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Preferred Drug List (List of Covered Drugs)
This document includes Passport Health Plan’s complete 2015 formulary.
What is the Passport Health Plan formulary?
The formulary is a list of preferred drugs covered by Passport. To get a drug on our formulary, you must:
• BeaPassportmember;
• Needadrugthatismedicallynecessary;
• GettheprescriptionfilledataPassportHealthPlannetworkpharmacy.AnetworkpharmacyisonethatissignedupwithPassport;and
• FollowallPassportrules(seelimitsbelow).
The formulary is not a complete list of covered drugs by Passport. Some drugs not listed may be covered, if medically necessary. These drugs may or may not need prior-authorization.
How do I find my drug on the formulary?
• Youcansearchforadrugusingtheonlinesearchableformularyonourwebsiteatwww.passporthealthplan.com.
Are there any limits to the drugs you have been prescribed?
Some covered drugs may have limits on them. This could include:
• Prior-Authorization:SomemedicinesmustbeapprovedbyPassportbeforePassportwillcoverorpayforthem.Thismeansyourproviderwillneedtogetapprovalbeforeyoucanhaveyourprescriptionsfilled.Ifyoudonotgetapproval,Passportmaynot cover the drug.
• Quantity Limits:Forsomedrugs,therearelimitsontheamountPassportwillcover.Thismeansyoumaynotgetthestandard one month supply.
• Step Therapy:SometimesPassportrequiresyoutotrycertaindrugsfirsttotreatyourmedicalconditionbeforewewillcoveranotherdrugforthatcondition.Forexample,ifDrugAandDrugBbothtreatyourmedicalcondition,PassportmaynotcoverdrugBunlessyoutryDrugAfirst.IfDrugAdoesnotworkforyou,PassportwillthencoverDrugB.
• Too Early to Refill:Ifyouaregivenamonthsupplyofamedicine,Passportwillnotcoverarefilloftheprescriptionuntil30 days has passed.
What if my drug is not on the formulary?
Remember,notalldrugsarelistedontheformulary.IfPassportdoesnotcoveryourdrug,youhave3options:
1. Workwithyourpharmacyorprovidertofindthepreferreddrug.
2. YoucancallMemberServicesat1-800-578-0603andaskforalistofsimilardrugsthatareonPassport’sPreferredDrugList.
3. IfadrugisnotcoveredbyPassportorisnotlistedonourPreferredDrugList,yourdoctorcanrequestapprovalforit.
i
Can the formulary change?
Yes.Passportmayaddorremovedrugsfromtheformularyduringtheyear.Togetupdatedinformationaboutcovereddrugs,pleasevisitourwebsiteatwww.passporthealthplan.comorcallMemberServicesat1-800-578-0603.
What are generic drugs?
Passportcoversbothbrand-nameandgenericdrugs.Agenericdrughasthesameactiveingredientasthebrand-namedrug.Thismeanstheyworkthesameandhavethesameeffect.GenericdrugsusuallycostlessthanbrandnamedrugsandareapprovedbytheFoodandDrugAdministration(FDA).
How much are my copays?
Aslongasyoutakegenericmedicines,youwillpay$0.Ifyoutakeapreferredbrandnamemedicine,yourcopaywillbe$2.Ifyoutakeanon-preferrednamebrandmedicine,yourcopaywillbe$4.
ii
LEGEND
TYPE DESCRIPTION
QL Quantity LimitThere is a limit on the amount of this drug that is covered perprescription, or within a specific time frame.
PA Prior AuthorizationYour provider is required to get prior authorization before you fill yourprescription, which ensures appropriate use of the selected drug.Without prior approval, we may not cover this drug.
ST Step TherapyIn some cases, you may be required to first try certain drugs to treatyour medical condition before you move up a “step” to other drugoptions.
GL Gender Limit This prescription drug is restricted for a single gender. .
AL Age LimitThis prescription drug may only be covered if you meet the minimumor maximum age limit.
C Custom This drug has unique restrictions.
S Specialty DrugSpecialty drugs are high-cost drugs used to treat complex or rareconditions. Some examples of the diseases include; multiple sclerosis,rheumatoid arthritis, hepatitis C, and hemophilia.
MED Medical DrugThis medication is not on our drug list. Click on the THERAPEUTICCLASS or sub class to find covered alternative medications. If youhave questions, please contact member services.
PAGE 4 LAST UPDATED 02/2016
LIST OF COVERED PRESCRIPTION MEDICATIONS DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
butalbital/aspirin/caffeine 50-325-40 capsule generic QL
CELEBREX 50 MG CAPSULEcelecoxib
BRAND PA
choline sal/mag salicylate 500 mg/5ml liquid generic
diclofenac potassium 50 mg tablet generic
DICLOFENAC SODIUM (50 MG TABLET DR, 100 MGTAB ER 24H, 25 MG TABLET DR, 75 MG TABLET DR)
generic
DICLOFENAC SODIUM/MISOPROSTOL (50 IR, 75 IR) genericQL
PA
diflunisal 500 mg tablet generic
ETODOLAC (200 MG CAPSULE, 400 MG TAB ER 24H,400 MG TABLET, 300 MG CAPSULE, 500 MG TABLET,500 MG TAB ER 24H, 600 MG TAB ER 24H)
generic
FENOPROFEN CALCIUM (400 MG CAPSULE, 600 MGTABLET)
generic
FLURBIPROFEN (50 MG, 100 MG) generic
IBUPROFEN (400 MG, 600 MG, 800 MG) generic
INDOMETHACIN (25 MG, 75 MG ER, 50 MG) generic
indomethacin sodium 1 mg vial generic
KETOPROFEN (75 MG CAPSULE, 50 MG CAPSULE, 200MG CAP24H PEL)
generic
KETOROLAC TROMETHAMINE (15 MG/ML VIAL,30MG/ML(1) VIAL, 30 MG/ML CARTRIDGE, 10 MGTABLET, 30 MG/ML VIAL, 15 MG/ML CARTRIDGE, 60MG/2 ML VIAL, 60 MG/2 ML SYRINGE)
generic
MECLOFENAMATE SODIUM (50 MG, 100 MG) generic
mefenamic acid 250 mg capsule generic
MELOXICAM (15 MG TABLET, 7.5 MG TABLET, 7.5MG/5ML ORAL SUSP)
generic
NABUMETONE (500 MG, 750 MG) generic
NAPROXEN (125 MG/5ML ORAL SUSP, 500 MG TABLETDR, 250 MG TABLET, 375 MG TABLET, 500 MG TABLET,375 MG TABLET DR)
generic
PAGE 5 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
NAPROXEN SODIUM (550 MG, 275 MG) generic
oxaprozin 600 mg tablet generic
PIROXICAM (20 MG, 10 MG) generic
SALSALATE (750 MG, 500 MG) generic
SULINDAC (200 MG, 150 MG) generic
TOLMETIN SODIUM (600 MG TABLET, 400 MGCAPSULE, 200 MG TABLET)
generic
OPIOID ANALGESICS, LONG-ACTING
DISKETS 40 MG TABLET DISPRmethadone hcl
BRAND QL
FENTANYL (37.5MCG/HR, 87.5MCG/HR, 62.5MCG/HR) generic
QL
PA
C 12 patches/28 days
FENTANYL (50MCG/HR, 25MCG/HR, 75MCG/HR, 12MCG/HR)
generic
QL
PA
C 12 patches/28 days
fentanyl 100 mcg/hr patch td72 genericPA
C 12 patches/28 days
HYDROMORPHONE HCL (16 MG ER, 12 MG ER) generic QL
hydromorphone hcl 32 mg tab er 24h generic QL
hydromorphone hcl 8 mg tab er 24h generic QL
levorphanol tartrate 2 mg tablet generic
methadone hcl 10 mg tablet generic QL
methadone hcl 10 mg/5 ml solution genericQL
C 40ml/day
methadone hcl 10 mg/ml oral conc genericQL
C 80ml/day
methadone hcl 10 mg/ml syringe generic QL
methadone hcl 10 mg/ml vial generic
methadone hcl 40 mg tablet sol generic QL
methadone hcl 5 mg tablet generic QL
PAGE 6 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
methadone hcl 5 mg/5 ml solution genericQL
C 80ml/day
METHADONE INTENSOL 10 MG/MLmethadone hcl
BRAND QL
METHADOSE 10 MG/ML ORAL CONCmethadone hcl
BRAND QL
METHADOSE 40 MG TABLET DISPRmethadone hcl
BRAND QL
MORPHINE SULFATE (100 MG CAP ER PEL, 80 MGCAP ER PEL, 75 MG CPMP 24HR)
generic QL
MORPHINE SULFATE (100 MG ER, 200 MG ER) genericQL
PA
MORPHINE SULFATE (30 MG CPMP 24HR, 30 MG CAPER PEL)
generic QL
MORPHINE SULFATE (60 MG CPMP 24HR, 60 MG CAPER PEL, 50 MG CAP ER PEL)
generic QL
MORPHINE SULFATE (90 MG CPMP 24HR, 45 MGCPMP 24HR, 120 MG CPMP 24HR, 60 MG TABLET ER)
genericQL
PA
morphine sulfate 10 mg cap er pel generic QL
morphine sulfate 15 mg tablet er genericQL
PA
morphine sulfate 20 mg cap er pel generic QL
morphine sulfate 30 mg tablet er genericQL
PA
oxycodone hcl 10 mg tab er 12h genericQL
PA
oxycodone hcl 20 mg tab er 12h genericQL
PA
oxycodone hcl 40 mg tab er 12h genericQL
PA
oxycodone hcl 80 mg tab er 12h genericQL
PA
OXYCONTIN (30 MG, 40 MG)oxycodone hcl
BRANDQL
PA
PAGE 7 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
OXYCONTIN (60 MG, 80 MG)oxycodone hcl
BRANDQL
PA
OXYCONTIN 10 MG TABLEToxycodone hcl
BRANDQL
PA
OXYCONTIN 15 MG TABLEToxycodone hcl
BRANDQL
PA
OXYCONTIN 20 MG TABLEToxycodone hcl
BRANDQL
PA
OXYMORPHONE HCL (20 MG ER, 15 MG ER) genericQL
PA
OXYMORPHONE HCL (40 MG ER, 30 MG ER) genericQL
PA
oxymorphone hcl 10 mg tab er 12h genericQL
PA
oxymorphone hcl 5 mg tab er 12h genericQL
PA
oxymorphone hcl 7.5 mg tab er 12h genericQL
PA
TRAMADOL HCL (100 MG CPBP 25-75, 100 MG TAB ER24H)
generic QL
TRAMADOL HCL (200 MG TBMP 24HR, 150 MG CPBP25-75, 100 MG TBMP 24HR, 300 MG TBMP 24HR)
genericQL
PA
TRAMADOL HCL (300 MG TAB ER 24H, 300 MG CPBP17-83, 200 MG TAB ER 24H, 200 MG CPBP 25-75)
generic QL
OPIOID ANALGESICS, SHORT-ACTING
acetaminophen with codeine 120-12mg/5 solution genericQL
C 150 ml/day
acetaminophen with codeine 300mg-15mg tablet generic QL
acetaminophen with codeine 300mg-30mg tablet generic QL
acetaminophen with codeine 300mg-60mg tablet generic QL
PAGE 8 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
acetaminophen with codeine 300mg/12.5 solution generic C 150 ml/day
alfentanil hcl 500 mcg/ml ampul generic
ASCOMP WITH CODEINE CAPSULEcodeine phosphate/butalbital/aspirin/caffeine
BRAND QL
ASTRAMORPH-PF 1 MG/ML AMPULmorphine sulfate/pf
BRAND
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINEPHOSPHATE (50-325-30, 50-300-30)
generic QL
BUTORPHANOL TARTRATE (2 MG/ML, 1 MG/ML) generic
butorphanol tartrate 10 mg/ml spray genericQL
C 2 nasal sprayers or5ml/month
codeine sulfate 15 mg tablet generic QL
codeine sulfate 30 mg tablet generic QL
codeine sulfate 60 mg tablet generic QL
codeine/butalbital/asa/caffein 30-50-325 capsule generic QL
dhcodeine bt/acetaminophn/caff 16-320.5mg capsule generic
dihydrocodeine/aspirin/caffein 16-356-30 capsule generic QL
DURAMORPH (5 ML, 10 ML)morphine sulfate/pf
BRAND
ENDOCET (10-325 MG, 2.5-325 MG)oxycodone hcl/acetaminophen
BRAND QL
ENDOCET 5-325 TABLEToxycodone hcl/acetaminophen
BRAND QL
ENDOCET 7.5-325 MG TABLEToxycodone hcl/acetaminophen
BRAND QL
ENDODAN 4.8355-325 MG TABLEToxycodone hcl/aspirin
BRAND QL
FENTANYL CITRATE (800 MCG, 1600 MCG, 1200 MCG) generic QL
fentanyl citrate 200 mcg lozenge hd generic QL
fentanyl citrate 400 mcg lozenge hd generic QL
fentanyl citrate 600 mcg lozenge hd generic QL
FENTANYL CITRATE IN 0.9 % SODIUM CHLORIDE/PF(10 MCG/ML SYRINGE, 20 MCG/ML PLAST. BAG)
generic
FENTANYL CITRATE/BUPIVACAINE HCL IN 0.9 % generic
PAGE 9 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
SODIUM CHLORIDE/PF (4MCG/ML-.1, 2MCG/ML-.1, 2-625MCG/1, 2-1250MCG)
FENTANYL CITRATE/PF (50 MCG/ML AMPUL,100MCG/2ML SYRINGE, 50 MCG/ML VIAL)
generic
HYDROCODONE BITARTRATE/ACETAMINOPHEN (2.5-167/5, 7.5-325/15, 5-217MG/10, 2.5-108/5)
genericQL
C 32ml/day
HYDROCODONE BITARTRATE/ACETAMINOPHEN (5MG-325MG, 10MG-325MG, 5MG-300MG, 10MG-300MG,7.5-325MG, 7.5-300MG)
generic QL
hydrocodone/acetaminophen 2.5-325mg tablet generic QL
HYDROCODONE/IBUPROFEN (10MG-200MG, 5MG-200MG)
generic
hydrocodone/ibuprofen 2.5-200mg tablet generic QL
hydrocodone/ibuprofen 7.5-200 mg tablet generic QL
HYDROMORPHONE HCL (1 MG/ML SYRINGE, 2 MG/MLSYRINGE, 4 MG/ML SYRINGE, 2 MG/ML VIAL)
generic
hydromorphone hcl 1 mg/ml liquid generic QL
hydromorphone hcl 2 mg tablet generic QL
hydromorphone hcl 3 mg supp.rect generic QL
hydromorphone hcl 4 mg tablet generic QL
hydromorphone hcl 8 mg tablet generic QL
HYDROMORPHONE HCL/PF (1 MG/ML AMPUL, 10MG/ML AMPUL, 2 MG/ML AMPUL, 10 MG/ML VIAL, 4MG/ML AMPUL)
generic
ibuprofen/oxycodone hcl 400mg-5mg tablet generic QL
LORCET 5-325 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
LORCET HD 10-325 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
LORCET PLUS 7.5-325 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
LORTAB (10-325 MG, 5-325 MG, 7.5-325 MG)hydrocodone bitartrate/acetaminophen
BRAND QL
meperidine hcl 10 mg/ml cartridge generic
meperidine hcl 50 mg/5 ml solution generic QL
PAGE 10 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
C 20ml/day
MORPHINE SULFATE (10 ML, 20 ML) genericQL
C 45ml/day
MORPHINE SULFATE (2 MG/ML CARTRIDGE,250MG/10ML VIAL PORT, 8 MG/ML VIAL, 4 MG/ML VIAL,25 MG/ML VIAL, 10 MG SUPP.RECT, 30 MGSUPP.RECT, 10 MG/ML VIAL, 10 MG/ML SYRINGE, 100MG/4ML VIAL PORT, 20 MG SUPP.RECT, 50 MG/MLVIAL, 15 MG/ML CARTRIDGE, 5 MG/ML VIAL, 15 MG/MLVIAL, 8 MG/ML SYRINGE, 4 MG/ML SYRINGE, 4 MG/MLCARTRIDGE, 2 MG/ML SYRINGE, 10 MG/MLCARTRIDGE, 30 MG/30ML PCA SYRING, 5 MG/MLSYRINGE, 5 MG SUPP.RECT)
generic
morphine sulfate 100 mg/5ml solution genericQL
C 9ml/day
morphine sulfate 15 mg tablet generic QL
morphine sulfate 30 mg tablet generic QL
MORPHINE SULFATE/PF (0.5 MG/ML, 1 MG/ML, 30MG/30ML PCA, 150MG/30ML PCA)
generic
morphine sulfate/pf 1 mg/2 ml syringe generic GL Male
NALBUPHINE HCL (10 MG/ML VIAL, 20 MG/ML VIAL, 10MG/ML AMPUL, 20 MG/ML AMPUL)
generic
OPIUM/BELLADONNA ALKALOIDS (60-16.2MG, 30-16.2MG)
generic
OXYCODONE HCL (10 MG, 5 MG, 30 MG, 15 MG) generic QL
oxycodone hcl 20 mg tablet generic QL
oxycodone hcl 20 mg/ml oral conc genericQL
C 8ml/day
oxycodone hcl 5 mg capsule generic QL
oxycodone hcl 5 mg/5 ml solution genericQL
C 80ml/day
OXYCODONE HCL/ACETAMINOPHEN (2.5-325MG, 5MG-325MG)
generic QL
oxycodone hcl/acetaminophen 10mg-325mg tablet generic QL
oxycodone hcl/acetaminophen 7.5-325mg tablet generic QL
PAGE 11 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
oxycodone hcl/aspirin 4.8355-325 tablet generic QL
oxymorphone hcl 10 mg tablet generic QL
oxymorphone hcl 5 mg tablet generic QL
pentazocine hcl/naloxone hcl 50mg-0.5mg tablet generic QL
REPREXAIN (10-200 MG, 2.5-200 MG, 5-200 MG)hydrocodone/ibuprofen
BRAND QL
ROXICET 5-325 TABLEToxycodone hcl/acetaminophen
BRAND QL
SUBLIMAZE 50 MCG/ML AMPULEfentanyl citrate/pf
BRAND
SUFENTA (50 MCG/ML AMPUL, 250 MCG/5 MLAMPULE, 100 MCG/2 ML AMPUL)sufentanil citrate
BRAND
sufentanil citrate 50 mcg/ml ampul generic
tramadol hcl 50 mg tablet generic QL
tramadol hcl/acetaminophen 37.5-325mg tablet generic QL
VERDROCET 2.5-325 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
VICODIN 5-300 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
VICODIN ES 7.5-300 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
VICODIN HP 10-300 MG TABLEThydrocodone bitartrate/acetaminophen
BRAND QL
ZAMICET 10-325 MG/15 ML SOLNhydrocodone bitartrate/acetaminophen
BRAND C 32ml/day
ANESTHETICS
LOCAL ANESTHETICS
BUFFERED LIDOCAINE 1% SYRINGElidocaine hcl buffered with 8.4 % sodium bicarbonate
BRAND
BUPIVACAINE HCL (2.5 MG/ML, 5 MG/ML) generic
bupivacaine hcl/dex-water/pf 0.75 % ampul generic
BUPIVACAINE HCL/EPINEPHRINE (0.25-.0005, 0.5-1:200K)
generic
BUPIVACAINE HCL/EPINEPHRINE/PF (0.5-1:200K, 0.25-.0005)
generic
PAGE 12 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
BUPIVACAINE HCL/PF (2.5 MG/ML VIAL, 2.5 MG/MLAMPUL, 7.5 MG/ML VIAL, 5 MG/ML VIAL, 5 MG/MLAMPUL, 7.5 MG/ML AMPUL)
generic
CARBOCAINE 1.5% VIALmepivacaine hcl/pf
BRAND
CHLOROPROCAINE HCL/PF (30 MG/ML, 20 MG/ML) generic
cocaine hcl 4 % solution generic
ethyl chloride 100 % spray generic
etomidate 2 mg/ml vial generic
GLYDO 2% JELLY SYRINGElidocaine hcl
BRAND
KETAMINE HCL (10 MG/ML, 50 MG/ML, 100 MG/ML) generic
lidocaine 5 % adh. patch generic PA
lidocaine 5 % oint. (g) generic
LIDOCAINE HCL (3 % CREAM (G), 20 MG/ML DISPSYRIN, 40 MG/ML SOLUTION, 100MG/10ML DISPSYRIN, 10 MG/ML DISP SYRIN, 30 MG/3 ML SYRINGE, 2% SOLUTION, 2 % JEL/PF APP, 4 % SOLUTION, 3 %LOTION, 2 % JEL (ML))
generic
lidocaine hcl/d7.5w/pf 5 % ampul generic
LIDOCAINE HCL/DEXTROSE 5%-WATER/PF (8 MG/ML,4 MG/ML)
generic
LIDOCAINE HCL/EPINEPHRINE (2 %-1:100K, 1%-1:100K, 0.5-1:200K)
generic
LIDOCAINE HCL/EPINEPHRINE/PF (2%-1:200K VIAL,1.5-1:200K VIAL, 1.5-1:200K AMPUL)
generic
LIDOCAINE HCL/PF (50 MG/5 ML SYRINGE, 15 MG/MLAMPUL, 5 MG/ML VIAL, 10 MG/ML VIAL, 20 MG/MLAMPUL LUER, 100 MG/5ML SYRINGE, 10 MG/MLAMPUL, 40 MG/ML AMPUL, 20 MG/ML VIAL)
generic
LIDOCAINE/PRILOCAINE (2.5 CREAM (G), 2.5 KIT) generic
LORENZA 4%-1% PATCHlidocaine/menthol
BRAND
NAROPIN (2 MG/ML INFUSION, 200 MG/100 ML INF,0.2% 400 MG/200 ML)ropivacaine hcl/pf
BRAND
PAIN RELIEF 5%-1% PATCHlidocaine hcl/menthol
BRAND
POLOCAINE 1% VIALmepivacaine hcl
BRAND
PAGE 13 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
POLOCAINE-MPF (1.5%, 2%, 1%)mepivacaine hcl/pf
BRAND
PRE-ATTACHED LTA KITlidocaine hcl
BRAND
propofol 10 mg/ml vial generic
RELADOR PAK 2.5-2.5% CRM-DRESSlidocaine/prilocaine
BRAND
RELADOR PAK PLUS 2.5%-2.5%lidocaine/prilocaine
BRAND
SENSORCAINE 0.5% VIALbupivacaine hcl
BRAND
SENSORCAINE-EPINEPHRINE (0.25%-EPI 1:200000,0.5%-EPI 1:200,000)bupivacaine hcl/epinephrine
BRAND
SENSORCAINE-MPF 0.5% VIALbupivacaine hcl/pf
BRAND
tetracaine hcl/pf 10 mg/ml ampul generic
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium 333 mg tablet dr generic
DEPADE 50 MG TABLETnaltrexone hcl
BRAND
DISULFIRAM (500 MG, 250 MG) generic
naltrexone hcl 50 mg tablet generic
OPIOID DEPENDENCE TREATMENTS
BUPRENORPHINE HCL (2 MG, 8 MG) genericQL
PA
buprenorphine hcl 0.3 mg/ml syringe generic PA
buprenorphine hcl 0.3 mg/ml vial generic
BUPRENORPHINE HCL/NALOXONE HCL (/NALOXONE8 MG-2 MG, /NALOXONE 2 MG-0.5MG)
genericQL
PA
SUBOXONE (12 MG-3 MG, 2 MG-0.5 MG, 4 MG-1 MG, 8MG-2 MG)buprenorphine hcl/naloxone hcl
BRANDQL
PA
OPIOID REVERSAL AGENTS
PAGE 14 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
NALOXONE HCL (1 MG/ML, 0.4 MG/ML) generic QL
SMOKING CESSATION AGENTS
BUPROBAN 150 MG TABLETbupropion hcl
BRAND
bupropion hcl 150 mg tablet er generic
CHANTIX (0.5 MG, 1 MG)varenicline tartrate
BRAND QL
CHANTIX (1 MG CONT, STARTING)varenicline tartrate
BRAND
ANTIBACTERIALS
AMINOGLYCOSIDES
AMIKACIN SULFATE (1000MG/4ML, 500 MG/2ML) generic
GARAMYCIN (0.3%, 3 MG/ML)gentamicin sulfate
BRAND
GENTAK 0.3 % EYE OINTMENTgentamicin sulfate
BRAND
GENTAMICIN SULFATE (0.3 % OINT. (G), 20 MG/2 MLVIAL, 0.1 % OINT. (G), 0.3 % DROPS, 0.1 % CREAM (G),40 MG/ML VIAL)
generic
GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC (GENTAMIC90MG/100ML,GENTAMIC100MG/0.1L, GENTAMIC80 MG/50ML,GENTAMIC80MG/100ML, GENTAMIC60 MG/50ML,GENTAMIC70 MG/50ML)
generic
GENTAMICIN SULFATE/PF (20 MG/2 ML, 100MG/10MLPORT)
generic
neomycin sulfate 500 mg tablet generic
paromomycin sulfate 250 mg capsule generic
tobramycin 0.3 % drops generic
TOBRAMYCIN SULFATE (10 MG/ML, 40 MG/ML, 1.2 G) generic S Specialty Drug
TOBRAMYCIN SULFATE/SODIUM CHLORIDE (60MG/50ML, 80MG/100ML)
generic S Specialty Drug
ANTIBACTERIALS, OTHER
acetic acid 0.25 % irrig soln generic
BACIIM 50,000 UNITS VIALbacitracin
BRAND
bacitracin 50000 unit vial generic
PAGE 15 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
BACTROBAN NASAL 2% OINTMENTmupirocin calcium
BRAND
chloramphenicol sod succ 1 g vial generic
CLINDACIN ETZ 1% PLEDGETclindamycin phosphate
BRAND
CLINDACIN P 1% PLEDGETSclindamycin phosphate
BRAND
CLINDAMYCIN HCL (150 MG, 75 MG, 300 MG) generic
clindamycin palmitate hcl 75 mg/5 ml soln recon generic
CLINDAMYCIN PHOSPHATE (1 % FOAM, 1 % LOTION,300 MG/2ML VIAL PORT, 2 % CREAM/APPL,900MG/6ML VIAL PORT, 600 MG/4ML VIAL PORT, 150MG/ML VIAL, 1 % MED. SWAB, 1 % GEL (GRAM), 1 %SOLUTION)
generic
CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % INWATER (300MG/50ML, 900MG/50ML, 600MG/50ML)
generic
colistin (colistimethate na) 150 mg vial generic
erythromycin/benzoyl peroxide 3 %-5 % gel (gram) generic
HYOPHEN TABLETmethenamine/methylene blue/benzoicacid/salicylate/hyoscy
BRAND
lincomycin hcl 300 mg/ml vial generic
LINEZOLID (600MG/300 IV SOLN, 600 MG TABLET, 100MG/5ML SUSP RECON)
generic
linezolid-0.9% sodium chloride 600mg/300 iv soln generic PA
mafenide acetate 50 g packet generic
methen/sod phos/meth blue/hyos 81.6-.12mg tablet generic
methenamine hippurate 1 g tablet generic
METHENAMINE MANDELATE (500 MG, 1 G) generic
METRO IV 500 MG/100 MLmetronidazole in sodium chloride
BRAND
METRONIDAZOLE (250 MG TABLET, 0.75 % GELW/APPL, 500 MG TABLET, 375 MG CAPSULE)
generic
metronidazole/sodium chloride 500mg/0.1l piggyback generic
mupirocin 2 % oint. (g) generic
mupirocin calcium 2 % cream (g) generic
NEOMYCIN SULFATE/POLYMYXIN B SULFATE(AMPUL, VIAL)
generic
PAGE 16 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
NITROFURANTOIN (25 MG/5 ML ORAL SUSP, 50 MGCAPSULE)
generic
NITROFURANTOIN MACROCRYSTAL (50 MG, 25 MG,100 MG)
generic
nitrofurantoin monohyd/m-cryst 100 mg capsule generic
PHOSPHASAL TABLETmethenamine/methylene blue/sodium phos/pnyl sal/hyoscsul
BRAND
polymyxin b sulfate 500k unit vial generic
SULFAMYLON 8.5% CREAMmafenide acetate
BRAND
TINIDAZOLE (250 MG, 500 MG) generic
trimethoprim 100 mg tablet generic
TYGACIL 50 MG VIALtigecycline
BRAND
UR N-C TABLETmethenamine/methylene blue/sodium phos/pnyl sal/hyoscsul
BRAND
URETRON D-S TABLETmethenamine/methylene blue/sodium phos/pnyl sal/hyoscsul
BRAND
URIMAR-T TABLETmethenamine/methylene blue/salicylate/sodiumphos/hyoscy
BRAND
URIN D.S. TABLETmethenamine/methylene blue/sodium phos/pnyl sal/hyoscsul
BRAND
URO-BLUE TABLETSmethenamine/sodium phosphate,monobasic/methblue/hyosc sul
BRAND
UROGESIC-BLUE TABLETmethenamine/sodium phosphate,monobasic/methblue/hyosc sul
BRAND
UROLET MB TABLETmethenamine/sodium phosphate,monobasic/methblue/hyosc sul
BRAND
UROPHEN MB TABLETmethenamine/methylene blue/benzoicacid/salicylate/hyoscy
BRAND
URYL TABLETmethenamine/sodium phosphate,monobasic/methblue/hyosc sul
BRAND
PAGE 17 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
USTELL CAPSULEmethenamine/methylene blue/salicylate/sodiumphos/hyoscy
BRAND
UTIRA-C TABLETmethenamine/methylene blue/sodium phos/pnyl sal/hyoscsul
BRAND
VANCOMYCIN HCL (10 G VIAL, 250 MG CAPSULE, 500MG VIAL, 750 MG VIAL PORT, 125 MG CAPSULE, 1 GVIAL, 750 MG VIAL, 5 G VIAL, 1 G VIAL PORT, 500 MGVIAL PORT)
generic
VANCOMYCIN HCL/DEXTROSE 5 % IN WATER(500MG/0.1L FROZ.PIGGY, 1G/200ML FROZ.PIGGY,1.25 G/250 PLAST. BAG, 1.5G/250ML PLAST. BAG)
generic
VANCOMYCIN IN 0.9 % SODIUM CHLORIDE(1.5G/250ML, 750MG/.15L, 1.25 G/250)
generic
vancomycin in dextrose,iso-osm 750mg/.15l froz.piggy generic
VANDAZOLE VAGINAL 0.75% GELmetronidazole
BRAND
XIFAXAN (550 MG, 200 MG)rifaximin
BRAND
ZYVOX 100 MG/5 ML SUSPENSIONlinezolid
BRAND PA
BETA-LACTAM, CEPHALOSPORINS
CEFACLOR (500 MG TAB ER 12H, 125 MG/5ML SUSPRECON, 500 MG CAPSULE, 250 MG/5ML SUSP RECON,250 MG CAPSULE, 375 MG/5ML SUSP RECON)
generic
CEFADROXIL (500 MG CAPSULE, 500 MG/5ML SUSPRECON, 250 MG/5ML SUSP RECON, 1 G TABLET)
generic
CEFAZOLIN SODIUM (300G BULKBAGINJ, 1 G VIAL, 20G VIAL, 10 G VIAL, 500 MG VIAL, 1 G VIAL PORT, 100 GBULKBAGINJ)
generic
CEFAZOLIN SODIUM IN 0.9 % SODIUM CHLORIDE (0.92 G/100 ML PLAST. BAG, 0.9 2 G/50 ML PIGGYBACK,0.9 2 G/10 ML SYRGE)
generic
cefazolin sodium/d5w 2 g/100 ml plast. bag generic
CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC (2 MLPIGGYBACK, 1 ML FROZ.PIGGY, 1 ML PIGGYBACK)
generic
CEFDINIR (125 MG/5ML SUSP RECON, 300 MGCAPSULE, 250 MG/5ML SUSP RECON)
generic
CEFDITOREN PIVOXIL (200 MG, 400 MG) generic
CEFEPIME HCL (2, 1) generic
PAGE 18 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CEFEPIME HCL/DEXTROSE, ISO-OSMOTIC (1 G/50 ML,2 G/100 ML)
generic
CEFIXIME (200, 100) generic
CEFOTAXIME SODIUM (10 G, 2 G, 1 G, 500 MG) generic
CEFOTETAN DISODIUM (2, 10, 1) generic
CEFOXITIN SODIUM (2, 1, 10) generic
CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC (2 ML,1 ML)
generic
CEFPODOXIME PROXETIL (100 MG TABLET, 100MG/5ML SUSP RECON, 50 MG/5 ML SUSP RECON, 200MG TABLET)
generic
CEFPROZIL (250 MG TABLET, 250 MG/5ML SUSPRECON, 125 MG/5ML SUSP RECON, 500 MG TABLET)
generic
CEFTAZIDIME (1, 2, 6) generic
CEFTIBUTEN (400 MG CAPSULE, 180 MG/5ML SUSPRECON)
generic
CEFTRIAXONE SODIUM (1 G, 2 G PORT, 1 G PORT, 10G, 500 MG, 250 MG, 2 G)
generic
CEFTRIAXONE SODIUM/DEXTROSE, ISO-OSMOTIC (2ML FROZ.PIGGY, 2 ML PIGGYBACK, 1 ML PIGGYBACK,1 ML FROZ.PIGGY)
generic
CEFUROXIME AXETIL (250 MG, 500 MG) generic
CEFUROXIME SODIUM (7.5G, 750 MG, 7.5 G, 1.5 G) generic
CEFUROXIME SODIUM/DEXTROSE, ISO-OSMOTIC(750MG/50ML, 1.5G/50ML)
generic
CEPHALEXIN (250 MG TABLET, 250 MG CAPSULE, 750MG CAPSULE, 500 MG TABLET, 250 MG/5ML SUSPRECON, 125 MG/5ML SUSP RECON, 500 MG CAPSULE)
generic
CLAFORAN-DEXTROSE (2 ML, 1 ML)cefotaxime sodium/dextrose, iso-osmotic
BRAND
BETA-LACTAM, OTHER
AZTREONAM (2, 1) generic
IMIPENEM/CILASTATIN SODIUM (250 MG, 500 MG) generic
MEROPENEM (500 MG, 1 G) generic
MEROPENEM IN 0.9 % SODIUM CHLORIDE (1 G/50 ML,500MG/50ML)
generic
BETA-LACTAM, PENICILLINS
PAGE 19 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
AMOXICILLIN (250 MG CAPSULE, 500 MG TABLET, 400MG/5ML SUSP RECON, 500 MG CAPSULE, 125 MG TABCHEW, 250 MG TAB CHEW, 125 MG/5ML SUSP RECON,875 MG TABLET, 250 MG/5ML SUSP RECON, 200MG/5ML SUSP RECON)
generic
AMOXICILLIN/POTASSIUM CLAVULANATE (600-42.9/5SUSP RECON, 400-57MG TAB CHEW, 200-28.5MG TABCHEW, 875-125 MG TABLET, 400-57MG/5 SUSPRECON, 250-62.5/5 SUSP RECON, 250-125 MGTABLET, 200-28.5/5 SUSP RECON, 1000-62.5 TAB ER12H, 500-125 MG TABLET)
generic
AMPICILLIN SODIUM (500 MG, 10 G, 1 G, 2 G PORT, 2G, 1 G PORT, 250 MG, 125 MG)
generic
AMPICILLIN SODIUM/SULBACTAM SODIUM (15, 1.5PORT, 3, 3 PORT, 1.5)
generic
AMPICILLIN TRIHYDRATE (250 MG CAPSULE, 500 MGCAPSULE, 250 MG/5ML SUSP RECON, 125 MG/5MLSUSP RECON)
generic
DICLOXACILLIN SODIUM (500 MG, 250 MG) generic
NAFCILLIN IN DEXTROSE, ISO-OSMOTIC (1 G/50 ML, 2G/100 ML)
generic
NAFCILLIN SODIUM (2 PORT, 2, 1 PORT, 1, 10) generic
OXACILLIN SODIUM (10, 2 PORT, 1, 2, 1 PORT) generic
OXACILLIN SODIUM/DEXTROSE, ISO-OSMOTIC (2 ML,1 ML)
generic
PENICILLIN G POTASSIUM (5MM, 20MM) generic
PENICILLIN G PROCAINE (1.2MM/2 ML SYRINE,600000/ML SYRINE)
generic
penicillin g sodium 5mm unit vial generic
PENICILLIN V POTASSIUM (500 MG TABLET, 250 MGTABLET, 250 MG/5ML SOLN RECON, 125 MG/5MLSOLN RECON)
generic
PFIZERPEN (20 UNIT, 5 UNITS)penicillin g potassium
BRAND
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM (40.5,4.5, 3.375, 4.5 PORT, 3.375 PORT, 2.25 PORT, 2.25)
generic
MACROLIDES
AZITHROMYCIN (200 MG/5ML SUSP RECON, 500 MGVIAL PORT, 100 MG/5ML SUSP RECON, 500 MG VIAL, 1G PACKET, 250 MG TABLET)
generic
AZITHROMYCIN (500 MG, 600 MG) generic QL
PAGE 20 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CLARITHROMYCIN (250, 125) generic C 150ml/fill
CLARITHROMYCIN (500 MG, 250 MG) generic QL
clarithromycin 500 mg tab er 24h generic QL
E.E.S. 200 MG/5 ML GRANULESerythromycin ethylsuccinate
BRAND
E.E.S. 400 FILMTABerythromycin ethylsuccinate
BRAND
ERY 2% PADSerythromycin base/ethyl alcohol
BRAND
ery e-succ/sulfisoxazole 200-600/5 susp recon generic
ERY-TAB (250 MG, 500 MG, 333 MG)erythromycin base
BRAND
ERYGEL 2% GELerythromycin base/ethyl alcohol
BRAND
ERYPED 200 MG/5 ML SUSPENSIONerythromycin ethylsuccinate
BRAND
ERYPED 400 MG/5 ML SUSPENSIONerythromycin ethylsuccinate
BRAND
ERYTHROCIN 250 MG FILMTABerythromycin stearate
BRAND
ERYTHROMYCIN BASE (500 MG TABLET, 250 MGTABLET, 250 MG CAPSULE DR, 5 MG/G OINT. (G),5MG/G OINT. (G))
generic
ERYTHROMYCIN BASE/ETHYL ALCOHOL (2 MED.SWAB, 2 SOLUTION, 2 GEL (GRAM))
generic
erythromycin ethylsuccinate 400 mg tablet generic
QUINOLONES
AVELOX IV 400 MG/250 MLmoxifloxacin hcl/sodium chloride, iso-osmotic
BRAND
CIPRO (5%, 10%)ciprofloxacin
BRAND C 10ml/day; 150ml/fill
CIPROFLOXACIN HCL (0.3 DROPS, 0.2 DROPERETTE) generic
CIPROFLOXACIN HCL (100 MG, 500 MG, 750 MG) generic QL
ciprofloxacin hcl 250 mg tablet generic QL
CIPROFLOXACIN LACTATE (400MG/40ML,200MG/20ML)
generic
CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN WATER generic
PAGE 21 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
(400MG/0.2L, 200MG/0.1L)
CIPROFLOXACIN/CIPROFLOXACIN HCL (500 MG, 1000MG)
generic QL
gatifloxacin 0.5 % drops generic
LEVOFLOXACIN (0.5 % DROPS, 25 MG/ML VIAL) generic
LEVOFLOXACIN (500 MG, 750 MG, 250 MG) generic C 5 tablets/30 days
levofloxacin 250mg/10ml solution generic C 480ml/fill
LEVOFLOXACIN/DEXTROSE 5 % IN WATER(750MG/.15L, 250MG/50ML, 500MG/0.1L)
generic
MOXEZA 0.5% EYE DROPSmoxifloxacin hcl
BRAND
moxifloxacin hcl 400 mg tablet generic QL
moxifloxacin/sod.ace,sul/water 400mg/.25l piggyback generic
OFLOXACIN (0.3 % DROPS, 400 MG TABLET, 300 MGTABLET, 200 MG TABLET)
generic
SULFONAMIDES
silver sulfadiazine 1 % cream (g) generic
SSD 1% CREAMsilver sulfadiazine
BRAND
SULFACETAMIDE SODIUM (10 DROPS, 10SUSPENSION, 10 OINT. (G))
generic
sulfadiazine 500 mg tablet generic
SULFAMETHOXAZOLE/TRIMETHOPRIM (800-160/20ORAL SUSP, 200-40MG/5 ORAL SUSP, 80-16MG/MLVIAL, 400MG-80MG TABLET, 800-160 MG TABLET)
generic
SULFATRIM PEDIATRIC SUSPENSIONsulfamethoxazole/trimethoprim
BRAND
THERMAZENE 1% CREAMsilver sulfadiazine
BRAND
TETRACYCLINES
AVIDOXY 100 MG TABLETdoxycycline monohydrate
BRAND
DEMECLOCYCLINE HCL (150 MG, 300 MG) generic
DOXYCYCLINE MONOHYDRATE (150 MG TABLET, 75MG CAPSULE, 50 MG CAPSULE, 100 MG TABLET, 75MG TABLET, 100 MG CAPSULE, 40 MG CAP IR DR, 150MG CAPSULE, 50 MG TABLET, 25 MG/5 ML SUSPRECON)
generic
PAGE 22 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MINOCYCLINE HCL (135 MG TAB ER 24H, 100 MGCAPSULE, 90 MG TAB ER 24H, 75 MG CAPSULE, 45MG TAB ER 24H, 100 MG TABLET, 50 MG TABLET, 75MG TABLET, 50 MG CAPSULE)
generic
MONDOXYNE NL (50 MG, 75 MG, 100 MG)doxycycline monohydrate
BRAND
OCUDOX CONVENIENCE KITdoxycycline hyclate/eyelid clns no.3/eyelid emollient no.1
BRAND
TETRACYCLINE HCL (500 MG, 250 MG) generic
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
LEVETIRACETAM (1000 MG TABLET, 500 MG/5MLSOLUTION, 500 MG TAB ER 24H, 100 MG/MLSOLUTION, 500 MG TABLET, 750 MG TABLET, 750 MGTAB ER 24H, 500 MG/5ML VIAL, 250 MG TABLET)
generic
POTIGA (50 MG, 300 MG, 200 MG, 400 MG)ezogabine
BRAND
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN 300 MG KAPSEALmethsuximide
BRAND
ETHOSUXIMIDE (250 MG/5ML SOLUTION, 250 MGCAPSULE)
generic
ZONISAMIDE (50 MG, 100 MG, 25 MG) generic
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
DIAZEPAM (12.5-15-20, 2.5 MG, 5-7.5-10MG) generic C 2 kits/30 days
DIVALPROEX SODIUM (125 MG TABLET DR, 250 MGTAB ER 24H, 125 MG CAP SPRINK, 500 MG TABLETDR, 500 MG TAB ER 24H, 250 MG TABLET DR)
generic
GABAPENTIN (250 MG/5ML SOLUTION, 800 MGTABLET, 100 MG CAPSULE, 300 MG/6ML SOLUTION,300 MG CAPSULE, 600 MG TABLET, 400 MG CAPSULE)
generic
GABITRIL (12 MG, 16 MG)tiagabine hcl
BRAND
ONFI (2.5 MG/ML SUSPENSION, 5 MG TABLET, 20 MGTABLET, 10 MG TABLET)clobazam
BRAND
PHENOBARBITAL (60 MG TABLET, 15 MG TABLET, 100MG TABLET, 64.8 MG TABLET, 30 MG TABLET, 97.2MGTABLET, 16.2 MG TABLET, 32.4 MG TABLET, 20 MG/5ML ELIXIR)
generic
PAGE 23 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
PHENOBARBITAL SODIUM (130MG/ML, 65 MG/ML) generic
PRIMIDONE (250 MG, 50 MG) generic
SABRIL (500 MG TABLET, 500 MG POWDER PACKET)vigabatrin
BRAND S Specialty Drug
TIAGABINE HCL (4 MG, 2 MG) generic
VALPROIC ACID (AS SODIUM SALT) (VALPROATESODIUM) (500 MG/5ML VIAL, 250 MG/5ML SOLUTION,500MG/10ML SOLUTION)
generic
valproic acid 250 mg capsule generic
GLUTAMATE REDUCING AGENTS
FELBAMATE (400 MG TABLET, 600 MG TABLET, 600MG/5ML ORAL SUSP)
generic
LAMOTRIGINE (50 MG TAB RAPDIS, 100 MG TAB ER24, 25-50-100 TB RD DSPK, 300 MG TAB ER 24, 5 MGTB CHW DSP, 100 MG TAB RAPDIS, 25MG (35) TAB DSPK, 200 MG TABLET, 200 MG TAB ER 24, 25(21)-50 TBRD DSPK, 150 MG TABLET, 50 MG TAB ER 24, 100 MGTABLET, 25 MG TABLET, 25 MG TAB ER 24, 250 MGTAB ER 24, 200 MG TAB RAPDIS, 25 MG TAB RAPDIS,50(42)-100 TB RD DSPK, 25 MG TB CHW DSP)
generic
TOPIRAGEN (200 MG, 50 MG, 25 MG, 100 MG)topiramate
BRAND
TOPIRAMATE (25 MG CAP SPRINK, 200 MG TABLET,50 MG TABLET, 25 MG TABLET, 100 MG TABLET, 15MG CAP SPRINK)
generic
SODIUM CHANNEL AGENTS
BANZEL (400 MG TABLET, 40 MG/ML SUSPENSION,200 MG TABLET)rufinamide
BRAND
CARBAMAZEPINE (400 MG TAB ER 12H, 200 MGTABLET, 300 MG CPMP 12HR, 200 MG TAB ER 12H, 200MG CPMP 12HR, 100 MG CPMP 12HR, 100 MG/5MLORAL SUSP, 100 MG TAB CHEW)
generic
DILANTIN 30 MG CAPSULEphenytoin sodium extended
BRAND
EPITOL 200 MG TABLETcarbamazepine
BRAND
FOSPHENYTOIN SODIUM (500 PE/10, 100MG PE/2) generic
OXCARBAZEPINE (150 MG TABLET, 300 MG TABLET,600 MG TABLET, 300 MG/5ML ORAL SUSP)
generic
PEGANONE 250 MG TABLET BRAND
PAGE 24 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ethotoin
PHENYTOIN (50 MG TAB CHEW, 125 MG/5ML ORALSUSP, 100 MG/4ML ORAL SUSP)
generic
PHENYTOIN SODIUM (50 MG/ML SYRINGE, 50 MG/MLVIAL, 50 MG/ML AMPUL)
generic
PHENYTOIN SODIUM EXTENDED (300 MG, 100 MG,200 MG)
generic
TEGRETOL XR 100 MG TABLETcarbamazepine
BRAND
VIMPAT (200 MG/20 ML VIAL, 10 MG/ML SOLUTION, 150MG TABLET, 100 MG TABLET, 200 MG TABLET, 50 MGTABLET)lacosamide
BRAND
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates 1 mg tablet generic
ISOXSUPRINE HCL (20 MG, 10 MG) generic
papaverine hcl 30 mg/ml vial generic
CHOLINESTERASE INHIBITORS
DONEPEZIL HCL (10 MG TABLET, 5 MG TAB RAPDIS,10 MG TAB RAPDIS, 23 MG TABLET, 5 MG TABLET)
generic
GALANTAMINE HBR (12 MG TABLET, 24 MG CAP24HPEL, 4 MG TABLET, 8 MG CAP24H PEL, 8 MG TABLET,16 MG CAP24H PEL, 4 MG/ML SOLUTION)
generic
RIVASTIGMINE (13.3MG/24H, 9.5MG/24HR,4.6MG/24HR)
generic
RIVASTIGMINE TARTRATE (1.5 MG, 6 MG, 4.5 MG, 3MG)
generic
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
MEMANTINE HCL (10 MG, 5 MG) generic GL Male
MEMANTINE HCL (5 MG-10 MG TAB DS PK, 2 MG/MLSOLUTION)
generic
NAMENDA (10 MG TABLET, 5-10 MG TITRATION PK, 5MG TABLET, 2 MG/ML SOLUTION)memantine hcl
BRAND
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
PAGE 25 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE (25 MG-10MG, 12.5MG-5MG)
generic
BUDEPRION XL 300 MG TABLETbupropion hcl
BRAND QL
BUPROPION HCL (75 MG TABLET, 200 MG TABLET ER,150 MG TABLET ER, 100 MG TABLET ER, 300 MG TABER 24H, 100 MG TABLET)
generic
bupropion hcl 150 mg tab er 24h generic QL
MIRTAZAPINE (15 MG TABLET, 45 MG TABLET, 7.5 MGTABLET, 45 MG TAB RAPDIS, 15 MG TAB RAPDIS, 30MG TABLET, 30 MG TAB RAPDIS)
generic
OLANZAPINE/FLUOXETINE HCL (6MG-50MG, 6MG-25MG, 12MG-25MG, 12MG-50MG, 3 MG-25 MG)
generic
PERPHENAZINE/AMITRIPTYLINE HCL (4 MG-25 MG,4MG-10MG, 2 MG-10 MG, 4 MG-50 MG, 2 MG-25 MG)
generic
MONOAMINE OXIDASE INHIBITORS
phenelzine sulfate 15 mg tablet generic
tranylcypromine sulfate 10 mg tablet generic
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINEREUPTAKE INHIBITOR
CITALOPRAM HYDROBROMIDE (40 MG TABLET, 10MG TABLET, 20 MG TABLET, 10 MG/5 ML SOLUTION)
generic
ESCITALOPRAM OXALATE (20 MG TABLET, 10 MGTABLET, 5 MG/5 ML SOLUTION, 5 MG TABLET)
generic
FLUOXETINE HCL (20 MG TABLET, 40 MG CAPSULE,20 MG/5 ML SOLUTION, 90 MG CAPSULE DR, 10 MGTABLET, 20 MG CAPSULE, 10 MG CAPSULE)
generic
FLUVOXAMINE MALEATE (150 MG CAP ER 24H, 100MG CAP ER 24H, 25 MG TABLET, 100 MG TABLET, 50MG TABLET)
generic
MAPROTILINE HCL (25 MG, 75 MG, 50 MG) generic
PAROXETINE HCL (12.5 MG TAB ER 24H, 10 MGTABLET, 25 MG TAB ER 24H, 20 MG TABLET, 40 MGTABLET, 30 MG TABLET, 37.5 MG TAB ER 24H)
generic
SERTRALINE HCL (50 MG TABLET, 25 MG TABLET, 20MG/ML ORAL CONC, 100 MG TABLET)
generic
TRAZODONE HCL (100 MG, 50 MG, 300 MG, 150 MG) generic
VENLAFAXINE HCL (37.5 MG ER, 150 MG ER) generic
VENLAFAXINE HCL (50 MG, 25 MG, 37.5 MG, 100 MG) generic QL
PAGE 26 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
venlafaxine hcl 225 mg tab er 24 generic QL
venlafaxine hcl 75 mg cap er 24h generic QL
venlafaxine hcl 75 mg tablet generic QL
TRICYCLICS
AMITRIPTYLINE HCL (50 MG, 75 MG, 100 MG, 25 MG,10 MG, 150 MG)
generic
AMOXAPINE (25 MG, 100 MG, 50 MG, 150 MG) generic
CLOMIPRAMINE HCL (50 MG, 75 MG, 25 MG) generic
DESIPRAMINE HCL (10 MG, 75 MG, 100 MG, 25 MG, 50MG, 150 MG)
generic
DOXEPIN HCL (150 MG CAPSULE, 75 MG CAPSULE, 50MG CAPSULE, 25 MG CAPSULE, 100 MG CAPSULE, 10MG/ML ORAL CONC, 10 MG CAPSULE)
generic
IMIPRAMINE HCL (25 MG, 10 MG, 50 MG) generic
IMIPRAMINE PAMOATE (150 MG, 75 MG, 100 MG, 125MG)
generic
NORTRIPTYLINE HCL (50 MG CAPSULE, 10 MG/5 MLSOLUTION, 25 MG CAPSULE, 10 MG CAPSULE, 75 MGCAPSULE)
generic
PROTRIPTYLINE HCL (5 MG, 10 MG) generic
ANTIEMETICS
ANTIEMETICS, OTHER
COMPRO 25 MG SUPPOSITORYprochlorperazine
BRAND
dimenhydrinate 50 mg/ml vial generic
MECLIZINE HCL (25 MG, 12.5 MG) generic
METOCLOPRAMIDE HCL (10 MG TABLET, 5 MG TABRAPDIS, 5 MG TABLET, 10 MG/10ML SOLUTION, 10 MGTAB RAPDIS, 5 MG/ML VIAL, 5 MG/5 ML SOLUTION)
generic
PERPHENAZINE (16 MG, 2 MG, 4 MG, 8 MG) generic
PHENADOZ (12.5 MG, 25 MG)promethazine hcl
BRAND
PHENERGAN (50 MG, 12.5 MG, 25 MG)promethazine hcl
BRAND
prochlorperazine 25 mg supp.rect generic
PROCHLORPERAZINE EDISYLATE (10 MG/2 ML, 5 generic
PAGE 27 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MG/ML)
PROCHLORPERAZINE MALEATE (5 MG, 10 MG) generic
PROMETHAZINE HCL (50 MG, 12.5 MG, 25 MG) generic
PROMETHEGAN (50 MG SUPPOSITORY, 25 MG SUPP,12.5 MG SUPPOS)promethazine hcl
BRAND
TRIMETHOBENZAMIDE HCL (300 MG CAPSULE, 100MG/ML VIAL)
generic
EMETOGENIC THERAPY ADJUNCTS
DRONABINOL (10 MG, 2.5 MG, 5 MG) generic
EMEND (TRIPACK, 40 MG CAPSULE, 125 MGCAPSULE, 80 MG CAPSULE, 150 MG VIAL)aprepitant
BRAND S Specialty Drug
GRANISETRON HCL (1 MG/ML(1), 1 MG/ML) genericPA
S Specialty Drug
granisetron hcl 1 mg tablet generic S Specialty Drug
GRANISETRON HCL/PF (100 MCG/ML, 1 MG/ML(1)) genericPA
S Specialty Drug
GRANISOL 2 MG/10 ML SOLUTIONgranisetron hcl
BRANDPA
C 50ml/30 days
ONDANSETRON (8 MG, 4 MG) generic
ONDANSETRON HCL (8 MG TABLET, 4 MG/5 MLSOLUTION, 4 MG TABLET, 24 MG TABLET)
generic
ondansetron hcl 2 mg/ml vial generic PA
ondansetron hcl/pf 4 mg/2 ml syringe genericPA
S Specialty Drug
ondansetron hcl/pf 4 mg/2 ml vial generic S Specialty Drug
ANTIFUNGALS
amphotericin b 50 mg vial generic
CANCIDAS (70 MG, 50 MG)caspofungin acetate
BRAND
CICLODAN 0.77% CREAMciclopirox olamine
BRAND
CICLOPIROX (1 SHAMPOO, 0.77 GEL (GRAM), 8 generic
PAGE 28 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
SOLUTION)
CICLOPIROX OLAMINE (0.77 CREAM (G), 0.77SUSPENSION)
generic
ciclopirox/ure/camph/menth/euc 8 % solution generic
econazole nitrate 1 % cream (g) generic
FIRST-BXN MOUTHWASHnystatin/lidocaine hcl/diphenhydramine hcl
BRAND
FLUCONAZOLE (10 MG/ML SUSP RECON, 50 MGTABLET, 40 MG/ML SUSP RECON, 100 MG TABLET)
generic
FLUCONAZOLE (150 MG, 200 MG) generic QL
FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC(400MG/0.2L, 200MG/0.1L)
generic
FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC(200MG/0.1L PGGYBK BTL, 400MG/0.2L PGGYBK BTL,100MG/50ML PGGYBK BTL, 200MG/0.1L PIGGYBACK,400MG/0.2L PIGGYBACK)
generic
FLUCYTOSINE (500 MG, 250 MG) generic
GRISEOFULVIN ULTRAMICROSIZE (125 MG, 250 MG) generic
GRISEOFULVIN, MICROSIZE (500 MG TABLET, 125MG/5ML ORAL SUSP)
generic
GYNAZOLE 1 2% CREAMbutoconazole nitrate
BRAND
itraconazole 100 mg capsule generic
KETOCONAZOLE (2 CREAM (G), 2 FOAM, 2 SHAMPOO) generic
ketoconazole 200 mg tablet generic QL
KETODAN (KIT, )ketoconazole/skin cleanser combination no.28
BRAND
LAMISIL (187.5 MG PACK, 125 MG PACKET)terbinafine hcl
BRAND
miconazole nitrate 200 mg supp.vag generic
MYCAMINE (50 MG, 100 MG)micafungin sodium
BRAND
naftifine hcl 2 % cream (g) generic
NATACYN EYE DROPSnatamycin
BRAND
NOXAFIL (40 MG/ML SUSPENSION, 300 MG/16.7 MLVIAL, DR 100 MG TABLET)posaconazole
BRAND
PAGE 29 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
NYAMYC 100,000 UNITS/GM POWDERnystatin
BRAND
NYSTATIN (100000/ML ORAL SUSP, 500MM UNITPOWDER(EA), 150MM UNIT POWDER(EA), 100000/GPOWDER, 100000/G CREAM (G), 100000/G OINT. (G),50MM UNIT POWDER(EA), 500K UNIT TABLET)
generic
NYSTATIN/TRIAMCINOLONE ACETONIDE (CREAM,OINT.)
generic
NYSTOP 100,000 UNITS/GM POWDERnystatin
BRAND
PEDI-DRI TOPICAL POWDERnystatin
BRAND
SPORANOX 10 MG/ML SOLUTIONitraconazole
BRAND
terbinafine hcl 250 mg tablet generic C max 84 daystherapy/365 days
TERCONAZOLE (0.4 % CREAM/APPL, 80 MGSUPP.VAG, 0.8 % CREAM/APPL)
generic
triacetin 100 % liquid generic
VORICONAZOLE (200 MG VIAL, 200 MG/5ML SUSPRECON, 50 MG TABLET)
generic
voriconazole 200 mg tablet generic QL
ANTIGOUT AGENTS
ALLOPURINOL (300 MG, 100 MG) generic
allopurinol sodium 500 mg vial generic
ALOPRIM 500 MG VIALallopurinol sodium
BRAND
COLCHICINE (0.6 MG CAPSULE, 0.6 MG TABLET) generic
colchicine/probenecid 0.5-500mg tablet generic
COLCRYS 0.6 MG TABLETcolchicine
BRAND PA
probenecid 500 mg tablet generic
ULORIC (40 MG, 80 MG)febuxostat
BRAND
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS
PAGE 30 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
DIHYDROERGOTAMINE MESYLATE (1 MG/ML AMPUL,1 MG/ML VIAL, 0.5MG/SPRY SPRAY/PUMP)
generic
ergotamine tartrate/caffeine 1 mg-100mg tablet generic
MIGERGOT SUPPOSITORYergotamine tartrate/caffeine
BRAND
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
ALMOTRIPTAN MALATE (12.5 MG, 6.25 MG) generic
NARATRIPTAN HCL (2.5 MG, 1 MG) generic QL
RIZATRIPTAN BENZOATE (10 MG TABLET, 5 MGTABLET, 5 MG TAB RAPDIS, 10 MG TAB RAPDIS)
generic
SUMATRIPTAN (20 MG, 5 MG) generic C 6 nasal sprayers/month
SUMATRIPTAN SUCCINATE (50 MG, 100 MG, 25 MG) generic
SUMATRIPTAN SUCCINATE (6 PEN INJCTR, 6SYRINGE, 6 CARTRIDGE, 4 PEN INJCTR, 4CARTRIDGE, 6 VIAL)
generic C 4 injections (2kits)/month
ZOLMITRIPTAN (5 MG TAB RAPDIS, 2.5 MG TABRAPDIS, 5 MG TABLET, 2.5 MG TABLET)
generic
ZOMIG (2.5 MG, 5 MG)zolmitriptan
BRAND C 6 nasal sprayers/month
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
ENLON 10 MG/ML VIALedrophonium chloride
BRAND
guanidine hcl 125 mg tablet generic
MESTINON (180 MG TIMESPAN, 60 MG/5 ML SYRUP)pyridostigmine bromide
BRAND
NEOSTIGMINE METHYLSULFATE (4 MG/4 MLSYRINGE, 1 MG/ML VIAL, 2 MG/2 ML SYRINGE, 1:2000VIAL, 1:1000 VIAL, 3 MG/3 ML SYRINGE, 0.5 MG/MLVIAL)
generic
physostigmine salicylate 1 mg/ml ampul generic
PROSTIGMIN 15 MG TABLETneostigmine bromide
BRAND
PYRIDOSTIGMINE BROMIDE (180 MG ER, 60 MG) generic
REGONOL 10 MG/2 ML AMPULpyridostigmine bromide
BRAND
ANTIMYCOBACTERIALS
PAGE 31 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ANTIMYCOBACTERIALS, OTHER
DAPSONE (100 MG, 25 MG) generic
MYCOBUTIN 150 MG CAPSULErifabutin
BRAND
rifabutin 150 mg capsule generic
ANTITUBERCULARS
ETHAMBUTOL HCL (100 MG, 400 MG) generic
ISONIAZID (50 MG/5 ML SOLUTION, 100 MG/ML VIAL,300 MG TABLET, 100 MG TABLET)
generic
PRIFTIN 150 MG TABLETrifapentine
BRAND
pyrazinamide 500 mg tablet generic
RIFAMPIN (600 MG VIAL, 150 MG CAPSULE, 300 MGCAPSULE)
generic
SIRTURO 100 MG TABLETbedaquiline fumarate
BRAND
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN 2 MG TABLETmelphalan
BRAND
BICNU 100 MG VIALcarmustine
BRAND
BUSULFEX 60 MG/10 ML VIALbusulfan
BRAND
CYCLOPHOSPHAMIDE (25 MG TABLET, 2 G VIAL, 50MG TABLET, 500 MG VIAL, 1 G VIAL)
generic
GLEOSTINE (40 MG, 100 MG, 10 MG, 5 MG)lomustine
BRAND
HEXALEN 50 MG CAPSULEaltretamine
BRAND S Specialty Drug
IFOSFAMIDE (1 G/20 ML, 3G/60ML, 3 G, 1 G) generic
IFOSFAMIDE/MESNA (1G-1G, 3G-1G) generic
LEUKERAN 2 MG TABLETchlorambucil
BRAND S Specialty Drug
LOMUSTINE (100 MG, 10 MG, 40 MG) generic S Specialty Drug
MATULANE 50 MG CAPSULEprocarbazine hcl
BRAND S Specialty Drug
PAGE 32 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
melphalan hcl 50 mg vial generic
MUSTARGEN 10 MG VIALmechlorethamine hcl
BRAND MED Medical Drug
MYLERAN 2 MG TABLETbusulfan
BRAND
TEMODAR 100 MG VIALtemozolomide
BRAND S Specialty Drug
TEMOZOLOMIDE (5 MG, 20 MG, 140 MG, 100 MG, 180MG, 250 MG)
generic S Specialty Drug
TREANDA (100 MG, 25 MG)bendamustine hcl
BRAND
VALCHLOR 0.016% GELmechlorethamine hcl
BRAND
ANTIANDROGENS
bicalutamide 50 mg tablet generic S Specialty Drug
flutamide 125 mg capsule generic
NILANDRON 150 MG TABLETnilutamide
BRAND S Specialty Drug
XTANDI 40 MG CAPSULEenzalutamide
BRAND S Specialty Drug
ZYTIGA 250 MG TABLETabiraterone acetate
BRAND S Specialty Drug
ANTIANGIOGENIC AGENTS
POMALYST (3 MG, 2 MG, 4 MG, 1 MG)pomalidomide
BRAND S Specialty Drug
REVLIMID (2.5 MG, 15 MG, 5 MG, 10 MG, 25 MG, 20 MG)lenalidomide
BRAND S Specialty Drug
THALOMID (50 MG, 150 MG, 100 MG, 200 MG)thalidomide
BRAND S Specialty Drug
ANTIESTROGENS/MODIFIERS
EMCYT 140 MG CAPSULEestramustine phosphate sodium
BRAND
FARESTON 60 MG TABLETtoremifene citrate
BRAND S Specialty Drug
TAMOXIFEN CITRATE (10 MG, 20 MG) generic
ANTIMETABOLITES
PAGE 33 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ADRUCIL (2,500 MG/50 ML, 500 MG/10 ML, 5 GRAM/100ML)fluorouracil
BRAND S Specialty Drug
ALIMTA (500 MG, 100 MG)pemetrexed disodium
BRAND
CAPECITABINE (500 MG, 150 MG) generic S Specialty Drug
cladribine 10 mg/10ml vial generic
cytarabine 20 mg/ml vial generic S Specialty Drug
CYTARABINE/PF (2 G/20 ML, 100 MG, 1 G, 500 MG, 20MG/ML, 100 MG/5ML)
generic S Specialty Drug
DROXIA (400 MG, 200 MG, 300 MG)hydroxyurea
BRAND
ELITEK (1.5 MG, 7.5 MG)rasburicase
BRAND
floxuridine 500 mg vial generic MED Medical Drug
FLUOROURACIL (2.5 G/50ML, 1 G/20 ML, 5 G/100 ML,500MG/10ML)
generic S Specialty Drug
FLUOROURACIL (5 SOLUTION, 2 SOLUTION, 5 CREAM(G))
generic
FOLOTYN (20 MG/ML, 40 MG/2 ML)pralatrexate
BRAND
GEMCITABINE HCL (200 MG, 2 G, 1 G, 2 G/52.6ML,200MG/5.26, 1 G/26.3ML)
generic
hydroxyurea 500 mg capsule generic
mercaptopurine 50 mg tablet generic
pentostatin 10 mg vial generic
PURINETHOL 50 MG TABLETmercaptopurine
BRAND PA
TABLOID 40 MG TABLETthioguanine
BRAND S Specialty Drug
ANTINEOPLASTICS, OTHER
ABRAXANE 100 MG VIALpaclitaxel protein-bound
BRAND
ADRIAMYCIN (50 MG, 10 MG, 2 MG/ML, 200 MG/100 ML,20 MG)doxorubicin hcl
BRAND
amifostine crystalline 500 mg vial generic
ARRANON 250 MG VIAL BRAND
PAGE 34 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
nelarabine
CARBOPLATIN (10 MG/ML, 150 MG) generic
CERUBIDINE 20 MG VIALdaunorubicin hcl
BRAND
cisplatin 1 mg/ml vial generic
DACARBAZINE (200 MG, 100 MG) generic
dactinomycin 0.5 mg vial generic
DAUNORUBICIN HCL (20 MG, 5 MG/ML) generic
DAUNOXOME (2 MG/ML, 50 MG (2 MG/ML))daunorubicin citrate liposomal
BRAND
decitabine 50 mg vial generic
DEXRAZOXANE HCL (250 MG, 500 MG) generic
DOCETAXEL (20 MG/2 ML, 160 MG/8ML, FNL 20MG/2,20MG/ML(1), 200MG/20ML, 160MG/16ML, 140 MG/7ML,80 MG/8 ML, 80 MG/4 ML, FNL 80MG/8)
generic
DOXIL 2 MG/ML VIALdoxorubicin hcl pegylated liposomal
BRAND
DOXORUBICIN HCL (50 MG, 10 MG, 50 MG/25ML, 20MG/10ML, 2 MG/ML, 10 MG/5 ML)
generic
doxorubicin hcl peg-liposomal 2 mg/ml vial generic
ELOXATIN (200 MG/40 ML, 100 MG/20 ML, 50 MG/10ML)oxaliplatin
BRAND
EPIRUBICIN HCL (50 MG, 50 MG/25ML, 200 MG,200MG/0.1L)
generic
FLUDARABINE PHOSPHATE (50 MG, 50 MG/2 ML) generic
FUSILEV I.V. 50 MG VIALlevoleucovorin calcium
BRAND
idarubicin hcl 1 mg/ml vial generic
IRINOTECAN HCL (40 MG/2 ML, 100 MG/5ML,500MG/25ML)
generic
ISTODAX 10 MG VIALromidepsin
BRAND
IXEMPRA (15 MG, 45 MG)ixabepilone
BRAND
LEUCOVORIN CALCIUM (100 MG VIAL, 500MG/50MLVIAL, 500 MG VIAL, 50 MG VIAL, 200 MG VIAL, 350 MGVIAL, 10 MG TABLET, 5 MG TABLET, 25 MG TABLET, 15MG TABLET)
generic S Specialty Drug
PAGE 35 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
leucovorin calcium 10 mg/ml vial generic
levoleucovorin calcium 10 mg/ml vial generic
LIPODOX 2 MG/ML VIALdoxorubicin hcl pegylated liposomal
BRAND
LIPODOX 50 2 MG/ML VIALdoxorubicin hcl pegylated liposomal
BRAND
LYSODREN 500 MG TABLETmitotane
BRAND S Specialty Drug
MARQIBO KITvincristine sulfate liposomal
BRAND
mesna 100 mg/ml vial generic
MESNEX 400 MG TABLETmesna
BRAND
MITOMYCIN (5 MG, 40 MG, 20 MG) generic
mitoxantrone hcl 2 mg/ml vial generic
ONXOL 30 MG/5 ML VIALpaclitaxel
BRAND
OXALIPLATIN (50 MG, 100 MG, 50 MG/10ML,100MG/20ML)
generic
paclitaxel 6 mg/ml vial generic
PHOTOFRIN 75 MG VIALporfimer sodium
BRAND
SYLATRON (200 MCG, 600 MCG, 300 MCG)peginterferon alfa-2b
BRAND S Specialty Drug
SYLATRON 4-PACK (300 MCG, 200 MCG)peginterferon alfa-2b
BRAND S Specialty Drug
SYLATRON 888 MCG 4-PACKpeginterferon alfa-2b
BRAND
teniposide 50 mg/5 ml ampul generic
THERACYS 81 MG VIALbcg live
BRAND MED Medical Drug
thiotepa 15 mg vial generic
TRISENOX 10 MG/10 ML AMPULEarsenic trioxide
BRAND
VINBLASTINE SULFATE (1 MG/ML, 10 MG) generic
VINCASAR PFS (2 MG/2 ML, 1 MG/ML)vincristine sulfate
BRAND
VINCRISTINE SULFATE (2 MG/2 ML, 1 MG/ML) generic
PAGE 36 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
VINORELBINE TARTRATE (50 MG/5 ML, 10 MG/ML) generic
VUMON 50 MG/5 ML AMPULEteniposide
BRAND
ZANOSAR 1 GM POWDER VIALstreptozocin
BRAND
ZOLINZA 100 MG CAPSULEvorinostat
BRAND S Specialty Drug
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole 1 mg tablet generic S Specialty Drug
exemestane 25 mg tablet generic S Specialty Drug
letrozole 2.5 mg tablet generic S Specialty Drug
ENZYME INHIBITORS
ETOPOSIDE (20 MG/ML VIAL, 50 MG CAPSULE) generic S Specialty Drug
TOPOSAR (100 MG/5 ML, 500 MG/25 ML, 1,000 MG/50ML)etoposide
BRAND S Specialty Drug
MOLECULAR TARGET INHIBITORS
AFINITOR (10 MG, 7.5 MG, 2.5 MG, 5 MG)everolimus
BRAND S Specialty Drug
AFINITOR DISPERZ (2 MG, 5 MG, 3 MG)everolimus
BRAND S Specialty Drug
BOSULIF (500 MG, 100 MG)bosutinib
BRAND S Specialty Drug
CAPRELSA (300 MG, 100 MG)vandetanib
BRAND S Specialty Drug
ERIVEDGE 150 MG CAPSULEvismodegib
BRAND S Specialty Drug
GILOTRIF (20 MG, 40 MG, 30 MG)afatinib dimaleate
BRAND S Specialty Drug
GLEEVEC (100 MG, 400 MG)imatinib mesylate
BRAND S Specialty Drug
IBRANCE (125 MG, 100 MG, 75 MG)palbociclib
BRANDPA
S Specialty Drug
ICLUSIG 15 MG TABLETponatinib hcl
BRAND S Specialty Drug
ICLUSIG 45 MG TABLETponatinib hcl
BRAND
PAGE 37 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
IMATINIB MESYLATE (400 MG, 100 MG) generic S Specialty Drug
IMBRUVICA 140 MG CAPSULEibrutinib
BRAND
QL
PA
S Specialty Drug
INLYTA (5 MG, 1 MG)axitinib
BRAND S Specialty Drug
JAKAFI (10 MG, 15 MG, 5 MG, 25 MG, 20 MG)ruxolitinib phosphate
BRAND S Specialty Drug
MEKINIST (2 MG, 0.5 MG)trametinib dimethyl sulfoxide
BRAND S Specialty Drug
NEXAVAR 200 MG TABLETsorafenib tosylate
BRAND S Specialty Drug
SPRYCEL (80 MG, 20 MG, 140 MG, 70 MG, 100 MG, 50MG)dasatinib
BRAND S Specialty Drug
STIVARGA 40 MG TABLETregorafenib
BRAND S Specialty Drug
SUTENT (50 MG, 12.5 MG, 25 MG)sunitinib malate
BRAND S Specialty Drug
TAFINLAR (50 MG, 75 MG)dabrafenib mesylate
BRAND S Specialty Drug
TARCEVA (150 MG, 100 MG, 25 MG)erlotinib hcl
BRAND S Specialty Drug
TASIGNA (150 MG, 200 MG)nilotinib hcl
BRAND S Specialty Drug
TORISEL 25 MG KITtemsirolimus
BRAND
TYKERB 250 MG TABLETlapatinib ditosylate
BRANDPA
S Specialty Drug
VOTRIENT 200 MG TABLETpazopanib hcl
BRAND S Specialty Drug
XALKORI (200 MG, 250 MG)crizotinib
BRAND S Specialty Drug
ZELBORAF 240 MG TABLETvemurafenib
BRAND S Specialty Drug
ZYDELIG (100 MG, 150 MG)idelalisib
BRANDPA
S Specialty Drug
ZYKADIA 150 MG CAPSULE BRAND QL
PAGE 38 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ceritinibPA
S Specialty Drug
MONOCLONAL ANTIBODIES
ARZERRA (1,000 MG/50 ML, 100 MG/5 ML)ofatumumab
BRAND
AVASTIN (100 MG/4 ML, 400 MG/16 ML)bevacizumab
BRAND
BEXXAR (14 MG/ML DOSIMETRIC, 14 MG/MLTHERAPEUTIC)tositumomab (with maltose)
BRAND
ERBITUX (100 MG/50 ML, 200 MG/100 ML)cetuximab
BRAND
HERCEPTIN 440 MG VIALtrastuzumab
BRAND PA
KADCYLA (160 MG, 100 MG)ado-trastuzumab emtansine
BRAND PA
PERJETA 420 MG/14 ML VIALpertuzumab
BRAND
RITUXAN 10 MG/ML VIALrituximab
BRAND PA
VECTIBIX (100 MG/5 ML, 400 MG/20 ML)panitumumab
BRAND
ZEVALIN Y-90 VIALkit for prep yttrium-90/ibritumomab tiuxetan/albumin human
BRAND
RETINOIDS
bexarotene 75 mg capsule generic
TARGRETIN (1% GEL, 75 MG CAPSULE)bexarotene
BRAND S Specialty Drug
TARGRETIN 75 MG SOFTGELbexarotene
BRAND
tretinoin 10 mg capsule generic
ANTIPARASITICS
ANTIHELMINTHICS
ALBENZA 200 MG TABLETalbendazole
BRAND
STROMECTOL 3 MG TABLETivermectin
BRAND
PAGE 39 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ANTIPROTOZOALS
ALINIA (500 MG TABLET, 100 MG/5 ML SUSPENSION)nitazoxanide
BRAND
atovaquone 750 mg/5ml oral susp generic
ATOVAQUONE/PROGUANIL HCL (250-100 MG, 62.5-25MG)
generic
CHLOROQUINE PHOSPHATE (500 MG, 250 MG) generic
COARTEM TABLETSartemether/lumefantrine
BRAND
DARAPRIM 25 MG TABLETpyrimethamine
BRAND
hydroxychloroquine sulfate 200 mg tablet generic
mefloquine hcl 250 mg tablet generic
MEPRON 750 MG/5 ML SUSPENSIONatovaquone
BRAND
NEBUPENT 300 MG INHAL POWDERpentamidine isethionate
BRAND
quinine sulfate 324 mg capsule generic
PEDICULICIDES/SCABICIDES
EURAX (CREAM, LOTION)crotamiton
BRAND
LINDANE (1 LOTION, 1 SHAMPOO) generic C
60ml/fill; must trypermethrin andpiperonylbutoxide/pyrethrins
malathion 0.5 % lotion generic C
60ml/fill; must trypermethrin andpiperonylbutoxide/pyrethrins
permethrin 5 % cream (g) generic C 120ml/fill
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
BENZTROPINE MESYLATE (2 MG/2 ML VIAL, 2 MG/2 MLAMPUL, 1 MG TABLET, 2 MG TABLET, 0.5 MG TABLET)
generic
TRIHEXYPHENIDYL HCL (2 MG/5 ML ELIXIR, 2 MGTABLET, 5 MG TABLET)
generic
ANTIPARKINSON AGENTS, OTHER
PAGE 40 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
AMANTADINE HCL (100 MG TABLET, 100 MGCAPSULE, 50 MG/5 ML SOLUTION)
generic
CARBIDOPA/LEVODOPA/ENTACAPONE (50-200-200,37.5-150MG, 18.75-75MG, 25-100-200, 31.25-125, 12.5-50 MG)
generic
entacapone 200 mg tablet generic
TASMAR 100 MG TABLETtolcapone
BRAND
tolcapone 100 mg tablet generic
DOPAMINE AGONISTS
APOKYN 30 MG/3 ML CARTRIDGEapomorphine hcl
BRAND S Specialty Drug
BROMOCRIPTINE MESYLATE (2.5 MG TABLET, 5 MGCAPSULE)
generic
PRAMIPEXOLE DI-HCL (0.375 MG TAB ER 24H, 1.5 MGTABLET, 0.125 MG TABLET, 2.25 MG TAB ER 24H, 0.5MG TABLET, 1.5 MG TAB ER 24H, 4.5 MG TAB ER 24H,0.25 MG TABLET, 0.75 MG TAB ER 24H, 3 MG TAB ER24H, 0.75 MG TABLET, 1 MG TABLET)
generic
ROPINIROLE HCL (3 MG TABLET, 2 MG TAB ER 24H, 8MG TAB ER 24H, 1 MG TABLET, 5 MG TABLET, 12 MGTAB ER 24H, 6 MG TAB ER 24H, 0.5 MG TABLET, 4 MGTABLET, 4 MG TAB ER 24H, 0.25 MG TABLET, 2 MGTABLET)
generic
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa 25 mg tablet generic
CARBIDOPA/LEVODOPA (25MG-250MG TAB RAPDIS,25MG-250MG TABLET, 25MG-100MG TAB RAPDIS,25MG-100MG TABLET ER, 10MG-100MG TAB RAPDIS,50MG-200MG TABLET ER, 10MG-100MG TABLET,25MG-100MG TABLET)
generic
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
SELEGILINE HCL (5 MG TABLET, 5 MG CAPSULE) generic
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
CHLORPROMAZINE HCL (100 MG TABLET, 200 MGTABLET, 25 MG TABLET, 10 MG TABLET, 25 MG/MLAMPUL, 50 MG TABLET)
generic
DROPERIDOL (2.5 MG/ML AMPUL, 2.5 MG/ML VIAL) generic
fluphenazine decanoate 25 mg/ml vial generic
PAGE 41 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
FLUPHENAZINE HCL (2.5 MG/5ML ELIXIR, 10 MGTABLET, 5 MG TABLET, 2.5 MG TABLET, 5 MG/MLORAL CONC, 2.5 MG/ML VIAL, 1 MG TABLET)
generic
HALOPERIDOL (20 MG, 0.5 MG, 2 MG, 10 MG, 1 MG, 5MG)
generic
HALOPERIDOL DECANOATE (50 MG/ML VIAL, 100MG/ML AMPUL, 50 MG/ML AMPUL, 100 MG/ML VIAL)
generic
HALOPERIDOL LACTATE (2 MG/ML ORAL CONC, 5MG/ML VIAL, 5 MG/ML AMPUL)
generic
LOXAPINE SUCCINATE (10 MG, 5 MG, 50 MG, 25 MG) generic
MOLINDONE HCL (10 MG, 5 MG, 25 MG) generic GL Male
PIMOZIDE (2 MG, 1 MG) generic
THIORIDAZINE HCL (50 MG, 10 MG, 25 MG, 100 MG) generic
THIOTHIXENE (1 MG, 10 MG, 2 MG, 5 MG) generic
TRIFLUOPERAZINE HCL (10 MG, 1 MG, 2 MG, 5 MG) generic
2ND GENERATION/ATYPICAL
ABILIFY (10 MG, 30 MG, 20 MG, 15 MG, 5 MG)aripiprazole
BRAND QL
ABILIFY 1 MG/ML SOLUTIONaripiprazole
BRAND C 30ml/DAY
ABILIFY 2 MG TABLETaripiprazole
BRAND QL
ABILIFY 9.7 MG/1.3 ML VIALaripiprazole
BRAND C 30ml/day
ABILIFY DISCMELT (10 MG, 15 MG)aripiprazole
BRAND QL
ABILIFY MAINTENA ER 300 MG SYRaripiprazole
BRANDQL
PA
ABILIFY MAINTENA ER 300 MG VLaripiprazole
BRANDPA
C 30ml/day
ABILIFY MAINTENA ER 400 MG SYRaripiprazole
BRANDQL
PA
ABILIFY MAINTENA ER 400 MG VLaripiprazole
BRANDPA
C 30ml/DAY
ARIPIPRAZOLE (15 MG, 10 MG) generic QL
QL
PAGE 42 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ARIPIPRAZOLE (15 MG, 10 MG, 30 MG, 5 MG, 20 MG, 2MG)
generic
aripiprazole 1 mg/ml solution generic QL
GEODON 20 MG/ML VIALziprasidone mesylate
BRAND
INVEGA SUSTENNA (156 MG SY, 117 MG SY, 39 MGSYR, 234 MG SY, 78 MG SYR)paliperidone palmitate
BRANDPA
C must try 1 oralantipsychotic
INVEGA TRINZA (819 MG/2.625 ML, 546 MG/1.75 ML)paliperidone palmitate
BRANDQL
PA
INVEGA TRINZA 273 MG/0.875 MLpaliperidone palmitate
BRANDQL
PA
INVEGA TRINZA 410 MG/1.315 MLpaliperidone palmitate
BRANDQL
PA
OLANZAPINE (10 MG, 5 MG, 20 MG) genericQL
PA
OLANZAPINE (15 MG TAB RAPDIS, 10 MG VIAL) generic QL
OLANZAPINE (20 MG, 10 MG, 5 MG, 2.5 MG, 7.5 MG, 15MG)
generic QL
PALIPERIDONE (9 MG ER 24, 6 MG ER 24, 1.5 MG ER24, 3 MG ER 24)
generic
QUETIAPINE FUMARATE (200 MG, 50 MG, 400 MG, 25MG, 300 MG, 100 MG)
generic QL
RISPERDAL CONSTA (25 MG, 12.5 MG, 50 MG, 37.5MG)risperidone microspheres
BRAND PA
RISPERIDONE (1 MG TAB RAPDIS, 2 MG TABLET, 4 MGTAB RAPDIS, 4 MG TABLET, 0.25 MG TABLET, 1 MG/MLSOLUTION, 2 MG TAB RAPDIS, 0.25 MG TAB RAPDIS, 3MG TAB RAPDIS, 0.5 MG TAB RAPDIS, 1 MG TABLET, 3MG TABLET, 0.5 MG TABLET)
generic
SEROQUEL XR (200 MG, 150 MG, 400 MG, 300 MG)quetiapine fumarate
BRAND
QL
C
dosage <150mg/daybeyond initial 30 dayswill require PA forthosebetween 13-64yrs ofage
SEROQUEL XR 50 MG TABLETquetiapine fumarate
BRAND QL
PAGE 43 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
C
dosage <150mg/daybeyond initial 30 dayswill require PA forthosebetween 13-64yrs ofage
SEROQUEL XR SAMPLE KITquetiapine fumarate
BRAND
ZIPRASIDONE HCL (80 MG, 60 MG, 20 MG, 40 MG) generic QL
TREATMENT-RESISTANT
CLOZAPINE (50 MG TABLET, 12.5 MG TAB RAPDIS, 200MG TABLET, 25 MG TABLET, 100 MG TABLET, 150 MGTAB RAPDIS, 25 MG TAB RAPDIS, 200 MG TABRAPDIS, 100 MG TAB RAPDIS)
generic
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
cidofovir 75 mg/ml vial generic
foscarnet sodium 24 mg/ml infus. btl generic
ganciclovir sodium 500 mg vial generic
VALCYTE (450 MG TABLET, 50 MG/ML SOLUTION)valganciclovir hcl
BRAND
valganciclovir hcl 450 mg tablet generic
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil 10 mg tablet generic
BARACLUDE 0.05 MG/ML SOLUTIONentecavir
BRAND S Specialty Drug
ENTECAVIR (0.5 MG, 1 MG) genericQL
S Specialty Drug
EPIVIR HBV 25 MG/5 ML SOLNlamivudine
BRAND
lamivudine 100 mg tablet generic
TYZEKA 600 MG TABLETtelbivudine
BRAND
ANTI-HEPATITIS C (HCV) AGENTS
HARVONI 90-400 MG TABLETledipasvir/sofosbuvir
BRAND
QL
PA
S Specialty Drug
PAGE 44 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
INCIVEK 375 MG TABLETtelaprevir
BRANDPA
S Specialty Drug
INFERGEN (15 MCG/0.5 ML, 9 MCG/0.3 ML)interferon alfacon-1
BRANDPA
S Specialty Drug
INTRON A (50 UNITS VIL, 6 UNIT/ML VL, 10 UNIT/ML, 18UNITS VIL, 10 UNITS VIL)interferon alfa-2b,recomb.
BRAND
MODERIBA 200 MG TABLETribavirin
BRANDPA
S Specialty Drug
PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 MLSYRINGE)peginterferon alfa-2a
BRANDPA
S Specialty Drug
PEGASYS PROCLICK (180, 135)peginterferon alfa-2a
BRANDPA
S Specialty Drug
RIBASPHERE (600 MG TABLET, 400 MG TABLET, 200MG TABLET, 200 MG CAPSULE)ribavirin
BRANDPA
S Specialty Drug
RIBASPHERE RIBAPAK (200-400 MG, 600-600 MG, 600-400 MG, 400-400 MG)ribavirin
BRANDPA
S Specialty Drug
RIBAVIRIN (200 MG CAPSULE, 200 MG TABLET) genericPA
S Specialty Drug
SOVALDI 400 MG TABLETsofosbuvir
BRAND
QL
PA
S Specialty Drug
TECHNIVIE DOSE PACKombitasvir/paritaprevir/ritonavir
BRAND
QL
PA
S Specialty Drug
VICTRELIS 200 MG CAPSULEboceprevir
BRANDPA
S Specialty Drug
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
ISENTRESS (100 MG POWDER PACKET, 25 MGTABLET CHEW, 400 MG TABLET, 100 MG TABLETCHEW)raltegravir potassium
BRAND PA
STRIBILD TABLET BRAND
PAGE 45 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
elvitegravir/cobicistat/emtricitabine/tenofovir
TIVICAY 50 MG TABLETdolutegravir sodium
BRAND
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA TABLETefavirenz/emtricitabine/tenofovir disoproxil fumarate
BRAND
COMPLERA TABLETemtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate
BRAND
EDURANT 25 MG TABLETrilpivirine hcl
BRAND
INTELENCE (25 MG, 200 MG, 100 MG)etravirine
BRAND
NEVIRAPINE (100 MG TAB ER 24H, 50 MG/5 ML ORALSUSP, 200 MG TABLET, 400 MG TAB ER 24H)
generic
RESCRIPTOR (100 MG, 200 MG)delavirdine mesylate
BRAND
SUSTIVA (200 MG CAPSULE, 600 MG TABLET, 50 MGCAPSULE)efavirenz
BRAND
VIRAMUNE XR (400 MG, 100 MG)nevirapine
BRAND
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 300 mg tablet generic
abacavir/lamivudine/zidovudine 150-300mg tablet generic
DIDANOSINE (250 MG, 400 MG, 200 MG, 125 MG) generic
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)emtricitabine
BRAND
EPIVIR 10 MG/ML ORAL SOLNlamivudine
BRAND
EPZICOM TABLETabacavir sulfate/lamivudine
BRAND
LAMIVUDINE (300 MG TABLET, 10 MG/ML SOLUTION,150 MG TABLET)
generic
lamivudine/zidovudine 150-300mg tablet generic
STAVUDINE (30 MG CAPSULE, 40 MG CAPSULE, 15MG CAPSULE, 20 MG CAPSULE, 1 MG/ML SOLNRECON)
generic
TRUVADA 200 MG-300 MG TABLETemtricitabine/tenofovir disoproxil fumarate
BRAND
PAGE 46 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
VIDEX (2, 4)didanosine
BRAND
VIREAD (POWDER, 300 MG TABLET, 200 MG TABLET,150 MG TABLET, 250 MG TABLET)tenofovir disoproxil fumarate
BRAND
ZIAGEN 20 MG/ML SOLUTIONabacavir sulfate
BRAND
ZIDOVUDINE (10 MG/ML SYRUP, 300 MG TABLET, 100MG CAPSULE)
generic
ANTI-HIV AGENTS, OTHER
FUZEON (90 MG VIAL, CONVENIENCE KIT)enfuvirtide
BRAND
SELZENTRY (300 MG, 150 MG)maraviroc
BRAND PA
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE)tipranavir
BRAND
CRIXIVAN (400 MG, 200 MG)indinavir sulfate
BRAND
INVIRASE (500 MG TABLET, 200 MG CAPSULE)saquinavir mesylate
BRAND
KALETRA (100-25 MG TABLET, 400-100/5 ML ORALSOLU, 200-50 MG TABLET)lopinavir/ritonavir
BRAND
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET)fosamprenavir calcium
BRAND
NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100MG SOFTGEL CAP)ritonavir
BRAND
PREZISTA (600 MG TABLET, 100 MG/ML SUSPENSION,150 MG TABLET, 400 MG TABLET, 800 MG TABLET, 75MG TABLET)darunavir ethanolate
BRAND
REYATAZ (200 MG, 100 MG, 300 MG, 150 MG)atazanavir sulfate
BRAND
VIRACEPT (625 MG, 250 MG)nelfinavir mesylate
BRAND
ANTI-INFLUENZA AGENTS
RELENZA 5 MG DISKHALERzanamivir
BRAND C max 10 day supply/fill
PAGE 47 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
rimantadine hcl 100 mg tablet generic
TAMIFLU (45 MG, 30 MG)oseltamivir phosphate
BRAND
TAMIFLU 6 MG/ML SUSPENSIONoseltamivir phosphate
BRAND C 25ml/day
TAMIFLU 75 MG CAPSULEoseltamivir phosphate
BRAND C 20 capsules/180 days
ANTIHERPETIC AGENTS
ACYCLOVIR (200 MG CAPSULE, 400 MG TABLET, 800MG TABLET, 200 MG/5ML ORAL SUSP)
generic
acyclovir 5 % oint. (g) generic C 15gm/fill
ACYCLOVIR SODIUM (500 MG, 50 MG/ML, 1000 MG) generic
FAMCICLOVIR (500 MG, 250 MG, 125 MG) generic
trifluridine 1 % drops generic
VALACYCLOVIR HCL (500 MG, 1000 MG) generic
ZOVIRAX 5% CREAMacyclovir
BRAND C 5gm/fill
ANXIOLYTICS
ANXIOLYTICS, OTHER
BUSPIRONE HCL (5 MG, 30 MG, 7.5 MG, 10 MG, 15 MG) generic
MIDAZOLAM HCL (5 MG/ML(1) VIAL, 2 MG/ML SYRUP, 2MG/2 ML VIAL, 5 MG/ML VIAL, 5 MG/5 ML VIAL, 10 MG/2ML VIAL, 10 MG/10ML VIAL)
generic
MIDAZOLAM HCL/PF (5 MG/ML SYRINGE, 5 MG/MLCARTRIDGE, 5 MG/5 ML VIAL, 2 MG/2 ML CARTRIDGE,10 MG/2 ML VIAL, 2 MG/2 ML VIAL, 10 MG/2 MLSYRINGE, 5 MG/ML(1) VIAL, 2 MG/2 ML SYRINGE)
generic
BENZODIAZEPINES
ALPRAZOLAM (2 MG TAB RAPDIS, 1 MG TABLET, 0.25MG TAB RAPDIS, 0.5 MG TAB RAPDIS, 0.5 MG TAB ER24H, 2 MG TABLET, 3 MG TAB ER 24H, 1 MG TABRAPDIS, 1 MG TAB ER 24H, 0.25 MG TABLET, 2 MGTAB ER 24H, 0.5 MG TABLET)
generic
ALPRAZOLAM 1 MG/ML ORAL CONCalprazolam
BRAND
CHLORDIAZEPOXIDE HCL (25 MG, 5 MG, 10 MG) generic
CLONAZEPAM (0.125 MG TAB RAPDIS, 0.5 MGTABLET, 1 MG TAB RAPDIS, 0.25 MG TAB RAPDIS, 1 generic
PAGE 48 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MG TABLET, 0.5 MG TAB RAPDIS, 2 MG TAB RAPDIS, 2MG TABLET)
CLORAZEPATE DIPOTASSIUM (7.5 MG, 3.75 MG, 15MG)
generic
DIAZEPAM (2 MG TABLET, 10 MG TABLET, 5 MG/5 MLSOLUTION, 5 MG/ML SYRINGE, 5 MG/ML ORAL CONC,5 MG TABLET, 5 MG/ML VIAL)
generic
LORAZEPAM (4 MG/ML SYRINGE, 2 MG/ML SYRINGE,0.5 MG TABLET, 4 MG/ML VIAL, 2 MG/ML VIAL, 1 MGTABLET, 2 MG/ML ORAL CONC, 2 MG TABLET)
generic
LORAZEPAM INTENSOL 2 MG/MLlorazepam
BRAND
OXAZEPAM (10 MG, 15 MG, 30 MG) generic
BIPOLAR AGENTS
MOOD STABILIZERS
LITHIUM CARBONATE (300 MG TABLET ER, 300 MGTABLET, 300 MG CAPSULE, 600 MG CAPSULE, 150 MGCAPSULE, 450 MG TABLET ER)
generic
lithium citrate 8 meq/5 ml solution generic
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
ACARBOSE (50 MG, 25 MG, 100 MG) generic
ACTOPLUS MET XR (30-1,000 MG, 15-1,000 MG)pioglitazone hcl/metformin hcl
BRAND PA
BYDUREON 2 MG PEN INJECTexenatide microspheres
BRANDPA
C 1 unit/7 days
BYDUREON 2 MG VIALexenatide microspheres
BRANDPA
C 1 unit/7 days
BYETTA (5 MCG, 10 MCG)exenatide
BRANDQL
PA
GLIMEPIRIDE (1 MG, 4 MG, 2 MG) generic
GLIPIZIDE (10 MG TAB ER 24, 5 MG TABLET, 10 MGTABLET, 5 MG TAB ER 24, 2.5 MG TAB ER 24)
generic
GLIPIZIDE/METFORMIN HCL (2.5-250 MG, 5 MG-500MG,2.5-500 MG)
generic
GLYBURIDE (2.5 MG, 5 MG, 1.25 MG) generic
PAGE 49 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
GLYBURIDE,MICRONIZED (3 MG, 6 MG, 1.5 MG) generic
GLYBURIDE/METFORMIN HCL (2.5-500 MG, 1.25-250MG, 5 MG-500MG)
generic
INVOKAMET (50-1,000 MG, 50-500 MG, 150-500 MG,150-1,000 MG)canagliflozin/metformin hcl
BRANDQL
C must try metformin for6 months
INVOKANA (100 MG, 300 MG)canagliflozin
BRAND
JANUMET (50-1,000 MG, 50-500 MG)sitagliptin phosphate/metformin hcl
BRANDST
C must try metformin for6 mos
JANUMET XR (50-500 MG, 50-1,000 MG, 100-1,000 MG)sitagliptin phosphate/metformin hcl
BRANDST
C must try metformin for6 mos
JANUVIA (25 MG, 100 MG)sitagliptin phosphate
BRANDST
C must try metformin for6 mos
JANUVIA 50 MG TABLETsitagliptin phosphate
BRAND
PA
ST
C must try metformin for6 mos
JENTADUETO (2.5 MG-850 MG, 2.5 MG-1000 MG, 2.5MG-500 MG)linagliptin/metformin hcl
BRANDST
C must try metformin for6 mos
METFORMIN HCL (850 MG TABLET, 750 MG TAB ER24H, 1000 MG TABERGR24H, 1000 MG TAB ER 24, 500MG TABERGR24H, 1000 MG TABLET, 500 MG TAB ER24, 500 MG TAB ER 24H)
generic
metformin hcl 500 mg tablet generic GL Male
NATEGLINIDE (120 MG, 60 MG) generic PA
PIOGLITAZONE HCL (30 MG, 15 MG, 45 MG) generic
PIOGLITAZONE HCL/GLIMEPIRIDE (30 MG-4 MG, 30MG-2 MG)
generic
PIOGLITAZONE HCL/METFORMIN HCL (15MG-500MG,15MG-850MG)
generic
REPAGLINIDE (1 MG, 2 MG, 0.5 MG) generic
REPAGLINIDE/METFORMIN HCL (1MG-500MG, 2 MG-500MG)
generic
RIOMET 500 MG/5 ML SOLUTION BRAND
PAGE 50 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
metformin hcl
SYMLINPEN 120 PEN INJECTORpramlintide acetate
BRAND PA
SYMLINPEN 60 PEN INJECTORpramlintide acetate
BRAND PA
TOLAZAMIDE (250 MG, 500 MG) generic
tolbutamide 500 mg tablet generic
TRADJENTA 5 MG TABLETlinagliptin
BRANDST
C must try metformin for6 mos
VICTOZA 2-PAK 18 MG/3 ML PENliraglutide
BRANDQL
PA
VICTOZA 3-PAK 18 MG/3 ML PENliraglutide
BRANDQL
PA
GLYCEMIC AGENTS
GLUCAGEN (1 MG HYPOKIT, DIAGNOSTIC 1 MG VIAL,1 MG HYPOKIT 2-PACK)glucagon,human recombinant
BRAND
GLUCAGON 1 MG EMERGENCY KITglucagon,human recombinant
BRAND
glucagon hcl 1 mg vial generic
PROGLYCEM 50 MG/ML ORAL SUSPdiazoxide
BRAND
INSULINS
HUMALOG 200 UNITS/ML KWIKPENinsulin lispro
BRAND
HUMULIN R 500 UNITS/ML VIALinsulin regular, human
BRAND
LANTUS 100 UNITS/ML VIALinsulin glargine,human recombinant analog
BRAND
LANTUS SOLOSTAR 100 UNITS/MLinsulin glargine,human recombinant analog
BRAND
LEVEMIR 100 UNITS/ML VIALinsulin detemir
BRAND
LEVEMIR FLEXPEN 100 UNITS/MLinsulin detemir
BRAND
LEVEMIR FLEXTOUCH 100 UNITS/MLinsulin detemir
BRAND
PAGE 51 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
ACD INJECTION SOLUTIONdextrose-water/sodium citrate/citric acid
BRAND
ACD-A SOLUTIONcitrate dextrose solution
BRAND
argatroban in nacl,iso-osmotic 50 mg/50ml vial generic PA
citrate phosphate dextros soln 2.63 g/100 solution generic
ENOXAPARIN SODIUM (300MG/3ML VIAL, 150 MG/MLSYRINGE, 120MG/.8ML SYRINGE, 100 MG/MLSYRINGE, 40MG/0.4ML SYRINGE, 30MG/0.3MLSYRINGE, 80MG/0.8ML SYRINGE, 60MG/0.6MLSYRINGE)
generic C PA required if days'supply > or =11 days
FONDAPARINUX SODIUM (10MG/0.8ML, 2.5 MG/0.5,5MG/0.4ML, 7.5MG/0.6)
generic
PA
C PA required if days'supply > or =11 days
S Specialty Drug
HEPARIN 50 UNITS/5 ML (10/ML)heparin sodium,porcine/pf
BRAND
HEPARIN SODIUM,PORCINE (20000/ML VIAL, 10UNIT/ML VIAL, 1000/ML VIAL, 100/ML (1) SYRINGE, 10UNIT/ML SYRINGE, 300/3 ML SYRINGE, 100/ML VIAL,5000/ML VIAL, 200/2 ML SYRINGE, 5000/ML(1)CARTRIDGE, 500/5 ML SYRINGE, 10000/ML VIAL)
generic
HEPARIN SODIUM,PORCINE IN 0.45 % SODIUMCHLORIDE (HEPAR25000/500, HEPAR25000/250)
generic
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUMCHLORIDE (1K/1000 ML IV SOLN, 100/ML KIT, 10UNIT/ML KIT, 6K/1000 ML IV SOLN)
generic
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUMCHLORIDE/PF (2K/1000ML, 1000/500ML)
generic
HEPARIN SODIUM,PORCINE/DEXTROSE 5 % INWATER (25000/250, 20K/500ML, 12500/250, 25000/500)
generic
HEPARIN SODIUM,PORCINE/PF (5000/0.5ML SYRINGE,500/5 ML SYRINGE, 300/3 ML SYRINGE, 100/ML (1)VIAL, 10 UNIT/ML SYRINGE, 100/ML (1) SYRINGE,5000/0.5ML VIAL, 1000/10 ML SYRINGE, 200/2 MLSYRINGE, 1000/ML VIAL, 10 UNIT/ML VIAL, 1 UNIT/MLSYRINGE)
generic
JANTOVEN (7.5 MG, 6 MG, 5 MG, 2.5 MG, 2 MG, 4 MG, 3MG, 1 MG, 10 MG)warfarin sodium
BRAND
PAGE 52 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MONOJECT PREFILL ADVANCED (500 UNIT/5 ML(100/ML), 50 UNITS/5 ML (10/ML), 30 UNITS/3 ML(10/ML), 300 UNIT/3 ML (100/ML), 1,000 UNIT/10(100/ML), 100 UNIT/10 ML (10/ML))heparin sodium,porcine/pf
BRAND
PRADAXA (75 MG, 150 MG)dabigatran etexilate mesylate
BRAND PA
protamine sulfate 10 mg/ml vial generic
TRICITRASOL 46.7% VIALsodium citrate dihydrate
BRAND
WARFARIN SODIUM (5 MG, 2.5 MG, 7.5 MG, 1 MG, 2MG, 10 MG, 6 MG, 3 MG, 4 MG)
generic
XARELTO (15 MG, 20 MG, 10 MG)rivaroxaban
BRAND
BLOOD FORMATION MODIFIERS
ANAGRELIDE HCL (1 MG, 0.5 MG) generic
LEUKINE (250 MCG, 500 MCG/ML)sargramostim
BRANDPA
S Specialty Drug
MOZOBIL (24 MG/1.2 ML, 20 MG/ML)plerixafor
BRAND
NEULASTA (6 ML SYRINGE, ONPRO 6 ML KIT)pegfilgrastim
BRANDPA
S Specialty Drug
NEUMEGA 5 MG VIALoprelvekin
BRAND S Specialty Drug
PROCRIT (20,000, 10,000, 2,000, 3,000, 40,000, 4,000)epoetin alfa
BRANDPA
S Specialty Drug
PROMACTA (75 MG, 50 MG, 25 MG, 12.5 MG)eltrombopag olamine
BRAND S Specialty Drug
COAGULANTS
ADVATE (801-1,200, 401-800, 200-400, 3,601-4,800,1,201-1,800, 1,801-2,400)antihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
ADVATE 1,201-1,800 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
ADVATE 1,801-2,400 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
ADVATE 200-400 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
PAGE 53 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ADVATE 401-800 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
ADVATE 801-1,200 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
ALPHANATE (1,500-600, 1,000-400, 250-100, 500-200,2,000-800)antihemophilic factor, human/von willebrand factor,human
BRAND S Specialty Drug
AMINOCAPROIC ACID (250 MG/ML VIAL, 250 MG/MLSOLUTION, 500 MG TABLET)
generic
BEBULIN 200-1,200 UNITS VIALfactor ix complex, prothrombin cplx conc(pcc) no.6, 3-factor
BRAND
BEBULIN VH IMMU 200-1,200 UNITfactor ix complex human
BRAND S Specialty Drug
BENEFIX (3,000 KIT, 2,000 VIAL, 1,000 KIT, 250 KIT,2,000 KIT, 1,000 VIAL, 500 KIT, 250 VIAL, 500 VIAL)factor ix human recombinant
BRAND S Specialty Drug
CORIFACT KITfactor xiii
BRAND
ELOCTATE (1,000, 250, 2,000, 3,000, 500, 1,500, 750)antihemophilic factor (fviii) recombinant, fc fusion protein
BRANDPA
S Specialty Drug
FEIBA NF (651-1,200 VIAL, 500 (NOMINAL), 1,750-3,250VIAL, 1,000 (NOMINAL), 2,500 (NOMINAL), 400-650VIAL)anti-inhibitor coagulant complex
BRAND
FEIBA VH IMMUNO 651-1,200 UNITanti-inhibitor coagulant complex
BRAND
HELIXATE FS (1,000, 250, 500, 2,000)antihemophilic factor viii, human recombinant
BRANDPA
S Specialty Drug
HELIXATE FS 3,000 UNITS VIALantihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
HUMATE-P (2,400, 1,200, 600)antihemophilic factor, human/von willebrand factor,human
BRAND S Specialty Drug
IXINITY (1,000, 1,000 -2 VLS, 1,500, 1,500 -2 VLS, 500)factor ix human recombinant, threonine 148
BRAND S Specialty Drug
KOATE-DVI (250 VIAL, 1,000 VIAL, 500 KIT)antihemophilic factor, human
BRAND S Specialty Drug
KOATE-DVI 500 UNITS VIALantihemophilic factor, human
BRANDPA
S Specialty Drug
KOGENATE FS (2,000 UNIT VIAL, 1,000 UNIT-ADAPTER, 2,000 UNIT-ADAPTER, 3,000 UNITS VIAL, BRAND PA
PAGE 54 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
250 UNIT VL-BIOSET, 500 UNIT VIAL, 1,000 UNIT-BIOSET, 500 UNIT VL-ADAPTR, 500 UNIT VL-BIOSET,1,000 UNITS VIAL)antihemophilic factor (fviii) recomb,full length (alb-free)
S Specialty Drug
KOGENATE FS (250 UNIT VIAL, 250 UNIT VL-ADAPTR,2,000 UNIT-BIOSET)antihemophilic factor (fviii) recomb,full length (alb-free)
BRAND S Specialty Drug
MONONINE 1,000 UNITS KITfactor ix
BRAND S Specialty Drug
MONSEL'S FERRIC SUBSULFATE SOLferric subsulfate
BRAND
NOVOEIGHT (250, 2,000, 1,000, 1,500, 500, 3,000)antihemophilic factor viii recombinant, b-domain truncated
BRAND
NOVOSEVEN RT (8 MG, 5 MG, 1 MG, 2 MG)coagulation factor viia (recombinant)
BRAND
PROFILNINE (500, 1,500, 1,000)factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor
BRANDPA
S Specialty Drug
PROFILNINE SD (1,500, 1,000, 500)factor ix complex human
BRANDPA
S Specialty Drug
RECOMBINATE (1,801-2,400, 1,241-1,800)antihemophilic factor viii, human recombinant
BRAND
RECOMBINATE (801-1,240 VL, 401-800 VIAL, 220-400VIAL)antihemophilic factor viii, human recombinant
BRANDPA
S Specialty Drug
RIASTAP VIALfibrinogen
BRAND
tranexamic acid 650 mg tablet generic
TRETTEN 2,500 UNIT VIALfactor xiii a-subunit, recombinant
BRAND
XYNTHA (500, 2,000, 250, 1,000)antihemophilic factor (factor viii) recomb,b-domain deleted
BRAND
XYNTHA SOLOFUSE (500 KIT, 3,000 KIT, 1,000 SYR,500 SYR, 3,000 SYR, 1,000 KIT, 2,000 SYR, 250 SYR,250 KIT, 2,000 KIT)antihemophilic factor (factor viii) recomb,b-domain deleted
BRAND
PLATELET MODIFYING AGENTS
aspirin/dipyridamole 25mg-200mg cpmp 12hr generic
BRILINTA (90 MG, 60 MG)ticagrelor
BRAND
CILOSTAZOL (50 MG, 100 MG) generic
PAGE 55 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CLOPIDOGREL BISULFATE (75 MG, 300 MG) generic
DIPYRIDAMOLE (75 MG TABLET, 25 MG TABLET, 50MG TABLET, 5 MG/ML VIAL)
generic
EFFIENT (10 MG, 5 MG)prasugrel hcl
BRAND
EPTIFIBATIDE (0.75 MG/ML, 2 MG/ML) generic PA
ZONTIVITY 2.08 MG TABLETvorapaxar sulfate
BRANDQL
PA
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
CLONIDINE (0.1MG/24HR, 0.2MG/24HR, 0.3MG/24HR) generic
CLONIDINE HCL (0.3 MG, 0.2 MG, 0.1 MG) generic
CLONIDINE HCL/PF (1000MCG/10, 5000MCG/10) generic
GUANFACINE HCL (2 MG, 1 MG) generic
METHYLDOPA (500 MG, 250 MG) generic
methyldopate hcl 250 mg/5ml vial generic
MIDODRINE HCL (5 MG, 2.5 MG, 10 MG) generic
ALPHA-ADRENERGIC BLOCKING AGENTS
DIBENZYLINE 10 MG CAPSULEphenoxybenzamine hcl
BRAND
DOXAZOSIN MESYLATE (4 MG, 1 MG, 2 MG, 8 MG) generic
phenoxybenzamine hcl 10 mg capsule generic
phentolamine mesylate 5 mg vial generic
PRAZOSIN HCL (1 MG, 2 MG, 5 MG) generic
RESERPINE (0.1 MG, 0.25 MG) generic
TERAZOSIN HCL (5 MG, 10 MG, 1 MG, 2 MG) generic
ANGIOTENSIN II RECEPTOR ANTAGONISTS
CANDESARTAN CILEXETIL (4 MG, 32 MG, 16 MG, 8MG)
generic
eprosartan mesylate 600 mg tablet generic
IRBESARTAN (75 MG, 300 MG, 150 MG) generic
LOSARTAN POTASSIUM (50 MG, 100 MG, 25 MG) generic
TELMISARTAN (80 MG, 20 MG, 40 MG) generic
PAGE 56 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
VALSARTAN (80 MG, 320 MG, 40 MG, 160 MG) generic
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
BENAZEPRIL HCL (20 MG, 5 MG, 40 MG, 10 MG) generic
CAPTOPRIL (50 MG, 25 MG, 100 MG, 12.5 MG) generic
ENALAPRIL MALEATE (5 MG, 20 MG, 2.5 MG, 10 MG) generic
enalaprilat dihydrate 1.25 mg/ml vial generic
FOSINOPRIL SODIUM (40 MG, 20 MG, 10 MG) generic
LISINOPRIL (10 MG, 30 MG, 40 MG, 2.5 MG, 5 MG, 20MG)
generic
MOEXIPRIL HCL (15 MG, 7.5 MG) generic
PERINDOPRIL ERBUMINE (4 MG, 8 MG, 2 MG) generic
QUINAPRIL HCL (5 MG, 10 MG, 40 MG, 20 MG) generic
RAMIPRIL (5 MG, 10 MG, 2.5 MG, 1.25 MG) generic
TRANDOLAPRIL (2 MG, 4 MG, 1 MG) generic
ANTIARRHYTHMICS
ADENOSINE (3 MG/ML SYRINGE, 3 MG/ML VIAL) generic
AMIODARONE HCL (50 MG/ML VIAL, 200 MG TABLET,100 MG TABLET, 50 MG/ML AMPUL, 400 MG TABLET,150 MG/3ML SYRINGE)
generic
FLECAINIDE ACETATE (50 MG, 150 MG, 100 MG) generic
ibutilide fumarate 0.1 mg/ml vial generic
MEXILETINE HCL (150 MG, 200 MG, 250 MG) generic
PACERONE (100 MG, 200 MG, 400 MG)amiodarone hcl
BRAND
PROCAINAMIDE HCL (500 MG/ML, 100 MG/ML) generic
PROPAFENONE HCL (300 MG TABLET, 425 MG CAPER 12H, 225 MG CAP ER 12H, 325 MG CAP ER 12H, 225MG TABLET, 150 MG TABLET)
generic
QUINIDINE GLUCONATE (80 MG/ML VIAL, 324 MGTABLET ER)
generic
QUINIDINE SULFATE (300 MG ER, 300 MG, 200 MG) generic
SORINE (80 MG, 160 MG, 240 MG, 120 MG)sotalol hcl
BRAND
SOTALOL HCL (240 MG, 160 MG, 120 MG, 80 MG) generic
TIKOSYN (500 MCG, 250 MCG, 125 MCG)dofetilide
BRAND
PAGE 57 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
BETA-ADRENERGIC BLOCKING AGENTS
ACEBUTOLOL HCL (400 MG, 200 MG) generic
ATENOLOL (25 MG, 50 MG, 100 MG) generic
BETAXOLOL HCL (20 MG, 10 MG) generic
BISOPROLOL FUMARATE (5 MG, 10 MG) generic
CARVEDILOL (12.5 MG, 25 MG, 6.25 MG, 3.125 MG) generic
esmolol hcl 100mg/10ml vial generic
LABETALOL HCL (100 MG TABLET, 20 MG/4 MLSYRINGE, 5 MG/ML VIAL, 200 MG TABLET, 300 MGTABLET)
generic
METOPROLOL SUCCINATE (25 MG ER, 50 MG ER, 100MG ER, 200 MG ER)
generic
METOPROLOL TARTRATE (5 MG/5 ML SYRINGE, 5MG/5 ML AMPUL, 5 MG/5 ML VIAL, 50 MG TABLET, 25MG TABLET, 100 MG TABLET)
generic
NADOLOL (20 MG, 80 MG, 40 MG) generic
PINDOLOL (5 MG, 10 MG) generic
PROPRANOLOL HCL (60 MG CAP SA 24H, 80 MGTABLET, 80 MG CAP SA 24H, 60 MG TABLET, 10 MGTABLET, 20 MG/5 ML SOLUTION, 40 MG TABLET, 20MG TABLET, 120 MG CAP SA 24H, 1 MG/ML VIAL, 160MG CAP SA 24H, 40MG/5ML SOLUTION)
generic
TIMOLOL MALEATE (10 MG, 20 MG, 5 MG) generic
CALCIUM CHANNEL BLOCKING AGENTS
AFEDITAB CR (30 MG, 60 MG)nifedipine
BRAND
AMLODIPINE BESYLATE (5 MG, 2.5 MG, 10 MG) generic
CARTIA XT (120 MG, 300 MG, 180 MG, 240 MG)diltiazem hcl
BRAND
DILT-XR (120 MG, 180 MG, 240 MG)diltiazem hcl
BRAND
DILTIAZEM HCL (120 MG CAP ER 12H, 180 MG CAP ER24H, 30 MG TABLET, 120 MG CAP ER 24H, 420MGCAPSULE ER, 60 MG CAP ER 12H, 240 MG TAB ER24H, 5 MG/ML VIAL, 240 MG CAP ER DEG, 240 MG CAPER 24H, 100 MG VIAL PORT, 300 MG CAP ER 24H, 60MG TABLET, 120 MG CAP ER DEG, 240 MG CAPSULEER, 180 MG CAP ER DEG, 300 MG CAPSULE ER, 180MG TAB ER 24H, 180 MG CAPSULE ER, 420MG TAB ER24H, 300 MG TAB ER 24H, 360 MG CAP ER 24H, 90 MGCAP ER 12H, 360 MG CAPSULE ER, 120 MG CAPSULE
generic
PAGE 58 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ER, 90 MG TABLET, 360 MG TAB ER 24H, 120 MGTABLET)
FELODIPINE (5 MG ER, 2.5 MG ER, 10 MG ER) generic
ISRADIPINE (2.5 MG, 5 MG) generic
MATZIM LA (180 MG, 300 MG, 360 MG, 240 MG, 420MG)diltiazem hcl
BRAND
NICARDIPINE HCL (25 MG/10ML VIAL, 25 MG/10MLAMPUL, 20 MG CAPSULE, 30 MG CAPSULE)
generic
nicardipine hcl in 0.9% nacl 1 mg/10 ml syringe generic
NIFEDIAC CC 30 MG TABLETnifedipine
BRAND
NIFEDICAL XL (30 MG, 60 MG)nifedipine
BRAND
NIFEDIPINE (60 MG TABLET ER, 30 MG TAB ER 24, 60MG TAB ER 24, 30 MG TABLET ER, 90 MG TAB ER 24,90 MG TABLET ER)
generic
nimodipine 30 mg capsule generic
NISOLDIPINE (25.5 MG ER, 30 MG ER, 8.5MG ER, 40MG ER, 17 MG ER, 20 MG ER, 34 MG ER)
generic
TAZTIA XT (300 MG, 120 MG, 180 MG, 240 MG)diltiazem hcl
BRAND
VERAPAMIL HCL (300 MG CAP24H PCT, 2.5 MG/MLAMPUL, 2.5 MG/ML VIAL, 240 MG CAP24H PEL, 200 MGCAP24H PCT, 2.5 MG/ML SYRINGE, 180 MG TABLETER, 120 MG CAP24H PEL, 40 MG TABLET, 80 MGTABLET, 120 MG TABLET, 120 MG TABLET ER, 240 MGTABLET ER, 180 MG CAP24H PEL, 360 MG CAP24HPEL, 100 MG CAP24H PCT)
generic
CARDIOVASCULAR AGENTS, OTHER
alprostadil 500 mcg/ml vial generic
amiloride/hydrochlorothiazide 5 mg-50 mg tablet generic
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM (10MG-80MG, 10 MG-20MG, 2.5MG-20MG, 5 MG-20 MG,2.5MG-40MG, 2.5MG-10MG, 5 MG-80 MG, 10 MG-40MG,5 MG-40 MG, 5 MG-10 MG, 10 MG-10MG)
generic
AMLODIPINE BESYLATE/BENAZEPRIL HCL (2.5MG-10MG, 10 MG-40MG, 5 MG-40 MG, 10 MG-20MG, 5 MG-10 MG, 5 MG-20 MG)
generic
AMLODIPINE BESYLATE/VALSARTAN (10MG-160MG,5MG-320MG, 10MG-320MG)
generic QL
PAGE 59 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
AMLODIPINEBESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE (5-160-25MG, 10MG-160MG, 5-160-12.5, 10-320-25, 10-160-25)
generic
amlodipine/valsartan 5 mg-160mg tablet generic
ATENOLOL/CHLORTHALIDONE (50 MG-25MG, 100MG-25MG)
generic
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE (20-12.5MG, 10-12.5MG, 5-6.25MG, 20 MG-25MG)
generic
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE(10-6.25MG, 2.5-6.25MG, 5-6.25MG)
generic
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE(16-12.5MG, 32-12.5MG, 32MG-25MG)
generic
CAPTOPRIL/HYDROCHLOROTHIAZIDE (25 MG-25MG,25 MG-15MG, 50 MG-15MG, 50 MG-25MG)
generic
cardioplegic solution no.1 k+=16meq/l plst bg pf generic
CLORPRES (0.1-15, 0.2-15)clonidine hcl/chlorthalidone
BRAND
CORLANOR (5 MG, 7.5 MG)ivabradine hcl
BRAND QL
DEMSER 250 MG CAPSULEmetyrosine
BRAND
DIGITEK 250 MCG TABLETdigoxin
BRAND
DIGOX (250 MCG, 125 MCG)digoxin
BRAND
DIGOXIN (250 MCG/ML AMPUL, 125 MCG TABLET, 50MCG/ML SOLUTION, 250 MCG TABLET, 250 MCG/MLSYRINGE)
generic
DOBUTAMINE HCL (500MG/40ML, 250MG/20ML) generic
DOBUTAMINE HCL/DEXTROSE 5 % IN WATER(500MG/250, 250MG/250, 500 MG/500, 1000MG/250)
generic
DOPAMINE HCL (200 MG/5ML, 400 MG/5ML,800MG/10ML, 400MG/10ML, 800MG/5ML)
generic
DOPAMINE HCL/DEXTROSE 5 % IN WATER(400MG/0.5L, 200MG/.25L, 800MG/0.5L, 400MG/.25L,800MG/.25L)
generic
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE(5MG-12.5MG, 10 MG-25MG)
generic
ephedrine sulfate 50 mg/ml vial generic
PAGE 60 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE (20-12.5 MG, 10-12.5MG)
generic
IRBESARTAN/HYDROCHLOROTHIAZIDE (300-12.5MG,150-12.5MG)
generic
LISINOPRIL/HYDROCHLOROTHIAZIDE (20-12.5 MG, 10-12.5MG, 20 MG-25MG, 20-25MG)
generic
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE(50-12.5 MG, 100-12.5MG, 100MG-25MG)
generic
METHYLDOPA/HYDROCHLOROTHIAZIDE (250MG-25MG, 250MG-15MG)
generic
METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE(50 MG-25MG, 100MG-50MG, 100MG-25MG)
generic
milrinone lactate 1 mg/ml vial generic
MILRINONE LACTATE/DEXTROSE 5 % IN WATER(40MG/200ML, 20MG/100ML)
generic
MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE (15-25MG,15-12.5MG, 7.5-12.5MG)
generic
NADOLOL/BENDROFLUMETHIAZIDE (40 MG, 80 MG) generic
NOREPINEPHRINE BITARTRATE (1 MG/ML AMPUL, 1MG/ML VIAL)
generic
NOREPINEPHRINE BITARTRATE IN 0.9 % SODIUMCHLORIDE (8 MG/250ML, 4MG/250ML)
generic
NORTHERA (200 MG, 300 MG, 100 MG)droxidopa
BRANDQL
PA
pentoxifylline 400 mg tablet er generic
phenylephrine hcl 10 mg/ml vial generic
PHENYLEPHRINE HCL IN 0.9 % SODIUM CHLORIDE/PF(1 MG/10 ML SYRINGE, 80MG/250ML PLAST. BAG)
generic
phenylephrine hcl in 0.9% nacl 1 mg/10 ml syringe generic
PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE (80,40)
generic
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE (10-12.5MG, 20 MG-25MG, 20-12.5 MG)
generic
spironolact/hydrochlorothiazid 25 mg-25mg tablet generic
TELMISARTAN/AMLODIPINE BESYLATE (80 MG-10MG,40 MG-10MG, 80 MG-5 MG, 40 MG-5 MG)
generic
TELMISARTAN/HYDROCHLOROTHIAZIDE (40-12.5 MG,80-12.5MG, 80 MG-25MG)
generic
PAGE 61 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
TRANDOLAPRIL/VERAPAMIL HCL (1-240MG, 4-240MG,2-240MG, 2 MG-180MG)
generic
TRIAMTERENE/HYDROCHLOROTHIAZIDE (50 MG-25MG CAPSULE, 37.5-25 MG CAPSULE, 75 MG-50MGTABLET, 37.5-25 MG TABLET)
generic
VALSARTAN/HYDROCHLOROTHIAZIDE (160-12.5MG,160-25MG, 320MG-25MG, 80-12.5MG, 320-12.5MG)
generic
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
ACETAZOLAMIDE (125 MG TABLET, 500 MG CAPSULEER, 250 MG TABLET)
generic
acetazolamide sodium 500 mg vial generic
DIURETICS, LOOP
BUMETANIDE (1 MG TABLET, 0.5 MG TABLET, 2 MGTABLET, 0.25 MG/ML VIAL)
generic
ethacrynate sodium 50 mg vial generic
FUROSEMIDE (80 MG TABLET, 20 MG TABLET, 10MG/ML SYRINGE, 40 MG TABLET, 10 MG/MLSOLUTION, 40MG/5ML SOLUTION, 10 MG/ML VIAL)
generic
TORSEMIDE (5 MG TABLET, 20 MG/2 ML VIAL, 10 MGTABLET, 20 MG TABLET, 100 MG TABLET)
generic
DIURETICS, POTASSIUM-SPARING
amiloride hcl 5 mg tablet generic
EPLERENONE (25 MG, 50 MG) generic
SPIRONOLACTONE (50 MG, 100 MG, 25 MG) generic
DIURETICS, THIAZIDE
CHLOROTHIAZIDE (250 MG, 500 MG) generic
chlorothiazide sodium 500 mg vial generic
CHLORTHALIDONE (25 MG, 50 MG) generic
HYDROCHLOROTHIAZIDE (12.5 MG CAPSULE, 50 MGTABLET, 12.5 MG TABLET, 25 MG TABLET)
generic
INDAPAMIDE (2.5 MG, 1.25 MG) generic
methyclothiazide 5 mg tablet generic
METOLAZONE (10 MG, 2.5 MG, 5 MG) generic
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
FENOFIBRATE (50 MG CAPSULE, 40 MG TABLET, 54MG TABLET, 160 MG TABLET, 150 MG CAPSULE, 120MG TABLET)
generic
PAGE 62 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
FENOFIBRATE NANOCRYSTALLIZED (145MG, 48 MG) generic
FENOFIBRATE,MICRONIZED (43 MG, 130 MG, 67 MG,134MG, 200 MG)
generic
FENOFIBRIC ACID (35 MG, 105 MG) generic
FENOFIBRIC ACID (CHOLINE) (45 MG, 135 MG) generic
gemfibrozil 600 mg tablet generic
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
ATORVASTATIN CALCIUM (20 MG, 40 MG, 80 MG, 10MG)
generic
FLUVASTATIN SODIUM (40 MG CAPSULE, 80 MG TABER 24H, 20 MG CAPSULE)
generic
LOVASTATIN (10 MG, 40 MG, 20 MG) generic
PRAVASTATIN SODIUM (20 MG, 80 MG, 40 MG, 10 MG) generic
SIMVASTATIN (20 MG, 40 MG, 5 MG, 80 MG, 10 MG) generic
DYSLIPIDEMICS, OTHER
CHOLESTYRAMINE (WITH SUGAR) (SUAR) 4 POWDER,SUAR) 4 POWD PACK)
generic
CHOLESTYRAMINE/ASPARTAME (4 POWD PACK, 4POWDER)
generic
COLESTIPOL HCL (5 PACKET, 1 TABLET, 5 RANULES) generic
JUXTAPID (60 MG, 40 MG, 30 MG, 5 MG, 20 MG, 10 MG)lomitapide mesylate
BRANDPA
S Specialty Drug
NIACIN (1000 MG ER, 750 MG ER, 500 MG ER) generic
omega-3 acid ethyl esters 1 g capsule generic
PREVALITE (PACKET, POWDER)cholestyramine/aspartame
BRAND
VASCEPA 1 GM CAPSULEicosapent ethyl
BRAND
ZETIA 10 MG TABLETezetimibe
BRAND PA
VASODILATORS, DIRECT-ACTING ARTERIAL
CORLOPAM 10 MG/ML VIALfenoldopam mesylate
BRAND
HYDRALAZINE HCL (50 MG TABLET, 10 MG TABLET, 25MG TABLET, 20 MG/ML VIAL, 100 MG TABLET)
generic
MINOXIDIL (10 MG, 2.5 MG) generic
PAGE 63 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
amyl nitrite 0.3 ml ampul generic
ISOSORBIDE DINITRATE (40 MG ER, 5 MG, 10 MG, 20MG, 30 MG)
generic
ISOSORBIDE MONONITRATE (10 MG TABLET, 60 MGTAB ER 24H, 30 MG TAB ER 24H, 20 MG TABLET, 120MG TAB ER 24H)
generic
NITRO-BID 2% OINTMENTnitroglycerin
BRAND
NITRO-TIME (ER 9 MG, ER 6.5 MG, ER 2.5 MG)nitroglycerin
BRAND
NITROGLYCERIN (2.5 MG CAPSULE ER, 0.2MG/HRPATCH TD24, 0.6MG/HR PATCH TD24, 400MCG/SPRSPRAY, 50 MG/10ML VIAL, 9 MG CAPSULE ER,0.4MG/HR PATCH TD24, 6.5 MG CAPSULE ER,0.1MG/HR PATCH TD24)
generic
NITROGLYCERIN/DEXTROSE 5 % IN WATER(50MG/500ML, 100MG/250, 200MG/500, 25MG/250ML,50MG/250ML)
generic
NITROSTAT (0.4 MG, 0.6 MG, 0.3 MG)nitroglycerin
BRAND
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
DEXEDRINE 10 MG TABLETdextroamphetamine sulfate
BRAND
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE (30MG TABLET, 20 MG TABLET, 10 MG TABLET, 30 MGCAP ER 24H, 7.5 MG TABLET, 12.5 MG TABLET, 15 MGTABLET, 10 MG CAP ER 24H, 20 MG CAP ER 24H, 15MG CAP ER 24H, 5 MG CAP ER 24H, 25 MG CAP ER24H, 5 MG TABLET)
generic
DEXTROAMPHETAMINE SULFATE (15 MG CAPSULEER, 5 MG/5 ML SOLUTION, 5 MG TABLET, 5 MGCAPSULE ER, 10 MG TABLET, 10 MG CAPSULE ER)
generic
methamphetamine hcl 5 mg tablet generic PA
PROCENTRA 5 MG/5 ML SOLUTIONdextroamphetamine sulfate
BRAND
VYVANSE (60 MG, 20 MG, 50 MG, 30 MG, 10 MG, 70MG, 40 MG)lisdexamfetamine dimesylate
BRAND
PAGE 64 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
clonidine hcl 0.1 mg tab er 12h generic
DEXMETHYLPHENIDATE HCL (30 MG CPBP 50-50, 5MG TABLET, 20 MG CPBP 50-50, 15 MG CPBP 50-50, 10MG CPBP 50-50, 40 MG CPBP 50-50, 5 MG CPBP 50-50,10 MG TABLET, 2.5 MG TABLET)
generic
GUANFACINE HCL (1 MG ER, 3 MG ER, 4 MG ER, 2 MGER)
generic
METADATE ER 20 MG TABLETmethylphenidate hcl
BRAND
METHYLPHENIDATE HCL (54 MG TAB ER 24, 10 MGTABLET, 10 MG TABLET ER, 27 MG TAB ER 24, 20 MGCPBP 30-70, 50 MG CPBP 30-70, 5 MG TABLET, 30 MGCPBP 50-50, 10 MG/5 ML SOLUTION, 5 MG/5 MLSOLUTION, 10 MG CPBP 30-70, 5 MG TAB CHEW, 40MG CPBP 50-50, 20 MG TABLET, 20 MG CPBP 50-50,2.5 MG TAB CHEW, 18 MG TAB ER 24, 40 MG CPBP 30-70, 10 MG TAB CHEW, 36 MG TAB ER 24, 60 MG CPBP30-70, 20 MG TABLET ER, 30 MG CPBP 30-70)
generic
STRATTERA (100 MG, 25 MG, 40 MG, 18 MG, 80 MG, 60MG, 10 MG)atomoxetine hcl
BRAND
CENTRAL NERVOUS SYSTEM, OTHER
ALAGESIC LQ ORAL SOLUTIONbutalbital/acetaminophen/caffeine
BRAND QL
benzphetamine hcl 50 mg tablet generic PA
butalbital/acetaminophen 50mg-325mg tablet generic
BUTALBITAL/ACETAMINOPHEN/CAFFEINE (50-300-40CAPSULE, 50-325-40 TABLET, 50-325-40 CAPSULE)
generic QL
CAPACET CAPSULEbutalbital/acetaminophen/caffeine
BRAND QL
DIETHYLPROPION HCL (75 MG ER, 25 MG) generic PA
ESGIC CAPSULEbutalbital/acetaminophen/caffeine
BRAND QL
MARGESIC CAPSULEbutalbital/acetaminophen/caffeine
BRAND QL
MARTEN-TAB 325-50 TABLETbutalbital/acetaminophen
BRAND
NUEDEXTA 20-10 MG CAPSULEdextromethorphan hbr/quinidine sulfate
BRAND
PHENDIMETRAZINE TARTRATE (35 MG TABLET, 105 generic PA
PAGE 65 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MG CAPSULE ER)
PHENTERMINE HCL (30 MG CAPSULE, 37.5 MGCAPSULE, 15 MG CAPSULE, 37.5 MG TABLET)
generic PA
riluzole 50 mg tablet generic
TENCON 50-325 MG TABLETbutalbital/acetaminophen
BRAND
TETRABENAZINE (12.5 MG, 25 MG) generic
XENAZINE (25 MG, 12.5 MG)tetrabenazine
BRAND S Specialty Drug
ZEBUTAL 50-325-40 MG CAPSULEbutalbital/acetaminophen/caffeine
BRAND QL
FIBROMYALGIA AGENTS
DULOXETINE HCL (30 MG, 20 MG) generic
PA
CPA depends onindicaton. 60mg maxdaily
duloxetine hcl 60 mg capsule dr genericPA
C 2/ day .
LYRICA (50 MG CAPSULE, 100 MG CAPSULE, 300 MGCAPSULE, 225 MG CAPSULE, 150 MG CAPSULE, 200MG CAPSULE, 20 MG/ML ORAL SOLUTION, 75 MGCAPSULE, 25 MG CAPSULE)pregabalin
BRAND PA
SAVELLA (50 MG TABLET, 100 MG TABLET, TITRATIONPACK, 25 MG TABLET, 12.5 MG TABLET)milnacipran hcl
BRAND PA
MULTIPLE SCLEROSIS AGENTS
AMPYRA ER 10 MG TABLETdalfampridine
BRANDPA
S Specialty Drug
AVONEX (30 MCG KT, 30 MCG)interferon beta-1a
BRANDPA
S Specialty Drug
AVONEX ADMIN PACK 30 MCG VLinterferon beta-1a/albumin human
BRANDPA
S Specialty Drug
AVONEX PEN (30 ML, 30 ML KIT)interferon beta-1a
BRANDPA
S Specialty Drug
COPAXONE (20 MG/ML, 40 MG/ML)glatiramer acetate
BRANDPA
S Specialty Drug
PAGE 66 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
EXTAVIA 0.3 MG KITinterferon beta-1b
BRANDPA
S Specialty Drug
GILENYA 0.5 MG CAPSULEfingolimod hcl
BRAND
QL
PA
S Specialty Drug
GLATOPA 20 MG/ML SYRINGEglatiramer acetate
BRANDPA
S Specialty Drug
REBIF (TITRATION PACK, 44 MCG/0.5 ML SYRINGE)interferon beta-1a/albumin human
BRANDPA
S Specialty Drug
REBIF 22 MCG/0.5 ML SYRINGEinterferon beta-1a/albumin human
BRAND S Specialty Drug
REBIF REBIDOSE (44 ML, 22 ML)interferon beta-1a/albumin human
BRAND S Specialty Drug
REBIF REBIDOSE TITRATION PACKinterferon beta-1a/albumin human
BRANDPA
S Specialty Drug
TECFIDERA (DR 240 MG CAPSULE, STARTER PACK,DR 120 MG CAPSULE)dimethyl fumarate
BRANDPA
S Specialty Drug
DENTAL AND ORAL AGENTS
cevimeline hcl 30 mg capsule generic
chlorhexidine gluconate 0.12 % mouthwash generic
DEBACTEROL SOLUTIONsulfuric acid/sulfonated phenol
BRAND
FIRST-MOUTHWASH BLM SUSPENSIONmag hydroxide/alhydroxide/simeth/diphenhydramine/lidocaine
BRAND
KEPIVANCE 6.25 MG VIALpalifermin
BRAND
PAROEX 0.12% ORAL RINSEchlorhexidine gluconate
BRAND
PERIOGARD 0.12% ORAL RINSEchlorhexidine gluconate
BRAND
PILOCARPINE HCL (7.5 MG, 5 MG) generic
DERMATOLOGICAL AGENTS
PAGE 67 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
8-MOP 10 MG CAPSULEmethoxsalen
BRAND
ABSORICA (30 MG, 20 MG, 10 MG, 40 MG)isotretinoin
BRAND
ACITRETIN (17.5 MG, 10 MG, 25 MG) generic
ADAPALENE (0.1 (GRAM), 0.3 W/PUMP) genericQL
C 45gm/30 days
ADAPALENE (0.3 GEL (GRAM), 0.1 CREAM (G)) generic C 45gm/30 days
adapalene 0.1 % lotion generic C 59gm/30 days
ALPHAQUIN HP 4% CREAMoxybenzone/octinoxate/hydroquinone
BRAND
ammonium lactate 12 % cream (g) generic
AMNESTEEM (10 MG, 20 MG, 40 MG)isotretinoin
BRAND
APLIGRAF DISKcult skin subst,human-bovine
BRAND
AVAR CLEANSERsulfacetamide sodium/sulfur
BRAND
AVITA 0.025% CREAMtretinoin
BRAND C 20gm/30 days
BENZEPRO (6% FOAMING CLOTHS, 7% CREAMYWASH)benzoyl peroxide microspheres
BRAND
BENZOYL PEROXIDE (5 % GEL (GRAM), 7 %CLEANSER, 5 % GEL ALCOHL, 9.8 % FOAM, 5.3%FOAM)
generic
BP 10-1 WASHsulfacetamide sodium/sulfur
BRAND
BP CLEANSING WASHsulfacetamide sodium/sulfur/urea
BRAND
BP-50% UREA EMULSIONurea/lactic acid/zinc undecylenate
BRAND
BPO (8% GEL, 4% GEL, 3% FOAMING CLOTHS, 9%FOAMING CLOTHS, 6% FOAMING CLOTHS)benzoyl peroxide
BRAND
CALCIPOTRIENE (0.005 CREAM (G), 0.005 OINT. (G),0.005 SOLUTION)
generic
calcipotriene/betamethasone 0.005-.064 oint. (g) generic
CALCITRENE 0.005% OINTMENT BRAND
PAGE 68 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
calcipotriene
calcitriol 3 mcg/g oint. (g) generic
CARB-O-PHILIC (GEL, CREAM)urea
BRAND
CEM-UREA 45% PRE-FILLED APPLurea
BRAND
CLARAVIS (40 MG, 30 MG, 20 MG, 10 MG)isotretinoin
BRAND
CLARIS CLARIFYING WASHsulfacetamide sodium/sulfur/urea
BRAND
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE (1%-5 %, 1.2(1)%-5%)
generic
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE (1-0.05 LOTION, 1 -0.05 CREAM (G))
generic
DERMAZENE CREAMhydrocortisone/iodoquinol
BRAND
DICLOFENAC SODIUM (1.5 DROPS, 3 GEL (GRAM)) generic
DRITHOCREME HP 1% CREAManthralin
BRAND
DRYSOL (DAB-O-MATIC, )aluminum chloride
BRAND
HYDROCORTISONE ACETATE/LIDOCAINE HCL/ALOEVERA (2 %-2 % KIT, 0.55%-2.8% GEL W/APPL, 2.5-3%(7G) KIT)
generic
HYDROCORTISONE ACETATE/PRAMOXINE HCL (1 %-1% CREAM/APPL, 2.5 %-1 % CREAM/APPL, 2.5 %-1 %CREAM (G), 2.5-1%(4G) CREAM/APPL)
generic
HYDROCORTISONEACETATE/PRAMOXINE/EMOLLIENT/PRAMOXINECOMB#1 (2.5%-1%-1%, 2.5-1%(4G))
generic
hydrocortisone/iodoquinol 1 %-1 % cream (g) generic
hydroquinone 4 % cream (g) generic
hydroquinone microspheres 4 % crm er (g) generic
HYPERCARE 20% SOLUTIONaluminum chloride
BRAND
imiquimod 5 % cream pack generic
LACLOTION 12% LOTIONammonium lactate
BRAND
LATRIX 50% TOPICAL SUSPENSIONurea/lactic acid/salicylic acid
BRAND
PAGE 69 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
LATRIX XM 45% EMULSIONurea/lactic acid/zinc undecylenate
BRAND
LIDOCAINE HCL/HYDROCORTISONE ACETATE (3 %-0.5 % KIT, 3%-1%(7 G) KIT, 3 %-0.5 % CREAM (G), 3 %-0.5 % CREAM/APPL)
generic
lidocaine/prilocaine 2.5 %-2.5% cream (g) generic
LUSTRA-ULTRA 4% CREAMvitamin a/vitamin e/avobenzone/octinoxate/hydroquinone
BRAND
MELPAQUE HP 4% CREAMhydroquinone/ferric oxide
BRAND
MELQUIN HP 4% CREAMhydroquinone
BRAND
MELQUIN-3 SOLUTIONhydroquinone
BRAND
METRONIDAZOLE (0.75 GEL (GRAM), 0.75 CREAM (G),1 GEL W/PUMP, 0.75 LOTION, 1 GEL (GRAM))
generic
MYORISAN (10 MG, 30 MG, 20 MG, 40 MG)isotretinoin
BRAND
NEUAC GELclindamycin phosphate/benzoyl peroxide
BRAND
NU-DERM (BLENDER, CLEAR)hydroquinone
BRAND
NUQUIN HP (GEL, CREAM)dioxybenzone/padimate o/hydroquinone
BRAND
OBAGI ELASTIDERM SKIN 4% CREAMhydroquinone
BRAND
OXSORALEN-ULTRA 10 MG CAPmethoxsalen, rapid
BRAND
podofilox 0.5 % solution generic
PR BENZOYL PEROXIDE 7% WASHbenzoyl peroxide microspheres
BRAND
PR CREAM KITprotectives combination no.2/ceramides 1,3,6-11
BRAND
PRAMCORT 1% CREAMhydrocortisone acetate/pramoxine hcl
BRAND
REA LO 39 CREAMurea
BRAND
REA LO 40 (40 CM, 40 TION)urea
BRAND
RECTIV 0.4% OINTMENT BRAND
PAGE 70 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
nitroglycerin
REGRANEX 0.01% GELbecaplermin
BRAND
REMEVEN 50% CREAMurea
BRAND
ROSADAN (GEL, CREAM)metronidazole
BRAND
ROSULA 10%-5% CLOTHSsulfacetamide sodium/sulfur
BRAND
SALACYN (CREAM, LOTION)salicylic acid
BRAND
SALICYLIC ACID (6 CREAM (G), 28.5 LIQ-FILM, 6 GEL(GRAM), 6 SHAMPOO, 27.5 LIQ-FILM, 6 CRM ER (G), 26LIQUID, 6 LOTION ER, 6 LOTION)
generic
salicylic acid/ammon lact/aloe 6 % foam generic
SALICYLIC ACID/CERAMIDES 1,3,6-11 (6 KIT CLCMER,6 COMBO. PKG)
generic
SALVAX 6% FOAMsalicylic acid
BRAND
SANTYL OINTMENTcollagenase clostridium histolyticum
BRAND
SE 10-5 SS CREAMsulfacetamide sodium/sulfur/witch hazel
BRAND
SE BPO 7% WASHbenzoyl peroxide microspheres
BRAND
SEB-PREV 10% WASHsulfacetamide sodium
BRAND
SELENIUM SULFIDE (2.5 SUSPENSION, 2.5 LOTION,2.25 SHAMPOO)
generic
SILVER NITRATE (50 SOLUTION, 10 OINT. (G), 10SOLUTION, 0.5 SOLUTION, 25 SOLUTION)
generic
silver nitrate applicator 75%-25% stick (ea) generic
spinosad 0.9 % suspension generic C
1420ml/fill; must trypermethrin andpiperonyl butoxide/pyrethrins andmalathion
SS 10-2 CLEANSERsulfacetamide sodium/sulfur
BRAND
SSS 10-5 (FOAM, CREAM)sulfacetamide sodium/sulfur
BRAND
PAGE 71 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
sulfacetamide sod/sulfur/urea 10%-5%-10% cleanser generic
SULFACETAMIDE SODIUM (10 CLNSGEL ER, 10SHAMPOO, 10 CLEANSER)
generic
SULFACETAMIDE SODIUM/SULFUR (10 %-4 % MED.PAD, 8 %-4 % SUSPENSION, 10 %-5 % MED. PAD,9.8%-4.8% CLEANSER, 9 %-4.5 % CLEANSER, 10-5%(W/W) LOTION, 10-5%(W/V) LOTION, 10-5%(W/W)CREAM (G), 10-5%(W/W) CLEANSER, 10-5%(W/W)SUSPENSION, 9 %-4 % CLEANSER, 10 %-2 %CLEANSER, 10 %-5 % FOAM)
generic
sulfacetamide/sulfur/cleansr23 9 %-4.5 % kit generic
SULFACLEANSE 8-4 SUSPENSIONsulfacetamide sodium/sulfur
BRAND
TACROLIMUS (0.1, 0.03) genericQL
PA
TAZORAC (0.05% CREAM, 0.1% GEL, 0.05% GEL, 0.1%CREAM)tazarotene
BRAND
TRETINOIN (0.025 GEL (GRAM), 0.025 CREAM (G), 0.01GEL (GRAM))
generic QL
TRETINOIN (0.05, 0.1) generic QL
tretinoin 0.05 % gel (gram) generic QL
TRETINOIN MICROSPHERES (0.1 (GRAM), 0.04W/PUMP, 0.1 W/PUMP, 0.04 (GRAM))
generic QL
TRI-CHLOR 80% SOLUTIONtrichloroacetic acid
BRAND
UMECTA 40% MOUSSEurea
BRAND
UREA (35 FOAM, 45 LOTION, 45 GEL (ML), 45 CREAM(G), 40 LOTION, 39 CREAM (G), 50 SOL/PF APP, 40 GEL(ML), 40 CREAM (G), 40 NL FM SUSP, 50 CREAM (G))
generic
urea/hyaluronate sodium 40%-0.2% kit generic
urea/lactic ac/zn undecylenate 50 % emulsn(g) generic
urea/lactic acid/salicylic ac 50 % suspension generic
VASHE WOUND THERAPY SOLUTIONsodium chloride irrigating solution/hypochlorous acid
BRAND
VASOLEX OINTMENTtrypsin/balsam peru/castor oil
BRAND
VIRTI-SULF EMOLLIENT CREAM BRAND
PAGE 72 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
sulfacetamide sodium/sulfur
X-VIATE (CREAM, LOTION, GEL)urea
BRAND
ZENCIA WASHsulfacetamide sodium/sulfur
BRAND
ENZYME REPLACEMENT/MODIFIERS
ALDURAZYME 2.9 MG/5 ML VIALlaronidase
BRAND
BUPHENYL 500 MG TABLETsodium phenylbutyrate
BRAND
CREON (12,000, 36,000, 24,000, 6,000, 3,000)lipase/protease/amylase
BRAND
CYSTADANE POWDERbetaine
BRAND
CYSTAGON (150 MG, 50 MG)cysteamine bitartrate
BRAND S Specialty Drug
ELAPRASE 6 MG/3 ML VIALidursulfase
BRAND
ELELYSO 200 UNITS VIALtaliglucerase alfa
BRAND
FABRAZYME (35 MG, 5 MG)agalsidase beta
BRAND
KUVAN (100 MG TABLET, 100 MG POWDER PACKET,500 MG POWDER PACKET)sapropterin dihydrochloride
BRANDPA
S Specialty Drug
LUMIZYME 50 MG VIALalglucosidase alfa
BRAND
MYOZYME 50 MG VIALalglucosidase alfa
BRAND
NAGLAZYME 5 MG/5 ML VIALgalsulfase
BRAND
ORFADIN (5 MG, 2 MG, 10 MG)nitisinone
BRAND
RAVICTI 1.1 GRAM/ML LIQUIDglycerol phenylbutyrate
BRAND
sodium phenylbutyrate 0.94 g/g powder generic
STRENSIQ (18 MG/0.45 ML, 28 MG/0.7 ML, 80 MG/0.8ML, 40 MG/ML)asfotase alfa
BRANDPA
S Specialty Drug
SUCRAID 8,500 UNITS/ML SOLN BRAND S Specialty Drug
PAGE 73 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
sacrosidase
VPRIV 400 UNITS VIALvelaglucerase alfa
BRAND
ZAVESCA 100 MG CAPSULEmiglustat
BRAND S Specialty Drug
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
ANASPAZ 0.125 MG TABLET ODThyoscyamine sulfate
BRAND
ATROPINE SULFATE (1 MG/ML VIAL, 0.4 MG/ML VIAL,0.1 MG/ML DISP SYRIN, 0.05MG/ML SYRINGE, 0.1MG/ML SYRINGE)
generic
B-DONNA TABLETphenobarbital/hyoscyamine sulf/atropine sulf/scopolaminehb
BRAND
chlordiazepoxide/clidinium br 5 mg-2.5mg capsule generic
DICYCLOMINE HCL (10 MG CAPSULE, 10 MG/5 MLSOLUTION, 20 MG TABLET)
generic
ED-SPAZ 0.125 MG ODThyoscyamine sulfate
BRAND
GLYCOPYRROLATE (1 MG/5 ML SYRINGE, 0.2 MG/MLVIAL, 0.6MG/3ML SYRINGE, 0.4MG/2ML SYRINGE, 1MG TABLET, 2 MG TABLET)
generic
HYOSCYAMINE SULFATE (125MCG/5ML ELIXIR,0.125MG/ML DROPS, 0.125 MG TABLET, 0.375 MG TABER 12H, 0.125 MG TAB RAPDIS)
generic
HYOSYNE (125 MCG/5 ML ELIXIR, 0.125 MG/ML DROP)hyoscyamine sulfate
BRAND
ME-PB-HYOS TABLETphenobarbital/hyoscyamine sulf/atropine sulf/scopolaminehb
BRAND
OSCIMIN (0.125 MG TABLET, 0.125 MG ODT)hyoscyamine sulfate
BRAND
OSCIMIN SL 0.125 MG TABLEThyoscyamine sulfate
BRAND
OSCIMIN SR 0.375 MG TABLEThyoscyamine sulfate
BRAND
SYMAX FASTABS 0.125 MG TABLEThyoscyamine sulfate
BRAND
SYMAX-SL 0.125 MG TABLET SL BRAND
PAGE 74 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
hyoscyamine sulfate
SYMAX-SR 0.375 MG TABLEThyoscyamine sulfate
BRAND
GASTROINTESTINAL AGENTS, OTHER
CHENODAL 250 MG TABLETchenodiol
BRAND
cromolyn sodium 20 mg/ml oral conc generic
dexpanthenol 250 mg/ml vial generic
DIPHENOXYLATE HCL/ATROPINE SULFATE (2.5-.025MG TABLET, 2.5-.025/5 LIQUID)
generic
GASTROCROM 100 MG/5 ML CONCcromolyn sodium
BRAND
lansoprazole/amoxiciln/clarith 30-500-500 combo. pkg generic
opium tincture 10 mg/ml tincture generic
paregoric 2 mg/5 ml liquid generic
RELISTOR (12 MG/0.6 ML KIT, 12 MG/0.6 ML VIAL, 12MG/0.6 ML SYRINGE, 8 MG/0.4 ML SYRINGE)methylnaltrexone bromide
BRAND
URSODIOL (250 MG TABLET, 300 MG CAPSULE, 500MG TABLET)
generic
VSL#3 DS PACKETlactobacillus combination no.2/s.thermophl/bif cmb no.1
BRAND
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
CIMETIDINE (300 MG, 800 MG, 400 MG) generic
cimetidine hcl 300 mg/5ml solution generic
FAMOTIDINE (40MG/5ML ORAL SUSP, 20 MG TABLET,10 MG/ML VIAL, 40 MG TABLET)
generic
famotidine/pf 20 mg/2 ml vial generic
NIZATIDINE (150MG/10ML SOLUTION, 300 MGCAPSULE, 150 MG CAPSULE)
generic
RANITIDINE HCL (25 MG/ML VIAL, 150 MG CAPSULE,50 MG/2 ML VIAL, 300 MG TABLET, 300 MG CAPSULE,150 MG TABLET, 15 MG/ML SYRUP)
generic
IRRITABLE BOWEL SYNDROME AGENTS
ALOSETRON HCL (0.5 MG, 1 MG) generic
LINZESS (290 MCG, 145 MCG)linaclotide
BRAND
PAGE 75 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
LOTRONEX (1 MG, 0.5 MG)alosetron hcl
BRAND
LAXATIVES
ENULOSE 10 GM/15 ML SOLUTIONlactulose
BRAND
GAVILYTE-G SOLUTIONpeg 3350/sod sulf/sod bicarbonate/sod chloride/potassiumchl
BRAND
GAVILYTE-H AND BISACODYL KITbisacodyl/sodium chlor/sodium bicarb/potassium chl/peg3350
BRAND
GENERLAC 10 GM/15 ML SOLUTIONlactulose
BRAND
POLYETHYLENE GLYCOL 3350 (3350 17G POWDPACK, 3350 17G/DOSE POWDER)
generic
PROTECTANTS
CARAFATE 1 GM/10 ML SUSPsucralfate
BRAND
MISOPROSTOL (200 MCG, 100 MCG) generic
sucralfate 1 g tablet generic
PROTON PUMP INHIBITORS
esomeprazole magnesium 20 mg capsule dr generic
esomeprazole magnesium 40 mg capsule dr generic C
must try 3 wks oftherapy within the last12 mos of omeprazole,omeprazole OTC orpantoprazole
ESOMEPRAZOLE SODIUM (20 MG, 40 MG) generic
esomeprazole strontium 49.3 mg capsule dr generic
FIRST-LANSOPRAZOLE 3 MG/MLlansoprazole
BRAND C
no STEP required if<12 yrs old; must try 3weeks of therapy withinlast 12 months ofomeprazole,omeprazole OTC orpantoprazole
FIRST-OMEPRAZOLE 2 MG/ML SUSPomeprazole
BRAND C
no PA required if <12yrs old; must try 3weeks of therapy withinlast 12 months ofomeprazole,omeprazole OTC orpantoprazole
lansoprazole 15 mg capsule dr generic PA
PAGE 76 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
lansoprazole 30 mg capsule dr generic C
must try 3 weeks oftherapy withinthe last 12months ofomeprazole,omeprazole OTC orpantoprazole
OMEPRAZOLE (10 MG, 40 MG, 20 MG) generic
OMEPRAZOLE/SODIUM BICARBONATE (20MG-1.1G,40MG-1.1G)
generic
PA
C
must try 3 weeks oftherapy withinthe last 12months ofomeprazole,omeprazole OTC orpantoprazole
PANTOPRAZOLE SODIUM (20 MG TABLET DR, 40 MGVIAL, 40 MG TABLET DR)
generic
rabeprazole sodium 20 mg tablet dr generic
PA
C
must try 3 weeks oftherapy withinthe last 12months ofomeprazole,omeprazole OTC orpantoprazole
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate hcl 100 mg tablet generic
OXYBUTYNIN CHLORIDE (5 MG/5 ML SYRUP, 10 MGTAB ER 24, 5 MG TABLET, 5 MG TAB ER 24, 15 MG TABER 24)
generic
TOLTERODINE TARTRATE (4 MG CAP ER 24H, 1 MGTABLET, 2 MG TABLET, 2 MG CAP ER 24H)
generic
TROSPIUM CHLORIDE (60 MG CAP ER 24H, 20 MGTABLET)
generic
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl 10 mg tab er 24h generic
dutasteride 0.5 mg capsule generic QL
dutasteride/tamsulosin hcl 0.5-0.4 mg cpmp 24hr generic
finasteride 5 mg tablet generic
tamsulosin hcl 0.4 mg cap er 24h generic
PAGE 77 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
GENITOURINARY AGENTS, OTHER
AMINOACETIC ACID 1.5% IRRIGglycine urologic solution
BRAND
BETHANECHOL CHLORIDE (5 MG, 25 MG, 10 MG, 50MG)
generic
citric acid/sodium citrate 334-500mg solution generic
CUPRIMINE 250 MG CAPSULEpenicillamine
BRAND
CYTRA-2 ORAL SOLUTIONcitric acid/sodium citrate
BRAND
CYTRA-3 SYRUPsodium/potassium/potassium citrate/sodium citrate/cit ac
BRAND
CYTRA-K (ORAL SOLUTION, CRYSTALS PACKET)potassium citrate/citric acid
BRAND
ELMIRON 100 MG CAPSULEpentosan polysulfate sodium
BRAND
FEM PH VAGINAL JELLYacetic acid/oxyquinoline sulfate
BRAND
glycine urologic solution 1.5 % irrig soln generic
K-PHOS #2 TABLETsodium phosphate,monobasic/potassiumphosphate,monobasic
BRAND
K-PHOS NEUTRAL TABLETphosphorus #1
BRAND
K-PHOS ORIGINAL TABLETpotassium phosphate,monobasic
BRAND
PHENAZOPYRIDINE HCL (200 MG, 100 MG) generic
PHOSPHA 250 NEUTRAL TABLETphosphorus #1
BRAND
POTASSIUM CITRATE (15 ER, 10 ER, 5 ER) generic
POTASSIUM CITRATE/CITRIC ACID (1100-334/5SOLUTION, 3300-1002 PACKET)
generic
RENACIDIN IRRIGATION SOLNcitric acid/gluconolactone/magnesium carbonate
BRAND
sod/pot/k cit/sod cit/cit acid 500-550/5 solution generic
TARON-CRYSTALS PACKETpotassium citrate/citric acid
BRAND
TRICITRATES ORAL SOLUTIONsodium/potassium/potassium citrate/sodium citrate/cit ac
BRAND
PAGE 78 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
VIRT-PHOS 250 NEUTRAL TABLETphosphorus #1
BRAND
VIRTRATE-2 SOLUTIONcitric acid/sodium citrate
BRAND
VIRTRATE-3 SOLUTIONsodium/potassium/potassium citrate/sodium citrate/cit ac
BRAND
VIRTRATE-K SOLUTIONpotassium citrate/citric acid
BRAND
PHOSPHATE BINDERS
CALCIUM ACETATE (667 MG CAPSULE, 667 MGTABLET)
generic
ELIPHOS 667 MG TABLETcalcium acetate
BRAND
RENVELA (800 MG TABLET, 0.8 GM POWDER PACKET,2.4 GM POWDER PACKET)sevelamer carbonate
BRAND
sevelamer carbonate 800 mg tablet generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
A-HYDROCORT 100 MG VIALhydrocortisone sod succinate
BRAND
A-METHAPRED 40 MG UNIVIALmethylprednisolone sodium succinate
BRAND
ALA-CORT 1% CREAMhydrocortisone
BRAND
ALCLOMETASONE DIPROPIONATE (0.05 OINT., 0.05CREAM)
generic
AMCINONIDE (0.1 CREAM (G), 0.1 LOTION, 0.1 OINT.(G))
generic
APEXICON 0.05% OINTMENTdiflorasone diacetate
BRAND
APEXICON E 0.05% CREAMdiflorasone diacetate/emollient base
BRAND
betamet acet/betamet na ph 6 mg/ml vial generic
BETAMETHASONE DIPROPIONATE (0.05 LOTION, 0.05GEL (GRAM), 0.05 CREAM (G), 0.05 OINT. (G))
generic
BETAMETHASONE DIPROPIONATE/PROPYLENEGLYCOL (0.05 CREAM (G), 0.05 OINT. (G), 0.05 LOTION)
generic
BETAMETHASONE VALERATE (0.1 CREAM (G), 0.1LOTION, 0.12 FOAM, 0.1 OINT. (G))
generic
PAGE 79 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CLOBETASOL PROPIONATE (0.05 SOLUTION, 0.05LOTION, 0.05 SHAMPOO, 0.05 SPRAY, 0.05 CREAM (G),0.05 FOAM, 0.05 OINT. (G), 0.05 GEL (GRAM))
generic
CLOBETASOL PROPIONATE/EMOLLIENT BASE (0.05FOAM, 0.05 CREAM (G))
generic
CLODAN 0.05% SHAMPOOclobetasol propionate
BRAND
CORMAX 0.05% SOLUTIONclobetasol propionate
BRAND
cortisone acetate 25 mg tablet generic
DELTASONE 20 MG TABLETprednisone
BRAND
DESONIDE (0.05 LOTION, 0.05 CREAM (G), 0.05 OINT.(G))
generic
DESOXIMETASONE (0.05 CREAM (G), 0.25 OINT. (G),0.25 CREAM (G), 0.05 GEL (GRAM), 0.05 OINT. (G))
generic
DEXAMETHASONE (6 MG TABLET, 0.5 MG TABLET, 2MG TABLET, 0.75 MG TABLET, 4 MG TABLET, 1.5 MGTABLET, 0.5 MG/5ML ELIXIR, 1 MG TABLET, 0.5MG/5ML SOLUTION)
generic
DEXAMETHASONE INTENSOL 1MG/1MLdexamethasone
BRAND
DEXAMETHASONE SOD PHOSPHATE (10 MG/ML VIAL,4 MG/ML VIAL, 4 MG/ML SYRINGE)
generic
dexamethasone sod phosphate/pf 10 mg/ml vial generic
DIFLORASONE DIACETATE (0.05 OINT., 0.05 CREAM) generic
fludrocortisone acetate 0.1 mg tablet generic
FLUOCINOLONE ACETONIDE (0.025 OINT. (G), 0.01CREAM (G), 0.025 CREAM (G), 0.01 OIL, 0.01SOLUTION)
generic
fluocinolone/shower cap 0.01 % oil generic
FLUOCINONIDE (0.05 GEL (GRAM), 0.05 SOLUTION, 0.1CREAM (G), 0.05 CREAM (G), 0.05 OINT. (G))
generic
fluocinonide/emollient base 0.05 % cream (g) generic
FLUTICASONE PROPIONATE (0.005 OINT. (G), 0.05LOTION, 0.05 CREAM (G))
generic
GRX HICORT 25 MG SUPPOSITORYhydrocortisone acetate
BRAND
HALOBETASOL PROPIONATE (0.05 OINT., 0.05CREAM)
generic
PAGE 80 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
HALONATE COMBO PACKhalobetasol propionate/ammonium lactate
BRAND
HALONATE PAC COMBO PACKhalobetasol propionate/ammonium lactate
BRAND
hc/mineral oil/petrolat,wht 1 % oint. (g) generic
HEMMOREX-HC (25 MG, 30 MG)hydrocortisone acetate
BRAND
HEMRIL-30 30 MG SUPPOSITORYhydrocortisone acetate
BRAND
HYDROCORTISONE (5 MG TABLET, 2.5 % LOTION, 10MG TABLET, 2.5 % CREAM (G), 1 % CREAM (G), 20 MGTABLET, 2.5 % OINT. (G))
generic
hydrocortisone acetate 25 mg supp.rect generic C only non-DESI NDCsare covered
hydrocortisone acetate 30 mg supp.rect generic
hydrocortisone acetate/aloe v 2 % gel (gram) generic
HYDROCORTISONE BUTYRATE (0.1 OINT. (G), 0.1SOLUTION, 0.1 CREAM (G))
generic
hydrocortisone butyrate/emoll 0.1 % cream (g) generic
HYDROCORTISONE VALERATE (0.2 CREAM, 0.2 OINT.) generic
METHYLPREDNISOLONE (4 MG TABLET, 16 MGTABLET, 8 MG TABLET, 4 MG TAB DS PK, 32 MGTABLET)
generic
METHYLPREDNISOLONE ACETATE (80 MG/ML, 40MG/ML)
generic
METHYLPREDNISOLONE SODIUM SUCCINATE (40 MG,1000 MG, 125 MG)
generic
MILLIPRED DP (5 MG 6-DAY, 5 MG 12-DAY)prednisolone
BRAND
MOMETASONE FUROATE (0.1 CREAM (G), 0.1 OINT.(G), 0.1 SOLUTION)
generic
PREDNICARBATE (0.1 CREAM, 0.1 OINT.) generic
prednisolone 15 mg/5 ml solution generic
PREDNISOLONE SOD PHOSPHATE (5 MG/5 MLSOLUTION, 10 MG TAB RAPDIS, 15 MG TAB RAPDIS,15 MG/5 ML SOLUTION, 30 MG TAB RAPDIS, 25 MG/5ML SOLUTION)
generic
PREDNISONE (2.5 MG TABLET, 5 MG TABLET, 1 MGTABLET, 50 MG TABLET, 5 MG/5 ML SOLUTION, 20 MGTABLET, 10 MG TABLET, 10 MG TAB DS PK, 5 MG TAB
generic
PAGE 81 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
DS PK)
PREDNISONE 5 MG/ML SOLUTIONprednisone
BRAND
PROCTO-PAK 1% CREAMhydrocortisone
BRAND
PROCTOSOL-HC 2.5% CREAMhydrocortisone
BRAND
PROCTOZONE-HC 2.5% CREAMhydrocortisone
BRAND
RECTACORT-HC 25 MG SUPPOSITORYhydrocortisone acetate
BRAND
SCALACORT 2% LOTIONhydrocortisone
BRAND
TRIAMCINOLONE ACETONIDE (0.5 % OINT. (G), 0.1 %LOTION, 10 MG/ML VIAL, 0.025 % CREAM (G), 0.5 %CREAM (G), 0.1 % OINT. (G), 0.1 % CREAM (G),0.147MG/G AEROSOL, 40 MG/ML VIAL, 0.025 % OINT.(G), 0.025 % LOTION)
generic
TRIANEX 0.05% OINTMENTtriamcinolone acetonide
BRAND
TRIDERM 0.1% CREAMtriamcinolone acetonide
BRAND
VERIPRED 20 20 MG/5 ML SOLNprednisolone sod phosphate
BRAND
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
chorionic gonadotropin, human 10000 unit vial generic
cosyntropin 0.25 mg vial generic
desmopressin (nonrefrigerated) 10/spray spray/pump generic
DESMOPRESSIN ACETATE (4MCG/ML AMPUL, 0.1 MGTABLET, 0.2 MG TABLET, 0.1 MG/ML SOLUTION,4MCG/ML VIAL, 10/SPRAY SPRAY/PUMP)
generic
GONAL-F RFF (900, 450, 300)follitropin alfa, recomb
BRAND
GONAL-F RFF REDI-JECT (900, 300, 450)follitropin alfa, recomb
BRAND S Specialty Drug
HP ACTHAR GEL 80 UNIT/ML VIALcorticotropin
BRANDPA
S Specialty Drug
INCRELEX 40 MG/4 ML VIALmecasermin
BRANDPA
S Specialty Drug
PAGE 82 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
NORDITROPIN (5 ML, 15 ML)somatropin
BRANDPA
S Specialty Drug
NORDITROPIN FLEXPRO (10 MG/1.5, 5 MG/1.5, 30MG/3 ML, 15 MG/1.5)somatropin
BRANDPA
S Specialty Drug
NORDITROPIN NORDIFLEX (NORDIFLX 15 MG/1.5,NORDIFLX 10 MG/1.5, NORDIFLEX 5 MG/1.5,NORDIFLEX 30 MG/3)somatropin
BRANDPA
S Specialty Drug
NOVAREL 10,000 UNITS VIALchorionic gonadotropin, human
BRAND
STIMATE 1.5 MG/ML NASAL SPRAYdesmopressin acetate
BRAND S Specialty Drug
vasopressin 20 unit/ml vial generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
ANDROGEL (1%(5G) PACKET, 1% PUMP)testosterone
BRAND QL
ANDROGEL (1.62%(1.25G) PCKT, 1.62% PUMP,1.62%(2.5G) PCKT, 1%(2.5G) PACKET)testosterone
BRAND
ANDROXY 10 MG TABLETfluoxymesterone
BRAND S Specialty Drug
DANAZOL (200 MG, 50 MG, 100 MG) generic
METHITEST 10 MG TABLETmethyltestosterone
BRAND
methyltestosterone 10 mg capsule generic GL Male
OXANDROLONE (2.5 MG, 10 MG) generic
TESTOPEL 75 MG PELLETStestosterone
BRAND
TESTOSTERONE (1.25G (1%) MD PMP, 50 MG (1%)PACKET, 25MG(1%) PACKET)
generic QL
testosterone 10 mg (2%) gel md pmp generic PA
TESTOSTERONE CYPIONATE (100 MG/ML, 200 MG/ML) generic
testosterone enanthate 200 mg/ml vial generic
ESTROGENS
PAGE 83 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ALTAVERA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
ALYACEN (7-7-7-28, 1-35-28)norethindrone-ethinyl estradiol
BRAND
AMETHIA 0.15-0.03-0.01 MG TABlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
AMETHIA LO TABLETlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
AMETHYST 90-20 MCG TABLETlevonorgestrel-ethinyl estradiol
BRAND
APRI 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
ARANELLE 28 TABLETnorethindrone-ethinyl estradiol
BRAND
ASHLYNA 0.15-0.03-0.01 MG TABlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
AUBRA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
AVIANE-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
AZURETTE 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
BALZIVA 28 TABLETnorethindrone-ethinyl estradiol
BRAND
BEKYREE 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
BLISOVI 24 FE TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
BLISOVI FE (1.5-30, 1-20)norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
BRIELLYN TABLETnorethindrone-ethinyl estradiol
BRAND
CAMRESE 0.15-0.03-0.01 MG TABlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
CAMRESE LO TABLETlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
CAZIANT 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
CHATEAL-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
PAGE 84 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CRYSELLE-28 TABLETnorgestrel-ethinyl estradiol
BRAND
CYCLAFEM (7-7-7-28, 1-35-28)norethindrone-ethinyl estradiol
BRAND
CYRED 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
DASETTA (7/7/7-28, 1-35-28)norethindrone-ethinyl estradiol
BRAND
DAYSEE 0.15-0.03-0.01 MG TABlevonorgestrel/ethinyl estradiol and ethinyl estradiol
BRAND
DELYLA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
desog-e.estradiol/e.estradiol 21-5 tablet generic
desogestrel-ethinyl estradiol 0.15-0.03 tablet generic
ELINEST-28 TABLETnorgestrel-ethinyl estradiol
BRAND
EMOQUETTE 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
ENPRESSE-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
ENSKYCE 28 TABLETdesogestrel-ethinyl estradiol
BRAND
ESTARYLLA 0.25-0.035 MG TABLETnorgestimate-ethinyl estradiol
BRAND
ESTRADIOL (.0375MG/24 PATCH TDWK, 0.05MG/24HPATCH TDSW, .075MG/24H PATCH TDWK, 2 MGTABLET, .025MG/24H PATCH TDWK, 0.5 MG TABLET,.025MG/24H PATCH TDSW, 0.06MG/24H PATCH TDWK,0.1MG/24HR PATCH TDWK, 1 MG TABLET, .0375MG/24PATCH TDSW, 0.05MG/24H PATCH TDWK, .075MG/24HPATCH TDSW)
generic
ESTRADIOL VALERATE (40 MG/ML, 20 MG/ML, 10MG/ML)
generic
ESTRADIOL/NORETHINDRONE ACETATE (0.5-0.1MG, 1MG-0.5MG)
generic
ESTROPIPATE (0.75 MG, 3 MG, 1.5 MG) generic
ETHINYL ESTRADIOL/DROSPIRENONE (0.03MG-3MG,0.02-3(24))
generic
FALMINA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
GIANVI 3 MG-0.02 MG TABLET BRAND
PAGE 85 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
ethinyl estradiol/drospirenone
GILDAGIA 0.4 MG-0.035 MG TABnorethindrone-ethinyl estradiol
BRAND
GILDESS (1.5 MG-30 MCG, 1 MG-20 MCG)norethindrone acetate-ethinyl estradiol
BRAND
GILDESS 24 FE 1-0.02 MG TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
GILDESS FE (1-20, 1.5-30)norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
INTROVALE 0.15-0.03 MG TABLETlevonorgestrel-ethinyl estradiol
BRAND
JINTELI 1 MG-5 MCG TABLETnorethindrone acetate-ethinyl estradiol
BRAND
JOLESSA 0.15 MG-0.03 MG TABLETlevonorgestrel-ethinyl estradiol
BRAND
JUNEL (1 MG-20 MCG, 1.5 MG-30 MCG)norethindrone acetate-ethinyl estradiol
BRAND
JUNEL FE (1.5 MG-30 MCG, 1 MG-20 MCG)norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
JUNEL FE 24 TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
KAITLIB FE CHEWABLE TABLETnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND
KARIVA 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
KELNOR 1-35 28 TABLETethynodiol diacetate-ethinyl estradiol
BRAND
KIMIDESS 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
KURVELO TABLETlevonorgestrel-ethinyl estradiol
BRAND
LARIN (21 1-20, 1.5 MG-30 MCG)norethindrone acetate-ethinyl estradiol
BRAND
LARIN 24 FE 1 MG-20 MCG TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
LARIN FE (1.5-30, 1-20)norethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
LEENA 28 TABLETnorethindrone-ethinyl estradiol
BRAND
LESSINA-28 TABLET BRAND
PAGE 86 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
levonorgestrel-ethinyl estradiol
LEVONEST-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
LEVONORGESTREL (1.5 MG, 0.75 MG) generic
LEVONORGESTREL-ETHINYL ESTRADIOL (90-20MCGTABLET, 0.15-0.03 TBDSPK 3MO, 0.1-0.02 TABLET, 6-5-10 TABLET, 0.15-0.03 TABLET)
generic
LEVONORGESTREL/ETHINYL ESTRADIOL ANDETHINYL ESTRADIOL (150-30(84), 100-20(84))
generic
LEVORA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
LOMEDIA 24 FE 1 MG-20 MCG TABnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
LOPREEZA 1 MG-0.5 MG TABLETestradiol/norethindrone acetate
BRAND
LORYNA 3 MG-0.02 MG TABLETethinyl estradiol/drospirenone
BRAND
LOW-OGESTREL-28 TABLETnorgestrel-ethinyl estradiol
BRAND
LUTERA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
MARLISSA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
MENEST (1.25 MG, 0.625 MG, 2.5 MG, 0.3 MG)estrogens,esterified
BRAND
MICROGESTIN (21 1.5-30 TAB, 21 1-20 TABLET)norethindrone acetate-ethinyl estradiol
BRAND
MICROGESTIN 24 FE 1 MG-20 MCGnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
MICROGESTIN FE 1-20 TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
MIMVEY 1-0.5 MG TABLETestradiol/norethindrone acetate
BRAND
MIMVEY LO 0.5-0.1 MG TABLETestradiol/norethindrone acetate
BRAND
MONO-LINYAH 28 TABLETnorgestimate-ethinyl estradiol
BRAND
MONONESSA 28 TABLETnorgestimate-ethinyl estradiol
BRAND
MY WAY 1.5 MG TABLET BRAND
PAGE 87 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
levonorgestrel
MYZILRA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
NECON (1-35-28, 7-7-7-28, 10-11-28, 1-50-28, 0.5-35-28)norethindrone-ethinyl estradiol
BRAND
NEXT CHOICE ONE DOSE 1.5 MG TBlevonorgestrel
BRAND
NIKKI 3 MG-0.02 MG TABLETethinyl estradiol/drospirenone
BRAND
noreth-ethinyl estradiol/iron 0.8-25(24) tab chew generic
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL(0.5MG-2.5, 1MG-20MCG, 1MG-5MCG)
generic
NORETHINDRONE ACETATE-ETHINYLESTRADIOL/FERROUS FUMARATE (1MG-20(24), 1MG-20(21))
generic
NORGESTIMATE-ETHINYL ESTRADIOL (0.25-0.035,7DAYSX3 28, 7DAYSX3 LO)
generic
NORTREL (7-7-7-28, 1-35, 0.5-35)norethindrone-ethinyl estradiol
BRAND
OCELLA 3 MG-0.03 MG TABLETethinyl estradiol/drospirenone
BRAND
OGEN 2.5 TABLETestropipate
BRAND
OGESTREL TABLETnorgestrel-ethinyl estradiol
BRAND
ORSYTHIA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
PHILITH 0.4-0.035 MG TABLETnorethindrone-ethinyl estradiol
BRAND
PIMTREA 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
PIRMELLA (1-35-28, 7-7-7-28)norethindrone-ethinyl estradiol
BRAND
PORTIA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
PREMPHASE 0.625-5 MG TABLETestrogens, conjugated/medroxyprogesterone acetate
BRAND
PREMPRO (0.625-5 MG, 0.625-2.5 MG, 0.45-1.5 MG, 0.3MG-1.5 MG)estrogens, conjugated/medroxyprogesterone acetate
BRAND
PAGE 88 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
PREVIFEM TABLETnorgestimate-ethinyl estradiol
BRAND
QUASENSE 0.15-0.03 MG TABLETlevonorgestrel-ethinyl estradiol
BRAND
RECLIPSEN 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
SETLAKIN 0.15 MG-0.03 MG TABlevonorgestrel-ethinyl estradiol
BRAND
SPRINTEC 28 DAY TABLETnorgestimate-ethinyl estradiol
BRAND
SRONYX 0.10-0.02 MG TABLETlevonorgestrel-ethinyl estradiol
BRAND
SYEDA 28 TABLETethinyl estradiol/drospirenone
BRAND
TARINA FE 1-20 TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
TRI-ESTARYLLA TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-LEGEST FE-28 DAY TABLETnorethindrone acetate-ethinyl estradiol/ferrous fumarate
BRAND
TRI-LINYAH TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-LO-ESTARYLLA TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-LO-MARZIA TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-LO-SPRINTEC TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-PREVIFEM TABLETnorgestimate-ethinyl estradiol
BRAND
TRI-SPRINTEC TABLETnorgestimate-ethinyl estradiol
BRAND
TRINESSA TABLETnorgestimate-ethinyl estradiol
BRAND
TRIVORA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
VAGIFEM 10 MCG VAGINAL TABestradiol
BRAND
VELIVET 28 DAY TABLETdesogestrel-ethinyl estradiol
BRAND
PAGE 89 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
VESTURA 3 MG-0.02 MG TABLETethinyl estradiol/drospirenone
BRAND
VIENVA-28 TABLETlevonorgestrel-ethinyl estradiol
BRAND
VIORELE 28 DAY TABLETdesogestrel-ethinyl estradiol/ethinyl estradiol
BRAND
VYFEMLA 28 TABLETnorethindrone-ethinyl estradiol
BRAND
WERA 0.5/0.035 MG 28 TABLETnorethindrone-ethinyl estradiol
BRAND
WYMZYA FE CHEWABLE TABLETnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND
ZARAH TABLETethinyl estradiol/drospirenone
BRAND
ZENCHENT 0.4 MG-35 MCG TABLETnorethindrone-ethinyl estradiol
BRAND
ZENCHENT FE TABLET CHEWABLEnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND
ZEOSA CHEWABLE TABLETnorethindrone-ethinyl estradiol/ferrous fumarate
BRAND
ZOVIA 1-35E TABLETethynodiol diacetate-ethinyl estradiol
BRAND
ZOVIA 1-50E TABLETethynodiol diacetate-ethinyl estradiol
BRAND
PROGESTINS
CAMILA TABLETnorethindrone
BRAND
DEBLITANE 0.35 MG TABLETnorethindrone
BRAND
DEPO-PROVERA 400 MG/ML VIALmedroxyprogesterone acetate
BRAND
ENDOMETRIN 100 MG SUPPOSITORYprogesterone,micronized
BRAND S Specialty Drug
ERRIN 0.35 MG TABLETnorethindrone
BRAND
HEATHER TABLETnorethindrone
BRAND
IMPLANON 68 MG IMPLANTetonogestrel
BRAND
JENCYCLA 0.35 MG TABLET BRAND
PAGE 90 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
norethindrone
JOLIVETTE TABLETnorethindrone
BRAND
LYZA 0.35 MG TABLETnorethindrone
BRAND
MAKENA 1,250 MG/5 ML VIALhydroxyprogesterone caproate
BRANDPA
GL Male
MEDROXYPROGESTERONE ACETATE (2.5 MGTABLET, 150 MG/ML VIAL, 5 MG TABLET, 150 MG/MLSYRINGE, 10 MG TABLET)
generic
MEGESTROL ACETATE (20 MG TABLET, 625MG/5MLORAL SUSP, 400MG/10ML ORAL SUSP, 40 MGTABLET)
generic
NORA-BE TABLETnorethindrone
BRAND
norethindrone 0.35 mg tablet generic
norethindrone acetate 5 mg tablet generic
NORLYROC 0.35 MG TABLETnorethindrone
BRAND
progesterone 50 mg/ml vial generic
PROGESTERONE,MICRONIZED (100 MG, 200 MG) generic
SHAROBEL 0.35 MG TABLETnorethindrone
BRAND
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
raloxifene hcl 60 mg tablet generic
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID (60 MG, 300 MG, 120 MG, 30 MG,90 MG, 240 MG, 180 MG, 15 MG)thyroid,pork
BRAND
LEVOTHYROXINE SODIUM (75 MCG, 300 MCG, 25MCG, 112 MCG, 137 MCG, 125 MCG, 100 MCG, 200MCG, 50 MCG, 175MCG, 88 MCG, 150 MCG)
generic
LEVOXYL (112 MCG, 125 MCG, 88 MCG, 50 MCG, 200MCG, 137 MCG, 75 MCG, 100 MCG, 150 MCG, 175 MCG,25 MCG)levothyroxine sodium
BRAND
LIOTHYRONINE SODIUM (25 MCG TABLET, 5 MCGTABLET, 50 MCG TABLET, 10 MCG/ML VIAL)
generic
NATURE-THROID (146.25 MG, 65 MG, 113.75 MG, 32.5 BRAND
PAGE 91 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MG, 81.25 MG, 162.5 MG, 130 MG, 16.25 MG, 325 MG,195 MG, 97.5 MG, 48.75 MG, 260 MG)thyroid,pork
NP THYROID (90 MG, 30 MG, 60 MG)thyroid,pork
BRAND
THYROLAR-1 STRENGTH TABLETliotrix
BRAND
THYROLAR-1/2 STRENGTH TABliotrix
BRAND
THYROLAR-1/4 STRENGTH TABliotrix
BRAND
THYROLAR-2 STRENGTH TABLETliotrix
BRAND
THYROLAR-3 STRENGTH TABLETliotrix
BRAND
UNITHROID (137 MCG, 88 MCG)levothyroxine sodium
BRAND
WESTHROID (130 MG, 97.5 MG, 16.25 MG, 65 MG, 48.75MG, 32.5 MG, 195 MG)thyroid,pork
BRAND
HORMONAL AGENTS, SUPPRESSANT (PARATHYROID)
SENSIPAR (30 MG, 60 MG)cinacalcet hcl
BRAND
QL
PA
S Specialty Drug
SENSIPAR 90 MG TABLETcinacalcet hcl
BRAND
QL
PA
S Specialty Drug
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline 0.5 mg tablet generic
EGRIFTA 1 MG VIALtesamorelin acetate
BRAND PA
EGRIFTA 2 MG VIALtesamorelin acetate
BRAND S Specialty Drug
LEUPROLIDE ACETATE (1 KIT, 1 VIAL) generic
LUPRON DEPOT (DEPOT 7.5 MG, DEPOT 22.5 MG3MO, DEPOT 11.25 MG 3MO, DEPOT-4 MONTH, DEPOT3.75 MG, DEPOT 45 MG 6MO)leuprolide acetate
BRANDPA
S Specialty Drug
PAGE 92 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
LUPRON DEPOT-PED (11.25 MG 3MO, 30 MG 3MO KIT,7.5 MG KIT, 11.25 MG KIT, 15 MG KIT)leuprolide acetate
BRANDPA
S Specialty Drug
OCTREOTIDE ACETATE (500 MCG/ML, 50 MCG/ML, 100MCG/ML)
genericPA
S Specialty Drug
SIGNIFOR (0.6 MG/ML, 0.9 MG/ML, 0.3 MG/ML)pasireotide diaspartate
BRAND S Specialty Drug
VANTAS 50 MG KIThistrelin acetate
BRAND PA
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
METHIMAZOLE (5 MG, 10 MG) generic
propylthiouracil 50 mg tablet generic
IMMUNOLOGICAL AGENTS
ANGIOEDEMA (HAE) AGENTS
FIRAZYR 30 MG/3 ML SYRINGEicatibant acetate
BRAND
IMMUNE SUPPRESSANTS
AZASAN (75 MG, 100 MG)azathioprine
BRAND
azathioprine 50 mg tablet generic
CELLCEPT (200 MG/ML ORAL SUSP, 500 MG VIAL)mycophenolate mofetil hcl
BRAND
CYCLOSPORINE (100 MG CAPSULE, 250 MG/5ML VIAL,250 MG/5ML AMPUL, 25 MG CAPSULE)
generic
CYCLOSPORINE, MODIFIED (50 MG CAPSULE, 100MG/ML SOLUTION, 100 MG CAPSULE, 25 MGCAPSULE)
generic
ENBREL (50 MG/ML SYRINGE, 25 MG KIT, 50 MG/MLSURECLICK SYR, 25 MG/0.5 ML SYRINGE)etanercept
BRANDPA
S Specialty Drug
GENGRAF (25 MG CAPSULE, 100 MG/ML SOLUTION,100 MG CAPSULE)cyclosporine, modified
BRAND
HECORIA (1 MG, 5 MG, 0.5 MG)tacrolimus
BRAND
HUMIRA (10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML)adalimumab
BRAND PA
PAGE 93 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
S Specialty Drug
HUMIRA 40 MG/0.8 ML PENadalimumab
BRANDPA
S Specialty Drug
HUMIRA PEDIATRIC CROHN'S STARTadalimumab
BRANDPA
S Specialty Drug
HUMIRA PEN CROHN'S-UC-HS STARTadalimumab
BRANDPA
S Specialty Drug
HUMIRA PEN PSORIASIS START PKadalimumab
BRANDPA
S Specialty Drug
METHOTREXATE SODIUM (25 MG/ML VIAL, 2.5 MGTABLET)
generic
methotrexate sodium/pf 1 g vial generic
methotrexate sodium/pf 25 mg/ml vial generic S Specialty Drug
MYCOPHENOLATE MOFETIL (500 MG TABLET, 250 MGCAPSULE)
generic
MYCOPHENOLATE SODIUM (180 MG, 360 MG) generic
MYFORTIC (360 MG, 180 MG)mycophenolate sodium
BRAND
NULOJIX 250 MG VIALbelatacept
BRAND
PROGRAF 5 MG/ML AMPULEtacrolimus
BRAND
RAPAMUNE (1 MG TABLET, 1 MG/ML ORAL SOLN, 2MG TABLET)sirolimus
BRAND
REMICADE 100 MG VIALinfliximab
BRAND PA
SIROLIMUS (1 MG, 0.5 MG) generic
TACROLIMUS (1 MG, 5 MG, 0.5 MG) generic
TREXALL (15 MG, 10 MG, 7.5 MG, 5 MG)methotrexate sodium
BRAND
ZORTRESS (0.75 MG, 0.5 MG, 0.25 MG)everolimus
BRAND S Specialty Drug
IMMUNIZING AGENTS, PASSIVE
PAGE 94 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
BIVIGAM LIQUID 10% VIALimmune globulin,gamm(igg)/glycine/iga greater than 50mcg/ml
BRAND PA
FLEBOGAMMA DIF (10%, 5%)immune globulin,gamma (igg)/sorbitol/iga 0 to 50 mcg/ml
BRAND PA
GAMMAGARD LIQUID 10% VIALimmune globulin,gamm(igg)/glycine/iga greater than 50mcg/ml
BRAND PA
GAMMAPLEX 5% VIALimmune globulin,gamm(igg)/sorbitol/glycin/iga 0 to 50mcg/ml
BRAND PA
GAMUNEX 10% VIALimmune globulin,gamma caprylate (igg)
BRAND PA
GAMUNEX-C (2.5 GRAM/25 ML, 1 GRAM/10 ML, 10GRAM/100 ML, 20 GRAM/200 ML, 5 GRAM/50 ML)immune globulin,gamm(igg)/glycine/iga greater than 50mcg/ml
BRAND PA
HIZENTRA (10 GRAM/50 ML, 2 GRAM/10 ML, 1 GRAM/5ML, 4 GRAM/20 ML)immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml
BRAND
HYPERRHO S-D 250 UNITS SYRINGErho(d) immune globulin
BRAND
PRIVIGEN 10% VIALimmune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml
BRAND PA
VARIZIG 125 UNIT VIALvaricella-zoster immune globulin (human)
BRAND
IMMUNOMODULATORS
ACTEMRA 162 MG/0.9 ML SYRINGEtocilizumab
BRAND PA
ACTIMMUNE 100 MCG/0.5 ML VIALinterferon gamma-1b,recomb.
BRAND S Specialty Drug
ARCALYST 220 MG INJECTIONrilonacept
BRAND S Specialty Drug
BENLYSTA (120 MG, 400 MG)belimumab
BRAND
ILARIS 180 MG VIALcanakinumab/pf
BRAND
LEFLUNOMIDE (20 MG, 10 MG) generic
RIDAURA 3 MG CAPSULEauranofin
BRAND
SYNAGIS (50 MG/0.5 ML, 100 MG/1 ML) BRAND PA
PAGE 95 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
palivizumab
VACCINES
ADACEL TDAP VIALdiphtheria,pertussis(acell),tetanus vaccine/pf
BRAND
EZ FLU 2015-16 (FLUVIRIN) KITinfluenza virus vaccine trivalnt 2015-2016 (4 yr & older)/pf
BRAND
FLUBLOK 2014-2015 VIALinfluenza virus vaccine tv 2014-2015(18 yrs &older)rcmb/pf
BRAND C Approved for known orsuspected egg allergy
PNEUMOVAX 23 SYRINGEpneumococcal 23-valent polysaccharide vaccine
BRAND
PNEUMOVAX 23 VIALpneumococcal 23-valent polysaccharide vaccine
BRAND AL 1 to 65 yrs old
ZOSTAVAX VIALzoster vaccine live/pf
BRAND
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISO ER 0.375 GRAM CAPSULEmesalamine
BRAND
balsalazide disodium 750 mg capsule generic
CANASA 1,000 MG SUPPOSITORYmesalamine
BRAND
mesalamine 4 g/60 ml enema generic
mesalamine w/cleansing wipes 4 g/60 ml enema kit generic
PENTASA (500 MG, 250 MG)mesalamine
BRAND
GLUCOCORTICOIDS
budesonide 3 mg capdr - er generic
COLOCORT 100 MG ENEMAhydrocortisone
BRAND
CORTIFOAM 10% AEROSOLhydrocortisone acetate
BRAND
hydrocortisone 100mg/60ml enema generic
UCERIS 9 MG ER TABLETbudesonide
BRAND
SULFONAMIDES
SULFASALAZINE (500 MG, 500 MG DR) generic
PAGE 96 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
SULFAZINE 500 MG TABLETsulfasalazine
BRAND
SULFAZINE EC 500 MG TABsulfasalazine
BRAND
METABOLIC BONE DISEASE AGENTS
ALENDRONATE SODIUM (10 MG TABLET, 70 MG/75MLSOLUTION, 40 MG TABLET, 35 MG TABLET, 70 MGTABLET, 5 MG TABLET)
generic
calcitonin,salmon,synthetic 200/spray spray/pump generic
CALCITRIOL (1 MCG/ML SOLUTION, 0.5 MCGCAPSULE, 0.25 MCG CAPSULE, 1 MCG/ML AMPUL)
generic
DOXERCALCIFEROL (1 MCG, 2.5 MCG, 0.5 MCG) generic S Specialty Drug
ETIDRONATE DISODIUM (200 MG, 400 MG) generic
FORTEO 600 MCG/2.4 ML PEN INJteriparatide
BRANDPA
S Specialty Drug
FORTICAL 200 UNITS NASAL SPRAYcalcitonin,salmon,synthetic
BRAND
HECTOROL (2 MCG/ML, 4 MCG/2 ML)doxercalciferol
BRAND S Specialty Drug
ibandronate sodium 150 mg tablet generic
PARICALCITOL (2 MCG/ML VIAL, 2 MCG CAPSULE, 5MCG/ML VIAL, 4MCG CAPSULE, 1 MCG CAPSULE)
generic
RISEDRONATE SODIUM (5 MG, 30 MG, 35 MG DR, 150MG, 35 MG)
generic
MISCELLANEOUS THERAPEUTIC AGENTS
acetylcysteine 200 mg/ml vial generic PA
ALBUTEIN 25% VIALalbumin human
BRAND
AVITENE SHEET 70MMX70MMmicrofibrillar collagen
BRAND
coal tar 20 % solution generic
COMPOUND 347 INHALATIONenflurane
BRAND
dexmedetomidine hcl 200mcg/2ml vial generic
ENDO-AVITENE 5MM SHEETmicrofibrillar collagen
BRAND
PAGE 97 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
EUFLEXXA 20 MG/2 ML SYRINGEhyaluronate sodium
BRAND PA
flumazenil 0.1 mg/ml vial generic
fomepizole 1 g/ml vial generic
FORANE LIQUIDisoflurane
BRAND
FORMA-RAY 20% SOLUTIONformaldehyde
BRAND
FORMADON 10% SOLUTIONformaldehyde
BRAND
formaldehyde 10 % sol w/appl generic
glutaraldehyde 25 % solution generic
glycine/sod/water/sod hydrox vial generic S Specialty Drug
HEMABATE 250 MCG/ML AMPULcarboprost tromethamine
BRAND
IC GREEN 25 MG VIALindocyanine green
BRAND
isoflurane 99.9 % liquid generic
isomethept/dichlphn/acetaminop 65-100-325 capsule generic
isomethepten/caf/acetaminophen 65-20-325 tablet generic
isosulfan blue 1 % vial generic
LMD 10% WITH 0.9% SOD CHL SOLNdextran 40 in 0.9 % sodium chloride
BRAND
LMD 10% WITH 5% DEXT SOLNdextran 40/dextrose 5 % in water
BRAND
LUGOL'S SOLUTIONpotassium iodide/iodine
BRAND
MANNITOL (25 VIAL, 20 IV SOLN, 5 IV SOLN, 10 IVSOLN)
generic
MD-GASTROVIEW 66%-10% SOLNdiatrizoate meglumine/diatrizoate sodium
BRAND
METHYLENE BLUE (1 VIAL, 1 AMPUL) generic
METHYLERGONOVINE MALEATE (0.2 MG TABLET,.2MG/ML(1) AMPUL)
generic
MIGRAGESIC IDA CAPSULEisometheptene mucate/dichloralphenazone/acetaminophen
BRAND
NODOLOR CAPSULEisometheptene mucate/dichloralphenazone/acetaminophen
BRAND
PAGE 98 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
OSMITROL (20%, 15%)mannitol
BRAND
oxytocin 10 unit/ml vial generic
PANHEMATIN 313 MG VIALhemin
BRAND
phenol liquid generic
potassium iodide/iodine 5 % solution generic
PROTOPAM CHLORIDE 1 GM VIALpralidoxime chloride
BRAND
sevoflurane liquid generic
SITZMARKS CAPSULEradiopaque pvc markers/barium sulfate
BRAND
sodium morrhuate 50 mg/ml vial generic
SOJOURN INHALATION LIQUIDsevoflurane
BRAND
SOLIRIS 300 MG/30 ML VIALeculizumab
BRAND PA
SOTRADECOL 3% VIALsodium tetradecyl sulfate
BRAND
TERRELL LIQUIDisoflurane
BRAND
water for inj.,bacteriostatic vial generic
WATER FOR INJECTION,STERILE (IVSOLN, AMPUL,VIAL)
generic
water for irrigation,sterile irrig soln generic
water/me-paraben/propylparaben vial generic
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
AKORN BALANCED SALT SOLNbalanced salt irrig soln no.2
BRAND
ALTACAINE 0.5% EYE DROPStetracaine hcl
BRAND
ALTAFLUOR EYE DROPSbenoxinate hcl/fluorescein sodium
BRAND
ATROPINE CARE 1% EYE DROPSatropine sulfate
BRAND
ATROPINE SULFATE (1 DROPS, 1 OINT. (G)) generic
PAGE 99 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
balanced salt irrig soln no.2 irrig soln generic
benoxinate hcl/fluorescein na 0.4%-0.25% drops generic
BIOGLO 1 MG OPHTHALMIC STRIPSfluorescein sodium
BRAND
BSS EYE SOLUTIONbalanced salt irrig soln no.2
BRAND
CYCLOPENTOLATE HCL (0.5, 2, 1) generic
CYSTARAN 0.44% EYE DROPScysteamine hcl
BRAND
FLUCAINE EYE DROPSproparacaine hcl/fluorescein sodium
BRAND
FLUOR-I-STRIP ATfluorescein sodium
BRAND
FLUORESCITE 10% VIALfluorescein sodium
BRAND
FLUROX EYE DROPSbenoxinate hcl/fluorescein sodium
BRAND
FUL-GLO 1 MG OPTH STRIPSfluorescein sodium
BRAND
HOMATROPAIRE 5% EYE DROPShomatropine hbr
BRAND
homatropine hbr 5 % drops generic
naphazoline hcl 0.1 % drops generic
NEO-POLYCIN EYE OINTMENTneomycin sulfate/bacitracin/polymyxin b
BRAND
NEO-POLYCIN HC EYE OINTMENTneomycin sulfate/bacitracin zinc/polymyxinb/hydrocortisone
BRAND
neomycin su/baci zn/poly/hc 3.5-10k-1 oint. (g) generic
neomycin su/bacitra/polymyxin 3.5mg-400 oint. (g) generic
neomycin/polymyxin b sulf/hc 3.5-10k-10 drops susp generic
NEOMYCIN/POLYMYXIN BSULFATE/DEXAMETHASONE (0.1 % DROPS SUSP, 3.5-10K-.1 OINT. (G))
generic
neomycin/polymyxn b/gramicidin 1.75mg-10k drops generic
OCUCOAT VISCOADHERENT SYRINGEhypromellose
BRAND
PHENYLEPHRINE HCL (10, 2.5) generic
PAGE 100 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
POLYCIN EYE OINTMENTbacitracin/polymyxin b sulfate
BRAND
polymyxin b sulf/trimethoprim 10000-1/ml drops generic
proparacaine hcl 0.5 % drops generic
proparacaine/fluorescein sod 0.5%-0.25% drops generic
RESTASIS 0.05% EYE EMULSIONcyclosporine
BRAND
sulfacetamide/prednisolone sp 10 %-0.23% drops generic
TETCAINE 0.5% EYE DROPStetracaine hcl
BRAND
tetracaine hcl 0.5 % drops generic
tetracaine hcl/pf 0.5 % drops generic
tobramycin/dexamethasone 0.3 %-0.1% drops susp generic
TROPICAMIDE (0.5, 1) generic
OPHTHALMIC ANTI-ALLERGY AGENTS
azelastine hcl 0.05 % drops generic
cromolyn sodium 4 % drops generic
epinastine hcl 0.05 % drops generic
olopatadine hcl 0.1 % drops generic
OPHTHALMIC ANTI-INFLAMMATORIES
bromfenac sodium 0.09% drops generic
dexamethasone sod phosphate 0.1 % drops generic
diclofenac sodium 0.1 % drops generic
fluorometholone 0.1 % drops susp generic
flurbiprofen sodium 0.03 % drops generic
KETOROLAC TROMETHAMINE (0.5, 0.4) generic
PRED MILD 0.12% EYE DROPSprednisolone acetate
BRAND
prednisolone acetate 1 % drops susp generic
prednisolone sod phosphate 1 % drops generic
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P 0.1% DROPSbrimonidine tartrate
BRAND
apraclonidine hcl 0.5 % drops generic
PAGE 101 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
betaxolol hcl 0.5 % drops generic
BRIMONIDINE TARTRATE (0.2, 0.15) generic
carteolol hcl 1 % drops generic
dorzolamide hcl 2 % drops generic
dorzolamide hcl/timolol maleat 22.3-6.8/1 drops generic
levobunolol hcl 0.5 % drops generic
METHAZOLAMIDE (50 MG, 25 MG) generic
metipranolol 0.3 % drops generic
MIOSTAT VIALcarbachol
BRAND
PHOSPHOLINE IODIDE 0.125%echothiophate iodide
BRAND
PILOCARPINE HCL (4, 2, 1) generic
TIMOLOL MALEATE (0.25 DROPS, 0.5 SOL-GEL, 0.5DROPS, 0.25 SOL-GEL)
generic
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
bimatoprost 0.03 % drops generic
latanoprost 0.005 % drops generic
travoprost (benzalkonium) 0.004 % drops generic
OTIC AGENTS
ACETASOL HC EAR DROPSacetic acid/hydrocortisone
BRAND
acetic acid 2 % solution generic
acetic acid/aluminum acetate 2 % drops generic
acetic acid/hydrocortisone 2 %-1 % drops generic
AERO OTIC HC EAR DROPShydrocortisone/pramoxine hcl/chloroxylenol
BRAND
ANTIPYRINE/BENZOCAINE (5.4, 5.5) generic
AURODEX OTIC SOLUTIONantipyrine/benzocaine
BRAND
AUROGUARD OTIC SOLUTIONantipyrine/benzocaine
BRAND
CIPRODEX OTIC SUSPENSIONciprofloxacin hcl/dexamethasone
BRAND
CORTANE-B OTIC DROPS BRAND
PAGE 102 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
hydrocortisone/pramoxine hcl/chloroxylenol/water
EXOTIC-HC EAR DROPhydrocortisone/pramoxine hcl/chloroxylenol
BRAND
fluocinolone acetonide oil 0.01 % drops generic
NEOMYCIN SULFATE/POLYMYXIN BSULFATE/HYDROCORTISONE (SOLUTION, DROPSSUSP)
generic
OTICIN HC DROPShydrocortisone/pramoxine hcl/chloroxylenol
BRAND
OTO-END 10 EAR DROPShydrocortisone/pramoxine hcl/chloroxylenol
BRAND
OTOMAX-HC EAR DROPShydrocortisone/pramoxine hcl/chloroxylenol
BRAND
OTOZIN EAR DROPSantipyrine/benzocaine/glycerin/zinc acetate
BRAND
PRAMOXINE-HC OTIC DROPShydrocortisone/pramoxine hcl/chloroxylenol
BRAND
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
ARNUITY ELLIPTA (200 MCG, 100 MCG)fluticasone furoate
BRAND QL
BUDESONIDE (1 MG/2 ML AMPUL-NEB, 32MCGSPRAY/PUMP)
generic
budesonide 0.25mg/2ml ampul-neb genericQL
C 2 vials (4ml)/day
budesonide 0.5 mg/2ml ampul-neb generic C 2 vials (4ml)/day
flunisolide 25 mcg spray generic
fluticasone propionate 50 mcg spray susp generic
PULMICORT FLEXHALER (90 MCG, 180 MCG)budesonide
BRAND
QVAR (80 MCG, 40 MCG)beclomethasone dipropionate
BRAND
triamcinolone acetonide 55 mcg spray generic
ANTIHISTAMINES
ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID)carbinoxamine maleate
BRAND
AZELASTINE HCL (205.5MCG, 137 MCG) generic
PAGE 103 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CARBINOXAMINE MALEATE (4 MG TABLET, 4 MG/5 MLLIQUID)
generic
CLEMASTINE FUMARATE (2.68 MG TABLET,0.67MG/5ML SYRUP)
generic
CYPROHEPTADINE HCL (4 MG TABLET, 2 MG/5 MLSYRUP)
generic
DESLORATADINE (2.5 MG, 5 MG) generic C
must trycetirizine,cetirizine/pseudoephedrine,loratadine,loratadine/pseudoephedrine
desloratadine 5 mg tablet generic
PA
C
must trycetirizine,cetirizine/pseudoephedrine,loratadine,loratadine/pseudoephedrine
diphenhydramine hcl 50 mg/ml vial generic
HYDROXYZINE HCL (10 MG TABLET, 50 MG/ML VIAL,25 MG/ML VIAL, 50 MG/25ML SOLUTION, 10 MG/5 MLSOLUTION, 50 MG TABLET, 25 MG TABLET)
generic
HYDROXYZINE PAMOATE (100 MG, 50 MG, 25 MG) generic
levocetirizine dihydrochloride 2.5 mg/5ml solution generic
PA
C
must try cetirizine,cetirizine/pseudoephedrine, loratadine,loratadine/pseudoephedrine
levocetirizine dihydrochloride 5 mg tablet generic
PA
C
must try cetirizine,cetirizine/pseudoephedrine, loratadine,loratadine/pseudoephedrine
olopatadine hcl 0.6 % spray/pump generic
PALGIC (4 MG/5 ML LIQUID, 4 MG TABLET)carbinoxamine maleate
BRAND
PROMETHAZINE HCL (25 MG/ML VIAL, 25 MG TABLET,50 MG/ML AMPUL, 50 MG TABLET, 12.5 MG TABLET, 25MG/ML AMPUL, 6.25MG/5ML SYRUP, 50 MG/ML VIAL)
generic
ANTILEUKOTRIENES
PAGE 104 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
MONTELUKAST SODIUM (4 MG GRAN PACK, 10 MGTABLET, 4 MG TAB CHEW, 5 MG TAB CHEW)
generic
zafirlukast 10 mg tablet generic PA
zafirlukast 20 mg tablet generic
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT HFA INHALERipratropium bromide
BRAND
IPRATROPIUM BROMIDE (42 MCG SPRAY, 21 MCGSPRAY, 0.2 MG/ML SOLUTION)
generic
SPIRIVA 18 MCG CP-HANDIHALERtiotropium bromide
BRAND
SPIRIVA RESPIMAT (2.5 MCG, 1.25 MCG)tiotropium bromide
BRAND
TUDORZA PRESSAIR 400 MCG INHaclidinium bromide
BRAND
BRONCHODILATORS, SYMPATHOMIMETIC
ADRENALIN 1 MG/ML VIALepinephrine
BRAND C 2 kits/fill
ADRENALIN CL 1 MG/ML VIALepinephrine
BRAND C 2 kits/fill
ALBUTEROL SULFATE (2 MG/5 ML SYRUP,1.25MG/3ML VIAL-NEB, 8 MG TAB ER 12H, 2.5 MG/3MLVIAL-NEB, 2.5 MG/0.5 VIAL-NEB, 4 MG TAB ER 12H, 2MG TABLET, 0.63MG/3ML VIAL-NEB, 5 MG/MLSOLUTION, 4 MG TABLET)
generic
EPINEPHRINE (1 MG/ML VIAL, 0.1 MG/ML SYRINGE,0.3MG/0.3 AUTO INJCT, 1 MG/ML(1) AMPUL, 0.15/0.15AUTO INJCT)
generic C 2 kits/fill
epinephrine hcl/pf 1 mg/ml(1) ampul generic C 2 kits/fill
epinephrine/pf 1 mg/ml(1) ampul generic C 2 kits/fill
EPIPEN 2-PAK 0.3 MG AUTO-INJCTepinephrine
BRAND C 2 kits/fill
EPIPEN JR 2-PAK 0.15 MG INJCTRepinephrine
BRAND C 2 kits/fill
LEVALBUTEROL HCL (0.63MG/3ML, 1.25MG/0.5,1.25MG/3ML, 0.31MG/3ML)
generic C 24 vials/month
METAPROTERENOL SULFATE (10 MG TABLET, 20 MGTABLET, 10 MG/5 ML SYRUP)
generic
PERFOROMIST 20 MCG/2 ML SOLN BRAND
PAGE 105 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
formoterol fumarate
STRIVERDI RESPIMAT INHAL SPRAYolodaterol hcl
BRAND QL
TERBUTALINE SULFATE (5 MG TABLET, 2.5 MGTABLET, 1 MG/ML VIAL)
generic
VENTOLIN HFA 90 MCG INHALERalbuterol sulfate
BRAND QL
CYSTIC FIBROSIS AGENTS
CAYSTON 75 MG INHAL SOLUTIONaztreonam lysine
BRAND
QL
PA
C 3 vials/day; max 84vials/56 days
S Specialty Drug
KALYDECO (75 MG, 50 MG)ivacaftor
BRAND
QL
PA
C 2 packets/day
S Specialty Drug
KALYDECO 150 MG TABLETivacaftor
BRAND
QL
PA
S Specialty Drug
TOBI 300 MG/5 ML SOLUTIONtobramycin in 0.225 % sodium chloride
BRAND
QL
PA
C 2 vials/day
S Specialty Drug
TOBI PODHALER 28 MG INHALE CAPtobramycin
BRAND
QL
PA
C 8 capsules/day
S Specialty Drug
tobramycin in 0.225% nacl 300 mg/5ml ampul-neb generic
QL
PA
C 2 vials/day
S Specialty Drug
tobramycin/nebulizer 300 mg/5ml ampul-neb generic
QL
PA
S Specialty Drug
PAGE 106 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
AMINOPHYLLINE (500MG/20ML VIAL, 250MG/10MLVIAL, 250MG/10ML AMPUL)
generic
CAFFEINE CITRATED (60 ML VIAL, 60 ML SOLUTION) generic
THEOCHRON (ER 300 MG, ER 200 MG, ER 100 MG)theophylline anhydrous
BRAND
THEOPHYLLINE ANHYDROUS (80 MG/15ML ELIXIR,300 MG TAB ER 12H, 600 MG TABLET ER, 400 MGTABLET ER, 100 MG TAB ER 12H, 450 MG TAB ER 12H,80 MG/15ML SOLUTION, 200 MG TAB ER 12H)
generic
THEOPHYLLINE/DEXTROSE 5 % IN WATER(800MG/.25L, 400MG/0.5L, 200MG/0.1L, 200MG/50ML,400MG/.25L)
generic
PULMONARY ANTIHYPERTENSIVES
ADCIRCA 20 MG TABLETtadalafil
BRANDPA
S Specialty Drug
ADEMPAS (0.5 MG, 1.5 MG, 1 MG, 2 MG, 2.5 MG)riociguat
BRANDPA
S Specialty Drug
EPOPROSTENOL SODIUM (GLYCINE) (1.5 MG, 0.5 MG) generic
LETAIRIS (5 MG, 10 MG)ambrisentan
BRANDPA
S Specialty Drug
OPSUMIT 10 MG TABLETmacitentan
BRANDPA
S Specialty Drug
REMODULIN (10 MG/ML, 5 MG/ML, 2.5 MG/ML, 1MG/ML)treprostinil sodium
BRANDPA
S Specialty Drug
REVATIO 10 MG/12.5 ML VIALsildenafil citrate
BRANDPA
S Specialty Drug
sildenafil citrate 10 mg/12.5 vial genericPA
S Specialty Drug
sildenafil citrate 20 mg tablet generic
QL
PA
S Specialty Drug
TRACLEER (125 MG, 62.5 MG)bosentan
BRANDPA
S Specialty Drug
PAGE 107 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
TYVASO (INHALATION REFILL KIT, INSTITUTIONALSTART KIT, INHALATION STARTER KIT, 1.74 MG/2.9 MLSOLUTION)treprostinil/nebulizer/nebulizer accessories
BRANDPA
S Specialty Drug
VELETRI (1.5 MG, 0.5 MG)epoprostenol sodium (arginine)
BRANDPA
S Specialty Drug
VENTAVIS (10 ML, 20 ML)iloprost tromethamine
BRANDPA
S Specialty Drug
RESPIRATORY TRACT AGENTS, OTHER
ACETYLCYSTEINE (100 MG/ML, 200 MG/ML) generic
ARALAST 1,000 MG VIALalpha-1-proteinase inhibitor
BRAND
ARALAST NP (1,000 MG, 500 MG)alpha-1-proteinase inhibitor
BRAND
BENZONATATE (150 MG, 200 MG, 100 MG) generic
BREO ELLIPTA (200-25 MCG, 100-25 MCG)fluticasone furoate/vilanterol trifenatate
BRAND
CENTERGY PEDIATRIC DROPSchlorpheniramine maleate/phenylephrine hcl
BRAND
COMBIVENT RESPIMAT INHAL SPRAYipratropium bromide/albuterol sulfate
BRAND
cromolyn sodium 20 mg/2 ml ampul-neb generic
doxapram hcl 20 mg/ml vial generic
DULERA (200 MCG, 100 MCG)mometasone furoate/formoterol fumarate
BRAND
fexofenadine/pseudoephedrine 180-240mg tab er 24h generic
PA
C
must try cetirizine,cetirizine/pseudoephedrine,loratadine, loratadine/pseudoephedrine
hydrocodone/chlorphen p-stirex 10-8mg/5ml sus er 12h generic
ipratropium/albuterol sulfate 0.5-3mg/3 ampul-neb generic
phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup generic
PROLASTIN (500 MG, 1,000 MG)alpha-1-proteinase inhibitor
BRAND
PROLASTIN C 1,000 MG VIALalpha-1-proteinase inhibitor
BRAND
promethazine hcl/codeine 6.25-10/5 syrup generic
PAGE 108 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
promethazine/dextromethorphan 6.25-15/5 syrup generic
PULMOZYME 1 MG/ML AMPULdornase alfa
BRANDPA
S Specialty Drug
sodium chloride for inhalation 7 % vial-neb generic
STIOLTO RESPIMAT INHAL SPRAYtiotropium bromide/olodaterol hcl
BRAND QL
SYMBICORT (80-4.5 MCG, 160-4.5 MCG)budesonide/formoterol fumarate
BRAND
TUSSIGON 5-1.5 MG TABLEThydrocodone bitartrate/homatropine methylbromide
BRAND
XOLAIR 150 MG VIALomalizumab
BRANDPA
S Specialty Drug
ZEMAIRA 1,000 MG VIALalpha-1-proteinase inhibitor
BRAND
SKELETAL MUSCLE RELAXANTS
ANECTINE 20 MG/ML VIALsuccinylcholine chloride
BRAND
atracurium besylate 10 mg/ml vial generic
BACLOFEN (20 MG, 10 MG) generic
carisoprodol 250 mg tablet generic
chlorzoxazone 500 mg tablet generic
CYCLOBENZAPRINE HCL (10 MG, 5 MG, 7.5 MG) generic
DANTROLENE SODIUM (100 MG, 50 MG, 25 MG) generic
GABLOFEN (50 MCG/ML SYRINGE, 40,000 MCG/20 MLVIAL, 10,000 MCG/20 ML VIAL)baclofen
BRAND S Specialty Drug
METAXALONE (800 MG, 400 MG) generic
METHOCARBAMOL (750 MG, 500 MG) generic
ORPHENADRINE CITRATE (100 MG TABLET ER, 30MG/ML AMPUL, 30 MG/ML VIAL)
generic
orphenadrine/aspirin/caffeine 50-770-60 tablet generic
pancuronium bromide 1 mg/ml vial generic
REVONTO 20 MG VIALdantrolene sodium
BRAND
ROCURONIUM BROMIDE (10 MG/ML VIAL,100MG/10ML SYRINGE, 50 MG/5 ML SYRINGE)
generic
PAGE 109 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
succinylcholine chloride 200mg/10ml syringe generic
TIZANIDINE HCL (6 MG CAPSULE, 4 MG TABLET, 2 MGCAPSULE, 4 MG CAPSULE, 2 MG TABLET)
generic
VECURONIUM BROMIDE (20 MG, 10 MG) generic
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
ESTAZOLAM (1 MG, 2 MG) generic
ESZOPICLONE (2 MG, 1 MG, 3 MG) generic
quazepam 15 mg tablet generic
TEMAZEPAM (7.5 MG, 15 MG, 30 MG, 22.5 MG) generic
TRIAZOLAM (0.25 MG, 0.125 MG) generic
ZALEPLON (10 MG, 5 MG) generic C
must try zolpidem andzaleplon for at least 2weeks of therapy in thepast 90 days
ZOLPIDEM TARTRATE (6.25 MG TAB MPHASE, 10 MGTABLET, 12.5 MG TAB MPHASE, 5 MG TABLET)
generic
SLEEP DISORDERS, OTHER
caffeine/sodium benzoate 250 mg/ml vial generic
FLURAZEPAM HCL (15 MG, 30 MG) generic
HETLIOZ 20 MG CAPSULEtasimelteon
BRAND
QL
PA
S Specialty Drug
MODAFINIL (100 MG, 200 MG) generic PA
ROZEREM 8 MG TABLETramelteon
BRAND
ST
C
must try zolpidem andzoleplon for at least 2weeks of therapy in thepast 90 days
SECONAL SODIUM 100 MG CAPSULEsecobarbital sodium
BRAND
XYREM 500 MG/ML ORAL SOLUTIONsodium oxybate
BRAND S Specialty Drug
THERAPEUTIC NUTRIENTS/MINERALS/ELECTROLYTES
ELECTROLYTE/MINERAL MODIFIERS
PAGE 110 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
CHEMET 100 MG CAPSULEsuccimer
BRAND
DEFEROXAMINE MESYLATE (2 G, 500 MG) generic
EXJADE (500 MG, 250 MG, 125 MG)deferasirox
BRAND PA
FERRIPROX 500 MG TABLETdeferiprone
BRAND S Specialty Drug
KIONEX (15 GM/60 ML SUSPENSION, POWDER)sodium polystyrene sulfonate
BRAND
MARLEXATE POWDERsodium polystyrene sulfonate
BRAND
SAMSCA (30 MG, 15 MG)tolvaptan
BRAND S Specialty Drug
SODIUM POLYSTYRENE SULFONATE (POWDER,30G/120ML ENEMA, 15 G/60 ML ORAL SUSP)
generic
SODIUM THIOSULFATE (1 G/10 ML, 12.5G/50ML) generic
SPS (15 GM/60 ML SUSPENSION, 30 GM/120 MLENEMA)sodium polystyrene sulfonate
BRAND
ELECTROLYTE/MINERAL REPLACEMENT
0.9 % SODIUM CHLORIDE (0.9 0.9 IV SOLN, 0.9 0.9SYRINGE, 0.9 PGGYBK PRT, 0.9 0.9 VIAL, 0.9 PGY VLPRT)
generic
CALCIUM CHLORIDE (100 MG/ML VIAL, 100 MG/MLSYRINGE)
generic
calcium gluconate 100 mg/ml vial generic
calcium/mag/d3/b12/fa/b6/boron 500-300-1 wafer generic
CARBAGLU 200 MG DISPER TABLETcarglumic acid
BRAND S Specialty Drug
CENTRATEX CAPSULEferrous fumarate/folic acid/multivitamins with min no. 15
BRAND
chromic chloride 4mcg/ml vial generic
CORVITA 150 TABLETiron,carbonyl/folic acid/vit c/pyridoxine hcl/vit b12/zinc
BRAND
cupric chloride 0.4 mg/ml vial generic
DELFLEX WITH 1.5% DEXTROSEperitoneal dialysis no.6 with dextrose 1.5 %
BRAND
DELFLEX WITH 2.5% DEXTROSEperitoneal dialysis no.7 with dextrose 2.5 %
BRAND
PAGE 111 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
DELFLEX WITH 4.25% DEXTROSEperitoneal dialysis no.8 with dextrose 4.25 %
BRAND
DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE (100.2 10 DEHP FR BG, 10 0.2 10 IV SOLN)
generic
dextrose 10 % and 0.45 % nacl 10%-0.45% iv soln generic
dextrose 10 % and 0.9 % nacl 10 %-0.9 % iv soln generic
dextrose 2.5 % and 0.45 % nacl 2.5%-0.45% iv soln generic
dextrose 5 % and 0.3 % nacl 5 %-0.3 % iv soln generic
dextrose 5 % and 0.9 % nacl 5 %-0.9 % iv soln generic
dextrose 5 %-0.2 % nacl 5 %-0.2 % iv soln generic
dextrose 5 %-0.45 % nacl 5 %-0.45 % iv soln generic
dextrose 5% in ringers 5 % iv soln generic
dextrose 5%-lactated ringers 5 % iv soln generic
EFFER-K 25 MEQ TABLET EFFpotassium bicarbonate/citric acid
BRAND
electrolyte-48 solution/d5w 5 % iv soln generic
FE 90 PLUS TABLETiron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium
BRAND
FE C PLUS TABLETiron,carbonyl/ascorbic acid/cyanocobalamin/folic acid
BRAND
FEROCON CAPSULEferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
FEROTRINSIC CAPSULEferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
FERRAPLUS 90 TABLETiron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na
BRAND
FERREX 150 FORTE CAPSULEiron polysaccharide complex/cyanocobalamin/folic acid
BRAND
FERREX 150 FORTE PLUS CAPSULEiron asp gly&ps cmplx/ascorb.cal/vit b12/fa/ca-thr/succ.acid
BRAND
FERREX 28 TABLETiron asp.glycin & fumarate /vit c/fa/mv comb 11/ca-threonate
BRAND
FERROCITE PLUS TABLETiron/folic acid/vitamin b comp and c/minerals
BRAND
FERROGELS FORTE SOFTGELferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
FLUOR-A-DAY (1 MG TABLET, 0.25 MG TAB, 0.5 MG BRAND
PAGE 112 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
TAB)sodium fluoride/xylitol
FOCALGIN DSS TABLETiron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium
BRAND
FOLIVANE-F CAPSULEiron fumarate & polysac comp/folic acid/vitamin c/niacin
BRAND
FOLIVANE-PLUS CAPSULEiron fumarate,polysac cplex/folic acid/vit b comp with c #9
BRAND
HEMATINIC-FOLIC ACID TABLETferrous fumarate/folic acid
BRAND
HEMATINIC-VITAMIN-MINERAL TABiron/folic acid/vitamin b comp and c/minerals
BRAND
HEMATOGEN FA SOFTGELferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
HEMATOGEN FORTE SOFTGELferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
HEMATOGEN SOFTGELferrous fumarate/ascorbic acid/cyanocobalamin/stomachconc
BRAND
HEMETAB IRON SUPPLEMENT TABLETiron polysacchar complx/iron heme polypeptide/folicacid/b12
BRAND
INFED 100 MG/2 ML VIALiron dextran complex
BRANDPA
S Specialty Drug
K EFFERVESCENT 25 MEQ TABLETpotassium bicarbonate/citric acid
BRAND
K-SOL (10% (20, 20% (40)potassium chloride
BRAND
K-TAB ER 8 MEQ TABLETpotassium chloride
BRAND
KLOR-CON (25, 20)potassium chloride
BRAND
KLOR-CON 10 MEQ TABLETpotassium chloride
BRAND
KLOR-CON 8 MEQ TABLETpotassium chloride
BRAND
KLOR-CON M10 TABLETpotassium chloride
BRAND
KLOR-CON M15 TABLETpotassium chloride
BRAND
PAGE 113 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
KLOR-CON M20 TABLETpotassium chloride
BRAND
KLOR-CON SPRINKLE (ER 8 CAP, ER 10 CP)potassium chloride
BRAND
KLOR-CON-EF 25 MEQ TAB EFFpotassium bicarbonate/citric acid
BRAND
magnesium chloride 200 mg/ml vial generic
MAGNESIUM SULFATE (4 SYRINGE, 4 VIAL) generic
MAGNESIUM SULFATE IN STERILE WATER (4 G/50 MLPIGGYBACK, 20 G/500ML IV SOLN, 4 G/100 MLPIGGYBACK, 40G/1000ML IV SOLN, 2 G/50 MLPIGGYBACK)
generic
manganese chloride 0.1 mg/ml vial generic
manganese sulfate 0.1 mg/ml vial generic
molybdenum(ammonium molybdate) 25 mcg/ml vial generic
MONOJECT 0.9% SODIUM CL SYRING0.9 % sodium chloride
BRAND
MONOJECT PREFILL 0.9% FLUSH0.9 % sodium chloride
BRAND
MONOJECT PREFILL 0.9% NA SYR0.9 % sodium chloride
BRAND
MULTIGEN CAPLETiron aspgly/ascorb.cal/vit b12/calciumthr/succ.acid/stomach
BRAND
MULTIGEN FOLIC CAPLETiron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid
BRAND
MULTIGEN PLUS CAPLETiron fumarte &asp gly/ascorb.cal/vit b12/fa/ca-thr/succ.acid
BRAND
MULTITRACE-4 CONC VIALzinc sulfate/cupric sulfate/manganese sulf/chromic chloride
BRAND
MULTITRACE-5 CONC VIALzinc sulfate heptahydrate/cuso4 p-hyd/manganese/chromium/se
BRAND
NATALVIRT FLT TABLETiron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium
BRAND
NUTRILYTE II VIALsodium/potassium/magnesium/calcium/chloride/acetate
BRAND
NUTRILYTE VIALsodium/potassium/magnes/calcium/chloride/acetate/gluconate
BRAND
PAGE 114 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
POLYSACCHARIDE IRON FORTEiron polysaccharide complex/cyanocobalamin/folic acid
BRAND
pot chloride/pot bicarb/cit ac 25 meq tablet eff generic
POTASSIUM ACETATE (2, 4) generic
potassium bicarbonate/cit ac 25 meq tablet eff generic
POTASSIUM CHLORIDE (40MEQ/0.1L PIGGYBACK, 10MEQ TAB ER PRT, 8 MEQ CAPSULE ER, 8 MEQTABLET ER, 10 MEQ CAPSULE ER, 10MEQ/50MLPIGGYBACK, 2 MEQ/ML VIAL, 20MEQ/50MLPIGGYBACK, 20 MEQ PACKET, 20MEQ/15ML LIQUID,10 MEQ TABLET ER, 30MEQ/0.1L PIGGYBACK,20MEQ/0.1L PIGGYBACK, 2 MEQ/ML IV SOLN, 20 MEQTABLET ER, 20 MEQ TAB ER PRT, 40MEQ/15MLLIQUID, 10MEQ/0.1L PIGGYBACK)
generic
POTASSIUM CHLORIDE IN 0.9 % SODIUM CHLORIDE(20, 40)
generic
POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER(40, 20, 30)
generic
POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 %SODIUM CHLORIDE (40, 20)
generic
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 %SODIUM CHLORIDE (20, 10, 30, 40)
generic
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 %SODIUM CHLORIDE (10, 20, 40, 30)
generic
POTASSIUM CHLORIDE IN LACTATED RINGERS AND 5% DEXTROSE (40, 20)
generic
potassium chloride-0.45% nacl 20 meq/l iv soln generic
potassium chloride/d5-0.3%nacl 20 meq/l iv soln generic
potassium phos in 0.9 % nacl 15mmol/250 plast. bag generic
potassium phos,m-basic-d-basic 3mmol/ml vial generic
PROFERRIN-FORTE TABLETiron heme polypeptide/folic acid
BRAND
PUREVIT DUALFE PLUS CAPSULEiron fumarate-iron polysacchar/folic acid/mv comb18
BRAND
ringers solution iv soln generic
ringers solution,lactated iv soln generic
SE-TAN PLUS CAPSULEiron fumarate-iron polysacchar/folic acid/mv comb18
BRAND
selenium 40 mcg/ml vial generic
SODIUM ACETATE (4, 2) generic
PAGE 115 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
SODIUM BICARBONATE (1 MEQ/ML SYRINGE,0.5MEQ/ML SYRINGE, 0.9MEQ/ML SYRINGE, 1 MEQ/MLVIAL, 10MEQ/10ML SYRINGE, 0.5MEQ/ML VIAL)
generic
SODIUM CHLORIDE 0.45 % (0.45 PGGYBK PRT, 0.450.45 IV SOLN)
generic
sodium chloride 3 % 3 % iv soln generic
sodium chloride 5 % 5 % iv soln generic
sodium chloride irrig solution 0.9 % irrig soln generic
sodium fluoride 0.25(0.55) tab chew generic
sodium lactate 5 meq/ml vial generic
sodium phos,m-basic-d-basic 3mmol/ml vial generic
SYREX SODIUM CHL 0.9% SYR0.9 % sodium chloride
BRAND
TARON FORTE CAPSULEiron bisgly,pscmplx/ascorbate calc/b12/folic acid/calc-threo
BRAND
TL G-FOL OS TABLETcalcium carb/mag oxide/vitamin d3/vit b12/fa/vit b6/boron
BRAND
TL ICON CAPSULEferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
TL-HEM 150 CAPLETiron,carbonyl/docusate sodium/b12-if/folic acid/multivit-min
BRAND
TRICON CAPSULEferrous fumarate/ascorbic acid/b12-if/folic acid
BRAND
TRIGELS-F FORTE SOFTGELferrous fumarate/ascorbic acid/cyanocobalamin/folic acid
BRAND
zinc chloride 1 mg/ml vial generic
ZINC SULFATE (1 MG/ML VIAL, 5 MG/ML VIAL,220(50)MG CAPSULE)
generic
AMINO ACIDS 15% SOLUTIONparenteral amino acid 15% combination no.1
BRAND
ascorbic acid 500 mg/ml vial generic
BAL-CARE DHA COMBO PACKprenatal vitamin no.81/sodium feredetate-ironpoly/fa/omega3
BRAND PA
cyanocobalamin (vitamin b-12) 1000mcg/ml vial generic
cysteine hcl 50 mg/ml vial generic
DEXTROSE 10 % IN WATER (10 10 IV SOLN, 10 10DEHP FR BG)
generic
PAGE 116 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
dextrose 2.5 % in water 2.5 % iv soln generic
dextrose 20 % in water 20 % iv soln generic
dextrose 25 % in water 25 % syringe generic
dextrose 30 % in water 30 % iv soln generic
dextrose 40 % in water 40 % iv soln generic
DEXTROSE 5 % IN WATER (5 5 IV SOLN, 5 PGY VLPRT, 5 5 VIAL, 5 PGGYBK PRT)
generic
DEXTROSE 50 % IN WATER (50 50 IV SOLN, 50 50VIAL, 50 50 SYRGE)
generic
dextrose 70 % in water 70 % iv soln generic
DIALYVITE TABLETfolic acid/vitamin b comp and c
BRAND
ergocalciferol (vitamin d2) 50000 unit capsule generic
ethyl alcohol 98 % ampul generic
FOLBEE PLUS TABLETfolic acid/vitamin b comp and c
BRAND
FOLIC ACID (5 MG/ML VIAL, 1 MG TABLET) generic
FREAMINE III 10% IV SOLN.parenteral amino acid 10% combination no. 4
BRAND
levocarnitine (with sugar) 100 mg/ml solution generic
levocarnitine 330 mg tablet generic
LEVOMEFOLATE CALCIUM/SCHIZOCHYTRIUM ALGALOIL (7.5-90.314, 15-90.314)
generic
LIPOSYN III (20%, 10%, 30%)fat emulsions
BRAND
MEPHYTON 5 MG TABLETphytonadione
BRAND
MYNATAL PLUS CAPTABprenatal vitamins with calcium/ferrous fumarate/folic acid
BRAND
MYNATAL-Z CAPTABprenatal vitamins with calcium/ferrous fumarate/folic acid
BRAND
MYNEPHROCAPS SOFTGELvitamin b complex & vitamin c no.20/folic acid
BRAND
NEPHPLEX RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin/znox
BRAND
NEPHRO-VITE RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
NIVA-PLUS TABLET BRAND
PAGE 117 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
prenatal vits with calcium #74/ferrous fumarate/folic acid
NUTRILIPID 20% IV FAT EMULSIONfat emulsions
BRAND
pedi mv #75/fluoride/iron 0.25-10/ml drops generic
PHYTONADIONE (10 MG/ML, 1MG/0.5ML) generic
PNV 29-1 TABLETprenatal vits with calcium #76/iron,carbonyl/folic acid
BRAND
pnv with ca,no.72/iron/fa 27 mg-1 mg tablet generic
pnv with ca,no.74/iron/fa 27 mg-1 mg tablet generic
PNV-SELECT TABLETprenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
BRAND
PNV-VP-U CAPSULEprenatal vits without calc no5/ferrous fumarate/folic acid
BRAND
PREMASOL 10% IV SOLUTIONparenteral amino acid 10% combination no.7
BRAND
PRENA1 CHEW TABLETprenatal vitamins combination no.42/folic acid
BRAND
PRENAPLUS TABLETprenatal vits with calcium #74/ferrous fumarate/folic acid
BRAND
PREPLUS CA-FE 27 MG-FA 1 MG TBprenatal vits with calcium #72/ferrous fumarate/folic acid
BRAND
PRETAB 29 MG-1 MG TABLETprenatal vits with calcium #78/ferrous fumarate/folic acid
BRAND
RENA-VITE RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
RENAL CAPS SOFTGELvitamin b complex & vitamin c no.20/folic acid
BRAND
RENO CAPS SOFTGELvitamin b complex & vitamin c no.20/folic acid
BRAND
ringers solution irrig soln generic
ringers solution,lactated irrig soln generic
THERAPEUTIC VIT-MINERAL CAPmultivitamins with min no.7/folic acid
BRAND
thiamine hcl 100 mg/ml vial generic
THRIVITE RX TABLETprenatal vits with calcium #76/iron,carbonyl/folic acid
BRAND
TRAVASOL 10% SOLN VIAFLEXparenteral amino acid 10% combination no. 6
BRAND
PAGE 118 LAST UPDATED 02/2016
DRUG DESCRIPTION (RX) BRAND/GEN LIMITS & RESTRICTIONS
VENA-BAL DHA COMBO PACKprenatal vitamin no.81/sodium feredetate-ironpoly/fa/omega3
BRAND PA
VIRT NATE TABLETprenatal vits with calcium #73/ferrous fumarate/folic acid
BRAND
VIRT-ADVANCE TABLETprenatal vitamin no.15/iron,carbonyl/folic acid/docusate sod
BRAND
VIRT-CAPS SOFTGELvitamin b complex & vitamin c no.20/folic acid
BRAND
VIRT-NATE DHA SOFTGELprenatal vitamins no.11/ferrous fumarate/folic acid/omega-3
BRAND
VIRT-NATE TABLETprenatal vits with calcium #73/ferrous fumarate/folic acid
BRAND
VIRT-PN TABLETprenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
BRAND
VIRT-VITE GT TABLETprenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod
BRAND
VIRTPREX CAPSULEprenatal vit with calcium no.66/iron fum/folic acid/dss/dha
BRAND
VITAFOL-OB CAPLETprenatal vitamins comb 10/ferrous fumarate/folic acid
BRAND
VITAFOL-PN CAPLETprenatal vit with calcium cmb 11/ferrous fumarate/folic acid
BRAND
VOL-CARE RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
VOL-PLUS TABLETprenatal vits with calcium #74/ferrous fumarate/folic acid
BRAND
VP-VITE RX TABLETvitamin b complx no.3/folic acid/ascorbic acid/biotin
BRAND
ZATEAN-PN TABLETprenatal vit with calcium no. 40/iron fumarate/fa cmb no.1
BRAND
PAGE 119 LAST UPDATED 02/2016
Index of covered drugs00.9 % SODIUM CHLORIDE 116
88-MOP 67
AA-HYDROCORT 79
A-METHAPRED 79
ABACAVIR SULFATE 47
ABACAVIR SULFATE/LAMIVUDINE 46
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE 46
ABILIFY 42
ABILIFY DISCMELT 42
ABILIFY MAINTENA 42
ABIRATERONE ACETATE 33
ABRAXANE 34
ABSORICA 68
ACAMPROSATE CALCIUM 14
ACARBOSE 49
ACD 51
ACD-A 52
ACEBUTOLOL HCL 57
ACETAMINOPHEN WITH CODEINE PHOSPHATE 8
ACETASOL HC 102
ACETAZOLAMIDE 62
ACETAZOLAMIDE SODIUM 62
ACETIC ACID 102
ACETIC ACID/ALUMINUM ACETATE 102
ACETIC ACID/HYDROCORTISONE 102
ACETIC ACID/OXYQUINOLINE SULFATE 78
ACETYLCYSTEINE 108
ACITRETIN 68
ACLIDINIUM BROMIDE 105
ACTEMRA 95
ACTIMMUNE 95
ACTOPLUS MET XR 49
ACYCLOVIR 48
ACYCLOVIR SODIUM 48
ADACEL TDAP 96
ADALIMUMAB 94
ADAPALENE 68
ADCIRCA 107
ADEFOVIR DIPIVOXIL 44
ADEMPAS 107
ADENOSINE 57
ADO-TRASTUZUMAB EMTANSINE 39
ADRENALIN 105
ADRENALIN CHLORIDE 105
ADRIAMYCIN 34
ADRUCIL 33
ADVATE 53
ADVATE H 54
ADVATE L 53
ADVATE M 53
ADVATE SH 53
ADVATE UH 53
AERO OTIC HC 102
AFATINIB DIMALEATE 37
AFEDITAB CR 58
AFINITOR 37
AFINITOR DISPERZ 37
AGALSIDASE BETA 73
AKORN BALANCED SALT 99
ALA-CORT 79
ALAGESIC LQ 65
ALBENDAZOLE 39
ALBENZA 39
ALBUMIN HUMAN 97
ALBUTEIN 97
ALBUTEROL SULFATE 106
ALCLOMETASONE DIPROPIONATE 79
ALDURAZYME 73
ALENDRONATE SODIUM 97
ALFENTANIL HCL 9
ALFUZOSIN HCL 77
ALGLUCOSIDASE ALFA 73
ALIMTA 34
ALINIA 39
ALKERAN 32
ALLOPURINOL 30
PAGE 120 LAST UPDATED 02/2016
ALLOPURINOL SODIUM 30
ALMOTRIPTAN MALATE 31
ALOPRIM 30
ALOSETRON HCL 75
ALPHA-1-PROTEINASE INHIBITOR 109
ALPHAGAN P 101
ALPHANATE 54
ALPHAQUIN HP 68
ALPRAZOLAM 48
ALPRAZOLAM INTENSOL 48
ALPROSTADIL 59
ALTACAINE 99
ALTAFLUOR 99
ALTAVERA 83
ALTRETAMINE 32
ALUMINUM CHLORIDE 69
ALYACEN 84
AMANTADINE HCL 40
AMBRISENTAN 107
AMCINONIDE 79
AMETHIA 84
AMETHIA LO 84
AMETHYST 84
AMIFOSTINE CRYSTALLINE 34
AMIKACIN SULFATE 15
AMILORIDE HCL 62
AMILORIDE HCL/HYDROCHLOROTHIAZIDE 59
AMINO ACIDS 116
AMINOACETIC ACID 77
AMINOCAPROIC ACID 54
AMINOPHYLLINE 106
AMIODARONE HCL 57
AMITRIPTYLINE HCL 27
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE 25
AMLODIPINE BESYLATE 58
AMLODIPINE BESYLATE/ATORVASTATIN
CALCIUM 59
AMLODIPINE BESYLATE/BENAZEPRIL HCL 59
AMLODIPINE BESYLATE/VALSARTAN 60
AMLODIPINE
BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE
59
AMMONIUM LACTATE 69
AMNESTEEM 68
AMOXAPINE 27
AMOXICILLIN 19
AMOXICILLIN/POTASSIUM CLAVULANATE 20
AMPHOTERICIN B 28
AMPICILLIN SODIUM 20
AMPICILLIN SODIUM/SULBACTAM SODIUM 20
AMPICILLIN TRIHYDRATE 20
AMPYRA 66
AMYL NITRITE 63
ANAGRELIDE HCL 53
ANASPAZ 74
ANASTROZOLE 37
ANDROGEL 83
ANDROXY 83
ANECTINE 109
ANTHRALIN 69
ANTI-INHIBITOR COAGULANT COMPLEX 54
ANTIHEMOPHILIC FACTOR (FACTOR VIII)
RECOMB,B-DOMAIN DELETED 55
ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL
LENGTH (ALB-FREE) 55
ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,
FC FUSION PROTEIN 54
ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B-
DOMAIN TRUNCATED 55
ANTIHEMOPHILIC FACTOR VIII, HUMAN
RECOMBINANT 55
ANTIHEMOPHILIC FACTOR, HUMAN 54
ANTIHEMOPHILIC FACTOR, HUMAN/VON
WILLEBRAND FACTOR,HUMAN 54
ANTIPYRINE/BENZOCAINE 102
ANTIPYRINE/BENZOCAINE/GLYCERIN/ZINC
ACETATE 103
APEXICON 79
APEXICON E 79
APLIGRAF 68
PAGE 121 LAST UPDATED 02/2016
APOKYN 41
APOMORPHINE HCL 41
APRACLONIDINE HCL 101
APREPITANT 28
APRI 84
APRISO 96
APTIVUS 47
ARALAST 108
ARALAST NP 108
ARANELLE 84
ARBINOXA 103
ARCALYST 95
ARGATROBAN IN SODIUM CHLORIDE, ISO-
OSMOTIC 52
ARIPIPRAZOLE 43
ARMOUR THYROID 91
ARNUITY ELLIPTA 103
ARRANON 34
ARSENIC TRIOXIDE 36
ARTEMETHER/LUMEFANTRINE 40
ARZERRA 39
ASCOMP WITH CODEINE 9
ASCORBIC ACID 116
ASFOTASE ALFA 73
ASHLYNA 84
ASPIRIN/DIPYRIDAMOLE 55
ASTRAMORPH-PF 9
ATAZANAVIR SULFATE 47
ATENOLOL 58
ATENOLOL/CHLORTHALIDONE 60
ATOMOXETINE HCL 65
ATORVASTATIN CALCIUM 63
ATOVAQUONE 40
ATOVAQUONE/PROGUANIL HCL 40
ATRACURIUM BESYLATE 109
ATRIPLA 46
ATROPINE CARE 99
ATROPINE SULFATE 99
ATROVENT HFA 105
AUBRA 84
AURANOFIN 95
AURODEX 102
AUROGUARD 102
AVAR 68
AVASTIN 39
AVELOX IV 21
AVIANE 84
AVIDOXY 22
AVITA 68
AVITENE 97
AVONEX 66
AVONEX ADMINISTRATION PACK 66
AVONEX PEN 66
AXITINIB 38
AZASAN 93
AZATHIOPRINE 93
AZELASTINE HCL 103
AZITHROMYCIN 20
AZTREONAM 19
AZTREONAM LYSINE 106
AZURETTE 84
BB-DONNA 74
BACIIM 15
BACITRACIN 15
BACITRACIN/POLYMYXIN B SULFATE 100
BACLOFEN 109
BACTROBAN NASAL 15
BAL-CARE DHA 116
BALANCED SALT IRRIG SOLN NO.2 100
BALSALAZIDE DISODIUM 96
BALZIVA 84
BANZEL 24
BARACLUDE 44
BCG LIVE 36
BEBULIN 54
BEBULIN VH IMMUNO 54
BECAPLERMIN 71
BECLOMETHASONE DIPROPIONATE 103
BEDAQUILINE FUMARATE 32
BEKYREE 84
PAGE 122 LAST UPDATED 02/2016
BELATACEPT 94
BELIMUMAB 95
BENAZEPRIL HCL 57
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE 60
BENDAMUSTINE HCL 33
BENEFIX 54
BENLYSTA 95
BENOXINATE HCL/FLUORESCEIN SODIUM 100
BENZEPRO 68
BENZONATATE 108
BENZOYL PEROXIDE 68
BENZOYL PEROXIDE MICROSPHERES 71
BENZPHETAMINE HCL 65
BENZTROPINE MESYLATE 40
BETAINE 73
BETAMETHASONE ACETATE/BETAMETHASONE
SODIUM PHOSPHATE 79
BETAMETHASONE DIPROPIONATE 79
BETAMETHASONE DIPROPIONATE/PROPYLENE
GLYCOL 79
BETAMETHASONE VALERATE 79
BETAXOLOL HCL 101
BETHANECHOL CHLORIDE 78
BEVACIZUMAB 39
BEXAROTENE 39
BEXXAR 39
BICALUTAMIDE 33
BICNU 32
BIMATOPROST 102
BIOGLO 100
BISACODYL/SODIUM CHLOR/SODIUM
BICARB/POTASSIUM CHL/PEG 3350 76
BISOPROLOL FUMARATE 58
BISOPROLOL
FUMARATE/HYDROCHLOROTHIAZIDE 60
BIVIGAM 94
BLISOVI 24 FE 84
BLISOVI FE 84
BOCEPREVIR 45
BOSENTAN 107
BOSULIF 37
BOSUTINIB 37
BP 10-1 68
BP-50% UREA 68
BPO 68
BREO ELLIPTA 108
BRIELLYN 84
BRILINTA 55
BRIMONIDINE TARTRATE 102
BROMFENAC SODIUM 101
BROMOCRIPTINE MESYLATE 41
BSS 100
BUDEPRION XL 26
BUDESONIDE 103
BUDESONIDE/FORMOTEROL FUMARATE 109
BUFFERED LIDOCAINE 12
BUMETANIDE 62
BUPHENYL 73
BUPIVACAINE HCL 14
BUPIVACAINE HCL/DEXTROSE-WATER/PF 12
BUPIVACAINE HCL/EPINEPHRINE 14
BUPIVACAINE HCL/EPINEPHRINE/PF 12
BUPIVACAINE HCL/PF 14
BUPRENORPHINE HCL 14
BUPRENORPHINE HCL/NALOXONE HCL 14
BUPROBAN 15
BUPROPION HCL 26
BUSPIRONE HCL 48
BUSULFAN 33
BUSULFEX 32
BUTALBITAL/ACETAMINOPHEN 66
BUTALBITAL/ACETAMINOPHEN/CAFFEINE 66
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEIN
E PHOSPHATE 9
BUTALBITAL/ASPIRIN/CAFFEINE 5
BUTOCONAZOLE NITRATE 29
BUTORPHANOL TARTRATE 9
BYDUREON 49
BYDUREON PEN 49
BYETTA 49
PAGE 123 LAST UPDATED 02/2016
CCABERGOLINE 92
CAFFEINE CITRATED 107
CAFFEINE/SODIUM BENZOATE 110
CALCIPOTRIENE 68
CALCIPOTRIENE/BETAMETHASONE
DIPROPIONATE 68
CALCITONIN,SALMON,SYNTHETIC 97
CALCITRENE 68
CALCITRIOL 97
CALCIUM ACETATE 79
CALCIUM CARB/MAG OXIDE/VITAMIN D3/VIT
B12/FA/VIT B6/BORON 116
CALCIUM CHLORIDE 111
CALCIUM GLUCONATE 111
CAMILA 90
CAMRESE 84
CAMRESE LO 84
CANAGLIFLOZIN 50
CANAGLIFLOZIN/METFORMIN HCL 50
CANAKINUMAB/PF 95
CANASA 96
CANCIDAS 28
CANDESARTAN CILEXETIL 56
CANDESARTAN
CILEXETIL/HYDROCHLOROTHIAZIDE 60
CAPACET 65
CAPECITABINE 34
CAPRELSA 37
CAPTOPRIL 57
CAPTOPRIL/HYDROCHLOROTHIAZIDE 60
CARAFATE 76
CARB-O-PHILIC 69
CARBACHOL 102
CARBAGLU 111
CARBAMAZEPINE 25
CARBIDOPA 41
CARBIDOPA/LEVODOPA 41
CARBIDOPA/LEVODOPA/ENTACAPONE 41
CARBINOXAMINE MALEATE 104
CARBOCAINE 13
CARBOPLATIN 35
CARBOPROST TROMETHAMINE 98
CARDIOPLEGIC SOLUTION NO.1 60
CARGLUMIC ACID 111
CARISOPRODOL 109
CARMUSTINE 32
CARTEOLOL HCL 102
CARTIA XT 58
CARVEDILOL 58
CASPOFUNGIN ACETATE 28
CAYSTON 106
CAZIANT 84
CEFACLOR 18
CEFADROXIL 18
CEFAZOLIN SODIUM 18
CEFAZOLIN SODIUM IN 0.9 % SODIUM
CHLORIDE 18
CEFAZOLIN SODIUM/DEXTROSE 5 % IN WATER 18
CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC 18
CEFDINIR 18
CEFDITOREN PIVOXIL 18
CEFEPIME HCL 18
CEFEPIME HCL/DEXTROSE, ISO-OSMOTIC 18
CEFIXIME 19
CEFOTAXIME SODIUM 19
CEFOTAXIME SODIUM/DEXTROSE, ISO-
OSMOTIC 19
CEFOTETAN DISODIUM 19
CEFOXITIN SODIUM 19
CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC 19
CEFPODOXIME PROXETIL 19
CEFPROZIL 19
CEFTAZIDIME 19
CEFTIBUTEN 19
CEFTRIAXONE SODIUM 19
CEFTRIAXONE SODIUM/DEXTROSE, ISO-
OSMOTIC 19
CEFUROXIME AXETIL 19
CEFUROXIME SODIUM 19
PAGE 124 LAST UPDATED 02/2016
CEFUROXIME SODIUM/DEXTROSE, ISO-
OSMOTIC 19
CELEBREX 5
CELECOXIB 5
CELLCEPT 93
CELONTIN 23
CEM-UREA 69
CENTERGY 108
CENTRATEX 111
CEPHALEXIN 19
CERITINIB 38
CERUBIDINE 35
CETUXIMAB 39
CEVIMELINE HCL 67
CHANTIX 15
CHATEAL 84
CHEMET 110
CHENODAL 75
CHENODIOL 75
CHLORAMBUCIL 32
CHLORAMPHENICOL SOD SUCC 16
CHLORDIAZEPOXIDE HCL 48
CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE 74
CHLORHEXIDINE GLUCONATE 67
CHLOROPROCAINE HCL/PF 13
CHLOROQUINE PHOSPHATE 40
CHLOROTHIAZIDE 62
CHLOROTHIAZIDE SODIUM 62
CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE
HCL 108
CHLORPROMAZINE HCL 41
CHLORTHALIDONE 62
CHLORZOXAZONE 109
CHOLESTYRAMINE (WITH SUGAR) 63
CHOLESTYRAMINE/ASPARTAME 63
CHOLINE SALICYLATE/MAGNESIUM SALICYLATE 5
CHORIONIC GONADOTROPIN, HUMAN 83
CHROMIC CHLORIDE 111
CICLODAN 28
CICLOPIROX 28
CICLOPIROX OLAMINE 29
CICLOPIROX/UREA/CAMPHOR/MENTHOL/EUCALY
PTOL 29
CIDOFOVIR 44
CILOSTAZOL 55
CIMETIDINE 75
CIMETIDINE HCL 75
CINACALCET HCL 92
CIPRO 21
CIPRODEX 102
CIPROFLOXACIN 21
CIPROFLOXACIN HCL 21
CIPROFLOXACIN HCL/DEXAMETHASONE 102
CIPROFLOXACIN LACTATE 21
CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN
WATER 21
CIPROFLOXACIN/CIPROFLOXACIN HCL 22
CISPLATIN 35
CITALOPRAM HYDROBROMIDE 26
CITRATE DEXTROSE SOLUTION 52
CITRATE PHOSPHATE DEXTROS SOLN 52
CITRIC ACID/GLUCONOLACTONE/MAGNESIUM
CARBONATE 78
CITRIC ACID/SODIUM CITRATE 79
CLADRIBINE 34
CLAFORAN-DEXTROSE 19
CLARAVIS 69
CLARIS 69
CLARITHROMYCIN 21
CLEANSING WASH 68
CLEMASTINE FUMARATE 104
CLINDACIN ETZ 16
CLINDACIN P 16
CLINDAMYCIN HCL 16
CLINDAMYCIN PALMITATE HCL 16
CLINDAMYCIN PHOSPHATE 16
CLINDAMYCIN PHOSPHATE/BENZOYL
PEROXIDE 70
CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN
WATER 16
CLOBAZAM 23
CLOBETASOL PROPIONATE 80
PAGE 125 LAST UPDATED 02/2016
CLOBETASOL PROPIONATE/EMOLLIENT BASE 80
CLODAN 80
CLOMIPRAMINE HCL 27
CLONAZEPAM 48
CLONIDINE 56
CLONIDINE HCL 64
CLONIDINE HCL/CHLORTHALIDONE 60
CLONIDINE HCL/PF 56
CLOPIDOGREL BISULFATE 55
CLORAZEPATE DIPOTASSIUM 49
CLORPRES 60
CLOTRIMAZOLE/BETAMETHASONE
DIPROPIONATE 69
CLOZAPINE 44
COAGULATION FACTOR VIIA (RECOMBINANT) 55
COAL TAR 97
COARTEM 40
COCAINE HCL 13
CODEINE
PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE 9
CODEINE SULFATE 9
COLCHICINE 30
COLCHICINE/PROBENECID 30
COLCRYS 30
COLESTIPOL HCL 63
COLISTIN (AS COLISTIMETHATE SODIUM) 16
COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 71
COLOCORT 96
COMBIVENT RESPIMAT 108
COMPLERA 46
COMPOUND 347 97
COMPRO 27
COPAXONE 66
CORIFACT 54
CORLANOR 60
CORLOPAM 63
CORMAX 80
CORTANE-B 102
CORTICOTROPIN 82
CORTIFOAM 96
CORTISONE ACETATE 80
CORVITA 150 111
COSYNTROPIN 82
CREON 73
CRIXIVAN 47
CRIZOTINIB 38
CROMOLYN SODIUM 108
CROTAMITON 40
CRYSELLE 84
CULT SKIN SUBST,HUMAN-BOVINE 68
CUPRIC CHLORIDE 111
CUPRIMINE 78
CYANOCOBALAMIN (VITAMIN B-12) 116
CYCLAFEM 85
CYCLOBENZAPRINE HCL 109
CYCLOPENTOLATE HCL 100
CYCLOPHOSPHAMIDE 32
CYCLOSPORINE 101
CYCLOSPORINE, MODIFIED 93
CYPROHEPTADINE HCL 104
CYRED 85
CYSTADANE 73
CYSTAGON 73
CYSTARAN 100
CYSTEAMINE BITARTRATE 73
CYSTEAMINE HCL 100
CYSTEINE HCL 116
CYTARABINE 34
CYTARABINE/PF 34
CYTRA-2 78
CYTRA-3 78
CYTRA-K 78
DDABIGATRAN ETEXILATE MESYLATE 53
DABRAFENIB MESYLATE 38
DACARBAZINE 35
DACTINOMYCIN 35
DALFAMPRIDINE 66
DANAZOL 83
DANTROLENE SODIUM 109
DAPSONE 31
PAGE 126 LAST UPDATED 02/2016
DARAPRIM 40
DARUNAVIR ETHANOLATE 47
DASATINIB 38
DASETTA 85
DAUNORUBICIN CITRATE LIPOSOMAL 35
DAUNORUBICIN HCL 35
DAUNOXOME 35
DAYSEE 85
DEBACTEROL 67
DEBLITANE 90
DECITABINE 35
DEFERASIROX 111
DEFERIPRONE 111
DEFEROXAMINE MESYLATE 111
DELAVIRDINE MESYLATE 46
DELFLEX WITH 1.5% DEXTROSE 111
DELFLEX WITH 2.5% DEXTROSE 111
DELFLEX WITH 4.25% DEXTROSE 111
DELTASONE 80
DELYLA 85
DEMECLOCYCLINE HCL 22
DEMSER 60
DEPADE 14
DEPO-PROVERA 90
DERMAZENE 69
DESIPRAMINE HCL 27
DESLORATADINE 104
DESMOPRESSIN ACETATE 83
DESMOPRESSIN ACETATE (NON-
REFRIGERATED) 82
DESOGESTREL-ETHINYL ESTRADIOL 89
DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL
ESTRADIOL 90
DESONIDE 80
DESOXIMETASONE 80
DEXAMETHASONE 80
DEXAMETHASONE INTENSOL 80
DEXAMETHASONE SOD PHOSPHATE 101
DEXAMETHASONE SODIUM PHOSPHATE/PF 80
DEXEDRINE 64
DEXMEDETOMIDINE HCL 97
DEXMETHYLPHENIDATE HCL 65
DEXPANTHENOL 75
DEXRAZOXANE HCL 35
DEXTRAN 40 IN 0.9 % SODIUM CHLORIDE 98
DEXTRAN 40/DEXTROSE 5 % IN WATER 98
DEXTROAMPHETAMINE SULF-
SACCHARATE/AMPHETAMINE SULF-
ASPARTATE 64
DEXTROAMPHETAMINE SULFATE 64
DEXTROMETHORPHAN HBR/QUINIDINE
SULFATE 65
DEXTROSE 10 % AND 0.2 % SODIUM
CHLORIDE 112
DEXTROSE 10 % AND 0.45 % SODIUM
CHLORIDE 112
DEXTROSE 10 % AND 0.9 % SODIUM
CHLORIDE 112
DEXTROSE 10 % IN WATER 116
DEXTROSE 2.5 % AND 0.45 % SODIUM
CHLORIDE 112
DEXTROSE 2.5 % IN WATER 116
DEXTROSE 20 % IN WATER 117
DEXTROSE 25 % IN WATER 117
DEXTROSE 30 % IN WATER 117
DEXTROSE 40 % IN WATER 117
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE 112
DEXTROSE 5 % AND 0.3 % SODIUM CHLORIDE 112
DEXTROSE 5 % AND 0.45 % SODIUM
CHLORIDE 112
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE 112
DEXTROSE 5 % IN LACTATED RINGERS 112
DEXTROSE 5 % IN WATER 117
DEXTROSE 5% IN RINGERS 112
DEXTROSE 50 % IN WATER 117
DEXTROSE 70 % IN WATER 117
DEXTROSE-WATER/SODIUM CITRATE/CITRIC
ACID 51
DIALYVITE 117
DIATRIZOATE MEGLUMINE/DIATRIZOATE
SODIUM 98
DIAZEPAM 49
PAGE 127 LAST UPDATED 02/2016
DIAZOXIDE 51
DIBENZYLINE 56
DICLOFENAC POTASSIUM 5
DICLOFENAC SODIUM 101
DICLOFENAC SODIUM/MISOPROSTOL 5
DICLOXACILLIN SODIUM 20
DICYCLOMINE HCL 74
DIDANOSINE 46
DIETHYLPROPION HCL 65
DIFLORASONE DIACETATE 80
DIFLORASONE DIACETATE/EMOLLIENT BASE 79
DIFLUNISAL 5
DIGITEK 60
DIGOX 60
DIGOXIN 60
DIHYDROCODEINE
BITARTRATE/ACETAMINOPHEN/CAFFEINE 9
DIHYDROCODEINE
BITARTRATE/ASPIRIN/CAFFEINE 9
DIHYDROERGOTAMINE MESYLATE 30
DILANTIN 24
DILT-XR 58
DILTIAZEM HCL 59
DIMENHYDRINATE 27
DIMETHYL FUMARATE 67
DIOXYBENZONE/PADIMATE O/HYDROQUINONE 70
DIPHENHYDRAMINE HCL 104
DIPHENOXYLATE HCL/ATROPINE SULFATE 75
DIPHTHERIA,PERTUSSIS(ACELL),TETANUS
VACCINE/PF 96
DIPYRIDAMOLE 56
DISKETS 6
DISULFIRAM 14
DIVALPROEX SODIUM 23
DOBUTAMINE HCL 60
DOBUTAMINE HCL/DEXTROSE 5 % IN WATER 60
DOCETAXEL 35
DOFETILIDE 57
DOLUTEGRAVIR SODIUM 46
DONEPEZIL HCL 25
DOPAMINE HCL 60
DOPAMINE HCL/DEXTROSE 5 % IN WATER 60
DORNASE ALFA 109
DORZOLAMIDE HCL 102
DORZOLAMIDE HCL/TIMOLOL MALEATE 102
DOXAPRAM HCL 108
DOXAZOSIN MESYLATE 56
DOXEPIN HCL 27
DOXERCALCIFEROL 97
DOXIL 35
DOXORUBICIN HCL 35
DOXORUBICIN HCL PEGYLATED LIPOSOMAL 36
DOXYCYCLINE HYCLATE/EYELID CLNS
NO.3/EYELID EMOLLIENT NO.1 23
DOXYCYCLINE MONOHYDRATE 23
DRITHOCREME HP 69
DRONABINOL 28
DROPERIDOL 41
DROXIA 34
DROXIDOPA 61
DRYSOL 69
DULERA 108
DULOXETINE HCL 66
DURAMORPH 9
DUTASTERIDE 77
DUTASTERIDE/TAMSULOSIN HCL 77
EE.E.S. 200 21
E.E.S. 400 21
ECHOTHIOPHATE IODIDE 102
ECONAZOLE NITRATE 29
ECULIZUMAB 99
ED-SPAZ 74
EDROPHONIUM CHLORIDE 31
EDURANT 46
EFAVIRENZ 46
EFAVIRENZ/EMTRICITABINE/TENOFOVIR
DISOPROXIL FUMARATE 46
EFFER-K 112
EFFIENT 56
EGRIFTA 92
PAGE 128 LAST UPDATED 02/2016
ELAPRASE 73
ELASTIDERM 70
ELECTROLYTE-48 SOLUTION/DEXTROSE 5 % IN
WATER 112
ELELYSO 73
ELINEST 85
ELIPHOS 79
ELITEK 34
ELMIRON 78
ELOCTATE 54
ELOXATIN 35
ELTROMBOPAG OLAMINE 53
ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TEN
OFOVIR 45
EMCYT 33
EMEND 28
EMOQUETTE 85
EMTRICITABINE 46
EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR
DISOPROXIL FUMARATE 46
EMTRICITABINE/TENOFOVIR DISOPROXIL
FUMARATE 46
EMTRIVA 46
ENALAPRIL MALEATE 57
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE 60
ENALAPRILAT DIHYDRATE 57
ENBREL 93
ENDO-AVITENE 97
ENDOCET 9
ENDODAN 9
ENDOMETRIN 90
ENFLURANE 97
ENFUVIRTIDE 47
ENLON 31
ENOXAPARIN SODIUM 52
ENPRESSE 85
ENSKYCE 85
ENTACAPONE 41
ENTECAVIR 44
ENULOSE 76
ENZALUTAMIDE 33
EPHEDRINE SULFATE 60
EPINASTINE HCL 101
EPINEPHRINE 105
EPINEPHRINE HCL/PF 105
EPINEPHRINE/PF 105
EPIPEN 2-PAK 105
EPIPEN JR 2-PAK 105
EPIRUBICIN HCL 35
EPITOL 24
EPIVIR 46
EPIVIR HBV 44
EPLERENONE 62
EPOETIN ALFA 53
EPOPROSTENOL SODIUM (ARGININE) 108
EPOPROSTENOL SODIUM (GLYCINE) 107
EPROSARTAN MESYLATE 56
EPTIFIBATIDE 56
EPZICOM 46
ERBITUX 39
ERGOCALCIFEROL (VITAMIN D2) 117
ERGOLOID MESYLATES 25
ERGOTAMINE TARTRATE/CAFFEINE 31
ERIVEDGE 37
ERLOTINIB HCL 38
ERRIN 90
ERY 21
ERY-TAB 21
ERYGEL 21
ERYPED 200 21
ERYPED 400 21
ERYTHROCIN STEARATE 21
ERYTHROMYCIN BASE 21
ERYTHROMYCIN BASE/BENZOYL PEROXIDE 16
ERYTHROMYCIN BASE/ETHYL ALCOHOL 21
ERYTHROMYCIN ETHYLSUCCINATE 21
ERYTHROMYCIN
ETHYLSUCCINATE/SULFISOXAZOLE ACETYL 21
ERYTHROMYCIN STEARATE 21
ESCITALOPRAM OXALATE 26
ESGIC 65
ESMOLOL HCL 58
PAGE 129 LAST UPDATED 02/2016
ESOMEPRAZOLE MAGNESIUM 76
ESOMEPRAZOLE SODIUM 76
ESOMEPRAZOLE STRONTIUM 76
ESTARYLLA 85
ESTAZOLAM 110
ESTRADIOL 89
ESTRADIOL VALERATE 85
ESTRADIOL/NORETHINDRONE ACETATE 87
ESTRAMUSTINE PHOSPHATE SODIUM 33
ESTROGENS,
CONJUGATED/MEDROXYPROGESTERONE
ACETATE 88
ESTROGENS,ESTERIFIED 87
ESTROPIPATE 88
ESZOPICLONE 110
ETANERCEPT 93
ETHACRYNATE SODIUM 62
ETHAMBUTOL HCL 32
ETHINYL ESTRADIOL/DROSPIRENONE 90
ETHOSUXIMIDE 23
ETHOTOIN 24
ETHYL ALCOHOL 117
ETHYL CHLORIDE 13
ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL 90
ETIDRONATE DISODIUM 97
ETODOLAC 5
ETOMIDATE 13
ETONOGESTREL 90
ETOPOSIDE 37
ETRAVIRINE 46
EUFLEXXA 97
EURAX 40
EVEROLIMUS 94
EXEMESTANE 37
EXENATIDE 49
EXENATIDE MICROSPHERES 49
EXJADE 111
EXOTIC-HC 103
EXTAVIA 67
EZ FLU 2015-2016 (FLUVIRIN) 96
EZETIMIBE 63
EZOGABINE 23
FFABRAZYME 73
FACTOR IX 55
FACTOR IX COMPLEX HUMAN 55
FACTOR IX COMPLEX, PROTHROMBIN CPLX
CONC(PCC) NO.4, 3-FACTOR 55
FACTOR IX COMPLEX, PROTHROMBIN CPLX
CONC(PCC) NO.6, 3-FACTOR 54
FACTOR IX HUMAN RECOMBINANT 54
FACTOR IX HUMAN RECOMBINANT, THREONINE
148 54
FACTOR XIII 54
FACTOR XIII A-SUBUNIT, RECOMBINANT 55
FALMINA 85
FAMCICLOVIR 48
FAMOTIDINE 75
FAMOTIDINE/PF 75
FARESTON 33
FAT EMULSIONS 118
FE 90 PLUS 112
FE C PLUS 112
FEBUXOSTAT 30
FEIBA NF 54
FEIBA VH IMMUNO 54
FELBAMATE 24
FELODIPINE 59
FEM PH 78
FENOFIBRATE 62
FENOFIBRATE NANOCRYSTALLIZED 62
FENOFIBRATE,MICRONIZED 63
FENOFIBRIC ACID 63
FENOFIBRIC ACID (CHOLINE) 63
FENOLDOPAM MESYLATE 63
FENOPROFEN CALCIUM 5
FENTANYL 6
FENTANYL CITRATE 9
FENTANYL CITRATE IN 0.9 % SODIUM
CHLORIDE/PF 9
PAGE 130 LAST UPDATED 02/2016
FENTANYL CITRATE/BUPIVACAINE HCL IN 0.9 %
SODIUM CHLORIDE/PF 9
FENTANYL CITRATE/PF 12
FEROCON 112
FEROTRINSIC 112
FERRAPLUS 90 112
FERREX 150 FORTE 112
FERREX 150 FORTE PLUS 112
FERREX 28 112
FERRIC SUBSULFATE 55
FERRIPROX 111
FERROCITE PLUS 112
FERROGELS FORTE 112
FERROUS FUMARATE/ASCORBIC ACID/B12-
IF/FOLIC ACID 116
FERROUS FUMARATE/ASCORBIC
ACID/CYANOCOBALAMIN/FOLIC ACID 116
FERROUS FUMARATE/ASCORBIC
ACID/CYANOCOBALAMIN/STOMACH CONC 113
FERROUS FUMARATE/FOLIC ACID 113
FERROUS FUMARATE/FOLIC
ACID/MULTIVITAMINS WITH MIN NO. 15 111
FEXOFENADINE HCL/PSEUDOEPHEDRINE HCL 108
FIBRINOGEN 55
FINASTERIDE 77
FINGOLIMOD HCL 67
FIRAZYR 93
FIRST-BXN 29
FIRST-LANSOPRAZOLE 76
FIRST-MOUTHWASH BLM 67
FIRST-OMEPRAZOLE 76
FLAVOXATE HCL 77
FLEBOGAMMA DIF 95
FLECAINIDE ACETATE 57
FLOXURIDINE 34
FLUBLOK 2014-2015 96
FLUCAINE 100
FLUCONAZOLE 29
FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC 29
FLUCONAZOLE IN SODIUM CHLORIDE, ISO-
OSMOTIC 29
FLUCYTOSINE 29
FLUDARABINE PHOSPHATE 35
FLUDROCORTISONE ACETATE 80
FLUMAZENIL 98
FLUNISOLIDE 103
FLUOCINOLONE ACETONIDE 80
FLUOCINOLONE ACETONIDE OIL 103
FLUOCINOLONE ACETONIDE/SHOWER CAP 80
FLUOCINONIDE 80
FLUOCINONIDE/EMOLLIENT BASE 80
FLUOR-A-DAY 112
FLUOR-I-STRIP AT 100
FLUORESCEIN SODIUM 100
FLUORESCITE 100
FLUOROMETHOLONE 101
FLUOROURACIL 34
FLUOXETINE HCL 26
FLUOXYMESTERONE 83
FLUPHENAZINE DECANOATE 41
FLUPHENAZINE HCL 41
FLURAZEPAM HCL 110
FLURBIPROFEN 5
FLURBIPROFEN SODIUM 101
FLUROX 100
FLUTAMIDE 33
FLUTICASONE FUROATE 103
FLUTICASONE FUROATE/VILANTEROL
TRIFENATATE 108
FLUTICASONE PROPIONATE 103
FLUVASTATIN SODIUM 63
FLUVOXAMINE MALEATE 26
FOCALGIN DSS 113
FOLBEE PLUS 117
FOLIC ACID 117
FOLIC ACID/VITAMIN B COMP AND C 117
FOLIVANE-F 113
FOLIVANE-PLUS 113
FOLLITROPIN ALFA, RECOMB 82
FOLOTYN 34
FOMEPIZOLE 98
FONDAPARINUX SODIUM 52
PAGE 131 LAST UPDATED 02/2016
FORANE 98
FORMA-RAY 98
FORMADON 98
FORMALDEHYDE 98
FORMOTEROL FUMARATE 105
FORTEO 97
FORTICAL 97
FOSAMPRENAVIR CALCIUM 47
FOSCARNET SODIUM 44
FOSINOPRIL SODIUM 57
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE 60
FOSPHENYTOIN SODIUM 24
FREAMINE III 117
FUL-GLO 100
FUROSEMIDE 62
FUSILEV 35
FUZEON 47
GGABAPENTIN 23
GABITRIL 23
GABLOFEN 109
GALANTAMINE HBR 25
GALSULFASE 73
GAMMAGARD LIQUID 95
GAMMAPLEX 95
GAMUNEX 95
GAMUNEX-C 95
GANCICLOVIR SODIUM 44
GARAMYCIN 15
GASTROCROM 75
GATIFLOXACIN 22
GAVILYTE-G 76
GAVILYTE-H AND BISACODYL 76
GEMCITABINE HCL 34
GEMFIBROZIL 63
GENERLAC 76
GENGRAF 93
GENTAK 15
GENTAMICIN SULFATE 15
GENTAMICIN SULFATE IN SODIUM CHLORIDE,
ISO-OSMOTIC 15
GENTAMICIN SULFATE/PF 15
GEODON 43
GIANVI 85
GILDAGIA 86
GILDESS 86
GILDESS 24 FE 86
GILDESS FE 86
GILENYA 67
GILOTRIF 37
GLATIRAMER ACETATE 67
GLATOPA 67
GLEEVEC 37
GLEOSTINE 32
GLIMEPIRIDE 49
GLIPIZIDE 49
GLIPIZIDE/METFORMIN HCL 49
GLUCAGEN 51
GLUCAGON EMERGENCY KIT 51
GLUCAGON HCL 51
GLUCAGON,HUMAN RECOMBINANT 51
GLUTARALDEHYDE 98
GLYBURIDE 49
GLYBURIDE,MICRONIZED 49
GLYBURIDE/METFORMIN HCL 50
GLYCEROL PHENYLBUTYRATE 73
GLYCINE UROLOGIC SOLUTION 78
GLYCINE/SODIUM/WATER FOR
INJECTION,STERILE/SODIUM HYDROXIDE 98
GLYCOPYRROLATE 74
GLYDO 13
GONAL-F RFF 82
GONAL-F RFF REDI-JECT 82
GRANISETRON HCL 28
GRANISETRON HCL/PF 28
GRANISOL 28
GRISEOFULVIN ULTRAMICROSIZE 29
GRISEOFULVIN, MICROSIZE 29
GRX HICORT 25 80
GUANFACINE HCL 65
PAGE 132 LAST UPDATED 02/2016
GUANIDINE HCL 31
GYNAZOLE 1 29
HH.P. ACTHAR 82
HALOBETASOL PROPIONATE 80
HALOBETASOL PROPIONATE/AMMONIUM
LACTATE 81
HALONATE 80
HALONATE PAC 81
HALOPERIDOL 42
HALOPERIDOL DECANOATE 42
HALOPERIDOL LACTATE 42
HARVONI 44
HEATHER 90
HECORIA 93
HECTOROL 97
HELIXATE FS 54
HEMABATE 98
HEMATINIC PLUS 113
HEMATINIC WITH FOLIC ACID 113
HEMATOGEN 113
HEMATOGEN FA 113
HEMATOGEN FORTE 113
HEMETAB 113
HEMIN 99
HEMMOREX-HC 81
HEMRIL 81
HEPARIN SODIUM,PORCINE 52
HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM
CHLORIDE 52
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM
CHLORIDE 52
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM
CHLORIDE/PF 52
HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN
WATER 52
HEPARIN SODIUM,PORCINE/PF 52
HERCEPTIN 39
HETLIOZ 110
HEXALEN 32
HISTRELIN ACETATE 93
HIZENTRA 95
HOMATROPAIRE 100
HOMATROPINE HBR 100
HUMALOG KWIKPEN U-200 51
HUMATE-P 54
HUMIRA 93
HUMIRA PEDIATRIC CROHN'S 94
HUMIRA PEN 94
HUMIRA PEN CROHN'S-UC-HS 94
HUMIRA PEN PSORIASIS 94
HUMULIN R U-500 51
HYALURONATE SODIUM 97
HYDRALAZINE HCL 63
HYDROCHLOROTHIAZIDE 62
HYDROCODONE
BITARTRATE/ACETAMINOPHEN 12
HYDROCODONE BITARTRATE/HOMATROPINE
METHYLBROMIDE 109
HYDROCODONE
POLISTIREX/CHLORPHENIRAMINE POLISTIREX108
HYDROCODONE/IBUPROFEN 12
HYDROCORTISONE 96
HYDROCORTISONE ACETATE 96
HYDROCORTISONE ACETATE/ALOE VERA 81
HYDROCORTISONE ACETATE/LIDOCAINE
HCL/ALOE VERA 69
HYDROCORTISONE ACETATE/PRAMOXINE HCL 70
HYDROCORTISONE
ACETATE/PRAMOXINE/EMOLLIENT/PRAMOXINE
COMB#1 69
HYDROCORTISONE BUTYRATE 81
HYDROCORTISONE BUTYRATE/EMOLLIENT
BASE 81
HYDROCORTISONE SOD SUCCINATE 79
HYDROCORTISONE VALERATE 81
HYDROCORTISONE/IODOQUINOL 69
HYDROCORTISONE/MINERAL
OIL/PETROLATUM,WHITE 81
HYDROCORTISONE/PRAMOXINE
HCL/CHLOROXYLENOL 103
PAGE 133 LAST UPDATED 02/2016
HYDROCORTISONE/PRAMOXINE
HCL/CHLOROXYLENOL/WATER 102
HYDROMORPHONE HCL 10
HYDROMORPHONE HCL/PF 10
HYDROQUINONE 70
HYDROQUINONE MICROSPHERES 69
HYDROQUINONE/FERRIC OXIDE 70
HYDROXYCHLOROQUINE SULFATE 40
HYDROXYPROGESTERONE CAPROATE 91
HYDROXYUREA 34
HYDROXYZINE HCL 104
HYDROXYZINE PAMOATE 104
HYOPHEN 16
HYOSCYAMINE SULFATE 75
HYOSYNE 74
HYPERCARE 69
HYPERRHO S-D 95
HYPROMELLOSE 100
IIBANDRONATE SODIUM 97
IBRANCE 37
IBRUTINIB 38
IBUPROFEN 5
IBUPROFEN/OXYCODONE HCL 10
IBUTILIDE FUMARATE 57
IC GREEN 98
ICATIBANT ACETATE 93
ICLUSIG 37
ICOSAPENT ETHYL 63
IDARUBICIN HCL 35
IDELALISIB 38
IDURSULFASE 73
IFOSFAMIDE 32
IFOSFAMIDE/MESNA 32
ILARIS 95
ILOPROST TROMETHAMINE 108
IMATINIB MESYLATE 37
IMBRUVICA 38
IMIPENEM/CILASTATIN SODIUM 19
IMIPRAMINE HCL 27
IMIPRAMINE PAMOATE 27
IMIQUIMOD 69
IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA
GREATER THAN 50 MCG/ML 95
IMMUNE
GLOBULIN,GAMM(IGG)/SORBITOL/GLYCIN/IGA 0
TO 50 MCG/ML 95
IMMUNE GLOBULIN,GAMMA (IGG)/PROLINE/IGA 0
TO 50 MCG/ML 95
IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0
TO 50 MCG/ML 95
IMMUNE GLOBULIN,GAMMA CAPRYLATE (IGG) 95
IMPLANON 90
INCIVEK 44
INCRELEX 82
INDAPAMIDE 62
INDINAVIR SULFATE 47
INDOCYANINE GREEN 98
INDOMETHACIN 5
INDOMETHACIN SODIUM 5
INFED 113
INFERGEN 45
INFLIXIMAB 94
INFLUENZA VIRUS VACCINE TRIVALNT 2015-2016
(4 YR & OLDER)/PF 96
INFLUENZA VIRUS VACCINE TV 2014-2015(18 YRS
& OLDER)RCMB/PF 96
INLYTA 38
INSULIN DETEMIR 51
INSULIN GLARGINE,HUMAN RECOMBINANT
ANALOG 51
INSULIN LISPRO 51
INSULIN REGULAR, HUMAN 51
INTELENCE 46
INTERFERON ALFA-2B,RECOMB. 45
INTERFERON ALFACON-1 45
INTERFERON BETA-1A 66
INTERFERON BETA-1A/ALBUMIN HUMAN 67
INTERFERON BETA-1B 67
INTERFERON GAMMA-1B,RECOMB. 95
INTRON A 45
PAGE 134 LAST UPDATED 02/2016
INTROVALE 86
INVEGA SUSTENNA 43
INVEGA TRINZA 43
INVIRASE 47
INVOKAMET 50
INVOKANA 50
IPRATROPIUM BROMIDE 105
IPRATROPIUM BROMIDE/ALBUTEROL
SULFATE 108
IRBESARTAN 56
IRBESARTAN/HYDROCHLOROTHIAZIDE 61
IRINOTECAN HCL 35
IRON ASP GLY&PS CMPLX/ASCORB.CAL/VIT
B12/FA/CA-THR/SUCC.ACID 112
IRON ASP GLY/ASCORB.CAL/VIT B12/FA/CA-
THREONTE/SUCCINIC ACID 114
IRON ASP.GLYCIN & FUMARATE /VIT C/FA/MV
COMB 11/CA-THREONATE 112
IRON ASPGLY/ASCORB.CAL/VIT B12/CALCIUM
THR/SUCC.ACID/STOMACH 114
IRON BISGLY,PSCMPLX/ASCORBATE
CALC/B12/FOLIC ACID/CALC-THREO 116
IRON CARBONYL,GLUC/FOLIC ACID/VIT B12/VIT
C/DOCUSATE SODIUM 114
IRON DEXTRAN COMPLEX 113
IRON FUMARATE & POLYSAC COMP/FOLIC
ACID/VITAMIN C/NIACIN 113
IRON FUMARATE,POLYSAC CPLEX/FOLIC
ACID/VIT B COMP WITH C #9 113
IRON FUMARATE-IRON POLYSACCHAR/FOLIC
ACID/MV COMB18 115
IRON FUMARTE &ASP GLY/ASCORB.CAL/VIT
B12/FA/CA-THR/SUCC.ACID 114
IRON HEME POLYPEPTIDE/FOLIC ACID 115
IRON POLYSACCHAR COMPLX/IRON HEME
POLYPEPTIDE/FOLIC ACID/B12 113
IRON POLYSACCHARIDE
COMPLEX/CYANOCOBALAMIN/FOLIC ACID 114
IRON,CARBONYL/ASCORBIC
ACID/CYANOCOBALAMIN/FOLIC ACID 112
IRON,CARBONYL/DOCUSATE SODIUM/B12-
IF/FOLIC ACID/MULTIVIT-MIN 116
IRON,CARBONYL/FOLIC ACID/VIT C/PYRIDOXINE
HCL/VIT B12/ZINC 111
IRON,CARBONYL/FOLIC ACID/VITAMIN
B12/VITAMIN C/DOCUSATE NA 112
IRON/FOLIC ACID/VITAMIN B COMP AND
C/MINERALS 113
ISENTRESS 45
ISOFLURANE 99
ISOMETHEPTENE
MUCATE/CAFFEINE/ACETAMINOPHEN 98
ISOMETHEPTENE
MUCATE/DICHLORALPHENAZONE/ACETAMINOPH
EN 98
ISONIAZID 32
ISOSORBIDE DINITRATE 64
ISOSORBIDE MONONITRATE 64
ISOSULFAN BLUE 98
ISOTRETINOIN 70
ISOXSUPRINE HCL 25
ISRADIPINE 59
ISTODAX 35
ITRACONAZOLE 30
IVABRADINE HCL 60
IVACAFTOR 106
IVERMECTIN 39
IXABEPILONE 35
IXEMPRA 35
IXINITY 54
JJAKAFI 38
JANTOVEN 52
JANUMET 50
JANUMET XR 50
JANUVIA 50
JENCYCLA 90
JENTADUETO 50
JINTELI 86
JOLESSA 86
PAGE 135 LAST UPDATED 02/2016
JOLIVETTE 91
JUNEL 86
JUNEL FE 86
JUNEL FE 24 86
JUXTAPID 63
KK EFFERVESCENT 113
K-PHOS NEUTRAL 78
K-PHOS NO.2 78
K-PHOS ORIGINAL 78
K-SOL 113
K-TAB ER 113
KADCYLA 39
KAITLIB FE 86
KALETRA 47
KALYDECO 106
KARIVA 86
KELNOR 1-35 86
KEPIVANCE 67
KETAMINE HCL 13
KETOCONAZOLE 29
KETOCONAZOLE/SKIN CLEANSER COMBINATION
NO.28 29
KETODAN 29
KETOPROFEN 5
KETOROLAC TROMETHAMINE 101
KIMIDESS 86
KIONEX 111
KIT FOR PREP YTTRIUM-90/IBRITUMOMAB
TIUXETAN/ALBUMIN HUMAN 39
KLOR-CON 113
KLOR-CON 10 113
KLOR-CON 8 113
KLOR-CON M10 113
KLOR-CON M15 113
KLOR-CON M20 113
KLOR-CON SPRINKLE 114
KLOR-CON-EF 114
KOATE-DVI 54
KOGENATE FS 55
KURVELO 86
KUVAN 73
LLABETALOL HCL 58
LACLOTION 69
LACOSAMIDE 25
LACTOBACILLUS COMBINATION
NO.2/S.THERMOPHL/BIF CMB NO.1 75
LACTULOSE 76
LAMISIL 29
LAMIVUDINE 46
LAMIVUDINE/ZIDOVUDINE 46
LAMOTRIGINE 24
LANSOPRAZOLE 77
LANSOPRAZOLE/AMOXICILLIN
TRIHYDRATE/CLARITHROMYCIN 75
LANTUS 51
LANTUS SOLOSTAR 51
LAPATINIB DITOSYLATE 38
LARIN 86
LARIN 24 FE 86
LARIN FE 86
LARONIDASE 73
LATANOPROST 102
LATRIX 69
LATRIX XM 69
LEDIPASVIR/SOFOSBUVIR 44
LEENA 86
LEFLUNOMIDE 95
LENALIDOMIDE 33
LESSINA 86
LETAIRIS 107
LETROZOLE 37
LEUCOVORIN CALCIUM 35
LEUKERAN 32
LEUKINE 53
LEUPROLIDE ACETATE 92
LEVALBUTEROL HCL 105
LEVEMIR 51
LEVEMIR FLEXPEN 51
PAGE 136 LAST UPDATED 02/2016
LEVEMIR FLEXTOUCH 51
LEVETIRACETAM 23
LEVOBUNOLOL HCL 102
LEVOCARNITINE 117
LEVOCARNITINE (WITH SUGAR) 117
LEVOCETIRIZINE DIHYDROCHLORIDE 104
LEVOFLOXACIN 22
LEVOFLOXACIN/DEXTROSE 5 % IN WATER 22
LEVOLEUCOVORIN CALCIUM 36
LEVOMEFOLATE CALCIUM/SCHIZOCHYTRIUM
ALGAL OIL 117
LEVONEST 87
LEVONORGESTREL 88
LEVONORGESTREL-ETHINYL ESTRADIOL 90
LEVONORGESTREL/ETHINYL ESTRADIOL AND
ETHINYL ESTRADIOL 87
LEVORA-28 87
LEVORPHANOL TARTRATE 6
LEVOTHYROXINE SODIUM 92
LEVOXYL 91
LEXIVA 47
LIDOCAINE 13
LIDOCAINE HCL 14
LIDOCAINE HCL BUFFERED WITH 8.4 % SODIUM
BICARBONATE 12
LIDOCAINE HCL/DEXTROSE 5%-WATER/PF 13
LIDOCAINE HCL/DEXTROSE 7.5%-WATER/PF 13
LIDOCAINE HCL/EPINEPHRINE 13
LIDOCAINE HCL/EPINEPHRINE/PF 13
LIDOCAINE HCL/HYDROCORTISONE ACETATE 70
LIDOCAINE HCL/MENTHOL 13
LIDOCAINE HCL/PF 13
LIDOCAINE/MENTHOL 13
LIDOCAINE/PRILOCAINE 70
LINACLOTIDE 75
LINAGLIPTIN 51
LINAGLIPTIN/METFORMIN HCL 50
LINCOMYCIN HCL 16
LINDANE 40
LINEZOLID 18
LINEZOLID IN 0.9 % SODIUM CHLORIDE 16
LINZESS 75
LIOTHYRONINE SODIUM 91
LIOTRIX 92
LIPASE/PROTEASE/AMYLASE 73
LIPODOX 36
LIPODOX 50 36
LIPOSYN III 117
LIRAGLUTIDE 51
LISDEXAMFETAMINE DIMESYLATE 64
LISINOPRIL 57
LISINOPRIL/HYDROCHLOROTHIAZIDE 61
LITHIUM CARBONATE 49
LITHIUM CITRATE 49
LMD 10% WITH 0.9% SOD CHLORIDE 98
LMD 10% WITH 5% DEXTROSE 98
LOMEDIA 24 FE 87
LOMITAPIDE MESYLATE 63
LOMUSTINE 32
LOPINAVIR/RITONAVIR 47
LOPREEZA 87
LORAZEPAM 49
LORAZEPAM INTENSOL 49
LORCET 10
LORCET HD 10
LORCET PLUS 10
LORENZA 13
LORTAB 10
LORYNA 87
LOSARTAN POTASSIUM 56
LOSARTAN
POTASSIUM/HYDROCHLOROTHIAZIDE 61
LOTRONEX 75
LOVASTATIN 63
LOW-OGESTREL 87
LOXAPINE SUCCINATE 42
LUGOL'S 98
LUMIZYME 73
LUPRON DEPOT 92
LUPRON DEPOT-PED 92
LUSTRA-ULTRA 70
LUTERA 87
PAGE 137 LAST UPDATED 02/2016
LYRICA 66
LYSODREN 36
LYZA 91
MMACITENTAN 107
MAFENIDE ACETATE 17
MAG HYDROXIDE/AL
HYDROXIDE/SIMETH/DIPHENHYDRAMINE/LIDOCAI
NE 67
MAGNESIUM CHLORIDE 114
MAGNESIUM SULFATE 114
MAGNESIUM SULFATE IN STERILE WATER 114
MAKENA 91
MALATHION 40
MANGANESE CHLORIDE 114
MANGANESE SULFATE 114
MANNITOL 98
MAPROTILINE HCL 26
MARAVIROC 47
MARGESIC 65
MARLEXATE 111
MARLISSA 87
MARQIBO 36
MARTEN-TAB 65
MATULANE 32
MATZIM LA 59
MD-GASTROVIEW 98
ME-PB-HYOS 74
MECASERMIN 82
MECHLORETHAMINE HCL 33
MECLIZINE HCL 27
MECLOFENAMATE SODIUM 5
MEDROXYPROGESTERONE ACETATE 91
MEFENAMIC ACID 5
MEFLOQUINE HCL 40
MEGESTROL ACETATE 91
MEKINIST 38
MELOXICAM 5
MELPAQUE HP 70
MELPHALAN 32
MELPHALAN HCL 32
MELQUIN HP 70
MELQUIN-3 70
MEMANTINE HCL 25
MENEST 87
MEPERIDINE HCL 10
MEPHYTON 117
MEPIVACAINE HCL 13
MEPIVACAINE HCL/PF 13
MEPRON 40
MERCAPTOPURINE 34
MEROPENEM 19
MEROPENEM IN 0.9 % SODIUM CHLORIDE 19
MESALAMINE 96
MESALAMINE WITH CLEANSING WIPES 96
MESNA 36
MESNEX 36
MESTINON 31
METADATE ER 65
METAPROTERENOL SULFATE 105
METAXALONE 109
METFORMIN HCL 50
METHADONE HCL 7
METHADONE INTENSOL 7
METHADOSE 7
METHAMPHETAMINE HCL 64
METHAZOLAMIDE 102
METHENAMINE HIPPURATE 16
METHENAMINE MANDELATE 16
METHENAMINE/METHYLENE BLUE/BENZOIC
ACID/SALICYLATE/HYOSCY 17
METHENAMINE/METHYLENE
BLUE/SALICYLATE/SODIUM PHOS/HYOSCY 17
METHENAMINE/METHYLENE BLUE/SODIUM
PHOS/PNYL SAL/HYOSC SUL 18
METHENAMINE/SODIUM
PHOSPHATE,MONOBASIC/METH BLUE/HYOSC
SUL 17
METHIMAZOLE 93
METHITEST 83
METHOCARBAMOL 109
PAGE 138 LAST UPDATED 02/2016
METHOTREXATE SODIUM 94
METHOTREXATE SODIUM/PF 94
METHOXSALEN 67
METHOXSALEN, RAPID 70
METHSUXIMIDE 23
METHYCLOTHIAZIDE 62
METHYLDOPA 56
METHYLDOPA/HYDROCHLOROTHIAZIDE 61
METHYLDOPATE HCL 56
METHYLENE BLUE 98
METHYLERGONOVINE MALEATE 98
METHYLNALTREXONE BROMIDE 75
METHYLPHENIDATE HCL 65
METHYLPREDNISOLONE 81
METHYLPREDNISOLONE ACETATE 81
METHYLPREDNISOLONE SODIUM SUCCINATE 81
METHYLTESTOSTERONE 83
METIPRANOLOL 102
METOCLOPRAMIDE HCL 27
METOLAZONE 62
METOPROLOL SUCCINATE 58
METOPROLOL TARTRATE 58
METOPROLOL
TARTRATE/HYDROCHLOROTHIAZIDE 61
METRO IV 16
METRONIDAZOLE 71
METRONIDAZOLE IN SODIUM CHLORIDE 16
METYROSINE 60
MEXILETINE HCL 57
MICAFUNGIN SODIUM 29
MICONAZOLE NITRATE 29
MICROFIBRILLAR COLLAGEN 97
MICROGESTIN 87
MICROGESTIN 24 FE 87
MICROGESTIN FE 87
MIDAZOLAM HCL 48
MIDAZOLAM HCL/PF 48
MIDODRINE HCL 56
MIGERGOT 31
MIGLUSTAT 74
MIGRAGESIC IDA 98
MILLIPRED DP 81
MILNACIPRAN HCL 66
MILRINONE LACTATE 61
MILRINONE LACTATE/DEXTROSE 5 % IN WATER61
MIMVEY 87
MIMVEY LO 87
MINOCYCLINE HCL 22
MINOXIDIL 63
MIOSTAT 102
MIRTAZAPINE 26
MISOPROSTOL 76
MITOMYCIN 36
MITOTANE 36
MITOXANTRONE HCL 36
MODAFINIL 110
MODERIBA 45
MOEXIPRIL HCL 57
MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE 61
MOLINDONE HCL 42
MOLYBDENUM (AMMONIUM MOLYBDATE) 114
MOMETASONE FUROATE 81
MOMETASONE FUROATE/FORMOTEROL
FUMARATE 108
MONDOXYNE NL 23
MONO-LINYAH 87
MONOJECT 0.9% SODIUM CHLORIDE 114
MONOJECT PREFILL 114
MONOJECT PREFILL ADVANCED 114
MONONESSA 87
MONONINE 55
MONSEL'S 55
MONTELUKAST SODIUM 104
MORPHINE SULFATE 11
MORPHINE SULFATE/PF 11
MOXEZA 22
MOXIFLOXACIN HCL 22
MOXIFLOXACIN HCL IN SODIUM ACETATE AND
SULFATE,WATER,ISO-OSM 22
MOXIFLOXACIN HCL/SODIUM CHLORIDE, ISO-
OSMOTIC 21
MOZOBIL 53
PAGE 139 LAST UPDATED 02/2016
MULTIGEN 114
MULTIGEN FOLIC 114
MULTIGEN PLUS 114
MULTITRACE-4 114
MULTITRACE-5 114
MULTIVITAMINS WITH MIN NO.7/FOLIC ACID 118
MUPIROCIN 16
MUPIROCIN CALCIUM 16
MUSTARGEN 33
MY WAY 87
MYCAMINE 29
MYCOBUTIN 32
MYCOPHENOLATE MOFETIL 94
MYCOPHENOLATE MOFETIL HCL 93
MYCOPHENOLATE SODIUM 94
MYFORTIC 94
MYLERAN 33
MYNATAL PLUS 117
MYNATAL-Z 117
MYNEPHROCAPS 117
MYORISAN 70
MYOZYME 73
MYZILRA 88
NNABUMETONE 5
NADOLOL 58
NADOLOL/BENDROFLUMETHIAZIDE 61
NAFCILLIN IN DEXTROSE, ISO-OSMOTIC 20
NAFCILLIN SODIUM 20
NAFTIFINE HCL 29
NAGLAZYME 73
NALBUPHINE HCL 11
NALOXONE HCL 14
NALTREXONE HCL 14
NAMENDA 25
NAPHAZOLINE HCL 100
NAPROXEN 5
NAPROXEN SODIUM 5
NARATRIPTAN HCL 31
NAROPIN 13
NATACYN 29
NATALVIRT FLT 114
NATAMYCIN 29
NATEGLINIDE 50
NATURE-THROID 91
NEBUPENT 40
NECON 88
NELARABINE 34
NELFINAVIR MESYLATE 47
NEO-POLYCIN 100
NEO-POLYCIN HC 100
NEOMYCIN SULFATE 15
NEOMYCIN SULFATE/BACITRACIN
ZINC/POLYMYXIN B/HYDROCORTISONE 100
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN
B 100
NEOMYCIN SULFATE/POLYMYXIN B SULFATE 16
NEOMYCIN SULFATE/POLYMYXIN B
SULFATE/GRAMICIDIN D 100
NEOMYCIN SULFATE/POLYMYXIN B
SULFATE/HYDROCORTISONE 103
NEOMYCIN/POLYMYXIN B
SULFATE/DEXAMETHASONE 100
NEOSTIGMINE BROMIDE 31
NEOSTIGMINE METHYLSULFATE 31
NEPHPLEX RX 117
NEPHRO-VITE RX 117
NEUAC 70
NEULASTA 53
NEUMEGA 53
NEVIRAPINE 46
NEXAVAR 38
NEXT CHOICE ONE DOSE 88
NIACIN 63
NICARDIPINE HCL 59
NICARDIPINE HCL IN 0.9 % SODIUM CHLORIDE 59
NIFEDIAC CC 59
NIFEDICAL XL 59
NIFEDIPINE 59
NIKKI 88
NILANDRON 33
PAGE 140 LAST UPDATED 02/2016
NILOTINIB HCL 38
NILUTAMIDE 33
NIMODIPINE 59
NISOLDIPINE 59
NITAZOXANIDE 39
NITISINONE 73
NITRO-BID 64
NITRO-TIME 64
NITROFURANTOIN 16
NITROFURANTOIN MACROCRYSTAL 17
NITROFURANTOIN
MONOHYDRATE/MACROCRYSTALS 17
NITROGLYCERIN 70
NITROGLYCERIN/DEXTROSE 5 % IN WATER 64
NITROSTAT 64
NIVA-PLUS 117
NIZATIDINE 75
NODOLOR 98
NORA-BE 91
NORDITROPIN 82
NORDITROPIN FLEXPRO 83
NORDITROPIN NORDIFLEX 83
NOREPINEPHRINE BITARTRATE 61
NOREPINEPHRINE BITARTRATE IN 0.9 % SODIUM
CHLORIDE 61
NORETHINDRONE 91
NORETHINDRONE ACETATE 91
NORETHINDRONE ACETATE-ETHINYL
ESTRADIOL 88
NORETHINDRONE ACETATE-ETHINYL
ESTRADIOL/FERROUS FUMARATE 89
NORETHINDRONE-ETHINYL ESTRADIOL 90
NORETHINDRONE-ETHINYL
ESTRADIOL/FERROUS FUMARATE 90
NORGESTIMATE-ETHINYL ESTRADIOL 89
NORGESTREL-ETHINYL ESTRADIOL 88
NORLYROC 91
NORTHERA 61
NORTREL 88
NORTRIPTYLINE HCL 27
NORVIR 47
NOVAREL 83
NOVOEIGHT 55
NOVOSEVEN RT 55
NOXAFIL 29
NP THYROID 92
NU-DERM 70
NUEDEXTA 65
NULOJIX 94
NUQUIN HP 70
NUTRILIPID 118
NUTRILYTE 114
NUTRILYTE II 114
NYAMYC 29
NYSTATIN 30
NYSTATIN/LIDOCAINE HCL/DIPHENHYDRAMINE
HCL 29
NYSTATIN/TRIAMCINOLONE ACETONIDE 30
NYSTOP 30
OOCELLA 88
OCTREOTIDE ACETATE 93
OCUCOAT 100
OCUDOX 23
OFATUMUMAB 39
OFLOXACIN 22
OGEN 88
OGESTREL 88
OLANZAPINE 43
OLANZAPINE/FLUOXETINE HCL 26
OLODATEROL HCL 106
OLOPATADINE HCL 104
OMALIZUMAB 109
OMBITASVIR/PARITAPREVIR/RITONAVIR 45
OMEGA-3 ACID ETHYL ESTERS 63
OMEPRAZOLE 77
OMEPRAZOLE/SODIUM BICARBONATE 77
ONDANSETRON 28
ONDANSETRON HCL 28
ONDANSETRON HCL/PF 28
ONFI 23
PAGE 141 LAST UPDATED 02/2016
ONXOL 36
OPIUM TINCTURE 75
OPIUM/BELLADONNA ALKALOIDS 11
OPRELVEKIN 53
OPSUMIT 107
ORFADIN 73
ORPHENADRINE CITRATE 109
ORPHENADRINE CITRATE/ASPIRIN/CAFFEINE 109
ORSYTHIA 88
OSCIMIN 74
OSCIMIN SL 74
OSCIMIN SR 74
OSELTAMIVIR PHOSPHATE 48
OSMITROL 98
OTICIN HC 103
OTO-END 10 103
OTOMAX-HC 103
OTOZIN 103
OXACILLIN SODIUM 20
OXACILLIN SODIUM/DEXTROSE, ISO-OSMOTIC 20
OXALIPLATIN 36
OXANDROLONE 83
OXAPROZIN 6
OXAZEPAM 49
OXCARBAZEPINE 24
OXSORALEN-ULTRA 70
OXYBENZONE/OCTINOXATE/HYDROQUINONE 68
OXYBUTYNIN CHLORIDE 77
OXYCODONE HCL 11
OXYCODONE HCL/ACETAMINOPHEN 12
OXYCODONE HCL/ASPIRIN 11
OXYCONTIN 8
OXYMORPHONE HCL 12
OXYTOCIN 99
PPACERONE 57
PACLITAXEL 36
PACLITAXEL PROTEIN-BOUND 34
PAIN RELIEF 13
PALBOCICLIB 37
PALGIC 104
PALIFERMIN 67
PALIPERIDONE 43
PALIPERIDONE PALMITATE 43
PALIVIZUMAB 95
PANCURONIUM BROMIDE 109
PANHEMATIN 99
PANITUMUMAB 39
PANTOPRAZOLE SODIUM 77
PAPAVERINE HCL 25
PAREGORIC 75
PARENTERAL AMINO ACID 10% COMBINATION
NO. 4 117
PARENTERAL AMINO ACID 10% COMBINATION
NO. 6 118
PARENTERAL AMINO ACID 10% COMBINATION
NO.7 118
PARENTERAL AMINO ACID 15% COMBINATION
NO.1 116
PARICALCITOL 97
PAROEX 67
PAROMOMYCIN SULFATE 15
PAROXETINE HCL 26
PASIREOTIDE DIASPARTATE 93
PAZOPANIB HCL 38
PEDI-DRI 30
PEDIATRIC MULTIVITAMIN COMBO
NO.75/FLUORIDE/FERROUS SULFATE 118
PEG 3350/SOD SULF/SOD BICARBONATE/SOD
CHLORIDE/POTASSIUM CHL 76
PEGANONE 24
PEGASYS 45
PEGASYS PROCLICK 45
PEGFILGRASTIM 53
PEGINTERFERON ALFA-2A 45
PEGINTERFERON ALFA-2B 36
PEMETREXED DISODIUM 34
PENICILLAMINE 78
PENICILLIN G POTASSIUM 20
PENICILLIN G PROCAINE 20
PENICILLIN G SODIUM 20
PAGE 142 LAST UPDATED 02/2016
PENICILLIN V POTASSIUM 20
PENTAMIDINE ISETHIONATE 40
PENTASA 96
PENTAZOCINE HCL/NALOXONE HCL 12
PENTOSAN POLYSULFATE SODIUM 78
PENTOSTATIN 34
PENTOXIFYLLINE 61
PERFOROMIST 105
PERINDOPRIL ERBUMINE 57
PERIOGARD 67
PERITONEAL DIALYSIS NO.6 WITH DEXTROSE 1.5
% 111
PERITONEAL DIALYSIS NO.7 WITH DEXTROSE 2.5
% 111
PERITONEAL DIALYSIS NO.8 WITH DEXTROSE
4.25 % 111
PERJETA 39
PERMETHRIN 40
PERPHENAZINE 27
PERPHENAZINE/AMITRIPTYLINE HCL 26
PERTUZUMAB 39
PFIZERPEN 20
PHENADOZ 27
PHENAZOPYRIDINE HCL 78
PHENDIMETRAZINE TARTRATE 65
PHENELZINE SULFATE 26
PHENERGAN 27
PHENOBARBITAL 23
PHENOBARBITAL SODIUM 23
PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE
SULF/SCOPOLAMINE HB 74
PHENOL 99
PHENOXYBENZAMINE HCL 56
PHENTERMINE HCL 66
PHENTOLAMINE MESYLATE 56
PHENYLEPHRINE HCL 100
PHENYLEPHRINE HCL IN 0.9 % SODIUM
CHLORIDE 61
PHENYLEPHRINE HCL IN 0.9 % SODIUM
CHLORIDE/PF 61
PHENYLEPHRINE HCL/PROMETHAZINE HCL 108
PHENYTOIN 25
PHENYTOIN SODIUM 25
PHENYTOIN SODIUM EXTENDED 25
PHILITH 88
PHOSPHA 250 NEUTRAL 78
PHOSPHASAL 17
PHOSPHOLINE IODIDE 102
PHOSPHORUS #1 78
PHOTOFRIN 36
PHYSOSTIGMINE SALICYLATE 31
PHYTONADIONE 118
PILOCARPINE HCL 102
PIMOZIDE 42
PIMTREA 88
PINDOLOL 58
PIOGLITAZONE HCL 50
PIOGLITAZONE HCL/GLIMEPIRIDE 50
PIOGLITAZONE HCL/METFORMIN HCL 50
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 20
PIRMELLA 88
PIROXICAM 6
PLERIXAFOR 53
PNEUMOCOCCAL 23-VALENT POLYSACCHARIDE
VACCINE 96
PNEUMOVAX 23 96
PNV 29-1 118
PNV-SELECT 118
PNV-VP-U 118
PODOFILOX 70
POLOCAINE 13
POLOCAINE-MPF 13
POLYCIN 100
POLYETHYLENE GLYCOL 3350 76
POLYMYXIN B SULFATE 17
POLYMYXIN B SULFATE/TRIMETHOPRIM 101
POLYSACCHARIDE IRON FORTE 114
POMALIDOMIDE 33
POMALYST 33
PONATINIB HCL 37
PORFIMER SODIUM 36
PORTIA 88
PAGE 143 LAST UPDATED 02/2016
POSACONAZOLE 29
POTASSIUM ACETATE 115
POTASSIUM BICARBONATE/CITRIC ACID 115
POTASSIUM CHLORIDE 115
POTASSIUM CHLORIDE IN 0.45 % SODIUM
CHLORIDE 115
POTASSIUM CHLORIDE IN 0.9 % SODIUM
CHLORIDE 115
POTASSIUM CHLORIDE IN 5 % DEXTROSE IN
WATER 115
POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9
% SODIUM CHLORIDE 115
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 %
SODIUM CHLORIDE 115
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 %
SODIUM CHLORIDE 115
POTASSIUM CHLORIDE IN DEXTROSE 5% AND 0.3
% SODIUM CHLORIDE 115
POTASSIUM CHLORIDE IN LACTATED RINGERS
AND 5 % DEXTROSE 115
POTASSIUM CHLORIDE/POTASSIUM
BICARBONATE/CITRIC ACID 115
POTASSIUM CITRATE 78
POTASSIUM CITRATE/CITRIC ACID 79
POTASSIUM IODIDE/IODINE 99
POTASSIUM PHOS,M-BASIC-D-BASIC 115
POTASSIUM PHOSPHATE IN 0.9 % SODIUM
CHLORIDE 115
POTASSIUM PHOSPHATE,MONOBASIC 78
POTIGA 23
PR BENZOYL PEROXIDE 70
PR CREAM 70
PRADAXA 53
PRALATREXATE 34
PRALIDOXIME CHLORIDE 99
PRAMCORT 70
PRAMIPEXOLE DI-HCL 41
PRAMLINTIDE ACETATE 51
PRAMOXINE-HC 103
PRASUGREL HCL 56
PRAVASTATIN SODIUM 63
PRAZOSIN HCL 56
PRE-ATTACHED LTA KIT 14
PRED MILD 101
PREDNICARBATE 81
PREDNISOLONE 81
PREDNISOLONE ACETATE 101
PREDNISOLONE SOD PHOSPHATE 101
PREDNISONE 82
PREDNISONE INTENSOL 82
PREGABALIN 66
PREMASOL 118
PREMPHASE 88
PREMPRO 88
PRENA1 CHEW 118
PRENAPLUS 118
PRENATAL VIT WITH CALCIUM CMB 11/FERROUS
FUMARATE/FOLIC ACID 119
PRENATAL VIT WITH CALCIUM NO. 40/IRON
FUMARATE/FA CMB NO.1 119
PRENATAL VIT WITH CALCIUM NO.66/IRON
FUM/FOLIC ACID/DSS/DHA 119
PRENATAL VITAMIN
NO.15/IRON,CARBONYL/FOLIC ACID/DOCUSATE
SOD 119
PRENATAL VITAMIN
NO.16/IRON,CARBONYL/FOLIC ACID/DOCUSATE
SOD 119
PRENATAL VITAMIN NO.81/SODIUM FEREDETATE-
IRON POLY/FA/OMEGA3 118
PRENATAL VITAMINS COMB 10/FERROUS
FUMARATE/FOLIC ACID 119
PRENATAL VITAMINS COMBINATION NO.42/FOLIC
ACID 118
PRENATAL VITAMINS NO.11/FERROUS
FUMARATE/FOLIC ACID/OMEGA-3 119
PRENATAL VITAMINS WITH CALCIUM/FERROUS
FUMARATE/FOLIC ACID 117
PRENATAL VITS WITH CALCIUM #72/FERROUS
FUMARATE/FOLIC ACID 118
PRENATAL VITS WITH CALCIUM #73/FERROUS
FUMARATE/FOLIC ACID 119
PAGE 144 LAST UPDATED 02/2016
PRENATAL VITS WITH CALCIUM #74/FERROUS
FUMARATE/FOLIC ACID 119
PRENATAL VITS WITH CALCIUM
#76/IRON,CARBONYL/FOLIC ACID 118
PRENATAL VITS WITH CALCIUM #78/FERROUS
FUMARATE/FOLIC ACID 118
PRENATAL VITS WITHOUT CALC NO5/FERROUS
FUMARATE/FOLIC ACID 118
PREPLUS 118
PRETAB 118
PREVALITE 63
PREVIFEM 88
PREZISTA 47
PRIFTIN 32
PRIMIDONE 24
PRIVIGEN 95
PROBENECID 30
PROCAINAMIDE HCL 57
PROCARBAZINE HCL 32
PROCENTRA 64
PROCHLORPERAZINE 27
PROCHLORPERAZINE EDISYLATE 27
PROCHLORPERAZINE MALEATE 28
PROCRIT 53
PROCTO-PAK 82
PROCTOSOL-HC 82
PROCTOZONE-HC 82
PROFERRIN-FORTE 115
PROFILNINE 55
PROFILNINE SD 55
PROGESTERONE 91
PROGESTERONE,MICRONIZED 91
PROGLYCEM 51
PROGRAF 94
PROLASTIN 108
PROLASTIN C 108
PROMACTA 53
PROMETHAZINE HCL 104
PROMETHAZINE HCL/CODEINE 108
PROMETHAZINE HCL/DEXTROMETHORPHAN
HBR 108
PROMETHEGAN 28
PROPAFENONE HCL 57
PROPARACAINE HCL 101
PROPARACAINE HCL/FLUORESCEIN SODIUM 101
PROPOFOL 14
PROPRANOLOL HCL 58
PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE 61
PROPYLTHIOURACIL 93
PROSTIGMIN 31
PROTAMINE SULFATE 53
PROTECTIVES COMBINATION NO.2/CERAMIDES
1,3,6-11 70
PROTOPAM CHLORIDE 99
PROTRIPTYLINE HCL 27
PULMICORT FLEXHALER 103
PULMOZYME 109
PUREVIT DUALFE PLUS 115
PURINETHOL 34
PYRAZINAMIDE 32
PYRIDOSTIGMINE BROMIDE 31
PYRIMETHAMINE 40
QQUASENSE 89
QUAZEPAM 110
QUETIAPINE FUMARATE 44
QUINAPRIL HCL 57
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE 61
QUINIDINE GLUCONATE 57
QUINIDINE SULFATE 57
QUININE SULFATE 40
QVAR 103
RRABEPRAZOLE SODIUM 77
RADIOPAQUE PVC MARKERS/BARIUM SULFATE 99
RALOXIFENE HCL 91
RALTEGRAVIR POTASSIUM 45
RAMELTEON 110
RAMIPRIL 57
RANITIDINE HCL 75
PAGE 145 LAST UPDATED 02/2016
RAPAMUNE 94
RASBURICASE 34
RAVICTI 73
REA LO 39 70
REA LO 40 70
REBIF 67
REBIF REBIDOSE 67
RECLIPSEN 89
RECOMBINATE 55
RECTACORT-HC 82
RECTIV 70
REGONOL 31
REGORAFENIB 38
REGRANEX 71
RELADOR PAK 14
RELADOR PAK PLUS 14
RELENZA 47
RELISTOR 75
REMEVEN 71
REMICADE 94
REMODULIN 107
RENA-VITE RX 118
RENACIDIN 78
RENAL CAPS 118
RENO CAPS 118
RENVELA 79
REPAGLINIDE 50
REPAGLINIDE/METFORMIN HCL 50
REPREXAIN 12
RESCRIPTOR 46
RESERPINE 56
RESTASIS 101
REVATIO 107
REVLIMID 33
REVONTO 109
REYATAZ 47
RHO(D) IMMUNE GLOBULIN 95
RIASTAP 55
RIBASPHERE 45
RIBASPHERE RIBAPAK 45
RIBAVIRIN 45
RIDAURA 95
RIFABUTIN 32
RIFAMPIN 32
RIFAPENTINE 32
RIFAXIMIN 18
RILONACEPT 95
RILPIVIRINE HCL 46
RILUZOLE 66
RIMANTADINE HCL 47
RINGERS SOLUTION 118
RINGERS SOLUTION,LACTATED 118
RIOCIGUAT 107
RIOMET 50
RISEDRONATE SODIUM 97
RISPERDAL CONSTA 43
RISPERIDONE 43
RISPERIDONE MICROSPHERES 43
RITONAVIR 47
RITUXAN 39
RITUXIMAB 39
RIVAROXABAN 53
RIVASTIGMINE 25
RIVASTIGMINE TARTRATE 25
RIZATRIPTAN BENZOATE 31
ROCURONIUM BROMIDE 109
ROMIDEPSIN 35
ROPINIROLE HCL 41
ROPIVACAINE HCL/PF 13
ROSADAN 71
ROSULA 71
ROXICET 12
ROZEREM 110
RUFINAMIDE 24
RUXOLITINIB PHOSPHATE 38
SSABRIL 24
SACROSIDASE 73
SALACYN 71
SALICYLIC ACID 71
PAGE 146 LAST UPDATED 02/2016
SALICYLIC ACID/AMMONIUM LACTATE/ALOE
VERA 71
SALICYLIC ACID/CERAMIDES 1,3,6-11 71
SALSALATE 6
SALVAX 71
SAMSCA 111
SANTYL 71
SAPROPTERIN DIHYDROCHLORIDE 73
SAQUINAVIR MESYLATE 47
SARGRAMOSTIM 53
SAVELLA 66
SCALACORT 82
SE 10-5 SS 71
SE BPO 71
SE-TAN PLUS 115
SEB-PREV 71
SECOBARBITAL SODIUM 110
SECONAL SODIUM 110
SELEGILINE HCL 41
SELENIUM 115
SELENIUM SULFIDE 71
SELZENTRY 47
SENSIPAR 92
SENSORCAINE 14
SENSORCAINE-EPINEPHRINE 14
SENSORCAINE-MPF 14
SEROQUEL XR 44
SERTRALINE HCL 26
SETLAKIN 89
SEVELAMER CARBONATE 79
SEVOFLURANE 99
SHAROBEL 91
SIGNIFOR 93
SILDENAFIL CITRATE 107
SILVER NITRATE 71
SILVER NITRATE/POTASSIUM NITRATE 71
SILVER SULFADIAZINE 22
SIMVASTATIN 63
SIROLIMUS 94
SIRTURO 32
SITAGLIPTIN PHOSPHATE 50
SITAGLIPTIN PHOSPHATE/METFORMIN HCL 50
SITZMARKS 99
SODIUM ACETATE 115
SODIUM BICARBONATE 115
SODIUM CHLORIDE 0.45 % 116
SODIUM CHLORIDE 3 % 116
SODIUM CHLORIDE 5 % 116
SODIUM CHLORIDE FOR INHALATION 109
SODIUM CHLORIDE IRRIGATING SOLUTION 116
SODIUM CHLORIDE IRRIGATING
SOLUTION/HYPOCHLOROUS ACID 72
SODIUM CITRATE DIHYDRATE 53
SODIUM FLUORIDE 116
SODIUM FLUORIDE/XYLITOL 112
SODIUM LACTATE 116
SODIUM MORRHUATE 99
SODIUM OXYBATE 110
SODIUM PHENYLBUTYRATE 73
SODIUM PHOS,M-BASIC-D-BASIC 116
SODIUM PHOSPHATE,MONOBASIC/POTASSIUM
PHOSPHATE,MONOBASIC 78
SODIUM POLYSTYRENE SULFONATE 111
SODIUM TETRADECYL SULFATE 99
SODIUM THIOSULFATE 111
SODIUM/POTASSIUM/MAGNES/CALCIUM/CHLORID
E/ACETATE/GLUCONATE 114
SODIUM/POTASSIUM/MAGNESIUM/CALCIUM/CHLO
RIDE/ACETATE 114
SODIUM/POTASSIUM/POTASSIUM
CITRATE/SODIUM CITRATE/CIT AC 79
SOFOSBUVIR 45
SOJOURN 99
SOLIRIS 99
SOMATROPIN 83
SORAFENIB TOSYLATE 38
SORINE 57
SOTALOL HCL 57
SOTRADECOL 99
SOVALDI 45
SPINOSAD 71
SPIRIVA 105
PAGE 147 LAST UPDATED 02/2016
SPIRIVA RESPIMAT 105
SPIRONOLACTONE 62
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE 61
SPORANOX 30
SPRINTEC 89
SPRYCEL 38
SPS 111
SRONYX 89
SS 10-2 71
SSD 22
SSS 10-5 71
STAVUDINE 46
STIMATE 83
STIOLTO RESPIMAT 109
STIVARGA 38
STRATTERA 65
STRENSIQ 73
STREPTOZOCIN 37
STRIBILD 45
STRIVERDI RESPIMAT 106
STROMECTOL 39
SUBLIMAZE 12
SUBOXONE 14
SUCCIMER 110
SUCCINYLCHOLINE CHLORIDE 109
SUCRAID 73
SUCRALFATE 76
SUFENTA 12
SUFENTANIL CITRATE 12
SULFACETAMIDE SODIUM 72
SULFACETAMIDE SODIUM/PREDNISOLONE
SODIUM PHOSPHATE 101
SULFACETAMIDE SODIUM/SULFUR 73
SULFACETAMIDE SODIUM/SULFUR/SKIN
CLEANSER COMB NO.23 72
SULFACETAMIDE SODIUM/SULFUR/UREA 71
SULFACETAMIDE SODIUM/SULFUR/WITCH
HAZEL 71
SULFACLEANSE 8-4 72
SULFADIAZINE 22
SULFAMETHOXAZOLE/TRIMETHOPRIM 22
SULFAMYLON 17
SULFASALAZINE 97
SULFATRIM 22
SULFAZINE 96
SULFAZINE EC 97
SULFURIC ACID/SULFONATED PHENOL 67
SULINDAC 6
SUMATRIPTAN 31
SUMATRIPTAN SUCCINATE 31
SUNITINIB MALATE 38
SUSTIVA 46
SUTENT 38
SYEDA 89
SYLATRON 36
SYLATRON 4-PACK 36
SYMAX 74
SYMAX-SL 74
SYMAX-SR 75
SYMBICORT 109
SYMLINPEN 120 51
SYMLINPEN 60 51
SYNAGIS 95
SYREX 116
TTABLOID 34
TACROLIMUS 94
TADALAFIL 107
TAFINLAR 38
TALIGLUCERASE ALFA 73
TAMIFLU 48
TAMOXIFEN CITRATE 33
TAMSULOSIN HCL 77
TARCEVA 38
TARGRETIN 39
TARINA FE 89
TARON FORTE 116
TARON-CRYSTALS 78
TASIGNA 38
TASIMELTEON 110
TASMAR 41
PAGE 148 LAST UPDATED 02/2016
TAZAROTENE 72
TAZORAC 72
TAZTIA XT 59
TECFIDERA 67
TECHNIVIE 45
TEGRETOL XR 25
TELAPREVIR 44
TELBIVUDINE 44
TELMISARTAN 56
TELMISARTAN/AMLODIPINE BESYLATE 61
TELMISARTAN/HYDROCHLOROTHIAZIDE 61
TEMAZEPAM 110
TEMODAR 33
TEMOZOLOMIDE 33
TEMSIROLIMUS 38
TENCON 66
TENIPOSIDE 37
TENOFOVIR DISOPROXIL FUMARATE 47
TERAZOSIN HCL 56
TERBINAFINE HCL 30
TERBUTALINE SULFATE 106
TERCONAZOLE 30
TERIPARATIDE 97
TERRELL 99
TESAMORELIN ACETATE 92
TESTOPEL 83
TESTOSTERONE 83
TESTOSTERONE CYPIONATE 83
TESTOSTERONE ENANTHATE 83
TETCAINE 101
TETRABENAZINE 66
TETRACAINE HCL 101
TETRACAINE HCL/PF 101
TETRACYCLINE HCL 23
THALIDOMIDE 33
THALOMID 33
THEOCHRON 107
THEOPHYLLINE ANHYDROUS 107
THEOPHYLLINE/DEXTROSE 5 % IN WATER 107
THERACYS 36
THERAPEUTIC VITAMIN W-MINERALS 118
THERMAZENE 22
THIAMINE HCL 118
THIOGUANINE 34
THIORIDAZINE HCL 42
THIOTEPA 36
THIOTHIXENE 42
THRIVITE RX 118
THYROID,PORK 92
THYROLAR-1 92
THYROLAR-1/2 92
THYROLAR-1/4 92
THYROLAR-2 92
THYROLAR-3 92
TIAGABINE HCL 24
TICAGRELOR 55
TIGECYCLINE 17
TIKOSYN 57
TIMOLOL MALEATE 102
TINIDAZOLE 17
TIOTROPIUM BROMIDE 105
TIOTROPIUM BROMIDE/OLODATEROL HCL 109
TIPRANAVIR 47
TIVICAY 46
TIZANIDINE HCL 110
TL G-FOL OS 116
TL ICON 116
TL-HEM 150 116
TOBI 106
TOBI PODHALER 106
TOBRAMYCIN 106
TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE 106
TOBRAMYCIN SULFATE 15
TOBRAMYCIN SULFATE/SODIUM CHLORIDE 15
TOBRAMYCIN/DEXAMETHASONE 101
TOBRAMYCIN/NEBULIZER 106
TOCILIZUMAB 95
TOLAZAMIDE 51
TOLBUTAMIDE 51
TOLCAPONE 41
TOLMETIN SODIUM 6
TOLTERODINE TARTRATE 77
PAGE 149 LAST UPDATED 02/2016
TOLVAPTAN 111
TOPIRAGEN 24
TOPIRAMATE 24
TOPOSAR 37
TOREMIFENE CITRATE 33
TORISEL 38
TORSEMIDE 62
TOSITUMOMAB (WITH MALTOSE) 39
TRACLEER 107
TRADJENTA 51
TRAMADOL HCL 12
TRAMADOL HCL/ACETAMINOPHEN 12
TRAMETINIB DIMETHYL SULFOXIDE 38
TRANDOLAPRIL 57
TRANDOLAPRIL/VERAPAMIL HCL 61
TRANEXAMIC ACID 55
TRANYLCYPROMINE SULFATE 26
TRASTUZUMAB 39
TRAVASOL 118
TRAVOPROST (BENZALKONIUM) 102
TRAZODONE HCL 26
TREANDA 33
TREPROSTINIL SODIUM 107
TREPROSTINIL/NEBULIZER/NEBULIZER
ACCESSORIES 107
TRETINOIN 72
TRETINOIN MICROSPHERES 72
TRETTEN 55
TREXALL 94
TRI-CHLOR 72
TRI-ESTARYLLA 89
TRI-LEGEST FE 89
TRI-LINYAH 89
TRI-LO-ESTARYLLA 89
TRI-LO-MARZIA 89
TRI-LO-SPRINTEC 89
TRI-PREVIFEM 89
TRI-SPRINTEC 89
TRIACETIN 30
TRIAMCINOLONE ACETONIDE 103
TRIAMTERENE/HYDROCHLOROTHIAZIDE 62
TRIANEX 82
TRIAZOLAM 110
TRICHLOROACETIC ACID 72
TRICITRASOL 53
TRICITRATES 78
TRICON 116
TRIDERM 82
TRIFLUOPERAZINE HCL 42
TRIFLURIDINE 48
TRIGELS-F FORTE 116
TRIHEXYPHENIDYL HCL 40
TRIMETHOBENZAMIDE HCL 28
TRIMETHOPRIM 17
TRINESSA 89
TRISENOX 36
TRIVORA-28 89
TROPICAMIDE 101
TROSPIUM CHLORIDE 77
TRUVADA 46
TRYPSIN/BALSAM PERU/CASTOR OIL 72
TUDORZA PRESSAIR 105
TUSSIGON 109
TYGACIL 17
TYKERB 38
TYVASO 107
TYZEKA 44
UUCERIS 96
ULORIC 30
UMECTA 72
UNITHROID 92
UR N-C 17
UREA 73
UREA/HYALURONATE SODIUM 72
UREA/LACTIC ACID/SALICYLIC ACID 72
UREA/LACTIC ACID/ZINC UNDECYLENATE 72
URETRON D-S 17
URIMAR-T 17
URIN D.S. 17
URO-BLUE 17
PAGE 150 LAST UPDATED 02/2016
UROGESIC-BLUE 17
UROLET MB 17
UROPHEN MB 17
URSODIOL 75
URYL 17
USTELL 17
UTIRA-C 18
VVAGIFEM 89
VALACYCLOVIR HCL 48
VALCHLOR 33
VALCYTE 44
VALGANCICLOVIR HCL 44
VALPROIC ACID 24
VALPROIC ACID (AS SODIUM SALT) (VALPROATE
SODIUM) 24
VALSARTAN 56
VALSARTAN/HYDROCHLOROTHIAZIDE 62
VANCOMYCIN HCL 18
VANCOMYCIN HCL/DEXTROSE 5 % IN WATER 18
VANCOMYCIN IN 0.9 % SODIUM CHLORIDE 18
VANCOMYCIN IN DEXTROSE, ISO-OSMOTIC 18
VANDAZOLE 18
VANDETANIB 37
VANTAS 93
VARENICLINE TARTRATE 15
VARICELLA-ZOSTER IMMUNE GLOBULIN
(HUMAN) 95
VARIZIG 95
VASCEPA 63
VASHE WOUND THERAPY 72
VASOLEX 72
VASOPRESSIN 83
VECTIBIX 39
VECURONIUM BROMIDE 110
VELAGLUCERASE ALFA 74
VELETRI 108
VELIVET 89
VEMURAFENIB 38
VENA-BAL DHA 118
VENLAFAXINE HCL 27
VENTAVIS 108
VENTOLIN HFA 106
VERAPAMIL HCL 59
VERDROCET 12
VERIPRED 20 82
VESTURA 89
VICODIN 12
VICODIN ES 12
VICODIN HP 12
VICTOZA 2-PAK 51
VICTOZA 3-PAK 51
VICTRELIS 45
VIDEX 46
VIENVA 90
VIGABATRIN 24
VIMPAT 25
VINBLASTINE SULFATE 36
VINCASAR PFS 36
VINCRISTINE SULFATE 36
VINCRISTINE SULFATE LIPOSOMAL 36
VINORELBINE TARTRATE 36
VIORELE 90
VIRACEPT 47
VIRAMUNE XR 46
VIREAD 47
VIRT NATE 119
VIRT-ADVANCE 119
VIRT-CAPS 119
VIRT-NATE 119
VIRT-NATE DHA 119
VIRT-PHOS 250 NEUTRAL 78
VIRT-PN 119
VIRT-VITE GT 119
VIRTI-SULF 72
VIRTPREX 119
VIRTRATE-2 79
VIRTRATE-3 79
VIRTRATE-K 79
VISMODEGIB 37
VITAFOL-OB 119
PAGE 151 LAST UPDATED 02/2016
VITAFOL-PN 119
VITAMIN A/VITAMIN
E/AVOBENZONE/OCTINOXATE/HYDROQUINONE 70
VITAMIN B COMPLEX & VITAMIN C NO.20/FOLIC
ACID 119
VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC
ACID/BIOTIN 119
VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC
ACID/BIOTIN/ZNOX 117
VOL-CARE RX 119
VOL-PLUS 119
VORAPAXAR SULFATE 56
VORICONAZOLE 30
VORINOSTAT 37
VOTRIENT 38
VP-VITE RX 119
VPRIV 74
VSL#3 DS 75
VUMON 37
VYFEMLA 90
VYVANSE 64
WWARFARIN SODIUM 53
WATER FOR INJ.,BACTERIOSTATIC 99
WATER FOR
INJ.,BACTERIOSTATIC/METHYLPARABEN/PROPYL
PARABEN 99
WATER FOR INJECTION,STERILE 99
WATER FOR IRRIGATION,STERILE 99
WERA 90
WESTHROID 92
WYMZYA FE 90
XX-VIATE 73
XALKORI 38
XARELTO 53
XENAZINE 66
XIFAXAN 18
XOLAIR 109
XTANDI 33
XYNTHA 55
XYNTHA SOLOFUSE 55
XYREM 110
ZZAFIRLUKAST 105
ZALEPLON 110
ZAMICET 12
ZANAMIVIR 47
ZANOSAR 37
ZARAH 90
ZATEAN-PN 119
ZAVESCA 74
ZEBUTAL 66
ZELBORAF 38
ZEMAIRA 109
ZENCHENT 90
ZENCHENT FE 90
ZENCIA 73
ZEOSA 90
ZETIA 63
ZEVALIN 39
ZIAGEN 47
ZIDOVUDINE 47
ZINC CHLORIDE 116
ZINC SULFATE 116
ZINC SULFATE HEPTAHYDRATE/CUSO4 P-
HYD/MANGANESE/CHROMIUM/SE 114
ZINC SULFATE/CUPRIC SULFATE/MANGANESE
SULF/CHROMIC CHLORIDE 114
ZIPRASIDONE HCL 44
ZIPRASIDONE MESYLATE 43
ZOLINZA 37
ZOLMITRIPTAN 31
ZOLPIDEM TARTRATE 110
ZOMIG 31
ZONISAMIDE 23
ZONTIVITY 56
ZORTRESS 94
ZOSTAVAX 96
PAGE 152 LAST UPDATED 02/2016
ZOSTER VACCINE LIVE/PF 96
ZOVIA 1-35E 90
ZOVIA 1-50E 90
ZOVIRAX 48
ZYDELIG 38
ZYKADIA 38
ZYTIGA 33
ZYVOX 18
PAGE 153 LAST UPDATED 02/2016
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