Kerry Kisslinger Binder1

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Birthday Planners BirthdayTheme:

Date:

Play!

Party Bags!

Drinks for Adults:

Children:

Cake (cupcakes), Ice Cream, Candles

Plates, Cups, Napkins, Silverware.

Eat

Open Presents(Have box to put presents in & trash sack)

(Sing: Present Time, Present Time open the

present to see whats inside.)

Cake & Ice-cream(B-day song)

Gift Bags(to parents) & Clean-up

__:50

__:10

__:20

__:30

Guest List!

Gift Suggestions!

Food!Friends Family

Place:

Time:


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Birthday Planners BirthdayTheme:

Date:

Program!Gathering Game

Party Bags!

Drinks for Adults:

Children:

Cake (cupcakes), Ice Cream, Candles

Plates, Cups, Napkins, Silverware.

Open Presents(Have box to put presents in & trash sack)

Cake & Ice-cream(B-day song)

Gift Bags(to parents) & Clean-up

__:15

__:25

__:25

__:45

__:55

__:05

__:15

__:25Guest List!

Gift Suggestions!

Food!Friends Family

Place:

Time:

Optional Games!


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Providence Health & Services

Self-Funded HSA Drug Formulary

2009List of Covered Prescription Drugs

www.providence.org/healthpla


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2

PrescriptiondrugbenefitsfromProvidenceProvidence Health Plan wants you to get the most from all of your covered benefits and for you

to have information to make smart decisions about medications. Our pharmacy benefit plan is

designed to provide resources to assist you and your doctor to become knowledgeable about the

latest and best information about effective, quality medications that also provide value.

ProvidenceHealthPlansprescriptiondrugProgramYour prescription drug coverage provides benefits for medications listed on the Providence

Health Plan formulary. The Formulary is a list of Food and Drug Administration (FDA)-

approved prescription generic, brand name and specialty medications. Providence consults with a

team of physicians and pharmacists to develop the Formulary which is designed to offer drug

treatment choices for covered medical conditions. The Formulary can help you and your

physician choose effective medications that minimize your out-of-pocket expense. There are

effective generic drug choices to treat most medical conditions. Medications included in theFormulary can be purchased at participating retail, mail order and specialty pharmacies. The

Providence Health Plan Formulary is available at our website: www.providence.org/healthplans/under Members, Pharmacy resources.

RetailPharmaciesYou have broad access to over 22,000 participating pharmacies and their services nationwide at

discounted rates. You can search the online directory to locate participating pharmacies near

you.

MailOrderPharmaciesA 90-day supply of maintenance medication is available through the mail order participating

pharmacies. Maintenance drugs are typically prescribed to treat long-term or chronic conditions,

such as diabetes, high blood pressure and high cholesterol. Maintenance drugs are those that you

have received under our plan for at least 30-days and you anticipate continuing to use in the

future. Your 90-day supply copayment or coinsurance applies. Not all covered prescription drugs

are available in a 90-day supply. Mail order pharmacies include:

Postal Prescription Services Walgreens Pharmacy Wellpartner Pharmacy

In addition, you have access to a 90-day supply of maintenance medications at preferred retail

stores, such as Costco, Fred Meyer, Providence (all pharmacy locations), QFC, Safeway,

Walgreens, and Yokes Food pharmacies.
http://providence.org/healthplans/members/pharmacy/postalrx.aspxhttp://providence.org/healthplans/members/pharmacy/walgreens.aspxhttp://providence.org/healthplans/members/pharmacy/wellpartner.aspxhttp://providence.org/healthplans/members/pharmacy/wellpartner.aspxhttp://providence.org/healthplans/members/pharmacy/walgreens.aspxhttp://providence.org/healthplans/members/pharmacy/postalrx.aspx


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3

SpecialtydrugsSpecialty drugs are prescriptions that require special delivery, handling, administration and

monitoring by your pharmacist. These drugs are available through Providence Specialty

Pharmacy Services and are listed in the Providence Health Plan formulary with a status of

Specialty. To order your specialty medication contact Providence Specialty Pharmacy at 503-215-4535 or 1-800-772-7053 ext. 54535.KnowMore.SaveMore.

1. Become smarter about your prescription drug benefits - refer to the Pharmacy BenefitTips section on our Web site.

2. Ask your physician if theres a generic medication available on the Formulary to treatyour medical condition.

GenericdrugsWhy should you consider switching to generic drugs? Generic drugs have the same active-

ingredient formula as the brand name drug. Generic drugs are tested by the Food and Drug

Administration (FDA) to be as safe and as effective as brand-name drugs. Generic drugs are

only available after the brand name patent expires. The bonus: They save you and your

employer money. Refer to our list of Effective Generic Options for Common Medical

Conditions available on our website: www.providence.org/healthplans/ under Members,Pharmacy resources. There are two types of generic drugs:

GenericEquivalentA generic equivalent means the exact same medication in generic form is substituted for

the brand name. A generic manufacturer makes it and charges less than the brand

manufacturer. The FDA assures equivalence through testing. More than 50% of the time

the same company makes the brand and the generic! They then license it to be

distributed under a generic manufacturing company (e.g. for high cholesterol: Zocor

(simvastatin) made by Merck is now as available in generic form as simvastatin).

GenericAlternativeA generic alternative is not the same medication. According to the evidence that includes

medical studies, the generic alternative can be expected to treat the same condition as

well as or better than the brand name alternative (e.g. for high cholesterol: simvastatin is

prescribed instead of LIPITOR

)Generic alternatives are an important option for drugs

not available in generic form yet. Visit the Consumer Reports Best Buy Drug website

http://www.consumerreports.org/health/best-buy-drugs/index.htm for more information on safe

and effective drug treatment options.


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4

FormularyBranddrugsBrand name drugs are protected by US patent laws for up to 17 years. Only the pharmaceutical

company holds the patent and has exclusive rights to produce and sell the drug; however, there

are effective generic equivalents or alternatives to treat most common ailments. If there is not a

generic option, Providence has identified formulary brand name drugs that evidence shows theycan be used safely, are effective, and offer value.

PriorAuthorizationSome prescription drugs require prior authorization for medical necessity, place of therapy,

length of therapy, step therapy, or number of doses. A limited number of medications need prior

authorization (PA) review by physicians and pharmacists at Providence Health Plan in order to

be approved for coverage. We consider many factors before requiring PA of a prescription

medication including: serious risks, Food and Drug Administration (FDA) approved indications,

cost-effectiveness, and new medications on the market that have not been widely used orevaluated. If your medication requires prior authorization, contact your doctor or other medical

provider to submit an authorization request or to consider changing your prescription to an

effective formulary alternative medication covered by your pharmacy benefits. The Formulary

and prior authorization form are available on our website: www.providence.org/healthplans/under Members, Pharmacy resources.

StepTherapyStep therapy uses Providence Health Plan pharmacy claims history to confirm if certain drugs

have been tried first and if they have, the drug requiring prior authorization will automatically beapproved. In the event these drugs are not tried first, cannot be tried first or the drug history is

not part of Providence Health Plan claims, prior authorization is required.

QuantityLimitFor certain drugs, Providence Health Plans limits the amount of the drug covered for a specified

time frame [e.g. Providence Health Plans provides 2 inhalers per 30 days for Proair or

Proventil

HFA (Albuterol HFA)].


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HowtosearchtheFormularyThere are two ways to search the Formulary:

1. The first section of the Formulary lists prescription medications by medical condition

category that the drug treats (e.g., drugs used to treat heart conditions are listed under thecategory, Cardiovascular Agents).

2. The Index, which provides an alphabetical listing of the drugs included in the Formulary.

ChangestotheFormularyOur pharmacy & therapeutics committee (comprised of community doctors and pharmacists who

practice in the communities we serve) continue to review the latest evidence to identify

opportunity to promote safe, effective and affordable drug therapy. The formulary is updated

every two months. Generally, formulary status for a drug you are taking will not change during

the year unless:

The same medication is now available in generic form, or Safety or effectiveness concerns are raised about the prescription drug, or The pharmacy & therapeutics committee determines that changes to the formulary would

overall be in the best interest of PHPs health plan members. In such cases, impacted

individuals are always notified in writing if the formulary change results in a reduction of

benefits or an increase in copayment.


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ProvidenceHealthPlanFormulary[Tohelpfindadrugseethebackofthedocumentforanalphabeticallisting]

DrugName Comment Status*Analgesics Drugstotreatpain

Non

opioid

AnalgesicsCELEBREX PA,QL(60CAPSPER30DAYS)BRAND

DICLOFENACPOTASSIUM GENERIC

DIFLUNISAL GENERIC

ETODOLAC GENERIC

FENOPROFEN GENERIC

FLURBIPROFEN GENERIC

IBUPROFEN GENERIC

INDOMETHACIN GENERIC

KETOPROFEN GENERIC

KETOROLACTROMETHAMINE GENERIC

MECLOFENAMATE GENERIC

MELOXICAM GENERIC

NAPROXEN GENERIC

NAPROXENSODIUM GENERIC

OXAPROZIN GENERIC

PIROXICAM GENERIC

SULINDAC GENERIC

TOLMETINSODIUM GENERIC

OpioidAnalgesics

ACETAMINOPHENCODEINE GENERIC

BUTORPHANOLTARTRATE GENERIC

CODEINESULFATE GENERIC

6

PA PriorAuthorization,QL QuantityLimits,ST StepTherapy

*SpecialtymedicationsareonlyavailablethroughtheProvidencespecialtynetwork.*DrugsthatareHSAqualifedthroughProvidenceHealthPlanarelabeled"HSAqualifed".

Updated9/14/2009


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Opioid

AnalgesicsCOGESIC GENERIC

ENDOCET GENERIC

FENTANYL QL(15PATCHESFOR30DAYS)GENERIC

FENTANYLCITRATE QL(120LOZENGESFOR30DAYS)GENERIC

HYDROCODONEBITIBUPROFEN GENERIC

HYDROCODONEACETAMINOPHEN GENERIC

HYDROCODONEAPAP GENERIC

HYDROMORPHONEHCL GENERIC

LEVORPHANOLTARTRATE GENERIC

MARGESICH GENERIC

MEPERIDINE GENERIC

METHADONEHCL GENERIC

METHADOSE GENERIC

MORPHINESULFATEER GENERIC

MORPHINESULFATEIR GENERIC

OXYCODONEER PA,QL(90TABLETSFOR30DAYS)GENERIC

OXYCODONEIR GENERIC

OXYCODONEACETAMINOPHEN GENERIC

OXYCODONEAPAP GENERIC

OXYCODONEASPIRIN GENERIC

OXYCODONEIBUPROFEN GENERIC

OXYCONTIN PA,QL(90TABLETSFOR30DAYS)BRAND

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Opioid

AnalgesicsPROPOXYPHENENAPSYLATE/APAP GENERIC

PROPOXYPHENEAPAP GENERIC

RMSSUPPOSITORY GENERIC

ROXICET GENERIC

STAGESIC GENERIC

SUBOXONE BRAND

SUBUTEX BRAND

TRAMADOLHCL GENERIC

TRAMADOLHCLACETAMINOPHEN QL(240TABSPER30DAYS)GENERIC

VANACET GENERIC

ZERLOR GENERIC

Anesthetics

LocalAnestheticsLIDOCAINEHCL GENERIC

LIDOCAINEPRILOCAINE GENERIC

LIDOCREAM GENERIC

LIDODERM BRAND

LIDOMARVISCOUS GENERIC

Antibacterials Drugstotreatbacterialinfections

Aminoglycosides

NEOMYCINSULFATE GENERIC

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DrugName Comment Status*Antibacterials Drugstotreatbacterialinfections

Antibacterials,

OtherBACITRACINOINTMENT GENERIC

BACITRACINZINCOINTMENT GENERIC

CLINDAMYCINHCL GENERIC

DAPSONE GENERIC

FURADANTIN BRAND

METHENAMINEHIPPURATE GENERIC

NITROFURANTOINMACROCRYSTALS GENERIC

UREX GENERIC

VANCOCIN BRAND

VANDAZOLE GENERIC

XIFAXAN PABRAND

ZYVOX PABRAND

Betalactam,CephalosporinsCEDAX BRAND

CEFACLOR GENERIC

CEFADROXIL GENERIC

CEFDINIR GENERIC

CEFEPIMEHCL GENERIC

CEFPODOXIMEPROXETIL GENERIC

CEFPROZIL GENERIC

CEFUROXIME GENERIC

CEFUROXIMEAXETIL GENERIC

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DrugName Comment Status*Antibacterials Drugstotreatbacterialinfections

QuinolonesLEVAQUIN BRAND

Sulfonamides

GANTRISIN BRAND

SULFAMETHOXAZOLETRIMETHOPRIM GENERIC

TRIMETHOPRIM GENERIC

Tetracyclines

DEMECLOCYCLINEHCL GENERIC

DOXYCYCLINEHYCLATE GENERIC

DOXYCYCLINEMONOHYDRATE GENERIC

EDDOXYCAPS GENERIC

MINOCYCLINEHCL GENERIC

MYRAC GENERIC

TETRACYCLINEHCL GENERIC

Anticonvulsants Drugstotreatorpreventseizures

Anticonvulsants,Other

BANZEL PABRAND

DIASTAT BRAND

LEVETIRACETAM GENERIC

PHENOBARBITAL GENERIC

VIMPAT PABRAND

CalciumChannelModifyingAgents

ETHOSUXIMIDE GENERIC

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DrugName Comment Status*Anticonvulsants Drugstotreatorpreventseizures

Calcium

Channel

Modifying

AgentsLYRICA PABRAND

ZONISAMIDE GENERIC

GammaaminobutyricAcid(GABA)AugmentingAgents

DEPAKOTESPRINKLE BRAND

DIVALPROEXSODIUM GENERIC

GABAPENTIN GENERIC

GABITRIL BRAND

NEURONTINSOLUTION BRAND

PRIMIDONE GENERIC

VALPROATESODIUM GENERIC

VALPROICACID GENERIC

GlutamateReducingAgents

FELBATOL BRAND

LAMOTRIGINE GENERIC

SodiumChannelInhibitors

CARBAMAZEPINE GENERIC

CARBAMAZEPINEXR GENERIC

DILANTININFATAB BRAND

DILANTINKAPSEAL BRAND

OXCARBAZEPINE GENERIC

PHENYTOIN GENERIC

PHENYTOINSODIUMEXTENDED GENERIC

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DrugName Comment Status*Anticonvulsants Drugstotreatorpreventseizures

Sodium

Channel

InhibitorsTRILEPTALSUSPENSION BRAND

AntidementiaAgents Drugstotreatdementia

CholinesteraseInhibitors

ARICEPTODT QL(30CAPSPER30DAYS)BRAND

ARICEPT QL(30CAPSPER30DAYS)BRAND

EXELONPATCH BRAND

EXELON QL(60CAPSPER30DAYS)BRAND

GlutamatePathwayModifiers

NAMENDASOLUTION PA,QL(300MLSPER30DAYS)BRAND

NAMENDA PA,QL(60TABSPER30DAYS)BRAND

Antidepressants Drugstotreatdepression

1.Serotonin/NorepinephrineReuptakeInhibitors

CITALOPRAM

HBR GENERIC

CITALOPRAMSOLUTION GENERIC

CYMBALTA PA,QL(60CAPSPER30DAYS)BRAND

EFFEXORXR (150MG) BRAND

EFFEXORXR(37.5MGOR75MG) QL(30CAPSPER30DAYS)BRAND

FLUOXETINEHCL GENERIC

FLUVOXAMINEMALEATE GENERIC

PAROXETINEHCL GENERIC

SERTRALINEHCL GENERIC

VENLAFAXINEERtablet BRAND

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DrugName Comment Status*Antidepressants Drugstotreatdepression

1.

Serotonin/

Norepinephrine

Reuptake

InhibitorsVENLAFAXINEHCL GENERIC

2.Antidepressants,Other

BUDEPRIONSR GENERIC

BUDEPRIONXL GENERIC

BUPROPIONHCL GENERIC

BUPROPIONHCL(SR,XL) GENERIC

MAPROTILINE GENERIC

MIRTAZAPINE GENERIC

TRAZODONEHCL GENERIC

3.Tricyclics

AMITRIPTYLINEHCL GENERIC

CLOMIPRAMINEHCL GENERIC

DESIPRAMINEHCL GENERIC

DOXEPINHCL GENERIC

IMIPRAMINEHCL GENERIC

IMIPRAMINEPAMOATE GENERIC

NORTRIPTYLINEHCL GENERIC

TRIMIPRAMINEMALEATE GENERIC

VIVACTIL BRAND

4.MonoamineOxidaseInhibitors

EMSAM PABRAND

MARPLAN BRAND

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DrugName Comment Status*Antidepressants Drugstotreatdepression

4.

Monoamine

Oxidase

InhibitorsNARDIL BRAND

TRANYLCYPROMINESULFATE GENERIC

Antidepressants,Other

NEFAZODONE GENERIC

Antidotes,Deterrents,andToxicologicAgents

Antidotes

BUPHENYL SPECIALTY

EXJADE SPECIALTY

LEUCOVORINCALCIUM GENERIC

SODIUMPOLYSTYRENESULFONATE GENERIC

SPS GENERIC

SYPRINE BRAND

DeterrentsANTABUSE BRAND

BUPROBAN GENERIC

BUPROPIONHCLSR GENERIC

CAMPRAL PABRAND

NALTREXONEHCL GENERIC

Antiemetics Drugstotreatorpreventnausea

Antiemetics

EMENDTRIFOLDPACK QL(1PACKPER15DAYS)BRAND

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DrugName Comment Status*Antiemetics Drugstotreatorpreventnausea

AntiemeticsEMEND QL(1(125MG)&2(80MG)TABSFOR

15DAYS)

HSAQUALIFIED

GRANISETRON(TAB&SOLN) PA,QL(8TABSPER30DAYS,30MLS

PER30DAYS)

HSAQUALIFIED

HYDROXYZINEPAMOATE GENERIC

MECLIZINEHCL GENERIC

METOCLOPRAMIDEHCL GENERIC

ONDANSETRONHCL(24MG)TABS QL(16TABLETSFOR30DAYS)HSAQUALIFIED

ONDANSETRONHCL(4OR8MG)TABS QL(48TABLETSFOR30DAYS)HSAQUALIFIED

ONDANSETRONHCLSOLUTION QL(480MLSFOR30DAYS)HSAQUALIFIED

ONDANSETRONODT(4OR8MG)TABS QL(48TABLETSFOR30DAYS)HSAQUALIFIED

PROCHLORPERAZINEEDISYLATE HSAQUALIFIED

PROMETHAZINE GENERIC

PROMETHEGAN GENERIC

TRANSDERMSCOP BRAND

TRIMETHOBENZAMIDE HSAQUALIFIED

Antifungals Drugstotreatfungalinfections

Antifungals

ANCOBON QL(120CAPSPER30DAYS)BRAND

FLUCONAZOLE QL(2(150MG)TABSFOR30DAYS)GENERIC

GRISEOFULVIN GENERIC

GRISEOFULVINULTRA GENERIC

ITRACONAZOLE PAGENERIC

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DrugName Comment Status*Antifungals Drugstotreatfungalinfections

AntifungalsKETOCONAZOLE GENERIC

KURIC GENERIC

NOXAFIL PABRAND

TERBINAFINEHCL GENERIC

TERCONAZOLE GENERIC

AntigoutAgents Drugstotreatorpreventgout

AntigoutAgents

ALLOPURINOL GENERIC

COLCHICINE GENERIC

PROBENECID GENERIC

PROBENECIDCOLCHICINE GENERIC

AntiinflammatoryAgents Drugstotreatinflammation

GlucocorticoidsCELESTONE BRAND

CORTISONE GENERIC

ENTOCORTEC BRAND

METHYLPREDNISOLONE GENERIC

ORAPREDODT BRAND

PREDNISOLONE GENERIC

PREDNISOLONESODPHOSPHATE GENERIC

PREDNISONE GENERIC

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DrugName Comment Status*AntiinflammatoryAgents Drugstotreatinflammation

Nonsteroidal

Anti

inflammatory

DrugsCELEBREX PA,QL(60CAPSPER30DAYS)BRAND

CHOLINEMAGTRISAL GENERIC

DICLOFENACPOTASSIUM GENERIC

DICLOFENACSODIUM GENERIC

ETODOLAC GENERIC

FENOPROFEN GENERIC

IBUPROFEN GENERIC

INDOMETHACIN GENERIC

KETOPROFEN GENERIC

KETOROLACTROMETHAMINE GENERIC

MECLOFENAMATE GENERIC

MELOXICAM GENERIC

NABUMETONE GENERIC

NAPROXEN GENERIC

NAPROXENSODIUM GENERIC

OXAPROZIN GENERIC

PIROXICAM GENERIC

TOLMETINSODIUM GENERIC

AntimigraineAgents Drugstotreatorpreventmigraines

Abortive

APAPBUTALBITAL GENERIC

ASCOMPWITHCODEINE GENERIC

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DrugName Comment Status*AntimigraineAgents Drugstotreatorpreventmigraines

AbortiveBUTALBITALCOMP/COD GENERIC

BUTALBITALCOMPOUND GENERIC

BUTALBITALAPAPCAFFEINE GENERIC

BUTALBITALCAFFAPAPCOD GENERIC

ERGOTAMINECAFFEINE GENERIC

MAXALTMLT QL(2PACKAGESFOR30DAYS)BRAND

MAXALT QL(2PACKAGESFOR30DAYS)BRAND

MIGERGOT GENERIC

MIGRANAL QL(1PACKAGEFOR30DAYS)BRAND

SUMATRIPTANSUCCINATE QL(2PACKAGESFOR30DAYS)GENERIC

ZOMIGZMT QL(2PACKAGESFOR30DAYS)BRAND

ZOMIG QL(2PACKAGESFOR30DAYS)BRAND

ProphylacticDEPAKOTEER BRAND

TOPAMAXSPRINKLE BRAND

TOPAMAX QL(60TABSPER30DAYS)BRAND

AntimyasthenicAgents DrugstotreatMyastheniaGravis

Parasympathomimetics

MESTINON BRAND

PYRIDOSTIGMINEBROMIDE GENERIC

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DrugName Comment Status*Antimycobacterials Drugstotreattuberculosis

AntitubercularsETHAMBUTOLHCL GENERIC

ISONARIF GENERIC

ISONIAZID GENERIC

PRIFTIN BRAND

RIFAMPIN GENERIC

RIFATER BRAND

TRECATOR BRAND

Antineoplastics Drugstotreatcancer

AlkylatingAgents

CEENU BRAND

HEXALEN SPECIALTY

LEUKERAN BRAND

MATULANE SPECIALTY

AntiangiogenicAgents

REVLIMID PASPECIALTY

THALOMID SPECIALTY

Antiestrogens/Modifiers

EMCYT SPECIALTY

EVISTA BRAND

FARESTON BRAND

TAMOXIFEN GENERIC

TAMOXIFENCITRATE GENERIC

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DrugName Comment Status*Antineoplastics Drugstotreatcancer

AntimetabolitesDROXIA BRAND

HYDROXYUREA GENERIC

MERCAPTOPURINE GENERIC

Antineoplastics

AFINITOR PA,QL(30TABSPER30DAYS)SPECIALTY

ARIMIDEX BRAND

AROMASIN BRAND

CYCLOPHOSPHAMIDE GENERIC

DACOGEN PASPECIALTY

FEMARA BRAND

GLEEVEC PASPECIALTY

HYCAMTINCAPSULES PABRAND

IRESSA PASPECIALTY

MESNEX BRAND

NEXAVAR PASPECIALTY

PANRETIN SPECIALTY

SPRYCEL PASPECIALTY

SUTENT PASPECIALTY

TARCEVA PASPECIALTY

TARGRETINCAPSULES SPECIALTY

TASIGNA PASPECIALTY

TEMODAR PASPECIALTY

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DrugName Comment Status*Antineoplastics Drugstotreatcancer

AntineoplasticsTRETINOINCAPSULES PAGENERIC

TYKERB PA,QL(30TABSPER30DAYS)SPECIALTY

VIDAZA PASPECIALTY

ZOLINZA PASPECIALTY

Antiparasitics Drugstotreatparasites

Antiprotozoals

ALINIA PABRAND

CHLOROQUINEPHOSPHATE PAGENERIC

DARAPRIM PABRAND

FANSIDAR PABRAND

HYDROXYCHLOROQUINESULFATE GENERIC

MEFLOQUINEHCL PAGENERIC

MEPRON BRAND

TINDAMAX PABRAND

Pediculicides/Scabicides

PERMETHRIN GENERIC

AntiparkinsonAgents DrugstotreatParkinsonism

AntiparkinsonAgents

AMANTADINE HSAQUALIFIED

APOKYN PASPECIALTY

ATAMET GENERIC

AZILECT BRAND

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DrugName Comment Status*AntiparkinsonAgents DrugstotreatParkinsonism

Antiparkinson

AgentsBENZTROPINEMESYLATE GENERIC

BROMOCRIPTINEMESYLATE GENERIC

CARBIDOPALEVODOPA GENERIC

COMTAN BRAND

LODOSYN BRAND

MIRAPEX BRAND

ROPINIROLE GENERIC

SELEGILINEHCL GENERIC

TRIHEXYPHENIDYL GENERIC

Antipsychotics Drugsusedinpsychotherapy

Atypicals

ABILIFYDISCMELT BRAND

ABILIFY BRAND

CLOZAPINE GENERIC

FAZACLO BRAND

INVEGA PABRAND

RISPERDALCONSTA QL(2VIALSPER30DAYS)BRAND

RISPERIDONE QL(90TABSPER30DAYS)GENERIC

SEROQUEL BRAND

SYMBYAX PABRAND

ZYPREXAZYDIS BRAND

ZYPREXA BRAND

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DrugName Comment Status*Antipsychotics Drugsusedinpsychotherapy

ConventionalCHLORPROMAZINE HSAQUALIFIED

COMPRO GENERIC

HALOPERIDOL GENERIC

LOXAPINE GENERIC

MOBAN BRAND

ORAP BRAND

PERPHENAZINE GENERIC

PERPHENAZINEAMITRIPYTILINE GENERIC

PROCHLORPERAZINEMALEATE HSAQUALIFIED

THIORIDAZINE GENERIC

THIOTHIXENE GENERIC

TRIFLUOPERAZINEHCL GENERIC

AntispasticityAgents Drugstotreatmusclespasms

AntispasticityAgents

BACLOFEN GENERIC

TIZANIDINEHCL GENERIC

Antivirals Drugstotreatviralinfections

Anticytomegalovirus(CMV)Agents

GANCICLOVIR GENERIC

VALCYTE BRAND

AntihepatitisAgents

BARACLUDE PASPECIALTY

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DrugName Comment Status*Antivirals Drugstotreatviralinfections

Antihepatitis

AgentsHEPSERA QL(30TABSPER30DAYS)SPECIALTY

INFERGEN SPECIALTY

PEGASYS PA,QLSPECIALTY

PEGINTRONREDIPEN PA,QLSPECIALTY

PEGINTRON PA,QLSPECIALTY

RIBASPHERE PASPECIALTY

RIBAVIRIN PASPECIALTY

TYZEKA PA,QL(30TABSPER30DAYS)BRAND

AntiherpeticAgents

ACYCLOVIR GENERIC

FAMCICLOVIR GENERIC

VALTREX BRAND

Anti

HIV

Agents,

Fusion

InhibitorsFUZEON BRAND

AntiHIVAgents,IntegraseInhibitors

ISENTRESS BRAND

AntiHIVAgents,NonnucleosideReverseTranscriptaseInhibitors

INTELENCE BRAND

SUSTIVA BRAND

VIRAMUNE BRAND

AntiHIVAgents,NucleosideandNucleotideReverseTranscriptaseInhibitors

COMBIVIR BRAND

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Anti

HIV

Agents,

Nucleoside

and

Nucleotide

Reverse

Transcriptase

InhibitorsEMTRIVA BRAND

EPIVIRHBV BRAND

EPIVIR BRAND

EPZICOM BRAND

TRIZIVIR BRAND

TRUVADA BRAND

VIREAD BRAND

ZERIT BRAND

ZIAGEN BRAND

ZIDOVUDINE GENERIC

AntiHIVAgents,NucleosideandNucleotideReverseTranscriptase

VIDEXEC BRAND

Anti

HIV

Agents,

Protease

InhibitorsAPTIVUS BRAND

ATRIPLA BRAND

CRIXIVAN BRAND

KALETRA BRAND

LEXIVA BRAND

NORVIR BRAND

PREZISTA BRAND

REYATAZ BRAND

VIRACEPT BRAND

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Anti

influenza

AgentsRIMANTADINEHCL GENERIC

TAMIFLU QL(20CAPSPER10DAYS)BRAND

ChemokineReceptorAntagonist

SELZENTRY BRAND

Anxiolytics Drugstotreatanxiety

Antidepressants

CITALOPRAMHBR GENERIC

CITALOPRAMSOLUTION GENERIC

CYMBALTA PA,QL(60CAPSPER30DAYS)BRAND

EFFEXORXR (150MG) BRAND

EFFEXORXR(37.5MGOR75MG) QL(30CAPSPER30DAYS)BRAND

FLUOXETINEHCL GENERIC

FLUVOXAMINE

MALEATE GENERIC

LEXAPRO QL(HALFTABLETREQUEST),ST

(LOOKSFORTRIALOFCITALOPRAM

ANDONEOTHERGENERICSSRI

ANTIDEPRESSANT)

BRAND

PAROXETINEHCL GENERIC

SERTRALINEHCL GENERIC

VENLAFAXINEHCL GENERIC

AnxiolyticsALPRAZOLAM GENERIC

ALPRAZOLAMER GENERIC

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DrugName Comment Status*Anxiolytics Drugstotreatanxiety

AnxiolyticsALPRAZOLAMXR GENERIC

CHLORDIAZEPOXIDE GENERIC

CLONAZEPAM GENERIC

CLORAZEPATE GENERIC

DIAZEPAM GENERIC

FLURAZEPAM GENERIC

LORAZEPAM GENERIC

LORAZEPAMINTENSOL GENERIC

OXAZEPAM GENERIC

TEMAZEPAM GENERIC

TRIAZOLAM GENERIC

Anxiolytics,Other

BUSPIRONE

HCL GENERIC

MEPROBAMATE GENERIC

BipolarAgents Drugstotreatbipolardisorders

BipolarAgents

GEODON BRAND

LITHIUMCARBONATE GENERIC

LITHIUMCITRATE GENERIC

LITHIUMER GENERIC

RISPERDALCONSTA BRAND

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DrugName Comment Status*BloodGlucoseRegulators Drugstotreatdiabetes

Antidiabetic

AgentsACARBOSE GENERIC

ACTOPLUSMET HSAQUALIFIED

ACTOS HSAQUALIFIED

AVANDAMET HSAQUALIFIED

AVANDARYL HSAQUALIFIED

AVANDIA HSAQUALIFIED

BYETTA PAHSAQUALIFIED

DUETACT HSAQUALIFIED

GLIMEPIRIDE HSAQUALIFIED

GLIPIZIDE HSAQUALIFIED

GLIPIZIDEER HSAQUALIFIED

GLIPIZIDEXL HSAQUALIFIED

GLIPIZIDEMETFORMIN HSAQUALIFIED

GLYBURIDE HSAQUALIFIED

GLYBURIDEMICRONIZED HSAQUALIFIED

GLYBURIDEMETFORMINHCL HSAQUALIFIED

GLYSET BRAND

JANUMET PABRAND

JANUVIA PABRAND

METFORMINHCL HSAQUALIFIED

METFORMINHCLER HSAQUALIFIED

RIOMET HSAQUALIFIED

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Antidiabetic

AgentsSTARLIX BRAND

SYMLIN PAHSAQUALIFIED

GlycemicAgents

GLUCAGEN QL(2PER30DAYS)GENERIC

PROGLYCEM BRAND

Insulins

APIDRA HSAQUALIFIED

HUMALOGMIX5050 HSAQUALIFIED

HUMALOGMIX7525 HSAQUALIFIED

HUMALOG HSAQUALIFIED

HUMULIN5050 HSAQUALIFIED

HUMULINMIX7030 HSAQUALIFIED

HUMULINN HSAQUALIFIED

HUMULINR HSAQUALIFIED

LANTUSSOLOSTAR HSAQUALIFIED

LANTUS HSAQUALIFIED

LEVEMIR HSAQUALIFIED

NOVOLINMIX7030INNOLET HSAQUALIFIED

NOVOLINNINNOLET HSAQUALIFIED

NOVOLINN HSAQUALIFIED

NOVOLINR HSAQUALIFIED

NOVOLOGMIX7030 HSAQUALIFIED

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InsulinsNOVOLOG HSAQUALIFIED

RELIONNOVOLINMIX7030INNOLET HSAQUALIFIED

RELIONNOVOLINMIX7030 HSAQUALIFIED

RELIONNOVOLINNINNOLET HSAQUALIFIED

RELIONNOVOLINN HSAQUALIFIED

RELIONNOVOLINR HSAQUALIFIED

BloodGlucoseTesting

Meters&Strips

ACCUCHECK(METERS&TESTSTRIPS) QLDMEBENEFIT

LIFESCAN(METERS&TESTSTRIPS) QLDMEBENEFIT

BloodProducts/Modifiers/VolumeExpanders

Anticoagulants

ARIXTRA HSAQUALIFIED

FRAGMIN HSAQUALIFIED

INNOHEP SPECIALTY

JANTOVEN HSAQUALIFIED

LOVENOX HSAQUALIFIED

WARFARINSODIUM HSAQUALIFIED

BloodFormationProducts

ARANESP PASPECIALTY

EPOGEN PASPECIALTY

LEUKINE PASPECIALTY

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DrugName Comment Status*BloodProducts/Modifiers/VolumeExpanders

Blood

Formation

ProductsNEULASTA PASPECIALTY

NEUMEGA PASPECIALTY

NEUPOGEN PASPECIALTY

PROCRIT PASPECIALTY

PROMACTA25MG PA,QL(90TABSPER30DAYS)SPECIALTY

PROMACTA50MG PA,QL(30TABSPER30DAYS)SPECIALTY

BloodProducts/Modifiers/VolumeExpanders

ANAGRELIDEHCL HSAQUALIFIED

PlateletAggregationInhibitors

AGGRENOX BRAND

CILOSTAZOL HSAQUALIFIED

DIPYRIDAMOLE HSAQUALIFIED

PENTOXIFYLLINESA HSAQUALIFIED

PLAVIX HSAQUALIFIED

TICLOPIDINE HSAQUALIFIED

CardiovascularAgents Drugstotreatbloodpressure,cholesterol&theheart

AlphaadrenergicAgonists

CLONIDINEHCL HSAQUALIFIED

CLONIDINETRANSDERMALPATCH HSAQUALIFIED

GUANFACINEHCL HSAQUALIFIED

METHYLDOPA HSAQUALIFIED

METHYLDOPAHCTZ HSAQUALIFIED

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DrugName Comment Status*CardiovascularAgents Drugstotreatbloodpressure,cholesterol&theheart

Alpha

adrenergic

AgonistsMIDODRINEHCL GENERIC

AlphaadrenergicBlockingAgents

GUANABENZACETATE HSAQUALIFIED

PRAZOSINHCL HSAQUALIFIED

TERAZOSINHCL HSAQUALIFIED

Antiarrhythmics

AMIODARONEHCL GENERIC

DISOPYRAMIDEPHOSPHATE GENERIC

FLECAINIDEACETATE GENERIC

MEXILETINE GENERIC

NORPACECR BRAND

PRONESTYL BRAND

PRONESTYLSR GENERIC

PROPAFENONEHCL GENERIC

QUINIDINEGLUCONATE GENERIC

QUINIDINESULFATE GENERIC

RYTHMOLSR BRAND

TIKOSYN BRAND

BetaadrenergicBlockingAgents

ACEBUTOLOLHCL GENERIC

ATENOLOL HSAQUALIFIED

ATENOLOLCHLORTHALIDONE HSAQUALIFIED

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Beta

adrenergic

Blocking

AgentsBETAXOLOLHCL HSAQUALIFIED

BISOPROLOLFUMARATE HSAQUALIFIED

CARVEDILOL HSAQUALIFIED

COREGCR HSAQUALIFIED

LABETALOLHCL HSAQUALIFIED

LEVATOL HSAQUALIFIED

METOPROLOLSUCCINATEER HSAQUALIFIED

METOPROLOLTARTRATE HSAQUALIFIED

METOPROLOLHYDROCHLOROTHIAZIDE HSAQUALIFIED

NADOLOL HSAQUALIFIED

NADOLOLBENDROFLUMETHIAZIDE HSAQUALIFIED

PINDOLOL HSAQUALIFIED

PROPRANOLOL HSAQUALIFIED

PROPRANOLOLER HSAQUALIFIED

PROPRANOLOLHCTZ HSAQUALIFIED

SOTALOL GENERIC

SOTALOLAF GENERIC

CalciumChannelBlockingAgents

AFEDITABCR HSAQUALIFIED

AMLODIPINEBESYLATE HSAQUALIFIED

CARTIAXT HSAQUALIFIED

DILTIAZEMCD HSAQUALIFIED

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DyslipidemicsCOLESTID HSAQUALIFIED

COLESTIPOLHCL HSAQUALIFIED

FENOFIBRATE HSAQUALIFIED

GEMFIBROZIL HSAQUALIFIED

LIPITOR QL(HALFTABLETREQUEST),ST

(LOOKSTRIALOFSIMVASTATIN

80MG)

HSAQUALIFIED

LOVASTATIN HSAQUALIFIED

LOVAZA STHSAQUALIFIED

NIASPAN HSAQUALIFIED

PRAVASTATINSODIUM HSAQUALIFIED

PREVALITE HSAQUALIFIED

SIMVASTATIN HSAQUALIFIED

TRICOR HSAQUALIFIED

ZETIA STHSAQUALIFIED

ReninangiotensinaldosteroneSystemInhibitors

BENAZEPRILHCL GENERIC

BENAZEPRILHYDROCHLOROTHIAZIDE GENERIC

CAPTOPRIL HSAQUALIFIED

CAPTOPRILHYDROCHLOROTHIAZIDE HSAQUALIFIED

COZAAR HSAQUALIFIED

DIOVANHCT HSAQUALIFIED

DIOVAN HSAQUALIFIED

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Renin

angiotensin

aldosterone

System

InhibitorsENALAPRILMALEATE HSAQUALIFIED

ENALAPRILHYDROCHLOROTHIAZIDE HSAQUALIFIED

EPLERENONE GENERIC

FOSINOPRILSODIUM HSAQUALIFIED

FOSINOPRILHYDROCHLOROTHIAZIDE HSAQUALIFIED

HYZAAR HSAQUALIFIED

LISINOPRIL HSAQUALIFIED

LISINOPRILHYDROCHLOROTHIAZIDE HSAQUALIFIED

MOEXIPRILHCL HSAQUALIFIED

MOEXIPRILHYDROCHLOROTHIAZIDE HSAQUALIFIED

QUINAPRILHCL HSAQUALIFIED

QUINAPRILHYDROCHLOROTHIAZIDE HSAQUALIFIED

QUINARETIC GENERIC

RAMIPRIL GENERIC

SPIRONOLACTONE HSAQUALIFIED

TRANDOLAPRIL HSAQUALIFIED

Vasodilators

DILATRATESR BRAND

HYDRALAZINE GENERIC

ISOSORBIDEDINITRATE GENERIC

ISOSORBIDEMONONITRATE GENERIC

NITROBID GENERIC

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VasodilatorsNITROGLYCERIN(TABLETS&PATCHES) GENERIC

NITROGLYCERINPATCH GENERIC

NITROGLYCERINSA GENERIC

NITROGLYCERINSL GENERIC

NITROQUICKSL GENERIC

TRACLEER PASPECIALTY

CentralNervousSystemAgents Drugsthataffectthebrain

Amphetamines,ADHD

ADDERALLXR BRAND

AMPHETAMINESALTCOMBO GENERIC

DEXTROAMPHETAMINESULFATESA GENERIC

DEXTROSTAT GENERIC

Nonamphetamines,ADHDCONCERTA BRAND

DAYTRANA PABRAND

DEXMETHYLPHENIDATEHCL GENERIC

FOCALINXR PABRAND

METHYLINER GENERIC

METHYLIN BRAND

METHYLPHENIDATEER GENERIC

METHYLPHENIDATEHCL GENERIC

RITALINLA BRAND

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DrugName Comment Status*CentralNervousSystemAgents Drugsthataffectthebrain

Non

amphetamines,

ADHDSTRATTERA PABRAND

Nonamphetamines,Other

PROVIGIL PA,QL(30TABSPER30DAYS)BRAND

RILUTEK SPECIALTY

XENAZINE PASPECIALTY

XYREM SPECIALTY

DentalandOralAgents

DentalandOralAgents

CHLORHEXIDINE GENERIC

CHLORHEXIDINEGLUCONATE GENERIC

PILOCARPINETABLETS GENERIC

DermatologicalAgents Drugstotreatskinconditions

DermatologicalAgentsALDARA BRAND

AMMONIUMLACTATE GENERIC

AMNESTEEM GENERIC

APEXICONE GENERIC

AVITA PAGENERIC

CARAC BRAND

CICLOPIROXCREAMORGEL GENERIC

CLARAVIS GENERIC

CLINDAMYCINPHOSPHATE GENERIC

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DrugName Comment Status*DermatologicalAgents Drugstotreatskinconditions

Dermatological

AgentsDELBETA GENERIC

DENAVIR BRAND

DIFFERIN BRAND

DOVONEX BRAND

ECONAZOLENITRATE GENERIC

ELIDEL STBRAND

ERYTHROMYCINBENZOYLPEROXIDE GENERIC

FLUOCINOLONEE GENERIC

FLUOROPLEX BRAND

FLUOROURACIL GENERIC

HYPERCARE20%SOLUTION GENERIC

LOKARA GENERIC

METRONIDAZOLE0.75% GENERIC

MUPIROCINOINTMENT GENERIC

NYAMYC GENERIC

NYSTATIN GENERIC

NYSTOP GENERIC

OXSORALEN GENERIC

OXSORALENULTRA SPECIALTY

PEDIDRI GENERIC

PODOFILOX GENERIC

PRAMOXINE GENERIC

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DrugName Comment Status*DermatologicalAgents Drugstotreatskinconditions

Dermatological

AgentsPROCTOCREAMHC GENERIC

PROCTOSOLHC GENERIC

PROCTOZONEHC GENERIC

PROTOPIC STBRAND

RAPTIVA PASPECIALTY

REGRANEX PASPECIALTY

SANTYL QL(30GRAMSPER30DAYS)BRAND

SILVERSULFADIAZINE GENERIC

SOTRET GENERIC

SSDAFCREAM GENERIC

SSDCREAM GENERIC

SULFACETAMIDESODIUMLOTION GENERIC

TAZORAC BRAND

THERMAZENECREAM GENERIC

TRETINOINCREAMORGEL PAGENERIC

TRIAMCINOLONE GENERIC

TRIAMCINOLONEACETONIDE GENERIC

TRIDERM GENERIC

EnzymeReplacements/Modifiers

ADAGEN SPECIALTY

CYSTAGON SPECIALTY

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DrugName Comment Status*EnzymeReplacements/Modifiers

DYGASE GENERIC

KUVAN PASPECIALTY

LAPASE GENERIC

LIPRAMPN GENERIC

ORFADIN SPECIALTY

PALCAPS10 GENERIC

PANCRELIPASE GENERIC

PANCRELIPASEMT GENERIC

PANCRON GENERIC

PANGESTYMECN GENERIC

PANGESTYMEEC GENERIC

PANGESTYMEMT GENERIC

PANGESTYMEUL GENERIC

PANOCAPS GENERIC

PANOCAPSMT GENERIC

PANOKASE GENERIC

PLARETASE GENERIC

SUCRAID SPECIALTY

VIOKASE BRAND

ZAVESCA SPECIALTY

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DrugName Comment Status*GastrointestinalAgents Drugstotreatacid,digestionandbowelconditions

Antispasmodics,

GastrointestinalDICYCLOMINE GENERIC

GLYCOPYRROLATE GENERIC

GastrointestinalAgents,Other

DIPHENOXYLATEATROPINE GENERIC

GOLYTELY BRAND

LACTULOSE GENERIC

LONOX GENERIC

LOPERAMIDE GENERIC

MOVIPREPPOWDERKIT BRAND

PEG3350ELECTROLYTE GENERIC

POLYETHYLENEGLYCOL GENERIC

TRILYTE GENERIC

URSODIOL GENERIC

Histamine2(H2)BlockingAgents

CIMETIDINE GENERIC

FAMOTIDINE GENERIC

NIZATIDINECAPSULES GENERIC

RANITIDINEHCL300mg GENERIC

Histamine2(H2)BlockingAgents

RANITIDINESYRUP GENERIC

IrritableBowelSyndromeAgents

LOTRONEX PABRAND

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DrugName Comment Status*GastrointestinalAgents Drugstotreatacid,digestionandbowelconditions

ProtectantsMISOPROSTOL GENERIC

SUCRALFATE GENERIC

ProtonPumpInhibitors

OMEPRAZOLE QL(60CAPSPER30DAYS)GENERIC

PANTOPRAZOLESODIUM PA,QL(30TABSPER30DAYS)BRAND

PROTONIX PA,QL(30TABSPER30DAYS)BRAND

PROTONIXSUSPENSION BRAND

GenitourinaryAgents Drugstotreatgenitourinaryconditions

Analgesics

PHENAZOPYRIDINE GENERIC

Antispasmodics,Urinary

BETHANECHOLCHLORIDE GENERIC

DETROLLA QL(30TABLETSPER30DAYS)BRAND

DETROL BRAND

FLAVOXATEHCL GENERIC

OXYBUTYNIN GENERIC

OXYBUTYNINCLER GENERIC

OXYBUTYNINER GENERIC

OXYTROL BRAND

BenignProstaticHypertrophyAgents

DOXAZOSINMESYLATE GENERIC

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DrugName Comment Status*GenitourinaryAgents Drugstotreatgenitourinaryconditions

Benign

Prostatic

Hypertrophy

AgentsFINASTERIDE GENERIC

FLOMAX BRAND

TERAZOSINHCL GENERIC

GenitourinaryAgents,Other

CUPRIMINE BRAND

DEPEN BRAND

THIOLA BRAND

PhosphateBinders

CALCIUMACETATE GENERIC

RENAGEL BRAND

RENVELA PABRAND

HormonalAgents,Modifying

AndrogensANADROL50 SPECIALTY

ANDROGEL BRAND

TESTIM BRAND

TESTOSTERONECYPIONATEINJECTABLE GENERIC

TESTOSTERONEENANTHATEINJECTABLE GENERIC

Contraceptives

APRI HSAQUALIFIED

ARANELLE HSAQUALIFIED

AVIANE HSAQUALIFIED

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DrugName Comment Status*HormonalAgents,Modifying

ContraceptivesBALZIVA HSAQUALIFIED

BREVICON HSAQUALIFIED

COMBIPATCH HSAQUALIFIED

CRYSELLE HSAQUALIFIED

ENPRESSE HSAQUALIFIED

JOLESSA HSAQUALIFIED

JUNELFE HSAQUALIFIED

JUNEL HSAQUALIFIED

KARIVA HSAQUALIFIED

KELNOR HSAQUALIFIED

LEENA HSAQUALIFIED

LEVORA HSAQUALIFIED

LOESTRINFE HSAQUALIFIED

LOWOGESTREL HSAQUALIFIED

LUTERA HSAQUALIFIED

LYBREL HSAQUALIFIED

MICROGESTINFE HSAQUALIFIED

MICROGESTIN HSAQUALIFIED

MONONESSA HSAQUALIFIED

NECON HSAQUALIFIED

NORINYL HSAQUALIFIED

NORTREL HSAQUALIFIED

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ContraceptivesNUVARING HSAQUALIFIED

OGESTREL HSAQUALIFIED

ORTHOEVRA HSAQUALIFIED

ORTHOTRICYCLENLO HSAQUALIFIED

ORTHOTRICYCLEN HSAQUALIFIED

PORTIA HSAQUALIFIED

QUASENSE HSAQUALIFIED

RECLIPSEN HSAQUALIFIED

TRILEGEST HSAQUALIFIED

TRINESSA HSAQUALIFIED

TRIPREVIFEM HSAQUALIFIED

TRISPRINTEC HSAQUALIFIED

YAZ HSAQUALIFIED

ZOVIA HSAQUALIFIED

Estrogens

CESIA GENERIC

ESTRACE BRAND

ESTRADERM BRAND

ESTRADIOL GENERIC

ESTRADIOLNORETHINDRONE GENERIC

ESTRING BRAND

ESTROPIPATE GENERIC

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EstrogensORTHOEST GENERIC

PREMARINVAGINALCREAM BRAND

PREMARIN QL(30TABSPER30DAYS)BRAND

PREMPHASE BRAND

PREMPRO BRAND

SOLIA GENERIC

VAGIFEM BRAND

VELIVET GENERIC

VIVELLEDOT BRAND

Glucocorticoids/Mineralocorticoids

ALCLOMETASONEDIPROPIONATE GENERIC

BETAMETHASONEDIPROPIONATE GENERIC

CLOBETASOL

EMOLLIENT GENERIC

CLOBETASOLPROPIONATE GENERIC

CLOTRIMAZOLEBETAMETHASONE GENERIC

CORMAX GENERIC

DESONIDE GENERIC

DESOXIMETASONE GENERIC

DEXAMETHASONE GENERIC

FLUDROCORTISONEACETATE GENERIC

FLUOCINOLONEACETONIDE GENERIC

FLUOCINONIDE GENERIC

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Glucocorticoids/MineralocorticoidsHALOBETASOLPROPIONATE GENERIC

HYDROCORTISONE GENERIC

HYDROCORTISONEBUTYRATE GENERIC

MOMETASONEFUROATE GENERIC

PROCTOPAK GENERIC

Other

ACTHARH.P.GEL PASPECIALTY

Pituitary

DESMOPRESSINACETATE PAGENERIC

GENOTROPIN PASPECIALTY

HUMATROPE PASPECIALTY

INCRELEX PASPECIALTY

NUTROPINAQ PASPECIALTY

NUTROPIN PASPECIALTY

Progestins

CAMILA GENERIC

ERRIN GENERIC

JOLIVETTE GENERIC

MEDROXYPROGESTERONE GENERIC

MEDROXYPROGESTERONEACETATE GENERIC

MEGESTROLACETATE GENERIC

NORABE GENERIC

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ProgestinsNORETHINDRONEACETATE GENERIC

SelectiveEstrogenReceptorModifyingAgents

EVISTA BRAND

Thyroid

CYTOMEL BRAND

LEVOTHROID GENERIC

LEVOTHYROXINESODIUM GENERIC

LEVOXYL GENERIC

UNITHROID GENERIC

HormonalAgents,Suppressant

Adrenal

LYSODREN BRAND

Antiandrogens

BICALUTAMIDE GENERIC

NILANDRON BRAND

Parathyroid

SENSIPAR(30OR60MG) QL(60TABSPER30DAYS)SPECIALTY

SENSIPAR(90MG) QL(120TABSPER30DAYS)SPECIALTY

Pituitary

CABERGOLINE GENERIC

DANAZOL GENERIC

ELIGARD PA,QL(1SYRINGEPER30DAYS)BRAND

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DrugName Comment Status*HormonalAgents,Suppressant

PituitaryLEUPROLIDEACETATE PA,QL(1SYRINGEPER30DAYS)GENERIC

LUPRON PA,QL(1SYRINGEPER30DAYS)BRAND

OCTREOTIDEACETATE PASPECIALTY

OXANDROLONE GENERIC

SOMAVERT PASPECIALTY

Thyroid

METHIMAZOLE GENERIC

PROPYLTHIOURACIL GENERIC

ImmunologicalAgents Drugstostimulate,suppressorregulatetheimmunes

ImmuneSuppressants

AZATHIOPRINE GENERIC

CELLCEPTSOLUTION BRAND

CYCLOSPORINE GENERIC

ENBREL PASPECIALTY

GENGRAF GENERIC

HUMIRA PASPECIALTY

METHOTREXATE GENERIC

METHOTREXATEINJECTABLE GENERIC

MYCOPHENOLATEMOFETIL GENERIC

MYFORTIC BRAND

RAPAMUNE BRAND

TACROLIMUSCAPSULE GENERIC

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DrugName Comment Status*ImmunologicalAgents Drugstostimulate,suppressorregulatetheimmunes

Immunizing

Agents,

PassiveGAMMAGARDSD BRAND

POLYGAMSD BRAND

VIVAGLOBIN PASPECIALTY

ImmunologicalAgents

KINERET PASPECIALTY

Immunomodulators

ACTIMMUNE PASPECIALTY

ALFERONN SPECIALTY

ARCALYST PA,QLSPECIALTY

AVONEX QL(4INJECTIONSFOR30DAYS)SPECIALTY

BETASERON PA,QL(15VIALSFOR30DAYS)SPECIALTY

COPAXONE QL(30INJECTIONSFOR30DAYS)SPECIALTY

INTRONA SPECIALTY

LEFLUNOMIDE GENERIC

REBIF QL(12INJECTIONSFOR30DAYS)SPECIALTY

InflammatoryBowelDiseaseAgents Drugstotreattheinflammatorybowel

Salicylates

APRISO BRAND

ASACOL BRAND

BALSALAZIDEDISODIUM GENERIC

CANASA BRAND

DIPENTUM BRAND

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DrugName Comment Status*InflammatoryBowelDiseaseAgents Drugstotreattheinflammatorybowel

SalicylatesLIALDA BRAND

MESALAMINE GENERIC

PENTASA BRAND

Sulfonamides

SULFASALAZINE GENERIC

SULFASALAZINEDR GENERIC

SULFAZINE GENERIC

SULFAZINEEC GENERIC

MetabolicBoneDiseaseAgents Drugstotreatmetabolicbonedisorders

MetabolicBoneDiseaseAgents

ACTONELWITHCALCIUM(35MG) ST:LOOKSFORTRIALOF

ALENDRONATE

HSAQUALIFIED

ACTONEL(5,30,35MG) ST:LOOKSFORTRIALOF

ALENDRONATE

HSAQUALIFIED

ALENDRONATESODIUM HSAQUALIFIED

CALCITRIOL GENERIC

ETIDRONATEDISODIUM GENERIC

FORTEO PASPECIALTY,HSAQUALI

FOSAMAX70MGORALSOLUTION BRAND

HECTOROL PABRAND

ZEMPLAR PABRAND

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DrugName Comment Status*OphthalmicAgents Drugstotreateyeconditions

Ophthalmic

Anti

allergy

AgentsALOMIDE BRAND

CROMOLYNEYEDROPS GENERIC

PATANOL PA,QL(5MLSPER30DAYS)BRAND

OphthalmicAntibacterialAgents

AKTOB GENERIC

BACITRACINPOLYMYXINEYEOINT GENERIC

GENTAMICINSULFATE GENERIC

GENTASOL GENERIC

NEOMYCINBACITRACINPOLYMYXIN GENERIC

NEOMYCINPOLYMYXINDEXAMETH GENERIC

NEOMYCINPOLYMYXINGRAMICIDIN GENERIC

OCUSULF10 GENERIC

OFLOXACIN GENERIC

POLYDEX GENERIC

POLYMYXINBSULTRIMETHOPRIM GENERIC

QUIXIN BRAND

TOBRADEXOINTMENT BRAND

TOBRAMYCINSULFATE GENERIC

TOBRASOL GENERIC

VIGAMOX BRAND

ZYLET BRAND

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Ophthalmic

Antifungal

AgentsNATACYN BRAND

OphthalmicAntiglaucomaAgents

ALPHAGANP BRAND

AZOPT BRAND

BETAXOLOLHCL0.5%EYEDROP GENERIC

BETIMOL BRAND

BETOPTICS BRAND

BRIMONIDINE GENERIC

CARTEOLOLHCL HSAQUALIFIED

DIPIVEFRINHCL GENERIC

ISTALOL BRAND

LEVOBUNOLOLHCL GENERIC

METIPRANOLOL GENERIC

PILOPINEHS BRAND

TIMOLOLMALEATE GENERIC

TRUSOPT BRAND

OphthalmicAntiherpeticAgents

TRIFLURIDINE GENERIC

OphthalmicAntiinflammatories

ACULARLS BRAND

ACULARPF BRAND

ACULAR BRAND

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Ophthalmic

Anti

inflammatoriesALREX BRAND

DEXAMETHASONEEYEOINT/DROP GENERIC

DICLOFENACEYEDROPS GENERIC

FLAREX BRAND

FLUOROMETHOLONE GENERIC

FLUOROP GENERIC

FLURBIPROFENSODIUM GENERIC

FMLFORTE BRAND

FMLS.O.P. BRAND

LOTEMAX BRAND

PREDNISOLONEACETATE GENERIC

VEXOL BRAND

XIBROM BRAND

OphthalmicOtherAgents

AKCON GENERIC

BLEPHAMIDE BRAND

COSOPT BRAND

LACRISERT BRAND

MYDRAL GENERIC

NAPHAZOLINEHCL GENERIC

NEOMYCPOLYMDEXAMETHEYE GENERIC

RESTASIS PA,QL(60VIALSPER30DAYS)BRAND

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Ophthalmic

Other

AgentsTROPICACYL GENERIC

TROPICAMIDE GENERIC

OphthalmicProstaglandinsandProstamideAnalogs

LUMIGAN BRAND

TRAVATANZ BRAND

TRAVATAN BRAND

XALATAN BRAND

OticAgents Drugstotreatearconditions

OticAgents

BOROFAIREARDROPS GENERIC

DERMOTIC BRAND

NEOMYCINPOLYMYXINHC GENERIC

RespiratoryTractAgents Drugstotreatallergiesorbreathingconditions

Antihistamines

ASTELIN BRAND

CLEMASTINEFUMARATE GENERIC

CYPROHEPTADINE GENERIC

FEXOFENADINEHCL GENERIC

HYDROXYZINEHCL GENERIC

INDAPAMIDE HSAQUALIFIED

Antiinflammatories,InhaledCorticosteroids

AEROBID HSAQUALIF

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DrugName Comment Status*RespiratoryTractAgents Drugstotreatallergiesorbreathingconditions

Anti

inflammatories,

Inhaled

CorticosteroidsAEROBIDM HSAQUALIFIED

ALVESCO HSAQUALIFIED

ASMANEX HSAQUALIFIED

AZMACORT HSAQUALIFIED

FLOVENTHFA HSAQUALIFIED

FLOVENTDISKUS HSAQUALIFIED

NASONEX QL(17GRAMSPER30DAYS)BRAND

PULMICORTFLEXHALER HSAQUALIFIED

PULMICORTRESPULE HSAQUALIFIED

QVAR HSAQUALIFIED

Antiinflammatories,NasalCorticosteroids

FLUNISOLIDENASAL GENERIC

FLUTICASONE

PROPIONATE

NASAL

INHALER QL

(16

MLS

PER

30

DAYS)GENERIC

RHINOCORTAQUANASALSPRAY BRAND

Antileukotrienes

ACCOLATE ST,QL(60TABS/30DAYS)HSAQUALIFIED

SINGULAIR ST,QL(30TABS/30DAYS)HSAQUALIFIED

ZYFLOCR PA,QL(120TABSPER30DAYS)BRAND

Antitussives(CoughSuppressants)

BENZONATATE GENERIC

CHERATUSSINAC GENERIC

CHERATUSSINDAC GENERIC

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Antitussives

(Cough

Suppressants)GUAIFENESINCODEINE GENERIC

PROMETHAZINEVC GENERIC

PROMETHAZINEVCCODEINE GENERIC

PROMETHAZINECODEINE GENERIC

PROMETHAZINEDM GENERIC

Bronchodilators,Anticholinergic

ATROVENTHFA BRAND

IPRATROPIUMBROMIDE GENERIC

SPIRIVA QL(1HANDIHALERFOR30DAYS)BRAND

Bronchodilators,PhosphodiesteraseInhibitors(Xanthines)

THEOPHYLLINEANHYDROUS HSAQUALIFIED

THEOPHYLLINEER HSAQUALIFIED

Bronchodilators,Sympathomimetic

ALBUTEROLINHALER HSAQUALIFIED

ALBUTEROLSOLUTION HSAQUALIFIED

ALBUTEROLSULFATE SEEPROAIRORPROVENTILHFAHSAQUALIFIED

COMBIVENT BRAND

PROAIRHFA QL(2INHALERSPER30DAYS)HSAQUALIFIED

PROVENTILHFA QL(2INHALERSPER30DAYS)HSAQUALIF

SEREVENTDISKUS HSAQUALIFIED

TERBUTALINESULFATE HSAQUALIFIED

TWINJECT QL(1.1MLSPER180DAYS)BRAND

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Bronchodilators,

SympathomimeticXOPENEXHFA HSAQUALIFIED

XOPENOX HSAQUALIFIED

MastCellStabilizers

CROMOLYNNEBULIZERSOLN GENERIC

GASTROCROM BRAND

INTAL BRAND

PulmonaryAntihypertensives

LETAIRIS PASPECIALTY

REVATIO PA,QL(90TABLETSFOR30DAYS)SPECIALTY

VENTAVIS PASPECIALTY

RespiratoryTractAgents

ADVAIRDISKUS HSAQUALIFIED

ADVAIRHFA HSAQUALIFIED

EPIPENJR QL(1"2PAK")PER90DAYSBRAND

EPIPEN QL(1"2PAK")PER90DAYSBRAND

IPRATROPRIUMALBUTEROL GENERIC

PULMOZYME SPECIALTY

SYMBICORT HSAQUALIFIED

TYZINE BRAND

Sedatives/Hypnotics Drugstotreatsleepdisorders

Sedatives/Hypnotics

ESTAZOLAM GENERIC

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DrugName Comment Status*Sedatives/Hypnotics Drugstotreatsleepdisorders

Sedatives/HypnoticsLUNESTA PA,QL(30TABLETSPER30DAYS)BRAND

ROZEREM PA,QL(30TABLETSFOR30DAYS)BRAND

ZALEPLON QL(30TABLETSFOR30DAYS)GENERIC

ZOLPIDEMTARTRATE QL(30TABLETSFOR30DAYS)GENERIC

SkeletalMuscleRelaxants Drugstotreatmusclespasms

SkeletalMuscleRelaxants

CARISOPRODOL GENERIC

CARISOPRODOLCOMPOUND GENERIC

CARISOPRODOLCPD/CODEINE GENERIC

CHLORZOXAZONE GENERIC

CYCLOBENZAPRINEHCL GENERIC

METHOCARBAMOL GENERIC

ORPHENADRINE GENERIC

ORPHENADRINECOMPFORTE GENERIC

TherapeuticNutrients/Minerals/Electrolytes

Nutrients/Minerals/Electrolytes Prescription

EDK+10 GENERIC

ETHEDENT GENERIC

KAONCL GENERIC

KLORCONM GENERIC

KLOTRIX GENERIC

POTASSIUMCHLORIDE GENERIC

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DrugName Comment Status*TherapeuticNutrients/Minerals/Electrolytes

Nutrients/Minerals/Electrolytes

PrescriptionPOTASSIUMCHLORIDESA GENERIC

POTASSIUMCITRATE GENERIC

POTASSIUMCITRATEER GENERIC

POTASSIUMGLUCONATE GENERIC

SODIUMFLUORIDE GENERIC

PrenatalVitamins Prescription

CALNATE HSAQUALIFIED

FOLICACID HSAQUALIFIED

NATALCARE GENERIC

PRENATABS GENERIC

PRENATALMR HSAQUALIFIED

PRENATALRX HSAQUALIFIED

PRENATAL

Z HSA

QUALIFIED

PRENATALH HSAQUALIFIED

PRENATALU HSAQUALIFIED

Vitamins Prescription

CYANOCOBALAMIN1,000MCG/MLINJ. GENERIC

FLUORABON GENERIC

MULTIVITFLUOR HSAQUALIFIED

MULTIVITFLUORIDE HSAQUALIFIED

MULTIVITIRONFL HSAQUALIFIED

POLYIRONFL HSAQUALIFIED

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DrugName Comment Status*TherapeuticNutrients/Minerals/Electrolytes

Vitamins

PrescriptionTRIVITFLUOR HSAQUALIFIED

TRIVITFLUORIRON HSAQUALIFIED

VITAMIND1.25MG(50,000IU) GENERIC

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58

AlphabeticalListingDrug Name _ Page

ABILIFY DISCMELT 21

ABILIFY 21ACARBOSE 26

ACCOLATE 54

ACCU-CHECK (METERS & TESTSTRIPS) 28

ACCUNEB - generic on formulary

as ALBUTEROL SULFATE

ACCUPRIL - generic on formularyas QUINAPRIL HCL

ACCURETIC - generic on

formulary as QUINAPRIL-

HYDROCHLOROTHIAZIDEACCUTANE - generic on formulary

as AMNESTEEMACEBUTOLOL HCL 30

ACETAMINOPHEN-CODEINE 6

ACETAZOLAMIDE 32ACIPHEXis non-formulary and

requires PA, a formulary alternative is

OMEPRAZOLE

ACTHAR H.P. GEL 45ACTIGALL - generic on formulary

as URSODIOLACTIMMUNE 48ACTIQ - generic on formulary as

FENTANYL CITRATE

ACTIVELLA - generic onformulary as ESTRADIOL-

NORETHINDRONE

ACTONEL WITH CALCIUM (35

MG) 49ACTONEL (5,30,35 MG) 49

ACTOPLUS MET 26

ACTOS 26ACULAR LS 51

ACULAR PF 51

ACULAR 51ACYCLOVIR 23

ACZONE is non-formulary and

requires PAADAGEN 39

ADALAT CC - generic on

Drug Name _ Page

formulary as NIFEDIAC CC

ADDERALL XR 35ADDERALL - generic on formulary

as AMPHETAMINE SALT COMBO

ADOXA - generic on formulary asDOXYCYCLINE MONOHYDRATE

ADOXA is non-formulary, a generic

alternative is DOXYCYCLINE

HYCLATEADVAIR DISKUS 55

ADVAIR HFA 55

ADVICOR is non-formulary, a

generic alternative is SIMVASTATIN+ NIASPAN

AEROBID 53AEROBID-M 53

AFEDITAB CR 31

AFINITOR 19AGGRENOX 29

AGRYLIN - generic on formulary

as ANAGRELIDE HCL

AK-CON 52AKTOB 50

ALBALON - generic on formularyas NAPHAZOLINE HCLALBUTEROL INHALER 54

ALBUTEROL SOLUTION 54

ALBUTEROL SULFATE 55ALCLOMETASONE

DIPROPIONATE 44

ALDACTAZIDE - generic on

formulary as SPIRONOLACTONE-HCTZ

ALDACTONE - generic on

formulary as SPIRONOLACTONEALDARA 36

ALENDRONATE SODIUM 49

ALFERON N 48ALINIA 20

ALLEGRA - generic on formulary

as FEXOFENADINE HCLALLEGRA-D is non-formulary and requires

PA, a formulary alternative is


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59

Drug Name _ Page Drug Name _

FEXOFENADINE + OTC DECONGESTANT

AS NEEDED

ALLEGRA-ODTis non-formulary andrequires PA, a formulary alternative is

FEXOFENADINE + OTC DECONGESTANTAS NEEDEDALLOPURINOL 16

ALOMIDE 49

ALPHAGAN P 50

ALPRAZOLAM 25ALPRAZOLAM ER 25

ALPRAZOLAM XR 25

ALREX 51ALTABAXis non-formulary and


MUPIROCINALTACE - generic on formulary as

RAMIPRIL

ALVESCO 53

AMANTADINE 21AMARYL - generic on formulary as

GLIMEPIRIDE

AMBIEN CRis non-formulary andrequires PA, a formulary alternative is

ZOLPIDEM TARTRATEAMBIEN - generic on formulary as

ZOLPIDEM TARTRATE

AMERGE is non-formulary, ageneric alternative is

SUMATRIPTAN

AMIDREN - is not FDA approved andtherefore not a covered benefit, formulary

alternatives are BULTALBITAL-APAP-

CAFFEINE, BUTALBITAL COMPOUND

AMILORIDE HCL 33AMILORIDE HCL-HCTZ 33

AMIODARONE HCL 30

AMITIZAis non-formulary andrequires PA, an alternative is OTC

Miralax

AMITRIPTYLINE HCL 13AMLODIPINE BESYLATE 31

AMLODIPINE BESYLATE-

BENAZEPRIL 32AMMONIUM LACTATE 36

AMNESTEEM 37

Page

AMOX TR-POTASSIUM

CLAVULANATE 9

AMOXAPINE 9AMOXICILLIN 9

AMOXIL - generic on formulary asAMOXICILLINAMPHETAMINE SALT COMBO 35

AMPICILLIN 9

AMRIXis non-formulary and

requires PA, a formulary alternative isCYCLOBENAZPRINE

ANADROL-50 42

ANAFRANIL - generic onformulary as CLOMIPRAMINE HCL

ANAGRELIDE HCL 29

ANALPRAM HC - is not FDA approved andtherefore not a covered benefit, an OTC

alternative is PREPARATION H and/or SITZ

BATH, a formulary alternative is

HYDROCORTISONE CREAMANCOBON 15

ANDROGEL 42

ANSAID - generic on formulary asFLURBIPROFEN

ANTABUSE 14ANTIVERT - generic on formulary

as MECLIZINE HCL

ANUCORT HC - is not FDA approved andtherefore not a covered benefit, an OTC

alternative is PREPARATION H and/or SITZ

BATH, a formulary alternative isHYDROCORTISONE CREAM

ANUSOL-HC - generic on

formulary as PROCTOCREAM-HC

APAP-BUTALBITAL 17APEXICON E 37

APIDRA 27

Aplenzin is non-formulary andrequires PA, a formulary alternative is

bupropion XL

APOKYN 21APRI 42

APRISO 48

APTIVUS 24ARALANis non-formulary and

requires PA


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61


formulary as ERYTHROMYCIN-

BENZOYL PEROXIDE

BENZONATATE 54BENZTROPINE MESYLATE 21

BETAGAN - generic on formularyas LEVOBUNOLOL HCLBETAMETHASONE

DIPROPIONATE 44

BETAPACE AF - generic on

formulary as SOTALOL AFBETAPACE - generic on formulary

as SOTALOL

BETASERON 48BETAXOLOL HCL 31

BETAXOLOL HCL 0.5% EYE

DROP 50BETHANECHOL CHLORIDE 41

BETIMOL 51

BETOPTIC S 51

BIAXIN XL - generic on formularyas CLARITHROMYCIN ER

BICALUTAMIDE 46

BIDIL is non-formulary and requires PA, aformulary alternative is ISOSORBIDE

DINITRATE + HYDRALAZINEBIONECTis non-formulary and


REGRANEX which also requiresPA

BISOPROLOL FUMARATE 31

BLEPH-10 - generic on formularyas OCUSULF-10

BLEPHAMIDE 52

BONIVAis non-formulary and

requires PA, a formulary alternative isALENDRONATE

BOROFAIR EAR DROPS 52

BOROFAIR - generic on formularyas BOROFAIR EAR DROPS

BREVICON 42

BRIMONIDINE 51BROMOCRIPTINE MESYLATE 21

BUDEPRION SR 13

BUDEPRION XL 13BUMETANIDE 33

BUMEX - generic on formulary as

Page

BUMETANIDE

BUPHENYL 14

BUPROBAN 14BUPROPION HCL 13

BUPROPION HCL (SR, XL) 13BUPROPION HCL SR 14BUSPAR - generic on formulary as

BUSPIRONE HCL

BUSPIRONE HCL 26

BUTALBITAL COMP/COD 17BUTALBITAL COMPOUND 17

BUTALBITAL-APAP-CAFFEINE 17

BUTALBITAL-CAFF-APAP-COD 17BUTORPHANOL TARTRATE 6

BYETTA 26

BYSTOLICis non-formulary andrequires PA, a formulary alternative is

CARVEDILOL

CABERGOLINE 47

CADUETis non-formulary andrequires PA, a formulary alternative is

AMLODIPINE + SIMVASTATIN

CALCITRIOL 49CALCIUM ACETATE 42

CAL-NATE 57CAMILA 45

CAMPRAL 14

CANASA 48CAPOTEN - generic on formulary

as CAPTOPRIL

CAPOZIDE - generic on formularyas CAPTOPRIL-

HYDROCHLOROTHIAZIDE

CAPTOPRIL 34

CAPTOPRIL-HYDROCHLOROTHIAZIDE 34

CARAC 37

CARAFATE - generic on formularyas SUCRALFATE

CARBAMAZEPINE 11

CARBAMAZEPINE XR 11CARBATROL is non-formulary, a

generic alternative is

CARBAMEZAPINECARBIDOPA-LEVODOPA 21

CARDIZEM CD - generic on


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62


formulary as DILTIAZEM CD

CARDIZEM LA is non-formulary

and requires PA, a formularyalternative is DILTIAZEM CD

CARDIZEM - generic on formularyas DILTIAZEM HCLCARDURA XLis non-formulary

and requires PA, a formulary

alternative is DOXAZOSIN

CARDURA - generic on formularyas DOXAZOSIN MESYLATE

Cardura XL is non-formulary and

requires PA, formulary alternatives areFlomax, doxazosin, and terazosin

CARISOPRODOL 56

CARISOPRODOL COMPOUND 56CARISOPRODOL CPD/CODEINE 56

CARTEOLOL HCL 51

CARTIA XT 31

CARVEDILOL 31CASODEX - generic on formulary

as BICLUTAMIDE

CATAFLAM - generic on formularyas DICLOFENAC POTASSIUM

CATAPRES - generic on formularyas CLONIDINE HCL

CATAPRES-TTS - generic on

formulary as CLONIDINETRANSDERMAL PATCH

CEDAX 9

CEENU 18CEFACLOR 9

CEFADROXIL 9

CEFDINIR 9

CEFEPIME HCL 9CEFPODOXIME PROXETIL 9

CEFPROZIL 9

CEFTIN - generic on formulary asCEFUROXIME

CEFUROXIME 9

CEFUROXIME AXETIL 9CEFZIL - generic on formulary as

CEFPROZIL

CELEBREX 6, 16CELESTONE 16

CELEXA - generic on formulary as

Page

CITALOPRAM HBR

CELLCEPT SOLUTION 47

CENESTIN is non-formulary, aformulary alternative is PREMARIN

CENTANY KITis non-formularyand requires PA, a formularyalternative is MUPIROCIN

OINTMENT

CEPHALEXIN 9

CESAMETis non-formulary andrequires PA, a formulary alternative is

ONDANSETRON

CESIA 44CHERATUSSIN AC 54

CHERATUSSIN DAC 54

CHLORDIAZEPOXIDE 25CHLORHEXIDINE 36

CHLORHEXIDINE GLUCONATE 36

CHLOROQUINE PHOSPHATE 20

CHLOROTHIAZIDE 33CHLORPROMAZINE 22

CHLORTHALIDONE 33

CHLORZOXAZONE 56CHOLESTYRAMINE 33

CHOLESTYRAMINE LIGHT 33CHOLINE MAG TRISAL 16

CICLOPIROX CREAM OR GEL 37

CILOSTAZOL 29CIMETIDINE 40

CIPRO HC 10

CIPRO XR - generic on formularyas CIPROFLOXACIN ER

CIPRO - generic on formulary as

CIPROFLOXACIN HCL

CIPRODEX 10CIPROFLOXACIN ER 10

CIPROFLOXACIN HCL 10

CITALOPRAM HBR 12, 25CITALOPRAM SOLUTION 12, 25

CLARAVIS 37

CLARIFOAM-Mis non-formularyand requires PA, a formulary

alternative is SULFACETAMIDE

CLARINEXis non-formulary andrequires PA, a formulary alternative is

FEXOFENADINE


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CLARINEX-D is non-formulary and requires

PA, a formulary alternative is

FEXOFENADINE + OTC DECONGESTANTAS NEEDED

CLARITHROMYCIN 9CLARITHROMYCIN ER 10CLEERAVUE-M is non-formulary

and requires PA

CLEMASTINE FUMARATE 53

CLEOCIN HCL - generic onformulary as CLINDAMYCIN HCL

CLEOCIN T - generic on formulary

as CLINDAMYCIN PHOSPHATECLIMARA - generic on formulary

as ESTRADIOL

CLINDAMYCIN HCL 8CLINDAMYCIN PHOSPHATE 37

CLINDAREACH KIT is non-

formulary and requires PA, a

formulary alternative isCLINDAMYCIN

CLINORIL - generic on formulary

as SULINDACCLOBETASOL EMOLLIENT 44

CLOBETASOL PROPIONATE 45CLOBEX is non-formulary and


CLOBETASOL PROPIONATECLOMIPRAMINE HCL 13

CLONAZEPAM 25

CLONIDINE HCL 30CLONIDINE TRANSDERMAL

PATCH 30

CLORAZEPATE 25

CLOTRIMAZOLE-BETAMETHASONE 45

CLOZAPINE 21

CLOZARIL - generic on formularyas CLOZAPINE

CODEINE SULFATE 6

CO-GESIC 6COLAZAL - generic on formulary

as BALSALAZIDE DISODIUM

COLCHICINE 16COLESTID 33

COLESTID - generic on formulary

Page

as COLESTIPOL HCL

COLESTIPOL HCL 33

COLYTE - generic on formulary asPEG 3350-ELECTROLYTE

COMBIGAN is non-formulary andrequires PA, a formulary alternative isBRIMONIDINE 2% + TIMOLOL

0.5%

COMBIPATCH 42

COMBIVENT 55COMBIVIR 23

COMBUNOX - generic on

formulary as OXYCODONE-IBUPROFEN

COMPRO 22

COMTAN 21CONCERTA 36

CONDYLOX - generic on

formulary as PODOFILOX

COPAXONE 48COREG CR 31

COREG - generic on formulary as

CARVEDILOLCORGARD - generic on formulary

as NADOLOLCORMAX 45

CORTEF - generic on formulary as

HYDROCORTISONECORTISONE 16

CORTISPORIN - generic on

formulary as NEOMYCIN-POLYMYXIN-HC

CORZIDE - generic on formulary as

NADOLOL-

BENDROFLUMETHIAZIDECOSOPT 52

COUMADIN - generic on formulary

as WARFARIN SODIUMCOZAAR 34

CRESTOR is non-formulary and

requires PA, a formulary alternative isSIMVASTATIN

CRIXIVAN 24

CROMOLYN EYE DROPS 49CROMOLYN NEBULIZER SOLN 55

CRYSELLE 42


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CUPRIMINE 41

CYANOCOBALAMIN 1,000

MCG/ML INJ. 57CYCLESSA - generic on formulary

as CESIACYCLOBENZAPRINE HCL 56CYCLOPHOSPHAMIDE 19

CYCLOSPORINE 47

CYMBALTA 12, 25

CYPROHEPTADINE 53CYSTAGON 39

CYTOMEL 46

CYTOTEC - generic on formularyas MISOPROSTOL

CYTOXAN - generic on formulary

as CYCLOPHOSPHAMIDEDACOGEN 19

DALMANE - generic on formulary

as FLURAZEPAM

DANAZOL 47DAPSONE 8

DARAPRIM 20

DARVOCET - generic on formularyas PROPOXYPHENE

NAPSYLATE/APAPDAYPRO - generic on formulary as

OXAPROZIN

DAYTRANA 36DDAVP TABLETS - generic on

formulary as DESMOPRESSIN

ACETAT

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