Ultimate Health Plans (HMO) abacavir-lamivudine 600-300 mg abacavir-lamivudine-zidov tab ACTEMRA 162 MG/0.9 ML SYRINGE ADCIRCA 20 MG TABLET ADEMPAS (0.5 MG TABLET, 1 MG TABLET, 1.5 MG TABLET, 2 MG TABLET, 2.5 MG TABLET) ADVAIR DISKUS (100-50, 250-50, 500-50) ADVAIR HFA (45-21 MCG, 115-21 MCG, 230-21 MCG) AEROSPAN 80 MCG INHALER AFINITOR (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 10 MG TABLET) albuterol sul 0.63 mg/3 ml sol albuterol sul 1.25 mg/3 ml sol albuterol sul 2.5 mg/3 ml soln albuterol sulfate (2.5 mg/0.5 ml sol, 5 mg/ml solution) ALECENSA 150 MG CAPSULE alendronate sodium 70 mg tab almotriptan malate 12.5 mg tab almotriptan malate 6.25 mg tab alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) alprazolam 2 mg tablet alprazolam er (er 0.5 mg tablet, er 1 mg tablet) alprazolam er 2 mg tablet alprazolam er 3 mg tablet alprazolam odt (odt 0.25 mg tab, odt 0.5 mg tab) alprazolam odt 1 mg tab alprazolam odt 2 mg tab alprazolam xr (0.5 mg tablet, 1 mg tablet) alprazolam xr 2 mg tablet alprazolam xr 3 mg tablet amethia 0.15-0.03-0.01 mg tab amethia lo tablet AMITIZA (8 MCG CAPSULE, 24 MCG CAPSULES) AMPYRA ER 10 MG TABLET A 30 / 30 Days 3.6 / 28 days 24 / 30 days 17.8 / 30 days 375 / 30 days 375 / 30 days 525 / 30 days 100 / 30 days 12 / 30 days 12 / 30 days 150 / 30 days 150 / 30 days 150 / 30 days 150 / 30 days 91 / 91 days 91 / 91 Days PAGE 1 LAST UPDATED 04/2017 H2962_QL Template v116 Accepted
ANORO ELLIPTA 62.5-25 MCG INH ANZEMET 100 MG TABLET ANZEMET 50 MG TABLET APLENZIN (ER 174 MG TABLET, ER 348 MG TABLET, ER 522 MG TABLET) APOKYN 30 MG/3 ML CARTRIDGE aprepitant 125 mg capsule aprepitant 125-80-80 mg pack aprepitant 40 mg capsule aprepitant 80 mg capsule ARCAPTA NEOHALER 75 MCG CAP aripiprazole (10 mg tablet, 15 mg tablet, 20 mg tablet) aripiprazole (2 mg tablet, 5 mg tablet) aripiprazole 30 mg tablet aripiprazole odt (odt 10 mg tablet, odt 15 mg tablet) armodafinil (150 mg tablet, 250 mg tablet) armodafinil 200 mg tablet armodafinil 50 mg tablet ashlyna 0.15-0.03-0.01 mg tab ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 220 MCG #60, TWISTHALER 220 MCG #30, TWISTHALR 220 MCG #120) ASMANEX HFA (100 MCG, 200 MCG) ATRIPLA TABLET ATROVENT HFA INHALER AUBAGIO (7 MG TABLET, 14 MG TABLET) AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT, PREFILLED SYR 30 MCG) AVONEX PEN (30 ML, 30 ML KIT) azelastine hcl (0.1% (137 mcg) spry, 0.15% nasal spray) BARACLUDE 0.05 MG/ML SOLUTION BECONASE AQ 0.042% SPRAY BETASERON 0.3 MG KIT BINOSTO 70 MG TABLET EFF BREO ELLIPTA (100-25 MCG, 200-25 MCG) BROVANA 15 MCG/2 ML SOLUTION A B 5 / 30 days 5 / 30 days 2 / 30 Days 6 / 30 Days 1 / 30 Days 8 / 30 Days 30 / 30 DAYS 30 / 30 DAYS 60 / 30 DAYS 91 / 91 days 1 / 30 days 26 / 30 days 25.8 / 30 days 600 / 30 days 50 / 25 days 15 / 30 days PAGE 2 LAST UPDATED 04/2017
B budesonide (0.25 ml, 0.5 ml, 1 ml inh) budesonide 32 mcg nasal spray buprenorphin-naloxon 8-2 mg sl buprenorphn-naloxn 2-0.5 mg sl bupropion hcl sr (100 mg tablet, 150 mg tablet, 200 mg tablet, 200 mg tab) bupropion hcl sr 150 mg tablet bupropion hcl xl 150 mg tablet bupropion hcl xl 300 mg tablet BYDUREON 2 MG PEN INJECT BYDUREON 2 MG VIAL BYETTA 10 MCG DOSE PEN INJ BYETTA 5 MCG DOSE PEN INJ C calcipotriene-betameth dp oint calcitonin-salmon 200 units sp camrese lo tablet CAPRELSA 100 MG TABLET celecoxib (100 mg capsule, 200 mg capsule) celecoxib (50 mg capsule, 400 mg capsule) CHANTIX (1 MG CONT MONTH BOX, 1 MG TABLET, STARTING MONTH BOX) CHANTIX 0.5 MG TABLET chlordiazepoxide 10 mg capsule chlordiazepoxide 25 mg capsule chlordiazepoxide 5 mg capsule CIALIS (10 MG TABLET, 20 MG TABLET) CIALIS (2.5 MG TABLET, 5 MG TABLET) clonazepam (0.125 mg odt, 0.5 mg odt, 1 mg odt) clonazepam 0.25 mg odt clonazepam 2 mg odt clorazepate 15 mg tablet clorazepate 3.75 mg tablet clorazepate 7.5 mg tablet clozapine (25 mg tablet, 100 mg tablet) clozapine 200 mg tablet 17.2 / 30 days 3 60 / 30 Days 2. 4.8 / 28 days 400 / 28 days 3.7 / 30 days 91 / 91 Days 504 / 365 days 504 / 365 days 900 / 30 days 3 6 / 30 DAYS 720 / 30 days 3 270 / 30 days PAGE 3 LAST UPDATED 04/2017
clozapine 50 mg tablet clozapine odt (odt 25 mg tablet, odt 100 mg tablet) clozapine odt 12.5 mg tablet clozapine odt 150 mg tablet clozapine odt 200 mg tablet COMBIVENT RESPIMAT INHAL SPRAY COMPLERA TABLET COPAXONE 20 MG/ML SYRINGE COPAXONE 40 MG/ML SYRINGE COTELLIC 20 MG TABLET CYSTARAN 0.44% EYE DROPS d-amphetamine er 10 mg capsule d-amphetamine er 15 mg capsule d-amphetamine er 5 mg capsule DAKLINZA 30 MG TABLET DAKLINZA 60 MG TABLET DAKLINZA 90 MG TABLET DEPO-PROVERA 400 MG/ML VIAL DEPO-SUBQ PROVERA 104 SYRINGE DESCOVY 200-25 MG TABLET desvenlafaxine er 100 mg tab desvenlafaxine er 50 mg tab DEXEDRINE 10 MG TABLET DEXEDRINE 5 MG TABLET DEXILANT (DR 30 MG CAPSULE, DR 60 MG CAPSULE) dexmethylphenidate 2.5 mg tab dexmethylphenidate er 20 mg cp dexmethylphenidate hcl (5 mg tab, 10 mg tab) dexmethylphenidate hcl er (er 25 mg, er 35 mg) dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er 15 mg cp, er 30 mg cp, er 40 mg cp) dextroamp-amphet er 5 mg cap dextroamphetamine 10 mg tab C D 270 / 30 days 8 / 30 days 12 / 28 days 60 / 28 days 504 / 365 days 168 / 365 days 168 / 365 OVER TIME 10 / 28 days 0.65 / 90 days 30 / 30 DAYS PAGE 4 LAST UPDATED 04/2017
dextroamphetamine 5 mg tab dextroamphetamine-amphet er (er 10 mg cap, er 15 mg cap, er 20 mg cap, er 25 mg cap, er 30 mg cap) dextroamphetamine-amphetamine (dextroamp-amphetam 7.5 mg tab, dextroampamphetam 12.5 mg tab, dextroamp-amphetamin 10 mg tab) dextroamphetamine-amphetamine (dextroamp-amphetamin 15 mg tab, dextroampamphetamin 20 mg tab, dextroamp-amphetamin 30 mg tab, dextroampamphetamine 5 mg tab) diclofenac sodium 1% gel digitek 125 mcg tablet digox 125 mcg tablet digoxin (0.125 mg tablet, 125 mcg tablet) dihydroergotamine 4 mg/ml spry dronabinol (2.5 mg capsule, 5 mg capsule, 10 mg capsule) DULERA (100 MCG, 200 MCG) duloxetine hcl (dr 20 mg cap, dr 60 mg cap) duloxetine hcl dr 30 mg cap duloxetine hcl dr 40 mg cap DYMISTA NASAL SPRAY EGRIFTA (1 MG VIAL, 2 MG VIAL) ELIGARD (22.5 MG B, 22.5 MG KIT) ELIGARD (30 MG B, 30 MG KIT) ELIGARD (45 MG B, 45 MG KIT) ELIGARD (7.5 MG B, 7.5 MG KIT) ELIQUIS 2.5 MG TABLET ELIQUIS 5 MG TABLET EMEND 125 MG CAPSULE EMEND 125 MG POWDER PACKET EMEND 40 MG CAPSULE EMEND 80 MG CAPSULE EMEND TRIPACK EMSAM (6, 9, 12) enoxaparin 100 mg/ml syringe enoxaparin 150 mg/ml syringe enoxaparin 30 mg/0.3 ml syr D E 1000 / 30 Days 30 / 30 DAYS 8 / 30 days 17.6 / 30 days 90 / 30 Days 23 / 30 days 1 / 84 days 1 / 112 days 1 / 168 days 2 / 30 days 6 / 30 Days 1 / 30 days 8 / 30 days 6 / 30 days 35 / 90 days 35 / 90 days 10.5 / 90 Days PAGE 5 LAST UPDATED 04/2017
E enoxaparin 300 mg/3 ml vial enoxaparin 40 mg/0.4 ml syr enoxaparin 60 mg/0.6 ml syr enoxaparin sodium (80 ml, 120 ml) entecavir (0.5 mg tablet, 1 mg tablet) ENTRESTO (24 MG-26 MG TABLET, 49 MG-51 MG TABLET) ENTRESTO 97 MG-103 MG TABLET EPCLUSA 400 MG-100 MG TABLET EPZICOM TABLET esomeprazole magnesium (dr 20 mg cap, dr 40 mg cap) estazolam (1 mg tablet, 2 mg tablet) ESTRING 2 MG VAGINAL RING eszopiclone (1 mg tablet, 2 mg tablet, 3 mg tablet) EVOTAZ 300 MG-150 MG TABLET EXTAVIA (0.3 MG VIAL, 0.3 MG KIT) F FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET) FANAPT (6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET) FANAPT TITRATION PACK FARYDAK (10 MG CAPSULE, 15 MG CAPSULE) FARYDAK 20 MG CAPSULE FEMRING (FEM0.05 MG, FEM0.10 MG) FETZIMA (ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 120 MG CAPSULE) FETZIMA 20-40 MG TITRATION PAK FETZIMA ER 80 MG CAPSULE FIRMAGON 2 X 120 MG KIT FIRMAGON 80 MG KIT FLOVENT 100 MCG DISKUS FLOVENT 250 MCG DISKUS FLOVENT 50 MCG DISKUS FLOVENT HFA (110 MCG, 220 MCG) FLOVENT HFA 44 MCG INHALER flunisolide 0.025% spray fluoxetine dr 90 mg capsule 105 / 90 days 14 / 90 Days 21 / 90 days 28 / 90 days 84 / 365 Days 1 / 90 days 15 / 30 days 8 / 180 days 6 / 21 days 6 / 21 days 1 / 90 days 56 / 365 days 4 / 365 days 24 / 30 days 21.2 / 30 days 50 / 30 days PAGE 6 LAST UPDATED 04/2017
F fluvoxamine maleate er (er 100 mg capsule, er 150 mg capsule) FOCALIN XR (25 MG CAPSULE, 35 MG CAPSULE) fondaparinux 10 mg/0.8 ml syr fondaparinux 2.5 mg/0.5 ml syr fondaparinux 5 mg/0.4 ml syr fondaparinux 7.5 mg/0.6 ml syr FORFIVO XL 450 MG TABLET FOSAMAX PLUS D 70 MG-2,800 IU FOSAMAX PLUS D 70 MG-5,600 IU FRAGMIN (25,000 UNITS/ML VIAL, 95,000 UNITS/3.8 ML VL) FRAGMIN 10,000 UNITS/ML SYRING FRAGMIN 12,500 UNITS/0.5 ML FRAGMIN 15,000 UNITS/0.6 ML FRAGMIN 18,000 UNITS/0.72 ML FRAGMIN 2,500 UNITS/0.2 ML SYR FRAGMIN 5,000 UNITS/0.2 ML SYR FRAGMIN 7,500 UNITS/0.3 ML SYR frovatriptan succ 2.5 mg tab FUZEON (90 MG VIAL, CONVENIENCE KIT) G GENVOYA TABLET GEODON 20 MG/ML VIAL GILENYA 0.5 MG CAPSULE GILOTRIF (20 MG TABLET, 30 MG TABLET, 40 MG TABLET) glatopa 20 mg/ml syringe glimepiride 1 mg tablet glimepiride 2 mg tablet glimepiride 4 mg tablet glipizide 10 mg tablet glipizide 5 mg tablet glipizide er 10 mg tablet glipizide er 2.5 mg tablet glipizide er 5 mg tablet glipizide xl 10 mg tablet 28 / 90 days 17.5 / 90 days 14 / 90 days 21 / 90 days 22.8 / 90 days 35 / 90 days 17.5 / 90 days 21 / 90 days 25.3 / 90 days 7 / 90 days 7 / 90 days 10.5 / 90 days 9 / 30 days PAGE 7 LAST UPDATED 04/2017
glipizide xl 2.5 mg tablet glipizide xl 5 mg tablet glipizide-metformin (2.5-500 mg, 5-500 mg) glipizide-metformin 2.5-250 mg glyburid-metformin 1.25-250 mg glyburide 1.25 mg tablet glyburide 2.5 mg tablet glyburide 5 mg tablet glyburide micro 1.5 mg tab glyburide micro 3 mg tablet glyburide micro 6 mg tablet glyburide-metformin hcl (2.5-500 mg, 5-500 mg) GRALISE 30-DAY STARTER PACK GRALISE ER 300 MG TABLET GRALISE ER 600 MG TABLET granisetron hcl 1 mg tablet HARVONI 90-400 MG TABLET HETLIOZ 20 MG CAPSULE ibandronate sodium 150 mg tab ICLUSIG 15 MG TABLET ILEVRO 0.3% OPHTH DROPS insulin pen needles insulin safety needles insulin syringes u-100 0.3 ml insulin syringes u-100 1/2 ml insulin syringes u-100 1 ml introvale 0.15-0.03 mg tablet INVOKAMET (50-1,000 MG TABLET, 150-500 MG TABLET, 150-1,000 MG TABLET) INVOKAMET 50-500 MG TABLET INVOKAMET XR (50-500 MG TABLET, 50-1,000 MG TAB, 150-1,000 MG TAB, 150-500 MG TABLET) INVOKANA 100 MG TABLET G H I 480 / 30 days 156 / 365 Days 180 / 30 Days 90 / 30 Days 168 / 365 days 6 / 30 days 200 / 30 Days 200 / 30 Days 200 / 30 Days 200 / 30 Days 200 / 30 Days 91 / 91 days 60 / 30 Days PAGE 8 LAST UPDATED 04/2017
INVOKANA 300 MG TABLET iprat-albut 0.5-3(2.5) mg/3 ml ipratropium br 0.02% soln I 540 / 30 days 312.5 / 30 days JAKAFI (5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 25 MG TABLET) JANUMET (50-1,000 MG TABLET, 50-500 MG TABLET) JANUMET XR (50-500 MG TABLET, 50-1,000 MG TABLET) JANUMET XR 100-1,000 MG TABLET JARDIANCE 10 MG TABLET JARDIANCE 25 MG TABLET JENTADUETO (2.5 MG-1000 MG TAB, 2.5 MG-500 MG TAB) JENTADUETO 2.5 MG-850 MG TAB JENTADUETO XR 2.5 MG-1,000 MG JENTADUETO XR 5 MG-1,000 MG TB JUXTAPID (5 MG CAPSULE, 10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE) J 60 / 30 DAYS 30 / 30 DAYS ketorolac 10 mg tablet KEVEYIS 50 MG TABLET KHEDEZLA ER 100 MG TABLET KHEDEZLA ER 50 MG TABLET KOMBIGLYZE XR (5-1,000 MG TAB, 5-500 MG TABLET) KOMBIGLYZE XR 2.5-1,000 MG TAB KORLYM 300 MG TABLET KYNAMRO 200 MG/ML SYRINGE K 20 / 30 days L lamivudine-zidovudine tablet LANOXIN 125 MCG TABLET LANOXIN 187.5 MCG TABLET LANOXIN 62.5 MCG TABLET lansoprazole (dr 15 mg capsule, dr 30 mg capsule) LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 120 MG TABLET) LATUDA 80 MG TABLET LETAIRIS (5 MG TABLET, 10 MG TABLET) PAGE 9 LAST UPDATED 04/2017
levalbuterol 0.31 mg/3 ml sol levalbuterol 0.63 mg/3 ml sol levalbuterol 1.25 mg/3 ml sol levalbuterol conc 1.25 mg/0.5 levalbuterol tar hfa 45mcg inh levono-e estrad 0.15-0.03-0.01 levonor-eth estrad 0.15-0.03 lidocaine-prilocaine cream linezolid 100 mg/5 ml susp linezolid 600 mg tablet LINZESS (145 MCG CAPSULE, 290 MCG CAPSULE) LONSURF 15 MG-6.14 MG TABLET LONSURF 20 MG-8.19 MG TABLET lorazepam (0.5 mg tablet, 1 mg tablet) lorazepam 2 mg tablet LOTEMAX 0.5% EYE OINTMENT LOTEMAX 0.5% OPHTHALMIC GEL lp lite pak 2.5-2.5% crm-dress LUPANETA PK 11.25-5 MG 3MO KIT LUPANETA PK 3.75-5 MG 1MO KIT LUPRON DEPO 11.25MG (LUPANETA) LUPRON DEPOT (11.25 MG, 22.5 MG) LUPRON DEPOT (3.75 MG, 7.5 MG) LUPRON DEPOT 3.75MG (LUPANETA) LUPRON DEPOT 45 MG 6MO KIT LUPRON DEPOT-4 MONTH KIT LUPRON DEPOT-PED (11.25 MG, 15 MG) LUPRON DEPOT-PED 11.25 MG 3MO LUPRON DEPOT-PED 30 MG 3MO KIT LUPRON DEPOT-PED 7.5 MG KIT LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE) LYRICA 20 MG/ML ORAL SOLUTION LYRICA 300 MG CAPSULE L 540 / 30 days 540 / 30 days 30 / 30 Days 91 / 91 days 91 / 91 days 1800 / 30 days 56 / 28 Days 100 / 28 days 80 / 28 days 150 / 30 days 14 / 365 days 20 / 365 days 1 / 84 days 1 / 84 days 1 / 84 days 1 / 168 days 1 / 112 days 1 / 84 days 1 / 112 days 900 / 30 days PAGE 10 LAST UPDATED 04/2017
medroxyprogesterone 150 mg/ml metadate er 20 mg tablet metformin hcl 1,000 mg tablet metformin hcl 500 mg tablet metformin hcl 850 mg tablet metformin hcl er (er 500 mg osm-tb, er 500 mg tablet) metformin hcl er 750 mg tablet methylphenidate 10 mg chew tab methylphenidate 2.5 mg chew tb methylphenidate 5 mg chew tab methylphenidate cd 50 mg cap methylphenidate er (er 18 mg tab, er 27 mg tab, er 30 mg cap, er 40 mg cap, er 54 mg tab) methylphenidate er 10 mg tab methylphenidate er 20 mg tab methylphenidate er 36 mg tab methylphenidate er 50 mg cap M methylphenidate hcl (5 mg tablet, 10 mg tablet, 20 mg tablet) methylphenidate hcl cd (10 mg cap, 30 mg cap, 60 mg cap) methylphenidate hcl cd (20 mg cap, 40 mg cap) methylphenidate hcl er (er 10 mg cap, er 30 mg cap, er 60 mg cap) methylphenidate hcl er (er 20 mg cap, er 40 mg cap) methylphenidate la (30 mg cap, 40 mg cap) methylphenidate sr 20 mg tab modafinil (100 mg tablet, 200 mg tablet) mometasone furoate 50 mcg spry MOZOBIL 24 MG/1.2 ML VIAL NAMENDA XR (21 MG CAPSULE, 28 MG CAPSULE) NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE) NAMENDA XR TITRATION PACK NAMZARIC 14 MG-10 MG CAPSULE NAMZARIC 28 MG-10 MG CAPSULE naratriptan 1 mg tablet N 1 / 90 days 150 / 30 days 30 / 30 Days 30 / 30 Days 34 / 30 days 38.4 / 365 days 56 / 365 days 9 / 30 days PAGE 11 LAST UPDATED 04/2017
naratriptan 2.5 mg tablet naratriptan hcl 1 mg tablet naratriptan hcl 2.5 mg tablet NASONEX 50 MCG NASAL SPRAY NATPARA (25 MCG, 50 MCG, 75 MCG, 100 MCG) NEVANAC 0.1% DROPTAINER NEXIUM PACKETS (DR 2.5 MG, DR 5 MG, DR 10 MG, DR 20 MG, DR 40 MG) NICOTROL CARTRIDGE INHALER NICOTROL NS 10 MG/ML SPRAY nitrofurantoin 25 mg/5 ml susp nitrofurantoin mcr 100 mg cap nitrofurantoin mcr 25 mg cap nitrofurantoin mcr 50 mg cap nitrofurantoin mono-mcr 100 mg NUPLAZID 17 MG TABLET OCALIVA (5 MG TABLET, 10 MG TABLET) ODEFSEY TABLET olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet) olanzapine odt (odt 10 mg tablet, odt 15 mg tablet, odt 20 mg tablet) olanzapine odt 5 mg tablet olanzapine-fluoxetine 12-25 mg olanzapine-fluoxetine hcl (3-25 mg, 6-25 mg) olanzapine-fluoxetine hcl (6-50 mg, 12-50 mg) olopatadine 665 mcg nasal spry OLYSIO 150 MG CAPSULE omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr 40 mg capsule) omeprazole-sodium bicarbonate (20-1,100 cap, 40-1,100 cap) omeprazole-sodium bicarbonate (20-1,680, 40-1,680) ondansetron 4 mg/5 ml solution ondansetron hcl (4 ml vial, 4 ml amp) ondansetron hcl (hcl 4 ml syr, 4 ml isecure) ondansetron hcl 24 mg tablet N O 9 / 30 days 9 / 30 days 9 / 30 days 34 / 30 days 2 / 28 days 6 / 30 days 2688 / 365 days 360 / 365 days 7200 / 365 days 360 / 365 Days 1440 / 365 days 720 / 365 Days 180 / 365 Days 60 / 30 DAYS 30 / 30 Days 30.5 / 30 days 168 / 365 days 60 / 30 Days 450 / 30 days 1 PAGE 12 LAST UPDATED 04/2017
O OPSUMIT 10 MG TABLET ORENCIA CLICKJECT 125 MG/ML ORKAMBI 100 MG-125 MG TABLET ORKAMBI 200 MG-125 MG TABLET oseltamivir phos 30 mg capsule oseltamivir phos 45 mg capsule oseltamivir phos 75 mg capsule oxandrolone 10 mg tablet oxandrolone 2.5 mg tablet oxazepam (10 mg capsule, 30 mg capsule) oxazepam 15 mg capsule P paliperidone er 1.5 mg tablet paliperidone er 3 mg tablet paliperidone er 6 mg tablet paliperidone er 9 mg tablet pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) PERFOROMIST 20 MCG/2 ML SOLN PEXEVA (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) PEXEVA 30 MG TABLET pioglitazone hcl 15 mg tablet pioglitazone hcl 30 mg tablet pioglitazone hcl 45 mg tablet pioglitazone-glimepiride (30-4, 30-2) pioglitazone-metformin (15-500, 15-850) PLEGRIDY 125 MCG/0.5 ML PEN PLEGRIDY 125 MCG/0.5 ML SYRING PLEGRIDY PEN INJ STARTER PACK PRADAXA (75 MG CAPSULE, 110 MG CAPSULE) PRADAXA 150 MG CAPSULE PRALUENT 75 MG/ML SYRINGE PRALUENT PEN (75 MG/ML, 150 MG/ML) PREZCOBIX 800 MG-150 MG TABLET PRISTIQ (ER 25 MG TABLET, ER 50 MG TABLET) 4 / 28 Days 112 / 28 Days 112 / 28 days 112 / 365 Days 60 / 365 Days 110 / 365 Days 45 / 30 days 45 / 30 days 2 / 365 days 2 / 28 days 2 / 28 days PAGE 13 LAST UPDATED 04/2017
PRISTIQ ER 100 MG TABLET PROAIR HFA 90 MCG INHALER PROAIR RESPICLICK INHAL POWDER PROLENSA 0.07% EYE DROPS PROLIA 60 MG/ML SYRINGE quasense 0.15-0.03 mg tablet quetiapine er 150 mg tablet quetiapine fumarate (25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) quetiapine fumarate (300 mg tab, 400 mg tab) QVAR 40 MCG ORAL INHALER QVAR 80 MCG ORAL INHALER rabeprazole sod dr 20 mg tab REBIF (22 ML, 44 ML) REBIF REBIDOSE (22 ML, 44 ML) REBIF REBIDOSE TITRATION PACK REBIF TITRATION PACK RELENZA 5 MG DISKHALER RELISTOR (12 ML KIT, 12 ML VIAL) RELISTOR 12 MG/0.6 ML SYRINGE RELISTOR 150 MG TABLET RELISTOR 8 MG/0.4 ML SYRINGE repaglinide-metformin hcl (1-500 mg, 2-500 mg) REPATHA 140 MG/ML SURECLICK REPATHA 140 MG/ML SYRINGE REPATHA 420 MG/3.5ML PUSHTRONX REXULTI (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET) RIOMET 500 MG/5 ML SOLUTION risedronate sod dr 35 mg tab risedronate sodium 150 mg tab risedronate sodium 35 mg tab risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet) P Q R 17 / 30 days 2 / 30 days 12 / 365 days 2 / 365 days 91 / 91 days 60 / 30 Days 17.4 / 30 days 26.1 / 30 days 6 / 28 days 6 / 28 days 8.4 / 365 days 8.4 / 365 days 240 / 365 days 18 / 30 days 18 / 30 days 90 / 30 Days 12 / 30 days 150 / 30 days 3 / 28 days 3 / 28 days 3.5 / 28 Days 765 / 30 days PAGE 14 LAST UPDATED 04/2017
risperidone 0.25 mg odt risperidone 1 mg/ml solution risperidone odt (0.5 mg odt, 1 mg odt, 2 mg odt, 3 mg odt, 4 mg odt) RITALIN LA 10 MG CAPSULE rizatriptan (5 mg tablet, 10 mg odt, 10 mg tablet) rizatriptan 5 mg odt ROZEREM 8 MG TABLET RUBRACA (200 MG TABLET, 300 MG TABLET) SAMSCA 15 MG TABLET SAMSCA 30 MG TABLET SANCUSO 3.1 MG/24 HR PATCH SAPHRIS (2.5 MG TAB SL BLK CHRY, 5 MG TAB SL BLK CHERRY, 5 MG TABLET SUBLINGUAL, 10 MG TAB SUBLINGUAL, 10 MG TAB SL BLK CHERY) SAVAYSA (15 MG TABLET, 30 MG TABLET, 60 MG TABLET) SAVELLA (12.5 MG TABLET, 25 MG TABLET) SAVELLA (50 MG TABLET, 100 MG TABLET) SAVELLA TITRATION PACK SEREVENT DISKUS 50 MCG setlakin 0.15 mg-0.03 mg tab SIGNIFOR (0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML) SIGNIFOR LAR (20 MG VIAL, 20 MG KIT, 40 MG KIT, 40 MG VIAL, 60 MG VIAL, 60 MG KIT) sildenafil 20 mg tablet SILENOR (3 MG TABLET, 6 MG TABLET) SIVEXTRO 200 MG TABLET SIVEXTRO 200 MG VIAL SOVALDI 400 MG TABLET SPIRIVA 18 MCG CP-HANDIHALER SPIRIVA RESPIMAT (1.25 MCG, 2.5 MCG) STIOLTO RESPIMAT INHAL SPRAY STRATTERA (18 MG CAPSULE, 25 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MG CAPSULE, 100 MG CAPSULE) STRATTERA 10 MG CAPSULE STRIBILD TABLET R S 18 / 30 days 18 / 30 days 120 / 30 DAYS 30 / 60 days 2 / 30 days 110 / 365 days 91 / 91 days 6 / 30 days 6 / 30 days 336 / 365 days 4 / 30 days 4 / 30 days PAGE 15 LAST UPDATED 04/2017
S STRIVERDI RESPIMAT INHAL SPRAY SUBOXONE 12 MG-3 MG SL FILM SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE 4 MG-1 MG SL FILM SUBOXONE 8 MG-2 MG SL FILM sumatriptan (5 mg, 20 mg) sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet) sumatriptan succinate (4 ml cart, 4 ml inject) sumatriptan succinate (6 ml refill, 6 ml inject) sumatriptan succinate (6 ml vial, 6 ml syrng) SYMBICORT 160-4.5 MCG INHALER SYMBICORT 80-4.5 MCG INHALER SYNJARDY (5-1,000 MG TABLET, 12.5-1,000 MG TABLET) SYNJARDY (5-500 MG TABLET, 12.5-500 MG TABLET) T TACLONEX 0.005%-0.064% SUSPENS TAGRISSO (40 MG TABLET, 80 MG TABLET) TAMIFLU 30 MG CAPSULE TAMIFLU 45 MG CAPSULE TAMIFLU 6 MG/ML SUSPENSION TAMIFLU 75 MG CAPSULE TARCEVA (100 MG TABLET, 150 MG TABLET) TARCEVA 25 MG TABLET TAZORAC (CREAM, GEL) TAZORAC (CREAM, GEL) TECFIDERA (DR 120 MG CAPSULE, DR 240 MG CAPSULE) TECFIDERA STARTER PACK TECHNIVIE DOSE PACK temazepam (7.5 mg capsule, 15 mg capsule, 30 mg capsule) temazepam 22.5 mg capsule terbinafine hcl 250 mg tablet TOBI PODHALER 28 MG INHALE CAP tolazamide 250 mg tablet tolazamide 500 mg tablet 4 / 30 days 3 12 / 30 days 9 / 30 days 8 / 30 Days 5 / 30 days 5 / 30 days 12 / 30 days 13.8 / 30 days 400 / 30 days 112 / 365 days 60 / 365 days 720 / 365 days 110 / 365 days 100 / 30 days 100 / 30 days 120 / 365 days 168 / 365 days 84 / 180 days 224 / 56 days PAGE 16 LAST UPDATED 04/2017
tolbutamide 500 mg tablet TRELSTAR (11.25 MG SYRINGE, 11.25 MG VIAL) TRELSTAR (22.5 MG VIAL, 22.5 MG SYRINGE) TRELSTAR (3.75 MG SYRINGE, 3.75 MG VIAL) TRINTELLIX (10 MG TABLET, 20 MG TABLET) TRINTELLIX 5 MG TABLET TRIUMEQ TABLET TRULICITY (0.75 ML, 1.5 ML) TRUVADA (100 MG-150 MG TABLET, 133 MG-200 MG TABLET, 167 MG-250 MG TABLET) TRUVADA 200 MG-300 MG TABLET TUDORZA PRESSAIR 400 MCG INH UPTRAVI (200 MCG TABLET, 400 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET) UPTRAVI 200-800 TITRATION PACK valacyclovir (1 gram tablet, 500 mg tablet) VENTAVIS (10 ML, 20 ML) VERSACLOZ 50 MG/ML SUSPENSION VICTOZA 2-PAK 18 MG/3 ML PEN VICTOZA 3-PAK 18 MG/3 ML PEN VIEKIRA PAK VIEKIRA XR TABLET VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) VIIBRYD 10-20 MG STARTER PACK VOLTAREN 1% GEL VRAYLAR (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE) VRAYLAR 1.5 MG-3 MG PACK VRAYLAR 6 MG CAPSULE T U V 1 / 84 days 1 / 168 days 30 / 30 DAYS 30 / 30 DAYS 2 / 28 days 30 / 30 DAYS 400 / 365 days 270 / 30 days 540 / 30 days 9 / 30 days 9 / 30 days 672 / 365 days 504 / 365 Days 60 / 365 days 1000 / 30 days 14 / 365 days XARELTO (10 MG TABLET, 20 MG TABLET) XARELTO 15 MG TABLET XARELTO STARTER PACK XOPENEX HFA 45 MCG INHALER X 102 / 365 days PAGE 17 LAST UPDATED 04/2017
X XYREM 500 MG/ML ORAL SOLUTION Z zaleplon 10 mg capsule zaleplon 5 mg capsule zenzedi (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 15 mg tablet, 20 mg tablet) zenzedi 10 mg tablet ZENZEDI 30 MG TABLET ZEPATIER 50-100 MG TABLET ziprasidone hcl (20 mg capsule, 40 mg capsule, 60 mg capsule, 80 mg capsule) zolmitriptan (2.5 mg tablet, 5 mg tablet) zolmitriptan 2.5 mg odt zolmitriptan 5 mg odt zolpidem tart er 6.25 mg tab zolpidem tartrate (1.75 mg tab, 3.5 mg tablet) zolpidem tartrate (5 mg tablet, 10 mg tablet) ZUBSOLV 1.4-0.36 MG TABLET SL ZUBSOLV 11.4-2.9 MG TABLET SL ZUBSOLV 2.9-0.71 MG TABLET SL ZUBSOLV 5.7-1.4 MG TABLET SL ZUBSOLV 8.6-2.1 MG TABLET SL ZURAMPIC 200 MG TABLET 540 / 30 days 112 / 365 days 12 / 30 days 12 / 30 days 9 / 30 days 30 / 30 Days 3 30 / 30 Days PAGE 18 LAST UPDATED 04/2017