Drug Name Tier Drug Name Tier
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1 Drug Name Tier Drug Name Tier ABELCET 100 MG/20 ML VIAL 4 ACETYLCYSTEINE 10% VIAL 2 ACETYLCYSTEINE 20% VIAL 2 ACYCLOVIR 1,000 MG/20 ML VIAL 2 ACYCLOVIR 500 MG/10 ML VIAL 2 ADRUCIL 500 MG/10 ML VIAL 2 ALBUTEROL 5 MG/ML SOLUTION 2 ALBUTEROL SUL 0.63 MG/3 ML SOL 2 ALBUTEROL SUL 1.25 MG/3 ML SOL 2 ALBUTEROL SUL 2.5 MG/3 ML SOLN 2 ALKERAN 50 MG VIAL 3 ALOXI 0.25 MG/5 ML VIAL 4 AMBISOME 50 MG VIAL 4 AMINO ACIDS 15% SOLUTION 2 AMINOSYN 7%-ELECTROLYTE SOL 4 AMINOSYN 8.5%-ELECTROLYTES SOL 3 AMINOSYN II 10% IV SOLUTION 4 AMINOSYN II 15% IV SOLUTION 4 AMINOSYN II 7% IV SOLUTION 4 AMINOSYN II 8.5% IV SOLUTION 4 AMINOSYN II 8.5%-ELECTROLYTES 3 AMINOSYN-HBC 7% IV SOLUTION 4 AMINOSYN-PF 10% IV SOLUTION 4 AMINOSYN-PF 7% IV SOLUTION 4 AMINOSYN-RF 5.2% IV SOLUTION 4 AMPHOTERICIN B 50 MG VIAL 2 ANZEMET 100 MG TABLET 4 ANZEMET 50 MG TABLET 4 APREPITANT 125 MG CAPSULE 2 APREPITANT MG PACK 2 APREPITANT 40 MG CAPSULE 2 APREPITANT 80 MG CAPSULE 2 ARANESP 10 MCG/0.4 ML SYRINGE 4 ARANESP 100 MCG/0.5 ML SYRINGE 4 ARANESP 100 MCG/ML VIAL 4 ARANESP 150 MCG/0.3 ML SYRINGE 4 ARANESP 200 MCG/0.4 ML SYRINGE 4 ARANESP 200 MCG/ML VIAL 4 ARANESP 25 MCG/0.42 ML SYRING 4 ARANESP 25 MCG/ML VIAL 4 ARANESP 300 MCG/0.6 ML SYRINGE 4 ARANESP 300 MCG/ML VIAL 4 ARANESP 40 MCG/0.4 ML SYRINGE 4 ARANESP 40 MCG/ML VIAL 4 ARANESP 500 MCG/1 ML SYRINGE 4 ARANESP 60 MCG/0.3 ML SYRINGE 4 ARANESP 60 MCG/ML VIAL 4 ASTAGRAF XL 0.5 MG CAPSULE 4 ASTAGRAF XL 1 MG CAPSULE 4 ASTAGRAF XL 5 MG CAPSULE 4 ATGAM 50 MG/ML AMPUL 5 AZACTAM-ISO-OSMOT 1 GM/50 ML 4 AZACTAM-ISO-OSMOT 2 GM/50 ML 4 AZASAN 100 MG TABLET 4 AZASAN 75 MG TABLET 4 AZATHIOPRINE 50 MG TABLET 2 AZATHIOPRINE SOD 100 MG VIAL 4 BAVENCIO 200 MG/10 ML VIAL 5 BETHKIS 300 MG/4 ML AMPULE 4 BLEOMYCIN SULFATE 30 UNIT VIAL 2 BROVANA 15 MCG/2 ML SOLUTION 4 BUDESONIDE 0.25 MG/2 ML SUSP 2 BUDESONIDE 0.5 MG/2 ML SUSP 2 BUDESONIDE 1 MG/2 ML INH SUSP 2 BUSULFAN 60 MG/10 ML VIAL 2 BUSULFEX 60 MG/10 ML VIAL 5 CALCITRIOL 0.25 MCG CAPSULE 5 CALCITRIOL 0.5 MCG CAPSULE 2 CALCITRIOL 1 MCG/ML AMPUL 2 CALCITRIOL 1 MCG/ML SOLUTION 2 CELLCEPT 200 MG/ML ORAL SUSP 5 CELLCEPT 250 MG CAPSULE 5 CELLCEPT 500 MG TABLET 5 CELLCEPT 500 MG VIAL 4 CESAMET 1 MG CAPSULE 4 CLADRIBINE 10 MG/10 ML VIAL 2 CLEOCIN PHOS 150 MG/ML VIAL 4 CLEOCIN PHOS 300 MG/2 ML VIAL 4 CLEOCIN PHOS 600 MG/4 ML VIAL 4 CLEOCIN PHOS 9 G/60 ML VIAL 4
2 CLEOCIN PHOS 900 MG/6 ML VIAL 4 DEXTROSE 10%-0.2% NACL IV SOLN 2 CLINDAMYCIN PH 300 MG/2 ML VL 2 DEXTROSE 10%-0.45% NACL IV SOL 4 CLINDAMYCIN PH 600 MG/4 ML VL 2 DEXTROSE 10%-WATER IV SOLUTION 2 CLINDAMYCIN PH 9 G/60 ML VIAL 2 DEXTROSE 2.5%-0.45% NACL IV 2 CLINDAMYCIN PH 900 MG/6 ML VL 2 DEXTROSE 5%-0.2% NACL IV SOLN 2 CLINIMIX 2.75%-5% SOLUTION 4 DEXTROSE 5%-0.225% NACL IV SOL 2 CLINIMIX 4.25%-10% SOLUTION 4 DEXTROSE 5%-0.3% NACL IV SOLN 2 CLINIMIX 4.25%-20% SOLUTION 4 DEXTROSE 5%-0.33% NACL IV SOLN 2 CLINIMIX 4.25%-25% SOLUTION 4 DEXTROSE 5%-0.45% NACL IV SOLN 2 CLINIMIX 4.25%-5% SOLUTION 4 DEXTROSE 5%-0.9% NACL IV SOLN 2 CLINIMIX 5%-15% SOLUTION 4 DEXTROSE 5%-WATER IV SOLN 2 CLINIMIX 5%-20% SOLUTION 4 DOXERCALCIFEROL 0.5 MCG CAP 2 CLINIMIX 5%-25% SOLUTION 4 DOXERCALCIFEROL 1 MCG CAPSULE 2 CLINIMIX E 2.75%-10% SOLUTION 4 DOXERCALCIFEROL 2.5 MCG CAP 2 CLINIMIX E 2.75%-5% SOLUTION 4 DOXERCALCIFEROL 4 MCG/2 ML AMP 2 CLINIMIX E 4.25%-10% SOLUTION 4 DRONABINOL 10 MG CAPSULE 2 CLINIMIX E 4.25%-25% SOLUTION 4 DRONABINOL 2.5 MG CAPSULE 2 CLINIMIX E 4.25%-5% SOLUTION 4 DRONABINOL 5 MG CAPSULE 2 CLINIMIX E 5%-15% SOLUTION 4 ELELYSO 200 UNITS VIAL 5 CLINIMIX E 5%-20% SOLUTION 4 EMEND 125 MG CAPSULE 3 CLINIMIX E 5%-25% SOLUTION 4 EMEND 125 MG POWDER PACKET 3 CLINISOL 15% SOLUTION 3 EMEND 150 MG VIAL 4 CROMOLYN 20 MG/2 ML NEB SOLN 2 EMEND 40 MG CAPSULE 3 CYCLOPHOSPHAMIDE 25 MG CAPSULE 4 EMEND 80 MG CAPSULE 3 CYCLOPHOSPHAMIDE 50 MG CAPSULE 4 EMEND TRIPACK 3 CYCLOSPORINE 100 MG CAPSULE 2 ENGERIX-B 10 MCG/0.5 ML PED VL 3 CYCLOSPORINE 100 MG/ML SOLN 2 ENGERIX-B 20 MCG/ML SYRN 3 CYCLOSPORINE 25 MG CAPSULE 2 ENGERIX-B PEDI 10 MCG/0.5 SYRN 3 CYCLOSPORINE 50 MG/ML AMPUL 2 ENVARSUS XR 0.75 MG TABLET 4 CYCLOSPORINE MODIFIED 100 MG 2 ENVARSUS XR 1 MG TABLET 4 CYCLOSPORINE MODIFIED 25 MG 2 ENVARSUS XR 4 MG TABLET 4 CYCLOSPORINE MODIFIED 50 MG 2 EPOGEN 2,000 UNITS/ML VIAL 4 CYTARABINE 1000 MG/50 ML VIAL 2 EPOGEN 20,000 UNITS/2 ML VIAL 4 CYTARABINE 2 G/20 ML VIAL 2 EPOGEN 20,000 UNITS/ML VIAL 4 CYTARABINE 20 MG/ML VIAL 2 EPOGEN 3,000 UNITS/ML VIAL 4 CYTOVENE 500 MG VIAL 4 EPOGEN 4,000 UNITS/ML VIAL 4 DEXAMETHASONE 10 MG/ML VIAL 2 FLUOROURACIL 2,500 MG/50 ML VL 2 DEXAMETHASONE 100 MG/10 ML VL 2 FLUOROURACIL 2.5 GM/50 ML BTL 2 DEXAMETHASONE 120 MG/30 ML VL 2 FLUOROURACIL 2.5 GM/50 ML VIAL 2 DEXAMETHASONE 20 MG/5 ML VIAL 2 FLUOROURACIL 5 GM/100 ML BTL 2 DEXAMETHASONE 4 MG/ML VIAL 2 FLUOROURACIL 5 GM/100 ML VIAL 2
3 FLUOROURACIL 5,000 MG/100 ML 2 IBANDRONATE 3 MG/3 ML VIAL 2 FRAGMIN 10,000 UNITS/ML SYRING 4 IMFINZI 120 MG/2.4 ML VIAL 5 FRAGMIN 12,500 UNITS/0.5 ML 4 IMFINZI 500 MG/10 ML VIAL 5 FRAGMIN 15,000 UNITS/0.6 ML 4 IMOGAM RABIES-HT 150 UNIT/ML 4 FRAGMIN 18,000 UNITS/0.72 ML 4 INTRALIPID 20% IV FAT EMUL 3 FRAGMIN 2,500 UNITS/0.2 ML SYR 4 INTRALIPID 30% IV FAT EMUL 3 FRAGMIN 5,000 UNITS/0.2 ML SYR 4 IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 2 FREAMINE HBC 6.9% IV SOLN 4 IPRATROPIUM BR 0.02% SOLN 2 GABLOFEN 10,000 MCG/20 ML VIAL 4 KETOROLAC 15 MG/ML VIAL 2 GABLOFEN 40,000 MCG/20 ML VIAL 4 KETOROLAC 30 MG/ML VIAL 2 GABLOFEN 50 MCG/ML SYRINGE 4 LEVALBUTEROL 0.31 MG/3 ML SOL 2 GANCICLOVIR 500 MG VIAL 2 LEVALBUTEROL 0.63 MG/3 ML SOL 2 GENGRAF 100 MG CAPSULE 2 LEVALBUTEROL 1.25 MG/3 ML SOL 2 GENGRAF 100 MG/ML SOLUTION 2 LEVALBUTEROL CONC 1.25 MG/0.5 2 GENGRAF 25 MG CAPSULE 2 LEVOCARNITINE 1 G/10 ML SOLN 2 GENGRAF 50 MG CAPSULE 2 LEVOCARNITINE 330 MG TABLET 2 GRANISETRON HCL 0.1 MG/ML VIAL 2 LEVOFLOXACIN 500 MG/100 ML-D5W 2 GRANISETRON HCL 1 MG TABLET 2 LEVOFLOXACIN 750 MG/150 ML-D5W 2 GRANISETRON HCL 1 MG/ML VIAL 2 LIORESAL IT 0.05 MG/1 ML AMP 4 GRANISETRON HCL 4 MG/4 ML VIAL 2 LIORESAL IT 10 MG/20 ML KIT 4 GRANIX 300 MCG/0.5 ML SAFE SYR 5 LIORESAL IT 10 MG/5 ML KIT 4 GRANIX 300 MCG/0.5 ML SYRINGE 5 LIORESAL IT 40 MG/20 ML KIT 4 GRANIX 480 MCG/0.8 ML SAFE SYR 5 MELPHALAN 50 MG VIAL W-DILUENT 2 GRANIX 480 MCG/0.8 ML SYRINGE 5 MELPHALAN HCL 50 MG VIAL 2 HEPARIN 10,000 UNIT/10 ML VIAL 2 METHOTREXATE 1 GM VIAL 2 HEPARIN 20,000 UNIT/500 ML-D5W 2 METHOTREXATE 1 GRAM/40 ML VIAL 2 HEPARIN 30,000 UNIT/30 ML VIAL 2 METHOTREXATE 100 MG/4 ML VIAL 2 HEPARIN 40,000 UNITS/4 ML VIAL 2 METHOTREXATE 200 MG/8 ML VIAL 2 HEPARIN 50,000 UNIT/10 ML VIAL 2 METHOTREXATE 25 MG/ML VIAL 2 HEPARIN 50,000 UNITS/10 ML VL 2 METHOTREXATE 250 MG/10 ML VIAL 2 HEPARIN 50,000 UNITS/5 ML VIAL 2 METHOTREXATE 50 MG/2 ML VIAL 2 HEPARIN SOD 1,000 UNIT/ML VIAL 2 METHYLPREDNISOLONE SS 1 GM VL 2 HEPARIN SOD 10,000 UNIT/ML VL 2 METHYLPREDNISOLONE SS 125 MG 2 HEPARIN SOD 20,000 UNIT/ML VL 2 METHYLPREDNISOLONE SS 40 MG VL 2 HEPARIN SOD 5,000 UNIT/ML VIAL 2 MIRCERA 100 MCG/0.3 ML SYRINGE 4 HEPARIN-D5W 25,000 UNIT/250 ML 2 MIRCERA 50 MCG/0.3 ML SYRINGE 4 HEPARIN-D5W 25,000 UNIT/500 ML 2 MIRCERA 75 MCG/0.3 ML SYRINGE 4 HEPATAMINE 8% IV SOLUTION 3 MORPHINE 10 MG/ML ISECURE SYRG 4 HUMULIN R 500 UNITS/ML VIAL 3 MORPHINE 2 MG/ML ISECURE SYR 4 HYCAMTIN 4 MG VIAL 3 MORPHINE 4 MG/ML ISECURE SYR 4 HYPERRAB S-D 150 UNITS/ML VIAL 4 MORPHINE 8 MG/ML ISECURE SYRNG 4
4 MYCOPHENOLATE 200 MG/ML SUSP 2 PIPERACIL-TAZOBACT 4.5 GM VIAL 2 MYCOPHENOLATE 250 MG CAPSULE 2 PIPERACIL-TAZOBACT 40.5 GRAM 2 MYCOPHENOLATE 500 MG TABLET 2 PREMASOL 10% IV SOLUTION 4 MYCOPHENOLATE 500 MG VIAL 2 PREMASOL 6% IV SOLUTION 3 MYCOPHENOLIC ACID DR 180 MG TB 2 PROCALAMINE IV SOLUTION 4 MYCOPHENOLIC ACID DR 360 MG TB 2 PROCRIT 10,000 UNITS/ML VIAL 4 MYFORTIC 180 MG TABLET 4 PROCRIT 2,000 UNITS/ML VIAL 4 MYFORTIC 360 MG TABLET 4 PROCRIT 20,000 UNITS/ML VIAL 4 NEBUPENT 300 MG INHAL POWDER 4 PROCRIT 3,000 UNITS/ML VIAL 4 NEORAL 100 MG GELATIN CAPSULE 4 PROCRIT 4,000 UNITS/ML VIAL 4 NEORAL 100 MG/ML SOLUTION 4 PROCRIT 40,000 UNITS/ML VIAL 4 NEORAL 25 MG GELATIN CAPSULE 4 PROGRAF 5 MG/ML AMPULE 4 NEPHRAMINE 5.4% IV SOLUTION 4 PROSOL 20% INJECTION 4 NEULASTA 6 MG/0.6 ML SYRINGE 5 PULMOZYME 1 MG/ML AMPUL 5 NEUPOGEN 300 MCG/0.5 ML SYR 5 RAPAMUNE 0.5 MG TABLET 4 NEUPOGEN 300 MCG/ML VIAL 5 RAPAMUNE 1 MG TABLET 4 NEUPOGEN 480 MCG/0.8 ML SYR 5 RAPAMUNE 1 MG/ML ORAL SOLN 4 NEUPOGEN 480 MCG/1.6 ML VIAL 5 RAPAMUNE 2 MG TABLET 4 NULOJIX 250 MG VIAL 5 RECOMBIVAX HB 10 MCG/ML SYR 3 NUTRILIPID 20% IV FAT EMULSION 3 RECOMBIVAX HB 10 MCG/ML VIAL 3 ONDANSETRON 4 MG/2 ML ISECURE 2 RECOMBIVAX HB 40 MCG/ML VIAL 3 ONDANSETRON 4 MG/5 ML SOLUTION 2 RECOMBIVAX HB 5 MCG/0.5 ML SYR 3 ONDANSETRON HCL 24 MG TABLET 2 RITUXAN 10 MG/ML VIAL 5 ONDANSETRON HCL 4 MG TABLET 2 SALINE 0.45% SOLN-EXCEL CON 2 ONDANSETRON HCL 4 MG/2 ML SYR 2 SALINE 0.9% SOLN-EXCEL CONT 2 ONDANSETRON HCL 4 MG/2 ML VIAL 2 SANCUSO 3.1 MG/24 HR PATCH 4 ONDANSETRON HCL 8 MG TABLET 2 SANDIMMUNE 100 MG CAPSULE 4 ONDANSETRON ODT 4 MG TABLET 2 SANDIMMUNE 100 MG/ML SOLN 4 ONDANSETRON ODT 8 MG TABLET 2 SANDIMMUNE 25 MG CAPSULE 4 PAMIDRONATE 30 MG/10 ML VIAL 2 SANDIMMUNE 50 MG/ML AMPUL 4 PAMIDRONATE 60 MG/10 ML VIAL 2 SIMULECT 20 MG VIAL 5 PAMIDRONATE 90 MG/10 ML VIAL 2 SIROLIMUS 0.5 MG TABLET 2 PARICALCITOL 1 MCG CAPSULE 2 SIROLIMUS 1 MG TABLET 2 PARICALCITOL 10 MCG/2 ML VIAL 2 SIROLIMUS 2 MG TABLET 2 PARICALCITOL 2 MCG CAPSULE 2 SODIUM CHLORIDE 0.45% SOLN 2 PARICALCITOL 2 MCG/ML VIAL 2 SODIUM CHLORIDE 0.45% SOLUTION 2 PARICALCITOL 4 MCG CAPSULE 2 SODIUM CHLORIDE 0.9% 1,000 ML 2 PARICALCITOL 5 MCG/ML VIAL 2 SODIUM CHLORIDE 0.9% 100 ML 2 PENTAM 300 VIAL 4 SODIUM CHLORIDE 0.9% 250 ML 2 PERFOROMIST 20 MCG/2 ML SOLN 4 SODIUM CHLORIDE 0.9% 50 ML 2 PIPERACIL-TAZOBACT GM VL 2 SODIUM CHLORIDE 0.9% 500 ML 2
5 SODIUM CHLORIDE 0.9% SOLN 2 ZORTRESS 0.5 MG TABLET 4 SODIUM CHLORIDE 0.9% SOLUTION 2 ZORTRESS 0.75 MG TABLET 4 SODIUM CHLORIDE 100 MEQ/40 ML 2 ZOSYN 2.25 GM/50 ML GALAXY BAG 4 SODIUM CHLORIDE 3% IV SOLN 2 ZOSYN GM/50 ML GALAXY 4 SODIUM CHLORIDE 5% IV SOLN 2 ZOSYN GRAM VIAL 4 SODIUM CHLORIDE 50 MEQ/20 ML 2 ZOSYN 40.5 GRAM BULK VIAL 4 SOLU-MEDROL 125 MG VIAL 4 SOLU-MEDROL 2,000 MG VIAL 4 SOLU-MEDROL 40 MG VIAL 4 SOLU-MEDROL 500 MG VIAL 4 TACROLIMUS 0.5 MG CAPSULE 2 TACROLIMUS 1 MG CAPSULE 2 TACROLIMUS 5 MG CAPSULE 2 TECENTRIQ 1,200 MG/20 ML VIAL 5 THYMOGLOBULIN 25 MG VIAL 4 TOBI PODHALER 28 MG INHALE CAP 5 TOBRAMYCIN 1,200 MG/30 ML VIAL 2 TOBRAMYCIN 1.2 GRAM/30 ML VIAL 2 TOBRAMYCIN 10 MG/ML VIAL 2 TOBRAMYCIN 300 MG/5 ML AMPULE 2 TOBRAMYCIN 40 MG/ML VIAL 2 TOBRAMYCIN 80 MG/2 ML VIAL 2 TOPOTECAN HCL 4 MG VIAL 2 TRAVASOL 10% SOLN VIAFLEX 4 TROPHAMINE 10% IV SOLUTION 4 TROPHAMINE 6% IV SOLUTION 4 VANCOMYCIN 1 GM VIAL 2 VANCOMYCIN 500 MG VIAL 2 VANCOMYCIN HCL 10 GM VIAL 2 VARUBI 90 MG TABLET 4 VENTAVIS 10 MCG/1 ML SOLUTION 5 VENTAVIS 20 MCG/1 ML SOLUTION 5 VINBLASTINE 1 MG/ML VIAL 4 VINCASAR PFS 1 MG/ML VIAL 2 VINCRISTINE 1 MG/ML VIAL 2 XOLAIR 150 MG VIAL 5 ZARXIO 300 MCG/0.5 ML SYRINGE 5 ZARXIO 480 MCG/0.8 ML SYRINGE 5 ZOLEDRONIC ACID 4 MG/5 ML VIAL 2 ZOLEDRONIC ACID 5 MG/100 ML 2 ZORTRESS 0.25 MG TABLET 4
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