Blue Cross and Blue Shield of North Carolina Basic Formulary April

5154-C NC © Prime Therapeutics LLC 03/13

Please consider talking to your doctor about prescribing formulary medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.

The drug formulary is regularly updated. Please visit bcbsnc.com for the most up-to-date information.

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

Blue Cross and Blue Shield of North Carolina Basic Formulary April 2013

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IMember Guide To Covered Medications

On The Basic Formulary. . . . . . . . . . . . . . . . . . . IFormulary Tiers . . . . . . . . . . . . . . . . . . . . . . . . . . . I5-Tier Formulary. . . . . . . . . . . . . . . . . . . . . . . . . . . IGeneric Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . ICompounded Prescriptions . . . . . . . . . . . . . . . . . . IIPrior Review, Quantity Limitations

and Restricted-Access Drugs . . . . . . . . . . . . . . IISpecialty Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . IIUsing The Member Guide To The

Enhanced Formulary . . . . . . . . . . . . . . . . . . . . IIIAbbreviation/Acronym Key . . . . . . . . . . . . . . . . . . III

Preferred Medication List . . . . . . . . . . . . . . . . . . . . 1Anti-Infective Drugs . . . . . . . . . . . . . . . . . . . . . . . . 1Cancer Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Hormones, Diabetes and Related Drugs . . . . . . . . 5Heart and Circulatory Drugs. . . . . . . . . . . . . . . . . . 8Respiratory Drugs . . . . . . . . . . . . . . . . . . . . . . . . 12Gastrointestinal Drugs . . . . . . . . . . . . . . . . . . . . . 13Genitourinary Drugs . . . . . . . . . . . . . . . . . . . . . . . 15Central Nervous System Drugs . . . . . . . . . . . . . . 16Pain Relief Drugs . . . . . . . . . . . . . . . . . . . . . . . . . 19Neuromuscular Drugs . . . . . . . . . . . . . . . . . . . . . 21Supplements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Blood Modifying Drugs . . . . . . . . . . . . . . . . . . . . . 24Topical Products . . . . . . . . . . . . . . . . . . . . . . . . . . 24Miscellaneous Categories . . . . . . . . . . . . . . . . . . 30

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

CONTENTS

IBlue Cross and Blue Shield of North Carolina (BCBSNC) April 2013 Basic Formulary

MEMBER GUIDE TO COVERED MEDICATIONS ON THE BASIC FORMULARY

This guide lists the approved brand name and generic prescription drugs that have been reviewed by Blue Cross and Blue Shield of North Carolina (BCBSNC) and are the only covered medications on BCBSNC’s Basic formulary, a closed formulary. Please refer to this formulary guide for information about medications covered by this formulary, and present this guide to your doctor if you or another covered family member requires a prescription. This guide was current at the time of printing and is subject to change. For a more complete listing of drug coverage and costs, you may use our drug search at bcbsnc.com. You may also call BCBSNC Customer Service at the number listed on the back of your ID card to verify prescription drug benefits.

A formulary is a list of prescription drugs covered by a health plan. BCBSNC Pharmacy & Therapeutics (P&T) Committee reviews medications at least quarterly. This includes ongoing reviews of clinical information about new drugs and reviews of new safety and efficacy information about older drugs. The majority of BCBSNC’s P&T Committee is composed of practicing physicians and pharmacists independent of BCBSNC.

Please refer to your member guide for detailed information regarding your pharmacy benefits, including your benefit design, out-of-pocket costs, non-formulary exception requests and applicable exclusions.

FORMULARY TIERS

The 5-Tier Basic formulary covers many medications approved by the United States Food & Drug Administration (FDA), within existing benefits. The plan design determines the member’s payment obligation. Note: Drugs listed as covered on Tier 1 and Tier 2 are generics. Brand names listed for Tier 1 and Tier 2 drugs are for reference only. Brands for which generic equivalents are available are listed on Tier 4 unless indicated otherwise.

5-Tier Formulary

Here are the definitions of each tier for the five-tiered benefit structure:

• Tier 1: Generic medications. Medications listed in Tier 1 have the lowest co-payment.

• Tier 2: Non-preferred generic medications. Medications listed in Tier 2 have the second-lowest co-payment.

• Tier 3: Includes select brand-name drugs recommended by the BCBSNC P&T Committee as preferred brand-name products based on safety, efficacy, and cost.

• Tier 4: Contains 1) brand-name products that, as recommended by the P&T Committee, usually have preferred and often less costly therapeutic alternatives at a lower tier, 2) some brands with therapeutically equivalent generics, and 3) selected biosimilar specialty drugs. Medications listed in Tier 4 have the second-highest co-payment.

• Tier 5: Specialty drugs. Those medications, as classified by the P&T Committee, that generally have unique uses, require special dosing or administration, are typically prescribed by a specialist provider and are significantly more costly than alternative drugs or therapies. This may include biosimilar specialty drugs. Medications listed in Tier 5 generally have the highest co-payment or co-insurance amount.

GENERIC DRUGS

In most cases choosing a generic drug equivalent, when available, will mean significant savings to you. We encourage you to discuss with your physician whether a generic alternative is available as these drugs represent safe, effective treatment options. Especially for drugs that are taken daily and refilled frequently, you will experience the long-term savings of a lower drug payment month after month. If you choose a brand name prescription drug and a generic equivalent is available, you may be subject to a reduced benefit and a higher out-of-pocket expense.

IIBlue Cross and Blue Shield of North Carolina (BCBSNC) April 2013 Basic Formulary

COMPOUNDED PRESCRIPTIONS

Compounded prescriptions contain two or more drugs mixed together. Compounded prescriptions are processed according to member benefits. To be eligible for coverage, compounded medications must contain at least one FDA-approved prescription ingredient and must not be a copy of a commercially available product. All compounded medications may be subject to review and may require prior review.

PRIOR REVIEW, QUANTITY LIMITATIONS AND RESTRICTED-ACCESS DRUGS

Certain medications may be subject to prior review, quantity limitations, or restricted-access programs. BCBSNC’s P&T Committee reviews the clinical criteria for these programs.

• Drugs that have prior review requirements must be reviewed by BCBSNC before coverage can be authorized.

• Certain medications may also have limitations on the quantity and days’ supply coverage. Quantities in excess of the coverage limit must be reviewed and approved by BCBSNC before coverage can be authorized for amounts in excess of the limits.

• For coverage of restricted-access and non-formulary drugs, BCBSNC requires that the member has tried preferred formulary drugs first. Coverage for restricted-access drugs may be provided without the use of a preferred drug if the provider certifies in writing that the member has previously used preferred drugs and the preferred drug has been detrimental to the member's health or has been ineffective in treating the same condition and, in the opinion of the provider, are likely to be detrimental to the member's health or ineffective in treating the condition in the future. Clinical rationale and documentation for exception requests may be required. If approval of coverage of a non-formulary drug is granted, the non-formulary non-specialty drug will be covered on the non-preferred brand tier (Tier 4) and the non-formulary specialty drug will be covered on the specialty tier (Tier 5).

The FDA is responsible for approving medications for use based on clinical data proving the medication is safe and effective for that specific use. BCBSNC’s prior review and quantity limitations programs follow FDA-approved uses for these drugs. However, BCBSNC recognizes that in many cases, “off-label” (non-FDA approved) uses of prescription drugs may be acceptable. In determining the acceptability of off-label uses, BCBSNC utilizes several sources of clinical information including but not limited to 1) nationally recognized clinical references including American Hospital Formulary Service Drug Information; 2) the results of at least two randomized controlled clinical studies that support a specific off-label use, and that are published in peer-reviewed professional medical journals; and 3) consultations with internal and external physician experts regarding community standards. Additional searches for current supporting medical literature may be performed utilizing standard electronic databases.

SPECIALTY DRUGS

These medications, as classified by BCBSNC, generally have unique uses, require special dosing or administration, are typically prescribed by a specialist provider and are significantly more costly than alternative drugs or therapies. Most specialty drugs can be found on Tier 5, but some are found on Tier 4.

Some of these specialty drugs will need to be filled at a participating specialty pharmacy in our network. These drugs are identified in the specialty column of the formulary guide. Call the customer service number on the back of your ID card to determine which pharmacy can fill your specialty drug prescription.

IIIBlue Cross and Blue Shield of North Carolina (BCBSNC) April 2013 Basic Formulary

USING THE MEMBER GUIDE TO THE ENHANCED FORMULARY 1 2 3 4 2013

Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2013 Basic Formulary 1

Drug Name Dru

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ANTI-INFECTIVE DRUGSPENICILLINSamoxicillin caps, tabs, susp 1

AMOXICILLIN chew tabs 1

amoxicillin/potassiumclavulanate chew tabs, 200 mg

2

amoxicillin/potassiumclavulanate chew tabs,400 mg; susp; tabs (Augmentin)

1

amoxicillin/potassiumclavulanate ext-release (Augmentin XR)

2

ampicillin caps 1

AMPICILLIN susp 1

AUGMENTIN susp, 125 mg/5 mL 3


AUGMENTIN tabs 4

AUGMENTIN XR 4

dicloxacillin 1

penicillin v potassium 1

CEPHALOSPORINSCEFACLOR susp 3

cefaclor caps 2

cefadroxil caps 1

cefadroxil susp, tabs 2

cefdinir 1

cefpodoxime 2

cefprozil 1

CEFTIN susp, 125 mg/5 mL; tabs 4

CEFTIN susp, 250 mg/5 mL 3

cefuroxime (Ceftin) 1

cephalexin caps, susp (Keflex) 1

KEFLEX 250 mg, 500 mg 4

SUPRAX susp, tabs 4

MACROLIDES

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AZITHROMYCIN powder pack forsusp

4

azithromycin susp,tabs (Zithromax)

1

BIAXIN 4

BIAXIN XL 4

clarithromycin (Biaxin) 2

clarithromycin ext-release (BiaxinXL)

2

DIFICID 5 • •E.E.S. 400 1

ERY-TAB 1

ERYTHROCIN STEARATE 3

ERYTHROMYCIN BASE 4

ERYTHROMYCIN delayed-releasecaps

1

ERYTHROMYCINETHYLSUCCINATE

1

ZITHROMAX 4

TETRACYCLINESADOXA 4

demeclocycline 2

DORYX 4 •doxycycline hyclate (Vibramycin) 1

DOXYCYCLINE HYCLATEdelayed-release tabs, 75 mg,100 mg

4 •

doxycycline hyclate delayed-release tabs, 150 mg (Doryx)

2

doxycyclinemonohydrate (Adoxa, Monodox)

2

DYNACIN 4

MINOCIN caps 4

minocycline caps (Minocin) 1

minocycline tabs (Dynacin) 2

minocycline ext-release (Solodyn) 2

MONODOX 4

The Medication List is organized into broad categories (e.g., Anti-Infectives).

1 The first column of the chart lists the medication name. Generic medications are listed in lowercase boldface (e.g., ampicillin). Brand name medications are capitalized (e.g., SUPRAX).

Separate medication entries are required for some dosage forms such as extended-release and delayed-release.

2 The second column indicates the Tier level.

3 The third column indicates if the medication is a Specialty medication and needs to be filled at a participating

specialty pharmacy in our network.

4 The remaining columns indicate the Pharmacy Program(s) that apply to the prescription medication (e.g.,

Prior Review, Quantity Limitations, and Restricted Access). If an indicator is present in the column(s), then the Pharmacy Program applies.

ABBREVIATION/ACRONYM KEYcaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .capsules chew tabs . . . . . . . . . . . . . . . . . . . . . chewable tablets conc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . concentrate crm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .cream ext-release . . . . . . . . . . . . . . . . . . . .extended-release inhal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . inhalation inj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . injection lotn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lotion ODT . . . . . . . . . . . . . . . . . . . . orally disintegrating tabs

OSM . . . . . . . . . . . . . . . . . . . . . . . . . . . osmotic-release OTC . . . . . . . . . . . . . . . . . . . . . . over-the-counter drugoint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ointmentSL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .sublingualsoln . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .solutionsupp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . suppositoriessusp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .suspensiontabs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . tablets

2013


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ANTI-INFECTIVE DRUGS

PENICILLINS

amoxicillin caps, tabs, susp 1

AMOXICILLIN chew tabs 1

amoxicillin/potassiumclavulanate chew tabs, 200 mg

2

amoxicillin/potassiumclavulanate chew tabs,400 mg; susp; tabs (Augmentin)

1

amoxicillin/potassiumclavulanate ext-release (Augmentin XR)

2

ampicillin caps 1

AMPICILLIN susp 1



AUGMENTIN tabs 4

AUGMENTIN XR 4

dicloxacillin 1

penicillin v potassium 1

CEPHALOSPORINS

CEFACLOR susp 3

cefaclor caps 2

cefadroxil caps 1

cefadroxil susp, tabs 2

cefdinir 1

cefpodoxime 2

cefprozil 1

CEFTIN susp, 125 mg/5 mL; tabs 4

CEFTIN susp, 250 mg/5 mL 3

cefuroxime (Ceftin) 1

cephalexin caps, susp (Keflex) 1

KEFLEX 250 mg, 500 mg 4

SUPRAX susp, tabs 4

MACROLIDES

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AZITHROMYCIN powder pack forsusp

4

azithromycin susp,tabs (Zithromax)

1

BIAXIN 4

BIAXIN XL 4

clarithromycin (Biaxin) 2

clarithromycin ext-release (BiaxinXL)

2

DIFICID 5 • •E.E.S. 400 1

ERY-TAB 1

ERYTHROCIN STEARATE 3

ERYTHROMYCIN BASE 4

ERYTHROMYCIN delayed-releasecaps

1

ERYTHROMYCINETHYLSUCCINATE

1

ZITHROMAX 4

TETRACYCLINES

ADOXA 4

demeclocycline 2

DORYX 4 •doxycycline hyclate (Vibramycin) 1

DOXYCYCLINE HYCLATEdelayed-release tabs, 75 mg,100 mg

4 •

doxycycline hyclate delayed-release tabs, 150 mg (Doryx)

2

doxycyclinemonohydrate (Adoxa, Monodox)

2

DYNACIN 4

MINOCIN caps 4

minocycline caps (Minocin) 1

minocycline tabs (Dynacin) 2

minocycline ext-release (Solodyn) 2

MONODOX 4

2013

2 Blue Cross and Blue Shield of North Carolina (BCBSNC) April 2013 Basic Formulary

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SOLODYN 45 mg, 90 mg, 135 mg 4 •TETRACYCLINE 1

VIBRAMYCIN caps 4

FLUOROQUINOLONES

CIPRO tabs 4

CIPRO XR 4

ciprofloxacin (Cipro) 1

ciprofloxacin ext-release tabs,1000 mg (Cipro XR)

1

ciprofloxacin ext-release tabs,500 mg (Cipro XR)

2

LEVAQUIN 4

levofloxacin soln (Levaquin) 2

levofloxacin tabs (Levaquin) 1

ofloxacin tabs 2

AMINOGLYCOSIDES

neomycin sulfate tabs 1

paromomycin 2

TOBI 5 •TUBERCULOSIS

ethambutol (Myambutol) 2

isoniazid tabs 1

MYAMBUTOL 4

pyrazinamide 2

RIFADIN 4

RIFAMATE 4

rifampin (Rifadin) 2

FUNGAL INFECTIONS

ANCOBON 4

DIFLUCAN 4

fluconazole (Diflucan) 1

flucytosine (Ancobon) 2

GRIFULVIN V 4

GRIS-PEG 4

griseofulvin microsize susp 2

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griseofulvin microsizetabs (Grifulvin V)

2

griseofulvin ultramicrosize (Gris-Peg)

2

itraconazole (Sporanox) 2 •ketoconazole tabs 1

LAMISIL tabs 4

NOXAFIL 5 •nystatin oral powder 2

nystatin tabs 1

SPORANOX caps 4 •terbinafine (Lamisil) 1

VFEND tabs 5 •voriconazole (Vfend) 5 •VIRAL INFECTIONS

Cytomegalovirus

VALCYTE 5 •Hepatitis

BARACLUDE 5 •COPEGUS 5 •EPIVIR-HBV 5

HEPSERA 5 •INCIVEK 5 • •PEGASYS 5 • •REBETOL caps 5 •RIBAPAK 800 mg, 1000 mg,

1200 mg/day5 •

RIBASPHERE tabs, 400 mg,600 mg

5 •

RIBATAB 5 •ribavirin (Copegus, Rebetol) 2 •TYZEKA 5 •VICTRELIS 5 • •Herpes

acyclovir (Zovirax) 1

famciclovir (Famvir) 2

2013


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FAMVIR 4

valacyclovir (Valtrex) 2

VALTREX 4

ZOVIRAX 4

HIV/AIDS

abacavir (Ziagen) 2 •APTIVUS 5

ATRIPLA 5 •COMBIVIR 5 •COMPLERA 5 •CRIXIVAN 5 •didanosine delayed-

release (Videx EC)2 •

EDURANT 5

EMTRIVA 5 •EPIVIR 5 •EPZICOM 5 •FUZEON 5 •INTELENCE 5 •INVIRASE 5 •ISENTRESS 5 •KALETRA 5 •lamivudine (Epivir) 2 •lamivudine/zidovudine (Combivir) 2 •LEXIVA 5 •NEVIRAPINE susp 5 •nevirapine tabs (Viramune) 2 •NORVIR 5 •PREZISTA tabs 5 •RESCRIPTOR 5 •RETROVIR 5 •REYATAZ 5 •SELZENTRY 5 •stavudine (Zerit) 2 •STRIBILD 5 •

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SUSTIVA 5 •TRIZIVIR 5 •TRUVADA 5 •VIDEX 5 •VIDEX EC 5 •VIRACEPT 5 •VIRAMUNE 5 •VIRAMUNE XR 5 •VIREAD 5 •ZERIT caps 5 •ZERIT soln 4 •ZIAGEN 5 •zidovudine (Retrovir) 2 •Influenza

FLUMADINE 4

rimantadine (Flumadine) 2

TAMIFLU 4

MALARIA

ARALEN 4

atovaquone/proguanil250-100 mg (Malarone)

2

ATOVAQUONE/PROGUANIL62.5-25 mg

4

chloroquine phosphate (Aralen) 1

COARTEM 3

DARAPRIM 4

hydroxychloroquine (Plaquenil) 1

MALARONE 4

mefloquine 1

PLAQUENIL 4

PRIMAQUINE 3

WORM INFECTIONS

ALBENZA 4

STROMECTOL 4

OTHER ANTI-INFECTIVES

2013


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BACTRIM 4

BACTRIM DS 4

CAYSTON 5

CLEOCIN 4

CLEOCIN PEDIATRIC 4

clindamycin caps (Cleocin) 1

clindamycin soln (CleocinPediatric)

2

DAPSONE 3

erythromycin/sulfisoxazole 2

FLAGYL 4

metronidazole tabs (Flagyl) 1

SEPTRA DS 4

sulfamethoxazole/trimethoprim (Bactrim, BactrimDS)

1

TINDAMAX 4

tinidazole (Tindamax) 2

trimethoprim 1

VANCOCIN 4

vancomycin (Vancocin) 2

XIFAXAN 200 mg 4

XIFAXAN 550 mg 5

YODOXIN 2

ZYVOX tabs 5

CANCER DRUGS

AFINITOR 5 •ALKERAN tabs 5 •anastrozole (Arimidex) 1

ARIMIDEX 4

AROMASIN 4

bicalutamide (Casodex) 1

CAPRELSA 5

CASODEX 4

CEENU 5 •COMETRIQ 5

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CYCLOPHOSPHAMIDE tabs 2 •ELIGARD 5 •EMCYT 5

ERIVEDGE 5

ETOPOSIDE caps 5 •exemestane (Aromasin) 2

FARESTON 5

FASLODEX 5 •FEMARA 4

flutamide 1 •GLEEVEC 4 •HEXALEN 5

HYCAMTIN caps 5 •HYDREA 4 •hydroxyurea (Hydrea) 1 •ICLUSIG 5

INLYTA 5

JAKAFI 5 •letrozole (Femara) 1

LEUCOVORIN CALCIUM tabs,10 mg, 15 mg

2

leucovorin calcium tabs, 5 mg,25 mg

2

LEUKERAN 5 •leuprolide acetate 5 •LUPRON DEPOT 5 •LYSODREN 5 •MATULANE 5 •MEGACE 4

megestrol susp (Megace) 2

megestrol tabs 1

mercaptopurine (Purinethol) 1

MESNEX tabs 5 •methotrexate inj, 25 mg/mL; tabs 1

MYLERAN 4

2013


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NEXAVAR 5 •NILANDRON 5

PURINETHOL 4

SPRYCEL 5 •SUTENT 5 •SYLATRON 5 •TABLOID 4 •tamoxifen 1

TARCEVA 5 •TARGRETIN caps 5 •TASIGNA 5 •TEMODAR caps 5 •tretinoin caps 5 •TYKERB 5 •VANDETANIB 5

VOTRIENT 5 •XALKORI 5 •XELODA 5 •XTANDI 5

ZELBORAF 5 • •ZOLINZA 5 •ZYTIGA 5 •HORMONES, DIABETES AND RELATED DRUGS

CORTICOSTEROIDS

budesonide ext-release (EntocortEC)

2

CORTEF 4

CORTISONE 3

dexamethasone elixir; tabs,0.5 mg, 0.75 mg, 1.5 mg, 4 mg,6 mg

1

DEXAMETHASONE soln 4

DEXAMETHASONE tabs, 1 mg,2 mg

1

DEXAMETHASONE INTENSOL 4

DEXPAK 4

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ENTOCORT EC 4

fludrocortisone 1

hydrocortisone (Cortef) 1

MEDROL 4

methylprednisolone (Medrol) 1

MILLIPRED soln 4

MILLIPRED tabs 1

MILLIPRED DP 4

ORAPRED 4

prednisolone (Prelone) 1

prednisolone sodium phosphatesoln, 15 mg/5 mL (Orapred)

1

PREDNISOLONE SODIUMPHOSPHATE soln, 5 mg/5 mL

1

PREDNISONE soln; tabs, 50 mg 1

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

1

PREDNISONE INTENSOL 4

PRELONE 4

VERIPRED 20 4

MALE HORMONES

ANDRODERM 3 •ANDROGEL 3 •ANDROID 4 •danazol 2

DEPO-TESTOSTERONE 4 •OXANDRIN 4 •oxandrolone (Oxandrin) 2 •testosterone cypionate (Depo-

Testosterone)1 •

testosteroneenanthate (Delatestryl)

1 •

TESTRED 4 •ESTROGENS

ACTIVELLA 4

ALORA 4

2013


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CLIMARA 4

DELESTROGEN 4

DIVIGEL 4

esterified estrogens/methyltestosterone

1

ESTRACE 4

ESTRADERM 4

estradiol (Climara, Estrace) 1

estradiol valerate (Delestrogen) 2

estradiol/norethindroneacetate (Activella)

2

estropipate 0.625 mg, 0.75 mg,1.25 mg, 1.5 mg

1

ESTROPIPATE 3 mg 1

FEMHRT LOW DOSE0.5 mg-2.5 mcg

4

FEMHRT 1/5 4

JINTELI 2

PREMARIN tabs 3

PREMPHASE 3

PREMPRO 3

VIVELLE-DOT 4

PROGESTINS

AYGESTIN 4

medroxyprogesteroneacetate (Provera)

1

norethindrone acetate (Aygestin) 2

progesterone 2

progesteronemicronized (Prometrium)

2

PROMETRIUM 4

PROVERA 4

BIRTH CONTROL

BREVICON-28 4

CYCLESSA 4

DEPO-PROVERA 150 mg/mL 4

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tric

ted

Acc

ess

DESOGEN 4

ELLA 3

ESTROSTEP FE 4

FEMCON FE 4

levonorgestrel (Plan B, Plan BOne-Step)

1

LOESTRIN 4

LOESTRIN FE 4

LOSEASONIQUE 4

LYBREL 4

medroxyprogesteroneacetate (Depo-Provera)

1

MIRCETTE 4

MODICON 4

NOR-QD 4

NORDETTE 4

NORINYL 1/35 4

NUVARING 3

oral contraceptives – generics attier 1 – all others

1

oral contraceptives – genericsat tier 2 – Amethia; AmethiaLo; Camrese; Camrese Lo;Gianvi; levonorgestrel/ethinylestradiol, 0.1-0.02 mg; Lornya;Ocella; Syeda;Vestura; WymzaFE; Zarah; Zenchent FE; Zeosa

2

ORTHO EVRA 4

ORTHO MICRONOR 4

ORTHO TRI-CYCLEN 4

ORTHO-CEPT 4

ORTHO-CYCLEN 4

ORTHO-NOVUM 4

OVCON-35 4

PLAN B 4

PLAN B ONE-STEP 4

SEASONALE 4

2013


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ted

Acc

ess

SEASONIQUE 4

TRI-NORINYL 4

YASMIN 4

YAZ 4

INFERTILITY

BRAVELLE 5

CETROTIDE 5

chorionic gonadotropin 5

CLOMID 4

clomiphene (Clomid) 1

FOLLISTIM AQ 5

GANIRELIX 5

GONAL-F 5

MENOPUR 5

OVIDREL 5

REPRONEX 5

DIABETES

acarbose (Precose) 2

ACTOPLUS MET 4

ACTOS 4

AMARYL 4

DEX4 GLUCOSE 4

DUETACT 4

FORTAMET 4

glimepiride (Amaryl) 1

glipizide (Glucotrol) 1

glipizide ext-release (Glucotrol XL) 1

glipizide/metformin (Metaglip) 2

GLUCAGEN 3

GLUCAGEN HYPOKIT 3

GLUCAGON EMERGENCY KIT 3

GLUCOPHAGE 4

GLUCOPHAGE XR 4

glucose gel, 40%; oral soln,15 g/59 mL

2

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ted

Acc

ess

GLUCOTROL 4

GLUCOTROL XL 4

GLUCOVANCE 4

glyburide (Micronase) 1

glyburide micronized (Glynase) 1

glyburide/metformin (Glucovance) 1

GLYBURIDE, distributor of Diabeta 1

GLYNASE 4

KOMBIGLYZE XR 3

METAGLIP 4

metformin (Glucophage) 1

metformin ext-release (Glucophage XR)

1

metformin ext-releaseOSM (Fortamet)

2

nateglinide (Starlix) 2

ONGLYZA 3

pioglitazone (Actos) 2

pioglitazone/glimepiride (Duetact) 2

pioglitazone/metformin (ActoplusMet)

2

PRECOSE 4

RIOMET 4

STARLIX 4

tolazamide 250 mg 1

TOLAZAMIDE 500 mg 1

TOLBUTAMIDE 1

VICTOZA 3

DIABETES - INSULINS

Rapid-Acting Insulins

NOVOLOG 3

Short-Acting Insulins

NOVOLIN R 3

Intermediate-Acting Insulins

NOVOLIN N 3

NOVOLIN 70/30 3

2013


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its

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ted

Acc

ess

NOVOLOG MIX 70/30 3

Basal Insulins

LANTUS 3

THYROID REGULATION

ARMOUR THYROID 4

CYTOMEL 4

levothyroxine (Synthroid) 1

liothyronine (Cytomel) 1

methimazole (Tapazole) 1

NATURE-THROID 1

propylthiouracil 1

SYNTHROID 4

TAPAZOLE 4

thyroid (Armour Thyroid) 1

TIROSINT 4

WESTHROID 1

GROWTH HORMONE

OMNITROPE 5 • •OTHER HORMONES AND RELATED DRUGS

ALENDRONATE 40 mg 1

alendronate 5 mg, 10 mg, 35 mg,70 mg (Fosamax)

1

BONIVA tabs 4

cabergoline 2

calcitonin-salmon (Miacalcin) 2

calcitriol caps (Rocaltrol) 1

calcitriol oral soln (Rocaltrol) 2

CARBAGLU 5

CARNITOR oral soln, tabs 4

CARNITOR SF 4

DDAVP spray, soln, tabs 4

desmopressin nasal spray, nasalsoln, tabs (DDAVP)

2

ETIDRONATE 400 mg 2

EVISTA 4

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Acc

ess

FORTEO 5 • •FORTICAL 2

FOSAMAX 4

ibandronate (Boniva) 2

levocarnitine oral soln,tabs (Carnitor)

2

LUPRON DEPOT-PED 5 •methylergonovine 1

MIACALCIN nasal 4

octreotide (Sandostatin) 2 •ROCALTROL 4

SAMSCA 5 •SANDOSTATIN 4 •SENSIPAR 4 •HEART AND CIRCULATORY DRUGS

ANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS AND COMBINATIONS

ACCUPRIL 4

ACCURETIC 4

ACEON 4 mg, 8 mg 4

ALTACE 4

benazepril (Lotensin) 1

benazepril/hydrochlorothiazide (LotensinHCT)

1

captopril 1

CAPTOPRIL/HYDROCHLOROTHIAZIDE

1

enalapril (Vasotec) 1

enalapril/hydrochlorothiazide (Vaseretic)

1

fosinopril 1

fosinopril/hydrochlorothiazide 1

lisinopril (Prinivil, Zestril) 1

lisinopril/hydrochlorothiazide (Prinzide,Zestoretic)

1

2013


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ted

Acc

ess

LOTENSIN 4

LOTENSIN HCT 4

MAVIK 4

moexipril (Univasc) 1

moexipril/hydrochlorothiazide (Uniretic)

1

perindopril (Aceon) 1

PRINIVIL 4

PRINZIDE 4

quinapril (Accupril) 1

quinapril/hydrochlorothiazide (Accuretic)

1

ramipril (Altace) 1

trandolapril (Mavik) 1

UNIRETIC 4

UNIVASC 4

VASERETIC 4

VASOTEC 4

ZESTORETIC 4

ZESTRIL 4

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONS

ATACAND HCT 4 •AVALIDE 4

AVAPRO 4

candesartan/hydrochlorothiazide (AtacandHCT)

2

COZAAR 4

DIOVAN HCT 4

eprosartan (Teveten) 2

HYZAAR 4

irbesartan (Avapro) 2

irbesartan/hydrochlorothiazide (Avalide)

2

losartan (Cozaar) 1

Drug Name Dru

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ted

Acc

ess

losartan/hydrochlorothiazide (Hyzaar)

1

TEVETEN 600 mg 4 •valsartan/hydrochlorothiazide

(Diovan HCT)2

BETA BLOCKERS AND COMBINATIONS

acebutolol (Sectral) 1

atenolol (Tenormin) 1

atenolol/chlorthalidone (Tenoretic)

1

betaxolol (Kerlone) 1

bisoprolol (Zebeta) 1

bisoprolol/hydrochlorothiazide (Ziac)

1

carvedilol (Coreg) 1

COREG 4

CORGARD 4

CORZIDE 4

DUTOPROL 3

INDERAL LA 4

KERLONE 4

labetalol (Trandate) 1

LOPRESSOR 4

LOPRESSOR HCT 4

metoprolol succinate ext-release (Toprol XL)

1

metoprolol tartrate (Lopressor) 1

metoprolol/hydrochlorothiazide (LopressorHCT)

1

nadolol (Corgard) 1

nadolol/bendroflumethiazide (Corzide)

2

propranolol ext-release (InderalLA)

1

propranolol tabs 1

2013


Drug Name Dru

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ty

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its

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ted

Acc

ess

PROPRANOLOL/HYDROCHLOROTHIAZIDE

1

SECTRAL 4

TENORETIC 4

TENORMIN 4

TOPROL XL 4

TRANDATE 4

ZEBETA 4

ZIAC 4

CALCIUM CHANNEL BLOCKERS ANDCOMBINATIONS

ADALAT CC 4

amlodipine (Norvasc) 1

amlodipine/benazepril (Lotrel) 2

CALAN 4

CALAN SR 4

CARDIZEM 4

CARDIZEM CD 4

CARDIZEM LA 4

DILACOR XR 4

diltiazem (Cardizem) 1

diltiazem ext-releasecaps (Cardizem CD, Dilacor XR,Tiazac)

1

diltiazem ext-releasetabs (Cardizem LA)

2

felodipine ext-release 2

ISOPTIN SR 4

LOTREL 4

nicardipine 1

nifedipine 10 mg (Procardia) 2

NIFEDIPINE 20 mg 2

nifedipine ext-release (Adalat CC,Procardia XL)

1

nifedipine ext-releaseOSM (Procardia XL)

1

nimodipine (Nimotop) 2

Drug Name Dru

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ted

Acc

ess

NIMOTOP 4

NISOLDIPINE ext-release 40 mg 2

nisoldipine ext-release 8.5 mg,17 mg, 25.5 mg, 34 mg (Sular)

2

NORVASC 4

PROCARDIA 4

PROCARDIA XL 4

SULAR 4

TIAZAC 4

trandolapril/verapamil ext-release (Tarka)

2

VERAPAMIL 40 mg 1

verapamil 80 mg, 120 mg (Calan) 1

verapamil ext-release (Calan SR,Isoptin SR, Verelan, Verelan PM)

1

VERELAN 4

VERELAN PM 4

CHEST PAIN

IMDUR 4

ISORDIL TITRADOSE 4

ISOSORBIDE DINITRATEsublingual

1

isosorbide dinitrate tabs (IsordilTitradose)

1

isosorbide dinitrate ext-release 1

isosorbide mononitrate (Monoket) 1

isosorbide mononitrate ext-release (Imdur)

1

NITRO-BID oint 1

NITRO-DUR 4

nitroglycerin ext-release caps 1

nitroglycerin ext-releasepatches (Nitro-Dur)

1

NITROSTAT 3

RANEXA 4

CHOLESTEROL LOWERING

ANTARA 4

2013


Drug Name Dru

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ted

Acc

ess

atorvastatin (Lipitor) 2

cholestyramine (Questran,Questran Light)

2

COLESTID 4

colestipol (Colestid) 2

CRESTOR 3 •fenofibrate (Lofibra) 1

fenofibrate (Tricor) 2

fenofibrate micronized (Antara) 2

fenofibrate micronized (Lofibra) 1

fluvastatin (Lescol) 2

gemfibrozil (Lopid) 1

LESCOL 4

LIPITOR 4 •LOFIBRA 4

LOPID 4

lovastatin (Mevacor) 1

MEVACOR 4

NIASPAN 3

PRAVACHOL 4

pravastatin (Pravachol) 1

QUESTRAN 4

QUESTRAN LIGHT 4

simvastatin (Zocor) 1

TRICOR 4

ZETIA 4

ZOCOR 4

FLUID RETENTION

ACETAZOLAMIDE 125 mg 1

acetazolamide 250 mg 1

acetazolamide ext-release (Diamox Sequels)

2

acetazolamide sodium for inj 2

ALDACTAZIDE 4

ALDACTONE 4

Drug Name Dru

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ty

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ted

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ess

amiloride 1

amiloride/hydrochlorothiazide 1

bumetanide 1

chlorothiazide 1

CHLORTHALIDONE 100 mg 4

chlorthalidone 25 mg 1

CHLORTHALIDONE 50 mg 1

DEMADEX 4

DIAMOX SEQUELS 4

DYAZIDE 4

DYRENIUM 4

furosemide soln, 10 mg/mL;tabs (Lasix)

1

FUROSEMIDE soln, 8 mg/mL 3

hydrochlorothiazidecaps (Microzide)

1

hydrochlorothiazide tabs,12.5 mg

2

hydrochlorothiazide tabs, 25 mg,50 mg

1

indapamide 1

LASIX 4

MAXZIDE 4

MAXZIDE-25 4

methazolamide (Neptazane) 2

metolazone (Zaroxolyn) 1

MICROZIDE 4

NEPTAZANE 4

spironolactone (Aldactone) 1

spironolactone/hydrochlorothiazide (Aldactazide)

1

torsemide (Demadex) 1

triamterene/hydrochlorothiazide (Dyazide,Maxzide, Maxzide-25)

1

ZAROXOLYN 4

HEART RHYTHM

2013


Drug Name Dru

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ted

Acc

ess

amiodarone (Cordarone,Pacerone)

1

BETAPACE 4

BETAPACE AF 4

CORDARONE 4

disopyramide (Norpace) 1

flecainide (Tambocor) 1

MEXILETINE 3

NORPACE 4

PACERONE 4

propafenone (Rythmol) 1

propafenone ext-release (RythmolSR)

2

quinidine gluconate ext-release 2

quinidine sulfate 2

RYTHMOL 4

RYTHMOL SR 4

sotalol (Betapace, Betapace AF) 1

TAMBOCOR 4

TIKOSYN 4

OTHER HEART RELATED DRUGS

AMLODIPINE/ATORVASTATIN 4

BIDIL 4

CADUET 4

CARDURA 4

CATAPRES 4

CATAPRES-TTS 4

clonidine 1

clonidine transdermalpatches (Catapres-TTS)

2

digoxin tabs (Lanoxin) 1

doxazosin (Cardura) 1

eplerenone (Inspra) 2

guanfacine (Tenex) 1

hydralazine 1

INSPRA 4

Drug Name Dru

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ted

Acc

ess

LANOXIN 4

methyldopa 1

METHYLDOPA/HYDROCHLOROTHIAZIDE

1

midodrine 1

MINIPRESS 4

minoxidil 1

prazosin (Minipress) 1

RESERPINE 3

REVATIO tabs 5 • •sildenafil (Revatio) 5 • •TENEX 4

terazosin 1

TRACLEER 5 • •ERECTILE DYSFUNCTION

VIAGRA 3

BEE STING KITS

EPINEPHRINE 3

EPIPEN 3

EPIPEN-JR 3

RESPIRATORY AGENTS

ANTIHISTAMINES

brompheniramine maleate ext-release

1

carbinoxamine maleate (Palgic) 1

CLARINEX tabs 4

CLARINEX REDITABS 4

cyproheptadine 1

desloratadine (Clarinex) 2

desloratadine ODT (ClarinexReditabs)

2

levocetirizine (Xyzal) 2

PALGIC 4

promethazine 1

PROMETHEGAN 1

XYZAL 4

2013


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ted

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ess

NASAL PRODUCTS

ASTELIN 4

ATROVENT 4

azelastine (Astelin) 2

FLONASE 4

fluticasone propionate (Flonase) 1

ipratropium (Atrovent) 1

NASACORT AQ 4

NASONEX 3

triamcinolone (Nasacort AQ) 2

COUGH/COLD/ALLERGY

acetylcysteine 2

benzonatate (Tessalon) 1

TESSALON 4

TESSALON PERLES 4

ZONATUSS 4

ASTHMA/COPD

ACCOLATE 4

ACCUNEB 4

ADVAIR DISKUS 3

ADVAIR HFA 3

albuterol inhal soln (Accuneb) 1

albuterol sulfate syrup, tabs 1

albuterol sulfate ext-release (Vospire ER)

1

ASMANEX 3

budesonide (Pulmicort Respules) 2

COMBIVENT 3

COMBIVENT RESPIMAT 3

cromolyn sodium inhal soln 2

DALIRESP 4

DUONEB 4

ELIXOPHYLLIN 1

FLOVENT DISKUS 3

FLOVENT HFA 3

Drug Name Dru

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ess

FORADIL AEROLIZER 3

ipratropium inhal soln 1

ipratropium/albuterol (Duoneb) 2

LEVALBUTEROL inhal soln,0.31 mg/3 mL, 0.63 mg/3 mL,1.25 mg/3 mL

4

levalbuterol inhal soln,1.25 mg/0.5 mL (XopenexConcentrate)

1

METAPROTERENOL 1

montelukast chew tabs,tabs (Singulair)

2

PROAIR HFA 3

PULMICORT RESPULES0.25 mg/2 mL, 0.5 mg/2 mL

4

SEREVENT DISKUS 3

SINGULAIR chew tabs, tabs 4

SPIRIVA HANDIHALER 3

SYMBICORT 3

terbutaline 1

theophylline ext-release 1

VOSPIRE ER 4

XOPENEX 4

XOPENEX CONCENTRATE 4

zafirlukast (Accolate) 2

OTHER RESPIRATORY DRUGS

PULMOZYME 5 •GASTROINTESTINAL DRUGS

LAXATIVES

COLYTE 227.1 g 3

COLYTE 240 g 4

GOLYTELY for soln, 236 g 4

GOLYTELY packet, 227.1 g 3

lactulose 1

NULYTELY/FLAVOR PACKS 4

PEG – electrolytes forsoln (Colyte, Golytely, Nulytely)

1

2013


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ess

polyethylene glycol 3350 oralpacket, pwd

2

ANTIDIARRHEALS

DIPHENOXYLATE/ATROPINEsoln

1

diphenoxylate/atropinetabs (Lomotil)

1

LOMOTIL 4

loperamide 1

ANTACIDS

ULCER/GERD

ANASPAZ 4

AXID 4

BENTYL 4

CARAFATE 4

cimetidine 1

clidinium/chlordiazepoxide (Librax)

2

CYTOTEC 4

dicyclomine caps, tabs (Bentyl) 1

DIGEX NF 4

DONNATAL 4

famotidine for susp (Pepcid) 2

famotidine tabs (Pepcid) 1

glycopyrrolate (Robinul) 2

hyoscyamine (Anaspaz, Levsin,Levsin/SL)

1

hyoscyamine ext-release (Levbid) 2

hyoscyamine ODT 1

hyoscyamine/phenyltoloxamine (Digex NF)

2

lansoprazole delayed-release (Prevacid)

2

LEVBID 4

LEVSIN 4

LEVSIN/SL 4

LIBRAX 4

Drug Name Dru

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ted

Acc

ess

methscopolamine (Pamine,Pamine Forte)

2

misoprostol (Cytotec) 1

NEXIUM 3

nizatidine caps (Axid) 1

nizatidine soln (Axid) 2

omeprazole delayed-release (Prilosec)

1

PAMINE 4

PAMINE FORTE 4

pantoprazole delayed-release (Protonix)

1

PEPCID 4

PREVACID 4

PRILOSEC caps 4

PROTONIX tabs 4

ranitidine (Zantac) 1

ROBINUL 4

ROBINUL FORTE 4

sucralfate tabs (Carafate) 1

SYMAX DUOTAB 4

ZANTAC syrup; tabs 4

NAUSEA AND VOMITING

ANTIVERT tabs, 12.5 mg, 25 mg 4

dronabinol (Marinol) 2

EMEND caps 5

MARINOL 4

meclizine 12.5 mg,25 mg (Antivert)

1

meclizine 32 mg 2

ondansetron ODT, tabs (Zofran,Zofran ODT)

1

ondansetron soln (Zofran) 2

ondansetron tabs, 24 mg 1

TIGAN 4

TRANSDERM-SCOP 4

2013


Drug Name Dru

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ess

trimethobenzamide (Tigan) 2

ZOFRAN 4

DIGESTIVE ENZYMES

PANCRELIPASE 3

ZENPEP 3

OTHER GASTROINTESTINAL DRUGS

ACTIGALL 4

ASACOL 3

AZULFIDINE 4

AZULFIDINE EN-TABS 4

balsalazide (Colazal) 2

calcium acetate (Eliphos, Phoslo) 2

CANASA 4

COLAZAL 4

cromolyn sodium (Gastrocrom) 2 •DELZICOL 3

DIPENTUM 5

ELIPHOS 4

ENTEREG 5

GASTROCROM 4 •lactulose 1

LIALDA 4

LOTRONEX 5

mesalamine (Rowasa) 2

METOCLOPRAMIDE inj, 5 mg/mL 4

metoclopramide soln,tabs (Reglan)

1

PENTASA 4

PHOSLO 4

REGLAN 4

RENAGEL 4

RENVELA 4

ROWASA 4

sulfasalazine (Azulfidine) 1

Drug Name Dru

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ty

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ted

Acc

ess

sulfasalazine delayed-release (Azulfidine EN-Tabs)

1

URSO 4

URSO FORTE 4

ursodiol (Actigall, Urso 250/Forte) 2

GENITOURINARY DRUGS

URINARY TRACT INFECTIONS

FURADANTIN 4

HIPREX 4

MACROBID 4

MACRODANTIN 4

methenamine hippurate (Hiprex,Urex)

2

METHENAMINE MANDELATE0.5 g

3

methenamine mandelate 1 g 2

nitrofurantoin (Furadantin) 2

nitrofurantoinmacrocrystalline (Macrodantin)

1

nitrofurantoin monohydrate/macrocrystalline (Macrobid)

1

PROSED/DS 4

UREX 4

URINARY TRACT SPASMS

bethanechol (Urecholine) 1

DETROL 4

DITROPAN XL 4

flavoxate 2

oxybutynin 1

oxybutynin ext-release (DitropanXL)

2

SANCTURA 4

SANCTURA XR 4

tolterodine (Detrol) 2

trospium (Sanctura) 2

trospium ext-release (SancturaXR)

2

2013


Drug Name Dru

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ess

URECHOLINE 4

VAGINAL PRODUCTS

CLEOCIN vaginal crm 4

clindamycin vaginal crm (Cleocin) 1

CRINONE 4

ENDOMETRIN 5

ESTRACE crm 3

ESTRING 4

METROGEL-VAGINAL 4

metronidazole (MetroGel-Vaginal) 1

NYSTATIN vaginal tabs 1

PREMARIN crm 3

TERAZOL 4

terconazole (Terazol) 1

OTHER GENITOURINARY DRUGS

alfuzosin ext-release (Uroxatral) 2

ELMIRON 4

finasteride (Proscar) 1

FLOMAX 4

phenazopyridine (Pyridium) 1

POLYCITRA-K CRYSTALS 4

POTASSIUM CITRATE ext-release 2

potassium citrate/citricacid granules (Polycitra-KCrystals)

1

PROSCAR 4

PYRIDIUM 4

SHOHL'S SOLUTION MODIFIED 4

sodium chloride irrigation soln 1

sodium citrate/citric acid (Shohl's) 1

tamsulosin (Flomax) 1

UROCIT-K 5, 10 4

UROXATRAL 4

CENTRAL NERVOUS SYSTEM DRUGS

ANXIETY

Drug Name Dru

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ty

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ted

Acc

ess

alprazolam (Xanax) 1

alprazolam ext-release (XanaxXR)

1

alprazolam ODT (Niravam) 2

ATIVAN 4

buspirone 5 mg, 10 mg, 15 mg,30 mg

1

BUSPIRONE 7.5 mg 3

chlordiazepoxide 1

clorazepate (Tranxene T) 1

diazepam tabs (Valium) 1

hydroxyzine hcl 1

HYDROXYZINE PAMOATE100 mg

1

hydroxyzine pamoate 25 mg,50 mg (Vistaril)

1

lorazepam tabs (Ativan) 1

LORAZEPAM INTENSOL 4

meprobamate 2

NIRAVAM 4

oxazepam 1

TRANXENE T 4

VALIUM 4

VISTARIL 4

XANAX 4

XANAX XR 4

DEPRESSION

amitriptyline 1

ANAFRANIL 4

bupropion (Wellbutrin) 1

bupropion ext-release (WellbutrinSR, Wellbutrin XL)

1

CELEXA 4

citalopram (Celexa) 1

clomipramine (Anafranil) 1

CYMBALTA 4

2013


Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r R

evie

w

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ntity

Lim

its

Res

tric

ted

Acc

ess

desipramine (Norpramin) 2

doxepin caps, 10 mg, 25 mg,50 mg, 100 mg; conc

1

doxepin caps, 150 mg 2

DOXEPIN 75 mg 1

EFFEXOR XR 4

escitalopram (Lexapro) 2

fluoxetine caps; soln; tabs,10 mg, 20 mg (Prozac)

1

FLUOXETINE 60 mg 4

fluoxetine delayed-release (Prozac Weekly)

2

fluvoxamine 1

imipramine hcl (Tofranil) 1

LEXAPRO 4 •mirtazapine (Remeron, Remeron

SolTab)1

NARDIL 4

NORPRAMIN 4

nortriptyline caps (Pamelor) 1

PAMELOR 4

PARNATE 4

paroxetine hcl tabs (Paxil) 1

paroxetine hcl ext-release (PaxilCR)

2

PAXIL tabs 4

PAXIL CR 4

phenelzine (Nardil) 2

protriptyline (Vivactil) 2

PROZAC 4

PROZAC WEEKLY 4

REMERON 4

REMERON SOLTAB 4

sertraline conc (Zoloft) 2

sertraline tabs (Zoloft) 1

TOFRANIL 4

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r R

evie

w

Qua

ntity

Lim

its

Res

tric

ted

Acc

ess

tranylcypromine (Parnate) 2

trazodone 1

venlafaxine 1

venlafaxine ext-releasecaps (Effexor XR)

1

venlafaxine ext-release tabs,37.5 mg, 75 mg, 150 mg

2

VENLAFAXINE ext-release tabs,37.5 mg, 75 mg, 150 mg, 225 mg

4

VIVACTIL 4

WELLBUTRIN 4

WELLBUTRIN SR 4

WELLBUTRIN XL 4

ZOLOFT 4

PSYCHOTIC AND BIPOLAR DISORDERS

ABILIFY 4

chlorpromazine 1

clozapine (Clozaril) 2

CLOZARIL 4

fluphenazine hcl 1

GEODON 4

haloperidol 1

haloperidol lactate 2

lithium carbonate caps, 150 mg,300 mg, 600 mg; tabs, 300 mg

1

LITHIUM CARBONATE caps,150 mg, 600 mg

4

lithium carbonate ext-release300 mg (Lithobid)

1

lithium carbonate ext-release450 mg

1

LITHIUM CITRATE 3

LITHOBID 4

loxapine (Loxitane) 1

LOXITANE 4

olanzapine (Zyprexa, ZyprexaZydis)

2

2013


Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r R

evie

w

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ntity

Lim

its

Res

tric

ted

Acc

ess

perphenazine 2

prochlorperazine 1

quetiapine (Seroquel) 2

RISPERDAL 4

RISPERDAL M-TAB 4

risperidone ODT, 0.5 mg,1 mg, 2 mg, 3 mg, 4 mg;tabs (Risperdal, Risperdal M-Tab)

1

risperidone ODT 0.25 mg 2

risperidone soln (Risperdal) 2

SEROQUEL 4

thioridazine 1

thiothixene (Navane) 1

trifluoperazine 1

ziprasidone (Geodon) 2

ZYPREXA 4

ZYPREXA ZYDIS 4

SLEEP AIDS

AMBIEN 4

AMBIEN CR 4

estazolam 1

flurazepam 1

HALCION 4

midazolam 1

phenobarbital elixir; tabs, 15 mg,16.2 mg, 30 mg, 32.4 mg,60 mg, 100 mg

1

PHENOBARBITAL tabs, 64.8 mg,97.2 mg

1

RESTORIL 4

SONATA 4

temazepam 15 mg,30 mg (Restoril)

1

temazepam 7.5 mg,22.5 mg (Restoril)

2

triazolam (Halcion) 1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r R

evie

w

Qua

ntity

Lim

its

Res

tric

ted

Acc

ess

zaleplon (Sonata) 1

zolpidem (Ambien) 1

zolpidem ext-release (Ambien CR) 2

HYPERACTIVITY/NARCOLEPSY

ADDERALL 4 •ADDERALL XR 4 •amphetamine/

dextroamphetamine (Adderall)2 •

amphetamine/dextroamphetamine ext-release (Adderall XR)

2 •

CONCERTA 4 •DEXEDRINE 4 •dexmethylphenidate (Focalin) 1 •dextroamphetamine 1 •dextroamphetamine ext-

release (Dexedrine)2 •

FOCALIN 4 •METHYLIN soln 4 •methylphenidate soln (Methylin) 2 •methylphenidate tabs (Ritalin) 1 •methylphenidate ext-release

caps; tabs, 20 mg (Ritalin LA,Ritalin SR)

2 •

METHYLPHENIDATE ext-releasetabs, 10 mg

2 •

METHYLPHENIDATE ext-releaseOSM tabs, 18 mg, 36 mg, 54 mg

4 •

methylphenidate ext-releaseOSM tabs, 27 mg (Concerta)

2 •

modafinil (Provigil) 2 • •PROVIGIL 4 • •RITALIN 4 •RITALIN LA 4 •RITALIN SR 4 •VYVANSE 4 •MULTIPLE SCLEROSIS

2013


Drug Name Dru

g T

ier

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cial

ty

Prio

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evie

w

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ntity

Lim

its

Res

tric

ted

Acc

ess

AMPYRA 5 • •BETASERON 5 • •COPAXONE 5 • •GILENYA 5 • •REBIF 5 • •OTHER CENTRAL NERVOUS SYSTEM DRUGS

ANTABUSE 4

ARICEPT 5 mg, 10 mg 4

ARICEPT ODT 4

bupropion ext-release (Zyban) 1

CAMPRAL 3

CHANTIX 3

disulfiram (Antabuse) 2

donepezil (Aricept, Aricept ODT) 2

EXELON caps 4

fluoxetine (PMDD) 1

galantamine (Razadyne) 2

galantamine ext-release (Razadyne ER)

2

NICOTROL INHALER 4

NICOTROL NS 4

olanzapine/fluoxetine (Symbyax) 2

RAZADYNE 4

RAZADYNE ER 4

rivastigmine (Exelon) 2

SYMBYAX 4

XYREM 5 • •ZYBAN 4

PAIN RELIEF DRUGS

NON-NARCOTIC DRUGS

BUPAP tabs, 50-650 mg 2

butalbital/acetaminophen tabs,50-325 mg

2

butalbital/acetaminophen/caffeine (Esgic, Esgic Plus,Fioricet)

2

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

r R

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w

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ntity

Lim

its

Res

tric

ted

Acc

ess

butalbital/aspirin/caffeine (Fiorinal)

2

diflunisal 1

ESGIC 4

ESGIC-PLUS 4

FIORICET 4

FIORINAL 4

salsalate 1

NARCOTIC DRUGS

acetaminophen/codeine (Tylenolw/Codeine)

1

ACTIQ 5 • •buprenorphine (Subutex) 2 • •buprenorphine/

naloxone (Suboxone)2 • •

butalbital/acetaminophen/caffeine (Fioricet/Codeine)

2

butalbital/aspirin/caffeine/codeine (Fiorinal/Codeine)

2

butorphanol nasal 2

CODEINE SULFATE tabs 1

DEMEROL 4

DILAUDID tabs 4

DOLOPHINE 4

DURAGESIC 4

fentanyl (Duragesic) 2

fentanyl (Actiq) 5 • •FIORICET/CODEINE 4

FIORINAL/CODEINE 4

HYCET 4

hydrocodone/acetaminophen (Various Brands)

1

hydrocodone/acetaminophensoln, 7.5-325 mg/15 mL,7.5-500 mg/15 mL; tabs,5-300 mg, 7.5-300 mg,10-300 mg (Various Brands)

2

2013


Drug Name Dru

g T

ier

Spe

cial

ty

Prio

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evie

w

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ntity

Lim

its

Res

tric

ted

Acc

ess

hydrocodone/ibuprofen tabs,2.5-200 mg, 10-200 mg (Ibudone,Reprexain)

2

hydrocodone/ibuprofentabs, 5-200 mg,7.5-200 mg (Reprexain)

1

HYDROMORPHONE supp 3

hydromorphone tabs (Dilaudid) 1

IBUDONE 4

KADIAN 10 mg, 20 mg, 30 mg,50 mg, 60 mg, 80 mg, 100 mg,200 mg

4

LORCET 4

LORCET PLUS 4

LORTAB 4

MAXIDONE 4

meperidine (Demerol) 1

methadone conc, tab for oralsusp (Methadone Intensol)

2

METHADONE soln 4

methadone tabs (Dolophine) 1

METHADONE INTENSOL 4

morphine sulfate conc 1

morphine sulfate soln (Roxanol) 1

MORPHINE SULFATE supp 4

MORPHINE SULFATE tabs 1

morphine sulfate ext-releasecaps (Kadian)

2

morphine sulfate ext-releasetabs (MS Contin)

1

MS CONTIN 4

NORCO 4

NUCYNTA 4

NUCYNTA ER 4

OPANA 4

oxycodone caps 1

oxycodone conc 2

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

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ntity

Lim

its

Res

tric

ted

Acc

ess

OXYCODONE conc, soln 2

oxycodone tabs, 10 mg, 20 mg 2

oxycodone tabs, 5 mg, 15 mg,30 mg (Roxicodone)

1

oxycodone/acetaminophen (Percocet)

1

oxycodone/aspirin (Percodan) 1

oxycodone/ibuprofen 2

OXYCONTIN 4 •oxymorphone (Opana) 2

pentazocine/acetaminophen 2

pentazocine/naloxone 2

PERCOCET 4

PERCODAN 4

REPREXAIN 4

ROXICET tabs 4

ROXICODONE tabs 4

SUBOXONE sublingual film 3 • •SUBOXONE sublingual tabs 4 • •tramadol (Ultram) 1

tramadol ext-release (Ultram ER) 2

tramadol ext-release biphasic200 mg, 300 mg

2

tramadol/acetaminophen (Ultracet)

1

TYLENOL/CODEINE 4

ULTRACET 4

ULTRAM 4

ULTRAM ER 4

VICODIN 4

VICODIN ES 4

VICOPROFEN 4

XODOL 4

RHEUMATOID AND OSTEOARTHRITIS

ANAPROX 4

ANAPROX DS 4

2013


Drug Name Dru

g T

ier

Spe

cial

ty

Prio

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evie

w

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ntity

Lim

its

Res

tric

ted

Acc

ess

ARAVA 5

ARTHROTEC 4

CATAFLAM 4

CELEBREX 4 •CLINORIL 4

DAYPRO 4

diclofenac potassium (Cataflam) 1

diclofenac sodium delayed-release

1

diclofenac sodium ext-release (Voltaren-XR)

2

diclofenac/misoprostol(Arthrotec)

2

EC-NAPROSYN 4

ENBREL 5 • • •etodolac 1

etodolac ext-release 1

FELDENE 4

flurbiprofen 1

HUMIRA 5 • • •ibuprofen tabs 1

indomethacin 1

indomethacin ext-release 2

ketoprofen 1

ketorolac 1

leflunomide (Arava) 1

MELOXICAM susp 4

meloxicam tabs (Mobic) 1

MOBIC 4

nabumetone 1

NAPROSYN 4

naproxen (Naprosyn) 1

naproxen delayed-release (EC-Naprosyn)

1

naproxen sodium (Anaprox) 1

oxaprozin (Daypro) 1

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

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evie

w

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ntity

Lim

its

Res

tric

ted

Acc

ess

piroxicam (Feldene) 2

sulindac (Clinoril) 1

tolmetin caps 2

VOLTAREN-XR 4

XELJANZ 5 • •MIGRAINE HEADACHES

acetaminophen/isometheptene/caffeine (Prodrin)

2

acetaminophen/isometheptene/dichloralphenazone

2

AMERGE 4 •D.H.E. 45 5

dihydroergotaminemesylate (D.H.E. 45)

2

IMITREX 4 •naratriptan (Amerge) 2 •PRODRIN 4

rizatriptan (Maxalt) 2 •rizatriptan ODT (Maxalt-MLT) 2 •sumatriptan inj (Imitrex) 2 •SUMATRIPTAN nasal 4 •sumatriptan tabs (Imitrex) 1 •GOUT

allopurinol (Zyloprim) 1

COLCRYS 3

probenecid 1

probenecid/colchicine 1

ZYLOPRIM 4

NEUROMUSCULAR DRUGS

SEIZURES

carbamazepine (Tegretol) 1

carbamazepine ext-release (Carbatrol)

2

CARBATROL 4

clonazepam (Klonopin) 1

clonazepam ODT 2

2013


Drug Name Dru

g T

ier

Spe

cial

ty

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evie

w

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ntity

Lim

its

Res

tric

ted

Acc

ess

DEPAKENE 4

DEPAKOTE 4

DEPAKOTE ER 4

DEPAKOTE SPRINKLES 4

DIASTAT 4

DIAZEPAM gel 4

DILANTIN 4

DILANTIN INFATABS 4

DILANTIN-125 4

divalproex ext-release (DepakoteER)

1

divalproex delayed-releasecaps (Depakote Sprinkles)

2

divalproex delayed-releasetabs (Depakote)

1

ethosuximide (Zarontin) 1

felbamate (Felbatol) 2

FELBATOL 4

gabapentin caps, tabs (Neurontin) 1

gabapentin soln (Neurontin) 2

GABITRIL 2 mg, 4 mg 4

KEPPRA 4

KEPPRA XR 4

KLONOPIN 4

LAMICTAL chew tabs; tabs, 25 mg,100 mg, 150 mg, 200 mg, starterkit

4

LAMICTAL XR 4

lamotrigine chew tabs (Lamictal) 2

lamotrigine tabs (Lamictal) 1

lamotrigine ext-releasetabs (Lamictal XR)

2

levetiracetam (Keppra) 1

levetiracetam ext-release (KeppraXR)

2

LYRICA 4

MYSOLINE 4

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

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ntity

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its

Res

tric

ted

Acc

ess

NEURONTIN 4

oxcarbazepine tabs (Trileptal) 1

PHENYTEK 4

phenytoin (Dilantin, DilantinInfatabs)

2

phenytoin sodium ext-release(Dilantin, Phenytek)

1

primidone (Mysoline) 1

TEGRETOL 4

TEGRETOL-XR 4

tiagabine (Gabitril) 2

TOPAMAX 4

TOPAMAX SPRINKLES 4

topiramate (Topamax) 1

topiramate sprinkle (TopamaxSprinkles)

2

TRILEPTAL tabs 4

valproic acid (Depakene) 1

ZARONTIN 4

ZONEGRAN 4

zonisamide (Zonegran) 1

PARKINSON'S DISEASE

amantadine caps, syrup 1

AMANTADINE tabs 1

AZILECT 4

benztropine 1

bromocriptine (Parlodel) 2

carbidopa/levodopa (Sinemet) 1

carbidopa/levodopa ext-release (Sinemet CR)

1

CARBIDOPA/LEVODOPA/ENTACAPONE

4

COMTAN 3

ELDEPRYL 4

LODOSYN 4

MIRAPEX 4

2013


Drug Name Dru

g T

ier

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cial

ty

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ntity

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its

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tric

ted

Acc

ess

PARCOPA 4

PARLODEL 4

pramipexole (Mirapex) 1

REQUIP 4

REQUIP XL 4

ropinirole (Requip) 1

ropinirole ext-release (Requip XL) 2

selegiline caps (Eldepryl) 2

selegiline tabs 2

SINEMET 4

SINEMET CR 4

STALEVO 4

trihexyphenidyl elixir 2

trihexyphenidyl tabs 1

MUSCLE RELAXANTS

baclofen 1

carisoprodol 350 mg (Soma) 2

chlorzoxazone (Parafon Forte) 1

cyclobenzaprine (Fexmid, Flexeril) 1

DANTRIUM 4

dantrolene (Dantrium) 2

FEXMID 4

FLEXERIL 4

metaxalone (Skelaxin) 2

methocarbamol (Robaxin) 1

orphenadrine citrate ext-release 1

PARAFON FORTE DSC 4

ROBAXIN 4

SKELAXIN 4

SOMA 350 mg 4

tizanidine caps (Zanaflex) 2

tizanidine tabs 1

ZANAFLEX 4

OTHER NEUROMUSCULAR DRUGS

MESTINON tabs, 60 mg 4

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

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ntity

Lim

its

Res

tric

ted

Acc

ess

pyridostigmine (Mestinon) 1

RILUTEK 5 •SUPPLEMENTS

VITAMINS

DRISDOL 4

ergocalciferol (Drisdol) 1

MEPHYTON 4

niacin 1

MULTIVITAMINS

pediatric multivitamins 1

pediatric multivitamins/fluoride/iron

1

pediatric vitamins ADC 1

PRENATAL – various brands 1

PRENATAL – various brands 4

MINERALS AND ELECTROLYTES

EFFER-K 4

K-LOR 4

K-PHOS NEUTRAL 4

K-TABS 4

LURIDE 4

MICRO-K 4

potassium bicarbonateeffervescent

1

potassium bicarbonate/chlorideeffervescent

2

potassium chloride powderpacket, 20 mEq; soln, 10% (K-Lor)

1

POTASSIUM CHLORIDE soln,20%

4

potassium chloride ext-releasecaps, 8 mEq, 10 mEq; tabs, 8mEq, 10 mEq (Micro-K, K-Tabs)

1

potassium chloridemicroencapsulated ext-releasetabs, 10 mEq, 20 mEq

1

2013


Drug Name Dru

g T

ier

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ty

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ntity

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its

Res

tric

ted

Acc

ess

potassium phosphate/sodiumphosphates (K-Phos Neutral)

1

sodium fluoride chewtabs (Luride)

1

sodium fluoride soln 2

SODIUM FLUORIDE tabs, 1 mg 1

zinc sulfate caps 1

BLOOD MODIFYING DRUGS

AGGRENOX 4

AGRYLIN 4

AMICAR 4

aminocaproic acid syrup; tabs,500 mg (Amicar)

2

AMINOCAPROIC ACID tabs,1000 mg

4

anagrelide (Agrylin) 1

ANIMI-3 4

ARANESP 5 •ARIXTRA 5

B-6 FOLIC ACID 3

BRILINTA 4

cilostazol (Pletal) 1

clopidogrel (Plavix) 1

CORVITE 150 4

COUMADIN 4

cyanocobalamin inj 1

dipyridamole (Persantine) 1

DROXIA 3 •EFFIENT 4

enoxaparin (Lovenox) 2

EPOGEN 5 •FIRAZYR 5 • •FOLGARD RX 4

folic acid tabs, 1 mg 1

FOLTRATE 3

fondaparinux (Arixtra) 2

Drug Name Dru

g T

ier

Spe

cial

ty

Prio

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ntity

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its

Res

tric

ted

Acc

ess

HEMATRON-AF 4

heparin sodium inj, 1000 unit/mL, 5000 unit/mL, 10000 unit/mL, 20000 unit/mL

1

HEPARIN SODIUM inj, 2500 unit/mL

1

heparin sodium/D5W 40 unit/mL,50 unit/mL, 100 unit/mL

1

HEPARIN SODIUM/D5W 50 unit/mL, 100 unit/mL

4

heparin sodium/sodium chlorideinj, 2 unit/mL

1

HEPARIN SODIUM/SODIUMCHLORIDE inj, 2 unit/mL

4

ICAR-C PLUS 4

LEUKINE 500 mcg/mL 5 •LOVENOX 4

NEULASTA 5 •NEUPOGEN 5 •pentoxifylline ext-release (Trental) 1

PERSANTINE 4

PLAVIX 4

PLETAL 4

PRADAXA 4

PROCRIT 5 •TANDEM PLUS 4

ticlopidine 1

tranexamic tab (Lysteda) 2

TRENTAL 4

warfarin (Coumadin) 1

XARELTO 4

TOPICAL DRUGS

EYE

Anti-infectives

BACITRACIN oint 1

bacitracin/polymyxin B oint 1

BLEPH-10 4

2013


Drug Name Dru

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ier

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ty

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Lim

its

Res

tric

ted

Acc

ess

CILOXAN soln 4

ciprofloxacin soln (Ciloxan) 1

erythromycin oint 1

GARAMYCIN 4

gentamicin oint, soln (Garamycin) 1

levofloxacin soln 2

neomycin/polymyxin B/bacitracin oint

1

neomycin/polymyxin B/gramicidin soln (Neosporin)

1

NEOSPORIN 4

OCUFLOX 4

ofloxacin soln (Ocuflox) 1

polymyxin B/trimethoprimsoln (Polytrim)

1

POLYTRIM 4

SULFACETAMIDE SODIUM oint 2

sulfacetamide sodiumsoln (Bleph-10)

2

tobramycin soln (Tobrex) 1

TOBREX soln 4

trifluridine soln (Viroptic) 2

VIGAMOX 4

VIROPTIC 4

Steroids and Combination Products

dexamethasone sodiumphosphate soln

1

fluorometholone susp (FMLLiquifilm)

1

FML LIQUIFILM 4

MAXITROL 4

neomycin/polymyxin B/bacitracin/hydrocortisone oint

1

neomycin/polymyxin B/dexamethasone oint,susp (Maxitrol)

1

Drug Name Dru

g T

ier

Spe

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ty

Prio

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ntity

Lim

its

Res

tric

ted

Acc

ess

NEOMYCIN/POLYMYXIN/HYDROCORTISONE susp

1

OMNIPRED 4

PRED FORTE 4

PRED MILD 3

PRED-G 2

prednisolone acetate susp (PredForte)

1

PREDNISOLONE SODIUMPHOSPHATE soln

1

sulfacetamide sodium/prednisolone soln

1

TOBRADEX susp 4

tobramycin/dexamethasonesusp (Tobradex)

2

Glaucoma

ALPHAGAN P 4

apraclonidine soln (Iopidine) 2

BETAGAN 4

betaxolol soln 1

brimonidine soln,0.15% (Alphagan P)

2

brimonidine soln, 0.2% 1

carteolol soln 1

COMBIGAN 4

COSOPT 4

dorzolamide soln (Trusopt) 1

dorzolamide/timolol maleatesoln (Cosopt)

1

IOPIDINE soln, 0.5% 4

ISOPTO CARPINE 4

latanoprost soln (Xalatan) 1

LEVOBUNOLOL soln, 0.25% 1

levobunolol soln, 0.5% (Betagan) 1

metipranolol soln (Optipranolol) 2

OPTIPRANOLOL 4

pilocarpine soln (Isopto Carpine) 1

2013


Drug Name Dru

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ty

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Lim

its

Res

tric

ted

Acc

ess

timolol maleate soln (Timoptic,Timoptic-XE)

1

TIMOPTIC 4

TIMOPTIC-XE 4

TRUSOPT 4

XALATAN 4

Other Eye Products

ACULAR 4

ACULAR LS 4

ALCAINE 4

atropine sulfate soln (IsoptoAtropine)

1

azelastine soln (Optivar) 2

CELLUGEL 4

cromolyn sodium soln 1

CYCLOGYL soln, 1%, 2% 4

cyclopentolate soln,1% (Cyclogyl)

1

cyclopentolate soln,2% (Cyclogyl)

2

diclofenac soln (Voltaren) 1

ELESTAT 4

epinastine soln (Elestat) 2

flurbiprofen soln (Ocufen) 1

homatropine soln (IsoptoHomatropine)

1

hypromellose intraocularsoln (Cellugel)

1

ISOPTO ATROPINE 4

ISOPTO HOMATROPINE soln, 5% 4

ISOPTO HYOSCINE 3

ketorolac soln (Acular, Acular LS) 1

MYDFRIN 4

MYDRIACYL 4

NAPHAZOLINE soln 1

OCUFEN 4

Drug Name Dru

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ier

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ty

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Lim

its

Res

tric

ted

Acc

ess

OPTIVAR 4

phenylephrine soln 2

proparacaine soln (Alcaine) 1

tetracaine soln 1

tropicamide soln (Mydriacyl) 2

VOLTAREN 4

EAR

acetic acid soln 1

ACETIC ACID/ALUMINUMACETATE soln

2

antipyrine/benzocaine 5.4-1.4% 1

antipyrine/benzocaine5.5-1.4% (Auralgan)

2

antipyrine/benzocaine/polycosanol soln (Treagan Otic)

2

AURALGAN 4

CETRAXAL 4

CIPROFLOXACIN soln 4

CORTANE-B AQUEOUS 4

CORTANE-B-OTIC 4

CORTISPORIN soln 4

DERMOTIC 4

fluocinolone acetonideoil (Dermotic)

1

neomycin/polymyxin B/hydrocortisone soln,susp (Cortisporin)

1

ofloxacin soln 1

OTICIN HC NR 4

PRAMOTIC 4

pramoxine/chloroxylenolsoln (Pramotic)

2

pramoxine/hydrocortisone/chloroxylenol soln (Cortane-BAqueous, Cortane-B Otic, OticinHC)

1

TREAGAN OTIC 4

2013


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MOUTH AND THROAT (local)

chlorhexidine (Peridex) 1

clotrimazole troche 1

GEL-KAM 4

lidocaine viscous 1

NUMOISYN lozenge 4

nystatin susp 1

PERIDEX 4

pilocarpine (Salagen) 2

PREVIDENT 4

SALAGEN 4

sodium fluoride (Prevident) 1

stannous fluoride conc,0.63% (Gel-Kam)

1

THERA-FLUR-N 4

triamcinolone dental paste 1

ANORECTAL AGENTS

ANALPRAM E 4

ANALPRAM-HC 4

ANUSOL-HC 4

CORTENEMA 4

CORTIFOAM 3

hydrocortisone crm (Anusol-HC) 1

hydrocortisoneenema (Cortenema)

2

hydrocortisone acetate rectalcrm, supp (Anusol-HC,Proctocort)

1

hydrocortisone acetate/pramoxine crm (Analpram-HC,Z-pram)

2

hydrocortisone/pramoxineemollient crm (Analpram E)

2

lidocaine/hydrocortisone acetatecrm, gel

2

PROCTOCORT 4

PROCTOFOAM HC 3

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Z-PRAM 4

SKIN CONDITIONS/PRODUCTS

Acne

ACZONE 4

adapalene (Differin) 2 • •BENZAC AC WASH 4

BENZAC W WASH 4

BENZACLIN 4

BENZAMYCIN 4

BENZEFOAM 4

BENZEFOAMULTRA 4

benzoyl peroxide cloth; creamywash; foam; gel; liq, 2.5%, 7%;lotn

2

BPO CREAMY WASH COMPLETE 4

BREVOXYL 4

CLARAVIS caps, 30 mg 2

CLARIFOAM EF 4

CLEOCIN-T 4

clindamycin foam (Evoclin) 2

clindamycin gel, lotn, soln,swab (Cleocin-T)

1

clindamycin/benzoylperoxide (Benzaclin, Duac)

2

DIFFERIN crm; gel, 0.1% 4 • •DUAC 4

erythromycin pads, soln 1

erythromycin/benzoylperoxide (Benzamycin)

2

EVOCLIN 4

FINACEA 4

isotretinoin caps, 10 mg, 20 mg,40 mg

2

KLARON 4

METROCREAM 4

METROLOTION 4

2013


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metronidazole (Metrocream,Metrolotion)

2

metronidazole topical gel 2

RETIN-A 4 • •sulfacetamide sodium (Klaron) 2

sulfacetamide sodium/sulfur 2

sulfacetamide sodium/sulfur/sunscreen

2

SUMADAN WASH 4

SUMAXIN 4

SUMAXIN TS 4

SUMAXIN WASH 4

TAZORAC 4 • •tretinoin (Retin-A) 2 • •Anti-infectives

BACTROBAN 4

CICLODAN SOLUTION KIT 4

ciclopirox (Ciclodan, Loprox,Penlac)

2

clotrimazole/betamethasone (Lotrisone)

2

DENAVIR 4

econazole 1

EXTINA 4

GENTAMICIN SULFATE 1

iodoquinol/hydrocortisone 1

KERALYT 4

ketoconazole crm,shampoo (Nizoral)

1

ketoconazole foam (Extina) 2

LOPROX gel 4

LOPROX shampoo 4

LOTRISONE 4

mafenide (Sulfamylon) 2

mupirocin crm (Bactroban) 2

mupirocin oint (Bactroban) 1

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NIZORAL 4

nystatin topical 1

PENLAC 4

SALEX 4

salicylic acid crm, foam, gel, liq,lotn, shampoo

2

SALICYLIC ACID soln 2

SALVAX 4

SILVADENE 4

silver sulfadiazine (Silvadene) 1

sodium thiosulfate/salicylic acid 2

SULFAMYLON powder for topicalsoln

4

VIRASAL 4

Corticosteroids

ACLOVATE crm 4

alclometasone (Aclovate) 1

amcinonide crm 2

AMCINONIDE lotn, oint 2

betamethasone dipropionate 2

betamethasone dipropionate,augmented (Diprolene, DiproleneAF)

2

betamethasone valerate crm,lotn, oint

1

betamethasone valeratefoam (Luxiq)

2

clobetasol crm, emollient, gel,oint, soln (Temovate, TemovateE)

1

clobetasol foam, lotn,shampoo (Clobex, Olux, Olux-E)

2

CLOBEX lotn, shampoo 4

CUTIVATE 4

DERMA-SMOOTHE/FS oil 4

DERMATOP 4

desonide crm, oint (Desowen) 1

2013


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desonide lotn (Desowen) 2

DESOWEN 4

DESOXIMETASONE crm, 0.05% 2

desoximetasone crm, 0.25%; gel;oint, 0.25% (Topicort)

2

DIFLORASONE crm 2

diflorasone oint 2

DIPROLENE 4

DIPROLENE AF 4

ELOCON 4

fluocinolone (Derma-Smoothe/FS,Synalar)

1

fluocinonide 1

fluticasone propionate (Cutivate) 1

halobetasol (Ultravate) 2

halobetasol/ammoniumlactate (Ultravate Pac)

2

hydrocortisone crm 1

hydrocortisone lotn, 2.5% 2

hydrocortisone acetate/pramoxine (Pramosone)

2

hydrocortisone butyrate (Locoid) 2

hydrocortisonevalerate (Westcort)

2

LOCOID crm, oint, soln 4

mometasone (Elocon) 1

NYSTATIN/TRIAMCINOLONE 1

OLUX 4

OLUX-E 4

PRAMOSONE crm 4

pramoxine/hydrocortisone (Pramosone)

2

prednicarbate (Dermatop) 1

SYNALAR crm, oint 1

TACLONEX 4

TEMOVATE 4

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TEMOVATE E 4

TOPICORT crm, 0.05% 2

TOPICORT crm, 0.25%; gel; oint 4

triamcinolone crm; lotn; oint,0.025%, 0.05%, 0.1%

1

TRIAMCINOLONE ACETONIDEoint, 0.5%

1

TRIANEX 4

ULTRAVATE 4

WESTCORT 4

Other Skin Products

ALDARA 4

aluminum chloride (Drysol) 1

ALUVEA 4

ARZOL SILVER NITRATEAPPLICATOR

4

calcipotriene crm, soln (Dovonex) 2

CALCIPOTRIENE oint 4

CALCITRENE 4

CALCITRIOL 4

CONDYLOX soln 4

DOVONEX crm 4

DRITHO-CREME HP 3

DRITHO-SCALP 3

DRYSOL 4

EFUDEX 4

EURAX 4

fluorouracil (Efudex) 2

GRANULEX 4

HYDRO 35 4

imiquimod (Aldara) 2

lactic acid (ammoniumlactate) (Lac-Hydrin)

2

lactic acid/vitamin E 2

lidocaine crm (Lidamantle) 2

2013


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lidocaine gel, oint,soln (Xylocaine)

1

lidocaine/prilocaine crm (Emla) 1

LIDODERM 4 • •lindane 2

malathion (Ovide) 2

OVACE WASH liq, 10% 4

OVIDE 4

permethrin 2

podofilox (Condylox) 2

PROTOPIC 4

selenium sulfide (Selsun) 1

SELENIUM SULFIDE/PYRITHIONE in UREA shampoo

1

SELSUN SHAMPOO 4

silver nitrate/potassiumnitrate (Arzol Silver Nitrate)

2

sulfacetamide sodium (OvaceWash)

2

TARGRETIN gel 5 •URAMAXIN crm, gel, lotn 4

urea crm, gel, lotn (Aluvea,Uramaxin)

2

urea in lactic acid (Hydro 35) 2

VECTICAL 4

XENADERM 4

XERAC AC 3

XYLOCAINE 4

XYLOCAINE JELLY 4

MISCELLANEOUS CATEGORIES (includes suppliesand devices)

DIABETIC SUPPLIESAll Brands 25% coinsurance

LANCETS – VARIOUSMANUFACTURERS

TEST STRIPS - BAYERASCENSIA AUTODISC,

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BREEZE 2, CONTOUR,CONTOUR NEXT

TEST STRIPS – LIFESCANONETOUCH BASIC/PROFILE,FASTTAKE, SURESTEP,ULTRA BLUE, VERIO, VERIO IQ

TEST STRIPS – other than Bayer,Lifescan

•

MISCELLANEOUS DRUGS

AZASAN 4

azathioprine (Imuran) 1

CELLCEPT 4 •CUPRIMINE 5

cyclosporine (Sandimmune) 2 •cyclosporine modified caps,

25 mg, 100 mg; soln (Neoral)2 •

CYCLOSPORINE MODIFIEDcaps, 50 mg

2

DEPEN TITRATABS 4

EXJADE 5 •IMURAN 4

KAYEXALATE 4

mycophenolate mofetil (Cellcept) 2 •naltrexone (ReVia) 1

NEORAL 4 •PROGRAF 4 •RAPAMUNE 4 •REVIA 5

REVLIMID 5 • •SANDIMMUNE 4 •sodium polystyrene

powder (Kayexalate)2

SPS 4

tacrolimus (Prograf) 2 •THALOMID 5 • •THYROGEN 5 •

2013


INDEX

A

abacavir........................................................................... 3ABILIFY...........................................................................17acarbose.......................................................................... 7ACCOLATE.....................................................................13ACCUNEB...................................................................... 13ACCUPRIL........................................................................8ACCURETIC..................................................................... 8acebutolol........................................................................ 9ACEON 4 mg, 8 mg.........................................................8acetaminophen/codeine............................................... 19acetaminophen/isometheptene/caffeine.....................21acetaminophen/isometheptene/dichloralphenazone 21ACETAZOLAMIDE 125 mg............................................ 11acetazolamide 250 mg................................................. 11acetazolamide ext-release........................................... 11acetazolamide sodium for inj...................................... 11ACETIC ACID/ALUMINUM ACETATE ear soln............. 26acetic acid ear soln......................................................26acetylcysteine............................................................... 13ACLOVATE crm............................................................. 28ACTIGALL.......................................................................15ACTIQ............................................................................. 19ACTIVELLA.......................................................................5ACTOPLUS MET..............................................................7ACTOS..............................................................................7ACULAR......................................................................... 26ACULAR LS....................................................................26acyclovir oral.................................................................. 2ACZONE......................................................................... 27ADALAT CC................................................................... 10adapalene...................................................................... 27ADDERALL..................................................................... 18ADDERALL XR...............................................................18ADOXA............................................................................. 1ADVAIR DISKUS............................................................13ADVAIR HFA.................................................................. 13AFINITOR......................................................................... 4AGGRENOX................................................................... 24AGRYLIN........................................................................ 24ALBENZA..........................................................................3albuterol inhal soln...................................................... 13albuterol sulfate ext-release........................................ 13albuterol sulfate syrup, tabs....................................... 13ALCAINE.........................................................................26alclometasone............................................................... 28ALDACTAZIDE............................................................... 11ALDACTONE.................................................................. 11ALDARA..........................................................................29ALENDRONATE 40 mg................................................... 8alendronate 5 mg, 10 mg, 35 mg, 70 mg...................... 8alfuzosin ext-release.................................................... 16

ALKERAN tabs................................................................. 4allopurinol......................................................................21ALORA..............................................................................5ALPHAGAN P.................................................................25alprazolam..................................................................... 16alprazolam ext-release................................................. 16alprazolam ODT............................................................ 16ALTACE............................................................................ 8aluminum chloride........................................................29ALUVEA..........................................................................29amantadine caps, syrup.............................................. 22AMANTADINE tabs........................................................ 22AMARYL........................................................................... 7AMBIEN.......................................................................... 18AMBIEN CR....................................................................18amcinonide crm............................................................ 28AMCINONIDE lotn, oint..................................................28AMERGE........................................................................ 21AMICAR.......................................................................... 24amiloride........................................................................ 11amiloride/hydrochlorothiazide.....................................11aminocaproic acid syrup; tabs, 500 mg..................... 24AMINOCAPROIC ACID tabs, 1000 mg..........................24amiodarone....................................................................12amitriptyline...................................................................16amlodipine..................................................................... 10AMLODIPINE/ATORVASTATIN..................................... 12amlodipine/benazepril.................................................. 10amoxicillin/potassium clavulanate chew tabs, 200mg...................................................................................1

amoxicillin/potassium clavulanate chew tabs, 400mg; susp; tabs..............................................................1

amoxicillin/potassium clavulanate ext-release............1amoxicillin caps, tabs, susp..........................................1AMOXICILLIN chew tabs................................................. 1amphetamine/dextroamphetamine..............................18amphetamine/dextroamphetamine ext-release..........18ampicillin caps................................................................1AMPICILLIN susp............................................................. 1AMPYRA.........................................................................19ANAFRANIL....................................................................16anagrelide...................................................................... 24ANALPRAM E................................................................ 27ANALPRAM-HC..............................................................27ANAPROX...................................................................... 20ANAPROX DS................................................................ 20ANASPAZ....................................................................... 14anastrozole...................................................................... 4ANCOBON........................................................................2ANDRODERM.................................................................. 5ANDROGEL......................................................................5ANDROID......................................................................... 5ANIMI-3...........................................................................24ANTABUSE.....................................................................19ANTARA......................................................................... 10antipyrine/benzocaine/polycosanol otic soln............ 26

2013


antipyrine/benzocaine ear soln, 5.4-1.4%...................26antipyrine/benzocaine ear soln, 5.5-1.4%...................26ANTIVERT tabs, 12.5 mg, 25 mg.................................. 14ANUSOL-HC...................................................................27apraclonidine eye soln.................................................25APTIVUS...........................................................................3ARALEN............................................................................3ARANESP.......................................................................24ARAVA............................................................................21ARICEPT 5 mg, 10 mg.................................................. 19ARICEPT ODT............................................................... 19ARIMIDEX.........................................................................4ARIXTRA........................................................................ 24ARMOUR THYROID........................................................ 8AROMASIN.......................................................................4ARTHROTEC..................................................................21ARZOL SILVER NITRATE APPLICATOR......................29ASACOL......................................................................... 15ASMANEX...................................................................... 13ASTELIN......................................................................... 13ATACAND HCT................................................................ 9atenolol............................................................................ 9atenolol/chlorthalidone.................................................. 9ATIVAN........................................................................... 16atorvastatin....................................................................11atovaquone/proguanil 250-100 mg............................... 3ATOVAQUONE/PROGUANIL 62.5-25 mg....................... 3ATRIPLA........................................................................... 3atropine sulfate eye soln............................................. 26ATROVENT.................................................................... 13AUGMENTIN susp, 125 mg/5 mL.................................... 1AUGMENTIN susp, 250 mg/5 mL.................................... 1AUGMENTIN tabs............................................................ 1AUGMENTIN XR.............................................................. 1AURALGAN.................................................................... 26AVALIDE...........................................................................9AVAPRO........................................................................... 9AXID................................................................................14AYGESTIN........................................................................6AZASAN..........................................................................30azathioprine...................................................................30azelastine eye soln.......................................................26azelastine nasal............................................................ 13AZILECT......................................................................... 22AZITHROMYCIN powder pack for susp...........................1azithromycin susp, tabs................................................ 1AZULFIDINE................................................................... 15AZULFIDINE EN-TABS.................................................. 15

B

B-6 FOLIC ACID.............................................................24bacitracin/polymyxin B eye oint................................. 24BACITRACIN eye oint.................................................... 24baclofen......................................................................... 23BACTRIM..........................................................................4BACTRIM DS................................................................... 4

BACTROBAN..................................................................28balsalazide.....................................................................15BARACLUDE.................................................................... 2benazepril........................................................................ 8benazepril/hydrochlorothiazide.....................................8BENTYL.......................................................................... 14BENZAC AC WASH....................................................... 27BENZACLIN....................................................................27BENZAC W WASH.........................................................27BENZAMYCIN................................................................ 27BENZEFOAM..................................................................27BENZEFOAMULTRA......................................................27benzonatate................................................................... 13benzoyl peroxide cloth; creamy wash; foam; gel; liq,2.5%, 7%; lotn............................................................. 27

benztropine....................................................................22BETAGAN.......................................................................25betamethasone dipropionate.......................................28betamethasone dipropionate, augmented................. 28betamethasone valerate crm, lotn, oint......................28betamethasone valerate foam..................................... 28BETAPACE.....................................................................12BETAPACE AF...............................................................12BETASERON..................................................................19betaxolol.......................................................................... 9betaxolol eye soln........................................................ 25bethanechol...................................................................15BIAXIN.............................................................................. 1BIAXIN XL........................................................................ 1bicalutamide.................................................................... 4BIDIL............................................................................... 12bisoprolol.........................................................................9bisoprolol/hydrochlorothiazide..................................... 9BLEPH-10....................................................................... 24BONIVA tabs.................................................................... 8BPO CREAMY WASH COMPLETE...............................27BRAVELLE....................................................................... 7BREVICON-28.................................................................. 6BREVOXYL.....................................................................27BRILINTA........................................................................24brimonidine eye soln, 0.15%....................................... 25brimonidine eye soln, 0.2%......................................... 25bromocriptine................................................................22brompheniramine maleate ext-release....................... 12budesonide....................................................................13budesonide ext-release..................................................5bumetanide....................................................................11BUPAP tabs, 50-650 mg................................................ 19buprenorphine...............................................................19buprenorphine/naloxone..............................................19bupropion...................................................................... 16bupropion ext-release.................................................. 16bupropion ext-release.................................................. 19buspirone 5 mg, 10 mg, 15 mg, 30 mg....................... 16BUSPIRONE 7.5 mg...................................................... 16butalbital/acetaminophen/caffeine.............................. 19

2013


butalbital/acetaminophen/caffeine.............................. 19butalbital/acetaminophen tabs, 50-325 mg................ 19butalbital/aspirin/caffeine.............................................19butalbital/aspirin/caffeine/codeine.............................. 19butorphanol nasal........................................................ 19

C

cabergoline......................................................................8CADUET......................................................................... 12CALAN............................................................................ 10CALAN SR......................................................................10calcipotriene crm, soln................................................ 29CALCIPOTRIENE oint....................................................29calcitonin-salmon........................................................... 8CALCITRENE................................................................. 29CALCITRIOL...................................................................29calcitriol caps..................................................................8calcitriol oral soln...........................................................8calcium acetate.............................................................15CAMPRAL.......................................................................19CANASA......................................................................... 15candesartan/hydrochlorothiazide................................. 9CAPRELSA.......................................................................4captopril...........................................................................8CAPTOPRIL/HYDROCHLOROTHIAZIDE........................8CARAFATE.....................................................................14CARBAGLU...................................................................... 8carbamazepine.............................................................. 21carbamazepine ext-release.......................................... 21CARBATROL.................................................................. 21carbidopa/levodopa...................................................... 22CARBIDOPA/LEVODOPA/ENTACAPONE.................... 22carbidopa/levodopa ext-release.................................. 22carbinoxamine maleate................................................12CARDIZEM..................................................................... 10CARDIZEM CD...............................................................10CARDIZEM LA............................................................... 10CARDURA...................................................................... 12carisoprodol 350 mg.................................................... 23CARNITOR oral soln, tabs............................................... 8CARNITOR SF................................................................. 8carteolol eye soln.........................................................25carvedilol......................................................................... 9CASODEX........................................................................ 4CATAFLAM.....................................................................21CATAPRES.....................................................................12CATAPRES-TTS.............................................................12CAYSTON.........................................................................4CEENU............................................................................. 4cefaclor caps...................................................................1CEFACLOR susp............................................................. 1cefadroxil caps............................................................... 1cefadroxil susp, tabs......................................................1cefdinir............................................................................. 1cefpodoxime....................................................................1cefprozil........................................................................... 1

CEFTIN susp, 125 mg/5 mL; tabs....................................1CEFTIN susp, 250 mg/5 mL............................................ 1cefuroxime.......................................................................1CELEBREX.....................................................................21CELEXA..........................................................................16CELLCEPT..................................................................... 30CELLUGEL..................................................................... 26cephalexin caps, susp................................................... 1CETRAXAL..................................................................... 26CETROTIDE..................................................................... 7CHANTIX........................................................................ 19chlordiazepoxide...........................................................16chlorhexidine.................................................................27chloroquine phosphate..................................................3chlorothiazide................................................................11chlorpromazine............................................................. 17CHLORTHALIDONE 100 mg......................................... 11chlorthalidone 25 mg................................................... 11CHLORTHALIDONE 50 mg........................................... 11chlorzoxazone............................................................... 23cholestyramine..............................................................11chorionic gonadotropin................................................. 7CICLODAN SOLUTION KIT...........................................28ciclopirox....................................................................... 28cilostazol........................................................................24CILOXAN eye soln......................................................... 25cimetidine...................................................................... 14ciprofloxacin....................................................................2CIPROFLOXACIN ear soln............................................ 26ciprofloxacin ext-release tabs, 1000 mg.......................2ciprofloxacin ext-release tabs, 500 mg........................ 2ciprofloxacin eye soln..................................................25CIPRO tabs...................................................................... 2CIPRO XR........................................................................ 2citalopram......................................................................16CLARAVIS caps, 30 mg.................................................27CLARIFOAM EF............................................................. 27CLARINEX REDITABS...................................................12CLARINEX tabs..............................................................12clarithromycin................................................................. 1clarithromycin ext-release............................................. 1CLEOCIN.......................................................................... 4CLEOCIN PEDIATRIC..................................................... 4CLEOCIN-T.....................................................................27CLEOCIN vaginal crm.................................................... 16clidinium/chlordiazepoxide..........................................14CLIMARA.......................................................................... 6clindamycin/benzoyl peroxide.....................................27clindamycin caps............................................................4clindamycin foam......................................................... 27clindamycin gel, lotn, soln, swab............................... 27clindamycin oral soln.....................................................4clindamycin vaginal crm..............................................16CLINORIL....................................................................... 21clobetasol crm, emollient, gel, oint, soln................... 28clobetasol foam, lotn, shampoo................................. 28

2013


CLOBEX lotn, shampoo................................................. 28CLOMID............................................................................ 7clomiphene...................................................................... 7clomipramine.................................................................16clonazepam................................................................... 21clonazepam ODT.......................................................... 21clonidine........................................................................ 12clonidine transdermal patches....................................12clopidogrel.....................................................................24clorazepate.................................................................... 16clotrimazole troche.......................................................27clotrimazole w/ betamethasone.................................. 28clozapine........................................................................17CLOZARIL...................................................................... 17COARTEM........................................................................ 3CODEINE SULFATE tabs.............................................. 19COLAZAL........................................................................15COLCRYS.......................................................................21COLESTID...................................................................... 11colestipol....................................................................... 11COLYTE 227.1 g............................................................13COLYTE 240 g...............................................................13COMBIGAN.................................................................... 25COMBIVENT...................................................................13COMBIVENT RESPIMAT...............................................13COMBIVIR........................................................................ 3COMETRIQ.......................................................................4COMPLERA......................................................................3COMTAN........................................................................ 22CONCERTA....................................................................18CONDYLOX soln............................................................29COPAXONE....................................................................19COPEGUS........................................................................ 2CORDARONE.................................................................12COREG.............................................................................9CORGARD........................................................................9CORTANE-B AQUEOUS................................................26CORTANE-B-OTIC......................................................... 26CORTEF........................................................................... 5CORTENEMA................................................................. 27CORTIFOAM.................................................................. 27CORTISONE.....................................................................5CORTISPORIN ear soln.................................................26CORVITE 150.................................................................24CORZIDE..........................................................................9COSOPT.........................................................................25COUMADIN.................................................................... 24COZAAR........................................................................... 9CRESTOR...................................................................... 11CRINONE....................................................................... 16CRIXIVAN......................................................................... 3cromolyn sodium..........................................................15cromolyn sodium eye soln..........................................26cromolyn sodium inhal soln........................................13CUPRIMINE....................................................................30CUTIVATE...................................................................... 28

cyanocobalamin inj...................................................... 24CYCLESSA.......................................................................6cyclobenzaprine............................................................23CYCLOGYL eye soln, 1%, 2%.......................................26cyclopentolate eye soln, 1%........................................26cyclopentolate eye soln, 2%........................................26CYCLOPHOSPHAMIDE tabs........................................... 4cyclosporine..................................................................30cyclosporine modified caps, 25 mg, 100 mg; soln.... 30CYCLOSPORINE MODIFIED caps, 50 mg....................30CYMBALTA.....................................................................16cyproheptadine............................................................. 12CYTOMEL.........................................................................8CYTOTEC.......................................................................14

D

D.H.E. 45........................................................................ 21DALIRESP...................................................................... 13danazol.............................................................................5DANTRIUM..................................................................... 23dantrolene......................................................................23DAPSONE........................................................................ 4DARAPRIM....................................................................... 3DAYPRO.........................................................................21DDAVP spray, soln, tabs..................................................8DELESTROGEN...............................................................6DELZICOL...................................................................... 15DEMADEX...................................................................... 11demeclocycline............................................................... 1DEMEROL...................................................................... 19DENAVIR........................................................................ 28DEPAKENE.................................................................... 22DEPAKOTE.................................................................... 22DEPAKOTE ER.............................................................. 22DEPAKOTE SPRINKLES...............................................22DEPEN TITRATABS...................................................... 30DEPO-PROVERA 150 mg/mL..........................................6DEPO-TESTOSTERONE................................................. 5DERMA-SMOOTHE/FS oil............................................. 28DERMATOP....................................................................28DERMOTIC.....................................................................26desipramine...................................................................17desloratadine.................................................................12desloratadine ODT........................................................12desmopressin nasal spray, nasal soln, tabs............... 8DESOGEN........................................................................ 6desonide crm, oint....................................................... 28desonide lotn................................................................ 29DESOWEN..................................................................... 29DESOXIMETASONE crm, 0.05%...................................29desoximetasone crm, 0.25%; gel; oint, 0.25%........... 29DETROL......................................................................... 15DEX4 GLUCOSE..............................................................7dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, 1.5 mg,4 mg, 6 mg.................................................................... 5

DEXAMETHASONE INTENSOL...................................... 5

2013


dexamethasone sodium phosphate eye soln............ 25DEXAMETHASONE soln..................................................5DEXAMETHASONE tabs, 1 mg, 2 mg.............................5DEXEDRINE................................................................... 18dexmethylphenidate..................................................... 18DEXPAK........................................................................... 5dextroamphetamine......................................................18dextroamphetamine ext-release..................................18DIAMOX SEQUELS....................................................... 11DIASTAT.........................................................................22DIAZEPAM gel............................................................... 22diazepam tabs...............................................................16diclofenac/misoprostol.................................................21diclofenac eye soln...................................................... 26diclofenac potassium...................................................21diclofenac sodium delayed-release............................ 21diclofenac sodium ext-release.................................... 21dicloxacillin..................................................................... 1dicyclomine caps, tabs................................................ 14didanosine delayed-release...........................................3DIFFERIN crm; gel, 0.1%...............................................27DIFICID............................................................................. 1DIFLORASONE crm.......................................................29diflorasone oint.............................................................29DIFLUCAN........................................................................ 2diflunisal........................................................................ 19DIGEX NF.......................................................................14digoxin tabs.................................................................. 12dihydroergotamine mesylate.......................................21DILACOR XR..................................................................10DILANTIN........................................................................22DILANTIN-125................................................................ 22DILANTIN INFATABS.....................................................22DILAUDID tabs............................................................... 19diltiazem.........................................................................10diltiazem ext-release caps........................................... 10diltiazem ext-release tabs............................................10DIOVAN HCT................................................................... 9DIPENTUM..................................................................... 15DIPHENOXYLATE/ATROPINE soln...............................14diphenoxylate/atropine tabs........................................ 14DIPROLENE................................................................... 29DIPROLENE AF............................................................. 29dipyridamole..................................................................24disopyramide.................................................................12disulfiram.......................................................................19DITROPAN XL................................................................15divalproex delayed-release caps................................ 22divalproex delayed-release tabs................................. 22divalproex ext-release..................................................22DIVIGEL............................................................................6DOLOPHINE...................................................................19donepezil....................................................................... 19DONNATAL.................................................................... 14DORYX............................................................................. 1dorzolamide/timolol maleate eye soln........................25

dorzolamide eye soln...................................................25DOVONEX crm...............................................................29doxazosin...................................................................... 12DOXEPIN 75 mg............................................................ 17doxepin caps, 10 mg, 25 mg, 50 mg, 100 mg; conc...17doxepin caps, 150 mg..................................................17doxycycline hyclate........................................................1doxycycline hyclate delayed-release tabs, 150 mg..... 1DOXYCYCLINE HYCLATE delayed-release tabs, 75mg, 100 mg.................................................................... 1

doxycycline monohydrate............................................. 1DRISDOL........................................................................ 23DRITHO-CREME HP......................................................29DRITHO-SCALP............................................................. 29dronabinol..................................................................... 14DROXIA.......................................................................... 24DRYSOL......................................................................... 29DUAC..............................................................................27DUETACT......................................................................... 7DUONEB.........................................................................13DURAGESIC...................................................................19DUTOPROL...................................................................... 9DYAZIDE........................................................................ 11DYNACIN..........................................................................1DYRENIUM.....................................................................11

E

E.E.S. 400........................................................................ 1EC-NAPROSYN..............................................................21econazole.......................................................................28EDURANT.........................................................................3EFFER-K.........................................................................23EFFEXOR XR.................................................................17EFFIENT......................................................................... 24EFUDEX......................................................................... 29ELDEPRYL..................................................................... 22ELESTAT........................................................................ 26ELIGARD.......................................................................... 4ELIPHOS........................................................................ 15ELIXOPHYLLIN.............................................................. 13ELLA................................................................................. 6ELMIRON........................................................................16ELOCON.........................................................................29EMCYT............................................................................. 4EMEND caps.................................................................. 14EMTRIVA.......................................................................... 3enalapril........................................................................... 8enalapril/hydrochlorothiazide........................................8ENBREL..........................................................................21ENDOMETRIN................................................................16enoxaparin.....................................................................24ENTEREG.......................................................................15ENTOCORT EC............................................................... 5epinastine eye soln...................................................... 26EPINEPHRINE................................................................12EPIPEN...........................................................................12

2013


EPIPEN-JR..................................................................... 12EPIVIR.............................................................................. 3EPIVIR-HBV......................................................................2eplerenone.....................................................................12EPOGEN.........................................................................24eprosartan....................................................................... 9EPZICOM..........................................................................3ergocalciferol................................................................ 23ERIVEDGE....................................................................... 4ERY-TAB.......................................................................... 1ERYTHROCIN STEARATE..............................................1erythromycin/benzoyl peroxide...................................27erythromycin/sulfisoxazole............................................4ERYTHROMYCIN BASE..................................................1ERYTHROMYCIN delayed-release caps......................... 1ERYTHROMYCIN ETHYLSUCCINATE........................... 1erythromycin eye oint.................................................. 25erythromycin topical pads, soln................................. 27escitalopram..................................................................17ESGIC.............................................................................19ESGIC-PLUS.................................................................. 19estazolam.......................................................................18esterified estrogens/methyltestosterone..................... 6ESTRACE crm................................................................16ESTRACE tabs.................................................................6ESTRADERM................................................................... 6estradiol........................................................................... 6estradiol/norethindrone acetate.................................... 6estradiol valerate............................................................ 6ESTRING........................................................................ 16estropipate 0.625 mg, 0.75 mg, 1.25 mg, 1.5 mg..........6ESTROPIPATE 3 mg....................................................... 6ESTROSTEP FE.............................................................. 6ethambutol.......................................................................2ethosuximide.................................................................22ETIDRONATE 400 mg..................................................... 8etodolac......................................................................... 21etodolac ext-release..................................................... 21ETOPOSIDE caps............................................................ 4EURAX............................................................................29EVISTA............................................................................. 8EVOCLIN........................................................................ 27EXELON caps................................................................ 19exemestane..................................................................... 4EXJADE.......................................................................... 30EXTINA........................................................................... 28

F

famciclovir....................................................................... 2famotidine for susp...................................................... 14famotidine tabs............................................................. 14FAMVIR............................................................................ 3FARESTON...................................................................... 4FASLODEX.......................................................................4felbamate....................................................................... 22FELBATOL......................................................................22

FELDENE....................................................................... 21felodipine ext-release...................................................10FEMARA........................................................................... 4FEMCON FE.................................................................... 6FEMHRT 1/5.....................................................................6FEMHRT LOW DOSE 0.5 mg-2.5 mcg............................6fenofibrate..................................................................... 11fenofibrate..................................................................... 11fenofibrate micronized................................................. 11fenofibrate micronized................................................. 11fentanyl.......................................................................... 19fentanyl patches........................................................... 19FEXMID.......................................................................... 23FINACEA........................................................................ 27finasteride......................................................................16FIORICET....................................................................... 19FIORICET/CODEINE......................................................19FIORINAL....................................................................... 19FIORINAL/CODEINE...................................................... 19FIRAZYR.........................................................................24FLAGYL............................................................................ 4flavoxate........................................................................ 15flecainide....................................................................... 12FLEXERIL....................................................................... 23FLOMAX......................................................................... 16FLONASE....................................................................... 13FLOVENT DISKUS.........................................................13FLOVENT HFA...............................................................13fluconazole...................................................................... 2flucytosine....................................................................... 2fludrocortisone................................................................5FLUMADINE..................................................................... 3fluocinolone...................................................................29fluocinolone acetonide ear oil.....................................26fluocinonide...................................................................29fluorometholone eye susp...........................................25fluorouracil.................................................................... 29fluoxetine (PMDD).........................................................19FLUOXETINE 60 mg......................................................17fluoxetine caps; soln; tabs, 10 mg, 20 mg................. 17fluoxetine delayed-release...........................................17fluphenazine hcl........................................................... 17flurazepam..................................................................... 18flurbiprofen....................................................................21flurbiprofen eye soln....................................................26flutamide.......................................................................... 4fluticasone propionate................................................. 29fluticasone propionate nasal spray............................ 13fluvastatin...................................................................... 11fluvoxamine................................................................... 17FML LIQUIFILM..............................................................25FOCALIN........................................................................ 18FOLGARD RX................................................................ 24folic acid tabs, 1 mg.................................................... 24FOLLISTIM AQ.................................................................7FOLTRATE..................................................................... 24

2013


fondaparinux................................................................. 24FORADIL AEROLIZER...................................................13FORTAMET...................................................................... 7FORTEO........................................................................... 8FORTICAL........................................................................ 8FOSAMAX........................................................................ 8fosinopril..........................................................................8fosinopril/hydrochlorothiazide...................................... 8FURADANTIN.................................................................15furosemide soln, 10 mg/mL; tabs............................... 11FUROSEMIDE soln, 8 mg/mL........................................11FUZEON........................................................................... 3

G

gabapentin caps, tabs..................................................22gabapentin soln............................................................ 22GABITRIL 2 mg, 4 mg................................................... 22galantamine................................................................... 19galantamine ext-release...............................................19GANIRELIX.......................................................................7GARAMYCIN.................................................................. 25GASTROCROM..............................................................15GEL-KAM........................................................................27gemfibrozil.....................................................................11gentamicin eye oint, soln............................................ 25GENTAMICIN SULFATE................................................28GEODON........................................................................ 17GILENYA........................................................................ 19GLEEVEC......................................................................... 4glimepiride.......................................................................7glipizide............................................................................7glipizide/metformin......................................................... 7glipizide ext-release....................................................... 7GLUCAGEN......................................................................7GLUCAGEN HYPOKIT.....................................................7GLUCAGON EMERGENCY KIT...................................... 7GLUCOPHAGE.................................................................7GLUCOPHAGE XR.......................................................... 7glucose gel, 40%; oral soln, 15 g/59 mL...................... 7GLUCOTROL....................................................................7GLUCOTROL XL..............................................................7GLUCOVANCE.................................................................7glyburide..........................................................................7GLYBURIDE, distributor of Diabeta................................. 7glyburide/metformin....................................................... 7glyburide micronized..................................................... 7glycopyrrolate............................................................... 14GLYNASE......................................................................... 7GOLYTELY for soln, 236 g............................................ 13GOLYTELY packet, 227.1 g...........................................13GONAL-F.......................................................................... 7GRANULEX.................................................................... 29GRIFULVIN V................................................................... 2griseofulvin microsize susp.......................................... 2griseofulvin microsize tabs........................................... 2griseofulvin ultramicrosize............................................2

GRIS-PEG........................................................................ 2guanfacine..................................................................... 12

H

HALCION........................................................................ 18halobetasol.................................................................... 29halobetasol/ammonium lactate................................... 29haloperidol.....................................................................17haloperidol lactate........................................................17HEMATRON-AF..............................................................24heparin sodium/D5W 40 unit/mL, 50 unit/mL, 100unit/mL......................................................................... 24

HEPARIN SODIUM/D5W 50 unit/mL, 100 unit/mL.........24heparin sodium/sodium chloride inj, 2 unit/mL......... 24HEPARIN SODIUM/SODIUM CHLORIDE inj, 2 unit/mL 24heparin sodium inj, 1000 unit/mL, 5000 unit/mL,10000 unit/mL, 20000 unit/mL....................................24

HEPARIN SODIUM inj, 2500 unit/mL.............................24HEPSERA.........................................................................2HEXALEN......................................................................... 4HIPREX...........................................................................15homatropine eye soln.................................................. 26HUMIRA..........................................................................21HYCAMTIN caps.............................................................. 4HYCET............................................................................19hydralazine.................................................................... 12HYDREA........................................................................... 4HYDRO 35......................................................................29hydrochlorothiazide caps............................................ 11hydrochlorothiazide tabs, 12.5 mg............................. 11hydrochlorothiazide tabs, 25 mg, 50 mg....................11hydrocodone/acetaminophen......................................19hydrocodone/acetaminophen soln, 7.5-325 mg/15mL, 7.5-500 mg/15 mL; tabs, 5-300 mg, 7.5-300 mg,10-300 mg.................................................................... 19

hydrocodone/ibuprofen tabs, 2.5-200 mg, 10-200mg.................................................................................20

hydrocodone/ibuprofen tabs, 5-200 mg, 7.5-200 mg. 20hydrocortisone................................................................5hydrocortisone/pramoxine emollient crm.................. 27hydrocortisone acetate/pramoxine............................. 29hydrocortisone acetate/pramoxine rectal crm...........27hydrocortisone acetate rectal crm, supp................... 27hydrocortisone butyrate.............................................. 29hydrocortisone crm......................................................29hydrocortisone enema................................................. 27hydrocortisone lotn, 2.5%............................................29hydrocortisone rectal crm........................................... 27hydrocortisone valerate...............................................29HYDROMORPHONE supp.............................................20hydromorphone tabs....................................................20hydroxychloroquine....................................................... 3hydroxyurea.................................................................... 4hydroxyzine hcl............................................................ 16HYDROXYZINE PAMOATE 100 mg..............................16hydroxyzine pamoate 25 mg, 50 mg...........................16

2013


hyoscyamine................................................................. 14hyoscyamine/phenyltoloxamine..................................14hyoscyamine ext-release............................................. 14hyoscyamine ODT........................................................ 14hypromellose intraocular soln.................................... 26HYZAAR........................................................................... 9

I

ibandronate..................................................................... 8IBUDONE........................................................................20ibuprofen tabs...............................................................21ICAR-C PLUS.................................................................24ICLUSIG............................................................................4IMDUR............................................................................ 10imipramine hcl.............................................................. 17imiquimod......................................................................29IMITREX......................................................................... 21IMURAN..........................................................................30INCIVEK............................................................................2indapamide.................................................................... 11INDERAL LA.....................................................................9indomethacin.................................................................21indomethacin ext-release.............................................21INLYTA............................................................................. 4INSPRA...........................................................................12INTELENCE......................................................................3INVIRASE......................................................................... 3iodoquinol/hydrocortisone.......................................... 28IOPIDINE eye soln, 0.5%...............................................25ipratropium/albuterol....................................................13ipratropium inhal soln..................................................13ipratropium nasal......................................................... 13irbesartan.........................................................................9irbesartan/hydrochlorothiazide..................................... 9ISENTRESS......................................................................3isoniazid tabs..................................................................2ISOPTIN SR................................................................... 10ISOPTO ATROPINE.......................................................26ISOPTO CARPINE......................................................... 25ISOPTO HOMATROPINE eye soln, 5%.........................26ISOPTO HYOSCINE...................................................... 26ISORDIL TITRADOSE....................................................10isosorbide dinitrate ext-release.................................. 10ISOSORBIDE DINITRATE sublingual............................ 10isosorbide dinitrate tabs..............................................10isosorbide mononitrate................................................10isosorbide mononitrate ext-release............................10isotretinoin caps, 10 mg, 20 mg, 40 mg..................... 27itraconazole..................................................................... 2

J

JAKAFI..............................................................................4JINTELI............................................................................. 6

K

KADIAN 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg,100 mg, 200 mg........................................................... 20

KALETRA..........................................................................3KAYEXALATE.................................................................30KEFLEX 250 mg, 500 mg................................................ 1KEPPRA......................................................................... 22KEPPRA XR................................................................... 22KERALYT........................................................................28KERLONE.........................................................................9ketoconazole crm, shampoo....................................... 28ketoconazole foam....................................................... 28ketoconazole tabs.......................................................... 2ketoprofen..................................................................... 21ketorolac........................................................................ 21ketorolac eye soln........................................................ 26KLARON......................................................................... 27KLONOPIN..................................................................... 22K-LOR............................................................................. 23KOMBIGLYZE XR............................................................ 7K-PHOS NEUTRAL........................................................ 23K-TABS........................................................................... 23

L

labetalol........................................................................... 9lactic acid/vitamin E..................................................... 29lactic acid (ammonium lactate)................................... 29lactulose........................................................................ 13lactulose........................................................................ 15LAMICTAL chew tabs; tabs, 25 mg, 100 mg, 150 mg,200 mg, starter kit........................................................ 22

LAMICTAL XR................................................................ 22LAMISIL tabs.................................................................... 2lamivudine....................................................................... 3lamivudine/zidovudine................................................... 3lamotrigine chew tabs..................................................22lamotrigine ext-release tabs........................................ 22lamotrigine tabs............................................................22LANCETS – VARIOUS MANUFACTURERS................. 30LANOXIN........................................................................ 12lansoprazole delayed-release......................................14LANTUS............................................................................8LASIX..............................................................................11latanoprost eye soln.................................................... 25leflunomide....................................................................21LESCOL..........................................................................11letrozole........................................................................... 4LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg.................4leucovorin calcium tabs, 5 mg, 25 mg......................... 4LEUKERAN.......................................................................4LEUKINE 500 mcg/mL................................................... 24leuprolide acetate........................................................... 4LEVALBUTEROL inhal soln, 0.31 mg/3 mL, 0.63 mg/3mL, 1.25 mg/3 mL........................................................ 13

levalbuterol inhal soln, 1.25 mg/0.5 mL......................13

2013


LEVAQUIN........................................................................2LEVBID........................................................................... 14levetiracetam................................................................. 22levetiracetam ext-release.............................................22LEVOBUNOLOL eye soln, 0.25%.................................. 25levobunolol eye soln, 0.5%..........................................25levocarnitine oral soln, tabs..........................................8levocetirizine................................................................. 12levofloxacin eye soln................................................... 25levofloxacin soln............................................................ 2levofloxacin tabs............................................................ 2levonorgestrel................................................................. 6levothyroxine...................................................................8LEVSIN........................................................................... 14LEVSIN/SL......................................................................14LEXAPRO....................................................................... 17LEXIVA............................................................................. 3LIALDA............................................................................15LIBRAX........................................................................... 14lidocaine/hydrocortisone acetate rectal crm, gel...... 27lidocaine/prilocaine crm...............................................30lidocaine crm................................................................ 29lidocaine gel, oint, soln............................................... 30lidocaine viscous..........................................................27LIDODERM..................................................................... 30lindane........................................................................... 30liothyronine..................................................................... 8LIPITOR.......................................................................... 11lisinopril........................................................................... 8lisinopril/hydrochlorothiazide........................................8lithium carbonate caps, 150 mg, 300 mg, 600 mg;tabs, 300 mg................................................................17

LITHIUM CARBONATE caps, 150 mg, 600 mg............. 17lithium carbonate ext-release 300 mg........................ 17lithium carbonate ext-release 450 mg........................ 17LITHIUM CITRATE.........................................................17LITHOBID....................................................................... 17LOCOID crm, oint, soln.................................................. 29LODOSYN...................................................................... 22LOESTRIN........................................................................ 6LOESTRIN FE.................................................................. 6LOFIBRA.........................................................................11LOMOTIL........................................................................ 14loperamide.....................................................................14LOPID............................................................................. 11LOPRESSOR....................................................................9LOPRESSOR HCT...........................................................9LOPROX gel...................................................................28LOPROX shampoo.........................................................28LORAZEPAM INTENSOL...............................................16lorazepam tabs............................................................. 16LORCET......................................................................... 20LORCET PLUS...............................................................20LORTAB..........................................................................20losartan............................................................................ 9losartan/hydrochlorothiazide.........................................9

LOSEASONIQUE............................................................. 6LOTENSIN........................................................................ 9LOTENSIN HCT............................................................... 9LOTREL.......................................................................... 10LOTRISONE................................................................... 28LOTRONEX.................................................................... 15lovastatin....................................................................... 11LOVENOX.......................................................................24loxapine......................................................................... 17LOXITANE...................................................................... 17LUPRON DEPOT............................................................. 4LUPRON DEPOT-PED.....................................................8LURIDE...........................................................................23LYBREL............................................................................ 6LYRICA........................................................................... 22LYSODREN...................................................................... 4

M

MACROBID.....................................................................15MACRODANTIN............................................................. 15mafenide........................................................................ 28MALARONE......................................................................3malathion....................................................................... 30MARINOL........................................................................14MATULANE...................................................................... 4MAVIK...............................................................................9MAXIDONE.....................................................................20MAXITROL......................................................................25MAXZIDE........................................................................ 11MAXZIDE-25...................................................................11meclizine 12.5 mg, 25 mg............................................ 14meclizine 32 mg............................................................14MEDROL...........................................................................5medroxyprogesterone acetate...................................... 6medroxyprogesterone acetate...................................... 6mefloquine.......................................................................3MEGACE.......................................................................... 4megestrol susp............................................................... 4megestrol tabs................................................................ 4MELOXICAM susp......................................................... 21meloxicam tabs.............................................................21MENOPUR........................................................................7meperidine.....................................................................20MEPHYTON....................................................................23meprobamate................................................................ 16mercaptopurine...............................................................4mesalamine................................................................... 15MESNEX tabs...................................................................4MESTINON tabs, 60 mg................................................ 23METAGLIP........................................................................7METAPROTERENOL..................................................... 13metaxalone.................................................................... 23metformin........................................................................ 7metformin ext-release.................................................... 7metformin ext-release OSM...........................................7methadone conc, tab for oral susp............................ 20

2013


METHADONE INTENSOL..............................................20METHADONE soln......................................................... 20methadone tabs............................................................ 20methazolamide.............................................................. 11methenamine hippurate............................................... 15METHENAMINE MANDELATE 0.5 g.............................15methenamine mandelate 1 g....................................... 15methimazole.................................................................... 8methocarbamol............................................................. 23methotrexate inj, 25 mg/mL; tabs................................. 4methscopolamine......................................................... 14methyldopa....................................................................12METHYLDOPA/HYDROCHLOROTHIAZIDE................. 12methylergonovine........................................................... 8METHYLIN soln..............................................................18methylphenidate ext-release caps; tabs, 20 mg........ 18METHYLPHENIDATE ext-release OSM tabs, 18 mg, 36mg, 54 mg.................................................................... 18

methylphenidate ext-release OSM tabs, 27 mg......... 18METHYLPHENIDATE ext-release tabs, 10 mg.............. 18methylphenidate soln...................................................18methylphenidate tabs...................................................18methylprednisolone........................................................5metipranolol eye soln.................................................. 25METOCLOPRAMIDE inj, 5 mg/mL.................................15metoclopramide soln, tabs..........................................15metolazone.................................................................... 11metoprolol/hydrochlorothiazide.................................... 9metoprolol succinate ext-release..................................9metoprolol tartrate..........................................................9METROCREAM.............................................................. 27METROGEL-VAGINAL................................................... 16METROLOTION..............................................................27metronidazole................................................................16metronidazole................................................................28metronidazole tabs.........................................................4metronidazole topical gel............................................ 28MEVACOR......................................................................11MEXILETINE...................................................................12MIACALCIN nasal............................................................ 8MICRO-K........................................................................ 23MICROZIDE....................................................................11midazolam..................................................................... 18midodrine.......................................................................12MILLIPRED DP.................................................................5MILLIPRED soln............................................................... 5MILLIPRED tabs...............................................................5MINIPRESS.................................................................... 12MINOCIN caps................................................................. 1minocycline caps............................................................1minocycline ext-release................................................. 1minocycline tabs............................................................ 1minoxidil........................................................................ 12MIRAPEX........................................................................22MIRCETTE........................................................................6mirtazapine.................................................................... 17

misoprostol................................................................... 14MOBIC............................................................................ 21modafinil........................................................................ 18MODICON.........................................................................6moexipril.......................................................................... 9moexipril/hydrochlorothiazide.......................................9mometasone..................................................................29MONODOX....................................................................... 1montelukast chew tabs, tabs...................................... 13morphine sulfate conc................................................. 20morphine sulfate ext-release caps..............................20morphine sulfate ext-release tabs.............................. 20morphine sulfate soln.................................................. 20MORPHINE SULFATE supp.......................................... 20MORPHINE SULFATE tabs........................................... 20MS CONTIN................................................................... 20mupirocin crm...............................................................28mupirocin oint...............................................................28MYAMBUTOL................................................................... 2mycophenolate mofetil caps 250 mg..........................30MYDFRIN........................................................................26MYDRIACYL................................................................... 26MYLERAN.........................................................................4MYSOLINE..................................................................... 22

N

nabumetone...................................................................21nadolol............................................................................. 9nadolol/bendroflumethiazide......................................... 9naltrexone......................................................................30NAPHAZOLINE eye soln................................................26NAPROSYN....................................................................21naproxen........................................................................21naproxen delayed-release............................................21naproxen sodium..........................................................21naratriptan..................................................................... 21NARDIL...........................................................................17NASACORT AQ............................................................. 13NASONEX...................................................................... 13nateglinide....................................................................... 7NATURE-THROID............................................................ 8NEOMYCIN/POLYMYXIN/HYDROCORTISONE eyesusp...............................................................................25

neomycin/polymyxin B/bacitracin/hydrocortisoneeye oint........................................................................ 25

neomycin/polymyxin B/bacitracin eye oint................ 25neomycin/polymyxin B/dexamethasone eye oint,susp..............................................................................25

neomycin/polymyxin B/gramicidin eye soln.............. 25neomycin/polymyxin B/hydrocortisone ear soln,susp..............................................................................26

neomycin sulfate tabs....................................................2NEORAL......................................................................... 30NEOSPORIN.................................................................. 25NEPTAZANE.................................................................. 11NEULASTA..................................................................... 24

2013


NEUPOGEN................................................................... 24NEURONTIN...................................................................22NEVIRAPINE susp........................................................... 3nevirapine tabs............................................................... 3NEXAVAR.........................................................................5NEXIUM.......................................................................... 14niacin..............................................................................23NIASPAN........................................................................ 11nicardipine.....................................................................10NICOTROL INHALER.................................................... 19NICOTROL NS............................................................... 19nifedipine 10 mg...........................................................10NIFEDIPINE 20 mg........................................................ 10nifedipine ext-release...................................................10nifedipine ext-release OSM..........................................10NILANDRON.....................................................................5nimodipine.....................................................................10NIMOTOP....................................................................... 10NIRAVAM........................................................................16NISOLDIPINE ext-release 40 mg...................................10nisoldipine ext-release 8.5 mg, 17 mg, 25.5 mg, 34mg.................................................................................10

NITRO-BID oint.............................................................. 10NITRO-DUR....................................................................10nitrofurantoin................................................................ 15nitrofurantoin macrocrystalline...................................15nitrofurantoin monohydrate/macrocrystalline........... 15nitroglycerin ext-release caps.....................................10nitroglycerin ext-release patches............................... 10NITROSTAT....................................................................10nizatidine caps..............................................................14nizatidine soln...............................................................14NIZORAL........................................................................ 28NORCO...........................................................................20NORDETTE...................................................................... 6norethindrone acetate....................................................6NORINYL 1/35..................................................................6NORPACE...................................................................... 12NORPRAMIN.................................................................. 17NOR-QD........................................................................... 6nortriptyline caps......................................................... 17NORVASC...................................................................... 10NORVIR............................................................................ 3NOVOLIN 70/30............................................................... 7NOVOLIN N......................................................................7NOVOLIN R......................................................................7NOVOLOG........................................................................7NOVOLOG MIX 70/30......................................................8NOXAFIL...........................................................................2NUCYNTA.......................................................................20NUCYNTA ER................................................................ 20NULYTELY/FLAVOR PACKS.........................................13NUMOISYN lozenge.......................................................27NUVARING....................................................................... 6NYSTATIN/TRIAMCINOLONE....................................... 29nystatin oral powder...................................................... 2

nystatin oral tabs............................................................2nystatin susp................................................................ 27nystatin topical............................................................. 28NYSTATIN vaginal tabs................................................. 16

O

octreotide.........................................................................8OCUFEN.........................................................................26OCUFLOX.......................................................................25ofloxacin ear soln.........................................................26ofloxacin eye soln........................................................ 25ofloxacin tabs................................................................. 2olanzapine..................................................................... 17olanzapine/fluoxetine................................................... 19OLUX.............................................................................. 29OLUX-E...........................................................................29omeprazole delayed-release........................................14OMNIPRED.....................................................................25OMNITROPE.................................................................... 8ondansetron ODT, tabs................................................14ondansetron soln......................................................... 14ondansetron tabs, 24 mg.............................................14ONGLYZA.........................................................................7OPANA........................................................................... 20OPTIPRANOLOL............................................................ 25OPTIVAR........................................................................ 26oral contraceptives – generics at tier 1 – all others.... 6oral contraceptives – generics at tier 2 –Amethia; Amethia Lo; Camrese; Camrese Lo;Gianvi; levonorgestrel/ethinyl estradiol, 0.1-0.02mg; Lornya; Ocella; Syeda;Vestura; Wymza FE;Zarah; Zenchent FE; Zeosa......................................... 6

ORAPRED........................................................................ 5orphenadrine citrate ext-release................................. 23ORTHO-CEPT.................................................................. 6ORTHO-CYCLEN............................................................. 6ORTHO EVRA..................................................................6ORTHO MICRONOR........................................................6ORTHO-NOVUM.............................................................. 6ORTHO TRI-CYCLEN...................................................... 6OTICIN HC NR...............................................................26OVACE WASH liq, 10%................................................. 30OVCON-35........................................................................6OVIDE.............................................................................30OVIDREL.......................................................................... 7OXANDRIN....................................................................... 5oxandrolone.................................................................... 5oxaprozin....................................................................... 21oxazepam.......................................................................16oxcarbazepine tabs...................................................... 22oxybutynin.....................................................................15oxybutynin ext-release.................................................15oxycodone/acetaminophen..........................................20oxycodone/aspirin........................................................ 20oxycodone/ibuprofen................................................... 20oxycodone caps........................................................... 20

2013


oxycodone conc........................................................... 20OXYCODONE conc, soln...............................................20oxycodone tabs, 10 mg, 20 mg...................................20oxycodone tabs, 5 mg, 15 mg, 30 mg.........................20OXYCONTIN...................................................................20oxymorphone................................................................ 20

P

PACERONE....................................................................12PALGIC...........................................................................12PAMELOR...................................................................... 17PAMINE.......................................................................... 14PAMINE FORTE.............................................................14PANCRELIPASE............................................................ 15pantoprazole delayed-release..................................... 14PARAFON FORTE DSC................................................ 23PARCOPA...................................................................... 23PARLODEL.....................................................................23PARNATE....................................................................... 17paromomycin.................................................................. 2paroxetine hcl ext-release........................................... 17paroxetine hcl tabs.......................................................17PAXIL CR....................................................................... 17PAXIL tabs......................................................................17pediatric multivitamins.................................................23pediatric multivitamins/fluoride/iron...........................23pediatric vitamins ADC................................................ 23PEGASYS.........................................................................2PEG – electrolytes for soln......................................... 13penicillin v potassium....................................................1PENLAC..........................................................................28PENTASA....................................................................... 15pentazocine/acetaminophen........................................20pentazocine/naloxone.................................................. 20pentoxifylline ext-release.............................................24PEPCID...........................................................................14PERCOCET.................................................................... 20PERCODAN....................................................................20PERIDEX........................................................................ 27perindopril....................................................................... 9permethrin..................................................................... 30perphenazine.................................................................18PERSANTINE................................................................. 24phenazopyridine........................................................... 16phenelzine..................................................................... 17phenobarbital elixir; tabs, 15 mg, 16.2 mg, 30 mg,32.4 mg, 60 mg, 100 mg.............................................18

PHENOBARBITAL tabs, 64.8 mg, 97.2 mg....................18phenylephrine eye soln............................................... 26PHENYTEK.....................................................................22phenytoin.......................................................................22phenytoin sodium ext-release.....................................22PHOSLO......................................................................... 15pilocarpine.....................................................................27pilocarpine eye soln.....................................................25pioglitazone..................................................................... 7

pioglitazone/glimepiride.................................................7pioglitazone/metformin.................................................. 7piroxicam....................................................................... 21PLAN B.............................................................................6PLAN B ONE-STEP......................................................... 6PLAQUENIL......................................................................3PLAVIX........................................................................... 24PLETAL...........................................................................24podofilox........................................................................30POLYCITRA-K CRYSTALS............................................16polyethylene glycol 3350 oral packet, pwd................ 14polymyxin B/trimethoprim eye soln............................25POLYTRIM......................................................................25potassium bicarbonate/chloride effervescent........... 23potassium bicarbonate effervescent.......................... 23potassium chloride ext-release caps, 8 mEq, 10mEq; tabs, 8 mEq, 10 mEq........................................ 23

potassium chloride microencapsulated ext-releasetabs, 10 mEq, 20 mEq................................................ 23

potassium chloride powder packet, 20 mEq; soln,10%............................................................................... 23

POTASSIUM CHLORIDE soln, 20%..............................23potassium citrate/citric acid granules........................ 16POTASSIUM CITRATE ext-release............................... 16potassium phosphate/sodium phosphates................24PRADAXA.......................................................................24pramipexole...................................................................23PRAMOSONE crm......................................................... 29PRAMOTIC..................................................................... 26pramoxine/chloroxylenol ear soln.............................. 26pramoxine/hydrocortisone...........................................29pramoxine/hydrocortisone/chloroxylenol ear soln... 26PRAVACHOL..................................................................11pravastatin.....................................................................11prazosin......................................................................... 12PRECOSE........................................................................ 7PRED FORTE................................................................ 25PRED-G.......................................................................... 25PRED MILD.................................................................... 25prednicarbate................................................................ 29prednisolone................................................................... 5prednisolone acetate eye susp................................... 25PREDNISOLONE SODIUM PHOSPHATE eye soln...... 25prednisolone sodium phosphate soln, 15 mg/5 mL.... 5PREDNISOLONE SODIUM PHOSPHATE soln, 5 mg/5mL................................................................................... 5

PREDNISONE INTENSOL...............................................5PREDNISONE soln; tabs, 50 mg..................................... 5prednisone tabs, 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg... 5PRELONE.........................................................................5PREMARIN crm..............................................................16PREMARIN tabs...............................................................6PREMPHASE................................................................... 6PREMPRO........................................................................6PRENATAL – various brands.........................................23PRENATAL – various brands.........................................23

2013


PREVACID......................................................................14PREVIDENT................................................................... 27PREZISTA tabs................................................................ 3PRILOSEC caps.............................................................14PRIMAQUINE................................................................... 3primidone.......................................................................22PRINIVIL........................................................................... 9PRINZIDE......................................................................... 9PROAIR HFA..................................................................13probenecid.....................................................................21probenecid/colchicine.................................................. 21PROCARDIA...................................................................10PROCARDIA XL.............................................................10prochlorperazine...........................................................18PROCRIT........................................................................24PROCTOCORT.............................................................. 27PROCTOFOAM HC........................................................27PRODRIN....................................................................... 21progesterone................................................................... 6progesterone micronized...............................................6PROGRAF...................................................................... 30promethazine.................................................................12PROMETHEGAN............................................................12PROMETRIUM................................................................. 6propafenone.................................................................. 12propafenone ext-release.............................................. 12proparacaine eye soln................................................. 26PROPRANOLOL/HYDROCHLOROTHIAZIDE 80/25.....10propranolol ext-release..................................................9propranolol tabs............................................................. 9propylthiouracil...............................................................8PROSCAR...................................................................... 16PROSED/DS...................................................................15PROTONIX tabs............................................................. 14PROTOPIC..................................................................... 30protriptyline................................................................... 17PROVERA........................................................................ 6PROVIGIL....................................................................... 18PROZAC......................................................................... 17PROZAC WEEKLY.........................................................17PULMICORT RESPULES 0.25 mg/2 mL, 0.5 mg/2 mL..13PULMOZYME................................................................. 13PURINETHOL...................................................................5pyrazinamide................................................................... 2PYRIDIUM...................................................................... 16pyridostigmine.............................................................. 23

Q

QUESTRAN.................................................................... 11QUESTRAN LIGHT........................................................ 11quetiapine...................................................................... 18quinapril...........................................................................9quinapril/hydrochlorothiazide....................................... 9quinidine gluconate ext-release..................................12quinidine sulfate........................................................... 12

R

ramipril.............................................................................9RANEXA......................................................................... 10ranitidine........................................................................14RAPAMUNE....................................................................30RAZADYNE.................................................................... 19RAZADYNE ER.............................................................. 19REBETOL caps................................................................ 2REBIF............................................................................. 19REGLAN......................................................................... 15REMERON......................................................................17REMERON SOLTAB...................................................... 17RENAGEL.......................................................................15RENVELA....................................................................... 15REPREXAIN................................................................... 20REPRONEX......................................................................7REQUIP.......................................................................... 23REQUIP XL.................................................................... 23RESCRIPTOR.................................................................. 3RESERPINE................................................................... 12RESTORIL...................................................................... 18RETIN-A..........................................................................28RETROVIR....................................................................... 3REVATIO tabs................................................................ 12REVIA............................................................................. 30REVLIMID....................................................................... 30REYATAZ......................................................................... 3RIBAPAK 800 mg, 1000 mg, 1200 mg/day......................2RIBASPHERE tabs, 400 mg, 600 mg.............................. 2RIBATAB...........................................................................2ribavirin............................................................................2RIFADIN............................................................................2RIFAMATE........................................................................2rifampin............................................................................2RILUTEK.........................................................................23rimantadine......................................................................3RIOMET............................................................................ 7RISPERDAL....................................................................18RISPERDAL M-TAB....................................................... 18risperidone ODT, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg;tabs...............................................................................18

risperidone ODT 0.25 mg.............................................18risperidone soln............................................................18RITALIN.......................................................................... 18RITALIN LA.................................................................... 18RITALIN SR....................................................................18rivastigmine...................................................................19rizatriptan.......................................................................21rizatriptan ODT..............................................................21ROBAXIN........................................................................23ROBINUL........................................................................ 14ROBINUL FORTE.......................................................... 14ROCALTROL.................................................................... 8ropinirole....................................................................... 23ropinirole ext-release................................................... 23

2013


ROWASA........................................................................ 15ROXICET tabs................................................................20ROXICODONE tabs....................................................... 20RYTHMOL...................................................................... 12RYTHMOL SR................................................................ 12

S

SALAGEN....................................................................... 27SALEX............................................................................ 28salicylic acid................................................................. 28SALICYLIC ACID soln....................................................28salsalate.........................................................................19SALVAX.......................................................................... 28SAMSCA...........................................................................8SANCTURA.................................................................... 15SANCTURA XR..............................................................15SANDIMMUNE............................................................... 30SANDOSTATIN................................................................ 8SEASONALE.................................................................... 6SEASONIQUE.................................................................. 7SECTRAL....................................................................... 10selegiline caps.............................................................. 23selegiline tabs...............................................................23selenium sulfide........................................................... 30SELENIUM SULFIDE/PYRITHIONE in UREA shampoo30SELSUN SHAMPOO......................................................30SELZENTRY.....................................................................3SENSIPAR........................................................................8SEPTRA DS..................................................................... 4SEREVENT DISKUS......................................................13SEROQUEL.................................................................... 18sertraline conc.............................................................. 17sertraline tabs............................................................... 17SHOHL'S SOLUTION MODIFIED.................................. 16sildenafil........................................................................ 12SILVADENE....................................................................28silver nitrate/potassium nitrate................................... 30silver sulfadiazine.........................................................28simvastatin.................................................................... 11SINEMET........................................................................ 23SINEMET CR................................................................. 23SINGULAIR chew tabs, tabs..........................................13SKELAXIN...................................................................... 23sodium chloride irrigation soln...................................16sodium citrate/citric acid............................................. 16sodium fluoride.............................................................27sodium fluoride chew tabs..........................................24sodium fluoride soln.................................................... 24SODIUM FLUORIDE tabs, 1 mg....................................24sodium polystyrene powder........................................30sodium thiosulfate/salicylic acid................................ 28SOLODYN 45 mg, 90 mg, 135 mg.................................. 2SOMA 350 mg................................................................23SONATA......................................................................... 18sotalol............................................................................ 12SPIRIVA HANDIHALER................................................. 13

spironolactone.............................................................. 11spironolactone/hydrochlorothiazide...........................11SPORANOX caps.............................................................2SPRYCEL......................................................................... 5SPS.................................................................................30STALEVO....................................................................... 23stannous fluoride conc, 0.63%....................................27STARLIX........................................................................... 7stavudine......................................................................... 3STRIBILD..........................................................................3STROMECTOL................................................................. 3SUBOXONE sublingual film........................................... 20SUBOXONE sublingual tabs.......................................... 20sucralfate tabs.............................................................. 14SULAR............................................................................ 10sulfacetamide sodium..................................................28sulfacetamide sodium..................................................30sulfacetamide sodium/prednisolone eye soln........... 25sulfacetamide sodium/sulfur....................................... 28sulfacetamide sodium/sulfur/sunscreen.................... 28SULFACETAMIDE SODIUM eye oint............................ 25sulfacetamide sodium eye soln.................................. 25sulfamethoxazole/trimethoprim.....................................4SULFAMYLON powder for topical soln.......................... 28sulfasalazine..................................................................15sulfasalazine delayed-release..................................... 15sulindac......................................................................... 21SUMADAN WASH..........................................................28sumatriptan inj..............................................................21SUMATRIPTAN nasal.................................................... 21sumatriptan tabs...........................................................21SUMAXIN........................................................................28SUMAXIN TS..................................................................28SUMAXIN WASH........................................................... 28SUPRAX susp, tabs......................................................... 1SUSTIVA...........................................................................3SUTENT............................................................................5SYLATRON.......................................................................5SYMAX DUOTAB........................................................... 14SYMBICORT...................................................................13SYMBYAX.......................................................................19SYNALAR crm, oint........................................................29SYNTHROID.....................................................................8

T

TABLOID...........................................................................5TACLONEX.....................................................................29tacrolimus......................................................................30TAMBOCOR................................................................... 12TAMIFLU...........................................................................3tamoxifen......................................................................... 5tamsulosin..................................................................... 16TANDEM PLUS.............................................................. 24TAPAZOLE....................................................................... 8TARCEVA......................................................................... 5TARGRETIN caps............................................................ 5

2013


TARGRETIN gel............................................................. 30TASIGNA.......................................................................... 5TAZORAC.......................................................................28TEGRETOL.....................................................................22TEGRETOL-XR.............................................................. 22temazepam 15 mg, 30 mg............................................18temazepam 7.5 mg, 22.5 mg........................................18TEMODAR caps............................................................... 5TEMOVATE.................................................................... 29TEMOVATE E................................................................ 29TENEX............................................................................ 12TENORETIC................................................................... 10TENORMIN.....................................................................10TERAZOL....................................................................... 16terazosin........................................................................ 12terbinafine........................................................................2terbutaline......................................................................13terconazole.................................................................... 16TESSALON.....................................................................13TESSALON PERLES..................................................... 13testosterone cypionate.................................................. 5testosterone enanthate.................................................. 5TESTRED......................................................................... 5TEST STRIPS - BAYER ASCENSIA AUTODISC,BREEZE 2, CONTOUR, CONTOUR NEXT..................30

TEST STRIPS – LIFESCAN ONETOUCH BASIC/PROFILE, FASTTAKE, SURESTEP, ULTRA BLUEVERIO, VERIO IQ........................................................ 30

TEST STRIPS – other than Bayer, Lifescan.................. 30tetracaine eye soln....................................................... 26TETRACYCLINE...............................................................2TEVETEN 600 mg............................................................9THALOMID..................................................................... 30theophylline ext-release...............................................13THERA-FLUR-N............................................................. 27thioridazine....................................................................18thiothixene.....................................................................18THYROGEN....................................................................30thyroid..............................................................................8tiagabine........................................................................ 22TIAZAC........................................................................... 10ticlopidine...................................................................... 24TIGAN............................................................................. 14TIKOSYN........................................................................ 12timolol maleate eye soln..............................................26TIMOPTIC.......................................................................26TIMOPTIC-XE.................................................................26TINDAMAX....................................................................... 4tinidazole......................................................................... 4TIROSINT......................................................................... 8tizanidine caps..............................................................23tizanidine tabs...............................................................23TOBI..................................................................................2TOBRADEX susp........................................................... 25tobramycin/dexamethasone eye susp........................25tobramycin eye soln.....................................................25

TOBREX soln................................................................. 25TOFRANIL...................................................................... 17tolazamide 250 mg......................................................... 7TOLAZAMIDE 500 mg..................................................... 7TOLBUTAMIDE................................................................ 7tolmetin caps................................................................ 21tolterodine..................................................................... 15TOPAMAX...................................................................... 22TOPAMAX SPRINKLES.................................................22TOPICORT crm, 0.05%..................................................29TOPICORT crm, 0.25%; gel; oint...................................29topiramate......................................................................22topiramate sprinkle...................................................... 22TOPROL XL................................................................... 10torsemide.......................................................................11TRACLEER.....................................................................12tramadol.........................................................................20tramadol/acetaminophen............................................. 20tramadol ext-release.....................................................20tramadol ext-release biphasic 200 mg, 300 mg......... 20TRANDATE.....................................................................10trandolapril...................................................................... 9trandolapril/verapamil ext-release.............................. 10tranexamic tab.............................................................. 24TRANSDERM-SCOP......................................................14TRANXENE T.................................................................16tranylcypromine............................................................ 17trazodone.......................................................................17TREAGAN OTIC.............................................................26TRENTAL........................................................................24tretinoin..........................................................................28tretinoin caps.................................................................. 5triamcinolone................................................................ 13TRIAMCINOLONE ACETONIDE oint, 0.5%...................29triamcinolone dental paste..........................................27triamcinolone topical crm; lotn; oint, 0.025%, 0.05%,0.1%.............................................................................. 29

triamterene/hydrochlorothiazide................................. 11TRIANEX........................................................................ 29triazolam........................................................................ 18TRICOR.......................................................................... 11trifluoperazine............................................................... 18trifluridine eye soln...................................................... 25trihexyphenidyl elixir....................................................23trihexyphenidyl tabs.....................................................23TRILEPTAL tabs.............................................................22trimethobenzamide....................................................... 15trimethoprim....................................................................4TRI-NORINYL................................................................... 7TRIZIVIR........................................................................... 3tropicamide eye soln....................................................26trospium.........................................................................15trospium ext-release.................................................... 15TRUSOPT.......................................................................26TRUVADA.........................................................................3TYKERB............................................................................5

2013


TYLENOL/CODEINE...................................................... 20TYZEKA............................................................................ 2

U

ULTRACET..................................................................... 20ULTRAM......................................................................... 20ULTRAM ER...................................................................20ULTRAVATE...................................................................29UNIRETIC......................................................................... 9UNIVASC.......................................................................... 9URAMAXIN crm, gel, lotn...............................................30urea crm, gel, lotn........................................................ 30urea in lactic acid.........................................................30URECHOLINE................................................................ 16UREX.............................................................................. 15UROCIT-K 5, 10.............................................................16UROXATRAL.................................................................. 16URSO..............................................................................15ursodiol..........................................................................15URSO FORTE................................................................ 15

V

valacyclovir..................................................................... 3VALCYTE..........................................................................2VALIUM...........................................................................16valproic acid..................................................................22valsartan/hydroclorothiazide......................................... 9VALTREX..........................................................................3VANCOCIN....................................................................... 4vancomycin..................................................................... 4VANDETANIB................................................................... 5VASERETIC......................................................................9VASOTEC.........................................................................9VECTICAL...................................................................... 30venlafaxine.................................................................... 17venlafaxine ext-release caps....................................... 17venlafaxine ext-release tabs, 37.5 mg, 75 mg, 150mg.................................................................................17

VENLAFAXINE ext-release tabs, 37.5 mg, 75 mg, 150mg, 225 mg.................................................................. 17

VERAPAMIL 40 mg........................................................10verapamil 80 mg, 120 mg............................................ 10verapamil ext-release................................................... 10VERELAN....................................................................... 10VERELAN PM................................................................ 10VERIPRED 20.................................................................. 5VFEND tabs......................................................................2VIAGRA.......................................................................... 12VIBRAMYCIN caps...........................................................2VICODIN......................................................................... 20VICODIN ES...................................................................20VICOPROFEN................................................................ 20VICTOZA.......................................................................... 7VICTRELIS....................................................................... 2VIDEX............................................................................... 3VIDEX EC.........................................................................3

VIGAMOX....................................................................... 25VIRACEPT........................................................................ 3VIRAMUNE....................................................................... 3VIRAMUNE XR.................................................................3VIRASAL.........................................................................28VIREAD.............................................................................3VIROPTIC....................................................................... 25VISTARIL........................................................................ 16VIVACTIL........................................................................ 17VIVELLE-DOT...................................................................6VOLTAREN eye soln......................................................26VOLTAREN-XR.............................................................. 21voriconazole.................................................................... 2VOSPIRE ER..................................................................13VOTRIENT........................................................................5VYVANSE....................................................................... 18

W

warfarin.......................................................................... 24WELLBUTRIN.................................................................17WELLBUTRIN SR.......................................................... 17WELLBUTRIN XL........................................................... 17WESTCORT................................................................... 29WESTHROID.................................................................... 8

X

XALATAN........................................................................26XALKORI.......................................................................... 5XANAX............................................................................16XANAX XR..................................................................... 16XARELTO....................................................................... 24XELJANZ........................................................................ 21XELODA........................................................................... 5XENADERM....................................................................30XERAC AC..................................................................... 30XIFAXAN 200 mg.............................................................4XIFAXAN 550 mg.............................................................4XODOL........................................................................... 20XOPENEX.......................................................................13XOPENEX CONCENTRATE.......................................... 13XTANDI.............................................................................5XYLOCAINE................................................................... 30XYLOCAINE JELLY....................................................... 30XYREM........................................................................... 19XYZAL.............................................................................12

Y

YASMIN............................................................................ 7YAZ................................................................................... 7YODOXIN......................................................................... 4

Z

zafirlukast...................................................................... 13zaleplon..........................................................................18ZANAFLEX..................................................................... 23ZANTAC syrup; tabs...................................................... 14

2013


ZARONTIN......................................................................22ZAROXOLYN..................................................................11ZEBETA.......................................................................... 10ZELBORAF....................................................................... 5ZENPEP..........................................................................15ZERIT caps.......................................................................3ZERIT soln........................................................................3ZESTORETIC................................................................... 9ZESTRIL........................................................................... 9ZETIA..............................................................................11ZIAC................................................................................10ZIAGEN.............................................................................3zidovudine....................................................................... 3zinc sulfate caps...........................................................24ziprasidone.................................................................... 18ZITHROMAX.....................................................................1ZOCOR........................................................................... 11ZOFRAN......................................................................... 15ZOLINZA...........................................................................5ZOLOFT..........................................................................17zolpidem........................................................................ 18zolpidem ext-release.................................................... 18ZONATUSS.................................................................... 13ZONEGRAN....................................................................22zonisamide.................................................................... 22ZOVIRAX.......................................................................... 3Z-PRAM.......................................................................... 27ZYBAN............................................................................ 19ZYLOPRIM......................................................................21ZYPREXA....................................................................... 18ZYPREXA ZYDIS........................................................... 18ZYTIGA............................................................................. 5ZYVOX tabs......................................................................4

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Blue Cross and Blue Shield of North Carolina Basic Formulary April