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Formulary - Sanford Health Plan

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1 Formulary for Simplicity & TRUE Members The following is a list of the most commonly prescribed medications covered under your pharmacy benefit. It represents an abbreviated version of the medication formulary for your pharmacy benefit coverage. Allowing substitution of generic products is encouraged when appropriate. The lowest co-payment is applied to all covered generic drugs (tier 1). Generic drugs are listed in lower case and italicized. Tier 2 co-payment will apply to all preferred brand name drugs listed on this formulary. Tier 3 co-payment will apply to all non-preferred brand name drugs listed on this formulary. Brand name drugs are listed in CAPITAL letters. Tier 4 will apply to all specialty medications (drugs in this tier may also be subject to network requirements). Tier 5 represents drugs covered at $0 member cost share if member meets certain criteria (such as age or gender) as defined by the Affordable Care Act. Consult your Summary of Benefits and Coverage (SBC) document for details on your co-payments or cost-share for these various tiers. Important: This is NOT a complete listing of covered drugs. For a complete list of medications, access your secure member account at sanfordhealthplan.com/member login and link to the Express Scripts website. If you have questions regarding coverage contact our Pharmacy Management Team at (855) 305-5062; TTY/TDD (877) 652-1844. HP-0370 8/18
Transcript

1

Formulary for Simplicity & TRUE Members

The following is a list of the most commonly prescribed medications covered under your pharmacy benefit. It represents an abbreviated version of the medication formulary for your pharmacy benefit coverage. Allowing substitution of generic products is encouraged when appropriate.

The lowest co-payment is applied to all covered generic drugs (tier 1). Generic drugs are listed in lower case and italicized. Tier 2 co-payment will apply to all preferred brand name drugs listed on this formulary. Tier 3 co-payment will apply to all non-preferred brand name drugs listed on this formulary. Brand name drugs are listed in CAPITAL letters. Tier 4 will apply to all specialty medications (drugs in this tier may also be subject to network requirements). Tier 5 represents drugs covered at $0 member cost share if member meets certain criteria (such as age or gender) as defined by the Affordable Care Act. Consult your Summary of Benefits and Coverage (SBC) document for details on your co-payments or cost-share for these various tiers.

Important: This is NOT a complete listing of covered drugs. For a complete list of medications, access your secure member account at sanfordhealthplan.com/member login and link to the Express Scripts website. If you have questions regarding coverage contact our Pharmacy Management Team at (855) 305-5062; TTY/TDD (877) 652-1844.

HP-0370 8/18

HP-0370 Formulary Simplicity TRUE (HIX) 08-18

Formulary

for Simplicity & TRUE Members

Table of Contents

LIST OF ABBREVIATIONS ....................................................................................................................3 ANTI-INFECTIVES................................................................................................................................5 ANTINEOPLASTIC/ IMMUNOSUPPRESSANT DRUGS ..........................................................................8 AUTONOMIC/ CNS DRUGS, NEUROLOGY/ PSYCHOLOGY ............................................................9 CARDIOVASCULAR / HYPERTENSION / LIPIDS ...............................................................................17 DERMATOLOGICALS / TOPICAL THERAPY .....................................................................................22 DIAGNOSTICS / MISCELLANEOUS AGENTS ...................................................................................27 EAR, NOSE, THROAT MEDICATIONS ...............................................................................................28 ENDOCRINE / DIABETES ..................................................................................................................28 GASTROENTEROLOGY .....................................................................................................................33 IMMUNOLOGY & BIOTECHNOLOGY ..............................................................................................36 MUSCULOSKELETAL / RHEUMATOLOGY .........................................................................................37 OBSTETRICS / GYNECOLOGY .........................................................................................................38 OPHTHALMOLOGY ..........................................................................................................................42 RESPIRATORY & ALLERGY ................................................................................................................44 UROLOGICALS .................................................................................................................................46 VITAMINS / HEMATINICS / ELECTROLYTES .....................................................................................47 INDEX ...............................................................................................................................................49

3

List of Abbreviations Tier 1: Generic Copay Tier 2: Preferred Brand Name Copay Tier 3: Non-preferred Brand Name Copay Tier 4: Specialty Medication Tier 5: Affordable Care Act ACA: Affordable Care Act – As part of the Affordable Care Act, certain drugs are

available at a $0 copay (no member cost-share) if the member meets specific conditions (such as age or gender). If the member does not meet the specific conditions, the usual copay and member cost-share will apply.

FE: Formulary Exception - this medication will only be available to the member if they

meet Sanford Health Plan criteria for a formulary override. LA: Limited Availability – May only be available at certain pharmacies. For more

information, please contact Sanford Health Plan. PA: Pre-Approval Needed – You or your attending healthcare professional must get

pre-approval for the medicine with Sanford Health Plan before you can get the prescription filled.

QL: Quantity Limit/Number Allowed – The Plan may limit the amount of medicine you

can receive of certain covered medications. SP: Specialty Medications – Specialty medications are typically used to treat

complex medical conditions. These medications may require frequent dosing adjustments, close monitoring, special training, or compliance assistance. In addition, specialty medications may need special handling and/or administration, and may have limited or exclusive product availability and distribution.

ST: Step-Therapy – With certain medications, you must first try lower cost and/or

generic versions before high cost options are covered. If the first step medication does not work or you have side effects, the next step may be covered.

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

5

Formulary for Simplicity and TRUE Members

Drug Name Tier Requirements/ Limitations

ANTI-INFECTIVES Antifungal Agents ANCOBON 3 clotrimazole 1 CRESEMBA 3 DIFLUCAN 3 fluconazole 1 flucytosine 1 griseofulvin microsize 1 griseofulvin ultramicrosize 1 itraconazole 1 QL ketoconazole 1 NOXAFIL 3 PA; FE nystatin 1 ONMEL 3 PA; FE ORAVIG 3 PA; FE SPORANOX 3 PA; FE; QL SPORANOX PULSEPAK 3 QL terbinafine hcl 1 VFEND 3 voriconazole 1 Antivirals abacavir 1 abacavir-lamivudine 1 abacavir-lamivudine-zidovudine 1

acyclovir 1 adefovir 1 amantadine hcl 1 APTIVUS 3 atazanavir 1 ATRIPLA 3 BARACLUDE ORAL SOLUTION 3 PA; FE

BARACLUDE ORAL TABLET 3 BIKTARVY 2 CIMDUO 2 COMBIVIR 3 COMPLERA 3

Drug Name Tier Requirements/ Limitations

CRIXIVAN 3 DAKLINZA 4 PA; FE DESCOVY 3 didanosine 1 EDURANT 3 efavirenz 1 EMTRIVA 3 entecavir 1 EPCLUSA 4 PA EPIVIR HBV ORAL SOLN 2 EPIVIR HBV TABLET 3 EPIVIR SOLUTION 3 EPIVIR TABLET 150 MG 3 QL EPIVIR TABLET 300 MG 3 EPZICOM 3 EVOTAZ 3 famciclovir 1 QL FLUMADINE 3 fosamprenavir 1 GENVOYA 3 HARVONI 4 PA HEPSERA 3 INTELENCE 3 INVIRASE 3 ISENTRESS 3 ISENTRESS HD 3 JULUCA 3 KALETRA 3 lamivudine oral solution 1 lamivudine tablet 100 mg, 300 mg 1

lamivudine tablet 150 mg 1 QL lamivudine-zidovudine 1 LEXIVA 3 lopinavir-ritonavir 1 MAVYRET 4 PA; QL nevirapine 1 NORVIR 3 ODEFSEY 3 oseltamivir 1 QL PREVYMIS 3 QL PREZCOBIX 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

6

Drug Name Tier Requirements/ Limitations

PREZISTA 3 RELENZA DISKHALER 2 QL RESCRIPTOR 3 RETROVIR 3 REYATAZ 3 ribavirin 1 rimantadine 1 ritonavir 1 SELZENTRY 3 SOVALDI 4 PA stavudine 1 STRIBILD 3 SUSTIVA 3 SYMFI 2 SYMFI LO 2 TAMIFLU 3 QL TECHNIVIE 4 PA tenofovir disoproxil fumarate 1

TIVICAY 3 TRIUMEQ 3 TRIZIVIR 3 TRUVADA 3 TYBOST 3 valacyclovir 1 VALCYTE 3 valganciclovir 1 VALTREX 3 VEMLIDY 3 PA; FE VIDEX 2 GRAM PEDIATRIC 3 VIDEX EC 3 VIEKIRA PAK 4 PA; FE VIEKIRA XR 4 PA; FE VIRACEPT 3 VIRAMUNE 3 VIRAMUNE XR 3 VIRAZOLE 3 PA; FE VIREAD 3 VOSEVI 4 PA; QL ZEPATIER 4 PA; FE ZERIT 3 ZIAGEN 3

Drug Name Tier Requirements/ Limitations

zidovudine 1 ZOVIRAX 3 Cephalosporins cefaclor 1 cefadroxil 1 cefdinir 1 cefditoren pivoxil 1 cefixime 1 cefpodoxime 1 cefprozil 1 cefuroxime axetil 1 cephalexin 1 DAXBIA 3 PA; FE KEFLEX 3 SPECTRACEF 3 SUPRAX 3 Erythromycins & Other Macrolides azithromycin 1 clarithromycin 1 DIFICID 3 e.e.s. 400 1 E.E.S. GRANULES 3 ERYPED 200 2 ERYPED 400 2 ery-tab oral tablet, delayed release (dr/ec) 250 mg, 333 mg

1

ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 500 MG

2

erythrocin (as stearate) 1 erythromycin 1 erythromycin ethylsuccinate 1

ZITHROMAX 3 ZITHROMAX TRI-PAK 3 ZITHROMAX Z-PAK 3 Miscellaneous Antiinfectives ALBENZA 2 ALINIA 2 atovaquone 1 atovaquone-proguanil 1 BENZNIDAZOLE 3 QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

7

Drug Name Tier Requirements/ Limitations

BETHKIS 4 QL BILTRICIDE 2 CAYSTON 4 LA chloroquine phosphate 1 CLEOCIN HCL 3 CLEOCIN PEDIATRIC 3 clindamycin hcl 1 clindamycin palmitate hcl 1

clindamycin pediatric 1 COARTEM 2 CYCLOSERINE 2 dapsone 1 DARAPRIM 4 PA EMVERM 3 ethambutol 1 FLAGYL 3 hydroxychloroquine 1 IMPAVIDO 3 isoniazid 1 ivermectin 1 KITABIS PAK 4 QL linezolid 1 PA MALARONE 3 MALARONE PEDIATRIC 3 mefloquine 1 MEPRON 3 metronidazole 1 MYAMBUTOL 3 MYCOBUTIN 3 QL NEBUPENT 2 neomycin 1 paromomycin 1 PASER 2 PLAQUENIL 3 praziquantel 1 PRIFTIN 2 PRIMAQUINE 2 pyrazinamide 1 QUALAQUIN 3 quinine sulfate 1 rifabutin 1 QL

Drug Name Tier Requirements/ Limitations

RIFADIN 3 RIFAMATE 3 PA; FE rifampin 1 RIFATER 2 SIRTURO 3 PA; FE; LA SIVEXTRO 2 PA SOLOSEC 3 PA; FE; QL STROMECTOL 3 TINDAMAX 3 tinidazole 1 TOBI 4 QL TOBI PODHALER 4 QL tobramycin in 0.225 % nacl 4 QL

TOBRAMYCIN WITH NEBULIZER 4 QL

TRECATOR 2 XIFAXAN 3 ZYVOX 3 PA Penicillins amoxicillin 1 amoxicillin-pot clavulanate 1

ampicillin 1 AUGMENTIN ES-600 3 PA; FE AUGMENTIN SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML

2

AUGMENTIN SUSPENSION FOR RECONSTITUTION 250-62.5 MG/5 ML

3

AUGMENTIN ORAL TABLET 3 PA; FE AUGMENTIN XR 3 dicloxacillin 1 MOXATAG 3 PA; FE penicillin v potassium 1 Quinolones AVELOX 3 BAXDELA 3 PA CIPRO 3 CIPRO XR 3 ciprofloxacin 1 ciprofloxacin (mixture) 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

8

Drug Name Tier Requirements/ Limitations

ciprofloxacin hcl 1 FACTIVE 3 LEVAQUIN 3 levofloxacin 1 moxifloxacin 1 ofloxacin 1 Sulfa's & Related Agents BACTRIM 3 BACTRIM DS 3 sulfadiazine 1 sulfamethoxazole-trimethoprim 1

sulfatrim 1 Tetracyclines ACTICLATE 3 avidoxy 1 AVIDOXY DK 3 PA; FE coremino 1 demeclocycline 1 DORYX 3 DORYX MPC 3 PA; FE doxycycline hyclate 1 doxycycline mono- hydrate oral capsule 1

DOXYCYCLINE MONO-HYDRATE ORAL CAPSULE, IR - DELAY REL, BIPHASE

3 PA; FE

doxycycline mono-hydrate oral suspension for reconstitution

1

doxycycline monohydrate oral tablet 1

MINOCIN 3 minocycline oral capsule 1 minocycline oral tablet 1 minocycline oral tablet extended release 24 hr 1 PA; FE

mondoxyne nl 1 MONODOX 3 morgidox 1 MORGIDOX 1X 50 3 PA; FE MORGIDOX 2X100 3 PA; FE okebo 1

Drug Name Tier Requirements/ Limitations

ORACEA 3 PA; FE SOLODYN 3 PA; FE soloxide 1 TARGADOX 3 PA; FE tetracycline 1 VIBRAMYCIN 3 XIMINO 3 PA; FE Urinary Tract Agents FURADANTIN 3 HIPREX 3 MACROBID 3 MACRODANTIN 3 methenamine hippurate 1 methenamine mandelate 1

MONUROL 2 nitrofurantoin 1 nitrofurantoin macrocrystal 1

nitrofurantoin monohyd/m-cryst 1

PRIMSOL 2 trimethoprim 1 TRIMPEX 3 PA; FE Vancomycin FIRVANQ 2 VANCOCIN 3 vancomycin 1

Drug Name Tier Requirements/ Limitations

ANTINEOPLASTIC/ IMMUNOSUPPRESSANT DRUGS

Adjunctive Agents leucovorin calcium 1 MESNEX 2 VISTOGARD 4 Antineoplastic & Immunosuppressant Drugs

anastrozole 1 ARIMIDEX 3 AROMASIN 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

9

Drug Name Tier Requirements/ Limitations

ASTAGRAF XL 3 PA; FE AZASAN 3 PA; FE azathioprine 1 bicalutamide 1 CASODEX 3 CELLCEPT 3 cyclosporine 1 cyclosporine modified 1 DROXIA 2 EMCYT 2 ENVARSUS XR 3 PA; FE exemestane 1 FARESTON 2 FEMARA 3 flutamide 1 gengraf 1 HYDREA 3 hydroxyurea 1 IMURAN 3 letrozole 1 MEGACE ES 3 megestrol 1 mercaptopurine 1 methotrexate sodium 1 methotrexate sodium (pf) 1 mycophenolate mofetil 1 mycophenolate sodium 1 MYFORTIC 3 NEORAL 3 NILANDRON 3 nilutamide 1 octreotide acetate 4 PROGRAF 3 PURIXAN 4 RAPAMUNE ORAL SOLUTION 2

RAPAMUNE ORAL TABLET 3 SANDIMMUNE ORAL CAPSULE 3

SANDIMMUNE ORAL SOLUTION 2

SANDOSTATIN 4 SIGNIFOR 4

Drug Name Tier Requirements/ Limitations

sirolimus 1 SOLTAMOX 5 ACA tacrolimus 1 tamoxifen 5 ACA TREXALL 2 XATMEP 3 PA; FE XERMELO 4 PA; QL ZORTRESS 2

Drug Name Tier Requirements/ Limitations

AUTONOMIC/ CNS DRUGS, NEUROLOGY/ PSYCHOLOGY

Anticonvulsants APTIOM 3 PA; FE BANZEL 3 BRIVIACT 3 PA; FE carbamazepine 1 CARBATROL 3 CELONTIN 2 clonazepam 1 DEPAKENE 3 DEPAKOTE 3 DEPAKOTE ER 3 DEPAKOTE SPRINKLES 3 DIASTAT 3 PA; FE DIASTAT ACUDIAL 3 diazepam 1 DILANTIN 3 PA; FE DILANTIN EXTENDED 3 DILANTIN INFATABS 3 DILANTIN-125 3 divalproex 1 epitol 1 EQUETRO 3 PA; FE ethosuximide 1 felbamate 1 FELBATOL 3 FYCOMPA 3 PA; FE gabapentin 1 GABITRIL 3 GRALISE 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

10

Drug Name Tier Requirements/ Limitations

GRALISE 30-DAY STARTER PACK 3

KEPPRA 3 KEPPRA XR 3 KLONOPIN 3 LAMICTAL 3 LAMICTAL ODT 3 LAMICTAL ODT STARTER (BLUE) 3

LAMICTAL ODT STARTER (GREEN) 3

LAMICTAL ODT STARTER (ORANGE) 3

LAMICTAL STARTER (BLUE) KIT 3

LAMICTAL STARTER (GREEN) KIT 3

LAMICTAL STARTER (ORANGE) KIT 3

LAMICTAL XR 3 LAMICTAL XR STARTER (BLUE) 3 PA; FE

LAMICTAL XR STARTER (GREEN) 3 PA; FE

LAMICTAL XR STARTER (ORANGE) 3 PA; FE

lamotrigine 1 levetiracetam 1 LYRICA 2 ST; QL LYRICA CR 3 PA;ST;FE;QL MYSOLINE 3 NEURONTIN 3 ONFI 3 oxcarbazepine 1 OXTELLAR XR 3 PA; FE PEGANONE 2 phenobarbital 1 PHENYTEK 3 phenytoin 1 phenytoin sodium extended 1

primidone 1 QUDEXY XR 3 PA; FE

Drug Name Tier Requirements/ Limitations

roweepra 1 roweepra xr 1 SABRIL 4 LA subvenite 1 subvenite starter (blue) kit 1 subvenite starter (green) kit 1

subvenite starter (orange) kit 1

TEGRETOL 3 TEGRETOL XR 3 tiagabine 1 TOPAMAX 3 topiramate oral capsule, sprinkle 1

TOPIRAMATE CAPSULE, SPRINKLE, ER 24HR 3 PA; FE

topiramate oral tablet 1 TRILEPTAL 3 TROKENDI XR 3 valproic acid 1 valproic acid (as sodium salt) 1

vigabatrin 4 LA VIMPAT 2 ZARONTIN 3 ZONEGRAN 3 zonisamide 1 Antiparkinsonism Agents APOKYN 4 LA AZILECT 3 benztropine 1 bromocriptine 1 carbidopa 1 carbidopa-levodopa 1 carbidopa-levodopa-entacapone 1

COMTAN 3 DUOPA 4 PA; FE entacapone 1 GOCOVRI 4 PA; FE LODOSYN 3 MIRAPEX 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

11

Drug Name Tier Requirements/ Limitations

MIRAPEX ER 3 NEUPRO 3 PARLODEL 3 pramipexole 1 rasagiline 1 REQUIP 3 REQUIP XL 3 ropinirole 1 RYTARY 3 PA; FE selegiline hcl 1 SINEMET 3 SINEMET CR 3 STALEVO 100 3 STALEVO 125 3 STALEVO 150 3 STALEVO 200 3 STALEVO 50 3 STALEVO 75 3 TASMAR 3 tolcapone 1 trihexyphenidyl 1 XADAGO 3 PA; FE; QL ZELAPAR 3 PA; FE Migraine & Cluster Headache Therapy almotriptan malate 1 QL AMERGE 3 QL CAFERGOT 3 D.H.E.45 3 QL dihydroergotamine 1 QL eletriptan 1 QL ERGOMAR 2 ergotamine-caffeine 1 frovatriptan 1 QL IMITREX NASAL 3 QL IMITREX ORAL 3 QL IMITREX STATDOSE KIT REFILL 3 QL

IMITREX STATDOSE PEN 3 QL IMITREX SUBCUTANEOUS 3 isomethepten-caf-acetaminophen 1

MAXALT 3 QL MAXALT-MLT 3 QL

Drug Name Tier Requirements/ Limitations

migergot 1 MIGRANAL 3 QL naratriptan 1 QL ONZETRA XSAIL 3 PA; FE PRODRIN 3 RELPAX 3 QL rizatriptan 1 QL sumatriptan 1 QL sumatriptan succinate oral 1 QL

sumatriptan succinate subcutaneous cartridge 1 QL

sumatriptan succinate subcutaneous pen injector

1 QL

sumatriptan succinate subcutaneous solution 1

sumatriptan-naproxen 1 PA; FE SUMAVEL DOSEPRO 3 PA; FE; QL TREXIMET 3 PA; FE ZEMBRACE SYMTOUCH 3 PA; FE; QL zolmitriptan 1 QL ZOMIG NASAL 3 PA; FE; QL ZOMIG ORAL 3 QL ZOMIG ZMT 3 QL Miscellaneous Neurological Therapy AMPYRA 4 PA; LA; QL ARICEPT 3 AUSTEDO 4 PA;FE;LA;QL donepezil 1 EXELON 3 galantamine 1 HORIZANT 3 INGREZZA 4 PA;FE;LA;QL KEVEYIS 4 memantine oral capsule, sprinkle, er 24hr 1

memantine oral solution 1 memantine oral tablet 1 MEMANTINE ORAL TABLETS, DOSE PACK 3 PA; FE

NAMENDA 3 NAMENDA TITRATION PAK 3 PA; FE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

12

Drug Name Tier Requirements/ Limitations

NAMENDA XR 3 NAMZARIC 3 PA; FE NUEDEXTA 3 QL RAZADYNE 3 RAZADYNE ER 3 rivastigmine 1 rivastigmine tartrate 1 tetrabenazine 4 PA XENAZINE 4 PA; LA Muscle Relaxants & Antispasmodic Therapy

AMRIX 3 PA; FE baclofen 1 carisoprodol 1 carisoprodol-asa-codeine 1 PA; QL carisoprodol-aspirin 1 chlorzoxazone 1 cyclobenzaprine 1 DANTRIUM 3 dantrolene 1 FEXMID 3 LORZONE 3 PA; FE meprobamate 1 MESTINON ORAL SYRUP 2 MESTINON ORAL TABLET 3 MESTINON TIMESPAN 3 metaxall 1 metaxalone 1 methocarbamol 1 orphenadrine citrate 1 pyridostigmine bromide 1 ROBAXIN 3 ROBAXIN-750 3 SKELAXIN 3 SOMA 3 tizanidine 1 ZANAFLEX 3 Narcotic Analgesics ABSTRAL 3 PA; QL acetaminophen-caff-dihydrocod oral capsule 1 PA; QL

Drug Name Tier Requirements/ Limitations

ACETAMINOPHEN-CAFF-DIHYDROCOD ORAL TABLET

3 PA; FE; QL

acetaminophen-codeine 1 PA; QL ACTIQ 3 PA; QL ALLZITAL 3 PA; FE ARYMO ER 3 PA; FE; QL ascomp with codeine 1 PA; QL BELBUCA 3 PA; FE; QL BUPAP 3 BUPRENORPHINE 3 PA; QL buprenorphine hcl 1 QL butalbital compound w/codeine 1 PA; QL

butalbital-acetaminop-caf-cod 1 PA; QL

butalbital-acetaminophen 1

butalbital-acetaminophen-caff 1

butalbital-aspirin-caffeine 1 BUTRANS 3 PA; QL capacet 1 codeine sulfate 1 PA; QL DEMEROL 3 PA; QL DILAUDID 3 PA; QL diskets 1 PA; QL DOLOPHINE 3 PA; QL DURAGESIC 3 PA; QL EMBEDA 3 PA; FE; QL endocet 1 PA; QL ESGIC 3 EXALGO ER 3 PA; QL fentanyl 1 PA; QL fentanyl citrate 1 PA; QL FENTORA 3 PA; QL FIORICET 3 FIORINAL 3 FIORINAL-CODEINE #3 3 PA; QL hydrocodone-acetaminophen 1 PA; QL

hydrocodone-ibuprofen 1 PA; QL hydromorphone 1 PA; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

13

Drug Name Tier Requirements/ Limitations

HYSINGLA ER 3 PA; FE; QL IBUDONE ORAL TABLET 10-200 MG 3 PA; QL

IBUDONE ORAL TABLET 5-200 MG 3 PA; FE; QL

ibuprofen-oxycodone 1 PA; QL KADIAN ORAL CAPSULE, EXT-REL PELLETS 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG

3 PA; QL

KADIAN ORAL CAPSULE, EXT-REL PELLETS 200 MG, 40 MG

3 PA; FE; QL

LAZANDA 3 PA; FE; QL levorphanol tartrate 1 PA; QL lorcet (hydrocodone) 1 PA; QL lorcet hd 1 PA; QL lorcet plus 1 PA; QL LORTAB ELIXIR 3 PA; FE; QL meperidine 1 PA; QL methadone 1 PA; QL methadose 1 PA; QL MORPHABOND ER 3 PA; FE; QL morphine 1 PA; QL morphine concentrate 1 PA; QL MS CONTIN 3 PA; QL NORCO 3 PA; QL OPANA 3 PA; QL OXAYDO 3 PA; FE; QL oxycodone oral capsule 1 PA; QL oxycodone oral concentrate 1 PA; QL

oxycodone oral solution 1 PA; QL oxycodone oral tablet 1 PA; QL OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

3 PA; FE; QL

oxycodone-acetaminophen 1 PA; QL

oxycodone-aspirin 1 PA; QL OXYCONTIN 2 PA; QL oxymorphone 1 PA; QL

Drug Name Tier Requirements/ Limitations

panlor (acetam-caff-dihydrocod) 1 PA; QL

PERCOCET 3 PA; QL phrenilin forte(with caffeine) 1

PRIMLEV 3 PA; FE; QL ROXICODONE 3 PA; QL SUBSYS 3 PA; FE; QL tencon 1 TREZIX 2 PA; QL TYLENOL-CODEINE #3 3 PA; QL TYLENOL-CODEINE #4 3 PA; QL VANATOL LQ 3 VANATOL S 3 verdrocet 1 PA; QL vicodin 1 PA; QL vicodin es 1 PA; QL vicodin hp 1 PA; QL XTAMPZA ER 3 PA; FE; QL xylon 10 1 PA; QL zebutal 1 ZOHYDRO ER 3 PA; FE; QL Non-Narcotic Analgesics adult aspirin regimen 5 ACA ANAPROX DS 3 ARTHROTEC 50 3 ARTHROTEC 75 3 aspir-81 5 ACA aspirin 5 ACA aspirin low dose 5 ACA aspir-low 5 ACA aspir-trin 5 ACA bayer aspirin 5 ACA BUNAVAIL 3 PA; FE; QL buprenorphine-naloxone 1 QL butorphanol tartrate 1 PA; QL CAMBIA 3 PA; FE CELEBREX 3 celecoxib 1 children's aspirin 5 ACA choline, magnesium salicylate 1

CONZIP 3 PA; FE; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

14

Drug Name Tier Requirements/ Limitations

DAYPRO 3 diclofenac potassium 1 diclofenac sodium oral 1 diclofenac sodium topical drops 1

diclofenac sodium topical gel 1 QL

diclofenac-misoprostol 1 diflunisal 1 DISALCID 3 DUEXIS 3 PA; FE e.c. prin 5 ACA EC-NAPROSYN 3 ecotrin 5 ACA ecotrin low strength 5 ACA etodolac 1 EVZIO 3 PA; FE FELDENE 3 FENOPROFEN ORAL CAPSULE 3 PA; FE

fenoprofen oral tablet 1 FENORTHO 3 PA; FE FLECTOR 3 QL flurbiprofen 1 ibu 1 ibuprofen 1 INDOCIN 3 PA; FE indomethacin 1 ketoprofen 1 ketorolac injection 1 ketorolac intramuscular 1 ketorolac oral 1 QL lite coat aspirin 5 ACA LODINE 3 meclofenamate 1 mefenamic acid 1 meloxicam 1 MOBIC 3 nabumetone 1 NALFON 3 PA; FE naltrexone 1 NAPRELAN CR 3 NAPROSYN 3

Drug Name Tier Requirements/ Limitations

naproxen 1 naproxen sodium 1 NARCAN 2 QL NUCYNTA 3 PA; QL NUCYNTA ER 3 PA; QL oxaprozin 1 PENNSAID 3 PA; FE; QL pentazocine-naloxone 1 PA; QL piroxicam 1 profeno 1 salsalate 1 SPRIX 4 SUBOXONE 2 QL sulindac 1 TIVORBEX 3 PA; FE tolmetin 1 TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 17-83

3 PA; FE; QL

TRAMADOL CAPSULE, ER BIPHASE 24 HR 25-75 3 PA; FE; QL

tramadol oral tablet 1 PA; QL tramadol oral tablet extended release 24 hr 1 PA; QL

tramadol oral tablet, er multiphase 24 hr 1 PA; QL

tramadol-acetaminophen 1 PA; QL

ULTRACET 3 PA; QL ULTRAM 3 PA; QL VIMOVO 3 PA; FE VIVLODEX 3 PA; FE VOLTAREN 3 QL VOLTAREN-XR 3 PA; FE ZIPSOR 3 PA; FE ZORVOLEX 3 ZUBSOLV 3 PA; FE; QL Psychotherapeutic Drugs ABILIFY 3 QL ADASUVE 3 PA; FE ADDERALL 3 ADDERALL XR 3 ADZENYS ER 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

15

Drug Name Tier Requirements/ Limitations

ADZENYS XR-ODT 3 PA; FE alprazolam 1 alprazolam intensol 1 AMBIEN 3 QL AMBIEN CR 3 QL amitriptyline 1 amitriptyline-chlordiazepoxide 1

amoxapine 1 ANAFRANIL 3 APLENZIN 3 PA; FE APTENSIO XR 3 PA; FE aripiprazole oral solution 1 aripiprazole oral tablet 1 QL aripiprazole oral tablet, disintegrating 1 QL

armodafinil 1 QL ATIVAN 3 atomoxetine 1 BELSOMRA 3 PA; FE; QL BRISDELLE 3 bupropion hcl 1 buspirone 1 BUTISOL 3 PA; FE CELEXA 3 QL chlordiazepoxide hcl 1 chlorpromazine 1 citalopram oral solution 1 citalopram oral tablet 1 QL clomipramine 1 clonidine hcl 1 clorazepate dipotassium 1 clozapine oral tablet 1 clozapine tablet, disinteg 100 mg, 12.5 mg, 25 mg 1

CLOZAPINE ORAL TABLET, DISINTEG 150 MG, 200 MG 2

CLOZARIL 3 CONCERTA 3 COTEMPLA XR-ODT 3 PA; FE CYMBALTA 3 DAYTRANA 3 desipramine 1

Drug Name Tier Requirements/ Limitations

DESOXYN 3 DESVENLAFAXINE 3 ST DESVENLAFAXINE FUMARATE 3 PA; ST; FE

desvenlafaxine succinate 1 DEXEDRINE SPANSULE 3 dexmethylphenidate 1 dextroamphetamine 1 dextroamphetamine-amphetamine 1

diazepam 1 diazepam intensol 1 DORAL 3 PA; FE doxepin 1 duloxetine 1 DYANAVEL XR 3 PA; FE EDLUAR 3 PA; FE; QL EFFEXOR XR 3 EMSAM 3 ergoloid 1 escitalopram oxalate 1 estazolam 1 eszopiclone 1 QL EVEKEO 3 PA; FE FANAPT 3 ST; QL FAZACLO ORAL TABLET, DISINTEG 100 MG, 12.5 MG, 25 MG

3

FAZACLO ORAL TABLET, DISINTEG 150 MG, 200 MG 3 PA; FE

FETZIMA 3 PA; ST; FE fluoxetine oral capsule 1 fluoxetine oral capsule, delayed release(dr/ec) 1

fluoxetine oral solution 1 fluoxetine tablet 10 mg, 20 mg 1

fluoxetine tablet 60 mg 1 PA fluphenazine hcl 1 flurazepam 1 fluvoxamine 1 FOCALIN 3 FOCALIN XR 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

16

Drug Name Tier Requirements/ Limitations

FORFIVO XL 3 PA; FE GEODON 3 guanfacine 1 guanidine 1 HALCION 3 haloperidol 1 haloperidol lactate 1 imipramine hcl 1 imipramine pamoate 1 INTERMEZZO 3 PA; FE INTUNIV ER 3 INVEGA 3 KAPVAY 3 KHEDEZLA 3 PA; ST; FE LATUDA 2 ST; QL LEXAPRO 3 lithium carbonate 1 lithium citrate 1 LITHOBID 3 lorazepam 1 lorazepam intensol 1 loxapine succinate 1 LUNESTA 3 QL maprotiline 1 MARPLAN 3 metadate er 1 methamphetamine 1 METHYLIN 3 methylphenidate hcl oral capsule, er biphasic 30-70 1

methylphenidate hcl oral capsule, er biphasic 50-50 1

methylphenidate hcl oral solution 1

methylphenidate hcl oral tablet 1

methylphenidate hcl oral tablet extended release 1

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

1

Drug Name Tier Requirements/ Limitations

METHYLPHENIDATE HCL ORAL TABLET EXTENDED RELEASE 24HR 72 MG

3 PA; FE

methylphenidate hcl oral tablet, chewable 1

midazolam 1 mirtazapine 1 modafinil 1 QL MYDAYIS 3 PA; FE NARDIL 3 nefazodone 1 NORPRAMIN 3 nortriptyline 1 NUPLAZID 4 ST; QL NUVIGIL 3 QL olanzapine 1 olanzapine-fluoxetine 1 ORAP 3 oxazepam 1 paliperidone 1 PAMELOR 3 PARNATE 3 paroxetine hcl oral tablet 1 QL paroxetine hcl oral tablet extended release 24 hr 1

paroxetine mesylate (menop. sym) 1

PAXIL CR 3 PAXIL ORAL SUSPENSION 3 PA; FE PAXIL ORAL TABLET 3 QL perphenazine 1 perphenazine-amitriptyline 1

PEXEVA 3 PA; ST; FE phenelzine 1 pimozide 1 PRISTIQ 3 procentra 1 protriptyline 1 PROVIGIL 3 QL PROZAC 3 quazepam 1 quetiapine 1 QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

17

Drug Name Tier Requirements/ Limitations

QUILLICHEW ER 3 PA; FE QUILLIVANT XR 3 REMERON 3 REMERON SOLTAB 3 RESTORIL 3 REXULTI 3 ST; QL RISPERDAL 3 risperidone 1 RITALIN 3 RITALIN LA 3 ROZEREM 3 SAPHRIS (BLACK CHERRY) 3 PA;ST;FE;QL SARAFEM 3 seconal sodium 1 SEROQUEL 3 QL SEROQUEL XR 3 QL sertraline 1 SILENOR 3 PA; FE; QL SONATA 3 QL STRATTERA 3 SURMONTIL 3 SYMBYAX 3 temazepam 1 thioridazine 1 thiothixene 1 TOFRANIL 3 TRANXENE T-TAB 3 tranylcypromine 1 trazodone 1 triazolam 1 trifluoperazine 1 trimipramine 1 TRINTELLIX 3 PA;ST;FE;QL VALIUM 3 venlafaxine 1 VERSACLOZ 3 PA; FE VIIBRYD 2 ST; QL VRAYLAR 3 PA;ST;FE;QL VYVANSE 2 WELLBUTRIN SR 3 WELLBUTRIN XL 3 XANAX 3

Drug Name Tier Requirements/ Limitations

XANAX XR 3 XYREM 4 PA; LA; QL zaleplon 1 QL zenzedi tablet 10mg, 5mg 1 ZENZEDI TABLET 15 MG, 2.5 MG, 20MG, 30MG, 7.5MG 3 PA; FE

ziprasidone hcl 1 ZOLOFT 3 zolpidem oral 1 QL zolpidem sublingual 1 PA; FE ZOLPIMIST 3 PA; FE; QL ZYPREXA 3 ZYPREXA ZYDIS 3

Drug Name Tier Requirements/ Limitations

CARDIOVASCULAR / HYPERTENSION / LIPIDS

Antiarrhythmic Agents amiodarone 1 BETAPACE 3 BETAPACE AF 3 disopyramide phosphate 1 dofetilide 1 flecainide 1 mexiletine 1 MULTAQ 2 NORPACE 3 NORPACE CR 3 PA; FE pacerone 1 propafenone 1 quinidine gluconate 1 quinidine sulfate 1 RYTHMOL SR 3 sotalol 1 sotalol af 1 SOTYLIZE 3 PA; FE TIKOSYN 3 Antihypertensive Therapy ACCUPRIL 3 ACCURETIC 3 acebutolol 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

18

Drug Name Tier Requirements/ Limitations

ADALAT CC 3 afeditab cr 1 ALDACTAZIDE ORAL TABLET 25-25 MG 3

ALDACTAZIDE ORAL TABLET 50-50 MG 3 PA; FE

ALDACTONE 3 ALTACE 3 amiloride 1 amiloride-hydrochlorothiazide 1

amlodipine 1 amlodipine-benazepril 1 amlodipine-olmesartan 1 amlodipine-valsartan 1 amlodipine-valsartan-hcthiazid 1

ATACAND 3 ATACAND HCT 3 atenolol 1 atenolol-chlorthalidone 1 AVALIDE 3 AVAPRO 3 AZOR 3 benazepril 1 benazepril-hydrochlorothiazide 1

BENICAR 3 BENICAR HCT 3 betaxolol 1 BIDIL 3 bisoprolol fumarate 1 bisoprolol-hydrochlorothiazide 1

bumetanide 1 BYSTOLIC 3 BYVALSON 3 PA; FE CALAN 3 CALAN SR 3 candesartan 1 candesartan-hydrochlorothiazide 1

captopril 1

Drug Name Tier Requirements/ Limitations

captopril-hydrochlorothiazide 1

CARDIZEM 3 CARDIZEM CD 3 CARDIZEM LA TABLET EXT-REL 24 HR 120 MG 3 PA; FE

CARDIZEM LA TABLET EXT-REL 24 HR 180MG, 240MG, 300 MG, 360 MG, 420 MG

3

CARDURA 3 QL CARDURA XL 3 PA; FE; QL CAROSPIR 3 PA; FE cartia xt 1 carvedilol 1 carvedilol phosphate 1 CATAPRES 3 CATAPRES-TTS-1 3 CATAPRES-TTS-2 3 CATAPRES-TTS-3 3 chlorothiazide 1 chlorthalidone 1 clonidine 1 clonidine hcl 1 COREG 3 COREG CR 3 CORGARD 3 CORZIDE 3 COZAAR 3 DEMADEX 3 DEMSER 3 PA; FE DIBENZYLINE 3 diltiazem 1 dilt-xr 1 DIOVAN 3 DIOVAN HCT 3 DIURIL 2 doxazosin 1 QL DUTOPROL 3 PA; FE DYAZIDE 3 DYRENIUM 3 EDARBI 3 EDARBYCLOR 3 PA; FE EDECRIN 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

19

Drug Name Tier Requirements/ Limitations

enalapril maleate 1 enalapril-hydrochlorothiazide 1

EPANED 3 PA; FE eplerenone 1 eprosartan 1 ethacrynic acid 1 EXFORGE 3 EXFORGE HCT 3 felodipine 1 fosinopril 1 fosinopril-hydrochlorothiazide 1

furosemide 1 guanfacine 1 HEMANGEOL 4 hydralazine 1 hydrochlorothiazide 1 HYZAAR 3 indapamide 1 INDERAL LA 3 INDERAL XL 3 PA; FE INNOPRAN XL 3 PA; FE INSPRA 3 irbesartan 1 irbesartan-hydrochlorothiazide 1

isradipine 1 labetalol 1 LASIX 3 LEVATOL 3 lisinopril 1 lisinopril-hydrochlorothiazide 1

LOPRESSOR 3 losartan 1 losartan-hydrochlorothiazide 1

LOTENSIN HCT 3 LOTENSIN ORAL TABLET 10 MG 3 PA; FE

LOTENSIN ORAL TABLET 20 MG, 40 MG 3

Drug Name Tier Requirements/ Limitations

LOTREL 3 matzim la 1 MAXZIDE 3 MAXZIDE-25MG 3 methyclothiazide 1 methyldopa 1 methyldopa-hydrochlorothiazide 1

metolazone 1 metoprolol succinate 1 METOPROLOL SU-HYDROCHLOROTHIAZ 3 PA; FE

metoprolol tartrate-hydrochlorothiazide 1

metoprolol tartrate 1 MICARDIS 3 MICARDIS HCT 3 MICROZIDE 3 MINIPRESS 3 minoxidil 1 moexipril 1 moexipril-hydrochlorothiazide 1

nadolol 1 nadolol-bendroflumethiazide 1

nicardipine 1 nifedipine 1 nimodipine 1 nisoldipine 1 NORVASC 3 olmesartan 1 olmesartan-amlodipine-hcthiazid 1

olmesartan-hydrochlorothiazide 1

ORENITRAM 4 PA perindopril erbumine 1 phenoxybenzamine 1 pindolol 1 prazosin 1 PRESTALIA 3 PA; FE PRINIVIL 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

20

Drug Name Tier Requirements/ Limitations

PROCARDIA 3 PROCARDIA XL 3 propranolol 1 propranolol-hydrochlorothiazide 1

QBRELIS 3 PA; FE quinapril 1 quinapril-hydrochlorothiazide 1

ramipril 1 spironolactone 1 spironolactone-hydrochlorothiazide 1

SULAR 3 TARKA 3 taztia xt 1 TEKTURNA 3 TEKTURNA HCT 3 telmisartan 1 telmisartan-amlodipine 1 telmisartan-hydrochlorothiazide 1

TENORETIC 100 3 TENORETIC 50 3 TENORMIN 3 terazosin 1 TIAZAC 3 timolol maleate 1 TOPROL XL 3 torsemide 1 trandolapril 1 trandolapril-verapamil 1 triamterene-hydrochlorothiazide 1

TRIBENZOR 3 TWYNSTA 3 UPTRAVI 4 PA; LA; QL valsartan 1 valsartan-hydrochlorothiazide 1

VASERETIC 3 VASOTEC 3 verapamil 1

Drug Name Tier Requirements/ Limitations

VERELAN 3 VERELAN PM 3 ZESTORETIC 3 ZESTRIL 3 ZIAC 3 Cardiac Glycosides digitek 1 digox 1 digoxin 1 LANOXIN ORAL TABLET 125 MCG, 250 MCG 3

LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG 3 PA; FE

Coagulation Therapy AGGRENOX 3 AMICAR 2 ARIXTRA 3 aspirin-dipyridamole 1 BEVYXXA 3 QL BRILINTA 2 cilostazol 1 clopidogrel 1 COUMADIN 3 dipyridamole 1 EFFIENT 3 ELIQUIS 2 enoxaparin 1 fondaparinux 1 FRAGMIN 2 hep flush-10 (pf) 1 heparin (porcine) 1 heparin lock flush 1 heparin lock flush (porcine) 1

heparin lockflush(porcine)(pf) 1

heparin, porcine (pf) 1 jantoven 1 LOVENOX 3 MEPHYTON 2 pentoxifylline 1 phytonadione (vitamin k1) 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

21

Drug Name Tier Requirements/ Limitations

PLAVIX 3 PRADAXA 3 PA; FE prasugrel 1 PROMACTA 4 PA; LA; QL SAVAYSA 3 PA; FE warfarin 1 XARELTO 2 YOSPRALA 3 PA; FE ZONTIVITY 2 Lipid/Cholesterol Lowering Agents ALTOPREV 3 PA; FE; QL amlodipine-atorvastatin 1 QL ANTARA 3 PA; FE atorvastatin oral tablet 10 mg, 20 mg 5 ACA; QL

atorvastatin oral tablet 40 mg, 80 mg 1 QL

CADUET 3 QL cholestyramine (with sugar) 1 QL

cholestyramine light oral powder 1 QL

cholestyramine light oral powder in packet 1

colesevelam 1 COLESTID FLAVORED 3 PA; FE COLESTID ORAL GRANULES 3 PA; FE

COLESTID ORAL PACKET 3 COLESTID ORAL TABLET 3 colestipol 1 CRESTOR 3 QL ezetimibe 1 QL ezetimibe-simvastatin 1 QL fenofibrate micronized 1 fenofibrate nanocrystallized 1

FENOFIBRATE ORAL CAPSULE 3 PA; FE

fenofibrate oral tablet 1 fenofibric acid 1 fenofibric acid (choline) 1 FENOGLIDE 3

Drug Name Tier Requirements/ Limitations

FIBRICOR 3 FLOLIPID 3 PA; FE fluvastatin 5 ACA; QL gemfibrozil 1 JUXTAPID 4 PA; FE; LA KYNAMRO 4 PA; FE; LA LESCOL XL 3 QL LIPITOR 3 QL LIPOFEN 3 PA; FE LIVALO 3 QL LOPID 3 lovastatin 5 ACA; QL LOVAZA 3 niacin 1 NIASPAN EXTENDED-RELEASE 3

omega-3 acid ethyl esters 1

PRALUENT PEN 4 PA PRAVACHOL 3 QL pravastatin 5 ACA; QL prevalite oral powder 1 QL prevalite oral powder in packet 1

QUESTRAN 3 QL QUESTRAN LIGHT 3 QL REPATHA PUSHTRONEX 4 PA; FE; QL REPATHA SURECLICK 4 PA; QL REPATHA SYRINGE 4 PA; QL rosuvastatin oral tablet 10 mg, 5 mg 5 ACA; QL

rosuvastatin oral tablet 20 mg, 40 mg 1 QL

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 5 ACA; QL

simvastatin oral tablet 80 mg 1 QL

TRICOR 3 TRIGLIDE 3 PA; FE triklo 1 TRILIPIX 3 VASCEPA 3 PA; FE VYTORIN 10-10 3 QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

22

Drug Name Tier Requirements/ Limitations

VYTORIN 10-20 3 QL VYTORIN 10-40 3 QL VYTORIN 10-80 3 QL WELCHOL ORAL POWDER IN PACKET 3

WELCHOL ORAL TABLET 2 ZETIA 3 QL ZOCOR 3 QL ZYPITAMAG 3 PA; FE; QL Miscellaneous Cardiovascular Agents CORLANOR 3 PA; FE ENTRESTO 3 RANEXA 2 VECAMYL 3 PA; FE Nitrates DILATRATE-SR 2 GONITRO 3 PA; FE ISOCHRON 3 PA; FE ISORDIL 2 ISORDIL TITRADOSE 3 isosorbide dinitrate 1 isosorbide mononitrate 1 MINITRAN 3 PA; FE nitro-bid 1 NITRO-DUR 3 PA; FE nitroglycerin 1 NITROLINGUAL 3 NITROMIST 3 NITROSTAT 3

Drug Name Tier Requirements/ Limitations

DERMATOLOGICALS / TOPICAL THERAPY

Antipsoriatic / Antiseborrheic acitretin 1 ANALPRAM-HC 3 calcipotriene 1 calcipotriene-betamethasone 1 QL

calcitrene 1 calcitriol 1

Drug Name Tier Requirements/ Limitations

COAL TAR 2 COSENTYX 4 PA; FE; QL COSENTYX (2 SYRINGES) 4 PA; QL COSENTYX PEN 4 PA; FE; QL COSENTYX PEN (2 PENS) 4 PA; QL DOVONEX 3 drithocreme hp 1 ENSTILAR 3 PA; FE EPIFOAM 2 OVACE 3 OVACE PLUS 3 PA; FE OVACE PLUS SHAMPOO 3 PA; FE OVACE PLUS WASH 3 PA; FE PRAMOSONE 2 PRAMOSONE E 3 PROMISEB COMPLETE 3 PA; FE seb-prev 1 selenium sulfide 1 SELRX 3 PA; FE SILIQ 4 PA; QL SORIATANE 3 SORILUX 3 STELARA 4 PA; QL sulfacetamide sodium 1 TACLONEX 3 QL TALTZ AUTOINJECTOR 4 PA; QL TALTZ AUTOINJECTOR (2 PACK) 4 PA; QL

TALTZ AUTOINJECTOR (3 PACK) 4 PA; QL

TALTZ SYRINGE 4 PA; QL TERSI FOAM 3 PA; FE TREMFYA 4 PA; QL VECTICAL 3 ZITHRANOL 3 PA; FE Burn Therapy SILVADENE 3 silver sulfadiazine 1 ssd 1 Keratolytics BENSAL HP 3 PA; FE KERALYT RX 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

23

Drug Name Tier Requirements/ Limitations

KERALYT SCALP COMPLETE 3 PA; FE

PODOCON 3 PA; FE SALEX 3 salicylic acid 1 salicylic acid er-ceramides 1

SALKERA 3 PA; FE salvax 1 SALVAX DUO PLUS 3 PA; FE Miscellaneous Dermatologicals AMELUZ 3 PA; FE CARAC 2 cem-urea 1 CONDYLOX 3 diclofenac sodium 1 doxepin 1 DUPIXENT 4 PA; QL EFUDEX 3 ELIDEL 2 EUCRISA 3 PA; QL FLUOROPLEX 2 FLUOROURACIL TOPICAL CREAM 0.5 % 3 PA; FE

fluorouracil topical cream 5 % 1

fluorouracil topical solution 1

HYDRO 35 3 PA; FE HYDRO 40 3 IODOFLEX 2 IODOSORB 2 KERAFOAM 3 PA; FE KERALAC 3 PA; FE LEVULAN 3 PA; FE LOUTREX 3 PA; FE methoxsalen 1 OXSORALEN ULTRA 3 PANRETIN 2 PICATO 3 PA; FE podofilox 1 PROMISEB 3 PA; FE PROTOPIC 3

Drug Name Tier Requirements/ Limitations

prudoxin 1 QUTENZA 3 PA; FE REGRANEX 2 QL silver nitrate 1 silver nitrate applicators 1 SOLARAZE 3 PA; FE sp antipruritic 1 tacrolimus 1 TOLAK 3 PA; FE umecta 1 URAMAXIN TOPICAL FOAM 3 PA; FE

URAMAXIN TOPICAL GEL 3 urea 1 urea nail stick 1 UTOPIC 3 PA; FE VEREGEN 2 ZONALON 2 Therapy For Acne ABSORICA 3 PA; FE ACANYA 3 ACZONE TOPICAL GEL 3 ACZONE TOPICAL GEL WITH PUMP 3 PA; FE

adapalene 1 adapalene-benzoyl peroxide 1

AKTIPAK 3 PA; FE amnesteem 1 ATRALIN 3 PA AVAR LS 3 PA; FE avar topical cleanser 1 AVAR TOPICAL FOAM 2 AVAR TOPICAL PADS, MEDICATED 2

AVAR-E GREEN 3 PA; FE AVAR-E LS 3 PA; FE avita topical cream 1 PA AVITA TOPICAL GEL 2 PA AZELEX 3 BENZACLIN 3 BENZACLIN PUMP 3 BENZAMYCIN 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

24

Drug Name Tier Requirements/ Limitations

bp 10-1 1 claravis 1 cleansing wash 1 CLEOCIN T 3 CLINDACIN ETZ 3 PA; FE clindacin p 1 CLINDACIN PAC 3 PA; FE CLINDAGEL 2 clindamycin phosphate 1 clindamycin-benzoyl peroxide 1

clindamycin-tretinoin 1 dapsone 1 PA DIFFERIN TOPICAL GEL 2 DIFFERIN TOPICAL GEL WITH PUMP 3

DUAC 3 EPIDUO 3 EPIDUO FORTE 2 ery pads 1 erygel 1 erythromycin w/ethanol 1 erythromycin-benzoyl peroxide 1

EVOCLIN 3 FABIOR 3 PA; FE FINACEA 3 isotretinoin 1 METROCREAM 3 METROGEL 3 METROLOTION 3 metronidazole 1 neuac 1 NEUAC KIT 3 PA; FE NORITATE 2 NUOX 2 ONEXTON 3 PA; FE PLEXION 3 PA; FE PLEXION CLEANSING CLOTHS 3 PA; FE

RETIN-A 3 PA RETIN-A MICRO 3 PA

Drug Name Tier Requirements/ Limitations

RETIN-A MICRO TOPICAL GEL W/ PUMP 0.04%, 01 % 3 PA

RETIN-A MICRO TOPICAL GEL W/PUMP 0.06%, 0.08% 3 PA; FE

rosadan topical cream 1 rosadan topical gel 1 ROSADAN TOPICAL KIT, CLEANSER AND GEL 3 PA; FE

ROSADAN TOPICAL KIT,CLEANSER AND CREAM

3 PA; FE

ROSANIL 3 ROSULA 3 PA; FE rosula cleansing cloths 1 SOOLANTRA 3 sss 10-5 1 sulfacetamide sod-sulfur 1 sulfacetamide sod-sulfur-urea 1

sulfacetamide-sulfur-cleansr23 1

sulfacleanse 8-4 1 sulfact na-sul-avobnz-otn-ocsa 1

SUMADAN 3 PA; FE SUMADAN XLT 3 PA; FE SUMAXIN CP 3 PA; FE SUMAXIN TOPICAL CLEANSER 3 PA; FE

SUMAXIN TOPICAL PADS, MEDICATED 3

SUMAXIN TS 3 PA; FE tazarotene 1 TAZORAC TOPICAL CREAM 0.05 % 2

TAZORAC TOPICAL CREAM 0.1 % 3

TAZORAC TOPICAL GEL 2 tretinoin 1 PA tretinoin microspheres 1 PA TRETIN-X 3 PA; FE TRETIN-X CREAM KIT 3 PA; FE VANOXIDE-HC 3 PA; FE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

25

Drug Name Tier Requirements/ Limitations

VELTIN 3 PA; FE zenatane 1 ZIANA 3 Topical Anesthetics BUCALSEP 3 PA; FE ethyl chloride 1 glydo 1 lidocaine 1 lidocaine hcl 1 lidocaine hcl-hydrocortisone ac 1

lidocaine viscous 1 lidocaine-prilocaine 1 LIDOCAINE-TETRACAINE 3 LIDODERM 3 lta pre-attached 1 PLIAGLIS 3 SYNERA 3 Topical Antibacterials ALCORTIN A 3 PA; FE ALTABAX 3 BACTROBAN 3 PA; FE CENTANY 3 PA; FE CENTANY AT 3 PA; FE CORTISPORIN 3 PA; FE gentamicin 1 hydrocortisone-iodoquinol-aloe 1

KLARON 3 lugols 1 mafenide acetate 1 PA; FE mupirocin 1 mupirocin calcium 1 NEO-SYNALAR 3 PA; FE NEO-SYNALAR KIT 3 PA; FE sulfacetamide sodium (acne) 1

SULFAMYLON CREAM 2 SULFAMYLON PACKET 3 PA; FE VYTONE 3 PA; FE Topical Antifungals ciclodan 1 CICLODAN KIT 3 PA; FE

Drug Name Tier Requirements/ Limitations

ciclopirox 1 ciclopirox-ure-camph-menth-euc 1

clotrimazole-betamethasone 1

econazole 1 ECOZA 3 PA; FE ERTACZO 3 EXELDERM 3 EXODERM 3 PA; FE EXTINA 3 JUBLIA 3 PA; FE KERYDIN 3 PA; FE ketoconazole 1 LOPROX 3 LOPROX (AS OLAMINE) 3 LOPROX KIT 3 PA; FE LOTRISONE 3 LUZU 3 naftifine 1 NAFTIN TOPICAL CREAM 3 NAFTIN TOPICAL GEL 3 PA; FE NIZORAL 3 nyamyc 1 nystatin 1 nystatin-triamcinolone 1 nystop 1 oxiconazole 1 OXISTAT 3 PENLAC 3 TRIACETIN 2 VUSION 3 PA; FE XOLEGEL 3 PA; FE Topical Antivirals acyclovir 1 DENAVIR 2 XERESE 3 PA; FE ZOVIRAX TOPICAL CREAM 2 ZOVIRAX TOPICAL OINTMENT 3

Topical Corticosteroids ala-cort 1 ALA-SCALP 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

26

Drug Name Tier Requirements/ Limitations

alclometasone 1 amcinonide 1 apexicon e 1 AQUA GLYCOLIC HC 3 PA; FE betamethasone dipropionate 1

betamethasone valerate 1 betamethasone, augmented 1

CAPEX 3 PA; FE clobetasol 1 clobetasol-emollient 1 CLOBEX 3 CLOCORTOLONE PIVALATE 2

clodan 1 CLODAN KIT 3 PA; FE CLODERM 2 CORDRAN 3 CORDRAN TAPE LG ROLL 3 cormax 1 CUTIVATE 3 DERMA-SMOOTHE/FS BODY OIL 3

DERMA-SMOOTHE/FS SCALP OIL 3

DERMASORB HC COMPLETE KIT 3 PA; FE

DERMASORB TA COMPLETE KIT 3 PA; FE

DERMATOP 3 DESONATE 3 PA; FE desonide 1 DESOWEN 3 desoximetasone 1 diflorasone 1 DIPROLENE 3 ELOCON 3 fluocinolone 1 fluocinolone and shower cap 1

fluocinonide 1 fluocinonide-emollient 1

Drug Name Tier Requirements/ Limitations

flurandrenolide 1 fluticasone 1 halobetasol propionate 1 HALOG 3 hydrocortisone 1 hydrocortisone butyrate 1 hydrocortisone butyr-emollient 1

hydrocortisone valerate 1 hydrocortisone-min oil-wht pet 1

IMPOYZ 3 PA; FE KENALOG 3 LOCOID 3 LOCOID LIPOCREAM 3 PA; FE LUXIQ 3 mometasone 1 nolix 1 NUCORT 3 PA; FE OLUX 3 OLUX-E 3 PANDEL 3 PA; FE prednicarbate 1 PSORCON 3 scalacort 1 SCALACORT DK 3 PA; FE SERNIVO 3 PA; FE SYNALAR 3 SYNALAR CREAM KIT 3 PA; FE SYNALAR OINTMENT KIT 3 PA; FE SYNALAR TS 3 PA; FE TEMOVATE 3 TEXACORT 2 TOPICORT TOPICAL CREAM 3

TOPICORT TOPICAL GEL 3 TOPICORT TOPICAL OINTMENT 3

TOPICORT TOPICAL SPRAY, NON-AEROSOL 3 PA; FE

triamcinolone acetonide 1 trianex 1 triderm 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

27

Drug Name Tier Requirements/ Limitations

TRIDESILON 3 ULTRAVATE TOPICAL CREAM 3

ULTRAVATE TOPICAL LOTION 3 PA; FE

ULTRAVATE TOPICAL OINTMENT 3

ULTRAVATE X 3 PA; FE VANOS 3 VERDESO 3 PA; FE Topical Enzymes SANTYL 2 Topical Scabicides / Pediculicides ELIMITE 3 EURAX 2 lindane 1 malathion 1 NATROBA 3 OVIDE 3 permethrin 1 SKLICE 3 spinosad 1 ULESFIA 3

Drug Name Tier Requirements/ Limitations

MISCELLANEOUS AGENTS Anorexiants ADIPEX-P 3 PA BELVIQ 2 PA BELVIQ XR 2 PA benzphetamine 1 PA CONTRAVE 3 PA; FE diethylpropion 1 PA LOMAIRA 3 PA; FE phendimetrazine tartrate 1 PA phentermine 1 PA QSYMIA 3 PA; FE REGIMEX 3 PA SAXENDA 3 PA; FE Miscellaneous Agents acamprosate 1

Drug Name Tier Requirements/ Limitations

ACTONEL 3 AGRYLIN 3 alendronate 1 anagrelide 1 ANTABUSE 3 BUPHENYL 3 caffeine citrate 1 CARBAGLU 4 LA CARNITOR 3 CARNITOR (SUGAR-FREE) 2 cevimeline 1 disulfiram 1 ENDARI 3 PA; FE etidronate disodium 1 EVOXAC 3 INCRELEX 4 PA; LA levocarnitine 1 levocarnitine (with sugar) 1 LIPOCHOL PLUS 3 PA; FE LITHOSTAT 3 PA; FE METOPIRONE 2 midodrine 1 NITYR 4 NORTHERA 4 ORFADIN 4 LA pilocarpine hcl 1 RAVICTI 4 PA RILUTEK 3 riluzole 1 risedronate 1 SALAGEN (PILOCARPINE) 3 sodium phenylbutyrate 1 THIOLA 4 XURIDEN 4 Smoking Deterrents bupropion hcl (smoking deter) 5 ACA; QL

CHANTIX 5 ACA; QL CHANTIX CONTINUING MONTH BOX 5 ACA; QL

CHANTIX STARTING MONTH BOX 5 ACA; QL

NICODERM CQ 3 ACA; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

28

Drug Name Tier Requirements/ Limitations

nicorelief 5 ACA; QL NICORETTE BUCCAL GUM 2 MG 3 ACA; QL

nicorette buccal gum 4 mg 5 ACA; QL

NICORETTE BUCCAL LOZ 5 ACA; QL NICORETTE BUCCAL MINI LOZENGE 5 ACA; QL

nicotine 5 ACA; QL nicotine (polacrilex) 5 ACA; QL NICOTROL 5 ACA; QL NICOTROL NS 5 ACA; QL quit 2 buccal gum 5 ACA; QL QUIT 2 BUCCAL LOZENGE 5 ACA; QL quit 4 buccal gum 5 ACA; QL QUIT 4 BUCCAL LOZENGE 5 ACA; QL stop smoking aid 5 ACA; QL ZYBAN 3 ACA; QL

Drug Name Tier Requirements/ Limitations

EAR, NOSE, THROAT MEDICATIONS Miscellaneous Agents ASTEPRO 3 azelastine 1 BACTROBAN NASAL 2 chlorhexidine gluconate 1 CLINPRO 5000 3 PA; FE DEBACTEROL 2 denta 5000 plus 1 dentagel 1 EPISIL 3 PA; FE FLUORIDEX DAILY DEFENSE 3 PA; FE

GELCLAIR 3 PA; FE GELX 3 PA; FE ipratropium bromide 1 MUGARD 3 olopatadine 1 oralone 1 ORAMAGICRX 3 PA; FE paroex oral rinse 1

Drug Name Tier Requirements/ Limitations

PATANASE 3 PERIDEX 3 periogard 1 pilocarpine hcl 1 PREVIDENT 3 PREVIDENT 5000 BOOSTER PLUS 2

PREVIDENT 5000 DRY MOUTH 3 PA; FE

PREVIDENT 5000 ENAMEL PROTECT 3 PA; FE

PREVIDENT 5000 PLUS 3 PREVIDENT 5000 SENSITIVE 3 PA; FE SALAGEN (PILOCARPINE) 3 sf 1 sf 5000 plus 1 triamcinolone acetonide 1 TYZINE 3 PA; FE Miscellaneous Otic Preparations acetic acid 1 CETRAXAL 3 PA; FE ciprofloxacin hcl 1 DERMOTIC OIL 3 fluocinolone acet oil 1 hydrocortisone-acetic acid 1

ofloxacin 1 Otic Steroid / Antibiotic CIPRO HC 3 CIPRODEX 3 COLY-MYCIN S 3 neomycin-polymyxin-hc 1 OTOVEL 3 PA; FE

Drug Name Tier Requirements/ Limitations

ENDOCRINE / DIABETES Adrenal Hormones ACTHAR H.P. 4 PA CORTEF 3 cortisone 1 decadron 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

29

Drug Name Tier Requirements/ Limitations

deltasone 1 dexamethasone 1 dexamethasone intensol 1 DEXPAK 10 DAY 2 DEXPAK 13 DAY 2 DEXPAK 6 DAY 2 EMFLAZA 4 PA; LA fludrocortisone 1 hydrocortisone 1 MEDROL (PAK) 3 MEDROL TABLET 16 MG, 32 MG, 4 MG, 8 MG 3

MEDROL TABLET 2 MG 2 methylprednisolone 1 millipred 1 millipred dp 1 ORAPRED ODT 3 prednisolone 1 prednisolone sodium phosphate 1

prednisone 1 prednisone intensol 1 RAYOS 3 PA; FE TAPERDEX 3 PA; FE veripred 20 1 Antithyroid Agents methimazole 1 propylthiouracil 1 SSKI 2 TAPAZOLE 3 Blood Glucose Monitoring Devices & Supplies

ONETOUCH ULTRA BLUE TEST STRIP 2 QL

ONETOUCH VERIO 2 QL Glucose Elevating Agents GLUCAGON EMERGENCY KIT (HUMAN) 2

PROGLYCEM 3 PA; FE GLUCAGON HCL 3 PA; FE Insulin Syringes/ Miscellaneous Durable Medical Equipment

AEROCHAMBER MINI 2

Drug Name Tier Requirements/ Limitations

AEROCHAMBER PLUS FLOW-VU 2

AEROCHAMBER PLUS Z STAT SM MSK 2

INSULIN SYRINGE-NEEDLE 1 LANCETS 2 LANCING DEVICE 2 ONETOUCH ULTRA CONTROL 2

ONETOUCH ULTRA2 2 ONETOUCH ULTRAMINI 2 ONETOUCH VERIO FLEX 2 QL ONETOUCH VERIO IQ METER 2 QL

ONETOUCH VERIO SYSTEM 2 QL PEN NEEDLE 1 Insulin Therapy ADMELOG SOLOSTAR U-100 INSULIN 3 PA; FE

ADMELOG U-100 INSULIN LISPRO 3 PA; FE

AFREZZA 3 PA; FE APIDRA SOLOSTAR U-100 INSULIN 3 PA; FE

APIDRA U-100 INSULIN 3 PA; FE BASAGLAR KWIKPEN U-100 INSULIN 2

FIASP FLEXTOUCH U-100 INSULIN 2

FIASP U-100 INSULIN 2 HUMALOG JUNIOR KWIKPEN U-100 3 PA; FE

HUMALOG KWIKPEN INSULIN 3 PA; FE

HUMALOG MIX 50-50 INSULIN U-100 3 PA; FE

HUMALOG MIX 50-50 KWIKPEN 3 PA; FE

HUMALOG MIX 75-25 KWIKPEN 3 PA; FE

HUMALOG MIX 75-25 (U-100) INSULIN 3 PA; FE

HUMALOG U-100 INSULIN 3 PA; FE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

30

Drug Name Tier Requirements/ Limitations

HUMULIN 70/30 U-100 INSULIN 3 PA; FE

HUMULIN 70/30 U-100 KWIKPEN 3 PA; FE

HUMULIN N NPH INSULIN KWIKPEN 3 PA; FE

HUMULIN N NPH U-100 INSULIN 3 PA; FE

HUMULIN R REGULAR U-100 INSULIN 3 PA; FE

HUMULIN R U-500 (CONC) INSULIN 2 PA

HUMULIN R U-500 (CONC) KWIKPEN 2

LANTUS SOLOSTAR U-100 INSULIN 2

LANTUS U-100 INSULIN 2 LEVEMIR FLEXTOUCH U-100 INSULIN 2

LEVEMIR U-100 INSULIN 2 NOVOLIN 70/30 2 NOVOLIN N 2 NOVOLIN R 2 NOVOLOG FLEXPEN U-100 INSULIN 2

NOVOLOG MIX 70-30 U-100 INSULIN 2

NOVOLOG MIX 70-30FLEXPEN U-100 2

NOVOLOG PENFILL U-100 INSULIN 2

NOVOLOG U-100 INSULIN ASPART 2

SOLIQUA 100/33 3 PA;ST;FE;QL TOUJEO MAX U-300 SOLOSTAR 2

TOUJEO SOLOSTAR U-300 INSULIN 2

TRESIBA FLEXTOUCH U-100 2 TRESIBA FLEXTOUCH U-200 2 XULTOPHY 100/3.6 2 ST; QL Miscellaneous Hormones ANADROL-50 2

Drug Name Tier Requirements/ Limitations

ANDRODERM 2 PA ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

3 PA; FE

ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)

3 PA

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

3 PA; FE

ANDROID 3 AXIRON 3 PA cabergoline 1 QL calcitonin (salmon) 1 calcitriol 1 CERDELGA 4 PA CHEMET 2 danazol 1 DDAVP NASAL SOLUTION 2 DDAVP NASAL SPRAY WITH PUMP 3

DDAVP ORAL 3 DEPO-TESTOSTERONE INTRAMUSCULAR OIL 100 MG/ML

2 PA

DEPO-TESTOSTERONE INTRAMUSCULAR OIL 200 MG/ML

3 PA

desmopressin 1 doxercalciferol oral capsule 0.5 mcg 5

doxercalciferol oral capsule 1 mcg, 2.5 mcg 1

EXJADE 4 LA FERRIPROX 4 FORTESTA 3 PA; FE JADENU 4 JADENU SPRINKLE 4 JYNARQUE 4 PA; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

31

Drug Name Tier Requirements/ Limitations

KORLYM 4 PA KUVAN 4 PA METHITEST 2 methyltestosterone 1 MIACALCIN 3 PA; FE miglustat 1 PA MYALEPT 4 PA; LA NATESTO 3 PA; FE NATPARA 4 PA; LA OXANDRIN 3 PA; FE oxandrolone 1 paricalcitol 1 RADIOGARDASE 3 PA; FE RAYALDEE 3 PA; FE ROCALTROL 3 SAMSCA 4 SENSIPAR 2 SOMAVERT 4 PA; FE STIMATE 4 STRENSIQ 4 PA; LA STRIANT 3 PA; FE SYNAREL 2 SYPRINE 3 TESTIM 3 PA testosterone cypionate 1 PA testosterone enanthate 1 PA testosterone transdermal gel 1 PA

TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG/0.5 GRAM /ACT

3 PA; FE

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)

1 PA

testosterone transdermal gel in packet 1 PA

testosterone transdermal solution in metered pump w/app

1 PA

TESTRED 3 trientine 1

Drug Name Tier Requirements/ Limitations

VOGELXO TRANSDERMAL GEL 3 PA

VOGELXO TRANSDERMAL GEL IN METERED-DOSE PUMP

3 PA; FE

VOGELXO TRANSDERMAL GEL IN PACKET 3 PA; FE

ZAVESCA 4 PA; LA ZEMPLAR 3 Non-Insulin Hypoglycemic Agents acarbose 1 ACTOPLUS MET 3 ACTOPLUS MET XR 2 ACTOS 3 QL ADLYXIN 3 PA;ST;FE;QL ALOGLIPTIN 3 PA; FE; QL ALOGLIPTIN-METFORMIN 3 PA; FE; QL ALOGLIPTIN-PIOGLITAZONE 3 PA; FE; QL

AMARYL 3 AVANDIA 3 PA; FE BYDUREON 2 ST; QL BYDUREON BCISE 2 ST; QL BYETTA 2 ST; QL chlorpropamide 1 CYCLOSET 3 DUETACT 3 FARXIGA 2 FORTAMET 3 glimepiride 1 glipizide 1 glipizide-metformin 1 GLUCOPHAGE 3 GLUCOPHAGE XR 3 GLUCOTROL 3 GLUCOTROL XL 3 GLUCOVANCE 3 GLUMETZA 3 PA; FE glyburide 1 glyburide micronized 1 glyburide-metformin 1 GLYNASE 3 GLYSET 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

32

Drug Name Tier Requirements/ Limitations

GLYXAMBI 2 QL INVOKAMET 2 QL INVOKAMET XR 2 QL INVOKANA 2 QL JANUMET 2 QL JANUMET XR 2 QL JANUVIA 2 QL JARDIANCE 3 PA; FE; QL JENTADUETO 2 QL JENTADUETO XR 2 QL KAZANO 3 PA; FE; QL KOMBIGLYZE XR 3 PA; FE; QL metformin oral tablet 1 metformin oral tablet extended release 24 hr 1

metformin oral tablet extended release 24hr 1 PA; FE

metformin oral tablet,er gast. retention 24 hr 1 PA; FE

miglitol 1 nateglinide 1 NESINA 3 PA; FE; QL ONGLYZA 3 PA; FE; QL OSENI 3 PA; FE; QL OZEMPIC 2 ST; QL pioglitazone 1 QL pioglitazone-glimepiride 1 pioglitazone-metformin 1 PRANDIN 3 PRECOSE 3 QTERN 2 QL repaglinide 1 repaglinide-metformin 1 RIOMET 3 SEGLUROMET ORAL TABLET 2.5-1,000 MG, 7.5-1,000 MG

3 PA; FE; QL

SEGLUROMET ORAL TABLET 2.5-500 MG, 7.5-500 MG

3 PA; FE

STARLIX 3 STEGLATRO 3 PA; FE; QL STEGLUJAN 3 PA; FE; QL

Drug Name Tier Requirements/ Limitations

SYMLINPEN 120 3 PA SYMLINPEN 60 3 PA SYNJARDY 3 PA; FE; QL SYNJARDY XR 3 PA; FE; QL TANZEUM 3 PA;ST;FE;QL tolazamide 1 tolbutamide 1 TRADJENTA 2 QL TRULICITY 3 PA;ST;FE;QL VICTOZA 2-PAK 2 ST; QL VICTOZA 3-PAK 2 ST; QL XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5-1,000 MG, 5-500 MG

2 QL

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG

2

Thyroid Hormones ARMOUR THYROID 2 CYTOMEL 3 LEVO-T 3 levothyroxine 1 levoxyl 1 liothyronine 1 nature-throid 1 np thyroid 1 SYNTHROID 3 thyroid (pork) 1 THYROLAR-1 3 PA; FE THYROLAR-1/2 3 PA; FE THYROLAR-1/4 3 PA; FE THYROLAR-2 3 PA; FE THYROLAR-3 3 PA; FE TIROSINT 3 PA; FE unithroid 1 westhroid 1 WP THYROID ORAL TABLET 113.75 MG, 16.25 MG, 48.75 MG, 97.5 MG

3

WP THYROID ORAL TABLET 130 MG, 32.5 MG, 65 MG, 81.25 MG

3 PA; FE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

33

Drug Name Tier Requirements/ Limitations

GASTROENTEROLOGY Antidiarrheals & Antispasmodics anaspaz 1 belladonna alkaloids-opium 1 PA

belladonna-opium 1 PA chlordiazepoxide-clidinium 1

CUVPOSA 3 PA; FE dicyclomine 1 diphenoxylate-atropine 1 DONNATAL ORAL ELIXIR 3 DONNATAL ORAL TABLET 3 PA; FE

ed-spaz 1 glycopyrrolate 1 hyoscyamine sulfate 1 hyosyne 1 LEVBID 3 LEVSIN 3 LEVSIN/SL 3 LOMOTIL 3 methscopolamine 1 MOTOFEN 3 PA; FE MYTESI 3 PA; FE NULEV 3 oscimin 1 oscimin sl 1 oscimin sr 1 paregoric 1 phenobarb-hyoscy-atropine-scop 1

phenohytro 1 propantheline 1 ROBINUL 3 ROBINUL FORTE 3 SYMAX DUOTAB 3 PA; FE symax fastabs 1 symax-sl 1 symax-sr 1

Drug Name Tier Requirements/ Limitations

Miscellaneous Gastrointestinal Agents

ACTIGALL 3 AKYNZEO (NETUPITANT) 3 PA; FE; QL alophen 5 ACA alosetron 1 AMITIZA 2 QL ANA-LEX KIT 3 PA; FE ANALPRAM-HC RECTAL CREAM 1-1 % 3 PA; FE

ANALPRAM-HC RECTAL CREAM 2.5-1 % 3

ANALPRAM-HC SINGLES 3 ANUSOL-HC 3 ANZEMET 3 PA; FE; QL aprepitant 1 QL APRISO 3 PA; FE ASACOL HD 2 AURYXIA 3 PA; FE AZULFIDINE 3 AZULFIDINE EN-TABS 3 balsalazide 1 bisacodyl 5 ACA bisa-lax 5 ACA budesonide 1 QL calcium acetate 1 CANASA 2 CESAMET 3 CHENODAL 4 PA; LA CHOLBAM 4 PA CIMZIA 4 PA; QL citrate of magnesia 5 ACA citroma 5 ACA clearlax 5 ACA CLENPIQ 3 COLAZAL 3 colocort 1 COLYTE WITH FLAVOR PACKS 3

COMPAZINE 3 compro 1 constulose 1 CORTENEMA 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

34

Drug Name Tier Requirements/ Limitations

CORTIFOAM 2 CREON 2 cromolyn 1 CYSTADANE 4 DELZICOL 2 DIPENTUM 3 dronabinol 1 ducodyl 5 ACA eliphos 1 EMEND ORAL CAPSULE 3 QL EMEND ORAL CAPSULE, DOSE PACK 3 QL

EMEND ORAL SUSPENSION FOR RECONSTITUTION 2 QL

ENTEREG 3 PA; FE ENTOCORT EC 3 QL enulose 1 fleet laxative 5 ACA FOSRENOL 3 GASTROCROM 3 gavilax 5 ACA gavilyte-c 5 ACA gavilyte-g 5 ACA gavilyte-n 5 ACA generlac 1 gentle laxative 5 ACA gentlelax 5 ACA GIALAX 3 PA; FE glycolax 5 ACA GOLYTELY ORAL POWDER IN PACKET 2

GOLYTELY ORAL RECON SOLN 3

granisetron hcl 1 QL healthylax 5 ACA hemmorex-hc 1 hydrocortisone 1 hydrocortisone acetate 1 kionex (with sorbitol) 1 KRISTALOSE 3 lactulose 1 lanthanum 1 laxaclear 5 ACA

Drug Name Tier Requirements/ Limitations

laxative (bisacodyl) 5 ACA laxative feminine 5 ACA laxative peg 3350 5 ACA LIALDA 3 LIDOCAINE HCL-HYDROCORTISON AC RECTAL CREAM 3 %-1 % (7 GRAM)

3 PA; FE

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

1

LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL

3 PA; FE

lidocaine hcl-hydrocortisone ac rectal kit

1

lidocaine-hydrocortisone-aloe 1

LINZESS 2 QL LOTRONEX 3 MAGNEBIND 400 3 PA; FE magnesium citrate 5 ACA MARINOL 3 mesalamine oral tablet, delayed release (dr/ec) 1.2 gram

1

MESALAMINE ORAL TABLET, DELAYED RELEASE (DR/EC) 800 MG

3 PA; FE

mesalamine rectal 1 mesalamine with cleansing wipe 1

metoclopramide hcl 1 MICORT-HC 3 PA; FE milk of magnesia 5 ACA milk of magnesia concentrated 5 ACA

miralax 5 ACA MOVANTIK 2 QL MOVIPREP 3 natura-lax 5 ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

35

Drug Name Tier Requirements/ Limitations

NULYTELY WITH FLAVOR PACKS 3

OCALIVA 4 PA;FE;LA;QL ondansetron 1 ondansetron hcl 1 oral saline laxative 5 ACA OSMOPREP 3 PANCREAZE 3 peg 3350-electrolytes 5 ACA peg3350 5 ACA peg-electrolyte soln 5 ACA peg-prep 5 ACA PENTASA 2 PERTZYE 3 PA; FE PHOSLYRA 3 phosphate laxative 5 ACA powderlax 5 ACA pramcort 1 PREPOPIK 3 prochlorperazine 1 prochlorperazine maleate 1

PROCORT 3 PA; FE PROCTOFOAM HC 2 procto-med hc 1 proctosol hc 1 proctozone-hc 1 purelax 5 ACA RECTIV 3 PA; FE REGLAN 3 RELISTOR 3 PA; FE RENAGEL 2 RENVELA 3 ROWASA 3 SANCUSO 3 PA; FE; QL scopolamine base 1 sevelamer carbonate 1 SFROWASA 3 smoothlax 5 ACA sodium polystyrene (sorb free) 1

sodium polystyrene sulfonate oral 1

Drug Name Tier Requirements/ Limitations

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

1

SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

3 PA; FE

sps (with sorbitol) 1 SUCRAID 4 PA sulfasalazine 1 SUPREP BOWEL PREP KIT 3 PA; FE SYMPROIC 2 QL SYNDROS 3 PA; FE TIGAN 3 TRANSDERM-SCOP 3 trilyte with flavor packets 5 ACA trimethobenzamide 1 TRULANCE 3 PA; FE; QL UCERIS ORAL 3 PA;ST;FE;QL UCERIS RECTAL 3 PA; ST; FE URSO 250 3 URSO FORTE 3 ursodiol 1 VARUBI 3 PA; FE; QL VELPHORO 3 PA; FE VELTASSA 2 VIBERZI 3 PA; FE VIOKACE 3 PA; FE woman's laxative 5 ACA women's gentle laxative(bisac) 5 ACA

women's laxative (bisacodyl) 5 ACA

ZENPEP 3 ZOFRAN 3 ZOFRAN ODT 3 ZUPLENZ 3 PA; FE Ulcer Therapy ACIPHEX 3 QL ACIPHEX SPRINKLE 3 PA; FE amoxicil-clarithromy-lansopraz 1 QL

CARAFATE ORAL SUSPENSION 3 PA; FE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

36

Drug Name Tier Requirements/ Limitations

CARAFATE ORAL TABLET 3 cimetidine 1 cimetidine hcl 1 CYTOTEC 3 DEXILANT 3 PA; FE; QL esomeprazole magnesium 40 mg 1 QL

ESOMEPRAZOLE STRONTIUM 3 PA; FE

famotidine 1 lansoprazole 1 QL misoprostol 1 NEXIUM 3 QL NEXIUM PACKET 3 PA; QL nizatidine 1 OMECLAMOX-PAK 3 PA; FE omeppi 1 omeprazole 1 QL omeprazole-sodium bicarbonate 1

pantoprazole 1 QL PEPCID 3 PREVACID 3 QL PREVACID SOLUTAB 3 QL PRILOSEC 3 PA; FE PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET

3 PA; FE; QL

PROTONIX ORAL TABLET, DEL-RELEASE (DR/EC) 3 QL

PYLERA 3 PA; FE rabeprazole 1 QL ranitidine hcl 1 sucralfate 1 ZANTAC 3 ZEGERID 3

Drug Name Tier Requirements/ Limitations

IMMUNOLOGY & BIOTECHNOLOGY Growth Hormones GENOTROPIN 4 PA

Drug Name Tier Requirements/ Limitations

GENOTROPIN MINIQUICK 4 PA HUMATROPE 4 PA NORDITROPIN FLEXPRO 4 PA NUTROPIN AQ NUSPIN 4 PA OMNITROPE 4 PA SAIZEN 4 PA SAIZEN SAIZENPREP 4 PA; FE SEROSTIM 4 PA ZOMACTON 4 PA ZORBTIVE 4 PA Interferons AUBAGIO 4 PA; QL AVONEX 4 PA; QL AVONEX (WITH ALBUMIN) 4 PA; QL BETASERON 4 PA; QL COPAXONE 20 MG/ML SUBCUTANEOUS SYRINGE 4 PA; FE; QL

COPAXONE 40 MG/ML SUBCUTANEOUS SYRINGE 4 PA; QL

EXTAVIA SUBCUTANEOUS KIT 4 PA; QL

EXTAVIA SUBCUTANEOUS RECON SOLN 4 PA

GILENYA 4 PA; QL glatiramer 4 PA; FE; QL glatopa subcutaneous syringe 20 mg/ml 4 PA; FE; QL

glatopa subcutaneous syringe 40 mg/ml 4 PA; QL

moderiba 1 moderiba dose pack 1 PEGASYS 4 PEGASYS PROCLICK 4 PEGINTRON 4 PLEGRIDY 4 PA; QL REBETOL 3 PA; FE REBIF (WITH ALBUMIN) 4 PA; FE; QL REBIF REBIDOSE 4 PA; FE; QL REBIF TITRATION PACK 4 PA; FE; QL ribasphere 1 ribasphere ribapak 1 ribavirin 1 TECFIDERA 4 PA; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

37

Drug Name Tier Requirements/ Limitations

Interleukins ACTIMMUNE 4 PA ALDARA 3 QL ARCALYST 4 PA imiquimod 1 QL KINERET 4 PA; QL ZYCLARA 2 QL Miscellaneous Immunologicals GRASTEK 3 PA; FE ODACTRA 3 PA; QL ORALAIR 4 RAGWITEK 3 PA; FE

Drug Name Tier Requirements/ Limitations

MUSCULOSKELETAL / RHEUMATOLOGY

Gout Therapy allopurinol 1 COLCHICINE 3 PA; FE COLCRYS 2 DUZALLO 3 MITIGARE 3 PA; FE probenecid 1 probenecid-colchicine 1 ULORIC 3 ST ZURAMPIC 3 PA; FE ZYLOPRIM 3 Osteoporosis Therapy ACTONEL 3 alendronate 1 ATELVIA 3 BINOSTO 3 PA; FE BONIVA 3 EVISTA 3 FORTEO 4 PA; FE; QL FOSAMAX 3 FOSAMAX PLUS D 3 ibandronate 1 raloxifene 5 ACA risedronate 1 TYMLOS 4 PA; QL

Drug Name Tier Requirements/ Limitations

Other Rheumatologicals ACTEMRA 4 PA; QL ARAVA 3 QL BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 4 PA

BENLYSTA SUBCUTANEOUS SYRINGE 4 PA; QL

CUPRIMINE 3 PA; FE DEPEN TITRATABS 2 ENBREL 4 PA; QL ENBREL MINI 4 PA; QL ENBREL SURECLICK 4 PA; QL HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

4 PA; QL

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML

4 PA

HUMIRA PEN CROHN'S-UC-HS START 4 PA; QL

HUMIRA PEN PSORIASIS-UVEITIS 4 PA; QL

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML

4 PA

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

4 PA; QL

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4 ML

4 PA

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML

4 PA; QL

KEVZARA SUBCUTANEOUS PEN INJECTOR 4 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

38

Drug Name Tier Requirements/ Limitations

KEVZARA SUBCUTANEOUS SYRINGE 4 PA; QL

leflunomide 1 QL ORENCIA 4 PA; QL ORENCIA CLICKJECT 4 PA; FE; QL OTEZLA 4 PA; QL OTEZLA STARTER 4 PA; QL OTREXUP (PF) 3 PA; FE RASUVO (PF) 3 PA; FE RIDAURA 2 SAVELLA 2 ST; QL SIMPONI 4 PA; QL XELJANZ TABLET 10 MG 4 QL XELJANZ TABLET 5 MG 4 PA; QL XELJANZ XR 4 PA; QL

Drug Name Tier Requirements/ Limitations

OBSTETRICS / GYNECOLOGY Diaphragms And Other Non-Oral Contraceptives

FC2 FEMALE CONDOM 5 ACA Estrogens & Progestins ACTIVELLA 3 ALORA 3 PA; FE; QL amabelz 1 ANGELIQ 3 PA; FE AYGESTIN 3 camila 5 ACA CLIMARA 3 QL CLIMARA PRO 3 PA; FE; QL COMBIPATCH 2 QL CRINONE 2 deblitane 5 ACA DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML

2

DELESTROGEN INTRAMUSCULAR OIL 20 MG/ML, 40 MG/ML

3

DEPO-ESTRADIOL 2

Drug Name Tier Requirements/ Limitations

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML

3 ACA

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

3 PA; FE

DEPO-PROVERA INTRAMUSCULAR SYRINGE 3 ACA

DEPO-SUBQ PROVERA 104 3 PA; FE DIVIGEL 3 DUAVEE 3 ELESTRIN 3 ENDOMETRIN 3 errin 5 ACA ESTRACE 3 estradiol oral 1 estradiol transdermal 1 QL estradiol vaginal 1 estradiol valerate 1 estradiol-norethindrone acet 1

ESTRING 3 PA; FE; QL ESTROGEL 3 estropipate 1 EVAMIST 3 PA; FE FEMHRT LOW DOSE 3 FEMRING 3 PA; FE; QL fyavolv 1 heather 5 ACA hydroxyprogesterone caproate 1

jencycla 5 ACA jevantique lo 1 jinteli 1 jolivette 5 ACA lopreeza 1 lyza 5 ACA MAKENA 4 PA; FE MAKENA (PF) 4 PA; FE medroxyprogesterone intramuscular 5 ACA

medroxyprogesterone oral 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

39

Drug Name Tier Requirements/ Limitations

MENEST 3 PA; FE MENOSTAR 3 PA; FE; QL mimvey 1 mimvey lo 1 MINIVELLE 3 PA; FE; QL nora-be 5 ACA norethindrone (contraceptive) 5 ACA

norethindrone acetate 1 norethindrone ac-eth estradiol 1

norlyda 5 ACA norlyroc 5 ACA ORTHO MICRONOR 3 ACA PREFEST 3 PA; FE PREMARIN ORAL 2 PREMARIN VAGINAL 3 PA; FE PREMPHASE 2 PREMPRO 2 progesterone 4 progesterone micronized 1 PROMETRIUM 3 PROVERA 3 sharobel 5 ACA tulana 5 ACA VAGIFEM 3 VIVELLE-DOT 3 QL yuvafem 1 Miscellaneous OB/GYN AVC VAGINAL 2 CERVIDIL 3 PA; FE CLEOCIN 3 clindamycin phosphate 1 CLINDESSE 3 fem ph 1 GYNAZOLE-1 3 gynol ii 5 ACA INTRAROSA 3 QL isoxsuprine 1 LYSTEDA 3 QL METROGEL VAGINAL 3 metronidazole 1 NUVARING 5 ACA; QL

Drug Name Tier Requirements/ Limitations

NUVESSA 3 PA; FE OSPHENA 3 PROSTIN E2 3 PA; FE RELAGARD 3 terconazole 1 QL TODAY CONTRACEPTIVE SPONGE 5 ACA

tranexamic acid 1 QL vaginal contraceptive foam 5 ACA

vandazole 1 VCF CONTRACEPTIVE FILM 2

xulane 5 ACA; QL Oral Contraceptives & Related Agents AFTERA 3 ACA altavera (28) 5 ACA alyacen 1/35 (28) 5 ACA alyacen 7/7/7 (28) 5 ACA amethia 5 ACA amethia lo 5 ACA amethyst 5 ACA apri 5 ACA aranelle (28) 5 ACA ashlyna 5 ACA aubra 5 ACA aviane 5 ACA azurette (28) 5 ACA BALCOLTRA 3 PA; FE balziva (28) 5 ACA bekyree (28) 5 ACA BEYAZ 3 ACA blisovi 24 fe 5 ACA blisovi fe 1.5/30 (28) 5 ACA blisovi fe 1/20 (28) 5 ACA BREVICON (28) 3 ACA briellyn 5 ACA camrese 5 ACA camrese lo 5 ACA caziant (28) 5 ACA chateal 5 ACA cryselle (28) 5 ACA cyclafem 1/35 (28) 5 ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

40

Drug Name Tier Requirements/ Limitations

cyclafem 7/7/7 (28) 5 ACA CYCLESSA (28) 3 ACA cyred 5 ACA dasetta 1/35 (28) 5 ACA dasetta 7/7/7 (28) 5 ACA daysee 5 ACA delyla (28) 5 ACA desog-e.estradiol/e.estradiol 5 ACA

desogestrel-ethinyl estradiol 5 ACA

drospirenone-e.estradiol-lm.fa 5 ACA

drospirenone-ethinyl estradiol 5 ACA

econtra ez 5 ACA econtra one-step 5 ACA elinest 5 ACA ELLA 5 ACA emoquette 5 ACA enpresse 5 ACA enskyce 5 ACA estarylla 5 ACA ESTROSTEP FE-28 3 ACA ethynodiol diac-eth estradiol 5 ACA

falmina (28) 5 ACA fayosim 5 ACA femynor 5 ACA GENERESS FE 3 ACA gianvi (28) 5 ACA introvale 5 ACA isibloom 5 ACA jolessa 5 ACA juleber 5 ACA junel 1.5/30 (21) 5 ACA junel 1/20 (21) 5 ACA junel fe 1.5/30 (28) 5 ACA junel fe 1/20 (28) 5 ACA junel fe 24 5 ACA kaitlib fe 5 ACA kariva (28) 5 ACA kelnor 1/35 (28) 5 ACA

Drug Name Tier Requirements/ Limitations

kelnor 1-50 5 ACA kurvelo 5 ACA l norgest/e.estradiol-e.estrad 5 ACA

larin 1.5/30 (21) 5 ACA larin 1/20 (21) 5 ACA larin 24 fe 5 ACA larin fe 1.5/30 (28) 5 ACA larin fe 1/20 (28) 5 ACA larissia 5 ACA layolis fe 5 ACA leena 28 5 ACA lessina 5 ACA levonest (28) 5 ACA levonorgestrel-ethinyl estrad 5 ACA

levonorg-eth estrad triphasic 5 ACA

levora-28 5 ACA lillow 5 ACA LO LOESTRIN FE 3 PA; FE LOESTRIN 1.5/30 (21) 3 ACA LOESTRIN 1/20 (21) 3 ACA LOESTRIN FE 1.5/30 (28-DAY) 3 ACA

LOESTRIN FE 1/20 (28-DAY) 3 ACA loryna (28) 5 ACA LOSEASONIQUE 3 ACA low-ogestrel (28) 5 ACA lutera (28) 5 ACA marlissa 5 ACA melodetta 24 fe 5 ACA mibelas 24 fe 5 ACA microgestin 1.5/30 (21) 5 ACA microgestin 1/20 (21) 5 ACA MICROGESTIN 24 FE 3 ACA microgestin fe 1.5/30 (28) 5 ACA microgestin fe 1/20 (28) 5 ACA mili 5 ACA MINASTRIN 24 FE 3 ACA MIRCETTE (28) 3 ACA mono-linyah 5 ACA mononessa (28) 5 ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

41

Drug Name Tier Requirements/ Limitations

my choice 5 ACA my way 5 ACA myzilra 5 ACA NATAZIA 3 PA; FE necon 0.5/35 (28) 5 ACA necon 7/7/7 (28) 5 ACA nikki (28) 5 ACA noreth-ethinyl estradiol-iron 5 ACA

norethindrone ac-eth estradiol 5 ACA

norethindrone-e.estradiol-iron 5 ACA

norgestimate-ethinyl estradiol 5 ACA

nortrel 0.5/35 (28) 5 ACA nortrel 1/35 (21) 5 ACA nortrel 1/35 (28) 5 ACA nortrel 7/7/7 (28) 5 ACA ocella 5 ACA ogestrel (28) 5 ACA opcicon one-step 5 ACA option-2 5 ACA orsythia 5 ACA ORTHO TRI-CYCLEN (28) 3 ACA ORTHO TRI-CYCLEN LO (28) 3 ACA

ORTHO-CYCLEN (28) 3 ACA ORTHO-NOVUM 1/35 (28) 3 ACA ORTHO-NOVUM 7/7/7(28) 3 ACA philith 5 ACA pimtrea (28) 5 ACA pirmella 5 ACA PLAN B ONE-STEP 3 ACA portia 5 ACA previfem 5 ACA QUARTETTE 3 ACA quasense 5 ACA rajani 5 ACA reclipsen (28) 5 ACA rivelsa 5 ACA SAFYRAL 3 ACA SEASONIQUE 3 ACA

Drug Name Tier Requirements/ Limitations

setlakin 5 ACA sprintec (28) 5 ACA sronyx 5 ACA syeda 5 ACA TAKE ACTION 3 ACA tarina fe 1/20 (28) 5 ACA TAYTULLA 3 PA; FE tilia fe 5 ACA tri femynor 5 ACA tri-estarylla 5 ACA tri-legest fe 5 ACA tri-linyah 5 ACA tri-lo-estarylla 5 ACA tri-lo-marzia 5 ACA tri-lo-sprintec 5 ACA tri-mili 5 ACA trinessa (28) 5 ACA trinessa lo 5 ACA TRI-NORINYL (28) 3 ACA tri-previfem (28) 5 ACA tri-sprintec (28) 5 ACA trivora (28) 5 ACA tri-vylibra 5 ACA tydemy 5 ACA velivet triphasic regimen (28) 5 ACA

vienva 5 ACA viorele (28) 5 ACA vyfemla (28) 5 ACA vylibra 5 ACA wera (28) 5 ACA wymzya fe 5 ACA YASMIN (28) 3 ACA YAZ (28) 3 ACA zarah 5 ACA zenchent (28) 5 ACA zovia 1/35e (28) 5 ACA Oxytocics methergine 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

42

Drug Name Tier Requirements/ Limitations

OPHTHALMOLOGY Antibiotics ak-poly-bac 1 AZASITE 2 bacitracin 1 bacitracin-polymyxin b 1 BESIVANCE 3 BETADINE OPHTHALMIC PREP 3 PA; FE

CILOXAN OPHTHALMIC (EYE) DROPS 3

CILOXAN OPHTHALMIC (EYE) OINTMENT 2

ciprofloxacin hcl 1 erythromycin 1 gatifloxacin 1 gentak 1 gentamicin 1 levofloxacin 1 MOXEZA 3 PA; FE moxifloxacin 1 NATACYN 3 neomycin-bacitracin-polymyxin 1

neomycin-polymyxin-gramicidin 1

neo-polycin 1 OCUFLOX 3 ofloxacin 1 polycin 1 polymyxin b sulf-trimethoprim 1

POLYTRIM 3 tobramycin 1 TOBREX OPHTHALMIC (EYE) DROPS 3

TOBREX OPHTHALMIC (EYE) OINTMENT 2

VIGAMOX 3 ZYMAXID 3 Antivirals trifluridine 1 VIROPTIC 3

Drug Name Tier Requirements/ Limitations

ZIRGAN 3 Beta-Blockers BETAGAN 3 betaxolol 1 BETIMOL 3 BETOPTIC S 3 carteolol 1 ISTALOL 3 levobunolol 1 metipranolol 1 timolol maleate 1 TIMOPTIC 3 TIMOPTIC OCUDOSE (PF) 3 TIMOPTIC-XE 3 Cholinesterase Inhibitor Miotics PHOSPHOLINE IODIDE 2 Cycloplegic Mydriatics atropine 1 CYCLOGYL OPHTHALMIC (EYE) DROPS 0.5 %, 2 % 3

CYCLOGYL OPHTHALMIC (EYE) DROPS 1 % 3 PA; FE

cyclopentolate 1 homatropaire 1 homatropine hbr 1 PAREMYD 3 PA; FE Direct Acting Miotics ISOPTO CARPINE 3 pilocarpine hcl 1 Miscellaneous Ophthalmologics ALOCRIL 3 ALOMIDE 3 azelastine 1 BEPREVE 3 cromolyn 1 CYSTARAN 4 ELESTAT 3 EMADINE 3 epinastine 1 LACRISERT 3 PA; FE LASTACAFT 3 olopatadine 1 PATADAY 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

43

Drug Name Tier Requirements/ Limitations

PATANOL 3 PAZEO 3 PA; FE proparacaine 1 RESTASIS 2 QL RESTASIS MULTIDOSE 2 QL XIIDRA 3 QL Non-Steroidal Anti-Inflammatory Agents

ACULAR 3 ACULAR LS 3 ACUVAIL (PF) 2 bromfenac 1 BROMSITE 3 PA; FE diclofenac sodium 1 flurbiprofen sodium 1 ILEVRO 2 ketorolac 1 NEVANAC 3 PA; FE PROLENSA 3 PA; FE Oral Drugs For Glaucoma acetazolamide 1 methazolamide 1 Other Glaucoma Drugs AZOPT 3 bimatoprost 1 COMBIGAN 3 COSOPT 3 COSOPT (PF) 3 dorzolamide 1 dorzolamide-timolol 1 latanoprost 1 LUMIGAN 2 ST MITOSOL 3 PA; FE RHOPRESSA 3 PA; FE SIMBRINZA 3 TRAVATAN Z 3 ST TRUSOPT 3 VYZULTA 3 PA; ST; FE XALATAN 3 ZIOPTAN (PF) 3 PA; ST; FE Steroid-Antibiotic Combinations MAXITROL 3

Drug Name Tier Requirements/ Limitations

neomycin-bacitracin-poly-hc 1

neomycin-polymyxin b-dexameth 1

neomycin-polymyxin-hc 1 neo-polycin hc 1 PRED-G 2 PRED-G S.O.P. 2 TOBRADEX 3 TOBRADEX ST 2 tobramycin-dexamethasone 1

ZYLET 3 Steroids ALREX 3 PA; FE dexamethasone sodium phosphate 1

DUREZOL 2 FLAREX 2 fluorometholone 1 FML FORTE 3 PA; FE FML LIQUIFILM 3 FML S.O.P. 2 LOTEMAX 2 MAXIDEX 2 OMNIPRED 3 PRED FORTE 3 PRED MILD 2 prednisolone acetate 1 prednisolone sodium phosphate 1

Steroid-Sulfonamide Combinations BLEPHAMIDE 2 BLEPHAMIDE S.O.P. 2 sulfacetamide-prednisolone 1

Sulfonamides BLEPH-10 3 sulfacetamide sodium 1 Sympathomimetics ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %

2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

44

Drug Name Tier Requirements/ Limitations

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.15 %

3

apraclonidine 1 brimonidine 1 IOPIDINE OPHTHALMIC (EYE) DROPPERETTE 3 PA; FE

IOPIDINE OPHTHALMIC (EYE) DROPS 3

Vasoconstrictor Decongestants phenylephrine hcl 1

Drug Name Tier Requirements/ Limitations

RESPIRATORY & ALLERGY Antihistamine & Antiallergenic Agents AUVI-Q 3 PA; FE; QL carbinoxamine maleate 1 CLARINEX ORAL SYRUP 3 PA; FE CLARINEX ORAL TABLET 3 cyproheptadine 1 desloratadine 1 EPINEPHRINE 2 QL EPIPEN 2-PAK 3 PA; FE; QL EPIPEN JR 2-PAK 3 PA; FE; QL hydroxyzine hcl 1 hydroxyzine pamoate 1 KARBINAL ER 3 PA; FE phenadoz 1 phenergan 1 promethazine 1 promethegan 1 RYVENT 3 PA; FE VISTARIL 3 Cough & Cold Therapy benzonatate 1 BROMFED DM 3 brompheniramine-pseudoeph-dm 1

CAPCOF 3 PA; FE centergy 1 cheratussin ac 1

Drug Name Tier Requirements/ Limitations

CLARINEX-D 12 HOUR 3 PA; FE codeine-guaifenesin 1 CODITUSSIN AC 3 PA; FE CODITUSSIN DAC 3 PA; FE g tussin ac 1 guaiatussin ac 1 guaifenesin ac 1 HISTEX-AC 3 PA; FE hydrocodone-chlorpheniramine 1

hydrocodone-cpm-pseudoephed 1

hydrocodone-homatropine 1

hydromet 1 lortuss ex 1 MAR-COF CG 3 PA; FE m-clear wc 1 M-END PE 3 PA; FE NINJACOF-XG 3 PA; FE OBREDON 3 PA; FE POLY-TUSSIN AC 3 PA; FE promethazine vc-codeine 1

promethazine-codeine 1 promethazine-dm 1 promethazine-phenylephrine 1

PRO-RED AC (W/ DEXCHLORPHENIR) 3 PA; FE

RESPA-AR 3 robafen ac 1 rydex 1 SEMPREX-D 3 PA; FE TESSALON PERLES 3 tusnel c 1 TUSNEL PEDIATRIC 3 PA; FE TUSSICAPS 3 PA; FE tussigon 1 TUSSIONEX PENNKINETIC ER 3

TUZISTRA XR 3 PA; FE virtussin ac 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

45

Drug Name Tier Requirements/ Limitations

virtussin dac 1 VITUZ 3 PA; FE ZODRYL AC 25 3 PA; FE ZODRYL AC 30 3 PA; FE ZODRYL AC 35 3 PA; FE ZODRYL AC 40 3 PA; FE ZODRYL AC 50 3 PA; FE ZODRYL AC 60 3 PA; FE ZODRYL AC 80 3 PA; FE ZODRYL DAC 25 3 PA; FE ZODRYL DAC 30 3 PA; FE ZODRYL DAC 35 3 PA; FE ZODRYL DAC 40 3 PA; FE ZODRYL DAC 50 3 PA; FE ZODRYL DAC 60 3 PA; FE ZODRYL DAC 80 3 PA; FE ZODRYL DEC 25 3 PA; FE ZODRYL DEC 30 2 ZODRYL DEC 35 3 PA; FE ZODRYL DEC 40 3 PA; FE ZODRYL DEC 50 3 PA; FE ZODRYL DEC 60 3 PA; FE ZODRYL DEC 80 3 PA; FE Pulmonary Agents ACCOLATE 3 acetylcysteine 1 ADCIRCA 4 PA; QL ADEMPAS 4 PA; LA; QL ADRENALIN 2 ADVAIR DISKUS 2 QL ADVAIR HFA 2 QL AEROSPAN 3 PA; FE; QL AIRDUO RESPICLICK 3 PA; FE; QL albuterol sulfate 1 ALVESCO 3 QL ANORO ELLIPTA 2 QL ARCAPTA NEOHALER 3 QL ARMONAIR RESPICLICK 2 QL ARNUITY ELLIPTA 2 QL ASMANEX HFA 3 PA; FE; QL ASMANEX TWISTHALER 3 PA; FE; QL ATROVENT HFA 2 QL

Drug Name Tier Requirements/ Limitations

BECONASE AQ 3 PA; FE BEVESPI AEROSPHERE 3 PA; FE; QL BREO ELLIPTA 2 QL BROVANA 3 PA; FE; QL budesonide 1 COMBIVENT RESPIMAT 2 QL cromolyn 1 DALIRESP TABLET 250MCG 3 PA; FE DALIRESP TABLET 500MCG 2 DULERA 2 QL DYMISTA 3 ELIXOPHYLLIN 3 PA; FE ESBRIET 4 PA; QL FIRAZYR 4 PA FLOVENT DISKUS 2 QL FLOVENT HFA 2 QL flunisolide 1 fluticasone 1 QL FLUTICASONE-SALMETEROL 3 PA; FE; QL

HAEGARDA 4 PA; LA HYPER-SAL 3 PA; FE INCRUSE ELLIPTA 2 QL ipratropium bromide 1 ipratropium-albuterol 1 KALYDECO 4 PA; QL LETAIRIS 4 PA; LA; QL levalbuterol hcl 1 LEVALBUTEROL TARTRATE 3 PA; FE; QL LONHALA MAGNAIR REFILL 3 PA; FE; QL

LONHALA MAGNAIR STARTER 3 PA; FE; QL

metaproterenol 1 mometasone 1 QL montelukast 1 NASONEX 3 QL nebusal 3 % inhalation soln for nebulization 1

NEBUSAL 6 % INHALATION SOLN FOR NEBULIZATION 3 PA; FE

OFEV 4 PA; QL OMNARIS 3 PA; FE

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

46

Drug Name Tier Requirements/ Limitations

OPSUMIT 4 PA; LA; QL ORKAMBI 4 PA; QL PERFOROMIST 2 QL PROAIR HFA 2 QL PROAIR RESPICLICK 2 QL PROVENTIL HFA 3 PA; FE; QL PULMICORT 3 PULMICORT FLEXHALER 2 QL pulmosal 1 PULMOZYME 4 QNASL 3 PA; FE QVAR REDIHALER 2 REVATIO ORAL SUSPENSION FOR RECON 2 PA

REVATIO ORAL TABLET 3 PA; QL SEEBRI NEOHALER 3 PA; FE SEREVENT DISKUS 2 QL sildenafil (antihypertensive) 1 PA; QL

SINGULAIR 3 sodium chloride 1 SPIRIVA RESPIMAT 2 QL SPIRIVA W/ HANDIHALER 2 QL STIOLTO RESPIMAT 2 QL STRIVERDI RESPIMAT 3 QL SURFAXIN 3 PA; FE SYMBICORT 2 QL SYMDEKO 4 PA; QL terbutaline 1 THEO-24 3 theochron 1 theophylline 1 TRACLEER 4 PA; LA; QL TRELEGY ELLIPTA 2 QL TUDORZA PRESSAIR 3 PA; FE; QL TYVASO 4 PA TYVASO REFILL KIT 4 PA TYVASO STARTER KIT 4 PA UTIBRON NEOHALER 3 PA; FE; QL VENTAVIS 4 PA; QL VENTOLIN HFA 2 QL XHANCE 3 PA; FE; QL XOPENEX 3

Drug Name Tier Requirements/ Limitations

XOPENEX CONCENTRATE 3 XOPENEX HFA 3 PA; FE; QL zafirlukast 1 ZETONNA 3 zileuton 1 ZYFLO 2 ZYFLO CR 3

Drug Name Tier Requirements/ Limitations

UROLOGICALS Anticholinergics & Antispasmodics darifenacin 1 DETROL 3 DETROL LA 3 DITROPAN XL 3 ENABLEX 3 flavoxate 1 GELNIQUE 3 PA; FE MYRBETRIQ 2 ST oxybutynin chloride 1 OXYTROL 3 PA; FE tolterodine 1 TOVIAZ 2 ST trospium 1 VESICARE 2 ST Benign Prostatic Hyperplasia (BPH) Therapy

alfuzosin 1 AVODART 3 CIALIS 3 PA; FE; QL dutasteride 1 dutasteride-tamsulosin 1 finasteride 1 FLOMAX 3 PA; FE JALYN 3 PROSCAR 3 RAPAFLO 3 PA; FE tamsulosin 1 UROXATRAL 3 Cholinergic Stimulants bethanechol chloride 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

47

Drug Name Tier Requirements/ Limitations

URECHOLINE 3 Miscellaneous Urologicals azuphen mb 1 CYSTAGON 4 LA cytra k crystals 1 cytra-2 1 cytra-3 1 cytra-k 1 ELMIRON 2 hyolev mb 1 hyophen 1 INDIOMIN MB 3 PA; FE K-PHOS NO 2 2 K-PHOS ORIGINAL 2 methen-sod phos-meth blue-hyos 1

ORACIT 2 phosphasal 1 pot,sodium citrate-citric acid 1

potassium citrate 1 potassium citrate-citric acid 1

PROCYSBI 4 SHOHL'S MODIFIED 2 sodium citrate-citric acid 1 tricitrates 1 URELLE 3 uretron d-s 1 URIBEL 3 urimar-t 1 urin ds 1 uro-458 1 UROCIT-K 10 3 UROCIT-K 15 3 UROCIT-K 5 3 urogesic-blue 1 uro-mp 1 urophen mb 1 UROQID-ACID NO.2 3 PA; FE uryl 1 ustell 1 UTA 3 PA; FE

Drug Name Tier Requirements/ Limitations

utira-c 1 vilamit mb 1 vilevev mb 1 virtrate-2 1 virtrate-3 1 virtrate-k 1 Urinary Anesthetics phenazopyridine 1 PYRIDIUM 3

Drug Name Tier Requirements/ Limitations

VITAMINS / HEMATINICS / ELECTROLYTES

Electrolytes calcium 500 + d 5 ACA calcium 500 with d 5 ACA calcium 600 + d(3) 5 ACA calcium 600 with vitamin d3 5 ACA

calcium carb and citrate-vitd3 5 ACA

calcium carbonate-vitamin d3 5 ACA

calcium citrate + d 5 ACA calcium citrate-vitamin d2 5 ACA

calcium citrate-vitamin d3 5 ACA

citrus calcium 5 ACA effer-k 1 GALZIN 3 PA; FE hi-cal plus vit d 5 ACA k-effervescent 1 klor-con 1 klor-con 10 1 klor-con 8 1 klor-con m10 1 klor-con m15 1 klor-con m20 1 klor-con sprinkle 1 klor-con/ef 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

48

Drug Name Tier Requirements/ Limitations

k-phos-neutral 1 K-TAB ORAL TABLET EXT-REL 10 MEQ, 20 MEQ 3 PA; FE

k-tab oral tablet extended release 8 meq 1

lugols 1 oysco 500/d 5 ACA oyster shell + d3 5 ACA oyster shell calcium-vit d3 5 ACA oystercal-d 5 ACA phospha 250 neutral 1 phosphorous 1 potassium bicarb and chloride 1

potassium bicarb-citric acid 1

potassium chloride 1 strong iodine 1 virt-phos 250 neutral 1 Vitamins & Hematinics b complex-vitamin b12 5 ACA b complex-vit c-folic acid 5 ACA balanced b-100 5 ACA balanced b-100 complex 5 ACA balanced b-50 5 ACA b-complex with vitamin c 5 ACA calcium-folic acid-vit d 1 cholecalciferol (vit d3) 5 ACA classic prenatal 5 ACA complex b-100 5 ACA delta d3 5 ACA dialyvite 800 5 ACA d-vi-sol 5 ACA ergocalciferol (vit d2) 5 ACA fluoride (sodium) 5 ACA fluoritab 5 ACA FOLGARD OS 3 PA; FE folic acid 5 ACA foltabs 800 5 ACA full spectrum b-vitamin c 5 ACA kobee 5 ACA kpn 5 ACA ludent fluoride 5 ACA

Drug Name Tier Requirements/ Limitations

multi-vitamin with fluoride 5 ACA multivitamins with fluoride 5 ACA mvc-fluoride 5 ACA natural b-100 complex 5 ACA one daily prenatal 5 ACA oyster shell calcium-vit d2 5 ACA perry prenatal 5 ACA prenatal 5 ACA prenatal complete 5 ACA prenatal formula 5 ACA prenatal multi-dha (algal oil) 5 ACA

prenatal one daily 5 ACA prenatal vitamin 5 ACA prenatal vitamin with minerals 5 ACA

prenatal vits96-iron fum-folic 5 ACA

rena-vite 5 ACA risacal-d 5 ACA stress formula 5 ACA stress formula with iron 5 ACA stress formula with iron(sulf) 5 ACA

super b complex-vit c 5 ACA super b maxi complex 5 ACA super b-50 complex plus 5 ACA super quints 5 ACA super quints b-50 5 ACA superplex-t 5 ACA tl g-fol os 1 total b/c 5 ACA tri-vitamin with fluoride 5 ACA ultra b-100 complex 5 ACA vitajoy daily d 5 ACA vitamin b complex 5 ACA vitamin b complex-folic acid 5 ACA

vitamin d3 5 ACA vitamins a, c, d, and fluoride 5 ACA

49

INDEX

A

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

zidovudine ..................... 5 ABILIFY .............................. 14 ABSORICA ....................... 23 ABSTRAL ........................... 12 acamprosate ................. 27 ACANYA .......................... 23 acarbose ......................... 31 ACCOLATE ...................... 45 ACCUPRIL ........................ 17 ACCURETIC ..................... 17 acebutolol ...................... 17 acetaminophen-caff-

dihydrocod .................. 12 ACETAMINOPHEN-CAFF-

DIHYDROCOD ............. 12 acetaminophen-codeine

....................................... 12 acetazolamide............... 43 acetic acid ..................... 28 acetylcysteine ................ 45 ACIPHEX........................... 35 ACIPHEX SPRINKLE .......... 35 acitretin ........................... 22 ACTEMRA ........................ 37 ACTHAR H.P. ................... 28 ACTICLATE ......................... 8 ACTIGALL......................... 33 ACTIMMUNE .................... 37 ACTIQ ............................... 12 ACTIVELLA ....................... 38 ACTONEL ................... 27, 37 ACTOPLUS MET ............... 31 ACTOPLUS MET XR .......... 31 ACTOS .............................. 31 ACULAR ........................... 43 ACULAR LS ....................... 43 ACUVAIL (PF) .................. 43 acyclovir ...................... 5, 25

ACZONE .......................... 23 ADALAT CC .................... 18 adapalene ..................... 23 adapalene-benzoyl

peroxide ...................... 23 ADASUVE ......................... 14 ADCIRCA ........................ 45 ADDERALL ....................... 14 ADDERALL XR.................. 14 adefovir ............................. 5 ADEMPAS ........................ 45 ADIPEX-P.......................... 27 ADLYXIN .......................... 31 ADMELOG SOLOSTAR U-

100 INSULIN .................. 29 ADMELOG U-100 INSULIN

LISPRO .......................... 29 ADRENALIN ..................... 45 adult aspirin regimen .... 13 ADVAIR DISKUS ............... 45 ADVAIR HFA .................... 45 ADZENYS ER .................... 14 ADZENYS XR-ODT ........... 15 AEROCHAMBER MINI ..... 29 AEROCHAMBER PLUS

FLOW-VU ...................... 29 AEROCHAMBER PLUS Z

STAT SM MSK ................ 29 AEROSPAN ...................... 45 afeditab cr ..................... 18 AFREZZA ........................... 29 AFTERA ............................. 39 AGGRENOX .................... 20 AGRYLIN .......................... 27 AIRDUO RESPICLICK ....... 45 ak-poly-bac .................... 42 AKTIPAK ........................... 23 AKYNZEO (NETUPITANT) . 33 ala-cort ........................... 25 ALA-SCALP ...................... 25 ALBENZA ............................ 6 albuterol sulfate ............. 45 alclometasone ............... 26 ALCORTIN A .................... 25

ALDACTAZIDE .................. 18 ALDACTONE .................... 18 ALDARA ........................... 37 alendronate .............. 27, 37 alfuzosin ........................... 46 ALINIA ................................. 6 allopurinol ........................ 37 ALLZITAL............................ 12 almotriptan malate........ 11 ALOCRIL ........................... 42 ALOGLIPTIN ...................... 31 ALOGLIPTIN-METFORMIN

....................................... 31 ALOGLIPTIN-

PIOGLITAZONE ............. 31 ALOMIDE .......................... 42 alophen ........................... 33 ALORA .............................. 38 alosetron .......................... 33 ALPHAGAN P ............ 43, 44 alprazolam ...................... 15 alprazolam intensol ........ 15 ALREX ............................... 43 ALTABAX .......................... 25 ALTACE ............................. 18 altavera (28) ................... 39 ALTOPREV ........................ 21 ALVESCO ......................... 45 alyacen 1/35 (28) ........... 39 alyacen 7/7/7 (28) ......... 39 amabelz ........................... 38 amantadine hcl ............... 5 AMARYL ........................... 31 AMBIEN ............................ 15 AMBIEN CR ...................... 15 amcinonide ..................... 26 AMELUZ ............................ 23 AMERGE ........................... 11 amethia ........................... 39 amethia lo ....................... 39 amethyst .......................... 39 AMICAR ........................... 20 amiloride .......................... 18

50

amiloride-hydrochlorothiazide ... 18

amiodarone .................... 17 AMITIZA ............................ 33 amitriptyline .................... 15 amitriptyline-

chlordiazepoxide........ 15 amlodipine ...................... 18 amlodipine-atorvastatin21 amlodipine-benazepril .. 18 amlodipine-olmesartan 18 amlodipine-valsartan .... 18 amlodipine-valsartan-

hcthiazid ...................... 18 amnesteem .................... 23 amoxapine ..................... 15 amoxicil-clarithromy-

lansopraz...................... 35 amoxicillin.......................... 7 amoxicillin-pot

clavulanate ................... 7 ampicillin ........................... 7 AMPYRA ........................... 11 AMRIX ............................... 12 ANADROL-50 ................... 30 ANAFRANIL ...................... 15 anagrelide ...................... 27 ANA-LEX KIT ..................... 33 ANALPRAM-HC ......... 22, 33 ANALPRAM-HC SINGLES 33 ANAPROX DS .................. 13 anaspaz ........................... 33 anastrozole ....................... 8 ANCOBON ........................ 5 ANDRODERM .................. 30 ANDROGEL ..................... 30 ANDROID ......................... 30 ANGELIQ .......................... 38 ANORO ELLIPTA .............. 45 ANTABUSE ........................ 27 ANTARA ........................... 21 ANUSOL-HC ..................... 33 ANZEMET .......................... 33 apexicon e ...................... 26 APIDRA SOLOSTAR U-100

INSULIN.......................... 29 APIDRA U-100 INSULIN .... 29

APLENZIN ......................... 15 APOKYN .......................... 10 apraclonidine ................ 44 aprepitant ....................... 33 apri ................................... 39 APRISO ............................. 33 APTENSIO XR ................... 15 APTIOM .............................. 9 APTIVUS ............................. 5 AQUA GLYCOLIC HC .... 26 aranelle (28) ................... 39 ARAVA ............................. 37 ARCALYST ........................ 37 ARCAPTA NEOHALER .... 45 ARICEPT ........................... 11 ARIMIDEX ........................... 8 aripiprazole ..................... 15 ARIXTRA ........................... 20 armodafinil ..................... 15 ARMONAIR RESPICLICK . 45 ARMOUR THYROID ......... 32 ARNUITY ELLIPTA ............. 45 AROMASIN ........................ 8 ARTHROTEC 50 ............... 13 ARTHROTEC 75 ............... 13 ARYMO ER ....................... 12 ASACOL HD .................... 33 ascomp with codeine .. 12 ashlyna ............................ 39 ASMANEX HFA ................ 45 ASMANEX TWISTHALER .. 45 aspir-81 ............................ 13 aspirin .............................. 13 aspirin low dose ............. 13 aspirin-dipyridamole ..... 20 aspir-low .......................... 13 aspir-trin ........................... 13 ASTAGRAF XL .................... 9 ASTEPRO .......................... 28 ATACAND ....................... 18 ATACAND HCT ............... 18 atazanavir ......................... 5 ATELVIA............................ 37 atenolol ........................... 18 atenolol-chlorthalidone 18 ATIVAN ............................ 15 atomoxetine ................... 15

atorvastatin ..................... 21 atovaquone ...................... 6 atovaquone-proguanil ... 6 ATRALIN ............................ 23 ATRIPLA .............................. 5 atropine ........................... 42 ATROVENT HFA ................ 45 AUBAGIO ......................... 36 aubra ............................... 39 AUGMENTIN ....................... 7 AUGMENTIN ES-600 .......... 7 AUGMENTIN XR ................. 7 AURYXIA ........................... 33 AUSTEDO .......................... 11 AUVI-Q ............................. 44 AVALIDE ........................... 18 AVANDIA ......................... 31 AVAPRO ........................... 18 avar .................................. 23 AVAR ................................ 23 AVAR LS ........................... 23 AVAR-E GREEN ................ 23 AVAR-E LS ........................ 23 AVC VAGINAL ................ 39 AVELOX .............................. 7 aviane .............................. 39 avidoxy .............................. 8 AVIDOXY DK ...................... 8 avita ................................. 23 AVITA ................................ 23 AVODART ........................ 46 AVONEX ........................... 36 AVONEX (WITH ALBUMIN)

....................................... 36 AXIRON ............................ 30 AYGESTIN ......................... 38 AZASAN .............................. 9 AZASITE ............................. 42 azathioprine ...................... 9 azelastine .................. 28, 42 AZELEX .............................. 23 AZILECT ............................. 10 azithromycin ...................... 6 AZOPT ............................... 43 AZOR ................................ 18 AZULFIDINE ....................... 33 AZULFIDINE EN-TABS ....... 33

51

azuphen mb ................... 47 azurette (28) ................... 39

B

b complex-vitamin b12 . 48 b complex-vitamin c-folic

acid .............................. 48 bacitracin ........................ 42 bacitracin-polymyxin b . 42 baclofen .......................... 12 BACTRIM ............................ 8 BACTRIM DS....................... 8 BACTROBAN .................... 25 BACTROBAN NASAL ....... 28 balanced b-100 ............. 48 balanced b-100 complex

....................................... 48 balanced b-50 ............... 48 BALCOLTRA ..................... 39 balsalazide ...................... 33 balziva (28)...................... 39 BANZEL ............................... 9 BARACLUDE ...................... 5 BASAGLAR KWIKPEN U-100

INSULIN.......................... 29 BAXDELA ............................ 7 bayer aspirin ................... 13 b-complex with vitamin c

....................................... 48 BECONASE AQ ............... 45 bekyree (28).................... 39 BELBUCA .......................... 12 belladonna alkaloids-

opium ........................... 33 belladonna-opium ........ 33 BELSOMRA ....................... 15 BELVIQ .............................. 27 BELVIQ XR ........................ 27 benazepril ....................... 18 benazepril-

hydrochlorothiazide ... 18 BENICAR .......................... 18 BENICAR HCT .................. 18 BENLYSTA ......................... 37 BENSAL HP ....................... 22 BENZACLIN ...................... 23 BENZACLIN PUMP ........... 23

BENZAMYCIN .................. 23 BENZNIDAZOLE ................. 6 benzonatate .................. 44 benzphetamine ............. 27 benztropine .................... 10 BEPREVE ........................... 42 BESIVANCE ...................... 42 BETADINE OPHTHALMIC

PREP .............................. 42 BETAGAN ......................... 42 betamethasone

dipropionate ............... 26 betamethasone valerate

...................................... 26 betamethasone,

augmented ................. 26 BETAPACE ....................... 17 BETAPACE AF .................. 17 BETASERON ..................... 36 betaxolol ................... 18, 42 bethanechol chloride ... 46 BETHKIS ............................... 7 BETIMOL ........................... 42 BETOPTIC S ...................... 42 BEVESPI AEROSPHERE .... 45 BEVYXXA .......................... 20 BEYAZ ............................... 39 bicalutamide .................... 9 BIDIL ................................. 18 BIKTARVY ........................... 5 BILTRICIDE .......................... 7 bimatoprost .................... 43 BINOSTO .......................... 37 bisacodyl ........................ 33 bisa-lax ............................ 33 bisoprolol fumarate ....... 18 bisoprolol-

hydrochlorothiazide ... 18 BLEPH-10 .......................... 43 BLEPHAMIDE ................... 43 BLEPHAMIDE S.O.P. ........ 43 blisovi 24 fe ..................... 39 blisovi fe 1.5/30 (28) ....... 39 blisovi fe 1/20 (28) .......... 39 BONIVA ........................... 37 bp 10-1 ............................ 24 BREO ELLIPTA .................. 45

BREVICON (28) ................ 39 briellyn .............................. 39 BRILINTA............................ 20 brimonidine ..................... 44 BRISDELLE ......................... 15 BRIVIACT ............................ 9 BROMFED DM .................. 44 bromfenac ...................... 43 bromocriptine ................. 10 brompheniramine-

pseudoeph-dm ........... 44 BROMSITE ......................... 43 BROVANA ........................ 45 BUCALSEP ........................ 25 budesonide ............... 33, 45 bumetanide .................... 18 BUNAVAIL ........................ 13 BUPAP ............................... 12 BUPHENYL ........................ 27 BUPRENORPHINE ............. 12 buprenorphine hcl ......... 12 buprenorphine-naloxone

....................................... 13 bupropion hcl ................. 15 bupropion hcl (smoking

deter) ............................ 27 buspirone ......................... 15 butalbital compound

w/codeine ................... 12 butalbital-acetaminop-

caf-cod ........................ 12 butalbital-

acetaminophen ......... 12 butalbital-

acetaminophen-caff . 12 butalbital-aspirin-caffeine

....................................... 12 BUTISOL ............................. 15 butorphanol tartrate...... 13 BUTRANS ........................... 12 BYDUREON ....................... 31 BYDUREON BCISE ............ 31 BYETTA .............................. 31 BYSTOLIC .......................... 18 BYVALSON ....................... 18

52

C

cabergoline .................... 30 CADUET ............................ 21 CAFERGOT ...................... 11 caffeine citrate .............. 27 CALAN ............................. 18 CALAN SR ........................ 18 calcipotriene .................. 22 calcipotriene-

betamethasone ......... 22 calcitonin (salmon) ........ 30 calcitrene ........................ 22 calcitriol ..................... 22, 30 calcium 500 + d.............. 47 calcium 500 with d ........ 47 calcium 600 + d(3) ......... 47 calcium 600 with vitamin

d3 .................................. 47 calcium acetate ............ 33 calcium carb and citrate-

vitd3 .............................. 47 calcium carbonate-

vitamin d3 .................... 47 calcium citrate + d ........ 47 calcium citrate-vitamin d2

....................................... 47 calcium citrate-vitamin d3

....................................... 47 calcium-folic acid-vitamin

d .................................... 48 CAMBIA ........................... 13 camila .............................. 38 camrese .......................... 39 camrese lo ...................... 39 CANASA .......................... 33 candesartan ................... 18 candesartan-

hydrochlorothiazid ..... 18 capacet .......................... 12 CAPCOF .......................... 44 CAPEX .............................. 26 captopril .......................... 18 captopril-

hydrochlorothiazide ... 18 CARAC ............................ 23 CARAFATE ................. 35, 36 CARBAGLU ...................... 27

carbamazepine ............... 9 CARBATROL ...................... 9 carbidopa ...................... 10 carbidopa-levodopa.... 10 carbidopa-levodopa-

entacapone ............... 10 carbinoxamine maleate

...................................... 44 CARDIZEM ....................... 18 CARDIZEM CD ................ 18 CARDIZEM LA ................. 18 CARDURA........................ 18 CARDURA XL ................... 18 carisoprodol ................... 12 carisoprodol-asa-codeine

...................................... 12 carisoprodol-aspirin ....... 12 CARNITOR ....................... 27 CARNITOR (SUGAR-FREE)

...................................... 27 CAROSPIR ....................... 18 carteolol .......................... 42 cartia xt ........................... 18 carvedilol ........................ 18 carvedilol phosphate ... 18 CASODEX .......................... 9 CATAPRES ....................... 18 CATAPRES-TTS-1 .............. 18 CATAPRES-TTS-2 .............. 18 CATAPRES-TTS-3 .............. 18 CAYSTON .......................... 7 caziant (28) ..................... 39 cefaclor............................. 6 cefadroxil .......................... 6 cefdinir .............................. 6 cefditoren pivoxil ............. 6 cefixime ............................. 6 cefpodoxime ................... 6 cefprozil ............................. 6 cefuroxime axetil ............. 6 CELEBREX ........................ 13 celecoxib ........................ 13 CELEXA ............................ 15 CELLCEPT........................... 9 CELONTIN .......................... 9 cem-urea ........................ 23 CENTANY ......................... 25

CENTANY AT .................... 25 centergy .......................... 44 cephalexin ........................ 6 CERDELGA ....................... 30 CERVIDIL .......................... 39 CESAMET .......................... 33 CETRAXAL ........................ 28 cevimeline ....................... 27 CHANTIX ........................... 27 CHANTIX CONTINUING

MONTH BOX ................. 27 CHANTIX STARTING

MONTH BOX ................. 27 chateal ............................ 39 CHEMET ............................ 30 CHENODAL ...................... 33 cheratussin ac ................ 44 children's aspirin ............. 13 chlordiazepoxide hcl ..... 15 chlordiazepoxide-

clidinium ....................... 33 chlorhexidine gluconate

....................................... 28 chloroquine phosphate .. 7 chlorothiazide ................. 18 chlorpromazine .............. 15 chlorpropamide ............. 31 chlorthalidone ................ 18 chlorzoxazone ................ 12 CHOLBAM ........................ 33 cholecalciferol (vitamin

d3) ................................. 48 cholestyramine (with

sugar) ............................ 21 cholestyramine light ...... 21 choline,magnesium

salicylate ...................... 13 CIALIS ............................... 46 ciclodan .......................... 25 CICLODAN KIT ................. 25 ciclopirox ......................... 25 ciclopirox-ure-camph-

menth-euc ................... 25 cilostazol .......................... 20 CILOXAN .......................... 42 CIMDUO ............................. 5 cimetidine ....................... 36

53

cimetidine hcl ................. 36 CIMZIA ............................. 33 CIPRO ................................. 7 CIPRO HC ........................ 28 CIPRO XR ........................... 7 CIPRODEX ........................ 28 ciprofloxacin ..................... 7 ciprofloxacin (mixture) .... 7 ciprofloxacin hcl .. 8, 28, 42 citalopram ...................... 15 citrate of magnesia ....... 33 citroma ............................ 33 citrus calcium ................. 47 claravis............................. 24 CLARINEX ......................... 44 CLARINEX-D 12 HOUR .... 44 clarithromycin ................... 6 classic prenatal .............. 48 cleansing wash .............. 24 clearlax ............................ 33 CLENPIQ .......................... 33 CLEOCIN .......................... 39 CLEOCIN HCL ................... 7 CLEOCIN PEDIATRIC ........ 7 CLEOCIN T ....................... 24 CLIMARA ......................... 38 CLIMARA PRO ................. 38 CLINDACIN ETZ ............... 24 clindacin p ...................... 24 CLINDACIN PAC ............. 24 CLINDAGEL ..................... 24 clindamycin hcl ................ 7 clindamycin palmitate hcl

......................................... 7 clindamycin pediatric ..... 7 clindamycin phosphate

................................. 24, 39 clindamycin-benzoyl

peroxide ....................... 24 clindamycin-tretinoin .... 24 CLINDESSE ....................... 39 CLINPRO 5000 ................. 28 clobetasol ....................... 26 clobetasol-emollient...... 26 CLOBEX ............................ 26 CLOCORTOLONE

PIVALATE ...................... 26

clodan ............................. 26 CLODAN KIT .................... 26 CLODERM ....................... 26 clomipramine ................. 15 clonazepam ..................... 9 clonidine ......................... 18 clonidine hcl ............. 15, 18 clopidogrel ..................... 20 clorazepate dipotassium

...................................... 15 clotrimazole ...................... 5 clotrimazole-

betamethasone ......... 25 clozapine ........................ 15 CLOZAPINE ..................... 15 CLOZARIL ........................ 15 COAL TAR ....................... 22 COARTEM.......................... 7 codeine sulfate .............. 12 codeine-guaifenesin ..... 44 CODITUSSIN AC .............. 44 CODITUSSIN DAC ........... 44 COLAZAL ......................... 33 COLCHICINE ................... 37 COLCRYS ........................ 37 colesevelam ................... 21 COLESTID ......................... 21 COLESTID FLAVORED ..... 21 colestipol ......................... 21 colocort........................... 33 COLY-MYCIN S ............... 28 COLYTE WITH FLAVOR

PACKS .......................... 33 COMBIGAN .................... 43 COMBIPATCH ................. 38 COMBIVENT RESPIMAT .. 45 COMBIVIR ......................... 5 COMPAZINE .................... 33 COMPLERA ....................... 5 complex b-100 ............... 48 compro ........................... 33 COMTAN ......................... 10 CONCERTA ..................... 15 CONDYLOX ..................... 23 constulose ....................... 33 CONTRAVE ...................... 27 CONZIP ............................ 13

COPAXONE ..................... 36 CORDRAN ....................... 26 CORDRAN TAPE LARGE

ROLL .............................. 26 COREG ............................. 18 COREG CR ...................... 18 coremino ........................... 8 CORGARD ....................... 18 CORLANOR ..................... 22 cormax ............................. 26 CORTEF ............................ 28 CORTENEMA ................... 33 CORTIFOAM .................... 34 cortisone .......................... 28 CORTISPORIN .................. 25 CORZIDE .......................... 18 COSENTYX........................ 22 COSENTYX (2 SYRINGES) 22 COSENTYX PEN ................ 22 COSENTYX PEN (2 PENS) 22 COSOPT ........................... 43 COSOPT (PF).................... 43 COTEMPLA XR-ODT ........ 15 COUMADIN ..................... 20 COZAAR ........................... 18 CREON ............................. 34 CRESEMBA ......................... 5 CRESTOR .......................... 21 CRINONE .......................... 38 CRIXIVAN ........................... 5 cromolyn............. 34, 42, 45 cryselle (28) ..................... 39 CUPRIMINE ....................... 37 CUTIVATE .......................... 26 CUVPOSA ........................ 33 cyclafem 1/35 (28) ......... 39 cyclafem 7/7/7 (28) ....... 40 CYCLESSA (28) ................ 40 cyclobenzaprine ............ 12 CYCLOGYL ...................... 42 cyclopentolate ............... 42 CYCLOSERINE .................... 7 CYCLOSET ........................ 31 cyclosporine ..................... 9 cyclosporine modified .... 9 CYMBALTA ....................... 15 cyproheptadine ............. 44

54

cyred ................................ 40 CYSTADANE .................... 34 CYSTAGON...................... 47 CYSTARAN ....................... 42 CYTOMEL ......................... 32 CYTOTEC.......................... 36 cytra k crystals ................ 47 cytra-2.............................. 47 cytra-3.............................. 47 cytra-k .............................. 47

D

D.H.E.45 ............................ 11 DAKLINZA ........................... 5 DALIRESP .......................... 45 danazol ........................... 30 DANTRIUM ....................... 12 dantrolene ...................... 12 dapsone ...................... 7, 24 DARAPRIM ......................... 7 darifenacin ..................... 46 dasetta 1/35 (28) ........... 40 dasetta 7/7/7 (28) .......... 40 DAXBIA ............................... 6 DAYPRO ........................... 14 daysee ............................. 40 DAYTRANA ...................... 15 DDAVP ............................. 30 DEBACTEROL ................... 28 deblitane ......................... 38 decadron ........................ 28 DELESTROGEN ................. 38 delta d3 ........................... 48 deltasone ........................ 29 delyla (28) ....................... 40 DELZICOL ......................... 34 DEMADEX ........................ 18 demeclocycline ............... 8 DEMEROL ......................... 12 DEMSER ............................ 18 DENAVIR .......................... 25 denta 5000 plus .............. 28 dentagel ......................... 28 DEPAKENE ......................... 9 DEPAKOTE ......................... 9 DEPAKOTE ER .................... 9 DEPAKOTE SPRINKLES ....... 9

DEPEN TITRATABS ............ 37 DEPO-ESTRADIOL ........... 38 DEPO-PROVERA ............. 38 DEPO-SUBQ PROVERA 104

...................................... 38 DEPO-TESTOSTERONE..... 30 DERMA-SMOOTHE/FS

BODY OIL ..................... 26 DERMA-SMOOTHE/FS

SCALP OIL .................... 26 DERMASORB HC

COMPLETE KIT .............. 26 DERMASORB TA

COMPLETE KIT .............. 26 DERMATOP ...................... 26 DERMOTIC OIL ................ 28 DESCOVY .......................... 5 desipramine.................... 15 desloratadine ................. 44 desmopressin ................. 30 desog-

e.estradiol/e.estradiol 40 desogestrel-ethinyl

estradiol ....................... 40 DESONATE ....................... 26 desonide ......................... 26 DESOWEN ........................ 26 desoximetasone ............ 26 DESOXYN ......................... 15 DESVENLAFAXINE ........... 15 DESVENLAFAXINE

FUMARATE ................... 15 desvenlafaxine succinate

...................................... 15 DETROL ............................ 46 DETROL LA ....................... 46 dexamethasone ............ 29 dexamethasone intensol

...................................... 29 dexamethasone sodium

phosphate ................... 43 DEXEDRINE SPANSULE .... 15 DEXILANT ......................... 36 dexmethylphenidate .... 15 DEXPAK 10 DAY .............. 29 DEXPAK 13 DAY .............. 29 DEXPAK 6 DAY ................ 29

dextroamphetamine ..... 15 dextroamphetamine-

amphetamine ............. 15 dialyvite 800 .................... 48 DIASTAT .............................. 9 DIASTAT ACUDIAL ............. 9 diazepam .................... 9, 15 diazepam intensol ......... 15 DIBENZYLINE ..................... 18 diclofenac potassium .... 14 diclofenac sodium .. 14, 23,

43 diclofenac-misoprostol . 14 dicloxacillin ........................ 7 dicyclomine .................... 33 didanosine ........................ 5 diethylpropion ................ 27 DIFFERIN ........................... 24 DIFICID................................ 6 diflorasone ....................... 26 DIFLUCAN .......................... 5 diflunisal ........................... 14 digitek .............................. 20 digox ................................ 20 digoxin ............................. 20 dihydroergotamine ........ 11 DILANTIN ............................ 9 DILANTIN EXTENDED ......... 9 DILANTIN INFATABS ........... 9 DILANTIN-125 ..................... 9 DILATRATE-SR ................... 22 DILAUDID.......................... 12 diltiazem hcl .................... 18 dilt-xr ................................. 18 DIOVAN ........................... 18 DIOVAN HCT ................... 18 DIPENTUM ........................ 34 diphenoxylate-atropine 33 DIPROLENE ....................... 26 dipyridamole ................... 20 DISALCID .......................... 14 diskets ............................... 12 disopyramide phosphate

....................................... 17 disulfiram .......................... 27 DITROPAN XL ................... 46 DIURIL................................ 18

55

divalproex ......................... 9 DIVIGEL ............................ 38 dofetilide ......................... 17 DOLOPHINE ..................... 12 donepezil ........................ 11 DONNATAL ...................... 33 DORAL ............................. 15 DORYX ............................... 8 DORYX MPC ...................... 8 dorzolamide .................... 43 dorzolamide-timolol....... 43 DOVONEX ....................... 22 doxazosin ........................ 18 doxepin ..................... 15, 23 doxercalciferol ............... 30 doxycycline hyclate ........ 8 doxycycline

monohydrate ................ 8 DOXYCYCLINE

MONOHYDRATE ............ 8 drithocreme hp .............. 22 dronabinol....................... 34 drospirenone-e.estradiol-

lm.fa .............................. 40 drospirenone-ethinyl

estradiol ....................... 40 DROXIA .............................. 9 DUAC ............................... 24 DUAVEE ............................ 38 ducodyl ........................... 34 DUETACT .......................... 31 DUEXIS .............................. 14 DULERA ............................ 45 duloxetine ....................... 15 DUOPA ............................. 10 DUPIXENT ......................... 23 DURAGESIC ..................... 12 DUREZOL .......................... 43 dutasteride ...................... 46 dutasteride-tamsulosin .. 46 DUTOPROL ....................... 18 DUZALLO .......................... 37 d-vi-sol .............................. 48 DYANAVEL XR ................. 15 DYAZIDE ........................... 18 DYMISTA ........................... 45 DYRENIUM ....................... 18

E

e.c. prin ........................... 14 e.e.s. 400 ........................... 6 E.E.S. GRANULES ............... 6 EC-NAPROSYN ................ 14 econazole ....................... 25 econtra ez ...................... 40 econtra one-step .......... 40 ecotrin ............................. 14 ecotrin low strength ...... 14 ECOZA ............................. 25 EDARBI ............................. 18 EDARBYCLOR ................. 18 EDECRIN .......................... 18 EDLUAR ............................ 15 ed-spaz ........................... 33 EDURANT ........................... 5 efavirenz ........................... 5 effer-k .............................. 47 EFFEXOR XR ..................... 15 EFFIENT ............................. 20 EFUDEX ............................ 23 ELESTAT ............................ 42 ELESTRIN ........................... 38 eletriptan ........................ 11 ELIDEL ............................... 23 ELIMITE ............................. 27 elinest .............................. 40 eliphos ............................. 34 ELIQUIS ............................. 20 ELIXOPHYLLIN .................. 45 ELLA .................................. 40 ELMIRON .......................... 47 ELOCON .......................... 26 EMADINE ......................... 42 EMBEDA ........................... 12 EMCYT................................ 9 EMEND ............................. 34 EMFLAZA .......................... 29 emoquette ..................... 40 EMSAM ............................ 15 EMTRIVA ............................ 5 EMVERM ............................ 7 ENABLEX .......................... 46 enalapril maleate .......... 19 enalapril-

hydrochlorothiazide ... 19

ENBREL.............................. 37 ENBREL MINI ..................... 37 ENBREL SURECLICK ......... 37 ENDARI ............................. 27 endocet ........................... 12 ENDOMETRIN ................... 38 enoxaparin ...................... 20 enpresse .......................... 40 enskyce ............................ 40 ENSTILAR ........................... 22 entacapone ................... 10 entecavir ........................... 5 ENTEREG ........................... 34 ENTOCORT EC ................. 34 ENTRESTO ......................... 22 enulose ............................ 34 ENVARSUS XR .................... 9 EPANED ............................ 19 EPCLUSA ............................ 5 EPIDUO ............................. 24 EPIDUO FORTE ................. 24 EPIFOAM .......................... 22 epinastine ........................ 42 EPINEPHRINE .................... 44 EPIPEN 2-PAK ................... 44 EPIPEN JR 2-PAK .............. 44 EPISIL ................................. 28 epitol .................................. 9 EPIVIR .................................. 5 EPIVIR HBV ......................... 5 eplerenone ..................... 19 eprosartan ....................... 19 EPZICOM ............................ 5 EQUETRO ............................ 9 ergocalciferol (vitamin

d2) ................................. 48 ergoloid ........................... 15 ERGOMAR ....................... 11 ergotamine-caffeine ..... 11 errin ................................... 38 ERTACZO .......................... 25 ery pads ........................... 24 erygel ............................... 24 ERYPED 200 ........................ 6 ERYPED 400 ........................ 6 ery-tab ............................... 6 ERY-TAB .............................. 6

56

erythrocin (as stearate) .. 6 erythromycin ............... 6, 42 erythromycin

ethylsuccinate .............. 6 erythromycin with ethanol

....................................... 24 erythromycin-benzoyl

peroxide ....................... 24 ESBRIET ............................. 45 escitalopram oxalate .... 15 ESGIC ............................... 12 esomeprazole

magnesium .................. 36 ESOMEPRAZOLE

STRONTIUM ................... 36 estarylla ........................... 40 estazolam ........................ 15 ESTRACE ........................... 38 estradiol ........................... 38 estradiol valerate ........... 38 estradiol-norethindrone

acet .............................. 38 ESTRING ............................ 38 ESTROGEL ........................ 38 estropipate ..................... 38 ESTROSTEP FE-28 ............. 40 eszopiclone ..................... 15 ethacrynic acid ............. 19 ethambutol ....................... 7 ethosuximide .................... 9 ethyl chloride .................. 25 ethynodiol diac-eth

estradiol ....................... 40 etidronate disodium ...... 27 etodolac ......................... 14 EUCRISA ........................... 23 EURAX .............................. 27 EVAMIST ........................... 38 EVEKEO ............................ 15 EVISTA .............................. 37 EVOCLIN .......................... 24 EVOTAZ .............................. 5 EVOXAC .......................... 27 EVZIO ................................ 14 EXALGO ER ...................... 12 EXELDERM ........................ 25 EXELON ............................ 11

exemestane ..................... 9 EXFORGE ......................... 19 EXFORGE HCT ................. 19 EXJADE ............................ 30 EXODERM ........................ 25 EXTAVIA ........................... 36 EXTINA .............................. 25 ezetimibe ........................ 21 ezetimibe-simvastatin ... 21

F

FABIOR ............................. 24 FACTIVE ............................. 8 falmina (28) .................... 40 famciclovir ........................ 5 famotidine ...................... 36 FANAPT ............................ 15 FARESTON .......................... 9 FARXIGA .......................... 31 fayosim ............................ 40 FAZACLO ......................... 15 FC2 FEMALE CONDOM . 38 felbamate ......................... 9 FELBATOL ........................... 9 FELDENE ........................... 14 felodipine ........................ 19 fem ph ............................. 39 FEMARA ............................. 9 FEMHRT LOW DOSE ........ 38 FEMRING ......................... 38 femynor ........................... 40 fenofibrate ...................... 21 FENOFIBRATE ................... 21 fenofibrate micronized . 21 fenofibrate

nanocrystallized ......... 21 fenofibric acid................ 21 fenofibric acid (choline)

...................................... 21 FENOGLIDE ..................... 21 fenoprofen ...................... 14 FENOPROFEN .................. 14 FENORTHO ...................... 14 fentanyl ........................... 12 fentanyl citrate .............. 12 FENTORA ......................... 12 FERRIPROX ....................... 30

FETZIMA ............................ 15 FEXMID ............................. 12 FIASP FLEXTOUCH U-100

INSULIN .......................... 29 FIASP U-100 INSULIN ........ 29 FIBRICOR .......................... 21 FINACEA .......................... 24 finasteride ........................ 46 FIORICET ........................... 12 FIORINAL .......................... 12 FIORINAL-CODEINE #3 ... 12 FIRAZYR ............................ 45 FIRVANQ ............................ 8 FLAGYL ............................... 7 FLAREX .............................. 43 flavoxate ......................... 46 flecainide ........................ 17 FLECTOR ........................... 14 fleet laxative ................... 34 FLOLIPID ........................... 21 FLOMAX ........................... 46 FLOVENT DISKUS .............. 45 FLOVENT HFA ................... 45 fluconazole ....................... 5 flucytosine ......................... 5 fludrocortisone ................ 29 FLUMADINE ........................ 5 flunisolide ......................... 45 fluocinolone .................... 26 fluocinolone acetonide oil

....................................... 28 fluocinolone and shower

cap ............................... 26 fluocinonide .................... 26 fluocinonide-emollient .. 26 fluoride (sodium) ............ 48 FLUORIDEX DAILY DEFENSE

....................................... 28 fluoritab ............................ 48 fluorometholone ............. 43 FLUOROPLEX .................... 23 fluorouracil ...................... 23 FLUOROURACIL ............... 23 fluoxetine ......................... 15 fluphenazine hcl ............. 15 flurandrenolide ............... 26 flurazepam ...................... 15

57

flurbiprofen ...................... 14 flurbiprofen sodium ........ 43 flutamide ........................... 9 fluticasone ................ 26, 45 FLUTICASONE-

SALMETEROL ................ 45 fluvastatin ........................ 21 fluvoxamine .................... 15 FML FORTE ....................... 43 FML LIQUIFILM ................. 43 FML S.O.P. ........................ 43 FOCALIN .......................... 15 FOCALIN XR .................... 15 FOLGARD OS .................. 48 folic acid ......................... 48 foltabs 800 ....................... 48 fondaparinux .................. 20 FORFIVO XL ..................... 16 FORTAMET........................ 31 FORTEO ............................ 37 FORTESTA ......................... 30 FOSAMAX ........................ 37 FOSAMAX PLUS D ........... 37 fosamprenavir .................. 5 fosinopril .......................... 19 fosinopril-

hydrochlorothiazide ... 19 FOSRENOL ....................... 34 FRAGMIN ......................... 20 frovatriptan ..................... 11 full spectrum b-vitamin c

....................................... 48 FURADANTIN ..................... 8 furosemide ...................... 19 fyavolv ............................. 38 FYCOMPA.......................... 9

G

g tussin ac ....................... 44 gabapentin ....................... 9 GABITRIL ............................. 9 galantamine ................... 11 GALZIN ............................. 47 GASTROCROM ............... 34 gatifloxacin ..................... 42 gavilax ............................. 34 gavilyte-c ........................ 34

gavilyte-g ........................ 34 gavilyte-n ........................ 34 GELCLAIR ........................ 28 GELNIQUE ........................ 46 GELX................................. 28 gemfibrozil ...................... 21 GENERESS FE ................... 40 generlac ......................... 34 gengraf ............................. 9 GENOTROPIN .................. 36 GENOTROPIN MINIQUICK

...................................... 36 gentak ............................. 42 gentamicin ............... 25, 42 gentle laxative ............... 34 gentlelax ......................... 34 GENVOYA ......................... 5 GEODON ......................... 16 GIALAX ............................ 34 gianvi (28) ....................... 40 GILENYA .......................... 36 glatiramer ....................... 36 glatopa ........................... 36 glimepiride ...................... 31 glipizide ........................... 31 glipizide-metformin ........ 31 GLUCAGON EMERGENCY

KIT (HUMAN) ................ 29 GLUCAGON HCL ........... 29 GLUCOPHAGE ............... 31 GLUCOPHAGE XR .......... 31 GLUCOTROL ................... 31 GLUCOTROL XL .............. 31 GLUCOVANCE ............... 31 GLUMETZA ....................... 31 glyburide ......................... 31 glyburide micronized .... 31 glyburide-metformin ..... 31 glycolax ........................... 34 glycopyrrolate ................ 33 glydo................................ 25 GLYNASE ......................... 31 GLYSET ............................. 31 GLYXAMBI ....................... 32 GOCOVRI ....................... 10 GOLYTELY ........................ 34 GONITRO ......................... 22

GRALISE .............................. 9 GRALISE 30-DAY STARTER

PACK ............................. 10 granisetron hcl ................ 34 GRASTEK........................... 37 griseofulvin microsize ....... 5 griseofulvin ultramicrosize5 guaiatussin ac ................ 44 guaifenesin ac ................ 44 guanfacine ............... 16, 19 guanidine ........................ 16 GYNAZOLE-1 ................... 39 gynol ii .............................. 39

H

HAEGARDA ..................... 45 HALCION .......................... 16 halobetasol propionate 26 HALOG ............................. 26 haloperidol ...................... 16 haloperidol lactate ........ 16 HARVONI ........................... 5 healthylax ........................ 34 heather ............................ 38 HEMANGEOL ................... 19 hemmorex-hc ................. 34 hep flush-10 (pf) ............. 20 heparin (porcine) ........... 20 heparin lock flush ........... 20 heparin lock flush

(porcine) ...................... 20 heparin

lockflush(porcine)(pf) . 20 heparin, porcine (pf) ..... 20 HEPSERA ............................. 5 hi-cal plus vit d ................ 47 HIPREX ................................ 8 HISTEX-AC ........................ 44 homatropaire.................. 42 homatropine hbr ............ 42 HORIZANT ......................... 11 HUMALOG JUNIOR

KWIKPEN U-100 ............ 29 HUMALOG KWIKPEN

INSULIN .......................... 29 HUMALOG MIX 50-50

INSULN U-100 ................ 29

58

HUMALOG MIX 50-50 KWIKPEN ....................... 29

HUMALOG MIX 75-25 KWIKPEN ....................... 29

HUMALOG MIX 75-25(U-100)INSULN ................... 29

HUMALOG U-100 INSULIN ....................................... 29

HUMATROPE .................... 36 HUMIRA ............................ 37 HUMIRA PEDIATRIC

CROHN'S START ........... 37 HUMIRA PEN .................... 37 HUMIRA PEN CROHN'S-

UC-HS START ................. 37 HUMIRA PEN PSORIASIS-

UVEITIS ........................... 37 HUMULIN 70/30 U-100

INSULIN.......................... 30 HUMULIN 70/30 U-100

KWIKPEN ....................... 30 HUMULIN N NPH INSULIN

KWIKPEN ....................... 30 HUMULIN N NPH U-100

INSULIN.......................... 30 HUMULIN R REGULAR U-

100 INSULN ................... 30 HUMULIN R U-500 (CONC)

INSULIN.......................... 30 HUMULIN R U-500 (CONC)

KWIKPEN ....................... 30 hydralazine ..................... 19 HYDREA .............................. 9 HYDRO 35 ........................ 23 HYDRO 40 ........................ 23 hydrochlorothiazide ...... 19 hydrocodone-

acetaminophen ......... 12 hydrocodone-

chlorpheniramine ....... 44 hydrocodone-cpm-

pseudoephed ............. 44 hydrocodone-

homatropine ............... 44 hydrocodone-ibuprofen

....................................... 12 hydrocortisone ... 26, 29, 34

hydrocortisone acetate 34 hydrocortisone butyrate26 hydrocortisone butyr-

emollient ...................... 26 hydrocortisone valerate 26 hydrocortisone-acetic

acid .............................. 28 hydrocortisone-

iodoquinol-aloe .......... 25 hydrocortisone-min oil-wht

pet ................................ 26 hydromet ........................ 44 hydromorphone ............ 12 hydroxychloroquine ........ 7 hydroxyprogesterone

caproate ..................... 38 hydroxyurea ..................... 9 hydroxyzine hcl .............. 44 hydroxyzine pamoate .. 44 hyolev mb ....................... 47 hyophen .......................... 47 hyoscyamine sulfate ..... 33 hyosyne ........................... 33 HYPER-SAL ....................... 45 HYSINGLA ER ................... 13 HYZAAR ........................... 19

I ibandronate ................... 37 ibu .................................... 14 IBUDONE .......................... 13 ibuprofen ........................ 14 ibuprofen-oxycodone .. 13 ILEVRO ............................. 43 imipramine hcl ............... 16 imipramine pamoate.... 16 imiquimod ....................... 37 IMITREX ............................. 11 IMITREX STATDOSE KIT

REFILL ............................ 11 IMITREX STATDOSE PEN .. 11 IMPAVIDO ......................... 7 IMPOYZ ............................ 26 IMURAN ............................. 9 INCRELEX ......................... 27 INCRUSE ELLIPTA ............. 45 indapamide ................... 19

INDERAL LA ...................... 19 INDERAL XL ...................... 19 INDIOMIN MB .................. 47 INDOCIN .......................... 14 indomethacin ................. 14 INGREZZA ......................... 11 INNOPRAN XL .................. 19 INSPRA .............................. 19 INSULIN SYRINGE-NEEDLE

U-100 ............................. 29 INTELENCE .......................... 5 INTERMEZZO ..................... 16 INTRAROSA ...................... 39 introvale ........................... 40 INTUNIV ER ....................... 16 INVEGA ............................ 16 INVIRASE ............................ 5 INVOKAMET ..................... 32 INVOKAMET XR................ 32 INVOKANA....................... 32 IODOFLEX ......................... 23 IODOSORB ....................... 23 IOPIDINE ........................... 44 ipratropium bromide28, 45 ipratropium-albuterol .... 45 irbesartan ........................ 19 irbesartan-

hydrochlorothiazide ... 19 ISENTRESS ........................... 5 ISENTRESS HD ..................... 5 isibloom ............................ 40 ISOCHRON ....................... 22 isomethepten-caf-

acetaminophen ......... 11 isoniazid ............................. 7 ISOPTO CARPINE ............. 42 ISORDIL ............................. 22 ISORDIL TITRADOSE ......... 22 isosorbide dinitrate ......... 22 isosorbide mononitrate . 22 isotretinoin ....................... 24 isoxsuprine ....................... 39 isradipine ......................... 19 ISTALOL ............................. 42 itraconazole ...................... 5 ivermectin ......................... 7

59

J

JADENU ............................ 30 JADENU SPRINKLE ........... 30 JALYN ............................... 46 jantoven .......................... 20 JANUMET ......................... 32 JANUMET XR .................... 32 JANUVIA .......................... 32 JARDIANCE ..................... 32 jencycla ........................... 38 JENTADUETO ................... 32 JENTADUETO XR .............. 32 jevantique lo ................... 38 jinteli ................................. 38 jolessa .............................. 40 jolivette ............................ 38 JUBLIA .............................. 25 juleber .............................. 40 JULUCA .............................. 5 junel 1.5/30 (21) .............. 40 junel 1/20 (21) ................. 40 junel fe 1.5/30 (28) ......... 40 junel fe 1/20 (28) ............ 40 junel fe 24 ........................ 40 JUXTAPID.......................... 21 JYNARQUE ....................... 30

K

KADIAN ............................ 13 kaitlib fe ........................... 40 KALETRA ............................. 5 KALYDECO ...................... 45 KAPVAY ........................... 16 KARBINAL ER ................... 44 kariva (28) ....................... 40 KAZANO ........................... 32 k-effervescent................. 47 KEFLEX ................................ 6 kelnor 1/35 (28) ............... 40 kelnor 1-50 ....................... 40 KENALOG ........................ 26 KEPPRA............................. 10 KEPPRA XR ....................... 10 KERAFOAM ...................... 23 KERALAC ......................... 23 KERALYT RX ...................... 22

KERALYT SCALP COMPLETE ................... 23

KERYDIN ........................... 25 ketoconazole ............. 5, 25 ketoprofen ...................... 14 ketorolac ................... 14, 43 KEVEYIS ............................ 11 KEVZARA ................... 37, 38 KHEDEZLA ........................ 16 KINERET ............................ 37 kionex (with sorbitol) ..... 34 KITABIS PAK ....................... 7 KLARON ........................... 25 KLONOPIN ....................... 10 klor-con ........................... 47 klor-con 10 ...................... 47 klor-con 8 ........................ 47 klor-con m10 ................... 47 klor-con m15 ................... 47 klor-con m20 ................... 47 klor-con sprinkle ............. 47 klor-con/ef ...................... 47 kobee .............................. 48 KOMBIGLYZE XR.............. 32 KORLYM ........................... 31 K-PHOS NO 2 .................. 47 K-PHOS ORIGINAL .......... 47 k-phos-neutral ................ 48 kpn ................................... 48 KRISTALOSE...................... 34 k-tab ................................ 48 K-TAB ................................ 48 kurvelo ............................. 40 KUVAN ............................. 31 KYNAMRO ....................... 21

L

l norgest/e.estradiol-e.estrad ........................ 40

labetalol .......................... 19 LACRISERT........................ 42 lactulose.......................... 34 LAMICTAL ........................ 10 LAMICTAL ODT ............... 10 LAMICTAL ODT STARTER

(BLUE) ........................... 10

LAMICTAL ODT STARTER (GREEN) ........................ 10

LAMICTAL ODT STARTER (ORANGE) .................... 10

LAMICTAL STARTER (BLUE) KIT .................................. 10

LAMICTAL STARTER (GREEN) KIT .................. 10

LAMICTAL STARTER (ORANGE) KIT .............. 10

LAMICTAL XR ................... 10 LAMICTAL XR STARTER

(BLUE) ............................ 10 LAMICTAL XR STARTER

(GREEN) ........................ 10 LAMICTAL XR STARTER

(ORANGE) .................... 10 lamivudine ......................... 5 lamivudine-zidovudine .... 5 lamotrigine ...................... 10 LANCETS ........................... 29 LANCING DEVICE ........... 29 LANOXIN .......................... 20 lansoprazole .................... 36 lanthanum ....................... 34 LANTUS SOLOSTAR U-100

INSULIN .......................... 30 LANTUS U-100 INSULIN .... 30 larin 1.5/30 (21) ............... 40 larin 1/20 (21) .................. 40 larin 24 fe ......................... 40 larin fe 1.5/30 (28) ........... 40 larin fe 1/20 (28) .............. 40 larissia ............................... 40 LASIX ................................. 19 LASTACAFT ....................... 42 latanoprost ...................... 43 LATUDA ............................ 16 laxaclear .......................... 34 laxative (bisacodyl) ....... 34 laxative feminine ............ 34 laxative peg 3350 ........... 34 layolis fe ........................... 40 LAZANDA ......................... 13 leena 28 ........................... 40 leflunomide ..................... 38 LESCOL XL ........................ 21

60

lessina............................... 40 LETAIRIS ............................ 45 letrozole ............................. 9 leucovorin calcium .......... 8 levalbuterol hcl .............. 45 LEVALBUTEROL TARTRATE

....................................... 45 LEVAQUIN .......................... 8 LEVATOL........................... 19 LEVBID .............................. 33 LEVEMIR FLEXTOUCH U-100

INSULN .......................... 30 LEVEMIR U-100 INSULIN .. 30 levetiracetam ................. 10 levobunolol ..................... 42 levocarnitine ................... 27 levocarnitine (with sugar)

....................................... 27 levofloxacin ................ 8, 42 levonest (28) ................... 40 levonorgestrel-ethinyl

estrad ........................... 40 levonorg-eth estrad

triphasic ........................ 40 levora-28 ......................... 40 levorphanol tartrate ...... 13 LEVO-T .............................. 32 levothyroxine .................. 32 levoxyl .............................. 32 LEVSIN .............................. 33 LEVSIN/SL ......................... 33 LEVULAN .......................... 23 LEXAPRO .......................... 16 LEXIVA ................................ 5 LIALDA .............................. 34 lidocaine ......................... 25 lidocaine hcl ................... 25 lidocaine hcl-

hydrocortison ac .. 25, 34 LIDOCAINE HCL-

HYDROCORTISON AC 34 lidocaine viscous............ 25 lidocaine-hydrocortisone-

aloe ............................... 34 lidocaine-prilocaine ...... 25 LIDOCAINE-TETRACAINE 25 LIDODERM ....................... 25

lillow ................................. 40 lindane ............................ 27 linezolid.............................. 7 LINZESS ............................. 34 liothyronine ..................... 32 LIPITOR ............................. 21 LIPOCHOL PLUS .............. 27 LIPOFEN ........................... 21 lisinopril ............................ 19 lisinopril-

hydrochlorothiazide ... 19 lite coat aspirin ............... 14 lithium carbonate .......... 16 lithium citrate.................. 16 LITHOBID .......................... 16 LITHOSTAT ........................ 27 LIVALO ............................. 21 LO LOESTRIN FE ............... 40 LOCOID ........................... 26 LOCOID LIPOCREAM ..... 26 LODINE ............................ 14 LODOSYN ........................ 10 LOESTRIN 1.5/30 (21) ...... 40 LOESTRIN 1/20 (21) ......... 40 LOESTRIN FE 1.5/30 (28-

DAY) ............................. 40 LOESTRIN FE 1/20 (28-DAY)

...................................... 40 LOMAIRA ......................... 27 LOMOTIL .......................... 33 LONHALA MAGNAIR

REFILL ............................ 45 LONHALA MAGNAIR

STARTER ........................ 45 LOPID ............................... 21 lopinavir-ritonavir ............. 5 lopreeza .......................... 38 LOPRESSOR ..................... 19 LOPROX ........................... 25 LOPROX (AS OLAMINE) . 25 LOPROX KIT ..................... 25 lorazepam ...................... 16 lorazepam intensol ........ 16 lorcet (hydrocodone) ... 13 lorcet hd .......................... 13 lorcet plus ....................... 13 LORTAB ELIXIR ................. 13

lortuss ex .......................... 44 loryna (28) ....................... 40 LORZONE ......................... 12 losartan ............................ 19 losartan-

hydrochlorothiazide ... 19 LOSEASONIQUE ............... 40 LOTEMAX ......................... 43 LOTENSIN .......................... 19 LOTENSIN HCT.................. 19 LOTREL .............................. 19 LOTRISONE ....................... 25 LOTRONEX ....................... 34 LOUTREX ........................... 23 lovastatin ......................... 21 LOVAZA ............................ 21 LOVENOX ......................... 20 low-ogestrel (28) ............. 40 loxapine succinate ........ 16 lta pre-attached ............ 25 ludent fluoride ................ 48 lugols .......................... 25, 48 LUMIGAN ......................... 43 LUNESTA ........................... 16 lutera (28) ........................ 40 LUXIQ ................................ 26 LUZU .................................. 25 LYRICA .............................. 10 LYRICA CR ....................... 10 LYSTEDA............................ 39 lyza.................................... 38

M

MACROBID ........................ 8 MACRODANTIN ................ 8 mafenide acetate ......... 25 MAGNEBIND 400 ............. 34 magnesium citrate ......... 34 MAKENA........................... 38 MAKENA (PF) ................... 38 MALARONE ........................ 7 MALARONE PEDIATRIC .... 7 malathion ........................ 27 maprotiline ...................... 16 MAR-COF CG ................. 44 MARINOL ......................... 34 marlissa ............................ 40

61

MARPLAN ........................ 16 matzim la ......................... 19 MAVYRET ........................... 5 MAXALT ............................ 11 MAXALT-MLT .................... 11 MAXIDEX .......................... 43 MAXITROL ........................ 43 MAXZIDE .......................... 19 MAXZIDE-25MG .............. 19 m-clear wc ...................... 44 meclofenamate ............. 14 MEDROL ........................... 29 MEDROL (PAK) ................ 29 medroxyprogesterone .. 38 mefenamic acid ............ 14 mefloquine ........................ 7 MEGACE ES ....................... 9 megestrol .......................... 9 melodetta 24 fe ............. 40 meloxicam ...................... 14 memantine ..................... 11 MEMANTINE ..................... 11 M-END PE ......................... 44 MENEST............................. 39 MENOSTAR ...................... 39 meperidine ..................... 13 MEPHYTON ...................... 20 meprobamate ............... 12 MEPRON ............................ 7 mercaptopurine ............... 9 mesalamine .................... 34 MESALAMINE ................... 34 mesalamine with

cleansing wipe ............ 34 MESNEX .............................. 8 MESTINON ........................ 12 MESTINON TIMESPAN ..... 12 metadate er ................... 16 metaproterenol .............. 45 metaxall ........................... 12 metaxalone .................... 12 metformin ........................ 32 methadone..................... 13 methadose ..................... 13 methamphetamine ....... 16 methazolamide .............. 43 methenamine hippurate 8

methenamine mandelate ........................................ 8

methen-sod phos-meth blue-hyos ..................... 47

methergine ..................... 41 methimazole .................. 29 METHITEST ........................ 31 methocarbamol ............ 12 methotrexate sodium ..... 9 methotrexate sodium (pf)

........................................ 9 methoxsalen ................... 23 methscopolamine ......... 33 methyclothiazide ........... 19 methyldopa .................... 19 methyldopa-

hydrochlorothiazide ... 19 METHYLIN ......................... 16 methylphenidate hcl .... 16 METHYLPHENIDATE HCL . 16 methylprednisolone ...... 29 methyltestosterone ....... 31 metipranolol ................... 42 metoclopramide hcl ..... 34 metolazone .................... 19 METOPIRONE .................. 27 metoprolol succinate ... 19 METOPROLOL SU-

HYDROCHLOROTHIAZ 19 metoprolol ta-

hydrochlorothiaz ........ 19 metoprolol tartrate ........ 19 METROCREAM ................ 24 METROGEL ...................... 24 METROGEL VAGINAL ..... 39 METROLOTION ................ 24 metronidazole ...... 7, 24, 39 mexiletine ....................... 17 MIACALCIN ..................... 31 mibelas 24 fe .................. 40 MICARDIS ........................ 19 MICARDIS HCT ................ 19 MICORT-HC ..................... 34 microgestin 1.5/30 (21) . 40 microgestin 1/20 (21) .... 40 MICROGESTIN 24 FE ....... 40

microgestin fe 1.5/30 (28) ....................................... 40

microgestin fe 1/20 (28) 40 MICROZIDE ...................... 19 midazolam ...................... 16 midodrine ........................ 27 migergot .......................... 11 miglitol .............................. 32 miglustat .......................... 31 MIGRANAL ....................... 11 mili ..................................... 40 milk of magnesia ............ 34 milk of magnesia

concentrated .............. 34 millipred ........................... 29 millipred dp ..................... 29 mimvey ............................ 39 mimvey lo ........................ 39 MINASTRIN 24 FE ............. 40 MINIPRESS ........................ 19 MINITRAN ......................... 22 MINIVELLE......................... 39 MINOCIN ............................ 8 minocycline....................... 8 minoxidil ........................... 19 miralax ............................. 34 MIRAPEX ........................... 10 MIRAPEX ER ..................... 11 MIRCETTE (28) .................. 40 mirtazapine ..................... 16 misoprostol ...................... 36 MITIGARE ......................... 37 MITOSOL........................... 43 MOBIC .............................. 14 modafinil .......................... 16 moderiba ......................... 36 moderiba dose pack .... 36 moexipril .......................... 19 moexipril-

hydrochlorothiazide ... 19 mometasone ............ 26, 45 mondoxyne nl ................... 8 MONODOX........................ 8 mono-linyah .................... 40 mononessa (28) .............. 40 montelukast .................... 45 MONUROL ......................... 8

62

morgidox ........................... 8 MORGIDOX 1X 50 ............ 8 MORGIDOX 2X100 ........... 8 MORPHABOND ER .......... 13 morphine ......................... 13 morphine concentrate . 13 MOTOFEN ........................ 33 MOVANTIK ....................... 34 MOVIPREP ....................... 34 MOXATAG ......................... 7 MOXEZA ........................... 42 moxifloxacin ................ 8, 42 MS CONTIN ...................... 13 MUGARD ......................... 28 MULTAQ ........................... 17 multi-vitamin with fluoride

....................................... 48 multivitamins with fluoride

....................................... 48 mupirocin ........................ 25 mupirocin calcium ......... 25 mvc-fluoride .................... 48 my choice ....................... 41 my way ............................ 41 MYALEPT .......................... 31 MYAMBUTOL ..................... 7 MYCOBUTIN ....................... 7 mycophenolate mofetil .. 9 mycophenolate sodium . 9 MYDAYIS .......................... 16 MYFORTIC .......................... 9 MYRBETRIQ ...................... 46 MYSOLINE ........................ 10 MYTESI .............................. 33 myzilra .............................. 41

N

nabumetone .................. 14 nadolol ............................ 19 nadolol-

bendroflumethiazide . 19 naftifine ............................ 25 NAFTIN .............................. 25 NALFON ........................... 14 naltrexone ....................... 14 NAMENDA ....................... 11

NAMENDA TITRATION PAK ...................................... 11

NAMENDA XR ................. 12 NAMZARIC ...................... 12 NAPRELAN CR ................ 14 NAPROSYN ...................... 14 naproxen ........................ 14 naproxen sodium........... 14 naratriptan ...................... 11 NARCAN ......................... 14 NARDIL ............................. 16 NASONEX ........................ 45 NATACYN ........................ 42 NATAZIA ........................... 41 nateglinide ..................... 32 NATESTO .......................... 31 NATPARA ......................... 31 NATROBA ........................ 27 natural b-100 complex . 48 natura-lax ....................... 34 nature-throid .................. 32 NEBUPENT .......................... 7 nebusal ............................ 45 NEBUSAL .......................... 45 necon 0.5/35 (28) .......... 41 necon 7/7/7 (28) ............ 41 nefazodone .................... 16 neomycin .......................... 7 neomycin-bacitracin-

poly-hc ......................... 43 neomycin-bacitracin-

polymyxin .................... 42 neomycin-polymyxin b-

dexameth .................... 43 neomycin-polymyxin-

gramicidin ................... 42 neomycin-polymyxin-hc

................................ 28, 43 neo-polycin .................... 42 neo-polycin hc ............... 43 NEORAL ............................. 9 NEO-SYNALAR ................ 25 NEO-SYNALAR KIT ........... 25 NESINA ............................. 32 neuac .............................. 24 NEUAC KIT ....................... 24 NEUPRO ........................... 11

NEURONTIN ...................... 10 NEVANAC ........................ 43 nevirapine ......................... 5 NEXIUM ............................. 36 NEXIUM PACKET .............. 36 niacin ............................... 21 NIASPAN EXTENDED-

RELEASE ........................ 21 nicardipine ...................... 19 NICODERM CQ ............... 27 nicorelief .......................... 28 nicorette .......................... 28 NICORETTE ....................... 28 nicotine ............................ 28 nicotine (polacrilex) ....... 28 NICOTROL ........................ 28 NICOTROL NS .................. 28 nifedipine ......................... 19 nikki (28) ........................... 41 NILANDRON ....................... 9 nilutamide ......................... 9 nimodipine ...................... 19 NINJACOF-XG ................. 44 nisoldipine........................ 19 nitro-bid............................ 22 NITRO-DUR ....................... 22 nitrofurantoin ..................... 8 nitrofurantoin

macrocrystal.................. 8 nitrofurantoin

monohyd/m-cryst ......... 8 nitroglycerin .................... 22 NITROLINGUAL ................ 22 NITROMIST ........................ 22 NITROSTAT ........................ 22 NITYR ................................. 27 nizatidine ......................... 36 NIZORAL ........................... 25 nolix .................................. 26 nora-be ............................ 39 NORCO ............................ 13 NORDITROPIN FLEXPRO . 36 noreth-ethinyl estradiol-

iron ................................ 41 norethindrone

(contraceptive) .......... 39 norethindrone acetate . 39

63

norethindrone ac-eth estradiol ................. 39, 41

norethindrone-e.estradiol-iron ................................ 41

norgestimate-ethinyl estradiol ....................... 41

NORITATE ......................... 24 norlyda ............................ 39 norlyroc ............................ 39 NORPACE ........................ 17 NORPACE CR .................. 17 NORPRAMIN .................... 16 NORTHERA ....................... 27 nortrel 0.5/35 (28) ........... 41 nortrel 1/35 (21) .............. 41 nortrel 1/35 (28) .............. 41 nortrel 7/7/7 (28) ............ 41 nortriptyline ..................... 16 NORVASC ........................ 19 NORVIR .............................. 5 NOVOLIN 70/30 .............. 30 NOVOLIN N ..................... 30 NOVOLIN R ...................... 30 NOVOLOG FLEXPEN U-100

INSULIN.......................... 30 NOVOLOG MIX 70-30 U-

100 INSULN ................... 30 NOVOLOG MIX 70-

30FLEXPEN U-100 ......... 30 NOVOLOG PENFILL U-100

INSULIN.......................... 30 NOVOLOG U-100 INSULIN

ASPART ......................... 30 NOXAFIL ............................. 5 np thyroid ........................ 32 NUCORT ........................... 26 NUCYNTA ......................... 14 NUCYNTA ER ................... 14 NUEDEXTA ........................ 12 NULEV ............................... 33 NULYTELY WITH FLAVOR

PACKS ........................... 35 NUOX ............................... 24 NUPLAZID ......................... 16 NUTROPIN AQ NUSPIN ... 36 NUVARING....................... 39 NUVESSA .......................... 39

NUVIGIL ........................... 16 nyamyc ........................... 25 nystatin ........................ 5, 25 nystatin-triamcinolone .. 25 nystop .............................. 25

O

OBREDON ....................... 44 OCALIVA ......................... 35 ocella .............................. 41 octreotide acetate ......... 9 OCUFLOX ........................ 42 ODACTRA ....................... 37 ODEFSEY ............................ 5 OFEV ................................ 45 ofloxacin ............... 8, 28, 42 ogestrel (28) .................... 41 okebo ................................ 8 olanzapine ...................... 16 olanzapine-fluoxetine ... 16 olmesartan...................... 19 olmesartan-amlodipin-

hcthiazid ...................... 19 olmesartan-

hydrochlorothiazide ... 19 olopatadine ............. 28, 42 OLUX ................................ 26 OLUX-E ............................. 26 OMECLAMOX-PAK ........ 36 omega-3 acid ethyl esters

...................................... 21 omeppi ............................ 36 omeprazole .................... 36 omeprazole-sodium

bicarbonate ................ 36 OMNARIS ......................... 45 OMNIPRED ...................... 43 OMNITROPE .................... 36 ondansetron ................... 35 ondansetron hcl ............ 35 one daily prenatal ......... 48 ONETOUCH ULTRA BLUE

TEST STRIP ...................... 29 ONETOUCH ULTRA

CONTROL ..................... 29 ONETOUCH ULTRA2 ....... 29 ONETOUCH ULTRAMINI . 29

ONETOUCH VERIO .......... 29 ONETOUCH VERIO FLEX . 29 ONETOUCH VERIO IQ

METER ............................ 29 ONETOUCH VERIO SYSTEM

....................................... 29 ONEXTON ......................... 24 ONFI .................................. 10 ONGLYZA ......................... 32 ONMEL ............................... 5 ONZETRA XSAIL ................ 11 OPANA ............................. 13 opcicon one-step .......... 41 OPSUMIT ........................... 46 option-2 ........................... 41 ORACEA ............................ 8 ORACIT ............................. 47 oral saline laxative ......... 35 ORALAIR ........................... 37 oralone ............................ 28 ORAMAGICRX ................ 28 ORAP ................................ 16 ORAPRED ODT ................ 29 ORAVIG ............................. 5 ORENCIA .......................... 38 ORENCIA CLICKJECT ..... 38 ORENITRAM ..................... 19 ORFADIN .......................... 27 ORKAMBI .......................... 46 orphenadrine citrate ..... 12 orsythia ............................. 41 ORTHO MICRONOR ........ 39 ORTHO TRI-CYCLEN (28) 41 ORTHO TRI-CYCLEN LO

(28) ................................ 41 ORTHO-CYCLEN (28) ...... 41 ORTHO-NOVUM 1/35 (28)

....................................... 41 ORTHO-NOVUM 7/7/7 (28)

....................................... 41 oscimin ............................. 33 oscimin sl .......................... 33 oscimin sr ......................... 33 oseltamivir ......................... 5 OSENI ................................ 32 OSMOPREP ...................... 35 OSPHENA ......................... 39

64

OTEZLA ............................. 38 OTEZLA STARTER .............. 38 OTOVEL ............................ 28 OTREXUP (PF) .................. 38 OVACE............................. 22 OVACE PLUS ................... 22 OVACE PLUS SHAMPOO 22 OVACE PLUS WASH ........ 22 OVIDE ............................... 27 OXANDRIN ....................... 31 oxandrolone ................... 31 oxaprozin ......................... 14 OXAYDO .......................... 13 oxazepam ....................... 16 oxcarbazepine ............... 10 oxiconazole .................... 25 OXISTAT ............................ 25 OXSORALEN ULTRA ........ 23 OXTELLAR XR ................... 10 oxybutynin chloride ....... 46 oxycodone ..................... 13 OXYCODONE ................. 13 oxycodone-

acetaminophen ......... 13 oxycodone-aspirin ......... 13 OXYCONTIN .................... 13 oxymorphone ................. 13 OXYTROL .......................... 46 oysco 500/d .................... 48 oyster shell + d3 .............. 48 oyster shell calcium-vit d2

....................................... 48 oyster shell calcium-vit d3

....................................... 48 oystercal-d ...................... 48 OZEMPIC .......................... 32

P

pacerone ........................ 17 paliperidone ................... 16 PAMELOR ......................... 16 PANCREAZE ..................... 35 PANDEL ............................ 26 panlor(acetam-caff-

dihydrocod) ................ 13 PANRETIN ......................... 23 pantoprazole .................. 36

paregoric ........................ 33 PAREMYD ........................ 42 paricalcitol ...................... 31 PARLODEL ....................... 11 PARNATE ......................... 16 paroex oral rinse ............ 28 paromomycin .................. 7 paroxetine hcl ................ 16 paroxetine

mesylate(menop.sym) ...................................... 16

PASER ................................. 7 PATADAY ......................... 42 PATANASE ....................... 28 PATANOL ......................... 43 PAXIL ................................ 16 PAXIL CR .......................... 16 PAZEO .............................. 43 peg 3350-electrolytes ... 35 peg3350 .......................... 35 PEGANONE ..................... 10 PEGASYS .......................... 36 PEGASYS PROCLICK ...... 36 peg-electrolyte soln ...... 35 PEGINTRON ..................... 36 peg-prep ........................ 35 PEN NEEDLE ..................... 29 penicillin v potassium ...... 7 PENLAC ........................... 25 PENNSAID ........................ 14 PENTASA .......................... 35 pentazocine-naloxone . 14 pentoxifylline .................. 20 PEPCID ............................. 36 PERCOCET ...................... 13 PERFOROMIST ................. 46 PERIDEX ........................... 28 perindopril erbumine .... 19 periogard ........................ 28 permethrin ...................... 27 perphenazine ................. 16 perphenazine-

amitriptyline................. 16 perry prenatal ................ 48 PERTZYE ............................ 35 PEXEVA ............................ 16 phenadoz ....................... 44

phenazopyridine ............ 47 phendimetrazine tartrate

....................................... 27 phenelzine ....................... 16 phenergan ...................... 44 phenobarb-hyoscy-

atropine-scop .............. 33 phenobarbital ................ 10 phenohytro ..................... 33 phenoxybenzamine....... 19 phentermine ................... 27 phenylephrine hcl .......... 44 PHENYTEK ......................... 10 phenytoin ........................ 10 phenytoin sodium

extended ..................... 10 philith ................................ 41 PHOSLYRA ........................ 35 phospha 250 neutral ...... 48 phosphasal ...................... 47 phosphate laxative ........ 35 PHOSPHOLINE IODIDE .... 42 phosphorous ................... 48 phrenilin forte(with

caffeine) ...................... 13 phytonadione (vitamin

k1) .................................. 20 PICATO ............................. 23 pilocarpine hcl... 27, 28, 42 pimozide .......................... 16 pimtrea (28) .................... 41 pindolol ............................ 19 pioglitazone .................... 32 pioglitazone-glimepiride

....................................... 32 pioglitazone-metformin . 32 pirmella ............................ 41 piroxicam ......................... 14 PLAN B ONE-STEP ............ 41 PLAQUENIL ......................... 7 PLAVIX .............................. 21 PLEGRIDY ......................... 36 PLEXION ........................... 24 PLEXION CLEANSING

CLOTHS ......................... 24 PLIAGLIS ........................... 25 PODOCON ...................... 23

65

podofilox ......................... 23 polycin ............................. 42 polymyxin b sulf-

trimethoprim ................ 42 POLYTRIM ......................... 42 POLY-TUSSIN AC ............. 44 portia ............................... 41 pot,sodium citrate-citric

acid .............................. 47 potassium bicarb and

chloride ........................ 48 potassium bicarb-citric

acid .............................. 48 potassium chloride ........ 48 potassium citrate ........... 47 potassium citrate-citric

acid .............................. 47 powderlax ....................... 35 PRADAXA ........................ 21 PRALUENT PEN................. 21 pramcort ......................... 35 pramipexole ................... 11 PRAMOSONE .................. 22 PRAMOSONE E ............... 22 PRANDIN .......................... 32 prasugrel ......................... 21 PRAVACHOL ................... 21 pravastatin ...................... 21 praziquantel ...................... 7 prazosin ........................... 19 PRECOSE .......................... 32 PRED FORTE ..................... 43 PRED MILD ....................... 43 PRED-G ............................ 43 PRED-G S.O.P. ................. 43 prednicarbate ................ 26 prednisolone ................... 29 prednisolone acetate ... 43 prednisolone sodium

phosphate ............. 29, 43 prednisone ...................... 29 prednisone intensol ....... 29 PREFEST ............................ 39 PREMARIN ........................ 39 PREMPHASE ..................... 39 PREMPRO ......................... 39 prenatal ........................... 48

prenatal complete ........ 48 prenatal formula ............ 48 prenatal multi-dha (algal

oil) ................................. 48 prenatal one daily ......... 48 prenatal vitamin ............ 48 prenatal vitamin with

minerals ........................ 48 prenatal vits96-iron fum-

folic ............................... 48 PREPOPIK ......................... 35 PRESTALIA ........................ 19 PREVACID ....................... 36 PREVACID SOLUTAB ....... 36 prevalite .......................... 21 PREVIDENT ....................... 28 PREVIDENT 5000 BOOSTER

PLUS .............................. 28 PREVIDENT 5000 DRY

MOUTH ......................... 28 PREVIDENT 5000 ENAMEL

PROTECT ...................... 28 PREVIDENT 5000 PLUS .... 28 PREVIDENT 5000 SENSITIVE

...................................... 28 previfem .......................... 41 PREVYMIS .......................... 5 PREZCOBIX ........................ 5 PREZISTA............................. 6 PRIFTIN ............................... 7 PRILOSEC ......................... 36 PRIMAQUINE ..................... 7 primidone ....................... 10 PRIMLEV ........................... 13 PRIMSOL ............................ 8 PRINIVIL ............................ 19 PRISTIQ ............................. 16 PROAIR HFA .................... 46 PROAIR RESPICLICK ....... 46 probenecid .................... 37 probenecid-colchicine 37 PROCARDIA .................... 20 PROCARDIA XL ............... 20 procentra ........................ 16 prochlorperazine ........... 35 prochlorperazine maleate

...................................... 35

PROCORT ......................... 35 PROCTOFOAM HC ......... 35 procto-med hc ............... 35 proctosol hc .................... 35 proctozone-hc ................ 35 PROCYSBI ......................... 47 PRODRIN .......................... 11 profeno ............................ 14 progesterone .................. 39 progesterone micronized

....................................... 39 PROGLYCEM ................... 29 PROGRAF ........................... 9 PROLENSA ........................ 43 PROMACTA ..................... 21 promethazine ................. 44 promethazine vc-codeine

....................................... 44 promethazine-codeine . 44 promethazine-dm .......... 44 promethazine-

phenylephrine ............. 44 promethegan ................. 44 PROMETRIUM ................... 39 PROMISEB ........................ 23 PROMISEB COMPLETE .... 22 propafenone .................. 17 propantheline ................. 33 proparacaine ................. 43 propranolol...................... 20 propranolol-

hydrochlorothiazid ...... 20 propylthiouracil ............... 29 PRO-RED AC (W/

DEXCHLORPHENIR) ..... 44 PROSCAR ......................... 46 PROSTIN E2 ....................... 39 PROTONIX ........................ 36 PROTOPIC ........................ 23 protriptyline ..................... 16 PROVENTIL HFA ............... 46 PROVERA ......................... 39 PROVIGIL ......................... 16 PROZAC ........................... 16 prudoxin ........................... 23 PSORCON ........................ 26 PULMICORT ...................... 46

66

PULMICORT FLEXHALER . 46 pulmosal .......................... 46 PULMOZYME .................... 46 purelax ............................. 35 PURIXAN ............................. 9 PYLERA ............................. 36 pyrazinamide .................... 7 PYRIDIUM ......................... 47 pyridostigmine bromide 12

Q

QBRELIS ............................ 20 QNASL .............................. 46 QSYMIA ............................ 27 QTERN .............................. 32 QUALAQUIN ...................... 7 QUARTETTE ....................... 41 quasense ......................... 41 quazepam ...................... 16 QUDEXY XR ...................... 10 QUESTRAN ....................... 21 QUESTRAN LIGHT ............ 21 quetiapine ...................... 16 QUILLICHEW ER ............... 17 QUILLIVANT XR ................ 17 quinapril ........................... 20 quinapril-

hydrochlorothiazide ... 20 quinidine gluconate ...... 17 quinidine sulfate ............. 17 quinine sulfate .................. 7 quit 2 ................................ 28 QUIT 2 ............................... 28 quit 4 ................................ 28 QUIT 4 ............................... 28 QUTENZA .......................... 23 QVAR REDIHALER ........... 46

R

rabeprazole .................... 36 RADIOGARDASE ............. 31 RAGWITEK ........................ 37 rajani ................................ 41 raloxifene......................... 37 ramipril ............................. 20 RANEXA ........................... 22 ranitidine hcl ................... 36

RAPAFLO ......................... 46 RAPAMUNE ....................... 9 rasagiline ......................... 11 RASUVO (PF) ................... 38 RAVICTI ............................ 27 RAYALDEE ....................... 31 RAYOS ............................. 29 RAZADYNE....................... 12 RAZADYNE ER ................. 12 REBETOL ........................... 36 REBIF (WITH ALBUMIN) ... 36 REBIF REBIDOSE ............... 36 REBIF TITRATION PACK ... 36 reclipsen (28) .................. 41 RECTIV ............................. 35 REGIMEX .......................... 27 REGLAN ........................... 35 REGRANEX ...................... 23 RELAGARD ...................... 39 RELENZA DISKHALER ......... 6 RELISTOR .......................... 35 RELPAX ............................. 11 REMERON ........................ 17 REMERON SOLTAB .......... 17 RENAGEL ......................... 35 rena-vite .......................... 48 RENVELA .......................... 35 repaglinide ..................... 32 repaglinide-metformin .. 32 REPATHA PUSHTRONEX .. 21 REPATHA SURECLICK ..... 21 REPATHA SYRINGE .......... 21 REQUIP ............................. 11 REQUIP XL ........................ 11 RESCRIPTOR ...................... 6 RESPA-AR ........................ 44 RESTASIS ........................... 43 RESTASIS MULTIDOSE ...... 43 RESTORIL .......................... 17 RETIN-A ............................ 24 RETIN-A MICRO ............... 24 RETIN-A MICRO PUMP ... 24 RETROVIR ........................... 6 REVATIO .......................... 46 REXULTI ............................. 17 REYATAZ ............................ 6 RHOPRESSA ..................... 43

ribasphere ....................... 36 ribasphere ribapak ........ 36 ribavirin......................... 6, 36 RIDAURA .......................... 38 rifabutin .............................. 7 RIFADIN .............................. 7 RIFAMATE ........................... 7 rifampin .............................. 7 RIFATER ............................... 7 RILUTEK ............................. 27 riluzole .............................. 27 rimantadine ...................... 6 RIOMET ............................. 32 risacal-d ........................... 48 risedronate ................ 27, 37 RISPERDAL ........................ 17 risperidone ....................... 17 RITALIN .............................. 17 RITALIN LA ........................ 17 ritonavir .............................. 6 rivastigmine ..................... 12 rivastigmine tartrate ....... 12 rivelsa ............................... 41 rizatriptan ......................... 11 robafen ac ...................... 44 ROBAXIN .......................... 12 ROBAXIN-750 ................... 12 ROBINUL ........................... 33 ROBINUL FORTE ............... 33 ROCALTROL ..................... 31 ropinirole .......................... 11 rosadan ........................... 24 ROSADAN ........................ 24 ROSANIL ........................... 24 ROSULA ............................ 24 rosula cleansing cloths .. 24 rosuvastatin ..................... 21 ROWASA .......................... 35 roweepra ......................... 10 roweepra xr ..................... 10 ROXICODONE ................. 13 ROZEREM ......................... 17 rydex................................. 44 RYTARY ............................. 11 RYTHMOL SR .................... 17 RYVENT ............................. 44

67

S

SABRIL ............................... 10 SAFYRAL ........................... 41 SAIZEN .............................. 36 SAIZEN SAIZENPREP ......... 36 SALAGEN (PILOCARPINE)

................................. 27, 28 SALEX ................................ 23 salicylic acid ................... 23 salicylic acid er-

ceramides .................... 23 SALKERA ........................... 23 salsalate .......................... 14 salvax ............................... 23 SALVAX DUO PLUS .......... 23 SAMSCA .......................... 31 SANCUSO ........................ 35 SANDIMMUNE ................... 9 SANDOSTATIN ................... 9 SANTYL ............................. 27 SAPHRIS (BLACK CHERRY)

....................................... 17 SARAFEM ......................... 17 SAVAYSA ......................... 21 SAVELLA ........................... 38 SAXENDA ......................... 27 scalacort ......................... 26 SCALACORT DK .............. 26 scopolamine base ......... 35 SEASONIQUE ................... 41 seb-prev .......................... 22 seconal sodium .............. 17 SEEBRI NEOHALER ........... 46 SEGLUROMET .................. 32 selegiline hcl ................... 11 selenium sulfide .............. 22 SELRX ................................ 22 SELZENTRY .......................... 6 SEMPREX-D ...................... 44 SENSIPAR .......................... 31 SEREVENT DISKUS ............ 46 SERNIVO ........................... 26 SEROQUEL ....................... 17 SEROQUEL XR .................. 17 SEROSTIM ......................... 36 sertraline .......................... 17 setlakin ............................. 41

sevelamer carbonate ... 35 sf 28 sf 5000 plus ...................... 28 SFROWASA ...................... 35 sharobel .......................... 39 SHOHL'S MODIFIED ......... 47 SIGNIFOR ........................... 9 sildenafil

(antihypertensive) ...... 46 SILENOR ........................... 17 SILIQ ................................. 22 SILVADENE....................... 22 silver nitrate ..................... 23 silver nitrate applicators 23 silver sulfadiazine ........... 22 SIMBRINZA ....................... 43 SIMPONI ........................... 38 simvastatin ...................... 21 SINEMET ........................... 11 SINEMET CR ..................... 11 SINGULAIR ....................... 46 sirolimus ............................. 9 SIRTURO ............................. 7 SIVEXTRO ........................... 7 SKELAXIN ......................... 12 SKLICE .............................. 27 smoothlax ....................... 35 sodium chloride ............. 46 sodium citrate-citric acid

...................................... 47 sodium phenylbutyrate 27 sodium polystyrene (sorb

free) .............................. 35 sodium polystyrene

sulfonate ...................... 35 SODIUM POLYSTYRENE

SULFONATE .................. 35 SOLARAZE ....................... 23 SOLIQUA 100/33 ............. 30 SOLODYN .......................... 8 SOLOSEC ........................... 7 soloxide ............................. 8 SOLTAMOX ........................ 9 SOMA .............................. 12 SOMAVERT ...................... 31 SONATA ........................... 17 SOOLANTRA .................... 24

SORIATANE ...................... 22 SORILUX ............................ 22 sotalol ............................... 17 sotalol af .......................... 17 SOTYLIZE ........................... 17 SOVALDI ............................. 6 sp antipruritic .................. 23 SPECTRACEF ...................... 6 spinosad .......................... 27 SPIRIVA RESPIMAT ........... 46 SPIRIVA WITH HANDIHALER

....................................... 46 spironolactone ............... 20 spironolacton-

hydrochlorothiaz ......... 20 SPORANOX ........................ 5 SPORANOX PULSEPAK ...... 5 sprintec (28) .................... 41 SPRIX ................................. 14 sps (with sorbitol) ............ 35 sronyx ............................... 41 ssd ..................................... 22 SSKI .................................... 29 sss 10-5 .............................. 24 STALEVO 100 ................... 11 STALEVO 125 ................... 11 STALEVO 150 ................... 11 STALEVO 200 ................... 11 STALEVO 50...................... 11 STALEVO 75...................... 11 STARLIX ............................. 32 stavudine ........................... 6 STEGLATRO ...................... 32 STEGLUJAN ...................... 32 STELARA ........................... 22 STIMATE ............................ 31 STIOLTO RESPIMAT .......... 46 stop smoking aid ............ 28 STRATTERA ........................ 17 STRENSIQ .......................... 31 stress formula................... 48 stress formula with iron ... 48 stress formula with

iron(sulf) ........................ 48 STRIANT ............................. 31 STRIBILD .............................. 6 STRIVERDI RESPIMAT ........ 46

68

STROMECTOL .................... 7 strong iodine ................... 48 SUBOXONE ...................... 14 SUBSYS .............................. 13 subvenite ......................... 10 subvenite starter (blue) kit

....................................... 10 subvenite starter (green)

kit ................................... 10 subvenite starter (orange)

kit ................................... 10 SUCRAID .......................... 35 sucralfate ........................ 36 SULAR ............................... 20 sulfacetamide sodium . 22,

43 sulfacetamide sodium

(acne) .......................... 25 sulfacetamide sodium-

sulfur .............................. 24 sulfacetamide sod-sulfur-

urea .............................. 24 sulfacetamide-

prednisolone ............... 43 sulfacetamide-sulfur-

cleansr23 ...................... 24 sulfacleanse 8-4 ............. 24 sulfact na-sul-avobnz-otn-

ocsa .............................. 24 sulfadiazine ....................... 8 sulfamethoxazole-

trimethoprim .................. 8 SULFAMYLON .................. 25 sulfasalazine .................... 35 sulfatrim ............................. 8 sulindac ........................... 14 SUMADAN ....................... 24 SUMADAN XLT ................. 24 sumatriptan ..................... 11 sumatriptan succinate .. 11 sumatriptan-naproxen .. 11 SUMAVEL DOSEPRO ....... 11 SUMAXIN .......................... 24 SUMAXIN CP .................... 24 SUMAXIN TS ..................... 24 super b complex-vitamin

c .................................... 48

super b maxi complex .. 48 super b-50 complex plus

...................................... 48 super quints .................... 48 super quints b-50 ............ 48 superplex-t ...................... 48 SUPRAX .............................. 6 SUPREP BOWEL PREP KIT 35 SURFAXIN ......................... 46 SURMONTIL ...................... 17 SUSTIVA .............................. 6 syeda ............................... 41 SYMAX DUOTAB ............. 33 symax fastabs ................. 33 symax-sl ........................... 33 symax-sr ........................... 33 SYMBICORT ..................... 46 SYMBYAX ......................... 17 SYMDEKO ........................ 46 SYMFI .................................. 6 SYMFI LO ............................ 6 SYMLINPEN 120 ............... 32 SYMLINPEN 60 ................. 32 SYMPROIC ....................... 35 SYNALAR ......................... 26 SYNALAR CREAM KIT ..... 26 SYNALAR OINTMENT KIT . 26 SYNALAR TS ..................... 26 SYNAREL .......................... 31 SYNDROS ......................... 35 SYNERA ............................ 25 SYNJARDY ....................... 32 SYNJARDY XR .................. 32 SYNTHROID ...................... 32 SYPRINE ............................ 31

T

TACLONEX ...................... 22 tacrolimus ................... 9, 23 TAKE ACTION .................. 41 TALTZ AUTOINJECTOR .... 22 TALTZ AUTOINJECTOR (2

PACK) ........................... 22 TALTZ AUTOINJECTOR (3

PACK) ........................... 22 TALTZ SYRINGE ................ 22 TAMIFLU ............................. 6

tamoxifen .......................... 9 tamsulosin ........................ 46 TANZEUM .......................... 32 TAPAZOLE ........................ 29 TAPERDEX ......................... 29 TARGADOX ........................ 8 tarina fe 1/20 (28) ........... 41 TARKA ............................... 20 TASMAR ............................ 11 TAYTULLA .......................... 41 tazarotene ....................... 24 TAZORAC ......................... 24 taztia xt ............................ 20 TECFIDERA ....................... 36 TECHNIVIE .......................... 6 TEGRETOL ......................... 10 TEGRETOL XR ................... 10 TEKTURNA ......................... 20 TEKTURNA HCT ................. 20 telmisartan ....................... 20 telmisartan-amlodipine . 20 telmisartan-

hydrochlorothiazid ...... 20 temazepam .................... 17 TEMOVATE ....................... 26 tencon ............................. 13 tenofovir disoproxil

fumarate ........................ 6 TENORETIC 100 ................ 20 TENORETIC 50 .................. 20 TENORMIN ........................ 20 terazosin ........................... 20 terbinafine hcl................... 5 terbutaline ....................... 46 terconazole ..................... 39 TERSI FOAM ...................... 22 TESSALON PERLES ............ 44 TESTIM ............................... 31 testosterone .................... 31 TESTOSTERONE................. 31 testosterone cypionate . 31 testosterone enanthate 31 TESTRED ............................ 31 tetrabenazine ................. 12 tetracycline ....................... 8 TEXACORT ........................ 26 THEO-24 ............................ 46

69

theochron ....................... 46 theophylline .................... 46 THIOLA ............................. 27 thioridazine ..................... 17 thiothixene ...................... 17 thyroid (pork) .................. 32 THYROLAR-1 .................... 32 THYROLAR-1/2 ................. 32 THYROLAR-1/4 ................. 32 THYROLAR-2 .................... 32 THYROLAR-3 .................... 32 tiagabine ......................... 10 TIAZAC ............................. 20 TIGAN ............................... 35 TIKOSYN ........................... 17 tilia fe ............................... 41 timolol maleate ........ 20, 42 TIMOPTIC ......................... 42 TIMOPTIC OCUDOSE (PF)

....................................... 42 TIMOPTIC-XE .................... 42 TINDAMAX ......................... 7 tinidazole ........................... 7 TIROSINT ........................... 32 TIVICAY .............................. 6 TIVORBEX ......................... 14 tizanidine ......................... 12 tl g-fol os .......................... 48 TOBI .................................... 7 TOBI PODHALER ................ 7 TOBRADEX ....................... 43 TOBRADEX ST ................... 43 tobramycin ..................... 42 tobramycin in 0.225 %

nacl ................................. 7 TOBRAMYCIN WITH

NEBULIZER ....................... 7 tobramycin-

dexamethasone ......... 43 TOBREX ............................. 42 TODAY CONTRACEPTIVE

SPONGE ....................... 39 TOFRANIL ......................... 17 TOLAK ............................... 23 tolazamide ...................... 32 tolbutamide .................... 32 tolcapone ....................... 11

tolmetin ........................... 14 tolterodine ...................... 46 TOPAMAX ........................ 10 TOPICORT ........................ 26 topiramate ..................... 10 TOPIRAMATE ................... 10 TOPROL XL ....................... 20 torsemide ........................ 20 total b/c .......................... 48 TOUJEO MAX U-300

SOLOSTAR .................... 30 TOUJEO SOLOSTAR U-300

INSULIN ......................... 30 TOVIAZ ............................. 46 TRACLEER ........................ 46 TRADJENTA ...................... 32 tramadol ......................... 14 TRAMADOL ..................... 14 tramadol-

acetaminophen ......... 14 trandolapril ..................... 20 trandolapril-verapamil .. 20 tranexamic acid ............ 39 TRANSDERM-SCOP ......... 35 TRANXENE T-TAB ............. 17 tranylcypromine ............ 17 TRAVATAN Z .................... 43 trazodone ....................... 17 TRECATOR ......................... 7 TRELEGY ELLIPTA ............. 46 TREMFYA .......................... 22 TRESIBA FLEXTOUCH U-100

...................................... 30 TRESIBA FLEXTOUCH U-200

...................................... 30 tretinoin ........................... 24 tretinoin microspheres .. 24 TRETIN-X ........................... 24 TRETIN-X CREAM KIT ....... 24 TREXALL ............................. 9 TREXIMET .......................... 11 TREZIX ............................... 13 tri femynor ....................... 41 TRIACETIN ........................ 25 triamcinolone acetonide

................................ 26, 28

triamterene-hydrochlorothiazid ...... 20

trianex .............................. 26 triazolam .......................... 17 TRIBENZOR ........................ 20 tricitrates .......................... 47 TRICOR ............................. 21 triderm .............................. 26 TRIDESILON ....................... 27 trientine ............................ 31 tri-estarylla ....................... 41 trifluoperazine ................. 17 trifluridine ......................... 42 TRIGLIDE ........................... 21 trihexyphenidyl ............... 11 triklo .................................. 21 tri-legest fe ....................... 41 TRILEPTAL .......................... 10 tri-linyah ........................... 41 TRILIPIX .............................. 21 tri-lo-estarylla ................... 41 tri-lo-marzia ...................... 41 tri-lo-sprintec ................... 41 trilyte with flavor packets

....................................... 35 trimethobenzamide ....... 35 trimethoprim ...................... 8 tri-mili ................................ 41 trimipramine .................... 17 TRIMPEX .............................. 8 trinessa (28) ..................... 41 trinessa lo ......................... 41 TRI-NORINYL (28) ............. 41 TRINTELLIX ......................... 17 tri-previfem (28) .............. 41 tri-sprintec (28) ................ 41 TRIUMEQ ............................. 6 tri-vitamin with fluoride .. 48 trivora (28) ....................... 41 tri-vylibra .......................... 41 TRIZIVIR ............................... 6 TROKENDI XR ................... 10 trospium ........................... 46 TRULANCE ........................ 35 TRULICITY .......................... 32 TRUSOPT ........................... 43 TRUVADA ........................... 6

70

TUDORZA PRESSAIR ........ 46 tulana............................... 39 tusnel c ............................ 44 TUSNEL PEDIATRIC ........... 44 TUSSICAPS ........................ 44 tussigon ............................ 44 TUSSIONEX PENNKINETIC

ER .................................. 44 TUZISTRA XR...................... 44 TWYNSTA .......................... 20 TYBOST................................ 6 tydemy ............................ 41 TYLENOL-CODEINE #3 ... 13 TYLENOL-CODEINE #4 ... 13 TYMLOS ............................ 37 TYVASO ............................ 46 TYVASO REFILL KIT ........... 46 TYVASO STARTER KIT ....... 46 TYZINE ............................... 28

U

UCERIS .............................. 35 ULESFIA ............................. 27 ULORIC ............................. 37 ultra b-100 complex ...... 48 ULTRACET ......................... 14 ULTRAM ............................ 14 ULTRAVATE ...................... 27 ULTRAVATE X ................... 27 umecta ............................ 23 unithroid .......................... 32 UPTRAVI ........................... 20 URAMAXIN ....................... 23 urea .................................. 23 urea nail stick .................. 23 URECHOLINE ................... 47 URELLE .............................. 47 uretron d-s ....................... 47 URIBEL ............................... 47 urimar-t ............................ 47 urin ds ............................... 47 uro-458 ............................. 47 UROCIT-K 10 .................... 47 UROCIT-K 15 .................... 47 UROCIT-K 5 ...................... 47 urogesic-blue .................. 47 uro-mp ............................. 47

urophen mb ................... 47 UROQID-ACID NO.2 ...... 47 UROXATRAL ..................... 46 URSO 250 ......................... 35 URSO FORTE .................... 35 ursodiol ............................ 35 uryl .................................... 47 ustell ................................. 47 UTA ................................... 47 UTIBRON NEOHALER ...... 46 utira-c .............................. 47 UTOPIC ............................ 23

V

VAGIFEM ......................... 39 vaginal contraceptive

foam ............................. 39 valacyclovir ...................... 6 VALCYTE ............................ 6 valganciclovir .................. 6 VALIUM ............................ 17 valproic acid .................. 10 valproic acid (as sodium

salt) ............................... 10 valsartan ......................... 20 valsartan-

hydrochlorothiazide ... 20 VALTREX ............................. 6 VANATOL LQ .................. 13 VANATOL S...................... 13 VANCOCIN ....................... 8 vancomycin ..................... 8 vandazole ....................... 39 VANOS ............................. 27 VANOXIDE-HC ................ 24 VARUBI ............................. 35 VASCEPA ......................... 21 VASERETIC ....................... 20 VASOTEC ......................... 20 VCF CONTRACEPTIVE FILM

...................................... 39 VECAMYL ........................ 22 VECTICAL ........................ 22 velivet triphasic regimen

(28) ............................... 41 VELPHORO ...................... 35 VELTASSA ......................... 35

VELTIN ............................... 25 VEMLIDY ............................. 6 venlafaxine ..................... 17 VENTAVIS ......................... 46 VENTOLIN HFA ................. 46 verapamil ........................ 20 VERDESO .......................... 27 verdrocet ......................... 13 VEREGEN .......................... 23 VERELAN .......................... 20 VERELAN PM .................... 20 veripred 20 ...................... 29 VERSACLOZ ..................... 17 VESICARE ......................... 46 VFEND ................................ 5 VIBERZI .............................. 35 VIBRAMYCIN ...................... 8 vicodin ............................. 13 vicodin es ........................ 13 vicodin hp ....................... 13 VICTOZA 2-PAK ............... 32 VICTOZA 3-PAK ............... 32 VIDEX 2 GRAM PEDIATRIC

......................................... 6 VIDEX EC ............................ 6 VIEKIRA PAK ....................... 6 VIEKIRA XR ......................... 6 vienva .............................. 41 vigabatrin ........................ 10 VIGAMOX ........................ 42 VIIBRYD ............................. 17 vilamit mb ........................ 47 vilevev mb ....................... 47 VIMOVO .......................... 14 VIMPAT ............................. 10 VIOKACE .......................... 35 viorele (28) ....................... 41 VIRACEPT ........................... 6 VIRAMUNE ......................... 6 VIRAMUNE XR .................... 6 VIRAZOLE ........................... 6 VIREAD ............................... 6 VIROPTIC .......................... 42 virt-phos 250 neutral....... 48 virtrate-2 ........................... 47 virtrate-3 ........................... 47 virtrate-k ........................... 47

71

virtussin ac ....................... 44 virtussin dac .................... 45 VISTARIL ............................ 44 VISTOGARD ....................... 8 vitajoy daily d ................. 48 vitamin b complex ......... 48 vitamin b complex-folic

acid .............................. 48 vitamin d3 ....................... 48 vitamins a,c,d and

fluoride ......................... 48 VITUZ ................................. 45 VIVELLE-DOT .................... 39 VIVLODEX ........................ 14 VOGELXO ........................ 31 VOLTAREN ....................... 14 VOLTAREN-XR.................. 14 voriconazole ..................... 5 VOSEVI ............................... 6 VRAYLAR .......................... 17 VUSION ............................ 25 vyfemla (28) .................... 41 vylibra .............................. 41 VYTONE ............................ 25 VYTORIN 10-10 ................ 21 VYTORIN 10-20 ................ 22 VYTORIN 10-40 ................ 22 VYTORIN 10-80 ................ 22 VYVANSE ......................... 17 VYZULTA ........................... 43

W

warfarin ............................ 21 WELCHOL ........................ 22 WELLBUTRIN SR ................ 17 WELLBUTRIN XL ................ 17 wera (28) ......................... 41 westhroid ......................... 32 woman's laxative ........... 35 women's gentle

laxative(bisac) ............ 35 women's laxative

(bisacodyl) ................... 35 WP THYROID .................... 32 wymzya fe ....................... 41

X

XADAGO ......................... 11 XALATAN ......................... 43 XANAX ............................. 17 XANAX XR ....................... 17 XARELTO .......................... 21 XATMEP .............................. 9 XELJANZ ........................... 38 XELJANZ XR ..................... 38 XENAZINE ......................... 12 XERESE ............................. 25 XERMELO ........................... 9 XHANCE .......................... 46 XIFAXAN ............................ 7 XIGDUO XR ..................... 32 XIIDRA .............................. 43 XIMINO .............................. 8 XOLEGEL .......................... 25 XOPENEX ......................... 46 XOPENEX CONCENTRATE

...................................... 46 XOPENEX HFA ................. 46 XTAMPZA ER .................... 13 xulane .............................. 39 XULTOPHY 100/3.6 .......... 30 XURIDEN .......................... 27 xylon 10 ........................... 13 XYREM .............................. 17

Y

YASMIN (28) .................... 41 YAZ (28) ........................... 41 YOSPRALA ....................... 21 yuvafem .......................... 39

Z

zafirlukast......................... 46 zaleplon .......................... 17 ZANAFLEX ........................ 12 ZANTAC ........................... 36 zarah ................................ 41 ZARONTIN ........................ 10 ZAVESCA ......................... 31 zebutal ............................ 13 ZEGERID ........................... 36 ZELAPAR .......................... 11 ZEMBRACE SYMTOUCH . 11

ZEMPLAR .......................... 31 zenatane ......................... 25 zenchent (28) .................. 41 ZENPEP ............................. 35 zenzedi ............................. 17 ZENZEDI ............................ 17 ZEPATIER ............................. 6 ZERIT .................................... 6 ZESTORETIC ...................... 20 ZESTRIL .............................. 20 ZETIA ................................. 22 ZETONNA .......................... 46 ZIAC .................................. 20 ZIAGEN ............................... 6 ZIANA ............................... 25 zidovudine ......................... 6 zileuton ............................. 46 ZIOPTAN (PF).................... 43 ziprasidone hcl ................ 17 ZIPSOR .............................. 14 ZIRGAN ............................. 42 ZITHRANOL ....................... 22 ZITHROMAX ........................ 6 ZITHROMAX TRI-PAK .......... 6 ZITHROMAX Z-PAK ............. 6 ZOCOR ............................. 22 ZODRYL AC 25................. 45 ZODRYL AC 30................. 45 ZODRYL AC 35................. 45 ZODRYL AC 40................. 45 ZODRYL AC 50................. 45 ZODRYL AC 60................. 45 ZODRYL AC 80................. 45 ZODRYL DAC 25 .............. 45 ZODRYL DAC 30 .............. 45 ZODRYL DAC 35 .............. 45 ZODRYL DAC 40 .............. 45 ZODRYL DAC 50 .............. 45 ZODRYL DAC 60 .............. 45 ZODRYL DAC 80 .............. 45 ZODRYL DEC 25............... 45 ZODRYL DEC 30............... 45 ZODRYL DEC 35............... 45 ZODRYL DEC 40............... 45 ZODRYL DEC 50............... 45 ZODRYL DEC 60............... 45 ZODRYL DEC 80............... 45

72

ZOFRAN ............................ 35 ZOFRAN ODT ................... 35 ZOHYDRO ER ................... 13 zolmitriptan ..................... 11 ZOLOFT ............................. 17 zolpidem .......................... 17 ZOLPIMIST ......................... 17 ZOMACTON .................... 36 ZOMIG .............................. 11 ZOMIG ZMT ...................... 11 ZONALON ........................ 23

ZONEGRAN ..................... 10 zonisamide ...................... 10 ZONTIVITY ........................ 21 ZORBTIVE ......................... 36 ZORTRESS ........................... 9 ZORVOLEX ....................... 14 zovia 1/35e (28) ............. 41 ZOVIRAX ...................... 6, 25 ZUBSOLV .......................... 14 ZUPLENZ ........................... 35 ZURAMPIC ....................... 37

ZYBAN ............................... 28 ZYCLARA .......................... 37 ZYFLO ................................ 46 ZYFLO CR ......................... 46 ZYLET ................................. 43 ZYLOPRIM ......................... 37 ZYMAXID .......................... 42 ZYPITAMAG ...................... 22 ZYPREXA ........................... 17 ZYPREXA ZYDIS................. 17 ZYVOX ................................ 7


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