MO
MO
MO
MO
3
3
MO
MO
1
3
1
3
2
3
1
2
3
3
3
2
MO
PAR MO
PAR MO
MO
MO
MO
MO
MO
MO
MO
LA
MO
2
3
3
1
2
3
1
1
MO
1
MO
ZYVOX TABS
2
Drug Name
37
MO
MO
B/D PAR MO
MO
MO
1
2
2
3
2
2
MO
MO
MO
MO
PAR QLL(1800 per
1 days) MO
PAR QLL(28 per 1
days) MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
Miscellaneous Cardiovascular Agents
dobutamine hcl
dobutamine hcl/d5w
dobutamine/dextrose 5%
dopamine hcl
dopamine hcl-dextrose 5%
dopamine hcl/dextrose 5%
dopamine/d5w
ISUPREL
milrinone in dextrose
milrinone lactate
NATRECOR
norepinephrine bitartrate
RANEXA [+]
3
3
3
3
3
3
3
3
3
3
3
3
2
MO
MO
Miscellaneous Dermatologicals
8-MOP
ALDARA
ammonium lactate
CARAC
CARMOL-HC
CONDYLOX
DRYSOL
EFUDEX
ELIDEL
3
3
1
2
3
3
3
3
2
FLUOROPLEX
fluorouracil crea
fluorouracil external soln
GORDONS UREA
HYDRO 35
HYDRO 40 FOAM
hypercare
imiquimod
KERAFOAM
KERAFOAM 42
LAC-HYDRIN
laclotion
LEVULAN KERASTICK
METVIXIA
OXSORALEN
OXSORALEN ULTRA
PANRETIN
PICATO
podofilox
PROTOPIC
3
1
1
3
3
3
3
1
3
3
3
1
3
3
3
3
2
3
1
3
Effective January 1, 2014
PAR MO
MO
MO
MO
MO
MO
MO
MO
PAR QLL(60 per 1
days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PAR MO
MO
MO
MO
PAR QLL(60 per 1
days) MO
38
Drug Name
Drug
Tier
Requirements/
Limits
prudoxin
QUTENZA
REGRANEX
remeven
SOLARAZE
1
3
3
3
2
U-CORT
u-kera e
UMECTA
umecta mousse
UMECTA NAIL FILM
UMECTA PD
URAMAXIN
URAMAXIN GT
URAMAXIN GT KIT
urea crea 40%, 45%, 50%
urea emul
urea gel
urea hydrating
urea lotn 40%
urea nail
urea susp
UVADEX
VEREGEN
x-viate
XERAC AC
ZONALON
ZYCLARA
ZYCLARA PUMP
3
3
3
1
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
MO
MO
MO
MO
PAR QLL(100 per
30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
B/D PAR
MO
MO
MO
MO
MO
MO
Miscellaneous Gastrointestinal Agents
ACTIGALL
ALOXI
AMITIZA
ANTIVERT
ANUSOL-HC CREA
ANZEMET INJ
ANZEMET TABS
3
2
3
3
3
2
3
APRISO [+]
ASACOL [+]
ASACOL HD [+]
AZULFIDINE
AZULFIDINE EN-TABS
balsalazide disodium
budesonide cp24
CANASA [+]
2
2
2
3
3
1
1
2
MO
MO
MO
MO
MO
MO
B/D PAR QLL(5 per
30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
CESAMET
CHENODAL
CIMZIA
3
3
2
CIMZIA STARTER KIT
2
B/D PAR MO
LA MO
PAR QLL(6 per 28
days) MO
PAR QLL(6 per 28
days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
COLAZAL
3
1
colocort
COLYTE-FLAVOR PACKS 3
1
compro
1
constulose
CORTENEMA
3
CORTIFOAM
3
CREON [+]
2
1
cromolyn sodium conc
CYSTADANE
2
DELZICOL [+]
2
3
dimenhydrinate inj
DIPENTUM
2
1
dronabinol
3
droperidol
EMEND CAPS [+]
2
EMEND CAPS 125MG [+] 2
EMEND CAPS 40MG [+] 2
EMEND CAPS 80MG [+] 2
EMEND INJ
ENTOCORT EC
enulose
GASTROCROM
GATTEX
gavilyte-c
gavilyte-g
gavilyte-n/flavor pack
generlac
GIAZO
GOLYTELY
granisetron hcl inj
granisetron hcl tabs
3
3
1
3
2
1
1
1
1
3
3
1
1
granisol
3
Comprehensive_P3TARO_10R
MO
B/D PAR MO
MO
B/D PAR QLL(12
per 30 days) MO
B/D PAR QLL(4 per
30 days) MO
B/D PAR QLL(1 per
1 days) MO
B/D PAR QLL(8 per
30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
B/D PAR QLL(30
per 30 days) MO
B/D PAR QLL(150
per 30 days)
Drug Name
Drug
Tier
HALFLYTELY BOWEL
2
PREP/FLAVOR PACKS
1
hydrocortisone enem
KRISTALOSE
3
1
lactulose
LIALDA [+]
2
lidocaine hcl/hydrocortisone 3
acetate crea
lidocaine hcl/hydrocortisone 3
acetate kit 0.5%; 3%, 2%; 2%
LINZESS
3
LOTRONEX
2
MARINOL
meclizine hcl tabs
mesalamine
metoclopramide hcl
METOZOLV ODT
MOVIPREP
NULYTELY/FLAVOR
PACKS
ondansetron hcl inj
ondansetron hcl oral soln
3
1
1
1
3
2
3
ondansetron hcl tabs 24mg
1
1
1
ondansetron hcl tabs 4mg, 8mg1
ondansetron odt
1
OSMOPREP
2
PANCREAZE
3
3
pancrelipase
1
peg 3350/electrolytes
1
peg-3350/electrolytes
peg-3350/nacl/na bicarbonate/1
kcl
PENTASA [+]
2
PERTZYE
3
polyethylene glycol 3350 pack 1
polyethylene glycol 3350 powd 1
PREPOPIK
3
1
prochlorperazine
1
prochlorperazine edisylate
1
prochlorperazine maleate
1
procto-pak
39
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
PAR QLL(60 per 30
days) MO
B/D PAR MO
MO
MO
MO
MO
MO
MO
MO
B/D PAR QLL(450
per 30 days) MO
B/D PAR QLL(30
per 30 days)
B/D PAR QLL(90
per 30 days) MO
B/D PAR QLL(90
per 30 days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
PROCTOCORT CREA
PROCTOCREAM HC
proctosol hc
proctozone-hc
RECTIV
REGLAN
RELISTOR
REMICADE
ROWASA
SANCUSO
3
3
1
1
3
3
2
2
3
3
MO
MO
MO
MO
MO
MO
PAR MO
PAR MO
MO
PAR QLL(4 per 28
days) MO
SCOPOLAMINE
HYDROBROMIDE
SFROWASA
SUCRAID
sulfasalazine
sulfazine
sulfazine ec
SUPREP BOWEL PREP
TIGAN
TRANSDERM-SCOP
3
trilyte
trimethobenzamide hcl caps
trimethobenzamide hcl inj
UCERIS
ULTRESA
URSO 250
URSO FORTE
ursodiol
VIOKACE
VISICOL
ZENPEP
ZOFRAN INJ
ZOFRAN ODT
1
3
3
2
3
3
3
1
3
3
3
2
3
ZOFRAN ORAL SOLN
3
ZOFRAN TABS
ZUPLENZ
3
2
1
1
1
2
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
QLL(4 per 12 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
B/D PAR QLL(90
per 30 days) MO
B/D PAR QLL(450
per 30 days) MO
B/D PAR QLL(90
per 30 days) MO
B/D PAR MO
Miscellaneous Hormones
ACTHREL
ALDURAZYME
ANADROL-50
Effective January 1, 2014
3
2
3
MO
PAR MO
MO
40
Drug Name
Drug
Tier
Requirements/
Limits
ANDRODERM
3
PAR QLL(30 per 30
days) MO
PAR QLL(30 per 30
days) MO
PAR QLL(300 per
30 days) MO
PAR QLL(60 per 30
days) MO
PAR QLL(300 per
30 days) MO
PAR QLL(150 per
30 days) MO
MO
PAR MO
QLL(90 per 1 days)
MO
MO
QLL(4 per 30 days)
MO
B/D PAR MO
B/D PAR MO
B/D PAR MO
PAR MO
B/D PAR MO
MO
MO
MO
MO
MO
MO
MO
PAR MO
MO
PAR MO
MO
MO
ANDROGEL GEL
2
20.25MG/1.25GM [+]
ANDROGEL GEL 25MG/ 2
2.5GM, 50MG/5GM [+]
ANDROGEL GEL 40.5MG/2
2.5GM [+]
ANDROGEL PUMP GEL 2
1% [+]
ANDROGEL PUMP GEL 2
1.62% [+]
ANDROID
3
1
androxy
AXIRON
3
cabergoline
calcitonin-salmon
1
1
1
calcitriol caps
1
calcitriol inj
1
calcitriol oral soln
CEREZYME
2
3
chorionic gonadotropin
1
danazol
DDAVP INJ
2
DDAVP NASAL SOLN
3
DDAVP TABS
3
DELATESTRYL
3
DEPO-TESTOSTERONE 3
1
desmopressin acetate
ELAPRASE
2
ELELYSO
3
FABRAZYME
2
FIRST-TESTOSTERONE 3
FIRST-TESTOSTERONE 3
MC COMPOUNDING KIT
FORTESTA
3
fortical
1
HECTOROL CAPS
HECTOROL INJ
KORLYM
KUVAN
LUMIZYME
METHITEST
3
2
3
2
3
3
QLL(120 per 30
days) MO
QLL(4 per 30 days)
MO
B/D PAR MO
B/D PAR MO
MO
LA PAR MO
LA MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
MIACALCIN INJ
3
MIACALCIN NASAL SOLN3
MYOZYME
3
NAGLAZYME
2
3
novarel
OXANDRIN
3
1
oxandrolone
1
pamidronate disodium inj
30mg, 30mg/10ml, 90mg,
90mg/10ml
pamidronate disodium inj 6mg/1
ml
PREGNYL W/DILUENT 3
BENZYL ALCOHOL/
NACL
ROCALTROL
3
SAMSCA TABS 15MG
2
SAMSCA TABS 30MG
2
SENSIPAR TABS 30MG,
60MG
SENSIPAR TABS 90MG
2
SOMAVERT
STIMATE
STRIANT
SYNAREL
TESTIM [+]
2
2
3
2
2
TESTOPEL
testosterone cypionate
testosterone enanthate
TESTRED
VPRIV
ZAVESCA
ZEMPLAR
zoledronic acid inj 4mg
zoledronic acid inj 4mg/5ml
ZOMETA
2
3
1
1
3
3
2
3
1
1
2
Requirements/
Limits
B/D PAR MO
QLL(4 per 30 days)
MO
MO
LA PAR MO
B/D PAR MO
MO
PAR MO
B/D PAR MO
Drug Name
ARICEPT TABS 10MG, 3
5MG
ARICEPT TABS 23MG [+] 2
AUBAGIO
2
ARICEPT ODT
3
Comprehensive_P3TARO_10R
3
COPAXONE
2
donepezil hcl tabs 10mg, 5mg 1
donepezil hcl tabs 23mg
donepezil hcl tbdp
1
1
EXELON CAPS
3
EXELON ORAL SOLN
2
EXELON PT24 [+]
2
galantamine
1
B/D PAR
B/D PAR MO
B/D PAR MO
PAR QLL(30 per 30
days) MO
PAR QLL(60 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(120 per 30
days) MO
LA PAR MO
MO
MO
PAR MO
PAR QLL(300 per
30 days) MO
MO
MO
MO
MO
MO
LA PAR MO
B/D PAR MO
MO
MO
galantamine hydrobromide 1
cp24
galantamine hydrobromide oral1
soln
galantamine hydrobromide tabs1
GILENYA
2
HORIZANT
2
NAMENDA ORAL SOLN 2
[+]
NAMENDA TABS [+]
2
NAMENDA TITRATION
PAK [+]
NAMENDA XR
NAMENDA XR
TITRATION PACK
NUEDEXTA [+]
RAZADYNE ER
Miscellaneous Neurological Therapy
AMPYRA
Drug
Tier
2
3
3
2
3
LA PAR QLL(60 per RAZADYNE ORAL SOLN 3
30 days) MO
3
QLL(30 per 30 days) RAZADYNE TABS
MO
41
Requirements/
Limits
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
ST MO
PAR QLL(30 per 30
days) MO
PAR MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(60 per 30 days)
MO
PAR QLL(30 per 30
days) MO
PAR QLL(60 per 30
days) MO
QLL(300 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
PAR MO
QLL(30 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(60 per 30 days)
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
rivastigmine tartrate
1
TECFIDERA
TECFIDERA STARTER
PACK
TYSABRI
XENAZINE
3
3
QLL(60 per 30 days)
MO
MO
MO
2
2
LA PAR MO
LA PAR MO
AVC
CERVIDIL
CLEOCIN
clindamycin phosphate
fem ph
GYNAZOLE-1
LYSTEDA
METROGEL-VAGINAL
metronidazole vaginal
miconazole 3
3
3
3
1
3
3
3
3
1
1
MO
NUVARING
ORTHO EVRA
PREPIDIL
PROSTIN E2
RELAGARD
TERAZOL 3
TERAZOL 7
terconazole
tranexamic acid tabs
vandazole
zazole crea 0.4%
ZAZOLE CREA 0.8%
3
3
3
3
3
3
3
1
3
1
1
1
Miscellaneous Ob/Gyn
MO
MO
MO
MO
MO
MO
MO
QLL(6 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
Requirements/
Limits
epinastine hcl
EYLEA
JETREA
LACRISERT
LASTACAFT
LUCENTIS
MACUGEN
OPTIVAR
parcaine
PATADAY [+]
PATANOL [+]
proparacaine hcl
RESTASIS [+]
VISUDYNE
1
3
3
2
3
3
3
3
3
2
2
3
2
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Miscellaneous Otic Preparations
1
acetasol hc
1
acetic acid otic soln
acetic acid/aluminum acetate 1
antipyrine/benzocaine otic soln3
5.4%; 1.4%, 54mg/ml; 14mg/
ml
3
aurodex
CETRAXAL
3
3
ciprofloxacin otic soln
DERMOTIC
3
1
fluocinolone acetonide
1
hydrocortisone/acetic acid
1
ofloxacin
PRAMOTIC
3
3
treagan otic
VOSOL HC
3
Miscellaneous Ophthalmologics
Miscellaneous Urologicals
akorn balanced salt solution 3
AKTEN
3
ALCAINE
3
ALOCRIL
3
ALOMIDE
3
azelastine hcl ophthalmic soln 1
BEPREVE
3
3
bss
BSS PLUS
3
cromolyn sodium ophthalmic 1
soln
CYSTARAN
3
ELESTAT
3
EMADINE
3
3
alprostadil
3
aminoacetic acid
AMMONIUM CHLORIDE2
CIALIS TABS 2.5MG, 5MG3
Effective January 1, 2014
MO
MO
MO
MO
MO
MO
MO
MO
citric acid/sodium citrate
CYSTAGON
cytra k crystals
cytra-2
cytra-3
cytra-k
ELMIRON
glycine irrigation soln
K-PHOS
MO
MO
MO
MO
42
1
2
1
1
1
1
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PAR QLL(30 per 30
days) MO
MO
LA MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
K-PHOS NO 2
3
ORACIT
3
1
potassium citrate tbcr
PROSTIN VR PEDIATRIC 3
RENACIDIN
3
1
tricitrates
UROCIT-K 10
3
UROCIT-K 15
3
UROCIT-K 5
3
UROQID #2
3
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Miscellaneous Vitamins, Hematinics, &
Electrolytes
3
amino acids
AMINOSYN 7%/
3
ELECTROLYTES
AMINOSYN 8.5%/
2
ELECTROLYTES
AMINOSYN II
2
AMINOSYN II 5/
3
DEXTROSE 25
AMINOSYN II 8.5%/
2
ELECTROLYTES
AMINOSYN INJ 148MEQ/2
L; 1280MG/100ML;
980MG/100ML; 1280MG/
100ML; 300MG/100ML;
720MG/100ML; 940MG/
100ML; 720MG/100ML;
400MG/100ML; 440MG/
100ML; 5.4MEQ/L;
860MG/100ML; 420MG/
100ML; 520MG/100ML;
160MG/100ML; 44MG/
100ML; 800MG/100ML,
90MEQ/L; 1100MG/
100ML; 850MG/100ML;
35MEQ/L; 1100MG/
100ML; 260MG/100ML;
620MG/100ML; 810MG/
100ML; 624MG/100ML;
340MG/100ML; 380MG/
100ML; 5.4MEQ/L;
750MG/100ML; 370MG/
100ML; 460MG/100ML;
150MG/100ML; 44MG/
100ML; 680MG/100ML
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
AMINOSYN INJ 50.3MEQ/3
L; 695MG/100ML; 713MG/
100ML; 490MG/100ML;
517MG/100ML; 350MG/
100ML; 210MG/100ML;
462MG/100ML; 700MG/
100ML; 735MG/100ML;
120MG/100ML; 209MG/
100ML; 505MG/100ML;
371MG/100ML; 31.3MEQ/
L; 280MG/100ML; 140MG/
100ML; 189MG/100ML;
350MG/100ML, 51MEQ/L;
448MG/100ML; 343MG/
100ML; 448MG/100ML;
105MG/100ML; 252MG/
100ML; 329MG/100ML;
252MG/100ML; 140MG/
100ML; 154MG/100ML;
300MG/100ML; 147MG/
100ML; 182MG/100ML;
56MG/100ML; 31MG/
100ML; 280MG/100ML
AMINOSYN M
2
AMINOSYN-HBC
2
AMINOSYN-PF
2
AMINOSYN-PF 7%
2
AMINOSYN-RF
3
CLINIMIX 2.75%/
2
DEXTROSE 5%
CLINIMIX 4.25%/
2
DEXTROSE 10%
CLINIMIX 4.25%/
2
DEXTROSE 20%
CLINIMIX 4.25%/
2
DEXTROSE 25%
CLINIMIX 5%/DEXTROSE2
15%
CLINIMIX 5%/DEXTROSE2
20%
CLINIMIX 5%/DEXTROSE2
25%
CLINIMIX E 4.25%/
2
DEXTROSE 10%
CLINIMIX E 4.25%/
2
DEXTROSE 25%
43
Effective January 1, 2014
Drug Name
Drug
Tier
CLINIMIX E 4.25%/
2
DEXTROSE 5%
CLINIMIX E 5%/
2
DEXTROSE 15%
CLINIMIX E 5%/
2
DEXTROSE 20%
CLINIMIX E 5%/
2
DEXTROSE 25%
CLINISOL SF 15%
2
dextrose 5% /electrolyte #48 3
viaflex
FREAMINE HBC 6.9% 3
FREAMINE III 3%
3
FREAMINE III INJ
2
72MEQ/L; 600MG/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/
100ML
1
freamine iii inj 89meq/l;
710mg/100ml; 950mg/100ml;
3meq/l; 24mg/100ml; 1400mg/
100ml; 280mg/100ml; 690mg/
100ml; 910mg/100ml; 730mg/
100ml; 530mg/100ml; 560mg/
100ml; 10mmole/l; 120mg/
100ml; 1120mg/100ml;
590mg/100ml; 10meq/l;
400mg/100ml; 150mg/100ml;
660mg/100ml
HEPATAMINE
2
HEPATASOL
2
HESPAN
3
3
hetastarch 6%/nacl
INTRALIPID INJ 1.7%; 2
30%
intralipid inj 2.25%; 20% 1
IONOSOL-B/DEXTROSE 2
5%
Effective January 1, 2014
Requirements/
Limits
Drug Name
Drug
Tier
IONOSOL-MB/
2
DEXTROSE 5%
ISOLYTE-M/DEXTROSE 2
5%
ISOLYTE-P/DEXTROSE 2
5%
ISOLYTE-S
2
ISOLYTE-S PH 7.4
2
LIPOSYN II
3
liposyn iii inj 1.2%; 2.5%; 1
10%, 1.8%; 2.5%; 30%
liposyn iii inj 1.2%; 2.5%; 1
20%
NEPHRAMINE
2
NORMOSOL-M IN D5W 2
NORMOSOL-R
2
PLASMA-LYTE A
2
PLASMA-LYTE-148
2
PLASMA-LYTE-56/D5W 2
premasol inj 52meq/l; 1760mg/1
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/
100ml
PREMASOL INJ 56MEQ/L;2
320MG/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/
100ML
PROCALAMINE
2
PROSOL
2
R-GENE 10
3
1
travasol
MO
MO
MO
44
Requirements/
Limits
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
TROPHAMINE
VOLUVEN
2
3
Requirements/
Limits
Muscle Relaxants & Antispasmodic Therapy
AMRIX
3
3
anectine
1
baclofen
3
carisoprodol
3
carisoprodol/aspirin
carisoprodol/aspirin/codeine 3
3
chlorzoxazone
cyclobenzaprine hcl tabs 10mg,1
5mg
cyclobenzaprine hcl tabs 7.5mg3
DANTRIUM
3
DANTRIUM IV
3
1
dantrolene sodium caps
3
enlon
ENLON-PLUS
3
FEXMID
3
GABLOFEN INJ
3
10000MCG/20ML,
40000MCG/20ML,
50MCG/ML
LIORESAL
3
INTRATHECAL INJ
0.05MG/ML
LIORESAL
3
INTRATHECAL INJ
10MG/20ML, 10MG/5ML,
40MG/20ML
LORZONE
3
3
meprobamate tabs 200mg
meprobamate tabs 400mg
3
MESTINON SYRP
MESTINON TABS
MESTINON TIMESPAN
metaxalone
methocarbamol
neostigmine methylsulfate inj
0.5mg/ml
neostigmine methylsulfate inj
1mg/ml
NORFLEX
orphenadrine citrate
2
3
2
3
3
3
PAR MO
MO
MO
MO
MO
MO
PAR MO
PAR MO
MO
Comprehensive_P3TARO_10R
Drug
Tier
Requirements/
Limits
orphenadrine citrate er
orphenadrine/asa/caffeine
PARAFON FORTE DSC
PROSTIGMIN TABS
pyridostigmine bromide
regonol
revonto
ROBAXIN
ROBAXIN-750
SKELAXIN
SOMA
tizanidine hcl
ZANAFLEX
3
3
3
3
1
1
3
3
3
3
3
1
3
MO
MO
MO
MO
MO
MO
PAR MO
B/D PAR MO
ABSTRAL SUBL 200MCG,2
300MCG, 400MCG,
600MCG, 800MCG
1
acetaminophen/caffeine/
dihydrocodeine bitartrate
acetaminophen/codeine #2 1
B/D PAR
acetaminophen/codeine #3
1
acetaminophen/codeine #4
1
acetaminophen/codeine oral
soln
acetaminophen/codeine
phosphate
acetaminophen/codeine tabs
1
ACTIQ
2
B/D PAR MO
MO
QLL(120 per 30
days) MO
QLL(180 per 30
days) MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Narcotic Analgesics
ABSTRAL SUBL 100MCG 3
1
1
2
alagesic lq
ALFENTA
3
3
alfentanil
3
ascomp/codeine
aspirin-caffeine-dihydrocodeine1
ASTRAMORPH
AVINZA CP24 120MG
3
3
3
Drug Name
2
3
PAR QLL(120 per
30 days) MO
PAR QLL(120 per
30 days) MO
QLL(150 per 30
days) MO
QLL(390 per 30
days) MO
QLL(390 per 30
days) MO
QLL(390 per 30
days) MO
QLL(4500 per 30
days)
QLL(390 per 30
days) MO
QLL(390 per 30
days) MO
PAR QLL(120 per
30 days) MO
MO
MO
QLL(240 per 30
days)
B/D PAR
QLL(180 per 30
days) MO
MO
MO
45
Effective January 1, 2014
Drug Name
AVINZA CP24 30MG,
45MG, 60MG, 75MG,
90MG
bupap tabs 650mg; 50mg
BUPRENEX
buprenorphine hcl inj
buprenorphine hcl subl 2mg
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
Requirements/
Limits
3
QLL(120 per 30
days) MO
DILAUDID INJ
DILAUDID TABS 2MG
3
3
2
2
1
1
MO
MO
DILAUDID TABS 4MG
3
DILAUDID TABS 8MG
3
DILAUDID-5
3
MO
QLL(960 per 30
days) MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(1920 per 30
days) MO
DILAUDID-HP
DOLGIC PLUS
dolophine hcl TABS 10MG
3
2
3
buprenorphine hcl subl 8mg 1
butal/asa/caff
butalbital/acetaminophen
butalbital/acetaminophen/
caffeine
butalbital/acetaminophen/
caffeine/codeine
butalbital/asa/caffeine
butalbital/aspirin/caffeine
butalbital/aspirin/caffeine/
codeine
BUTRANS
1
1
1
capacet
CAPITAL/CODEINE
2
3
co-gesic
3
1
1
3
3
1
codeine phosphate
CODEINE SULFATE
ORAL SOLN
codeine sulfate tabs 15mg
3
3
codeine sulfate tabs 30mg
1
codeine sulfate tabs 60mg
1
1
DEMEROL INJ 100MG/ 3
2ML, 25MG/0.5ML, 75MG/
1.5ML, 75MG/ML
3
demerol inj 100mg/ml
DEMEROL INJ 100MG/ 3
ML, 25MG/ML, 50MG/ML
DEMEROL TABS 100MG 3
DEMEROL TABS 50MG 3
DEPODUR
Effective January 1, 2014
PAR QLL(240 per
30 days) MO
PAR QLL(60 per 30
days) MO
MO
MO
MO
DOLOPHINE HCL TABS 3
5MG
DURAGESIC
3
QLL(180 per 30
days) MO
MO
MO
MO
QLL(4 per 28 days)
MO
MO
QLL(5000 per 30
days) MO
QLL(240 per 30
days) MO
QLL(720 per 30
days) MO
QLL(360 per 30
days) MO
QLL(180 per 30
days) MO
MO
MO
QLL(360 per 30
days) MO
QLL(720 per 30
days) MO
1
duramorph
endocet tabs 325mg; 10mg, 1
325mg; 5mg, 325mg; 7.5mg
endocet tabs 500mg; 7.5mg 1
endocet tabs 650mg; 10mg
1
endodan
1
ESGIC
ESGIC-PLUS
EXALGO TB24 12MG,
16MG, 8MG
EXALGO TB24 32MG
fentanyl citrate
fentanyl citrate oral
transmucosal
fentanyl patches
2
2
3
FENTORA
2
FIORICET TABS
FIORICET/CODEINE
CAPS 325MG; 50MG;
40MG; 30MG
FIORINAL
FIORINAL/CODEINE #3
HYCET
2
3
3
3
1
1
2
3
3
MO
QLL(360 per 30
days) MO
QLL(720 per 30
days) MO
QLL(15 per 30 days)
MO
B/D PAR MO
QLL(360 per 30
days) MO
QLL(240 per 30
days) MO
QLL(180 per 30
days) MO
QLL(360 per 30
days) MO
MO
MO
QLL(60 per 30 days)
MO
MO
MO
PAR QLL(120 per
30 days) MO
QLL(15 per 30 days)
MO
PAR QLL(120 per
30 days) MO
MO
QLL(180 per 30
days) MO
MO
MO
QLL(3600 per 30
days) MO
3
46
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
1
hydrocodone bitartrate/
acetaminophen oral soln
3
hydrocodone bitartrate/
acetaminophen tabs 300mg;
10mg, 300mg; 5mg, 300mg;
7.5mg
3
hydrocodone bitartrate/
acetaminophen tabs 325mg;
2.5mg
1
hydrocodone bitartrate/
acetaminophen tabs 750mg;
10mg
hydrocodone/acetaminophen 1
oral soln
hydrocodone/acetaminophen 1
tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg
hydrocodone/acetaminophen 1
tabs 500mg; 10mg, 500mg;
2.5mg, 500mg; 5mg, 500mg;
7.5mg
hydrocodone/acetaminophen 1
tabs 650mg; 10mg, 650mg;
7.5mg, 660mg; 10mg
hydrocodone/acetaminophen 1
tabs 750mg; 7.5mg
hydrocodone/ibuprofen tabs 3
10mg; 200mg, 2.5mg; 200mg,
5mg; 200mg
hydrocodone/ibuprofen tabs 1
7.5mg; 200mg
3
hydrogesic
1
hydromorphone hcl dosette
HYDROMORPHONE
1
HCL INJ 1MG/ML
hydromorphone hcl inj 1mg/ml,1
500mg/50ml
hydromorphone hcl inj 2mg/ml,1
4mg/ml
1
hydromorphone hcl liqd
1
hydromorphone hcl supp
hydromorphone hcl tabs 2mg 1
Comprehensive_P3TARO_10R
Requirements/
Limits
QLL(3600 per 30
days) MO
QLL(390 per 30
days) MO
QLL(150 per 30
days) MO
QLL(2700 per 30
days) MO
QLL(360 per 30
days) MO
QLL(240 per 30
days) MO
QLL(180 per 30
days) MO
QLL(150 per 30
days) MO
QLL(480 per 30
days) MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
MO
MO
QLL(1920 per 30
days) MO
MO
QLL(960 per 30
days) MO
Drug Name
Drug
Tier
hydromorphone hcl tabs 4mg 1
hydromorphone hcl tabs 8mg 1
INFUMORPH 200
INFUMORPH 500
KADIAN CP24 100MG,
200MG
KADIAN CP24 10MG,
20MG, 30MG, 50MG,
60MG, 80MG
KADIAN CP24 130MG,
150MG, 40MG, 70MG
LAZANDA
3
3
3
levorphanol tartrate
1
LORCET 10/650
3
LORCET PLUS
3
LORTAB ELIX
3
LORTAB TABS
3
MAGNACET TABS
400MG; 10MG
MAGNACET TABS
400MG; 5MG, 400MG;
7.5MG
margesic
marten-tab
MAXIDONE
3
3
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
B/D PAR MO
B/D PAR MO
QLL(180 per 30
days) MO
QLL(120 per 30
days) MO
3
MO
2
LA PAR QLL(30 per
30 days) MO
QLL(180 per 30
days) MO
QLL(180 per 30
days) MO
QLL(180 per 30
days) MO
QLL(2700 per 30
days) MO
QLL(240 per 30
days) MO
MO
3
QLL(300 per 30
days) MO
2
2
3
MO
MO
QLL(150 per 30
days) MO
MO
meperidine hcl inj 100mg/ml, 3
25mg/ml, 50mg/ml
meperidine hcl inj 10mg/ml 3
3
meperidine hcl oral soln
meperidine hcl tabs 100mg
3
meperidine hcl tabs 50mg
3
meperitab tabs 100mg
3
meperitab tabs 50mg
3
47
Requirements/
Limits
QLL(3600 per 30
days) MO
QLL(360 per 30
days) MO
QLL(720 per 30
days) MO
QLL(360 per 30
days) MO
QLL(720 per 30
days) MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
methadone hcl conc
1
QLL(360 per 30
days) MO
methadone hcl inj
methadone hcl intensol
1
1
methadone hcl oral soln 10mg/1
5ml
methadone hcl oral soln 5mg/ 1
5ml
1
methadone hcl tabs 10mg
methadone hcl tabs 5mg
1
methadone hcl tbso
methadose conc
1
1
methadose sugar-free
1
methadose tabs
1
1
methadose tbso
3
morphine sulfate er cp24
100mg
morphine sulfate er cp24 20mg,3
30mg, 50mg, 60mg, 80mg
1
morphine sulfate er tbcr
100mg, 200mg
morphine sulfate er tbcr 15mg,1
30mg, 60mg
morphine sulfate in dextrose 3
5%
morphine sulfate inj 0.5mg/ml,1
1mg/ml
morphine sulfate inj 10mg/ml,1
150mg/30ml, 15mg/ml, 1mg/
ml, 2mg/ml, 4mg/ml, 50mg/ml,
5mg/ml
morphine sulfate inj 25mg/ml,1
8mg/ml
MORPHINE SULFATE INJ1
8MG/ML
1
morphine sulfate oral soln
10mg/5ml
1
morphine sulfate oral soln
20mg/5ml
Effective January 1, 2014
Drug
Tier
Requirements/
Limits
morphine sulfate oral soln
20mg/ml
morphine sulfate supp
morphine sulfate tabs 15mg
1
morphine sulfate tabs 30mg
1
QLL(360 per 30
days) MO
MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(180 per 30
days) MO
QLL(120 per 30
days) MO
QLL(360 per 30
days) MO
LA PAR QLL(120
per 30 days) MO
QLL(120 per 30
days) MO
Drug Name
QLL(360 per 30
days) MO
QLL(1800 per 30
days) MO
QLL(3600 per 30
days) MO
QLL(360 per 30
days) MO
QLL(720 per 30
days) MO
MO
QLL(360 per 30
days) MO
QLL(360 per 30
days) MO
QLL(360 per 30
days) MO
MO
QLL(180 per 30
days) MO
QLL(120 per 30
days) MO
QLL(180 per 30
days) MO
QLL(120 per 30
days) MO
1
1
MS CONTIN TBCR
3
100MG, 200MG
MS CONTIN TBCR 15MG,3
30MG, 60MG
NORCO
3
ONSOLIS
2
OPANA ER (CRUSH
3
RESISTANT) TB12 10MG,
15MG, 20MG, 30MG,
5MG, 7.5MG
OPANA ER (CRUSH
3
RESISTANT) TB12 40MG
OPANA TABS
3
ORBIVAN
ORBIVAN CF
OXECTA TABS 5MG
2
3
3
OXECTA TABS 7.5MG
3
oxycodone hcl caps
1
B/D PAR MO
oxycodone hcl conc
1
MO
oxycodone hcl oral soln
oxycodone hcl tabs 10mg
1
1
oxycodone hcl tabs 15mg
1
oxycodone hcl tabs 20mg
1
oxycodone hcl tabs 30mg
1
oxycodone hcl tabs 5mg
1
QLL(3600 per 30
days) MO
QLL(1800 per 30
days) MO
48
oxycodone/acetaminophen caps1
QLL(180 per 30
days) MO
QLL(120 per 30
days) MO
MO
QLL(540 per 30
days) MO
QLL(360 per 30
days) MO
QLL(1620 per 30
days) MO
QLL(405 per 30
days) MO
MO
QLL(810 per 30
days) MO
QLL(540 per 30
days) MO
QLL(390 per 30
days) MO
QLL(270 per 30
days) MO
QLL(1620 per 30
days) MO
QLL(240 per 30
days) MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
oxycodone/acetaminophen tabs 1
325mg; 10mg, 325mg; 2.5mg,
325mg; 5mg, 325mg; 7.5mg
oxycodone/acetaminophen tabs 1
500mg; 7.5mg
oxycodone/acetaminophen tabs 1
650mg; 10mg
1
oxycodone/aspirin
oxycodone/ibuprofen
1
OXYCONTIN TB12 10MG,3
15MG, 20MG, 30MG,
40MG
OXYCONTIN TB12 60MG3
OXYCONTIN TB12 80MG2
oxymorphone hydrochloride
3
oxymorphone hydrochloride er 3
tb12 10mg, 15mg, 20mg,
30mg, 5mg, 7.5mg
oxymorphone hydrochloride er 3
tb12 40mg
PERCOCET TABS 325MG;3
10MG, 325MG; 2.5MG,
325MG; 5MG, 325MG;
7.5MG
PERCOCET TABS 500MG;3
7.5MG
PERCOCET TABS 650MG;3
10MG
PERCODAN
3
PHRENILIN FORTE
PRIMLEV
repan
reprexain
2
3
2
3
ROXICET ORAL SOLN
3
roxicet tabs
1
ROXICODONE TABS
15MG
3
Comprehensive_P3TARO_10R
Requirements/
Limits
QLL(360 per 30
days) MO
QLL(240 per 30
days) MO
QLL(180 per 30
days) MO
QLL(360 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
ST MO
Drug Name
ROXICODONE TABS
30MG
stagesic
Drug
Tier
Requirements/
Limits
3
QLL(270 per 30
days) MO
QLL(240 per 30
days) MO
MO
LA QLL(360 per 30
days) MO
1
3
sublimaze
SUBSYS LIQD 100MCG, 3
1200MCG, 200MCG,
400MCG, 800MCG
SUBSYS LIQD 1600MCG, 3
600MCG
3
sufenta
3
sufentanil citrate
SYNALGOS-DC
3
QLL(120 per 30
days) ST MO
QLL(120 per 30
days) ST MO
QLL(120 per 30
days) MO
QLL(120 per 30
days) MO
2
tencon
3
trezix
TYLENOL/CODEINE #3 3
ULTIVA
vicodin
3
1
QLL(180 per 30
days) MO
QLL(360 per 30
days) MO
vicodin es
1
vicodin hp
1
VICOPROFEN
3
XODOL
3
xolox
zamicet
1
1
zebutal
ZOLVIT
ZYDONE
2
3
3
QLL(240 per 30
days) MO
QLL(180 per 30
days) MO
QLL(360 per 30
days) MO
MO
MO
MO
QLL(480 per 30
days) MO
QLL(1800 per 30
days) MO
QLL(360 per 30
days) MO
QLL(540 per 30
days) MO
TYLENOL/CODEINE #4 3
LA MO
MO
MO
QLL(240 per 30
days) MO
MO
MO
QLL(390 per 30
days) MO
QLL(390 per 30
days) MO
QLL(390 per 30
days) MO
QLL(390 per 30
days) MO
QLL(390 per 30
days) MO
QLL(480 per 30
days) MO
QLL(390 per 30
days) MO
MO
QLL(2700 per 30
days) MO
MO
MO
QLL(300 per 30
days) MO
Nitrates
DILATRATE SR
IMDUR
isoditrate er
ISORDIL TITRADOSE
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
49
3
3
3
3
1
1
1
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Requirements/
Limits
3
3
1
1
1
1
1
1
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
3
1
1
3
1
3
MO
MO
MO
MO
MO
QLL(60 per 30 days)
MO
MO
MO
MO
1
isosorbide mononitrate er
MINITRAN
3
1
nitro-bid
NITRO-DUR
3
nitroglycerin in 5% dextrose 3
nitroglycerin in dextrose 5% inj3
5%; 200mcg/ml, 5%; 400mcg/
ml
1
nitroglycerin inj
1
nitroglycerin lingual aers
1
nitroglycerin lingual
translingual soln
1
nitroglycerin pt24
1
nitroglycerin transdermal
NITROLINGUAL
3
PUMPSPRAY
NITROMIST
3
NITROSTAT
2
MO
MO
MO
MO
Non-Narcotic Analgesics
1
flurbiprofen
1
ibuprofen susp
MO
ibuprofen tabs 400mg, 600mg,1
MO
800mg
MO
INDOCIN
3
MO
INDOCIN IV
3
PAR QLL(360 per
3
indomethacin
30 days) MO
3
PAR QLL(90 per 30 indomethacin er
3
indomethacin sodium
days) MO
1
ketoprofen
MO
1
QLL(10 per 30 days) ketoprofen er
ketorolac tromethamine inj 3
MO
15mg/ml, 30mg/ml, 60mg/2ml
QLL(4 per 30 days) ketorolac tromethamine inj 3
300mg/10ml
MO
ketorolac tromethamine tabs 3
MO
PAR QLL(60 per 30
1
meclofenamate sodium
days) MO
1
mefenamic
acid
MO
1
meloxicam susp
MO
1
meloxicam tabs
ANAPROX
3
ANAPROX DS
3
ARTHROTEC 50
3
ARTHROTEC 75
3
buprenorphine hcl/naloxone hcl1
subl 2mg; 0.5mg
buprenorphine hcl/naloxone hcl1
subl 8mg; 2mg
1
butorphanol tartrate inj
butorphanol tartrate nasal soln1
CALDOLOR
CAMBIA
3
3
CATAFLAM
CELEBREX
3
3
1
childrens ibuprofen susp
100mg/5ml
choline magnesium trisalicylate3
liqd
choline magnesium trisalicylate3
tabs
CLINORIL
3
3
clonidine hcl inj
CONZIP
3
Effective January 1, 2014
DAYPRO
depade
diclofenac potassium
diclofenac sodium dr
diclofenac sodium er
diclofenac sodium xr
diclofenac sodium/misoprostol
diflunisal
DUEXIS
DURACLON INJ
500MCG/ML
EC-NAPROSYN
etodolac
etodolac er
FELDENE
fenoprofen calcium
FLECTOR
Drug
Tier
B/D PAR
MO
MO
MO
MO
MO
MO
MOBIC SUSP
3
MOBIC TABS
3
MO
QLL(30 per 30 days)
nabumetone
MO
50
1
MO
MO
MO
MO
MO
MO
MO
MO
QLL(20 per 30 days)
MO
MO
MO
QLL(300 per 30
days) MO
QLL(30 per 30 days)
MO
QLL(300 per 30
days) MO
QLL(30 per 30 days)
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
1
nalbuphine hcl
NALFON
3
1
naloxone hcl inj 0.4mg/ml
1
naloxone hcl inj 1mg/ml
1
naltrexone hcl
NAPRELAN
3
NAPROSYN
3
1
naproxen
1
naproxen dr
naproxen sodium tabs 275mg, 1
550mg
NEOPROFEN
3
NUCYNTA
3
NUCYNTA ER
3
OFIRMEV
oxaprozin
PENNSAID
3
1
3
pentazocine/acetaminophen
1
pentazocine/naloxone hcl
3
piroxicam
PONSTEL
PRIALT
REVIA
salsalate
SPRIX
1
3
3
3
3
3
SUBOXONE FILM 12MG; 3
3MG
SUBOXONE FILM 2MG; 3
0.5MG
SUBOXONE FILM 4MG; 3
1MG
SUBOXONE FILM 8MG; 3
2MG
1
sulindac
TALWIN
3
1
tolmetin sodium
1
tramadol hcl
TRAMADOL HCL ER
CP24
1
Comprehensive_P3TARO_10R
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(181 per 30
days) MO
QLL(60 per 30 days)
MO
MO
MO
QLL(300 per 30
days) MO
QLL(180 per 30
days) MO
QLL(360 per 30
days) MO
MO
MO
MO
MO
MO
QLL(5 per 30 days)
MO
PAR QLL(60 per 30
days) MO
PAR QLL(360 per
30 days) MO
PAR QLL(180 per
30 days) MO
PAR QLL(90 per 30
days) MO
MO
MO
MO
QLL(240 per 30
days) MO
Drug Name
Drug
Tier
tramadol hcl er tb24 100mg, 1
200mg, 300mg
1
tramadol hydrochloride/
acetaminophen
ULTRACET
3
ULTRAM
3
ULTRAM ER
3
VIMOVO
3
VIVITROL
VOLTAREN [+]
3
2
VOLTAREN-XR
ZIPSOR
3
3
Requirements/
Limits
QLL(30 per 30 days)
MO
QLL(300 per 30
days) MO
QLL(300 per 30
days) MO
QLL(240 per 30
days) MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
QLL(1000 per 30
days) MO
MO
MO
Non-Steroidal Anti-Inflammatory Agents
ACULAR
ACULAR LS
ACUVAIL
BROMDAY
bromfenac
diclofenac sodium
flurbiprofen sodium
ILEVRO
ketorolac tromethamine
ophthalmic soln
NEVANAC [+]
OCUFEN
PROLENSA
3
3
3
3
3
1
1
3
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
2
3
3
MO
MO
MO
Oral Contraceptives & Related Agents
altavera
alyacen 1/35
alyacen 7/7/7
amethia
amethia lo
amethyst
apri
aranelle
aviane
azurette
balziva
BEYAZ
BREVICON-28
briellyn
51
1
1
1
3
3
3
1
1
1
1
1
3
3
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
camrese
camrese lo
caziant
cesia
chateal
cryselle-28
cyclafem 1/35
cyclafem 7/7/7
CYCLESSA
dasetta 1/35
dasetta 7/7/7
daysee
DESOGEN
drospirenone/ethinyl estradiol
elinest
ELLA
emoquette
enpresse-28
enskyce
estarylla
ESTROSTEP FE
falmina
FEMCON FE
GENERESS FE
gianvi
gildagia
gildess 1.5/30
gildess 1/20
gildess fe 1.5/30
gildess fe 1/20
introvale
jolessa
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
kariva
kelnor 1/35
kurvelo
leena
lessina
levonest
levonorgestrel
levonorgestrel and ethinyl
estradiol
levonorgestrel/ethinyl estradiol
Effective January 1, 2014
Drug
Tier
Requirements/
Limits
1
1
1
3
3
1
1
1
3
1
1
1
3
1
1
3
1
1
1
1
3
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
MO
Drug Name
Drug
Tier
1
levora 0.15/30-28
LO LOESTRIN FE
3
LOESTRIN 1.5/30-21
3
LOESTRIN 1/20-21
3
LOESTRIN 24 FE
3
LOESTRIN FE 1.5/30
3
LOESTRIN FE 1/20
3
1
loryna
LOSEASONIQUE
3
1
low-ogestrel
1
lutera
1
marlissa
1
microgestin 1.5/30
1
microgestin 1/20
1
microgestin fe
1
microgestin fe 1.5/30
MIRCETTE
3
MODICON
3
1
mono-linyah
1
mononessa
1
my way
1
myzilra
NATAZIA
3
1
necon 0.5/35-28
1
necon 1/35
1
necon 1/50-28
1
necon 10/11-28
1
necon 7/7/7
3
next choice one dose
NORDETTE-28
3
norgestimate/ethinyl estradiol 1
NORINYL 1+35
3
NORINYL 1+50
3
1
nortrel 0.5/35 (28)
1
nortrel 1/35
1
nortrel 7/7/7
1
ocella
1
ogestrel
1
orsythia
ORTHO TRI-CYCLEN
3
ORTHO TRI-CYCLEN LO3
ORTHO-CEPT
3
ORTHO-CYCLEN
3
ORTHO-NOVUM 1/35 3
ORTHO-NOVUM 7/7/7 3
OVCON-35
3
52
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
Requirements/
Limits
philith
PLAN B
PLAN B ONE-STEP
portia-28
previfem
quasense
reclipsen
SAFYRAL
SEASONIQUE
solia
sprintec 28
sronyx
syeda
tilia fe
tri-estarylla
tri-legest fe
tri-linyah
TRI-NORINYL 28
tri-previfem
tri-sprintec
trinessa
trivora-28
velivet
vestura
viorele
wera
wymzya fe
YASMIN 28
YAZ
zarah
zenchent
zenchent fe
zovia 1/35e
zovia 1/50e
1
3
3
1
1
1
1
3
3
3
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
3
3
3
3
1
1
1
1
1
MO
ACTONEL TABS 5MG
2
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
alendronate sodium oral soln 1
alendronate sodium tabs 10mg,1
5mg
alendronate sodium tabs 35mg,1
70mg
ATELVIA
3
QLL(30 per 30 days)
ST MO
MO
QLL(30 per 30 days)
MO
QLL(4 per 28 days)
MO
QLL(4 per 28 days)
MO
QLL(4 per 28 days)
MO
B/D PAR MO
QLL(1 per 28 days)
ST MO
QLL(30 per 30 days)
MO
PAR QLL(3 per 28
days) MO
QLL(4 per 28 days)
ST MO
QLL(4 per 28 days)
ST MO
QLL(1 per 28 days)
MO
PAR QLL(2 per 365
days) MO
Oral Drugs For Glaucoma
acetazolamide
acetazolamide er
acetazolamide sodium
DIAMOX
methazolamide
NEPTAZANE
1
1
1
3
1
3
MO
MO
MO
MO
MO
Osteoporosis Therapy
ACTONEL TABS 150MG 2
ACTONEL TABS 35MG
2
Comprehensive_P3TARO_10R
QLL(1 per 30 days)
ST MO
QLL(4 per 28 days)
ST MO
BINOSTO
3
BONIVA INJ
BONIVA TABS
2
2
EVISTA [+]
2
FORTEO [+]
2
FOSAMAX
2
FOSAMAX PLUS D
2
ibandronate sodium
1
PROLIA [+]
2
Other Glaucoma Drugs
AZOPT
COMBIGAN [+]
COSOPT
COSOPT PF
dorzolamide hcl
dorzolamide hcl/timolol
maleate
ISOPTO CARBACHOL
latanoprost
LUMIGAN [+]
miostat
physostigmine salicylate
RESCULA
SIMBRINZA
TRAVATAN Z [+]
travoprost
TRUSOPT
XALATAN
ZIOPTAN
53
3
2
3
3
1
1
MO
MO
MO
MO
MO
MO
3
1
2
3
3
3
3
2
1
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Other Rheumatologicals
ACTEMRA
2
ARAVA
3
BENLYSTA
2
CUPRIMINE
3
DEPEN TITRATABS
3
ENBREL INJ 25MG,
2
50MG/ML [+]
ENBREL INJ 25MG/0.5ML2
[+]
ENBREL SURECLICK [+] 2
HUMIRA INJ 20MG/0.4ML2
[+]
HUMIRA INJ 40MG/0.8ML2
[+]
HUMIRA PEN [+]
2
HUMIRA PEN-CROHNS 2
DISEASESTARTER [+]
HUMIRA PEN-PSORIASIS2
STARTER [+]
KINERET
2
1
leflunomide
ORENCIA INJ 125MG/ML2
ORENCIA INJ 250MG
2
RIDAURA
3
SAVELLA TABS 100MG [+]2
SAVELLA TABS 12.5MG 2
[+]
SAVELLA TABS 25MG [+] 2
SAVELLA TABS 50MG [+] 2
SAVELLA TITRATION
2
PACK [+]
SIMPONI INJ 100MG/ML 2
SIMPONI INJ 100MG/ML,2
50MG/0.5ML
XELJANZ
3
Effective January 1, 2014
Drug
Tier
Requirements/
Limits
Otic Steroid / Antibiotic
PAR MO
MO
PAR MO
MO
MO
PAR QLL(8 per 28
days) MO
PAR QLL(4.08 per
28 days) MO
PAR QLL(8 per 28
days) MO
PAR QLL(2 per 28
days) MO
PAR QLL(6 per 28
days) MO
PAR QLL(6 per 28
days) MO
PAR QLL(6 per 365
days) MO
PAR QLL(4 per 365
days) MO
PAR QLL(28 per 28
days) MO
MO
PAR QLL(4 per 28
days) MO
PAR MO
MO
QLL(60 per 30 days)
MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(1 per 365 days)
MO
PAR QLL(1 per 28
days)
PAR QLL(1 per 28
days) MO
PAR QLL(60 per 30
days) MO
54
CIPRO HC
CIPRODEX [+]
COLY-MYCIN S
CORTISPORIN
CORTISPORIN-TC
neomycin/polymyxin/hc
neomycin/polymyxin/
hydrocortisone
3
2
3
3
3
1
1
MO
MO
MO
MO
MO
MO
MO
HEMABATE
3
methylergonovine maleate inj 3
methylergonovine maleate tabs 1
3
oxytocin
PITOCIN
3
MO
MO
MO
Oxytocics
Penicillins
1
amoxicillin
1
amoxicillin/clavulanate
potassium
1
amoxicillin/clavulanate
potassium er
1
amoxicillin/potassium
clavulanate
1
ampicillin
ampicillin sodium inj 10gm, 1
125mg, 250mg, 2gm
ampicillin sodium inj 1gm, 1
500mg
ampicillin-sulbactam inj 10gm;1
5gm, 1gm; 0.5gm
ampicillin-sulbactam inj 2gm;1
1gm
AUGMENTIN
3
AUGMENTIN XR
3
1
bactocill in dextrose
BICILLIN C-R
2
BICILLIN L-A
2
1
dicloxacillin sodium
MOXATAG
2
1
nafcillin sodium
nallpen iso-osmotic in dextrose 1
1
nallpen/dextrose
oxacillin sodium inj 10gm, 1
1gm, 2gm
OXACILLIN SODIUM INJ1
2GM
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
1
penicillin g potassium
PENICILLIN G
2
POTASSIUM IN ISOOSMOTIC DEXTROSE
1
penicillin g procaine
1
penicillin g sodium
1
penicillin v potassium
1
pfizerpen-g
1
piperacillin sodium/
tazobactam sodium
piperacillin sodium/tazobactam1
sodium
1
piperacillin/tazobactam
TIMENTIN INJ 0.1GM/ 2
100ML; 3GM/100ML,
1GM; 30GM
TIMENTIN INJ 0.1GM; 2
3GM
UNASYN BULK PACK
3
UNASYN INJ 1GM; 0.5GM3
UNASYN INJ 2GM; 1GM 3
ZOSYN INJ 2GM; 0.25GM,3
36GM; 4.5GM, 3GM;
0.375GM, 4GM; 0.5GM,
5%; 3GM/50ML; 0.375GM/
50ML
ZOSYN INJ 5%; 2GM/
3
50ML; 0.25GM/50ML, 5%;
4GM/100ML; 0.5GM/
100ML
Requirements/
Limits
Drug Name
Drug
Tier
Requirements/
Limits
MO
ABILIFY TABS 30MG
2
ABILIFY TABS 5MG [+]
2
QLL(30 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Psychotherapeutic Drugs
ABILIFY DISCMELT TBDP2
10MG
ABILIFY DISCMELT TBDP2
15MG
ABILIFY INJ
2
ABILIFY MAINTENA
2
ABILIFY ORAL SOLN [+] 2
ABILIFY TABS 10MG [+] 2
ABILIFY TABS 15MG [+] 2
ABILIFY TABS 20MG
2
ABILIFY TABS 2MG [+]
2
Comprehensive_P3TARO_10R
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
MO
QLL(900 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(450 per 30
days) MO
ADDERALL TABS 1.25MG;3
1.25MG; 1.25MG; 1.25MG,
1.875MG; 1.875MG;
1.875MG; 1.875MG,
2.5MG; 2.5MG; 2.5MG;
2.5MG, 3.125MG;
3.125MG; 3.125MG;
3.125MG, 3.75MG;
3.75MG; 3.75MG; 3.75MG,
5MG; 5MG; 5MG; 5MG
ADDERALL TABS 7.5MG; 3
7.5MG; 7.5MG; 7.5MG
ADDERALL XR
3
alprazolam
1
alprazolam er
1
alprazolam intensol
1
alprazolam odt
1
alprazolam xr
1
AMBIEN
3
AMBIEN CR
3
1
amitriptyline hcl
1
amoxapine
3
amphetamine/
dextroamphetamine cp24
1
amphetamine/
dextroamphetamine tabs
1.25mg; 1.25mg; 1.25mg;
1.25mg, 1.875mg; 1.875mg;
1.875mg; 1.875mg, 2.5mg;
2.5mg; 2.5mg; 2.5mg,
3.125mg; 3.125mg; 3.125mg;
3.125mg, 3.75mg; 3.75mg;
3.75mg; 3.75mg, 5mg; 5mg;
5mg; 5mg
55
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(300 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
PAR MO
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
Effective January 1, 2014
Drug Name
Drug
Tier
1
amphetamine/
dextroamphetamine tabs
7.5mg; 7.5mg; 7.5mg; 7.5mg
AMYTAL SODIUM
2
ANAFRANIL
3
APLENZIN TB24 174MG 3
APLENZIN TB24 348MG 3
APLENZIN TB24 522MG 3
ATIVAN INJ
ATIVAN TABS
3
2
budeprion sr tb12 100mg
1
1
budeprion sr tb12 150mg
bupropion hcl er tb12 100mg 1
bupropion hcl er tb12 150mg 1
bupropion hcl er tb12 200mg 1
bupropion hcl sr tb12 100mg 1
bupropion hcl sr tb12 150mg 1
bupropion hcl sr tb12 200mg 1
bupropion hcl tabs 100mg
bupropion hcl tabs 75mg
1
1
bupropion hcl xl tb24 150mg 1
bupropion hcl xl tb24 300mg 1
1
buspirone hcl
BUTISOL SODIUM ELIX 2
BUTISOL SODIUM TABS 2
30MG
BUTISOL SODIUM TABS 2
50MG
CELEXA TABS 10MG
3
CELEXA TABS 20MG
Effective January 1, 2014
3
Requirements/
Limits
Drug Name
QLL(60 per 30 days) CELEXA TABS 40MG
MO
chlordiazepoxide hcl
MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
QLL(90 per 30 days)
MO
QLL(120 per 30
days) MO
MO
QLL(120 per 30
days) MO
MO
QLL(60 per 30 days)
MO
QLL(120 per 30
days) MO
MO
QLL(60 per 30 days)
MO
QLL(135 per 30
days) MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
MO
QLL(1000 per 30
days) MO
QLL(180 per 30
days) MO
QLL(120 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
56
Drug
Tier
Requirements/
Limits
3
QLL(30 per 30 days)
MO
QLL(120 per 30
days) MO
MO
MO
MO
QLL(600 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
QLL(120 per 30
days) MO
QLL(270 per 30
days)
QLL(2160 per 30
days)
QLL(1080 per 30
days)
QLL(270 per 30
days)
QLL(135 per 30
days)
QLL(1080 per 30
days)
QLL(540 per 30
days)
QLL(270 per 30
days) MO
QLL(1080 per 30
days) MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
1
chlordiazepoxide/amitriptyline1
1
chlorpromazine hcl inj
1
chlorpromazine hcl tabs
citalopram hydrobromide oral 1
soln
citalopram hydrobromide tabs 1
10mg
citalopram hydrobromide tabs 1
20mg
citalopram hydrobromide tabs 1
40mg
1
clomipramine hcl
1
clorazepate dipotassium
clozapine odt tbdp 100mg
1
clozapine odt tbdp 12.5mg
1
clozapine odt tbdp 25mg
1
clozapine tabs 100mg
1
clozapine tabs 200mg
1
clozapine tabs 25mg
1
clozapine tabs 50mg
1
CLOZARIL TABS 100MG 3
CLOZARIL TABS 25MG 3
CONCERTA TBCR 18MG,3
27MG, 54MG
CONCERTA TBCR 36MG 3
CYMBALTA CPEP 20MG 3
CYMBALTA CPEP 30MG 3
CYMBALTA CPEP 60MG 3
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
DAYTRANA
3
desipramine hcl
DESOXYN
1
3
QLL(30 per 30 days)
MO
MO
QLL(150 per 30
days) MO
QLL(120 per 30
days) MO
QLL(240 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(60 per 30 days)
MO
PAR QLL(180 per
30 days) MO
PAR QLL(90 per 30
days) MO
MO
QLL(240 per 30
days) MO
QLL(1200 per 30
days) MO
QLL(120 per 30
days) MO
QLL(600 per 30
days) MO
QLL(240 per 30
days) MO
MO
PAR MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
QLL(600 per 30
days) MO
QLL(60 per 30 days)
MO
DESVENLAFAXINE ER
TB24 100MG
DESVENLAFAXINE ER
TB24 50MG
DEXEDRINE
dexmethylphenidate hcl
3
3
3
3
dextroamphetamine sulfate er 3
dextroamphetamine sulfate tabs1
10mg
dextroamphetamine sulfate tabs1
5mg
1
diazepam inj 5mg/ml
1
diazepam intensol
diazepam oral soln
1
diazepam tabs 10mg
1
diazepam tabs 2mg
1
diazepam tabs 5mg
1
DORAL
doxepin hcl
EDLUAR
3
1
3
EFFEXOR XR CP24
3
150MG
EFFEXOR XR CP24
3
37.5MG
EFFEXOR XR CP24 75MG3
EMSAM
2
3
ergoloid mesylates
escitalopram oxalate oral soln 1
escitalopram oxalate tabs 10mg1
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
escitalopram oxalate tabs 20mg1
escitalopram oxalate tabs 5mg 1
estazolam
1
FANAPT TABS 10MG
2
FANAPT TABS 12MG
2
FANAPT TABS 1MG
2
FANAPT TABS 2MG
2
FANAPT TABS 4MG
2
FANAPT TABS 6MG
2
FANAPT TABS 8MG
2
FANAPT TITRATION
2
PACK
FAZACLO TBDP 100MG 2
FAZACLO TBDP 12.5MG 2
FAZACLO TBDP 150MG 2
FAZACLO TBDP 200MG 2
FAZACLO TBDP 25MG
2
flumazenil
fluoxetine caps 10mg
3
1
fluoxetine caps 20mg
1
fluoxetine dr
1
fluoxetine hcl caps 10mg
1
fluoxetine hcl caps 20mg
1
fluoxetine hcl caps 40mg
1
fluoxetine hcl oral soln
1
57
Requirements/
Limits
QLL(30 per 30 days)
MO
QLL(120 per 30
days) MO
QLL(30 per 30 days)
MO
QLL(72 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(720 per 30
days) MO
QLL(360 per 30
days) MO
QLL(180 per 30
days) MO
QLL(120 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(8 per 30 days)
MO
QLL(270 per 30
days)
QLL(2160 per 30
days)
QLL(180 per 30
days)
QLL(135 per 30
days)
QLL(1080 per 30
days)
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(4 per 28 days)
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(600 per 30
days) MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
Drug Name
Drug
Tier
Requirements/
Limits
fluoxetine hcl tabs 10mg
1
fluoxetine hcl tabs 20mg
1
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(30 per 30 days)
MO
MO
haloperidol
haloperidol decanoate
haloperidol lactate
imipramine hcl
imipramine pamoate
INTERMEZZO
INTUNIV
1
1
1
1
3
3
3
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(360 per 30
days) MO
QLL(180 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
INVEGA SUSTENNA
2
INVEGA TB24 1.5MG
2
INVEGA TB24 3MG
2
INVEGA TB24 6MG
2
INVEGA TB24 9MG
2
KAPVAY
KAPVAY DOSE PACK
LATUDA TABS 120MG
3
3
2
LATUDA TABS 20MG
2
LATUDA TABS 40MG
2
LATUDA TABS 80MG
2
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
LEXAPRO ORAL SOLN
3
LEXAPRO TABS 10MG
3
LEXAPRO TABS 20MG
3
LEXAPRO TABS 5MG
3
lithium carbonate
lithium carbonate er
lithium citrate
LITHOBID
lorazepam conc
1
1
1
3
1
lorazepam inj
lorazepam intensol
1
1
MO
lorazepam tabs
1
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(2 per 28 days)
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(40 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(600 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(120 per 30
days) MO
MO
MO
MO
MO
QLL(90 per 30 days)
MO
MO
QLL(90 per 30 days)
MO
QLL(90 per 30 days)
MO
FLUOXETINE HCL TABS 2
60MG
1
fluphenazine decanoate
1
fluphenazine hcl conc
1
fluphenazine hcl elix
1
fluphenazine hcl inj
1
fluphenazine hcl tabs
1
flurazepam hcl
fluvoxamine maleate er cp24 1
100mg
fluvoxamine maleate er cp24 1
150mg
1
fluvoxamine maleate tabs
100mg
fluvoxamine maleate tabs 25mg1
fluvoxamine maleate tabs 50mg1
FOCALIN
3
FOCALIN XR CP24 10MG,3
15MG, 25MG, 30MG,
35MG, 40MG, 5MG
FOCALIN XR CP24 20MG3
FORFIVO XL
3
GEODON CAPS 20MG
3
GEODON CAPS 40MG
3
GEODON CAPS 60MG,
80MG
GEODON INJ
guanidine hcl
HALCION
3
2
1
2
HALDOL
3
HALDOL DECANOATE 3
100
HALDOL DECANOATE 3
50
Effective January 1, 2014
58
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
loxapine
loxapine succinate
LOXITANE
LUNESTA
1
1
3
3
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(270 per 30
days) MO
QLL(135 per 30
days) MO
MO
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(150 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(900 per 30
days) MO
QLL(1800 per 30
days) MO
PAR QLL(90 per 30
days) MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
midazolam hcl inj 10mg/10ml,1
1mg/ml, 2mg/2ml, 5mg/5ml
midazolam hcl inj 10mg/2ml, 1
25mg/5ml, 50mg/10ml, 5mg/
ml
1
midazolam hcl syrp
mirtazapine odt tbdp 15mg 1
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(900 per 30
days) MO
QLL(1800 per 30
days) MO
LUVOX CR CP24 100MG 3
LUVOX CR CP24 150MG 3
maprotiline hcl tabs 25mg
1
maprotiline hcl tabs 50mg
1
maprotiline hcl tabs 75mg
MARPLAN
METADATE CD
1
2
3
metadate er
3
methamphetamine hcl
3
METHYLIN CHEW
3
METHYLIN ORAL SOLN 3
10MG/5ML
METHYLIN ORAL SOLN 3
5MG/5ML
1
methylphenidate hcl
methylphenidate hcl cd
3
methylphenidate hcl er cp24 3
methylphenidate hcl er tbcr
10mg
methylphenidate hcl er tbcr
18mg, 27mg, 54mg
methylphenidate hcl er tbcr
20mg
methylphenidate hcl er tbcr
36mg
methylphenidate hcl sr
3
3
3
3
3
methylphenidate hydrochloride3
oral soln 10mg/5ml
methylphenidate hydrochloride3
oral soln 5mg/5ml
Comprehensive_P3TARO_10R
Drug Name
mirtazapine odt tbdp 30mg
Drug
Tier
1
mirtazapine odt tbdp 45mg 1
mirtazapine tabs 15mg
1
mirtazapine tabs 30mg
1
mirtazapine tabs 45mg
1
mirtazapine tabs 7.5mg
1
mirtazapine tbdp
1
modafinil tabs 100mg
1
modafinil tabs 200mg
1
NARDIL
nefazodone hcl tabs 100mg
3
1
nefazodone hcl tabs 150mg
1
nefazodone hcl tabs 200mg
1
nefazodone hcl tabs 250mg
1
nefazodone hcl tabs 50mg
1
NIRAVAM
2
NORPRAMIN
nortriptyline hcl
NUVIGIL TABS 150MG
NUVIGIL TABS 250MG
3
1
3
3
NUVIGIL TABS 50MG
3
olanzapine inj
1
59
Requirements/
Limits
MO
MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
PAR QLL(30 per 30
days) MO
PAR QLL(60 per 30
days) MO
MO
QLL(180 per 30
days) MO
QLL(120 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(72 per 30 days)
MO
QLL(360 per 30
days) MO
QLL(90 per 30 days)
MO
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
olanzapine odt tbdp 10mg
1
olanzapine odt tbdp 15mg
1
olanzapine odt tbdp 20mg
1
olanzapine odt tbdp 5mg
1
olanzapine tabs 10mg
1
olanzapine tabs 15mg
1
olanzapine tabs 2.5mg
1
olanzapine tabs 20mg
1
olanzapine tabs 5mg
1
olanzapine tabs 7.5mg
1
QLL(60 per 30 days)
MO
QLL(40 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(40 per 30 days)
MO
QLL(240 per 30
days) MO
QLL(30 per 30 days)
MO
QLL(120 per 30
days) MO
QLL(80 per 30 days)
MO
QLL(30 per 30 days)
MO
3
olanzapine/fluoxetine caps
25mg; 12mg, 50mg; 12mg,
50mg; 6mg
3
olanzapine/fluoxetine caps
25mg; 3mg, 25mg; 6mg
OLEPTRO TB24 150MG 3
OLEPTRO TB24 300MG 3
ORAP
oxazepam
2
1
PAMELOR
3
PARNATE
3
paroxetine hcl er tb24 12.5mg 1
paroxetine hcl er tb24 25mg 1
paroxetine hcl er tb24 37.5mg 1
paroxetine hcl tabs 10mg
1
paroxetine hcl tabs 20mg
1
paroxetine hcl tabs 30mg
1
Effective January 1, 2014
QLL(90 per 30 days)
MO
QLL(75 per 30 days)
MO
QLL(38 per 30 days)
MO
MO
QLL(120 per 30
days) MO
MO
MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
60
Drug Name
Drug
Tier
Requirements/
Limits
paroxetine hcl tabs 40mg
1
QLL(45 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(1200 per 30
days) MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(45 per 30 days)
MO
MO
PAR MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(45 per 30 days)
MO
MO
PAR QLL(120 per
30 days) MO
PAR QLL(240 per
30 days) MO
QLL(1920 per 30
days) MO
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
PAXIL CR TB24 12.5MG 3
PAXIL CR TB24 25MG
3
PAXIL CR TB24 37.5MG 3
PAXIL SUSP
3
PAXIL TABS 10MG
3
PAXIL TABS 20MG
3
PAXIL TABS 30MG
3
PAXIL TABS 40MG
3
perphenazine
perphenazine/amitriptyline
PEXEVA TABS 10MG
1
1
3
PEXEVA TABS 20MG
3
PEXEVA TABS 30MG
3
PEXEVA TABS 40MG
3
phenelzine sulfate
PRISTIQ TB24 100MG
1
2
PRISTIQ TB24 50MG
2
procentra
3
1
protriptyline hcl
PROVIGIL TABS 100MG 3
PROVIGIL TABS 200MG 3
PROZAC CAPS 10MG
3
PROZAC CAPS 20MG
3
PROZAC CAPS 40MG
3
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
PROZAC WEEKLY
3
QLL(4 per 28 days)
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(960 per 30
days) MO
QLL(80 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(480 per 30
days) MO
QLL(360 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(2 per 28 days)
MO
MO
RISPERDAL TABS 0.25MG3
QLL(960 per 30
days) MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(160 per 30
days) MO
QLL(120 per 30
days) MO
QLL(480 per 30
days) MO
1
quetiapine fumarate tabs
100mg
1
quetiapine fumarate tabs
200mg
quetiapine fumarate tabs 25mg1
1
quetiapine fumarate tabs
300mg
1
quetiapine fumarate tabs
400mg
quetiapine fumarate tabs 50mg1
QUILLIVANT XR
3
REMERON SOLTAB
TBDP 15MG
REMERON SOLTAB
TBDP 30MG
REMERON SOLTAB
TBDP 45MG
REMERON TABS 15MG
3
3
3
3
REMERON TABS 30MG 3
REMERON TABS 45MG 3
RESTORIL
2
RISPERDAL CONSTA INJ 2
12.5MG, 25MG, 37.5MG
RISPERDAL CONSTA INJ 2
50MG
RISPERDAL M-TAB TBDP3
0.5MG
RISPERDAL M-TAB TBDP3
1MG
RISPERDAL M-TAB TBDP3
2MG
RISPERDAL M-TAB TBDP3
3MG
RISPERDAL M-TAB TBDP3
4MG
RISPERDAL ORAL SOLN 3
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
RISPERDAL TABS 0.5MG 3
RISPERDAL TABS 1MG
3
RISPERDAL TABS 2MG
3
RISPERDAL TABS 3MG
3
RISPERDAL TABS 4MG
3
risperidone m-tab tbdp 0.5mg 1
risperidone m-tab tbdp 1mg 1
risperidone m-tab tbdp 2mg 1
risperidone m-tab tbdp 3mg 1
risperidone m-tab tbdp 4mg 1
risperidone odt tbdp 0.25mg 1
risperidone odt tbdp 0.5mg
1
risperidone odt tbdp 1mg
1
risperidone odt tbdp 2mg
1
risperidone odt tbdp 3mg
1
risperidone odt tbdp 4mg
1
risperidone oral soln
1
risperidone tabs 0.25mg
1
risperidone tabs 0.5mg
1
risperidone tabs 1mg
1
risperidone tabs 2mg
1
risperidone tabs 3mg
1
61
Requirements/
Limits
QLL(1920 per 30
days) MO
QLL(960 per 30
days) MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(160 per 30
days) MO
QLL(120 per 30
days) MO
QLL(960 per 30
days) MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(160 per 30
days) MO
QLL(120 per 30
days) MO
QLL(1920 per 30
days) MO
QLL(960 per 30
days) MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(160 per 30
days) MO
QLL(120 per 30
days) MO
QLL(480 per 30
days) MO
QLL(1920 per 30
days) MO
QLL(960 per 30
days) MO
QLL(480 per 30
days) MO
QLL(240 per 30
days) MO
QLL(160 per 30
days) MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
risperidone tabs 4mg
1
RITALIN
3
RITALIN LA
3
RITALIN SR
3
ROZEREM
3
SAPHRIS SUBL 10MG
2
SAPHRIS SUBL 5MG
2
SARAFEM TABS 10MG
3
SARAFEM TABS 20MG
3
seconal
1
QLL(120 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(120 per 30
days) MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(960 per 30
days) MO
QLL(80 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(480 per 30
days) MO
QLL(160 per 30
days) MO
QLL(120 per 30
days) MO
QLL(80 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(480 per 30
days) MO
QLL(300 per 30
days) MO
QLL(60 per 30 days)
MO
SEROQUEL TABS 100MG 3
SEROQUEL TABS 200MG 3
SEROQUEL TABS 25MG 3
SEROQUEL TABS 300MG 3
SEROQUEL TABS 400MG 3
SEROQUEL TABS 50MG 3
SEROQUEL XR TB24
150MG [+]
SEROQUEL XR TB24
200MG [+]
SEROQUEL XR TB24
300MG [+]
SEROQUEL XR TB24
400MG [+]
SEROQUEL XR TB24
50MG [+]
sertraline hcl conc
2
sertraline hcl tabs 100mg
1
Effective January 1, 2014
2
2
2
2
1
62
Drug Name
Drug
Tier
Requirements/
Limits
sertraline hcl tabs 25mg
1
sertraline hcl tabs 50mg
1
SILENOR
3
SONATA CAPS 10MG
3
SONATA CAPS 5MG
3
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(30 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
PAR QLL(30 per 30
days) MO
PAR QLL(60 per 30
days) MO
MO
QLL(30 per 30 days)
MO
STRATTERA CAPS
2
100MG, 60MG, 80MG
STRATTERA CAPS 10MG,2
18MG, 25MG, 40MG
SURMONTIL
2
SYMBYAX CAPS 25MG; 3
12MG, 50MG; 12MG,
50MG; 6MG
SYMBYAX CAPS 25MG; 3
3MG, 25MG; 6MG
1
temazepam
thioridazine hcl
thiothixene
TOFRANIL
TOFRANIL-PM
TRANXENE T
1
1
3
3
2
tranylcypromine sulfate
trazodone hcl
triazolam
1
1
1
trifluoperazine hcl
trimipramine maleate
VALIUM TABS 10MG
1
3
2
VALIUM TABS 2MG
2
VALIUM TABS 5MG
2
venlafaxine hcl er cp24 150mg1
venlafaxine hcl er cp24 37.5mg1
venlafaxine hcl er cp24 75mg 1
QLL(90 per 30 days)
MO
QLL(30 per 30 days)
MO
PAR MO
MO
MO
MO
QLL(120 per 30
days) MO
MO
MO
QLL(30 per 30 days)
MO
MO
MO
QLL(120 per 30
days) MO
QLL(600 per 30
days) MO
QLL(240 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
venlafaxine hcl er tb24 150mg1
venlafaxine hcl er tb24 225mg1
venlafaxine hcl er tb24 37.5mg1
venlafaxine hcl er tb24 75mg 1
venlafaxine hcl tabs 100mg
1
venlafaxine hcl tabs 25mg
1
venlafaxine hcl tabs 37.5mg 1
venlafaxine hcl tabs 50mg
1
venlafaxine hcl tabs 75mg
1
VIIBRYD KIT
2
VIIBRYD TABS 10MG
2
VIIBRYD TABS 20MG
2
VIIBRYD TABS 40MG
2
VIVACTIL
VYVANSE
3
3
WELLBUTRIN SR TB12
100MG
WELLBUTRIN SR TB12
150MG
WELLBUTRIN SR TB12
200MG
WELLBUTRIN TABS
100MG
WELLBUTRIN TABS
75MG
WELLBUTRIN XL TB24
150MG
WELLBUTRIN XL TB24
300MG
XANAX
3
XANAX XR
2
3
3
3
3
3
3
2
Comprehensive_P3TARO_10R
Requirements/
Limits
Drug Name
Drug
Tier
Requirements/
Limits
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(113 per 30
days) MO
QLL(450 per 30
days) MO
QLL(300 per 30
days) MO
QLL(225 per 30
days) MO
QLL(150 per 30
days) MO
QLL(30 per 30 days)
ST MO
QLL(120 per 30
days) ST MO
QLL(60 per 30 days)
ST MO
QLL(30 per 30 days)
ST MO
MO
QLL(30 per 30 days)
MO
QLL(120 per 30
days) MO
MO
XYREM
2
zaleplon caps 10mg
1
zaleplon caps 5mg
1
zenzedi tabs 10mg
3
ZENZEDI TABS 2.5MG
zenzedi tabs 5mg
3
3
ZENZEDI TABS 7.5MG
3
ziprasidone hcl caps 20mg
1
ziprasidone hcl caps 40mg
1
ziprasidone hcl caps 60mg,
80mg
ZOLOFT CONC
1
ZOLOFT TABS 100MG
3
ZOLOFT TABS 25MG
3
ZOLOFT TABS 50MG
3
zolpidem tartrate
1
zolpidem tartrate er
1
ZOLPIMIST
3
QLL(60 per 30 days)
MO
QLL(135 per 30
days) MO
QLL(180 per 30
days) MO
QLL(90 per 30 days)
MO
QLL(45 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(30 per 30 days)
MO
ZYPREXA INJ
2
LA PAR QLL(540
per 30 days) MO
QLL(60 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(120 per 30
days) MO
QLL(90 per 30 days)
QLL(90 per 30 days)
MO
QLL(120 per 30
days)
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(300 per 30
days) MO
QLL(60 per 30 days)
MO
QLL(240 per 30
days) MO
QLL(120 per 30
days) MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(8 per 30 days)
MO
QLL(60 per 30 days)
MO
3
ZYPREXA RELPREVV INJ 3
210MG, 405MG
ZYPREXA RELPREVV INJ 3
300MG
ZYPREXA TABS 10MG
3
ZYPREXA TABS 15MG
3
ZYPREXA TABS 2.5MG
3
ZYPREXA TABS 20MG
3
63
MO
QLL(60 per 30 days)
MO
QLL(40 per 30 days)
MO
QLL(240 per 30
days) MO
QLL(30 per 30 days)
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
ZYPREXA TABS 5MG
3
ZYPREXA TABS 7.5MG
3
ZYPREXA ZYDIS TBDP
10MG
ZYPREXA ZYDIS TBDP
15MG
ZYPREXA ZYDIS TBDP
20MG
ZYPREXA ZYDIS TBDP
5MG
3
QLL(120 per 30
days) MO
QLL(80 per 30 days)
MO
QLL(60 per 30 days)
MO
QLL(40 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(120 per 30
days) MO
3
3
3
Pulmonary Agents
ACCOLATE
ACCUNEB
3
3
acetylcysteine inhalation soln 1
ADCIRCA
2
ADRENALIN NASAL
SOLN
ADVAIR DISKUS [+]
3
ADVAIR HFA [+]
2
2
1
albuterol sulfate er
albuterol sulfate nebu 0.083%,1
0.63mg/3ml, 1.25mg/3ml
albuterol sulfate nebu 0.5% 1
1
albuterol sulfate syrp
1
albuterol sulfate tabs
ALVESCO AERS 160MCG/3
ACT
ALVESCO AERS 80MCG/ 3
ACT
1
aminophylline
ARCAPTA NEOHALER 3
ASMANEX 120 METERED3
DOSES
ASMANEX 14 METERED 3
DOSES
ASMANEX 30 METERED 3
DOSES AEPB 110MCG/
INH
Effective January 1, 2014
Drug
Tier
Requirements/
Limits
ASMANEX 30 METERED
DOSES AEPB 220MCG/
INH
ASMANEX 60 METERED
DOSES
ASMANEX 7 METERED
DOSES
ATROVENT HFA
3
QLL(0.24 per 30
days) MO
3
QLL(0.24 per 30
days) MO
MO
BECONASE AQ
2
BERINERT
BROVANA
3
3
budesonide susp
3
CINRYZE
COMBIVENT
2
2
Drug Name
QLL(60 per 30 days)
MO
B/D PAR QLL(360
per 30 days) MO
B/D PAR MO
PAR QLL(60 per 30
days) MO
MO
QLL(60 per 30 days)
MO
QLL(12 per 30 days)
MO
MO
B/D PAR QLL(360
per 30 days) MO
B/D PAR QLL(60
per 30 days) MO
MO
MO
QLL(14 per 30 days)
MO
QLL(7 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(0.24 per 30
days) MO
QLL(0.14 per 30
days) MO
64
3
2
COMBIVENT RESPIMAT 2
cromolyn sodium nebu
1
DALIRESP
3
DULERA [+]
2
DUONEB
3
DYMISTA
3
ELIXOPHYLLIN
FIRAZYR
FLONASE
2
2
3
FLOVENT DISKUS AEPB 2
100MCG/BLIST [+]
FLOVENT DISKUS AEPB 2
250MCG/BLIST, 50MCG/
BLIST [+]
FLOVENT HFA AERO
2
110MCG/ACT [+]
FLOVENT HFA AERO
2
220MCG/ACT [+]
FLOVENT HFA AERO
2
44MCG/ACT [+]
QLL(26 per 30 days)
MO
QLL(50 per 30 days)
ST MO
MO
B/D PAR QLL(120
per 30 days) MO
B/D PAR QLL(120
per 30 days) MO
PAR MO
QLL(30 per 30 days)
MO
QLL(8 per 30 days)
MO
B/D PAR QLL(240
per 30 days) MO
QLL(30 per 30 days)
MO
QLL(13 per 30 days)
MO
B/D PAR QLL(540
per 30 days) MO
QLL(1 per 28 days)
MO
MO
PAR MO
QLL(16 per 30 days)
ST MO
QLL(60 per 30 days)
MO
QLL(240 per 30
days) MO
QLL(12 per 30 days)
MO
QLL(24 per 30 days)
MO
QLL(11 per 30 days)
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
flunisolide
1
fluticasone propionate susp
1
FORADIL AEROLIZER [+]2
1
ipratropium bromide
inhalation soln
ipratropium bromide/albuterol1
sulfate
KALBITOR
3
KALYDECO
2
LETAIRIS [+]
levalbuterol
2
1
levalbuterol hcl nebu 0.31mg/ 1
3ml
levalbuterol hcl nebu 0.63mg/ 1
3ml
levalbuterol hcl nebu 1.25mg/ 1
3ml
LUFYLLIN
3
MAXAIR AUTOHALER 3
metaproterenol sulfate
montelukast sodium
1
1
NASACORT AQ
3
NASONEX [+]
2
OMNARIS
2
PERFOROMIST
2
PROAIR HFA [+]
2
PROVENTIL HFA [+]
2
PULMICORT FLEXHALER3
PULMICORT SUSP
3
0.25MG/2ML, 0.5MG/2ML
PULMICORT SUSP 1MG/ 3
2ML
PULMOZYME
2
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
QLL(50 per 30 days)
MO
QLL(16 per 30 days)
MO
QLL(60 per 30 days)
MO
B/D PAR MO
QNASL
3
QVAR [+]
2
REVATIO INJ
2
REVATIO TABS
3
B/D PAR QLL(540
per 30 days) MO
MO
PAR QLL(60 per 30
days) MO
LA PAR MO
B/D PAR QLL(45
per 30 days) MO
QLL(270 per 30
days) MO
QLL(540 per 30
days) MO
B/D PAR QLL(270
per 30 days) MO
MO
QLL(28 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(34 per 30 days)
ST MO
QLL(34 per 30 days)
MO
QLL(13 per 30 days)
ST MO
B/D PAR QLL(120
per 30 days) MO
QLL(18 per 30 days)
MO
QLL(14 per 30 days)
MO
QLL(2 per 30 days)
MO
B/D PAR QLL(120
per 30 days) MO
B/D PAR QLL(60
per 30 days) MO
B/D PAR MO
RHINOCORT AQUA
2
SEREVENT DISKUS [+]
2
sildenafil citrate
1
SINGULAIR
3
sodium chloride nebu 0.9%
sodium chloride nebu 10%,
3%, 7%
SPIRIVA HANDIHALER
[+]
SYMBICORT [+]
1
3
QLL(9 per 30 days)
ST MO
QLL(27 per 30 days)
MO
PAR QLL(1125 per
30 days) MO
PAR QLL(90 per 30
days) MO
QLL(18 per 30 days)
ST MO
QLL(60 per 30 days)
MO
PAR QLL(90 per 30
days) MO
QLL(30 per 30 days)
MO
B/D PAR MO
B/D PAR MO
terbutaline sulfate
THEO-24
theochron
theophylline
theophylline cr
theophylline er
TRACLEER [+]
triamcinolone acetonide inha
1
3
3
1
1
1
2
1
TUDORZA PRESSAIR
3
TYVASO
TYVASO REFILL
TYVASO STARTER
VENTAVIS
VENTOLIN HFA
2
2
2
2
2
VERAMYST
2
VOSPIRE ER
XOLAIR
3
2
XOPENEX
CONCENTRATE
3
65
2
2
QLL(30 per 30 days)
MO
QLL(11 per 30 days)
MO
MO
MO
MO
MO
MO
LA PAR MO
QLL(34 per 30 days)
MO
QLL(1 per 30 days)
MO
PAR MO
PAR MO
PAR MO
PAR MO
QLL(36 per 30 days)
ST MO
QLL(10 per 30 days)
ST MO
MO
LA PAR QLL(6 per
28 days) MO
B/D PAR QLL(45
per 30 days) MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
XOPENEX HFA
3
XOPENEX NEBU 0.31MG/3
3ML, 1.25MG/3ML
XOPENEX NEBU 0.63MG/3
3ML
1
zafirlukast
ZETONNA
3
ZYFLO
2
ZYFLO CR
2
Drug Name
Drug
Tier
Requirements/
Limits
QLL(45 per 30 days)
ST MO
B/D PAR QLL(270
per 30 days) MO
B/D PAR QLL(540
per 30 days) MO
QLL(60 per 30 days)
MO
QLL(6.1 per 30
days) MO
QLL(120 per 30
days) MO
QLL(120 per 30
days) MO
levofloxacin tabs
1
NOROXIN
ofloxacin
3
1
QLL(14 per 1 days)
MO
MO
MO
QLL(5 per 1 days)
MO
MO
QLL(21 per 1 days)
MO
MO
Steroid-Antibiotic Combinations
Quinolones
AVELOX ABC PACK
3
AVELOX INJ
AVELOX TABS
2
3
CIPRO
3
CIPRO I.V.-IN D5W
2
CIPRO XR TB24 1000MG; 3
0
CIPRO XR TB24 500MG; 3
0
ciprofloxacin er tb24 1000mg;1
0
ciprofloxacin er tb24 500mg; 1
0
1
ciprofloxacin hcl
1
ciprofloxacin i.v.-in d5w
ciprofloxacin inj 200mg/20ml 1
ciprofloxacin inj 400mg/40ml 1
FACTIVE
3
LEVAQUIN INJ 5%;
3
250MG/50ML, 5%;
750MG/150ML
LEVAQUIN INJ 5%;
3
500MG/100ML
LEVAQUIN ORAL SOLN 3
LEVAQUIN TABS
3
levofloxacin in d5w
levofloxacin inj
levofloxacin oral soln
Effective January 1, 2014
1
1
1
QLL(14 per 1 days)
MO
QLL(3 per 1 days)
QLL(14 per 1 days)
MO
QLL(3 per 1 days)
MO
MO
MO
MO
Smoking Deterrents
1
buproban
bupropion hcl sr tb12 150mg 1
CHANTIX
2
CHANTIX CONTINUING2
MONTH PAK
CHANTIX STARTING
2
MONTH PAK
NICOTROL INHALER 3
NICOTROL NS
2
ZYBAN
3
MAXITROL
3
1
neo-polycin hc
neomycin/polymyxin/bacitracin/1
hydrocortisone
1
neomycin/polymyxin/
dexamethasone
1
neomycin/polymyxin/
hydrocortisone
3
poly-dex
PRED-G
3
PRED-G S.O.P.
3
TOBRADEX OINT [+]
2
TOBRADEX ST [+]
2
TOBRADEX SUSP
3
tobramycin/dexamethasone 1
ZYLET
3
PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Steroid-Sulfonamide Combinations
BLEPHAMIDE
3
BLEPHAMIDE S.O.P.
3
1
sulfacetamide sodium/
prednisolone sodium phosphate
MO
MO
MO
PAR MO
PAR MO
MO
MO
MO
Steroids
MO
MO
QLL(14 per 1 days)
MO
MO
MO
66
ALREX
dexamethasone sodium
phosphate
DUREZOL [+]
FLAREX
fluorometholone
FML
FML FORTE
3
1
MO
MO
2
3
1
3
3
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
FML LIQUIFILM
3
LOTEMAX
3
MAXIDEX
3
OMNIPRED
3
PRED FORTE
3
PRED MILD
3
1
prednisolone acetate
prednisolone sodium phosphate1
ophthalmic soln
RETISERT
3
VEXOL
3
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Sulfa'S & Related Agents
BACTRIM
3
BACTRIM DS
3
1
sulfadiazine
sulfamethoxazole/trimethoprim1
sulfamethoxazole/trimethoprim1
ds
MO
MO
MO
MO
MO
Sulfonamides
BLEPH-10
sodium sulfacetamide
sulfacetamide sodium
3
1
1
MO
MO
MO
2
MO
3
MO
Sympathomimetics
ALPHAGAN P
OPHTHALMIC SOLN
0.1% [+]
ALPHAGAN P
OPHTHALMIC SOLN
0.15%
apraclonidine
brimonidine tartrate
IOPIDINE
1
1
3
MO
MO
MO
3
3
3
3
3
MO
MO
MO
MO
MO
3
3
1
3
1
1
3
MO
MO
MO
MO
MO
Tetracyclines
ADOXA CAPS
ADOXA PAK 1/100
ADOXA PAK 1/150
ADOXA PAK 2/100
ADOXA TABS 100MG,
50MG
ADOXA TABS 75MG
avidoxy
demeclocycline hcl
DORYX
doxy 100
doxycycline hyclate caps
doxycycline hyclate cpep
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
3
doxycycline hyclate dr
1
doxycycline hyclate inj
1
doxycycline hyclate tabs
doxycycline monohydrate caps 1
100mg, 150mg, 50mg
doxycycline monohydrate caps 1
75mg
doxycycline monohydrate susr 1
doxycycline monohydrate tabs 1
DYNACIN
3
MINOCIN
3
MINOCIN KIT
3
1
minocycline hcl
3
minocycline hcl er
MONODOX CAPS 100MG3
MONODOX CAPS 75MG 3
Requirements/
Limits
MO
MO
MO
MO
3
3
QLL(60 per 1 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(60 per 1 days)
MO
MO
MO
3
3
MO
MO
3
3
1
3
MO
MO
MO
MO
ABSORICA
ACANYA
3
3
ACZONE
adapalene crea
adapalene gel
AKNE-MYCIN
amnesteem
ATRALIN
3
3
1
3
1
3
avar cleanser
AVAR LS CLEANSER
AVAR-E EMOLLIENT
AVAR-E GREEN
AVAR-E LS
avita crea
1
3
3
3
3
3
LA MO
QLL(50 per 30 days)
MO
MO
MO
MO
MO
MO
QLL(90 per 30 days)
MO
MO
MO
MO
MO
MO
QLL(90 per 30 days)
MO
morgidox 1x100mg caps
MORGIDOX 1X100MG
KIT
morgidox 2x100mg caps
MORGIDOX 2X100MG
KIT
ORACEA
SOLODYN
tetracycline hcl
VIBRAMYCIN
Therapy For Acne
67
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
AVITA GEL
3
QLL(90 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
AZELEX
3
BENZACLIN
3
BENZACLIN WITH PUMP3
BENZAMYCIN
3
BENZAMYCINPAK
3
3
bp 10-1
3
cerisa wash
1
claravis
CLARIFOAM EF
3
CLEOCIN-T
3
CLINDACIN PAC
3
3
clindacin-p
CLINDAGEL
3
CLINDAMAX
3
1
clindamycin phosphate
clindamycin/benzoyl peroxide 1
DIFFERIN
3
DUAC
3
EPIDUO
3
1
ery
1
erythromycin
erythromycin/benzoyl peroxide 1
EVOCLIN
3
FINACEA
3
METROCREAM
3
METROGEL
3
METROLOTION
3
1
metronidazole
1
myorisan
NORITATE
3
1
prascion
3
prascion fc
RETIN-A
3
RETIN-A MICRO
3
RETIN-A MICRO PUMP 3
rosadan
ROSADAN KIT
ROSANIL CLEANSER
sodium sulfacetamide/sulfur
cleanser
Effective January 1, 2014
1
3
3
1
Drug
Tier
Requirements/
Limits
sodium sulfacetamide/sulfur
cleanser in urea
sodium sulfacetamide/sulfur
foam
sodium sulfacetamide/sulfur
lotn
sodium sulfacetamide/sulfur
pads
sodium sulfacetamide/sulfur
susp 10%; 5%
sodium sulfacetamide/sulfur
wash liqd 9%; 4%
sulfacetamide sodium/sulfur
cleanser
SUMADAN WASH
SUMAXIN
SUMAXIN TS
SUMAXIN WASH
TAZORAC
TRETIN-X
tretinoin crea
1
MO
3
MO
3
MO
3
MO
3
MO
1
MO
1
MO
3
3
3
3
2
3
1
tretinoin emollient
tretinoin gel
1
1
tretinoin microsphere
1
tretinoin microsphere pump
1
VELTIN
zenatane
zencia
ZIANA
3
1
3
3
MO
MO
MO
MO
MO
MO
QLL(90 per 30 days)
MO
MO
QLL(90 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
MO
MO
MO
3
3
1
3
MO
MO
MO
MO
Drug Name
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(90 per 30 days)
MO
QLL(90 per 30 days)
MO
QLL(90 per 30 days)
MO
MO
MO
MO
MO
68
Thyroid Hormones
ARMOUR THYROID
CYTOMEL
levothroid
LEVOTHYROXINE
SODIUM INJ 100MCG
levothyroxine sodium inj
200mcg
levothyroxine sodium inj
500mcg
levothyroxine sodium tabs
levoxyl
liothyronine sodium inj
1
3
MO
1
1
1
MO
MO
Comprehensive_P3TARO_10R
Drug Name
liothyronine sodium tabs
SYNTHROID
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
TIROSINT
TRIOSTAT
unithroid tabs 100mcg,
112mcg, 125mcg, 150mcg,
175mcg, 200mcg, 25mcg,
300mcg, 50mcg, 75mcg,
88mcg
unithroid tabs 137mcg
Drug
Tier
Requirements/
Limits
1
2
3
3
3
3
3
3
3
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
Topical Anesthetics
bupivacaine hcl inj 0.25% 3
1
bupivacaine hcl inj 0.5%
bupivacaine hcl inj 0.75% 1
bupivacaine/epinephrine inj 3
0.25%; 1:200000
bupivacaine/epinephrine inj 3
0.5%; 1:200000
CARBOCAINE INJ 1%, 2%3
3
carbocaine inj 1.5%
CARBOCAINE INJ 2%
3
3
chloroprocaine hcl
EMLA
3
EXPAREL
3
3
lidocaine crea
1
lidocaine hcl external soln
1
lidocaine hcl gel
lidocaine hcl inj 0.5%, 1%, 3
2%, 4%
3
lidocaine hcl inj 1.5%
1
lidocaine hcl inj 2%
1
lidocaine hcl jelly
3
lidocaine hcl lotn
lidocaine hcl mouth/throat soln1
lidocaine hcl/hydrocortisone 3
acetate crea
1
lidocaine oint
1
lidocaine viscous
3
lidocaine/epinephrine inj
1:100000; 1%, 1:100000; 2%
Comprehensive_P3TARO_10R
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
3
lidocaine/epinephrine inj
1:200000; 0.5%, 1:200000;
1.5%, 1:200000; 2%
1
lidocaine/prilocaine
LIDODERM [+]
2
3
lta 360 kit
MARCAINE
3
3
marcaine w/o epi
MARCAINE/
3
EPINEPHRINE INJ 0.25%;
1:200000
MARCAINE/
3
EPINEPHRINE INJ 0.5%;
1:200000
NAROPIN
3
NESACAINE
3
NESACAINE-MPF
3
3
orasep
PLIAGLIS
3
3
polocaine inj 1%
POLOCAINE INJ 2%
3
polocaine-mpf inj 1%, 1.5% 3
3
polocaine-mpf inj 2%
SENSORCAINE INJ 0.25%3
3
sensorcaine inj 0.5%
SENSORCAINE-MPF INJ 3
0.25%
3
sensorcaine-mpf inj 0.5%
SENSORCAINE-MPF INJ 3
0.5%, 0.75%
SENSORCAINE-MPF/
3
EPINEPHRINE
sensorcaine/epinephrine inj 3
0.25%; 1:200000
sensorcaine/epinephrine inj 3
0.5%; 1:200000
SYNERA
3
XYLOCAINE EXTERNAL 3
SOLN
XYLOCAINE INJ 0.5%, 1%,3
2%
XYLOCAINE-MPF INJ
3
0.5%, 1.5%, 2%
XYLOCAINE-MPF INJ 1%,3
4%
69
Requirements/
Limits
MO
QLL(90 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
XYLOCAINE-MPF/
EPINEPHRINE
XYLOCAINE/
EPINEPHRINE INJ
1:100000; 1%, 1:200000;
0.5%
XYLOCAINE/
EPINEPHRINE INJ
1:100000; 2%
Drug
Tier
Requirements/
Limits
3
1
3
1
3
1
ketoconazole crea
3
ketoconazole foam
1
ketoconazole sham
3
ketodan
3
ketodan kit
LAMISIL SPRAY
3
MO
LOPROX
3
LOPROX SHAMPOO
3
LOTRISONE
3
MENTAX
3
QLL(30 per 30 days) NAFTIN CREA
3
MO
NAFTIN GEL 1%
3
MO
NIZORAL
3
MO
1
nyamyc
MO
1
nystatin
MO
1
nystatin/triamcinolone
MO
1
nystop
MO
OXISTAT
3
MO
1
pedi-dri
PEDIADERM AF
3
MO
COMPLETE KIT
MO
PEDIPIROX-4 NAIL
3
MO
PENLAC NAIL LACQUER3
MO
VUSION
3
XOLEGEL
3
MO
MO
Topical Antivirals
1
acyclovir oint
MO
DENAVIR
2
MO
PAR MO
XERESE
3
MO
1
1
1
1
1
1
1
1
MO
PAR MO
MO
PAR MO
MO
MO
MO
MO
3
1
3
3
3
MO
MO
MO
MO
MO
3
3
Topical Antibacterials
ALTABAX
3
bacitracin
BACTROBAN
CENTANY
CENTANY AT
CORTISPORIN
gentamicin sulfate
KLARON
mafenide acetate
mupirocin
mupirocin calcium
PHISOHEX
sodium sulfacetamide
sulfacetamide sodium
SULFAMYLON
1
3
3
3
3
1
3
1
1
1
3
1
1
3
Topical Antifungals
ciclodan crea
CICLODAN CREAM KIT
ciclodan external soln
CICLODAN SOLUTION
KIT
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine
ciclopirox topical solution kit
ciclopirox treatment
clotrimazole external crea
clotrimazole external soln
clotrimazole/betamethasone
dipropionate
CNL8 NAIL KIT
econazole nitrate
ERTACZO
EXELDERM
EXTINA
Effective January 1, 2014
Drug
Tier
Drug Name
ZOVIRAX CREA
2
ZOVIRAX OINT
3
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PAR MO
MO
MO
QLL(30 per 1 days)
MO
QLL(5 per 1 days)
MO
QLL(5 per 30 days)
MO
QLL(5 per 1 days)
MO
QLL(30 per 1 days)
MO
Topical Corticosteroids
ACLOVATE
ala cort
ALA SCALP
alclometasone dipropionate
amcinonide
APEXICON
apexicon e
augmented betamethasone
dipropionate
70
3
1
3
1
1
3
1
1
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
betamethasone dipropionate 1
1
betamethasone valerate
CAPEX
3
1
clobetasol propionate
1
clobetasol propionate e
clobetasol propionate emollient1
CLOBEX
3
CLODERM
3
CLODERM PUMP
3
CORDRAN
3
CORDRAN SP
3
CORDRAN TAPE
3
1
cormax scalp application
CUTIVATE
3
DERMA-SMOOTHE/FS 3
BODY
DERMA-SMOOTHE/FS 3
BODY OIL
DERMA-SMOOTHE/FS 3
SCALP
DERMATOP
3
DESONATE
3
1
desonide
DESOWEN
3
DESOWEN CREAM/
3
CETAPHIL LOTION
DESOWEN LOTION/
3
CETAPHIL CREAM
DESOWEN OINTMENT/ 3
CETAPHIL LOTION
1
desoximetasone
1
diflorasone diacetate
DIPROLENE
3
DIPROLENE AF
3
ELOCON
3
FIRST3
HYDROCORTISONE
1
fluocinolone acetonide
fluocinolone acetonide body 1
fluocinolone acetonide scalp 1
1
fluocinonide
1
fluocinonide-e
fluticasone propionate crea 1
1
fluticasone propionate lotn
fluticasone propionate oint 1
1
halobetasol propionate
Comprehensive_P3TARO_10R
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
HALOG
3
3
halonate
3
halonate pac
1
hydrocortisone butyrate
hydrocortisone crea 1%, 2.5% 1
hydrocortisone in absorbase 1
1
hydrocortisone lotn 2.5%
hydrocortisone oint 1%, 2.5% 1
1
hydrocortisone valerate
KENALOG
3
LOCOID
3
LOCOID LIPOCREAM 3
LOKARA
3
LUXIQ
3
1
mometasone furoate crea
mometasone furoate external 1
soln
1
mometasone furoate oint
MOMEXIN
3
OLUX
3
OLUX-E
3
PANDEL
3
PEDIADERM HC
3
PEDIADERM TA
3
1
prednicarbate
3
scalacort
SYNALAR CREA
3
SYNALAR CREAM KIT 3
SYNALAR EXTERNAL
3
SOLN
SYNALAR OINT
3
SYNALAR TS
3
TEMOVATE
3
TEMOVATE E
3
TEXACORT
3
TOPICORT
3
triamcinolone acetonide crea 1
triamcinolone acetonide lotn 1
triamcinolone acetonide oint 1
1
trianex
1
triderm
ULTRAVATE
3
ULTRAVATE PAC
3
ULTRAVATE X
3
VANOS
3
VERDESO
3
71
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
WESTCORT
3
MO
3
QLL(30 per 1 days)
MO
Drug Name
Topical Enzymes
SANTYL
Topical Scabicides / Pediculicides
3
3
3
1
1
3
3
1
3
3
3
MO
ACIPHEX
3
AXID ORAL SOLN
carafate susp
CARAFATE TABS
cimetidine
cimetidine hcl inj
cimetidine hcl oral soln
CYTOTEC
DEXILANT
3
3
3
3
1
3
3
3
famotidine inj
famotidine premixed
famotidine susr
famotidine tabs 20mg, 40mg
HELIDAC
lansoprazole
1
1
1
1
3
1
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
ST MO
MO
misoprostol
NEXIUM [+]
1
2
NEXIUM I.V. INJ 20MG
NEXIUM I.V. INJ 40MG
nizatidine caps
nizatidine oral soln
OMECLAMOX-PAK
omeprazole cpdr
2
2
1
3
3
1
acticin
ELIMITE
EURAX
lindane
malathion
NATROBA
OVIDE
permethrin crea
SKLICE
spinosad
ULESFIA
MO
MO
MO
MO
MO
MO
MO
MO
MO
Ulcer Therapy
Effective January 1, 2014
MO
MO
MO
QLL(30 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
Drug
Tier
OMEPRAZOLE/SODIUM 1
BICARBONATE CAPS
20MG; 1100MG
omeprazole/sodium bicarbonate1
caps 20mg; 1100mg, 40mg;
1100mg
1
pantoprazole sodium inj
1
pantoprazole sodium tbec
PEPCID
PREVACID
3
3
PREVACID SOLUTAB
3
PREVPAC
PRILOSEC CPDR
3
3
PRILOSEC PACK
PROTONIX INJ
PROTONIX PACK
3
3
3
PROTONIX TBEC
3
PYLERA
ranitidine hcl caps
ranitidine hcl inj
ranitidine hcl syrp
ranitidine hcl tabs 150mg,
300mg
sucralfate susp
sucralfate tabs
ZANTAC
ZEGERID
3
3
1
1
1
3
1
3
3
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
QLL(30 per 30 days)
MO
MO
MO
QLL(30 per 30 days)
MO
QLL(30 per 30 days)
MO
MO
MO
MO
MO
MO
MO
MO
MO
QLL(30 per 30 days)
MO
Urinary Tract Agents
FURADANTIN
3
HIPREX
3
MACROBID
3
MACRODANTIN
3
1
methenamine hippurate
MO
1
methenamine mandelate
MO
MONUROL
3
MO
1
nitrofurantoin
MO
nitrofurantoin macrocrystal 1
QLL(30 per 30 days)
nitrofurantoin macrocrystalline1
MO
nitrofurantoin macrocrystals 1
72
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
nitrofurantoin monohydrate
nitrofurantoin monohydrate/
macrocrystals
PRIMSOL
trimethoprim
UREX
Drug
Tier
Requirements/
Limits
1
1
MO
MO
3
1
3
MO
MO
MO
Vaccines & Miscellaneous Immunologicals
ACTHIB
2
ADACEL
2
ANTIZOL
3
ATGAM
3
BCG VACCINE
3
BIOTHRAX
3
BIVIGAM
2
BOOSTRIX
2
BOTOX
2
CARIMUNE
2
NANOFILTERED
CERVARIX
2
COMVAX
2
CYTOGAM
3
DAPTACEL
2
DECAVAC
3
DIPHTHERIA/TETANUS 3
TOXOIDS ADSORBED
PEDIATRIC
DYSPORT
2
ENGERIX-B INJ 10MCG/ 2
0.5ML
ENGERIX-B INJ 20MCG/ 2
ML
FLEBOGAMMA
3
FLEBOGAMMA DIF
3
1
fomepizole
GAMASTAN S/D
2
GAMMAGARD LIQUID 2
GAMMAGARD S/D
2
GAMMAGARD S/D IGA 2
LESS THAN 1MCG/ML
GAMMAKED
3
GAMMAPLEX
2
GAMUNEX-C
2
GARDASIL
2
HAVRIX INJ 1440ELU/ML2
HAVRIX INJ 720ELU/
2
0.5ML
Comprehensive_P3TARO_10R
MO
MO
B/D PAR
PAR MO
MO
PAR MO
PAR MO
MO
MO
MO
MO
MO
PAR MO
B/D PAR
B/D PAR MO
PAR MO
PAR MO
MO
PAR MO
PAR MO
PAR MO
PAR MO
MO
PAR MO
PAR MO
MO
MO
Drug Name
Drug
Tier
HEPAGAM B
3
HIBERIX
3
HIZENTRA
3
HYPERHEP B S/D
3
HYPERRAB S/D
3
HYPERRHO S/D INJ
3
300MCG
HYPERRHO S/D INJ
3
50MCG
HYPERTET S/D
3
IMOGAM RABIES-HT
3
IMOVAX RABIES
2
(H.D.C.V.)
INFANRIX
2
IPOL INACTIVATED IPV 2
IXIARO
2
JE-VAX
3
KINRIX
3
M-M-R II W/DILUENT 102
DOSE
MENACTRA
2
MENOMUNE-A/C/Y/W- 2
135
MENVEO
2
MICRHOGAM ULTRA- 3
FILTERED PLUS
MYOBLOC
3
NABI-HB
3
OCTAGAM
3
PEDIARIX
3
PEDVAX HIB
2
PENTACEL
3
PRIVIGEN
2
PROQUAD
1
RABAVERT
2
RECOMBIVAX HB
2
RHOGAM ULTRA3
FILTERED PLUS
RHOPHYLAC
3
ROTARIX
3
ROTATEQ
2
TENIVAC
3
1
tetanus toxoid adsorbed
TETANUS/DIPHTHERIA 2
TOXOIDS-ADSORBED
ADULT
THERACYS
3
73
Requirements/
Limits
MO
B/D PAR MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PAR MO
MO
PAR MO
MO
MO
PAR MO
MO
B/D PAR MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
THYMOGLOBULIN
TICE BCG
TWINRIX
TYPHIM VI
VAQTA
VARIVAX
VARIZIG
VIVOTIF BERNA
WINRHO SDF INJ
15000UNIT/13ML
WINRHO SDF INJ
1500UNIT/1.3ML,
2500UNIT/2.2ML,
5000UNIT/4.4ML
XEOMIN
YF-VAX
ZOSTAVAX
Drug
Tier
Requirements/
Limits
2
3
2
2
2
2
2
3
3
B/D PAR
MO
MO
3
MO
2
2
2
PAR MO
MO
MO
Drug Name
MO
MO
MO
Vancomycin
VANCOCIN HCL CAPS 3
125MG
VANCOCIN HCL CAPS 3
250MG
vancomycin hcl caps 125mg 1
vancomycin hcl caps 250mg 1
VANCOMYCIN HCL IN 2
DEXTROSE INJ 0; 1GM/
200ML
VANCOMYCIN HCL IN 2
DEXTROSE INJ 0; 500MG/
100ML, 0; 750MG/150ML
vancomycin hcl inj 1000mg, 1
10gm, 5000mg, 750mg
vancomycin hcl inj 500mg 1
VIBATIV
3
PAR QLL(40 per 1
days) MO
PAR QLL(80 per 1
days) MO
PAR QLL(40 per 1
days) MO
PAR QLL(80 per 1
days) MO
B/D PAR MO
B/D PAR
B/D PAR MO
B/D PAR
PAR
Vasoconstrictor Decongestants
altafrin
MYDFRIN
naphazoline hcl
neofrin
phenylephrine hcl ophthalmic
soln
3
3
1
3
1
MO
MO
MO
MO
MO
Vitamins & Hematinics
B-NEXA
bal-care dha
Effective January 1, 2014
3
3
MO
MO
74
Drug
Tier
BAL-CARE DHA
3
ESSENTIAL
3
cavan-alpha kit
3
cavan-ec sod dha
CITRANATAL 90 DHA 3
CITRANATAL DHA
3
CITRANATAL HARMONY3
CITRANATAL RX
3
CONCEPT DHA
3
CONCEPT OB
3
DUET DHA BALANCED 3
MISC 120MG; 2840UNIT;
215MG; 840UNIT; 2MG;
12MCG; 0; 0; 0; 1MG;
210MCG; 26MG; 0; 25MG;
20MG; 278MG; 0; 50MG;
4MG; 0; 1.5MG; 2MG;
25MG
3
epiflur
3
fe c plus
3
fluor-a-day chew
FLUOR-A-DAY ORAL
3
SOLN
FLUORABON
3
1
fluoride
fluoritab chew 0.5mg, 1mg 3
FLUORITAB ORAL SOLN 3
FLURA-DROPS ORAL
3
SOLN 0.25MG/DROP
1
folbecal
1
folcal dha
1
folcaps omega 3
3
folivane-prx dha nf
GESTICARE DHA
3
1
hemenatal ob
1
hemenatal ob + dha
ICAR-C PLUS
3
3
inatal advance
3
inatal gt
3
inatal ultra
3
lozi-flur
1
ludent
NATA KOMPLETE
3
NATACHEW
3
NATAFORT
3
3
natalvirt 90 dha
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
3
natalvirt ca
NATELLE ONE
3
NESTABS
3
NESTABS DHA
3
NEXA PLUS
3
O-CAL FA
3
O-CAL PRENATAL
3
3
ob-natal one caps 150mg;
25mg; 170unit; 260mg; 40mg;
7mg; 1mg; 20mg; 30mg;
30mg; 330mg; 25mg; 30unit
OBSTETRIX EC
3
OBTREX
3
PAIRE OB
3
3
pnv ob+dha
pnv prenatal plus multivitamin1
3
pnv-dha
3
pnv-first
1
pnv-select
3
pr natal 400
3
pr natal 400 ec
1
pr natal 430
1
pr natal 430 ec
PREFERA OB
3
PREFERA OB + DHA
3
PREFERAOB ONE
3
3
prena1 chew/quatrefolic
3
prena1 plus/quatrefolic
3
prena1/quatrefolic
3
prenafirst
1
prenaissance
3
prenaissance plus
3
prenaplus
PRENATA
3
1
prenatabs fa
1
prenatabs obn
1
prenatabs rx
1
prenatal 19 chew 100mg;
1000unit; 200mg; 7mg;
12mcg; 25mg; 29mg; 1mg;
6mg; 20mg; 3mg; 3mg;
400unit; 30unit; 20mg
1
prenatal 19 chew 100mg;
1000unit; 200mg; 7mg;
400unit; 12mcg; 29mg; 1mg;
Comprehensive_P3TARO_10R
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
15mg; 20mg; 3mg; 3mg;
30unit; 20mg
PRENATAL 19 TABS
1
100MG; 1000UNIT;
200MG; 7MG; 400UNIT;
12MCG; 25MG; 29MG;
1MG; 15MG; 20MG; 3MG;
3MG; 30UNIT; 20MG
1
prenatal 19 tabs 100mg;
200mg; 400unit; 12mcg;
25mg; 29mg; 1mg; 15mg;
7mg; 20mg; 3mg; 3mg;
1000unit; 30unit; 20mg
3
prenatal ad
prenatal low iron tabs 120mg; 3
0; 200mg; 400unit; 2mg;
12mcg; 27mg; 1mg; 20mg;
10mg; 3mg; 1.84mg; 22unit;
4000unit; 25mg
1
prenatal plus
1
prenatal plus iron
prenatal tabs 120mg; 0; 0; 1
200mg; 400unit; 2mg; 12mcg;
27mg; 1mg; 20mg; 10mg;
3mg; 1.84mg; 22mg;
4000unit; 25mg
1
prenatal vitamins plus
1
prenatal-u
PRENATE ELITE
3
PRENATE ESSENTIAL 3
PRENEXA
3
PREQUE 10
3
PUREFE OB PLUS
3
REAPHIRM
3
3
relnate dha
1
se-care
1
se-natal 19
3
se-natal one
1
se-tan dha
SELECT-OB
3
SELECT-OB+DHA
3
3
seton et-ec
3
setonet
1
sodium fluoride chew
3
sodium fluoride oral soln
1
sodium fluoride tabs
75
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
TANDEM DHA
TANDEM OB
taron-prex
tl-care dha
triadvance
TRICARE
TRICARE PRENATAL
DHA ONE
trinatal gt
trinate
triveen-prx rnf
ultimatecare one nf
vemavite-prx 2
vinacal
vinate az
vinate az extra
vinate c
vinate calcium
vinate care
vinate gt
vinate ic
vinate ii
vinate m
vinate one
vinate pn care
vinate ultra
virt-bal dha plus
virt-pn
virt-pn dha
vitafol-ob
VITAFOL-OB+DHA
VITAFOL-ONE
VITAFOL-PLUS
vitafol-pn
VITAMEDMD ONE RX/
QUATREFOLIC
VITAMEDMD PLUS RX/
QUATRE FOLIC
VITAMEDMD
REDICHEW RX/
QUATREFOLIC
VIVA CT PRENATAL
vol-nate
vp-ch-pnv
VP-PNV-DHA
zatean-ch
Effective January 1, 2014
Drug
Tier
Requirements/
Limits
3
3
3
3
1
3
3
MO
MO
MO
1
1
3
3
3
3
1
3
3
3
1
3
3
3
1
3
3
3
3
1
3
1
3
3
3
3
3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
3
MO
3
MO
3
1
3
3
3
MO
MO
MO
MO
MO
MO
76
Comprehensive_P3TARO_10R
Extra Covered Drugs
Additional coverage for the following drugs is provided by your group sponsored plan.
These prescription drugs are not normally covered in a Medicare Prescription Drug plan. The amount you pay when
you fill a prescription for these drugs does not count towards your total drug costs (that is, the amount you pay does not
help you qualify for deductible, inital coverage limit or catastrophic coverage). In addition, if you are receiving extra help
to pay for your prescriptions, you will not get any extra help to pay for these drugs.
Drug Name
Drug
Tier
Requirements/
Limits
Antidiarrheals & Antispasmodics
chlordiazepoxide hcl/clidinium
bromide
DONNATAL EXTENTABS
DONNATAL TABS
1
MO
2
2
MO
MO
Antineoplastic & Immunosuppressant Drugs
IODOPEN
2
Antipsoriatic / Antiseborrheic
hydrocortisone acetate/pramoxine 1
OVACE WASH
2
PRAMOSONE CREA 2.5%; 2
1%
PRAMOSONE OINT
2
1
seb-prev wash
1
sodium sulfacetamide wash
MO
MO
MO
MO
MO
MO
Antithyroid Agents
SSKI
2
MO
2
2
2
1
MO
2
1
2
MO
2
MO
1
1
1
1
1
2
1
MO
MO
MO
MO
Coagulation Therapy
MEPHYTON
PHYTONADIONE
VITAMIN K
vitamin k1
MO
MO
Cough & Cold Therapy
ALAHIST DM
albatussin nn
ALKA-SELTZER PLUS DAY
COLD & FLU FORMULA
ALKA-SELTZER PLUS
SEVERE SINUS
CONGESTION & COUGH
allfen dm
altarussin dm
benzonatate
biocotron
bionel
BIOSPEC DMX
biotuss pediatric
Comprehensive_P3TARO_10R
MO
Drug Name
Drug
Tier
1
brom/pse/dm
BROMFED DM
2
brompheniramine/phenylephrine/ 1
dm
1
broncotron
BROVEX PEB DM
2
1
cheracol-d cough
1
cheratussin ac
1
cheratussin dac
1
chest congestion relief plus dm
1
childrens mucus relief cough
CLOFERA
2
1
codituss dm
COLD HEAD CONGESTION2
DAYTIME
cold head congestion nighttime 1
cold head congestion severe daytime1
COLD MULTI-SYMPTOM 2
DAYTIME
cold multi-symptom nighttime 1
cold multi-symptom severe daytime1
1
cold/cough dm childrens
COMTREX COLD &
2
COUGH MAXIMUM
STRENGTH
COMTREX COLD &
2
COUGH NIGHTTIME
MAXIMUM STRENGTH
1
corfen-dm
COTAB AX
2
COUGH DM
2
DAY TIME MULTI2
SYMPTOM COLD/FLU
RELIEF
1
day-time pe
daytime pe multi-symptom cold/flu1
relief
DELSYM
2
77
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
1
despec eda
1
dextromethorphan hbr/
phenylephrine hcl/
chlorpheniramine
DEXTROMETHORPHAN 2
POLISTIREX
dextromethorphan/guaifenesin 1
1
diabetic tussin dm
diabetic tussin maximum strength1
DICEL CD
2
DICEL DM
2
dimaphen dm cold/cough childrens1
DIMETANE DX
2
DIMETAPP LONG ACTING 2
COUGH PLUS COLD
1
endacof-c
1
endacof-dm
eql tussin cough/chest congestion 1
1
exefen dmx
1
extra action cough
FLU/SEVERE COLD &
2
COUGH DAYTIME
1
g-tron
GILTUSS PED-C
2
GILTUSS PEDIATRIC
2
1
giltuss tr caps
1
guaiatussin ac
1
guaifenesin dac
1
guaifenesin-dm
guaifenesin/dextromethorphan 1
1
hydrocodone bitartrate/
homatropine methylbromide
1
hydrocodone polistirex and
chlorpheniramine polistirex
1
hydrocodone/homatropine
1
hydromet
1
intense cough reliever
1
iophen c-nr
1
iophen dm-nr
1
lohist-peb-dm
1
m-clear wc
1
m-end dm
1
mapap cold formula multisymptom
MAXIFED DM
2
MAXIFED DMX
2
Effective January 1, 2014
Requirements/
Limits
Drug Name
Drug
Tier
1
medi-tussin dm
1
meijer cough syrup dm
1
mesehist dm
1
mucinex cough childrens
MUCINEX FAST-MAX COLD2
FLU& SORE THROAT TABS
1
mucinex fast-max dm max
MUCINEX FAST-MAX
2
SEVERE CONGESTION &
COLD
1
mucosa dm
1
mucus relief cough childrens
1
mucus relief dm
1
mytussin dac
1
neotuss
1
nohist-dm
NORTUSS-DE LIQD 5MG/ 2
ML; 50MG/ML; 2.5MG/ML
pain relief cold severe congestion 1
pedia care multi-symptom cold 1
children
1
poly-tussin
1
poly-tussin d
PRESGEN B
2
PRO-RED AC
2
1
promethazine vc/codeine
1
promethazine-dm
1
promethazine/codeine
promethazine/dextromethorphan 1
1
q-tussin dm
1
ra tussin dm
1
refenesen dm
1
relcof c
RESCON DM
2
RESPA C&C IR
2
1
robafen cf cough & cold
1
robafen cough
1
robafen dm
1
robafen dm cough clear
ROBITUSSIN COLD+FLU 2
DAYTIME
robitussin cough & chest congestion1
dm max
1
robitussin cough & cold d
1
robitussin cough/cold cf
1
robitussin dm
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
78
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
1
rynex dm
1
silphen dm cough
1
siltussin dm das
1
siltussin-dm
1
supress-dx pediatric
TESSALON PERLES
2
THERAFLU SEVERE COLD 2
& COUGH DAYTIME
THERAFLU SEVERE COLD 2
NIGHTTIME
THERAFLU WARMING
2
RELIEF MULTI-SYMPTOM
COLD DAYTIME
theraflu warming relief severe cold1
daytime
TRIAMINIC COLD &
2
COUGH DAY TIME
CHILDRENS ORAL SOLN
1
triaminic long acting cough
childrens
TRIAMINIC LONG ACTING2
COUGH STRP
1
trigofen dm
TUSNEL
2
1
tusnel c
1
tusnel diabetic
TUSSI-PRES B
2
1
tussigon
1
tussin cf
1
tussin cf cough & cold
1
tussin cough
1
tussin dm
1
tussin dm clear
1
tussin dm max
TUSSIONEX PENNKINETIC2
EXTENDED RELEASE
1
tylenol cold head congestion
daytime
TYLENOL COLD HEAD
2
CONGESTION NIGHTTIME
TYLENOL COLD MULTI- 2
SYMPTOM DAYTIME TABS
TYLENOL COLD SEVERE 2
CONGESTION
VANACOF DX
2
1
vicks dayquil cold & flu
Comprehensive_P3TARO_10R
Requirements/
Limits
MO
MO
MO
Drug Name
Drug
Tier
Requirements/
Limits
vicks dayquil cold & flu multi- 1
symptom relief liqd
VICKS DAYQUIL NATURE 2
FUSION COLD & FLU
MULTI-SYMPTOM RELIEF
TABS 325MG; 10MG; 5MG
Electrolytes
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
calcium citrate plus/magnesium 1
1
calcium/magnesium/zinc tabs
333mg; 133mg; 5mg
1
chelated zinc lozenges
1
chromium chloride
COLD-EEZE LOZG
2
COPPER SULFATE
2
GALZIN
2
1
iodine strong
1
mag-delay
1
mag-sr
1
mag-sr plus calcium
1
mag64
MAGNESIUM CHLORIDE 2
POWD
1
manganese sulfate inj
1
manganese trace metal
MULTITRACE-4
2
MULTITRACE-5
2
MULTITRACE-5
2
CONCENTRATE
ORAZINC TABS
2
POTABA
2
1
selenium inj
1
selenium tabs 100mcg
1
selenium tabs 200mcg
TRACE ELEMENTS 4/
2
PEDIATRIC
ZINC 15
2
ZINC CHLORIDE
2
zinc gluconate tabs 100mg, 30mg1
1
zinc gluconate tabs 50mg
1
zinc sulfate caps
1
zinc sulfate inj 5mg/ml
ZINC SULFATE POWD
2
1
zinc sulfate tabs 220mg
1
zinc tabs 30mg
1
zinc tabs 50mg
1
zinc trace metal
79
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
Requirements/
Limits
Estrogens & Progestins
covaryx
covaryx hs
eemt
eemt hs
esterified estrogens/
methyltestosterone
esterified estrogens/
methyltestosterone hs
1
1
1
1
1
MO
MO
MO
MO
MO
1
MO
1
2
2
1
1
1
1
1
MO
MO
MO
MO
MO
MO
MO
MO
ACLARO
alphaquin hp
CORTANE-B
ELDOPAQUE FORTE
EPIQUIN MICRO
HYDRO 40 FOAM
hydroquinone time release
latrix
LUSTRA-AF
lustra-ultra
melpaque hp
nuquin hp crea
PARA-AMINOBENZOIC
ACID
remeven
TRI-LUMA
UMECTA EMUL
umecta mousse
UMECTA PD EMUL
urea crea 40%, 50%
urea emul
urea nail stck
urea susp
VANIQA
x-viate crea
Lipid/Cholesterol Lowering Agents
1
niacin cpcr
1
niacin er cpcr 500mg
niacin tabs 100mg, 250mg, 50mg1
NIACIN TR TBCR 1000MG 2
niacin tr tbcr 250mg, 500mg, 1
750mg
1
niacinamide
1
slo-niacin tbcr 500mg
SLO-NIACIN TBCR 750MG 2
MO
MO
MO
MO
MO
MO
MO
MO
1
isometheptene/caffeine/
acetaminophen
isometheptene/dichloralphenazone/1
acetaminophen
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
2
2
1
2
1
1
1
1
2
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
ANUSOL-HC SUPP
2
1
hemril-30
1
hydrocortisone acetate supp
hydrocortisone acetate/pramoxine 1
PROCTOCORT SUPP
2
MO
MO
MO
MO
MO
MO
Miscellaneous Ophthalmologics
LATISSE
Miscellaneous Agents
BREVITAL SODIUM INJ
2
2.5GM, 500MG
1
chromium picolinate caps
chromium picolinate tabs 200mcg1
FERRLECIT
2
1
finasteride tabs 1mg
PROPECIA
2
sodium ferric gluconate complex/ 1
sucrose
ZINC SULFATE
2
HEPTAHYDRATE
2
1
2
2
2
2
1
1
2
1
1
1
2
Miscellaneous Gastrointestinal Agents
Migraine & Cluster Headache Therapy
Effective January 1, 2014
Requirements/
Limits
Miscellaneous Dermatologicals
Keratolytics
aliclen
SALEX
SALEX CREAM
salicylic acid cream
salicylic acid foam
salicylic acid liqd
salicylic acid sham
salvax
Drug
Tier
Drug Name
2
MO
Miscellaneous Otic Preparations
aero otic hc
cortane-b-otic
oto-end 10
MO
1
1
1
MO
MO
MO
MO
Miscellaneous Urologicals
MO
EDEX
CAVERJECT
2
CAVERJECT IMPULSE
2
CIALIS TABS 10MG, 20MG 3
80
2
MO
MO
MO
MO
MO
QLL(6 per 30
days) MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
Requirements/
Limits
LEVITRA
3
MUSE
STAXYN
2
3
VIAGRA
3
QLL(6 per 30
days) MO
MO
QLL(6 per 30
days) MO
QLL(6 per 30
days) MO
Miscellaneous Vitamins, Hematinics, &
Electrolytes
ap-zel
bioflex
biotect plus liqd
DIVISTA
ear health formula
FLEXGEN
l-methyl-mc nac
lipoflavovit
metafolbic plus
niacin flush free caps 100mg;
400mg, 500mg
NO FLUSH NIACIN CAPS
phlexy-vits
PROTECT PLUS LIQD
risanoid plus
tri-zel
VASOFLEX FORTE
VASOFLEX HD
VASOFLEX TABS
vp-zel
1
1
1
2
1
2
1
1
1
1
MO
2
1
2
1
1
2
2
2
1
MO
1
MO
2
2
2
1
1
1
1
1
1
1
2
1
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Nitrates
nitro-time
Therapy For Acne
AVAGE
BENZAC AC WASH
BENZAC W WASH
benzoyl peroxide wash
bp 10-1
bp wash liqd 10%
cerisa wash
desquam-x wash
panoxyl wash
refissa
RENOVA
tretinoin emollient
Comprehensive_P3TARO_10R
Drug
Tier
Requirements/
Limits
2
1
MO
MO
2
MO
1
MO
1
a thru z advanced
1
a thru z select advanced
1
a thru z select tabs
1
acerola c-500
1
advanced am/pm
1
airavite
AKEDAMINS
2
ALBAFORT INJ 50MCG/ML;2
67MG/ML; 10MCG/ML
1
antioxidant vitamins
APATATE
2
1
apatate forte
APETEX
2
APETIGEN
2
1
apetigen-plus oral soln
APETIGEN-PLUS TABS
2
AQUADEKS CHEW
2
AQUASOL A PARENTERAL 2
1
aquasol e
AQUAVIT-E
2
AQUEOUS VITAMIN E
2
ASCORBIC ACID GRAN
2
1
ascorbic acid inj
ASCORBIC ACID POWD
2
ascorbic acid tabs 250mg, 500mg 1
1
b complete
b complex caps 5mg; 1mcg; 60mg;1
20mg; 0.5mg; 3mg; 3mg; 60mg
1
b complex tabs
1
b complex with vitamin c
b complex/c tabs 300mg; 50mg; 1
10mg; 5mg; 10.2mg; 15mg
1
b-100 tabs
B-12 MICROLOZENGE
2
b-12 subl 1000mcg, 2500mcg 1
1
b-12 tabs 500mcg
1
b-2 tabs 50mg
1
b-6 tabs 100mg
MO
MO
MO
Drug Name
Topical Antibacterials
ALOQUIN
hydrocortisone/iodoquinol
Topical Enzymes
XENADERM
Urinary Anesthetics
urelief plus
Vitamins & Hematinics
81
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
b-complex caps 5mg; 1mcg; 60mg;1
20mg; 0.5mg; 3mg; 3mg; 60mg
1
b-complex formula 1
1
b-complex inj
1
b-complex plus vitamin c
b-complex tabs 6mcg; 400mcg; 1
20mg; 2mg; 1.7mg; 1.5mg
1
b-complex w/c tabs
1
b-complex with b-12
1
b-plex plus
1
b1 high potency
1
b2
1
balance b-100
1
balance b-50
BALANCED B COMPLEX TR2
1
balanced b-100 tabs
1
balanced b-50 complex tabs
1
balanced b-50 tabs
1
bee zee
1
beta carotene caps 25000unit
BIFERA
2
BIFERARX
2
1
biocel
1
biosupp
1
biotin caps 5mg
1
biotin tabs 1000mcg
BIOTIN TABS 10MG
2
1
biotin tabs 300mcg
1
biovol
1
bronto-vites
1
c 250 tabs
1
c 500 tabs
c 500/rose hips tabs 500mg; 37mg1
1
c complex
1
calcet plus
1
calcidol
1
calciferol
1
calcium ascorbate
CARDIOTEK-RX
2
1
cemill
1
cemill sr
1
centamin
1
centavite a-z complete
multivitamin/minerals
1
centratex
1
centravites
Effective January 1, 2014
Requirements/
Limits
MO
Drug Name
Drug
Tier
1
centravites 50 plus
CENTRUM CHEW
2
1
centrum liqd
CENTRUM SILVER CHEW 2
1
centrum silver ultra womens
CENTRUM ULTRA MENS 2
1
century
1
century senior
1
century/lutein
1
cerovite advanced formula
1
cerovite jr
1
cerovite senior
1
certa-vite/lutein
1
certavite senior/antioxidant
nutrients
1
certavite/antioxidants
chewable vitamin c chew 500mg 1
cod liver oil caps 0; 1250unit; 1
130unit, 1250unit; 130unit,
1250unit; 133.33unit, 1250unit;
133unit, 4000unit; 200unit
cod liver oil oil 0; 4000unit/5ml; 1
400unit/5ml, 5000unit/5ml;
500unit/5ml
1
companion
1
compete
1
complete
1
complete senior
1
corvita
1
corvita 150
CORVITE
2
CORVITE FE
2
1
cranberry urinary comfort
CYANOCOBALAMIN CRYS 2
1
daily combo multi vitamin
1
daily multi
daily multiple vitamin tabs 60mg;1
5000unit; 6mcg; 400unit; 0.4mg;
20mg; 10mg; 2mg; 1.7mg; 1.5mg;
30unit
1
daily multiple vitamins
1
daily value multivitamin
1
daily vitamin
1
daily vitamins
1
daily vite
1
delta d3
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
82
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
1
dexferrum
1
dialyvite
DIALYVITE 3000
2
DIALYVITE 5000
2
1
dialyvite 800
DIALYVITE 800/IRON
2
DIALYVITE 800/ZINC
2
DIALYVITE SUPREME D
2
1
dialyvite/zinc
DIATX ZN
2
1
dino-life w/iron & zinc
DRISDOL ORAL SOLN
2
1
duofer
E-OIL OIL 100UNT/0.25ML 2
ED CYTE F
2
1
eldertonic
1
eql beta carotene
1
eql one daily womens
1
eql vitamin c tabs 500mg
1
ergocalciferol
1
essentia
ESTER-C TABS 500MG;
2
55MG; 200MG
1
ezfe 200
1
fabb
FEOSOL BIFERA
2
1
feosol tabs 200mg, 65mg
1
fer-iron
FERAHEME
2
1
ferocon
1
ferotrinsic
FERRALET 90
2
1
ferretts
FERRETTS IPS
2
1
ferrex 150
1
ferrex 150 forte
1
ferrex 150 forte plus
1
ferrex 150 plus
1
ferrocite
1
ferrocite plus
1
ferrogels forte
1
ferrous drops
1
ferrous fumarate 324
FERROUS FUMARATE TABS2
90MG
Comprehensive_P3TARO_10R
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
ferrous gluconate tabs 240mg, 1
324mg, 325mg
1
ferrous sulfate elix
FERROUS SULFATE
2
HEPTAHYDRATE
1
ferrous sulfate liqd
1
ferrous sulfate oral soln
1
ferrous sulfate syrp
1
ferrous sulfate tabs 134mg
1
ferrous sulfate tabs 325mg
1
ferrous sulfate tbec 325mg
1
ferrousul
1
ferus
1
folastin
1
folbee
FOLBEE AR
2
1
folbee plus cz
1
folbic
1
folcaps
FOLGARD OS
2
FOLGARD RX
2
1
folic acid inj
FOLIC ACID POWD
2
1
folic acid tabs
1
folic acid xtra
folic acid/vitamin b-6/vitamin b- 1
12
1
folitab 500
1
folivane-f
1
folivane-plus
1
folplex 2.2
1
foltabs 800
1
foltanx
1
foltanx rf
FOLTRATE
2
1
foltrin
1
fosfree
1
fruit c 500
fruity chewables multivitamin 1
1
fruity chews/iron
1
full spectrum b/vitamin c
1
geravim
1
geri-tonic
1
geriaton
GERITOL COMPLETE
2
GERITOL TONIC
2
83
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
gnp vitamin a caps 8000unit
golden age vitamin/minerals
healthy eyes
hematinic/folic acid
hematogen
hematogen fa
hematogen forte
HEMATRON
HEMATRON-AF
HEMAX
hemetab
high potency multivitamin/
multimineral with iron
hydroxocobalamin
i-vite
i-vite protect
I.L.X. B-12
ICAPS LUTEIN &
ZEAXANTHIN
icaps plus
ICAR PEDIATRIC
iferex 150
iferex 150 forte
infed
INFUVITE
INFUVITE PEDIATRIC
INTEGRA
INTEGRA F
INTEGRA PLUS
IROMIN-G
iron 100/c
iron chews pediatric
iron supplement childrens
iron tabs 28mg
IROSPAN 24/6
kobee
l-methyl-b6-b12
l-methyl-mc
l-methylfolate ca/p-5-p/me-cbl
lysiplex plus liqd
m.v.i. adult
M.V.I. PEDIATRIC
M.V.I.-12 WITHOUT
VITAMIN K
macuvite
macuvite eye care
Effective January 1, 2014
Drug
Tier
1
1
1
1
1
1
1
2
2
2
1
1
Requirements/
Limits
MO
MO
MO
MO
MO
MO
1
2
1
1
1
2
2
2
2
2
2
1
1
1
1
2
1
1
1
1
1
1
2
2
MO
MO
MO
MO
MO
Drug
Tier
mega multiple w/chelated minerals1
1
meijer c
MERIBIN
2
1
metafolbic
METANX
2
1
milltrium senior
MONSELS FERRIC
2
SUBSULFATE
1
multi complete/iron
1
multi-day
1
multi-day plus iron
MULTI-DELYN/IRON
2
1
multi-vitamin
1
multi-vitamin/minerals
1
multi-vitamins
1
multigen
1
multigen folic
1
multilex
1
multilex-t&m
1
multiple vitamins plain
1
multiple vitamins tabs 50mg;
1mcg; 20mg; 1mg; 1mg; 2.5mg;
2mg; 5000unit; 400unit
1
multiple vitamins/iron chew
1
multivitamin & mineral
1
myferon 150
MYKIDZ IRON
2
MYKIDZ IRON 10
2
1
mynephrocaps
1
nail-ex
NASCOBAL
2
1
natalvirt flt
1
nephplex rx
1
nephro-vite rx
NEPHRON FA
2
NEPHRONEX LIQD
2
NERVO B-12 SL
2
NEURIN-SL
2
no iron multiple vitamin/minerals1
NUTRIVIT
2
1
ocutabs
1
ocutabs/lutein
OCUVITE
2
1
omnicap
1
once daily/iron
1
one daily
MO
MO
MO
MO
MO
1
1
1
2
2
Drug Name
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
1
1
84
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Comprehensive_P3TARO_10R
Drug Name
Drug
Tier
1
one daily adults 50+
ONE DAILY FOR WOMEN 2
1
one daily maximum
1
one daily mens
1
one daily/calcium/iron/zinc
1
one daily/iron/calcium
1
one daily/minerals
1
one-a-day essential
ONE-A-DAY WOMENS
2
FORMULA
1
one-daily multi vitamins
1
optivite p.m.t.
1
pa b-complex with b-12
PERIDIN-C
2
1
poly-iron 150
1
poly-iron 150 forte
1
poly-vitamin drops
1
poly-vitamin/iron drops
1
polysaccharide iron
1
polysaccharide iron forte
1
polyvitamin
1
polyvitamin/iron
1
poten b-150 tr
PROFE
2
PROFERRIN ES
2
PROFERRIN-FORTE
2
1
prosight
PROTECTIRON
2
1
purevit dualfe plus
1
pyridoxine hcl inj
pyridoxine hcl tabs 100mg, 25mg 1
1
ra b-complex/vitamin c tr
1
rena-vite
1
rena-vite rx
1
renal caps
1
renalpren
RENATABS
2
RENATABS WITH IRON
2
RENAX
2
1
reno caps
SCOOBY-DOO ONE A DAY 2
SLOW FE TBCR 142MG
2
1
slow release iron tbcr 160mg
SLOW RELEASE IRON TBCR2
47.5MG
SODIUM ASCORBATE
2
Comprehensive_P3TARO_10R
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Drug Name
Drug
Tier
SOURCECF CHEW
2
1
stress formula w/iron
STROVITE FORTE SYRP
2
1
strovite plus
1
sunvite advanced
1
super b with c
1
super quints b-50
1
super thera vite m
1
superplex-t
SUPERVITE
2
SUPERVITE EC
2
1
support
SYNAGEX
2
1
tab-a-vite womens
1
tab-a-vite/iron
TANDEM
2
TANDEM F
2
TANDEM PLUS
2
1
taron forte
TH B COMPLEX/IRON/
2
VITAMIN C/VITAMIN E
1
th vision vitamins/lutein
1
th vitamin b1
TH WOMENS DAILY
2
1
thera m plus
1
thera-m
1
thera-plus
1
thera-tabs
1
thera-tabs m
1
thera/beta-carotene
1
therapeutic
therapeutic formula/hematinics 1
1
therapeutic m
THERAPEUTIC-M/LUTEIN 2
1
theratrum complete
1
therems
1
therems-m
1
thiamine hcl inj
THIAMINE HCL POWD
2
1
thiamine hcl tabs
1
tl g-fol os
1
tl icon
1
tl-fol 500
1
tl-hem 150
1
total b/c
1
tri-vita
85
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Effective January 1, 2014
Drug Name
Drug
Tier
1
tri-vitamin
1
tricon
1
trigels-f forte
1
triphrocaps
TROMBONEX
2
1
unicomplex-m
1
v-r beta carotene
1
v-r super b complex/c
VENOFER
2
1
virt-vite
1
virt-vite forte
1
vit c
1
vit c/rose hips
1
vita s forte
1
vita-bee/c
1
vitacel
VITAFOL
2
VITAL-D RX
2
1
vitalee
1
vitamin a caps 10000unit
1
vitamin a caps 8000unit
1
vitamin a/beta carotene caps
vitamin b complex tabs 10mg; 1
10mg; 0.2mg; 2mg; 1.5mg
1
vitamin b complex-c
vitamin b-1 tabs 100mg, 250mg,1
50mg
1
vitamin b-12 natural
1
vitamin b-12 subl 1000mcg
1
vitamin b-12 tabs
vitamin b-12 tr tbcr 2000mcg 1
1
vitamin b-2
vitamin b-6 tabs 100mg, 25mg 1
1
vitamin b-complex 100
1
vitamin b1
1
vitamin b12
1
vitamin c chew 500mg
1
vitamin c cr tbcr
1
vitamin c sr
1
vitamin c syrp
vitamin c tabs 1000mg, 250mg, 1
500mg
1
vitamin c tabs 100mg
VITAMIN C TR CPCR
2
1
vitamin c tr tbcr 500mg
Effective January 1, 2014
Requirements/
Limits
Drug Name
Drug
Tier
vitamin c/rose hips tabs 1000mg, 1
1000mg; 0, 500mg, 500mg; 0
1
vitamin d caps 50000unit
1
vitamin d tabs 400unit
1
vitamin e caps 100unit
VITAMIN E OIL
2
1
vitamins & minerals
1
vitatrum
1
vitatrum complete
1
vitrum senior
1
vol-care rx
1
wee care
womens daily formula/folic acid/ 1
calcium/iron
1
womens one daily
1
yelets teenage formula
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
Requirements/
Limits
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
86
Comprehensive_P3TARO_10R
Index:
Legend
Generic drugs are shown in lowercase italics (e.g. enalapril)
Brand name drugs are shown in capital letters (e.g. HUMALOG)
8-MOP.............................................................................38
a thru z advanced..............................................................81
a thru z select advanced......................................................81
a thru z select tabs..............................................................81
a-hydrocort..........................................................................8
a-methapred........................................................................8
abacavir............................................................................21
ABELCET.......................................................................13
ABILIFY DISCMELT TBDP 10MG...............................55
ABILIFY DISCMELT TBDP 15MG...............................55
ABILIFY INJ...................................................................55
ABILIFY MAINTENA....................................................55
ABILIFY ORAL SOLN...................................................55
ABILIFY TABS 10MG.....................................................55
ABILIFY TABS 15MG.....................................................55
ABILIFY TABS 20MG.....................................................55
ABILIFY TABS 2MG.......................................................55
ABILIFY TABS 30MG.....................................................55
ABILIFY TABS 5MG.......................................................55
ABRAXANE....................................................................18
ABSORICA.....................................................................67
ABSTRAL SUBL 100MCG.............................................45
ABSTRAL SUBL 200MCG, 300MCG, 400MCG,
600MCG, 800MCG.....................................................45
ACANYA.........................................................................67
acarbose tabs 100mg..........................................................26
acarbose tabs 25mg............................................................26
acarbose tabs 50mg............................................................26
ACCOLATE....................................................................64
ACCUNEB......................................................................64
ACCUPRIL.....................................................................14
ACCURETIC..................................................................14
acebutolol hcl.....................................................................14
ACEON...........................................................................14
acerola c-500.....................................................................81
ACETADOTE.................................................................13
acetaminophen/caffeine/dihydrocodeine bitartrate................45
acetaminophen/codeine #2..................................................45
acetaminophen/codeine #3..................................................45
acetaminophen/codeine #4..................................................45
acetaminophen/codeine oral soln.........................................45
acetaminophen/codeine phosphate.......................................45
acetaminophen/codeine tabs................................................45
acetasol hc.........................................................................42
acetazolamide....................................................................53
acetazolamide er................................................................53
acetazolamide sodium........................................................53
acetic acid 0.25%..............................................................34
acetic acid otic soln............................................................42
acetic acid/aluminum acetate..............................................42
acetylcysteine inhalation soln..............................................64
acetylcysteine inj................................................................13
ACIPHEX........................................................................72
acitretin............................................................................21
ACLARO.........................................................................80
ACLOVATE....................................................................70
ACTEMRA......................................................................54
ACTHAR HP....................................................................8
ACTHIB..........................................................................73
ACTHREL......................................................................40
acticin...............................................................................72
ACTIGALL.....................................................................38
ACTIMMUNE................................................................23
ACTIQ............................................................................45
ACTIVELLA...................................................................31
ACTONEL TABS 150MG..............................................53
ACTONEL TABS 30MG................................................34
ACTONEL TABS 35MG................................................53
ACTONEL TABS 5MG..................................................53
ACTOPLUS MET...........................................................26
ACTOPLUS MET XR TB24 1000MG; 15MG..............26
ACTOPLUS MET XR TB24 1000MG; 30MG..............26
ACTOS TABS 15MG......................................................26
ACTOS TABS 30MG......................................................26
ACTOS TABS 45MG......................................................26
ACULAR.........................................................................51
ACULAR LS....................................................................51
ACUVAIL........................................................................51
acyclovir caps.....................................................................21
acyclovir oint.....................................................................70
Comprehensive_P3TARO_10R
87
Effective January 1, 2014
acyclovir sodium inj 1000mg, 50mg/ml..............................21
acyclovir sodium inj 500mg................................................21
acyclovir susp.....................................................................21
acyclovir tabs.....................................................................21
ACZONE........................................................................67
ADACEL.........................................................................73
ADAGEN........................................................................34
ADALAT CC...................................................................14
adapalene crea...................................................................67
adapalene gel.....................................................................67
ADCETRIS.....................................................................18
ADCIRCA.......................................................................64
ADDERALL TABS 1.25MG; 1.25MG; 1.25MG;
1.25MG, 1.875MG; 1.875MG; 1.875MG; 1.875MG,
2.5MG; 2.5MG; 2.5MG; 2.5MG, 3.125MG;
3.125MG; 3.125MG; 3.125MG, 3.75MG; 3.75MG;
3.75MG; 3.75MG, 5MG; 5MG; 5MG; 5MG..............55
ADDERALL TABS 7.5MG; 7.5MG; 7.5MG;
7.5MG..........................................................................55
ADDERALL XR..............................................................55
ADOXA CAPS................................................................67
ADOXA PAK 1/100........................................................67
ADOXA PAK 1/150........................................................67
ADOXA PAK 2/100........................................................67
ADOXA TABS 100MG, 50MG......................................67
ADOXA TABS 75MG.....................................................67
ADRENACLICK.............................................................14
adrenalin inj.....................................................................14
ADRENALIN NASAL SOLN.........................................64
adriamycin inj 10mg, 20mg, 50mg....................................18
adriamycin inj 2mg/ml......................................................18
adrucil..............................................................................18
ADVAIR DISKUS...........................................................64
ADVAIR HFA.................................................................64
advanced am/pm...............................................................81
ADVICOR TB24 20MG; 1000MG, 20MG;
750MG.........................................................................32
ADVICOR TB24 20MG; 500MG, 40MG;
1000MG.......................................................................32
aero otic hc........................................................................80
afeditab cr.........................................................................14
AFINITOR......................................................................18
AFINITOR DISPERZ.....................................................18
AGGRASTAT..................................................................25
AGGRENOX..................................................................25
AGRYLIN........................................................................34
Effective January 1, 2014
88
airavite.............................................................................81
ak-poly-bac..........................................................................9
AKEDAMINS.................................................................81
AKNE-MYCIN...............................................................67
akorn balanced salt solution...............................................42
AKTEN...........................................................................42
ala cort.............................................................................70
ALA SCALP.....................................................................70
alagesic lq..........................................................................45
ALAHIST DM................................................................77
ALBAFORT INJ 50MCG/ML; 67MG/ML; 10MCG/
ML................................................................................81
albatussin nn.....................................................................77
ALBENZA.......................................................................36
ALBUKED 25.................................................................24
ALBUKED 5...................................................................24
albumin human inj 25%...................................................24
albuminar-25...................................................................24
albuminar-5.....................................................................24
alburx...............................................................................24
albutein inj 25%...............................................................24
albutein inj 5%.................................................................24
albuterol sulfate er.............................................................64
albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/
3ml................................................................................64
albuterol sulfate nebu 0.5%...............................................64
albuterol sulfate syrp..........................................................64
albuterol sulfate tabs..........................................................64
ALCAINE........................................................................42
alclometasone dipropionate.................................................70
alcohol preps pads..............................................................26
ALDACTAZIDE.............................................................14
ALDACTONE................................................................14
ALDARA.........................................................................38
ALDURAZYME..............................................................40
alendronate sodium oral soln..............................................53
alendronate sodium tabs 10mg, 5mg...................................53
alendronate sodium tabs 35mg, 70mg.................................53
alendronate sodium tabs 40mg...........................................34
ALFENTA.......................................................................45
alfentanil..........................................................................45
ALFERON N..................................................................23
alfuzosin hcl er..................................................................23
aliclen...............................................................................80
ALIMTA..........................................................................18
ALINIA...........................................................................36
Comprehensive_P3TARO_10R
ALKA-SELTZER PLUS DAY COLD & FLU
FORMULA..................................................................77
ALKA-SELTZER PLUS SEVERE SINUS
CONGESTION & COUGH......................................77
ALKERAN INJ................................................................18
ALKERAN TABS............................................................18
allfen dm...........................................................................77
allopurinol........................................................................32
allopurinol sodium.............................................................32
ALOCRIL........................................................................42
ALOMIDE......................................................................42
aloprim.............................................................................32
ALOQUIN......................................................................81
ALORA............................................................................31
ALOXI.............................................................................38
ALPHAGAN P OPHTHALMIC SOLN 0.1%...............67
ALPHAGAN P OPHTHALMIC SOLN 0.15%.............67
alphaquin hp.....................................................................80
alprazolam........................................................................55
alprazolam er....................................................................55
alprazolam intensol............................................................55
alprazolam odt..................................................................55
alprazolam xr....................................................................55
alprostadil.........................................................................42
ALREX............................................................................66
ALSUMA.........................................................................33
ALTABAX........................................................................70
ALTACE..........................................................................14
altafrin.............................................................................74
altarussin dm....................................................................77
altavera.............................................................................51
ALTOPREV.....................................................................32
ALVESCO AERS 160MCG/ACT...................................64
ALVESCO AERS 80MCG/ACT.....................................64
alyacen 1/35......................................................................51
alyacen 7/7/7.....................................................................51
amantadine hcl caps...........................................................21
amantadine hcl syrp...........................................................21
amantadine hcl tabs...........................................................21
AMARYL TABS 1MG.....................................................26
AMARYL TABS 2MG.....................................................26
AMARYL TABS 4MG.....................................................26
AMBIEN.........................................................................55
AMBIEN CR...................................................................55
AMBISOME...................................................................13
amcinonide.......................................................................70
AMERGE........................................................................33
amethia.............................................................................51
amethia lo.........................................................................51
amethyst............................................................................51
AMICAR.........................................................................25
amifostine...........................................................................8
amikacin sulfate................................................................36
amiloride hcl.....................................................................14
amiloride/hydrochlorothiazide............................................14
amino acids.......................................................................43
aminoacetic acid................................................................42
aminocaproic acid inj........................................................25
aminocaproic acid syrp.......................................................25
AMINOCAPROIC ACID TABS 1000MG.....................25
aminocaproic acid tabs 500mg...........................................25
aminophylline...................................................................64
AMINOSYN 7%/ELECTROLYTES..............................43
AMINOSYN 8.5%/ELECTROLYTES...........................43
AMINOSYN II................................................................43
AMINOSYN II 5/DEXTROSE 25..................................43
AMINOSYN II 8.5%/ELECTROLYTES........................43
AMINOSYN INJ 148MEQ/L; 1280MG/100ML;
980MG/100ML; 1280MG/100ML; 300MG/100ML;
720MG/100ML; 940MG/100ML; 720MG/100ML;
400MG/100ML; 440MG/100ML; 5.4MEQ/L;
860MG/100ML; 420MG/100ML; 520MG/100ML;
160MG/100ML; 44MG/100ML; 800MG/100ML,
90MEQ/L; 1100MG/100ML; 850MG/100ML;
35MEQ/L; 1100MG/100ML; 260MG/100ML;
620MG/100ML; 810MG/100ML; 624MG/100ML;
340MG/100ML; 380MG/100ML; 5.4MEQ/L;
750MG/100ML; 370MG/100ML; 460MG/100ML;
150MG/100ML; 44MG/100ML; 680MG/100ML......43
AMINOSYN INJ 50.3MEQ/L; 695MG/100ML;
713MG/100ML; 490MG/100ML; 517MG/100ML;
350MG/100ML; 210MG/100ML; 462MG/100ML;
700MG/100ML; 735MG/100ML; 120MG/100ML;
209MG/100ML; 505MG/100ML; 371MG/100ML;
31.3MEQ/L; 280MG/100ML; 140MG/100ML;
189MG/100ML; 350MG/100ML, 51MEQ/L;
448MG/100ML; 343MG/100ML; 448MG/100ML;
105MG/100ML; 252MG/100ML; 329MG/100ML;
252MG/100ML; 140MG/100ML; 154MG/100ML;
300MG/100ML; 147MG/100ML; 182MG/100ML;
56MG/100ML; 31MG/100ML; 280MG/100ML........43
AMINOSYN M...............................................................43
Comprehensive_P3TARO_10R
89
Effective January 1, 2014
AMINOSYN-HBC..........................................................43
AMINOSYN-PF..............................................................43
AMINOSYN-PF 7%.......................................................43
AMINOSYN-RF.............................................................43
amiodarone hcl inj...............................................................9
amiodarone hcl tabs 200mg, 400mg.....................................9
AMITIZA........................................................................38
amitriptyline hcl................................................................55
amlodipine besylate tabs 10mg, 2.5mg................................14
amlodipine besylate tabs 5mg..............................................14
amlodipine besylate/atorvastatin calcium.............................32
amlodipine besylate/benazepril hcl......................................14
amlodipine besylate/benazepril hydrochloride.......................14
AMMONIUM CHLORIDE...........................................42
ammonium lactate.............................................................38
AMMONUL...................................................................34
amnesteem.........................................................................67
amoxapine........................................................................55
amoxicillin........................................................................54
amoxicillin/clavulanate potassium.......................................54
amoxicillin/clavulanate potassium er...................................54
amoxicillin/potassium clavulanate.......................................54
amphetamine/dextroamphetamine cp24..............................55
amphetamine/dextroamphetamine tabs 1.25mg; 1.25mg;
1.25mg; 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg,
2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg;
3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg,
5mg; 5mg; 5mg; 5mg......................................................55
amphetamine/dextroamphetamine tabs 7.5mg; 7.5mg;
7.5mg; 7.5mg.................................................................56
AMPHOTEC INJ 100MG..............................................13
AMPHOTEC INJ 50MG................................................13
amphotericin b..................................................................13
ampicillin.........................................................................54
ampicillin sodium inj 10gm, 125mg, 250mg, 2gm..............54
ampicillin sodium inj 1gm, 500mg.....................................54
ampicillin-sulbactam inj 10gm; 5gm, 1gm; 0.5gm..............54
ampicillin-sulbactam inj 2gm; 1gm....................................54
AMPYRA.........................................................................41
AMRIX............................................................................45
AMTURNIDE................................................................14
AMYTAL SODIUM........................................................56
ANADROL-50................................................................40
ANAFRANIL..................................................................56
anagrelide hydrochloride.....................................................34
ANAPROX......................................................................50
Effective January 1, 2014
90
ANAPROX DS................................................................50
anastrozole........................................................................18
ANCOBON....................................................................13
ANDRODERM..............................................................40
ANDROGEL GEL 20.25MG/1.25GM..........................40
ANDROGEL GEL 25MG/2.5GM, 50MG/5GM...........40
ANDROGEL GEL 40.5MG/2.5GM..............................40
ANDROGEL PUMP GEL 1%........................................40
ANDROGEL PUMP GEL 1.62%...................................40
ANDROID......................................................................40
androxy.............................................................................40
anectine............................................................................45
ANGELIQ.......................................................................31
ANGIOMAX...................................................................25
ANTABUSE....................................................................34
ANTARA.........................................................................32
antioxidant vitamins.........................................................81
antipyrine/benzocaine otic soln 5.4%; 1.4%, 54mg/ml;
14mg/ml........................................................................42
ANTIVERT.....................................................................38
ANTIZOL.......................................................................73
ANUSOL-HC CREA......................................................38
ANUSOL-HC SUPP.......................................................80
ANZEMET INJ..............................................................38
ANZEMET TABS...........................................................38
ap-zel................................................................................81
APATATE........................................................................81
apatate forte......................................................................81
APETEX..........................................................................81
APETIGEN.....................................................................81
apetigen-plus oral soln........................................................81
APETIGEN-PLUS TABS................................................81
APEXICON.....................................................................70
apexicon e.........................................................................70
APIDRA..........................................................................26
APIDRA SOLOSTAR.....................................................26
APLENZIN TB24 174MG..............................................56
APLENZIN TB24 348MG..............................................56
APLENZIN TB24 522MG..............................................56
APOKYN.........................................................................20
apraclonidine....................................................................67
apri..................................................................................51
APRISO...........................................................................38
APTIVUS CAPS..............................................................21
APTIVUS ORAL SOLN.................................................21
AQUADEKS CHEW......................................................81
Comprehensive_P3TARO_10R
AQUASOL A PARENTERAL.........................................81
aquasol e...........................................................................81
AQUAVIT-E....................................................................81
AQUEOUS VITAMIN E................................................81
ARALAST NP INJ 1000MG, 800MG............................34
ARALAST NP INJ 400MG, 500MG..............................34
ARALEN.........................................................................36
aranelle.............................................................................51
ARANESP ALBUMIN FREE..........................................23
ARAVA............................................................................54
arbinoxa...........................................................................14
ARCALYST.....................................................................23
ARCAPTA NEOHALER.................................................64
ARESTIN........................................................................34
ARGATROBAN INJ 100MG/ML..................................25
ARGATROBAN INJ 125MG/125ML; 0.9%, 50MG/
50ML............................................................................25
ARICEPT ODT..............................................................41
ARICEPT TABS 10MG, 5MG........................................41
ARICEPT TABS 23MG..................................................41
ARIMIDEX.....................................................................18
ARISTOSPAN INTRA-ARTICULAR..............................8
ARISTOSPAN INTRALESIONAL...................................8
ARIXTRA INJ 10MG/0.8ML, 5MG/0.4ML, 7.5MG/
0.6ML...........................................................................25
ARIXTRA INJ 2.5MG/0.5ML........................................25
ARMOUR THYROID....................................................68
AROMASIN....................................................................18
ARRANON.....................................................................18
ARTHROTEC 50...........................................................50
ARTHROTEC 75...........................................................50
ARZERRA.......................................................................18
ASACOL.........................................................................38
ASACOL HD..................................................................38
ASCLERA........................................................................34
ascomp/codeine..................................................................45
ASCORBIC ACID GRAN..............................................81
ascorbic acid inj.................................................................81
ASCORBIC ACID POWD.............................................81
ascorbic acid tabs 250mg, 500mg.......................................81
ASMALPRED PLUS.........................................................8
ASMANEX 120 METERED DOSES.............................64
ASMANEX 14 METERED DOSES...............................64
ASMANEX 30 METERED DOSES AEPB 110MCG/
INH..............................................................................64
ASMANEX 30 METERED DOSES AEPB 220MCG/
INH..............................................................................64
ASMANEX 60 METERED DOSES...............................64
ASMANEX 7 METERED DOSES.................................64
aspirin-caffeine-dihydrocodeine...........................................45
ASTELIN........................................................................34
ASTEPRO.......................................................................34
ASTRAMORPH..............................................................45
ATACAND HCT TABS 16MG; 12.5MG.......................14
ATACAND HCT TABS 32MG; 12.5MG, 32MG;
25MG...........................................................................15
ATACAND TABS 16MG, 4MG, 8MG...........................15
ATACAND TABS 32MG................................................15
ATELVIA.........................................................................53
atenolol.............................................................................15
atenolol/chlorthalidone.......................................................15
ATGAM...........................................................................73
ATIVAN INJ...................................................................56
ATIVAN TABS................................................................56
atorvastatin calcium..........................................................32
atovaquone/proguanil hcl...................................................36
ATRALIN........................................................................67
ATRIPLA.........................................................................21
ATROPEN INJ 0.5MG/0.7ML, 1MG/0.7ML, 2MG/
0.7ML...........................................................................13
atropine sulfate inj 0.05mg/ml, 0.1mg/ml, 0.8mg/ml...........13
atropine sulfate inj 0.4mg/ml, 1mg/ml................................13
atropine sulfate oint...........................................................26
atropine sulfate ophthalmic soln..........................................26
atropine-care.....................................................................26
ATROVENT...................................................................34
ATROVENT HFA...........................................................64
AUBAGIO.......................................................................41
augmented betamethasone dipropionate...............................70
AUGMENTIN................................................................54
AUGMENTIN XR..........................................................54
aurodex.............................................................................42
AUVI-Q...........................................................................14
AVAGE............................................................................81
AVALIDE........................................................................15
AVANDAMET TABS 1000MG; 2MG, 1000MG; 4MG,
500MG; 4MG..............................................................26
AVANDAMET TABS 500MG; 2MG..............................26
AVANDARYL TABS 1MG; 4MG, 2MG; 4MG..............26
AVANDARYL TABS 2MG; 8MG, 4MG; 4MG, 4MG;
8MG.............................................................................26
Comprehensive_P3TARO_10R
91
Effective January 1, 2014
AVANDIA TABS 2MG....................................................26
AVANDIA TABS 4MG....................................................26
AVANDIA TABS 8MG....................................................26
AVAPRO..........................................................................15
avar cleanser......................................................................67
AVAR LS CLEANSER.....................................................67
AVAR-E EMOLLIENT...................................................67
AVAR-E GREEN.............................................................67
AVAR-E LS......................................................................67
AVASTIN........................................................................18
AVC.................................................................................42
AVELOX ABC PACK......................................................66
AVELOX INJ...................................................................66
AVELOX TABS...............................................................66
aviane...............................................................................51
avidoxy.............................................................................67
AVINZA CP24 120MG..................................................45
AVINZA CP24 30MG, 45MG, 60MG, 75MG,
90MG...........................................................................46
avita crea..........................................................................67
AVITA GEL.....................................................................68
AVITENE FLOUR..........................................................25
AVODART......................................................................23
AVONEX.........................................................................23
AVONEX PEN................................................................23
AXERT............................................................................33
AXID ORAL SOLN........................................................72
AXIRON.........................................................................40
AYGESTIN......................................................................31
AZACTAM......................................................................36
AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 1GM;
0....................................................................................36
AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 2GM;
0....................................................................................36
AZASAN.........................................................................18
AZASITE...........................................................................9
azathioprine......................................................................18
azathioprine sodium..........................................................18
azelastine hcl nasal soln......................................................34
azelastine hcl ophthalmic soln.............................................42
AZELEX..........................................................................68
AZILECT........................................................................20
AZITHROMYCIN INJ 2.5GM......................................30
azithromycin inj 500mg.....................................................30
azithromycin pack.............................................................30
azithromycin susr 100mg/5ml............................................30
Effective January 1, 2014
92
azithromycin susr 200mg/5ml............................................30
azithromycin tabs 250mg...................................................30
azithromycin tabs 500mg...................................................30
azithromycin tabs 600mg...................................................30
AZOPT............................................................................53
AZOR..............................................................................15
aztreonam.........................................................................36
AZULFIDINE.................................................................38
AZULFIDINE EN-TABS................................................38
azurette.............................................................................51
b complete.........................................................................81
b complex caps 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg; 3mg;
60mg.............................................................................81
b complex tabs...................................................................81
b complex with vitamin c...................................................81
b complex/c tabs 300mg; 50mg; 10mg; 5mg; 10.2mg;
15mg.............................................................................81
b-100 tabs.........................................................................81
B-12 MICROLOZENGE................................................81
b-12 subl 1000mcg, 2500mcg............................................81
b-12 tabs 500mcg..............................................................81
b-2 tabs 50mg...................................................................81
b-6 tabs 100mg.................................................................81
b-complex caps 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg; 3mg;
60mg.............................................................................82
b-complex formula 1..........................................................82
b-complex inj....................................................................82
b-complex plus vitamin c....................................................82
b-complex tabs 6mcg; 400mcg; 20mg; 2mg; 1.7mg;
1.5mg............................................................................82
b-complex w/c tabs.............................................................82
b-complex with b-12..........................................................82
B-NEXA..........................................................................74
b-plex plus.........................................................................82
b1 high potency.................................................................82
b2.....................................................................................82
baciim..............................................................................36
bacitracin............................................................................9
bacitracin..........................................................................36
bacitracin..........................................................................70
bacitracin/polymyxin b.........................................................9
baclofen............................................................................45
bactocill in dextrose............................................................54
BACTRIM.......................................................................67
BACTRIM DS.................................................................67
BACTROBAN.................................................................70
Comprehensive_P3TARO_10R
BACTROBAN NASAL...................................................34
bal-care dha......................................................................74
BAL-CARE DHA ESSENTIAL.......................................74
balance b-100...................................................................82
balance b-50.....................................................................82
BALANCED B COMPLEX TR......................................82
balanced b-100 tabs..........................................................82
balanced b-50 complex tabs................................................82
balanced b-50 tabs............................................................82
balsalazide disodium..........................................................38
balziva..............................................................................51
BANZEL SUSP...............................................................10
BANZEL TABS 200MG..................................................10
BANZEL TABS 400MG..................................................10
BARACLUDE.................................................................21
baycadron...........................................................................8
BCG VACCINE..............................................................73
BECONASE AQ.............................................................64
bee zee..............................................................................82
benazepril hcl....................................................................15
benazepril hcl/hydrochlorothiazide......................................15
BENLYSTA......................................................................54
BENTYL.........................................................................13
BENZAC AC WASH......................................................81
BENZAC W WASH........................................................81
BENZACLIN..................................................................68
BENZACLIN WITH PUMP..........................................68
BENZAMYCIN..............................................................68
BENZAMYCINPAK.......................................................68
benzonatate.......................................................................77
benzoyl peroxide wash........................................................81
benztropine mesylate inj.....................................................20
benztropine mesylate tabs...................................................20
BEPREVE........................................................................42
BERINERT.....................................................................64
BESIVANCE.....................................................................9
beta carotene caps 25000unit.............................................82
BETADINE OPHTHALMIC PREP.................................9
BETAGAN......................................................................23
betamethasone dipropionate................................................71
betamethasone sodium phosphate/betamethasone acetate.........8
betamethasone valerate.......................................................71
BETAPACE.......................................................................9
BETAPACE AF..................................................................9
BETASERON..................................................................23
betaxolol hcl......................................................................15
betaxolol hcl......................................................................23
bethanechol chloride...........................................................25
BETIMOL.......................................................................23
BETOPTIC-S..................................................................23
BEYAZ............................................................................51
BIAXIN...........................................................................30
BIAXIN XL.....................................................................30
BIAXIN XL PAC.............................................................30
bicalutamide.....................................................................18
BICILLIN C-R................................................................54
BICILLIN L-A.................................................................54
BICNU............................................................................18
BIDIL..............................................................................15
BIFERA...........................................................................82
BIFERARX......................................................................82
BILTRICIDE...................................................................36
BINOSTO.......................................................................53
biocel................................................................................82
biocotron...........................................................................77
bioflex...............................................................................81
bionel................................................................................77
BIOSPEC DMX..............................................................77
biosupp.............................................................................82
biotect plus liqd.................................................................81
BIOTHRAX....................................................................73
biotin caps 5mg.................................................................82
biotin tabs 1000mcg..........................................................82
BIOTIN TABS 10MG.....................................................82
biotin tabs 300mcg............................................................82
biotuss pediatric.................................................................77
biovol................................................................................82
bisoprolol fumarate............................................................15
bisoprolol fumarate/hydrochlorothiazide..............................15
BIVIGAM........................................................................73
bleomycin sulfate...............................................................18
BLEPH-10.......................................................................67
BLEPHAMIDE...............................................................66
BLEPHAMIDE S.O.P......................................................66
BONIVA INJ...................................................................53
BONIVA TABS...............................................................53
BOOSTRIX.....................................................................73
BOSULIF........................................................................18
BOTOX...........................................................................73
bp 10-1.............................................................................68
bp 10-1.............................................................................81
bp wash liqd 10%.............................................................81
Comprehensive_P3TARO_10R
93
Effective January 1, 2014
BREVICON-28...............................................................51
BREVITAL SODIUM INJ 2.5GM, 500MG...................80
briellyn.............................................................................51
BRILINTA.......................................................................25
brimonidine tartrate..........................................................67
brom/pse/dm......................................................................77
BROMDAY.....................................................................51
BROMFED DM.............................................................77
bromfenac.........................................................................51
bromocriptine mesylate.......................................................20
brompheniramine/phenylephrine/dm...................................77
broncotron.........................................................................77
bronto-vites.......................................................................82
BROVANA......................................................................64
BROVEX PEB DM.........................................................77
bss.....................................................................................42
BSS PLUS........................................................................42
budeprion sr tb12 100mg...................................................56
budeprion sr tb12 150mg...................................................56
budesonide cp24................................................................38
budesonide susp.................................................................64
bumetanide.......................................................................15
buminate inj 25%.............................................................24
buminate inj 5%...............................................................24
bupap tabs 650mg; 50mg...................................................46
BUPHENYL POWD.......................................................34
BUPHENYL TABS..........................................................34
bupivacaine hcl inj 0.25%.................................................69
bupivacaine hcl inj 0.5%...................................................69
bupivacaine hcl inj 0.75%.................................................69
bupivacaine spinal.............................................................34
bupivacaine/epinephrine inj 0.25%; 1:200000...................69
bupivacaine/epinephrine inj 0.5%; 1:200000.....................69
BUPRENEX....................................................................46
buprenorphine hcl inj.........................................................46
buprenorphine hcl subl 2mg...............................................46
buprenorphine hcl subl 8mg...............................................46
buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg.................50
buprenorphine hcl/naloxone hcl subl 8mg; 2mg....................50
buproban..........................................................................66
bupropion hcl er tb12 100mg.............................................56
bupropion hcl er tb12 150mg.............................................56
bupropion hcl er tb12 200mg.............................................56
bupropion hcl sr tb12 100mg.............................................56
bupropion hcl sr tb12 150mg.............................................56
bupropion hcl sr tb12 150mg.............................................66
Effective January 1, 2014
94
bupropion hcl sr tb12 200mg.............................................56
bupropion hcl tabs 100mg..................................................56
bupropion hcl tabs 75mg....................................................56
bupropion hcl xl tb24 150mg.............................................56
bupropion hcl xl tb24 300mg.............................................56
buspirone hcl.....................................................................56
BUSULFEX.....................................................................18
butal/asa/caff.....................................................................46
butalbital/acetaminophen...................................................46
butalbital/acetaminophen/caffeine.......................................46
butalbital/acetaminophen/caffeine/codeine...........................46
butalbital/asa/caffeine........................................................46
butalbital/aspirin/caffeine...................................................46
butalbital/aspirin/caffeine/codeine.......................................46
BUTISOL SODIUM ELIX.............................................56
BUTISOL SODIUM TABS 30MG.................................56
BUTISOL SODIUM TABS 50MG.................................56
butorphanol tartrate inj.....................................................50
butorphanol tartrate nasal soln...........................................50
BUTRANS......................................................................46
BYDUREON..................................................................26
BYETTA INJ 10MCG/0.04ML......................................26
BYETTA INJ 5MCG/0.02ML........................................26
BYSTOLIC......................................................................15
c 250 tabs.........................................................................82
c 500 tabs.........................................................................82
c 500/rose hips tabs 500mg; 37mg......................................82
c complex..........................................................................82
cabergoline........................................................................40
CADUET........................................................................32
CAFCIT..........................................................................34
CAFERGOT....................................................................33
caffeine citrate inj..............................................................34
caffeine citrate oral soln......................................................34
CALAN...........................................................................15
CALAN SR......................................................................15
calcet plus..........................................................................82
calcidol.............................................................................82
calciferol............................................................................82
calcipotriene crea...............................................................21
calcipotriene external soln...................................................21
calcipotriene oint...............................................................21
calcitonin-salmon..............................................................40
calcitrene...........................................................................21
calcitriol caps.....................................................................40
calcitriol inj.......................................................................40
Comprehensive_P3TARO_10R
calcitriol oint.....................................................................21
calcitriol oral soln..............................................................40
calcium acetate caps...........................................................29
calcium acetate tabs 667mg................................................29
calcium ascorbate...............................................................82
calcium chloride................................................................29
calcium citrate plus/magnesium..........................................79
calcium folinate...................................................................8
calcium/magnesium/zinc tabs 333mg; 133mg; 5mg.............79
CALDOLOR...................................................................50
CAMBIA.........................................................................50
camila...............................................................................31
CAMPRAL......................................................................34
CAMPTOSAR INJ 100MG/5ML, 40MG/2ML.............18
CAMPTOSAR INJ 300MG/15ML.................................18
camrese.............................................................................52
camrese lo..........................................................................52
CANASA.........................................................................38
CANCIDAS....................................................................13
candesartan cilexetil tabs 16mg, 4mg, 8mg..........................15
candesartan cilexetil tabs 32mg...........................................15
candesartan cilexetil/hydrochlorothiazide tabs 16mg;
12.5mg..........................................................................15
candesartan cilexetil/hydrochlorothiazide tabs 32mg; 12.5mg,
32mg; 25mg...................................................................15
CANTIL..........................................................................13
capacet..............................................................................46
CAPASTAT SULFATE....................................................36
CAPEX............................................................................71
CAPITAL/CODEINE.....................................................46
CAPRELSA.....................................................................18
captopril............................................................................15
captopril/hydrochlorothiazide..............................................15
CARAC...........................................................................38
carafate susp......................................................................72
CARAFATE TABS...........................................................72
CARBAGLU....................................................................34
carbamazepine..................................................................10
carbamazepine er...............................................................10
CARBATROL..................................................................10
carbidopa/levodopa............................................................20
carbidopa/levodopa cr........................................................20
carbidopa/levodopa er........................................................20
carbidopa/levodopa odt.......................................................20
carbidopa/levodopa sr.........................................................20
carbidopa/levodopa/entacapone...........................................20
carbinoxamine maleate......................................................14
CARBOCAINE INJ 1%, 2%..........................................69
carbocaine inj 1.5%..........................................................69
CARBOCAINE INJ 2%..................................................69
carboplatin........................................................................18
CARDENE I.V................................................................15
CARDENE SR................................................................15
CARDIOTEK-RX...........................................................82
CARDIZEM....................................................................15
CARDIZEM CD.............................................................15
CARDIZEM LA..............................................................15
CARDURA.....................................................................15
CARDURA XL................................................................15
CARIMUNE NANOFILTERED....................................73
carisoprodol.......................................................................45
carisoprodol/aspirin............................................................45
carisoprodol/aspirin/codeine................................................45
CARMOL-HC................................................................38
CARNITOR....................................................................34
CARNITOR SF...............................................................34
carteolol hcl.......................................................................23
cartia xt............................................................................15
carvedilol..........................................................................15
CASODEX......................................................................18
CATAFLAM....................................................................50
CATAPRES......................................................................15
CATAPRES-TTS-1..........................................................15
CATAPRES-TTS-2..........................................................15
CATAPRES-TTS-3..........................................................15
cavan-alpha kit.................................................................74
cavan-ec sod dha................................................................74
CAVERJECT...................................................................80
CAVERJECT IMPULSE.................................................80
CAVIRINSE....................................................................34
CAYSTON......................................................................36
caziant..............................................................................52
CEDAX CAPS.................................................................24
CEDAX SUSR 180MG/5ML..........................................24
CEDAX SUSR 90MG/5ML............................................24
CEENU...........................................................................18
cefaclor..............................................................................24
cefaclor er..........................................................................24
cefadroxil..........................................................................24
cefazolin sodium inj 100gm, 10gm, 1gm; 5%, 20gm, 300gm,
500mg...........................................................................24
cefazolin sodium inj 1gm...................................................24
Comprehensive_P3TARO_10R
95
Effective January 1, 2014
cefazolin sodium/dextrose inj 1gm; 4%...............................24
cefazolin sodium/dextrose inj 2gm; 3%................................24
cefdinir.............................................................................24
cefditoren pivoxil tabs 200mg.............................................24
cefditoren pivoxil tabs 400mg.............................................24
cefepime inj 1gm................................................................24
cefepime inj 1gm/50ml, 2gm, 2gm/100ml...........................24
cefotaxime sodium inj 10gm, 2gm......................................24
cefotaxime sodium inj 1gm, 500mg....................................24
cefotetan............................................................................24
cefoxitin sodium inj 10gm, 1gm; 4%, 2gm, 2gm; 2.2%.......24
cefoxitin sodium inj 1gm....................................................24
cefpodoxime proxetil...........................................................24
cefprozil............................................................................24
ceftazidime inj 1gm, 6gm...................................................24
ceftazidime inj 2gm...........................................................24
CEFTAZIDIME/DEXTROSE........................................24
CEFTIN..........................................................................24
ceftriaxone in iso-osmotic dextrose.......................................24
ceftriaxone sodium.............................................................24
ceftriaxone/dextrose............................................................24
cefuroxime axetil susr.........................................................24
cefuroxime axetil tabs.........................................................24
cefuroxime sodium inj 1.5gm, 750mg.................................24
cefuroxime sodium inj 7.5gm..............................................24
cefuroxime/dextrose............................................................24
CELEBREX.....................................................................50
CELESTONE....................................................................8
CELESTONE-SOLUSPAN...............................................8
CELEXA TABS 10MG....................................................56
CELEXA TABS 20MG....................................................56
CELEXA TABS 40MG....................................................56
CELLCEPT CAPS...........................................................18
CELLCEPT INTRAVENOUS........................................18
CELLCEPT SUSR...........................................................18
CELLCEPT TABS...........................................................18
CELONTIN....................................................................10
cemill................................................................................82
cemill sr............................................................................82
CENESTIN.....................................................................31
centamin...........................................................................82
CENTANY......................................................................70
CENTANY AT................................................................70
centavite a-z complete multivitamin/minerals......................82
centratex...........................................................................82
centravites.........................................................................82
Effective January 1, 2014
96
centravites 50 plus.............................................................82
CENTRUM CHEW.......................................................82
centrum liqd.....................................................................82
CENTRUM SILVER CHEW..........................................82
centrum silver ultra womens...............................................82
CENTRUM ULTRA MENS...........................................82
century..............................................................................82
century senior....................................................................82
century/lutein....................................................................82
cephalexin.........................................................................24
CEREZYME....................................................................40
cerisa wash........................................................................68
cerisa wash........................................................................81
cerovite advanced formula..................................................82
cerovite jr..........................................................................82
cerovite senior....................................................................82
certa-vite/lutein.................................................................82
certavite senior/antioxidant nutrients..................................82
certavite/antioxidants.........................................................82
cerubidine.........................................................................18
CERVARIX......................................................................73
CERVIDIL......................................................................42
CESAMET......................................................................39
cesia..................................................................................52
cetirizine hcl syrp...............................................................14
CETRAXAL....................................................................42
cevimeline hcl....................................................................34
CHANTIX......................................................................66
CHANTIX CONTINUING MONTH PAK..................66
CHANTIX STARTING MONTH PAK.........................66
chateal..............................................................................52
chelated zinc lozenges.........................................................79
CHEMET........................................................................34
CHENODAL..................................................................39
cheracol-d cough................................................................77
cheratussin ac....................................................................77
cheratussin dac..................................................................77
chest congestion relief plus dm.............................................77
chewable vitamin c chew 500mg........................................82
childrens ibuprofen susp 100mg/5ml...................................50
childrens mucus relief cough................................................77
chloramphenicol sodium succinate.......................................36
chlordiazepoxide hcl...........................................................56
chlordiazepoxide hcl/clidinium bromide..............................77
chlordiazepoxide/amitriptyline............................................56
chlorhexidine gluconate mouth/throat soln...........................34
Comprehensive_P3TARO_10R
chlorhexidine gluconate oral rinse........................................34
chloroprocaine hcl..............................................................69
chloroquine phosphate........................................................36
chlorothiazide....................................................................15
chlorothiazide sodium........................................................15
chlorpromazine hcl inj.......................................................56
chlorpromazine hcl tabs......................................................56
chlorpropamide..................................................................26
chlorthalidone tabs 25mg, 50mg.........................................15
chlorzoxazone....................................................................45
cholestyramine...................................................................32
cholestyramine light............................................................32
choline magnesium trisalicylate liqd....................................50
choline magnesium trisalicylate tabs....................................50
chorionic gonadotropin.......................................................40
chromium chloride.............................................................79
chromium picolinate caps...................................................80
chromium picolinate tabs 200mcg......................................80
CIALIS TABS 10MG, 20MG..........................................80
CIALIS TABS 2.5MG, 5MG...........................................42
ciclodan crea......................................................................70
CICLODAN CREAM KIT.............................................70
ciclodan external soln.........................................................70
CICLODAN SOLUTION KIT......................................70
ciclopirox...........................................................................70
ciclopirox nail lacquer........................................................70
ciclopirox olamine..............................................................70
ciclopirox topical solution kit..............................................70
ciclopirox treatment...........................................................70
cidofovir............................................................................21
cilostazol...........................................................................25
CILOXAN.........................................................................9
cimetidine.........................................................................72
cimetidine hcl inj...............................................................72
cimetidine hcl oral soln.......................................................72
CIMZIA..........................................................................39
CIMZIA STARTER KIT.................................................39
CINRYZE........................................................................64
CIPRO.............................................................................66
CIPRO HC......................................................................54
CIPRO I.V.-IN D5W......................................................66
CIPRO XR TB24 1000MG; 0.........................................66
CIPRO XR TB24 500MG; 0...........................................66
CIPRODEX.....................................................................54
ciprofloxacin er tb24 1000mg; 0........................................66
ciprofloxacin er tb24 500mg; 0..........................................66
ciprofloxacin hcl..................................................................9
ciprofloxacin hcl................................................................66
ciprofloxacin i.v.-in d5w....................................................66
ciprofloxacin inj 200mg/20ml............................................66
ciprofloxacin inj 400mg/40ml............................................66
ciprofloxacin otic soln.........................................................42
cisplatin............................................................................18
citalopram hydrobromide oral soln......................................56
citalopram hydrobromide tabs 10mg...................................56
citalopram hydrobromide tabs 20mg...................................56
citalopram hydrobromide tabs 40mg...................................56
CITRANATAL 90 DHA.................................................74
CITRANATAL DHA......................................................74
CITRANATAL HARMONY...........................................74
CITRANATAL RX..........................................................74
citric acid/sodium citrate....................................................42
cladribine..........................................................................18
CLAFORAN INJ 10GM, 1GM, 2GM............................24
CLAFORAN INJ 500MG...............................................24
claravis..............................................................................68
CLARIFOAM EF............................................................68
CLARINEX REDITABS.................................................14
CLARINEX SYRP...........................................................14
CLARINEX TABS...........................................................14
CLARINEX-D 12 HOUR...............................................26
CLARINEX-D 24 HOUR...............................................26
clarithromycin...................................................................30
clarithromycin er...............................................................31
clemastine fumarate syrp....................................................14
clemastine fumarate tabs 2.68mg........................................14
CLEOCIN.......................................................................36
CLEOCIN.......................................................................42
CLEOCIN IN D5W.......................................................36
CLEOCIN PEDIATRIC GRANULES............................36
CLEOCIN PHOSPHATE INJ 150MG/ML...................36
CLEOCIN PHOSPHATE INJ 300MG/2ML, 600MG/
4ML, 900MG/6ML, 9GM/60ML................................36
CLEOCIN-T...................................................................68
CLEVIPREX...................................................................15
CLIMARA.......................................................................31
CLIMARA PRO..............................................................31
CLINDACIN PAC..........................................................68
clindacin-p........................................................................68
CLINDAGEL..................................................................68
CLINDAMAX.................................................................68
clindamycin hcl.................................................................36
Comprehensive_P3TARO_10R
97
Effective January 1, 2014
clindamycin palmitate hcl..................................................36
clindamycin phosphate.......................................................36
clindamycin phosphate.......................................................42
clindamycin phosphate.......................................................68
clindamycin phosphate add-vantage....................................36
clindamycin phosphate in d5w inj 300mg/50ml; 5%,
600mg/50ml; 5%...........................................................36
clindamycin phosphate in d5w inj 900mg/50ml; 5%...........36
clindamycin phosphate pharmacy bulk package....................36
clindamycin/benzoyl peroxide.............................................68
CLINIMIX 2.75%/DEXTROSE 5%..............................43
CLINIMIX 4.25%/DEXTROSE 10%............................43
CLINIMIX 4.25%/DEXTROSE 20%............................43
CLINIMIX 4.25%/DEXTROSE 25%............................43
CLINIMIX 4.25%/DEXTROSE 5%..............................34
CLINIMIX 5%/DEXTROSE 15%.................................43
CLINIMIX 5%/DEXTROSE 20%.................................43
CLINIMIX 5%/DEXTROSE 25%.................................43
CLINIMIX E 2.75%/DEXTROSE 10%.........................34
CLINIMIX E 2.75%/DEXTROSE 5%...........................34
CLINIMIX E 4.25%/DEXTROSE 10%.........................43
CLINIMIX E 4.25%/DEXTROSE 25%.........................43
CLINIMIX E 4.25%/DEXTROSE 5%...........................44
CLINIMIX E 5%/DEXTROSE 15%..............................44
CLINIMIX E 5%/DEXTROSE 20%..............................44
CLINIMIX E 5%/DEXTROSE 25%..............................44
CLINISOL SF 15%.........................................................44
CLINORIL......................................................................50
clobetasol propionate..........................................................71
clobetasol propionate e........................................................71
clobetasol propionate emollient............................................71
CLOBEX.........................................................................71
CLODERM.....................................................................71
CLODERM PUMP.........................................................71
CLOFERA.......................................................................77
CLOLAR.........................................................................18
clomipramine hcl...............................................................56
clonazepam odt tbdp 0.125mg...........................................10
clonazepam odt tbdp 0.25mg.............................................10
clonazepam odt tbdp 0.5mg...............................................10
clonazepam odt tbdp 1mg..................................................11
clonazepam odt tbdp 2mg..................................................11
clonazepam tabs 0.5mg......................................................11
clonazepam tabs 1mg.........................................................11
clonazepam tabs 2mg.........................................................11
clonidine hcl inj.................................................................15
Effective January 1, 2014
98
clonidine hcl inj.................................................................50
clonidine hcl ptwk.............................................................15
clonidine hcl tabs...............................................................15
clopidogrel tabs 300mg.......................................................25
clopidogrel tabs 75mg.........................................................25
clorazepate dipotassium......................................................56
clorpres tabs 15mg; 0.1mg, 15mg; 0.2mg............................15
CLORPRES TABS 15MG; 0.3MG.................................15
clotrimazole external crea...................................................70
clotrimazole external soln...................................................70
clotrimazole troc................................................................13
clotrimazole/betamethasone dipropionate.............................70
clozapine odt tbdp 100mg..................................................56
clozapine odt tbdp 12.5mg.................................................56
clozapine odt tbdp 25mg....................................................56
clozapine tabs 100mg.........................................................56
clozapine tabs 200mg.........................................................56
clozapine tabs 25mg...........................................................56
clozapine tabs 50mg...........................................................56
CLOZARIL TABS 100MG.............................................56
CLOZARIL TABS 25MG...............................................56
CNL8 NAIL KIT............................................................70
co-gesic..............................................................................46
COARTEM.....................................................................37
cod liver oil caps 0; 1250unit; 130unit, 1250unit; 130unit,
1250unit; 133.33unit, 1250unit; 133unit, 4000unit;
200unit.........................................................................82
cod liver oil oil 0; 4000unit/5ml; 400unit/5ml, 5000unit/
5ml; 500unit/5ml..........................................................82
codeine phosphate..............................................................46
CODEINE SULFATE ORAL SOLN..............................46
codeine sulfate tabs 15mg...................................................46
codeine sulfate tabs 30mg...................................................46
codeine sulfate tabs 60mg...................................................46
codituss dm.......................................................................77
COGENTIN...................................................................20
COLAZAL......................................................................39
COLCRYS.......................................................................32
COLD HEAD CONGESTION DAYTIME...................77
cold head congestion nighttime............................................77
cold head congestion severe daytime.....................................77
COLD MULTI-SYMPTOM DAYTIME........................77
cold multi-symptom nighttime............................................77
cold multi-symptom severe daytime.....................................77
COLD-EEZE LOZG.......................................................79
cold/cough dm childrens.....................................................77
Comprehensive_P3TARO_10R
COLESTID.....................................................................32
COLESTID FLAVORED................................................32
colestipol hcl......................................................................32
colestipol hcl for oral suspension...........................................32
colistimethate sodium.........................................................37
colocort.............................................................................39
COLY-MYCIN M............................................................37
COLY-MYCIN S.............................................................54
COLYTE-FLAVOR PACKS............................................39
COMBIGAN...................................................................53
COMBIPATCH..............................................................31
COMBIVENT................................................................64
COMBIVENT RESPIMAT............................................64
COMBIVIR....................................................................21
COMETRIQ...................................................................18
companion........................................................................82
compete.............................................................................82
COMPLERA...................................................................21
complete............................................................................82
complete senior..................................................................82
compro..............................................................................39
COMTAN.......................................................................20
COMTREX COLD & COUGH MAXIMUM
STRENGTH................................................................77
COMTREX COLD & COUGH NIGHTTIME
MAXIMUM STRENGTH...........................................77
COMVAX.......................................................................73
CONCEPT DHA............................................................74
CONCEPT OB...............................................................74
CONCERTA TBCR 18MG, 27MG, 54MG...................56
CONCERTA TBCR 36MG............................................56
CONDYLOX..................................................................38
constulose..........................................................................39
CONTROLRX CREA.....................................................34
CONZIP.........................................................................50
COPAXONE...................................................................41
COPEGUS......................................................................21
COPPER SULFATE........................................................79
CORDARONE.................................................................9
CORDRAN.....................................................................71
CORDRAN SP...............................................................71
CORDRAN TAPE..........................................................71
COREG...........................................................................15
COREG CR....................................................................15
corfen-dm..........................................................................77
CORGARD.....................................................................15
CORLOPAM..................................................................15
cormax scalp application....................................................71
CORTANE-B..................................................................80
cortane-b-otic....................................................................80
CORTEF...........................................................................8
CORTENEMA................................................................39
CORTIFOAM.................................................................39
cortisone acetate...................................................................8
CORTISPORIN..............................................................54
CORTISPORIN..............................................................70
CORTISPORIN-TC.......................................................54
CORVERT........................................................................9
corvita..............................................................................82
corvita 150.......................................................................82
CORVITE.......................................................................82
CORVITE FE..................................................................82
CORZIDE.......................................................................15
COSMEGEN..................................................................18
COSOPT.........................................................................53
COSOPT PF...................................................................53
COTAB AX.....................................................................77
COUGH DM..................................................................77
COUMADIN..................................................................25
covaryx..............................................................................80
covaryx hs..........................................................................80
COZAAR TABS 100MG.................................................15
COZAAR TABS 25MG, 50MG......................................15
cranberry urinary comfort..................................................82
CREON..........................................................................39
CRESTOR.......................................................................32
CRINONE......................................................................31
CRIXIVAN......................................................................21
cromolyn sodium conc........................................................39
cromolyn sodium nebu.......................................................64
cromolyn sodium ophthalmic soln.......................................42
cryselle-28.........................................................................52
CUBICIN........................................................................37
CUPRIMINE..................................................................54
CUTIVATE.....................................................................71
CUVPOSA......................................................................13
CYANOCOBALAMIN CRYS........................................82
cyclafem 1/35....................................................................52
cyclafem 7/7/7...................................................................52
CYCLESSA......................................................................52
cyclobenzaprine hcl tabs 10mg, 5mg...................................45
cyclobenzaprine hcl tabs 7.5mg...........................................45
Comprehensive_P3TARO_10R
99
Effective January 1, 2014
CYCLOGYL....................................................................26
cyclopentolate hcl ophthalmic soln 1%.................................26
cyclopentolate hcl ophthalmic soln 2%.................................26
cyclophosphamide tabs........................................................18
CYCLOSERINE..............................................................37
CYCLOSET....................................................................27
cyclosporine caps................................................................18
cyclosporine inj..................................................................18
cyclosporine modified caps 100mg, 50mg.............................18
cyclosporine modified caps 25mg.........................................18
cyclosporine modified oral soln............................................18
CYKLOKAPRON...........................................................25
CYMBALTA CPEP 20MG..............................................56
CYMBALTA CPEP 30MG..............................................56
CYMBALTA CPEP 60MG..............................................56
cyproheptadine hcl syrp.......................................................14
cyproheptadine hcl tabs......................................................14
CYSTADANE..................................................................39
CYSTAGON...................................................................42
CYSTARAN....................................................................42
cytarabine.........................................................................18
cytarabine aqueous.............................................................18
CYTOGAM.....................................................................73
CYTOMEL.....................................................................68
CYTOTEC......................................................................72
CYTOVENE...................................................................21
cytra k crystals...................................................................42
cytra-2..............................................................................42
cytra-3..............................................................................42
cytra-k..............................................................................42
D.H.E. 45........................................................................33
dacarbazine inj 100mg......................................................18
dacarbazine inj 200mg......................................................18
DACOGEN.....................................................................18
daily combo multi vitamin.................................................82
daily multi........................................................................82
daily multiple vitamin tabs 60mg; 5000unit; 6mcg; 400unit;
0.4mg; 20mg; 10mg; 2mg; 1.7mg; 1.5mg; 30unit............82
daily multiple vitamins......................................................82
daily value multivitamin....................................................82
daily vitamin.....................................................................82
daily vitamins...................................................................82
daily vite...........................................................................82
DALIRESP......................................................................64
danazol.............................................................................40
DANTRIUM...................................................................45
Effective January 1, 2014
100
DANTRIUM IV.............................................................45
dantrolene sodium caps......................................................45
DAPSONE......................................................................37
DAPTACEL.....................................................................73
DARAPRIM....................................................................37
dasetta 1/35......................................................................52
dasetta 7/7/7.....................................................................52
daunorubicin hcl inj 20mg.................................................18
daunorubicin hcl inj 5mg/ml..............................................18
DAY TIME MULTI-SYMPTOM COLD/FLU
RELIEF.........................................................................77
day-time pe.......................................................................77
DAYPRO.........................................................................50
daysee................................................................................52
daytime pe multi-symptom cold/flu relief.............................77
DAYTRANA...................................................................57
DDAVP INJ....................................................................40
DDAVP NASAL SOLN..................................................40
DDAVP TABS.................................................................40
DEBACTEROL...............................................................34
DECAVAC......................................................................73
DELATESTRYL..............................................................40
DELESTROGEN............................................................31
DELSYM.........................................................................77
delta d3............................................................................82
DELZICOL.....................................................................39
DEMADEX.....................................................................15
demeclocycline hcl..............................................................67
DEMEROL INJ 100MG/2ML, 25MG/0.5ML, 75MG/
1.5ML, 75MG/ML.......................................................46
demerol inj 100mg/ml.......................................................46
DEMEROL INJ 100MG/ML, 25MG/ML, 50MG/
ML................................................................................46
DEMEROL TABS 100MG..............................................46
DEMEROL TABS 50MG................................................46
DEMSER.........................................................................15
DENAVIR.......................................................................70
denta 5000 plus................................................................34
dentagel............................................................................34
DEPACON.....................................................................11
depade..............................................................................50
DEPAKENE....................................................................11
DEPAKOTE....................................................................11
DEPAKOTE ER..............................................................11
DEPAKOTE SPRINKLES...............................................11
DEPEN TITRATABS......................................................54
Comprehensive_P3TARO_10R
DEPO-ESTRADIOL.......................................................31
DEPO-MEDROL.............................................................8
DEPO-PROVERA...........................................................31
DEPO-PROVERA CONTRACEPTIVE........................31
DEPO-SUBQ PROVERA 104........................................31
DEPO-TESTOSTERONE..............................................40
DEPOCYT......................................................................18
DEPODUR.....................................................................46
DERMA-SMOOTHE/FS BODY....................................71
DERMA-SMOOTHE/FS BODY OIL............................71
DERMA-SMOOTHE/FS SCALP...................................71
DERMATOP...................................................................71
DERMOTIC...................................................................42
desipramine hcl..................................................................57
desloratadine.....................................................................14
desloratadine odt................................................................14
desmopressin acetate...........................................................40
DESOGEN.....................................................................52
DESONATE....................................................................71
desonide............................................................................71
DESOWEN.....................................................................71
DESOWEN CREAM/CETAPHIL LOTION.................71
DESOWEN LOTION/CETAPHIL CREAM.................71
DESOWEN OINTMENT/CETAPHIL LOTION.........71
desoximetasone...................................................................71
DESOXYN......................................................................57
despec eda..........................................................................78
desquam-x wash................................................................81
DESVENLAFAXINE ER TB24 100MG.........................57
DESVENLAFAXINE ER TB24 50MG...........................57
DETROL LA...................................................................10
DETROL TABS 1MG.....................................................10
DETROL TABS 2MG.....................................................10
dexamethasone.....................................................................8
dexamethasone intensol........................................................8
dexamethasone sodium phosphate..........................................8
dexamethasone sodium phosphate........................................66
dexchlorpheniramine maleate.............................................14
DEXEDRINE..................................................................57
dexferrum.........................................................................83
DEXILANT.....................................................................72
dexmethylphenidate hcl......................................................57
DEXPAK 10 DAY..............................................................8
DEXPAK 13 DAY..............................................................8
DEXPAK 6 DAY................................................................8
dexrazoxane inj 250mg........................................................8
dexrazoxane inj 500mg........................................................8
dextroamphetamine sulfate er.............................................57
dextroamphetamine sulfate tabs 10mg.................................57
dextroamphetamine sulfate tabs 5mg...................................57
dextromethorphan hbr/phenylephrine hcl/
chlorpheniramine............................................................78
DEXTROMETHORPHAN POLISTIREX....................78
dextromethorphan/guaifenesin............................................78
dextrose 10% flex container................................................34
DEXTROSE 10% INJ 10%............................................34
dextrose 10% inj 10%.......................................................34
dextrose 10%/nacl 0.2%....................................................34
dextrose 10%/nacl 0.225%................................................35
dextrose 10%/nacl 0.45%..................................................34
dextrose 2.5%....................................................................34
dextrose 2.5%/nacl 0.45%.................................................35
dextrose 2.5%/sodium chloride 0.45%................................35
dextrose 25%.....................................................................35
dextrose 30%.....................................................................35
dextrose 30% partial fill....................................................35
dextrose 40%.....................................................................35
dextrose 5%.......................................................................35
dextrose 5% /electrolyte #48 viaflex.....................................44
dextrose 5% viaflex............................................................35
dextrose 5%/lactated ringers...............................................35
dextrose 5%/nacl 0.2%......................................................35
dextrose 5%/nacl 0.225%..................................................35
dextrose 5%/nacl 0.3%......................................................35
dextrose 5%/nacl 0.33%....................................................35
dextrose 5%/nacl 0.45%....................................................35
dextrose 5%/nacl 0.9%......................................................35
dextrose 5%/potassium chloride 0.15%...............................29
dextrose 5%/ringers............................................................35
dextrose 5%/sodium chloride 0.2%.....................................35
dextrose 5%/sodium chloride 0.33%...................................35
dextrose 5%/sodium chloride 0.45%...................................35
dextrose 5%/sodium chloride 0.9%.....................................35
dextrose 50%.....................................................................35
dextrose 70%.....................................................................35
dextrose thermoject system...................................................35
DIABETA........................................................................27
diabetic tussin dm..............................................................78
diabetic tussin maximum strength.......................................78
dialyvite............................................................................83
DIALYVITE 3000...........................................................83
DIALYVITE 5000...........................................................83
Comprehensive_P3TARO_10R
101
Effective January 1, 2014
dialyvite 800.....................................................................83
DIALYVITE 800/IRON..................................................83
DIALYVITE 800/ZINC..................................................83
DIALYVITE SUPREME D.............................................83
dialyvite/zinc.....................................................................83
DIAMOX........................................................................53
DIASTAT ACUDIAL......................................................11
DIASTAT PEDIATRIC...................................................11
DIATX ZN......................................................................83
diazepam gel.....................................................................11
diazepam inj 5mg/ml.........................................................57
diazepam intensol..............................................................57
diazepam oral soln.............................................................57
diazepam tabs 10mg..........................................................57
diazepam tabs 2mg............................................................57
diazepam tabs 5mg............................................................57
DIBENZYLINE..............................................................15
DICEL CD......................................................................78
DICEL DM.....................................................................78
diclofenac potassium...........................................................50
diclofenac sodium..............................................................51
diclofenac sodium dr..........................................................50
diclofenac sodium er...........................................................50
diclofenac sodium xr..........................................................50
diclofenac sodium/misoprostol.............................................50
dicloxacillin sodium...........................................................54
dicyclomine hcl..................................................................13
didanosine.........................................................................21
DIDRONEL....................................................................35
DIFFERIN......................................................................68
DIFICID.........................................................................31
diflorasone diacetate...........................................................71
DIFLUCAN....................................................................13
diflunisal...........................................................................50
digoxin inj........................................................................24
digoxin oral soln................................................................24
digoxin tabs 0.125mg........................................................24
digoxin tabs 0.25mg..........................................................24
dihydroergotamine mesylate inj...........................................33
dihydroergotamine mesylate nasal soln.................................33
DILACOR XR.................................................................15
DILANTIN CAPS 100MG.............................................11
DILANTIN CAPS 30MG...............................................11
DILANTIN INFATABS..................................................11
DILANTIN SUSP...........................................................11
DILATRATE SR..............................................................49
Effective January 1, 2014
102
DILAUDID INJ..............................................................46
DILAUDID TABS 2MG.................................................46
DILAUDID TABS 4MG.................................................46
DILAUDID TABS 8MG.................................................46
DILAUDID-5..................................................................46
DILAUDID-HP..............................................................46
dilt-cd...............................................................................15
dilt-xr...............................................................................15
diltiazem cd......................................................................15
diltiazem hcl cd.................................................................15
diltiazem hcl cp24.............................................................15
diltiazem hcl er..................................................................15
diltiazem hcl inj................................................................15
diltiazem hcl tabs..............................................................15
diltzac...............................................................................15
dimaphen dm cold/cough childrens......................................78
dimenhydrinate inj............................................................39
DIMETANE DX.............................................................78
DIMETAPP LONG ACTING COUGH PLUS
COLD..........................................................................78
dino-life w/iron & zinc......................................................83
DIOVAN HCT...............................................................15
DIOVAN TABS 160MG.................................................16
DIOVAN TABS 320MG.................................................16
DIOVAN TABS 40MG, 80MG.......................................16
DIPENTUM...................................................................39
diphenhydramine hcl caps 50mg.........................................14
diphenhydramine hcl elix...................................................14
diphenhydramine hcl inj....................................................14
diphenoxylate/atropine.......................................................13
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC.................................................................73
DIPROLENE..................................................................71
DIPROLENE AF.............................................................71
dipyridamole tabs..............................................................25
disopyramide phosphate........................................................9
disulfiram.........................................................................35
DITROPAN XL TB24 10MG, 15MG............................10
DITROPAN XL TB24 5MG...........................................10
DIURIL...........................................................................16
divalproex sodium..............................................................11
divalproex sodium dr.........................................................11
divalproex sodium er..........................................................11
DIVIGEL........................................................................31
DIVISTA.........................................................................81
dobutamine hcl..................................................................38
Comprehensive_P3TARO_10R
dobutamine hcl/d5w..........................................................38
dobutamine/dextrose 5%....................................................38
DOCEFREZ...................................................................18
docetaxel inj 160mg/16ml, 160mg/8ml, 20mg/0.5ml, 20mg/
2ml, 80mg/2ml, 80mg/8ml.............................................18
docetaxel inj 20mg/ml, 80mg/4ml......................................18
DOLGIC PLUS...............................................................46
dolophine hcl TABS 10MG................................................46
DOLOPHINE HCL TABS 5MG....................................46
donepezil hcl tabs 10mg, 5mg.............................................41
donepezil hcl tabs 23mg.....................................................41
donepezil hcl tbdp..............................................................41
DONNATAL EXTENTABS...........................................77
DONNATAL TABS.........................................................77
dopamine hcl.....................................................................38
dopamine hcl-dextrose 5%..................................................38
dopamine hcl/dextrose 5%..................................................38
dopamine/d5w..................................................................38
DORAL...........................................................................57
DORIBAX.......................................................................37
DORYX...........................................................................67
dorzolamide hcl.................................................................53
dorzolamide hcl/timolol maleate.........................................53
DOVONEX....................................................................21
doxazosin mesylate.............................................................16
doxepin hcl........................................................................57
DOXIL............................................................................18
doxorubicin hcl..................................................................18
doxy 100...........................................................................67
doxycycline hyclate caps......................................................67
doxycycline hyclate cpep......................................................67
doxycycline hyclate dr.........................................................67
doxycycline hyclate inj........................................................67
doxycycline hyclate tabs......................................................67
doxycycline monohydrate caps 100mg, 150mg, 50mg...........67
doxycycline monohydrate caps 75mg....................................67
doxycycline monohydrate susr..............................................67
doxycycline monohydrate tabs.............................................67
DRISDOL ORAL SOLN................................................83
dritho-creme hp.................................................................21
dronabinol........................................................................39
droperidol.........................................................................39
drospirenone/ethinyl estradiol..............................................52
DROXIA.........................................................................18
DRYSOL.........................................................................38
DUAC.............................................................................68
DUET DHA BALANCED MISC 120MG; 2840UNIT;
215MG; 840UNIT; 2MG; 12MCG; 0; 0; 0; 1MG;
210MCG; 26MG; 0; 25MG; 20MG; 278MG; 0;
50MG; 4MG; 0; 1.5MG; 2MG; 25MG.......................74
DUETACT......................................................................27
DUEXIS..........................................................................50
DULERA.........................................................................64
duofer...............................................................................83
DUONEB.......................................................................64
DURACLON INJ 100MCG/ML....................................16
DURACLON INJ 500MCG/ML....................................50
DURAGESIC..................................................................46
duramorph........................................................................46
DUREZOL......................................................................66
DUTOPROL...................................................................16
DYAZIDE.......................................................................16
DYMISTA.......................................................................64
DYNACIN......................................................................67
DYRENIUM...................................................................16
DYSPORT.......................................................................73
E-OIL OIL 100UNT/0.25ML........................................83
e.e.s. 400...........................................................................31
E.E.S. GRANULES.........................................................31
e.s.p..................................................................................31
ear health formula.............................................................81
EC-NAPROSYN.............................................................50
econazole nitrate................................................................70
ED CYTE F.....................................................................83
EDARBI..........................................................................16
EDARBYCLOR...............................................................16
EDECRIN.......................................................................16
EDEX..............................................................................80
EDLUAR.........................................................................57
EDURANT.....................................................................21
eemt..................................................................................80
eemt hs..............................................................................80
EFFER-K TBEF 0.84GM; 1GM, 1.68GM; 2GM...........29
effer-k tbef 25meq..............................................................29
effervescent pot chloride......................................................29
effervescent potassium.........................................................29
effervescent potassium/chloride............................................29
EFFEXOR XR CP24 150MG..........................................57
EFFEXOR XR CP24 37.5MG.........................................57
EFFEXOR XR CP24 75MG............................................57
EFFIENT........................................................................25
EFUDEX.........................................................................38
Comprehensive_P3TARO_10R
103
Effective January 1, 2014
EGRIFTA........................................................................23
ELAPRASE......................................................................40
ELDEPRYL.....................................................................20
eldertonic..........................................................................83
ELDOPAQUE FORTE...................................................80
ELELYSO........................................................................40
ELESTAT........................................................................42
ELESTRIN......................................................................31
ELIDEL...........................................................................38
ELIGARD.......................................................................18
ELIMITE.........................................................................72
elinest...............................................................................52
eliphos...............................................................................29
ELIQUIS.........................................................................25
ELITEK.............................................................................8
ELIXOPHYLLIN............................................................64
ELLA...............................................................................52
ELLENCE.......................................................................18
ELMIRON......................................................................42
ELOCON........................................................................71
ELOXATIN INJ 100MG/20ML, 50MG/10ML..............18
ELOXATIN INJ 200MG/40ML.....................................18
ELSPAR...........................................................................18
EMADINE......................................................................42
EMCYT...........................................................................18
EMEND CAPS................................................................39
EMEND CAPS 125MG..................................................39
EMEND CAPS 40MG....................................................39
EMEND CAPS 80MG....................................................39
EMEND INJ...................................................................39
EMLA..............................................................................69
emoquette..........................................................................52
EMSAM..........................................................................57
EMTRIVA.......................................................................21
ENABLEX.......................................................................10
enalapril maleate...............................................................16
enalapril maleate/hydrochlorothiazide.................................16
enalaprilat........................................................................16
ENBREL INJ 25MG, 50MG/ML...................................54
ENBREL INJ 25MG/0.5ML...........................................54
ENBREL SURECLICK...................................................54
endacof-c...........................................................................78
endacof-dm.......................................................................78
endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg;
7.5mg............................................................................46
endocet tabs 500mg; 7.5mg................................................46
Effective January 1, 2014
104
endocet tabs 650mg; 10mg.................................................46
endodan............................................................................46
ENDOMETRIN.............................................................31
ENGERIX-B INJ 10MCG/0.5ML..................................73
ENGERIX-B INJ 20MCG/ML.......................................73
ENJUVIA........................................................................31
enlon.................................................................................45
ENLON-PLUS................................................................45
enoxaparin sodium............................................................25
enpresse-28........................................................................52
enskyce..............................................................................52
entacapone........................................................................21
ENTOCORT EC............................................................39
enulose..............................................................................39
EPIDUO.........................................................................68
epiflur...............................................................................74
epinastine hcl.....................................................................42
epinephrine.......................................................................14
epinephrine hcl..................................................................14
EPIPEN 2-PAK................................................................14
EPIPEN-JR 2-PAK..........................................................14
EPIQUIN MICRO..........................................................80
epirubicin hcl....................................................................18
epitol................................................................................11
EPIVIR HBV...................................................................21
EPIVIR ORAL SOLN.....................................................21
EPIVIR TABS..................................................................21
eplerenone.........................................................................16
EPOGEN........................................................................23
epoprostenol sodium...........................................................16
eprosartan mesylate............................................................16
EPZICOM......................................................................21
eql beta carotene................................................................83
eql one daily womens.........................................................83
eql tussin cough/chest congestion..........................................78
eql vitamin c tabs 500mg...................................................83
EQUETRO CP12 100MG..............................................11
EQUETRO CP12 200MG..............................................11
EQUETRO CP12 300MG..............................................11
ERAXIS...........................................................................13
ERBITUX INJ 100MG/50ML........................................19
ERBITUX INJ 200MG/100ML......................................19
ergocalciferol......................................................................83
ergoloid mesylates...............................................................57
ERGOMAR.....................................................................33
ERIVEDGE.....................................................................19
Comprehensive_P3TARO_10R
errin.................................................................................31
ERTACZO.......................................................................70
ERWINAZE....................................................................19
ery....................................................................................68
ery-tab tbec 250mg, 333mg................................................31
ERY-TAB TBEC 500MG.................................................31
ERYPED 200...................................................................31
ERYPED 400...................................................................31
ERYTHROCIN LACTOBIONATE...............................31
erythrocin stearate..............................................................31
erythromycin.......................................................................9
erythromycin.....................................................................31
erythromycin.....................................................................68
erythromycin base..............................................................31
erythromycin ethylsuccinate................................................31
erythromycin/benzoyl peroxide............................................68
erythromycin/sulfisoxazole...................................................31
escitalopram oxalate oral soln..............................................57
escitalopram oxalate tabs 10mg...........................................57
escitalopram oxalate tabs 20mg...........................................57
escitalopram oxalate tabs 5mg.............................................57
ESGIC.............................................................................46
ESGIC-PLUS...................................................................46
essentia..............................................................................83
estarylla.............................................................................52
estazolam..........................................................................57
ESTER-C TABS 500MG; 55MG; 200MG......................83
esterified estrogens/methyltestosterone...................................80
esterified estrogens/methyltestosterone hs...............................80
ESTRACE CREA............................................................31
ESTRACE TABS.............................................................31
estradiol ptwk....................................................................31
estradiol tabs.....................................................................31
estradiol valerate................................................................31
estradiol/norethindrone acetate............................................31
ESTRASORB..................................................................31
ESTRING........................................................................31
ESTROGEL....................................................................31
estropipate.........................................................................31
ESTROSTEP FE.............................................................52
ethambutol hcl...................................................................37
ethosuximide.....................................................................11
ETHYOL...........................................................................8
etidronate disodium...........................................................35
etodolac.............................................................................50
etodolac er.........................................................................50
ETOPOPHOS.................................................................19
etoposide inj......................................................................19
EURAX............................................................................72
EVAMIST........................................................................31
EVISTA...........................................................................53
EVOCLIN.......................................................................68
EVOXAC.........................................................................35
EXALGO TB24 12MG, 16MG, 8MG............................46
EXALGO TB24 32MG...................................................46
exefen dmx........................................................................78
EXELDERM...................................................................70
EXELON CAPS..............................................................41
EXELON ORAL SOLN..................................................41
EXELON PT24...............................................................41
exemestane........................................................................19
EXFORGE.......................................................................16
EXFORGE HCT.............................................................16
EXJADE..........................................................................35
EXPAREL........................................................................69
EXTAVIA........................................................................23
EXTINA..........................................................................70
extra action cough..............................................................78
EYLEA.............................................................................42
ezfe 200............................................................................83
fabb..................................................................................83
FABRAZYME..................................................................40
FACTIVE........................................................................66
falmina.............................................................................52
famciclovir tabs 125mg, 250mg.........................................21
famciclovir tabs 500mg......................................................21
famotidine inj...................................................................72
famotidine premixed..........................................................72
famotidine susr..................................................................72
famotidine tabs 20mg, 40mg..............................................72
FAMVIR TABS 125MG, 250MG...................................21
FAMVIR TABS 500MG..................................................22
FANAPT TABS 10MG....................................................57
FANAPT TABS 12MG....................................................57
FANAPT TABS 1MG......................................................57
FANAPT TABS 2MG......................................................57
FANAPT TABS 4MG......................................................57
FANAPT TABS 6MG......................................................57
FANAPT TABS 8MG......................................................57
FANAPT TITRATION PACK........................................57
FARESTON....................................................................19
FASLODEX.....................................................................19
Comprehensive_P3TARO_10R
105
Effective January 1, 2014
FAZACLO TBDP 100MG..............................................57
FAZACLO TBDP 12.5MG.............................................57
FAZACLO TBDP 150MG..............................................57
FAZACLO TBDP 200MG..............................................57
FAZACLO TBDP 25MG................................................57
fe c plus.............................................................................74
felbamate..........................................................................11
FELBATOL.....................................................................11
FELDENE.......................................................................50
felodipine er......................................................................16
fem ph..............................................................................42
FEMARA.........................................................................19
FEMCON FE..................................................................52
FEMHRT LOW DOSE...................................................31
FEMRING......................................................................31
fenofibrate caps..................................................................32
fenofibrate micronized caps 134mg, 200mg.........................32
fenofibrate micronized caps 67mg.......................................32
fenofibrate tabs 145mg, 48mg............................................32
fenofibrate tabs 160mg.......................................................32
fenofibrate tabs 54mg.........................................................32
fenofibric acid...................................................................32
fenofibric acid dr...............................................................32
FENOGLIDE..................................................................32
fenoprofen calcium.............................................................50
fentanyl citrate...................................................................46
fentanyl citrate oral transmucosal........................................46
fentanyl patches.................................................................46
FENTORA......................................................................46
FEOSOL BIFERA...........................................................83
feosol tabs 200mg, 65mg....................................................83
fer-iron.............................................................................83
FERAHEME...................................................................83
ferocon..............................................................................83
ferotrinsic..........................................................................83
FERRALET 90................................................................83
ferretts...............................................................................83
FERRETTS IPS...............................................................83
ferrex 150.........................................................................83
ferrex 150 forte..................................................................83
ferrex 150 forte plus...........................................................83
ferrex 150 plus...................................................................83
FERRIPROX...................................................................35
FERRLECIT....................................................................80
ferrocite.............................................................................83
ferrocite plus......................................................................83
Effective January 1, 2014
106
ferrogels forte.....................................................................83
ferrous drops......................................................................83
ferrous fumarate 324.........................................................83
FERROUS FUMARATE TABS 90MG...........................83
ferrous gluconate tabs 240mg, 324mg, 325mg.....................83
ferrous sulfate elix..............................................................83
FERROUS SULFATE HEPTAHYDRATE.....................83
ferrous sulfate liqd..............................................................83
ferrous sulfate oral soln.......................................................83
ferrous sulfate syrp..............................................................83
ferrous sulfate tabs 134mg..................................................83
ferrous sulfate tabs 325mg..................................................83
ferrous sulfate tbec 325mg..................................................83
ferrousul............................................................................83
ferus..................................................................................83
FEXMID.........................................................................45
FIBRICOR......................................................................33
FINACEA........................................................................68
finasteride tabs 1mg...........................................................80
finasteride tabs 5mg...........................................................23
FIORICET TABS............................................................46
FIORICET/CODEINE CAPS 325MG; 50MG; 40MG;
30MG...........................................................................46
FIORINAL......................................................................46
FIORINAL/CODEINE #3..............................................46
FIRAZYR........................................................................64
FIRMAGON...................................................................19
FIRST-HYDROCORTISONE........................................71
FIRST-PROGESTERONE VGS 100
COMPOUNDING KIT..............................................31
FIRST-PROGESTERONE VGS 200
COMPOUNDING KIT..............................................31
FIRST-PROGESTERONE VGS 25 COMPOUNDING
KIT...............................................................................31
FIRST-PROGESTERONE VGS 400
COMPOUNDING KIT..............................................31
FIRST-PROGESTERONE VGS 50 COMPOUNDING
KIT...............................................................................32
FIRST-TESTOSTERONE..............................................40
FIRST-TESTOSTERONE MC COMPOUNDING
KIT...............................................................................40
FLAGYL..........................................................................37
FLAGYL ER....................................................................37
FLAREX..........................................................................66
flavoxate hcl......................................................................10
FLEBOGAMMA.............................................................73
Comprehensive_P3TARO_10R
FLEBOGAMMA DIF.....................................................73
flecainide acetate..................................................................9
FLECTOR.......................................................................50
FLEXBUMIN..................................................................24
FLEXGEN.......................................................................81
FLO-PRED.......................................................................8
FLOLAN.........................................................................16
FLOMAX........................................................................23
FLONASE.......................................................................64
FLOVENT DISKUS AEPB 100MCG/BLIST................64
FLOVENT DISKUS AEPB 250MCG/BLIST, 50MCG/
BLIST...........................................................................64
FLOVENT HFA AERO 110MCG/ACT.........................64
FLOVENT HFA AERO 220MCG/ACT.........................64
FLOVENT HFA AERO 44MCG/ACT...........................64
FLU/SEVERE COLD & COUGH DAYTIME..............78
fluconazole........................................................................13
fluconazole in dextrose........................................................13
fluconazole in nacl.............................................................13
flucytosine.........................................................................13
fludarabine phosphate inj 50mg.........................................19
fludarabine phosphate inj 50mg/2ml...................................19
fludrocortisone acetate..........................................................8
FLUMADINE.................................................................22
flumazenil.........................................................................57
flunisolide.........................................................................65
fluocinolone acetonide........................................................42
fluocinolone acetonide........................................................71
fluocinolone acetonide body................................................71
fluocinolone acetonide scalp................................................71
fluocinonide......................................................................71
fluocinonide-e....................................................................71
fluor-a-day chew................................................................74
FLUOR-A-DAY ORAL SOLN........................................74
FLUORABON................................................................74
fluoride.............................................................................74
fluoridex daily defense........................................................35
FLUORIDEX DAILY DEFENSE SENSITIVITY
RELIEF PSTE..............................................................35
fluoritab chew 0.5mg, 1mg................................................74
FLUORITAB ORAL SOLN............................................74
fluorometholone.................................................................66
FLUOROPLEX...............................................................38
fluorouracil crea.................................................................38
fluorouracil external soln....................................................38
fluorouracil inj..................................................................19
fluoxetine caps 10mg..........................................................57
fluoxetine caps 20mg..........................................................57
fluoxetine dr......................................................................57
fluoxetine hcl caps 10mg.....................................................57
fluoxetine hcl caps 20mg.....................................................57
fluoxetine hcl caps 40mg.....................................................57
fluoxetine hcl oral soln........................................................57
fluoxetine hcl tabs 10mg.....................................................58
fluoxetine hcl tabs 20mg.....................................................58
FLUOXETINE HCL TABS 60MG.................................58
fluphenazine decanoate......................................................58
fluphenazine hcl conc.........................................................58
fluphenazine hcl elix..........................................................58
fluphenazine hcl inj...........................................................58
fluphenazine hcl tabs.........................................................58
FLURA-DROPS ORAL SOLN 0.25MG/DROP............74
flurazepam hcl...................................................................58
flurbiprofen.......................................................................50
flurbiprofen sodium...........................................................51
flutamide..........................................................................19
fluticasone propionate crea..................................................71
fluticasone propionate lotn..................................................71
fluticasone propionate oint..................................................71
fluticasone propionate susp..................................................65
fluvastatin.........................................................................33
fluvoxamine maleate er cp24 100mg...................................58
fluvoxamine maleate er cp24 150mg...................................58
fluvoxamine maleate tabs 100mg........................................58
fluvoxamine maleate tabs 25mg..........................................58
fluvoxamine maleate tabs 50mg..........................................58
FML................................................................................66
FML FORTE...................................................................66
FML LIQUIFILM...........................................................67
FOCALIN.......................................................................58
FOCALIN XR CP24 10MG, 15MG, 25MG, 30MG,
35MG, 40MG, 5MG....................................................58
FOCALIN XR CP24 20MG...........................................58
folastin..............................................................................83
folbecal.............................................................................74
folbee................................................................................83
FOLBEE AR....................................................................83
folbee plus cz.....................................................................83
folbic.................................................................................83
folcal dha..........................................................................74
folcaps...............................................................................83
folcaps omega 3..................................................................74
Comprehensive_P3TARO_10R
107
Effective January 1, 2014
FOLGARD OS................................................................83
FOLGARD RX................................................................83
folic acid inj......................................................................83
FOLIC ACID POWD.....................................................83
folic acid tabs....................................................................83
folic acid xtra....................................................................83
folic acid/vitamin b-6/vitamin b-12...................................83
folitab 500........................................................................83
folivane-f...........................................................................83
folivane-plus......................................................................83
folivane-prx dha nf............................................................74
FOLOTYN......................................................................19
folplex 2.2.........................................................................83
foltabs 800........................................................................83
foltanx..............................................................................83
foltanx rf...........................................................................83
FOLTRATE.....................................................................83
foltrin...............................................................................83
fomepizole.........................................................................73
fondaparinux sodium.........................................................25
FORADIL AEROLIZER.................................................65
FORFIVO XL..................................................................58
FORTAMET TB24 1000MG..........................................27
FORTAMET TB24 500MG............................................27
FORTAZ INJ 1GM, 2GM..............................................24
FORTAZ INJ 1GM/50ML; 5%, 2GM/50ML; 5%,
500MG, 6GM..............................................................24
FORTEO.........................................................................53
FORTESTA.....................................................................40
fortical..............................................................................40
FOSAMAX......................................................................53
FOSAMAX PLUS D........................................................53
foscarnet sodium................................................................22
FOSCAVIR......................................................................22
fosfree................................................................................83
fosinopril sodium...............................................................16
fosinopril sodium/hydrochlorothiazide.................................16
fosphenytoin sodium...........................................................11
FOSRENOL....................................................................35
FRAGMIN......................................................................25
FREAMINE HBC 6.9%..................................................44
FREAMINE III 3%.........................................................44
FREAMINE III INJ 72MEQ/L; 600MG/100ML;
810MG/100ML; 3MEQ/L; 14MG/100ML; 1190MG/
100ML; 240MG/100ML; 590MG/100ML; 770MG/
100ML; 620MG/100ML; 450MG/100ML; 480MG/
Effective January 1, 2014
108
100ML; 10MMOLE/L; 115MG/100ML; 950MG/
100ML; 500MG/100ML; 10MEQ/L; 340MG/100ML;
130MG/100ML; 560MG/100ML................................44
freamine iii inj 89meq/l; 710mg/100ml; 950mg/100ml;
3meq/l; 24mg/100ml; 1400mg/100ml; 280mg/100ml;
690mg/100ml; 910mg/100ml; 730mg/100ml; 530mg/
100ml; 560mg/100ml; 10mmole/l; 120mg/100ml;
1120mg/100ml; 590mg/100ml; 10meq/l; 400mg/100ml;
150mg/100ml; 660mg/100ml.........................................44
FROVA............................................................................33
fruit c 500........................................................................83
fruity chewables multivitamin............................................83
fruity chews/iron................................................................83
full spectrum b/vitamin c....................................................83
FULYZAQ.......................................................................13
FURADANTIN..............................................................72
furosemide.........................................................................16
FUSILEV...........................................................................8
FUZEON........................................................................22
g-tron................................................................................78
gabapentin caps 100mg......................................................11
gabapentin caps 300mg......................................................11
gabapentin caps 400mg......................................................11
gabapentin oral soln...........................................................11
gabapentin tabs 600mg......................................................11
gabapentin tabs 800mg......................................................11
GABITRIL......................................................................11
GABLOFEN INJ 10000MCG/20ML, 40000MCG/
20ML, 50MCG/ML.....................................................45
galantamine......................................................................41
galantamine hydrobromide cp24.........................................41
galantamine hydrobromide oral soln...................................41
galantamine hydrobromide tabs..........................................41
GALZIN..........................................................................79
GAMASTAN S/D............................................................73
GAMMAGARD LIQUID...............................................73
GAMMAGARD S/D.......................................................73
GAMMAGARD S/D IGA LESS THAN 1MCG/ML......73
GAMMAKED.................................................................73
GAMMAPLEX................................................................73
GAMUNEX-C................................................................73
ganciclovir.........................................................................22
GARAMYCIN OINT......................................................10
garamycin ophthalmic soln.................................................10
GARDASIL.....................................................................73
GASTROCROM.............................................................39
Comprehensive_P3TARO_10R
GATTEX.........................................................................39
gauze pads 2"x2"...............................................................27
gavilyte-c...........................................................................39
gavilyte-g...........................................................................39
gavilyte-n/flavor pack.........................................................39
GEL-KAM ORAL CARE RINSE....................................35
GELNIQUE GEL 10%...................................................10
GELNIQUE GEL 3%.....................................................10
gemcitabine.......................................................................19
gemcitabine hcl inj 1gm, 200mg.........................................19
gemcitabine hcl inj 2gm.....................................................19
gemfibrozil........................................................................33
GEMZAR........................................................................19
GENERESS FE...............................................................52
generlac.............................................................................39
gengraf..............................................................................19
GENOTROPIN..............................................................23
GENOTROPIN MINIQUICK.......................................23
gentak...............................................................................10
gentamicin sulfate..............................................................10
gentamicin sulfate..............................................................37
gentamicin sulfate..............................................................70
gentamicin sulfate/0.9% sodium chloride............................37
gentamicin sulfate/sodium chloride......................................37
GEODON CAPS 20MG.................................................58
GEODON CAPS 40MG.................................................58
GEODON CAPS 60MG, 80MG....................................58
GEODON INJ................................................................58
geravim.............................................................................83
geri-tonic...........................................................................83
geriaton.............................................................................83
GERITOL COMPLETE.................................................83
GERITOL TONIC..........................................................83
GESTICARE DHA.........................................................74
gianvi...............................................................................52
GIAZO............................................................................39
gildagia.............................................................................52
gildess 1.5/30.....................................................................52
gildess 1/20........................................................................52
gildess fe 1.5/30.................................................................52
gildess fe 1/20....................................................................52
GILENYA........................................................................41
GILTUSS PED-C............................................................78
GILTUSS PEDIATRIC...................................................78
giltuss tr caps.....................................................................78
GLASSIA.........................................................................35
GLEEVEC.......................................................................19
glimepiride tabs 1mg..........................................................27
glimepiride tabs 2mg..........................................................27
glimepiride tabs 4mg..........................................................27
glipizide er tb24 10mg.......................................................27
glipizide er tb24 2.5mg......................................................27
glipizide er tb24 5mg.........................................................27
glipizide tabs 10mg............................................................27
glipizide tabs 5mg..............................................................27
glipizide xl tb24 10mg.......................................................27
glipizide xl tb24 2.5mg......................................................27
glipizide xl tb24 5mg.........................................................27
glipizide/metformin hcl tabs 2.5mg; 250mg........................27
glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg;
500mg...........................................................................27
GLUCAGEN...................................................................27
GLUCAGEN HYPOKIT................................................27
GLUCAGON EMERGENCY KIT.................................27
GLUCOPHAGE TABS 1000MG....................................27
GLUCOPHAGE TABS 500MG......................................27
GLUCOPHAGE TABS 850MG......................................27
GLUCOPHAGE XR TB24 500MG................................27
GLUCOPHAGE XR TB24 750MG................................27
GLUCOTROL TABS 10MG..........................................27
GLUCOTROL TABS 5MG............................................27
GLUCOTROL XL TB24 10MG.....................................27
GLUCOTROL XL TB24 2.5MG....................................27
GLUCOTROL XL TB24 5MG.......................................27
GLUCOVANCE TABS 2.5MG; 500MG, 5MG;
500MG.........................................................................27
GLUMETZA TB24 1000MG.........................................27
GLUMETZA TB24 500MG...........................................27
glyburide...........................................................................27
glyburide micronized..........................................................27
glyburide/metformin hcl tabs 1.25mg; 250mg.....................27
glyburide/metformin hcl tabs 2.5mg; 500mg, 5mg;
500mg...........................................................................27
glycine irrigation soln.........................................................42
glycopyrrolate.....................................................................13
GLYNASE.......................................................................27
GLYSET TABS 100MG...................................................27
GLYSET TABS 25MG.....................................................27
GLYSET TABS 50MG.....................................................27
gnp vitamin a caps 8000unit.............................................84
golden age vitamin/minerals...............................................84
GOLYTELY.....................................................................39
Comprehensive_P3TARO_10R
109
Effective January 1, 2014
GORDONS UREA.........................................................38
GRALISE STARTER.......................................................11
GRALISE TABS 300MG.................................................11
GRALISE TABS 600MG.................................................11
granisetron hcl inj..............................................................39
granisetron hcl tabs............................................................39
granisol.............................................................................39
GRIFULVIN V................................................................13
GRIS-PEG.......................................................................13
griseofulvin microsize.........................................................13
griseofulvin ultramicrosize..................................................13
guaiatussin ac....................................................................78
guaifenesin dac..................................................................78
guaifenesin-dm..................................................................78
guaifenesin/dextromethorphan............................................78
guanfacine hcl...................................................................16
guanidine hcl....................................................................58
GYNAZOLE-1................................................................42
HALAVEN......................................................................19
HALCION......................................................................58
HALDOL........................................................................58
HALDOL DECANOATE 100........................................58
HALDOL DECANOATE 50..........................................58
HALFLYTELY BOWEL PREP/FLAVOR PACKS...........39
halobetasol propionate........................................................71
HALOG..........................................................................71
halonate............................................................................71
halonate pac......................................................................71
haloperidol........................................................................58
haloperidol decanoate.........................................................58
haloperidol lactate..............................................................58
HAVRIX INJ 1440ELU/ML...........................................73
HAVRIX INJ 720ELU/0.5ML........................................73
healthy eyes........................................................................84
heather..............................................................................32
hecoria..............................................................................19
HECTOROL CAPS........................................................40
HECTOROL INJ............................................................40
HELIDAC.......................................................................72
HEMABATE...................................................................54
hematinic/folic acid............................................................84
hematogen.........................................................................84
hematogen fa.....................................................................84
hematogen forte.................................................................84
HEMATRON..................................................................84
HEMATRON-AF............................................................84
Effective January 1, 2014
110
HEMAX..........................................................................84
hemenatal ob.....................................................................74
hemenatal ob + dha...........................................................74
hemetab............................................................................84
hemril-30..........................................................................80
HEPAGAM B..................................................................73
heparin lock flush inj 100unit/ml.......................................25
heparin lock inj 100unit/ml...............................................25
heparin sodium dcu...........................................................25
heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/
ml, 2000unit/ml, 5000unit/0.5ml, 5000unit/ml.............25
heparin sodium inj 2500unit/ml........................................25
heparin sodium lock flush inj 100unit/ml............................25
heparin sodium/d5w..........................................................25
heparin sodium/nacl 0.45%...............................................25
heparin sodium/nacl 0.9%.................................................25
heparin sodium/sodium chloride 0.9%................................25
heparin sodium/sodium chloride 0.9% premix.....................25
HEPATAMINE...............................................................44
HEPATASOL..................................................................44
HEPSERA.......................................................................22
HERCEPTIN..................................................................19
HESPAN.........................................................................44
hetastarch 6%/nacl............................................................44
HEXALEN......................................................................19
HEXTEND.....................................................................35
HIBERIX.........................................................................73
high potency multivitamin/multimineral with iron..............84
HIPREX..........................................................................72
HIZENTRA....................................................................73
homatropaire.....................................................................26
homatropine hbr................................................................26
HORIZANT...................................................................41
HUMALOG....................................................................27
HUMALOG KWIKPEN.................................................27
HUMALOG MIX 50/50.................................................27
HUMALOG MIX 50/50 KWIKPEN..............................27
HUMALOG MIX 75/25.................................................27
HUMALOG MIX 75/25 KWIKPEN..............................27
human albumin grifols.......................................................24
HUMAPEN LUXURA HD............................................27
HUMAPEN MEMOIR...................................................27
HUMATROPE................................................................23
HUMATROPE COMBO PACK.....................................23
HUMIRA INJ 20MG/0.4ML..........................................54
HUMIRA INJ 40MG/0.8ML..........................................54
Comprehensive_P3TARO_10R
HUMIRA PEN................................................................54
HUMIRA PEN-CROHNS DISEASESTARTER............54
HUMIRA PEN-PSORIASIS STARTER..........................54
HUMULIN 70/30...........................................................27
HUMULIN 70/30 PEN..................................................27
HUMULIN N.................................................................27
HUMULIN N U-100 PEN.............................................28
HUMULIN R.................................................................28
HUMULIN R U-500 (CONCENTRATED)..................28
HYCAMTIN INJ............................................................19
HYCET...........................................................................46
hydralazine hcl..................................................................16
HYDREA........................................................................19
HYDRO 35.....................................................................38
HYDRO 40 FOAM.........................................................38
HYDRO 40 FOAM.........................................................80
hydrochlorothiazide............................................................16
hydrocodone bitartrate/acetaminophen oral soln...................47
hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg,
300mg; 5mg, 300mg; 7.5mg...........................................47
hydrocodone bitartrate/acetaminophen tabs 325mg;
2.5mg............................................................................47
hydrocodone bitartrate/acetaminophen tabs 750mg;
10mg.............................................................................47
hydrocodone bitartrate/homatropine methylbromide.............78
hydrocodone polistirex and chlorpheniramine polistirex.........78
hydrocodone/acetaminophen oral soln..................................47
hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg;
5mg, 325mg; 7.5mg.......................................................47
hydrocodone/acetaminophen tabs 500mg; 10mg, 500mg;
2.5mg, 500mg; 5mg, 500mg; 7.5mg...............................47
hydrocodone/acetaminophen tabs 650mg; 10mg, 650mg;
7.5mg, 660mg; 10mg.....................................................47
hydrocodone/acetaminophen tabs 750mg; 7.5mg..................47
hydrocodone/homatropine...................................................78
hydrocodone/ibuprofen tabs 10mg; 200mg, 2.5mg; 200mg,
5mg; 200mg...................................................................47
hydrocodone/ibuprofen tabs 7.5mg; 200mg..........................47
hydrocortisone acetate supp.................................................80
hydrocortisone acetate/pramoxine........................................77
hydrocortisone acetate/pramoxine........................................80
hydrocortisone butyrate.......................................................71
hydrocortisone crea 1%, 2.5%............................................71
hydrocortisone enem...........................................................39
hydrocortisone in absorbase.................................................71
hydrocortisone lotn 2.5%...................................................71
hydrocortisone oint 1%, 2.5%............................................71
hydrocortisone tabs...............................................................8
hydrocortisone valerate.......................................................71
hydrocortisone/acetic acid...................................................42
hydrocortisone/iodoquinol...................................................81
hydrogesic..........................................................................47
hydromet...........................................................................78
hydromorphone hcl dosette..................................................47
HYDROMORPHONE HCL INJ 1MG/ML..................47
hydromorphone hcl inj 1mg/ml, 500mg/50ml......................47
hydromorphone hcl inj 2mg/ml, 4mg/ml..............................47
hydromorphone hcl liqd......................................................47
hydromorphone hcl supp.....................................................47
hydromorphone hcl tabs 2mg..............................................47
hydromorphone hcl tabs 4mg..............................................47
hydromorphone hcl tabs 8mg..............................................47
hydroquinone time release...................................................80
hydroxocobalamin..............................................................84
hydroxychloroquine sulfate..................................................37
hydroxyurea.......................................................................19
hydroxyzine hcl..................................................................14
hydroxyzine pamoate..........................................................14
hypercare...........................................................................38
HYPERHEP B S/D.........................................................73
HYPERLYTE-CR............................................................29
HYPERRAB S/D.............................................................73
HYPERRHO S/D INJ 300MCG....................................73
HYPERRHO S/D INJ 50MCG......................................73
HYPERTET S/D.............................................................73
HYZAAR.........................................................................16
i-vite.................................................................................84
i-vite protect......................................................................84
I.L.X. B-12.......................................................................84
ibandronate sodium...........................................................53
ibuprofen susp...................................................................50
ibuprofen tabs 400mg, 600mg, 800mg...............................50
ibutilide fumarate................................................................9
ICAPS LUTEIN & ZEAXANTHIN...............................84
icaps plus...........................................................................84
ICAR PEDIATRIC..........................................................84
ICAR-C PLUS.................................................................74
ICLUSIG.........................................................................19
IDAMYCIN PFS.............................................................19
idarubicin hcl....................................................................19
iferex 150..........................................................................84
iferex 150 forte..................................................................84
Comprehensive_P3TARO_10R
111
Effective January 1, 2014
IFEX................................................................................19
ifosfamide inj 1gm.............................................................19
ifosfamide inj 1gm/20ml, 3gm, 3gm/60ml..........................19
ILARIS.............................................................................23
ILEVRO..........................................................................51
ILOTYCIN......................................................................10
IMDUR...........................................................................49
imipenem/cilastatin...........................................................37
imipramine hcl..................................................................58
imipramine pamoate..........................................................58
imiquimod........................................................................38
IMITREX INJ.................................................................33
IMITREX NASAL SOLN 20MG/ACT..........................33
IMITREX NASAL SOLN 5MG/ACT............................33
IMITREX STATDOSE REFILL.....................................33
IMITREX STATDOSE SYSTEM...................................33
IMITREX TABS..............................................................33
IMOGAM RABIES-HT..................................................73
IMOVAX RABIES (H.D.C.V.)........................................73
IMURAN........................................................................19
inatal advance...................................................................74
inatal gt............................................................................74
inatal ultra........................................................................74
INCIVEK........................................................................22
INCRELEX.....................................................................35
indapamide.......................................................................16
INDERAL LA..................................................................16
INDOCIN......................................................................50
INDOCIN IV.................................................................50
indomethacin....................................................................50
indomethacin er.................................................................50
indomethacin sodium.........................................................50
INFANRIX......................................................................73
infed.................................................................................84
INFERGEN.....................................................................23
INFUMORPH 200.........................................................47
INFUMORPH 500.........................................................47
INFUVITE......................................................................84
INFUVITE PEDIATRIC................................................84
INLYTA...........................................................................19
INNOPRAN XL..............................................................16
INSPRA...........................................................................16
INSULIN PEN NEEDLE...............................................28
INSULIN SYRINGE (DISP) U-100 0.3 ML..................28
INSULIN SYRINGE (DISP) U-100 1 ML.....................28
INSULIN SYRINGE (DISP) U-100 1/2 ML..................28
Effective January 1, 2014
112
INTEGRA.......................................................................84
INTEGRA F....................................................................84
INTEGRA PLUS.............................................................84
INTEGRILIN INJ 0.75MG/ML.....................................25
INTEGRILIN INJ 2MG/ML..........................................25
INTELENCE TABS 100MG, 200MG............................22
INTELENCE TABS 25MG.............................................22
intense cough reliever.........................................................78
INTERMEZZO..............................................................58
INTRALIPID INJ 1.7%; 30%.........................................44
intralipid inj 2.25%; 20%................................................44
INTRON-A.....................................................................23
INTRON-A W/DILUENT.............................................23
introvale............................................................................52
INTUNIV.......................................................................58
INVANZ.........................................................................37
INVEGA SUSTENNA....................................................58
INVEGA TB24 1.5MG...................................................58
INVEGA TB24 3MG......................................................58
INVEGA TB24 6MG......................................................58
INVEGA TB24 9MG......................................................58
INVIRASE.......................................................................22
INVOKANA TABS 100MG............................................28
INVOKANA TABS 300MG............................................28
iodine strong......................................................................79
IODOPEN......................................................................77
IONOSOL-B/DEXTROSE 5%......................................44
IONOSOL-MB/DEXTROSE 5%...................................44
iophen c-nr........................................................................78
iophen dm-nr....................................................................78
IOPIDINE.......................................................................67
IPOL INACTIVATED IPV.............................................73
ipratropium bromide inhalation soln..................................65
ipratropium bromide nasal soln..........................................35
ipratropium bromide/albuterol sulfate.................................65
IPRIVASK.......................................................................25
irbesartan..........................................................................16
irbesartan/hydrochlorothiazide............................................16
irinotecan inj 100mg/5ml, 40mg/2ml.................................19
irinotecan inj 500mg/25ml................................................19
IROMIN-G.....................................................................84
iron 100/c.........................................................................84
iron chews pediatric...........................................................84
iron supplement childrens...................................................84
iron tabs 28mg..................................................................84
IROSPAN 24/6................................................................84
Comprehensive_P3TARO_10R
ISENTRESS CHEW 100MG.........................................22
ISENTRESS CHEW 25MG...........................................22
ISENTRESS TABS..........................................................22
isoditrate er.......................................................................49
ISOLYTE-M/DEXTROSE 5%........................................44
ISOLYTE-P/DEXTROSE 5%.........................................44
ISOLYTE-S......................................................................44
ISOLYTE-S PH 7.4.........................................................44
isometheptene/caffeine/acetaminophen.................................80
isometheptene/dichloralphenazone/acetaminophen................80
isoniazid inj......................................................................37
isoniazid syrp.....................................................................37
isoniazid tabs....................................................................37
ISOPTIN SR...................................................................16
ISOPTO ATROPINE......................................................26
ISOPTO CARBACHOL.................................................53
ISOPTO CARPINE........................................................29
ISOPTO HOMATROPINE............................................26
ISOPTO HYOSCINE.....................................................26
ISORDIL TITRADOSE..................................................49
isosorbide dinitrate.............................................................49
isosorbide dinitrate er.........................................................49
isosorbide mononitrate.......................................................49
isosorbide mononitrate er....................................................50
isotonic gentamicin inj 0.8mg/ml; 0.9%, 1.2mg/ml; 0.9%,
1.6mg/ml; 0.9%, 1mg/ml; 0.9%.....................................37
ISOTONIC GENTAMICIN INJ 2MG/ML; 0.9%.........37
isradipine..........................................................................16
ISTALOL.........................................................................23
ISTODAX.......................................................................19
ISUPREL.........................................................................38
itraconazole.......................................................................13
IXEMPRA KIT................................................................19
IXIARO...........................................................................73
JAKAFI............................................................................19
JALYN.............................................................................23
jantoven............................................................................25
JANUMET......................................................................28
JANUMET XR TB24 1000MG; 100MG........................28
JANUMET XR TB24 1000MG; 50MG, 500MG;
50MG...........................................................................28
JANUVIA TABS 100MG................................................28
JANUVIA TABS 25MG..................................................28
JANUVIA TABS 50MG..................................................28
JE-VAX............................................................................73
JENTADUETO...............................................................28
JETREA...........................................................................42
JEVTANA........................................................................19
jinteli................................................................................32
jolessa................................................................................52
jolivette.............................................................................32
junel 1.5/30......................................................................52
junel 1/20.........................................................................52
junel fe 1.5/30...................................................................52
junel fe 1/20......................................................................52
JUVISYNC......................................................................28
JUXTAPID......................................................................33
k-effervescent.....................................................................29
K-PHOS..........................................................................42
k-phos neutral....................................................................29
K-PHOS NO 2................................................................43
K-TABS...........................................................................29
k-vescent tbef.....................................................................29
KADCYLA......................................................................19
KADIAN CP24 100MG, 200MG...................................47
KADIAN CP24 10MG, 20MG, 30MG, 50MG, 60MG,
80MG...........................................................................47
KADIAN CP24 130MG, 150MG, 40MG, 70MG..........47
KALBITOR.....................................................................65
KALETRA ORAL SOLN................................................22
KALETRA TABS.............................................................22
kalexate.............................................................................35
KALYDECO....................................................................65
KAPVAY..........................................................................58
KAPVAY DOSE PACK....................................................58
kariva...............................................................................52
KAYEXALATE................................................................35
KAZANO........................................................................28
kcl 0.075%/d5w/nacl 0.45%.............................................29
kcl 0.15%/d5w/ nacl 0.3%................................................29
kcl 0.15%/d5w/lr..............................................................29
kcl 0.15%/d5w/nacl 0.2%.................................................29
kcl 0.15%/d5w/nacl 0.225%.............................................29
kcl 0.15%/d5w/nacl 0.45%...............................................29
kcl 0.15%/d5w/nacl 0.9%.................................................29
kcl 0.3%/d5w/lr iv lac ring................................................29
kcl 0.3%/d5w/nacl 0.45%.................................................29
kcl 0.3%/d5w/nacl 0.9%...................................................29
KEDBUMIN...................................................................24
KEFLEX..........................................................................24
kelnor 1/35.......................................................................52
KENALOG......................................................................71
Comprehensive_P3TARO_10R
113
Effective January 1, 2014
KENALOG-10..................................................................9
KENALOG-40..................................................................9
KEPIVANCE.....................................................................8
KEPPRA..........................................................................11
KEPPRA XR TB24 500MG............................................11
KEPPRA XR TB24 750MG............................................11
KERAFOAM...................................................................38
KERAFOAM 42..............................................................38
KERLONE......................................................................16
KETEK............................................................................37
ketoconazole crea...............................................................70
ketoconazole foam..............................................................70
ketoconazole sham..............................................................70
ketoconazole tabs...............................................................13
ketodan.............................................................................70
ketodan kit........................................................................70
ketoprofen.........................................................................50
ketoprofen er......................................................................50
ketorolac tromethamine inj 15mg/ml, 30mg/ml, 60mg/
2ml................................................................................50
ketorolac tromethamine inj 300mg/10ml............................50
ketorolac tromethamine ophthalmic soln..............................51
ketorolac tromethamine tabs...............................................50
KINERET.......................................................................54
KINRIX...........................................................................73
kionex...............................................................................35
KLARON........................................................................70
KLONOPIN TABS 0.5MG.............................................11
KLONOPIN TABS 1MG................................................11
KLONOPIN TABS 2MG................................................11
klor-con............................................................................29
klor-con 10.......................................................................29
KLOR-CON 25...............................................................29
klor-con 8.........................................................................29
klor-con m10.....................................................................29
klor-con m15.....................................................................29
klor-con m20.....................................................................29
klor-con/ef.........................................................................29
kobee................................................................................84
KOMBIGLYZE XR TB24 1000MG; 2.5MG..................28
KOMBIGLYZE XR TB24 1000MG; 5MG, 500MG;
5MG.............................................................................28
KORLYM........................................................................40
KRISTALOSE.................................................................39
KRYSTEXXA...................................................................32
kurvelo..............................................................................52
Effective January 1, 2014
114
KUVAN...........................................................................40
KYNAMRO.....................................................................33
KYPROLIS......................................................................19
l-methyl-b6-b12................................................................84
l-methyl-mc.......................................................................84
l-methyl-mc nac.................................................................81
l-methylfolate ca/p-5-p/me-cbl............................................84
labetalol hcl.......................................................................16
LAC-HYDRIN................................................................38
laclotion............................................................................38
LACRISERT....................................................................42
lactated ringers..................................................................29
lactated ringers dextrose 5% viaflex.....................................35
lactated ringers irrigation...................................................32
lactated ringers viaflex........................................................30
lactulose............................................................................39
LAMICTAL CHEWABLE DISPERSIBLE......................11
LAMICTAL ODT...........................................................11
LAMICTAL STARTER/NOT TAKING
CARBAMAZEPINE.....................................................11
LAMICTAL STARTER/TAKING CARBAMAZEPINE/
NOT TAKING VALPROATE......................................11
LAMICTAL STARTER/TAKING VALPROATE............11
LAMICTAL TABS...........................................................11
LAMICTAL XR...............................................................11
LAMISIL.........................................................................13
LAMISIL SPRAY.............................................................70
lamivudine........................................................................22
lamivudine/zidovudine......................................................22
lamotrigine........................................................................11
lamotrigine er....................................................................11
LANOXIN INJ................................................................24
LANOXIN TABS 0.125MG............................................24
LANOXIN TABS 0.25MG..............................................24
lansoprazole.......................................................................72
LANTUS.........................................................................28
LANTUS SOLOSTAR....................................................28
LASIX..............................................................................16
LASTACAFT...................................................................42
latanoprost........................................................................53
LATISSE..........................................................................80
latrix................................................................................80
LATUDA TABS 120MG.................................................58
LATUDA TABS 20MG...................................................58
LATUDA TABS 40MG...................................................58
LATUDA TABS 80MG...................................................58
Comprehensive_P3TARO_10R
LAZANDA......................................................................47
leena.................................................................................52
leflunomide.......................................................................54
LESCOL..........................................................................33
LESCOL XL....................................................................33
lessina...............................................................................52
LETAIRIS........................................................................65
letrozole............................................................................19
leucovorin calcium inj 100mg, 10mg/ml, 200mg, 350mg,
50mg...............................................................................8
leucovorin calcium inj 500mg..............................................8
leucovorin calcium tabs........................................................8
LEUKERAN....................................................................19
LEUKINE.......................................................................23
leuprolide acetate...............................................................19
levalbuterol.......................................................................65
levalbuterol hcl nebu 0.31mg/3ml.......................................65
levalbuterol hcl nebu 0.63mg/3ml.......................................65
levalbuterol hcl nebu 1.25mg/3ml.......................................65
LEVAQUIN INJ 5%; 250MG/50ML, 5%; 750MG/
150ML..........................................................................66
LEVAQUIN INJ 5%; 500MG/100ML............................66
LEVAQUIN ORAL SOLN..............................................66
LEVAQUIN TABS..........................................................66
LEVATOL.......................................................................16
LEVEMIR.......................................................................28
LEVEMIR FLEXPEN.....................................................28
levetiracetam er tb24 500mg..............................................11
levetiracetam er tb24 750mg..............................................11
levetiracetam inj 500mg/5ml..............................................11
levetiracetam oral soln........................................................11
levetiracetam tabs..............................................................11
LEVITRA........................................................................81
levobunolol hcl...................................................................23
levocarnitine......................................................................35
levocetirizine dihydrochloride oral soln................................14
levocetirizine dihydrochloride tabs.......................................14
levofloxacin in d5w............................................................66
levofloxacin inj..................................................................66
levofloxacin ophthalmic soln...............................................10
levofloxacin oral soln..........................................................66
levofloxacin tabs................................................................66
levonest.............................................................................52
levonorgestrel.....................................................................52
levonorgestrel and ethinyl estradiol......................................52
levonorgestrel/ethinyl estradiol.............................................52
levora 0.15/30-28..............................................................52
levorphanol tartrate...........................................................47
levothroid..........................................................................68
LEVOTHYROXINE SODIUM INJ 100MCG...............68
levothyroxine sodium inj 200mcg........................................68
levothyroxine sodium inj 500mcg........................................68
levothyroxine sodium tabs...................................................68
levoxyl...............................................................................68
LEVULAN KERASTICK................................................38
LEXAPRO ORAL SOLN................................................58
LEXAPRO TABS 10MG.................................................58
LEXAPRO TABS 20MG.................................................58
LEXAPRO TABS 5MG...................................................58
LEXIVA...........................................................................22
LIALDA...........................................................................39
lidocaine crea....................................................................69
lidocaine hcl external soln...................................................69
lidocaine hcl gel.................................................................69
lidocaine hcl in d5w............................................................9
lidocaine hcl inj 0.5%, 1%, 2%, 4%.................................69
lidocaine hcl inj 1.5%.......................................................69
lidocaine hcl inj 10mg/ml.....................................................9
lidocaine hcl inj 2%..........................................................69
lidocaine hcl inj 20mg/ml.....................................................9
lidocaine hcl inj 20mg/ml.....................................................9
lidocaine hcl jelly...............................................................69
lidocaine hcl lotn...............................................................69
lidocaine hcl mouth/throat soln...........................................69
lidocaine hcl/dextrose............................................................9
lidocaine hcl/hydrocortisone acetate crea..............................39
lidocaine hcl/hydrocortisone acetate crea..............................69
lidocaine hcl/hydrocortisone acetate kit 0.5%; 3%, 2%;
2%................................................................................39
lidocaine oint....................................................................69
lidocaine viscous................................................................69
lidocaine/epinephrine inj 1:100000; 1%, 1:100000;
2%................................................................................69
lidocaine/epinephrine inj 1:200000; 0.5%, 1:200000;
1.5%, 1:200000; 2%.....................................................69
lidocaine/prilocaine............................................................69
LIDODERM...................................................................69
LINCOCIN.....................................................................37
lindane.............................................................................72
LINZESS.........................................................................39
LIORESAL INTRATHECAL INJ 0.05MG/ML.............45
Comprehensive_P3TARO_10R
115
Effective January 1, 2014
LIORESAL INTRATHECAL INJ 10MG/20ML, 10MG/
5ML, 40MG/20ML......................................................45
liothyronine sodium inj......................................................68
liothyronine sodium tabs....................................................69
LIPITOR.........................................................................33
LIPOFEN........................................................................33
lipoflavovit........................................................................81
LIPOSYN II....................................................................44
liposyn iii inj 1.2%; 2.5%; 10%, 1.8%; 2.5%; 30%.........44
liposyn iii inj 1.2%; 2.5%; 20%........................................44
lisinopril...........................................................................16
lisinopril/hydrochlorothiazide.............................................16
lithium carbonate..............................................................58
lithium carbonate er..........................................................58
lithium citrate...................................................................58
LITHOBID.....................................................................58
LITHOSTAT...................................................................35
LIVALO...........................................................................33
LO LOESTRIN FE.........................................................52
LOCOID.........................................................................71
LOCOID LIPOCREAM.................................................71
LODOSYN.....................................................................21
LOESTRIN 1.5/30-21.....................................................52
LOESTRIN 1/20-21........................................................52
LOESTRIN 24 FE...........................................................52
LOESTRIN FE 1.5/30....................................................52
LOESTRIN FE 1/20.......................................................52
LOFIBRA CAPS 134MG, 200MG.................................33
LOFIBRA CAPS 67MG..................................................33
LOFIBRA TABS 160MG................................................33
LOFIBRA TABS 54MG..................................................33
lohist-peb-dm....................................................................78
LOKARA.........................................................................71
LOMOTIL......................................................................13
loperamide hcl caps............................................................13
LOPID.............................................................................33
LOPRESSOR HCT.........................................................16
LOPRESSOR INJ............................................................16
LOPRESSOR TABS........................................................16
LOPROX.........................................................................70
LOPROX SHAMPOO....................................................70
lorazepam conc..................................................................58
lorazepam inj....................................................................58
lorazepam intensol.............................................................58
lorazepam tabs...................................................................58
LORCET 10/650.............................................................47
Effective January 1, 2014
116
LORCET PLUS...............................................................47
LORTAB ELIX................................................................47
LORTAB TABS...............................................................47
loryna...............................................................................52
LORZONE.....................................................................45
losartan potassium tabs 100mg...........................................16
losartan potassium tabs 25mg, 50mg...................................16
losartan potassium/hydrochlorothiazide...............................16
LOSEASONIQUE..........................................................52
LOTEMAX......................................................................67
LOTENSIN.....................................................................16
LOTENSIN HCT...........................................................16
LOTREL..........................................................................16
LOTRISONE..................................................................70
LOTRONEX...................................................................39
lovastatin tabs 10mg, 20mg................................................33
lovastatin tabs 40mg..........................................................33
LOVAZA.........................................................................33
LOVENOX INJ 100MG/ML, 120MG/0.8ML, 150MG/
ML, 60MG/0.6ML, 80MG/0.8ML..............................25
LOVENOX INJ 300MG/3ML, 30MG/0.3ML, 40MG/
0.4ML...........................................................................25
low-ogestrel........................................................................52
loxapine............................................................................59
loxapine succinate..............................................................59
LOXITANE.....................................................................59
lozi-flur.............................................................................74
lta 360 kit.........................................................................69
LUCENTIS.....................................................................42
ludent...............................................................................74
LUFYLLIN......................................................................65
LUMIGAN......................................................................53
LUMINAL.......................................................................11
LUMIZYME....................................................................40
LUNESTA.......................................................................59
LUPRON DEPOT INJ 11.25MG, 22.5MG, 3.75MG,
7.5MG..........................................................................19
LUPRON DEPOT INJ 30MG, 45MG...........................19
LUPRON DEPOT-PED INJ 11.25MG, 15MG,
30MG...........................................................................19
LUPRON DEPOT-PED INJ 11.25MG, 7.5MG............19
LUSTRA-AF....................................................................80
lustra-ultra........................................................................80
lutera................................................................................52
LUVOX CR CP24 100MG.............................................59
LUVOX CR CP24 150MG.............................................59
Comprehensive_P3TARO_10R
LUXIQ............................................................................71
LYRICA CAPS 100MG...................................................12
LYRICA CAPS 150MG...................................................12
LYRICA CAPS 200MG...................................................12
LYRICA CAPS 225MG, 300MG....................................12
LYRICA CAPS 25MG.....................................................12
LYRICA CAPS 50MG.....................................................12
LYRICA CAPS 75MG.....................................................12
LYRICA ORAL SOLN....................................................12
lysiplex plus liqd................................................................84
LYSODREN....................................................................19
LYSTEDA........................................................................42
m-clear wc.........................................................................78
m-end dm.........................................................................78
M-M-R II W/DILUENT 10 DOSE................................73
m.v.i. adult.......................................................................84
M.V.I. PEDIATRIC.........................................................84
M.V.I.-12 WITHOUT VITAMIN K..............................84
MACROBID...................................................................72
MACRODANTIN..........................................................72
MACUGEN....................................................................42
macuvite...........................................................................84
macuvite eye care...............................................................84
mafenide acetate................................................................70
mag-delay.........................................................................79
mag-sr...............................................................................79
mag-sr plus calcium...........................................................79
mag64..............................................................................79
MAGNACET TABS 400MG; 10MG..............................47
MAGNACET TABS 400MG; 5MG, 400MG;
7.5MG..........................................................................47
MAGNESIUM CHLORIDE POWD.............................79
MAGNESIUM SULFATE IN D5W INJ 5%; 10MG/
ML................................................................................30
magnesium sulfate inj 40mg/ml, 80mg/ml...........................30
magnesium sulfate inj 50%................................................30
MAKENA........................................................................32
MALARONE...................................................................37
malathion.........................................................................72
manganese sulfate inj.........................................................79
manganese trace metal........................................................79
mannitol inj 10%, 20%, 5%............................................16
mannitol inj 25%.............................................................16
mapap cold formula multi-symptom....................................78
maprotiline hcl tabs 25mg..................................................59
maprotiline hcl tabs 50mg..................................................59
maprotiline hcl tabs 75mg..................................................59
MARCAINE....................................................................69
MARCAINE SPINAL......................................................35
marcaine w/o epi...............................................................69
MARCAINE/EPINEPHRINE INJ 0.25%;
1:200000.......................................................................69
MARCAINE/EPINEPHRINE INJ 0.5%; 1:200000.......69
margesic............................................................................47
MARINOL......................................................................39
marlissa.............................................................................52
MARPLAN......................................................................59
marten-tab........................................................................47
MATULANE...................................................................19
matzim la.........................................................................16
MAVIK............................................................................16
MAXAIR AUTOHALER................................................65
MAXALT.........................................................................33
MAXALT-MLT................................................................33
MAXIDEX......................................................................67
MAXIDONE...................................................................47
MAXIFED DM...............................................................78
MAXIFED DMX............................................................78
MAXITROL....................................................................66
MAXZIDE......................................................................16
MAXZIDE-25.................................................................16
meclizine hcl tabs...............................................................39
meclofenamate sodium.......................................................50
medi-tussin dm..................................................................78
MEDROL..........................................................................9
MEDROL DOSEPAK.......................................................9
medroxyprogesterone acetate................................................32
mefenamic acid.................................................................50
mefloquine hcl...................................................................37
MEFOXIN......................................................................24
mega multiple w/chelated minerals......................................84
MEGACE ES...................................................................19
MEGACE ORAL.............................................................19
megestrol acetate................................................................19
meijer c.............................................................................84
meijer cough syrup dm.......................................................78
MEKINIST.....................................................................19
meloxicam susp..................................................................50
meloxicam tabs..................................................................50
melpaque hp......................................................................80
melphalan hydrochloride....................................................19
MENACTRA..................................................................73
Comprehensive_P3TARO_10R
117
Effective January 1, 2014
MENEST........................................................................32
MENOMUNE-A/C/Y/W-135........................................73
MENOSTAR...................................................................32
MENTAX........................................................................70
MENVEO.......................................................................73
meperidine hcl inj 100mg/ml, 25mg/ml, 50mg/ml...............47
meperidine hcl inj 10mg/ml...............................................47
meperidine hcl oral soln......................................................47
meperidine hcl tabs 100mg.................................................47
meperidine hcl tabs 50mg...................................................47
meperitab tabs 100mg........................................................47
meperitab tabs 50mg..........................................................47
MEPHYTON..................................................................77
meprobamate tabs 200mg..................................................45
meprobamate tabs 400mg..................................................45
MEPRON........................................................................37
mercaptopurine..................................................................19
MERIBIN........................................................................84
meropenem........................................................................37
MERREM.......................................................................37
mesalamine.......................................................................39
mesehist dm.......................................................................78
mesna.................................................................................8
MESNEX INJ....................................................................8
MESNEX TABS................................................................8
MESTINON SYRP.........................................................45
MESTINON TABS.........................................................45
MESTINON TIMESPAN...............................................45
METADATE CD............................................................59
metadate er.......................................................................59
metafolbic.........................................................................84
metafolbic plus...................................................................81
METANX........................................................................84
metaproterenol sulfate........................................................65
metaxalone........................................................................45
metformin hcl er tb24 1000mg...........................................28
metformin hcl er tb24 500mg.............................................28
metformin hcl er tb24 500mg.............................................28
metformin hcl er tb24 750mg.............................................28
metformin hcl tabs 1000mg...............................................28
metformin hcl tabs 500mg.................................................28
metformin hcl tabs 850mg.................................................28
methadone hcl conc............................................................48
methadone hcl inj..............................................................48
methadone hcl intensol.......................................................48
methadone hcl oral soln 10mg/5ml......................................48
Effective January 1, 2014
118
methadone hcl oral soln 5mg/5ml........................................48
methadone hcl tabs 10mg...................................................48
methadone hcl tabs 5mg.....................................................48
methadone hcl tbso.............................................................48
methadose conc..................................................................48
methadose sugar-free..........................................................48
methadose tabs...................................................................48
methadose tbso...................................................................48
methamphetamine hcl........................................................59
methazolamide..................................................................53
methenamine hippurate.....................................................72
methenamine mandelate....................................................72
methimazole......................................................................21
METHITEST..................................................................40
methocarbamol..................................................................45
methotrexate......................................................................19
methotrexate sodium inj 1gm..............................................19
methotrexate sodium inj 25mg/ml.......................................19
methscopolamine bromide..................................................13
methyclothiazide................................................................16
methyldopa........................................................................16
methyldopa/hydrochlorothiazide..........................................16
methyldopate hcl................................................................16
methylergonovine maleate inj..............................................54
methylergonovine maleate tabs............................................54
METHYLIN CHEW.......................................................59
METHYLIN ORAL SOLN 10MG/5ML........................59
METHYLIN ORAL SOLN 5MG/5ML..........................59
methylphenidate hcl...........................................................59
methylphenidate hcl cd.......................................................59
methylphenidate hcl er cp24...............................................59
methylphenidate hcl er tbcr 10mg.......................................59
methylphenidate hcl er tbcr 18mg, 27mg, 54mg..................59
methylphenidate hcl er tbcr 20mg.......................................59
methylphenidate hcl er tbcr 36mg.......................................59
methylphenidate hcl sr........................................................59
methylphenidate hydrochloride oral soln 10mg/5ml..............59
methylphenidate hydrochloride oral soln 5mg/5ml................59
methylprednisolone...............................................................9
methylprednisolone acetate....................................................9
methylprednisolone dose pack................................................9
methylprednisolone sodiumsuccinate inj 1000mg, 125mg,
1gm, 40mg.......................................................................9
methylprednisolone sodiumsuccinate inj 500mg.....................9
metipranolol......................................................................23
metoclopramide hcl............................................................39
Comprehensive_P3TARO_10R
metolazone........................................................................16
metoprolol succinate er.......................................................16
metoprolol tartrate inj........................................................16
metoprolol tartrate tabs......................................................16
metoprolol/hydrochlorothiazide...........................................16
METOZOLV ODT.........................................................39
metro iv............................................................................37
METROCREAM............................................................68
METROGEL...................................................................68
METROGEL-VAGINAL................................................42
METROLOTION...........................................................68
metronidazole....................................................................37
metronidazole....................................................................68
metronidazole in nacl 0.79%.............................................37
metronidazole vaginal........................................................42
METVIXIA.....................................................................38
MEVACOR TABS 20MG...............................................33
MEVACOR TABS 40MG...............................................33
mexiletine hcl......................................................................9
MIACALCIN INJ...........................................................41
MIACALCIN NASAL SOLN..........................................41
MICARDIS HCT TABS 12.5MG; 40MG, 25MG;
80MG...........................................................................16
MICARDIS HCT TABS 12.5MG; 80MG......................16
MICARDIS TABS 20MG, 40MG...................................16
MICARDIS TABS 80MG................................................17
miconazole 3.....................................................................42
MICRHOGAM ULTRA-FILTERED PLUS...................73
MICRO-K.......................................................................30
microgestin 1.5/30.............................................................52
microgestin 1/20................................................................52
microgestin fe.....................................................................52
microgestin fe 1.5/30..........................................................52
micronized colestipol hcl.....................................................33
MICROZIDE..................................................................17
midazolam hcl inj 10mg/10ml, 1mg/ml, 2mg/2ml, 5mg/
5ml................................................................................59
midazolam hcl inj 10mg/2ml, 25mg/5ml, 50mg/10ml, 5mg/
ml..................................................................................59
midazolam hcl syrp............................................................59
midodrine hcl....................................................................35
migergot............................................................................33
MIGRANAL....................................................................34
millipred dp........................................................................9
MILLIPRED ORAL SOLN...............................................9
millipred tabs......................................................................9
milltrium senior................................................................84
milrinone in dextrose.........................................................38
milrinone lactate...............................................................38
mimvey.............................................................................32
MINIPRESS....................................................................17
MINITRAN....................................................................50
MINIVELLE...................................................................32
MINOCIN......................................................................67
MINOCIN KIT..............................................................67
minocycline hcl..................................................................67
minocycline hcl er..............................................................67
minoxidil tabs...................................................................17
miostat..............................................................................53
MIRAPEX.......................................................................21
MIRAPEX ER.................................................................21
MIRCETTE....................................................................52
mirtazapine odt tbdp 15mg................................................59
mirtazapine odt tbdp 30mg................................................59
mirtazapine odt tbdp 45mg................................................59
mirtazapine tabs 15mg......................................................59
mirtazapine tabs 30mg......................................................59
mirtazapine tabs 45mg......................................................59
mirtazapine tabs 7.5mg.....................................................59
mirtazapine tbdp...............................................................59
misoprostol........................................................................72
mitomycin.........................................................................19
mitoxantrone hcl................................................................19
MOBIC SUSP.................................................................50
MOBIC TABS.................................................................50
modafinil tabs 100mg........................................................59
modafinil tabs 200mg........................................................59
MODICON....................................................................52
moexipril hcl.....................................................................17
moexipril/hydrochlorothiazide.............................................17
mometasone furoate crea.....................................................71
mometasone furoate external soln........................................71
mometasone furoate oint.....................................................71
MOMEXIN.....................................................................71
mono-linyah......................................................................52
MONODOX CAPS 100MG...........................................67
MONODOX CAPS 75MG.............................................67
mononessa.........................................................................52
MONSELS FERRIC SUBSULFATE...............................84
montelukast sodium...........................................................65
MONUROL....................................................................72
morgidox 1x100mg caps.....................................................67
Comprehensive_P3TARO_10R
119
Effective January 1, 2014
MORGIDOX 1X100MG KIT........................................67
morgidox 2x100mg caps.....................................................67
MORGIDOX 2X100MG KIT........................................67
morphine sulfate er cp24 100mg.........................................48
morphine sulfate er cp24 20mg, 30mg, 50mg, 60mg,
80mg.............................................................................48
morphine sulfate er tbcr 100mg, 200mg..............................48
morphine sulfate er tbcr 15mg, 30mg, 60mg.......................48
morphine sulfate in dextrose 5%.........................................48
morphine sulfate inj 0.5mg/ml, 1mg/ml..............................48
morphine sulfate inj 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/
ml, 2mg/ml, 4mg/ml, 50mg/ml, 5mg/ml..........................48
morphine sulfate inj 25mg/ml, 8mg/ml...............................48
MORPHINE SULFATE INJ 8MG/ML..........................48
morphine sulfate oral soln 10mg/5ml..................................48
morphine sulfate oral soln 20mg/5ml..................................48
morphine sulfate oral soln 20mg/ml....................................48
morphine sulfate supp........................................................48
morphine sulfate tabs 15mg................................................48
morphine sulfate tabs 30mg................................................48
MOTOFEN....................................................................13
MOVIPREP....................................................................39
MOXATAG.....................................................................54
MOXEZA........................................................................10
MOZOBIL......................................................................23
MS CONTIN TBCR 100MG, 200MG..........................48
MS CONTIN TBCR 15MG, 30MG, 60MG..................48
mucinex cough childrens.....................................................78
MUCINEX FAST-MAX COLD FLU& SORE
THROAT TABS...........................................................78
mucinex fast-max dm max.................................................78
MUCINEX FAST-MAX SEVERE CONGESTION &
COLD..........................................................................78
mucosa dm........................................................................78
mucus relief cough childrens................................................78
mucus relief dm.................................................................78
MULTAQ..........................................................................9
multi complete/iron............................................................84
multi-day..........................................................................84
multi-day plus iron............................................................84
MULTI-DELYN/IRON...................................................84
multi-vitamin...................................................................84
multi-vitamin/minerals......................................................84
multi-vitamins..................................................................84
multigen...........................................................................84
multigen folic....................................................................84
Effective January 1, 2014
120
multilex............................................................................84
multilex-t&m....................................................................84
multiple vitamins plain......................................................84
multiple vitamins tabs 50mg; 1mcg; 20mg; 1mg; 1mg;
2.5mg; 2mg; 5000unit; 400unit.....................................84
multiple vitamins/iron chew...............................................84
MULTITRACE-4............................................................79
MULTITRACE-5............................................................79
MULTITRACE-5 CONCENTRATE.............................79
multivitamin & mineral....................................................84
mupirocin.........................................................................70
mupirocin calcium.............................................................70
MUSE..............................................................................81
MUSTARGEN................................................................19
my way.............................................................................52
MYAMBUTOL...............................................................37
MYCAMINE...................................................................13
MYCOBUTIN................................................................37
mycophenolate mofetil........................................................19
MYDFRIN......................................................................74
mydral..............................................................................26
MYDRIACYL..................................................................26
myferon 150......................................................................84
MYFORTIC....................................................................19
MYKIDZ IRON..............................................................84
MYKIDZ IRON 10.........................................................84
mynephrocaps....................................................................84
MYOBLOC.....................................................................73
myorisan...........................................................................68
MYOZYME.....................................................................41
MYRBETRIQ.................................................................10
MYSOLINE....................................................................12
mytussin dac......................................................................78
myzilra.............................................................................52
NABI-HB........................................................................73
nabumetone......................................................................50
nadolol..............................................................................17
nadolol/bendroflumethiazide..............................................17
nafcillin sodium.................................................................54
NAFTIN CREA..............................................................70
NAFTIN GEL 1%...........................................................70
NAGLAZYME................................................................41
nail-ex..............................................................................84
nalbuphine hcl..................................................................51
NALFON........................................................................51
nallpen iso-osmotic in dextrose............................................54
Comprehensive_P3TARO_10R
nallpen/dextrose.................................................................54
naloxone hcl inj 0.4mg/ml..................................................51
naloxone hcl inj 1mg/ml.....................................................51
naltrexone hcl....................................................................51
NAMENDA ORAL SOLN.............................................41
NAMENDA TABS..........................................................41
NAMENDA TITRATION PAK.....................................41
NAMENDA XR..............................................................41
NAMENDA XR TITRATION PACK............................41
naphazoline hcl.................................................................74
NAPRELAN....................................................................51
NAPROSYN....................................................................51
naproxen...........................................................................51
naproxen dr.......................................................................51
naproxen sodium tabs 275mg, 550mg.................................51
naratriptan hcl..................................................................34
NARDIL..........................................................................59
NAROPIN.......................................................................69
NASACORT AQ.............................................................65
NASCOBAL....................................................................84
NASONEX......................................................................65
NATA KOMPLETE........................................................74
NATACHEW..................................................................74
NATACYN......................................................................10
NATAFORT....................................................................74
natalvirt 90 dha................................................................74
natalvirt ca.......................................................................75
natalvirt flt.......................................................................84
NATAZIA........................................................................52
nateglinide tabs 120mg......................................................28
nateglinide tabs 60mg........................................................28
NATELLE ONE..............................................................75
NATRECOR...................................................................38
NATROBA......................................................................72
NEBUPENT...................................................................37
necon 0.5/35-28................................................................52
necon 1/35........................................................................52
necon 1/50-28...................................................................52
necon 10/11-28.................................................................52
necon 7/7/7.......................................................................52
NEEDLES, INSULIN DISP., SAFETY...........................28
nefazodone hcl tabs 100mg.................................................59
nefazodone hcl tabs 150mg.................................................59
nefazodone hcl tabs 200mg.................................................59
nefazodone hcl tabs 250mg.................................................59
nefazodone hcl tabs 50mg...................................................59
NEO-FRADIN................................................................37
neo-polycin........................................................................10
neo-polycin hc....................................................................66
neofrin..............................................................................74
neomycin sulfate tabs.........................................................37
neomycin/bacitracin/polymyxin...........................................10
neomycin/polymyxin b sulfates............................................32
neomycin/polymyxin/bacitracin zinc....................................10
neomycin/polymyxin/bacitracin/hydrocortisone.....................66
neomycin/polymyxin/dexamethasone....................................66
neomycin/polymyxin/gramicidin..........................................10
neomycin/polymyxin/hc......................................................54
neomycin/polymyxin/hydrocortisone.....................................54
neomycin/polymyxin/hydrocortisone.....................................66
NEOPROFEN................................................................51
NEORAL.........................................................................19
NEOSPORIN.................................................................10
NEOSPORIN GU IRRIGANT......................................32
neostigmine methylsulfate inj 0.5mg/ml...............................45
neostigmine methylsulfate inj 1mg/ml..................................45
neotuss..............................................................................78
nephplex rx.......................................................................84
NEPHRAMINE..............................................................44
nephro-vite rx....................................................................84
NEPHRON FA...............................................................84
NEPHRONEX LIQD.....................................................84
NEPTAZANE.................................................................53
NERVO B-12 SL.............................................................84
NESACAINE...................................................................69
NESACAINE-MPF.........................................................69
NESINA TABS 12.5MG.................................................28
NESINA TABS 25MG....................................................28
NESINA TABS 6.25MG.................................................28
NESTABS........................................................................75
NESTABS DHA..............................................................75
NEULASTA....................................................................23
NEUMEGA.....................................................................23
NEUPOGEN..................................................................23
NEUPRO........................................................................21
NEURIN-SL....................................................................84
NEURONTIN CAPS 100MG........................................12
NEURONTIN CAPS 300MG........................................12
NEURONTIN CAPS 400MG........................................12
NEURONTIN ORAL SOLN.........................................12
NEURONTIN TABS 600MG........................................12
NEURONTIN TABS 800MG........................................12
Comprehensive_P3TARO_10R
121
Effective January 1, 2014
NEUT.............................................................................30
neutragard advanced..........................................................35
neutral sodium fluoride......................................................35
NEVANAC......................................................................51
nevirapine.........................................................................22
NEXA PLUS....................................................................75
NEXAVAR.......................................................................19
NEXIUM........................................................................72
NEXIUM I.V. INJ 20MG...............................................72
NEXIUM I.V. INJ 40MG...............................................72
next choice one dose............................................................52
NEXTERONE..................................................................9
niacin cpcr........................................................................80
niacin er cpcr 500mg.........................................................80
niacin flush free caps 100mg; 400mg, 500mg......................81
niacin tabs 100mg, 250mg, 50mg......................................80
NIACIN TR TBCR 1000MG.........................................80
niacin tr tbcr 250mg, 500mg, 750mg.................................80
niacinamide......................................................................80
NIACOR.........................................................................33
NIASPAN........................................................................33
nicardipine hcl caps...........................................................17
nicardipine hcl inj.............................................................17
NICOTROL INHALER.................................................66
NICOTROL NS..............................................................66
nifediac cc.........................................................................17
nifedical xl........................................................................17
nifedipine..........................................................................17
nifedipine er......................................................................17
NILANDRON................................................................19
nimodipine........................................................................17
NIPENT..........................................................................19
NIRAVAM.......................................................................59
nisoldipine........................................................................17
nisoldipine er.....................................................................17
nitro-bid...........................................................................50
NITRO-DUR..................................................................50
nitro-time.........................................................................81
nitrofurantoin...................................................................72
nitrofurantoin macrocrystal................................................72
nitrofurantoin macrocrystalline...........................................72
nitrofurantoin macrocrystals...............................................72
nitrofurantoin monohydrate...............................................73
nitrofurantoin monohydrate/macrocrystals...........................73
nitroglycerin in 5% dextrose...............................................50
Effective January 1, 2014
122
nitroglycerin in dextrose 5% inj 5%; 200mcg/ml, 5%;
400mcg/ml.....................................................................50
nitroglycerin inj.................................................................50
nitroglycerin lingual aers....................................................50
nitroglycerin lingual translingual soln..................................50
nitroglycerin pt24..............................................................50
nitroglycerin transdermal....................................................50
NITROLINGUAL PUMPSPRAY...................................50
NITROMIST..................................................................50
NITROSTAT...................................................................50
nizatidine caps..................................................................72
nizatidine oral soln............................................................72
NIZORAL.......................................................................70
NO FLUSH NIACIN CAPS...........................................81
no iron multiple vitamin/minerals......................................84
nohist-dm..........................................................................78
NOR-QD........................................................................32
nora-be.............................................................................32
NORCO..........................................................................48
NORDETTE-28.............................................................52
NORDITROPIN FLEXPRO..........................................23
NORDITROPIN NORDIFLEX PEN............................23
norepinephrine bitartrate...................................................38
norethindrone....................................................................32
norethindrone acetate.........................................................32
NORFLEX......................................................................45
norgestimate/ethinyl estradiol..............................................52
NORINYL 1+35..............................................................52
NORINYL 1+50..............................................................52
NORITATE.....................................................................68
NORMOSOL -R.............................................................30
NORMOSOL-M IN D5W.............................................44
NORMOSOL-R..............................................................44
NORMOSOL-R IN D5W..............................................30
NOROXIN......................................................................66
NORPACE........................................................................9
NORPACE CR..................................................................9
NORPRAMIN................................................................59
nortrel 0.5/35 (28)............................................................52
nortrel 1/35.......................................................................52
nortrel 7/7/7......................................................................52
nortriptyline hcl.................................................................59
NORTUSS-DE LIQD 5MG/ML; 50MG/ML; 2.5MG/
ML................................................................................78
NORVASC TABS 10MG, 2.5MG...................................17
NORVASC TABS 5MG...................................................17
Comprehensive_P3TARO_10R
NORVIR.........................................................................22
novarel..............................................................................41
NOVOLIN 70/30...........................................................28
NOVOLIN 70/30 RELION............................................28
NOVOLIN N..................................................................28
NOVOLIN N RELION..................................................28
NOVOLIN R..................................................................28
NOVOLIN R RELION..................................................28
NOVOLOG....................................................................28
NOVOLOG FLEXPEN..................................................28
NOVOLOG MIX 70/30.................................................28
NOVOLOG MIX 70/30 PREFILLED FLEXPEN..........28
NOVOLOG PENFILL....................................................28
NOXAFIL........................................................................13
NUCYNTA.....................................................................51
NUCYNTA ER...............................................................51
NUEDEXTA...................................................................41
NULOJIX........................................................................19
NULYTELY/FLAVOR PACKS........................................39
nuquin hp crea..................................................................80
NUTRESTORE..............................................................35
nutrilyte............................................................................30
nutrilyte ii.........................................................................30
NUTRIVIT.....................................................................84
NUTROPIN...................................................................23
NUTROPIN AQ.............................................................23
NUTROPIN AQ NUSPIN 10........................................23
NUTROPIN AQ NUSPIN 20........................................23
NUTROPIN AQ NUSPIN 5..........................................23
NUTROPIN AQ PEN....................................................23
NUVARING...................................................................42
NUVIGIL TABS 150MG................................................59
NUVIGIL TABS 250MG................................................59
NUVIGIL TABS 50MG..................................................59
nyamyc..............................................................................70
nystatin.............................................................................13
nystatin.............................................................................70
nystatin/triamcinolone.......................................................70
nystop...............................................................................70
O-CAL FA.......................................................................75
O-CAL PRENATAL........................................................75
ob-natal one caps 150mg; 25mg; 170unit; 260mg; 40mg;
7mg; 1mg; 20mg; 30mg; 30mg; 330mg; 25mg;
30unit...........................................................................75
OBSTETRIX EC.............................................................75
OBTREX.........................................................................75
ocella................................................................................52
OCTAGAM.....................................................................73
octreotide acetate................................................................19
OCUFEN........................................................................51
OCUFLOX......................................................................10
ocutabs..............................................................................84
ocutabs/lutein....................................................................84
OCUVITE.......................................................................84
OFIRMEV.......................................................................51
ofloxacin...........................................................................10
ofloxacin...........................................................................42
ofloxacin...........................................................................66
ogestrel..............................................................................52
olanzapine inj...................................................................59
olanzapine odt tbdp 10mg..................................................60
olanzapine odt tbdp 15mg..................................................60
olanzapine odt tbdp 20mg..................................................60
olanzapine odt tbdp 5mg....................................................60
olanzapine tabs 10mg........................................................60
olanzapine tabs 15mg........................................................60
olanzapine tabs 2.5mg.......................................................60
olanzapine tabs 20mg........................................................60
olanzapine tabs 5mg..........................................................60
olanzapine tabs 7.5mg.......................................................60
olanzapine/fluoxetine caps 25mg; 12mg, 50mg; 12mg, 50mg;
6mg...............................................................................60
olanzapine/fluoxetine caps 25mg; 3mg, 25mg; 6mg.............60
OLEPTRO TB24 150MG...............................................60
OLEPTRO TB24 300MG...............................................60
OLUX..............................................................................71
OLUX-E..........................................................................71
OMECLAMOX-PAK......................................................72
omeprazole cpdr.................................................................72
OMEPRAZOLE/SODIUM BICARBONATE CAPS
20MG; 1100MG..........................................................72
omeprazole/sodium bicarbonate caps 20mg; 1100mg, 40mg;
1100mg.........................................................................72
OMNARIS......................................................................65
omnicap............................................................................84
OMNIPRED...................................................................67
OMNITROPE................................................................23
OMONTYS....................................................................23
once daily/iron...................................................................84
ondansetron hcl inj............................................................39
ondansetron hcl oral soln....................................................39
ondansetron hcl tabs 24mg.................................................39
Comprehensive_P3TARO_10R
123
Effective January 1, 2014
ondansetron hcl tabs 4mg, 8mg...........................................39
ondansetron odt.................................................................39
one daily...........................................................................84
one daily adults 50+..........................................................85
ONE DAILY FOR WOMEN..........................................85
one daily maximum...........................................................85
one daily mens...................................................................85
one daily/calcium/iron/zinc.................................................85
one daily/iron/calcium........................................................85
one daily/minerals..............................................................85
one-a-day essential.............................................................85
ONE-A-DAY WOMENS FORMULA............................85
one-daily multi vitamins....................................................85
ONFI TABS 10MG.........................................................12
ONFI TABS 20MG.........................................................12
ONFI TABS 5MG...........................................................12
ONGLYZA TABS 2.5MG...............................................28
ONGLYZA TABS 5MG..................................................28
ONMEL..........................................................................13
ONSOLIS........................................................................48
ONTAK...........................................................................19
OPANA ER (CRUSH RESISTANT) TB12 10MG,
15MG, 20MG, 30MG, 5MG, 7.5MG.........................48
OPANA ER (CRUSH RESISTANT) TB12 40MG.........48
OPANA TABS.................................................................48
opium...............................................................................13
opium tincture...................................................................13
OPTIPRANOLOL..........................................................23
OPTIVAR........................................................................42
optivite p.m.t.....................................................................85
ORACEA.........................................................................67
ORACIT..........................................................................43
oralone..............................................................................35
ORAP..............................................................................60
ORAPRED........................................................................9
ORAPRED ODT..............................................................9
orasep................................................................................69
ORAVIG..........................................................................13
ORAZINC TABS............................................................79
ORBIVAN.......................................................................48
ORBIVAN CF.................................................................48
ORENCIA INJ 125MG/ML...........................................54
ORENCIA INJ 250MG..................................................54
ORFADIN.......................................................................35
orphenadrine citrate...........................................................45
orphenadrine citrate er.......................................................45
Effective January 1, 2014
124
orphenadrine/asa/caffeine...................................................45
orsythia.............................................................................52
ORTHO EVRA...............................................................42
ORTHO MICRONOR...................................................32
ORTHO TRI-CYCLEN..................................................52
ORTHO TRI-CYCLEN LO...........................................52
ORTHO-CEPT...............................................................52
ORTHO-CYCLEN.........................................................52
ORTHO-NOVUM 1/35.................................................52
ORTHO-NOVUM 7/7/7...............................................52
OSENI TABS 12.5MG; 15MG.......................................28
OSENI TABS 12.5MG; 30MG, 12.5MG; 45MG,
25MG; 15MG, 25MG; 30MG, 25MG; 45MG............28
OSMITROL VIAFLEX INJ 10%....................................17
osmitrol viaflex inj 20%....................................................17
OSMOPREP...................................................................39
oto-end 10.........................................................................80
OVACE WASH...............................................................77
OVCON-35....................................................................52
OVIDE............................................................................72
oxacillin sodium inj 10gm, 1gm, 2gm.................................54
OXACILLIN SODIUM INJ 2GM..................................54
oxaliplatin inj 100mg, 50mg..............................................19
oxaliplatin inj 100mg/20ml, 50mg/10ml............................19
OXANDRIN...................................................................41
oxandrolone.......................................................................41
oxaprozin..........................................................................51
oxazepam..........................................................................60
oxcarbazepine....................................................................12
OXECTA TABS 5MG.....................................................48
OXECTA TABS 7.5MG..................................................48
OXISTAT........................................................................70
OXSORALEN.................................................................38
OXSORALEN ULTRA...................................................38
OXTELLAR XR TB24 150MG.......................................12
OXTELLAR XR TB24 300MG.......................................12
OXTELLAR XR TB24 600MG.......................................12
oxybutynin chloride er tb24 10mg, 15mg............................10
oxybutynin chloride er tb24 5mg........................................10
oxybutynin chloride syrp.....................................................10
oxybutynin chloride tabs.....................................................10
oxycodone hcl caps..............................................................48
oxycodone hcl conc.............................................................48
oxycodone hcl oral soln.......................................................48
oxycodone hcl tabs 10mg....................................................48
oxycodone hcl tabs 15mg....................................................48
Comprehensive_P3TARO_10R
oxycodone hcl tabs 20mg....................................................48
oxycodone hcl tabs 30mg....................................................48
oxycodone hcl tabs 5mg......................................................48
oxycodone/acetaminophen caps............................................48
oxycodone/acetaminophen tabs 325mg; 10mg, 325mg;
2.5mg, 325mg; 5mg, 325mg; 7.5mg...............................49
oxycodone/acetaminophen tabs 500mg; 7.5mg.....................49
oxycodone/acetaminophen tabs 650mg; 10mg......................49
oxycodone/aspirin...............................................................49
oxycodone/ibuprofen...........................................................49
OXYCONTIN TB12 10MG, 15MG, 20MG, 30MG,
40MG...........................................................................49
OXYCONTIN TB12 60MG...........................................49
OXYCONTIN TB12 80MG...........................................49
oxymorphone hydrochloride................................................49
oxymorphone hydrochloride er tb12 10mg, 15mg, 20mg,
30mg, 5mg, 7.5mg.........................................................49
oxymorphone hydrochloride er tb12 40mg...........................49
oxytocin............................................................................54
OXYTROL......................................................................10
pa b-complex with b-12.....................................................85
pacerone..............................................................................9
paclitaxel...........................................................................19
pain relief cold severe congestion..........................................78
PAIRE OB.......................................................................75
palgic................................................................................14
PAMELOR......................................................................60
pamidronate disodium inj 30mg, 30mg/10ml, 90mg, 90mg/
10ml..............................................................................41
pamidronate disodium inj 6mg/ml......................................41
PAMINE..........................................................................13
PAMINE FORTE............................................................13
PANCREAZE..................................................................39
pancrelipase.......................................................................39
PANDEL.........................................................................71
PANHEMATIN..............................................................35
panoxyl wash.....................................................................81
PANRETIN.....................................................................38
pantoprazole sodium inj.....................................................72
pantoprazole sodium tbec...................................................72
PARA-AMINOBENZOIC ACID...................................80
PARAFON FORTE DSC................................................45
parcaine............................................................................42
PARCOPA.......................................................................21
paregoric...........................................................................13
PARLODEL....................................................................21
PARNATE.......................................................................60
paromomycin sulfate..........................................................37
paroxetine hcl er tb24 12.5mg............................................60
paroxetine hcl er tb24 25mg...............................................60
paroxetine hcl er tb24 37.5mg............................................60
paroxetine hcl tabs 10mg....................................................60
paroxetine hcl tabs 20mg....................................................60
paroxetine hcl tabs 30mg....................................................60
paroxetine hcl tabs 40mg....................................................60
PASER.............................................................................37
PATADAY........................................................................42
PATANASE.....................................................................35
PATANOL.......................................................................42
PAXIL CR TB24 12.5MG...............................................60
PAXIL CR TB24 25MG..................................................60
PAXIL CR TB24 37.5MG...............................................60
PAXIL SUSP....................................................................60
PAXIL TABS 10MG........................................................60
PAXIL TABS 20MG........................................................60
PAXIL TABS 30MG........................................................60
PAXIL TABS 40MG........................................................60
PCE.................................................................................31
pedi-dri.............................................................................70
pedia care multi-symptom cold children...............................78
PEDIADERM AF COMPLETE KIT..............................70
PEDIADERM HC..........................................................71
PEDIADERM TA............................................................71
PEDIAPRED.....................................................................9
PEDIARIX.......................................................................73
PEDIPIROX-4 NAIL.......................................................70
PEDVAX HIB..................................................................73
peg 3350/electrolytes...........................................................39
peg-3350/electrolytes..........................................................39
peg-3350/nacl/na bicarbonate/kcl.......................................39
PEG-INTRON................................................................23
PEG-INTRON REDIPEN..............................................23
PEG-INTRON REDIPEN PAK 4...................................23
PEGANONE...................................................................12
PEGASYS........................................................................23
PEGASYS PROCLICK....................................................23
penicillin g potassium.........................................................55
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE.................................................................55
penicillin g procaine...........................................................55
penicillin g sodium.............................................................55
penicillin v potassium.........................................................55
Comprehensive_P3TARO_10R
125
Effective January 1, 2014
PENLAC NAIL LACQUER............................................70
PENNSAID.....................................................................51
PENTACEL.....................................................................73
PENTAM 300.................................................................37
PENTASA........................................................................39
pentazocine/acetaminophen................................................51
pentazocine/naloxone hcl....................................................51
pentostatin........................................................................20
pentoxifylline er.................................................................25
PEPCID...........................................................................72
PERCOCET TABS 325MG; 10MG, 325MG; 2.5MG,
325MG; 5MG, 325MG; 7.5MG..................................49
PERCOCET TABS 500MG; 7.5MG...............................49
PERCOCET TABS 650MG; 10MG................................49
PERCODAN...................................................................49
PERFOROMIST.............................................................65
PERIDEX........................................................................35
PERIDIN-C....................................................................85
perindopril erbumine.........................................................17
perio med..........................................................................35
periogard...........................................................................35
PERJETA.........................................................................20
permethrin crea.................................................................72
perphenazine.....................................................................60
perphenazine/amitriptyline.................................................60
PERSANTINE................................................................25
PERTZYE........................................................................39
PEXEVA TABS 10MG.....................................................60
PEXEVA TABS 20MG.....................................................60
PEXEVA TABS 30MG.....................................................60
PEXEVA TABS 40MG.....................................................60
pfizerpen-g........................................................................55
phenadoz...........................................................................14
phenelzine sulfate...............................................................60
PHENERGAN INJ 25MG/ML.......................................14
PHENERGAN INJ 50MG/ML.......................................14
phenobarbital elix..............................................................12
phenobarbital sodium........................................................12
phenobarbital tabs 100mg..................................................12
phenobarbital tabs 15mg....................................................12
phenobarbital tabs 16.2mg.................................................12
phenobarbital tabs 30mg....................................................12
phenobarbital tabs 32.4mg.................................................12
phenobarbital tabs 60mg....................................................12
phenobarbital tabs 64.8mg.................................................12
phenobarbital tabs 97.2mg.................................................12
Effective January 1, 2014
126
phentolamine mesylate inj 5mg...........................................17
phenylephrine hcl ophthalmic soln.......................................74
PHENYTEK....................................................................12
phenytoin..........................................................................12
phenytoin infatabs.............................................................12
phenytoin sodium...............................................................12
phenytoin sodium extended.................................................12
philith...............................................................................53
PHISOHEX.....................................................................70
phlexy-vits.........................................................................81
PHOS-FLUR...................................................................35
PHOSLO.........................................................................30
PHOSLYRA.....................................................................30
phospha 250 neutral..........................................................30
PHOSPHOLINE IODIDE.............................................25
PHRENILIN FORTE.....................................................49
PHYSIOLYTE.................................................................32
PHYSIOSOL IRRIGATION...........................................32
PHYSIOSOL IRRIGATION PH 7.4..............................32
physostigmine salicylate......................................................53
PHYTONADIONE........................................................77
PICATO..........................................................................38
pilocarpine hcl...................................................................29
pilocarpine hcl...................................................................35
pilocarpine hydrochloride...................................................35
PILOPINE HS.................................................................29
pindolol............................................................................17
pioglitazone hcl tabs 15mg.................................................29
pioglitazone hcl tabs 30mg.................................................29
pioglitazone hcl tabs 45mg.................................................29
pioglitazone hcl-glimepiride................................................29
pioglitazone hcl/metformin hcl............................................29
piperacillin sodium/ tazobactam sodium..............................55
piperacillin sodium/tazobactam sodium...............................55
piperacillin/tazobactam......................................................55
piroxicam..........................................................................51
PITOCIN........................................................................54
PLAN B...........................................................................53
PLAN B ONE-STEP.......................................................53
PLAQUENIL..................................................................37
plasbumin-25....................................................................24
PLASMA-LYTE A...........................................................44
PLASMA-LYTE-148........................................................44
PLASMA-LYTE-56/D5W...............................................44
PLAVIX TABS 300MG....................................................25
PLAVIX TABS 75MG......................................................25
Comprehensive_P3TARO_10R
PLETAL...........................................................................25
PLIAGLIS........................................................................69
pnv ob+dha.......................................................................75
pnv prenatal plus multivitamin..........................................75
pnv-dha............................................................................75
pnv-first............................................................................75
pnv-select..........................................................................75
podofilox...........................................................................38
polocaine inj 1%...............................................................69
POLOCAINE INJ 2%....................................................69
polocaine-mpf inj 1%, 1.5%..............................................69
polocaine-mpf inj 2%........................................................69
poly-dex............................................................................66
poly-iron 150....................................................................85
poly-iron 150 forte.............................................................85
poly-tussin.........................................................................78
poly-tussin d......................................................................78
poly-vitamin drops.............................................................85
poly-vitamin/iron drops......................................................85
polycin..............................................................................10
polyethylene glycol 3350 pack.............................................39
polyethylene glycol 3350 powd............................................39
POLYETHYLENE GLYCOL 3350-GRX........................35
polymyxin b sulfate............................................................37
polymyxin b sulfate/trimethoprim sulfate.............................10
polysaccharide iron.............................................................85
polysaccharide iron forte.....................................................85
POLYTRIM.....................................................................10
polyvitamin.......................................................................85
polyvitamin/iron................................................................85
POMALYST....................................................................20
PONSTEL.......................................................................51
portia-28..........................................................................53
POTABA.........................................................................79
potassium acetate inj..........................................................30
potassium chloride 0.15% /nacl 0.45% viaflex....................30
potassium chloride 0.15% d5w/nacl 0.33%........................30
potassium chloride 0.15% d5w/nacl 0.45%........................30
potassium chloride 0.15% d5w/nacl 0.45% viaflex.............30
potassium chloride 0.15% nacl 0.9%.................................30
potassium chloride 0.15% w/nacl 0.9% viaflex...................30
potassium chloride 0.15%/d5w..........................................30
potassium chloride 0.15%/nacl 0.9%.................................30
potassium chloride 0.22% d5w/nacl 0.45%........................30
potassium chloride 0.224%/d5w/nacl 0.45%......................30
potassium chloride 0.224%d5w/nacl 0.45% viaflex............30
potassium chloride 0.3%/ nacl 0.9%..................................30
potassium chloride 0.3%/d5w............................................30
potassium chloride 0.3%/nacl 0.9%/viaflex.........................30
potassium chloride cr..........................................................30
potassium chloride er..........................................................30
potassium chloride inj 0.4meq/ml, 10meq/100ml, 10meq/
50ml, 20meq/100ml, 20meq/50ml, 30meq/100ml,
40meq/100ml................................................................30
potassium chloride inj 2meq/ml..........................................30
potassium chloride liqd.......................................................30
potassium chloride oral soln................................................30
potassium chloride sr..........................................................30
potassium citrate tbcr.........................................................43
poten b-150 tr...................................................................85
POTIGA TABS 200MG, 300MG, 400MG.....................12
POTIGA TABS 50MG....................................................12
pr natal 400......................................................................75
pr natal 400 ec..................................................................75
pr natal 430......................................................................75
pr natal 430 ec..................................................................75
PRADAXA.......................................................................25
pramipexole dihydrochloride...............................................21
PRAMOSONE CREA 2.5%; 1%....................................77
PRAMOSONE OINT....................................................77
PRAMOTIC....................................................................42
PRANDIMET.................................................................29
PRANDIN TABS 0.5MG................................................29
PRANDIN TABS 1MG...................................................29
PRANDIN TABS 2MG...................................................29
prascion.............................................................................68
prascion fc.........................................................................68
PRAVACHOL.................................................................33
pravastatin sodium............................................................33
prazosin hcl.......................................................................17
PRECOSE TABS 100MG...............................................29
PRECOSE TABS 25MG.................................................29
PRECOSE TABS 50MG.................................................29
PRED FORTE.................................................................67
PRED MILD...................................................................67
PRED-G..........................................................................66
PRED-G S.O.P................................................................66
prednicarbate....................................................................71
prednisolone........................................................................9
prednisolone acetate...........................................................67
prednisolone sodium phosphate ophthalmic soln...................67
Comprehensive_P3TARO_10R
127
Effective January 1, 2014
prednisolone sodium phosphate oral soln 15mg/5ml, 5mg/
5ml..................................................................................9
prednisolone sodium phosphate oral soln 25mg/5ml................9
prednisone...........................................................................9
prednisone intensol...............................................................9
PREFERA OB.................................................................75
PREFERA OB + DHA....................................................75
PREFERAOB ONE.........................................................75
PREFEST........................................................................32
PREGNYL W/DILUENT BENZYL ALCOHOL/
NACL...........................................................................41
PRELONE.........................................................................9
PREMARIN CREA.........................................................32
PREMARIN INJ.............................................................32
PREMARIN TABS..........................................................32
premasol inj 52meq/l; 1760mg/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/100ml...........................................44
PREMASOL INJ 56MEQ/L; 320MG/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/
100ML..........................................................................44
PREMPHASE..................................................................32
PREMPRO......................................................................32
prena1 chew/quatrefolic.....................................................75
prena1 plus/quatrefolic.......................................................75
prena1/quatrefolic..............................................................75
prenafirst...........................................................................75
prenaissance.......................................................................75
prenaissance plus................................................................75
prenaplus..........................................................................75
PRENATA.......................................................................75
prenatabs fa.......................................................................75
prenatabs obn....................................................................75
prenatabs rx......................................................................75
prenatal 19 chew 100mg; 1000unit; 200mg; 7mg; 12mcg;
25mg; 29mg; 1mg; 6mg; 20mg; 3mg; 3mg; 400unit;
30unit; 20mg.................................................................75
Effective January 1, 2014
128
prenatal 19 chew 100mg; 1000unit; 200mg; 7mg; 400unit;
12mcg; 29mg; 1mg; 15mg; 20mg; 3mg; 3mg; 30unit;
20mg.............................................................................75
PRENATAL 19 TABS 100MG; 1000UNIT; 200MG;
7MG; 400UNIT; 12MCG; 25MG; 29MG; 1MG;
15MG; 20MG; 3MG; 3MG; 30UNIT; 20MG.............75
prenatal 19 tabs 100mg; 200mg; 400unit; 12mcg; 25mg;
29mg; 1mg; 15mg; 7mg; 20mg; 3mg; 3mg; 1000unit;
30unit; 20mg.................................................................75
prenatal ad........................................................................75
prenatal low iron tabs 120mg; 0; 200mg; 400unit; 2mg;
12mcg; 27mg; 1mg; 20mg; 10mg; 3mg; 1.84mg; 22unit;
4000unit; 25mg.............................................................75
prenatal plus......................................................................75
prenatal plus iron..............................................................75
prenatal tabs 120mg; 0; 0; 200mg; 400unit; 2mg; 12mcg;
27mg; 1mg; 20mg; 10mg; 3mg; 1.84mg; 22mg; 4000unit;
25mg.............................................................................75
prenatal vitamins plus........................................................75
prenatal-u.........................................................................75
PRENATE ELITE...........................................................75
PRENATE ESSENTIAL..................................................75
PRENEXA.......................................................................75
PREPIDIL.......................................................................42
PREPOPIK......................................................................39
PREQUE 10....................................................................75
PRESGEN B....................................................................78
PREVACID.....................................................................72
PREVACID SOLUTAB...................................................72
prevalite............................................................................33
PREVIDENT..................................................................35
PREVIDENT 5000 BOOSTER......................................35
PREVIDENT 5000 BOOSTER PLUS............................35
PREVIDENT 5000 DRY MOUTH................................35
PREVIDENT 5000 ENAMEL PROTECT.....................35
PREVIDENT 5000 PLUS...............................................35
PREVIDENT 5000 SENSITIVE....................................35
PREVIDENT FLUORIDE.............................................35
previfem............................................................................53
PREVPAC.......................................................................72
PREZISTA SUSP.............................................................22
PREZISTA TABS 150MG, 75MG..................................22
PREZISTA TABS 400MG, 600MG, 800MG..................22
PRIALT...........................................................................51
PRIFTIN.........................................................................37
PRILOSEC CPDR..........................................................72
Comprehensive_P3TARO_10R
PRILOSEC PACK...........................................................72
PRIMAQUINE PHOSPHATE.......................................37
PRIMAXIN IV................................................................37
PRIMAXIN IV ADD-VANTAGE...................................37
primidone.........................................................................12
PRIMLEV........................................................................49
PRIMSOL.......................................................................73
PRINIVIL........................................................................17
PRISTIQ TB24 100MG..................................................60
PRISTIQ TB24 50MG....................................................60
PRIVIGEN......................................................................73
PRO-RED AC.................................................................78
PROAIR HFA..................................................................65
probenecid.........................................................................32
probenecid/colchicine..........................................................32
procainamide hcl inj 100mg/ml............................................9
procainamide hcl inj 500mg/ml............................................9
PROCALAMINE............................................................44
PROCARDIA..................................................................17
PROCARDIA XL............................................................17
procentra...........................................................................60
prochlorperazine................................................................39
prochlorperazine edisylate...................................................39
prochlorperazine maleate....................................................39
PROCRIT.......................................................................23
procto-pak.........................................................................39
PROCTOCORT CREA..................................................40
PROCTOCORT SUPP...................................................80
PROCTOCREAM HC...................................................40
proctosol hc........................................................................40
proctozone-hc....................................................................40
PROFE............................................................................85
PROFERRIN ES.............................................................85
PROFERRIN-FORTE.....................................................85
progesterone caps................................................................32
progesterone inj..................................................................32
PROGLYCEM.................................................................29
PROGRAF CAPS............................................................20
PROGRAF INJ................................................................20
PROLASTIN-C...............................................................35
PROLENSA.....................................................................51
PROLEUKIN..................................................................23
PROLIA...........................................................................53
PROMACTA...................................................................26
promethazine hcl inj 25mg/ml............................................14
promethazine hcl inj 50mg/ml............................................14
promethazine hcl plain.......................................................14
promethazine hcl supp........................................................14
promethazine hcl syrp.........................................................14
promethazine hcl tabs........................................................14
promethazine vc................................................................26
promethazine vc plain........................................................26
promethazine vc/codeine.....................................................78
promethazine-dm..............................................................78
promethazine/codeine.........................................................78
promethazine/dextromethorphan.........................................78
promethegan......................................................................14
PROMETRIUM..............................................................32
propafenone hcl...................................................................9
propafenone hcl er................................................................9
propantheline bromide.......................................................13
proparacaine hcl................................................................42
PROPECIA......................................................................80
propranolol hcl er...............................................................17
propranolol hcl inj.............................................................17
propranolol hcl oral soln.....................................................17
propranolol hcl tabs............................................................17
propranolol/hydrochlorothiazide..........................................17
propylthiouracil.................................................................21
PROQUAD.....................................................................73
PROSCAR.......................................................................23
prosight.............................................................................85
PROSOL.........................................................................44
PROSTIGMIN TABS......................................................45
PROSTIN E2..................................................................42
PROSTIN VR PEDIATRIC............................................43
protamine sulfate...............................................................26
PROTECT PLUS LIQD.................................................81
PROTECTIRON............................................................85
PROTONIX INJ.............................................................72
PROTONIX PACK.........................................................72
PROTONIX TBEC.........................................................72
PROTOPAM CHLORIDE.............................................13
PROTOPIC.....................................................................38
protriptyline hcl.................................................................60
PROVENTIL HFA..........................................................65
PROVERA.......................................................................32
PROVIGIL TABS 100MG..............................................60
PROVIGIL TABS 200MG..............................................60
PROZAC CAPS 10MG...................................................60
PROZAC CAPS 20MG...................................................60
PROZAC CAPS 40MG...................................................60
Comprehensive_P3TARO_10R
129
Effective January 1, 2014
PROZAC WEEKLY........................................................61
prudoxin...........................................................................38
PULMICORT FLEXHALER..........................................65
PULMICORT SUSP 0.25MG/2ML, 0.5MG/2ML........65
PULMICORT SUSP 1MG/2ML....................................65
PULMOZYME...............................................................65
PUREFE OB PLUS.........................................................75
purevit dualfe plus.............................................................85
PURINETHOL...............................................................20
PYLERA..........................................................................72
pyrazinamide....................................................................37
pyridostigmine bromide......................................................45
pyridoxine hcl inj...............................................................85
pyridoxine hcl tabs 100mg, 25mg.......................................85
q-tussin dm.......................................................................78
QNASL............................................................................65
QUALAQUIN.................................................................37
quasense............................................................................53
QUESTRAN...................................................................33
QUESTRAN LIGHT......................................................33
quetiapine fumarate tabs 100mg........................................61
quetiapine fumarate tabs 200mg........................................61
quetiapine fumarate tabs 25mg..........................................61
quetiapine fumarate tabs 300mg........................................61
quetiapine fumarate tabs 400mg........................................61
quetiapine fumarate tabs 50mg..........................................61
QUILLIVANT XR..........................................................61
quinapril hcl.....................................................................17
quinapril/hydrochlorothiazide.............................................17
quinidine gluconate.............................................................9
quinidine gluconate cr..........................................................9
quinidine gluconate er..........................................................9
quinidine sulfate..................................................................9
quinidine sulfate er..............................................................9
quinine sulfate...................................................................37
QUTENZA.....................................................................38
QVAR..............................................................................65
R-GENE 10.....................................................................44
ra b-complex/vitamin c tr...................................................85
ra tussin dm......................................................................78
RABAVERT.....................................................................73
ramipril............................................................................17
RANEXA.........................................................................38
ranitidine hcl caps..............................................................72
ranitidine hcl inj...............................................................72
ranitidine hcl syrp..............................................................72
Effective January 1, 2014
130
ranitidine hcl tabs 150mg, 300mg......................................72
RAPAFLO.......................................................................23
RAPAMUNE...................................................................20
RAVICTI.........................................................................35
RAYOS..............................................................................9
RAZADYNE ER..............................................................41
RAZADYNE ORAL SOLN.............................................41
RAZADYNE TABS.........................................................41
REAPHIRM....................................................................75
REBETOL.......................................................................22
REBIF..............................................................................23
REBIF REBIDOSE.........................................................23
REBIF REBIDOSE TITRATION PACK........................23
REBIF TITRATION PACK............................................23
RECLAST.......................................................................35
reclipsen............................................................................53
RECOMBIVAX HB........................................................73
RECTIV..........................................................................40
refenesen dm......................................................................78
refissa................................................................................81
REGLAN.........................................................................40
regonol..............................................................................45
REGRANEX...................................................................38
RELAGARD....................................................................42
relcof c..............................................................................78
RELENZA DISKHALER................................................22
RELISTOR......................................................................40
relnate dha........................................................................75
RELPAX..........................................................................34
REMERON SOLTAB TBDP 15MG...............................61
REMERON SOLTAB TBDP 30MG...............................61
REMERON SOLTAB TBDP 45MG...............................61
REMERON TABS 15MG...............................................61
REMERON TABS 30MG...............................................61
REMERON TABS 45MG...............................................61
remeven............................................................................38
remeven............................................................................80
REMICADE....................................................................40
REMODULIN................................................................17
rena-vite...........................................................................85
rena-vite rx.......................................................................85
RENACIDIN..................................................................43
RENAGEL......................................................................35
renal caps..........................................................................85
renalpren...........................................................................85
RENATABS.....................................................................85
Comprehensive_P3TARO_10R
RENATABS WITH IRON..............................................85
RENAX...........................................................................85
reno caps...........................................................................85
RENOVA........................................................................81
RENVELA PACK............................................................35
RENVELA TABS.............................................................36
REOPRO.........................................................................26
repaglinide tabs 1mg..........................................................29
repaglinide tabs 2mg..........................................................29
repan................................................................................49
reprexain...........................................................................49
REQUIP..........................................................................21
REQUIP XL....................................................................21
RESCON DM.................................................................78
RESCRIPTOR................................................................22
RESCULA.......................................................................53
RESECTISOL.................................................................17
reserpine tabs 0.1mg..........................................................17
reserpine tabs 0.25mg........................................................17
RESPA C&C IR..............................................................78
RESTASIS.......................................................................42
RESTORIL......................................................................61
RETIN-A.........................................................................68
RETIN-A MICRO..........................................................68
RETIN-A MICRO PUMP..............................................68
RETISERT......................................................................67
RETROVIR.....................................................................22
RETROVIR IV INFUSION...........................................22
REVATIO INJ.................................................................65
REVATIO TABS..............................................................65
REVIA.............................................................................51
REVLIMID CAPS 10MG...............................................20
REVLIMID CAPS 15MG, 20MG, 25MG......................20
REVLIMID CAPS 2.5MG..............................................20
REVLIMID CAPS 5MG.................................................20
revonto..............................................................................45
REYATAZ CAPS 100MG................................................22
REYATAZ CAPS 150MG, 200MG, 300MG..................22
RHEUMATREX.............................................................20
RHINOCORT AQUA....................................................65
RHOGAM ULTRA-FILTERED PLUS...........................73
RHOPHYLAC................................................................73
ribapak.............................................................................22
ribasphere caps...................................................................22
ribasphere tabs 200mg, 600mg...........................................22
ribasphere tabs 400mg.......................................................22
RIBATAB.........................................................................22
ribavirin...........................................................................22
RIDAURA.......................................................................54
RIFADIN CAPS..............................................................37
RIFADIN INJ..................................................................37
RIFAMATE.....................................................................37
rifampin...........................................................................37
RIFATER.........................................................................37
RILUTEK........................................................................36
riluzole.............................................................................36
rimantadine hcl.................................................................22
RIMSO-50.......................................................................37
ringers injection.................................................................30
ringers irrigation................................................................32
RIOMET.........................................................................29
risanoid plus......................................................................81
RISPERDAL CONSTA INJ 12.5MG, 25MG,
37.5MG........................................................................61
RISPERDAL CONSTA INJ 50MG................................61
RISPERDAL M-TAB TBDP 0.5MG...............................61
RISPERDAL M-TAB TBDP 1MG..................................61
RISPERDAL M-TAB TBDP 2MG..................................61
RISPERDAL M-TAB TBDP 3MG..................................61
RISPERDAL M-TAB TBDP 4MG..................................61
RISPERDAL ORAL SOLN.............................................61
RISPERDAL TABS 0.25MG...........................................61
RISPERDAL TABS 0.5MG.............................................61
RISPERDAL TABS 1MG................................................61
RISPERDAL TABS 2MG................................................61
RISPERDAL TABS 3MG................................................61
RISPERDAL TABS 4MG................................................61
risperidone m-tab tbdp 0.5mg............................................61
risperidone m-tab tbdp 1mg...............................................61
risperidone m-tab tbdp 2mg...............................................61
risperidone m-tab tbdp 3mg...............................................61
risperidone m-tab tbdp 4mg...............................................61
risperidone odt tbdp 0.25mg...............................................61
risperidone odt tbdp 0.5mg.................................................61
risperidone odt tbdp 1mg....................................................61
risperidone odt tbdp 2mg....................................................61
risperidone odt tbdp 3mg....................................................61
risperidone odt tbdp 4mg....................................................61
risperidone oral soln...........................................................61
risperidone tabs 0.25mg.....................................................61
risperidone tabs 0.5mg.......................................................61
risperidone tabs 1mg..........................................................61
Comprehensive_P3TARO_10R
131
Effective January 1, 2014
risperidone tabs 2mg..........................................................61
risperidone tabs 3mg..........................................................61
risperidone tabs 4mg..........................................................62
RITALIN.........................................................................62
RITALIN LA...................................................................62
RITALIN SR...................................................................62
RITUXAN.......................................................................20
rivastigmine tartrate..........................................................42
rizatriptan benzoate...........................................................34
rizatriptan benzoate odt.....................................................34
robafen cf cough & cold......................................................78
robafen cough....................................................................78
robafen dm........................................................................78
robafen dm cough clear......................................................78
ROBAXIN.......................................................................45
ROBAXIN-750................................................................45
ROBINUL.......................................................................13
ROBINUL FORTE.........................................................13
ROBITUSSIN COLD+FLU DAYTIME.........................78
robitussin cough & chest congestion dm max........................78
robitussin cough & cold d...................................................78
robitussin cough/cold cf.......................................................78
robitussin dm....................................................................78
ROCALTROL.................................................................41
ROCEPHIN....................................................................24
romycin.............................................................................10
ropinirole er......................................................................21
ropinirole hcl.....................................................................21
rosadan.............................................................................68
ROSADAN KIT..............................................................68
ROSANIL CLEANSER...................................................68
ROTARIX........................................................................73
ROTATEQ......................................................................73
ROWASA.........................................................................40
ROXICET ORAL SOLN................................................49
roxicet tabs........................................................................49
ROXICODONE TABS 15MG........................................49
ROXICODONE TABS 30MG........................................49
ROZEREM.....................................................................62
rynex dm...........................................................................79
RYTHMOL.......................................................................9
RYTHMOL SR.................................................................9
SABRIL...........................................................................12
SAFYRAL........................................................................53
SAIZEN CLICK.EASY....................................................23
SAIZEN INJ 5MG..........................................................23
Effective January 1, 2014
132
SAIZEN INJ 8.8MG.......................................................23
SALAGEN.......................................................................36
SALEX.............................................................................80
SALEX CREAM..............................................................80
salicylic acid cream............................................................80
salicylic acid foam..............................................................80
salicylic acid gel.................................................................32
salicylic acid liqd...............................................................80
salicylic acid sham..............................................................80
saline flush........................................................................36
saline flush zr/sterile field...................................................36
salsalate.............................................................................51
salvax................................................................................80
SAMSCA TABS 15MG...................................................41
SAMSCA TABS 30MG...................................................41
SANCTURA...................................................................10
SANCTURA XR.............................................................10
SANCUSO......................................................................40
SANDIMMUNE.............................................................20
SANDOSTATIN.............................................................20
SANDOSTATIN LAR DEPOT......................................20
SANTYL..........................................................................72
SAPHRIS SUBL 10MG...................................................62
SAPHRIS SUBL 5MG.....................................................62
SARAFEM TABS 10MG.................................................62
SARAFEM TABS 20MG.................................................62
SAVELLA TABS 100MG.................................................54
SAVELLA TABS 12.5MG................................................54
SAVELLA TABS 25MG...................................................54
SAVELLA TABS 50MG...................................................54
SAVELLA TITRATION PACK.......................................54
scalacort............................................................................71
SCOOBY-DOO ONE A DAY........................................85
SCOPOLAMINE HYDROBROMIDE..........................40
se-care...............................................................................75
se-natal 19........................................................................75
se-natal one.......................................................................75
se-tan dha.........................................................................75
SEASONIQUE................................................................53
seb-prev wash....................................................................77
seconal..............................................................................62
SECTRAL........................................................................17
SELECT-OB....................................................................75
SELECT-OB+DHA.........................................................75
selegiline hcl......................................................................21
selenium inj.......................................................................79
Comprehensive_P3TARO_10R
selenium sulfide.................................................................21
selenium tabs 100mcg........................................................79
selenium tabs 200mcg........................................................79
SELZENTRY...................................................................22
SEMPREX-D..................................................................26
SENSIPAR TABS 30MG, 60MG....................................41
SENSIPAR TABS 90MG.................................................41
SENSORCAINE INJ 0.25%...........................................69
sensorcaine inj 0.5%..........................................................69
SENSORCAINE-MPF INJ 0.25%..................................69
sensorcaine-mpf inj 0.5%...................................................69
SENSORCAINE-MPF INJ 0.5%, 0.75%........................69
SENSORCAINE-MPF SPINAL......................................36
SENSORCAINE-MPF/EPINEPHRINE.........................69
sensorcaine/epinephrine inj 0.25%; 1:200000.....................69
sensorcaine/epinephrine inj 0.5%; 1:200000.......................69
SEREVENT DISKUS.....................................................65
SEROMYCIN.................................................................37
SEROQUEL TABS 100MG............................................62
SEROQUEL TABS 200MG............................................62
SEROQUEL TABS 25MG..............................................62
SEROQUEL TABS 300MG............................................62
SEROQUEL TABS 400MG............................................62
SEROQUEL TABS 50MG..............................................62
SEROQUEL XR TB24 150MG......................................62
SEROQUEL XR TB24 200MG......................................62
SEROQUEL XR TB24 300MG......................................62
SEROQUEL XR TB24 400MG......................................62
SEROQUEL XR TB24 50MG........................................62
SEROSTIM.....................................................................23
sertraline hcl conc..............................................................62
sertraline hcl tabs 100mg....................................................62
sertraline hcl tabs 25mg......................................................62
sertraline hcl tabs 50mg......................................................62
seton et-ec..........................................................................75
setonet...............................................................................75
sf......................................................................................36
sf 5000 plus.......................................................................36
SFROWASA.....................................................................40
SIGNIFOR......................................................................20
sildenafil citrate.................................................................65
SILENOR........................................................................62
silphen dm cough...............................................................79
siltussin dm das.................................................................79
siltussin-dm.......................................................................79
SILVADENE....................................................................24
silver sulfadiazine..............................................................24
SIMBRINZA...................................................................53
SIMCOR TB24 1000MG; 20MG, 500MG; 20MG,
750MG; 20MG............................................................33
SIMCOR TB24 1000MG; 40MG, 500MG; 40MG........33
SIMPONI INJ 100MG/ML............................................54
SIMPONI INJ 100MG/ML, 50MG/0.5ML...................54
SIMULECT INJ 10MG..................................................20
SIMULECT INJ 20MG..................................................20
simvastatin........................................................................33
SINEMET.......................................................................21
SINEMET CR.................................................................21
SINGULAIR...................................................................65
SIRTURO........................................................................37
SKELAXIN......................................................................45
SKELID...........................................................................36
SKLICE...........................................................................72
slo-niacin tbcr 500mg........................................................80
SLO-NIACIN TBCR 750MG.........................................80
SLOW FE TBCR 142MG...............................................85
slow release iron tbcr 160mg...............................................85
SLOW RELEASE IRON TBCR 47.5MG.......................85
sodium acetate...................................................................30
SODIUM ASCORBATE.................................................85
sodium bicarbonate inj 4.2%.............................................30
sodium bicarbonate inj 7.5%, 8.4%...................................30
sodium bicarbonate partial fill............................................30
sodium chloride 0.45%......................................................30
sodium chloride 0.45% viaflex...........................................30
sodium chloride 0.9%........................................................36
sodium chloride 0.9%........................................................36
sodium chloride bacteriostatic.............................................36
sodium chloride bacteriostatic/benzyl alcohol........................36
sodium chloride flush.........................................................36
sodium chloride inj 0.9%...................................................36
sodium chloride inj 2.5meq/ml, 3%, 4meq/ml.....................30
sodium chloride inj 5%......................................................30
sodium chloride irrigation soln............................................36
sodium chloride nebu 0.9%................................................65
sodium chloride nebu 10%, 3%, 7%..................................65
sodium chloride pab...........................................................36
sodium chloride thermoject system.......................................36
SODIUM DIURIL..........................................................17
SODIUM EDECRIN......................................................17
sodium ferric gluconate complex/sucrose...............................80
sodium fluoride chew.........................................................75
Comprehensive_P3TARO_10R
133
Effective January 1, 2014
sodium fluoride oral soln....................................................75
sodium fluoride tabs...........................................................75
sodium lactate inj..............................................................30
sodium phenylbutyrate.......................................................36
sodium phosphate...............................................................30
sodium polystyrene sulfonate powd.......................................36
sodium polystyrene sulfonate susp 15gm/60ml......................36
sodium polystyrene sulfonate susp 30gm/120ml....................36
sodium sulfacetamide.........................................................67
sodium sulfacetamide.........................................................70
sodium sulfacetamide wash.................................................21
sodium sulfacetamide wash.................................................77
sodium sulfacetamide/sulfur cleanser...................................68
sodium sulfacetamide/sulfur cleanser in urea........................68
sodium sulfacetamide/sulfur foam.......................................68
sodium sulfacetamide/sulfur lotn.........................................68
sodium sulfacetamide/sulfur pads........................................68
sodium sulfacetamide/sulfur susp 10%; 5%.........................68
sodium sulfacetamide/sulfur wash liqd 9%; 4%...................68
SOLARAZE.....................................................................38
solia..................................................................................53
SOLODYN......................................................................67
SOLTAMOX...................................................................20
SOLU-CORTEF INJ 1000MG.........................................9
SOLU-CORTEF INJ 100MG, 250MG, 500MG..............9
SOLU-MEDROL INJ 1000MG, 125MG, 40MG,
500MG...........................................................................9
SOLU-MEDROL INJ 2GM..............................................9
SOMA.............................................................................45
SOMATULINE DEPOT................................................20
SOMAVERT...................................................................41
SONATA CAPS 10MG...................................................62
SONATA CAPS 5MG.....................................................62
SORBITOL IRRIGATION SOLN 3.3%........................32
SORIATANE...................................................................21
SORILUX........................................................................21
sorine..................................................................................9
sotalol hcl............................................................................9
sotalol hcl (af ).....................................................................9
SOTALOL HYDROCHLORIDE.....................................9
SOTRADECOL..............................................................36
SOURCECF CHEW.......................................................85
SPECTRACEF................................................................24
spinosad............................................................................72
SPIRIVA HANDIHALER...............................................65
spironolactone....................................................................17
Effective January 1, 2014
134
spironolactone/hydrochlorothiazide......................................17
SPORANOX CAPS.........................................................13
SPORANOX ORAL SOLN............................................13
SPORANOX PULSEPAK...............................................13
sprintec 28........................................................................53
SPRIX..............................................................................51
SPRYCEL........................................................................20
sps.....................................................................................36
sronyx...............................................................................53
ssd.....................................................................................24
SSKI.................................................................................77
stagesic..............................................................................49
STALEVO 100................................................................21
STALEVO 125................................................................21
STALEVO 150................................................................21
STALEVO 200................................................................21
STALEVO 50..................................................................21
STALEVO 75..................................................................21
stannous fluoride oral rinse.................................................36
STARLIX TABS 120MG.................................................29
STARLIX TABS 60MG...................................................29
stavudine..........................................................................22
STAVZOR.......................................................................12
STAXYN..........................................................................81
STELARA........................................................................21
sterile water irrigation........................................................36
sterile water irrigation plastic bottle....................................36
sterile water irrigation w/hanger.........................................36
STIMATE........................................................................41
STIVARGA......................................................................20
STRATTERA CAPS 100MG, 60MG, 80MG.................62
STRATTERA CAPS 10MG, 18MG, 25MG, 40MG......62
STREPTOMYCIN SULFATE.........................................37
stress formula w/iron..........................................................85
STRIANT........................................................................41
STRIBILD.......................................................................22
STROMECTOL..............................................................37
STROVITE FORTE SYRP..............................................85
strovite plus.......................................................................85
sublimaze..........................................................................49
SUBOXONE FILM 12MG; 3MG..................................51
SUBOXONE FILM 2MG; 0.5MG.................................51
SUBOXONE FILM 4MG; 1MG....................................51
SUBOXONE FILM 8MG; 2MG....................................51
SUBSYS LIQD 100MCG, 1200MCG, 200MCG,
400MCG, 800MCG.....................................................49
Comprehensive_P3TARO_10R
SUBSYS LIQD 1600MCG, 600MCG............................49
SUCRAID.......................................................................40
sucralfate susp....................................................................72
sucralfate tabs....................................................................72
sufenta..............................................................................49
sufentanil citrate................................................................49
SULAR............................................................................17
sulfacetamide sodium.........................................................67
sulfacetamide sodium.........................................................70
sulfacetamide sodium/prednisolone sodium phosphate...........66
sulfacetamide sodium/sulfur cleanser...................................68
sulfadiazine.......................................................................67
sulfamethoxazole/trimethoprim...........................................67
sulfamethoxazole/trimethoprim ds.......................................67
SULFAMYLON..............................................................70
sulfasalazine......................................................................40
sulfazine............................................................................40
sulfazine ec........................................................................40
sulindac............................................................................51
SUMADAN WASH.........................................................68
sumatriptan nasal soln 20mg/act.........................................34
sumatriptan nasal soln 5mg/act...........................................34
sumatriptan succinate inj...................................................34
sumatriptan succinate refill.................................................34
sumatriptan succinate tabs.................................................34
SUMAVEL DOSEPRO...................................................34
SUMAXIN......................................................................68
SUMAXIN TS.................................................................68
SUMAXIN WASH..........................................................68
sunvite advanced...............................................................85
super b with c....................................................................85
super quints b-50...............................................................85
super thera vite m..............................................................85
superplex-t.........................................................................85
SUPERVITE....................................................................85
SUPERVITE EC..............................................................85
support..............................................................................85
SUPPRELIN LA..............................................................20
SUPRAX CAPS...............................................................24
SUPRAX CHEW 100MG...............................................24
SUPRAX CHEW 200MG...............................................24
SUPRAX SUSR 100MG/5ML, 200MG/5ML.................24
SUPRAX SUSR 500MG/5ML........................................25
SUPRAX TABS................................................................25
SUPREP BOWEL PREP.................................................40
supress-dx pediatric............................................................79
SURMONTIL.................................................................62
SUSTIVA.........................................................................22
SUTENT.........................................................................20
syeda.................................................................................53
SYLATRON....................................................................23
SYMBICORT..................................................................65
SYMBYAX CAPS 25MG; 12MG, 50MG; 12MG, 50MG;
6MG.............................................................................62
SYMBYAX CAPS 25MG; 3MG, 25MG; 6MG...............62
SYMLINPEN 120...........................................................29
SYMLINPEN 60.............................................................29
SYNAGEX.......................................................................85
SYNAGIS........................................................................22
SYNALAR CREA............................................................71
SYNALAR CREAM KIT.................................................71
SYNALAR EXTERNAL SOLN.......................................71
SYNALAR OINT............................................................71
SYNALAR TS..................................................................71
SYNALGOS-DC.............................................................49
SYNAREL.......................................................................41
SYNERA..........................................................................69
SYNERCID.....................................................................37
SYNRIBO........................................................................20
SYNTHROID.................................................................69
SYPRINE.........................................................................36
tab-a-vite womens.............................................................85
tab-a-vite/iron...................................................................85
TABLOID.......................................................................20
TACLONEX....................................................................21
tacrolimus.........................................................................20
TAFINLAR......................................................................20
TALWIN..........................................................................51
TAMBOCOR....................................................................9
TAMIFLU CAPS 30MG.................................................22
TAMIFLU CAPS 45MG.................................................22
TAMIFLU CAPS 75MG.................................................22
TAMIFLU SUSR.............................................................22
tamoxifen citrate................................................................20
tamsulosin hcl....................................................................23
TANDEM.......................................................................85
TANDEM DHA..............................................................76
TANDEM F....................................................................85
TANDEM OB.................................................................76
TANDEM PLUS.............................................................85
TAPAZOLE.....................................................................21
TARCEVA.......................................................................20
Comprehensive_P3TARO_10R
135
Effective January 1, 2014
TARGRETIN CAPS........................................................20
TARGRETIN GEL..........................................................20
TARKA............................................................................17
taron forte.........................................................................85
taron-prex.........................................................................76
TASIGNA........................................................................20
TASMAR.........................................................................21
TAXOTERE....................................................................20
TAZICEF INJ 1GM, 2GM, 6GM...................................25
TAZORAC......................................................................68
taztia xt............................................................................17
TECFIDERA...................................................................42
TECFIDERA STARTER PACK......................................42
TEFLARO.......................................................................25
TEGRETOL....................................................................12
TEGRETOL-XR.............................................................12
TEKAMLO.....................................................................17
TEKTURNA...................................................................17
TEKTURNA HCT.........................................................17
temazepam........................................................................62
TEMOVATE...................................................................71
TEMOVATE E................................................................71
tencon...............................................................................49
TENEX...........................................................................17
TENIVAC.......................................................................73
TENORETIC 100...........................................................17
TENORETIC 50.............................................................17
TENORMIN...................................................................17
TERAZOL 3....................................................................42
TERAZOL 7....................................................................42
terazosin hcl......................................................................17
terbinafine hcl tabs............................................................13
TERBINEX.....................................................................13
terbutaline sulfate..............................................................65
terconazole........................................................................42
TERSI FOAM.................................................................21
TESSALON PERLES......................................................79
TESTIM..........................................................................41
TESTOPEL.....................................................................41
testosterone cypionate..........................................................41
testosterone enanthate.........................................................41
TESTRED.......................................................................41
tetanus toxoid adsorbed......................................................73
TETANUS/DIPHTHERIA TOXOIDS-ADSORBED
ADULT........................................................................73
tetracycline hcl...................................................................67
Effective January 1, 2014
136
TEV-TROPIN.................................................................23
TEVETEN HCT.............................................................17
TEVETEN TABS 400MG...............................................17
TEVETEN TABS 600MG...............................................17
TEXACORT....................................................................71
TH B COMPLEX/IRON/VITAMIN C/VITAMIN
E...................................................................................85
th vision vitamins/lutein....................................................85
th vitamin b1....................................................................85
TH WOMENS DAILY...................................................85
THALOMID...................................................................20
THEO-24........................................................................65
theochron..........................................................................65
theophylline.......................................................................65
theophylline cr...................................................................65
theophylline er...................................................................65
thera m plus......................................................................85
thera-m.............................................................................85
thera-plus..........................................................................85
thera-tabs..........................................................................85
thera-tabs m......................................................................85
thera/beta-carotene.............................................................85
THERACYS....................................................................73
THERAFLU SEVERE COLD & COUGH
DAYTIME....................................................................79
THERAFLU SEVERE COLD NIGHTTIME................79
THERAFLU WARMING RELIEF MULTI-SYMPTOM
COLD DAYTIME........................................................79
theraflu warming relief severe cold daytime..........................79
therapeutic........................................................................85
therapeutic formula/hematinics...........................................85
therapeutic m....................................................................85
THERAPEUTIC-M/LUTEIN........................................85
theratrum complete............................................................85
therems.............................................................................85
therems-m.........................................................................85
thiamine hcl inj.................................................................85
THIAMINE HCL POWD..............................................85
thiamine hcl tabs...............................................................85
THIOLA.........................................................................36
thioridazine hcl.................................................................62
thiotepa.............................................................................20
thiothixene........................................................................62
THROMBATE III W/10 ML STERILE WATER...........26
THROMBATE III W/20 ML STERILE WATER...........26
THYMOGLOBULIN.....................................................74
Comprehensive_P3TARO_10R
THYROLAR-1................................................................69
THYROLAR-1/2.............................................................69
THYROLAR-1/4.............................................................69
THYROLAR-2................................................................69
THYROLAR-3................................................................69
tiagabine hydrochloride......................................................12
TIAZAC..........................................................................17
TICE BCG......................................................................74
ticlopidine hcl....................................................................26
TIGAN............................................................................40
TIKOSYN.........................................................................9
tilia fe...............................................................................53
TIMENTIN INJ 0.1GM/100ML; 3GM/100ML, 1GM;
30GM...........................................................................55
TIMENTIN INJ 0.1GM; 3GM......................................55
timolol maleate..................................................................17
timolol maleate..................................................................23
timolol maleate ophthalmic gel forming...............................23
TIMOPTIC.....................................................................23
TIMOPTIC OCUDOSE................................................23
TIMOPTIC-XE...............................................................23
TINDAMAX...................................................................37
tinidazole..........................................................................37
TIROSINT......................................................................69
tizanidine hcl....................................................................45
tl g-fol os...........................................................................85
tl icon...............................................................................85
tl-care dha.........................................................................76
tl-fol 500..........................................................................85
tl-hem 150........................................................................85
TOBI...............................................................................37
TOBI PODHALER.........................................................37
TOBRADEX OINT........................................................66
TOBRADEX ST..............................................................66
TOBRADEX SUSP.........................................................66
tobramycin sulfate inj 1.2gm..............................................37
tobramycin sulfate inj 1.2gm/30ml, 10mg/ml, 40mg/ml,
80mg/2ml......................................................................37
tobramycin sulfate ophthalmic soln......................................10
tobramycin sulfate/sodium chloride inj 0.9%; 0.8mg/ml.......37
tobramycin sulfate/sodium chloride inj 0.9%; 1.2mg/ml.......37
tobramycin/dexamethasone.................................................66
TOBREX.........................................................................10
TOFRANIL.....................................................................62
TOFRANIL-PM..............................................................62
tolazamide tabs 250mg......................................................29
tolazamide tabs 500mg......................................................29
tolbutamide.......................................................................29
tolmetin sodium.................................................................51
tolterodine tartrate tabs 1mg...............................................10
tolterodine tartrate tabs 2mg...............................................10
TOPAMAX SPRINKLE..................................................12
TOPAMAX TABS 100MG..............................................12
TOPAMAX TABS 200MG..............................................12
TOPAMAX TABS 25MG................................................12
TOPAMAX TABS 50MG................................................12
TOPICORT....................................................................71
topiragen tabs 100mg.........................................................12
topiragen tabs 200mg.........................................................12
topiragen tabs 25mg...........................................................12
topiragen tabs 50mg...........................................................13
topiramate cpsp..................................................................13
topiramate tabs 100mg......................................................13
topiramate tabs 200mg......................................................13
topiramate tabs 25mg........................................................13
topiramate tabs 50mg........................................................13
toposar..............................................................................20
topotecan hcl inj 4mg.........................................................20
topotecan hcl inj 4mg/4ml..................................................20
TOPROL XL...................................................................17
TORISEL........................................................................20
torsemide inj 20mg/2ml.....................................................17
TORSEMIDE INJ 50MG/5ML......................................17
torsemide tabs....................................................................17
total b/c.............................................................................85
TOVIAZ..........................................................................10
TPN ELECTROLYTES..................................................30
TPN ELECTROLYTES II...............................................30
TRACE ELEMENTS 4/PEDIATRIC.............................79
TRACLEER.....................................................................65
TRADJENTA..................................................................29
tramadol hcl......................................................................51
TRAMADOL HCL ER CP24.........................................51
tramadol hcl er tb24 100mg, 200mg, 300mg......................51
tramadol hydrochloride/acetaminophen...............................51
TRANDATE...................................................................17
trandolapril.......................................................................17
tranexamic acid inj............................................................26
tranexamic acid tabs..........................................................42
TRANSDERM-SCOP.....................................................40
TRANXENE T................................................................62
tranylcypromine sulfate.......................................................62
Comprehensive_P3TARO_10R
137
Effective January 1, 2014
travasol.............................................................................44
TRAVATAN Z.................................................................53
travoprost..........................................................................53
trazodone hcl.....................................................................62
treagan otic.......................................................................42
TREANDA INJ 100MG.................................................20
TREANDA INJ 25MG...................................................20
TRECATOR....................................................................37
TRELSTAR DEPOT.......................................................20
TRELSTAR DEPOT MIXJECT.....................................20
TRELSTAR LA................................................................20
TRELSTAR LA MIXJECT..............................................20
TRELSTAR MIXJECT....................................................20
TRENTAL.......................................................................26
TRETIN-X......................................................................68
tretinoin caps.....................................................................20
tretinoin crea.....................................................................68
tretinoin emollient.............................................................68
tretinoin emollient.............................................................81
tretinoin gel.......................................................................68
tretinoin microsphere..........................................................68
tretinoin microsphere pump................................................68
TREXALL.......................................................................20
TREXIMET....................................................................34
trezix................................................................................49
tri-estarylla........................................................................53
tri-legest fe.........................................................................53
tri-linyah..........................................................................53
TRI-LUMA.....................................................................80
TRI-NORINYL 28..........................................................53
tri-previfem.......................................................................53
tri-sprintec........................................................................53
tri-vita..............................................................................85
tri-vitamin........................................................................86
tri-zel................................................................................81
triadvance.........................................................................76
triamcinolone acetonide crea...............................................71
triamcinolone acetonide inha..............................................65
triamcinolone acetonide lotn...............................................71
triamcinolone acetonide oint...............................................71
triamcinolone acetonide pste...............................................36
triamcinolone in orabase....................................................36
TRIAMINIC COLD & COUGH DAY TIME
CHILDRENS ORAL SOLN........................................79
triaminic long acting cough childrens..................................79
TRIAMINIC LONG ACTING COUGH STRP............79
Effective January 1, 2014
138
triamterene/hydrochlorothiazide..........................................17
trianex..............................................................................71
triazolam..........................................................................62
TRIBENZOR..................................................................17
TRICARE........................................................................76
TRICARE PRENATAL DHA ONE................................76
tricitrates...........................................................................43
tricon................................................................................86
TRICOR.........................................................................33
triderm.............................................................................71
TRIESENCE.....................................................................9
trifluoperazine hcl..............................................................62
trifluridine........................................................................22
trigels-f forte......................................................................86
TRIGLIDE......................................................................33
trigofen dm.......................................................................79
trihexyphenidyl hcl.............................................................21
TRILEPTAL....................................................................13
TRILIPIX........................................................................33
trilyte................................................................................40
trimethobenzamide hcl caps................................................40
trimethobenzamide hcl inj..................................................40
trimethoprim.....................................................................73
trimethoprim sulfate/polymyxin b sulfate.............................10
trimipramine maleate........................................................62
trinatal gt..........................................................................76
trinate...............................................................................76
trinessa..............................................................................53
TRIOSTAT......................................................................69
triphrocaps........................................................................86
TRISENOX.....................................................................20
triveen-prx rnf...................................................................76
trivora-28.........................................................................53
TRIZIVIR.......................................................................22
TROMBONEX...............................................................86
TROPHAMINE..............................................................45
tropicamide.......................................................................26
trospium chloride...............................................................10
trospium chloride er...........................................................10
TRUSOPT......................................................................53
TRUVADA......................................................................22
TUDORZA PRESSAIR..................................................65
TUSNEL.........................................................................79
tusnel c..............................................................................79
tusnel diabetic...................................................................79
TUSSI-PRES B................................................................79
Comprehensive_P3TARO_10R
tussigon.............................................................................79
tussin cf.............................................................................79
tussin cf cough & cold........................................................79
tussin cough.......................................................................79
tussin dm..........................................................................79
tussin dm clear..................................................................79
tussin dm max...................................................................79
TUSSIONEX PENNKINETIC EXTENDED
RELEASE.....................................................................79
TWINRIX.......................................................................74
TWYNSTA......................................................................17
TYGACIL........................................................................37
TYKERB.........................................................................20
tylenol cold head congestion daytime....................................79
TYLENOL COLD HEAD CONGESTION
NIGHTTIME..............................................................79
TYLENOL COLD MULTI-SYMPTOM DAYTIME
TABS............................................................................79
TYLENOL COLD SEVERE CONGESTION...............79
TYLENOL/CODEINE #3..............................................49
TYLENOL/CODEINE #4..............................................49
TYPHIM VI....................................................................74
TYSABRI.........................................................................42
TYVASO.........................................................................65
TYVASO REFILL............................................................65
TYVASO STARTER........................................................65
TYZEKA.........................................................................22
TYZINE..........................................................................36
TYZINE PEDIATRIC NASAL DROPS.........................36
U-CORT.........................................................................38
u-kera e.............................................................................38
UCERIS...........................................................................40
ULESFIA.........................................................................72
ULORIC.........................................................................32
ultimatecare one nf............................................................76
ULTIVA...........................................................................49
ULTRACET....................................................................51
ULTRAM........................................................................51
ULTRAM ER..................................................................51
ULTRAVATE...................................................................71
ULTRAVATE PAC..........................................................71
ULTRAVATE X...............................................................71
ULTRESA........................................................................40
UMECTA........................................................................38
UMECTA EMUL............................................................80
umecta mousse...................................................................38
umecta mousse...................................................................80
UMECTA NAIL FILM...................................................38
UMECTA PD..................................................................38
UMECTA PD EMUL.....................................................80
UNASYN BULK PACK..................................................55
UNASYN INJ 1GM; 0.5GM..........................................55
UNASYN INJ 2GM; 1GM.............................................55
unicomplex-m...................................................................86
UNIRETIC.....................................................................17
unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg,
200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg.............69
unithroid tabs 137mcg.......................................................69
UNIVASC.......................................................................17
URAMAXIN...................................................................38
URAMAXIN GT.............................................................38
URAMAXIN GT KIT.....................................................38
urea crea 40%, 45%, 50%................................................38
urea crea 40%, 50%.........................................................80
urea emul..........................................................................38
urea emul..........................................................................80
urea gel.............................................................................38
urea hydrating...................................................................38
urea lotn 40%...................................................................38
urea nail...........................................................................38
urea nail stck.....................................................................80
urea susp...........................................................................38
urea susp...........................................................................80
URECHOLINE..............................................................25
urelief plus.........................................................................81
UREX..............................................................................73
UROCIT-K 10.................................................................43
UROCIT-K 15.................................................................43
UROCIT-K 5...................................................................43
UROQID #2...................................................................43
UROXATRAL.................................................................23
URSO 250.......................................................................40
URSO FORTE................................................................40
ursodiol.............................................................................40
UVADEX.........................................................................38
V-GO 20..........................................................................29
V-GO 30..........................................................................29
V-GO 40..........................................................................29
v-r beta carotene................................................................86
v-r super b complex/c..........................................................86
VAGIFEM.......................................................................32
valacyclovir hcl..................................................................22
Comprehensive_P3TARO_10R
139
Effective January 1, 2014
VALCYTE.......................................................................22
VALIUM TABS 10MG....................................................62
VALIUM TABS 2MG......................................................62
VALIUM TABS 5MG......................................................62
valproate sodium...............................................................13
valproic acid......................................................................13
valsartan/hydrochlorothiazide.............................................17
VALTREX........................................................................22
VANACOF DX...............................................................79
VANCOCIN HCL CAPS 125MG..................................74
VANCOCIN HCL CAPS 250MG..................................74
vancomycin hcl caps 125mg................................................74
vancomycin hcl caps 250mg................................................74
VANCOMYCIN HCL IN DEXTROSE INJ 0; 1GM/
200ML..........................................................................74
VANCOMYCIN HCL IN DEXTROSE INJ 0; 500MG/
100ML, 0; 750MG/150ML..........................................74
vancomycin hcl inj 1000mg, 10gm, 5000mg, 750mg..........74
vancomycin hcl inj 500mg.................................................74
vandazole..........................................................................42
VANIQA..........................................................................80
VANOS...........................................................................71
VANTAS..........................................................................20
VAQTA............................................................................74
VARIVAX........................................................................74
VARIZIG.........................................................................74
VASCEPA........................................................................33
VASERETIC....................................................................17
VASOFLEX FORTE.......................................................81
VASOFLEX HD..............................................................81
VASOFLEX TABS...........................................................81
VASOTEC.......................................................................17
VECTIBIX......................................................................20
VECTICAL.....................................................................21
VELCADE.......................................................................20
veletri...............................................................................17
velivet...............................................................................53
VELTIN...........................................................................68
vemavite-prx 2..................................................................76
venlafaxine hcl er cp24 150mg...........................................62
venlafaxine hcl er cp24 37.5mg..........................................62
venlafaxine hcl er cp24 75mg.............................................62
venlafaxine hcl er tb24 150mg...........................................63
venlafaxine hcl er tb24 225mg...........................................63
venlafaxine hcl er tb24 37.5mg..........................................63
venlafaxine hcl er tb24 75mg.............................................63
Effective January 1, 2014
140
venlafaxine hcl tabs 100mg................................................63
venlafaxine hcl tabs 25mg..................................................63
venlafaxine hcl tabs 37.5mg...............................................63
venlafaxine hcl tabs 50mg..................................................63
venlafaxine hcl tabs 75mg..................................................63
VENOFER......................................................................86
VENTAVIS......................................................................65
VENTOLIN HFA...........................................................65
VERAMYST....................................................................65
verapamil hcl er.................................................................17
verapamil hcl inj...............................................................18
verapamil hcl sr.................................................................18
verapamil hcl tabs..............................................................18
VERDESO......................................................................71
VEREGEN......................................................................38
VERELAN.......................................................................18
VERELAN PM................................................................18
veripred 20..........................................................................9
VESICARE......................................................................10
vestura..............................................................................53
VEXOL............................................................................67
VFEND IV......................................................................14
VFEND SUSR.................................................................14
VFEND TABS.................................................................14
VIAGRA..........................................................................81
VIBATIV.........................................................................74
VIBRAMYCIN................................................................67
vicks dayquil cold & flu.....................................................79
vicks dayquil cold & flu multi-symptom relief liqd...............79
VICKS DAYQUIL NATURE FUSION COLD & FLU
MULTI-SYMPTOM RELIEF TABS 325MG; 10MG;
5MG.............................................................................79
vicodin..............................................................................49
vicodin es..........................................................................49
vicodin hp.........................................................................49
VICOPROFEN...............................................................49
VICTOZA.......................................................................29
VICTRELIS.....................................................................22
VIDAZA..........................................................................20
VIDEX EC......................................................................22
VIDEX PEDIATRIC.......................................................22
VIGAMOX......................................................................10
VIIBRYD KIT.................................................................63
VIIBRYD TABS 10MG...................................................63
VIIBRYD TABS 20MG...................................................63
VIIBRYD TABS 40MG...................................................63
Comprehensive_P3TARO_10R
VIMOVO........................................................................51
VIMPAT INJ...................................................................13
VIMPAT ORAL SOLN...................................................13
VIMPAT TABS 100MG..................................................13
VIMPAT TABS 150MG..................................................13
VIMPAT TABS 200MG..................................................13
VIMPAT TABS 50MG....................................................13
vinacal..............................................................................76
vinate az...........................................................................76
vinate az extra...................................................................76
vinate c.............................................................................76
vinate calcium...................................................................76
vinate care.........................................................................76
vinate gt............................................................................76
vinate ic............................................................................76
vinate ii............................................................................76
vinate m...........................................................................76
vinate one.........................................................................76
vinate pn care....................................................................76
vinate ultra.......................................................................76
vinblastine sulfate inj 10mg...............................................20
vinblastine sulfate inj 1mg/ml.............................................20
vincasar pfs.......................................................................20
vincristine sulfate...............................................................20
vinorelbine tartrate............................................................20
VIOKACE.......................................................................40
viorele...............................................................................53
VIRACEPT.....................................................................22
VIRAMUNE SUSP.........................................................22
VIRAMUNE TABS.........................................................22
VIRAMUNE XR TB24 100MG......................................22
VIRAMUNE XR TB24 400MG......................................22
VIRAZOLE.....................................................................22
VIREAD..........................................................................22
VIROPTIC......................................................................22
virt-bal dha plus................................................................76
virt-pn..............................................................................76
virt-pn dha........................................................................76
virt-vite.............................................................................86
virt-vite forte.....................................................................86
VISICOL.........................................................................40
VISTARIL.......................................................................14
VISTIDE.........................................................................22
VISUDYNE.....................................................................42
vit c..................................................................................86
vit c/rose hips.....................................................................86
vita s forte.........................................................................86
vita-bee/c...........................................................................86
vitacel...............................................................................86
VITAFOL........................................................................86
vitafol-ob..........................................................................76
VITAFOL-OB+DHA......................................................76
VITAFOL-ONE..............................................................76
VITAFOL-PLUS.............................................................76
vitafol-pn..........................................................................76
VITAL-D RX...................................................................86
vitalee...............................................................................86
VITAMEDMD ONE RX/QUATREFOLIC...................76
VITAMEDMD PLUS RX/QUATRE FOLIC.................76
VITAMEDMD REDICHEW RX/QUATREFOLIC......76
vitamin a caps 10000unit..................................................86
vitamin a caps 8000unit....................................................86
vitamin a/beta carotene caps...............................................86
vitamin b complex tabs 10mg; 10mg; 0.2mg; 2mg;
1.5mg............................................................................86
vitamin b complex-c...........................................................86
vitamin b-1 tabs 100mg, 250mg, 50mg.............................86
vitamin b-12 natural.........................................................86
vitamin b-12 subl 1000mcg...............................................86
vitamin b-12 tabs..............................................................86
vitamin b-12 tr tbcr 2000mcg............................................86
vitamin b-2.......................................................................86
vitamin b-6 tabs 100mg, 25mg..........................................86
vitamin b-complex 100......................................................86
vitamin b1........................................................................86
vitamin b12......................................................................86
vitamin c chew 500mg.......................................................86
vitamin c cr tbcr................................................................86
vitamin c sr.......................................................................86
vitamin c syrp....................................................................86
vitamin c tabs 1000mg, 250mg, 500mg.............................86
vitamin c tabs 100mg........................................................86
VITAMIN C TR CPCR..................................................86
vitamin c tr tbcr 500mg.....................................................86
vitamin c/rose hips tabs 1000mg, 1000mg; 0, 500mg,
500mg; 0.......................................................................86
vitamin d caps 50000unit..................................................86
vitamin d tabs 400unit......................................................86
vitamin e caps 100unit......................................................86
VITAMIN E OIL............................................................86
VITAMIN K....................................................................77
vitamin k1........................................................................77
Comprehensive_P3TARO_10R
141
Effective January 1, 2014
vitamins & minerals..........................................................86
vitatrum...........................................................................86
vitatrum complete..............................................................86
VITRASERT...................................................................22
vitrum senior.....................................................................86
VIVA CT PRENATAL.....................................................76
VIVACTIL.......................................................................63
VIVELLE-DOT...............................................................32
VIVITROL......................................................................51
VIVOTIF BERNA...........................................................74
vol-care rx.........................................................................86
vol-nate.............................................................................76
VOLTAREN....................................................................51
VOLTAREN-XR..............................................................51
VOLUVEN.....................................................................45
VORAXAZE......................................................................8
voriconazole inj.................................................................14
voriconazole tabs................................................................14
VOSOL HC....................................................................42
VOSPIRE ER..................................................................65
VOTRIENT....................................................................20
vp-ch-pnv..........................................................................76
VP-PNV-DHA................................................................76
vp-zel................................................................................81
VPRIV.............................................................................41
VUSION.........................................................................70
VYTORIN.......................................................................33
VYVANSE.......................................................................63
warfarin sodium................................................................26
wee care............................................................................86
WELCHOL.....................................................................33
WELLBUTRIN SR TB12 100MG..................................63
WELLBUTRIN SR TB12 150MG..................................63
WELLBUTRIN SR TB12 200MG..................................63
WELLBUTRIN TABS 100MG.......................................63
WELLBUTRIN TABS 75MG.........................................63
WELLBUTRIN XL TB24 150MG..................................63
WELLBUTRIN XL TB24 300MG..................................63
wera..................................................................................53
WESTCORT...................................................................72
WINRHO SDF INJ 15000UNIT/13ML........................74
WINRHO SDF INJ 1500UNIT/1.3ML, 2500UNIT/
2.2ML, 5000UNIT/4.4ML..........................................74
womens daily formula/folic acid/calcium/iron......................86
womens one daily...............................................................86
wymzya fe.........................................................................53
Effective January 1, 2014
142
x-viate..............................................................................38
x-viate crea........................................................................80
XALATAN.......................................................................53
XALKORI........................................................................20
XANAX...........................................................................63
XANAX XR.....................................................................63
XARELTO TABS 10MG, 20MG.....................................26
XARELTO TABS 15MG.................................................26
XELJANZ........................................................................54
XENADERM..................................................................81
XENAZINE.....................................................................42
XEOMIN........................................................................74
XERAC AC......................................................................38
XERESE..........................................................................70
XGEVA..............................................................................8
XIAFLEX.........................................................................36
XIFAXAN........................................................................37
XODOL..........................................................................49
XOLAIR..........................................................................65
XOLEGEL.......................................................................70
xolox.................................................................................49
XOPENEX CONCENTRATE........................................65
XOPENEX HFA..............................................................66
XOPENEX NEBU 0.31MG/3ML, 1.25MG/3ML..........66
XOPENEX NEBU 0.63MG/3ML...................................66
XTANDI.........................................................................20
XYLOCAINE EXTERNAL SOLN.................................69
XYLOCAINE INJ 0.5%, 1%, 2%...................................69
XYLOCAINE INJ 20MG/ML...........................................9
XYLOCAINE-MPF INJ 0.5%, 1.5%, 2%.......................69
XYLOCAINE-MPF INJ 1%, 4%....................................69
XYLOCAINE-MPF/EPINEPHRINE..............................70
XYLOCAINE/EPINEPHRINE INJ 1:100000; 1%,
1:200000; 0.5%............................................................70
XYLOCAINE/EPINEPHRINE INJ 1:100000; 2%.........70
XYREM...........................................................................63
XYZAL ORAL SOLN.....................................................14
XYZAL TABS..................................................................14
YASMIN 28.....................................................................53
YAZ.................................................................................53
yelets teenage formula.........................................................86
YERVOY..........................................................................20
YF-VAX...........................................................................74
zafirlukast.........................................................................66
zaleplon caps 10mg............................................................63
zaleplon caps 5mg..............................................................63
Comprehensive_P3TARO_10R
ZALTRAP........................................................................20
zamicet.............................................................................49
ZANAFLEX.....................................................................45
ZANOSAR......................................................................20
ZANTAC.........................................................................72
zarah................................................................................53
ZARONTIN....................................................................13
ZAROXOLYN.................................................................18
zatean-ch..........................................................................76
ZAVESCA.......................................................................41
zazole crea 0.4%...............................................................42
ZAZOLE CREA 0.8%.....................................................42
ZEBETA..........................................................................18
zebutal..............................................................................49
ZEGERID.......................................................................72
ZELAPAR........................................................................21
ZELBORAF.....................................................................20
ZEMAIRA.......................................................................36
ZEMPLAR......................................................................41
zenatane...........................................................................68
zenchent............................................................................53
zenchent fe........................................................................53
zencia...............................................................................68
ZENPEP..........................................................................40
zenzedi tabs 10mg.............................................................63
ZENZEDI TABS 2.5MG................................................63
zenzedi tabs 5mg...............................................................63
ZENZEDI TABS 7.5MG................................................63
ZERIT.............................................................................22
ZESTORETIC................................................................18
ZESTRIL.........................................................................18
ZETIA.............................................................................33
ZETONNA.....................................................................66
ZIAC...............................................................................18
ZIAGEN ORAL SOLN...................................................22
ZIAGEN TABS................................................................22
ZIANA............................................................................68
zidovudine........................................................................22
ZINACEF........................................................................25
ZINACEF IN ISO-OSMOTIC DILUENT....................25
ZINC 15..........................................................................79
ZINC CHLORIDE.........................................................79
zinc gluconate tabs 100mg, 30mg.......................................79
zinc gluconate tabs 50mg...................................................79
zinc sulfate caps.................................................................79
ZINC SULFATE HEPTAHYDRATE.............................80
zinc sulfate inj 5mg/ml.......................................................79
ZINC SULFATE POWD................................................79
zinc sulfate tabs 220mg......................................................79
zinc tabs 30mg..................................................................79
zinc tabs 50mg..................................................................79
zinc trace metal.................................................................79
ZINECARD......................................................................8
ZIOPTAN.......................................................................53
ziprasidone hcl caps 20mg..................................................63
ziprasidone hcl caps 40mg..................................................63
ziprasidone hcl caps 60mg, 80mg........................................63
ZIPSOR...........................................................................51
ZIRGAN..........................................................................22
ZITHRANOL.................................................................21
ZITHRANOL-RR...........................................................21
ZITHROMAX INJ..........................................................31
ZITHROMAX PACK.....................................................31
ZITHROMAX SUSR 100MG/5ML...............................31
ZITHROMAX SUSR 200MG/5ML...............................31
ZITHROMAX TABS 250MG.........................................31
ZITHROMAX TABS 500MG.........................................31
ZITHROMAX TABS 600MG.........................................31
ZITHROMAX TRI-PAK................................................31
ZITHROMAX Z-PAK....................................................31
ZMAX.............................................................................31
ZOCOR..........................................................................33
ZOFRAN INJ..................................................................40
ZOFRAN ODT...............................................................40
ZOFRAN ORAL SOLN..................................................40
ZOFRAN TABS..............................................................40
ZOLADEX......................................................................20
zoledronic acid inj 4mg......................................................41
zoledronic acid inj 4mg/5ml...............................................41
zoledronic acid inj 5mg/100ml...........................................36
ZOLINZA.......................................................................20
zolmitriptan......................................................................34
zolmitriptan odt................................................................34
ZOLOFT CONC............................................................63
ZOLOFT TABS 100MG.................................................63
ZOLOFT TABS 25MG...................................................63
ZOLOFT TABS 50MG...................................................63
zolpidem tartrate...............................................................63
zolpidem tartrate er...........................................................63
ZOLPIMIST....................................................................63
ZOLVIT..........................................................................49
ZOMETA........................................................................41
Comprehensive_P3TARO_10R
143
Effective January 1, 2014
ZOMIG NASAL SOLN..................................................34
ZOMIG TABS.................................................................34
ZOMIG ZMT.................................................................34
ZONALON.....................................................................38
ZONEGRAN..................................................................13
zonisamide........................................................................13
ZORBTIVE.....................................................................23
ZORTRESS.....................................................................20
ZOSTAVAX.....................................................................74
ZOSYN INJ 2GM; 0.25GM, 36GM; 4.5GM, 3GM;
0.375GM, 4GM; 0.5GM, 5%; 3GM/50ML; 0.375GM/
50ML............................................................................55
ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%;
4GM/100ML; 0.5GM/100ML.....................................55
zovia 1/35e.......................................................................53
zovia 1/50e.......................................................................53
ZOVIRAX CAPS.............................................................22
ZOVIRAX CREA............................................................70
ZOVIRAX OINT............................................................70
ZOVIRAX SUSP.............................................................22
ZOVIRAX TABS.............................................................22
ZUPLENZ.......................................................................40
ZYBAN............................................................................66
ZYCLARA.......................................................................38
Effective January 1, 2014
144
ZYCLARA PUMP...........................................................38
ZYDONE........................................................................49
ZYFLO............................................................................66
ZYFLO CR......................................................................66
ZYLET............................................................................66
ZYLOPRIM.....................................................................32
ZYMAXID......................................................................10
ZYPREXA INJ.................................................................63
ZYPREXA RELPREVV INJ 210MG, 405MG................63
ZYPREXA RELPREVV INJ 300MG..............................63
ZYPREXA TABS 10MG..................................................63
ZYPREXA TABS 15MG..................................................63
ZYPREXA TABS 2.5MG.................................................63
ZYPREXA TABS 20MG..................................................63
ZYPREXA TABS 5MG....................................................64
ZYPREXA TABS 7.5MG.................................................64
ZYPREXA ZYDIS TBDP 10MG....................................64
ZYPREXA ZYDIS TBDP 15MG....................................64
ZYPREXA ZYDIS TBDP 20MG....................................64
ZYPREXA ZYDIS TBDP 5MG......................................64
ZYTIGA..........................................................................20
ZYVOX INJ....................................................................37
ZYVOX SUSR.................................................................37
ZYVOX TABS.................................................................37
Comprehensive_P3TARO_10R
This formulary was updated on August 1, 2013. For more recent information or other questions, please contact
us, Empire BlueCross at 1-866-222-0444 or, for TTY users, 711, Monday through Friday, except holidays from
8 a.m. to 9 p.m. ET, or visit www.empireblue.com.
Empire BlueCross is a LPPO with a Medicare contract. Enrollment in Empire BlueCross depends on contract
renewal. Services provided by Empire HealthChoice Assurance, Inc., licensee of the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield plans.
Y0071_14_17549_I_024 08/16/2013
38687MUSENMUB_024