Download SilverScript 2017 Choice Formulary

SilverScript
2017 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS
INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary File 17255, Version 11
This formulary was updated on May 1, 2017. For more recent information or other questions, please
contact SilverScript at 1-866-235-5660 or, for TTY users, 711, 24 hours a day, 7 days a week, or visit
www.silverscript.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 SilverScript® Insurance Company. When
it refers to “plan” or “our plan,” it means SilverScript Choice (PDP).
This document includes a list of the drugs (formulary) for our plan which is current as of
May 1, 2017. 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. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time
during the year.
Y0080_62001_FORM_COMP_2017 Accepted
0
FRM-CM-CHC-9110-17
What is the SilverScript
Formulary?
A formulary is a list of covered drugs selected by
SilverScript Choice (PDP) 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.
Our plan will generally cover the drugs listed in
our formulary as long as the drug is medically
necessary, the prescription is filled at a plan
network pharmacy, and other plan rules are
followed. For more information on how to fill your
prescriptions, please review your Evidence of
Coverage.
Can the Formulary (drug list)
change?
Generally, if you are taking a drug on our 2017
formulary that was covered at the beginning of
the year, we will not discontinue or reduce
coverage of the drug during the 2017 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.
Other types of formulary changes, such as
removing a drug from our formulary, will not affect
members who are currently taking the drug. It will
remain available at the same cost-sharing for
those members taking it for the remainder of the
coverage year.
We feel it is important that you have continued
access for the remainder of the coverage year to
the formulary drugs that were available when you
chose our plan, except for cases in which you can
save additional money or we can ensure your
safety.
If the Food and Drug Administration deems a
drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market,
we will immediately remove the drug from our
formulary and provide notice to members who
take the drug.
The enclosed formulary is current as of May 1,
2017. To get updated information about the
drugs covered by SilverScript Choice (PDP),
please contact us. Our contact information
appears on the front and back cover pages.
If we have other types of mid-year
non-maintenance formulary changes unrelated to
the reasons stated above (e.g. remove drugs
from our formulary, add prior authorization
requirements, quantity limits and/or step therapy
restrictions on a drug, or move a drug to a higher
cost-sharing tier), we will notify you by mail. We
will also update our formulary with the new
information. The updated formulary may be
obtained from our website or by calling us. Our
contact information appears on the front and back
cover pages.
How do I use the Formulary?
There are two ways to find your drug within the
formulary:
Medical Condition
The formulary begins on page 7. 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”. If you know what your drug is
used for, look for the category name in the list
that begins on page 7. Then look under the
category name for your drug.
If we remove drugs from our formulary, add prior
authorization, quantity limits and/or step therapy
restrictions on a drug, or move a drug to a higher
cost-sharing tier, we must notify affected
members of the change at least 60 days before
the change becomes effective, or at the time the
member requests a refill of the drug, at which
time the member will receive a 60-day supply of
the drug.
1
Alphabetical Listing
Step Therapy (ST)
If you are not sure what category to look under,
you should look for your drug in the Index that
begins on page 53. 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 will see
the page number where you can find coverage
information. Turn to the page listed in the Index
and find the name of your drug in the first column
of the list.
In some cases, SilverScript Choice (PDP)
requires 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.
What are generic drugs?
SilverScript Choice (PDP) covers both brand
name drugs and generic drugs. A generic drug is
approved by the FDA as having the same active
ingredient as the brand name drug. Generally,
generic drugs cost less than brand name drugs.
Are there any restrictions on
my coverage?
Some covered drugs may have additional
requirements or limits on coverage. These
requirements and limits may include:
Prior Authorization (PA)
You can find out if your drug has any additional
requirements or limits by looking in the formulary
that begins on page 7. You can also get more
information about the restrictions applied to
specific covered drugs by visiting our website. We
have posted on line documents that explain our
prior authorization and step therapy restrictions.
You may also ask us to send you a copy. Our
contact information, along with the date we last
updated the formulary, appears on the front and
back cover pages.
You can ask us to make an exception to these
restrictions or limits or for a list of other, similar
drugs that may treat your health condition. See
the section, “How do I request an exception to the
SilverScript formulary?” on page 3 for information
about how to request an exception.
SilverScript Choice (PDP) requires you or your
physician 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, we may
not cover the drug.
What if my drug is not on the
Formulary?
Quantity Limits (QL)
If you learn that SilverScript Choice (PDP) does
not cover your drug, you have two options:
For certain drugs, SilverScript Choice (PDP)
limits the amount of the drug that we will cover.
For example, our plan provides up to 30 tablets
per prescription for doxazosin. This may be in
addition to a standard one-month or three-month
supply.
If your drug is not included in this formulary (list of
covered drugs), you should first contact Customer
Care and ask if your drug is covered.
 You can ask Customer Care for a list of
similar drugs that are covered by our plan.
When you receive the list, show it to your
doctor and ask him or her to prescribe a
similar drug that is covered by our plan.
 You can ask us to make an exception and
cover your drug. See below for
information about how to request an
exception.
2
How do I request an exception
to the SilverScript 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.
 You can ask us to cover a 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, our plan limits
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.
Generally, SilverScript Choice (PDP) 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
utilization restriction exception. When you
request a formulary, tiering or utilization
restriction exception you should submit a
statement from your prescriber or physician
supporting your request.
Generally, we must make our decision within 72
hours of getting your prescriber’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 doctor
or other prescriber.
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.
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 allow you to refill your prescription until we
have provided you with a 102-day transition
supply, consistent with the 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 34-day
emergency supply of that drug (unless you have
a prescription for fewer days) while you pursue a
formulary exception.
3
If you experience a change in your level of care,
such as a move from a home to a long-term care
setting, and need a drug that is not on our
formulary (or if your ability to get your drugs is
limited), we may cover a one-time temporary
supply from a network pharmacy for up to 34 days
unless you have a prescription for fewer days.
You should use the plan's exception process if
you wish to have continued coverage of the drug
after the temporary supply is finished.
For more information
For more detailed information about your
SilverScript Choice (PDP) prescription drug
coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about our plan, please
contact us. Our contact information, along with
the date we last updated the 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 users should call
1-877-486-2048. Or, visit
http://www.medicare.gov.
SilverScript Choice (PDP)’s
Formulary
The formulary that begins on page 7 provides
coverage information about the drugs covered by
our plan. If you have trouble finding your drug in
the list, turn to the Index that begins on page 53.
The first column of the chart lists the drug name.
Brand name drugs are capitalized (e.g.,
SYNTHROID) and generic drugs are listed in
lower-case italics (e.g., levothyroxine).
4
The information in the Requirements/Limits column tells you if our plan has any special
requirements for coverage of your drug.
PA – Prior authorization.
QL – Drug has quantity limit.
ST – Step therapy required.
NM – Not available at our mail-order pharmacies.
NDS – Non-extended day supply. Not available for an extended (long-term) supply.
LA – Limited access. This prescription may be
available only at certain pharmacies. For more
information consult your Pharmacy Directory or
call Customer Care at 1-866-235-5660, 24 hours
a day, 7 days a week. TTY users should call 711.
HR – High Risk Drug. According to medical
experts, these drugs may cause more side effects if you are 65 years of age or older. If you are taking one of these drugs, ask your doctor if there are safer options available.
B/D – This drug may be covered under Medicare Part B or Part D depending upon the
circumstances. Information may need to be
submitted describing the use and setting of the
drug to make the determination.
The Tier column of the drug list that begins on page 7 tells you which tier your drug is in. The table below
tells you the copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay during the
initial coverage stage) for up to a one-month supply of drugs in each tier.
Initial Coverage Stage Copayment / Coinsurance Levels
Standard retail cost-sharing (in-network) (Up to a 30-day supply)
Tier 1
(Preferred
Generic)
State
(includes low
cost preferred
generic drugs)
Tier 2
(Generic)
Tier 3
(Preferred
Brand)
Tier 4
(Non-Preferred
Drug)
(includes
(includes
generic and
(includes
non-preferred
some low cost preferred brand
brand and
preferred
and non-preferred non-preferred
brand drugs)
generic drugs) generic drugs)
Tier 5
(Specialty
Tier)
(includes high
cost generic
and brand
drugs)
Alabama
$3.00
$13.00
$45.00
50%
33%
Alaska
$1.00
$4.00
15%
35%
25%
Arizona
$7.00
$20.00
$47.00
50%
33%
Arkansas
$3.00
$13.00
$46.00
50%
33%
California
$3.00
$17.00
$47.00
48%
33%
Colorado
$3.00
$20.00
$47.00
50%
33%
Connecticut
$3.00
$13.00
$42.00
44%
33%
Delaware
$3.00
$19.00
$47.00
50%
33%
District of Columbia
$3.00
$19.00
$47.00
50%
33%
Florida
$4.00
$20.00
$47.00
50%
33%
Georgia
$3.00
$13.00
$46.00
50%
33%
Hawaii
$1.00
$4.00
17%
36%
25%
Idaho
$3.00
$14.00
$45.00
50%
33%
Illinois
$3.00
$18.00
$46.00
50%
33%
Indiana
$3.00
$14.00
$45.00
50%
33%
Iowa
$3.00
$14.00
$42.00
48%
33%
Kansas
$3.00
$14.00
$45.00
50%
33%
Kentucky
$3.00
$14.00
$45.00
50%
33%
Louisiana
$3.00
$12.00
$43.00
47%
33%
Maine
$3.00
$17.00
$46.00
50%
33%
Maryland
$3.00
$19.00
$47.00
50%
33%
Massachusetts
$3.00
$13.00
$42.00
44%
33%
Michigan
$3.00
$14.00
$45.00
49%
33%
Minnesota
$3.00
$14.00
$42.00
48%
33%
Mississippi
$3.00
$14.00
$45.00
50%
33%
Missouri
$3.00
$12.00
$43.00
47%
33%
Montana
$3.00
$14.00
$42.00
48%
33%
Nebraska
$3.00
$14.00
$42.00
48%
33%
5
Tier 1
(Preferred
Generic)
Tier 2
(Generic)
Tier 3
(Preferred
Brand)
Tier 4
(Non-Preferred
Drug)
(includes
(includes
generic and
(includes
non-preferred
some low cost preferred brand
brand and
preferred
and non-preferred non-preferred
brand drugs)
generic drugs) generic drugs)
Tier 5
(Specialty
Tier)
(includes high
cost generic
and brand
drugs)
State
(includes low
cost preferred
generic drugs)
Nevada
$7.00
$20.00
$47.00
50%
33%
New Hampshire
$3.00
$17.00
$46.00
50%
33%
New Jersey
$3.00
$15.00
$47.00
49%
33%
New Mexico
$3.00
$15.00
$47.00
50%
33%
New York
$3.00
$13.00
$46.00
48%
33%
North Carolina
$3.00
$14.00
$45.00
50%
33%
North Dakota
$3.00
$14.00
$42.00
48%
33%
Ohio
$3.00
$17.00
$46.00
49%
33%
Oklahoma
$3.00
$12.00
$43.00
49%
33%
Oregon
$3.00
$12.00
$44.00
48%
33%
Pennsylvania
$3.00
$13.00
$45.00
50%
33%
Rhode Island
$3.00
$13.00
$42.00
44%
33%
South Carolina
$3.00
$17.00
$47.00
50%
33%
South Dakota
$3.00
$14.00
$42.00
48%
33%
Tennessee
$3.00
$13.00
$45.00
50%
33%
Texas
$3.00
$20.00
$47.00
50%
33%
Utah
$3.00
$14.00
$45.00
50%
33%
Vermont
$3.00
$13.00
$42.00
44%
33%
Virginia
$3.00
$18.00
$47.00
50%
33%
Washington
$3.00
$12.00
$44.00
48%
33%
West Virginia
$3.00
$13.00
$45.00
50%
33%
Wisconsin
$3.00
$12.00
$43.00
46%
33%
Wyoming
$3.00
$14.00
$42.00
48%
33%
You can find complete cost-sharing information, including costs for long-term supplies and mail-order,
long-term care, and out-of-network pharmacy pricing, in your Evidence of Coverage.
6
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
ANALGESICS
GOUT
allopurinol tab (generic of
ZYLOPRIM)
colchicine w/ probenecid
COLCRYS
QL (120 tabs / 30 days)
probenecid
ULORIC
2
3
3
QL
3
3
ST
Drug Requirements/
Tier
Limits
naproxen TABS 375mg
naproxen (generic of
EC-NAPROSYN) TBEC
naproxen sodium TABS
275mg
naproxen sodium (generic of
ANAPROX DS) TABS
550mg
sulindac TABS
1
2
4
4
2
OPIOID ANALGESICS
NSAIDS
celecoxib (generic of
CELEBREX) CAPS 50mg
QL (240 caps / 30 days)
celecoxib (generic of
CELEBREX) CAPS 100mg
QL (120 caps / 30 days)
celecoxib (generic of
CELEBREX) CAPS 200mg
QL (60 caps / 30 days)
celecoxib (generic of
CELEBREX) CAPS 400mg
QL (30 caps / 30 days)
diclofenac potassium
QL (120 tabs / 30 days)
diclofenac sodium TB24
diclofenac sodium TBEC
diflunisal
etodolac CAPS
etodolac (generic of LODINE)
TABS 400mg
etodolac TABS 500mg
flurbiprofen TABS
ibuprofen SUSP
ibuprofen TABS 400mg,
600mg, 800mg
ketoprofen CAPS
MELOXICAM SUSP
meloxicam (generic of
MOBIC) TABS
nabumetone TABS
naproxen (generic of
NAPROSYN) SUSP
naproxen (generic of
NAPROSYN) TABS 250mg,
500mg
Drug Name
4
QL
4
QL
4
QL
4
QL
3
2
2
4
4
4
4
3
3
2
3
4
1
2
3
1
QL
acetaminophen w/ codeine
SOLN
QL (5000 mL / 30 days)
acetaminophen w/ codeine
TABS
QL (400 tabs / 30 days)
acetaminophen w/ codeine
(generic of
TYLENOL/CODEINE #3)
TABS
QL (400 tabs / 30 days)
acetaminophen w/ codeine
(generic of
TYLENOL/CODEINE #4)
TABS
QL (400 tabs / 30 days)
butorphanol tartrate SOLN
1mg/ml, 2mg/ml
BUTRANS 5mcg/hr
QL (16 patches / 28
days)
BUTRANS 10mcg/hr
QL (8 patches / 28 days)
BUTRANS 15mcg/hr,
20mcg/hr
QL (4 patches / 28 days)
BUTRANS 7.5MCG/HR
QL (8 patches / 28 days)
nalbuphine hcl SOLN
tramadol hcl (generic of
ULTRAM) TABS
QL (240 tabs / 30 days)
tramadol-acetaminophen
(generic of ULTRACET)
QL (240 tabs / 30 days)
2
QL
2
QL
2
QL
2
QL
4
3
QL
3
QL
3
QL
3
QL
4
2
QL
3
QL
4
B/D
OPIOID ANALGESICS, CII
DURAMORPH
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
7
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
EMBEDA
QL (60 caps / 30 days)
endocet (generic of
PERCOCET)
QL (360 tabs / 30 days)
fentanyl citrate (generic of
ACTIQ) LPOP
QL (120 lozenges / 30
days)
fentanyl patch 12 mcg/hr
(generic of DURAGESIC)
QL (10 patches / 30
days)
fentanyl patch 25 mcg/hr
(generic of DURAGESIC)
QL (10 patches / 30
days)
fentanyl patch 50 mcg/hr
(generic of DURAGESIC)
QL (10 patches / 30
days)
fentanyl patch 75 mcg/hr
(generic of DURAGESIC)
QL (10 patches / 30
days)
fentanyl patch 100 mcg/hr
(generic of DURAGESIC)
QL (10 patches / 30
days)
FENTORA
QL (120 tabs / 30 days)
hydroco/apap tab 5-325mg
(generic of NORCO)
QL (360 tabs / 30 days)
hydroco/apap tab 7.5-325mg
(generic of NORCO)
QL (360 tabs / 30 days)
hydroco/apap tab 10-325mg
(generic of NORCO)
QL (360 tabs / 30 days)
hydrocodone-acetaminophen
7.5-325 mg/15ml (generic of
HYCET)
QL (5400 mL / 30 days)
hydrocodone-ibuprofen
7.5-200mg
QL (150 tabs / 30 days)
3
QL
3
QL
5 NDS QL PA
4
4
QL
QL
4
QL
4
QL
4
QL
5 NDS QL PA
2
2
2
4
3
QL
QL
QL
QL
QL
Drug Name
Drug Requirements/
Tier
Limits
hydromorphone hcl (generic
of DILAUDID) LIQD
hydromorphone hcl SOLN
10mg/ml, 50mg/5ml,
500mg/50ml
hydromorphone hcl (generic
of DILAUDID) TABS
QL (270 tabs / 30 days)
HYSINGLA ER 20mg, 30mg,
40mg, 60mg
QL (60 tabs / 30 days)
HYSINGLA ER 80mg,
100mg, 120mg
QL (30 tabs / 30 days)
lorcet hd tab 10-325mg
(generic of NORCO)
QL (360 tabs / 30 days)
lorcet plus tab 7.5-325
(generic of NORCO)
QL (360 tabs / 30 days)
lorcet tab 5-325mg (generic of
NORCO)
QL (360 tabs / 30 days)
lortab tab 5-325mg (generic of
NORCO)
QL (360 tabs / 30 days)
lortab tab 7.5-325 (generic of
NORCO)
QL (360 tabs / 30 days)
lortab tab 10-325mg (generic
of NORCO)
QL (360 tabs / 30 days)
methadone hcl (generic of
METHADOSE) CONC
QL (120 mL / 30 days)
methadone hcl SOLN
5mg/5ml, 10mg/5ml
QL (600 mL / 30 days)
methadone hcl 5mg (generic
of DOLOPHINE)
QL (240 tabs / 30 days)
methadone hcl 10mg (generic
of DOLOPHINE)
QL (240 tabs / 30 days)
morphine ext-rel tab (generic
of MS CONTIN) 15mg,
30mg, 60mg, 100mg
QL (90 tabs / 30 days)
3
4
B/D
3
QL
3
QL
3
QL
2
QL
2
QL
2
QL
2
QL
2
QL
2
QL
3
QL
3
QL
3
QL
3
QL
4
QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
8
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
morphine ext-rel tab (generic
of MS CONTIN) 200mg
QL (60 tabs / 30 days)
MORPHINE SUL INJ
1MG/ML
MORPHINE SUL INJ
2MG/ML
MORPHINE SUL INJ
4MG/ML
MORPHINE SUL INJ
10MG/ML
MORPHINE SUL INJ
15MG/ML
morphine sulfate (generic of
MORPHINE SULFATE)
SOLN 4mg/ml, 8mg/ml
MORPHINE SULFATE
SOLN 8mg/ml, 150mg/30ml
morphine sulfate SOLN
.5mg/ml, 1mg/ml
MORPHINE SULFATE
TABS
QL (180 tabs / 30 days)
MORPHINE SULFATE ORAL
SOL
NUCYNTA ER 50mg,
100mg
QL (120 tabs / 30 days)
NUCYNTA ER 150mg,
200mg, 250mg
QL (60 tabs / 30 days)
OPANA ER (CRUSH
RESISTANT)
QL (120 tabs / 30 days)
oxycodone hcl CAPS
QL (180 caps / 30 days)
oxycodone hcl CONC
OXYCODONE HCL SOLN
oxycodone hcl (generic of
ROXICODONE) TABS 5mg,
15mg, 30mg
QL (180 tabs / 30 days)
oxycodone hcl TABS 10mg,
20mg
QL (180 tabs / 30 days)
4
QL
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
3
QL
Drug Name
Drug Requirements/
Tier
Limits
oxycodone w/ acetaminophen
2.5-325mg (generic of
PERCOCET)
QL (360 tabs / 30 days)
oxycodone w/ acetaminophen
5-325mg (generic of
PERCOCET)
QL (360 tabs / 30 days)
oxycodone w/ acetaminophen
7.5-325mg (generic of
PERCOCET)
QL (360 tabs / 30 days)
oxycodone w/ acetaminophen
10-325mg (generic of
PERCOCET)
QL (360 tabs / 30 days)
oxycodone w/ acetaminophen
soln
QL (1800 mL / 30 days)
OXYCONTIN
QL (120 tabs / 30 days)
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
ANESTHETICS
LOCAL ANESTHETICS
3
3
3
QL
QL
3
QL
4
QL
4
4
3
3
QL
QL
lidocaine hcl (local anesth.)
(generic of
XYLOCAINE-MPF) 1%
lidocaine hcl (local anesth.)
(generic of XYLOCAINE)
.5%
lidocaine inj 0.5% (generic of
XYLOCAINE-MPF)
lidocaine inj 1% (generic of
XYLOCAINE)
lidocaine inj 1.5% (generic of
XYLOCAINE-MPF)
lidocaine inj 2% (generic of
XYLOCAINE)
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate SOLN
gentamicin in saline
gentamicin sulfate SOLN
gentamicin sulfate/0.9% s
neomycin sulfate TABS
paromomycin sulfate CAPS
streptomycin sulfate SOLR
4
4
4
4
3
4
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
sulfadiazine TABS
tobramycin (generic of
KITABIS PAK) NEBU
tobramycin inj 1.2 gm/30ml
tobramycin inj 1.2gm
tobramycin inj 10mg/ml
tobramycin inj 40mg/ml
tobramycin inj 80mg/2ml
4
5 NDS NM PA
4
5
4
4
4
NDS
ANTI-INFECTIVES - MISCELLANEOUS
ALBENZA
ALINIA
atovaquone (generic of
MEPRON) SUSP
AZACTAM IN ISO-OSMOTIC
DE
AZACTAM/DEX INJ 2GM
aztreonam (generic of
AZACTAM)
BILTRICIDE
CAYSTON
clindamycin cap 75mg
(generic of CLEOCIN)
clindamycin cap 300mg
(generic of CLEOCIN)
clindamycin hcl cap 150 mg
(generic of CLEOCIN)
clindamycin phosphate
(generic of CLEOCIN
PHOSPHATE) SOLN
clindamycin phosphate in d5w
(generic of CLEOCIN IN
D5W)
clindamycin phosphate inj
(generic of CLEOCIN
PHOSPHATE)
clindamycin sol 75mg/5ml
(generic of CLEOCIN
PEDIATRIC GRANULE)
colistimethate sodium
(generic of COLY-MYCIN M)
SOLR
CUBICIN
dapsone TABS
daptomycin (generic of
CUBICIN)
5
4
5
NDS
NDS
4
4
3
3
5 NDS NM LA
PA
2
2
2
4
4
4
4
4
5
3
5
NDS
NDS
Drug Name
Drug Requirements/
Tier
Limits
emverm
imipenem-cilastatin (generic
of PRIMAXIN IV)
INVANZ
ivermectin (generic of
STROMECTOL) TABS
linezolid (generic of ZYVOX)
SOLN
LINEZOLID SUSR; TABS
LINEZOLID IN SODIUM
CHLORIDE
meropenem (generic of
MERREM)
methenamine hippurate
(generic of HIPREX)
metronidazole (generic of
FLAGYL) TABS
metronidazole in nacl
NEBUPENT
nitrofurantoin macrocrystal
(generic of MACRODANTIN)
50mg, 100mg
PA applies if 70 years and
older after a 90 day supply
in a calendar year; HR
nitrofurantoin monohyd macro
(generic of MACROBID)
PA applies if 70 years and
older after a 90 day supply
in a calendar year; HR
PENTAM 300
SIVEXTRO
sulfamethoxazole-trimethop
ds (generic of BACTRIM DS)
sulfamethoxazole-trimethopri
m inj
sulfamethoxazole-trimethopri
m susp
sulfamethoxazole-trimethopri
m tab (generic of BACTRIM)
SYNERCID
TIGECYCLINE
trimethoprim TABS
TYGACIL
vancomycin hcl (generic of
VANCOCIN HCL) CAPS
4
4
4
3
5
NDS
5
5
NDS
NDS
4
4
2
4
4
4
B/D
PA
4
PA
4
5
2
NDS
4
4
2
5
5
2
5
5
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
NDS
NDS
NDS
NDS
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
vancomycin hcl SOLR
VANCOMYCIN IN NACL
4
4
ANTIFUNGALS
ABELCET
AMBISOME
amphotericin b SOLR
CANCIDAS
fluconazole (generic of
DIFLUCAN) SUSR
fluconazole (generic of
DIFLUCAN) TABS
fluconazole in dextrose
fluconazole inj nacl 100
fluconazole inj nacl 200
fluconazole inj nacl 400
flucytosine (generic of
ANCOBON) CAPS
griseofulvin microsize SUSP
griseofulvin microsize TABS
griseofulvin ultramicrosize
(generic of GRIS-PEG)
itraconazole (generic of
SPORANOX) CAPS
ketoconazole TABS
MYCAMINE
NOXAFIL SUSP; TBEC
nystatin TABS
terbinafine hcl (generic of
LAMISIL) TABS
voriconazole (generic of
VFEND IV) SOLR
voriconazole (generic of
VFEND) SUSR; TABS
5
4
4
5
3
NDS B/D
B/D
B/D
NDS
2
4
4
4
4
5
NDS
3
4
4
4
PA
4
5
5
3
2
PA
NDS
NDS
4
5
NDS
ANTIMALARIALS
atovaquone-proguanil hcl
(generic of MALARONE)
chloroquine phosphate
TABS
COARTEM
mefloquine hcl
PRIMAQUINE PHOSPHATE
quinine sulfate (generic of
QUALAQUIN) CAPS
4
3
4
3
3
4
ANTIRETROVIRAL AGENTS
PA
Drug Name
Drug Requirements/
Tier
Limits
abacavir sulfate (generic of
ZIAGEN)
APTIVUS
CRIXIVAN
didanosine (generic of VIDEX
EC)
EDURANT
EMTRIVA
FUZEON
INTELENCE 25mg
INTELENCE 100mg, 200mg
INVIRASE
ISENTRESS CHEW 25mg
ISENTRESS CHEW 100mg
ISENTRESS PACK
ISENTRESS TABS
lamivudine (generic of
EPIVIR)
LEXIVA SUSP
LEXIVA TABS
NEVIRAPINE SUSP 50
MG/5ML
nevirapine tab 100mg
(generic of VIRAMUNE XR)
nevirapine tab 200mg
(generic of VIRAMUNE)
nevirapine tb24 (generic of
VIRAMUNE XR)
NORVIR
PREZISTA SUSP
PREZISTA TABS 75mg,
150mg
PREZISTA TABS 600mg,
800mg
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ
SELZENTRY 25mg
SELZENTRY 75mg, 150mg,
300mg
stavudine (generic of ZERIT)
SUSTIVA CAPS 50mg
SUSTIVA CAPS 200mg
SUSTIVA TABS
TIVICAY 10mg
3
5
4
4
NDS
5
3
5
4
5
5
3
5
5
5
3
NDS
NDS NM
4
5
4
NDS
NDS
NDS
NDS
NDS
NDS
4
3
4
3
5
3
NDS
5
NDS
4
4
5
4
5
NDS
4
3
5
5
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
NDS
NDS
NDS
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
TIVICAY 25mg, 50mg
TYBOST
VIDEX PEDIATRIC
VIRACEPT
VIREAD
ZERIT SOLR
ZIAGEN SOLN
zidovudine (generic of
RETROVIR) CAPS; SYRP
zidovudine TABS
5
3
4
5
5
5
3
4
NDS
NDS
NDS
NDS
3
ANTIRETROVIRAL COMBINATION
AGENTS
ABACAVIR
SULFATE-LAMIVUDINE
abacavir
sulfate-lamivudine-zidovudine
(generic of TRIZIVIR)
ATRIPLA
COMPLERA
DESCOVY
EPZICOM
EVOTAZ
GENVOYA
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine-zidovudine
(generic of COMBIVIR)
lopinavir-ritonavir (generic of
KALETRA)
ODEFSEY
PREZCOBIX
STRIBILD
TRIUMEQ
TRUVADA TAB 100-150
QL (60 tabs / 30 days)
TRUVADA TAB 133-200
QL (30 tabs / 30 days)
TRUVADA TAB 167-250
QL (30 tabs / 30 days)
TRUVADA TAB 200-300
QL (30 tabs / 30 days)
5
NDS
5
NDS
5
5
5
5
5
5
5
3
5
4
NDS
NDS
NDS
NDS
NDS
NDS
NDS
5
NDS
5
5
5
5
5
NDS
NDS
NDS
NDS
NDS QL
5
NDS QL
5
NDS QL
5
NDS QL
NDS
ANTITUBERCULAR AGENTS
CAPASTAT SULFATE
cycloserine CAPS
4
5
NDS
Drug Name
Drug Requirements/
Tier
Limits
ethambutol hcl (generic of
MYAMBUTOL) TABS
isoniazid TABS
isoniazid inj 100 mg/ml
isoniazid syp 50mg/5ml
paser d/r
PRIFTIN
pyrazinamide TABS
rifabutin (generic of
MYCOBUTIN)
rifampin (generic of RIFADIN)
CAPS
rifampin (generic of RIFADIN)
SOLR
RIFATER
SIRTURO
TRECATOR
4
2
4
4
3
4
4
4
3
4
4
5 NDS LA PA
4
ANTIVIRALS
acyclovir (generic of
ZOVIRAX) CAPS
acyclovir (generic of
ZOVIRAX) SUSP
acyclovir (generic of
ZOVIRAX) TABS
acyclovir sodium
adefovir dipivoxil (generic of
HEPSERA)
BARACLUDE SOLN
DAKLINZA
entecavir (generic of
BARACLUDE)
EPIVIR HBV SOLN
famciclovir TABS 125mg,
250mg
famciclovir (generic of
FAMVIR) TABS 500mg
ganciclovir inj 500mg (generic
of CYTOVENE)
lamivudine (hbv) (generic of
EPIVIR HBV)
moderiba tab 200mg (generic
of COPEGUS)
oseltamivir phosphate
(generic of TAMIFLU)
PEGASYS
PEGASYS PROCLICK
2
4
2
4
5
B/D
NDS
5
NDS
5 NDS NM PA
5
NDS
4
3
3
3
B/D
4
4
NM
3
5 NDS NM PA
5 NDS NM PA
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
REBETOL SOL 40MG/ML
RELENZA DISKHALER
ribasphere (generic of
REBETOL) CAPS
ribasphere (generic of
COPEGUS) TABS 200mg
ribasphere TABS 400mg,
600mg
ribavirin cap 200mg (generic
of REBETOL)
ribavirin tab 200mg (generic
of COPEGUS)
rimantadine hydrochloride
(generic of FLUMADINE)
SOVALDI
TAMIFLU
TYZEKA
valacyclovir hcl (generic of
VALTREX) TABS
VALCYTE SOLR
valganciclovir hcl (generic of
VALCYTE)
VEMLIDY
ZEPATIER
5
3
3
NDS NM
4
NM
5
NDS NM
3
NM
4
NM
4
5 NDS NM PA
3
5
NDS
3
5
5
NDS
NDS
5
NDS
5 NDS NM PA
CEPHALOSPORINS
cefaclor CAPS
cefaclor SUSR
cefaclor er tab 500mg
cefadroxil CAPS
cefadroxil SUSR
cefadroxil TABS
CEFAZOLIN IN DEXTROSE
2GM/100ML-4%
cefazolin inj
cefazolin sodium SOLR
1gm, 20gm
cefazolin sodium 1 gm/50ml
cefdinir CAPS
cefdinir SUSR
cefepime hcl (generic of
MAXIPIME)
cefixime (generic of SUPRAX)
cefotaxime sodium 1gm,
2gm, 500mg
cefoxitin sodium
NM
3
4
4
2
3
4
4
4
4
4
3
4
4
4
4
4
Drug Name
Drug Requirements/
Tier
Limits
cefpodoxime proxetil
cefprozil SUSR
cefprozil TABS
ceftazidime (generic of
FORTAZ) SOLR
CEFTAZIDIME/DEXTROSE
ceftriaxone sodium (generic of
ROCEPHIN) SOLR 1gm
ceftriaxone sodium SOLR
1gm, 2gm, 10gm, 250mg,
500mg
cefuroxime axetil (generic of
CEFTIN)
cefuroxime sodium (generic of
ZINACEF)
cephalexin (generic of
KEFLEX) CAPS 250mg,
500mg
cephalexin SUSR
SUPRAX CAPS
suprax CHEW
SUPRAX SUSR 500mg/5ml
tazicef (generic of FORTAZ)
SOLR
tazicef vial (generic of
FORTAZ)
TEFLARO
4
4
3
4
4
4
4
3
4
2
3
3
4
3
4
4
5
NDS
ERYTHROMYCINS/MACROLIDES
AZITHROMYCIN PACK
azithromycin (generic of
ZITHROMAX) SOLR
azithromycin (generic of
ZITHROMAX) SUSR
azithromycin (generic of
ZITHROMAX) TABS
clarithromycin (generic of
BIAXIN) TABS
clarithromycin er (generic of
BIAXIN XL)
clarithromycin for susp
125mg/5ml
clarithromycin for susp
(generic of BIAXIN)
250mg/5ml
DIFICID
e.e.s. 400mg tab
3
4
3
2
3
4
4
4
5
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
NDS
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Drug Name
Drug Requirements/
Tier
Limits
ery-tab
erythrocin lactobionate
erythrocin stearate
erythromycin base
erythromycin cap 250mg ec
erythromycin ethylsuccinate
TABS
4
4
4
4
4
4
FLUOROQUINOLONES
ciprofloxacin (generic of
CIPRO) SUSR
ciprofloxacin er (generic of
CIPRO XR)
ciprofloxacin hcl tab 100mg,
750mg
ciprofloxacin hcl tab (generic
of CIPRO) 250mg, 500mg
ciprofloxacin in d5w
ciprofloxacin in d5w (generic
of CIPRO I.V.-IN D5W)
ciprofloxacin inj
levofloxacin (generic of
LEVAQUIN) TABS
levofloxacin in d5w
levofloxacin inj 25mg/ml
levofloxacin oral soln 25
mg/ml
4
4
2
2
4
4
4
2
4
4
4
PENICILLINS
amoxicillin
amoxicillin & pot clavulanate
CHEW
amoxicillin & pot clavulanate
SUSR
amoxicillin & pot clavulanate
(generic of AUGMENTIN)
SUSR
amoxicillin & pot clavulanate
(generic of AUGMENTIN
ES-600) SUSR
amoxicillin & pot clavulanate
TABS
amoxicillin & pot clavulanate
(generic of AUGMENTIN)
TABS
amoxicillin & pot clavulanate
(generic of AUGMENTIN XR)
TB12
2
3
3
3
3
2
2
4
Drug Name
Drug Requirements/
Tier
Limits
ampicillin & sulbactam sodium
ampicillin & sulbactam sodium
(generic of UNASYN)
ampicillin & sulbactam sodium
(generic of UNASYN BULK
PACK)
ampicillin cap
ampicillin inj
ampicillin sodium
ampicillin susp
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium
oxacillin sodium 1gm, 2gm
oxacillin sodium 10gm
PENICILLIN G POT IN
DEXTROSE
penicillin g procaine
penicillin g sodium
penicillin v potassium
penicilln gk inj 5mu
penicilln gk inj 20mu
pfizerpen-g
piperacillin
sodium-tazobactam sodium
(generic of ZOSYN)
piperacillin/tazobactam
4
4
4
2
4
4
3
4
2
4
4
5
4
NDS
4
4
2
4
4
4
4
4
TETRACYCLINES
doxy
doxycycline (monohydrate)
CAPS 50mg
doxycycline (monohydrate)
(generic of MONODOX)
CAPS 100mg
doxycycline (monohydrate)
(generic of ADOXA) TABS
50mg, 75mg, 100mg
doxycycline (monohydrate)
(generic of ADOXA PAK
1/150) TABS 150mg
doxycycline hyclate CAPS
50mg
doxycycline hyclate (generic
of VIBRAMYCIN) CAPS
100mg
4
2
2
3
3
3
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
doxycycline hyclate SOLR
doxycycline hyclate TABS
minocycline hcl (generic of
MINOCIN) CAPS
morgidox cap 1x50mg
4
4
2
3
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BENDEKA
BICNU
BUSULFEX
CYCLOPHOSPHAMIDE
CAPS
cyclophosphamide SOLR
dacarbazine
EMCYT
GLEOSTINE
HEXALEN
IFEX 3gm
ifosfamide inj 1gm (generic of
IFEX)
ifosfamide inj 1gm/20ml
IFOSFAMIDE INJ 3GM
ifosfamide inj 3gm/60ml
LEUKERAN
melphalan hcl (generic of
ALKERAN)
MUSTARGEN
TREANDA
5 NDS B/D NM
5 NDS B/D
5 NDS B/D
4
B/D
5
3
4
4
5
4
4
NDS B/D
B/D
4
4
4
4
5
B/D
B/D
B/D
NDS
B/D
B/D
NDS B/D
5 NDS B/D
5 NDS B/D NM
ANTHRACYCLINES
adriamycin
daunorubicin hcl
doxorubicin hcl 50mg
doxorubicin hcl inj 2 mg/ml
doxorubicin hcl liposomal
(generic of DOXIL)
epirubicin hcl (generic of
ELLENCE)
idarubicin hcl (generic of
IDAMYCIN PFS)
4
4
4
4
5
B/D
B/D
B/D
B/D
NDS B/D
4
B/D
5
NDS B/D
4
5
B/D
NDS B/D
4
5
B/D
NDS B/D
ANTIBIOTICS
bleomycin sulfate
mitomycin SOLR
ANTIMETABOLITES
adrucil
ALIMTA
Drug Name
Drug Requirements/
Tier
Limits
azacitidine (generic of
VIDAZA)
cladribine
cytarabine 20mg/ml
fludarabine phosphate
fluorouracil SOLN
GEMCITABINE HCL SOLN
gemcitabine hcl (generic of
GEMZAR) SOLR 1gm,
200mg
gemcitabine hcl SOLR 2gm
mercaptopurine TABS
METHOTREXATE SODIUM
50mg/2ml
methotrexate sodium
50mg/2ml, 100mg/4ml,
200mg/8ml, 250mg/10ml
methotrexate sodium inj
NIPENT
PURIXAN
TABLOID
5 NDS B/D NM
5
4
4
4
5
5
NDS B/D
B/D
B/D
B/D
NDS B/D
NDS B/D
5
4
4
NDS B/D
4
B/D
4
5
5
4
B/D
NDS B/D
NDS NM
5
5
5
NDS B/D
NDS B/D
NDS B/D
5
NDS B/D
5
NDS B/D
5
5
NDS B/D
NDS B/D
4
5
B/D
NDS B/D
B/D
ANTIMITOTIC, TAXOIDS
ABRAXANE
DOCEFREZ
DOCETAXEL CONC
20mg/ml
docetaxel (generic of
TAXOTERE) CONC
80mg/4ml
DOCETAXEL CONC
80mg/4ml, 160mg/8ml
DOCETAXEL SOLN
DOCETAXEL SOLN
80MG/8ML
paclitaxel
TAXOTERE 80mg/4ml
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine sulfate
vincasar
vincristine sulfate
vinorelbine tartrate (generic of
NAVELBINE)
4
4
4
4
B/D
B/D
B/D
B/D
BIOLOGIC RESPONSE MODIFIERS
AVASTIN
BELEODAQ
5 NDS NM LA
PA
5 NDS NM PA
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
ERIVEDGE
FARYDAK
HERCEPTIN
IBRANCE
ISTODAX (OVERFILL)
KADCYLA
KEYTRUDA
LYNPARZA
NINLARO
PROLEUKIN
RITUXAN
RUBRACA
TECENTRIQ
VELCADE
VENCLEXTA 10mg, 50mg
VENCLEXTA 100mg
VENCLEXTA STARTING
PACK
YERVOY
ZOLINZA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS B/D NM
5 NDS B/D NM
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS B/D NM
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
4 NM LA PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM PA
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole (generic of
ARIMIDEX) TABS
bicalutamide (generic of
CASODEX)
DEPO-PROVERA INJ 400/ML
exemestane (generic of
AROMASIN)
FARESTON
FASLODEX
flutamide
hydroxyprogesterone
caproate (antineoplastic)
letrozole (generic of
FEMARA) TABS
leuprolide inj 1mg/0.2
LUPRON DEPOT (1-MONTH)
3.75mg
2
Drug Name
LUPRON DEPOT INJ
11.25MG (3-MONTH)
LYSODREN
megestrol ac sus 40mg/ml
(generic of MEGACE ORAL)
HR
megestrol ac tab 20mg
HR
megestrol ac tab 40mg
HR
MEGESTROL SUS
625MG/5ML
HR
NILANDRON
nilutamide (generic of
NILANDRON)
SOLTAMOX
tamoxifen citrate TABS
TRELSTAR DEP INJ 3.75MG
TRELSTAR LA INJ 11.25MG
XTANDI
ZYTIGA
AFINITOR
AFINITOR DISPERZ
ALECENSA
3
CAPRELSA
B/D
5
5
4
4
NDS
NDS B/D
COMETRIQ
COTELLIC
GILOTRIF TAB 20MG
B/D
GILOTRIF TAB 30MG
3
GILOTRIF TAB 40MG
3
NM PA
5 NDS NM PA
5 NDS NM PA
3
4
4
4
4
PA
5
5
NDS
NDS
4
1
5 NDS NM PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM LA
PA
KINASE INHIBITORS
BOSULIF
CABOMETYX
4
4
Drug Requirements/
Tier
Limits
ICLUSIG
5 NDS NM PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
16
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
imatinib mesylate (generic of
GLEEVEC) 100mg
QL (90 tabs / 30 days)
imatinib mesylate (generic of
GLEEVEC) 400mg
QL (60 tabs / 30 days)
IMBRUVICA CAP 140MG
Drug Requirements/
Tier
Limits
5 NDS QL NM
PA
Drug Name
Drug Requirements/
Tier
Limits
ZELBORAF
ZYDELIG
5 NDS QL NM
PA
5 NDS NM LA
PA
INLYTA
5 NDS NM LA
PA
IRESSA
5 NDS NM LA
PA
JAKAFI
5 NDS NM LA
PA
LENVIMA 8 MG DAILY DOSE 5 NDS NM LA
PA
LENVIMA 10 MG DAILY
5 NDS NM LA
DOSE
PA
LENVIMA 14 MG DAILY
5 NDS NM LA
DOSE
PA
LENVIMA 18 MG DAILY
5 NDS NM LA
DOSE
PA
LENVIMA 20 MG DAILY
5 NDS NM LA
DOSE
PA
LENVIMA 24 MG DAILY
5 NDS NM LA
DOSE
PA
MEKINIST
5 NDS NM LA
PA
NEXAVAR
5 NDS NM LA
PA
SPRYCEL
5 NDS NM PA
STIVARGA
5 NDS NM LA
PA
SUTENT
5 NDS NM PA
TAFINLAR
5 NDS NM LA
PA
TAGRISSO
5 NDS NM LA
PA
TARCEVA
5 NDS NM LA
PA
TASIGNA
5 NDS NM PA
TYKERB
5 NDS NM LA
PA
VOTRIENT
5 NDS NM LA
PA
XALKORI
5 NDS NM LA
PA
ZYKADIA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
MISCELLANEOUS
bexarotene (generic of
TARGRETIN)
DROXIA
hydroxyurea (generic of
HYDREA) CAPS
LONSURF
MATULANE
mitoxantrone hcl
ODOMZO
SYLATRON KIT 200MCG
SYLATRON KIT 300MCG
SYLATRON KIT 600MCG
SYNRIBO
tretinoin (chemotherapy)
TRISENOX
5 NDS NM PA
3
3
5 NDS NM PA
5
NDS LA
3
B/D NM
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
5
NDS
5 NDS B/D
PLATINUM-BASED AGENTS
carboplatin
cisplatin
oxaliplatin
4
3
4
B/D
B/D
B/D
5
5
NDS B/D
NDS B/D
PROTECTIVE AGENTS
AMIFOSTINE
dexrazoxane (generic of
ZINECARD)
ELITEK
FUSILEV
leucovorin calcium SOLR
leucovorin calcium TABS
leucovorin calcium for inj 500
mg
levoleucovorin calcium
SOLN
levoleucovorin calcium
(generic of FUSILEV) SOLR
mesna (generic of MESNEX)
MESNEX TABS
5 NDS B/D
5 NDS B/D NM
4
B/D
3
4
B/D
5 NDS B/D NM
5 NDS B/D NM
4
5
B/D
NDS
TOPOISOMERASE INHIBITORS
etoposide SOLN
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
B/D
17
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
irinotecan hcl (generic of
CAMPTOSAR) 40mg/2ml,
100mg/5ml
irinotecan hcl 500mg/25ml
toposar
TOPOTECAN HCL SOLN
topotecan hcl (generic of
HYCAMTIN) SOLR
4
B/D
4
3
5
5
B/D
B/D
NDS B/D
NDS B/D
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine
besylate-benazepril hcl cap
2.5-10 mg
amlodipine
besylate-benazepril hcl cap
5-10 mg (generic of LOTREL)
amlodipine
besylate-benazepril hcl cap
5-20 mg (generic of LOTREL)
amlodipine
besylate-benazepril hcl cap
5-40 mg
amlodipine
besylate-benazepril hcl cap
10-20 mg (generic of
LOTREL)
amlodipine
besylate-benazepril hcl cap
10-40 mg (generic of
LOTREL)
benazepril &
hydrochlorothiazide
benazepril &
hydrochlorothiazide (generic
of LOTENSIN HCT)
captopril &
hydrochlorothiazide
enalapril maleate &
hydrochlorothiazide
enalapril maleate &
hydrochlorothiazide (generic
of VASERETIC)
fosinopril sodium &
hydrochlorothiazide
lisinopril &
hydrochlorothiazide (generic
of ZESTORETIC)
2
2
2
2
2
2
2
2
2
2
2
2
1
Drug Name
Drug Requirements/
Tier
Limits
moexipril-hydrochlorothiazide
quinapril-hydrochlorothiazide
(generic of ACCURETIC)
2
2
ACE INHIBITORS
benazepril hcl TABS 5mg
benazepril hcl (generic of
LOTENSIN) TABS 10mg,
20mg, 40mg
captopril TABS
enalapril maleate (generic of
VASOTEC) TABS
fosinopril sodium
lisinopril (generic of ZESTRIL)
TABS 2.5mg, 30mg, 40mg
lisinopril (generic of PRINIVIL)
TABS 5mg, 10mg, 20mg
moexipril hcl
perindopril erbumine 2mg
perindopril erbumine (generic
of ACEON) 4mg, 8mg
quinapril hcl (generic of
ACCUPRIL)
ramipril (generic of ALTACE)
trandolapril (generic of
MAVIK)
1
1
2
2
2
1
1
2
2
2
2
2
2
ALDOSTERONE RECEPTOR
ANTAGONISTS
eplerenone (generic of
INSPRA)
spironolactone (generic of
ALDACTONE) TABS
4
1
ALPHA BLOCKERS
doxazosin mesylate (generic
of CARDURA) 1mg, 2mg,
4mg
QL (30 tabs / 30 days)
doxazosin mesylate (generic
of CARDURA) 8mg
prazosin hcl (generic of
MINIPRESS)
terazosin hcl
3
QL
3
3
2
ANGIOTENSIN II RECEPTOR
ANTAGONIST COMBINATIONS
amlodipine
besylate-olmesartan
medoxomil (generic of AZOR)
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
18
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
amlodipine besylate-valsartan
tab 5-160 mg (generic of
EXFORGE)
amlodipine besylate-valsartan
tab 5-320 mg (generic of
EXFORGE)
amlodipine besylate-valsartan
tab 10-160 mg (generic of
EXFORGE)
amlodipine besylate-valsartan
tab 10-320 mg (generic of
EXFORGE)
amlodipine-valsartan-hctz tab
5-160-12.5 mg (generic of
EXFORGE HCT)
amlodipine-valsartan-hctz tab
5-160-25 mg (generic of
EXFORGE HCT)
amlodipine-valsartan-hctz tab
10-160-12.5 mg (generic of
EXFORGE HCT)
amlodipine-valsartan-hctz tab
10-160-25 mg (generic of
EXFORGE HCT)
amlodipine-valsartan-hctz tab
10-320-25 mg (generic of
EXFORGE HCT)
BENICAR HCT
ENTRESTO
irbesartan-hydrochlorothiazide
(generic of AVALIDE)
losartan potassium & hctz tab
50-12.5 mg (generic of
HYZAAR)
losartan potassium & hctz tab
100-12.5 mg (generic of
HYZAAR)
losartan potassium & hctz tab
100-25 mg (generic of
HYZAAR)
olmesartan
medoxomil-amlodipine-hydroc
hlorothiazide (generic of
TRIBENZOR)
valsartan & hctz tab
80-12.5mg (generic of
DIOVAN HCT)
2
2
2
2
2
2
2
2
2
3
3
2
2
2
2
2
2
Drug Name
Drug Requirements/
Tier
Limits
valsartan & hctz tab
160-12.5mg (generic of
DIOVAN HCT)
valsartan & hctz tab
160-25mg (generic of
DIOVAN HCT)
valsartan & hctz tab
320-12.5mg (generic of
DIOVAN HCT)
valsartan & hctz tab
320-25mg (generic of
DIOVAN HCT)
2
2
2
2
ANGIOTENSIN II RECEPTOR
ANTAGONISTS
BENICAR
irbesartan (generic of
AVAPRO)
losartan potassium (generic of
COZAAR)
valsartan (generic of
DIOVAN)
3
2
1
2
ANTIARRHYTHMICS
amiodarone hcl soln
amiodarone tab 100mg
amiodarone tab 200mg
amiodarone tab 400mg
disopyramide phosphate
(generic of NORPACE)
HR
DOFETILIDE
flecainide acetate
mexiletine hcl
MULTAQ
NORPACE CR
HR
pacerone 100mg, 400mg
pacerone 200mg
propafenone hcl
propafenone hcl 12hr (generic
of RYTHMOL SR)
quinidine gluconate TBCR
quinidine sulfate TABS
sorine (generic of
BETAPACE) 80mg, 120mg,
160mg
4
4
2
4
4
4
3
4
4
4
NM
4
2
3
4
4
2
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
19
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
sorine 240mg
sotalol hcl (generic of
BETAPACE) 80mg, 120mg,
160mg
sotalol hcl 240mg
sotalol hcl (afib/afl) (generic of
BETAPACE AF)
2
2
2
3
ANTILIPEMICS, HMG-CoA REDUCTASE
INHIBITORS
atorvastatin calcium (generic
of LIPITOR) TABS
CRESTOR
QL (30 tabs / 30 days)
lovastatin 10mg, 20mg
lovastatin (generic of
MEVACOR) 40mg
pravastatin sodium 10mg
pravastatin sodium (generic of
PRAVACHOL) 20mg, 40mg,
80mg
rosuvastatin calcium (generic
of CRESTOR)
QL (30 tabs / 30 days)
simvastatin (generic of
ZOCOR) TABS 5mg, 10mg,
20mg, 40mg
simvastatin (generic of
ZOCOR) TABS 80mg
QL (30 tabs / 30 days)
1
4
QL
2
2
2
2
2
QL
1
1
QL
ANTILIPEMICS, MISCELLANEOUS
cholestyramine (generic of
QUESTRAN)
cholestyramine light PACK
cholestyramine light (generic
of QUESTRAN LIGHT)
POWD
colestipol hcl (generic of
COLESTID)
fenofibrate (generic of
TRICOR) TABS 48mg,
145mg
fenofibrate (generic of
LOFIBRA) TABS 54mg,
160mg
4
4
4
4
4
4
Drug Name
Drug Requirements/
Tier
Limits
fenofibrate micronized
3
(generic of LOFIBRA) 67mg,
134mg, 200mg
gemfibrozil (generic of LOPID) 2
TABS
JUXTAPID
5 NDS NM LA
PA
KYNAMRO
5 NDS NM PA
niacin er (antihyperlipidemic)
4
(generic of NIASPAN)
niacor
3
omega-3-acid ethyl esters
4
(generic of LOVAZA)
PRALUENT
5 NDS NM PA
prevalite (generic of
4
QUESTRAN LIGHT)
VASCEPA
4
WELCHOL
3
ZETIA
3
BETA-BLOCKER/DIURETIC
COMBINATIONS
atenolol & chlorthalidone
(generic of TENORETIC 50)
atenolol & chlorthalidone
(generic of TENORETIC 100)
bisoprolol &
hydrochlorothiazide (generic
of ZIAC)
metoprolol &
hydrochlorothiazide
metoprolol &
hydrochlorothiazide (generic
of LOPRESSOR HCT)
3
3
2
3
3
BETA-BLOCKERS
acebutolol hcl CAPS
atenolol (generic of
TENORMIN) TABS
bisoprolol fumarate 5mg
bisoprolol fumarate (generic
of ZEBETA) 10mg
BYSTOLIC
carvedilol (generic of
COREG)
labetalol hcl TABS
metoprolol succinate (generic
of TOPROL XL)
2
1
2
2
4
2
3
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
20
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
metoprolol tartrate SOCT
metoprolol tartrate SOLN
metoprolol tartrate TABS
25mg
metoprolol tartrate (generic of
LOPRESSOR) TABS 50mg,
100mg
pindolol
propranolol cap er (generic of
INDERAL LA)
propranolol hcl SOLN
propranolol hcl TABS
propranolol oral sol
timolol maleate TABS
4
4
1
1
4
4
4
3
3
4
CALCIUM CHANNEL BLOCKERS
afeditab cr (generic of
ADALAT CC)
amlodipine besylate (generic
of NORVASC) TABS
cartia xt (generic of
CARDIZEM CD) 120mg,
180mg, 240mg
cartia xt 300mg
dilt-xr cap
diltiazem cap 120mg cd
(generic of CARDIZEM CD)
diltiazem cap 180mg cd
(generic of CARDIZEM CD)
diltiazem cap 240mg cd
(generic of CARDIZEM CD)
diltiazem cap 300mg cd
DILTIAZEM CAP 360MG CD
diltiazem cap er/12hr
diltiazem hcl SOLN
diltiazem hcl (generic of
CARDIZEM) TABS 30mg,
60mg, 120mg
diltiazem hcl TABS 90mg
diltiazem hcl cap sr 24hr
diltiazem hcl coated beads
cap sr 24hr (generic of
CARDIZEM CD) 120mg,
180mg, 360mg
diltiazem hcl coated beads
cap sr 24hr 300mg
3
1
3
3
3
3
3
3
3
3
4
4
2
2
3
3
3
Drug Name
Drug Requirements/
Tier
Limits
diltiazem hcl extended release
beads cap sr (generic of
TIAZAC)
felodipine
isradipine
nicardipine hcl CAPS
nifedical xl (generic of
PROCARDIA XL)
nifedipine (generic of
PROCARDIA XL) TB24
nifedipine er (generic of
ADALAT CC)
nimodipine CAPS
NYMALIZE
taztia (generic of TIAZAC)
verapamil cap er (generic of
VERELAN PM) 100mg,
200mg, 300mg
verapamil cap er (generic of
VERELAN) 120mg, 180mg,
240mg
VERAPAMIL CAP ER
360mg
verapamil hcl SOLN
verapamil hcl TABS 40mg
verapamil hcl (generic of
CALAN) TABS 80mg,
120mg
verapamil hcl (generic of
CALAN SR) TBCR
verapamil tab er (generic of
CALAN SR)
3
3
4
4
3
3
3
5
5
3
4
NDS
NDS
4
4
4
2
2
2
2
DIGITALIS GLYCOSIDES
digitek (generic of LANOXIN)
.25mg
PA if 70 years and older;
HR
digitek (generic of LANOXIN)
.125mg
QL (30 tabs / 30 days)
HR (doses > 0.125 mg/day)
digox (generic of LANOXIN)
125mcg
QL (30 tabs / 30 days)
HR (doses > 0.125 mg/day)
3
PA
3
QL
3
QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
21
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
digox (generic of LANOXIN)
250mcg
PA if 70 years and older;
HR
digoxin (generic of LANOXIN)
TABS 125mcg
QL (30 tabs / 30 days)
HR (doses > 0.125 mg/day)
digoxin (generic of LANOXIN)
TABS 250mcg
PA if 70 years and older;
HR
digoxin inj (generic of
LANOXIN)
HR (doses > 0.125 mg/day)
DIGOXIN SOL 50MCG/ML
PA if 70 years and older;
HR
3
PA
3
QL
3
4
Drug Requirements/
Tier
Limits
torsemide tabs 5mg, 100mg
torsemide tabs (generic of
DEMADEX) 10mg, 20mg
triamterene &
hydrochlorothiazide (generic
of MAXZIDE) TABS
triamterene &
hydrochlorothiazide (generic
of MAXZIDE-25) TABS
triamterene &
hydrochlorothiazide cap
37.5-25 mg (generic of
DYAZIDE)
2
2
1
1
2
MISCELLANEOUS
3
DIURETICS
acetazolamide (generic of
DIAMOX) CP12
acetazolamide TABS
amiloride &
hydrochlorothiazide
amiloride hcl TABS
bumetanide SOLN
bumetanide (generic of
BUMEX) TABS
chlorothiazide tabs
chlorthalidone 25mg, 50mg
furosemide SOLN
furosemide (generic of LASIX)
TABS
furosemide inj 10mg/ml
FUROSEMIDE INJ 10mg/ml
hydrochlorothiazide (generic
of MICROZIDE) CAPS
hydrochlorothiazide TABS
indapamide
methazolamide (generic of
NEPTAZANE) TABS
methyclothiazide
metolazone
spironolactone &
hydrochlorothiazide (generic
of ALDACTAZIDE)
PA
Drug Name
4
3
2
3
4
3
3
3
2
1
PA
clonidine hcl (generic of
CATAPRES-TTS-1) PTWK
.1mg/24hr
clonidine hcl (generic of
CATAPRES-TTS-2) PTWK
.2mg/24hr
clonidine hcl (generic of
CATAPRES-TTS-3) PTWK
.3mg/24hr
clonidine hcl (generic of
CATAPRES) TABS
DEMSER
hydralazine hcl SOLN
hydralazine hcl TABS
midodrine hcl
minoxidil TABS
NORTHERA
RANEXA
4
4
1
1
2
4
3
3
3
4
4
4
2
5
NDS
4
2
4
2
5 NDS NM LA
PA
4
NITRATES
isosorb mononitrate tab
isosorbide dinitrate (generic of
ISORDIL TITRADOSE) 5mg
isosorbide dinitrate 10mg,
20mg, 30mg
isosorbide dinitrate er
isosorbide mononitrate er
minitran (generic of
NITRO-DUR)
nitro-bid
NITRO-DUR DIS 0.3MG/HR
NITRO-DUR DIS 0.8MG/HR
2
3
3
4
2
3
3
4
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
22
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
nitroglycerin (generic of
NITROSTAT) SUBL
nitroglycerin td patch
NITROSTAT
3
3
3
PULMONARY ARTERIAL
HYPERTENSION
ADCIRCA
ADEMPAS
QL (90 tabs / 30 days)
LETAIRIS
QL (30 tabs / 30 days)
OPSUMIT
REMODULIN
REVATIO SUSR
QL (224 mL / 30 days)
sildenafil citrate (pulmonary
hypertension) (generic of
REVATIO) TABS
QL (90 tabs / 30 days)
TRACLEER 62.5mg
QL (120 tabs / 30 days)
TRACLEER 125mg
QL (60 tabs / 30 days)
UPTRAVI TABS 200mcg
QL (480 tabs / 30 days)
UPTRAVI TABS 400mcg
QL (240 tabs / 30 days)
UPTRAVI TABS 600mcg
QL (150 tabs / 30 days)
UPTRAVI TABS 800mcg
QL (120 tabs / 30 days)
UPTRAVI TABS 1000mcg
QL (90 tabs / 30 days)
UPTRAVI TABS 1200mcg,
1400mcg, 1600mcg
QL (60 tabs / 30 days)
UPTRAVI TBPK
VENTAVIS
5 NDS NM PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS QL NM
PA
3 QL NM PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS NM LA
PA
5 NDS NM PA
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam tab 0.5mg
(generic of XANAX)
QL (240 tabs / 30 days)
2
QL
Drug Name
Drug Requirements/
Tier
Limits
alprazolam tab 0.25mg
(generic of XANAX)
QL (480 tabs / 30 days)
alprazolam tab 1mg (generic
of XANAX)
QL (120 tabs / 30 days)
alprazolam tab 2 mg (generic
of XANAX)
QL (150 tabs / 30 days)
buspirone hcl TABS
fluvoxamine maleate TABS
25mg, 50mg
QL (45 tabs / 30 days)
fluvoxamine maleate TABS
100mg
lorazepam CONC
QL (150 mL / 30 days)
lorazepam (generic of
ATIVAN) SOLN
lorazepam (generic of
ATIVAN) TABS
QL (150 tabs / 30 days)
2
QL
2
QL
2
QL
2
3
QL
3
3
QL
4
2
QL
4
QL
4
QL
4
QL
5
5
5
5
4
5
3
4
NDS PA
NDS PA
NDS PA
NDS PA
PA
NDS PA
ANTICONVULSANTS
APTIOM 200mg
QL (180 tabs / 30 days)
APTIOM 400mg
QL (90 tabs / 30 days)
APTIOM 600mg, 800mg
QL (60 tabs / 30 days)
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
BRIVIACT SOLN 10mg/ml
BRIVIACT SOLN 50mg/5ml
BRIVIACT TABS
carbamazepine CHEW
carbamazepine (generic of
CARBATROL) CP12
carbamazepine (generic of
TEGRETOL) SUSP
carbamazepine (generic of
TEGRETOL) TABS
carbamazepine TB12 100mg
carbamazepine (generic of
TEGRETOL-XR) TB12
200mg, 400mg
4
4
4
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
CELONTIN
clonazepam (generic of
KLONOPIN) TABS 1mg
QL (120 tabs / 30 days)
clonazepam (generic of
KLONOPIN) TABS 2mg
QL (300 tabs / 30 days)
clonazepam (generic of
KLONOPIN) TABS .5mg
QL (240 tabs / 30 days)
clonazepam TBDP 1mg
QL (120 tabs / 30 days)
clonazepam TBDP 2mg
QL (300 tabs / 30 days)
clonazepam TBDP .5mg
QL (240 tabs / 30 days)
clonazepam TBDP .25mg
QL (480 tabs / 30 days)
clonazepam TBDP .125mg
QL (960 tabs / 30 days)
clorazepate dipotassium
3.75mg
QL (120 tabs / 30 days)
PA if 65 years and older
clorazepate dipotassium
(generic of TRANXENE T)
7.5mg
QL (120 tabs / 30 days)
PA if 65 years and older
clorazepate dipotassium
15mg
QL (180 tabs / 30 days)
PA if 65 years and older
diazepam CONC
QL (240 mL / 30 days)
PA if 65 years and older
diazepam SOLN 1mg/ml
QL (1200 mL / 30 days)
PA if 65 years and older
diazepam SOLN 5mg/ml
diazepam (generic of
VALIUM) TABS
QL (120 tabs / 30 days)
PA if 65 years and older
DIAZEPAM GEL
(ANTICONVULSANT)
dilantin
4
2
QL
2
QL
2
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL PA
3
3
3
3
4
2
4
4
QL PA
QL PA
QL PA
QL PA
QL PA
Drug Name
Drug Requirements/
Tier
Limits
DILANTIN-125 SUS 125/5ML
divalproex sodium (generic of
DEPAKOTE SPRINKLES)
CSDR
divalproex sodium (generic of
DEPAKOTE ER) TB24
divalproex sodium (generic of
DEPAKOTE) TBEC
epitol (generic of TEGRETOL)
ethosuximide (generic of
ZARONTIN) CAPS; SOLN
felbamate (generic of
FELBATOL) SUSP
felbamate (generic of
FELBATOL) TABS
FYCOMPA SUSP
QL (720 mL / 30 days)
FYCOMPA TABS 2mg
QL (180 tabs / 30 days)
FYCOMPA TABS 4mg
QL (90 tabs / 30 days)
FYCOMPA TABS 6mg
QL (60 tabs / 30 days)
FYCOMPA TABS 8mg,
10mg, 12mg
QL (30 tabs / 30 days)
gabapentin (generic of
NEURONTIN) CAPS; TABS
gabapentin (generic of
NEURONTIN) SOLN
GABITRIL 12mg, 16mg
lamotrigine (generic of
LAMICTAL CHEWABLE
DISPERS) CHEW
lamotrigine (generic of
LAMICTAL) TABS
lamotrigine (generic of
LAMICTAL XR) TB24
levetiracetam (generic of
KEPPRA) TABS
levetiracetam (generic of
KEPPRA XR) TB24
levetiracetam in sodium
chloride (generic of
LEVETIRACETAM)
levetiracetam inj (generic of
KEPPRA)
4
4
4
3
4
4
5
NDS
4
4
QL PA
4
QL PA
4
QL PA
4
QL PA
4
QL PA
2
4
4
3
2
4
3
3
4
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
LEVETIRACETAM IV
levetiracetam sol 100mg/ml
(generic of KEPPRA)
LYRICA CAPS 25mg, 50mg,
75mg, 100mg, 150mg
QL (120 caps / 30 days)
LYRICA CAPS 200mg
QL (90 caps / 30 days)
LYRICA CAPS 225mg,
300mg
QL (60 caps / 30 days)
LYRICA SOLN
QL (946 mL / 30 days)
ONFI SOLN
ONFI TAB 10mg
ONFI TAB 20mg
oxcarbazepine (generic of
TRILEPTAL) SUSP
oxcarbazepine (generic of
TRILEPTAL) TABS
PEGANONE
phenobarbital ELIX; TABS
PA if 70 years and older;
HR
PHENOBARBITAL SODIUM
SOLN 65mg/ml
PA if 70 years and older;
HR
phenobarbital sodium SOLN
130mg/ml
PA if 70 years and older;
HR
phenytek
phenytoin (generic of
DILANTIN INFATABS)
CHEW
phenytoin (generic of
DILANTIN-125) SUSP
phenytoin sodium SOLN
phenytoin sodium extended
(generic of DILANTIN)
100mg
phenytoin sodium extended
(generic of PHENYTEK)
200mg, 300mg
POTIGA 50mg
4
3
3
QL
3
QL
3
QL
3
QL
5
4
5
4
NDS PA
PA
NDS PA
3
4
4
PA
4
PA
4
4
3
3
4
3
3
PA
Drug Name
Drug Requirements/
Tier
Limits
POTIGA 200mg
QL (180 tabs / 30 days)
POTIGA 300mg, 400mg
QL (90 tabs / 30 days)
primidone (generic of
MYSOLINE) TABS
roweepra (generic of
KEPPRA)
SABRIL PACK
QL (180 packets / 30
days)
SABRIL TABS
QL (180 tabs / 30 days)
SPRITAM
TEGRETOL
TEGRETOL-XR
tiagabine hcl (generic of
GABITRIL)
topiramate (generic of
TOPAMAX SPRINKLE)
CPSP
topiramate (generic of
TOPAMAX) TABS
valproate sodium (generic of
DEPAKENE) SOLN
250mg/5ml
valproate sodium (generic of
DEPACON) SOLN
500mg/5ml
valproic acid (generic of
DEPAKENE)
VIMPAT SOLN 10mg/ml
QL (1200 mL / 30 days)
VIMPAT SOLN 200mg/20ml
VIMPAT TABS 50mg
QL (180 tabs / 30 days)
VIMPAT TABS 100mg,
150mg, 200mg
QL (60 tabs / 30 days)
zonisamide (generic of
ZONEGRAN) CAPS 25mg,
100mg
zonisamide CAPS 50mg
4
QL
4
QL
2
3
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
4
4
4
4
4
3
2
4
3
4
QL
4
4
QL
4
QL
3
3
ANTIDEMENTIA
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
donepezil hydrochloride
(generic of ARICEPT) TABS
5mg
QL (60 tabs / 30 days)
donepezil hydrochloride
(generic of ARICEPT) TABS
10mg
donepezil hydrochloride
(generic of ARICEPT) TABS
23mg
donepezil hydrochloride
TBDP 5mg
QL (60 tabs / 30 days)
donepezil hydrochloride
TBDP 10mg
EXELON PATCHES
QL (30 patches / 30
days)
galantamine hydrobromide
SOLN
galantamine hydrobromide
(generic of RAZADYNE)
TABS
galantamine hydrobromide er
(generic of RAZADYNE ER)
memantine hcl (generic of
NAMENDA) SOLN
PA if < 30 yrs
memantine hcl (generic of
NAMENDA) TABS 5mg
PA if < 30 yrs
MEMANTINE HCL TABS
10mg
PA if < 30 yrs
NAMENDA XR
PA if < 30 yrs
NAMENDA XR TITRATION
PACK
PA if < 30 yrs
NAMZARIC
rivastigmine tartrate
2
QL
2
4
3
QL
3
3
QL
4
4
4
3
4
4
PA
PA
PA
4
PA
4
PA
4
4
ANTIDEPRESSANTS
amitriptyline hcl TABS 10mg, 4
50mg, 75mg, 100mg, 150mg
HR
Drug Name
Drug Requirements/
Tier
Limits
amitriptyline hcl (generic of
ELAVIL) TABS 25mg
HR
amoxapine
bupropion hcl TABS
bupropion hcl (generic of
WELLBUTRIN SR) TB12
bupropion hcl (generic of
WELLBUTRIN XL) TB24
citalopram hydrobromide
SOLN
citalopram hydrobromide
(generic of CELEXA) TABS
clomipramine hcl (generic of
ANAFRANIL) CAPS
HR
desipramine hcl (generic of
NORPRAMIN) TABS 10mg,
25mg
desipramine hcl TABS
50mg, 75mg, 100mg, 150mg
desvenlafaxine succinate
(generic of PRISTIQ)
QL (30 tabs / 30 days)
doxepin hcl CAPS; CONC
HR
duloxetine hcl (generic of
CYMBALTA) CPEP 20mg
QL (180 caps / 30 days)
duloxetine hcl (generic of
CYMBALTA) CPEP 30mg
QL (120 caps / 30 days)
duloxetine hcl (generic of
CYMBALTA) CPEP 60mg
QL (60 caps / 30 days)
EMSAM
QL (30 patches / 30
days)
escitalopram oxalate (generic
of LEXAPRO) SOLN
escitalopram oxalate (generic
of LEXAPRO) TABS
FETZIMA 20mg
QL (180 caps / 30 days)
FETZIMA 40mg
QL (90 caps / 30 days)
4
3
3
2
3
4
1
4
4
4
3
QL
4
4
QL
4
QL
4
QL
5 NDS QL PA
4
2
4
QL
4
QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
FETZIMA 80mg, 120mg
QL (30 caps / 30 days)
FETZIMA TITRATION PACK
fluoxetine cap 10mg (generic
of PROZAC)
fluoxetine cap 20mg (generic
of PROZAC)
fluoxetine cap 40mg (generic
of PROZAC)
fluoxetine hcl SOLN
fluoxetine hcl TABS 10mg
QL (45 tabs / 30 days)
fluoxetine hcl TABS 20mg
imipramine hcl (generic of
TOFRANIL) TABS
HR
maprotiline hcl
MARPLAN TAB 10MG
QL (180 tabs / 30 days)
mirtazapine TABS 7.5mg
QL (45 tabs / 30 days)
mirtazapine (generic of
REMERON) TABS 15mg
QL (45 tabs / 30 days)
mirtazapine (generic of
REMERON) TABS 30mg,
45mg
mirtazapine (generic of
REMERON SOLTAB) TBDP
15mg
QL (30 tabs / 30 days)
mirtazapine (generic of
REMERON SOLTAB) TBDP
30mg, 45mg
nefazodone hcl
nortriptyline hcl (generic of
PAMELOR) CAPS
nortriptyline hcl SOLN
paroxetine hcl (generic of
PAXIL) TABS
PAXIL SUSP
QL (900 mL / 30 days)
phenelzine sulfate (generic of
NARDIL) TABS
PRISTIQ
QL (30 tabs / 30 days)
4
QL
4
1
1
1
3
4
QL
4
4
4
4
QL
2
QL
2
QL
2
3
QL
3
4
2
4
1
4
Drug Requirements/
Tier
Limits
protriptyline hcl
sertraline hcl (generic of
ZOLOFT) CONC
sertraline hcl (generic of
ZOLOFT) TABS
tranylcypromine sulfate
(generic of PARNATE)
trazodone hcl TABS 50mg,
100mg, 150mg
trimipramine maleate CAPS
25mg
QL (240 caps / 30 days)
HR
trimipramine maleate CAPS
50mg
QL (120 caps / 30 days)
HR
trimipramine maleate (generic
of SURMONTIL) CAPS
100mg
QL (60 caps / 30 days)
HR
TRINTELLIX 5mg
QL (120 tabs / 30 days)
TRINTELLIX 10mg
QL (60 tabs / 30 days)
TRINTELLIX 20mg
QL (30 tabs / 30 days)
venlafaxine hcl (generic of
EFFEXOR XR) CP24
37.5mg, 75mg
QL (30 caps / 30 days)
venlafaxine hcl (generic of
EFFEXOR XR) CP24 150mg
QL (60 caps / 30 days)
venlafaxine hcl TABS
VIIBRYD STARTER PACK
VIIBRYD TAB
QL (30 tabs / 30 days)
4
4
1
4
2
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
2
QL
2
QL
3
4
4
QL
ANTIPARKINSONIAN AGENTS
QL
3
3
Drug Name
QL
amantadine hcl CAPS
QL (120 caps / 30 days)
amantadine hcl SYRP
amantadine hcl TABS
APOKYN
AZILECT
4
QL
2
4
5 NDS NM LA
PA
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
BENZTROPINE MESYLATE
SOLN
benztropine mesylate TABS
PA if 70 years and older;
HR
bromocriptine mesylate
(generic of PARLODEL)
CAPS; TABS
carbidopa-levodopa (generic
of SINEMET) TABS
carbidopa-levodopa (generic
of SINEMET CR) TBCR
carbidopa-levodopa TBDP
CARBIDOPA/LEVODOPA/EN
TACAPONE
CARBIDOPA/LEVODOPA/EN
TACAPONE
CARBIDOPA/LEVODOPA/EN
TACAPONE
CARBIDOPA/LEVODOPA/EN
TACAPONE
CARBIDOPA/LEVODOPA/EN
TACAPONE
CARBIDOPA/LEVODOPA/EN
TACAPONE
ENTACAPONE
NEUPRO
pramipexole tab 0.5mg
(generic of MIRAPEX)
pramipexole tab 0.25mg
(generic of MIRAPEX)
pramipexole tab 0.75mg
(generic of MIRAPEX)
pramipexole tab 0.125mg
(generic of MIRAPEX)
pramipexole tab 1.5mg
(generic of MIRAPEX)
pramipexole tab 1mg (generic
of MIRAPEX)
ropinirole tab 0.5mg (generic
of REQUIP)
ropinirole tab 0.25mg (generic
of REQUIP)
ropinirole tab 1mg (generic of
REQUIP)
ropinirole tab 2mg (generic of
REQUIP)
3
3
4
2
3
4
4
4
4
4
4
4
4
4
2
2
2
2
2
2
2
2
2
2
PA
Drug Name
Drug Requirements/
Tier
Limits
ropinirole tab 3mg (generic of
REQUIP)
ropinirole tab 4mg (generic of
REQUIP)
ropinirole tab 5mg (generic of
REQUIP)
selegiline hcl (generic of
ELDEPRYL) CAPS
selegiline hcl TABS
2
2
2
4
4
ANTIPSYCHOTICS
ABILIFY MAINTENA 300mg,
400mg
QL (1 syringe / 28 days)
ABILIFY MAINTENA 300mg,
400mg
QL (1 vial / 28 days)
aripiprazole odt
QL (60 tabs / 30 days)
aripiprazole oral solution 1
mg/ml
QL (900 mL / 30 days)
aripiprazole tab (generic of
ABILIFY)
QL (30 tabs / 30 days)
ARISTADA
QL (1 syringe / 28 days)
chlorpromazine hcl TABS
chlorpromazine inj
CLOZAPINE ODT 12.5mg
CLOZAPINE ODT 25mg,
100mg, 150mg, 200mg
clozapine tab 25mg (generic
of CLOZARIL)
clozapine tab 50mg
clozapine tab 100mg (generic
of CLOZARIL)
clozapine tab 200mg
FANAPT
QL (60 tabs / 30 days)
FANAPT TITRATION PACK
fluphenazine decanoate
SOLN
fluphenazine hcl CONC;
ELIX; SOLN
fluphenazine hcl TABS
4
QL
4
QL
5
NDS QL
5
NDS QL
4
QL
4
QL
4
4
4
4
PA
PA
3
3
4
4
4
QL
4
4
4
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
GEODON SOLR
QL (6 mL / 3 days)
haloperidol TABS
haloperidol decanoate
(generic of HALDOL
DECANOATE 50) SOLN
50mg/ml
haloperidol decanoate
(generic of HALDOL
DECANOATE 100) SOLN
100mg/ml
haloperidol lactate conc
haloperidol lactate inj 5mg/ml
(generic of HALDOL)
INVEGA 1.5mg, 3mg, 9mg
QL (30 tabs / 30 days)
INVEGA 6mg
QL (60 tabs / 30 days)
INVEGA SUST INJ
39MG/0.25ML
QL (1 injection / 28
days)
INVEGA SUST INJ
78MG/0.5ML
QL (1 injection / 28
days)
INVEGA SUST INJ
117MG/0.75ML
QL (1 injection / 28
days)
INVEGA SUST INJ
156MG/ML
QL (1 injection / 28
days)
INVEGA SUST INJ
234MG/1.5ML
QL (1 injection / 28
days)
INVEGA TRINZA
QL (1 syringe / 90 days)
LATUDA 20mg
QL (240 tabs / 30 days)
LATUDA 40mg, 120mg
QL (30 tabs / 30 days)
LATUDA 60mg, 80mg
QL (60 tabs / 30 days)
loxapine succinate
4
QL
3
4
4
3
4
3
QL
3
QL
4
QL
4
4
4
4
QL
QL
QL
QL
4
QL
4
QL
4
QL
4
QL
Drug Name
Drug Requirements/
Tier
Limits
molindone hcl
NUPLAZID
QL (60 tabs / 30 days)
olanzapine (generic of
ZYPREXA) SOLR
QL (3 vials / 1 day)
olanzapine (generic of
ZYPREXA) TABS 2.5mg
QL (240 tabs / 30 days)
olanzapine (generic of
ZYPREXA) TABS 5mg
QL (120 tabs / 30 days)
olanzapine (generic of
ZYPREXA) TABS 7.5mg
QL (30 tabs / 30 days)
olanzapine (generic of
ZYPREXA) TABS 10mg,
15mg, 20mg
QL (60 tabs / 30 days)
olanzapine (generic of
ZYPREXA ZYDIS) TBDP
5mg
QL (30 tabs / 30 days)
olanzapine (generic of
ZYPREXA ZYDIS) TBDP
10mg, 15mg, 20mg
QL (60 tabs / 30 days)
perphenazine TABS
pimozide (generic of ORAP)
quetiapine fumarate (generic
of SEROQUEL) TABS
QL (90 tabs / 30 days)
REXULTI 1mg
QL (90 tabs / 30 days)
REXULTI 2mg
QL (60 tabs / 30 days)
REXULTI 3mg, 4mg
QL (30 tabs / 30 days)
REXULTI .5mg
QL (180 tabs / 30 days)
REXULTI .25mg
QL (360 tabs / 30 days)
RISPERDAL INJ 12.5MG
QL (2 injections / 28
days)
4
5 NDS QL NM
LA PA
4
QL
3
QL
3
QL
3
QL
3
QL
4
QL
4
QL
4
4
3
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
RISPERDAL INJ 25MG
QL (2 injections / 28
days)
RISPERDAL INJ 37.5MG
QL (2 injections / 28
days)
RISPERDAL INJ 50MG
QL (2 injections / 28
days)
risperidone (generic of
RISPERDAL) SOLN
risperidone (generic of
RISPERDAL) TABS
risperidone (generic of
RISPERDAL M-TAB) TBDP
.5mg, 1mg, 2mg, 3mg, 4mg
risperidone TBDP .25mg
SAPHRIS 2.5mg
QL (240 tabs / 30 days)
SAPHRIS 5mg
QL (120 tabs / 30 days)
SAPHRIS 10mg
QL (60 tabs / 30 days)
SEROQUEL XR 50mg
QL (120 tabs / 30 days)
SEROQUEL XR 150mg,
200mg
QL (30 tabs / 30 days)
SEROQUEL XR 300mg,
400mg
QL (60 tabs / 30 days)
thioridazine hcl TABS
HR
thiothixene
trifluoperazine hcl
VERSACLOZ
QL (600 mL / 30 days)
VRAYLAR 1.5mg
QL (120 caps / 30 days)
VRAYLAR 3mg
QL (60 caps / 30 days)
VRAYLAR 4.5mg, 6mg
QL (30 caps / 30 days)
VRAYLAR THERAPY PACK
ziprasidone hcl (generic of
GEODON)
4
QL
4
QL
4
QL
Drug Name
Drug Requirements/
Tier
Limits
ZYPREXA RELPREVV
300mg
QL (2 vials / 28 days)
ZYPREXA RELPREVV
405mg
QL (1 vial / 28 days)
ZYPREXA RELPREVV
210MG
QL (2 vials / 28 days)
4
QL PA
4
QL PA
4
QL PA
4
ATTENTION DEFICIT HYPERACTIVITY
DISORDER
3
amphetamine-dextroampheta
mine cap sr 24hr 5 mg
(generic of ADDERALL XR)
QL (90 caps / 30 days)
amphetamine-dextroampheta
mine cap sr 24hr 10 mg
(generic of ADDERALL XR)
QL (90 caps / 30 days)
amphetamine-dextroampheta
mine cap sr 24hr 15 mg
(generic of ADDERALL XR)
QL (30 caps / 30 days)
amphetamine-dextroampheta
mine cap sr 24hr 20 mg
(generic of ADDERALL XR)
QL (30 caps / 30 days)
amphetamine-dextroampheta
mine cap sr 24hr 25 mg
(generic of ADDERALL XR)
QL (30 caps / 30 days)
amphetamine-dextroampheta
mine cap sr 24hr 30 mg
(generic of ADDERALL XR)
QL (30 caps / 30 days)
amphetamine-dextroampheta
mine tab 5 mg (generic of
ADDERALL)
QL (360 tabs / 30 days)
amphetamine-dextroampheta
mine tab 7.5 mg (generic of
ADDERALL)
QL (240 tabs / 30 days)
amphetamine-dextroampheta
mine tab 10 mg (generic of
ADDERALL)
QL (180 tabs / 30 days)
4
4
4
QL
4
QL
4
QL
3
QL
3
QL
3
QL
4
4
4
5 NDS QL PA
5
NDS QL
5
NDS QL
5
NDS QL
4
4
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
3
QL
3
QL
3
QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
amphetamine-dextroampheta
mine tab 12.5 mg (generic of
ADDERALL)
QL (144 tabs / 30 days)
amphetamine-dextroampheta
mine tab 15 mg (generic of
ADDERALL)
QL (120 tabs / 30 days)
amphetamine-dextroampheta
mine tab 20 mg (generic of
ADDERALL)
QL (90 tabs / 30 days)
amphetamine-dextroampheta
mine tab 30 mg (generic of
ADDERALL)
QL (60 tabs / 30 days)
guanfacine er (adhd) (generic
of INTUNIV)
PA if 70 years and older;
HR
metadate tab 20mg er
QL (90 tabs / 30 days)
methylphenidate hcl (generic
of RITALIN) TABS 5mg,
10mg
QL (180 tabs / 30 days)
methylphenidate hcl (generic
of RITALIN) TABS 20mg
QL (90 tabs / 30 days)
methylphenidate hcl TBCR
QL (90 tabs / 30 days)
methylphenidate hcl oral soln
(generic of METHYLIN)
5mg/5ml
QL (1800 mL / 30 days)
methylphenidate hcl oral soln
(generic of METHYLIN)
10mg/5ml
QL (900 mL / 30 days)
STRATTERA 10mg, 18mg,
25mg
QL (120 caps / 30 days)
STRATTERA 40mg
QL (60 caps / 30 days)
STRATTERA 60mg, 80mg,
100mg
QL (30 caps / 30 days)
HYPNOTICS
3
3
QL
QL
3
QL
3
QL
4
PA
4
QL
3
QL
3
QL
4
QL
4
QL
4
QL
4
QL
4
QL
4
QL
Drug Name
HETLIOZ
SILENOR 3mg
QL (60 tabs / 30 days)
HR (doses > 6mg/day)
SILENOR 6mg
QL (30 tabs / 30 days)
HR (doses > 6mg/day)
temazepam (generic of
RESTORIL) 7.5mg
QL (30 caps / 30 days)
PA applies if 65 years and
older after a 90 day supply
in a calendar year
temazepam (generic of
RESTORIL) 15mg
QL (60 caps / 30 days)
PA applies if 65 years and
older after a 90 day supply
in a calendar year
zolpidem tartrate (generic of
AMBIEN) TABS
QL (30 tabs / 30 days)
PA applies if 70 years and
older after a 90 day supply
in a calendar year; HR
Drug Requirements/
Tier
Limits
5 NDS NM LA
PA
3
QL
3
QL
2
QL PA
2
QL PA
3
QL PA
MIGRAINE
cafergot
dihydroergotamine mesylate
(generic of D.H.E. 45)
1mg/ml
ergotamine w/ caffeine
(generic of CAFERGOT)
migergot
naratriptan hcl (generic of
AMERGE)
RELPAX
rizatriptan benzoate (generic
of MAXALT) TABS
rizatriptan benzoate (generic
of MAXALT-MLT) TBDP
SUMATRIPTAN INJ
4MG/0.5ML
sumatriptan inj 6mg/0.5ml
(generic of IMITREX
STATDOSE SYSTEM)
SOAJ
4
3
4
5
3
NDS
3
3
3
4
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
sumatriptan inj 6mg/0.5ml
(generic of IMITREX
STATDOSE REFILL) SOCT
sumatriptan inj 6mg/0.5ml
(generic of IMITREX) SOLN
sumatriptan inj 6mg/0.5ml
SOSY
SUMATRIPTAN NASAL
SPRAY
sumatriptan succinate
(generic of IMITREX) TABS
zolmitriptan (generic of
ZOMIG) TABS
zolmitriptan odt (generic of
ZOMIG ZMT)
4
4
4
MUSCULOSKELETAL THERAPY AGENTS
4
2
4
4
3
QL
3
QL
3
2
2
2
3
4
3
BETASERON
QL (14 syringes / 28
days)
COPAXONE INJ 40MG/ML
QL (12 syringes / 28
days)
baclofen TABS
cyclobenzaprine hcl TABS
5mg, 10mg
PA if 70 years and older;
HR
dantrolene sodium (generic of
DANTRIUM) CAPS 25mg,
50mg
dantrolene sodium CAPS
100mg
tizanidine hcl TABS 2mg
tizanidine hcl (generic of
ZANAFLEX) TABS 4mg
5 NDS QL NM
PA
5 NDS QL NM
PA
5 NDS NM LA
PA
2
3
PA
4
4
2
2
NARCOLEPSY/CATAPLEXY
PA
3
5 NDS QL NM
PA
5 NDS QL NM
PA
MULTIPLE SCLEROSIS AGENTS
AMPYRA
Drug Requirements/
Tier
Limits
COPAXONE KIT 20MG/ML
QL (30 syringes per 30
days)
GILENYA CAP 0.5MG
QL (28 caps / 28 days)
TYSABRI
MISCELLANEOUS
GRALISE 300mg
QL (180 tabs / 30 days)
GRALISE 600mg
QL (90 tabs / 30 days)
GRALISE STARTER
lithium carbonate CAPS;
TABS
lithium carbonate er (generic
of LITHOBID) 300mg
lithium carbonate er 450mg
LITHIUM SOLN 8MEQ/5ML
NUEDEXTA
pyridostigmine tab 60mg
(generic of MESTINON)
riluzole (generic of RILUTEK)
TETRABENAZINE 12.5mg
QL (240 tabs / 30 days)
TETRABENAZINE 25mg
QL (120 tabs / 30 days)
Drug Name
5 NDS NM LA
PA
5 NDS QL NM
PA
5 NDS QL NM
PA
armodafinil (generic of
NUVIGIL) 50mg
QL (150 tabs / 30 days)
armodafinil (generic of
NUVIGIL) 150mg
QL (60 tabs / 30 days)
ARMODAFINIL 200mg
QL (30 tabs / 30 days)
armodafinil (generic of
NUVIGIL) 250mg
QL (30 tabs / 30 days)
NUVIGIL 50mg
QL (150 tabs / 30 days)
NUVIGIL 150mg
QL (60 tabs / 30 days)
NUVIGIL 200mg, 250mg
QL (30 tabs / 30 days)
XYREM
QL (540 mL / 30 days)
3
QL PA
3
QL PA
3
QL PA
3
QL PA
3
QL PA
3
QL PA
3
QL PA
5 NDS QL LA
PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium
buprenorphine hcl SUBL
buprenorphine hcl-naloxone
hcl sl
QL (120 tabs / 30 days)
4
3
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
PA
QL PA
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
buproban tab 150mg (generic
of ZYBAN)
bupropion hcl (smoking
deterrent) (generic of ZYBAN)
CHANTIX CONTINUING
MONTH
CHANTIX PAK 0.5& 1MG
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
disulfiram (generic of
ANTABUSE) TABS
naloxone inj 0.4mg/ml
naloxone inj 1mg/ml
naltrexone hcl TABS
NICOTROL INHALER
NICOTROL NS
SUBOXONE MIS 2-0.5MG
QL (120 SL films / 30
days)
SUBOXONE MIS 4-1MG
QL (120 SL films / 30
days)
SUBOXONE MIS 8-2MG
QL (120 SL films / 30
days)
SUBOXONE MIS 12-3MG
QL (60 SL films / 30
days)
3
4
4
4
4
4
3
3
3
4
4
4
QL PA
4
QL PA
4
QL PA
QL PA
ENDOCRINE AND METABOLIC
ANDROGENS
ANADROL-50
ANDRODERM
QL (30 patches / 30
days)
AXIRON
QL (440 mL / 30 days)
oxandrolone tab 2.5mg
(generic of OXANDRIN)
oxandrolone tab 10mg
(generic of OXANDRIN)
testosterone cypionate
(generic of
DEPO-TESTOSTERONE)
SOLN
testosterone enanthate
SOLN
Drug Requirements/
Tier
Limits
ANTIDIABETICS, INJECTABLE
3
4
Drug Name
5
4
NDS PA
QL PA
3
QL PA
3
PA
3
PA
4
PA
ALCOHOL SWABS
BYDUREON INJ
QL (4 vials / 28 days)
BYDUREON PEN
QL (4 pens / 28 days)
BYETTA
QL (1 pen / 30 days)
GAUZE PADS 2" X 2"
HUMULIN R INJ U-500
HUMULIN R U-500 KWIKPEN
INSULIN PEN NEEDLE
INSULIN SYRINGE
LANTUS
LANTUS SOLOSTAR
LEVEMIR
LEVEMIR FLEXTOUCH
NOVOLIN 70/30
(brand RELION not
covered)
NOVOLIN N
(brand RELION not
covered)
NOVOLIN R
(brand RELION not
covered)
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30
PREFILL
NOVOLOG PENFILL
SYMLINPEN 60
QL (8 pens / 30 days)
SYMLINPEN 120
QL (4 pens / 30 days)
TOUJEO SOLOSTAR
TRESIBA FLEXTOUCH
TRULICITY
QL (4 pens / 28 days)
VICTOZA
QL (3 pens / 30 days)
3
3
QL
3
QL
4
QL
3
5
5
3
3
3
3
3
3
3
NDS B/D
NDS
3
3
3
3
3
3
3
5 NDS QL PA
5 NDS QL PA
3
3
4
QL
3
QL
ANTIDIABETICS, ORAL
4
PA
acarbose (generic of
PRECOSE)
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
FARXIGA 5mg
QL (60 tabs / 30 days)
FARXIGA 10mg
QL (30 tabs / 30 days)
glimepiride (generic of
AMARYL) 1mg
QL (240 tabs / 30 days)
glimepiride (generic of
AMARYL) 2mg
QL (120 tabs / 30 days)
glimepiride (generic of
AMARYL) 4mg
QL (60 tabs / 30 days)
glip/metform tab 2.5-250mg
QL (240 tabs / 30 days)
glip/metform tab 2.5-500mg
QL (120 tabs / 30 days)
glip/metform tab 5-500mg
QL (120 tabs / 30 days)
glipizide (generic of
GLUCOTROL) TABS 5mg
QL (240 tabs / 30 days)
glipizide (generic of
GLUCOTROL) TABS 10mg
QL (120 tabs / 30 days)
glipizide (generic of
GLUCOTROL XL) TB24
2.5mg
QL (240 tabs / 30 days)
glipizide (generic of
GLUCOTROL XL) TB24
5mg
QL (120 tabs / 30 days)
glipizide (generic of
GLUCOTROL XL) TB24
10mg
QL (60 tabs / 30 days)
GLIPIZIDE XL TB24 2.5MG
QL (240 tabs / 30 days)
GLIPIZIDE XL TB24 5MG
QL (120 tabs / 30 days)
INVOKAMET TAB 50-500MG
QL (120 tabs / 30 days)
INVOKAMET TAB
50-1000MG
QL (60 tabs / 30 days)
3
QL
3
QL
1
QL
1
QL
1
QL
2
QL
2
QL
2
QL
1
QL
1
QL
2
QL
2
2
QL
QL
2
QL
2
QL
3
QL
3
QL
Drug Name
Drug Requirements/
Tier
Limits
INVOKAMET TAB
150-500MG
QL (60 tabs / 30 days)
INVOKAMET TAB
150-1000MG
QL (60 tabs / 30 days)
INVOKAMET XR TAB
50-500MG
QL (120 tabs / 30 days)
INVOKAMET XR TAB
50-1000MG
QL (60 tabs / 30 days)
INVOKAMET XR TAB
150-500MG
QL (60 tabs / 30 days)
INVOKAMET XR TAB
150-1000MG
QL (60 tabs / 30 days)
INVOKANA 100mg
QL (90 tabs / 30 days)
INVOKANA 300mg
QL (30 tabs / 30 days)
JANUMET
QL (60 tabs / 30 days)
JANUMET XR TAB
50-500MG
QL (60 tabs / 30 days)
JANUMET XR TAB 50-1000
QL (60 tabs / 30 days)
JANUMET XR TAB 100-1000
QL (30 tabs / 30 days)
JANUVIA
QL (30 tabs / 30 days)
JENTADUETO
QL (60 tabs / 30 days)
JENTADUETO TAB XR
2.5-1000 MG
QL (60 tabs / 30 days)
JENTADUETO TAB XR
5-1000 MG
QL (30 tabs / 30 days)
metformin er (generic of
GLUCOPHAGE XR) 500mg
QL (120 tabs / 30 days)
(generic of GLUCOPHAGE
XR)
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
3
QL
1
QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
metformin er (generic of
GLUCOPHAGE XR) 750mg
QL (60 tabs / 30 days)
(generic of GLUCOPHAGE
XR)
metformin hcl (generic of
GLUCOPHAGE) TABS
500mg
QL (150 tabs / 30 days)
metformin hcl (generic of
GLUCOPHAGE) TABS
850mg
QL (90 tabs / 30 days)
metformin hcl (generic of
GLUCOPHAGE) TABS
1000mg
QL (75 tabs / 30 days)
nateglinide (generic of
STARLIX)
QL (90 tabs / 30 days)
pioglitazone hcl (generic of
ACTOS)
QL (30 tabs / 30 days)
repaglinide (generic of
PRANDIN) 1mg
QL (120 tabs / 30 days)
repaglinide (generic of
PRANDIN) 2mg
QL (240 tabs / 30 days)
repaglinide .5mg
QL (120 tabs / 30 days)
TRADJENTA
QL (30 tabs / 30 days)
XIGDUO XR TAB 5-500MG
QL (60 tabs / 30 days)
XIGDUO XR TAB 5-1000MG
QL (60 tabs / 30 days)
XIGDUO XR TAB 10-500MG
QL (30 tabs / 30 days)
XIGDUO XR TAB 10-1000MG
QL (30 tabs / 30 days)
1
1
QL
QL
Drug Requirements/
Tier
Limits
zoledronic acid (generic of
RECLAST) SOLN
5mg/100ml
zoledronic acid SOLR
zoledronic inj 4mg/5ml
(generic of ZOMETA)
4
B/D NM
4
4
B/D NM
B/D NM
CALCIUM RECEPTOR AGONISTS
1
1
2
QL
QL
QL
SENSIPAR 30mg
QL (120 tabs / 30 days)
SENSIPAR 60mg
QL (60 tabs / 30 days)
SENSIPAR 90mg
QL (120 tabs / 30 days)
2
QL
2
QL
2
QL
2
QL
3
QL
3
QL
3
QL
3
QL
3
QL
1
1
4
3
QL NM
5 NDS QL NM
5 NDS QL NM
CHELATING AGENTS
CHEMET
DEPEN TITRATABS
EXJADE
FERRIPROX
BISPHOSPHONATES
alendronate sodium TABS
5mg, 10mg, 35mg, 40mg
alendronate sodium (generic
of FOSAMAX) TABS 70mg
pamidronate disodium
Drug Name
kionex powder (generic of
KAYEXALATE)
kionex susp 15gm/60ml
sodium polystyrene sulfonate
(generic of KAYEXALATE)
POWD
sodium polystyrene sulfonate
SUSP
sps
SYPRINE
4
5
NDS
5 NDS NM LA
PA
5 NDS NM LA
PA
4
3
4
3
3
5
NDS
CONTRACEPTIVES
altavera tab
alyacen 1/35 (generic of
NORINYL 1+35)
apri 28 day (generic of
DESOGEN)
aranelle 28 (generic of
TRI-NORINYL 28)
aubra 28 day
aviane 28
balziva 28 day (generic of
OVCON-35)
bekyree 28 day (generic of
MIRCETTE)
3
3
3
3
3
3
3
3
B/D
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
blisovi 21 fe 1.5/30 28 day
pack (generic of LOESTRIN
FE 1.5/30)
blisovi 21 fe 1/20 28 day pack
(generic of LOESTRIN FE
1/20)
briellyn 28 day (generic of
OVCON-35)
camila 28 day
caziant pak (generic of
CYCLESSA)
cryselle 28
cyclafem 1/35 28 day (generic
of NORINYL 1+35)
cyclafem 7/7/7 28 day
(generic of ORTHO-NOVUM
7/7/7)
cyred tab (generic of
DESOGEN)
deblitane 28 day
delyla 28 day
desogestrel-ethinyl estradiol
(biphasic) (generic of
MIRCETTE)
drospirenone-ethinyl estradiol
(generic of YASMIN 28)
drospirenone-ethinyl estradiol
(generic of YAZ)
ELLA
emoquette (generic of
DESOGEN)
enpresse 28 day
errin 28 day (generic of
ORTHO MICRONOR)
estarylla tab 0.25-35 (generic
of ORTHO-CYCLEN)
ethynodiol tab 1-50
falmina 28 day
femynor 28 day (generic of
ORTHO-CYCLEN)
GIANVI TAB 3-0.02MG
gildagia (generic of
OVCON-35)
gildess tab 1.5/30 (generic of
LOESTRIN 1.5/30-21)
heather
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
3
3
3
3
3
3
3
3
3
3
3
Drug Name
Drug Requirements/
Tier
Limits
introvale 91 day
JOLESSA TAB 0.15-0.03 MG
JOLIVETTE
juleber 28 day (generic of
DESOGEN)
junel 1.5/30 21 day (generic of
LOESTRIN 1.5/30-21)
junel 1/20 21 day (generic of
LOESTRIN 1/20-21)
junel fe 1.5/30 28 day (generic
of LOESTRIN FE 1.5/30)
junel fe 1/20 28 day (generic
of LOESTRIN FE 1/20)
kariva 28 day (generic of
MIRCETTE)
kelnor 1/35 28 day
kimidess 28 day (generic of
MIRCETTE)
larin 1.5/30 (generic of
LOESTRIN 1.5/30-21)
larin 1/20 (generic of
LOESTRIN 1/20-21)
larin fe 1.5/30 (generic of
LOESTRIN FE 1.5/30)
larin fe 1/20 (generic of
LOESTRIN FE 1/20)
larissia tab
LEENA TAB
lessina 28 day
levonest 28 day
levonor/ethi tab
levonorgestrel & eth estradiol
levonorgestrel (emergency
oc) (generic of PLAN B
ONE-STEP)
levonorgestrel-ethinyl
estradiol (91-day)
levora 0.15/30 28 day
loryna 28 day (generic of
YAZ)
low-ogestrel
lutera 28 day
lyza (generic of ORTHO
MICRONOR)
marlissa 28 day
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
36
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
medroxyprogesterone acetate
(contraceptive) (generic of
DEPO-PROVERA
CONTRACEPTIV) SUSP
MEDROXYPROGESTERON
E ACETATE
(CONTRACEPTIVE) SUSY
MICROGESTIN 1.5/30
MICROGESTIN 1/20
MICROGESTIN FE 1.5/30
MICROGESTIN FE 1/20
mono-linyah tab 0.25-35
(generic of ORTHO-CYCLEN)
MONONESSA
myzilra
necon 0.5/35 28 day (generic
of BREVICON-28)
NECON 1/50-28
NECON 7/7/7
necon 10/11 28 day
necon tab 1/35 (generic of
NORINYL 1+35)
nikki 28 day (generic of YAZ)
NORA-BE TAB 0.35MG
norethindrone (contraceptive)
norethindrone acet & eth estra
(generic of LOESTRIN
1/20-21)
norgest/ethi tab 0.25/35
(generic of ORTHO-CYCLEN)
norgestimate-ethinyl estradiol
(triphasic) (generic of ORTHO
TRI-CYCLEN)
norgestimate-ethinyl estradiol
(triphasic) (generic of ORTHO
TRI-CYCLEN LO)
norlyroc 28 day
nortrel 0.5/35 28 day (generic
of BREVICON-28)
nortrel 1/35 21 day (generic of
NORINYL 1+35)
nortrel 1/35 28 day (generic of
NORINYL 1+35)
nortrel 7/7/7 28 day (generic
of ORTHO-NOVUM 7/7/7)
NUVARING
4
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Drug Name
Drug Requirements/
Tier
Limits
OCELLA TAB 3-0.03MG
orsythia 28 day
philith (generic of OVCON-35)
pimtrea pack (generic of
MIRCETTE)
pirmella 1/35 28 day (generic
of NORINYL 1+35)
portia 28 day
previfem 28 day (generic of
ORTHO-CYCLEN)
quasense 91 day
reclipsen 28 day (generic of
DESOGEN)
setlakin tab
sharobel 28 day (generic of
ORTHO MICRONOR)
sprintec 28 day (generic of
ORTHO-CYCLEN)
sronyx 28 day
syeda (generic of YASMIN
28)
tarina fe 1/20 28 day (generic
of LOESTRIN FE 1/20)
TILIA FE
tri-legest 28 day (generic of
ESTROSTEP FE)
tri-linyah (generic of ORTHO
TRI-CYCLEN)
tri-lo marzia (generic of
ORTHO TRI-CYCLEN LO)
tri-lo-estarylla (generic of
ORTHO TRI-CYCLEN LO)
tri-lo-sprintec 28 day (generic
of ORTHO TRI-CYCLEN LO)
tri-previfem 28 day (generic of
ORTHO TRI-CYCLEN)
tri-sprintec 28 day (generic of
ORTHO TRI-CYCLEN)
TRINESSA
TRINESSA LO TAB
trivora 28 day
velivet 28 day (generic of
CYCLESSA)
vestura (generic of YAZ)
vienva 28 day
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
viorele (generic of
MIRCETTE)
vyfemla 28 day (generic of
OVCON-35)
xulane
zarah (generic of YASMIN 28)
zenchent 28 day (generic of
OVCON-35)
zovia 1/35e 28 day
zovia 1/50e 28 day
3
3
4
3
3
NDS
ENZYME REPLACEMENTS
ADAGEN
ALDURAZYME
BUPHENYL TABS
CARBAGLU
CERDELGA
CEREZYME
CYSTADANE POW
CYSTAGON
FABRAZYME
KUVAN
levocarnitine (metabolic
modifiers) (generic of
CARNITOR) SOLN
1gm/10ml
levocarnitine (metabolic
modifiers) SOLN 200mg/ml
levocarnitine (metabolic
modifiers) (generic of
CARNITOR) TABS
LUMIZYME
NAGLAZYME
ORFADIN
5 NDS NM PA
5 NDS NM PA
5 NDS NM LA
PA
ESTROGENS
3
3
4
5
Drug Requirements/
Tier
Limits
RAVICTI
sodium phenylbutyrate
(generic of BUPHENYL)
ZAVESCA
ENDOMETRIOSIS
danazol CAPS
SYNAREL
Drug Name
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM LA
4 NM LA PA
5 NDS NM LA
PA
5 NDS NM LA
PA
4
B/D
4
B/D
4
B/D
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
DELESTROGEN 10mg/ml
estrace CREA
estrad val inj 20mg/ml
(generic of DELESTROGEN)
estrad val inj 40mg/ml
(generic of DELESTROGEN)
estradiol (generic of
CLIMARA) PTWK
HR
estradiol (generic of
ESTRACE) TABS
HR
fyavolv tab 1-5mg
HR
jinteli
HR
norethindrone acetate-ethinyl
estradiol
HR
VAGIFEM
4
4
3
3
4
3
4
4
4
3
GLUCOCORTICOIDS
cortisone acetate TABS
dexamethasone CONC;
ELIX; SOLN
dexamethasone TABS
dexamethasone sodium
phosphate
fludrocortisone acetate
TABS
hydrocortisone (generic of
CORTEF) TABS
methylpr ace inj 40mg/ml
(generic of DEPO-MEDROL)
methylpr ace inj 80mg/ml
(generic of DEPO-MEDROL)
methylpr ss inj 1gm (generic
of SOLU-MEDROL)
methylpr ss inj 40mg (generic
of SOLU-MEDROL)
4
3
2
4
2
3
4
B/D
4
B/D
4
B/D
4
B/D
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
methylpr ss inj 125 mg
(generic of SOLU-MEDROL)
methylpred pak 4mg (generic
of MEDROL DOSEPAK)
methylpred tab 4mg (generic
of MEDROL)
methylpred tab 8mg (generic
of MEDROL)
methylpred tab 16mg (generic
of MEDROL)
methylpred tab 32mg (generic
of MEDROL)
pred sod pho sol 5mg/5ml
(generic of PEDIAPRED)
prednisolone sol 15mg/5ml
prednisolone sol 25mg/5ml
prednisolone syrup 15 mg/5ml
prednisone con 5mg/ml
prednisone pak 5mg
prednisone pak 10mg
prednisone sol 5mg/5ml
prednisone tab 1mg
prednisone tab 2.5mg
prednisone tab 5mg
prednisone tab 10mg
prednisone tab 20mg
prednisone tab 50mg
SOLU-CORTEF 250mg
4
B/D
2
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
3
2
3
2
2
3
2
2
2
2
2
2
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
GLUCOSE ELEVATING AGENTS
GLUCAGEN HYPOKIT
3
GLUCAGON EMERGENCY
3
KIT
PROGLYCEM SUS 50MG/ML 4
Drug Name
Drug Requirements/
Tier
Limits
LUPRON DEP-PED INJ
11.25MG
LUPRON DEP-PED INJ
11.25MG (3-MONTH)
LUPRON DEP-PED INJ
15MG
LUPRON DEP-PED INJ
30MG (3-MONTH)
methergine 0.2 mg tab
methylergonovine maleate
(generic of METHERGINE)
TABS
MIACALCIN 200unit/ml
octreotide acetate (generic of
SANDOSTATIN) 50mcg/ml,
100mcg/ml, 200mcg/ml
octreotide acetate (generic of
SANDOSTATIN)
500mcg/ml, 1000mcg/ml
PROLIA
QL (1 syringe / 180
days)
raloxifene tab 60mg (generic
of EVISTA)
SANDOSTATIN LAR DEPOT
SIGNIFOR
SOMATULINE DEPOT
SOMAVERT
XGEVA
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
4
4
4
4
5 NDS NM PA
4
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM PA
PARATHYROID HORMONES
HUMAN GROWTH HORMONES
NORDITROPIN FLEXPRO
PHOSPHATE BINDER AGENTS
5 NDS NM PA
MISCELLANEOUS
KORLYM
LUPRON DEP-PED INJ
7.5MG
4
3
QL NM
3
FORTEO
QL (1 pen / 28 days)
NATPARA
cabergoline
calcitonin (salmon) (generic of
MIACALCIN)
FORTICAL
INCRELEX
B/D
NM PA
B/D
3
B/D
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
AURYXIA
calcium acetate (phosphate
binder) (generic of PHOSLO)
CAPS
calcium acetate (phosphate
binder) (generic of ELIPHOS)
TABS
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
5 NDS QL NM
PA
5 NDS NM PA
4
3
3
3
3
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
PROGESTINS
medroxyprogesterone acetate
tab (generic of PROVERA)
norethindrone acetate
(generic of AYGESTIN)
TABS
2
3
THYROID AGENTS
levothyroxine sodium (generic
of SYNTHROID) TABS
25mcg, 50mcg, 88mcg,
100mcg, 112mcg, 125mcg,
137mcg, 150mcg, 175mcg,
200mcg
LEVOTHYROXINE SODIUM
TABS 75mcg, 300mcg
liothyronine sodium (generic
of CYTOMEL) TABS
methimazole (generic of
TAPAZOLE) TABS
propylthiouracil TABS
SYNTHROID
2
2
3
2
3
4
VASOPRESSINS
desmopressin acetate spray
(generic of DDAVP)
desmopressin acetate spray
refrigerated
desmopressin acetate tabs
(generic of DDAVP)
desmopressin inj 4mcg/ml
(generic of DDAVP)
DESMOPRESSIN SOL 0.01%
STIMATE
4
4
3
4
4
4
NM
4
4
B/D
B/D
GASTROINTESTINAL
ANTIEMETICS
aprepitant
aprepitant (generic of
EMEND) 40mg, 80mg,
125mg
compro
dronabinol (generic of
MARINOL)
QL (60 caps / 30 days)
EMEND SUSR
EMEND CAP 40MG
EMEND CAP 80MG
EMEND CAP 125MG
4
4
B/D QL
4
4
4
4
B/D
B/D
B/D
B/D
Drug Name
Drug Requirements/
Tier
Limits
EMEND PAK 80 & 125
granisetron hcl SOLN
granisetron hcl TABS
meclizine hcl TABS
metoclopramide hcl SOLN
metoclopramide hcl (generic
of REGLAN) TABS
metoclopramide hcl inj
ondansetron hcl (generic of
ZOFRAN) TABS 4mg, 8mg
ondansetron hcl TABS 24mg
ondansetron hcl inj
ondansetron hcl oral soln
(generic of ZOFRAN)
ondansetron odt (generic of
ZOFRAN ODT)
phenadoz
PA if 70 years and older;
HR
phenergan SUPP
PA if 70 years and older;
HR
prochlorperazine inj
prochlorperazine maleate
TABS
prochlorperazine supp
promethazine hcl (generic of
PHENERGAN) SOLN
PA if 70 years and older;
HR
promethazine hcl SUPP;
SYRP; TABS
PA if 70 years and older;
HR
promethegan
PA if 70 years and older;
HR
TRANSDERM-SCOP
QL (10 patches / 30
days)
PA if 65 years and older;
HR
4
4
4
2
2
2
B/D
B/D
4
3
3
4
3
2
4
PA
4
PA
4
2
4
4
PA
4
PA
4
PA
4
QL PA
ANTISPASMODICS
dicyclomine hcl (generic of
BENTYL) CAPS
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
dicyclomine hcl SOLN
10mg/5ml
dicyclomine hcl (generic of
BENTYL) TABS
glycopyrrolate (generic of
ROBINUL) SOLN 4mg/20ml
glycopyrrolate (generic of
ROBINUL) TABS 1mg
glycopyrrolate (generic of
ROBINUL FORTE) TABS
2mg
4
2
4
3
3
H2-RECEPTOR ANTAGONISTS
famotidine SOLN
famotidine inj
famotidine tab (generic of
PEPCID)
ranitidine hcl (generic of
ZANTAC) TABS 150mg,
300mg
ranitidine hcl inj (generic of
ZANTAC)
ranitidine syrup
4
4
2
2
4
3
INFLAMMATORY BOWEL DISEASE
APRISO
ASACOL HD
balsalazide disodium (generic
of COLAZAL)
budesonide ec (generic of
ENTOCORT EC)
CANASA
colocort (generic of
CORTENEMA)
DELZICOL
DIPENTUM
HYDROCORTISONE
(ENEMA)
mesalamine enema
mesalamine w/ cleanser
(generic of ROWASA)
sulfasalazine (generic of
AZULFIDINE) TABS
sulfasalazine ec (generic of
AZULFIDINE EN-TABS)
3
4
4
5
4
4
4
5
4
4
4
NDS
3
2
2
Drug Requirements/
Tier
Limits
gavilyte-c (generic of
COLYTE-FLAVOR PACKS)
gavilyte-g (generic of
GOLYTELY)
gavilyte-h
gavilyte-n (generic of
NULYTELY/FLAVOR PACKS)
generlac
GOLYTELY
lactulose
lactulose (encephalopathy)
MOVIPREP
NULYTELY/FLAVOR PACKS
PEG 3350-KCL-SOD
BICARB-SOD
CHLORIDE-SOD SULFATE
peg 3350-potassium
chloride-sod bicarbonate-sod
chloride (generic of
NULYTELY/FLAVOR PACKS)
PEG 3350/ELECTROLYTES
polyethylene glycol 3350
PACK; POWD
SUPREP BOWEL PREP
trilyte (generic of
NULYTELY/FLAVOR PACKS)
2
2
3
2
2
3
2
2
4
3
2
2
2
2
4
2
MISCELLANEOUS
alosetron hcl (generic of
LOTRONEX)
AMITIZA
QL (60 caps / 30 days)
cromolyn sodium
(mastocytosis) (generic of
GASTROCROM)
diphenoxylate w/ atropine
LIQD
diphenoxylate w/ atropine
(generic of LOMOTIL) TABS
GATTEX
3
LAXATIVES
constulose
enulose
NDS
Drug Name
LINZESS 72mcg, 290mcg
QL (30 caps / 30 days)
LINZESS 145mcg
QL (60 caps / 30 days)
loperamide hcl CAPS
5
NDS PA
3
QL
5
NDS
3
3
5 NDS NM LA
PA
3
QL
3
QL
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
misoprostol (generic of
CYTOTEC) TABS
MOVANTIK 12.5mg
QL (60 tabs / 30 days)
MOVANTIK 25mg
QL (30 tabs / 30 days)
RELISTOR SOLN
SUCRAID
sucralfate (generic of
CARAFATE) TABS
ursodiol (generic of
ACTIGALL) CAPS
ursodiol (generic of URSO
250) TABS 250mg
ursodiol (generic of URSO
FORTE) TABS 500mg
XIFAXAN 550mg
3
3
QL
3
QL
5
5
3
NDS PA
NDS LA
4
4
NDS PA
PANCREATIC ENZYMES
CREON
ZENPEP
3
4
PROTON PUMP INHIBITORS
DEXILANT CAP 30MG DR
DEXILANT CAP 60MG DR
esomeprazole magnesium
(generic of NEXIUM)
esomeprazole sodium inj
20mg
esomeprazole sodium inj
(generic of NEXIUM I.V.)
40mg
NEXIUM CAP 20MG
NEXIUM CAP 40MG
NEXIUM GRA 2.5MG DR
NEXIUM GRA 5MG DR
NEXIUM GRA 10MG DR
NEXIUM GRA 20MG DR
NEXIUM GRA 40MG DR
omeprazole cap 10mg
omeprazole cap 20mg
(generic of PRILOSEC)
omeprazole cap 40mg
pantoprazole sodium (generic
of PROTONIX) TBEC
Drug Requirements/
Tier
Limits
alfuzosin hcl (generic of
UROXATRAL)
dutasteride (generic of
AVODART)
QL (30 caps / 30 days)
dutasteride-tamsulosin hcl
(generic of JALYN)
QL (30 caps / 30 days)
finasteride (generic of
PROSCAR) TABS 5mg
tamsulosin hcl (generic of
FLOMAX)
2
4
QL
4
QL
2
2
MISCELLANEOUS
4
5
Drug Name
3
3
3
4
4
3
3
3
3
3
3
3
2
2
2
2
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
bethanechol chloride (generic
of URECHOLINE) TABS
ELMIRON
potassium citrate (alkalinizer)
(generic of UROCIT-K 15)
15meq
POTASSIUM CITRATE
(ALKALINIZER) 540mg
POTASSIUM CITRATE
(ALKALINIZER) 1080mg
3
4
4
4
4
URINARY ANTISPASMODICS
MYRBETRIQ TAB 25MG
QL (60 tabs / 30 days)
MYRBETRIQ TAB 50MG
QL (30 tabs / 30 days)
oxybutynin chloride SYRP
oxybutynin chloride TABS
oxybutynin chloride (generic
of DITROPAN XL) TB24
tolterodine tartrate cap er
(generic of DETROL LA)
QL (30 caps / 30 days)
tolterodine tartrate tabs
(generic of DETROL)
TOVIAZ
QL (30 tabs / 30 days)
trospium chloride TABS
VESICARE
QL (30 tabs / 30 days)
4
QL
4
QL
2
3
3
4
QL
4
3
QL
4
4
QL
VAGINAL ANTI-INFECTIVES
clindamycin phosphate
vaginal (generic of CLEOCIN)
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
metronidazole vaginal
(generic of
METROGEL-VAGINAL)
terconazole vaginal (generic
of TERAZOL 7) CREA .4%
terconazole vaginal CREA
.8%
terconazole vaginal SUPP
VANDAZOLE
ZAZOLE CREAM 0.8%
4
3
3
4
4
3
4
4
4
anagrelide hcl 1mg
anagrelide hcl (generic of
AGRYLIN) .5mg
cilostazol
CINRYZE
PA
4
NDS
4
4
5 NDS NM PA
FIRAZYR
pentoxifylline TBCR
PROMACTA 12.5mg
QL (360 tabs / 30 days)
PROMACTA 25mg
QL (180 tabs / 30 days)
PROMACTA 50mg
QL (90 tabs / 30 days)
PROMACTA 75mg
QL (60 tabs / 30 days)
tranexamic acid (generic of
CYKLOKAPRON) SOLN
tranexamic acid (generic of
LYSTEDA) TABS
4
4
2
5 NDS NM LA
PA
5 NDS NM PA
3
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
5 NDS QL NM
LA PA
3
4
PLATELET AGGREGATION INHIBITORS
4
4
4
4
4
4
B/D
B/D
B/D
B/D
1
3
1
3
3
HEMATOPOIETIC GROWTH FACTORS
GRANIX
LEUKINE
5 NDS NM PA
5 NDS NM PA
3
NM PA
MISCELLANEOUS
4
5
Drug Requirements/
Tier
Limits
MOZOBIL
NEUPOGEN
PROCRIT 2000unit/ml,
3000unit/ml, 4000unit/ml,
10000unit/ml
PROCRIT 20000unit/ml,
40000unit/ml
HEMATOLOGIC
ANTICOAGULANTS
COUMADIN
ELIQUIS
enoxaparin sodium (generic of
LOVENOX) 30mg/0.3ml,
40mg/0.4ml, 60mg/0.6ml,
80mg/0.8ml, 100mg/ml,
120mg/0.8ml, 150mg/ml
ENOXAPARIN SODIUM
300mg/3ml
fondaparinux sodium (generic
of ARIXTRA) 2.5mg/0.5ml
fondaparinux sodium (generic
of ARIXTRA) 5mg/0.4ml,
7.5mg/0.6ml, 10mg/0.8ml
heparin sod (porcine) in d5w
HEPARIN SOD (PORCINE)
IN D5W
heparin sod inj 1000/ml
heparin sod inj 5000/ml
heparin sod inj 10000/ml
heparin sod inj 20000/ml
HEPARIN SODIUM/D5W
HEPARIN SODIUM/NACL
0.45%
jantoven (generic of
COUMADIN)
PRADAXA
warfarin sodium (generic of
COUMADIN)
XARELTO
XARELTO STARTER PACK
Drug Name
AGGRENOX
BRILINTA
clopidogrel bisulfate (generic
of PLAVIX) TABS 75mg
EFFIENT
ZONTIVITY
3
3
1
4
4
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC
DRUGS (DMARDS)
HUMIRA INJ 10MG/0.2ML
QL (2 syringes / 28
days)
HUMIRA KIT 20MG/0.4ML
QL (2 syringes / 28
days)
5 NDS QL NM
PA
5 NDS QL NM
PA
5 NDS NM PA
5 NDS NM PA
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
HUMIRA KIT 40MG/0.8ML
QL (6 syringes / 28
days)
HUMIRA PEDIATRIC
CROHNS DISEASE
HUMIRA PEN
QL (6 pens / 28 days)
HUMIRA PEN-CROHNS
DISEASE
HUMIRA PEN-PSORIASIS
STAR
hydroxychloroquine sulfate
(generic of PLAQUENIL)
leflunomide (generic of
ARAVA) TABS
methotrexate sodium tabs
REMICADE INJ 100MG
XELJANZ
QL (60 tabs / 30 days)
XELJANZ XR
QL (30 tabs / 30 days)
5 NDS QL NM
PA
ARCALYST
INTRON-A INJ 10MU
INTRON-A INJ 18MU
INTRON-A INJ 25MU
INTRON-A INJ 50MU
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
5 NDS QL NM
PA
5 NDS NM PA
POMALYST CAP 4MG
REVLIMID
5 NDS NM PA
THALOMID
4
3
4
5 NDS NM PA
5 NDS QL NM
PA
5 NDS QL NM
PA
5
5
5
3
5
5
5
5
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM LA
PA
5 NDS NM PA
IMMUNOSUPPRESSANTS
NDS NM PA
NDS NM PA
NDS NM PA
B/D NM
NDS NM PA
NDS NM PA
NDS NM PA
NDS NM PA
5 NDS NM PA
5 NDS NM PA
5 NDS NM PA
IMMUNOMODULATORS
ACTIMMUNE
Drug Requirements/
Tier
Limits
5 NDS NM PA
IMMUNOGLOBULINS
BIVIGAM
CARIMUNE NANOFILTERED
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAGARD S/D
GAMMAKED
GAMMAPLEX 5gm/100ml,
10gm/200ml
GAMUNEX-C
OCTAGAM 1gm/20ml,
2gm/20ml, 2.5gm/50ml,
5gm/100ml, 10gm/200ml,
25gm/500ml
PRIVIGEN
Drug Name
5 NDS NM LA
PA
5 NDS NM PA
5 NDS B/D NM
5 NDS B/D NM
5 NDS B/D NM
5 NDS B/D NM
azathioprine SOLR
azathioprine (generic of
IMURAN) TABS
BENLYSTA
cyclosporine (generic of
SANDIMMUNE) CAPS;
SOLN
cyclosporine modified (for
microemulsion) (generic of
NEORAL) CAPS 25mg,
100mg
cyclosporine modified (for
microemulsion) CAPS 50mg
cyclosporine modified (for
microemulsion) (generic of
NEORAL) SOLN
gengraf (generic of NEORAL)
CAPS 25mg, 100mg
gengraf CAPS 50mg
gengraf (generic of NEORAL)
SOLN
mycophenolate mofetil
(generic of CELLCEPT)
CAPS; TABS
mycophenolate mofetil
(generic of CELLCEPT)
SUSR
mycophenolate sodium
(generic of MYFORTIC)
NEORAL
NULOJIX
PROGRAF CAPS 5mg
PROGRAF CAPS .5mg,
1mg
RAPAMUNE SOLN
4
3
B/D
B/D
5 NDS NM PA
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
4
B/D
B/D
4
B/D
5
NDS B/D
4
B/D
3
5
5
4
B/D
NDS B/D
NDS B/D
B/D
5
NDS B/D
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
SANDIMMUNE SOLN
100mg/ml
sirolimus (generic of
RAPAMUNE) TABS 2mg
sirolimus (generic of
RAPAMUNE) TABS .5mg,
1mg
tacrolimus (generic of
PROGRAF) CAPS
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
Drug Requirements/
Tier
Limits
3
B/D
5
NDS B/D
4
B/D
4
B/D
5
3
5
NDS B/D
B/D
NDS B/D
VACCINES
ACTHIB
ADACEL
BCG VACCINE
BEXSERO
BOOSTRIX
DAPTACEL
DIPHTHERIA/TETANUS
TOXOID
ENGERIX-B SUSP
GARDASIL
GARDASIL 9
HAVRIX
HIBERIX
IMOVAX RABIES (H.D.C.V.)
INFANRIX
IPOL INACTIVATED IPV
IXIARO
KINRIX
M-M-R II
MENACTRA
MENHIBRIX
MENOMUNE-A/C/Y/W-135
MENVEO
PEDIARIX
PEDVAX HIB
PENTACEL
PROQUAD
QUADRACEL
RABAVERT
RECOMBIVAX HB
ROTARIX
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Drug Name
Drug Requirements/
Tier
Limits
ROTATEQ
SYNAGIS
TENIVAC
TETANUS/DIPHTHERIA
TOXOID
TRUMENBA
TWINRIX INJ
TYPHIM VI
VAQTA
VARIVAX
YF-VAX
ZOSTAVAX
QL (1 vial per lifetime)
3
5
3
3
NDS NM
B/D
B/D
3
3
3
3
3
3
3
QL
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
B/D
B/D
B/D
KLOR-CON 8
KLOR-CON 10
klor-con m10
klor-con m15
klor-con m20
klor-con pow 20 meq
klor-con spr cap 8meq
(generic of MICRO-K)
klor-con spr cap 10meq
(generic of MICRO-K)
magnesium sulfate (generic of
MAGNESIUM SULFATE)
SOLN 2gm/50ml
MAGNESIUM SULFATE
SOLN 2gm/50ml, 4gm/100ml,
4gm/50ml, 20gm/500ml,
40gm/1000ml, 50%
magnesium sulfate SOLN
50%
MAGNESIUM SULFATE IN
D5W
potassium chloride (generic of
MICRO-K) CPCR
POTASSIUM CHLORIDE
SOLN 10%, 20%
potassium chloride TBCR
potassium chloride
microencapsulated crystals cr
SODIUM CHLORIDE SOLN
2.5meq/ml
2
2
2
2
2
4
3
3
4
4
4
4
3
4
2
2
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
sodium fluoride chew; tab; 1.1
(0.5 f) mg/ml soln
TPN ELECTROLYTES
2
4
B/D
4
4
B/D
B/D
4
B/D
4
4
B/D
B/D
4
4
4
4
4
4
B/D
B/D
B/D
B/D
B/D
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
IV NUTRITION
AMINOSYN
AMINOSYN
7%/ELECTROLYTES
AMINOSYN
8.5%/ELECTROLYTE
AMINOSYN II
AMINOSYN II
8.5%/ELECTROL
AMINOSYN M
AMINOSYN-HBC
AMINOSYN-PF 7%
AMINOSYN-PF 10%
AMINOSYN-RF
CLINIMIX 2.75%/DEXTROSE
5%
CLINIMIX 4.25%/DEXTROSE
5%
CLINIMIX 4.25%/DEXTROSE
25%
CLINIMIX 5%/DEXTROSE
15%
CLINIMIX 5%/DEXTROSE
20%
CLINIMIX 5%/DEXTROSE
25%
CLINIMIX INJ 4.25/D10
CLINIMIX INJ 4.25/D20
FREAMINE HBC 6.9%
FREAMINE III
HEPATAMINE
INTRALIPID INJ 20%
INTRALIPID INJ 30%
NEPHRAMINE
nutrilipid inj 20%
premasol 6%
premasol 10%
PROCALAMINE
PROSOL
TRAVASOL
TROPHAMINE INJ 10%
IV REPLACEMENT SOLUTIONS
Drug Name
Drug Requirements/
Tier
Limits
DEXTROSE 2.5%/NACL
0.45%
DEXTROSE 5%
DEXTROSE 5%
/ELECTROLYTE
DEXTROSE 5%/LACTATED
RING
DEXTROSE 5%/NACL 0.2%
DEXTROSE 5%/NACL 0.3%
DEXTROSE 5%/NACL 0.9%
DEXTROSE 5%/NACL 0.33%
DEXTROSE 5%/NACL 0.45%
DEXTROSE 5%/NACL
0.225%
DEXTROSE 5%/POTASSIUM
CHL
DEXTROSE 10% FLEX
CONTAIN
DEXTROSE 10%/NACL 0.2%
DEXTROSE 10%/NACL
0.45%
DEXTROSE 50%
DEXTROSE INJ 70%
IONOSOL-B/DEXTROSE 5%
IONOSOL-MB/DEXTROSE
5%
ISOLYTE P
ISOLYTE S
KCL0.15%/D5W/NACL0.2%
KCL0.15%/D5W/NACL0.225
%
KCL 0.3%/D5W/NACL 0.9%
KCL 0.3%/D5W/NACL 0.45%
KCL 0.15%/D5W/NACL 0.9%
KCL 0.075%/D5W/NACL
0.45%
KCL IN NACL INJ .15-0.45
KCL/D5W INJ 0.3%
KCL/D5W/NACL INJ
0.22%/0.45%
KCL/D5W/NACL INJ .15/.33%
KCL/D5W/NACL INJ .15/.45%
KCL/NACL INJ 0.3-0.9
KCL/NACL INJ 0.15%-0.9%
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
LACTATED RINGER'S INJ
NORMOSOL-M IN D5W
NORMOSOL-R
NORMOSOL-R IN D5W
PLASMA-LYTE A
PLASMA-LYTE-148
pot chloride inj 2meq/ml
POTASSIUM CHLORIDE
SOLN .4meq/ml,
10meq/100ml, 10meq/50ml,
20meq/100ml, 40meq/100ml
potassium chloride in nacl
RINGER'S
SOD CHLORIDE INJ 0.9%
SODIUM CHLORIDE SOLN
3%, 5%
SODIUM CHLORIDE 0.45%
VIA
4
4
4
4
4
3
B/D
4
4
B/D
B/D
4
B/D
4
2
B/D
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-poly-neomycin-hc
blephamide OINT
neomycin-polymy-dexameth
(generic of MAXITROL)
neomycin-polymyxin-hc
(ophth)
sulfacetamide
sod-prednisolone
TOBRADEX OINT
TOBRADEX ST
tobramycin-dexamethasone
(generic of TOBRADEX)
ZYLET
3
4
2
4
2
4
4
4
3
Drug Requirements/
Tier
Limits
ANTI-INFECTIVES
4
4
4
4
4
4
4
4
VITAMINS
calcitriol (generic of
ROCALTROL) CAPS
calcitriol inj
calcitriol oral soln 1 mcg/ml
(generic of ROCALTROL)
paricalcitol (generic of
ZEMPLAR) CAPS 1mcg,
2mcg
paricalcitol CAPS 4mcg
prenatal vitamin/folic acid >
0.8 mg (generic)
Drug Name
bacitracin (ophthalmic)
bacitracin-polymyxin b (ophth)
BESIVANCE
CILOXAN OINT
ciprofloxacin hcl (ophth)
(generic of CILOXAN)
erythromycin (ophth)
gatifloxacin (ophth) (generic of
ZYMAXID)
gentak
gentamicin sulfate (ophth)
ilotycin
MOXEZA
NATACYN
neomycin-bacitracin
zn-polymyxin
neomycin-polymyxin-gramicidi
n (generic of NEOSPORIN)
ofloxacin (ophth) (generic of
OCUFLOX)
polymyxin b-trimethoprim
(generic of POLYTRIM)
sulfacet sod oin 10% op
sulfacetamide sodium (ophth)
(generic of BLEPH-10)
tobramycin (ophth) (generic of
TOBREX)
TOBREX OINT
trifluridine (generic of
VIROPTIC) SOLN
VIGAMOX
ZIRGAN
4
2
3
3
2
2
4
2
2
2
4
4
3
3
2
2
3
3
2
4
4
4
4
ANTI-INFLAMMATORIES
ALREX
bromfenac sodium (ophth)
BROMSITE
dexamethasone sodium
phosphate (ophth)
diclofenac sodium (ophth)
DUREZOL
FLUOROMETHOLONE
flurbiprofen sodium (generic
of OCUFEN)
3
4
4
3
3
4
4
2
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
ILEVRO
ketorolac tromethamine
(ophth) (generic of ACULAR
LS) .4%
ketorolac tromethamine
(ophth) (generic of ACULAR)
.5%
LOTEMAX
MAXIDEX
PREDNISOLONE ACETATE
(OPHTH)
prednisolone sodium
phosphate (ophth)
4
3
3
3
3
3
3
3
3
2
4
3
3
ANTIGLAUCOMA
ALPHAGAN P SOL 0.1%
ALPHAGAN P SOL 0.15%
AZOPT
betaxolol hcl (ophth)
BETOPTIC-S
brimonidine sol 0.2%
carteolol hcl (ophth)
COMBIGAN
dorzolamide hcl (generic of
TRUSOPT)
dorzolamide hcl-timolol
maleate (generic of COSOPT)
ISTALOL
latanoprost (generic of
XALATAN) SOLN
levobunolol hcl (generic of
BETAGAN)
LUMIGAN
metipranolol
PHOSPHOLINE IODIDE
PILOCARPINE HCL SOLN
SIMBRINZA
Drug Requirements/
Tier
Limits
timolol maleate (ophth) soln
(generic of TIMOPTIC)
TIMOLOL MALEATE GEL
TRAVATAN Z
3
3
4
4
4
2
2
3
3
2
4
3
MISCELLANEOUS
CYSTARAN
ANTIALLERGICS
azelastine drop 0.05%
BEPREVE
cromolyn sodium (ophth)
LASTACAFT
PATADAY
PAZEO
Drug Name
naphazoline hcl SOLN
PROLENSA
proparacaine hcl (generic of
ALCAINE) SOLN
RESTASIS
QL (64 vials / 30 days)
5 NDS NM LA
PA
2
3
2
3
QL
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST
COMBINATIONS
ANORO ELLIPTA
QL (60 blisters / 30
days)
BEVESPI AEROSPHERE
QL (1 inhaler / 30 days)
COMBIVENT RESPIMAT
QL (2 inhalers / 30 days)
ipratropium-albuterol nebu
3
QL
3
QL
4
QL
3
B/D
4
QL
3
QL
2
3
B/D
ANTICHOLINERGICS
ATROVENT HFA
QL (2 inhalers / 30 days)
INCRUSE ELLIPTA
QL (1 inhaler / 30 days)
ipratropium bromide SOLN
ipratropium bromide (nasal)
ANTIHISTAMINES
3
3
2
2
3
3
4
4
4
azelastine spr 0.1%
azelastine spr 0.15% (generic
of ASTEPRO)
cetirizine syrup
cyproheptadine hcl SYRP;
TABS
PA if 70 years and older;
HR
diphenhydramine hcl inj
hydroxyz hcl inj
PA if 70 years and older;
HR
3
3
3
4
PA
4
4
PA
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
hydroxyzine hcl SYRP;
TABS
PA if 70 years and older;
HR
hydroxyzine pamoate (generic
of VISTARIL) CAPS 25mg,
50mg
PA if 70 years and older;
HR
hydroxyzine pamoate CAPS
100mg
PA if 70 years and older;
HR
levocetirizine dihydrochloride
(generic of XYZAL) SOLN
levocetirizine dihydrochloride
(generic of XYZAL) TABS
4
PA
4
PA
4
PA
NDS NM PA
NDS NM PA
NDS NM PA
NDS NM PA
NDS NM LA
PA
5 NDS NM PA
5 NDS NM LA
PA
5 NDS NM LA
PA
NASAL STEROIDS
2
2
4
3
flunisolide (nasal)
3
QL (2 bottles / 30 days)
fluticasone propionate (nasal) 2
(generic of FLONASE)
QL (1 bottle / 30 days)
NASONEX
3
QL (2 inhalers / 30 days)
B/D
QL
QL
QL
QL
STEROID INHALANTS
B/D
ARNUITY ELLIPTA
QL (30 inhalations / 30
days)
budesonide (inhalation)
(generic of PULMICORT)
.25mg/2ml, .5mg/2ml
FLOVENT DISKUS
50mcg/blist, 100mcg/blist
QL (120 inhalations / 30
days)
FLOVENT DISKUS
250mcg/blist
QL (240 inhalations / 30
days)
FLOVENT HFA
QL (2 inhalers / 30 days)
PULMICORT FLEXHALER
QL (2 inhalers / 30 days)
B/D
STEROID/BETA-AGONIST
COMBINATIONS
5
4
3
NDS
3
QL
QL
3
4
2
4
3
MISCELLANEOUS
acetylcysteine SOLN 10%,
20%
ARALAST NP
PULMOZYME
XOLAIR
4
3
3
5
5
5
5
5
2
MAST CELL STABILIZERS
cromolyn sod neb 20mg/2ml
DALIRESP
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
ESBRIET
KALYDECO
OFEV
ORKAMBI
PROLASTIN-C
ZEMAIRA
LEUKOTRIENE MODULATORS
montelukast sodium (generic
of SINGULAIR) CHEW
montelukast sodium (generic
of SINGULAIR) PACK
montelukast sodium (generic
of SINGULAIR) TABS
zafirlukast (generic of
ACCOLATE)
Drug Requirements/
Tier
Limits
4
BETA AGONISTS
albuterol sulfate NEBU
albuterol sulfate SYRP
albuterol sulfate TABS
SEREVENT DISKUS
QL (60 inhalations / 30
days)
terbutaline sulfate SOLN
terbutaline sulfate TABS
VENTOLIN HFA
QL (2 inhalers / 30 days)
XOPENEX HFA
QL (2 inhalers / 30 days)
Drug Name
3
5 NDS NM LA
PA
ADVAIR DISKUS
QL (60 inhalations / 30
days)
4
QL
4
B/D
4
QL
4
QL
4
QL
3
QL
4
QL
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
ADVAIR HFA
QL (1 inhaler / 30 days)
BREO ELLIPTA
QL (60 blisters / 30
days)
SYMBICORT
QL (1 inhaler / 30 days)
4
QL
3
QL
3
QL
XANTHINES
aminophylline inj
elixophyllin
theophylline SOLN
theophylline TB12; TB24
4
4
4
PA
PA
4
3
PA
2
2
2
4
5
NDS
ciclopirox (generic of
LOPROX) CREA; SUSP
ciclopirox GEL
ciclopirox shampoo 1%
(generic of LOPROX
SHAMPOO)
clotrimazole (topical)
ketoconazole cream
nyamyc
nyata
nystatin (topical)
nystop
3
4
4
3
3
3
3
3
3
DERMATOLOGY, ANTIPRURITIC
DOXEPIN HCL
(ANTIPRURITIC)
procto-med (generic of
ANUSOL-HC)
procto-pak
proctosol hc cre 2.5%
(generic of ANUSOL-HC)
proctozone hc (generic of
ANUSOL-HC)
4
4
3
4
4
4
4
4
4
4
DERMATOLOGY, ANTIPSORIATICS
3
4
4
PA
4
PA
4
4
PA
PA
4
PA
acitretin (generic of
SORIATANE)
calcipotriene (generic of
DOVONEX) CREA
calcipotriene SOLN
8-MOP
TAZORAC CREA
5
NDS PA
4
4
4
4
PA
DERMATOLOGY, ANTISEBORRHEICS
DERMATOLOGY, ANTIBIOTICS
gentamicin sulfate (topical)
mupirocin (generic of
BACTROBAN) OINT
SILVER SULFADIAZINE
CREA
SSD
SULFAMYLON CREA
SULFAMYLON PACK
Drug Requirements/
Tier
Limits
DERMATOLOGY, ANTIFUNGALS
4
4
4
3
TOPICAL
DERMATOLOGY, ACNE
AVITA CREA
AVITA GEL
benzoyl
peroxide-erythromycin
(generic of BENZAMYCIN)
claravis
clindacin-p pad 1% (generic of
CLEOCIN-T)
clindamax (generic of
CLEOCIN-T)
clindamycin phosphate
(topical) (generic of
CLEOCIN-T) GEL; LOTN
clindamycin phosphate
(topical) (generic of
CLEOCIN-T) SOLN; SWAB
ery pad 2%
erythromycin (acne aid)
(generic of ERYGEL) GEL
erythromycin (acne aid)
SOLN
myorisan
sulfacetamide sodium (acne)
(generic of KLARON)
tretinoin (generic of RETIN-A)
CREA
TRETINOIN GEL .01%
tretinoin (generic of RETIN-A)
GEL .025%
zenatane
Drug Name
ketoconazole shampoo
(generic of NIZORAL)
selenium sulfide LOTN
2
2
DERMATOLOGY, CORTICOSTEROIDS
ala-cort
2
3
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
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Drug Name
Drug Requirements/
Tier
Limits
alclometasone dipropionate
(generic of ACLOVATE)
CREA
alclometasone dipropionate
OINT
betamethasone dipropionate
(topical) CREA; OINT
betamethasone dipropionate
(topical) LOTN
betamethasone dipropionate
augmented (generic of
DIPROLENE AF) CREA
betamethasone dipropionate
augmented GEL
betamethasone dipropionate
augmented (generic of
DIPROLENE) LOTN
BETAMETHASONE
DIPROPIONATE
AUGMENTED OINT
betamethasone valerate
CREA; LOTN; OINT
fluocinolone acetonide
(generic of SYNALAR)
SOLN
fluocinonide CREA .05%
fluocinonide GEL
fluocinonide SOLN
fluocinonide emulsified base
fluticasone propionate
(generic of CUTIVATE)
CREA
fluticasone propionate OINT
halobetasol propionate
(generic of ULTRAVATE)
hydrocortisone (topical)
CREA; OINT
hydrocortisone (topical)
LOTN
hydrocortisone butyrate
(generic of LOCOID)
mometasone furoate (generic
of ELOCON) CREA; OINT;
SOLN
triamcinolone acetonide
(topical) CREA; OINT
Drug Name
Drug Requirements/
Tier
Limits
4
triamcinolone acetonide
(topical) LOTN
triderm
3
DERMATOLOGY, LOCAL ANESTHETICS
4
3
3
4
4
4
3
4
4
4
4
4
2
2
4
2
3
4
3
2
lidocaine (generic of
LIDODERM) PTCH
QL (3 patches / 1 day)
lidocaine hcl GEL
lidocaine hcl (generic of
XYLOCAINE) SOLN 4%
lidocaine oint 5%
lidocaine-prilocaine
3
2
4
QL PA
3
2
PA
PA
4
4
PA
PA
DERMATOLOGY, MISCELLANEOUS SKIN
AND MUCOUS MEMBRANE
ammonium lactate (generic of
LAC-HYDRIN) CREA; LOTN
fluorouracil (topical) (generic
of EFUDEX) CREA 5%
fluorouracil (topical) SOLN
imiquimod (generic of
ALDARA) CREA
metronidazole (topical)
(generic of METROCREAM)
CREA
metronidazole (topical)
(generic of METROLOTION)
LOTN
metronidazole gel 0.75%
PANRETIN
podofilox (generic of
CONDYLOX) SOLN
rosadan cre 0.75% (generic of
METROCREAM)
tacrolimus (topical) (generic of
PROTOPIC)
TARGRETIN GEL
VALCHLOR
VOLTAREN GEL 1%
3
4
4
4
4
4
4
5
3
NDS
4
4
5 NDS NM PA
5 NDS NM LA
PA
3
DERMATOLOGY, SCABICIDES AND
PEDICULIDES
EURAX
malathion (generic of OVIDE)
permethrin (generic of
ELIMITE)
4
4
3
DERMATOLOGY, WOUND CARE AGENTS
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
51
2017 SSI Choice 17255 v11 eff 05/01/2017
Drug Name
Drug Requirements/
Tier
Limits
ACETIC ACID .25%
REGRANEX
SANTYL
SODIUM CHLORIDE 0.9%
STERILE WATER
IRRIGATION
2
5
4
2
3
NDS PA
MOUTH/THROAT/DENTAL AGENTS
chlorhexidine gluconate
(mouth-throat) (generic of
PERIDEX)
clotrimazole TROC
lidocaine hcl (mouth-throat)
nystatin (mouth-throat)
paroex sol 0.12% (generic of
PERIDEX)
periogard (generic of
PERIDEX)
PILOCARPINE HCL (ORAL)
5mg
pilocarpine hcl (oral) (generic
of SALAGEN) 7.5mg
triamcinolone acetonide
(mouth)
2
4
2
3
2
2
4
4
3
OTIC
ACETIC ACID (OTIC)
acetic acid-aluminum acetate
CIPRODEX
fluocinolone acetonide (otic)
(generic of DERMOTIC)
neomycin-polymyxin-hc (otic)
(generic of CORTISPORIN)
SOLN
neomycin-polymyxin-hc (otic)
SUSP
ofloxacin (otic) (generic of
FLOXIN OTIC)
3
3
4
4
3
3
4
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
NM - Not available at
mail-order
B/D - Covered under Medicare B or D
LA - Limited Access
NDS Non-Extended Days Supply
HR - High Risk Medication
52
2017 SSI Choice 17255 v11 eff 05/01/2017
Index
8
8-MOP ..............................50
A
abacavir sulfate .................11
ABACAVIR
SULFATE-LAMIVUDINE ...12
abacavir
sulfate-lamivudine-zidovudin
e ........................................12
ABELCET..........................11
ABILIFY
see aripiprazole tab .......28
ABILIFY MAINTENA .........28
ABRAXANE ......................15
acamprosate calcium ........32
acarbose ...........................33
ACCOLATE
see zafirlukast ...............49
ACCUPRIL
see quinapril hcl ............18
ACCURETIC
see
quinapril-hydrochlorothiazi
de ..................................18
acebutolol hcl ....................20
ACEON
see perindopril erbumine
......................................18
acetaminophen w/ codeine .7
acetazolamide ...................22
ACETIC ACID ...................52
ACETIC ACID (OTIC) .......52
acetic acid-aluminum acetate
..........................................52
acetylcysteine ...................49
acitretin .............................50
ACLOVATE
see alclometasone
dipropionate...................51
ACTHIB .............................45
ACTIGALL
see ursodiol ...................42
ACTIMMUNE ....................44
ACTIQ
see fentanyl citrate ..........8
ACTOS
see pioglitazone hcl .......35
ACULAR
see ketorolac
tromethamine (ophth) .... 48
ACULAR LS
see ketorolac
tromethamine (ophth) .... 48
acyclovir ............................ 12
acyclovir sodium ............... 12
ADACEL ........................... 45
ADAGEN........................... 38
ADALAT CC
see afeditab cr ............... 21
see nifedipine er ............ 21
ADCIRCA.......................... 23
ADDERALL
see
amphetamine-dextroamph
etamine tab 10 mg......... 30
see
amphetamine-dextroamph
etamine tab 12.5 mg...... 31
see
amphetamine-dextroamph
etamine tab 15 mg......... 31
see
amphetamine-dextroamph
etamine tab 20 mg......... 31
see
amphetamine-dextroamph
etamine tab 30 mg......... 31
see
amphetamine-dextroamph
etamine tab 5 mg .......... 30
see
amphetamine-dextroamph
etamine tab 7.5 mg........ 30
ADDERALL XR
see
amphetamine-dextroamph
etamine cap sr 24hr 10 mg
...................................... 30
see
amphetamine-dextroamph
etamine cap sr 24hr 15 mg
...................................... 30
see
amphetamine-dextroamph
etamine cap sr 24hr 20 mg
...................................... 30
see
amphetamine-dextroamph
etamine cap sr 24hr 25 mg
...................................... 30
see
amphetamine-dextroamph
etamine cap sr 24hr 30 mg
...................................... 30
see
amphetamine-dextroamph
etamine cap sr 24hr 5 mg
...................................... 30
adefovir dipivoxil ............... 12
ADEMPAS ........................ 23
ADOXA
see doxycycline
(monohydrate) ............... 14
ADOXA PAK 1/150
see doxycycline
(monohydrate) ............... 14
adriamycin ........................ 15
adrucil ............................... 15
ADVAIR DISKUS .............. 49
ADVAIR HFA .................... 50
afeditab cr ......................... 21
AFINITOR ......................... 16
AFINITOR DISPERZ ........ 16
AGGRENOX ..................... 43
AGRYLIN
see anagrelide hcl ......... 43
ala-cort.............................. 50
ALBENZA ......................... 10
albuterol sulfate ................ 49
ALCAINE
see proparacaine hcl ..... 48
alclometasone dipropionate
.......................................... 51
ALCOHOL SWABS........... 33
ALDACTAZIDE
see spironolactone &
hydrochlorothiazide ....... 22
ALDACTONE
see spironolactone ........ 18
ALDARA
see imiquimod ............... 51
53
2017 SSI Choice 17255 v11 eff 05/01/2017
ALDURAZYME .................38
ALECENSA .......................16
alendronate sodium ..........35
alfuzosin hcl ......................42
ALIMTA .............................15
ALINIA ..............................10
ALKERAN
see melphalan hcl .........15
allopurinol tab......................7
alosetron hcl......................41
ALPHAGAN P SOL 0.1% ..48
ALPHAGAN P SOL 0.15% 48
alprazolam tab 0.25mg .....23
alprazolam tab 0.5mg .......23
alprazolam tab 1mg ..........23
alprazolam tab 2 mg .........23
ALREX ..............................47
ALTACE
see ramipril ....................18
altavera tab .......................35
alyacen 1/35......................35
amantadine hcl..................27
AMARYL
see glimepiride ..............34
AMBIEN
see zolpidem tartrate .....31
AMBISOME.......................11
AMERGE
see naratriptan hcl .........31
AMIFOSTINE ....................17
amikacin sulfate ..................9
amiloride &
hydrochlorothiazide ...........22
amiloride hcl ......................22
aminophylline inj ...............50
AMINOSYN .......................46
AMINOSYN
7%/ELECTROLYTES .......46
AMINOSYN
8.5%/ELECTROLYTE .......46
AMINOSYN II ....................46
AMINOSYN II
8.5%/ELECTROL ..............46
AMINOSYN M ...................46
AMINOSYN-HBC ..............46
AMINOSYN-PF 10% .........46
AMINOSYN-PF 7% ...........46
AMINOSYN-RF .................46
amiodarone hcl soln .......... 19
amiodarone tab 100mg ..... 19
amiodarone tab 200mg ..... 19
amiodarone tab 400mg ..... 19
AMITIZA............................ 41
amitriptyline hcl ................. 26
amlodipine besylate .......... 21
amlodipine
besylate-benazepril hcl cap
10-20 mg........................... 18
amlodipine
besylate-benazepril hcl cap
10-40 mg........................... 18
amlodipine
besylate-benazepril hcl cap
2.5-10 mg.......................... 18
amlodipine
besylate-benazepril hcl cap
5-10 mg............................. 18
amlodipine
besylate-benazepril hcl cap
5-20 mg............................. 18
amlodipine
besylate-benazepril hcl cap
5-40 mg............................. 18
amlodipine
besylate-olmesartan
medoxomil ........................ 18
amlodipine
besylate-valsartan tab
10-160 mg......................... 19
amlodipine
besylate-valsartan tab
10-320 mg......................... 19
amlodipine
besylate-valsartan tab 5-160
mg ..................................... 19
amlodipine
besylate-valsartan tab 5-320
mg ..................................... 19
amlodipine-valsartan-hctz
tab 10-160-12.5 mg .......... 19
amlodipine-valsartan-hctz
tab 10-160-25 mg ............. 19
amlodipine-valsartan-hctz
tab 10-320-25 mg ............. 19
amlodipine-valsartan-hctz
tab 5-160-12.5 mg ............ 19
amlodipine-valsartan-hctz
tab 5-160-25 mg ............... 19
ammonium lactate ............ 51
amoxapine ........................ 26
amoxicillin ......................... 14
amoxicillin & pot clavulanate
.......................................... 14
amphetamine-dextroamphet
amine cap sr 24hr 10 mg .. 30
amphetamine-dextroamphet
amine cap sr 24hr 15 mg .. 30
amphetamine-dextroamphet
amine cap sr 24hr 20 mg .. 30
amphetamine-dextroamphet
amine cap sr 24hr 25 mg .. 30
amphetamine-dextroamphet
amine cap sr 24hr 30 mg .. 30
amphetamine-dextroamphet
amine cap sr 24hr 5 mg .... 30
amphetamine-dextroamphet
amine tab 10 mg ............... 30
amphetamine-dextroamphet
amine tab 12.5 mg ............ 31
amphetamine-dextroamphet
amine tab 15 mg ............... 31
amphetamine-dextroamphet
amine tab 20 mg ............... 31
amphetamine-dextroamphet
amine tab 30 mg ............... 31
amphetamine-dextroamphet
amine tab 5 mg ................. 30
amphetamine-dextroamphet
amine tab 7.5 mg .............. 30
amphotericin b .................. 11
ampicillin & sulbactam
sodium .............................. 14
ampicillin cap .................... 14
ampicillin inj ...................... 14
ampicillin sodium .............. 14
ampicillin susp .................. 14
AMPYRA .......................... 32
ANADROL-50 ................... 33
ANAFRANIL
see clomipramine hcl .... 26
anagrelide hcl ................... 43
ANAPROX DS
see naproxen sodium ...... 7
anastrozole ....................... 16
54
2017 SSI Choice 17255 v11 eff 05/01/2017
ANCOBON
see flucytosine...............11
ANDRODERM ..................33
ANORO ELLIPTA .............48
ANTABUSE
see disulfiram ................33
ANUSOL-HC
see procto-med .............50
see proctosol hc cre 2.5%
......................................50
see proctozone hc .........50
APOKYN ...........................27
aprepitant ..........................40
apri 28 day ........................35
APRISO ............................41
APTIOM ............................23
APTIVUS...........................11
ARALAST NP....................49
aranelle 28 ........................35
ARAVA
see leflunomide .............44
ARCALYST .......................44
ARICEPT
see donepezil
hydrochloride .................26
ARIMIDEX
see anastrozole .............16
aripiprazole odt .................28
aripiprazole oral solution 1
mg/ml ................................28
aripiprazole tab .................28
ARISTADA ........................28
ARIXTRA
see fondaparinux sodium
......................................43
armodafinil ........................32
ARMODAFINIL .................32
ARNUITY ELLIPTA ...........49
AROMASIN
see exemestane ............16
ASACOL HD .....................41
ASTEPRO
see azelastine spr 0.15%
......................................48
atenolol .............................20
atenolol & chlorthalidone ...20
ATIVAN
see lorazepam ...............23
atorvastatin calcium .......... 20
atovaquone ....................... 10
atovaquone-proguanil hcl.. 11
ATRIPLA ........................... 12
ATROVENT HFA .............. 48
aubra 28 day ..................... 35
AUGMENTIN
see amoxicillin & pot
clavulanate .................... 14
AUGMENTIN ES-600
see amoxicillin & pot
clavulanate .................... 14
AUGMENTIN XR
see amoxicillin & pot
clavulanate .................... 14
AURYXIA .......................... 39
AVALIDE
see
irbesartan-hydrochlorothia
zide................................ 19
AVAPRO
see irbesartan ............... 19
AVASTIN .......................... 15
aviane 28 .......................... 35
AVITA ............................... 50
AVODART
see dutasteride .............. 42
AXIRON ............................ 33
AYGESTIN
see norethindrone acetate
...................................... 40
azacitidine ......................... 15
AZACTAM
see aztreonam .............. 10
AZACTAM IN
ISO-OSMOTIC DE ............ 10
AZACTAM/DEX INJ 2GM . 10
azathioprine ...................... 44
azelastine drop 0.05% ...... 48
azelastine spr 0.1% .......... 48
azelastine spr 0.15%......... 48
AZILECT ........................... 27
azithromycin ...................... 13
AZITHROMYCIN .............. 13
AZOPT .............................. 48
AZOR
see amlodipine
besylate-olmesartan
medoxomil ..................... 18
aztreonam ......................... 10
AZULFIDINE
see sulfasalazine........... 41
AZULFIDINE EN-TABS
see sulfasalazine ec ...... 41
B
bacitracin (ophthalmic) ...... 47
bacitracin-polymyxin b
(ophth) .............................. 47
bacitracin-poly-neomycin-hc
.......................................... 47
baclofen ............................ 32
BACTRIM
see
sulfamethoxazole-trimetho
prim tab ......................... 10
BACTRIM DS
see
sulfamethoxazole-trimetho
p ds ............................... 10
BACTROBAN
see mupirocin ................ 50
balsalazide disodium ........ 41
balziva 28 day ................... 35
BANZEL SUS 40MG/ML ... 23
BANZEL TAB 200MG ....... 23
BANZEL TAB 400MG ....... 23
BARACLUDE .................... 12
see entecavir ................. 12
BCG VACCINE ................. 45
bekyree 28 day ................. 35
BELEODAQ ...................... 15
benazepril &
hydrochlorothiazide........... 18
benazepril hcl ................... 18
BENDEKA ........................ 15
BENICAR .......................... 19
BENICAR HCT ................. 19
BENLYSTA ....................... 44
BENTYL
see dicyclomine hcl . 40, 41
BENZAMYCIN
see benzoyl
peroxide-erythromycin ... 50
benzoyl
peroxide-erythromycin ...... 50
benztropine mesylate........ 28
55
2017 SSI Choice 17255 v11 eff 05/01/2017
BENZTROPINE MESYLATE
..........................................28
BEPREVE .........................48
BESIVANCE .....................47
BETAGAN
see levobunolol hcl ........48
betamethasone dipropionate
(topical) .............................51
betamethasone dipropionate
augmented ........................51
BETAMETHASONE
DIPROPIONATE
AUGMENTED ...................51
betamethasone valerate ...51
BETAPACE
see sorine ......................19
see sotalol hcl................20
BETAPACE AF
see sotalol hcl (afib/afl) ..20
BETASERON ....................32
betaxolol hcl (ophth) ..........48
bethanechol chloride .........42
BETOPTIC-S ....................48
BEVESPI AEROSPHERE .48
bexarotene ........................17
BEXSERO.........................45
BIAXIN
see clarithromycin .........13
see clarithromycin for susp
......................................13
BIAXIN XL
see clarithromycin er .....13
bicalutamide ......................16
BICILLIN L-A .....................14
BICNU ...............................15
BILTRICIDE ......................10
bisoprolol &
hydrochlorothiazide ...........20
bisoprolol fumarate ...........20
BIVIGAM ...........................44
bleomycin sulfate ..............15
BLEPH-10
see sulfacetamide sodium
(ophth) ...........................47
blephamide .......................47
blisovi 21 fe 1.5/30 28 day
pack ..................................36
blisovi 21 fe 1/20 28 day
pack .................................. 36
BOOSTRIX ....................... 45
BOSULIF .......................... 16
BREO ELLIPTA ................ 50
BREVICON-28
see necon 0.5/35 28 day
...................................... 37
see nortrel 0.5/35 28 day
...................................... 37
briellyn 28 day................... 36
BRILINTA.......................... 43
brimonidine sol 0.2%......... 48
BRIVIACT ......................... 23
bromfenac sodium (ophth) 47
bromocriptine mesylate ..... 28
BROMSITE ....................... 47
budesonide (inhalation)..... 49
budesonide ec .................. 41
bumetanide ....................... 22
BUMEX
see bumetanide ............. 22
BUPHENYL ...................... 38
see sodium phenylbutyrate
...................................... 38
buprenorphine hcl ............. 32
buprenorphine hcl-naloxone
hcl sl.................................. 32
buproban tab 150mg ......... 33
bupropion hcl .................... 26
bupropion hcl (smoking
deterrent) .......................... 33
buspirone hcl .................... 23
BUSULFEX ....................... 15
butorphanol tartrate ............ 7
BUTRANS........................... 7
BUTRANS 7.5MCG/HR ...... 7
BYDUREON INJ ............... 33
BYDUREON PEN ............. 33
BYETTA ............................ 33
BYSTOLIC ........................ 20
C
cabergoline ....................... 39
CABOMETYX ................... 16
cafergot ............................. 31
CAFERGOT
see ergotamine w/ caffeine
...................................... 31
CALAN
see verapamil hcl .......... 21
CALAN SR
see verapamil hcl .......... 21
see verapamil tab er...... 21
calcipotriene ..................... 50
calcitonin (salmon) ............ 39
calcitriol ............................. 47
calcitriol inj ........................ 47
calcitriol oral soln 1 mcg/ml
.......................................... 47
calcium acetate (phosphate
binder) .............................. 39
camila 28 day ................... 36
CAMPTOSAR
see irinotecan hcl .......... 18
CANASA ........................... 41
CANCIDAS ....................... 11
CAPASTAT SULFATE...... 12
CAPRELSA ...................... 16
captopril ............................ 18
captopril &
hydrochlorothiazide........... 18
CARAFATE
see sucralfate ................ 42
CARBAGLU ...................... 38
carbamazepine ................. 23
CARBATROL
see carbamazepine ....... 23
CARBIDOPA/LEVODOPA/E
NTACAPONE ................... 28
carbidopa-levodopa .......... 28
carboplatin ........................ 17
CARDIZEM
see diltiazem hcl............ 21
CARDIZEM CD
see cartia xt ................... 21
see diltiazem cap 120mg
cd .................................. 21
see diltiazem cap 180mg
cd .................................. 21
see diltiazem cap 240mg
cd .................................. 21
see diltiazem hcl coated
beads cap sr 24hr ......... 21
CARDURA
see doxazosin mesylate 18
CARIMUNE
NANOFILTERED .............. 44
56
2017 SSI Choice 17255 v11 eff 05/01/2017
CARNITOR
see levocarnitine
(metabolic modifiers) .....38
carteolol hcl (ophth) ..........48
cartia xt .............................21
carvedilol ...........................20
CASODEX
see bicalutamide ...........16
CATAPRES
see clonidine hcl ............22
CATAPRES-TTS-1
see clonidine hcl ............22
CATAPRES-TTS-2
see clonidine hcl ............22
CATAPRES-TTS-3
see clonidine hcl ............22
CAYSTON.........................10
caziant pak ........................36
cefaclor .............................13
cefaclor er tab 500mg .......13
cefadroxil...........................13
CEFAZOLIN IN DEXTROSE
2GM/100ML-4% ................13
cefazolin inj .......................13
cefazolin sodium ...............13
cefazolin sodium 1 gm/50ml
..........................................13
cefdinir ..............................13
cefepime hcl ......................13
cefixime .............................13
cefotaxime sodium ............13
cefoxitin sodium ................13
cefpodoxime proxetil .........13
cefprozil.............................13
ceftazidime ........................13
CEFTAZIDIME/DEXTROSE
..........................................13
CEFTIN
see cefuroxime axetil .....13
ceftriaxone sodium ............13
cefuroxime axetil ...............13
cefuroxime sodium ............13
CELEBREX
see celecoxib...................7
celecoxib .............................7
CELEXA
see citalopram
hydrobromide ................26
CELLCEPT
see mycophenolate mofetil
...................................... 44
CELONTIN........................ 24
cephalexin......................... 13
CERDELGA ...................... 38
CEREZYME ...................... 38
cetirizine syrup .................. 48
CHANTIX CONTINUING
MONTH............................. 33
CHANTIX PAK 0.5& 1MG . 33
CHANTIX TAB 0.5MG ...... 33
CHANTIX TAB 1MG ......... 33
CHEMET........................... 35
chlorhexidine gluconate
(mouth-throat) ................... 52
chloroquine phosphate...... 11
chlorothiazide tabs ............ 22
chlorpromazine hcl ............ 28
chlorpromazine inj ............. 28
chlorthalidone ................... 22
cholestyramine .................. 20
cholestyramine light .......... 20
ciclopirox ........................... 50
ciclopirox shampoo 1% ..... 50
cilostazol ........................... 43
CILOXAN .......................... 47
see ciprofloxacin hcl
(ophth) ........................... 47
CINRYZE .......................... 43
CIPRO
see ciprofloxacin ........... 14
see ciprofloxacin hcl tab 14
CIPRO I.V.-IN D5W
see ciprofloxacin in d5w 14
CIPRO XR
see ciprofloxacin er ....... 14
CIPRODEX ....................... 52
ciprofloxacin ...................... 14
ciprofloxacin er .................. 14
ciprofloxacin hcl (ophth) .... 47
ciprofloxacin hcl tab .......... 14
ciprofloxacin in d5w .......... 14
ciprofloxacin inj ................. 14
cisplatin ............................. 17
citalopram hydrobromide .. 26
cladribine .......................... 15
claravis.............................. 50
clarithromycin ................... 13
clarithromycin er ............... 13
clarithromycin for susp ...... 13
CLEOCIN
see clindamycin cap
300mg ........................... 10
see clindamycin cap 75mg
...................................... 10
see clindamycin hcl cap
150 mg .......................... 10
see clindamycin
phosphate vaginal ......... 42
CLEOCIN IN D5W
see clindamycin
phosphate in d5w .......... 10
CLEOCIN PEDIATRIC
GRANULE
see clindamycin sol
75mg/5ml ...................... 10
CLEOCIN PHOSPHATE
see clindamycin
phosphate ..................... 10
see clindamycin
phosphate inj ................. 10
CLEOCIN-T
see clindacin-p pad 1% . 50
see clindamax ............... 50
see clindamycin
phosphate (topical)........ 50
CLIMARA
see estradiol .................. 38
clindacin-p pad 1% ........... 50
clindamax ......................... 50
clindamycin cap 300mg .... 10
clindamycin cap 75mg ...... 10
clindamycin hcl cap 150 mg
.......................................... 10
clindamycin phosphate ..... 10
clindamycin phosphate
(topical) ............................. 50
clindamycin phosphate in
d5w ................................... 10
clindamycin phosphate inj . 10
clindamycin phosphate
vaginal .............................. 42
clindamycin sol 75mg/5ml . 10
CLINIMIX
2.75%/DEXTROSE 5%..... 46
57
2017 SSI Choice 17255 v11 eff 05/01/2017
CLINIMIX
4.25%/DEXTROSE 25% ...46
CLINIMIX
4.25%/DEXTROSE 5% .....46
CLINIMIX 5%/DEXTROSE
15% ...................................46
CLINIMIX 5%/DEXTROSE
20% ...................................46
CLINIMIX 5%/DEXTROSE
25% ...................................46
CLINIMIX INJ 4.25/D10 ....46
CLINIMIX INJ 4.25/D20 ....46
clomipramine hcl ...............26
clonazepam.......................24
clonidine hcl ......................22
clopidogrel bisulfate ..........43
clorazepate dipotassium ...24
clotrimazole .......................52
clotrimazole (topical) .........50
CLOZAPINE ODT .............28
clozapine tab 100mg .........28
clozapine tab 200mg .........28
clozapine tab 25mg ...........28
clozapine tab 50mg ...........28
CLOZARIL
see clozapine tab 100mg
......................................28
see clozapine tab 25mg 28
COARTEM ........................11
COLAZAL
see balsalazide disodium
......................................41
colchicine w/ probenecid .....7
COLCRYS...........................7
COLESTID
see colestipol hcl ...........20
colestipol hcl .....................20
colistimethate sodium .......10
colocort .............................41
COLY-MYCIN M
see colistimethate sodium
......................................10
COLYTE-FLAVOR PACKS
see gavilyte-c ................41
COMBIGAN ......................48
COMBIVENT RESPIMAT .48
COMBIVIR
see lamivudine-zidovudine
...................................... 12
COMETRIQ ...................... 16
COMPLERA...................... 12
compro .............................. 40
CONDYLOX
see podofilox ................. 51
constulose......................... 41
COPAXONE INJ 40MG/ML
.......................................... 32
COPAXONE KIT 20MG/ML
.......................................... 32
COPEGUS
see moderiba tab 200mg
...................................... 12
see ribasphere .............. 13
see ribavirin tab 200mg . 13
COREG
see carvedilol ................ 20
CORTEF
see hydrocortisone ........ 38
CORTENEMA
see colocort ................... 41
cortisone acetate .............. 38
CORTISPORIN
see
neomycin-polymyxin-hc
(otic) .............................. 52
COSOPT
see dorzolamide
hcl-timolol maleate ........ 48
COTELLIC ........................ 16
COUMADIN ...................... 43
see jantoven .................. 43
see warfarin sodium ...... 43
COZAAR
see losartan potassium . 19
CREON ............................. 42
CRESTOR ........................ 20
see rosuvastatin calcium
...................................... 20
CRIXIVAN ......................... 11
cromolyn sod neb 20mg/2ml
.......................................... 49
cromolyn sodium
(mastocytosis)................... 41
cromolyn sodium (ophth) .. 48
cryselle 28......................... 36
CUBICIN ........................... 10
see daptomycin ............. 10
CUTIVATE
see fluticasone propionate
...................................... 51
cyclafem 1/35 28 day ........ 36
cyclafem 7/7/7 28 day ....... 36
CYCLESSA
see caziant pak ............. 36
see velivet 28 day ......... 37
cyclobenzaprine hcl .......... 32
cyclophosphamide ............ 15
CYCLOPHOSPHAMIDE ... 15
cycloserine ........................ 12
cyclosporine ...................... 44
cyclosporine modified (for
microemulsion) ................. 44
CYKLOKAPRON
see tranexamic acid ...... 43
CYMBALTA
see duloxetine hcl ......... 26
cyproheptadine hcl............ 48
cyred tab ........................... 36
CYSTADANE POW .......... 38
CYSTAGON ..................... 38
CYSTARAN ...................... 48
cytarabine ......................... 15
CYTOMEL
see liothyronine sodium 40
CYTOTEC
see misoprostol ............. 42
CYTOVENE
see ganciclovir inj 500mg
...................................... 12
D
D.H.E. 45
see dihydroergotamine
mesylate ........................ 31
dacarbazine ...................... 15
DAKLINZA ........................ 12
DALIRESP ........................ 49
danazol ............................. 38
DANTRIUM
see dantrolene sodium .. 32
dantrolene sodium ............ 32
dapsone ............................ 10
DAPTACEL ....................... 45
daptomycin ....................... 10
daunorubicin hcl................ 15
58
2017 SSI Choice 17255 v11 eff 05/01/2017
DDAVP
see desmopressin acetate
spray .............................40
see desmopressin acetate
tabs ...............................40
see desmopressin inj
4mcg/ml .........................40
deblitane 28 day................36
DELESTROGEN ...............38
see estrad val inj 20mg/ml
......................................38
see estrad val inj 40mg/ml
......................................38
delyla 28 day .....................36
DELZICOL ........................41
DEMADEX
see torsemide tabs ........22
DEMSER...........................22
DEPACON
see valproate sodium ....25
DEPAKENE
see valproate sodium ....25
see valproic acid............25
DEPAKOTE
see divalproex sodium ...24
DEPAKOTE ER
see divalproex sodium ...24
DEPAKOTE SPRINKLES
see divalproex sodium ...24
DEPEN TITRATABS .........35
DEPO-MEDROL
see methylpr ace inj
40mg/ml.........................38
see methylpr ace inj
80mg/ml.........................38
DEPO-PROVERA
CONTRACEPTIV
see medroxyprogesterone
acetate (contraceptive) ..37
DEPO-PROVERA INJ
400/ML ..............................16
DEPO-TESTOSTERONE
see testosterone cypionate
......................................33
DERMOTIC
see fluocinolone acetonide
(otic) ..............................52
DESCOVY ........................12
desipramine hcl ................. 26
desmopressin acetate spray
.......................................... 40
desmopressin acetate spray
refrigerated ....................... 40
desmopressin acetate tabs
.......................................... 40
desmopressin inj 4mcg/ml 40
DESMOPRESSIN SOL
0.01%................................ 40
DESOGEN
see apri 28 day .............. 35
see cyred tab ................. 36
see emoquette .............. 36
see juleber 28 day ......... 36
see reclipsen 28 day ..... 37
desogestrel-ethinyl estradiol
(biphasic) .......................... 36
desvenlafaxine succinate .. 26
DETROL
see tolterodine tartrate
tabs ............................... 42
DETROL LA
see tolterodine tartrate cap
er ................................... 42
dexamethasone ................ 38
dexamethasone sodium
phosphate ......................... 38
dexamethasone sodium
phosphate (ophth) ............. 47
DEXILANT CAP 30MG DR
.......................................... 42
DEXILANT CAP 60MG DR
.......................................... 42
dexrazoxane ..................... 17
DEXTROSE 10% FLEX
CONTAIN.......................... 46
DEXTROSE 10%/NACL
0.2%.................................. 46
DEXTROSE 10%/NACL
0.45%................................ 46
DEXTROSE 2.5%/NACL
0.45%................................ 46
DEXTROSE 5% ................ 46
DEXTROSE 5%
/ELECTROLYTE ............... 46
DEXTROSE 5%/LACTATED
RING ................................. 46
DEXTROSE 5%/NACL 0.2%
.......................................... 46
DEXTROSE 5%/NACL
0.225% ............................. 46
DEXTROSE 5%/NACL 0.3%
.......................................... 46
DEXTROSE 5%/NACL
0.33% ............................... 46
DEXTROSE 5%/NACL
0.45% ............................... 46
DEXTROSE 5%/NACL 0.9%
.......................................... 46
DEXTROSE
5%/POTASSIUM CHL ...... 46
DEXTROSE 50% .............. 46
DEXTROSE INJ 70% ....... 46
DIAMOX
see acetazolamide ........ 22
diazepam .......................... 24
DIAZEPAM GEL
(ANTICONVULSANT)....... 24
diclofenac potassium .......... 7
diclofenac sodium ............... 7
diclofenac sodium (ophth). 47
dicloxacillin sodium ........... 14
dicyclomine hcl ........... 40, 41
didanosine ........................ 11
DIFICID ............................. 13
DIFLUCAN
see fluconazole ............. 11
diflunisal.............................. 7
digitek ............................... 21
digox ........................... 21, 22
digoxin .............................. 22
digoxin inj.......................... 22
DIGOXIN SOL 50MCG/ML
.......................................... 22
dihydroergotamine mesylate
.......................................... 31
dilantin .............................. 24
DILANTIN
see phenytoin sodium
extended ....................... 25
DILANTIN INFATABS
see phenytoin ................ 25
DILANTIN-125
see phenytoin ................ 25
DILANTIN-125 SUS
59
2017 SSI Choice 17255 v11 eff 05/01/2017
125/5ML ............................24
DILAUDID
see hydromorphone hcl ...8
diltiazem cap 120mg cd ....21
diltiazem cap 180mg cd ....21
diltiazem cap 240mg cd ....21
diltiazem cap 300mg cd ....21
DILTIAZEM CAP 360MG CD
..........................................21
diltiazem cap er/12hr .........21
diltiazem hcl ......................21
diltiazem hcl cap sr 24hr ...21
diltiazem hcl coated beads
cap sr 24hr ........................21
diltiazem hcl extended
release beads cap sr .........21
dilt-xr cap ..........................21
DIOVAN
see valsartan .................19
DIOVAN HCT
see valsartan & hctz tab
160-12.5mg ...................19
see valsartan & hctz tab
160-25mg ......................19
see valsartan & hctz tab
320-12.5mg ...................19
see valsartan & hctz tab
320-25mg ......................19
see valsartan & hctz tab
80-12.5mg .....................19
DIPENTUM .......................41
diphenhydramine hcl inj ....48
diphenoxylate w/ atropine .41
DIPHTHERIA/TETANUS
TOXOID ............................45
DIPROLENE
see betamethasone
dipropionate augmented 51
DIPROLENE AF
see betamethasone
dipropionate augmented 51
disopyramide phosphate ...19
disulfiram...........................33
DITROPAN XL
see oxybutynin chloride .42
divalproex sodium .............24
DOCEFREZ ......................15
docetaxel...........................15
DOCETAXEL .................... 15
DOCETAXEL SOLN
80MG/8ML ........................ 15
DOFETILIDE..................... 19
DOLOPHINE
see methadone hcl 10mg 8
see methadone hcl 5mg .. 8
donepezil hydrochloride .... 26
dorzolamide hcl ................. 48
dorzolamide hcl-timolol
maleate ............................. 48
DOVONEX
see calcipotriene ........... 50
doxazosin mesylate .......... 18
doxepin hcl........................ 26
DOXEPIN HCL
(ANTIPRURITIC) .............. 50
DOXIL
see doxorubicin hcl
liposomal ....................... 15
doxorubicin hcl .................. 15
doxorubicin hcl inj 2 mg/ml 15
doxorubicin hcl liposomal .. 15
doxy .................................. 14
doxycycline (monohydrate)
.......................................... 14
doxycycline hyclate ..... 14, 15
dronabinol ......................... 40
drospirenone-ethinyl
estradiol ............................ 36
DROXIA ............................ 17
duloxetine hcl .................... 26
DURAGESIC
see fentanyl patch 100
mcg/hr ............................. 8
see fentanyl patch 12
mcg/hr ............................. 8
see fentanyl patch 25
mcg/hr ............................. 8
see fentanyl patch 50
mcg/hr ............................. 8
see fentanyl patch 75
mcg/hr ............................. 8
DURAMORPH .................... 7
DUREZOL......................... 47
dutasteride ........................ 42
dutasteride-tamsulosin hcl 42
DYAZIDE
see triamterene &
hydrochlorothiazide cap
37.5-25 mg .................... 22
E
e.e.s. 400mg tab ............... 13
EC-NAPROSYN
see naproxen .................. 7
EDURANT ........................ 11
EFFEXOR XR
see venlafaxine hcl........ 27
EFFIENT ........................... 43
EFUDEX
see fluorouracil (topical) 51
ELAVIL
see amitriptyline hcl....... 26
ELDEPRYL
see selegiline hcl ........... 28
ELIMITE
see permethrin .............. 51
ELIPHOS
see calcium acetate
(phosphate binder) ........ 39
ELIQUIS ........................... 43
ELITEK ............................. 17
elixophyllin ........................ 50
ELLA ................................. 36
ELLENCE
see epirubicin hcl .......... 15
ELMIRON ......................... 42
ELOCON
see mometasone furoate
...................................... 51
EMBEDA ............................ 8
EMCYT ............................. 15
EMEND ............................. 40
see aprepitant ............... 40
EMEND CAP 125MG........ 40
EMEND CAP 40MG.......... 40
EMEND CAP 80MG.......... 40
EMEND PAK 80 & 125 ..... 40
emoquette ......................... 36
EMSAM ............................ 26
EMTRIVA.......................... 11
emverm ............................. 10
enalapril maleate .............. 18
enalapril maleate &
hydrochlorothiazide........... 18
endocet ............................... 8
60
2017 SSI Choice 17255 v11 eff 05/01/2017
ENGERIX-B ......................45
enoxaparin sodium............43
ENOXAPARIN SODIUM ...43
enpresse 28 day ...............36
ENTACAPONE .................28
entecavir ...........................12
ENTOCORT EC
see budesonide ec ........41
ENTRESTO ......................19
enulose .............................41
EPIPEN 2-PAK .................49
EPIPEN-JR 2-PAK ............49
epirubicin hcl .....................15
epitol .................................24
EPIVIR
see lamivudine ..............11
EPIVIR HBV ......................12
see lamivudine (hbv) .....12
eplerenone ........................18
EPZICOM..........................12
ergotamine w/ caffeine ......31
ERIVEDGE .......................16
errin 28 day .......................36
ery pad 2% ........................50
ERYGEL
see erythromycin (acne
aid) ................................50
ery-tab ...............................14
erythrocin lactobionate ......14
erythrocin stearate ............14
erythromycin (acne aid) ....50
erythromycin (ophth) .........47
erythromycin base .............14
erythromycin cap 250mg ec
..........................................14
erythromycin ethylsuccinate
..........................................14
ESBRIET...........................49
escitalopram oxalate .........26
esomeprazole magnesium 42
esomeprazole sodium inj ..42
estarylla tab 0.25-35 .........36
estrace ..............................38
ESTRACE
see estradiol ..................38
estrad val inj 20mg/ml .......38
estrad val inj 40mg/ml .......38
estradiol ............................38
ESTROSTEP FE
see tri-legest 28 day ...... 37
ethambutol hcl .................. 12
ethosuximide ..................... 24
ethynodiol tab 1-50 ........... 36
etodolac .............................. 7
etoposide .......................... 17
EURAX ............................. 51
EVISTA
see raloxifene tab 60mg 39
EVOTAZ ........................... 12
EXELON PATCHES ......... 26
exemestane ...................... 16
EXFORGE
see amlodipine
besylate-valsartan tab
10-160 mg ..................... 19
see amlodipine
besylate-valsartan tab
10-320 mg ..................... 19
see amlodipine
besylate-valsartan tab
5-160 mg ....................... 19
see amlodipine
besylate-valsartan tab
5-320 mg ....................... 19
EXFORGE HCT
see
amlodipine-valsartan-hctz
tab 10-160-12.5 mg ....... 19
see
amlodipine-valsartan-hctz
tab 10-160-25 mg .......... 19
see
amlodipine-valsartan-hctz
tab 10-320-25 mg .......... 19
see
amlodipine-valsartan-hctz
tab 5-160-12.5 mg ......... 19
see
amlodipine-valsartan-hctz
tab 5-160-25 mg ............ 19
EXJADE ............................ 35
F
FABRAZYME .................... 38
falmina 28 day .................. 36
famciclovir ......................... 12
famotidine ......................... 41
famotidine inj .................... 41
famotidine tab ................... 41
FAMVIR
see famciclovir .............. 12
FANAPT ........................... 28
FANAPT TITRATION PACK
.......................................... 28
FARESTON ...................... 16
FARXIGA .......................... 34
FARYDAK ......................... 16
FASLODEX ...................... 16
felbamate .......................... 24
FELBATOL
see felbamate................ 24
felodipine .......................... 21
FEMARA
see letrozole .................. 16
femynor 28 day ................. 36
fenofibrate ......................... 20
fenofibrate micronized ...... 20
fentanyl citrate .................... 8
fentanyl patch 100 mcg/hr .. 8
fentanyl patch 12 mcg/hr .... 8
fentanyl patch 25 mcg/hr .... 8
fentanyl patch 50 mcg/hr .... 8
fentanyl patch 75 mcg/hr .... 8
FENTORA .......................... 8
FERRIPROX ..................... 35
FETZIMA .................... 26, 27
FETZIMA TITRATION PACK
.......................................... 27
finasteride ......................... 42
FIRAZYR .......................... 43
FLAGYL
see metronidazole ......... 10
FLEBOGAMMA DIF.......... 44
flecainide acetate .............. 19
FLOMAX
see tamsulosin hcl......... 42
FLONASE
see fluticasone propionate
(nasal) ........................... 49
FLOVENT DISKUS ........... 49
FLOVENT HFA ................. 49
FLOXIN OTIC
see ofloxacin (otic) ........ 52
fluconazole ....................... 11
fluconazole in dextrose ..... 11
61
2017 SSI Choice 17255 v11 eff 05/01/2017
fluconazole inj nacl 100 .....11
fluconazole inj nacl 200 .....11
fluconazole inj nacl 400 .....11
flucytosine .........................11
fludarabine phosphate ......15
fludrocortisone acetate ......38
FLUMADINE
see rimantadine
hydrochloride .................13
flunisolide (nasal) ..............49
fluocinolone acetonide ......51
fluocinolone acetonide (otic)
..........................................52
fluocinonide .......................51
fluocinonide emulsified base
..........................................51
FLUOROMETHOLONE ....47
fluorouracil ........................15
fluorouracil (topical) ...........51
fluoxetine cap 10mg ..........27
fluoxetine cap 20mg ..........27
fluoxetine cap 40mg ..........27
fluoxetine hcl .....................27
fluphenazine decanoate ....28
fluphenazine hcl ................28
flurbiprofen ..........................7
flurbiprofen sodium ...........47
flutamide ...........................16
fluticasone propionate .......51
fluticasone propionate
(nasal) ...............................49
fluvoxamine maleate .........23
fondaparinux sodium .........43
FORTAZ
see ceftazidime .............13
see tazicef .....................13
see tazicef vial ...............13
FORTEO ...........................39
FORTICAL ........................39
FOSAMAX
see alendronate sodium 35
fosinopril sodium ...............18
fosinopril sodium &
hydrochlorothiazide ...........18
FREAMINE HBC 6.9% ......46
FREAMINE III ...................46
furosemide ........................22
furosemide inj....................22
FUROSEMIDE INJ ........... 22
FUSILEV ........................... 17
see levoleucovorin calcium
...................................... 17
FUZEON ........................... 11
fyavolv tab 1-5mg ............. 38
FYCOMPA ........................ 24
G
gabapentin ........................ 24
GABITRIL ......................... 24
see tiagabine hcl ........... 25
galantamine hydrobromide26
galantamine hydrobromide
er ...................................... 26
GAMASTAN S/D ............... 44
GAMMAGARD LIQUID ..... 44
GAMMAGARD S/D ........... 44
GAMMAKED ..................... 44
GAMMAPLEX ................... 44
GAMUNEX-C .................... 44
ganciclovir inj 500mg ........ 12
GARDASIL........................ 45
GARDASIL 9..................... 45
GASTROCROM
see cromolyn sodium
(mastocytosis) ............... 41
gatifloxacin (ophth) ........... 47
GATTEX ........................... 41
GAUZE PADS 2" X 2" ....... 33
gavilyte-c........................... 41
gavilyte-g .......................... 41
gavilyte-h .......................... 41
gavilyte-n .......................... 41
gemcitabine hcl ................. 15
GEMCITABINE HCL ......... 15
gemfibrozil ........................ 20
GEMZAR
see gemcitabine hcl....... 15
generlac ............................ 41
gengraf.............................. 44
gentak ............................... 47
gentamicin in saline ............ 9
gentamicin sulfate ............... 9
gentamicin sulfate (ophth). 47
gentamicin sulfate (topical)
.......................................... 50
gentamicin sulfate/0.9% s ... 9
GENVOYA ........................ 12
GEODON .......................... 29
see ziprasidone hcl ....... 30
GIANVI TAB 3-0.02MG..... 36
gildagia ............................. 36
gildess tab 1.5/30.............. 36
GILENYA CAP 0.5MG ...... 32
GILOTRIF TAB 20MG ...... 16
GILOTRIF TAB 30MG ...... 16
GILOTRIF TAB 40MG ...... 16
GLEEVEC
see imatinib mesylate.... 17
GLEOSTINE ..................... 15
glimepiride ........................ 34
glip/metform tab 2.5-250mg
.......................................... 34
glip/metform tab 2.5-500mg
.......................................... 34
glip/metform tab 5-500mg . 34
glipizide ............................. 34
GLIPIZIDE XL TB24 2.5MG
.......................................... 34
GLIPIZIDE XL TB24 5MG . 34
GLUCAGEN HYPOKIT ..... 39
GLUCAGON EMERGENCY
KIT .................................... 39
GLUCOPHAGE
see metformin hcl .......... 35
GLUCOPHAGE XR
see metformin er ..... 34, 35
GLUCOTROL
see glipizide .................. 34
GLUCOTROL XL
see glipizide .................. 34
glycopyrrolate ................... 41
GOLYTELY ....................... 41
see gavilyte-g ................ 41
GRALISE .......................... 32
GRALISE STARTER ........ 32
granisetron hcl .................. 40
GRANIX ............................ 43
griseofulvin microsize ....... 11
griseofulvin ultramicrosize 11
GRIS-PEG
see griseofulvin
ultramicrosize ................ 11
guanfacine er (adhd)......... 31
H
HALDOL
62
2017 SSI Choice 17255 v11 eff 05/01/2017
see haloperidol lactate inj
5mg/ml...........................29
HALDOL DECANOATE 100
see haloperidol decanoate
......................................29
HALDOL DECANOATE 50
see haloperidol decanoate
......................................29
halobetasol propionate ......51
haloperidol ........................29
haloperidol decanoate .......29
haloperidol lactate conc ....29
haloperidol lactate inj 5mg/ml
..........................................29
HAVRIX.............................45
heather ..............................36
heparin sod (porcine) in d5w
..........................................43
HEPARIN SOD (PORCINE)
IN D5W .............................43
heparin sod inj 1000/ml .....43
heparin sod inj 10000/ml ...43
heparin sod inj 20000/ml ...43
heparin sod inj 5000/ml .....43
HEPARIN SODIUM/D5W ..43
HEPARIN SODIUM/NACL
0.45% ................................43
HEPATAMINE...................46
HEPSERA
see adefovir dipivoxil .....12
HERCEPTIN .....................16
HETLIOZ ...........................31
HEXALEN .........................15
HIBERIX............................45
HIPREX
see methenamine
hippurate .......................10
HUMIRA INJ 10MG/0.2ML 43
HUMIRA KIT 20MG/0.4ML43
HUMIRA KIT 40MG/0.8ML44
HUMIRA PEDIATRIC
CROHNS DISEASE ..........44
HUMIRA PEN ...................44
HUMIRA PEN-CROHNS
DISEASE ..........................44
HUMIRA PEN-PSORIASIS
STAR ................................44
HUMULIN R INJ U-500 .....33
HUMULIN R U-500
KWIKPEN ......................... 33
HYCAMTIN
see topotecan hcl .......... 18
HYCET
see
hydrocodone-acetaminoph
en 7.5-325 mg/15ml ........ 8
hydralazine hcl .................. 22
HYDREA
see hydroxyurea ............ 17
hydrochlorothiazide ........... 22
hydroco/apap tab 10-325mg
............................................ 8
hydroco/apap tab 5-325mg . 8
hydroco/apap tab 7.5-325mg
............................................ 8
hydrocodone-acetaminophen
7.5-325 mg/15ml ................. 8
hydrocodone-ibuprofen
7.5-200mg........................... 8
hydrocortisone .................. 38
HYDROCORTISONE
(ENEMA)........................... 41
hydrocortisone (topical)..... 51
hydrocortisone butyrate .... 51
hydromorphone hcl ............. 8
hydroxychloroquine sulfate
.......................................... 44
hydroxyprogesterone
caproate (antineoplastic)... 16
hydroxyurea ...................... 17
hydroxyz hcl inj ................. 48
hydroxyzine hcl ................. 49
hydroxyzine pamoate ........ 49
HYSINGLA ER .................... 8
HYZAAR
see losartan potassium &
hctz tab 100-12.5 mg..... 19
see losartan potassium &
hctz tab 100-25 mg........ 19
see losartan potassium &
hctz tab 50-12.5 mg....... 19
I
IBRANCE .......................... 16
ibuprofen ............................. 7
ICLUSIG ........................... 16
IDAMYCIN PFS
see idarubicin hcl .......... 15
idarubicin hcl ..................... 15
IFEX.................................. 15
see ifosfamide inj 1gm .. 15
ifosfamide inj 1gm ............. 15
ifosfamide inj 1gm/20ml .... 15
IFOSFAMIDE INJ 3GM ..... 15
ifosfamide inj 3gm/60ml .... 15
ILEVRO ............................ 48
ilotycin............................... 47
imatinib mesylate .............. 17
IMBRUVICA CAP 140MG . 17
imipenem-cilastatin ........... 10
imipramine hcl .................. 27
imiquimod ......................... 51
IMITREX
see sumatriptan inj
6mg/0.5ml ..................... 32
see sumatriptan succinate
...................................... 32
IMITREX STATDOSE
REFILL
see sumatriptan inj
6mg/0.5ml ..................... 32
IMITREX STATDOSE
SYSTEM
see sumatriptan inj
6mg/0.5ml ..................... 31
IMOVAX RABIES (H.D.C.V.)
.......................................... 45
IMURAN
see azathioprine ............ 44
INCRELEX ........................ 39
INCRUSE ELLIPTA .......... 48
indapamide ....................... 22
INDERAL LA
see propranolol cap er .. 21
INFANRIX ......................... 45
INLYTA ............................. 17
INSPRA
see eplerenone ............. 18
INSULIN PEN NEEDLE .... 33
INSULIN SYRINGE .......... 33
INTELENCE ..................... 11
INTRALIPID INJ 20% ....... 46
INTRALIPID INJ 30% ....... 46
INTRON-A INJ 10MU ....... 44
INTRON-A INJ 18MU ....... 44
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INTRON-A INJ 25MU ........44
INTRON-A INJ 50MU ........44
introvale 91 day.................36
INTUNIV
see guanfacine er (adhd)
......................................31
INVANZ .............................10
INVEGA ............................29
INVEGA SUST INJ
117MG/0.75ML .................29
INVEGA SUST INJ
156MG/ML ........................29
INVEGA SUST INJ
234MG/1.5ML ...................29
INVEGA SUST INJ
39MG/0.25ML ...................29
INVEGA SUST INJ
78MG/0.5ML .....................29
INVEGA TRINZA ..............29
INVIRASE .........................11
INVOKAMET TAB
150-1000MG .....................34
INVOKAMET TAB
150-500MG .......................34
INVOKAMET TAB
50-1000MG .......................34
INVOKAMET TAB
50-500MG .........................34
INVOKAMET XR TAB
150-1000MG .....................34
INVOKAMET XR TAB
150-500MG .......................34
INVOKAMET XR TAB
50-1000MG .......................34
INVOKAMET XR TAB
50-500MG .........................34
INVOKANA .......................34
IONOSOL-B/DEXTROSE
5% .....................................46
IONOSOL-MB/DEXTROSE
5% .....................................46
IPOL INACTIVATED IPV ..45
ipratropium bromide ..........48
ipratropium bromide (nasal)
..........................................48
ipratropium-albuterol nebu 48
irbesartan ..........................19
irbesartan-hydrochlorothiazid
e ........................................ 19
IRESSA............................. 17
irinotecan hcl..................... 18
ISENTRESS ..................... 11
ISOLYTE P ....................... 46
ISOLYTE S ....................... 46
isoniazid ............................ 12
isoniazid inj 100 mg/ml...... 12
isoniazid syp 50mg/5ml..... 12
ISORDIL TITRADOSE
see isosorbide dinitrate . 22
isosorb mononitrate tab .... 22
isosorbide dinitrate ............ 22
isosorbide dinitrate er........ 22
isosorbide mononitrate er . 22
isradipine .......................... 21
ISTALOL ........................... 48
ISTODAX (OVERFILL) ..... 16
itraconazole ...................... 11
ivermectin ......................... 10
IXIARO.............................. 45
J
JAKAFI.............................. 17
JALYN
see dutasteride-tamsulosin
hcl.................................. 42
jantoven ............................ 43
JANUMET ......................... 34
JANUMET XR TAB
100-1000........................... 34
JANUMET XR TAB 50-1000
.......................................... 34
JANUMET XR TAB
50-500MG ......................... 34
JANUVIA........................... 34
JENTADUETO .................. 34
JENTADUETO TAB XR
2.5-1000 MG ..................... 34
JENTADUETO TAB XR
5-1000 MG ........................ 34
jinteli.................................. 38
JOLESSA TAB 0.15-0.03
MG .................................... 36
JOLIVETTE....................... 36
juleber 28 day ................... 36
junel 1.5/30 21 day ........... 36
junel 1/20 21 day .............. 36
junel fe 1.5/30 28 day........ 36
junel fe 1/20 28 day .......... 36
JUXTAPID ........................ 20
K
KADCYLA ......................... 16
KALETRA
see lopinavir-ritonavir .... 12
KALETRA SOL ................. 12
KALETRA TAB 100-25MG 12
KALETRA TAB 200-50MG 12
KALYDECO ...................... 49
kariva 28 day .................... 36
KAYEXALATE
see kionex powder ........ 35
see sodium polystyrene
sulfonate ....................... 35
KCL 0.075%/D5W/NACL
0.45% ............................... 46
KCL 0.15%/D5W/NACL
0.9% ................................. 46
KCL 0.3%/D5W/NACL
0.45% ............................... 46
KCL 0.3%/D5W/NACL 0.9%
.......................................... 46
KCL IN NACL INJ .15-0.45
.......................................... 46
KCL/D5W INJ 0.3% .......... 46
KCL/D5W/NACL INJ
.15/.33% ........................... 46
KCL/D5W/NACL INJ
.15/.45% ........................... 46
KCL/D5W/NACL INJ
0.22%/0.45% .................... 46
KCL/NACL INJ 0.15%-0.9%
.......................................... 46
KCL/NACL INJ 0.3-0.9...... 46
KCL0.15%/D5W/NACL0.2%
.......................................... 46
KCL0.15%/D5W/NACL0.225
% ...................................... 46
KEFLEX
see cephalexin .............. 13
kelnor 1/35 28 day ............ 36
KEPPRA
see levetiracetam .......... 24
see levetiracetam inj ..... 24
see levetiracetam sol
100mg/ml ...................... 25
see roweepra ................ 25
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KEPPRA XR
see levetiracetam ..........24
ketoconazole .....................11
ketoconazole cream ..........50
ketoconazole shampoo .....50
ketoprofen ...........................7
ketorolac tromethamine
(ophth) ..............................48
KEYTRUDA ......................16
kimidess 28 day ................36
KINRIX ..............................45
kionex powder ...................35
kionex susp 15gm/60ml ....35
KITABIS PAK
see tobramycin ..............10
KLARON
see sulfacetamide sodium
(acne) ............................50
KLONOPIN
see clonazepam ............24
KLOR-CON 10 ..................45
KLOR-CON 8 ....................45
klor-con m10 .....................45
klor-con m15 .....................45
klor-con m20 .....................45
klor-con pow 20 meq .........45
klor-con spr cap 10meq ....45
klor-con spr cap 8meq ......45
KORLYM ...........................39
KUVAN .............................38
KYNAMRO ........................20
L
labetalol hcl .......................20
LAC-HYDRIN
see ammonium lactate ..51
LACTATED RINGER'S INJ
..........................................47
lactulose ............................41
lactulose (encephalopathy)
..........................................41
LAMICTAL
see lamotrigine ..............24
LAMICTAL CHEWABLE
DISPERS
see lamotrigine ..............24
LAMICTAL XR
see lamotrigine ..............24
LAMISIL
see terbinafine hcl ......... 11
lamivudine......................... 11
lamivudine (hbv) ............... 12
lamivudine-zidovudine ...... 12
lamotrigine ........................ 24
LANOXIN
see digitek ..................... 21
see digox ................. 21, 22
see digoxin .................... 22
see digoxin inj ............... 22
LANTUS............................ 33
LANTUS SOLOSTAR ....... 33
larin 1.5/30 ........................ 36
larin 1/20 ........................... 36
larin fe 1.5/30 .................... 36
larin fe 1/20 ....................... 36
larissia tab......................... 36
LASIX
see furosemide .............. 22
LASTACAFT ..................... 48
latanoprost ........................ 48
LATUDA............................ 29
LEENA TAB ...................... 36
leflunomide ....................... 44
LENVIMA 10 MG DAILY
DOSE................................ 17
LENVIMA 14 MG DAILY
DOSE................................ 17
LENVIMA 18 MG DAILY
DOSE................................ 17
LENVIMA 20 MG DAILY
DOSE................................ 17
LENVIMA 24 MG DAILY
DOSE................................ 17
LENVIMA 8 MG DAILY
DOSE................................ 17
lessina 28 day ................... 36
LETAIRIS .......................... 23
letrozole ............................ 16
leucovorin calcium ............ 17
leucovorin calcium for inj 500
mg ..................................... 17
LEUKERAN ...................... 15
LEUKINE .......................... 43
leuprolide inj 1mg/0.2 ........ 16
LEVAQUIN
see levofloxacin ............. 14
LEVEMIR .......................... 33
LEVEMIR FLEXTOUCH ... 33
levetiracetam .................... 24
LEVETIRACETAM
see levetiracetam in
sodium chloride ............. 24
levetiracetam in sodium
chloride ............................. 24
levetiracetam inj ................ 24
LEVETIRACETAM IV ....... 25
levetiracetam sol 100mg/ml
.......................................... 25
levobunolol hcl .................. 48
levocarnitine (metabolic
modifiers) .......................... 38
levocetirizine dihydrochloride
.......................................... 49
levofloxacin ....................... 14
levofloxacin in d5w............ 14
levofloxacin inj 25mg/ml.... 14
levofloxacin oral soln 25
mg/ml ................................ 14
levoleucovorin calcium...... 17
levonest 28 day ................ 36
levonor/ethi tab ................. 36
levonorgestrel & eth estradiol
.......................................... 36
levonorgestrel (emergency
oc)..................................... 36
levonorgestrel-ethinyl
estradiol (91-day) .............. 36
levora 0.15/30 28 day ....... 36
levothyroxine sodium ........ 40
LEVOTHYROXINE SODIUM
.......................................... 40
LEXAPRO
see escitalopram oxalate
...................................... 26
LEXIVA ............................. 11
lidocaine ........................... 51
lidocaine hcl ...................... 51
lidocaine hcl (local anesth.) 9
lidocaine hcl (mouth-throat)
.......................................... 52
lidocaine inj 0.5% ................ 9
lidocaine inj 1% ................... 9
lidocaine inj 1.5% ................ 9
lidocaine inj 2% ................... 9
lidocaine oint 5%............... 51
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lidocaine-prilocaine ...........51
LIDODERM
see lidocaine .................51
linezolid .............................10
LINEZOLID .......................10
LINEZOLID IN SODIUM
CHLORIDE .......................10
LINZESS ...........................41
liothyronine sodium ...........40
LIPITOR
see atorvastatin calcium 20
lisinopril .............................18
lisinopril &
hydrochlorothiazide ...........18
lithium carbonate...............32
lithium carbonate er ..........32
LITHIUM SOLN 8MEQ/5ML
..........................................32
LITHOBID
see lithium carbonate er 32
LOCOID
see hydrocortisone
butyrate .........................51
LODINE
see etodolac ....................7
LOESTRIN 1.5/30-21
see gildess tab 1.5/30 ...36
see junel 1.5/30 21 day .36
see larin 1.5/30 ..............36
LOESTRIN 1/20-21
see junel 1/20 21 day ....36
see larin 1/20 .................36
see norethindrone acet &
eth estra ........................37
LOESTRIN FE 1.5/30
see blisovi 21 fe 1.5/30 28
day pack ........................36
see junel fe 1.5/30 28 day
......................................36
see larin fe 1.5/30 ..........36
LOESTRIN FE 1/20
see blisovi 21 fe 1/20 28
day pack ........................36
see junel fe 1/20 28 day 36
see larin fe 1/20 .............36
see tarina fe 1/20 28 day
......................................37
LOFIBRA
see fenofibrate .............. 20
see fenofibrate micronized
...................................... 20
LOMOTIL
see diphenoxylate w/
atropine ......................... 41
LONSURF......................... 17
loperamide hcl .................. 41
LOPID
see gemfibrozil .............. 20
lopinavir-ritonavir .............. 12
LOPRESSOR
see metoprolol tartrate .. 21
LOPRESSOR HCT
see metoprolol &
hydrochlorothiazide ....... 20
LOPROX
see ciclopirox ................ 50
LOPROX SHAMPOO
see ciclopirox shampoo
1% ................................. 50
lorazepam ......................... 23
lorcet hd tab 10-325mg ....... 8
lorcet plus tab 7.5-325 ........ 8
lorcet tab 5-325mg .............. 8
lortab tab 10-325mg ............ 8
lortab tab 5-325mg .............. 8
lortab tab 7.5-325 ................ 8
loryna 28 day .................... 36
losartan potassium ............ 19
losartan potassium & hctz
tab 100-12.5 mg ................ 19
losartan potassium & hctz
tab 100-25 mg ................... 19
losartan potassium & hctz
tab 50-12.5 mg .................. 19
LOTEMAX......................... 48
LOTENSIN
see benazepril hcl ......... 18
LOTENSIN HCT
see benazepril &
hydrochlorothiazide ....... 18
LOTREL
see amlodipine
besylate-benazepril hcl
cap 10-20 mg ................ 18
see amlodipine
besylate-benazepril hcl
cap 10-40 mg ................ 18
see amlodipine
besylate-benazepril hcl
cap 5-10 mg .................. 18
see amlodipine
besylate-benazepril hcl
cap 5-20 mg .................. 18
LOTRONEX
see alosetron hcl ........... 41
lovastatin .......................... 20
LOVAZA
see omega-3-acid ethyl
esters ............................ 20
LOVENOX
see enoxaparin sodium . 43
low-ogestrel ...................... 36
loxapine succinate ............ 29
LUMIGAN ......................... 48
LUMIZYME ....................... 38
LUPRON DEPOT
(1-MONTH) ....................... 16
LUPRON DEPOT INJ
11.25MG (3-MONTH) ....... 16
LUPRON DEP-PED INJ
11.25MG ........................... 39
LUPRON DEP-PED INJ
11.25MG (3-MONTH) ....... 39
LUPRON DEP-PED INJ
15MG ................................ 39
LUPRON DEP-PED INJ
30MG (3-MONTH) ............ 39
LUPRON DEP-PED INJ
7.5MG ............................... 39
lutera 28 day ..................... 36
LYNPARZA ....................... 16
LYRICA ............................. 25
LYSODREN ...................... 16
LYSTEDA
see tranexamic acid ...... 43
lyza ................................... 36
M
MACROBID
see nitrofurantoin
monohyd macro ............ 10
MACRODANTIN
see nitrofurantoin
macrocrystal .................. 10
magnesium sulfate............ 45
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MAGNESIUM SULFATE ...45
see magnesium sulfate .45
MAGNESIUM SULFATE IN
D5W ..................................45
MALARONE
see atovaquone-proguanil
hcl ..................................11
malathion ..........................51
maprotiline hcl ...................27
MARINOL
see dronabinol ...............40
marlissa 28 day .................36
MARPLAN TAB 10MG ......27
MATULANE ......................17
MAVIK
see trandolapril ..............18
MAXALT
see rizatriptan benzoate 31
MAXALT-MLT
see rizatriptan benzoate 31
MAXIDEX ..........................48
MAXIPIME
see cefepime hcl ...........13
MAXITROL
see
neomycin-polymy-dexamet
h ....................................47
MAXZIDE
see triamterene &
hydrochlorothiazide .......22
MAXZIDE-25
see triamterene &
hydrochlorothiazide .......22
meclizine hcl .....................40
MEDROL
see methylpred tab 16mg
......................................39
see methylpred tab 32mg
......................................39
see methylpred tab 4mg 39
see methylpred tab 8mg 39
MEDROL DOSEPAK
see methylpred pak 4mg
......................................39
medroxyprogesterone
acetate (contraceptive) .....37
MEDROXYPROGESTERON
E ACETATE
(CONTRACEPTIVE) ......... 37
medroxyprogesterone
acetate tab ........................ 40
mefloquine hcl................... 11
MEGACE ORAL
see megestrol ac sus
40mg/ml ........................ 16
megestrol ac sus 40mg/ml 16
megestrol ac tab 20mg ..... 16
megestrol ac tab 40mg ..... 16
MEGESTROL SUS
625MG/5ML ...................... 16
MEKINIST ......................... 17
meloxicam........................... 7
MELOXICAM ...................... 7
melphalan hcl.................... 15
memantine hcl .................. 26
MEMANTINE HCL ............ 26
MENACTRA...................... 45
MENHIBRIX ...................... 45
MENOMUNE-A/C/Y/W-135
.......................................... 45
MENVEO .......................... 45
MEPRON
see atovaquone ............. 10
mercaptopurine ................. 15
meropenem....................... 10
MERREM
see meropenem ............ 10
mesalamine enema .......... 41
mesalamine w/ cleanser ... 41
mesna ............................... 17
MESNEX........................... 17
see mesna..................... 17
MESTINON
see pyridostigmine tab
60mg ............................. 32
metadate tab 20mg er ....... 31
metformin er ................ 34, 35
metformin hcl .................... 35
methadone hcl .................... 8
methadone hcl 10mg .......... 8
methadone hcl 5mg ............ 8
METHADOSE
see methadone hcl .......... 8
methazolamide ................. 22
methenamine hippurate .... 10
METHERGINE
see methylergonovine
maleate ......................... 39
methergine 0.2 mg tab ...... 39
methimazole ..................... 40
methotrexate sodium ........ 15
METHOTREXATE SODIUM
.......................................... 15
methotrexate sodium inj.... 15
methotrexate sodium tabs 44
methyclothiazide ............... 22
methylergonovine maleate 39
METHYLIN
see methylphenidate hcl
oral soln ........................ 31
methylphenidate hcl .......... 31
methylphenidate hcl oral soln
.......................................... 31
methylpr ace inj 40mg/ml .. 38
methylpr ace inj 80mg/ml .. 38
methylpr ss inj 125 mg ...... 39
methylpr ss inj 1gm ........... 38
methylpr ss inj 40mg ......... 38
methylpred pak 4mg ......... 39
methylpred tab 16mg ........ 39
methylpred tab 32mg ........ 39
methylpred tab 4mg .......... 39
methylpred tab 8mg .......... 39
metipranolol ...................... 48
metoclopramide hcl........... 40
metoclopramide hcl inj ...... 40
metolazone ....................... 22
metoprolol &
hydrochlorothiazide........... 20
metoprolol succinate ......... 20
metoprolol tartrate............. 21
METROCREAM
see metronidazole
(topical) ......................... 51
see rosadan cre 0.75% . 51
METROGEL-VAGINAL
see metronidazole vaginal
...................................... 43
METROLOTION
see metronidazole
(topical) ......................... 51
metronidazole ................... 10
metronidazole (topical) ..... 51
metronidazole gel 0.75% .. 51
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2017 SSI Choice 17255 v11 eff 05/01/2017
metronidazole in nacl ........10
metronidazole vaginal .......43
MEVACOR
see lovastatin ................20
mexiletine hcl ....................19
MIACALCIN ......................39
see calcitonin (salmon) ..39
MICROGESTIN 1.5/30 ......37
MICROGESTIN 1/20 .........37
MICROGESTIN FE 1.5/30 37
MICROGESTIN FE 1/20 ...37
MICRO-K
see klor-con spr cap
10meq ...........................45
see klor-con spr cap 8meq
......................................45
see potassium chloride ..45
MICROZIDE
see hydrochlorothiazide 22
midodrine hcl.....................22
migergot ............................31
MINIPRESS
see prazosin hcl ............18
minitran .............................22
MINOCIN
see minocycline hcl .......15
minocycline hcl..................15
minoxidil ............................22
MIRAPEX
see pramipexole tab
0.125mg ........................28
see pramipexole tab
0.25mg ..........................28
see pramipexole tab
0.5mg ............................28
see pramipexole tab
0.75mg ..........................28
see pramipexole tab
1.5mg ............................28
see pramipexole tab 1mg
......................................28
MIRCETTE
see bekyree 28 day .......35
see desogestrel-ethinyl
estradiol (biphasic) ........36
see kariva 28 day ..........36
see kimidess 28 day ......36
see pimtrea pack ...........37
see viorele ..................... 38
mirtazapine ....................... 27
misoprostol ....................... 42
mitomycin .......................... 15
mitoxantrone hcl ............... 17
M-M-R II ............................ 45
MOBIC
see meloxicam ................ 7
moderiba tab 200mg ......... 12
moexipril hcl ...................... 18
moexipril-hydrochlorothiazid
e ........................................ 18
molindone hcl.................... 29
mometasone furoate ......... 51
MONODOX
see doxycycline
(monohydrate) ............... 14
mono-linyah tab 0.25-35 ... 37
MONONESSA .................. 37
montelukast sodium .......... 49
morgidox cap 1x50mg....... 15
morphine ext-rel tab ........ 8, 9
MORPHINE SUL INJ
10MG/ML ............................ 9
MORPHINE SUL INJ
15MG/ML ............................ 9
MORPHINE SUL INJ
1MG/ML .............................. 9
MORPHINE SUL INJ
2MG/ML .............................. 9
MORPHINE SUL INJ
4MG/ML .............................. 9
morphine sulfate ................. 9
MORPHINE SULFATE ....... 9
see morphine sulfate ....... 9
MORPHINE SULFATE
ORAL SOL .......................... 9
MOVANTIK ....................... 42
MOVIPREP ....................... 41
MOXEZA........................... 47
MOZOBIL.......................... 43
MS CONTIN
see morphine ext-rel tab. 8,
9
MULTAQ ........................... 19
mupirocin .......................... 50
MUSTARGEN ................... 15
MYAMBUTOL
see ethambutol hcl ........ 12
MYCAMINE ...................... 11
MYCOBUTIN
see rifabutin .................. 12
mycophenolate mofetil ...... 44
mycophenolate sodium ..... 44
MYFORTIC
see mycophenolate
sodium .......................... 44
myorisan ........................... 50
MYRBETRIQ TAB 25MG .. 42
MYRBETRIQ TAB 50MG .. 42
MYSOLINE
see primidone................ 25
myzilra .............................. 37
N
nabumetone ........................ 7
nafcillin sodium ................. 14
NAGLAZYME ................... 38
nalbuphine hcl .................... 7
naloxone inj 0.4mg/ml ....... 33
naloxone inj 1mg/ml .......... 33
naltrexone hcl ................... 33
NAMENDA
see memantine hcl ........ 26
NAMENDA XR .................. 26
NAMENDA XR TITRATION
PACK ................................ 26
NAMZARIC ....................... 26
naphazoline hcl ................. 48
NAPROSYN
see naproxen .................. 7
naproxen ............................. 7
naproxen sodium ................ 7
naratriptan hcl ................... 31
NARDIL
see phenelzine sulfate .. 27
NASONEX ........................ 49
NATACYN ........................ 47
nateglinide ........................ 35
NATPARA ......................... 39
NAVELBINE
see vinorelbine tartrate.. 15
NEBUPENT ...................... 10
necon 0.5/35 28 day ......... 37
NECON 1/50-28................ 37
necon 10/11 28 day .......... 37
NECON 7/7/7 .................... 37
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necon tab 1/35 ..................37
nefazodone hcl..................27
neomycin sulfate .................9
neomycin-bacitracin
zn-polymyxin .....................47
neomycin-polymy-dexameth
..........................................47
neomycin-polymyxin-gramici
din .....................................47
neomycin-polymyxin-hc
(ophth) ..............................47
neomycin-polymyxin-hc (otic)
..........................................52
NEORAL ...........................44
see cyclosporine modified
(for microemulsion) ........44
see gengraf ...................44
NEOSPORIN
see
neomycin-polymyxin-grami
cidin ...............................47
NEPHRAMINE ..................46
NEPTAZANE
see methazolamide .......22
NEUPOGEN .....................43
NEUPRO...........................28
NEURONTIN
see gabapentin ..............24
NEVIRAPINE SUSP 50
MG/5ML ............................11
nevirapine tab 100mg .......11
nevirapine tab 200mg .......11
nevirapine tb24 .................11
NEXAVAR .........................17
NEXIUM
see esomeprazole
magnesium ....................42
NEXIUM CAP 20MG .........42
NEXIUM CAP 40MG .........42
NEXIUM GRA 10MG DR ..42
NEXIUM GRA 2.5MG DR .42
NEXIUM GRA 20MG DR ..42
NEXIUM GRA 40MG DR ..42
NEXIUM GRA 5MG DR ....42
NEXIUM I.V.
see esomeprazole sodium
inj ...................................42
niacin er (antihyperlipidemic)
.......................................... 20
niacor ................................ 20
NIASPAN
see niacin er
(antihyperlipidemic) ....... 20
nicardipine hcl ................... 21
NICOTROL INHALER ....... 33
NICOTROL NS ................. 33
nifedical xl ......................... 21
nifedipine .......................... 21
nifedipine er ...................... 21
nikki 28 day ....................... 37
NILANDRON ..................... 16
see nilutamide ............... 16
nilutamide ......................... 16
nimodipine ........................ 21
NINLARO .......................... 16
NIPENT............................. 15
nitro-bid ............................. 22
NITRO-DUR
see minitran ................... 22
NITRO-DUR DIS 0.3MG/HR
.......................................... 22
NITRO-DUR DIS 0.8MG/HR
.......................................... 22
nitrofurantoin macrocrystal 10
nitrofurantoin monohyd
macro ................................ 10
nitroglycerin ...................... 23
nitroglycerin td patch ......... 23
NITROSTAT ..................... 23
see nitroglycerin ............ 23
NIZORAL
see ketoconazole
shampoo ....................... 50
NORA-BE TAB 0.35MG .... 37
NORCO
see hydroco/apap tab
10-325mg ........................ 8
see hydroco/apap tab
5-325mg .......................... 8
see hydroco/apap tab
7.5-325mg ....................... 8
see lorcet hd tab
10-325mg ........................ 8
see lorcet plus tab 7.5-325
........................................ 8
see lorcet tab 5-325mg.... 8
see lortab tab 10-325mg . 8
see lortab tab 5-325mg ... 8
see lortab tab 7.5-325 ..... 8
NORDITROPIN FLEXPRO
.......................................... 39
norethindrone
(contraceptive) .................. 37
norethindrone acet & eth
estra.................................. 37
norethindrone acetate ....... 40
norethindrone acetate-ethinyl
estradiol ............................ 38
norgest/ethi tab 0.25/35 .... 37
norgestimate-ethinyl
estradiol (triphasic) ........... 37
NORINYL 1+35
see alyacen 1/35 ........... 35
see cyclafem 1/35 28 day
...................................... 36
see necon tab 1/35........ 37
see nortrel 1/35 21 day . 37
see nortrel 1/35 28 day . 37
see pirmella 1/35 28 day
...................................... 37
norlyroc 28 day ................. 37
NORMOSOL-M IN D5W ... 47
NORMOSOL-R ................. 47
NORMOSOL-R IN D5W ... 47
NORPACE
see disopyramide
phosphate ..................... 19
NORPACE CR .................. 19
NORPRAMIN
see desipramine hcl ...... 26
NORTHERA ..................... 22
nortrel 0.5/35 28 day ......... 37
nortrel 1/35 21 day ............ 37
nortrel 1/35 28 day ............ 37
nortrel 7/7/7 28 day ........... 37
nortriptyline hcl ................. 27
NORVASC
see amlodipine besylate 21
NORVIR ............................ 11
NOVOLIN 70/30................ 33
NOVOLIN N ...................... 33
NOVOLIN R ...................... 33
NOVOLOG ....................... 33
NOVOLOG FLEXPEN ...... 33
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NOVOLOG MIX 70/30 ......33
NOVOLOG MIX 70/30
PREFILL ...........................33
NOVOLOG PENFILL ........33
NOXAFIL...........................11
NUCYNTA ER.....................9
NUEDEXTA ......................32
NULOJIX ...........................44
NULYTELY/FLAVOR
PACKS ..............................41
see gavilyte-n ................41
see peg 3350-potassium
chloride-sod
bicarbonate-sod chloride
......................................41
see trilyte .......................41
NUPLAZID ........................29
nutrilipid inj 20% ................46
NUVARING .......................37
NUVIGIL............................32
see armodafinil ..............32
nyamyc .............................50
nyata .................................50
NYMALIZE ........................21
nystatin .............................11
nystatin (mouth-throat) ......52
nystatin (topical) ................50
nystop ...............................50
O
OCELLA TAB 3-0.03MG ...37
OCTAGAM ........................44
octreotide acetate .............39
OCUFEN
see flurbiprofen sodium .47
OCUFLOX
see ofloxacin (ophth) .....47
ODEFSEY .........................12
ODOMZO ..........................17
OFEV ................................49
ofloxacin (ophth) ...............47
ofloxacin (otic) ...................52
olanzapine.........................29
olmesartan
medoxomil-amlodipine-hydro
chlorothiazide ....................19
omega-3-acid ethyl esters .20
omeprazole cap 10mg ......42
omeprazole cap 20mg ......42
omeprazole cap 40mg ...... 42
ondansetron hcl ................ 40
ondansetron hcl inj ............ 40
ondansetron hcl oral soln .. 40
ondansetron odt ................ 40
ONFI SOLN ...................... 25
ONFI TAB ......................... 25
OPANA ER (CRUSH
RESISTANT) ...................... 9
OPSUMIT ......................... 23
ORAP
see pimozide ................. 29
ORFADIN.......................... 38
ORKAMBI ......................... 49
orsythia 28 day ................. 37
ORTHO MICRONOR
see errin 28 day ............ 36
see lyza ......................... 36
see sharobel 28 day ...... 37
ORTHO TRI-CYCLEN
see norgestimate-ethinyl
estradiol (triphasic) ........ 37
see tri-linyah .................. 37
see tri-previfem 28 day .. 37
see tri-sprintec 28 day ... 37
ORTHO TRI-CYCLEN LO
see norgestimate-ethinyl
estradiol (triphasic) ........ 37
see tri-lo marzia ............. 37
see tri-lo-estarylla .......... 37
see tri-lo-sprintec 28 day
...................................... 37
ORTHO-CYCLEN
see estarylla tab 0.25-35
...................................... 36
see femynor 28 day ....... 36
see mono-linyah tab
0.25-35 .......................... 37
see norgest/ethi tab
0.25/35 .......................... 37
see previfem 28 day ...... 37
see sprintec 28 day ....... 37
ORTHO-NOVUM 7/7/7
see cyclafem 7/7/7 28 day
...................................... 36
see nortrel 7/7/7 28 day. 37
oseltamivir phosphate ....... 12
OVCON-35
see balziva 28 day ........ 35
see briellyn 28 day ........ 36
see gildagia ................... 36
see philith ...................... 37
see vyfemla 28 day ....... 38
see zenchent 28 day ..... 38
OVIDE
see malathion ................ 51
oxacillin sodium ................ 14
oxaliplatin.......................... 17
OXANDRIN
see oxandrolone tab 10mg
...................................... 33
see oxandrolone tab
2.5mg ............................ 33
oxandrolone tab 10mg ...... 33
oxandrolone tab 2.5mg ..... 33
oxcarbazepine .................. 25
oxybutynin chloride ........... 42
oxycodone hcl ..................... 9
OXYCODONE HCL ............ 9
oxycodone w/
acetaminophen 10-325mg .. 9
oxycodone w/
acetaminophen 2.5-325mg . 9
oxycodone w/
acetaminophen 5-325mg .... 9
oxycodone w/
acetaminophen 7.5-325mg . 9
oxycodone w/
acetaminophen soln............ 9
OXYCONTIN ...................... 9
P
pacerone ........................... 19
paclitaxel........................... 15
PAMELOR
see nortriptyline hcl ....... 27
pamidronate disodium ...... 35
PANRETIN ....................... 51
pantoprazole sodium ........ 42
paricalcitol ......................... 47
PARLODEL
see bromocriptine
mesylate ........................ 28
PARNATE
see tranylcypromine
sulfate ........................... 27
paroex sol 0.12% .............. 52
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paromomycin sulfate ...........9
paroxetine hcl....................27
paser d/r ............................12
PATADAY .........................48
PAXIL ................................27
see paroxetine hcl .........27
PAZEO ..............................48
PEDIAPRED
see pred sod pho sol
5mg/5ml.........................39
PEDIARIX .........................45
PEDVAX HIB ....................45
PEG 3350/ELECTROLYTES
..........................................41
PEG 3350-KCL-SOD
BICARB-SOD
CHLORIDE-SOD SULFATE
..........................................41
peg 3350-potassium
chloride-sod bicarbonate-sod
chloride .............................41
PEGANONE......................25
PEGASYS .........................12
PEGASYS PROCLICK .....12
PENICILLIN G POT IN
DEXTROSE ......................14
penicillin g procaine ..........14
penicillin g sodium.............14
penicillin v potassium ........14
penicilln gk inj 20mu ..........14
penicilln gk inj 5mu ............14
PENTACEL .......................45
PENTAM 300 ....................10
pentoxifylline .....................43
PEPCID
see famotidine tab .........41
PERCOCET
see endocet .....................8
see oxycodone w/
acetaminophen 10-325mg
........................................9
see oxycodone w/
acetaminophen 2.5-325mg
........................................9
see oxycodone w/
acetaminophen 5-325mg .9
see oxycodone w/
acetaminophen 7.5-325mg
........................................ 9
PERIDEX
see chlorhexidine
gluconate (mouth-throat)
...................................... 52
see paroex sol 0.12% .... 52
see periogard ................ 52
perindopril erbumine ......... 18
periogard........................... 52
permethrin......................... 51
perphenazine .................... 29
pfizerpen-g ........................ 14
phenadoz .......................... 40
phenelzine sulfate ............. 27
phenergan......................... 40
PHENERGAN
see promethazine hcl .... 40
phenobarbital .................... 25
phenobarbital sodium........ 25
PHENOBARBITAL SODIUM
.......................................... 25
phenytek ........................... 25
PHENYTEK
see phenytoin sodium
extended ....................... 25
phenytoin .......................... 25
phenytoin sodium .............. 25
phenytoin sodium extended
.......................................... 25
philith ................................ 37
PHOSLO
see calcium acetate
(phosphate binder) ........ 39
PHOSPHOLINE IODIDE... 48
PILOCARPINE HCL.......... 48
pilocarpine hcl (oral).......... 52
PILOCARPINE HCL (ORAL)
.......................................... 52
pimozide ........................... 29
pimtrea pack ..................... 37
pindolol ............................. 21
pioglitazone hcl ................. 35
piperacillin
sodium-tazobactam sodium
.......................................... 14
piperacillin/tazobactam ..... 14
pirmella 1/35 28 day ......... 37
PLAN B ONE-STEP
see levonorgestrel
(emergency oc) ............. 36
PLAQUENIL
see hydroxychloroquine
sulfate ........................... 44
PLASMA-LYTE A.............. 47
PLASMA-LYTE-148 .......... 47
PLAVIX
see clopidogrel bisulfate 43
podofilox ........................... 51
polyethylene glycol 3350 .. 41
polymyxin b-trimethoprim.. 47
POLYTRIM
see polymyxin
b-trimethoprim ............... 47
POMALYST CAP 1MG ..... 44
POMALYST CAP 2MG ..... 44
POMALYST CAP 3MG ..... 44
POMALYST CAP 4MG ..... 44
portia 28 day ..................... 37
pot chloride inj 2meq/ml .... 47
potassium chloride ............ 45
POTASSIUM CHLORIDE 45,
47
potassium chloride in nacl 47
potassium chloride
microencapsulated crystals
cr....................................... 45
potassium citrate (alkalinizer)
.......................................... 42
POTASSIUM CITRATE
(ALKALINIZER) ................ 42
POTIGA ............................ 25
PRADAXA ........................ 43
PRALUENT ...................... 20
pramipexole tab 0.125mg . 28
pramipexole tab 0.25mg ... 28
pramipexole tab 0.5mg ..... 28
pramipexole tab 0.75mg ... 28
pramipexole tab 1.5mg ..... 28
pramipexole tab 1mg ........ 28
PRANDIN
see repaglinide .............. 35
PRAVACHOL
see pravastatin sodium . 20
pravastatin sodium............ 20
prazosin hcl ...................... 18
PRECOSE
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see acarbose .................33
pred sod pho sol 5mg/5ml .39
PREDNISOLONE ACETATE
(OPHTH) ...........................48
prednisolone sodium
phosphate (ophth) .............48
prednisolone sol 15mg/5ml
..........................................39
prednisolone sol 25mg/5ml
..........................................39
prednisolone syrup 15
mg/5ml ..............................39
prednisone con 5mg/ml .....39
prednisone pak 10mg .......39
prednisone pak 5mg .........39
prednisone sol 5mg/5ml ....39
prednisone tab 10mg ........39
prednisone tab 1mg ..........39
prednisone tab 2.5mg .......39
prednisone tab 20mg ........39
prednisone tab 50mg ........39
prednisone tab 5mg ..........39
premasol 10% ...................46
premasol 6% .....................46
prenatal vitamin/folic acid >
0.8 mg (generic) ................47
prevalite ............................20
previfem 28 day ................37
PREZCOBIX .....................12
PREZISTA ........................11
PRIFTIN ............................12
PRILOSEC
see omeprazole cap 20mg
......................................42
PRIMAQUINE PHOSPHATE
..........................................11
PRIMAXIN IV
see imipenem-cilastatin .10
primidone ..........................25
PRINIVIL
see lisinopril...................18
PRISTIQ............................27
see desvenlafaxine
succinate .......................26
PRIVIGEN .........................44
probenecid ..........................7
PROCALAMINE ................46
PROCARDIA XL
see nifedical xl ............... 21
see nifedipine ................ 21
prochlorperazine inj .......... 40
prochlorperazine maleate . 40
prochlorperazine supp ...... 40
PROCRIT.......................... 43
procto-med........................ 50
procto-pak ......................... 50
proctosol hc cre 2.5% ....... 50
proctozone hc ................... 50
PROGLYCEM SUS
50MG/ML .......................... 39
PROGRAF ........................ 44
see tacrolimus ............... 45
PROLASTIN-C.................. 49
PROLENSA ...................... 48
PROLEUKIN ..................... 16
PROLIA............................. 39
PROMACTA ..................... 43
promethazine hcl .............. 40
promethegan..................... 40
propafenone hcl ................ 19
propafenone hcl 12hr ........ 19
proparacaine hcl ............... 48
propranolol cap er ............. 21
propranolol hcl .................. 21
propranolol oral sol ........... 21
propylthiouracil .................. 40
PROQUAD........................ 45
PROSCAR
see finasteride ............... 42
PROSOL ........................... 46
PROTONIX
see pantoprazole sodium
...................................... 42
PROTOPIC
see tacrolimus (topical) . 51
protriptyline hcl .................. 27
PROVERA
see medroxyprogesterone
acetate tab .................... 40
PROZAC
see fluoxetine cap 10mg27
see fluoxetine cap 20mg27
see fluoxetine cap 40mg27
PULMICORT
see budesonide
(inhalation) .................... 49
PULMICORT FLEXHALER
.......................................... 49
PULMOZYME ................... 49
PURIXAN .......................... 15
pyrazinamide .................... 12
pyridostigmine tab 60mg ... 32
Q
QUADRACEL ................... 45
QUALAQUIN
see quinine sulfate ........ 11
quasense 91 day .............. 37
QUESTRAN
see cholestyramine ....... 20
QUESTRAN LIGHT
see cholestyramine light 20
see prevalite .................. 20
quetiapine fumarate .......... 29
quinapril hcl ...................... 18
quinapril-hydrochlorothiazide
.......................................... 18
quinidine gluconate ........... 19
quinidine sulfate ................ 19
quinine sulfate .................. 11
R
RABAVERT ...................... 45
raloxifene tab 60mg .......... 39
ramipril .............................. 18
RANEXA ........................... 22
ranitidine hcl ..................... 41
ranitidine hcl inj ................. 41
ranitidine syrup ................. 41
RAPAMUNE ..................... 44
see sirolimus ................. 45
RAVICTI ........................... 38
RAZADYNE
see galantamine
hydrobromide ................ 26
RAZADYNE ER
see galantamine
hydrobromide er ............ 26
REBETOL
see ribasphere .............. 13
see ribavirin cap 200mg 13
REBETOL SOL 40MG/ML 13
RECLAST
see zoledronic acid ....... 35
reclipsen 28 day................ 37
RECOMBIVAX HB ............ 45
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REGLAN
see metoclopramide hcl.40
REGRANEX ......................52
RELENZA DISKHALER ....13
RELISTOR ........................42
RELPAX ............................31
REMERON
see mirtazapine .............27
REMERON SOLTAB
see mirtazapine .............27
REMICADE INJ 100MG ....44
REMODULIN ....................23
RENVELA PAK 0.8GM .....39
RENVELA PAK 2.4GM .....39
RENVELA TAB 800MG ....39
repaglinide ........................35
REQUIP
see ropinirole tab 0.25mg
......................................28
see ropinirole tab 0.5mg 28
see ropinirole tab 1mg ...28
see ropinirole tab 2mg ...28
see ropinirole tab 3mg ...28
see ropinirole tab 4mg ...28
see ropinirole tab 5mg ...28
RESCRIPTOR ..................11
RESTASIS ........................48
RESTORIL
see temazepam .............31
RETIN-A
see tretinoin ...................50
RETROVIR
see zidovudine ..............12
RETROVIR IV INFUSION .11
REVATIO ..........................23
see sildenafil citrate
(pulmonary hypertension)
......................................23
REVLIMID .........................44
REXULTI ...........................29
REYATAZ .........................11
ribasphere .........................13
ribavirin cap 200mg ...........13
ribavirin tab 200mg ...........13
rifabutin .............................12
RIFADIN
see rifampin ...................12
rifampin .............................12
RIFATER .......................... 12
RILUTEK
see riluzole .................... 32
riluzole .............................. 32
rimantadine hydrochloride. 13
RINGER'S ......................... 47
RISPERDAL
see risperidone .............. 30
RISPERDAL INJ 12.5MG . 29
RISPERDAL INJ 25MG .... 30
RISPERDAL INJ 37.5MG . 30
RISPERDAL INJ 50MG .... 30
RISPERDAL M-TAB
see risperidone .............. 30
risperidone ........................ 30
RITALIN
see methylphenidate hcl 31
RITUXAN .......................... 16
rivastigmine tartrate .......... 26
rizatriptan benzoate .......... 31
ROBINUL
see glycopyrrolate ......... 41
ROBINUL FORTE
see glycopyrrolate ......... 41
ROCALTROL
see calcitriol .................. 47
see calcitriol oral soln 1
mcg/ml ........................... 47
ROCEPHIN
see ceftriaxone sodium . 13
ropinirole tab 0.25mg ........ 28
ropinirole tab 0.5mg .......... 28
ropinirole tab 1mg ............. 28
ropinirole tab 2mg ............. 28
ropinirole tab 3mg ............. 28
ropinirole tab 4mg ............. 28
ropinirole tab 5mg ............. 28
rosadan cre 0.75% ............ 51
rosuvastatin calcium ......... 20
ROTARIX .......................... 45
ROTATEQ ........................ 45
ROWASA
see mesalamine w/
cleanser......................... 41
roweepra ........................... 25
ROXICODONE
see oxycodone hcl........... 9
RUBRACA ........................ 16
RYTHMOL SR
see propafenone hcl 12hr
...................................... 19
S
SABRIL ............................. 25
SALAGEN
see pilocarpine hcl (oral)
...................................... 52
SANDIMMUNE ................. 45
see cyclosporine ........... 44
SANDOSTATIN
see octreotide acetate ... 39
SANDOSTATIN LAR
DEPOT ............................. 39
SANTYL............................ 52
SAPHRIS .......................... 30
selegiline hcl ..................... 28
selenium sulfide ................ 50
SELZENTRY .................... 11
SENSIPAR ....................... 35
SEREVENT DISKUS ........ 49
SEROQUEL
see quetiapine fumarate 29
SEROQUEL XR ................ 30
sertraline hcl ..................... 27
setlakin tab ....................... 37
sharobel 28 day ................ 37
SIGNIFOR ........................ 39
sildenafil citrate (pulmonary
hypertension) .................... 23
SILENOR .......................... 31
SILVER SULFADIAZINE .. 50
SIMBRINZA ...................... 48
simvastatin ........................ 20
SINEMET
see carbidopa-levodopa 28
SINEMET CR
see carbidopa-levodopa 28
SINGULAIR
see montelukast sodium 49
sirolimus ........................... 45
SIRTURO ......................... 12
SIVEXTRO ....................... 10
SOD CHLORIDE INJ 0.9%
.......................................... 47
SODIUM CHLORIDE .. 45, 47
SODIUM CHLORIDE 0.45%
VIA .................................... 47
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SODIUM CHLORIDE 0.9%
..........................................52
sodium fluoride chew; tab;
1.1 (0.5 f) mg/ml soln ........46
sodium phenylbutyrate ......38
sodium polystyrene sulfonate
..........................................35
SOLTAMOX ......................16
SOLU-CORTEF ................39
SOLU-MEDROL
see methylpr ss inj 125 mg
......................................39
see methylpr ss inj 1gm .38
see methylpr ss inj 40mg
......................................38
SOMATULINE DEPOT .....39
SOMAVERT ......................39
SORIATANE
see acitretin ...................50
sorine ..........................19, 20
sotalol hcl ..........................20
sotalol hcl (afib/afl) ............20
SOVALDI ..........................13
spironolactone...................18
spironolactone &
hydrochlorothiazide ...........22
SPORANOX
see itraconazole ............11
sprintec 28 day..................37
SPRITAM ..........................25
SPRYCEL .........................17
sps ....................................35
sronyx 28 day....................37
SSD ..................................50
STARLIX
see nateglinide ..............35
stavudine...........................11
STERILE WATER
IRRIGATION .....................52
STIMATE ..........................40
STIVARGA ........................17
STRATTERA.....................31
streptomycin sulfate ............9
STRIBILD ..........................12
STROMECTOL
see ivermectin ...............10
SUBOXONE MIS 12-3MG 33
SUBOXONE MIS 2-0.5MG
.......................................... 33
SUBOXONE MIS 4-1MG .. 33
SUBOXONE MIS 8-2MG .. 33
SUCRAID.......................... 42
sucralfate .......................... 42
sulfacet sod oin 10% op .... 47
sulfacetamide sodium (acne)
.......................................... 50
sulfacetamide sodium
(ophth) .............................. 47
sulfacetamide
sod-prednisolone .............. 47
sulfadiazine ....................... 10
sulfamethoxazole-trimethop
ds ...................................... 10
sulfamethoxazole-trimethopri
m inj .................................. 10
sulfamethoxazole-trimethopri
m susp .............................. 10
sulfamethoxazole-trimethopri
m tab ................................. 10
SULFAMYLON ................. 50
sulfasalazine ..................... 41
sulfasalazine ec ................ 41
sulindac............................... 7
SUMATRIPTAN INJ
4MG/0.5ML ....................... 31
sumatriptan inj 6mg/0.5ml 31,
32
SUMATRIPTAN NASAL
SPRAY.............................. 32
sumatriptan succinate ....... 32
suprax ............................... 13
SUPRAX ........................... 13
see cefixime .................. 13
SUPREP BOWEL PREP .. 41
SURMONTIL
see trimipramine maleate
...................................... 27
SUSTIVA .......................... 11
SUTENT ........................... 17
syeda ................................ 37
SYLATRON KIT 200MCG. 17
SYLATRON KIT 300MCG. 17
SYLATRON KIT 600MCG. 17
SYMBICORT .................... 50
SYMLINPEN 120 .............. 33
SYMLINPEN 60 ................ 33
SYNAGIS .......................... 45
SYNALAR
see fluocinolone acetonide
...................................... 51
SYNAREL ......................... 38
SYNERCID ....................... 10
SYNRIBO ......................... 17
SYNTHROID .................... 40
see levothyroxine sodium
...................................... 40
SYPRINE .......................... 35
T
TABLOID .......................... 15
tacrolimus ......................... 45
tacrolimus (topical)............ 51
TAFINLAR ........................ 17
TAGRISSO ....................... 17
TAMIFLU .......................... 13
see oseltamivir phosphate
...................................... 12
tamoxifen citrate ............... 16
tamsulosin hcl ................... 42
TAPAZOLE
see methimazole ........... 40
TARCEVA ......................... 17
TARGRETIN ..................... 51
see bexarotene ............. 17
tarina fe 1/20 28 day ......... 37
TASIGNA .......................... 17
TAXOTERE ...................... 15
see docetaxel ................ 15
tazicef ............................... 13
tazicef vial ......................... 13
TAZORAC ........................ 50
taztia ................................. 21
TECENTRIQ ..................... 16
TEFLARO ......................... 13
TEGRETOL ...................... 25
see carbamazepine ....... 23
see epitol ....................... 24
TEGRETOL-XR ................ 25
see carbamazepine ....... 23
temazepam ....................... 31
TENIVAC .......................... 45
TENORETIC 100
see atenolol &
chlorthalidone ................ 20
TENORETIC 50
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2017 SSI Choice 17255 v11 eff 05/01/2017
see atenolol &
chlorthalidone ................20
TENORMIN
see atenolol ...................20
TERAZOL 7
see terconazole vaginal .43
terazosin hcl ......................18
terbinafine hcl....................11
terbutaline sulfate ..............49
terconazole vaginal ...........43
testosterone cypionate ......33
testosterone enanthate .....33
TETANUS/DIPHTHERIA
TOXOID ............................45
TETRABENAZINE ............32
THALOMID .......................44
theophylline .......................50
thioridazine hcl ..................30
thiothixene.........................30
tiagabine hcl ......................25
TIAZAC
see diltiazem hcl extended
release beads cap sr .....21
see taztia .......................21
TIGECYCLINE ..................10
TILIA FE ............................37
timolol maleate ..................21
timolol maleate (ophth) soln
..........................................48
TIMOLOL MALEATE GEL 48
TIMOPTIC
see timolol maleate
(ophth) soln ...................48
TIVICAY ......................11, 12
tizanidine hcl .....................32
TOBRADEX ......................47
see
tobramycin-dexamethason
e ....................................47
TOBRADEX ST.................47
tobramycin ........................10
tobramycin (ophth) ............47
tobramycin inj 1.2 gm/30ml
..........................................10
tobramycin inj 1.2gm .........10
tobramycin inj 10mg/ml .....10
tobramycin inj 40mg/ml .....10
tobramycin inj 80mg/2ml ...10
tobramycin-dexamethasone
.......................................... 47
TOBREX ........................... 47
see tobramycin (ophth).. 47
TOFRANIL
see imipramine hcl ........ 27
tolterodine tartrate cap er .. 42
tolterodine tartrate tabs ..... 42
TOPAMAX
see topiramate .............. 25
TOPAMAX SPRINKLE
see topiramate .............. 25
topiramate ......................... 25
toposar .............................. 18
topotecan hcl .................... 18
TOPOTECAN HCL ........... 18
TOPROL XL
see metoprolol succinate
...................................... 20
torsemide tabs .................. 22
TOUJEO SOLOSTAR ....... 33
TOVIAZ ............................. 42
TPN ELECTROLYTES ..... 46
TRACLEER....................... 23
TRADJENTA..................... 35
tramadol hcl ........................ 7
tramadol-acetaminophen .... 7
trandolapril ........................ 18
tranexamic acid ................. 43
TRANSDERM-SCOP ........ 40
TRANXENE T
see clorazepate
dipotassium ................... 24
tranylcypromine sulfate ..... 27
TRAVASOL....................... 46
TRAVATAN Z ................... 48
trazodone hcl .................... 27
TREANDA......................... 15
TRECATOR ...................... 12
TRELSTAR DEP INJ
3.75MG ............................. 16
TRELSTAR LA INJ 11.25MG
.......................................... 16
TRESIBA FLEXTOUCH .... 33
tretinoin ............................. 50
TRETINOIN ...................... 50
tretinoin (chemotherapy) ... 17
triamcinolone acetonide
(mouth) ............................. 52
triamcinolone acetonide
(topical) ............................. 51
triamterene &
hydrochlorothiazide........... 22
triamterene &
hydrochlorothiazide cap
37.5-25 mg ....................... 22
TRIBENZOR
see olmesartan
medoxomil-amlodipine-hyd
rochlorothiazide ............. 19
TRICOR
see fenofibrate .............. 20
triderm .............................. 51
trifluoperazine hcl.............. 30
trifluridine .......................... 47
tri-legest 28 day ................ 37
TRILEPTAL
see oxcarbazepine ........ 25
tri-linyah ............................ 37
tri-lo marzia ....................... 37
tri-lo-estarylla .................... 37
tri-lo-sprintec 28 day ......... 37
trilyte ................................. 41
trimethoprim ...................... 10
trimipramine maleate ........ 27
TRINESSA ........................ 37
TRINESSA LO TAB .......... 37
TRI-NORINYL 28
see aranelle 28.............. 35
TRINTELLIX ..................... 27
tri-previfem 28 day ............ 37
TRISENOX ....................... 17
tri-sprintec 28 day ............. 37
TRIUMEQ ......................... 12
trivora 28 day .................... 37
TRIZIVIR
see abacavir
sulfate-lamivudine-zidovud
ine ................................. 12
TROPHAMINE INJ 10% ... 46
trospium chloride .............. 42
TRULICITY ....................... 33
TRUMENBA ..................... 45
TRUSOPT
see dorzolamide hcl ...... 48
TRUVADA TAB 100-150 .. 12
75
2017 SSI Choice 17255 v11 eff 05/01/2017
TRUVADA TAB 133-200 ...12
TRUVADA TAB 167-250 ...12
TRUVADA TAB 200-300 ...12
TWINRIX INJ ....................45
TYBOST............................12
TYGACIL...........................10
TYKERB............................17
TYLENOL/CODEINE #3
see acetaminophen w/
codeine ............................7
TYLENOL/CODEINE #4
see acetaminophen w/
codeine ............................7
TYPHIM VI ........................45
TYSABRI...........................32
TYZEKA ............................13
U
ULORIC ..............................7
ULTRACET
see
tramadol-acetaminophen .7
ULTRAM
see tramadol hcl ..............7
ULTRAVATE
see halobetasol
propionate .....................51
UNASYN
see ampicillin & sulbactam
sodium ...........................14
UNASYN BULK PACK
see ampicillin & sulbactam
sodium ...........................14
UPTRAVI ..........................23
URECHOLINE
see bethanechol chloride
......................................42
UROCIT-K 15
see potassium citrate
(alkalinizer) ....................42
UROXATRAL
see alfuzosin hcl ............42
URSO 250
see ursodiol ...................42
URSO FORTE
see ursodiol ...................42
ursodiol .............................42
V
VAGIFEM ..........................38
valacyclovir hcl .................. 13
VALCHLOR ...................... 51
VALCYTE ......................... 13
see valganciclovir hcl .... 13
valganciclovir hcl ............... 13
VALIUM
see diazepam ................ 24
valproate sodium .............. 25
valproic acid ...................... 25
valsartan ........................... 19
valsartan & hctz tab
160-12.5mg....................... 19
valsartan & hctz tab
160-25mg.......................... 19
valsartan & hctz tab
320-12.5mg....................... 19
valsartan & hctz tab
320-25mg.......................... 19
valsartan & hctz tab
80-12.5mg......................... 19
VALTREX
see valacyclovir hcl ....... 13
VANCOCIN HCL
see vancomycin hcl ....... 10
vancomycin hcl ........... 10, 11
VANCOMYCIN IN NACL .. 11
VANDAZOLE .................... 43
VAQTA.............................. 45
VARIVAX .......................... 45
VASCEPA ......................... 20
VASERETIC
see enalapril maleate &
hydrochlorothiazide ....... 18
VASOTEC
see enalapril maleate .... 18
VELCADE ......................... 16
velivet 28 day .................... 37
VEMLIDY .......................... 13
VENCLEXTA .................... 16
VENCLEXTA STARTING
PACK ................................ 16
venlafaxine hcl .................. 27
VENTAVIS ........................ 23
VENTOLIN HFA ................ 49
verapamil cap er ............... 21
VERAPAMIL CAP ER ....... 21
verapamil hcl ..................... 21
verapamil tab er ................ 21
VERELAN
see verapamil cap er ..... 21
VERELAN PM
see verapamil cap er ..... 21
VERSACLOZ .................... 30
VESICARE ....................... 42
vestura .............................. 37
VFEND
see voriconazole ........... 11
VFEND IV
see voriconazole ........... 11
VIBRAMYCIN
see doxycycline hyclate 14
VICTOZA .......................... 33
VIDAZA
see azacitidine .............. 15
VIDEX EC
see didanosine .............. 11
VIDEX PEDIATRIC ........... 12
vienva 28 day ................... 37
VIGAMOX ......................... 47
VIIBRYD STARTER PACK
.......................................... 27
VIIBRYD TAB ................... 27
VIMPAT ............................ 25
vinblastine sulfate ............. 15
vincasar ............................ 15
vincristine sulfate .............. 15
vinorelbine tartrate ............ 15
viorele ............................... 38
VIRACEPT ........................ 12
VIRAMUNE
see nevirapine tab 200mg
...................................... 11
VIRAMUNE XR
see nevirapine tab 100mg
...................................... 11
see nevirapine tb24 ....... 11
VIREAD ............................ 12
VIROPTIC
see trifluridine ................ 47
VISTARIL
see hydroxyzine pamoate
...................................... 49
VOLTAREN GEL 1% ........ 51
voriconazole ..................... 11
VOTRIENT ....................... 17
VRAYLAR ......................... 30
76
2017 SSI Choice 17255 v11 eff 05/01/2017
VRAYLAR THERAPY PACK
..........................................30
vyfemla 28 day ..................38
W
warfarin sodium.................43
WELCHOL ........................20
WELLBUTRIN SR
see bupropion hcl ..........26
WELLBUTRIN XL
see bupropion hcl ..........26
X
XALATAN
see latanoprost ..............48
XALKORI ..........................17
XANAX
see alprazolam tab
0.25mg ..........................23
see alprazolam tab 0.5mg
......................................23
see alprazolam tab 1mg 23
see alprazolam tab 2 mg
......................................23
XARELTO .........................43
XARELTO STARTER PACK
..........................................43
XELJANZ ..........................44
XELJANZ XR ....................44
XGEVA .............................39
XIFAXAN...........................42
XIGDUO XR TAB
10-1000MG .......................35
XIGDUO XR TAB 10-500MG
..........................................35
XIGDUO XR TAB 5-1000MG
..........................................35
XIGDUO XR TAB 5-500MG
..........................................35
XOLAIR .............................49
XOPENEX HFA ................49
XTANDI .............................16
xulane ...............................38
XYLOCAINE
see lidocaine hcl ............51
see lidocaine hcl (local
anesth.) ...........................9
see lidocaine inj 1% .........9
see lidocaine inj 2% .........9
XYLOCAINE-MPF
see lidocaine hcl (local
anesth.) ........................... 9
see lidocaine inj 0.5%...... 9
see lidocaine inj 1.5%...... 9
XYREM ............................. 32
XYZAL
see levocetirizine
dihydrochloride .............. 49
Y
YASMIN 28
see drospirenone-ethinyl
estradiol......................... 36
see syeda ...................... 37
see zarah ...................... 38
YAZ
see drospirenone-ethinyl
estradiol......................... 36
see loryna 28 day .......... 36
see nikki 28 day ............ 37
see vestura.................... 37
YERVOY ........................... 16
YF-VAX ............................. 45
Z
zafirlukast.......................... 49
ZANAFLEX
see tizanidine hcl ........... 32
ZANTAC
see ranitidine hcl ........... 41
see ranitidine hcl inj ....... 41
zarah ................................. 38
ZARONTIN
see ethosuximide .......... 24
ZAVESCA ......................... 38
ZAZOLE CREAM 0.8% ..... 43
ZEBETA
see bisoprolol fumarate . 20
ZELBORAF ....................... 17
ZEMAIRA .......................... 49
ZEMPLAR
see paricalcitol .............. 47
zenatane ........................... 50
zenchent 28 day ............... 38
ZENPEP ........................... 42
ZEPATIER ........................ 13
ZERIT ............................... 12
see stavudine ................ 11
ZESTORETIC
see lisinopril &
hydrochlorothiazide ....... 18
ZESTRIL
see lisinopril .................. 18
ZETIA ............................... 20
ZIAC
see bisoprolol &
hydrochlorothiazide ....... 20
ZIAGEN ............................ 12
see abacavir sulfate ...... 11
zidovudine ........................ 12
ZINACEF
see cefuroxime sodium . 13
ZINECARD
see dexrazoxane ........... 17
ziprasidone hcl .................. 30
ZIRGAN ............................ 47
ZITHROMAX
see azithromycin ........... 13
ZOCOR
see simvastatin ............. 20
ZOFRAN
see ondansetron hcl ...... 40
see ondansetron hcl oral
soln ............................... 40
ZOFRAN ODT
see ondansetron odt ..... 40
zoledronic acid .................. 35
zoledronic inj 4mg/5ml ...... 35
ZOLINZA .......................... 16
zolmitriptan ....................... 32
zolmitriptan odt ................. 32
ZOLOFT
see sertraline hcl ........... 27
zolpidem tartrate ............... 31
ZOMETA
see zoledronic inj 4mg/5ml
...................................... 35
ZOMIG
see zolmitriptan ............. 32
ZOMIG ZMT
see zolmitriptan odt ....... 32
ZONEGRAN
see zonisamide ............. 25
zonisamide ....................... 25
ZONTIVITY ....................... 43
ZORTRESS TAB 0.25MG 45
ZORTRESS TAB 0.5MG .. 45
ZORTRESS TAB 0.75MG 45
77
2017 SSI Choice 17255 v11 eff 05/01/2017
ZOSTAVAX .......................45
ZOSYN
see piperacillin
sodium-tazobactam
sodium ...........................14
zovia 1/35e 28 day ............38
zovia 1/50e 28 day ............38
ZOVIRAX
see acyclovir..................12
ZYBAN
see buproban tab 150mg
...................................... 33
see bupropion hcl
(smoking deterrent) ....... 33
ZYDELIG .......................... 17
ZYKADIA .......................... 17
ZYLET............................... 47
ZYLOPRIM
see allopurinol tab ........... 7
ZYMAXID
see gatifloxacin (ophth) . 47
ZYPREXA
see olanzapine .............. 29
ZYPREXA RELPREVV ..... 30
ZYPREXA RELPREVV
210MG .............................. 30
ZYPREXA ZYDIS
see olanzapine .............. 29
ZYTIGA............................. 16
ZYVOX
see linezolid .................. 10
78
P.O. Box 52424 Phoenix, AZ 85072-2424
This formulary was updated on May 1, 2017. For more recent information or other questions, please
contact SilverScript at 1-866-235-5660 or, for TTY users, 711, 24 hours a day, 7 days a week, or
visit www.silverscript.com.
The Formulary may change at any time. You will receive notice when necessary.
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or
copayments/coinsurance may change on January 1 of each year.
This information is available for free in other languages. Please call our Customer Care number
at 1-866-235-5660 (TTY: 711), 24 hours a day, 7 days a week. Esta información está disponible
gratuitamente en otros idiomas. Llame a nuestro Cuidado al Cliente al 1-866-235-5660 (teléfono
de texto (TTY): 711), las 24 horas del día, los 7 días de la semana.
SilverScript is a Prescription Drug Plan with a Medicare contract offered by SilverScript
Insurance Company. Enrollment in SilverScript depends on contract renewal.