eutf.silverscript.comc183553f... · 2013-12-13 · P.O. Box 52424, Phoenix, AZ 85072-2424...

P.O. Box 52424, Phoenix, AZ 85072-2424

SilverScript (Employer PDP) sponsored by HawaiiEmployer-Union Health Benefits Trust Fund (HSTA VBPlan)

2014 Formulary(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WECOVER IN THIS PLAN

This formulary was updated on 08/27/2013. For more recent information or other questions, pleasecontact SilverScript (Employer PDP), at 1-877-878-5715 or, for TTY users, 1-866-236-1069, 24 hours aday, 7 days a week.

Note to existing members: This formulary has changed since last year. Please review this document tomake sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we”, “us”, or “our”, it means SilverScript® InsuranceCompany. When it refers to “plan” or “our plan,” it means SilverScript (Employer PDP).

This document includes a list of the drugs (formulary) for our plan which is current as of 01/01/2014.For an updated formulary, please contact us. Our contact information, along with the date we lastupdated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2015.

Y0080_FORM_Comp_10002CLT_2014_9445_2631_801

What is the SilverScript (Employer PDP) formulary?

A formulary is a list of covered drugs selected by SilverScript (Employer PDP) in consultation with ateam of health care providers, which represents the prescription therapies believed to be a necessary partof a quality treatment program.

SilverScript (Employer PDP) will generally cover the drugs listed in our formulary as long as the drug ismedically necessary, the prescription is filled at a SilverScript (Employer PDP) network pharmacy, andother plan rules are followed. For more information on how to fill your prescriptions, please review yourEvidence of Coverage.

Please note: Your employer provides secondary coverage that may differ in structure from the primarybenefit and also cover additional medications. There may be instances where your cost share may bemore or less when it is paid by the secondary. If you are unsure about the cost share on the secondary orwhich drugs may or may not be covered, please call Customer Care to verify drug coverage.

Can the formulary (drug list) change?

Generally, if you are taking a drug on our 2014 formulary that was covered at the beginning of the year,we will not discontinue or reduce coverage of the drug during the 2014 coverage year except when anew, less expensive generic drug becomes available or when new adverse information about the safetyor effectiveness of a drug is released.

Other types of formulary changes, such as removing a drug from our formulary, will not affect memberswho are currently taking the drug. It will remain available at the same cost-sharing for those memberstaking it for the remainder of the coverage year.

We feel it is important that you have continued access for the remainder of the coverage year to theformulary drugs that were available when you chose our plan, except for cases in which you can saveadditional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits, and/or step therapyrestrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members ofthe change at least 60 days before the change becomes effective, or at the time the member requests arefill of the drug, at which time the member will receive a 60-day supply of the drug.

If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’smanufacturer removes the drug from the market, we will immediately remove the drug from ourformulary and provide notice to members who take the drug.

The enclosed formulary is current as of January 1, 2014. To get updated information about the drugscovered by SilverScript (Employer PDP), please contact us. Our contact information appears on thefront and back cover pages.

If we have a mid-year non-maintenance formulary change (i.e. remove drugs from our formulary, addprior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a highercost-sharing tier), we will notify you by mail. We will also update our print formulary by reprinting itwith the new information. The updated formulary may be obtained by calling us. Our contactinformation appears on the front and back cover pages.

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How do I use the formulary?

There are two ways to find your drug within the formulary:

Medical ConditionThe formulary begins after this introduction on page 1. The drugs in this formulary are groupedinto categories depending on the type of medical conditions that they are used to treat. Forexample, drugs used to treat a heart condition are listed under the category, “Cardiovascular”. Ifyou know what your drug is used for, look for the category name in the list that begins on page 1.Then look under the category name for your drug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index at theback of this document. The Index provides an alphabetical list of all of the drugs included in thisdocument. Both brand-name drugs and generic drugs are listed in the Index. Look in the Indexand find your drug. Next to your drug, you will see the page number where you can findcoverage information. Turn to the page listed in the Index and find the name of your drug in thefirst column of the list.

What are generic drugs?

SilverScript (Employer PDP) covers both brand-name drugs and generic drugs. A generic drug isapproved by the FDA as having the same active ingredient as the brand name drug. Generally, genericdrugs cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements andlimits may include:

Prior Authorization (PA)SilverScript (Employer PDP) requires you or your physician to get prior authorization for certaindrugs. This means that you will need to get approval from SilverScript (Employer PDP) beforeyou fill your prescriptions. If you don’t get approval, SilverScript (Employer PDP) may notcover the drug.

Quantity Limits (QL)For certain drugs, SilverScript (Employer PDP) limits the amount of the drug that SilverScript(Employer PDP) will cover. For example, SilverScript (Employer PDP) provides up to ninetablets per prescription for sumatriptan tab 50mg.

Step Therapy (ST)In some cases, SilverScript (Employer PDP) requires you to first try a certain drug to treat yourmedical condition before we will cover another drug for that condition. For example, if Drug Aand Drug B both treat your medical condition, SilverScript (Employer PDP) may not cover DrugB unless you try Drug A first. If Drug A does not work for you, SilverScript (Employer PDP)will then cover Drug B.

III

You can find out if your drug has any additional requirements or limits by looking in the formulary thatbegins on page 1. Our contact information, along with the date we last updated the formulary, appears onthe front and back cover pages.

You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugsthat may treat your health condition. See the section, “How do I request an exception to the SilverScript(Employer PDP) formulary?” below for information about how to request an exception.

What if my drug is not on the formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact CustomerCare and ask if your drug is covered.

If you learn that SilverScript (Employer PDP) does not cover your drug, you have two options

§ You can ask Customer Care for a list of similar drugs that are covered by our plan. When youreceive the list, show it to your doctor and ask him or her to prescribe a similar drug that iscovered by our plan.

§ You can ask us to make an exception and cover your drug. See below for information about howto request an exception.

Hawaii Employer-Union Health Benefits Trust Fund (HSTA VB Plan) has elected to cover certain drugsnot covered under Medicare Part D as described and dispensed as part of a supplemental benefit. Theseare not subject to the appeals and exceptions process. Please contact Customer Care for any questionsregarding your supplemental benefit.

How do I request an exception to the SilverScript (Employer PDP) formulary?

You can ask us to make an exception to our coverage rules. There are several types of exceptions thatyou can ask us to make.

§ You can ask us to cover your drug even if it is not on our formulary. If approved, this drug willbe covered at a pre-determined cost-sharing level, and you would not be able to ask us toprovide the drug at a lower cost-sharing level.

§ You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on thespecialty tier. If approved this would lower the amount you must pay for your drug.

§ You can ask us to waive coverage restrictions or limits on your drug. For example, for certaindrugs our plan limits the amount of the drug that we will cover. If applicable, and your drug hasa quantity limit, you can ask us to waive the limit and cover a greater amount.

Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us toprovide a higher level of coverage for the drug.

Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty Tier.

IV

Generally, SilverScript (Employer PDP) will only approve your request for an exception if thealternative drug is included on the plan’s formulary, the lower cost-sharing drug or additional utilizationrestrictions would not be as effective in treating your condition and/or would cause you to have adversemedical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilizationrestriction exception. When you request a formulary, tiering or utilization restriction exception youshould submit a statement from your prescriber or physician supporting your request.

Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement.You can request an expedited (fast) exception if you or your doctor believe that your health could beseriously harmed by waiting up to 72 hours for a decision.

If your request to expedite is granted, we must give you a decision no later than 24 hours after we get asupporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting anexception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or,you may be taking a drug that is on our formulary but your ability to get it is limited. For example, youmay need a prior authorization from us before you can fill your prescription. You should talk to yourdoctor to decide if you should switch to an appropriate drug that we cover or request a formularyexception so that we will cover the drug you take.

While you talk to your doctor to determine the right course of action for you, we may cover your drug incertain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we willcover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go toa network pharmacy.

After your first 30-day supply, we will not pay for these drugs, even if you have been a member of theplan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until wehave provided you with a 31-day transition supply, consistent with the dispensing increment, (unlessyou have a prescription written for fewer days). We will cover more than one refill of these drugs for thefirst 90 days you are a member of our plan. If you need a drug that is not on our formulary or if yourability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we willcover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while youpursue a formulary exception.

If you experience a change in your level of care, such as a move from a hospital to a home setting, andyou need a drug that is not on our formulary (or if your ability to get your drugs is limited), we maycover a one-time temporary supply from a network pharmacy for up to 30 days (or 31 days if you are along-term care resident) unless you have a prescription for fewer days. You should use the plan'sexception process if you wish to have continued coverage of the drug after the temporary supply isfinished.

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For more information

For more detailed information about your SilverScript (Employer PDP) prescription drug coverage,please review your Evidence of Coverage.

If you have questions about our plan, please contact us. Our contact information, along with the date welast updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call1-877-486-2048. Or, visit www.medicare.gov. Or, visit www.medicare.gov.

SilverScript (Employer PDP)'s Formulary

The formulary that begins on page 1 provides coverage information about some of the drugs covered byour plan. If you have trouble finding your drug in the list, turn to the Index at the back of this book.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., SYNTHROID)and generic drugs are listed in lowercase italics (e.g., levothyroxine).

The information in the Notes column tells you if SilverScript (Employer PDP) has any specialrequirements for coverage of your drug.

PA Prior Authorization.

QL Drug has Quantity Limits.

ST Step Therapy required.

NM Not available at our mail-order pharmacies.

LA Limited Access. This prescription may be available only at certain pharmacies. For moreinformation consult your Pharmacy Directory or call Customer Care at 1-877-878-5715,24 hours a day, 7 days a week. TTY Users should call .

HR High Risk Drug. According to medical experts, these drugs may cause more side effectsif you are 65 years of age or older. If you are taking one of these drugs, ask your doctor ifthere are safer options available.

B/D This drug may be covered under Medicare Part B or D depending upon thecircumstances. Information may need to be submitted describing the use and setting ofthe drug to make the determination.

GC We provide coverage of this prescription drug in the coverage gap. Please refer to yourEvidence of Coverage for more information about this coverage.

VI

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access

1

2014 601 4T Copper Comm (Effective January 1)

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol inj 500mg (generic of ALOPRIM)

1

ALLOPURINOL SODIUM 3 allopurinol tab (generic of ZYLOPRIM)

1

colchicine w/ probenecid 1 COLCRYS

QL (120 tabs / 30 days) 2 QL

probenecid 1 ULORIC 2 ST

ZYLOPRIM 3

MISCELLANEOUS ARTHROTEC 3 diclofenac w/ misoprostol (generic of ARTHROTEC 50)

1

diclofenac w/ misoprostol (generic of ARTHROTEC 75)

1

DUEXIS 3 VIMOVO 2

NSAIDS ANAPROX 2 ANAPROX DS 2 CATAFLAM 3 CELEBREX 2 DAYPRO 2 diclofenac potassium (generic of CATAFLAM)

1

diclofenac sodium (generic of VOLTAREN-XR) TB24

1

diclofenac sodium TBEC 1 diflunisal 1 EC-NAPROSYN 3 etodolac CAPS; TABS 1 etodolac er 1 FELDENE 3 fenoprofen calcium TABS 1 flurbiprofen TABS 1 ibuprofen SUSP 1

Drug Name Drug Tier

Requirements/Limits

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS; CP24 1 mefenamic acid (generic of PONSTEL) CAPS

1

MELOXICAM SUSP 7.5 MG/5ML

1

meloxicam tabs (generic of MOBIC)

1

MOBIC 2 nabumetone TABS 1 NALFON 3 NAPRELAN 3 NAPROSYN 2 naproxen (generic of NAPROSYN) SUSP; TABS

1

naproxen (generic of EC-NAPROSYN) TBEC

1

naproxen sodium (generic of ANAPROX) TABS 275mg

1

naproxen sodium (generic of ANAPROX DS) TABS 550mg

1

oxaprozin (generic of DAYPRO)

1

piroxicam (generic of FELDENE) CAPS

1

PONSTEL 4 NM

sulindac TABS 150mg 1 sulindac (generic of CLINORIL) TABS 200mg

1

tolmetin sodium 1 VOLTAREN-XR 3 ZIPSOR 3

OPIOID ANALGESICS acetaminophen w/ codeine SOLN

QL (5000mL / 30 days)

1 QL

acetaminophen w/ codeine TABS

QL (400 tabs / 30 days)

1 QL

acetaminophen w/ codeine (generic of TYLENOL/CODEINE #3) TABS


1 QL

1


2

Drug Name Drug Tier

Requirements/Limits

acetaminophen w/ codeine (generic of TYLENOL/CODEINE #4) TABS


1 QL

butorphanol nasal spray QL (10 mL / 30 days)

1 QL

butorphanol tartrate SOLN 1 BUTRANS 5mcg/hr

QL (16 ea / 28 days) 3 QL

BUTRANS 10mcg/hr QL (8 ea / 28 days)

3 QL

BUTRANS 20mcg/hr QL (4 ea / 28 days)

3 QL

capital and codeine QL (5000mL / 30 days)

3 QL

co-gesic 5-500mg (generic of LORTAB)


1 QL

CONZIP 100mg QL (90 caps / 30 days)

3 QL


3 QL


3 QL

hycet QL (5400mL / 30 days)

3 QL

hydrocodone-acetaminophen 2.5-325mg


1 QL



1 QL

hydrocodone-acetaminophen 5-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen 5-325mg (generic of NORCO)


1 QL

hydrocodone-acetaminophen 5-500mg (generic of LORTAB)


1 QL

hydrocodone-acetaminophen 7.5-300mg (generic of XODOL)


1 QL

Drug Name Drug Tier

Requirements/Limits

hydrocodone-acetaminophen 7.5-325 mg/15ml (generic of HYCET)

QL (5400mL / 30 days)

1 QL

hydrocodone-acetaminophen 7.5-325mg (generic of NORCO)


1 QL

hydrocodone-acetaminophen 7.5-500mg (generic of LORTAB)


1 QL

hydrocodone-acetaminophen 7.5-500mg/15ml (generic of LORTAB)

QL (3600 mL / 30 days)

1 QL

hydrocodone-acetaminophen 7.5-650mg (generic of ANEXSIA)


1 QL



1 QL

hydrocodone-acetaminophen 10-300mg (generic of XODOL)


1 QL

hydrocodone-acetaminophen 10-500mg (generic of LORTAB)


1 QL

hydrocodone-acetaminophen 10-650mg (generic of LORCET 10/650)


1 QL

hydrocodone-acetaminophen 10-660mg


1 QL

hydrocodone-acetaminophen 10-750mg (generic of MAXIDONE)


1 QL

hydrocodone-acetaminophen tab 10-325mg (generic of NORCO)


1 QL

2


3

Drug Name Drug Tier

Requirements/Limits

hydrocodone-ibuprofen 2.5-200mg (generic of REPREXAIN)

QL (150 tabs per 30 days)

1 QL

hydrocodone-ibuprofen 7.5-200mg (generic of VICOPROFEN)


1 QL

ibudone tab 5-200mg (generic of REPREXAIN)


1 QL

lorcet 10/650 QL (185 tabs / 30 days)

3 QL

lorcet plus QL (185 tabs / 30 days)

3 QL

lortab 5/500 QL (240 tabs / 30 days)

3 QL

lortab 7.5/500 ELIX QL (3600 mL / 30 days)

3 QL

lortab 7.5/500 TABS QL (240 tabs / 30 days)

3 QL

lortab 10/500 QL (240 tabs / 30 days)

3 QL

maxidone QL (160 tabs / 30 days)

3 QL

norco 5/325 QL (360 tabs / 30 days)

3 QL

norco 7.5/325 QL (360 tabs / 30 days)

3 QL

norco 10/325 QL (360 tabs / 30 days)

3 QL

percocet 7.5/500 QL (240 tabs / 30 days)

3 QL

percocet 10/650 QL (180 tabs / 30 days)

3 QL

reprexain 2.5/200 QL (150 tabs / 30 days)

3 QL

reprexain 5/200 QL (150 tabs / 30 days)

3 QL

reprexain 10/200 QL (150 tabs / 30 days)

1 QL

stagesic 500-5mg QL (240 caps / 30 days)

1 QL

SYNALGOS-DC QL (360 caps / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

tramadol hcl er (generic of ULTRAM ER) TB24 100mg


1 QL

tramadol hcl er (generic of ULTRAM ER) TB24 200mg


1 QL

TRAMADOL HCL ER TB24 300mg


1 QL

TRAMADOL HCL ER (BIPHASIC) 100MG


1 QL

TRAMADOL HCL ER (BIPHASIC) 200MG


1 QL

tramadol hcl er (biphasic) 300mg


1 QL

tramadol hcl tab 50 mg (generic of ULTRAM)


1 QL

tramadol-acetaminophen (generic of ULTRACET)


1 QL

tylenol with codeine #3 QL (400 tabs / 30 days)

3 QL

tylenol with codeine #4 QL (400 tabs / 30 days)

3 QL

ULTRACET QL (240 tabs / 30 days)

3 QL

ULTRAM QL (240 tabs / 30 days)

2 QL

ULTRAM ER 100mg QL (90 tabs / 30 days)

3 QL


3 QL


3 QL

vicodin (generic of XODOL) QL (400 tabs / 30 days)

1 QL

vicodin es (generic of XODOL)


1 QL

vicodin hp (generic of XODOL)


1 QL

3


4

Drug Name Drug Tier

Requirements/Limits

VICOPROFEN QL (150 tabs / 30 days)

3 QL

xodol 5/300 3 xodol 7.5/300


xodol 10/300 QL (400 tabs / 30 days)

3 QL

zamicet QL (5400mL / 30 days)

3 QL

OPIOID ANALGESICS, CII ABSTRAL

QL (120 ea / 30 days) 4 QL NM PA

ACTIQ QL (120 lpop / 30 days)

4 QL NM PA

astramorph 1 B/D

AVINZA QL (60 ea / 30 days)

2 QL

CODEINE SULFATE TABS 1 DILAUDID INJ 3 B/D

DILAUDID TAB 3 DILAUDID-5 ORAL LIQD 3 DILAUDID-HP INJ 3 B/D

DOLOPHINE QL (240 tabs / 30 days)

3 QL

DURAGESIC 12mcg/hr, 25mcg/hr, 50mcg/hr

QL (10 ea / 30 days)

3 QL

DURAGESIC 75mcg/hr, 100mcg/hr


4 QL NM

DURAMORPH 1 B/D

endocet 5/325 (generic of PERCOCET)


1 QL

endocet 7.5/325 (generic of PERCOCET)


1 QL

endocet 7.5/500 (generic of PERCOCET)


1 QL



1 QL



1 QL

ENDODAN QL (360 tabs / 30 days)

1 QL

Drug Name Drug Tier

Requirements/Limits

EXALGO 8mg, 12mg QL (60 ea / 30 days)

2 QL

EXALGO 16mg, 32mg QL (60 ea / 30 days)

4 QL NM

fentanyl citrate (generic of ACTIQ) LPOP

QL (120 lpop / 30 days)

4 QL NM PA

fentanyl patch (generic of DURAGESIC)


1 QL

FENTORA QL (120 tabs / 30 days)

4 QL NM PA

hydromorphone hcl (generic of DILAUDID-5) LIQD

1

hydromorphone hcl (generic of DILAUDID-HP) SOLN 500mg/50ml

1 B/D

hydromorphone hcl (generic of DILAUDID) TABS

1

INFUMORPH 200 3 B/D

INFUMORPH 500 3 B/D

KADIAN QL (60 caps / 30 days)

2 QL

LAZANDA QL (30 / 30 days)

4 QL NM PA

levorphanol tartrate TABS 1 methadone hcl CONC 1 methadone hcl SOLN 1 methadone hcl (generic of DOLOPHINE HCL) TABS 5mg


1 QL

methadone hcl (generic of DOLOPHINE) TABS 10mg


1 QL

METHADONE INJ 10MG/ML 3 MORPHINE SUL 20MG/ML ORAL SOL

1

MORPHINE SULFATE SOLN 10mg/5ml, 20mg/5ml

1

MORPHINE SULFATE TABS


1 QL

morphine sulfate ext-rel tab (generic of MS CONTIN) 15mg, 30mg, 60mg, 100mg


1 QL

4


5

Drug Name Drug Tier

Requirements/Limits

morphine sulfate ext-rel tab (generic of MS CONTIN) 200mg


1 QL

MORPHINE SULFATE INJ 1mg/ml, 4mg/ml, 8mg/ml, 10mg/ml, 15mg/ml

1 B/D

morphine sulfate inj .5mg/ml, 1mg/ml

1 B/D

MS CONTIN 15mg, 30mg, 60mg


3 QL

MS CONTIN 100mg QL (90 ea / 30 days)

4 QL NM

MS CONTIN 200mg QL (60 ea / 30 days)

4 QL NM

NUCYNTA 2 NUCYNTA ER 50mg, 100mg

QL (120 ea / 30 days)

2 QL

NUCYNTA ER 150mg, 200mg, 250mg


2 QL

ONSOLIS QL (120 ea / 30 days)

4 QL NM PA

OPANA TABS 3 OPANA ER (CRUSH RESISTANT

QL (120 ea / 30 days)

2 QL

OXECTA 3 OXYCODONE HCL CAPS

QL (180 caps / 30 days) 1 QL

OXYCODONE HCL CONC 1 OXYCODONE HCL SOLN 1 oxycodone hcl (generic of ROXICODONE) TABS 5mg, 15mg, 30mg


1 QL

oxycodone hcl TABS 10mg, 20mg


1 QL

oxycodone w/ acetaminophen 2.5-325mg (generic of PERCOCET)


1 QL

oxycodone w/ acetaminophen 5-325mg (generic of PERCOCET)


1 QL

Drug Name Drug Tier

Requirements/Limits

oxycodone w/ acetaminophen 5-500mg

QL (240 caps / 30 days)

1 QL



1 QL



1 QL



1 QL



1 QL

oxycodone-aspirin (generic of PERCODAN)


1 QL

oxycodone-ibuprofen QL (28 tabs / 30 days)

1 QL

OXYCONTIN QL (120 ea / 30 days)

2 QL

oxymorphone hcl (generic of OPANA) TABS

1


3 QL


3 QL


3 QL


4 QL NM

PERCODAN QL (360 tabs / 30 days)

3 QL

roxicet SOLN QL (1800mL / 30 days)

2 QL

ROXICODONE 15mg, 30mg QL (180 tabs / 30 days)

3 QL

SUBSYS QL (120 ea / 30 days)

4 QL NM PA

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) 4%

1

5


6

Drug Name Drug Tier

Requirements/Limits

lidocaine hcl (local anesth.) (generic of XYLOCAINE) .5%

1 B/D

lidocaine inj 0.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 1% (generic of XYLOCAINE) 1%

1 B/D

lidocaine inj 1% (generic of XYLOCAINE-MPF) 1%

1 B/D

lidocaine inj 1.5% (generic of XYLOCAINE-MPF)

1 B/D

lidocaine inj 2% (generic of XYLOCAINE) 2%

1 B/D

lidocaine inj 2% (generic of XYLOCAINE-MPF) 2%

1 B/D

XYLOCAINE .5%, 2% 3 B/D

XYLOCAINE INJ 1% 3 B/D

XYLOCAINE-MPF 3 B/D

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1 gentamicin in saline 0.9mg/ml 3 gentamicin in saline 1.4mg/ml 3 gentamicin in saline 60mg 1 gentamicin in saline 80mg 1 gentamicin in saline 100mg 1 gentamicin sulfate SOLN 1 neomycin sulfate TABS 1 paromomycin sulfate CAPS 1 streptomycin sulfate SOLR 1 sulfadiazine TABS 3 TOBI NEB 4 B/D NM

tobramycin sulfate SOLN; SOLR

1

tobramycin sulfate in saline 3

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 3 ALINIA SUSR

QL (9 bottles / 30 days) 2 QL

ALINIA TABS QL (20 tabs / 30 days)

2 QL

AZACTAM 3 AZACTAM/DEX INJ 1GM 3 AZACTAM/DEX INJ 2GM 4 NM

aztreonam (generic of AZACTAM)

1

BACTRIM 2

Drug Name Drug Tier

Requirements/Limits

BACTRIM DS 2 BILTRICIDE 2 CLEOCIN CAPS 2 cleocin SOLR 2 CLEOCIN CAP 75MG 2 CLEOCIN IN D5W 3 CLEOCIN INJ 3 CLEOCIN PHOSPHATE 3 clindamycin hcl (generic of CLEOCIN) CAPS

1

clindamycin palmitate hydrochloride (generic of CLEOCIN PEDIATRIC GRANULE)

1

clindamycin phosphate SOLN 150mg/ml

1

clindamycin phosphate (generic of CLEOCIN PHOSPHATE) SOLN 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml, 9000mg/60ml

1

clindamycin phosphate in d5w (generic of CLEOCIN IN D5W)

1

colistimethate sodium (generic of COLY-MYCIN M) SOLR

1

COLY-MYCIN M 3 CUBICIN 4 B/D NM

dapsone TABS 1 DARAPRIM 3 DORIBAX 3 erythromycin-sulfisoxazole 1 FLAGYL 3 FLAGYL ER 3 FURADANTIN 4 NM

HIPREX 3 imipenem-cilastatin (generic of PRIMAXIN IV)

1

INVANZ 3 MACROBID 2 MACRODANTIN 2 MEPRON 4 NM

meropenem (generic of MERREM)

1

MERREM 3

6


7

Drug Name Drug Tier

Requirements/Limits

methenamine hippurate (generic of HIPREX)

1

METRO IV 3 metronidazole (generic of FLAGYL) TABS

1

metronidazole inj 1 NEBUPENT 3 B/D

nitrofurantoin (generic of FURADANTIN) SUSP

1

nitrofurantoin macrocrystal (generic of MACRODANTIN)

1

nitrofurantoin monohyd macro (generic of MACROBID)

1

PENTAM 300 3 polymyxin b sulfate SOLR 1 PRIMAXIN 3 PRIMSOL SOL 50MG/5ML 3 STROMECTOL 3 sulfamethoxazole-trimethoprim SUSP

1

sulfamethoxazole-trimethoprim (generic of BACTRIM) TABS

1

sulfamethoxazole-trimethoprim (generic of BACTRIM DS) TABS

1

sulfamethoxazole-trimethoprim inj

1

SYNERCID 4 NM

trimethoprim TABS 1 TYGACIL 4 NM

VANCOCIN HCL 4 NM

vancomycin hcl (generic of VANCOCIN HCL) CAPS

4 NM

vancomycin hcl SOLR 10gm, 500mg, 1000mg, 5000mg

1 B/D

vancomycin hcl SOLR 750mg

3 B/D

VIBATIV 3 XIFAXAN TAB 200MG 4 NM

ZYVOX 4 NM

ANTIFUNGALS ABELCET 4 B/D NM

AMBISOME 4 B/D NM

AMPHOTEC 3 B/D

amphotericin b SOLR 1 B/D

ANCOBON 4 NM

Drug Name Drug Tier

Requirements/Limits

CANCIDAS 4 NM

DIFLUCAN 3 ERAXIS 4 NM

fluconazole (generic of DIFLUCAN) SUSR; TABS

1

fluconazole in dextrose 1 fluconazole in nacl 100mg 3 fluconazole in nacl 200mg 1 fluconazole in nacl 400mg 1 flucytosine (generic of ANCOBON) CAPS

4 NM

GRIS-PEG 2 griseofulvin microsize SUSP 1 griseofulvin microsize (generic of GRIFULVIN V) TABS

1

griseofulvin ultramicrosize (generic of GRIS-PEG)

1

itraconazole (generic of SPORANOX) CAPS

1 PA

ketoconazole TABS 1 LAMISIL PACK 3 LAMISIL TABS

QL (90 tabs / year) 3 QL

MYCAMINE 50mg 3 MYCAMINE 100mg 4 NM

NOXAFIL 4 NM

nystatin TABS 1 ONMEL 3 PA

SPORANOX 4 NM PA

SPORANOX PULSEPAK 4 NM PA

SPORANOX SOL 10MG/ML 4 NM

terbinafine hcl (generic of LAMISIL) TABS

QL (90 tabs / year)

1 QL

VFEND 4 NM

VFEND IV 3 VFEND SUS 40MG/ML 4 NM

voriconazole (generic of VFEND) TABS

4 NM

voriconazole inj 200mg (generic of VFEND IV)

1

ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG

1

atovaquone-proguanil hcl tab 250-100 mg (generic of MALARONE)

1

7


8

Drug Name Drug Tier

Requirements/Limits

chloroquine phosphate TABS 250mg

1

chloroquine phosphate (generic of ARALEN) TABS 500mg

1

COARTEM 2 MALARONE 2 mefloquine hcl 1 PRIMAQUINE PHOSPHATE 3 QUALAQUIN 3 quinine sulfate (generic of QUALAQUIN) CAPS

1

ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN)

1

APTIVUS 4 NM

CRIXIVAN 3 didanosine (generic of VIDEX EC)

1

EDURANT 4 NM

EMTRIVA 2 EPIVIR SOL 10MG/ML 2 EPIVIR TABS 2 FUZEON 4 NM

INTELENCE 25mg 2 INTELENCE 100mg, 200mg 4 NM

INVIRASE CAPS 3 INVIRASE TABS 4 NM

ISENTRESS CHEW 25mg 2 ISENTRESS CHEW 100mg 4 NM

ISENTRESS TABS 4 NM

lamivudine (generic of EPIVIR)

1

LEXIVA SUSP 3 LEXIVA TABS 4 NM

NEVIRAPINE SUSP 1 nevirapine (generic of VIRAMUNE) TABS

1

NORVIR 2 PREZISTA SUSP 4 NM

PREZISTA TABS 75mg, 150mg

2

PREZISTA TABS 400mg, 600mg, 800mg

4 NM

RESCRIPTOR 2 RETROVIR CAPS 2 RETROVIR IV INFUSION 3

Drug Name Drug Tier

Requirements/Limits

RETROVIR SYRP 2 REYATAZ 100mg 2 REYATAZ 150mg, 200mg, 300mg

4 NM

SELZENTRY 4 NM

stavudine (generic of ZERIT) 1 SUSTIVA 2 VIDEX EC 2 VIDEX PEDIATRIC 3 VIRACEPT 4 NM

VIRAMUNE 2 VIRAMUNE XR 2 VIREAD 4 NM

ZERIT 2 ZIAGEN SOLN 3 ZIAGEN TABS 2 zidovudine (generic of RETROVIR) CAPS; SYRP

1

zidovudine TABS 1

ANTIRETROVIRAL COMBINATION AGENTS ATRIPLA 4 NM

COMBIVIR 4 NM

COMPLERA 4 NM

EPZICOM 4 NM

KALETRA SOL 4 NM

KALETRA TAB 100-25MG 2 KALETRA TAB 200-50MG 4 NM

lamivudine-zidovudine (generic of COMBIVIR)

4 NM

STRIBILD 4 NM

TRIZIVIR 4 NM

TRUVADA 4 NM

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 4 NM

ethambutol hcl (generic of MYAMBUTOL) TABS

1

isoniazid SOLN; SYRP 1 isoniazid tabs 1 MYAMBUTOL 2 MYCOBUTIN 3 paser d/r 3 PRIFTIN 3 pyrazinamide 1 rifadin CAPS 150mg 2 RIFADIN CAPS 300mg 2

8


9

Drug Name Drug Tier

Requirements/Limits

RIFADIN SOLR 3 rifamate 3 rifampin (generic of RIFADIN) CAPS; SOLR

1

RIFATER 3 seromycin 3 SIRTURO 4 NM LA PA

TRECATOR 3

ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS; SUSP; TABS

1

acyclovir sodium SOLN 3 B/D

acyclovir sodium SOLR 1 B/D

BARACLUDE SOLN 2 BARACLUDE TABS 4 NM

cidofovir (generic of VISTIDE) 1 COPEGUS 4 NM PA

CYTOVENE 3 B/D

EPIVIR HBV 2 famciclovir (generic of FAMVIR)

1

FAMVIR 3 FLUMADINE 3 foscarnet sodium 1 ganciclovir inj 500mg (generic of CYTOVENE)

1 B/D

HEPSERA 4 NM ST

INCIVEK 4 NM PA

REBETOL 4 NM PA

RELENZA DISKHALER 2 ribapak mis 600/day 4 NM PA

ribasphere (generic of REBETOL) CAPS

1 NM PA

ribasphere (generic of COPEGUS) TABS 200mg

1 NM PA

ribasphere TABS 400mg 1 NM PA

ribasphere TABS 600mg 4 NM PA

ribasphere ribapak 800 4 NM PA



ribavirin 200mg (generic of REBETOL) CAPS

1 NM PA

ribavirin 200mg (generic of COPEGUS) TABS

1 NM PA

rimantadine hydrochloride (generic of FLUMADINE)

1

Drug Name Drug Tier

Requirements/Limits

TAMIFLU 2 TYZEKA 4 NM

valacyclovir hcl (generic of VALTREX) TABS

1

VALCYTE 4 NM

VALTREX 3 VICTRELIS 4 NM PA

VISTIDE 3 ZOVIRAX CAPS; SUSP; TABS

3

CEPHALOSPORINS CEDAX 3 cefaclor 1 cefaclor monohydrate 3 cefadroxil 1 cefazolin inj 1 cefazolin sodium 1gm, 20gm 1 cefazolin/dextrose 3 cefdinir 1 CEFEPIME 1GM SOLN 3 CEFEPIME 2GM SOLN 3 cefepime inj 1gm (generic of MAXIPIME)

1

cefepime inj 2gm (generic of MAXIPIME)

1

cefotaxime sodium (generic of CLAFORAN)

1

cefotetan disodium 3 cefoxitin sodium 1 CEFOXITIN SODIUM IN DEXTROSE

3

cefpodoxime proxetil 1 cefprozil 1 ceftazidime (generic of FORTAZ) SOLR 1gm, 2gm, 6gm

1

CEFTAZIDIME/DEXTROSE 3 CEFTIN 3 ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg

1

ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm, 500mg

1

cefuroxime axetil (generic of CEFTIN) TABS

1

9


10

Drug Name Drug Tier

Requirements/Limits

cefuroxime sodium (generic of ZINACEF) 1.5gm, 7.5gm, 750mg

1

cefuroxime sodium 7.5mg soln

3

cephalexin (generic of KEFLEX) CAPS 250mg, 500mg

1

cephalexin SUSR 1 cephalexin TABS 1 claforan 1gm, 2gm 3 CLAFORAN 1gm, 2gm, 10gm, 500mg

3

FORTAZ SOLN 3 FORTAZ SOLR 2gm, 6gm, 500mg

3

KEFLEX 3 MAXIPIME 3 rocephin 3 SUPRAX CAPS 2 suprax CHEW 2 suprax SUSR 100mg/5ml, 200mg/5ml

2

SUPRAX SUSR 500mg/5ml 3 suprax TABS 2 tazicef vial (generic of FORTAZ)

1

TEFLARO 3 ZINACEF 1.5gm, 7.5gm 3

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1 azithromycin (generic of ZITHROMAX) SOLR 500mg

1

azithromycin (generic of ZITHROMAX) SUSR

1

azithromycin (generic of ZITHROMAX) TABS

1

BIAXIN 3 BIAXIN XL 3 BIAXIN XL PAC 3 clarithromycin SUSR 125mg/5ml

1

clarithromycin (generic of BIAXIN) SUSR 250mg/5ml

1

clarithromycin (generic of BIAXIN) TABS

1

Drug Name Drug Tier

Requirements/Limits

clarithromycin (generic of BIAXIN XL) TB24

1

DIFICID 4 NM ST

e.e.s. 1 E.E.S. GRANULES 3 ery-tab 3 ERYPED 200 3 ERYPED 400 3 erythrocin lactobionate 500mg

3

erythrocin stearate 1 erythromycin base CPEP; TABS

1

erythromycin ethylsuccinate 1 PCE 3 ZITHROMAX 3 ZITHROMAX TRI-PAK 3 ZITHROMAX Z-PAK 3 ZMAX 3

FLUOROQUINOLONES AVELOX SOLN 3 AVELOX TABS 2 AVELOX ABC PACK 2 CIPRO SUSR 2 CIPRO TABS 3 CIPRO I.V.-IN D5W 3 ciprofloxacin SOLN 200mg/20ml

1

ciprofloxacin er (generic of CIPRO XR)

1

ciprofloxacin hcl TABS 100mg, 750mg

1

ciprofloxacin hcl (generic of CIPRO) TABS 250mg, 500mg

1

ciprofloxacin in d5w (generic of CIPRO I.V.-IN D5W)

1

ciprofloxacn inj 1 FACTIVE 3 LEVAQUIN 3 LEVAQUIN INJ 3 levofloxacin SOLN 25mg/ml 1 levofloxacin (generic of LEVAQUIN) SOLN 25mg/ml

1

levofloxacin (generic of LEVAQUIN) TABS

1

10


11

Drug Name Drug Tier

Requirements/Limits

levofloxacin in d5w (generic of LEVAQUIN)

1

NOROXIN 3

PENICILLINS amoxicillin 1 amoxicillin & pot clavulanate CHEW

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) CHEW

1

amoxicillin & pot clavulanate SUSR

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR

1

amoxicillin & pot clavulanate (generic of AUGMENTIN ES-600) SUSR

1

amoxicillin & pot clavulanate TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS

1

amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB12

1

ampicillin 1 ampicillin & sulbactam sodium 1 ampicillin & sulbactam sodium (generic of UNASYN)

1

ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)

1

ampicillin inj 1 ampicillin sodium 1 AUGMENTIN 3 AUGMENTIN ES-600 3 AUGMENTIN XR 3 BACTOCILL IN DEXTROSE 3 BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin sodium 1 MOXATAG 3 nafcillin sodium 1gm 1 nafcillin sodium 2gm, 10gm 4 NM

NALLPEN ISO-OSMOTIC IN DE

3

Drug Name Drug Tier

Requirements/Limits

NALLPEN/DEXTROSE 3 oxacillin sodium 1gm, 2gm 1 oxacillin sodium 10gm 4 NM

PENICILLIN G POT IN DEXTROSE

3

PENICILLIN G POTASSIUM SOLN

3

penicillin g potassium SOLR 1 penicillin g procaine 3 penicillin g sodium 1 penicillin v potassium 1 pfizerpen 1 piperacillin sodium-tazobactam sodium (generic of ZOSYN)

1

TIMENTIN 3 TIMENTIN INJ 3.1GM 3 UNASYN 3 UNASYN BULK PACK 3 ZOSYN 3

TETRACYCLINES adoxa CAPS 3 demeclocycline hcl 1 DORYX 3 doxycycline (monohydrate) CAPS 50mg

1

doxycycline (monohydrate) (generic of MONODOX) CAPS 75mg, 100mg

1

doxycycline (monohydrate) (generic of ADOXA) CAPS 150mg

1

doxycycline (monohydrate) (generic of VIBRAMYCIN) SUSR

1

doxycycline (monohydrate) (generic of ADOXA) TABS 50mg, 75mg, 100mg

1

doxycycline (monohydrate) (generic of ADOXA PAK 1/150) TABS 150mg

1

doxycycline hyclate CAPS 50mg

1

doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg

1

doxycycline hyclate SOLR 1

11


12

Drug Name Drug Tier

Requirements/Limits

doxycycline hyclate TABS 1 doxycycline hyclate TBEC 1 dynacin 3 MINOCIN CAPS 3 minocycline hcl (generic of MINOCIN) CAPS 50mg, 100mg

1

minocycline hcl CAPS 75mg 1 minocycline hcl TABS 1 minocycline hcl (generic of SOLODYN) TB24

1

MONODOX 3 SOLODYN 4 NM

VIBRAMYCIN CAPS 3 VIBRAMYCIN SUSR; SYRP 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN SOLR 3 B/D

BICNU 3 B/D

BUSULFEX 3 B/D

CEENU 2 cyclophosphamide SOLR 3 B/D

cyclophosphamide TABS 1 B/D

dacarbazine 200mg 1 B/D

EMCYT 2 HEXALEN 4 NM

IFEX 3 B/D

IFEX INJ 3GM 3 B/D

ifosfamide SOLN 1gm/20ml, 3gm/60ml

3 B/D

ifosfamide (generic of IFOSFAMIDE) SOLN 1gm/20ml, 3gm/60ml

1 B/D

ifosfamide (generic of IFEX) SOLR 1gm

1 B/D

LEUKERAN 2 melphalan hcl (generic of ALKERAN)

4 B/D NM

MUSTARGEN 3 B/D

thiotepa SOLR 3 B/D

TREANDA 4 B/D NM

ZANOSAR 3 B/D

ANTHRACYCLINES adriamycin 20mg 3 B/D

adriamycin inj 2mg/ml 1 B/D

cerubidine 3 B/D

daunorubicin hcl INJ 1 B/D

Drug Name Drug Tier

Requirements/Limits

daunorubicin hcl (generic of CERUBIDINE) SOLR

1 B/D

DOXIL 4 B/D NM

doxorubicin hcl SOLN 1 B/D

doxorubicin hcl SOLR 50mg 1 B/D

ELLENCE 4 B/D NM

EPIRUBICIN INJ 50MG 3 B/D

epirubicin inj 50mg/25ml (generic of ELLENCE)

1 B/D

epirubicin inj 200mg (generic of ELLENCE)

1 B/D

IDAMYCIN PFS 3 B/D

idarubicin hcl (generic of IDAMYCIN PFS)

4 B/D NM

ANTIBIOTICS bleomycin sulfate 1 B/D

COSMEGEN 4 B/D NM

mitomycin SOLR 20mg 1 B/D

ANTIMETABOLITES adrucil 1 B/D

ALIMTA 4 B/D NM

ARRANON 3 B/D

cladribine 4 B/D NM

CLOLAR 3 B/D

cytarabine inj 1 B/D

DACOGEN 4 B/D NM

fludarabine phosphate SOLN

1 B/D

fludarabine phosphate (generic of FLUDARA) SOLR

1 B/D

fluorouracil SOLN 1 B/D

GEMCITABINE 4 B/D NM

gemcitabine hcl (generic of GEMZAR) 1gm, 200mg

4 B/D NM

gemcitabine hcl 2gm 4 B/D NM

GEMZAR 4 B/D NM

mercaptopurine (generic of PURINETHOL) TABS

1

methotrexate sodium inj 1 B/D

NIPENT 4 B/D NM

pentostatin (generic of NIPENT)

4 B/D NM

PURINETHOL 2 TABLOID 2 VIDAZA 4 B/D NM

ANTIMITOTIC, TAXOIDS ABRAXANE 4 B/D NM

12


13

Drug Name Drug Tier

Requirements/Limits

DOCETAXEL CONC 20mg/0.5ml, 20mg/ml, 80mg/4ml

4 B/D NM

docetaxel CONC 140mg/7ml 4 B/D NM

DOCETAXEL SOLN 80mg/8ml

4 B/D NM

paclitaxel 1 B/D

TAXOTERE 4 B/D NM

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate SOLR 3 B/D

vincasar 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate (generic of NAVELBINE)

1 B/D

BIOLOGIC RESPONSE MODIFIERS AVASTIN 4 B/D NM

ERBITUX 4 B/D NM

ERIVEDGE 4 NM LA PA

HERCEPTIN 4 B/D NM

ISTODAX 4 B/D NM

KADCYLA 4 B/D NM

ONTAK 4 B/D NM

PROLEUKIN 4 B/D NM

RITUXAN 4 NM PA

TORISEL 4 B/D NM

VECTIBIX 4 B/D NM

VELCADE 4 B/D NM

ZOLINZA 4 NM PA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS

1

ARIMIDEX 2 AROMASIN 2 ST

ARZERRA 4 B/D NM

bicalutamide (generic of CASODEX)

1

CASODEX 2 DEPO-PROVERA INJ 400/ML 3 B/D

ELIGARD 7.5mg, 22.5mg, 30mg

3 B/D NM

ELIGARD 45mg 4 B/D NM

exemestane (generic of AROMASIN)

1 ST

FARESTON 4 NM

FASLODEX 4 B/D NM

FEMARA 2 FIRMAGON 80mg 3 B/D NM

FIRMAGON 120mg 4 B/D NM

Drug Name Drug Tier

Requirements/Limits

flutamide 1 letrozole (generic of FEMARA) TABS

1

leuprolide acetate KIT 1 NM PA

LUPR DEP-PED INJ 11.25MG (3-MONTH)

4 NM PA

LUPR DEP-PED INJ 30MG (3-MONTH)

4 NM PA

LUPRON DEPOT 3.75mg, 7.5mg, 11.25mg

4 NM PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

4 NM PA

LUPRON DEPOT INJ 30MG (3-MONTH)

4 NM PA

LUPRON DEPOT-PED 4 NM PA

LYSODREN 2 MEGACE ES 2 MEGACE ORAL 2 megestrol acetate (generic of MEGACE ORAL) SUSP

1

megestrol acetate TABS 1 NILANDRON 4 NM

SOLTAMOX 3 tamoxifen citrate TABS 1 TRELSTAR DEPOT MIXJECT

4 NM PA

TRELSTAR LA MIXJECT 4 NM PA

TRELSTAR MIXJECT 4 NM PA

XTANDI 4 NM LA PA

ZYTIGA 4 NM PA

KINASE INHIBITORS AFINITOR 4 NM PA

AFINITOR DISPERZ 4 NM PA

BOSULIF 4 NM PA

CAPRELSA 4 NM LA PA

COMETRIQ 4 NM PA

GLEEVEC 4 NM PA

ICLUSIG 4 NM PA

INLYTA 4 NM LA PA

IRESSA 4 NM

JAKAFI 4 NM LA PA

MEKINIST 4 NM PA

NEXAVAR 4 NM LA PA

SPRYCEL 4 NM PA

STIVARGA 4 NM LA PA

SUTENT 4 NM PA

TAFINLAR 4 NM PA

TARCEVA 4 NM PA

13


14

Drug Name Drug Tier

Requirements/Limits

TASIGNA 4 NM PA

TYKERB 4 NM LA PA

VOTRIENT 4 NM PA

XALKORI 4 NM LA PA

ZELBORAF 4 NM LA PA

MISCELLANEOUS DROXIA 3 ELSPAR 3 B/D NM

HALAVEN 4 B/D NM

HYDREA 2 hydroxyurea (generic of HYDREA) CAPS

1

IXEMPRA KIT 4 B/D NM

MATULANE 4 NM

mitoxantrone hcl 1 B/D NM

POMALYST CAP 4 NM LA PA

SYLATRON 4 NM PA

TARGRETIN CAPS 4 NM PA

tretinoin CAPS 4 NM

TRISENOX 4 B/D NM

UVADEX 3 B/D

PLATINUM-BASED AGENTS carboplatin SOLN 1 B/D

cisplatin SOLN 1 B/D

ELOXATIN 4 B/D NM

oxaliplatin 4 B/D NM

PROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)

4 B/D NM

dexrazoxane (generic of ZINECARD)

4 B/D NM

ELITEK 4 B/D NM

KEPIVANCE 4 B/D NM

leucovor ca inj 1 B/D

leucovorin calcium SOLN 1 B/D

leucovorin calcium SOLR 50mg, 200mg

1 B/D

leucovorin calcium SOLR 500mg

3 B/D

leucovorin calcium TABS 1 mesna (generic of MESNEX) 1 B/D

MESNEX SOLN 3 B/D

MESNEX TABS 4 NM

ZINECARD 3 B/D

TOPOISOMERASE INHIBITORS CAMPTOSAR 3 B/D

ETOPOPHOS 3 B/D

Drug Name Drug Tier

Requirements/Limits

etoposide SOLN 1 B/D

HYCAMTIN SOLR 4 B/D NM

irinotecan hcl (generic of CAMPTOSAR) 40mg/2ml, 100mg/5ml

4 B/D NM

irinotecan hcl 500mg/25ml 4 B/D NM

toposar 1 B/D

topotecan hcl (generic of HYCAMTIN) SOLR

4 B/D NM

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS ACCURETIC 3 amlodipine besylate-benazepril hcl (generic of LOTREL)

1

benazepril & hydrochlorothiazide

1

benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide (generic of VASERETIC)

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide (generic of PRINZIDE)

1

lisinopril & hydrochlorothiazide (generic of ZESTORETIC)

1

LOTENSIN HCT 3 LOTREL 2 moexipril-hydrochlorothiazide (generic of UNIRETIC)

1

quinapril-hydrochlorothiazide (generic of ACCURETIC)

1

TARKA 2 UNIRETIC 3 VASERETIC 3 ZESTORETIC 3

ACE INHIBITORS ACCUPRIL 3 ALTACE 3

14


15

Drug Name Drug Tier

Requirements/Limits

benazepril hcl TABS 5mg 1 benazepril hcl (generic of LOTENSIN) TABS 10mg, 20mg, 40mg

1

captopril TABS 1 enalapril maleate (generic of VASOTEC) TABS

1

fosinopril sodium 1 lisinopril (generic of ZESTRIL) TABS 2.5mg, 30mg, 40mg

1

lisinopril (generic of PRINIVIL) TABS 5mg, 10mg, 20mg

1

LOTENSIN 3 MAVIK 3 moexipril hcl (generic of UNIVASC)

1

perindopril erbumine 2mg 1 perindopril erbumine (generic of ACEON) 4mg, 8mg

1

PRINIVIL 3 quinapril hcl (generic of ACCUPRIL)

1

ramipril (generic of ALTACE) 1 trandolapril (generic of MAVIK)

1

UNIVASC 3 VASOTEC 3 ZESTRIL 3

ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE 2 eplerenone (generic of INSPRA)

1 PA

INSPRA 2 PA

spironolactone (generic of ALDACTONE) TABS

1

ALPHA BLOCKERS CARDURA 3 doxazosin mesylate (generic of CARDURA)

1

MINIPRESS 3 prazosin hcl (generic of MINIPRESS)

1

terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS ATACAND HCT 3

Drug Name Drug Tier

Requirements/Limits

AVALIDE 3 AZOR 2 BENICAR HCT 2 candesartan cilexetil-hydrochlorothiazide (generic of ATACAND HCT)

1

DIOVAN HCT 3 EDARBYCLOR 3 EXFORGE 2 EXFORGE HCT 2 HYZAAR 3 irbesartan-hydrochlorothiazide (generic of AVALIDE)

1

losartan potassium & hydrochlorothiazide (generic of HYZAAR)

1

MICARDIS HCT 2 TEVETEN HCT 3 TRIBENZOR 2 TWYNSTA 3 valsartan-hydrochlorothiazide (generic of DIOVAN HCT)

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND 3 AVAPRO 3 BENICAR 2 candesartan cilexetil (generic of ATACAND)

1

COZAAR 3 DIOVAN 2 EDARBI 3 eprosartan mesylate (generic of TEVETEN)

1

irbesartan (generic of AVAPRO)

1

losartan potassium (generic of COZAAR)

1

MICARDIS 2 TEVETEN 3

ANTIARRHYTHMICS amiodarone hcl SOLN 1 amiodarone hcl (generic of CORDARONE) TABS 200mg

1

amiodarone hcl (generic of PACERONE) TABS 400mg

1

15


16

Drug Name Drug Tier

Requirements/Limits

amiodarone inj 50mg/ml 1 BETAPACE 2 BETAPACE AF 2 CORDARONE 2 disopyramide phosphate (generic of NORPACE)

1

flecainide acetate (generic of TAMBOCOR)

1

mexiletine hcl 1 MULTAQ 3 NORPACE 2 NORPACE CR 2 pacerone 100mg, 400mg 2 pacerone (generic of CORDARONE) 200mg

1

propafenone hcl (generic of RYTHMOL SR) CP12

1

propafenone hcl (generic of RYTHMOL) TABS 150mg, 225mg

1

propafenone hcl TABS 300mg

1

quinidine gluconate er 1 quinidine sulfate 1 RYTHMOL 2 RYTHMOL SR 2 sorine (generic of BETAPACE) 80mg, 120mg, 160mg

1

sorine 240mg 1 sotalol hcl (generic of BETAPACE) 80mg, 160mg

1

sotalol hcl 240mg 1 sotalol hcl (afib/afl) (generic of BETAPACE AF)

1

TAMBOCOR 2 TIKOSYN 2 NM PA

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3 atorvastatin calcium (generic of LIPITOR)

1

CRESTOR 2 fluvastatin sodium (generic of LESCOL)

1

LESCOL 3 LESCOL XL 3

Drug Name Drug Tier

Requirements/Limits

LIPITOR 3 LIVALO 3 lovastatin 10mg 1 lovastatin (generic of MEVACOR) 20mg, 40mg

1

MEVACOR 3 PRAVACHOL 3 pravastatin sodium 10mg 1 pravastatin sodium (generic of PRAVACHOL) 20mg, 40mg, 80mg

1

simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 20mg, 40mg

1

simvastatin (generic of ZOCOR) TABS 80mg


1 QL

ZOCOR 5mg, 10mg, 20mg, 40mg

3

ZOCOR 80mg QL (30 tabs / 30 days)

3 QL

ANTILIPEMICS, MISCELLANEOUS ADVICOR 3 ANTARA 2 cholestyramine (generic of QUESTRAN)

1

cholestyramine light (generic of QUESTRAN LIGHT)

1

choline fenofibrate (generic of TRILIPIX)

1

COLESTID 3 colestipol hcl (generic of COLESTID)

1

fenofibrate (generic of TRICOR) 48mg, 145mg

1

fenofibrate (generic of LOFIBRA) 54mg, 160mg

1

FENOFIBRATE MICRONIZED 43mg, 130mg

1

fenofibrate micronized (generic of LOFIBRA) 67mg, 134mg, 200mg

1

FENOFIBRIC ACID 1 FENOGLIDE 3 FIBRICOR 3 gemfibrozil (generic of LOPID) TABS

1

LIPOFEN 2

16


17

Drug Name Drug Tier

Requirements/Limits

lofibra 3 LOPID 3 LOVAZA 2 niacor 1 NIASPAN 2 prevalite (generic of QUESTRAN LIGHT)

1

questran 3 questran light 3 SIMCOR 2 TRICOR 3 TRIGLIDE 3 TRILIPIX 2 VASCEPA 3 VYTORIN 2 WELCHOL 2 ZETIA 2

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone (generic of TENORETIC 50)

1

atenolol & chlorthalidone (generic of TENORETIC 100)

1

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1

CORZIDE 3 LOPRESSOR HCT 2 metoprolol & hctz tab 50-25mg (generic of LOPRESSOR HCT)

1

metoprolol & hctz tab 100-25mg (generic of LOPRESSOR HCT)

1

metoprolol & hctz tab 100-50mg

1

nadolol & bendroflumethiazide (generic of CORZIDE)

1

propranolol & hydrochlorothiazide

1

TENORETIC 2 ZIAC 2

BETA-BLOCKERS acebutolol hcl (generic of SECTRAL) CAPS

1

atenolol (generic of TENORMIN) TABS

1

Drug Name Drug Tier

Requirements/Limits

betaxolol hcl (generic of KERLONE)

1

bisoprolol fumarate (generic of ZEBETA)

1

BYSTOLIC 2 carvedilol (generic of COREG)

1

COREG 3 COREG CR 2 CORGARD 3 INDERAL LA 3 labetalol hcl SOLN 1 labetalol hcl (generic of TRANDATE) TABS

1

LEVATOL 3 LOPRESSOR 3 metoprolol succinate (generic of TOPROL XL)

1

metoprolol tartrate (generic of LOPRESSOR) SOLN

1

metoprolol tartrate TABS 25mg

1

metoprolol tartrate (generic of LOPRESSOR) TABS 50mg, 100mg

1

nadolol (generic of CORGARD) TABS

1

pindolol 1 propranolol hcl er (generic of INDERAL LA)

1

propranolol inj 1mg/ml 1 propranolol sol 1 propranolol tab 1 SECTRAL 3 TENORMIN 3 timolol maleate TABS 1 TOPROL XL 3 TRANDATE 3 ZEBETA 3

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS AMLODIPINE BESYLATE/ATORV

1

CADUET 3

CALCIUM CHANNEL BLOCKERS ADALAT CC 3

17


18

Drug Name Drug Tier

Requirements/Limits

afeditab cr (generic of ADALAT CC)

1

amlodipine besylate (generic of NORVASC) TABS

1

CALAN 3 CALAN SR 3 CARDIZEM 3 CARDIZEM CD 3 CARDIZEM LA 3 cartia xt (generic of CARDIZEM CD)

1

dilacor 3 dilt-cd (generic of CARDIZEM CD)

1

dilt-xr 120mg, 180mg 1 dilt-xr (generic of DILACOR XR) 240mg

1

diltiazem cap 120mg/24hr 1 diltiazem cap er/12hr 1 diltiazem hcl SOLN 1 diltiazem hcl SOLR 3 diltiazem hcl (generic of CARDIZEM) TABS

1

diltiazem hcl coated beads (generic of CARDIZEM CD)

1

DILTIAZEM HCL ER 1 diltiazem hcl extended release beads (generic of TIAZAC)

1

diltzac (generic of TIAZAC) 1 felodipine 1 isradipine 1 matzim la (generic of CARDIZEM LA)

1

nicardipine hcl CAPS 1 nifediac (generic of ADALAT CC)

1

nifedical (generic of PROCARDIA XL)

1

nifedipine (generic of ADALAT CC) TB24

1

nifedipine er (generic of PROCARDIA XL)

1

nimodipine (generic of NIMOTOP) CAPS

1

nisoldipine (generic of SULAR) 8.5mg, 17mg, 34mg

1

Drug Name Drug Tier

Requirements/Limits

nisoldipine 20mg, 25.5mg, 30mg, 40mg

1

NORVASC 3 NYMALIZE 4 NM

PROCARDIA XL 3 SULAR 3 taztia xt (generic of TIAZAC) 1 TIAZAC 3 verapamil hcl (generic of VERELAN PM) CP24 100mg, 200mg, 300mg

1

verapamil hcl (generic of VERELAN) CP24 120mg, 180mg, 240mg

1

VERAPAMIL HCL CP24 360mg

1

verapamil hcl SOLN 1 verapamil hcl TABS 40mg 1 verapamil hcl (generic of CALAN) TABS 80mg, 120mg

1

verapamil hcl (generic of CALAN SR) TBCR

1

VERELAN 3 VERELAN PM 3

DIGITALIS GLYCOSIDES digoxin (generic of LANOXIN) TABS

1

digoxin inj (generic of LANOXIN)

1

DIGOXIN SOL 50MCG/ML 1 LANOXIN PEDIATRIC 3 LANOXIN TAB 2

DIRECT RENIN INHIBITORS/COMBINATIONS AMTURNIDE 2 TEKAMLO 2 TEKTURNA 2 TEKTURNA HCT 2

DIURETICS acetazolamide (generic of DIAMOX) CP12

1

acetazolamide TABS 1 acetazolamide sodium 1 ALDACTAZIDE 3 amiloride & hydrochlorothiazide

1

18


19

Drug Name Drug Tier

Requirements/Limits

amiloride hcl 1 bumetanide SOLN; TABS 1 chlorothiazide 1 chlorthalidone 25mg, 50mg 1 DEMADEX 3 DIAMOX 2 DIURIL SUS 250/5ML 3 DYAZIDE 3 DYRENIUM 3 EDECRIN 3 furosemide SOLN 1 furosemide (generic of LASIX) TABS

1

furosemide inj 1 furosemide oral soln 8 mg/ml 2 hydrochlorothiazide (generic of MICROZIDE) CAPS

1

hydrochlorothiazide TABS 1 indapamide TABS 1 LASIX 3 MAXZIDE 3 MAXZIDE-25 3 methazolamide (generic of NEPTAZANE) TABS

1

methyclothiazide 1 metolazone (generic of ZAROXOLYN) 2.5mg, 5mg

1

metolazone 10mg 1 MICROZIDE 3 SODIUM DIURIL 3 spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE)

1

torsemide inj 3 torsemide tabs (generic of DEMADEX)

1

triamterene & hydrochlorothiazide cap 37.5-25 mg (generic of DYAZIDE)

1

triamterene & hydrochlorothiazide tab 37.5-25 mg (generic of MAXZIDE-25)

1

triamterene & hydrochlorothiazide tab 75-50 mg (generic of MAXZIDE)

1

Drug Name Drug Tier

Requirements/Limits

ZAROXOLYN 3

MISCELLANEOUS BIDIL 2 CATAPRES 2 CATAPRES-TTS 2 clonidine hcl (generic of CATAPRES-TTS-1) PTWK .1mg/24hr

1

clonidine hcl (generic of CATAPRES-TTS-2) PTWK .2mg/24hr

1

clonidine hcl (generic of CATAPRES-TTS-3) PTWK .3mg/24hr

1

clonidine hcl (generic of CATAPRES) TABS

1

clorpres 0.1/15 1 clorpres 0.2/15 1 clorpres 0.3/15 1 DEMSER 4 NM

DIBENZYLINE 3 hydralazine hcl SOLN; TABS 1 midodrine hcl 1 minoxidil TABS 1 RANEXA 2

NITRATES DILATRATE SR 3 imdur 2 ISORDIL TITRADOSE 2 isosorbide dinitrate SUBL 1 isosorbide dinitrate (generic of ISORDIL TITRADOSE) TABS 5mg

1

isosorbide dinitrate TABS 10mg, 20mg, 30mg

1

isosorbide dinitrate TBCR 1 isosorbide mononitrate TABS

1

isosorbide mononitrate (generic of IMDUR) TB24

1

minitran (generic of NITRO-DUR)

1

nitro-bid 3 NITRO-DUR 2 NITROGLYCERIN .4mg/spray

1

NITROGLYCERIN LINGUAL 1

19


20

Drug Name Drug Tier

Requirements/Limits

nitroglycerin patches 1 NITROLINGUAL SPR PUMPSPRA

2

NITROMIST 2 NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 4 NM PA

LETAIRIS 4 NM LA PA

REMODULIN 4 B/D NM LA

REVATIO TABS 4 NM PA

sildenafil citrate (pulmonary hypertension) (generic of REVATIO)

4 NM PA

TRACLEER 4 NM LA PA

VENTAVIS 4 B/D NM

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC

QL (300 ml / 30 days) 2 QL

alprazolam (generic of XANAX) TABS 2mg


1 QL

alprazolam (generic of XANAX) TABS .25mg, .5mg, 1mg


1 QL

ATIVAN SOLN 3 ATIVAN TABS


buspirone hcl TABS 1 fluvoxamine maleate 1 fluvoxamine maleate er (generic of LUVOX CR)

1

fluvoxamine tabs 1 lorazepam CONC

QL (150 mls / 30 days) 1 QL

lorazepam (generic of ATIVAN) SOLN

1

lorazepam (generic of ATIVAN) TABS


1 QL

LUVOX CR 3 XANAX 2mg


XANAX .25mg, .5mg, 1mg QL (90 tabs / 30 days)

2 QL

ANTICONVULSANTS

Drug Name Drug Tier

Requirements/Limits

BANZEL SUSP 4 NM

BANZEL TABS 200mg 3 BANZEL TABS 400mg 4 NM

carbamazepine CHEW 1 carbamazepine (generic of CARBATROL) CP12

1

carbamazepine (generic of TEGRETOL) SUSP; TABS

1

carbamazepine (generic of TEGRETOL-XR) TB12

1

CARBATROL 2 CELONTIN 3 clonazepam (generic of KLONOPIN) TABS 1mg


1 QL

clonazepam (generic of KLONOPIN) TABS 2mg


1 QL

clonazepam (generic of KLONOPIN) TABS .5mg


1 QL

clonazepam TBDP 1mg QL (600 tabs / 30 days)

1 QL

clonazepam TBDP 2mg QL (300 tabs / 30 days)

1 QL

clonazepam TBDP .5mg QL (1200 tabs / 30 days)

1 QL


1 QL


1 QL

clorazepate dipotassium (generic of TRANXENE T) 3.75mg, 7.5mg


1 QL PA

clorazepate dipotassium (generic of TRANXENE T) 15mg


1 QL PA

DEPACON 3 DEPAKENE 2 DEPAKOTE 2 DEPAKOTE ER 2 DEPAKOTE SPRINKLES 2

20


21

Drug Name Drug Tier

Requirements/Limits

diazepam CONC QL (240 ml / 30 days)

1 QL PA

diazepam SOLN QL (1200mL / 30 days)

1 QL PA

diazepam (generic of VALIUM) TABS


1 QL PA

DIAZEPAM GEL 1 diazepam inj 1 dilantin CAPS; CHEW 2 DILANTIN SUSP 2 divalproex sodium (generic of DEPAKOTE SPRINKLES) CPSP

1

divalproex sodium (generic of DEPAKOTE ER) TB24

1

divalproex sodium (generic of DEPAKOTE) TBEC

1

epitol (generic of TEGRETOL) 1 ethosuximide (generic of ZARONTIN) CAPS; SOLN

1

felbamate (generic of FELBATOL) SUSP

4 NM

felbamate (generic of FELBATOL) TABS 400mg

1

felbamate (generic of FELBATOL) TABS 600mg

4 NM

FELBATOL 4 NM

gabapentin (generic of NEURONTIN) CAPS 100mg


1 QL



1 QL



1 QL

gabapentin (generic of NEURONTIN) SOLN

QL (2160mL / 30 days)

1 QL

gabapentin (generic of NEURONTIN) TABS 600mg


1 QL

gabapentin (generic of NEURONTIN) TABS 800mg


1 QL

GABITRIL 2 KEPPRA SOLN 100mg/ml 2

Drug Name Drug Tier

Requirements/Limits

KEPPRA SOLN 500mg/5ml 4 NM

KEPPRA TABS 250mg, 500mg

2

KEPPRA TABS 750mg, 1000mg

4 NM

KEPPRA XR 500mg 2 KEPPRA XR 750mg 4 NM

KLONOPIN 1mg QL (600 tabs / 30 days)

2 QL

KLONOPIN 2mg QL (300 tabs / 30 days)

2 QL

KLONOPIN .5mg QL (1200 tabs / 30 days)

2 QL

LAMICTAL TABS 2 LAMICTAL CHEWABLE DISPERS 5mg

2

LAMICTAL CHEWABLE DISPERS 25mg

4 NM

LAMICTAL ODT 2 LAMICTAL STARTER 2 LAMICTAL XR 2 lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW

1

lamotrigine (generic of LAMICTAL) TABS

1

lamotrigine (generic of LAMICTAL XR) TB24

1

levetiracetam (generic of KEPPRA) SOLN; TABS

1

levetiracetam (generic of KEPPRA XR) TB24

1

LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg


2 QL

LYRICA CAPS 200mg QL (90 caps / 30 days)

2 QL

LYRICA CAPS 225mg, 300mg


2 QL

LYRICA SOLN QL (946mL / 30 days)

2 QL

MYSOLINE 2 NEURONTIN CAPS 100mg


2 QL

NEURONTIN CAPS 300mg QL (360 caps / 30 days)

2 QL

21


22

Drug Name Drug Tier

Requirements/Limits

NEURONTIN CAPS 400mg QL (270 caps / 30 days)

2 QL

NEURONTIN SOLN QL (2160mL / 30 days)

2 QL

NEURONTIN TABS 600mg QL (180 tabs / 30 days)

2 QL

NEURONTIN TABS 800mg QL (120 tabs / 30 days)

2 QL

ONFI TABS 3 PA

oxcarbazepine (generic of TRILEPTAL)

1

PEGANONE 3 phenobarbital ELIX; TABS 1 PHENOBARBITAL SODIUM 65mg/ml

1

phenobarbital sodium 130mg/ml

1

phenytek 3 phenytoin (generic of DILANTIN INFATABS) CHEW

1

phenytoin (generic of DILANTIN) SUSP

1

phenytoin inj 50mg/ml 1 phenytoin sodium extended (generic of DILANTIN) 100mg

1

phenytoin sodium extended (generic of PHENYTEK) 200mg, 300mg

1

POTIGA 3 primidone (generic of MYSOLINE) TABS

1

SABRIL 4 NM LA PA

STAVZOR 3 TEGRETOL 2 TEGRETOL-XR 2 tiagabine hcl (generic of GABITRIL)

1

TOPAMAX 25mg, 50mg, 100mg

2

TOPAMAX 200mg 4 NM

TOPAMAX SPRINKLE 15mg

2

TOPAMAX SPRINKLE 25mg

4 NM

Drug Name Drug Tier

Requirements/Limits

topiramate (generic of TOPAMAX SPRINKLE) CPSP

1

topiramate (generic of TOPAMAX) TABS

1

TRANXENE T 3.75mg, 7.5mg


3 QL PA

TRANXENE T 15mg QL (180 tabs / 30 days)

3 QL PA

TRILEPTAL 2 TRILEPTAL SUSP 2 VALIUM

QL (120 tabs / 30 days) 2 QL PA

valproate sodium (generic of DEPACON) SOLN

1

valproate sodium (generic of DEPAKENE) SYRP

1

valproic acid (generic of DEPAKENE) CAPS

1

VIMPAT 2 ZARONTIN CAPS 2 zarontin SOLN 2 ZONEGRAN 2 zonisamide (generic of ZONEGRAN) 25mg, 100mg

1

zonisamide 50mg 1

ANTIDEMENTIA ARICEPT 3 ARICEPT ODT 3 donepezil odt 5mg (generic of ARICEPT ODT)

1

donepezil odt 10mg (generic of ARICEPT ODT)

1

donepezil tabs 5mg (generic of ARICEPT)

1

donepezil tabs 10mg (generic of ARICEPT)

1

EXELON 3 EXELON PATCHES 2 galantamine hydrobromide (generic of RAZADYNE ER) CP24

1

galantamine hydrobromide (generic of RAZADYNE) SOLN; TABS

1

NAMENDA 2 NAMENDA TITRATION PAK 2

22


23

Drug Name Drug Tier

Requirements/Limits

NAMENDA XR 3 NAMENDA XR TITRATION PACK

3

RAZADYNE 3 RAZADYNE ER 3 rivastigmine tartrate (generic of EXELON)

1

ANTIDEPRESSANTS amitriptyline hcl TABS 1 amoxapine 2 ANAFRANIL 4 NM

APLENZIN 3 budeprion (generic of WELLBUTRIN SR)

1

bupropion hcl (generic of WELLBUTRIN) TABS

1

bupropion hcl (generic of WELLBUTRIN SR) TB12

1

bupropion hcl (generic of WELLBUTRIN XL) TB24

1

CELEXA 3 citalopram hydrobromide SOLN

1

citalopram hydrobromide (generic of CELEXA) TABS

1

clomipramine hcl (generic of ANAFRANIL) CAPS

1

CYMBALTA 2 desipramine hcl (generic of NORPRAMIN) TABS

1

doxepin hcl CAPS; CONC 1 EFFEXOR XR 3 EMSAM 3 PA

escitalopram oxalate (generic of LEXAPRO)

1

fluoxetine hcl (generic of PROZAC) CAPS

1

fluoxetine hcl (generic of PROZAC WEEKLY) CPDR

1

fluoxetine hcl SOLN 1 fluoxetine hcl TABS 10mg, 20mg

1

FLUOXETINE HCL TABS 60mg

2

FORFIVO XL 3 imipramine hcl (generic of TOFRANIL) TABS

1

Drug Name Drug Tier

Requirements/Limits

imipramine pamoate (generic of TOFRANIL-PM)

1

LEXAPRO 3 maprotiline hcl 1 MARPLAN 2 mirtazapine TABS 7.5mg 1 mirtazapine (generic of REMERON) TABS 15mg, 30mg, 45mg

1

mirtazapine (generic of REMERON SOLTAB) TBDP

1

NARDIL 2 nefazodone hcl 1 NORPRAMIN 2 nortriptyline hcl (generic of PAMELOR) CAPS

1

nortriptyline hcl SOLN 1 OLEPTRO 3 PAMELOR 4 NM

PARNATE 2 paroxetine er tab (generic of PAXIL CR)

1

paroxetine hcl (generic of PAXIL)

1

PAXIL 3 PAXIL CR 3 PEXEVA 3 phenelzine sulfate (generic of NARDIL) TABS

1

PRISTIQ 2 protriptyline hcl (generic of VIVACTIL)

1

PROZAC 3 PROZAC WEEKLY 3 REMERON 3 REMERON SOLTAB 3 sertraline hcl (generic of ZOLOFT) CONC; TABS

1

SURMONTIL 3 tofranil 2 TOFRANIL-PM 3 tranylcypromine sulfate (generic of PARNATE)

1

trazodone hcl TABS 1 trimipramine maleate (generic of SURMONTIL)

1

23


24

Drug Name Drug Tier

Requirements/Limits

venlafaxine cap er (generic of EFFEXOR XR)

1

VENLAFAXINE HCL ER TAB (VERT)

3

venlafaxine tab 1 venlafaxine tab er (generic of VENLAFAXINE HCL ER)

1

VIIBRYD 2 vivactil 3 WELLBUTRIN 3 WELLBUTRIN SR 3 WELLBUTRIN XL 3 ZOLOFT 3

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

1

APOKYN 4 NM LA PA

AZILECT 2 benztropine mesylate (generic of COGENTIN) SOLN

1

benztropine mesylate TABS 1 bromocriptine mesylate CAPS

1

bromocriptine mesylate (generic of PARLODEL) TABS

1

carbidopa-levodopa (generic of SINEMET) TABS

1

carbidopa-levodopa (generic of SINEMET CR) TBCR

1

carbidopa-levodopa (generic of PARCOPA) TBDP

1

CARBIDOPA/LEVODOPA/ENTACA

1


1


1


1


1


1

COGENTIN 3 COMTAN 3 ELDEPRYL 3 ENTACAPONE 1

Drug Name Drug Tier

Requirements/Limits

LODOSYN 3 MIRAPEX 3 MIRAPEX ER 3 NEUPRO 2 parcopa 10/100 3 parcopa 25/100 3 parcopa 25/250 3 PARLODEL CAPS 2 PARLODEL TABS 3 pramipexole dihydrochloride .75mg

1

pramipexole dihydrochloride (generic of MIRAPEX) .125mg, .25mg, .5mg, 1mg, 1.5mg

1

REQUIP 3 REQUIP XL 3 ropinirole hydrochloride (generic of REQUIP) TABS

1

ropinirole hydrochloride (generic of REQUIP XL) TB24

1

selegiline hcl (generic of ELDEPRYL) CAPS

1

selegiline hcl TABS 1 SINEMET 3 SINEMET CR 3 STALEVO 3 ZELAPAR 3

ANTIPSYCHOTICS ABILIFY SOLN 4 NM

ABILIFY TABS 2mg, 5mg, 10mg, 15mg

2

ABILIFY TABS 20mg, 30mg 4 NM

ABILIFY DISCMELT 4 NM

ABILIFY INJ 2 ABILIFY MAINTENA 4 NM

chlorpromaz inj 25mg/ml 3 chlorpromazine hcl TABS 1 CLOZAPINE ODT 1 PA

clozapine tab (generic of CLOZARIL) 25mg, 100mg

1

clozapine tab 50mg, 200mg 1 CLOZARIL 25mg 3 CLOZARIL 100mg 4 NM

FANAPT 3 ST

24


25

Drug Name Drug Tier

Requirements/Limits

FANAPT TITRATION PACK 3 ST

FAZACLO 3 PA

fluphenazine decanoate SOLN

1

fluphenazine hcl 1 GEODON 3 GEODON INJ 3 HALDOL 3 HALDOL DECANOATE 50 3 HALDOL DECANOATE 100 3 haloperidol TABS 1 haloperidol decanoate (generic of HALDOL DECANOATE 50) SOLN 50mg/ml

1

haloperidol decanoate (generic of HALDOL DECANOATE 100) SOLN 100mg/ml

1

haloperidol lactate CONC 1 haloperidol lactate (generic of HALDOL) SOLN

1

INVEGA 3 INVEGA SUSTENNA 39mg/0.25ml, 78mg/0.5ml

3

INVEGA SUSTENNA 117mg/0.75ml, 156mg/ml, 234mg/1.5ml

4 NM

LATUDA 2 loxapine succinate (generic of LOXITANE) CAPS 5mg, 25mg, 50mg

1

loxapine succinate CAPS 10mg

1

loxitane 5mg, 10mg, 25mg 3 NAVANE 3 olanzapine (generic of ZYPREXA) SOLR

QL (3 vials / 1 day)

1 QL

olanzapine (generic of ZYPREXA) TABS

1

olanzapine odt (generic of ZYPREXA ZYDIS) 5mg, 10mg, 15mg

1

olanzapine odt (generic of ZYPREXA ZYDIS) 20mg

4 NM

ORAP 3 perphenazine TABS 1

Drug Name Drug Tier

Requirements/Limits

quetiapine fumarate (generic of SEROQUEL)

1

RISPERDAL 3 RISPERDAL CONSTA 12.5mg, 25mg

2

RISPERDAL CONSTA 37.5mg, 50mg

4 NM

RISPERDAL M-TAB 3 risperidone (generic of RISPERDAL)

1

risperidone odt (generic of RISPERDAL M-TAB) .5mg, 1mg, 2mg, 3mg, 4mg

1

risperidone odt .25mg 1 SAPHRIS 3 SEROQUEL 3 SEROQUEL XR 2 thioridazine hcl TABS 1 PA

thiothixene 1 trifluoperazine hcl 1 ziprasidone hcl (generic of GEODON)

1

ZYPREXA SOLR 3 ZYPREXA TABS 2.5mg, 5mg, 7.5mg, 10mg

3

ZYPREXA TABS 15mg, 20mg

4 NM

ZYPREXA ZYDIS 5mg 3 ZYPREXA ZYDIS 10mg, 15mg, 20mg

4 NM

ATTENTION DEFICIT HYPERACTIVITY DISORDER adderall tab 5mg


3 QL

adderall tab 7.5mg QL (240 tabs per 30 days)

3 QL

adderall tab 10mg QL (180 tabs per 30 days)

3 QL

adderall tab 12.5mg QL (140 tabs per 30 days)

3 QL


3 QL

25


26

Drug Name Drug Tier

Requirements/Limits


3 QL


3 QL

ADDERALL XR CAP 5MG QL (90 caps / 30 days)

2 QL


2 QL


2 QL


2 QL


2 QL


2 QL

amphetamine-dextroamphetamine cap sr 24hr 5 mg (generic of ADDERALL XR)


1 QL



1 QL



1 QL



1 QL



1 QL



1 QL

amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL)


1 QL

amphetamine-dextroamphetamine tab 7.5 mg (generic of ADDERALL)


1 QL

Drug Name Drug Tier

Requirements/Limits



1 QL

amphetamine-dextroamphetamine tab 12.5 mg (generic of ADDERALL)


1 QL



1 QL



1 QL



1 QL

CONCERTA 18mg, 27mg, 36mg


2 QL

CONCERTA 54mg QL (30 tabs / 30 days)

2 QL

DAYTRANA 10mg/9hr, 20mg/9hr, 30mg/9hr

QL (30 ptch / 30 days)

2 QL

DAYTRANA 15mg/9hr QL (30 patches / 30 days)

2 QL

INTUNIV 2 METADATE CD 10mg, 20mg, 30mg


3 QL

METADATE CD 40mg, 50mg, 60mg


3 QL

metadate tab 20mg er QL (90 tabs / 30 days)

1 QL

METHYLIN 5mg/5ml QL (1800 ml / 30 days)

2 QL

METHYLIN 10mg/5ml QL (900 ml / 30 days)

2 QL

METHYLIN CHEW TAB QL (180 tabs / 30 days)

2 QL

methylphenidate hcl (generic of RITALIN LA) CP24 20mg, 30mg


1 QL

26


27

Drug Name Drug Tier

Requirements/Limits

methylphenidate hcl (generic of RITALIN LA) CP24 40mg


1 QL

methylphenidate hcl (generic of METADATE CD) CPCR 10mg, 20mg, 30mg


1 QL

methylphenidate hcl (generic of METADATE CD) CPCR 40mg, 50mg, 60mg


1 QL

methylphenidate hcl (generic of METHYLIN) SOLN 5mg/5ml

QL (1800 ml / 30 days)

1 QL

methylphenidate hcl (generic of METHYLIN) SOLN 10mg/5ml

QL (900 ml / 30 days)

1 QL

methylphenidate hcl (generic of RITALIN) TABS 5mg, 10mg


1 QL

methylphenidate hcl (generic of RITALIN) TABS 20mg


1 QL

METHYLPHENIDATE HCL ER 18mg, 36mg


1 QL

methylphenidate hcl er (generic of CONCERTA) 27mg


1 QL

METHYLPHENIDATE HCL ER 54mg


1 QL

methylphenidate tab 10mg er QL (90 ea / 30 days)

1 QL

methylphenidate tab 20mg er QL (90 tabs / 30 days)

1 QL

QUILLIVANT XR QL (360 ml / 30 days)

2 QL

RITALIN 5mg, 10mg QL (180 tabs / 30 days)

2 QL

RITALIN 20mg QL (90 tabs / 30 days)

2 QL

RITALIN LA 10mg, 20mg, 30mg


2 QL

Drug Name Drug Tier

Requirements/Limits

RITALIN LA 40mg QL (30 caps / 30 days)

2 QL

RITALIN SR QL (90 tabs / 30 days)

3 QL

STRATTERA 10mg, 18mg, 25mg


2 QL

STRATTERA 40mg QL (60 caps / 30 days)

2 QL

STRATTERA 60mg, 80mg, 100mg


2 QL

VYVANSE 20mg, 30mg QL (60 caps / 30 days)

2 QL

VYVANSE 40mg, 50mg, 60mg, 70mg


2 QL

HYPNOTICS AMBIEN


AMBIEN CR QL (30 ea / 30 days)

3 QL

EDLUAR QL (30 ea / 30 days)

3 QL

INTERMEZZO QL (30 ea / 30 days)

3 QL

LUNESTA QL (30 tabs / 30 days)

3 QL

ROZEREM QL (30 tabs / 30 days)

3 QL

SILENOR 3mg QL (60 tabs / 30 days)

2 QL

SILENOR 6mg QL (30 tabs / 30 days)

2 QL

SONATA QL (30 caps / 30 days)

3 QL

zaleplon (generic of SONATA) QL (30 caps / 30 days)

1 QL

zolpidem tartrate (generic of AMBIEN) TABS


1 QL

zolpidem tartrate (generic of AMBIEN CR) TBCR


1 QL

ZOLPIMIST QL (1 bottle / 30 days)

3 QL

MIGRAINE ALSUMA

QL (4 mL / 30 days) 3 QL

27


28

Drug Name Drug Tier

Requirements/Limits

AMERGE QL (9 tabs / 30 days)

3 QL

AXERT QL (12 tabs / 30 days)

3 QL

cafergot tab 1-100mg 2 D.H.E. 45 4 NM

dihydroergotamine mesylate (generic of D.H.E. 45) 1mg/ml

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

QL (8 mL / 30 days)

1 QL

ergomar 3 FROVA TAB 2.5MG


IMITREX SOLN 5mg/act, 20mg/act

QL (12 inhalers / 30 days)

3 QL

IMITREX SOLN 6mg/0.5ml QL (8 vials / 30 days)

3 QL

IMITREX TABS QL (9 tabs / 30 days)

3 QL

IMITREX STATDOSE REFILL 4mg/0.5ml

QL (8 cartridges / 30 days)

3 QL

IMITREX STATDOSE REFILL 6mg/0.5ml

QL (8 syringes / 30 days)

3 QL

MAXALT QL (12 tabs / 30 days)

3 QL

MAXALT-MLT QL (12 ea / 30 days)

3 QL

migergot 2 MIGRANAL

QL (8 bottles / 30 days) 4 QL NM

naratriptan hcl (generic of AMERGE)


1 QL

RELPAX QL (12 tabs / 30 days)

3 QL

rizatriptan benzoate (generic of MAXALT) TABS


1 QL

rizatriptan benzoate (generic of MAXALT-MLT) TBDP


1 QL

Drug Name Drug Tier

Requirements/Limits

SUMATRIPTAN SUCCINATE SOLN


1 QL

sumatriptan succinate (generic of IMITREX) TABS


1 QL

SUMATRIPTAN SUCCINATE INJ 4mg/0.5ml

QL (4 mL / 30 days)

1 QL

sumatriptan succinate inj (generic of IMITREX) 6mg/0.5ml

QL (8 syringes/vials / 30 days)

1 QL

SUMAVEL DOSEPRO QL (6 mL / 30 days)

2 QL

TREXIMET QL (9 tabs / 30 days)

2 QL

zolmitriptan (generic of ZOMIG)


1 QL

zolmitriptan odt (generic of ZOMIG ZMT)


1 QL

ZOMIG SOLN QL (2 bottles / 30 days)

2 QL

ZOMIG TABS QL (12 tabs / 30 days)

3 QL

ZOMIG ZMT QL (12 ea / 30 days)

3 QL

MISCELLANEOUS EQUETRO 3 GRALISE 300mg


GRALISE 600mg QL (90 tabs / 30 days)

2 QL

GRALISE STARTER 2 HORIZANT 3 lithium carbonate CAPS 1 lithium carbonate TABS 1 lithium carbonate (generic of LITHOBID) TBCR 300mg

1

lithium carbonate TBCR 450mg

1

LITHIUM CITRATE 2 LITHOBID 2

28


29

Drug Name Drug Tier

Requirements/Limits

MESTINON SYRUP 2 MESTINON TAB 2 MESTINON TIMESPAN 2 NUEDEXTA

QL (60 caps / 30 days) 2 QL PA

pyridostigmine bromide (generic of MESTINON) TABS

1

REGONOL 3 RILUTEK 4 NM

riluzole (generic of RILUTEK) 1 SAVELLA 12.5mg


SAVELLA 25mg QL (240 tabs / 30 days)

2 QL


2 QL


2 QL

SAVELLA TITRATION PACK 2 XENAZINE 4 NM LA PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 4 NM LA PA

AUBAGIO QL (30 tabs / 30 days)

4 QL NM PA

AVONEX QL (4 syringes / 28 days)

4 QL NM PA

AVONEX PEN QL (4 boxes / 28 days)

4 QL NM PA

BETASERON QL (14 vials / 28 days)

4 QL NM PA

COPAXONE QL (1 box / 30 days)

4 QL NM PA

EXTAVIA QL (15 syringes / 30 days)

4 QL NM PA

GILENYA QL (30 caps / 30 days)

4 QL NM PA

REBIF QL (6 syringes / 28 days)

4 QL NM PA

REBIF TITRATION PACK QL (6 syringes / 30 days)

4 QL NM PA

TECFIDERA 120mg QL (14 ea / 7 days)

4 QL NM PA

Drug Name Drug Tier

Requirements/Limits

TECFIDERA 240mg QL (60 ea / 30 days)

4 QL NM PA

TECFIDERA STARTER PACK

4 NM PA

TYSABRI 4 NM LA PA

MUSCULOSKELETAL THERAPY AGENTS AMRIX 15mg

QL (60 ea / 30 days) 3 QL PA

AMRIX 30mg QL (30 ea / 30 days)

3 QL PA

baclofen TABS 1 chlorzoxazone (generic of PARAFON FORTE DSC) TABS

1 PA

cyclobenzaprine hcl (generic of FLEXERIL) TABS 5mg, 10mg


1 QL PA

cyclobenzaprine hcl (generic of FEXMID) TABS 7.5mg


1 QL PA

DANTRIUM 2 dantrolene sodium (generic of DANTRIUM) CAPS

1

fexmid QL (90 tabs / 30 days)

3 QL PA

methocarbamol (generic of ROBAXIN) TABS 500mg

1 PA

methocarbamol (generic of ROBAXIN-750) TABS 750mg

1 PA

PARAFON FORTE DSC 2 PA

tizanidine (generic of ZANAFLEX) CAPS

1

tizanidine TABS 2mg 1 tizanidine (generic of ZANAFLEX) TABS 4mg

1

ZANAFLEX CAPS 3 ZANAFLEX TABS 2

NARCOLEPSY/CATAPLEXY modafinil (generic of PROVIGIL) 100mg

1 PA

modafinil (generic of PROVIGIL) 200mg

4 NM PA

NUVIGIL 2 PA

PROVIGIL 4 NM PA

XYREM 4 NM LA PA

PSYCHOTHERAPEUTIC-MISC

29


30

Drug Name Drug Tier

Requirements/Limits

antabuse 2 buprenorphine hcl SUBL 1 PA

buprenorphine hcl-naloxone hcl sl (generic of SUBOXONE)

QL (120 ea / 30 days)

1 QL PA

buproban (generic of ZYBAN) 1 CAMPRAL 2 CHANTIX

QL (336 tabs / year) 2 QL PA

CHANTIX STARTER PACK QL (106 tabs / year)

2 QL PA

disulfiram (generic of ANTABUSE) TABS

1

naloxone hcl SOLN 1 naltrexone hcl (generic of REVIA) TABS

1

NICOTROL INHALER QL (16 inhalers / year)

3 QL

NICOTROL NS QL (36 bottles / year)

3 QL

revia 2 SARAFEM 3 SUBOXONE MIS 2-0.5MG


SUBOXONE MIS 4-1MG QL (120 ea / 30 days)

3 QL PA


3 QL PA


3 QL PA

VIVITROL 4 NM

ZYBAN 2

ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM


ANDROGEL QL (300 gm / 30 days)

3 QL PA

ANDROGEL 1% QL (300 gm / 30 days)

3 QL PA

ANDROGEL 1.62% QL (150 gm / 30 days)

3 QL PA

androxy 3 PA

AXIRON QL (440 mL / 30 days)

2 QL PA

DELATESTRYL 3 depo-testosterone 3

Drug Name Drug Tier

Requirements/Limits

FORTESTA QL (120 gm / 30 days)

2 QL PA

oxandrolone (generic of OXANDRIN) TABS

1 PA

STRIANT QL (60 tabs per 30 days)

3 QL PA

TESTIM QL (300 gm / 30 days)

3 QL PA

testosterone cypionate (generic of DEPO-TESTOSTERONE) OIL

1

testosterone enanthate (generic of DELATESTRYL) OIL

1

ANTIDIABETICS, INJECTABLE ALCOHOL PREPS PADS 2 APIDRA 2 APIDRA SOLOSTAR 2 BYDUREON

QL (4 vials / 30 days) 2 QL PA

BYETTA 3 PA

GAUZE PADS 2X2 2 HUMALOG 3 HUMALOG KWIKPEN 3 HUMALOG MIX 50/50 3 HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3 HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3 HUMULIN 70/30 PEN 3 HUMULIN N 3 HUMULIN N U-100 PEN 3 HUMULIN R 3 HUMULIN R U-500 (CONCENTRATE)

4 B/D NM

INSULIN PEN NEEDLES 2 INSULIN SAFETY NEEDLES 2 INSULIN SYRINGES 2 LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 NOVOLIN 70/30 2

30


31

Drug Name Drug Tier

Requirements/Limits

NOVOLIN 70/30 RELION 3 NOVOLIN N 2 NOVOLIN N RELION 3 NOVOLIN R 2 NOVOLIN R RELION 3 NOVOLOG 2 NOVOLOG FLEXPEN 2 NOVOLOG MIX 70/30 2 NOVOLOG MIX 70/30 PREFILL

2

SYMLINPEN 60 2 PA

SYMLINPEN 120 2 PA

VICTOZA QL (9 mL / 30 days)

2 QL

ANTIDIABETICS, ORAL acarbose (generic of PRECOSE)

1

ACTOPLUS MET TAB 15-500MG


3 QL

ACTOPLUS MET TAB 15-850MG


3 QL

ACTOPLUS MET XR 15-1000MG


3 QL

ACTOPLUS MET XR 30-1000MG


3 QL

ACTOS QL (30 tabs / 30 days)

3 QL

AMARYL 1mg QL (240 tabs / 30 days)

3 QL


3 QL


3 QL

DIABETA 1.25mg QL (480 tabs / 30 days)

3 QL PA

DIABETA 2.5mg QL (240 tabs / 30 days)

3 QL PA

DIABETA 5mg QL (120 tabs / 30 days)

3 QL PA

DUETACT QL (30 tabs / 30 days)

3 QL

FORTAMET 500mg QL (150 ea / 30 days)

3 QL

Drug Name Drug Tier

Requirements/Limits

FORTAMET 1000mg QL (75 ea / 30 days)

3 QL

glimepiride (generic of AMARYL) 1mg


1 QL



1 QL



1 QL

glipizide (generic of GLUCOTROL) TABS 5mg


1 QL

glipizide (generic of GLUCOTROL) TABS 10mg


1 QL

glipizide er (generic of GLUCOTROL XL) 2.5mg


1 QL

glipizide er (generic of GLUCOTROL XL) 5mg


1 QL

glipizide er (generic of GLUCOTROL XL) 10mg


1 QL

glipizide-metformin 2.5-250mg (generic of METAGLIP)


1 QL

glipizide-metformin 2.5-500mg QL (120 tabs / 30 days)

1 QL

glipizide-metformin 5-500mg QL (120 tabs / 30 days)

1 QL

GLUCOPHAGE 500mg QL (150 tabs / 30 days)

3 QL


3 QL


3 QL

GLUCOPHAGE XR 500mg QL (120 ea / 30 days)

3 QL

GLUCOPHAGE XR 750mg QL (60 ea / 30 days)

3 QL

GLUCOTROL 5mg QL (240 tabs / 30 days)

3 QL

GLUCOTROL 10mg QL (120 tabs / 30 days)

3 QL

GLUCOTROL XL 2.5mg QL (240 ea / 30 days)

3 QL

31


32

Drug Name Drug Tier

Requirements/Limits

GLUCOTROL XL 5mg QL (120 ea / 30 days)

3 QL

GLUCOTROL XL 10mg QL (60 ea / 30 days)

3 QL

GLUCOVANCE 1.25-250MG QL (240 tabs / 30 days)

3 QL PA

GLUCOVANCE 2.5-500MG QL (120 tabs / 30 days)

3 QL PA

GLUCOVANCE 5-500MG QL (120 tabs / 30 days)

3 QL PA

GLUMETZA 500mg QL (120 ea / 30 days)

3 QL

GLUMETZA 1000mg QL (60 ea / 30 days)

3 QL

glyburide 1.25mg QL (480 tabs / 30 days)

1 QL PA

glyburide 2.5mg QL (240 tabs / 30 days)

1 QL PA

glyburide 5mg QL (120 tabs / 30 days)

1 QL PA

glyburide micronized (generic of GLYNASE) 1.5mg


1 QL PA

glyburide micronized (generic of GLYNASE) 3mg


1 QL PA

glyburide micronized (generic of GLYNASE) 6mg


1 QL PA

glyburide-metformin 1.25-250mg (generic of GLUCOVANCE)


1 QL PA

glyburide-metformin 2.5-500mg (generic of GLUCOVANCE)


1 QL PA

glyburide-metformin 5-500mg (generic of GLUCOVANCE)


1 QL PA

GLYNASE 1.5mg QL (240 tabs / 30 days)

3 QL PA

GLYNASE 3mg QL (120 tabs / 30 days)

3 QL PA

GLYNASE 6mg QL (60 tabs / 30 days)

3 QL PA

GLYSET 3

Drug Name Drug Tier

Requirements/Limits

INVOKANA 100mg QL (90 tabs per 30 days)

2 QL

INVOKANA 300mg QL (30 tabs per 30 days)

2 QL

JANUMET 2 JANUMET XR TAB 50-500MG

2

JANUMET XR TAB 50-1000 2 JANUMET XR TAB 100-1000 2 JANUVIA 2 JENTADUETO


JUVISYNC QL (30 tabs / 30 days)

3 QL

KAZANO QL (60 tabs / 30 days)

3 QL

KOMBIGLYZE XR 2.5-1000MG


3 QL

KOMBIGLYZE XR 5-500MG QL (30 ea / 30 days)

3 QL

KOMBIGLYZE XR 5-1000MG QL (30 ea / 30 days)

3 QL

metformin er (generic of GLUCOPHAGE XR) 500mg


1 QL

metformin er (generic of GLUCOPHAGE XR) 750mg


1 QL

metformin hcl (generic of GLUCOPHAGE) TABS 500mg


1 QL



1 QL



1 QL

metformin hcl (generic of FORTAMET) TB24 500mg

QL (150 ea / 30 days)

1 QL

metformin hcl (generic of FORTAMET) TB24 1000mg


1 QL

32


33

Drug Name Drug Tier

Requirements/Limits

nateglinide (generic of STARLIX)


1 QL

NESINA 6.25mg QL (120 tabs / 30 days)

3 QL

NESINA 12.5mg QL (60 tabs / 30 days)

3 QL

NESINA 25mg QL (30 tabs / 30 days)

3 QL

ONGLYZA QL (30 tabs / 30 days)

3 QL

OSENI TAB 12.5-15MG QL (60 tabs / 30 days)

3 QL


3 QL


3 QL

OSENI TAB 25-15MG QL (30 tabs / 30 days)

3 QL


3 QL


3 QL

pioglitazone hcl (generic of ACTOS)


1 QL

pioglitazone hcl-glimepiride (generic of DUETACT)


1 QL

pioglitazone hcl-metformin hcl (generic of ACTOPLUS MET)


1 QL

PRANDIMET QL (150 tabs / 30 days)

3 QL

PRANDIN 2mg QL (240 tabs / 30 days)

2 QL

PRANDIN .5mg, 1mg QL (120 tabs / 30 days)

2 QL

PRECOSE 2 RIOMET

QL (946mL / 30 days) 3 QL

STARLIX QL (90 tabs / 30 days)

3 QL

TRADJENTA 2

BISPHOSPHONATES ACTONEL 2 alendronate sodium SOLN

QL (300 mL / 28 days) 1 QL

Drug Name Drug Tier

Requirements/Limits

alendronate sodium TABS 5mg, 10mg, 35mg, 40mg

1

alendronate sodium (generic of FOSAMAX) TABS 70mg

1

ATELVIA 2 BINOSTO 3 BONIVA SOLN

QL (1 syringe / 90 days) 3 B/D QL

BONIVA TABS 3 B/D

FOSAMAX 3 FOSAMAX PLUS D 3 ibandronate sodium (generic of BONIVA)

1 B/D

pamidronate disodium SOLN 6mg/ml

2 B/D

pamidronate disodium SOLN 30mg/10ml, 90mg/10ml

1 B/D

zoledronic inj 4mg/5ml (generic of ZOMETA)

4 B/D NM

ZOMETA 4 B/D NM

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg 2 NM

SENSIPAR 60mg, 90mg 4 NM

CHELATING AGENTS CHEMET 3 EXJADE 4 NM LA PA

FERRIPROX 4 NM PA

KAYEXALATE 3 kionex (generic of KAYEXALATE) POWD

1

kionex SUSP 1 sodium polystyrene sulfonate 1 sps sus 15gm/60ml 1 SYPRINE 4 NM

CONTRACEPTIVES altavera 1 amethia 91 day (generic of SEASONIQUE)

1

amethyst 28 day 1 apri 28 day (generic of DESOGEN)

1

aranelle 28 (generic of TRI-NORINYL 28)

1

aviane 28 1 balziva 28 day (generic of OVCON-35)

1

BEYAZ 2

33


34

Drug Name Drug Tier

Requirements/Limits

BREVICON-28 3 briellyn 28 day (generic of OVCON-35)

1

camila 28 day (generic of NOR-QD)

1

CAMRESE LO TAB 1 cryselle 28 1 cyclafem 1/35 28 day (generic of NORINYL 1+35)

1

cyclafem 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)

1

CYCLESSA 3 DEPO-PROVERA CONTRACEPTIV

2

DEPO-SUBQ PROVERA 104 2 DESOGEN 3 drospirenone-ethinyl estradiol (generic of YASMIN 28)

1

ELLA 2 emoquette (generic of DESOGEN)

1

enpresse 28 day 1 errin 28 day (generic of ORTHO MICRONOR)

1

ESTROSTEP FE 3 FEMCON FE 3 GENERESS FE 3 GIANVI 1 gildagia (generic of OVCON-35)

1

heather tab 0.35mg (generic of NOR-QD)

1

introvale 91 day 1 JOLIVETTE 1 junel 1.5/30 21 day (generic of LOESTRIN 1.5/30-21)

1

junel 1/20 21 day (generic of LOESTRIN 1/20-21)

1

junel fe 1.5/30 28 day (generic of LOESTRIN FE 1.5/30)

1

junel fe 1/20 28 day (generic of LOESTRIN FE 1/20)

1

kariva 28 day (generic of MIRCETTE)

1

kelnor 1/35 28 day 1 LEENA 1

Drug Name Drug Tier

Requirements/Limits

lessina 28 day 1 levonest 28 day 1 levonorgestrel-ethinyl estradiol (91-day)

1

levora 0.15/30 28 day 1 LO LOESTRIN FE 2 loestrin 1.5/30-21 3 loestrin 1/20-21 3 LOESTRIN 24 FE 2 loestrin fe 1.5/30 3 loestrin fe 1/20 3 loryna 28 day (generic of YAZ)

1

LOSEASONIQUE 3 low-ogestrel 28 day 1 lutera 28 day 1 marlissa 28 day 1 medroxyprogesterone acetate (contraceptive) (generic of DEPO-PROVERA CONTRACEPTIV)

1

microgestin 1.5/30 21 day (generic of LOESTRIN 1.5/30-21)

1

microgestin 1/20 21 day (generic of LOESTRIN 1/20-21)

1

microgestin fe 1.5/30 28 day (generic of LOESTRIN FE 1.5/30)

1

microgestin fe 1/20 28 day (generic of LOESTRIN FE 1/20)

1

MINASTRIN 24 FE 3 MODICON 3 MONONESSA 1 myzilra 1 necon 0.5/35 28 day (generic of BREVICON-28)

1

necon 1/35 28 day (generic of NORINYL 1+35)

1

NECON 1/50-28 1 NECON 7/7/7 1 necon 10/11 28 day 3 next choice tab 1.5mg (generic of PLAN B ONE-STEP)

1

34


35

Drug Name Drug Tier

Requirements/Limits

NOR-QD 2 NORA-BE 1 NORDETTE-28 3 norethindrone (contraceptive) (generic of NOR-QD)

1

norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO TRI-CYCLEN)

1

NORINYL 1+35 3 NORINYL 1+50 3 nortrel 0.5/35 28 day (generic of BREVICON-28)

1

nortrel 1/35 21 day (generic of NORINYL 1+35)

1

nortrel 1/35 28 day (generic of NORINYL 1+35)

1

nortrel 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)

1

NUVARING 2 OCELLA 1 ogestrel 28 day 1 orsythia 28 day 1 ORTHO EVRA 2 ORTHO MICRONOR 2 ORTHO TRI-CYCLEN LO 2 ORTHO-CEPT 3 ORTHO-CYCLEN 3 ORTHO-NOVUM 7/7/7 3 ovcon 35 28 day 3 philith (generic of OVCON-35) 1 portia 28 day 1 previfem 28 day (generic of ORTHO-CYCLEN)

1

QUARTETTE 3 quasense 91 day 1 reclipsen 28 day (generic of DESOGEN)

1

SEASONIQUE 3 SOLIA 1 sprintec 28 day (generic of ORTHO-CYCLEN)

1

sronyx 28 day 1 syeda (generic of YASMIN 28)

1

tri-legest 28 day (generic of ESTROSTEP FE)

1

Drug Name Drug Tier

Requirements/Limits

TRI-NORINYL 28 3 tri-previfem 28 day (generic of ORTHO TRI-CYCLEN)

1

tri-sprintec 28 day (generic of ORTHO TRI-CYCLEN)

1

TRINESSA 1 trivora 28 day 1 velivet 28 day (generic of CYCLESSA)

1

vestura (generic of YAZ) 1 viorele (generic of MIRCETTE)

1

YASMIN 28 3 YAZ 3 zarah (generic of YASMIN 28) 1 zenchent fe 28 day (generic of FEMCON FE)

1

zenchent tab (generic of OVCON-35)

1

zovia 1/35e 28 day 1 zovia 1/50e 28 day 1

ENDOMETRIOSIS danazol CAPS 1 SYNAREL 4 NM

ENZYME REPLACEMENTS ADAGEN 4 NM LA PA

ALDURAZYME 4 NM LA PA

BUPHENYL 4 NM

BUPHENYL TAB 500MG 4 NM

CARBAGLU 4 NM LA PA

CARNITOR SOLN 1gm/10ml

2 B/D

CARNITOR SOLN 200mg/ml

3 B/D

CARNITOR TABS 2 B/D

CEREZYME 4 NM PA

CYSTADANE 4 NM

CYSTAGON 3 NM PA

ELAPRASE 4 NM PA

ELELYSO 4 NM PA

FABRAZYME 4 NM PA

KUVAN 4 NM PA

levocarnitine (metabolic modifiers) (generic of CARNITOR)

1 B/D

LUMIZYME 4 NM PA

MYOZYME 4 NM PA

35


36

Drug Name Drug Tier

Requirements/Limits

NAGLAZYME 4 NM LA PA

ORFADIN 4 NM LA PA

PROCYSBI 4 NM LA PA

sodium phenylbutyrate (generic of BUPHENYL)

4 NM

VPRIV 4 NM PA

ZAVESCA 4 NM LA PA

ESTROGEN/PROGESTINS estradiol & norethindrone acetate (generic of ACTIVELLA)

1

jinteli 1 PA

ESTROGENS ALORA 3 PA

CLIMARA 3 PA

COMBIPATCH 2 PA

DELESTROGEN 3 depo-estradiol 3 estrace CREA 3 estrace TABS 3 PA

estradiol (generic of CLIMARA) PTWK

1 PA

estradiol (generic of ESTRACE) TABS

1 PA

ESTRADIOL VALERATE OIL 10mg/ml

1

estradiol valerate (generic of DELESTROGEN) OIL 20mg/ml, 40mg/ml

1

ESTRING 3 estropipate TABS 1 PA

FEMRING 3 menest 3 PA

MENOSTAR 3 PA

MINIVELLE 3 PA

PREMARIN 2 PA

PREMARIN CREAM 2 PREMARIN INJ 3 PREMPHASE 2 PA

PREMPRO 2 PA

VAGIFEM 2 VIVELLE-DOT 2 PA

GLUCOCORTICOIDS a-hydrocort inj 100mg 1 CELESTONE 3 CORTEF 2 cortisone acetate TABS 1

Drug Name Drug Tier

Requirements/Limits

DEPO-MEDROL 3 dexamethasone CONC 2 dexamethasone ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

dexpak taperpak 13 day 2 FLO-PRED 3 fludrocortisone acetate TABS

1

hydrocortisone (generic of CORTEF) TABS

1

MEDROL 2 MEDROL DOSEPAK 2 methylprednisolone (generic of MEDROL DOSEPAK) TABS 4mg

1

methylprednisolone (generic of MEDROL) TABS 4mg, 8mg, 16mg, 32mg

1

methylprednisolone acetate (generic of DEPO-MEDROL)

1

methylprednisolone sod succ (generic of SOLU-MEDROL)

1

millipred 3 orapred 2 ORAPRED ODT 2 pediapred 2 prednisolone (generic of PRELONE)

1

prednisolone sodium phosphate (generic of PEDIAPRED) 5mg/5ml

1

prednisolone sodium phosphate (generic of ORAPRED) 15mg/5ml

1

prednisolone sodium phosphate 25mg/5ml

1

prednisone CONC 3 prednisone SOLN; TABS 1 RAYOS 3 SOLU-CORTEF 100MG 3 SOLU-CORTEF 250MG 3 SOLU-CORTEF 500MG 3 SOLU-CORTEF 1000MG 3 SOLU-MEDROL 3 veripred 3

36


37

Drug Name Drug Tier

Requirements/Limits

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2 GLUCAGON EMERGENCY KIT

2

PROGLYCEM 4 NM

HUMAN GROWTH HORMONES GENOTROPIN 4 NM PA

GENOTROPIN MINIQUICK .2mg

3 NM PA

GENOTROPIN MINIQUICK .4mg, .6mg, .8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg

4 NM PA

HUMATROPE 4 NM PA

HUMATROPE COMBO PACK 4 NM PA

NORDITROPIN FLEXPRO 4 NM PA

NORDITROPIN NORDIFLEX PEN

4 NM PA

NUTROPIN 4 NM PA

NUTROPIN AQ 4 NM PA

NUTROPIN AQ NUSPIN 5 4 NM PA

NUTROPIN AQ PEN 4 NM PA

OMNITROPE 5.8MG 4 NM PA

OMNITROPE 5MG 3 NM PA

OMNITROPE 10MG 4 NM PA

SAIZEN 4 NM PA

SAIZEN CLICK.EASY 4 NM PA

SEROSTIM 4 NM PA

TEV-TROPIN 4 NM PA

ZORBTIVE 4 NM PA

MISCELLANEOUS cabergoline 1 calcitonin (salmon) nasal spray (generic of MIACALCIN)

1

CHORIONIC GONADOTROPIN SOLR

1 NM PA

EGRIFTA 4 NM PA

FORTICAL SPR 200/ACT 3 INCRELEX 4 NM LA PA

methylergonovine maleate (generic of METHERGINE) TABS

1

MIACALCIN INJ 200U/ML 2 B/D

MIACALCIN SPR 200/ACT 3 NOVAREL INJ 10000UNT 1 NM PA

Drug Name Drug Tier

Requirements/Limits

octreotide acetate (generic of SANDOSTATIN) 50mcg/ml, 100mcg/ml, 200mcg/ml

1 NM PA

octreotide acetate (generic of SANDOSTATIN) 500mcg/ml, 1000mcg/ml

4 NM PA

PREGNYL W/DILUENT BENZYL

1 NM PA

PROLIA 3 NM

SAMSCA 4 NM PA

SANDOSTATIN 50mcg/ml, 500mcg/ml

3 NM PA

SANDOSTATIN 100mcg/ml, 200mcg/ml, 1000mcg/ml

4 NM PA

SANDOSTATIN LAR DEPOT 4 NM PA

SOMATULINE DEPOT 4 NM PA

SOMAVERT 4 NM LA PA

XGEVA 4 NM PA

PARATHYROID HORMONES FORTEO 4 NM PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) (generic of PHOSLO) CAPS

1

calcium acetate (phosphate binder) (generic of ELIPHOS) TABS

1

eliphos 3 FOSRENOL 2 PHOSLO 3 PHOSLYRA 2 RENAGEL 3 RENVELA 2

PROGESTINS aygestin 3 CRINONE 2 ENDOMETRIN 2 medroxyprogesterone acetate (generic of PROVERA)

1

norethindrone acetate (generic of AYGESTIN) TABS

1

progesterone micronized (generic of PROMETRIUM) CAPS

1

PROMETRIUM 3 PROVERA 3

37


38

Drug Name Drug Tier

Requirements/Limits

SELECTIVE ESTROGEN RECEPTOR MODULATORS EVISTA 2

THYROID AGENTS CYTOMEL 2 LEVOTHROID 1 levothyroxine sodium (generic of SYNTHROID) TABS

1

LEVOXYL 1 liothyronine sodium (generic of TRIOSTAT) SOLN

1

liothyronine sodium (generic of CYTOMEL) TABS

1

methimazole (generic of TAPAZOLE) TABS

1

propylthiouracil TABS 1 SYNTHROID 2 tapazole 2 TIROSINT 3 TRIOSTAT 3 UNITHROID 1

VASOPRESSINS DDAVP SOLN 4mcg/ml 4 NM

DDAVP SOLN .01% 2 DDAVP TABS 2 DESMOPRESSIN ACETATE SOLN

1

desmopressin acetate (generic of DDAVP) TABS

1

desmopressin acetate inj (generic of DDAVP)

1

desmopressin acetate spray (generic of DDAVP)

1

desmopressin acetate spray refrigerated

1

STIMATE 3 NM

GASTROINTESTINAL ANTIEMETICS ALOXI 4 NM

ANTIVERT 3 CESAMET

QL (60 caps / 30 days) 4 B/D QL NM

compro supp 1 dronabinol (generic of MARINOL) 2.5mg, 5mg


1 B/D QL

Drug Name Drug Tier

Requirements/Limits

dronabinol (generic of MARINOL) 10mg


4 B/D QL NM

EMEND CAPS 40mg QL (3 caps / 180 days)

3 QL


3 B/D QL


3 B/D QL

EMEND PAK 80 & 125 QL (12 caps / 30 days)

3 B/D QL

granisetron hcl SOLN 1 granisetron hcl TABS 1 B/D

granisol 4 B/D NM

MARINOL 2.5mg QL (60 caps / 30 days)

3 B/D QL

MARINOL 5mg, 10mg QL (60 caps / 30 days)

4 B/D QL NM

meclizine hcl (generic of ANTIVERT)

1

metoclopramide hcl SOLN 1 metoclopramide hcl (generic of REGLAN) TABS

1

metoclopramide hcl inj 5 mg/ml

1

METOZOLV ODT 3 ondansetron hcl (generic of ZOFRAN) TABS 4mg, 8mg

1 B/D

ondansetron hcl TABS 24mg 1 B/D

ondansetron hcl inj 4mg/2ml 1 ondansetron hcl inj (generic of ZOFRAN) 40mg/20ml

1

ondansetron hcl oral soln (generic of ZOFRAN)

1 B/D

ondansetron odt (generic of ZOFRAN ODT)

1 B/D

phenadoz 1 PA

phenergan 3 PA

prochlorperazine inj 5 mg/ml 1 prochlorperazine maleate TABS

1

prochlorperazine supp 1 promethazine hcl (generic of PHENERGAN) SOLN

1 PA

promethazine hcl SUPP; SYRP; TABS

1 PA

promethegan 1 PA

REGLAN 3

38


39

Drug Name Drug Tier

Requirements/Limits

SANCUSO QL (4 ptch / 30 days)

4 QL NM

TRANSDERM-SCOP QL (10 ptch / 30 days)

2 QL PA

ZOFRAN SOLN 4mg/5ml 4 B/D NM

ZOFRAN SOLN 40mg/20ml 3 ZOFRAN TABS 4 B/D NM

ZOFRAN ODT 4 B/D NM

ANTISPASMODICS ATROPINE SULFATE SOLN .05mg/ml, .1mg/ml

1

BENTYL CAPS; TABS 2 BENTYL SOLN 3 CANTIL 3 CUVPOSA 3 dicyclomine hcl (generic of BENTYL) CAPS; TABS

1

dicyclomine hcl SOLN 1 glycopyrrolate (generic of ROBINUL) SOLN

1

glycopyrrolate (generic of ROBINUL) TABS 1mg

1

glycopyrrolate (generic of ROBINUL FORTE) TABS 2mg

1

methscopolamine bromide (generic of PAMINE) TABS 2.5mg

1

methscopolamine bromide (generic of PAMINE FORTE) TABS 5mg

1

PAMINE 3 PAMINE FORTE 3 ROBINUL 3 ROBINUL FORTE 3

H2-RECEPTOR ANTAGONISTS AXID SOLN 3 cimetidine TABS 1 cimetidine inj 150mg/ml 1 cimetidine sol 300/5ml 1 famotidine SOLN 1 famotidine (generic of PEPCID) SUSR

1

famotidine (generic of PEPCID) TABS 20mg, 40mg

1

nizatidine CAPS 150mg 1

Drug Name Drug Tier

Requirements/Limits

nizatidine (generic of AXID) CAPS 300mg

1

nizatidine (generic of AXID) SOLN

1

PEPCID 3 ranitidine hcl CAPS 1 ranitidine hcl (generic of ZANTAC) SOLN

1

ranitidine hcl (generic of ZANTAC) SYRP

1

ranitidine hcl (generic of ZANTAC) TABS 150mg, 300mg

1

ZANTAC SYRP 2 ZANTAC TABS 3

INFLAMMATORY BOWEL DISEASE APRISO 2 ASACOL 3 ASACOL HD 3 AZULFIDINE 2 AZULFIDINE EN-TABS 2 balsalazide disodium (generic of COLAZAL)

1

budesonide (generic of ENTOCORT EC) CP24

4 NM

CANASA 2 COLAZAL 3 colocort (generic of CORTENEMA)

1

CORTENEMA 2 DELZICOL 3 DIPENTUM 4 NM

ENTOCORT EC 4 NM

GIAZO 3 HYDROCORTISONE (INTRARECTAL)

1

LIALDA 2 mesalamine enema 1 mesalamine enema kit (generic of ROWASA)

1

PENTASA 2 ROWASA 2 SFROWASA 2 sulfasalazine dr (generic of AZULFIDINE EN-TABS)

1

sulfasalazine ir (generic of AZULFIDINE)

1

39


40

Drug Name Drug Tier

Requirements/Limits

UCERIS 3

LAXATIVES COLYTE-FLAVOR PACKS 3 constulose 1 enulose 1 gaviltye-g (generic of GOLYTELY)

1

gavilyte-c (generic of COLYTE-FLAVOR PACKS)

1

gavilyte-n (generic of NULYTELY/FLAVOR PACKS)

1

generlac 1 GOLYTELY 3 HALFLYTELY BOWEL PREP/FLA

3

kristalose 2 lactulose 1 lactulose (encephalopathy) 1 MOVIPREP 2 NULYTELY/FLAVOR PACKS 3 OSMOPREP 3 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE

1

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (generic of GOLYTELY)

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic of NULYTELY/FLAVOR PACKS)

1

polyethylene glycol 3350 PACK; POWD

1

PREPOPIK 3 RELISTOR 2 PA

SUCLEAR 3 SUPREP BOWEL PREP 2 trilyte (generic of NULYTELY/FLAVOR PACKS)

1

VISICOL 3

MISCELLANEOUS ACTIGALL 2 AMITIZA 2 ST

CARAFATE 2 cromolyn sodium (mastocytosis) (generic of GASTROCROM)

4 NM

Drug Name Drug Tier

Requirements/Limits

CYTOTEC 2 diphenoxylate w/ atropine LIQD

1 PA

diphenoxylate w/ atropine (generic of LOMOTIL) TABS

1 PA

GASTROCROM 4 NM

GATTEX 4 NM LA PA

HELIDAC 4 NM

LINZESS CAP 145MCG QL (60 caps / 30 days)

3 QL ST

LINZESS CAP 290MCG QL (30 caps / 30 days)

3 QL ST

LOMOTIL 2 PA

loperamide hcl CAPS 1 LOTRONEX 4 NM PA

misoprostol (generic of CYTOTEC)

1

OMECLAMOX-PAK 3 PREVPAC 2 PYLERA 2 SUCRAID 4 NM

sucralfate (generic of CARAFATE) TABS

1

URSO 250 2 URSO FORTE 2 ursodiol (generic of ACTIGALL) CAPS

1

ursodiol (generic of URSO 250) TABS 250mg

1

ursodiol (generic of URSO FORTE) TABS 500mg

1

XIFAXAN TAB 550MG 4 NM PA

PANCREATIC ENZYMES CREON 2 PANCREAZE 3 PERTZYE 3 ULTRESA 2 VIOKACE 10440 UNIT 2 VIOKACE 20880 UNIT 4 NM

ZENPEP 2

PROTON PUMP INHIBITORS ACIPHEX

QL (30 ea / 30 days) 3 QL

DEXILANT 2 lansoprazole (generic of PREVACID) CPDR


1 QL

40


41

Drug Name Drug Tier

Requirements/Limits

NEXIUM 2 NEXIUM GRANULES 2.5MG DR

2

NEXIUM GRANULES 5MG DR

2


2


2


2

NEXIUM I.V. 3 omeprazole (generic of PRILOSEC) CPDR 10mg, 40mg


1 QL

omeprazole (generic of PRILOSEC) CPDR 20mg


1 QL

pantoprazole sodium (generic of PROTONIX) SOLR

1

pantoprazole sodium (generic of PROTONIX) TBEC


1 QL

PREVACID QL (30 ea / 30 days)

3 QL

PREVACID SOLUTAB QL (30 ea / 30 days)

3 QL

PRILOSEC CPDR 10mg, 40mg


3 QL

PRILOSEC CPDR 20mg QL (60 ea / 30 days)

3 QL

PROTONIX QL (30 ea / 30 days)

3 QL

PROTONIX INJ 3 ZEGERID PACK

QL (1 packet / 30 days) 3 QL

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL)

1

AVODART 2 CARDURA XL 3 finasteride (generic of PROSCAR) TABS 5mg

1

FLOMAX 3 JALYN 3

Drug Name Drug Tier

Requirements/Limits

PROSCAR 3 RAPAFLO 2 tamsulosin hcl (generic of FLOMAX)

1

UROXATRAL 3

MISCELLANEOUS bethanechol chloride (generic of URECHOLINE) TABS

1

ELMIRON 2 POTASSIUM CITRATE (ALKALINIZER) 540mg

1

POTASSIUM CITRATE (ALKALINIZER) 1080mg

1

urecholine 2 UROCIT-K 2

URINARY ANTISPASMODICS DETROL 3 DETROL LA 3 DITROPAN XL 3 ENABLEX 3 GELNIQUE 2 MYRBETRIQ 3 oxybutynin chloride SYRP; TABS

1

oxybutynin chloride (generic of DITROPAN XL) TB24

1

OXYTROL 3 SANCTURA 3 SANCTURA XR 3 tolterodine tartrate (generic of DETROL)

1

TOVIAZ 3 trospium chloride (generic of SANCTURA XR) CP24

1

trospium chloride (generic of SANCTURA) TABS

1

VESICARE 2

VAGINAL ANTI-INFECTIVES CLEOCIN CREA 2 CLEOCIN VAG SUPP 100MG 2 clindamycin cre 2% vag (generic of CLEOCIN)

1

METROGEL-VAGINAL 2 metronidazole vaginal (generic of METROGEL-VAGINAL)

1

41


42

Drug Name Drug Tier

Requirements/Limits

miconazole nitrate vaginal 1 TERAZOL 3 2 TERAZOL 7 2 terconazole vaginal (generic of TERAZOL 7) CREA .4%

1

terconazole vaginal (generic of TERAZOL 3) CREA .8%

1

terconazole vaginal (generic of TERAZOL 3) SUPP

1

VANDAZOLE 1 zazole (generic of TERAZOL 7) .4%

1

ZAZOLE .8% 1

HEMATOLOGIC ANTICOAGULANTS ARIXTRA 2.5mg/0.5ml 2 ARIXTRA 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

4 NM

COUMADIN 3 COUMADIN INJ 3 ELIQUIS 3 enoxaparin sodium (generic of LOVENOX) 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml

1

enoxaparin sodium (generic of LOVENOX) 100mg/ml, 120mg/0.8ml, 150mg/ml

4 NM

fondaparinux sodium (generic of ARIXTRA) 2.5mg/0.5ml

1

fondaparinux sodium (generic of ARIXTRA) 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml

4 NM

FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml

2

FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 25000unit/ml

4 NM

HEP SOD/NACL INJ 25000 3 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

2

heparin sod inj 1000u/ml 1 B/D

HEPARIN SOD INJ 2000U/ML

2 B/D

Drug Name Drug Tier

Requirements/Limits

HEPARIN SOD INJ 2500U/ML

3 B/D

heparin sod inj 5000u/0.5ml 1 B/D




HEPARIN SODIUM/D5W 1 HEPARIN SODIUM/SODIUM CHL

1

jantoven (generic of COUMADIN)

1

LOVENOX 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 300mg/3ml

2

LOVENOX 80mg/0.8ml, 100mg/ml, 120mg/0.8ml, 150mg/ml

4 NM

PRADAXA 2 warfarin sodium (generic of COUMADIN)

1

XARELTO 2

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 25mcg/0.42ml, 25mcg/ml, 40mcg/0.4ml, 40mcg/ml, 60mcg/0.3ml, 60mcg/ml

2 NM PA

ARANESP ALBUMIN FREE 100mcg/0.5ml, 100mcg/ml, 150mcg/0.3ml, 150mcg/0.75ml, 200mcg/0.4ml, 200mcg/ml, 300mcg/0.6ml, 300mcg/ml, 500mcg/ml

4 NM PA

EPOGEN 2 NM PA

LEUKINE 4 NM PA

MOZOBIL 4 NM PA

NEULASTA 4 NM PA

NEUMEGA 4 NM PA

NEUPOGEN 4 NM PA

PROCRIT 2000unit/ml, 3000unit/ml, 4000unit/ml, 10000unit/ml

2 NM PA

PROCRIT 20000unit/ml, 40000unit/ml

4 NM PA

MISCELLANEOUS AGRYLIN 2 PA

anagrelide hcl 1mg 1 PA

anagrelide hcl (generic of AGRYLIN) .5mg

1 PA

42


43

Drug Name Drug Tier

Requirements/Limits

cilostazol (generic of PLETAL) 1 CYKLOKAPRON 3 LYSTEDA 3 pentoxifylline (generic of TRENTAL) TBCR

1

PLETAL 2 PROMACTA 4 NM LA PA

tranexamic acid (generic of CYKLOKAPRON) SOLN

1

tranexamic acid (generic of LYSTEDA) TABS

1

TRENTAL 3

PLATELET AGGREGATION INHIBITORS AGGRENOX 2 BRILINTA 2 clopidogrel bisulfate (generic of PLAVIX)

1

dipyridamole (generic of PERSANTINE) TABS

1 PA

EFFIENT 2 PERSANTINE 2 PA

PLAVIX 3

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 4 NM PA

ARAVA 10mg 2 ARAVA 20mg 4 NM

CIMZIA 4 NM PA

ENBREL 4 NM PA

HUMIRA 4 NM PA

HUMIRA PEN 4 NM PA

HUMIRA PEN-CROHNS STARTER KIT

4 NM PA

HUMIRA PEN-PSORIASIS STARTER KIT

4 NM PA

hydroxychloroquine sulfate (generic of PLAQUENIL)

1

KINERET 4 NM PA

leflunomide (generic of ARAVA) TABS

1

methotrexate sodium tabs 1 ORENCIA 4 NM PA

PLAQUENIL 2 REMICADE 4 NM PA

RHEUMATREX 2 SIMPONI 50mg/0.5ml 4 NM PA

Drug Name Drug Tier

Requirements/Limits

trexall 2 B/D

XELJANZ 4 NM PA

IMMUNOGLOBULINS CARIMUNE NANOFILTERED 4 NM PA

FLEBOGAMMA 4 NM PA

FLEBOGAMMA DIF 4 NM PA

GAMASTAN S/D 2 B/D NM

GAMMAGARD LIQUID 4 NM PA

GAMMAGARD S/D 4 NM PA

GAMMAKED 4 NM PA

GAMMAPLEX 4 NM PA

GAMUNEX 4 NM PA

GAMUNEX-C 4 NM PA

GAMUNEX-C 1GM/10ML 3 NM PA

OCTAGAM 4 NM PA

PRIVIGEN 4 NM PA

IMMUNOMODULATORS ACTIMMUNE 4 NM LA PA

ARCALYST 4 NM PA

INFERGEN 4 NM PA

INTRON-A 4 B/D NM

INTRON-A W/DILUENT 4 B/D NM

PEG-INTRON 4 NM PA

PEG-INTRON REDIPEN 4 NM PA

PEGASYS 4 NM PA

PEGASYS PROCLICK 4 NM PA

REVLIMID 4 NM LA PA

THALOMID 4 NM PA

IMMUNOSUPPRESSANTS ATGAM 3 B/D

azasan 2 B/D

azathioprine (generic of IMURAN) TABS

1 B/D

azathioprine inj 100mg 1 B/D

CELLCEPT 4 B/D NM

CELLCEPT INTRAVENOUS 3 B/D

cyclosporine (generic of SANDIMMUNE) CAPS; SOLN

1 B/D

cyclosporine modified (for microemulsion) (generic of NEORAL) CAPS 25mg, 100mg

1 B/D

cyclosporine modified (for microemulsion) CAPS 50mg

1 B/D

cyclosporine modified (for microemulsion) (generic of NEORAL) SOLN

1 B/D

43


44

Drug Name Drug Tier

Requirements/Limits

gengraf (generic of NEORAL) 1 B/D

IMURAN 2 B/D

mycophenolate mofetil (generic of CELLCEPT)

1 B/D

MYFORTIC 180mg 2 B/D

MYFORTIC 360mg 4 B/D NM

NEORAL 2 B/D

NULOJIX 4 B/D NM

PROGRAF CAPS 5mg 4 B/D NM

PROGRAF CAPS .5mg, 1mg

2 B/D

PROGRAF SOLN 3 B/D

RAPAMUNE SOLN 4 B/D NM

RAPAMUNE TABS 1mg, 2mg

4 B/D NM

RAPAMUNE TABS .5mg 2 B/D

SANDIMMUNE CAPS 2 B/D

SANDIMMUNE INJ 3 B/D

SANDIMMUNE SOLN 2 B/D

SIMULECT 3 B/D

tacrolimus (generic of PROGRAF) CAPS 5mg

4 B/D NM

tacrolimus (generic of PROGRAF) CAPS .5mg, 1mg

1 B/D

THYMOGLOBULIN 4 B/D NM

ZORTRESS 4 B/D NM

VACCINES ACTHIB 3 ADACEL 3 BOOSTRIX 3 CERVARIX 3 COMVAX 3 DAPTACEL 3 DECAVAC 3 B/D

DIPHTHERIA/TETANUS TOXOID

3 B/D

ENGERIX-B SUSP 3 B/D

GARDASIL 3 HAVRIX 3 HIBERIX 3 IMOVAX RABIES (H.D.C.V.) 3 INFANRIX 3 IPOL INACTIVATED IPV 2 IXIARO 3 M-M-R II W/DILUENT 10 DOS

3

Drug Name Drug Tier

Requirements/Limits

MENACTRA 3 MENHIBRIX 3 MENOMUNE-A/C/Y/W-135 3 MENVEO 3 PEDVAX HIB 3 PROQUAD 3 RABAVERT 3 RECOMBIVAX HB 3 B/D

ROTATEQ 3 SYNAGIS 4 NM

TETANUS TOXOID ADSORBED

3 B/D

TETANUS/DIPHTHERIA TOXOID

3 B/D

TWINRIX 3 B/D

TYPHIM VI 3 VAQTA 3 VARIVAX 3 YF-VAX 3 ZOSTAVAX 3

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3 K-TABS 2 KLOR-CON 8 1 KLOR-CON 10 1 klor-con m15 1 klor-con m20 1 MAGNESIUM SULFATE SOLN 40mg/ml, 80mg/ml

3

magnesium sulfate SOLN 50%

1

MAGNESIUM SULFATE IN D5W 1%

2

MAGNESIUM SULFATE IN D5W 2%

3

MICRO-K 2 POTASSIUM CHLORIDE TBCR

1

potassium chloride caps er (generic of MICRO-K)

1

potassium chloride microencapsulated crystals cr

1

SOD FLUORIDE 2.2MG TAB 1 SODIUM CHLORIDE SOLN 2.5meq/ml

1

44


45

Drug Name Drug Tier

Requirements/Limits

TPN ELECTROLYTES 1 B/D

IV NUTRITION AMINOSYN 3 B/D

AMINOSYN 7%/ELECTROLYTES

3 B/D

AMINOSYN II 3 B/D

AMINOSYN II 8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/D

AMINOSYN M 3 B/D

AMINOSYN-HBC 3 B/D

AMINOSYN-PF 3 B/D

AMINOSYN-PF 7% 3 B/D

AMINOSYN-RF 3 B/D

CLINIMIX 2.75%/DEXTROSE 5%

3 B/D


3 B/D


3 B/D


3 B/D


3 B/D

CLINIMIX 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

CLINIMIX E 2.75%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 4.25%/DEXTROSE

3 B/D


3 B/D


3 B/D

CLINIMIX E 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

clinisol 15 1 B/D

FREAMINE HBC 6.9% 3 B/D

FREAMINE III 3 B/D

Drug Name Drug Tier

Requirements/Limits

HEPATAMINE 1 B/D

hepatasol 8 1 B/D

INTRALIPID INJ 20% 1 B/D

INTRALIPID INJ 30% 3 B/D

LIPOSYN II 3 B/D

LIPOSYN III 3 B/D

NEPHRAMINE 3 B/D

premasol 6% 1 B/D

premasol 10% 3 B/D

PROCALAMINE 3 B/D

PROSOL 3 B/D

travasol 10 3 B/D

TROPHAMINE 3 B/D

IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 50% 1 dextrose SOLN 70% 1 DEXTROSE 2.5%/NACL 0.45%

1

DEXTROSE 5% 1 DEXTROSE 5% /ELECTROLYTE

2

DEXTROSE 5%/LACTATED RING

1

DEXTROSE 5%/NACL 0.2% 1 DEXTROSE 5%/NACL 0.3% 3 DEXTROSE 5%/NACL 0.9% 1 DEXTROSE 5%/NACL 0.33% 1 DEXTROSE 5%/NACL 0.45% 1 DEXTROSE 5%/NACL 0.225%

1

DEXTROSE 5%/POTASSIUM CHL

1

DEXTROSE 10% FLEX CONTAIN

1

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

2

DEXTROSE 10%/NACL 0.45%

1

ELECTROLYTE-M IN DEXTROSE

1

ELECTROLYTE-R IN DEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3 IONOSOL-MB/DEXTROSE 5%

3

ISOLYTE P 3 isolyte s 3

45


46

Drug Name Drug Tier

Requirements/Limits

KCL0.15%/D5W/NACL0.2% 1 KCL0.15%/D5W/NACL0.225%

2

kcl 0.3%/d5w/lr iv lac ri 3 KCL 0.3%/D5W/NACL 0.9% 1 KCL 0.3%/D5W/NACL 0.45% 1 KCL 0.15%/D5W/LR 3 KCL 0.15%/D5W/NACL 0.9% 1 KCL 0.075%/D5W/NACL 0.45%

1

KCL 10 MEQ/L (0.075%) IN DEXTROSE 5% & NACL 0.2% INJ

1

kcl 20 meq/l (0.15%) in nacl 0.45% inj

1

KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ

1


1


1

KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ

1

LACTATED RINGERS VIAFLEX

1

normosol-m 1 NORMOSOL-R 3 PLASMA-LYTE A 3 PLASMA-LYTE-56/D5W 3 PLASMA-LYTE-148 3 POTASSIUM CHLORIDE SOLN 10meq/100ml, 20meq/100ml, 30meq/100ml

1

potassium chloride (generic of POTASSIUM CHLORIDE) SOLN 40meq/100ml

1

potassium chloride SOLN .4meq/ml, 2meq/ml, 10meq/50ml

1

POTASSIUM CHLORIDE 0.3%/D

1

POTASSIUM CHLORIDE 0.15%

1

POTASSIUM CHLORIDE 0.22%

1

RINGER'S 1

Drug Name Drug Tier

Requirements/Limits

SODIUM CHLORIDE SOLN .9%, 3%, 5%

1

SODIUM CHLORIDE 0.45% VIA

1

VITAMINS calcitriol (generic of ROCALTROL) CAPS

1 B/D

calcitriol SOLN 1mcg/ml 1 B/D

calcitriol (generic of ROCALTROL) SOLN 1mcg/ml

1 B/D

HECTOROL CAPS 2 B/D

HECTOROL SOLN 3 B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

1

ROCALTROL 2 B/D

ZEMPLAR CAPS 1mcg, 2mcg

2 B/D

ZEMPLAR CAPS 4mcg 4 B/D NM

ZEMPLAR SOLN 3 B/D

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 1 blephamide OINT 3 BLEPHAMIDE SUSP 3 MAXITROL 3 neomycin-polymy-dexameth (generic of MAXITROL)

1

neomycin-polymyxin-hc (ophth)

1

PRED-G 3 PRED-G S.O.P. 3 sulfacetamide sod-prednisolone

1

TOBRADEX 2 TOBRADEX ST 2 tobramycin-dexamethasone (generic of TOBRADEX)

1

ZYLET 2

ANTI-INFECTIVES AZASITE 3 bacitracin (ophthalmic) 1 bacitracin-polymyxin b (ophth) 1 BESIVANCE 2 BLEPH-10 3 CILOXAN OIN 0.3% OP 3 CILOXAN SOL 0.3% OP 3

46


47

Drug Name Drug Tier

Requirements/Limits

ciprofloxacin hcl (ophth) (generic of CILOXAN)

1

erythromycin (ophth) 1 gentak 1 gentamicin sulfate (ophth) (generic of GARAMYCIN)

1

levofloxacin (ophth) 1 MOXEZA 2 NATACYN 2 neomycin-bacitracin zn-polymyxin

1

neomycin-polymy-gramicid (generic of NEOSPORIN)

1

neosporin solution 3 OCUFLOX 3 ofloxacin (ophth) (generic of OCUFLOX)

1

polymyxin b-trimethoprim (generic of POLYTRIM)

1

POLYTRIM 3 sulfacetamide sodium (ophth) OINT

1

sulfacetamide sodium (ophth) (generic of BLEPH-10) SOLN

1

tobramycin sulfate (ophth) (generic of TOBREX)

1

TOBREX OINT 0.3% 3 TOBREX SOL 0.3% OP 3 trifluridine (generic of VIROPTIC) SOLN

1

VIGAMOX 2 VIROPTIC 2 ZIRGAN 3 ZYMAXID 3

ANTI-INFLAMMATORIES ACULAR 3 ACULAR LS 3 ACUVAIL 3 ALREX 2 BROMDAY 2 bromfenac sodium (ophth) 1 dexamethasone sodium phosphate (ophth)

1

diclofenac sodium (ophth) 1 DUREZOL 2

Drug Name Drug Tier

Requirements/Limits

FLAREX 3 FLUOROMETHOLONE SUSP

1

FLUOROMETHOLONE (OPHTH)

1

flurbiprofen sodium (generic of OCUFEN)

1

FML 3 FML FORTE 3 FML LIQUIFILM 3 ILEVRO 3 ketorolac tromethamine (ophth) (generic of ACULAR LS) .4%

1

ketorolac tromethamine (ophth) (generic of ACULAR) .5%

1

LOTEMAX 2 MAXIDEX 3 NEVANAC 3 OCUFEN 3 OMNIPRED 3 PRED FORTE 3 PRED MILD 3 PREDNISOLONE ACETATE SUSP

1

prednisolone sodium phosphate (ophth)

2

VEXOL 3

ANTIALLERGICS ALOCRIL 3 ALOMIDE 3 azelastine hcl (ophth) (generic of OPTIVAR)

1

BEPREVE 3 cromolyn sodium (ophth) 1 ELESTAT 3 EMADINE 3 epinastine hcl (ophth) (generic of ELESTAT)

1

LASTACAFT 3 OPTIVAR 3 PATADAY 2 PATANOL 3

ANTIGLAUCOMA ALPHAGAN P 0.1% 2

47


48

Drug Name Drug Tier

Requirements/Limits

ALPHAGAN P 0.15% 2 AZOPT 2 BETAGAN 3 betaxolol hcl (ophth) 1 BETIMOL 2 BETOPTIC-S 2 brimonidine sol 0.2% 1 BRIMONIDINE SOL 0.15% 1 carteolol hcl (ophth) 1 COMBIGAN 2 COSOPT 3 COSOPT PF 2 dorzolamide hcl (generic of TRUSOPT)

1

dorzolamide hcl-timolol maleate (generic of COSOPT)

1

ISOPTO CARPINE 3 ISTALOL 3 latanoprost (generic of XALATAN)

1

levobunolol hcl (generic of BETAGAN) .5%

1

LEVOBUNOLOL HCL .25% 1 LUMIGAN .01% 3 metipranolol (generic of OPTIPRANOLOL)

1

OPTIPRANOLOL 3 PHOSPHOLINE IODIDE 3 PILOCARPINE HCL SOLN 1 PILOPINE HS 3 timolol maleate (ophth) (generic of TIMOPTIC)

1

TIMOLOL MALEATE GEL 1 TIMOPTIC 3 TIMOPTIC OCUDOSE 3 TIMOPTIC-XE 3 TRAVATAN Z 2 TRUSOPT 3 XALATAN 3 ZIOPTAN 2

MISCELLANEOUS ak-con 1 alcaine 3 BOTOX 100unit 3 NM PA

LACRISERT 3

Drug Name Drug Tier

Requirements/Limits

PROLENSA 3 proparacaine hcl (generic of ALCAINE) SOLN

1

RESTASIS 2 XEOMIN 3 NM PA

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS COMBIVENT

QL (2 inhalers / 30 days) 3 QL

COMBIVENT RESPIMAT QL (2 inhalers / 30 days)

2 QL

DUONEB 3 B/D

ipratropium-albuterol (generic of DUONEB)

1 B/D

ANTICHOLINERGICS ATROVENT 2 ATROVENT HFA


ipratropium bromide (nasal) (generic of ATROVENT)

1

ipratropium sol inhal 1 B/D

SPIRIVA HANDIHALER QL (30 caps / 30 days)

2 QL

TUDORZA PRESSAIR QL (1 kit / 30 days)

3 QL

ANTIHISTAMINE/DECONGESTANT COMBINATIONS CLARINEX-D 3 SEMPREX-D 3

ANTIHISTAMINES ASTELIN 3 ASTEPRO 2 azelastine hcl (generic of ASTELIN)

1

cetirizine syrup 1 CLARINEX 3 CLARINEX REDITABS 3 cyproheptadine hcl SYRP; TABS

1 PA

desloratadine (generic of CLARINEX) TABS

1

desloratadine (generic of CLARINEX REDITABS) TBDP

1

diphenhydram inj 50mg/ml 1

48


49

Drug Name Drug Tier

Requirements/Limits

hydroxyzine hcl SOLN; TABS

1 PA

hydroxyzine pamoate (generic of VISTARIL) CAPS 25mg, 50mg

1 PA

hydroxyzine pamoate CAPS 100mg

1 PA

levocetirizine soln 2.5mg/5ml (generic of XYZAL)

1

levocetirizine tab 5 mg (generic of XYZAL)

1

PATANASE 3 VISTARIL 3 PA

XYZAL 2

BETA AGONISTS ACCUNEB 3 B/D

albuterol sulfate (generic of ACCUNEB) NEBU .63mg/3ml, 1.25mg/3ml

1 B/D

albuterol sulfate NEBU .083%, .5%

1 B/D

albuterol sulfate SYRP 1 albuterol sulfate TABS 1 albuterol sulfate er (generic of VOSPIRE ER)

1

ARCAPTA NEOHALER QL (30 caps / 30 days)

2 QL

BROVANA 3 B/D

FORADIL AEROLIZER QL (60 caps / 30 days)

2 QL

levalbuterol conc 1.25mg/0.5ml (generic of XOPENEX CONCENTRATE)

1 B/D

LEVALBUTEROL HCL NEBU

1 B/D

PERFOROMIST 2 B/D

PROAIR HFA QL (2 inhalers / 30 days)

2 QL

PROVENTIL HFA QL (2 inhalers / 30 days)

2 QL

SEREVENT DISKUS QL (1 inhaler / 30 days)

2 QL

terbutaline sulfate SOLN; TABS

1

VENTOLIN HFA QL (2 inhalers / 30 days)

3 QL

vospire 2 XOPENEX 3 B/D

Drug Name Drug Tier

Requirements/Limits

XOPENEX CONCENTRATE 3 B/D

XOPENEX HFA QL (2 inhalers / 30 days)

3 QL

LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE 3 montelukast sodium (generic of SINGULAIR) CHEW; PACK; TABS

1

SINGULAIR 3 zafirlukast (generic of ACCOLATE)

1

ZYFLO CR 4 NM

MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

1 B/D

ADRENACLICK 3 ARALAST NP 4 NM LA PA

AUVI-Q 3 CAYSTON 4 NM LA PA

DALIRESP 2 DYMISTA

QL (1 bottle / 30 days) 3 QL

EPIPEN 2-PAK 2 EPIPEN-JR 2-PAK 2 GLASSIA 4 NM LA PA

PROLASTIN-C 4 NM LA PA

PULMOZYME 4 B/D NM

tyzine 3 XOLAIR 4 NM LA PA

ZEMAIRA 4 NM LA PA

NASAL STEROIDS BECONASE AQ

QL (2 bottles / 30 days) 3 QL

FLONASE QL (1 bottle / 30 days)

3 QL

flunisolide (nasal) QL (2 bottles / 30 days)

1 QL

fluticasone propionate (nasal) (generic of FLONASE)

QL (1 bottle / 30 days)

1 QL

NASACORT AQ QL (1 bottle / 30 days)

3 QL

NASONEX QL (2 bottles / 30 days)

2 QL

49


50

Drug Name Drug Tier

Requirements/Limits

OMNARIS QL (1 bottle / 30 days)

3 QL

QNASL QL (1 bottle / 30 days)

3 QL

RHINOCORT AQUA QL (2 bottles / 30 days)

3 QL

triamcinolone acetonide (nasal) (generic of NASACORT AQ)

QL (1 bottle / 30 days)

1 QL

VERAMYST QL (1 bottle / 30 days)

3 QL

ZETONNA QL (1 bottle / 30 days)

3 QL

STEROID INHALANTS ALVESCO


ASMANEX QL (2 inhalers / 30 days)

2 QL

ASMANEX 14 METERED DOSES

QL (2 inhalers per 30 days)

2 QL

budesonide (inhalation) (generic of PULMICORT)

1 B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist


2 QL

FLOVENT DISKUS 250mcg/blist


2 QL

FLOVENT HFA QL (2 inhalers / 30 days)

2 QL

PULMICORT FLEXHALER QL (2 inhalers / 30 days)

2 QL

PULMICORT INH SUSP 1mg/2ml

4 B/D NM

PULMICORT INH SUSP .25mg/2ml, .5mg/2ml

3 B/D

QVAR 40mcg/act QL (1 inhaler / 30 days)

2 QL

QVAR 80mcg/act QL (2 inhalers / 30 days)

2 QL

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS

QL (1 inhaler / 30 days) 2 QL

ADVAIR HFA QL (1 inhaler / 30 days)

2 QL

Drug Name Drug Tier

Requirements/Limits

DULERA QL (1 inhaler / 30 days)

2 QL

SYMBICORT QL (1 inhaler / 30 days)

2 QL

XANTHINES aminophylline inj 1 elixophyllin 2 LUFYLLIN 3 theo-24 2 theophylline TB12; TB24 1

TOPICAL DERMATOLOGY, ACNE ABSORICA 4 NM

ACANYA 2 ACZONE 3 adapalene (generic of DIFFERIN)

1

AKNE-MYCIN 3 amnesteem 1 ATRALIN 2 AVITA CREA 1 AVITA GEL 1 AZELEX 3 BENZAMYCIN 3 benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

1

claravis 1 CLEOCIN-T 3 CLINDAGEL 3 clindamycin phosphate (topical) (generic of EVOCLIN) FOAM

1

clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL; LOTN; SOLN; SWAB

1

clindamycin phosphate-benzoyl peroxide (generic of BENZACLIN)

1

DIFFERIN 2 EPIDUO 2 erythromycin (acne aid) 1 EVOCLIN 3 KLARON 3 myorisan 1

50


51

Drug Name Drug Tier

Requirements/Limits

RETIN-A 3 RETIN-A MICRO 2 sulfacetamide sodium (acne) (generic of KLARON)

1

tretin x 3 tretinoin (generic of RETIN-A) CREA; GEL

1

TRETINOIN MICROSPHERE .1%

1

TRETINOIN MICROSPHERE .04%

1

VELTIN 3 zenatane 1 ZIANA 3

DERMATOLOGY, ACTINIC KERATOSIS CARAC 2 EFUDEX 3 FLUOROPLEX 3 fluorouracil (topical) (generic of EFUDEX) CREA

1

fluorouracil (topical) SOLN 1 PICATO 2 SOLARAZE 3 PA

DERMATOLOGY, ANTIBIOTICS ALTABAX 2 BACTROBAN 2 BACTROBAN NASAL 3 CORTISPORIN CREA; OINT

3

gentamicin sulfate (topical) 1 mafenide acetate (generic of SULFAMYLON) PACK

1

mupirocin (generic of BACTROBAN) OINT

1

mupirocin calcium (topical) (generic of BACTROBAN)

1

PHISOHEX 3 SILVADENE 2 SILVER SULFADIAZINE CREA

1

SSD 1 SULFAMYLON 3 THERMAZENE 1

DERMATOLOGY, ANTIFUNGALS ciclopirox (generic of LOPROX) GEL

1

Drug Name Drug Tier

Requirements/Limits

ciclopirox cre 0.77% 1 ciclopirox shampoo 1% (generic of LOPROX SHAMPOO)

1

ciclopirox sus 0.77% 1 clotrimazole (topical) 1 econazole nitrate CREA 1 EXELDERM 3 EXTINA 3 ketoconazole (topical) CREA 1 ketoconazole (topical) (generic of EXTINA) FOAM

1

LOPROX SHAMPOO 2 MENTAX 2 NAFTIN CREA 3 NAFTIN GEL 1% 3 nyamyc 1 nystatin (topical) 1 nystatin pow 100000 1 nystop 1 OXISTAT 2 pedi-dri 1

DERMATOLOGY, ANTIPRURITIC anusol hc 2 CORTIFOAM 2 procto-pak 1 proctocream (generic of ANUSOL-HC)

1

proctozone hc (generic of ANUSOL-HC)

1

PRUDOXIN CRE 5% 1 ZONALON 3

DERMATOLOGY, ANTIPSORIATICS calcipotriene (generic of DOVONEX) CREA

1

calcipotriene OINT; SOLN 1 CALCITRIOL OINT 1 DOVONEX 3 8-MOP 3 OXSORALEN ULTRA 4 NM

SORIATANE 4 NM PA

SORILUX 2 STELARA 4 NM PA

TAZORAC 2 PA

VECTICAL 4 NM

DERMATOLOGY, ANTISEBORRHEICS

51


52

Drug Name Drug Tier

Requirements/Limits

ketoconazole shampoo (generic of NIZORAL)

1

NIZORAL 2 selenium sulfide (generic of SELSUN SHAMPOO) LOTN

1

DERMATOLOGY, ANTIVIRALS acyclovir topical (generic of ZOVIRAX)

1

DENAVIR 3 XERESE 3 ZOVIRAX CREA; OINT 3

DERMATOLOGY, CORTICOSTEROIDS aclovate 2 ala-cort 1 ala-scalp 3 alclometasone dipropionate (generic of ACLOVATE) CREA

1

alclometasone dipropionate OINT

1

amcinonide CREA; LOTN 1 amcinonide OINT 3 betamethasone dipropionate (topical)

1

betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA

1

betamethasone dipropionate augmented GEL

1

betamethasone dipropionate augmented (generic of DIPROLENE) LOTN; OINT

1

betamethasone valerate CREA; LOTN; OINT

1

betamethasone valerate (generic of LUXIQ) FOAM

1

CAPEX 2 carmol hc 3 clobetasol propionate (generic of TEMOVATE) CREA; GEL; OINT; SOLN

1

clobetasol propionate (generic of OLUX) FOAM

1

clobetasol propionate (generic of CLOBEX) LOTN; SHAM

1

clobetasol propionate emollient base (generic of TEMOVATE E)

1

Drug Name Drug Tier

Requirements/Limits

clobetasol propionate emulsion (generic of OLUX-E)

1

CLOBEX LIQD 3 CLOBEX LOTN; SHAM 2 CLODERM PUMP 2 CORDRAN 3 CUTIVATE CREA 3 CUTIVATE LOTN 4 NM

CUTIVATE OINT 2 DERMA-SMOOTHE/FS BODY OIL

2

DERMATOP 3 DESONATE 3 DESONIDE CREA 1 desonide (generic of DESOWEN) LOTN; OINT

1

DESOWEN CREA 2 desowen LOTN 2 desowen oint kit 0.05% 2 desoximetasone (generic of TOPICORT) CREA

1

desoximetasone (generic of TOPICORT) GEL

1

DESOXIMETASONE OINT .05%

1

desoximetasone (generic of TOPICORT) OINT .25%

1

diflorasone diacetate 1 DIPROLENE LOTN 3 DIPROLENE OINT 2 DIPROLENE AF 3 ELOCON CREA; LOTN 3 ELOCON OINT 2 fluocinolone acetonide CREA .01%

1

fluocinolone acetonide (generic of SYNALAR) CREA .025%

1

fluocinolone acetonide (generic of DERMA-SMOOTHE/FS BODY) OIL

1

fluocinolone acetonide (generic of SYNALAR) OINT

1

fluocinolone acetonide (generic of SYNALAR) SOLN

1

52


53

Drug Name Drug Tier

Requirements/Limits

fluocinonide CREA; GEL; OINT; SOLN

1

fluocinonide emulsified base 1 fluticasone propionate (generic of CUTIVATE) CREA; LOTN; OINT

1

halobetasol propionate (generic of ULTRAVATE)

1

HALOG 3 hydrocortisone (topical) 1 hydrocortisone butyrate (generic of LOCOID)

1

hydrocortisone valerate CREA

1

hydrocortisone valerate (generic of WESTCORT) OINT

1

KENALOG 3 LOCOID LOTN; OINT; SOLN

2

LOCOID LIPOCREAM 2 LOKARA LOTN 0.05% 1 LUXIQ 3 mometasone furoate (generic of ELOCON) CREA; OINT; SOLN

1

OLUX-E 3 PANDEL 3 PREDNICARBATE CREA 1 prednicarbate (generic of DERMATOP) OINT

1

SYNALAR CREA; OINT 3 SYNALAR SOLN 2 TACLONEX 3 TEMOVATE CREA; GEL; OINT

2

TEMOVATE SOLN 3 TEMOVATE E 2 texacort 2 topicort CREA 3 topicort GEL 2 TOPICORT LIQD 3 TOPICORT OINT .05% 2 topicort OINT .25% 2 triamcinolone acetonide (topical)

1

triderm 1

Drug Name Drug Tier

Requirements/Limits

u-cort (generic of CARMOL-HC)

1

ULTRAVATE 2 VANOS 3 VERDESO 3 WESTCORT 2

DERMATOLOGY, LOCAL ANESTHETICS EMLA 3 B/D

lidocaine OINT 1 lidocaine hcl GEL 1 lidocaine hcl (generic of XYLOCAINE) SOLN 4%

1

lidocaine-prilocaine (generic of EMLA)

1 B/D

LIDODERM 2 SYNERA 3 XYLOCAINE 4% 3

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ALDARA 3 ammonium lactate (generic of LAC-HYDRIN) CREA; LOTN

1

CONDYLOX 2 ELIDEL 2 PA

FINACEA 2 imiquimod (generic of ALDARA) CREA

1

LAC-HYDRIN 2 laclotion lotn 12% (generic of LAC-HYDRIN)

1

METROCREAM 3 METROGEL 3 METROLOTION 3 metronidazole (topical) (generic of METROCREAM) CREA

1

metronidazole (topical) (generic of METROGEL) GEL 1%

1

metronidazole (topical) GEL .75%

1

metronidazole (topical) (generic of METROLOTION) LOTN

1

ORACEA 2 OXSORALEN 3 PANRETIN 4 NM

53


54

Drug Name Drug Tier

Requirements/Limits

PENNSAID 2 podofilox (generic of CONDYLOX) SOLN

1

PROTOPIC 2 PA

RECTIV 3 rosadan cre 0.75% (generic of METROCREAM)

1

TARGRETIN GEL 4 NM PA

VOLTAREN GEL 1% 2 ZYCLARA 4 NM

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3 malathion (generic of OVIDE) 1 OVIDE 2 permethrin (generic of ELIMITE) CREA

1

SKLICE 3 ULESFIA 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1 neomycin/polymyxin b gu (generic of NEOSPORIN GU IRRIGANT)

1

SANTYL 3 SODIUM CHLORIDE 0.9% 1 STERILE WATER IRRIGATION

1

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl (generic of EVOXAC)

1

chlorhexidine gluconate (mouth-throat) (generic of PERIDEX)

1

clotrimazole TROC 1 EVOXAC 2 lidocaine hcl (mouth-throat) 1 nystatin (mouth-throat) 1 periogard sol 0.12% (generic of PERIDEX)

1

pilocarpine hcl (oral) (generic of SALAGEN)

1

SALAGEN 2 triamcinolone acetonide (mouth)

1

OTIC

Drug Name Drug Tier

Requirements/Limits

acetasol hc (generic of VOSOL HC)

1

acetic acid (otic) 1 acetic acid sol/hc (generic of VOSOL HC)

1

acetic acid-aluminum acetate 1 CIPRO HC 2 CIPRODEX 2 COLY-MYCIN S 3 CORTISPORIN SOLN 2 CORTISPORIN-TC 3 DERMOTIC 3 fluocinolone acetonide (otic) (generic of DERMOTIC)

1

neomycin-polymyxin-hc (otic) (generic of CORTISPORIN) SOLN

1

neomycin-polymyxin-hc (otic) SUSP

1

ofloxacin (otic) 1

54

55

Index 8 8-MOP .............................. 51 A abacavir sulfate ...................8 ABELCET............................7 ABILIFY............................. 24 ABILIFY DISCMELT ......... 24 ABILIFY INJ ...................... 24 ABILIFY MAINTENA ......... 24 ABRAXANE ...................... 12 ABSORICA ....................... 50 ABSTRAL............................4 ACANYA ........................... 50 acarbose ........................... 31 ACCOLATE ....................... 49

see zafirlukast ............... 49 ACCUNEB ........................ 49

see albuterol sulfate ...... 49 ACCUPRIL ........................ 14

see quinapril hcl ............ 15 ACCURETIC ..................... 14

see quinapril-hydrochlorothiazide .................................. 14

acebutolol hcl .................... 17 ACEON

see perindopril erbumine ...................................... 15

acetaminophen w/ codeine 1, 2 acetasol hc ........................ 54 acetazolamide ................... 18 acetazolamide sodium ...... 18 acetic acid ......................... 54 acetic acid (otic) ................ 54 acetic acid sol/hc ............... 54 acetic acid-aluminum acetate .......................................... 54 acetylcysteine ................... 49 ACIPHEX .......................... 40 aclovate............................. 52 ACLOVATE

see alclometasone dipropionate ................... 52

ACTEMRA ........................ 43 ACTHIB ............................. 44 ACTIGALL......................... 40

see ursodiol ................... 40 ACTIMMUNE .................... 43

ACTIQ ................................. 4 see fentanyl citrate .......... 4

ACTIVELLA see estradiol & norethindrone acetate ... 36

ACTONEL ......................... 33 ACTOPLUS MET

see pioglitazone hcl-metformin hcl ........... 33

ACTOPLUS MET TAB 15-500MG ......................... 31 ACTOPLUS MET TAB 15-850MG ......................... 31 ACTOPLUS MET XR 15-1000MG ....................... 31 ACTOPLUS MET XR 30-1000MG ....................... 31 ACTOS ............................. 31

see pioglitazone hcl ....... 33 ACULAR ........................... 47

see ketorolac tromethamine (ophth) .... 47

ACULAR LS ...................... 47 see ketorolac tromethamine (ophth) .... 47

ACUVAIL .......................... 47 acyclovir .............................. 9 acyclovir sodium ................. 9 acyclovir topical ................ 52 ACZONE ........................... 50 ADACEL ........................... 44 ADAGEN ........................... 35 ADALAT CC ...................... 17

see afeditab cr ............... 18 see nifediac ................... 18 see nifedipine ................ 18

adapalene ......................... 50 ADCIRCA .......................... 20 ADDERALL

see amphetamine-dextroamphetamine tab 10 mg......... 26 see amphetamine-dextroamphetamine tab 12.5 mg...... 26 see amphetamine-dextroamphetamine tab 15 mg......... 26 see

amphetamine-dextroamphetamine tab 20 mg ........ 26 see amphetamine-dextroamphetamine tab 30 mg ........ 26 see amphetamine-dextroamphetamine tab 5 mg .......... 26 see amphetamine-dextroamphetamine tab 7.5 mg ....... 26

adderall tab 10mg ............. 25 adderall tab 12.5mg .......... 25 adderall tab 15mg ............. 25 adderall tab 20mg ............. 26 adderall tab 30mg ............. 26 adderall tab 5mg ............... 25 adderall tab 7.5mg ............ 25 ADDERALL XR

see amphetamine-dextroamphetamine cap sr 24hr 10 mg ...................................... 26 see amphetamine-dextroamphetamine cap sr 24hr 15 mg ...................................... 26 see amphetamine-dextroamphetamine cap sr 24hr 20 mg ...................................... 26 see amphetamine-dextroamphetamine cap sr 24hr 25 mg ...................................... 26 see amphetamine-dextroamphetamine cap sr 24hr 30 mg ...................................... 26 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 26

ADDERALL XR CAP 10MG.......................................... 26 ADDERALL XR CAP 15MG.......................................... 26 ADDERALL XR CAP 20MG.......................................... 26

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ADDERALL XR CAP 25MG .......................................... 26 ADDERALL XR CAP 30MG .......................................... 26 ADDERALL XR CAP 5MG 26 adoxa ................................ 11 ADOXA

see doxycycline (monohydrate) ............... 11

ADOXA PAK 1/150 see doxycycline (monohydrate) ............... 11

ADRENACLICK ................ 49 adriamycin......................... 12 adriamycin inj 2mg/ml ....... 12 adrucil ............................... 12 ADVAIR DISKUS .............. 50 ADVAIR HFA .................... 50 ADVICOR.......................... 16 afeditab cr ......................... 18 AFINITOR ......................... 13 AFINITOR DISPERZ ......... 13 AGGRENOX ..................... 43 AGRYLIN .......................... 42

see anagrelide hcl ......... 42 a-hydrocort inj 100mg ....... 36 ak-con ............................... 48 AKNE-MYCIN ................... 50 ala-cort .............................. 52 ala-scalp............................ 52 ALBENZA............................6 albuterol sulfate ................. 49 albuterol sulfate er ............ 49 alcaine .............................. 48 ALCAINE

see proparacaine hcl ..... 48 alclometasone dipropionate .......................................... 52 ALCOHOL PREPS ............ 30 ALDACTAZIDE ................. 18

see spironolactone & hydrochlorothiazide ....... 19

ALDACTONE .................... 15 see spironolactone ........ 15

ALDARA............................ 53 see imiquimod ............... 53

ALDURAZYME ................. 35 alendronate sodium .......... 33 alfuzosin hcl ...................... 41 ALIMTA ............................. 12

ALINIA ................................ 6 ALKERAN ......................... 12

see melphalan hcl ......... 12 allopurinol inj 500mg ........... 1 ALLOPURINOL SODIUM ... 1 allopurinol tab ..................... 1 ALOCRIL .......................... 47 ALOMIDE .......................... 47 ALOPRIM

see allopurinol inj 500mg . 1 ALORA .............................. 36 ALOXI ............................... 38 ALPHAGAN P 0.1% .......... 47 ALPHAGAN P 0.15% ........ 48 alprazolam ........................ 20 ALREX .............................. 47 ALSUMA ........................... 27 ALTABAX .......................... 51 ALTACE ............................ 14

see ramipril .................... 15 altavera ............................. 33 ALTOPREV ....................... 16 ALVESCO ......................... 50 amantadine hcl ................. 24 AMARYL ........................... 31

see glimepiride .............. 31 AMBIEN ............................ 27

see zolpidem tartrate ..... 27 AMBIEN CR ...................... 27

see zolpidem tartrate ..... 27 AMBISOME ........................ 7 amcinonide ....................... 52 AMERGE .......................... 28

see naratriptan hcl ......... 28 amethia 91 day ................. 33 amethyst 28 day ............... 33 amifostine crystalline......... 14 amikacin sulfate .................. 6 amiloride & hydrochlorothiazide ........... 18 amiloride hcl ...................... 19 aminophylline inj ............... 50 AMINOSYN ....................... 45 AMINOSYN 7%/ELECTROLYTES ....... 45 AMINOSYN II .................... 45 AMINOSYN II 8.5%/ELECTROL .............. 45 AMINOSYN INJ 8.5/LYTE 45 AMINOSYN M ................... 45

AMINOSYN-HBC .............. 45 AMINOSYN-PF ................. 45 AMINOSYN-PF 7% ........... 45 AMINOSYN-RF................. 45 amiodarone hcl ................. 15 amiodarone inj 50mg/ml ... 16 AMITIZA ........................... 40 amitriptyline hcl ................. 23 amlodipine besylate .......... 18 AMLODIPINE BESYLATE/ATORV .......... 17 amlodipine besylate-benazepril hcl ..... 14 ammonium chloride .......... 44 ammonium lactate ............ 53 amnesteem ....................... 50 amoxapine ........................ 23 amoxicillin ......................... 11 amoxicillin & pot clavulanate.......................................... 11 amphetamine-dextroamphetamine cap sr 24hr 10 mg .. 26 amphetamine-dextroamphetamine cap sr 24hr 15 mg .. 26 amphetamine-dextroamphetamine cap sr 24hr 20 mg .. 26 amphetamine-dextroamphetamine cap sr 24hr 25 mg .. 26 amphetamine-dextroamphetamine cap sr 24hr 30 mg .. 26 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 26 amphetamine-dextroamphetamine tab 10 mg ............... 26 amphetamine-dextroamphetamine tab 12.5 mg ............ 26 amphetamine-dextroamphetamine tab 15 mg ............... 26 amphetamine-dextroamphetamine tab 20 mg ............... 26 amphetamine-dextroamphetamine tab 30 mg ............... 26 amphetamine-dextroamphetamine tab 5 mg ................. 26 amphetamine-dextroamphetamine tab 7.5 mg .............. 26 AMPHOTEC ....................... 7 amphotericin b .................... 7 ampicillin ........................... 11 ampicillin & sulbactam

56

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sodium .............................. 11 ampicillin inj ....................... 11 ampicillin sodium ............... 11 AMPYRA ........................... 29 AMRIX .............................. 29 AMTURNIDE ..................... 18 ANAFRANIL ...................... 23

see clomipramine hcl ..... 23 anagrelide hcl .................... 42 ANAPROX ..........................1

see naproxen sodium ......1 ANAPROX DS ....................1

see naproxen sodium ......1 anastrozole ....................... 13 ANCOBON ..........................7

see flucytosine .................7 ANDRODERM .................. 30 ANDROGEL ...................... 30 ANDROGEL 1% ................ 30 ANDROGEL 1.62% ........... 30 androxy ............................. 30 ANEXSIA

see hydrocodone-acetaminophen 7.5-650mg ..................2

antabuse ........................... 30 ANTABUSE

see disulfiram ................ 30 ANTARA ........................... 16 ANTIVERT ........................ 38

see meclizine hcl ........... 38 anusol hc........................... 51 ANUSOL-HC

see proctocream ............ 51 see proctozone hc ......... 51

APIDRA............................. 30 APIDRA SOLOSTAR ........ 30 APLENZIN ........................ 23 APOKYN ........................... 24 apri 28 day ........................ 33 APRISO ............................ 39 APTIVUS.............................8 ARALAST NP .................... 49 ARALEN

see chloroquine phosphate ........................8

aranelle 28 ........................ 33 ARANESP ALBUMIN FREE .......................................... 42 ARAVA .............................. 43

see leflunomide ............. 43 ARCALYST ....................... 43 ARCAPTA NEOHALER .... 49 ARICEPT .......................... 22

see donepezil tabs 10mg ...................................... 22 see donepezil tabs 5mg 22

ARICEPT ODT .................. 22 see donepezil odt 10mg 22 see donepezil odt 5mg .. 22

ARIMIDEX ........................ 13 see anastrozole ............. 13

ARIXTRA .......................... 42 see fondaparinux sodium ...................................... 42

AROMASIN ....................... 13 see exemestane ............ 13

ARRANON ........................ 12 ARTHROTEC ..................... 1 ARTHROTEC 50

see diclofenac w/ misoprostol ...................... 1

ARTHROTEC 75 see diclofenac w/ misoprostol ...................... 1

ARZERRA ......................... 13 ASACOL ........................... 39 ASACOL HD ..................... 39 ASMANEX ........................ 50 ASMANEX 14 METERED DOSES ............................. 50 ASTELIN ........................... 48

see azelastine hcl .......... 48 ASTEPRO ......................... 48 astramorph .......................... 4 ATACAND ......................... 15

see candesartan cilexetil ...................................... 15

ATACAND HCT ................ 15 see candesartan cilexetil-hydrochlorothiazide .................................... 15

ATELVIA ........................... 33 atenolol ............................. 17 atenolol & chlorthalidone ... 17 ATGAM ............................. 43 ATIVAN ............................. 20

see lorazepam ............... 20 atorvastatin calcium .......... 16 atovaquone-proguanil hcl tab

250-100 mg ........................ 7 ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG ...... 7 ATRALIN .......................... 50 ATRIPLA ............................. 8 ATROPINE SULFATE ...... 39 ATROVENT ...................... 48

see ipratropium bromide (nasal) ........................... 48

ATROVENT HFA .............. 48 AUBAGIO ......................... 29 AUGMENTIN .................... 11

see amoxicillin & pot clavulanate .................... 11

AUGMENTIN ES-600 ....... 11 see amoxicillin & pot clavulanate .................... 11

AUGMENTIN XR .............. 11 see amoxicillin & pot clavulanate .................... 11

AUVI-Q ............................. 49 AVALIDE .......................... 15

see irbesartan-hydrochlorothiazide ............................... 15

AVAPRO ........................... 15 see irbesartan ............... 15

AVASTIN .......................... 13 AVELOX ........................... 10 AVELOX ABC PACK ........ 10 aviane 28 .......................... 33 AVINZA ............................... 4 AVITA ............................... 50 AVODART ........................ 41 AVONEX ........................... 29 AVONEX PEN .................. 29 AXERT .............................. 28 AXID ................................. 39

see nizatidine ................ 39 AXIRON ............................ 30 aygestin ............................ 37 AYGESTIN

see norethindrone acetate ...................................... 37

AZACTAM .......................... 6 see aztreonam ................ 6

AZACTAM/DEX INJ 1GM ... 6 AZACTAM/DEX INJ 2GM ... 6 azasan .............................. 43 AZASITE ........................... 46

57

58

azathioprine ...................... 43 azathioprine inj 100mg ...... 43 azelastine hcl .................... 48 azelastine hcl (ophth) ........ 47 AZELEX ............................ 50 AZILECT ........................... 24 azithromycin ...................... 10 AZITHROMYCIN ............... 10 AZOPT .............................. 48 AZOR ................................ 15 aztreonam ...........................6 AZULFIDINE ..................... 39

see sulfasalazine ir ........ 39 AZULFIDINE EN-TABS .... 39

see sulfasalazine dr ....... 39 B bacitracin (ophthalmic) ...... 46 bacitracin-polymyxin b (ophth) .............................. 46 bacitracin-poly-neomycin-hc .......................................... 46 baclofen ............................ 29 BACTOCILL IN DEXTROSE .......................................... 11 BACTRIM ............................6

see sulfamethoxazole-trimethoprim .................................7

BACTRIM DS ......................6 see sulfamethoxazole-trimethoprim .................................7

BACTROBAN .................... 51 see mupirocin ................ 51 see mupirocin calcium (topical).......................... 51

BACTROBAN NASAL ....... 51 balsalazide disodium ......... 39 balziva 28 day ................... 33 BANZEL ............................ 20 BARACLUDE ......................9 BECONASE AQ ................ 49 benazepril & hydrochlorothiazide ........... 14 benazepril hcl .................... 15 BENICAR .......................... 15 BENICAR HCT .................. 15 BENTYL ............................ 39

see dicyclomine hcl ....... 39 BENZACLIN

see clindamycin phosphate-benzoyl peroxide ........................ 50

BENZAMYCIN .................. 50 see benzoyl peroxide-erythromycin ... 50

benzoyl peroxide-erythromycin ...... 50 benztropine mesylate ........ 24 BEPREVE ......................... 47 BESIVANCE ..................... 46 BETAGAN ......................... 48

see levobunolol hcl ........ 48 betamethasone dipropionate (topical) ............................. 52 betamethasone dipropionate augmented ........................ 52 betamethasone valerate ... 52 BETAPACE ....................... 16

see sorine ...................... 16 see sotalol hcl ............... 16

BETAPACE AF ................. 16 see sotalol hcl (afib/afl) .. 16

BETASERON .................... 29 betaxolol hcl ...................... 17 betaxolol hcl (ophth) ......... 48 bethanechol chloride ......... 41 BETIMOL .......................... 48 BETOPTIC-S .................... 48 BEYAZ .............................. 33 BIAXIN .............................. 10

see clarithromycin ......... 10 BIAXIN XL ......................... 10

see clarithromycin ......... 10 BIAXIN XL PAC ................ 10 bicalutamide ...................... 13 BICILLIN C-R .................... 11 BICILLIN L-A ..................... 11 BICNU ............................... 12 BIDIL ................................. 19 BILTRICIDE ........................ 6 BINOSTO .......................... 33 bisoprolol & hydrochlorothiazide ........... 17 bisoprolol fumarate ........... 17 bleomycin sulfate .............. 12 BLEPH-10 ......................... 46

see sulfacetamide sodium (ophth) ........................... 47

blephamide ....................... 46

BLEPHAMIDE .................. 46 BONIVA ............................ 33

see ibandronate sodium 33 BOOSTRIX ....................... 44 BOSULIF .......................... 13 BOTOX ............................. 48 BREVICON-28 .................. 34

see necon 0.5/35 28 day ...................................... 34 see nortrel 0.5/35 28 day ...................................... 35

briellyn 28 day .................. 34 BRILINTA ......................... 43 BRIMONIDINE SOL 0.15%.......................................... 48 brimonidine sol 0.2% ........ 48 BROMDAY ....................... 47 bromfenac sodium (ophth) 47 bromocriptine mesylate ..... 24 BROVANA ........................ 49 budeprion .......................... 23 budesonide ....................... 39 budesonide (inhalation) .... 50 bumetanide ....................... 19 BUPHENYL ...................... 35

see sodium phenylbutyrate ...................................... 36

BUPHENYL TAB 500MG .. 35 buprenorphine hcl ............. 30 buprenorphine hcl-naloxone hcl sl ................................. 30 buproban .......................... 30 bupropion hcl .................... 23 buspirone hcl .................... 20 BUSULFEX ....................... 12 butorphanol nasal spray ..... 2 butorphanol tartrate ............ 2 BUTRANS .......................... 2 BYDUREON ..................... 30 BYETTA ............................ 30 BYSTOLIC ........................ 17 C cabergoline ....................... 37 CADUET ........................... 17 cafergot tab 1-100mg ........ 28 CALAN .............................. 18

see verapamil hcl .......... 18 CALAN SR ........................ 18

see verapamil hcl .......... 18 calcipotriene ..................... 51

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calcitonin (salmon) nasal spray ................................. 37 calcitriol ............................. 46 CALCITRIOL ..................... 51 calcium acetate (phosphate binder) ............................... 37 camila 28 day .................... 34 CAMPRAL ......................... 30 CAMPTOSAR ................... 14

see irinotecan hcl .......... 14 CAMRESE LO TAB .......... 34 CANASA ........................... 39 CANCIDAS .........................7 candesartan cilexetil ......... 15 candesartan cilexetil-hydrochlorothiazide .......................................... 15 CANTIL ............................. 39 CAPASTAT SULFATE ........8 CAPEX .............................. 52 capital

and codeine .....................2 CAPRELSA ....................... 13 captopril ............................ 15 captopril & hydrochlorothiazide ........... 14 CARAC ............................. 51 CARAFATE ....................... 40

see sucralfate ................ 40 CARBAGLU ...................... 35 carbamazepine ................. 20 CARBATROL .................... 20

see carbamazepine ....... 20 CARBIDOPA/LEVODOPA/ENTACA .............................. 24 carbidopa-levodopa .......... 24 carboplatin ........................ 14 CARDIZEM ....................... 18

see diltiazem hcl ............ 18 CARDIZEM CD ................. 18

see cartia xt ................... 18 see dilt-cd ...................... 18 see diltiazem hcl coated beads............................. 18

CARDIZEM LA .................. 18 see matzim la ................ 18

CARDURA ........................ 15 see doxazosin mesylate 15

CARDURA XL ................... 41 CARIMUNE

NANOFILTERED .............. 43 carmol hc .......................... 52 CARMOL-HC

see u-cort ...................... 53 CARNITOR ....................... 35

see levocarnitine (metabolic modifiers) ..... 35

carteolol hcl (ophth) .......... 48 cartia xt ............................. 18 carvedilol ........................... 17 CASODEX ........................ 13

see bicalutamide ........... 13 CATAFLAM ......................... 1

see diclofenac potassium 1 CATAPRES ...................... 19

see clonidine hcl ............ 19 CATAPRES-TTS .............. 19 CATAPRES-TTS-1

see clonidine hcl ............ 19 CATAPRES-TTS-2

see clonidine hcl ............ 19 CATAPRES-TTS-3

see clonidine hcl ............ 19 CAYSTON ........................ 49 CEDAX ............................... 9 CEENU ............................. 12 cefaclor ............................... 9 cefaclor monohydrate ......... 9 cefadroxil ............................ 9 cefazolin inj ......................... 9 cefazolin sodium ................. 9 cefazolin/dextrose ............... 9 cefdinir ................................ 9 CEFEPIME 1GM SOLN ...... 9 CEFEPIME 2GM SOLN ...... 9 cefepime inj 1gm ................. 9 cefepime inj 2gm ................. 9 cefotaxime sodium .............. 9 cefotetan disodium .............. 9 cefoxitin sodium .................. 9 CEFOXITIN SODIUM IN DEXTROSE ........................ 9 cefpodoxime proxetil ........... 9 cefprozil .............................. 9 ceftazidime .......................... 9 CEFTAZIDIME/DEXTROSE ............................................ 9 CEFTIN ............................... 9

see cefuroxime axetil ....... 9 ceftriaxone sodium .............. 9

cefuroxime axetil ................. 9 cefuroxime sodium ............ 10 cefuroxime sodium 7.5mg soln ................................... 10 CELEBREX ........................ 1 CELESTONE .................... 36 CELEXA ........................... 23

see citalopram hydrobromide ................ 23

CELLCEPT ....................... 43 see mycophenolate mofetil ...................................... 44

CELLCEPT INTRAVENOUS.......................................... 43 CELONTIN ....................... 20 cephalexin ........................ 10 CEREZYME ...................... 35 cerubidine ......................... 12 CERUBIDINE

see daunorubicin hcl ..... 12 CERVARIX ....................... 44 CESAMET ........................ 38 cetirizine syrup .................. 48 cevimeline hcl ................... 54 CHANTIX .......................... 30 CHANTIX STARTER PACK.......................................... 30 CHEMET .......................... 33 chlorhexidine gluconate (mouth-throat) ................... 54 chloroquine phosphate ....... 8 chlorothiazide ................... 19 chlorpromaz inj 25mg/ml ... 24 chlorpromazine hcl ............ 24 chlorthalidone ................... 19 chlorzoxazone .................. 29 cholestyramine ................. 16 cholestyramine light .......... 16 choline fenofibrate ............ 16 CHORIONIC GONADOTROPIN ............ 37 ciclopirox ........................... 51 ciclopirox cre 0.77% .......... 51 ciclopirox shampoo 1% ..... 51 ciclopirox sus 0.77% ......... 51 cidofovir .............................. 9 cilostazol ........................... 43 CILOXAN

see ciprofloxacin hcl (ophth) ........................... 47

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60

CILOXAN OIN 0.3% OP ... 46 CILOXAN SOL 0.3% OP ... 46 cimetidine .......................... 39 cimetidine inj 150mg/ml .... 39 cimetidine sol 300/5ml ...... 39 CIMZIA .............................. 43 CIPRO .............................. 10

see ciprofloxacin hcl ...... 10 CIPRO HC ........................ 54 CIPRO I.V.-IN D5W .......... 10

see ciprofloxacin in d5w 10 CIPRO XR

see ciprofloxacin er ....... 10 CIPRODEX ....................... 54 ciprofloxacin ...................... 10 ciprofloxacin er .................. 10 ciprofloxacin hcl ................ 10 ciprofloxacin hcl (ophth) .... 47 ciprofloxacin in d5w ........... 10 ciprofloxacn inj .................. 10 cisplatin ............................. 14 citalopram hydrobromide... 23 cladribine........................... 12 claforan ............................. 10 CLAFORAN ...................... 10

see cefotaxime sodium ....9 claravis .............................. 50 CLARINEX ........................ 48

see desloratadine .......... 48 CLARINEX REDITABS ..... 48

see desloratadine .......... 48 CLARINEX-D .................... 48 clarithromycin .................... 10 cleocin .................................6 CLEOCIN ...................... 6, 41

see clindamycin cre 2% vag ................................ 41 see clindamycin hcl .........6

CLEOCIN CAP 75MG .........6 CLEOCIN IN D5W ..............6

see clindamycin phosphate in d5w ............6

CLEOCIN INJ ......................6 CLEOCIN PEDIATRIC GRANULE

see clindamycin palmitate hydrochloride ...................6

CLEOCIN PHOSPHATE .....6 see clindamycin phosphate ........................6

CLEOCIN VAG SUPP 100MG .............................. 41 CLEOCIN-T ...................... 50

see clindamycin phosphate (topical) ........ 50

CLIMARA .......................... 36 see estradiol .................. 36

CLINDAGEL ..................... 50 clindamycin cre 2% vag .... 41 clindamycin hcl ................... 6 clindamycin palmitate hydrochloride ...................... 6 clindamycin phosphate ....... 6 clindamycin phosphate (topical) ............................. 50 clindamycin phosphate in d5w ..................................... 6 clindamycin phosphate-benzoyl peroxide .......................................... 50 CLINIMIX 2.75%/DEXTROSE 5% ..... 45 CLINIMIX 4.25%/DEXTROSE 10% ... 45 CLINIMIX 4.25%/DEXTROSE 20% ... 45 CLINIMIX 4.25%/DEXTROSE 25% ... 45 CLINIMIX 4.25%/DEXTROSE 5% ..... 45 CLINIMIX 5%/DEXTROSE 15%................................... 45 CLINIMIX 5%/DEXTROSE 20%................................... 45 CLINIMIX 5%/DEXTROSE 25%................................... 45 CLINIMIX E 2.75%/DEXTROSE 10% ... 45 CLINIMIX E 2.75%/DEXTROSE 5% ..... 45 CLINIMIX E 4.25%/DEXTROSE ........... 45 CLINIMIX E 4.25%/DEXTROSE 25% ... 45 CLINIMIX E 4.25%/DEXTROSE 5% ..... 45 CLINIMIX E 5%/DEXTROSE 15%................................... 45 CLINIMIX E 5%/DEXTROSE 20%................................... 45

CLINIMIX E 5%/DEXTROSE 25% .................................. 45 clinisol 15 .......................... 45 CLINORIL

see sulindac .................... 1 clobetasol propionate ........ 52 clobetasol propionate emollient base .................. 52 clobetasol propionate emulsion ........................... 52 CLOBEX ........................... 52

see clobetasol propionate ...................................... 52

CLODERM PUMP ............ 52 CLOLAR ........................... 12 clomipramine hcl ............... 23 clonazepam ...................... 20 clonidine hcl ...................... 19 clopidogrel bisulfate .......... 43 clorazepate dipotassium ... 20 clorpres 0.1/15 .................. 19 clorpres 0.2/15 .................. 19 clorpres 0.3/15 .................. 19 clotrimazole ...................... 54 clotrimazole (topical) ......... 51 CLOZAPINE ODT ............. 24 clozapine tab .................... 24 CLOZARIL ........................ 24

see clozapine tab .......... 24 COARTEM .......................... 8 codeine

and capital ....................... 2 CODEINE SULFATE .......... 4 COGENTIN ....................... 24

see benztropine mesylate ...................................... 24

co-gesic 5-500mg ............... 2 COLAZAL ......................... 39

see balsalazide disodium ...................................... 39

colchicine w/ probenecid ..... 1 COLCRYS .......................... 1 COLESTID ........................ 16

see colestipol hcl ........... 16 colestipol hcl ..................... 16 colistimethate sodium ......... 6 colocort ............................. 39 COLY-MYCIN M ................. 6

see colistimethate sodium ........................................ 6

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61

COLY-MYCIN S ................ 54 COLYTE-FLAVOR PACKS .......................................... 40

see gavilyte-c ................ 40 COMBIGAN ...................... 48 COMBIPATCH .................. 36 COMBIVENT ..................... 48 COMBIVENT RESPIMAT . 48 COMBIVIR ..........................8

see lamivudine-zidovudine ........................................8

COMETRIQ ....................... 13 COMPLERA ........................8 compro supp ..................... 38 COMTAN .......................... 24 COMVAX .......................... 44 CONCERTA ...................... 26

see methylphenidate hcl er ...................................... 27

CONDYLOX ...................... 53 see podofilox ................. 54

constulose ......................... 40 CONZIP ..............................2 COPAXONE ...................... 29 COPEGUS ..........................9

see ribasphere .................9 see ribavirin 200mg .........9

CORDARONE ................... 16 see amiodarone hcl ....... 15 see pacerone ................. 16

CORDRAN ........................ 52 COREG ............................. 17

see carvedilol ................ 17 COREG CR ....................... 17 CORGARD ........................ 17

see nadolol .................... 17 CORTEF ........................... 36

see hydrocortisone ........ 36 CORTENEMA ................... 39

see colocort ................... 39 CORTIFOAM .................... 51 cortisone acetate ............... 36 CORTISPORIN ........... 51, 54

see neomycin-polymyxin-hc (otic) .............................. 54

CORTISPORIN-TC ........... 54 CORZIDE .......................... 17

see nadolol & bendroflumethiazide ...... 17

COSMEGEN ..................... 12 COSOPT ........................... 48

see dorzolamide hcl-timolol maleate ........ 48

COSOPT PF ..................... 48 COUMADIN ...................... 42

see jantoven .................. 42 see warfarin sodium ...... 42

COUMADIN INJ ................ 42 COZAAR ........................... 15

see losartan potassium . 15 CREON ............................. 40 CRESTOR ........................ 16 CRINONE ......................... 37 CRIXIVAN ........................... 8 cromolyn sodium ............... 49 cromolyn sodium (mastocytosis) ................... 40 cromolyn sodium (ophth) .. 47 cryselle 28 ......................... 34 CUBICIN ............................. 6 CUTIVATE ........................ 52

see fluticasone propionate ...................................... 53

CUVPOSA ........................ 39 cyclafem 1/35 28 day ........ 34 cyclafem 7/7/7 28 day ....... 34 CYCLESSA ....................... 34

see velivet 28 day ......... 35 cyclobenzaprine hcl .......... 29 cyclophosphamide ............ 12 cyclosporine ...................... 43 cyclosporine modified (for microemulsion) ................. 43 CYKLOKAPRON .............. 43

see tranexamic acid ...... 43 CYMBALTA ...................... 23 cyproheptadine hcl ............ 48 CYSTADANE .................... 35 CYSTAGON ...................... 35 cytarabine inj ..................... 12 CYTOMEL ........................ 38

see liothyronine sodium . 38 CYTOTEC ......................... 40

see misoprostol ............. 40 CYTOVENE ........................ 9

see ganciclovir inj 500mg 9 D D.H.E. 45 .......................... 28

see dihydroergotamine

mesylate ........................ 28 dacarbazine ...................... 12 DACOGEN ....................... 12 DALIRESP ........................ 49 danazol ............................. 35 DANTRIUM ....................... 29

see dantrolene sodium .. 29 dantrolene sodium ............ 29 dapsone .............................. 6 DAPTACEL ....................... 44 DARAPRIM ......................... 6 daunorubicin hcl................ 12 DAYPRO ............................ 1

see oxaprozin .................. 1 DAYTRANA ...................... 26 DDAVP ............................. 38

see desmopressin acetate ...................................... 38 see desmopressin acetate inj .................................. 38 see desmopressin acetate spray ............................. 38

DECAVAC ........................ 44 DELATESTRYL ................ 30

see testosterone enanthate ...................... 30

DELESTROGEN............... 36 see estradiol valerate .... 36

DELZICOL ........................ 39 DEMADEX ........................ 19

see torsemide tabs ........ 19 demeclocycline hcl ............ 11 DEMSER .......................... 19 DENAVIR .......................... 52 DEPACON ........................ 20

see valproate sodium .... 22 DEPAKENE ...................... 20

see valproate sodium .... 22 see valproic acid ........... 22

DEPAKOTE ...................... 20 see divalproex sodium .. 21

DEPAKOTE ER ................ 20 see divalproex sodium .. 21

DEPAKOTE SPRINKLES . 20 see divalproex sodium .. 21

depo-estradiol ................... 36 DEPO-MEDROL ............... 36

see methylprednisolone acetate .......................... 36

DEPO-PROVERA

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CONTRACEPTIV .............. 34 see medroxyprogesterone acetate (contraceptive) .. 34

DEPO-PROVERA INJ 400/ML .............................. 13 DEPO-SUBQ PROVERA 104 .................................... 34 depo-testosterone ............. 30 DEPO-TESTOSTERONE

see testosterone cypionate ...................................... 30

DERMA-SMOOTHE/FS BODY

see fluocinolone acetonide ...................................... 52

DERMA-SMOOTHE/FS BODY OIL ......................... 52 DERMATOP ...................... 52

see prednicarbate .......... 53 DERMOTIC ....................... 54

see fluocinolone acetonide (otic) .............................. 54

desipramine hcl ................. 23 desloratadine .................... 48 desmopressin acetate ....... 38 DESMOPRESSIN ACETATE .......................................... 38 desmopressin acetate inj .. 38 desmopressin acetate spray .......................................... 38 desmopressin acetate spray refrigerated ........................ 38 DESOGEN ........................ 34

see apri 28 day .............. 33 see emoquette ............... 34 see reclipsen 28 day ..... 35

DESONATE ...................... 52 desonide ........................... 52 DESONIDE ....................... 52 desowen............................ 52 DESOWEN ....................... 52

see desonide ................. 52 desowen oint kit 0.05% ..... 52 desoximetasone ................ 52 DESOXIMETASONE ........ 52 DETROL ........................... 41

see tolterodine tartrate .. 41 DETROL LA ...................... 41 dexamethasone ................ 36 dexamethasone sodium

phosphate ......................... 36 dexamethasone sodium phosphate (ophth) ............. 47 DEXILANT ........................ 40 dexpak taperpak 13 day.... 36 dexrazoxane ..................... 14 dextrose ............................ 45 DEXTROSE ...................... 45 DEXTROSE 10% FLEX CONTAIN .......................... 45 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% .......................................... 45 DEXTROSE 10%/NACL 0.45%................................ 45 DEXTROSE 2.5%/NACL 0.45%................................ 45 DEXTROSE 5% ................ 45 DEXTROSE 5% /ELECTROLYTE ............... 45 DEXTROSE 5%/LACTATED RING ................................. 45 DEXTROSE 5%/NACL 0.2% .......................................... 45 DEXTROSE 5%/NACL 0.225% .............................. 45 DEXTROSE 5%/NACL 0.3% .......................................... 45 DEXTROSE 5%/NACL 0.33%................................ 45 DEXTROSE 5%/NACL 0.45%................................ 45 DEXTROSE 5%/NACL 0.9% .......................................... 45 DEXTROSE 5%/POTASSIUM CHL ...... 45 DIABETA .......................... 31 DIAMOX ............................ 19

see acetazolamide ........ 18 diazepam .......................... 21 DIAZEPAM GEL ............... 21 diazepam inj ...................... 21 DIBENZYLINE .................. 19 diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (ophth) . 47 diclofenac w/ misoprostol .... 1 dicloxacillin sodium ........... 11 dicyclomine hcl ................. 39 didanosine .......................... 8

DIFFERIN ......................... 50 see adapalene............... 50

DIFICID ............................. 10 diflorasone diacetate ......... 52 DIFLUCAN .......................... 7

see fluconazole ............... 7 diflunisal .............................. 1 digoxin .............................. 18 digoxin inj .......................... 18 DIGOXIN SOL 50MCG/ML.......................................... 18 dihydroergotamine mesylate.......................................... 28 DIHYDROERGOTAMINE MESYLATE ...................... 28 dilacor ............................... 18 DILACOR XR

see dilt-xr ...................... 18 dilantin .............................. 21 DILANTIN ......................... 21

see phenytoin ................ 22 see phenytoin sodium extended ....................... 22

DILANTIN INFATABS see phenytoin ................ 22

DILATRATE SR ................ 19 DILAUDID

see hydromorphone hcl ... 4 DILAUDID INJ .................... 4 DILAUDID TAB ................... 4 DILAUDID-5

see hydromorphone hcl ... 4 DILAUDID-5 ORAL LIQD .... 4 DILAUDID-HP

see hydromorphone hcl ... 4 DILAUDID-HP INJ .............. 4 dilt-cd ................................ 18 diltiazem cap 120mg/24hr . 18 diltiazem cap er/12hr ........ 18 diltiazem hcl ...................... 18 diltiazem hcl coated beads 18 DILTIAZEM HCL ER ......... 18 diltiazem hcl extended release beads ................... 18 dilt-xr ................................. 18 diltzac ............................... 18 DIOVAN ............................ 15 DIOVAN HCT ................... 15

see valsartan-hydrochlorothiazi

62

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de .................................. 15 DIPENTUM ....................... 39 diphenhydram inj 50mg/ml 48 diphenoxylate w/ atropine . 40 DIPHTHERIA/TETANUS TOXOID ............................ 44 DIPROLENE ..................... 52

see betamethasone dipropionate augmented 52

DIPROLENE AF ................ 52 see betamethasone dipropionate augmented 52

dipyridamole ...................... 43 disopyramide phosphate ... 16 disulfiram........................... 30 DITROPAN XL .................. 41

see oxybutynin chloride . 41 DIURIL SUS 250/5ML ....... 19 divalproex sodium ............. 21 docetaxel........................... 13 DOCETAXEL .................... 13 DOLOPHINE .......................4

see methadone hcl ..........4 DOLOPHINE HCL

see methadone hcl ..........4 donepezil odt 10mg ........... 22 donepezil odt 5mg ............. 22 donepezil tabs 10mg ......... 22 donepezil tabs 5mg ........... 22 DORIBAX ............................6 DORYX ............................. 11 dorzolamide hcl ................. 48 dorzolamide hcl-timolol maleate ............................. 48 DOVONEX ........................ 51

see calcipotriene ........... 51 doxazosin mesylate .......... 15 doxepin hcl ........................ 23 DOXIL ............................... 12 doxorubicin hcl .................. 12 doxycycline (monohydrate) .......................................... 11 doxycycline hyclate ..... 11, 12 dronabinol ......................... 38 drospirenone-ethinyl estradiol ............................ 34 DROXIA ............................ 14 DUETACT ......................... 31

see pioglitazone hcl-glimepiride ............... 33

DUEXIS .............................. 1 DULERA ........................... 50 DUONEB .......................... 48

see ipratropium-albuterol ...................................... 48

DURAGESIC ...................... 4 see fentanyl patch ........... 4

DURAMORPH .................... 4 DUREZOL ......................... 47 DYAZIDE .......................... 19

see triamterene & hydrochlorothiazide cap 37.5-25 mg .................... 19

DYMISTA .......................... 49 dynacin ............................. 12 DYRENIUM ....................... 19 E e.e.s. ................................. 10 E.E.S. GRANULES ........... 10 EC-NAPROSYN ................. 1

see naproxen .................. 1 econazole nitrate .............. 51 EDARBI ............................ 15 EDARBYCLOR ................. 15 EDECRIN .......................... 19 EDLUAR ........................... 27 EDURANT .......................... 8 EFFEXOR XR ................... 23

see venlafaxine cap er .. 24 EFFIENT ........................... 43 EFUDEX ........................... 51

see fluorouracil (topical) 51 EGRIFTA .......................... 37 ELAPRASE ....................... 35 ELDEPRYL ....................... 24

see selegiline hcl ........... 24 ELECTROLYTE-M IN DEXTROSE ...................... 45 ELECTROLYTE-R IN DEXTROSE ...................... 45 ELELYSO ......................... 35 ELESTAT .......................... 47

see epinastine hcl (ophth) ...................................... 47

ELIDEL ............................. 53 ELIGARD .......................... 13 ELIMITE

see permethrin .............. 54 eliphos .............................. 37 ELIPHOS

see calcium acetate (phosphate binder) ........ 37

ELIQUIS ........................... 42 ELITEK ............................. 14 elixophyllin ........................ 50 ELLA ................................. 34 ELLENCE ......................... 12

see epirubicin inj 200mg 12 see epirubicin inj 50mg/25ml .................... 12

ELMIRON ......................... 41 ELOCON .......................... 52

see mometasone furoate ...................................... 53

ELOXATIN ........................ 14 ELSPAR ........................... 14 EMADINE ......................... 47 EMCYT ............................. 12 EMEND ............................. 38 EMEND PAK 80 & 125 ..... 38 EMLA ................................ 53

see lidocaine-prilocaine . 53 emoquette ......................... 34 EMSAM ............................ 23 EMTRIVA ............................ 8 ENABLEX ......................... 41 enalapril maleate .............. 15 enalapril maleate & hydrochlorothiazide ........... 14 ENBREL ........................... 43 endocet 10/325 ................... 4 endocet 10/650 ................... 4 endocet 5/325 ..................... 4 endocet 7.5/325 .................. 4 endocet 7.5/500 .................. 4 ENDODAN .......................... 4 ENDOMETRIN.................. 37 ENGERIX-B ...................... 44 enoxaparin sodium ........... 42 enpresse 28 day ............... 34 ENTACAPONE ................. 24 ENTOCORT EC................ 39

see budesonide ............. 39 enulose ............................. 40 EPIDUO ............................ 50 epinastine hcl (ophth) ....... 47 EPIPEN 2-PAK ................. 49 EPIPEN-JR 2-PAK ............ 49 epirubicin inj 200mg .......... 12 EPIRUBICIN INJ 50MG .... 12

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epirubicin inj 50mg/25ml ... 12 epitol ................................. 21 EPIVIR

see lamivudine ................8 EPIVIR HBV ........................9 EPIVIR SOL 10MG/ML .......8 EPIVIR TABS ......................8 eplerenone ........................ 15 EPOGEN........................... 42 eprosartan mesylate ......... 15 EPZICOM............................8 EQUETRO ........................ 28 ERAXIS ...............................7 ERBITUX .......................... 13 ergomar............................. 28 ERIVEDGE ....................... 13 errin 28 day ....................... 34 ERYPED 200 .................... 10 ERYPED 400 .................... 10 ery-tab ............................... 10 erythrocin lactobionate ...... 10 erythrocin stearate ............ 10 erythromycin (acne aid) .... 50 erythromycin (ophth) ......... 47 erythromycin base ............. 10 erythromycin ethylsuccinate .......................................... 10 erythromycin-sulfisoxazole ..6 escitalopram oxalate ......... 23 estrace .............................. 36 ESTRACE

see estradiol .................. 36 estradiol ............................ 36 estradiol & norethindrone acetate .............................. 36 estradiol valerate ............... 36 ESTRADIOL VALERATE .. 36 ESTRING .......................... 36 estropipate ........................ 36 ESTROSTEP FE ............... 34

see tri-legest 28 day ...... 35 ethambutol hcl .....................8 ethosuximide ..................... 21 ETHYOL

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

etodolac ..............................1 etodolac er ..........................1 ETOPOPHOS ................... 14 etoposide .......................... 14

EURAX ............................. 54 EVISTA ............................. 38 EVOCLIN .......................... 50

see clindamycin phosphate (topical) ........ 50

EVOXAC ........................... 54 see cevimeline hcl ......... 54

EXALGO ............................. 4 EXELDERM ...................... 51 EXELON ........................... 22

see rivastigmine tartrate 23 EXELON PATCHES ......... 22 exemestane ...................... 13 EXFORGE ........................ 15 EXFORGE HCT ................ 15 EXJADE ............................ 33 EXTAVIA ........................... 29 EXTINA ............................. 51

see ketoconazole (topical) ...................................... 51

F FABRAZYME .................... 35 FACTIVE ........................... 10 famciclovir ........................... 9 famotidine ......................... 39 FAMVIR .............................. 9

see famciclovir ................ 9 FANAPT ............................ 24 FANAPT TITRATION PACK .......................................... 25 FARESTON ...................... 13 FASLODEX ....................... 13 FAZACLO ......................... 25 felbamate .......................... 21 FELBATOL ....................... 21

see felbamate ................ 21 FELDENE ........................... 1

see piroxicam .................. 1 felodipine .......................... 18 FEMARA ........................... 13

see letrozole .................. 13 FEMCON FE ..................... 34

see zenchent fe 28 day . 35 FEMRING ......................... 36 fenofibrate ......................... 16 fenofibrate micronized....... 16 FENOFIBRATE MICRONIZED ................... 16 FENOFIBRIC ACID........... 16 FENOGLIDE ..................... 16

fenoprofen calcium ............. 1 fentanyl citrate .................... 4 fentanyl patch ..................... 4 FENTORA .......................... 4 FERRIPROX ..................... 33 fexmid ............................... 29 FEXMID

see cyclobenzaprine hcl 29 FIBRICOR ........................ 16 FINACEA .......................... 53 finasteride ......................... 41 FIRMAGON ...................... 13 FLAGYL .............................. 6

see metronidazole ........... 7 FLAGYL ER ........................ 6 FLAREX ............................ 47 FLEBOGAMMA ................ 43 FLEBOGAMMA DIF .......... 43 flecainide acetate .............. 16 FLEXERIL

see cyclobenzaprine hcl 29 FLOMAX ........................... 41

see tamsulosin hcl ......... 41 FLONASE ......................... 49

see fluticasone propionate (nasal) ........................... 49

FLO-PRED ....................... 36 FLOVENT DISKUS ........... 50 FLOVENT HFA ................. 50 fluconazole ......................... 7 fluconazole in dextrose ....... 7 fluconazole in nacl 100mg .. 7 fluconazole in nacl 200mg .. 7 fluconazole in nacl 400mg .. 7 flucytosine ........................... 7 FLUDARA

see fludarabine phosphate ...................................... 12

fludarabine phosphate ...... 12 fludrocortisone acetate ..... 36 FLUMADINE ....................... 9

see rimantadine hydrochloride................... 9

flunisolide (nasal) .............. 49 fluocinolone acetonide ...... 52 fluocinolone acetonide (otic).......................................... 54 fluocinonide ...................... 53 fluocinonide emulsified base.......................................... 53

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FLUOROMETHOLONE .... 47 FLUOROMETHOLONE (OPHTH) ........................... 47 FLUOROPLEX .................. 51 fluorouracil ........................ 12 fluorouracil (topical) ........... 51 fluoxetine hcl ..................... 23 FLUOXETINE HCL ........... 23 fluphenazine decanoate .... 25 fluphenazine hcl ................ 25 flurbiprofen ..........................1 flurbiprofen sodium ........... 47 flutamide ........................... 13 fluticasone propionate ....... 53 fluticasone propionate (nasal) ............................... 49 fluvastatin sodium ............. 16 fluvoxamine maleate ......... 20 fluvoxamine maleate er ..... 20 fluvoxamine tabs ............... 20 FML ................................... 47 FML FORTE ...................... 47 FML LIQUIFILM ................ 47 fondaparinux sodium ......... 42 FORADIL AEROLIZER ..... 49 FORFIVO XL ..................... 23 FORTAMET ...................... 31

see metformin hcl .......... 32 FORTAZ............................ 10

see ceftazidime ...............9 see tazicef vial ............... 10

FORTEO ........................... 37 FORTESTA ....................... 30 FORTICAL SPR 200/ACT . 37 FOSAMAX ........................ 33

see alendronate sodium 33 FOSAMAX PLUS D .......... 33 foscarnet sodium .................9 fosinopril sodium ............... 15 fosinopril sodium & hydrochlorothiazide ........... 14 FOSRENOL ...................... 37 FRAGMIN ......................... 42 FREAMINE HBC 6.9% ...... 45 FREAMINE III ................... 45 FROVA TAB 2.5MG .......... 28 FURADANTIN .....................6

see nitrofurantoin .............7 furosemide ........................ 19 furosemide inj .................... 19

furosemide oral soln 8 mg/ml .......................................... 19 FUZEON ............................. 8 G gabapentin ........................ 21 GABITRIL ......................... 21

see tiagabine hcl ........... 22 galantamine hydrobromide 22 GAMASTAN S/D ............... 43 GAMMAGARD LIQUID ..... 43 GAMMAGARD S/D ........... 43 GAMMAKED ..................... 43 GAMMAPLEX ................... 43 GAMUNEX ........................ 43 GAMUNEX-C .................... 43 GAMUNEX-C 1GM/10ML . 43 ganciclovir inj 500mg .......... 9 GARAMYCIN

see gentamicin sulfate (ophth) ........................... 47

GARDASIL ........................ 44 GASTROCROM ................ 40

see cromolyn sodium (mastocytosis) ............... 40

GATTEX ........................... 40 GAUZE PADS 2X2 ........... 30 gaviltye-g .......................... 40 gavilyte-c ........................... 40 gavilyte-n .......................... 40 GELNIQUE ....................... 41 GEMCITABINE ................. 12 gemcitabine hcl ................. 12 gemfibrozil ........................ 16 GEMZAR .......................... 12

see gemcitabine hcl....... 12 GENERESS FE ................ 34 generlac ............................ 40 gengraf .............................. 44 GENOTROPIN .................. 37 GENOTROPIN MINIQUICK .......................................... 37 gentak ............................... 47 gentamicin in saline 0.9mg/ml ............................. 6 gentamicin in saline 1.4mg/ml ............................. 6 gentamicin in saline 100mg 6 gentamicin in saline 60mg .. 6 gentamicin in saline 80mg .. 6 gentamicin sulfate ............... 6

gentamicin sulfate (ophth) 47 gentamicin sulfate (topical).......................................... 51 GEODON .......................... 25

see ziprasidone hcl ....... 25 GEODON INJ ................... 25 GIANVI ............................. 34 GIAZO .............................. 39 gildagia ............................. 34 GILENYA .......................... 29 GLASSIA .......................... 49 GLEEVEC ......................... 13 glimepiride ........................ 31 glipizide ............................. 31 glipizide er ........................ 31 glipizide-metformin 2.5-250mg ........................ 31 glipizide-metformin 2.5-500mg ........................ 31 glipizide-metformin 5-500mg.......................................... 31 GLUCAGEN HYPOKIT ..... 37 GLUCAGON EMERGENCY KIT .................................... 37 GLUCOPHAGE ................ 31

see metformin hcl .......... 32 GLUCOPHAGE XR .......... 31

see metformin er ........... 32 GLUCOTROL ................... 31

see glipizide .................. 31 GLUCOTROL XL ........ 31, 32

see glipizide er .............. 31 GLUCOVANCE

see glyburide-metformin 1.25-250mg ................... 32 see glyburide-metformin 2.5-500mg ..................... 32 see glyburide-metformin 5-500mg ........................ 32

GLUCOVANCE 1.25-250MG.......................................... 32 GLUCOVANCE 2.5-500MG.......................................... 32 GLUCOVANCE 5-500MG . 32 GLUMETZA ...................... 32 glyburide ........................... 32 glyburide micronized ......... 32 glyburide-metformin 1.25-250mg ...................... 32 glyburide-metformin

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2.5-500mg ......................... 32 glyburide-metformin 5-500mg ............................ 32 glycopyrrolate .................... 39 GLYNASE ......................... 32

see glyburide micronized ...................................... 32

GLYSET ............................ 32 GOLYTELY ....................... 40

see gaviltye-g ................ 40 see peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ............................ 40

GRALISE .......................... 28 GRALISE STARTER ......... 28 granisetron hcl .................. 38 granisol ............................. 38 GRIFULVIN V

see griseofulvin microsize ........................................7

griseofulvin microsize ..........7 griseofulvin ultramicrosize ...7 GRIS-PEG ..........................7

see griseofulvin ultramicrosize ..................7

H HALAVEN ......................... 14 HALDOL............................ 25

see haloperidol lactate .. 25 HALDOL DECANOATE 100 .......................................... 25

see haloperidol decanoate ...................................... 25

HALDOL DECANOATE 50 .......................................... 25

see haloperidol decanoate ...................................... 25

HALFLYTELY BOWEL PREP/FLA......................... 40 halobetasol propionate ...... 53 HALOG ............................. 53 haloperidol ........................ 25 haloperidol decanoate ....... 25 haloperidol lactate ............. 25 HAVRIX............................. 44 heather tab 0.35mg ........... 34 HECTOROL ...................... 46 HELIDAC .......................... 40 HEP SOD/NACL INJ 25000 .......................................... 42

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................... 42 heparin sod inj 10000u/ml . 42 heparin sod inj 1000u/ml ... 42 heparin sod inj 20000u/ml . 42 HEPARIN SOD INJ 2000U/ML ......................... 42 HEPARIN SOD INJ 2500U/ML ......................... 42 heparin sod inj 5000u/0.5ml .......................................... 42 heparin sod inj 5000u/ml ... 42 HEPARIN SODIUM/D5W .. 42 HEPARIN SODIUM/SODIUM CHL .... 42 HEPATAMINE .................. 45 hepatasol 8 ....................... 45 HEPSERA ........................... 9 HERCEPTIN ..................... 13 HEXALEN ......................... 12 HIBERIX ........................... 44 HIPREX .............................. 6

see methenamine hippurate ......................... 7

HORIZANT ....................... 28 HUMALOG ........................ 30 HUMALOG KWIKPEN ...... 30 HUMALOG MIX 50/50 ...... 30 HUMALOG MIX 50/50 KWIKPEN ......................... 30 HUMALOG MIX 75/25 ...... 30 HUMALOG MIX 75/25 KWIKPEN ......................... 30 HUMATROPE ................... 37 HUMATROPE COMBO PACK ................................ 37 HUMIRA ............................ 43 HUMIRA PEN ................... 43 HUMIRA PEN-CROHNS STARTER KIT .................. 43 HUMIRA PEN-PSORIASIS STARTER KIT .................. 43 HUMULIN 70/30 ............... 30 HUMULIN 70/30 PEN ....... 30 HUMULIN N ...................... 30 HUMULIN N U-100 PEN ... 30 HUMULIN R ...................... 30 HUMULIN R U-500 (CONCENTRATE) ............ 30

HYCAMTIN ....................... 14 see topotecan hcl .......... 14

hycet ................................... 2 HYCET

see hydrocodone-acetaminophen 7.5-325 mg/15ml ........ 2

hydralazine hcl .................. 19 HYDREA ........................... 14

see hydroxyurea ............ 14 hydrochlorothiazide ........... 19 hydrocodone-acetaminophen 10-300mg ........................... 2 hydrocodone-acetaminophen 10-500mg ........................... 2 hydrocodone-acetaminophen 10-650mg ........................... 2 hydrocodone-acetaminophen 10-660mg ........................... 2 hydrocodone-acetaminophen 10-750mg ........................... 2 hydrocodone-acetaminophen 2.5-325mg .......................... 2 hydrocodone-acetaminophen 2.5-500mg .......................... 2 hydrocodone-acetaminophen 5-300mg ............................. 2 hydrocodone-acetaminophen 5-325mg ............................. 2 hydrocodone-acetaminophen 5-500mg ............................. 2 hydrocodone-acetaminophen 7.5-300mg .......................... 2 hydrocodone-acetaminophen 7.5-325 mg/15ml ................. 2 hydrocodone-acetaminophen 7.5-325mg .......................... 2 hydrocodone-acetaminophen 7.5-500mg .......................... 2 hydrocodone-acetaminophen 7.5-500mg/15ml .................. 2 hydrocodone-acetaminophen 7.5-650mg .......................... 2 hydrocodone-acetaminophen 7.5-750mg .......................... 2 hydrocodone-acetaminophen tab 10-325mg ..................... 2 hydrocodone-ibuprofen 2.5-200mg .......................... 3 hydrocodone-ibuprofen

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7.5-200mg ...........................3 hydrocortisone .................. 36 HYDROCORTISONE (INTRARECTAL) ............... 39 hydrocortisone (topical) ..... 53 hydrocortisone butyrate .... 53 hydrocortisone valerate ..... 53 hydromorphone hcl .............4 hydroxychloroquine sulfate .......................................... 43 hydroxyurea ...................... 14 hydroxyzine hcl ................. 49 hydroxyzine pamoate ........ 49 HYZAAR ........................... 15

see losartan potassium & hydrochlorothiazide ....... 15

I ibandronate sodium .......... 33 ibudone tab 5-200mg ..........3 ibuprofen .............................1 ICLUSIG............................ 13 IDAMYCIN PFS ................ 12

see idarubicin hcl ........... 12 idarubicin hcl ..................... 12 IFEX .................................. 12

see ifosfamide ............... 12 IFEX INJ 3GM ................... 12 ifosfamide.......................... 12 IFOSFAMIDE

see ifosfamide ............... 12 ILEVRO ............................. 47 imdur ................................. 19 IMDUR

see isosorbide mononitrate ................... 19

imipenem-cilastatin .............6 imipramine hcl ................... 23 imipramine pamoate ......... 23 imiquimod.......................... 53 IMITREX ........................... 28

see sumatriptan succinate ...................................... 28 see sumatriptan succinate inj ................................... 28

IMITREX STATDOSE REFILL .............................. 28 IMOVAX RABIES (H.D.C.V.) .......................................... 44 IMURAN ............................ 44

see azathioprine ............ 43

INCIVEK ............................. 9 INCRELEX ........................ 37 indapamide ....................... 19 INDERAL LA ..................... 17

see propranolol hcl er .... 17 INFANRIX ......................... 44 INFERGEN ....................... 43 INFUMORPH 200 ............... 4 INFUMORPH 500 ............... 4 INLYTA ............................. 13 INSPRA ............................ 15

see eplerenone ............. 15 INSULIN PEN NEEDLES .. 30 INSULIN SAFETY NEEDLES ......................... 30 INSULIN SYRINGES ........ 30 INTELENCE ........................ 8 INTERMEZZO .................. 27 INTRALIPID INJ 20%........ 45 INTRALIPID INJ 30%........ 45 INTRON-A ........................ 43 INTRON-A W/DILUENT .... 43 introvale 91 day ................ 34 INTUNIV ........................... 26 INVANZ ............................... 6 INVEGA ............................ 25 INVEGA SUSTENNA ........ 25 INVIRASE ........................... 8 INVOKANA ....................... 32 IONOSOL-B/DEXTROSE 5% .................................... 45 IONOSOL-MB/DEXTROSE 5% .................................... 45 IPOL INACTIVATED IPV .. 44 ipratropium bromide (nasal) .......................................... 48 ipratropium sol inhal .......... 48 ipratropium-albuterol ......... 48 irbesartan .......................... 15 irbesartan-hydrochlorothiazide ........................................ 15 IRESSA ............................. 13 irinotecan hcl ..................... 14 ISENTRESS ....................... 8 ISOLYTE P ....................... 45 isolyte s ............................. 45 isoniazid .............................. 8 isoniazid tabs ...................... 8 ISOPTO CARPINE ........... 48 ISORDIL TITRADOSE ...... 19

see isosorbide dinitrate . 19 isosorbide dinitrate ............ 19 isosorbide mononitrate ..... 19 isradipine .......................... 18 ISTALOL ........................... 48 ISTODAX .......................... 13 itraconazole ........................ 7 IXEMPRA KIT ................... 14 IXIARO ............................. 44 J JAKAFI ............................. 13 JALYN .............................. 41 jantoven ............................ 42 JANUMET ......................... 32 JANUMET XR TAB 100-1000 .......................... 32 JANUMET XR TAB 50-1000.......................................... 32 JANUMET XR TAB 50-500MG ......................... 32 JANUVIA .......................... 32 JENTADUETO .................. 32 jinteli ................................. 36 JOLIVETTE ...................... 34 junel 1.5/30 21 day ........... 34 junel 1/20 21 day .............. 34 junel fe 1.5/30 28 day ....... 34 junel fe 1/20 28 day .......... 34 JUVISYNC ........................ 32 K KADCYLA ......................... 13 KADIAN .............................. 4 KALETRA SOL ................... 8 KALETRA TAB 100-25MG . 8 KALETRA TAB 200-50MG . 8 kariva 28 day .................... 34 KAYEXALATE .................. 33

see kionex ..................... 33 KAZANO ........................... 32 KCL 0.075%/D5W/NACL 0.45% ............................... 46 KCL 0.15%/D5W/LR ......... 46 KCL 0.15%/D5W/NACL 0.9% ................................. 46 kcl 0.3%/d5w/lr iv lac ri ..... 46 KCL 0.3%/D5W/NACL 0.45% ............................... 46 KCL 0.3%/D5W/NACL 0.9%.......................................... 46 KCL 10 MEQ/L (0.075%) IN

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DEXTROSE 5% & NACL 0.2% INJ ........................... 46 kcl 20 meq/l (0.15%) in nacl 0.45% inj ........................... 46 KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ ............... 46 KCL 30 MEQ/L (0.224%) IN DEXTROSE 5% & NACL 0.2% INJ ........................... 46 KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & NACL 0.2% INJ ........................... 46 KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ ................. 46 KCL0.15%/D5W/NACL0.2% .......................................... 46 KCL0.15%/D5W/NACL0.225% ....................................... 46 KEFLEX ............................ 10

see cephalexin .............. 10 kelnor 1/35 28 day ............ 34 KENALOG......................... 53 KEPIVANCE ..................... 14 KEPPRA ........................... 21

see levetiracetam .......... 21 KEPPRA XR ..................... 21

see levetiracetam .......... 21 KERLONE

see betaxolol hcl ............ 17 ketoconazole .......................7 ketoconazole (topical) ....... 51 ketoconazole shampoo ..... 52 ketoprofen ...........................1 ketorolac tromethamine (ophth) .............................. 47 KINERET .......................... 43 kionex ............................... 33 KLARON ........................... 50

see sulfacetamide sodium (acne) ............................ 51

KLONOPIN ....................... 21 see clonazepam ............ 20

KLOR-CON 10 .................. 44 KLOR-CON 8 .................... 44 klor-con m15 ..................... 44 klor-con m20 ..................... 44 KOMBIGLYZE XR 2.5-1000MG ...................... 32 KOMBIGLYZE XR 5-1000MG ......................... 32

KOMBIGLYZE XR 5-500MG .......................................... 32 kristalose ........................... 40 K-TABS ............................. 44 KUVAN ............................. 35 L labetalol hcl ....................... 17 LAC-HYDRIN .................... 53

see ammonium lactate .. 53 see laclotion lotn 12% ... 53

laclotion lotn 12% .............. 53 LACRISERT ...................... 48 LACTATED RINGERS VIAFLEX ........................... 46 lactulose ............................ 40 lactulose (encephalopathy) .......................................... 40 LAMICTAL ........................ 21

see lamotrigine .............. 21 LAMICTAL CHEWABLE DISPERS .......................... 21

see lamotrigine .............. 21 LAMICTAL ODT ................ 21 LAMICTAL STARTER....... 21 LAMICTAL XR .................. 21

see lamotrigine .............. 21 LAMISIL .............................. 7

see terbinafine hcl ........... 7 lamivudine ........................... 8 lamivudine-zidovudine ........ 8 lamotrigine ........................ 21 LANOXIN

see digoxin .................... 18 see digoxin inj ............... 18

LANOXIN PEDIATRIC ...... 18 LANOXIN TAB .................. 18 lansoprazole ..................... 40 LANTUS ............................ 30 LANTUS SOLOSTAR ....... 30 LASIX................................ 19

see furosemide .............. 19 LASTACAFT ..................... 47 latanoprost ........................ 48 LATUDA ............................ 25 LAZANDA ........................... 4 LEENA .............................. 34 leflunomide ....................... 43 LESCOL ............................ 16

see fluvastatin sodium ... 16 LESCOL XL ...................... 16

lessina 28 day ................... 34 LETAIRIS .......................... 20 letrozole ............................ 13 leucovor ca inj ................... 14 leucovorin calcium ............ 14 LEUKERAN ...................... 12 LEUKINE .......................... 42 leuprolide acetate ............. 13 levalbuterol conc 1.25mg/0.5ml .................... 49 LEVALBUTEROL HCL ..... 49 LEVAQUIN ....................... 10

see levofloxacin............. 10 see levofloxacin in d5w . 11

LEVAQUIN INJ ................. 10 LEVATOL ......................... 17 LEVEMIR .......................... 30 LEVEMIR FLEXPEN ......... 30 levetiracetam .................... 21 levobunolol hcl .................. 48 LEVOBUNOLOL HCL ....... 48 levocarnitine (metabolic modifiers) .......................... 35 levocetirizine soln 2.5mg/5ml.......................................... 49 levocetirizine tab 5 mg ...... 49 levofloxacin ....................... 10 levofloxacin (ophth) ........... 47 levofloxacin in d5w ............ 11 levonest 28 day ................ 34 levonorgestrel-ethinyl estradiol (91-day) .............. 34 levora 0.15/30 28 day ....... 34 levorphanol tartrate ............. 4 LEVOTHROID .................. 38 levothyroxine sodium ........ 38 LEVOXYL ......................... 38 LEXAPRO ......................... 23

see escitalopram oxalate ...................................... 23

LEXIVA ............................... 8 LIALDA ............................. 39 lidocaine ........................... 53 lidocaine hcl ...................... 53 lidocaine hcl (local anesth.) 5, 6 lidocaine hcl (mouth-throat).......................................... 54 lidocaine inj 0.5% ................ 6 lidocaine inj 1% ................... 6

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lidocaine inj 1.5% ................6 lidocaine inj 2% ...................6 lidocaine-prilocaine ........... 53 LIDODERM ....................... 53 LINZESS CAP 145MCG ... 40 LINZESS CAP 290MCG ... 40 liothyronine sodium ........... 38 LIPITOR ............................ 16

see atorvastatin calcium 16 LIPOFEN........................... 16 LIPOSYN II ....................... 45 LIPOSYN III ...................... 45 lisinopril ............................. 15 lisinopril & hydrochlorothiazide ........... 14 lithium carbonate ............... 28 LITHIUM CITRATE ........... 28 LITHOBID ......................... 28

see lithium carbonate .... 28 LIVALO ............................. 16 LO LOESTRIN FE ............. 34 LOCOID ............................ 53

see hydrocortisone butyrate ......................... 53

LOCOID LIPOCREAM ...... 53 LODOSYN ........................ 24 loestrin 1.5/30-21 .............. 34 LOESTRIN 1.5/30-21

see junel 1.5/30 21 day . 34 see microgestin 1.5/30 21 day ................................ 34

loestrin 1/20-21 ................. 34 LOESTRIN 1/20-21

see junel 1/20 21 day .... 34 see microgestin 1/20 21 day ................................ 34

LOESTRIN 24 FE ............. 34 loestrin fe 1.5/30 ............... 34 LOESTRIN FE 1.5/30

see junel fe 1.5/30 28 day ...................................... 34 see microgestin fe 1.5/30 28 day............................ 34

loestrin fe 1/20 .................. 34 LOESTRIN FE 1/20

see junel fe 1/20 28 day 34 see microgestin fe 1/20 28 day ................................ 34

lofibra ................................ 17 LOFIBRA

see fenofibrate .............. 16 see fenofibrate micronized ...................................... 16

LOKARA LOTN 0.05%...... 53 LOMOTIL .......................... 40

see diphenoxylate w/ atropine ......................... 40

loperamide hcl .................. 40 LOPID ............................... 17

see gemfibrozil .............. 16 LOPRESSOR ................... 17

see metoprolol tartrate .. 17 LOPRESSOR HCT ........... 17

see metoprolol & hctz tab 100-25mg ...................... 17 see metoprolol & hctz tab 50-25mg ........................ 17

LOPROX see ciclopirox ................ 51

LOPROX SHAMPOO........ 51 see ciclopirox shampoo 1% ................................. 51

lorazepam ......................... 20 lorcet 10/650 ....................... 3 LORCET 10/650

see hydrocodone-acetaminophen 10-650mg ................... 2

lorcet plus ........................... 3 LORTAB

see co-gesic 5-500mg ..... 2 see hydrocodone-acetaminophen 10-500mg ................... 2 see hydrocodone-acetaminophen 5-500mg ..................... 2 see hydrocodone-acetaminophen 7.5-500mg .................. 2 see hydrocodone-acetaminophen 7.5-500mg/15ml ......... 2

lortab 10/500 ....................... 3 lortab 5/500 ......................... 3 lortab 7.5/500 ...................... 3 loryna 28 day .................... 34 losartan potassium ............ 15 losartan potassium & hydrochlorothiazide ........... 15

LOSEASONIQUE ............. 34 LOTEMAX ........................ 47 LOTENSIN ........................ 15

see benazepril hcl ......... 15 LOTENSIN HCT ............... 14

see benazepril & hydrochlorothiazide ....... 14

LOTREL ............................ 14 see amlodipine besylate-benazepril hcl . 14

LOTRONEX ...................... 40 lovastatin .......................... 16 LOVAZA ........................... 17 LOVENOX ........................ 42

see enoxaparin sodium . 42 low-ogestrel 28 day ........... 34 loxapine succinate ............ 25 loxitane ............................. 25 LOXITANE

see loxapine succinate .. 25 LUFYLLIN ......................... 50 LUMIGAN ......................... 48 LUMIZYME ....................... 35 LUNESTA ......................... 27 LUPR DEP-PED INJ 11.25MG (3-MONTH) ....... 13 LUPR DEP-PED INJ 30MG (3-MONTH) ....................... 13 LUPRON DEPOT ............. 13 LUPRON DEPOT INJ 22.5MG (3-MONTH) ......... 13 LUPRON DEPOT INJ 30MG (3-MONTH) ....................... 13 LUPRON DEPOT-PED ..... 13 lutera 28 day ..................... 34 LUVOX CR ....................... 20

see fluvoxamine maleate er ................................... 20

LUXIQ ............................... 53 see betamethasone valerate ......................... 52

LYRICA ............................. 21 LYSODREN ...................... 13 LYSTEDA ......................... 43

see tranexamic acid ...... 43 M MACROBID ........................ 6

see nitrofurantoin monohyd macro .............. 7

MACRODANTIN ................. 6

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see nitrofurantoin macrocrystal ....................7

mafenide acetate .............. 51 magnesium sulfate ............ 44 MAGNESIUM SULFATE ... 44 MAGNESIUM SULFATE IN D5W 1% ............................ 44 MAGNESIUM SULFATE IN D5W 2% ............................ 44 MALARONE ........................8

see atovaquone-proguanil hcl tab 250-100 mg ..........7

malathion .......................... 54 maprotiline hcl ................... 23 MARINOL.......................... 38

see dronabinol ............... 38 marlissa 28 day ................. 34 MARPLAN ......................... 23 MATULANE ...................... 14 matzim la........................... 18 MAVIK ............................... 15

see trandolapril .............. 15 MAXALT............................ 28

see rizatriptan benzoate 28 MAXALT-MLT ................... 28

see rizatriptan benzoate 28 MAXIDEX .......................... 47 maxidone ............................3 MAXIDONE

see hydrocodone-acetaminophen 10-750mg ...................2

MAXIPIME ........................ 10 see cefepime inj 1gm ......9 see cefepime inj 2gm ......9

MAXITROL ........................ 46 see neomycin-polymy-dexameth .................................... 46

MAXZIDE .......................... 19 see triamterene & hydrochlorothiazide tab 75-50 mg ....................... 19

MAXZIDE-25 ..................... 19 see triamterene & hydrochlorothiazide tab 37.5-25 mg .................... 19

meclizine hcl ..................... 38 MEDROL........................... 36

see methylprednisolone 36

MEDROL DOSEPAK ........ 36 see methylprednisolone 36

medroxyprogesterone acetate .............................. 37 medroxyprogesterone acetate (contraceptive) ..... 34 mefenamic acid ................... 1 mefloquine hcl ..................... 8 MEGACE ES .................... 13 MEGACE ORAL ............... 13

see megestrol acetate ... 13 megestrol acetate ............. 13 MEKINIST ......................... 13 MELOXICAM SUSP 7.5 MG/5ML .............................. 1 meloxicam tabs ................... 1 melphalan hcl .................... 12 MENACTRA ...................... 44 menest .............................. 36 MENHIBRIX ...................... 44 MENOMUNE-A/C/Y/W-135 .......................................... 44 MENOSTAR ..................... 36 MENTAX ........................... 51 MENVEO .......................... 44 MEPRON ............................ 6 mercaptopurine ................. 12 meropenem ......................... 6 MERREM ............................ 6

see meropenem .............. 6 mesalamine enema .......... 39 mesalamine enema kit ...... 39 mesna ............................... 14 MESNEX ........................... 14

see mesna ..................... 14 MESTINON

see pyridostigmine bromide ......................... 29

MESTINON SYRUP.......... 29 MESTINON TAB ............... 29 MESTINON TIMESPAN .... 29 METADATE CD ................ 26

see methylphenidate hcl 27 metadate tab 20mg er ....... 26 METAGLIP

see glipizide-metformin 2.5-250mg ..................... 31

metformin er ...................... 32 metformin hcl .................... 32 methadone hcl .................... 4

METHADONE INJ 10MG/ML............................................ 4 methazolamide ................. 19 methenamine hippurate ...... 7 METHERGINE

see methylergonovine maleate ......................... 37

methimazole ..................... 38 methocarbamol ................. 29 methotrexate sodium inj .... 12 methotrexate sodium tabs 43 methscopolamine bromide 39 methyclothiazide ............... 19 methylergonovine maleate 37 METHYLIN ....................... 26

see methylphenidate hcl 27 METHYLIN CHEW TAB .... 26 methylphenidate hcl .... 26, 27 methylphenidate hcl er ...... 27 METHYLPHENIDATE HCL ER ..................................... 27 methylphenidate tab 10mg er.......................................... 27 methylphenidate tab 20mg er.......................................... 27 methylprednisolone ........... 36 methylprednisolone acetate.......................................... 36 methylprednisolone sod succ.......................................... 36 metipranolol ...................... 48 metoclopramide hcl ........... 38 metoclopramide hcl inj 5 mg/ml ................................ 38 metolazone ....................... 19 metoprolol & hctz tab 100-25mg ......................... 17 metoprolol & hctz tab 100-50mg ......................... 17 metoprolol & hctz tab 50-25mg ........................... 17 metoprolol succinate ......... 17 metoprolol tartrate............. 17 METOZOLV ODT ............. 38 METRO IV .......................... 7 METROCREAM ................ 53

see metronidazole (topical) ......................... 53 see rosadan cre 0.75% . 54

METROGEL ..................... 53

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see metronidazole (topical).......................... 53

METROGEL-VAGINAL ..... 41 see metronidazole vaginal ...................................... 41

METROLOTION ................ 53 see metronidazole (topical).......................... 53

metronidazole .....................7 metronidazole (topical) ...... 53 metronidazole inj .................7 metronidazole vaginal ....... 41 MEVACOR ........................ 16

see lovastatin ................ 16 mexiletine hcl .................... 16 MIACALCIN

see calcitonin (salmon) nasal spray .................... 37

MIACALCIN INJ 200U/ML. 37 MIACALCIN SPR 200/ACT .......................................... 37 MICARDIS ........................ 15 MICARDIS HCT ................ 15 miconazole nitrate vaginal. 42 microgestin 1.5/30 21 day . 34 microgestin 1/20 21 day .... 34 microgestin fe 1.5/30 28 day .......................................... 34 microgestin fe 1/20 28 day 34 MICRO-K .......................... 44

see potassium chloride caps er........................... 44

MICROZIDE ...................... 19 see hydrochlorothiazide 19

midodrine hcl ..................... 19 migergot ............................ 28 MIGRANAL ....................... 28 millipred............................. 36 MINASTRIN 24 FE ............ 34 MINIPRESS ...................... 15

see prazosin hcl ............ 15 minitran ............................. 19 MINIVELLE ....................... 36 MINOCIN .......................... 12

see minocycline hcl ....... 12 minocycline hcl .................. 12 minoxidil ............................ 19 MIRAPEX .......................... 24

see pramipexole dihydrochloride .............. 24

MIRAPEX ER .................... 24 MIRCETTE

see kariva 28 day .......... 34 see viorele ..................... 35

mirtazapine ....................... 23 misoprostol ....................... 40 mitomycin .......................... 12 mitoxantrone hcl ............... 14 M-M-R II W/DILUENT 10 DOS .................................. 44 MOBIC ................................ 1

see meloxicam tabs......... 1 modafinil ........................... 29 MODICON ........................ 34 moexipril hcl ...................... 15 moexipril-hydrochlorothiazide ........................................ 14 mometasone furoate ......... 53 MONODOX ....................... 12

see doxycycline (monohydrate) ............... 11

MONONESSA .................. 34 montelukast sodium .......... 49 MORPHINE SUL 20MG/ML ORAL SOL .......................... 4 MORPHINE SULFATE ....... 4 morphine sulfate ext-rel tab4, 5 morphine sulfate inj ............. 5 MORPHINE SULFATE INJ . 5 MOVIPREP ....................... 40 MOXATAG ........................ 11 MOXEZA ........................... 47 MOZOBIL .......................... 42 MS CONTIN ........................ 5

see morphine sulfate ext-rel tab .................... 4, 5

MULTAQ ........................... 16 mupirocin .......................... 51 mupirocin calcium (topical) 51 MUSTARGEN ................... 12 MYAMBUTOL ..................... 8

see ethambutol hcl .......... 8 MYCAMINE ........................ 7 MYCOBUTIN ...................... 8 mycophenolate mofetil ...... 44 MYFORTIC ....................... 44 myorisan ........................... 50 MYOZYME ........................ 35 MYRBETRIQ .................... 41

MYSOLINE ....................... 21 see primidone................ 22

myzilra .............................. 34 N nabumetone ........................ 1 nadolol .............................. 17 nadolol & bendroflumethiazide ......... 17 nafcillin sodium ................. 11 NAFTIN ............................. 51 NAGLAZYME ................... 36 NALFON ............................. 1 NALLPEN ISO-OSMOTIC IN DE ..................................... 11 NALLPEN/DEXTROSE ..... 11 naloxone hcl ..................... 30 naltrexone hcl ................... 30 NAMENDA ........................ 22 NAMENDA TITRATION PAK.......................................... 22 NAMENDA XR .................. 23 NAMENDA XR TITRATION PACK ................................ 23 NAPRELAN ........................ 1 NAPROSYN ....................... 1

see naproxen .................. 1 naproxen ............................. 1 naproxen sodium ................ 1 naratriptan hcl ................... 28 NARDIL ............................ 23

see phenelzine sulfate .. 23 NASACORT AQ................ 49

see triamcinolone acetonide (nasal) ........... 50

NASONEX ........................ 49 NATACYN ........................ 47 nateglinide ........................ 33 NAVANE ........................... 25 NAVELBINE

see vinorelbine tartrate .. 13 NEBUPENT ........................ 7 necon 0.5/35 28 day ......... 34 necon 1/35 28 day ............ 34 NECON 1/50-28................ 34 necon 10/11 28 day .......... 34 NECON 7/7/7 .................... 34 nefazodone hcl ................. 23 neomycin sulfate ................. 6 neomycin/polymyxin b gu . 54 neomycin-bacitracin

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zn-polymyxin ..................... 47 neomycin-polymy-dexameth .......................................... 46 neomycin-polymy-gramicid .......................................... 47 neomycin-polymyxin-hc (ophth) .............................. 46 neomycin-polymyxin-hc (otic) .......................................... 54 NEORAL ........................... 44

see cyclosporine modified (for microemulsion) ........ 43 see gengraf ................... 44

NEOSPORIN see neomycin-polymy-gramicid ...................................... 47

NEOSPORIN GU IRRIGANT see neomycin/polymyxin b gu .................................. 54

neosporin solution ............. 47 NEPHRAMINE .................. 45 NEPTAZANE

see methazolamide ....... 19 NESINA............................. 33 NEULASTA ....................... 42 NEUMEGA ........................ 42 NEUPOGEN ..................... 42 NEUPRO........................... 24 NEURONTIN ............... 21, 22

see gabapentin .............. 21 NEVANAC ......................... 47 nevirapine ...........................8 NEVIRAPINE ......................8 NEXAVAR ......................... 13 NEXIUM ............................ 41 NEXIUM GRANULES 10MG DR ..................................... 41 NEXIUM GRANULES 2.5MG DR ..................................... 41 NEXIUM GRANULES 20MG DR ..................................... 41 NEXIUM GRANULES 40MG DR ..................................... 41 NEXIUM GRANULES 5MG DR ..................................... 41 NEXIUM I.V. ...................... 41 next choice tab 1.5mg ....... 34 niacor ................................ 17 NIASPAN .......................... 17

nicardipine hcl ................... 18 NICOTROL INHALER ....... 30 NICOTROL NS ................. 30 nifediac ............................. 18 nifedical ............................. 18 nifedipine .......................... 18 nifedipine er ...................... 18 NILANDRON ..................... 13 nimodipine ........................ 18 NIMOTOP

see nimodipine .............. 18 NIPENT ............................. 12

see pentostatin .............. 12 nisoldipine ......................... 18 nitro-bid ............................. 19 NITRO-DUR ...................... 19

see minitran ................... 19 nitrofurantoin ....................... 7 nitrofurantoin macrocrystal .. 7 nitrofurantoin monohyd macro .................................. 7 NITROGLYCERIN ............ 19 NITROGLYCERIN LINGUAL .......................................... 19 nitroglycerin patches ......... 20 NITROLINGUAL SPR PUMPSPRA ...................... 20 NITROMIST ...................... 20 NITROSTAT ..................... 20 nizatidine ........................... 39 NIZORAL .......................... 52

see ketoconazole shampoo ....................... 52

NORA-BE ......................... 35 NORCO

see hydrocodone-acetaminophen 5-325mg ..................... 2 see hydrocodone-acetaminophen 7.5-325mg .................. 2 see hydrocodone-acetaminophen tab 10-325mg ............. 2

norco 10/325 ....................... 3 norco 5/325 ......................... 3 norco 7.5/325 ...................... 3 NORDETTE-28 ................. 35 NORDITROPIN FLEXPRO .......................................... 37

NORDITROPIN NORDIFLEX PEN ............. 37 norethindrone (contraceptive) .................. 35 norethindrone acetate ....... 37 norgestimate-ethinyl estradiol (triphasic) ........... 35 NORINYL 1+35 ................. 35

see cyclafem 1/35 28 day ...................................... 34 see necon 1/35 28 day .. 34 see nortrel 1/35 21 day . 35 see nortrel 1/35 28 day . 35

NORINYL 1+50 ................. 35 normosol-m ....................... 46 NORMOSOL-R ................. 46 NOROXIN ......................... 11 NORPACE ........................ 16

see disopyramide phosphate ..................... 16

NORPACE CR .................. 16 NORPRAMIN .................... 23

see desipramine hcl ...... 23 NOR-QD ........................... 35

see camila 28 day ......... 34 see heather tab 0.35mg 34 see norethindrone (contraceptive) .............. 35

nortrel 0.5/35 28 day ......... 35 nortrel 1/35 21 day ............ 35 nortrel 1/35 28 day ............ 35 nortrel 7/7/7 28 day ........... 35 nortriptyline hcl ................. 23 NORVASC ........................ 18

see amlodipine besylate 18 NORVIR .............................. 8 NOVAREL INJ 10000UNT 37 NOVOLIN 70/30................ 30 NOVOLIN 70/30 RELION . 31 NOVOLIN N ...................... 31 NOVOLIN N RELION ........ 31 NOVOLIN R ...................... 31 NOVOLIN R RELION ........ 31 NOVOLOG ....................... 31 NOVOLOG FLEXPEN ...... 31 NOVOLOG MIX 70/30 ...... 31 NOVOLOG MIX 70/30 PREFILL ........................... 31 NOXAFIL ............................ 7 NUCYNTA .......................... 5

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NUCYNTA ER .....................5 NUEDEXTA ...................... 29 NULOJIX ........................... 44 NULYTELY/FLAVOR PACKS .............................. 40

see gavilyte-n ................ 40 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ...................................... 40 see trilyte ....................... 40

NUTROPIN ....................... 37 NUTROPIN AQ ................. 37 NUTROPIN AQ NUSPIN 5 37 NUTROPIN AQ PEN ......... 37 NUVARING ....................... 35 NUVIGIL............................ 29 nyamyc ............................. 51 NYMALIZE ........................ 18 nystatin ...............................7 nystatin (mouth-throat) ...... 54 nystatin (topical) ................ 51 nystatin pow 100000 ......... 51 nystop ............................... 51 O OCELLA ............................ 35 OCTAGAM ........................ 43 octreotide acetate ............. 37 OCUFEN ........................... 47

see flurbiprofen sodium . 47 OCUFLOX ......................... 47

see ofloxacin (ophth) ..... 47 ofloxacin (ophth) ............... 47 ofloxacin (otic) ................... 54 ogestrel 28 day ................. 35 olanzapine......................... 25 olanzapine odt ................... 25 OLEPTRO ......................... 23 OLUX


OLUX-E............................. 53 see clobetasol propionate emulsion ........................ 52

OMECLAMOX-PAK .......... 40 omeprazole ....................... 41 OMNARIS ......................... 50 OMNIPRED ....................... 47 OMNITROPE 10MG ......... 37 OMNITROPE 5.8MG ........ 37

OMNITROPE 5MG ........... 37 ondansetron hcl ................ 38 ondansetron hcl inj ............ 38 ondansetron hcl oral soln .. 38 ondansetron odt ................ 38 ONFI ................................. 22 ONGLYZA ......................... 33 ONMEL ............................... 7 ONSOLIS ............................ 5 ONTAK ............................. 13 OPANA ............................... 5

see oxymorphone hcl ...... 5 OPANA ER (CRUSH RESISTANT ........................ 5 OPTIPRANOLOL .............. 48

see metipranolol ............ 48 OPTIVAR .......................... 47

see azelastine hcl (ophth) ...................................... 47

ORACEA ........................... 53 ORAP ................................ 25 orapred ............................. 36 ORAPRED

see prednisolone sodium phosphate ..................... 36

ORAPRED ODT ............... 36 ORENCIA ......................... 43 ORFADIN .......................... 36 orsythia 28 day ................. 35 ORTHO EVRA .................. 35 ORTHO MICRONOR ........ 35

see errin 28 day ............ 34 ORTHO TRI-CYCLEN

see norgestimate-ethinyl estradiol (triphasic) ........ 35 see tri-previfem 28 day .. 35 see tri-sprintec 28 day ... 35

ORTHO TRI-CYCLEN LO . 35 ORTHO-CEPT .................. 35 ORTHO-CYCLEN ............. 35

see previfem 28 day ...... 35 see sprintec 28 day ....... 35

ORTHO-NOVUM 7/7/7 ..... 35 see cyclafem 7/7/7 28 day ...................................... 34 see nortrel 7/7/7 28 day . 35

OSENI TAB 12.5-15MG .... 33 OSENI TAB 12.5-30MG .... 33 OSENI TAB 12.5-45MG .... 33 OSENI TAB 25-15MG ....... 33

OSENI TAB 25-30MG ....... 33 OSENI TAB 25-45MG ....... 33 OSMOPREP ..................... 40 ovcon 35 28 day ............... 35 OVCON-35

see balziva 28 day ........ 33 see briellyn 28 day ........ 34 see gildagia ................... 34 see philith ...................... 35 see zenchent tab ........... 35

OVIDE .............................. 54 see malathion ................ 54

oxacillin sodium ................ 11 oxaliplatin .......................... 14 OXANDRIN

see oxandrolone............ 30 oxandrolone ...................... 30 oxaprozin ............................ 1 oxcarbazepine .................. 22 OXECTA ............................. 5 OXISTAT .......................... 51 OXSORALEN ................... 53 OXSORALEN ULTRA ....... 51 oxybutynin chloride ........... 41 oxycodone hcl ..................... 5 OXYCODONE HCL ............ 5 oxycodone w/ acetaminophen 10-325mg .. 5 oxycodone w/ acetaminophen 10-650mg .. 5 oxycodone w/ acetaminophen 2.5-325mg . 5 oxycodone w/ acetaminophen 5-325mg .... 5 oxycodone w/ acetaminophen 5-500mg .... 5 oxycodone w/ acetaminophen 7.5-325mg . 5 oxycodone w/ acetaminophen 7.5-500mg . 5 oxycodone-aspirin............... 5 oxycodone-ibuprofen .......... 5 OXYCONTIN ...................... 5 oxymorphone hcl ................ 5 OXYTROL ........................ 41 P pacerone ........................... 16 PACERONE

see amiodarone hcl ....... 15 paclitaxel ........................... 13

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PAMELOR ........................ 23 see nortriptyline hcl ....... 23

pamidronate disodium ....... 33 PAMINE ............................ 39

see methscopolamine bromide ......................... 39

PAMINE FORTE ............... 39 see methscopolamine bromide ......................... 39

PANCREAZE .................... 40 PANDEL............................ 53 PANRETIN ........................ 53 pantoprazole sodium ......... 41 PARAFON FORTE DSC ... 29

see chlorzoxazone ........ 29 PARCOPA

see carbidopa-levodopa 24 parcopa 10/100 ................. 24 parcopa 25/100 ................. 24 parcopa 25/250 ................. 24 PARLODEL ....................... 24

see bromocriptine mesylate ........................ 24

PARNATE ......................... 23 see tranylcypromine sulfate ............................ 23

paromomycin sulfate ...........6 paroxetine er tab ............... 23 paroxetine hcl .................... 23 paser d/r ..............................8 PATADAY ......................... 47 PATANASE ....................... 49 PATANOL ......................... 47 PAXIL ................................ 23

see paroxetine hcl ......... 23 PAXIL CR.......................... 23

see paroxetine er tab ..... 23 PCE .................................. 10 pediapred .......................... 36 PEDIAPRED

see prednisolone sodium phosphate ...................... 36

pedi-dri .............................. 51 PEDVAX HIB .................... 44 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 40 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE .......................................... 40

peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 40 PEGANONE ..................... 22 PEGASYS ......................... 43 PEGASYS PROCLICK ..... 43 PEG-INTRON ................... 43 PEG-INTRON REDIPEN .. 43 PENICILLIN G POT IN DEXTROSE ...................... 11 penicillin g potassium ........ 11 PENICILLIN G POTASSIUM .......................................... 11 penicillin g procaine .......... 11 penicillin g sodium ............ 11 penicillin v potassium ........ 11 PENNSAID ....................... 54 PENTAM 300 ...................... 7 PENTASA ......................... 39 pentostatin ........................ 12 pentoxifylline ..................... 43 PEPCID ............................ 39

see famotidine ............... 39 PERCOCET

see endocet 10/325 ......... 4 see endocet 10/650 ......... 4 see endocet 5/325 ........... 4 see endocet 7.5/325 ........ 4 see endocet 7.5/500 ........ 4 see oxycodone w/ acetaminophen 10-325mg ........................................ 5 see oxycodone w/ acetaminophen 10-650mg ........................................ 5 see oxycodone w/ acetaminophen 2.5-325mg ........................................ 5 see oxycodone w/ acetaminophen 5-325mg . 5 see oxycodone w/ acetaminophen 7.5-325mg ........................................ 5 see oxycodone w/ acetaminophen 7.5-500mg ........................................ 5

percocet 10/325 .................. 5 percocet 10/650 .................. 3 percocet 2.5/325 ................. 5 percocet 5/325 .................... 5

percocet 7.5/325 ................. 5 percocet 7.5/500 ................. 3 PERCODAN ....................... 5

see oxycodone-aspirin .... 5 PERFOROMIST ............... 49 PERIDEX

see chlorhexidine gluconate (mouth-throat) ...................................... 54 see periogard sol 0.12% 54

perindopril erbumine ......... 15 periogard sol 0.12% .......... 54 permethrin ........................ 54 perphenazine .................... 25 PERSANTINE ................... 43

see dipyridamole ........... 43 PERTZYE ......................... 40 PEXEVA ........................... 23 pfizerpen ........................... 11 phenadoz .......................... 38 phenelzine sulfate ............. 23 phenergan ........................ 38 PHENERGAN

see promethazine hcl .... 38 phenobarbital .................... 22 phenobarbital sodium ....... 22 PHENOBARBITAL SODIUM.......................................... 22 phenytek ........................... 22 PHENYTEK

see phenytoin sodium extended ....................... 22

phenytoin .......................... 22 phenytoin inj 50mg/ml ....... 22 phenytoin sodium extended.......................................... 22 philith ................................ 35 PHISOHEX ....................... 51 PHOSLO ........................... 37

see calcium acetate (phosphate binder) ........ 37

PHOSLYRA ...................... 37 PHOSPHOLINE IODIDE .. 48 PICATO ............................ 51 PILOCARPINE HCL ......... 48 pilocarpine hcl (oral) ......... 54 PILOPINE HS ................... 48 pindolol ............................. 17 pioglitazone hcl ................. 33 pioglitazone hcl-glimepiride

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.......................................... 33 pioglitazone hcl-metformin hcl ..................................... 33 piperacillin sodium-tazobactam sodium .......................................... 11 piroxicam.............................1 PLAN B ONE-STEP

see next choice tab 1.5mg ...................................... 34

PLAQUENIL ...................... 43 see hydroxychloroquine sulfate ............................ 43

PLASMA-LYTE A .............. 46 PLASMA-LYTE-148 .......... 46 PLASMA-LYTE-56/D5W ... 46 PLAVIX ............................. 43

see clopidogrel bisulfate 43 PLETAL............................. 43

see cilostazol ................. 43 podofilox............................ 54 polyethylene glycol 3350 ... 40 polymyxin b sulfate .............7 polymyxin b-trimethoprim .. 47 POLYTRIM ........................ 47

see polymyxin b-trimethoprim ............... 47

POMALYST CAP .............. 14 PONSTEL ...........................1

see mefenamic acid ........1 portia 28 day ..................... 35 potassium chloride ............ 46 POTASSIUM CHLORIDE 44, 46

see potassium chloride .. 46 POTASSIUM CHLORIDE 0.15% ................................ 46 POTASSIUM CHLORIDE 0.22% ................................ 46 POTASSIUM CHLORIDE 0.3%/D .............................. 46 potassium chloride caps er .......................................... 44 potassium chloride microencapsulated crystals cr ....................................... 44 POTASSIUM CITRATE (ALKALINIZER) ................. 41 POTIGA ............................ 22 PRADAXA ......................... 42

pramipexole dihydrochloride .......................................... 24 PRANDIMET ..................... 33 PRANDIN .......................... 33 PRAVACHOL .................... 16

see pravastatin sodium . 16 pravastatin sodium ............ 16 prazosin hcl ....................... 15 PRECOSE ........................ 33

see acarbose ................. 31 PRED FORTE ................... 47 PRED MILD ...................... 47 PRED-G ............................ 46 PRED-G S.O.P. ................ 46 prednicarbate .................... 53 PREDNICARBATE ........... 53 prednisolone ..................... 36 PREDNISOLONE ACETATE .......................................... 47 prednisolone sodium phosphate ......................... 36 prednisolone sodium phosphate (ophth) ............. 47 prednisone ........................ 36 PREGNYL W/DILUENT BENZYL ............................ 37 PRELONE

see prednisolone ........... 36 PREMARIN ....................... 36 PREMARIN CREAM ......... 36 PREMARIN INJ ................ 36 premasol 10% ................... 45 premasol 6% ..................... 45 PREMPHASE ................... 36 PREMPRO ........................ 36 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) .......................................... 46 PREPOPIK ....................... 40 PREVACID ....................... 41

see lansoprazole ........... 40 PREVACID SOLUTAB ...... 41 prevalite ............................ 17 previfem 28 day ................ 35 PREVPAC ......................... 40 PREZISTA .......................... 8 PRIFTIN .............................. 8 PRILOSEC ........................ 41

see omeprazole ............. 41 PRIMAQUINE PHOSPHATE

............................................ 8 PRIMAXIN .......................... 7 PRIMAXIN IV

see imipenem-cilastatin ... 6 primidone .......................... 22 PRIMSOL SOL 50MG/5ML . 7 PRINIVIL ........................... 15

see lisinopril .................. 15 PRINZIDE

see lisinopril & hydrochlorothiazide ....... 14

PRISTIQ ........................... 23 PRIVIGEN ........................ 43 PROAIR HFA .................... 49 probenecid .......................... 1 PROCALAMINE................ 45 PROCARDIA XL ............... 18

see nifedical .................. 18 see nifedipine er ............ 18

prochlorperazine inj 5 mg/ml.......................................... 38 prochlorperazine maleate . 38 prochlorperazine supp ...... 38 PROCRIT ......................... 42 proctocream ...................... 51 procto-pak ......................... 51 proctozone hc ................... 51 PROCYSBI ....................... 36 progesterone micronized .. 37 PROGLYCEM ................... 37 PROGRAF ........................ 44

see tacrolimus ............... 44 PROLASTIN-C.................. 49 PROLENSA ...................... 48 PROLEUKIN ..................... 13 PROLIA ............................ 37 PROMACTA ..................... 43 promethazine hcl .............. 38 promethegan .................... 38 PROMETRIUM ................. 37

see progesterone micronized ..................... 37

propafenone hcl ................ 16 proparacaine hcl ............... 48 propranolol & hydrochlorothiazide ........... 17 propranolol hcl er .............. 17 propranolol inj 1mg/ml ...... 17 propranolol sol .................. 17 propranolol tab .................. 17

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propylthiouracil .................. 38 PROQUAD ........................ 44 PROSCAR ........................ 41

see finasteride ............... 41 PROSOL ........................... 45 PROTONIX ....................... 41

see pantoprazole sodium ...................................... 41

PROTONIX INJ ................. 41 PROTOPIC ....................... 54 protriptyline hcl .................. 23 PROVENTIL HFA ............. 49 PROVERA ........................ 37

see medroxyprogesterone acetate........................... 37

PROVIGIL ......................... 29 see modafinil ................. 29

PROZAC ........................... 23 see fluoxetine hcl ........... 23

PROZAC WEEKLY ........... 23 see fluoxetine hcl ........... 23

PRUDOXIN CRE 5% ........ 51 PULMICORT

see budesonide (inhalation) ..................... 50

PULMICORT FLEXHALER .......................................... 50 PULMICORT INH SUSP ... 50 PULMOZYME ................... 49 PURINETHOL ................... 12

see mercaptopurine ....... 12 PYLERA ............................ 40 pyrazinamide .......................8 pyridostigmine bromide ..... 29 Q QNASL .............................. 50 QUALAQUIN .......................8

see quinine sulfate ..........8 QUARTETTE .................... 35 quasense 91 day ............... 35 questran ............................ 17 QUESTRAN

see cholestyramine ....... 16 questran light .................... 17 QUESTRAN LIGHT

see cholestyramine light 16 see prevalite .................. 17

quetiapine fumarate .......... 25 QUILLIVANT XR ............... 27 quinapril hcl ....................... 15

quinapril-hydrochlorothiazide .......................................... 14 quinidine gluconate er ....... 16 quinidine sulfate ................ 16 quinine sulfate ..................... 8 QVAR ................................ 50 R RABAVERT ...................... 44 ramipril .............................. 15 RANEXA ........................... 19 ranitidine hcl ...................... 39 RAPAFLO ......................... 41 RAPAMUNE ..................... 44 RAYOS ............................. 36 RAZADYNE ...................... 23

see galantamine hydrobromide ................ 22

RAZADYNE ER ................ 23 see galantamine hydrobromide ................ 22

REBETOL ........................... 9 see ribasphere ................ 9 see ribavirin 200mg ......... 9

REBIF ............................... 29 REBIF TITRATION PACK . 29 reclipsen 28 day ................ 35 RECOMBIVAX HB ............ 44 RECTIV ............................. 54 REGLAN ........................... 38

see metoclopramide hcl 38 REGONOL ........................ 29 RELENZA DISKHALER ...... 9 RELISTOR ........................ 40 RELPAX ............................ 28 REMERON ....................... 23

see mirtazapine ............. 23 REMERON SOLTAB ........ 23

see mirtazapine ............. 23 REMICADE ....................... 43 REMODULIN .................... 20 RENAGEL ......................... 37 RENVELA ......................... 37 REPREXAIN

see hydrocodone-ibuprofen 2.5-200mg ....................... 3 see ibudone tab 5-200mg 3

reprexain 10/200 ................. 3 reprexain 2.5/200 ................ 3 reprexain 5/200 ................... 3

REQUIP ............................ 24 see ropinirole hydrochloride................. 24

REQUIP XL ...................... 24 see ropinirole hydrochloride................. 24

RESCRIPTOR .................... 8 RESTASIS ........................ 48 RETIN-A ........................... 51

see tretinoin .................. 51 RETIN-A MICRO .............. 51 RETROVIR

see zidovudine ................ 8 RETROVIR CAPS .............. 8 RETROVIR IV INFUSION ... 8 RETROVIR SYRP .............. 8 REVATIO .......................... 20

see sildenafil citrate (pulmonary hypertension) ...................................... 20

revia .................................. 30 REVIA

see naltrexone hcl ......... 30 REVLIMID ......................... 43 REYATAZ ........................... 8 RHEUMATREX................. 43 RHINOCORT AQUA ......... 50 ribapak mis 600/day ............ 9 ribasphere ........................... 9 ribasphere ribapak 1000 ..... 9 ribasphere ribapak 1200 ..... 9 ribasphere ribapak 800 ....... 9 ribavirin 200mg ................... 9 rifadin .................................. 8 RIFADIN ......................... 8, 9

see rifampin .................... 9 rifamate ............................... 9 rifampin ............................... 9 RIFATER ............................ 9 RILUTEK .......................... 29

see riluzole .................... 29 riluzole .............................. 29 rimantadine hydrochloride .. 9 RINGER'S ......................... 46 RIOMET ............................ 33 RISPERDAL ..................... 25

see risperidone.............. 25 RISPERDAL CONSTA ..... 25 RISPERDAL M-TAB ......... 25

see risperidone odt ........ 25

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risperidone ........................ 25 risperidone odt .................. 25 RITALIN ............................ 27

see methylphenidate hcl 27 RITALIN LA ....................... 27

see methylphenidate hcl ................................ 26, 27

RITALIN SR ...................... 27 RITUXAN .......................... 13 rivastigmine tartrate .......... 23 rizatriptan benzoate .......... 28 ROBAXIN

see methocarbamol ....... 29 ROBAXIN-750

see methocarbamol ....... 29 ROBINUL .......................... 39

see glycopyrrolate ......... 39 ROBINUL FORTE ............. 39

see glycopyrrolate ......... 39 ROCALTROL .................... 46

see calcitriol ................... 46 rocephin ............................ 10 ROCEPHIN

see ceftriaxone sodium....9 ropinirole hydrochloride ..... 24 rosadan cre 0.75% ............ 54 ROTATEQ ......................... 44 ROWASA .......................... 39

see mesalamine enema kit ...................................... 39

roxicet .................................5 ROXICODONE ...................5

see oxycodone hcl ...........5 ROZEREM ........................ 27 RYTHMOL ........................ 16

see propafenone hcl ...... 16 RYTHMOL SR .................. 16

see propafenone hcl ...... 16 S SABRIL ............................. 22 SAIZEN ............................. 37 SAIZEN CLICK.EASY ....... 37 SALAGEN ......................... 54

see pilocarpine hcl (oral) ...................................... 54

SAMSCA ........................... 37 SANCTURA ...................... 41

see trospium chloride .... 41 SANCTURA XR ................ 41

see trospium chloride .... 41

SANCUSO ........................ 39 SANDIMMUNE

see cyclosporine ........... 43 SANDIMMUNE CAPS....... 44 SANDIMMUNE INJ ........... 44 SANDIMMUNE SOLN....... 44 SANDOSTATIN ................ 37

see octreotide acetate ... 37 SANDOSTATIN LAR DEPOT ............................. 37 SANTYL ............................ 54 SAPHRIS .......................... 25 SARAFEM ........................ 30 SAVELLA .......................... 29 SAVELLA TITRATION PACK ................................ 29 SEASONIQUE .................. 35

see amethia 91 day ....... 33 SECTRAL ......................... 17

see acebutolol hcl ......... 17 selegiline hcl ..................... 24 selenium sulfide ................ 52 SELSUN SHAMPOO

see selenium sulfide ...... 52 SELZENTRY ....................... 8 SEMPREX-D .................... 48 SENSIPAR ........................ 33 SEREVENT DISKUS ........ 49 seromycin ........................... 9 SEROQUEL ...................... 25

see quetiapine fumarate 25 SEROQUEL XR ................ 25 SEROSTIM ....................... 37 sertraline hcl ..................... 23 SFROWASA ..................... 39 sildenafil citrate (pulmonary hypertension) .................... 20 SILENOR .......................... 27 SILVADENE ...................... 51 SILVER SULFADIAZINE .. 51 SIMCOR ........................... 17 SIMPONI ........................... 43 SIMULECT ........................ 44 simvastatin ........................ 16 SINEMET .......................... 24

see carbidopa-levodopa 24 SINEMET CR .................... 24

see carbidopa-levodopa 24 SINGULAIR ...................... 49

see montelukast sodium 49

SIRTURO ........................... 9 SKLICE ............................. 54 SOD FLUORIDE 2.2MG TAB ................................... 44 SODIUM CHLORIDE .. 44, 46 SODIUM CHLORIDE 0.45% VIA .................................... 46 SODIUM CHLORIDE 0.9%.......................................... 54 SODIUM DIURIL............... 19 sodium phenylbutyrate ...... 36 sodium polystyrene sulfonate.......................................... 33 SOLARAZE ...................... 51 SOLIA ............................... 35 SOLODYN ........................ 12

see minocycline hcl ....... 12 SOLTAMOX ...................... 13 SOLU-CORTEF 1000MG . 36 SOLU-CORTEF 100MG ... 36 SOLU-CORTEF 250MG ... 36 SOLU-CORTEF 500MG ... 36 SOLU-MEDROL ............... 36

see methylprednisolone sod succ ........................ 36

SOMATULINE DEPOT ..... 37 SOMAVERT ..................... 37 SONATA ........................... 27

see zaleplon .................. 27 SORIATANE ..................... 51 SORILUX .......................... 51 sorine ................................ 16 sotalol hcl .......................... 16 sotalol hcl (afib/afl) ............ 16 SPIRIVA HANDIHALER ... 48 spironolactone .................. 15 spironolactone & hydrochlorothiazide ........... 19 SPORANOX ....................... 7

see itraconazole .............. 7 SPORANOX PULSEPAK ... 7 SPORANOX SOL 10MG/ML............................................ 7 sprintec 28 day ................. 35 SPRYCEL ......................... 13 sps sus 15gm/60ml ........... 33 sronyx 28 day ................... 35 SSD .................................. 51 stagesic 500-5mg ............... 3 STALEVO ......................... 24

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STARLIX ........................... 33 see nateglinide .............. 33

stavudine.............................8 STAVZOR ......................... 22 STELARA.......................... 51 STERILE WATER IRRIGATION ..................... 54 STIMATE .......................... 38 STIVARGA ........................ 13 STRATTERA ..................... 27 streptomycin sulfate ............6 STRIANT........................... 30 STRIBILD ............................8 STROMECTOL ...................7 SUBOXONE

see buprenorphine hcl-naloxone hcl sl ......... 30

SUBOXONE MIS 12-3MG 30 SUBOXONE MIS 2-0.5MG .......................................... 30 SUBOXONE MIS 4-1MG .. 30 SUBOXONE MIS 8-2MG .. 30 SUBSYS .............................5 SUCLEAR ......................... 40 SUCRAID .......................... 40 sucralfate .......................... 40 SULAR .............................. 18

see nisoldipine ............... 18 sulfacetamide sodium (acne) .......................................... 51 sulfacetamide sodium (ophth) .............................. 47 sulfacetamide sod-prednisolone .............. 46 sulfadiazine .........................6 sulfamethoxazole-trimethoprim .........................................7 sulfamethoxazole-trimethoprim inj ....................................7 SULFAMYLON .................. 51

see mafenide acetate .... 51 sulfasalazine dr ................. 39 sulfasalazine ir .................. 39 sulindac ...............................1 sumatriptan succinate ....... 28 SUMATRIPTAN SUCCINATE ..................... 28 sumatriptan succinate inj .. 28 SUMATRIPTAN SUCCINATE INJ ............... 28

SUMAVEL DOSEPRO ...... 28 suprax ............................... 10 SUPRAX ........................... 10 SUPREP BOWEL PREP .. 40 SURMONTIL ..................... 23

see trimipramine maleate ...................................... 23

SUSTIVA ............................ 8 SUTENT ........................... 13 syeda ................................ 35 SYLATRON ...................... 14 SYMBICORT .................... 50 SYMLINPEN 120 .............. 31 SYMLINPEN 60 ................ 31 SYNAGIS .......................... 44 SYNALAR ......................... 53

see fluocinolone acetonide ...................................... 52

SYNALGOS-DC .................. 3 SYNAREL ......................... 35 SYNERA ........................... 53 SYNERCID ......................... 7 SYNTHROID ..................... 38

see levothyroxine sodium ...................................... 38

SYPRINE .......................... 33 T TABLOID .......................... 12 TACLONEX ...................... 53 tacrolimus ......................... 44 TAFINLAR ........................ 13 TAMBOCOR ..................... 16

see flecainide acetate .... 16 TAMIFLU ............................ 9 tamoxifen citrate ............... 13 tamsulosin hcl ................... 41 tapazole ............................ 38 TAPAZOLE

see methimazole ........... 38 TARCEVA ......................... 13 TARGRETIN ............... 14, 54 TARKA .............................. 14 TASIGNA .......................... 14 TAXOTERE ...................... 13 tazicef vial ......................... 10 TAZORAC ......................... 51 taztia xt ............................. 18 TECFIDERA ..................... 29 TECFIDERA STARTER PACK ................................ 29

TEFLARO ......................... 10 TEGRETOL ...................... 22

see carbamazepine ....... 20 see epitol ....................... 21

TEGRETOL-XR ................ 22 see carbamazepine ....... 20

TEKAMLO ........................ 18 TEKTURNA ...................... 18 TEKTURNA HCT .............. 18 TEMOVATE ...................... 53


TEMOVATE E .................. 53 see clobetasol propionate emollient base ............... 52

TENORETIC ..................... 17 TENORETIC 100

see atenolol & chlorthalidone ................ 17

TENORETIC 50 see atenolol & chlorthalidone ................ 17

TENORMIN ...................... 17 see atenolol ................... 17

TERAZOL 3 ...................... 42 see terconazole vaginal 42

TERAZOL 7 ...................... 42 see terconazole vaginal 42 see zazole ..................... 42

terazosin hcl ..................... 15 terbinafine hcl ..................... 7 terbutaline sulfate ............. 49 terconazole vaginal ........... 42 TESTIM ............................ 30 testosterone cypionate ...... 30 testosterone enanthate ..... 30 TETANUS TOXOID ADSORBED ..................... 44 TETANUS/DIPHTHERIA TOXOID ............................ 44 TEVETEN ......................... 15

see eprosartan mesylate ...................................... 15

TEVETEN HCT ................. 15 TEV-TROPIN .................... 37 texacort ............................. 53 THALOMID ....................... 43 theo-24 ............................. 50 theophylline ...................... 50 THERMAZENE ................. 51

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thioridazine hcl .................. 25 thiotepa ............................. 12 thiothixene......................... 25 THYMOGLOBULIN ........... 44 tiagabine hcl ...................... 22 TIAZAC ............................. 18

see diltiazem hcl extended release beads ................ 18 see diltzac ..................... 18 see taztia xt ................... 18

TIKOSYN .......................... 16 TIMENTIN ......................... 11 TIMENTIN INJ 3.1GM ....... 11 timolol maleate .................. 17 timolol maleate (ophth) ..... 48 TIMOLOL MALEATE GEL 48 TIMOPTIC ......................... 48

see timolol maleate (ophth) ........................... 48

TIMOPTIC OCUDOSE ...... 48 TIMOPTIC-XE ................... 48 TIROSINT ......................... 38 tizanidine ........................... 29 TOBI NEB ...........................6 TOBRADEX ...................... 46

see tobramycin-dexamethasone .................................... 46

TOBRADEX ST ................. 46 tobramycin sulfate ...............6 tobramycin sulfate (ophth). 47 tobramycin sulfate in saline .6 tobramycin-dexamethasone .......................................... 46 TOBREX

see tobramycin sulfate (ophth) ........................... 47

TOBREX OINT 0.3% ........ 47 TOBREX SOL 0.3% OP .... 47 tofranil ............................... 23 TOFRANIL

see imipramine hcl ........ 23 TOFRANIL-PM .................. 23

see imipramine pamoate ...................................... 23

tolmetin sodium ...................1 tolterodine tartrate ............. 41 TOPAMAX ........................ 22

see topiramate ............... 22 TOPAMAX SPRINKLE ...... 22

see topiramate .............. 22 topicort .............................. 53 TOPICORT ....................... 53

see desoximetasone ..... 52 topiramate ......................... 22 toposar .............................. 14 topotecan hcl .................... 14 TOPROL XL ...................... 17

see metoprolol succinate ...................................... 17

TORISEL .......................... 13 torsemide inj ..................... 19 torsemide tabs .................. 19 TOVIAZ ............................. 41 TPN ELECTROLYTES ..... 45 TRACLEER ....................... 20 TRADJENTA ..................... 33 tramadol hcl er .................... 3 TRAMADOL HCL ER .......... 3 TRAMADOL HCL ER (BIPHASIC) 100MG ............ 3 TRAMADOL HCL ER (BIPHASIC) 200MG ............ 3 tramadol hcl er (biphasic) 300mg ................................. 3 tramadol hcl tab 50 mg ....... 3 tramadol-acetaminophen .... 3 TRANDATE ...................... 17

see labetalol hcl ............ 17 trandolapril ........................ 15 tranexamic acid ................. 43 TRANSDERM-SCOP ........ 39 TRANXENE T ................... 22

see clorazepate dipotassium ................... 20

tranylcypromine sulfate ..... 23 travasol 10 ........................ 45 TRAVATAN Z ................... 48 trazodone hcl .................... 23 TREANDA ......................... 12 TRECATOR ........................ 9 TRELSTAR DEPOT MIXJECT .......................... 13 TRELSTAR LA MIXJECT . 13 TRELSTAR MIXJECT ....... 13 TRENTAL ......................... 43

see pentoxifylline ........... 43 tretin x ............................... 51 tretinoin ....................... 14, 51 TRETINOIN

MICROSPHERE ............... 51 trexall ................................ 43 TREXIMET ....................... 28 triamcinolone acetonide (mouth) ............................. 54 triamcinolone acetonide (nasal) ............................... 50 triamcinolone acetonide (topical) ............................. 53 triamterene & hydrochlorothiazide cap 37.5-25 mg ....................... 19 triamterene & hydrochlorothiazide tab 37.5-25 mg ....................... 19 triamterene & hydrochlorothiazide tab 75-50 mg .......................... 19 TRIBENZOR ..................... 15 TRICOR ............................ 17

see fenofibrate .............. 16 triderm .............................. 53 trifluoperazine hcl.............. 25 trifluridine .......................... 47 TRIGLIDE ......................... 17 tri-legest 28 day ................ 35 TRILEPTAL ...................... 22

see oxcarbazepine ........ 22 TRILEPTAL SUSP ............ 22 TRILIPIX ........................... 17

see choline fenofibrate .. 16 trilyte ................................. 40 trimethoprim ........................ 7 trimipramine maleate ........ 23 TRINESSA ........................ 35 TRI-NORINYL 28 .............. 35

see aranelle 28.............. 33 TRIOSTAT ........................ 38

see liothyronine sodium 38 tri-previfem 28 day ............ 35 TRISENOX ....................... 14 tri-sprintec 28 day ............. 35 trivora 28 day .................... 35 TRIZIVIR ............................. 8 TROPHAMINE .................. 45 trospium chloride .............. 41 TRUSOPT ........................ 48

see dorzolamide hcl ...... 48 TRUVADA .......................... 8 TUDORZA PRESSAIR ..... 48

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TWINRIX ........................... 44 TWYNSTA ........................ 15 TYGACIL.............................7 TYKERB............................ 14 tylenol with codeine #3 ........3 tylenol with codeine #4 ........3 TYLENOL/CODEINE #3

see acetaminophen w/ codeine ............................1

TYLENOL/CODEINE #4 see acetaminophen w/ codeine ............................2

TYPHIM VI ........................ 44 TYSABRI........................... 29 TYZEKA ..............................9 tyzine ................................ 49 U UCERIS ............................ 40 u-cort ................................. 53 ULESFIA ........................... 54 ULORIC ..............................1 ULTRACET .........................3

see tramadol-acetaminophen .3

ULTRAM .............................3 see tramadol hcl tab 50 mg ...................................3

ULTRAM ER .......................3 see tramadol hcl er ..........3

ULTRAVATE ..................... 53 see halobetasol propionate ..................... 53

ULTRESA ......................... 40 UNASYN ........................... 11

see ampicillin & sulbactam sodium ........................... 11

UNASYN BULK PACK ...... 11 see ampicillin & sulbactam sodium ........................... 11

UNIRETIC ......................... 14 see moexipril-hydrochlorothiazide .................................. 14

UNITHROID ...................... 38 UNIVASC .......................... 15

see moexipril hcl ............ 15 urecholine ......................... 41 URECHOLINE

see bethanechol chloride ...................................... 41

UROCIT-K ........................ 41 UROXATRAL .................... 41

see alfuzosin hcl ............ 41 URSO 250 ........................ 40

see ursodiol ................... 40 URSO FORTE .................. 40

see ursodiol ................... 40 ursodiol ............................. 40 UVADEX ........................... 14 V VAGIFEM .......................... 36 valacyclovir hcl .................... 9 VALCYTE ........................... 9 VALIUM ............................ 22

see diazepam ................ 21 valproate sodium .............. 22 valproic acid ...................... 22 valsartan-hydrochlorothiazide ........................................ 15 VALTREX ........................... 9

see valacyclovir hcl ......... 9 VANCOCIN HCL ................. 7

see vancomycin hcl ......... 7 vancomycin hcl ................... 7 VANDAZOLE .................... 42 VANOS ............................. 53 VAQTA .............................. 44 VARIVAX .......................... 44 VASCEPA ......................... 17 VASERETIC ..................... 14

see enalapril maleate & hydrochlorothiazide ....... 14

VASOTEC ......................... 15 see enalapril maleate .... 15

VECTIBIX ......................... 13 VECTICAL ........................ 51 VELCADE ......................... 13 velivet 28 day .................... 35 VELTIN ............................. 51 venlafaxine cap er ............. 24 VENLAFAXINE HCL ER

see venlafaxine tab er ... 24 VENLAFAXINE HCL ER TAB (VERT) ...................... 24 venlafaxine tab .................. 24 venlafaxine tab er ............. 24 VENTAVIS ........................ 20 VENTOLIN HFA ................ 49 VERAMYST ...................... 50 verapamil hcl ..................... 18

VERAPAMIL HCL ............. 18 VERDESO ........................ 53 VERELAN ......................... 18

see verapamil hcl .......... 18 VERELAN PM .................. 18

see verapamil hcl .......... 18 veripred ............................. 36 VESICARE ....................... 41 vestura .............................. 35 VEXOL .............................. 47 VFEND ............................... 7

see voriconazole ............. 7 VFEND IV ........................... 7

see voriconazole inj 200mg ............................. 7

VFEND SUS 40MG/ML ...... 7 VIBATIV .............................. 7 VIBRAMYCIN ................... 12

see doxycycline (monohydrate) ............... 11 see doxycycline hyclate 11

vicodin ................................ 3 vicodin es ............................ 3 vicodin hp ........................... 3 VICOPROFEN .................... 4

see hydrocodone-ibuprofen 7.5-200mg ....................... 3

VICTOZA .......................... 31 VICTRELIS ......................... 9 VIDAZA ............................. 12 VIDEX EC ........................... 8

see didanosine ................ 8 VIDEX PEDIATRIC ............. 8 VIGAMOX ......................... 47 VIIBRYD ........................... 24 VIMOVO ............................. 1 VIMPAT ............................ 22 vinblastine sulfate ............. 13 vincasar ............................ 13 vincristine sulfate .............. 13 vinorelbine tartrate ............ 13 VIOKACE 10440 UNIT ..... 40 VIOKACE 20880 UNIT ..... 40 viorele ............................... 35 VIRACEPT .......................... 8 VIRAMUNE ......................... 8

see nevirapine ................. 8 VIRAMUNE XR ................... 8 VIREAD .............................. 8

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VIROPTIC ......................... 47 see trifluridine ................ 47

VISICOL ............................ 40 VISTARIL .......................... 49

see hydroxyzine pamoate ...................................... 49

VISTIDE ..............................9 see cidofovir ....................9

vivactil ............................... 24 VIVACTIL

see protriptyline hcl ....... 23 VIVELLE-DOT ................... 36 VIVITROL.......................... 30 VOLTAREN GEL 1% ........ 54 VOLTAREN-XR ..................1

see diclofenac sodium .....1 voriconazole ........................7 voriconazole inj 200mg .......7 VOSOL HC

see acetasol hc ............. 54 see acetic acid sol/hc .... 54

vospire .............................. 49 VOSPIRE ER

see albuterol sulfate er .. 49 VOTRIENT ........................ 14 VPRIV ............................... 36 VYTORIN .......................... 17 VYVANSE ......................... 27 W warfarin sodium ................. 42 WELCHOL ........................ 17 WELLBUTRIN ................... 24

see bupropion hcl .......... 23 WELLBUTRIN SR ............. 24

see budeprion ................ 23 see bupropion hcl .......... 23

WELLBUTRIN XL ............. 24 see bupropion hcl .......... 23

WESTCORT ..................... 53 see hydrocortisone valerate.......................... 53

X XALATAN.......................... 48

see latanoprost .............. 48 XALKORI .......................... 14 XANAX .............................. 20

see alprazolam .............. 20 XARELTO ......................... 42 XELJANZ .......................... 43 XENAZINE ........................ 29

XEOMIN ............................ 48 XERESE ........................... 52 XGEVA ............................. 37 XIFAXAN TAB 200MG ........ 7 XIFAXAN TAB 550MG ...... 40 XODOL

see hydrocodone-acetaminophen 10-300mg ................... 2 see hydrocodone-acetaminophen 5-300mg ..................... 2 see hydrocodone-acetaminophen 7.5-300mg .................. 2 see vicodin ...................... 3 see vicodin es ................. 3 see vicodin hp ................. 3

xodol 10/300 ....................... 4 xodol 5/300 ......................... 4 xodol 7.5/300 ...................... 4 XOLAIR ............................. 49 XOPENEX ........................ 49 XOPENEX CONCENTRATE .......................................... 49

see levalbuterol conc 1.25mg/0.5ml ................ 49

XOPENEX HFA ................ 49 XTANDI ............................. 13 XYLOCAINE ................. 6, 53

see lidocaine hcl ............ 53 see lidocaine hcl (local anesth.) ........................... 6 see lidocaine inj 1%......... 6 see lidocaine inj 2%......... 6

XYLOCAINE INJ 1% ........... 6 XYLOCAINE-MPF .............. 6

see lidocaine hcl (local anesth.) ........................... 5 see lidocaine inj 0.5% ...... 6 see lidocaine inj 1%......... 6 see lidocaine inj 1.5% ...... 6 see lidocaine inj 2%......... 6

XYREM ............................. 29 XYZAL .............................. 49

see levocetirizine soln 2.5mg/5ml ..................... 49 see levocetirizine tab 5 mg ...................................... 49

Y YASMIN 28 ....................... 35

see drospirenone-ethinyl estradiol ........................ 34 see syeda ...................... 35 see zarah ...................... 35

YAZ ................................... 35 see loryna 28 day .......... 34 see vestura ................... 35

YF-VAX ............................. 44 Z zafirlukast ......................... 49 zaleplon ............................ 27 zamicet ............................... 4 ZANAFLEX ....................... 29

see tizanidine ................ 29 ZANOSAR ........................ 12 ZANTAC ........................... 39

see ranitidine hcl ........... 39 zarah ................................. 35 zarontin ............................. 22 ZARONTIN ....................... 22

see ethosuximide .......... 21 ZAROXOLYN ................... 19

see metolazone ............. 19 ZAVESCA ......................... 36 zazole ............................... 42 ZAZOLE ............................ 42 ZEBETA ............................ 17

see bisoprolol fumarate . 17 ZEGERID .......................... 41 ZELAPAR ......................... 24 ZELBORAF ....................... 14 ZEMAIRA .......................... 49 ZEMPLAR ......................... 46 zenatane ........................... 51 zenchent fe 28 day ........... 35 zenchent tab ..................... 35 ZENPEP ........................... 40 ZERIT ................................. 8

see stavudine .................. 8 ZESTORETIC ................... 14

see lisinopril & hydrochlorothiazide ....... 14

ZESTRIL ........................... 15 see lisinopril .................. 15

ZETIA ............................... 17 ZETONNA ........................ 50 ZIAC ................................. 17

see bisoprolol &

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hydrochlorothiazide ....... 17 ZIAGEN...............................8

see abacavir sulfate ........8 ZIANA ............................... 51 zidovudine ...........................8 ZINACEF........................... 10

see cefuroxime sodium.. 10 ZINECARD ........................ 14

see dexrazoxane ........... 14 ZIOPTAN .......................... 48 ziprasidone hcl .................. 25 ZIPSOR...............................1 ZIRGAN ............................ 47 ZITHROMAX ..................... 10

see azithromycin ........... 10 ZITHROMAX TRI-PAK ...... 10 ZITHROMAX Z-PAK ......... 10 ZMAX ................................ 10 ZOCOR ............................. 16

see simvastatin .............. 16 ZOFRAN ........................... 39

see ondansetron hcl ...... 38 see ondansetron hcl inj.. 38 see ondansetron hcl oral

soln ................................ 38 ZOFRAN ODT .................. 39

see ondansetron odt...... 38 zoledronic inj 4mg/5ml ...... 33 ZOLINZA ........................... 13 zolmitriptan ....................... 28 zolmitriptan odt ................. 28 ZOLOFT ............................ 24

see sertraline hcl ........... 23 zolpidem tartrate ............... 27 ZOLPIMIST ....................... 27 ZOMETA ........................... 33

see zoledronic inj 4mg/5ml ...................................... 33

ZOMIG .............................. 28 see zolmitriptan ............. 28

ZOMIG ZMT ...................... 28 see zolmitriptan odt ....... 28

ZONALON ........................ 51 ZONEGRAN ..................... 22

see zonisamide ............. 22 zonisamide ........................ 22 ZORBTIVE ........................ 37 ZORTRESS ...................... 44

ZOSTAVAX ...................... 44 ZOSYN ............................. 11

see piperacillin sodium-tazobactam sodium .......................... 11

zovia 1/35e 28 day............ 35 zovia 1/50e 28 day............ 35 ZOVIRAX ...................... 9, 52

see acyclovir ................... 9 see acyclovir topical ...... 52

ZYBAN .............................. 30 see buproban ................ 30

ZYCLARA ......................... 54 ZYFLO CR ........................ 49 ZYLET .............................. 46 ZYLOPRIM ......................... 1

see allopurinol tab ........... 1 ZYMAXID .......................... 47 ZYPREXA ......................... 25

see olanzapine .............. 25 ZYPREXA ZYDIS ............. 25

see olanzapine odt ........ 25 ZYTIGA ............................. 13 ZYVOX ............................... 7

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This formulary was updated on 08/27/2013. For more recent information or other questions, please contactSilverScript (Employer PDP), at 1-877-878-5715 or, for TTY users, 1-866-236-1069, 24 hours a day, 7 daysa week.

This information is available for free in other languages. Please call our Customer Care number at1-877-878-5715 (TTY: 1-866-236-1069), 24 hours a day, 7 days a week.

Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro Servicio al Miembro,al 1-877-878-5715 (teléfono de texto (TTY): 1-866-236-1069), las 24 horas del día, los 7 días de lasemana.

SilverScript (Employer PDP) is a Prescription Drug Plan. This plan is offered by SilverScript InsuranceCompany, which has a Medicare contract. Enrollment depends on contract renewal.

P.O. Box 52424, Phoenix, AZ 85072-2424

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