Aon Hewitt's Corporate Health Exchange Drug List...Aon Hewitt’s Corporate Health Exchange Drug List or formulary is a list of covered drugs used to treat common diseases or health

Aon Hewitt's Corporate Health Exchange

Drug List (Oregon)

Aon Hewitt’s Corporate Health Exchange Drug List includes a list of drugs covered by Health Net. This drug list is for Oregon. The drug list is updated often and may change. To get the most up-to-date information, you may view the latest drug list on our website at www.healthnet.com/aonhewitt or call us at 1-888-926-1692.

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Welcome to Health Net What is Aon Hewitt’s Corporate Health Exchange Drug List? Aon Hewitt’s Corporate Health Exchange Drug List or formulary is a list of covered drugs used to treat common diseases or health problems. The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on: Safety; Effectiveness; Side effects; and Value (If two drugs are equally effective, the less costly drug will be preferred) How much will I pay for my drugs? To figure out how much you will pay for a drug, the abbreviations in the table below appear in the Drug Tier column on the formulary. The copayment or coinsurance level you will pay is shown in the Copayment/Coinsurance column. If you do not know your copayment or coinsurance for each tier, please refer to your Summary of Benefits or other plan documents. Abbreviation Copayment/Coinsurance Description1 Tier 1 copayment or

coinsurance Generic drugs

2 Tier 2 copayment or coinsurance

Preferred brand drugs

3 Tier 3 copayment or coinsurance

Non-preferred brand drugs and specialty/covered injectable drugs. You may be required to obtain some drugs from a Specialty Pharmacy.

AC Anticancer drug copayment or coinsurance

Oral anticancer drugs

GP You may pay your copayment or coinsurance plus the difference in cost between the brand and generic drugs.

Generics are preferred. A generic version of this brand drug is available. You can get the brand drug, but you may pay your copayment or coinsurance plus the difference in cost between the brand and generic drugs.

PV $0 Preventive benefit drugs. These drugs must be covered at no cost to members under the Affordable Care Act. A deductible does not apply.

NF Non-formulary – If Health Net approves an exception request for a non-formulary drug, the non-preferred brand tier (Tier 3) copayment will apply

Drugs not covered on the formulary.

How do I use the drug list?

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Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug. What if my drug is not on the drug list? If your drug is not on the drug list, call us at 1-888-926-1692 and ask if your drug is covered. If your drug is not covered, you can ask your doctor to prescribe a similar drug that is covered. If your doctor feels you need to have the drug that is not covered, your doctor can ask us to make an exception. What are generic drugs? A generic drug contains the same active ingredient and works the same way as the brand name drug. Generic drugs are safe and effective, and generally cost less. Generic drugs are available on the drug list at Tier 1. If you request a brand name drug that has an available generic version, you may be charged a higher cost share. Are there any limits on my drug coverage? Some drugs have limits on coverage. The table below provides a description of abbreviations that may appear in the Limits column on the drug list:

Abbreviation Definition DescriptionAL Age Limit These drugs may require prior

authorization if your age does not fall within manufacturer, FDA, or clinical recommendations.

MO Mail Order These drugs are available from the mail order pharmacy.

PA Prior Authorization These drugs require prior authorization for coverage, effectiveness, or safety reasons. This means that your doctor must request approval from Health Net before the drug will be covered.

QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval for a higher quantity of the drug from Health Net.

RX/OTC Prescription & Over-the-Counter (OTC)

Certain drugs are available both in a prescription form and in an OTC form. Only prescription drugs are covered by your plan with the exception of some insulins, insulin supplies and some covered preventive drugs.

ST Step Therapy You must first try another specific drug(s) before these drugs will be covered.

How can I get an exception to the rules for drug coverage? Your doctor can ask for an exception to our rules for drug coverage.

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Your doctor can ask us to cover your drug even if it is not on the drug list. Your doctor can ask us to make an exception for limits on your drug. For example, if your drug has a

quantity limit of 1 tablet per day, your doctor can ask us to cover more. To request an exception, your doctor can fax a prior authorization form along with a written statement supporting the request to us at 1-800-255-9198. Are injectable drugs covered? Injectable drugs are not covered, except for those listed on the drug list. Some injectable drugs are considered “specialty drugs” that must be obtained from one of Health Net’s Specialty Pharmacies. Are compounded prescriptions covered? Compounded prescriptions require prior authorization for coverage. If prior authorization is granted, your Tier 3 copayment or coinsurance applies. Can I go to any pharmacy? To get the best benefit, you should use pharmacies that are in the network. These pharmacies have a contract with Health Net. Most chain pharmacies and many independent pharmacies are in the network. To find a pharmacy near you, visit our website at www.healthnet.com/aonhewitt or call us at 1-888-926-1692. If you fill your prescription at an out-of-network pharmacy, the pharmacy may not be able to bill Health Net online so you may have to pay the full cost of your drug. However, you can send us your pharmacy receipt and ask for reimbursement, minus your copayment or coinsurance. Some injectable and high cost drugs may be considered “specialty drugs”. These drugs must be obtained from one of Health Net’s Specialty Pharmacies. Can I use a mail order pharmacy? You can use the CVS Caremark Mail Order Pharmacy for the home delivery of most maintenance drugs. Maintenance drugs are those needed for a long term condition. To use the mail order pharmacy, your doctor must provide new prescriptions that allow up to a 90-day supply of each drug. Mail order forms are available on our website at www.healthnet.com/aonhewitt or you may call us at 1-888-926-1692 to request a form. How often can I refill my prescription? For prescriptions written for 10-days or less, you may refill after 50 percent of the supply has been used as

directed. For prescriptions written for more than 10-days, you may refill after 74 percent of the supply has been used

as directed. If your physician has increased your dose, your pharmacy must be notified of the change. If this change will result in an early refill request, your pharmacy can contact Health Net for an override.

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How can I save money on my prescription drugs? You can save time and money with these simple steps: Ask your doctor about generic drugs that may work for you. Fill prescriptions at Health Net participating pharmacies. Be sure your doctor prescribes drugs on the drug list Fill your maintenance drugs through our mail order pharmacy program.

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesADDERALL (UseAmphetamine-Dextroamphetamine)

GPMO

ADDERALL XR (UseAmphetamine-Dextroamphetamine)

GPQL(1 ea daily);MO

amphetamine-dextroamphetamine cp241.25mg-1.25mg-1.25mg-1.25mg, 2.5mg-2.5mg-2.5mg-2.5mg, 3.75mg-3.75mg-3.75mg-3.75mg,5mg-5mg-5mg-5mg,6.25mg-6.25mg-6.25mg-6.25mg, 7.5mg-7.5mg-7.5mg-7.5mg

1

QL(1 ea daily);MO

amphetamine-dextroamphetamine tabs1.25mg-1.25mg-1.25mg-1.25mg, 1.875mg-1.875mg-1.875mg-1.875mg, 2.5mg-2.5mg-2.5mg-2.5mg, 3.125mg-3.125mg-3.125mg-3.125mg, 3.75mg-3.75mg-3.75mg-3.75mg, 5mg-5mg-5mg-5mg, 7.5mg-7.5mg-7.5mg-7.5mg

1

MO

DESOXYN (UseMethamphetamine HCl) GP PA; MO

DEXEDRINE (UseDextroamphetamineSulfate)

GPMO

dextroamphetamine sulfate 1 MO

methamphetamine hcl 1 PA; MO

PROCENTRA (UseDextroamphetamineSulfate)

GPMO

VYVANSE 2 QL(1 ea daily);MO

ZENZEDI 3

Drug Name DrugTier

Requirements/Limits

AnalepticsCAFCIT (Use CaffeineCitrate) GP MO

caffeine citrate 1 MO

Anorexiants Non-AmphetamineADIPEX-P CAPS (UsePhentermine HCl) GP PA

ADIPEX-P TABS (UsePhentermine HCl) GP PA; MO

BONTRIL PDM (UsePhendimetrazine Tartrate) GP PA; MO

diethylpropion hcl 3 PA; MO

phendimetrazine tartrate 3 PA; MO

PHENDIMETRAZINETARTRATEER 3 PA; MO

phentermine hcl caps 15mg, 30 mg, 37.5 mg 3 PA

phentermine hcl tabs 37.5mg 3 PA; MO

QSYMIA 3 PA; MO

SUPRENZA 3 PA; MO

Anti-Obesity AgentsBELVIQ 3 PA; MO

XENICAL 3 PA

Attention-Deficit/Hyperactivity Disorder (ADHD)

clonidine hcl (adhd) 1 QL(4 ea daily);MO

INTUNIV 3 QL(1 ea daily);MO

KAPVAY (Use ClonidineHCl (ADHD)) GP QL(4 ea daily);

MO

KAPVAY DOSE PACK 3 MO

STRATTERA 10 MG, 18MG, 25 MG, 40 MG 3 QL(2 ea daily);

MOSTRATTERA 100 MG, 60MG, 80 MG 3 QL(1 ea daily);

MOStimulants - Misc.

Please refer to pages ii - iii for a complete description of abbreviations.AC=Anticancer AL=Age Limit GP=Generic PreferredMO=Available at Mail Order NF=Non Formulary PA=Prior AuthorizationPV=$0 Co-pay QL=Quantity Limit ST=Step TherapyLast Updated: April 1, 20141

Drug Name DrugTier

Requirements/Limits

CONCERTA 18 MG, 27MG, 54 MG (UseMethylphenidate HCl)

GPQL(1 ea daily);MO

CONCERTA 36 MG (UseMethylphenidate HCl) GP QL(2 ea daily);

MO

DAYTRANA 3 MO

dexmethylphenidate hclcp24 15 mg, 30 mg, 40 mg 1 QL(1 ea daily);

MOdexmethylphenidate hcltabs 10 mg, 2.5 mg, 5 mg 1 QL(2 ea daily);

MOFOCALIN (UseDexmethylphenidate HCl) GP QL(2 ea daily);

MOFOCALIN XR 10 MG, 20MG, 5 MG 3 QL(1 ea daily);

MOFOCALIN XR 15 MG, 30MG, 40 MG (UseDexmethylphenidate HCl)

GPQL(1 ea daily);MO

FOCALIN XR 25 MG, 35MG 3 MO

METADATE CD 10 MG, 40MG, 50 MG, 60 MG (UseMethylphenidate HCl)

GPMO

METADATE CD 20 MG, 30MG (Use MethylphenidateHCl)

GPQL(2 ea daily);MO

METHYLIN CHEW 10 MG,2.5 MG, 5 MG 3 MO

METHYLIN SOLN 10MG/5ML, 5 MG/5ML (UseMethylphenidate HCl)

GPMO

methylphenidate hcl cp2420 mg, 30 mg, 40 mg 1 MO

methylphenidate hcl cpcr10 mg, 40 mg, 50 mg, 60mg

1MO

methylphenidate hcl cpcr20 mg, 30 mg 1 QL(2 ea daily);

MO

methylphenidate hcl er 1 QL(1 ea daily);MO

methylphenidate hcl soln10 mg/5ml, 5 mg/5ml 1 MO

methylphenidate hcl tabs10 mg, 20 mg, 5 mg 1 MO

methylphenidate hcl tbcr 18mg, 20 mg, 27 mg, 54 mg 1 QL(1 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

methylphenidate hcl tbcr 27mg, 54 mg 1

QL(1 eadaily,90 day(s)limit); MO

methylphenidate hcl tbcr 36mg 1 QL(2 ea daily);

MO

methylphenidate hcl tbcr 36mg 1

QL(2 eadaily,90 day(s)limit); MO

modafinil 1 PA; QL(1 eadaily); MO

NUVIGIL 150 MG, 250 MG,50 MG 3 ST; MO

NUVIGIL 200 MG 3 MO

PROVIGIL (Use Modafinil) GP PA; QL(1 eadaily); MO

QUILLIVANT XR 3 QL(12 mldaily); MO

RITALIN (UseMethylphenidate HCl) GP MO

RITALIN LA 10 MG 3 MO

RITALIN LA 20 MG, 30MG, 40 MG (UseMethylphenidate HCl)

GPMO

RITALIN SR (UseMethylphenidate HCl) GP QL(1 ea daily);

MOAMEBICIDES - Drugs to Treat AmoebozoaInfectionsAmebicidesYODOXIN 2 MO

AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosidesBETHKIS 3 MO

NEO-FRADIN 2

neomycin sulfate 1 MO

paromomycin sulfate 1 MO

TOBI (Use Tobramycin) GP


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Drug Name DrugTier

Requirements/Limits

TOBI PODHALER 3

tobramycin 3

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonoal AntibodiesHUMIRA 3 PA

HUMIRA PEN 3 PA

SIMPONI 3 PA

Antirheumatic - Enzyme InhibitorsXELJANZ 3 PA

Antirheumatic AntimetabolitesOTREXUP 3 PA

RHEUMATREX 2 MO

Gold CompoundsRIDAURA 2 MO

Interleukin-1 BlockersARCALYST 3 PA

Interleukin-1 Receptor Antagonist (IL-1Ra)KINERET 3 PA

Interleukin-6 Receptor InhibitorsACTEMRA 3 PA

Nonsteroidal Anti-inflammatory Agents (NSAIDs)ANAPROX (Use NaproxenSodium) GP MO

ANAPROX DS (UseNaproxen Sodium) GP MO

ARTHROTEC 50 (UseDiclofenac w/ Misoprostol) GP MO

ARTHROTEC 75 (UseDiclofenac w/ Misoprostol) GP MO

CATAFLAM (UseDiclofenac Potassium) GP MO

Drug Name DrugTier

Requirements/Limits

CELEBREX 100 MG, 200MG 3 ST; QL(1 ea

daily); MO

CELEBREX 400 MG 3 ST; QL(2 eadaily); AL; MO

CELEBREX 50 MG 3 ST; MO

CLINORIL (Use Sulindac) GP MO

DAYPRO (Use Oxaprozin) GP MO

diclofenac potassium 1 MO

diclofenac sodium 1 MO

diclofenac w/ misoprostol 1 MO

DUEXIS 3 MO

EC-NAPROSYN 500 MG(Use Naproxen) GP MO

etodolac caps 200 mg, 300mg 1 MO

etodolac tabs 400 mg, 500mg 1 MO

etodolac tb24 400 mg, 500mg, 600 mg 1 QL(2 ea daily);

MO

FELDENE (Use Piroxicam) GP MO

fenoprofen calcium 1 MO

flurbiprofen 1 MO

ibuprofen tabs 400 mg, 600mg, 800 mg 1 MO

INDOCIN SUPP RE 50 MG 3 MO

INDOCIN SUSP OR 25MG/5ML 2 MO

indomethacin caps or 25mg, 50 mg 1 MO

indomethacin cpcr or 75mg 1 MO

ketoprofen 1 MO

KETOPROFEN ER 3 MO

ketorolac tromethaminetabs or 10 mg 1 QL(0.67 ea

daily); MO


Drug Name DrugTier

Requirements/Limits

meclofenamate sodium 1 MO

mefenamic acid 1 MO

MELOXICAM SUSP 7.5MG/5ML 2 MO

meloxicam tabs 15 mg 1 QL(1 ea daily);MO

meloxicam tabs 7.5 mg 1 QL(2 ea daily);MO

MOBIC SUSP 7.5 MG/5ML 2 MO

MOBIC TABS 15 MG (UseMeloxicam) GP QL(1 ea daily);

MOMOBIC TABS 7.5 MG (UseMeloxicam) GP QL(2 ea daily);

MO

nabumetone 500 mg 1 QL(4 ea daily);MO

nabumetone 750 mg 1 QL(3 ea daily);MO

NALFON 200 MG 3

NALFON 400 MG 3 MO

NAPRELAN 3 PA

NAPRELAN 375 MG, 500MG, 750 MG 3 MO

NAPROSYN (UseNaproxen) GP MO

naproxen sodium 1 MO

naproxen susp 125 mg/5ml 1 MO

naproxen tabs 250 mg, 375mg, 500 mg 1 MO

naproxen tbec 500 mg 1 MO

oxaprozin 1 MO

piroxicam 1 MO

PONSTEL (UseMefenamic Acid) GP MO

SPRIX 3QL(1 ea daily,5day(s) limit);MO

Drug Name DrugTier

Requirements/Limits

sulindac 1 MO

tolmetin sodium 1 MO

VIMOVO 3 PA; MO

VOLTAREN-XR (UseDiclofenac Sodium) GP MO

ZIPSOR 3ST; QL(4 eadaily,7 day(s)limit); MO

ZORVOLEX 3 ST; QL(3 eadaily); MO

Pyrimidine Synthesis InhibitorsARAVA 10 MG (UseLeflunomide) GP QL(2 ea daily);

MOARAVA 20 MG (UseLeflunomide) GP QL(1 ea daily);

MO

leflunomide 10 mg 1 QL(2 ea daily);MO

leflunomide 20 mg 1 QL(1 ea daily);MO

Selective Costimulation ModulatorsORENCIA 3 PA

Soluble Tumor Necrosis Factor Receptor AgentsENBREL 3 PA

ENBREL SURECLICK 3 PA

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint ConditionsAnalgesic Combinationsacetaminophen-salicylamide-phenyltoloxamine

1

ALAGESIC LQ 3

ALPAIN 3

ANABAR 3 MO

BIOREGESIC 3

BUPAP 300MG-50MG 3 MO


4

Drug Name DrugTier

Requirements/Limits

BUPAP 650MG-50MG 1

butalbital-acetaminophen325mg-50mg 1 MO

butalbital-acetaminophen650mg-50mg 1

butalbital-acetaminophen-caffeine 1 MO

butalbital-aspirin-caffeine 1 MO

BUTALBITAL/ASPIRIN/CAFFEINE 2 MO

DOLGIC PLUS 3 MO

DOLOGESIC 3

EQUAGESIC 3

ESGIC (Use Butalbital-Acetaminophen-Caffeine) GP MO

ESGIC-PLUS (UseButalbital-Acetaminophen-Caffeine)

GPMO

FIORICET (Use Butalbital-Acetaminophen-Caffeine) GP MO

FIORINAL (Use Butalbital-Aspirin-Caffeine) GP MO

FRENADOL 3

LEVACET 3 MO

ORBIVAN 3 MO

ORBIVAN CF 3 MO

phenyltoloxamine-acetaminophen 500mg-50mg, 55mg-500mg

1

PHRENILIN FORTE 2 MO

RELAGESIC 3

RHINOFLEX-650 3

SEDAPAP (Use Butalbital-Acetaminophen) GP

Drug Name DrugTier

Requirements/Limits

STAFLEX (UsePhenyltoloxamine-Acetaminophen)

GP

TENCON (Use Butalbital-Acetaminophen) GP

ZGESIC 3 MO

SalicylatesASCRIPTIN PV PV

aspirin chew 81 mg PV MO; PV

ASPIRIN LOW DOSE PV PV

aspirin tabs 325 mg PV MO; PV

aspirin tabs 81 mg PV PV

aspirin tbec 324 mg, 325mg, 81 mg PV MO; PV

choline & mag salicylateliqd 500 mg/5ml 1 MO

choline & mag salicylatetabs 1000 mg, 500 mg, 750mg

1

diflunisal 1 MO

ECOTRIN REGULARSTRENGTH (Use Aspirin) GP MO; PV

HALFPRIN PV MO; PV

MST 600 3

ST JOSEPH ADULT (UseAspirin) GP PV

ST JOSEPH ADULTANALGESICLOW DOSEBITE SIZE (Use Aspirin)

GPPV

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid AgonistsABSTRAL 3 PA

ACTIQ (Use FentanylCitrate) GP PA; MO

AVINZA (Use MorphineSulfate Beads) GP QL(1 ea daily);

MO


Drug Name DrugTier

Requirements/Limits

CODEINE SULFATESOLN 30 MG/5ML 3 MO

codeine sulfate tabs 15 mg,30 mg, 60 mg 1 MO

CONZIP 3 MO

DEMEROL TABS OR 100MG, 50 MG (UseMeperidine HCl)

GPMO

DILAUDID (UseHydromorphone HCl) GP MO

DOLOPHINE (UseMethadone HCl) GP QL(12 ea

daily); MODOLOPHINE HCL (UseMethadone HCl) GP QL(12 ea

daily); MODURAGESIC (UseFentanyl) GP QL(0.5 ea

daily); MOEXALGO 12 MG, 16 MG, 8MG 3 QL(4 ea daily);

MO

EXALGO 32 MG 3 QL(2 ea daily);MO

fentanyl 1 QL(0.5 eadaily); MO

fentanyl citrate lpop bu1200 mcg, 1600 mcg, 200mcg, 400 mcg, 600 mcg,800 mcg

1

PA; MO

FENTORA 3 PA; QL(3 eadaily); MO

hydromorphone hcl liqd or1 mg/ml 1 MO

hydromorphone hcl tabs or2 mg, 4 mg, 8 mg 1 MO

KADIAN 10 MG (UseMorphine Sulfate) GP MO

KADIAN 100 MG, 20 MG,30 MG, 50 MG, 60 MG, 80MG (Use Morphine Sulfate)

GPQL(2 ea daily);MO

KADIAN 130 MG, 150 MG 3

KADIAN 200 MG, 40 MG,70 MG 3 MO

LAZANDA 100 MCG/ACT 3 PA; MO

LAZANDA 400 MCG/ACT 3 PA

Drug Name DrugTier

Requirements/Limits

LEVORPHANOLTARTRATE 3 MO

MEPERIDINE HCL SOLNOR 50 MG/5ML 2 MO

meperidine hcl tabs or 100mg, 50 mg 1 MO

methadone hcl conc or 10mg/ml 1 MO

methadone hcl soln or 10mg/5ml, 5 mg/5ml 1 MO

methadone hcl tabs or 10mg, 5 mg 1 QL(12 ea

daily); MOmethadone hcl tbso or 40mg 1

METHADOSE (UseMethadone HCl) 1 MO

METHADOSE SUGAR-FREE (Use MethadoneHCl)

1MO

morphine sulfate beads 1 QL(1 ea daily);MO

morphine sulfate cp24 or10 mg 1 MO

morphine sulfate cp24 or100 mg, 20 mg, 30 mg, 50mg, 60 mg, 80 mg

1QL(2 ea daily);MO

morphine sulfate soln or 10mg/5ml, 100 mg/5ml, 20mg/5ml, 20 mg/ml

1MO

morphine sulfate supp re10 mg, 20 mg 1 MO

MORPHINE SULFATESUPP RE 30 MG, 5 MG(Use Morphine Sulfate)

GP

morphine sulfate tabs or 15mg, 30 mg 1 MO

morphine sulfate tbcr or100 mg, 15 mg, 200 mg, 30mg, 60 mg

1QL(3 ea daily);MO

MS CONTIN (UseMorphine Sulfate) GP QL(3 ea daily);

MO

NUCYNTA 2 QL(6 ea daily);MO

NUCYNTA ER 2 QL(2 ea daily);MO


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Drug Name DrugTier

Requirements/Limits

OPANA TABS OR 10 MG,5 MG (Use OxymorphoneHCl)

GPMO

OXECTA 3 QL(4 ea daily);MO

oxycodone hcl caps 5 mg 1 MO

oxycodone hcl conc 100mg/5ml 1 MO

OXYCODONE HCL CONC100 MG/5ML (UseOxycodone HCl)

GPMO

oxycodone hcl soln 5mg/5ml 1 MO

oxycodone hcl tabs 10 mg,15 mg, 20 mg, 30 mg, 5 mg 1 MO

OXYCONTIN 3 QL(3 ea daily);MO

oxymorphone hcl 1 MO

ROXICODONE (UseOxycodone HCl) GP MO

RYBIX ODT 3

RYZOLT (Use TramadolHCl) GP MO

SUBSYS 100 MCG, 1200MCG, 1600 MCG, 600MCG

3PA

SUBSYS 200 MCG, 400MCG, 800 MCG 3 PA; MO

TRAMADOL HCL ER 3

tramadol hcl tabs 50 mg 1 QL(8 ea daily);MO

tramadol hcl tb24 100 mg,200 mg, 300 mg 1 MO

ULTRAM (Use TramadolHCl) GP QL(8 ea daily);

MOULTRAM ER (UseTramadol HCl) GP MO

ZOHYDRO ER 3 MO

Opioid Combinationsacetaminophen w/ codeine 1 MO

Drug Name DrugTier

Requirements/Limits

ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINEBITARTRATE

3

ASPIRIN-CAFFEINE-DIHYDROCODEINE 3 MO

butalbital-acetaminophen-caffeine w/ codeine 1 MO

butalbital-aspirin-caffeinew/cod 1 MO

CAPITAL/CODEINE 3 MO

COCET 3

COCET PLUS 3

FIORICET/CODEINE (UseButalbital-Acetaminophen-Caffeine w/ Codeine)

GPMO

FIORINAL/CODEINE #3(Use Butalbital-Aspirin-Caffeine w/Cod)

GPMO

HYCET (UseHydrocodone-Acetaminophen)

GPMO

HYDROCODONEBITARTRATE/ACETAMINOPHEN 10MG-750MG

2MO

HYDROCODONEBITARTRATE/ACETAMINOPHEN 2.5MG-325MG

3

hydrocodone-acetaminophen 1 MO

hydrocodone-ibuprofen 1 MO

HYDROCODONE/ACETAMINOPHEN 2 MO

ibudone 1 MO

LIQUICET 3

LORCET 10/650 (UseHydrocodone-Acetaminophen)

GPMO

LORCET PLUS (UseHydrocodone-Acetaminophen)

GPMO

LORTAB ELIX10MG/15ML-300MG/15ML 3 MO


Drug Name DrugTier

Requirements/Limits

LORTAB ELIX7.5MG/15ML-500MG/15ML(Use Hydrocodone-Acetaminophen)

GP

MO

LORTAB TABS 10MG-500MG, 5MG-500MG,7.5MG-500MG (UseHydrocodone-Acetaminophen)

GP

MO

MAGNACET 10MG-400MG, 5MG-400MG 3 MO

MAGNACET 7.5MG-400MG 3

MAXIDONE (UseHydrocodone-Acetaminophen)

GPMO

NORCO (UseHydrocodone-Acetaminophen)

GPMO

oxycodone w/acetaminophen 1 MO

oxycodone-ibuprofen 1 QL(4 ea daily);MO

pentazocine-acetaminophen 1 MO

PERCOCET (UseOxycodone w/Acetaminophen)

GPMO

PRIMLEV 3 MO

REPREXAIN 200MG-2.5MG (Use Hydrocodone-Ibuprofen)

1MO

REPREXAIN 200MG-2.5MG, 200MG-5MG (UseHydrocodone-Ibuprofen)

GPMO

ROXICET 2 MO

SYNALGOS-DC 3 MO

tramadol-acetaminophen 1 MO

TREZIX 3 MO

TYLENOL/CODEINE #3(Use Acetaminophen w/Codeine)

GPMO

Drug Name DrugTier

Requirements/Limits

TYLENOL/CODEINE #4(Use Acetaminophen w/Codeine)

GPMO

TYLOX (Use Oxycodonew/ Acetaminophen) GP MO

ULTRACET (UseTramadol-Acetaminophen) GP MO

VICODIN (UseHydrocodone-Acetaminophen)

GPMO

VICODIN ES (UseHydrocodone-Acetaminophen)

GPMO

VICOPROFEN (UseHydrocodone-Ibuprofen) GP MO

XODOL (UseHydrocodone-Acetaminophen)

GPMO

XOLOX 3 MO

ZOLVIT 3 MO

ZYDONE 3 MO

Opioid Partial Agonistsbuprenorphine hcl subl sl 2mg 1 PA; QL(3 ea

daily); MObuprenorphine hcl subl sl 8mg 1 PA; QL(4 ea

daily); MObuprenorphine hcl-naloxone hcl dihydrate2mg-0.5mg

1PA; QL(3 eadaily); MO

buprenorphine hcl-naloxone hcl dihydrate8mg-2mg


butorphanol tartrate na 10mg/ml 1 QL(0.25 ml

daily); MO

BUTRANS 3 QL(0.15 eadaily); MO

pentazocine w/ naloxone 1 QL(12 ea perfill retail)

SUBOXONE FILM 12MG-3MG, 2MG-0.5MG, 4MG-1MG, 8MG-2MG

3PA; MO


8

Drug Name DrugTier

Requirements/Limits

SUBOXONE SUBL 2MG-0.5MG (Use BuprenorphineHCl-Naloxone HClDihydrate)

GP

PA; QL(3 eadaily); MO

SUBOXONE SUBL 8MG-2MG (Use BuprenorphineHCl-Naloxone HClDihydrate)

GP

PA; QL(4 eadaily); MO

ZUBSOLV 3 PA; MO

ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAnabolic SteroidsANADROL-50 3 MO

OXANDRIN (UseOxandrolone) GP MO

oxandrolone 1 MO

Androgens

ANDRODERM 3 QL(1 ea daily);MO

ANDROGEL 2 QL(10 gmdaily); MO

ANDROGEL PUMP 2 QL(10 gmdaily); MO

ANDROXY 2 MO

AXIRON 3 ST; QL(6 mldaily); MO

danazol 1 MO

FORTESTA 3 ST; QL(4 gmdaily); MO

METHITEST 2 MO

methyltestosterone 1 MO

STRIANT 3 QL(2 ea daily);MO

TESTIM 3 PA; QL(10 gmdaily); MO

TESTRED (UseMethyltestosterone) GP MO

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and Itching

Drug Name DrugTier

Requirements/Limits

Intrarectal SteroidsCORTENEMA (UseHydrocortisone(Intrarectal))

GPMO

CORTIFOAM 2 MO

hydrocortisone (intrarectal) 1 MO

Rectal CombinationsANALPRAM-HC CREA(Use HydrocortisoneAcetate w/ Pramoxine)

GPMO

ANALPRAM-HC LOTN 3 MO

hydrocortisone acetate w/pramoxine 1 MO

lidocaine-hydrocortisoneacetate (rectal) 1 MO

PROCORT 3 MO

PROCTOFOAM HC 2 MO

Z-PRAM (UseHydrocortisone Acetate w/Pramoxine)

GP

Rectal SteroidsANUSOL-HC (UseHydrocortisone (Rectal)) GP MO

ANUSOL-HC (UseHydrocortisone Acetate(Rectal))

GPMO

hydrocortisone (rectal) 1 MO

hydrocortisone acetate(rectal) 1 MO

PROCTOCORT (UseHydrocortisone Acetate(Rectal))

GPMO

Vasodilating AgentsRECTIV 3 MO

ANTHELMINTICS - Drugs to Treat WormInfectionsAnthelminticsALBENZA 3 MO


Drug Name DrugTier

Requirements/Limits

BILTRICIDE 2 MO

STROMECTOL 3 MO

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.CAYSTON 3

FLAGYL (UseMetronidazole) GP MO

FLAGYL ER 3 MO

metronidazole 1 MO

NEBUPENT 2 MO

PRIMSOL 3 MO

TINDAMAX (UseTinidazole) GP MO

tinidazole 1 MO

trimethoprim 1 MO

VANCOCIN HCL (UseVancomycin HCl) GP PA; MO

vancomycin hcl caps or125 mg, 250 mg 1 PA; MO

XIFAXAN 200 MG 3QL(9 ea per fillretail,9 ea perfill mail); MO

XIFAXAN 550 MG 3 PA; QL(2 eadaily); MO

Anti-infective Misc. - CombinationsBACTRIM (UseSulfamethoxazole-Trimethoprim)

GPMO

BACTRIM DS (UseSulfamethoxazole-Trimethoprim)

GPMO

erythromycin-sulfisoxazole 1 MO

sulfamethoxazole-trimethoprim 1 MO

Antiprotozoal Agents

Drug Name DrugTier

Requirements/Limits

ALINIA 3 MO

atovaquone 1 MO

MEPRON (UseAtovaquone) GP MO

KetolidesKETEK 300 MG 3

KETEK 400 MG 3 MO

Leprostaticsdapsone 1 MO

LincosamidesCLEOCIN CAPS OR 150MG, 300 MG, 75 MG (UseClindamycin HCl)

GPMO

CLEOCIN PEDIATRICGRANULES (UseClindamycin PalmitateHydrochloride)

GP

MO

clindamycin hcl 1 MO

clindamycin palmitatehydrochloride 1 MO

OxazolidinonesZYVOX SUSR OR 100MG/5ML 2 MO

ZYVOX TABS OR 600 MG 2

QL(20 ea per90 daysretail,20 ea per90 days mail);MO

ANTIANGINAL AGENTS - Drugs to Treat ChestPainAntianginals-OtherRANEXA 1000 MG 3 MO

RANEXA 500 MG 3 QL(4 ea daily);MO

NitratesDILATRATE SR 3 MO

IMDUR (Use IsosorbideMononitrate) GP MO


10

Drug Name DrugTier

Requirements/Limits

ISORDIL TITRADOSE 40MG 2 MO

ISORDIL TITRADOSE 5MG (Use IsosorbideDinitrate)

GPMO

isosorbide dinitrate subl sl2.5 mg 1

ISOSORBIDE DINITRATESUBL SL 5 MG (UseIsosorbide Dinitrate)

GP

isosorbide dinitrate tabs or10 mg, 20 mg, 30 mg, 5 mg 1 MO

ISOSORBIDE DINITRATETABS OR 30 MG 2 MO

isosorbide dinitrate tbcr or40 mg 1 MO

isosorbide mononitrate 1 MO

MONOKET (UseIsosorbide Mononitrate) GP MO

NITRO-BID 2 MO

NITRO-DUR 0.1 MG/HR,0.2 MG/HR, 0.4 MG/HR,0.6 MG/HR (UseNitroglycerin)

GP

QL(1 ea daily);MO

NITRO-DUR 0.3 MG/HR,0.8 MG/HR 2 QL(1 ea daily);

MOnitroglycerin cpcr or 2.5mg, 9 mg 1 MO

NITROGLYCERINLINGUAL 3 MO

nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

1QL(1 ea daily);MO

nitroglycerin soln tl 0.4mg/spray 1 MO

NITROLINGUALPUMPSPRAY (UseNitroglycerin)

GPMO

NITROMIST 3 MO

NITROSTAT 2 MO

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

Drug Name DrugTier

Requirements/Limits

buspirone hcl 1 MO

hydroxyzine hcl 1 MO

HYDROXYZINEPAMOATE 100 MG 2 MO

hydroxyzine pamoate 25mg, 50 mg 1 MO

meprobamate 1 MO

VISTARIL (UseHydroxyzine Pamoate) GP MO

Benzodiazepinesalprazolam 1 MO

ALPRAZOLAM INTENSOL 3 MO

ATIVAN TABS OR 0.5 MG,1 MG, 2 MG (UseLorazepam)

GPMO

chlordiazepoxide hcl 1 MO

clorazepate dipotassium 1 MO

DIAZEPAM INTENSOL 2 MO

diazepam soln or 1 mg/ml 1 MO

diazepam tabs or 10 mg, 2mg, 5 mg 1 MO

lorazepam conc or 2 mg/ml 1 MO

lorazepam intensol 1 MO

lorazepam tabs or 0.5 mg,1 mg, 2 mg 1 MO

NIRAVAM (UseAlprazolam) GP MO

oxazepam 1 MO

TRANXENE T (UseClorazepate Dipotassium) GP MO

VALIUM (Use Diazepam) GP MO

XANAX (Use Alprazolam) GP MO

XANAX XR (UseAlprazolam) GP MO


Drug Name DrugTier

Requirements/Limits

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-Adisopyramide phosphate 1 MO

NORPACE (UseDisopyramide Phosphate) GP MO

NORPACE CR 100 MG 2 MO

NORPACE CR 150 MG(Use DisopyramidePhosphate)

GPMO

quinidine gluconate tbcr or324 mg 1 MO

QUINIDINE SULFATE 200MG 2 MO

quinidine sulfate 200 mg,300 mg 1 MO

quinidine sulfate er 1 MO

Antiarrhythmics Type I-Bmexiletine hcl 1 MO

Antiarrhythmics Type I-Cflecainide acetate 1 MO

propafenone hcl cp12 225mg, 325 mg, 425 mg 1 MO

propafenone hcl tabs 150mg 1 QL(6 ea daily);

MOpropafenone hcl tabs 225mg, 300 mg 1 QL(3 ea daily);

MORYTHMOL 150 MG (UsePropafenone HCl) GP QL(6 ea daily);

MORYTHMOL 225 MG (UsePropafenone HCl) GP QL(3 ea daily);

MORYTHMOL SR (UsePropafenone HCl) GP MO

TAMBOCOR (UseFlecainide Acetate) GP MO

Antiarrhythmics Type IIIamiodarone hcl 1 MO

CORDARONE (UseAmiodarone HCl) GP MO

Drug Name DrugTier

Requirements/Limits

MULTAQ 2 MO

TIKOSYN 2

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory Agentscromolyn sodium 1 MO

Asthma and Bronchodilator Agent CombinationsBRONCOMAR-1 3

Bronchodilators - Anticholinergics

ATROVENT HFA 2 QL(0.86 gmdaily); MO

ipratropium bromide 1 MO

SPIRIVA HANDIHALER 2 QL(1 ea daily);MO

TUDORZA PRESSAIR 2 QL(0.04 eadaily); MO

Leukotriene ModulatorsACCOLATE (UseZafirlukast) GP MO

montelukast sodium 1 QL(1 ea daily);MO

SINGULAIR (UseMontelukast Sodium) GP QL(1 ea daily);

MO

zafirlukast 1 MO

ZYFLO 3 MO

ZYFLO CR 3 MO

Selective Phosphodiesterase 4 (PDE4) InhibitorsDALIRESP 3 MO

Steroid InhalantsAEROSPAN 3 MO

ALVESCO 3 QL(0.41 gmdaily); MO

ASMANEX 120 METEREDDOSES 2 QL(0.04 ea

daily); MO


12

Drug Name DrugTier

Requirements/Limits

ASMANEX 14 METEREDDOSES 2 QL(0.04 ea

daily); MOASMANEX 30 METEREDDOSES 2 QL(0.04 ea



daily); MObudesonide (inhalation)0.25 mg/2ml 1 QL(8 ml daily);

MObudesonide (inhalation) 0.5mg/2ml 1 QL(4 ml daily);

MOFLOVENT DISKUS 100MCG/BLIST 2 QL(20 ea

daily); MOFLOVENT DISKUS 250MCG/BLIST 2 QL(8 ea daily);

MOFLOVENT DISKUS 50MCG/BLIST 2 QL(40 ea

daily); MOFLOVENT HFA 110MCG/ACT, 220 MCG/ACT 2 QL(0.8 gm

daily); MOFLOVENT HFA 44MCG/ACT 2 QL(0.36 gm

daily); MOPULMICORT 0.25 MG/2ML(Use Budesonide(Inhalation))

GPQL(8 ml daily);MO

PULMICORT 0.5 MG/2ML(Use Budesonide(Inhalation))

GPQL(4 ml daily);MO

PULMICORT 1 MG/2ML 2 QL(2 ml daily);MO

PULMICORT FLEXHALER180 MCG/ACT 2 QL(0.07 ea

daily); MOPULMICORT FLEXHALER90 MCG/ACT 2 QL(0.27 ea

daily); MO

QVAR 40 MCG/ACT 2 QL(0.58 gmdaily); MO

QVAR 80 MCG/ACT 2 QL(0.29 gmdaily); MO

SympathomimeticsACCUNEB (Use AlbuterolSulfate) GP MO

ADVAIR DISKUS 2 QL(2 ea daily);MO

ADVAIR HFA 2 QL(0.4 gmdaily); MO

Drug Name DrugTier

Requirements/Limits

albuterol sulfate nebu in0.083 %, 0.5 %, 0.63mg/3ml, 1.25 mg/3ml

1MO

albuterol sulfate syrp or 2mg/5ml 1 MO

albuterol sulfate tabs or 2mg, 4 mg 1 MO

albuterol sulfate tb12 or 4mg, 8 mg 1 QL(2 ea daily);

MO

ANORO ELLIPTA 3 MO

ARCAPTA NEOHALER 3 QL(1 ea daily);MO

BREO ELLIPTA 2 QL(2 ea daily);MO

BROVANA 3 MO

COMBIVENT 3 MO

COMBIVENT RESPIMAT 3 MO

DULERA 2 QL(0.45 gmdaily); MO

DUONEB (UseIpratropium-Albuterol) GP MO

FORADIL AEROLIZER 3 MO

ipratropium-albuterol 1 MO

levalbuterol hcl 1 MO

MAXAIR AUTOHALER 2 QL(0.94 gmdaily); MO

metaproterenol sulfate syrp10 mg/5ml 1 MO

METAPROTERENOLSULFATE TABS 10 MG,20 MG

2MO

PERFOROMIST 3 MO

PROAIR HFA 3 QL(0.57 gmdaily); MO

PROVENTIL HFA 2 QL(0.45 gmdaily); MO

SEREVENT DISKUS 2 QL(2 ea daily);MO


Drug Name DrugTier

Requirements/Limits

SYMBICORT 3 MO

terbutaline sulfate tabs or2.5 mg, 5 mg 1 MO

VENTOLIN HFA 3 QL(1.2 gmdaily); MO

VENTOLIN HFA 3 QL(0.54 gmdaily); MO

VOSPIRE ER (UseAlbuterol Sulfate) GP QL(2 ea daily);

MOXOPENEX (UseLevalbuterol HCl) GP MO

XOPENEXCONCENTRATE (UseLevalbuterol HCl)

GPMO

XOPENEX HFA 2 QL(0.6 gmdaily); MO

XanthinesAMINOPHYLLINE TABSOR 100 MG, 200 MG (UseAminophylline)

GP

ELIXOPHYLLIN 3 MO

LUFYLLIN 3 MO

THEO-24 2 MO

theophylline soln 80mg/15ml 1

theophylline tb12 100 mg,200 mg, 300 mg, 450 mg 1 MO

theophylline tb24 400 mg,600 mg 1 MO

ANTICOAGULANTS - Blood Thinners

Coumarin AnticoagulantsCOUMADIN TABS OR 1MG, 10 MG, 2 MG, 2.5 MG,3 MG, 4 MG, 5 MG, 6 MG,7.5 MG (Use WarfarinSodium)

GP

MO

warfarin sodium 1 MO

Direct Factor Xa InhibitorsELIQUIS 3 MO

Drug Name DrugTier

Requirements/Limits

XARELTO 10 MG 2 QL(1 ea daily);MO

XARELTO 15 MG, 20 MG 2 MO

Heparins And Heparinoid-Like AgentsARIXTRA (UseFondaparinux Sodium) GP

enoxaparin sodium ij 300mg/3ml 3 QL(0.1 ml

daily)enoxaparin sodium sc 100mg/ml, 120 mg/0.8ml, 150mg/ml, 30 mg/0.3ml, 40mg/0.4ml, 60 mg/0.6ml, 80mg/0.8ml

3

fondaparinux sodium 3

FRAGMIN 10000 UNIT/ML,12500 UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML, 25000UNIT/ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML

3

FRAGMIN 2500UNIT/0.2ML 3 QL(4 ml per

365 days retail)LOVENOX IJ 300 MG/3ML(Use Enoxaparin Sodium) GP QL(0.1 ml

daily)LOVENOX SC 100 MG/ML,120 MG/0.8ML, 150MG/ML, 30 MG/0.3ML, 40MG/0.4ML, 60 MG/0.6ML,80 MG/0.8ML (UseEnoxaparin Sodium)

GP

Thrombin InhibitorsPRADAXA 2 MO

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor AntagonistsFYCOMPA 3 MO

Anticonvulsants - Benzodiazepinesclonazepam 1 MO

DIASTAT ACUDIAL 3 QL(0.14 eadaily); MO


14

Drug Name DrugTier

Requirements/Limits

DIASTAT PEDIATRIC 3 QL(0.14 eadaily); MO

DIAZEPAM GEL RE 10MG, 2.5 MG, 20 MG 3 QL(0.14 ea

daily); MOKLONOPIN (UseClonazepam) GP MO

ONFI 3 MO

Anticonvulsants - Misc.APTIOM 3 MO

BANZEL 2 MO

carbamazepine 1 MO

CARBATROL (UseCarbamazepine) GP MO

gabapentin 1 MO

KEPPRA SOLN OR 100MG/ML (UseLevetiracetam)

GPMO

KEPPRA TABS OR 1000MG, 250 MG, 500 MG, 750MG (Use Levetiracetam)

GPMO

KEPPRA XR (UseLevetiracetam) GP MO

LAMICTAL CHEW 2 MG 2

LAMICTAL CHEWABLEDISPERSIBLE (UseLamotrigine)

GPMO

LAMICTAL ODT 3 PA; MO

LAMICTAL TABS 100 MG,150 MG, 200 MG, 25 MG(Use Lamotrigine)

GPMO

LAMICTAL XR 100 MG,200 MG, 25 MG, 50 MG(Use Lamotrigine)

GPPA; QL(1 eadaily); MO

LAMICTAL XR 250 MG,300 MG (Use Lamotrigine) GP PA; MO

lamotrigine chew 25 mg, 5mg 1 MO

lamotrigine tabs 100 mg,150 mg, 200 mg, 25 mg 1 MO

Drug Name DrugTier

Requirements/Limits

lamotrigine tb24 100 mg,200 mg, 25 mg, 50 mg 1 PA; QL(1 ea

daily); MOlamotrigine tb24 250 mg,300 mg 1 PA; MO

levetiracetam soln or 100mg/ml, 500 mg/5ml 1 MO

levetiracetam tabs or 1000mg, 250 mg, 500 mg, 750mg

1MO

levetiracetam tb24 or 500mg, 750 mg 1 MO

LYRICA CAPS 100 MG,200 MG, 25 MG, 50 MG,75 MG


LYRICA CAPS 150 MG,225 MG, 300 MG 3 PA; QL(2 ea

daily); MO

LYRICA SOLN 20 MG/ML 3 PA; QL(30 mldaily); MO

MYSOLINE (UsePrimidone) GP MO

NEURONTIN (UseGabapentin) GP MO

oxcarbazepine 1 MO

OXTELLAR XR 3 ST; MO

POTIGA 200 MG, 300 MG,50 MG 3 MO

POTIGA 400 MG 3

primidone 1 MO

TEGRETOL (UseCarbamazepine) GP MO

TEGRETOL-XR 100 MG 2 MO

TEGRETOL-XR 200 MG,400 MG (UseCarbamazepine)

GPMO

TOPAMAX (UseTopiramate) GP MO

TOPAMAX SPRINKLE(Use Topiramate) GP MO

topiramate 1 MO

TRILEPTAL (UseOxcarbazepine) GP MO


Drug Name DrugTier

Requirements/Limits

TROKENDI XR 3 PA; MO

VIMPAT SOLN OR 10MG/ML 2 MO

VIMPAT TABS OR 100MG, 150 MG, 200 MG, 50MG

2MO

ZONEGRAN (UseZonisamide) GP MO

zonisamide 1 MO

Carbamatesfelbamate 1 MO

FELBATOL (UseFelbamate) GP MO

GABA ModulatorsGABITRIL 12 MG, 16 MG 3 MO

GABITRIL 2 MG, 4 MG(Use Tiagabine HCl) GP MO

SABRIL 2

tiagabine hcl 1 MO

HydantoinsDILANTIN CAPS 100 MG(Use Phenytoin SodiumExtended)

GPMO

DILANTIN CAPS 30 MG 2 MO

DILANTIN INFATABS(Use Phenytoin) GP MO

DILANTIN SUSP 125MG/5ML (Use Phenytoin) GP MO

PEGANONE 3 MO

PHENYTEK (UsePhenytoin SodiumExtended)

GPMO

phenytoin 1 MO

phenytoin sodium extended 1 MO

SuccinimidesCELONTIN 2 MO

Drug Name DrugTier

Requirements/Limits

ethosuximide 1 MO

ZARONTIN (UseEthosuximide) GP MO

Valproic AcidDEPAKENE (UseValproate Sodium) GP MO

DEPAKENE (Use ValproicAcid) GP MO

DEPAKOTE (UseDivalproex Sodium) GP MO

DEPAKOTE ER (UseDivalproex Sodium) GP MO

DEPAKOTE SPRINKLES(Use Divalproex Sodium) GP MO

divalproex sodium 1 MO

STAVZOR 3 MO

valproate sodium soln or250 mg/5ml 1 MO

valproate sodium syrp or250 mg/5ml 1 MO

valproic acid 1 MO

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics)mirtazapine tabs 15 mg, 30mg, 45 mg 1 MO

mirtazapine tabs 7.5 mg 1

mirtazapine tbdp 15 mg, 30mg, 45 mg 1 MO

REMERON (UseMirtazapine) GP MO

REMERON SOLTAB (UseMirtazapine) GP MO

Antidepressants - Misc.

APLENZIN 3 ST; QL(1 eadaily); MO

bupropion hcl tabs 100 mg,75 mg 1 MO

bupropion hcl tb12 100 mg,150 mg, 200 mg 1 MO


16

Drug Name DrugTier

Requirements/Limits

bupropion hcl tb24 150 mg,300 mg 1 QL(1 ea daily);

MO

FORFIVO XL 3 ST; QL(1 eadaily); MO

maprotiline hcl 1 MO

WELLBUTRIN (UseBupropion HCl) GP MO

WELLBUTRIN SR (UseBupropion HCl) GP MO

WELLBUTRIN XL (UseBupropion HCl) GP QL(1 ea daily);

MOModified Cyclics

BRINTELLIX 3 ST; QL(1 eadaily); MO

NEFAZODONE HCL 100MG, 150 MG, 200 MG, 50MG

3MO

nefazodone hcl 250 mg 1 MO

trazodone hcl 1 MO

VIIBRYD KIT 3 PA; MO

VIIBRYD TABS 10 MG, 20MG, 40 MG 3 ST; MO

Monoamine Oxidase Inhibitors (MAOIs)

EMSAM 3 QL(1 ea daily);MO

MARPLAN 3 MO

NARDIL (Use PhenelzineSulfate) GP MO

PARNATE (UseTranylcypromine Sulfate) GP MO

phenelzine sulfate 1 MO

tranylcypromine sulfate 1 MO

Selective Serotonin Reuptake Inhibitors (SSRIs)CELEXA 10 MG (UseCitalopram Hydrobromide) GP QL(4 ea daily);

MOCELEXA 20 MG (UseCitalopram Hydrobromide) GP QL(2 ea daily);

MOCELEXA 40 MG (UseCitalopram Hydrobromide) GP QL(1 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

citalopram hydrobromidesoln 10 mg/5ml 1 QL(20 ml

daily); MOcitalopram hydrobromidetabs 10 mg 1 QL(4 ea daily);

MOcitalopram hydrobromidetabs 20 mg 1 QL(2 ea daily);

MOcitalopram hydrobromidetabs 40 mg 1 QL(1 ea daily);

MO

escitalopram oxalate 1 MO

fluoxetine hcl caps 10 mg,20 mg, 40 mg 1 MO

fluoxetine hcl cpdr 90 mg 1 MO

fluoxetine hcl soln 20mg/5ml 1 MO

fluoxetine hcl tabs 10 mg,20 mg 1 MO

FLUOXETINE HCL TABS60 MG 3 ST; QL(1 ea

daily); MO

fluvoxamine maleate 1 MO

LEXAPRO (UseEscitalopram Oxalate) GP MO

LUVOX CR (UseFluvoxamine Maleate) GP MO

paroxetine hcl 1 MO

PAXIL (Use ParoxetineHCl) GP MO

PAXIL CR (Use ParoxetineHCl) GP MO

PEXEVA 3 MO

PROZAC (Use FluoxetineHCl) GP MO

PROZAC WEEKLY (UseFluoxetine HCl) GP MO

sertraline hcl 1 MO

ZOLOFT (Use SertralineHCl) GP MO

Serotonin-Norepinephrine Reuptake InhibitorsCYMBALTA 20 MG, 30MG, 60 MG (UseDuloxetine HCl)

GPQL(2 ea daily);MO


Drug Name DrugTier

Requirements/Limits

CYMBALTA 60 MG 2 QL(2 ea daily);MO

DESVENLAFAXINE ER 3 ST; QL(1 eadaily); MO

duloxetine hcl 1 QL(2 ea daily);MO

EFFEXOR XR 150 MG(Use Venlafaxine HCl) GP QL(2 ea daily);

MOEFFEXOR XR 37.5 MG, 75MG (Use Venlafaxine HCl) GP QL(1 ea daily);

MOFETZIMA 120 MG, 40 MG,80 MG 3 ST; QL(1 ea

daily); MO

FETZIMA 20 MG 3 ST; QL(2 eadaily); MO

KHEDEZLA 3 ST; QL(1 eadaily); MO

PRISTIQ 3 ST; MO

venlafaxine hcl cp24 150mg 1 QL(2 ea daily);

MOvenlafaxine hcl cp24 37.5mg, 75 mg 1 QL(1 ea daily);

MOVENLAFAXINE HCL ER150 MG, 37.5 MG, 75 MG(Use Venlafaxine HCl)

GPMO

VENLAFAXINE HCL ER225 MG 2 MO

venlafaxine hcl tabs 100mg, 25 mg, 37.5 mg, 50mg, 75 mg

1MO

venlafaxine hcl tb24 150mg, 37.5 mg, 75 mg 1 MO

Tricyclic Agentsamitriptyline hcl 1 MO

AMOXAPINE 2 MO

ANAFRANIL (UseClomipramine HCl) GP MO

clomipramine hcl 1 MO

desipramine hcl 1 MO

doxepin hcl caps 10 mg,100 mg, 150 mg, 25 mg, 50mg

1MO

Drug Name DrugTier

Requirements/Limits

DOXEPIN HCL CAPS 75MG (Use Doxepin HCl) GP MO

doxepin hcl conc 10 mg/ml 1 MO

imipramine hcl 1 MO

imipramine pamoate 1 MO

NORPRAMIN (UseDesipramine HCl) GP MO

nortriptyline hcl caps 10mg, 25 mg, 50 mg, 75 mg 1 MO

NORTRIPTYLINE HCLSOLN 10 MG/5ML (UseNortriptyline HCl)

GPMO

PAMELOR (UseNortriptyline HCl) GP MO

protriptyline hcl 1 MO

SURMONTIL 3 MO

TOFRANIL (UseImipramine HCl) GP MO

TOFRANIL-PM (UseImipramine Pamoate) GP MO

trimipramine maleate 1 MO

VIVACTIL (UseProtriptyline HCl) GP MO

ANTIDIABETICS - Drugs to Regulate Blood Sugar

Alpha-Glucosidase Inhibitorsacarbose 1 MO

GLYSET 3 MO

PRECOSE (UseAcarbose) GP MO

Antidiabetic CombinationsACTOPLUS MET (UsePioglitazone HCl-MetforminHCl)

GPMO

ACTOPLUS MET XR 3 MO

AVANDAMET 2


18

Drug Name DrugTier

Requirements/Limits

AVANDARYL 2

DUETACT (UsePioglitazone HCl-Glimepiride)

GPMO

glipizide-metformin hcl 1 MO

GLUCOVANCE (UseGlyburide-Metformin) GP MO

glyburide-metformin 1 MO

JANUMET 2 MO

JANUMET XR 2 MO

JENTADUETO 2 MO

JUVISYNC 100MG-10MG,100MG-20MG 2 MO

JUVISYNC 40MG-100MG 2 QL(1 ea daily);MO

JUVISYNC 40MG-50MG 2 QL(1 ea daily)

JUVISYNC 50MG-10MG,50MG-20MG 2

KAZANO 3 MO

KOMBIGLYZE XR 3 MO

OSENI 3 MO

pioglitazone hcl-glimepiride 1 MO

pioglitazone hcl-metforminhcl 1 MO

PRANDIMET 3 MO

BiguanidesFORTAMET (UseMetformin HCl) GP MO

GLUCOPHAGE (UseMetformin HCl) GP MO

GLUCOPHAGE XR (UseMetformin HCl) GP MO

GLUMETZA 3 MO

metformin hcl 1 MO

Drug Name DrugTier

Requirements/Limits

RIOMET 3 MO

Diabetic OtherGLUCAGEN 3

GLUCAGEN HYPOKIT 3

GLUCAGONEMERGENCY KIT 3 QL(0.04 ea

daily)

KORLYM 3 PA

PROGLYCEM 3 MO

Dipeptidyl Peptidase-4 (DPP-4) InhibitorsJANUVIA 2 MO

NESINA 3 MO

ONGLYZA 3 MO

TRADJENTA 2 MO

Dopamine Receptor Agonists - AntidiabeticCYCLOSET 3 MO

Incretin Mimetic Agents (GLP-1 ReceptorBYDUREON 3 PA

BYETTA 3 PA

VICTOZA 3 PA

Insulin Sensitizing AgentsACTOS (Use PioglitazoneHCl) GP MO

AVANDIA 2

pioglitazone hcl 1 MO

InsulinAPIDRA 3 MO

APIDRA SOLOSTAR 3 MO

HUMALOG 2 QL(1.5 mldaily); MO


Drug Name DrugTier

Requirements/Limits

HUMALOG MIX 50/50 2 QL(1.5 mldaily); MO

HUMALOG MIX 75/25 2 MO

HUMULIN 70/30 2 QL(1.5 mldaily); MO

HUMULIN 70/30 KWIKPEN 2QL(1.5 mldaily); RX/OTC;MO

HUMULIN 70/30 KWIKPEN 2 QL(1 ml daily);RX/OTC; MO

HUMULIN N 2 QL(1.5 mldaily); MO

HUMULIN N KWIKPEN 2 QL(1 ml daily);RX/OTC; MO

HUMULIN N KWIKPEN 2QL(1.5 mldaily); RX/OTC;MO

HUMULIN R 2 QL(1.5 mldaily); MO

HUMULIN R U-500(CONCENTRATED) 2 QL(1.5 ml

daily); MO

LANTUS 2 QL(1.5 mldaily); MO

LEVEMIR 2 QL(1.5 mldaily); MO

NOVOLIN 70/30 3 QL(1.5 mldaily); MO

NOVOLIN 70/30 RELION 3 QL(1.5 mldaily); MO

NOVOLIN N 3 QL(1.5 mldaily); MO

NOVOLIN N RELION 3 QL(1.5 mldaily); MO

NOVOLIN R 3 QL(1.5 mldaily); MO

NOVOLIN R RELION 3 QL(1.5 mldaily); MO

NOVOLOG 3 PA; QL(1.5 mldaily); MO

NOVOLOG MIX 70/30 3 MO

Meglitinide Analoguesnateglinide 1 MO

Drug Name DrugTier

Requirements/Limits

PRANDIN (UseRepaglinide) GP MO

repaglinide 1 MO

STARLIX (UseNateglinide) GP MO

Sodium-Glucose Co-Transporter 2 (SGLT2)FARXIGA 3 MO

INVOKANA 2 MO

SulfonylureasAMARYL (UseGlimepiride) GP MO

CHLORPROPAMIDE (UseChlorpropamide) GP MO

DIABETA 2 MO

glimepiride 1 MO

glipizide 1 MO

GLUCOTROL (UseGlipizide) GP MO

GLUCOTROL XL (UseGlipizide) GP MO

glyburide 1.25 mg, 2.5 mg,5 mg 1 MO

GLYBURIDE 1.25 MG, 2.5MG, 5 MG 2 MO

glyburide micronized 1 MO

GLYNASE (Use GlyburideMicronized) GP MO

tolazamide 1 MO

tolbutamide 1 MO

ANTIDIARRHEALS - Drugs to Treat Diarrhea

Antidiarrheal - Chloride Channel Antagonists

FULYZAQ 3 PA; QL(2 eadaily); MO

Antidiarrheal Agents - Misc.REZYST SB 3 MO


20

Drug Name DrugTier

Requirements/Limits

Antiperistaltic Agentsdiphenoxylate w/ atropine 1 MO

diphenoxylate/atropine 1 MO

LOMOTIL (UseDiphenoxylate w/ Atropine) GP MO

loperamide hcl caps 1 RX/OTC; MO

MOTOFEN 2 MO

OPIUM TINCTURE(PAREGORIC) 3 MO

ANTIDOTES - Drugs to Treat Overdose orToxicityAntidotes - Chelating AgentsCHEMET 3 MO

EXJADE 3

FERRIPROX 3

AntidotesRADIOGARDASE 3 MO

Opioid Antagonistsnaltrexone hcl 1 MO

REVIA (Use NaltrexoneHCl) GP MO

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor AntagonistsANZEMET TABS OR 100MG, 50 MG 3 PA; QL(0.07 ea

daily); MOgranisetron hcl tabs or 1mg 1 QL(6 ea per fill

retail)

GRANISOL 3 PA; MO

ondansetron 1 QL(20 ea perfill retail)

ondansetron hcl soln or 4mg/5ml 1 QL(100 ml per

fill retail); MOondansetron hcl tabs or 4mg, 8 mg 1 QL(20 ea per

fill retail)

Drug Name DrugTier

Requirements/Limits

SANCUSO 3 QL(1 ea per fillretail); MO

ZOFRAN ODT (UseOndansetron) GP QL(20 ea per

fill retail)ZOFRAN SOLN 4 MG/5ML(Use Ondansetron HCl) GP QL(100 ml per

fill retail); MOZOFRAN TABS 4 MG, 8MG (Use OndansetronHCl)

GPQL(20 ea perfill retail)

ZUPLENZ 3 QL(20 ea perfill retail)

Antiemetics - AnticholinergicANTIVERT 50 MG 3

TIGAN (UseTrimethobenzamide HCl) GP MO

TRANSDERM-SCOP 3 MO

trimethobenzamide hcl 1 MO

Antiemetics - Miscellaneous

CESAMET 3 PA; QL(2 eadaily); MO

DICLEGIS 3 QL(4 ea daily)

dronabinol 1 PA; MO

MARINOL (UseDronabinol) GP PA; MO

Substance P/Neurokinin 1 (NK1) Receptor

EMEND 3 QL(0.1 eadaily); MO

EMEND 125 MG, 80 MG 3 QL(0.04 eadaily); MO

EMEND 40 MG 3 QL(0.07 eadaily); MO

ANTIFUNGALS - Drugs to Treat Fungal Infections

AntifungalsANCOBON 250 MG (UseFlucytosine) GP

ANCOBON 500 MG (UseFlucytosine) GP MO

BIO-STATIN 1000000UNIT 3 MO


Drug Name DrugTier

Requirements/Limits

BIO-STATIN 500000 UNIT 3

flucytosine 250 mg 1

flucytosine 500 mg 1 MO

GRIFULVIN V (UseGriseofulvin Microsize) GP MO

GRIS-PEG (UseGriseofulvin Ultramicrosize) GP MO

griseofulvin microsize 1 MO

griseofulvin ultramicrosize 1 MO

LAMISIL PACK 125 MG,187.5 MG 3 PA; MO

LAMISIL TABS 250 MG(Use Terbinafine HCl) GP PA; MO

nystatin 1 MO

terbinafine hcl 1 PA; MO

Imidazole-Related AntifungalsDIFLUCAN (UseFluconazole) GP MO

fluconazole 1 MO

itraconazole 1 PA; MO

ketoconazole 1 MO

NOXAFIL SUSP 40 MG/ML 3 MO

NOXAFIL TBEC 100 MG 3

SPORANOX CAPS 100MG (Use Itraconazole) GP PA; MO

SPORANOX PULSEPAK(Use Itraconazole) GP PA; MO

SPORANOX SOLN 10MG/ML 2 PA; MO

VFEND (UseVoriconazole) GP MO

voriconazole susr or 40mg/ml 1 MO

voriconazole tabs or 200mg, 50 mg 1 MO

Drug Name DrugTier

Requirements/Limits

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - AlkylaminesAHIST 3

BROMPHENIRAMINETANNATE 3

DEXCHLORPHENIRAMINE MALEATE 2

ED CHLORPED 3

ED-CHLOR-TAN 3

RESPA-BR 3

Antihistamines - Ethanolaminescarbinoxamine maleate 1 MO

clemastine fumarate 1 MO

DOXYTEX 3

KARBINAL ER 3 MO

PALGIC (UseCarbinoxamine Maleate) GP MO

Antihistamines - Non-SedatingCLARINEX REDITABS(Use Desloratadine) GP MO

CLARINEX SYRP 0.5MG/ML 3 MO

CLARINEX TABS 5 MG(Use Desloratadine) GP QL(1 ea daily);

MO

desloratadine tabs 5 mg 1 QL(1 ea daily);MO

desloratadine tbdp 2.5 mg,5 mg 1 MO

levocetirizinedihydrochloride soln or 2.5mg/5ml

1MO

levocetirizinedihydrochloride tabs or 5mg

1QL(1 ea daily);MO

XYZAL SOLN 2.5 MG/5ML(Use LevocetirizineDihydrochloride)

GPMO


22

Drug Name DrugTier

Requirements/Limits

XYZAL TABS 5 MG (UseLevocetirizineDihydrochloride)

GPQL(1 ea daily);MO

Antihistamines - Phenothiazinespromethazine hcl soln or6.25 mg/5ml 1 MO

promethazine hcl supp re12.5 mg, 25 mg 1 MO

promethazine hcl syrp or6.25 mg/5ml 1 MO

promethazine hcl tabs or12.5 mg, 25 mg, 50 mg 1 MO

PROMETHEGAN (UsePromethazine HCl) GP MO

Antihistamines - Piperidinescyproheptadine hcl 1 MO

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolAntihyperlipidemics - Combinations

LIPTRUZET 2 QL(1 ea daily);MO

VYTORIN 10MG-10MG 2 ST; QL(1 eadaily); MO

VYTORIN 10MG-20MG,40MG-10MG, 80MG-10MG 2 QL(1 ea daily);

MOAntihyperlipidemics - Misc.KYNAMRO 3 PA

LOVAZA 3 MO

VASCEPA 3 MO

Bile Acid Sequestrantscholestyramine 1 MO

cholestyramine light 1 MO

COLESTID (UseColestipol HCl) GP MO

COLESTID FLAVORED(Use Colestipol HCl) GP MO

colestipol hcl 1 MO

Drug Name DrugTier

Requirements/Limits

QUESTRAN (UseCholestyramine) GP MO

QUESTRAN LIGHT (UseCholestyramine Light) GP MO

WELCHOL 3 MO

Fibric Acid DerivativesANTARA 130 MG, 43 MG(Use FenofibrateMicronized)

GPMO

ANTARA 30 MG, 90 MG 3

choline fenofibrate 1 MO

fenofibrate 1 MO

fenofibrate micronized 1 MO

FENOFIBRIC ACID 3 MO

FENOGLIDE 3 MO

FIBRICOR 3 MO

gemfibrozil 1 MO

LIPOFEN 3 MO

LOFIBRA (Use FenofibrateMicronized) GP MO

LOFIBRA (UseFenofibrate) GP MO

LOPID (Use Gemfibrozil) GP MO

TRICOR (Use Fenofibrate) GP MO

TRIGLIDE 160 MG (UseFenofibrate) GP MO

TRIGLIDE 50 MG 3

TRILIPIX (Use CholineFenofibrate) GP MO

HMG CoA Reductase InhibitorsADVICOR 20MG-1000MG,20MG-500MG, 20MG-750MG

2MO


Drug Name DrugTier

Requirements/Limits

ADVICOR 40MG-1000MG 2 QL(1 ea daily);MO

ALTOPREV 3 MO

atorvastatin calcium 1 QL(1 ea daily);MO

CRESTOR 10 MG, 20 MG,40 MG 3 QL(1 ea daily);

MO

CRESTOR 5 MG 3 ST; QL(1 eadaily); MO

fluvastatin sodium 1 QL(1 ea daily);MO

LESCOL (Use FluvastatinSodium) GP QL(1 ea daily);

MO

LESCOL XL 3 QL(1 ea daily);MO

LIPITOR (Use AtorvastatinCalcium) GP QL(1 ea daily);

MO

LIVALO 3 ST; QL(1 eadaily); MO

lovastatin 1 MO

MEVACOR (UseLovastatin) GP MO

PRAVACHOL 20 MG, 80MG (Use PravastatinSodium)

GPQL(1 ea daily);MO

PRAVACHOL 40 MG (UsePravastatin Sodium) GP QL(2 ea daily);

MOpravastatin sodium 10 mg,20 mg, 80 mg 1 QL(1 ea daily);

MO

pravastatin sodium 40 mg 1 QL(2 ea daily);MO

SIMCOR 2 MO

simvastatin 1 QL(1 ea daily);MO

ZOCOR (Use Simvastatin) GP QL(1 ea daily);MO

Intestinal Cholesterol Absorption InhibitorsZETIA 2 MO

Microsomal Triglyceride Transfer Protein (MTP)JUXTAPID 3 PA

Nicotinic Acid Derivatives

Drug Name DrugTier

Requirements/Limits

niacin (antihyperlipidemic) 1 MO

NIASPAN (Use Niacin(Antihyperlipidemic)) GP MO

ANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE InhibitorsACCUPRIL (Use QuinaprilHCl) GP MO

ACEON (Use PerindoprilErbumine) GP MO

ALTACE 1.25 MG, 2.5 MG,5 MG (Use Ramipril) GP QL(1 ea daily);

MOALTACE 10 MG (UseRamipril) GP QL(2 ea daily);

MO

benazepril hcl 1 MO

captopril 1 MO

enalapril maleate 1 QL(2 ea daily);MO

EPANED 3 QL(5 ml daily);MO

fosinopril sodium 1 MO

lisinopril 1 MO

LOTENSIN (UseBenazepril HCl) GP MO

MAVIK (Use Trandolapril) GP MO

moexipril hcl 1 MO

perindopril erbumine 1 MO

PRINIVIL (Use Lisinopril) GP MO

quinapril hcl 1 MO

ramipril 1.25 mg, 2.5 mg, 5mg 1 QL(1 ea daily);

MO

ramipril 10 mg 1 QL(2 ea daily);MO

trandolapril 1 MO

UNIVASC (Use MoexiprilHCl) GP MO


24

Drug Name DrugTier

Requirements/Limits

VASOTEC (Use EnalaprilMaleate) GP QL(2 ea daily);

MO

ZESTRIL (Use Lisinopril) GP MO

Agents for PheochromocytomaDEMSER 3 MO

DIBENZYLINE 2 MO

Angiotensin II Receptor AntagonistsATACAND (UseCandesartan Cilexetil) GP MO

AVAPRO (Use Irbesartan) GP MO

BENICAR 2 MO

candesartan cilexetil 1 MO

COZAAR (Use LosartanPotassium) GP MO

DIOVAN 2 MO

EDARBI 3 MO

eprosartan mesylate 1 MO

irbesartan 1 MO

losartan potassium 1 MO

MICARDIS (UseTelmisartan) GP MO

telmisartan 1 MO

TEVETEN 400 MG 3 MO

TEVETEN 600 MG (UseEprosartan Mesylate) GP MO

Antiadrenergic AntihypertensivesCARDURA (UseDoxazosin Mesylate) GP MO

CATAPRES (UseClonidine HCl) GP MO

CATAPRES-TTS-1 (UseClonidine HCl) GP MO


Drug Name DrugTier

Requirements/Limits


clonidine hcl 1 MO

doxazosin mesylate 1 MO

guanfacine hcl 1 MO

methyldopa 1 MO

MINIPRESS (UsePrazosin HCl) GP MO

NEXICLON XR 3 ST

prazosin hcl 1 MO

reserpine 0.1 mg 1 MO

RESERPINE 0.25 MG 2 MO

TENEX (Use GuanfacineHCl) GP MO

terazosin hcl 1 MO

Antihypertensive CombinationsACCURETIC (UseQuinapril-Hydrochlorothiazide)

GPMO

amlodipine besylate-benazepril hcl 1 MO

AMTURNIDE 2 MO

ATACAND HCT (UseCandesartan Cilexetil-Hydrochlorothiazide)

GPST; MO

atenolol & chlorthalidone 1 MO

AVALIDE (Use Irbesartan-Hydrochlorothiazide) GP MO

AZOR 2 ST; MO

benazepril &hydrochlorothiazide 1 MO

BENICAR HCT 2 MO

bisoprolol &hydrochlorothiazide 1 MO


Drug Name DrugTier

Requirements/Limits

candesartan cilexetil-hydrochlorothiazide 1 ST; MO

captopril/hydrochlorothiazide 25mg-15mg, 50mg-15mg 1 MO

CAPTOPRIL/HYDROCHLOROTHIAZIDE 25MG-25MG, 50MG-25MG (UseCaptopril &Hydrochlorothiazide)

GP

MO

CLORPRES 3 MO

CORZIDE (Use Nadolol &Bendroflumethiazide) GP MO

DIOVAN HCT (UseValsartan-Hydrochlorothiazide)

GPMO

DUTOPROL 3 MO

EDARBYCLOR 3 MO

enalapril maleate &hydrochlorothiazide 1 MO

EXFORGE 2 ST; MO

EXFORGE HCT 2 ST; MO

fosinopril sodium &hydrochlorothiazide 1 MO

HYZAAR (Use LosartanPotassium &Hydrochlorothiazide)

GPMO

irbesartan-hydrochlorothiazide 1 MO

lisinopril &hydrochlorothiazide 1 MO

LOPRESSOR HCT (UseMetoprolol &Hydrochlorothiazide)

GPMO

losartan potassium &hydrochlorothiazide 1 MO

LOTENSIN HCT (UseBenazepril &Hydrochlorothiazide)

GPMO

LOTREL (Use AmlodipineBesylate-Benazepril HCl) GP MO

Drug Name DrugTier

Requirements/Limits

METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-15MG

2MO

methyldopa/hydrochlorothiazide 250mg-25mg 1 MO

metoprolol &hydrochlorothiazide 1 MO

metoprolol/hydrochlorothiazide 1 MO

MICARDIS HCT (UseTelmisartan-Hydrochlorothiazide)

GPST; MO

moexipril-hydrochlorothiazide 1 MO

nadolol &bendroflumethiazide 1 MO

PRINZIDE (Use Lisinopril& Hydrochlorothiazide) GP MO

propranolol/hydrochlorothiazide 1 MO

quinapril-hydrochlorothiazide 1 MO

TARKA 3 MO

TEKAMLO 2 ST; MO

TEKTURNA HCT 2 ST; MO

telmisartan-amlodipine 1 MO

telmisartan-hydrochlorothiazide 1 ST; MO

TENORETIC 100 (UseAtenolol & Chlorthalidone) GP MO

TENORETIC 50 (UseAtenolol & Chlorthalidone) GP MO

TEVETEN HCT 3 MO

TRIBENZOR 2 ST; MO

TWYNSTA (UseTelmisartan-Amlodipine) GP MO

UNIRETIC (Use Moexipril-Hydrochlorothiazide) GP MO

valsartan-hydrochlorothiazide 1 MO


26

Drug Name DrugTier

Requirements/Limits

VASERETIC (UseEnalapril Maleate &Hydrochlorothiazide)

GPMO

ZESTORETIC (UseLisinopril &Hydrochlorothiazide)

GPMO

ZIAC (Use Bisoprolol &Hydrochlorothiazide) GP MO

Antihypertensives - Misc.VECAMYL 3

Direct Renin InhibitorsTEKTURNA 2 ST; MO

Selective Aldosterone Receptor Antagonistseplerenone 1 MO

INSPRA (Use Eplerenone) GP MO

Vasodilatorshydralazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg 1 MO

minoxidil 1 MO

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)Antimalarial Combinationsatovaquone-proguanil hcl 1 MO

ATOVAQUONE/PROGUANIL HCL 3 MO

COARTEM 2 QL(0.8 eadaily); MO

MALARONE 250MG-100MG (Use Atovaquone-Proguanil HCl)

GPMO

MALARONE 62.5MG-25MG 3 MO

AntimalarialsARALEN (UseChloroquine Phosphate) GP MO

chloroquine phosphate 1 MO

DARAPRIM 3 MO

Drug Name DrugTier

Requirements/Limits

hydroxychloroquine sulfate 1 MO

mefloquine hcl 1QL(6 ea per fillretail,6 ea perfill mail); MO

PLAQUENIL (UseHydroxychloroquineSulfate)

GPMO

PRIMAQUINEPHOSPHATE 2 MO

QUALAQUIN (Use QuinineSulfate) GP PA; QL(2 ea

daily); MO

quinine sulfate 1 PA; QL(2 eadaily); MO

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic AgentsGUANIDINE HCL 2

MESTINON SYRP 60MG/5ML 2 MO

MESTINON TABS 60 MG(Use PyridostigmineBromide)

GPMO

MESTINON TIMESPAN 2 MO

MYTELASE 2

pyridostigmine bromide 1 MO

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Anti TB Combinationsisoniazid & rifampin 1 MO

RIFAMATE 2 MO

RIFATER 3 MO

Antimycobacterial AgentsCYCLOSERINE 3 MO

ethambutol hcl 1 MO

isoniazid syrp or 50 mg/5ml 1 MO


Drug Name DrugTier

Requirements/Limits

isoniazid tabs or 100 mg,300 mg 1 MO

MYAMBUTOL (UseEthambutol HCl) GP MO

MYCOBUTIN 2 MO

PASER 3 MO

PRIFTIN 3 MO

pyrazinamide 1 MO

RIFADIN CAPS OR 150MG, 300 MG (UseRifampin)

GPMO

rifampin caps or 150 mg,300 mg 1 MO

SEROMYCIN 3 MO

SIRTURO 3

TRECATOR 2 MO

ANTINEOPLASTICS AND ADJUNCTIVETHERAPIES - Drugs to Treat CancerAlkylating AgentsALKERAN TABS OR 2 MG AC

CEENU (Use Lomustine) AC

CYCLOPHOSPHAMIDETABS OR 25 MG, 50 MG AC

HEXALEN AC

LEUKERAN AC

LOMUSTINE AC

MYLERAN AC

TEMODAR (UseTemozolomide) AC

temozolomide AC

Antimetabolitescapecitabine AC

Drug Name DrugTier

Requirements/Limits

mercaptopurine AC

methotrexate sodium soln ij1 gm/40ml, 100 mg/4ml,200 mg/8ml, 25 mg/ml, 250mg/10ml, 50 mg/2ml

3

PA

methotrexate sodium tabsor 2.5 mg 1 MO

PURINETHOL (UseMercaptopurine) AC

TABLOID AC

TREXALL 3 MO

XELODA (UseCapecitabine) AC

Antineoplastic - Hedgehog Pathway InhibitorsERIVEDGE AC

Antineoplastic - Hormonal and Related Agentsanastrozole AC

ARIMIDEX (UseAnastrozole) AC

AROMASIN (UseExemestane) AC

bicalutamide AC

CASODEX (UseBicalutamide) AC

EMCYT AC

exemestane AC

FARESTON AC

FEMARA (Use Letrozole) AC

flutamide AC

letrozole AC

LYSODREN AC

MEGACE ORAL (UseMegestrol Acetate) AC

megestrol acetate AC


28

Drug Name DrugTier

Requirements/Limits

NILANDRON AC

SOLTAMOX AC

tamoxifen citrate AC

XTANDI AC PA

ZYTIGA AC PA

Antineoplastic - ImmunomodulatorsPOMALYST AC

Antineoplastic Enzyme Inhibitors

AFINITOR AC PA; QL(1 eadaily)

AFINITOR DISPERZ AC PA

BOSULIF AC PA

CAPRELSA AC

COMETRIQ AC

GILOTRIF AC PA

GLEEVEC AC

ICLUSIG AC PA

IMBRUVICA AC PA

INLYTA AC PA

JAKAFI AC

MEKINIST AC

NEXAVAR AC

SPRYCEL AC

STIVARGA AC PA

SUTENT AC

TAFINLAR AC PA

Drug Name DrugTier

Requirements/Limits

TARCEVA AC PA

TASIGNA AC PA

TYKERB AC

VANDETANIB AC

VOTRIENT AC

XALKORI AC PA

ZELBORAF AC PA

ZOLINZA AC PA

Antineoplastics Misc.ALFERON N 3 PA

HYDREA (UseHydroxyurea) AC

hydroxyurea AC

INTRON-A 3 PA

INTRON-A W/DILUENT 3 PA

MATULANE AC

TARGRETIN CAPS OR 75MG AC

tretinoin (chemotherapy) AC

Chemotherapy Rescue/Antidote Agentsleucovorin calcium tabs or10 mg, 25 mg, 5 mg AC

LEUCOVORIN CALCIUMTABS OR 15 MG AC

MESNEX TABS OR 400MG AC

Mitotic InhibitorsETOPOSIDE AC

Topoisomerase I InhibitorsHYCAMTIN CAPS OR 0.25MG, 1 MG AC PA


Drug Name DrugTier

Requirements/Limits

ANTIPARKINSON AGENTS - Drugs to TreatParkinson's DiseaseAntiparkinson Adjuvantscarbidopa 1 MO

LODOSYN (UseCarbidopa) GP MO

Antiparkinson Anticholinergicsbenztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg 1 MO

trihexyphenidyl hcl 1 MO

Antiparkinson COMT InhibitorsCOMTAN (UseEntacapone) GP MO

entacapone 1 MO

TASMAR 3 MO

Antiparkinson Dopaminergicsamantadine hcl caps 100mg 1 MO

amantadine hcl syrp 50mg/5ml 1 MO

AMANTADINE HCL TABS100 MG 3 MO

APOKYN 3 PA

bromocriptine mesylate 1 MO

carbidopa-levodopa 1 MO

CARBIDOPA/LEVODOPA/ENTACAPONE 2 MO

MIRAPEX (UsePramipexoleDihydrochloride)

GPMO

MIRAPEX ER 3 MO

NEUPRO 1 MG/24HR, 3MG/24HR, 8 MG/24HR 3 MO

NEUPRO 2 MG/24HR 3 QL(3 ea daily);MO

NEUPRO 4 MG/24HR, 6MG/24HR 3 QL(1 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

PARCOPA (UseCarbidopa-Levodopa) GP MO

PARLODEL (UseBromocriptine Mesylate) GP MO

pramipexoledihydrochloride 1 MO

REQUIP (Use RopiniroleHydrochloride) GP MO

REQUIP XL (UseRopinirole Hydrochloride) GP MO

ropinirole hydrochloride 1 MO

SINEMET (UseCarbidopa-Levodopa) GP MO

SINEMET CR (UseCarbidopa-Levodopa) GP MO

STALEVO 100 2 MO

STALEVO 125 2 MO

STALEVO 150 2 MO

STALEVO 200 2 MO

STALEVO 50 2 MO

STALEVO 75 2 MO

Antiparkinson Monoamine Oxidase InhibitorsAZILECT 2 MO

ELDEPRYL (UseSelegiline HCl) GP MO

selegiline hcl 1 MO

ZELAPAR 3 MO

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agentslithium carbonate 1 MO

LITHIUM CITRATE (UseLithium Citrate) GP MO

LITHOBID (Use LithiumCarbonate) GP MO


30

Drug Name DrugTier

Requirements/Limits

Antipsychotics - Misc.EQUETRO 3 MO

GEODON (UseZiprasidone HCl) GP MO

LATUDA 3 MO

ziprasidone hcl 1 MO

BenzisoxazolesFANAPT 3 PA; MO

INVEGA 3 MO

RISPERDAL (UseRisperidone) GP MO

RISPERDAL M-TAB (UseRisperidone) GP MO

risperidone 1 MO

Butyrophenoneshaloperidol 1 MO

haloperidol lactate conc or2 mg/ml 1 MO

Dibenzapinesclozapine 1

CLOZAPINE ODT 3

CLOZARIL (UseClozapine) GP

FAZACLO 3

loxapine succinate 1 MO

LOXITANE (Use LoxapineSuccinate) GP MO

olanzapine 1 MO

quetiapine fumarate 1 MO

SAPHRIS 2 MO

SEROQUEL (UseQuetiapine Fumarate) GP MO

Drug Name DrugTier

Requirements/Limits

SEROQUEL XR 3 MO

VERSACLOZ 3 MO

ZYPREXA (UseOlanzapine) GP MO

ZYPREXA ZYDIS (UseOlanzapine) GP MO

Phenothiazineschlorpromazine hcl tabs or10 mg, 100 mg, 200 mg, 25mg, 50 mg

1MO

COMPAZINE (UseProchlorperazine Maleate) GP MO

FLUPHENAZINE HCLCONC OR 5 MG/ML 2 MO

FLUPHENAZINE HCLELIX OR 2.5 MG/5ML 2 MO

fluphenazine hcl tabs or 1mg, 10 mg, 2.5 mg, 5 mg 1 MO

perphenazine 1 MO

prochlorperazine 1 MO

prochlorperazine maleate 1 MO

thioridazine hcl 1 MO

trifluoperazine hcl 1 MO

Quinolinone DerivativesABILIFY 2 MO

ABILIFY DISCMELT 3 PA; MO

Thioxanthenesthiothixene 1 MO

ANTISEPTICS & DISINFECTANTS - Drugs toPrevent Bacterial Skin InfectionsAntiseptics & Disinfectantsformaldehyde 1 MO

Chlorine AntisepticsPHISOHEX 3


Drug Name DrugTier

Requirements/Limits

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretroviralsabacavir sulfate 1 MO

abacavir sulfate-lamivudine-zidovudine 1 MO

APTIVUS CAPS 250 MG 2 MO

APTIVUS SOLN 100MG/ML 2

ATRIPLA 2 MO

COMBIVIR (UseLamivudine-Zidovudine) GP MO

COMPLERA 2 MO

CRIXIVAN 2 MO

didanosine 1 MO

EDURANT 2 MO

EMTRIVA 2 MO

EPIVIR HBV SOLN 5MG/ML 3 MO

EPIVIR HBV TABS 100MG (Use Lamivudine) GP MO

EPIVIR SOLN 10 MG/ML 2 MO

EPIVIR TABS 150 MG, 300MG (Use Lamivudine) GP MO

EPZICOM 2 MO

FUZEON 3 PA

INTELENCE 100 MG, 200MG 2 MO

INTELENCE 25 MG 2

INVIRASE 2 MO

ISENTRESS CHEW 100MG 2 PA; MO

ISENTRESS CHEW 25 MG 2 MO

Drug Name DrugTier

Requirements/Limits

ISENTRESS TABS 400MG 2 MO

KALETRA 2 MO

lamivudine 1 MO

lamivudine-zidovudine 1 MO

LEXIVA 2 MO

NEVIRAPINE SUSP 50MG/5ML 2 MO

nevirapine tabs 200 mg 1 MO

NORVIR 2 MO

PREZISTA SUSP 100MG/ML 2 MO

PREZISTA TABS 150 MG,600 MG, 800 MG 2 MO

PREZISTA TABS 400 MG,75 MG 2

RESCRIPTOR 2 MO

RETROVIR (UseZidovudine) GP MO

REYATAZ 100 MG 2

REYATAZ 150 MG, 200MG, 300 MG 2 MO

SELZENTRY 2 MO

stavudine 1 MO

STRIBILD 2 MO

SUSTIVA 2 MO

TIVICAY 2 MO

TRIZIVIR (Use AbacavirSulfate-Lamivudine-Zidovudine)

GPMO

TRUVADA 2 MO

VIDEX EC (UseDidanosine) GP MO


32

Drug Name DrugTier

Requirements/Limits

VIDEXPEDIATRIC 2 MO

VIRACEPT 2 MO

VIRAMUNE SUSP 50MG/5ML 2 MO

VIRAMUNE TABS 200 MG(Use Nevirapine) GP MO

VIRAMUNE XR 100 MG 3

VIRAMUNE XR 400 MG 3 MO

VIREAD POWD 40 MG/GM 2 MO

VIREAD TABS 150 MG,300 MG 2 MO

VIREAD TABS 200 MG,250 MG 2

ZERIT (Use Stavudine) GP MO

ZIAGEN SOLN 20 MG/ML 2 MO

ZIAGEN TABS 300 MG(Use Abacavir Sulfate) GP MO

zidovudine 1 MO

CMV AgentsVALCYTE SOLR 50MG/ML 2 QL(21 ml

daily); MO

VALCYTE TABS 450 MG 2 MO

Hepatitis Agentsadefovir dipivoxil 1 MO

BARACLUDE 2 MO

COPEGUS (Use Ribavirin(Hepatitis C)) GP PA

HEPSERA (Use AdefovirDipivoxil) GP MO

INCIVEK 3 PA

INFERGEN 3 PA

MODERIBA MISC 3 PA

MODERIBA MISC 3 PA; MO

Drug Name DrugTier

Requirements/Limits

MODERIBA TABS 400MG, 600 MG 3 PA; MO

OLYSIO 3 PA

PEG-INTRON 3 PA

PEG-INTRON REDIPEN 3 PA

PEG-INTRON REDIPENPAK 4 3 PA

PEGASYS 3 PA

PEGASYS PROCLICK 3 PA

REBETOL CAPS 200 MG(Use Ribavirin (HepatitisC))

GPPA

REBETOL SOLN 40MG/ML 2 PA

RIBAPAK MISC 3 PA

ribapak tabs 400 mg, 600mg 1 PA

ribasphere 1 PA

ribatab 1 PA

ribavirin (hepatitis c) 1 PA

SOVALDI 3 PA

TYZEKA 3 ST; MO

VICTRELIS 3 PA

Herpes Agentsacyclovir 1 MO

famciclovir 1 MO

FAMVIR (Use Famciclovir) GP MO

valacyclovir hcl 1 MO

VALTREX (UseValacyclovir HCl) GP MO

ZOVIRAX CAPS OR 200MG (Use Acyclovir) GP MO


Drug Name DrugTier

Requirements/Limits

ZOVIRAX SUSP OR 200MG/5ML (Use Acyclovir) GP MO

ZOVIRAX TABS OR 400MG, 800 MG (UseAcyclovir)

GPMO

Influenza AgentsFLUMADINE (UseRimantadineHydrochloride)

GPMO

RELENZA DISKHALER 3 QL(0.67 eadaily); MO

rimantadine hydrochloride 1 MO

TAMIFLU CAPS 30 MG, 45MG 3 QL(10 ea per

fill retail)

TAMIFLU CAPS 75 MG 3

TAMIFLU SUSR 6 MG/ML 3QL(75 mldaily,5 day(s)limit); AL

Respiratory Syncytial Virus (RSV) AgentsVIRAZOLE 3

ASSORTED CLASSES - Miscellaneous Drugs

Chelating AgentsCUPRIMINE 2 MO

DEPEN TITRATABS 2 MO

SYPRINE 3

ImmunomodulatorsREVLIMID AC PA

THALOMID AC

Immunosuppressive AgentsASTAGRAF XL 0.5 MG, 1MG 3 ST; MO

ASTAGRAF XL 5 MG 3 ST

AZASAN 3 MO

azathioprine 1 MO

Drug Name DrugTier

Requirements/Limits

CELLCEPT CAPS 250 MG(Use MycophenolateMofetil)

GPMO

CELLCEPT SUSR 200MG/ML 2 MO

CELLCEPT TABS 500 MG(Use MycophenolateMofetil)

GPMO

cyclosporine caps or 100mg, 25 mg 1 MO

cyclosporine modified 1 MO

cyclosporine modified (formicroemulsion) 1 MO

IMURAN (UseAzathioprine) GP MO

mycophenolate mofetil 1 MO

mycophenolate sodium 1 MO

MYFORTIC (UseMycophenolate Sodium) GP MO

NEORAL (UseCyclosporine Modified (ForMicroemulsion))

GPMO

PROGRAF CAPS OR 0.5MG, 1 MG, 5 MG (UseTacrolimus)

GPMO

RAPAMUNE SOLN 1MG/ML 3 MO

RAPAMUNE TABS 0.5 MG(Use Sirolimus) GP MO

RAPAMUNE TABS 1 MG,2 MG 3 MO

SANDIMMUNE CAPS OR100 MG, 25 MG (UseCyclosporine)

GPMO

SANDIMMUNE SOLN OR100 MG/ML (UseCyclosporine)

GPMO

sirolimus 1 MO

tacrolimus 1 MO

ZORTRESS 2 MO

Potassium Removing Resins


34

Drug Name DrugTier

Requirements/Limits

KAYEXALATE (UseSodium PolystyreneSulfonate)

GPMO

sodium polystyrenesulfonate powd or 1 MO

sodium polystyrenesulfonate susp or 15gm/60ml

1MO

sodium polystyrenesulfonate susp re 30gm/120ml, 50 gm/200ml

1

sps 1 MO

BETA BLOCKERS - Drugs to Treat High BloodPressureAlpha-Beta Blockerscarvedilol 12.5 mg, 25 mg,6.25 mg 1 MO

carvedilol 3.125 mg 1 QL(2 ea daily);MO

COREG 12.5 MG, 25 MG,6.25 MG (Use Carvedilol) GP MO

COREG 3.125 MG (UseCarvedilol) GP QL(2 ea daily);

MO

COREG CR 3 MO

labetalol hcl tabs or 100mg, 200 mg, 300 mg 1 MO

TRANDATE (UseLabetalol HCl) GP MO

Beta Blockers Cardio-Selectiveacebutolol hcl 1 MO

atenolol 1 MO

betaxolol hcl 1 MO

bisoprolol fumarate 1 QL(1 ea daily);MO

BYSTOLIC 3 MO

KERLONE (Use BetaxololHCl) GP MO

LOPRESSOR TABS OR100 MG, 50 MG (UseMetoprolol Tartrate)

GPMO

Drug Name DrugTier

Requirements/Limits

metoprolol succinate 1 MO

metoprolol tartrate tabs or100 mg, 25 mg, 50 mg 1 MO

SECTRAL (Use AcebutololHCl) GP MO

TENORMIN (Use Atenolol) GP MO

TOPROL XL (UseMetoprolol Succinate) GP MO

ZEBETA (Use BisoprololFumarate) GP QL(1 ea daily);

MOBeta Blockers Non-SelectiveBETAPACE (Use SotalolHCl) GP MO

BETAPACE AF (UseSotalol HCl (AFIB/AFL)) GP MO

CORGARD (Use Nadolol) GP MO

INDERAL LA (UsePropranolol HCl) GP MO

INDERAL XL 3 MO

INNOPRAN XL 3 MO

LEVATOL 3 MO

nadolol 1 MO

pindolol 1 MO

propranolol hcl cp24 or 120mg, 160 mg, 60 mg, 80 mg 1 MO

propranolol hcl soln or 20mg/5ml 1 MO

PROPRANOLOL HCLSOLN OR 40 MG/5ML 2 MO

propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg

1MO

sotalol hcl 1 MO

sotalol hcl (afib/afl) 1 MO

timolol maleate 1 QL(2 ea daily);MO


Drug Name DrugTier

Requirements/Limits

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood PressureCalcium Channel BlockersADALAT CC 30 MG, 60MG (Use Nifedipine) GP MO

ADALAT CC 90 MG (UseNifedipine) GP QL(1 ea daily);

MO

amlodipine besylate 1 QL(2 ea daily);MO

CALAN (Use VerapamilHCl) GP MO

CALAN SR (UseVerapamil HCl) GP MO

CARDENE SR 30 MG, 60MG 3 MO

CARDENE SR 45 MG 3

CARDIZEM (Use DiltiazemHCl) GP MO

CARDIZEM CD (UseDiltiazem HCl CoatedBeads)

GPMO

CARDIZEM LA 120 MG 2 MO

CARDIZEM LA 180 MG,240 MG, 300 MG, 360 MG,420 MG (Use DiltiazemHCl Coated Beads)

GP

MO

COVERA-HS 3

DILACOR XR (UseDiltiazem HCl) GP MO

diltiazem hcl coated beads 1 MO

diltiazem hcl cp12 or 120mg, 60 mg, 90 mg 1 MO

diltiazem hcl cp24 or 120mg, 180 mg, 240 mg 1 MO

diltiazem hcl extendedrelease beads 1 MO

diltiazem hcl tabs or 120mg, 30 mg, 60 mg, 90 mg 1 MO

DYNACIRC CR 3

felodipine 1 MO

Drug Name DrugTier

Requirements/Limits

ISOPTIN SR (UseVerapamil HCl) GP MO

ISRADIPINE 3 MO

nicardipine hcl caps or 20mg, 30 mg 1 MO

nifedipine caps 10 mg, 20mg 1 MO

nifedipine tb24 30 mg, 60mg 1 MO

nifedipine tb24 30 mg, 60mg, 90 mg 1 QL(1 ea daily);

MO

nimodipine 1 MO

nisoldipine 17 mg, 34 mg,8.5 mg 1 MO

nisoldipine er 1 MO

NORVASC (UseAmlodipine Besylate) GP QL(2 ea daily);

MO

NYMALIZE 3 MO

PROCARDIA (UseNifedipine) GP MO

PROCARDIA XL (UseNifedipine) GP QL(1 ea daily);

MO

SULAR (Use Nisoldipine) GP MO

TIAZAC (Use DiltiazemHCl Extended ReleaseBeads)

GPMO

verapamil hcl cp24 or 100mg, 120 mg, 180 mg, 200mg, 240 mg, 300 mg, 360mg

1

MO

verapamil hcl tabs or 120mg, 80 mg 1 MO

VERAPAMIL HCL TABSOR 40 MG (Use VerapamilHCl)

GPMO

verapamil hcl tbcr or 120mg, 180 mg, 240 mg 1 MO

VERELAN (Use VerapamilHCl) GP MO

VERELAN PM (UseVerapamil HCl) GP MO


36

Drug Name DrugTier

Requirements/Limits

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart RhythmCardiac GlycosidesDIGOXIN SOLN OR 0.05MG/ML 2 MO

digoxin tabs or 125 mcg,250 mcg 1 MO

LANOXIN TABS OR 125MCG, 250 MCG (UseDigoxin)

GPMO

LANOXIN TABS OR 187.5MCG, 62.5 MCG 3 MO

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsCardiovascular Agents Misc. - Combinationsamlodipine besylate-atorvastatin calcium 1 MO

AMLODIPINEBESYLATE/ATORVASTATIN CALCIUM

3MO

BIDIL 3 MO

CADUET 10MG-10MG,10MG-2.5MG, 10MG-5MG,20MG-2.5MG, 20MG-5MG,40MG-2.5MG, 40MG-5MG,80MG-10MG, 80MG-5MG

3

MO

CADUET 20MG-10MG,40MG-10MG (UseAmlodipine Besylate-Atorvastatin Calcium)

GP

MO

Impotence Agents

CIALIS 2.5 MG, 5 MG 3 PA; QL(0.27 eadaily); MO

Peripheral Vasodilatorsisoxsuprine hcl 10 mg 1 MO

ISOXSUPRINE HCL 20MG 3

Prostaglandin VasodilatorsVENTAVIS 3 PA

Pulmonary Hypertension - Endothelin ReceptorLETAIRIS 3 QL(1 ea daily)

Drug Name DrugTier

Requirements/Limits

OPSUMIT 3 PA

TRACLEER 3 QL(2 ea daily)

Pulmonary Hypertension - PhosphodiesteraseADCIRCA 3 PA

REVATIO (Use SildenafilCitrate (PulmonaryHypertension))

GPPA

sildenafil citrate (pulmonaryhypertension) 3 PA

Pulmonary Hypertension - Sol Guanylate CyclaseADEMPAS 3 PA

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generationcefadroxil 1 MO

cephalexin caps 250 mg,500 mg, 750 mg 1 MO

cephalexin susr 125mg/5ml, 250 mg/5ml 1 MO

CEPHALEXIN TABS 250MG, 500 MG 3 MO

KEFLEX (Use Cephalexin) GP MO

Cephalosporins - 2nd Generationcefaclor caps 250 mg, 500mg 1 MO

CEFACLOR ER 3 MO

CEFACLOR SUSR 125MG/5ML, 250 MG/5ML,375 MG/5ML (UseCefaclor)

GP

cefprozil 1 MO

CEFTIN (Use CefuroximeAxetil) GP MO

cefuroxime axetil 1 MO

Cephalosporins - 3rd GenerationCEDAX CAPS 400 MG 3 MO


Drug Name DrugTier

Requirements/Limits

CEDAX SUSR 180MG/5ML 3 MO

CEDAX SUSR 90 MG/5ML 3

cefdinir 1 MO

CEFDITOREN PIVOXIL 3 MO

cefpodoxime proxetil 1 MO

CEFTIBUTEN 3 MO

SPECTRACEF 3 MO

SUPRAX CAPS 400 MG 3

SUPRAX CHEW 100 MG,200 MG 3

SUPRAX SUSR 100MG/5ML, 200 MG/5ML 3 MO

SUPRAX SUSR 500MG/5ML 3

SUPRAX TABS 400 MG 3 MO

CONTRACEPTIVES - Drugs to PreventPregnancyCombination Contraceptives - OralAMETHYST PV MO; PV

BEYAZ PV QL(1 ea daily);MO; PV

BREVICON-28 (UseNorethindrone & EthEstradiol)

GPMO; PV

CYCLESSA (UseDesogestrel-EthinylEstradiol (Triphasic))

GPMO; PV

DESOGEN (UseDesogestrel & EthinylEstradiol)

GPMO; PV

desogestrel & ethinylestradiol PV MO; PV

desogestrel-ethinylestradiol (biphasic) PV MO; PV

desogestrel-ethinylestradiol (triphasic) PV MO; PV

Drug Name DrugTier

Requirements/Limits

drospirenone-ethinylestradiol PV QL(1 ea daily);

MO; PVESTROSTEP FE (UseNorethindrone Acetate-Ethinyl Estradiol-Fe)

GPMO; PV

ethynodiol diacet & ethestrad PV MO; PV

FALESSA PV PA; MO; PV

FEMCON FE (UseNorethindrone & EthinylEstradiol-Fe)

GPMO; PV

GENERESS FE PV QL(1 ea daily);MO; PV

levonorgestrel & ethestradiol PV MO; PV

levonorgestrel-eth estradiol(triphasic) PV MO; PV

levonorgestrel-ethinylestradiol (91-day) PV QL(1 ea daily);

MO; PV

LO LOESTRIN FE PV QL(1 ea daily);MO; PV

LO MINASTRIN FE PV

QL(84 ea perfill retail,3copay(s) per fillretail); MO; PV

LO/OVRAL-28 (UseNorgestrel & EthinylEstradiol)

GPMO; PV

LOESTRIN 1.5/30-21 (UseNorethindrone Acet & EthEstra)

GPMO; PV

LOESTRIN 1/20-21 (UseNorethindrone Acet & EthEstra)

GPMO; PV

LOESTRIN 24 FE PV MO; PV

LOESTRIN FE 1.5/30 (UseNorethin Acet & Estrad-Fe) GP MO; PV

LOESTRIN FE 1/20 (UseNorethin Acet & Estrad-Fe) GP MO; PV

LOMEDIA 24 FE PV MO; PV

LOSEASONIQUE (UseLevonorgestrel-EthinylEstradiol (91-Day))

GPQL(1 ea daily);MO; PV


38

Drug Name DrugTier

Requirements/Limits

MINASTRIN 24 FE PV

PA; QL(84 eaper fill retail,3copay(s) per fillretail); MO; PV

MIRCETTE (UseDesogestrel-EthinylEstradiol (Biphasic))

GPMO; PV

MODICON (UseNorethindrone & EthEstradiol)

GPMO; PV

NATAZIA PV QL(1 ea daily);MO; PV

NECON 1/50-28 PV MO; PV

NECON 10/11-28 PV MO; PV

NORDETTE-28 (UseLevonorgestrel & EthEstradiol)

GPMO; PV

norethin acet & estrad-fe PV MO; PV

norethindrone & ethestradiol PV MO; PV

norethindrone & ethinylestradiol-fe PV MO; PV

norethindrone acet & ethestra PV MO; PV

norethindrone acetate-ethinyl estradiol-fe PV MO; PV

norethindrone-eth estradiol(triphasic) PV QL(1 ea daily);

MO; PVnorethindrone-eth estradiol(triphasic) PV MO; PV

norgestimate-ethinylestradiol PV QL(1 ea daily);

MO; PVnorgestimate-ethinylestradiol (triphasic) PV QL(1 ea daily);

MO; PVnorgestrel & ethinylestradiol PV MO; PV

NORINYL 1+35 (UseNorethindrone & EthEstradiol)

GPMO; PV

NORINYL 1+50 PV MO; PV

ogestrel PV MO; PV

Drug Name DrugTier

Requirements/Limits

ORTHO TRI-CYCLEN(Use Norgestimate-EthinylEstradiol (Triphasic))


ORTHO TRI-CYCLEN LO PV MO; PV

ORTHO-CEPT (UseDesogestrel & EthinylEstradiol)

GPMO; PV

ORTHO-CYCLEN (UseNorgestimate-EthinylEstradiol)


ORTHO-NOVUM 1/35(Use Norethindrone & EthEstradiol)

GPMO; PV

ORTHO-NOVUM 7/7/7(Use Norethindrone-EthEstradiol (Triphasic))


OVCON-35 (UseNorethindrone & EthEstradiol)

GPMO; PV

OVCON-50 28 PV PV

QUARTETTE PV

QL(91 ea perfill retail,91 eaper fill mail,3copay(s) per fillretail,2copay(s) per fillmail); MO; PV

SAFYRAL PV QL(1 ea daily);MO; PV

SEASONALE (UseLevonorgestrel-EthinylEstradiol (91-Day))


SEASONIQUE (UseLevonorgestrel-EthinylEstradiol (91-Day))


TRI-NORINYL 28 (UseNorethindrone-EthEstradiol (Triphasic))

GPMO; PV

YASMIN 28 (UseDrospirenone-EthinylEstradiol)


YAZ (Use Drospirenone-Ethinyl Estradiol) GP QL(1 ea daily);

MO; PV

zovia 1/50e PV MO; PV

Combination Contraceptives - Transdermal


Drug Name DrugTier

Requirements/Limits

ORTHO EVRA PV MO; PV

Combination Contraceptives - Vaginal

NUVARING PV QL(0.04 eadaily); MO; PV

Emergency ContraceptivesELLA PV PV

levonorgestrel (emergencyoc) 0.75 mg PV PV

levonorgestrel (emergencyoc) 1.5 mg PV RX/OTC; PV

PLAN B (UseLevonorgestrel(Emergency OC))

GPPV

PLAN B ONE-STEP (UseLevonorgestrel(Emergency OC))

GPRX/OTC; PV

Progestin Contraceptives - IUDMIRENA PV PV

SKYLA PVQL(1 ea per365 daysretail); PV

Progestin Contraceptives - ImplantsIMPLANON PV PV

NEXPLANON PV PV

Progestin Contraceptives - InjectableDEPO-PROVERACONTRACEPTIVE (UseMedroxyprogesteroneAcetate (Contraceptive))

GP

MO; PV

DEPO-SUBQ PROVERA104 PV MO; PV

medroxyprogesteroneacetate (contraceptive) PV MO; PV

Progestin Contraceptives - OralNOR-QD (UseNorethindrone(Contraceptive))


norethindrone(contraceptive) PV QL(1 ea daily);

MO; PV

Drug Name DrugTier

Requirements/Limits

ORTHO MICRONOR (UseNorethindrone(Contraceptive))


CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroidsbudesonide 1 MO

CELESTONE 3

CORTEF (UseHydrocortisone) GP MO

cortisone acetate 1 MO

dexamethasone 1 MO

DEXAMETHASONEINTENSOL 2 MO

DEXPAK 10 DAY 3 MO

DEXPAK 13 DAY 3 MO

DEXPAK 6 DAY 3 MO

ENTOCORT EC (UseBudesonide) GP MO

FLO-PRED 3 MO

hydrocortisone 1 MO

MEDROL 16 MG, 32 MG, 4MG, 8 MG (UseMethylprednisolone)

GPMO

MEDROL 2 MG 2 MO

MEDROL DOSEPAK (UseMethylprednisolone) GP MO

methylprednisolone 1 MO

MILLIPRED DP 3 MO

MILLIPRED SOLN 10MG/5ML 3 MO

MILLIPRED TABS 5 MG 2 MO

ORAPRED (UsePrednisolone SodiumPhosphate)

GPMO


40

Drug Name DrugTier

Requirements/Limits

ORAPRED ODT 3 MO

prednisolone 1 MO

prednisolone sodiumphosphate or 15 mg/5ml 1 MO

PREDNISOLONE SODIUMPHOSPHATE OR 25MG/5ML

3

PREDNISONE INTENSOL 2 MO

prednisone soln 5 mg/5ml 1 MO

prednisone tabs 1 mg, 10mg, 2.5 mg, 20 mg, 5 mg,50 mg

1MO

PREDNISONE TABS 10MG 2 MO

PREDNISONE TABS 5 MG 3 MO

PRELONE (UsePrednisolone) GP MO

RAYOS 3 MO

UCERIS 3 PA; MO

VERIPRED 20 3 MO

Mineralocorticoidsfludrocortisone acetate 1 MO

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy SymptomsAntitussivesbenzonatate 1 MO

hydrocodone w/homatropine 1 MO

TESSALON (UseBenzonatate) GP MO

TESSALON PERLES (UseBenzonatate) GP MO

ZONATUSS 3

Cough/Cold/Allergy CombinationsALAHIST AC 3 MO

Drug Name DrugTier

Requirements/Limits

ALAHIST DHC 3 MO

ALBATUSSIN 3

ALBATUSSIN NN 3

ALLFEN CD 3 MO

ALLFEN CDX 3

AMBIFED CD 3

AMBIFED CDX 3

AMBIFED-G CD 3

AMBIFED-G CDX 3

BRONCOPECTOL 3

CARBAPHEN 12 3

CARBAPHEN 12 PED 3

CLARINEX-D 12 HOUR 3 MO

CLARINEX-D 24 HOUR 3 MO

COTAB A 3

COTAB AX 3

COTABFLU 3

CPB WC 3

DECON-G 3

DESPEC-EXP 3

DESPEC-PDC 3

DOMETUSS-DMX 3 RX/OTC

DONATUSS DC 3

EXACTUSS 3

GILPHEX TR 3


Drug Name DrugTier

Requirements/Limits

GILTUSS 3

GILTUSS PED-C 3

GILTUSS TR 3

guaifenesin-codeine liqd100mg/5ml-10mg/5ml 1 RX/OTC; MO

guaifenesin-codeine soln100mg/5ml-10mg/5ml 1 RX/OTC; MO

guaifenesin-codeine syrp100mg/5ml-10mg/5ml 1 RX/OTC; MO

HDC DM 3

HISTEX-PE 3 RX/OTC

J-COF DHC 3 MO

J-MAX DHC 3

LARTUS 3

LEMOHIST PLUS 3

MAXIFED CD 3

MAXIFED CDX 3

MAXIFED-G CD 3

MAXIFED-G CDX 3

MAXIFLU CD 3

MAXIFLU CDX 3

MAXIPHEN CD 3

MAXIPHEN CDX 3

NEOTUSS PLUS 3

NEOTUSS-D 3

PEDIATEX TDM 3

PHENFLU CD 3

Drug Name DrugTier

Requirements/Limits

PHENFLU CDX 3

phenyleph-promethazine w/cod 1 MO

phenylephrine w/ dm-ggliqd 7.5mg/ml-88mg/ml-2.5mg/ml

1RX/OTC

POLY HIST DHC 3

POLY HIST NC 3

POLY-TUSSIN DHC 3

POLY-TUSSIN EX 3

PROHIST CD 3

PROHIST CF 3

PROHIST LQ 3 RX/OTC

promethazine &phenylephrine 1 MO

PROMETHAZINE VCPLAIN 2 MO

PROMETHAZINEVC/CODEINE 2 MO

promethazine w/codeine 1 MO

promethazine-dm 1 MO

PROTID 3

pseudoephed-cpm w/hydrocod 1 MO

pseudoephedrine w/codeine-gg soln 1 MO

RELHIST 3

RESCON 3

RESCON-JR 3 MO

RESCON-MX 3

REZIRA 3 MO

SEMPREX-D 3 MO


42

Drug Name DrugTier

Requirements/Limits

TEKRAL 3 MO

TGQ30PSE/150GFN/15DM 3

TGQ 30PSE/3BRM/15DM 3 MO

TUSNEL CAPS 2MG-15MG-200MG 3

TUSNEL PED-C 3

TUSSAFED EX 3 RX/OTC

TUSSICAPS 3 MO

VITUZ 3

Z-COF I 3

ZUTRIPRO (UsePseudoephed-CPM w/Hydrocod)

GPMO

Misc. Respiratory InhalantsHYPER-SAL (Use SodiumChloride (Inhalant)) GP MO

HYPERSAL 3.5 % 3 MO

HYPERSAL 7 % (UseSodium Chloride (Inhalant)) GP MO

NEBUSAL 3 MO

sodium chloride (inhalant) 1 MO

Mucolyticsacetylcysteine 1 MO

DERMATOLOGICALS - Drugs to Treat SkinConditionsAcne ProductsABSORICA 3 PA

ACANYA 3 MO

ACZONE 3 MO

adapalene 1 QL(1.5 gmdaily); MO

Drug Name DrugTier

Requirements/Limits

AKNE-MYCIN 2 MO

ATRALIN 3 QL(1.5 gmdaily); MO

AVAR 3

AVAR LS 3

AVAR LS CLEANSER(Use SulfacetamideSodium w/ Sulfur)

GPMO

AVAR-E LS (UseSulfacetamide Sodium w/Sulfur)

GPMO

AZELEX 3 MO

BENZACLIN (UseClindamycin Phosphate-Benzoyl Peroxide)

GPMO

BENZACLIN WITH PUMP(Use ClindamycinPhosphate-BenzoylPeroxide)

GP

MO

CLARAVIS 1

CLARIFOAM EF (UseSulfacetamide Sodium w/Sulfur)

GPMO

CLEOCIN-T (UseClindamycin Phosphate(Topical))

GPMO

CLINDAGEL 3 MO

clindamycin phosphate(topical) 1 MO

clindamycin phosphate-benzoyl peroxide 1 MO

clindamycin phosphate-benzoyl peroxide(refrigerate)

1MO

CLINDAREACH 3

DIFFERIN CREA 0.1 %(Use Adapalene) GP QL(1.5 gm

daily); MODIFFERIN GEL 0.1 % (UseAdapalene) GP QL(1.5 gm

daily); MO

DIFFERIN GEL 0.3 % 2 QL(1.5 gmdaily); MO


Drug Name DrugTier

Requirements/Limits

DIFFERIN LOTN 0.1 % 3 QL(1.97 mldaily); MO

DUAC (Use ClindamycinPhosphate-BenzoylPeroxide (Refrigerate))

GPMO

EPIDUO 3 QL(1.5 gmdaily); MO

ERYGEL (UseErythromycin (Acne Aid)) 3 MO

erythromycin (acne aid) 1 MO

EVOCLIN (UseClindamycin Phosphate(Topical))

GPMO

FABIOR 3 QL(1.67 gmdaily); MO

isotretinoin 10 mg 1 QL(4 ea daily)

isotretinoin 10 mg, 20 mg,40 mg 1 QL(150 ea per

365 days retail)



KLARON (UseSulfacetamide Sodium(Acne))

GPMO

RETIN-A (Use Tretinoin) GP MO

RETIN-A MICRO (UseTretinoin Microsphere) GP QL(0.67 gm

daily); MORETIN-A MICRO PUMP(Use TretinoinMicrosphere)

GPQL(1.7 gmdaily); MO

RIAX 3

ROSANIL 3

SODIUMSULFACETAMIDE/SULFUR

3MO

SODIUMSULFACETAMIDE/SULFUR CLEANSER IN UREA

3MO

SODIUMSULFACETAMIDE/SULFUR IN UREA

3MO

Drug Name DrugTier

Requirements/Limits

SSS 10-4 3 MO

sulfacetamide sodium(acne) 1 MO

sulfacetamide sodium w/sulfur crea 2%-10%, 5%-10%

1MO

sulfacetamide sodium w/sulfur emul 1%-10%, 5%-10%

1MO

sulfacetamide sodium w/sulfur foam 5%-10% 1 MO

sulfacetamide sodium w/sulfur liqd 2%-10%, 4%-9%, 4.5%-9%

1MO

sulfacetamide sodium w/sulfur lotn 5%-10% 1 QL(1 ml daily);

MOsulfacetamide sodium w/sulfur susp 4%-8% 1 MO

sulfacetamide sodium-sulfur in urea vehicle 1 MO

SULFOAM 3

SUMADAN WASH (UseSulfacetamide Sodium w/Sulfur)

GPMO

SUMAXIN TS (UseSulfacetamide Sodium w/Sulfur)

GPMO

SUMAXIN WASH (UseSulfacetamide Sodium w/Sulfur)

GPMO

TRETIN-X CREA 0.038 % 3 QL(1.2 gmdaily); MO

TRETIN-X CREA 0.075 % 3 QL(1.2 gmdaily)

tretinoin 1 MO

tretinoin microsphere 0.04%, 0.1 % 1 QL(1.7 gm

daily); MOtretinoin microsphere 0.04%, 0.1 % 1 QL(0.67 gm



daily); MO


44

Drug Name DrugTier

Requirements/Limits

VANOXIDE-HC 3 MO

VELTIN 3 QL(1 gm daily);MO

ZIANA 3 QL(1 gm daily);MO

Agents for External Genital and Perianal Warts

VEREGEN 3 QL(0.5 gmdaily); MO

Anti-inflammatory Agents - TopicalFLECTOR 3 MO

PENNSAID 1.5 % 3 QL(5 ml daily);MO

PENNSAID 2 % 3 QL(4 gm daily);MO

VOLTAREN GEL TD 1 % 3 MO

Antibiotics - TopicalALTABAX 3 MO

BACTROBAN (UseMupirocin Calcium(Topical))

GPMO

BACTROBAN (UseMupirocin) GP MO

CENTANY 2 MO

CENTANY AT 3 MO

CORTISPORIN CREA EX10000UNIT/GM-0.5%-0.5% 3 MO

CORTISPORIN OINT EX400UNIT/GM-5000UNIT/GM-0.5%-1%

3MO

gentamicin sulfate crea ex0.1 % 1 MO

gentamicin sulfate oint ex0.1 % 1 MO

mupirocin 1 MO

mupirocin calcium (topical) 1 MO

Antifungals - TopicalALA QUIN 3 MO

Drug Name DrugTier

Requirements/Limits

ALCORTIN A 3 MO

ALOQUIN 3 MO

CICLODAN SOLUTIONKIT (Use Ciclopirox) GP MO

ciclopirox 1 MO

ciclopirox olamine 1 MO

clotrimazole w/betamethasone crea 1 QL(1.5 gm

daily); MOclotrimazole w/betamethasone lotn 1 QL(2 ml daily);

MO

econazole nitrate 1 MO

ECOZA 3 MO

ERTACZO 3 MO

EXELDERM CREA 3 MO

EXELDERM SOLN 2 MO

EXTINA (UseKetoconazole (Topical)) GP MO

HALOTIN 3

iodoquinol-hc 1 MO

ketoconazole (topical) crea 1 QL(2 gm daily);MO

ketoconazole (topical) foam 1 MO

ketoconazole (topical)sham 1 MO

LOPROX (Use Ciclopirox) GP MO

LOPROX SHAMPOO (UseCiclopirox) GP MO

LOTRISONE (UseClotrimazole w/Betamethasone)


NAFTIN CREA 1 %, 2 % 3 MO

NAFTIN GEL 1 % 3 MO


Drug Name DrugTier

Requirements/Limits

NAFTIN GEL 2 % 2 MO

NIZORAL (UseKetoconazole (Topical)) GP MO

nystatin (topical) 1 MO

nystatin-triamcinolone 1 MO

nystatin/triamcinolone 1 MO

OXISTAT 3 MO

sodium thiosulfate-salicylicacid 1

VUSION 3 MO

VYTONE 3

XOLEGEL 3 MO

Antineoplastic or Premalignant Lesion Agents -CARAC 2 MO

diclofenac sodium (actinickeratoses) 1 MO

EFUDEX (Use Fluorouracil(Topical)) GP MO

FLUOROPLEX 2 MO

fluorouracil (topical) 1 MO

PANRETIN 3 PA; MO

PICATO 3 MO

SOLARAZE (UseDiclofenac Sodium (ActinicKeratoses))

GPMO

TARGRETIN GEL EX 1 % 3

VALCHLOR 3 PA

Antipruritics - TopicalPRUDOXIN 3 MO

ZONALON 3 MO

Antipsoriatics

Drug Name DrugTier

Requirements/Limits

8-MOP 3

acitretin 10 mg 1 QL(1 ea daily);MO

acitretin 17.5 mg 1 MO

acitretin 25 mg 1 QL(2 ea daily);MO

calcipotriene crea 1 QL(5 gm daily);MO

calcipotriene oint 1 QL(5 gm daily);MO

calcipotriene soln 1 MO

calcitriol (topical) 1 QL(3.4 gmdaily); MO

DOVONEX (UseCalcipotriene) GP QL(5 gm daily);

MO

OXSORALEN ULTRA 2 MO

SORIATANE 10 MG (UseAcitretin) GP QL(1 ea daily);

MOSORIATANE 17.5 MG (UseAcitretin) GP MO

SORIATANE 25 MG (UseAcitretin) GP QL(2 ea daily);

MO

SORILUX 3 PA; MO

TAZORAC 2 QL(1 gm daily);MO

VECTICAL (Use Calcitriol(Topical)) GP QL(3.4 gm

daily); MO

ZITHRANOL-RR 3 MO

Antiseborrheic ProductsOVACE PLUS (UseSulfacetamide Sodium) GP MO

OVACE PLUS WASH(Use SulfacetamideSodium)

GPMO

OVACE WASH (UseSulfacetamide Sodium) GP MO

selenium sulfide lotn 2.5 % 1 MO


46

Drug Name DrugTier

Requirements/Limits

SELENIUM SULFIDESHAM 2.25% (UseSelenium Sulfide-Pyrithione Zinc in UreaVehicle)

GP

MO

selenium sulfide-pyrithionezinc in urea vehicle 1 MO

SELRX 3

SELSUN SHAMPOO (UseSelenium Sulfide) GP MO

SODIUMSULFACETAMIDE WASH 3

SODIUMSULFACETAMIDE/UREA 3

sulfacetamide sodium liqdex 1 MO

sulfacetamide sodiumsham ex 1 MO

TERSI FOAM 3 MO

Antivirals - Topical

acyclovir topical 1 QL(1 gm daily);MO

DENAVIR 3 QL(0.05 gmdaily); MO

LIDOVIR 3 MO

XERESE 3 QL(0.17 gmdaily); MO

ZOVIRAX CREA EX 5 % 3 MO

ZOVIRAX OINT EX 5 %(Use Acyclovir Topical) GP QL(1 gm daily);

MOBurn Productsmafenide acetate 1 MO

SILVADENE (Use SilverSulfadiazine) GP MO

silver sulfadiazine 1 MO

SULFAMYLON CREA 85MG/GM 3 MO

SULFAMYLON PACK 5 %(Use Mafenide Acetate) GP MO

Corticosteroids - Topical

Drug Name DrugTier

Requirements/Limits

ACLOVATE (UseAlclometasoneDipropionate)

GPMO

ALA SCALP (UseHydrocortisone (Topical)) GP MO

alclometasone dipropionate 1 MO

amcinonide crea 1 MO

AMCINONIDE LOTN 3 MO

AMCINONIDE OINT 3 MO

APEXICON E 2 MO

betamethasonedipropionate (topical) 1 MO

betamethasonedipropionate augmented 1 MO

betamethasone valerate 1 MO

CAPEX 2 MO

CARMOL-HC (Use Urea-HC Acetate) GP MO

clobetasol propionate 1 MO

clobetasol propionateemollient base 1 MO

clobetasol propionateemulsion 1 MO

CLOBEX LIQD 3 MO

CLOBEX LOTN (UseClobetasol Propionate) GP MO

CLOBEX SHAM (UseClobetasol Propionate) GP MO

CLOCORTOLONEPIVALATE 3 MO

CLOCORTOLONEPIVALATE PUMP 3 MO

CLODERM 3 MO

CLODERM PUMP 3 MO

CORDRAN 3 MO


Drug Name DrugTier

Requirements/Limits

CORDRAN SP 3 MO

CORDRAN TAPE 3 MO

CORTANE-B 3 MO

CUTIVATE (UseFluticasone Propionate) GP MO

DERMA-SMOOTHE/FSBODY (Use FluocinoloneAcetonide)

GPMO

DERMA-SMOOTHE/FSBODY OIL (UseFluocinolone Acetonide)

GPMO

DERMA-SMOOTHE/FSSCALP (Use FluocinoloneAcetonide)

GPMO

DERMA-SMOOTHE/FSSCALP OIL (UseFluocinolone Acetonide)

GPMO

DERMATOP (UsePrednicarbate) GP MO

DESONATE 3 MO

desonide 1 MO

DESOWEN (UseDesonide) GP MO

DESOXIMETASONECREA 0.05 % 2 MO

desoximetasone crea 0.25% 1 MO

desoximetasone gel 0.05% 1 MO

DESOXIMETASONE OINT0.05 % 3 MO

desoximetasone oint 0.25% 1 MO

diflorasone diacetate 1 MO

DIPROLENE (UseBetamethasoneDipropionate Augmented)

GPMO

DIPROLENE AF (UseBetamethasoneDipropionate Augmented)

GPMO

Drug Name DrugTier

Requirements/Limits

ELOCON (UseMometasone Furoate) GP MO

EPIFOAM 3 MO

fluocinolone acetonide 1 MO

fluocinonide 1 MO

fluocinonide emulsifiedbase 1 MO

fluticasone propionate 1 MO

halobetasol propionate 1 MO

halobetasol propionate &ammonium lactate 1 MO

HALOG 3 MO

HALONATE 3 MO

hydrocortisone (topical)crea 2.5 % 1 MO

hydrocortisone (topical) lotn2 %, 2.5 % 1 MO

hydrocortisone (topical) oint2.5 % 1 MO

hydrocortisone butyrate 1 MO

hydrocortisone butyratehydrophilic lipo base 1 MO

hydrocortisone valerate 1 MO

KENALOG 2 MO

LOCOID CREA (UseHydrocortisone Butyrate) GP MO

LOCOID LIPOCREAM(Use HydrocortisoneButyrate Hydrophilic LipoBase)

GP

MO

LOCOID LOTN 3 MO

LOCOID OINT (UseHydrocortisone Butyrate) GP MO

LOCOID SOLN (UseHydrocortisone Butyrate) GP MO

LUXIQ (UseBetamethasone Valerate) GP MO


48

Drug Name DrugTier

Requirements/Limits

mometasone furoate 1 MO

NOVACORT 3 MO

NUCORT 3

OLUX (Use ClobetasolPropionate) GP MO

OLUX-E (Use ClobetasolPropionate Emulsion) GP MO

PANDEL 3 MO

PRAMOSONE CREA 1%-1% 2 MO

PRAMOSONE CREA 1%-2.5% (Use Pramoxine-HC) GP MO

PRAMOSONE E 3 MO

PRAMOSONE LOTN 1%-1%, 1%-2.5% 3 MO

PRAMOSONE OINT 1%-1%, 1%-2.5% 3 MO

pramoxine-hc 1 MO

prednicarbate 1 MO

SYNALAR (UseFluocinolone Acetonide) GP MO

TACLONEX OINT 3 ST; QL(2 gmdaily); MO

TACLONEX SUSP 3 QL(2 gm daily);MO

TEMOVATE (UseClobetasol Propionate) GP MO

TEMOVATE E (UseClobetasol PropionateEmollient Base)

GPMO

TEXACORT 3 MO

TOPICORT CREA 0.05 % 2 MO

TOPICORT CREA 0.25 %(Use Desoximetasone) GP MO

TOPICORT GEL 0.05 %(Use Desoximetasone) GP MO

TOPICORT LIQD 0.25 % 3 ST; MO

Drug Name DrugTier

Requirements/Limits

TOPICORT OINT 0.05 % 3 MO

TOPICORT OINT 0.25 %(Use Desoximetasone) GP MO

triamcinolone acetonide 1 MO

triamcinolone acetonide(topical) 1 MO

trianex 1 MO

ULTRAVATE (UseHalobetasol Propionate) GP MO

ULTRAVATE PAC (UseHalobetasol Propionate &Ammonium Lactate)

GPMO

urea-hc acetate 1 MO

VANOS (UseFluocinonide) GP MO

VERDESO 3 MO

WESTCORT (UseHydrocortisone Valerate) GP MO

Emollient/Keratolytic AgentsALUVEA (Use Urea) GP MO

CEM-UREA 3 MO

GORDONS UREA 3

HYDRO 35 (Use Urea inLactic Acid Vehicle) GP MO

HYDRO 40 FOAM (UseUrea) GP MO

KERAFOAM 3

KERAFOAM 42 3

UMECTA EMUL 3 MO

UMECTA NAIL FILM (UseUrea) GP MO

UMECTA SUSP (UseUrea) GP MO

URAMAXIN CREA 45 %(Use Urea) GP MO


Drug Name DrugTier

Requirements/Limits

URAMAXIN FOAM 20% 3 MO

URAMAXIN GEL 45 %(Use Urea) GP MO

URAMAXIN GT (UseUrea) GP MO

URAMAXIN LOTN 45 %(Use Urea) GP MO

urea 1 MO

urea in lactic acid vehicle 1 MO

urea in lactic acid-salicylicacid vehicle 1 MO

urea in zinc undecylenate-lactic acid vehicle 1 MO

UREA NAIL 3 MO

UTOPIC 3

Emollientshyaluronate sodium(emollient) 1

HYLIRA GEL 0.2 % (UseHyaluronate Sodium(Emollient))

GP

HYLIRA LOTN 0.1 % 3

LAC-HYDRIN (Use LacticAcid (Ammonium Lactate)) GP RX/OTC; MO

LAC-HYDRIN TWELVE(Use Lactic Acid(Ammonium Lactate))

GPRX/OTC; MO

lactic acid (ammoniumlactate) crea 12 % 1 RX/OTC; MO

lactic acid (ammoniumlactate) lotn 10 % 1 MO

lactic acid (ammoniumlactate) lotn 12 % 1 RX/OTC; MO

Enzymes - TopicalGRANULEX (Use Trypsinw/ Castor Oil & PeruvianBalsam)

GPMO

OPTASE 3 MO

SANTYL 3 MO

Drug Name DrugTier

Requirements/Limits

trypsin w/ castor oil &peruvian balsam 1 MO

XENADERM (Use Trypsinw/ Castor Oil & PeruvianBalsam)

GPMO

Immunomodulating Agents - TopicalALDARA (Use Imiquimod) GP MO

imiquimod 1 MO

ZYCLARA 3 QL(1 gm daily);MO

ZYCLARA PUMP 2.5 % 3 QL(0.6 gmdaily); MO

ZYCLARA PUMP 3.75 % 3 QL(1 gm daily);MO

Immunosuppressive Agents - Topical

ELIDEL 3 QL(2 gm daily);MO

PROTOPIC 2 PA; QL(2 gmdaily); AL; MO

Keratolytic/Antimitotic AgentsBENSAL HP 3 MO

CONDYLOX GEL 2 MO

CONDYLOX SOLN (UsePodofilox) GP MO

PODOCON 25 INBENZOIN TINCTURE 3

podofilox 1 MO

SALEX (Use SalicylicAcid) GP MO

SALEX LOTION (UseSalicylic Acid w/ Cleanser) GP MO

salicylic acid crea 6 % 1 MO

salicylic acid foam 6 % 1 MO

salicylic acid in ammoniumlactate vehicle 1 MO

SALICYLIC ACID LIQD 26% 3 MO

salicylic acid liqd 27.5 % 1 MO


50

Drug Name DrugTier

Requirements/Limits

salicylic acid lotn 6 % 1 MO

salicylic acid sham 6 % 1 MO

salicylic acid w/ cleanser 1 MO

SALKERA (Use SalicylicAcid in Ammonium LactateVehicle)

GPMO

SALVAX (Use SalicylicAcid) GP MO

VIRASAL (Use SalicylicAcid) GP MO

LinimentsMEDROX-RX 3 PA

Local Anesthetics - TopicalCOCAINE HCL 3

EMLA (Use Lidocaine-Prilocaine) GP MO

ETHYL CHLORIDE 3

ETHYL CHLORIDE/FINEPINPOINT 3

ETHYL CHLORIDE/FINESTREAM 3

ETHYLCHLORIDE/MEDIUM JETSTREAM

3

ETHYLCHLORIDE/MEDIUMSTREAM

3

ETHYL CHLORIDE/MIST 3

GEBAUERS PAIN EASE 3 MO

GEBAUERS SPRAY ANDSTRETCH 3 MO

lidocaine hcl gel ex 2 % 1 RX/OTC; MO

lidocaine hcl soln ex 4 % 1 MO

lidocaine oint 1 MO

lidocaine ptch 1 QL(3 ea daily);MO

Drug Name DrugTier

Requirements/Limits

lidocaine-prilocaine 1 MO

LIDOCAINE/PRILOCAINE 3

LIDODERM (UseLidocaine) GP QL(3 ea daily);

MO

LIDORX 3 MO

SYNERA 3 MO

XYLOCAINE EX 4 % (UseLidocaine HCl) GP MO

Misc. Dermatological ProductsEMULSION SB 3 MO

EPICERAM 3 MO

TL-CERMIDE 3 MO

Misc. Topicalaluminum chloride 1 MO

DRYSOL (Use AluminumChloride) GP MO

XERAC AC 3 MO

Rosacea AgentsFINACEA 2 MO

METROCREAM (UseMetronidazole (Topical)) GP MO

METROGEL (UseMetronidazole (Topical)) GP MO

METROLOTION (UseMetronidazole (Topical)) GP QL(2 ml daily);

MOmetronidazole (topical)crea 0.75 % 1 MO

metronidazole (topical) gel0.75 % 1 QL(1.5 gm

daily); MOmetronidazole (topical) gel1 % 1 MO

metronidazole (topical) lotn0.75 % 1 QL(2 ml daily);

MO

MIRVASO 3 PA; MO

NORITATE 3 MO


Drug Name DrugTier

Requirements/Limits

ORACEA 3 MO

Scabicides & Pediculicides

ELIMITE (Use Permethrin) GP QL(2 gm daily);MO

EURAX 2 MO

lindane 1 MO

malathion 1 MO

NATROBA 3 AL; MO

OVIDE (Use Malathion) GP MO

permethrin 1 QL(2 gm daily);MO

SKLICE 3 MO

SPINOSAD 3 AL; MO

ULESFIA 3 MO

Wound Care Products

REGRANEX 3 QL(0.5 gmdaily); MO

DIAGNOSTIC PRODUCTS

Diagnostic DrugsMETOPIRONE 3

Diagnostic Tests

ACCU-CHEK AVIVA PLUS 3 PA; QL(6.67 eadaily); MO

ACCU-CHEK SMARTVIEWSTRIPS 3 PA; QL(6.67 ea

daily); MOFREESTYLE INSULINXBLOODGLUCOSE TEST 2 QL(6.67 ea

daily); MOFREESTYLE INSULINXBLOODGLUCOSE TESTSTRIPS

2QL(6.67 eadaily); MO

FREESTYLE LITE TESTSTRIPS 2 QL(6.67 ea

daily); MOFREESTYLE TESTSTRIPS 2 QL(6.67 ea

daily); MO

Drug Name DrugTier

Requirements/Limits

NON PREFERRED TESTSTRIPS 3 PA

ON CALL EXPRESSBLOOD GLUCOSE TESTSTRIPS

3PA; QL(6.67 eadaily); MO

ON CALL VIVID BLOODGLUCOSE TEST STRIPS 3 PA; QL(6.67 ea

daily); MO

ONETOUCH ULTRA BLUE 2 QL(6.67 eadaily); MO

ONETOUCH VERIO TESTSTRIPS 2 QL(6.67 ea

daily); MOONETOUCH VERIO TESTSTRIPS 3 PA; QL(6.67 ea

daily); MOPRECISION XTRA BLOODGLUCOSE TEST STRIPS 2 QL(6.67 ea

daily); MORELION ULTIMA BLOODGLUCOSE TEST STRIPS 3 PA; QL(6.67 ea

daily); MO

UNISTRIP1 GENERIC 3 PA; QL(6.67 eadaily); MO

Radiographic Contrast MediaPOLIBAR ACB 3

DIETARY PRODUCTS/DIETARY MANAGEMENTPRODUCTSDietary Management ProductsDEPLIN 15 3 MO

DEPLIN 7.5 3 MO

L-METHYLFOLATEFORMULA 15 3 MO

L-METHYLFOLATEFORMULA 7.5 3 MO

L-METHYLFOLATEFORTE 3 MO

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymesDigestive EnzymesCREON 2 MO

PANCREAZE 3 MO

pancrelipase (lipase-protease-amylase) 1 MO


52

Drug Name DrugTier

Requirements/Limits

PERTZYE 3 MO

SUCRAID 3 PA

ULTRESA 3 MO

VIOKACE 3 MO

ZENPEP 10000UNIT-3000UNIT-16000UNIT,34000UNIT-10000UNIT-55000UNIT, 51000UNIT-15000UNIT-82000UNIT,68000UNIT-20000UNIT-109000UNIT, 85000UNIT-25000UNIT-136000UNIT

2

MO

ZENPEP 17000UNIT-5000UNIT-27000UNIT(Use Pancrelipase (Lipase-Protease-Amylase))

GP

MO

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood PressureCarbonic Anhydrase Inhibitorsacetazolamide 1 MO

DIAMOX (UseAcetazolamide) GP MO

methazolamide 1 MO

NEPTAZANE (UseMethazolamide) GP MO

Diuretic CombinationsALDACTAZIDE 25MG-25MG (Use Spironolactone& Hydrochlorothiazide)

GPMO

ALDACTAZIDE 50MG-50MG 2 MO

amiloride &hydrochlorothiazide 1 MO

DYAZIDE (UseTriamterene &Hydrochlorothiazide)

GPMO

MAXZIDE (UseTriamterene &Hydrochlorothiazide)

GPMO

Drug Name DrugTier

Requirements/Limits

MAXZIDE-25 (UseTriamterene &Hydrochlorothiazide)

GPMO

spironolactone &hydrochlorothiazide 1 MO

triamterene &hydrochlorothiazide 1 MO

TRIAMTERENE/HYDROCHLOROTHIAZIDE 2

Loop Diureticsbumetanide tabs or 0.5 mg,1 mg, 2 mg 1 MO

DEMADEX (UseTorsemide) GP MO

EDECRIN 3 MO

furosemide soln or 10mg/ml 1 MO

FUROSEMIDE SOLN OR 8MG/ML 3 MO

furosemide tabs or 20 mg,40 mg, 80 mg 1 MO

LASIX (Use Furosemide) GP MO

torsemide 1 MO

Potassium Sparing DiureticsALDACTONE (UseSpironolactone) GP MO

amiloride hcl 1 MO

DYRENIUM 3 MO

spironolactone 1 MO

Thiazides and Thiazide-Like DiureticsCHLOROTHIAZIDE 250MG 3 MO

chlorothiazide 250 mg, 500mg 1 MO

CHLORTHALIDONE 100MG 2

CHLORTHALIDONE 25MG 2 MO

CHLORTHALIDONE 50MG (Use Chlorthalidone) GP MO


Drug Name DrugTier

Requirements/Limits

DIURIL 3 MO

hydrochlorothiazide 1 MO

indapamide 1 MO

METHYCLOTHIAZIDE 3 MO

metolazone 1 MO

MICROZIDE (UseHydrochlorothiazide) GP MO

THALITONE 2

ZAROXOLYN (UseMetolazone) GP MO

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density Regulators

ACTONEL 150 MG 3 ST; QL(0.04 eadaily); MO

ACTONEL 30 MG, 5 MG 3 ST; QL(1 eadaily); MO

ACTONEL 35 MG 3 ST; QL(0.15 eadaily); MO

alendronate sodium soln70 mg/75ml 1 MO

alendronate sodium tabs10 mg, 5 mg 1 QL(1 ea daily);

MOalendronate sodium tabs35 mg, 70 mg 1 QL(0.15 ea

daily); MOalendronate sodium tabs40 mg 1 MO

ATELVIA 3 ST; QL(0.15 eadaily); MO

BINOSTO 3 QL(0.15 eadaily); MO

BONIVA (Use IbandronateSodium) GP QL(0.04 ea

daily); MO

calcitonin (salmon) 1 MO

DIDRONEL (UseEtidronate Disodium) GP MO

ETIDRONATE DISODIUM 3 MO

Drug Name DrugTier

Requirements/Limits

FORTEO 3 PA

FOSAMAX (UseAlendronate Sodium) GP QL(0.15 ea

daily); MO

FOSAMAX PLUS D 3 PA; QL(0.15 eadaily); MO

ibandronate sodium 1 QL(0.04 eadaily); MO

MIACALCIN IJ 200UNIT/ML 3 PA

MIACALCIN NA 200UNIT/ACT (Use Calcitonin(Salmon))

GPMO

SKELID 3

Fertility RegulatorsBRAVELLE 3

chorionic gonadotropin 3

CLOMID (Use ClomipheneCitrate) GP QL(0.5 ea

daily); MO

clomiphene citrate 1 QL(0.5 eadaily); MO

FOLLISTIM AQ 3

GONAL-F 3

GONAL-F RFF 3

GONAL-F RFF PEN 3

GONAL-F RFF REDIJECT 3

LUVERIS 3

MENOPUR 3

OVIDREL 3

REPRONEX 3

GnRH/LHRH AntagonistsCETROTIDE 3

GANIRELIX ACETATE 3


54

Drug Name DrugTier

Requirements/Limits

Growth Hormone Receptor AntagonistsSOMAVERT 3 PA

Hormone Receptor Modulators

EVISTA 2 QL(1 ea daily);MO

OSPHENA 3 MO

Insulin-Like Growth Factors (Somatomedins)INCRELEX 3 PA

LHRH/GnRH Agonist Analog PituitarySYNAREL 2 MO

Metabolic ModifiersBUPHENYL POWD 3GM/TSP (Use SodiumPhenylbutyrate)

GP

BUPHENYL TABS 500 MG 3

calcitriol caps or 0.25 mcg,0.5 mcg 1 MO

calcitriol soln or 1 mcg/ml 1 MO

CARBAGLU 3

CARNITOR SF (UseLevocarnitine (MetabolicModifiers))

GPMO

CARNITOR SOLN OR 1GM/10ML (UseLevocarnitine (MetabolicModifiers))

GP

MO

CARNITOR TABS OR 330MG (Use Levocarnitine(Metabolic Modifiers))

GPMO

CYSTADANE 3

doxercalciferol caps or 0.5mcg, 1 mcg, 2.5 mcg 1 MO

HECTOROL CAPS OR 0.5MCG, 1 MCG, 2.5 MCG(Use Doxercalciferol)

GPMO

KUVAN 3 PA

Drug Name DrugTier

Requirements/Limits

levocarnitine (metabolicmodifiers) soln or 1gm/10ml

1MO

levocarnitine (metabolicmodifiers) tabs or 330 mg 1 MO

ORFADIN 3

paricalcitol 1 MO

RAVICTI 3 PA

ROCALTROL (UseCalcitriol) GP MO

SENSIPAR 3

sodium phenylbutyrate 3

ZEMPLAR CAPS OR 1MCG, 2 MCG, 4 MCG (UseParicalcitol)

GPMO

Posterior Pituitary HormonesDDAVP SOLN NA 0.01 %(Use DesmopressinAcetate Refrigerated)

GPMO

DDAVP SOLN NA 0.01 %(Use DesmopressinAcetate Spray)

GPMO

DDAVP TABS OR 0.1 MG,0.2 MG (UseDesmopressin Acetate)

GPMO

desmopressin acetaterefrigerated 1 MO

desmopressin acetatespray 1 MO

desmopressin acetatespray refrigerated 1 MO

desmopressin acetate tabsor 0.1 mg, 0.2 mg 1 MO

STIMATE 3

Prolactin Inhibitors

cabergoline 1 QL(0.27 eadaily); MO

Somatostatic Agentsoctreotide acetate 3 PA


Drug Name DrugTier

Requirements/Limits

SANDOSTATIN (UseOctreotide Acetate) GP PA

SIGNIFOR 3 PA

Vasopressin Receptor AntagonistsSAMSCA 3 QL(1 ea daily)

ESTROGENS - Hormone Replacement/ModifyingDrugsEstrogen CombinationsACTIVELLA (Use Estradiol& Norethindrone Acetate) GP MO

ANGELIQ 3 MO

CLIMARA PRO 2 QL(0.14 eadaily); MO

COMBIPATCH 3 MO

DUAVEE 3 MO

esterified estrogens &methyltestosterone 1 QL(1 ea daily);

MOestradiol & norethindroneacetate 1 MO

FEMHRT 1/5 (UseNorethindrone Acetate-Ethinyl Estradiol)

GPMO

FEMHRT LOW DOSE 3 MO

JINTELI (UseNorethindrone Acetate-Ethinyl Estradiol)

GPMO

norethindrone acetate-ethinyl estradiol 1 MO

PREFEST 3 MO

PREMPHASE 2 MO

PREMPRO 0.3MG-1.5MG 2 QL(1 ea daily);MO

PREMPRO 0.45MG-1.5MG, 0.625MG-2.5MG,0.625MG-5MG

2MO

Estrogens

ALORA 0.025 MG/24HR 3 QL(0.27 eadaily); MO

Drug Name DrugTier

Requirements/Limits

ALORA 0.05 MG/24HR,0.075 MG/24HR, 0.1MG/24HR


CENESTIN 0.3 MG, 0.625MG, 0.9 MG, 1.25 MG 3 MO

CENESTIN 0.45 MG 3 QL(1 ea daily);MO

CLIMARA (Use Estradiol) GP QL(0.14 eadaily); MO

DIVIGEL 3 MO

ELESTRIN 3 MO

ENJUVIA 0.3 MG, 0.45MG, 1.25 MG 3 QL(1 ea daily);

MO

ENJUVIA 0.625 MG 3 QL(1 ea daily)

ENJUVIA 0.9 MG 3 MO

ESTRACE TABS OR 0.5MG, 1 MG, 2 MG (UseEstradiol)

GPMO

estradiol ptwk td 0.025mg/24hr, 0.05 mg/24hr,0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr

1

QL(0.14 eadaily); MO

estradiol tabs or 0.5 mg, 1mg, 2 mg 1 MO

ESTRASORB 3 QL(1.87 gmdaily); MO

ESTROGEL 3 QL(1.67 gmdaily); MO

estropipate 1 MO

EVAMIST 3 MO

FEMTRACE 3

MENEST 2 MO

MENOSTAR 3 QL(0.14 eadaily); MO

MINIVELLE 0.0375MG/24HR 2 MO

MINIVELLE 0.05MG/24HR, 0.075MG/24HR, 0.1 MG/24HR



56

Drug Name DrugTier

Requirements/Limits

PREMARIN TABS OR 0.3MG, 0.45 MG, 0.625 MG,0.9 MG, 1.25 MG

2MO

VIVELLE-DOT 0.025MG/24HR 3 QL(0.27 ea

daily); MOVIVELLE-DOT 0.0375MG/24HR 2 MO

VIVELLE-DOT 0.05MG/24HR, 0.075MG/24HR, 0.1 MG/24HR


FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolonesAVELOX ABC PACK (UseMoxifloxacin HCl) GP MO

AVELOX TABS OR 400MG (Use Moxifloxacin HCl) GP MO

CIPRO SUSR 5GM/100ML, 500 MG/5ML 2 MO

CIPRO TABS 250 MG, 500MG (Use CiprofloxacinHCl)

GPMO

CIPRO XR 1000MG (UseCiprofloxacin-CiprofloxacinHCl)


CIPRO XR 500MG (UseCiprofloxacin-CiprofloxacinHCl)

GPQL(3 ea per fillretail)

ciprofloxacin hcl 1 MO

ciprofloxacin-ciprofloxacinhcl 1000mg 1 QL(14 ea per

fill retail)ciprofloxacin-ciprofloxacinhcl 500mg 1 QL(3 ea per fill

retail)

FACTIVE 3 QL(7 ea per fillretail)

LEVAQUIN SOLN 25MG/ML (Use Levofloxacin) GP MO

LEVAQUIN TABS 250 MG,500 MG, 750 MG (UseLevofloxacin)


levofloxacin soln or 25mg/ml 1 MO

levofloxacin tabs or 250mg, 500 mg, 750 mg 1 QL(14 ea per

fill retail)

Drug Name DrugTier

Requirements/Limits

moxifloxacin hcl 1 MO

NOROXIN 3 MO

ofloxacin 200 mg 1

ofloxacin 300 mg, 400 mg 1

QL(28 ea per90 daysretail,28 ea per90 days mail);MO

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsGallstone Solubilizing AgentsACTIGALL (Use Ursodiol) GP MO

CHENODAL 3

URSO 250 (Use Ursodiol) GP MO

URSO FORTE (UseUrsodiol) GP MO

ursodiol 1 MO

Gastrointestinal Antiallergy Agentscromolyn sodium(mastocytosis) 1 MO

GASTROCROM (UseCromolyn Sodium(Mastocytosis))

GPMO

Gastrointestinal Chloride Channel ActivatorsAMITIZA 2 MO

Gastrointestinal Stimulantsmetoclopramide hcl soln or10 mg/10ml, 5 mg/5ml 1 MO

metoclopramide hcl tabs or10 mg, 5 mg 1 MO

METOZOLV ODT 10 MG 3

METOZOLV ODT 5 MG 3 MO

REGLAN (UseMetoclopramide HCl) GP MO

Inflammatory Bowel Agents


Drug Name DrugTier

Requirements/Limits

APRISO 3 MO

ASACOL 2 QL(12 ea daily)

ASACOL HD 2 MO

AZULFIDINE (UseSulfasalazine) GP MO

AZULFIDINE EN-TABS(Use Sulfasalazine) GP MO

balsalazide disodium 1 QL(9.4 eadaily); MO

CANASA 2 MO

CIMZIA 3 PA

COLAZAL (UseBalsalazide Disodium) GP QL(9.4 ea

daily); MO

DELZICOL 2 QL(12 eadaily); MO

DIPENTUM 3 MO

GIAZO 3 ST; QL(6 eadaily); MO

LIALDA 2 MO

mesalamine 1 MO

PENTASA 3 MO

SFROWASA 2 MO

sulfasalazine 1 MO

Intestinal Acidifierslactulose (encephalopathy) 1 MO

Irritable Bowel Syndrome (IBS) AgentsLINZESS 2 MO

LOTRONEX 3 MO

Peripheral Opioid Receptor AntagonistsENTEREG 3

RELISTOR 3 PA

Drug Name DrugTier

Requirements/Limits

Phosphate Binder Agentscalcium acetate (phosphatebinder) 1 MO

FOSRENOL 3 MO

PHOSLO (Use CalciumAcetate (PhosphateBinder))

GPMO

PHOSLYRA 3 MO

RENAGEL 3 MO

RENVELA 3 MO

VELPHORO 3 MO

Short Bowel Syndrome (SBS) AgentsGATTEX 3 PA

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemAcidifiersK-PHOS NO 2 2 MO

AlkalinizersCITROLITH 3

cytra-3 1 MO

CYTRA-K (Use PotassiumCitrate-Citric Acid) GP MO

ORACIT 3 MO

POTASSIUM CITRATE 2 MO

POTASSIUM CITRATE ER 2 MO

potassium citrate-citric acid 1 MO

SHOHLS SOLUTIONMODIFIED (Use SodiumCitrate & Citric Acid)

GPMO

sodium citrate & citric acid 1 MO

TRICITRATES 3


58

Drug Name DrugTier

Requirements/Limits

UROCIT-K 10 2 MO

UROCIT-K 15 2 MO

UROCIT-K 5 2 MO

Cystinosis AgentsCYSTAGON 3

PROCYSBI 3

Interstitial Cystitis AgentsELMIRON 3 MO

Prostatic Hypertrophy Agents

alfuzosin hcl 1 QL(1 ea daily);MO

AVODART 3 ST; MO

CARDURA XL 3 MO

finasteride 1 QL(1 ea daily);AL; MO

FLOMAX (Use TamsulosinHCl) GP QL(2 ea daily);

MO

JALYN 3 ST; MO

PROSCAR (UseFinasteride) GP QL(1 ea daily);

AL; MO

RAPAFLO 3 MO

tamsulosin hcl 1 QL(2 ea daily);MO

UROXATRAL (UseAlfuzosin HCl) GP QL(1 ea daily);

MOUrinary Analgesicsphenazopyridine hcl 1 MO

PYRIDIUM (UsePhenazopyridine HCl) GP MO

Urinary Stone AgentsLITHOSTAT 3 MO

THIOLA 3 MO

Drug Name DrugTier

Requirements/Limits

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinationscolchicine w/ probenecid 1 MO

Gout Agentsallopurinol 1 MO

COLCRYS (UseColchicine) GP MO

ULORIC 2 MO

ZYLOPRIM (UseAllopurinol) GP MO

Uricosuricsprobenecid 1 MO

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood DisordersBradykinin B2 Receptor AntagonistsFIRAZYR 3 PA

Complement InhibitorsBERINERT 3 PA

Hematorheologic Agentspentoxifylline 1 MO

TRENTAL (UsePentoxifylline) GP MO

Platelet Aggregation InhibitorsAGGRENOX 3 MO

AGRYLIN (Use AnagrelideHCl) GP MO

anagrelide hcl 1 MO

BRILINTA 2 MO

cilostazol 1 QL(2 ea daily);MO

clopidogrel bisulfate 300mg 1 QL(2 ea daily)

clopidogrel bisulfate 75 mg 1 QL(2 ea daily);MO


Drug Name DrugTier

Requirements/Limits

dipyridamole 1 MO

EFFIENT 2 MO

PERSANTINE (UseDipyridamole) GP MO

PLAVIX 300 MG (UseClopidogrel Bisulfate) GP QL(2 ea daily)

PLAVIX 75 MG (UseClopidogrel Bisulfate) GP QL(2 ea daily);

MO

PLETAL (Use Cilostazol) GP QL(2 ea daily);MO

ticlopidine hcl 1 MO

HEMATOPOIETIC AGENTS - Drugs to TreatBlood DisordersAgents for Gaucher DiseaseZAVESCA 3 PA

Agents for Sickle Cell AnemiaDROXIA AC

Folic Acid/Folatesfolic acid tabs or 1 mg 1 RX/OTC; MO

folic acid tabs or 400 mcg,800 mcg PV MO; PV

Hematopoietic Growth FactorsARANESP ALBUMINFREE 3 PA

EPOGEN 3 PA

GRANIX 3 PA; MO

LEUKINE 3 PA

NEULASTA 3 PA

NEUMEGA 3 PA

NEUPOGEN 3 PA

PROCRIT 3 PA

PROMACTA 3 PA

Drug Name DrugTier

Requirements/Limits

Hematopoietic MixturesFOLIVANE-F 2 MO

FUSION PLUS 3 MO

INTEGRA F 2 MO

NIRON KOMPLETE 3

Ironcarbonyl iron PV MO; PV

FER-IN-SOL (Use FerrousSulfate) GP MO; PV

ferrous sulfate elix 220mg/5ml PV MO; PV

ferrous sulfate soln 15mg/ml PV MO; PV

FERROUS SULFATESYRP 300 MG/5ML PV PV

ICAR PEDIATRIC (UseCarbonyl Iron) GP MO; PV

MYKIDZ IRON 10 PV MO; PV

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood DisordersHemostatics - SystemicAMICAR SYRP 25 % (UseAminocaproic Acid) GP MO

AMICAR TABS 1000 MG 3 MO

AMICAR TABS 500 MG(Use Aminocaproic Acid) GP MO

aminocaproic acid syrp or25 % 1 MO

AMINOCAPROIC ACIDTABS OR 1000 MG 3 MO

aminocaproic acid tabs or500 mg 1 MO

LYSTEDA (UseTranexamic Acid) GP QL(6 ea daily,5

day(s) limit)tranexamic acid tabs or 650mg 1 QL(6 ea daily,5

day(s) limit)

HYPNOTICS - Drugs to Help Sleep

Barbiturate HypnoticsPlease refer to pages ii - iii for a complete description of abbreviations.AC=Anticancer AL=Age Limit GP=Generic PreferredMO=Available at Mail Order NF=Non Formulary PA=Prior AuthorizationPV=$0 Co-pay QL=Quantity Limit ST=Step TherapyLast Updated: April 1, 2014

60

Drug Name DrugTier

Requirements/Limits

BUTISOL SODIUM 3 MO

phenobarbital elix 20mg/5ml 1 MO

phenobarbital soln 20mg/5ml 1 MO

PHENOBARBITAL TABS100 MG, 15 MG, 30 MG,60 MG

2MO

phenobarbital tabs 16.2mg, 30 mg, 32.4 mg, 64.8mg, 97.2 mg

1MO

SECONAL 3 MO

Hypnotics - Tricyclic Agents

SILENOR 3 ST; QL(1 eadaily); MO

Non-Barbiturate HypnoticsAMBIEN (Use ZolpidemTartrate) GP QL(1 ea daily);

MOAMBIEN CR (UseZolpidem Tartrate) GP QL(1 ea daily);

MO

DORAL 3 MO

EDLUAR 3 ST; QL(1 eadaily); MO

estazolam 1 MO

flurazepam hcl 1 MO

HALCION (Use Triazolam) GP MO

INTERMEZZO 3 PA; MO

LUNESTA 3 ST; QL(1 eadaily); MO

midazolam hcl syrp or 2mg/ml 1 MO

QUAZEPAM 3 MO

RESTORIL (UseTemazepam) GP MO

SOMNOTE 2

SONATA (Use Zaleplon) GP QL(1 ea daily);MO

Drug Name DrugTier

Requirements/Limits

temazepam 1 MO

triazolam 1 MO

zaleplon 1 QL(1 ea daily);MO

zolpidem tartrate 1 QL(1 ea daily);MO

ZOLPIMIST 3 ST; QL(0.26 mldaily); MO

Selective Melatonin Receptor Agonists

ROZEREM 3 ST; QL(1 eadaily); MO

LAXATIVES - Bowel Treatment Drugs

Laxative CombinationsCOLYTE-FLAVOR PACKS227.1GM-21.5GM-5.53GM-2.82GM-6.36GM

3

COLYTE-FLAVOR PACKS240GM-22.72GM-5.84GM-2.98GM-6.72GM (Use PEG3350-KCl-Sod Bicarb-SodChloride-Sod Sulfate)

GP

QL(4000 ml perfill retail)

GOLYTELY 227.1GM-21.5GM-5.53GM-2.82GM-6.36GM

2QL(4000 ea perfill retail)

GOLYTELY 236GM-22.74GM-5.86GM-2.97GM-6.74GM (Use PEG 3350-KCl-Sod Bicarb-SodChloride-Sod Sulfate)

GP

QL(4000 ml perfill retail)

HALFLYTELY BOWELPREP/FLAVOR PACKS 3

QL(1 ea per fillretail,1 ea perfill mail); MO

MOVIPREP 3 MO

NULYTELY/FLAVORPACKS (Use PEG 3350-Potassium Chloride-SodBicarbonate-Sod Chloride)

GP

MO

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 1 QL(4000 ml per

fill retail)peg 3350-potassiumchloride-sod bicarbonate-sod chloride

1MO


Drug Name DrugTier

Requirements/Limits

PREPOPIK 3 MO

SUCLEAR 3 MO

SUPREP BOWEL PREP 3 MO

Laxatives - MiscellaneousKRISTALOSE 3 MO

lactulose 1 MO

MIRALAX POWD (UsePolyethylene Glycol 3350) GP

QL(17.6 gmdaily); RX/OTC;MO

polyethylene glycol 3350powd 1

QL(17.6 gmdaily); RX/OTC;MO

Saline LaxativesOSMOPREP 3 MO

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycinAZITHROMYCIN PACKOR 1 GM 2 MO

azithromycin susr or 100mg/5ml, 200 mg/5ml 1 MO

azithromycin tabs or 250mg 1


azithromycin tabs or 500mg 1 QL(3 ea daily);

MO

azithromycin tabs or 600mg 1

QL(10 ea perfill retail,10 eaper fill mail);MO

ZITHROMAX PACK OR 1GM 2 MO

ZITHROMAX SUSR OR100 MG/5ML, 200 MG/5ML(Use Azithromycin)

GPMO

ZITHROMAX TABS OR250 MG (UseAzithromycin)

GPQL(6 ea per fillretail,6 ea perfill mail); MO

Drug Name DrugTier

Requirements/Limits

ZITHROMAX TABS OR500 MG (Use Azithromycin) GP QL(3 ea daily);

MO

ZITHROMAX TABS OR600 MG (Use Azithromycin) GP


ZITHROMAX TRI-PAK(Use Azithromycin) GP QL(3 ea daily);

MO

ZITHROMAX Z-PAK (UseAzithromycin) GP


ZMAX 2 QL(2 ea daily);MO

ClarithromycinBIAXIN (UseClarithromycin) GP MO

BIAXIN XL (UseClarithromycin) GP


BIAXIN XL PAC (UseClarithromycin) GP


clarithromycin susr 125mg/5ml, 250 mg/5ml 1 MO

clarithromycin tabs 250 mg,500 mg 1 MO

clarithromycin tb24 500 mg 1


Erythromycinse.e.s. 400 1 MO

E.E.S. GRANULES 2 MO

ERY-TAB 2 MO

ERYPED 200 2 MO

ERYPED 400 2 MO

erythrocin stearate 1 MO

erythromycin 1 MO


62

Drug Name DrugTier

Requirements/Limits

erythromycin base 1 MO

erythromycinethylsuccinate 1 MO

PCE 3 MO

FidaxomicinDIFICID 3 MO

MEDICAL DEVICES

Contraceptives

DIAPHRAGM PVQL(1 EA PER365 DAYSRETAIL);PV

FC FEMALE CONDOM PV PV

FC2 FEMALE CONDOM PV PV

FEMCAP PV PV

PRENTIF CAVITY-RIMCERVICAL CAP PV PV

Diabetic Supplies

FREESTYLE FREEDOMLITE 2

QL(1 ea per365 daysretail); RX/OTC

FREESTYLE INSULINXBLOODGLUCOSEMONITORING SYSTEM

2

QL(1 ea per365 daysretail);RX/OTC; MO

FREESTYLE LITE BLOODGLUCOSE MONITORINGSYSTEM

2QL(1 ea per365 daysretail); MO

ONETOUCH ULTRA 2 2QL(1 ea per365 daysretail); RX/OTC

ONETOUCH ULTRA MINI 2


ONETOUCH ULTRASYSTEM KIT 2


Drug Name DrugTier

Requirements/Limits

ONETOUCHULTRASMART 2


ONETOUCH VERIO IQBLOOD GLUCOSEMONITORING SYSTEM

2QL(1 ea per365 daysretail); RX/OTC

PRECISION XTRA 2QL(1 ea per365 daysretail); MO

Parenteral Therapy SuppliesINSULIN SYRINGES ANDPEN NEEDLES 2 MO

SPACER/AEROSOL-HOLDING CHAMBER 2

QL(1 EA PER365 DAYSRETAIL);RX/OTC

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadachesMigraine Combinationsacetaminophen-isometheptene-dichloralphenazone

1MO

CAFERGOT (UseErgotamine w/ Caffeine) GP MO

ISOMETHEPTENE/CAFFEINE/ACETAMINOPHEN 1 MO

MIGERGOT 2 MO

MIGRALAM 3

PRODRIN 130MG-500MG-20MG (UseAcetaminophen-Isometheptene-Caffeine)

GP

MO

PRODRIN 65MG-325MG-20MG 3 MO

TREXIMET 3 PA; QL(0.3 eadaily); MO

Migraine Products - NSAIDs

CAMBIA 3 QL(0.3 eadaily); MO

Migraine ProductsD.H.E. 45 (UseDihydroergotamineMesylate)

GP


Drug Name DrugTier

Requirements/Limits

dihydroergotaminemesylate ij 1 mg/ml 3

DIHYDROERGOTAMINEMESYLATE NA 4 MG/ML 3 QL(8 ml per fill

retail)

ERGOMAR 2

MIGRAL 3

MIGRANAL 3 QL(8 ml per fillretail)

Serotonin AgonistsAMERGE (Use NaratriptanHCl) GP QL(0.3 ea

daily); MO

AXERT 3 QL(0.2 eadaily); MO

FROVA 3 QL(0.3 eadaily); MO

IMITREX SOLN NA 20MG/ACT, 5 MG/ACT 2 QL(0.2 ea

daily); MO

IMITREX SOLN SC 6MG/0.5ML (UseSumatriptan Succinate)

GP

PA; QL(2 mlper fill retail,4ml per 30 daysretail)

IMITREX TABS OR 100MG, 25 MG, 50 MG (UseSumatriptan Succinate)

GPQL(0.3 eadaily); MO

MAXALT (Use RizatriptanBenzoate) GP QL(12 ea per

fill retail); MOMAXALT-MLT (UseRizatriptan Benzoate) GP QL(12 ea per

fill retail)

naratriptan hcl 1 QL(0.3 eadaily); MO

RELPAX 3 QL(0.2 eadaily); MO

rizatriptan benzoate tabs10 mg, 5 mg 1 QL(12 ea per

fill retail); MOrizatriptan benzoate tbdp10 mg, 5 mg 1 QL(12 ea per

fill retail)

SUMATRIPTAN 2 QL(0.2 eadaily); MO

SUMATRIPTANSUCCINATE SOLN SC 4MG/0.5ML

2PA; QL(0.14 mldaily); MO

sumatriptan succinate solnsc 4 mg/0.5ml 1 PA; QL(0.14 ml

daily); MO

Drug Name DrugTier

Requirements/Limits

sumatriptan succinate solnsc 6 mg/0.5ml 3

PA; QL(2 mlper fill retail,4ml per 30 daysretail)

sumatriptan succinate tabsor 100 mg, 25 mg, 50 mg 1 QL(0.3 ea

daily); MO

zolmitriptan 1 QL(0.2 eadaily); MO

ZOMIG NASAL SPRAY 3

QL(6 ea per 30days retail,18ea per 90 daysmail); MO

ZOMIG SOLN NA 2.5 MG,5 MG 3

QL(6 ea per 30days retail,18ea per 90 daysmail); MO

ZOMIG TABS OR 2.5 MG,5 MG (Use Zolmitriptan) GP QL(0.2 ea

daily); MOZOMIG ZMT (UseZolmitriptan) GP QL(0.2 ea

daily); MO

MINERALS & ELECTROLYTES

CalciumCALCIFOL 3

CALCIUM-FOLIC ACIDPLUS D 3 MO

FluorideFLUORABON PV MO; PV

flura-drops PV MO; PV

LOZI-FLUR PV MO; PV

LURIDE (Use SodiumFluoride) GP MO; PV

sodium fluoride chew 0.25mg, 0.5 mg, 0.55 mg, 1 mg,1.1 mg, 2.2 mg

PVMO; PV

sodium fluoride soln 0.125mg/drop, 0.5 mg/ml PV MO; PV

SODIUM FLUORIDE TABS0.5 MG, 1 MG PV PV

Iodine ProductsSSKI 2 MO


64

Drug Name DrugTier

Requirements/Limits

MagnesiumMAGNEBIND 400 3 MO

PhosphateK-PHOS 2 MO

K-PHOS NEUTRAL (UsePot Phosphate Monobasicw/ Sod Phosphate Dibasic& Monobasic)

GP

MO

pot phosphate monobasicw/ sod phosphate dibasic &monobasic

1MO

PotassiumEFFER-K 3 MO

K-LOR HOSPITAL PACK(Use Potassium Chloride) GP MO

K-TAB 10 MEQ (UsePotassium Chloride) GP MO

K-TAB 20 MEQ 3 MO

KLOR-CON 25 (UsePotassium Chloride) GP MO

KLOR-CON M15 (UsePotassium ChlorideMicroencapsulatedCrystals CR)

GP

MO

MICRO-K (Use PotassiumChloride) GP MO

potassium bicarb &chloride 1 MO

potassium bicarbonate 1 MO

potassium chloride cpcr or10 meq, 8 meq 1 MO

POTASSIUM CHLORIDEER 3 MO

potassium chloridemicroencapsulated crystalscr

1MO

potassium chloride pack or20 meq 1 MO

potassium chloride tbcr or10 meq, 8 meq 1 MO

Zinc

Drug Name DrugTier

Requirements/Limits

GALZIN 3 MO

zinc sulfate caps or 220 mg 1 RX/OTC; MO

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical OralFIRST-MOUTHWASH BLM 3 MO

lidocaine hcl (mouth-throat)2 % 1 MO

lidocaine hcl (mouth-throat)4 % 1

LTA 360 KIT (UseLidocaine HCl (Mouth-Throat))

GP

Anti-infectives - Throatclotrimazole 1 MO

FIRST-BXN MOUTHWASH 3 MO

FIRST-DUKESMOUTHWASH 3 MO

FIRST-MARYSMOUTHWASH 3

nystatin (mouth-throat) 1 MO

ORAVIG 3 MO

Steroids - Mouth/Throattriamcinolone acetonide(mouth) 1 MO

Throat Products - Misc.cevimeline hcl 1 MO

EVOXAC (Use CevimelineHCl) GP MO

GELCLAIR 3

MUCOTROL 3 MO

pilocarpine hcl (oral) 1 MO

SALAGEN (UsePilocarpine HCl (Oral)) GP MO

MULTIVITAMINS


Drug Name DrugTier

Requirements/Limits

Ped MV w/ Fluoridepediatric multivitamins w/fl 1 AL; MO

pediatric vitamins acd w/fluoride 1 AL; MO

POLY-VI-FLOR CHEW200MCG-0.25MG-15UNIT-400UNIT, 200MCG-0.5MG-15UNIT-400UNIT,200MCG-1MG-15UNIT-400UNIT

3

AL; MO

POLY-VI-FLOR SUSP200MCG/ML-0.25MG/ML 3 MO

QUFLORA PEDIATRIC 2 AL; MO

TRI-VI-FLOR 3 MO

TRI-VI-FLORO 3 MO

Ped Multi Vitamins w/Fl & FEESCAVITE LQ 2 MO

MULTI-VIT/IRON/FLUORIDE 2 MO

MULTI-VITAMIN/FLUORIDE/IRON 2 MO

MYKIDZ IRON FL 3

POLY-VI-FLOR/IRONCHEW 200MCG-0.5MG-10MG-15UNIT-400UNIT

3AL; MO

POLY-VI-FLOR/IRONSUSP 200MCG/ML-7MG/ML-0.25MG/ML

3MO

tri-vit/fluoride/iron 1 AL; MO

Prenatal VitaminsACTIVE OB 3

ATABEX EC 2

B-NEXA 3 MO

BAL-CARE DHA 2 MO

BAL-CARE DHAESSENTIAL 3

Drug Name DrugTier

Requirements/Limits

BP MULTINATAL PLUS 2

C-NATE DHA 3 MO

CAVAN ONE OMEGA 3 MO

CAVAN-ALPHA KIT 2 MO

CAVAN-EC SOD DHA 2 MO

CHOICE-OB+DHA 3 MO

CITRANATAL 90 DHA 2 MO

CITRANATAL ASSURE(Use Prenatal w/o Vit A w/Fe Carbonyl-Fe Gluconate-DSS-FA-DHA)

GP

MO

CITRANATAL B-CALM 3 MO

CITRANATAL DHA 2 MO

CITRANATAL HARMONY 3 MO

CITRANATAL RX (UsePrenatal without Vit A w/ FeCarbonyl-Fe Gluc-Docusate-FA)

GP

MO

COMPLETE-RFPRENATAL (Use Prenatalwithout A w/ Fe Carbonyl-Docusate-Folic Acid)

GP

COMPLETENATE 2 MO

CONCEPT DHA 2 MO

CONCEPT OB 2 MO

DUET DHA 3 MO

DUET DHA 400 3 MO

DUET DHA 400EC 3 MO

DUET DHA 430 3 MO

DUET DHA 430EC 3


66

Drug Name DrugTier

Requirements/Limits

DUET DHA BALANCED220MCG-24MG-2900UNIT-2MG-25MG-25MG-1.2MG-210MG-15MG-4MG-12MCG-840UNIT-1MG-2MG-45MG-115MG, 278MG-210MCG-26MG-2840UNIT-2MG-25MG-25MG-1.5MG-215MG-20MG-4MG-12MCG-840UNIT-1MG-2MG-50MG-120MG

3

DUET DHA BALANCED267MG-65MCG-210MCG-25MG-2800UNIT-1.8MG-25MG-25MG-1.5MG-215MG-20MG-55MG-2MG-12MCG-640UNIT-1MG-15MG-50MG-120MG,380MG-3MG-220MCG-27MG-2850UNIT-2MG-25MG-25MG-1.8MG-219MG-20MG-4MG-12MCG-840UNIT-1MG-50MG-120MG

3

MO

DUET DHA EC 400MG-2825UNIT-3MG-220MCG-25MG-2MG-25MG-25MG-1.8MG-200MG-20MG-4MG-12MCG-800UNIT-1MG-45MG-120MG

3

MO

DUET DHA EC 430MG-2825UNIT-3MG-220MCG-25MG-2MG-25MG-25MG-1.8MG-200MG-20MG-4MG-12MCG-800UNIT-1MG-45MG-120MG

3

ELITE-OB 400 3

EXTRA-VIRT PLUS DHA 3 MO

FOCALGIN-B 3 MO

FOLCAL DHA 3 MO

FOLCAPS OMEGA 3 3 MO

FOLIVANE-EC CALCIUMDHA NF 2 MO

Drug Name DrugTier

Requirements/Limits

FOLIVANE-OB 2 MO

GESTICARE DHA 2 MO

HEMENATAL OB 3 MO

HEMENATAL OB + DHA 2 MO

inatal advance 1 MO

inatal gt 1 MO

inatal ultra 1 MO

INFANATE BALANCE 3 MO

LEVOMEFOLATE PNV 3

MACNATAL CN DHA 3 MO

MARNATAL-F 2 MO

MOMS CHOICE RX 3

MYNATAL ADVANCE 2 MO

MYNATAL ULTRACAPLET 2 MO

MYNATE 90 PLUS (UsePrenatal Vit w/ Docusate-Fe Fumarate-Folic Acid)

GP

NATA KOMPLETE 3 MO

NATACHEW 3

NATAFORT 2

NATALVIRT 90 DHA 2 MO

NATALVIRT CA (UsePrenatal w/o Vit A w/ FeCarbonyl-Fe Gluconate-DSS-FA-DHA)

GP

MO

NATELLE ONE 3 MO

NEEVO 3

NEEVO DHA 3 MO


Drug Name DrugTier

Requirements/Limits

NESTABS 3 MO

NESTABS ABC 3

NESTABS DHA 2 MO

NEXA PLUS 3 MO

NEXA SELECT 325MG-160MG-55MG-29MG-800UNIT-1.25MG-30UNIT-25MG-28MG

3

MO

NEXA SELECT 337.5MG-750MG-160MG-55MG-29MG-800UNIT-1.25MG-30UNIT-28MG-28MG

3

NUTRI-TAB OB 3 MO

NUTRI-TAB OB + DHA 2 MO

OB COMPLETE 3

OB COMPLETE 400 3 MO

OB COMPLETE ONE 3 MO

OB COMPLETE PETITE 3 MO

OB COMPLETE PREMIER 3 MO

OB COMPLETE/DHA 3 MO

OB-NATAL ONE 3 MO

PAIRE OB 2 MO

PNV FERROUSFUMARATE/DOCUSATE/FOLIC ACID

3MO

PNV OB+DHA 2 MO

PNV-DHA 3 MO

PNV-DHA+DOCUSATE 3 MO

PNV-FIRST 3 MO

PNV-OMEGA 3 MO

Drug Name DrugTier

Requirements/Limits

PNV-SELECT 3 MO

PNV-TOTAL 3

PR NATAL 400 EC (UsePrenatal MV & Min w/FeBisglyc-Fe Prot Succ-FA-CA-Omega 3)

GP

MO

PR NATAL 430 (UsePrenatal MV & Min w/FeBisglyc-Fe Prot Succ-FA-CA-Omega 3)

GP

MO

PR NATAL 430 EC (UsePrenatal MV & Min w/FeBisglyc-Fe Prot Succ-FA-CA-Omega 3)

GP

MO

PREFERA OB 3 MO

PREFERA OB + DHA 2 MO

PREFOL-DHA 3 MO

PRENA1CHEW/QUATREFOLIC 3 MO

PRENA1 PEARL 3 MO

PRENA1PLUS/QUATREFOLIC 3 MO

PRENA1/QUATREFOLIC 3 MO

PRENAISSANCE 3 MO

PRENAISSANCE 90 DHA 2 MO

PRENAISSANCEBALANCE 3 MO

PRENAISSANCE DHA 2 MO

PRENAISSANCEHARMONY DHA 3 MO

PRENAISSANCE NEXT 3 MO

PRENAISSANCE NEXT-B 3 MO

PRENAISSANCE PLUS 3 MO


68

Drug Name DrugTier

Requirements/Limits

PRENAISSANCEPROMISE (Use Prenatalw/o Vit A w/ Fe Carbonyl-Fe Gluconate-DSS-FA-DHA)

GP

MO

PRENATA 2 MO

prenatal 19 chew 1000unit-400unit-20mg-25mg-3mg-200mg-29mg-7mg-6mg-3mg-12mcg-1mg-30unit-20mg-100mg

1

MO

PRENATAL 19 CHEW30UNIT-1000UNIT-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG-100MG

2

MO

PRENATAL 19 TABS1000UNIT-30UNIT-20MG-25MG-3MG-200MG-29MG-15MG-3MG-7MG-12MCG-400UNIT-20MG-1MG-100MG, 30UNIT-1000UNIT-20MG-25MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG-100MG

3

MO

PRENATAL MV & MIN/FE-FA-DHA 3

prenatal vit w/ docusate-iron carbonyl-folic acid 1 MO

PRENATAL-U 2 MO

PRENATE 3 MO

PRENATE AM 3 MO

PRENATE DHA 2 QL(1 ea daily);MO

PRENATE ELITE 2 MO

PRENATE ENHANCE 3

PRENATE MINI 3 MO

PRENATE RESTORE 3

Drug Name DrugTier

Requirements/Limits

PRENEXA 3 MO

PREQUE 10 3 MO

PROVIDA OB 2 MO

R-NATAL OB 3

REAPHIRM 3 MO

RELNATE DHA 3 MO

SE-CARE CONCEIVE 2

SE-NATAL 19 CHEW30UNIT-1000UNIT-100MG-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG

2

MO

SE-NATAL 19 TABS30UNIT-1000UNIT-20MG-25MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-3MG-20MG-1MG-100MG

3

MO

SE-NATAL 90 (UsePrenatal Vit w/ Docusate-Fe Fumarate-Folic Acid)

GP

SELECT-OB 3 MO

SELECT-OB+DHA 3 MO

SETON ET-EC (UsePrenatal MV & Min w/FeBisglyc-Fe Prot Succ-FA-CA-Omega 3)

GP

MO

SETONET (Use PrenatalMV & Min w/Fe Bisglyc-FeProt Succ-FA-CA-Omega3)

GP

MO

TARON EC CALCIUM 2 MO

TARON-BC 3 MO

TARON-C DHA 2 MO


Drug Name DrugTier

Requirements/Limits

TARON-DUO EC (UsePrenatal MV & Min w/FeBisglyc-Fe Prot Succ-FA-CA-Omega 3)

GP

MO

TARON-PREX 3 MO

TL-ASSURE ONE 3 MO

TL-ASSURE+DHA 3 MO

TL-CARE DHA 3 MO

TL-SELECT 3 MO

TL-SELECT DHA 3 MO

TRI RX (Use Prenatalwithout Vit A w/ FeCarbonyl-Fe Gluc-Docusate-FA)

GP

MO

TRI-TABS DHA 2 MO

triadvance 1 MO

TRICARE DHA 301 3

TRICARE PRENATALCOMPLEAT 3

TRICARE PRENATALDHA ONE 3 MO

TRINATAL GT 2 MO

TRINATAL ULTRA 2 MO

TRIVEEN-ONE 3

TRIVEEN-PRX RNF 3 MO

TRIVEEN-TEN 3 MO

TRIVEEN-U 2 MO

ULTIMATE OB DHA 2 MO

ULTIMATECAREADVANTAGE 3 MO

ULTIMATECARE COMBO 3 MO

Drug Name DrugTier

Requirements/Limits

ULTIMATECARE ONE 3 MO

ULTIMATECARE ONE NF 3 MO

ultra tabs 1 MO

V-NATAL 3 MO

V-NATAL DHA 2 MO

VEMAVITE-PRX 2 3 MO

VENA-BAL DHA 2 MO

VENATAL COMPLETEDHA 2 MO

VINACAL (Use Prenatalwithout Vit A w/ FeCarbonyl-Fe Gluc-Docusate-FA)

GP

MO

VINACAL B 3 MO

VINATE C 2

VINATE CALCIUM 2

VINATE DHA 3 MO

VINATE DHA RF 3 MO

VINATE GT 2 MO

VINATE ULTRA 2 MO

VIRT-BAL DHA 3

VIRT-BAL DHA PLUS 3 MO

VIRT-PN 3 MO

VIRT-PN DHA 3 MO

VIRT-PN PLUS 3 MO

VIRT-SELECT 3 MO

VITAFOL ULTRA 2 MO

VITAFOL-NANO 3 MO


70

Drug Name DrugTier

Requirements/Limits

VITAFOL-ONE 3 MO

VITAFOL-PLUS 3

VITAMEDMD ONERX/QUATREFOLIC 3 MO

VITAMEDMD PLUSRX/QUATREFOLIC 3 MO

VITAMEDMD REDICHEWRX/QUATREFOLIC 3 MO

VITAPEARL 3 MO

VIVA CT PRENATAL 3

VIVA DHA 3 MO

VP-CH PLUS 3 MO

VP-CH-PNV 3 MO

VP-GGR-B6 PRENATAL 3 MO

VP-HEME OB 3 MO

VP-HEME OB + DHA 2 MO

VP-PNV-DHA 3

ZATEAN-CH 3 MO

ZATEAN-PN 3 MO

ZATEAN-PN DHA 3 MO

ZATEAN-PN PLUS 3 MO

ZINGIBER 3 MO

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxants

AMRIX 3 ST; QL(1 eadaily); MO

baclofen 1 MO

CARISOPRODOL 250 MG 3 MO

Drug Name DrugTier

Requirements/Limits

carisoprodol 350 mg 1 MO

chlorzoxazone 1 MO

cyclobenzaprine hcl 1 MO

FEXMID (UseCyclobenzaprine HCl) GP MO

FLEXERIL (UseCyclobenzaprine HCl) GP MO

LORZONE 3 MO

metaxalone 1 MO

methocarbamol 1 MO

orphenadrine citrate tb12 or100 mg 1 MO

PARAFON FORTE DSC(Use Chlorzoxazone) GP MO

ROBAXIN TABS OR 500MG (Use Methocarbamol) GP MO

ROBAXIN-750 (UseMethocarbamol) GP MO

SKELAXIN (UseMetaxalone) GP MO

SOMA 250 MG 3 MO

SOMA 350 MG (UseCarisoprodol) GP MO

tizanidine hcl 1 MO

ZANAFLEX (UseTizanidine HCl) GP MO

Direct Muscle RelaxantsDANTRIUM (UseDantrolene Sodium) GP MO

dantrolene sodium caps or100 mg, 25 mg, 50 mg 1 MO

Muscle Relaxant Combinationscarisoprodol w/ aspirin 1 MO

carisoprodol w/ aspirin &codeine 1 MO

orphenadrine compound ds 1


Drug Name DrugTier

Requirements/Limits

orphenadrine w/ aspirin &caff 1

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Agent Combinations

DYMISTA 3 QL(0.77 gmdaily); MO

Nasal Anti-infectivesBACTROBAN NASAL 2 MO

Nasal AntiallergyASTELIN (Use AzelastineHCl) GP QL(1.2 ml

daily); MO

ASTEPRO 2 QL(1 ml daily);MO

azelastine hcl 1 QL(1.2 mldaily); MO

PATANASE 3 MO

Nasal AnticholinergicsATROVENT (UseIpratropium Bromide(Nasal))

GPMO

ipratropium bromide (nasal) 1 MO

Nasal Steroids

BECONASE AQ 3 QL(1.67 gmdaily); MO

FLONASE (UseFluticasone Propionate(Nasal))


flunisolide 0.025 % 1 MO

FLUNISOLIDE 29MCG/ACT 3

fluticasone propionate(nasal) 1 QL(1.1 gm

daily); MONASACORT AQ (UseTriamcinolone Acetonide(Nasal))


NASONEX 2 QL(1.14 gmdaily); MO

OMNARIS 3 MO

Drug Name DrugTier

Requirements/Limits

QNASL 3 MO

RHINOCORT AQUA 3 QL(0.6 gmdaily); MO

triamcinolone acetonide(nasal) 1 QL(1.2 gm

daily); MO

VERAMYST 3 QL(0.34 gmdaily); MO

ZETONNA 3 QL(0.3 gmdaily); MO

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze MusclesALS AgentsRILUTEK (Use Riluzole) GP MO

riluzole 1 MO

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and LubricantsLACRISERT 3 MO

Beta-blockers - OphthalmicBETAGAN (UseLevobunolol HCl) GP MO

betaxolol hcl (ophth) 1 MO

BETIMOL 2 MO

BETOPTIC-S 2 MO

carteolol hcl (ophth) 1 MO

COMBIGAN 3 MO

COSOPT (UseDorzolamide HCl-TimololMaleate)

GPMO

COSOPT PF 3 MO

dorzolamide hcl-timololmaleate 1 MO

ISTALOL 2 MO

levobunolol hcl 1 MO


72

Drug Name DrugTier

Requirements/Limits

metipranolol 1 MO

OPTIPRANOLOL (UseMetipranolol) GP MO

timolol maleate (ophth) 1 MO

TIMOPTIC (Use TimololMaleate (Ophth)) GP MO

TIMOPTIC OCUDOSE 3 MO

TIMOPTIC-XE (UseTimolol Maleate (Ophth)) GP MO

Cycloplegic Mydriaticsatropine sulfate(ophthalmic) 1 MO

ATROPINE SULFATEOINT OP 1 % (UseAtropine Sulfate(Ophthalmic))

GP

MO

CYCLOGYL 0.5 % 2 MO

CYCLOGYL 1 %, 2 % (UseCyclopentolate HCl) GP MO

CYCLOMYDRIL 3 MO

cyclopentolate hcl 1 MO

homatropine hbr 1

ISOPTO ATROPINE (UseAtropine Sulfate(Ophthalmic))

GPMO

ISOPTO HOMATROPINE2 % 2

ISOPTO HOMATROPINE5 % (Use HomatropineHBr)

GP

ISOPTO HYOSCINE 2

MYDRIACYL (UseTropicamide) GP MO

tropicamide 1 MO

MioticsPHOSPHOLINE IODIDE 2

Ophthalmic Adrenergic Agents

Drug Name DrugTier

Requirements/Limits

ALPHAGAN P 0.1 % 2 MO

ALPHAGAN P 0.15 % (UseBrimonidine Tartrate) GP MO

apraclonidine hcl 1 MO

brimonidine tartrate 1 MO

IOPIDINE 0.5 % (UseApraclonidine HCl) GP MO

IOPIDINE 1 % 3 MO

SIMBRINZA 3 MO

Ophthalmic Anti-infectives

AZASITE 3 QL(0.17 mldaily); MO

BACITRACIN 2 MO

bacitracin (ophthalmic) 1 MO

bacitracin-polymyxin b(ophth) 1 MO

BESIVANCE 3 MO

BETADINE OPHTHALMICPREP 3

BLEPH-10 (UseSulfacetamide Sodium(Ophth))

GPMO

CILOXAN OINT 2 MO

CILOXAN SOLN (UseCiprofloxacin HCl (Ophth)) GP MO

ciprofloxacin hcl (ophth) 1 MO

erythromycin (ophth) 1 MO

GARAMYCIN (UseGentamicin Sulfate(Ophth))

GPMO

gatifloxacin (ophth) 1 MO

gentamicin sulfate (ophth) 1 MO

levofloxacin (ophth) 1 MO


Drug Name DrugTier

Requirements/Limits

MOXEZA 2 MO

NATACYN 2 MO

neomycin-bacitracin zn-polymyxin 1 MO

neomycin-polymyxin-gramicidin 1 MO

NEOSPORIN (UseNeomycin-Polymyxin-Gramicidin)

GPMO

OCUFLOX (Use Ofloxacin(Ophth)) GP

QL(5 ml per fillretail,5 ml perfill mail); MO

ofloxacin (ophth) 1QL(5 ml per fillretail,5 ml perfill mail); MO

polymyxin b-trimethoprim 1 MO

POLYTRIM (UsePolymyxin B-Trimethoprim) GP MO

sulfacetamide sodium(ophth) 1 MO

SULFACETAMIDESODIUM OINT OP 2 MO

tobramycin sulfate (ophth) 1 MO

TOBREX OINT 2 MO

TOBREX SOLN (UseTobramycin Sulfate(Ophth))

GPMO

trifluridine 1 MO

VIGAMOX 2QL(3 ml per fillretail,3 ml perfill mail); MO

VIROPTIC (UseTrifluridine) GP MO

ZIRGAN 3 MO

ZYMAXID (UseGatifloxacin (Ophth)) GP MO

Ophthalmic DecongestantsMYDFRIN (UsePhenylephrine HCl(Ophth))

GPMO

Drug Name DrugTier

Requirements/Limits

NAPHAZOLINE HCL 3 MO

phenylephrine hcl (ophth) 1 MO

Ophthalmic Immunomodulators

RESTASIS 3 QL(2.14 eadaily); MO

Ophthalmic Local AnestheticsAKTEN 3

ALCAINE (UseProparacaine HCl) GP MO

proparacaine hcl 1 MO

tetracaine hcl (ophth) 1 MO

Ophthalmic SteroidsALREX 3 MO

bacitracin-poly-neomycin-hc 1

QL(4 gm per fillretail,4 gm perfill mail); MO

BLEPHAMIDE 2 MO

BLEPHAMIDE S.O.P. 2 MO

dexamethasone sodiumphosphate (ophth) 1 MO

DUREZOL 3 MO

FLAREX 2 MO

fluorometholone (ophth) 1 MO

FML 2 MO

FML FORTE 2 MO

FML LIQUIFILM (UseFluorometholone (Ophth)) GP MO

LOTEMAX 3 MO

MAXIDEX 2 MO

MAXITROL (UseNeomycin-Polymy-Dexameth)

GPMO


74

Drug Name DrugTier

Requirements/Limits

neomycin-polymy-dexameth 1 MO

neomycin/polymyxin/hydrocortisone 1 MO

OMNIPRED (UsePrednisolone Acetate(Ophth))

GPMO

PRED FORTE (UsePrednisolone Acetate(Ophth))

GPMO

PRED MILD 2 MO

PRED-G 3 MO

PRED-G S.O.P. 3 MO

prednisolone acetate(ophth) 1 MO

PREDNISOLONE SODIUMPHOSPHATE OP 1 % (UsePrednisolone SodiumPhosphate (Ophth))

GP

MO

sulfacetamide sod-prednisolone 1 MO

TOBRADEX OINT 3 MO

TOBRADEX ST 3 MO

TOBRADEX SUSP (UseTobramycin-Dexamethasone)

GPQL(5 ml per fillretail)

tobramycin-dexamethasone 1 QL(5 ml per fill

retail)

VEXOL 3 MO

ZYLET 2QL(5 ml per fillretail,5 ml perfill mail); MO

Ophthalmic Surgical AidsGELFILM OP 3

Ophthalmics - Misc.ACULAR (Use KetorolacTromethamine (Ophth)) GP MO

ACULAR LS (UseKetorolac Tromethamine(Ophth))

GPMO

Drug Name DrugTier

Requirements/Limits

ACUVAIL 3 MO

ALOCRIL 3 MO

ALOMIDE 2 MO

azelastine hcl (ophth) 1 MO

AZOPT 2 QL(0.4 mldaily); MO

BEPREVE 3 QL(0.34 mldaily); MO

BROMDAY 3

BROMFENAC 3 MO

bromfenac sodium (ophth) 1

cromolyn sodium (ophth) 1 MO

CYSTARAN 3 QL(2.15 mldaily)

diclofenac sodium (ophth) 1 MO

dorzolamide hcl 1 MO

ELESTAT (Use EpinastineHCl (Ophth)) GP MO

EMADINE 3 MO

epinastine hcl (ophth) 1 MO

flurbiprofen sodium 1 MO

ILEVRO 3 MO

ketorolac tromethamine(ophth) 1 MO

LASTACAFT 2 MO

NEVANAC 3 MO

OCUFEN (UseFlurbiprofen Sodium) GP MO

OPTIVAR (Use AzelastineHCl (Ophth)) GP MO

PAREMYD 3


Drug Name DrugTier

Requirements/Limits

PATADAY 2 QL(0.09 mldaily); MO

PATANOL 3 QL(0.34 mldaily); MO

PROLENSA 3 MO

TRUSOPT (UseDorzolamide HCl) GP MO

VOLTAREN SOLN OP 0.1% (Use Diclofenac Sodium(Ophth))

GPMO

Prostaglandins - Ophthalmic

latanoprost 1 QL(0.09 mldaily); MO

LUMIGAN 0.01 % 2 QL(0.09 mldaily); MO

LUMIGAN 0.03 % 2 QL(0.09 mldaily)

RESCULA 3 QL(0.17 mldaily); MO

TRAVATAN Z 2 QL(0.09 mldaily); MO

TRAVOPROST 2 QL(0.09 mldaily); MO

XALATAN (UseLatanoprost) GP QL(0.09 ml

daily); MO

ZIOPTAN 3 MO

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneousacetic acid (otic) 1 MO

ACETIC ACID/ALUMINUMACETATE (Use AceticAcid-Aluminum Acetate)

GPMO

CRESYLATE 3 MO

Otic AnalgesicsPINNACAINE OTIC 3 MO

Otic Anti-infectivesCETRAXAL 3 MO

CIPROFLOXACIN 3 MO

Drug Name DrugTier

Requirements/Limits

ofloxacin (otic) 1 MO

Otic CombinationsCIPRO HC 3 MO

CIPRODEX 2QL(8 ml per fillretail,8 ml perfill mail); MO

COLY-MYCIN S 3 MO

CORTANE-B AQUEOUS(Use Pramoxine-HC-Chloroxylenol Aqueous)

GPMO

CORTANE-B-OTIC (UsePramoxine-HC-Chloroxylenol)

GPMO

CORTISPORIN SOLN OT10000UNIT/ML-3.5MG/ML-1% (Use Neomycin-Polymyxin-HC (Otic))

GP

MO

CORTISPORIN-TC 3 MO

MYOXIN 3

neomycin-polymyxin-hc(otic) 1 MO

OTICIN HC NR (UsePramoxine-HC-Chloroxylenol)

GPMO

PRAMOTIC (UsePramoxine-Chloroxylenol) GP MO

pramoxine-chloroxylenol 1 MO

pramoxine-hc-chloroxylenol 1 MO

pramoxine-hc-chloroxylenolaqueous 1 MO

Otic SteroidsDERMOTIC (UseFluocinolone Acetonide(Otic))

GPMO

fluocinolone acetonide(otic) 1 MO

hydrocortisone w/aceticacid 1

QL(10 ml perfill retail,30 mlper fill mail);MO


76

Drug Name DrugTier

Requirements/Limits

VOSOL HC (UseHydrocortisone w/AceticAcid)

GP

QL(10 ml perfill retail,30 mlper fill mail);MO

OXYTOCICS - Drugs to Prevent/Control UterineBleedingOxytocicsMETHERGINE TABS OR0.2 MG (UseMethylergonovine Maleate)

GPMO

methylergonovine maleatetabs or 0.2 mg 1 MO

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillinsamoxicillin caps 250 mg,500 mg 1 MO

AMOXICILLIN CHEW 125MG, 250 MG (UseAmoxicillin)

GPMO

amoxicillin susr 125mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

1MO

amoxicillin tabs 500 mg,875 mg 1 MO

ampicillin caps 250 mg,500 mg 1 MO

ampicillin susr 125 mg/5ml 1

ampicillin susr 250 mg/5ml 1 MO

MOXATAG 3

PA; QL(1 eadaily,10 ea perfill retail,10 eaper fill mail);MO

Natural Penicillinspenicillin v potassium 1 MO

Penicillin Combinationsamoxicillin & potclavulanate 1 MO

AUGMENTIN ES-600 (UseAmoxicillin & PotClavulanate)

GPMO

Drug Name DrugTier

Requirements/Limits

AUGMENTIN SUSR125MG/5ML-31.25MG/5ML 2 MO

AUGMENTIN SUSR250MG/5ML-62.5MG/5ML(Use Amoxicillin & PotClavulanate)

GP

MO

AUGMENTIN TABS500MG-125MG, 875MG-125MG (Use Amoxicillin &Pot Clavulanate)

GP

MO

AUGMENTIN XR (UseAmoxicillin & PotClavulanate)

GPMO

Penicillinase-Resistant Penicillinsdicloxacillin sodium 1 MO

PROGESTINS - Hormone Replacement/ModifyingDrugsProgestinsAYGESTIN (UseNorethindrone Acetate) GP MO

medroxyprogesteroneacetate 1 MO

MEGACE ES 3 MO

norethindrone acetate 1 MO

progesterone 1 MO

progesterone micronized 1 QL(2 ea daily);MO

PROMETRIUM (UseProgesterone Micronized) GP QL(2 ea daily);

MOPROVERA (UseMedroxyprogesteroneAcetate)

GPMO

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependencyacamprosate calcium 1 PA; MO

ANTABUSE (UseDisulfiram) GP MO

CAMPRAL (UseAcamprosate Calcium) GP PA; MO


Drug Name DrugTier

Requirements/Limits

disulfiram 1 MO

Anti-Cataplectic AgentsXYREM 3 PA

Antidementia AgentsARICEPT (Use DonepezilHydrochloride) GP QL(1 ea daily);

MOARICEPT ODT (UseDonepezil Hydrochloride) GP QL(1 ea daily);

MO

donepezil hydrochloride 1 QL(1 ea daily);MO

EXELON CAPS OR 1.5MG, 3 MG, 4.5 MG, 6 MG(Use Rivastigmine Tartrate)

GPMO

EXELON PT24 TD 13.3MG/24HR, 4.6 MG/24HR,9.5 MG/24HR

2MO

EXELON SOLN OR 2MG/ML 2 MO

galantamine hydrobromide 1 MO

NAMENDA 3 PA; MO

NAMENDA XR 3 PA; MO

RAZADYNE (UseGalantamineHydrobromide)

GPMO

RAZADYNE ER (UseGalantamineHydrobromide)

GPMO

rivastigmine tartrate 1 MO

Combination PsychotherapeuticsCHLORDIAZEPOXIDE/AMITRIPTYLINE 3 MO

olanzapine-fluoxetine hcl 1 MO

PERPHENAZINE/AMITRIPTYLINE 3 MO

SYMBYAX (UseOlanzapine-FluoxetineHCl)

GPMO

Fibromyalgia Agents

Drug Name DrugTier

Requirements/Limits

SAVELLA 3 PA; QL(2 eadaily); MO

Movement Disorder Drug TherapyXENAZINE 3

Multiple Sclerosis AgentsAMPYRA 3 PA

AUBAGIO 3 PA

AVONEX 3 PA

AVONEX PEN 3 PA

BETASERON 3 PA

COPAXONE 3 PA

EXTAVIA 3 PA

GILENYA 3 PA

REBIF 3 PA

REBIF REBIDOSE 3 PA

TECFIDERA 3 PA

TECFIDERA STARTERPACK 3 PA

Postherpetic Neuralgia (PHN) AgentsGRALISE 3 PA; MO

Premenstrual Dysphoric Disorder (PMDD) Agentsfluoxetine hcl (pmdd) 1 MO

SARAFEM 3 MO

Pseudobulbar Affect (PBA) AgentsNUEDEXTA 2 MO

Psychotherapeutic and Neurological Agents -ERGOLOID MESYLATES 3 MO

ORAP 3 MO


78

Drug Name DrugTier

Requirements/Limits

Restless Leg Syndrome (RLS) Agents

HORIZANT 300 MG 3 QL(2 ea daily);MO

HORIZANT 600 MG 3 QL(1 ea daily);MO

Smoking Deterrentsbupropion hcl (smokingdeterrent) 1 PA; MO

CHANTIX 3 PA; MO

NICOTROL INHALER 3 PA; MO

NICOTROL NS 3 PA; MO

ZYBAN (Use BupropionHCl (Smoking Deterrent)) GP PA; MO

Vasomotor Symptom AgentsBRISDELLE 3

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung ConditionsCystic Fibrosis AgentsKALYDECO 3 PA

PULMOZYME 3 QL(2.5 mldaily)

SULFONAMIDES - Drugs to Treat BacterialInfectionsSulfonamidesSULFADIAZINE 3 MO

TETRACYCLINES - Drugs to Treat BacterialInfectionsTetracyclinesADOXA CAPS 150 MG(Use Doxycycline(Monohydrate))

GPMO

ADOXA PAK 1/100 (UseDoxycycline(Monohydrate))

GPST; MO


GPST; MO

Drug Name DrugTier

Requirements/Limits


GPST; MO

ADOXA TABS 100 MG, 50MG, 75 MG (UseDoxycycline(Monohydrate))

GP

ST; MO

demeclocycline hcl 1 MO

DORYX 150 MG (UseDoxycycline Hyclate) GP ST; MO

DORYX 200 MG 3 PA; MO

DOXYCYCLINE (UseDoxycycline(Monohydrate))

GPMO

doxycycline (monohydrate)caps 100 mg, 150 mg, 50mg, 75 mg

1MO

doxycycline (monohydrate)tabs 100 mg, 150 mg, 50mg, 75 mg

1ST; MO

doxycycline hyclate caps or100 mg, 50 mg 1 MO

DOXYCYCLINE HYCLATECPEP OR 100 MG 3

doxycycline hyclate tabs or100 mg 1 MO

doxycycline hyclate tbec or100 mg, 150 mg, 75 mg 1 ST; MO

DYNACIN 100 MG, 50 MG(Use Minocycline HCl) GP MO

DYNACIN 75 MG (UseMinocycline HCl) GP PA; MO

MINOCIN (UseMinocycline HCl) GP MO

minocycline hcl caps 100mg, 50 mg, 75 mg 1 MO

minocycline hcl tabs 100mg, 50 mg 1 MO

minocycline hcl tabs 75 mg 1 PA; MO

minocycline hcl tb24 135mg, 45 mg, 90 mg 1 ST; MO

MONODOX (UseDoxycycline(Monohydrate))

GPMO


Drug Name DrugTier

Requirements/Limits

ORAXYL 3

SOLODYN 3 ST; MO

tetracycline hcl 250 mg 1 MO

TETRACYCLINE HCL 500MG 2

VIBRAMYCIN CAPS 100MG (Use DoxycyclineHyclate)

GPMO

VIBRAMYCIN SUSR 25MG/5ML (Use Doxycycline(Monohydrate))

GPMO

VIBRAMYCIN SYRP 50MG/5ML 2 MO

THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agentsmethimazole 1 MO

propylthiouracil 1 MO

TAPAZOLE (UseMethimazole) GP MO

Thyroid HormonesARMOUR THYROID 120MG, 15 MG, 180 MG, 240MG, 300 MG

2MO

ARMOUR THYROID 30MG, 60 MG, 90 MG (UseThyroid)

GPMO

CYTOMEL (UseLiothyronine Sodium) GP MO

levothyroxine sodium 1 MO

liothyronine sodium tabs or25 mcg, 5 mcg, 50 mcg 1 MO

NATURE-THROID 113.75MG, 146.25 MG, 16.25MG, 48.75 MG, 81.25 MG,97.5 MG

2

MO

NATURE-THROID 130MG, 195 MG, 32.5 MG, 65MG (Use Thyroid)

GPMO

NATURE-THROID 260MG, 325 MG 2

Drug Name DrugTier

Requirements/Limits

NATURE-THROID NT-2.5 3 MO

SYNTHROID (UseLevothyroxine Sodium) GP MO

thyroid 1 MO

THYROLAR-1 3 MO

THYROLAR-1/2 3 MO

THYROLAR-1/4 3 MO

THYROLAR-2 3 MO

THYROLAR-3 3 MO

TIROSINT 3 MO

WESTHROID 113.75 MG,146.25 MG, 16.25 MG,48.75 MG, 81.25 MG, 97.5MG

2

MO

WESTHROID 162.5 MG 3 MO

WESTHROID 260 MG, 325MG 2

WESTHROID-P 2 MO

WP THYROID 113.75 MG,16.25 MG, 48.75 MG, 97.5MG

2MO

WP THYROID 130 MG,32.5 MG, 65 MG (UseThyroid)

GPMO

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodicsANASPAZ (UseHyoscyamine Sulfate) GP MO

BELLADONNA & OPIUM 3 MO

BELLADONNAALKALOIDS 3

BELLADONNAALKALOIDS & OPIUM 3 MO

belladonna alkaloids-phenobarbital 1 MO


80

Drug Name DrugTier

Requirements/Limits

BENTYL (Use DicyclomineHCl) GP MO

CANTIL 3 MO

clidinium &chlordiazepoxide 1 MO

CUVPOSA 2 MO

dicyclomine hcl caps 10 mg 1 MO

DICYCLOMINE HCL SOLN10 MG/5ML 2 MO

dicyclomine hcl tabs 20 mg 1 MO

DIGEX NF (UseHyoscyamine-Phenyltoloxamine)

GPMO

DONNATAL (UseBelladonna Alkaloids-Phenobarbital)

GPMO

DONNATAL EXTENTABS(Use Belladonna Alkaloids-Phenobarbital)

GPMO

GASTRINEX NF 3 MO

GLYCATE 3

glycopyrrolate tabs or 1mg, 2 mg 1 MO

hyoscyamine sulfate 1 MO

LIBRAX (Use Clidinium &Chlordiazepoxide) GP MO

methscopolamine bromide 1 MO

PAMINE (UseMethscopolamine Bromide) GP MO

PAMINE FORTE (UseMethscopolamine Bromide) GP MO

PAMINE FQ 3 MO

propantheline bromide 1 MO

ROBINUL FORTE (UseGlycopyrrolate) GP MO

ROBINUL TABS OR 1 MG(Use Glycopyrrolate) GP MO

Drug Name DrugTier

Requirements/Limits

H-2 AntagonistsAXID (Use Nizatidine) GP MO

cimetidine 300 mg, 400 mg,800 mg 1 MO

cimetidine hcl 1 MO

famotidine susr 40 mg/5ml 1 MO

famotidine tabs 40 mg 1 QL(2 ea daily);MO

nizatidine 1 MO

PEPCID SUSR 40 MG/5ML(Use Famotidine) GP MO

PEPCID TABS 40 MG (UseFamotidine) GP QL(2 ea daily);

MO

ranitidine hcl 1 MO

ZANTAC SYRP OR 15MG/ML (Use RanitidineHCl)

GPMO

ZANTAC TABS OR 300MG (Use Ranitidine HCl) GP MO

ZANTAC TBEF OR 25 MG 3

Misc. Anti-UlcerCARAFATE SUSP 1GM/10ML 2 MO

CARAFATE TABS 1 GM(Use Sucralfate) GP MO

sucralfate 1 MO

Proton Pump InhibitorsACIPHEX (UseRabeprazole Sodium) GP PA; QL(2 ea

daily); MO

ACIPHEX SPRINKLE 3 PA; MO

DEXILANT 3 PA; QL(1 eadaily); MO

ESOMEPRAZOLESTRONTIUM 3 PA; QL(1 ea

daily); MO

FIRST-LANSOPRAZOLE 3 MO

FIRST-OMEPRAZOLE 3 MO


Drug Name DrugTier

Requirements/Limits

lansoprazole 15 mg 1 QL(1 ea daily);RX/OTC; MO

lansoprazole 30 mg 1 QL(1 ea daily);MO

lansoprazole 30 mg 1 PA; QL(1 eadaily); MO

NEXIUM CPDR 20 MG, 40MG 3 PA; QL(1 ea

daily); MONEXIUM PACK 10 MG, 2.5MG, 20 MG, 40 MG, 5 MG 3 PA; MO

OMEPRAZOLE +SYRSPEND SFALKA 3 MO

omeprazole 10 mg 1 MO

omeprazole 20 mg, 40 mg 1 QL(1 ea daily);MO

pantoprazole sodium tbecor 20 mg, 40 mg 1 QL(1 ea daily);

MOPREVACID 15 MG (UseLansoprazole) GP QL(1 ea daily);

RX/OTC; MOPREVACID 30 MG (UseLansoprazole) GP QL(1 ea daily);

MO

PREVACID SOLUTAB 3 QL(1 ea daily);AL; MO

PRILOSEC CPDR 10 MG(Use Omeprazole) GP MO

PRILOSEC CPDR 20 MG,40 MG (Use Omeprazole) GP QL(1 ea daily);

MOPRILOSEC PACK 10 MG,2.5 MG 3 PA; MO

PROTONIX PACK OR 40MG 3 MO

PROTONIX TBEC OR 20MG, 40 MG (UsePantoprazole Sodium)

GPQL(1 ea daily);MO

rabeprazole sodium 1 PA; QL(2 eadaily); MO

Ulcer Drugs - ProstaglandinsCYTOTEC (UseMisoprostol) GP MO

misoprostol 1 MO

Ulcer Therapy Combinationsamoxicillin-clarithromycinw/ lansoprazole 1 MO

Drug Name DrugTier

Requirements/Limits

HELIDAC 3 MO

OMECLAMOX-PAK 3 MO

omeprazole-sodiumbicarbonate 40mg-1100mg 1 PA; MO

PREVPAC (UseAmoxicillin-Clarithromycinw/ Lansoprazole)

GPMO

PYLERA 3 MO

ZEGERID CAPS 40MG-1100MG (Use Omeprazole-Sodium Bicarbonate)

GPPA; MO

ZEGERID PACK 20MG-1680MG, 40MG-1680MG 3 MO

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney InfectionsUrinary Anti-infective Combinationsmethenamine-hyosc-methylene blue-benzoicacid-phenyl sal

1MO

methenamine-hyosc-methylene blue-sod phos-phenyl sal

1MO

PROSED/DS (UseMethenamine-Hyosc-Methylene Blue-BenzoicAcid-Phenyl Sal)

GP

MO

URELLE 3 MO

URETRON D/S 3

URIBEL 3 MO

URIMAR-T 3

UROQID #2 3 MO

Urinary Anti-infectivesFURADANTIN (UseNitrofurantoin) GP MO

HIPREX (UseMethenamine Hippurate) GP MO

MACROBID (UseNitrofurantoin MonohydMacro)

GPMO


82

Drug Name DrugTier

Requirements/Limits

MACRODANTIN 100 MG,50 MG (Use NitrofurantoinMacrocrystal)

GPMO

MACRODANTIN 25 MG 2 MO

methenamine hippurate 1 MO

METHENAMINEMANDELATE 0.5 GM (UseMethenamine Mandelate)

GPMO

methenamine mandelate 1gm 1 MO

MONUROL 3 MO

nitrofurantoin 1 MO

nitrofurantoin macrocrystal 1 MO

nitrofurantoin monohydmacro 1 MO

UREX (Use MethenamineHippurate) GP MO

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodic - AntimuscarinicsDETROL 1 MG (UseTolterodine Tartrate) GP QL(2 ea daily);

MODETROL 2 MG (UseTolterodine Tartrate) GP MO

DETROL LA (UseTolterodine Tartrate) GP QL(1 ea daily);

MODITROPAN XL (UseOxybutynin Chloride) GP MO

ENABLEX 3 MO

GELNIQUE 3 MO

oxybutynin chloride 1 MO

SANCTURA (UseTrospium Chloride) GP MO

tolterodine tartrate cp24 2mg, 4 mg 1 QL(1 ea daily);

MOtolterodine tartrate tabs 1mg 1 QL(2 ea daily);

MOtolterodine tartrate tabs 2mg 1 MO

Drug Name DrugTier

Requirements/Limits

TOVIAZ 2 QL(1 ea daily);MO

trospium chloride 1 MO

VESICARE 3 MO

Urinary Antispasmodics - Beta-3 Adrenergic

MYRBETRIQ 3 QL(1 ea daily);MO

Urinary Antispasmodics - Cholinergic Agonistsbethanechol chloride 1 MO

URECHOLINE (UseBethanechol Chloride) GP MO

Urinary Antispasmodics - Direct Muscle Relaxantsflavoxate hcl 1 MO

VACCINES

Bacterial Vaccines

VIVOTIF BERNA 3 QL(4 ea per fillretail)

Viral VaccinesFLUMISTQUADRIVALENT PV PV

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low HormonesMiscellaneous Vaginal ProductsFEM PH (Use Acetic Acid-Oxyquinoline Vaginal) GP MO

RELAGARD (Use AceticAcid-Oxyquinoline Vaginal) GP MO

SpermicidesENCARE PV PV

OPTIONS CONCEPTROLVAGINALCONTRACEPTIVE

PVPV

OPTIONS GYNOL IIVAGINALCONTRACEPTIVE

PVMO; PV

SHUR-SEAL PV PV

VCF VAGINALCONTRACEPTIVE FILM PV PV


Drug Name DrugTier

Requirements/Limits

VCF VAGINALCONTRACEPTIVE FOAM PV PV

Vaginal Anti-infectivesAVC 3 MO

CLEOCIN CREA VA 2 %(Use ClindamycinPhosphate Vaginal)

GPMO

CLEOCIN SUPP VA 100MG 3 MO

clindamycin phosphatevaginal 1 MO

CLINDESSE 3 MO

GYNAZOLE-1 3

METROGEL-VAGINAL(Use MetronidazoleVaginal)

GPMO

metronidazole vaginal 1 MO

MICONAZOLE 3 3 MO

NYSTATIN VAGINAL 2

TERAZOL 3 (UseTerconazole Vaginal) GP MO

TERAZOL 7 (UseTerconazole Vaginal) GP MO

terconazole vaginal 1 MO

Vaginal EstrogensESTRACE CREA VA 0.1MG/GM 2 MO

ESTRING 3 MO

FEMRING 3

QL(1 ea per 90days retail,1 eaper 90 daysmail); MO

PREMARIN CREA VA0.625 MG/GM 2 MO

VAGIFEM 3 MO

Vaginal ProgestinsCRINONE 8 % 3 PA; MO

Drug Name DrugTier

Requirements/Limits

ENDOMETRIN 3 PA; MO

VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy Agents

ADRENACLICK 3 QL(4 ea per fillretail)

AUVI-Q 2 QL(4 ea per fillretail)

EPIPEN 2-PAK 2 QL(4 ea per fillretail)

EPIPEN-JR 2-PAK 2 QL(4 ea per fillretail)

TWINJECT 3 QL(4 ea per fillretail)

Vasopressorsmidodrine hcl 1 MO

VITAMINS

Oil Soluble VitaminsBABY DDROPS (UseCholecalciferol) GP AL; PV

cholecalciferol chew 400unit PV AL; PV

cholecalciferol liqd 400unit/ml PV AL; MO; PV

cholecalciferol liqd 400unt/0.03ml PV AL; PV

cholecalciferol tabs 400unit PV AL; MO; PV

CVS VITAMIN D3 PV AL; PV

D-VI-SOL (UseCholecalciferol) GP AL; MO; PV

D3 PV AL; PV

DRISDOL (UseErgocalciferol) GP MO

ergocalciferol 1 MO

MEPHYTON 2 MO

VITAMIN D PV AL; PV


84

Drug Name DrugTier

Requirements/Limits

VITAMIN D2 PV AL; PV

VITAMIN D3 PV AL; PV

VITAMIN D3 400 PV AL; PV

WELLESSE VITAMIN D3 PV AL; PV

Water Soluble VitaminsAMINOBENZOATEPOTASSIUM 3

POTABA CAPS 3 MO

POTABA TABS 3


Index8-MOP 46abacavir sulfate 32abacavir sulfate-lamivudine-zidovudine 32ABILIFY 31ABILIFY DISCMELT 31ABSORICA 43ABSTRAL 5acamprosate calcium 77ACANYA 43acarbose 18ACCOLATE 12ACCU-CHEK AVIVA PLUS 52ACCU-CHEK SMARTVIEWSTRIPS 52ACCUNEB 13ACCUPRIL 24ACCURETIC 25acebutolol hcl 35ACEON 24acetaminophen w/ codeine 7acetaminophen-isometheptene-dichloralphenazone 63acetaminophen-salicylamide-phenyltoloxamine 4ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINEBITARTRATE 7acetazolamide 53acetic acid (otic) 76ACETIC ACID/ALUMINUMACETATE 76acetylcysteine 43ACIPHEX 81ACIPHEX SPRINKLE 81acitretin 10 mg 46acitretin 17.5 mg 46acitretin 25 mg 46ACLOVATE 47ACTEMRA 3ACTIGALL 57ACTIQ 5ACTIVE OB 66ACTIVELLA 56ACTONEL 150 MG 54ACTONEL 30 MG, 5 MG 54ACTONEL 35 MG 54ACTOPLUS MET 18ACTOPLUS MET XR 18

ACTOS 19ACULAR 75ACULAR LS 75ACUVAIL 75acyclovir 33acyclovir topical 47ACZONE 43ADALAT CC 30 MG, 60MG 36ADALAT CC 90 MG 36adapalene 43ADCIRCA 37ADDERALL 1ADDERALL XR 1adefovir dipivoxil 33ADEMPAS 37ADIPEX-P 1ADOXA 100 MG, 50 MG, 75MG 79ADOXA 150 MG 79ADOXA PAK 1/100 79ADOXA PAK 1/150 79ADOXA PAK 2/100 79ADRENACLICK 84ADVAIR DISKUS 13ADVAIR HFA 13ADVICOR 20MG-1000MG,20MG-500MG, 20MG-750MG 23ADVICOR 40MG-1000MG 24AEROSPAN 12AFINITOR 29AFINITOR DISPERZ 29AGGRENOX 59AGRYLIN 59AHIST 22AKNE-MYCIN 43AKTEN 74ALA QUIN 45ALA SCALP 47ALAGESIC LQ 4ALAHIST AC 41ALAHIST DHC 41ALBATUSSIN 41ALBATUSSIN NN 41ALBENZA 9

albuterol sulfate 0.083 %, 0.5 %,0.63 mg/3ml, 1.25 mg/3ml 13albuterol sulfate 2 mg, 4 mg 13albuterol sulfate 2 mg/5ml 13albuterol sulfate 4 mg, 8 mg 13ALCAINE 74alclometasone dipropionate 47ALCORTIN A 45ALDACTAZIDE 25MG-25MG 53ALDACTAZIDE 50MG-50MG 53ALDACTONE 53ALDARA 50alendronate sodium 10 mg, 5mg 54alendronate sodium 35 mg, 70mg 54alendronate sodium 40 mg 54alendronate sodium 70mg/75ml 54ALFERON N 29alfuzosin hcl 59ALINIA 10ALKERAN 2 MG 28ALLFEN CD 41ALLFEN CDX 41allopurinol 59ALOCRIL 75ALOMIDE 75ALOQUIN 45ALORA 0.025 MG/24HR 56ALORA 0.05 MG/24HR, 0.075MG/24HR, 0.1 MG/24HR 56ALPAIN 4ALPHAGAN P 0.1 % 73ALPHAGAN P 0.15 % 73alprazolam 11ALPRAZOLAM INTENSOL 11ALREX 74ALTABAX 45ALTACE 1.25 MG, 2.5 MG, 5MG 24ALTACE 10 MG 24ALTOPREV 24aluminum chloride 51ALUVEA 49ALVESCO 12amantadine hcl 100 mg 30AMANTADINE HCL 100 MG 30

Index 1

amantadine hcl 50 mg/5ml 30AMARYL 20AMBIEN 61AMBIEN CR 61AMBIFED CD 41AMBIFED CDX 41AMBIFED-G CD 41AMBIFED-G CDX 41amcinonide 47AMCINONIDE 47AMERGE 64AMETHYST 38AMICAR 1000 MG 60AMICAR 25 % 60AMICAR 500 MG 60amiloride &hydrochlorothiazide 53amiloride hcl 53AMINOBENZOATEPOTASSIUM 85AMINOCAPROIC ACID 1000MG 60aminocaproic acid 25 % 60aminocaproic acid 500 mg 60AMINOPHYLLINE 100 MG, 200MG 14amiodarone hcl 12AMITIZA 57amitriptyline hcl 18amlodipine besylate 36amlodipine besylate-atorvastatincalcium 37amlodipine besylate-benazeprilhcl 25AMLODIPINEBESYLATE/ATORVASTATINCALCIUM 37AMOXAPINE 18amoxicillin & pot clavulanate 77AMOXICILLIN 125 MG, 250MG 77amoxicillin 125 mg/5ml, 200mg/5ml, 250 mg/5ml, 400mg/5ml 77amoxicillin 250 mg, 500 mg 77amoxicillin 500 mg, 875 mg 77amoxicillin-clarithromycin w/lansoprazole 82

amphetamine-dextroamphetamine 1.25mg-1.25mg-1.25mg-1.25mg,1.875mg-1.875mg-1.875mg-1.875mg, 2.5mg-2.5mg-2.5mg-2.5mg, 3.125mg-3.125mg-3.125mg-3.125mg, 3.75mg-3.75mg-3.75mg-3.75mg, 5mg-5mg-5mg-5mg, 7.5mg-7.5mg-7.5mg-7.5mg 1amphetamine-dextroamphetamine 1.25mg-1.25mg-1.25mg-1.25mg,2.5mg-2.5mg-2.5mg-2.5mg,3.75mg-3.75mg-3.75mg-3.75mg, 5mg-5mg-5mg-5mg,6.25mg-6.25mg-6.25mg-6.25mg, 7.5mg-7.5mg-7.5mg-7.5mg 1ampicillin 125 mg/5ml 77ampicillin 250 mg, 500 mg 77ampicillin 250 mg/5ml 77AMPYRA 78AMRIX 71AMTURNIDE 25ANABAR 4ANADROL-50 9ANAFRANIL 18anagrelide hcl 59ANALPRAM-HC 9ANAPROX 3ANAPROX DS 3ANASPAZ 80anastrozole 28ANCOBON 250 MG 21ANCOBON 500 MG 21ANDRODERM 9ANDROGEL 9ANDROGEL PUMP 9ANDROXY 9ANGELIQ 56ANORO ELLIPTA 13ANTABUSE 77ANTARA 130 MG, 43 MG 23ANTARA 30 MG, 90 MG 23ANTIVERT 50 MG 21ANUSOL-HC 9ANZEMET 100 MG, 50MG 21APEXICON E 47

APIDRA 19APIDRA SOLOSTAR 19APLENZIN 16APOKYN 30apraclonidine hcl 73APRISO 58APTIOM 15APTIVUS 100 MG/ML 32APTIVUS 250 MG 32ARALEN 27ARANESP ALBUMIN FREE 60ARAVA 10 MG 4ARAVA 20 MG 4ARCALYST 3ARCAPTA NEOHALER 13ARICEPT 78ARICEPT ODT 78ARIMIDEX 28ARIXTRA 14ARMOUR THYROID 120 MG, 15MG, 180 MG, 240 MG, 300MG 80ARMOUR THYROID 30 MG, 60MG, 90 MG 80AROMASIN 28ARTHROTEC 50 3ARTHROTEC 75 3ASACOL 58ASACOL HD 58ASCRIPTIN 5ASMANEX 120 METEREDDOSES 12ASMANEX 14 METEREDDOSES 13ASMANEX 30 METEREDDOSES 13ASMANEX 60 METEREDDOSES 13ASMANEX 7 METEREDDOSES 13aspirin 324 mg, 325 mg, 81mg 5aspirin 325 mg 5aspirin 81 mg 5ASPIRIN LOW DOSE 5ASPIRIN-CAFFEINE-DIHYDROCODEINE 7ASTAGRAF XL 0.5 MG, 1MG 34ASTAGRAF XL 5 MG 34ASTELIN 72

Index 2

ASTEPRO 72ATABEX EC 66ATACAND 25ATACAND HCT 25ATELVIA 54atenolol 35atenolol & chlorthalidone 25ATIVAN 0.5 MG, 1 MG, 2MG 11atorvastatin calcium 24atovaquone 10atovaquone-proguanil hcl 27ATOVAQUONE/PROGUANILHCL 27ATRALIN 43ATRIPLA 32atropine sulfate (ophthalmic) 73ATROPINE SULFATE 1 % 73ATROVENT 72ATROVENT HFA 12AUBAGIO 78AUGMENTIN 125MG/5ML-31.25MG/5ML 77AUGMENTIN 250MG/5ML-62.5MG/5ML 77AUGMENTIN 500MG-125MG,875MG-125MG 77AUGMENTIN ES-600 77AUGMENTIN XR 77AUVI-Q 84AVALIDE 25AVANDAMET 18AVANDARYL 19AVANDIA 19AVAPRO 25AVAR 43AVAR LS 43AVAR LS CLEANSER 43AVAR-E LS 43AVC 84AVELOX 400 MG 57AVELOX ABC PACK 57AVINZA 5AVODART 59AVONEX 78AVONEX PEN 78AXERT 64AXID 81

AXIRON 9AYGESTIN 77AZASAN 34AZASITE 73azathioprine 34azelastine hcl 72azelastine hcl (ophth) 75AZELEX 43AZILECT 30AZITHROMYCIN 1 GM 62azithromycin 100 mg/5ml, 200mg/5ml 62azithromycin 250 mg 62azithromycin 500 mg 62azithromycin 600 mg 62AZOPT 75AZOR 25AZULFIDINE 58AZULFIDINE EN-TABS 58B-NEXA 66BABY DDROPS 84BACITRACIN 73bacitracin (ophthalmic) 73bacitracin-poly-neomycin-hc

74bacitracin-polymyxin b(ophth) 73baclofen 71BACTRIM 10BACTRIM DS 10BACTROBAN 45BACTROBAN NASAL 72BAL-CARE DHA 66BAL-CARE DHAESSENTIAL 66balsalazide disodium 58BANZEL 15BARACLUDE 33BECONASE AQ 72BELLADONNA & OPIUM 80BELLADONNAALKALOIDS 80BELLADONNA ALKALOIDS &OPIUM 80belladonna alkaloids-phenobarbital 80BELVIQ 1benazepril &hydrochlorothiazide 25benazepril hcl 24

BENICAR 25BENICAR HCT 25BENSAL HP 50BENTYL 81BENZACLIN 43BENZACLIN WITH PUMP 43benzonatate 41benztropine mesylate 0.5 mg, 1mg, 2 mg 30BEPREVE 75BERINERT 59BESIVANCE 73BETADINE OPHTHALMICPREP 73BETAGAN 72betamethasone dipropionate(topical) 47betamethasone dipropionateaugmented 47betamethasone valerate 47BETAPACE 35BETAPACE AF 35BETASERON 78betaxolol hcl 35betaxolol hcl (ophth) 72bethanechol chloride 83BETHKIS 2BETIMOL 72BETOPTIC-S 72BEYAZ 38BIAXIN 62BIAXIN XL 62BIAXIN XL PAC 62bicalutamide 28BIDIL 37BILTRICIDE 10BINOSTO 54BIO-STATIN 1000000 UNIT 21BIO-STATIN 500000 UNIT 22BIOREGESIC 4bisoprolol &hydrochlorothiazide 25bisoprolol fumarate 35BLEPH-10 73BLEPHAMIDE 74BLEPHAMIDE S.O.P. 74BONIVA 54BONTRIL PDM 1

Index 3

BOSULIF 29BP MULTINATAL PLUS 66BRAVELLE 54BREO ELLIPTA 13BREVICON-28 38BRILINTA 59brimonidine tartrate 73BRINTELLIX 17BRISDELLE 79BROMDAY 75BROMFENAC 75bromfenac sodium (ophth) 75bromocriptine mesylate 30BROMPHENIRAMINETANNATE 22BRONCOMAR-1 12BRONCOPECTOL 41BROVANA 13budesonide 40budesonide (inhalation) 0.25mg/2ml 13budesonide (inhalation) 0.5mg/2ml 13bumetanide 0.5 mg, 1 mg, 2mg 53BUPAP 300MG-50MG 4BUPAP 650MG-50MG 5BUPHENYL 3 GM/TSP 55BUPHENYL 500 MG 55buprenorphine hcl 2 mg 8buprenorphine hcl 8 mg 8buprenorphine hcl-naloxone hcldihydrate 2mg-0.5mg 8buprenorphine hcl-naloxone hcldihydrate 8mg-2mg 8bupropion hcl (smokingdeterrent) 79bupropion hcl 100 mg, 150 mg,200 mg 16bupropion hcl 100 mg, 75mg 16bupropion hcl 150 mg, 300mg 17buspirone hcl 11butalbital-acetaminophen 325mg-50mg 5butalbital-acetaminophen 650mg-50mg 5butalbital-acetaminophen-caffeine 5butalbital-acetaminophen-caffeine w/ codeine 7

butalbital-aspirin-caffeine 5butalbital-aspirin-caffeinew/cod 7BUTALBITAL/ASPIRIN/CAFFEINE 5BUTISOL SODIUM 61butorphanol tartrate 10mg/ml 8BUTRANS 8BYDUREON 19BYETTA 19BYSTOLIC 35C-NATE DHA 66cabergoline 55CADUET 10MG-10MG, 10MG-2.5MG, 10MG-5MG, 20MG-2.5MG, 20MG-5MG, 40MG-2.5MG, 40MG-5MG, 80MG-10MG, 80MG-5MG 37CADUET 20MG-10MG, 40MG-10MG 37CAFCIT 1CAFERGOT 63caffeine citrate 1CALAN 36CALAN SR 36CALCIFOL 64calcipotriene 46calcitonin (salmon) 54calcitriol (topical) 46calcitriol 0.25 mcg, 0.5mcg 55calcitriol 1 mcg/ml 55calcium acetate (phosphatebinder) 58CALCIUM-FOLIC ACID PLUSD 64CAMBIA 63CAMPRAL 77CANASA 58candesartan cilexetil 25candesartan cilexetil-hydrochlorothiazide 26CANTIL 81capecitabine 28CAPEX 47CAPITAL/CODEINE 7CAPRELSA 29captopril 24captopril/hydrochlorothiazide25mg-15mg, 50mg-15mg 26

CAPTOPRIL/HYDROCHLOROTHIAZIDE 25MG-25MG, 50MG-25MG 26CARAC 46CARAFATE 1 GM 81CARAFATE 1 GM/10ML 81CARBAGLU 55carbamazepine 15CARBAPHEN 12 41CARBAPHEN 12 PED 41CARBATROL 15carbidopa 30carbidopa-levodopa 30CARBIDOPA/LEVODOPA/ENTACAPONE 30carbinoxamine maleate 22carbonyl iron 60CARDENE SR 30 MG, 60MG 36CARDENE SR 45 MG 36CARDIZEM 36CARDIZEM CD 36CARDIZEM LA 120 MG 36CARDIZEM LA 180 MG, 240 MG,300 MG, 360 MG, 420 MG 36CARDURA 25CARDURA XL 59CARISOPRODOL 250 MG 71carisoprodol 350 mg 71carisoprodol w/ aspirin 71carisoprodol w/ aspirin &codeine 71CARMOL-HC 47CARNITOR 1 GM/10ML 55CARNITOR 330 MG 55CARNITOR SF 55carteolol hcl (ophth) 72carvedilol 12.5 mg, 25 mg, 6.25mg 35carvedilol 3.125 mg 35CASODEX 28CATAFLAM 3CATAPRES 25CATAPRES-TTS-1 25CATAPRES-TTS-2 25CATAPRES-TTS-3 25CAVAN ONE OMEGA 66CAVAN-ALPHA KIT 66CAVAN-EC SOD DHA 66

Index 4

CAYSTON 10CEDAX 180 MG/5ML 38CEDAX 400 MG 37CEDAX 90 MG/5ML 38CEENU 28CEFACLOR 125 MG/5ML, 250MG/5ML, 375 MG/5ML 37cefaclor 250 mg, 500 mg 37CEFACLOR ER 37cefadroxil 37cefdinir 38CEFDITOREN PIVOXIL 38cefpodoxime proxetil 38cefprozil 37CEFTIBUTEN 38CEFTIN 37cefuroxime axetil 37CELEBREX 100 MG, 200 MG 3CELEBREX 400 MG 3CELEBREX 50 MG 3CELESTONE 40CELEXA 10 MG 17CELEXA 20 MG 17CELEXA 40 MG 17CELLCEPT 200 MG/ML 34CELLCEPT 250 MG 34CELLCEPT 500 MG 34CELONTIN 16CEM-UREA 49CENESTIN 0.3 MG, 0.625 MG,0.9 MG, 1.25 MG 56CENESTIN 0.45 MG 56CENTANY 45CENTANY AT 45cephalexin 125 mg/5ml, 250mg/5ml 37CEPHALEXIN 250 MG, 500MG 37cephalexin 250 mg, 500 mg, 750mg 37CESAMET 21CETRAXAL 76CETROTIDE 54cevimeline hcl 65CHANTIX 79CHEMET 21CHENODAL 57chlordiazepoxide hcl 11

CHLORDIAZEPOXIDE/AMITRIPTYLINE 78chloroquine phosphate 27CHLOROTHIAZIDE 250MG 53chlorothiazide 250 mg, 500mg 53chlorpromazine hcl 10 mg, 100mg, 200 mg, 25 mg, 50 mg31CHLORPROPAMIDE 20CHLORTHALIDONE 100MG 53CHLORTHALIDONE 25MG 53CHLORTHALIDONE 50MG 53chlorzoxazone 71CHOICE-OB+DHA 66cholecalciferol 400 unit 84cholecalciferol 400 unit/ml 84cholecalciferol 400unt/0.03ml 84cholestyramine 23cholestyramine light 23choline & mag salicylate 1000mg, 500 mg, 750 mg 5choline & mag salicylate 500mg/5ml 5choline fenofibrate 23chorionic gonadotropin 54CIALIS 2.5 MG, 5 MG 37CICLODAN SOLUTIONKIT 45ciclopirox 45ciclopirox olamine 45cilostazol 59CILOXAN 73cimetidine 300 mg, 400 mg,800 mg 81cimetidine hcl 81CIMZIA 58CIPRO 250 MG, 500 MG 57CIPRO 5 GM/100ML, 500MG/5ML 57CIPRO HC 76CIPRO XR 1000MG 57CIPRO XR 500MG 57CIPRODEX 76CIPROFLOXACIN 76ciprofloxacin hcl 57ciprofloxacin hcl (ophth) 73

ciprofloxacin-ciprofloxacin hcl1000mg 57ciprofloxacin-ciprofloxacin hcl500mg 57citalopram hydrobromide 10mg 17citalopram hydrobromide 10mg/5ml 17citalopram hydrobromide 20mg 17citalopram hydrobromide 40mg 17CITRANATAL 90 DHA 66CITRANATAL ASSURE 66CITRANATAL B-CALM 66CITRANATAL DHA 66CITRANATAL HARMONY 66CITRANATAL RX 66CITROLITH 58CLARAVIS 43CLARIFOAM EF 43CLARINEX 0.5 MG/ML 22CLARINEX 5 MG 22CLARINEX REDITABS 22CLARINEX-D 12 HOUR 41CLARINEX-D 24 HOUR 41clarithromycin 125 mg/5ml, 250mg/5ml 62clarithromycin 250 mg, 500mg 62clarithromycin 500 mg 62clemastine fumarate 22CLEOCIN 100 MG 84CLEOCIN 150 MG, 300 MG, 75MG 10CLEOCIN 2 % 84CLEOCIN PEDIATRICGRANULES 10CLEOCIN-T 43clidinium & chlordiazepoxide 81CLIMARA 56CLIMARA PRO 56CLINDAGEL 43clindamycin hcl 10clindamycin palmitatehydrochloride 10clindamycin phosphate(topical) 43clindamycin phosphatevaginal 84clindamycin phosphate-benzoylperoxide 43

Index 5

clindamycin phosphate-benzoylperoxide (refrigerate) 43CLINDAREACH 43CLINDESSE 84CLINORIL 3clobetasol propionate 47clobetasol propionate emollientbase 47clobetasol propionateemulsion 47CLOBEX 47CLOCORTOLONEPIVALATE 47CLOCORTOLONE PIVALATEPUMP 47CLODERM 47CLODERM PUMP 47CLOMID 54clomiphene citrate 54clomipramine hcl 18clonazepam 14clonidine hcl 25clonidine hcl (adhd) 1clopidogrel bisulfate 300 mg 59clopidogrel bisulfate 75 mg 59clorazepate dipotassium 11CLORPRES 26clotrimazole 65clotrimazole w/betamethasone 45clozapine 31CLOZAPINE ODT 31CLOZARIL 31COARTEM 27COCAINE HCL 51COCET 7COCET PLUS 7codeine sulfate 15 mg, 30 mg, 60mg 6CODEINE SULFATE 30MG/5ML 6COLAZAL 58colchicine w/ probenecid 59COLCRYS 59COLESTID 23COLESTID FLAVORED 23colestipol hcl 23COLY-MYCIN S 76

COLYTE-FLAVOR PACKS227.1GM-21.5GM-5.53GM-2.82GM-6.36GM 61COLYTE-FLAVOR PACKS240GM-22.72GM-5.84GM-2.98GM-6.72GM 61COMBIGAN 72COMBIPATCH 56COMBIVENT 13COMBIVENT RESPIMAT 13COMBIVIR 32COMETRIQ 29COMPAZINE 31COMPLERA 32COMPLETE-RFPRENATAL 66COMPLETENATE 66COMTAN 30CONCEPT DHA 66CONCEPT OB 66CONCERTA 18 MG, 27 MG, 54MG 2CONCERTA 36 MG 2CONDYLOX 50CONZIP 6COPAXONE 78COPEGUS 33CORDARONE 12CORDRAN 47CORDRAN SP 48CORDRAN TAPE 48COREG 12.5 MG, 25 MG, 6.25MG 35COREG 3.125 MG 35COREG CR 35CORGARD 35CORTANE-B 48CORTANE-B AQUEOUS 76CORTANE-B-OTIC 76CORTEF 40CORTENEMA 9CORTIFOAM 9cortisone acetate 40CORTISPORIN10000UNIT/GM-0.5%-0.5%

45CORTISPORIN10000UNIT/ML-3.5MG/ML-1%

76

CORTISPORIN 400UNIT/GM-5000UNIT/GM-0.5%-1% 45CORTISPORIN-TC 76CORZIDE 26COSOPT 72COSOPT PF 72COTAB A 41COTAB AX 41COTABFLU 41COUMADIN 1 MG, 10 MG, 2 MG,2.5 MG, 3 MG, 4 MG, 5 MG, 6MG, 7.5 MG 14COVERA-HS 36COZAAR 25CPB WC 41CREON 52CRESTOR 10 MG, 20 MG, 40MG 24CRESTOR 5 MG 24CRESYLATE 76CRINONE 8 % 84CRIXIVAN 32cromolyn sodium 12cromolyn sodium(mastocytosis) 57cromolyn sodium (ophth) 75CUPRIMINE 34CUTIVATE 48CUVPOSA 81CVS VITAMIN D3 84CYCLESSA 38cyclobenzaprine hcl 71CYCLOGYL 0.5 % 73CYCLOGYL 1 %, 2 % 73CYCLOMYDRIL 73cyclopentolate hcl 73CYCLOPHOSPHAMIDE 25 MG,50 MG 28CYCLOSERINE 27CYCLOSET 19cyclosporine 100 mg, 25 mg 34cyclosporine modified 34cyclosporine modified (formicroemulsion) 34CYMBALTA 20 MG, 30 MG, 60MG 17CYMBALTA 60 MG 18cyproheptadine hcl 23CYSTADANE 55

Index 6

CYSTAGON 59CYSTARAN 75CYTOMEL 80CYTOTEC 82cytra-3 58CYTRA-K 58D-VI-SOL 84D.H.E. 45 63D3 84DALIRESP 12danazol 9DANTRIUM 71dantrolene sodium 100 mg, 25mg, 50 mg 71dapsone 10DARAPRIM 27DAYPRO 3DAYTRANA 2DDAVP 0.01 % 55DDAVP 0.1 MG, 0.2 MG 55DECON-G 41DELZICOL 58DEMADEX 53demeclocycline hcl 79DEMEROL 100 MG, 50 MG 6DEMSER 25DENAVIR 47DEPAKENE 16DEPAKOTE 16DEPAKOTE ER 16DEPAKOTE SPRINKLES 16DEPEN TITRATABS 34DEPLIN 15 52DEPLIN 7.5 52DEPO-PROVERACONTRACEPTIVE 40DEPO-SUBQ PROVERA104 40DERMA-SMOOTHE/FSBODY 48DERMA-SMOOTHE/FS BODYOIL 48DERMA-SMOOTHE/FSSCALP 48DERMA-SMOOTHE/FS SCALPOIL 48DERMATOP 48DERMOTIC 76desipramine hcl 18

desloratadine 2.5 mg, 5mg 22desloratadine 5 mg 22desmopressin acetate 0.1 mg,0.2 mg 55desmopressin acetaterefrigerated 55desmopressin acetatespray 55desmopressin acetate sprayrefrigerated 55DESOGEN 38desogestrel & ethinylestradiol 38desogestrel-ethinyl estradiol(biphasic) 38desogestrel-ethinyl estradiol(triphasic) 38DESONATE 48desonide 48DESOWEN 48DESOXIMETASONE 0.05% 48desoximetasone 0.05 % 48desoximetasone 0.25 % 48DESOXYN 1DESPEC-EXP 41DESPEC-PDC 41DESVENLAFAXINE ER 18DETROL 1 MG 83DETROL 2 MG 83DETROL LA 83dexamethasone 40DEXAMETHASONEINTENSOL 40dexamethasone sodiumphosphate (ophth) 74DEXCHLORPHENIRAMINEMALEATE 22DEXEDRINE 1DEXILANT 81dexmethylphenidate hcl 10 mg,2.5 mg, 5 mg 2dexmethylphenidate hcl 15 mg,30 mg, 40 mg 2DEXPAK 10 DAY 40DEXPAK 13 DAY 40DEXPAK 6 DAY 40dextroamphetamine sulfate 1DIABETA 20DIAMOX 53DIAPHRAGM 63

DIASTAT ACUDIAL 14DIASTAT PEDIATRIC 15diazepam 1 mg/ml 11diazepam 10 mg, 2 mg, 5mg 11DIAZEPAM 10 MG, 2.5 MG, 20MG 15DIAZEPAM INTENSOL 11DIBENZYLINE 25DICLEGIS 21diclofenac potassium 3diclofenac sodium 3diclofenac sodium (actinickeratoses) 46diclofenac sodium (ophth) 75diclofenac w/ misoprostol 3dicloxacillin sodium 77dicyclomine hcl 10 mg 81DICYCLOMINE HCL 10MG/5ML 81dicyclomine hcl 20 mg 81didanosine 32DIDRONEL 54diethylpropion hcl 1DIFFERIN 0.1 % 43DIFFERIN 0.3 % 43DIFICID 63diflorasone diacetate 48DIFLUCAN 22diflunisal 5DIGEX NF 81DIGOXIN 0.05 MG/ML 37digoxin 125 mcg, 250 mcg 37dihydroergotamine mesylate 1mg/ml 64DIHYDROERGOTAMINEMESYLATE 4 MG/ML 64DILACOR XR 36DILANTIN 100 MG 16DILANTIN 125 MG/5ML 16DILANTIN 30 MG 16DILANTIN INFATABS 16DILATRATE SR 10DILAUDID 6diltiazem hcl 120 mg, 180 mg,240 mg 36diltiazem hcl 120 mg, 30 mg, 60mg, 90 mg 36diltiazem hcl 120 mg, 60 mg, 90mg 36

Index 7

diltiazem hcl coated beads 36diltiazem hcl extended releasebeads 36DIOVAN 25DIOVAN HCT 26DIPENTUM 58diphenoxylate w/ atropine 21diphenoxylate/atropine 21DIPROLENE 48DIPROLENE AF 48dipyridamole 60disopyramide phosphate 12disulfiram 78DITROPAN XL 83DIURIL 54divalproex sodium 16DIVIGEL 56DOLGIC PLUS 5DOLOGESIC 5DOLOPHINE 6DOLOPHINE HCL 6DOMETUSS-DMX 41DONATUSS DC 41donepezil hydrochloride 78DONNATAL 81DONNATAL EXTENTABS 81DORAL 61DORYX 150 MG 79DORYX 200 MG 79dorzolamide hcl 75dorzolamide hcl-timololmaleate 72DOVONEX 46doxazosin mesylate 25doxepin hcl 10 mg, 100 mg, 150mg, 25 mg, 50 mg 18doxepin hcl 10 mg/ml 18DOXEPIN HCL 75 MG 18doxercalciferol 0.5 mcg, 1 mcg,2.5 mcg 55DOXYCYCLINE 79doxycycline (monohydrate) 100mg, 150 mg, 50 mg, 75 mg 79DOXYCYCLINE HYCLATE 100MG 79doxycycline hyclate 100 mg 79doxycycline hyclate 100 mg, 150mg, 75 mg 79doxycycline hyclate 100 mg, 50mg 79

DOXYTEX 22DRISDOL 84dronabinol 21drospirenone-ethinylestradiol 38DROXIA 60DRYSOL 51DUAC 44DUAVEE 56DUET DHA 66DUET DHA 400 66DUET DHA 400EC 66DUET DHA 430 66DUET DHA 430EC 66DUET DHA BALANCED220MCG-24MG-2900UNIT-2MG-25MG-25MG-1.2MG-210MG-15MG-4MG-12MCG-840UNIT-1MG-2MG-45MG-115MG, 278MG-210MCG-26MG-2840UNIT-2MG-25MG-25MG-1.5MG-215MG-20MG-4MG-12MCG-840UNIT-1MG-2MG-50MG-120MG 67DUET DHA BALANCED267MG-65MCG-210MCG-25MG-2800UNIT-1.8MG-25MG-25MG-1.5MG-215MG-20MG-55MG-2MG-12MCG-640UNIT-1MG-15MG-50MG-120MG, 380MG-3MG-220MCG-27MG-2850UNIT-2MG-25MG-25MG-1.8MG-219MG-20MG-4MG-12MCG-840UNIT-1MG-50MG-120MG

67DUET DHA EC 400MG-2825UNIT-3MG-220MCG-25MG-2MG-25MG-25MG-1.8MG-200MG-20MG-4MG-12MCG-800UNIT-1MG-45MG-120MG 67DUET DHA EC 430MG-2825UNIT-3MG-220MCG-25MG-2MG-25MG-25MG-1.8MG-200MG-20MG-4MG-12MCG-800UNIT-1MG-45MG-120MG 67DUETACT 19DUEXIS 3DULERA 13duloxetine hcl 18DUONEB 13

DURAGESIC 6DUREZOL 74DUTOPROL 26DYAZIDE 53DYMISTA 72DYNACIN 100 MG, 50 MG 79DYNACIN 75 MG 79DYNACIRC CR 36DYRENIUM 53e.e.s. 400 62E.E.S. GRANULES 62EC-NAPROSYN 500 MG 3econazole nitrate 45ECOTRIN REGULARSTRENGTH 5ECOZA 45ED CHLORPED 22ED-CHLOR-TAN 22EDARBI 25EDARBYCLOR 26EDECRIN 53EDLUAR 61EDURANT 32EFFER-K 65EFFEXOR XR 150 MG 18EFFEXOR XR 37.5 MG, 75MG 18EFFIENT 60EFUDEX 46ELDEPRYL 30ELESTAT 75ELESTRIN 56ELIDEL 50ELIMITE 52ELIQUIS 14ELITE-OB 400 67ELIXOPHYLLIN 14ELLA 40ELMIRON 59ELOCON 48EMADINE 75EMCYT 28EMEND 21EMEND 125 MG, 80 MG 21EMEND 40 MG 21EMLA 51EMSAM 17

Index 8

EMTRIVA 32EMULSION SB 51ENABLEX 83enalapril maleate 24enalapril maleate &hydrochlorothiazide 26ENBREL 4ENBREL SURECLICK 4ENCARE 83ENDOMETRIN 84ENJUVIA 0.3 MG, 0.45 MG, 1.25MG 56ENJUVIA 0.625 MG 56ENJUVIA 0.9 MG 56enoxaparin sodium 100 mg/ml,120 mg/0.8ml, 150 mg/ml, 30mg/0.3ml, 40 mg/0.4ml, 60mg/0.6ml, 80 mg/0.8ml 14enoxaparin sodium 300mg/3ml 14entacapone 30ENTEREG 58ENTOCORT EC 40EPANED 24EPICERAM 51EPIDUO 44EPIFOAM 48epinastine hcl (ophth) 75EPIPEN 2-PAK 84EPIPEN-JR 2-PAK 84EPIVIR 10 MG/ML 32EPIVIR 150 MG, 300 MG 32EPIVIR HBV 100 MG 32EPIVIR HBV 5 MG/ML 32eplerenone 27EPOGEN 60eprosartan mesylate 25EPZICOM 32EQUAGESIC 5EQUETRO 31ergocalciferol 84ERGOLOID MESYLATES 78ERGOMAR 64ERIVEDGE 28ERTACZO 45ERY-TAB 62ERYGEL 44ERYPED 200 62

ERYPED 400 62erythrocin stearate 62erythromycin 62erythromycin (acne aid) 44erythromycin (ophth) 73erythromycin base 63erythromycinethylsuccinate 63erythromycin-sulfisoxazole

10ESCAVITE LQ 66escitalopram oxalate 17ESGIC 5ESGIC-PLUS 5ESOMEPRAZOLESTRONTIUM 81estazolam 61esterified estrogens &methyltestosterone 56ESTRACE 0.1 MG/GM 84ESTRACE 0.5 MG, 1 MG, 2MG 56estradiol & norethindroneacetate 56estradiol 0.025 mg/24hr, 0.05mg/24hr, 0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr 56estradiol 0.5 mg, 1 mg, 2mg 56ESTRASORB 56ESTRING 84ESTROGEL 56estropipate 56ESTROSTEP FE 38ethambutol hcl 27ethosuximide 16ETHYL CHLORIDE 51ETHYL CHLORIDE/FINEPINPOINT 51ETHYL CHLORIDE/FINESTREAM 51ETHYL CHLORIDE/MEDIUMJET STREAM 51ETHYL CHLORIDE/MEDIUMSTREAM 51ETHYL CHLORIDE/MIST 51ethynodiol diacet & ethestrad 38ETIDRONATE DISODIUM 54etodolac 200 mg, 300 mg 3etodolac 400 mg, 500 mg 3

etodolac 400 mg, 500 mg, 600mg 3ETOPOSIDE 29EURAX 52EVAMIST 56EVISTA 55EVOCLIN 44EVOXAC 65EXACTUSS 41EXALGO 12 MG, 16 MG, 8MG 6EXALGO 32 MG 6EXELDERM 45EXELON 1.5 MG, 3 MG, 4.5 MG,6 MG 78EXELON 13.3 MG/24HR, 4.6MG/24HR, 9.5 MG/24HR 78EXELON 2 MG/ML 78exemestane 28EXFORGE 26EXFORGE HCT 26EXJADE 21EXTAVIA 78EXTINA 45EXTRA-VIRT PLUS DHA 67FABIOR 44FACTIVE 57FALESSA 38famciclovir 33famotidine 40 mg 81famotidine 40 mg/5ml 81FAMVIR 33FANAPT 31FARESTON 28FARXIGA 20FAZACLO 31FC FEMALE CONDOM 63FC2 FEMALE CONDOM 63felbamate 16FELBATOL 16FELDENE 3felodipine 36FEM PH 83FEMARA 28FEMCAP 63FEMCON FE 38FEMHRT 1/5 56FEMHRT LOW DOSE 56

Index 9

FEMRING 84FEMTRACE 56fenofibrate 23fenofibrate micronized 23FENOFIBRIC ACID 23FENOGLIDE 23fenoprofen calcium 3fentanyl 6fentanyl citrate 1200 mcg, 1600mcg, 200 mcg, 400 mcg, 600mcg, 800 mcg 6FENTORA 6FER-IN-SOL 60FERRIPROX 21ferrous sulfate 15 mg/ml 60ferrous sulfate 220 mg/5ml 60FERROUS SULFATE 300MG/5ML 60FETZIMA 120 MG, 40 MG, 80MG 18FETZIMA 20 MG 18FEXMID 71FIBRICOR 23FINACEA 51finasteride 59FIORICET 5FIORICET/CODEINE 7FIORINAL 5FIORINAL/CODEINE #3 7FIRAZYR 59FIRST-BXN MOUTHWASH 65FIRST-DUKESMOUTHWASH 65FIRST-LANSOPRAZOLE 81FIRST-MARYSMOUTHWASH 65FIRST-MOUTHWASH BLM 65FIRST-OMEPRAZOLE 81FLAGYL 10FLAGYL ER 10FLAREX 74flavoxate hcl 83flecainide acetate 12FLECTOR 45FLEXERIL 71FLO-PRED 40FLOMAX 59FLONASE 72

FLOVENT DISKUS 100MCG/BLIST 13FLOVENT DISKUS 250MCG/BLIST 13FLOVENT DISKUS 50MCG/BLIST 13FLOVENT HFA 110 MCG/ACT,220 MCG/ACT 13FLOVENT HFA 44MCG/ACT 13fluconazole 22flucytosine 250 mg 22flucytosine 500 mg 22fludrocortisone acetate 41FLUMADINE 34FLUMISTQUADRIVALENT 83flunisolide 0.025 % 72FLUNISOLIDE 29MCG/ACT 72fluocinolone acetonide 48fluocinolone acetonide(otic) 76fluocinonide 48fluocinonide emulsifiedbase 48FLUORABON 64fluorometholone (ophth) 74FLUOROPLEX 46fluorouracil (topical) 46fluoxetine hcl (pmdd) 78fluoxetine hcl 10 mg, 20mg 17fluoxetine hcl 10 mg, 20 mg, 40mg 17fluoxetine hcl 20 mg/5ml 17FLUOXETINE HCL 60 MG 17fluoxetine hcl 90 mg 17fluphenazine hcl 1 mg, 10 mg,2.5 mg, 5 mg 31FLUPHENAZINE HCL 2.5MG/5ML 31FLUPHENAZINE HCL 5MG/ML 31flura-drops 64flurazepam hcl 61flurbiprofen 3flurbiprofen sodium 75flutamide 28fluticasone propionate 48fluticasone propionate(nasal) 72fluvastatin sodium 24

fluvoxamine maleate 17FML 74FML FORTE 74FML LIQUIFILM 74FOCALGIN-B 67FOCALIN 2FOCALIN XR 10 MG, 20 MG, 5MG 2FOCALIN XR 15 MG, 30 MG, 40MG 2FOCALIN XR 25 MG, 35 MG 2FOLCAL DHA 67FOLCAPS OMEGA 3 67folic acid 1 mg 60folic acid 400 mcg, 800 mcg 60FOLIVANE-EC CALCIUM DHANF 67FOLIVANE-F 60FOLIVANE-OB 67FOLLISTIM AQ 54fondaparinux sodium 14FORADIL AEROLIZER 13FORFIVO XL 17formaldehyde 31FORTAMET 19FORTEO 54FORTESTA 9FOSAMAX 54FOSAMAX PLUS D 54fosinopril sodium 24fosinopril sodium &hydrochlorothiazide 26FOSRENOL 58FRAGMIN 10000 UNIT/ML,12500 UNIT/0.5ML, 15000UNIT/0.6ML, 18000 UNT/0.72ML,25000 UNIT/ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML 14FRAGMIN 2500 UNIT/0.2ML14FREESTYLE FREEDOMLITE 63FREESTYLE INSULINXBLOODGLUCOSEMONITORING SYSTEM 63FREESTYLE INSULINXBLOODGLUCOSE TEST 52FREESTYLE INSULINXBLOODGLUCOSE TESTSTRIPS 52

Index 10

FREESTYLE LITE BLOODGLUCOSE MONITORINGSYSTEM 63FREESTYLE LITE TESTSTRIPS 52FREESTYLE TEST STRIPS 52FRENADOL 5FROVA 64FULYZAQ 20FURADANTIN 82furosemide 10 mg/ml 53furosemide 20 mg, 40 mg, 80mg 53FUROSEMIDE 8 MG/ML 53FUSION PLUS 60FUZEON 32FYCOMPA 14gabapentin 15GABITRIL 12 MG, 16 MG 16GABITRIL 2 MG, 4 MG 16galantamine hydrobromide 78GALZIN 65GANIRELIX ACETATE 54GARAMYCIN 73GASTRINEX NF 81GASTROCROM 57gatifloxacin (ophth) 73GATTEX 58GEBAUERS PAIN EASE 51GEBAUERS SPRAY ANDSTRETCH 51GELCLAIR 65GELFILM OP 75GELNIQUE 83gemfibrozil 23GENERESS FE 38gentamicin sulfate (ophth) 73gentamicin sulfate 0.1 % 45GEODON 31GESTICARE DHA 67GIAZO 58GILENYA 78GILOTRIF 29GILPHEX TR 41GILTUSS 42GILTUSS PED-C 42GILTUSS TR 42GLEEVEC 29

glimepiride 20glipizide 20glipizide-metformin hcl 19GLUCAGEN 19GLUCAGEN HYPOKIT 19GLUCAGON EMERGENCYKIT 19GLUCOPHAGE 19GLUCOPHAGE XR 19GLUCOTROL 20GLUCOTROL XL 20GLUCOVANCE 19GLUMETZA 19glyburide 1.25 mg, 2.5 mg, 5mg 20GLYBURIDE 1.25 MG, 2.5 MG,5 MG 20glyburide micronized 20glyburide-metformin 19GLYCATE 81glycopyrrolate 1 mg, 2 mg 81GLYNASE 20GLYSET 18GOLYTELY 227.1GM-21.5GM-5.53GM-2.82GM-6.36GM 61GOLYTELY 236GM-22.74GM-5.86GM-2.97GM-6.74GM 61GONAL-F 54GONAL-F RFF 54GONAL-F RFF PEN 54GONAL-F RFF REDIJECT 54GORDONS UREA 49GRALISE 78granisetron hcl 1 mg 21GRANISOL 21GRANIX 60GRANULEX 50GRIFULVIN V 22GRIS-PEG 22griseofulvin microsize 22griseofulvin ultramicrosize 22guaifenesin-codeine100mg/5ml-10mg/5ml 42guanfacine hcl 25GUANIDINE HCL 27GYNAZOLE-1 84HALCION 61HALFLYTELY BOWELPREP/FLAVOR PACKS 61

HALFPRIN 5halobetasol propionate 48halobetasol propionate &ammonium lactate 48HALOG 48HALONATE 48haloperidol 31haloperidol lactate 2 mg/ml 31HALOTIN 45HDC DM 42HECTOROL 0.5 MCG, 1 MCG,2.5 MCG 55HELIDAC 82HEMENATAL OB 67HEMENATAL OB + DHA 67HEPSERA 33HEXALEN 28HIPREX 82HISTEX-PE 42homatropine hbr 73HORIZANT 300 MG 79HORIZANT 600 MG 79HUMALOG 19HUMALOG MIX 50/50 20HUMALOG MIX 75/25 20HUMIRA 3HUMIRA PEN 3HUMULIN 70/30 20HUMULIN 70/30 KWIKPEN 20HUMULIN N 20HUMULIN N KWIKPEN 20HUMULIN R 20HUMULIN R U-500(CONCENTRATED) 20hyaluronate sodium(emollient) 50HYCAMTIN 0.25 MG, 1 MG 29HYCET 7hydralazine hcl 10 mg, 100 mg,25 mg, 50 mg 27HYDREA 29HYDRO 35 49HYDRO 40 FOAM 49hydrochlorothiazide 54HYDROCODONEBITARTRATE/ACETAMINOPHEN 10MG-750MG 7HYDROCODONEBITARTRATE/ACETAMINOPHEN 2.5MG-325MG 7

Index 11

hydrocodone w/homatropine 41hydrocodone-acetaminophen 7hydrocodone-ibuprofen 7HYDROCODONE/ACETAMINOPHEN 7hydrocortisone 40hydrocortisone (intrarectal) 9hydrocortisone (rectal) 9hydrocortisone (topical) 2 %, 2.5% 48hydrocortisone (topical) 2.5% 48hydrocortisone acetate(rectal) 9hydrocortisone acetate w/pramoxine 9hydrocortisone butyrate 48hydrocortisone butyratehydrophilic lipo base 48hydrocortisone valerate 48hydrocortisone w/acetic acid 76hydromorphone hcl 1 mg/ml 6hydromorphone hcl 2 mg, 4 mg, 8mg 6hydroxychloroquine sulfate 27hydroxyurea 29hydroxyzine hcl 11HYDROXYZINE PAMOATE 100MG 11hydroxyzine pamoate 25 mg, 50mg 11HYLIRA 0.1 % 50HYLIRA 0.2 % 50hyoscyamine sulfate 81HYPER-SAL 43HYPERSAL 3.5 % 43HYPERSAL 7 % 43HYZAAR 26ibandronate sodium 54ibudone 7ibuprofen 400 mg, 600 mg, 800mg 3ICAR PEDIATRIC 60ICLUSIG 29ILEVRO 75IMBRUVICA 29IMDUR 10imipramine hcl 18imipramine pamoate 18imiquimod 50

IMITREX 100 MG, 25 MG, 50MG 64IMITREX 20 MG/ACT, 5MG/ACT 64IMITREX 6 MG/0.5ML 64IMPLANON 40IMURAN 34inatal advance 67inatal gt 67inatal ultra 67INCIVEK 33INCRELEX 55indapamide 54INDERAL LA 35INDERAL XL 35INDOCIN 25 MG/5ML 3INDOCIN 50 MG 3indomethacin 25 mg, 50 mg 3indomethacin 75 mg 3INFANATE BALANCE 67INFERGEN 33INLYTA 29INNOPRAN XL 35INSPRA 27INSULIN SYRINGES AND PENNEEDLES 63INTEGRA F 60INTELENCE 100 MG, 200MG 32INTELENCE 25 MG 32INTERMEZZO 61INTRON-A 29INTRON-A W/DILUENT 29INTUNIV 1INVEGA 31INVIRASE 32INVOKANA 20iodoquinol-hc 45IOPIDINE 0.5 % 73IOPIDINE 1 % 73ipratropium bromide 12ipratropium bromide(nasal) 72ipratropium-albuterol 13irbesartan 25irbesartan-hydrochlorothiazide

26ISENTRESS 100 MG 32ISENTRESS 25 MG 32

ISENTRESS 400 MG 32ISOMETHEPTENE/CAFFEINE/ACETAMINOPHEN 63isoniazid & rifampin 27isoniazid 100 mg, 300 mg 28isoniazid 50 mg/5ml 27ISOPTIN SR 36ISOPTO ATROPINE 73ISOPTO HOMATROPINE 2% 73ISOPTO HOMATROPINE 5% 73ISOPTO HYOSCINE 73ISORDIL TITRADOSE 40MG 11ISORDIL TITRADOSE 5 MG 11isosorbide dinitrate 10 mg, 20mg, 30 mg, 5 mg 11isosorbide dinitrate 2.5 mg 11ISOSORBIDE DINITRATE 30MG 11isosorbide dinitrate 40 mg 11ISOSORBIDE DINITRATE 5MG 11isosorbide mononitrate 11isotretinoin 10 mg 44isotretinoin 10 mg, 20 mg, 40mg 44isotretinoin 20 mg 44isotretinoin 40 mg 44isoxsuprine hcl 10 mg 37ISOXSUPRINE HCL 20 MG 37ISRADIPINE 36ISTALOL 72itraconazole 22J-COF DHC 42J-MAX DHC 42JAKAFI 29JALYN 59JANUMET 19JANUMET XR 19JANUVIA 19JENTADUETO 19JINTELI 56JUVISYNC 100MG-10MG,100MG-20MG 19JUVISYNC 40MG-100MG 19JUVISYNC 40MG-50MG 19JUVISYNC 50MG-10MG, 50MG-20MG 19

Index 12

JUXTAPID 24K-LOR HOSPITAL PACK 65K-PHOS 65K-PHOS NEUTRAL 65K-PHOS NO 2 58K-TAB 10 MEQ 65K-TAB 20 MEQ 65KADIAN 10 MG 6KADIAN 100 MG, 20 MG, 30 MG,50 MG, 60 MG, 80 MG 6KADIAN 130 MG, 150 MG 6KADIAN 200 MG, 40 MG, 70MG 6KALETRA 32KALYDECO 79KAPVAY 1KAPVAY DOSE PACK 1KARBINAL ER 22KAYEXALATE 35KAZANO 19KEFLEX 37KENALOG 48KEPPRA 100 MG/ML 15KEPPRA 1000 MG, 250 MG, 500MG, 750 MG 15KEPPRA XR 15KERAFOAM 49KERAFOAM 42 49KERLONE 35KETEK 300 MG 10KETEK 400 MG 10ketoconazole 22ketoconazole (topical) 45ketoprofen 3KETOPROFEN ER 3ketorolac tromethamine(ophth) 75ketorolac tromethamine 10mg 3KHEDEZLA 18KINERET 3KLARON 44KLONOPIN 15KLOR-CON 25 65KLOR-CON M15 65KOMBIGLYZE XR 19KORLYM 19KRISTALOSE 62

KUVAN 55KYNAMRO 23L-METHYLFOLATE FORMULA15 52L-METHYLFOLATE FORMULA7.5 52L-METHYLFOLATEFORTE 52labetalol hcl 100 mg, 200 mg,300 mg 35LAC-HYDRIN 50LAC-HYDRIN TWELVE 50LACRISERT 72lactic acid (ammonium lactate)10 % 50lactic acid (ammonium lactate)12 % 50lactulose 62lactulose (encephalopathy)58LAMICTAL 100 MG, 150 MG,200 MG, 25 MG 15LAMICTAL 2 MG 15LAMICTAL CHEWABLEDISPERSIBLE 15LAMICTAL ODT 15LAMICTAL XR 100 MG, 200MG, 25 MG, 50 MG 15LAMICTAL XR 250 MG, 300MG 15LAMISIL 125 MG, 187.5MG 22LAMISIL 250 MG 22lamivudine 32lamivudine-zidovudine 32lamotrigine 100 mg, 150 mg,200 mg, 25 mg 15lamotrigine 100 mg, 200 mg, 25mg, 50 mg 15lamotrigine 25 mg, 5 mg 15lamotrigine 250 mg, 300mg 15LANOXIN 125 MCG, 250MCG 37LANOXIN 187.5 MCG, 62.5MCG 37lansoprazole 15 mg 82lansoprazole 30 mg 82LANTUS 20LARTUS 42LASIX 53LASTACAFT 75latanoprost 76LATUDA 31

LAZANDA 100 MCG/ACT 6LAZANDA 400 MCG/ACT 6leflunomide 10 mg 4leflunomide 20 mg 4LEMOHIST PLUS 42LESCOL 24LESCOL XL 24LETAIRIS 37letrozole 28leucovorin calcium 10 mg, 25 mg,5 mg 29LEUCOVORIN CALCIUM 15MG 29LEUKERAN 28LEUKINE 60LEVACET 5levalbuterol hcl 13LEVAQUIN 25 MG/ML 57LEVAQUIN 250 MG, 500 MG,750 MG 57LEVATOL 35LEVEMIR 20levetiracetam 100 mg/ml, 500mg/5ml 15levetiracetam 1000 mg, 250 mg,500 mg, 750 mg 15levetiracetam 500 mg, 750mg 15levobunolol hcl 72levocarnitine (metabolicmodifiers) 1 gm/10ml 55levocarnitine (metabolicmodifiers) 330 mg 55levocetirizine dihydrochloride 2.5mg/5ml 22levocetirizine dihydrochloride 5mg 22levofloxacin (ophth) 73levofloxacin 25 mg/ml 57levofloxacin 250 mg, 500 mg, 750mg 57LEVOMEFOLATE PNV 67levonorgestrel & ethestradiol 38levonorgestrel (emergency oc)0.75 mg 40levonorgestrel (emergency oc)1.5 mg 40levonorgestrel-eth estradiol(triphasic) 38levonorgestrel-ethinyl estradiol(91-day) 38LEVORPHANOL TARTRATE 6

Index 13

levothyroxine sodium 80LEXAPRO 17LEXIVA 32LIALDA 58LIBRAX 81lidocaine 51lidocaine hcl (mouth-throat) 2% 65lidocaine hcl (mouth-throat) 4% 65lidocaine hcl 2 % 51lidocaine hcl 4 % 51lidocaine-hydrocortisone acetate(rectal) 9lidocaine-prilocaine 51LIDOCAINE/PRILOCAINE 51LIDODERM 51LIDORX 51LIDOVIR 47lindane 52LINZESS 58liothyronine sodium 25 mcg, 5mcg, 50 mcg 80LIPITOR 24LIPOFEN 23LIPTRUZET 23LIQUICET 7lisinopril 24lisinopril &hydrochlorothiazide 26lithium carbonate 30LITHIUM CITRATE 30LITHOBID 30LITHOSTAT 59LIVALO 24LO LOESTRIN FE 38LO MINASTRIN FE 38LO/OVRAL-28 38LOCOID 48LOCOID LIPOCREAM 48LODOSYN 30LOESTRIN 1.5/30-21 38LOESTRIN 1/20-21 38LOESTRIN 24 FE 38LOESTRIN FE 1.5/30 38LOESTRIN FE 1/20 38LOFIBRA 23LOMEDIA 24 FE 38

LOMOTIL 21LOMUSTINE 28loperamide hcl 21LOPID 23LOPRESSOR 100 MG, 50MG 35LOPRESSOR HCT 26LOPROX 45LOPROX SHAMPOO 45lorazepam 0.5 mg, 1 mg, 2mg 11lorazepam 2 mg/ml 11lorazepam intensol 11LORCET 10/650 7LORCET PLUS 7LORTAB 10MG-500MG, 5MG-500MG, 7.5MG-500MG 8LORTAB 10MG/15ML-300MG/15ML 7LORTAB 7.5MG/15ML-500MG/15ML 8LORZONE 71losartan potassium 25losartan potassium &hydrochlorothiazide 26LOSEASONIQUE 38LOTEMAX 74LOTENSIN 24LOTENSIN HCT 26LOTREL 26LOTRISONE 45LOTRONEX 58lovastatin 24LOVAZA 23LOVENOX 100 MG/ML, 120MG/0.8ML, 150 MG/ML, 30MG/0.3ML, 40 MG/0.4ML, 60MG/0.6ML, 80 MG/0.8ML 14LOVENOX 300 MG/3ML 14loxapine succinate 31LOXITANE 31LOZI-FLUR 64LTA 360 KIT 65LUFYLLIN 14LUMIGAN 0.01 % 76LUMIGAN 0.03 % 76LUNESTA 61LURIDE 64LUVERIS 54LUVOX CR 17

LUXIQ 48LYRICA 100 MG, 200 MG, 25MG, 50 MG, 75 MG 15LYRICA 150 MG, 225 MG, 300MG 15LYRICA 20 MG/ML 15LYSODREN 28LYSTEDA 60MACNATAL CN DHA 67MACROBID 82MACRODANTIN 100 MG, 50MG 83MACRODANTIN 25 MG 83mafenide acetate 47MAGNACET 10MG-400MG,5MG-400MG 8MAGNACET 7.5MG-400MG 8MAGNEBIND 400 65MALARONE 250MG-100MG27MALARONE 62.5MG-25MG 27malathion 52maprotiline hcl 17MARINOL 21MARNATAL-F 67MARPLAN 17MATULANE 29MAVIK 24MAXAIR AUTOHALER 13MAXALT 64MAXALT-MLT 64MAXIDEX 74MAXIDONE 8MAXIFED CD 42MAXIFED CDX 42MAXIFED-G CD 42MAXIFED-G CDX 42MAXIFLU CD 42MAXIFLU CDX 42MAXIPHEN CD 42MAXIPHEN CDX 42MAXITROL 74MAXZIDE 53MAXZIDE-25 53meclofenamate sodium 4MEDROL 16 MG, 32 MG, 4 MG,8 MG 40MEDROL 2 MG 40MEDROL DOSEPAK 40

Index 14

MEDROX-RX 51medroxyprogesteroneacetate 77medroxyprogesterone acetate(contraceptive) 40mefenamic acid 4mefloquine hcl 27MEGACE ES 77MEGACE ORAL 28megestrol acetate 28MEKINIST 29meloxicam 15 mg 4meloxicam 7.5 mg 4MELOXICAM 7.5 MG/5ML 4MENEST 56MENOPUR 54MENOSTAR 56meperidine hcl 100 mg, 50 mg6MEPERIDINE HCL 50MG/5ML 6MEPHYTON 84meprobamate 11MEPRON 10mercaptopurine 28mesalamine 58MESNEX 400 MG 29MESTINON 60 MG 27MESTINON 60 MG/5ML 27MESTINON TIMESPAN 27METADATE CD 10 MG, 40 MG,50 MG, 60 MG 2METADATE CD 20 MG, 30MG 2METAPROTERENOL SULFATE10 MG, 20 MG 13metaproterenol sulfate 10mg/5ml 13metaxalone 71metformin hcl 19methadone hcl 10 mg, 5 mg 6methadone hcl 10 mg/5ml, 5mg/5ml 6methadone hcl 10 mg/ml 6methadone hcl 40 mg 6METHADOSE 6METHADOSE SUGAR-FREE 6methamphetamine hcl 1methazolamide 53methenamine hippurate 83

METHENAMINE MANDELATE0.5 GM 83methenamine mandelate 1gm 83methenamine-hyosc-methyleneblue-benzoic acid-phenylsal 82methenamine-hyosc-methyleneblue-sod phos-phenyl sal 82METHERGINE 0.2 MG 77methimazole 80METHITEST 9methocarbamol 71methotrexate sodium 1gm/40ml, 100 mg/4ml, 200mg/8ml, 25 mg/ml, 250mg/10ml, 50 mg/2ml 28methotrexate sodium 2.5mg 28methscopolamine bromide 81METHYCLOTHIAZIDE 54methyldopa 25METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-15MG 26methyldopa/hydrochlorothiazide250mg-25mg 26methylergonovine maleate 0.2mg 77METHYLIN 10 MG, 2.5 MG, 5MG 2METHYLIN 10 MG/5ML, 5MG/5ML 2methylphenidate hcl 10 mg, 20mg, 5 mg 2methylphenidate hcl 10 mg, 40mg, 50 mg, 60 mg 2methylphenidate hcl 10 mg/5ml,5 mg/5ml 2methylphenidate hcl 18 mg, 20mg, 27 mg, 54 mg 2methylphenidate hcl 20 mg, 30mg 2methylphenidate hcl 20 mg, 30mg, 40 mg 2methylphenidate hcl 27 mg, 54mg 2methylphenidate hcl 36 mg 2methylphenidate hcl er 2methylprednisolone 40methyltestosterone 9metipranolol 73metoclopramide hcl 10 mg, 5mg 57metoclopramide hcl 10mg/10ml, 5 mg/5ml 57

metolazone 54METOPIRONE 52metoprolol &hydrochlorothiazide 26metoprolol succinate 35metoprolol tartrate 100 mg, 25mg, 50 mg 35metoprolol/hydrochlorothiazide

26METOZOLV ODT 10 MG 57METOZOLV ODT 5 MG 57METROCREAM 51METROGEL 51METROGEL-VAGINAL 84METROLOTION 51metronidazole 10metronidazole (topical) 0.75% 51metronidazole (topical) 1 % 51metronidazole vaginal 84MEVACOR 24mexiletine hcl 12MIACALCIN 200 UNIT/ACT 54MIACALCIN 200 UNIT/ML 54MICARDIS 25MICARDIS HCT 26MICONAZOLE 3 84MICRO-K 65MICROZIDE 54midazolam hcl 2 mg/ml 61midodrine hcl 84MIGERGOT 63MIGRAL 64MIGRALAM 63MIGRANAL 64MILLIPRED 10 MG/5ML 40MILLIPRED 5 MG 40MILLIPRED DP 40MINASTRIN 24 FE 39MINIPRESS 25MINIVELLE 0.0375MG/24HR 56MINIVELLE 0.05 MG/24HR,0.075 MG/24HR, 0.1MG/24HR 56MINOCIN 79minocycline hcl 100 mg, 50mg 79minocycline hcl 100 mg, 50 mg,75 mg 79

Index 15

minocycline hcl 135 mg, 45 mg,90 mg 79minocycline hcl 75 mg 79minoxidil 27MIRALAX 62MIRAPEX 30MIRAPEX ER 30MIRCETTE 39MIRENA 40mirtazapine 15 mg, 30 mg, 45mg 16mirtazapine 7.5 mg 16MIRVASO 51misoprostol 82MOBIC 15 MG 4MOBIC 7.5 MG 4MOBIC 7.5 MG/5ML 4modafinil 2MODERIBA 33MODERIBA 400 MG, 600MG 33MODICON 39moexipril hcl 24moexipril-hydrochlorothiazide

26mometasone furoate 49MOMS CHOICE RX 67MONODOX 79MONOKET 11montelukast sodium 12MONUROL 83morphine sulfate 10 mg 6morphine sulfate 10 mg, 20mg 6morphine sulfate 10 mg/5ml, 100mg/5ml, 20 mg/5ml, 20 mg/ml 6morphine sulfate 100 mg, 15 mg,200 mg, 30 mg, 60 mg 6morphine sulfate 100 mg, 20 mg,30 mg, 50 mg, 60 mg, 80 mg 6morphine sulfate 15 mg, 30mg 6MORPHINE SULFATE 30 MG, 5MG 6morphine sulfate beads 6MOTOFEN 21MOVIPREP 61MOXATAG 77MOXEZA 74moxifloxacin hcl 57

MS CONTIN 6MST 600 5MUCOTROL 65MULTAQ 12MULTI-VIT/IRON/FLUORIDE

66MULTI-VITAMIN/FLUORIDE/IRON

66mupirocin 45mupirocin calcium (topical) 45MYAMBUTOL 28MYCOBUTIN 28mycophenolate mofetil 34mycophenolate sodium 34MYDFRIN 74MYDRIACYL 73MYFORTIC 34MYKIDZ IRON 10 60MYKIDZ IRON FL 66MYLERAN 28MYNATAL ADVANCE 67MYNATALULTRACAPLET 67MYNATE 90 PLUS 67MYOXIN 76MYRBETRIQ 83MYSOLINE 15MYTELASE 27nabumetone 500 mg 4nabumetone 750 mg 4nadolol 35nadolol &bendroflumethiazide 26NAFTIN 1 % 45NAFTIN 1 %, 2 % 45NAFTIN 2 % 46NALFON 200 MG 4NALFON 400 MG 4naltrexone hcl 21NAMENDA 78NAMENDA XR 78NAPHAZOLINE HCL 74NAPRELAN 4NAPRELAN 375 MG, 500 MG,750 MG 4NAPROSYN 4naproxen 125 mg/5ml 4

naproxen 250 mg, 375 mg, 500mg 4naproxen 500 mg 4naproxen sodium 4naratriptan hcl 64NARDIL 17NASACORT AQ 72NASONEX 72NATA KOMPLETE 67NATACHEW 67NATACYN 74NATAFORT 67NATALVIRT 90 DHA 67NATALVIRT CA 67NATAZIA 39nateglinide 20NATELLE ONE 67NATROBA 52NATURE-THROID 113.75 MG,146.25 MG, 16.25 MG, 48.75MG, 81.25 MG, 97.5 MG 80NATURE-THROID 130 MG, 195MG, 32.5 MG, 65 MG 80NATURE-THROID 260 MG, 325MG 80NATURE-THROID NT-2.5 80NEBUPENT 10NEBUSAL 43NECON 1/50-28 39NECON 10/11-28 39NEEVO 67NEEVO DHA 67NEFAZODONE HCL 100 MG,150 MG, 200 MG, 50 MG 17nefazodone hcl 250 mg 17NEO-FRADIN 2neomycin sulfate 2neomycin-bacitracin zn-polymyxin 74neomycin-polymy-dexameth 75neomycin-polymyxin-gramicidin

74neomycin-polymyxin-hc(otic) 76neomycin/polymyxin/hydrocortisone 75NEORAL 34NEOSPORIN 74NEOTUSS PLUS 42NEOTUSS-D 42

Index 16

NEPTAZANE 53NESINA 19NESTABS 68NESTABS ABC 68NESTABS DHA 68NEULASTA 60NEUMEGA 60NEUPOGEN 60NEUPRO 1 MG/24HR, 3MG/24HR, 8 MG/24HR 30NEUPRO 2 MG/24HR 30NEUPRO 4 MG/24HR, 6MG/24HR 30NEURONTIN 15NEVANAC 75nevirapine 200 mg 32NEVIRAPINE 50 MG/5ML 32NEXA PLUS 68NEXA SELECT 325MG-160MG-55MG-29MG-800UNIT-1.25MG-30UNIT-25MG-28MG 68NEXA SELECT 337.5MG-750MG-160MG-55MG-29MG-800UNIT-1.25MG-30UNIT-28MG-28MG 68NEXAVAR 29NEXICLON XR 25NEXIUM 10 MG, 2.5 MG, 20 MG,40 MG, 5 MG 82NEXIUM 20 MG, 40 MG 82NEXPLANON 40niacin (antihyperlipidemic) 24NIASPAN 24nicardipine hcl 20 mg, 30 mg36NICOTROL INHALER 79NICOTROL NS 79nifedipine 10 mg, 20 mg 36nifedipine 30 mg, 60 mg 36nifedipine 30 mg, 60 mg, 90mg 36NILANDRON 29nimodipine 36NIRAVAM 11NIRON KOMPLETE 60nisoldipine 17 mg, 34 mg, 8.5mg 36nisoldipine er 36NITRO-BID 11

NITRO-DUR 0.1 MG/HR, 0.2MG/HR, 0.4 MG/HR, 0.6MG/HR 11NITRO-DUR 0.3 MG/HR, 0.8MG/HR 11nitrofurantoin 83nitrofurantoin macrocrystal 83nitrofurantoin monohydmacro 83nitroglycerin 0.1 mg/hr, 0.2mg/hr, 0.4 mg/hr, 0.6mg/hr 11nitroglycerin 0.4 mg/spray 11nitroglycerin 2.5 mg, 9 mg 11NITROGLYCERINLINGUAL 11NITROLINGUALPUMPSPRAY 11NITROMIST 11NITROSTAT 11nizatidine 81NIZORAL 46NON PREFERRED TESTSTRIPS 52NOR-QD 40NORCO 8NORDETTE-28 39norethin acet & estrad-fe 39norethindrone & ethestradiol 39norethindrone & ethinylestradiol-fe 39norethindrone(contraceptive) 40norethindrone acet & ethestra 39norethindrone acetate 77norethindrone acetate-ethinylestradiol 56norethindrone acetate-ethinylestradiol-fe 39norethindrone-eth estradiol(triphasic) 39norgestimate-ethinylestradiol 39norgestimate-ethinyl estradiol(triphasic) 39norgestrel & ethinylestradiol 39NORINYL 1+35 39NORINYL 1+50 39NORITATE 51NOROXIN 57NORPACE 12

NORPACE CR 100 MG 12NORPACE CR 150 MG 12NORPRAMIN 18nortriptyline hcl 10 mg, 25 mg, 50mg, 75 mg 18NORTRIPTYLINE HCL 10MG/5ML 18NORVASC 36NORVIR 32NOVACORT 49NOVOLIN 70/30 20NOVOLIN 70/30 RELION 20NOVOLIN N 20NOVOLIN N RELION 20NOVOLIN R 20NOVOLIN R RELION 20NOVOLOG 20NOVOLOG MIX 70/30 20NOXAFIL 100 MG 22NOXAFIL 40 MG/ML 22NUCORT 49NUCYNTA 6NUCYNTA ER 6NUEDEXTA 78NULYTELY/FLAVORPACKS 61NUTRI-TAB OB 68NUTRI-TAB OB + DHA 68NUVARING 40NUVIGIL 150 MG, 250 MG, 50MG 2NUVIGIL 200 MG 2NYMALIZE 36nystatin 22nystatin (mouth-throat) 65nystatin (topical) 46NYSTATIN VAGINAL 84nystatin-triamcinolone 46nystatin/triamcinolone 46OB COMPLETE 68OB COMPLETE 400 68OB COMPLETE ONE 68OB COMPLETE PETITE 68OB COMPLETE PREMIER 68OB COMPLETE/DHA 68OB-NATAL ONE 68octreotide acetate 55OCUFEN 75

Index 17

OCUFLOX 74ofloxacin (ophth) 74ofloxacin (otic) 76ofloxacin 200 mg 57ofloxacin 300 mg, 400 mg 57ogestrel 39olanzapine 31olanzapine-fluoxetine hcl 78OLUX 49OLUX-E 49OLYSIO 33OMECLAMOX-PAK 82OMEPRAZOLE + SYRSPENDSFALKA 82omeprazole 10 mg 82omeprazole 20 mg, 40 mg 82omeprazole-sodium bicarbonate40mg-1100mg 82OMNARIS 72OMNIPRED 75ON CALL EXPRESS BLOODGLUCOSE TEST STRIPS 52ON CALL VIVID BLOODGLUCOSE TEST STRIPS 52ondansetron 21ondansetron hcl 4 mg, 8 mg 21ondansetron hcl 4 mg/5ml 21ONETOUCH ULTRA 2 63ONETOUCH ULTRA BLUE 52ONETOUCH ULTRA MINI 63ONETOUCH ULTRA SYSTEMKIT 63ONETOUCH ULTRASMART63ONETOUCH VERIO IQ BLOODGLUCOSE MONITORINGSYSTEM 63ONETOUCH VERIO TESTSTRIPS 52ONFI 15ONGLYZA 19OPANA 10 MG, 5 MG 7OPIUM TINCTURE(PAREGORIC) 21OPSUMIT 37OPTASE 50OPTIONS CONCEPTROLVAGINALCONTRACEPTIVE 83OPTIONS GYNOL IIVAGINALCONTRACEPTIVE

83

OPTIPRANOLOL 73OPTIVAR 75ORACEA 52ORACIT 58ORAP 78ORAPRED 40ORAPRED ODT 41ORAVIG 65ORAXYL 80ORBIVAN 5ORBIVAN CF 5ORENCIA 4ORFADIN 55orphenadrine citrate 100mg 71orphenadrine compoundds 71orphenadrine w/ aspirin &caff 72ORTHO EVRA 40ORTHO MICRONOR 40ORTHO TRI-CYCLEN 39ORTHO TRI-CYCLEN LO 39ORTHO-CEPT 39ORTHO-CYCLEN 39ORTHO-NOVUM 1/35 39ORTHO-NOVUM 7/7/7 39OSENI 19OSMOPREP 62OSPHENA 55OTICIN HC NR 76OTREXUP 3OVACE PLUS 46OVACE PLUS WASH 46OVACE WASH 46OVCON-35 39OVCON-50 28 39OVIDE 52OVIDREL 54OXANDRIN 9oxandrolone 9oxaprozin 4oxazepam 11oxcarbazepine 15OXECTA 7OXISTAT 46OXSORALEN ULTRA 46

OXTELLAR XR 15oxybutynin chloride 83oxycodone hcl 10 mg, 15 mg, 20mg, 30 mg, 5 mg 7oxycodone hcl 100 mg/5ml 7OXYCODONE HCL 100MG/5ML 7oxycodone hcl 5 mg 7oxycodone hcl 5 mg/5ml 7oxycodone w/ acetaminophen 8oxycodone-ibuprofen 8OXYCONTIN 7oxymorphone hcl 7PAIRE OB 68PALGIC 22PAMELOR 18PAMINE 81PAMINE FORTE 81PAMINE FQ 81PANCREAZE 52pancrelipase (lipase-protease-amylase) 52PANDEL 49PANRETIN 46pantoprazole sodium 20 mg, 40mg 82PARAFON FORTE DSC 71PARCOPA 30PAREMYD 75paricalcitol 55PARLODEL 30PARNATE 17paromomycin sulfate 2paroxetine hcl 17PASER 28PATADAY 76PATANASE 72PATANOL 76PAXIL 17PAXIL CR 17PCE 63PEDIATEX TDM 42pediatric multivitamins w/fl 66pediatric vitamins acd w/fluoride 66peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 61peg 3350-potassium chloride-sodbicarbonate-sod chloride 61

Index 18

PEG-INTRON 33PEG-INTRON REDIPEN 33PEG-INTRON REDIPEN PAK4 33PEGANONE 16PEGASYS 33PEGASYS PROCLICK 33penicillin v potassium 77PENNSAID 1.5 % 45PENNSAID 2 % 45PENTASA 58pentazocine w/ naloxone 8pentazocine-acetaminophen 8pentoxifylline 59PEPCID 40 MG 81PEPCID 40 MG/5ML 81PERCOCET 8PERFOROMIST 13perindopril erbumine 24permethrin 52perphenazine 31PERPHENAZINE/AMITRIPTYLINE 78PERSANTINE 60PERTZYE 53PEXEVA 17phenazopyridine hcl 59phendimetrazine tartrate 1PHENDIMETRAZINETARTRATEER 1phenelzine sulfate 17PHENFLU CD 42PHENFLU CDX 42PHENOBARBITAL 100 MG, 15MG, 30 MG, 60 MG 61phenobarbital 16.2 mg, 30 mg,32.4 mg, 64.8 mg, 97.2 mg 61phenobarbital 20 mg/5ml 61phentermine hcl 15 mg, 30 mg,37.5 mg 1phentermine hcl 37.5 mg 1phenyleph-promethazine w/cod 42phenylephrine hcl (ophth) 74phenylephrine w/ dm-gg7.5mg/ml-88mg/ml-2.5mg/ml 42phenyltoloxamine-acetaminophen500mg-50mg, 55mg-500mg 5PHENYTEK 16phenytoin 16

phenytoin sodiumextended 16PHISOHEX 31PHOSLO 58PHOSLYRA 58PHOSPHOLINE IODIDE 73PHRENILIN FORTE 5PICATO 46pilocarpine hcl (oral) 65pindolol 35PINNACAINE OTIC 76pioglitazone hcl 19pioglitazone hcl-glimepiride 19pioglitazone hcl-metforminhcl 19piroxicam 4PLAN B 40PLAN B ONE-STEP 40PLAQUENIL 27PLAVIX 300 MG 60PLAVIX 75 MG 60PLETAL 60PNV FERROUSFUMARATE/DOCUSATE/FOLIC ACID 68PNV OB+DHA 68PNV-DHA 68PNV-DHA+DOCUSATE 68PNV-FIRST 68PNV-OMEGA 68PNV-SELECT 68PNV-TOTAL 68PODOCON 25 IN BENZOINTINCTURE 50podofilox 50POLIBAR ACB 52POLY HIST DHC 42POLY HIST NC 42POLY-TUSSIN DHC 42POLY-TUSSIN EX 42POLY-VI-FLOR 200MCG-0.25MG-15UNIT-400UNIT,200MCG-0.5MG-15UNIT-400UNIT, 200MCG-1MG-15UNIT-400UNIT 66POLY-VI-FLOR 200MCG/ML-0.25MG/ML 66POLY-VI-FLOR/IRON200MCG-0.5MG-10MG-15UNIT-400UNIT 66

POLY-VI-FLOR/IRON200MCG/ML-7MG/ML-0.25MG/ML 66polyethylene glycol 3350 62polymyxin b-trimethoprim 74POLYTRIM 74POMALYST 29PONSTEL 4pot phosphate monobasic w/ sodphosphate dibasic &monobasic 65POTABA 85potassium bicarb & chloride 65potassium bicarbonate 65potassium chloride 10 meq, 8meq 65potassium chloride 20 meq 65POTASSIUM CHLORIDEER 65potassium chloridemicroencapsulated crystalscr 65POTASSIUM CITRATE 58POTASSIUM CITRATE ER 58potassium citrate-citric acid 58POTIGA 200 MG, 300 MG, 50MG 15POTIGA 400 MG 15PR NATAL 400 EC 68PR NATAL 430 68PR NATAL 430 EC 68PRADAXA 14pramipexole dihydrochloride 30PRAMOSONE 1%-1% 49PRAMOSONE 1%-1%, 1%-2.5% 49PRAMOSONE 1%-2.5% 49PRAMOSONE E 49PRAMOTIC 76pramoxine-chloroxylenol 76pramoxine-hc 49pramoxine-hc-chloroxylenol 76pramoxine-hc-chloroxylenolaqueous 76PRANDIMET 19PRANDIN 20PRAVACHOL 20 MG, 80MG 24PRAVACHOL 40 MG 24pravastatin sodium 10 mg, 20mg, 80 mg 24

Index 19

pravastatin sodium 40 mg 24prazosin hcl 25PRECISION XTRA 63PRECISION XTRA BLOODGLUCOSE TEST STRIPS 52PRECOSE 18PRED FORTE 75PRED MILD 75PRED-G 75PRED-G S.O.P. 75prednicarbate 49prednisolone 41prednisolone acetate (ophth) 75PREDNISOLONE SODIUMPHOSPHATE 1 % 75prednisolone sodium phosphate15 mg/5ml 41PREDNISOLONE SODIUMPHOSPHATE 25 MG/5ML 41prednisone 1 mg, 10 mg, 2.5 mg,20 mg, 5 mg, 50 mg 41PREDNISONE 10 MG 41PREDNISONE 5 MG 41prednisone 5 mg/5ml 41PREDNISONE INTENSOL 41PREFERA OB 68PREFERA OB + DHA 68PREFEST 56PREFOL-DHA 68PRELONE 41PREMARIN 0.3 MG, 0.45 MG,0.625 MG, 0.9 MG, 1.25 MG 57PREMARIN 0.625 MG/GM 84PREMPHASE 56PREMPRO 0.3MG-1.5MG 56PREMPRO 0.45MG-1.5MG,0.625MG-2.5MG, 0.625MG-5MG 56PRENA1CHEW/QUATREFOLIC 68PRENA1 PEARL 68PRENA1PLUS/QUATREFOLIC 68PRENA1/QUATREFOLIC 68PRENAISSANCE 68PRENAISSANCE 90 DHA 68PRENAISSANCE BALANCE68PRENAISSANCE DHA 68PRENAISSANCE HARMONYDHA 68PRENAISSANCE NEXT 68

PRENAISSANCE NEXT-B 68PRENAISSANCE PLUS 68PRENAISSANCEPROMISE 69PRENATA 69PRENATAL 19 1000UNIT-30UNIT-20MG-25MG-3MG-200MG-29MG-15MG-3MG-7MG-12MCG-400UNIT-20MG-1MG-100MG, 30UNIT-1000UNIT-20MG-25MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG-100MG 69prenatal 19 1000unit-400unit-20mg-25mg-3mg-200mg-29mg-7mg-6mg-3mg-12mcg-1mg-30unit-20mg-100mg 69PRENATAL 19 30UNIT-1000UNIT-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG-100MG 69PRENATAL MV & MIN/FE-FA-DHA 69prenatal vit w/ docusate-ironcarbonyl-folic acid 69PRENATAL-U 69PRENATE 69PRENATE AM 69PRENATE DHA 69PRENATE ELITE 69PRENATE ENHANCE 69PRENATE MINI 69PRENATE RESTORE 69PRENEXA 69PRENTIF CAVITY-RIMCERVICAL CAP 63PREPOPIK 62PREQUE 10 69PREVACID 15 MG 82PREVACID 30 MG 82PREVACID SOLUTAB 82PREVPAC 82PREZISTA 100 MG/ML 32PREZISTA 150 MG, 600 MG,800 MG 32PREZISTA 400 MG, 75MG 32PRIFTIN 28PRILOSEC 10 MG 82PRILOSEC 10 MG, 2.5MG 82

PRILOSEC 20 MG, 40 MG 82PRIMAQUINE PHOSPHATE27primidone 15PRIMLEV 8PRIMSOL 10PRINIVIL 24PRINZIDE 26PRISTIQ 18PROAIR HFA 13probenecid 59PROCARDIA 36PROCARDIA XL 36PROCENTRA 1prochlorperazine 31prochlorperazine maleate 31PROCORT 9PROCRIT 60PROCTOCORT 9PROCTOFOAM HC 9PROCYSBI 59PRODRIN 130MG-500MG-20MG 63PRODRIN 65MG-325MG-20MG 63progesterone 77progesterone micronized 77PROGLYCEM 19PROGRAF 0.5 MG, 1 MG, 5MG 34PROHIST CD 42PROHIST CF 42PROHIST LQ 42PROLENSA 76PROMACTA 60promethazine &phenylephrine 42promethazine hcl 12.5 mg, 25mg 23promethazine hcl 12.5 mg, 25mg, 50 mg 23promethazine hcl 6.25mg/5ml 23PROMETHAZINE VC PLAIN42PROMETHAZINEVC/CODEINE 42promethazine w/codeine 42promethazine-dm 42PROMETHEGAN 23PROMETRIUM 77propafenone hcl 150 mg 12

Index 20

propafenone hcl 225 mg, 300mg 12propafenone hcl 225 mg, 325 mg,425 mg 12propantheline bromide 81proparacaine hcl 74propranolol hcl 10 mg, 20 mg, 40mg, 60 mg, 80 mg 35propranolol hcl 120 mg, 160 mg,60 mg, 80 mg 35propranolol hcl 20 mg/5ml 35PROPRANOLOL HCL 40MG/5ML 35propranolol/hydrochlorothiazide

26propylthiouracil 80PROSCAR 59PROSED/DS 82PROTID 42PROTONIX 20 MG, 40 MG 82PROTONIX 40 MG 82PROTOPIC 50protriptyline hcl 18PROVENTIL HFA 13PROVERA 77PROVIDA OB 69PROVIGIL 2PROZAC 17PROZAC WEEKLY 17PRUDOXIN 46pseudoephed-cpm w/hydrocod 42pseudoephedrine w/ codeine-gg 42PULMICORT 0.25 MG/2ML 13PULMICORT 0.5 MG/2ML 13PULMICORT 1 MG/2ML 13PULMICORT FLEXHALER 180MCG/ACT 13PULMICORT FLEXHALER 90MCG/ACT 13PULMOZYME 79PURINETHOL 28PYLERA 82pyrazinamide 28PYRIDIUM 59pyridostigmine bromide 27QNASL 72QSYMIA 1QUALAQUIN 27

QUARTETTE 39QUAZEPAM 61QUESTRAN 23QUESTRAN LIGHT 23quetiapine fumarate 31QUFLORA PEDIATRIC 66QUILLIVANT XR 2quinapril hcl 24quinapril-hydrochlorothiazide

26quinidine gluconate 324mg 12QUINIDINE SULFATE 200MG 12quinidine sulfate 200 mg, 300mg 12quinidine sulfate er 12quinine sulfate 27QVAR 40 MCG/ACT 13QVAR 80 MCG/ACT 13R-NATAL OB 69rabeprazole sodium 82RADIOGARDASE 21ramipril 1.25 mg, 2.5 mg, 5mg 24ramipril 10 mg 24RANEXA 1000 MG 10RANEXA 500 MG 10ranitidine hcl 81RAPAFLO 59RAPAMUNE 0.5 MG 34RAPAMUNE 1 MG, 2 MG 34RAPAMUNE 1 MG/ML 34RAVICTI 55RAYOS 41RAZADYNE 78RAZADYNE ER 78REAPHIRM 69REBETOL 200 MG 33REBETOL 40 MG/ML 33REBIF 78REBIF REBIDOSE 78RECTIV 9REGLAN 57REGRANEX 52RELAGARD 83RELAGESIC 5RELENZA DISKHALER 34

RELHIST 42RELION ULTIMA BLOODGLUCOSE TEST STRIPS 52RELISTOR 58RELNATE DHA 69RELPAX 64REMERON 16REMERON SOLTAB 16RENAGEL 58RENVELA 58repaglinide 20REPREXAIN 200MG-2.5MG 8REPREXAIN 200MG-2.5MG,200MG-5MG 8REPRONEX 54REQUIP 30REQUIP XL 30RESCON 42RESCON-JR 42RESCON-MX 42RESCRIPTOR 32RESCULA 76reserpine 0.1 mg 25RESERPINE 0.25 MG 25RESPA-BR 22RESTASIS 74RESTORIL 61RETIN-A 44RETIN-A MICRO 44RETIN-A MICRO PUMP 44RETROVIR 32REVATIO 37REVIA 21REVLIMID 34REYATAZ 100 MG 32REYATAZ 150 MG, 200 MG, 300MG 32REZIRA 42REZYST SB 20RHEUMATREX 3RHINOCORT AQUA 72RHINOFLEX-650 5RIAX 44RIBAPAK 33ribapak 400 mg, 600 mg 33ribasphere 33ribatab 33

Index 21

ribavirin (hepatitis c) 33RIDAURA 3RIFADIN 150 MG, 300 MG 28RIFAMATE 27rifampin 150 mg, 300 mg 28RIFATER 27RILUTEK 72riluzole 72rimantadine hydrochloride 34RIOMET 19RISPERDAL 31RISPERDAL M-TAB 31risperidone 31RITALIN 2RITALIN LA 10 MG 2RITALIN LA 20 MG, 30 MG, 40MG 2RITALIN SR 2rivastigmine tartrate 78rizatriptan benzoate 10 mg, 5mg 64ROBAXIN 500 MG 71ROBAXIN-750 71ROBINUL 1 MG 81ROBINUL FORTE 81ROCALTROL 55ropinirole hydrochloride 30ROSANIL 44ROXICET 8ROXICODONE 7ROZEREM 61RYBIX ODT 7RYTHMOL 150 MG 12RYTHMOL 225 MG 12RYTHMOL SR 12RYZOLT 7SABRIL 16SAFYRAL 39SALAGEN 65SALEX 50SALEX LOTION 50SALICYLIC ACID 26 % 50salicylic acid 27.5 % 50salicylic acid 6 % 50salicylic acid in ammoniumlactate vehicle 50salicylic acid w/ cleanser 51

SALKERA 51SALVAX 51SAMSCA 56SANCTURA 83SANCUSO 21SANDIMMUNE 100 MG, 25MG 34SANDIMMUNE 100MG/ML 34SANDOSTATIN 56SANTYL 50SAPHRIS 31SARAFEM 78SAVELLA 78SE-CARE CONCEIVE 69SE-NATAL 19 30UNIT-1000UNIT-100MG-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG 69SE-NATAL 19 30UNIT-1000UNIT-20MG-25MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-3MG-20MG-1MG-100MG 69SE-NATAL 90 69SEASONALE 39SEASONIQUE 39SECONAL 61SECTRAL 35SEDAPAP 5SELECT-OB 69SELECT-OB+DHA 69selegiline hcl 30SELENIUM SULFIDE2.25% 47selenium sulfide 2.5 % 46selenium sulfide-pyrithione zincin urea vehicle 47SELRX 47SELSUN SHAMPOO 47SELZENTRY 32SEMPREX-D 42SENSIPAR 55SEREVENT DISKUS 13SEROMYCIN 28SEROQUEL 31SEROQUEL XR 31sertraline hcl 17SETON ET-EC 69

SETONET 69SFROWASA 58SHOHLS SOLUTIONMODIFIED 58SHUR-SEAL 83SIGNIFOR 56sildenafil citrate (pulmonaryhypertension) 37SILENOR 61SILVADENE 47silver sulfadiazine 47SIMBRINZA 73SIMCOR 24SIMPONI 3simvastatin 24SINEMET 30SINEMET CR 30SINGULAIR 12sirolimus 34SIRTURO 28SKELAXIN 71SKELID 54SKLICE 52SKYLA 40sodium chloride (inhalant) 43sodium citrate & citric acid 58sodium fluoride 0.125 mg/drop,0.5 mg/ml 64sodium fluoride 0.25 mg, 0.5 mg,0.55 mg, 1 mg, 1.1 mg, 2.2mg 64SODIUM FLUORIDE 0.5 MG, 1MG 64sodium phenylbutyrate 55sodium polystyrenesulfonate 35sodium polystyrene sulfonate 15gm/60ml 35sodium polystyrene sulfonate 30gm/120ml, 50 gm/200ml 35SODIUM SULFACETAMIDEWASH 47SODIUMSULFACETAMIDE/SULFUR

44SODIUMSULFACETAMIDE/SULFURCLEANSER IN UREA 44SODIUMSULFACETAMIDE/SULFUR INUREA 44SODIUMSULFACETAMIDE/UREA 47

Index 22

sodium thiosulfate-salicylicacid 46SOLARAZE 46SOLODYN 80SOLTAMOX 29SOMA 250 MG 71SOMA 350 MG 71SOMAVERT 55SOMNOTE 61SONATA 61SORIATANE 10 MG 46SORIATANE 17.5 MG 46SORIATANE 25 MG 46SORILUX 46sotalol hcl 35sotalol hcl (afib/afl) 35SOVALDI 33SPACER/AEROSOL-HOLDINGCHAMBER 63SPECTRACEF 38SPINOSAD 52SPIRIVA HANDIHALER 12spironolactone 53spironolactone &hydrochlorothiazide 53SPORANOX 10 MG/ML 22SPORANOX 100 MG 22SPORANOX PULSEPAK 22SPRIX 4SPRYCEL 29sps 35SSKI 64SSS 10-4 44ST JOSEPH ADULT 5ST JOSEPH ADULTANALGESICLOW DOSE BITESIZE 5STAFLEX 5STALEVO 100 30STALEVO 125 30STALEVO 150 30STALEVO 200 30STALEVO 50 30STALEVO 75 30STARLIX 20stavudine 32STAVZOR 16STIMATE 55

STIVARGA 29STRATTERA 10 MG, 18 MG,25 MG, 40 MG 1STRATTERA 100 MG, 60 MG,80 MG 1STRIANT 9STRIBILD 32STROMECTOL 10SUBOXONE 12MG-3MG,2MG-0.5MG, 4MG-1MG, 8MG-2MG 8SUBOXONE 2MG-0.5MG 9SUBOXONE 8MG-2MG 9SUBSYS 100 MCG, 1200MCG, 1600 MCG, 600 MCG7SUBSYS 200 MCG, 400 MCG,800 MCG 7SUCLEAR 62SUCRAID 53sucralfate 81SULAR 36sulfacetamide sod-prednisolone 75sulfacetamide sodium 47SULFACETAMIDESODIUM 74sulfacetamide sodium(acne) 44sulfacetamide sodium(ophth) 74sulfacetamide sodium w/ sulfur1%-10%, 5%-10% 44sulfacetamide sodium w/ sulfur2%-10%, 4%-9%, 4.5%-9% 44sulfacetamide sodium w/ sulfur2%-10%, 5%-10% 44sulfacetamide sodium w/ sulfur4%-8% 44sulfacetamide sodium w/ sulfur5%-10% 44sulfacetamide sodium-sulfur inurea vehicle 44SULFADIAZINE 79sulfamethoxazole-trimethoprim

10SULFAMYLON 5 % 47SULFAMYLON 85 MG/GM47sulfasalazine 58SULFOAM 44sulindac 4SUMADAN WASH 44SUMATRIPTAN 64

sumatriptan succinate 100 mg, 25mg, 50 mg 64SUMATRIPTAN SUCCINATE 4MG/0.5ML 64sumatriptan succinate 4mg/0.5ml 64sumatriptan succinate 6mg/0.5ml 64SUMAXIN TS 44SUMAXIN WASH 44SUPRAX 100 MG, 200 MG 38SUPRAX 100 MG/5ML, 200MG/5ML 38SUPRAX 400 MG 38SUPRAX 500 MG/5ML 38SUPRENZA 1SUPREP BOWEL PREP 62SURMONTIL 18SUSTIVA 32SUTENT 29SYMBICORT 14SYMBYAX 78SYNALAR 49SYNALGOS-DC 8SYNAREL 55SYNERA 51SYNTHROID 80SYPRINE 34TABLOID 28TACLONEX 49tacrolimus 34TAFINLAR 29TAMBOCOR 12TAMIFLU 30 MG, 45 MG 34TAMIFLU 6 MG/ML 34TAMIFLU 75 MG 34tamoxifen citrate 29tamsulosin hcl 59TAPAZOLE 80TARCEVA 29TARGRETIN 1 % 46TARGRETIN 75 MG 29TARKA 26TARON EC CALCIUM 69TARON-BC 69TARON-C DHA 69TARON-DUO EC 70TARON-PREX 70

Index 23

TASIGNA 29TASMAR 30TAZORAC 46TECFIDERA 78TECFIDERA STARTERPACK 78TEGRETOL 15TEGRETOL-XR 100 MG 15TEGRETOL-XR 200 MG, 400MG 15TEKAMLO 26TEKRAL 43TEKTURNA 27TEKTURNA HCT 26telmisartan 25telmisartan-amlodipine 26telmisartan-hydrochlorothiazide

26temazepam 61TEMODAR 28TEMOVATE 49TEMOVATE E 49temozolomide 28TENCON 5TENEX 25TENORETIC 100 26TENORETIC 50 26TENORMIN 35TERAZOL 3 84TERAZOL 7 84terazosin hcl 25terbinafine hcl 22terbutaline sulfate 2.5 mg, 5mg 14terconazole vaginal 84TERSI FOAM 47TESSALON 41TESSALON PERLES 41TESTIM 9TESTRED 9tetracaine hcl (ophth) 74tetracycline hcl 250 mg 80TETRACYCLINE HCL 500MG 80TEVETEN 400 MG 25TEVETEN 600 MG 25TEVETEN HCT 26TEXACORT 49

TGQ30PSE/150GFN/15DM 43TGQ 30PSE/3BRM/15DM 43THALITONE 54THALOMID 34THEO-24 14theophylline 100 mg, 200 mg,300 mg, 450 mg 14theophylline 400 mg, 600mg 14theophylline 80 mg/15ml 14THIOLA 59thioridazine hcl 31thiothixene 31thyroid 80THYROLAR-1 80THYROLAR-1/2 80THYROLAR-1/4 80THYROLAR-2 80THYROLAR-3 80tiagabine hcl 16TIAZAC 36ticlopidine hcl 60TIGAN 21TIKOSYN 12timolol maleate 35timolol maleate (ophth) 73TIMOPTIC 73TIMOPTIC OCUDOSE 73TIMOPTIC-XE 73TINDAMAX 10tinidazole 10TIROSINT 80TIVICAY 32tizanidine hcl 71TL-ASSURE ONE 70TL-ASSURE+DHA 70TL-CARE DHA 70TL-CERMIDE 51TL-SELECT 70TL-SELECT DHA 70TOBI 2TOBI PODHALER 3TOBRADEX 75TOBRADEX ST 75tobramycin 3tobramycin sulfate (ophth) 74

tobramycin-dexamethasone 75TOBREX 74TOFRANIL 18TOFRANIL-PM 18tolazamide 20tolbutamide 20tolmetin sodium 4tolterodine tartrate 1 mg 83tolterodine tartrate 2 mg 83tolterodine tartrate 2 mg, 4mg 83TOPAMAX 15TOPAMAX SPRINKLE 15TOPICORT 0.05 % 49TOPICORT 0.25 % 49topiramate 15TOPROL XL 35torsemide 53TOVIAZ 83TRACLEER 37TRADJENTA 19tramadol hcl 100 mg, 200 mg,300 mg 7tramadol hcl 50 mg 7TRAMADOL HCL ER 7tramadol-acetaminophen 8TRANDATE 35trandolapril 24tranexamic acid 650 mg 60TRANSDERM-SCOP 21TRANXENE T 11tranylcypromine sulfate 17TRAVATAN Z 76TRAVOPROST 76trazodone hcl 17TRECATOR 28TRENTAL 59TRETIN-X 0.038 % 44TRETIN-X 0.075 % 44tretinoin 44tretinoin (chemotherapy) 29tretinoin microsphere 0.04 %, 0.1% 44TREXALL 28TREXIMET 63TREZIX 8TRI RX 70

Index 24

TRI-NORINYL 28 39TRI-TABS DHA 70TRI-VI-FLOR 66TRI-VI-FLORO 66tri-vit/fluoride/iron 66triadvance 70triamcinolone acetonide 49triamcinolone acetonide(mouth) 65triamcinolone acetonide(nasal) 72triamcinolone acetonide(topical) 49triamterene &hydrochlorothiazide 53TRIAMTERENE/HYDROCHLOROTHIAZIDE 53trianex 49triazolam 61TRIBENZOR 26TRICARE DHA 301 70TRICARE PRENATALCOMPLEAT 70TRICARE PRENATAL DHAONE 70TRICITRATES 58TRICOR 23trifluoperazine hcl 31trifluridine 74TRIGLIDE 160 MG 23TRIGLIDE 50 MG 23trihexyphenidyl hcl 30TRILEPTAL 15TRILIPIX 23trimethobenzamide hcl 21trimethoprim 10trimipramine maleate 18TRINATAL GT 70TRINATAL ULTRA 70TRIVEEN-ONE 70TRIVEEN-PRX RNF 70TRIVEEN-TEN 70TRIVEEN-U 70TRIZIVIR 32TROKENDI XR 16tropicamide 73trospium chloride 83TRUSOPT 76TRUVADA 32

trypsin w/ castor oil & peruvianbalsam 50TUDORZA PRESSAIR 12TUSNEL 2MG-15MG-200MG 43TUSNEL PED-C 43TUSSAFED EX 43TUSSICAPS 43TWINJECT 84TWYNSTA 26TYKERB 29TYLENOL/CODEINE #3 8TYLENOL/CODEINE #4 8TYLOX 8TYZEKA 33UCERIS 41ULESFIA 52ULORIC 59ULTIMATE OB DHA 70ULTIMATECAREADVANTAGE 70ULTIMATECARE COMBO 70ULTIMATECARE ONE 70ULTIMATECARE ONE NF 70ultra tabs 70ULTRACET 8ULTRAM 7ULTRAM ER 7ULTRAVATE 49ULTRAVATE PAC 49ULTRESA 53UMECTA 49UMECTA NAIL FILM 49UNIRETIC 26UNISTRIP1 GENERIC 52UNIVASC 24URAMAXIN 20% 50URAMAXIN 45 % 49URAMAXIN GT 50urea 50urea in lactic acid vehicle 50urea in lactic acid-salicylic acidvehicle 50urea in zinc undecylenate-lacticacid vehicle 50UREA NAIL 50urea-hc acetate 49URECHOLINE 83

URELLE 82URETRON D/S 82UREX 83URIBEL 82URIMAR-T 82UROCIT-K 10 59UROCIT-K 15 59UROCIT-K 5 59UROQID #2 82UROXATRAL 59URSO 250 57URSO FORTE 57ursodiol 57UTOPIC 50V-NATAL 70V-NATAL DHA 70VAGIFEM 84valacyclovir hcl 33VALCHLOR 46VALCYTE 450 MG 33VALCYTE 50 MG/ML 33VALIUM 11valproate sodium 250mg/5ml 16valproic acid 16valsartan-hydrochlorothiazide

26VALTREX 33VANCOCIN HCL 10vancomycin hcl 125 mg, 250mg 10VANDETANIB 29VANOS 49VANOXIDE-HC 45VASCEPA 23VASERETIC 27VASOTEC 25VCF VAGINALCONTRACEPTIVE FILM 83VCF VAGINALCONTRACEPTIVE FOAM 84VECAMYL 27VECTICAL 46VELPHORO 58VELTIN 45VEMAVITE-PRX 2 70VENA-BAL DHA 70VENATAL COMPLETE DHA 70

Index 25

venlafaxine hcl 100 mg, 25 mg,37.5 mg, 50 mg, 75 mg 18venlafaxine hcl 150 mg 18venlafaxine hcl 150 mg, 37.5 mg,75 mg 18venlafaxine hcl 37.5 mg, 75mg 18VENLAFAXINE HCL ER 150 MG,37.5 MG, 75 MG 18VENLAFAXINE HCL ER 225MG 18VENTAVIS 37VENTOLIN HFA 14VERAMYST 72verapamil hcl 100 mg, 120 mg,180 mg, 200 mg, 240 mg, 300mg, 360 mg 36verapamil hcl 120 mg, 180 mg,240 mg 36verapamil hcl 120 mg, 80 mg36VERAPAMIL HCL 40 MG 36VERDESO 49VEREGEN 45VERELAN 36VERELAN PM 36VERIPRED 20 41VERSACLOZ 31VESICARE 83VEXOL 75VFEND 22VIBRAMYCIN 100 MG 80VIBRAMYCIN 25 MG/5ML 80VIBRAMYCIN 50 MG/5ML 80VICODIN 8VICODIN ES 8VICOPROFEN 8VICTOZA 19VICTRELIS 33VIDEX EC 32VIDEXPEDIATRIC 33VIGAMOX 74VIIBRYD 17VIIBRYD 10 MG, 20 MG, 40MG 17VIMOVO 4VIMPAT 10 MG/ML 16VIMPAT 100 MG, 150 MG, 200MG, 50 MG 16VINACAL 70VINACAL B 70

VINATE C 70VINATE CALCIUM 70VINATE DHA 70VINATE DHA RF 70VINATE GT 70VINATE ULTRA 70VIOKACE 53VIRACEPT 33VIRAMUNE 200 MG 33VIRAMUNE 50 MG/5ML 33VIRAMUNE XR 100 MG 33VIRAMUNE XR 400 MG 33VIRASAL 51VIRAZOLE 34VIREAD 150 MG, 300 MG 33VIREAD 200 MG, 250 MG 33VIREAD 40 MG/GM 33VIROPTIC 74VIRT-BAL DHA 70VIRT-BAL DHA PLUS 70VIRT-PN 70VIRT-PN DHA 70VIRT-PN PLUS 70VIRT-SELECT 70VISTARIL 11VITAFOL ULTRA 70VITAFOL-NANO 70VITAFOL-ONE 71VITAFOL-PLUS 71VITAMEDMD ONERX/QUATREFOLIC 71VITAMEDMD PLUSRX/QUATREFOLIC 71VITAMEDMD REDICHEWRX/QUATREFOLIC 71VITAMIN D 84VITAMIN D2 85VITAMIN D3 85VITAMIN D3 400 85VITAPEARL 71VITUZ 43VIVA CT PRENATAL 71VIVA DHA 71VIVACTIL 18VIVELLE-DOT 0.025MG/24HR 57VIVELLE-DOT 0.0375MG/24HR 57

VIVELLE-DOT 0.05 MG/24HR,0.075 MG/24HR, 0.1MG/24HR 57VIVOTIF BERNA 83VOLTAREN 0.1 % 76VOLTAREN 1 % 45VOLTAREN-XR 4voriconazole 200 mg, 50 mg 22voriconazole 40 mg/ml 22VOSOL HC 77VOSPIRE ER 14VOTRIENT 29VP-CH PLUS 71VP-CH-PNV 71VP-GGR-B6 PRENATAL 71VP-HEME OB 71VP-HEME OB + DHA 71VP-PNV-DHA 71VUSION 46VYTONE 46VYTORIN 10MG-10MG 23VYTORIN 10MG-20MG, 40MG-10MG, 80MG-10MG 23VYVANSE 1warfarin sodium 14WELCHOL 23WELLBUTRIN 17WELLBUTRIN SR 17WELLBUTRIN XL 17WELLESSE VITAMIN D3 85WESTCORT 49WESTHROID 113.75 MG, 146.25MG, 16.25 MG, 48.75 MG, 81.25MG, 97.5 MG 80WESTHROID 162.5 MG 80WESTHROID 260 MG, 325MG 80WESTHROID-P 80WP THYROID 113.75 MG, 16.25MG, 48.75 MG, 97.5 MG 80WP THYROID 130 MG, 32.5 MG,65 MG 80XALATAN 76XALKORI 29XANAX 11XANAX XR 11XARELTO 10 MG 14XARELTO 15 MG, 20 MG 14XELJANZ 3

Index 26

XELODA 28XENADERM 50XENAZINE 78XENICAL 1XERAC AC 51XERESE 47XIFAXAN 200 MG 10XIFAXAN 550 MG 10XODOL 8XOLEGEL 46XOLOX 8XOPENEX 14XOPENEX CONCENTRATE 14XOPENEX HFA 14XTANDI 29XYLOCAINE 4 % 51XYREM 78XYZAL 2.5 MG/5ML 22XYZAL 5 MG 23YASMIN 28 39YAZ 39YODOXIN 2Z-COF I 43Z-PRAM 9zafirlukast 12zaleplon 61ZANAFLEX 71ZANTAC 15 MG/ML 81ZANTAC 25 MG 81ZANTAC 300 MG 81ZARONTIN 16ZAROXOLYN 54ZATEAN-CH 71ZATEAN-PN 71ZATEAN-PN DHA 71ZATEAN-PN PLUS 71ZAVESCA 60ZEBETA 35ZEGERID 20MG-1680MG,40MG-1680MG 82ZEGERID 40MG-1100MG 82ZELAPAR 30ZELBORAF 29ZEMPLAR 1 MCG, 2 MCG, 4MCG 55

ZENPEP 10000UNIT-3000UNIT-16000UNIT,34000UNIT-10000UNIT-55000UNIT, 51000UNIT-15000UNIT-82000UNIT,68000UNIT-20000UNIT-109000UNIT, 85000UNIT-25000UNIT-136000UNIT 53ZENPEP 17000UNIT-5000UNIT-27000UNIT 53ZENZEDI 1ZERIT 33ZESTORETIC 27ZESTRIL 25ZETIA 24ZETONNA 72ZGESIC 5ZIAC 27ZIAGEN 20 MG/ML 33ZIAGEN 300 MG 33ZIANA 45zidovudine 33zinc sulfate 220 mg 65ZINGIBER 71ZIOPTAN 76ziprasidone hcl 31ZIPSOR 4ZIRGAN 74ZITHRANOL-RR 46ZITHROMAX 1 GM 62ZITHROMAX 100 MG/5ML, 200MG/5ML 62ZITHROMAX 250 MG 62ZITHROMAX 500 MG 62ZITHROMAX 600 MG 62ZITHROMAX TRI-PAK 62ZITHROMAX Z-PAK 62ZMAX 62ZOCOR 24ZOFRAN 4 MG, 8 MG 21ZOFRAN 4 MG/5ML 21ZOFRAN ODT 21ZOHYDRO ER 7ZOLINZA 29zolmitriptan 64ZOLOFT 17zolpidem tartrate 61ZOLPIMIST 61ZOLVIT 8

ZOMIG 2.5 MG, 5 MG 64ZOMIG NASAL SPRAY 64ZOMIG ZMT 64ZONALON 46ZONATUSS 41ZONEGRAN 16zonisamide 16ZORTRESS 34ZORVOLEX 4zovia 1/50e 39ZOVIRAX 200 MG 33ZOVIRAX 200 MG/5ML 34ZOVIRAX 400 MG, 800 MG 34ZOVIRAX 5 % 47ZUBSOLV 9ZUPLENZ 21ZUTRIPRO 43ZYBAN 79ZYCLARA 50ZYCLARA PUMP 2.5 % 50ZYCLARA PUMP 3.75 % 50ZYDONE 8ZYFLO 12ZYFLO CR 12ZYLET 75ZYLOPRIM 59ZYMAXID 74ZYPREXA 31ZYPREXA ZYDIS 31ZYTIGA 29ZYVOX 100 MG/5ML 10ZYVOX 600 MG 10

Index 27

Documents

Aon Hewitt's Corporate Health Exchange Drug List...Aon Hewitt’s Corporate Health Exchange Drug List or formulary is a list of covered drugs used to treat common diseases or health