Moda Health Plan, Inc.Moda Health Plan, Inc. is a PPO and an HMO plan with a Medicare contract....

Moda Health Plan, Inc.

Please read: this document contains information about the drugs we cover in this planNote to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year. Moda Health Plan, Inc. is a PPO and HMO plan with a Medicare contract. Enrollment in Moda Health Plan, Inc. depends on contract renewal.To receive this document in an alternate format or language, please contact Pharmacy Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week.

H3813-004 H3813-005 H3813-006 H8506-001

2015 Comprehensive Formulary (complete list of covered drugs)

H3813_108515A Accepted

The Centers for Medicare and Medicaid Services (CMS) require that we send you important plan documents every year.These documents contain information specific to your Moda Health plan:

> Combined Annual Notice of Changes (ANOC) and Evidence of Coverage (EOC)

> Comprehensive formulary (if applicable) > Provider and/or pharmacy directory (if applicable)

That’s a lot of paper to clutter your home. Luckily, all of these documents are available electronically through your myModa account. To receive an email from Moda Health when new materials are available, simply log in to your myModa account by visiting www.modahealth.com. The myModa log in is on the right side of your screen. You can also create an account on this page. Once logged in, select the “Account” tab. Next, click on “Change account settings.” From here, you can update your email and make your electronic delivery preference.Once you request electronic delivery, you will no longer receive these documents in the mail.

Next year, you can get plan documents delivered to you online

Online documents give you easy access to all your Medicare information.

Cut down on more paper — sign up for ODS eBill today!Now you can pay your premium online with eBill. Using eBill, you can view invoices online and set up your preferred payment methods (credit card, debit card, checking or savings) and set a recurring payment using our AutoPay feature. To access eBill, log in to myModa and click on the eBill tab.

903239 (8/13) MDCR-1432

Questions? Call us at 877-299-9062.

www.modahealth.com

Health plans in Oregon, Washington and Alaska provided by Moda Health Plan, Inc. Dental plans in Oregon provided by Oregon Dental Service. Dental plans in Alaska provided by Oregon Dental Service doing business as Delta Dental of Alaska.

English: We have free interpreter services to answer any questions you may

have about our health or drug plan. To get an interpreter, just call us at 1- 877-299-9062. Someone who speaks English can help you. This is a free

service.

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這是一項免費服務。

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です。


Salem Health Medicare, powered by Moda Health (PPO)

Legacy Health Medicare, powered by Moda Health (PPO)

Moda Health PPORX (PPO)

Moda Health HMO

2015 Comprehensive Formulary

(Complete List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE

COVER IN THIS PLAN

This formulary was updated on September 1, 2014. For more recent information or other questions, please

contact Moda Health Customer Service, at 1-888-786-7509 or, for TTY users 711, from 7 am to 8 pm Pacific

time seven days a week, from October 1st to February14th (After February 15th, your call will be handled by

our automated phone system Saturdays, Sundays and holidays.) or visit www.modahealth.com/medicare.

Note to existing members: This formulary has changed since last year. Please review this document to

make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Moda Health Plan, Inc. When it

refers to “plan” or “our plan,” it means Salem Health Medicare, powered by Moda Health; Legacy Health

Medicare, powered by Moda Health; Moda Health PPORX or Moda Health HMO.

This document includes a list of the drugs (formulary) for our plan which is current as of September 1, 2014.

For an updated formulary, please contact us. Our contact information, along with the date we last updated the

formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,

pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2016, and from time

to time during the year.

Moda Health Plan, Inc. is a PPO and an HMO plan with a Medicare contract. Enrollment in Moda Health

Plan, Inc. depends on contract renewal.

This information is available for free in other languages. Please call our Customer Service number at 1-888-

786-7509. TTY users call 711. Customer Service is available from 7 am to 8 pm Pacific time, seven days a

week.

Esta información está disponible en otros idiomas, sin costo. Por favor comuníquese al departamento de

servicios a los miembros al 1-888-786-7509. Usuarios de TTY (teléfono de texto), llamen al 711. El

departamento de servicios a los miembros está disponible de 7 a.m. a 8 p.m., hora oficial del Pacífico, los

siete días de la semana.

Last updated September 1, 2014

Formulary ID 00015472, Version 5


What is the Moda Health Formulary?

A formulary is a list of covered drugs selected by Moda Health in consultation with a team of health

care providers, which represents the prescription therapies believed to be a necessary part of a quality

treatment program. Moda Health will generally cover the drugs listed in our formulary as long as the

drug is medically necessary, the prescription is filled at a Moda Health network pharmacy, and other

plan rules are followed. For more information on how to fill your prescriptions, please review your

Evidence of Coverage.

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year,

we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a

new, less expensive generic drug becomes available or when new adverse information about the safety

or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from

our formulary, will not affect members who are currently taking the drug. It will remain available at the

same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is

important that you have continued access for the remainder of the coverage year to the formulary drugs

that were available when you chose our plan, except for cases in which you can save additional money

or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy

restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of

the change at least 60 days before the change becomes effective, or at the time the member requests a

refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and

Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes

the drug from the market, we will immediately remove the drug from our formulary and provide notice

to members who take the drug. The enclosed formulary is current as of September 1, 2014. To get

updated information about the drugs covered by Moda Health, please contact us. Our contact

information appears on the front and back cover pages.

How do I use the Formulary?

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

Medical Condition

The formulary begins on page 1. The drugs in this formulary are grouped into categories depending

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

condition are listed under the category Cardiovascular Agents. If you know what your drug is used

for, look for the category name in the list that begins on page 1. Then look under the category name

for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that

begins on page I-1 (at the back of this booklet). The Index provides an alphabetical list of all of the

drugs included in this document. Both brand name drugs and generic drugs are listed in the Index.

Look in the Index and find your drug. Next to your drug, you will see the page number where you

can find coverage information. Turn to the page listed in the Index and find the name of your drug

in the first column of the list.

What are generic drugs?

Moda Health covers both brand name drugs and generic drugs. A generic drug is approved by the

FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less

than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and

limits may include:

Prior Authorization: Moda Health requires you or your physician to get prior authorization for

certain drugs. This means that you will need to get approval from Moda Health before you fill

your prescriptions. If you don’t get approval, Moda Health may not cover the drug.

Quantity Limits: For certain drugs, Moda Health limits the amount of the drug that Moda

Health will cover. For example, Moda Health provides 18 tablets in 28 days per prescription for

sumatriptan (Imitrex) tablets. This may be in addition to a standard one month or three month

supply.

Step Therapy: In some cases, Moda Health requires you to first try certain drugs to treat your

medical condition before we will cover another drug for that condition. For example, if Drug A

and Drug B both treat your medical condition, Moda Health may not cover Drug B unless you

try Drug A first. If Drug A does not work for you, Moda Health will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that

begins on page 1. You can also get more information about the restrictions applied to specific covered

drugs by visiting our Web site. You may also ask us to send you a copy. Our contact information, along

with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Moda Health to make an exception to these restrictions or limits or for a list of other,

similar drugs that may treat your health condition. See the section, “How do I request an exception to the

Moda Health formulary?” on page IV for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Customer

Service and ask if your drug is covered.

If you learn that Moda Health does not cover your drug, you have two options:

You can ask Customer Service for a list of similar drugs that are covered by Moda Health.

When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug

that is covered by Moda Health.

You can ask Moda Health to make an exception and cover your drug. See below for information

about how to request an exception.

How do I request an exception to the Moda Health Formulary? You can ask Moda Health to make an exception to our coverage rules. There are several types of

exceptions that you can ask us to make.

You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will

be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide

the drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the

specialty tier. If approved this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain

drugs, Moda Health limits the amount of the drug that we will cover. If your drug has a quantity

limit, you can ask us to waive the limit and cover a greater amount.

Generally, Moda Health will only approve your request for an exception if the alternative drugs included

on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as

effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization

restriction exception. When you request a formulary, tiering or utilization restriction exception

you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement.

You can request an expedited (fast) exception if you or your doctor believe that your health could be

seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we

must give you a decision no later than 24 hours after we get a supporting statement from your doctor or

other prescriber.

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

an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or,

you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you

may need a prior authorization from us before you can fill your prescription. You should talk to your

doctor to decide if you should switch to an appropriate drug that we cover or request a formulary

exception so that we will cover the drug you take. While you talk to your doctor to determine the right

course of action for you, we may cover your drug in certain cases during the first 90 days you are a

member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will

cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to

a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have

been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we

have provided you with a 93-day transition supply, consistent with the dispensing increment, (unless

you have a prescription written for fewer days). We will cover more than one refill of these drugs for the

first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your

ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will

cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you

pursue a formulary exception.

If you have a level of care change, (going into or coming out of a skilled nursing facility or long term

care home) we will provide you with a 31-day transition supply (unless you have a prescription written

for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member

of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited,

but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply

of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

For more information

For more detailed information about your Moda Health prescription drug coverage, please review your

Evidence of Coverage and other plan materials.

If you have questions about Moda Health, please contact us. Our contact information, along with the

date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-

MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048.

Or, visit www.medicare.gov.

Moda Health Formulary

The formulary that begins on page 1 provides coverage information about the drugs covered by Moda

Health. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1 (at the

back of this booklet).

http://www.medicare.gov/

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX)

and generic drugs are listed in lower-case italics (e.g., sumatriptan).

The information in the Requirements/Limits column tells you if Moda Health has any special

requirements for coverage of your drug.

o LA – This prescription may be available only at certain pharmacies. For more information call

Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week, from

October 1st to February14th (After February 15th, your call will be handled by our automated

phone system Saturdays, Sundays and holidays.). TTY users should call 711.

o PA – Prior authorization is required for these drugs. This means you or your provider will need

to get approval from Moda Health before you can fill your prescription. If you don’t get

approval, Moda Health may not cover the drug. See page IV for how to request an exception. If

you need help requesting an exception please call Customer Service at 1-888-786-7509 from 7

am to 8 pm, Pacific time, seven days a week, from October 1st to February14th (After February

15th, your call will be handled by our automated phone system Saturdays, Sundays and

holidays.). TTY users should call 711.

o PA- HRM – Prior Authorization Restriction for High Risk Medication. The Centers for

Medicare and Medicaid Services (CMS) considers this medication to be high risk for patients 65

years old or older. Please contact your provider for more information.

o PA BvD - This drug may be covered under Medicare Part B or Part D depending upon the

circumstances. Information may need to be submitted describing the use and setting of the drug

to make the determination. If you need help requesting an exception please call Customer

Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week, from October 1st

to February14th (After February 15th, your call will be handled by our automated phone system

Saturdays, Sundays and holidays.). TTY users should call 711.

o PA for ESRD only – These drugs are also prescribed for members who have End-Stage Renal

Disease (ESRD). If you have ESRD then you may need to receive these drugs from your dialysis

facility. If you don’t have ESRD, see page IV for how to request an exception. If you need help

requesting an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm,

Pacific time, seven days a week, from October 1st to February14th (After February 15th, your

call will be handled by our automated phone system Saturdays, Sundays and holidays.). TTY

users should call 711.

o PA NSO - Prior Authorization Restriction for New Starts Only. If you are a new member or

taking this drug for the first time, you or your physician are required to get prior authorization

from Moda Health before you fill your prescription for this drug. Without prior approval, Moda

Health may not cover this drug. See page IV for how to request an exception. If you need help

requesting an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm,




o QL – These drugs have a quantity limit. This means you will receive a limited amount of these

drugs unless you or your provider asks for an exception to the quantity limit. See page IV for

how to request an exception. The maximum dosage allowed for the drug is noted first, then the

days supply (e.g., sumatriptan tablets QL 18 in 28 days, this means a maximum of 18 tablets are

allowed within 28 days). If you need help asking for an exception please call Customer Service

at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week, from October 1st to

February14th (After February 15th, your call will be handled by our automated phone system

Saturdays, Sundays and holidays.) TTY users should call 711.

o Rx Product Only - This drug is now available as a generic over-the-counter (OTC) medication.

OTC products are not covered under your Part D benefit. The prescription strength is only

covered under your Part D benefit. If you have questions please call Customer Service at 1-888-

786-7509 from 7 am to 8 pm, Pacific time, seven days a week, from October 1st to February14th

(After February 15th, your call will be handled by our automated phone system Saturdays,

Sundays and holidays.). TTY users should call 711.

o ST – These drugs require you to first try certain other drugs to treat your medical condition

before we will cover this drug. See page IV for how to request an exception. If you need help

asking for an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm,




Below is your cost sharing by plan and tier.

Salem Health Medicare, powered by Moda Health (PPO)

Deductible $0.00

Drug Tier up to a 31-day supply up to a 93-day supply

Tier 1 $5.00 copay $15.00 copay



Tier 4 50% coinsurance 50% coinsurance

Tier 5 33% coinsurance drugs on this tier are limited to a 31-

day supply

Legacy Health Medicare, powered by Moda Health (PPO)

Deductible $0.00







day supply

Moda Health PPORX (PPO)

Deductible $120.00







day supply

Moda Health HMO

Deductible $120.00







day supply

You can find information on what the symbols and abbreviations in this table mean by going to page VI of this

document

1

Moda Health 2015 Part D Formulary Effective: January 01, 2015

Formulary ID: 15472.000, Version: 5

Drug Name Drug Tier Requirements/Limits

Analgesics Analgesics, Miscellaneous

acetaminophen with codeine solution (Acetaminophen with

Codeine)

2 QL: 2700 in 30 days

acetaminophen with codeine tablet: 300mg-

60mg

(Vopac) 2 QL: 180 in 30 days

acetaminophen with codeine tablet: 300mg-

15mg, 300mg-30mg

(Vopac) 2 QL: 360 in 30 days

buprenorphine hcl (Buprenorphine HCl) 2 (injectable)

butalb/acetaminophen/caffeine tablet (Esgic) 2 PA-HRM, QL: 180 in 30

days

butalbit/acetamin/caff/codeine (Fioricet with Codeine) 2 PA-HRM, QL: 180 in 30

days

butalbital/acetaminophen tablet: 50mg-

325mg

(Tencon) 2 PA-HRM, QL: 180 in 30

days

butalbital/aspirin/caffeine (Fiorinal) 2 PA-HRM, QL: 180 in 30

days

butorphanol tartrate spray (Butorphanol Tartrate) 2 QL: 5 in 28 days

BUTRANS 3 QL: 4 in 28 days

codeine sulfate tablet (Codeine Sulfate) 2 QL: 180 in 30 days

codeine/butalbital/asa/caffein (Fiorinal w/Codeine

#3)

2 PA-HRM, QL: 180 in 30

days

DURAMORPH 4

fentanyl citrate (Actiq) 5 PA, QL: 120 in 30 days

fentanyl patch td72: 12mcg/hr, 25mcg/hr,

50mcg/hr, 75mcg/hr

(Duragesic) 2 PA, QL: 10 in 30 days

fentanyl patch td72: 100mcg/hr (Duragesic) 2 PA, QL: 20 in 30 days

hydrocodone/acetaminophen solution: 2.5-

167/5

(Hycet) 2 QL: 2700 in 30 days

hydrocodone/acetaminophen solution: 7.5-

325/15

(Hycet) 2 QL: 2700 in 30 days

hydrocodone/acetaminophen tablet: 2.5-

325mg

(Norco) 2 QL: 360 in 30 days

hydrocodone/acetaminophen tablet: 5mg-

325mg, 7.5-325mg, 10mg-325mg


hydrocodone/acetaminophen tablet: 5mg-

300mg, 7.5-300mg, 10mg-300mg


hydrocodone/ibuprofen (Ibudone) 2 QL: 150 in 30 days

hydromorphone hcl liquid (Dilaudid) 2 QL: 1200 in 30 days


document

2




hydromorphone hcl tablet: 2mg, 4mg (Dilaudid) 2 QL: 180 in 30 days

hydromorphone hcl tablet: 8mg (Dilaudid) 2 QL: 240 in 30 days

hydromorphone hcl syringe, vial (Hydromorphone HCl) 2

hydromorphone hcl/pf ampul (Dilaudid) 2

hydromorphone hcl/pf vial (Hydromorphone HCl/

PF)

2

LAZANDA 5 PA, QL: 30 in 30 days

levorphanol tartrate (Levo-dromoran) 2 QL: 180 in 30 days

methadone hcl tablet sol (Diskets) 2 QL: 90 in 30 days

methadone hcl vial (Methadone HCl) 2

methadone hcl solution (Methadone HCl) 2 QL: 1800 in 30 days

methadone hcl tablet (Methadose) 2 QL: 360 in 30 days

morphine sulfate cartridge: 2mg/ml, 4mg/

ml

(Morphine Sulfate) 2

morphine sulfate various dosage and/or

strengths are available

(Morphine Sulfate) 2

morphine sulfate tablet er: 30mg, 60mg,

100mg

(MS Contin) 2 QL: 120 in 30 days

morphine sulfate tablet er: 15mg, 200mg (MS Contin) 2 QL: 180 in 30 days

morphine sulfate solution: 100mg/5ml (MSIR) 2 QL: 200 in 30 days



MORPHINE SULFATE tablet 2 QL: 180 in 30 days

NUCYNTA ER 3 QL: 60 in 30 days

NUCYNTA 3 QL: 181 in 30 days

oxycodone hcl oral conc, tablet (Dazidox) 2 QL: 180 in 30 days

oxycodone hcl solution (Oxycodone HCl) 2 QL: 1300 in 30 days

oxycodone hcl/acetaminophen tablet:

10mg-650mg

(Alcet) 2 QL: 180 in 30 days

oxycodone hcl/acetaminophen tablet: 5mg-

500mg, 7.5-500mg


oxycodone hcl/acetaminophen tablet: 2.5-

325mg, 5mg-325mg, 7.5-325mg, 10mg-

325mg


oxycodone hcl/acetaminophen solution (Oxycodone HCl/

acetaminophen)

2 QL: 1800 in 30 days

oxycodone hcl/aspirin (Endodan) 2 QL: 360 in 30 days

OXYCONTIN tab er 12h: 80mg 3 QL: 120 in 30 days


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3




OXYCONTIN tab er 12h: 10mg, 15mg,

20mg, 30mg, 40mg, 60mg

3 QL: 60 in 30 days

oxymorphone hcl tablet (Opana) 2 QL: 180 in 30 days

oxymorphone hcl tab er 12h: 30mg, 40mg (Oxymorphone HCl) 2 QL: 120 in 30 days

oxymorphone hcl tab er 12h: 5mg, 7.5mg,

10mg, 15mg, 20mg

(Oxymorphone HCl) 2 QL: 60 in 30 days

tramadol hcl tablet (Ultram) 2 QL: 240 in 30 days

tramadol hcl/acetaminophen (Ultracet) 2 QL: 240 in 30 days

Nonsteroidal Anti-inflammatory Agents

CALDOLOR 4

CELEBREX 3 ST, QL: 60 in 30 days

choline sal/mag salicylate (Choline Sal/mag

Salicylate)

2

diclofenac potassium (Cataflam) 2

diclofenac sodium gel (gram) (Solaraze) 5

diclofenac sodium tab er 24h, tablet dr (Voltaren) 2

diclofenac sodium/misoprostol (Arthrotec 50) 2

diflunisal (Diflunisal) 2

etodolac (Etodolac) 2

fenoprofen calcium (Fenoprofen Calcium) 2

FLECTOR 3 PA

flurbiprofen (Ansaid) 2

ibuprofen oral susp (Ibuprofen) 2

ibuprofen tablet (Motrin) 1

indomethacin sodium (Indocin I.v.) 2 PA-HRM

indomethacin capsule er (Indocin SR) 2 PA-HRM, QL: 60 in 30

days

indomethacin capsule: 50mg (Indomethacin) 2 PA-HRM, QL: 120 in 30

days

indomethacin capsule: 25mg (Indomethacin) 2 PA-HRM, QL: 240 in 30

days

ketoprofen (Ketoprofen) 2

ketorolac tromethamine vial: 15mg/ml (Ketorolac

Tromethamine)

2 QL: 40 in 30 days

ketorolac tromethamine cartridge: 30mg/ml (Toradol) 2 QL: 20 in 30 days

ketorolac tromethamine tablet, vial: 30mg/

ml

(Toradol) 2 QL: 20 in 30 days

ketorolac tromethamine cartridge: 15mg/ml (Toradol) 2 QL: 40 in 30 days

mefenamic acid (Ponstel) 2


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meloxicam tablet (Mobic) 1

meloxicam oral susp (Mobic) 2

nabumetone (Relafen) 2

naproxen sodium (Anaprox) 1

naproxen tablet (Naprosyn) 1

naproxen oral susp, tablet dr (Naprosyn) 2

piroxicam (Feldene) 2

salsalate (Salflex) 2

sulindac (Clinoril) 2

tolmetin sodium (Tolmetin Sodium) 2

VOLTAREN 3 (Topical Gel)

Anesthetics Local Anesthetics

lidocaine hcl disp syrin, solution: 4% (Xylocaine) 2

lidocaine hcl jel (ml), jel/pf app, solution:

2%, 40mg/ml

(Xylocaine) 2

lidocaine hcl vial (Xylocaine) 2 PA BvD (PA for ESRD

Only)

lidocaine hcl/pf ampul: 15mg/ml, 40mg/ml (Xylocaine-MPF) 2 PA BvD (PA for ESRD

Only)

lidocaine hcl/pf vial: 5mg/ml (Xylocaine-MPF) 2 PA BvD (PA for ESRD

Only)

lidocaine oint. (g) (Lidocaine) 2 PA BvD (PA for ESRD

Only)

lidocaine/prilocaine (EMLA) 2 PA BvD (PA for ESRD

Only)

LIDODERM 4 PA

Anti-addiction/substance Abuse Treatment Agents Anti-addiction/substance Abuse Treatment Agents

acamprosate calcium (Campral) 2

buprenorphine hcl (Subutex) 2 PA, QL: 90 in 30 days

buprenorphine hcl/naloxone hcl (Suboxone) 2 PA, QL: 90 in 30 days

CHANTIX tablet: 0.5mg, 1mg 3 QL: 168 in 84 days

CHANTIX tab ds pk 3 QL: 53 in 28 days

CHANTIX tablet: 1mg 3 QL: 56 in 28 days

disulfiram (Antabuse) 2

naloxone hcl syringe: 0.4mg/ml; vial (Naloxone HCl) 2

naloxone hcl syringe: 1mg/ml (Naloxone HCl) 2

naltrexone hcl (Revia) 2


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5




NICOTROL 4

ZUBSOLV 3 PA, QL: 90 in 30 days

Antianxiety Agents Benzodiazepines

alprazolam tab er 24h: 1mg, 2mg, 3mg (Xanax XR) 2 QL: 60 in 30 days

alprazolam tab er 24h: 0.5mg; tab rapdis,

tablet

(Xanax) 2 QL: 90 in 30 days

chlordiazepoxide hcl (Librium) 2 QL: 120 in 30 days

clonazepam tab rapdis: 2mg; tablet: 2mg (Klonopin) 2 QL: 300 in 30 days

clonazepam tab rapdis: 0.125mg, 0.25mg,

0.5mg, 1mg; tablet: 0.5mg, 1mg

(Klonopin) 2 QL: 90 in 30 days

clorazepate dipotassium tablet: 15mg (Tranxene T-tab) 2 QL: 120 in 30 days

clorazepate dipotassium tablet: 3.75mg,

7.5mg

(Tranxene T-tab) 2 QL: 60 in 30 days

DIASTAT ACUDIAL kit: 12.5-15-20 4

diazepam kit (Diastat) 2

diazepam oral conc, solution (Diazepam) 2 QL: 1200 in 30 days

diazepam vial (Diazepam) 2 QL: 2 in 28 days

diazepam tablet (Valium) 2 QL: 120 in 30 days

estazolam tablet: 2mg (Prosom) 2 PA-HRM, QL: 30 in 30

days

estazolam tablet: 1mg (Prosom) 2 PA-HRM, QL: 60 in 30

days

flurazepam hcl capsule: 30mg (Dalmane) 2 PA-HRM, QL: 30 in 30

days

flurazepam hcl capsule: 15mg (Dalmane) 2 PA-HRM, QL: 60 in 30

days

lorazepam syringe, vial (Ativan) 2 QL: 2 in 30 days

lorazepam tablet (Ativan) 2 QL: 90 in 30 days

lorazepam oral conc (Lorazepam) 2 QL: 150 in 30 days

midazolam hcl syrup (Midazolam HCl) 2 QL: 10 in 30 days

midazolam hcl vial (Midazolam HCl) 2 QL: 2 in 30 days

midazolam hcl/pf (Midazolam HCl/PF) 2 QL: 2 in 30 days

ONFI oral susp 4 PA NSO, QL: 480 in 30

days

ONFI tablet 4 PA NSO, QL: 60 in 30

days

temazepam capsule: 7.5mg (Restoril) 2 PA-HRM, QL: 120 in 30

days


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6




temazepam capsule: 15mg, 22.5mg, 30mg (Restoril) 2 PA-HRM, QL: 30 in 30

days

triazolam tablet: 0.125mg (Halcion) 2 PA-HRM, QL: 120 in 30

days

triazolam tablet: 0.25mg (Halcion) 2 PA-HRM, QL: 60 in 30

days

Antibacterials Aminoglycosides

BETHKIS 5 PA BvD

gentamicin in nacl, iso-osm piggyback:

100mg/50ml

(Gentamicin In Nacl,

Iso-osm)

2

gentamicin in nacl, iso-osm piggyback:

70mg/50ml, 80mg/100ml, 80mg/50ml,

90mg/100ml, 100mg/0.1l, 120mg/0.1l

(Gentamicin In Nacl,

Iso-osm)

2

gentamicin sulfate (Garamycin) 2

neomycin sulfate (Neomycin Sulfate) 2

streptomycin sulfate (Streptomycin Sulfate) 2

TOBI PODHALER 5 QL: 224 in 28 days

tobramycin in 0.225% nacl (Tobi) 5 PA BvD

tobramycin sulfate (Nebcin) 2

tobramycin/sodium chloride piggyback:

60mg/50ml

(Tobramycin/sodium

Chloride)

2

tobramycin/sodium chloride piggyback:

80mg/100ml

(Tobramycin/sodium

Chloride)

2

Antibacterials, Miscellaneous

bacitracin vial: 50000unit (Bacitracin) 2

chloramphenicol sod succ (Chloramphenicol Sod

Succ)

2

clindamycin hcl (Cleocin HCl) 2

clindamycin palmitate hcl (Cleocin Palmitate) 2

clindamycin phosphate vial port (Cleocin Phosphate) 2

clindamycin phosphate/d5w (Cleocin Phosphate In

D5w)

2

colistin (colistimethate na) (Coly-mycin M

Parenteral)

2

CUBICIN 5 PA BvD (PA for ESRD

Only)

methenamine hippurate (Urex) 2


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7




nitrofurantoin macrocrystal (Macrodantin) 2 PA-HRM, QL: 120 in 30

days (High Risk Med.

QL applies to all

members; PA required

for 65 years and older

with over 90 days

cumulative use of

nitrofurantoin drugs)

SYNERCID 5

trimethoprim (Trimethoprim) 2

vancomycin hcl capsule (Vancocin HCl) 5

vancomycin hcl vial: 5g, 10g (Vancomycin HCl) 2 PA BvD (PA for ESRD

Only)

vancomycin hcl vial: 750mg (Vancomycin HCl) 2 PA BvD (PA for ESRD

Only)

vancomycin hcl/d5w (Vancomycin HCl/

D5W)

2

VANCOMYCIN HCL 4

XIFAXAN tablet: 200mg 5 PA, QL: 9 in 30 days

XIFAXAN tablet: 550mg 5 ST, QL: 60 in 30 days

ZYVOX 5

Cephalosporins

cefaclor capsule, susp recon (Ceclor) 2

cefadroxil (Cefadroxil) 2

cefazolin sodium (Ancef) 2

cefazolin sodium/dextrose,iso (Cefazolin Sodium/

dextrose, Iso)

2

cefdinir (Omnicef) 2

cefepime hcl (Maxipime) 2

CEFEPIME 4

CEFEPIME-DEXTROSE 4

cefotaxime sodium (Claforan) 2

cefoxitin sodium (Mefoxin) 2

cefoxitin sodium/dextrose,iso (Cefoxitin Sodium/

dextrose, Iso)

2

cefpodoxime proxetil (Vantin) 2

cefprozil (Cefzil) 2

ceftazidime pentahydrate vial (Fortaz) 2

ceftazidime pentahydrate vial port (Fortaz) 2


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8




ceftibuten dihydrate (Cedax) 2

ceftriaxone na/dextrose,iso (Ceftriaxone Na/

dextrose, Iso)

2

ceftriaxone sodium (Rocephin) 2

cefuroxime axetil (Ceftin) 2

cefuroxime sodium (Zinacef) 2

cefuroxime sodium/dextrose,iso (Cefuroxime Sodium/

dextrose, Iso)

2

cephalexin monohydrate (Cephalexin

Monohydrate)

1

cephalexin (Keflex) 1

MEFOXIN froz.piggy 4

SUPRAX tab chew, tablet 4

TAZICEF IN DEXTROSE 4

TEFLARO 4

Macrolides

azithromycin (Zithromax) 2

clarithromycin (Biaxin) 2

DIFICID 5 QL: 20 in 10 days

ery e-succ/sulfisoxazole (Pediazole) 2

ERY-TAB 2

ERYTHROCIN LACTOBIONATE vial

port: 1g

4

ERYTHROCIN LACTOBIONATE vial

port: 500mg

4

erythromycin base capsule dr (Eryc) 2

erythromycin base tablet, tablet dr (Erythromycin Base) 2

erythromycin ethylsuccinate susp recon (Erythromycin

Ethylsuccinate)

2

erythromycin ethylsuccinate tablet (Erythromycin

Ethylsuccinate)

2

erythromycin stearate (Erythromycin

Stearate)

2

Miscellaneous B-lactam Antibiotics

aztreonam (Azactam) 2

CAYSTON 5 LA

imipenem/cilastatin sodium (Primaxin) 2

INVANZ vial 4

INVANZ vial port 4


document

9




meropenem (Merrem) 2

Penicillins

amoxicillin trihydrate (Amoxicillin

Trihydrate)

1

amoxicillin (Amoxil) 1

amoxicillin/potassium clav (Augmentin) 2

ampicillin sodium vial (Totacillin-N) 2

ampicillin sodium vial port (Totacillin-N) 2

ampicillin sodium/sulbactam na vial (Unasyn) 2

ampicillin sodium/sulbactam na vial port (Unasyn) 2

ampicillin trihydrate (Ampicillin Trihydrate) 1

BICILLIN C-R 4

BICILLIN L-A 4

dicloxacillin sodium (Dicloxacillin Sodium) 2

NAFCILL IN DEXTROSE 4

nafcillin sodium vial (Unipen) 2

nafcillin sodium vial port (Unipen) 2

oxacillin sodium (Oxacillin Sodium) 2

oxacillin sodium/dextrose,iso (Oxacillin Sodium/

dextrose, Iso)

2

pen g pot/dextrose-water froz.piggy: 1mm/

50ml

(Pen G Pot/dextrose-

water)

2

pen g pot/dextrose-water froz.piggy: 2mm/

50ml, 3mm/50ml

(Pen G Pot/dextrose-

water)

2

penicillin g potassium (Penicillin G

Potassium)

2

penicillin g potassium/d5w (Penicillin G

Potassium/D5W)

2

penicillin g procaine syringe: 1.2mm/2ml (Penicillin G Procaine) 2

penicillin g procaine syringe: 600000/ml (Penicillin G Procaine) 2

penicillin v potassium (Veetids 500) 2

piperacillin sodium/tazobactam (Zosyn) 2

Quinolones

ciprofloxacin hcl (Cipro) 1

ciprofloxacin lactate (Cipro I.V.) 2

ciprofloxacin lactate/d5w (Cipro I.V.) 2

ciprofloxacin (Ciprofloxacin) 2

levofloxacin tablet (Levaquin) 1

levofloxacin solution, vial (Levaquin) 2


document

10




levofloxacin/d5w (Levaquin) 2

moxifloxacin hcl (Avelox) 2

nalidixic acid (Nalidixic Acid) 2

ofloxacin (Floxin) 2

Sulfonamides

sulfadiazine (Sulfadiazine) 2

sulfamethoxazole/trimethoprim tablet (Septra) 1

sulfamethoxazole/trimethoprim oral susp,

vial

(Sulfamethoxazole/

trimethoprim)

2

sulfasalazine (Azulfidine) 2

Tetracyclines

doxycycline hyclate capsule, tablet: 20mg;

vial

(Morgidox) 2

doxycycline hyclate tablet: 100mg (Periostat) 2

doxycycline monohydrate (Adoxa) 2

minocycline hcl capsule, tablet (Dynacin) 2

tetracycline hcl capsule (Ala-tet) 2

tetracycline hcl oral susp (Tetracycline HCl) 2

TYGACIL 5

Anticancer Agents Anticancer Agents

ABRAXANE 5

ADCETRIS 5 PA NSO, QL: 4 in 21

days

AFINITOR DISPERZ 5 PA NSO, QL: 112 in 28

days

AFINITOR tablet: 2.5mg, 5mg, 7.5mg 5 PA NSO, QL: 28 in 28

days

AFINITOR tablet: 10mg 5 PA NSO, QL: 56 in 28

days

ALIMTA 5

anastrozole (Arimidex) 2

ARRANON 5

ARZERRA 5 PA NSO

AVASTIN 5 PA NSO

azacitidine (Vidaza) 5

bicalutamide (Casodex) 2

bleomycin sulfate (Bleomycin Sulfate) 2 PA BvD


document

11




BOSULIF tablet: 100mg 5 PA NSO, QL: 120 in 30

days

BOSULIF tablet: 500mg 5 PA NSO, QL: 30 in 30

days

CAPRELSA tablet: 300mg 5 PA NSO, QL: 30 in 30

days

CAPRELSA tablet: 100mg 5 PA NSO, QL: 60 in 30

days

carboplatin (Carboplatin) 2

cisplatin (Cisplatin) 2

COMETRIQ 5 PA NSO, QL: 112 in 28

days

cyclophosphamide tablet (Cyclophosphamide) 2 PA BvD, ST

cyclophosphamide vial (Cytoxan) 2 PA BvD

CYCLOPHOSPHAMIDE 4 PA BvD, ST

cytarabine (Tarabine Pfs) 2 PA BvD

cytarabine/pf (Cytarabine/PF) 2 PA BvD

dacarbazine (Dtic-Dome IV) 2

dactinomycin (Cosmegen) 2

decitabine (Dacogen) 5

doxorubicin hcl peg-liposomal (Doxil) 5 PA BvD

doxorubicin hcl vial: 10mg (Adriamycin RDF) 2 PA BvD

DROXIA 3

ELIGARD syringe: 30mg 4 QL: 1 in 112 days

ELIGARD syringe: 7.5mg 4 QL: 1 in 28 days

ELIGARD syringe: 22.5mg 4 QL: 1 in 84 days

ELIGARD syringe: 45mg 5 QL: 1 in 168 days

EMCYT 3

epirubicin hcl (Ellence) 2

ERBITUX 5 PA NSO

ERIVEDGE 5 PA NSO, QL: 30 in 30

days

ETOPOPHOS 4

etoposide (Etoposide) 2

exemestane (Aromasin) 2

FARESTON 5

FASLODEX 5

FIRMAGON 4

floxuridine (FUDR) 2 PA BvD


document

12




fludarabine phosphate (Fludara) 3

fluorouracil vial: 500mg/10ml (Fluorouracil) 2 PA BvD

fluorouracil vial: 5g/100ml (Fluorouracil) 2 PA BvD

flutamide (Flutamide) 2

GAZYVA 5 PA NSO, QL: 40 in 28

days

gemcitabine hcl (Gemzar) 5

GILOTRIF 5 PA NSO, QL: 30 in 30

days

GLEEVEC tablet: 400mg 5 PA NSO, QL: 60 in 30

days

GLEEVEC tablet: 100mg 5 PA NSO, QL: 90 in 30

days

HALAVEN 5 PA NSO, QL: 24 in 28

days

HERCEPTIN 5 PA NSO

HEXALEN 5

hydroxyurea (Hydrea) 2

ICLUSIG tablet: 45mg 5 PA NSO, QL: 30 in 30

days

ICLUSIG tablet: 15mg 5 PA NSO, QL: 60 in 30

days

ifosfamide (Ifex) 2 PA BvD

ifosfamide/mesna kit: 1g-1g, 3g-1g (Ifex-mesnex) 5 PA BvD

IMBRUVICA 5 PA NSO, QL: 120 in 30

days

INLYTA tablet: 1mg 5 PA NSO, QL: 180 in 30

days

INLYTA tablet: 5mg 5 PA NSO, QL: 60 in 30

days

ISTODAX 5 PA NSO

IXEMPRA 5

JAKAFI 5 PA NSO, QL: 60 in 30

days

JEVTANA 5

KADCYLA 5 PA NSO

KYPROLIS 5 PA NSO, QL: 6 in 28

days

letrozole (Femara) 2


document

13




LEUKERAN 4

leuprolide acetate (Leuprolide Acetate) 2

lomustine (Ceenu) 2

LUPRON DEPOT syringekit: 45mg 5 QL: 1 in 168 days

LUPRON DEPOT syringekit: 3.75mg 5 QL: 1 in 28 days

LUPRON DEPOT syringekit: 11.25mg,

22.5mg

5 QL: 1 in 84 days

LUPRON DEPOT-PED syringekit 5 QL: 1 in 112 days

LUPRON DEPOT-PED kit 5 QL: 1 in 28 days

LYSODREN 3

MARQIBO 5 PA NSO, QL: 4 in 28

days

MATULANE 5

MEGACE ES 5

megestrol acetate (Megestrol Acetate) 2

MEKINIST tablet: 2mg 5 PA NSO, QL: 30 in 30

days

MEKINIST tablet: 0.5mg 5 PA NSO, QL: 90 in 30

days

melphalan hcl (Alkeran) 5

mercaptopurine (Purinethol) 2

methotrexate sodium (Methotrexate Sodium) 2 PA BvD, ST

methotrexate sodium/pf (Methotrexate Sodium/

PF)

2 PA BvD

mitomycin (Mitomycin) 2 PA BvD

mitoxantrone hcl (Novantrone) 2

MUSTARGEN 3

NEXAVAR 5 PA NSO, QL: 120 in 30

days

NILANDRON 3

ONCASPAR 5 PA

oxaliplatin (Oxaliplatin) 5

paclitaxel (Taxol) 2

PERJETA 5 PA NSO

POMALYST 5 PA NSO, QL: 21 in 28

days

PROLEUKIN 5

REVLIMID 5 LA, PA NSO, QL: 21 in

28 days


document

14




RITUXAN 5 PA NSO

SOLTAMOX 4

SPRYCEL tablet: 50mg, 70mg, 80mg,

100mg, 140mg

5 PA NSO, QL: 30 in 30

days

SPRYCEL tablet: 20mg 5 PA NSO, QL: 60 in 30

days

STIVARGA 5 PA NSO, QL: 84 in 28

days

SUTENT 5 PA NSO, QL: 30 in 30

days

SYLVANT 5 PA

SYNRIBO 5 PA NSO, QL: 28 in 28

days

TABLOID 3

TAFINLAR 5 PA NSO, QL: 120 in 30

days

tamoxifen citrate (Nolvadex) 2

TARCEVA tablet: 25mg, 100mg 5 PA NSO, QL: 60 in 30

days

TARCEVA tablet: 150mg 5 PA NSO, QL: 90 in 30

days

TARGRETIN capsule 5 PA NSO, QL: 420 in 30

days

TARGRETIN gel (gram) 5 PA NSO, QL: 60 in 28

days

TASIGNA 5 PA NSO, QL: 112 in 28

days

TEMODAR 5 PA NSO (vial only)

topotecan hcl (Hycamtin) 5

TORISEL 5 PA BvD, QL: 4 in 28

days

TREANDA 5

TRELSTAR syringe: 22.5mg/2ml 5 QL: 1 in 168 days

TRELSTAR syringe: 3.75mg/2ml 5 QL: 1 in 28 days

TRELSTAR syringe: 11.25/2ml 5 QL: 1 in 84 days

tretinoin (Tretinoin) 5 (capsule: 10mg)

TREXALL 4 PA BvD, ST

TYKERB 5

VALSTAR 5


document

15




VECTIBIX 5 PA NSO

VELCADE 5 PA NSO

vinblastine sulfate (Vinblastine Sulfate) 2 PA BvD

vincristine sulfate (Vincristine Sulfate) 2 PA BvD

vinorelbine tartrate (Navelbine) 2

VOTRIENT 5 PA NSO, QL: 120 in 30

days

XALKORI 5 PA NSO, QL: 60 in 30

days

XTANDI 5 PA NSO, QL: 120 in 30

days

YERVOY 5 PA NSO, QL: 80 in 21

days

ZALTRAP 5 PA NSO

ZELBORAF 5 PA NSO, QL: 240 in 30

days

ZOLADEX implant: 3.6mg 4 QL: 1 in 28 days

ZOLADEX implant: 10.8mg 4 QL: 1 in 84 days

ZOLINZA 5

ZYKADIA 5 PA NSO, QL: 140 in 28

days

ZYTIGA 5 PA NSO, QL: 120 in 30

days

Anticholinergic Agents Antimuscarinics/Antispasmodics

atropine sulfate syringe: 0.05mg/ml,

0.1mg/ml

(Atropine Sulfate) 2

atropine sulfate vial: 0.4mg/ml (Atropine Sulfate) 2

propantheline bromide (Propantheline

Bromide)

2

Anticonvulsants Anticonvulsants

APTIOM 4 ST

BANZEL 4 ST

carbamazepine (Tegretol) 2

CELONTIN 3

DILANTIN capsule: 30mg 3

divalproex sodium (Depakote ER) 2

ethosuximide (Zarontin) 2


document

16




felbamate (Felbatol) 2

fosphenytoin sodium (Cerebyx) 2

FYCOMPA 4 ST

gabapentin (Neurontin) 2

GABITRIL tablet: 12mg, 16mg 3

LAMICTAL tb chw dsp: 2mg 4

lamotrigine tab ds pk (Lamictal (blue)) 2

lamotrigine tab er 24, tablet, tb chw dsp (Lamictal) 2

levetiracetam (Keppra) 2

LUMINAL SODIUM 4 QL: 2 in 30 days

LYRICA capsule 3 QL: 90 in 30 days

LYRICA solution 3 QL: 900 in 30 days

oxcarbazepine (Trileptal) 2

OXTELLAR XR 4 ST

PEGANONE 3

phenobarbital sodium (Phenobarbital Sodium) 2 QL: 2 in 30 days

phenobarbital elixir (Phenobarbital) 2 QL: 1500 in 30 days

phenobarbital tablet: 30mg (Phenobarbital) 2 QL: 200 in 30 days

phenobarbital tablet: 15mg, 16.2mg,

32.4mg, 60mg, 64.8mg, 97.2mg, 100mg

(Phenobarbital) 2 QL: 90 in 30 days

phenytoin sodium extended (Dilantin) 2

phenytoin sodium syringe (Phenytoin Sodium) 2

phenytoin sodium vial (Phenytoin Sodium) 2

phenytoin (Dilantin) 2

POTIGA tablet: 50mg 4 ST, QL: 270 in 30 days

POTIGA tablet: 200mg, 300mg, 400mg 4 ST, QL: 90 in 30 days

primidone (Mysoline) 2

QUDEXY XR 4 ST

SABRIL 5

tiagabine hcl (Gabitril) 2

topiramate cap sprink, tablet (Topamax) 2

TRILEPTAL oral susp 4

TROKENDI XR 4 ST

valproic acid (as sodium salt) (Depakene) 2

valproic acid (Depakene) 2

VIMPAT solution 4 ST, QL: 1200 in 30 days

VIMPAT vial 4 ST, QL: 200 in 5 days

VIMPAT tablet 4 ST, QL: 60 in 30 days

zonisamide (Zonegran) 2


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Antidementia Agents Antidementia Agents

donepezil hcl (Aricept) 2 QL: 30 in 30 days

galantamine hbr cap24h pel (Razadyne ER) 2 QL: 30 in 30 days

galantamine hbr solution (Razadyne) 2 QL: 200 in 30 days

galantamine hbr tablet (Razadyne) 2 QL: 60 in 30 days

NAMENDA XR cap24 dspk 3 QL: 28 in 28 days

NAMENDA XR cap spr 24 3 QL: 30 in 30 days

NAMENDA 3 QL: 360 in 30 days

rivastigmine tartrate (Exelon) 2 QL: 60 in 30 days

Antidepressants Antidepressants

amitriptyline hcl (Amitriptyline HCl) 2 PA-HRM

amoxapine (Amoxapine) 2

BRINTELLIX 4 ST

bupropion hcl (Wellbutrin XL) 2

citalopram hydrobromide tablet (Celexa) 1 QL: 30 in 30 days

citalopram hydrobromide solution (Celexa) 2

clomipramine hcl (Anafranil) 2 PA-HRM

desipramine hcl (Norpramin) 2

doxepin hcl (Doxepin HCl) 2 PA-HRM

duloxetine hcl capsule dr: 30mg (Cymbalta) 2 QL: 30 in 30 days

duloxetine hcl capsule dr: 20mg, 60mg (Cymbalta) 2 QL: 60 in 30 days

EMSAM 4 QL: 30 in 30 days

escitalopram oxalate tablet (Lexapro) 2 QL: 30 in 30 days

escitalopram oxalate solution (Lexapro) 2 QL: 697 in 30 days

FETZIMA 4 ST

fluoxetine hcl capsule (Prozac) 1

fluoxetine hcl capsule dr, solution, tablet (Rapiflux) 2

fluvoxamine maleate (Fluvoxamine Maleate) 2

imipramine hcl (Tofranil) 2 PA-HRM

imipramine pamoate (Tofranil-PM) 2 PA-HRM

KHEDEZLA 4 ST, QL: 30 in 30 days

maprotiline hcl (Maprotiline HCl) 2

MARPLAN 4

mirtazapine (Remeron) 2

nefazodone hcl (Nefazodone HCl) 2

nortriptyline hcl (Pamelor) 2

olanzapine/fluoxetine hcl (Symbyax) 2


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paroxetine hcl (Paxil) 2

PAXIL oral susp 4

perphenazine/amitriptyline hcl (Perphenazine/

amitriptyline HCl)

2 PA-HRM

phenelzine sulfate (Nardil) 2

PRISTIQ ER 4 ST, QL: 30 in 30 days

protriptyline hcl (Vivactil) 2

sertraline hcl tablet (Zoloft) 1

sertraline hcl oral conc (Zoloft) 2

SILENOR 3 QL: 30 in 30 days

SURMONTIL 4 PA-HRM

tranylcypromine sulfate (Parnate) 2

trazodone hcl (Trazodone HCl) 1

venlafaxine hcl (Effexor XR) 2

VIIBRYD 4

Antidiabetic Agents Antidiabetic Agents, Miscellaneous

acarbose (Precose) 2 QL: 90 in 30 days

BYDUREON 3 ST, QL: 4 in 28 days

BYETTA pen injctr: 5mcg/0.02 3 ST, QL: 1.2 in 28 days

BYETTA pen injctr: 10mcg/0.04 3 ST, QL: 2.4 in 28 days

CYCLOSET 4 QL: 180 in 30 days

INVOKANA tablet: 300mg 3 ST, QL: 30 in 30 days

INVOKANA tablet: 100mg 3 ST, QL: 60 in 30 days

JANUMET XR tbmp 24hr: 50mg-500mg,

100-1000mg

3 QL: 30 in 30 days

JANUMET XR tbmp 24hr: 50-1000mg 3 QL: 60 in 30 days

JANUMET 3 QL: 60 in 30 days

JANUVIA 3 QL: 30 in 30 days

JENTADUETO 3 QL: 60 in 30 days

KORLYM 5 PA, QL: 112 in 28 days

metformin hcl tab er 24h: 500mg (Fortamet) 2 QL: 120 in 30 days

metformin hcl tab er 24 (Fortamet) 2 QL: 60 in 30 days

metformin hcl tab er 24h: 750mg (Fortamet) 2 QL: 90 in 30 days

metformin hcl tablet: 500mg (Glucophage) 1 QL: 120 in 30 days



nateglinide (Starlix) 2 QL: 90 in 30 days

pioglitazone hcl (Actos) 2 QL: 30 in 30 days


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pioglitazone hcl/glimepiride (Duetact) 2 QL: 30 in 30 days

pioglitazone hcl/metformin hcl (Actoplus Met) 2 QL: 90 in 30 days

PRANDIMET 3 QL: 150 in 30 days

repaglinide (Prandin) 2 QL: 240 in 30 days

SYMLINPEN 120 4 PA, QL: 10.8 in 28 days

SYMLINPEN 60 4 PA, QL: 6 in 28 days

TRADJENTA 3 QL: 30 in 30 days

VICTOZA 3-PAK 4 PA, QL: 9 in 28 days

Insulins

HUMALOG MIX 50-50 insuln pen 3 QL: 30 in 28 days

HUMALOG MIX 50-50 vial 3 QL: 40 in 28 days

HUMALOG MIX 75-25 insuln pen 3 QL: 30 in 28 days

HUMALOG MIX 75-25 vial 3 QL: 40 in 28 days

HUMALOG insuln pen 3 QL: 30 in 28 days

HUMALOG vial 3 QL: 40 in 28 days

HUMULIN 70/30 KWIKPEN 3 QL: 30 in 28 days

HUMULIN 70-30 3 QL: 40 in 28 days

HUMULIN N KWIKPEN 3 QL: 30 in 28 days

HUMULIN N 3 QL: 40 in 28 days

HUMULIN R 3 QL: 40 in 28 days

LANTUS SOLOSTAR 3 QL: 30 in 28 days

LANTUS 3 QL: 40 in 28 days

NOVOLIN 70-30 cartridge 3 QL: 30 in 28 days

NOVOLIN 70-30 vial 3 QL: 40 in 28 days

NOVOLIN N cartridge 3 QL: 30 in 28 days

NOVOLIN N vial 3 QL: 40 in 28 days

NOVOLIN R cartridge 3 QL: 30 in 28 days

NOVOLIN R vial 3 QL: 40 in 28 days

NOVOLOG FLEXPEN 3 QL: 30 in 28 days

NOVOLOG MIX 70-30 FLEXPEN 3 QL: 30 in 28 days

NOVOLOG MIX 70-30 3 QL: 40 in 28 days

NOVOLOG 3 QL: 40 in 28 days

Sulfonylureas

glimepiride tablet: 1mg, 2mg (Amaryl) 1 QL: 30 in 30 days

glimepiride tablet: 4mg (Amaryl) 1 QL: 60 in 30 days

glipizide tab er 24: 2.5mg, 5mg (Glucotrol XL) 2 QL: 30 in 30 days

glipizide tab er 24: 10mg (Glucotrol XL) 2 QL: 60 in 30 days

glipizide tablet: 10mg (Glucotrol) 1 QL: 120 in 30 days

glipizide tablet: 5mg (Glucotrol) 1 QL: 60 in 30 days


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glipizide/metformin hcl tablet: 2.5-500mg,

5mg-500mg

(Metaglip) 2 QL: 120 in 30 days

glipizide/metformin hcl tablet: 2.5-250mg (Metaglip) 2 QL: 60 in 30 days

glyburide tablet: 5mg (Micronase) 2 PA-HRM, QL: 120 in 30

days

glyburide tablet: 2.5mg (Micronase) 2 PA-HRM, QL: 240 in 30

days

glyburide tablet: 1.25mg (Micronase) 2 PA-HRM, QL: 280 in 30

days

glyburide,micronized tablet: 6mg (Glynase) 2 PA-HRM, QL: 120 in 30

days

glyburide,micronized tablet: 3mg (Glynase) 2 PA-HRM, QL: 180 in 30

days

glyburide,micronized tablet: 1.5mg (Glynase) 2 PA-HRM, QL: 400 in 30

days

glyburide/metformin hcl tablet: 2.5-500mg,

5mg-500mg

(Glucovance) 2 PA-HRM, QL: 120 in 30

days

glyburide/metformin hcl tablet: 1.25-250mg (Glucovance) 2 PA-HRM, QL: 240 in 30

days

tolazamide tablet: 250mg (Tolazamide) 2 QL: 120 in 30 days

tolazamide tablet: 500mg (Tolazamide) 2 QL: 60 in 30 days

tolbutamide (Tolbutamide) 2 QL: 180 in 30 days

Antifungals Antifungals

ABELCET 5 PA BvD

AMBISOME 5 PA BvD

amphotericin b (Amphotericin B) 2 PA BvD

CANCIDAS 5

ciclopirox olamine (Loprox) 2

ciclopirox (Penlac) 2

clotrimazole (Mycelex) 2

clotrimazole/betamethasone dip (Lotrisone) 2

econazole nitrate (Spectazole) 2

fluconazole in nacl,iso-osm (Diflucan in Saline) 2

fluconazole (Diflucan) 2

flucytosine (Ancobon) 5

griseofulvin, microsize tablet (Grifulvin V) 2

itraconazole (Sporanox) 2

ketoconazole (Kuric) 2


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miconazole nitrate (Monistat 3) 2

NOXAFIL oral susp, tablet dr 5

nystatin (Nystatin) 2

nystatin/triamcin (Mycogen II) 2

terbinafine hcl (Lamisil) 2

voriconazole vial (Vfend IV) 2

voriconazole susp recon, tablet (Vfend) 5

Antihistamines Antihistamines

clemastine fumarate syrup, tablet: 2.68mg (Clemastine Fumarate) 2 PA-HRM

clemastine fumarate tablet: 1.34mg (Clemastine Fumarate) 2 PA-HRM

cyproheptadine hcl (Cyproheptadine HCl) 2 PA-HRM

diphenhydramine hcl vial (Benadryl) 2

diphenhydramine hcl syringe (Diphenhydramine

HCl)

2

levocetirizine dihydrochloride (Xyzal) 2

p-epd tan/chlor-tan (P-epd Tan/chlor-tan) 2

promethazine hcl (Promethazine HCl) 2 PA-HRM

Anti-infectives (Skin and Mucous Membrane) Anti-infectives (Skin and Mucous Membrane)

AVC 3

clindamycin phosphate (Cleocin) 2

metronidazole (Metrogel-vaginal) 2

sod propion/inositol/aa14/urea (Sod Propion/inositol/

aa14/urea)

2

terconazole (Terazol 3) 2

Antimigraine Agents Antimigraine Agents

dihydroergotamine mesylate ampul (D.H.E. 45) 2 QL: 30 in 28 days

dihydroergotamine mesylate spray/pump (Migranal) 2 QL: 4 in 28 days

ERGOMAR 4 QL: 40 in 28 days

naratriptan hcl (Amerge) 2 QL: 18 in 28 days

rizatriptan benzoate (Maxalt Mlt) 2 QL: 18 in 28 days

sumatriptan succinate tablet (Imitrex) 2 QL: 18 in 28 days

sumatriptan succinate cartridge (Imitrex) 2 QL: 4 in 28 days

sumatriptan succinate pen injctr, vial (Imitrex) 2 QL: 4 in 28 days

sumatriptan (Imitrex) 2 QL: 12 in 28 days

zolmitriptan (Zomig) 2 QL: 12 in 28 days


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Antimycobacterials Antimycobacterials

CAPASTAT SULFATE 4

dapsone (Dapsone) 2

ethambutol hcl (Myambutol) 2

isoniazid tablet (Isoniazid) 1

isoniazid solution (Isoniazid) 2

PASER 4

PRIFTIN 4

pyrazinamide (Pyrazinamide) 2

rifabutin (Mycobutin) 2

rifampin (Rifadin) 2

RIFATER 4

SIRTURO 5 PA, QL: 188 in 168 days

TRECATOR 4

Antinausea Agents Antinausea Agents

dimenhydrinate (Dimenhydrinate) 2

dronabinol (Marinol) 2

EMEND capsule: 40mg, 125mg 4 PA BvD, QL: 1 per fill

EMEND capsule: 80mg 4 PA BvD, QL: 2 per fill

EMEND cap ds pk 4 PA BvD, QL: 3 per fill

EMEND vial 4 QL: 2 in 28 days

granisetron hcl vial (Kytril) 2

granisetron hcl tablet (Kytril) 2 PA BvD

granisetron hcl/pf (Kytril) 2

meclizine hcl (Antivert) 2

ondansetron hcl (Zofran) 2 PA BvD

ondansetron hcl/pf (Zofran) 2

ondansetron (Zofran Odt) 2 PA BvD

prochlorperazine edisylate (Compazine) 2

prochlorperazine maleate tablet (Compazine) 1

prochlorperazine maleate supp.rect (Compazine) 2

promethazine hcl supp.rect, tablet (Promethazine HCl) 2 PA-HRM

TRANSDERM-SCOP 4 QL: 10 in 30 days

Antiparasite Agents Antiparasite Agents

ALBENZA 4


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ALINIA 4

atovaquone (Mepron) 5

atovaquone/proguanil hcl (Malarone) 2

BILTRICIDE 4

chloroquine phosphate (Aralen Phosphate) 2

COARTEM 4

DARAPRIM 4

hydroxychloroquine sulfate (Plaquenil) 2

mefloquine hcl (Lariam) 2

metronidazole (Flagyl) 2

metronidazole/sodium chloride (Metro IV) 2

NEBUPENT 4 PA BvD

paromomycin sulfate (Paromomycin Sulfate) 2

PENTAM 300 4

pentamidine isethionate (Pentam 300) 2

PRIMAQUINE 4 QL: 90 in 30 days

quinine sulfate (Qualaquin) 2 PA, QL: 42 in 7 days

STROMECTOL 3

Antiparkinsonian Agents Antiparkinsonian Agents

amantadine hcl (Amantadine HCl) 2

APOKYN 5 QL: 60 in 30 days

AZILECT 3

benztropine mesylate tablet (Benztropine Mesylate) 2 PA-HRM

bromocriptine mesylate (Parlodel) 2

cabergoline (Cabergoline) 2

carbidopa (Lodosyn) 2

carbidopa/levodopa tablet, tablet er (Sinemet 10-100) 2

carbidopa/levodopa/entacapone (Stalevo 50) 2

entacapone (Comtan) 2

NEUPRO 3 ST, QL: 30 in 30 days

pramipexole di-hcl (Mirapex) 2

ropinirole hcl (Requip) 2

selegiline hcl (Eldepryl) 2

trihexyphenidyl hcl (Trihexyphenidyl HCl) 2 PA-HRM

Antipsychotic Agents Antipsychotic Agents

ABILIFY DISCMELT tab rapdis: 15mg 3 QL: 60 in 30 days

ABILIFY DISCMELT tab rapdis: 10mg 3 QL: 90 in 30 days


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ABILIFY MAINTENA 5 QL: 1 in 28 days

ABILIFY vial 3 QL: 161.2 in 28 days

ABILIFY tablet: 5mg, 10mg, 15mg, 20mg,

30mg

3 QL: 30 in 30 days

ABILIFY tablet: 2mg 3 QL: 60 in 30 days

ABILIFY solution 3 QL: 900 in 30 days

chlorpromazine hcl ampul, tablet (Chlorpromazine HCl) 2

chlorpromazine hcl oral conc. (Chlorpromazine HCl) 2

clozapine tablet: 200mg (Clozaril) 2 QL: 135 in 30 days

clozapine tablet: 100mg (Clozaril) 2 QL: 270 in 30 days

clozapine tablet: 25mg, 50mg (Clozaril) 2 QL: 90 in 30 days

clozapine tab rapdis (Fazaclo) 2 ST, QL: 90 in 30 days

FANAPT tablet 4 ST, QL: 60 in 30 days

FANAPT tab ds pk 4 ST, QL: 8 in 28 days

FAZACLO tab rapdis: 200mg 4 ST, QL: 120 in 30 days

FAZACLO tab rapdis: 150mg 4 ST, QL: 180 in 30 days

fluphenazine decanoate (Fluphenazine

Decanoate)

2

fluphenazine hcl (Fluphenazine HCl) 2

GEODON vial 4 QL: 6 in 28 days

haloperidol decanoate (Haloperidol

Decanoate)

2

haloperidol lactate (Haloperidol Lactate) 2

haloperidol (Haloperidol) 2

INVEGA SUSTENNA syringe: 39mg/0.25 3 QL: 0.25 in 28 days

INVEGA SUSTENNA syringe: 78mg/

0.5ml

3 QL: 0.5 in 28 days

INVEGA SUSTENNA syringe: 117mg/

0.75

5 QL: 0.75 in 28 days

INVEGA SUSTENNA syringe: 156mg/ml 5 QL: 1 in 28 days

INVEGA SUSTENNA syringe: 234mg/1.5 5 QL: 1.5 in 28 days

INVEGA tab er 24: 1.5mg, 3mg, 9mg 4 ST, QL: 30 in 30 days

INVEGA tab er 24: 6mg 4 ST, QL: 60 in 30 days

LATUDA tablet: 20mg, 40mg, 60mg,

120mg

4 ST, QL: 30 in 30 days

LATUDA tablet: 80mg 4 ST, QL: 60 in 30 days

loxapine succinate (Loxitane) 2

olanzapine tab rapdis: 20mg (Zyprexa Zydis) 2 QL: 31 in 30 days


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olanzapine tab rapdis: 5mg, 10mg, 15mg;

tablet, vial

(Zyprexa) 2 QL: 30 in 30 days

ORAP 4

perphenazine (Perphenazine) 2

quetiapine fumarate (Seroquel) 2 QL: 90 in 30 days

RISPERDAL CONSTA 4 QL: 4 in 28 days

risperidone tab rapdis: 3mg, 4mg (Risperdal M-tab) 2 QL: 120 in 30 days

risperidone solution (Risperdal) 2 QL: 480 in 30 days

risperidone tab rapdis: 0.25mg, 0.5mg,

1mg, 2mg; tablet

(Risperdal) 2 QL: 60 in 30 days

SAPHRIS 4 ST, QL: 60 in 30 days

SEROQUEL XR tab er 24h: 200mg 4 ST, QL: 30 in 30 days

SEROQUEL XR tab er 24h: 50mg,

150mg, 300mg, 400mg

4 ST, QL: 60 in 30 days

thioridazine hcl oral conc. (Thioridazine HCl) 2 PA-HRM

thioridazine hcl tablet (Thioridazine HCl) 2 PA-HRM

thiothixene (Navane) 2

trifluoperazine hcl (Trifluoperazine HCl) 2

VERSACLOZ 5 ST, QL: 540 in 30 days

ziprasidone hcl (Geodon) 2 QL: 60 in 30 days

ZYPREXA RELPREVV 5 QL: 2 in 28 days

Antivirals (Systemic) Antiretrovirals

abacavir sulfate (Ziagen) 2

abacavir/lamivudine/zidovudine (Trizivir) 5

APTIVUS solution 4

APTIVUS capsule 5

ATRIPLA 5

COMPLERA 5

CRIXIVAN 4

didanosine (Videx EC) 2

EDURANT 5

EMTRIVA 3

EPIVIR HBV solution 4

EPIVIR solution 4

EPZICOM 5

FUZEON 5

INTELENCE tablet: 25mg 3

INTELENCE tablet: 100mg, 200mg 5


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INVIRASE 5

ISENTRESS powd pack, tab chew 3

ISENTRESS tablet 5

KALETRA tablet: 100mg-25mg 3

KALETRA solution, tablet: 200mg-50mg 5

lamivudine (Epivir) 2

lamivudine/zidovudine (Combivir) 5

LEXIVA oral susp 3

LEXIVA tablet 5

nevirapine (Viramune) 2

NORVIR 4

PREZISTA tablet: 75mg, 150mg 3

PREZISTA oral susp 4

PREZISTA tablet: 400mg 5

PREZISTA tablet: 600mg, 800mg 5

RESCRIPTOR 4

RETROVIR vial 3

REYATAZ 5

SELZENTRY 5

stavudine (Zerit) 2

STRIBILD 5

SUSTIVA capsule: 100mg 4

SUSTIVA capsule: 50mg, 200mg; tablet 4

TIVICAY 5

TRUVADA 5

VIDEX 3

VIRACEPT 4

VIRAMUNE XR tab er 24h: 100mg 3

VIREAD 5

ZIAGEN solution 4

zidovudine (Retrovir) 2

Antivirals, Miscellaneous

foscarnet sodium (Foscavir) 2 PA BvD

RELENZA 4

rimantadine hcl (Flumadine) 2

SYNAGIS 5

TAMIFLU capsule: 75mg 3 QL: 42 in 180 days


TAMIFLU susp recon 3 QL: 540 in 180 days


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27





Hcv Antivirals

OLYSIO 5 PA, QL: 28 in 28 days

SOVALDI 5 PA, QL: 28 in 28 days

Interferons

INTRON A pen ij kit, vial: 18mmunit,

50mmunit

4 PA NSO

INTRON A vial: 6mmunit/ml, 10mm/ml 4 PA NSO

PEGASYS PROCLICK 5 PA

PEGASYS 5 PA

PEGINTRON REDIPEN 5 PA

PEGINTRON 5 PA

SYLATRON 4-PACK 5 PA NSO, QL: 4 in 28

days

Nucleosides and Nucleotides

acyclovir sodium (Acyclovir Sodium) 2 PA BvD

acyclovir (Zovirax) 2

adefovir dipivoxil (Hepsera) 5

BARACLUDE tablet 5

famciclovir (Famvir) 2

ganciclovir sodium (Cytovene) 2 PA BvD

ribavirin capsule, tablet (Rebetol) 2

TYZEKA 5

valacyclovir hcl (Valtrex) 2

VALCYTE tablet 5

VIRAZOLE 5 PA BvD

Blood Products/modifiers/volume Expanders Anticoagulants

CEPROTIN 5

ELIQUIS 3

enoxaparin sodium syringe: 40mg/0.4ml (Lovenox) 2 QL: 13.6 in 30 days

enoxaparin sodium syringe: 30mg/0.3ml (Lovenox) 2 QL: 18 in 30 days



enoxaparin sodium vial (Lovenox) 2 QL: 36 in 30 days

enoxaparin sodium syringe: 120mg/.8ml (Lovenox) 5 QL: 27.2 in 30 days

enoxaparin sodium syringe: 150mg/ml (Lovenox) 5 QL: 34 in 30 days

enoxaparin sodium syringe: 100mg/ml (Lovenox) 5 QL: 36 in 30 days

fondaparinux sodium syringe: 5mg/0.4ml (Arixtra) 2 QL: 12 in 30 days


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fondaparinux sodium syringe: 2.5mg/0.5 (Arixtra) 2 QL: 15 in 30 days

fondaparinux sodium syringe: 7.5mg/0.6 (Arixtra) 2 QL: 18 in 30 days

fondaparinux sodium syringe: 10mg/0.8ml (Arixtra) 2 QL: 24 in 30 days

heparin sodium,porcine (Hep-lock) 2 PA BvD (PA for ESRD

Only)

heparin sodium,porcine/d5w (Heparin Sodium,

porcine/D5W)

2

heparin sodium,porcine/ns/pf (Heparin Sodium,

porcine/ns/PF)

2

heparin sodium,porcine/pf (Monoject Prefill

Advanced)

2 PA BvD (PA for ESRD

Only)

IPRIVASK 5 PA, QL: 24 in 28 days

PRADAXA 4 QL: 60 in 30 days

warfarin sodium (Coumadin) 1

XARELTO tablet: 10mg, 20mg 3 QL: 30 in 30 days

XARELTO tablet: 15mg 3 QL: 42 in 21 days

Blood Formation Modifiers

EPOGEN 3 PA, QL: 12 in 28 days

GRANIX 5

LEUKINE 5

MOZOBIL 5

NEULASTA 5

NEUMEGA 5

NEUPOGEN 5

PROCRIT vial: 2000/ml, 3000/ml, 4000/

ml, 20000/2ml

3 PA, QL: 12 in 28 days

PROCRIT vial: 20000/ml 5 PA, QL: 12 in 28 days

PROCRIT vial: 40000/ml 5 PA, QL: 6 in 28 days

PROMACTA 5 PA, QL: 30 in 30 days

Hematologic Agents, Miscellaneous

aminocaproic acid solution, tablet (Amicar) 2

anagrelide hcl (Agrylin) 2

protamine sulfate (Protamine Sulfate) 2 PA BvD (PA for ESRD

Only)

tranexamic acid tablet (Lysteda) 2 QL: 30 in 30 days

tranexamic acid vial (Tranexamic Acid) 2

Platelet-aggregation Inhibitors

AGGRENOX 4 QL: 60 in 30 days

BRILINTA 3


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29




cilostazol (Pletal) 2

clopidogrel bisulfate (Plavix) 2

EFFIENT 3 QL: 30 in 30 days

pentoxifylline (Trental) 2

Volume Expanders

ALBUKED-25 4

ALBUKED-5 4

ALBUMIN (HUMAN) 4

ALBUMINAR-25 4

ALBUMINAR-5 4

ALBURX 4

ALBUTEIN 4

BUMINATE 4

FLEXBUMIN 4

KEDBUMIN 4

PLASBUMIN-25 4

PLASBUMIN-5 4

STERILE DILUENT 4

Caloric Agents Caloric Agents

AMINO ACIDS 4 PA BvD

AMINOSYN II iv soln: 10% 4 PA BvD



AMINOSYN II iv soln: 8.5% 4 PA BvD

AMINOSYN II iv soln: 8.5% 4 PA BvD

AMINOSYN M 4 PA BvD

AMINOSYN with ELECTROLYTES 4 PA BvD

AMINOSYN iv soln: 10% 4 PA BvD

AMINOSYN iv soln: 3.5% 4 PA BvD

AMINOSYN iv soln: 7% 4 PA BvD



AMINOSYN-HBC 4 PA BvD

AMINOSYN-PF iv soln: 10% 4 PA BvD

AMINOSYN-PF iv soln: 7% 4 PA BvD

AMINOSYN-RF 4 PA BvD

CLINIMIX E iv soln: 2.75% 4 PA BvD



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30







CLINIMIX E iv soln: 5% 4 PA BvD




CLINIMIX iv soln: 2.75% 4 PA BvD





CLINIMIX iv soln: 5% 4 PA BvD



CLINISOL 4 PA BvD

cysteine hcl (Cysteine HCl) 2 PA BvD

dextrose 10 % and 0.2 % nacl dehp fr bg (Dextrose 10 % and 0.2

% NaCl)

2

dextrose 10 % and 0.2 % nacl iv soln (Dextrose 10 % and 0.2

% NaCl)

2

dextrose 10 % and 0.9 % nacl (Dextrose 10 % and 0.9

% NaCl)

2

dextrose 10 % in water (Dextrose 10 % in

Water)

2 PA BvD

dextrose 10%-0.5 normal saline (Dextrose 10%-0.5

Normal Saline)

2

dextrose 2.5 % in water (Dextrose 2.5 % in

Water)

2 PA BvD

dextrose 2.5% in half ringers (Dextrose 2.5% In Half

Ringers)

2

dextrose 2.5%-0.5normal saline (Dextrose 2.5%-0.5

Normal Saline)

2

dextrose 20%-water (Dextrose 20%-water) 2 PA BvD


Water)

2 PA BvD



% NaCl)

2


document

31





% NaCl)

2


Water)

2

dextrose 5 %-0.2 % nacl (Dextrose 5 %-0.2 %

NaCl)

2

dextrose 5 %-0.45 % nacl (Dextrose 5 %-0.45 %

NaCl)

2

dextrose 5% in ringers (Dextrose 5% In

Ringers)

2

dextrose 5%-lactated ringers (Dextrose 5%-Lactated

Ringers)

2


Water)

2 PA BvD


Water)

2 PA BvD


FREAMINE HBC 4 PA BvD

FREAMINE III 4 PA BvD

fructose 10% (Fructose 10%) 2 PA BvD

HEPATAMINE 4 PA BvD

HEPATASOL 4 PA BvD

INTRALIPID emulsion: 10% 4 PA BvD

INTRALIPID emulsion: 20%, 30% 4 PA BvD

LIPOSYN II 4 PA BvD

LIPOSYN III emulsion: 10%, 20% 4 PA BvD

LIPOSYN III emulsion: 30% 4 PA BvD

NEPHRAMINE 4 PA BvD

NOVAMINE 4 PA BvD

potassium chloride in lr-d5 (Potassium Chloride In

Lr-d5)

2

PREMASOL iv soln: 10% 4 PA BvD

PREMASOL iv soln: 6% 4 PA BvD

PROCALAMINE 4 PA BvD

PROSOL 4 PA BvD

QUICK MIX with LYTES 4 PA BvD

TRAVAMULSION 4 PA BvD

TRAVASOL W/DEXTROSE 4 PA BvD


document

32




TRAVASOL W/ELECTROLYTES iv

soln.: 5.5%

4 PA BvD

TRAVASOL W/ELECTROLYTES iv

soln.: 8.5%

4 PA BvD

TRAVASOL with DEXTROSE iv soln:

8.5%

4 PA BvD


8.5%

4 PA BvD


8.5%

4 PA BvD

TRAVASOL with ELECTROLYTES 4 PA BvD

TRAVASOL iv soln. 4 PA BvD

TRAVASOL iv soln: 10% 4 PA BvD

TRAVASOL iv soln: 5.5% 4 PA BvD

TRAVASOL iv soln: 8.5% 4 PA BvD

TRAVERT IN NORMAL SALINE 4 PA BvD

TRAVERT iv soln: 10% 4 PA BvD

TRAVERT iv soln: 5% 4 PA BvD

TROPHAMINE iv soln: 10% 4 PA BvD

TROPHAMINE iv soln: 6% 4 PA BvD

Cardiovascular Agents Alpha-adrenergic Agents

clonidine hcl (Catapres) 1

clonidine hcl/chlorthalidone (Clonidine HCl/

chlorthalidone)

2

clonidine patch tdwk: 0.1mg/24hr, 0.2mg/

24hr

(Catapres-tts 1) 2 QL: 4 in 28 days

clonidine patch tdwk: 0.3mg/24hr (Catapres-tts 1) 2 QL: 8 in 28 days

doxazosin mesylate (Cardura) 2

guanfacine hcl (Tenex) 2 PA-HRM

midodrine hcl (Proamatine) 2

phenylephrine hcl (Vazculep) 2

prazosin hcl (Minipress) 2

Angiotensin II Receptor Antagonists

BENICAR HCT 3 ST

BENICAR 3 ST

candesartan cilexetil (Atacand) 2

candesartan/hydrochlorothiazid (Atacand HCT) 2

DIOVAN 3 ST


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33




irbesartan (Avapro) 2

irbesartan/hydrochlorothiazide (Avalide) 2

losartan potassium (Cozaar) 1

losartan/hydrochlorothiazide (Hyzaar) 2

telmisartan (Micardis) 2

telmisartan/hydrochlorothiazid (Micardis HCT) 2

TRIBENZOR 3 ST

valsartan/hydrochlorothiazide (Diovan HCT) 2

Angiotensin-Converting Enzyme Inhibitors

benazepril hcl (Lotensin) 1

benazepril/hydrochlorothiazide (Lotensin HCT) 2

captopril (Capoten) 2

captopril/hydrochlorothiazide (Capozide) 2

enalapril maleate (Vasotec) 1

enalapril/hydrochlorothiazide (Vaseretic) 2

enalaprilat dihydrate (Enalaprilat Dihydrate) 2

fosinopril sodium (Monopril) 2

fosinopril/hydrochlorothiazide (Monopril HCT) 2

lisinopril (Zestril) 1

lisinopril/hydrochlorothiazide (Prinzide) 1

moexipril hcl (Univasc) 2

moexipril/hydrochlorothiazide (Uniretic) 2

perindopril erbumine (Aceon) 2

quinapril hcl (Accupril) 2

quinapril/hydrochlorothiazide (Accuretic) 2

ramipril (Altace) 2

trandolapril (Mavik) 2

Antiarrhythmic Agents

amiodarone hcl tablet (Cordarone) 2

disopyramide phosphate (Norpace) 2

flecainide acetate (Tambocor) 2

lidocaine hcl (Lidocaine HCl) 2

lidocaine hcl/d5w/pf iv soln: 2mg/ml, 8mg/

ml

(Lidocaine HCl/d5w/

PF)

2

lidocaine hcl/pf syringe (Lidocaine HCl/PF) 2

mexiletine hcl (Mexitil) 2

MULTAQ 3

procainamide hcl capsule, tablet sa (Procainamide HCl) 2

procainamide hcl vial (Procainamide HCl) 2


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34




PRONESTYL 4

propafenone hcl (Rythmol) 2

quinidine gluconate tablet er (Quinidine Gluconate) 2

quinidine sulfate (Quinidine Sulfate) 2

TIKOSYN 3

Beta-Adrenergic Blocking Agents

acebutolol hcl (Sectral) 2

atenolol (Tenormin) 1

atenolol/chlorthalidone (Tenoretic 50) 1

betaxolol hcl (Kerlone) 2

bisoprolol fumarate (Zebeta) 2

bisoprolol fumarate/hctz (Ziac) 2

BYSTOLIC 3

carvedilol (Coreg) 1

esmolol hcl (Brevibloc) 2 PA BvD

labetalol hcl (Trandate) 2

metoprolol succinate (Toprol XL) 2

metoprolol tartrate tablet (Lopressor) 1

metoprolol tartrate vial (Metoprolol Tartrate) 2

metoprolol/hydrochlorothiazide (Lopressor HCT) 2

nadolol (Corgard) 2

pindolol (Pindolol) 2

propranolol hcl (Propranolol HCl) 2

propranolol/hydrochlorothiazid (Propranolol/

hydrochlorothiazid)

2

sotalol hcl (Betapace) 2

timolol maleate (Timolol Maleate) 2

Calcium-channel Blocking Agents

diltiazem hcl tablet (Cardizem CD) 1

diltiazem hcl cap er 12h, cap er 24h, cap er

deg, capsule er, tab er 24h, vial, vial port

(Cardizem CD) 2

verapamil hcl tablet (Calan) 1

verapamil hcl cap24h pct, cap24h pel,

tablet er

(Calan) 2

verapamil hcl syringe (Verapamil HCl) 2

Cardiovascular Agents, Miscellaneous

DEMSER 4

digoxin syringe (Digoxin) 2 PA-HRM


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35




digoxin tablet (Lanoxin) 2 PA-HRM, QL: 30 in 30

days (High Risk Med

for Ages 65 and Older

and Dose is Greater

Than 125mcg Per Day)

DIGOXIN 3 PA-HRM, QL: 300 in 30

days (High Risk Med


and Dose is Greater


dobutamine hcl (Dobutamine HCl) 2 PA BvD

dobutamine hcl/d5w (Dobutamine HCl/

D5W)

2 PA BvD

dopamine hcl (Dopamine HCl) 2 PA BvD

dopamine hcl/d5w (Dopamine HCl/D5W) 2 PA BvD

dopamine hcl/dextrose 5%-water (Dopamine HCl/

dextrose 5%-water)

2 PA BvD

ephedrine sulfate (Ephedrine Sulfate) 2

epinephrine auto injct, syringe (Adrenaclick) 2

epinephrine ampul (Epinephrine) 2

EPIPEN 2-PAK 3

EPIPEN JR 2-PAK 3

ethanolamine oleate (Ethanolamine Oleate) 2

FIRAZYR 5

hydralazine hcl (Apresoline) 2

hydralazine/hydrochlorothiazid (Hydralazine/

hydrochlorothiazid)

2

LANOXIN tablet: 62.5mcg, 187.5mcg 4 PA-HRM, QL: 30 in 30

days (High Risk Med


and Dose is Greater


milrinone lactate (Milrinone Lactate) 5 PA BvD

milrinone lactate/d5w (Primacor in 5%

Dextrose)

5 PA BvD

norepinephrine bitartrate (Levophed Bitartrate) 2 PA BvD

papaverine hcl (Papaverine HCl) 2 PA

RANEXA 3


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36




Dihydropyridines

amlodipine besylate (Norvasc) 1

amlodipine besylate/benazepril (Lotrel) 2

AZOR 3 ST

CLEVIPREX 4

felodipine (Plendil) 2

isradipine (Dynacirc) 2

nicardipine hcl capsule (Nicardipine HCl) 2

nifedipine tab er 24, tablet er (Procardia XL) 2

Diuretics

amiloride hcl (Midamor) 2

amiloride/hydrochlorothiazide (Amiloride/

hydrochlorothiazide)

2

bumetanide (Bumex) 2

chlorothiazide sodium (Sodium Diuril) 2

chlorothiazide (Chlorothiazide) 1

chlorthalidone (Chlorthalidone) 1

DYRENIUM 4

furosemide solution, vial (Furosemide) 2

furosemide syringe (Furosemide) 2

furosemide tablet (Lasix) 1

hydrochlorothiazide (Microzide) 1

indapamide (Lozol) 1

methyclothiazide (Methyclothiazide) 2

metolazone (Zaroxolyn) 2

torsemide tablet (Demadex) 2

triamterene/hydrochlorothiazid (Maxzide) 2

Dyslipidemics

amlodipine/atorvastatin (Caduet) 2

atorvastatin calcium (Lipitor) 2

cholestyramine (with sugar) (Questran) 2

cholestyramine/aspartame (Questran Light) 2

colestipol hcl (Colestid) 2

CRESTOR 3

fenofibrate nanocrystallized (Tricor) 2

fenofibrate tablet (Lofibra) 2

fenofibrate,micronized (Antara) 2

fenofibric acid (choline) (Trilipix) 2

fenofibric acid (Fibricor) 2


document

37




gemfibrozil (Lopid) 2

lovastatin (Mevacor) 1

niacin tab er 24h, tablet: 500mg (Niaspan) 2

omega-3 acid ethyl esters (Lovaza) 2

pravastatin sodium (Pravachol) 1

simvastatin (Zocor) 1 QL: 30 in 30 days

VASCEPA 3

WELCHOL 3

ZETIA 4

Renin-Angiotensin-Aldosterone System Inhibitors

eplerenone (Inspra) 2

spironolact/hydrochlorothiazid (Aldactazide) 2

spironolactone (Aldactone) 2

Vasodilators

isosorbide dinitrate tablet, tablet er (Isordil) 2

isosorbide dinitrate tab subl (Isosorbide Dinitrate) 1

isosorbide mononitrate (Imdur) 2

minoxidil (Minoxidil) 2

NITRO-BID 3

nitroglycerin patch td24: 0.1mg/hr, 0.2mg/

hr, 0.6mg/hr

(Nitro-dur) 2 QL: 30 in 30 days

nitroglycerin patch td24: 0.4mg/hr (Nitro-dur) 2 QL: 60 in 30 days

nitroglycerin vial: 50mg/10ml (Nitroglycerin) 2

nitroglycerin vial: 5mg/ml (Nitroglycerin) 2

nitroglycerin/d5w (Nitroglycerin/D5W) 2

NITROSTAT 3

PROGLYCEM 4

Central Nervous System Agents Central Nervous System Agents

AMPYRA 5 PA, QL: 60 in 30 days

caffeine citrated (Cafcit) 2

caffeine/sodium benzoate (Caffeine/sodium

Benzoate)

2

clonidine hcl (Kapvay) 2

dexmethylphenidate hcl tablet (Focalin) 2 QL: 60 in 30 days

dextroamphetamine sulfate capsule er (Dexedrine) 2 QL: 120 in 30 days

dextroamphetamine sulfate tablet: 5mg,

10mg

(Dextrostat) 2 QL: 180 in 30 days


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38




dextroamphetamine/amphetamine cap er

24h: 5mg, 10mg, 15mg

(Adderall XR) 2 QL: 30 in 30 days

dextroamphetamine/amphetamine cap er

24h: 20mg, 25mg, 30mg; tablet

(Adderall) 2 QL: 60 in 30 days

flumazenil (Romazicon) 2

INTUNIV 4 QL: 30 in 30 days

lithium carbonate (Eskalith) 2

lithium citrate (Lithium Citrate) 2

methylphenidate hcl cpbp 30-70: 10mg,

20mg, 40mg, 50mg, 60mg; tab er 24:

18mg, 27mg, 54mg

(Concerta) 2 QL: 30 in 30 days

methylphenidate hcl cpbp 30-70: 30mg; tab

er 24: 36mg

(Concerta) 2 QL: 60 in 30 days

methylphenidate hcl solution (Methylin) 2 QL: 900 in 30 days

methylphenidate hcl tablet, tablet er (Ritalin) 2 QL: 90 in 30 days

NUEDEXTA 3 QL: 60 in 30 days

QUILLIVANT XR 3

riluzole (Rilutek) 2

SAVELLA 3 QL: 60 in 30 days

STRATTERA 3

XENAZINE 5 PA, QL: 112 in 28 days

Contraceptives Contraceptives

desog-e.estradiol/e.estradiol (Mircette) 2

desogestrel-ethinyl estradiol (Desogen) 2

ELLA 3

ethinyl estradiol/drospirenone (Yaz) 2

ethynodiol d-ethinyl estradiol (Demulen 1/50-28) 2

levonorgestrel (Plan B) 2

levonorgestrel-ethin estradiol tablet: 0.1-

0.02, 0.15-0.03, 6-5-10

(Nordette-28) 2

levonorgestrel-ethin estradiol tbdspk 3mo (Seasonale) 2 QL: 91 in 84 days

l-norgest-eth estr/ethin estra tbdspk 3mo:

100-20(84)

(Seasonique) 2 QL: 91 in 84 days

l-norgest-eth estr/ethin estra tbdspk 3mo:

150-30(84)

(Seasonique) 2 QL: 91 in 84 days

norelgestromin/ethin.estradiol (Ortho Evra) 2 QL: 3 in 28 days

noreth-ethinyl estradiol/iron (Femcon Fe) 2

norethindrone ac-eth estradiol (Loestrin) 2


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39




norethindrone (Nor-Q-D) 2

norethindrone-e.estradiol-iron (Loestrin Fe) 2

norethindrone-ethinyl estrad tablet: 0.4-

0.035, 0.5-0.035, 1mg-35mcg, 7-9-5,

7daysx3, 10-11

(Modicon) 2

norethindrone-mestranol (Ortho-novum) 2

norgestimate-ethinyl estradiol (Ortho-cyclen) 2

norgestrel-ethinyl estradiol (Ovral-21) 2

NUVARING 3 ST, QL: 1 in 28 days

Dental And Oral Agents Dental And Oral Agents

cevimeline hcl (Evoxac) 2

chlorhexidine gluconate (Peridex) 2

pilocarpine hcl (Salagen) 2

triamcinolone acetonide (Kenalog In Orabase) 2

Dermatological Agents Dermatological Agents, Other

8-MOP 4

acitretin (Soriatane) 5

acyclovir (Zovirax) 2 QL: 30 in 30 days

alcohol antiseptic pads (Alcohol Antiseptic

Pads)

1

aluminum chloride (Drysol) 2

ammonium lactate (Lac-hydrin) 2

ANACAINE 4

calcipotriene (Dovonex) 2

calcitriol (Vectical) 2

CONDYLOX gel (gram) 4

FLUOROPLEX 4

fluorouracil (Efudex) 2

imiquimod (Aldara) 2 PA NSO, QL: 24 in 30

days

isotretinoin capsule: 10mg, 20mg, 40mg (Accutane) 2

mafenide acetate (Sulfamylon) 2

methoxsalen, rapid (Oxsoralen-ultra) 5

PANRETIN 5

PICATO gel (ea): 0.05% 3 QL: 2 in 56 days

PICATO gel (ea): 0.015% 3 QL: 3 in 56 days

podofilox (Condylox) 2


document

40




podophyllum resin (Pododerm) 2

potassium hydroxide (Potassium Hydroxide) 2

SANTYL 4

silver nitrate applicator (Silver Nitrate

Applicator)

2

VALCHLOR 5

ZOVIRAX cream (g) 3 QL: 15 in 30 days

Dermatological Antibacterials

clindamycin phosphate gel (gram), lotion,

med. swab, solution

(Cleocin T) 2

erythromycin base/ethanol (A-T-S) 2

gentamicin sulfate (Gentamicin Sulfate) 2

metronidazole (Nydamax) 2

mupirocin calcium (Bactroban) 2

mupirocin (Centany) 2

neomy sulf/polymyxin b sulfate (Neosporin G.U.

Irrigant)

2

selenium sulfide suspension (Selenium Sulfide) 2

selenium sulfide shampoo (Selseb) 2

silver nitrate (Silver Nitrate) 2

silver sulfadiazine (Silvadene) 2

sulfacetamide sodium (Klaron) 2

Dermatological Anti-inflammatory Agents

alclometasone dipropionate (Aclovate) 2

betamethasone dipropionate (Del-beta) 2

betamethasone valerate (Betamethasone

Valerate)

2

betamethasone/propylene glyc (Diprolene AF) 2

clobetasol propionate (Temovate) 2

clocortolone pivalate (Cloderm) 2

CORDRAN oint. (g) 4

desonide cream (g), oint. (g) (Desowen) 2

desoximetasone (Topicort) 2

ELIDEL 3 PA (PA for Ages < 2)

fluocinonide cream (g): 0.05%; gel (gram),

oint. (g), solution

(Vanos) 2

fluticasone propionate cream (g), oint. (g) (Cutivate) 2

halobetasol propionate (Ultravate) 2

hydrocortisone acetate/aloe v (Nuzon) 2


document

41




hydrocortisone acetate/urea (Carmol HC) 2

hydrocortisone butyrate (Hydrocortisone

Butyrate)

2

hydrocortisone valerate (Hydrocortisone

Valerate)

2

hydrocortisone cream(gm) (Hydrocortisone) 2

hydrocortisone cream (g), cream/appl,

enema, lotion, oint. (g)

(Hytone) 2

mometasone furoate (Elocon) 2

prednicarbate (Dermatop) 2

PROTOPIC 4 PA (0.03%; PA for

Ages < 2)

PROTOPIC 4 PA (0.1%; PA for Ages

< 15)

triamcinolone acetonide cream (g), lotion,

oint. (g): 0.025%, 0.1%, 0.5%

(Triamcinolone

Acetonide)

2

triamcinolone acetonide oint. (g): 0.05% (Triderm) 2

Dermatological Retinoids

adapalene cream (g), gel (gram) (Differin) 2

TAZORAC cream (g) 4

tretinoin microspheres (Retin-a Micro) 2 PA

tretinoin cream (g): 0.025%, 0.05%, 0.1%;

gel (gram): 0.01%, 0.025%

(Retin-A) 2 PA

Scabicides and Pediculicides

malathion (Ovide) 2

permethrin (Elimite) 2

Devices Devices

needles, insulin disposable (Needles, Insulin

Disposable)

2

syring w-ndl,disp,insul,0.3ml (Syring W-

ndl,disp,insul,0.3ml)

2

syring w-ndl,disp,insul,0.5ml (Syring W-

ndl,disp,insul,0.5ml)

2

syringe & needle,insulin,1 ml (Syringe &

Needle,insulin,1 Ml)

2

Enzyme Replacement/modifiers Enzyme Replacement/modifiers

ADAGEN 5


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42




ALDURAZYME 5

CEREZYME 5

CIMZIA 5 PA

CREON 3

ELAPRASE 5

ELITEK 5

FABRAZYME 5

KRYSTEXXA 5

KUVAN 5

LINZESS 3 QL: 30 in 30 days

lipase/protease/amylase (Zenpep) 2

LOTRONEX 5

LUMIZYME 5

MYOZYME 5

NAGLAZYME 5

ORFADIN 5

PULMOZYME 5 PA BvD

VIMIZIM 5 PA

VPRIV 5

ZAVESCA 5 QL: 90 in 30 days

ZENPEP 3

Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous

AKTEN 4

apraclonidine hcl (Iopidine) 2

atropine sulfate (Isopto Atropine) 2

azelastine hcl spray/pump (Astelin) 2 QL: 30 in 25 days

azelastine hcl drops (Optivar) 2

carteolol hcl (Carteolol HCl) 2

cromolyn sodium (Cromolyn Sodium) 2

CYCLOGYL drops: 0.5% 3

cyclopentolate hcl (Cyclogyl) 2

CYSTARAN 5

epinastine hcl (Elestat) 2

homatropine hbr (Isopto Homatropine) 2

ipratropium bromide spray: 42mcg (Atrovent) 2 QL: 15 in 10 days

ipratropium bromide spray: 21mcg (Atrovent) 2 QL: 30 in 28 days

LACRISERT 3


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43




naphazoline hcl/antazoline (Naphazoline HCl/

antazoline)

2

PATADAY 3 ST

PATANOL 3 ST

phenylephrine hcl (Mydfrin) 2

proparacaine hcl (Ophthetic) 2

proparacaine/fluorescein sod (Proparacaine/

fluorescein Sod)

2

tetracaine hcl (Tetcaine) 2

Eye, Ear, Nose, Throat Anti-infectives Agents

acetic acid (Vosol) 2

bacitracin (Bacitracin) 2

bacitracin/polymyxin b sulfate (Polycin-b) 2

CIPRODEX 4

ciprofloxacin hcl droperette (Cetraxal) 2

ciprofloxacin hcl drops (Ciloxan) 2

COLY-MYCIN S 4

erythromycin base (Ilotycin) 2

gatifloxacin (Zymaxid) 2

gentamicin sulfate (Garamycin) 2

levofloxacin (Quixin) 2

MOXEZA 3

NATACYN 3

neo/polymyx b sulf/dexameth (Maxitrol) 2

neomy sulf/bacitra/polymyxin b (Neo-polycin) 2

neomy sulf/bacitrac zn/poly/hc (Triple Antibiotic HC) 2

neomycin sulfate/dex na ph (Neomycin Sulfate/dex

Na Ph)

2

neomycin/polymyxin b sulf/hc (Oticin HC) 2

neomycin/polymyxn b/gramicidin (Neosporin) 2

ofloxacin (Floxin) 2

polymyxin b sulf/trimethoprim (Polytrim) 2

sulfacetamide sodium (Sulfac) 2

sulfacetamide/prednisolone sp (Sulfacetamide/

prednisolone Sp)

2

TOBRADEX ST 3

tobramycin sulfate (Tobramycin Sulfate) 2

trifluridine (Viroptic) 2

VIGAMOX 3


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44




ZYLET 3

Eye, Ear, Nose, Throat Anti-inflammatory Agents

ALREX 3

bromfenac sodium (Bromfenac Sodium) 2

dexamethasone sod phosphate (Ak-dex) 2

diclofenac sodium (Voltaren) 2

DUREZOL 3

fluorometholone (FML) 2

flurbiprofen sodium (Ocufen) 2

fluticasone propionate (Flonase) 2 QL: 16 in 30 days

ILEVRO 3

ketorolac tromethamine (Acular) 2

LOTEMAX 3

NASONEX 4 QL: 34 in 28 days

NEVANAC 3

prednisolone sod phosphate (Prednisol) 2

PROLENSA 3

RESTASIS 3 QL: 60 in 30 days

Gastrointestinal Agents Antiulcer Agents And Acid Suppressants

CARAFATE oral susp 3

cimetidine hcl (Cimetidine HCl) 2

cimetidine (Tagamet) 2 (Rx Product Only)

esomeprazole sodium (Nexium I.v.) 2

famotidine in nacl,iso-osm/pf (Famotidine In

Nacl,iso-osm/PF)

2

famotidine tablet (Pepcid) 1 (Rx Product Only)

famotidine tablet (Pepcid) 1

famotidine/pf (Famotidine/PF) 2

lansoprazole (Prevacid) 2 (Rx Product Only)

lansoprazole/amoxiciln/clarith (Prevpac) 2

misoprostol (Cytotec) 2

omeprazole (Prilosec) 2

pantoprazole sodium (Protonix) 2

ranitidine hcl tablet (Zantac) 1 (Rx Product Only)

ranitidine hcl syrup, vial (Zantac) 2 (Rx Product Only)

ranitidine hcl syrup, vial (Zantac) 2

sucralfate tablet (Carafate) 2

sucralfate oral susp (Sucralfate) 2


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45




Gastrointestinal Agents, Other

AMITIZA 3 QL: 60 in 30 days

BUPHENYL tablet 5

cromolyn sodium (Gastrocrom) 5

dicyclomine hcl (Bentyl) 2

diphenoxylate hcl/atropine (Lomotil) 2

glycopyrrolate (Robinul) 2

isopropamide/prochlorperazine (Isopropamide/

prochlorperazine)

2

lactulose solution: 10; syrup (Lactulose) 2

lactulose solution: 10g/15ml (Lactulose) 2

loperamide hcl (Loperamide HCl) 2

methscopolamine bromide (Pamine) 2

metoclopramide hcl solution, vial (Metoclopramide HCl) 2

metoclopramide hcl syringe (Metoclopramide HCl) 2

metoclopramide hcl tablet (Reglan) 1

NUTRESTORE 4

RELISTOR syringe: 12mg/0.6ml 4 PA, QL: 28 in 28 days

RELISTOR syringe: 8mg/0.4ml 4 PA, QL: 28 in 28 days

ursodiol (Actigall) 2

Laxatives

MOVIPREP 3

peg 3350/na sulf,bicarb,cl/kcl (Golytely) 2

polyethylene glycol 3350 (Miralax) 2

sodium chloride/nahco3/kcl/peg (Nulytely with Flavor

Packs)

2

Phosphate Binders

calcium acetate (Phoslo) 2

calcium carbonate/mag carb/fa (Calcium Carbonate/

mag Carb/fa)

2

PHOSLYRA 4

RENAGEL 3

RENVELA 3

sodium polystyrene sulfonate oral susp (Sodium Polystyrene

Sulfonate)

2

sodium polystyrene sulfonate enema (Sps) 2

Genitourinary Agents Antispasmodics, Urinary

oxybutynin chloride tab er 24, tablet (Ditropan) 2


document

46




tolterodine tartrate (Detrol LA) 2

TOVIAZ 3

trospium chloride (Sanctura) 2

Genitourinary Agents, Miscellaneous

alfuzosin hcl (Uroxatral) 2

tamsulosin hcl (Flomax) 2

terazosin hcl (Hytrin) 1

Heavy Metal Antagonists Heavy Metal Antagonists

deferoxamine mesylate (Desferal) 2 PA BvD

DEPEN 4

edetate disodium (Edetate Disodium) 2

EXJADE tab disper: 125mg 4

EXJADE tab disper: 250mg, 500mg 5

FERRIPROX 5

sodium thiosulfate (Sodium Thiosulfate) 2

SYPRINE 5

Hormonal Agents, Stimulant/replacement/modifying Androgens

ANDRODERM 3 PA, QL: 30 in 30 days

ANDROGEL gel md pmp: 20.25/1.25 3 PA, QL: 150 in 30 days

ANDROGEL gel md pmp: 1.25g(1%) 3 PA, QL: 300 in 30 days

danazol (Danocrine) 2

fluoxymesterone (Fluoxymesterone) 2

oxandrolone (Oxandrin) 2

testosterone cypionate (Depo-testosterone) 2 PA

testosterone enanthate (Delatestryl) 2 PA, QL: 5 in 28 days

Estrogens and Antiestrogens

COMBIPATCH 3 PA-HRM, QL: 8 in 28

days

DUAVEE 3 PA-HRM

ESTRACE cream/appl 3

estradiol valerate vial: 10mg/ml (Delestrogen) 2

estradiol valerate vial: 20mg/ml, 40mg/ml (Delestrogen) 2

estradiol patch tdwk (Climara) 2 PA-HRM, QL: 4 in 28

days

estradiol tablet (Estrace) 2 PA-HRM

estradiol/norethindrone acet (Activella) 2 PA-HRM


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47




ESTRASORB 4 PA-HRM, QL: 97.44 in

28 days

estropipate (Ogen) 2 PA-HRM

FEMRING 4 QL: 1 in 84 days

MENEST 4 PA-HRM

norethindrone ac-eth estradiol (Femhrt) 2 PA-HRM

PREMARIN cream/appl, vial 3

PREMARIN tablet 3 PA-HRM

PREMPHASE 3 PA-HRM

PREMPRO 3 PA-HRM

raloxifene hcl (Evista) 2

VAGIFEM 3 QL: 18 in 28 days

VIVELLE-DOT 3 PA-HRM, QL: 8 in 28

days

Glucocorticoids/mineralocorticoids

A-HYDROCORT 4 PA BvD

betamet acet/betamet na ph (Celestone) 2 PA BvD

cortisone acetate (Cortisone Acetate) 2 PA BvD

dexamethasone acetate (Dexamethasone

Acetate)

2 PA BvD

dexamethasone sod phosphate (Dexamethasone Sod

Phosphate)

2 PA BvD

dexamethasone tablet (Dexamethasone) 1 PA BvD

dexamethasone elixir (Dexamethasone) 2 PA BvD

fludrocortisone acetate (Fludrocortisone

Acetate)

2

hydrocortisone sod succinate (Hydrocortisone Sod

Succinate)

2 PA BvD

hydrocortisone (Cortef) 2 PA BvD

methylprednisolone acetate (Depo-medrol) 2 PA BvD

methylprednisolone sod succ vial: 40mg,

125mg

(A-methapred) 2 PA BvD

methylprednisolone sod succ vial: 500mg,

1000mg

(A-methapred) 2 PA BvD

methylprednisolone (Medrol) 2 PA BvD

prednisolone acetate (Prednisolone Acetate) 2 PA BvD

prednisolone sod phosphate (Orapred) 2 PA BvD

prednisone tablet (Prednisone) 1 PA BvD

prednisone solution (Prednisone) 2 PA BvD


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48




prednisone tab ds pk (Sterapred Ds) 2 PA BvD

SOLU-CORTEF vial: 100mg/2ml 4 PA BvD

triamcinolone acetonide (Triamcinolone

Acetonide)

2

Pituitary

desmopressin acetate tablet, vial (DDAVP) 2

desmopressin acetate solution (Desmopressin Acetate) 2 QL: 15 in 30 days

desmopressin acetate spray/pump (Desmopressin Acetate) 2 QL: 15 in 30 days

GENOTROPIN syringe: 0.2mg/0.25 4 PA

GENOTROPIN various dosage and/or

strengths are available

5 PA

HUMATROPE 5 PA

INCRELEX 5

NORDITROPIN FLEXPRO 5 PA

NORDITROPIN NORDIFLEX 5 PA

NUTROPIN AQ NUSPIN 5 PA

NUTROPIN 5 PA

octreotide acetate syringe, vial: 100mcg/

ml, 200mcg/ml

(Sandostatin) 2

octreotide acetate vial: 1000mcg/ml (Sandostatin) 5

OMNITROPE cartridge: 10mg/1.5ml 4 PA

OMNITROPE cartridge: 5mg/1.5ml; vial 5 PA

PREGNYL 4

SAIZEN cartridge, vial: 5mg 5 PA

SAIZEN vial: 8.8mg 5 PA

SANDOSTATIN LAR 5

SEROSTIM 5 PA

SOMATULINE DEPOT 5 QL: 1 in 28 days

SOMAVERT 5

SUPPRELIN LA 5 QL: 1 in 360 days

TEV-TROPIN 4 PA

vasopressin (Pitressin) 2

Progestins

DEPO-PROVERA vial: 400mg/ml 4 QL: 10 in 28 days

medroxyprogesterone acet (Medroxyprogesterone

Acet)

2

medroxyprogesterone acetate syringe (Depo-provera) 2 QL: 1 in 84 days

medroxyprogesterone acetate vial (Depo-provera) 2 QL: 1 in 84 days

medroxyprogesterone acetate tablet (Provera) 2


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49




norethindrone acetate (Aygestin) 2

progesterone (Progesterone) 2

progesterone,micronized (Prometrium) 2

Thyroid and Antithyroid Agents

levothyroxine sodium vial: 100mcg (Levothyroxine

Sodium)

2

levothyroxine sodium vial: 200mcg (Levothyroxine

Sodium)

2

levothyroxine sodium tablet (Levoxyl) 1

liothyronine sodium tablet (Cytomel) 2

methimazole tablet: 20mg (Tapazole) 2

methimazole tablet: 5mg, 10mg (Tapazole) 2

propylthiouracil (Propylthiouracil) 2

Immunological Agents Immunological Agents

ARCALYST 5

ASTAGRAF XL 4 PA BvD

AUBAGIO 5 PA, QL: 28 in 28 days

azathioprine sodium (Azathioprine Sodium) 2 PA BvD

azathioprine (Imuran) 2 PA BvD

CARIMUNE NF NANOFILTERED 5 PA BvD

CELLCEPT vial 4 PA BvD

CELLCEPT susp recon 5 PA BvD

cyclosporine (Sandimmune) 2 PA BvD

cyclosporine, modified (Neoral) 2 PA BvD

ENBREL pen injctr 5 PA, QL: 3.92 in 28 days

ENBREL vial 5 PA, QL: 8 in 28 days

ENBREL syringe 5 PA, QL: 8.16 in 28 days

FLEBOGAMMA DIF 5 PA BvD

GAMASTAN S-D 3 PA BvD

GAMMAGARD LIQUID 5 PA BvD

GAMMAPLEX 5 PA BvD

GAMUNEX-C 5 PA BvD

HUMIRA kit 5 PA, QL: 2 in 28 days

HUMIRA pen ij kit: 40mg/0.8ml 5 PA, QL: 6 in 28 days

(Starter Kit)

HUMIRA pen ij kit: 40mg/0.8ml 5 PA

HYPERRAB S-D 4

ILARIS 5 PA


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50




IMOGAM RABIES-HT 4

KINERET 5 PA, QL: 18.76 in 28

days

leflunomide (Arava) 2

mycophenolate mofetil (Cellcept) 2 PA BvD

mycophenolate sodium (Myfortic) 2 PA BvD

NULOJIX 5 PA BvD

OCTAGAM 5 PA BvD

ORENCIA syringe 5 PA, QL: 4 in 28 days

ORENCIA vial 5 PA

PRIVIGEN 5 PA BvD

PROGRAF ampul 4 PA BvD

RAPAMUNE solution, tablet: 1mg, 2mg 5 PA BvD

RIDAURA 5

sirolimus (Rapamune) 2 PA BvD

tacrolimus (Hecoria) 2 PA BvD

TYSABRI 5 LA, PA, QL: 15 in 28

days

ZORTRESS tablet: 0.25mg 4 PA BvD, QL: 120 in 30

days

ZORTRESS tablet: 0.5mg, 0.75mg 5 PA BvD, QL: 120 in 30

days

Vaccines

ACTHIB 3

ADACEL TDAP syringe 3

ADACEL TDAP vial 3

BCG VACCINE (TICE STRAIN) 3 PA BvD

BOOSTRIX TDAP 3

CERVARIX 3

COMVAX 3

DAPTACEL DTAP 3

DIPHTHERIA-TETANUS TOXOIDS-

PED

3

ENGERIX-B ADULT 3 PA BvD

ENGERIX-B PEDIATRIC-

ADOLESCENT

3 PA BvD

GARDASIL syringe 3

GARDASIL vial 3

HAVRIX syringe: 1440/ml 3 PA BvD


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51




HAVRIX syringe: 720/0.5ml 3 PA BvD

HAVRIX vial 3 PA BvD

IMOVAX RABIES VACCINE 3 PA BvD

INFANRIX DTAP 3

IPOL 3

IXIARO 3

KINRIX 3

MENACTRA 3

MENHIBRIX 3

MENOMUNE-A-C-Y-W-135 3

MENVEO A-C-Y-W-135-DIP 3

M-M-R II VACCINE 3

PEDIARIX 3

PEDVAXHIB 3

PENTACEL ACTHIB COMPONENT 3

PENTACEL DTAP-IPV COMPONENT 3

PENTACEL 3

PROQUAD 3

RABAVERT 3 PA BvD

RECOMBIVAX HB syringe, vial: 5mcg/

0.5ml

3 PA BvD

RECOMBIVAX HB vial: 10mcg/ml,

40mcg/ml

3 PA BvD

ROTARIX 3

ROTATEQ 3

TE ANATOXAL BERNA 3 PA BvD

TENIVAC 3

TETANUS DIPHTHERIA TOXOIDS 3

TETANUS TOXOID ADSORBED 3 PA BvD

TWINRIX syringe 3

TWINRIX vial 3

TYPHIM VI 3

VAQTA syringe, vial: 25/0.5ml 3 PA BvD

VAQTA vial: 50unit/ml 3 PA BvD

VARIVAX VACCINE 3

YF-VAX 3

ZOSTAVAX 3 QL: 1 in 365 days


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Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents

APRISO 3

ASACOL HD 3 ST

balsalazide disodium (Colazal) 2

budesonide (Entocort EC) 5

DELZICOL 3 ST

DIPENTUM 4 ST

Irrigating Solutions Irrigating Solutions

acetic acid (Acetic Acid) 2

glycine (Glycine) 2

LACTATED RINGERS 3

mannitol/sorbitol solution (Mannitol/sorbitol

Solution)

2

ringers solution (Tis-u-sol) 2

sodium chloride irrig solution (Sodium Chloride Irrig

Solution)

2

sorbitol solution (Sorbitol Solution) 2

UROLOGIC SOLUTION G 3

water for irrigation,sterile (Water for Irrigation,

Sterile)

2

Metabolic Bone Disease Agents Metabolic Bone Disease Agents

alendronate sodium tablet: 5mg, 10mg,

40mg

(Fosamax) 1

alendronate sodium tablet: 35mg, 70mg (Fosamax) 1 QL: 4 in 28 days

alendronate sodium solution (Fosamax) 2 QL: 300 in 28 days

calcitonin,salmon,synthetic (Miacalcin) 2 QL: 3.7 in 28 days

calcitriol (Rocaltrol) 2 PA BvD (PA for ESRD

Only)

doxercalciferol (Hectorol) 2 PA BvD (PA for ESRD

Only)

etidronate disodium (Didronel) 2

FORTEO 4 PA, QL: 2.4 in 28 days

FORTICAL 4 QL: 3.7 in 28 days

ibandronate sodium tablet (Boniva) 2 QL: 1 in 28 days


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53




ibandronate sodium vial (Ibandronate Sodium) 2 PA BvD, QL: 3 in 84

days (PA for ESRD

Only)

MIACALCIN vial 3 PA BvD (PA for ESRD

Only)

paricalcitol (Zemplar) 2 PA BvD (PA for ESRD

Only)

PROLIA 3 QL: 1 in 180 days

risedronate sodium (Actonel) 2 QL: 1 in 28 days

XGEVA 5 PA, QL: 1.7 in 28 days

ZEMPLAR vial 3 PA BvD (PA for ESRD

Only)

zoledronic acid (Zometa) 2

zoledronic acid/mannitol&water infus. btl (Reclast) 2 QL: 100 in 300 days

zoledronic acid/mannitol&water piggyback (Zoledronic Acid/

mannitol&water)

2

ZOMETA infus. btl 5

Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents

ACTEMRA syringe 5 PA, QL: 3.6 in 28 days

ACTEMRA vial 5 PA, QL: 40 in 30 days

ACTIMMUNE 5

allopurinol (Zyloprim) 1

amifostine crystalline (Ethyol) 2

AVODART 3

AVONEX ADMINISTRATION PACK 5 ST

AVONEX 5 ST

BENLYSTA 5 PA

BETASERON 5 ST

bethanechol chloride (Urecholine) 2

BOTOX vial: 200unit 4 PA, QL: 1 in 90 days

BOTOX vial: 100unit 4 PA, QL: 4 in 90 days

buspirone hcl (Buspar) 2

citrate phosphate dextros soln (Citrate Phosphate

Dextros Soln)

2

colchicine/probenecid (Colchicine/

probenecid)

2

COLCRYS 3

COPAXONE 5


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54




CYSTADANE 5

droperidol (Inapsine) 2

ELMIRON 4

ergoloid mesylates tablet (Ergoloid Mesylates) 2

EXTAVIA 5 ST

finasteride (Proscar) 2

fomepizole (Antizol) 5

FUSILEV 5

gauze bandage (Dermacea) 1

GILENYA 5 PA, QL: 28 in 28 days

GLUCAGEN 3

GLUCAGON EMERGENCY KIT 4

glutethimide (Glutethimide) 2

guanidine hcl (Guanidine HCl) 2

hydroxyzine hcl (Hydroxyzine HCl) 2 PA-HRM

hydroxyzine pamoate (Vistaril) 2 PA-HRM

JALYN 3 QL: 30 in 30 days

leucovorin calcium (Leucovorin Calcium) 2

levocarnitine (with sugar) (Carnitor) 2 PA BvD (PA for ESRD

Only)

levocarnitine tablet (Carnitor) 2 PA BvD (PA for ESRD

Only)

mesna (Mesnex) 2

MESNEX tablet 5

MESTINON syrup, tablet er 4

OTEZLA 5 PA, QL: 60 in 30 days

probenecid (Probenecid) 2

PROCYSBI 5

pyridostigmine bromide (Mestinon) 2

REBIF REBIDOSE 5

REBIF 5

REMICADE 5 PA

SENSIPAR tablet: 30mg 3

SENSIPAR tablet: 60mg, 90mg 5

SIMPONI ARIA 5 PA, QL: 12 in 28 days

SIMPONI pen injctr: 50mg/0.5ml 5 PA, QL: 0.5 in 28 days

SIMPONI pen injctr: 100mg/ml 5 PA, QL: 1 in 28 days

sodium morrhuate (Sodium Morrhuate) 2

SOLIRIS 5


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STELARA syringe: 45mg/0.5ml 5 PA, QL: 10 in 360 days

STELARA syringe: 90mg/ml 5 PA, QL: 5 in 360 days

SYNAREL 5

TECFIDERA capsule dr: 120mg 5 PA, QL: 14 in 30 days

TECFIDERA capsule dr: 120-240mg,

240mg

5 PA, QL: 60 in 30 days

THALOMID 5 PA NSO, QL: 60 in 30

days

ULORIC 3 ST, QL: 30 in 30 days

XELJANZ 5 PA, QL: 60 in 30 days

Ophthalmic Agents Antiglaucoma Agents

acetazolamide sodium (Acetazolamide

Sodium)

2

acetazolamide (Acetazolamide) 2

ALPHAGAN P drops: 0.1% 3

AZOPT 3

betaxolol hcl (Betaxolol HCl) 2

brimonidine tartrate (Alphagan P) 2 (drops: 0.15%, 0.20%)

COMBIGAN 3

dorzolamide hcl (Trusopt) 2

dorzolamide hcl/timolol maleat (Cosopt) 2

ISOPTO CARPINE drops: 8% 3

latanoprost (Xalatan) 2

levobunolol hcl drops: 0.25% (Betagan) 2

levobunolol hcl drops: 0.5% (Betagan) 2

LUMIGAN 3 QL: 2.5 in 25 days

methazolamide (Neptazane) 2

metipranolol (Optipranolol) 2

PHOSPHOLINE IODIDE 3

pilocarpine hcl (Isopto Carpine) 2

SIMBRINZA 3

timolol maleate (Timoptic) 2

TRAVATAN Z 3 QL: 2.5 in 25 days

travoprost (benzalkonium) (Travatan) 2 QL: 2.5 in 25 days

Replacement Preparations Replacement Preparations

0.9 % sodium chloride (0.9 % Sodium

Chloride)

2


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56




calcium chloride (Calcium Chloride) 2

calcium gluconate (Calcium Gluconate) 2 PA BvD (PA for ESRD

Only)

citric acid/sodium citrate (Bicitra) 2

dex 2.5%-half str lact.ringers (Dex 2.5%-half Str

Lact.ringers)

2

DEXTROSE W/ELECTROLYTE A 4

DEXTROSE W/ELECTROLYTE B 4

electrolyte-48 solution/d5w (Electrolyte-48

Solution/D5W)

2

electrolyte-48/fructose 10% (Electrolyte-48/fructose

10%)

2


5%)

2

electrolyte-75 solution/d5w (Electrolyte-75

Solution/D5W)

2


5%)

2

HYPERLYTE CR 4

HYPERLYTE R 4

IONOSOL B with DEXTROSE 5% 4

IONOSOL MB-DEXTROSE 5% 4

IONOSOL T-DEXTROSE 5% 4

ISOLYTE E 4

ISOLYTE H W/DEXTROSE 4

ISOLYTE M W/DEXTROSE 4

ISOLYTE P with DEXTROSE 4

ISOLYTE S with DEXTROSE 4

ISOLYTE S 4

magnesium chloride (Magnesium Chloride) 2

magnesium sulfate piggyback, vial (Magnesium Sulfate) 2

magnesium sulfate syringe (Magnesium Sulfate) 2

magnesium sulfate/d5w (Magnesium Sulfate/

D5W)

2

NORMOSOL-M and DEXTROSE 4

NORMOSOL-R PH 7.4 4

NUTRILYTE II 4

NUTRILYTE 4

phosphorus #1 (K-phos Neutral) 2


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PLASMA-LYTE 148 4

PLASMA-LYTE 56 IN DEXTROSE 4

PLASMA-LYTE A PH 7.4 4

PLASMA-LYTE M IN DEXTROSE 4

pot chloride/pot bicarb/cit ac (Pot Chloride/pot

Bicarb/cit Ac)

2

potassium acetate (Potassium Acetate) 2

potassium bicarbonate/cit ac (Potassium

Bicarbonate/cit Ac)

2

potassium chlorid/d10-0.2%nacl (Potassium Chlorid/

d10-0.2%NaCl)

2

potassium chloride in 0.9%nacl (Potassium Chloride In

0.9%NaCl)

2

potassium chloride in d5w iv soln: 10meq/l,

30meq/l

(Potassium Chloride In

D5w)

2

potassium chloride in d5w iv soln: 20meq/l,

40meq/l

(Potassium Chloride In

D5w)

2

potassium chloride liquid, packet,

piggyback: 30meq/0.1l; tablet sa

(Kaochlor) 2

potassium chloride capsule er, piggyback:

10meq/0.1l, 10meq/50ml, 20meq/50ml; tab

er prt, tablet er, vial

(K-dur) 2

potassium chloride/d5-0.2%nacl iv soln:

10meq/l, 30meq/l, 40meq/l

(Potassium Chloride/

d5-0.2%NaCl)

2

potassium chloride/d5-0.2%nacl iv soln:

20meq/l

(Potassium Chloride/

d5-0.2%NaCl)

2

potassium chloride/d5-0.25ns (Potassium Chloride/

D5-0.25 NS)

2

potassium chloride/d5-0.3%nacl (Potassium Chloride/

d5-0.3%NaCl)

2

potassium chloride/d5-0.45nacl (Potassium Chloride/

d5-0.45NaCl)

2

potassium chloride/d5-0.9%nacl (Potassium Chloride/

d5-0.9%NaCl)

2

potassium chloride-0.45% nacl (Potassium Chloride-

0.45% NaCl)

2

potassium citrate/citric acid (Polycitra-k) 2

potassium gluconate (Potassium Gluconate) 2

potassium phos,m-basic-d-basic (Potassium Phos,m-

basic-d-basic)

2


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58




ringers solution (Ringers Solution) 2

sod/pot/k cit/sod cit/cit acid (Polycitra-lc) 2

sodium acetate (Sodium Acetate) 2

sodium bicarbonate (Sodium Bicarbonate) 2

sodium chloride 0.45 % (Sodium Chloride 0.45

%)

2

sodium chloride 3% (Sodium Chloride 3%) 2

sodium chloride 5 % (Sodium Chloride 5 %) 2

sodium chloride vial: 2.5meq/ml (Sodium Chloride) 2

sodium chloride vial: 4meq/ml (Sodium Chloride) 2

sodium lactate iv soln (Sodium Lactate) 2

sodium lactate vial (Sodium Lactate) 2

sodium phos,m-basic-d-basic (Sodium Phos,m-basic-

d-basic)

2

TPN ELECTROLYTES II 4

TRAVERT-ELECTROLYTE NO.1 4

TRAVERT-ELECTROLYTE NO.2 iv

soln: 10%

4

TRAVERT-ELECTROLYTE NO.2 iv

soln: 5%

4



Respiratory Tract Agents Anti-inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS 3 QL: 60 in 30 days

ADVAIR HFA 3 QL: 12 in 28 days

DULERA 3 QL: 13 in 28 days

FLOVENT DISKUS blst w/dev: 250mcg 3 QL: 120 in 30 days

FLOVENT DISKUS blst w/dev: 50mcg,

100mcg

3 QL: 60 in 30 days

FLOVENT HFA aer w/adap: 110mcg 3 QL: 12 in 28 days

FLOVENT HFA aer w/adap: 44mcg 3 QL: 21.2 in 28 days

FLOVENT HFA aer w/adap: 220mcg 3 QL: 24 in 28 days

QVAR 3 QL: 17.4 in 25 days

Antileukotrienes

montelukast sodium (Singulair) 2

zafirlukast (Accolate) 2


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59




Bronchodilators

albuterol sulfate solution, vial-neb:

0.63mg/3ml, 1.25mg/3ml, 2.5mg/3ml

(Accuneb) 2 PA BvD

albuterol sulfate syrup, tab er 12h, tablet (Albuterol Sulfate) 2

ANORO ELLIPTA 3 QL: 60 in 30 days

ATROVENT HFA 3 QL: 25.8 in 28 days

COMBIVENT RESPIMAT 3 QL: 8 in 30 days

metaproterenol sulfate (Metaproterenol

Sulfate)

2

PROAIR HFA 3 QL: 17 in 25 days

SEREVENT DISKUS 3 QL: 60 in 30 days

SPIRIVA 3 QL: 30 in 30 days

terbutaline sulfate (Brethine) 2

theophylline anhydrous solution, tab er

12h, tablet er

(Theochron) 2

theophylline/d5w (Theophylline/D5W) 2

TUDORZA PRESSAIR 3 QL: 1 in 28 days

Respiratory Tract Agents, Other

acetylcysteine (Acetadote) 2 PA BvD

ARALAST NP 5

cromolyn sodium (Intal) 2 PA BvD

DALIRESP 3 QL: 30 in 30 days

KALYDECO 5 PA, QL: 60 in 30 days

XOLAIR 5 PA, QL: 6 in 28 days

ZEMAIRA 5

Skeletal Muscle Relaxants Skeletal Muscle Relaxants

baclofen (Baclofen) 2

carisoprodol tablet: 250mg (Soma) 2 PA-HRM, QL: 120 in 30

days

carisoprodol tablet: 350mg (Soma) 2 PA-HRM, QL: 120 in 30

days

chlorzoxazone (Parafon Forte DSC) 2 PA-HRM

chlorzoxazone/acetaminophen (Chlorzoxazone/

acetaminophen)

2 PA-HRM

cyclobenzaprine hcl tablet: 5mg, 10mg (Fexmid) 2 PA-HRM

dantrolene sodium capsule (Dantrium) 2

dantrolene sodium vial (Dantrium) 2

metaxalone (Skelaxin) 2 PA-HRM


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60




methocarbamol (Robaxin) 2 PA-HRM

tizanidine hcl (Zanaflex) 2

Sleep Disorder Agents Sleep Disorder Agents

NUVIGIL tablet: 200mg 3 PA

NUVIGIL tablet: 50mg, 150mg, 250mg 3 PA

ROZEREM 3

XYREM 5 LA

zaleplon (Sonata) 2 PA-HRM, QL: 60 in 30


QL applies to all



with over 90 days

cumulative use with any

non-benzodiazepine

hypnotic drug)

zolpidem tartrate (Ambien) 2 PA-HRM, QL: 30 in 30


QL applies to all



with over 90 days

cumulative use with any

non-benzodiazepine

hypnotic drug)

Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents

phentolamine mesylate (Phentolamine

Mesylate)

2 PA

Vasodilating Agents Vasodilating Agents

ADCIRCA 5 PA, QL: 60 in 30 days

ADEMPAS 5 PA, QL: 90 in 30 days

epoprostenol sodium (glycine) vial: 0.5mg (Flolan) 2 PA BvD

epoprostenol sodium (glycine) vial: 1.5mg (Flolan) 5 PA BvD

LETAIRIS 5 PA, QL: 30 in 30 days

OPSUMIT 5 PA, QL: 30 in 30 days

ORENITRAM ER tablet er: 0.125mg 3 PA


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61




ORENITRAM ER tablet er: 0.25mg, 1mg,

2.5mg

5 PA

REMODULIN 5 PA BvD

REVATIO vial 5 PA, QL: 37.5 in 1 day

sildenafil citrate (Revatio) 2 PA, QL: 90 in 30 days

TRACLEER 5 LA, PA, QL: 60 in 30

days

TYVASO 5 PA

VENTAVIS 5 PA BvD

Vitamins and Minerals Vitamins and Minerals

ped mv a,c,d3 #21 w-fluoride (Ped Mv A,c,d3 #21

W-fluoride)

2

pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/

iron/fa)

3 (All Rx Prenatal

Vitamins Covered)

I-1

MODA Health 2015 Part D Formulary Effective: January 01, 2015


INDEX

0.9 % sodium chloride .......... 55

8-MOP................................... 39

abacavir sulfate ..................... 25

abacavir/lamivudine/zidovudine

........................................... 25

ABELCET............................. 20

ABILIFY ............................... 24

ABILIFY DISCMELT .......... 23

ABILIFY MAINTENA ........ 24

ABRAXANE ........................ 10

acamprosate calcium .............. 4

acarbose ................................ 18

acebutolol hcl ........................ 34

acetaminophen with codeine ... 1

acetazolamide ....................... 55

acetazolamide sodium ........... 55

acetic acid ....................... 43, 52

acetylcysteine ........................ 59

acitretin ................................. 39

ACTEMRA ........................... 53

ACTHIB ................................ 50

ACTIMMUNE ...................... 53

acyclovir .......................... 27, 39

acyclovir sodium ................... 27

ADACEL TDAP ................... 50

ADAGEN .............................. 41

adapalene .............................. 41

ADCETRIS ........................... 10

ADCIRCA............................. 60

adefovir dipivoxil .................. 27

ADEMPAS ........................... 60

ADVAIR DISKUS................ 58

ADVAIR HFA ...................... 58

AFINITOR ............................ 10

AFINITOR DISPERZ ........... 10

AGGRENOX ........................ 28

A-HYDROCORT ................. 47

AKTEN ................................. 42

ALBENZA ............................ 22

ALBUKED-25 ...................... 29

ALBUKED-5 ........................ 29

ALBUMIN HUMAN ............ 29

ALBUMINAR-25 ................. 29

ALBUMINAR-5 ................... 29

ALBURX .............................. 29

ALBUTEIN........................... 29

albuterol sulfate .................... 59

alclometasone dipropionate .. 40

alcohol antiseptic pads ......... 39

ALDURAZYME................... 42

alendronate sodium ............... 52

alfuzosin hcl .......................... 46

ALIMTA ............................... 10

ALINIA ................................. 23

allopurinol............................. 53

ALPHAGAN P ..................... 55

alprazolam .............................. 5

ALREX ................................. 44

aluminum chloride ................ 39

amantadine hcl ...................... 23

AMBISOME ......................... 20

amifostine crystalline ............ 53

amiloride hcl ......................... 36

amiloride/hydrochlorothiazide

........................................... 36

AMINO ACIDS .................... 29

aminocaproic acid ................ 28

AMINOSYN ......................... 29

AMINOSYN II ..................... 29

AMINOSYN M .................... 29

AMINOSYN with

ELECTROLYTES ............ 29

AMINOSYN-HBC ............... 29

AMINOSYN-PF ................... 29

AMINOSYN-RF ................... 29

amiodarone hcl ..................... 33

AMITIZA .............................. 45

amitriptyline hcl .................... 17

amlodipine besylate .............. 36

amlodipine besylate/benazepril

........................................... 36

amlodipine/atorvastatin ........ 36

ammonium lactate ................. 39

amoxapine ............................. 17

amoxicillin............................... 9

amoxicillin trihydrate.............. 9

amoxicillin/potassium clav...... 9

amphotericin b ...................... 20

ampicillin sodium .................... 9

ampicillin sodium/sulbactam na

............................................. 9

ampicillin trihydrate ............... 9

AMPYRA ............................. 37

ANACAINE .......................... 39

anagrelide hcl ....................... 28

anastrozole ............................ 10

ANDRODERM ..................... 46

ANDROGEL......................... 46

ANORO ELLIPTA ............... 59

APOKYN .............................. 23

apraclonidine hcl .................. 42

APRISO ................................ 52

APTIOM ............................... 15

APTIVUS .............................. 25

ARALAST NP ...................... 59

ARCALYST ......................... 49

ARRANON ........................... 10

ARZERRA ............................ 10

ASACOL HD ........................ 52

ASTAGRAF XL ................... 49

atenolol ................................. 34

atenolol/chlorthalidone ......... 34

atorvastatin calcium.............. 36

atovaquone ............................ 23

atovaquone/proguanil hcl ..... 23

ATRIPLA .............................. 25

atropine sulfate ............... 15, 42

I-2



ATROVENT HFA ................ 59

AUBAGIO ............................ 49

AVASTIN ............................. 10

AVC ...................................... 21

AVODART ........................... 53

AVONEX .............................. 53

AVONEX

ADMINISTRATION PACK

........................................... 53

azacitidine ............................. 10

azathioprine .......................... 49

azathioprine sodium .............. 49

azelastine hcl ......................... 42

AZILECT .............................. 23

azithromycin ............................ 8

AZOPT .................................. 55

AZOR .................................... 36

aztreonam ................................ 8

bacitracin .......................... 6, 43

bacitracin/polymyxin b sulfate

........................................... 43

baclofen ................................. 59

balsalazide disodium ............. 52

BANZEL ............................... 15

BARACLUDE ...................... 27

BCG VACCINE TICE

STRAIN ............................ 50

benazepril hcl ........................ 33

benazepril/hydrochlorothiazide

........................................... 33

BENICAR ............................. 32

BENICAR HCT .................... 32

BENLYSTA .......................... 53

benztropine mesylate ............. 23

betamet acet/betamet na ph .. 47

betamethasone dipropionate . 40

betamethasone valerate ........ 40

betamethasone/propylene glyc

........................................... 40

BETASERON ....................... 53

betaxolol hcl .................... 34, 55

bethanechol chloride ............. 53

BETHKIS ................................ 6

bicalutamide .......................... 10

BICILLIN C-R ........................ 9

BICILLIN L-A ........................ 9

BILTRICIDE ........................ 23

bisoprolol fumarate ............... 34

bisoprolol fumarate/hctz ....... 34

bleomycin sulfate .................. 10

BOOSTRIX TDAP ............... 50

BOSULIF .............................. 11

BOTOX ................................. 53

BRILINTA ............................ 28

brimonidine tartrate .............. 55

BRINTELLIX ....................... 17

bromfenac sodium ................. 44

bromocriptine mesylate ......... 23

budesonide ............................ 52

bumetanide ............................ 36

BUMINATE ......................... 29

BUPHENYL ......................... 45

buprenorphine hcl ............... 1, 4

buprenorphine hcl/naloxone hcl

............................................. 4

bupropion hcl ........................ 17

buspirone hcl ......................... 53

butalb/acetaminophen/caffeine 1

butalbit/acetamin/caff/codeine 1

butalbital/acetaminophen ....... 1

butalbital/aspirin/caffeine ....... 1

butorphanol tartrate................ 1

BUTRANS .............................. 1

BYDUREON ........................ 18

BYETTA ............................... 18

BYSTOLIC ........................... 34

cabergoline ........................... 23

caffeine citrated .................... 37

caffeine/sodium benzoate ...... 37

calcipotriene ......................... 39

calcitonin,salmon,synthetic ... 52

calcitriol .......................... 39, 52

calcium acetate ..................... 45

calcium carbonate/mag carb/fa

........................................... 45

calcium chloride.................... 56

calcium gluconate ................. 56

CALDOLOR ........................... 3

CANCIDAS .......................... 20

candesartan cilexetil ............. 32

candesartan/hydrochlorothiazid

........................................... 32

CAPASTAT SULFATE ....... 22

CAPRELSA .......................... 11

captopril ................................ 33

captopril/hydrochlorothiazide

........................................... 33

CARAFATE ......................... 44

carbamazepine ...................... 15

carbidopa .............................. 23

carbidopa/levodopa .............. 23

carbidopa/levodopa/entacapone

........................................... 23

carboplatin ............................ 11

CARIMUNE NF

NANOFILTERED ............ 49

carisoprodol .......................... 59

carteolol hcl .......................... 42

carvedilol .............................. 34

CAYSTON .............................. 8

cefaclor ................................... 7

cefadroxil ................................ 7

cefazolin sodium...................... 7

cefazolin sodium/dextrose,iso . 7

cefdinir .................................... 7

CEFEPIME ............................. 7

cefepime hcl ............................ 7

CEFEPIME-DEXTROSE ....... 7

cefotaxime sodium ................... 7

cefoxitin sodium ...................... 7

cefoxitin sodium/dextrose,iso .. 7

cefpodoxime proxetil ............... 7

cefprozil................................... 7

ceftazidime pentahydrate ........ 7

ceftibuten dihydrate ................ 8

I-3



ceftriaxone na/dextrose,iso ..... 8

ceftriaxone sodium .................. 8

cefuroxime axetil ..................... 8

cefuroxime sodium .................. 8

cefuroxime sodium/dextrose,iso

............................................. 8

CELEBREX ............................ 3

CELLCEPT ........................... 49

CELONTIN........................... 15

cephalexin ............................... 8

cephalexin monohydrate ......... 8

CEPROTIN ........................... 27

CEREZYME ......................... 42

CERVARIX .......................... 50

cevimeline hcl........................ 39

CHANTIX............................... 4

chloramphenicol sod succ ....... 6

chlordiazepoxide hcl ............... 5

chlorhexidine gluconate ........ 39

chloroquine phosphate .......... 23

chlorothiazide ....................... 36

chlorothiazide sodium ........... 36

chlorpromazine hcl ............... 24

chlorthalidone ....................... 36

chlorzoxazone ....................... 59

chlorzoxazone/acetaminophen

........................................... 59

cholestyramine (with sugar) . 36

cholestyramine/aspartame .... 36

choline sal/mag salicylate ....... 3

ciclopirox .............................. 20

ciclopirox olamine ................ 20

cilostazol ............................... 29

cimetidine .............................. 44

cimetidine hcl ........................ 44

CIMZIA ................................ 42

CIPRODEX........................... 43

ciprofloxacin ........................... 9

ciprofloxacin hcl ............... 9, 43

ciprofloxacin lactate ............... 9

ciprofloxacin lactate/d5w........ 9

cisplatin ................................. 11

citalopram hydrobromide ..... 17

citrate phosphate dextros soln

........................................... 53

citric acid/sodium citrate ...... 56

clarithromycin ......................... 8

clemastine fumarate .............. 21

CLEVIPREX......................... 36

clindamycin hcl ....................... 6

clindamycin palmitate hcl ....... 6

clindamycin phosphate 6, 21, 40

clindamycin phosphate/d5w .... 6

CLINIMIX ............................ 30

CLINIMIX E ................... 29, 30

CLINISOL ............................ 30

clobetasol propionate............ 40

clocortolone pivalate ............ 40

clomipramine hcl .................. 17

clonazepam ............................. 5

clonidine ................................ 32

clonidine hcl .................... 32, 37

clonidine hcl/chlorthalidone . 32

clopidogrel bisulfate ............. 29

clorazepate dipotassium.......... 5

clotrimazole........................... 20

clotrimazole/betamethasone dip

........................................... 20

clozapine ............................... 24

COARTEM ........................... 23

codeine sulfate ........................ 1

codeine/butalbital/asa/caffein . 1

colchicine/probenecid ........... 53

COLCRYS ............................ 53

colestipol hcl ......................... 36

colistin (colistimethate na) ...... 6

COLY-MYCIN S .................. 43

COMBIGAN ......................... 55

COMBIPATCH .................... 46

COMBIVENT RESPIMAT .. 59

COMETRIQ .......................... 11

COMPLERA ......................... 25

COMVAX ............................. 50

CONDYLOX ........................ 39

COPAXONE ......................... 53

CORDRAN ........................... 40

cortisone acetate ................... 47

CREON ................................. 42

CRESTOR............................. 36

CRIXIVAN ........................... 25

cromolyn sodium ....... 42, 45, 59

CUBICIN ................................ 6

cyclobenzaprine hcl .............. 59

CYCLOGYL ......................... 42

cyclopentolate hcl ................. 42

cyclophosphamide ................. 11

CYCLOPHOSPHAMIDE..... 11

CYCLOSET .......................... 18

cyclosporine .......................... 49

cyclosporine, modified .......... 49

cyproheptadine hcl ................ 21

CYSTADANE ...................... 54

CYSTARAN ......................... 42

cysteine hcl ............................ 30

cytarabine ............................. 11

cytarabine/pf ......................... 11

dacarbazine ........................... 11

dactinomycin ......................... 11

DALIRESP ........................... 59

danazol .................................. 46

dantrolene sodium ................. 59

dapsone ................................. 22

DAPTACEL DTAP .............. 50

DARAPRIM ......................... 23

decitabine .............................. 11

deferoxamine mesylate .......... 46

DELZICOL ........................... 52

DEMSER .............................. 34

DEPEN .................................. 46

DEPO-PROVERA ................ 48

desipramine hcl ..................... 17

desmopressin acetate ............ 48

desog-e.estradiol/e.estradiol . 38

desogestrel-ethinyl estradiol . 38

desonide ................................ 40

desoximetasone ..................... 40

I-4



dex 2.5%-half str lact.ringers 56

dexamethasone ...................... 47

dexamethasone acetate ......... 47

dexamethasone sod phosphate

..................................... 44, 47

dexmethylphenidate hcl ......... 37

dextroamphetamine sulfate ... 37

dextroamphetamine/

amphetamine ..................... 38

dextrose 10 % and 0.2 % nacl

........................................... 30

dextrose 10 % and 0.9 % nacl

........................................... 30

dextrose 10 % in water ......... 30

dextrose 10%-0.5 normal saline

........................................... 30

dextrose 2.5 % in water ........ 30

dextrose 2.5% in half ringers 30

dextrose 2.5%-0.5normal saline

........................................... 30

dextrose 20%-water .............. 30


dextrose 40%-water .............. 30

dextrose 5 % and 0.3 % nacl 30

dextrose 5 % and 0.9 % nacl 31

dextrose 5 % in water ........... 31

dextrose 5 %-0.2 % nacl ....... 31

dextrose 5 %-0.45 % nacl ..... 31

dextrose 5% in ringers .......... 31

dextrose 5%-lactated ringers 31



dextrose 70%-water .............. 31

DEXTROSE W/

ELECTROLYTE A .......... 56

DEXTROSE W/

ELECTROLYTE B ........... 56

DIASTAT ACUDIAL ............ 5

diazepam ................................. 5

diclofenac potassium ............... 3

diclofenac sodium ............. 3, 44

diclofenac sodium/misoprostol 3

dicloxacillin sodium ................ 9

dicyclomine hcl ..................... 45

didanosine ............................. 25

DIFICID .................................. 8

diflunisal ................................. 3

digoxin............................. 34, 35

DIGOXIN ............................. 35

dihydroergotamine mesylate . 21

DILANTIN ........................... 15

diltiazem hcl .......................... 34

dimenhydrinate ..................... 22

DIOVAN ............................... 32

DIPENTUM .......................... 52

diphenhydramine hcl ............. 21

diphenoxylate hcl/atropine .... 45

DIPHTHERIA-TETANUS

TOXOIDS-PED ................ 50

disopyramide phosphate ....... 33

disulfiram ................................ 4

divalproex sodium ................. 15

dobutamine hcl ...................... 35

dobutamine hcl/d5w .............. 35

donepezil hcl ......................... 17

dopamine hcl ......................... 35

dopamine hcl/d5w ................. 35

dopamine hcl/dextrose 5%-

water ................................. 35

dorzolamide hcl ..................... 55

dorzolamide hcl/timolol maleat

........................................... 55

doxazosin mesylate................ 32

doxepin hcl ............................ 17

doxercalciferol ...................... 52

doxorubicin hcl ..................... 11

doxorubicin hcl peg-liposomal

........................................... 11

doxycycline hyclate ............... 10

doxycycline monohydrate ...... 10

dronabinol ............................. 22

droperidol ............................. 54

DROXIA ............................... 11

DUAVEE .............................. 46

DULERA .............................. 58

duloxetine hcl ........................ 17

DURAMORPH ....................... 1

DUREZOL ............................ 44

DYRENIUM ......................... 36

econazole nitrate ................... 20

edetate disodium ................... 46

EDURANT ........................... 25

EFFIENT............................... 29

ELAPRASE .......................... 42

electrolyte-48 solution/d5w ... 56

electrolyte-48/fructose 10% .. 56

electrolyte-48/fructose 5% .... 56

electrolyte-75 solution/d5w ... 56

electrolyte-75/fructose 5% .... 56

ELIDEL................................. 40

ELIGARD ............................. 11

ELIQUIS ............................... 27

ELITEK................................. 42

ELLA .................................... 38

ELMIRON ............................ 54

EMCYT................................. 11

EMEND ................................ 22

EMSAM ................................ 17

EMTRIVA ............................ 25

enalapril maleate .................. 33

enalapril/hydrochlorothiazide

........................................... 33

enalaprilat dihydrate ............ 33

ENBREL ............................... 49

ENGERIX-B ADULT .......... 50

ENGERIX-B PEDIATRIC-

ADOLESCENT ................ 50

enoxaparin sodium ................ 27

entacapone ............................ 23

ephedrine sulfate ................... 35

epinastine hcl ........................ 42

epinephrine ........................... 35

EPIPEN 2-PAK ..................... 35

EPIPEN JR 2-PAK ............... 35

epirubicin hcl ........................ 11

EPIVIR .................................. 25

I-5



EPIVIR HBV ........................ 25

eplerenone ............................. 37

EPOGEN ............................... 28

epoprostenol sodium (glycine)

........................................... 60

EPZICOM ............................. 25

ERBITUX ............................. 11

ergoloid mesylates ................ 54

ERGOMAR........................... 21

ERIVEDGE........................... 11

ery e-succ/sulfisoxazole .......... 8

ERY-TAB ............................... 8

ERYTHROCIN

LACTOBIONATE .............. 8

erythromycin base ............. 8, 43

erythromycin base/ethanol .... 40

erythromycin ethylsuccinate ... 8

erythromycin stearate ............. 8

escitalopram oxalate ............. 17

esmolol hcl ............................ 34

esomeprazole sodium ............ 44

estazolam................................. 5

ESTRACE ............................. 46

estradiol ................................ 46

estradiol valerate .................. 46

estradiol/norethindrone acet . 46

ESTRASORB ....................... 47

estropipate............................. 47

ethambutol hcl ....................... 22

ethanolamine oleate .............. 35

ethinyl estradiol/drospirenone

........................................... 38

ethosuximide ......................... 15

ethynodiol d-ethinyl estradiol 38

etidronate disodium .............. 52

etodolac ................................... 3

ETOPOPHOS ....................... 11

etoposide ............................... 11

exemestane ............................ 11

EXJADE ............................... 46

EXTAVIA ............................. 54

FABRAZYME ...................... 42

famciclovir ............................ 27

famotidine ............................. 44

famotidine in nacl,iso-osm/pf 44

famotidine/pf ......................... 44

FANAPT ............................... 24

FARESTON .......................... 11

FASLODEX .......................... 11

FAZACLO ............................ 24

felbamate ............................... 16

felodipine............................... 36

FEMRING............................. 47

fenofibrate ............................. 36

fenofibrate nanocrystallized.. 36

fenofibrate,micronized .......... 36

fenofibric acid ....................... 36

fenofibric acid (choline) ........ 36

fenoprofen calcium.................. 3

fentanyl .................................... 1

fentanyl citrate ........................ 1

FERRIPROX......................... 46

FETZIMA ............................. 17

finasteride ............................. 54

FIRAZYR ............................. 35

FIRMAGON ......................... 11

FLEBOGAMMA DIF ........... 49

flecainide acetate .................. 33

FLECTOR ............................... 3

FLEXBUMIN ....................... 29

FLOVENT DISKUS ............. 58

FLOVENT HFA ................... 58

floxuridine ............................. 11

fluconazole ............................ 20

fluconazole in nacl,iso-osm ... 20

flucytosine ............................. 20

fludarabine phosphate .......... 12

fludrocortisone acetate ......... 47

flumazenil .............................. 38

fluocinonide........................... 40

fluorometholone .................... 44

FLUOROPLEX..................... 39

fluorouracil ..................... 12, 39

fluoxetine hcl ......................... 17

fluoxymesterone .................... 46

fluphenazine decanoate ......... 24

fluphenazine hcl .................... 24

flurazepam hcl ......................... 5

flurbiprofen ............................. 3

flurbiprofen sodium ............... 44

flutamide ............................... 12

fluticasone propionate .... 40, 44

fluvoxamine maleate ............. 17

fomepizole ............................. 54

fondaparinux sodium ...... 27, 28

FORTEO ............................... 52

FORTICAL ........................... 52

foscarnet sodium ................... 26

fosinopril sodium .................. 33

fosinopril/hydrochlorothiazide

........................................... 33

fosphenytoin sodium.............. 16

FREAMINE HBC ................. 31

FREAMINE III ..................... 31

fructose 10% ......................... 31

furosemide ............................. 36

FUSILEV .............................. 54

FUZEON ............................... 25

FYCOMPA ........................... 16

gabapentin............................. 16

GABITRIL ............................ 16

galantamine hbr .................... 17

GAMASTAN S-D ................ 49

GAMMAGARD LIQUID ..... 49

GAMMAPLEX ..................... 49

GAMUNEX-C ...................... 49

ganciclovir sodium ................ 27

GARDASIL .......................... 50

gatifloxacin ........................... 43

gauze bandage ...................... 54

GAZYVA .............................. 12

gemcitabine hcl ..................... 12

gemfibrozil ............................ 37

GENOTROPIN ..................... 48

gentamicin in nacl, iso-osm .... 6

gentamicin sulfate ....... 6, 40, 43

I-6



GEODON .............................. 24

GILENYA ............................. 54

GILOTRIF ............................ 12

GLEEVEC ............................ 12

glimepiride ............................ 19

glipizide ................................. 19

glipizide/metformin hcl ......... 20

GLUCAGEN......................... 54

GLUCAGON EMERGENCY

KIT .................................... 54

glutethimide........................... 54

glyburide ............................... 20

glyburide,micronized ............ 20

glyburide/metformin hcl ........ 20

glycine ................................... 52

glycopyrrolate ....................... 45

granisetron hcl ...................... 22

granisetron hcl/pf .................. 22

GRANIX ............................... 28

griseofulvin, microsize .......... 20

guanfacine hcl ....................... 32

guanidine hcl ......................... 54

HALAVEN ........................... 12

halobetasol propionate ......... 40

haloperidol ............................ 24

haloperidol decanoate .......... 24

haloperidol lactate ................ 24

HAVRIX ......................... 50, 51

heparin sodium,porcine ........ 28

heparin sodium,porcine/d5w. 28

heparin sodium,porcine/ns/pf 28

heparin sodium,porcine/pf .... 28

HEPATAMINE..................... 31

HEPATASOL ....................... 31

HERCEPTIN......................... 12

HEXALEN ............................ 12

homatropine hbr.................... 42

HUMALOG .......................... 19

HUMALOG MIX 50-50 ....... 19

HUMALOG MIX 75-25 ....... 19

HUMATROPE ...................... 48

HUMIRA .............................. 49

HUMULIN 70/30 KWIKPEN

........................................... 19

HUMULIN 70-30 ................. 19

HUMULIN N ........................ 19

HUMULIN N KWIKPEN .... 19

HUMULIN R ........................ 19

hydralazine hcl ...................... 35

hydralazine/hydrochlorothiazid

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

hydrochlorothiazide .............. 36

hydrocodone/acetaminophen .. 1

hydrocodone/ibuprofen ........... 1

hydrocortisone ................ 41, 47

hydrocortisone acetate/aloe v 40

hydrocortisone acetate/urea . 41

hydrocortisone butyrate ........ 41

hydrocortisone sod succinate 47

hydrocortisone valerate ........ 41

hydromorphone hcl ............. 1, 2

hydromorphone hcl/pf ............. 2

hydroxychloroquine sulfate ... 23

hydroxyurea .......................... 12

hydroxyzine hcl ..................... 54

hydroxyzine pamoate ............ 54

HYPERLYTE CR ................. 56

HYPERLYTE R.................... 56

HYPERRAB S-D .................. 49

ibandronate sodium ........ 52, 53

ibuprofen ................................. 3

ICLUSIG ............................... 12

ifosfamide .............................. 12

ifosfamide/mesna................... 12

ILARIS .................................. 49

ILEVRO ................................ 44

IMBRUVICA ........................ 12

imipenem/cilastatin sodium .... 8

imipramine hcl ...................... 17

imipramine pamoate ............. 17

imiquimod ............................. 39

IMOGAM RABIES-HT........ 50

IMOVAX RABIES VACCINE

........................................... 51

INCRELEX ........................... 48

indapamide ............................ 36

indomethacin ........................... 3

indomethacin sodium .............. 3

INFANRIX DTAP ................ 51

INLYTA ................................ 12

INTELENCE......................... 25

INTRALIPID ........................ 31

INTRON A............................ 27

INTUNIV .............................. 38

INVANZ ................................. 8

INVEGA ............................... 24

INVEGA SUSTENNA ......... 24

INVIRASE ............................ 26

INVOKANA ......................... 18

IONOSOL B with DEXTROSE

5% ..................................... 56

IONOSOL MB-DEXTROSE

5% ..................................... 56

IONOSOL T-DEXTROSE 5%

........................................... 56

IPOL ...................................... 51

ipratropium bromide ............. 42

IPRIVASK ............................ 28

irbesartan .............................. 33

irbesartan/hydrochlorothiazide

........................................... 33

ISENTRESS .......................... 26

ISOLYTE E .......................... 56

ISOLYTE H W/DEXTROSE 56

ISOLYTE M W/DEXTROSE56

ISOLYTE P with DEXTROSE

........................................... 56

ISOLYTE S ........................... 56

ISOLYTE S with DEXTROSE

........................................... 56

isoniazid ................................ 22

isopropamide/prochlorperazine

........................................... 45

ISOPTO CARPINE .............. 55

isosorbide dinitrate ............... 37

isosorbide mononitrate ......... 37

I-7



isotretinoin ............................ 39

isradipine .............................. 36

ISTODAX ............................. 12

itraconazole........................... 20

IXEMPRA............................. 12

IXIARO................................. 51

JAKAFI ................................. 12

JALYN .................................. 54

JANUMET ............................ 18

JANUMET XR ..................... 18

JANUVIA ............................. 18

JENTADUETO ..................... 18

JEVTANA............................. 12

KADCYLA ........................... 12

KALETRA ............................ 26

KALYDECO......................... 59

KEDBUMIN ......................... 29

ketoconazole .......................... 20

ketoprofen ............................... 3

ketorolac tromethamine .... 3, 44

KHEDEZLA ......................... 17

KINERET ............................. 50

KINRIX................................. 51

KORLYM ............................. 18

KRYSTEXXA ...................... 42

KUVAN ................................ 42

KYPROLIS ........................... 12

labetalol hcl .......................... 34

LACRISERT ......................... 42

LACTATED RINGERS ....... 52

lactulose ................................ 45

LAMICTAL .......................... 16

lamivudine ............................. 26

lamivudine/zidovudine .......... 26

lamotrigine ............................ 16

LANOXIN ............................ 35

lansoprazole .......................... 44

lansoprazole/amoxiciln/clarith

........................................... 44

LANTUS ............................... 19

LANTUS SOLOSTAR ......... 19

latanoprost ............................ 55

LATUDA .............................. 24

LAZANDA ............................. 2

leflunomide ............................ 50

LETAIRIS ............................. 60

letrozole................................. 12

leucovorin calcium ................ 54

LEUKERAN ......................... 13

LEUKINE ............................. 28

leuprolide acetate.................. 13

levetiracetam ......................... 16

levobunolol hcl ...................... 55

levocarnitine ......................... 54

levocarnitine (with sugar) ..... 54

levocetirizine dihydrochloride

........................................... 21

levofloxacin ....................... 9, 43

levofloxacin/d5w ................... 10

levonorgestrel ....................... 38

levonorgestrel-ethin estradiol 38

levorphanol tartrate ................ 2

levothyroxine sodium ............ 49

LEXIVA ................................ 26

lidocaine .................................. 4

lidocaine hcl ...................... 4, 33

lidocaine hcl/d5w/pf .............. 33

lidocaine hcl/pf.................. 4, 33

lidocaine/prilocaine ................ 4

LIDODERM ........................... 4

LINZESS............................... 42

liothyronine sodium .............. 49

lipase/protease/amylase ........ 42

LIPOSYN II .......................... 31

LIPOSYN III ......................... 31

lisinopril ................................ 33

lisinopril/hydrochlorothiazide

........................................... 33

lithium carbonate .................. 38

lithium citrate ........................ 38

l-norgest-eth estr/ethin estra . 38

lomustine ............................... 13

loperamide hcl ...................... 45

lorazepam ................................ 5

losartan potassium ................ 33

losartan/hydrochlorothiazide 33

LOTEMAX ........................... 44

LOTRONEX ......................... 42

lovastatin ............................... 37

loxapine succinate ................. 24

LUMIGAN ............................ 55

LUMINAL SODIUM ........... 16

LUMIZYME ......................... 42

LUPRON DEPOT ................. 13

LUPRON DEPOT-PED ........ 13

LYRICA ................................ 16

LYSODREN ......................... 13

mafenide acetate ................... 39

magnesium chloride .............. 56

magnesium sulfate ................. 56

magnesium sulfate/d5w ......... 56

malathion .............................. 41

mannitol/sorbitol solution ..... 52

maprotiline hcl ...................... 17

MARPLAN ........................... 17

MARQIBO ............................ 13

MATULANE ........................ 13

meclizine hcl.......................... 22

medroxyprogesterone acet .... 48

medroxyprogesterone acetate 48

mefenamic acid ....................... 3

mefloquine hcl ....................... 23

MEFOXIN .............................. 8

MEGACE ES ........................ 13

megestrol acetate .................. 13

MEKINIST ........................... 13

meloxicam ............................... 4

melphalan hcl ........................ 13

MENACTRA ........................ 51

MENEST............................... 47

MENHIBRIX ........................ 51

MENOMUNE-A-C-Y-W-135

........................................... 51

MENVEO A-C-Y-W-135-DIP

........................................... 51

mercaptopurine ..................... 13

I-8



meropenem .............................. 9

mesna .................................... 54

MESNEX .............................. 54

MESTINON .......................... 54

metaproterenol sulfate .......... 59

metaxalone ............................ 59

metformin hcl ........................ 18

methadone hcl ......................... 2

methazolamide ...................... 55

methenamine hippurate ........... 6

methimazole .......................... 49

methocarbamol ..................... 60

methotrexate sodium ............. 13

methotrexate sodium/pf ......... 13

methoxsalen, rapid ................ 39

methscopolamine bromide .... 45

methyclothiazide ................... 36

methylphenidate hcl .............. 38

methylprednisolone ............... 47

methylprednisolone acetate .. 47

methylprednisolone sod succ 47

metipranolol .......................... 55

metoclopramide hcl ............... 45

metolazone ............................ 36

metoprolol succinate ............. 34

metoprolol tartrate ................ 34

metoprolol/hydrochlorothiazide

........................................... 34

metronidazole ............ 21, 23, 40

metronidazole/sodium chloride

........................................... 23

mexiletine hcl ........................ 33

MIACALCIN ........................ 53

miconazole nitrate ................. 21

midazolam hcl ......................... 5

midazolam hcl/pf ..................... 5

midodrine hcl ........................ 32

milrinone lactate ................... 35

milrinone lactate/d5w ........... 35

minocycline hcl ..................... 10

minoxidil ............................... 37

mirtazapine ........................... 17

misoprostol ............................ 44

mitomycin .............................. 13

mitoxantrone hcl ................... 13

M-M-R II VACCINE ............ 51

moexipril hcl ......................... 33

moexipril/hydrochlorothiazide

........................................... 33

mometasone furoate .............. 41

montelukast sodium ............... 58

morphine sulfate...................... 2

MORPHINE SULFATE ......... 2

MOVIPREP .......................... 45

MOXEZA ............................. 43

moxifloxacin hcl .................... 10

MOZOBIL ............................ 28

MULTAQ ............................. 33

mupirocin .............................. 40

mupirocin calcium ................ 40

MUSTARGEN ...................... 13

mycophenolate mofetil .......... 50

mycophenolate sodium .......... 50

MYOZYME .......................... 42

nabumetone ............................. 4

nadolol .................................. 34

NAFCILL IN DEXTROSE..... 9

nafcillin sodium ....................... 9

NAGLAZYME ..................... 42

nalidixic acid ......................... 10

naloxone hcl ............................ 4

naltrexone hcl.......................... 4

NAMENDA .......................... 17

NAMENDA XR.................... 17

naphazoline hcl/antazoline ... 43

naproxen ................................. 4

naproxen sodium ..................... 4

naratriptan hcl ...................... 21

NASONEX ........................... 44

NATACYN ........................... 43

nateglinide............................. 18

NEBUPENT .......................... 23

needles, insulin disposable.... 41

nefazodone hcl ...................... 17

neo/polymyx b sulf/dexameth 43

neomy sulf/bacitra/polymyxin b

........................................... 43

neomy sulf/bacitrac zn/poly/hc

........................................... 43

neomy sulf/polymyxin b sulfate

........................................... 40

neomycin sulfate...................... 6

neomycin sulfate/dex na ph ... 43

neomycin/polymyxin b sulf/hc 43

neomycin/polymyxn b/

gramicidin ......................... 43

NEPHRAMINE .................... 31

NEULASTA ......................... 28

NEUMEGA........................... 28

NEUPOGEN ......................... 28

NEUPRO............................... 23

NEVANAC ........................... 44

nevirapine ............................. 26

NEXAVAR ........................... 13

niacin..................................... 37

nicardipine hcl ...................... 36

NICOTROL ............................ 5

nifedipine............................... 36

NILANDRON ....................... 13

NITRO-BID .......................... 37

nitrofurantoin macrocrystal .... 7

nitroglycerin .......................... 37

nitroglycerin/d5w .................. 37

NITROSTAT ........................ 37

NORDITROPIN FLEXPRO . 48

NORDITROPIN NORDIFLEX

........................................... 48

norelgestromin/ethin.estradiol

........................................... 38

norepinephrine bitartrate...... 35

noreth-ethinyl estradiol/iron . 38

norethindrone ........................ 39

norethindrone acetate ........... 49

norethindrone ac-eth estradiol

..................................... 38, 47

I-9



norethindrone-e.estradiol-iron

........................................... 39

norethindrone-ethinyl estrad 39

norethindrone-mestranol ...... 39

norgestimate-ethinyl estradiol

........................................... 39

norgestrel-ethinyl estradiol ... 39

NORMOSOL-M and

DEXTROSE ...................... 56

NORMOSOL-R PH 7.4 ........ 56

nortriptyline hcl .................... 17

NORVIR ............................... 26

NOVAMINE ......................... 31

NOVOLIN 70-30 .................. 19

NOVOLIN N ........................ 19

NOVOLIN R ......................... 19

NOVOLOG ........................... 19

NOVOLOG FLEXPEN ........ 19

NOVOLOG MIX 70-30 ........ 19

NOVOLOG MIX 70-30

FLEXPEN ......................... 19

NOXAFIL ............................. 21

NUCYNTA ............................. 2

NUCYNTA ER ....................... 2

NUEDEXTA ......................... 38

NULOJIX .............................. 50

NUTRESTORE..................... 45

NUTRILYTE ........................ 56

NUTRILYTE II .................... 56

NUTROPIN .......................... 48

NUTROPIN AQ NUSPIN .... 48

NUVARING ......................... 39

NUVIGIL .............................. 60

nystatin .................................. 21

nystatin/triamcin ................... 21

OCTAGAM .......................... 50

octreotide acetate .................. 48

ofloxacin .......................... 10, 43

olanzapine ....................... 24, 25

olanzapine/fluoxetine hcl ...... 17

OLYSIO ................................ 27

omega-3 acid ethyl esters...... 37

omeprazole ............................ 44

OMNITROPE ....................... 48

ONCASPAR ......................... 13

ondansetron........................... 22

ondansetron hcl ..................... 22

ondansetron hcl/pf ................ 22

ONFI ....................................... 5

OPSUMIT ............................. 60

ORAP .................................... 25

ORENCIA ............................. 50

ORENITRAM ER ........... 60, 61

ORFADIN ............................. 42

OTEZLA ............................... 54

oxacillin sodium ...................... 9

oxacillin sodium/dextrose,iso .. 9

oxaliplatin ............................. 13

oxandrolone .......................... 46

oxcarbazepine ....................... 16

OXTELLAR XR ................... 16

oxybutynin chloride ............... 45

oxycodone hcl.......................... 2

oxycodone hcl/acetaminophen 2

oxycodone hcl/aspirin ............. 2

OXYCONTIN ..................... 2, 3

oxymorphone hcl ..................... 3

paclitaxel ............................... 13

PANRETIN ........................... 39

pantoprazole sodium ............. 44

papaverine hcl ....................... 35

paricalcitol ............................ 53

paromomycin sulfate ............. 23

paroxetine hcl........................ 18

PASER .................................. 22

PATADAY ........................... 43

PATANOL ............................ 43

PAXIL ................................... 18

ped mv a,c,d3 #21 w-fluoride 61

PEDIARIX ............................ 51

PEDVAXHIB ....................... 51

peg 3350/na sulf,bicarb,cl/kcl 45

PEGANONE ......................... 16

PEGASYS ............................. 27

PEGASYS PROCLICK ........ 27

PEGINTRON ........................ 27

PEGINTRON REDIPEN ...... 27

pen g pot/dextrose-water......... 9

penicillin g potassium ............. 9

penicillin g potassium/d5w ..... 9

penicillin g procaine ............... 9

penicillin v potassium ............. 9

PENTACEL .......................... 51

PENTACEL ACTHIB

COMPONENT .................. 51

PENTACEL DTAP-IPV

COMPONENT .................. 51

PENTAM 300 ....................... 23

pentamidine isethionate ........ 23

pentoxifylline ......................... 29

p-epd tan/chlor-tan ............... 21

perindopril erbumine ............ 33

PERJETA .............................. 13

permethrin ............................. 41

perphenazine ......................... 25

perphenazine/amitriptyline hcl

........................................... 18

phenelzine sulfate .................. 18

phenobarbital ........................ 16

phenobarbital sodium ........... 16

phentolamine mesylate .......... 60

phenylephrine hcl ............ 32, 43

phenytoin ............................... 16

phenytoin sodium .................. 16

phenytoin sodium extended ... 16

PHOSLYRA ......................... 45

PHOSPHOLINE IODIDE .... 55

phosphorus #1 ....................... 56

PICATO ................................ 39

pilocarpine hcl ................ 39, 55

pindolol ................................. 34

pioglitazone hcl ..................... 18

pioglitazone hcl/glimepiride . 19

pioglitazone hcl/metformin hcl

........................................... 19

I-10



piperacillin sodium/tazobactam

............................................. 9

piroxicam ................................ 4

PLASBUMIN-25 .................. 29

PLASBUMIN-5 .................... 29

PLASMA-LYTE 148 ............ 57

PLASMA-LYTE 56 IN

DEXTROSE ...................... 57

PLASMA-LYTE A PH 7.4 ... 57

PLASMA-LYTE M IN

DEXTROSE ...................... 57

pnv with ca,no.72/iron/fa ...... 61

podofilox ............................... 39

podophyllum resin ................. 40

polyethylene glycol 3350....... 45

polymyxin b sulf/trimethoprim

........................................... 43

POMALYST ......................... 13

pot chloride/pot bicarb/cit ac 57

potassium acetate .................. 57

potassium bicarbonate/cit ac 57

potassium chlorid/d10-

0.2%nacl ........................... 57

potassium chloride ................ 57

potassium chloride in 0.9%nacl

........................................... 57

potassium chloride in d5w .... 57

potassium chloride in lr-d5 ... 31

potassium chloride/d5-

0.2%nacl ........................... 57

potassium chloride/d5-0.25ns 57


0.3%nacl ........................... 57

potassium chloride/d5-0.45nacl

........................................... 57


0.9%nacl ........................... 57

potassium chloride-0.45% nacl

........................................... 57

potassium citrate/citric acid . 57

potassium gluconate.............. 57

potassium hydroxide ............. 40

potassium phos,m-basic-d-basic

........................................... 57

POTIGA ................................ 16

PRADAXA ........................... 28

pramipexole di-hcl ................ 23

PRANDIMET ....................... 19

pravastatin sodium ................ 37

prazosin hcl ........................... 32

prednicarbate ........................ 41

prednisolone acetate ............. 47

prednisolone sod phosphate . 44,

47

prednisone ....................... 47, 48

PREGNYL ............................ 48

PREMARIN .......................... 47

PREMASOL ......................... 31

PREMPHASE ....................... 47

PREMPRO ............................ 47

PREZISTA ............................ 26

PRIFTIN ............................... 22

PRIMAQUINE ..................... 23

primidone .............................. 16

PRISTIQ ER ......................... 18

PRIVIGEN ............................ 50

PROAIR HFA ....................... 59

probenecid............................. 54

procainamide hcl .................. 33

PROCALAMINE .................. 31

prochlorperazine edisylate.... 22

prochlorperazine maleate ..... 22

PROCRIT .............................. 28

PROCYSBI ........................... 54

progesterone ......................... 49

progesterone,micronized ....... 49

PROGLYCEM ...................... 37

PROGRAF ............................ 50

PROLENSA .......................... 44

PROLEUKIN ........................ 13

PROLIA ................................ 53

PROMACTA ........................ 28

promethazine hcl ............. 21, 22

PRONESTYL ....................... 34

propafenone hcl .................... 34

propantheline bromide .......... 15

proparacaine hcl ................... 43

proparacaine/fluorescein sod 43

propranolol hcl ..................... 34

propranolol/hydrochlorothiazid

........................................... 34

propylthiouracil .................... 49

PROQUAD ........................... 51

PROSOL ............................... 31

protamine sulfate .................. 28

PROTOPIC ........................... 41

protriptyline hcl .................... 18

PULMOZYME ..................... 42

pyrazinamide ......................... 22

pyridostigmine bromide ........ 54

QUDEXY XR ....................... 16

quetiapine fumarate .............. 25

QUICK MIX with LYTES.... 31

QUILLIVANT XR................ 38

quinapril hcl .......................... 33

quinapril/hydrochlorothiazide

........................................... 33

quinidine gluconate ............... 34

quinidine sulfate .................... 34

quinine sulfate ....................... 23

QVAR ................................... 58

RABAVERT ......................... 51

raloxifene hcl ........................ 47

ramipril ................................. 33

RANEXA .............................. 35

ranitidine hcl ......................... 44

RAPAMUNE ........................ 50

REBIF ................................... 54

REBIF REBIDOSE ............... 54

RECOMBIVAX HB ............. 51

RELENZA ............................ 26

RELISTOR ........................... 45

REMICADE .......................... 54

REMODULIN....................... 61

RENAGEL ............................ 45

RENVELA ............................ 45

I-11



repaglinide ............................ 19

RESCRIPTOR ...................... 26

RESTASIS ............................ 44

RETROVIR........................... 26

REVATIO ............................. 61

REVLIMID ........................... 13

REYATAZ ............................ 26

ribavirin ................................ 27

RIDAURA ............................ 50

rifabutin................................. 22

rifampin ................................. 22

RIFATER .............................. 22

riluzole .................................. 38

rimantadine hcl ..................... 26

ringers solution ............... 52, 58

risedronate sodium................ 53

RISPERDAL CONSTA ........ 25

risperidone ............................ 25

RITUXAN............................. 14

rivastigmine tartrate ............. 17

rizatriptan benzoate .............. 21

ropinirole hcl ........................ 23

ROTARIX ............................. 51

ROTATEQ ............................ 51

ROZEREM ........................... 60

SABRIL ................................ 16

SAIZEN ................................ 48

salsalate .................................. 4

SANDOSTATIN LAR.......... 48

SANTYL ............................... 40

SAPHRIS .............................. 25

SAVELLA ............................ 38

selegiline hcl ......................... 23

selenium sulfide ..................... 40

SELZENTRY ........................ 26

SENSIPAR ............................ 54

SEREVENT DISKUS ........... 59

SEROQUEL XR ................... 25

SEROSTIM ........................... 48

sertraline hcl ......................... 18

sildenafil citrate .................... 61

SILENOR .............................. 18

silver nitrate .......................... 40

silver nitrate applicator ........ 40

silver sulfadiazine ................. 40

SIMBRINZA......................... 55

SIMPONI .............................. 54

SIMPONI ARIA ................... 54

simvastatin ............................ 37

sirolimus ................................ 50

SIRTURO ............................. 22

sod propion/inositol/aa14/urea

........................................... 21

sod/pot/k cit/sod cit/cit acid .. 58

sodium acetate ...................... 58

sodium bicarbonate ............... 58

sodium chloride ..................... 58

sodium chloride 0.45 % ........ 58

sodium chloride 3% .............. 58

sodium chloride 5 % ............. 58

sodium chloride irrig solution

........................................... 52

sodium chloride/nahco3/kcl/peg

........................................... 45

sodium lactate ....................... 58

sodium morrhuate ................. 54

sodium phos,m-basic-d-basic 58

sodium polystyrene sulfonate 45

sodium thiosulfate ................. 46

SOLIRIS ............................... 54

SOLTAMOX ........................ 14

SOLU-CORTEF ................... 48

SOMATULINE DEPOT ....... 48

SOMAVERT......................... 48

sorbitol solution .................... 52

sotalol hcl .............................. 34

SOVALDI ............................. 27

SPIRIVA ............................... 59

spironolact/hydrochlorothiazid

........................................... 37

spironolactone....................... 37

SPRYCEL ............................. 14

stavudine ............................... 26

STELARA............................. 55

STERILE DILUENT ............ 29

STIVARGA .......................... 14

STRATTERA ....................... 38

streptomycin sulfate ................ 6

STRIBILD............................. 26

STROMECTOL .................... 23

sucralfate............................... 44

sulfacetamide sodium ...... 40, 43

sulfacetamide/prednisolone sp

........................................... 43

sulfadiazine ........................... 10

sulfamethoxazole/trimethoprim

........................................... 10

sulfasalazine .......................... 10

sulindac ................................... 4

sumatriptan ........................... 21

sumatriptan succinate ........... 21

SUPPRELIN LA ................... 48

SUPRAX ................................. 8

SURMONTIL ....................... 18

SUSTIVA .............................. 26

SUTENT ............................... 14

SYLATRON 4-PACK .......... 27

SYLVANT ............................ 14

SYMLINPEN 120 ................. 19

SYMLINPEN 60 ................... 19

SYNAGIS ............................. 26

SYNAREL ............................ 55

SYNERCID............................. 7

SYNRIBO ............................. 14

SYPRINE .............................. 46

syring w-ndl,disp,insul,0.3ml 41

syring w-ndl,disp,insul,0.5ml 41

syringe & needle,insulin,1 ml 41

TABLOID ............................. 14

tacrolimus ............................. 50

TAFINLAR ........................... 14

TAMIFLU ....................... 26, 27

tamoxifen citrate ................... 14

tamsulosin hcl ....................... 46

TARCEVA ............................ 14

TARGRETIN ........................ 14

I-12



TASIGNA ............................. 14

TAZICEF IN DEXTROSE ..... 8

TAZORAC ............................ 41

TE ANATOXAL BERNA .... 51

TECFIDERA......................... 55

TEFLARO............................... 8

telmisartan ............................ 33

telmisartan/hydrochlorothiazid

........................................... 33

temazepam........................... 5, 6

TEMODAR ........................... 14

TENIVAC ............................. 51

terazosin hcl .......................... 46

terbinafine hcl ....................... 21

terbutaline sulfate ................. 59

terconazole ............................ 21

testosterone cypionate ........... 46

testosterone enanthate .......... 46

TETANUS DIPHTHERIA

TOXOIDS ......................... 51

TETANUS TOXOID

ADSORBED ..................... 51

tetracaine hcl ........................ 43

tetracycline hcl ...................... 10

TEV-TROPIN ....................... 48

THALOMID ......................... 55

theophylline anhydrous ......... 59

theophylline/d5w ................... 59

thioridazine hcl ..................... 25

thiothixene ............................. 25

tiagabine hcl.......................... 16

TIKOSYN ............................. 34

timolol maleate................ 34, 55

TIVICAY .............................. 26

tizanidine hcl ......................... 60

TOBI PODHALER ................. 6

TOBRADEX ST ................... 43

tobramycin in 0.225% nacl ..... 6

tobramycin sulfate ............. 6, 43

tobramycin/sodium chloride ... 6

tolazamide ............................. 20

tolbutamide ........................... 20

tolmetin sodium ....................... 4

tolterodine tartrate ................ 46

topiramate ............................. 16

topotecan hcl ......................... 14

TORISEL .............................. 14

torsemide ............................... 36

TOVIAZ ................................ 46

TPN ELECTROLYTES II .... 58

TRACLEER .......................... 61

TRADJENTA ....................... 19

tramadol hcl ............................ 3

tramadol hcl/acetaminophen .. 3

trandolapril ........................... 33

tranexamic acid ..................... 28

TRANSDERM-SCOP........... 22

tranylcypromine sulfate ........ 18

TRAVAMULSION............... 31

TRAVASOL ......................... 32

TRAVASOL W/DEXTROSE

........................................... 31

TRAVASOL W/


TRAVASOL with DEXTROSE

........................................... 32

TRAVASOL with


TRAVATAN Z ..................... 55

TRAVERT ............................ 32

TRAVERT IN NORMAL

SALINE ............................ 32

TRAVERT-ELECTROLYTE

NO.1 .................................. 58

TRAVERT-ELECTROLYTE

NO.2 .................................. 58

TRAVERT-ELECTROLYTE

NO.3 .................................. 58

TRAVERT-ELECTROLYTE

NO.4 .................................. 58

travoprost (benzalkonium) .... 55

trazodone hcl ......................... 18

TREANDA ........................... 14

TRECATOR ......................... 22

TRELSTAR .......................... 14

tretinoin ........................... 14, 41

tretinoin microspheres .......... 41

TREXALL ............................ 14

triamcinolone acetonide. 39, 41,

48

triamterene/hydrochlorothiazid

........................................... 36

triazolam ................................. 6

TRIBENZOR ........................ 33

trifluoperazine hcl ................. 25

trifluridine ............................. 43

trihexyphenidyl hcl ................ 23

TRILEPTAL ......................... 16

trimethoprim ........................... 7

TROKENDI XR.................... 16

TROPHAMINE .................... 32

trospium chloride .................. 46

TRUVADA ........................... 26

TUDORZA PRESSAIR ........ 59

TWINRIX ............................. 51

TYGACIL ............................. 10

TYKERB............................... 14

TYPHIM VI .......................... 51

TYSABRI ............................. 50

TYVASO .............................. 61

TYZEKA............................... 27

ULORIC ................................ 55

UROLOGIC SOLUTION G . 52

ursodiol ................................. 45

VAGIFEM ............................ 47

valacyclovir hcl ..................... 27

VALCHLOR ......................... 40

VALCYTE ............................ 27

valproic acid ......................... 16

valproic acid (as sodium salt) 16

valsartan/hydrochlorothiazide

........................................... 33

VALSTAR ............................ 14

vancomycin hcl........................ 7

VANCOMYCIN HCL ............ 7

vancomycin hcl/d5w ................ 7

I-13



VAQTA................................. 51

VARIVAX VACCINE ......... 51

VASCEPA ............................ 37

vasopressin ............................ 48

VECTIBIX ............................ 15

VELCADE ............................ 15

venlafaxine hcl ...................... 18

VENTAVIS........................... 61

verapamil hcl ........................ 34

VERSACLOZ ....................... 25

VICTOZA 3-PAK ................. 19

VIDEX .................................. 26

VIGAMOX ........................... 43

VIIBRYD .............................. 18

VIMIZIM .............................. 42

VIMPAT ............................... 16

vinblastine sulfate ................. 15

vincristine sulfate .................. 15

vinorelbine tartrate ............... 15

VIRACEPT ........................... 26

VIRAMUNE XR .................. 26

VIRAZOLE........................... 27

VIREAD ............................... 26

VIVELLE-DOT .................... 47

VOLTAREN ........................... 4

voriconazole .......................... 21

VOTRIENT........................... 15

VPRIV................................... 42

warfarin sodium .................... 28

water for irrigation,sterile .... 52

WELCHOL ........................... 37

XALKORI............................. 15

XARELTO ............................ 28

XELJANZ ............................. 55

XENAZINE .......................... 38

XGEVA................................. 53

XIFAXAN............................... 7

XOLAIR ............................... 59

XTANDI ............................... 15

XYREM ................................ 60

YERVOY .............................. 15

YF-VAX ............................... 51

zafirlukast .............................. 58

zaleplon ................................. 60

ZALTRAP............................. 15

ZAVESCA ............................ 42

ZELBORAF .......................... 15

ZEMAIRA ............................ 59

ZEMPLAR ............................ 53

ZENPEP ................................ 42

ZETIA ................................... 37

ZIAGEN ................................ 26

zidovudine ............................. 26

ziprasidone hcl ...................... 25

ZOLADEX ............................ 15

zoledronic acid ...................... 53

zoledronic acid/

mannitol&water ................ 53

ZOLINZA ............................. 15

zolmitriptan ........................... 21

zolpidem tartrate ................... 60

ZOMETA .............................. 53

zonisamide............................. 16

ZORTRESS........................... 50

ZOSTAVAX ......................... 51

ZOVIRAX............................. 40

ZUBSOLV .............................. 5

ZYKADIA ............................ 15

ZYLET .................................. 44

ZYPREXA RELPREVV ...... 25

ZYTIGA ................................ 15

ZYVOX................................... 7

Moda Health Customer Service

CALL 1-888-786-7509

Calls to this number are free. Customer Service is available from 7

am to 8 pm Pacific time seven days a week, from October 1st to

February14th (After February 15th, your call will be handled by our

automated phone system Saturdays, Sundays and holidays. When

leaving a message, please include your name, number and the time

that you called, and a Customer Service representative will return

your call the next business day.)

Customer Service also has free language interpreter services available

for non-English speakers.

TTY 711

This number requires special telephone equipment and is only for

people who have difficulties with hearing or speaking.

Calls to this number are free. This number is available 24 hours a day

seven days a week.

FAX 1-800-207-8235

WRITE Moda Health Plan, Inc.

P.O. Box 40327

Portland OR 97240-0327

[email protected]

WEB SITE www.modahealth.com/medicare

This formulary was updated on September 1, 2014. For more recent information or other questions,

please contact us.

Questions? Call 888-786-7509 (TTY users please dial 711) 601 S.W. Second Ave.

Portland, OR 97204-3156

www.modahealth.com/medicare

7830833 (9/14)

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