2017 Kaiser Permanente Federal Employees Health enefit...

All drug product strengths, formulations, and package sizes &/or types of a formulary drug may not be included on the formulary,

check with your Kaiser Permanente pharmacist for clarification, if needed.

2017 Kaiser Permanente Federal Employees Health Benefit Formulary Page 1 (Colorado Region - March 2017)

2017 Kaiser Permanente Federal Employees Health Benefit (FEHB) Drug Formulary Colorado Region

This document contains information about the drugs we cover when you participate in a Federal Employees

Health Benefits (FEHB) plan offered by Kaiser Permanente.

This formulary is effective January 1, 2017.

What is the Kaiser Permanente FEHB Drug Formulary?

A formulary is a list of drugs determined to be safe and effective for our members by our Pharmacy and

Therapeutics Committee. Use of formulary drugs enables Kaiser Permanente to provide high quality care to

you and your family at reasonable costs. Kaiser Permanente continually updates the formulary throughout the

year based on new medical evidence, considering the recommendations of appropriate physician experts.

How much will I pay for covered drugs?

The cost-sharing you will pay for most drugs depends on:

the tier in which your drug is categorized, and

whether your drug is included in our formulary. Preferred drugs are included in our formulary. Non-

preferred drugs are not included in our formulary.

We categorize prescription drugs into four tiers:

Drug Tier

Type Description

Tier 1 Preferred generic drugs

Generic drugs are produced and sold under their generic names

after the patent on the brand-name drug expires. Although the price is usually lower, the quality of generic drugs is the same as brand-name drugs. Generic drugs are also just as effective as brand-name

drugs. The U.S. Food and Drug Administration (FDA) requires that a generic drug contain the same active drug ingredient in the same amount as the brand-name drug. Preferred generic drugs are listed on our drug formulary.

Tier 2 Preferred brand-name drugs

Brand-name drugs are produced and sold under the original manufacturer's brand name. Preferred brand-name drugs are listed on our drug formulary.

Tier 3 Non-preferred generic and brand-name drugs

Non-preferred generic and brand-name drugs are not listed on our drug formulary.




Drug Tier

Type Description

Tier 4 Specialty drugs Specialty drugs are high-cost drugs that are on our specialty drug list. Kaiser Permanente adopts the model used by most Medicare plans to determine which drugs are in the specialty tier.

The amount you pay and other coverage information is determined by the outpatient prescription drug

benefit in your FEHB brochure (RI 73-019, See Section 5(f) Prescription drug benefits).

Some drugs may be covered at no cost or a different cost-sharing amount. Examples of these include tobacco

cessation medications, women’s contraceptive drugs and devices at no cost; fertility drugs and sexual

dysfunction drugs have different cost-sharing amounts. Cost-sharing for these drugs is listed in your FEHB

brochure.

All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure. To get a

copy of your FEHB brochure or if you have questions, please visit our website at kp.org/feds or call Member

Services at 1-800-632-9700 for Denver/Boulder, Mountain Colorado or Northern Colorado, or 1-888-681-7878

for Southern Colorado (TTY 1-800-521-4874), Monday through Friday, 8 a.m. to 5 p.m.

How do I use the FEHB Drug Formulary?

Our formulary drugs are listed in this formulary by medical condition and alphabetically. We consider drugs

not listed on our formulary to be “non-preferred drugs”. You may pay higher cost-sharing for non-formulary

drugs that are medically necessary.

The cost-sharing you pay and other coverage information is determined by the outpatient prescription drug

benefit in your FEHB brochure (RI 73-019, See Section 5(f) Prescription drug benefits).

Formulary Drugs by Medical Condition

The formulary begins on page 4. The drugs in this formulary are grouped into categories depending on the

type of medical condition that they are used to treat. For example, drugs used to treat a heart condition are

listed under the category, “Cardiovascular Agents.” If you know the medical condition your drug is used for,

simply look for the category name in the list. Then look under the category name for your drug.

Formulary Drugs by Alphabetical Listing

If you are not sure what category to look under, the Index starting on page 18, provides an alphabetical list of

all of the drugs included in this document. Both brand-name drugs and generic drugs are listed. Look in the

Index to find the drug name and the page number where you can locate coverage information. Turn to the

page listed in the Index and find the name of the drug on the list. If you are using a computer to view this

document, you also use the search function (Ctrl F) to find the medication by name.

Columns on Medical Condition and Alphabetical Listings

There are three columns in the attached chart.

https://healthplans.kaiserpermanente.org/federalemployees/




The first column lists the drug name. Brand-name drugs are capitalized (e.g. ALBENZA) and generic drugs

are listed in lower-case italics (e.g. amoxicillin). Some drugs include different dosage forms and strengths.

All dosage forms and strengths for a particular drug listed may not be on the Formulary. Some drugs have

multiple dosage forms. In such cases, some dosages may be on the Formulary and others not. Some of

these drugs may be available only in a clinic setting.

The second column indicates drug tier. Some drugs may have more than one tier listed in this column. This

means that the amount you pay may vary based on the dosage or the way the drug is administered. You

will find cost-sharing for your drug in your FEHB brochure. To get a copy of your FEHB brochure or if you

have questions, please visit our website at kp.org/feds or call Member Services at 1-800-632-9700 for

Denver/Boulder or Northern Colorado, or 1-888-681-7878 for Southern Colorado (TTY 1-800-521-4874),

Monday through Friday, 8 a.m. to 5 p.m.

The third column indicates additional requirements or limits on coverage. These requirements and limits may

include:

PA = Prior Authorization. You need to get approval from Kaiser Permanente to fill your

prescription. If you don’t get approval, we may not cover the drug.

QL = Quantity Limit. For certain drugs, we may limit the amount of the drug you can receive.

Additionally, when there is a national shortage of a drug, we may limit the quantity of

the drug dispensed.

MO = Mail Order. A drug that is considered to be a maintenance medication and is available

at an extended day supply through our mail order pharmacy.

RB = Restricted Benefit. A drug that is restricted to a certain benefit for coverage.

Does the FEHB Drug Formulary ever change?

Yes, Kaiser Permanente continually updates the formulary based on new medical evidence, considering the

recommendations of appropriate physician experts and notifies our doctors, pharmacists, and other clinicians

about any changes. If a change in the formulary affects any of your prescriptions, your doctor or pharmacist

will let you know.

Our online formulary at kp.org/formulary is updated on a regular basis. To get updated information about the

drugs covered by Kaiser Permanente or if you have questions, please visit our website at kp.org/feds or call

Member Services at 1-800-632-9700 for Denver/Boulder, Mountain Colorado or Northern Colorado, or 1-888-

681-7878 for Southern Colorado (TTY 1-800-521-4874), Monday through Friday, 8 a.m. to 5 p.m.


https://www.kaiserpermanente.org/formulary





Formulary Drugs by Medical Condition

Name of drug

What the drug will cost you

(tier level)

Necessary actions,

restrictions, or limits on

use

ANTI-INFECTIVE AGENTS

ANTHELMINTICS

ALBENZA 2

BILTRICIDE 2

ANTIBACTERIALS

amoxicillin 1, 2

amoxicillin & pot clavulanate 1, 2

ampicillin 1, 2

ampicillin & sulbactam sodium 1, 2

ampicillin sodium 1

AVELOX 2

azithromycin 1, 2 MO

aztreonam 1

BACTOCILL IN DEXTROSE 2

BICILLIN L-A 2

CAYSTON 4 LD

cefazolin sodium 1, 2

cefdinir 1

cefepime hcl 1, 2

cefixime 1, 2

cefotaxime sodium 1, 2

cefotetan disodium 1

CEFOTETAN DISODIUM-

DEXTROSE 2

ceftazidime 1

ceftriaxone sodium 1

CEFTRIAXONE SODIUM IN

DEXTROSE 2

cefuroxime axetil 1, 2

cefuroxime sodium 1, 2

cephalexin 1

ciprofloxacin 1, 2

ciprofloxacin hcl 1, 2

ciprofloxacin in d5w 1

clarithromycin 1

clindamycin hcl 1

clindamycin palmitate hydrochloride

1

clindamycin phosphate 1, 2

dicloxacillin sodium 1

doxycycline (monohydrate) 1 MO

Name of drug


(tier level)

Necessary actions,


use

doxycycline hyclate 1 MO

E.E.S. 400 2

ERYTHROCIN LACTOBIONATE 2

erythromycin base 1, 2

gentamicin sulfate 1

imipenem-cilastatin 1, 2

INVANZ 2

levofloxacin 1

levofloxacin in d5w 1

linezolid 1, 4 QL

minocycline hcl 1 MO

moxifloxacin hcl 1

neomycin sulfate 1

penicillin g potassium 1

PENICILLIN G PROCAINE 2

PENICILLIN G SODIUM 2

penicillin v potassium 1

piperacillin sodium-tazobactam sodium

1

PRIMSOL 2

STREPTOMYCIN SULFATE 2

sulfamethoxazole-trimethoprim 1, 2 MO

sulfasalazine 1 MO

tetracycline hcl 1, 2

tobramycin 1, 4 QL

TOBRAMYCIN SULFATE 2

vancomycin hcl 1 QL

VANCOMYCIN HCL IN DEXTROSE

2

ZOSYN 2

ANTIFUNGALS

AMBISOME 4

AMPHOTERICIN B 2

CANCIDAS 4

fluconazole 1

fluconazole in nacl 1

flucytosine 1, 4 QL

griseofulvin microsize 1

griseofulvin ultramicrosize 1

ketoconazole 1 PA

nystatin 1




Name of drug


(tier level)

Necessary actions,


use

nystatin (mouth-throat) 1

voriconazole 1, 2

ANTIMYCOBACTERIALS

atovaquone-proguanil hcl 1

dapsone 1 MO

ethambutol hcl 1

isoniazid 1, 2

pyrazinamide 1

rifampin 1

ANTIPROTOZOALS

chloroquine phosphate 1

DARAPRIM 2

hydroxychloroquine sulfate 1 MO

mefloquine hcl 1

MEPRON 4 QL

METRO 2

metronidazole 1

NEBUPENT 2 MO

paromomycin sulfate 1

PRIMAQUINE PHOSPHATE 2

ANTIVIRALS

abacavir sulfate 1, 2 MO

abacavir sulfate-lamivudine 1 MO

acyclovir 1 MO

acyclovir sodium 1, 2

adefovir dipivoxil 1 QL

amantadine hcl 1 MO

APTIVUS 2 MO

ATRIPLA 2 MO

COMPLERA 2 MO

CRIXIVAN 2 MO

CYTOVENE 2

DESCOVY 2 MO

didanosine 1, 2 MO

EDURANT 2 MO

EMTRIVA 2 MO

entecavir 1 MO

EPCLUSA 4 PA, QL

famciclovir 1 MO

FOSCAVIR 2

GENVOYA 2 MO

HARVONI 4 QL

INTELENCE 2 MO

INVIRASE 2 MO

Name of drug


(tier level)

Necessary actions,


use

ISENTRESS 2 MO

lamivudine 1, 2 MO

lamivudine (hbv) 1, 2 MO

lamivudine-zidovudine 1 MO

LEXIVA 2 MO

lopinavir-ritonavir 1, 2 MO

nevirapine 1, 2 MO

NORVIR 2 MO

ODEFSEY 2 MO

PEGASYS 4 QL

PREZISTA 2 MO

RESCRIPTOR 2 MO

REYATAZ 2 MO

ribavirin (hepatitis c) 1 QL

rimantadine hydrochloride 1

SELZENTRY 2 MO

SOVALDI 4 QL

stavudine 1 MO

STRIBILD 2 MO

SUSTIVA 2 MO

SYNAGIS 4

TAMIFLU 2

TIVICAY 2 MO

TRIZIVIR 2 MO

TRUVADA 2 MO

valganciclovir hcl 1 QL

VIRACEPT 2 MO

VIREAD 2 MO

zidovudine 1 MO

URINARY ANTI-INFECTIVES

methenamine hippurate 1

methenamine mandelate 1, 2

nitrofurantoin 1

nitrofurantoin macrocrystal 1

nitrofurantoin monohyd macro 1

trimethoprim 1

UROQID #2 2

ANTIHISTAMINE DRUGS

ANTIHISTAMINE DRUGS

cyproheptadine hcl 1

diphenhydramine hcl 1

promethazine hcl 1

ANTINEOPLASTIC AGENTS

ANTINEOPLASTIC AGENTS




Name of drug


(tier level)

Necessary actions,


use

ABRAXANE 2

AFINITOR 4 QL

ALKERAN 2

anastrozole 1 MO

AVASTIN 2

azacitidine 1

BICNU 2

bleomycin sulfate 1

capecitabine 1 MO

carboplatin 1, 2

cisplatin 1

COSMEGEN 2

cyclophosphamide 1, 2

cytarabine 1, 2

dacarbazine 1, 2

daunorubicin hcl 1, 2

DOCETAXEL 2

doxorubicin hcl 1, 2

EMCYT 2 QL

ERBITUX 2

etoposide 1, 2

exemestane 1 MO

fludarabine phosphate 1

fluorouracil 1

flutamide 1 MO

gemcitabine hcl 1

GLEOSTINE 2

HERCEPTIN 2

HEXALEN 4

hydroxyurea 1 MO

idarubicin hcl 1

ifosfamide 1, 2

IFOSFAMIDE-MESNA 2

imatinib mesylate 1 QL

IMBRUVICA 4 QL

INTRON A 4 QL

IRESSA 4 QL

letrozole 1 MO

LEUKERAN 2

leuprolide acetate 1, 2 PA

LUPRON DEPOT 2 PA

LUPRON DEPOT-PED 2 PA

LYSODREN 2 QL

MATULANE 4 QL, LD

Name of drug


(tier level)

Necessary actions,


use

megestrol acetate 1 MO

melphalan hcl 1

mercaptopurine 1, 4 QL, MO

methotrexate sodium 1, 2 MO

mitomycin 1, 2

mitoxantrone hcl 1 MO

MUSTARGEN 2

MYLERAN 2

NEXAVAR 4 QL

NIPENT 2

paclitaxel 1

REVLIMID 4 QL, LD

RITUXAN 2

SPRYCEL 4 QL

SUTENT 4 QL

TABLOID 2 MO

tamoxifen citrate 1 MO

TARCEVA 4 QL

TASIGNA 4 QL

temozolomide 1 QL

THIOTEPA 2

topotecan hcl 1

TORISEL 2

tretinoin (chemotherapy) 1 QL

TYKERB 4 QL

VINBLASTINE SULFATE 2

vincristine sulfate 1

vinorelbine tartrate 1

VOTRIENT 4 QL

XALKORI 4 QL

XTANDI 4 QL

ZELBORAF 4 QL

ZOLADEX 2

ZYDELIG 4 QL

ZYTIGA 4 QL

AUTONOMIC DRUGS

ANTICHOLINERGIC AGENTS

atropine sulfate 1, 2

ATROVENT HFA 2 MO

benztropine mesylate 1 MO

dicyclomine hcl 1, 2

glycopyrrolate 1 MO

ipratropium bromide 1 MO

PROPANTHELINE BROMIDE 2




Name of drug


(tier level)

Necessary actions,


use

SCOPOLAMINE HBR 2

SPIRIVA RESPIMAT 2 MO

STIOLTO RESPIMAT 2 MO

trihexyphenidyl hcl 1 MO

AUTONOMIC DRUGS, MISCELLANEOUS

phenoxybenzamine hcl 1

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS

bethanechol chloride 1

donepezil hydrochloride 1 MO

ENLON 2

NEOSTIGMINE METHYLSULFATE

2

pilocarpine hcl (oral) 1 MO

pyridostigmine bromide 1, 2 MO

SKELETAL MUSCLE RELAXANTS

baclofen 1 MO

cyclobenzaprine hcl 1

dantrolene sodium 1 MO

methocarbamol 1

tizanidine hcl 1 MO

SYMPATHOMIMETIC (ADRENERGIC) AGENTS

ADRENALIN 2

ADVAIR DISKUS 2 MO

albuterol sulfate 1, 2 MO

COMBIVENT RESPIMAT 2 MO

DULERA 2 MO

ephedrine sulfate (pressors) 1

epinephrine hcl 1

ERGOLOID MESYLATES 2 MO

FORADIL AEROLIZER 2 MO

LEVOPHED 2

METAPROTERENOL SULFATE 2 MO

midodrine hcl 1 MO

SEREVENT DISKUS 2 MO

STRIVERDI RESPIMAT 2 MO

terbutaline sulfate 1 MO

BLOOD FORMATION, COAGULATION, AND THROMBOSIS

ANTITHROMBOTIC AGENTS

anagrelide hcl 1 MO

heparin sodium (porcine) 1

heparin sodium (porcine) lock flush

1

COAGULANTS AND ANTICOAGULANTS

ACTIVASE 2

Name of drug


(tier level)

Necessary actions,


use

ADVATE 2 QL

ALPHANINE SD 2 MO

AMICAR 2

aspirin-dipyridamole 1 MO

BRILINTA 2 MO

clopidogrel bisulfate 1 MO

dipyridamole 1 MO

EFFIENT 2 MO

fondaparinux sodium 1 QL

HELIXATE FS 2 QL, MO

HEMOFIL M 2 QL, MO

heparin sod (porcine) in d5w 1

heparin sodium (porcine) 1

heparin sodium (porcine) lock flush

1

HESPAN 2

HUMATE-P 2 QL

LOVENOX 2 QL

pentoxifylline 1 MO

PLASMANATE 2

PRADAXA 2 MO

PROFILNINE 2 QL

PROTAMINE SULFATE 2

THROMBIN-JMI 2

TNKASE 2

tranexamic acid 1

warfarin sodium 1 MO

HEMATOPOIETIC AGENTS

NEUPOGEN 4 QL

PROCRIT 2 QL

ZARXIO 4 QL

CARDIOVASCULAR DRUGS

ALPHA-ADRENERGIC BLOCKING AGENTS

alfuzosin hcl 1

doxazosin mesylate 1 MO

prazosin hcl 1 MO

terazosin hcl 1 MO

ANTILIPEMIC AGENTS

atorvastatin calcium 1 MO

cholestyramine 1 MO

cholestyramine light 1 MO

colestipol hcl 1, 2 MO

fenofibrate 1 MO

gemfibrozil 1 MO

lovastatin 1 MO




Name of drug


(tier level)

Necessary actions,


use

pravastatin sodium 1 MO

rosuvastatin calcium 1 MO

simvastatin 1 MO

BETA-ADRENERGIC BLOCKING AGENTS

acebutolol hcl 1 MO

atenolol 1 MO

atenolol & chlorthalidone 1 MO

bisoprolol & hydrochlorothiazide 1 MO

carvedilol 1 MO

labetalol hcl 1 MO

metoprolol succinate 1 MO

metoprolol tartrate 1 MO

propranolol hcl 1, 2 MO

sotalol hcl 1 MO

CALCIUM-CHANNEL BLOCKING AGENTS

amlodipine besylate 1 MO

diltiazem hcl 1 MO

diltiazem hcl coated beads 1 MO

felodipine 1 MO

nifedipine 1 MO

nimodipine 1

verapamil hcl 1 MO

CARDIAC DRUGS

adenosine 1

amiodarone hcl 1 MO

digoxin 1, 2 MO

disopyramide phosphate 1, 2 MO

dofetilide 1 MO

dopamine hcl 1

flecainide acetate 1 MO

lidocaine hcl (cardiac) 1, 2

lidocaine w/ epinephrine 1

PROCAINAMIDE HCL 2

propafenone hcl 1 MO

quinidine gluconate 1 MO

QUINIDINE SULFATE 2 MO

HYPOTENSIVE AGENTS

acetazolamide 1, 2 MO

acetazolamide sodium 1

clonidine hcl 1 MO

guanfacine hcl 1 MO

hydralazine hcl 1 MO

methazolamide 1 MO

methyldopa 1 MO

Name of drug


(tier level)

Necessary actions,


use

minoxidil 1 MO

NITROPRESS 2

PHENTOLAMINE MESYLATE 2

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS

benazepril hcl 1 MO

captopril 1 MO

lisinopril 1 MO

lisinopril & hydrochlorothiazide 1 MO

losartan potassium 1 MO

losartan potassium & hydrochlorothiazide

1 MO

spironolactone 1 MO

spironolactone & hydrochlorothiazide

1 MO

VASODILATING AGENTS

epoprostenol sodium 1, 2 MO, LD

isosorbide dinitrate 1, 2 MO

isosorbide mononitrate 1 MO

nitroglycerin 1, 2 MO

OPSUMIT 4 QL

sildenafil citrate (pulmonary hypertension)

1 QL, MO

TRACLEER 4 QL, LD

VENTAVIS 4 QL, LD

CENTRAL NERVOUS SYSTEM AGENTS

ANALGESICS AND ANTIPYRETICS

acetaminophen w/ codeine 1 QL

buprenorphine hcl-naloxone hcl dihydrate

1 QL

butorphanol tartrate 1 QL

choline & mag salicylate 1

codeine sulfate 1, 2 QL

etodolac 1 MO

fentanyl 1 QL

fentanyl citrate 1 QL

hydrocodone-acetaminophen 1 QL

hydromorphone hcl 1, 2 QL

ibuprofen 1 MO

indomethacin 1, 2

indomethacin sodium 1

ketoprofen 1

ketorolac tromethamine 1

meloxicam 1 MO

methadone hcl 1, 2 QL

morphine sulfate 1, 2 QL




Name of drug


(tier level)

Necessary actions,


use

nabumetone 1

naproxen 1 MO

oxycodone hcl 1 QL

oxycodone w/ acetaminophen 1 QL

salsalate 1

sufentanil citrate 1 QL

sulindac 1

tramadol hcl 1 QL

ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS

amphetamine-dextroamphetamine

1, 2 QL

dextroamphetamine sulfate 1 QL

methylphenidate hcl 1 QL

ANTICONVULSANTS

carbamazepine 1 MO

CELONTIN 2 MO

clonazepam 1 QL

DIASTAT ACUDIAL 2 QL

divalproex sodium 1 MO

ethosuximide 1 MO

felbamate 1 MO

gabapentin 1 MO

lamotrigine 1 PA, MO

levetiracetam 1 MO

magnesium sulfate 1

oxcarbazepine 1 MO

phenytoin 1, 2 MO

phenytoin sodium 1

phenytoin sodium extended 1, 2 MO

primidone 1 MO

topiramate 1 MO

valproate sodium 1 MO

valproic acid 1 MO

zonisamide 1 MO

ANTIMIGRAINE AGENTS

dihydroergotamine mesylate 1, 2

ERGOMAR 2

ergotamine w/ caffeine 1, 2 QL

naratriptan hcl 1

rizatriptan benzoate 1

sumatriptan 1

sumatriptan succinate 1

ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

alprazolam 1 QL

Name of drug


(tier level)

Necessary actions,


use

buspirone hcl 1 MO

chlordiazepoxide hcl 1 QL

clonazepam 1 QL

diazepam 1, 2 QL

hydroxyzine hcl 1 MO

lorazepam 1 QL

midazolam hcl 1 QL

oxazepam 1 QL

phenobarbital 1, 2 MO

temazepam 1 QL

triazolam 1, 2 QL

zolpidem tartrate 1 QL

CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS

acamprosate calcium 1 MO

amantadine hcl 1 MO

atracurium besylate 1

carbidopa-levodopa 1 MO

entacapone 1, 2 MO

galantamine hydrobromide 1 MO

levetiracetam 1 MO

memantine hcl 1, 2 MO

pramipexole dihydrochloride 1 MO

riluzole 1 MO

rocuronium bromide 1

ropinirole hydrochloride 1 MO

selegiline hcl 1 MO

vecuronium bromide 1

OPIATE ANTAGONISTS

naloxone hcl 1, 2

naltrexone hcl 1

PSYCHOTHERAPEUTIC AGENTS

amitriptyline hcl 1 MO

aripiprazole 1 MO

bupropion hcl 1 MO

bupropion hcl (smoking deterrent) 1

chlorpromazine hcl 1, 2 MO

citalopram hydrobromide 1 MO

clomipramine hcl 1 MO

clozapine 1 QL

desipramine hcl 1 MO

doxepin hcl 1, 2 MO

duloxetine hcl 1 MO

escitalopram oxalate 1 MO

fluoxetine hcl 1 MO




Name of drug


(tier level)

Necessary actions,


use

fluphenazine decanoate 1 MO

fluphenazine hcl 1, 2 MO

fluvoxamine maleate 1 MO

haloperidol 1 MO

haloperidol decanoate 1 MO

haloperidol lactate 1 MO

imipramine hcl 1 MO

LITHIUM 2 MO

lithium carbonate 1, 2 MO

loxapine succinate 1 MO

mirtazapine 1 MO

nefazodone hcl 1, 2 MO

nortriptyline hcl 1, 2 MO

olanzapine 1 MO

paroxetine hcl 1 MO

perphenazine 1 MO

phenelzine sulfate 1 MO

pimozide 1 MO

prochlorperazine edisylate 1

prochlorperazine maleate 1

quetiapine fumarate 1 MO

risperidone 1 MO

SAVELLA 2 PA, MO

sertraline hcl 1 MO

thioridazine hcl 1 MO

thiothixene 1 MO

tranylcypromine sulfate 1 MO

trazodone hcl 1 MO

trifluoperazine hcl 1 MO

venlafaxine hcl 1 MO

ziprasidone hcl 1 MO

RESPIRATORY AGENTS, MISCELLANEOUS

ANECTINE 2

benzonatate 1

guaifenesin-codeine 1 QL

hydrocodone polistirex-chlorpheniramine polistirex

1 QL

hydrocodone w/ homatropine 1 QL

DEVICES

DEVICES

ASSESS FULL RANGE PEAK METER

2

NORDIPEN DELIVERY SYSTEM 2

DIABETIC SUPPLIES

DIABETIC SUPPLIES

Name of drug


(tier level)

Necessary actions,


use

ACCU-CHEK COMPACT PLUS 2 MO

ACCU-CHEK COMPACT PLUS CARE

2 MO

ACETEST 2 MO

ACTI-LANCE LITE LANCETS 28G

2 MO

ADVOCATE DUO 2 MO

ANTI-STICK INSULIN SYRINGE 2 MO

AUTOLET II CLINISAFE 2 MO

BAYER MICROLET 2 LANCING DEVIC

2 MO

BD AUTOSHIELD 2 MO

BD DISP NEEDLES 2

BD INSULIN SYRINGE 2 MO

BD INSULIN SYRINGE U-40 2 MO

BD SAFE CLIP NEEDLE CLIPPER

2 MO

CHEMSTRIP 2 2

CHEMSTRIP MICRAL 2

CHEMSTRIP UGK 2 MO

CLINITEST 2 MO

DIASTIX 2 MO

HUMAPEN LUXURA HD 2 MO

INJECT-EASE AUTOMATIC INJECTOR

2

INSULIN PUMP SYRINGE RESERVOIR

2 MO

MINILINK REAL-TIME REPLACEMENT

2 MO

ONETOUCH VERIO 2 MO

PRECISION XTRA KETONE 2 MO

SIDEKICK BLOOD GLUCOSE SYSTEM

2 MO

ELECTROLYTIC, CALORIC, AND WATER BALANCE

ACIDIFYING AND ALKALINIZING AGENTS

potassium citrate (alkalinizer) 1 MO

potassium citrate-citric acid 1 MO

sodium acetate 1

sodium bicarbonate 1, 2

sodium citrate & citric acid 1 MO

AMMONIA DETOXICANTS

lactulose 1 MO

lactulose (encephalopathy) 1 MO

CALORIC AGENTS

dextrose 1

fat emulsion 1

PROSOL 2




Name of drug


(tier level)

Necessary actions,


use

DIURETICS

amiloride & hydrochlorothiazide 1 MO

amiloride hcl 1 MO

bumetanide 1 MO

chlorothiazide 1, 2 MO

chlorthalidone 1 MO

DYRENIUM 2 MO

furosemide 1 MO

hydrochlorothiazide 1 MO

metolazone 1 MO

SODIUM EDECRIN 2

torsemide 1 MO

triamterene & hydrochlorothiazide 1 MO

ION-REMOVING AGENTS

RENVELA 2 MO

sodium polystyrene sulfonate 1

IRRIGATING SOLUTIONS

lactated ringer's (irrigation) 1

ringer's irrigation 1

sodium chloride (gu irrigant) 1

water for irrigation, sterile 1

REPLACEMENT PREPARATIONS

ADDAMEL N 2

BACTERIOSTATIC WATER(BENZ ALC)

2

calcium chloride (dihydrate) 1

calcium gluconate 1

CHROMIC CHLORIDE 2

COPPER CHLORIDE 2

dextrose in lactated ringers 1

dextrose w/ sodium chloride 1

ELIPHOS 2 MO

K-PHOS 2

lactated ringer's 1

MANGANESE CHLORIDE 2

MANGANESE SULFATE 2

pot phosphate monobasic w/ sod phosphate dibasic & monobasic

1

potassium acetate 1

potassium chloride 1, 2 MO

potassium chloride in dextrose & sodium chloride

1

potassium chloride microencapsulated crystals cr

1 MO

potassium phosphates 1

Name of drug


(tier level)

Necessary actions,


use

ringer's 1

saline, bacteriostatic 1

SELENIUM 2

sodium bicarbonate 1

sodium chloride 1

sodium phosphate 1

SSKI 2

water for injection, sterile 1

zinc sulfate 1, 2

ZINC TRACE METAL 2

URICOSURIC AGENTS

COLCHICINE 2 MO

probenecid 1 MO

ENZYMES

ENZYMES

ADAGEN 2 LD

CEREZYME 4 QL

CREON 2 MO

VPRIV 4 QL

EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS

ANTI-INFECTIVES

BACITRACIN 2

bacitracin-polymyxin b (ophth) 1

chlorhexidine gluconate (mouth-throat)

1

ciprofloxacin hcl (ophth) 1, 2

erythromycin (ophth) 1

gatifloxacin (ophth) 1

gentamicin sulfate (ophth) 1

ofloxacin (ophth) 1

ofloxacin (otic) 1

polymyxin b-trimethoprim 1

sulfacetamide sodium (ophth) 1

tobramycin (ophth) 1, 2

trifluridine 1

ANTI-INFLAMMATORY AGENTS

CIPRODEX 2

COLY-MYCIN S 2

DEXAMETHASONE SODIUM PHOSPHATE

2 MO

diclofenac sodium (ophth) 1

flunisolide (nasal) 1 MO

fluorometholone (ophth) 1, 2 MO

flurbiprofen sodium 1




Name of drug


(tier level)

Necessary actions,


use

fluticasone propionate (nasal) 1 MO

ketorolac tromethamine (ophth) 1

LOTEMAX 2 MO

neomycin-polymy-dexameth 1

NEOMYCIN-POLYMYXIN-HC 2

neomycin-polymyxin-hc (otic) 1

PRED-G 2

prednisolone acetate (ophth) 1, 2 MO

PREDNISOLONE SODIUM PHOSPHATE

2 MO

RESTASIS 2 MO

sulfacetamide sod-prednisolone 1, 2

ANTIALLERGIC AGENTS

azelastine hcl 1 MO

cromolyn sodium (ophth) 1 MO

ANTIGLAUCOMA AGENTS

levobunolol hcl 1 MO

EENT DRUGS, MISCELLANEOUS

acetic acid (otic) 1 MO

ACETIC ACID-ALUMINUM ACETATE

2

betaxolol hcl (ophth) 1 MO

brimonidine tartrate 1 MO

dorzolamide hcl 1 MO

dorzolamide hcl-timolol maleate 1 MO

EYLEA 2 MO

fluorescein sodium topical 1

fluorescein w/ benoxinate 1

fluorescein w/ proparacaine 1

HEALON GV 2

LACRISERT 2 MO

latanoprost 1 MO

levobunolol hcl 1 MO

LUCENTIS 2 MO

ophthalmic irrigation solution - intraocular

1, 2

PHOSPHOLINE IODIDE 2 MO

pilocarpine hcl 1 MO

timolol maleate (ophth) 1 MO

LOCAL ANESTHETICS

antipyrine-benzocaine 1

COCAINE HCL 2

lidocaine hcl (mouth-throat) 1 MO

proparacaine hcl 1

PROVISC 2

Name of drug


(tier level)

Necessary actions,


use

tetracaine hcl (ophth) 1

MYDRIATICS

ATROPINE SULFATE 2 MO

CYCLOMYDRIL 2 MO

cyclopentolate hcl 1, 2 MO

homatropine hbr 1, 2 MO

ISOPTO HYOSCINE 2 MO

tropicamide 1 MO

VASOCONSTRICTORS

ADRENALIN 2

phenylephrine hcl (ophth) 1

GASTROINTESTINAL DRUGS


balsalazide disodium 1 MO

mesalamine 1, 2 MO

ANTIEMETICS

DIMENHYDRINATE 2

dronabinol 1

droperidol 1

EMEND 2

ondansetron 1

ondansetron hcl 1

prochlorperazine 1

TRANSDERM-SCOP (1.5 MG) 2

ANTIULCER AGENTS AND ACID SUPPRESSANTS

cimetidine hcl 1 MO

famotidine 1 MO

FAMOTIDINE PREMIXED 2

misoprostol 1 MO

omeprazole 1, 2 MO

pantoprazole sodium 1 MO

ranitidine hcl 1, 2 MO

sucralfate 1, 2 MO

DIGESTANTS

PANCRELIPASE (LIP-PROT-AMYL)

2 MO

GI DRUGS, MISCELLANEOUS

chlordiazepoxide hcl-clidinium bromide

1, 2 QL

diphenoxylate w/ atropine 1, 2

LINZESS 2 PA, MO

metoclopramide hcl 1

PAREGORIC 2 QL

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

1




Name of drug


(tier level)

Necessary actions,


use

URSO FORTE 2 MO

GOLD COMPOUNDS

GOLD COMPOUNDS

RIDAURA 2 MO

HEAVY METAL ANTAGONISTS

HEAVY METAL ANTAGONISTS

BAL IN OIL 2

CHEMET 2

deferoxamine mesylate 1

DEPEN TITRATABS 2 QL

EXJADE 2, 4 QL

flumazenil 1

methylene blue (antidote) 1, 2

PHYSOSTIGMINE SALICYLATE 2

SODIUM THIOSULFATE 2

HORMONES AND SYNTHETIC SUBSTITUTES

ADRENALS

ARISTOSPAN INTRA-ARTICULAR

2

betamethasone sod phosphate & acetate

1

budesonide 1

CORTISONE ACETATE 2

dexamethasone 1, 2

dexamethasone sodium phosphate

1, 2

FLOVENT HFA 2 MO

fludrocortisone acetate 1 MO

hydrocortisone 1 MO

KENALOG 2

methylprednisolone 1, 2

methylprednisolone acetate 1, 2

methylprednisolone sod succ 1, 2

prednisolone 1, 2

prednisolone sodium phosphate 1

prednisone 1, 2 MO

QVAR 2 MO

SOLU-CORTEF 2

ANDROGENS

ANADROL-50 2

ANDRODERM 2 MO

danazol 1 MO

DEPO-TESTOSTERONE 2 MO

methyltestosterone 1, 2 MO

TESTOSTERONE PROPIONATE 2

Name of drug


(tier level)

Necessary actions,


use

CONTRACEPTIVES

desogestrel & ethinyl estradiol 1 MO

ELLA 2

ethynodiol diacet & eth estrad 1 MO

levonorgestrel & eth estradiol 1 MO

levonorgestrel-eth estradiol (triphasic)

1 MO

NECON 1/50 (28) 2 MO

norethin acet & estrad-fe 1 MO

norethindrone & eth estradiol 1, 2 MO

norethindrone (contraceptive) 1 MO

norethindrone-eth estradiol (triphasic)

1 MO

norgestimate-ethinyl estradiol 1 MO

norgestimate-ethinyl estradiol (triphasic)

1 MO

NUVARING 2 MO

DIABETIC AGENTS

acarbose 1 MO

glimepiride 1 MO

glipizide 1 MO

GLUCAGON EMERGENCY 2

glyburide 1 MO

HUMALOG 2 MO

HUMULIN 70/30 2 MO

HUMULIN N 2 MO

HUMULIN R 2 MO

LANTUS 2 PA, MO

metformin hcl 1, 2 MO

pioglitazone hcl 1 MO

TOLBUTAMIDE 2 MO

ESTROGENS AND ANTIESTROGENS

DEPO-ESTRADIOL 2

esterified estrogens & methyltestosterone

1 MO

estradiol 1, 2 MO

estradiol vaginal 1, 2 MO

estradiol valerate 1

ESTROPIPATE 2 MO

PREMARIN INJ 2

PREMARIN CRM 2 MO

raloxifene hcl 1 MO

GONADOTROPINS

BRAVELLE 2

chorionic gonadotropin 1




Name of drug


(tier level)

Necessary actions,


use

clomiphene citrate 1

MENOPUR 2

SYNAREL 2

PARATHYROID

calcitonin (salmon) 1, 2 MO

PITUITARY

desmopressin acetate 1, 2 MO

desmopressin acetate spray 1 MO

desmopressin acetate spray refrigerated

1 MO

HP ACTHAR 4 PA, QL

vasopressin 1

PROGESTINS

DEPO-PROVERA 2 MO

medroxyprogesterone acetate 1 MO

medroxyprogesterone acetate (contraceptive)

1, 2 MO

norethindrone acetate 1 MO

progesterone 1, 2

SOMATOTROPIN AGONISTS AND ANTAGONISTS

OMNITROPE 2 PA, MO

THYROID AND ANTITHYROID AGENTS

levothyroxine sodium 1 MO

liothyronine sodium 1 MO

methimazole 1 MO

propylthiouracil 1 MO

MISCELLANEOUS THERAPEUTIC AGENTS

CONTRACEPTIVES

ORTHO DIAPHRAGM ALL-FLEX KIT 65

2

DIAGNOSTIC AGENT

adenosine (diagnostic) 1

CANDIN 2

CORTROSYN 2

INDIGO CARMINE 2

METOPIRONE 2

OMNIPAQUE 2

PROVOCHOLINE 2

TUBERSOL 2


acitretin 1

ADCIRCA 4 QL

alendronate sodium 1, 2 MO

allopurinol 1 MO

amifostine crystalline 1

Name of drug


(tier level)

Necessary actions,


use

amino acid infusion 1, 2

AMPHADASE 2

ARALAST NP 4 MO

AVONEX 4 PA, QL

azathioprine 1 MO

benztropine mesylate 1

bicalutamide 1 MO

BORIC ACID TOPICAL 2

BOTOX 2

BREVITAL SODIUM 2

bromocriptine mesylate 1 MO

bupivacaine hcl 1

bupivacaine w/ epinephrine 1

cabergoline 1 MO

calcium acetate (phosphate binder)

1 MO

cyclosporine modified (for microemulsion)

1, 2 MO

CYSTAGON 2 MO

CYTRA-3 2 MO

DILTIAZEM HCL 2

disulfiram 1, 2 MO

ELMIRON 2

ENBREL 4 QL

ETIDRONATE DISODIUM 2 MO

EXTAVIA 2 QL

finasteride 1 MO

FIRAZYR 4 QL

GELFILM 2

GILENYA 4 PA, QL

glatiramer acetate 1 PA, QL

HUMIRA 4 QL

HYPERTET S/D 2

isoflurane 1, 2

ketamine hcl 1

KINERET 4 QL

leflunomide 1 MO

leucovorin calcium 1

levocarnitine (metabolic modifiers)

1, 2 MO

lidocaine hcl (local anesth.) 1

lidocaine in d5w 1

lidocaine w/ epinephrine 1

lidocaine-prilocaine 1 MO

mesna 1, 2




Name of drug


(tier level)

Necessary actions,


use

methotrexate sodium 1 MO

mycophenolate mofetil 1 MO

NESACAINE 2

octreotide acetate 1, 2, 4 QL, MO

OMNITROPE PEN 10 INJ DEVICE

2

ORENCIA 4 QL

OTEZLA 4 QL

pamidronate disodium 1

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

1

propofol 1

REMICADE 4 MO

RIMSO-50 2

SANDIMMUNE 2 MO

SENSIPAR 2, 4 QL

sevoflurane 1, 2

sirolimus 1, 2 MO

sodium polystyrene sulfonate 1

SUPRANE 2

tacrolimus 1, 2 MO

tamsulosin hcl 1 MO

THALOMID 4 QL

THIOLA 2

ursodiol 1, 2 MO

water for injection, sterile 1

XGEVA 4 PA, QL

zoledronic acid 1 MO

OXYTOCICS

OXYTOCICS

HEMABATE 2

methylergonovine maleate 1, 2

oxytocin 1

RESPIRATORY TRACT AGENTS


ASMANEX 120 METERED DOSES

2 MO

budesonide (inhalation) 1 MO

CROMOLYN SODIUM 2 MO

montelukast sodium 1 MO

ANTITUSSIVES

benzonatate 1

RESPIRATORY AGENTS, MISCELLANEOUS

acetylcysteine 1

ipratropium bromide (nasal) 1 MO

Name of drug


(tier level)

Necessary actions,


use

LETAIRIS 4 QL, LD

PULMOZYME 4 QL

sodium chloride (inhalant) 1

theophylline 1, 2 MO

SERUMS, TOXOIDS, AND VACCINES

SERUMS

CARIMUNE NF 2 MO

HIZENTRA 2 QL

HYPERRHO S/D 2

HYQVIA 4 PA, QL

IMOGAM RABIES-HT 2

NABI-HB 2

VARIZIG 2

VACCINES

GAMUNEX-C 2 MO

SEXUAL DYSFUNCTION


CAVERJECT 2 QL

CIALIS 2 QL

OSPHENA 2 QL

SKIN AND MUCOUS MEMBRANE AGENTS

ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)

BACTROBAN NASAL 2

BENZAMYCINPAK 2 MO

BENZOIC ACID 2

clindamycin phosphate (topical) 1 MO

clindamycin phosphate vaginal 1

clotrimazole 1

clotrimazole w/ betamethasone 1

erythromycin (acne aid) 1 MO

gentamicin sulfate (topical) 1, 2

iodoquinol-hc 1

ketoconazole (topical) 1

metronidazole (topical) 1, 2

metronidazole vaginal 1

mupirocin 1

mupirocin calcium (topical) 1

nystatin (topical) 1

selenium sulfide 1

silver sulfadiazine 1

sulfacetamide sodium (acne) 1 MO

terbinafine hcl 1

ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE)

alclometasone dipropionate 1 MO




Name of drug


(tier level)

Necessary actions,


use

benzoyl peroxide-erythromycin 1 MO

betamethasone dipropionate (topical)

1 MO

betamethasone dipropionate augmented

1 MO

betamethasone valerate 1 MO

ciclopirox olamine 1

clobetasol propionate 1, 2 MO

clobetasol propionate emollient base

1 MO

CORDRAN 2 MO

desonide 1, 2 MO

desoximetasone 1 MO

fluocinolone acetonide 1 MO

fluocinonide 1 MO

fluocinonide emulsified base 1 MO

halobetasol propionate 1 MO

hydrocortisone (intrarectal) 1 MO

hydrocortisone (rectal) 1 MO

hydrocortisone (topical) 1 MO

hydrocortisone acetate (rectal) 1 MO

hydrocortisone butyrate 1 MO

hydrocortisone butyrate hydrophilic lipo base

1 MO

HYDROCORTISONE MICRONIZED

2 MO

mometasone furoate 1 MO

nystatin-triamcinolone 1

PROCTOFOAM HC 2 MO

triamcinolone acetonide (mouth) 1 MO

triamcinolone acetonide (topical) 1, 2 MO

CELL STIMULANTS AND PROLIFERANTS

tretinoin 1, 2 MO

SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS

adapalene 1, 2 MO

AZELEX 2 MO

calcipotriene 1 MO

DRITHO-CREME HP 2 MO

DRYSOL 2 MO

Name of drug


(tier level)

Necessary actions,


use

ETHYL CHLORIDE 2

FINACEA 2 MO

fluorouracil (topical) 1

GLYCOPYRROLATE 2

GRANULEX 2

imiquimod 1

isotretinoin 1

ketoconazole (topical) 1

lidocaine hcl 1 MO

methoxsalen rapid 1, 2

permethrin 1, 2

podofilox 1, 2 MO

SANTYL 2

tacrolimus (topical) 1 MO

TAZORAC 2 MO

VECTICAL 2 MO

SMOOTH MUSCLE RELAXANTS

SMOOTH MUSCLE RELAXANTS

oxybutynin chloride 1 MO

OXYTROL 2 MO

theophylline 1, 2 MO

trospium chloride 1 MO

VITAMINS

VITAMINS

AQUASOL A 2

calcitriol 1, 2 MO

cholecalciferol 1

cyanocobalamin 1 MO

ergocalciferol 1 MO

folic acid 1, 2 MO

INFED 2

INFUVITE 2

MEPHYTON 2

POTABA 2 MO

pyridoxine hcl 1

thiamine hcl 1

VENOFER 2




Formulary Drugs by Alphabetical Listing Index

A

abacavir sulfate ................................................................................ 5

abacavir sulfate-lamivudine ............................................................ 5

ABRAXANE ...................................................................................... 6

acamprosate calcium ...................................................................... 9

acarbose ......................................................................................... 13

ACCU-CHEK COMPACT PLUS .................................................. 10

ACCU-CHEK COMPACT PLUS CARE ...................................... 10

acebutolol hcl .................................................................................... 8

acetaminophen w/ codeine ............................................................. 8

acetazolamide .................................................................................. 8

acetazolamide sodium .................................................................... 8

ACETEST........................................................................................ 10

acetic acid (otic) ............................................................................. 12

ACETIC ACID-ALUMINUM ACETATE ....................................... 12

acetylcysteine ................................................................................. 15

acitretin ............................................................................................ 14

ACTI-LANCE LITE LANCETS 28G ............................................. 10

ACTIVASE ........................................................................................ 7

acyclovir ............................................................................................ 5

acyclovir sodium ............................................................................... 5

ADAGEN ......................................................................................... 11

adapalene ....................................................................................... 16

ADCIRCA ........................................................................................ 14

ADDAMEL N ................................................................................... 11

adefovir dipivoxil ............................................................................... 5

adenosine.................................................................................... 8, 14

adenosine (diagnostic) .................................................................. 14

ADRENALIN ............................................................................... 7, 12

ADVAIR DISKUS ............................................................................. 7

ADVATE ............................................................................................ 7

ADVOCATE DUO .......................................................................... 10

AFINITOR ......................................................................................... 6

ALBENZA ...................................................................................... 3, 4

albuterol sulfate ................................................................................ 7

alclometasone dipropionate ......................................................... 15

alendronate sodium ....................................................................... 14

alfuzosin hcl ...................................................................................... 7

ALKERAN ......................................................................................... 6

allopurinol ........................................................................................ 14

ALPHANINE SD ............................................................................... 7

alprazolam ........................................................................................ 9

amantadine hcl ............................................................................. 5, 9

AMBISOME ...................................................................................... 4

AMICAR ............................................................................................ 7

amifostine crystalline ..................................................................... 14

amiloride & hydrochlorothiazide .................................................. 11

amiloride hcl ................................................................................... 11

amino acid infusion ........................................................................ 14

amiodarone hcl ................................................................................ 8

amitriptyline hcl ................................................................................ 9

amlodipine besylate......................................................................... 8

amoxicillin ..................................................................................... 3, 4

amoxicillin & pot clavulanate .......................................................... 4

AMPHADASE ................................................................................. 14

amphetamine-dextroamphetamine ............................................... 9

AMPHOTERICIN B ......................................................................... 4

ampicillin ........................................................................................... 4

ampicillin & sulbactam sodium ....................................................... 4

ampicillin sodium .............................................................................. 4

ANADROL-50 ................................................................................. 13

anagrelide hcl ................................................................................... 7

anastrozole ....................................................................................... 6

ANDRODERM................................................................................ 13

ANECTINE ..................................................................................... 10

antipyrine-benzocaine ................................................................... 12

ANTI-STICK INSULIN SYRINGE ................................................ 10

APTIVUS........................................................................................... 5

AQUASOL A ................................................................................... 16

ARALAST NP ................................................................................. 14

aripiprazole ....................................................................................... 9

ARISTOSPAN INTRA-ARTICULAR ........................................... 13

ASMANEX 120 METERED DOSES ........................................... 15

aspirin-dipyridamole ........................................................................ 7

ASSESS FULL RANGE PEAK METER ..................................... 10

atenolol .............................................................................................. 8

atenolol & chlorthalidone ................................................................ 8

atorvastatin calcium......................................................................... 7

atovaquone-proguanil hcl ............................................................... 5

atracurium besylate ......................................................................... 9

ATRIPLA ........................................................................................... 5

atropine sulfate ................................................................................ 6

ATROPINE SULFATE .................................................................. 12

ATROVENT HFA ............................................................................. 6

AUTOLET II CLINISAFE .............................................................. 10

AVASTIN........................................................................................... 6

AVELOX ............................................................................................. 4

AVONEX ......................................................................................... 14

azacitidine ......................................................................................... 6

azathioprine .................................................................................... 14

azelastine hcl.................................................................................. 12

AZELEX .......................................................................................... 16




azithromycin ...................................................................................... 4

aztreonam ......................................................................................... 4

B

BACITRACIN .................................................................................. 11

bacitracin-polymyxin b (ophth) ..................................................... 11

baclofen ............................................................................................. 7

BACTERIOSTATIC WATER(BENZ ALC) .................................. 11

BACTOCILL IN DEXTROSE .............................................................. 4

BACTROBAN NASAL ................................................................... 15

BAL IN OIL ...................................................................................... 13

balsalazide disodium ..................................................................... 12

BAYER MICROLET 2 LANCING DEVIC .................................... 10

BD AUTOSHIELD .......................................................................... 10

BD DISP NEEDLES ...................................................................... 10

BD INSULIN SYRINGE ................................................................. 10

BD INSULIN SYRINGE U-40 ....................................................... 10

BD SAFE CLIP NEEDLE CLIPPER ............................................ 10

benazepril hcl ................................................................................... 8

BENZAMYCINPAK ........................................................................ 15

BENZOIC ACID .............................................................................. 15

benzonatate .............................................................................. 10, 15

benzoyl peroxide-erythromycin .................................................... 16

benztropine mesylate ................................................................ 6, 14

betamethasone dipropionate (topical) ......................................... 16

betamethasone dipropionate augmented ................................... 16

betamethasone sod phosphate & acetate .................................. 13

betamethasone valerate ............................................................... 16

betaxolol hcl (ophth) ...................................................................... 12

bethanechol chloride ....................................................................... 7

bicalutamide .................................................................................... 14

BICILLIN L-A ..................................................................................... 4

BICNU ............................................................................................... 6

BILTRICIDE ....................................................................................... 4

bisoprolol & hydrochlorothiazide .................................................... 8

bleomycin sulfate ............................................................................. 6

BORIC ACID TOPICAL ................................................................. 14

BOTOX ............................................................................................ 14

BRAVELLE ..................................................................................... 13

BREVITAL SODIUM ...................................................................... 14

BRILINTA .......................................................................................... 7

brimonidine tartrate ........................................................................ 12

bromocriptine mesylate ................................................................. 14

budesonide ............................................................................... 13, 15

budesonide (inhalation) ................................................................. 15

bumetanide ..................................................................................... 11

bupivacaine hcl............................................................................... 14

bupivacaine w/ epinephrine .......................................................... 14

buprenorphine hcl-naloxone hcl dihydrate ................................... 8

bupropion hcl .................................................................................... 9

bupropion hcl (smoking deterrent) ................................................. 9

buspirone hcl .................................................................................... 9

butorphanol tartrate ......................................................................... 8

C

cabergoline ..................................................................................... 14

calcipotriene ................................................................................... 16

calcitonin (salmon)......................................................................... 14

calcitriol ........................................................................................... 16

calcium acetate (phosphate binder) ............................................ 14

calcium chloride (dihydrate) ......................................................... 11

calcium gluconate .......................................................................... 11

CANCIDAS ....................................................................................... 4

CANDIN .......................................................................................... 14

capecitabine ..................................................................................... 6

captopril ............................................................................................ 8

carbamazepine ................................................................................ 9

carbidopa-levodopa ......................................................................... 9

carboplatin ........................................................................................ 6

CARIMUNE NF .............................................................................. 15

carvedilol ........................................................................................... 8

CAVERJECT .................................................................................. 15

CAYSTON .......................................................................................... 4

cefazolin sodium............................................................................... 4

cefdinir ............................................................................................... 4

cefepime hcl...................................................................................... 4

cefixime ............................................................................................. 4

cefotaxime sodium ........................................................................... 4

cefotetan disodium .......................................................................... 4

CEFOTETAN DISODIUM-DEXTROSE ............................................. 4

ceftazidime ........................................................................................ 4

ceftriaxone sodium .......................................................................... 4

CEFTRIAXONE SODIUM IN DEXTROSE......................................... 4

cefuroxime axetil .............................................................................. 4

cefuroxime sodium........................................................................... 4

CELONTIN ....................................................................................... 9

cephalexin......................................................................................... 4

CEREZYME ................................................................................... 11

CHEMET ......................................................................................... 13

CHEMSTRIP 2 ............................................................................... 10

CHEMSTRIP MICRAL .................................................................. 10

CHEMSTRIP UGK......................................................................... 10

chlordiazepoxide hcl .................................................................. 9, 12

chlordiazepoxide hcl-clidinium bromide ...................................... 12

chlorhexidine gluconate (mouth-throat) ...................................... 11

chloroquine phosphate ................................................................... 5

chlorothiazide ................................................................................. 11

chlorpromazine hcl .......................................................................... 9

chlorthalidone ................................................................................. 11

cholecalciferol ................................................................................ 16

cholestyramine ................................................................................. 7

cholestyramine light......................................................................... 7

choline & mag salicylate ................................................................. 8

chorionic gonadotropin ................................................................. 13

CHROMIC CHLORIDE ................................................................. 11

CIALIS ............................................................................................. 15

ciclopirox olamine .......................................................................... 16

cimetidine hcl.................................................................................. 12




CIPRODEX ..................................................................................... 11

ciprofloxacin ................................................................................ 4, 11

ciprofloxacin hcl .......................................................................... 4, 11

ciprofloxacin hcl (ophth) ................................................................ 11

ciprofloxacin in d5w ......................................................................... 4

cisplatin ............................................................................................. 6

citalopram hydrobromide ................................................................ 9

clarithromycin ................................................................................... 4

clindamycin hcl ................................................................................. 4

clindamycin palmitate hydrochloride ............................................. 4

clindamycin phosphate .............................................................. 4, 15

clindamycin phosphate (topical) .................................................. 15

clindamycin phosphate vaginal .................................................... 15

CLINITEST ...................................................................................... 10

clobetasol propionate .................................................................... 16

clobetasol propionate emollient base .......................................... 16

clomiphene citrate .......................................................................... 14

clomipramine hcl .............................................................................. 9

clonazepam ...................................................................................... 9

clonidine hcl ...................................................................................... 8

clopidogrel bisulfate ......................................................................... 7

clotrimazole ..................................................................................... 15

clotrimazole w/ betamethasone ................................................... 15

clozapine ........................................................................................... 9

COCAINE HCL ............................................................................... 12

codeine sulfate ................................................................................. 8

COLCHICINE ................................................................................. 11

colestipol hcl ..................................................................................... 7

COLY-MYCIN S ............................................................................. 11

COMBIVENT RESPIMAT ............................................................... 7

COMPLERA ...................................................................................... 5

COPPER CHLORIDE .................................................................... 11

CORDRAN ...................................................................................... 16

CORTISONE ACETATE ............................................................... 13

CORTROSYN................................................................................. 14

COSMEGEN ..................................................................................... 6

CREON ........................................................................................... 11

CRIXIVAN ......................................................................................... 5

CROMOLYN SODIUM .................................................................. 15

cromolyn sodium (ophth) .............................................................. 12

cyanocobalamin ............................................................................. 16

cyclobenzaprine hcl ......................................................................... 7

CYCLOMYDRIL ............................................................................. 12

cyclopentolate hcl .......................................................................... 12

cyclophosphamide ........................................................................... 6

cyclosporine modified (for microemulsion) ................................. 14

cyproheptadine hcl ........................................................................... 5

CYSTAGON .................................................................................... 14

cytarabine.......................................................................................... 6

CYTOVENE ...................................................................................... 5

CYTRA-3 ......................................................................................... 14

D

dacarbazine ...................................................................................... 6

danazol ............................................................................................ 13

dantrolene sodium ........................................................................... 7

dapsone ............................................................................................ 5

DARAPRIM ....................................................................................... 5

daunorubicin hcl ............................................................................... 6

deferoxamine mesylate ................................................................. 13

DEPEN TITRATABS ..................................................................... 13

DEPO-ESTRADIOL....................................................................... 13

DEPO-PROVERA .......................................................................... 14

DEPO-TESTOSTERONE ............................................................. 13

DESCOVY ........................................................................................ 5

desipramine hcl ................................................................................ 9

desmopressin acetate ................................................................... 14

desmopressin acetate spray ........................................................ 14

desmopressin acetate spray refrigerated ................................... 14

desogestrel & ethinyl estradiol ..................................................... 13

desonide ......................................................................................... 16

desoximetasone ............................................................................. 16

dexamethasone ............................................................................. 13

dexamethasone sodium phosphate ............................................ 13

DEXAMETHASONE SODIUM PHOSPHATE ........................... 11

dextroamphetamine sulfate ............................................................ 9

dextrose .................................................................................... 10, 11

dextrose in lactated ringers .......................................................... 11

dextrose w/ sodium chloride ........................................................ 11

DIASTAT ACUDIAL......................................................................... 9

DIASTIX .......................................................................................... 10

diazepam .......................................................................................... 9

diclofenac sodium (ophth) ............................................................ 11

dicloxacillin sodium .......................................................................... 4

dicyclomine hcl ................................................................................. 6

didanosine ........................................................................................ 5

digoxin ............................................................................................... 8

dihydroergotamine mesylate .......................................................... 9

diltiazem hcl ...................................................................................... 8

DILTIAZEM HCL ............................................................................ 14

diltiazem hcl coated beads ............................................................. 8

DIMENHYDRINATE ...................................................................... 12

diphenhydramine hcl ....................................................................... 5

diphenoxylate w/ atropine ............................................................. 12

dipyridamole ..................................................................................... 7

disopyramide phosphate ................................................................ 8

disulfiram......................................................................................... 14

divalproex sodium ............................................................................ 9

DOCETAXEL.................................................................................... 6

dofetilide ............................................................................................ 8

donepezil hydrochloride .................................................................. 7

dopamine hcl .................................................................................... 8

dorzolamide hcl .............................................................................. 12

dorzolamide hcl-timolol maleate .................................................. 12

doxazosin mesylate ......................................................................... 7

doxepin hcl ....................................................................................... 9

doxorubicin hcl ................................................................................. 6

doxycycline (monohydrate) ............................................................ 4

doxycycline hyclate ......................................................................... 4




DRITHO-CREME HP .................................................................... 16

dronabinol ....................................................................................... 12

droperidol ........................................................................................ 12

DRYSOL.......................................................................................... 16

DULERA ............................................................................................ 7

duloxetine hcl .................................................................................... 9

DYRENIUM ..................................................................................... 11

E

E.E.S. 400 ......................................................................................... 4

EDURANT ......................................................................................... 5

EFFIENT ........................................................................................... 7

ELIPHOS ......................................................................................... 11

ELLA ................................................................................................ 13

ELMIRON ........................................................................................ 14

EMCYT .............................................................................................. 6

EMEND ........................................................................................... 12

EMTRIVA .......................................................................................... 5

ENBREL .......................................................................................... 14

ENLON .............................................................................................. 7

entacapone ....................................................................................... 9

entecavir ............................................................................................ 5

EPCLUSA ......................................................................................... 5

ephedrine sulfate (pressors) ........................................................... 7

epinephrine hcl ................................................................................. 7

epoprostenol sodium ....................................................................... 8

ERBITUX ........................................................................................... 6

ergocalciferol .................................................................................. 16

ERGOLOID MESYLATES .............................................................. 7

ERGOMAR ....................................................................................... 9

ergotamine w/ caffeine .................................................................... 9

ERYTHROCIN LACTOBIONATE .................................................. 4

erythromycin (acne aid) ................................................................ 15

erythromycin (ophth)...................................................................... 11

erythromycin base ........................................................................... 4

escitalopram oxalate........................................................................ 9

esterified estrogens & methyltestosterone ................................. 13

estradiol ........................................................................................... 13

estradiol vaginal ............................................................................. 13

estradiol valerate ............................................................................ 13

ESTROPIPATE .............................................................................. 13

ethambutol hcl .................................................................................. 5

ethosuximide .................................................................................... 9

ETHYL CHLORIDE........................................................................ 16

ethynodiol diacet & eth estrad ...................................................... 13

ETIDRONATE DISODIUM ........................................................... 14

etodolac ............................................................................................. 8

etoposide ........................................................................................... 6

exemestane ...................................................................................... 6

EXJADE .......................................................................................... 13

EXTAVIA ......................................................................................... 14

EYLEA ............................................................................................. 12

F

famciclovir ......................................................................................... 5

famotidine ....................................................................................... 12

FAMOTIDINE PREMIXED ........................................................... 12

fat emulsion .................................................................................... 10

felbamate .......................................................................................... 9

felodipine........................................................................................... 8

fenofibrate ......................................................................................... 7

fentanyl .............................................................................................. 8

fentanyl citrate .................................................................................. 8

FINACEA ........................................................................................ 16

finasteride ....................................................................................... 14

FIRAZYR......................................................................................... 14

flecainide acetate ............................................................................. 8

FLOVENT HFA .............................................................................. 13

fluconazole ....................................................................................... 4

fluconazole in nacl ........................................................................... 4

flucytosine ......................................................................................... 4

fludarabine phosphate .................................................................... 6

fludrocortisone acetate ................................................................. 13

flumazenil ........................................................................................ 13

flunisolide (nasal) ........................................................................... 11

fluocinolone acetonide .................................................................. 16

fluocinonide .................................................................................... 16

fluocinonide emulsified base ........................................................ 16

fluorescein sodium topical ............................................................ 12

fluorescein w/ benoxinate ............................................................. 12

fluorescein w/ proparacaine ......................................................... 12

fluorometholone (ophth)................................................................ 11

fluorouracil .................................................................................. 6, 16

fluorouracil (topical) ....................................................................... 16

fluoxetine hcl .................................................................................... 9

fluphenazine decanoate ............................................................... 10

fluphenazine hcl ............................................................................. 10

flurbiprofen sodium ........................................................................ 11

flutamide ........................................................................................... 6

fluticasone propionate (nasal) ...................................................... 12

fluvoxamine maleate ..................................................................... 10

folic acid .......................................................................................... 16

fondaparinux sodium ....................................................................... 7

FORADIL AEROLIZER ................................................................... 7

FOSCAVIR ....................................................................................... 5

furosemide ...................................................................................... 11

G

gabapentin ........................................................................................ 9

galantamine hydrobromide ............................................................. 9

GAMUNEX-C ................................................................................. 15

gatifloxacin (ophth) ........................................................................ 11

GELFILM......................................................................................... 14

gemcitabine hcl ................................................................................ 6

gemfibrozil ........................................................................................ 7

gentamicin sulfate ................................................................ 4, 11, 15




gentamicin sulfate (ophth) ............................................................ 11

gentamicin sulfate (topical) ........................................................... 15

GENVOYA ........................................................................................ 5

GILENYA ......................................................................................... 14

glatiramer acetate .......................................................................... 14

GLEOSTINE ..................................................................................... 6

glimepiride ....................................................................................... 13

glipizide ........................................................................................... 13

GLUCAGON EMERGENCY ......................................................... 13

glyburide .......................................................................................... 13

glycopyrrolate ................................................................................... 6

GLYCOPYRROLATE .................................................................... 16

GRANULEX .................................................................................... 16

griseofulvin microsize ...................................................................... 4

griseofulvin ultramicrosize .............................................................. 4

guaifenesin-codeine ...................................................................... 10

guanfacine hcl .................................................................................. 8

H

halobetasol propionate .................................................................. 16

haloperidol ...................................................................................... 10

haloperidol decanoate ................................................................... 10

haloperidol lactate .......................................................................... 10

HARVONI .......................................................................................... 5

HEALON GV ................................................................................... 12

HELIXATE FS................................................................................... 7

HEMABATE .................................................................................... 15

HEMOFIL M ...................................................................................... 7

heparin sod (porcine) in d5w .......................................................... 7

heparin sodium (porcine) ................................................................ 7

heparin sodium (porcine) lock flush............................................... 7

HERCEPTIN ..................................................................................... 6

HESPAN............................................................................................ 7

HEXALEN ......................................................................................... 6

HIZENTRA ...................................................................................... 15

homatropine hbr ............................................................................. 12

HP ACTHAR ................................................................................... 14

HUMALOG ...................................................................................... 13

HUMAPEN LUXURA HD .............................................................. 10

HUMATE-P ....................................................................................... 7

HUMIRA .......................................................................................... 14

HUMULIN 70/30 ............................................................................. 13

HUMULIN N .................................................................................... 13

HUMULIN R .................................................................................... 13

hydralazine hcl ................................................................................. 8

hydrochlorothiazide........................................................................ 11

hydrocodone polistirex-chlorpheniramine polistirex .................. 10

hydrocodone w/ homatropine ....................................................... 10

hydrocodone-acetaminophen ......................................................... 8

hydrocortisone .......................................................................... 13, 16

hydrocortisone (intrarectal) ........................................................... 16

hydrocortisone (rectal) .................................................................. 16

hydrocortisone (topical) ................................................................. 16

hydrocortisone acetate (rectal) .................................................... 16

hydrocortisone butyrate ................................................................ 16

hydrocortisone butyrate hydrophilic lipo base ........................... 16

HYDROCORTISONE MICRONIZED .......................................... 16

hydromorphone hcl .......................................................................... 8

hydroxychloroquine sulfate ............................................................ 5

hydroxyurea ...................................................................................... 6

hydroxyzine hcl ................................................................................ 9

HYPERRHO S/D ........................................................................... 15

HYPERTET S/D ............................................................................. 14

HYQVIA........................................................................................... 15

I

ibuprofen ........................................................................................... 8

idarubicin hcl .................................................................................... 6

ifosfamide ......................................................................................... 6

IFOSFAMIDE-MESNA .................................................................... 6

imatinib mesylate ............................................................................. 6

IMBRUVICA ..................................................................................... 6

imipenem-cilastatin .......................................................................... 4

imipramine hcl ................................................................................ 10

imiquimod ....................................................................................... 16

IMOGAM RABIES-HT ................................................................... 15

INDIGO CARMINE ........................................................................ 14

indomethacin .................................................................................... 8

indomethacin sodium ...................................................................... 8

INFED .............................................................................................. 16

INFUVITE ....................................................................................... 16

INJECT-EASE AUTOMATIC INJECTOR ................................... 10

INSULIN PUMP SYRINGE RESERVOIR .................................. 10

INTELENCE ..................................................................................... 5

INTRON A ......................................................................................... 6

INVANZ ............................................................................................. 4

INVIRASE ......................................................................................... 5

iodoquinol-hc .................................................................................. 15

ipratropium bromide .................................................................. 6, 15

ipratropium bromide (nasal) ......................................................... 15

IRESSA ............................................................................................. 6

ISENTRESS ..................................................................................... 5

isoflurane ........................................................................................ 14

isoniazid ............................................................................................ 5

ISOPTO HYOSCINE ..................................................................... 12

isosorbide dinitrate .......................................................................... 8

isosorbide mononitrate ................................................................... 8

isotretinoin ...................................................................................... 16

K

KENALOG ...................................................................................... 13

ketamine hcl ................................................................................... 14

ketoconazole ........................................................................ 4, 15, 16

ketoconazole (topical) ............................................................. 15, 16

ketoprofen ......................................................................................... 8

ketorolac tromethamine ............................................................ 8, 12

ketorolac tromethamine (ophth) ................................................... 12




KINERET ......................................................................................... 14

K-PHOS ........................................................................................... 11

L

labetalol hcl ....................................................................................... 8

LACRISERT .................................................................................... 12

lactated ringer's .............................................................................. 11

lactated ringer's (irrigation) ........................................................... 11

lactulose .......................................................................................... 10

lactulose (encephalopathy) ........................................................... 10

lamivudine ......................................................................................... 5

lamivudine (hbv) ............................................................................... 5

lamivudine-zidovudine ..................................................................... 5

lamotrigine ........................................................................................ 9

LANTUS .......................................................................................... 13

latanoprost ...................................................................................... 12

leflunomide...................................................................................... 14

LETAIRIS ........................................................................................ 15

letrozole ............................................................................................. 6

leucovorin calcium ......................................................................... 14

LEUKERAN ...................................................................................... 6

leuprolide acetate ............................................................................. 6

levetiracetam .................................................................................... 9

levobunolol hcl ................................................................................ 12

levocarnitine (metabolic modifiers) .............................................. 14

levofloxacin ....................................................................................... 4

levofloxacin in d5w ........................................................................... 4

levonorgestrel & eth estradiol ....................................................... 13

levonorgestrel-eth estradiol (triphasic) ........................................ 13

LEVOPHED ...................................................................................... 7

levothyroxine sodium ..................................................................... 14

LEXIVA .............................................................................................. 5

lidocaine hcl .................................................................... 8, 12, 14, 16

lidocaine hcl (cardiac) ...................................................................... 8

lidocaine hcl (local anesth.) .......................................................... 14

lidocaine hcl (mouth-throat) .......................................................... 12

lidocaine in d5w .............................................................................. 14

lidocaine w/ epinephrine ........................................................... 8, 14

lidocaine-prilocaine ........................................................................ 14

linezolid ............................................................................................. 4

LINZESS ......................................................................................... 12

liothyronine sodium ........................................................................ 14

lisinopril ............................................................................................. 8

lisinopril & hydrochlorothiazide ...................................................... 8

LITHIUM .......................................................................................... 10

lithium carbonate ............................................................................ 10

lopinavir-ritonavir .............................................................................. 5

lorazepam ......................................................................................... 9

losartan potassium ........................................................................... 8

losartan potassium & hydrochlorothiazide.................................... 8

LOTEMAX ....................................................................................... 12

lovastatin ........................................................................................... 7

LOVENOX ......................................................................................... 7

loxapine succinate ......................................................................... 10

LUCENTIS ...................................................................................... 12

LUPRON DEPOT ............................................................................ 6

LUPRON DEPOT-PED ................................................................... 6

LYSODREN ...................................................................................... 6

M

magnesium sulfate .......................................................................... 9

MANGANESE CHLORIDE ........................................................... 11

MANGANESE SULFATE ............................................................. 11

MATULANE ...................................................................................... 6

medroxyprogesterone acetate ..................................................... 14

medroxyprogesterone acetate (contraceptive) .......................... 14

mefloquine hcl .................................................................................. 5

megestrol acetate ............................................................................ 6

meloxicam ......................................................................................... 8

melphalan hcl ................................................................................... 6

memantine hcl .................................................................................. 9

MENOPUR ..................................................................................... 14

MEPHYTON ................................................................................... 16

MEPRON .......................................................................................... 5

mercaptopurine ................................................................................ 6

mesalamine .................................................................................... 12

mesna .............................................................................................. 14

METAPROTERENOL SULFATE .................................................. 7

metformin hcl .................................................................................. 13

methadone hcl.................................................................................. 8

methazolamide ................................................................................. 8

methenamine hippurate .................................................................. 5

methenamine mandelate ................................................................ 5

methimazole ................................................................................... 14

methocarbamol ................................................................................ 7

methotrexate sodium ................................................................. 6, 15

methoxsalen rapid ......................................................................... 16

methyldopa ....................................................................................... 8

methylene blue (antidote) ............................................................. 13

methylergonovine maleate ........................................................... 15

methylphenidate hcl ........................................................................ 9

methylprednisolone ....................................................................... 13

methylprednisolone acetate ......................................................... 13

methylprednisolone sod succ....................................................... 13

methyltestosterone ........................................................................ 13

metoclopramide hcl ....................................................................... 12

metolazone ..................................................................................... 11

METOPIRONE ............................................................................... 14

metoprolol succinate ....................................................................... 8

metoprolol tartrate ........................................................................... 8

METRO ............................................................................................. 5

metronidazole ............................................................................. 5, 15

metronidazole (topical) ................................................................. 15

metronidazole vaginal ................................................................... 15

midazolam hcl .................................................................................. 9

midodrine hcl .................................................................................... 7

MINILINK REAL-TIME REPLACEMENT ................................... 10

minocycline hcl ................................................................................. 4




minoxidil ............................................................................................ 8

mirtazapine ..................................................................................... 10

misoprostol ...................................................................................... 12

mitomycin .......................................................................................... 6

mitoxantrone hcl ............................................................................... 6

mometasone furoate...................................................................... 16

montelukast sodium ....................................................................... 15

morphine sulfate............................................................................... 8

moxifloxacin hcl ................................................................................ 4

mupirocin ......................................................................................... 15

mupirocin calcium (topical) ........................................................... 15

MUSTARGEN................................................................................... 6

mycophenolate mofetil .................................................................. 15

MYLERAN ......................................................................................... 6

N

NABI-HB .......................................................................................... 15

nabumetone ...................................................................................... 9

naloxone hcl ...................................................................................... 9

naltrexone hcl ................................................................................... 9

naproxen ........................................................................................... 9

naratriptan hcl ................................................................................... 9

NEBUPENT ...................................................................................... 5

NECON 1/50 (28) ........................................................................... 13

nefazodone hcl ............................................................................... 10

neomycin sulfate .............................................................................. 4

neomycin-polymy-dexameth ........................................................ 12

NEOMYCIN-POLYMYXIN-HC ..................................................... 12

neomycin-polymyxin-hc (otic) ....................................................... 12

NEOSTIGMINE METHYLSULFATE ............................................. 7

NESACAINE ................................................................................... 15

NEUPOGEN ..................................................................................... 7

nevirapine.......................................................................................... 5

NEXAVAR ......................................................................................... 6

nifedipine ........................................................................................... 8

nimodipine ......................................................................................... 8

NIPENT ............................................................................................. 6

nitrofurantoin ..................................................................................... 5

nitrofurantoin macrocrystal ............................................................. 5

nitrofurantoin monohyd macro ....................................................... 5

nitroglycerin ...................................................................................... 8

NITROPRESS .................................................................................. 8

NORDIPEN DELIVERY SYSTEM ............................................... 10

norethin acet & estrad-fe............................................................... 13

norethindrone & eth estradiol ....................................................... 13

norethindrone (contraceptive) ...................................................... 13

norethindrone acetate ................................................................... 14

norethindrone-eth estradiol (triphasic) ........................................ 13

norgestimate-ethinyl estradiol ...................................................... 13

norgestimate-ethinyl estradiol (triphasic) .................................... 13

nortriptyline hcl ............................................................................... 10

NORVIR ............................................................................................ 5

NUVARING ..................................................................................... 13

nystatin .............................................................................. 4, 5, 15, 16

nystatin (mouth-throat) .................................................................... 5

nystatin (topical) ............................................................................. 15

nystatin-triamcinolone ................................................................... 16

O

octreotide acetate .......................................................................... 15

ODEFSEY ......................................................................................... 5

ofloxacin (ophth) ............................................................................ 11

ofloxacin (otic) ................................................................................ 11

olanzapine ...................................................................................... 10

omeprazole ..................................................................................... 12

OMNIPAQUE ................................................................................. 14

OMNITROPE............................................................................ 14, 15

OMNITROPE PEN 10 INJ DEVICE ............................................ 15

ondansetron ................................................................................... 12

ondansetron hcl ............................................................................. 12

ONETOUCH VERIO ..................................................................... 10

ophthalmic irrigation solution - intraocular ................................. 12

OPSUMIT ......................................................................................... 8

ORENCIA ....................................................................................... 15

ORTHO DIAPHRAGM ALL-FLEX KIT 65 .................................. 14

OSPHENA ...................................................................................... 15

OTEZLA .......................................................................................... 15

oxazepam ......................................................................................... 9

oxcarbazepine .................................................................................. 9

oxybutynin chloride ........................................................................ 16

oxycodone hcl .................................................................................. 9

oxycodone w/ acetaminophen ....................................................... 9

oxytocin ........................................................................................... 15

OXYTROL ....................................................................................... 16

P

paclitaxel ........................................................................................... 6

pamidronate disodium ................................................................... 15

PANCRELIPASE (LIP-PROT-AMYL) ......................................... 12

pantoprazole sodium ..................................................................... 12

PAREGORIC .................................................................................. 12

paromomycin sulfate ....................................................................... 5

paroxetine hcl ................................................................................. 10

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate .............. 12, 15

PEGASYS......................................................................................... 5

penicillin g potassium ...................................................................... 4

PENICILLIN G PROCAINE ............................................................ 4

PENICILLIN G SODIUM ................................................................. 4

penicillin v potassium ...................................................................... 4

pentoxifylline ..................................................................................... 7

permethrin....................................................................................... 16

perphenazine ................................................................................. 10

phenelzine sulfate .......................................................................... 10

phenobarbital ................................................................................... 9

phenoxybenzamine hcl ................................................................... 7

PHENTOLAMINE MESYLATE ...................................................... 8

phenylephrine hcl (ophth) ............................................................. 12




phenytoin ........................................................................................... 9

phenytoin sodium ............................................................................. 9

phenytoin sodium extended ........................................................... 9

PHOSPHOLINE IODIDE............................................................... 12

PHYSOSTIGMINE SALICYLATE ................................................ 13

pilocarpine hcl............................................................................. 7, 12

pilocarpine hcl (oral) ........................................................................ 7

pimozide .......................................................................................... 10

pioglitazone hcl............................................................................... 13

piperacillin sodium-tazobactam sodium ........................................ 4

PLASMANATE ................................................................................. 7

podofilox .......................................................................................... 16

polymyxin b-trimethoprim .............................................................. 11

pot phosphate monobasic w/ sod phosphate dibasic &

monobasic ................................................................................. 11

POTABA .......................................................................................... 16

potassium acetate .......................................................................... 11

potassium chloride ......................................................................... 11

potassium chloride in dextrose & sodium chloride .................... 11

potassium chloride microencapsulated crystals cr .................... 11

potassium citrate (alkalinizer) ....................................................... 10

potassium citrate-citric acid .......................................................... 10

potassium phosphates .................................................................. 11

PRADAXA ......................................................................................... 7

pramipexole dihydrochloride .......................................................... 9

pravastatin sodium ........................................................................... 8

prazosin hcl ....................................................................................... 7

PRECISION XTRA KETONE ....................................................... 10

PRED-G .......................................................................................... 12

prednisolone ............................................................................. 12, 13

prednisolone acetate (ophth) ....................................................... 12

prednisolone sodium phosphate .................................................. 13

PREDNISOLONE SODIUM PHOSPHATE ................................ 12

prednisone ...................................................................................... 13

PREMARIN CRM ........................................................................... 13

PREMARIN INJ .............................................................................. 13

PREZISTA ........................................................................................ 5

PRIMAQUINE PHOSPHATE ......................................................... 5

primidone .......................................................................................... 9

PRIMSOL .......................................................................................... 4

probenecid ...................................................................................... 11

PROCAINAMIDE HCL .................................................................... 8

prochlorperazine ...................................................................... 10, 12

prochlorperazine edisylate ............................................................ 10

prochlorperazine maleate ............................................................. 10

PROCRIT .......................................................................................... 7

PROCTOFOAM HC ....................................................................... 16

PROFILNINE .................................................................................... 7

progesterone .................................................................................. 14

promethazine hcl .............................................................................. 5

propafenone hcl ............................................................................... 8

PROPANTHELINE BROMIDE ....................................................... 6

proparacaine hcl............................................................................. 12

propofol ........................................................................................... 15

propranolol hcl .................................................................................. 8

propylthiouracil ............................................................................... 14

PROSOL ......................................................................................... 10

PROTAMINE SULFATE ................................................................. 7

PROVISC ........................................................................................ 12

PROVOCHOLINE .......................................................................... 14

PULMOZYME ................................................................................ 15

pyrazinamide .................................................................................... 5

pyridostigmine bromide ................................................................... 7

pyridoxine hcl ................................................................................. 16

Q

quetiapine fumarate....................................................................... 10

quinidine gluconate ......................................................................... 8

QUINIDINE SULFATE .................................................................... 8

QVAR .............................................................................................. 13

R

raloxifene hcl .................................................................................. 13

ranitidine hcl ................................................................................... 12

REMICADE ..................................................................................... 15

RENVELA ....................................................................................... 11

RESCRIPTOR.................................................................................. 5

RESTASIS ...................................................................................... 12

REVLIMID ......................................................................................... 6

REYATAZ ......................................................................................... 5

ribavirin (hepatitis c) ........................................................................ 5

RIDAURA ........................................................................................ 13

rifampin ............................................................................................. 5

riluzole ............................................................................................... 9

rimantadine hydrochloride .............................................................. 5

RIMSO-50 ....................................................................................... 15

risperidone ...................................................................................... 10

RITUXAN .......................................................................................... 6

rizatriptan benzoate ......................................................................... 9

rocuronium bromide ........................................................................ 9

ropinirole hydrochloride .................................................................. 9

rosuvastatin calcium ........................................................................ 8

S

saline, bacteriostatic ...................................................................... 11

salsalate ............................................................................................ 9

SANDIMMUNE .............................................................................. 15

SANTYL .......................................................................................... 16

SAVELLA ........................................................................................ 10

SCOPOLAMINE HBR ..................................................................... 7

selegiline hcl ..................................................................................... 9

SELENIUM ..................................................................................... 11

selenium sulfide ............................................................................. 15

SELZENTRY .................................................................................... 5

SENSIPAR ..................................................................................... 15

SEREVENT DISKUS ...................................................................... 7

sertraline hcl ................................................................................... 10




sevoflurane ..................................................................................... 15

SIDEKICK BLOOD GLUCOSE SYSTEM ................................... 10

sildenafil citrate (pulmonary hypertension) ................................... 8

silver sulfadiazine ........................................................................... 15

simvastatin ........................................................................................ 8

sirolimus .......................................................................................... 15

sodium acetate ............................................................................... 10

sodium bicarbonate ................................................................. 10, 11

sodium chloride ........................................................................ 11, 15

sodium chloride (gu irrigant) ......................................................... 11

sodium chloride (inhalant)............................................................. 15

sodium citrate & citric acid ............................................................ 10

SODIUM EDECRIN ....................................................................... 11

sodium phosphate ......................................................................... 11

sodium polystyrene sulfonate ................................................. 11, 15

SODIUM THIOSULFATE .............................................................. 13

SOLU-CORTEF ............................................................................. 13

sotalol hcl .......................................................................................... 8

SOVALDI ........................................................................................... 5

SPIRIVA RESPIMAT ....................................................................... 7

spironolactone .................................................................................. 8

spironolactone & hydrochlorothiazide ........................................... 8

SPRYCEL ......................................................................................... 6

SSKI ................................................................................................. 11

stavudine ........................................................................................... 5

STIOLTO RESPIMAT ...................................................................... 7

STREPTOMYCIN SULFATE.......................................................... 4

STRIBILD .......................................................................................... 5

STRIVERDI RESPIMAT ................................................................. 7

sucralfate ......................................................................................... 12

sufentanil citrate ............................................................................... 9

sulfacetamide sodium (acne) ....................................................... 15

sulfacetamide sodium (ophth) ...................................................... 11

sulfacetamide sod-prednisolone .................................................. 12

sulfamethoxazole-trimethoprim ...................................................... 4

sulfasalazine ..................................................................................... 4

sulindac ............................................................................................. 9

sumatriptan ....................................................................................... 9

sumatriptan succinate ..................................................................... 9

SUPRANE ....................................................................................... 15

SUSTIVA ........................................................................................... 5

SUTENT ............................................................................................ 6

SYNAGIS .......................................................................................... 5

SYNAREL ....................................................................................... 14

T

TABLOID ........................................................................................... 6

tacrolimus .................................................................................. 15, 16

tacrolimus (topical) ......................................................................... 16

TAMIFLU ........................................................................................... 5

tamoxifen citrate ............................................................................... 6

tamsulosin hcl ................................................................................. 15

TARCEVA ......................................................................................... 6

TASIGNA .......................................................................................... 6

TAZORAC ....................................................................................... 16

temazepam ....................................................................................... 9

temozolomide ................................................................................... 6

terazosin hcl ..................................................................................... 7

terbinafine hcl ................................................................................. 15

terbutaline sulfate ............................................................................ 7

TESTOSTERONE PROPIONATE .............................................. 13

tetracaine hcl (ophth) .................................................................... 12

tetracycline hcl ................................................................................. 4

THALOMID ..................................................................................... 15

theophylline .............................................................................. 15, 16

thiamine hcl .................................................................................... 16

THIOLA ........................................................................................... 15

thioridazine hcl ............................................................................... 10

THIOTEPA ........................................................................................ 6

thiothixene ...................................................................................... 10

THROMBIN-JMI ............................................................................... 7

timolol maleate (ophth) ................................................................. 12

TIVICAY ............................................................................................ 5

tizanidine hcl ..................................................................................... 7

TNKASE ............................................................................................ 7

tobramycin .................................................................................. 4, 11

tobramycin (ophth)......................................................................... 11

TOBRAMYCIN SULFATE .............................................................. 4

TOLBUTAMIDE ............................................................................. 13

topiramate ......................................................................................... 9

topotecan hcl .................................................................................... 6

TORISEL........................................................................................... 6

torsemide ........................................................................................ 11

TRACLEER ...................................................................................... 8

tramadol hcl ...................................................................................... 9

tranexamic acid ................................................................................ 7

TRANSDERM-SCOP (1.5 MG) ................................................... 12

tranylcypromine sulfate ................................................................. 10

trazodone hcl .................................................................................. 10

tretinoin ....................................................................................... 6, 16

tretinoin (chemotherapy) ................................................................. 6

triamcinolone acetonide (mouth) ................................................. 16

triamcinolone acetonide (topical) ................................................. 16

triamterene & hydrochlorothiazide .............................................. 11

triazolam ........................................................................................... 9

trifluoperazine hcl .......................................................................... 10

trifluridine ........................................................................................ 11

trihexyphenidyl hcl ........................................................................... 7

trimethoprim ..................................................................................... 5

TRIZIVIR ........................................................................................... 5

tropicamide ..................................................................................... 12

trospium chloride ........................................................................... 16

TRUVADA ......................................................................................... 5

TUBERSOL .................................................................................... 14

TYKERB ............................................................................................ 6

U

UROQID #2 ...................................................................................... 5




URSO FORTE ................................................................................ 13

ursodiol ............................................................................................ 15

V

valganciclovir hcl .............................................................................. 5

valproate sodium .............................................................................. 9

valproic acid ...................................................................................... 9

vancomycin hcl ................................................................................. 4

VANCOMYCIN HCL IN DEXTROSE ............................................ 4

VARIZIG .......................................................................................... 15

vasopressin ..................................................................................... 14

VECTICAL ...................................................................................... 16

vecuronium bromide ........................................................................ 9

venlafaxine hcl ................................................................................ 10

VENOFER ....................................................................................... 16

VENTAVIS ........................................................................................ 8

verapamil hcl .................................................................................... 8

VINBLASTINE SULFATE ............................................................... 6

vincristine sulfate ............................................................................. 6

vinorelbine tartrate ........................................................................... 6

VIRACEPT ........................................................................................ 5

VIREAD ............................................................................................. 5

voriconazole ...................................................................................... 5

VOTRIENT ........................................................................................ 6

VPRIV .............................................................................................. 11

W

warfarin sodium ................................................................................ 7

water for injection, sterile ........................................................ 11, 15

water for irrigation, sterile ............................................................. 11

X

XALKORI .......................................................................................... 6

XGEVA ............................................................................................ 15

XTANDI ............................................................................................. 6

Z

ZARXIO ............................................................................................. 7

ZELBORAF ....................................................................................... 6

zidovudine......................................................................................... 5

zinc sulfate ...................................................................................... 11

ZINC TRACE METAL ................................................................... 11

ziprasidone hcl ............................................................................... 10

ZOLADEX ......................................................................................... 6

zoledronic acid ............................................................................... 15

zolpidem tartrate .............................................................................. 9

zonisamide ....................................................................................... 9

ZOSYN .............................................................................................. 4

ZYDELIG........................................................................................... 6

ZYTIGA ............................................................................................. 6

Please recycle. <MOM Tracking Number> 11/2015

Colorado Region Member Services 1-800-632-9700 for Denver/Boulder, Mountain Colorado or Northern Colorado 1-888-681-7878 for Southern Colorado TTY 1-800-521-4874 Monday through Friday, 8 a.m. to 5 p.m.








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