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EFFECTIVE July 1, 2017 MEMBER PRESCRIPTION DRUG LIST 2017 For group HMO and PPO members with an insurance plan that includes a prescription drug benefit

EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

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Page 1: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

EFFECTIVE July 1, 2017

MEMBER PRESCRIPTION DRUG LIST

2017

For group HMO and PPO members with an insurance plan that

includes a prescription drug benefit

Page 2: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

Blue Cross and Blue Shield of Kansas City 2017 Prescription Drug List

Introduction

Medications are evaluated on the basis of safety, effectiveness, adverse events, proven advantages over existing agents and cost. Tier 1 medications are typically generic drugs that contain the same active ingredients as brand name drugs and have the lowest copay. New drugs will require an exception or prior authorization until they are reviewed by the committee. While extensive, this is not an exhaustive list of all available medications and this list is subject to change. The most current PDL is available on our website at www.BlueKC.com. If you require additional information or clarification, contact our Clinical Pharmacy unit at 816-395-2176 or 800-228-1436. Please be aware that as new products are released and post-marketing information on existing therapies becomes available, changes in the PDL status may occur. The committee may also implement prior authorization or other utilization management processes as deemed necessary. Doctors and pharmacists will be notified of any such changes via direct mailings.

How to use this list:

1) Find the page number for your drug by searching the alphabetical index at the end 2) Locate your drug and identify the Drug Tier. You will also want to note restrictions and

preferred alternatives if applicable. 3) Refer to the Drug Tier description tables at the end of this introduction to identify the tier

copay for your drug (based on the benefit schedule described in your member certificate or in your Blue KC benefit summary).

Prior Authorization/Drug Utilization Management

Some drugs have coverage rules or have limits on the amount dispensed. In some cases, the prescriber must do something in order to obtain the drug. For example:

Prior approval (or prior authorization): For some drugs, the prescriber must get approval from BlueKC before the prescription can be filled. Without that approval, the drug may not be covered.

Quantity limits: For some drugs, there are limits to the amount of drug that may be obtained. Step Therapy: For some drugs, BlueKC requires step therapy. This means that drugs will have to be tried

in a certain order for a medical condition. If the doctor feels that the first drugs are not appropriate, the prescriber will have to submit a prior authorization request.

Prescribers may request exceptions to these coverage rules or limits by submitting an electronic prior authorization request form. www.BlueKC.com > Providers > Forms > Prior Authorizations for Medications.

HOW TO REACH US

The Prescription Drug List (PDL) has been developed and is maintained by the Medical and Pharmacy Management Committee of Blue Cross and Blue Shield of Kansas City (Blue KC). The committee is composed of practicing doctors and pharmacists within the Kansas City area. Quarterly meetings are held to evaluate new drug therapies and review drug utilization issues.

Blue Cross and Blue Shield of Kansas City Pharmacy Services P.O. Box 419169

Kansas City, MO 64141-2735 816-395-2176 or 800-228-1436

www.BlueKC.com

Page 3: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

FREQUENTLY ASKED QUESTIONS

What is the difference between brand name drugs and generic drugs? When a drug company develops a new medication they apply for a patent. This patent protects the drug from being copied by other drug companies for a certain period of time. These drugs are brand name drugs. Once the patent period expires, other manufacturers can produce the same drug as long as they follow strict guidelines established by the Food and Drug Administration's (FDA) guidelines. These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose patents have expired. They are made with the same active ingredients of the brand name drug, but they may have a different color, shape or filler material. The cost of a generic drug is typically less than a brand name drug. All generic medications are approved by the FDA before they are released on the market.

What is the difference between a generic equivalent and a generic alternative? A generic equivalent is a medication that contains the same active ingredient and works the same way as the original brand name drug. A generic alternative is a generic medication that may not have the same active ingredient, but works in the same way as another drug.

What is a maintenance drug? A maintenance drug is a medication used to treat a chronic condition like diabetes or high blood pressure. The FDA must approve maintenance drugs as safe for long-term use. Blue KC uses a national drug information database called First DataBank to determine which medications are included on the maintenance drug list. If your prescription is a maintenance drug, you can have it filled for several months instead of just one prescription at a time.

Does Blue KC cover all prescription drugs? Blue KC covers most prescription drugs. However, some drug classes require an additional benefit be added to your health insurance plan in order to be covered. This additional benefit is referred to as a ‘rider.’ Examples of such drug classes are fertility, birth control, impotency, and weight loss.

How is the tier level status determined for medications? The PDL is a list of prescription medications that have been reviewed and recommended by the Blue KC Medical and Pharmacy Management Committee. The list has a combination of brand name and generic medications. Each of these medications has been reviewed for its safety, effectiveness, clinical outcomes, and cost. Doctors and pharmacists on the committee look at drug utilization issues, the number of adverse events, and any proven advantages over other drugs on the PDL. The most efficient and cost-effective drugs are on Tier 1 of the PDL.

Why does Blue KC require prior authorization for some drugs before they are covered? Blue KC may require prior authorization for some drugs or a class. Medications on the prior authorization list may have safety concerns or have FDA approval, only for a certain use. Some of the prior authorization medications may also have a lower-cost alternative that should be considered first or the drug may not be as effective as something else in the same drug class. Some medications are also on the prior authorization list because they have the potential to be misused. Your doctor and Blue KC will work together to get prior authorization and approval for your prescription when needed.

Do I need to show my member ID card at the pharmacy? Yes, show your member ID card to your pharmacist whenever you have a prescription filled. Your prescription claim is electronically transmitted to Blue KC when you fill your prescription. Please make sure the pharmacy has your most current health insurance information and correct birth date so there won’t be any delays or claim denials when we process your claim.

What do I do if I need to refill my prescription early (i.e., leaving on vacation, the doctor increased my dosage)? To have a prescription refilled early, have your pharmacist call the Pharmacy Customer Service unit at 816-395- 2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.

What if I am out of town and need to have a prescription filled? Blue KC contracts with most major pharmacy chains and has a network of over 44,000 pharmacies nationwide. If the pharmacy you are using has difficulty in processing your prescription claim, have them contact the Pharmacy Customer Service unit for assistance at 816-395-2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.

Page 4: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

Why must some drugs be purchased through a Specialty Pharmacy?

Specialty drugs are those that require special ordering, handling, clinical monitoring and/or customer service. These drugs are best purchased through a Specialty Pharmacy. Blue KC has a network of Specialty Pharmacies available to provide specialized care for patients with complex chronic health conditions to obtain their medications and manage their health conditions. Specialty medications are limited to a 34 day supply.

What if I have questions about my prescription drug coverage? For more information on your prescription drug coverage, call the Pharmacy Customer Service unit at 816-395-2176 or 800-228-1436, Monday through Friday from 8 a.m. to 5 p.m. Central Time.

Miscellaneous Information

Specialty Pharmacy

A Specialty Pharmacy is one that provides specialized care for patients with complex chronic health conditions such as Rheumatoid Arthritis, Multiple Sclerosis or Psoriasis. Specialty drugs may be oral or injectable medications that can either be self-administered or administered by a health care professional. These pharmacies do everything from dispense the specialty medication to help patients manage their health condition. Most specialty medications are covered under the pharmacy benefit. Specialty medications are limited to a 34 day supply. The following is a list of other services provided by the Specialty Pharmacies:

Assigns a Patient Care Coordinator who serves as a personal advocate and point of contact Offers access to a dedicated clinical staff of nurses and pharmacists who are knowledgeable about the

medications and conditions Provides the necessary supplies to administer the medications — at no additional cost Offers care management programs to help patients get the most from their medications Provides patients with refill reminder calls Allows the medications to be delivered to either the physician’s office or patients home Works directly with patients to arrange a convenient shipment date Ships all medications overnight Coordinates with Blue KC to take care of billing issues

These services are provided to you at no additional cost. Prescriptions for a specialty medication will need to be filled at the Specialty Pharmacy listed below.

Accredo Health Services Phone: 877-259-2295

Fax: 888-773-7386

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DRUG TIER DESCRIPTIONS

To find out what prescription drug tier is on your plan, please see the benefit schedule in your member certificate or in your Blue KC benefit summary.

2‐Tier Benefit Drug TierGG-SPBPB-SNPBNPB-S

3‐Tier Benefit Drug TierGG-SPBPB-SNPBNPB-S

3‐Tier Retail/Specialty Benefit Drug TierTier 1 copay GTier 2 copay PBTier 3 copay NPBGeneric Specialty copay G-SPreferred Brand Specialty copay PB-S

Non-Preferred Brand Specialty copay NPB-S

GG-S

Tier 2 copay PBPB-SNPB

Tier 4 copay NPB-S

Tier 2 copay

Tier 3 copay

4‐Tier Benefit Drug Tier

Tier 3 copay

Tier 1 copay

Tier 1 copay

Tier 2 copay

Not Covered

Tier 1 copay

Page 6: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

ANTI - INFECTIVES .............................................................................................................................................. 3

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ........................................................................... 14

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ............................................................................. 18

CARDIOVASCULAR, HYPERTENSION & LIPIDS ....................................................................................... 43

DERMATOLOGICALS/TOPICAL THERAPY ................................................................................................ 56

DIAGNOSTICS & MISCELLANEOUS AGENTS ............................................................................................ 71

EAR, NOSE & THROAT MEDICATIONS ........................................................................................................ 74

ENDOCRINE/DIABETES .................................................................................................................................... 76

GASTROENTEROLOGY .................................................................................................................................. 115

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ................................................................................. 124

MUSCULOSKELETAL & RHEUMATOLOGY ............................................................................................. 126

OBSTETRICS & GYNECOLOGY .................................................................................................................... 128

OPHTHALMOLOGY ......................................................................................................................................... 138

RESPIRATORY, ALLERGY, COUGH & COLD ........................................................................................... 144

UROLOGICALS .................................................................................................................................................. 153

VITAMINS, HEMATINICS & ELECTROLYTES ......................................................................................... 156

Table of Contents

Page 7: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

List of Abbreviations G: Generic Drug. G-S: Generic Specialty Drug. NPB: Non-preferred Brand Drug. NPB-S: Non-preferred Brand Specialty Drug. PB: Preferred Brand Drug. PB-S: Preferred Brand Specialty Drug. 2ST: Drug requires trial of at least 2 preferred alternatives. ACA: Affordable Care Act. These preventative drugs may be covered at no cost (check your benefits to confirm). Tobacco use includes two tobacco cessation attempts per year (both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by an in-network health care provider without prior authorization. M: Maintenance Drug. OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, your plan may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

Page 8: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.

3

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

ANCOBON NPB flucytosine

clotrimazole mucous membrane G

CRESEMBA ORAL PB

DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION

NPB fluconazole

DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG

NPB fluconazole

DIFLUCAN ORAL TABLET 150 MG NPB QL fluconazole

fluconazole oral suspension for reconstitution

G

fluconazole oral tablet 100 mg, 200 mg, 50 mg

G

fluconazole oral tablet 150 mg G QL

flucytosine G

griseofulvin microsize G

griseofulvin ultramicrosize G

GRIS-PEG (ULTRAMICROSIZE) NPB griseofulvin ultramicrosize

itraconazole G QL

ketoconazole oral G

LAMISIL ORAL TABLET NPB terbinafine

NOXAFIL ORAL PB

nystatin oral powder 150 million unit, 500 million unit

G

nystatin oral suspension G

nystatin oral tablet G

ONMEL NPB QL itraconazole

ORAVIG NPB nystatin, clotrimazole

SPORANOX ORAL SOLUTION PB

SPORANOX PULSEPAK NPB QL itraconazole

terbinafine hcl oral G

VFEND NPB voriconazole

voriconazole oral G

ANTIVIRALS

abacavir G-S QL

Page 9: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.

4

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

abacavir-lamivudine G-S QL

abacavir-lamivudine-zidovudine G-S QL

acyclovir oral capsule G

acyclovir oral suspension 200 mg/5 ml G

acyclovir oral tablet G

adefovir G

amantadine hcl G M

APTIVUS PB-S QL

ATRIPLA PB-S QL

BARACLUDE ORAL SOLUTION PB

BARACLUDE ORAL TABLET NPB entecavir

COMBIVIR NPB-S QL lamivudine-zidovudine

COMPLERA PB-S QL

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

PB-S QL

DAKLINZA NPB-S PA; 2ST HARVONI, VIEKIRA PAK, VIEKIRA XR

DESCOVY PB-S

didanosine G-S QL

EDURANT PB-S QL

EMTRIVA PB-S QL

entecavir G

EPCLUSA PB-S PA; 2ST HARVONI, VIEKIRA PAK, VIEKIRA XR

EPIVIR NPB-S QL lamivudine

EPIVIR HBV ORAL SOLUTION PB

EPIVIR HBV ORAL TABLET NPB QL lamivudine

EPZICOM NPB-S QL abacavir-lamivudine

EVOTAZ NPB-S QL REYATAZ, NORVIR

famciclovir G QL

FLUMADINE ORAL TABLET NPB rimantadine hcl

FUZEON SUBCUTANEOUS RECON SOLN

PB-S QL

GENVOYA PB-S

HARVONI PB-S PA; QL

HEPSERA NPB adefovir dipivoxil

Page 10: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.

5

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

INTELENCE PB-S QL

INVIRASE PB-S QL

ISENTRESS PB-S QL

ISENTRESS HD NPB-S

KALETRA ORAL SOLUTION PB-S QL LOPINAVIR-RITONAVIR

KALETRA ORAL TABLET PB-S QL

lamivudine oral solution G-S QL

lamivudine oral tablet 100 mg G QL

lamivudine oral tablet 150 mg, 300 mg G-S QL

lamivudine-zidovudine G-S QL

LEXIVA PB-S QL

lopinavir-ritonavir G-S QL

nevirapine G-S QL

NORVIR PB-S QL

ODEFSEY PB-S

OLYSIO NPB-S PA; 2ST HARVONI, VIEKIRA PAK, VIEKIRA XR

oseltamivir G QL

PREZCOBIX NPB-S PREZISTA, NORVIR

PREZISTA ORAL SUSPENSION PB-S QL

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

PB-S QL

RELENZA DISKHALER PB QL

RESCRIPTOR PB-S QL

RETROVIR ORAL CAPSULE NPB-S QL zidovudine

RETROVIR ORAL SYRUP NPB-S QL zidovudine

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

PB-S

REYATAZ ORAL POWDER IN PACKET

PB-S

ribavirin inhalation G-S

rimantadine G

SELZENTRY ORAL SOLUTION NPB-S

SELZENTRY ORAL TABLET 150 MG, 300 MG

PB-S QL

Page 11: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.

6

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

SELZENTRY ORAL TABLET 25 MG, 75 MG

PB-S

SITAVIG NPB 2ST acyclovir, acyclovir, famciclovir, valacyclovir, ZOVIRAX

SOVALDI NPB-S PA; QL; 2ST HARVONI, VIEKIRA PAK, VIEKIRA XR

stavudine G-S QL

STRIBILD PB-S QL

SUSTIVA PB-S QL

TAMIFLU ORAL CAPSULE NPB QL oseltamivir phosphate

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

PB QL

TECHNIVIE PB-S PA

TIVICAY ORAL TABLET 10 MG, 25 MG

PB-S

TIVICAY ORAL TABLET 50 MG PB-S QL

TRIUMEQ PB-S QL

TRIZIVIR NPB-S QL abacavir-lamivudine-zidovudine

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG

PB-S

TRUVADA ORAL TABLET 200-300 MG

PB-S QL

TYBOST NPB-S QL NORVIR

valacyclovir G QL

VALCYTE NPB valganciclovir hcl

valganciclovir G

VALTREX NPB QL valacyclovir

VEMLIDY PB

VIDEX 2 GRAM PEDIATRIC PB-S QL

VIDEX EC NPB-S QL didanosine

VIEKIRA PAK PB-S PA; QL

VIEKIRA XR PB-S PA

VIRACEPT ORAL TABLET PB-S QL

VIRAMUNE NPB-S QL nevirapine

VIRAMUNE XR NPB-S QL nevirapine er

Page 12: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.

7

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

VIRAZOLE NPB-S RIBAVIRIN

VIREAD PB-S QL

ZEPATIER NPB-S PA; 2ST HARVONI, VIEKIRA PAK, VIEKIRA XR

ZERIT NPB-S QL stavudine

ZIAGEN ORAL SOLUTION PB-S QL

ZIAGEN ORAL TABLET NPB-S QL abacavir

zidovudine G-S QL

ZOVIRAX ORAL NPB acyclovir

CEPHALOSPORINS

CEDAX NPB ceftibuten

cefaclor oral capsule G

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

G

cefaclor oral tablet extended release 12 hr

G

cefadroxil oral capsule G

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

G

cefadroxil oral tablet G

cefdinir G

cefditoren pivoxil G

cefixime G

cefpodoxime G

cefprozil G

ceftibuten G

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

NPB amoxicillin-clavulanate potass, cefdinir, cefpodoxime proxetil

cefuroxime axetil oral tablet G

cephalexin G

DAXBIA NPB cephalexin

KEFLEX ORAL CAPSULE NPB cephalexin

SPECTRACEF ORAL TABLET 400 MG

NPB cefditoren pivoxil

Page 13: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.

8

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

SUPRAX ORAL CAPSULE NPB cefpodoxime proxetil, cefuroxime axetil, cefdinir

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION

NPB cefpodoxime proxetil, cefuroxime axetil, cefdinir

SUPRAX ORAL TABLET,CHEWABLE

NPB cefpodoxime proxetil, cefuroxime axetil, cefdinir

ERYTHROMYCINS & OTHER MACROLIDES

azithromycin oral G

BIAXIN ORAL TABLET 500 MG NPB clarithromycin

clarithromycin G

DIFICID NPB metronidazole, vancomycin hcl

e.e.s. 400 oral tablet G

E.E.S. GRANULES NPB azithromycin

ERYPED 200 NPB azithromycin

ERYPED 400 NPB azithromycin

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

G

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

NPB erythromycin

erythrocin (as stearate) oral tablet 250 mg

G

erythromycin ethylsuccinate oral suspension for reconstitution

G

erythromycin ethylsuccinate oral tablet G

erythromycin oral capsule,delayed release(dr/ec)

G

erythromycin oral tablet G

PCE NPB clarithromycin, erythromycin

ZITHROMAX ORAL NPB azithromycin

ZITHROMAX TRI-PAK NPB azithromycin

ZITHROMAX Z-PAK NPB azithromycin

ZMAX NPB azithromycin

MISCELLANEOUS ANTIINFECTIVES

ALBENZA PB

Page 14: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.

9

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ALINIA PB

atovaquone G

atovaquone-proguanil G QL

BILTRICIDE PB

CAYSTON PB-S QL

chloroquine phosphate G

CLEOCIN HCL NPB clindamycin hcl

CLEOCIN PEDIATRIC NPB clindamycin palmitate hcl

clindamycin hcl G

clindamycin palmitate hcl G

clindamycin pediatric G

COARTEM PB

colistin (colistimethate na) G

COLY-MYCIN M PARENTERAL NPB colistimethate sodium

CYCLOSERINE NPB

dapsone G M

DARAPRIM PB-S PA; QL

EMVERM PB

ethambutol G

FLAGYL NPB metronidazole

FLAGYL ER NPB metronidazole

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml

G

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML

PB

GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 120 MG/100 ML

NPB

gentamicin sulfate (ped) (pf) G

gentamicin sulfate (pf) intravenous solution 100 mg/10 ml

G

GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML

NPB

Page 15: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.

10

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

hydroxychloroquine G M

IMPAVIDO PB-S

isoniazid oral G

ivermectin G

KETEK NPB azithromycin, clarithromycin, erythromycin

KITABIS PAK PB-S

linezolid oral G

MALARONE NPB QL atovaquone-proguanil hcl

MALARONE PEDIATRIC NPB QL atovaquone-proguanil hcl

mefloquine G QL

MEPRON NPB atovaquone

metronidazole oral G

MYAMBUTOL ORAL TABLET 400 MG

NPB ethambutol hcl

MYCOBUTIN NPB rifabutin

NEBUPENT PB QL

neomycin G

paromomycin G

PASER NPB

PLAQUENIL NPB M hydroxychloroquine sulfate

PRIFTIN PB

PRIMAQUINE PB QL; M

pyrazinamide G

QUALAQUIN NPB quinine sulfate

quinine sulfate G

rifabutin G

RIFADIN ORAL NPB rifampin

RIFAMATE NPB isoniazid, rifampin

rifampin oral G

RIFATER NPB

SIRTURO PB

SIVEXTRO ORAL NPB linezolid

STROMECTOL NPB ivermectin

TINDAMAX ORAL TABLET 500 MG NPB tinidazole

Page 16: EFFECTIVE July 1, 2017 - Live Healthy With Blue KC · 2019-06-18 · These same drugs are generic drugs. Generic drugs are less expensive versions of those brand name drugs whose

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not affiliated companies.

11

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

tinidazole G

TOBI NPB QL tobramycin sulfate

TOBI PODHALER PB QL

tobramycin in 0.225 % nacl G QL

TOBRAMYCIN WITH NEBULIZER NPB-S tobramycin sulfate, BETHKIS, TOBI PODHALER

TRECATOR NPB

XIFAXAN PB

ZYVOX ORAL NPB linezolid

PENICILLINS

amoxicillin oral capsule G

amoxicillin oral suspension for reconstitution

G

amoxicillin oral tablet G

amoxicillin oral tablet,chewable 125 mg, 250 mg

G

amoxicillin-pot clavulanate G

ampicillin oral capsule G

ampicillin oral suspension for reconstitution 250 mg/5 ml

G

AUGMENTIN ES-600 NPB amoxicillin-clavulanate potass

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML

PB

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 250-62.5 MG/5 ML

NPB amoxicillin-clavulanate potass

AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG

NPB amoxicillin-clavulanate potass

AUGMENTIN XR NPB amoxicillin-clavulanate pot er

dicloxacillin G

MOXATAG NPB amoxicillin

penicillin v potassium G

QUINOLONES

AVELOX NPB moxifloxacin hcl

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12

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON

NPB ciprofloxacin

CIPRO ORAL TABLET 250 MG, 500 MG

NPB ciprofloxacin hcl

CIPRO XR NPB ciprofloxacin er

ciprofloxacin G

ciprofloxacin (mixture) G

ciprofloxacin hcl oral G

FACTIVE NPB QL ciprofloxacin hcl, levofloxacin hemihydrate, moxifloxacin hcl, ofloxacin

LEVAQUIN ORAL TABLET NPB levofloxacin hemihydrate

levofloxacin oral G

moxifloxacin oral G

ofloxacin oral tablet 300 mg, 400 mg G

SULFA'S & RELATED AGENTS

BACTRIM NPB sulfamethoxazole/trimethoprim

BACTRIM DS NPB sulfamethoxazole/trimethoprim

sulfadiazine G

sulfamethoxazole-trimethoprim oral G

sulfatrim G

TETRACYCLINES

ACTICLATE NPB ST doxycycline hyclate, doxycycline monohydrate

avidoxy G

demeclocycline G

DORYX MPC NPB ST doxycycline hyclate

DORYX ORAL TABLET,DELAYED RELEASE (DR/EC) 200 MG, 50 MG

NPB ST doxycycline hyclate

doxycycline hyclate oral capsule G

doxycycline hyclate oral tablet G

doxycycline hyclate oral tablet,delayed release (dr/ec)

G

doxycycline monohydrate oral capsule G

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13

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE

NPB 2ST doxycycline hyclate, doxycycline monohydrate, ORACEA

doxycycline monohydrate oral suspension for reconstitution

G

doxycycline monohydrate oral tablet G

MINOCIN ORAL NPB minocycline hcl

minocycline oral capsule G

minocycline oral tablet G

minocycline oral tablet extended release 24 hr

G ST; QL

mondoxyne nl G

MONODOX NPB ST doxycycline monohydrate

morgidox oral capsule 100 mg G

ORACEA PB ST

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG

PB ST; QL

TARGADOX NPB ST doxycycline hyclate

tetracycline G

VIBRAMYCIN ORAL CAPSULE 100 MG

NPB ST doxycycline hyclate

VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION

NPB ST doxycycline monohydrate

VIBRAMYCIN ORAL SYRUP NPB ST doxycycline hyclate

URINARY TRACT AGENTS

FURADANTIN NPB nitrofurantoin

HIPREX NPB methenamine hippurate

MACROBID NPB nitrofurantoin macrocrystal

MACRODANTIN NPB nitrofurantoin

methenamine hippurate G

methenamine mandelate G

MONUROL NPB ciprofloxacin hcl, nitrofurantoin

nitrofurantoin G

nitrofurantoin macrocrystal G

nitrofurantoin monohyd/m-cryst G

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14

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

PRIMSOL NPB trimethoprim

trimethoprim G

VANCOMYCIN

VANCOCIN NPB vancomycin hcl

vancomycin oral capsule G

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

leucovorin calcium injection recon soln G-S

leucovorin calcium oral G

MESNEX ORAL PB

VISTOGARD PB

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS

AFINITOR PB-S QL

AFINITOR DISPERZ PB-S QL

ALECENSA NPB-S ZYKADIA

ALKERAN ORAL PB-S

anastrozole G

ARIMIDEX NPB-S anastrozole

AROMASIN NPB-S exemestane

ASTAGRAF XL NPB ST tacrolimus

AZASAN PB

azathioprine G

bexarotene G-S

bicalutamide G

BOSULIF PB-S

CABOMETYX NPB-S QL INLYTA, NEXAVAR, SUTENT, VOTRIENT

capecitabine G-S

CAPRELSA PB-S QL

CASODEX NPB-S bicalutamide

CELLCEPT NPB mycophenolate mofetil

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15

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

COMETRIQ NPB-S QL CAPRELSA

COTELLIC PB-S

CYCLOPHOSPHAMIDE ORAL CAPSULE

PB-S

cyclosporine intravenous G-S

cyclosporine modified G

cyclosporine oral capsule G

DROXIA PB-S

ELIGARD PB-S

ELIGARD (3 MONTH) PB-S QL

ELIGARD (4 MONTH) PB-S

ELIGARD (6 MONTH) PB-S

EMCYT PB-S

ENVARSUS XR NPB ST tacrolimus

ERIVEDGE PB-S

etoposide oral G-S

exemestane G-S

FARESTON PB-S

FARYDAK NPB-S

DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, THALOMID, VELCADE

FEMARA NPB-S letrozole

FIRMAGON KIT W DILUENT SYRINGE

PB-S

flutamide G

gengraf G

GILOTRIF PB-S

GLEEVEC NPB-S QL imatinib mesylate

GLEOSTINE PB-S

HEXALEN PB-S

HYCAMTIN ORAL PB-S

HYDREA NPB-S hydroxyurea

hydroxyurea G-S

IBRANCE PB-S

ICLUSIG PB-S

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16

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

imatinib G-S QL

IMBRUVICA PB-S

IMURAN NPB azathioprine

INLYTA PB-S QL

IRESSA PB-S

JAKAFI PB-S QL

LENVIMA PB-S

letrozole G-S

LEUKERAN PB-S

leuprolide subcutaneous kit G-S

LONSURF PB-S

LUPRON DEPOT PB-S

LUPRON DEPOT (3 MONTH) PB-S QL

LUPRON DEPOT (4 MONTH) PB-S

LUPRON DEPOT (6 MONTH) PB-S

LUPRON DEPOT-PED PB-S

LUPRON DEPOT-PED (3 MONTH) PB

LYNPARZA PB-S

LYSODREN PB-S

MATULANE PB-S

MEGACE ES NPB-S megestrol acetate

megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml

G

megestrol oral tablet G-S

MEKINIST PB-S

mercaptopurine G

methotrexate sodium G

methotrexate sodium (pf) G

mycophenolate mofetil G

mycophenolate sodium G

MYFORTIC NPB mycophenolic acid

MYLERAN PB-S

NEORAL NPB cyclosporine

NEXAVAR PB-S QL

NILANDRON NPB-S nilutamide

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17

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

nilutamide G-S

NINLARO PB-S

octreotide acetate G-S

ODOMZO NPB-S ERIVEDGE

PROGRAF ORAL NPB TACROLIMUS

PURIXAN PB-S

RAPAMUNE ORAL SOLUTION PB

RAPAMUNE ORAL TABLET NPB sirolimus

RUBRACA PB PA

SANDIMMUNE INTRAVENOUS NPB-S cyclosporine

SANDIMMUNE ORAL CAPSULE NPB cyclosporine

SANDIMMUNE ORAL SOLUTION PB

SANDOSTATIN NPB-S octreotide acetate

sirolimus G

SOLTAMOX NPB-S tamoxifen citrate

SOMATULINE DEPOT PB-S

SPRYCEL PB-S QL

STIVARGA PB-S

SUTENT PB-S QL

TABLOID PB-S

tacrolimus oral G

TAFINLAR PB-S

TAGRISSO PB-S

tamoxifen G

TARCEVA PB-S QL

TARGRETIN ORAL NPB-S bexarotene

TARGRETIN TOPICAL PB

TASIGNA PB-S QL

TEMODAR ORAL NPB-S temozolomide

temozolomide G-S

THALOMID PB-S

tretinoin (chemotherapy) G-S

TREXALL PB-S

TYKERB PB-S QL

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18

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

VENCLEXTA ORAL TABLET 100 MG

PB-S

VENCLEXTA STARTING PACK PB-S

VOTRIENT PB-S QL

XALKORI PB-S QL

XATMEP NPB

XELODA NPB-S capecitabine

XTANDI NPB-S QL ZYTIGA

ZELBORAF PB-S QL

ZOLINZA PB-S QL

ZORTRESS PB

ZYDELIG PB-S

ZYKADIA PB-S

ZYTIGA PB-S QL

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH

ANTICONVULSANTS

APTIOM NPB carbamazepine, oxcarbazepine, topiramate, LYRICA, POTIGA, VIMPAT

BANZEL PB

BRIVIACT ORAL NPB levetiracetam

carbamazepine oral capsule, er multiphase 12 hr

G

carbamazepine oral suspension 100 mg/5 ml

G

carbamazepine oral tablet G

carbamazepine oral tablet extended release 12 hr

G

carbamazepine oral tablet,chewable G

CARBATROL NPB carbamazepine er

CELONTIN ORAL CAPSULE 300 MG PB

clonazepam G

DEPAKENE NPB valproic acid

DEPAKOTE NPB divalproex sodium

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19

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

DEPAKOTE ER NPB divalproex sodium er

DEPAKOTE SPRINKLES NPB divalproex sodium

DIASTAT NPB diazepam

DIASTAT ACUDIAL NPB diazepam

DILANTIN PB

DILANTIN EXTENDED NPB phenytoin sodium

DILANTIN INFATABS NPB phenytoin

DILANTIN-125 NPB phenytoin

divalproex G

epitol G

EQUETRO NPB carbamazepine, carbamazepine er

ethosuximide G

felbamate G

FELBATOL NPB felbamate

FYCOMPA ORAL SUSPENSION PB

FYCOMPA ORAL TABLET PB

gabapentin oral capsule G

gabapentin oral solution 250 mg/5 ml G

gabapentin oral tablet 600 mg, 800 mg G

GABITRIL ORAL TABLET 12 MG, 16 MG

PB

GABITRIL ORAL TABLET 2 MG, 4 MG

NPB tiagabine hcl

GRALISE PB ST; QL

GRALISE 30-DAY STARTER PACK PB ST; QL

KEPPRA ORAL NPB levetiracetam

KEPPRA XR NPB levetiracetam

KLONOPIN NPB clonazepam

LAMICTAL ODT NPB lamotrigine odt

LAMICTAL ODT STARTER (BLUE) NPB lamotrigine odt

LAMICTAL ODT STARTER (GREEN) NPB lamotrigine odt

LAMICTAL ODT STARTER (ORANGE)

NPB lamotrigine odt

LAMICTAL ORAL TABLET NPB lamotrigine

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20

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG

NPB lamotrigine

LAMICTAL STARTER (BLUE) KIT NPB lamotrigine

LAMICTAL STARTER (GREEN) KIT NPB lamotrigine

LAMICTAL STARTER (ORANGE) KIT

NPB lamotrigine

LAMICTAL XR NPB lamotrigine

LAMICTAL XR STARTER (BLUE) PB

LAMICTAL XR STARTER (GREEN) PB

LAMICTAL XR STARTER (ORANGE)

PB

lamotrigine oral tablet G

lamotrigine oral tablet disintegrating, dose pk

G

lamotrigine oral tablet extended release 24hr

G

lamotrigine oral tablet, chewable dispersible

G

lamotrigine oral tablet,disintegrating G

levetiracetam oral G

LYRICA PB ST

MYSOLINE NPB primidone

NEURONTIN NPB ST gabapentin

ONFI ORAL SUSPENSION PB

ONFI ORAL TABLET 10 MG, 20 MG PB

oxcarbazepine G

OXTELLAR XR NPB oxcarbazepine

PEGANONE PB

phenobarbital G

PHENYTEK NPB phenytoin sodium

phenytoin oral suspension 125 mg/5 ml G

phenytoin oral tablet,chewable G

phenytoin sodium extended G

primidone G

QUDEXY XR PB

roweepra G

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21

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

SABRIL PB-S PA

TEGRETOL ORAL SUSPENSION NPB carbamazepine

TEGRETOL ORAL TABLET NPB carbamazepine

TEGRETOL XR NPB carbamazepine er

tiagabine G

TOPAMAX NPB topiramate

topiramate oral capsule, sprinkle G

TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR

NPB topiramate

topiramate oral tablet G

TRILEPTAL NPB oxcarbazepine

TROKENDI XR NPB topiramate

valproic acid G

valproic acid (as sodium salt) oral solution 250 mg/5 ml

G

VIMPAT ORAL SOLUTION PB

VIMPAT ORAL TABLET PB

ZARONTIN NPB ethosuximide

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

NPB zonisamide

zonisamide G

ANTIPARKINSONISM AGENTS

APOKYN PB-S

AZILECT NPB M RASAGILINE MESYLATE

benztropine oral G

bromocriptine G

carbidopa G M

carbidopa-levodopa G M

carbidopa-levodopa-entacapone G M

COMTAN NPB M entacapone

ELDEPRYL NPB M selegiline hcl

entacapone G M

LODOSYN NPB M carbidopa

MIRAPEX NPB M pramipexole di-hcl

MIRAPEX ER NPB M pramipexole er

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22

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

NEUPRO NPB M pramipexole di-hcl, pramipexole er, ropinirole hcl

PARLODEL NPB bromocriptine mesylate

pramipexole G M

rasagiline G M

REQUIP NPB M ropinirole hcl

REQUIP XL NPB M ropinirole hcl

ropinirole G M

RYTARY NPB M carbidopa/levodopa, carbidopa-levodopa er

selegiline hcl G M

SINEMET NPB M carbidopa/levodopa

SINEMET CR NPB M carbidopa-levodopa er

STALEVO 100 NPB M carbidopa-levodopa-entacapone

STALEVO 125 NPB M carbidopa-levodopa-entacapone

STALEVO 150 NPB M carbidopa-levodopa-entacapone

STALEVO 200 NPB M carbidopa-levodopa-entacapone

STALEVO 50 NPB M carbidopa-levodopa-entacapone

STALEVO 75 NPB M carbidopa-levodopa-entacapone

TASMAR ORAL TABLET 100 MG NPB M tolcapone

tolcapone G M

trihexyphenidyl G

XADAGO NPB PA; M

ZELAPAR NPB M RASAGILINE MESYLATE, selegiline hcl

MIGRAINE & CLUSTER HEADACHE THERAPY

almotriptan malate G QL

ALSUMA NPB ST; QL sumatriptan succinate

AMERGE NPB ST; QL naratriptan hcl

AXERT NPB ST; QL almotriptan malate

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23

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

CAFERGOT NPB ergotamine-caffeine

D.H.E.45 NPB dihydroergotamine mesylate

dihydroergotamine injection G

dihydroergotamine nasal G QL

ERGOMAR NPB

ergotamine-caffeine G

frovatriptan G QL

IMITREX NASAL NPB ST sumatriptan succinate

IMITREX ORAL NPB ST; QL sumatriptan succinate

IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML

NPB ST; QL sumatriptan succinate

IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML

NPB ST; QL sumatriptan succinate

IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML

NPB ST; QL sumatriptan succinate

IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 6 MG/0.5 ML

NPB ST; QL sumatriptan succinate

IMITREX SUBCUTANEOUS NPB ST; QL sumatriptan succinate

isometh-dichloral-acetaminophn G QL

isomethepten-caf-acetaminophen oral tablet 65-20-325 mg

G QL

MAXALT NPB ST; QL rizatriptan

MAXALT-MLT NPB ST; QL rizatriptan

migergot G

MIGRANAL NPB QL dihydroergotamine mesylate

naratriptan G QL

nodolor G QL

ONZETRA XSAIL NPB ST sumatriptan succinate, ZOMIG

PRODRIN ORAL TABLET 65-20-325 MG

NPB QL isomethept-caffeine-apap

RELPAX PB ST; QL

rizatriptan G QL

sumatriptan G

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24

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

sumatriptan succinate oral G QL

sumatriptan succinate subcutaneous cartridge

G QL

sumatriptan succinate subcutaneous pen injector

G QL

sumatriptan succinate subcutaneous solution

G QL

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml

G QL

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML

PB ST sumatriptan succinate

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML

PB ST; QL sumatriptan succinate

TREXIMET NPB ST; QL naproxen, naproxen sodium, sumatriptan succinate

ZEMBRACE SYMTOUCH NPB ST; QL sumatriptan succinate

zolmitriptan G QL

ZOMIG NASAL PB ST

ZOMIG ORAL NPB ST; QL zolmitriptan

ZOMIG ZMT NPB ST; QL zolmitriptan odt

MISCELLANEOUS NEUROLOGICAL THERAPY

AMPYRA PB-S PA; QL

ARICEPT NPB M donepezil hcl

donepezil G M

EXELON TRANSDERMAL NPB QL; M rivastigmine

galantamine oral capsule,ext rel. pellets 24 hr

G QL; M

galantamine oral solution G QL; M

galantamine oral tablet 12 mg G M

galantamine oral tablet 4 mg, 8 mg G QL; M

HORIZANT NPB ST; QL gabapentin, GRALISE, LYRICA

KEVEYIS NPB acetazolamide

memantine oral solution G M

memantine oral tablet G M

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25

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

MEMANTINE ORAL TABLETS,DOSE PACK

NPB QL; M memantine hcl, NAMENDA XR

NAMENDA ORAL TABLET NPB M memantine hcl

NAMENDA TITRATION PAK NPB QL; M memantine hcl

NAMENDA XR PB QL; M

NAMZARIC PB

NUEDEXTA PB

RAZADYNE ER NPB QL; M GALANTAMINE ER

RAZADYNE ORAL TABLET 12 MG NPB M galantamine

RAZADYNE ORAL TABLET 4 MG, 8 MG

NPB QL; M galantamine

rivastigmine G QL; M

rivastigmine tartrate G QL; M

tetrabenazine G PA

XENAZINE NPB PA tetrabenazine

MUSCLE RELAXANTS & ANTISPASMODIC THERAPY

AMRIX NPB 2ST cyclobenzaprine hcl

baclofen G M

carisoprodol G metaxalone, tizanidine hcl

carisoprodol-asa-codeine G metaxalone, tizanidine hcl

carisoprodol-aspirin G metaxalone, tizanidine hcl

chlorzoxazone G

cyclobenzaprine oral tablet G

DANTRIUM ORAL CAPSULE 25 MG, 50 MG

NPB M dantrolene sodium

dantrolene G M

FEXMID NPB 2ST cyclobenzaprine hcl

LORZONE NPB 2ST chlorzoxazone

meprobamate G alprazolam, buspirone hcl, chlordiazepoxide hcl, diazepam, lorazepam

MESTINON ORAL SYRUP PB M

MESTINON ORAL TABLET NPB M pyridostigmine bromide

MESTINON TIMESPAN NPB M pyridostigmine bromide er

metaxall G

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26

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

metaxalone G

methocarbamol oral G

orphenadrine citrate oral G

PARAFON FORTE DSC NPB chlorzoxazone

pyridostigmine bromide G M

ROBAXIN ORAL NPB methocarbamol

ROBAXIN-750 NPB methocarbamol

SKELAXIN NPB metaxalone

SOMA NPB metaxalone, tizanidine hcl

tizanidine G

ZANAFLEX NPB tizanidine hcl

NARCOTIC ANALGESICS

ABSTRAL NPB PA; QL; 2ST fentanyl citrate, LAZANDA

acetaminophen-caff-dihydrocod oral capsule

G QL

ACETAMINOPHEN-CAFF-DIHYDROCOD ORAL TABLET 325-30-16 MG

NPB QL

acetaminophen-codeine oral solution 120-12 mg/5 ml

G QL

acetaminophen-codeine oral tablet G QL

ACTIQ NPB PA; QL fentanyl citrate

ALLZITAL NPB QL; 2ST acetaminophen w/butalbital

ARYMO ER NPB PA; ST

hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN

ascomp with codeine G

aspirin-caffeine-dihydrocodein G

BELBUCA NPB PA morphine sulfate cr, morphine sulfate er, oxymorphone hcl er

BUPAP ORAL TABLET 50-300 MG NPB QL; 2ST acetaminophen w/butalbital

BUPRENORPHINE NPB ST; QL fentanyl

buprenorphine hcl sublingual G PA

butalbital compound w/codeine G

butalbital-acetaminop-caf-cod G QL

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27

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

butalbital-acetaminophen G QL

butalbital-acetaminophen-caff oral capsule

G QL

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

G QL

butalbital-aspirin-caffeine oral capsule G

BUTRANS PB ST; QL fentanyl

capacet G QL

CAPITAL WITH CODEINE NPB QL acetaminophen w/codeine

codeine sulfate oral tablet G

codeine-butalbital-asa-caff G

DEMEROL ORAL TABLET 100 MG NPB codeine sulfate, hydromorphone hcl, morphine sulfate, oxycodone hcl

DILAUDID ORAL LIQUID NPB hydromorphone hcl

DILAUDID ORAL TABLET 2 MG, 4 MG

NPB hydromorphone hcl

DILAUDID ORAL TABLET 8 MG NPB QL hydromorphone hcl

diskets G

DOLOPHINE ORAL NPB methadone hcl

DURAGESIC NPB fentanyl

EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL

NPB ST

hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

G QL

ESGIC NPB QL; 2ST butalbital/apap/caffeine

EXALGO ER NPB ST hydromorphone er

fentanyl citrate G PA; QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

G

FENTANYL TRANSDERMAL PATCH 72 HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR, 87.5 MCG/HOUR

NPB fentanyl

FENTORA NPB PA; QL; 2ST fentanyl citrate, LAZANDA

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28

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

FIORINAL NPB 2ST butalbital-asp-caffeine

FIORINAL-CODEINE #3 NPB 2ST asa-butalb-caff-cod

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

G QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

G QL

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

G

hydromorphone oral liquid G

hydromorphone oral tablet 2 mg, 4 mg G

hydromorphone oral tablet 8 mg G QL

hydromorphone oral tablet extended release 24 hr

G

hydromorphone rectal G

HYSINGLA ER PB ST

IBUDONE NPB hydrocodone bit-ibuprofen, reprexain

ibuprofen-oxycodone G

IONSYS NPB

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG

NPB ST morphine sulfate er

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG, 40 MG

NPB ST

hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN

LAZANDA PB PA

levorphanol tartrate G

lorcet (hydrocodone) G QL

lorcet hd G QL

lorcet plus oral tablet 7.5-325 mg G QL

LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML

NPB QL hydrocodone w/acetaminophen

marten-tab G QL

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29

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

meperidine oral solution G hydromorphone hcl, morphine sulfate, oxycodone hcl

meperidine oral tablet G codeine sulfate, hydromorphone hcl, morphine sulfate, oxycodone hcl

methadone oral concentrate G

methadone oral solution G

methadone oral tablet G

methadone oral tablet,soluble G

methadose oral concentrate G

methadose oral tablet,soluble G

MORPHABOND ER NPB ST

morphine concentrate oral solution G

morphine oral G

morphine rectal G

MS CONTIN NPB ST MORPHINE SULFATE

NORCO NPB QL hydrocodone w/acetaminophen

OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

PB ST

OPANA ORAL NPB oxymorphone hcl

OXAYDO ORAL TABLET, ORAL ONLY 5 MG

NPB QL oxycodone hcl

OXAYDO ORAL TABLET, ORAL ONLY 7.5 MG

NPB oxycodone hcl

oxycodone oral capsule G QL

oxycodone oral concentrate G QL

oxycodone oral solution G

oxycodone oral tablet 10 mg, 20 mg G

oxycodone oral tablet 15 mg, 30 mg, 5 mg

G QL

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

NPB ST; QL

hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN

oxycodone-acetaminophen oral solution G QL

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30

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

G QL

oxycodone-aspirin G

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

PB ST; QL

oxymorphone G

PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG

NPB QL oxycodone w/acetaminophen

PRIMLEV NPB QL oxycodone w/acetaminophen

ROXICODONE NPB QL oxycodone hcl

SUBSYS NPB PA; 2ST fentanyl citrate, LAZANDA

SYNALGOS-DC NPB aspirin-caffeine-dihydrocodein

tencon oral tablet 50-325 mg G QL

TREZIX ORAL CAPSULE 320.5-30-16 MG

NPB QL apap-caffeine-dihydrocodeine

TYLENOL-CODEINE #3 NPB QL acetaminophen w/codeine

TYLENOL-CODEINE #4 NPB QL acetaminophen w/codeine

VANATOL LQ NPB QL; 2ST

verdrocet G QL

vicodin G QL

vicodin es G QL

vicodin hp G QL

XODOL 10/300 NPB QL hydrocodone w/acetaminophen

XODOL 5/300 NPB QL hydrocodone w/acetaminophen

XODOL 7.5/300 NPB QL hydrocodone w/acetaminophen

XTAMPZA ER NPB ST; QL

hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN

xylon 10 G

zamicet G QL

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31

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

zebutal oral capsule 50-325-40 mg G QL

ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR

NPB ST

hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN

NON-NARCOTIC ANALGESICS

ANAPROX DS NPB ST; M naproxen sodium

ARTHROTEC 50 NPB ST; M diclofenac sodium-misoprostol

ARTHROTEC 75 NPB ST; M diclofenac sodium-misoprostol

aspir-81 G M; ACA; OTC

aspirin low dose G M; ACA; OTC

aspirin oral tablet G ACA; OTC

aspirin oral tablet,chewable G M; ACA; OTC

aspirin oral tablet,delayed release (dr/ec) 325 mg

G ACA; OTC

aspirin oral tablet,delayed release (dr/ec) 81 mg

G M; ACA; OTC

aspir-low G M; ACA; OTC

aspir-trin G ACA; OTC

bayer aspirin G ACA; OTC

BUNAVAIL NPB PA buprenorphine-naloxone, SUBOXONE, ZUBSOLV

buprenorphine-naloxone G PA; QL

butorphanol tartrate nasal G QL

CAMBIA NPB ST; QL diclofenac potassium, diclofenac sodium, diclofenac sodium

CELEBREX NPB ST; QL; M celecoxib

celecoxib G QL; M

children's aspirin G M; ACA; OTC

choline,magnesium salicylate G

CONZIP NPB QL tramadol hcl er

DAYPRO NPB ST; M oxaprozin

diclofenac potassium G

diclofenac sodium oral G M

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32

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

diclofenac sodium topical drops G QL; M

diclofenac sodium topical gel 1 % G QL; M

diclofenac-misoprostol G M

diflunisal G M

DISALCID NPB salsalate

DUEXIS NPB ST; QL; M ibuprofen, famotidine

e.c. prin G ACA; OTC

EC-NAPROSYN NPB ST; M naproxen

ecotrin G ACA; OTC

ecotrin low strength G M; ACA; OTC

etodolac G M

EVZIO NPB 2ST naloxone hcl, naloxone hcl

FELDENE NPB ST; M piroxicam

FENOPROFEN ORAL CAPSULE NPB ST; M

fenoprofen oral tablet G M

FENORTHO NPB ST; M

fenoprofen calcium, diclofenac sodium, indomethacin, ibuprofen, meloxicam, naproxen sodium, nabumetone

FLECTOR PB ST; QL

flurbiprofen G M

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

G M

INDOCIN ORAL NPB ST ibuprofen, meloxicam, naproxen sodium

INDOCIN RECTAL NPB ST

indomethacin oral G

ketoprofen oral capsule G M

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

G M

ketorolac oral G QL

klofensaid ii G QL; M

lite coat aspirin G ACA; OTC

LODINE ORAL TABLET NPB ST; M

meclofenamate G M

mefenamic acid G

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33

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

meloxicam oral suspension G M

meloxicam oral tablet 15 mg G M

meloxicam oral tablet 7.5 mg G QL; M

MOBIC ORAL TABLET 15 MG NPB ST; M meloxicam

MOBIC ORAL TABLET 7.5 MG NPB ST; QL; M meloxicam

nabumetone G M

NALFON ORAL CAPSULE 400 MG NPB ST; M

fenoprofen calcium, diclofenac sodium, indomethacin, ibuprofen, meloxicam, naproxen sodium, nabumetone

naltrexone G

NAPRELAN CR NPB ST; M naproxen sodium er

NAPROSYN ORAL SUSPENSION NPB ST; M naproxen

NAPROSYN ORAL TABLET 500 MG NPB ST; M naproxen

naproxen G M

naproxen sodium oral tablet 275 mg, 550 mg

G M

naproxen sodium oral tablet, er multiphase 24 hr

G M

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

PB

NUCYNTA PB QL

NUCYNTA ER PB ST

oxaprozin G M

PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP

NPB ST; QL; M diclofenac sodium, diclofenac sodium, FLECTOR

pentazocine-naloxone G codeine sulfate, hydromorphone hcl, morphine sulfate, oxycodone hcl

piroxicam G M

PONSTEL NPB ST mefenamic acid

REVIA NPB naltrexone hydrochloride

salsalate G

SPRIX NPB ST; QL

diclofenac sodium, etodolac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen

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34

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

SUBOXONE PB PA; QL

sulindac G M

TIVORBEX NPB ST; M

diclofenac sodium, indomethacin, ibuprofen, meloxicam, naproxen sodium, nabumetone, piroxicam

tolmetin G M

TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 17-83

NPB QL tramadol hcl er

TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 25-75

NPB QL tramadol hcl er

tramadol oral tablet G QL

tramadol oral tablet extended release 24 hr

G QL

tramadol oral tablet, er multiphase 24 hr G QL

tramadol-acetaminophen G QL

ULTRACET NPB QL tramadol hcl-acetaminophen

ULTRAM NPB QL tramadol hcl

ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 300 MG

NPB QL tramadol hcl er

VIMOVO NPB ST; QL; M naproxen sodium, omeprazole

VIVLODEX NPB ST; M meloxicam

VOLTAREN TOPICAL NPB ST; QL; M diclofenac sodium

VOLTAREN-XR NPB ST; M diclofenac sodium

ZIPSOR NPB ST; QL diclofenac potassium, diclofenac sodium, diclofenac sodium

ZORVOLEX PB ST; QL; M

ZUBSOLV PB PA

PSYCHOTHERAPEUTIC DRUGS

ABILIFY ORAL TABLET NPB QL aripiprazole

ADASUVE NPB

ADDERALL NPB QL dextroamphetamine-amphetamine

ADDERALL XR NPB QL dextroamphetamine-amphet er

ADDYI NPB PA; QL

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35

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ADZENYS XR-ODT NPB

dextroamphetamine sulfate er, dextroamphetamine-amphet er, dexmethylphenidate hcl er, methylphenidate er, VYVANSE

alprazolam G

alprazolam intensol G

AMBIEN NPB ST zolpidem tartrate

AMBIEN CR NPB ST zolpidem tartrate er

amitriptyline G

amitriptyline-chlordiazepoxide G

amoxapine G

ANAFRANIL NPB clomipramine hcl

APLENZIN NPB QL; M bupropion hcl xl

APTENSIO XR NPB

methylphenidate er, methylphenidate hcl cd, dexmethylphenidate hcl er, VYVANSE

aripiprazole oral solution G

aripiprazole oral tablet G QL

aripiprazole oral tablet,disintegrating G QL

armodafinil G ST; QL

ATIVAN ORAL NPB lorazepam

atomoxetine G QL

BELSOMRA NPB ST zolpidem tartrate, zolpidem tartrate er, eszopiclone, zaleplon, ROZEREM

BRISDELLE PB ST; M

bupropion hcl oral tablet G M

bupropion hcl oral tablet extended release 12 hr

G QL; M

bupropion hcl oral tablet extended release 24 hr

G QL; M

buspirone G M

BUTISOL ORAL TABLET 30 MG NPB phenobarbital sodium

CELEXA ORAL TABLET NPB ST; QL; M citalopram hbr

chlordiazepoxide hcl G

chlorpromazine G

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36

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

citalopram oral solution G M

citalopram oral tablet G QL; M

clomipramine G

clonidine hcl oral tablet extended release 12 hr

G QL

clorazepate dipotassium G

clozapine oral tablet G

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

G

CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG

NPB clozapine, clozapine odt

CLOZARIL NPB clozapine

CONCERTA NPB QL methylphenidate er

CYMBALTA NPB ST; QL; M duloxetine hcl

DAYTRANA PB QL

desipramine G

DESOXYN NPB QL methamphetamine hcl

DESVENLAFAXINE FUMARATE NPB QL; M

DESVENLAFAXINE SUCCINATE ER, duloxetine hcl, venlafaxine hcl er, FETZIMA

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR

NPB M

DESVENLAFAXINE SUCCINATE ER, duloxetine hcl, venlafaxine hcl er, FETZIMA

DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR

NPB QL; M

DESVENLAFAXINE SUCCINATE ER, duloxetine hcl, venlafaxine hcl er, FETZIMA

desvenlafaxine succinate G QL; M

dexedrine G QL

DEXEDRINE SPANSULE NPB QL dextroamphetamine sulfate er

dexmethylphenidate G QL

dextroamphetamine G QL

dextroamphetamine-amphetamine G QL

diazepam intensol G

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37

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

diazepam oral solution 5 mg/5 ml (1 mg/ml)

G

diazepam oral tablet G

DORAL NPB temazepam

doxepin oral G

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

G QL; M

duloxetine oral capsule,delayed release(dr/ec) 40 mg

G M

DYANAVEL XR NPB

dextroamphetamine sulfate er, dextroamphetamine-amphet er, dexmethylphenidate hcl er, methylphenidate er, VYVANSE

EDLUAR NPB ST; QL eszopiclone, zolpidem tartrate, zolpidem tartrate er

EFFEXOR XR NPB ST; QL; M venlafaxine hcl er

EMSAM NPB QL; M phenelzine sulfate, tranylcypromine sulfate

ergoloid G M

escitalopram oxalate oral solution G M

escitalopram oxalate oral tablet G QL; M

estazolam G

eszopiclone G

EVEKEO PB

FANAPT NPB QL

aripiprazole, olanzapine, quetiapine fumarate, quetiapine fumarate er, risperidone, ziprasidone hcl, LATUDA

FAZACLO NPB clozapine odt

FETZIMA PB QL; M

fluoxetine oral capsule G QL; M

fluoxetine oral capsule,delayed release(dr/ec)

G QL; M

fluoxetine oral solution G M

fluoxetine oral tablet 10 mg G QL; M

fluoxetine oral tablet 20 mg G M

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38

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

FLUOXETINE ORAL TABLET 60 MG NPB ST citalopram hbr, fluoxetine hcl, paroxetine hcl, sertraline hcl, VIIBRYD

fluphenazine decanoate G

fluphenazine hcl G

flurazepam G

fluvoxamine G QL; M

FOCALIN NPB QL dexmethylphenidate hcl

FOCALIN XR NPB QL dexmethylphenidate hcl er

FORFIVO XL NPB ST; QL; M bupropion hcl xl

GEODON INTRAMUSCULAR NPB olanzapine

GEODON ORAL NPB QL ziprasidone hcl

guanfacine oral tablet extended release 24 hr

G QL

guanidine G

HALCION ORAL TABLET 0.25 MG NPB triazolam

HALDOL NPB haloperidol lactate

HALDOL DECANOATE NPB haloperidol decanoate

haloperidol G

haloperidol decanoate G

haloperidol lactate G

HETLIOZ NPB-S

imipramine hcl G

imipramine pamoate G

INTERMEZZO NPB ST; QL zolpidem tartrate

INTUNIV ER NPB QL guanfacine hcl er

INVEGA NPB QL paliperidone er

IRENKA NPB ST; M duloxetine hcl

KAPVAY NPB QL clonidine hcl er

KHEDEZLA NPB QL; M

DESVENLAFAXINE SUCCINATE ER, duloxetine hcl, venlafaxine hcl er, FETZIMA

LATUDA PB QL

LEXAPRO ORAL TABLET NPB ST; QL; M escitalopram oxalate

lithium carbonate G

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39

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

lithium citrate oral solution 8 meq/5 ml G

LITHOBID NPB lithium carbonate

lorazepam intensol G

lorazepam oral G

loxapine succinate G

LUNESTA NPB ST eszopiclone

maprotiline G

MARPLAN NPB M phenelzine sulfate, tranylcypromine sulfate

METADATE CD ORAL CAPSULE, ER BIPHASIC 30-70 10 MG, 30 MG, 40 MG, 50 MG, 60 MG

NPB methylphenidate hcl cd

METADATE CD ORAL CAPSULE, ER BIPHASIC 30-70 20 MG

NPB QL methylphenidate hcl cd

metadate er G QL

methamphetamine G QL

METHYLIN ORAL SOLUTION NPB QL methylphenidate hcl

METHYLIN ORAL TABLET,CHEWABLE

NPB QL methylphenidate hcl

methylphenidate oral capsule, er biphasic 30-70 10 mg, 30 mg, 40 mg, 50 mg, 60 mg

G

methylphenidate oral capsule, er biphasic 30-70 20 mg

G QL

methylphenidate oral capsule,er biphasic 50-50 20 mg

G QL

methylphenidate oral capsule,er biphasic 50-50 30 mg, 40 mg, 60 mg

G

methylphenidate oral solution G QL

methylphenidate oral tablet G QL

methylphenidate oral tablet extended release 10 mg

G

methylphenidate oral tablet extended release 20 mg

G QL

methylphenidate oral tablet extended release 24hr

G QL

methylphenidate oral tablet,chewable G QL

mirtazapine G QL

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40

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

modafinil G ST; QL

NARDIL NPB M phenelzine sulfate

nefazodone G M bupropion hcl, mirtazapine, trazodone hcl

NORPRAMIN ORAL TABLET 10 MG, 25 MG

NPB desipramine hcl

nortriptyline G

NUPLAZID NPB-S clozapine, quetiapine fumarate

NUVIGIL NPB ST; QL armodafinil

olanzapine oral G QL

olanzapine-fluoxetine G

ORAP NPB pimozide

oxazepam G

paliperidone G QL

PAMELOR NPB nortriptyline hcl

PARNATE NPB M tranylcypromine sulfate

paroxetine hcl oral tablet G QL; M

paroxetine hcl oral tablet extended release 24 hr

G QL; M

PAXIL CR NPB ST; QL; M paroxetine er

PAXIL ORAL SUSPENSION NPB ST; M paroxetine hcl

PAXIL ORAL TABLET NPB ST; QL; M paroxetine hcl

perphenazine G

perphenazine-amitriptyline G

PEXEVA NPB ST; QL; M paroxetine hcl, citalopram hbr, escitalopram oxalate, fluoxetine hcl, sertraline hcl

phenelzine G M

pimozide G

PRISTIQ NPB ST; QL; M DESVENLAFAXINE SUCCINATE ER

procentra G QL

protriptyline G

PROVIGIL NPB ST; QL modafinil

PROZAC ORAL CAPSULE 10 MG, 40 MG

NPB ST; QL; M fluoxetine hcl

PROZAC ORAL CAPSULE 20 MG NPB ST; M fluoxetine hcl

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41

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

PROZAC WEEKLY NPB ST; QL; M fluoxetine dr

quazepam G

quetiapine oral tablet G QL

quetiapine oral tablet extended release 24 hr 150 mg, 200 mg

G

quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg

G QL

QUILLICHEW ER PB

QUILLIVANT XR PB QL

REMERON NPB QL mirtazapine

REMERON SOLTAB NPB QL mirtazapine

RESTORIL NPB temazepam

REXULTI NPB QL

aripiprazole, olanzapine, quetiapine fumarate, quetiapine fumarate er, risperidone, ziprasidone hcl, LATUDA

RISPERDAL M-TAB NPB QL risperidone odt

RISPERDAL ORAL SOLUTION NPB risperidone

RISPERDAL ORAL TABLET NPB QL risperidone

risperidone oral solution G

risperidone oral tablet G QL

risperidone oral tablet,disintegrating G QL

RITALIN NPB QL methylphenidate hcl

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG

NPB

methylphenidate er, methylphenidate hcl cd, dexmethylphenidate hcl er, QUILLIVANT XR, VYVANSE

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 20 MG

NPB QL methylphenidate er

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 30 MG, 40 MG

NPB methylphenidate er

ROZEREM PB ST; QL

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG, 5 MG

NPB QL

aripiprazole, olanzapine, quetiapine fumarate, quetiapine fumarate er, risperidone, ziprasidone hcl, LATUDA

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42

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

SARAFEM ORAL TABLET 10 MG NPB ST; QL; M fluoxetine hcl

SARAFEM ORAL TABLET 20 MG NPB ST; M fluoxetine hcl

seconal sodium G

SEROQUEL NPB QL quetiapine fumarate

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 400 MG, 50 MG

NPB QL quetiapine fumarate er

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG

NPB quetiapine fumarate er

sertraline oral concentrate G M

sertraline oral tablet G QL; M

SILENOR NPB ST; QL eszopiclone, zaleplon, zolpidem tartrate, zolpidem tartrate er, ROZEREM

SONATA NPB ST zaleplon

STRATTERA NPB QL ATOMOXETINE HCL

SURMONTIL NPB trimipramine maleate

SYMBYAX NPB olanzapine-fluoxetine hcl

temazepam G

thioridazine G

thiothixene G

TOFRANIL NPB imipramine hcl

TRANXENE T-TAB ORAL TABLET 7.5 MG

NPB clorazepate dipotassium

tranylcypromine G M

trazodone G

triazolam G

trifluoperazine G

trimipramine G

TRINTELLIX NPB ST citalopram hbr, escitalopram oxalate, fluoxetine hcl, sertraline hcl, VIIBRYD

VALIUM NPB diazepam

venlafaxine oral capsule,extended release 24hr

G QL; M

venlafaxine oral tablet G QL; M

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43

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

venlafaxine oral tablet extended release 24hr

G ST; QL; M

VERSACLOZ NPB clozapine odt, clozapine

VIIBRYD ORAL TABLET PB ST; QL; M

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23)

PB ST

VRAYLAR NPB

aripiprazole, olanzapine, quetiapine fumarate, quetiapine fumarate er, risperidone, ziprasidone hcl, LATUDA

VYVANSE PB QL

WELLBUTRIN SR NPB QL; M bupropion sr

WELLBUTRIN XL NPB ST; QL; M bupropion hcl xl

XANAX NPB alprazolam

XANAX XR NPB alprazolam er

XYREM PB-S PA; QL

zaleplon G

zenzedi oral tablet 10 mg, 5 mg G QL

ZENZEDI ORAL TABLET 15 MG NPB QL dextroamphetamine sulfate

ZENZEDI ORAL TABLET 2.5 MG, 20 MG, 30 MG, 7.5 MG

NPB dextroamphetamine sulfate

ziprasidone hcl G QL

ZOLOFT ORAL CONCENTRATE NPB ST; M sertraline hcl

ZOLOFT ORAL TABLET NPB ST; QL; M sertraline hcl

zolpidem oral G

zolpidem sublingual G QL

ZOLPIMIST NPB ST; QL eszopiclone, zolpidem tartrate, zolpidem tartrate er

ZYPREXA ORAL NPB QL olanzapine

ZYPREXA ZYDIS NPB QL olanzapine odt

CARDIOVASCULAR, HYPERTENSION & LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone oral G M

BETAPACE NPB M sotalol

BETAPACE AF NPB M sotalol af

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44

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

disopyramide phosphate oral capsule G M amiodarone hcl, quinidine sulfate, sotalol

dofetilide G

flecainide G M

mexiletine G M

MULTAQ NPB M

amiodarone hcl, dofetilide, flecainide acetate, propafenone hcl, quinidine sulfate, sotalol

NORPACE NPB M amiodarone hcl, quinidine sulfate, sotalol

NORPACE CR NPB M amiodarone hcl, quinidine sulfate, sotalol

pacerone oral tablet 100 mg, 200 mg, 400 mg

G M

propafenone G M

quinidine gluconate oral G M

quinidine sulfate oral tablet G M

RYTHMOL SR NPB M propafenone hcl

sotalol af G M

sotalol oral G M

SOTYLIZE PB M

TIKOSYN NPB dofetilide

ANTIHYPERTENSIVE THERAPY

ACCUPRIL NPB M quinapril

ACCURETIC NPB M quinapril-hydrochlorothiazide

acebutolol G M

ADALAT CC NPB ST; M nifedipine er

afeditab cr G M

ALDACTAZIDE NPB M spironolactone w/hctz

ALDACTONE NPB M spironolactone

ALTACE NPB M ramipril

amiloride G M

amiloride-hydrochlorothiazide G M

amlodipine G M

amlodipine-benazepril G M

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45

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

amlodipine-olmesartan G M

amlodipine-valsartan G M

amlodipine-valsartan-hcthiazid G M

ATACAND NPB ST; M candesartan cilexetil

ATACAND HCT NPB ST; M candesartan-hydrochlorothiazid

atenolol G M

atenolol-chlorthalidone G M

AVALIDE NPB ST; M irbesartan-hydrochlorothiazide

AVAPRO NPB ST; M irbesartan

AZOR NPB ST; M amlodipine-olmesartan

benazepril G M

benazepril-hydrochlorothiazide G M

BENICAR NPB ST; M olmesartan medoxomil

BENICAR HCT NPB ST; M olmesartan-hydrochlorothiazide

betaxolol oral G M

BIDIL NPB M isosorbide dinitrate, hydralazine hcl

bisoprolol fumarate G M

bisoprolol-hydrochlorothiazide G M

bumetanide oral G M

BYSTOLIC PB M

BYVALSON PB M

CALAN NPB ST; M verapamil hcl

CALAN SR NPB ST; M verapamil er

candesartan oral tablet 16 mg G

candesartan oral tablet 32 mg, 4 mg, 8 mg

G M

candesartan-hydrochlorothiazid G M

captopril G M

captopril-hydrochlorothiazide G M

CARDIZEM CD NPB M cartia xt, diltiazem 24hr cd, diltiazem er

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 120 MG

NPB M diltiazem 24hr cd

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46

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG

NPB M diltiazem er, matzim la

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG

NPB M diltiazem hcl

CARDURA NPB QL; M doxazosin mesylate

CARDURA XL NPB QL; M alfuzosin hcl er, doxazosin mesylate, tamsulosin hcl, terazosin hcl, RAPAFLO

cartia xt G M

carvedilol G M

CATAPRES NPB M clonidine hcl

CATAPRES-TTS-1 NPB QL; M clonidine hcl

CATAPRES-TTS-2 NPB QL; M clonidine hcl

CATAPRES-TTS-3 NPB QL; M clonidine hcl

chlorothiazide G M

chlorthalidone oral tablet 25 mg, 50 mg G M

clonidine G QL; M

clonidine hcl oral tablet G M

clorpres oral tablet 0.1-15 mg, 0.2-15 mg G M

CLORPRES ORAL TABLET 0.3-15 MG

NPB M clonidine hcl, chlorthalidone

COREG NPB M carvedilol

COREG CR PB M

CORGARD NPB M nadolol

CORZIDE NPB M nadolol-bendroflumethiazide

COZAAR NPB ST; M losartan potassium

DEMADEX ORAL TABLET 10 MG, 20 MG

NPB M torsemide

DEMSER PB

DIBENZYLINE NPB phenoxybenzamine hcl

diltiazem hcl oral capsule, extended release 420 mg

G M

diltiazem hcl oral capsule,ext release degradable 240 mg

G M

diltiazem hcl oral capsule,extended release 12 hr

G M

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47

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

diltiazem hcl oral capsule,extended release 24hr

G M

diltiazem hcl oral tablet G M

diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg

G M

dilt-xr G M

DIOVAN NPB ST; M valsartan

DIOVAN HCT NPB ST; M valsartan-hydrochlorothiazide

DIURIL NPB M chlorothiazide

doxazosin G QL; M

DUTOPROL NPB M

metoprolol-hydrochlorothiazide, hydrochlorothiazide, metoprolol succinate

DYAZIDE NPB M triamterene w/hctz

DYRENIUM NPB M spironolactone

EDARBI NPB ST; M

candesartan cilexetil, irbesartan, losartan potassium, olmesartan medoxomil, telmisartan, valsartan

EDARBYCLOR NPB ST; M

chlorthalidone, valsartan, candesartan-hydrochlorothiazid, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, olmesartan-hydrochlorothiazide, valsartan-hydrochlorothiazide

EDECRIN NPB M ethacrynic acid

enalapril maleate G M

enalapril-hydrochlorothiazide G M

EPANED ORAL SOLUTION NPB M enalapril maleate

eplerenone G M

eprosartan G M

ethacrynic acid G M

EXFORGE NPB ST; M amlodipine-valsartan

EXFORGE HCT NPB ST; M amlodipine-valsartan-hctz

felodipine G M

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48

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

fosinopril G M

fosinopril-hydrochlorothiazide G M

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

G M

furosemide oral tablet G M

guanfacine oral tablet G M

HEMANGEOL NPB propranolol hcl

hydralazine oral G M

hydrochlorothiazide G M

HYZAAR NPB ST; M losartan-hydrochlorothiazide

indapamide G M

INDERAL LA NPB M propranolol hcl er

INDERAL XL NPB M propranolol hcl

INNOPRAN XL NPB M propranolol hcl er

INSPRA NPB M eplerenone

irbesartan G M

irbesartan-hydrochlorothiazide G M

isradipine G M

labetalol oral G M

LASIX NPB M furosemide

LEVATOL NPB M atenolol, metoprolol tartrate, propranolol hcl

lisinopril G M

lisinopril-hydrochlorothiazide G M

LOPRESSOR HCT NPB M metoprolol-hydrochlorothiazide

LOPRESSOR ORAL NPB M metoprolol tartrate

losartan G M

losartan-hydrochlorothiazide G M

LOTENSIN HCT NPB M benazepril hcl-hctz

LOTENSIN ORAL TABLET 20 MG, 40 MG

NPB M benazepril hcl

LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG

NPB M amlodipine besylate-benazepril

matzim la G M

MAVIK ORAL TABLET 2 MG NPB M trandolapril

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49

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

MAXZIDE NPB M triamterene w/hctz

MAXZIDE-25MG NPB M triamterene w/hctz

methyclothiazide G M

methyldopa G M

methyldopa-hydrochlorothiazide G M

metolazone G M

metoprolol succinate G M

METOPROLOL SU-HYDROCHLOROTHIAZ

NPB M

metoprolol-hydrochlorothiazide, hydrochlorothiazide, metoprolol succinate

metoprolol ta-hydrochlorothiaz G M

metoprolol tartrate oral G M

MICARDIS NPB ST; M telmisartan

MICARDIS HCT NPB ST; M telmisartan-hydrochlorothiazid

MICROZIDE NPB M hydrochlorothiazide

MINIPRESS NPB M prazosin hcl

minoxidil oral G M

moexipril G M

moexipril-hydrochlorothiazide G M

nadolol G M

nadolol-bendroflumethiazide G M

nicardipine oral G M

nifedipine oral capsule G M nicardipine hcl, isradipine

nifedipine oral tablet extended release G M

nifedipine oral tablet extended release 24hr

G M

nimodipine G

nisoldipine G M

NORVASC NPB ST; M amlodipine besylate

NYMALIZE NPB nimodipine

olmesartan G M

olmesartan-amlodipin-hcthiazid G M

olmesartan-hydrochlorothiazide G M

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50

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ORENITRAM NPB-S M sildenafil citrate, ADCIRCA, ADEMPAS, LETAIRIS, OPSUMIT, TRACLEER

perindopril erbumine G M

phenoxybenzamine G

pindolol G M

prazosin G M

PRESTALIA NPB M

amlodipine besylate, perindopril erbumine, amlodipine besylate-benazepril

PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG

NPB M lisinopril

PROCARDIA NPB ST; M amlodipine besylate, diltiazem hcl, verapamil hcl

PROCARDIA XL NPB ST; M nifedical xl, nifedipine er

propranolol oral G M

propranolol-hydrochlorothiazid G M

QBRELIS NPB M lisinopril

quinapril G M

quinapril-hydrochlorothiazide G M

ramipril G M

spironolactone G M

spironolacton-hydrochlorothiaz G M

SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 34 MG, 8.5 MG

NPB ST; M nisoldipine

TARKA NPB M trandolapril-verapamil

taztia xt G M

TEKTURNA PB ST; M

TEKTURNA HCT PB ST; M

telmisartan G M

telmisartan-amlodipine G M

telmisartan-hydrochlorothiazid G M

TENORETIC 100 NPB M atenolol w/chlorthalidone

TENORETIC 50 NPB M atenolol w/chlorthalidone

TENORMIN NPB M atenolol

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51

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

terazosin G QL; M

TIAZAC NPB M diltiazem er, taztia xt

timolol maleate oral G M

TOPROL XL NPB M metoprolol succinate

torsemide oral G M

trandolapril G M

trandolapril-verapamil G M

triamterene-hydrochlorothiazid G M

TRIBENZOR NPB ST; M olmesartan-amlodipine-hctz

TWYNSTA NPB ST; M telmisartan-amlodipine

UPTRAVI PB-S M

valsartan G M

valsartan-hydrochlorothiazide G M

VASERETIC NPB M enalapril maleate/hctz

VASOTEC NPB M enalapril maleate

verapamil oral G M

VERELAN NPB ST; M verapamil er

VERELAN PM NPB ST; M verapamil er pm

ZESTORETIC NPB M lisinopril-hctz

ZESTRIL NPB M lisinopril

ZIAC NPB M bisoprolol fumarate/hctz

CARDIAC GLYCOSIDES

digitek G M

digox G M

digoxin oral solution 50 mcg/ml G M

digoxin oral tablet G M

LANOXIN ORAL NPB M digoxin

COAGULATION THERAPY

AGGRENOX NPB M aspirin-dipyridamole er

AMICAR PB

ARIXTRA NPB fondaparinux sodium

aspirin-dipyridamole G M

BRILINTA PB M

cilostazol G M

clopidogrel oral tablet 300 mg G QL

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52

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

clopidogrel oral tablet 75 mg G QL; M

COUMADIN ORAL NPB warfarin sodium

dipyridamole oral G M

DURLAZA NPB ST; M aspirin

EFFIENT PB M

ELIQUIS PB

enoxaparin subcutaneous syringe G

fondaparinux G

FRAGMIN SUBCUTANEOUS SOLUTION

PB

FRAGMIN SUBCUTANEOUS SYRINGE

PB

heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml

G

heparin (porcine) injection cartridge G

heparin (porcine) injection solution G

heparin (porcine) injection syringe 5,000 unit/ml

G

HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML

NPB

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

G

heparin, porcine (pf) injection G

jantoven G

LOVENOX SUBCUTANEOUS SYRINGE

NPB enoxaparin sodium

MEPHYTON PB

pentoxifylline G M

PLAVIX ORAL TABLET 300 MG NPB QL clopidogrel

PLAVIX ORAL TABLET 75 MG NPB QL; M clopidogrel

PRADAXA ORAL CAPSULE 150 MG, 75 MG

PB M

PROMACTA PB PA

SAVAYSA NPB ELIQUIS, XARELTO, PRADAXA

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53

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ticlopidine G M clopidogrel

warfarin G

XARELTO PB

YOSPRALA NPB M; 2ST

aspirin, omeprazole, esomeprazole magnesium, lansoprazole, pantoprazole sodium, rabeprazole sodium

ZONTIVITY PB M

LIPID/CHOLESTEROL LOWERING AGENTS

ALTOPREV NPB ST; QL; M

atorvastatin calcium, lovastatin, rosuvastatin calcium, simvastatin, LIVALO

amlodipine-atorvastatin G QL; M

ANTARA ORAL CAPSULE 30 MG, 90 MG

NPB ST; QL; M fenofibrate, fenofibric acid, LIPOFEN

atorvastatin G QL; M

CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG

NPB QL; M amlodipine-atorvastatin

cholestyramine (with sugar) G M

cholestyramine light G M

COLESTID NPB M colestipol hcl

COLESTID FLAVORED ORAL PACKET

NPB M colestipol hcl

colestipol G M

CRESTOR NPB ST; QL; M rosuvastatin calcium

ezetimibe G ST; M

ezetimibe-simvastatin G QL; M

fenofibrate micronized G QL; M

fenofibrate nanocrystallized G QL; M

FENOFIBRATE ORAL CAPSULE NPB ST; QL; M fenofibrate, fenofibric acid, LIPOFEN

fenofibrate oral tablet G QL; M

fenofibric acid G QL; M

fenofibric acid (choline) G QL; M

FENOGLIDE NPB ST; QL; M fenofibrate

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54

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

FIBRICOR NPB ST; QL; M fenofibric acid

fluvastatin G QL; M

gemfibrozil G QL; M

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG

PB-S PA; QL

JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG

PB-S PA

KYNAMRO NPB-S PA; QL REPATHA PUSHTRONEX, REPATHA SURECLICK, REPATHA SYRINGE

LESCOL NPB ST; QL; M fluvastatin sodium

LESCOL XL NPB ST; QL; M fluvastatin er

LIPITOR NPB ST; QL; M atorvastatin calcium

LIPOFEN PB ST; QL; M

LIVALO PB ST; QL; M

LOPID NPB QL; M gemfibrozil

lovastatin G QL; M

LOVAZA NPB M omega-3 acid ethyl esters

niacin oral tablet extended release 24 hr G M

NIACOR NPB M niacin er

NIASPAN EXTENDED-RELEASE NPB M niacin er

omega-3 acid ethyl esters G M

PRALUENT PEN PB-S PA

PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG

NPB ST; QL; M pravastatin sodium

pravastatin G QL; M

prevalite G M

QUESTRAN NPB M cholestyramine

QUESTRAN LIGHT ORAL POWDER NPB M cholestyramine light

REPATHA PUSHTRONEX PB-S PA

REPATHA SURECLICK PB-S PA

REPATHA SYRINGE PB-S PA

rosuvastatin G QL; M

simvastatin G QL; M

TRICOR NPB ST; QL; M fenofibrate

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55

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

TRIGLIDE ORAL TABLET 160 MG NPB ST; QL; M fenofibrate, fenofibric acid, LIPOFEN

TRILIPIX NPB ST; QL; M fenofibric acid

VASCEPA PB M

VYTORIN 10-10 NPB ST; QL; M EZETIMIBE-SIMVASTATIN

VYTORIN 10-20 NPB ST; QL; M EZETIMIBE-SIMVASTATIN

VYTORIN 10-40 NPB ST; QL; M EZETIMIBE-SIMVASTATIN

VYTORIN 10-80 NPB ST; QL; M EZETIMIBE-SIMVASTATIN

WELCHOL PB M

ZETIA NPB ST; M EZETIMIBE

ZOCOR NPB ST; QL; M simvastatin

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR PB M

ENTRESTO PB M

RANEXA PB M

VECAMYL NPB clonidine hcl, reserpine

NITRATES

DILATRATE-SR PB M

GONITRO NPB nitroglycerin, nitroglycerin

ISOCHRON NPB M isosorbide dinitrate

ISORDIL NPB M isosorbide dinitrate

ISORDIL TITRADOSE ORAL TABLET 5 MG

NPB M isosorbide dinitrate

isosorbide dinitrate oral G M

isosorbide mononitrate G M

MINITRAN NPB M nitroglycerin

nitro-bid G M

NITRO-DUR NPB M nitroglycerin

nitroglycerin oral G M

nitroglycerin sublingual G

nitroglycerin transdermal patch 24 hour G M

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56

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

nitroglycerin translingual G

NITROLINGUAL NPB nitroglycerin

NITROMIST NPB nitroglycerin

NITROSTAT NPB nitroglycerin

nitro-time G M

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin G

ANALPRAM-HC TOPICAL NPB ST

calcipotriene G QL

calcipotriene-betamethasone G QL

calcitrene G QL

calcitriol topical G QL

COAL TAR PB

COSENTYX PB-S PA; QL

COSENTYX (2 SYRINGES) PB-S PA; QL

COSENTYX PEN PB-S PA; QL

COSENTYX PEN (2 PENS) PB-S PA; QL

DOVONEX TOPICAL NPB QL calcipotriene

drithocreme hp G

ENSTILAR PB

EPIFOAM NPB ST hc pramoxine

hydrocortisone-pramoxine topical G

OVACE NPB sodium sulfacetamide

OVACE PLUS SHAMPOO NPB sodium sulfacetamide

OVACE PLUS TOPICAL CLEANSER,EXTENDED RELEASE

NPB sodium sulfacetamide

OVACE PLUS TOPICAL CREAM NPB ST sodium sulfacetamide

OVACE PLUS TOPICAL FOAM NPB sodium sulfacetamide

OVACE PLUS TOPICAL LOTION NPB ST sodium sulfacetamide

OVACE PLUS WASH NPB sodium sulfacetamide

PRAMOSONE NPB ST hc pramoxine

PRAMOSONE E NPB ST hc pramoxine

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57

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

seb-prev G

selenium sulfide topical lotion G

selenium sulfide topical shampoo 2.25 % G

SELRX NPB selenium sulfide

SILIQ NPB-S PA; ST

COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG

NPB acitretin

SORILUX NPB QL calcipotriene, calcitriol, ENSTILAR, TACLONEX

sulfacetamide sodium topical G

TACLONEX TOPICAL OINTMENT NPB QL calcipotriene-betamethasone dp

TACLONEX TOPICAL SUSPENSION PB

TALTZ AUTOINJECTOR NPB-S PA; 2ST

COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA

TALTZ AUTOINJECTOR (2 PACK) NPB-S PA; 2ST

COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA

TALTZ AUTOINJECTOR (3 PACK) NPB-S PA; 2ST

COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA

TALTZ SYRINGE NPB-S PA; 2ST

COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA

TALTZ SYRINGE (2 PACK) NPB-S PA; 2ST

COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA

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58

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

TALTZ SYRINGE (3 PACK) NPB-S PA; 2ST

COSENTYX 150MG, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA

TERSI FOAM NPB selenium sulfide

VECTICAL NPB QL calcitriol

ZITHRANOL NPB

BURN THERAPY

SILVADENE NPB silver sulfadiazine

silver sulfadiazine G

ssd G

thermazene G

KERATOLYTICS

BENSAL HP TOPICAL OINTMENT 3 %

NPB

INOVA 4-1 NPB ST benzoyl peroxide

KERALYT RX NPB salicylic acid

PODOCON NPB podofilox

POTASSIUM HYDROXIDE NPB

salacyn G

SALEX TOPICAL COMBO PACK NPB salicylic acid, salicylic acid

SALEX TOPICAL SHAMPOO NPB salicylic acid

salicylic acid topical cream G

salicylic acid topical cream,extended release

G

salicylic acid topical film forming liquid w/appl

G

salicylic acid topical film-forming soln er w/ appl

G

salicylic acid topical foam G

salicylic acid topical gel G

salicylic acid topical liquid 26 % G

salicylic acid topical lotion G

salicylic acid topical lotion,extended release

G

salicylic acid topical shampoo G

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59

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

SALKERA NPB salicylic acid

salvax G

SALVAX DUO PLUS NPB salicylic acid

ULTRASAL-ER NPB

VIRASAL NPB salicylic acid

MISCELLANEOUS DERMATOLOGICALS

ATOPICLAIR NPB pruclair

ATRAPRO CP NPB prumyx, prutect, sonafine

ATRAPRO HYDROGEL NPB

avo cream G

BIAFINE EMULSION NPB avo, prutect, sonafine

bp-50% urea G

CARAC PB QL

celacyn G

CONDYLOX TOPICAL GEL PB

CORTANE-B TOPICAL NPB hc pramoxine

DEXERYL NPB

diclofenac sodium topical gel 3 % G QL

doxepin topical G

DUPIXENT PB-S PA

EFUDEX TOPICAL CREAM NPB fluorouracil

eletone G

ELIDEL PB ST; QL

EPICERAM NPB emulsion sb

EUCRISA NPB PA; ST; QL tacrolimus, ELIDEL

FLUOROPLEX NPB QL

diclofenac sodium, fluorouracil, fluorouracil, imiquimod, CARAC, PICATO

FLUOROURACIL TOPICAL CREAM 0.5 %

NPB QL; 2ST

diclofenac sodium, fluorouracil, fluorouracil, imiquimod, CARAC, PICATO

fluorouracil topical cream 5 % G

fluorouracil topical solution G QL

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60

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

GORDONS UREA TOPICAL OINTMENT 40 %

NPB

hpr G

hpr plus G

hpr plus hydrogel G

HPR PLUS-MB HYDROGEL NPB

HYDRO 35 NPB urea

HYDRO 40 NPB urea

HYLATOPIC NPB prumyx

HYLATOPICPLUS NPB hpr plus

KERAFOAM NPB umecta

KERALAC NPB urea

lactic acid G

lactic acid e G

latrix G

LOUTREX NPB ciclopirox, ketoconazole

luxamend G

methoxsalen G

NEOSALUS NPB prumyx

nivatopic plus G

OXSORALEN ULTRA NPB METHOXSALEN

PANRETIN NPB

PICATO PB QL

podofilox G

PRESERA NPB hpr

PROMISEB NPB selenium sulfide, sodium sulfacetamide

PROTOPIC NPB ST; QL tacrolimus

pruclair G

prudoxin G

prumyx G

prutect G

rea lo 39 G

rea lo 40 topical lotion G

REGRANEX PB QL

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61

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

remeven G

RESTIZAN NPB

silver nitrate G

silver nitrate applicators G

SOLARAZE NPB QL diclofenac sodium

sonafine G

sp antipruritic G

sp scar management G

tacrolimus topical G ST; QL

TOLAK NPB QL

diclofenac sodium, fluorouracil, fluorouracil, imiquimod, CARAC, PICATO

umecta topical foam G

urea nail stick G

urea topical cream 39 %, 40 %, 45 %, 47 %, 50 %

G

urea topical foam G

urea topical gel 45 % G

urea topical lotion 40 %, 45 % G

UTOPIC NPB urea

VALCHLOR PB-S

VEREGEN NPB imiquimod, podofilox

XCLAIR NPB emulsion sb

ZANABIN NPB

ZONALON NPB prudoxin

THERAPY FOR ACNE

ABSORICA PB QL

ACANYA TOPICAL GEL WITH PUMP

PB ST; QL

ACZONE NPB ST benzoyl peroxide, clindamycin phosphate, erythromycin

adapalene topical cream G QL

adapalene topical gel 0.3 % G QL

adapalene topical gel with pump G QL

ADAPALENE TOPICAL LOTION NPB ST; QL adapalene, adapalene

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62

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ATRALIN NPB QL tretinoin

AVAR LS NPB ST sulfacetamide sodium-sulfur

avar topical cleanser G

AVAR TOPICAL FOAM NPB ST sulfacetamide sodium-sulfur

AVAR TOPICAL PADS, MEDICATED NPB ST sulfacetamide sodium-sulfur

AVAR-E GREEN NPB ST sulfacetamide sodium-sulfur

AVAR-E LS NPB ST sulfacetamide sodium-sulfur

avita topical cream G QL

AVITA TOPICAL GEL NPB QL tretinoin, adapalene, EPIDUO

AZELEX NPB ST; QL adapalene, metronidazole, tretinoin, FINACEA, TAZORAC

BENZACLIN NPB ST clindamycin-benzoyl peroxide

BENZACLIN PUMP NPB ST; QL clindamycin-benzoyl peroxide

BENZAMYCIN NPB ST erythromycin-benzoyl peroxide

BENZEFOAM NPB ST benzoyl peroxide

BENZEFOAM ULTRA NPB ST benzoyl peroxide

benzepro topical towelette G

bp 10-1 G

bpo topical gel G

bpo topical towelette 6 % G

claravis G QL

cleansing wash topical cleanser G

CLEOCIN T NPB ST clindamycin phosphate

CLINDACIN ETZ TOPICAL KIT NPB ST clindamycin phosphate, clindacin etz

clindacin p G

CLINDACIN PAC NPB ST clindamycin phosphate, clindacin etz

CLINDAGEL NPB ST clindamycin phosphate

clindamycin phosphate topical G

clindamycin-benzoyl peroxide topical gel 1.2 %(1 % base) -5 %

G QL

clindamycin-benzoyl peroxide topical gel 1-5 %

G

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63

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

clindamycin-benzoyl peroxide topical gel with pump

G QL

clindamycin-tretinoin G

DIFFERIN TOPICAL CREAM NPB ST; QL adapalene

DIFFERIN TOPICAL GEL 0.3 % NPB ST; QL adapalene

DIFFERIN TOPICAL GEL WITH PUMP

NPB ST; QL adapalene

DIFFERIN TOPICAL LOTION NPB ST; QL adapalene, adapalene

DUAC NPB ST; QL clindamycin-benzoyl peroxide

EPIDUO FORTE PB ST

EPIDUO TOPICAL GEL WITH PUMP PB ST; QL

ery pads G

erygel G

erythromycin with ethanol G

erythromycin-benzoyl peroxide G

EVOCLIN NPB ST clindamycin phosphate

FABIOR NPB PA; QL TAZORAC

FINACEA PB ST

INOVA TOPICAL COMBO PACK 4-5 %

NPB ST benzoyl peroxide

METROCREAM NPB ST metronidazole

METROGEL TOPICAL GEL 1 % NPB ST metronidazole

METROGEL TOPICAL GEL WITH PUMP

NPB ST metronidazole

METROLOTION NPB ST metronidazole

metronidazole topical G

MIRVASO PB

neuac G QL

NEUAC KIT NPB ST

NORITATE NPB ST metronidazole

NUOX NPB ST

ONEXTON TOPICAL GEL WITH PUMP

PB ST; QL

PLEXION NPB ST sulfacetamide sodium-sulfur

PLEXION CLEANSING CLOTHS NPB ST sulfacetamide sodium-sulfur

RETIN-A MICRO NPB tretinoin microsphere

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64

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.04 %, 0.1 %

NPB tretinoin microsphere

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.08 %

NPB adapalene, tretinoin, EPIDUO

RETIN-A TOPICAL CREAM 0.025 % NPB QL tretinoin

RETIN-A TOPICAL CREAM 0.05 %, 0.1 %

NPB tretinoin

RETIN-A TOPICAL GEL 0.01 % NPB tretinoin

RETIN-A TOPICAL GEL 0.025 % NPB QL tretinoin

rosadan topical cream G

rosadan topical gel G

ROSADAN TOPICAL KIT, CLEANSER AND GEL

NPB ST metronidazole

ROSADAN TOPICAL KIT,CLEANSER AND CREAM

NPB ST metronidazole

ROSANIL NPB ST sulfacetamide sodium-sulfur

ROSULA NPB ST

rosula cleansing cloths G

SOOLANTRA PB ST

ss 10-2 G

sss 10-5 G

sulfacetamide sodium-sulfur topical cleanser

G

sulfacetamide sodium-sulfur topical cream

G

sulfacetamide sodium-sulfur topical lotion

G

sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

G

sulfacetamide sodium-sulfur topical suspension

G

sulfacetamide sod-sulfur-urea topical cleanser

G

sulfacleanse 8-4 G

SUMADAN TOPICAL CLEANSER NPB ST sulfacetamide sodium-sulfur

SUMAXIN NPB ST sulfacetamide sodium-sulfur

SUMAXIN TS NPB ST sulfacetamide sodium-sulfur

tazarotene G QL

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65

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

TAZORAC TOPICAL CREAM 0.05 % PB QL

TAZORAC TOPICAL CREAM 0.1 % NPB QL TAZAROTENE

TAZORAC TOPICAL GEL PB QL

tretinoin microspheres G

tretinoin topical cream 0.025 % G QL

tretinoin topical cream 0.05 %, 0.1 % G

tretinoin topical gel 0.01 % G

tretinoin topical gel 0.025 %, 0.05 % G QL

TRETIN-X CREAM KIT NPB tretinoin

TRETIN-X TOPICAL CREAM 0.075 % NPB tretinoin

VANOXIDE-HC NPB ST

VELTIN NPB 2ST

clindamycin phos-tretinoin, clindamycin phosphate, tretinoin, ACANYA, ONEXTON

zenatane G QL

zencia G

ZIANA NPB ST clindamycin phos-tretinoin

TOPICAL ANESTHETICS

BUCALSEP NPB

ethyl chloride G

glydo G

lidocaine hcl laryngotracheal G

lidocaine hcl mucous membrane jelly G

lidocaine hcl mucous membrane jelly in applicator

G

lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

G

lidocaine hcl-hydrocortison ac topical G

lidocaine topical adhesive patch,medicated

G

lidocaine topical ointment G

lidocaine viscous G

lidocaine-prilocaine G

LIDOCAINE-TETRACAINE NPB ST lidocaine-prilocaine, lidocaine hcl

LIDODERM NPB lidocaine

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66

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

lta pre-attached G

PLIAGLIS NPB

SYNERA NPB lidocaine, lidocaine-prilocaine

TOPICAL ANTIBACTERIALS

ALTABAX NPB mupirocin, mupirocin

BACTROBAN TOPICAL CREAM NPB mupirocin

CENTANY NPB mupirocin, mupirocin

CENTANY AT NPB mupirocin, mupirocin

CORTISPORIN TOPICAL NPB gentamicin sulfate

dermazene G

gentamicin topical G

hydrocortisone-iodoquinol-aloe G

iodoquinol-hc G

KLARON NPB ST sulfacetamide sodium

lugols topical G

mupirocin G

mupirocin calcium G

NEO-SYNALAR NPB

NEO-SYNALAR KIT NPB

SILVRSTAT NPB avo, prutect, sonafine

sulfacetamide sodium (acne) G

SULFAMYLON PB

TOPICAL ANTIFUNGALS

ciclodan G

CICLODAN KIT TOPICAL COMBO PACK

NPB

CICLODAN KIT TOPICAL SOLUTION

NPB ciclopirox

ciclopirox G

clotrimazole-betamethasone G

econazole G

ECOZA NPB econazole nitrate, ciclopirox, ketoconazole, naftifine hcl

ERTACZO NPB ciclopirox, econazole nitrate, ketoconazole, naftifine hcl

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67

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

EXELDERM NPB

ciclopirox, ciclopirox, econazole nitrate, ketoconazole, oxiconazole nitrate

EXODERM NPB clotrimazole, ketoconazole, miconazole nitrate

EXTINA NPB ketoconazole

JUBLIA NPB QL ciclopirox

KERYDIN NPB QL ciclopirox

ketoconazole topical G

LOPROX (AS OLAMINE) NPB ciclopirox

LOPROX KIT NPB ciclopirox

LOPROX TOPICAL SHAMPOO NPB ciclopirox

LOTRISONE TOPICAL CREAM NPB clotrimazole/betamethasone

LUZU NPB QL

ciclopirox, ciclopirox, econazole nitrate, ketoconazole, oxiconazole nitrate

naftifine G

NAFTIN TOPICAL CREAM 2 % NPB naftifine hcl

NAFTIN TOPICAL GEL NPB

naftifine hcl, ciclopirox, clotrimazole, econazole nitrate, ketoconazole, oxiconazole nitrate

NIZORAL TOPICAL SHAMPOO NPB ketoconazole

nyamyc G

nyata G

nystatin topical G

nystatin-triamcinolone G

nystop G

oxiconazole G

OXISTAT TOPICAL CREAM NPB oxiconazole nitrate

OXISTAT TOPICAL LOTION NPB

oxiconazole nitrate, ciclopirox, clotrimazole, econazole nitrate, ketoconazole, naftifine hcl

PENLAC NPB ciclopirox

TRIACETIN PB

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68

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

TRIPLE DYE NPB

VUSION NPB miconazole nitrate

XOLEGEL NPB

ciclopirox, ciclopirox, econazole nitrate, ketoconazole, oxiconazole nitrate

TOPICAL ANTIVIRALS

acyclovir topical G QL

DENAVIR NPB acyclovir, acyclovir, famciclovir, valacyclovir, ZOVIRAX

XERESE NPB QL acyclovir, acyclovir, famciclovir, valacyclovir, ZOVIRAX

ZOVIRAX TOPICAL CREAM PB QL

ZOVIRAX TOPICAL OINTMENT NPB QL acyclovir

TOPICAL CORTICOSTEROIDS

ala-cort topical cream 2.5 % G

ALA-SCALP NPB ST hydrocortisone

alclometasone G

amcinonide G

apexicon e G QL

AQUA GLYCOLIC HC NPB ST

betamethasone dipropionate G

betamethasone valerate G

betamethasone, augmented G

CAPEX NPB ST; QL fluocinolone acetonide

clobetasol G

clobetasol-emollient G

CLOBEX NPB ST clobetasol propionate

CLOCORTOLONE PIVALATE NPB ST; QL

clodan G

CLODAN KIT NPB ST

CLODERM NPB ST; QL betamethasone valerate, fluocinolone acetonide, triamcinolone acetonide

CORDRAN TAPE LARGE ROLL NPB ST; QL flurandrenolide

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69

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

CORDRAN TOPICAL CREAM NPB ST flurandrenolide

CORDRAN TOPICAL LOTION NPB ST flurandrenolide

CORDRAN TOPICAL OINTMENT NPB ST flurandrenolide

cormax scalp G

CUTIVATE TOPICAL CREAM NPB ST fluticasone propionate

CUTIVATE TOPICAL LOTION NPB ST fluticasone propionate

DERMA-SMOOTHE/FS BODY OIL NPB ST; QL fluocinolone acetonide

DERMA-SMOOTHE/FS SCALP OIL NPB ST; QL fluocinolone acetonide

DERMATOP NPB ST prednicarbate

DESONATE NPB ST desonide

desonide G QL

DESOWEN NPB ST; QL desonide

desoximetasone G QL

diflorasone G QL

DIPROLENE AF NPB ST betamethasone dipropionate

DIPROLENE TOPICAL OINTMENT NPB ST betamethasone dipropionate

ELOCON TOPICAL CREAM NPB ST mometasone furoate

ELOCON TOPICAL OINTMENT NPB ST mometasone furoate

fluocinolone G QL

fluocinolone and shower cap G QL

fluocinonide G

fluocinonide-e G

flurandrenolide G

fluticasone topical G

halobetasol propionate G QL

HALOG NPB ST

betamethasone dipropionate, betamethasone dipropionate, betamethasone valerate, fluocinonide, triamcinolone acetonide

hydrocortisone butyrate G

hydrocortisone butyr-emollient G

hydrocortisone topical cream 2.5 % G

hydrocortisone topical lotion 2.5 % G

hydrocortisone topical ointment 2.5 % G

hydrocortisone valerate G

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70

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

hydrocortisone-min oil-wht pet G

KENALOG TOPICAL NPB ST triamcinolone acetonide

LOCOID NPB ST hydrocortisone butyrate

LOCOID LIPOCREAM NPB ST hydrocortisone butyrate

LUXIQ NPB ST betamethasone valerate

mometasone topical G

nolix G

OLUX NPB ST clobetasol propionate

OLUX-E NPB ST clobetasol propionate

PANDEL NPB ST betamethasone valerate, hydrocortisone valerate, triamcinolone acetonide

prednicarbate G

PSORCON NPB ST; QL

scalacort G

SERNIVO NPB ST

betamethasone dipropionate, betamethasone valerate, desoximetasone, fluocinolone acetonide, fluocinonide, triamcinolone acetonide

SYNALAR NPB ST; QL fluocinolone acetonide

SYNALAR CREAM KIT NPB ST fluocinolone acetonide

SYNALAR OINTMENT KIT NPB ST fluocinolone acetonide

SYNALAR TS NPB ST fluocinolone acetonide

TEMOVATE TOPICAL CREAM NPB ST clobetasol propionate

TEMOVATE TOPICAL OINTMENT NPB ST clobetasol propionate

TEXACORT NPB ST hydrocortisone butyrate

TOPICORT TOPICAL CREAM NPB ST; QL desoximetasone

TOPICORT TOPICAL GEL NPB ST; QL desoximetasone

TOPICORT TOPICAL OINTMENT NPB ST; QL desoximetasone

TOPICORT TOPICAL SPRAY,NON-AEROSOL

NPB ST desoximetasone

triamcinolone acetonide topical aerosol G

triamcinolone acetonide topical cream G

triamcinolone acetonide topical lotion G

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

G

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71

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

trianex G

triderm topical cream G

TRIDESILON NPB ST; QL

ULTRAVATE TOPICAL CREAM NPB ST; QL halobetasol propionate

ULTRAVATE TOPICAL LOTION NPB ST

halobetasol propionate, betamethasone dipropionate, clobetasol propionate, diflorasone diacetate, fluocinonide

ULTRAVATE TOPICAL OINTMENT NPB ST; QL halobetasol propionate

ULTRAVATE X NPB ST halobetasol propionate

VANOS NPB ST fluocinonide

VERDESO NPB ST desonide

TOPICAL ENZYMES

SANTYL PB

TOPICAL SCABICIDES / PEDICULICIDES

ELIMITE NPB permethrin

EURAX NPB permethrin, lindane

lindane topical shampoo G

malathion G

NATROBA NPB QL spinosad

OVIDE NPB malathion

permethrin topical cream G

SKLICE NPB lindane, malathion, permethrin, spinosad

spinosad G QL

ULESFIA NPB permethrin, malathion, spinosad, lindane

DIAGNOSTICS & MISCELLANEOUS AGENTS

ANOREXIANTS

BELVIQ NPB benzphetamine hcl, diethylpropion hcl, phentermine hcl

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72

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

BELVIQ XR NPB benzphetamine hcl, diethylpropion hcl, phentermine hcl

QSYMIA NPB 2ST benzphetamine hcl, diethylpropion hcl, phentermine hcl

IRRIGATING SOLUTIONS

lactated ringers irrigation G

PHYSIOLYTE NPB

PHYSIOSOL IRRIGATION NPB

ringer's irrigation G

SORBITOL-MANNITOL NPB

tis-u-sol pentalyte G

VASHE WOUND THERAPY NPB

MISCELLANEOUS AGENTS

acamprosate G

ACTONEL ORAL TABLET 30 MG NPB QL risedronate sodium

AGRYLIN NPB-S M anagrelide hydrochloride

alendronate oral tablet 40 mg G QL; M

anagrelide G M

ANTABUSE NPB disulfiram

BUPHENYL ORAL POWDER NPB sodium phenylbutyrate

BUPHENYL ORAL TABLET PB

caffeine citrate oral G

CARBAGLU PB-S PA

CARNITOR (SUGAR-FREE) NPB M levocarnitine

CARNITOR ORAL NPB M levocarnitine

cevimeline G M

CHEMET PB

disulfiram G

etidronate disodium G M

EVOXAC NPB M cevimeline hcl

EXJADE PB-S

FERRIPROX PB-S

INCRELEX PB-S PA

JADENU PB-S

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73

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

levocarnitine (with sugar) G M

levocarnitine oral tablet G M

LIPOCHOL PLUS NPB LIPOCHOL

LITHOSTAT NPB

METOPIRONE NPB

midodrine G

NORTHERA NPB-S fludrocortisone acetate, midodrine hcl

NUTRESTORE NPB

ORFADIN PB-S

pilocarpine hcl oral tablet 5 mg G

RAVICTI PB-S

RILUTEK NPB riluzole

riluzole G

risedronate oral tablet 30 mg G QL

SALAGEN (PILOCARPINE) ORAL TABLET 5 MG

NPB pilocarpine hcl

sodium phenylbutyrate G

SYPRINE NPB DEPEN

THIOLA NPB

water for irrigation, sterile G

XURIDEN PB

SMOKING DETERRENTS

bupropion hcl (smoking deter) G M; ACA

CHANTIX PB ACA

CHANTIX CONTINUING MONTH BOX

PB ACA

CHANTIX STARTING MONTH BOX PB ACA

NICODERM CQ TRANSDERMAL PATCH 24 HOUR 14 MG/24 HR, 7 MG/24 HR

PB ACA; OTC

NICODERM CQ TRANSDERMAL PATCH 24 HOUR 21 MG/24 HR

PB M; ACA; OTC

nicorelief G ACA; OTC

NICORETTE BUCCAL GUM 2 MG PB ACA; OTC

nicorette buccal gum 4 mg G ACA; OTC

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74

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

NICORETTE BUCCAL LOZENGE PB ACA; OTC

NICORETTE BUCCAL MINI LOZENGE

PB ACA; OTC

nicotine (polacrilex) G ACA; OTC

nicotine transdermal patch 24 hour 14 mg/24 hr, 7 mg/24 hr

G ACA; OTC

nicotine transdermal patch 24 hour 21 mg/24 hr

G M; ACA; OTC

nicotine transdermal patch, td daily, sequential

G ACA; OTC

NICOTROL NPB ACA nicotine, nicotine gum

NICOTROL NS NPB ACA nicotine, nicotine gum

nts step 1 G M; ACA; OTC

quit 2 buccal gum G ACA; OTC

QUIT 2 BUCCAL LOZENGE PB ACA; OTC

quit 4 buccal gum G ACA; OTC

QUIT 4 BUCCAL LOZENGE PB ACA; OTC

stop smoking aid G ACA; OTC

ZYBAN NPB M; ACA bupropion sr

EAR, NOSE & THROAT MEDICATIONS

MISCELLANEOUS AGENTS

ASTEPRO NASAL SPRAY,NON-AEROSOL

NPB QL azelastine hcl

azelastine nasal G QL

BACTROBAN NASAL NPB mupirocin

chlorhexidine gluconate mucous membrane

G

CLINPRO 5000 NPB M

DEBACTEROL NPB

denta 5000 plus G M

dentagel G M

EPISIL NPB

fluoride (sodium) dental G M

FLUORIDEX DAILY DEFENSE DENTAL PASTE

NPB M

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75

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

GELCLAIR NPB

GELX NPB

ipratropium bromide nasal G QL

MUGARD NPB

olopatadine nasal G QL

oralone G

ORAMAGICRX NPB

paroex oral rinse G

PATANASE NPB QL olopatadine hcl

PERIDEX NPB chlorhexidine gluconate

periogard G

pilocarpine hcl oral tablet 7.5 mg G

PREVIDENT NPB M

PREVIDENT 5000 BOOSTER PLUS NPB M

PREVIDENT 5000 DRY MOUTH NPB M

PREVIDENT 5000 ENAMEL PROTECT

NPB M denta 5000 plus, sf 5000 plus

PREVIDENT 5000 PLUS NPB M

PREVIDENT 5000 SENSITIVE NPB M denta 5000 plus, sf 5000 plus

Q-CARE RX Q4 NPB

SALAGEN (PILOCARPINE) ORAL TABLET 7.5 MG

NPB pilocarpine hcl

sf G M

sf 5000 plus G M

triamcinolone acetonide dental G

TYZINE NASAL DROPS 0.1 % NPB

TYZINE NASAL SPRAY,NON-AEROSOL

NPB

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic G

acetic acid-aluminum acetate G

CETRAXAL NPB 2ST ciprofloxacin hcl, ofloxacin, CIPRODEX, OTOVEL

ciprofloxacin hcl otic G

DERMOTIC OIL NPB fluocinolone acetonide oil

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76

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

floxin otic drops G

fluocinolone acetonide oil G

hydrocortisone-acetic acid G

ofloxacin otic G

OTIPRIO NPB

OTIC STEROID / ANTIBIOTIC

CIPRO HC NPB CIPRODEX, OTOVEL

CIPRODEX PB

COLY-MYCIN S NPB neomycin/polymyxin/hc

neomycin-polymyxin-hc otic G

OTOVEL PB

ENDOCRINE/DIABETES

ADRENAL HORMONES

CORTEF NPB M hydrocortisone

cortisone G

deltasone oral tablet 20 mg G

dexamethasone G

dexamethasone intensol G

DEXPAK 10 DAY NPB ST dexamethasone

DEXPAK 13 DAY NPB ST dexamethasone

DEXPAK 6 DAY NPB ST dexamethasone

EMFLAZA NPB PA prednisone, prednisone

fludrocortisone G M

hydrocortisone oral G M

MEDROL NPB methylprednisolone

MEDROL (PAK) NPB methylprednisolone

methylprednisolone G

millipred dp G

MILLIPRED ORAL SOLUTION NPB prednisolone sodium phosphate

millipred oral tablet G

ORAPRED ODT NPB prednisolone sodium phosphate

PEDIAPRED NPB prednisolone sodium phosphate

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77

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

prednisolone oral solution 15 mg/5 ml G

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

G

prednisolone sodium phosphate oral tablet,disintegrating

G

prednisone G

prednisone intensol G

RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) 1 MG, 2 MG

NPB 2ST prednisone

RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) 5 MG

NPB 2ST prednisone

veripred 20 G

ANTITHYROID AGENTS

methimazole oral tablet 10 mg, 5 mg G M

propylthiouracil G M

SSKI NPB M strong iodine

TAPAZOLE NPB M methimazole

BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES

ACCU-CHEK AVIVA PLUS TEST STRP

NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ACCU-CHEK COMPACT PLUS TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ACCU-CHEK GUIDE NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ACCU-CHEK SMARTVIEW TEST STRIP

NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ACCUTREND GLUCOSE NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

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78

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ADVANCED GLUC METER TEST STRIP

NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ADVOCATE REDI-CODE NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ADVOCATE TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

AGAMATRIX AMP TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ASSURE 4 STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ASSURE PLATINUM STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ASSURE PRISM MULTI STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

BIONIME RIGHTEST TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

BLOOD GLUCOSE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

BREEZE 2 TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

CARESENS N TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

CLEVER CHOICE MICRO TEST STRIP

NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

CLEVER CHOICE PRO STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

CLEVER CHOICE TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

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79

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

CLEVER CHOICE VOICE+ TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

CONTOUR NEXT STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

CONTOUR TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

COOL GLUCOSE TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

DIATRUE PLUS TEST STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EASY PLUS II TEST NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EASY STEP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EASY TALK GLUCOSE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EASY TOUCH TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EASY TRAK GLUCOSE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EASYGLUCO PLUS STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EASYGLUCO TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EASYMAX NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ELEMENT COMPACT TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

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80

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ELEMENT TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EMBRACE BLOOD GLUCOSE SYSTEM STRIP

NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EMBRACE EVO TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EMBRACE PRO TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EVENCARE G2 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EVENCARE G3 TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EVENCARE MINI GLUCOSE TEST STR

NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EVOLUTION TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EZ SMART PLUS TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

EZ SMART TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FIFTY50 TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORA D15G NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORA D20 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORA D40-G31 TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

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81

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

FORA G20 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORA G30A STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORA GD50 TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORA TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORA TN'G VOICE TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORA V10 STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORA V10-V12-D10-D20 STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORA V12 GLUCOSE NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORA V20 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORACARE GD20 NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORACARE GD40 NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FORTISCARE GLUCOSE TEST STRIPS

NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FREESTYLE INSULINX STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FREESTYLE INSULINX TEST STRIPS

NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

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82

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

FREESTYLE LITE STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FREESTYLE PRECISION NEO STRIPS

NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

FREESTYLE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

GE100 BLOOD GLUCOSE TEST STRIP

NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

GENSTRIP TEST STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

GLUCO NAVII TEST STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

GLUCOCARD 01 SENSOR PLUS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

GLUCOCARD EXPRESSION STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

GLUCOCARD SHINE TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

GLUCOCARD VITAL SENSOR NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

GLUCOCARD VITAL TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

GLUCOCOM GLUCOSE NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

GM100 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

GMATE TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

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83

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

HEALTHPRO TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

INFINITY TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

LIBERTY TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

MICRO BLOOD GLUCOSE NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

MICRODOT BLOOD GLUCOSE SYSTEM STRIP

NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

MYGLUCOHEALTH STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

NEUTEK 2TEK TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

NOVA MAX GLUCOSE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ON CALL EXPRESS TEST STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ON CALL PLUS TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ON CALL VIVID TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ONETOUCH ULTRA TEST PB QL; OTC

ONETOUCH VERIO PB QL; OTC

OPTIUM EZ NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

OPTIUM TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

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84

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

OPTUMRX STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

PHARMACIST CHOICE NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

PRECISION PCX PLUS TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

PRECISION PCX TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

PRECISION POINT OF CARE TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

PRECISION Q-I-D TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

PRECISION XTRA TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

PREMIUM V10 STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

PRODIGY NO CODING NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

QUINTET AC STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

REFUAH PLUS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

RELION CONFIRM-MICRO NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

RELION PRIME TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

REVEAL TEST STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

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85

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

RIGHTEST GS550 TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

SMART SENSE TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

SMARTEST TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

SOLUS V2 TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

SURE-TEST EASYPLUS MINI STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

TELCARE TEST STRIPS NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

TEST N'GO TEST NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

TRUE METRIX GLUCOSE TEST STRIP

NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

TRUETEST TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

TRUETRACK TEST NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ULTIMA TEST STRIPS NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ULTRATRAK NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

ULTRATRAK ULTIMATE STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

UNISTRIP1 TEST STRIP NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

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86

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

WAVESENSE JAZZ NPB ST; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

WAVESENSE PRESTO STRIP NPB ST; QL; OTC ONE TOUCH ULTRA TEST STRIPS, ONE TOUCH VERIO

DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT

GLUCAGEN DIAGNOSTIC KIT PB

GLUCAGON HCL NPB

INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.5 ML 29 GAUGE X 1/2"

PB M

GLUCOSE ELEVATING AGENTS

GLUCAGEN HYPOKIT PB

GLUCAGON EMERGENCY KIT (HUMAN)

PB

PROGLYCEM PB M

INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU

2TEK GLUCOSE/BLOOD PRESSURE NPB QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ACCU-CHEK AVIVA CONNECT METER

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ACCU-CHEK AVIVA PLUS METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ACCU-CHEK COMPACT PLUS CONTROL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

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87

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ACCU-CHEK GUIDE GLUCOSE METER

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ACCU-CHEK GUIDE L1-L2 CTRL SOL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ACCU-CHEK NANO NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ACCU-CHEK SMARTVIEW CONTRL SOL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ACCUTREND GLUCOSE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ADVANCED GLUCOSE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ADVOCATE BLOOD GLUCOSE MONITOR

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ADVOCATE DUO NPB QL; 2ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ADVOCATE LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ADVOCATE REDI-CODE DUO METER

NPB QL; 2ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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88

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ADVOCATE REDI-CODE GLU MONITOR

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ADVOCATE REDI-CODE+ CTRL LOW

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

AGAMATRIX AMP GLUC MONITOR SYS

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

AGAMATRIX CONTROL HIGH NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ASSURE 4 CONTROL SOLUTION NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ASSURE DOSE NORMAL CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ASSURE PLATINUM NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ASSURE PRISM CONTROL 1-2 SOLN NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ASSURE PRISM MULTI METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

AUTOJECT 2 INJECTION DEVICE PB OTC

AUTOPEN 1 TO 21 UNITS PB OTC

BIONIME RIGHTEST GM300 SYSTEM

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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89

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

BLOOD GLUCOSE CONTROL, NORMAL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

BLOOD-GLUCOSE METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

BREEZE 2 CONTROL SOLUTION,HIGH

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

CARESENS CONTROL A NORMAL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

CARESENS N NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

CARESENS N VOICE NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

CLEO 90 INFUSION SET 24" PB

CLEVER CHEK BLOOD GLUCOSE NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

CLEVER CHOICE GLUCOSE MONITOR

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

CLEVER CHOICE LEVEL 2 CONTROL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

CLEVER CHOICE MICRO NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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90

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

CLEVER CHOICE PRO NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

COMFORT SHORT INSULIN PUMP 23"

PB

CONTOUR CONTROL SOLUTION, NML

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

CONTOUR LINK NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

CONTOUR NEXT EZ METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

CONTOUR NEXT LEV 2 CONTROL SOL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

CONTOUR NEXT LINK NPB QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

CONTOUR NEXT METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

CONTOUR NEXT ONE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

CONTROL AST MONITORING SYSTEM

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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91

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

COOL BLOOD GLUCOSE METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

COOL CONTROL A SOLUTION NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

DEXCOM G4 RECEIVER PB QL

DEXCOM G5 RECEIVER PB QL

DIATRUE CONTROL SOLN NORMAL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

DIATRUE PLUS BLOOD GLUCOSE MET

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EASY PLUS II BLOOD GLUCOSE MET

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EASY STEP BLOOD GLUCOSE METER

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EASY TALK BLOOD GLUCOSE METER

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EASY TOUCH GLUCOSE MONITOR NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EASY TRAK LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

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92

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

EASYGLUCO MONITORING SYSTEM

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EASYGLUCO PLUS KIT NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EASYGLUCO PLUS NORMAL CONTROL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

EASYMAX L BLOOD GLUCOSE METER

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EASYMAX LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

EASYMAX NG KIT NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EASYMAX NORMAL CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

EASYMAX V SPEAKING GLUCOSE SYS

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EASYMAX V2 BLOOD GLUCOSE METER

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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93

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ELEMENT COMPACT GLUCOSE METER

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ELEMENT COMPACT NORMAL CONTROL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ELEMENT COMPACT V GLUCOSE MTR

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ELEMENT NORMAL CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ELEMENT PLUS BLOOD GLUCOSE KIT

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EMBRACE BLOOD GLUCOSE SYSTEM

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EMBRACE EVO LEVEL 1 NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

EMBRACE GLUCOSE CONTROL LOW

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

EMBRACE PRO GLUCOSE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EVENCARE G2 NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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94

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

EVENCARE G3 GLUCOSE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EVENCARE MINI MONITOR SYSTEM

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EVOLUTION BLOOD GLUCOSE METER

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EVOLUTION NORMAL CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

EZ SMART PLUS SYSTEM NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

EZ SMART SYSTEM NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORA D10 NPB QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORA D20 KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORA G20 KIT NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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95

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

FORA G30A NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORA GD50 BLOOD GLUCOSE SYSTEM

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORA NORMAL CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

FORA PREMIUM V10 GLUCOSE METER

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORA TEST N'GO VOICE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORA TN'G VOICE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORA V10 KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORA V12 BLOOD GLUCOSE SYSTEM

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORA V20 KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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96

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

FORA V30A KIT NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORACARE GD20 GLUCOSE METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORACARE GD40A GLUCOSE METER

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORACARE GD40B GLUCOSE METER

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORACARE GDH LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

FORTISCARE BLOOD GLUCOSE SYST

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FORTISCARE NORMAL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

FREESTYLE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

FREESTYLE FLASH SYSTEM NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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97

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

FREESTYLE FREEDOM NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FREESTYLE FREEDOM LITE NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FREESTYLE INSULINX NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FREESTYLE LITE METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FREESTYLE PRECISION NEO METER

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FREESTYLE SIDEKICK II NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

FREESTYLE SYSTEM KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

GE100 BLOOD GLUCOSE SYSTEM NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

GE100 CONTROL SOLUTION NORMAL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

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98

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

GLUCO NAVII GLUCOSE MONITOR NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

GLUCOCARD 01 METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

GLUCOCARD 01 NORMAL CONTROL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

GLUCOCARD EXPRESSION NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

GLUCOCARD SHINE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

GLUCOCARD VITAL NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

GLUCOCOM BLOOD GLUCOSE NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

GLUCOCOM CONTROL NORMAL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

GLUCOSE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

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99

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

GM100 KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

GMATE CONTROL SOLUTION, NORMAL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

GMATE SMART METER NPB QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

GMATE SMART STARTER NPB QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

GMATE VOICE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

HEALTHPRO GLUCOSE MONITOR NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

HEALTHPRO HIGH-LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

HUMAPEN LUXURA HD PB

INFINITY CONTROL SOLUTION NORM

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

INFINITY STARTER KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

INSET 30 INFUSION SET 23" PB

INSET INFUSION SET 23" PB

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100

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

JAZZ WIRELESS 2 METER KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

LANCETS 33 GAUGE PB OTC

LANCING DEVICE PB OTC

LIBERTY BLOOD GLUCOSE MONITOR

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

LIBERTY LEV 1 GLUCOSE CONTROL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

LIBERTY LEV 2 GLUCOSE CONTROL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

MEDISENSE NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

MEDISENSE GLUCOSE KETONE NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

MICRODOT BLOOD GLUCOSE SYSTEM

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

MYGLUCOHEALTH CONTROL SOLUTION

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

MYGLUCOHEALTH KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

NOVA MAX BLOOD GLUCOSE METER

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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101

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

NOVA MAX GLUCOSE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

NOVAMAX PLUS GLU-KET NPB OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

NOVOPEN ECHO NPB

ON CALL EXPRESS CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ON CALL EXPRESS METER KIT NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ON CALL PLUS CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ON CALL PLUS METER KIT NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ON CALL VIVID CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

ON CALL VIVID METER KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ON CALL VIVID PAL METER KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ONETOUCH ULTRA CONTROL PB OTC

ONETOUCH ULTRA2 PB QL; OTC

ONETOUCH ULTRAMINI PB QL; OTC

ONETOUCH VERIO FLEX PB ST; OTC

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102

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ONETOUCH VERIO IQ METER PB QL; OTC

ONETOUCH VERIO SYNC PB OTC

ONETOUCH VERIO SYSTEM PB OTC

OPTUMRX KIT NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

PEN NEEDLE NEEDLE 31 GAUGE X 1/4"

PB M; OTC

PHARMACIST CHOICE GLUCOSE SYS

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

PRECISION XTRA MONITOR PB ST; QL; OTC

PREMIUM BLOOD GLUCOSE MONITOR

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

PREMIUM V10 NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

PRESTO PRO BLOOD GLUCOSE METER

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

PRODIGY AUTOCODE METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

PRODIGY AUTOCODE MONITOR SYST

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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103

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

PRODIGY CONTROL SOLUTION, LOW

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

PRODIGY CONTROL SOLUTION,HIGH

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

PRODIGY POCKET METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

PRODIGY VOICE GLUCOSE METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

QUINTET BLOOD GLUCOSE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

REFUAH PLUS GLUCOSE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

REFUAH PLUS GLUCOSE MONITOR NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

RELION ALL-IN-ONE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

RELION CONFIRM NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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104

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

RELION MICRO GLUCOSE MONITOR KIT

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

RELION PRIME METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

REVEAL BLOOD GLUCOSE METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

RIGHTEST CONTROL SOLUTION HIGH

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

RIGHTEST GM550 SYSTEM NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

SIDEKICK BLOOD GLUCOSE SYSTEM

NPB OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

SMART SENSE MONITORING SYSTEM

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

SMARTEST CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

SMARTEST EJECT NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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105

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

SMARTEST PERSONA STARTER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

SMARTEST PRONTO STARTER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

SMARTEST PROTEGE NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

SNAP INSULIN PUMP CONTROLLER

PB

SOLUS V2 AUDIBLE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

SOLUS V2 AUDIBLE METER KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

SOLUS V2 CONTROL SOLUTION,HIGH

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

SURE-TEST EASYPLUS MINI METER

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

T:30 INFUSION SET PB

T:90 INFUSION SET 23" PB

T:SLIM PB

T:SLIM G4 PB

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106

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

TELCARE BGM NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

TELCARE BLOOD GLUCOSE KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

TELCARE CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

TEST N'GO BLOOD GLUCOSE SYSTEM

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

TRUE METRIX AIR GLUCOSE METER

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

TRUE METRIX GLUCOSE METER NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

TRUE METRIX GO GLUCOSE METER

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

TRUE METRIX LEVEL 1 NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

TRUE2GO BLOOD GLUCOSE SYSTEM

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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107

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

TRUECONTROL LEVEL 0 NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

TRUERESULT BLOOD GLUCOSE SYSTM

NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

TRUERESULT BLOOD GLUCOSE SYSTM KIT

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

TRUETEST LOW GLUCOSE CONTROL

NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

TRUETRACK BLOOD GLUCOSE SYSTEM

NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

TRUETRACK SMART SYSTEM KIT NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ULTIMA MONITOR NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ULTRATRAK GLUCOSE METER NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

ULTRATRAK ULTIMATE NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

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108

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

UNISTRIP LOW CONTROL NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

WAVESENSE AMP NPB ST; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

WAVESENSE CONTROL SOLUTION NPB OTC ONE TOUCH ULTRA CONTROL SOLN, ONE TOUCH VERIO

WAVESENSE PRESTO NPB ST; QL; OTC

ONE TOUCH ULTRAMINI, ONE TOUCH VERIO, ONETOUCH VERIO FLEX, ONE TOUCH VERIO IQ, ONE TOUCH VERIO SYNC

INSULIN THERAPY

AFREZZA INHALATION CARTRIDGE WITH INHALER 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60)

NPB M HUMALOG

AFREZZA INHALATION CARTRIDGE WITH INHALER 4 UNIT, 4 UNIT (30)/ 8 UNIT (60), 4 UNIT (60)/ 8 UNIT (30), 8 UNIT (60)/ 12 UNIT (30)

NPB QL; M HUMALOG

APIDRA NPB ST; QL; M HUMALOG

APIDRA SOLOSTAR NPB ST; QL; M HUMALOG

BASAGLAR KWIKPEN PB QL; M

HUMALOG PB QL; M

HUMALOG KWIKPEN PB QL; M

HUMALOG MIX 50-50 PB QL; M

HUMALOG MIX 50-50 KWIKPEN PB QL; M

HUMALOG MIX 75-25 PB QL; M

HUMALOG MIX 75-25 KWIKPEN PB QL; M

HUMULIN 70/30 PB QL; M

HUMULIN 70/30 KWIKPEN PB QL; M

HUMULIN N PB QL; M

HUMULIN N KWIKPEN PB M

HUMULIN R U-100 PB QL; M

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109

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

HUMULIN R U-500 (CONC) KWIKPEN

PB M

HUMULIN R U-500 (CONCENTRATED)

PB QL; M

LANTUS PB QL; M

LANTUS SOLOSTAR PB QL; M

LEVEMIR PB QL; M

LEVEMIR FLEXTOUCH PB QL; M

NOVOLOG NPB ST; QL; M HUMALOG

NOVOLOG FLEXPEN NPB ST; QL; M HUMALOG

NOVOLOG MIX 70-30 NPB ST; QL; M HUMALOG MIX 75-25

NOVOLOG MIX 70-30 FLEXPEN NPB ST; QL; M HUMALOG MIX 75-25

NOVOLOG PENFILL NPB ST; QL; M HUMALOG

RELION NOVOLIN 70/30 NPB ST; QL; M HUMULIN 70-30

RELION NOVOLIN N NPB ST; QL; M HUMULIN N

RELION NOVOLIN R NPB ST; QL; M HUMULIN R

SOLIQUA 100/33 NPB ST; QL; M

BASAGLAR KWIKPEN U-100, LANTUS SOLOSTAR, LEVEMIR FLEXTOUCH, TRESIBA FLEXTOUCH U-100, BYDUREON PEN, BYETTA, TRULICITY

TOUJEO SOLOSTAR PB QL; M

TRESIBA FLEXTOUCH U-100 PB M

TRESIBA FLEXTOUCH U-200 PB M

XULTOPHY 100/3.6 NPB PA; ST; M

BASAGLAR KWIKPEN U-100, LANTUS SOLOSTAR, LEVEMIR FLEXTOUCH, TRESIBA FLEXTOUCH U-100, BYDUREON PEN, BYETTA, TRULICITY

MISCELLANEOUS HORMONES

ANDRODERM NPB PA testosterone, ANDROGEL, AXIRON

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

PB PA

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110

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)

NPB PA testosterone, ANDROGEL, AXIRON

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

PB PA

ANDROID NPB 2ST methyltestosterone, METHITEST

androxy G

AXIRON PB PA

cabergoline G QL; M

calcitonin (salmon) G M

calcitriol oral G M

CERDELGA PB-S

CETROTIDE SUBCUTANEOUS KIT 0.25 MG

PB

danazol G

DDAVP NASAL NPB M desmopressin acetate

DDAVP ORAL NPB M desmopressin acetate

DEPO-TESTOSTERONE NPB testosterone cypionate

desmopressin nasal solution G M

desmopressin nasal spray,non-aerosol G M

desmopressin oral G M

doxercalciferol oral G M

FORTESTA NPB PA; 2ST testosterone, ANDROGEL, AXIRON

GANIRELIX NPB-S ST CETROTIDE

HECTOROL ORAL NPB M doxercalciferol

KORLYM NPB-S PA ketoconazole, LYSODREN, SIGNIFOR

KUVAN ORAL POWDER IN PACKET 500 MG

PB-S PA

KUVAN ORAL TABLET,SOLUBLE PB-S PA

METHITEST PB

methyltestosterone oral capsule G

MIACALCIN NASAL NPB M calcitonin-salmon

MYALEPT PB-S

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111

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

NATESTO NPB 2ST testosterone, ANDROGEL, AXIRON

NATPARA PB-S

paricalcitol oral G M

RAYALDEE NPB M calcitriol, doxercalciferol, paricalcitol

ROCALTROL NPB M calcitriol

SAMSCA PB PA; QL

SENSIPAR PB

SOMAVERT PB-S

STIMATE PB M

STRENSIQ PB-S

STRIANT NPB ANDROGEL, ANDROGEL, AXIRON

SYNAREL PB

TESTIM NPB PA; 2ST testosterone, ANDROGEL, AXIRON

TESTOPEL NPB testosterone cypionate, testosterone enanthate

testosterone cypionate G

testosterone enanthate G

TESTOSTERONE TRANSDERMAL GEL

NPB PA; 2ST testosterone, ANDROGEL, AXIRON

TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG/0.5 GRAM /ACTUATION

NPB PA; 2ST testosterone, ANDROGEL, AXIRON

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)

G

testosterone transdermal gel in packet G

TESTRED NPB 2ST methyltestosterone, METHITEST

VOGELXO NPB PA; 2ST testosterone, ANDROGEL, AXIRON

ZAVESCA PB

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG

NPB M paricalcitol

NON-INSULIN HYPOGLYCEMIC AGENTS

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112

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

acarbose G M

ACTOPLUS MET NPB QL; M pioglitazone-metformin

ACTOPLUS MET XR PB QL; M

ACTOS NPB QL; M pioglitazone hcl

ADLYXIN NPB M; 2ST BYDUREON, BYDUREON PEN, BYETTA, TRULICITY

ALOGLIPTIN NPB QL; M; 2ST JANUVIA, TRADJENTA

ALOGLIPTIN-METFORMIN NPB QL; M; 2ST JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

ALOGLIPTIN-PIOGLITAZONE NPB QL; M pioglitazone hcl, JANUVIA, TRADJENTA

AMARYL NPB M glimepiride

AVANDIA ORAL TABLET 2 MG, 4 MG

NPB QL; M pioglitazone hcl

BYDUREON SUBCUTANEOUS PEN INJECTOR

PB ST; M

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

PB ST; QL; M

BYETTA PB ST; QL; M

chlorpropamide G M glimepiride, glipizide, glyburide

CYCLOSET NPB QL; M metformin hcl, glimepiride, glipizide, glyburide

DUETACT NPB QL; M pioglitazone-glimepiride

FARXIGA PB ST; QL; M

FORTAMET NPB ST; M metformin hcl er

glimepiride G M

glipizide G M

glipizide-metformin G M

GLUCOPHAGE NPB ST; M metformin hcl

GLUCOPHAGE XR NPB ST; M metformin hcl er

GLUCOTROL NPB M glipizide

GLUCOTROL XL NPB M glipizide er

GLUCOVANCE NPB M glyburide-metformin hcl

GLUMETZA NPB QL; M; 2ST metformin hcl, metformin hcl er

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113

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

glyburide G M

glyburide micronized G M

glyburide-metformin G M

GLYNASE NPB M glyburide micronized

GLYSET NPB M miglitol

GLYXAMBI PB ST; M

INVOKAMET PB ST; QL; M

INVOKAMET XR PB ST; QL; M

INVOKANA PB ST; QL; M

JANUMET PB ST; QL; M

JANUMET XR PB ST; QL; M

JANUVIA PB ST; QL; M

JARDIANCE PB ST; QL; M

JENTADUETO PB ST; QL; M

JENTADUETO XR PB ST; M

KAZANO NPB QL; M; 2ST JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

KOMBIGLYZE XR NPB QL; M; 2ST JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

metformin oral tablet G M

metformin oral tablet extended release 24 hr (generic GLUCOPHAGE XR)

G M

metformin oral tablet extended release 24hr (generic FORTAMET)

G ST; M

metformin oral tablet,er gast.retention 24 hr (generic GLUMETZA)

G ST; QL; M

miglitol G M

nateglinide G M

NESINA NPB QL; M; 2ST JANUVIA, TRADJENTA

ONGLYZA NPB QL; M; 2ST JANUVIA, TRADJENTA

OSENI NPB QL; M pioglitazone hcl, JANUVIA, TRADJENTA

pioglitazone G QL; M

pioglitazone-glimepiride G QL; M

pioglitazone-metformin G QL; M

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114

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

PRANDIN ORAL TABLET 1 MG, 2 MG

NPB M repaglinide

PRECOSE NPB M acarbose

repaglinide G M

repaglinide-metformin G QL; M

RIOMET NPB ST; QL; M metformin hcl, metformin hcl er

STARLIX NPB M nateglinide

SYMLINPEN 120 PB QL; M

SYMLINPEN 60 PB QL; M

SYNJARDY PB ST; M

SYNJARDY XR PB ST; M

TANZEUM NPB QL; M; 2ST BYDUREON, BYDUREON PEN, BYETTA, TRULICITY

tolazamide G M

tolbutamide G M

TRADJENTA PB ST; QL

TRULICITY PB QL; M

VICTOZA 2-PAK NPB QL; M; 2ST BYDUREON, BYDUREON PEN, BYETTA, TRULICITY

VICTOZA 3-PAK NPB QL; M; 2ST BYDUREON, BYDUREON PEN, BYETTA, TRULICITY

XIGDUO XR PB ST; QL; M

THYROID HORMONES

ARMOUR THYROID PB M

CYTOMEL NPB M liothyronine sodium

LEVO-T NPB M levothyroxine sodium, levoxyl, unithroid

levothyroxine oral G M

levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

G M

liothyronine oral G M

nature-throid G M

np thyroid G M

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115

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

SYNTHROID NPB M levothyroxine sodium, levoxyl, unithroid

THYROLAR-1 NPB M levothyroxine sodium, levoxyl, liothyronine sodium, unithroid

THYROLAR-1/2 NPB M levothyroxine sodium, levoxyl, liothyronine sodium, unithroid

THYROLAR-1/4 NPB M levothyroxine sodium, levoxyl, liothyronine sodium, unithroid

THYROLAR-2 NPB M levothyroxine sodium, levoxyl, liothyronine sodium, unithroid

THYROLAR-3 NPB M levothyroxine sodium, levoxyl, liothyronine sodium, unithroid

TIROSINT NPB M levothyroxine sodium, levoxyl, unithroid

unithroid G M

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg

G M

WP THYROID NPB M westhroid

GASTROENTEROLOGY

ANTIDIARRHEALS & ANTISPASMODICS

anaspaz G

belladonna alkaloids-opium G

belladonna-opium G

BENTYL ORAL CAPSULE NPB dicyclomine hcl

chlordiazepoxide-clidinium G

CUVPOSA NPB glycopyrrolate

dicyclomine oral capsule G

dicyclomine oral solution G

dicyclomine oral tablet G

diphenoxylate-atropine G

DONNATAL ORAL ELIXIR 16.2-0.1037 -0.0194 MG/5 ML

NPB belladonna-phenobarbital

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116

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

DONNATAL ORAL TABLET NPB

ed-spaz G

glycopyrrolate oral G

hyoscyamine sulfate G

hyosyne G

LEVBID NPB hyoscyamine sulfate

LEVSIN ORAL NPB hyoscyamine sulfate

LEVSIN/SL NPB hyoscyamine sulfate

LIBRAX (WITH CLIDINIUM) NPB clidinium w/chlordiazepoxide

LOMOTIL NPB diphenoxylate w/atropine

methscopolamine G glycopyrrolate

MOTOFEN NPB diphenoxylate w/atropine

MYTESI NPB diphenoxylate w/atropine, loperamide hcl

NULEV NPB hyoscyamine sulfate

opium tincture G

oscimin G

oscimin sl G

oscimin sr G

paregoric G

phenobarb-hyoscy-atropine-scop oral tablet

G

phenohytro G

propantheline G dicyclomine hcl, glycopyrrolate

ROBINUL FORTE NPB glycopyrrolate

ROBINUL ORAL NPB glycopyrrolate

SYMAX DUOTAB NPB hyoscyamine sulfate

symax fastabs G

symax-sl G

symax-sr G

MISCELLANEOUS GASTROINTESTINAL AGENTS

ACTIGALL NPB M ursodiol

AKYNZEO PB

alosetron G

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117

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

AMITIZA PB

ANALPRAM-HC RECTAL CREAM NPB hc pramoxine, pramcort

ANALPRAM-HC SINGLES RECTAL CREAM 2.5-1 % (4G)

NPB hc pramoxine, pramcort

anucort-hc G

ANUSOL-HC RECTAL SUPPOSITORY

NPB hydrocortisone acetate

ANUSOL-HC TOPICAL CREAM WITH PERINEAL APPLICATOR

NPB ST

ANZEMET ORAL NPB QL granisetron hcl, ondansetron hcl

aprepitant G QL

APRISO PB M

ASACOL HD NPB M; 2ST balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA

AURYXIA NPB FOSRENOL, RENVELA

AZULFIDINE NPB M sulfasalazine

AZULFIDINE EN-TABS NPB M sulfasalazine

balsalazide G

budesonide oral G

calcium acetate oral capsule G

calcium acetate oral tablet 667 mg G

CANASA PB

CESAMET NPB QL ondansetron hcl

CHENODAL PB-S PA

CHOLBAM PB

CIMZIA NPB-S 2ST

ACTEMRA, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, STELARA, XELJANZ

CIMZIA POWDER FOR RECONST NPB-S 2ST

ACTEMRA, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, STELARA, XELJANZ

COLAZAL NPB balsalazide disodium

colocort G

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118

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

COLYTE WITH FLAVOR PACKS ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM

NPB gavilyte-c, peg 3350-electrolyte

COMPAZINE NPB prochlorperazine maleate

compro G

constulose G

CORTENEMA NPB hydrocortisone

CORTIFOAM PB

CREON PB

cromolyn oral G

CYSTADANE PB

DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS)

NPB M; 2ST balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA

DICLEGIS NPB UNISOM, pyridoxine hcl

DIPENTUM NPB M; 2ST balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA

dronabinol G

eliphos G

EMEND ORAL CAPSULE 125 MG, 40 MG

PB QL

EMEND ORAL CAPSULE 80 MG NPB QL

EMEND ORAL CAPSULE,DOSE PACK

NPB QL APREPITANT

EMEND ORAL SUSPENSION FOR RECONSTITUTION

PB

ENTOCORT EC NPB budesonide ec

enulose G

FOSRENOL PB

GASTROCROM NPB cromolyn sodium

GATTEX 30-VIAL NPB-S diphenoxylate w/atropine, loperamide hcl, opium, paregoric

gavilyte-c G ACA

gavilyte-g G ACA

gavilyte-h and bisacodyl G ACA

gavilyte-n G ACA

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119

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

generlac G

GIALAX NPB ACA glycolax, polyethylene glycol

GIAZO NPB balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA

GOLYTELY ORAL POWDER IN PACKET

NPB ACA

gavilyte-g, peg 3350-electrolyte, trilyte with flavor packets, PREPOPIK, SUPREP

GOLYTELY ORAL RECON SOLN NPB

gavilyte-g, peg 3350-electrolyte, trilyte with flavor packets, PREPOPIK, SUPREP

granisetron hcl oral G QL

hemmorex-hc G

hydrocortisone acetate rectal G

hydrocortisone rectal G

hydrocortisone topical cream with perineal applicator

G

hydrocortisone-pramoxine rectal G

KAYEXALATE NPB sodium polystyrene sulfonate

kionex G

kionex (with sorbitol) G

KRISTALOSE NPB M lactulose

lactulose oral solution 10 gram/15 ml G

LIALDA PB M

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

G

LINZESS PB

LOTRONEX NPB alosetron hcl

MAGNEBIND 400 NPB

MARINOL NPB dronabinol

MESALAMINE ORAL NPB M; 2ST balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASA

mesalamine rectal G

mesalamine with cleansing wipe G

metoclopramide hcl oral G

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120

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

MICORT-HC NPB ST hydrocortisone

MOVANTIK PB

MOVIPREP NPB ACA

gavilyte-g, peg 3350-electrolyte, trilyte with flavor packets, PREPOPIK, SUPREP

NULYTELY WITH FLAVOR PACKS NPB gavilyte-n, peg-3350 with flavor packs, trilyte with flavor packets

OCALIVA PB-S PA

ondansetron G QL

ondansetron hcl oral G QL

OSMOPREP NPB ACA

gavilyte-g, peg 3350-electrolyte, trilyte with flavor packets, PREPOPIK, SUPREP

PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-6,200- 10,850 UNIT, 21,000-54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT

NPB 2ST CREON, ZENPEP

peg 3350-electrolytes G ACA

peg-electrolyte soln G ACA

PENTASA PB M

PERTZYE NPB 2ST CREON, ZENPEP

PHOSLYRA NPB

polyethylene glycol 3350 G ACA

pramcort G

PREPOPIK PB ACA

prochlorperazine G

prochlorperazine maleate G

PROCORT NPB hc pramoxine

PROCTOCORT RECTAL NPB hydrocortisone acetate

PROCTOFOAM HC PB

procto-med hc G

proctosol hc topical G

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121

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

proctozone-hc G

RECTIV PB

REGLAN ORAL NPB metoclopramide hcl

RELISTOR ORAL NPB bisacodyl, lactulose, milk of magnesia, senna, AMITIZA, MOVANTIK

RELISTOR SUBCUTANEOUS SOLUTION

PB

RELISTOR SUBCUTANEOUS SYRINGE

PB

RENAGEL NPB RENVELA

RENVELA PB

ROWASA NPB mesalamine

SANCUSO PB QL

sevelamer carbonate oral powder in packet

G

SFROWASA NPB mesalamine

sodium polystyrene sulfonate oral G

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

G

SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

NPB

sps (with sorbitol) G

SUCRAID PB-S

sulfasalazine G M

SUPREP BOWEL PREP KIT PB ACA

SYNDROS NPB

TIGAN ORAL CAPSULE 300 MG NPB trimethobenzamide hcl

TRANSDERM-SCOP NPB meclizine hcl

trilyte with flavor packets G ACA

trimethobenzamide oral G

TRULANCE NPB PA AMITIZA, LINZESS

UCERIS ORAL PB

UCERIS RECTAL NPB hydrocortisone, CORTIFOAM

URSO 250 NPB M ursodiol

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122

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

URSO FORTE NPB M ursodiol

ursodiol G M

VARUBI PB

VELPHORO NPB FOSRENOL, RENVELA

VELTASSA PB-S

VIBERZI PB

VIOKACE PB

ZENPEP PB

ZOFRAN (AS HYDROCHLORIDE) ORAL

NPB QL ondansetron hcl

ZOFRAN ODT NPB QL ondansetron odt

ZUPLENZ NPB QL ondansetron odt, ondansetron hcl, granisetron hcl

ULCER THERAPY

ACIPHEX NPB ST; QL; M rabeprazole sodium

ACIPHEX SPRINKLE NPB ST; QL; M

esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole sodium, rabeprazole sodium, NEXIUM RX

amoxicil-clarithromy-lansopraz G QL

CARAFATE ORAL SUSPENSION PB M

CARAFATE ORAL TABLET NPB M sucralfate

cimetidine hcl oral G M

cimetidine oral tablet 300 mg, 400 mg, 800 mg

G M

CYTOTEC NPB M misoprostol

DEXILANT NPB ST; QL; M

esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole sodium, rabeprazole sodium, NEXIUM RX

esomeprazole magnesium PB QL; M

ESOMEPRAZOLE STRONTIUM NPB ST; QL; M

esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole sodium, rabeprazole sodium, NEXIUM RX

famotidine oral suspension G M

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123

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

famotidine oral tablet 40 mg G M

lansoprazole oral capsule,delayed release(dr/ec)

PB QL; M

misoprostol G M

NEXIUM NPB ST; QL; M esomeprazole magnesium

NEXIUM PACKET PB ST; QL; M

nizatidine G M

OMECLAMOX-PAK NPB QL lansoprazol-amoxicil-clarithro, PYLERA

omeprazole oral capsule,delayed release(dr/ec)

PB M

omeprazole-sodium bicarbonate oral capsule

PB QL; M

omeprazole-sodium bicarbonate oral packet

PB QL

pantoprazole oral PB QL; M

PEPCID ORAL SUSPENSION NPB M famotidine

PEPCID ORAL TABLET 40 MG NPB M famotidine

PREVACID NPB ST; QL; M lansoprazole

PREVACID SOLUTAB NPB ST; QL; M lansoprazole

PREVPAC NPB QL lansoprazol-amoxicil-clarithro

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON

NPB ST; QL; M

esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole sodium, rabeprazole sodium, NEXIUM RX

PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET

NPB ST; QL; M

esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole sodium, rabeprazole sodium, NEXIUM RX

PROTONIX ORAL TABLET,DELAYED RELEASE (DR/EC)

NPB ST; QL; M pantoprazole sodium

PYLERA PB

rabeprazole PB QL; M

ranitidine hcl oral capsule G M

ranitidine hcl oral syrup G M

ranitidine hcl oral tablet 150 mg, 300 mg G M

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124

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

sucralfate oral tablet G M

ZANTAC ORAL TABLET 300 MG NPB M ranitidine hcl

ZEGERID ORAL CAPSULE NPB ST; QL; M omeprazole-sodium bicarbonate

ZEGERID ORAL PACKET NPB ST; QL omeprazole-sodium bicarbonate

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY

GROWTH HORMONES

EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG

PB-S PA

GENOTROPIN PB-S PA

GENOTROPIN MINIQUICK PB-S PA

HUMATROPE PB-S PA

NORDITROPIN FLEXPRO PB-S PA

NUTROPIN AQ NUSPIN NPB-S 2ST GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO

OMNITROPE NPB-S 2ST GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO

SAIZEN NPB-S 2ST GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO

SAIZEN CLICK.EASY NPB-S 2ST GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO

SAIZEN SAIZENPREP NPB-S PA GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG

PB-S PA

ZOMACTON NPB-S 2ST GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO

ZORBTIVE NPB-S PA GENOTROPIN, HUMATROPE, NORDITROPIN FLEXPRO

INTERFERONS

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125

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

AUBAGIO NPB-S QL

AVONEX (WITH ALBUMIN) PB-S QL

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

PB-S QL

AVONEX INTRAMUSCULAR SYRINGE KIT

PB-S QL

BETASERON SUBCUTANEOUS KIT PB-S QL

COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

NPB-S QL

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

PB-S

COPEGUS NPB-S

EXTAVIA SUBCUTANEOUS KIT PB-S QL

EXTAVIA SUBCUTANEOUS RECON SOLN

PB-S

GILENYA PB-S

glatopa G-S QL

moderiba G-S

moderiba dose pack G-S

PEGASYS PB-S PA; QL

PEGASYS PROCLICK PB-S PA; QL

PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML

NPB-S PA; QL PEGASYS, PEGASYS PROCLICK

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML

NPB-S PA; QL PEGASYS, PEGASYS PROCLICK

PLEGRIDY PB-S

POMALYST PB-S QL

REBETOL ORAL SOLUTION NPB-S

REBIF (WITH ALBUMIN) PB-S QL

REBIF REBIDOSE PB-S QL

REBIF TITRATION PACK PB-S QL

REVLIMID PB-S

ribasphere G-S 2ST

ribasphere ribapak G-S 2ST

ribavirin oral capsule G-S

ribavirin oral tablet 200 mg G-S

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126

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

SYLATRON PB-S PA; QL

TECFIDERA PB-S QL

ZINBRYTA NPB-S

INTERLEUKINS

ACTIMMUNE PB-S

ALDARA NPB QL

ARCALYST PB-S PA

imiquimod G QL

INTRON A INJECTION PB-S

KINERET NPB-S QL; 2ST

ZYCLARA NPB QL; 2ST

VACCINES & MISCELLANEOUS IMMUNOLOGICALS

GRASTEK PB

ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY

NPB-S GRASTEK

RAGWITEK PB

MUSCULOSKELETAL & RHEUMATOLOGY

GOUT THERAPY

allopurinol G M

COLCHICINE NPB 2ST COLCRYS, MITIGARE

COLCRYS PB

MITIGARE PB

probenecid G M

probenecid-colchicine G M

ULORIC PB M

ZURAMPIC NPB ST; M probenecid

ZYLOPRIM NPB M allopurinol

OSTEOPOROSIS THERAPY

ACTONEL ORAL TABLET 150 MG, 35 MG, 5 MG

NPB QL; M risedronate sodium

alendronate oral solution G QL; M

alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg

G QL; M

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127

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ATELVIA NPB QL; M risedronate sodium dr

BINOSTO NPB QL; M alendronate sodium

BONIVA ORAL NPB QL; M ibandronate sodium

EVISTA NPB PA; M raloxifene hcl

FORTEO PB-S QL

FOSAMAX ORAL TABLET 70 MG NPB QL; M alendronate sodium

FOSAMAX PLUS D NPB QL; M alendronate sodium

ibandronate oral G QL; M

raloxifene G PA; M

risedronate oral tablet 150 mg, 35 mg, 5 mg

G QL; M

risedronate oral tablet,delayed release (dr/ec)

G QL; M

TYMLOS PB-S PA

OTHER RHEUMATOLOGICALS

ACTEMRA SUBCUTANEOUS PB-S PA; QL

ARAVA NPB QL leflunomide

CUPRIMINE NPB ST; M DEPEN

DEPEN TITRATABS PB M

ENBREL PB-S PA; QL

ENBREL SURECLICK PB-S PA; QL

HUMIRA PB-S PA; QL

HUMIRA PEDIATRIC CROHN'S START

PB PA; QL

HUMIRA PEN CROHN'S-UC-HS START

PB-S PA; QL

HUMIRA PEN PSORIASIS-UVEITIS PB-S PA; QL

KEVZARA NPB-S PA

leflunomide G QL

ORENCIA CLICKJECT NPB-S 2ST ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML

NPB-S 2ST ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR

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128

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML, 87.5 MG/0.7 ML

NPB-S PA ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XR

OTEZLA PB-S PA; QL

OTEZLA STARTER PB-S PA; QL

OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML

PB-S QL

RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML

PB-S QL

RIDAURA PB M

SAVELLA ORAL TABLET PB QL; M

SAVELLA ORAL TABLETS,DOSE PACK

PB QL

SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML

PB-S PA; QL

SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML

NPB-S PA; QL; 2ST

ACTEMRA, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, STELARA, XELJANZ

SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML

PB-S PA; QL

SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML

NPB-S PA; QL; 2ST

ACTEMRA, COSENTYX 300MG, ENBREL, HUMIRA, OTEZLA, STELARA, XELJANZ

XELJANZ PB-S PA; QL

XELJANZ XR PB-S PA; QL

OBSTETRICS & GYNECOLOGY

DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES

CAYA CONTOURED NPB ACA

FC2 FEMALE CONDOM PB ACA; OTC

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129

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

FEMCAP VAGINAL DEVICE 22 MM PB ACA

WIDE-SEAL DIAPHRAGM NPB ACA

ESTROGENS & PROGESTINS

ACTIVELLA NPB M estradiol-norethindrone acetat

ALORA NPB QL; M estradiol, MINIVELLE

amabelz G M

ANGELIQ NPB M estradiol-norethindrone acetat, jinteli, mimvey, PREMPHASE, PREMPRO

AYGESTIN NPB M norethindrone acetate

camila G QL; M; ACA

CLIMARA NPB QL; M estradiol

CLIMARA PRO NPB QL; M COMBIPATCH

COMBIPATCH PB M

covaryx G

covaryx h.s. G

CRINONE VAGINAL GEL 4 % PB

deblitane G QL; M; ACA

DELESTROGEN NPB estradiol valerate

DEPO-ESTRADIOL PB

DEPO-PROVERA INTRAMUSCULAR SUSPENSION

NPB QL; ACA medroxyprogesterone acetate

DEPO-PROVERA INTRAMUSCULAR SYRINGE

NPB QL; ACA medroxyprogesterone acetate

DEPO-SUBQ PROVERA 104 NPB QL; ACA medroxyprogesterone acetate

DIVIGEL PB QL; M

DUAVEE PB

eemt G

eemt hs G

ELESTRIN NPB QL; M DIVIGEL

ENDOMETRIN NPB 2ST CRINONE

errin G QL; M; ACA

ESTRACE ORAL NPB M estradiol

ESTRACE VAGINAL PB M

estradiol oral G M

estradiol transdermal G QL; M

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130

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

G

estradiol-norethindrone acet G M

ESTRING NPB QL; M yuvafem, ESTRACE, PREMARIN

ESTROGEL NPB QL; M; 2ST DIVIGEL

estrogens-methyltestosterone G

estropipate G M

EVAMIST NPB QL DIVIGEL

FEMHRT LOW DOSE NPB M jinteli, jevantique lo

FEMRING NPB QL; M estradiol, estradiol, yuvafem, ESTRACE, PREMARIN, PREMARIN

fyavolv G M

heather G QL; M; ACA

jencycla G QL; M; ACA

jevantique lo G M

jinteli G M

jolivette G QL; M; ACA

lopreeza G M

lyza G QL; M; ACA

medroxyprogesterone intramuscular G QL; ACA

medroxyprogesterone oral G M

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

NPB M estradiol, estropipate, PREMARIN

MENOSTAR NPB QL; M estradiol, MINIVELLE

mimvey G M

mimvey lo G M

MINIVELLE PB QL; M

nora-be G QL; M; ACA

norethindrone (contraceptive) G QL; M; ACA

norethindrone acetate G M

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

G M

norlyda G QL; M; ACA

norlyroc G QL; M; ACA

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131

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ORTHO MICRONOR NPB QL; M errin, jolivette

PREFEST NPB M estradiol-norethindrone acetat, jinteli, mimvey, PREMPHASE, PREMPRO

PREMARIN ORAL PB M

PREMARIN VAGINAL PB M

PREMPHASE PB M

PREMPRO PB M

progesterone micronized G M

PROMETRIUM NPB M progesterone

PROVERA NPB M medroxyprogesterone acetate

sharobel G QL; M; ACA

VAGIFEM NPB M yuvafem

VIVELLE-DOT NPB QL; M estradiol

yuvafem G M

MISCELLANEOUS OB/GYN

AVC VAGINAL NPB fluconazole, terconazole

CERVIDIL NPB

CLEOCIN VAGINAL CREAM NPB

CLEOCIN VAGINAL SUPPOSITORY NPB clindamycin phosphate, metronidazole

clindamycin phosphate vaginal G

CLINDESSE NPB clindamycin phosphate, metronidazole

CONCEPTROL PB ACA; OTC

fem ph G

GYNAZOLE-1 NPB terconazole

gynol ii G ACA; OTC

INTRAROSA NPB PA

isoxsuprine G M

LUPANETA PACK (1 MONTH) NPB QL norethindrone acetate, LUPRON DEPOT

LUPANETA PACK (3 MONTH) NPB QL norethindrone acetate, LUPRON DEPOT

LYSTEDA NPB tranexamic acid

METROGEL VAGINAL NPB metronidazole

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132

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

metronidazole vaginal G

MIFEPREX NPB-S

NUVARING PB QL; M; ACA

NUVESSA NPB metronidazole, clindamycin phosphate

OSPHENA NPB yuvafem, ESTRACE, PREMARIN

PREPIDIL NPB

PROSTIN E2 NPB

RELAGARD NPB fem ph

TERAZOL 7 NPB QL terconazole

terconazole G QL

TODAY CONTRACEPTIVE SPONGE PB ACA; OTC

tranexamic acid oral G

vaginal contraceptive foam G ACA; OTC

vandazole G

VCF CONTRACEPTIVE FILM PB ACA; OTC

VCF CONTRACEPTIVE GEL PB ACA; OTC

xulane G QL; M; ACA

ORAL CONTRACEPTIVES & RELATED AGENTS

AFTERA NPB QL; OTC

altavera (28) G QL; M; ACA

alyacen 1/35 (28) G QL; M; ACA

alyacen 7/7/7 (28) G QL; M; ACA

amethia G QL; M; ACA

amethia lo G QL; M; ACA

amethyst G QL; M; ACA

apri G QL; M; ACA

aranelle (28) G QL; M; ACA

ashlyna G QL; M; ACA

aubra G QL; M; ACA

aviane G QL; M; ACA

azurette (28) G QL; M; ACA

balziva (28) G QL; M; ACA

bekyree (28) G QL; M; ACA

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133

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

BEYAZ NPB QL; M drospirenone-eth estra-levomef, rajani

blisovi 24 fe G QL; M; ACA

blisovi fe 1.5/30 (28) G QL; M; ACA

blisovi fe 1/20 (28) G QL; M; ACA

BREVICON (28) NPB QL; M necon, nortrel, wera

briellyn G QL; M; ACA

camrese G QL; M; ACA

camrese lo G QL; M; ACA

caziant (28) G QL; M; ACA

chateal G QL; M; ACA

cryselle (28) G QL; M; ACA

cyclafem 1/35 (28) G QL; M; ACA

cyclafem 7/7/7 (28) G QL; M; ACA

CYCLESSA (28) NPB QL; M caziant, velivet

cyred G QL; M; ACA

dasetta 1/35 (28) G QL; M; ACA

dasetta 7/7/7 (28) G QL; M; ACA

daysee G QL; M; ACA

delyla (28) G QL; M; ACA

desog-e.estradiol/e.estradiol G QL; M; ACA

DESOGEN NPB QL; M apri, emoquette, enskyce, reclipsen

desogestrel-ethinyl estradiol G QL; M; ACA

drospirenone-e.estradiol-lm.fa G QL; M; ACA

drospirenone-ethinyl estradiol G QL; M; ACA

econtra ez G QL; ACA; OTC

elinest G QL; M; ACA

ELLA NPB QL; ACA econtra ez, fallback solo, my way, next choice one dose, react

emoquette G QL; M; ACA

enpresse G QL; M; ACA

enskyce G QL; M; ACA

estarylla G QL; M; ACA

ESTROSTEP FE-28 NPB QL; M tri-legest fe, tilia fe

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134

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ethynodiol diac-eth estradiol G QL; M; ACA

fallback solo G QL; ACA; OTC

falmina (28) G QL; M; ACA

fayosim G QL; M; ACA

femynor G QL; M; ACA

GENERESS FE NPB QL kaitlib fe, layolis fe, norethin-eth estra ferrous fum

gianvi (28) G QL; M; ACA

gildagia G QL; M; ACA

introvale G QL; M; ACA

jolessa G QL; M; ACA

juleber G QL; M; ACA

junel 1.5/30 (21) G QL; M; ACA

junel 1/20 (21) G QL; M; ACA

junel fe 1.5/30 (28) G QL; M; ACA

junel fe 1/20 (28) G QL; M; ACA

junel fe 24 G QL; M; ACA

kaitlib fe G QL; ACA

kariva (28) G QL; M; ACA

kelnor 1/35 (28) G QL; M; ACA

kimidess (28) G QL; M; ACA

kurvelo G QL; M; ACA

l norgest/e.estradiol-e.estrad G QL; M; ACA

larin 1.5/30 (21) G QL; M; ACA

larin 1/20 (21) G QL; M; ACA

larin 24 fe G QL; M; ACA

larin fe 1.5/30 (28) G QL; M; ACA

larin fe 1/20 (28) G QL; M; ACA

larissia G QL; M; ACA

layolis fe G QL; ACA

leena 28 G QL; M; ACA

lessina G QL; M; ACA

levonest (28) G QL; M; ACA

levonorgestrel oral tablet 1.5 mg G QL; ACA; OTC

levonorgestrel-ethinyl estrad G QL; M; ACA

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135

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

levonorg-eth estrad triphasic G QL; M; ACA

levora-28 G QL; M; ACA

LO LOESTRIN FE PB QL; M; ACA

LOESTRIN 1.5/30 (21) NPB QL; M junel, microgestin

LOESTRIN 1/20 (21) NPB QL; M junel, microgestin

LOESTRIN FE 1.5/30 (28-DAY) NPB QL; M blisovi fe, junel fe, larin fe, microgestin fe, tarina fe

LOESTRIN FE 1/20 (28-DAY) NPB QL; M blisovi fe, junel fe, larin fe, microgestin fe, tarina fe

lomedia 24 fe G QL; M; ACA

loryna (28) G QL; M; ACA

LOSEASONIQUE NPB QL; M amethia lo, camrese lo

low-ogestrel (28) G QL; M; ACA

lutera (28) G QL; M; ACA

marlissa G QL; M; ACA

mibelas 24 fe G QL; M; ACA

microgestin 1.5/30 (21) G QL; M; ACA

microgestin 1/20 (21) G QL; M; ACA

MICROGESTIN 24 FE NPB QL; M

microgestin fe 1.5/30 (28) G QL; M; ACA

microgestin fe 1/20 (28) G QL; M; ACA

MINASTRIN 24 FE NPB QL; M; ACA MIBELAS 24 FE, NORETHIN-ETH ESTRA FERROUS FUM

MIRCETTE (28) NPB QL; M azurette, kariva, kimidess, pimtrea, viorele

mono-linyah G QL; M; ACA

mononessa (28) G QL; M; ACA

my way G QL; ACA; OTC

myzilra G QL; M; ACA

NATAZIA PB QL; M; ACA

necon 0.5/35 (28) G QL; M; ACA

necon 1/50 (28) G QL; M; ACA

necon 10/11 (28) G QL; M; ACA

necon 7/7/7 (28) G QL; M; ACA

next choice one dose G QL; ACA; OTC

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136

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

nikki (28) G QL; M; ACA

noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7)

G QL; M; ACA

noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)

G QL; ACA

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

G QL; M; ACA

norethindrone-e.estradiol-iron G QL; M; ACA

norgestimate-ethinyl estradiol G QL; M; ACA

NORINYL 1/35 (28) NPB QL; M alyacen, cyclafem, necon, nortrel

nortrel 0.5/35 (28) G QL; M; ACA

nortrel 1/35 (21) G QL; M; ACA

nortrel 1/35 (28) G QL; M; ACA

nortrel 7/7/7 (28) G QL; M; ACA

ocella G QL; M; ACA

ogestrel (28) G QL; M; ACA

opcicon one-step G QL; ACA; OTC

option-2 G QL; ACA; OTC

orsythia G QL; M; ACA

ORTHO TRI-CYCLEN (28) NPB QL; M trinessa, tri-previfem, tri-sprintec

ORTHO TRI-CYCLEN LO (28) NPB QL; M norgestimate-ethinyl estradiol, tri-lo-estarylla, tri-lo-marzia, tri-lo-sprintec, trinessa lo

ORTHO-CYCLEN (28) NPB QL; M mononessa, previfem, sprintec

ORTHO-NOVUM 1/35 (28) NPB QL; M alyacen, cyclafem, necon, nortrel

ORTHO-NOVUM 7/7/7 (28) NPB QL; M alyacen, cyclafem, necon, nortrel

OVCON-35 (28) NPB QL; M balziva, briellyn, philith, zenchent

philith G QL; M; ACA

pimtrea (28) G QL; M; ACA

pirmella G QL; M; ACA

PLAN B ONE-STEP PB QL; OTC

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137

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

portia G QL; M; ACA

previfem G QL; M; ACA

QUARTETTE NPB QL; M FAYOSIM, RIVELSA

quasense G QL; M; ACA

rajani G QL; M; ACA

react G QL; ACA; OTC

reclipsen (28) G QL; M; ACA

rivelsa G QL; M; ACA

SAFYRAL PB QL; M; ACA

SEASONIQUE NPB QL; M amethia, camrese

setlakin G QL; M; ACA

sprintec (28) G QL; M; ACA

sronyx G QL; M; ACA

syeda G QL; M; ACA

TAKE ACTION NPB QL; OTC

tarina fe 1/20 (28) G QL; M; ACA

TAYTULLA PB QL; M; ACA

tilia fe G QL; M; ACA

tri femynor G QL; M; ACA

tri-estarylla G QL; M; ACA

tri-legest fe G QL; M; ACA

tri-linyah G QL; M; ACA

tri-lo-estarylla G QL; M; ACA

tri-lo-marzia G QL; M; ACA

tri-lo-sprintec G QL; M; ACA

trinessa (28) G QL; M; ACA

trinessa lo G QL; M; ACA

TRI-NORINYL (28) NPB QL; M aranelle, leena

tri-previfem (28) G QL; M; ACA

tri-sprintec (28) G QL; M; ACA

trivora (28) G QL; M; ACA

velivet triphasic regimen (28) G QL; M; ACA

vestura (28) G QL; M; ACA

vienva G QL; M; ACA

viorele (28) G QL; M; ACA

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138

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

vyfemla (28) G QL; M; ACA

wera (28) G QL; M; ACA

wymzya fe G QL; M; ACA

YASMIN (28) NPB QL; M ocella, syeda, zarah

YAZ (28) NPB QL; M gianvi, loryna, nikki, vestura

zarah G QL; M; ACA

zenchent (28) G QL; M; ACA

zenchent fe G QL; M; ACA

zovia 1/35e (28) G QL; M; ACA

zovia 1/50e (28) G QL; M; ACA

OXYTOCICS

methergine G

OPHTHALMOLOGY

ANTIBIOTICS

AZASITE PB

bacitracin ophthalmic G

bacitracin-polymyxin b ophthalmic G

BESIVANCE NPB

ciprofloxacin hcl, gatifloxacin, levofloxacin hemihydrate, ofloxacin, MOXEZA, VIGAMOX

BETADINE OPHTHALMIC PREP NPB

CILOXAN NPB ciprofloxacin hcl

ciprofloxacin hcl ophthalmic G

erythromycin ophthalmic G

gatifloxacin G

gentak ophthalmic ointment G

gentamicin ophthalmic G

levofloxacin ophthalmic G

MOXEZA PB

NATACYN PB

neomycin-bacitracin-polymyxin G M

neomycin-polymyxin-gramicidin G

neo-polycin G M

OCUFLOX NPB ofloxacin

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139

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ofloxacin ophthalmic G

polycin G

polymyxin b sulf-trimethoprim G

POLYTRIM NPB polymyxin b sul-trimethoprim

tobramycin G

TOBREX NPB tobramycin sulfate

VIGAMOX PB

ZYMAXID NPB gatifloxacin

ANTIVIRALS

trifluridine G

VIROPTIC NPB trifluridine

ZIRGAN NPB trifluridine

BETA-BLOCKERS

BETAGAN OPHTHALMIC DROPS 0.5 %

NPB M levobunolol hcl

betaxolol ophthalmic G M

BETIMOL NPB M timolol maleate, ALPHAGAN P, COMBIGAN

BETOPTIC S NPB M betaxolol hcl, timolol maleate, ALPHAGAN P, COMBIGAN

carteolol G M

ISTALOL NPB M; 2ST timolol maleate, betaxolol hcl, levobunolol hcl, ALPHAGAN P, COMBIGAN

levobunolol ophthalmic drops 0.5 % G M

metipranolol G M

timolol maleate ophthalmic G M

TIMOPTIC NPB M timolol maleate

TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE 0.5 %

NPB M timolol maleate

TIMOPTIC-XE NPB M timolol maleate

CHOLINESTERASE INHIBITOR MIOTICS

PHOSPHOLINE IODIDE PB M

CYCLOPLEGIC MYDRIATICS

atropine ophthalmic G M

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140

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

CYCLOGYL NPB M cyclopentolate hcl

cyclopentolate G M

homatropaire G M

homatropine hbr G M

MYDRIACYL NPB M tropicamide

PAREMYD NPB

tropicamide G M

DIRECT ACTING MIOTICS

ISOPTO CARPINE NPB M pilocarpine hcl

MIOCHOL-E NPB

pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 %

G M

MISCELLANEOUS OPHTHALMOLOGICS

acuicyn G

AKTEN (PF) NPB

ALOCRIL NPB ST azelastine hcl, olopatadine hcl, ALREX, BEPREVE, PAZEO

ALOMIDE NPB ST azelastine hcl, olopatadine hcl, ALREX, BEPREVE, PAZEO

altacaine G

altafluor G

azelastine ophthalmic G

BEPREVE PB ST

cromolyn ophthalmic G

CYSTARAN PB-S PA

ELESTAT NPB ST epinastine hcl

EMADINE NPB ST azelastine hcl, olopatadine hcl, ALREX, BEPREVE, PAZEO

epinastine G

flucaine G

fluorescein-proparacaine G

flurox G

LACRISERT NPB RESTASIS

LASTACAFT NPB ST azelastine hcl, olopatadine hcl, ALREX, BEPREVE, PAZEO

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141

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

olopatadine ophthalmic G

PATADAY NPB ST olopatadine hcl

PATANOL NPB ST olopatadine hcl

PAZEO PB ST

proparacaine G

RESTASIS PB QL; M

RESTASIS MULTIDOSE PB M

tetcaine G

tetracaine hcl G

tetracaine hcl (pf) ophthalmic G

TETRAVISC NPB tetracaine hcl

TETRAVISC FORTE OPHTHALMIC DROPS,HYPERVISCOUS

NPB tetracaine hcl

XIIDRA PB M

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

ACULAR NPB ketorolac tromethamine

ACULAR LS NPB ketorolac tromethamine

ACUVAIL (PF) NPB 2ST

bromfenac sodium, diclofenac sodium, ketorolac tromethamine, ILEVRO, NEVANAC, PROLENSA

bromfenac G

BROMSITE NPB

bromfenac sodium, diclofenac sodium, ketorolac tromethamine, ILEVRO, NEVANAC, PROLENSA

diclofenac sodium ophthalmic G QL

flurbiprofen sodium G

ILEVRO PB

ketorolac ophthalmic G

NEVANAC PB

OCUFEN NPB flurbiprofen sodium

PROLENSA PB

ORAL DRUGS FOR GLAUCOMA

acetazolamide G M

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Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

DIAMOX SEQUELS NPB M acetazolamide

methazolamide G M

NEPTAZANE NPB M methazolamide

OTHER GLAUCOMA DRUGS

AZOPT NPB M

dorzolamide hcl, dorzolamide-timolol, betaxolol hcl, timolol maleate, latanoprost, ALPHAGAN P, COMBIGAN

bimatoprost ophthalmic G M

COMBIGAN PB M

COSOPT NPB M dorzolamide-timolol

COSOPT (PF) NPB M dorzolamide-timolol, ALPHAGAN P, COMBIGAN

dorzolamide G M

dorzolamide-timolol G M

latanoprost G M

LUMIGAN OPHTHALMIC DROPS 0.01 %

PB M

MITOSOL NPB

SIMBRINZA NPB M brimonidine tartrate, dorzolamide-timolol, ALPHAGAN P, COMBIGAN

TRAVATAN Z PB M

TRUSOPT NPB M dorzolamide hcl

XALATAN NPB M latanoprost

ZIOPTAN (PF) NPB M; 2ST bimatoprost, latanoprost, LUMIGAN, TRAVATAN Z

STEROID-ANTIBIOTIC COMBINATIONS

MAXITROL NPB neo/polymyxin/dexamethasone

neomycin-bacitracin-poly-hc G

neomycin-polymyxin b-dexameth G

neomycin-polymyxin-hc ophthalmic G

neo-polycin hc G

PRED-G NPB tobramycin-dexamethasone, ZYLET

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143

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

PRED-G S.O.P. NPB TOBRADEX

TOBRADEX OPHTHALMIC DROPS,SUSPENSION

NPB tobramycin-dexamethasone

TOBRADEX OPHTHALMIC OINTMENT

PB

TOBRADEX ST PB

tobramycin-dexamethasone G

ZYLET PB

STEROIDS

ALREX PB

dexamethasone sodium phosphate ophthalmic

G

DUREZOL NPB

dexamethasone sodium phosphate, fluorometholone, prednisolone acetate, LOTEMAX

FLAREX NPB

dexamethasone sodium phosphate, fluorometholone, prednisolone acetate, LOTEMAX

fluorometholone G

FML FORTE NPB

dexamethasone sodium phosphate, fluorometholone, prednisolone acetate, LOTEMAX

FML LIQUIFILM NPB fluorometholone

FML S.O.P. PB

LOTEMAX PB

MAXIDEX NPB dexamethasone sodium phosphate

OMNIPRED NPB prednisolone acetate

PRED FORTE NPB prednisolone acetate

PRED MILD PB

prednisolone acetate G

prednisolone sodium phosphate ophthalmic

G

STEROID-SULFONAMIDE COMBINATIONS

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144

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

BLEPHAMIDE NPB sulfacetamide w/prednisolone

BLEPHAMIDE S.O.P. NPB sulfacetamide w/prednisolone

sulfacetamide-prednisolone G

SULFONAMIDES

BLEPH-10 NPB sulfacetamide sodium

sulfacetamide sodium ophthalmic G

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC DROPS 0.1 %

PB M

ALPHAGAN P OPHTHALMIC DROPS 0.15 %

NPB M brimonidine tartrate

apraclonidine G M

brimonidine G M

IOPIDINE OPHTHALMIC DROPPERETTE

NPB M brimonidine tartrate, ALPHAGAN P

IOPIDINE OPHTHALMIC DROPS NPB M apraclonidine hcl

VASOCONSTRICTOR DECONGESTANTS

CYCLOMYDRIL NPB M

phenylephrine hcl ophthalmic G

RESPIRATORY, ALLERGY, COUGH & COLD

ANTIHISTAMINE & ANTIALLERGENIC AGENTS

ADRENACLICK NPB QL epinephrine, EPIPEN, EPIPEN JR.

AUVI-Q NPB PA; QL epinephrine, EPIPEN, EPIPEN JR.

carbinoxamine maleate G

cetirizine oral solution 1 mg/ml PB

CLARINEX ORAL SYRUP NPB desloratadine

CLARINEX ORAL TABLET NPB QL desloratadine

clemastine oral tablet 2.68 mg G

cyproheptadine G

desloratadine PB QL

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145

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

EPINEPHRINE INJECTION AUTO-INJECTOR

PB QL epinephrine, EPIPEN, EPIPEN JR.

EPIPEN 2-PAK PB QL

EPIPEN JR 2-PAK PB QL

hydroxyzine hcl oral solution 10 mg/5 ml

G

hydroxyzine hcl oral tablet G

hydroxyzine pamoate G

KARBINAL ER NPB carbinoxamine

phenadoz G

phenergan rectal G

promethazine oral G

promethazine rectal G

promethegan G

RYVENT NPB carbinoxamine

VISTARIL NPB hydroxyzine pamoate

COUGH & COLD THERAPY

benzonatate G

BROMFED DM NPB

brompheniramine-pseudoeph-dm oral syrup

G

CAPCOF NPB promethazine vc w/codeine

centergy G

cheratussin ac G

CLARINEX-D 12 HOUR NPB QL desloratadine, fexofenadine-pse er

codeine-guaifenesin G

CODITUSSIN AC NPB

cheratussin ac, guaifenesin ac, guaifenesin with codeine, iophen c-nr, m-clear wc, virtussin ac

CODITUSSIN DAC NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac

FLOWTUSS NPB 2ST

cheratussin ac, guaifenesin ac, guaifenesin with codeine, iophen c-nr, m-clear wc, virtussin ac

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146

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

g tussin ac G

guaiatussin ac G

guaifenesin ac G

guaifenesin dac G

HISTEX-AC NPB promethazine vc w/codeine

HYCOFENIX NPB 2ST cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac

hydrocodone-chlorpheniramine G

hydrocodone-cpm-pseudoephed G

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

G

hydrocodone-homatropine oral tablet G

hydromet G

lortuss ex oral syrup G

MAR-COF BP NPB promethazine vc w/codeine

MAR-COF CG NPB

cheratussin ac, guaifenesin ac, guaifenesin with codeine, iophen c-nr, m-clear wc, virtussin ac

m-clear wc G

M-END PE NPB promethazine vc w/codeine

NINJACOF-XG NPB

cheratussin ac, guaifenesin ac, guaifenesin with codeine, iophen c-nr, m-clear wc, virtussin ac

OBREDON NPB 2ST

cheratussin ac, guaifenesin ac, guaifenesin with codeine, iophen c-nr, m-clear wc, virtussin ac

POLY-TUSSIN AC ORAL LIQUID 4-10-10 MG/5 ML

NPB

promethazine vc-codeine G

promethazine-codeine G

promethazine-dm G

promethazine-phenyleph-codeine G

promethazine-phenylephrine G

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147

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

PRO-RED AC (W/ DEXCHLORPHENIR)

NPB

relcof c G

RESPA-AR NPB

REZIRA NPB hydrocod-cpm-pseudoephedrine

rydex G

SEMPREX-D NPB desloratadine, levocetirizine dihydrochloride

TESSALON PERLES NPB benzonatate

tusnel c G

TUSNEL PEDIATRIC ORAL LIQUID NPB

TUSSICAPS PB 2ST

tussigon G

TUSSIONEX PENNKINETIC ER NPB hydrocodone-chlorpheniramine

TUZISTRA XR NPB 2ST hydrocodone-chlorpheniramine, promethazine w/codeine

virtussin ac G

virtussin dac G

VITUZ NPB 2ST hydrocodone-chlorpheniramine, promethazine w/codeine

ZODRYL AC 25 NPB hydrocodone-chlorpheniramine, promethazine w/codeine

ZODRYL AC 30 NPB hydrocodone-chlorpheniramine, promethazine w/codeine

ZODRYL AC 35 NPB hydrocodone-chlorpheniramine, promethazine w/codeine

ZODRYL AC 40 PB

ZODRYL AC 50 NPB hydrocodone-chlorpheniramine, promethazine w/codeine

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148

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ZODRYL AC 60 NPB hydrocodone-chlorpheniramine, promethazine w/codeine

ZODRYL AC 80 NPB hydrocodone-chlorpheniramine, promethazine w/codeine

ZODRYL DAC 25 NPB

ZODRYL DAC 30 NPB

ZODRYL DAC 35 NPB

ZODRYL DAC 40 NPB

ZODRYL DAC 50 NPB

ZODRYL DAC 60 NPB

ZODRYL DAC 80 NPB

ZODRYL DEC 25 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac

ZODRYL DEC 30 PB

ZODRYL DEC 35 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac

ZODRYL DEC 40 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac

ZODRYL DEC 50 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac

ZODRYL DEC 60 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac

ZODRYL DEC 80 NPB cheratussin dac, guaifenesin dac, lortuss ex, tusnel c, virtussin dac

Z-TUSS AC NPB hydrocodone-chlorpheniramine, promethazine w/codeine

ZUTRIPRO NPB hydrocod-cpm-pseudoephedrine

PULMONARY AGENTS

ACCOLATE NPB QL; M zafirlukast

acetylcysteine G

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149

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ADCIRCA PB-S PA; QL

ADEMPAS PB-S M

ADRENALIN NASAL NPB

ADVAIR DISKUS PB QL; M

ADVAIR HFA PB QL; M

AEROSPAN NPB M

ARNUITY ELLIPTA, ASMANEX, ASMANEX HFA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR

AIRDUO RESPICLICK NPB M ADVAIR DISKUS, ADVAIR HFA, BREO ELLIPTA, DULERA, SYMBICORT

albuterol sulfate inhalation solution for nebulization

G

albuterol sulfate oral G M

ALVESCO NPB QL; M; 2ST

ARNUITY ELLIPTA, ASMANEX, ASMANEX HFA, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR

ANORO ELLIPTA PB M

ARCAPTA NEOHALER PB QL; M

ARNUITY ELLIPTA PB M

ASMANEX HFA PB M

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (14 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)

PB QL; M

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES)

PB M

ATROVENT HFA PB QL; M

BECONASE AQ NPB QL; 2ST budesonide, flunisolide, fluticasone propionate, mometasone furoate, QNASL

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150

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

BEVESPI AEROSPHERE PB M

BREO ELLIPTA PB QL; M

BROVANA NPB QL; M PERFOROMIST

budesonide inhalation G QL; M

budesonide nasal PB QL

COMBIVENT RESPIMAT PB QL

cromolyn inhalation G M

CUROSURF NPB

DALIRESP PB PA; QL

DULERA PB QL; M

DYMISTA PB ST; QL

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML

NPB M theophylline anhydrous

ESBRIET PB-S PA

FIRAZYR PB-S

FLOVENT DISKUS PB QL; M

FLOVENT HFA PB QL; M

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

PB QL

fluticasone nasal PB QL

FLUTICASONE-SALMETEROL NPB M

FORADIL AEROLIZER NPB QL ARCAPTA NEOHALER, SEREVENT DISKUS, STRIVERDI RESPIMAT

HYPER-SAL NPB sodium chloride

INCRUSE ELLIPTA PB M

ipratropium bromide inhalation G M

ipratropium-albuterol G QL

KALYDECO PB-S PA

LETAIRIS PB-S PA; M

levalbuterol hcl G

LEVALBUTEROL TARTRATE NPB QL; 2ST PROAIR HFA, PROAIR RESPICLICK, VENTOLIN HFA

metaproterenol G M

mometasone nasal PB QL

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151

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

montelukast oral granules in packet G M

montelukast oral tablet G QL; M

montelukast oral tablet,chewable G QL; M

NASONEX NPB ST; QL mometasone furoate

nebusal inhalation solution for nebulization 3 %

G

NEBUSAL INHALATION SOLUTION FOR NEBULIZATION 6 %

NPB

OFEV PB-S PA

OMNARIS NPB QL; 2ST budesonide, flunisolide, fluticasone propionate, mometasone furoate, QNASL

OPSUMIT PB-S M

ORKAMBI PB-S PA

PERFOROMIST PB QL; M

PROAIR HFA PB QL

PROAIR RESPICLICK PB

PROVENTIL HFA NPB QL; 2ST PROAIR HFA, PROAIR RESPICLICK, VENTOLIN HFA

PULMICORT NPB QL; M budesonide

PULMICORT FLEXHALER PB QL; M

pulmosal G

PULMOZYME PB

QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION

PB ST

QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION

PB ST; QL

QVAR PB QL; M

REVATIO INTRAVENOUS NPB-S PA sildenafil citrate

REVATIO ORAL SUSPENSION FOR RECONSTITUTION

NPB-S PA sildenafil citrate

REVATIO ORAL TABLET NPB-S PA; QL sildenafil citrate

SEEBRI NEOHALER NPB M

INCRUSE ELLIPTA, SPIRIVA, SPIRIVA RESPIMAT, TUDORZA PRESSAIR

SEREVENT DISKUS PB QL; M

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152

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

sildenafil oral G-S PA; QL

SINGULAIR ORAL GRANULES IN PACKET

NPB M montelukast sodium

SINGULAIR ORAL TABLET NPB QL; M montelukast sodium

SINGULAIR ORAL TABLET,CHEWABLE

NPB QL; M montelukast sodium

sodium chloride inhalation solution for nebulization 10 %, 3 %, 7 %

G

SPIRIVA RESPIMAT PB M

SPIRIVA WITH HANDIHALER PB QL; M

STIOLTO RESPIMAT PB M

STRIVERDI RESPIMAT PB M

SYMBICORT PB QL; M

terbutaline oral G M

terbutaline subcutaneous G

THEO-24 NPB M theophylline anhydrous

theochron G M

theophylline oral solution G M

theophylline oral tablet extended release 12 hr

G M

theophylline oral tablet extended release 24 hr

G M

TRACLEER PB-S PA; M

triamcinolone acetonide nasal PB QL

TUDORZA PRESSAIR PB QL; M

UTIBRON NEOHALER NPB M ANORO ELLIPTA, BEVESPI AEROSPHERE, STIOLTO RESPIMAT

VENTAVIS PB-S PA

VENTOLIN HFA PB QL

XOPENEX NPB levalbuterol hcl

XOPENEX CONCENTRATE NPB levalbuterol hcl

XOPENEX HFA NPB QL; 2ST PROAIR HFA, PROAIR RESPICLICK, VENTOLIN HFA

zafirlukast G QL; M

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153

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ZETONNA NPB QL; 2ST budesonide, flunisolide, fluticasone propionate, mometasone furoate, QNASL

zileuton G QL; M

ZYFLO NPB M; 2ST montelukast sodium, zafirlukast

ZYFLO CR NPB QL; M; 2ST ZILEUTON

UROLOGICALS

ANTICHOLINERGICS & ANTISPASMODICS

darifenacin G M

DETROL NPB ST; M tolterodine tartrate

DETROL LA NPB ST; M tolterodine tartrate er

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG, 15 MG

NPB ST; M oxybutynin chloride er

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 5 MG

NPB ST; QL; M oxybutynin chloride er

ENABLEX NPB ST; M darifenacin er

flavoxate G M

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %)

PB ST

GELNIQUE TRANSDERMAL GEL IN PACKET

PB ST; QL; M

MYRBETRIQ PB ST; M

oxybutynin chloride oral syrup G M

oxybutynin chloride oral tablet G M

oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg

G M

oxybutynin chloride oral tablet extended release 24hr 5 mg

G QL; M

OXYTROL NPB ST; QL; M

oxybutynin chloride er, tolterodine tartrate er, trospium chloride, GELNIQUE, TOVIAZ, MYRBETRIQ, VESICARE

tolterodine G M

TOVIAZ PB ST; M

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154

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

trospium G M

VESICARE PB ST; M

BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY

alfuzosin G M

AVODART NPB M dutasteride

CIALIS ORAL TABLET 2.5 MG, 5 MG PB

dutasteride G M

dutasteride-tamsulosin G M

finasteride oral tablet 5 mg G M

FLOMAX NPB M tamsulosin hcl

JALYN NPB M dutasteride-tamsulosin

PROSCAR NPB M finasteride

RAPAFLO PB M

tamsulosin G M

UROXATRAL NPB M alfuzosin hcl er

CHOLINERGIC STIMULANTS

bethanechol chloride G

URECHOLINE NPB bethanechol chloride

MISCELLANEOUS UROLOGICALS

azuphen mb G

CIALIS ORAL TABLET 10 MG, 20 MG

PB

CYSTAGON PB-S PA

cytra k crystals G

cytra-2 G

cytra-3 G

cytra-k G

EDEX NPB CAVERJECT, MUSE

ELMIRON PB

hyolev mb G

hyophen G

INDIOMIN MB NPB

K-PHOS NO 2 NPB phospha 250 neutral

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155

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

K-PHOS ORIGINAL PB

LEVITRA NPB 2ST CIALIS, VIAGRA

methen-sod phos-meth blue-hyos G

ORACIT NPB sodium citrate & citric acid

phosphasal G

pot,sodium citrate-citric acid G

potassium citrate G M

potassium citrate-citric acid G

PROCYSBI NPB-S PA; ST CYSTAGON

SHOHL'S MODIFIED NPB sodium citrate & citric acid

sodium citrate-citric acid G

STAXYN NPB 2ST CIALIS, VIAGRA

STENDRA ORAL TABLET 100 MG, 50 MG

NPB 2ST CIALIS, VIAGRA

tricitrates G

ur n-c G

uramit mb G

URELLE NPB phosphasal, ur n-c, uretron d-s

uretron d-s oral tablet 81.6-10.8-40.8 mg G

URIBEL NPB ustell

urimar-t G

urin ds G

uro-458 G

UROCIT-K 10 NPB M potassium citrate er

UROCIT-K 15 NPB M potassium citrate er

UROCIT-K 5 NPB M potassium citrate er

urogesic-blue G

uro-mp G

urophen mb G

UROQID-ACID NO.2 NPB methenamine mandelate

uryl G

ustell G

UTA NPB

utira-c G

VIAGRA PB

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156

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

virtrate-2 G

virtrate-3 G

virtrate-k G

URINARY ANESTHETICS

phenazopyridine oral tablet 100 mg, 200 mg

G

PYRIDIUM NPB phenazopyridine hcl

VITAMINS, HEMATINICS & ELECTROLYTES

ELECTROLYTES

calcium 500 + d oral tablet 500 mg(1,250mg) -200 unit

G ACA; OTC

calcium 500 + d oral tablet,chewable G ACA; OTC

calcium 500 with d G ACA; OTC

calcium 600 + d(3) oral capsule G ACA; OTC

calcium 600 + d(3) oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit

G ACA; OTC

calcium 600 with vitamin d3 oral capsule

G ACA; OTC

calcium 600 with vitamin d3 oral tablet,chewable

G ACA; OTC

calcium carb and citrate-vitd3 G ACA; OTC

calcium carbonate-vitamin d3 oral capsule 600 mg(1,500mg) -400 unit

G ACA; OTC

calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit

G ACA; OTC

calcium carbonate-vitamin d3 oral tablet,chewable 500-100 mg-unit

G ACA; OTC

calcium citrate + d G ACA; OTC

calcium citrate-vitamin d2 G ACA; OTC

calcium citrate-vitamin d3 oral tablet 200-125 mg-unit, 250 mg calcium- 200 unit, 315-200 mg-unit, 315-250 mg-unit

G ACA; OTC

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157

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

citrus calcium G ACA; OTC

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ

NPB M potassium bicarbonate

effer-k oral tablet, effervescent 25 meq G M

GALZIN NPB

hi-cal plus vit d G ACA; OTC

k-effervescent G M

klor-con G M

klor-con 10 G M

klor-con 8 G M

klor-con m10 G M

klor-con m15 G M

klor-con m20 G M

klor-con sprinkle G M

KLOR-CON/25 NPB M potassium chloride

klor-con/ef G M

k-phos-neutral G

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ

NPB M potassium chloride

k-tab oral tablet extended release 8 meq G M

lugols oral G

oysco 500/d oral tablet G ACA; OTC

oyster shell + d3 G ACA; OTC

oyster shell calcium-vit d3 G ACA; OTC

oystercal-d G ACA; OTC

phospha 250 neutral G

POTABA ORAL CAPSULE NPB M

potassium bicarb and chloride G M

potassium bicarb-citric acid G M

potassium chloride oral G M

strong iodine oral G

virt-phos 250 neutral G

MISCELLANEOUS VITAMINS, HEMATINICS, & ELECTROLYTES

FORTAVIT NPB

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158

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

VITAMINS & HEMATINICS

ACTIVE FE NPB

cholecalciferol (vitamin d3) oral capsule 1,000 unit

G ACA; OTC

cholecalciferol (vitamin d3) oral drops 400 unit/ml

G ACA; OTC

cholecalciferol (vitamin d3) oral tablet 1,000 unit, 400 unit

G ACA; OTC

cholecalciferol (vitamin d3) oral tablet,chewable 1,000 unit

G ACA; OTC

delta d3 G ACA; OTC

d-vi-sol G ACA; OTC

d-vita G ACA; OTC

ergocalciferol (vitamin d2) oral tablet 400 unit

G ACA; OTC

ESCAVITE D NPB M

ESCAVITE LQ NPB M

FLORIVA NPB M

FLORIVA (FLUORIDE-VITAMIN D3) NPB M; ACA

FLORIVA PLUS NPB M

FLUORABON NPB M; ACA

FLUOR-A-DAY NPB M; ACA

fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)-236.79mg, 1 mg f (2.2 mg)-236.79 mg

G M

fluoride (sodium) oral drops G M; ACA

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

G M; ACA

fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

G M

fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)

G M; ACA

fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

G M

FLURA-DROPS NPB M; ACA

folic acid oral tablet 1 mg G M

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159

Drug Name Drug Tier Restrictions / Limits PREFERRED ALTERNATIVES

ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

G M; ACA

ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

G M

multi-vit with fluoride-iron G ACA

multi-vitamin with fluoride oral drops G ACA

multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

G ACA

multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

G ACA

mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg

G ACA

mynephron G

NASCOBAL PB M

oyster shell calcium-vit d2 oral tablet 250 (625)-125 mg-unit

G ACA; OTC

POLY-VI-FLOR FS NPB M

PRENATAL PLUS DHA ORAL COMBO PACK

NPB pnv-dha, prena1 pearl, virt-pn dha

PURALOR CI NPB M

QUFLORA FE NPB M

QUFLORA FE (FERROUS SULFATE) NPB M; ACA

QUFLORA PEDIATRIC NPB M

QUFLORA PEDIATRIC DROPS NPB M

risacal-d G ACA; OTC

TEXAVITE LQ NPB M

tri-vit with fluoride and iron G ACA

tri-vitamin with fluoride G ACA

VIRT-VITE PLUS NPB M

vitajoy daily d G ACA; OTC

vitamin d3 oral capsule 1,000 unit, 400 unit

G ACA; OTC

vitamin d3 oral tablet 1,000 unit, 400 unit

G ACA; OTC

vitamin d3 oral tablet,chewable G ACA; OTC

vitamins a,c,d and fluoride G ACA

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160

2 2TEK GLUCOSE/BLOOD

PRESSURE ........................ 86 A abacavir .................................... 3 abacavir-lamivudine ................. 4 abacavir-lamivudine-zidovudine

.............................................. 4 ABILIFY ................................ 34 ABSORICA ............................ 61 ABSTRAL .............................. 26 acamprosate ............................ 72 ACANYA ............................... 61 acarbose ................................ 112 ACCOLATE ......................... 148 ACCU-CHEK AVIVA

CONNECT METER .......... 86 ACCU-CHEK AVIVA PLUS

METER .............................. 86 ACCU-CHEK AVIVA PLUS

TEST STRP ........................ 77 ACCU-CHEK COMPACT

PLUS CONTROL .............. 86 ACCU-CHEK COMPACT

PLUS TEST........................ 77 ACCU-CHEK GUIDE ........... 77 ACCU-CHEK GUIDE

GLUCOSE METER ........... 87 ACCU-CHEK GUIDE L1-L2

CTRL SOL ......................... 87 ACCU-CHEK NANO ............ 87 ACCU-CHEK SMARTVIEW

CONTRL SOL ................... 87 ACCU-CHEK SMARTVIEW

TEST STRIP ...................... 77 ACCUPRIL ............................ 44 ACCURETIC ......................... 44 ACCUTREND GLUCOSE .... 77 ACCUTREND GLUCOSE

CONTROL ......................... 87 acebutolol ............................... 44 acetaminophen-caff-dihydrocod

............................................ 26 ACETAMINOPHEN-CAFF-

DIHYDROCOD ................. 26

acetaminophen-codeine .......... 26 acetazolamide ....................... 141 acetic acid ............................... 75 acetic acid-aluminum acetate . 75 acetylcysteine ....................... 148 ACIPHEX ............................. 122 ACIPHEX SPRINKLE ........ 122 acitretin ................................... 56 ACTEMRA .......................... 127 ACTICLATE .......................... 12 ACTIGALL .......................... 116 ACTIMMUNE ..................... 126 ACTIQ .................................... 26 ACTIVE FE .......................... 158 ACTIVELLA........................ 129 ACTONEL ..................... 72, 126 ACTOPLUS MET ................ 112 ACTOPLUS MET XR ......... 112 ACTOS ................................. 112 acuicyn.................................. 140 ACULAR.............................. 141 ACULAR LS ........................ 141 ACUVAIL (PF) .................... 141 acyclovir ............................. 4, 68 ACZONE ................................ 61 ADALAT CC ......................... 44 adapalene ................................ 61 ADAPALENE ........................ 61 ADASUVE ............................. 34 ADCIRCA ............................ 149 ADDERALL .......................... 34 ADDERALL XR .................... 34 ADDYI ................................... 34 adefovir ..................................... 4 ADEMPAS ........................... 149 ADLYXIN ............................ 112 ADRENACLICK ................. 144 ADRENALIN ....................... 149 ADVAIR DISKUS ............... 149 ADVAIR HFA ..................... 149 ADVANCED GLUC METER

TEST STRIP....................... 78 ADVANCED GLUCOSE

METER .............................. 87

ADVOCATE BLOOD GLUCOSE MONITOR ...... 87

ADVOCATE DUO ................ 87 ADVOCATE LOW CONTROL

............................................ 87 ADVOCATE REDI-CODE.... 78 ADVOCATE REDI-CODE

DUO METER ..................... 87 ADVOCATE REDI-CODE

GLU MONITOR ................ 88 ADVOCATE REDI-CODE+

CTRL LOW ........................ 88 ADVOCATE TEST STRIPS . 78 ADZENYS XR-ODT ............. 35 AEROSPAN ......................... 149 afeditab cr ............................... 44 AFINITOR ............................. 14 AFINITOR DISPERZ ............ 14 AFREZZA ............................ 108 AFTERA............................... 132 AGAMATRIX AMP GLUC

MONITOR SYS ................. 88 AGAMATRIX AMP TEST

STRIPS ............................... 78 AGAMATRIX CONTROL

HIGH .................................. 88 AGGRENOX .......................... 51 AGRYLIN .............................. 72 AIRDUO RESPICLICK ....... 149 AKTEN (PF) ........................ 140 AKYNZEO ........................... 116 ala-cort .................................... 68 ALA-SCALP .......................... 68 ALBENZA ............................... 8 albuterol sulfate .................... 149 alclometasone ......................... 68 ALDACTAZIDE .................... 44 ALDACTONE ........................ 44 ALDARA ............................. 126 ALECENSA ........................... 14 alendronate ..................... 72, 126 alfuzosin ............................... 154 ALINIA .................................... 9 ALKERAN ............................. 14 allopurinol............................. 126

Index of Drugs

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ALLZITAL ............................. 26 almotriptan malate .................. 22 ALOCRIL............................. 140 ALOGLIPTIN ...................... 112 ALOGLIPTIN-METFORMIN

.......................................... 112 ALOGLIPTIN-

PIOGLITAZONE ............. 112 ALOMIDE ........................... 140 ALORA ................................ 129 alosetron ............................... 116 ALPHAGAN P ..................... 144 alprazolam .............................. 35 alprazolam intensol ................ 35 ALREX................................. 143 ALSUMA ............................... 22 ALTABAX ............................. 66 altacaine ................................ 140 ALTACE ................................ 44 altafluor ................................ 140 altavera (28) .......................... 132 ALTOPREV ........................... 53 ALVESCO ........................... 149 alyacen 1/35 (28) .................. 132 alyacen 7/7/7 (28) ................. 132 amabelz ................................. 129 amantadine hcl .......................... 4 AMARYL............................. 112 AMBIEN ................................ 35 AMBIEN CR .......................... 35 amcinonide ............................. 68 AMERGE ............................... 22 amethia ................................. 132 amethia lo ............................. 132 amethyst ............................... 132 AMICAR ................................ 51 amiloride ................................. 44 amiloride-hydrochlorothiazide44 amiodarone ............................. 43 AMITIZA ............................. 117 amitriptyline ........................... 35 amitriptyline-chlordiazepoxide

............................................ 35 amlodipine .............................. 44 amlodipine-atorvastatin .......... 53 amlodipine-benazepril ............ 44 amlodipine-olmesartan ........... 45 amlodipine-valsartan .............. 45

amlodipine-valsartan-hcthiazid ............................................ 45

amoxapine .............................. 35 amoxicil-clarithromy-lansopraz

.......................................... 122 amoxicillin .............................. 11 amoxicillin-pot clavulanate .... 11 ampicillin ................................ 11 AMPYRA ............................... 24 AMRIX ................................... 25 ANAFRANIL ......................... 35 anagrelide ............................... 72 ANALPRAM-HC ........... 56, 117 ANALPRAM-HC SINGLES117 ANAPROX DS ...................... 31 anaspaz ................................. 115 anastrozole .............................. 14 ANCOBON .............................. 3 ANDRODERM .................... 109 ANDROGEL ................ 109, 110 ANDROID............................ 110 androxy ................................. 110 ANGELIQ ............................ 129 ANORO ELLIPTA............... 149 ANTABUSE ........................... 72 ANTARA ............................... 53 anucort-hc ............................. 117 ANUSOL-HC ....................... 117 ANZEMET ........................... 117 apexicon e ............................... 68 APIDRA ............................... 108 APIDRA SOLOSTAR ......... 108 APLENZIN ............................ 35 APOKYN ............................... 21 apraclonidine ........................ 144 aprepitant .............................. 117 apri ........................................ 132 APRISO ................................ 117 APTENSIO XR ...................... 35 APTIOM ................................. 18 APTIVUS ................................. 4 AQUA GLYCOLIC HC ......... 68 aranelle (28) .......................... 132 ARAVA ................................ 127 ARCALYST ......................... 126 ARCAPTA NEOHALER ..... 149 ARICEPT ............................... 24 ARIMIDEX ............................ 14 aripiprazole ............................. 35

ARIXTRA .............................. 51 armodafinil ............................. 35 ARMOUR THYROID.......... 114 ARNUITY ELLIPTA ........... 149 AROMASIN ........................... 14 ARTHROTEC 50 ................... 31 ARTHROTEC 75 ................... 31 ARYMO ER ........................... 26 ASACOL HD ....................... 117 ascomp with codeine .............. 26 ashlyna .................................. 132 ASMANEX HFA ................. 149 ASMANEX TWISTHALER 149 aspir-81 ................................... 31 aspirin ..................................... 31 aspirin low dose ...................... 31 aspirin-caffeine-dihydrocodein

............................................ 26 aspirin-dipyridamole ............... 51 aspir-low ................................. 31 aspir-trin ................................. 31 ASSURE 4 CONTROL

SOLUTION ........................ 88 ASSURE 4 STRIPS ................ 78 ASSURE DOSE NORMAL

CONTROL ......................... 88 ASSURE PLATINUM ..... 78, 88 ASSURE PRISM CONTROL 1-

2 SOLN ............................... 88 ASSURE PRISM MULTI

METER............................... 88 ASSURE PRISM MULTI

STRIP ................................. 78 ASTAGRAF XL ..................... 14 ASTEPRO .............................. 74 ATACAND............................. 45 ATACAND HCT.................... 45 ATELVIA ............................. 127 atenolol ................................... 45 atenolol-chlorthalidone ........... 45 ATIVAN ................................. 35 atomoxetine ............................ 35 ATOPICLAIR ........................ 59 atorvastatin ............................. 53 atovaquone ................................ 9 atovaquone-proguanil ............... 9 ATRALIN............................... 62 ATRAPRO CP........................ 59 ATRAPRO HYDROGEL ...... 59

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162

ATRIPLA ................................. 4 atropine ................................. 139 ATROVENT HFA ............... 149 AUBAGIO ........................... 125 aubra ..................................... 132 AUGMENTIN ........................ 11 AUGMENTIN ES-600 ........... 11 AUGMENTIN XR ................. 11 AURYXIA ........................... 117 AUTOJECT 2 INJECTION

DEVICE ............................. 88 AUTOPEN 1 TO 21 UNITS .. 88 AUVI-Q ................................ 144 AVALIDE .............................. 45 AVANDIA ........................... 112 AVAPRO ............................... 45 avar ......................................... 62 AVAR..................................... 62 AVAR LS ............................... 62 AVAR-E GREEN .................. 62 AVAR-E LS ........................... 62 AVC VAGINAL .................. 131 AVELOX ............................... 11 aviane ................................... 132 avidoxy ................................... 12 avita ........................................ 62 AVITA ................................... 62 avo cream ............................... 59 AVODART .......................... 154 AVONEX ............................. 125 AVONEX (WITH ALBUMIN)

.......................................... 125 AXERT................................... 22 AXIRON .............................. 110 AYGESTIN .......................... 129 AZASAN ................................ 14 AZASITE ............................. 138 azathioprine ............................ 14 azelastine ........................ 74, 140 AZELEX ................................ 62 AZILECT ............................... 21 azithromycin ............................. 8 AZOPT ................................. 142 AZOR ..................................... 45 AZULFIDINE ...................... 117 AZULFIDINE EN-TABS .... 117 azuphen mb .......................... 154 azurette (28) .......................... 132

B bacitracin .............................. 138 bacitracin-polymyxin b......... 138 baclofen .................................. 25 BACTRIM .............................. 12 BACTRIM DS ........................ 12 BACTROBAN ....................... 66 BACTROBAN NASAL ......... 74 balsalazide ............................ 117 balziva (28) ........................... 132 BANZEL ................................ 18 BARACLUDE ......................... 4 BASAGLAR KWIKPEN ..... 108 bayer aspirin ........................... 31 BECONASE AQ .................. 149 bekyree (28) .......................... 132 BELBUCA ............................. 26 belladonna alkaloids-opium . 115 belladonna-opium ................. 115 BELSOMRA .......................... 35 BELVIQ ................................. 71 BELVIQ XR ........................... 72 benazepril ............................... 45 benazepril-hydrochlorothiazide

............................................ 45 BENICAR .............................. 45 BENICAR HCT ..................... 45 BENSAL HP .......................... 58 BENTYL .............................. 115 BENZACLIN ......................... 62 BENZACLIN PUMP ............. 62 BENZAMYCIN ..................... 62 BENZEFOAM........................ 62 BENZEFOAM ULTRA ......... 62 benzepro ................................. 62 benzonatate ........................... 145 benztropine ............................. 21 BEPREVE ............................ 140 BESIVANCE........................ 138 BETADINE OPHTHALMIC

PREP ................................ 138 BETAGAN ........................... 139 betamethasone dipropionate ... 68 betamethasone valerate........... 68 betamethasone, augmented ..... 68 BETAPACE ........................... 43 BETAPACE AF ..................... 43 BETASERON ...................... 125 betaxolol ......................... 45, 139

bethanechol chloride ............. 154 BETIMOL ............................ 139 BETOPTIC S ........................ 139 BEVESPI AEROSPHERE ... 150 bexarotene ............................... 14 BEYAZ ................................. 133 BIAFINE EMULSION ........... 59 BIAXIN .................................... 8 bicalutamide ........................... 14 BIDIL ..................................... 45 BILTRICIDE ............................ 9 bimatoprost ........................... 142 BINOSTO ............................. 127 BIONIME RIGHTEST GM300

SYSTEM ............................ 88 BIONIME RIGHTEST TEST

STRIPS ............................... 78 bisoprolol fumarate ................. 45 bisoprolol-hydrochlorothiazide

............................................ 45 BLEPH-10 ............................ 144 BLEPHAMIDE .................... 144 BLEPHAMIDE S.O.P. ......... 144 blisovi 24 fe .......................... 133 blisovi fe 1.5/30 (28) ............ 133 blisovi fe 1/20 (28) ............... 133 BLOOD GLUCOSE

CONTROL, NORMAL ...... 89 BLOOD GLUCOSE TEST .... 78 BLOOD-GLUCOSE METER 89 BONIVA............................... 127 BOSULIF ............................... 14 bp 10-1 .................................... 62 bp-50% urea............................ 59 bpo .......................................... 62 BREEZE 2 CONTROL

SOLUTION,HIGH ............. 89 BREEZE 2 TEST STRIPS ..... 78 BREO ELLIPTA .................. 150 BREVICON (28) .................. 133 briellyn .................................. 133 BRILINTA ............................. 51 brimonidine........................... 144 BRISDELLE........................... 35 BRIVIACT ............................. 18 BROMFED DM ................... 145 bromfenac ............................. 141 bromocriptine ......................... 21

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brompheniramine-pseudoeph-dm ..................................... 145

BROMSITE .......................... 141 BROVANA .......................... 150 BUCALSEP ........................... 65 budesonide .................... 117, 150 bumetanide ............................. 45 BUNAVAIL ........................... 31 BUPAP ................................... 26 BUPHENYL ........................... 72 BUPRENORPHINE ............... 26 buprenorphine hcl ................... 26 buprenorphine-naloxone ......... 31 bupropion hcl .......................... 35 bupropion hcl (smoking deter)73 buspirone ................................ 35 butalbital compound w/codeine

............................................ 26 butalbital-acetaminop-caf-cod 26 butalbital-acetaminophen ....... 27 butalbital-acetaminophen-caff 27 butalbital-aspirin-caffeine ...... 27 BUTISOL ............................... 35 butorphanol tartrate ................ 31 BUTRANS ............................. 27 BYDUREON ........................ 112 BYETTA .............................. 112 BYSTOLIC ............................ 45 BYVALSON .......................... 45 C cabergoline ........................... 110 CABOMETYX....................... 14 CADUET ................................ 53 CAFERGOT ........................... 23 caffeine citrate ........................ 72 CALAN .................................. 45 CALAN SR ............................ 45 calcipotriene ........................... 56 calcipotriene-betamethasone .. 56 calcitonin (salmon) ............... 110 calcitrene ................................ 56 calcitriol .......................... 56, 110 calcium 500 + d .................... 156 calcium 500 with d ............... 156 calcium 600 + d(3) ............... 156 calcium 600 with vitamin d3 156 calcium acetate ..................... 117 calcium carb and citrate-vitd3

.......................................... 156

calcium carbonate-vitamin d3 .......................................... 156

calcium citrate + d ................ 156 calcium citrate-vitamin d2 .... 156 calcium citrate-vitamin d3 .... 156 CAMBIA ................................ 31 camila ................................... 129 camrese ................................. 133 camrese lo ............................. 133 CANASA.............................. 117 candesartan ............................. 45 candesartan-hydrochlorothiazid

............................................ 45 capacet .................................... 27 CAPCOF .............................. 145 capecitabine ............................ 14 CAPEX ................................... 68 CAPITAL WITH CODEINE . 27 CAPRELSA............................ 14 captopril .................................. 45 captopril-hydrochlorothiazide 45 CARAC .................................. 59 CARAFATE ......................... 122 CARBAGLU .......................... 72 carbamazepine ........................ 18 CARBATROL ........................ 18 carbidopa ................................ 21 carbidopa-levodopa ................ 21 carbidopa-levodopa-entacapone

............................................ 21 carbinoxamine maleate ......... 144 CARDIZEM ........................... 46 CARDIZEM CD .................... 45 CARDIZEM LA ............... 45, 46 CARDURA ............................ 46 CARDURA XL ...................... 46 CARESENS CONTROL A

NORMAL ........................... 89 CARESENS N ........................ 89 CARESENS N TEST STRIPS

............................................ 78 CARESENS N VOICE .......... 89 carisoprodol ............................ 25 carisoprodol-asa-codeine ........ 25 carisoprodol-aspirin ................ 25 CARNITOR............................ 72 CARNITOR (SUGAR-FREE)72 carteolol ................................ 139 cartia xt ................................... 46

carvedilol ................................ 46 CASODEX ............................. 14 CATAPRES ............................ 46 CATAPRES-TTS-1 ................ 46 CATAPRES-TTS-2 ................ 46 CATAPRES-TTS-3 ................ 46 CAYA CONTOURED ......... 128 CAYSTON ............................... 9 caziant (28) ........................... 133 CEDAX .................................... 7 cefaclor ..................................... 7 cefadroxil .................................. 7 cefdinir ...................................... 7 cefditoren pivoxil ...................... 7 cefixime .................................... 7 cefpodoxime ............................. 7 cefprozil .................................... 7 ceftibuten .................................. 7 CEFTIN .................................... 7 cefuroxime axetil ...................... 7 celacyn .................................... 59 CELEBREX ........................... 31 celecoxib ................................. 31 CELEXA ................................ 35 CELLCEPT ............................ 14 CELONTIN ............................ 18 CENTANY ............................. 66 CENTANY AT ....................... 66 centergy ................................ 145 cephalexin ................................. 7 CERDELGA ......................... 110 CERVIDIL ........................... 131 CESAMET ........................... 117 cetirizine ............................... 144 CETRAXAL ........................... 75 CETROTIDE ........................ 110 cevimeline ............................... 72 CHANTIX .............................. 73 CHANTIX CONTINUING

MONTH BOX .................... 73 CHANTIX STARTING

MONTH BOX .................... 73 chateal ................................... 133 CHEMET ................................ 72 CHENODAL ........................ 117 cheratussin ac........................ 145 children's aspirin ..................... 31 chlordiazepoxide hcl ............... 35 chlordiazepoxide-clidinium .. 115

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chlorhexidine gluconate ......... 74 chloroquine phosphate .............. 9 chlorothiazide ......................... 46 chlorpromazine ....................... 35 chlorpropamide ..................... 112 chlorthalidone ......................... 46 chlorzoxazone ......................... 25 CHOLBAM .......................... 117 cholecalciferol (vitamin d3) . 158 cholestyramine (with sugar) ... 53 cholestyramine light ............... 53 choline,magnesium salicylate . 31 CIALIS ................................. 154 ciclodan .................................. 66 CICLODAN KIT.................... 66 ciclopirox ................................ 66 cilostazol ................................. 51 CILOXAN ............................ 138 cimetidine ............................. 122 cimetidine hcl ....................... 122 CIMZIA ................................ 117 CIMZIA POWDER FOR

RECONST ........................ 117 CIPRO .................................... 12 CIPRO HC.............................. 76 CIPRO XR.............................. 12 CIPRODEX ............................ 76 ciprofloxacin ........................... 12 ciprofloxacin (mixture) .......... 12 ciprofloxacin hcl ....... 12, 75, 138 citalopram ............................... 36 citrus calcium ....................... 157 claravis ................................... 62 CLARINEX .......................... 144 CLARINEX-D 12 HOUR .... 145 clarithromycin .......................... 8 cleansing wash........................ 62 clemastine ............................. 144 CLEO 90 INFUSION SET 24 89 CLEOCIN............................. 131 CLEOCIN HCL........................ 9 CLEOCIN PEDIATRIC ........... 9 CLEOCIN T ........................... 62 CLEVER CHEK BLOOD

GLUCOSE ......................... 89 CLEVER CHOICE GLUCOSE

MONITOR ......................... 89 CLEVER CHOICE LEVEL 2

CONTROL ......................... 89

CLEVER CHOICE MICRO .. 89 CLEVER CHOICE MICRO

TEST STRIP....................... 78 CLEVER CHOICE PRO .. 78, 90 CLEVER CHOICE TEST

STRIPS ............................... 78 CLEVER CHOICE VOICE+

TEST .................................. 79 CLIMARA............................ 129 CLIMARA PRO ................... 129 CLINDACIN ETZ .................. 62 clindacin p .............................. 62 CLINDACIN PAC ................. 62 CLINDAGEL ......................... 62 clindamycin hcl ........................ 9 clindamycin palmitate hcl ........ 9 clindamycin pediatric ............... 9 clindamycin phosphate ... 62, 131 clindamycin-benzoyl peroxide

...................................... 62, 63 clindamycin-tretinoin ............. 63 CLINDESSE ........................ 131 CLINPRO 5000 ...................... 74 clobetasol ................................ 68 clobetasol-emollient ............... 68 CLOBEX ................................ 68 CLOCORTOLONE PIVALATE

............................................ 68 clodan ..................................... 68 CLODAN KIT ........................ 68 CLODERM ............................ 68 clomipramine .......................... 36 clonazepam ............................. 18 clonidine ................................. 46 clonidine hcl ..................... 36, 46 clopidogrel ........................ 51, 52 clorazepate dipotassium ......... 36 clorpres ................................... 46 CLORPRES ............................ 46 clotrimazole .............................. 3 clotrimazole-betamethasone ... 66 clozapine ................................. 36 CLOZAPINE .......................... 36 CLOZARIL ............................ 36 COAL TAR ............................ 56 COARTEM .............................. 9 codeine sulfate ........................ 27 codeine-butalbital-asa-caff ..... 27 codeine-guaifenesin .............. 145

CODITUSSIN AC ................ 145 CODITUSSIN DAC ............. 145 COLAZAL ........................... 117 COLCHICINE ...................... 126 COLCRYS ............................ 126 COLESTID ............................. 53 COLESTID FLAVORED ...... 53 colestipol................................. 53 colistin (colistimethate na) ....... 9 colocort ................................. 117 COLY-MYCIN M

PARENTERAL .................... 9 COLY-MYCIN S ................... 76 COLYTE WITH FLAVOR

PACKS ............................. 118 COMBIGAN ........................ 142 COMBIPATCH .................... 129 COMBIVENT RESPIMAT .. 150 COMBIVIR .............................. 4 COMETRIQ ........................... 15 COMFORT SHORT INSULIN

PUMP 23 ............................ 90 COMPAZINE ....................... 118 COMPLERA ............................ 4 compro .................................. 118 COMTAN ............................... 21 CONCEPTROL .................... 131 CONCERTA ........................... 36 CONDYLOX .......................... 59 constulose ............................. 118 CONTOUR CONTROL

SOLUTION, NML ............. 90 CONTOUR LINK .................. 90 CONTOUR NEXT EZ METER

............................................ 90 CONTOUR NEXT LEV 2

CONTROL SOL ................. 90 CONTOUR NEXT LINK ....... 90 CONTOUR NEXT METER... 90 CONTOUR NEXT ONE

METER............................... 90 CONTOUR NEXT STRIPS ... 79 CONTOUR TEST STRIPS .... 79 CONTROL AST

MONITORING SYSTEM.. 90 CONZIP .................................. 31 COOL BLOOD GLUCOSE

METER............................... 91

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COOL CONTROL A SOLUTION ........................ 91

COOL GLUCOSE TEST STRIP ............................................ 79

COPAXONE ........................ 125 COPEGUS ............................ 125 CORDRAN ............................ 69 CORDRAN TAPE LARGE

ROLL ................................. 68 COREG .................................. 46 COREG CR ............................ 46 CORGARD ............................ 46 CORLANOR .......................... 55 cormax .................................... 69 CORTANE-B ......................... 59 CORTEF................................. 76 CORTENEMA ..................... 118 CORTIFOAM ...................... 118 cortisone ................................. 76 CORTISPORIN ...................... 66 CORZIDE............................... 46 COSENTYX ........................... 56 COSENTYX (2 SYRINGES) 56 COSENTYX PEN .................. 56 COSENTYX PEN (2 PENS) .. 56 COSOPT............................... 142 COSOPT (PF) ...................... 142 COTELLIC ............................. 15 COUMADIN .......................... 52 covaryx ................................. 129 covaryx h.s. .......................... 129 COZAAR ............................... 46 CREON ................................ 118 CRESEMBA ............................ 3 CRESTOR .............................. 53 CRINONE ............................ 129 CRIXIVAN .............................. 4 cromolyn ............... 118, 140, 150 cryselle (28) .......................... 133 CUPRIMINE ........................ 127 CUROSURF ......................... 150 CUTIVATE ............................ 69 CUVPOSA ........................... 115 cyclafem 1/35 (28) ............... 133 cyclafem 7/7/7 (28) .............. 133 CYCLESSA (28) .................. 133 cyclobenzaprine ...................... 25 CYCLOGYL ........................ 140 CYCLOMYDRIL................. 144

cyclopentolate ....................... 140 CYCLOPHOSPHAMIDE ...... 15 CYCLOSERINE ...................... 9 CYCLOSET ......................... 112 cyclosporine............................ 15 cyclosporine modified ............ 15 CYMBALTA.......................... 36 cyproheptadine ..................... 144 cyred ..................................... 133 CYSTADANE ...................... 118 CYSTAGON ........................ 154 CYSTARAN ........................ 140 CYTOMEL ........................... 114 CYTOTEC............................ 122 cytra k crystals ...................... 154 cytra-2 ................................... 154 cytra-3 ................................... 154 cytra-k ................................... 154 D D.H.E.45 ................................. 23 DAKLINZA ............................. 4 DALIRESP ........................... 150 danazol.................................. 110 DANTRIUM .......................... 25 dantrolene ............................... 25 dapsone ..................................... 9 DARAPRIM ............................. 9 darifenacin ............................ 153 dasetta 1/35 (28) ................... 133 dasetta 7/7/7 (28) .................. 133 DAXBIA .................................. 7 DAYPRO................................ 31 daysee ................................... 133 DAYTRANA.......................... 36 DDAVP ................................ 110 DEBACTEROL...................... 74 deblitane ............................... 129 DELESTROGEN ................. 129 delta d3 ................................. 158 deltasone ................................. 76 delyla (28)............................. 133 DELZICOL .......................... 118 DEMADEX ............................ 46 demeclocycline ....................... 12 DEMEROL ............................. 27 DEMSER ................................ 46 DENAVIR .............................. 68 denta 5000 plus ....................... 74 dentagel .................................. 74

DEPAKENE ........................... 18 DEPAKOTE ........................... 18 DEPAKOTE ER ..................... 19 DEPAKOTE SPRINKLES ..... 19 DEPEN TITRATABS .......... 127 DEPO-ESTRADIOL ............ 129 DEPO-PROVERA ................ 129 DEPO-SUBQ PROVERA 104

.......................................... 129 DEPO-TESTOSTERONE .... 110 DERMA-SMOOTHE/FS

BODY OIL ......................... 69 DERMA-SMOOTHE/FS

SCALP OIL ........................ 69 DERMATOP .......................... 69 dermazene ............................... 66 DERMOTIC OIL.................... 75 DESCOVY ............................... 4 desipramine ............................. 36 desloratadine ......................... 144 desmopressin ........................ 110 desog-e.estradiol/e.estradiol . 133 DESOGEN ........................... 133 desogestrel-ethinyl estradiol . 133 DESONATE ........................... 69 desonide .................................. 69 DESOWEN............................. 69 desoximetasone....................... 69 DESOXYN ............................. 36 DESVENLAFAXINE ............ 36 DESVENLAFAXINE

FUMARATE ...................... 36 desvenlafaxine succinate ........ 36 DETROL .............................. 153 DETROL LA ........................ 153 dexamethasone ....................... 76 dexamethasone intensol .......... 76 dexamethasone sodium

phosphate .......................... 143 DEXCOM G4 RECEIVER .... 91 DEXCOM G5 RECEIVER .... 91 dexedrine ................................ 36 DEXEDRINE SPANSULE .... 36 DEXERYL ............................. 59 DEXILANT .......................... 122 dexmethylphenidate ................ 36 DEXPAK 10 DAY ................. 76 DEXPAK 13 DAY ................. 76 DEXPAK 6 DAY ................... 76

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166

dextroamphetamine ................ 36 dextroamphetamine-

amphetamine ...................... 36 DIAMOX SEQUELS ........... 142 DIASTAT ............................... 19 DIASTAT ACUDIAL ............ 19 DIATRUE CONTROL SOLN

NORMAL........................... 91 DIATRUE PLUS BLOOD

GLUCOSE MET ................ 91 DIATRUE PLUS TEST STRIP

............................................ 79 diazepam ................................. 37 diazepam intensol ................... 36 DIBENZYLINE ..................... 46 DICLEGIS ............................ 118 diclofenac potassium .............. 31 diclofenac sodium ..... 31, 32, 59,

141 diclofenac-misoprostol ........... 32 dicloxacillin ............................ 11 dicyclomine .......................... 115 didanosine ................................. 4 DIFFERIN .............................. 63 DIFICID ................................... 8 diflorasone .............................. 69 DIFLUCAN .............................. 3 diflunisal ................................. 32 digitek ..................................... 51 digox ....................................... 51 digoxin .................................... 51 dihydroergotamine ................. 23 DILANTIN ............................. 19 DILANTIN EXTENDED ...... 19 DILANTIN INFATABS ........ 19 DILANTIN-125 ..................... 19 DILATRATE-SR ................... 55 DILAUDID ............................ 27 diltiazem ........................... 46, 47 dilt-xr ...................................... 47 DIOVAN ................................ 47 DIOVAN HCT ....................... 47 DIPENTUM ......................... 118 diphenoxylate-atropine ......... 115 DIPROLENE .......................... 69 DIPROLENE AF.................... 69 dipyridamole........................... 52 DISALCID ............................. 32 diskets ..................................... 27

disopyramide phosphate ......... 44 disulfiram................................ 72 DITROPAN XL ................... 153 DIURIL .................................. 47 divalproex ............................... 19 DIVIGEL .............................. 129 dofetilide ................................. 44 DOLOPHINE ......................... 27 donepezil ................................ 24 DONNATAL ................ 115, 116 DORAL .................................. 37 DORYX .................................. 12 DORYX MPC ........................ 12 dorzolamide .......................... 142 dorzolamide-timolol ............. 142 DOVONEX ............................ 56 doxazosin ................................ 47 doxepin ............................. 37, 59 doxercalciferol ...................... 110 doxycycline hyclate ................ 12 doxycycline monohydrate 12, 13 DOXYCYCLINE

MONOHYDRATE ............. 13 drithocreme hp ........................ 56 dronabinol ............................. 118 drospirenone-e.estradiol-lm.fa

.......................................... 133 drospirenone-ethinyl estradiol

.......................................... 133 DROXIA ................................ 15 DUAC ..................................... 63 DUAVEE.............................. 129 DUETACT ........................... 112 DUEXIS ................................. 32 DULERA .............................. 150 duloxetine ............................... 37 DUPIXENT ............................ 59 DURAGESIC ......................... 27 DUREZOL ........................... 143 DURLAZA ............................. 52 dutasteride ............................ 154 dutasteride-tamsulosin .......... 154 DUTOPROL ........................... 47 d-vi-sol.................................. 158 d-vita ..................................... 158 DYANAVEL XR ................... 37 DYAZIDE .............................. 47 DYMISTA ............................ 150 DYRENIUM .......................... 47

E e.c. prin ................................... 32 e.e.s. 400 ................................... 8 E.E.S. GRANULES .................. 8 EASY PLUS II BLOOD

GLUCOSE MET ................ 91 EASY PLUS II TEST ............. 79 EASY STEP ........................... 79 EASY STEP BLOOD

GLUCOSE METER ........... 91 EASY TALK BLOOD

GLUCOSE METER ........... 91 EASY TALK GLUCOSE TEST

............................................ 79 EASY TOUCH GLUCOSE

MONITOR ......................... 91 EASY TOUCH TEST STRIP 79 EASY TRAK GLUCOSE TEST

............................................ 79 EASY TRAK LOW CONTROL

............................................ 91 EASYGLUCO MONITORING

SYSTEM ............................ 92 EASYGLUCO PLUS ....... 79, 92 EASYGLUCO PLUS

NORMAL CONTROL ....... 92 EASYGLUCO TEST ............. 79 EASYMAX ............................ 79 EASYMAX L BLOOD

GLUCOSE METER ........... 92 EASYMAX LOW CONTROL

............................................ 92 EASYMAX NG...................... 92 EASYMAX NORMAL

CONTROL ......................... 92 EASYMAX V SPEAKING

GLUCOSE SYS ................. 92 EASYMAX V2 BLOOD

GLUCOSE METER ........... 92 EC-NAPROSYN .................... 32 econazole ................................ 66 econtra ez .............................. 133 ecotrin ..................................... 32 ecotrin low strength ................ 32 ECOZA ................................... 66 EDARBI ................................. 47 EDARBYCLOR ..................... 47 EDECRIN ............................... 47 EDEX ................................... 154

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167

EDLUAR ................................ 37 ed-spaz .................................. 116 EDURANT ............................... 4 eemt ...................................... 129 eemt hs .................................. 129 effer-k ................................... 157 EFFER-K .............................. 157 EFFEXOR XR........................ 37 EFFIENT ................................ 52 EFUDEX ................................ 59 EGRIFTA ............................. 124 ELDEPRYL ........................... 21 ELEMENT COMPACT

GLUCOSE METER ........... 93 ELEMENT COMPACT

NORMAL CONTROL ....... 93 ELEMENT COMPACT TEST

STRIPS ............................... 79 ELEMENT COMPACT V

GLUCOSE MTR ................ 93 ELEMENT NORMAL

CONTROL ......................... 93 ELEMENT PLUS BLOOD

GLUCOSE KIT .................. 93 ELEMENT TEST STRIPS ..... 80 ELESTAT ............................. 140 ELESTRIN ........................... 129 eletone .................................... 59 ELIDEL .................................. 59 ELIGARD .............................. 15 ELIGARD (3 MONTH) ......... 15 ELIGARD (4 MONTH) ......... 15 ELIGARD (6 MONTH) ......... 15 ELIMITE ................................ 71 elinest ................................... 133 eliphos .................................. 118 ELIQUIS ................................ 52 ELIXOPHYLLIN ................. 150 ELLA .................................... 133 ELMIRON ............................ 154 ELOCON ................................ 69 EMADINE ........................... 140 EMBEDA ............................... 27 EMBRACE BLOOD

GLUCOSE SYSTEM ... 80, 93 EMBRACE EVO LEVEL 1 ... 93 EMBRACE EVO TEST

STRIPS ............................... 80

EMBRACE GLUCOSE CONTROL LOW ............... 93

EMBRACE PRO GLUCOSE METER .............................. 93

EMBRACE PRO TEST STRIPS ............................................ 80

EMCYT .................................. 15 EMEND ................................ 118 EMFLAZA ............................. 76 emoquette ............................. 133 EMSAM ................................. 37 EMTRIVA ................................ 4 EMVERM ................................ 9 ENABLEX ........................... 153 enalapril maleate ..................... 47 enalapril-hydrochlorothiazide 47 ENBREL .............................. 127 ENBREL SURECLICK ....... 127 endocet.................................... 27 ENDOMETRIN.................... 129 enoxaparin .............................. 52 enpresse ................................ 133 enskyce ................................. 133 ENSTILAR ............................. 56 entacapone .............................. 21 entecavir ................................... 4 ENTOCORT EC................... 118 ENTRESTO............................ 55 enulose .................................. 118 ENVARSUS XR .................... 15 EPANED ................................ 47 EPCLUSA ................................ 4 EPICERAM ............................ 59 EPIDUO ................................. 63 EPIDUO FORTE .................... 63 EPIFOAM .............................. 56 epinastine .............................. 140 EPINEPHRINE .................... 145 EPIPEN 2-PAK .................... 145 EPIPEN JR 2-PAK ............... 145 EPISIL .................................... 74 epitol ....................................... 19 EPIVIR ..................................... 4 EPIVIR HBV ............................ 4 eplerenone .............................. 47 eprosartan ............................... 47 EPZICOM ................................ 4 EQUETRO ............................. 19 ergocalciferol (vitamin d2) ... 158

ergoloid ................................... 37 ERGOMAR ............................ 23 ergotamine-caffeine ................ 23 ERIVEDGE ............................ 15 errin....................................... 129 ERTACZO .............................. 66 ery pads ................................... 63 erygel ...................................... 63 ERYPED 200............................ 8 ERYPED 400............................ 8 ery-tab ....................................... 8 ERY-TAB ................................. 8 erythrocin (as stearate) ............. 8 erythromycin ..................... 8, 138 erythromycin ethylsuccinate ..... 8 erythromycin with ethanol ...... 63 erythromycin-benzoyl peroxide

............................................ 63 ESBRIET .............................. 150 ESCAVITE D ....................... 158 ESCAVITE LQ .................... 158 escitalopram oxalate ............... 37 ESGIC..................................... 27 esomeprazole magnesium ..... 122 ESOMEPRAZOLE

STRONTIUM ................... 122 estarylla ................................. 133 estazolam ................................ 37 ESTRACE ............................ 129 estradiol ................................ 129 estradiol valerate ................... 130 estradiol-norethindrone acet . 130 ESTRING ............................. 130 ESTROGEL .......................... 130 estrogens-methyltestosterone 130 estropipate ............................. 130 ESTROSTEP FE-28 ............. 133 eszopiclone ............................. 37 ethacrynic acid ........................ 47 ethambutol ................................ 9 ethosuximide........................... 19 ethyl chloride .......................... 65 ethynodiol diac-eth estradiol 134 etidronate disodium ................ 72 etodolac ................................... 32 etoposide ................................. 15 EUCRISA ............................... 59 EURAX .................................. 71 EVAMIST ............................ 130

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168

EVEKEO ................................ 37 EVENCARE G2 ............... 80, 93 EVENCARE G3 GLUCOSE

METER .............................. 94 EVENCARE G3 TEST .......... 80 EVENCARE MINI GLUCOSE

TEST STR .......................... 80 EVENCARE MINI MONITOR

SYSTEM ............................ 94 EVISTA ................................ 127 EVOCLIN .............................. 63 EVOLUTION BLOOD

GLUCOSE METER ........... 94 EVOLUTION NORMAL

CONTROL ......................... 94 EVOLUTION TEST STRIPS 80 EVOTAZ .................................. 4 EVOXAC ............................... 72 EVZIO .................................... 32 EXALGO ER ......................... 27 EXELDERM .......................... 67 EXELON ................................ 24 exemestane ............................. 15 EXFORGE ............................. 47 EXFORGE HCT .................... 47 EXJADE ................................. 72 EXODERM ............................ 67 EXTAVIA ............................ 125 EXTINA ................................. 67 EZ SMART PLUS SYSTEM . 94 EZ SMART PLUS TEST ....... 80 EZ SMART SYSTEM ........... 94 EZ SMART TEST .................. 80 ezetimibe ................................ 53 ezetimibe-simvastatin ............. 53 F FABIOR ................................. 63 FACTIVE ............................... 12 fallback solo ......................... 134 falmina (28) .......................... 134 famciclovir ............................... 4 famotidine ..................... 122, 123 FANAPT ................................ 37 FARESTON ........................... 15 FARXIGA ............................ 112 FARYDAK............................. 15 fayosim ................................. 134 FAZACLO ............................. 37 FC2 FEMALE CONDOM ... 128

felbamate ................................ 19 FELBATOL............................ 19 FELDENE .............................. 32 felodipine ................................ 47 fem ph ................................... 131 FEMARA ............................... 15 FEMCAP .............................. 129 FEMHRT LOW DOSE ........ 130 FEMRING ............................ 130 femynor ................................ 134 fenofibrate .............................. 53 FENOFIBRATE ..................... 53 fenofibrate micronized ........... 53 fenofibrate nanocrystallized ... 53 fenofibric acid......................... 53 fenofibric acid (choline) ......... 53 FENOGLIDE.......................... 53 fenoprofen .............................. 32 FENOPROFEN ...................... 32 FENORTHO ........................... 32 fentanyl ................................... 27 FENTANYL ........................... 27 fentanyl citrate ........................ 27 FENTORA.............................. 27 FERRIPROX .......................... 72 FETZIMA ............................... 37 FEXMID ................................. 25 FIBRICOR.............................. 54 FIFTY50 TEST STRIP .......... 80 FINACEA ............................... 63 finasteride ............................. 154 FIORINAL ............................. 28 FIORINAL-CODEINE #3 ..... 28 FIRAZYR ............................. 150 FIRMAGON KIT W DILUENT

SYRINGE ........................... 15 FLAGYL .................................. 9 FLAGYL ER ............................ 9 FLAREX .............................. 143 flavoxate ............................... 153 flecainide ................................ 44 FLECTOR .............................. 32 FLOMAX ............................. 154 FLORIVA ............................. 158 FLORIVA (FLUORIDE-

VITAMIN D3) ................. 158 FLORIVA PLUS .................. 158 FLOVENT DISKUS ............ 150 FLOVENT HFA ................... 150

FLOWTUSS ......................... 145 floxin....................................... 76 flucaine ................................. 140 fluconazole ............................... 3 flucytosine ................................ 3 fludrocortisone ........................ 76 FLUMADINE........................... 4 flunisolide ............................. 150 fluocinolone ............................ 69 fluocinolone acetonide oil ...... 76 fluocinolone and shower cap .. 69 fluocinonide ............................ 69 fluocinonide-e ......................... 69 FLUORABON ...................... 158 FLUOR-A-DAY ................... 158 fluor-a-day (with xylitol) ...... 158 fluorescein-proparacaine ...... 140 fluoride (sodium) ............ 74, 158 FLUORIDEX DAILY

DEFENSE........................... 74 fluoritab ................................ 158 fluorometholone ................... 143 FLUOROPLEX ...................... 59 fluorouracil ............................. 59 FLUOROURACIL ................. 59 fluoxetine ................................ 37 FLUOXETINE ....................... 38 fluphenazine decanoate .......... 38 fluphenazine hcl ...................... 38 FLURA-DROPS ................... 158 flurandrenolide ....................... 69 flurazepam .............................. 38 flurbiprofen ............................. 32 flurbiprofen sodium .............. 141 flurox .................................... 140 flutamide ................................. 15 fluticasone ....................... 69, 150 FLUTICASONE-

SALMETEROL ................ 150 fluvastatin ............................... 54 fluvoxamine ............................ 38 FML FORTE ........................ 143 FML LIQUIFILM ................ 143 FML S.O.P............................ 143 FOCALIN ............................... 38 FOCALIN XR ........................ 38 folic acid ............................... 158 fondaparinux ........................... 52 FORA D10.............................. 94

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169

FORA D15G .......................... 80 FORA D20 ....................... 80, 94 FORA D40-G31 TEST STRIPS

............................................ 80 FORA G20 ....................... 81, 94 FORA G30A .................... 81, 95 FORA GD50 BLOOD

GLUCOSE SYSTEM ......... 95 FORA GD50 TEST STRIPS .. 81 FORA NORMAL CONTROL

............................................ 95 FORA PREMIUM V10

GLUCOSE METER ........... 95 FORA TEST N'GO VOICE

METER .............................. 95 FORA TEST STRIP ............... 81 FORA TN'G VOICE METER 95 FORA TN'G VOICE TEST

STRIPS ............................... 81 FORA V10 ....................... 81, 95 FORA V10-V12-D10-D20

STRIPS ............................... 81 FORA V12 BLOOD GLUCOSE

SYSTEM ............................ 95 FORA V12 GLUCOSE .......... 81 FORA V20 ....................... 81, 95 FORA V30A .......................... 96 FORACARE GD20 ................ 81 FORACARE GD20 GLUCOSE

METER .............................. 96 FORACARE GD40 ................ 81 FORACARE GD40A

GLUCOSE METER ........... 96 FORACARE GD40B

GLUCOSE METER ........... 96 FORACARE GDH LOW

CONTROL ......................... 96 FORADIL AEROLIZER ..... 150 FORFIVO XL ........................ 38 FORTAMET ........................ 112 FORTAVIT .......................... 157 FORTEO .............................. 127 FORTESTA .......................... 110 FORTISCARE BLOOD

GLUCOSE SYST ............... 96 FORTISCARE GLUCOSE

TEST STRIPS .................... 81 FORTISCARE NORMAL ..... 96 FOSAMAX .......................... 127

FOSAMAX PLUS D ............ 127 fosinopril ................................ 48 fosinopril-hydrochlorothiazide

............................................ 48 FOSRENOL ......................... 118 FRAGMIN.............................. 52 FREESTYLE CONTROL ...... 96 FREESTYLE FLASH SYSTEM

............................................ 96 FREESTYLE FREEDOM ...... 97 FREESTYLE FREEDOM LITE

............................................ 97 FREESTYLE INSULINX 81, 97 FREESTYLE INSULINX TEST

STRIPS ............................... 81 FREESTYLE LITE METER.. 97 FREESTYLE LITE STRIPS .. 82 FREESTYLE PRECISION

NEO METER ..................... 97 FREESTYLE PRECISION

NEO STRIPS ...................... 82 FREESTYLE SIDEKICK II .. 97 FREESTYLE SYSTEM KIT . 97 FREESTYLE TEST ............... 82 frovatriptan ............................. 23 FURADANTIN ...................... 13 furosemide .............................. 48 FUZEON .................................. 4 fyavolv .................................. 130 FYCOMPA ............................. 19 G g tussin ac ............................. 146 gabapentin .............................. 19 GABITRIL ............................. 19 galantamine ............................ 24 GALZIN ............................... 157 GANIRELIX ........................ 110 GASTROCROM .................. 118 gatifloxacin ........................... 138 GATTEX 30-VIAL .............. 118 gavilyte-c .............................. 118 gavilyte-g .............................. 118 gavilyte-h and bisacodyl ....... 118 gavilyte-n .............................. 118 GE100 BLOOD GLUCOSE

SYSTEM ............................ 97 GE100 BLOOD GLUCOSE

TEST STRIP....................... 82

GE100 CONTROL SOLUTION NORMAL ........................... 97

GELCLAIR ............................ 75 GELNIQUE .......................... 153 GELX ..................................... 75 gemfibrozil ............................. 54 GENERESS FE .................... 134 generlac ................................. 119 gengraf .................................... 15 GENOTROPIN ..................... 124 GENOTROPIN MINIQUICK

.......................................... 124 GENSTRIP TEST STRIP....... 82 gentak ................................... 138 gentamicin ...................... 66, 138 gentamicin in nacl (iso-osm) .... 9 GENTAMICIN IN NACL (ISO-

OSM) .................................... 9 gentamicin sulfate (ped) (pf) .... 9 gentamicin sulfate (pf) .............. 9 GENTAMICIN SULFATE (PF)

.............................................. 9 GENVOYA .............................. 4 GEODON ............................... 38 GIALAX ............................... 119 gianvi (28) ............................ 134 GIAZO .................................. 119 gildagia ................................. 134 GILENYA ............................ 125 GILOTRIF .............................. 15 glatopa .................................. 125 GLEEVEC .............................. 15 GLEOSTINE .......................... 15 glimepiride ............................ 112 glipizide ................................ 112 glipizide-metformin .............. 112 GLUCAGEN DIAGNOSTIC

KIT ..................................... 86 GLUCAGEN HYPOKIT ........ 86 GLUCAGON EMERGENCY

KIT (HUMAN) ................... 86 GLUCAGON HCL ................. 86 GLUCO NAVII GLUCOSE

MONITOR ......................... 98 GLUCO NAVII TEST STRIP 82 GLUCOCARD 01 METER .... 98 GLUCOCARD 01 NORMAL

CONTROL ......................... 98

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170

GLUCOCARD 01 SENSOR PLUS .................................. 82

GLUCOCARD EXPRESSION ...................................... 82, 98

GLUCOCARD SHINE METER ............................................ 98

GLUCOCARD SHINE TEST STRIPS ............................... 82

GLUCOCARD VITAL .......... 98 GLUCOCARD VITAL

SENSOR............................. 82 GLUCOCARD VITAL TEST

STRIPS ............................... 82 GLUCOCOM BLOOD

GLUCOSE ......................... 98 GLUCOCOM CONTROL

NORMAL........................... 98 GLUCOCOM GLUCOSE...... 82 GLUCOPHAGE ................... 112 GLUCOPHAGE XR ............ 112 GLUCOSE CONTROL .......... 98 GLUCOTROL ...................... 112 GLUCOTROL XL ............... 112 GLUCOVANCE .................. 112 GLUMETZA ........................ 112 glyburide ............................... 113 glyburide micronized ............ 113 glyburide-metformin ............ 113 glycopyrrolate ....................... 116 glydo ....................................... 65 GLYNASE ........................... 113 GLYSET............................... 113 GLYXAMBI ........................ 113 GM100 ............................. 82, 99 GMATE CONTROL

SOLUTION, NORMAL..... 99 GMATE SMART METER .... 99 GMATE SMART STARTER 99 GMATE TEST STRIPS ......... 82 GMATE VOICE METER ...... 99 GOLYTELY ......................... 119 GONITRO .............................. 55 GORDONS UREA ................. 60 GRALISE ............................... 19 GRALISE 30-DAY STARTER

PACK ................................. 19 granisetron hcl ...................... 119 GRASTEK ........................... 126 griseofulvin microsize .............. 3

griseofulvin ultramicrosize ....... 3 GRIS-PEG

(ULTRAMICROSIZE) ........ 3 guaiatussin ac ....................... 146 guaifenesin ac ....................... 146 guaifenesin dac ..................... 146 guanfacine ........................ 38, 48 guanidine ................................ 38 GYNAZOLE-1 ..................... 131 gynol ii .................................. 131 H HALCION .............................. 38 HALDOL................................ 38 HALDOL DECANOATE ...... 38 halobetasol propionate ............ 69 HALOG .................................. 69 haloperidol .............................. 38 haloperidol decanoate ............. 38 haloperidol lactate .................. 38 HARVONI................................ 4 HEALTHPRO GLUCOSE

MONITOR ......................... 99 HEALTHPRO HIGH-LOW

CONTROL ......................... 99 HEALTHPRO TEST STRIPS 83 heather .................................. 130 HECTOROL ......................... 110 HEMANGEOL ....................... 48 hemmorex-hc ........................ 119 heparin (porcine) .................... 52 heparin (porcine) in nacl (pf) .. 52 heparin(porcine) in 0.45% nacl

............................................ 52 HEPARIN(PORCINE) IN

0.45% NACL ...................... 52 heparin, porcine (pf) ............... 52 HEPSERA ................................ 4 HETLIOZ ............................... 38 HEXALEN ............................. 15 hi-cal plus vit d ..................... 157 HIPREX.................................. 13 HISTEX-AC ......................... 146 homatropaire ......................... 140 homatropine hbr ................... 140 HORIZANT............................ 24 hpr ........................................... 60 hpr plus ................................... 60 hpr plus hydrogel .................... 60

HPR PLUS-MB HYDROGEL ............................................ 60

HUMALOG .......................... 108 HUMALOG KWIKPEN ...... 108 HUMALOG MIX 50-50 ....... 108 HUMALOG MIX 50-50

KWIKPEN ........................ 108 HUMALOG MIX 75-25 ....... 108 HUMALOG MIX 75-25

KWIKPEN ........................ 108 HUMAPEN LUXURA HD .... 99 HUMATROPE ..................... 124 HUMIRA .............................. 127 HUMIRA PEDIATRIC

CROHN'S START ........... 127 HUMIRA PEN CROHN'S-UC-

HS START ....................... 127 HUMIRA PEN PSORIASIS-

UVEITIS........................... 127 HUMULIN 70/30 ................. 108 HUMULIN 70/30 KWIKPEN

.......................................... 108 HUMULIN N ....................... 108 HUMULIN N KWIKPEN .... 108 HUMULIN R U-100 ............ 108 HUMULIN R U-500 (CONC)

KWIKPEN ........................ 109 HUMULIN R U-500

(CONCENTRATED) ....... 109 HYCAMTIN ........................... 15 HYCOFENIX ....................... 146 hydralazine ............................. 48 HYDREA ............................... 15 HYDRO 35 ............................. 60 HYDRO 40 ............................. 60 hydrochlorothiazide ................ 48 hydrocodone-acetaminophen .. 28 hydrocodone-chlorpheniramine

.......................................... 146 hydrocodone-cpm-pseudoephed

.......................................... 146 hydrocodone-homatropine .... 146 hydrocodone-ibuprofen .......... 28 hydrocortisone .......... 69, 76, 119 hydrocortisone acetate .......... 119 hydrocortisone butyrate .......... 69 hydrocortisone butyr-emollient

............................................ 69 hydrocortisone valerate .......... 69

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171

hydrocortisone-acetic acid ...... 76 hydrocortisone-iodoquinol-aloe

............................................ 66 hydrocortisone-min oil-wht pet

............................................ 70 hydrocortisone-pramoxine .... 56,

119 hydromet ............................... 146 hydromorphone ...................... 28 hydroxychloroquine ............... 10 hydroxyurea ............................ 15 hydroxyzine hcl .................... 145 hydroxyzine pamoate ........... 145 HYLATOPIC ......................... 60 HYLATOPICPLUS ............... 60 hyolev mb ............................. 154 hyophen ................................ 154 hyoscyamine sulfate ............. 116 hyosyne................................. 116 HYPER-SAL ........................ 150 HYSINGLA ER ..................... 28 HYZAAR ............................... 48 I ibandronate ........................... 127 IBRANCE .............................. 15 IBUDONE .............................. 28 ibuprofen ................................ 32 ibuprofen-oxycodone ............. 28 ICLUSIG ................................ 15 ILEVRO ............................... 141 imatinib................................... 16 IMBRUVICA ......................... 16 imipramine hcl ........................ 38 imipramine pamoate ............... 38 imiquimod ............................ 126 IMITREX ............................... 23 IMITREX STATDOSE KIT

REFILL .............................. 23 IMITREX STATDOSE PEN . 23 IMPAVIDO ............................ 10 IMURAN ................................ 16 INCRELEX ............................ 72 INCRUSE ELLIPTA............ 150 indapamide ............................. 48 INDERAL LA ........................ 48 INDERAL XL ........................ 48 INDIOMIN MB .................... 154 INDOCIN ............................... 32 indomethacin .......................... 32

INFINITY CONTROL SOLUTION NORM ........... 99

INFINITY STARTER KIT .... 99 INFINITY TEST STRIPS ...... 83 INLYTA ................................. 16 INNOPRAN XL ..................... 48 INOVA ................................... 63 INOVA 4-1 ............................. 58 INSET 30 INFUSION SET 23

............................................ 99 INSET INFUSION SET 23 .... 99 INSPRA .................................. 48 INSULIN SYRINGE-NEEDLE

U-100 .................................. 86 INTELENCE ............................ 5 INTERMEZZO ...................... 38 INTRAROSA ....................... 131 INTRON A ........................... 126 introvale ................................ 134 INTUNIV ER ......................... 38 INVEGA ................................. 38 INVIRASE ............................... 5 INVOKAMET ...................... 113 INVOKAMET XR ............... 113 INVOKANA ........................ 113 iodoquinol-hc.......................... 66 IONSYS.................................. 28 IOPIDINE ............................. 144 ipratropium bromide ....... 75, 150 ipratropium-albuterol............ 150 irbesartan ................................ 48 irbesartan-hydrochlorothiazide

............................................ 48 IRENKA ................................. 38 IRESSA .................................. 16 ISENTRESS ............................. 5 ISENTRESS HD ...................... 5 ISOCHRON............................ 55 isometh-dichloral-acetaminophn

............................................ 23 isomethepten-caf-

acetaminophen .................... 23 isoniazid.................................. 10 ISOPTO CARPINE .............. 140 ISORDIL ................................ 55 ISORDIL TITRADOSE ......... 55 isosorbide dinitrate ................. 55 isosorbide mononitrate ........... 55 isoxsuprine............................ 131

isradipine ................................ 48 ISTALOL ............................. 139 itraconazole ............................... 3 ivermectin ............................... 10 J JADENU................................. 72 JAKAFI .................................. 16 JALYN ................................. 154 jantoven .................................. 52 JANUMET ........................... 113 JANUMET XR ..................... 113 JANUVIA ............................. 113 JARDIANCE ........................ 113 JAZZ WIRELESS 2 METER

KIT ................................... 100 jencycla ................................. 130 JENTADUETO .................... 113 JENTADUETO XR .............. 113 jevantique lo ......................... 130 jinteli ..................................... 130 jolessa ................................... 134 jolivette ................................. 130 JUBLIA .................................. 67 juleber ................................... 134 junel 1.5/30 (21) ................... 134 junel 1/20 (21) ...................... 134 junel fe 1.5/30 (28) ............... 134 junel fe 1/20 (28) .................. 134 junel fe 24 ............................. 134 JUXTAPID ............................. 54 K KADIAN ................................ 28 kaitlib fe ................................ 134 KALETRA ............................... 5 KALYDECO ........................ 150 KAPVAY ............................... 38 KARBINAL ER ................... 145 kariva (28) ............................ 134 KAYEXALATE ................... 119 KAZANO ............................. 113 k-effervescent ....................... 157 KEFLEX ................................... 7 kelnor 1/35 (28) .................... 134 KENALOG ............................. 70 KEPPRA ................................. 19 KEPPRA XR .......................... 19 KERAFOAM .......................... 60 KERALAC ............................. 60 KERALYT RX ....................... 58

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KERYDIN .............................. 67 KETEK ................................... 10 ketoconazole ....................... 3, 67 ketoprofen ............................... 32 ketorolac ......................... 32, 141 KEVEYIS ............................... 24 KEVZARA ........................... 127 KHEDEZLA ........................... 38 kimidess (28) ........................ 134 KINERET ............................. 126 kionex ................................... 119 kionex (with sorbitol) ........... 119 KITABIS PAK ....................... 10 KLARON ............................... 66 klofensaid ii ............................ 32 KLONOPIN ........................... 19 klor-con ................................ 157 klor-con 10 ........................... 157 klor-con 8 ............................. 157 klor-con m10 ........................ 157 klor-con m15 ........................ 157 klor-con m20 ........................ 157 klor-con sprinkle .................. 157 KLOR-CON/25 .................... 157 klor-con/ef ............................ 157 KOMBIGLYZE XR ............. 113 KORLYM............................. 110 K-PHOS NO 2 ...................... 154 K-PHOS ORIGINAL ........... 155 k-phos-neutral ....................... 157 KRISTALOSE ..................... 119 k-tab ...................................... 157 K-TAB .................................. 157 kurvelo .................................. 134 KUVAN ............................... 110 KYNAMRO ........................... 54 L l norgest/e.estradiol-e.estrad . 134 labetalol .................................. 48 LACRISERT ........................ 140 lactated ringers ....................... 72 lactic acid ................................ 60 lactic acid e ............................. 60 lactulose ................................ 119 LAMICTAL ..................... 19, 20 LAMICTAL ODT .................. 19 LAMICTAL ODT STARTER

(BLUE) ............................... 19

LAMICTAL ODT STARTER (GREEN) ............................ 19

LAMICTAL ODT STARTER (ORANGE) ......................... 19

LAMICTAL STARTER (BLUE) KIT ....................... 20

LAMICTAL STARTER (GREEN) KIT .................... 20

LAMICTAL STARTER (ORANGE) KIT ................. 20

LAMICTAL XR ..................... 20 LAMICTAL XR STARTER

(BLUE) ............................... 20 LAMICTAL XR STARTER

(GREEN) ............................ 20 LAMICTAL XR STARTER

(ORANGE) ......................... 20 LAMISIL .................................. 3 lamivudine ................................ 5 lamivudine-zidovudine ............. 5 lamotrigine.............................. 20 LANCETS ............................ 100 LANCING DEVICE ............ 100 LANOXIN .............................. 51 lansoprazole .......................... 123 LANTUS .............................. 109 LANTUS SOLOSTAR......... 109 larin 1.5/30 (21) .................... 134 larin 1/20 (21) ....................... 134 larin 24 fe.............................. 134 larin fe 1.5/30 (28) ................ 134 larin fe 1/20 (28) ................... 134 larissia ................................... 134 LASIX .................................... 48 LASTACAFT ....................... 140 latanoprost ............................ 142 latrix........................................ 60 LATUDA................................ 38 layolis fe ............................... 134 LAZANDA ............................. 28 leena 28................................. 134 leflunomide ........................... 127 LENVIMA.............................. 16 LESCOL ................................. 54 LESCOL XL........................... 54 lessina ................................... 134 LETAIRIS ............................ 150 letrozole .................................. 16 leucovorin calcium ................. 14

LEUKERAN ........................... 16 leuprolide ................................ 16 levalbuterol hcl ..................... 150 LEVALBUTEROL

TARTRATE ..................... 150 LEVAQUIN ........................... 12 LEVATOL .............................. 48 LEVBID ............................... 116 LEVEMIR ............................ 109 LEVEMIR FLEXTOUCH.... 109 levetiracetam ........................... 20 LEVITRA ............................. 155 levobunolol ........................... 139 levocarnitine ........................... 73 levocarnitine (with sugar) ....... 73 levofloxacin .................... 12, 138 levonest (28) ......................... 134 levonorgestrel ....................... 134 levonorgestrel-ethinyl estrad 134 levonorg-eth estrad triphasic 135 levora-28 ............................... 135 levorphanol tartrate ................. 28 LEVO-T ................................ 114 levothyroxine ........................ 114 levoxyl .................................. 114 LEVSIN ................................ 116 LEVSIN/SL .......................... 116 LEXAPRO .............................. 38 LEXIVA ................................... 5 LIALDA ............................... 119 LIBERTY BLOOD GLUCOSE

MONITOR ....................... 100 LIBERTY LEV 1 GLUCOSE

CONTROL ....................... 100 LIBERTY LEV 2 GLUCOSE

CONTROL ....................... 100 LIBERTY TEST ..................... 83 LIBRAX (WITH CLIDINIUM)

.......................................... 116 lidocaine ................................. 65 lidocaine hcl............................ 65 lidocaine hcl-hydrocortison ac

.................................... 65, 119 lidocaine viscous .................... 65 lidocaine-prilocaine ................ 65 LIDOCAINE-TETRACAINE 65 LIDODERM ........................... 65 lindane .................................... 71 linezolid .................................. 10

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173

LINZESS .............................. 119 liothyronine .......................... 114 LIPITOR................................. 54 LIPOCHOL PLUS ................. 73 LIPOFEN ............................... 54 lisinopril ................................. 48 lisinopril-hydrochlorothiazide 48 lite coat aspirin ....................... 32 lithium carbonate .................... 38 lithium citrate ......................... 39 LITHOBID ............................. 39 LITHOSTAT .......................... 73 LIVALO ................................. 54 LO LOESTRIN FE............... 135 LOCOID ................................. 70 LOCOID LIPOCREAM ......... 70 LODINE ................................. 32 LODOSYN ............................. 21 LOESTRIN 1.5/30 (21) ........ 135 LOESTRIN 1/20 (21) ........... 135 LOESTRIN FE 1.5/30 (28-

DAY) ................................ 135 LOESTRIN FE 1/20 (28-DAY)

.......................................... 135 lomedia 24 fe ........................ 135 LOMOTIL ............................ 116 LONSURF .............................. 16 LOPID .................................... 54 lopinavir-ritonavir .................... 5 lopreeza ................................ 130 LOPRESSOR ......................... 48 LOPRESSOR HCT ................ 48 LOPROX ................................ 67 LOPROX (AS OLAMINE) .... 67 LOPROX KIT ........................ 67 lorazepam ............................... 39 lorazepam intensol .................. 39 lorcet (hydrocodone) .............. 28 lorcet hd .................................. 28 lorcet plus ............................... 28 LORTAB ELIXIR .................. 28 lortuss ex .............................. 146 loryna (28) ............................ 135 LORZONE ............................. 25 losartan ................................... 48 losartan-hydrochlorothiazide .. 48 LOSEASONIQUE ............... 135 LOTEMAX .......................... 143 LOTENSIN ............................ 48

LOTENSIN HCT ................... 48 LOTREL ................................. 48 LOTRISONE .......................... 67 LOTRONEX ........................ 119 LOUTREX ............................. 60 lovastatin ................................ 54 LOVAZA................................ 54 LOVENOX ............................. 52 low-ogestrel (28) .................. 135 loxapine succinate .................. 39 lta pre-attached ....................... 66 ludent fluoride ...................... 159 lugols .............................. 66, 157 LUMIGAN ........................... 142 LUNESTA .............................. 39 LUPANETA PACK (1

MONTH) .......................... 131 LUPANETA PACK (3

MONTH) .......................... 131 LUPRON DEPOT .................. 16 LUPRON DEPOT (3 MONTH)

............................................ 16 LUPRON DEPOT (4 MONTH)

............................................ 16 LUPRON DEPOT (6 MONTH)

............................................ 16 LUPRON DEPOT-PED ......... 16 LUPRON DEPOT-PED (3

MONTH) ............................ 16 lutera (28) ............................. 135 luxamend ................................ 60 LUXIQ.................................... 70 LUZU ..................................... 67 LYNPARZA ........................... 16 LYRICA ................................. 20 LYSODREN ........................... 16 LYSTEDA ............................ 131 lyza ....................................... 130 M MACROBID .......................... 13 MACRODANTIN .................. 13 MAGNEBIND 400............... 119 MALARONE ......................... 10 MALARONE PEDIATRIC ... 10 malathion ................................ 71 maprotiline.............................. 39 MAR-COF BP ...................... 146 MAR-COF CG ..................... 146 MARINOL ........................... 119

marlissa ................................. 135 MARPLAN............................. 39 marten-tab ............................... 28 MATULANE .......................... 16 matzim la ................................ 48 MAVIK................................... 48 MAXALT ............................... 23 MAXALT-MLT ..................... 23 MAXIDEX ........................... 143 MAXITROL ......................... 142 MAXZIDE .............................. 49 MAXZIDE-25MG .................. 49 m-clear wc ............................ 146 meclofenamate ........................ 32 MEDISENSE ........................ 100 MEDISENSE GLUCOSE

KETONE .......................... 100 MEDROL ............................... 76 MEDROL (PAK).................... 76 medroxyprogesterone ........... 130 mefenamic acid ....................... 32 mefloquine .............................. 10 MEGACE ES.......................... 16 megestrol ................................ 16 MEKINIST ............................. 16 meloxicam .............................. 33 memantine .............................. 24 MEMANTINE ........................ 25 M-END PE ........................... 146 MENEST .............................. 130 MENOSTAR ........................ 130 meperidine .............................. 29 MEPHYTON .......................... 52 meprobamate .......................... 25 MEPRON ............................... 10 mercaptopurine ....................... 16 mesalamine ........................... 119 MESALAMINE ................... 119 mesalamine with cleansing wipe

.......................................... 119 MESNEX ................................ 14 MESTINON ........................... 25 MESTINON TIMESPAN ...... 25 METADATE CD.................... 39 metadate er .............................. 39 metaproterenol ...................... 150 metaxall .................................. 25 metaxalone .............................. 26 metformin ............................. 113

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174

methadone .............................. 29 methadose ............................... 29 methamphetamine .................. 39 methazolamide ..................... 142 methenamine hippurate .......... 13 methenamine mandelate ......... 13 methen-sod phos-meth blue-

hyos .................................. 155 methergine ............................ 138 methimazole ........................... 77 METHITEST ........................ 110 methocarbamol ....................... 26 methotrexate sodium .............. 16 methotrexate sodium (pf) ....... 16 methoxsalen ............................ 60 methscopolamine .................. 116 methyclothiazide .................... 49 methyldopa ............................. 49 methyldopa-hydrochlorothiazide

............................................ 49 METHYLIN ........................... 39 methylphenidate ..................... 39 methylprednisolone ................ 76 methyltestosterone ................ 110 metipranolol ......................... 139 metoclopramide hcl .............. 119 metolazone ............................. 49 METOPIRONE ...................... 73 metoprolol succinate .............. 49 METOPROLOL SU-

HYDROCHLOROTHIAZ . 49 metoprolol ta-hydrochlorothiaz

............................................ 49 metoprolol tartrate .................. 49 METROCREAM .................... 63 METROGEL .......................... 63 METROGEL VAGINAL ..... 131 METROLOTION ................... 63 metronidazole ........... 10, 63, 132 mexiletine ............................... 44 MIACALCIN ....................... 110 mibelas 24 fe ........................ 135 MICARDIS ............................ 49 MICARDIS HCT ................... 49 MICORT-HC ....................... 120 MICRO BLOOD GLUCOSE . 83 MICRODOT BLOOD

GLUCOSE SYSTEM . 83, 100 microgestin 1.5/30 (21) ........ 135

microgestin 1/20 (21) ........... 135 MICROGESTIN 24 FE ........ 135 microgestin fe 1.5/30 (28) .... 135 microgestin fe 1/20 (28) ....... 135 MICROZIDE .......................... 49 midodrine................................ 73 MIFEPREX .......................... 132 migergot.................................. 23 miglitol ................................. 113 MIGRANAL .......................... 23 millipred ................................. 76 MILLIPRED ........................... 76 millipred dp ............................ 76 mimvey ................................. 130 mimvey lo ............................. 130 MINASTRIN 24 FE ............. 135 MINIPRESS ........................... 49 MINITRAN ............................ 55 MINIVELLE ........................ 130 MINOCIN .............................. 13 minocycline ............................ 13 minoxidil ................................ 49 MIOCHOL-E........................ 140 MIRAPEX .............................. 21 MIRAPEX ER ........................ 21 MIRCETTE (28) .................. 135 mirtazapine ............................. 39 MIRVASO.............................. 63 misoprostol ........................... 123 MITIGARE .......................... 126 MITOSOL ............................ 142 MOBIC ................................... 33 modafinil ................................ 40 moderiba ............................... 125 moderiba dose pack .............. 125 moexipril ................................ 49 moexipril-hydrochlorothiazide

............................................ 49 mometasone .................... 70, 150 mondoxyne nl ......................... 13 MONODOX ........................... 13 mono-linyah.......................... 135 mononessa (28)..................... 135 montelukast .......................... 151 MONUROL ............................ 13 morgidox ................................ 13 MORPHABOND ER ............. 29 morphine ................................. 29 morphine concentrate ............. 29

MOTOFEN ........................... 116 MOVANTIK ........................ 120 MOVIPREP .......................... 120 MOXATAG ............................ 11 MOXEZA ............................. 138 moxifloxacin ........................... 12 MS CONTIN .......................... 29 MUGARD .............................. 75 MULTAQ ............................... 44 multi-vit with fluoride-iron... 159 multi-vitamin with fluoride .. 159 multivitamins with fluoride .. 159 mupirocin ................................ 66 mupirocin calcium .................. 66 mvc-fluoride ......................... 159 my way ................................. 135 MYALEPT ........................... 110 MYAMBUTOL ...................... 10 MYCOBUTIN ........................ 10 mycophenolate mofetil ........... 16 mycophenolate sodium ........... 16 MYDRIACYL ...................... 140 MYFORTIC ........................... 16 MYGLUCOHEALTH .... 83, 100 MYGLUCOHEALTH

CONTROL SOLUTION .. 100 MYLERAN ............................ 16 mynephron ............................ 159 MYRBETRIQ....................... 153 MYSOLINE ........................... 20 MYTESI ............................... 116 myzilra .................................. 135 N nabumetone ............................. 33 nadolol .................................... 49 nadolol-bendroflumethiazide .. 49 naftifine ................................... 67 NAFTIN ................................. 67 NALFON ................................ 33 naltrexone ............................... 33 NAMENDA ............................ 25 NAMENDA TITRATION PAK

............................................ 25 NAMENDA XR ..................... 25 NAMZARIC ........................... 25 NAPRELAN CR .................... 33 NAPROSYN........................... 33 naproxen ................................. 33 naproxen sodium .................... 33

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175

naratriptan ............................... 23 NARCAN ............................... 33 NARDIL ................................. 40 NASCOBAL ........................ 159 NASONEX ........................... 151 NATACYN .......................... 138 NATAZIA ............................ 135 nateglinide ............................ 113 NATESTO ............................ 111 NATPARA ........................... 111 NATROBA............................. 71 nature-throid ......................... 114 NEBUPENT ........................... 10 nebusal .................................. 151 NEBUSAL ........................... 151 necon 0.5/35 (28) .................. 135 necon 1/50 (28)..................... 135 necon 10/11 (28) ................... 135 necon 7/7/7 (28) ................... 135 nefazodone ............................. 40 neomycin ................................ 10 neomycin-bacitracin-poly-hc 142 neomycin-bacitracin-polymyxin

.......................................... 138 neomycin-polymyxin b-

dexameth .......................... 142 neomycin-polymyxin-

gramicidin ......................... 138 neomycin-polymyxin-hc 76, 142 neo-polycin ........................... 138 neo-polycin hc ...................... 142 NEORAL ................................ 16 NEOSALUS ........................... 60 NEO-SYNALAR ................... 66 NEO-SYNALAR KIT ............ 66 NEPTAZANE ...................... 142 NESINA ............................... 113 neuac ....................................... 63 NEUAC KIT .......................... 63 NEUPRO ................................ 22 NEURONTIN ......................... 20 NEUTEK 2TEK TEST STRIPS

............................................ 83 NEVANAC .......................... 141 nevirapine ................................. 5 NEXAVAR ............................ 16 NEXIUM .............................. 123 NEXIUM PACKET ............. 123 next choice one dose ............ 135

niacin ...................................... 54 NIACOR ................................. 54 NIASPAN EXTENDED-

RELEASE .......................... 54 nicardipine .............................. 49 NICODERM CQ .................... 73 nicorelief ................................. 73 nicorette .................................. 73 NICORETTE .................... 73, 74 nicotine ................................... 74 nicotine (polacrilex) ............... 74 NICOTROL ............................ 74 NICOTROL NS ...................... 74 nifedipine ................................ 49 nikki (28) .............................. 136 NILANDRON ........................ 16 nilutamide ............................... 17 nimodipine .............................. 49 NINJACOF-XG.................... 146 NINLARO .............................. 17 nisoldipine .............................. 49 nitro-bid .................................. 55 NITRO-DUR .......................... 55 nitrofurantoin .......................... 13 nitrofurantoin macrocrystal .... 13 nitrofurantoin monohyd/m-cryst

............................................ 13 nitroglycerin ..................... 55, 56 NITROLINGUAL .................. 56 NITROMIST .......................... 56 NITROSTAT .......................... 56 nitro-time ................................ 56 nivatopic plus ......................... 60 nizatidine .............................. 123 NIZORAL .............................. 67 nodolor.................................... 23 nolix ........................................ 70 nora-be .................................. 130 NORCO .................................. 29 NORDITROPIN FLEXPRO 124 noreth-ethinyl estradiol-iron . 136 norethindrone (contraceptive)

.......................................... 130 norethindrone acetate ........... 130 norethindrone ac-eth estradiol

.................................. 130, 136 norethindrone-e.estradiol-iron

.......................................... 136

norgestimate-ethinyl estradiol .......................................... 136

NORINYL 1/35 (28) ............ 136 NORITATE ............................ 63 norlyda .................................. 130 norlyroc................................. 130 NORPACE ............................. 44 NORPACE CR ....................... 44 NORPRAMIN ........................ 40 NORTHERA .......................... 73 nortrel 0.5/35 (28) ................. 136 nortrel 1/35 (21) .................... 136 nortrel 1/35 (28) .................... 136 nortrel 7/7/7 (28) ................... 136 nortriptyline ............................ 40 NORVASC ............................. 49 NORVIR ................................... 5 NOVA MAX BLOOD

GLUCOSE METER ......... 100 NOVA MAX GLUCOSE

CONTROL ....................... 101 NOVA MAX GLUCOSE TEST

............................................ 83 NOVAMAX PLUS GLU-KET

.......................................... 101 NOVOLOG .......................... 109 NOVOLOG FLEXPEN ........ 109 NOVOLOG MIX 70-30 ....... 109 NOVOLOG MIX 70-30

FLEXPEN......................... 109 NOVOLOG PENFILL ......... 109 NOVOPEN ECHO ............... 101 NOXAFIL................................. 3 np thyroid.............................. 114 nts step 1 ................................. 74 NUCYNTA............................. 33 NUCYNTA ER ...................... 33 NUEDEXTA .......................... 25 NULEV................................. 116 NULYTELY WITH FLAVOR

PACKS ............................. 120 NUOX..................................... 63 NUPLAZID ............................ 40 NUTRESTORE ...................... 73 NUTROPIN AQ NUSPIN .... 124 NUVARING ......................... 132 NUVESSA ............................ 132 NUVIGIL ............................... 40 nyamyc ................................... 67

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176

nyata ....................................... 67 NYMALIZE ........................... 49 nystatin ............................... 3, 67 nystatin-triamcinolone ............ 67 nystop ..................................... 67 O OBREDON........................... 146 OCALIVA ............................ 120 ocella .................................... 136 octreotide acetate .................... 17 OCUFEN .............................. 141 OCUFLOX ........................... 138 ODEFSEY ................................ 5 ODOMZO .............................. 17 OFEV ................................... 151 ofloxacin ................... 12, 76, 139 ogestrel (28) .......................... 136 olanzapine ............................... 40 olanzapine-fluoxetine ............. 40 olmesartan .............................. 49 olmesartan-amlodipin-hcthiazid

............................................ 49 olmesartan-hydrochlorothiazide

............................................ 49 olopatadine ..................... 75, 141 OLUX ..................................... 70 OLUX-E ................................. 70 OLYSIO ................................... 5 OMECLAMOX-PAK .......... 123 omega-3 acid ethyl esters ....... 54 omeprazole ........................... 123 omeprazole-sodium bicarbonate

.......................................... 123 OMNARIS ........................... 151 OMNIPRED ......................... 143 OMNITROPE ....................... 124 ON CALL EXPRESS

CONTROL ....................... 101 ON CALL EXPRESS METER

.......................................... 101 ON CALL EXPRESS TEST

STRIP ................................. 83 ON CALL PLUS CONTROL

.......................................... 101 ON CALL PLUS METER ... 101 ON CALL PLUS TEST STRIP

............................................ 83 ON CALL VIVID CONTROL

.......................................... 101

ON CALL VIVID METER .. 101 ON CALL VIVID PAL METER

.......................................... 101 ON CALL VIVID TEST STRIP

............................................ 83 ondansetron .......................... 120 ondansetron hcl..................... 120 ONETOUCH ULTRA

CONTROL ....................... 101 ONETOUCH ULTRA TEST . 83 ONETOUCH ULTRA2 ........ 101 ONETOUCH ULTRAMINI . 101 ONETOUCH VERIO ............. 83 ONETOUCH VERIO FLEX 101 ONETOUCH VERIO IQ

METER ............................ 102 ONETOUCH VERIO SYNC

.......................................... 102 ONETOUCH VERIO SYSTEM

.......................................... 102 ONEXTON ............................. 63 ONFI ....................................... 20 ONGLYZA ........................... 113 ONMEL .................................... 3 ONZETRA XSAIL................. 23 OPANA .................................. 29 OPANA ER ............................ 29 opcicon one-step ................... 136 opium tincture....................... 116 OPSUMIT ............................ 151 option-2 ................................ 136 OPTIUM EZ ........................... 83 OPTIUM TEST ...................... 83 OPTUMRX .................... 84, 102 ORACEA................................ 13 ORACIT ............................... 155 ORALAIR ............................ 126 oralone .................................... 75 ORAMAGICRX ..................... 75 ORAP ..................................... 40 ORAPRED ODT .................... 76 ORAVIG .................................. 3 ORENCIA .................... 127, 128 ORENCIA CLICKJECT ...... 127 ORENITRAM ........................ 50 ORFADIN .............................. 73 ORKAMBI ........................... 151 orphenadrine citrate ................ 26 orsythia ................................. 136

ORTHO MICRONOR .......... 131 ORTHO TRI-CYCLEN (28) 136 ORTHO TRI-CYCLEN LO (28)

.......................................... 136 ORTHO-CYCLEN (28) ....... 136 ORTHO-NOVUM 1/35 (28) 136 ORTHO-NOVUM 7/7/7 (28)

.......................................... 136 oscimin ................................. 116 oscimin sl .............................. 116 oscimin sr.............................. 116 oseltamivir ................................ 5 OSENI .................................. 113 OSMOPREP ......................... 120 OSPHENA ............................ 132 OTEZLA............................... 128 OTEZLA STARTER ............ 128 OTIPRIO ................................ 76 OTOVEL ................................ 76 OTREXUP (PF).................... 128 OVACE .................................. 56 OVACE PLUS........................ 56 OVACE PLUS SHAMPOO ... 56 OVACE PLUS WASH ........... 56 OVCON-35 (28) ................... 136 OVIDE .................................... 71 oxaprozin ................................ 33 OXAYDO ............................... 29 oxazepam ................................ 40 oxcarbazepine ......................... 20 oxiconazole ............................. 67 OXISTAT ............................... 67 OXSORALEN ULTRA .......... 60 OXTELLAR XR .................... 20 oxybutynin chloride .............. 153 oxycodone............................... 29 OXYCODONE ....................... 29 oxycodone-acetaminophen .... 29,

30 oxycodone-aspirin .................. 30 OXYCONTIN ........................ 30 oxymorphone .......................... 30 OXYTROL ........................... 153 oysco 500/d ........................... 157 oyster shell + d3 ................... 157 oyster shell calcium-vit d2 .... 159 oyster shell calcium-vit d3 .... 157 oystercal-d ............................ 157

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177

P pacerone ................................. 44 paliperidone ............................ 40 PAMELOR ............................. 40 PANCREAZE ...................... 120 PANDEL ................................ 70 PANRETIN ............................ 60 pantoprazole ......................... 123 PARAFON FORTE DSC ....... 26 paregoric ............................... 116 PAREMYD .......................... 140 paricalcitol ............................ 111 PARLODEL ........................... 22 PARNATE ............................. 40 paroex oral rinse ..................... 75 paromomycin .......................... 10 paroxetine hcl ......................... 40 PASER ................................... 10 PATADAY ........................... 141 PATANASE ........................... 75 PATANOL ........................... 141 PAXIL .................................... 40 PAXIL CR .............................. 40 PAZEO ................................. 141 PCE........................................... 8 PEDIAPRED .......................... 76 peg 3350-electrolytes ........... 120 PEGANONE .......................... 20 PEGASYS ............................ 125 PEGASYS PROCLICK ....... 125 peg-electrolyte soln .............. 120 PEGINTRON ....................... 125 PEGINTRON REDIPEN ..... 125 PEN NEEDLE ...................... 102 penicillin v potassium ............. 11 PENLAC ................................ 67 PENNSAID ............................ 33 PENTASA ............................ 120 pentazocine-naloxone ............. 33 pentoxifylline ......................... 52 PEPCID ................................ 123 PERCOCET ........................... 30 PERFOROMIST .................. 151 PERIDEX ............................... 75 perindopril erbumine .............. 50 periogard ................................. 75 permethrin .............................. 71 perphenazine ........................... 40 perphenazine-amitriptyline ..... 40

PERTZYE ............................ 120 PEXEVA ................................ 40 PHARMACIST CHOICE ...... 84 PHARMACIST CHOICE

GLUCOSE SYS ............... 102 phenadoz ............................... 145 phenazopyridine ................... 156 phenelzine ............................... 40 phenergan ............................. 145 phenobarb-hyoscy-atropine-scop

.......................................... 116 phenobarbital .......................... 20 phenohytro ............................ 116 phenoxybenzamine ................. 50 phenylephrine hcl ................. 144 PHENYTEK ........................... 20 phenytoin ................................ 20 phenytoin sodium extended .... 20 philith.................................... 136 PHOSLYRA ......................... 120 phospha 250 neutral.............. 157 phosphasal ............................ 155 PHOSPHOLINE IODIDE .... 139 PHYSIOLYTE ....................... 72 PHYSIOSOL IRRIGATION .. 72 PICATO.................................. 60 pilocarpine hcl .......... 73, 75, 140 pimozide ................................. 40 pimtrea (28) .......................... 136 pindolol ................................... 50 pioglitazone .......................... 113 pioglitazone-glimepiride ...... 113 pioglitazone-metformin ........ 113 pirmella ................................. 136 piroxicam ................................ 33 PLAN B ONE-STEP ............ 136 PLAQUENIL.......................... 10 PLAVIX ................................. 52 PLEGRIDY .......................... 125 PLEXION ............................... 63 PLEXION CLEANSING

CLOTHS ............................ 63 PLIAGLIS .............................. 66 PODOCON ............................. 58 podofilox ................................ 60 polycin .................................. 139 polyethylene glycol 3350 ..... 120 polymyxin b sulf-trimethoprim

.......................................... 139

POLYTRIM .......................... 139 POLY-TUSSIN AC .............. 146 POLY-VI-FLOR FS ............. 159 POMALYST......................... 125 PONSTEL............................... 33 portia ..................................... 137 pot,sodium citrate-citric acid 155 POTABA .............................. 157 potassium bicarb and chloride

.......................................... 157 potassium bicarb-citric acid .. 157 potassium chloride ................ 157 potassium citrate ................... 155 potassium citrate-citric acid .. 155 POTASSIUM HYDROXIDE . 58 PRADAXA ............................. 52 PRALUENT PEN ................... 54 pramcort ................................ 120 pramipexole ............................ 22 PRAMOSONE ....................... 56 PRAMOSONE E .................... 56 PRANDIN ............................ 114 PRAVACHOL ........................ 54 pravastatin ............................... 54 prazosin................................... 50 PRECISION PCX PLUS TEST

............................................ 84 PRECISION PCX TEST ........ 84 PRECISION POINT OF CARE

TEST................................... 84 PRECISION Q-I-D TEST ...... 84 PRECISION XTRA MONITOR

.......................................... 102 PRECISION XTRA TEST ..... 84 PRECOSE............................. 114 PRED FORTE ...................... 143 PRED MILD ......................... 143 PRED-G ................................ 142 PRED-G S.O.P. .................... 143 prednicarbate .......................... 70 prednisolone ........................... 77 prednisolone acetate ............. 143 prednisolone sodium phosphate

.................................... 77, 143 prednisone............................... 77 prednisone intensol ................. 77 PREFEST ............................. 131 PREMARIN ......................... 131

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PREMIUM BLOOD GLUCOSE MONITOR .... 102

PREMIUM V10 ............. 84, 102 PREMPHASE ...................... 131 PREMPRO ........................... 131 PRENATAL PLUS DHA ..... 159 PREPIDIL ............................ 132 PREPOPIK ........................... 120 PRESERA .............................. 60 PRESTALIA .......................... 50 PRESTO PRO BLOOD

GLUCOSE METER ......... 102 PREVACID .......................... 123 PREVACID SOLUTAB ...... 123 prevalite .................................. 54 PREVIDENT .......................... 75 PREVIDENT 5000 BOOSTER

PLUS .................................. 75 PREVIDENT 5000 DRY

MOUTH ............................. 75 PREVIDENT 5000 ENAMEL

PROTECT .......................... 75 PREVIDENT 5000 PLUS ...... 75 PREVIDENT 5000 SENSITIVE

............................................ 75 previfem ............................... 137 PREVPAC ............................ 123 PREZCOBIX ............................ 5 PREZISTA ............................... 5 PRIFTIN ................................. 10 PRILOSEC ........................... 123 PRIMAQUINE ....................... 10 primidone ............................... 20 PRIMLEV .............................. 30 PRIMSOL............................... 14 PRINIVIL ............................... 50 PRISTIQ ................................. 40 PROAIR HFA ...................... 151 PROAIR RESPICLICK ....... 151 probenecid ............................ 126 probenecid-colchicine .......... 126 PROCARDIA ......................... 50 PROCARDIA XL .................. 50 procentra ................................. 40 prochlorperazine ................... 120 prochlorperazine maleate ..... 120 PROCORT ........................... 120 PROCTOCORT ................... 120 PROCTOFOAM HC ............ 120

procto-med hc ....................... 120 proctosol hc .......................... 120 proctozone-hc ....................... 121 PROCYSBI .......................... 155 PRODIGY AUTOCODE

METER ............................ 102 PRODIGY AUTOCODE

MONITOR SYST............. 102 PRODIGY CONTROL

SOLUTION, LOW ........... 103 PRODIGY CONTROL

SOLUTION,HIGH ........... 103 PRODIGY NO CODING ....... 84 PRODIGY POCKET METER

.......................................... 103 PRODIGY VOICE GLUCOSE

METER ............................ 103 PRODRIN .............................. 23 progesterone micronized ...... 131 PROGLYCEM ....................... 86 PROGRAF ............................. 17 PROLENSA ......................... 141 PROMACTA .......................... 52 promethazine ........................ 145 promethazine vc-codeine ...... 146 promethazine-codeine .......... 146 promethazine-dm .................. 146 promethazine-phenyleph-

codeine.............................. 146 promethazine-phenylephrine 146 promethegan ......................... 145 PROMETRIUM ................... 131 PROMISEB ............................ 60 propafenone ............................ 44 propantheline ........................ 116 proparacaine ......................... 141 propranolol ............................. 50 propranolol-hydrochlorothiazid

............................................ 50 propylthiouracil ...................... 77 PRO-RED AC (W/

DEXCHLORPHENIR) .... 147 PROSCAR ............................ 154 PROSTIN E2 ........................ 132 PROTONIX .......................... 123 PROTOPIC ............................. 60 protriptyline ............................ 40 PROVENTIL HFA ............... 151 PROVERA ........................... 131

PROVIGIL ............................. 40 PROZAC ................................ 40 PROZAC WEEKLY .............. 41 pruclair .................................... 60 prudoxin .................................. 60 prumyx .................................... 60 prutect ..................................... 60 PSORCON .............................. 70 PULMICORT ....................... 151 PULMICORT FLEXHALER

.......................................... 151 pulmosal ............................... 151 PULMOZYME ..................... 151 PURALOR CI ...................... 159 PURIXAN .............................. 17 PYLERA............................... 123 pyrazinamide .......................... 10 PYRIDIUM .......................... 156 pyridostigmine bromide .......... 26 Q QBRELIS ............................... 50 Q-CARE RX Q4 ..................... 75 QNASL ................................. 151 QSYMIA ................................ 72 QUALAQUIN ........................ 10 QUARTETTE ....................... 137 quasense ................................ 137 quazepam ................................ 41 QUDEXY XR ......................... 20 QUESTRAN ........................... 54 QUESTRAN LIGHT .............. 54 quetiapine ............................... 41 QUFLORA FE ...................... 159 QUFLORA FE (FERROUS

SULFATE) ....................... 159 QUFLORA PEDIATRIC ..... 159 QUFLORA PEDIATRIC

DROPS ............................. 159 QUILLICHEW ER ................. 41 QUILLIVANT XR ................. 41 quinapril .................................. 50 quinapril-hydrochlorothiazide 50 quinidine gluconate ................ 44 quinidine sulfate ..................... 44 quinine sulfate ........................ 10 QUINTET AC ........................ 84 QUINTET BLOOD GLUCOSE

METER............................. 103 quit 2 ....................................... 74

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QUIT 2 ................................... 74 quit 4 ....................................... 74 QUIT 4 ................................... 74 QVAR................................... 151 R rabeprazole ........................... 123 RAGWITEK ......................... 126 rajani ..................................... 137 raloxifene .............................. 127 ramipril ................................... 50 RANEXA ............................... 55 ranitidine hcl ......................... 123 RAPAFLO ............................ 154 RAPAMUNE ......................... 17 rasagiline ................................ 22 RASUVO (PF) ..................... 128 RAVICTI ................................ 73 RAYALDEE ........................ 111 RAYOS .................................. 77 RAZADYNE .......................... 25 RAZADYNE ER .................... 25 rea lo 39 .................................. 60 rea lo 40 .................................. 60 react ...................................... 137 REBETOL ............................ 125 REBIF (WITH ALBUMIN) . 125 REBIF REBIDOSE .............. 125 REBIF TITRATION PACK. 125 reclipsen (28) ........................ 137 RECTIV ............................... 121 REFUAH PLUS ..................... 84 REFUAH PLUS GLUCOSE

CONTROL ....................... 103 REFUAH PLUS GLUCOSE

MONITOR ....................... 103 REGLAN .............................. 121 REGRANEX .......................... 60 RELAGARD ........................ 132 relcof c .................................. 147 RELENZA DISKHALER ........ 5 RELION ALL-IN-ONE

METER ............................ 103 RELION CONFIRM ............ 103 RELION CONFIRM-MICRO 84 RELION MICRO GLUCOSE

MONITOR ....................... 104 RELION NOVOLIN 70/30 .. 109 RELION NOVOLIN N ........ 109 RELION NOVOLIN R ........ 109

RELION PRIME METER.... 104 RELION PRIME TEST STRIPS

............................................ 84 RELISTOR ........................... 121 RELPAX ................................ 23 REMERON ............................ 41 REMERON SOLTAB ............ 41 remeven .................................. 61 RENAGEL ........................... 121 RENVELA ........................... 121 repaglinide ............................ 114 repaglinide-metformin .......... 114 REPATHA PUSHTRONEX .. 54 REPATHA SURECLICK ...... 54 REPATHA SYRINGE ........... 54 REQUIP.................................. 22 REQUIP XL ........................... 22 RESCRIPTOR .......................... 5 RESPA-AR ........................... 147 RESTASIS............................ 141 RESTASIS MULTIDOSE ... 141 RESTIZAN ............................. 61 RESTORIL ............................. 41 RETIN-A ................................ 64 RETIN-A MICRO .................. 63 RETIN-A MICRO PUMP ...... 64 RETROVIR .............................. 5 REVATIO ............................ 151 REVEAL BLOOD GLUCOSE

METER ............................ 104 REVEAL TEST STRIP .......... 84 REVIA .................................... 33 REVLIMID .......................... 125 REXULTI ............................... 41 REYATAZ ............................... 5 REZIRA................................ 147 ribasphere ............................. 125 ribasphere ribapak ................ 125 ribavirin ............................ 5, 125 RIDAURA ............................ 128 rifabutin .................................. 10 RIFADIN ................................ 10 RIFAMATE............................ 10 rifampin .................................. 10 RIFATER ............................... 10 RIGHTEST CONTROL

SOLUTION HIGH ........... 104 RIGHTEST GM550 SYSTEM

.......................................... 104

RIGHTEST GS550 TEST STRIPS ............................... 85

RILUTEK ............................... 73 riluzole .................................... 73 rimantadine ............................... 5 ringer's .................................... 72 RIOMET ............................... 114 risacal-d ................................ 159 risedronate ...................... 73, 127 RISPERDAL .......................... 41 RISPERDAL M-TAB ............ 41 risperidone .............................. 41 RITALIN ................................ 41 RITALIN LA .......................... 41 rivastigmine ............................ 25 rivastigmine tartrate ................ 25 rivelsa ................................... 137 rizatriptan ................................ 23 ROBAXIN .............................. 26 ROBAXIN-750....................... 26 ROBINUL ............................ 116 ROBINUL FORTE ............... 116 ROCALTROL ...................... 111 ropinirole ................................ 22 rosadan .................................... 64 ROSADAN ............................. 64 ROSANIL ............................... 64 ROSULA ................................ 64 rosula cleansing cloths ............ 64 rosuvastatin ............................. 54 ROWASA ............................. 121 roweepra ................................. 20 ROXICODONE ...................... 30 ROZEREM ............................. 41 RUBRACA ............................. 17 rydex ..................................... 147 RYTARY ................................ 22 RYTHMOL SR ...................... 44 RYVENT .............................. 145 S SABRIL .................................. 21 SAFYRAL ............................ 137 SAIZEN ................................ 124 SAIZEN CLICK.EASY ....... 124 SAIZEN SAIZENPREP ....... 124 salacyn .................................... 58 SALAGEN (PILOCARPINE)

...................................... 73, 75 SALEX ................................... 58

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180

salicylic acid ........................... 58 SALKERA ............................. 59 salsalate .................................. 33 salvax ...................................... 59 SALVAX DUO PLUS ........... 59 SAMSCA ............................. 111 SANCUSO ........................... 121 SANDIMMUNE .................... 17 SANDOSTATIN .................... 17 SANTYL ................................ 71 SAPHRIS (BLACK CHERRY)

............................................ 41 SARAFEM ............................. 42 SAVAYSA ............................. 52 SAVELLA ............................ 128 scalacort .................................. 70 SEASONIQUE ..................... 137 seb-prev .................................. 57 seconal sodium ....................... 42 SEEBRI NEOHALER.......... 151 selegiline hcl ........................... 22 selenium sulfide ...................... 57 SELRX ................................... 57 SELZENTRY ....................... 5, 6 SEMPREX-D ....................... 147 SENSIPAR ........................... 111 SEREVENT DISKUS .......... 151 SERNIVO............................... 70 SEROQUEL ........................... 42 SEROQUEL XR .................... 42 SEROSTIM .......................... 124 sertraline ................................. 42 setlakin ................................. 137 sevelamer carbonate ............. 121 sf 75 sf 5000 plus ............................ 75 SFROWASA ........................ 121 sharobel ................................ 131 SHOHL'S MODIFIED ......... 155 SIDEKICK BLOOD

GLUCOSE SYSTEM ....... 104 sildenafil ............................... 152 SILENOR ............................... 42 SILIQ ...................................... 57 SILVADENE ......................... 58 silver nitrate ............................ 61 silver nitrate applicators ......... 61 silver sulfadiazine ................... 58 SILVRSTAT .......................... 66

SIMBRINZA ........................ 142 SIMPONI.............................. 128 simvastatin .............................. 54 SINEMET ............................... 22 SINEMET CR ........................ 22 SINGULAIR ........................ 152 sirolimus ................................. 17 SIRTURO ............................... 10 SITAVIG .................................. 6 SIVEXTRO ............................ 10 SKELAXIN ............................ 26 SKLICE .................................. 71 SMART SENSE

MONITORING SYSTEM 104 SMART SENSE TEST STRIPS

............................................ 85 SMARTEST CONTROL ..... 104 SMARTEST EJECT............. 104 SMARTEST PERSONA

STARTER ........................ 105 SMARTEST PRONTO

STARTER ........................ 105 SMARTEST PROTEGE ...... 105 SMARTEST TEST................. 85 SNAP INSULIN PUMP

CONTROLLER................ 105 sodium chloride .................... 152 sodium citrate-citric acid ...... 155 sodium phenylbutyrate ........... 73 sodium polystyrene sulfonate

.......................................... 121 SODIUM POLYSTYRENE

SULFONATE ................... 121 SOLARAZE ........................... 61 SOLIQUA 100/33 ................ 109 SOLODYN ............................. 13 SOLTAMOX .......................... 17 SOLUS V2 AUDIBLE METER

.......................................... 105 SOLUS V2 CONTROL

SOLUTION,HIGH ........... 105 SOLUS V2 TEST STRIPS ..... 85 SOMA .................................... 26 SOMATULINE DEPOT ........ 17 SOMAVERT ........................ 111 sonafine .................................. 61 SONATA ................................ 42 SOOLANTRA ........................ 64 SORBITOL-MANNITOL ...... 72

SORIATANE ......................... 57 SORILUX ............................... 57 sotalol ..................................... 44 sotalol af ................................. 44 SOTYLIZE ............................. 44 SOVALDI................................. 6 sp antipruritic .......................... 61 sp scar management ................ 61 SPECTRACEF ......................... 7 spinosad .................................. 71 SPIRIVA RESPIMAT .......... 152 SPIRIVA WITH

HANDIHALER ................ 152 spironolactone......................... 50 spironolacton-hydrochlorothiaz

............................................ 50 SPORANOX............................. 3 SPORANOX PULSEPAK ....... 3 sprintec (28) .......................... 137 SPRIX ..................................... 33 SPRYCEL............................... 17 sps (with sorbitol) ................. 121 sronyx ................................... 137 ss 10-2 ..................................... 64 ssd ........................................... 58 SSKI ....................................... 77 sss 10-5 ................................... 64 STALEVO 100 ....................... 22 STALEVO 125 ....................... 22 STALEVO 150 ....................... 22 STALEVO 200 ....................... 22 STALEVO 50 ......................... 22 STALEVO 75 ......................... 22 STARLIX ............................. 114 stavudine ................................... 6 STAXYN .............................. 155 STENDRA ............................ 155 STIMATE ............................. 111 STIOLTO RESPIMAT ......... 152 STIVARGA ............................ 17 stop smoking aid ..................... 74 STRATTERA ......................... 42 STRENSIQ ........................... 111 STRIANT ............................. 111 STRIBILD ................................ 6 STRIVERDI RESPIMAT .... 152 STROMECTOL ..................... 10 strong iodine ......................... 157 SUBOXONE .......................... 34

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SUBSYS ................................. 30 SUCRAID ............................ 121 sucralfate .............................. 124 SULAR ................................... 50 sulfacetamide sodium ..... 57, 144 sulfacetamide sodium (acne) .. 66 sulfacetamide sodium-sulfur .. 64 sulfacetamide sod-sulfur-urea 64 sulfacetamide-prednisolone .. 144 sulfacleanse 8-4 ...................... 64 sulfadiazine ............................. 12 sulfamethoxazole-trimethoprim

............................................ 12 SULFAMYLON..................... 66 sulfasalazine ......................... 121 sulfatrim ................................. 12 sulindac ................................... 34 SUMADAN ............................ 64 sumatriptan ............................. 23 sumatriptan succinate ............. 24 SUMAVEL DOSEPRO ......... 24 SUMAXIN ............................. 64 SUMAXIN TS ........................ 64 SUPRAX .................................. 8 SUPREP BOWEL PREP KIT

.......................................... 121 SURE-TEST EASYPLUS MINI

............................................ 85 SURE-TEST EASYPLUS MINI

METER ............................ 105 SURMONTIL......................... 42 SUSTIVA ................................. 6 SUTENT................................. 17 syeda ..................................... 137 SYLATRON ......................... 126 SYMAX DUOTAB .............. 116 symax fastabs ....................... 116 symax-sl ............................... 116 symax-sr ............................... 116 SYMBICORT....................... 152 SYMBYAX ............................ 42 SYMLINPEN 120 ................ 114 SYMLINPEN 60 .................. 114 SYNALAR ............................. 70 SYNALAR CREAM KIT ...... 70 SYNALAR OINTMENT KIT 70 SYNALAR TS ....................... 70 SYNALGOS-DC .................... 30 SYNAREL ........................... 111

SYNDROS ........................... 121 SYNERA ................................ 66 SYNJARDY ......................... 114 SYNJARDY XR................... 114 SYNTHROID ....................... 115 SYPRINE ............................... 73 T T

30 INFUSION SET .......... 105 90 INFUSION SET 23 ..... 105 SLIM ................................ 105 SLIM G4........................... 105

TABLOID .............................. 17 TACLONEX .......................... 57 tacrolimus ......................... 17, 61 TAFINLAR ............................ 17 TAGRISSO ............................ 17 TAKE ACTION ................... 137 TALTZ AUTOINJECTOR .... 57 TALTZ AUTOINJECTOR (2

PACK) ................................ 57 TALTZ AUTOINJECTOR (3

PACK) ................................ 57 TALTZ SYRINGE ................. 57 TALTZ SYRINGE (2 PACK) 57 TALTZ SYRINGE (3 PACK) 58 TAMIFLU ................................ 6 tamoxifen ................................ 17 tamsulosin ............................. 154 TANZEUM .......................... 114 TAPAZOLE ........................... 77 TARCEVA ............................. 17 TARGADOX.......................... 13 TARGRETIN ......................... 17 tarina fe 1/20 (28) ................. 137 TARKA .................................. 50 TASIGNA .............................. 17 TASMAR ............................... 22 TAYTULLA ......................... 137 tazarotene................................ 64 TAZORAC ............................. 65 taztia xt ................................... 50 TECFIDERA ........................ 126 TECHNIVIE ............................. 6 TEGRETOL ........................... 21 TEGRETOL XR ..................... 21 TEKTURNA .......................... 50 TEKTURNA HCT ................. 50 TELCARE BGM .................. 106

TELCARE BLOOD GLUCOSE KIT ................................... 106

TELCARE CONTROL ........ 106 TELCARE TEST STRIPS ..... 85 telmisartan .............................. 50 telmisartan-amlodipine ........... 50 telmisartan-hydrochlorothiazid

............................................ 50 temazepam .............................. 42 TEMODAR ............................ 17 TEMOVATE .......................... 70 temozolomide ......................... 17 tencon ..................................... 30 TENORETIC 100 ................... 50 TENORETIC 50 ..................... 50 TENORMIN ........................... 50 TERAZOL 7 ......................... 132 terazosin .................................. 51 terbinafine hcl ........................... 3 terbutaline ............................. 152 terconazole ............................ 132 TERSI FOAM ........................ 58 TESSALON PERLES .......... 147 TEST N'GO BLOOD

GLUCOSE SYSTEM ....... 106 TEST N'GO TEST .................. 85 TESTIM ................................ 111 TESTOPEL........................... 111 testosterone ........................... 111 TESTOSTERONE ................ 111 testosterone cypionate .......... 111 testosterone enanthate ........... 111 TESTRED............................. 111 tetcaine .................................. 141 tetrabenazine ........................... 25 tetracaine hcl ......................... 141 tetracaine hcl (pf) .................. 141 tetracycline ............................. 13 TETRAVISC ........................ 141 TETRAVISC FORTE .......... 141 TEXACORT ........................... 70 TEXAVITE LQ .................... 159 THALOMID ........................... 17 THEO-24 .............................. 152 theochron .............................. 152 theophylline .......................... 152 thermazene .............................. 58 THIOLA ................................. 73 thioridazine ............................. 42

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182

thiothixene .............................. 42 THYROLAR-1 ..................... 115 THYROLAR-1/2 .................. 115 THYROLAR-1/4 .................. 115 THYROLAR-2 ..................... 115 THYROLAR-3 ..................... 115 tiagabine ................................. 21 TIAZAC ................................. 51 ticlopidine ............................... 53 TIGAN ................................. 121 TIKOSYN .............................. 44 tilia fe .................................... 137 timolol maleate ............... 51, 139 TIMOPTIC ........................... 139 TIMOPTIC OCUDOSE (PF)

.......................................... 139 TIMOPTIC-XE .................... 139 TINDAMAX .......................... 10 tinidazole ................................ 11 TIROSINT ............................ 115 tis-u-sol pentalyte ................... 72 TIVICAY ................................. 6 TIVORBEX ............................ 34 tizanidine ................................ 26 TOBI....................................... 11 TOBI PODHALER ................ 11 TOBRADEX ........................ 143 TOBRADEX ST .................. 143 tobramycin ............................ 139 tobramycin in 0.225 % nacl .... 11 TOBRAMYCIN WITH

NEBULIZER ...................... 11 tobramycin-dexamethasone .. 143 TOBREX .............................. 139 TODAY CONTRACEPTIVE

SPONGE .......................... 132 TOFRANIL ............................ 42 TOLAK .................................. 61 tolazamide ............................ 114 tolbutamide ........................... 114 tolcapone ................................ 22 tolmetin................................... 34 tolterodine ............................. 153 TOPAMAX ............................ 21 TOPICORT ............................ 70 topiramate ............................... 21 TOPIRAMATE ...................... 21 TOPROL XL .......................... 51 torsemide ................................ 51

TOUJEO SOLOSTAR ......... 109 TOVIAZ ............................... 153 TRACLEER ......................... 152 TRADJENTA ....................... 114 tramadol .................................. 34 TRAMADOL ......................... 34 tramadol-acetaminophen ........ 34 trandolapril ............................. 51 trandolapril-verapamil ............ 51 tranexamic acid ..................... 132 TRANSDERM-SCOP .......... 121 TRANXENE T-TAB .............. 42 tranylcypromine...................... 42 TRAVATAN Z..................... 142 trazodone ................................ 42 TRECATOR ........................... 11 TRESIBA FLEXTOUCH U-100

.......................................... 109 TRESIBA FLEXTOUCH U-200

.......................................... 109 tretinoin .................................. 65 tretinoin (chemotherapy) ........ 17 tretinoin microspheres ............ 65 TRETIN-X.............................. 65 TRETIN-X CREAM KIT ....... 65 TREXALL .............................. 17 TREXIMET ............................ 24 TREZIX .................................. 30 tri femynor ............................ 137 TRIACETIN ........................... 67 triamcinolone acetonide .. 70, 75,

152 triamterene-hydrochlorothiazid

............................................ 51 trianex ..................................... 71 triazolam ................................. 42 TRIBENZOR.......................... 51 tricitrates ............................... 155 TRICOR ................................. 54 triderm .................................... 71 TRIDESILON ........................ 71 tri-estarylla............................ 137 trifluoperazine ........................ 42 trifluridine ............................. 139 TRIGLIDE.............................. 55 trihexyphenidyl ....................... 22 tri-legest fe ............................ 137 TRILEPTAL ........................... 21 tri-linyah ............................... 137

TRILIPIX ............................... 55 tri-lo-estarylla ....................... 137 tri-lo-marzia .......................... 137 tri-lo-sprintec ........................ 137 trilyte with flavor packets ..... 121 trimethobenzamide ............... 121 trimethoprim ........................... 14 trimipramine ........................... 42 trinessa (28) .......................... 137 trinessa lo .............................. 137 TRI-NORINYL (28) ............. 137 TRINTELLIX ......................... 42 TRIPLE DYE ......................... 68 tri-previfem (28) ................... 137 tri-sprintec (28) ..................... 137 TRIUMEQ ................................ 6 tri-vit with fluoride and iron . 159 tri-vitamin with fluoride ....... 159 trivora (28) ............................ 137 TRIZIVIR ................................. 6 TROKENDI XR ..................... 21 tropicamide ........................... 140 trospium ................................ 154 TRUE METRIX AIR

GLUCOSE METER ......... 106 TRUE METRIX GLUCOSE

METER............................. 106 TRUE METRIX GLUCOSE

TEST STRIP ....................... 85 TRUE METRIX GO

GLUCOSE METER ......... 106 TRUE METRIX LEVEL 1 ... 106 TRUE2GO BLOOD GLUCOSE

SYSTEM .......................... 106 TRUECONTROL LEVEL 0 107 TRUERESULT BLOOD

GLUCOSE SYSTM ......... 107 TRUETEST LOW GLUCOSE

CONTROL ....................... 107 TRUETEST TEST STRIPS ... 85 TRUETRACK BLOOD

GLUCOSE SYSTEM ....... 107 TRUETRACK SMART

SYSTEM .......................... 107 TRUETRACK TEST.............. 85 TRULANCE ......................... 121 TRULICITY ......................... 114 TRUSOPT ............................ 142 TRUVADA............................... 6

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183

TUDORZA PRESSAIR ....... 152 tusnel c .................................. 147 TUSNEL PEDIATRIC ......... 147 TUSSICAPS ......................... 147 tussigon................................. 147 TUSSIONEX PENNKINETIC

ER ..................................... 147 TUZISTRA XR .................... 147 TWYNSTA ............................ 51 TYBOST .................................. 6 TYKERB ................................ 17 TYLENOL-CODEINE #3...... 30 TYLENOL-CODEINE #4...... 30 TYMLOS ............................. 127 TYZINE ................................. 75 U UCERIS ................................ 121 ULESFIA ............................... 71 ULORIC ............................... 126 ULTIMA MONITOR ........... 107 ULTIMA TEST STRIPS ........ 85 ULTRACET ........................... 34 ULTRAM ............................... 34 ULTRAM ER ......................... 34 ULTRASAL-ER ..................... 59 ULTRATRAK ........................ 85 ULTRATRAK GLUCOSE

METER ............................ 107 ULTRATRAK ULTIMATE . 85,

107 ULTRAVATE ........................ 71 ULTRAVATE X .................... 71 umecta .................................... 61 UNISTRIP LOW CONTROL

.......................................... 108 UNISTRIP1 TEST STRIP ..... 85 unithroid ............................... 115 UPTRAVI............................... 51 ur n-c .................................... 155 uramit mb ............................. 155 urea ......................................... 61 urea nail stick ......................... 61 URECHOLINE .................... 154 URELLE ............................... 155 uretron d-s ............................ 155 URIBEL ............................... 155 urimar-t ................................. 155 urin ds ................................... 155 uro-458 ................................. 155

UROCIT-K 10 ...................... 155 UROCIT-K 15 ...................... 155 UROCIT-K 5 ........................ 155 urogesic-blue ........................ 155 uro-mp .................................. 155 urophen mb ........................... 155 UROQID-ACID NO.2.......... 155 UROXATRAL ..................... 154 URSO 250 ............................ 121 URSO FORTE ...................... 122 ursodiol ................................. 122 uryl........................................ 155 ustell ..................................... 155 UTA ...................................... 155 UTIBRON NEOHALER ...... 152 utira-c.................................... 155 UTOPIC.................................. 61 V VAGIFEM ............................ 131 vaginal contraceptive foam .. 132 valacyclovir .............................. 6 VALCHLOR .......................... 61 VALCYTE ............................... 6 valganciclovir ........................... 6 VALIUM ................................ 42 valproic acid ........................... 21 valproic acid (as sodium salt) . 21 valsartan.................................. 51 valsartan-hydrochlorothiazide 51 VALTREX ............................... 6 VANATOL LQ ...................... 30 VANCOCIN ........................... 14 vancomycin ............................ 14 vandazole .............................. 132 VANOS .................................. 71 VANOXIDE-HC .................... 65 VARUBI ............................... 122 VASCEPA .............................. 55 VASERETIC .......................... 51 VASHE WOUND THERAPY

............................................ 72 VASOTEC.............................. 51 VCF CONTRACEPTIVE FILM

.......................................... 132 VCF CONTRACEPTIVE GEL

.......................................... 132 VECAMYL ............................ 55 VECTICAL ............................ 58

velivet triphasic regimen (28) .......................................... 137

VELPHORO ......................... 122 VELTASSA .......................... 122 VELTIN .................................. 65 VEMLIDY ................................ 6 VENCLEXTA ........................ 18 VENCLEXTA STARTING

PACK ................................. 18 venlafaxine ....................... 42, 43 VENTAVIS .......................... 152 VENTOLIN HFA ................. 152 verapamil ................................ 51 VERDESO .............................. 71 verdrocet ................................. 30 VEREGEN ............................. 61 VERELAN ............................. 51 VERELAN PM ....................... 51 veripred 20 .............................. 77 VERSACLOZ......................... 43 VESICARE........................... 154 vestura (28) ........................... 137 VFEND ..................................... 3 VIAGRA............................... 155 VIBERZI .............................. 122 VIBRAMYCIN ...................... 13 vicodin .................................... 30 vicodin es ................................ 30 vicodin hp ............................... 30 VICTOZA 2-PAK ................ 114 VICTOZA 3-PAK ................ 114 VIDEX 2 GRAM PEDIATRIC 6 VIDEX EC................................ 6 VIEKIRA PAK ......................... 6 VIEKIRA XR ........................... 6 vienva ................................... 137 VIGAMOX ........................... 139 VIIBRYD ............................... 43 VIMOVO ................................ 34 VIMPAT ................................. 21 VIOKACE ............................ 122 viorele (28) ........................... 137 VIRACEPT............................... 6 VIRAMUNE............................. 6 VIRAMUNE XR ...................... 6 VIRASAL ............................... 59 VIRAZOLE .............................. 7 VIREAD ................................... 7 VIROPTIC ............................ 139

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184

virt-phos 250 neutral ............ 157 virtrate-2 ............................... 156 virtrate-3 ............................... 156 virtrate-k ............................... 156 virtussin ac ............................ 147 virtussin dac .......................... 147 VIRT-VITE PLUS ............... 159 VISTARIL ............................ 145 VISTOGARD ......................... 14 vitajoy daily d ....................... 159 vitamin d3 ............................. 159 vitamins a,c,d and fluoride ... 159 VITUZ .................................. 147 VIVELLE-DOT ................... 131 VIVLODEX ........................... 34 VOGELXO ........................... 111 VOLTAREN .......................... 34 VOLTAREN-XR ................... 34 voriconazole ............................. 3 VOTRIENT ............................ 18 VRAYLAR............................. 43 VUSION ................................. 68 vyfemla (28) ......................... 138 VYTORIN 10-10.................... 55 VYTORIN 10-20.................... 55 VYTORIN 10-40.................... 55 VYTORIN 10-80.................... 55 VYVANSE ............................. 43 W warfarin .................................. 53 water for irrigation, sterile ...... 73 WAVESENSE AMP ............ 108 WAVESENSE CONTROL

SOLUTION ...................... 108 WAVESENSE JAZZ ............. 86 WAVESENSE PRESTO 86, 108 WELCHOL ............................ 55 WELLBUTRIN SR ................ 43 WELLBUTRIN XL ................ 43 wera (28) .............................. 138 westhroid .............................. 115 WIDE-SEAL DIAPHRAGM

.......................................... 129 WP THYROID ..................... 115 wymzya fe ............................ 138 X XADAGO............................... 22 XALATAN ........................... 142 XALKORI .............................. 18

XANAX.................................. 43 XANAX XR ........................... 43 XARELTO ............................. 53 XATMEP................................ 18 XCLAIR ................................. 61 XELJANZ ............................ 128 XELJANZ XR ...................... 128 XELODA................................ 18 XENAZINE ............................ 25 XERESE ................................. 68 XIFAXAN .............................. 11 XIGDUO XR ........................ 114 XIIDRA ................................ 141 XODOL 10/300 ...................... 30 XODOL 5/300 ........................ 30 XODOL 7.5/300 ..................... 30 XOLEGEL.............................. 68 XOPENEX ........................... 152 XOPENEX CONCENTRATE

.......................................... 152 XOPENEX HFA .................. 152 XTAMPZA ER ...................... 30 XTANDI ................................. 18 xulane ................................... 132 XULTOPHY 100/3.6 ........... 109 XURIDEN .............................. 73 xylon 10 .................................. 30 XYREM.................................. 43 Y YASMIN (28) ...................... 138 YAZ (28) .............................. 138 YOSPRALA ........................... 53 yuvafem ................................ 131 Z zafirlukast ............................. 152 zaleplon .................................. 43 zamicet.................................... 30 ZANABIN .............................. 61 ZANAFLEX ........................... 26 ZANTAC .............................. 124 zarah ..................................... 138 ZARONTIN............................ 21 ZAVESCA............................ 111 zebutal .................................... 31 ZEGERID ............................. 124 ZELAPAR .............................. 22 ZELBORAF ........................... 18 ZEMBRACE SYMTOUCH ... 24 ZEMPLAR ........................... 111

zenatane .................................. 65 zenchent (28) ........................ 138 zenchent fe ............................ 138 zencia ...................................... 65 ZENPEP ............................... 122 zenzedi .................................... 43 ZENZEDI ............................... 43 ZEPATIER ............................... 7 ZERIT ....................................... 7 ZESTORETIC ........................ 51 ZESTRIL ................................ 51 ZETIA..................................... 55 ZETONNA ........................... 153 ZIAC ....................................... 51 ZIAGEN ................................... 7 ZIANA .................................... 65 zidovudine ................................ 7 zileuton ................................. 153 ZINBRYTA .......................... 126 ZIOPTAN (PF) ..................... 142 ziprasidone hcl ........................ 43 ZIPSOR .................................. 34 ZIRGAN ............................... 139 ZITHRANOL ......................... 58 ZITHROMAX .......................... 8 ZITHROMAX TRI-PAK ......... 8 ZITHROMAX Z-PAK ............. 8 ZMAX ...................................... 8 ZOCOR................................... 55 ZODRYL AC 25 .................. 147 ZODRYL AC 30 .................. 147 ZODRYL AC 35 .................. 147 ZODRYL AC 40 .................. 147 ZODRYL AC 50 .................. 147 ZODRYL AC 60 .................. 148 ZODRYL AC 80 .................. 148 ZODRYL DAC 25 ............... 148 ZODRYL DAC 30 ............... 148 ZODRYL DAC 35 ............... 148 ZODRYL DAC 40 ............... 148 ZODRYL DAC 50 ............... 148 ZODRYL DAC 60 ............... 148 ZODRYL DAC 80 ............... 148 ZODRYL DEC 25 ................ 148 ZODRYL DEC 30 ................ 148 ZODRYL DEC 35 ................ 148 ZODRYL DEC 40 ................ 148 ZODRYL DEC 50 ................ 148 ZODRYL DEC 60 ................ 148

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185

ZODRYL DEC 80 ................ 148 ZOFRAN (AS

HYDROCHLORIDE) ...... 122 ZOFRAN ODT ..................... 122 ZOHYDRO ER ...................... 31 ZOLINZA ............................... 18 zolmitriptan ............................ 24 ZOLOFT................................. 43 zolpidem ................................. 43 ZOLPIMIST ........................... 43 ZOMACTON ....................... 124 ZOMIG ................................... 24 ZOMIG ZMT ......................... 24 ZONALON ............................. 61

ZONEGRAN .......................... 21 zonisamide .............................. 21 ZONTIVITY .......................... 53 ZORBTIVE .......................... 124 ZORTRESS ............................ 18 ZORVOLEX .......................... 34 zovia 1/35e (28) .................... 138 zovia 1/50e (28) .................... 138 ZOVIRAX .......................... 7, 68 Z-TUSS AC .......................... 148 ZUBSOLV.............................. 34 ZUPLENZ ............................ 122 ZURAMPIC ......................... 126 ZUTRIPRO .......................... 148

ZYBAN .................................. 74 ZYCLARA ........................... 126 ZYDELIG ............................... 18 ZYFLO ................................. 153 ZYFLO CR ........................... 153 ZYKADIA .............................. 18 ZYLET ................................. 143 ZYLOPRIM .......................... 126 ZYMAXID ........................... 139 ZYPREXA .............................. 43 ZYPREXA ZYDIS ................. 43 ZYTIGA ................................. 18 ZYVOX .................................. 11