MEDICAL (MISCELLANEOUS) SUPPLIES DIABETIC … Express Scripts...2011 Medicare National Preferred 4T Comprehensive w/ Diabetic Supplies Version 09 2010 Drug Generic Tier Restrictions

2011 Medicare National Preferred 4T Comprehensive w/ Diabetic Supplies Version 09 2010

The symbol [INJ] next to a drug name indicates that the drug is available in injectable form.

The symbol [G] next to a drug name indicates that the drug may be available in a generic form.

The symbol [LA] next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs.

The symbol [PAR] in the Restrictions column indicates that prior authorization may apply.

The symbol [QLL] in the Restrictions column indicates that quantities dispensed may be limited.

The symbol [ST] in the Restrictions column indicates that step therapy may apply.

OTC Drug Table

Drug Generic Tier Restrictions MEDICAL (MISCELLANEOUS) SUPPLIES DIABETIC SUPPLIES ACCU-CHEK ACTIVE 2 ACCU-CHEK ACTIVE METER, -AVIVA

METER, -COMBINATION PACKAGE, -COMPACT PLUS METER, -EACH, -KIT

2

ACCU-CHEK ADVANTAGE 2 ACCU-CHEK AVIVA 2 ACCU-CHEK COMFORT CURVE 2 ACCU-CHEK COMPACT 2 ACCU-CHEK COMPACT BLUE

CONTROL 2

ACCU-CHEK III 2 ACCU-CHEK INSTANT 2 ACCU-CHEK INSTANT PLUS 2 ASCENSIA AUTODISC 2 ASCENSIA ELITE 2 AUTODISC NORMAL 2 BREEZE 2 2 CONTOUR 2


General Drug Table

Drug Generic Tier Restrictions ANESTHETICS LOCAL ANESTHETICS bupivacaine hcl injection [INJ] 1 bupivacaine hcl-epinephrine [INJ] 1 bupivacaine-dextrose [INJ] 1 CARBOCAINE [INJ] mepivacaine 3 chloroprocaine hcl [INJ] 1 droperidol injection [INJ] 1 INAPSINE [INJ] droperidol 3 lidocaine hcl 0.5% vial, -1%

abboject, -1% ampul, -1% syringe, -1% vial, -1.5% ampul, -2% abboject, -2% ampul, -2% luer-jet, -2% min-i-jet, -2% syringe, -2% vial, -20% vial, -4% ampul [INJ]

1

lidocaine hcl in 7.5% dextrose [INJ] 1 lidocaine hcl-epinephrine [INJ] 1 MARCAINE [INJ] bupivacaine 3 MARCAINE SPINAL [INJ] bupivacaine hcl/dextrose-h2o 3 MARCAINE WITH EPINEPHRINE

[INJ][G] bupivacaine hydrochloride/epi 3

MARCAINE-EPINEPHRINE [INJ] bupivacaine hydrochloride/epi 3 NAROPIN [INJ] ropivacaine 3 NESACAINE [INJ] chloroprocaine 3 NESACAINE-MPF [INJ] chloroprocaine 3 NOVOCAIN [INJ] procaine 3 POLOCAINE [INJ] mepivacaine 3 SENSORCAINE [INJ] bupivacaine 3 SENSORCAINE WITH DEXTROSE

[INJ] bupivacaine hcl/dextrose-h2o 3

SENSORCAINE WITH EPINEPHRINE [INJ]

bupivacaine hydrochloride/epi 3

SENSORCAINE-MPF [INJ][G] bupivacaine 3


Drug Generic Tier Restrictions SENSORCAINE-MPF EPINEPHRINE

[INJ][G] bupivacaine hydrochloride/epi 3

XYLOCAINE 2% VIAL, -0.5% VIAL, -1% VIAL [INJ][G]

lidocaine 3

XYLOCAINE IV [INJ] lidocaine 3 XYLOCAINE IV FOR CARDIAC [INJ] lidocaine 3 XYLOCAINE WITH EPINEPHRINE

[INJ] lidocaine hydrochloride/epi 3

XYLOCAINE-MPF [INJ][G] lidocaine 3 XYLOCAINE-MPF WITH

EPINEPHRINE [INJ][G] lidocaine hydrochloride/epi 3

TOPICAL ANESTHETICS ANESTACON lidocaine 3 EMLA [G] lidocaine/prilocaine 3 LIDAMANTLE lidocaine 3 lidocaine hcl cream, -jelly with

prefilled applicator, -lotion, -ointment, -solution non-oral

1

lidocaine hcl viscous 1 lidocaine-prilocaine 1 LIDODERM lidocaine 2 [PAR] SYNERA lidocaine/tetracaine 3 XYLOCAINE JEL, -SOLUTION NON-

ORAL [G] lidocaine 3

ANTIINFECTIVES AMEBICIDES paromomycin sulfate 1 AMINOGLYCOSIDES amikacin sulfate injection [INJ] 1 gentamicin 100 mg/ns 100 ml, -60

mg/ns 50 ml pb, -70 mg/ns 50 ml pb, -80 mg/ns 50 ml pb, -90 mg/ns 100 ml pb, -gentamicin 100 mg/100 ml, -gentamicin 60 mg/50 ml, -gentamicin 80 mg/50 ml [INJ]

1


Drug Generic Tier Restrictions GENTAMICIN 60 MG/NS 100 ML PB,

-80 MG/NS 100 ML PB, -GENTAMICIN 100 MG/50 ML, -GENTAMICIN 60 MG/100 ML, -GENTAMICIN 80 MG/100 ML [INJ]

gentamicin/sodium chloride 3

gentamicin sulfate injection [INJ] 1 ISO GENTAMICIN 120 MG/100 ML, -

GENTAMICIN 120 MG/50 ML, -GENTAMICIN 40 MG/100 ML, -GENTAMICIN 40 MG/50 ML [INJ]

gentamicin/sodium chloride 2

kanamycin sulfate [INJ] 1 NEBCIN IN DEXTROSE [INJ] tobramycin 3 NEO-FRADIN neomycin 2 neomycin sulfate tablet 1 tobramycin sulfate in ns [INJ] 1 tobramycin sulfate injection [INJ] 1 ANTHELMINTICS ALBENZA albendazole 2 BILTRICIDE praziquantel 3 mebendazole tablet chewable 1 STROMECTOL ivermectin 2 ANTIINFECTIVES SPECIALIZED INDICATIONS DAPSONE dapsone 2 FLAGYL [G] metronidazole 3 FLAGYL ER metronidazole 3 metro iv [INJ] 1 metronidazole capsule, -tablet 1 metronidazole injection [INJ] 1 metryl 1 TINDAMAX tinidazole 3 ANTIRETROVIRALS AND PROTEASE INH APTIVUS tipranavir/vitamin e tpgs 4 ATRIPLA emtricitabine/tenofovir/efavir 4 COMBIVIR lamivudine/zidovudine 4


Drug Generic Tier Restrictions CRIXIVAN indinavir 2 didanosine 1 EMTRIVA emtricitabine 2 EPIVIR lamivudine 2 EPZICOM abacavir sulfate/lamivudine 4 FUZEON [INJ] enfuvirtide 4 INTELENCE etravirine 4 INVIRASE saquinavir mesylate 4 ISENTRESS raltegravir potassium 4 KALETRA 100-25 MG TABLET ritonavir/lopinavir 2 KALETRA 200-50 MG TABLET, -

SOLUTION ritonavir/lopinavir 4

LEXIVA SUSPENSION ORAL fosamprenavir calcium 2 LEXIVA TABLET fosamprenavir calcium 4 NORVIR CAPSULE, -TABLET ritonavir 2 NORVIR SOLUTION ritonavir 4 PREZISTA 150 MG TABLET, -300 MG

TABLET, -75 MG TABLET darunavir ethanolate 2

PREZISTA 400 MG TABLET, -600 MG TABLET

darunavir ethanolate 4

RESCRIPTOR delavirdine mesylate 2 RETROVIR CAPSULE, -SYRUP, -

TABLET [G] zidovudine 3

RETROVIR INJECTION [INJ] zidovudine 2 REYATAZ atazanavir sulfate 4 SELZENTRY maraviroc 4 stavudine 1 SUSTIVA efavirenz 2 TRIZIVIR zidovudine/lamivudine/abacavir 4 TRUVADA emtricitabine/tenofovir 4 VIDEX didanosine 2 VIDEX EC [G] didanosine 3 VIRACEPT nelfinavir mesylate 2 VIRAMUNE nevirapine 2 VIREAD tenofovir disproxil fumarate 2 ZERIT [G] stavudine 3 ZIAGEN abacavir sulfate 2 zidovudine 1


Drug Generic Tier Restrictions ANTITUBERCULOSIS DRUGS CAPASTAT SULFATE [INJ] capreomycin 4 CYCLOSERINE cycloserine 2 ethambutol hcl tablet 1 isonarif 1 isoniazid injection [INJ] 1 isoniazid syrup, -tablet 1 MYAMBUTOL [G] ethambutol 3 MYCOBUTIN rifabutin 2 PASER aminosalicylic acid 2 PRIFTIN rifapentine 2 pyrazinamide 1 RIFADIN CAPSULE rifampin 3 RIFADIN INJECTION [INJ] rifampin 4 RIFAMATE rifampin/isoniazid 3 rifampin capsule 1 rifampin injection [INJ] 4 RIFATER rifampin/inh/pyrazinamide 3 SEROMYCIN cycloserine 2 STREPTOMYCIN SULFATE

INJECTION [INJ] streptomycin 2

TRECATOR ethionamide 2 CEPHALOSPORINS CEDAX ceftibuten 3 cefaclor 1 cefaclor er 1 cefadroxil 1 cefazolin 1 gm add-van vial, -1 gm

vial, -1 gm-d5w bag, -10 gm vial, -20 gm bulk vial, -500 mg vial [INJ]

1

cefdinir 1 CEFDITOREN PIVOXIL cefditoren pivoxil 3 cefepime [INJ] 1 cefepime hcl [INJ] 1 cefotaxime sodium [INJ] 1 cefotetan [INJ] 1 cefoxitin [INJ] 1


Drug Generic Tier Restrictions cefoxitin sodium [INJ] 1 cefpodoxime proxetil 1 cefprozil 1 ceftazidime [INJ] 1 CEFTIN [G] cefuroxime axetil 3 ceftriaxone [INJ] 1 cefuroxime axetil 1 cefuroxime injection [INJ] 1 cefuroxime sod 1.5 gm vial, -sod 7.5

gm vial, -sod 750 mg vial [INJ] 1

cefuroxime tablet 1 cephalexin 1 CLAFORAN [INJ][G] cefotaxime 3 FORTAZ 1 GM ADD-VANTAGE VIAL,

-1 GM VIAL, -2 GM VIAL, -6 GM VIAL [INJ][G]

ceftazidime 3

FORTAZ 2 GM ADD-VANTAGE VIAL [INJ]

ceftazidime 4

FORTAZ 500 MG VIAL [INJ] ceftazidime 2 FORTAZ IN ISO-OSMOTIC

DEXTROSE [INJ] ceftazidime 2

KEFLEX [G] cephalexin 3 MAXIPIME 1 GM ADD-VANTAGE VL,

-2 GM ADD-VANTAGE VL, -1 GRAM VIAL, -2 GRAM VIAL [INJ][G]

cefepime 3

MAXIPIME 500 MG VIAL [INJ] cefepime 2 MEFOXIN [INJ][G] cefoxitin 3 OMNICEF cefdinir 3 RANICLOR cefaclor 3 ROCEPHIN [INJ][G] ceftriaxone 3 SPECTRACEF cefditoren pivoxil 3 SUPRAX cefixime 2 TAZICEF [INJ][G] ceftazidime 3 VANTIN cefpodoxime 3 ZINACEF [INJ][G] cefuroxime 3 ZINACEF IN ISO-OSMOTIC WATER

[INJ] cefuroxime 3

ZINACEF ISO-OSMOTIC DEXTROSE [INJ]

cefuroxime 3


Drug Generic Tier Restrictions CHLORAMPHENICOLS chloramphenicol sod succinate [INJ] 1 CLINDAMYCINS CLEOCIN HCL [G] clindamycin hcl 3 CLEOCIN PALMITATE [G] clindamycin palmitate 2 CLEOCIN PHOSPHATE [INJ][G] clindamycin phosphate 3 CLEOCIN PHOSPHATE IN D5W [INJ] clindamycin phosphate 3 clindamycin hcl capsule 1 clindamycin palmitate hcl 1 clindamycin phosphate injection

[INJ] 1

ERYTHROMYCINS E.E.S. 200 erythromycin ethylsuccinate 3 E.E.S. 400 [G] erythromycin ethylsuccinate 3 ERYPED 200 erythromycin ethylsuccinate 3 ERYPED 400 erythromycin ethylsuccinate 3 ERY-TAB erythromycin base 2 ERYTHROCIN LACTOBIONATE [INJ] erythromycin lactobionate 2 erythrocin stearate 1 erythromycin capsule enteric coated,

-tablet 1

erythromycin ethylsuccinate tablet 1 PCE erythromycin base 3 KETOLIDES KETEK telithromycin 3 ORAL ANTIFUNGAL DRUGS ANCOBON flucytosine 4 clotrimazole troche 1 DIFLUCAN 100 MG TABLET, -200

MG TABLET, -50 MG TABLET [G] fluconazole 3 [PAR]

DIFLUCAN 150 MG TABLET [G] fluconazole 3 [QLL, 2/7]


Drug Generic Tier Restrictions DIFLUCAN SUSPENSION [G] fluconazole 3 fluconazole 100 mg tablet, -200 mg

tablet, -50 mg tablet 1 [PAR]

fluconazole 150 mg tablet 1 [QLL, 2/7] fluconazole suspension 1 GRIFULVIN V SUSPENSION ORAL griseofulvin microsize 3 GRIFULVIN V TABLET griseofulvin microsize 2 griseofulvin suspension oral 1 GRIS-PEG griseofulvin ultramicrosize 2 itraconazole capsule 1 [PAR] ketoconazole tablet 1 LAMISIL PKT terbinafine 2 LAMISIL TABLET [G] terbinafine 3 [PAR] MYCOSTATIN nystatin 3 NOXAFIL posaconazole 4 nystatin 150,000,000 units pwd, -

50,000,000 units pwd, -500,000,000 units pwd, -suspension oral, -tablet

1

ORAVIG miconazole 3 SPORANOX CAPSULE [G] itraconazole 3 [PAR] SPORANOX SOLUTION itraconazole 2 terbinafine hcl 1 [PAR] TERBINEX terbinafine/hydroxy chitosan 3 [PAR] VFEND voriconazole 4 [PAR] OTHER ANTIINFECTIVE DRUGS ALINIA nitazoxanide 2 AZACTAM 1 GM VIAL [INJ] aztreonam 2 AZACTAM 2 GM VIAL [INJ][G] aztreonam 4 AZACTAM-ISO-OSMOT 1 GM/50 ML

[INJ] aztreonam/dextrose water 2

AZACTAM-ISO-OSMOT 2 GM/50 ML [INJ]

aztreonam/dextrose water 4

aztreonam 1 gm vial [INJ] 1 aztreonam 2 gm vial [INJ] 4 baciim [INJ] 1 bacitracin injection [INJ] 1 colistimethate 150 mg vial [INJ] 4 COLY-MYCIN M PARENTERAL

[INJ][G] colistimethate, sodium 4


Drug Generic Tier Restrictions CUBICIN [INJ] daptomycin 4 DORIBAX [INJ] doripenem 4 INVANZ 1 GM ADD-VANTAGE VIAL

[INJ] ertapenem sodium 3

INVANZ 1 GM VIAL [INJ] ertapenem sodium 2 LINCOCIN [INJ] lincomycin 3 lincoject [INJ] 1 MEPRON atovaquone 4 meropenem [INJ] 1 MERREM IV 1 GM VIAL [INJ] meropenem 4 MERREM IV 500 MG VIAL [INJ][G] meropenem 2 PENTAM 300 [INJ][G] pentamidine 3 pentamidine isethionate [INJ] 1 polymyxin b sulfate injection [INJ] 1 POLYMYXIN B SULFATE POWDER polymyxin b 3 PRIMAXIN 250 MG VIAL [INJ] imipenem/cilastatin sodium 2 PRIMAXIN 500 MG VIAL [INJ] imipenem/cilastatin sodium 4 PRIMAXIN I.M. [INJ] imipenem/cilastatin sodium 4 SYNERCID [INJ] quinupristin/dalfopristin 4 TYGACIL [INJ] tigecycline 4 VANCOCIN HCL vancomycin 4 vancomycin 1 gm add-van vial, -1

gm vial, -10 gm vial, -5 gm vial, -500 mg a/v vial, -500 mg vial, -750 mg vial [INJ]

1

VANCOMYCIN HCL 1G/200 ML BAG [INJ]

vancomycin 3

VANCOMYCIN-D5W [INJ] vancomycin 3 VIBATIV [INJ] telavancin 4 XIFAXAN 200 MG TABLET rifaximin 2 XIFAXAN 550 MG TABLET rifaximin 4 ZYVOX INJECTION [INJ] linezolid 4 ZYVOX SUSPENSION

RECONSTITUTED ORAL, -TABLET linezolid 4 [PAR]

OTHER ANTIVIRAL DRUGS acyclovir capsule, -suspension oral, -

tablet 1

acyclovir sodium [INJ] 1 amantadine 1


Drug Generic Tier Restrictions BARACLUDE SOLUTION entecavir 2 BARACLUDE TABLET entecavir 4 COPEGUS [G] ribavirin 4 CYTOVENE [INJ][G] ganciclovir 2 DENAVIR penciclovir 2 EPIVIR HBV lamivudine 2 famciclovir 125 mg tablet 1 [QLL,

21/10] famciclovir 250 mg tablet 1 [QLL,

68/34] famciclovir 500 mg tablet 1 [QLL, 21/7] FAMVIR 125 MG TABLET [G] famciclovir 3 [QLL,

21/10] FAMVIR 250 MG TABLET [G] famciclovir 3 [QLL,

68/34] FAMVIR 500 MG TABLET [G] famciclovir 3 [QLL, 21/7] FLUMADINE [G] rimantadine 3 foscarnet sodium [INJ] 1 FOSCAVIR [INJ] foscarnet 3 ganciclovir 4 ganciclovir sodium [INJ] 1 HEPSERA adefovir dipivoxil 4 REBETOL SOLUTION, -CAPSULE [G] ribavirin 4 RELENZA zanamivir 2 [QLL,

60/180] ribapak 4 ribasphere 200 mg tablet 1 ribasphere 400 mg tablet, -600 mg

tablet, -capsule 4

RIBATAB [G] ribavirin 4 ribavirin 200 mg tablet 1 ribavirin 400 mg tablet, -600 mg

tablet, -capsule 4

rimantadine hcl 1 TAMIFLU 30 MG GELCAP oseltamivir phosphate 2 [QLL,

84/180] TAMIFLU 45 MG GELCAP, -75 MG

GELCAP oseltamivir phosphate 2 [QLL,

42/180] TAMIFLU SUSPENSION oseltamivir phosphate 2 [QLL,

900/180] TYZEKA telbivudine 2


Drug Generic Tier Restrictions valacyclovir 1 [QLL,

34/34] VALCYTE valganciclovir 4 VALTREX [G] valacyclovir 3 [QLL,

34/34] VIRAZOLE [INJ] ribavirin 2 VISTIDE [INJ] cidofovir 4 ZOVIRAX CAPSULE, -SUSPENSION

ORAL, -TABLET [G] acyclovir 3

ZOVIRAX CREAM, -OINTMENT acyclovir 2 OTHER MACROLIDES azithromycin 100 mg/5 ml susp 1 [QLL, 30

ml/5] azithromycin 200 mg/5 ml susp 1 [QLL, 90

ml/5] azithromycin 250 mg tablet 1 [QLL, 8/7] azithromycin 500 mg tablet 1 [QLL, 4/4] azithromycin 600 mg tablet, -packet 1 azithromycin injection [INJ] 1 BIAXIN [G] clarithromycin 3 BIAXIN XL [G] clarithromycin 3 clarithromycin 1 clarithromycin er 1 ZITHROMAX 100 MG/5 ML SUSP [G] azithromycin 3 [QLL, 30

ml/5] ZITHROMAX 200 MG/5 ML SUSP [G] azithromycin 3 [QLL, 68

ml/5] ZITHROMAX 250 MG TABLET, -250

MG Z-PAK TABLET [G] azithromycin 3 [QLL, 8/7]

ZITHROMAX 500 MG TABLET [G] azithromycin 3 [QLL, 4/4] ZITHROMAX INJECTION [INJ][G] azithromycin 3 ZITHROMAX PACKET, -600 MG

TABLET [G] azithromycin 3

ZITHROMAX TRI-PAK [G] azithromycin 3 [QLL, 4/4] ZMAX azithromycin 3 [QLL, 60

ml/1] ZMAX ADULT-PEDIATRIC azithromycin 3 [QLL, 60/1] ZMAX PEDIATRIC azithromycin 3 [QLL, 60/1]


Drug Generic Tier Restrictions OTHER TOPICAL ANTIFUNGALS ciclopirox cream, -gel, -kit, -

shampoo, -suspension topical 1

ciclopirox solution non-oral 1 [PAR] clotrimazole 1% cream, -1%

solution, -af 1% cream 1

CNL 8 ciclopirox/nail lacquer remov 3 econazole nitrate cream 1 ERTACZO sertaconazole nitrate 3 EXELDERM sulconazole nitrate 3 EXTINA ketoconazole 3 HALOTIN haloprogin 3 ketoconazole cream, -shampoo 1 KURIC [G] ketoconazole 3 LAMISIL SOLUTION terbinafine 3 LOPROX [G] ciclopirox 3 MENTAX butenafine 3 NAFTIN naftifine 3 NIZORAL [G] ketoconazole 3 nyamyc 1 nystatin 100,000 unit/gm powd, -

cream, -ointment 1

nystop 1 OXISTAT oxiconazole 3 pedi-dri 1 PENLAC [G] ciclopirox 3 [PAR] VUSION miconazole nitrate/zinc oxide 3 XOLEGEL ketoconazole 3 PARENTERAL ANTIFUNGALS ABELCET [INJ] amphotericin b lipid complex 4 AMBISOME [INJ] amphotericin b liposome 4 AMPHOTEC 100 MG VIAL [INJ] ampho b c-s 2 AMPHOTEC 50 MG VIAL [INJ] ampho b c-s 3 amphotericin b injection [INJ] 1 CANCIDAS [INJ] caspofungin acetate 4 DIFLUCAN IN DEXTROSE [INJ] fluconazole/dextrose-water 3 DIFLUCAN IN SALINE [INJ][G] fluconazole/sodium chloride 3


Drug Generic Tier Restrictions ERAXIS (ALCOHOL DILUENT) [INJ] anidulafungin 3 ERAXIS (WATER DILUENT) [INJ] anidulafungin 3 fluconazole in dextrose [INJ] 1 fluconazole in saline [INJ] 1 MYCAMINE [INJ] micafungin sodium 4 VFEND IV [INJ] voriconazole 4 PENICILLINS amoclan 1 amox tr-potassium clavulanate 1 amoxicillin 1 amoxicillin-clavulanate er 1 AMOXIL 125 MG/5 ML SUSPENSION

[INJ] amoxicillin 2

AMOXIL 400 MG/5 ML SUSPENSION, -50 MG/ML PED DROPS, -CAPSULE, -250 MG/5 ML SUSPENSION [G]

amoxicillin 2

ampicillin sodium [INJ] 1 ampicillin trihydrate 1 ampicillin-sulbactam [INJ] 1 AUGMENTIN 125-31.25 SUSPEN, -

TABLET CHEWABLE amoxicillin clavulanate 2

AUGMENTIN 400-57 MG/5 ML, -250-62.5 MG/5 ML, -TABLET [G]

amoxicillin clavulanate 3

AUGMENTIN ES-600 amoxicillin clavulanate 3 AUGMENTIN XR [G] amoxicillin clavulanate 3 BACTOCILL oxacillin 3 BICILLIN C-R [INJ] pen g procaine/pen g benz 2 BICILLIN L-A [INJ] penicillin g benzathine 2 dicloxacillin sodium 1 MOXATAG amoxicillin 3 NAFCILL IN DEXTROSE [INJ] nafcillin 4 nafcillin [INJ] 4 nafcillin sodium [INJ] 4 NALLPEN [INJ] nafcillin 4 NALLPEN IN DEXTROSE [INJ] nafcillin 4 NALLPEN-ISO-OSMOTIC DEXTROSE

[INJ] nafcillin 4

oxacillin [INJ] 4


Drug Generic Tier Restrictions oxacillin 1 gm add-vantage vl, -10

gm vial, -2 gm add-vantage vl, -2 gm vial [INJ]

4

oxacillin 1 gm vial [INJ] 1 penicillin g potassium [INJ] 1 PENICILLIN G POTASSIUM IN D5W

[INJ] pen g pot/dextrose-water 2

penicillin g procaine [INJ] 1 penicillin g sodium [INJ] 1 PENICILLIN GK-ISO-OSM

DEXTROSE [INJ] pen g pot/dextrose-water 2

penicillin v potassium 1 PFIZERPEN [INJ][G] penicillin g potassium 3 piperacillin [INJ] 1 piperacillin-tazobactam [INJ] 1 PIPRACIL IN DEXTROSE [INJ] piperacillin 2 TIMENTIN [INJ] ticarcillin/k clavulanate 2 TOTACILLIN-N [INJ] ampicillin sodium 3 UNASYN [INJ][G] ampicillin sodium/sulbactam na 3 ZOSYN [INJ][G] piperacillin/tazobactam sodium 3 PLASMODICIDES ARALEN PHOSPHATE [G] chloroquine phosphate 3 chloroquine phosphate tablet 1 COARTEM artemether/lumefantrine 2 DARAPRIM pyrimethamine 2 FANSIDAR pyrimethamine/sulfadoxine 2 HALFAN halofantrine 2 hydroxychloroquine sulfate tablet 1 MALARONE atovaquone/proguanil hcl 2 mefloquine hcl 1 PLAQUENIL [G] hydroxychloroquine 3 PRIMAQUINE primaquine 2 QUALAQUIN quinine sulfate 2 QUINOLONES AVELOX moxifloxacin 2 AVELOX ABC PACK moxifloxacin 2


Drug Generic Tier Restrictions AVELOX IV [INJ] moxifloxacin 2 CIPRO [G] ciprofloxacin 3 CIPRO I.V. [INJ][G] ciprofloxacin 3 CIPRO XR ciprofloxacin 3 ciprofloxacin [INJ] 1 ciprofloxacin er 1 ciprofloxacin hcl tablet 1 ciprofloxacin-d5w [INJ] 1 FACTIVE gemifloxacin 3 [QLL, 7/7] FLOXIN I.V. [INJ] ofloxacin 3 LEVAQUIN INJECTION [INJ] levofloxacin 3 LEVAQUIN SOLUTION, -TABLET levofloxacin 3 NOROXIN norfloxacin 3 ofloxacin tablet 1 PROQUIN XR ciprofloxacin 3 SULFONAMIDES BACTRIM [G] sulfamethoxazole/trimethoprim 3 BACTRIM DS [G] sulfamethoxazole/trimethoprim 3 erythromycin-sulfisoxazole 1 GANTRISIN sulfisoxazole acetyl 2 SEPTRA [G] sulfamethoxazole/trimethoprim 3 SEPTRA DS [G] sulfamethoxazole/trimethoprim 3 sulfadiazine tablet 1 sulfamethoxazole-trimethoprim

injection [INJ] 1

sulfamethoxazole-trimethoprim suspension oral, -tablet

1

sulfatrim 1 TETRACYCLINES ADOXA [G] doxycycline monohydrate 3 ADOXA PAK [G] doxycycline monohydrate 3 ALA-TET [INJ] tetracycline 3 AVIDOXY doxycycline monohydrate 3 DECLOMYCIN demeclocycline hcl 3 demeclocycline hcl 1 DORYX doxycycline hyclate 3


Drug Generic Tier Restrictions doxycycline 1 doxycycline hyclate 100 mg tab, -

capsule, -capsule enteric coated 1

doxycycline hyclate injection [INJ] 1 doxycycline monohydrate 1 doxy-lemmon 1 DYNACIN [G] minocycline 3 MINOCIN COMBINATION PACKAGE,

-KIT, -CAPSULE [G] minocycline 3

MINOCIN INJECTION [INJ] minocycline 3 minocycline hcl capsule, -tablet, -

tablet sustained release 24hr 1

MONODOX [G] doxycycline monohydrate 3 ORACEA doxycycline monohydrate 3 SOLODYN [G] minocycline 3 TERRAMYCIN [INJ] oxytetracycline 3 TERRAMYCIN IM [INJ] oxytetracycline 3 tetracycline hcl capsule 1 VIBRAMYCIN 50 MG CAPSULE [INJ] doxycycline hyclate 3 VIBRAMYCIN SUSPENSION, -SYRUP,

-100 MG CAPSULE [G] doxycycline hyclate 3

VIBRA-TABS doxycycline hyclate 3 TOPICAL ANTIBACTERIAL DRUGS ALTABAX retapamulin 2 BACTROBAN [G] mupirocin 3 BACTROBAN NASAL mupirocin calcium 2 CENTANY mupirocin 3 CHLORHEXIDINE GLUCONATE SOL chlorhexidine 2 CORTISPORIN CREAM, -OINTMENT neomycin/bacitracin/poly/hc 3 gentamicin 0.1% ointment, -cream 1 mupirocin ointment 1 PHISOHEX hexachlorophene 3 SILVADENE [G] silver sulfadiazine 3 silver sulfadiazine 1 ssd 1 ssd af 1 SULFAMYLON mafenide acetate 2 thermazene 1


Drug Generic Tier Restrictions TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB. clotrimazole-betamethasone 1 LOTRISONE [G] clotrimazole/betamethasone 3 nystatin-triamcinolone 1 URINARY ANTIINFECTIVES FURADANTIN nitrofurantoin 2 HIPREX [G] methenamine hippurate 3 MACROBID [G] nitrofurantoin/nitrofuran mac 3 MACRODANTIN [G] nitrofurantoin macrocrystal 3 methenamine hippurate 1 methenamine mandelate 1 MONUROL fosfomycin tromethamine 2 nitrofurantoin capsule 1 nitrofurantoin macrocrystal 1 nitrofurantoin mono-macro 1 PRIMSOL trimethoprim 2 trimethoprim tablet 1 UREX [G] methenamine hippurate 3 UROQID-ACID NO.2 methenamine mandelate 3 utac 1 visqid a-a 1 VAGINAL ANTIFUNGALS GYNAZOLE-1 butoconazole 3 miconazole 3 200 mg vag supp 1 [QLL, 3/3] nystatin tablet 1 TERAZOL 3 80 MG SUPPOSITORY

[G] terconazole 3 [QLL, 3/3]

TERAZOL 3 CREAM [G] terconazole 3 [QLL, 20 gm/3]

TERAZOL 7 [G] terconazole 3 [QLL, 45 gm/7]

terconazole 0.4% cream 1 [QLL, 45 gm/7]


Drug Generic Tier Restrictions terconazole 0.8% cream 1 [QLL, 20

gm/3] terconazole 80 mg suppository 1 [QLL, 3/3] ZAZOLE 0.8% VAGINAL CREAM terconazole 3 [QLL, 20

gm/3] ZAZOLE 80 MG VAGINAL SUPP [G] terconazole 3 [QLL, 3/3] ZAZOLE VAGINAL 0.4% CREAM [G] terconazole 3 [QLL, 45

gm/7] ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS AFINITOR everolimus 4 AGRYLIN [G] anagrelide 3 ALIMTA [INJ] pemetrexed disodium 4 AMEVIVE [INJ][LA] alefacept 4 [PAR] amifostine [INJ] 4 anagrelide hcl 1 anastrozole tablet 1 ARAVA [G] leflunomide 3 [QLL,

34/34] ARIMIDEX [G] anastrozole 2 AROMASIN exemestane 2 AVASTIN [INJ] bevacizumab 2 [PAR] AZASAN azathioprine 2 [PAR] azathioprine sodium [INJ] 1 [PAR] azathioprine tablet 1 [PAR] bicalutamide 1 CAMPATH [INJ] alemtuzumab 4 CASODEX [G] bicalutamide 3 CEENU lomustine 2 CELLCEPT CAPSULE [G] mycophenolate mofetil 3 [PAR] CELLCEPT INJECTION [INJ] mycophenolate mofetil 2 [PAR] CELLCEPT TABLET, -SUSPENSION

RECONSTITUTED ORAL [G] mycophenolate mofetil 4 [PAR]

CIMZIA [INJ] certolizumab pegol 4 [PAR] cyclophosphamide tablet 1 [PAR] cyclosporine capsule, -solution 1 [PAR] cyclosporine injection [INJ] 1 [PAR] cyclosporine modified 1 [PAR]


Drug Generic Tier Restrictions DEPO-PROVERA 400 MG/ML VIAL

[INJ] medroxyprogesterone 2

DROXIA hydroxyurea 2 ELIGARD [INJ] leuprolide 2 [PAR] ELITEK [INJ] rasburicase 4 EMCYT estramustine phosphate sodium 2 ENBREL [INJ] etanercept 4 [PAR] ETHYOL [INJ][G] amifostine 4 FARESTON toremifene 2 FASLODEX [INJ] fulvestrant 4 FEMARA letrozole 2 floxuridine [INJ] 1 flutamide 1 fudr [INJ] 1 gengraf 1 [PAR] GLEEVEC imatinib mesylate 4 HEXALEN altretamine 4 HUMIRA 20 MG/0.4 ML SYRINGE, -

40 MG/0.8 ML SYRINGE [INJ] adalimumab 4 [PAR][QLL,

5/35] HUMIRA 40 MG/0.8 ML PEN, -

CROHN'S STARTER PACK, -PSORIASIS STARTER PACK [INJ]

adalimumab 4 [PAR][QLL, 6/180]

HYDREA [G] hydroxyurea 3 hydroxyurea capsule 1 IMURAN [G] azathioprine 3 [PAR] IRESSA [LA] gefitinib 4 leflunomide 1 [QLL,

34/34] leucovorin calcium injection [INJ] 1 leucovorin calcium tablet 1 LEUKERAN chlorambucil 2 LYSODREN mitotane 4 MATULANE procarbazine 4 MEGACE [G] megestrol 3 MEGACE ES megestrol 2 megestrol acetate suspension oral, -

tablet 1

mercaptopurine tablet 1 MESNEX TABLET mesna 4 methotrexate injection [INJ] 1 [PAR] methotrexate tablet 1 [PAR]


Drug Generic Tier Restrictions mitoxantrone hcl injection [INJ] 4 [PAR] MUSTARGEN [INJ] mechlorethamine 2 mycophenolate mofetil capsule 1 [PAR] mycophenolate mofetil tablet 4 [PAR] MYFORTIC mycophenolate sodium 2 [PAR] NEORAL [G] cyclosporine 3 [PAR] NEXAVAR [LA] sorafenib tosylate 4 NILANDRON nilutamide 2 NOVANTRONE [INJ][G] mitoxantrone 4 [PAR] octreotide 1,000 mcg/ml vial, -acet

100 mcg/ml amp, -acet 100 mcg/ml vl, -acet 200 mcg/ml vl, -acet 500 mcg/ml amp, -acet 500 mcg/ml vl [INJ]

4

octreotide acet 50 mcg/ml amp, -acet 50 mcg/ml vial [INJ]

1

ORENCIA [INJ] abatacept/maltose 4 [PAR] ORTHOCLONE OKT-3 [INJ] muronab-cd3 2 [PAR] PROGRAF 0.5 MG CAPSULE, -1 MG

CAPSULE [G] tacrolimus 3 [PAR]

PROGRAF 5 MG CAPSULE [G] tacrolimus 4 [PAR] PROGRAF INJECTION [INJ] tacrolimus 2 [PAR] PURINETHOL [G] mercaptopurine 3 RAPAMUNE sirolimus 2 [PAR] RAPTIVA [INJ] efalizumab 4 REMICADE [INJ] infliximab 4 [PAR] REVLIMID [LA] lenalidomide 4 RHEUMATREX methotrexate 3 [PAR] RITUXAN [INJ] rituximab 4 [PAR] SANDIMMUNE CAPSULE, -

SOLUTION [G] cyclosporine 3 [PAR]

SANDIMMUNE INJECTION [INJ][G] cyclosporine 3 [PAR] SANDOSTATIN [INJ][G] octreotide 4 SANDOSTATIN LAR 10 MG KIT, -30

MG KIT [INJ] octreotide 4 [QLL, 1/28]

SANDOSTATIN LAR 20 MG KIT [INJ] octreotide 4 [QLL, 2/28] SIMPONI [INJ] golimumab 4 [PAR] SIMULECT [INJ] basiliximab 2 [PAR] SOMATULINE DEPOT [INJ] lanreotide acetate 4 SPRYCEL dasatinib 4 STELARA [INJ] ustekinumab 4 [PAR]


Drug Generic Tier Restrictions SUTENT sunitinib malate 4 tacrolimus 0.5 mg capsule, -1 mg

capsule 1 [PAR]

tacrolimus 5 mg capsule 4 [PAR] tamoxifen citrate tablet 1 TARCEVA erlotinib hcl 4 TARGRETIN bexarotene 4 TASIGNA nilotinib hydrochloride 4 THERACYS [INJ] bcg vaccine 2 THIOGUANINE thioguanine 2 TRELSTAR 11.25 MG SYRINGE, -

3.75 MG SYRINGE [INJ][LA] triptorelin pamoate 2

TRELSTAR 22.5 MG SYRINGE, -22.5 MG VIAL [INJ][LA]

triptorelin pamoate 4

TRELSTAR DEPOT [INJ][LA] triptorelin pamoate 2 TRELSTAR LA [INJ][LA] triptorelin pamoate 2 tretinoin capsule 4 TREXALL methotrexate sodium 2 [PAR] TYKERB lapatinib ditosylate 4 TYSABRI [INJ][LA] natalizumab 4 [PAR] VANTAS [INJ] histrelin ac 2 VELCADE [INJ] bortezomib 4 VESANOID tretinoin 4 VIDAZA [INJ] azacitidine 4 VOTRIENT pazopanib 4 ZOLADEX [INJ] goserelin acetate 2 ZOLINZA vorinostat 4 ZORTRESS 0.25 MG TABLET everolimus 2 [PAR] ZORTRESS 0.5 MG TABLET, -0.75

MG TABLET everolimus 4 [PAR]

AUTONOMIC AND CNS MEDICATIONS ANALGESICS BUPRENEX [INJ] buprenorphine 3 buprenorphine injection [INJ] 1 butorphanol tartrate injection [INJ] 1 nalbuphine hcl [INJ] 1 PRIALT [INJ] ziconotide acetate 2


Drug Generic Tier Restrictions RYBIX ODT tramadol 3 [QLL,

272/34][ST] RYZOLT tramadol 3 [QLL,

34/34][ST] sufenta [INJ] 1 sufentanil citrate injection [INJ] 1 TALWIN INJECTION [INJ] pentazocine 3 tramadol hcl tablet 1 [QLL,

272/34] tramadol hcl tablet sustained release

24hr 1 [QLL,

34/34] tramadol hcl-acetaminophen 1 [QLL,

272/34] ULTIVA [INJ] remifentanil 2 ULTRACET [G] tramadol/apap 3 [QLL,

272/34][ST] ULTRAM [G] tramadol 3 [QLL,

272/34][ST] ULTRAM ER [G] tramadol 3 [QLL,

34/34][ST] ANTIDEMENTIA DRUGS ARICEPT 10 MG TABLET, -5 MG

TABLET donepezil 2

ARICEPT 23 MG TABLET donepezil 3 ARICEPT ODT donepezil 2 COGNEX tacrine 3 EXELON [G] rivastigmine tartrate 2 galantamine hbr 1 galantamine hydrobromide 1 NAMENDA memantine hcl 2 RAZADYNE [G] galantamine 3 RAZADYNE ER [G] galantamine 3 rivastigmine 1 ANTIMANIA DRUGS ESKALITH [INJ] lithium carbonate 3 lithium 1


Drug Generic Tier Restrictions lithium carbonate capsule, -tablet, -

tablet sustained action 1

lithium citrate 1 LITHOBID [G] lithium carbonate 3 ANTIPARKINSON ANTICHOLINERGIC DRUGS benztropine mesylate injection [INJ] 1 benztropine mesylate tablet 1 COGENTIN [INJ][G] benztropine 3 trihexyphenidyl hcl 1 ANTIPSYCHOTIC DRUGS ABILIFY DISCMELT aripiprazole 2 [QLL,

68/34] ABILIFY INJECTION [INJ] aripiprazole 2 ABILIFY SOLUTION aripiprazole 2 ABILIFY TABLET aripiprazole 2 [QLL,

34/34] chlorpromazine hcl injection [INJ] 1 chlorpromazine hcl tablet 1 clozapine 1 CLOZARIL [G] clozapine 3 FANAPT 1 MG TABLET, -10 MG

TABLET, -12 MG TABLET, -2 MG TABLET, -4 MG TABLET, -6 MG TABLET, -8 MG TABLET

iloperidone 2 [QLL, 68/34]

FANAPT TITRATION PACK iloperidone 2 [QLL, 1/34] FAZACLO clozapine 2 fluphenazine decanoate [INJ] 1 fluphenazine hcl elixir, -solution, -

tablet 1

fluphenazine hcl injection [INJ] 1 GEODON CAPSULE ziprasidone 2 [QLL,

68/34] GEODON INJECTION [INJ] ziprasidone 2 HALDOL [INJ] haloperidol 3 HALDOL DECANOATE 100 [INJ] haloperidol decanoate 3 HALDOL DECANOATE 50 [INJ] haloperidol decanoate 3 haloperidol decanoate [INJ] 1


Drug Generic Tier Restrictions haloperidol lactate injection [INJ] 1 haloperidol lactate solution 1 haloperidol tablet 1 INVEGA ER 1.5 MG TABLET, -ER 3

MG TABLET, -ER 9 MG TABLET paliperidone 2 [QLL,

34/34] INVEGA ER 6 MG TABLET paliperidone 2 [QLL,

68/34] INVEGA SUSTENNA 117 MG PREF

SY, -156 MG PREF SY, -234 MG PREF SY [INJ]

paliperidone 4

INVEGA SUSTENNA 39 MG PREF SYR, -78 MG PREF SYR [INJ]

paliperidone 2

loxapine 1 LOXITANE [G] loxapine succinate 3 MOBAN molindone 2 NAVANE [G] thiothixene 3 ORAP pimozide 2 perphenazine 1 RISPERDAL CONSTA 12.5 MG SYR, -

25 MG SYR [INJ] risperidone 2

RISPERDAL CONSTA 37.5 MG SYR, -50 MG SYR [INJ]

risperidone 4

RISPERDAL M-TAB [G] risperidone 3 [QLL, 68/34]

RISPERDAL SOLUTION [G] risperidone 3 [QLL, 544 ml/34]

RISPERDAL TABLET [G] risperidone 3 [QLL, 68/34]

risperidone m-tab 1 [QLL, 68/34]

risperidone odt 1 [QLL, 68/34]

risperidone solution 1 [QLL, 544 ml/34]

risperidone tablet 1 [QLL, 68/34]

SAPHRIS asenapine 2 [QLL, 68/34]

SEROQUEL 100 MG TABLET, -200 MG TABLET, -25 MG TABLET, -50 MG TABLET

quetiapine fumarate 2 [QLL, 102/34]


Drug Generic Tier Restrictions SEROQUEL 300 MG TABLET, -400

MG TABLET quetiapine fumarate 2 [QLL,

68/34] SEROQUEL XR 150 MG TABLET, -

200 MG TABLET quetiapine fumarate 2 [QLL,

34/34] SEROQUEL XR 300 MG TABLET, -

400 MG TABLET, -50 MG TABLET quetiapine fumarate 2 [QLL,

68/34] SYMBYAX olanzapine/fluoxetine hcl 3 thioridazine hcl 1 thiothixene 1 trifluoperazine hcl 1 ZYPREXA INJECTION [INJ] olanzapine 2 ZYPREXA RELPREVV [INJ][LA] olanzapine pamoate 4 ZYPREXA TABLET olanzapine 2 [QLL,

34/34] ZYPREXA ZYDIS olanzapine 2 [QLL,

34/34] ANTIVERTIGO AND ANTIEMETIC DRUGS ALOXI [INJ] palonosetron hcl 4 ANTIVERT [G] meclizine hcl 3 ANZEMET INJECTION [INJ] dolasetron mesylate 3 ANZEMET TABLET dolasetron mesylate 3 [PAR][QLL,

1/1] CESAMET nabilone 4 [QLL, 30/5] COMPAZINE INJECTION [INJ] prochlorperazine edisylate 3 COMPAZINE SYRUP prochlorperazine edisylate 2 compro 1 dimenhydrinate injection [INJ] 1 dronabinol 10 mg capsule, -5 mg

capsule 4 [PAR]

dronabinol 2.5 mg capsule 1 [PAR] EMEND 125 MG CAPSULE, -40 MG

CAPSULE aprepitant 2 [PAR][QLL,

1/1] EMEND 80 MG CAPSULE aprepitant 2 [PAR][QLL,

2/2] EMEND INJECTION [INJ] aprepitant 2 EMEND TRIFOLD PACK aprepitant 2 [PAR][QLL,

3/3] granisetron hcl injection [INJ] 1


Drug Generic Tier Restrictions granisetron hcl tablet 1 [PAR][QLL,

2/1] granisol 1 [PAR][QLL,

30 ml/3] KYTRIL INJECTION [INJ][G] granisetron 4 KYTRIL TABLET [G] granisetron 4 [PAR][QLL,

2/1] MARINOL 10 MG CAPSULE, -5 MG

CAPSULE [G] dronabinol 4 [PAR]

MARINOL 2.5 MG CAPSULE [G] dronabinol 3 [PAR] meclizine 12.5 mg tablet, -25 mg

tablet 1

ondansetron hcl 24 mg tablet 1 [PAR][QLL, 1/1]

ondansetron hcl 4 mg tablet, -8 mg tablet

1 [PAR][QLL, 12/5]

ondansetron hcl in dextrose [INJ] 1 ondansetron hcl injection [INJ] 1 ondansetron hcl solution 1 [PAR][QLL,

150 ml/5] ondansetron odt 1 [PAR][QLL,

12/5] phenadoz 1 prochlorperazine edisylate [INJ] 1 prochlorperazine maleate

suppository rectal, -tablet 1

promethazine hcl suppository rectal 1 promethegan 1 SANCUSO granisetron 4 [QLL, 1/7] TIGAN CAPSULE [G] trimethobenzamide 3 TIGAN INJECTION [INJ] trimethobenzamide 3 TRANSDERM-SCOP scopolamine 3 trimethobenzamide hcl capsule 1 trimethobenzamide hcl injection

[INJ] 1

ZOFRAN INJECTION [INJ][G] ondansetron 3 ZOFRAN ODT [G] ondansetron 3 [PAR][QLL,

12/5] ZOFRAN SOLUTION [G] ondansetron 3 [PAR][QLL,

150 ml/5] ZOFRAN TABLET [G] ondansetron 3 [PAR][QLL,

12/5]


Drug Generic Tier Restrictions ZUPLENZ ondansetron 3 [PAR][QLL,

12/5] ANXIOLYTICS BUSPAR buspirone 3 buspirone hcl tablet 1 meprobamate 1 CARBAMAZEPINES carbamazepine suspension oral, -

tablet, -tablet chewable 1

carbamazepine xr 1 CARBATROL carbamazepine 3 epitol 1 EQUETRO carbamazepine 3 oxcarbazepine 1 TEGRETOL [G] carbamazepine 3 TEGRETOL XR 100 MG TABLET carbamazepine 2 TEGRETOL XR 200 MG TABLET, -

400 MG TABLET [G] carbamazepine 3

TRILEPTAL [G] oxcarbazepine 3 CLASS II NARCOTICS ACTIQ [G] fentanyl citrate 4 [PAR][QLL,

120/30] ALCET oxycodone/acetaminophen 3 ALFENTA [INJ] alfentanil 3 alfentanil hydrochloride [INJ] 1 ASTRAMORPH-PF [INJ][G] morphine 3 AVINZA morphine 3 [QLL,

60/30][ST] codeine phosphate injection [INJ] 1 codeine sulfate 1 COMBUNOX oxycodone/ibuprofen 3 DAZIDOX oxycodone 3 DEMEROL [INJ] meperidine 3 DEPODUR [INJ] morphine sulfate liposomal 3


Drug Generic Tier Restrictions DILAUDID INJECTION [INJ] hydromorphone 3 DILAUDID TABLET [G] hydromorphone 3 DILAUDID-5 hydromorphone 3 DILAUDID-HP [INJ][G] hydromorphone 3 diskets 1 DOLOPHINE HCL [G] methadone 3 DURAGESIC [G] fentanyl 3 DURAMORPH [INJ][G] morphine 3 EMBEDA morphine sulfate/naltrexone 3 [QLL,

90/30][ST] endocet 1 endodan 1 eth-oxydose 1 EXALGO hydromorphone 3 [QLL,

60/30][ST] fentanyl 1 fentanyl citrate injection [INJ] 1 fentanyl citrate loz 4 [PAR][QLL,

120/30] FENTORA fentanyl citrate 4 [PAR][QLL,

112/28] hydromorphone hcl injection [INJ] 1 hydromorphone hcl suppository

rectal, -tablet 1

INFUMORPH [INJ] morphine 3 KADIAN morphine 3 [QLL,

90/30][ST] levorphanol tartrate tablet 1 MAGNACET oxycodone/acetaminophen 3 meperidine hcl injection [INJ] 1 methadone hcl injection [INJ] 1 methadone hcl solution, -tablet, -

tablet soluble 1

methadone intensol 1 methadose 1 morphine sulfate in dextrose [INJ] 1 morphine sulfate injection [INJ] 1 morphine sulfate solution, -

suppository rectal, -tablet 1

morphine sulfate tablet sustained action

1 [QLL, 120/30]


Drug Generic Tier Restrictions MS CONTIN [G] morphine 3 [QLL,

120/30][ST] NUCYNTA tapentadol hcl 3 [QLL,

205/34] NUMORPHAN [INJ] oxymorphone 2 ONSOLIS [LA] fentanyl citrate 4 [PAR][QLL,

120/30] OPANA oxymorphone 3 OPANA ER oxymorphone 2 [QLL,

90/30][ST] OPIUM opium 3 ORAMORPH SR morphine 3 [QLL,

120/30][ST] oxycodone hcl 1 oxycodone hcl-acetaminophen 1 oxycodone hcl-ibuprofen 1 oxycodone-acetaminophen 1 oxycodone-aspirin 1 OXYCONTIN [G] oxycodone 2 [QLL,

90/30][ST] PERCOCET [G] oxycodone/acetaminophen 3 PERCODAN [G] oxycodone/aspirin 3 PRIMALEV oxycodone/acetaminophen 3 PRIMLEV oxycodone/acetaminophen 3 ROXANOL morphine 3 ROXICET SOLUTION oxycodone/acetaminophen 3 roxicet tablet 1 ROXICODONE [G] oxycodone 3 ROXICODONE INTENSOL oxycodone 3 sublimaze [INJ] 1 TYLOX oxycodone/acetaminophen 3 XOLOX oxycodone/acetaminophen 3 CLASS III NARCOTICS acetaminophen-codeine 1 apap-caffeine-dihydrocodeine 1 buprenorphine hcl tablet sublingual 1 CAPITAL W-CODEINE codeine phosphate/apap 2 co-gesic 1 DOLOREX FORTE [INJ] hydrocodone bitartrate/apap 3


Drug Generic Tier Restrictions HYCET hydrocodone bitartrate/apap 3 hydrocodone bit-ibuprofen 1 hydrocodone-acetaminophen 1 hydrogesic 1 IBUDONE hydrocodone bitartrate/ibuprof 3 LORCET 10-650 [G] hydrocodone bitartrate/apap 3 LORCET PLUS [G] hydrocodone bitartrate/apap 3 LORTAB [G] hydrocodone bitartrate/apap 3 margesic h 1 MAXIDONE [G] hydrocodone bitartrate/apap 3 NORCO [G] hydrocodone bitartrate/apap 3 PANLOR DC dihydrocodeine/apap/caffeine 3 PANLOR SS [G] dihydrocodeine/apap/caffeine 3 POLYGESIC [INJ] hydrocodone bitartrate/apap 3 reprexain 1 stagesic 1 SUBOXONE buprenorphine/naloxone 2 [QLL,

102/34] SUBUTEX [G] buprenorphine 3 SYNALGOS-DC dihydrocodeine/asa/caffeine 3 trezix 1 TYLENOL-CODEINE NO.3 [G] codeine phosphate/apap 3 TYLENOL-CODEINE NO.4 [G] codeine phosphate/apap 3 VICODIN [G] hydrocodone bitartrate/apap 3 VICODIN ES [G] hydrocodone bitartrate/apap 3 VICODIN HP [G] hydrocodone bitartrate/apap 3 VICOPROFEN [G] hydrocodone bitartrate/ibuprof 3 VOPAC codeine phosphate/apap 3 XODOL 10-300 hydrocodone bitartrate/apap 3 XODOL 5-300 hydrocodone bitartrate/apap 3 XODOL 7.5-300 hydrocodone bitartrate/apap 3 zamicet 1 ZERLOR [G] dihydrocodeine/apap/caffeine 3 ZYDONE hydrocodone bitartrate/apap 3 CNS STIMULANT DRUGS ADDERALL [G] amphetamine/dextroamphetamine 3 ADDERALL XR amphetamine/dextroamphetamine 3 amphetamine salt combo 1


Drug Generic Tier Restrictions CAFCIT INJECTION [INJ] caffeine citrated 3 caffeine citrate injection [INJ] 1 CONCERTA methylphenidate 2 DAYTRANA methylphenidate 3 DESOXYN [G] methamphetamine 3 DEXEDRINE [G] d-amphetamine 3 dexmethylphenidate hcl 1 dextroamphetamine sulfate 1 dextroamphetamine-amphetamine 1 FOCALIN [G] dexmethylphenidate 3 FOCALIN XR dexmethylphenidate 3 liquadd 1 METADATE CD methylphenidate 2 METADATE ER 10 MG TABLET SA methylphenidate 2 metadate er 20 mg tablet 1 methamphetamine hcl 1 METHYLIN 10 MG CHEWABLE

TABLET, -2.5 MG CHEWABLE TAB, -5 MG CHEWABLE TABLET, -SOLUTION

methylphenidate 3

methylin 10 mg tablet, -20 mg tablet, -5 mg tablet

1

methylin er 1 methylphenidate er 1 methylphenidate hcl solution, -tablet 1 methylphenidate sr 1 NUVIGIL armodafinil 3 [PAR] PROCENTRA d-amphetamine 3 PROVIGIL modafinil 2 [PAR] RITALIN [G] methylphenidate 3 RITALIN LA methylphenidate 3 RITALIN-SR [G] methylphenidate 3 VYVANSE lisdexamfetamine dimesylate 3 DRUGS TO PREVENT AND TREAT HEADACHES AMERGE [G] naratriptan 3 [QLL,

18/28] ascomp with codeine 1 AXERT 12.5 MG TABLET almotriptan 3 [QLL,

24/28]


Drug Generic Tier Restrictions AXERT 6.25 MG TABLET almotriptan 3 [QLL,

18/28] butalbital compound-codeine 1 butalbital-caff-apap-codeine 1 butorphanol tartrate aerosol spray 1 [QLL, 5

ml/3] CAFERGOT [G] ergotamine tartrate/caffeine 3 D.H.E.45 [INJ][G] dihydroergotamine 4 dihydroergotamine mesylate

injection [INJ] 1

EQUAGESIC aspirin/meprobamate 3 ERGOMAR ergotamine 3 ergotamine-caffeine 1 FIORICET WITH CODEINE [G] codeine/apap/caffeine/butalb 3 FIORINAL WITH CODEINE #3 [G] codeine/asa/caffeine/butalb 3 FROVA frovatriptan 2 [QLL,

27/28] IMITREX 20 MG NASAL SPRAY sumatriptan 3 [QLL, 18

nasal sprayers/28]

IMITREX 4 MG/0.5 ML SYRNG KIT, -6 MG/0.5 ML SYRNG KIT [INJ]

sumatriptan 3 [QLL, 8/28]

IMITREX 5 MG NASAL SPRAY sumatriptan 3 [QLL, 36 nasal sprayers/28]

IMITREX 6 MG/0.5 ML VIAL, -4 MG/0.5 ML KIT REFILL, -6 MG/0.5 ML KIT REFILL [INJ][G]

sumatriptan 3 [QLL, 8 vials/28]

IMITREX TABLET [G] sumatriptan 3 [QLL, 18/28]

MAXALT rizatriptan benzoate 2 [QLL, 27/28]

MAXALT MLT rizatriptan benzoate 2 [QLL, 27/28]

migergot 1 MIGRANAL dihydroergotamine 2 [QLL, 16

mg/28] naratriptan hcl 1 [QLL,

18/28] RELPAX eletriptan 3 [QLL,

18/28]


Drug Generic Tier Restrictions SUMATRIPTAN 20 MG NASAL SPRAY sumatriptan 3 [QLL,

18/28] sumatriptan 4 mg/0.5 ml kit, -4

mg/0.5 ml refill, -4 mg/0.5 ml syrng, -6 mg/0.5 ml kit, -6 mg/0.5 ml refill, -6 mg/0.5 ml syrng [INJ]

1 [QLL, 8/28]

sumatriptan 4 mg/0.5 ml vial, -6 mg/0.5 ml vial [INJ]

1 [QLL, 8 ml/28]

SUMATRIPTAN 5 MG NASAL SPRAY sumatriptan 3 [QLL, 36/28]

sumatriptan succinate tablet 1 [QLL, 18/28]

SUMAVEL DOSEPRO [INJ] sumatriptan 3 [QLL, 18 devices/28]

TREXIMET sumatriptan suc/naproxen sod 3 [QLL, 18/28]

ZOMIG SPRAY NON-AEROSOL zolmitriptan 2 [QLL, 18 nasal sprayers/28]

ZOMIG TABLET zolmitriptan 3 [QLL, 18/28]

ZOMIG ZMT zolmitriptan 3 [QLL, 18/28]

HYDANTOINS CEREBYX [INJ] fosphenytoin 3 DILANTIN 100 MG CAPSULE [G] phenytoin sodium 3 DILANTIN 30 MG CAPSULE, -30 MG

KAPSEAL, -TABLET CHEWABLE phenytoin 2

DILANTIN-125 [G] phenytoin sodium 3 fosphenytoin sodium [INJ] 1 PEGANONE ethotoin 2 PHENYTEK [G] phenytoin sodium 3 phenytoin sodium extended 1 phenytoin sodium injection [INJ] 1 phenytoin suspension oral 1 MAO INHIBITORS EMSAM selegiline 2


Drug Generic Tier Restrictions MARPLAN isocarboxazid 2 NARDIL phenelzine 2 PARNATE tranylcypromine 3 tranylcypromine sulfate 1 OTHER ANTICONVULSANTS BANZEL 200 MG TABLET rufinamide 2 BANZEL 400 MG TABLET rufinamide 4 FELBATOL felbamate 2 gabapentin capsule, -tablet 1 GABITRIL tiagabine 2 KEPPRA INJECTION [INJ][G] levetiracetam 2 KEPPRA SOLUTION, -TABLET [G] levetiracetam 3 [ST] KEPPRA XR levetiracetam 3 [ST] LAMICTAL [G] lamotrigine 3 [ST] LAMICTAL (BLUE) lamotrigine 3 [ST] LAMICTAL (GREEN) [G] lamotrigine 3 [ST] LAMICTAL (ORANGE) [G] lamotrigine 3 [ST] LAMICTAL ODT lamotrigine 3 [ST] LAMICTAL ODT (BLUE) lamotrigine 3 [ST] LAMICTAL ODT (GREEN) lamotrigine 3 [ST] LAMICTAL ODT (ORANGE) lamotrigine 3 [ST] LAMICTAL XR lamotrigine 3 [ST] LAMICTAL XR (BLUE) lamotrigine 3 [ST] LAMICTAL XR (GREEN) lamotrigine 3 [ST] LAMICTAL XR (ORANGE) lamotrigine 3 [ST] lamotrigine 1 levetiracetam injection [INJ] 1 levetiracetam solution, -tablet 1 LYRICA pregabalin 2 [ST] MYSOLINE [G] primidone 3 NEURONTIN CAPSULE, -TABLET [G] gabapentin 3 NEURONTIN SOLUTION gabapentin 2 primidone 1 SABRIL [LA] vigabatrin 4 TOPAMAX [G] topiramate 3 [PAR] topiragen 1 [PAR] topiramate capsule sprinkle, -tablet 1 [PAR] VIMPAT INJECTION [INJ] lacosamide 2


Drug Generic Tier Restrictions VIMPAT SOLUTION, -TABLET lacosamide 2 ZONEGRAN [G] zonisamide 3 [PAR] zonisamide 1 [PAR] OTHER ANTIDEPRESSANTS amitriptyline-chlordiazepoxide 1 APLENZIN bupropion hbr 3 [QLL,

34/34][ST] budeprion sr 1 [QLL,

68/34] budeprion xl 1 [QLL,

34/34] bupropion hcl 1 bupropion hcl sr 100 mg tab, -100

mg tablet, -200 mg tab 1 [QLL,

68/34] bupropion sr 150 mg tablet 1 bupropion xl 1 [QLL,

34/34] CYMBALTA 20 MG CAPSULE, -60 MG

CAPSULE duloxetine 2 [QLL,

68/34][ST] CYMBALTA 30 MG CAPSULE duloxetine 2 [QLL,

34/34][ST] EFFEXOR venlafaxine 3 [QLL,

102/34][ST] EFFEXOR XR 150 MG CAPSULE, -

37.5 MG CAPSULE [G] venlafaxine 2 [QLL,

34/34][ST] EFFEXOR XR 75 MG CAPSULE [G] venlafaxine 2 [QLL,

102/34][ST] LIMBITROL amitriptyline/chlordiazepoxide 3 maprotiline hcl 1 mirtazapine 1 nefazodone hcl 1 OLEPTRO ER trazodone 3 perphenazine-amitriptyline 1 PRISTIQ desvenlafaxine succinate 2 [QLL,

34/34][ST] REMERON [G] mirtazapine 3 SAVELLA 100 MG TABLET, -12.5 MG

TABLET, -25 MG TABLET, -50 MG TABLET

milnacipran hcl 2 [QLL, 68/34][ST]


Drug Generic Tier Restrictions SAVELLA TITRATION PACK milnacipran hcl 2 [QLL,

1/34][ST] trazodone hcl tablet 1 venlafaxine hcl 1 [QLL,

102/34] venlafaxine hcl er capsule sustained

release 24 hr 1 [QLL,

34/34] VENLAFAXINE HCL ER TAB SA venlafaxine 3 [QLL,

34/34][ST] WELLBUTRIN bupropion 3 WELLBUTRIN SR [G] bupropion 3 [QLL,

68/34][ST] WELLBUTRIN XL [G] bupropion 3 [QLL,

34/34][ST] OTHER ANTIPARKINSON DRUGS APOKYN [INJ][LA] apomorphine hcl 4 AZILECT rasagiline mesylate 2 bromocriptine mesylate capsule, -

tablet 1

carbidopa-levodopa 1 COMTAN entacapone 2 ELDEPRYL selegiline 3 LODOSYN carbidopa 2 MIRAPEX [G] pramipexole 3 MIRAPEX ER pramipexole 3 PARCOPA [G] carbidopa/levodopa 3 PARLODEL [G] bromocriptine mesylate 3 pramipexole dihydrochloride 1 REQUIP [G] ropinirole 3 REQUIP XL ropinirole 2 ropinirole hcl 1 selegiline hcl capsule, -tablet 1 SINEMET 10-100 [G] carbidopa/levodopa 3 SINEMET 25-100 [G] carbidopa/levodopa 3 SINEMET 25-250 [G] carbidopa/levodopa 3 SINEMET CR [G] carbidopa/levodopa 3 STALEVO 100 carbidopa/levodopa/entacap 2 STALEVO 125 carbidopa/levodopa/entacap 2 STALEVO 150 carbidopa/levodopa/entacap 2


Drug Generic Tier Restrictions STALEVO 200 carbidopa/levodopa/entacap 2 STALEVO 50 carbidopa/levodopa/entacap 2 STALEVO 75 carbidopa/levodopa/entacap 2 TASMAR tolcapone 2 ZELAPAR selegiline 3 OTHER CNS/AUTONOMIC DRUGS ANTABUSE disulfiram 2 atropine sulfate injection [INJ] 1 CAMPRAL acamprosate calcium 3 depade 1 ENLON [INJ] edrophonium 2 ENLON-PLUS [INJ] edrophonium/atropine sulfate 2 flumazenil [INJ] 1 guanidine hcl 1 INTUNIV guanfacine 3 [ST] MESTINON SYRUP, -TABLET

SUSTAINED ACTION pyridostigmine 2

MESTINON TABLET [G] pyridostigmine 3 MYTELASE ambenonium chloride 3 naloxone hcl injection [INJ] 1 naltrexone hcl tablet 1 neostigmine methylsulfate [INJ] 1 physostigmine salicylate injection

[INJ] 1

PROSTIGMIN neostigmine bromide 2 pyridostigmine bromide 1 REGONOL [INJ] pyridostigmine 3 REVIA [G] naltrexone 3 ROMAZICON [INJ] flumazenil 3 STRATTERA atomoxetine 2 [ST] VIVITROL [INJ] naltrexone microspheres 4 XENAZINE [LA] tetrabenazine 4 [PAR] XYREM [LA] sodium oxybate 4 SECONDARY AMINES amoxapine 1 desipramine hcl 1


Drug Generic Tier Restrictions NORPRAMIN [G] desipramine 3 nortriptyline hcl capsule, -solution 1 PAMELOR [G] nortriptyline 3 protriptyline hcl 1 VIVACTIL [G] protriptyline 3 SEDATIVE/HYPNOTIC DRUGS AMBIEN [G] zolpidem 3 [QLL,

34/34][ST] AMBIEN CR zolpidem 2 [QLL,

34/34][ST] EDLUAR zolpidem 3 [QLL,

34/34][ST] LUNESTA eszopiclone 2 [QLL,

34/34][ST] ROZEREM ramelteon 2 [QLL,

34/34][ST] SONATA 10 MG CAPSULE [G] zaleplon 3 [QLL,

68/34][ST] SONATA 5 MG CAPSULE [G] zaleplon 3 [QLL,

34/34][ST] zaleplon 10 mg capsule 1 [QLL,

68/34] zaleplon 5 mg capsule 1 [QLL,

34/34] zolpidem tartrate 1 [QLL,

34/34] SELECTIVE SEROTONIN REUPTAKE INHIBITORS CELEXA SOLUTION citalopram 3 [ST] CELEXA TABLET [G] citalopram 3 [QLL,

34/34][ST] citalopram 1 citalopram hbr 1 [QLL,

34/34] fluoxetine dr 1 [QLL, 5/34] fluoxetine hcl 10 mg capsule, -10

mg tablet 1 [QLL,

34/34]


Drug Generic Tier Restrictions fluoxetine hcl 20 mg capsule, -20

mg tablet, -solution 1

fluoxetine hcl 40 mg capsule 1 [QLL, 68/34]

fluvoxamine maleate 100 mg tab 1 [QLL, 102/34]



LEXAPRO SOLUTION escitalopram oxalate 2 [ST] LEXAPRO TABLET escitalopram oxalate 2 [QLL,

34/34][ST] LUVOX CR fluvoxamine 3 [QLL,

68/34][ST] paroxetine hcl 10 mg tablet, -40 mg

tablet 1 [QLL,

34/34] paroxetine hcl 20 mg tablet, -30 mg

tablet, -tablet sustained release 24hr 1 [QLL,

68/34] paroxetine hcl suspension oral 1 PAXIL 10 MG TABLET, -40 MG

TABLET [G] paroxetine 3 [QLL,

34/34][ST] PAXIL 20 MG TABLET, -30 MG

TABLET [G] paroxetine 3 [QLL,

68/34][ST] PAXIL CR [G] paroxetine 3 [QLL,

68/34][ST] PAXIL SUSPENSION ORAL [G] paroxetine 3 [ST] PEXEVA 10 MG TABLET, -40 MG

TABLET paroxetine mesylate 3 [QLL,

34/34][ST] PEXEVA 20 MG TABLET, -30 MG

TABLET paroxetine mesylate 3 [QLL,

68/34][ST] PROZAC 10 MG PULVULE [G] fluoxetine 3 [QLL,

34/34][ST] PROZAC 20 MG PULVULE, -

SOLUTION [G] fluoxetine 3 [ST]

PROZAC 40 MG PULVULE [G] fluoxetine 3 [QLL, 68/34][ST]

PROZAC WEEKLY [G] fluoxetine 3 [QLL, 5/34][ST]

rapiflux 20 mg tablet 1 SARAFEM 10 MG TABLET fluoxetine 3 [QLL,

35/14][ST]


Drug Generic Tier Restrictions SARAFEM 15 MG TABLET fluoxetine 3 [ST] SARAFEM 20 MG TABLET fluoxetine 3 [QLL,

140/14][ST] selfemra 10 mg capsule 1 [QLL,

35/14] selfemra 20 mg capsule 1 [QLL,

140/14] sertraline hcl 100 mg tablet, -50 mg

tablet 1 [QLL,

68/34] sertraline hcl 25 mg tablet 1 [QLL,

34/34] sertraline hcl solution 1 ZOLOFT 100 MG TABLET, -50 MG

TABLET [G] sertraline 3 [QLL,

68/34][ST] ZOLOFT 25 MG TABLET [G] sertraline 3 [QLL,

34/34][ST] ZOLOFT SOLUTION [G] sertraline 3 [ST] SMOKING CESSATION PRODUCTS buproban 1 CHANTIX varenicline tartrate 2 NICOTROL nicotine inhaler 2 NICOTROL NS nicotine ns 2 ZYBAN [G] bupropion 3 SUCCINIMIDES CELONTIN methsuximide 2 ethosuximide 1 ZARONTIN [G] ethosuximide 3 TERTIARY AMINES amitriptyline hcl tablet 1 ANAFRANIL [G] clomipramine 3 clomipramine hcl capsule 1 doxepin hcl capsule, -solution 1 imipramine hcl tablet 1 imipramine pamoate 1 SURMONTIL trimipramine 2


Drug Generic Tier Restrictions TOFRANIL [G] imipramine hcl 3 TOFRANIL-PM [G] imipramine pamoate 3 trimipramine maleate 1 VALPROIC ACID AND DERIVATIVES DEPACON [INJ][G] valproate sodium 3 DEPAKENE [G] valproic acid 3 [ST] DEPAKOTE [G] divalproex 3 [ST] DEPAKOTE ER [G] divalproex 3 [ST] DEPAKOTE SPRINKLE [G] divalproex 3 [ST] divalproex sodium 1 divalproex sodium er 1 STAVZOR valproic acid 3 [ST] valproate sodium injection [INJ] 1 valproic acid capsule, -syrup 1 CARDIOVASCULAR MEDICATIONS AMIODARONES amiodarone hcl injection [INJ] 1 amiodarone hcl tablet 1 CORDARONE [G] amiodarone 3 PACERONE 100 MG TABLET, -400

MG TABLET [G] amiodarone 3

pacerone 200 mg tablet 1 ANGIOTENSIN CONVERTING ENZYME INHIBITORS ACCUPRIL [G] quinapril 3 [ST] ACEON [G] perindopril erbumine 3 [ST] ALTACE [G] ramipril 3 [ST] benazepril hcl 1 CAPOTEN captopril 3 [ST] captopril tablet 1 enalapril maleate tablet 1 enalaprilat [INJ] 1 fosinopril sodium 1 lisinopril tablet 1 LOTENSIN [G] benazepril 3 [ST]


Drug Generic Tier Restrictions MAVIK [G] trandolapril 3 [ST] moexipril hcl 1 MONOPRIL fosinopril 3 [ST] perindopril erbumine 1 PRINIVIL [G] lisinopril 3 [ST] quinapril hcl 1 ramipril 1 trandolapril 1 UNIVASC [G] moexipril 3 [ST] VASOTEC [G] enalapril 3 [ST] ZESTRIL [G] lisinopril 3 [ST] ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND candesartan cilexetil 3 [ST] AVAPRO irbesartan 3 [ST] BENICAR olmesartan medoxomil 2 [ST] COZAAR [G] losartan 3 [ST] DIOVAN valsartan 2 [ST] losartan potassium 1 [ST] MICARDIS telmisartan 3 [ST] TEVETEN eprosartan mesylate 3 [ST] ANTIDYSRHYTHMIC DRUGS flecainide acetate 1 mexiletine hcl capsule 1 procainamide hcl injection [INJ] 1 PRONESTYL procainamide 3 propafenone hcl 1 quinidine gluconate injection [INJ] 1 quinidine gluconate tablet sustained

action 1

quinidine sulfate tablet, -tablet sustained action

1

RYTHMOL [G] propafenone 3 RYTHMOL SR propafenone 2 TAMBOCOR [G] flecainide 3


Drug Generic Tier Restrictions BETA-ADRENERGIC ANTAGONIST DRUGS acebutolol hcl capsule 1 atenolol tablet 1 betaxolol hcl tablet 1 bisoprolol fumarate 1 BYSTOLIC nebivolol hcl 2 carvedilol 1 COREG [G] carvedilol 3 COREG CR carvedilol 2 CORGARD [G] nadolol 3 INDERAL LA [G] propranolol 3 INNOPRAN XL propranolol 3 KERLONE [G] betaxolol 3 labetalol hcl injection [INJ] 1 labetalol hcl tablet 1 LEVATOL penbutolol 3 LOPRESSOR INJECTION [INJ][G] metoprolol tartrate 3 LOPRESSOR TABLET [G] metoprolol tartrate 3 metoprolol succinate 1 metoprolol tartrate injection [INJ] 1 metoprolol tartrate tablet 1 nadolol 1 pindolol 1 propranolol hcl cap sa, -solution, -

tablet 1

propranolol hcl injection [INJ] 1 SECTRAL [G] acebutolol 3 TENORMIN [G] atenolol 3 timolol maleate tablet 1 TOPROL XL [G] metoprolol succinate 3 TRANDATE [G] labetalol 3 ZEBETA [G] bisoprolol 3 CALCIUM ANTAGONISTS ADALAT CC [G] nifedipine 3 [ST] afeditab cr 1 amlodipine besylate 1 CALAN [G] verapamil 3 [ST]


Drug Generic Tier Restrictions CALAN SR [G] verapamil 3 [ST] CARDENE I.V. [INJ] nicardipine 3 CARDENE SR nicardipine 3 [ST] CARDIZEM [G] diltiazem 3 CARDIZEM CD [G] diltiazem 3 CARDIZEM LA diltiazem 3 cartia xt 1 COVERA-HS verapamil 3 [ST] DILACOR XR [G] diltiazem 3 dilt-cd 1 diltia xt 1 diltiazem 24hr er 1 diltiazem er 1 diltiazem hcl injection [INJ] 1 diltiazem hcl tablet 1 dilt-xr 1 diltzac er 1 DYNACIRC CR isradipine 3 [ST] felodipine er 1 ISOPTIN SR [G] verapamil 3 [ST] isradipine 1 nicardipine hcl capsule 1 nicardipine hcl injection [INJ] 1 nifediac cc 1 nifedical xl 1 nifedipine capsule 1 nifedipine er 1 nimodipine 4 NIMOTOP [INJ] nimodipine 3 NISOLDIPINE ER 17 MG TABLET, -

ER 25.5 MG TABLET, -ER 34 MG TABLET, -ER 8.5 MG TABLET

nisoldipine 3 [ST]

nisoldipine er 20 mg tablet, -er 30 mg tablet, -er 40 mg tablet

1

NORVASC [G] amlodipine 3 [ST] PROCARDIA [G] nifedipine 3 [ST] PROCARDIA XL [G] nifedipine 3 [ST] SULAR nisoldipine 3 [ST] taztia xt 1 TIAZAC [G] diltiazem 3


Drug Generic Tier Restrictions verapamil 360 mg cap pellet 1 verapamil er 1 verapamil hcl capsule 24hr sustained

release pellets, -er 120 mg capsule, -er 180 mg capsule, -er 240 mg capsule, -tablet, -tablet sustained action

1

verapamil hcl injection [INJ] 1 VERELAN [G] verapamil 3 [ST] VERELAN PM [G] verapamil 3 [ST] CARDIAC GLYCOSIDES digoxin injection [INJ] 1 digoxin solution, -tablet 1 LANOXIN INJECTION [INJ][G] digoxin 3 LANOXIN PEDIATRIC [INJ] digoxin 2 LANOXIN TABLET [G] digoxin 3 milrinone in 5% dextrose [INJ] 1 milrinone lactate [INJ] 1 CENTRALLY ACTING ANTIHYPERTENSIVES CATAPRES [G] clonidine 3 CATAPRES-TTS 1 [G] clonidine 3 [QLL, 5/35] CATAPRES-TTS 2 [G] clonidine 3 [QLL, 5/35] CATAPRES-TTS 3 [G] clonidine 3 [QLL, 5/35] clonidine 1 [QLL, 5/35] clonidine hcl injection [INJ] 1 clonidine hcl tablet 1 DURACLON [INJ] clonidine 3 guanabenz acetate 1 guanfacine hcl 1 methyldopa 1 methyldopate hcl [INJ] 1 TENEX [G] guanfacine 3 DRUGS FOR PHEOCHROMOCYTOMA DEMSER metyrosine 2


Drug Generic Tier Restrictions DIBENZYLINE phenoxybenzamine 2 PHENTOLAMINE MESYLATE

INJECTION [INJ] phentolamine 2

ENDOTHELIN RECPTR ANTAGONIST LETAIRIS [LA] ambrisentan 4 [PAR] TRACLEER [LA] bosentan 4 [PAR] HMG-COA REDUCTASE INHIBITORS ADVICOR 1,000 MG-20 MG TABLET,

-1,000 MG-40 MG TABLET, -750 MG-20 MG TABLET

lovastatin/niacin 2 [QLL, 68/34]

ADVICOR 500 MG-20 MG TABLET lovastatin/niacin 2 [QLL, 34/34]

ALTOPREV lovastatin 3 [QLL, 34/34][ST]

CADUET amlodipine/atorvast cal 3 [QLL, 34/34][ST]

CRESTOR 10 MG TABLET, -20 MG TABLET, -40 MG TABLET

rosuvastatin calcium 2 [QLL, 34/34]

CRESTOR 5 MG TABLET rosuvastatin calcium 2 [QLL, 34/34][ST]

LESCOL 20 MG CAPSULE fluvastatin 3 [QLL, 34/34][ST]

LESCOL 40 MG CAPSULE fluvastatin 3 [QLL, 68/34][ST]

LESCOL XL fluvastatin 3 [QLL, 34/34][ST]

LIPITOR atorvastatin calcium 3 [QLL, 34/34][ST]

LIVALO pitavastatin calcium 3 [QLL, 34/34][ST]

lovastatin 10 mg tablet 1 [QLL, 34/34]

lovastatin 20 mg tablet, -40 mg tablet

1 [QLL, 68/34]

MEVACOR [G] lovastatin 3 [QLL, 68/34][ST]

PRAVACHOL [G] pravastatin 3 [QLL, 34/34][ST]


Drug Generic Tier Restrictions pravastatin sodium 1 [QLL,

34/34] SIMCOR 1,000-20 MG TABLET, -

750-20 MG TABLET niacin/simvastatin 2 [QLL,

68/34] SIMCOR 500-20 MG TABLET niacin/simvastatin 2 [QLL,

34/34] simvastatin tablet 1 [QLL,

34/34] VYTORIN 10-10 MG TABLET ezetimibe/simvastatin 2 [QLL,

34/34][ST] VYTORIN 10-20 MG TABLET, -10-40

MG TABLET, -10-80 MG TABLET ezetimibe/simvastatin 2 [QLL,

34/34] ZOCOR [G] simvastatin 3 [QLL,

34/34][ST] HYPOLIPOPROTEINEMICS ANTARA fenofibrate 3 [ST] cholestyramine 1 cholestyramine light 1 COLESTID [G] colestipol 3 colestipol hcl 1 fenofibrate 1 FENOFIBRIC ACID fenofibric acid 3 [ST] FENOGLIDE fenofibrate 3 [ST] FIBRICOR fenofibric acid 3 [ST] gemfibrozil 1 LIPOFEN fenofibrate 3 [ST] LOFIBRA [G] fenofibrate 3 [ST] LOPID [G] gemfibrozil 3 LOVAZA omega-3 acid ethyl esters 2 NIACOR niacin 3 NIASPAN niacin 2 prevalite 1 QUESTRAN [G] cholestyramine/sucrose 3 QUESTRAN LIGHT [G] cholestyramine/aspartame 3 TRICOR fenofibrate 2 [ST] TRIGLIDE fenofibrate 3 [ST] TRILIPIX fenofibric acid 2 [ST] WELCHOL colesevelam 2 [ST] ZETIA ezetimibe 2 [ST]


Drug Generic Tier Restrictions LOOP DIURETICS bumetanide injection [INJ] 1 bumetanide tablet 1 DEMADEX [G] torsemide 3 EDECRIN ethacrynic acid 3 furosemide injection [INJ] 1 furosemide solution, -tablet 1 LASIX [G] furosemide 3 SODIUM EDECRIN [INJ] ethacrynate sodium 3 torsemide injection [INJ] 1 torsemide tablet 1 NITRATES DILATRATE-SR isosorbide dinitrate 2 IMDUR [G] isosorbide mononitrate 3 ISMO [G] isosorbide mononitrate 3 ISOCHRON [G] isosorbide dinitrate 3 ISORDIL isosorbide dinitrate 3 ISORDIL TITRADOSE [G] isosorbide dinitrate 3 isosorbide dinitrate 1 isosorbide mononitrate 1 MINITRAN [G] nitroglycerin 3 MONOKET [G] isosorbide mononitrate 3 nitro-bid 1 NITRO-DUR [G] nitroglycerin 3 nitroglycerin in d5w [INJ] 1 nitroglycerin injection [INJ] 1 nitroglycerin patch 1 nitroglycerin tablet sublingual 1 NITROLINGUAL nitroglycerin 2 NITROMIST nitroglycerin 3 nitroquick 1 NITROSTAT nitroglycerin 2 OTHER ANTIARRHYTHMICS BETAPACE [G] sotalol 3


Drug Generic Tier Restrictions BETAPACE AF [G] sotalol 3 CORVERT [INJ] ibutilide fumarate 3 ibutilide fumarate [INJ] 1 lidocaine hcl 10% vial [INJ] 1 MULTAQ dronedarone 3 sorine 1 sotalol 1 sotalol af 1 SOTALOL HCL [INJ] sotalol 3 TIKOSYN dofetilide 2 OTHER ANTIHYPERTENSIVES ACCURETIC [G] quinapril/hctz 3 [ST] amlodipine besylate-benazepril 1 ATACAND HCT candesartan cilexetil/hctz 3 [ST] atenolol-chlorthalidone 1 AVALIDE irbesartan/hctz 3 [ST] AZOR amlodipine bes/olmesartan med 2 [ST] benazepril hcl-hctz 1 benazepril-hydrochlorothiazide 1 BENICAR HCT olmesartan medoxomil/hctz 2 [ST] bisoprolol fumarate-hctz 1 bisoprolol-hydrochlorothiazide 1 captopril-hydrochlorothiazide 1 CLORPRES clonidine hcl/chlorthalidone 2 CORLOPAM [INJ] fenoldopam mesylate 3 CORZIDE [G] bendroflumethiazide/nadolol 3 DIOVAN HCT hctz/valsartan 2 [ST] enalapril-hydrochlorothiazide 1 EXFORGE amlodipine/valsartan 2 [ST] EXFORGE HCT amlodipine/valsartan/hctz 2 [ST] fosinopril-hydrochlorothiazide 1 hydra-zide 1 HYZAAR [G] losartan /hctz 3 [ST] INVERSINE mecamylamine 3 lisinopril-hctz 1 lisinopril-hydrochlorothiazide 1 LOPRESSOR HCT [G] hctz/metoprolol 3 losartan-hydrochlorothiazide 1 [ST]


Drug Generic Tier Restrictions LOTENSIN HCT [G] benazepril/hctz 3 [ST] LOTREL [G] benazepril/amlodipine besylate 3 [ST] methyldopa-hydrochlorothiazide 1 metoprolol-hydrochlorothiazide 1 MICARDIS HCT telmisartan/hctz 3 [ST] moexipril-hydrochlorothiazide 1 nadolol-bendroflumethiazide 1 PRINZIDE [G] lisinopril/hctz 3 [ST] propranolol-hydrochlorothiazid 1 quinapril-hydrochlorothiazide 1 quinaretic 1 reserpine 1 TARKA [G] trandolapril/verapamil 3 [ST] TEKTURNA aliskiren hemifumarate 2 [ST] TEKTURNA HCT aliskiren/hydrochlorothiazid 2 [ST] TENORETIC 100 [G] chlorthalidone/atenolol 3 TENORETIC 50 [G] chlorthalidone/atenolol 3 TEVETEN HCT eprosartan mesylate/hctz 3 [ST] trandolapril-verapamil 1 TRIBENZOR olmesartan med/amlodipine/hct 3 [ST] TWYNSTA telmisartan/amlodipine 3 [ST] UNIRETIC [G] moexipril/hctz 3 [ST] VALTURNA aliskiren/valsartan 3 [ST] VASERETIC [G] enalapril maleate/hctz 3 [ST] ZESTORETIC [G] lisinopril/hctz 3 [ST] ZIAC [G] hctz/bisoprolol fumarate 3 OTHER CARDIOVASCULAR DRUGS alprostadil injection [INJ] 1 dobutamine hcl [INJ] 1 dobutamine hcl in dextrose [INJ] 1 dopamine hcl [INJ] 1 dopamine hcl in 5% dextrose [INJ] 1 isoproterenol hcl [INJ] 1 ISUPREL [INJ] isoproterenol hcl 3 midodrine hcl 1 norepinephrine bitartrate [INJ] 1 pentopak 1 pentoxifylline tablet sustained action 1


Drug Generic Tier Restrictions pentoxil 1 PROAMATINE [G] midodrine 3 PROSTIN VR PEDIATRIC [INJ] alprostadil 3 RANEXA ranolazine 2 RETAVASE [INJ] reteplase 3 TRENTAL [G] pentoxifylline 3 OTHER VASODILATING DRUGS ADCIRCA adcirca (tadalafil) 4 [PAR][QLL,

68/34] BIDIL isosorb dinit/hydralazine hcl 3 epoprostenol sodium [INJ] 1 FLOLAN [INJ] epoprostenol na 3 NATRECOR [INJ] nesiritide 3 REMODULIN [INJ][LA] treprostinil sodium 4 REVATIO INJECTION [INJ] revatio (sildenafil citrate) 4 REVATIO TABLET revatio (sildenafil citrate) 4 [PAR][QLL,

102/34] POTASSIUM SPARING DIURETICS ALDACTAZIDE [G] spironolactone/hctz 3 ALDACTONE [G] spironolactone 3 amiloride hcl tablet 1 amiloride-hydrochlorothiazide 1 DYAZIDE [G] hctz/triamterene 3 DYRENIUM triamterene 3 eplerenone 1 INSPRA [G] eplerenone 3 MAXZIDE [G] hctz/triamterene 3 MAXZIDE-25 MG [G] hctz/triamterene 3 MIDAMOR amiloride hydrochloride 3 spironolactone tablet 1 spironolactone-hctz 1 triamterene-hctz 1 THIAZIDE AND RELATED DRUGS chlorothiazide 1


Drug Generic Tier Restrictions chlorothiazide sodium [INJ] 4 chlorthalidone 1 DIURIL chlorothiazide 3 DIURIL SODIUM [INJ][G] chlorothiazide sodium 3 hydrochlorothiazide capsule, -tablet 1 indapamide 1 methyclothiazide tablet 1 metolazone 1 MICROZIDE [G] hydrochlorothiazide 3 NATURETIN-5 bendroflumethiazide 3 THALITONE chlorthalidone 3 ZAROXOLYN [G] metolazone 3 VASODILATOR ANTIHYPERTENSIVES CARDURA 1 MG TABLET, -2 MG

TABLET, -4 MG TABLET [G] doxazosin 3 [QLL,

34/34] CARDURA 8 MG TABLET [G] doxazosin 3 [QLL,

68/34] CARDURA XL doxazosin 3 [QLL,

34/34] doxazosin mesylate 1 mg tab, -2 mg

tab, -4 mg tab 1 [QLL,

34/34] doxazosin mesylate 8 mg tab 1 [QLL,

68/34] hydralazine hcl injection [INJ] 1 hydralazine hcl tablet 1 MINIPRESS [G] prazosin 3 minoxidil tablet 1 prazosin hcl 1 terazosin 1 mg capsule, -2 mg

capsule, -5 mg capsule 1 [QLL,

34/34] terazosin 10 mg capsule 1 [QLL,

68/34] DERMATOLOGICAL MEDICATIONS ANTIACNE DRUGS ACANYA clindamycin phos/benz per 3 ACZONE dapsone 3 adapalene 1 [PAR]


Drug Generic Tier Restrictions AKNE-MYCIN erythromycin base 3 ATRALIN tretinoin 3 [PAR] AVAR sulfacetamide/sulfur 3 AVAR LS sulfacetamide/sulfur 3 AVAR-E sulfacetamide/sulfur 3 AVAR-E GREEN sulfacetamide/sulfur 3 AVAR-E LS CREAM sulfacetamide/sulfur 3 AVITA [G] tretinoin 3 [PAR] AZELEX azelaic acid 3 BENZACLIN clindamycin/benz per/hyalur na 3 BENZAMYCIN erythromycin base/benz per 3 BENZAMYCINPAK erythromycin base/benz per 3 bp 10-1 1 CLARIFOAM EF sulfacetamide/sulfur 3 clenia cleanser 1 CLENIA CREAM sulfacetamide/sulfur 3 CLEOCIN T [G] clindamycin phosphate 3 clinda-derm 1 CLINDAGEL clindamycin phosphate 3 CLINDAMAX GEL, -LOTION [INJ] clindamycin phosphate 3 clindamycin phosphate foam, -gel, -

lotion, -solution non-oral, -swab medicated

1

clindamycin-benzoyl peroxide 1 CLINDAREACH clindamycin phosphate 3 CLINDETS [INJ] clindamycin phosphate 3 DEL-MYCIN erythromycin base 3 DIFFERIN [G] adapalene 3 [PAR] DUAC CS clindamycin/benzoyl prx/skn #5 3 EMGEL [INJ] erythromycin base 3 EPIDUO adapalene/benzoyl peroxide 3 [PAR] ery 1 erythromycin gel, -solution non-oral 1 erythromycin-benzoyl peroxide 1 EVOCLIN [G] clindamycin phosphate 3 FINACEA azelaic acid 2 METROCREAM [G] metronidazole 3 METROGEL metronidazole 2 METROLOTION [G] metronidazole 3 metronidazole cream, -gel, -lotion 1


Drug Generic Tier Restrictions NORITATE metronidazole 3 PLEXION sulfacetamide/sulfur 3 prascion 1 prascion fc 1 prascion ts 1 RETIN-A [G] tretinoin 3 [PAR] RETIN-A MICRO tretinoin 3 [PAR] RETIN-A MICRO PUMP tretinoin 3 [PAR] ROSAC sulfacetamide/sulfur 3 rosaderm cleanser 1 sodium sulfacetamide-sulfur

cleanser, -foam, -pads medicated, -sulfacetamide-sulfur lotn, -sulf-sulfur wash, -suspensions, (not oral)

1

sulfatol c 1 sulzee 1 SUMAXIN sulfacetamide/sulfur 3 topisulf 1 tretinoin 0.025% cream, -0.05%

cream, -0.1% cream, -gel 1 [PAR]

TRETIN-X tretinoin/emol cmb9/skin cln1 3 [PAR] vitazol 1 ZETACET sulfacetamide/sulfur 3 ZIANA clindamycin/tretinoin 3 [PAR] ANTIPRURITIC DRUGS hydroxyzine hcl injection [INJ] 1 hydroxyzine hcl syrup, -tablet 1 [PAR] hydroxyzine pamoate capsule 1 [PAR] VISTARIL [G] hydroxyzine pamoate 3 [PAR] ANTIPSORIASIS AND ANTIECZEMA DRUGS 10 wash 1 calcipotriene 1 CARMOL SCALP sulfacetamide sodium 3 DOVONEX CREAM calcipotriene 2 DOVONEX SOLUTION calcipotriene 3 DRITHOCREME HP anthralin 2


Drug Generic Tier Restrictions DRITHO-SCALP anthralin 3 KLARON [G] sulfacetamide sodium 3 OVACE PLUS sulfacetamide sodium 3 PSORIATEC anthralin 3 scalp treatment 1 seb-prev 1 selenium sulfide 2.25% shampoo, -

2.5% lotion, -sulf 2.5% shampoo 1

selenos 1 SELSEB selenium sulfide 3 SORIATANE acitretin 4 SORIATANE CK 10 MG KIT acitretin/emollient comb 2 SORIATANE CK 25 MG KIT acitretin/emollient comb 4 sulfacetamide sodium lotion, -

suspension topical 1

TACLONEX betamet diprop/calcipotriene 3 TACLONEX SCALP betamet diprop/calcipotriene 3 TAZORAC tazarotene 2 [PAR] TERSI FOAM selenium sulfide 3 VECTICAL calcitriol 3 ZITHRANOL-RR anthralin 3 KERATOLYTIC DRUGS CONDYLOX GEL podofilox 2 CONDYLOX SOLUTION NON-ORAL

[G] podofilox 3

podofilox 1 ORAL DERMATOLOGICAL DRUGS 8-MOP methoxsalen 4 ACCUTANE isotretinoin 3 amnesteem 1 claravis 1 OXSORALEN-ULTRA methoxsalen 4 sotret 1


Drug Generic Tier Restrictions SCABICIDES acticin 1 ELIMITE permethrin 3 EURAX crotamiton 2 LINDANE benzene hexachloride gamma 2 malathion 1 OVIDE [G] malathion 3 permethrin cream 1 ULESFIA benzyl alcohol 3 TOPICAL ANTI-INFLAMMATORY DRUGS FLECTOR diclofenac epolamine 2 [QLL,

60/34][ST] PENNSAID diclofenac sodium 3 [ST] VOLTAREN GEL diclofenac sodium 2 [ST] TOPICAL CORTICOSTEROID DRUGS ACLOVATE [G] alclometasone 3 [ST] ALA-CORT [G] hydrocortisone 3 [ST] ALA-SCALP HP hydrocortisone 3 [ST] alclometasone dipropionate 1 amcinonide 1 ANAMANTLE HC CREAM WITH

APPLICATOR, -KIT hc acetate/lidocaine hcl 3

ANAMANTLE HC FORTE hc acetate/lidocaine hcl 3 APEXICON [INJ] diflorasone 3 APEXICON E diflorasone 3 [ST] betamethasone dipropionate cream,

-gel, -lotion, -ointment 1

betamethasone valerate cream, -lotion, -ointment

1

betanate 1 beta-val 1 CAPEX SHAMPOO fluocinolone acetonide 3 CARMOL HC hydrocortisone acetate/urea 3 [ST] clobetasol emollient 1


Drug Generic Tier Restrictions clobetasol propionate cream, -foam,

-gel, -ointment, -solution non-oral 1

CLOBEX clobetasol propionate 3 [ST] CLODERM clocortolone pivalate 3 [ST] CORDRAN LOTION, -OINTMENT flurandrenolide 3 [ST] CORDRAN SP flurandrenolide 3 [ST] CORDRAN TAPE MEDICATED flurandrenolide 3 [QLL, 900

square cm/34][ST]

cormax 1 CUTIVATE [G] fluticasone propionate 3 [ST] del-beta 1 DERMA-SMOOTHE-FS fluocinolone acetonide 3 [ST] DERMATOP [G] prednicarbate 3 [ST] DESONATE desonide 3 [ST] desonide cream, -lotion, -ointment 1 DESOWEN desonide/emollient combo #30 3 [ST] desoximetasone cream, -gel, -

ointment 1

diflorasone diacetate 1 DIPROLENE [G] betameth/propylene glycol 3 [ST] DIPROLENE AF [G] betameth/propylene glycol 3 [ST] DIPROSONE betamethasone dipropionate 3 [ST] ELOCON [G] mometasone 3 [ST] FIRST-HYDROCORTISONE hydrocortisone 3 fluocinolone acetonide cream, -

ointment, -solution non-oral 1

fluocinonide cream, -gel, -ointment, -solution non-oral

1

fluocinonide emollient 1 fluocinonide-e 1 fluticasone propionate cream, -

ointment 1

halobetasol propionate 1 HALOG halcinonide 3 [ST] HALONATE halobetasol prop/amonium lac 3 [ST] halonate pac 1


Drug Generic Tier Restrictions hydrocortisone 1% absorbase, -1%

cream, -1% lotion, -1% oin, -1% oint, -1% ointment, -2.5% cream, -2.5% lotion, -2.5% ointment, -aloe 1% cream, -plus 1% cream

1

hydrocortisone butyrate 1 hydrocortisone valerate 1 KENALOG triamcinolone acetonide 3 [ST] LIDAMANTLE HC hc acetate/lidocaine hcl 3 lidazone hc 1 lidocaine-hc 1 lidocaine-hydrocortisone cream, -

cream with applicator, -kit, -lotion 1

LOCOID [G] hydrocortisone butyrate 3 [ST] LOCOID LIPOCREAM hydrocortisone butyrate 3 [ST] LOKARA [G] desonide 3 [ST] LUXIQ betamethasone valerate 3 [ST] mometasone furoate 1 MOMEXIN mometasone furoat/ammonium l 3 [ST] OLUX clobetasol propionate 3 [ST] OLUX-E clobetasol propionate 3 [ST] OLUX-OLUX-E clobetasol propionate 3 [ST] PANDEL hydrocortisone buteprate 3 [ST] PEDIADERM HC hydrocortisone/emol no.45 3 [ST] PERANEX HC PADS MEDICATED hc acetate/lidocaine hcl 3 prednicarbate 1 SCALACORT hydrocortisone 3 [ST] TEMOVATE [G] clobetasol propionate 3 [ST] TEMOVATE EMOLLIENT clobetasol propionate 3 [ST] TEXACORT hydrocortisone 3 [ST] TOPICORT [G] desoximetasone 3 [ST] TOPICORT LP [G] desoximetasone 3 [ST] triamcinolone acetonide cream, -

lotion, -ointment 1

triderm 1 TRIDESILON desonide 3 [ST] U-CORT hydrocortisone acetate/urea 3 [ST] ULTRAVATE [G] halobetasol propionate 3 [ST] ULTRAVATE PAC halobetasol prop/amonium lac 3 VANOS fluocinonide 3 [ST] VERDESO desonide 3 [ST]


Drug Generic Tier Restrictions WESTCORT [G] hydrocortisone valerate 3 [ST] TOPICAL DERMATOLOGICAL DRUGS ALDARA [G] imiquimod 3 ammonium lactate 12% cream, -

12% lotion 1

CARAC fluorouracil 3 CARMOL 40 urea 3 cerovel 1 DRYSOL aluminum chloride hexahydrate 3 EFUDEX [G] fluorouracil 3 ELIDEL pimecrolimus 2 [ST] FLUOROPLEX fluorouracil 2 fluorouracil cream, -solution non-

oral 1

GORDO-UREA urea 3 HYDRO 35 urea 3 HYDRO 40 urea 3 hypercare 1 imiquimod 1 KERAFOAM urea 3 KERALAC urea 3 keratol 40 1 keratol plus 1 KEROL urea 3 LAC-HYDRIN [G] lactate, ammonium 3 LACLOTION [G] lactate, ammonium 3 LEVULAN aminolevulinic acid hcl 3 METVIXIA methyl aminolevulinate hcl 3 OXSORALEN methoxsalen 2 PANRETIN alitretinoin 4 PROTOPIC tacrolimus 2 [ST] PRUDOXIN doxepin 2 QUTENZA capsaicin/skin cleanser 3 REGRANEX becaplermin 2 [PAR][QLL,

30 gm/34] remeven 1 re-u40 1 SANTYL collagenase 2


Drug Generic Tier Restrictions SOLARAZE diclofenac sodium 2 [PAR] u-kera e urea emollient 1 UMECTA urea 3 UMECTA PD urea 3 URAMAXIN urea 3 urea 40 1 urea 40% cream, -40% nail film

susp, -45% cream, -50% cream, -50% nail stick, -50% nailstik, -foam, -gel, -kit, -lotion, -ointment, -towelette

1

urealac cream, -gel, -lotion, -soln, top

1

VEREGEN sinecatechins 3 XERAC AC aluminum chloride hexahydrate 3 x-viate 1 ZONALON doxepin 2 ZYCLARA imiquimod 2 DIAGNOSTIC AND MISCELLANEOUS MEDICATIONS DIAGNOSTIC PRODUCTS CHEMET succimer 2 EXJADE [LA] deferasirox 4 THIOLA tiopronin 2 MISCELLANEOUS DRUGS ACETADOTE [INJ] acetylcysteine 3 ADAGEN [INJ][LA] pegademase bovine 4 AMICAR SYRUP [INJ] aminocaproic acid 3 AMICAR TABLET aminocaproic acid 3 aminocaproic acid injection [INJ] 1 aminocaproic acid syrup, -tablet 1 AMMONUL [INJ] sodium benzoate/na ph-acetate 3 AMPYRA [LA] dalfampridine 4 [PAR] ANTIZOL [INJ][G] fomepizole 3 BUPHENYL sodium phenylbutyrate 4 COPAXONE [INJ] glatiramer acetate 4 [PAR][QLL,

30 ml/30]


Drug Generic Tier Restrictions CYKLOKAPRON [INJ] tranexamic acid 2 ENDRATE [INJ] endrate disodium 3 ergoloid mesylates tablet 1 fomepizole [INJ] 1 HESPAN [INJ] hetastarch/na chlor 0.9% 3 hetastarch in ns [INJ] 1 HEXTEND LACTATED ELECTROLYTE

[INJ] hetastarch/e-lytes,lactate 3

LYSTEDA tranexamic acid 3 ORFADIN [LA] nitisinone 4 PANHEMATIN [INJ] hemin 3 PROTOPAM CHLORIDE [INJ] pralidoxime chloride 2 SOTRADECOL [INJ] sodium tetradecyl sulfate 3 THALOMID thalidomide 4 VOLUVEN [INJ] hetastarch/na chlor 0.9% 3 XIAFLEX [INJ][LA] collagenase clostridium hist. 4 EAR-NOSE-THROAT MEDICATIONS DRUGS AFFECTING THE EAR aabp 1 a-b otic 1 acetasol hc 1 acetic acid solution non-oral 1 acetic acid-aluminum 1 acetic acid-hydrocortisone 1 antipyrine-benzocaine 1 aurodex 1 aurodex ear drops 1 auroguard 1 BENZOTIC antipyrine/benzocaine 3 borofair 1 CETRAXAL ciprofloxacin 3 chloroxylenol-pramoxine hcl 1 CIPRO HC ciprofloxacin/hc 3 CIPRODEX ciprofloxacin/dexameth 2 COLY-MYCIN S neomycin sulfate/colist sul/hc 3 CORTISPORIN SUSPENSION DROPS,

-SOLUTION NON-ORAL [G] neomycin sulfate/polymyxin/hc 3

CORTISPORIN-TC neomycin/colist sul/hc/thonz 3


Drug Generic Tier Restrictions cortomycin solution non-oral, -

suspension drops 1

DERMOTIC fluocinolone acetonide 2 DOMEBORO DROPS [INJ] acetic acid/aluminum acetate 3 FLOXIN ofloxacin 3 neomycin-polymyxin-hc solution, -

solution non-oral, -suspension drops 1

ofloxacin drops 1 otic edge 1 oticin hc ear solution, -suspension

drops 1

otocidin 1 otomycet-hc 1 PEDIOTIC neomycin suf/polymy/buffers/hc 3 pr otic solution 1 PRAMOTIC pramoxine hcl/chloroxylenol 3 treagan otic 1 VOSOL [G] acetic acid 3 VOSOL HC [INJ] acetic acid/hydrocortisone 3 DRUGS AFFECTING THE NOSE ASTELIN [G] azelastine hcl 3 [QLL, 60

ml/34] ASTEPRO 0.15% NASAL SPRAY azelastine hcl 2 [QLL, 60

ml/34] ASTEPRO 137 MCG NASAL SPRAY azelastine hcl 2 [QLL,

60/34] ATROVENT 0.03% SPRAY [G] ipratropium 3 [QLL, 60

ml/34] ATROVENT 0.06% SPRAY [G] ipratropium 3 [QLL, 30

ml/34] azelastine hcl aerosol spray w/pump 1 [QLL, 60

ml/34] BECONASE AQ beclomethasone 3 [QLL, 50

gm/34] FLONASE [G] fluticasone propionate 3 [QLL, 32

gm/34] flunisolide 0.025% spray 1 [QLL, 75

ml/34]


Drug Generic Tier Restrictions flunisolide 29 mcg-0.025% spr 1 [QLL,

75/34] fluticasone propionate nasal inhaled

steroids 1 [QLL, 32

gm/34] ipratropium 0.03% spray 1 [QLL, 60

ml/34] ipratropium 0.06% spray 1 [QLL, 30

ml/34] NASACORT AQ triamcinolone acetonide 2 [QLL, 33

gm/34] NASAREL flunisolide 3 [QLL,

75/34] NASONEX mometasone 3 [QLL, 51

gm/34] OMNARIS ciclesonide 3 [QLL, 25

gm/34] PATANASE olopatadine hcl 3 [QLL, 61

gm/34] RHINOCORT AQUA budesonide 3 [QLL, 26

gm/34] TYZINE tetrahydrozoline 2 VERAMYST fluticasone furoate 2 [QLL, 20

gm/34] DRUGS AFFECTING THE THROAT AND MOUTH APHTHASOL amlexanox 3 AQUORAL saliva substitution combo no.3 3 ARESTIN minocycline 3 BUCALCIDE zinc cl/b-caine/cetylpyrd cl 2 BUCALSEP b-caine/tan ac/menth/cpyrd 3 CAPHOSOL saliva subst combo no. 2 3 chlorhexidine gluconate mouthwash 1 DEBACTEROL sulfuric acid/sulf phenol 3 doxycycline hyclate 20 mg tab 1 EVOXAC cevimeline 3 FIRST-MOUTHWASH BLM mag hydrox/alh/smc/dpha/lido 2 GELCLAIR k sorbate/he-cel/pvp/hyalur ac 3 MUCOTROL mucositis & stomatitis combo 1 3 NEUTRASAL saliva substitution combo no.5 3 NUMOISYN cahpo4/saliva cmb 1/malic/sorb 3


Drug Generic Tier Restrictions ORALONE triamcinolone acetonide 3 ORAMAGICRX k sorbate/malto/alo v/mann ps 3 ORASEP b-caine/tan ac/menth/cpyrd 3 oraxyl 1 PERIDEX [G] chlorhexidine 3 periogard 1 PERIOSTAT [G] doxycycline hyclate 3 perisol 1 pilocarpine hcl tablet 1 SALAGEN [G] pilocarpine hcl 3 triamcinolone acetonide paste 1 XYLOCAINE 2% VIAL [INJ] lidocaine 3 ENDOCRINE MEDICATIONS ANTITHYROID DRUGS methimazole tablet 1 northyx 1 propylthiouracil 1 TAPAZOLE [G] methimazole 3 GLUCOCORTICOID DRUGS A-HYDROCORT [INJ] hydrocortisone sod succinate 3 a-methapred [INJ] 1 ARISTOSPAN [INJ] triamcinolone hexacetonide 2 baycadron 1 betamethasone acetate-sod phos

[INJ] 1

CELESTONE INJECTION [INJ] betamethasone/betamethasone 2 CELESTONE SOLUTION ORAL betamethasone 2 CORTEF [G] hydrocortisone 3 cortisone tablet 1 DEPO-MEDROL [INJ][G] methylprednisolone acetate 3 dexamethasone elixir, -solution oral,

-tablet 1

dexamethasone intensol 1 dexamethasone sodium phosphate

injection [INJ] 1

DEXPAK [G] dexamethasone 3


Drug Generic Tier Restrictions hydrocortisone tablet 1 KENALOG-10 [INJ] triamcinolone acetonide 3 KENALOG-40 [INJ] triamcinolone acetonide 3 MEDROL [G] methylprednisolone 3 meprolone unipak 1 methylprednisolone acetate injection

[INJ] 1

methylprednisolone sod succ [INJ] 1 methylprednisolone tablet, -tablet

dose pack 1

MILLIPRED prednisolone 3 MILLIPRED DP prednisolone 3 ORAPRED [G] prednisolone sod phosphate 3 ORAPRED ODT prednisolone sod phosphate 3 PEDIAPRED [G] prednisolone sod phosphate 3 prednisolone sodium phosphate

solution 1

prednisolone solution oral 1 prednisone intensol 1 prednisone solution, -tablet, -tablet

dose pack 1

PRELONE [G] prednisolone 3 SOLU-CORTEF [INJ] hydrocortisone sod succinate 3 SOLU-CORTEF (PF) [INJ] hydrocortisone sod succinate 3 SOLU-MEDROL [INJ][G] methylprednisolone sod succ 3 SOLU-MEDROL (PF) [INJ] methylprednisolone sod succ 3 STERAPRED prednisone 3 STERAPRED DS prednisone 3 triamcinolone acetonide injection

[INJ] 1

veripred 20 1 zema-pak 1 GLUCOSE ELEVATING DRUGS GLUCAGEN [INJ] glucagon, human recombinant 2 GLUCAGON EMERGENCY KIT [INJ] glucagon, human recombinant 2 PROGLYCEM diazoxide 2


Drug Generic Tier Restrictions HYPOGLYCEMIC DRUGS BYETTA 10 MCG DOSE PEN INJ

[INJ] exenatide 2 [PAR][QLL,

5 ml/34] BYETTA 5 MCG DOSE PEN INJ [INJ] exenatide 2 [PAR][QLL,

2 ml/34] SYMLIN [INJ] pramlintide acetate 2 [PAR][QLL,

35 ml/34] SYMLINPEN 120 [INJ] pramlintide acetate 2 [PAR][QLL,

22 ml/34] SYMLINPEN 60 [INJ] pramlintide acetate 2 [PAR][QLL,

12 pens/34] VICTOZA 2-PAK [INJ] liraglutide 3 [PAR][QLL,

3/30] VICTOZA 3-PAK [INJ] liraglutide 3 [PAR][QLL,

3 pens/30] INSULIN APIDRA [INJ] 3 APIDRA SOLOSTAR [INJ] 3 HUMALOG [INJ] 2 HUMALOG MIX 50-50 [INJ] 2 HUMALOG MIX 75-25 [INJ] 2 HUMULIN 50-50 [INJ] 2 HUMULIN 70-30 [INJ] 2 HUMULIN N [INJ] 2 HUMULIN R [INJ] 2 LANTUS [INJ] 2 LANTUS SOLOSTAR [INJ] 2 LEVEMIR [INJ] 2 NOVOLIN 70-30 100 UNIT/ML VIAL,

-U100 CARTRIDGE [INJ] 2

NOVOLIN 70-30 INNOLET [INJ] 2 NOVOLIN N 100 UNIT/ML INNOLET,

-100 UNITS/ML CARTRDG, -100 UNITS/ML VIAL [INJ]

2

NOVOLIN R 100 UNIT/ML CARTRIDG, -100 UNIT/ML INNOLET, -100 UNITS/ML VIAL [INJ]

2

NOVOLOG [INJ] 2


Drug Generic Tier Restrictions NOVOLOG MIX 70-30 [INJ] 2 RELION NOVOLIN 70-30 VIAL, -

RELION VIAL [INJ] 3

RELION NOVOLIN N 100 UNITS/ML, -RELION 100 UNITS/ML [INJ]

3

RELION NOVOLIN R 100 UNITS/ML [INJ]

3

MINERALOCORTICOID DRUGS fludrocortisone acetate tablet 1 ORAL HYPOGLYCEMICS AND COMBOS acarbose 1 ACTOPLUS MET pioglitazone hcl/metformin hc 2 [QLL,

102/34][ST] ACTOPLUS MET XR 15-1,000 MG TB pioglitazone hcl/metformin hc 2 [QLL,

68/34][ST] ACTOPLUS MET XR 30-1,000 MG TB pioglitazone hcl/metformin hc 2 [QLL,

34/34][ST] ACTOS pioglitazone hcl 2 [QLL,

34/34][ST] AMARYL [G] glimepiride 3 AVANDAMET rosiglitazone/metformin hcl 2 [QLL,

68/34][ST] AVANDARYL rosiglitazone maleate/glimepir 2 [QLL,

34/34][ST] AVANDIA 2 MG TABLET, -4 MG

TABLET rosiglitazone maleate 2 [QLL,

68/34][ST] AVANDIA 8 MG TABLET rosiglitazone maleate 2 [QLL,

34/34][ST] DIABETA glyburide 3 DUETACT pioglitazone/glimepiride 2 [QLL,

34/34][ST] FORTAMET metformin 3 [ST] glimepiride 1 glipizide er 1 glipizide tablet 1 glipizide xl 1 glipizide-metformin 1


Drug Generic Tier Restrictions GLUCOPHAGE [G] metformin 3 [ST] GLUCOPHAGE XR [G] metformin 3 [ST] GLUCOTROL [G] glipizide 3 GLUCOTROL XL [G] glipizide 3 GLUCOVANCE [G] glyburide/metformin hcl 3 GLUMETZA metformin 3 [ST] glyburide 1 glyburide micronized 1 glyburide-metformin hcl 1 glycron 1 GLYNASE [G] glyburide 3 GLYSET miglitol 3 JANUMET sitagliptin phos/metformin hcl 2 [QLL,

68/34] JANUVIA sitagliptin phosphate 2 [QLL,

34/34] METAGLIP [G] glipizide/metformin hcl 3 metformin hcl 1 metformin hcl er 1 nateglinide 1 ONGLYZA saxagliptin hydrochloride 2 [QLL,

34/34] PRANDIMET repaglinide/metformin hcl 3 [QLL,

170/34] PRANDIN repaglinide 2 PRECOSE [G] acarbose 3 RIOMET metformin 2 [ST] STARLIX [G] nateglinide 3 tolazamide 1 tolbutamide 1 OTHER ENDOCRINE DRUGS ACTHAR H.P. [INJ] corticotropin 4 ACTHREL [INJ] corticorelin ovine triflutate 3 ACTONEL 150 MG TABLET risedronate 2 [QLL,

1/34][ST] ACTONEL 30 MG TABLET, -5 MG

TABLET risedronate 2 [QLL,

34/34][ST] ACTONEL 35 MG TABLET risedronate 2 [QLL,

5/35][ST]


Drug Generic Tier Restrictions ACTONEL 75 MG TABLET risedronate 2 [QLL,

2/34][ST] ACTONEL WITH CALCIUM risedron sod/calcium carbona 2 [QLL,

35/35][ST] ALDURAZYME [INJ][LA] laronidase 4 alendronate sodium 10 mg tab, -40

mg tab, -5 mg tablet 1 [QLL,

34/34] alendronate sodium 35 mg tab, -70

mg tab 1 [QLL, 5/35]

AREDIA 30 MG VIAL [INJ][G] pamidronate disodium 3 AREDIA 90 MG VIAL [INJ][G] pamidronate disodium 4 BONIVA 150 MG TABLET ibandronate 2 [QLL,

1/34][ST] BONIVA 2.5 MG TABLET ibandronate 2 [QLL,

34/34][ST] BONIVA INJECTION [INJ] ibandronate 3 [PAR] cabergoline 1 [QLL,

20/34] calcitonin-salmon 1 CEREDASE [INJ][LA] alglucerase 4 CEREZYME [INJ][LA] imiglucerase 4 [PAR] DDAVP 4 MCG/ML AMPUL [INJ][G] desmopressin acetate 4 DDAVP 4 MCG/ML VIAL [INJ][G] desmopressin acetate 3 DDAVP SOLUTION, -AEROSOL

SPRAY W/PUMP, -TABLET [G] desmopressin acetate 3

desmopressin acetate aerosol spray w/pump, -solution, -tablet

1

desmopressin acetate injection [INJ] 1 DIDRONEL [G] etidronate 3 ELAPRASE [INJ][LA] idursulfase 4 etidronate disodium 1 EVISTA raloxifene 2 FABRAZYME [INJ][LA] agalsidase 4 [PAR] FORTEO [INJ] teriparatide 2 [PAR][QLL,

1/28] fortical 1 FOSAMAX 10 MG TABLET, -40 MG

TABLET, -5 MG TABLET [G] alendronate 3 [QLL,

34/34][ST] FOSAMAX 35 MG TABLET, -70 MG

TABLET [G] alendronate 3 [QLL,

5/35][ST]


Drug Generic Tier Restrictions FOSAMAX PLUS D alendronate/vitamin d3 3 [QLL,

5/35][ST] FOSAMAX SOLUTION alendronate 3 [QLL, 375

ml/35][ST] KUVAN [LA] sapropterin dihydrochloride 4 LUMIZYME [INJ][LA] alglucosidase alfa 4 MIACALCIN AEROSOL SPRAY

W/PUMP [G] calcitonin 3

MIACALCIN INJECTION [INJ] calcitonin 2 MYOZYME [INJ][LA] alglucosidase alfa 4 NAGLAZYME [INJ][LA] galsulfase 4 pamidronate disodium [INJ] 1 PROLIA [INJ] denosumab 3 RECLAST [INJ] zoledronic acid 4 [PAR] SAMSCA tolvaptan 4 [PAR][QLL,

68/34] SENSIPAR cinacalcet hcl 2 SKELID tiludronate 3 SOMAVERT [INJ][LA] pegvisomant 4 STIMATE desmopressin acetate 3 VPRIV [INJ] velaglucerase alfa 4 ZAVESCA [LA] miglustat 4 ZOMETA [INJ] zoledronic acid 4 THYROID SUPPLEMENTS ARMOUR THYROID thyroid 2 CYTOMEL [G] liothyronine 3 levothroid 1 levothyroxine sodium injection [INJ] 1 levothyroxine sodium tablet 1 levoxyl 1 liothyronine sodium injection [INJ] 1 liothyronine sodium tablet 1 nature-throid 1 SYNTHROID [G] levothyroxine 3 thyroid tablet 1 THYROLAR-1 liotrix 2 THYROLAR-1/2 liotrix 2 THYROLAR-1/4 liotrix 2


Drug Generic Tier Restrictions THYROLAR-2 liotrix 2 THYROLAR-3 liotrix 2 TIROSINT levothyroxine 3 TRIOSTAT [INJ] liothyronine 3 unithroid 1 westhroid 1 GASTROINTESTINAL MEDICATIONS ANTIDIARRHEAL DRUGS diphenoxylate-atropine 1 LOMOTIL [G] diphenoxylate/atropine sulfate 3 lonox 1 loperamide capsule 1 MOTOFEN difenoxin/atropine sulfate 3 paregoric 1 ANTISPASMODICS/DRUGS AFFECT GI MOTILITY BENTYL CAPSULE, -SYRUP, -TABLET

[G] dicyclomine 3

BENTYL INJECTION [INJ] dicyclomine 3 CANTIL mepenzolate 3 dicyclomine hcl capsule, -syrup, -

tablet 1

dicyclomine hcl injection [INJ] 1 glycopyrrolate injection [INJ] 1 glycopyrrolate tablet 1 methscopolamine bromide 1 metoclopramide hcl injection [INJ] 1 metoclopramide hcl solution oral, -

tablet 1

METOZOLV ODT metoclopramide 3 PAMINE [G] methscopolamine 3 PAMINE FORTE [G] methscopolamine 3 propantheline bromide 1 REGLAN INJECTION [INJ][G] metoclopramide 3 REGLAN TABLET [G] metoclopramide 3 ROBINUL FORTE [G] glycopyrrolate 3 ROBINUL INJECTION [INJ][G] glycopyrrolate 3


Drug Generic Tier Restrictions ROBINUL TABLET [G] glycopyrrolate 3 SAL-TROPINE atropine sulfate 3 SCOPACE scopolamine 3 SCOPOLAMINE HYDROBROMIDE

INJECTION [INJ] scopolamine 3

ANTIULCER DRUGS AXID [G] nizatidine 3 cimetidine 200 mg tablet, -300 mg

tablet, -400 mg tablet, -800 mg tablet, -solution

1

cimetidine injection [INJ] 1 famotidine 20 mg tablet, -40 mg

tablet, -suspension oral 1

famotidine injection [INJ] 1 nizatidine 1 PEPCID INJECTION [INJ] famotidine 3 PEPCID SUSPENSION ORAL, -

TABLET [G] famotidine 3

ranitidine 150 mg tablet, -300 mg tablet, -capsule, -syrup

1

ranitidine hcl injection [INJ] 1 TAGAMET cimetidine 3 ZANTAC 25 ranitidine 3 ZANTAC INJECTION [INJ][G] ranitidine 3 ZANTAC SYRUP, -TABLET [G] ranitidine 3 IRRITABLE BOWEL DRUGS AMITIZA lubiprostone 2 LOTRONEX alosetron 4 LAXATIVES AND CATHARTICS glycerin liquid 1 OSMOPREP sodium phosphate/na biphos 2 polyethylene glycol 3350, -pkt, -

powd 1

VISICOL sodium phosphate/na biphos 2


Drug Generic Tier Restrictions OTHER ANTIULCER DRUGS CARAFATE SUSPENSION ORAL sucralfate 2 CARAFATE TABLET [G] sucralfate 3 CYTOTEC [G] misoprostol 3 misoprostol 1 sucralfate suspension oral, -tablet 1 OTHER GI DRUGS ACTIGALL [G] ursodiol 3 ANUSOL-HC [G] hydrocortisone 3 APRISO mesalamine 2 ASACOL mesalamine 2 ASACOL HD mesalamine 2 AZULFIDINE [G] sulfasalazine 3 balsalazide disodium 1 CANASA mesalamine 2 CHENODAL [LA] chenodiol 4 COLAZAL [G] balsalazide disodium 3 COLOCORT [G] hydrocortisone 3 COLYTE electrolyte solution/peg's 3 COLYTE WITH FLAVOR PACKETS

[INJ] electrolyte solution/peg's 3

CORTENEMA [G] hydrocortisone 3 CORTIFOAM hydrocortisone acetate 2 CREON amylase/lipase/protease 2 DIPENTUM olsalazine 3 ENTOCORT EC budesonide 2 ENZYMAX 500 MG TABLET enzymes, digestive 2 gavilyte-c 1 gavilyte-g 1 gavilyte-n 1 GOLYTELY [G] electrolyte solution/peg's 3 HALFLYTELY-BISACODYL electrolyte solution/peg's 3 HELIDAC tetracyc hcl/bis ss/metronid 3 hydrocortisone enema 1 LIALDA mesalamine 3 mesalamine 1 MOVIPREP electrolyte solution/peg's 2


Drug Generic Tier Restrictions NULYTELY WITH FLAVOR PACKS [G] electrolyte solution/peg's 3 OCL electrolyte solution/peg's 2 PANCREAZE amylase/lipase/protease 3 PANCRELIPASE 5,000 amylase/lipase/protease 3 peg 3350-electrolyte 1 peg-3350 and electrolytes 1 peg-3350 with flavor packs 1 PENTASA mesalamine 2 PREVPAC lansoprazole/amox tr/clarith 3 [QLL,

14/14] PROCTOCORT [G] hydrocortisone 3 PROCTOCREAM-HC [G] hydrocortisone 3 procto-pak 1 proctosol-hc 1 proctozone-hc 1 PYLERA bismuth/metronid/tetracyclin 2 RELISTOR [INJ] methylnaltrexone bromide 2 ROWASA [G] mesalamine 3 SFROWASA [INJ] mesalamine 3 SUCRAID sacrosidase 4 sulfasalazine dr 1 sulfasalazine tablet 1 sulfazine 1 sulfazine ec 1 trilyte with flavor packets 1 URSO [G] ursodiol 3 URSO FORTE [G] ursodiol 3 ursodiol capsule, -tablet 1 ZENPEP amylase/lipase/protease 3 PROTON PUMP INHIBITORS ACIPHEX rabeprazole sodium 3 [ST] DEXILANT DR 30 MG CAPSULE dexlansoprazole 3 [QLL,

34/34][ST] DEXILANT DR 60 MG CAPSULE dexlansoprazole 3 [ST] KAPIDEX DR 30 MG CAPSULE dexlansoprazole 3 [QLL,

34/34][ST] KAPIDEX DR 60 MG CAPSULE dexlansoprazole 3 [ST]


Drug Generic Tier Restrictions lansoprazole dr 15 mg capsule 1 [QLL,

34/34] lansoprazole dr 30 mg capsule 1 NEXIUM 10 MG PACKET, -20 MG

CAPSULE, -20 MG PACKET esomeprazole mag trihyd 2 [QLL,

34/34][ST] NEXIUM 40 MG CAPSULE, -40 MG

PACKET esomeprazole mag trihyd 2 [ST]

NEXIUM I.V. [INJ] esomeprazole mag trihyd 2 omeprazole dr 10 mg capsule 1 [QLL,

34/34] omeprazole dr 20 mg capsule, -dr

40 mg capsule 1

omeprazole-bicarb 20-1,100 cap 1 [QLL, 34/34]

omeprazole-bicarb 40-1,100 cap 1 pantoprazole sod dr 20 mg tab 1 [QLL,

34/34][ST] pantoprazole sod dr 40 mg tab 1 [ST] PREVACID 30 MG CAPSULE DR, -30

MG SOLUTAB, -DR 30 MG CAPSULE lansoprazole 3 [ST]

PREVACID DR 15 MG CAPSULE, -15 MG SOLUTAB [G]

lansoprazole 3 [QLL, 34/34][ST]

PREVACID IV [INJ] lansoprazole 3 PRILOSEC DR 10 MG CAPSULE, -DR

20 MG CAPSULE [G] omeprazole 3 [QLL,

34/34][ST] PRILOSEC DR 40 MG CAPSULE, -PKT

[G] omeprazole magnesium-legend 3 [ST]

PROTONIX DR 20 MG TABLET [G] pantoprazole 3 [QLL, 34/34][ST]

PROTONIX DR 40 MG TABLET, -PKT [G]

pantoprazole 3 [ST]

PROTONIX IV [INJ] pantoprazole 3 ZEGERID 20 MG CAPSULE [G] omeprazole/sodium bicarbonat 3 [QLL,

34/34][ST] ZEGERID 20 MG PACKET omeprazole/sodium bicarbonat 3 [QLL,

34/34][ST] ZEGERID 40 MG CAPSULE [G] omeprazole/sodium bicarbonat 3 [ST] ZEGERID 40 MG PACKET omeprazole/sodium bicarbonat 3 [ST]


Drug Generic Tier Restrictions IMMUNOLOGICALS AND VACCINES GROWTH HORMONES AND RELATED DRUGS GENOTROPIN 12 MG CARTRIDGE, -

5 MG CARTRIDGE [INJ] somatropin 4 [PAR]

GENOTROPIN MINIQUICK 0.2 MG, -MINIQUICK 0.4 MG, -MINIQUICK 0.6 MG, -MINIQUICK 0.8 MG, -MINIQUICK 1 MG, -MINIQUICK 1.2 MG, -MINIQUICK 1.4 MG, -MINIQUICK 1.6 MG, -MINIQUICK 1.8 MG, -MINIQUICK 2 MG [INJ]

somatropin 3 [PAR]

HUMATROPE [INJ] somatropin 4 [PAR] NORDITROPIN [INJ] somatropin 4 [PAR] NORDITROPIN FLEXPRO [INJ] somatropin 4 [PAR] NORDITROPIN NORDIFLEX [INJ] somatropin 4 [PAR] NUTROPIN [INJ] somatropin 4 [PAR] NUTROPIN AQ [INJ] somatropin 4 [PAR] NUTROPIN AQ NUSPIN [INJ] somatropin 4 [PAR] OMNITROPE [INJ] somatropin 4 [PAR] SAIZEN [INJ] somatropin 4 [PAR] SEROSTIM [INJ][LA] somatropin 4 [PAR] TEV-TROPIN [INJ] somatropin 4 [PAR] ZORBTIVE [INJ][LA] somatropin 4 [PAR] IMMUNOLOGICALS AND VACCINES ACTHIB [INJ] haemophilus b-tet toxoid 2 ADACEL [INJ] diphther,pertuss,tetanus vac 2 ARANESP 100 MCG/0.5 ML

AUTOINJ, -100 MCG/0.5 ML SYRINGE, -100 MCG/ML VIAL, -150 MCG/0.3 ML AUTOINJ, -150 MCG/0.3 ML SYRINGE, -150 MCG/0.75 ML VIAL, -200 MCG/0.4 ML AUTOINJ, -200 MCG/0.4 ML SYRINGE, -200 MCG/ML VIAL, -300 MCG/0.6 ML AUTOINJ, -300 MCG/0.6 M [INJ]

darbepoetin alfa 4 [PAR]


Drug Generic Tier Restrictions ARANESP 25 MCG/0.42 ML

AUTOINJ, -25 MCG/0.42 ML SYRING, -25 MCG/ML VIAL, -40 MCG/0.4 ML AUTOINJ, -40 MCG/0.4 ML SYRINGE, -40 MCG/ML VIAL [INJ]

darbepoetin alfa 2 [PAR]

ATGAM [INJ] lymphocyte immune globulin 4 [PAR] ATTENUVAX VACCINE WITH

DILUENT [INJ] measles vaccine,atten 2

BOOSTRIX [INJ] diphther,pertuss,tetanus vac 2 CARIMUNE NF NANOFILTERED [INJ] immune globulin - iv 4 [PAR] CERVARIX [INJ] human papillomav vacc bival/pf 2 COMVAX [INJ] hepatitis b/haemophilus b vacc 2 DAPTACEL [INJ] diphther,pertuss,tetanus vac 2 DIPHTHERIA-TETANUS TOXOID

[INJ] tetanus,diphtheria toxoid 2

ENGERIX-B [INJ] hepatitis b virus vaccine 2 EPOGEN 10,000 UNITS/ML VIAL, -

20,000 UNITS/2 ML VIAL, -20,000 UNITS/ML VIAL, -40,000 UNITS/ML VIAL [INJ]

epoetin alfa 4 [PAR]

EPOGEN 2,000 UNITS/ML VIAL, -3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL [INJ]


FLEBOGAMMA [INJ] immune globulin - iv 4 [PAR] FLEBOGAMMA DIF [INJ] immune globulin - iv 4 [PAR] GAMASTAN S-D [INJ] immune globulin - im 2 GAMMAGARD LIQUID [INJ] immune globulin - iv 4 [PAR] GAMMAGARD S-D [INJ] immune globulin - iv 4 [PAR] GAMMAPLEX [INJ] immune globulin - iv 4 [PAR] GAMUNEX [INJ] immune globulin - iv 4 [PAR] GARDASIL [INJ] human papillomavirus vacc 2 HAVRIX [INJ] hepatatis a virus vaccine 2 HEPAGAM B [INJ] hep.b immune glob/maltose 3 HIBERIX [INJ] haemophilus b-tet toxoid 3 HIBTITER [INJ] haemophilus b vaccine 2 HIZENTRA 1 GRAM/5 ML VIAL [INJ] immune globulin- sq 2 [PAR] HIZENTRA 2 GRAM/10 ML VIAL, -4

GRAM/20 ML VIAL [INJ] immune globulin- sq 4 [PAR]

HYPERHEP B S-D [INJ] hepatitis b immune globulin 2 HYPERRAB S-D [INJ] rabies immune globulin 3


Drug Generic Tier Restrictions HYPERRHO S-D [INJ] rho(d) immune globulin 2 HYPERTET S-D [INJ] tetanus immune globulin 3 IMOGAM RABIES-HT [INJ] rabies immune globulin 2 IMOVAX RABIES VACCINE [INJ] rabies vaccine,human diploid 2 INFANRIX [INJ] diphther,pertuss,tetanus vac 2 IPOL [INJ] poliomyelitis vac,killed 2 IXIARO [INJ] japanese encephalitis vaccine 2 JE-VAX [INJ] japanese encephalitis vaccine 2 KEPIVANCE [INJ][LA] palifermin 4 MENACTRA [INJ] meningococcal vac a,c,y,w-135 2 MENOMUNE-A-C-Y-W-135 [INJ] meningococcal vac a,c,y,w-135 2 MENVEO A-C-Y-W-135-DIP mening vac a,c,y,w-135 dip 3 MERUVAX II VACCINE W-DILUENT

[INJ] rubella vaccine 2

MICRHOGAM [INJ] rho(d) immune globulin 3 MICRHOGAM PLUS [INJ] rho(d) immune globulin 3 M-M-R II VACCINE [INJ] measles,mumps&rubella vaccine 2 MOZOBIL [INJ] plerixafor 4 MUMPSVAX VACCINE W-DILUENT

[INJ] mumps vaccine,live 2

NABI-HB [INJ] hepatitis b immune globulin 3 OCTAGAM [INJ] immune globulin - iv 4 [PAR] PEDIARIX [INJ] hep b vaccine/dp (a) t-polio 2 PEDVAXHIB [INJ] haemophilus b vaccine 2 PENTACEL [INJ] dp (a) t-polio/hib conj-tet/pf 3 PRIVIGEN [INJ] immune globulin - iv 4 [PAR] PROCRIT 10,000 UNITS/ML VIAL, -

2,000 UNITS/ML VIAL, -3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL [INJ]


PROCRIT 20,000 UNITS/ML VIAL, -40,000 UNITS/ML VIAL [INJ]


PROQUAD [INJ] measles,mumps,rub,varicella 2 RABAVERT [INJ] rabies vac,pf chick-emb cell 2 RECOMBIVAX HB [INJ] hepatitis b virus vaccine 2 RHOGAM rho(d) immune globulin 3 RHOGAM PLUS [INJ] rho(d) immune globulin 3 RHOPHYLAC [INJ] rho(d) immune globulin 3 ROTARIX rotavirus vac, live att, 89-12 3 ROTATEQ rotavirus vac, live pentav 2 SYNAGIS [INJ][LA] palivizumab 4


Drug Generic Tier Restrictions TE ANATOXAL BERNA [INJ] tetanus toxoid,adsorbed 2 TETANUS DIPHTHERIA TOXOIDS


tetanus toxoid adsorbed [INJ] 1 TETANUS-DIPHTERIA-DECAVAC


THYMOGLOBULIN [INJ] lymphocyte immune globulin 4 [PAR] TICE BCG [INJ] bcg vaccine 2 TRIHIBIT [INJ] dp (a) ped/hib conj-tet 2 TRIPEDIA [INJ] diphther,pertuss,tetanus vac 2 TWINRIX [INJ] hep b vir recomb/hep a vir 2 TYPHIM VI [INJ] typhoid vaccine 2 VAQTA [INJ] hepatatis a virus vaccine 2 VARIVAX VACCINE [INJ] varicella virus vaccine live 2 VIVAGLOBIN [INJ] immune globulin- sq 4 [PAR] VIVOTIF BERNA typhoid vaccine 2 WINRHO SDF [INJ] rho(d) immune globulin 3 YF-VAX [INJ] yellow fever vaccine 2 ZOSTAVAX [INJ] varicella vacc/pf 2 INSULIN LIKE GROWTH FACTORS-1 INCRELEX [INJ][LA] mecasermin 4 [PAR] INTERFERONS ACTIMMUNE [INJ][LA] interferon gamma-1b,recomb. 4 ALFERON N [INJ] interferon alfa-n3 4 AVONEX [INJ] interferon beta-1a 4 [PAR][QLL,

4 kits/28] AVONEX ADMINISTRATION PACK

[INJ] interferon beta-1a 4 [PAR][QLL,

4 kits/28] BETASERON [INJ] interferon beta-1b 4 [PAR][QLL,

15/30] EXTAVIA [INJ] interferon beta-1b 4 [PAR][QLL,

15 trays/30] INFERGEN [INJ] interferon alfacon-1 4


Drug Generic Tier Restrictions INTRON A 10 MILLION UNIT PEN, -

10 MILLION UNIT/ML, -18 MILLION UNITS VIAL, -5 MILLION UNIT/ML PEN, -50 MILLION UNITS VIAL, -6 MILLION UNIT/ML VL [INJ]

interferon alfa-2b , recomb. 4

INTRON A 10 MILLION UNITS VIAL, -3 MILLION UNIT/ML PEN [INJ]

interferon alfa-2b , recomb. 2

PEGASYS 180 MCG/0.5 ML CONV.PK [INJ]

peginterferon alfa-2a 4 [PAR][QLL, 4 syringes/28]

PEGASYS 180 MCG/ML VIAL [INJ] peginterferon alfa-2a 4 [PAR][QLL, 4/28]

PEGINTRON 120 MCG KIT, -150 MCG KIT, -80 MCG KIT [INJ]

peginterferon alfa-2b 4 [PAR][QLL, 5/34]

PEGINTRON 50 MCG KIT [INJ] peginterferon alfa-2b 4 [PAR][QLL, 5 kits/34]

PEGINTRON REDIPEN [INJ] peginterferon alfa-2b 4 [PAR][QLL, 5 pens/34]

REBIF 22 MCG/0.5 ML SYRINGE, -44 MCG/0.5 ML SYRINGE [INJ]

interferon beta-1a/albumin 4 [PAR][QLL, 8 syringes/35]

REBIF TITRATION PACK [INJ] interferon beta-1a/albumin 4 [PAR][QLL, 12 syringes/28]

INTERLEUKIN RECPTR ANTAGONIST ACTEMRA 200 MG/10 ML VIAL, -400

MG/20 ML VIAL [INJ] tocilizumab 4 [PAR]

ACTEMRA 80 MG/4 ML VIAL [INJ] tocilizumab 2 [PAR] ARCALYST [INJ][LA] rilonacept 4 [PAR] ILARIS [INJ] canakinumab 2 KINERET [INJ] anakinra 4 [PAR] INTERLEUKINS NEUMEGA [INJ] oprelvekin 4 [QLL, 21

vials/21] PROLEUKIN [INJ] aldesleukin 4 ZENAPAX [INJ] daclizumab 4 [PAR]


Drug Generic Tier Restrictions MYELOID STIMULANTS LEUKINE [INJ] sargramostim 4 NEULASTA [INJ] pegfilgrastim 4 [PAR][QLL,

2/30] NEUPOGEN [INJ] filgrastim 4 [PAR] THROMBOPOIETIC AGENTS PROMACTA [LA] eltrombopag olamine 4 MEDICAL (MISCELLANEOUS) SUPPLIES DIABETIC SUPPLIES 1ST TIER UNIFINE PENTIPS 2 ACCUSURE 2 AIMSCO ULTRA THIN II 2 ALCOHOL PREP PADS 2 ALCOHOL PREP SWABS 2 ALCOHOL SWABS 2 ALCOHOL WIPES 2 ANTI-STICK INSULIN 2 AUTO INJECTOR 2 AUTOJECT 2 2 AUTOPEN 2 CURAD GAUZE PADS misc supp (dress,tape,gauze) 2 CURITY ALCOHOL PREPS 2 CURITY GAUZE SPONGES misc supp (dress,tape,gauze) 2 EASY COMFORT INSULIN SYRINGE 2 EASY TOUCH NEEDLE DISPOSABLE,

-SYRINGE EMPTY DISPOSABLE 2

EXEL INSULIN SYRINGE 2 GLUCOPRO SYRINGE EMPTY

DISPOSABLE 2

HUMAPEN LUXURA HD 2 HUMAPEN MEMOIR 2 IN CONTROL PEN NEEDLE 2 INJECT-EASE 2 INSULIN PEN NEEDLE 2 INSULIN SYRINGE 2


Drug Generic Tier Restrictions INSUMED 2 INSUPEN 2 INTEGRA SYRINGE SYRINGE EMPTY

DISPOSABLE 2

LISCO SPONGES misc supp (dress,tape,gauze) 2 LITE TOUCH INSULIN PEN NEEDLES 2 LITE TOUCH SYRINGE EMPTY

DISPOSABLE 2

LUER-LOK SYRINGE SYRINGE EMPTY DISPOSABLE

2

MEDI-JECTOR NEEDLE-FREE SYR A 2 MEDI-JECTOR NEEDLE-FREE SYR B 2 MEDI-JECTOR NEEDLE-FREE SYR C 2 MEDI-JECTOR VISION 2 MONOJECT 0.5 ML SYRN 28GX1/2 2 MONOJECT INSULIN SAFETY SYRNG 2 MONOJECT INSULIN SYRINGE 2 NANO PEN NEEDLE 3 NORDIPEN 15 2 NORDIPEN 5 2 NOVOFINE 32 2 NOVOFINE AUTOCOVER 2 NOVOPEN 3 2 NOVOPEN JR 2 ORSINI INSULIN SYRINGE 2 PEN 12MM 29G NEEDLES, -

31GX3/16, -31GX5/16, -6MM 31G, -8MM 31G NEEDLES, -AURORA 6MM 31G, -AURORA S 12MM 29G, -AURORA S 8MM 31G, -BD 29GX1/2, -BD 29GX3/16, -BD 29GX5/16, -BD MINI 31GX3/16, -BD ORIG 29GX1/2, -BD SHORT 31GX5/16, -LIVE BETTER 6MM 31G, -LIVE B

2

PEN NEEDLES 2 PRECISION SYRINGE EMPTY

DISPOSABLE 2

PRODIGY INSULIN SYRINGE 2 PRODIGY PEN NEEDLE 2 SAFESNAP INSULIN SYRINGE 2 SAFETYGLIDE INSULIN SYRINGE 2


Drug Generic Tier Restrictions SAFETYGLIDE SYRINGE SYRINGE

EMPTY DISPOSABLE 2

SINGLE USE SWAB 2 SURE COMFORT 2 SURE COMFORT ALCOHOL 2 SURE-FINE PEN NEEDLES 2 SURE-JECT INSULIN SYRINGE 2 SURE-PREP ALCOHOL PREP PADS 2 TERUMO INSULIN SYRINGE 2 TERUMO SURGUARD 2 THINPRO INSULIN SYRINGE 2 TOPCARE CLICKFINE 2 TOPCARE ULTRA COMFORT 2 ULTICARE NEEDLE DISPOSABLE, -

SYRINGE EMPTY DISPOSABLE 2

ULTIGUARD 30GX0.5 ML SYRINGE, -30GX1 ML SYRINGE, -SYRINGE EMPTY DISPOSABLE

2

ULTILET ALCOHOL SWAB 2 ULTILET INSULIN SYRINGE 2 ULTILET PEN NEEDLE 2 ULTRA COMFORT 2 ULTRACOMFORT DISPOSABLE

SYRINGE, -NEEDLE DISPOSABLE, -SYRINGE EMPTY DISPOSABLE

2

UNIFINE PENTIPS 2 VANISHPOINT SYRINGE EMPTY

DISPOSABLE 2

VERSALON ALL PURPOSE SPONGE misc supp (dress,tape,gauze) 2 WEBCOL 2 MUSCULOSKELETAL MEDICATIONS CNS MUSCLE RELAXANTS AMRIX cyclobenzaprine 3 [PAR] carisoprodol compound 1 [PAR] carisoprodol compound-codeine 1 [PAR] carisoprodol tablet 1 [PAR] chlorzoxazone 1 [PAR] cyclobenzaprine hcl tablet 1 [PAR] FEXMID cyclobenzaprine 3 [PAR]


Drug Generic Tier Restrictions FLEXERIL [G] cyclobenzaprine 3 [PAR] metaxalone 1 [PAR] methocarbamol tablet 1 [PAR] NORFLEX [INJ][G] orphenadrine 3 orphenadrine citrate injection [INJ] 1 orphenadrine citrate tablet sustained

action 1 [PAR]

orphenadrine compound 1 [PAR] orphenadrine compound forte 1 [PAR] PARAFON FORTE DSC [G] chlorzoxazone 3 [PAR] RILUTEK riluzole 4 ROBAXIN INJECTION [INJ] methocarbamol 3 ROBAXIN TABLET [G] methocarbamol 3 [PAR] ROBAXIN-750 [G] methocarbamol 3 [PAR] SKELAXIN [G] metaxalone 3 [PAR] SOMA [G] carisoprodol 3 [PAR] DIRECT MUSCLE RELAXANTS ANECTINE [INJ] succinylcholine 3 baclofen tablet 1 DANTRIUM CAPSULE [G] dantrolene 3 DANTRIUM INJECTION [INJ] dantrolene 3 dantrolene sodium 1 DYSPORT [INJ] abobotulinumtoxina 3 LIORESAL INTRATHECAL [INJ] baclofen 2 MYOBLOC [INJ] botulinum toxin type b 2 [PAR] revonto [INJ] 1 tizanidine hcl 1 ZANAFLEX [G] tizanidine 3 DRUGS TO PREVENT AND TREAT GOUT allopurinol sodium [INJ] 1 allopurinol tablet 1 ALOPRIM [INJ][G] allopurinol 3 COLCRYS colchicine 2 probenecid 1 probenecid-colchicine 1 ULORIC febuxostat 2 [ST]


Drug Generic Tier Restrictions ZYLOPRIM [G] allopurinol 3 NON-STEROIDAL ANTIINFLAMMATORY AGENTS ANAPROX [G] naproxen sodium 3 [ST] ANAPROX DS [G] naproxen sodium 3 [ST] ANSAID flurbiprofen 3 [ST] ARTHROTEC 50 diclofenac sodium/misoprostol 3 [ST] ARTHROTEC 75 diclofenac sodium/misoprostol 3 [ST] CAMBIA diclofenac potassium 3 [QLL,

34/28][ST] CATAFLAM [G] diclofenac potassium 3 [ST] CELEBREX celecoxib 2 [ST] CLINORIL [G] sulindac 3 [ST] DAYPRO [G] oxaprozin 3 [ST] diclofenac potassium 1 diclofenac sodium tablet enteric

coated, -tablet sustained release 24hr

1

EC-NAPROSYN [G] naproxen 3 [ST] etodolac 1 FELDENE [G] piroxicam 3 [ST] fenoprofen calcium 1 flurbiprofen tablet 1 ibuprofen 100 mg/5 ml, -100 mg/5

ml sus, -100 mg/5 ml susp, -400 mg tablet, -600 mg tablet, -800 mg tablet

1

INDOCIN I.V. [INJ] indomethacin sodium trihydrate 3 INDOCIN SR indomethacin 3 [ST] INDOCIN SUPPOSITORY RECTAL indomethacin 3 INDOCIN SUSPENSION ORAL indomethacin 3 [ST] indomethacin capsule, -capsule

sustained action 1

indomethacin injection [INJ] 4 ketoprofen capsule, -capsule 24hr

sustained release pellets 1

ketorolac tromethamine injection [INJ]

1

ketorolac tromethamine tablet 1 [QLL, 20/5] meclofenamate sodium capsule 1


Drug Generic Tier Restrictions meloxicam 15 mg tablet, -

suspension oral 1

meloxicam 7.5 mg tablet 1 [QLL, 34/34]

MOBIC 15 MG TABLET, -SUSPENSION ORAL [G]

meloxicam 3 [ST]

MOBIC 7.5 MG TABLET [G] meloxicam 3 [QLL, 34/34][ST]

nabumetone 1 NALFON fenoprofen 3 [ST] NAPRELAN naproxen sodium 3 [ST] NAPRELAN CR DOSE CARD naproxen 3 [ST] NAPROSYN [G] naproxen 3 [ST] naproxen 250 mg tablet, -375 mg

tablet, -suspension oral, -tablet enteric coated

1

naproxen 500 mg tablet 1 naproxen sodium 275 mg tab, -550

mg tab 1

NEOPROFEN [INJ] ibuprofen lysine 3 oxaprozin 1 piroxicam capsule 1 PONSTEL mefenamic acid 3 [ST] sulindac tablet 1 tolmetin sodium 1 TORADOL [INJ] ketorolac 3 VIMOVO naproxen/esomeprazole mag 3 [ST] VOLTAREN TABLET ENTERIC

COATED diclofenac sodium 3 [ST]

VOLTAREN-XR [G] diclofenac sodium 3 [ST] ZIPSOR diclofenac potassium 3 [ST] OTHER DRUGS FOR ARTHRITIS CUPRIMINE penicillamine 2 DEPEN penicillamine 3 gold sodium thiomalate [INJ] 1 myochrysine [INJ] 1 RIDAURA auranofin 2 SYPRINE trientine 2


Drug Generic Tier Restrictions SALICYLATES AND RELATED DRUGS aspirin ec 975 mg tablet 1 choline mag trisalicylate 1 diflunisal 1 EASPRIN aspirin 3 salsalate 1 ZORPRIN aspirin 3 NUTRITION,BLOOD MODIFIERS,ELECTROLYTES ANTIPLATELET DRUGS AGGRASTAT [INJ] tirofib hc m-hyd/na chlor 3 AGGRENOX aspirin/dipyridamole 2 cilostazol 1 dipyridamole tablet 1 EFFIENT prasugrel 2 INTEGRILIN [INJ] eptifibatide 3 PERSANTINE [G] dipyridamole 3 PLAVIX clopidogrel 2 PLETAL [G] cilostazol 3 REOPRO [INJ] abciximab 3 ticlopidine hcl 1 BLOOD DETOXICANTS constulose 1 enulose 1 FOSRENOL lanthanum carbonate 3 generlac 1 KRISTALOSE lactulose 3 lactulose 1 RENAGEL sevelamer 3 RENVELA sevelamer carbonate 2 ELECTROLYTES, IRRIGATING SOLUTIONS, ETC. ALBUMINAR-25 [INJ] albumin human 3 alburx [INJ] 1 albutein [INJ] 1


Drug Generic Tier Restrictions alcohol in dextrose [INJ] 1 AMINOSYN [INJ] amino acids 2 AMINOSYN II [INJ] amino acids 2 AMINOSYN II 3.5% M-DEXTROSE

5% [INJ] amino acids 2

AMINOSYN II 3.5%-DEXTROSE 25% [INJ]

amino acids 2


amino acids 2

AMINOSYN II 4.25% M-DEXT 10% [INJ]

amino acids 2


amino acids 2

AMINOSYN II 5% IN 25% DEXTROSE [INJ]

amino acids 2

AMINOSYN II IN DEXTROSE [INJ] amino acids 2 AMINOSYN II WITH LYTES-CA-DW

[INJ] amino acids 2

AMINOSYN M [INJ] amino acids 2 AMINOSYN WITH ELECTROLYTES

[INJ] amino acids 2

AMINOSYN-HBC [INJ] amino acids 2 AMINOSYN-HF [INJ] amino acids 2 AMINOSYN-PF [INJ] amino acids 2 AMINOSYN-RF [INJ] amino acids 2 AMMONIUM CHLORIDE INJECTION

[INJ] ammonium chloride 2

BRANCHAMIN [INJ] amino acids 2 BUMINATE [INJ] albumin human 3 calcium chloride injection [INJ] 1 CLINIMIX [INJ] amino acids 2 CLINIMIX E [INJ] amino acids 2 CLINISOL [INJ] amino acids 2 CYSTAGON [LA] cysteamine 2 d5w/kcl 10 meq/l iv solution, -30

meq/l iv solution [INJ] 1

dextrose 10%-1/4ns [INJ] 1 dextrose 10%-1/4ns-kcl [INJ] 1 dextrose 2.5%-lr 1/2 str sol [INJ] 1 dextrose 5%-1/2ns-kcl [INJ] 1 dextrose 5%-1/3ns-kcl [INJ] 1


Drug Generic Tier Restrictions dextrose 5%-1/4ns-kcl [INJ] 1 dextrose 5%-electrolyte #48 [INJ] 1 dextrose 5%-electrolyte #75 [INJ] 1 dextrose 5%-ns-kcl [INJ] 1 dextrose in ringers injection [INJ] 1 dextrose in water [INJ] 1 dextrose with sodium chloride [INJ] 1 FLEXBUMIN [INJ] albumin human 3 FREAMINE HBC [INJ] amino acids 3 FREAMINE III [INJ] amino acids 2 FREAMINE III WITH ELECTROLYTES

[INJ] aa 3%/electrolyte-tpn/glycerin 3

HEPATAMINE [INJ] amino acids 2 HEPATASOL [INJ] amino acids 2 HUMAN ALBUMIN 25% IV

SOLUTION [INJ] albumin human 3

HYPERLYTE CR [INJ] electrolyte solutions 3 IONOSOL B WITH DEXTROSE 5%

[INJ] electrolyte solutions 2

IONOSOL MB-DEXTROSE 5% [INJ] electrolyte solutions 2 IONOSOL T-DEXTROSE 5% [INJ] electrolyte solutions 2 ISOLYTE H WITH DEXTROSE [INJ] dextrose/electrolytes 2 ISOLYTE M WITH DEXTROSE [INJ] dextrose/electrolytes 2 ISOLYTE P WITH DEXTROSE [INJ] dextrose/electrolytes 2 ISOLYTE S [INJ] electrolyte solutions 2 ISOLYTE S WITH DEXTROSE [INJ] dextrose/electrolytes 2 kcl 40 meq in d5w-lact ringer [INJ] 1 lactated ringers injection [INJ] 1 magnesium sulfate injection [INJ] 1 MAGNESIUM SULFATE-D5W [INJ] magnesium sulfate/d5w 2 mannitol injection [INJ] 1 NEPHRAMINE [INJ] amino acids 2 NEUT [INJ] sodium bicarbonate 2 NORMOSOL-M AND DEXTROSE

[INJ] dextrose/electrolytes 2

NORMOSOL-R [INJ] electrolyte solutions 2 NORMOSOL-R AND DEXTROSE [INJ] electrolyte solutions 2 NORMOSOL-R PH 7.4 [INJ] electrolyte solutions 2 NOVAMINE [INJ] amino acids 2 nutrilyte [INJ] 1


Drug Generic Tier Restrictions nutrilyte ii [INJ] 1 OSMITROL [INJ] mannitol 3 PLASBUMIN-25 [INJ] albumin human 3 PLASMA-LYTE 148 [INJ] electrolyte solutions 2 PLASMA-LYTE 148 IN DEXTROSE

[INJ] electrolyte solutions 2

PLASMA-LYTE 56 [INJ] electrolyte solutions 2 PLASMA-LYTE 56 IN DEXTROSE

[INJ] d5w/electrolyte-56 solution 2

PLASMA-LYTE A PH 7.4 [INJ] electrolyte solutions 2 PLASMA-LYTE R [INJ] electrolyte solutions 2 potassium chl-normal saline [INJ] 1 potassium chloride-nacl [INJ] 1 PREMASOL [INJ] amino acids 2 PROCALAMINE [INJ] aa 3%/electrolyte-tpn/glycerin 2 PROSOL [INJ] amino acids 3 QUICK MIX WITH LYTES [INJ] amino acids 2 RENAMIN [INJ] amino acids 2 RESECTISOL mannitol 3 R-GENE 10 [INJ] arginine 2 ringers injection [INJ] 1 sodium acetate [INJ] 1 sodium bicarbonate injection [INJ] 1 sodium chloride 0.45% irrig, -0.9%

irrig., -sterile saline 0.9% irr 1

sodium chloride 0.45% soln, -0.45% soln-excel con, -0.9% soln, -0.9% soln., -0.9% soln-excel cont, -0.9% solution, -3% iv soln, -4 meq/ml vl, -5% iv soln, -cl 2.5 meq/ml vial [INJ]

1

sodium lactate [INJ] 1 sodium phosphate injection [INJ] 1 TPN ELECTROLYTES [INJ][G] electrolyte solutions 3 TPN ELECTROLYTES II [INJ] electrolyte solutions 2 TRAVASOL [INJ] amino acids 2 TRAVASOL WITH DEXTROSE [INJ] amino acids 2 TRAVASOL WITH ELECTROLYTES

[INJ] amino acids 2

TRAVERT [INJ] inverted sugar 2 TRAVERT IN NORMAL SALINE [INJ] inverted sugar 2


Drug Generic Tier Restrictions TRAVERT-1/2 NS WITH KCL [INJ] inverted sugar 2 TRAVERT-ELECTROLYTE NO.2 [INJ] inverted sugar 2 TROPHAMINE [INJ] amino acids 2 FLUORIDE PRODUCTS CAVAREST sodium fluoride 3 CAVIRINSE sodium fluoride 3 CLINPRO 5000 sodium fluoride 3 CONTROL RX sodium fluoride 3 denta 5000 plus 1 dentagel 1 easygel 1 epiflur 1 ethedent 1 FLUORABON sodium fluoride 3 FLUOR-A-DAY DROPS sodium fluoride 3 fluor-a-day tablet chewable 1 fluoridex daily defense 1 FLUORIDEX SENSITIVITY RELIEF sodium fluoride/pot nitrate 3 FLUORITAB DROPS sodium fluoride 3 fluoritab tablet chewable 1 flura 1 FLURA-DROPS sodium fluoride 3 GEL-KAM stannous fluoride 3 lozi-flur 1 ludent fluoride 1 LURIDE sodium fluoride 3 neutragard advanced 1 perio med 1 PHOS-FLUR sodium fluoride 3 PREVIDENT sodium fluoride 3 PREVIDENT 5000 sodium fluoride 3 PREVIDENT 5000 PLUS sodium fluoride 3 PREVIDENT 5000 SENSITIVE sodium fluoride/pot nitrate 3 renaf 1 sf 1 sf 5000 plus 1 sodium fluoride drops, -solution

non-oral, -tablet, -tablet chewable 1


Drug Generic Tier Restrictions stanimax 1 stannous fluoride solution 1 HEPARIN ANTAGONISTS PROTAMINE SULFATE [INJ] protamine 3 INJECTABLE ANTICOAGULANTS ARIXTRA 10 MG SYRINGE, -5 MG

SYRINGE, -7.5 MG SYRINGE [INJ] fondaparinux sodium 4

ARIXTRA 2.5 MG SYRINGE [INJ] fondaparinux sodium 2 enoxaparin 100 mg/ml syr, -30

mg/0.3 ml syr, -40 mg/0.4 ml syr, -60 mg/0.6 ml syr, -80 mg/0.8 ml syr [INJ]

1

enoxaparin 120 mg/0.8 ml syr, -150 mg/ml syr [INJ]

4

FRAGMIN 10,000 UNITS SYRINGE, -10,000 UNITS/ML VIAL, -12,500 UNITS SYRINGE, -15,000 UNITS SYRINGE, -18,000 UNITS SYRINGE, -25,000 UNITS/ML VIAL, -7,500 UNITS SYRINGE [INJ]

dalteparin (porcine) 4

FRAGMIN 2,500 UNITS SYRINGE, -5,000 UNITS SYRINGE [INJ]

dalteparin (porcine) 3

heparin sodium in 0.45% nacl [INJ] 1 heparin sodium in 0.9% nacl [INJ] 1 heparin sodium in 5% dextrose

[INJ] 1

heparin sodium injection [INJ] 1 INNOHEP [INJ] tinzaparin sodium, porcine 3 LOVENOX 100 MG PREFILLED SYR, -

120 MG PREFILLED SYR, -150 MG PREFILLED SYR, -300 MG VIAL, -60 MG PREFILLED SYRN, -80 MG PREFILLED SYRN [INJ]

enoxaparin 4

LOVENOX 30 MG PREFILLED SYRN, -40 MG PREFILLED SYRN [INJ]

enoxaparin 2


Drug Generic Tier Restrictions ORAL ANTICOAGULANTS, VITAMIN K ARGATROBAN [INJ] argatroban 3 COUMADIN INJECTION [INJ] warfarin sodium 3 COUMADIN TABLET [G] warfarin sodium 3 jantoven 1 warfarin sodium 1 OTHER DRUGS AFFECTING COAGULATION ANGIOMAX [INJ] bivalirudin 2 ATRYN [INJ] antithrombin iii, human recomb 3 REFLUDAN [INJ] lepirudin,recombinant 2 THROMBATE III [INJ] antithrombin iii,human 3 POTASSIUM REMOVING RESINS kalexate 1 KAYEXALATE [G] sodium polystyrene sulfonate 3 KIONEX POWDER [G] sodium polystyrene sulfonate 3 kionex suspension oral 1 marlexate 1 sodium polystyrene sulfonate 1 sps 1 POTASSIUM SUPPLEMENTS cytra-2 1 dextrose 5%-lr iv solution [INJ] 1 EFFER-K 10 MEQ TABLET EFF, -20

MEQ TABLET EFF potassium bicarb/ca 3

effer-k 25 meq tablet eff 1 epiklor 1 k effervescent 1 KAOCHLOR potassium chloride 3 kaon-cl 10 1 KAY CIEL potassium chloride 3 kcl 20 meq in d5w solution, -20

meq/l iv solution, -40 meq in d5w solution, -40 meq/l iv solution [INJ]

1


Drug Generic Tier Restrictions kcl 20 meq in d5w-lact ringer, -40

meq in d5w-lact ringer [INJ] 1

klor-con 10 1 klor-con 20 meq packet 1 KLOR-CON 25 MEQ PACKET potassium chloride 3 klor-con 8 1 klor-con m10 1 klor-con m15 1 klor-con m20 1 klor-con-ef 1 K-PHOS NEUTRAL phosphorus 3 K-TAB potassium chloride 3 liqui-dualcitra 1 MICRO-K [INJ] potassium chloride 3 ORACIT sodium citrate/citric acid 3 phospha 250 neutral 1 potassium acetate injection [INJ] 1 potassium bicarbonate tablet

effervescent 1

potassium chloride capsule sustained action, -cl 20 meq tab er, -cl er 10 meq tablet, -cl er 20 meq tablet, -cl er 8 meq tablet, -solution

1

potassium chloride injection [INJ] 1 potassium cl 10 meq tab sa, -tablet

effervescent 1

sodium citrate & citric acid 1 vis-phos n 1 THERAPEUTIC VITAMINS AND MINERALS CALCIJEX [INJ][G] calcitriol 3 calcitriol capsule, -solution 1 calcitriol injection [INJ] 1 calcium acetate 1 CARNITOR INJECTION [INJ][G] levocarnitine 3 CARNITOR SF levocarnitine 3 CARNITOR SOLUTION, -TABLET [G] levocarnitine 3 eliphos 1 HECTOROL CAPSULE doxercalciferol 3 HECTOROL INJECTION [INJ] doxercalciferol 3


Drug Generic Tier Restrictions levocarnitine injection [INJ] 1 levocarnitine solution, -tablet 1 PHOSLO [G] calcium acetate 3 ROCALTROL [G] calcitriol 3 ZEMPLAR CAPSULE paricalcitol 2 ZEMPLAR INJECTION [INJ] paricalcitol 2 VITAMINS AND MINERALS AND RELATED PRODUCTS INTRALIPID 30% IV FAT EMUL

[INJ][G] fat emulsions 2

INTRALIPID 10% IV FAT EMUL, -20% IV FAT EMUL [INJ][G]

fat emulsions 3

LIPOSYN II [INJ] fat emulsions 2 liposyn iii [INJ] 1 NUTRESTORE glutamine 2 OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS ABORTIFACIENTS CERVIDIL dinoprostone 3 HEMABATE [INJ] carboprost tromethamine 2 PROSTIN E2 VAGINAL

SUPPOSITORY dinoprostone 2

ANDROGEN DRUGS ANADROL-50 oxymetholone 4 [PAR] ANDRODERM testosterone 3 [PAR] ANDROGEL testosterone 2 [PAR] ANDROID methyltestosterone 3 ANDROXY fluoxymesterone 2 danazol capsule 1 DELATESTRYL [INJ][G] testosterone enanthate 3 DEPO-TESTOSTERONE [INJ][G] testosterone cypionate 3 FIRST-TESTOSTERONE testosterone propionate 3 FIRST-TESTOSTERONE MC testosterone propionate 3 METHITEST methyltestosterone 2 OXANDRIN 10 MG TABLET [G] oxandrolone 4 [PAR] OXANDRIN 2.5 MG TABLET [G] oxandrolone 3 [PAR]


Drug Generic Tier Restrictions oxandrolone 1 [PAR] STRIANT testosterone 3 [PAR] TESTIM testosterone 2 [PAR] TESTOPEL [INJ] testosterone 2 testosterone cypionate injection

[INJ] 1

testosterone enanthate [INJ] 1 TESTRED methyltestosterone 3 CONTRACEPTIVES apri 1 aranelle 1 aviane 1 azurette 1 balziva 1 BREVICON [G] norethindrone-ethin estradiol 3 caziant 1 cesia 1 cryselle 1 CYCLESSA [G] desogestrel-ethinyl estradiol 3 DEMULEN 1-50-21 ethynodiol diace-eth estradiol 3 DESOGEN [G] desogestrel-ethinyl estradiol 3 enpresse 1 ESTROSTEP FE [G] noreth a-et estra/fe fumarate 3 FEMCON FE noreth-ethinyl estradiol/iron 3 gianvi 1 gildess fe 1 jolessa 1 junel 1 junel fe 1 kariva 1 kelnor 1-35 1 leena 1 lessina 1 LEVLEN 28 levonorgestrel-ethin estradiol 3 levora-28 1 LOESTRIN [G] norethindrone a-e estradiol 3 LOESTRIN 24 FE noreth a-et estra/fe fumarate 3 LOESTRIN FE [G] noreth a-et estra/fe fumarate 3


Drug Generic Tier Restrictions LO-OVRAL-28 [G] norgestrel-ethinyl estradiol 3 LOSEASONIQUE l-norgest-eth estr/ethin estr 3 low-ogestrel 1 lutera 1 LYBREL levonorgestrel-ethin estradiol 3 microgestin 1 microgestin fe 1 MIRCETTE desog-et estra/ethin estra 3 MODICON [G] norethindrone-ethin estradiol 3 mononessa 1 NATAZIA estradiol valerate/dienogest 3 necon 1 next choice 1 NORDETTE-28 [G] levonorgestrel-ethin estradiol 3 norgestrel-ethiny estra 1 NORINYL 1+35 [G] norethindrone-ethin estradiol 3 NORINYL 1+50 norethindrone-mestranol 3 nortrel 1 NUVARING etonogestrel/ethin estradiol 3 ocella 1 ogestrel 1 ORTHO EVRA ethinyl estradiol/norelgest 3 ORTHO TRI-CYCLEN norgestimate-ethinyl estradiol 3 ORTHO TRI-CYCLEN LO norgestimate-ethinyl estradiol 3 ORTHO-CEPT [G] desogestrel-ethinyl estradiol 3 ORTHO-CYCLEN [G] norgestimate-ethinyl estradiol 3 ORTHO-NOVUM [G] norethindrone-ethin estradiol 3 OVCON-35 [G] norethindrone-ethin estradiol 3 OVCON-50 norethindrone-ethin estradiol 3 PLAN B [G] levonorgestrel 3 PLAN B ONE-STEP levonorgestrel 3 portia 1 previfem 1 quasense 1 reclipsen 1 SEASONALE [G] levonorgestrel-ethin estradiol 3 SEASONIQUE l-norgest-eth estr/ethin estr 3 solia 1 sprintec 1 sronyx 1


Drug Generic Tier Restrictions tilia fe 1 tri-legest fe 1 tri-lo-sprintec 1 trinessa 1 TRI-NORINYL [G] norethindrone-ethin estradiol 3 tri-previfem 1 tri-sprintec 1 trivora-28 1 velivet 1 YASMIN 28 [G] eth estradiol/drospirenone 3 YAZ [G] eth estradiol/drospirenone 3 zenchent 1 zovia 1-35e 1 zovia 1-50e 1 ESTROGEN DRUGS ALORA estradiol 3 [QLL,

10/35] CENESTIN estrogen,conjug,synthetic a 3 CLIMARA [G] estradiol 3 [QLL, 5/35] DELESTROGEN [INJ][G] estradiol valerate 3 DEPO-ESTRADIOL [INJ] estradiol cypionate 3 DIVIGEL estradiol 3 [QLL,

34/34] ELESTRIN estradiol 3 [QLL, 144

gm/34] ENJUVIA estrogen,conjug,synthetic b 2 ESTRACE CREAM WITH

APPLICATOR estradiol 2

ESTRACE TABLET [G] estradiol 3 ESTRADERM estradiol 2 [QLL,

10/35] estradiol patch transdermal weekly 1 [QLL, 5/35] estradiol tablet 1 estradiol valerate injection [INJ] 1 ESTRASORB estradiol 3 [QLL,

118/34] ESTRING estradiol 2 ESTROGEL estradiol 3 [QLL, 100

gm/34]


Drug Generic Tier Restrictions estropipate 1 EVAMIST estradiol 3 [QLL, 16

ml/34] FEMRING estradiol 3 FEMTRACE estradiol 3 GYNODIOL estradiol 3 MENEST estrogens,esterified 3 MENOSTAR estradiol 3 [QLL, 5/35] OGEN [G] estropipate 3 ORTHO-EST estropipate 3 PREMARIN CREAM WITH

APPLICATOR, -TABLET estrogens,conjugated 2

PREMARIN INJECTION [INJ] estrogens,conjugated 2 VAGIFEM estradiol 2 VIVELLE estradiol 2 [QLL,

10/35] VIVELLE-DOT estradiol 2 [QLL,

10/35] ESTROGEN/PROGESTIN COMBINATIONS ACTIVELLA [G] estradiol/noreth ac 3 ANGELIQ estradiol/drospirenone 3 CLIMARA PRO estradiol/levonorgestrel 2 [QLL, 5/35] COMBIPATCH estradiol/noreth ac 2 estradiol-norethindrone acetat 1 FEMHRT norethindrone a-e estradiol 3 mimvey 1 PREFEST estradiol/norgestimate 3 PREMPHASE estrogen/medroxyprogesterone 2 PREMPRO estrogen/medroxyprogesterone 2 OB/GYN TOPICAL ANTIINFECTIVES ACID JELLY acetic ac/ricinoleic/oxyquinol 3 AVC sulfanilamide 3 CLEOCIN [G] clindamycin phosphate 3 CLINDAMAX CREAM WITH

APPLICATOR clindamycin phosphate 3

clindamycin phosphate cream with applicator

1


Drug Generic Tier Restrictions CLINDESSE clindamycin phosphate 3 fem ph 1 METROGEL-VAGINAL [G] metronidazole 3 metronidazole gel with applicator 1 RELAGARD acetic acid/oxyquin so4 3 vandazole 1 OXYTOCICS METHERGINE INJECTION [INJ] methylergonovine 2 METHERGINE TABLET methylergonovine 2 oxytocin injection [INJ] 1 PITOCIN [INJ] oxytocin 3 PRENATAL VITAMINS advanced care plus 1 advanced natalcare 1 ATABEX prenatal vit( = or > 1mg fa) 3 ATABEX EC prenatal vit( = or > 1mg fa) 3 cal-nate 1 carenatal dha 1 cavan one omega 1 cavan-alpha kit 1 cavan-ec sod dha 1 CITRANATAL 90 DHA prenatal vit( = or > 1mg fa) 3 CITRANATAL ASSURE prenatal vit( = or > 1mg fa) 3 CITRANATAL B-CALM prenatal vit( = or > 1mg fa) 3 CITRANATAL DHA prenatal vit( = or > 1mg fa) 3 CITRANATAL HARMONY prenatal vit( = or > 1mg fa) 3 CITRANATAL RX prenatal vit( = or > 1mg fa) 3 combi rx 1 complete natal dha 1 completenate 1 COMPLETE-RF PRENATAL prenatal vit( = or > 1mg fa) 3 co-natal fa 1 CONCEPT DHA prenatal vit( = or > 1mg fa) 3 CONCEPT OB prenatal vit( = or > 1mg fa) 3 docosavit 1 dualvit ob 1


Drug Generic Tier Restrictions DUET DHA prenatal vit( = or > 1mg fa) 3 DUET DHA COMPLETE prenatal vit( = or > 1mg fa) 3 DUET DHA EC prenatal vit( = or > 1mg fa) 3 DUET DHA WITH FERRAZONE prenatal vit( = or > 1mg fa) 3 DUET STUARTNATAL prenatal vit( = or > 1mg fa) 3 edge ob 1 elite ob dha 1 elite-ob 1 fe c plus tablet 1 FEMECAL OB prenatal vit( = or > 1mg fa) 3 FEMECAL OB PLUS DHA prenatal vit( = or > 1mg fa) 3 folbecal 1 folcal dha 1 folcaps omega-3 1 folinatal plus b 1 folivane-ec calcium dha nf 1 folivane-ob 1 folivane-prx dha nf 1 foltabs 1 foltabs 90 plus dha 1 FOLTABS PRENATAL PLUS DHA prenatal vit( = or > 1mg fa) 3 gentex ade 1 GESTICARE prenatal vit( = or > 1mg fa) 3 GESTICARE DHA prenatal vit( = or > 1mg fa) 3 hip prenatal 1 ICAR-C PLUS iron,carbonyl/vit c/vit b12/fa 3 inatal advance 1 inatal gt 1 inatal ultra 1 kolnatal dha 1 LACTOCAL-F prenatal vit( = or > 1mg fa) 3 MARNATAL-F prenatal vit( = or > 1mg fa) 3 MARNATAL-F PLUS prenatal vit( = or > 1mg fa) 3 maternity 1 MAXINATE prenatal vitamins (< 1mg fa) 3 multinatal plus 1 multi-nate 30 1 multi-nate 30 dha 1 multi-nate dha extra 1 M-VIT prenatal vit( = or > 1mg fa) 3


Drug Generic Tier Restrictions mynatal 1 mynatal advance 1 mynatal plus 1 mynatal-z 1 mynate 90 plus 1 natacaps 1 NATACHEW prenatal vitamins (< 1mg fa) 3 NATAFORT prenatal vitamins (< 1mg fa) 3 natalcare pic forte 1 natalcare plus 1 NATALVIT prenatal vit( = or > 1mg fa) 3 natatab 1 NATELLE prenatal vit( = or > 1mg fa) 3 NATELLE C prenatal vit( = or > 1mg fa) 3 NATELLE ONE prenatal vit( = or > 1mg fa) 3 NATELLE PLUS prenatal vit( = or > 1mg fa) 3 NATELLE PREFER prenatal vit( = or > 1mg fa) 3 NATELLE-EZ prenatal vit( = or > 1mg fa) 3 NEEVO prenatal vit( = or > 1mg fa) 3 NEEVO DHA prenatal vit( = or > 1mg fa) 3 NOVANATAL prenatal vit( = or > 1mg fa) 3 NOVASTART prenatal vit( = or > 1mg fa) 3 nutrinate 1 nutrispire 1 ob + dha 1 ob 90 + dha 1 OB COMPLETE prenatal vitamins (< 1mg fa) 3 OB COMPLETE 400 prenatal vitamins (< 1mg fa) 3 OB COMPLETE DHA prenatal vitamins (< 1mg fa) 3 ob-natal one 1 OBSTETRIX DHA prenatal vit( = or > 1mg fa) 3 OBSTETRIX EC prenatal vit( = or > 1mg fa) 3 OBTREX prenatal vit( = or > 1mg fa) 3 OBTREX DHA prenatal vit( = or > 1mg fa) 3 O-CAL FA prenatal vit( = or > 1mg fa) 3 O-CAL PRENATAL prenatal vit( = or > 1mg fa) 3 OPTINATE prenatal vit( = or > 1mg fa) 3 pnv-dha 1 PNV-DHA PLUS prenatal vit( = or > 1mg fa) 3 pnv-iron 1


Drug Generic Tier Restrictions pnv-omega 1 pnv-select 1 poly iron pn 1 POLY IRON PN FORTE prenatal vitamins (< 1mg fa) 3 PR NATAL 400 prenatal vit( = or > 1mg fa) 3 PR NATAL 400 EC prenatal vit( = or > 1mg fa) 3 pr natal 430 1 pr natal 430 ec 1 pr natal 440 ec 1 PRECARE prenatal vitamins (< 1mg fa) 3 PRECARE CONCEIVE prenatal vitamins (< 1mg fa) 3 PRECARE PREMIER prenatal vit( = or > 1mg fa) 3 PREFERA-OB prenatal vit( = or > 1mg fa) 3 PREFERA-OB ONE prenatal vit( = or > 1mg fa) 3 PREFERA-OB PLUS DHA prenatal vit( = or > 1mg fa) 3 PREMESIS RX prenatal vitamins (< 1mg fa) 3 prenacare 1 prenafirst 1 prenaplus 1 prenatabs fa 1 prenatabs obn 1 prenatabs rx 1 prenatal 19 1 prenatal ad 1 prenatal formula tablet 1 prenatal low iron 1 prenatal mr 90 fe 1 prenatal multivitamin w-iron 1 prenatal plus 1 prenatal rx 1 1 prenatal z 1 prenatal-u 1 PRENATE DHA prenatal vit( = or > 1mg fa) 3 PRENATE ELITE prenatal vit( = or > 1mg fa) 3 PRENATE ESSENTIAL prenatal vit( = or > 1mg fa) 3 prenate plus 1 PRENEXA prenatal vitamins (< 1mg fa) 3 PREQUE 10 prenatal vitamins (< 1mg fa) 3 previt+dha 1 previte rx 1


Drug Generic Tier Restrictions PRIMACARE prenatal vit( = or > 1mg fa) 3 PRIMACARE ADVANTAGE prenatal vit( = or > 1mg fa) 3 PRIMACARE ONE prenatal vit( = or > 1mg fa) 3 pruet dha 1 pruet dha ec 1 re-nata 29 1 re-nata 29 ob 1 renate 1 renate dha 1 renate dha extra 1 rovin-nv 1 rovin-nv dha 1 se-care 1 se-care conceive 1 se-care gesture 1 SELECT-OB prenatal vit( = or > 1mg fa) 3 SELECT-OB + DHA prenatal vit( = or > 1mg fa) 3 se-natal 19 1 se-natal 90 1 se-natal one 1 se-plete dha 1 se-tan dha 1 setonet 1 setonet-ec 1 TANDEM DHA prenatal vit( = or > 1mg fa) 3 TANDEM OB prenatal vit( = or > 1mg fa) 3 taron a prenatal 1 taron ec calcium 1 taron-c dha 1 taron-ec cal 1 taron-prex prenatal 1 tri rx 1 triadvance 1 TRICARE prenatal vit( = or > 1mg fa) 3 TRICARE DHA prenatal vit( = or > 1mg fa) 3 TRICARE PRENATAL DHA ONE prenatal vit( = or > 1mg fa) 3 trifera ob 1 trimesis rx 1 trinatal rx 1 1 trinate 1


Drug Generic Tier Restrictions triveen-one 1 triveen-prx rnf 1 triveen-u 1 TRUST NATAL DHA prenatal vit( = or > 1mg fa) 3 ultimatecare advantage 1 ULTIMATECARE COMBO prenatal vit( = or > 1mg fa) 3 ultimatecare one 1 ultimatecare one nf 1 vinacal 1 vinate az 1 vinate az extra 1 vinate c 1 vinate calcium 1 vinate care 1 vinate gt 1 vinate ic 1 vinate ii 1 vinate iii 1 vinate one 1 vinate pn care 1 vinate ultra 1 vinate-m 1 vitafol-ob 1 VITAFOL-OB+DHA prenatal vit( = or > 1mg fa) 3 vitafol-pn 1 vitanatal ob + dha 1 vitaphil 1 vitaphil + dha 1 vitaphil + dha 90 1 vitaphil aide 1 vitaspire 1 VIVA DHA prenatal vitamins (< 1mg fa) 3 VOL-TAB RX prenatal vit( = or > 1mg fa) 3 vynatal-fa 1 zatean-pn 1 zatean-pn dha 1 zatean-pn plus 1


Drug Generic Tier Restrictions PROGESTIN DRUGS AYGESTIN [G] norethindrone acetate 3 camila 1 CRINONE progesterone 3 DEPO-PROVERA 150 MG/ML VIAL

[INJ][G] medroxyprogesterone 3 [QLL, 1

ml/90] DEPO-SUBQ PROVERA 104 [INJ] medroxyprogesterone 3 [QLL, 1

syringe/90] errin 1 FIRST-PROGESTERONE VGS 100 progesterone 2 FIRST-PROGESTERONE VGS 200 progesterone 2 FIRST-PROGESTERONE VGS 25 progesterone 2 FIRST-PROGESTERONE VGS 400 progesterone 2 FIRST-PROGESTERONE VGS 50 progesterone 2 jolivette 1 medroxyprogesterone acetate

injection [INJ] 1 [QLL, 1

ml/90] medroxyprogesterone acetate tablet 1 MICRONOR [G] norethindrone 3 nora-be 1 norethindrone acetate tablet 1 NOR-Q-D [G] norethindrone 3 PROCHIEVE progesterone 3 progesterone in oil [INJ] 1 progesterone injection [INJ] 1 PROMETRIUM progesterone 2 PROVERA [G] medroxyprogesterone 3 SPECIALIZED OB/GYN DRUGS leuprolide acetate [INJ] 1 LUPRON [INJ] leuprolide 4 LUPRON DEPOT 11.25 MG 3MO KIT,

-22.5 MG 3MO KIT, -3.75 MG KIT, -4 MONTH KIT [INJ]

leuprolide 2 [PAR]

LUPRON DEPOT 7.5 MG KIT [INJ] leuprolide 4 [PAR] LUPRON DEPOT-PED [INJ] leuprolide 4 [PAR] PREPIDIL dinoprostone 3 SUPPRELIN LA [INJ] histrelin ac 4


Drug Generic Tier Restrictions SYNAREL nafarelin 4 OPHTHALMIC MEDICATIONS ANTIGLAUCOMA DRUGS acetazolamide capsule sustained

action, -tablet 1

acetazolamide sodium [INJ] 1 ALPHAGAN P 0.1% DROPS brimonidine tartrate 2 ALPHAGAN P 0.15% EYE DROPS [G] brimonidine tartrate 3 apraclonidine hcl 1 AZOPT brinzolamide 3 BETAGAN [G] levobunolol 3 [ST] betaxolol hcl drops 1 BETIMOL timolol 3 [ST] BETOPTIC S betaxolol 3 [ST] brimonidine 0.2% eye drop 1 brimonidine tartrate 0.15% drp 1 carteolol hcl 1 COMBIGAN brimonidine tartrate/timolol 2 [ST] COSOPT [G] dorzolamide/timolol 3 [ST] DIAMOX SEQUELS [G] acetazolamide 3 dorzolamide hcl 1 dorzolamide-timolol 1 IOPIDINE [G] apraclonidine 3 ISOPTO CARBACHOL carbachol 3 ISOPTO CARPINE pilocarpine hcl 3 ISTALOL timolol 3 [ST] levobunolol hcl 1 LUMIGAN bimatoprost 3 methazolamide 1 metipranolol 1 MIOSTAT [INJ] carbachol 3 OPTIPRANOLOL [G] metipranolol 3 [ST] PHOSPHOLINE IODIDE echothiophate iodide 2 pilocarpine hcl drops 1 PILOPINE HS pilocarpine hcl 2 PROPINE dipivefrin 3 timolol maleate drops, -gel-forming

solution 1


Drug Generic Tier Restrictions TIMOPTIC timolol 3 [ST] TIMOPTIC OCUDOSE timolol 3 [ST] TIMOPTIC-XE [G] timolol 3 [ST] TRAVATAN travoprost 2 TRAVATAN Z travoprost 2 TRUSOPT [G] dorzolamide 3 XALATAN latanoprost 2 OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS BLEPHAMIDE sulfacetamide/prednisolone ac 3 BLEPHAMIDE S.O.P. sulfacetamide/prednisolone ac 3 CORTISPORIN SUSPENSION DROPS neomycin sulfate/polymyxin/hc 3 cortomycin ointment 1 dexasporin 1 MAXITROL [G] neomycin/polymyxin/dexameth 3 methadex 1 neomycin-bacitracin-poly-hc 1 neomycin-polymyxin-dexameth 1 neomycin-polymyxin-hc suspension

drops 1

poly-dex 1 POLY-PRED neomycin/polymyxin/prednisol 2 PRED-G gentamicin/prednisolone 2 sulfacetamide-prednisolone 1 TOBRADEX [G] tobramycin sulfate/dexameth 3 tobramycin-dexamethasone 1 ZYLET tobramycin/lotepred etab 2 OPHTHALMIC CORTICOSTEROID DRUGS ALREX loteprednol etabonate 2 dexamethasone sodium phosphate

drops 1

dexasol 1 DUREZOL difluprednate 3 FLAREX fluorometholone 3 fluorometholone 1 FML [G] fluorometholone 3 FML FORTE fluorometholone 3


Drug Generic Tier Restrictions FML S.O.P. fluorometholone 2 LOTEMAX loteprednol etabonate 2 MAXIDEX dexamethasone 3 OMNIPRED [G] prednisolone acetate 3 PRED FORTE [G] prednisolone acetate 3 PRED MILD prednisolone acetate 2 prednisol 1 prednisolone acetate suspension

drops 1

prednisolone sodium phosphate drops

1

RETISERT fluocinolone acetonide 3 TRIESENCE [INJ] triamcinolone acetonide 3 VEXOL rimexolone 3 OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS ak-poly-bac 1 aktob 1 AZASITE azithromycin 2 bacitracin 500 unit/gm ointmnt 1 bacitracin-polymyxin eye oint 1 BESIVANCE besifloxacin 3 BLEPH-10 [G] sulfacetamide sodium 3 CILOXAN [G] ciprofloxacin 3 ciprofloxacin hcl drops 1 erythromycin ointment 1 gentak 1 gentamicin 3 mg/gm eye oint 1 gentamicin sulfate drops 1 gentasol 1 IQUIX levofloxacin 3 neocidin 1 neomycin-bacitracin-polymyxin 1 neomycin-polymyxin-gramicidin 1 NEOSPORIN DROPS [G] neomycin/gramicidin/polymyxin 3 OCUFLOX [G] ofloxacin 3 ofloxacin drops 1 polycin-b 1 polymyxin b sul-trimethoprim 1


Drug Generic Tier Restrictions POLYTRIM [G] polymyxin b sulfate/tmp 3 QUIXIN levofloxacin 3 romycin 1 sulfac 1 sulfacetamide sodium drops 1 sulfamide 1 TERRAMYCIN WITH POLYMYXIN oxytetracycline hcl/polymyxin 3 tobramycin sulfate drops 1 tobrasol 1 TOBREX [G] tobramycin 3 VIGAMOX moxifloxacin 2 ZYMAR gatifloxacin 2 ZYMAXID gatifloxacin 2 OPHTHALMIC TOPICAL ANTIVIRAL DRUGS trifluridine 1 VIROPTIC [G] trifluridine 3 OTHER OPHTHALMIC DRUGS ACULAR [G] ketorolac 3 ACULAR LS [G] ketorolac 3 ACULAR PF ketorolac 3 ACUVAIL ketorolac 3 ak-con 1 ak-dilate 1 akorn balanced salt 1 ak-pentolate 1 AKTEN lidocaine 3 ALAMAST pemirolast potassium 3 ALBALON naphazoline 3 ALCAINE [G] proparacaine 3 allersol 1 ALOCRIL nedocromil 3 ALOMIDE lodoxamide 3 altafrin 1 atropine care 1 atropine sulfate drops, -ointment 1 azelastine hcl drops 1


Drug Generic Tier Restrictions BEPREVE bepotastine besilate 3 BETADINE SOLUTION povidone-iodine 3 BOTOX [INJ] botulinum toxin a 2 [PAR] BSS [INJ] sodium/calcium/mag/potassium 3 BSS PLUS sodium/calcium/mag/potassium 3 CROLOM cromolyn 3 cromolyn sodium drops 1 CYCLOGYL 0.5% EYE DROPS, -2%

EYE DROPS cyclopentolate 3

CYCLOGYL 1% EYE DROPS [INJ] cyclopentolate 3 cyclopentolate hcl 1 cylate 1 diclofenac sodium drops 1 ELESTAT epinastine hcl 3 EMADINE emedastine difumarate 3 flurbiprofen sodium 1 homatropaire 1 homatropine 1 ISOPTO ATROPINE atropine sulfate 3 ISOPTO HOMATROPINE homatropine hbr 3 ISOPTO HYOSCINE scopolamine 3 ketorolac tromethamine drops 1 LACRISERT hydroxypropylmethylcellulose 3 LUCENTIS [INJ] ranibizumab 3 MACUGEN [INJ] pegaptanib sodium 3 MYDFRIN phenylephrine hcl 3 mydral 1 MYDRIACYL [G] tropicamide 3 naphazoline hcl drops 1 NATACYN natamycin 2 neofrin 1 NEVANAC nepafenac 2 OCUFEN [G] flurbiprofen 3 OPHTHETIC proparacaine 3 OPTIVAR [G] azelastine hcl 3 parcaine 1 PATADAY olopatadine hcl 2 PATANOL olopatadine hcl 2 phenylephrine hcl drops 1 proparacaine hcl 1


Drug Generic Tier Restrictions RESTASIS cyclosporine 2 [QLL, 60

vials/30] tropicacyl 1 tropicamide 1 VISUDYNE [INJ] verteporfin 2 VITRASERT ganciclovir 3 VOLTAREN DROPS [G] diclofenac sodium 3 XIBROM bromfenac 3 ZIRGAN ganciclovir 3 RESPIRATORY MEDICATIONS ANTIHISTAMINE/DECONGESTANT COMBINATIONS ALLEGRA-D 12 HOUR [G] pse/fexofenadine 3 [QLL,

68/34][ST] ALLEGRA-D 24 HOUR pse/fexofenadine 3 [QLL,

34/34][ST] CLARINEX-D 12 HOUR pse/desloratadine 3 [QLL,

68/34][ST] CLARINEX-D 24 HOUR pse/desloratadine 3 [QLL,

34/34][ST] fexofenadine-pse er 1 [QLL,

68/34] promethazine vc 1 [PAR] SEMPREX-D pse/acrivas 3 ANTIHISTAMINES ALLEGRA 180 MG TABLET [G] fexofenadine 3 [QLL,

34/34][ST] ALLEGRA 60 MG TABLET [G] fexofenadine 3 [QLL,

68/34][ST] ALLEGRA ODT fexofenadine 3 [QLL,

68/34][ST] ALLEGRA SUSPENSION ORAL fexofenadine 3 [ST] ben-tann 1 [PAR] carbinoxamine maleate 1 cetirizine 1 mg/1 ml soln, -1 mg/ml

soln, -1 mg/ml syrup, -5 mg/5 ml syrup

1

CLARINEX SYRUP desloratadine 3 [ST]


Drug Generic Tier Restrictions CLARINEX TABLET, -TABLET

DISPERSIBLE LINGUAL desloratadine 3 [QLL,

34/34][ST] clemastine fum 2.68 mg tab, -syrup 1 complete allergy medicine 1 [PAR] cyproheptadine hcl syrup, -tablet 1 [PAR] dexchlorpheniramine maleate 1 [PAR] diphenhydramine 12.5 mg/5 ml, -25

mg cap, -50 mg cap, -50 mg capsule 1 [PAR]

diphenhydramine hcl injection [INJ] 1 diphenmax 1 [PAR] DYTAN diphenhydramine tannate 3 [PAR] fexofenadine hcl 180 mg tablet 1 [QLL,

34/34] fexofenadine hcl 30 mg tablet, -60

mg tablet 1 [QLL,

68/34] palgic 1 PHENERGAN [INJ][G] promethazine 3 promethazine hcl injection [INJ] 1 promethazine hcl syrup, -tablet 1 [PAR] tripohist 1 triprolidine hcl syrup 1 XYZAL SOLUTION levocetirizine dihydrochlor 2 [ST] XYZAL TABLET levocetirizine dihydrochlor 2 [QLL,

34/34][ST] ZYMINE [INJ] triprolidine hcl 3 ZYMINE XR triprolidine hcl 3 BETA-2 ADRENERGIC DRUGS albuterol sulfate nebs, -solution non-

oral, -syrup, -tablet, -tablet sustained release 12hr, -vial nebulizer

1

FORADIL formoterol fumarate 2 [QLL, 120/34]

MAXAIR AUTOHALER pirbuterol 3 [QLL, 28/34]

metaproterenol sulfate syrup, -tablet 1 PROAIR HFA albuterol 2 [QLL, 26

gm/34]


Drug Generic Tier Restrictions PROVENTIL HFA albuterol 3 [QLL, 20

gm/34] SEREVENT DISKUS salmeterol 2 [QLL, 120

doses/34] terbutaline sulfate injection [INJ] 1 terbutaline sulfate tablet 1 VENTOLIN HFA albuterol 2 [QLL, 54

gm/34] VOSPIRE ER [G] albuterol 3 XOPENEX HFA levalbuterol 3 [QLL, 45

gm/34] LEUKOTRIENE MODIFIERS ACCOLATE zafirlukast 3 SINGULAIR montelukast sodium 2 ZYFLO zileuton 3 ZYFLO CR zileuton 2 METHYL XANTHINE DRUGS aminophylline injection [INJ] 1 aminophylline tablet 1 CAFCIT SOLUTION [INJ] caffeine citrated 3 caffeine citrate solution 1 dylix 1 ELIXOPHYLLIN theophylline 3 LUFYLLIN dyphylline 3 THEO-24 theophylline 3 theochron 1 theophylline 1 theophylline anhydrous tablet

sustained release 12hr 1

UNIPHYL theophylline 3 OTHER DRUGS FOR ASTHMA ADRENACLICK [INJ] epinephrine hcl 3 [QLL, 4/2] ADRENALIN CHLORIDE INJECTION

[INJ] epinephrine hcl 3


Drug Generic Tier Restrictions ADRENALIN CHLORIDE SOLUTION

NON-ORAL epinephrine hcl 3

ADVAIR DISKUS salmeterol/fluticasone 2 [QLL, 120 doses/34]

ADVAIR HFA salmeterol/fluticasone 2 [QLL, 24 gm/34]

AEROBID flunisolide 3 [QLL, 21/34]

AEROBID-M flunisolide 3 [QLL, 21 gm/34]

ALVESCO 160 MCG INHALER ciclesonide 3 [QLL, 18 gm/34]

ALVESCO 80 MCG INHALER ciclesonide 3 [QLL, 12 gm/34]

ASMANEX TWISTHALER 110 MCG #30

mometasone 2 [QLL, 60 doses/30]







ASMANEX TWISTHALR 220 MCG #120


ATROVENT HFA ipratropium 2 [QLL, 26 gm/34]

AZMACORT triamcinolone acetonide 3 [QLL, 60/34]

COMBIVENT albuterol sulfate/ipratropium 2 [QLL, 44 gm/34]

cromolyn sodium ampul for nebulization

1

DULERA mometasone/formoterol 3 [PAR][QLL, 120/30]

epinephrine 0.1 mg/ml syringe, -1 mg/ml ampul, -1 mg/ml vial [INJ]

1

EPINEPHRINE 0.15 MG AUTO-INJCT, -0.3 MG AUTO-INJECT [INJ]

epinephrine hcl 3 [QLL, 4/2]

EPINEPHRINE 0.3 MG/0.3 ML SYR [INJ]

epinephrine hcl 2

EPIPEN [INJ] epinephrine hcl 2 [QLL, 4 pens/2]


Drug Generic Tier Restrictions EPIPEN JR [INJ] epinephrine hcl 2 [QLL, 4

pens/2] FLOVENT 100 MCG DISKUS, -50

MCG DISKUS fluticasone propionate 2 [QLL, 120

doses/34] FLOVENT 250 MCG DISKUS fluticasone propionate 2 [QLL, 300

doses/34] FLOVENT HFA 110 MCG INHALER fluticasone propionate 2 [QLL, 12

gm/34] FLOVENT HFA 220 MCG INHALER fluticasone propionate 2 [QLL, 36

gm/34] FLOVENT HFA 44 MCG INHALER fluticasone propionate 2 [QLL, 21

gm/34] GASTROCROM cromolyn 2 INTAL cromolyn 2 ipratropium bromide solution non-

oral 1

PULMICORT 180 MCG FLEXHALER budesonide 3 [QLL, 3 inhalers/34]

PULMICORT 90 MCG FLEXHALER budesonide 3 [QLL, 2 inhalers/34]

QVAR beclomethasone 2 [QLL, 22 gm/34]

SPIRIVA tiotropium bromide 2 [QLL, 60 capsules/34]

SYMBICORT budesonide/formoterol fum 2 [QLL, 20 gm/34]

TWINJECT [INJ] epinephrine hcl 3 [QLL, 4 pens/2]

XOLAIR [INJ][LA] omalizumab 4 [PAR][QLL, 6/28]

OTHER RESPIRATORY DRUGS ARALAST [INJ][LA] alpha-1-proteinase inhibitor 4 [PAR] PROLASTIN [INJ][LA] alpha-1-proteinase inhibitor 4 [PAR] ZEMAIRA [INJ][LA] alpha-1-proteinase inhibitor 4 [PAR] UROLOGICAL MEDICATIONS ANTICHOLINERGIC ANTISPASMODICS DETROL tolterodine tartrate 3 [ST]


Drug Generic Tier Restrictions DETROL LA tolterodine tartrate 3 [ST] DITROPAN XL 10 MG TABLET, -15

MG TABLET [G] oxybutynin 3 [ST]

DITROPAN XL 5 MG TABLET, -5 MG TABLET SA [G]

oxybutynin 3 [QLL, 34/34][ST]

ENABLEX darifenacin hydrobromide 2 [ST] flavoxate hcl 1 GELNIQUE oxybutynin 3 [QLL,

34/34][ST] oxybutynin chloride syrup, -tablet 1 oxybutynin cl er 10 mg tablet, -cl er

15 mg tablet 1

oxybutynin cl er 5 mg tablet 1 [QLL, 34/34]

OXYTROL oxybutynin 3 [QLL, 10/35][ST]

SANCTURA trospium chloride 2 [ST] SANCTURA XR trospium chloride 2 [ST] TOVIAZ fesoterodine fumarate 3 [ST] VESICARE solifenacin succinate 3 [ST] CHOLINERGIC STIMULANTS bethanechol chloride tablet 1 URECHOLINE [G] bethanechol 3 OTHER GENITOURINARY PRODUCTS acetic acid 0.25% irrig soln 1 AVODART dutasteride 2 CYSTADANE betaine hcl 2 cytra-3 1 cytra-k 1 ELMIRON pentosan polysulfate sodium 2 finasteride 1 FLOMAX [G] tamsulosin 3 glycine solution 1 JALYN dutasteride/tamsulosin hcl 3 K-PHOS M.F. pot acid phos/sod acid phos 2 K-PHOS NO.2 pot acid phos/sod acid phos 2 K-PHOS ORIGINAL potassium acid phosphate 2


Drug Generic Tier Restrictions LITHOSTAT acetohydroxamic acid 3 neomycin-polymyxin b [INJ] 1 NEOSPORIN G.U. IRRIGANT [INJ] neomycin sulfate/polymyxin 3 potassium citrate tablet sustained

action 1

potassium citrate-citric acid 1 PROSCAR [G] finasteride 3 RAPAFLO silodosin 3 RENACIDIN gluconic acid/citric acid 2 RIMSO-50 dimethyl sulfoxide 3 tamsulosin hcl 1 tricitrates 1 UROCIT-K [G] potassium citrate 3 UROXATRAL alfuzosin hcl 2


Index:

10 wash, 56 1ST TIER UNIFINE PENTIPS, 83 8-MOP, 57 aa 3%/electrolyte-tpn/glycerin, 91, 92 aabp, 63 a-b otic, 63 abacavir sulfate, 5 abacavir sulfate/lamivudine, 5 abatacept/maltose, 21 abciximab, 89 ABELCET, 14 ABILIFY DISCMELT, 24 ABILIFY INJECTION, 24 ABILIFY SOLUTION, 24 ABILIFY TABLET, 24 abobotulinumtoxina, 86 ABORTIFACIENTS, 97 acamprosate calcium, 38 ACANYA, 54 acarbose, 69, 70 ACCOLATE, 116 ACCU-CHEK ACTIVE, 1 ACCU-CHEK ACTIVE METER, -AVIVA METER,

-COMBINATION PACKAGE, -COMPACT PLUS METER, -EACH, -KIT, 1

ACCU-CHEK ADVANTAGE, 1 ACCU-CHEK AVIVA, 1 ACCU-CHEK COMFORT CURVE, 1 ACCU-CHEK COMPACT, 1 ACCU-CHEK COMPACT BLUE CONTROL, 1 ACCU-CHEK III, 1 ACCU-CHEK INSTANT, 1 ACCU-CHEK INSTANT PLUS, 1 ACCUPRIL, 43 ACCURETIC, 51 ACCUSURE, 83 ACCUTANE, 57 acebutolol, 45 acebutolol hcl capsule, 44

ACEON, 43 ACETADOTE, 62 acetaminophen-codeine, 31 acetasol hc, 63 acetazolamide, 109 acetazolamide capsule sustained action, -

tablet, 109 acetazolamide sodium, 109 acetic ac/ricinoleic/oxyquinol, 102 acetic acid, 64 acetic acid 0.25% irrig soln, 120 acetic acid solution non-oral, 63 acetic acid/aluminum acetate, 63 acetic acid/hydrocortisone, 64 acetic acid/oxyquin so4, 102 acetic acid-aluminum, 63 acetic acid-hydrocortisone, 63 acetohydroxamic acid, 120 acetylcysteine, 62 ACID JELLY, 102 ACIPHEX, 76 acitretin, 57 acitretin/emollient comb, 57 ACLOVATE, 58 ACTEMRA 200 MG/10 ML VIAL, -400 MG/20

ML VIAL, 82 ACTEMRA 80 MG/4 ML VIAL, 82 ACTHAR H.P., 70 ACTHIB, 78 ACTHREL, 70 acticin, 57 ACTIGALL, 75 ACTIMMUNE, 81 ACTIQ, 29 ACTIVELLA, 101 ACTONEL 150 MG TABLET, 70 ACTONEL 30 MG TABLET, -5 MG TABLET, 70 ACTONEL 35 MG TABLET, 70 ACTONEL 75 MG TABLET, 70


ACTONEL WITH CALCIUM, 71 ACTOPLUS MET, 69 ACTOPLUS MET XR 15-1,000 MG TB, 69 ACTOPLUS MET XR 30-1,000 MG TB, 69 ACTOS, 69 ACULAR, 112 ACULAR LS, 112 ACULAR PF, 112 ACUVAIL, 113 acyclovir, 12 acyclovir capsule, -suspension oral, -tablet,

11 acyclovir sodium, 11 ACZONE, 54 ADACEL, 78 ADAGEN, 62 ADALAT CC, 45 adalimumab, 20 adapalene, 54, 55 adapalene/benzoyl peroxide, 55 ADCIRCA, 53 adcirca (tadalafil), 53 ADDERALL, 32 ADDERALL XR, 32 adefovir dipivoxil, 11 ADOXA, 17 ADOXA PAK, 17 ADRENACLICK, 117 ADRENALIN CHLORIDE INJECTION, 117 ADRENALIN CHLORIDE SOLUTION NON-

ORAL, 117 ADVAIR DISKUS, 117 ADVAIR HFA, 117 advanced care plus, 102 advanced natalcare, 102 ADVICOR 1,000 MG-20 MG TABLET, -1,000

MG-40 MG TABLET, -750 MG-20 MG TABLET, 47

ADVICOR 500 MG-20 MG TABLET, 47 AEROBID, 117 AEROBID-M, 117 afeditab cr, 45

AFINITOR, 19 agalsidase, 71 AGGRASTAT, 89 AGGRENOX, 89 AGRYLIN, 19 A-HYDROCORT, 66 AIMSCO ULTRA THIN II, 83 ak-con, 113 ak-dilate, 113 AKNE-MYCIN, 54 akorn balanced salt, 113 ak-pentolate, 113 ak-poly-bac, 111 AKTEN, 113 aktob, 111 ALA-CORT, 58 ALAMAST, 113 ALA-SCALP HP, 58 ALA-TET, 17 ALBALON, 113 albendazole, 4 ALBENZA, 4 albumin human, 90, 91, 92 ALBUMINAR-25, 90 alburx, 90 albutein, 90 albuterol, 116 albuterol sulfate nebs, -solution non-oral, -

syrup, -tablet, -tablet sustained release 12hr, -vial nebulizer, 116

albuterol sulfate/ipratropium, 118 ALCAINE, 113 ALCET, 29 alclometasone, 58 alclometasone dipropionate, 58 alcohol in dextrose, 90 ALCOHOL PREP PADS, 83 ALCOHOL PREP SWABS, 83 ALCOHOL SWABS, 83 ALCOHOL WIPES, 83 ALDACTAZIDE, 53 ALDACTONE, 53


ALDARA, 60 aldesleukin, 82 ALDURAZYME, 71 alefacept, 19 alemtuzumab, 19 alendronate, 71, 72 alendronate sodium 10 mg tab, -40 mg tab, -

5 mg tablet, 71 alendronate sodium 35 mg tab, -70 mg tab,

71 alendronate/vitamin d3, 71 ALFENTA, 29 alfentanil, 29 alfentanil hydrochloride, 29 ALFERON N, 81 alfuzosin hcl, 120 alglucerase, 71 alglucosidase alfa, 72 ALIMTA, 19 ALINIA, 9 aliskiren hemifumarate, 52 aliskiren/hydrochlorothiazid, 52 aliskiren/valsartan, 52 alitretinoin, 61 ALLEGRA 180 MG TABLET, 115 ALLEGRA 60 MG TABLET, 115 ALLEGRA ODT, 115 ALLEGRA SUSPENSION ORAL, 115 ALLEGRA-D 12 HOUR, 114 ALLEGRA-D 24 HOUR, 114 allersol, 113 allopurinol, 86, 87 allopurinol sodium, 86 allopurinol tablet, 86 almotriptan, 33 ALOCRIL, 113 ALOMIDE, 113 ALOPRIM, 86 ALORA, 100 alosetron, 74 ALOXI, 26 alpha-1-proteinase inhibitor, 119

ALPHAGAN P 0.1% DROPS, 109 ALPHAGAN P 0.15% EYE DROPS, 109 alprostadil, 52 alprostadil injection, 52 ALREX, 111 ALTABAX, 17 ALTACE, 43 altafrin, 113 ALTOPREV, 48 altretamine, 20 aluminum chloride hexahydrate, 61, 62 ALVESCO 160 MCG INHALER, 117 ALVESCO 80 MCG INHALER, 117 amantadine, 11 AMARYL, 69 ambenonium chloride, 39 AMBIEN, 39 AMBIEN CR, 39 AMBISOME, 14 ambrisentan, 47 amcinonide, 58 AMEBICIDES, 3 AMERGE, 33 a-methapred, 66 AMEVIVE, 19 AMICAR SYRUP, 62 AMICAR TABLET, 62 amifostine, 19, 20 amikacin sulfate injection, 3 amiloride hcl tablet, 53 amiloride hydrochloride, 53 amiloride-hydrochlorothiazide, 53 amino acids, 90, 91, 92, 93 aminocaproic acid, 62 aminocaproic acid injection, 62 aminocaproic acid syrup, -tablet, 62 AMINOGLYCOSIDES, 3 aminolevulinic acid hcl, 61 aminophylline injection, 116 aminophylline tablet, 117 aminosalicylic acid, 6 AMINOSYN, 90


AMINOSYN II, 90 AMINOSYN II 3.5% M-DEXTROSE 5%, 90 AMINOSYN II 3.5%-DEXTROSE 25%, 90 AMINOSYN II 3.5%-DEXTROSE 5%, 90 AMINOSYN II 4.25% M-DEXT 10%, 90 AMINOSYN II 4.25%-DEXTROSE 25%, 90 AMINOSYN II 5% IN 25% DEXTROSE, 90 AMINOSYN II IN DEXTROSE, 90 AMINOSYN II WITH LYTES-CA-DW, 90 AMINOSYN M, 90 AMINOSYN WITH ELECTROLYTES, 90 AMINOSYN-HBC, 90 AMINOSYN-HF, 90 AMINOSYN-PF, 90 AMINOSYN-RF, 90 amiodarone, 43 amiodarone hcl injection, 43 amiodarone hcl tablet, 43 AMIODARONES, 43 AMITIZA, 74 amitriptyline hcl tablet, 42 amitriptyline/chlordiazepoxide, 37 amitriptyline-chlordiazepoxide, 36 amlexanox, 65 amlodipine, 46 amlodipine bes/olmesartan med, 51 amlodipine besylate, 45 amlodipine besylate-benazepril, 51 amlodipine/atorvast cal, 48 amlodipine/valsartan, 51 amlodipine/valsartan/hctz, 51 ammonium chloride, 90 AMMONIUM CHLORIDE INJECTION, 90 ammonium lactate 12% cream, -12% lotion,

60 AMMONUL, 62 amnesteem, 57 amoclan, 14 amox tr-potassium clavulanate, 14 amoxapine, 39 amoxicillin, 14, 15 amoxicillin clavulanate, 14

amoxicillin-clavulanate er, 14 AMOXIL 125 MG/5 ML SUSPENSION, 14 AMOXIL 400 MG/5 ML SUSPENSION, -50

MG/ML PED DROPS, -CAPSULE, -250 MG/5 ML SUSPENSION, 14

amphetamine salt combo, 32 amphetamine/dextroamphetamine, 32 ampho b c-s, 14 AMPHOTEC 100 MG VIAL, 14 AMPHOTEC 50 MG VIAL, 14 amphotericin b injection, 14 amphotericin b lipid complex, 14 amphotericin b liposome, 14 ampicillin sodium, 14, 15 ampicillin sodium/sulbactam na, 15 ampicillin trihydrate, 14 ampicillin-sulbactam, 14 AMPYRA, 62 AMRIX, 85 amylase/lipase/protease, 75, 76 ANADROL-50, 97 ANAFRANIL, 42 anagrelide, 19 anagrelide hcl, 19 anakinra, 82 ANALGESICS, 23 ANAMANTLE HC CREAM WITH APPLICATOR,

-KIT, 58 ANAMANTLE HC FORTE, 58 ANAPROX, 87 ANAPROX DS, 87 anastrozole, 19 anastrozole tablet, 19 ANCOBON, 8 ANDRODERM, 97 ANDROGEL, 97 ANDROGEN DRUGS, 97 ANDROID, 97 ANDROXY, 98 ANECTINE, 86 ANESTACON, 3 ANESTHETICS, 2


ANGELIQ, 101 ANGIOMAX, 95 ANGIOTENSIN CONVERTING ENZYME

INHIBITORS, 43 ANGIOTENSIN II RECEPTOR ANTAGONISTS,

43 anidulafungin, 14 ANSAID, 87 ANTABUSE, 38 ANTARA, 49 ANTHELMINTICS, 4 anthralin, 56, 57 ANTIACNE DRUGS, 54 ANTICHOLINERGIC ANTISPASMODICS, 119 ANTIDEMENTIA DRUGS, 23 ANTIDIARRHEAL DRUGS, 73 ANTIDYSRHYTHMIC DRUGS, 44 ANTIGLAUCOMA DRUGS, 109 ANTIHISTAMINE/DECONGESTANT

COMBINATIONS, 114 ANTIHISTAMINES, 115 ANTIINFECTIVES, 3 ANTIINFECTIVES SPECIALIZED

INDICATIONS, 4 ANTIMANIA DRUGS, 24 ANTINEOPLASTIC/IMMUNOSUPPRESSANT

DRUGS, 19 ANTIPARKINSON ANTICHOLINERGIC

DRUGS, 24 ANTIPLATELET DRUGS, 89 ANTIPRURITIC DRUGS, 56 ANTIPSORIASIS AND ANTIECZEMA DRUGS,

56 ANTIPSYCHOTIC DRUGS, 24 antipyrine/benzocaine, 63 antipyrine-benzocaine, 63 ANTIRETROVIRALS AND PROTEASE INH, 4 ANTISPASMODICS/DRUGS AFFECT GI

MOTILITY, 73 ANTI-STICK INSULIN, 83 antithrombin iii, human recomb, 95 antithrombin iii,human, 95

ANTITHYROID DRUGS, 66 ANTITUBERCULOSIS DRUGS, 6 ANTIULCER DRUGS, 74 ANTIVERT, 26 ANTIVERTIGO AND ANTIEMETIC DRUGS, 26 ANTIZOL, 62 ANUSOL-HC, 75 ANXIOLYTICS, 28 ANZEMET INJECTION, 26 ANZEMET TABLET, 26 apap-caffeine-dihydrocodeine, 31 APEXICON, 58 APEXICON E, 58 APHTHASOL, 65 APIDRA, 68 APIDRA SOLOSTAR, 68 APLENZIN, 36 APOKYN, 37 apomorphine hcl, 37 apraclonidine, 109 apraclonidine hcl, 109 aprepitant, 27 apri, 98 APRISO, 75 APTIVUS, 4 AQUORAL, 65 ARALAST, 119 ARALEN PHOSPHATE, 15 aranelle, 98 ARANESP 100 MCG/0.5 ML AUTOINJ, -100

MCG/0.5 ML SYRINGE, -100 MCG/ML VIAL, -150 MCG/0.3 ML AUTOINJ, -150 MCG/0.3 ML SYRINGE, -150 MCG/0.75 ML VIAL, -200 MCG/0.4 ML AUTOINJ, -200 MCG/0.4 ML SYRINGE, -200 MCG/ML VIAL, -300 MCG/0.6 ML AUTOINJ, -300 MCG/0.6 M, 78

ARANESP 25 MCG/0.42 ML AUTOINJ, -25 MCG/0.42 ML SYRING, -25 MCG/ML VIAL, -40 MCG/0.4 ML AUTOINJ, -40 MCG/0.4 ML SYRINGE, -40 MCG/ML VIAL, 79

ARAVA, 19


ARCALYST, 82 AREDIA 30 MG VIAL, 71 AREDIA 90 MG VIAL, 71 ARESTIN, 65 argatroban, 95 ARGATROBAN, 95 arginine, 92 ARICEPT 10 MG TABLET, -5 MG TABLET, 23 ARICEPT 23 MG TABLET, 23 ARICEPT ODT, 23 ARIMIDEX, 19 aripiprazole, 24 ARISTOSPAN, 66 ARIXTRA 10 MG SYRINGE, -5 MG SYRINGE, -

7.5 MG SYRINGE, 94 ARIXTRA 2.5 MG SYRINGE, 94 armodafinil, 33 ARMOUR THYROID, 72 AROMASIN, 19 artemether/lumefantrine, 15 ARTHROTEC 50, 87 ARTHROTEC 75, 87 ASACOL, 75 ASACOL HD, 75 ASCENSIA AUTODISC, 1 ASCENSIA ELITE, 1 ascomp with codeine, 33 asenapine, 26 ASMANEX TWISTHALER 110 MCG #30, 117 ASMANEX TWISTHALER 220 MCG #14, 117 ASMANEX TWISTHALER 220 MCG #30, 117 ASMANEX TWISTHALER 220 MCG #60, 117 ASMANEX TWISTHALR 220 MCG #120, 118 aspirin, 89 aspirin ec 975 mg tablet, 89 aspirin/dipyridamole, 89 aspirin/meprobamate, 33 ASTELIN, 64 ASTEPRO 0.15% NASAL SPRAY, 64 ASTEPRO 137 MCG NASAL SPRAY, 64 ASTRAMORPH-PF, 29 ATABEX, 102

ATABEX EC, 102 ATACAND, 43 ATACAND HCT, 51 atazanavir sulfate, 5 atenolol, 45 atenolol tablet, 44 atenolol-chlorthalidone, 51 ATGAM, 79 atomoxetine, 39 atorvastatin calcium, 48 atovaquone, 10 atovaquone/proguanil hcl, 16 ATRALIN, 54 ATRIPLA, 4 atropine care, 113 atropine sulfate, 73, 113 atropine sulfate drops, -ointment, 113 atropine sulfate injection, 38 ATROVENT 0.03% SPRAY, 64 ATROVENT 0.06% SPRAY, 64 ATROVENT HFA, 118 ATRYN, 95 ATTENUVAX VACCINE WITH DILUENT, 79 AUGMENTIN 125-31.25 SUSPEN, -TABLET

CHEWABLE, 14 AUGMENTIN 400-57 MG/5 ML, -250-62.5

MG/5 ML, -TABLET, 14 AUGMENTIN ES-600, 14 AUGMENTIN XR, 14 auranofin, 89 aurodex, 63 aurodex ear drops, 63 auroguard, 63 AUTO INJECTOR, 83 AUTODISC NORMAL, 1 AUTOJECT 2, 83 AUTONOMIC AND CNS MEDICATIONS, 23 AUTOPEN, 83 AVALIDE, 51 AVANDAMET, 69 AVANDARYL, 69 AVANDIA 2 MG TABLET, -4 MG TABLET, 69


AVANDIA 8 MG TABLET, 69 AVAPRO, 44 AVAR, 54 AVAR LS, 54 AVAR-E, 54 AVAR-E GREEN, 55 AVAR-E LS CREAM, 55 AVASTIN, 19 AVC, 102 AVELOX, 16 AVELOX ABC PACK, 16 AVELOX IV, 16 aviane, 98 AVIDOXY, 17 AVINZA, 29 AVITA, 55 AVODART, 120 AVONEX, 81 AVONEX ADMINISTRATION PACK, 81 AXERT 12.5 MG TABLET, 33 AXERT 6.25 MG TABLET, 33 AXID, 74 AYGESTIN, 108 azacitidine, 22 AZACTAM 1 GM VIAL, 9 AZACTAM 2 GM VIAL, 9 AZACTAM-ISO-OSMOT 1 GM/50 ML, 9 AZACTAM-ISO-OSMOT 2 GM/50 ML, 9 AZASAN, 19 AZASITE, 111 azathioprine, 19, 20 azathioprine sodium, 19 azathioprine tablet, 19 azelaic acid, 55 azelastine hcl, 64, 114 azelastine hcl aerosol spray w/pump, 64 azelastine hcl drops, 113 AZELEX, 55 AZILECT, 37 azithromycin, 12, 13, 111 azithromycin 100 mg/5 ml susp, 12 azithromycin 200 mg/5 ml susp, 12

azithromycin 250 mg tablet, 12 azithromycin 500 mg tablet, 12 azithromycin 600 mg tablet, -packet, 12 azithromycin injection, 12 AZMACORT, 118 AZOPT, 109 AZOR, 51 aztreonam, 9 aztreonam 1 gm vial, 9 aztreonam 2 gm vial, 9 aztreonam/dextrose water, 9 AZULFIDINE, 75 azurette, 98 baciim, 9 bacitracin 500 unit/gm ointmnt, 111 bacitracin injection, 9 bacitracin-polymyxin eye oint, 111 baclofen, 86 baclofen tablet, 86 BACTOCILL, 14 BACTRIM, 16 BACTRIM DS, 16 BACTROBAN, 17 BACTROBAN NASAL, 17 balsalazide disodium, 75 balziva, 98 BANZEL 200 MG TABLET, 35 BANZEL 400 MG TABLET, 35 BARACLUDE SOLUTION, 11 BARACLUDE TABLET, 11 basiliximab, 22 baycadron, 66 b-caine/tan ac/menth/cpyrd, 65 bcg vaccine, 22, 81 becaplermin, 61 beclomethasone, 64, 118 BECONASE AQ, 64 benazepril, 43 benazepril hcl, 43 benazepril hcl-hctz, 51 benazepril/amlodipine besylate, 51 benazepril/hctz, 51


benazepril-hydrochlorothiazide, 51 bendroflumethiazide, 54 bendroflumethiazide/nadolol, 51 BENICAR, 44 BENICAR HCT, 51 ben-tann, 115 BENTYL CAPSULE, -SYRUP, -TABLET, 73 BENTYL INJECTION, 73 BENZACLIN, 55 BENZAMYCIN, 55 BENZAMYCINPAK, 55 benzene hexachloride gamma, 57 BENZOTIC, 63 benztropine, 24 benztropine mesylate injection, 24 benztropine mesylate tablet, 24 benzyl alcohol, 58 bepotastine besilate, 113 BEPREVE, 113 besifloxacin, 111 BESIVANCE, 111 BETA-2 ADRENERGIC DRUGS, 116 BETA-ADRENERGIC ANTAGONIST DRUGS,

44 BETADINE SOLUTION, 113 BETAGAN, 109 betaine hcl, 120 betamet diprop/calcipotriene, 57 betameth/propylene glycol, 59 betamethasone, 66 betamethasone acetate-sod phos, 66 betamethasone dipropionate, 59 betamethasone dipropionate cream, -gel, -

lotion, -ointment, 58 betamethasone valerate, 60 betamethasone valerate cream, -lotion, -

ointment, 58 betamethasone/betamethasone, 66 betanate, 58 BETAPACE, 50 BETAPACE AF, 50 BETASERON, 81

beta-val, 58 betaxolol, 44, 109 betaxolol hcl drops, 109 betaxolol hcl tablet, 44 bethanechol, 120 bethanechol chloride tablet, 120 BETIMOL, 109 BETOPTIC S, 109 bevacizumab, 19 bexarotene, 22 BIAXIN, 12 BIAXIN XL, 12 bicalutamide, 19 BICILLIN C-R, 14 BICILLIN L-A, 14 BIDIL, 53 BILTRICIDE, 4 bimatoprost, 110 bismuth/metronid/tetracyclin, 76 bisoprolol, 45 bisoprolol fumarate, 44 bisoprolol fumarate-hctz, 51 bisoprolol-hydrochlorothiazide, 51 bivalirudin, 95 BLEPH-10, 111 BLEPHAMIDE, 110 BLEPHAMIDE S.O.P., 110 BLOOD DETOXICANTS, 89 BONIVA 150 MG TABLET, 71 BONIVA 2.5 MG TABLET, 71 BONIVA INJECTION, 71 BOOSTRIX, 79 borofair, 63 bortezomib, 22 bosentan, 47 BOTOX, 113 botulinum toxin a, 113 botulinum toxin type b, 86 bp 10-1, 55 BRANCHAMIN, 90 BREEZE 2, 1 BREVICON, 98


brimonidine 0.2% eye drop, 109 brimonidine tartrate, 109 brimonidine tartrate 0.15% drp, 109 brimonidine tartrate/timolol, 109 brinzolamide, 109 bromfenac, 114 bromocriptine mesylate, 38 bromocriptine mesylate capsule, -tablet, 37 BSS, 113 BSS PLUS, 113 BUCALCIDE, 65 BUCALSEP, 65 budeprion sr, 36 budeprion xl, 36 budesonide, 65, 75, 118 budesonide/formoterol fum, 119 bumetanide injection, 49 bumetanide tablet, 49 BUMINATE, 90 BUPHENYL, 62 bupivacaine, 2 bupivacaine hcl injection, 2 bupivacaine hcl/dextrose-h2o, 2 bupivacaine hcl-epinephrine, 2 bupivacaine hydrochloride/epi, 2 bupivacaine-dextrose, 2 BUPRENEX, 23 buprenorphine, 23, 31 buprenorphine hcl tablet sublingual, 31 buprenorphine injection, 23 buprenorphine/naloxone, 31 buproban, 42 bupropion, 37, 42 bupropion hbr, 36 bupropion hcl, 36 bupropion hcl sr 100 mg tab, -100 mg tablet,

-200 mg tab, 36 bupropion sr 150 mg tablet, 36 bupropion xl, 36 BUSPAR, 28 buspirone, 28 buspirone hcl tablet, 28

butalbital compound-codeine, 33 butalbital-caff-apap-codeine, 33 butenafine, 13 butoconazole, 18 butorphanol tartrate aerosol spray, 33 butorphanol tartrate injection, 23 BYETTA 10 MCG DOSE PEN INJ, 67 BYETTA 5 MCG DOSE PEN INJ, 67 BYSTOLIC, 44 cabergoline, 71 CADUET, 48 CAFCIT INJECTION, 32 CAFCIT SOLUTION, 117 CAFERGOT, 33 caffeine citrate injection, 32 caffeine citrate solution, 117 caffeine citrated, 32, 117 cahpo4/saliva cmb 1/malic/sorb, 65 CALAN, 45 CALAN SR, 45 CALCIJEX, 96 calcipotriene, 56 calcitonin, 72 calcitonin-salmon, 71 calcitriol, 57, 96, 97 calcitriol capsule, -solution, 97 calcitriol injection, 97 calcium acetate, 97 CALCIUM ANTAGONISTS, 45 calcium chloride injection, 90 cal-nate, 102 CAMBIA, 87 camila, 108 CAMPATH, 19 CAMPRAL, 38 canakinumab, 82 CANASA, 75 CANCIDAS, 14 candesartan cilexetil, 43 candesartan cilexetil/hctz, 51 CANTIL, 73 CAPASTAT SULFATE, 6


CAPEX SHAMPOO, 58 CAPHOSOL, 65 CAPITAL W-CODEINE, 31 CAPOTEN, 43 capreomycin, 6 capsaicin/skin cleanser, 61 captopril, 43 captopril tablet, 43 captopril-hydrochlorothiazide, 51 CARAC, 60 CARAFATE SUSPENSION ORAL, 75 CARAFATE TABLET, 75 carbachol, 110 carbamazepine, 28 carbamazepine suspension oral, -tablet, -

tablet chewable, 28 carbamazepine xr, 28 CARBAMAZEPINES, 28 CARBATROL, 28 carbidopa, 38 carbidopa/levodopa, 38 carbidopa/levodopa/entacap, 38 carbidopa-levodopa, 38 carbinoxamine maleate, 115 CARBOCAINE, 2 carboprost tromethamine, 97 CARDENE I.V., 45 CARDENE SR, 45 CARDIAC GLYCOSIDES, 46 CARDIOVASCULAR MEDICATIONS, 43 CARDIZEM, 45 CARDIZEM CD, 45 CARDIZEM LA, 45 CARDURA 1 MG TABLET, -2 MG TABLET, -4

MG TABLET, 54 CARDURA 8 MG TABLET, 54 CARDURA XL, 54 carenatal dha, 102 CARIMUNE NF NANOFILTERED, 79 carisoprodol, 86 carisoprodol compound, 85 carisoprodol compound-codeine, 85

carisoprodol tablet, 85 CARMOL 40, 61 CARMOL HC, 58 CARMOL SCALP, 56 CARNITOR INJECTION, 97 CARNITOR SF, 97 CARNITOR SOLUTION, -TABLET, 97 carteolol hcl, 109 cartia xt, 45 carvedilol, 44 CASODEX, 19 caspofungin acetate, 14 CATAFLAM, 87 CATAPRES, 47 CATAPRES-TTS 1, 47 CATAPRES-TTS 2, 47 CATAPRES-TTS 3, 47 cavan one omega, 102 cavan-alpha kit, 102 cavan-ec sod dha, 102 CAVAREST, 93 CAVIRINSE, 93 caziant, 98 CEDAX, 6 CEENU, 20 cefaclor, 6, 7 cefaclor er, 6 cefadroxil, 6 cefazolin 1 gm add-van vial, -1 gm vial, -1

gm-d5w bag, -10 gm vial, -20 gm bulk vial, -500 mg vial, 6

cefdinir, 6, 7 cefditoren pivoxil, 6, 7 CEFDITOREN PIVOXIL, 6 cefepime, 6, 7 cefepime hcl, 6 cefixime, 7 cefotaxime, 7 cefotaxime sodium, 6 cefotetan, 6 cefoxitin, 6, 7 cefoxitin sodium, 7


cefpodoxime, 7 cefpodoxime proxetil, 7 cefprozil, 7 ceftazidime, 7 ceftibuten, 6 CEFTIN, 7 ceftriaxone, 7 cefuroxime, 7 cefuroxime axetil, 7 cefuroxime injection, 7 cefuroxime sod 1.5 gm vial, -sod 7.5 gm vial,

-sod 750 mg vial, 7 cefuroxime tablet, 7 CELEBREX, 87 celecoxib, 87 CELESTONE INJECTION, 66 CELESTONE SOLUTION ORAL, 66 CELEXA SOLUTION, 40 CELEXA TABLET, 40 CELLCEPT CAPSULE, 20 CELLCEPT INJECTION, 20 CELLCEPT TABLET, -SUSPENSION

RECONSTITUTED ORAL, 20 CELONTIN, 42 CENESTIN, 100 CENTANY, 17 CENTRALLY ACTING ANTIHYPERTENSIVES,

47 cephalexin, 7 CEPHALOSPORINS, 6 CEREBYX, 35 CEREDASE, 71 CEREZYME, 71 cerovel, 61 certolizumab pegol, 20 CERVARIX, 79 CERVIDIL, 97 CESAMET, 26 cesia, 98 cetirizine 1 mg/1 ml soln, -1 mg/ml soln, -1

mg/ml syrup, -5 mg/5 ml syrup, 115 CETRAXAL, 63

cevimeline, 65 CHANTIX, 42 CHEMET, 62 CHENODAL, 75 chenodiol, 75 chlorambucil, 21 chloramphenicol sod succinate, 8 CHLORAMPHENICOLS, 8 chlorhexidine, 17, 65 chlorhexidine gluconate mouthwash, 65 CHLORHEXIDINE GLUCONATE SOL, 17 chloroprocaine, 2 chloroprocaine hcl, 2 chloroquine phosphate, 15 chloroquine phosphate tablet, 15 chlorothiazide, 53 chlorothiazide sodium, 53 chloroxylenol-pramoxine hcl, 63 chlorpromazine hcl injection, 24 chlorpromazine hcl tablet, 24 chlorthalidone, 53, 54 chlorthalidone/atenolol, 52 chlorzoxazone, 85, 86 cholestyramine, 49 cholestyramine light, 49 cholestyramine/aspartame, 49 cholestyramine/sucrose, 49 choline mag trisalicylate, 89 CHOLINERGIC STIMULANTS, 120 ciclesonide, 65, 117 ciclopirox, 13 ciclopirox cream, -gel, -kit, -shampoo, -

suspension topical, 13 ciclopirox solution non-oral, 13 ciclopirox/nail lacquer remov, 13 cidofovir, 12 cilostazol, 89 CILOXAN, 111 cimetidine, 74 cimetidine 200 mg tablet, -300 mg tablet, -

400 mg tablet, -800 mg tablet, -solution, 74


cimetidine injection, 74 CIMZIA, 20 cinacalcet hcl, 72 CIPRO, 16 CIPRO HC, 63 CIPRO I.V., 16 CIPRO XR, 16 CIPRODEX, 63 ciprofloxacin, 16, 63, 111 ciprofloxacin er, 16 ciprofloxacin hcl drops, 112 ciprofloxacin hcl tablet, 16 ciprofloxacin/dexameth, 63 ciprofloxacin/hc, 63 ciprofloxacin-d5w, 16 citalopram, 40 citalopram hbr, 40 CITRANATAL 90 DHA, 102 CITRANATAL ASSURE, 102 CITRANATAL B-CALM, 102 CITRANATAL DHA, 103 CITRANATAL HARMONY, 103 CITRANATAL RX, 103 CLAFORAN, 7 claravis, 57 CLARIFOAM EF, 55 CLARINEX SYRUP, 115 CLARINEX TABLET, -TABLET DISPERSIBLE

LINGUAL, 115 CLARINEX-D 12 HOUR, 114 CLARINEX-D 24 HOUR, 114 clarithromycin, 12 clarithromycin er, 12 CLASS II NARCOTICS, 29 CLASS III NARCOTICS, 31 clemastine fum 2.68 mg tab, -syrup, 115 clenia cleanser, 55 CLENIA CREAM, 55 CLEOCIN, 102 CLEOCIN HCL, 8 CLEOCIN PALMITATE, 8 CLEOCIN PHOSPHATE, 8

CLEOCIN PHOSPHATE IN D5W, 8 CLEOCIN T, 55 CLIMARA, 100 CLIMARA PRO, 101 clinda-derm, 55 CLINDAGEL, 55 CLINDAMAX CREAM WITH APPLICATOR, 102 CLINDAMAX GEL, -LOTION, 55 clindamycin hcl, 8 clindamycin hcl capsule, 8 clindamycin palmitate, 8 clindamycin palmitate hcl, 8 clindamycin phos/benz per, 54 clindamycin phosphate, 8, 55, 102 clindamycin phosphate cream with

applicator, 102 clindamycin phosphate foam, -gel, -lotion, -

solution non-oral, -swab medicated, 55 clindamycin phosphate injection, 8 clindamycin/benz per/hyalur na, 55 clindamycin/benzoyl prx/skn #5, 55 clindamycin/tretinoin, 56 clindamycin-benzoyl peroxide, 55 CLINDAMYCINS, 8 CLINDAREACH, 55 CLINDESSE, 102 CLINDETS, 55 CLINIMIX, 90 CLINIMIX E, 90 CLINISOL, 90 CLINORIL, 87 CLINPRO 5000, 93 clobetasol emollient, 58 clobetasol propionate, 58, 60 clobetasol propionate cream, -foam, -gel, -

ointment, -solution non-oral, 58 CLOBEX, 58 clocortolone pivalate, 58 CLODERM, 58 clomipramine, 42 clomipramine hcl capsule, 42 clonidine, 47


clonidine hcl injection, 47 clonidine hcl tablet, 47 clonidine hcl/chlorthalidone, 51 clopidogrel, 89 CLORPRES, 51 clotrimazole 1% cream, -1% solution, -af 1%

cream, 13 clotrimazole troche, 8 clotrimazole/betamethasone, 18 clotrimazole-betamethasone, 18 clozapine, 24, 25 CLOZARIL, 24 CNL 8, 13 CNS MUSCLE RELAXANTS, 85 CNS STIMULANT DRUGS, 32 COARTEM, 15 codeine phosphate injection, 29 codeine phosphate/apap, 31, 32 codeine sulfate, 29 codeine/apap/caffeine/butalb, 33 codeine/asa/caffeine/butalb, 33 COGENTIN, 24 co-gesic, 31 COGNEX, 23 COLAZAL, 75 colchicine, 86 COLCRYS, 86 colesevelam, 49 COLESTID, 49 colestipol, 49 colestipol hcl, 49 colistimethate 150 mg vial, 9 colistimethate, sodium, 10 collagenase, 61 collagenase clostridium hist., 63 COLOCORT, 75 COLY-MYCIN M PARENTERAL, 10 COLY-MYCIN S, 63 COLYTE, 75 COLYTE WITH FLAVOR PACKETS, 75 combi rx, 103 COMBIGAN, 109

COMBIPATCH, 101 COMBIVENT, 118 COMBIVIR, 4 COMBUNOX, 29 COMPAZINE INJECTION, 26 COMPAZINE SYRUP, 26 complete allergy medicine, 115 complete natal dha, 103 completenate, 103 COMPLETE-RF PRENATAL, 103 compro, 26 COMTAN, 38 COMVAX, 79 co-natal fa, 103 CONCEPT DHA, 103 CONCEPT OB, 103 CONCERTA, 32 CONDYLOX GEL, 57 CONDYLOX SOLUTION NON-ORAL, 57 constulose, 89 CONTOUR, 1 CONTRACEPTIVES, 98 CONTROL RX, 93 COPAXONE, 62 COPEGUS, 11 CORDARONE, 43 CORDRAN LOTION, -OINTMENT, 58 CORDRAN SP, 58 CORDRAN TAPE MEDICATED, 59 COREG, 44 COREG CR, 44 CORGARD, 44 CORLOPAM, 51 cormax, 59 CORTEF, 66 CORTENEMA, 75 corticorelin ovine triflutate, 70 corticotropin, 70 CORTIFOAM, 75 cortisone tablet, 66 CORTISPORIN CREAM, -OINTMENT, 18 CORTISPORIN SUSPENSION DROPS, 110


CORTISPORIN SUSPENSION DROPS, -SOLUTION NON-ORAL, 63

CORTISPORIN-TC, 63 cortomycin ointment, 110 cortomycin solution non-oral, -suspension

drops, 63 CORVERT, 50 CORZIDE, 51 COSOPT, 109 COUMADIN INJECTION, 95 COUMADIN TABLET, 95 COVERA-HS, 45 COZAAR, 44 CREON, 75 CRESTOR 10 MG TABLET, -20 MG TABLET, -

40 MG TABLET, 48 CRESTOR 5 MG TABLET, 48 CRINONE, 108 CRIXIVAN, 5 CROLOM, 113 cromolyn, 113, 118 cromolyn sodium ampul for nebulization, 118 cromolyn sodium drops, 113 crotamiton, 57 cryselle, 98 CUBICIN, 10 CUPRIMINE, 88 CURAD GAUZE PADS, 83 CURITY ALCOHOL PREPS, 83 CURITY GAUZE SPONGES, 83 CUTIVATE, 59 CYCLESSA, 98 cyclobenzaprine, 85, 86 cyclobenzaprine hcl tablet, 86 CYCLOGYL 0.5% EYE DROPS, -2% EYE

DROPS, 113 CYCLOGYL 1% EYE DROPS, 113 cyclopentolate, 113 cyclopentolate hcl, 113 cyclophosphamide tablet, 20 cycloserine, 6 CYCLOSERINE, 6

cyclosporine, 21, 22, 114 cyclosporine capsule, -solution, 20 cyclosporine injection, 20 cyclosporine modified, 20 CYKLOKAPRON, 62 cylate, 113 CYMBALTA 20 MG CAPSULE, -60 MG

CAPSULE, 36 CYMBALTA 30 MG CAPSULE, 37 cyproheptadine hcl syrup, -tablet, 115 CYSTADANE, 120 CYSTAGON, 90 cysteamine, 90 CYTOMEL, 72 CYTOTEC, 75 CYTOVENE, 11 cytra-2, 95 cytra-3, 120 cytra-k, 120 D.H.E.45, 33 d5w/electrolyte-56 solution, 92 d5w/kcl 10 meq/l iv solution, -30 meq/l iv

solution, 91 daclizumab, 82 dalfampridine, 62 dalteparin (porcine), 94 d-amphetamine, 32, 33 danazol capsule, 98 DANTRIUM CAPSULE, 86 DANTRIUM INJECTION, 86 dantrolene, 86 dantrolene sodium, 86 dapsone, 4, 54 DAPSONE, 4 DAPTACEL, 79 daptomycin, 10 DARAPRIM, 15 darbepoetin alfa, 78, 79 darifenacin hydrobromide, 119 darunavir ethanolate, 5 dasatinib, 22 DAYPRO, 87


DAYTRANA, 32 DAZIDOX, 29 DDAVP 4 MCG/ML AMPUL, 71 DDAVP 4 MCG/ML VIAL, 71 DDAVP SOLUTION, -AEROSOL SPRAY

W/PUMP, -TABLET, 71 DEBACTEROL, 65 DECLOMYCIN, 17 deferasirox, 62 DELATESTRYL, 98 delavirdine mesylate, 5 del-beta, 59 DELESTROGEN, 100 DEL-MYCIN, 55 DEMADEX, 49 demeclocycline hcl, 17 DEMEROL, 29 DEMSER, 47 DEMULEN 1-50-21, 98 DENAVIR, 11 denosumab, 72 denta 5000 plus, 93 dentagel, 93 DEPACON, 42 depade, 38 DEPAKENE, 42 DEPAKOTE, 42 DEPAKOTE ER, 42 DEPAKOTE SPRINKLE, 42 DEPEN, 88 DEPODUR, 29 DEPO-ESTRADIOL, 100 DEPO-MEDROL, 66 DEPO-PROVERA 150 MG/ML VIAL, 108 DEPO-PROVERA 400 MG/ML VIAL, 20 DEPO-SUBQ PROVERA 104, 108 DEPO-TESTOSTERONE, 98 DERMA-SMOOTHE-FS, 59 DERMATOLOGICAL MEDICATIONS, 54 DERMATOP, 59 DERMOTIC, 63 desipramine, 39

desipramine hcl, 39 desloratadine, 115 desmopressin acetate, 71, 72 desmopressin acetate aerosol spray w/pump,

-solution, -tablet, 71 desmopressin acetate injection, 71 DESOGEN, 98 desogestrel-ethinyl estradiol, 98, 99 desog-et estra/ethin estra, 99 DESONATE, 59 desonide, 59, 60 desonide cream, -lotion, -ointment, 59 desonide/emollient combo #30, 59 DESOWEN, 59 desoximetasone, 60 desoximetasone cream, -gel, -ointment, 59 DESOXYN, 32 desvenlafaxine succinate, 37 DETROL, 119 DETROL LA, 119 dexamethasone, 66, 111 dexamethasone elixir, -solution oral, -tablet,

66 dexamethasone intensol, 66 dexamethasone sodium phosphate drops,

111 dexamethasone sodium phosphate injection,

66 dexasol, 111 dexasporin, 110 dexchlorpheniramine maleate, 115 DEXEDRINE, 32 DEXILANT DR 30 MG CAPSULE, 76 DEXILANT DR 60 MG CAPSULE, 76 dexlansoprazole, 76 dexmethylphenidate, 32 dexmethylphenidate hcl, 32 DEXPAK, 66 dextroamphetamine sulfate, 32 dextroamphetamine-amphetamine, 32 dextrose 10%-1/4ns, 91 dextrose 10%-1/4ns-kcl, 91


dextrose 2.5%-lr 1/2 str sol, 91 dextrose 5%-1/2ns-kcl, 91 dextrose 5%-1/3ns-kcl, 91 dextrose 5%-1/4ns-kcl, 91 dextrose 5%-electrolyte #48, 91 dextrose 5%-electrolyte #75, 91 dextrose 5%-lr iv solution, 95 dextrose 5%-ns-kcl, 91 dextrose in ringers injection, 91 dextrose in water, 91 dextrose with sodium chloride, 91 dextrose/electrolytes, 91, 92 DIABETA, 69 DIABETIC SUPPLIES, 1, 83 DIAGNOSTIC AND MISCELLANEOUS

MEDICATIONS, 62 DIAGNOSTIC PRODUCTS, 62 DIAMOX SEQUELS, 109 diazoxide, 67 DIBENZYLINE, 47 diclofenac epolamine, 58 diclofenac potassium, 87, 88 diclofenac sodium, 58, 61, 88, 114 diclofenac sodium drops, 113 diclofenac sodium tablet enteric coated, -

tablet sustained release 24hr, 87 diclofenac sodium/misoprostol, 87 dicloxacillin sodium, 15 dicyclomine, 73 dicyclomine hcl capsule, -syrup, -tablet, 73 dicyclomine hcl injection, 73 didanosine, 5 DIDRONEL, 71 difenoxin/atropine sulfate, 73 DIFFERIN, 55 diflorasone, 58 diflorasone diacetate, 59 DIFLUCAN 100 MG TABLET, -200 MG

TABLET, -50 MG TABLET, 8 DIFLUCAN 150 MG TABLET, 9 DIFLUCAN IN DEXTROSE, 14 DIFLUCAN IN SALINE, 14

DIFLUCAN SUSPENSION, 9 diflunisal, 89 difluprednate, 111 digoxin, 46, 47 digoxin injection, 46 digoxin solution, -tablet, 46 dihydrocodeine/apap/caffeine, 31, 32 dihydrocodeine/asa/caffeine, 31 dihydroergotamine, 33, 34 dihydroergotamine mesylate injection, 33 DILACOR XR, 45 DILANTIN 100 MG CAPSULE, 35 DILANTIN 30 MG CAPSULE, -30 MG

KAPSEAL, -TABLET CHEWABLE, 35 DILANTIN-125, 35 DILATRATE-SR, 50 DILAUDID INJECTION, 29 DILAUDID TABLET, 29 DILAUDID-5, 29 DILAUDID-HP, 29 dilt-cd, 45 diltia xt, 45 diltiazem, 45, 46 diltiazem 24hr er, 45 diltiazem er, 45 diltiazem hcl injection, 45 diltiazem hcl tablet, 45 dilt-xr, 45 diltzac er, 46 dimenhydrinate injection, 27 dimethyl sulfoxide, 120 dinoprostone, 97, 109 DIOVAN, 44 DIOVAN HCT, 51 DIPENTUM, 75 diphenhydramine 12.5 mg/5 ml, -25 mg cap,

-50 mg cap, -50 mg capsule, 115 diphenhydramine hcl injection, 115 diphenhydramine tannate, 115 diphenmax, 115 diphenoxylate/atropine sulfate, 73 diphenoxylate-atropine, 73


diphther,pertuss,tetanus vac, 78, 79, 80, 81 DIPHTHERIA-TETANUS TOXOID, 79 dipivefrin, 110 DIPROLENE, 59 DIPROLENE AF, 59 DIPROSONE, 59 dipyridamole, 89 dipyridamole tablet, 89 DIRECT MUSCLE RELAXANTS, 86 diskets, 29 disulfiram, 38 DITROPAN XL 10 MG TABLET, -15 MG

TABLET, 119 DITROPAN XL 5 MG TABLET, -5 MG TABLET

SA, 119 DIURIL, 53 DIURIL SODIUM, 53 divalproex, 42 divalproex sodium, 42 divalproex sodium er, 42 DIVIGEL, 100 dobutamine hcl, 52 dobutamine hcl in dextrose, 52 docosavit, 103 dofetilide, 50 dolasetron mesylate, 26 DOLOPHINE HCL, 29 DOLOREX FORTE, 31 DOMEBORO DROPS, 63 donepezil, 23 dopamine hcl, 52 dopamine hcl in 5% dextrose, 52 DORIBAX, 10 doripenem, 10 DORYX, 17 dorzolamide, 110 dorzolamide hcl, 109 dorzolamide/timolol, 109 dorzolamide-timolol, 109 DOVONEX CREAM, 56 DOVONEX SOLUTION, 56 doxazosin, 54

doxazosin mesylate 1 mg tab, -2 mg tab, -4 mg tab, 54

doxazosin mesylate 8 mg tab, 54 doxepin, 61, 62 doxepin hcl capsule, -solution, 42 doxercalciferol, 97 doxycycline, 17 doxycycline hyclate, 17, 66 doxycycline hyclate 100 mg tab, -capsule, -

capsule enteric coated, 17 doxycycline hyclate 20 mg tab, 65 doxycycline hyclate injection, 17 doxycycline monohydrate, 17 doxy-lemmon, 17 dp (a) ped/hib conj-tet, 81 dp (a) t-polio/hib conj-tet/pf, 80 DRITHOCREME HP, 56 DRITHO-SCALP, 56 dronabinol, 27 dronabinol 10 mg capsule, -5 mg capsule, 27 dronabinol 2.5 mg capsule, 27 dronedarone, 50 droperidol, 2 droperidol injection, 2 DROXIA, 20 DRUGS AFFECTING THE EAR, 63 DRUGS AFFECTING THE NOSE, 64 DRUGS AFFECTING THE THROAT AND

MOUTH, 65 DRUGS FOR PHEOCHROMOCYTOMA, 47 DRUGS TO PREVENT AND TREAT GOUT, 86 DRUGS TO PREVENT AND TREAT

HEADACHES, 33 DRYSOL, 61 DUAC CS, 55 dualvit ob, 103 DUET DHA, 103 DUET DHA COMPLETE, 103 DUET DHA EC, 103 DUET DHA WITH FERRAZONE, 103 DUET STUARTNATAL, 103 DUETACT, 69


DULERA, 118 duloxetine, 36, 37 DURACLON, 47 DURAGESIC, 29 DURAMORPH, 29 DUREZOL, 111 dutasteride, 120 dutasteride/tamsulosin hcl, 120 DYAZIDE, 53 dylix, 117 DYNACIN, 17 DYNACIRC CR, 46 dyphylline, 117 DYRENIUM, 53 DYSPORT, 86 DYTAN, 115 E.E.S. 200, 8 E.E.S. 400, 8 EAR-NOSE-THROAT MEDICATIONS, 63 EASPRIN, 89 EASY COMFORT INSULIN SYRINGE, 83 EASY TOUCH NEEDLE DISPOSABLE, -

SYRINGE EMPTY DISPOSABLE, 83 easygel, 93 echothiophate iodide, 110 EC-NAPROSYN, 87 econazole nitrate cream, 13 EDECRIN, 49 edge ob, 103 EDLUAR, 39 edrophonium, 38 edrophonium/atropine sulfate, 38 efalizumab, 21 efavirenz, 5 EFFER-K 10 MEQ TABLET EFF, -20 MEQ

TABLET EFF, 95 effer-k 25 meq tablet eff, 95 EFFEXOR, 37 EFFEXOR XR 150 MG CAPSULE, -37.5 MG

CAPSULE, 37 EFFEXOR XR 75 MG CAPSULE, 37 EFFIENT, 89

EFUDEX, 61 ELAPRASE, 71 ELDEPRYL, 38 electrolyte solution/peg's, 75, 76 electrolyte solutions, 91, 92, 93 ELECTROLYTES, IRRIGATING SOLUTIONS,

ETC., 90 ELESTAT, 113 ELESTRIN, 100 eletriptan, 34 ELIDEL, 61 ELIGARD, 20 ELIMITE, 57 eliphos, 97 elite ob dha, 103 ELITEK, 20 elite-ob, 103 ELIXOPHYLLIN, 117 ELMIRON, 120 ELOCON, 59 eltrombopag olamine, 83 EMADINE, 113 EMBEDA, 29 EMCYT, 20 emedastine difumarate, 113 EMEND 125 MG CAPSULE, -40 MG CAPSULE,

27 EMEND 80 MG CAPSULE, 27 EMEND INJECTION, 27 EMEND TRIFOLD PACK, 27 EMGEL, 55 EMLA, 3 EMSAM, 35 emtricitabine, 5 emtricitabine/tenofovir, 5 emtricitabine/tenofovir/efavir, 4 EMTRIVA, 5 ENABLEX, 119 enalapril, 43 enalapril maleate tablet, 43 enalapril maleate/hctz, 52 enalaprilat, 43


enalapril-hydrochlorothiazide, 51 ENBREL, 20 endocet, 29 ENDOCRINE MEDICATIONS, 66 endodan, 29 ENDOTHELIN RECPTR ANTAGONIST, 47 ENDRATE, 62 endrate disodium, 62 enfuvirtide, 5 ENGERIX-B, 79 ENJUVIA, 100 ENLON, 38 ENLON-PLUS, 38 enoxaparin, 95 enoxaparin 100 mg/ml syr, -30 mg/0.3 ml

syr, -40 mg/0.4 ml syr, -60 mg/0.6 ml syr, -80 mg/0.8 ml syr, 94

enoxaparin 120 mg/0.8 ml syr, -150 mg/ml syr, 94

enpresse, 98 entacapone, 38 entecavir, 11 ENTOCORT EC, 75 enulose, 89 ENZYMAX 500 MG TABLET, 75 enzymes, digestive, 75 EPIDUO, 55 epiflur, 93 epiklor, 96 epinastine hcl, 113 epinephrine 0.1 mg/ml syringe, -1 mg/ml

ampul, -1 mg/ml vial, 118 EPINEPHRINE 0.15 MG AUTO-INJCT, -0.3 MG

AUTO-INJECT, 118 EPINEPHRINE 0.3 MG/0.3 ML SYR, 118 epinephrine hcl, 117, 118, 119 EPIPEN, 118 EPIPEN JR, 118 epitol, 28 EPIVIR, 5 EPIVIR HBV, 11 eplerenone, 53

epoetin alfa, 79, 80 EPOGEN 10,000 UNITS/ML VIAL, -20,000

UNITS/2 ML VIAL, -20,000 UNITS/ML VIAL, -40,000 UNITS/ML VIAL, 79

EPOGEN 2,000 UNITS/ML VIAL, -3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL, 79

epoprostenol na, 53 epoprostenol sodium, 53 eprosartan mesylate, 44 eprosartan mesylate/hctz, 52 eptifibatide, 89 EPZICOM, 5 EQUAGESIC, 33 EQUETRO, 28 ERAXIS (ALCOHOL DILUENT), 14 ERAXIS (WATER DILUENT), 14 ergoloid mesylates tablet, 62 ERGOMAR, 33 ergotamine, 33 ergotamine tartrate/caffeine, 33 ergotamine-caffeine, 33 erlotinib hcl, 22 errin, 108 ERTACZO, 13 ertapenem sodium, 10 ery, 55 ERYPED 200, 8 ERYPED 400, 8 ERY-TAB, 8 ERYTHROCIN LACTOBIONATE, 8 erythrocin stearate, 8 erythromycin base, 8, 54, 55 erythromycin base/benz per, 55 erythromycin capsule enteric coated, -tablet,

8 erythromycin ethylsuccinate, 8 erythromycin ethylsuccinate tablet, 8 erythromycin gel, -solution non-oral, 55 erythromycin lactobionate, 8 erythromycin ointment, 112 erythromycin-benzoyl peroxide, 55


ERYTHROMYCINS, 8 erythromycin-sulfisoxazole, 16 escitalopram oxalate, 40 ESKALITH, 24 esomeprazole mag trihyd, 77 ESTRACE CREAM WITH APPLICATOR, 100 ESTRACE TABLET, 101 ESTRADERM, 101 estradiol, 100, 101 estradiol cypionate, 100 estradiol patch transdermal weekly, 101 estradiol tablet, 101 estradiol valerate, 100 estradiol valerate injection, 101 estradiol valerate/dienogest, 99 estradiol/drospirenone, 101 estradiol/levonorgestrel, 101 estradiol/noreth ac, 101 estradiol/norgestimate, 101 estradiol-norethindrone acetat, 101 estramustine phosphate sodium, 20 ESTRASORB, 101 ESTRING, 101 ESTROGEL, 101 ESTROGEN DRUGS, 100 estrogen,conjug,synthetic a, 100 estrogen,conjug,synthetic b, 100 estrogen/medroxyprogesterone, 102 ESTROGEN/PROGESTIN COMBINATIONS,

101 estrogens,conjugated, 101 estrogens,esterified, 101 estropipate, 101 ESTROSTEP FE, 98 eszopiclone, 39 etanercept, 20 eth estradiol/drospirenone, 100 ethacrynate sodium, 49 ethacrynic acid, 49 ethambutol, 6 ethambutol hcl tablet, 6 ethedent, 93

ethinyl estradiol/norelgest, 99 ethionamide, 6 ethosuximide, 42 ethotoin, 35 eth-oxydose, 29 ethynodiol diace-eth estradiol, 98 ETHYOL, 20 etidronate, 71 etidronate disodium, 71 etodolac, 87 etonogestrel/ethin estradiol, 99 etravirine, 5 EURAX, 57 EVAMIST, 101 everolimus, 19, 22, 23 EVISTA, 71 EVOCLIN, 55 EVOXAC, 65 EXALGO, 29 EXEL INSULIN SYRINGE, 83 EXELDERM, 13 EXELON, 23 exemestane, 19 exenatide, 67 EXFORGE, 51 EXFORGE HCT, 51 EXJADE, 62 EXTAVIA, 81 EXTINA, 13 ezetimibe, 49 ezetimibe/simvastatin, 48 FABRAZYME, 71 FACTIVE, 16 famciclovir, 11 famciclovir 125 mg tablet, 11 famciclovir 250 mg tablet, 11 famciclovir 500 mg tablet, 11 famotidine, 74 famotidine 20 mg tablet, -40 mg tablet, -

suspension oral, 74 famotidine injection, 74 FAMVIR 125 MG TABLET, 11


FAMVIR 250 MG TABLET, 11 FAMVIR 500 MG TABLET, 11 FANAPT 1 MG TABLET, -10 MG TABLET, -12

MG TABLET, -2 MG TABLET, -4 MG TABLET, -6 MG TABLET, -8 MG TABLET, 24

FANAPT TITRATION PACK, 24 FANSIDAR, 15 FARESTON, 20 FASLODEX, 20 fat emulsions, 97 FAZACLO, 25 fe c plus tablet, 103 febuxostat, 87 felbamate, 35 FELBATOL, 35 FELDENE, 87 felodipine er, 46 fem ph, 102 FEMARA, 20 FEMCON FE, 98 FEMECAL OB, 103 FEMECAL OB PLUS DHA, 103 FEMHRT, 101 FEMRING, 101 FEMTRACE, 101 fenofibrate, 49 fenofibric acid, 49 FENOFIBRIC ACID, 49 FENOGLIDE, 49 fenoldopam mesylate, 51 fenoprofen, 88 fenoprofen calcium, 87 fentanyl, 29 fentanyl citrate, 29, 30 fentanyl citrate injection, 29 fentanyl citrate loz, 29 FENTORA, 29 fesoterodine fumarate, 119 FEXMID, 86 fexofenadine, 115 fexofenadine hcl 180 mg tablet, 115

fexofenadine hcl 30 mg tablet, -60 mg tablet, 115

fexofenadine-pse er, 114 FIBRICOR, 49 filgrastim, 83 FINACEA, 55 finasteride, 120 FIORICET WITH CODEINE, 33 FIORINAL WITH CODEINE #3, 33 FIRST-HYDROCORTISONE, 59 FIRST-MOUTHWASH BLM, 65 FIRST-PROGESTERONE VGS 100, 108 FIRST-PROGESTERONE VGS 200, 108 FIRST-PROGESTERONE VGS 25, 108 FIRST-PROGESTERONE VGS 400, 108 FIRST-PROGESTERONE VGS 50, 108 FIRST-TESTOSTERONE, 98 FIRST-TESTOSTERONE MC, 98 FLAGYL, 4 FLAGYL ER, 4 FLAREX, 111 flavoxate hcl, 119 FLEBOGAMMA, 79 FLEBOGAMMA DIF, 79 flecainide, 44 flecainide acetate, 44 FLECTOR, 58 FLEXBUMIN, 91 FLEXERIL, 86 FLOLAN, 53 FLOMAX, 120 FLONASE, 64 FLOVENT 100 MCG DISKUS, -50 MCG

DISKUS, 118 FLOVENT 250 MCG DISKUS, 118 FLOVENT HFA 110 MCG INHALER, 118 FLOVENT HFA 220 MCG INHALER, 118 FLOVENT HFA 44 MCG INHALER, 118 FLOXIN, 63 FLOXIN I.V., 16 floxuridine, 20 fluconazole, 8, 9


fluconazole 100 mg tablet, -200 mg tablet, -50 mg tablet, 9

fluconazole 150 mg tablet, 9 fluconazole in dextrose, 14 fluconazole in saline, 14 fluconazole suspension, 9 fluconazole/dextrose-water, 14 fluconazole/sodium chloride, 14 flucytosine, 8 fludrocortisone acetate tablet, 69 FLUMADINE, 11 flumazenil, 38, 39 flunisolide, 65, 117 flunisolide 0.025% spray, 64 flunisolide 29 mcg-0.025% spr, 64 fluocinolone acetonide, 58, 59, 63, 111 fluocinolone acetonide cream, -ointment, -

solution non-oral, 59 fluocinonide, 60 fluocinonide cream, -gel, -ointment, -solution

non-oral, 59 fluocinonide emollient, 59 fluocinonide-e, 59 FLUORABON, 93 FLUOR-A-DAY DROPS, 93 fluor-a-day tablet chewable, 93 FLUORIDE PRODUCTS, 93 fluoridex daily defense, 93 FLUORIDEX SENSITIVITY RELIEF, 93 FLUORITAB DROPS, 93 fluoritab tablet chewable, 93 fluorometholone, 111 FLUOROPLEX, 61 fluorouracil, 60, 61 fluorouracil cream, -solution non-oral, 61 fluoxetine, 41 fluoxetine dr, 40 fluoxetine hcl 10 mg capsule, -10 mg tablet,

40 fluoxetine hcl 20 mg capsule, -20 mg tablet,

-solution, 40 fluoxetine hcl 40 mg capsule, 40

fluoxymesterone, 98 fluphenazine decanoate, 25 fluphenazine hcl elixir, -solution, -tablet, 25 fluphenazine hcl injection, 25 flura, 93 FLURA-DROPS, 93 flurandrenolide, 58, 59 flurbiprofen, 87, 114 flurbiprofen sodium, 113 flurbiprofen tablet, 87 flutamide, 20 fluticasone furoate, 65 fluticasone propionate, 59, 64, 118 fluticasone propionate cream, -ointment, 59 fluticasone propionate nasal inhaled steroids,

64 fluvastatin, 48 fluvoxamine, 40 fluvoxamine maleate 100 mg tab, 40 fluvoxamine maleate 25 mg tab, 40 fluvoxamine maleate 50 mg tab, 40 FML, 111 FML FORTE, 111 FML S.O.P., 111 FOCALIN, 32 FOCALIN XR, 32 folbecal, 103 folcal dha, 103 folcaps omega-3, 103 folinatal plus b, 103 folivane-ec calcium dha nf, 103 folivane-ob, 103 folivane-prx dha nf, 103 foltabs, 103 foltabs 90 plus dha, 103 FOLTABS PRENATAL PLUS DHA, 103 fomepizole, 62 fondaparinux sodium, 94 FORADIL, 116 formoterol fumarate, 116 FORTAMET, 69


FORTAZ 1 GM ADD-VANTAGE VIAL, -1 GM VIAL, -2 GM VIAL, -6 GM VIAL, 7

FORTAZ 2 GM ADD-VANTAGE VIAL, 7 FORTAZ 500 MG VIAL, 7 FORTAZ IN ISO-OSMOTIC DEXTROSE, 7 FORTEO, 71 fortical, 71 FOSAMAX 10 MG TABLET, -40 MG TABLET, -

5 MG TABLET, 71 FOSAMAX 35 MG TABLET, -70 MG TABLET,

71 FOSAMAX PLUS D, 71 FOSAMAX SOLUTION, 72 fosamprenavir calcium, 5 foscarnet, 11 foscarnet sodium, 11 FOSCAVIR, 11 fosfomycin tromethamine, 18 fosinopril, 43 fosinopril sodium, 43 fosinopril-hydrochlorothiazide, 51 fosphenytoin, 35 fosphenytoin sodium, 35 FOSRENOL, 89 FRAGMIN 10,000 UNITS SYRINGE, -10,000

UNITS/ML VIAL, -12,500 UNITS SYRINGE, -15,000 UNITS SYRINGE, -18,000 UNITS SYRINGE, -25,000 UNITS/ML VIAL, -7,500 UNITS SYRINGE, 94

FRAGMIN 2,500 UNITS SYRINGE, -5,000 UNITS SYRINGE, 94

FREAMINE HBC, 91 FREAMINE III, 91 FREAMINE III WITH ELECTROLYTES, 91 FROVA, 33 frovatriptan, 33 fudr, 20 fulvestrant, 20 FURADANTIN, 18 furosemide, 49 furosemide injection, 49 furosemide solution, -tablet, 49

FUZEON, 5 gabapentin, 36 gabapentin capsule, -tablet, 35 GABITRIL, 35 galantamine, 24 galantamine hbr, 24 galantamine hydrobromide, 24 galsulfase, 72 GAMASTAN S-D, 79 GAMMAGARD LIQUID, 79 GAMMAGARD S-D, 79 GAMMAPLEX, 79 GAMUNEX, 79 ganciclovir, 11, 114 ganciclovir sodium, 11 GANTRISIN, 16 GARDASIL, 79 GASTROCROM, 118 GASTROINTESTINAL MEDICATIONS, 73 gatifloxacin, 112 gavilyte-c, 75 gavilyte-g, 75 gavilyte-n, 75 gefitinib, 20 GELCLAIR, 65 GEL-KAM, 93 GELNIQUE, 119 gemfibrozil, 49 gemifloxacin, 16 generlac, 89 gengraf, 20 GENOTROPIN 12 MG CARTRIDGE, -5 MG

CARTRIDGE, 78 GENOTROPIN MINIQUICK 0.2 MG, -

MINIQUICK 0.4 MG, -MINIQUICK 0.6 MG, -MINIQUICK 0.8 MG, -MINIQUICK 1 MG, -MINIQUICK 1.2 MG, -MINIQUICK 1.4 MG, -MINIQUICK 1.6 MG, -MINIQUICK 1.8 MG, -MINIQUICK 2 MG, 78

gentak, 112 gentamicin 0.1% ointment, -cream, 18


gentamicin 100 mg/ns 100 ml, -60 mg/ns 50 ml pb, -70 mg/ns 50 ml pb, -80 mg/ns 50 ml pb, -90 mg/ns 100 ml pb, -gentamicin 100 mg/100 ml, -gentamicin 60 mg/50 ml, -gentamicin 80 mg/50 ml, 3

gentamicin 3 mg/gm eye oint, 112 GENTAMICIN 60 MG/NS 100 ML PB, -80

MG/NS 100 ML PB, -GENTAMICIN 100 MG/50 ML, -GENTAMICIN 60 MG/100 ML, -GENTAMICIN 80 MG/100 ML, 4

gentamicin sulfate drops, 112 gentamicin sulfate injection, 4 gentamicin/prednisolone, 110 gentamicin/sodium chloride, 4 gentasol, 112 gentex ade, 103 GEODON CAPSULE, 25 GEODON INJECTION, 25 GESTICARE, 103 GESTICARE DHA, 103 gianvi, 98 gildess fe, 98 glatiramer acetate, 62 GLEEVEC, 20 glimepiride, 69 glipizide, 69 glipizide er, 69 glipizide tablet, 69 glipizide xl, 69 glipizide/metformin hcl, 70 glipizide-metformin, 69 GLUCAGEN, 67 GLUCAGON EMERGENCY KIT, 67 glucagon, human recombinant, 67 GLUCOCORTICOID DRUGS, 66 gluconic acid/citric acid, 120 GLUCOPHAGE, 69 GLUCOPHAGE XR, 69 GLUCOPRO SYRINGE EMPTY DISPOSABLE,

83 GLUCOSE ELEVATING DRUGS, 67 GLUCOTROL, 69

GLUCOTROL XL, 69 GLUCOVANCE, 70 GLUMETZA, 70 glutamine, 97 glyburide, 69, 70 glyburide micronized, 70 glyburide/metformin hcl, 70 glyburide-metformin hcl, 70 glycerin liquid, 74 glycine solution, 120 glycopyrrolate, 73 glycopyrrolate injection, 73 glycopyrrolate tablet, 73 glycron, 70 GLYNASE, 70 GLYSET, 70 gold sodium thiomalate, 89 golimumab, 22 GOLYTELY, 75 GORDO-UREA, 61 goserelin acetate, 22 granisetron, 27 granisetron hcl injection, 27 granisetron hcl tablet, 27 granisol, 27 GRIFULVIN V SUSPENSION ORAL, 9 GRIFULVIN V TABLET, 9 griseofulvin microsize, 9 griseofulvin suspension oral, 9 griseofulvin ultramicrosize, 9 GRIS-PEG, 9 GROWTH HORMONES AND RELATED

DRUGS, 78 guanabenz acetate, 47 guanfacine, 38, 47 guanfacine hcl, 47 guanidine hcl, 38 GYNAZOLE-1, 18 GYNODIOL, 101 haemophilus b vaccine, 79, 80 haemophilus b-tet toxoid, 78, 79 halcinonide, 59


HALDOL, 25 HALDOL DECANOATE 100, 25 HALDOL DECANOATE 50, 25 HALFAN, 15 HALFLYTELY-BISACODYL, 75 halobetasol prop/amonium lac, 59, 60 halobetasol propionate, 59, 60 halofantrine, 15 HALOG, 59 HALONATE, 59 halonate pac, 59 haloperidol, 25 haloperidol decanoate, 25 haloperidol lactate injection, 25 haloperidol lactate solution, 25 haloperidol tablet, 25 haloprogin, 13 HALOTIN, 13 HAVRIX, 79 hc acetate/lidocaine hcl, 58, 59, 60 hctz/bisoprolol fumarate, 52 hctz/metoprolol, 51 hctz/triamterene, 53 hctz/valsartan, 51 HECTOROL CAPSULE, 97 HECTOROL INJECTION, 97 HELIDAC, 75 HEMABATE, 97 hemin, 63 hep b vaccine/dp (a) t-polio, 80 hep b vir recomb/hep a vir, 81 hep.b immune glob/maltose, 79 HEPAGAM B, 79 HEPARIN ANTAGONISTS, 94 heparin sodium in 0.45% nacl, 94 heparin sodium in 0.9% nacl, 94 heparin sodium in 5% dextrose, 94 heparin sodium injection, 94 HEPATAMINE, 91 HEPATASOL, 91 hepatatis a virus vaccine, 79, 81 hepatitis b immune globulin, 79, 80

hepatitis b virus vaccine, 79, 80 hepatitis b/haemophilus b vacc, 79 HEPSERA, 11 HESPAN, 62 hetastarch in ns, 62 hetastarch/e-lytes,lactate, 63 hetastarch/na chlor 0.9%, 62, 63 hexachlorophene, 18 HEXALEN, 20 HEXTEND LACTATED ELECTROLYTE, 63 HIBERIX, 79 HIBTITER, 79 hip prenatal, 103 HIPREX, 18 histrelin ac, 22, 109 HIZENTRA 1 GRAM/5 ML VIAL, 79 HIZENTRA 2 GRAM/10 ML VIAL, -4 GRAM/20

ML VIAL, 79 HMG-COA REDUCTASE INHIBITORS, 47 homatropaire, 113 homatropine, 113 homatropine hbr, 113 HUMALOG, 68 HUMALOG MIX 50-50, 68 HUMALOG MIX 75-25, 68 HUMAN ALBUMIN 25% IV SOLUTION, 91 human papillomav vacc bival/pf, 79 human papillomavirus vacc, 79 HUMAPEN LUXURA HD, 83 HUMAPEN MEMOIR, 83 HUMATROPE, 78 HUMIRA 20 MG/0.4 ML SYRINGE, -40 MG/0.8

ML SYRINGE, 20 HUMIRA 40 MG/0.8 ML PEN, -CROHN'S

STARTER PACK, -PSORIASIS STARTER PACK, 20

HUMULIN 50-50, 68 HUMULIN 70-30, 68 HUMULIN N, 68 HUMULIN R, 68 HYCET, 31 HYDANTOINS, 35


hydralazine hcl injection, 54 hydralazine hcl tablet, 54 hydra-zide, 51 HYDREA, 20 HYDRO 35, 61 HYDRO 40, 61 hydrochlorothiazide, 54 hydrochlorothiazide capsule, -tablet, 53 hydrocodone bitartrate/apap, 31, 32 hydrocodone bitartrate/ibuprof, 31, 32 hydrocodone bit-ibuprofen, 31 hydrocodone-acetaminophen, 31 hydrocortisone, 58, 59, 60, 66, 75, 76 hydrocortisone 1% absorbase, -1% cream, -

1% lotion, -1% oin, -1% oint, -1% ointment, -2.5% cream, -2.5% lotion, -2.5% ointment, -aloe 1% cream, -plus 1% cream, 59

hydrocortisone acetate, 75 hydrocortisone acetate/urea, 58, 60 hydrocortisone buteprate, 60 hydrocortisone butyrate, 59, 60 hydrocortisone enema, 75 hydrocortisone sod succinate, 66, 67 hydrocortisone tablet, 66 hydrocortisone valerate, 59, 60 hydrocortisone/emol no.45, 60 hydrogesic, 31 hydromorphone, 29 hydromorphone hcl injection, 29 hydromorphone hcl suppository rectal, -

tablet, 29 hydroxychloroquine, 16 hydroxychloroquine sulfate tablet, 15 hydroxypropylmethylcellulose, 113 hydroxyurea, 20 hydroxyurea capsule, 20 hydroxyzine hcl injection, 56 hydroxyzine hcl syrup, -tablet, 56 hydroxyzine pamoate, 56 hydroxyzine pamoate capsule, 56 hypercare, 61

HYPERHEP B S-D, 79 HYPERLYTE CR, 91 HYPERRAB S-D, 79 HYPERRHO S-D, 80 HYPERTET S-D, 80 HYPOGLYCEMIC DRUGS, 67 HYPOLIPOPROTEINEMICS, 49 HYZAAR, 51 ibandronate, 71 IBUDONE, 31 ibuprofen 100 mg/5 ml, -100 mg/5 ml sus, -

100 mg/5 ml susp, -400 mg tablet, -600 mg tablet, -800 mg tablet, 87

ibuprofen lysine, 88 ibutilide fumarate, 50 ICAR-C PLUS, 103 idursulfase, 71 ILARIS, 82 iloperidone, 24 imatinib mesylate, 20 IMDUR, 50 imiglucerase, 71 imipenem/cilastatin sodium, 10 imipramine hcl, 42 imipramine hcl tablet, 42 imipramine pamoate, 42 imiquimod, 60, 61, 62 IMITREX 20 MG NASAL SPRAY, 33 IMITREX 4 MG/0.5 ML SYRNG KIT, -6 MG/0.5

ML SYRNG KIT, 33 IMITREX 5 MG NASAL SPRAY, 34 IMITREX 6 MG/0.5 ML VIAL, -4 MG/0.5 ML

KIT REFILL, -6 MG/0.5 ML KIT REFILL, 34 IMITREX TABLET, 34 immune globulin - im, 79 immune globulin - iv, 79, 80 immune globulin- sq, 79, 81 IMMUNOLOGICALS AND VACCINES, 78 IMOGAM RABIES-HT, 80 IMOVAX RABIES VACCINE, 80 IMURAN, 20 IN CONTROL PEN NEEDLE, 83


INAPSINE, 2 inatal advance, 103 inatal gt, 104 inatal ultra, 104 INCRELEX, 81 indapamide, 53 INDERAL LA, 44 indinavir, 5 INDOCIN I.V., 87 INDOCIN SR, 87 INDOCIN SUPPOSITORY RECTAL, 87 INDOCIN SUSPENSION ORAL, 87 indomethacin, 87 indomethacin capsule, -capsule sustained

action, 87 indomethacin injection, 87 indomethacin sodium trihydrate, 87 INFANRIX, 80 INFERGEN, 81 infliximab, 21 INFUMORPH, 30 INJECTABLE ANTICOAGULANTS, 94 INJECT-EASE, 83 INNOHEP, 94 INNOPRAN XL, 44 INSPRA, 53 INSULIN, 68 INSULIN LIKE GROWTH FACTORS-1, 81 INSULIN PEN NEEDLE, 83 INSULIN SYRINGE, 83 INSUMED, 84 INSUPEN, 84 INTAL, 118 INTEGRA SYRINGE SYRINGE EMPTY

DISPOSABLE, 84 INTEGRILIN, 89 INTELENCE, 5 interferon alfa-2b , recomb., 82 interferon alfacon-1, 81 interferon alfa-n3, 81 interferon beta-1a, 81 interferon beta-1a/albumin, 82

interferon beta-1b, 81 interferon gamma-1b,recomb., 81 INTERFERONS, 81 INTERLEUKIN RECPTR ANTAGONIST, 82 INTERLEUKINS, 82 INTRALIPID 10% IV FAT EMUL, -20% IV FAT

EMUL, 97 INTRALIPID 30% IV FAT EMUL, 97 INTRON A 10 MILLION UNIT PEN, -10

MILLION UNIT/ML, -18 MILLION UNITS VIAL, -5 MILLION UNIT/ML PEN, -50 MILLION UNITS VIAL, -6 MILLION UNIT/ML VL, 82

INTRON A 10 MILLION UNITS VIAL, -3 MILLION UNIT/ML PEN, 82

INTUNIV, 38 INVANZ 1 GM ADD-VANTAGE VIAL, 10 INVANZ 1 GM VIAL, 10 INVEGA ER 1.5 MG TABLET, -ER 3 MG

TABLET, -ER 9 MG TABLET, 25 INVEGA ER 6 MG TABLET, 25 INVEGA SUSTENNA 117 MG PREF SY, -156

MG PREF SY, -234 MG PREF SY, 25 INVEGA SUSTENNA 39 MG PREF SYR, -78

MG PREF SYR, 25 INVERSINE, 51 inverted sugar, 93 INVIRASE, 5 IONOSOL B WITH DEXTROSE 5%, 91 IONOSOL MB-DEXTROSE 5%, 91 IONOSOL T-DEXTROSE 5%, 91 IOPIDINE, 109 IPOL, 80 ipratropium, 64, 118 ipratropium 0.03% spray, 64 ipratropium 0.06% spray, 65 ipratropium bromide solution non-oral, 118 IQUIX, 112 irbesartan, 44 irbesartan/hctz, 51 IRESSA, 20 iron,carbonyl/vit c/vit b12/fa, 103


IRRITABLE BOWEL DRUGS, 74 ISENTRESS, 5 ISMO, 50 ISO GENTAMICIN 120 MG/100 ML, -

GENTAMICIN 120 MG/50 ML, -GENTAMICIN 40 MG/100 ML, -GENTAMICIN 40 MG/50 ML, 4

isocarboxazid, 35 ISOCHRON, 50 ISOLYTE H WITH DEXTROSE, 91 ISOLYTE M WITH DEXTROSE, 91 ISOLYTE P WITH DEXTROSE, 91 ISOLYTE S, 91 ISOLYTE S WITH DEXTROSE, 91 isonarif, 6 isoniazid injection, 6 isoniazid syrup, -tablet, 6 isoproterenol hcl, 52 ISOPTIN SR, 46 ISOPTO ATROPINE, 113 ISOPTO CARBACHOL, 110 ISOPTO CARPINE, 110 ISOPTO HOMATROPINE, 113 ISOPTO HYOSCINE, 113 ISORDIL, 50 ISORDIL TITRADOSE, 50 isosorb dinit/hydralazine hcl, 53 isosorbide dinitrate, 50 isosorbide mononitrate, 50 isotretinoin, 57 isradipine, 46 ISTALOL, 110 ISUPREL, 52 itraconazole, 9 itraconazole capsule, 9 ivermectin, 4 IXIARO, 80 JALYN, 120 jantoven, 95 JANUMET, 70 JANUVIA, 70 japanese encephalitis vaccine, 80

JE-VAX, 80 jolessa, 98 jolivette, 108 junel, 98 junel fe, 98 k effervescent, 96 k sorbate/he-cel/pvp/hyalur ac, 65 k sorbate/malto/alo v/mann ps, 65 KADIAN, 30 KALETRA 100-25 MG TABLET, 5 KALETRA 200-50 MG TABLET, -SOLUTION, 5 kalexate, 95 kanamycin sulfate, 4 KAOCHLOR, 96 kaon-cl 10, 96 KAPIDEX DR 30 MG CAPSULE, 76 KAPIDEX DR 60 MG CAPSULE, 76 kariva, 99 KAY CIEL, 96 KAYEXALATE, 95 kcl 20 meq in d5w solution, -20 meq/l iv

solution, -40 meq in d5w solution, -40 meq/l iv solution, 96

kcl 20 meq in d5w-lact ringer, -40 meq in d5w-lact ringer, 96

kcl 40 meq in d5w-lact ringer, 91 KEFLEX, 7 kelnor 1-35, 99 KENALOG, 59 KENALOG-10, 66 KENALOG-40, 66 KEPIVANCE, 80 KEPPRA INJECTION, 35 KEPPRA SOLUTION, -TABLET, 35 KEPPRA XR, 35 KERAFOAM, 61 KERALAC, 61 keratol 40, 61 keratol plus, 61 KERATOLYTIC DRUGS, 57 KERLONE, 44 KEROL, 61


KETEK, 8 ketoconazole, 13 ketoconazole cream, -shampoo, 13 ketoconazole tablet, 9 KETOLIDES, 8 ketoprofen capsule, -capsule 24hr sustained

release pellets, 87 ketorolac, 88, 112, 113 ketorolac tromethamine drops, 113 ketorolac tromethamine injection, 88 ketorolac tromethamine tablet, 88 KINERET, 82 KIONEX POWDER, 95 kionex suspension oral, 95 KLARON, 56 klor-con 10, 96 klor-con 20 meq packet, 96 KLOR-CON 25 MEQ PACKET, 96 klor-con 8, 96 klor-con m10, 96 klor-con m15, 96 klor-con m20, 96 klor-con-ef, 96 kolnatal dha, 104 K-PHOS M.F., 120 K-PHOS NEUTRAL, 96 K-PHOS NO.2, 120 K-PHOS ORIGINAL, 120 KRISTALOSE, 89 K-TAB, 96 KURIC, 13 KUVAN, 72 KYTRIL INJECTION, 27 KYTRIL TABLET, 27 labetalol, 45 labetalol hcl injection, 44 labetalol hcl tablet, 44 LAC-HYDRIN, 61 LACLOTION, 61 lacosamide, 36 LACRISERT, 113 lactate, ammonium, 61

lactated ringers injection, 91 LACTOCAL-F, 104 lactulose, 89 LAMICTAL, 35 LAMICTAL (BLUE), 35 LAMICTAL (GREEN), 35 LAMICTAL (ORANGE), 35 LAMICTAL ODT, 35 LAMICTAL ODT (BLUE), 35 LAMICTAL ODT (GREEN), 36 LAMICTAL ODT (ORANGE), 36 LAMICTAL XR, 36 LAMICTAL XR (BLUE), 36 LAMICTAL XR (GREEN), 36 LAMICTAL XR (ORANGE), 36 LAMISIL PKT, 9 LAMISIL SOLUTION, 13 LAMISIL TABLET, 9 lamivudine, 5, 11 lamivudine/zidovudine, 4 lamotrigine, 35, 36 LANOXIN INJECTION, 46 LANOXIN PEDIATRIC, 47 LANOXIN TABLET, 47 lanreotide acetate, 22 lansoprazole, 77 lansoprazole dr 15 mg capsule, 77 lansoprazole dr 30 mg capsule, 77 lansoprazole/amox tr/clarith, 76 lanthanum carbonate, 89 LANTUS, 68 LANTUS SOLOSTAR, 68 lapatinib ditosylate, 22 laronidase, 71 LASIX, 49 latanoprost, 110 LAXATIVES AND CATHARTICS, 74 leena, 99 leflunomide, 19, 20 lenalidomide, 21 lepirudin,recombinant, 95 LESCOL 20 MG CAPSULE, 48


LESCOL 40 MG CAPSULE, 48 LESCOL XL, 48 lessina, 99 LETAIRIS, 47 letrozole, 20 leucovorin calcium injection, 20 leucovorin calcium tablet, 20 LEUKERAN, 21 LEUKINE, 83 LEUKOTRIENE MODIFIERS, 116 leuprolide, 20, 109 leuprolide acetate, 109 levalbuterol, 116 LEVAQUIN INJECTION, 16 LEVAQUIN SOLUTION, -TABLET, 16 LEVATOL, 45 LEVEMIR, 68 levetiracetam, 35 levetiracetam injection, 36 levetiracetam solution, -tablet, 36 LEVLEN 28, 99 levobunolol, 109 levobunolol hcl, 110 levocarnitine, 97 levocarnitine injection, 97 levocarnitine solution, -tablet, 97 levocetirizine dihydrochlor, 115, 116 levofloxacin, 16, 112 levonorgestrel, 99, 100 levonorgestrel-ethin estradiol, 99, 100 levora-28, 99 levorphanol tartrate tablet, 30 levothroid, 72 levothyroxine, 72, 73 levothyroxine sodium injection, 72 levothyroxine sodium tablet, 72 levoxyl, 72 LEVULAN, 61 LEXAPRO SOLUTION, 40 LEXAPRO TABLET, 40 LEXIVA SUSPENSION ORAL, 5 LEXIVA TABLET, 5

LIALDA, 75 LIDAMANTLE, 3 LIDAMANTLE HC, 59 lidazone hc, 60 lidocaine, 3, 66, 113 lidocaine hcl 0.5% vial, -1% abboject, -1%

ampul, -1% syringe, -1% vial, -1.5% ampul, -2% abboject, -2% ampul, -2% luer-jet, -2% min-i-jet, -2% syringe, -2% vial, -20% vial, -4% ampul, 2

lidocaine hcl 10% vial, 50 lidocaine hcl cream, -jelly with prefilled

applicator, -lotion, -ointment, -solution non-oral, 3

lidocaine hcl in 7.5% dextrose, 2 lidocaine hcl viscous, 3 lidocaine hcl-epinephrine, 2 lidocaine hydrochloride/epi, 3 lidocaine/prilocaine, 3 lidocaine/tetracaine, 3 lidocaine-hc, 60 lidocaine-hydrocortisone cream, -cream with

applicator, -kit, -lotion, 60 lidocaine-prilocaine, 3 LIDODERM, 3 LIMBITROL, 37 LINCOCIN, 10 lincoject, 10 lincomycin, 10 LINDANE, 57 linezolid, 10 LIORESAL INTRATHECAL, 86 liothyronine, 72, 73 liothyronine sodium injection, 72 liothyronine sodium tablet, 72 liotrix, 72 LIPITOR, 48 LIPOFEN, 49 LIPOSYN II, 97 liposyn iii, 97 liquadd, 32 liqui-dualcitra, 96


liraglutide, 68 LISCO SPONGES, 84 lisdexamfetamine dimesylate, 33 lisinopril, 43 lisinopril tablet, 43 lisinopril/hctz, 51, 52 lisinopril-hctz, 51 lisinopril-hydrochlorothiazide, 51 LITE TOUCH INSULIN PEN NEEDLES, 84 LITE TOUCH SYRINGE EMPTY DISPOSABLE,

84 lithium, 24 lithium carbonate, 24 lithium carbonate capsule, -tablet, -tablet

sustained action, 24 lithium citrate, 24 LITHOBID, 24 LITHOSTAT, 120 LIVALO, 48 l-norgest-eth estr/ethin estr, 99, 100 LOCAL ANESTHETICS, 2 LOCOID, 60 LOCOID LIPOCREAM, 60 LODOSYN, 38 lodoxamide, 113 LOESTRIN, 99 LOESTRIN 24 FE, 99 LOESTRIN FE, 99 LOFIBRA, 49 LOKARA, 60 LOMOTIL, 73 lomustine, 20 lonox, 73 LOOP DIURETICS, 49 LO-OVRAL-28, 99 loperamide capsule, 73 LOPID, 49 LOPRESSOR HCT, 51 LOPRESSOR INJECTION, 45 LOPRESSOR TABLET, 45 LOPROX, 13 LORCET 10-650, 31

LORCET PLUS, 31 LORTAB, 31 losartan, 44 losartan /hctz, 51 losartan potassium, 44 losartan-hydrochlorothiazide, 51 LOSEASONIQUE, 99 LOTEMAX, 111 LOTENSIN, 43 LOTENSIN HCT, 51 loteprednol etabonate, 111 LOTREL, 51 LOTRISONE, 18 LOTRONEX, 74 lovastatin, 48 lovastatin 10 mg tablet, 48 lovastatin 20 mg tablet, -40 mg tablet, 48 lovastatin/niacin, 47 LOVAZA, 49 LOVENOX 100 MG PREFILLED SYR, -120 MG

PREFILLED SYR, -150 MG PREFILLED SYR, -300 MG VIAL, -60 MG PREFILLED SYRN, -80 MG PREFILLED SYRN, 95

LOVENOX 30 MG PREFILLED SYRN, -40 MG PREFILLED SYRN, 95

low-ogestrel, 99 loxapine, 25 loxapine succinate, 25 LOXITANE, 25 lozi-flur, 93 lubiprostone, 74 LUCENTIS, 113 ludent fluoride, 93 LUER-LOK SYRINGE SYRINGE EMPTY

DISPOSABLE, 84 LUFYLLIN, 117 LUMIGAN, 110 LUMIZYME, 72 LUNESTA, 39 LUPRON, 109


LUPRON DEPOT 11.25 MG 3MO KIT, -22.5 MG 3MO KIT, -3.75 MG KIT, -4 MONTH KIT, 109

LUPRON DEPOT 7.5 MG KIT, 109 LUPRON DEPOT-PED, 109 LURIDE, 93 lutera, 99 LUVOX CR, 40 LUXIQ, 60 LYBREL, 99 lymphocyte immune globulin, 79, 81 LYRICA, 36 LYSODREN, 21 LYSTEDA, 63 MACROBID, 18 MACRODANTIN, 18 MACUGEN, 114 mafenide acetate, 18 mag hydrox/alh/smc/dpha/lido, 65 MAGNACET, 30 magnesium sulfate injection, 91 magnesium sulfate/d5w, 91 MAGNESIUM SULFATE-D5W, 91 MALARONE, 16 malathion, 57, 58 mannitol, 92 mannitol injection, 91 MAO INHIBITORS, 35 maprotiline hcl, 37 maraviroc, 5 MARCAINE, 2 MARCAINE SPINAL, 2 MARCAINE WITH EPINEPHRINE, 2 MARCAINE-EPINEPHRINE, 2 margesic h, 31 MARINOL 10 MG CAPSULE, -5 MG CAPSULE,

27 MARINOL 2.5 MG CAPSULE, 27 marlexate, 95 MARNATAL-F, 104 MARNATAL-F PLUS, 104 MARPLAN, 35

maternity, 104 MATULANE, 21 MAVIK, 43 MAXAIR AUTOHALER, 116 MAXALT, 34 MAXALT MLT, 34 MAXIDEX, 111 MAXIDONE, 31 MAXINATE, 104 MAXIPIME 1 GM ADD-VANTAGE VL, -2 GM

ADD-VANTAGE VL, -1 GRAM VIAL, -2 GRAM VIAL, 7

MAXIPIME 500 MG VIAL, 7 MAXITROL, 110 MAXZIDE, 53 MAXZIDE-25 MG, 53 measles vaccine,atten, 79 measles,mumps&rubella vaccine, 80 measles,mumps,rub,varicella, 80 mebendazole tablet chewable, 4 mecamylamine, 51 mecasermin, 81 mechlorethamine, 21 meclizine 12.5 mg tablet, -25 mg tablet, 27 meclizine hcl, 26 meclofenamate sodium capsule, 88 MEDICAL (MISCELLANEOUS) SUPPLIES, 1,

83 MEDI-JECTOR NEEDLE-FREE SYR A, 84 MEDI-JECTOR NEEDLE-FREE SYR B, 84 MEDI-JECTOR NEEDLE-FREE SYR C, 84 MEDI-JECTOR VISION, 84 MEDROL, 66 medroxyprogesterone, 20, 108, 109 medroxyprogesterone acetate injection, 108 medroxyprogesterone acetate tablet, 108 mefenamic acid, 88 mefloquine hcl, 16 MEFOXIN, 7 MEGACE, 21 MEGACE ES, 21 megestrol, 21


megestrol acetate suspension oral, -tablet, 21

meloxicam, 88 meloxicam 15 mg tablet, -suspension oral, 88 meloxicam 7.5 mg tablet, 88 memantine hcl, 24 MENACTRA, 80 MENEST, 101 mening vac a,c,y,w-135 dip, 80 meningococcal vac a,c,y,w-135, 80 MENOMUNE-A-C-Y-W-135, 80 MENOSTAR, 101 MENTAX, 13 MENVEO A-C-Y-W-135-DIP, 80 mepenzolate, 73 meperidine, 29 meperidine hcl injection, 30 mepivacaine, 2 meprobamate, 28 meprolone unipak, 66 MEPRON, 10 mercaptopurine, 21 mercaptopurine tablet, 21 meropenem, 10 MERREM IV 1 GM VIAL, 10 MERREM IV 500 MG VIAL, 10 MERUVAX II VACCINE W-DILUENT, 80 mesalamine, 75, 76 mesna, 21 MESNEX TABLET, 21 MESTINON SYRUP, -TABLET SUSTAINED

ACTION, 38 MESTINON TABLET, 38 METADATE CD, 32 METADATE ER 10 MG TABLET SA, 32 metadate er 20 mg tablet, 32 METAGLIP, 70 metaproterenol sulfate syrup, -tablet, 116 metaxalone, 86 metformin, 69, 70 metformin hcl, 70 metformin hcl er, 70

methadex, 110 methadone, 29 methadone hcl injection, 30 methadone hcl solution, -tablet, -tablet

soluble, 30 methadone intensol, 30 methadose, 30 methamphetamine, 32 methamphetamine hcl, 32 methazolamide, 110 methenamine hippurate, 18 methenamine mandelate, 18 METHERGINE INJECTION, 102 METHERGINE TABLET, 102 methimazole, 66 methimazole tablet, 66 METHITEST, 98 methocarbamol, 86 methocarbamol tablet, 86 methotrexate, 21 methotrexate injection, 21 methotrexate sodium, 22 methotrexate tablet, 21 methoxsalen, 57, 61 methscopolamine, 73 methscopolamine bromide, 73 methsuximide, 42 methyclothiazide tablet, 54 methyl aminolevulinate hcl, 61 METHYL XANTHINE DRUGS, 116 methyldopa, 47 methyldopa-hydrochlorothiazide, 51 methyldopate hcl, 47 methylergonovine, 102 METHYLIN 10 MG CHEWABLE TABLET, -2.5

MG CHEWABLE TAB, -5 MG CHEWABLE TABLET, -SOLUTION, 32

methylin 10 mg tablet, -20 mg tablet, -5 mg tablet, 32

methylin er, 32 methylnaltrexone bromide, 76 methylphenidate, 32, 33


methylphenidate er, 33 methylphenidate hcl solution, -tablet, 33 methylphenidate sr, 33 methylprednisolone, 66 methylprednisolone acetate, 66 methylprednisolone acetate injection, 67 methylprednisolone sod succ, 67 methylprednisolone tablet, -tablet dose pack,

67 methyltestosterone, 97, 98 metipranolol, 110 metoclopramide, 73 metoclopramide hcl injection, 73 metoclopramide hcl solution oral, -tablet, 73 metolazone, 54 metoprolol succinate, 45 metoprolol tartrate, 45 metoprolol tartrate injection, 45 metoprolol tartrate tablet, 45 metoprolol-hydrochlorothiazide, 51 METOZOLV ODT, 73 metro iv, 4 METROCREAM, 55 METROGEL, 55 METROGEL-VAGINAL, 102 METROLOTION, 55 metronidazole, 4, 55, 102 metronidazole capsule, -tablet, 4 metronidazole cream, -gel, -lotion, 55 metronidazole gel with applicator, 102 metronidazole injection, 4 metryl, 4 METVIXIA, 61 metyrosine, 47 MEVACOR, 48 mexiletine hcl capsule, 44 MIACALCIN AEROSOL SPRAY W/PUMP, 72 MIACALCIN INJECTION, 72 micafungin sodium, 14 MICARDIS, 44 MICARDIS HCT, 51 miconazole, 9

miconazole 3 200 mg vag supp, 19 miconazole nitrate/zinc oxide, 13 MICRHOGAM, 80 MICRHOGAM PLUS, 80 microgestin, 99 microgestin fe, 99 MICRO-K, 96 MICRONOR, 108 MICROZIDE, 54 MIDAMOR, 53 midodrine, 52 midodrine hcl, 52 migergot, 34 miglitol, 70 miglustat, 72 MIGRANAL, 34 MILLIPRED, 67 MILLIPRED DP, 67 milnacipran hcl, 37 milrinone in 5% dextrose, 47 milrinone lactate, 47 mimvey, 101 MINERALOCORTICOID DRUGS, 69 MINIPRESS, 54 MINITRAN, 50 MINOCIN COMBINATION PACKAGE, -KIT, -

CAPSULE, 17 MINOCIN INJECTION, 17 minocycline, 17, 65 minocycline hcl capsule, -tablet, -tablet

sustained release 24hr, 17 minoxidil tablet, 54 MIOSTAT, 110 MIRAPEX, 38 MIRAPEX ER, 38 MIRCETTE, 99 mirtazapine, 37 misc supp (dress,tape,gauze), 83, 84, 85 MISCELLANEOUS DRUGS, 62 misoprostol, 75 mitotane, 21 mitoxantrone, 21


mitoxantrone hcl injection, 21 M-M-R II VACCINE, 80 MOBAN, 25 MOBIC 15 MG TABLET, -SUSPENSION ORAL,

88 MOBIC 7.5 MG TABLET, 88 modafinil, 33 MODICON, 99 moexipril, 43 moexipril hcl, 43 moexipril/hctz, 52 moexipril-hydrochlorothiazide, 51 molindone, 25 mometasone, 59, 65, 117, 118 mometasone furoat/ammonium l, 60 mometasone furoate, 60 mometasone/formoterol, 118 MOMEXIN, 60 MONODOX, 17 MONOJECT 0.5 ML SYRN 28GX1/2, 84 MONOJECT INSULIN SAFETY SYRNG, 84 MONOJECT INSULIN SYRINGE, 84 MONOKET, 50 mononessa, 99 MONOPRIL, 43 montelukast sodium, 116 MONUROL, 18 morphine, 29, 30, 31 morphine sulfate in dextrose, 30 morphine sulfate injection, 30 morphine sulfate liposomal, 29 morphine sulfate solution, -suppository

rectal, -tablet, 30 morphine sulfate tablet sustained action, 30 morphine sulfate/naltrexone, 29 MOTOFEN, 73 MOVIPREP, 76 MOXATAG, 15 moxifloxacin, 16, 112 MOZOBIL, 80 MS CONTIN, 30 mucositis & stomatitis combo 1, 65

MUCOTROL, 65 MULTAQ, 50 multinatal plus, 104 multi-nate 30, 104 multi-nate 30 dha, 104 multi-nate dha extra, 104 mumps vaccine,live, 80 MUMPSVAX VACCINE W-DILUENT, 80 mupirocin, 17 mupirocin calcium, 17 mupirocin ointment, 18 muronab-cd3, 21 MUSCULOSKELETAL MEDICATIONS, 85 MUSTARGEN, 21 M-VIT, 104 MYAMBUTOL, 6 MYCAMINE, 14 MYCOBUTIN, 6 mycophenolate mofetil, 20 mycophenolate mofetil capsule, 21 mycophenolate mofetil tablet, 21 mycophenolate sodium, 21 MYCOSTATIN, 9 MYDFRIN, 114 mydral, 114 MYDRIACYL, 114 MYELOID STIMULANTS, 83 MYFORTIC, 21 mynatal, 104 mynatal advance, 104 mynatal plus, 104 mynatal-z, 104 mynate 90 plus, 104 MYOBLOC, 86 myochrysine, 89 MYOZYME, 72 MYSOLINE, 36 MYTELASE, 39 NABI-HB, 80 nabilone, 26 nabumetone, 88 nadolol, 44, 45


nadolol-bendroflumethiazide, 51 nafarelin, 109 NAFCILL IN DEXTROSE, 15 nafcillin, 15 nafcillin sodium, 15 naftifine, 13 NAFTIN, 13 NAGLAZYME, 72 nalbuphine hcl, 23 NALFON, 88 NALLPEN, 15 NALLPEN IN DEXTROSE, 15 NALLPEN-ISO-OSMOTIC DEXTROSE, 15 naloxone hcl injection, 39 naltrexone, 39 naltrexone hcl tablet, 39 naltrexone microspheres, 39 NAMENDA, 24 NANO PEN NEEDLE, 84 naphazoline, 113 naphazoline hcl drops, 114 NAPRELAN, 88 NAPRELAN CR DOSE CARD, 88 NAPROSYN, 88 naproxen, 87, 88 naproxen 250 mg tablet, -375 mg tablet, -

suspension oral, -tablet enteric coated, 88 naproxen 500 mg tablet, 88 naproxen sodium, 87, 88 naproxen sodium 275 mg tab, -550 mg tab,

88 naproxen/esomeprazole mag, 88 naratriptan, 33 naratriptan hcl, 34 NARDIL, 35 NAROPIN, 2 NASACORT AQ, 65 NASAREL, 65 NASONEX, 65 natacaps, 104 NATACHEW, 104 NATACYN, 114

NATAFORT, 104 natalcare pic forte, 104 natalcare plus, 104 natalizumab, 22 NATALVIT, 104 natamycin, 114 natatab, 104 NATAZIA, 99 nateglinide, 70 NATELLE, 104 NATELLE C, 104 NATELLE ONE, 104 NATELLE PLUS, 104 NATELLE PREFER, 104 NATELLE-EZ, 104 NATRECOR, 53 nature-throid, 72 NATURETIN-5, 54 NAVANE, 25 NEBCIN IN DEXTROSE, 4 nebivolol hcl, 44 necon, 99 nedocromil, 113 NEEVO, 104 NEEVO DHA, 104 nefazodone hcl, 37 nelfinavir mesylate, 5 neocidin, 112 NEO-FRADIN, 4 neofrin, 114 neomycin, 4 neomycin suf/polymy/buffers/hc, 64 neomycin sulfate tablet, 4 neomycin sulfate/colist sul/hc, 63 neomycin sulfate/polymyxin, 120 neomycin sulfate/polymyxin/hc, 63, 110 neomycin/bacitracin/poly/hc, 18 neomycin/colist sul/hc/thonz, 63 neomycin/gramicidin/polymyxin, 112 neomycin/polymyxin/dexameth, 110 neomycin/polymyxin/prednisol, 110 neomycin-bacitracin-poly-hc, 110


neomycin-bacitracin-polymyxin, 112 neomycin-polymyxin b, 120 neomycin-polymyxin-dexameth, 110 neomycin-polymyxin-gramicidin, 112 neomycin-polymyxin-hc solution, -solution

non-oral, -suspension drops, 64 neomycin-polymyxin-hc suspension drops,

110 NEOPROFEN, 88 NEORAL, 21 NEOSPORIN DROPS, 112 NEOSPORIN G.U. IRRIGANT, 120 neostigmine bromide, 39 neostigmine methylsulfate, 39 nepafenac, 114 NEPHRAMINE, 91 NESACAINE, 2 NESACAINE-MPF, 2 nesiritide, 53 NEULASTA, 83 NEUMEGA, 82 NEUPOGEN, 83 NEURONTIN CAPSULE, -TABLET, 36 NEURONTIN SOLUTION, 36 NEUT, 91 neutragard advanced, 93 NEUTRASAL, 65 NEVANAC, 114 nevirapine, 5 NEXAVAR, 21 NEXIUM 10 MG PACKET, -20 MG CAPSULE, -

20 MG PACKET, 77 NEXIUM 40 MG CAPSULE, -40 MG PACKET,

77 NEXIUM I.V., 77 next choice, 99 niacin, 49 niacin/simvastatin, 48 NIACOR, 49 NIASPAN, 49 nicardipine, 45 nicardipine hcl capsule, 46

nicardipine hcl injection, 46 nicotine inhaler, 42 nicotine ns, 42 NICOTROL, 42 NICOTROL NS, 42 nifediac cc, 46 nifedical xl, 46 nifedipine, 45, 46 nifedipine capsule, 46 nifedipine er, 46 NILANDRON, 21 nilotinib hydrochloride, 22 nilutamide, 21 nimodipine, 46 NIMOTOP, 46 nisoldipine, 46 NISOLDIPINE ER 17 MG TABLET, -ER 25.5

MG TABLET, -ER 34 MG TABLET, -ER 8.5 MG TABLET, 46

nisoldipine er 20 mg tablet, -er 30 mg tablet, -er 40 mg tablet, 46

nitazoxanide, 9 nitisinone, 63 NITRATES, 50 nitro-bid, 50 NITRO-DUR, 50 nitrofurantoin, 18 nitrofurantoin capsule, 18 nitrofurantoin macrocrystal, 18 nitrofurantoin mono-macro, 18 nitrofurantoin/nitrofuran mac, 18 nitroglycerin, 50 nitroglycerin in d5w, 50 nitroglycerin injection, 50 nitroglycerin patch, 50 nitroglycerin tablet sublingual, 50 NITROLINGUAL, 50 NITROMIST, 50 nitroquick, 50 NITROSTAT, 50 nizatidine, 74 NIZORAL, 13


NON-STEROIDAL ANTIINFLAMMATORY AGENTS, 87

nora-be, 108 NORCO, 31 NORDETTE-28, 99 NORDIPEN 15, 84 NORDIPEN 5, 84 NORDITROPIN, 78 NORDITROPIN FLEXPRO, 78 NORDITROPIN NORDIFLEX, 78 norepinephrine bitartrate, 52 noreth a-et estra/fe fumarate, 98, 99 noreth-ethinyl estradiol/iron, 98 norethindrone, 108 norethindrone acetate, 108 norethindrone acetate tablet, 108 norethindrone a-e estradiol, 99, 101 norethindrone-ethin estradiol, 98, 99, 100 norethindrone-mestranol, 99 NORFLEX, 86 norfloxacin, 16 norgestimate-ethinyl estradiol, 99 norgestrel-ethiny estra, 99 norgestrel-ethinyl estradiol, 99 NORINYL 1+35, 99 NORINYL 1+50, 99 NORITATE, 55 NORMOSOL-M AND DEXTROSE, 92 NORMOSOL-R, 92 NORMOSOL-R AND DEXTROSE, 92 NORMOSOL-R PH 7.4, 92 NOROXIN, 16 NORPRAMIN, 39 NOR-Q-D, 108 northyx, 66 nortrel, 99 nortriptyline, 39 nortriptyline hcl capsule, -solution, 39 NORVASC, 46 NORVIR CAPSULE, -TABLET, 5 NORVIR SOLUTION, 5 NOVAMINE, 92

NOVANATAL, 104 NOVANTRONE, 21 NOVASTART, 104 NOVOCAIN, 2 NOVOFINE 32, 84 NOVOFINE AUTOCOVER, 84 NOVOLIN 70-30 100 UNIT/ML VIAL, -U100

CARTRIDGE, 68 NOVOLIN 70-30 INNOLET, 68 NOVOLIN N 100 UNIT/ML INNOLET, -100

UNITS/ML CARTRDG, -100 UNITS/ML VIAL, 68

NOVOLIN R 100 UNIT/ML CARTRIDG, -100 UNIT/ML INNOLET, -100 UNITS/ML VIAL, 68

NOVOLOG, 68 NOVOLOG MIX 70-30, 68 NOVOPEN 3, 84 NOVOPEN JR, 84 NOXAFIL, 9 NUCYNTA, 30 NULYTELY WITH FLAVOR PACKS, 76 NUMOISYN, 65 NUMORPHAN, 30 NUTRESTORE, 97 nutrilyte, 92 nutrilyte ii, 92 nutrinate, 104 nutrispire, 104 NUTRITION,BLOOD

MODIFIERS,ELECTROLYTES, 89 NUTROPIN, 78 NUTROPIN AQ, 78 NUTROPIN AQ NUSPIN, 78 NUVARING, 99 NUVIGIL, 33 nyamyc, 13 nystatin, 9 nystatin 100,000 unit/gm powd, -cream, -

ointment, 13


nystatin 150,000,000 units pwd, -50,000,000 units pwd, -500,000,000 units pwd, -suspension oral, -tablet, 9

nystatin tablet, 19 nystatin-triamcinolone, 18 nystop, 13 ob + dha, 104 ob 90 + dha, 104 OB COMPLETE, 105 OB COMPLETE 400, 105 OB COMPLETE DHA, 105 OB/GYN TOPICAL ANTIINFECTIVES, 102 ob-natal one, 105 OBSTETRICAL AND GYNECOLOGICAL

MEDICATIONS, 97 OBSTETRIX DHA, 105 OBSTETRIX EC, 105 OBTREX, 105 OBTREX DHA, 105 O-CAL FA, 105 O-CAL PRENATAL, 105 ocella, 99 OCL, 76 OCTAGAM, 80 octreotide, 22 octreotide 1,000 mcg/ml vial, -acet 100

mcg/ml amp, -acet 100 mcg/ml vl, -acet 200 mcg/ml vl, -acet 500 mcg/ml amp, -acet 500 mcg/ml vl, 21

octreotide acet 50 mcg/ml amp, -acet 50 mcg/ml vial, 21

OCUFEN, 114 OCUFLOX, 112 ofloxacin, 16, 63, 112 ofloxacin drops, 64, 112 ofloxacin tablet, 16 OGEN, 101 ogestrel, 99 olanzapine, 26 olanzapine pamoate, 26 olanzapine/fluoxetine hcl, 26 OLEPTRO ER, 37

olmesartan med/amlodipine/hct, 52 olmesartan medoxomil, 44 olmesartan medoxomil/hctz, 51 olopatadine hcl, 65, 114 olsalazine, 75 OLUX, 60 OLUX-E, 60 OLUX-OLUX-E, 60 omalizumab, 119 omega-3 acid ethyl esters, 49 omeprazole, 77 omeprazole dr 10 mg capsule, 77 omeprazole dr 20 mg capsule, -dr 40 mg

capsule, 77 omeprazole magnesium-legend, 77 omeprazole/sodium bicarbonat, 77 omeprazole-bicarb 20-1,100 cap, 77 omeprazole-bicarb 40-1,100 cap, 77 OMNARIS, 65 OMNICEF, 7 OMNIPRED, 111 OMNITROPE, 78 ondansetron, 28 ondansetron hcl 24 mg tablet, 27 ondansetron hcl 4 mg tablet, -8 mg tablet,

27 ondansetron hcl in dextrose, 27 ondansetron hcl injection, 27 ondansetron hcl solution, 27 ondansetron odt, 27 ONGLYZA, 70 ONSOLIS, 30 OPANA, 30 OPANA ER, 30 OPHTHALMIC

ANTIINFECTIVE/CORTICOSTEROIDS, 110 OPHTHALMIC CORTICOSTEROID DRUGS,

111 OPHTHALMIC MEDICATIONS, 109 OPHTHALMIC TOPICAL ANTIBACTERIAL

DRUGS, 111


OPHTHALMIC TOPICAL ANTIVIRAL DRUGS, 112

OPHTHETIC, 114 opium, 30 OPIUM, 30 oprelvekin, 82 OPTINATE, 105 OPTIPRANOLOL, 110 OPTIVAR, 114 ORACEA, 17 ORACIT, 96 ORAL ANTICOAGULANTS, VITAMIN K, 95 ORAL ANTIFUNGAL DRUGS, 8 ORAL DERMATOLOGICAL DRUGS, 57 ORAL HYPOGLYCEMICS AND COMBOS, 69 ORALONE, 65 ORAMAGICRX, 65 ORAMORPH SR, 30 ORAP, 25 ORAPRED, 67 ORAPRED ODT, 67 ORASEP, 65 ORAVIG, 9 oraxyl, 65 ORENCIA, 21 ORFADIN, 63 orphenadrine, 86 orphenadrine citrate injection, 86 orphenadrine citrate tablet sustained action,

86 orphenadrine compound, 86 orphenadrine compound forte, 86 ORSINI INSULIN SYRINGE, 84 ORTHO EVRA, 99 ORTHO TRI-CYCLEN, 99 ORTHO TRI-CYCLEN LO, 99 ORTHO-CEPT, 99 ORTHOCLONE OKT-3, 21 ORTHO-CYCLEN, 99 ORTHO-EST, 101 ORTHO-NOVUM, 99 oseltamivir phosphate, 12

OSMITROL, 92 OSMOPREP, 74 OTHER ANTIARRHYTHMICS, 50 OTHER ANTICONVULSANTS, 35 OTHER ANTIDEPRESSANTS, 36 OTHER ANTIHYPERTENSIVES, 51 OTHER ANTIINFECTIVE DRUGS, 9 OTHER ANTIPARKINSON DRUGS, 37 OTHER ANTIULCER DRUGS, 75 OTHER ANTIVIRAL DRUGS, 11 OTHER CARDIOVASCULAR DRUGS, 52 OTHER CNS/AUTONOMIC DRUGS, 38 OTHER DRUGS AFFECTING COAGULATION,

95 OTHER DRUGS FOR ARTHRITIS, 88 OTHER DRUGS FOR ASTHMA, 117 OTHER ENDOCRINE DRUGS, 70 OTHER GENITOURINARY PRODUCTS, 120 OTHER GI DRUGS, 75 OTHER MACROLIDES, 12 OTHER OPHTHALMIC DRUGS, 112 OTHER RESPIRATORY DRUGS, 119 OTHER TOPICAL ANTIFUNGALS, 13 OTHER VASODILATING DRUGS, 53 otic edge, 64 oticin hc ear solution, -suspension drops, 64 otocidin, 64 otomycet-hc, 64 OVACE PLUS, 56 OVCON-35, 99 OVCON-50, 99 OVIDE, 58 oxacillin, 14, 15 oxacillin 1 gm add-vantage vl, -10 gm vial, -2

gm add-vantage vl, -2 gm vial, 15 oxacillin 1 gm vial, 15 OXANDRIN 10 MG TABLET, 98 OXANDRIN 2.5 MG TABLET, 98 oxandrolone, 98 oxaprozin, 87, 88 oxcarbazepine, 28 oxiconazole, 13


OXISTAT, 13 OXSORALEN, 61 OXSORALEN-ULTRA, 57 oxybutynin, 119 oxybutynin chloride syrup, -tablet, 119 oxybutynin cl er 10 mg tablet, -cl er 15 mg

tablet, 119 oxybutynin cl er 5 mg tablet, 119 oxycodone, 29, 30, 31 oxycodone hcl, 30 oxycodone hcl-acetaminophen, 30 oxycodone hcl-ibuprofen, 30 oxycodone/acetaminophen, 29, 30, 31 oxycodone/aspirin, 30 oxycodone/ibuprofen, 29 oxycodone-acetaminophen, 30 oxycodone-aspirin, 30 OXYCONTIN, 30 oxymetholone, 97 oxymorphone, 30 oxytetracycline, 17 oxytetracycline hcl/polymyxin, 112 OXYTOCICS, 102 oxytocin, 102 oxytocin injection, 102 OXYTROL, 119 PACERONE 100 MG TABLET, -400 MG

TABLET, 43 pacerone 200 mg tablet, 43 palgic, 115 palifermin, 80 paliperidone, 25 palivizumab, 81 palonosetron hcl, 26 PAMELOR, 39 pamidronate disodium, 71, 72 PAMINE, 73 PAMINE FORTE, 73 PANCREAZE, 76 PANCRELIPASE 5,000, 76 PANDEL, 60 PANHEMATIN, 63

PANLOR DC, 31 PANLOR SS, 31 PANRETIN, 61 pantoprazole, 77 pantoprazole sod dr 20 mg tab, 77 pantoprazole sod dr 40 mg tab, 77 PARAFON FORTE DSC, 86 parcaine, 114 PARCOPA, 38 paregoric, 73 PARENTERAL ANTIFUNGALS, 14 paricalcitol, 97 PARLODEL, 38 PARNATE, 35 paromomycin sulfate, 3 paroxetine, 41 paroxetine hcl 10 mg tablet, -40 mg tablet,

40 paroxetine hcl 20 mg tablet, -30 mg tablet, -

tablet sustained release 24hr, 40 paroxetine hcl suspension oral, 40 paroxetine mesylate, 41 PASER, 6 PATADAY, 114 PATANASE, 65 PATANOL, 114 PAXIL 10 MG TABLET, -40 MG TABLET, 41 PAXIL 20 MG TABLET, -30 MG TABLET, 41 PAXIL CR, 41 PAXIL SUSPENSION ORAL, 41 pazopanib, 22 PCE, 8 PEDIADERM HC, 60 PEDIAPRED, 67 PEDIARIX, 80 pedi-dri, 13 PEDIOTIC, 64 PEDVAXHIB, 80 peg 3350-electrolyte, 76 peg-3350 and electrolytes, 76 peg-3350 with flavor packs, 76 pegademase bovine, 62


PEGANONE, 35 pegaptanib sodium, 114 PEGASYS 180 MCG/0.5 ML CONV.PK, 82 PEGASYS 180 MCG/ML VIAL, 82 pegfilgrastim, 83 peginterferon alfa-2a, 82 peginterferon alfa-2b, 82 PEGINTRON 120 MCG KIT, -150 MCG KIT, -

80 MCG KIT, 82 PEGINTRON 50 MCG KIT, 82 PEGINTRON REDIPEN, 82 pegvisomant, 72 pemetrexed disodium, 19 pemirolast potassium, 113 PEN 12MM 29G NEEDLES, -31GX3/16, -

31GX5/16, -6MM 31G, -8MM 31G NEEDLES, -AURORA 6MM 31G, -AURORA S 12MM 29G, -AURORA S 8MM 31G, -BD 29GX1/2, -BD 29GX3/16, -BD 29GX5/16, -BD MINI 31GX3/16, -BD ORIG 29GX1/2, -BD SHORT 31GX5/16, -LIVE BETTER 6MM 31G, -LIVE B, 84

pen g pot/dextrose-water, 15 pen g procaine/pen g benz, 14 PEN NEEDLES, 84 penbutolol, 45 penciclovir, 11 penicillamine, 88 penicillin g benzathine, 14 penicillin g potassium, 15 PENICILLIN G POTASSIUM IN D5W, 15 penicillin g procaine, 15 penicillin g sodium, 15 PENICILLIN GK-ISO-OSM DEXTROSE, 15 penicillin v potassium, 15 PENICILLINS, 14 PENLAC, 13 PENNSAID, 58 PENTACEL, 80 PENTAM 300, 10 pentamidine, 10 pentamidine isethionate, 10

PENTASA, 76 pentazocine, 23 pentopak, 52 pentosan polysulfate sodium, 120 pentoxifylline, 52 pentoxifylline tablet sustained action, 52 pentoxil, 52 PEPCID INJECTION, 74 PEPCID SUSPENSION ORAL, -TABLET, 74 PERANEX HC PADS MEDICATED, 60 PERCOCET, 30 PERCODAN, 30 PERIDEX, 65 perindopril erbumine, 43 perio med, 93 periogard, 66 PERIOSTAT, 66 perisol, 66 permethrin, 57 permethrin cream, 58 perphenazine, 25 perphenazine-amitriptyline, 37 PERSANTINE, 89 PEXEVA 10 MG TABLET, -40 MG TABLET, 41 PEXEVA 20 MG TABLET, -30 MG TABLET, 41 PFIZERPEN, 15 phenadoz, 27 phenelzine, 35 PHENERGAN, 115 phenoxybenzamine, 47 phentolamine, 47 PHENTOLAMINE MESYLATE INJECTION, 47 phenylephrine hcl, 114 phenylephrine hcl drops, 114 PHENYTEK, 35 phenytoin, 35 phenytoin sodium, 35 phenytoin sodium extended, 35 phenytoin sodium injection, 35 phenytoin suspension oral, 35 PHISOHEX, 18 PHOS-FLUR, 93


PHOSLO, 97 phospha 250 neutral, 96 PHOSPHOLINE IODIDE, 110 phosphorus, 96 physostigmine salicylate injection, 39 pilocarpine hcl, 66, 110 pilocarpine hcl drops, 110 pilocarpine hcl tablet, 66 PILOPINE HS, 110 pimecrolimus, 61 pimozide, 25 pindolol, 45 pioglitazone hcl, 69 pioglitazone hcl/metformin hc, 69 pioglitazone/glimepiride, 69 piperacillin, 15 piperacillin/tazobactam sodium, 15 piperacillin-tazobactam, 15 PIPRACIL IN DEXTROSE, 15 pirbuterol, 116 piroxicam, 87 piroxicam capsule, 88 pitavastatin calcium, 48 PITOCIN, 102 PLAN B, 99 PLAN B ONE-STEP, 100 PLAQUENIL, 16 PLASBUMIN-25, 92 PLASMA-LYTE 148, 92 PLASMA-LYTE 148 IN DEXTROSE, 92 PLASMA-LYTE 56, 92 PLASMA-LYTE 56 IN DEXTROSE, 92 PLASMA-LYTE A PH 7.4, 92 PLASMA-LYTE R, 92 PLASMODICIDES, 15 PLAVIX, 89 plerixafor, 80 PLETAL, 89 PLEXION, 55 pnv-dha, 105 PNV-DHA PLUS, 105 pnv-iron, 105

pnv-omega, 105 pnv-select, 105 podofilox, 57 poliomyelitis vac,killed, 80 POLOCAINE, 2 poly iron pn, 105 POLY IRON PN FORTE, 105 polycin-b, 112 poly-dex, 110 polyethylene glycol 3350, -pkt, -powd, 74 POLYGESIC, 31 polymyxin b, 10 polymyxin b sulfate injection, 10 POLYMYXIN B SULFATE POWDER, 10 polymyxin b sulfate/tmp, 112 polymyxin b sul-trimethoprim, 112 POLY-PRED, 110 POLYTRIM, 112 PONSTEL, 88 portia, 100 posaconazole, 9 pot acid phos/sod acid phos, 120 potassium acetate injection, 96 potassium acid phosphate, 120 potassium bicarb/ca, 95 potassium bicarbonate tablet effervescent,

96 potassium chl-normal saline, 92 potassium chloride, 96 potassium chloride capsule sustained action,

-cl 20 meq tab er, -cl er 10 meq tablet, -cl er 20 meq tablet, -cl er 8 meq tablet, -solution, 96

potassium chloride injection, 96 potassium chloride-nacl, 92 potassium citrate, 120 potassium citrate tablet sustained action, 120 potassium citrate-citric acid, 120 potassium cl 10 meq tab sa, -tablet

effervescent, 96 POTASSIUM REMOVING RESINS, 95 POTASSIUM SPARING DIURETICS, 53


POTASSIUM SUPPLEMENTS, 95 povidone-iodine, 113 PR NATAL 400, 105 PR NATAL 400 EC, 105 pr natal 430, 105 pr natal 430 ec, 105 pr natal 440 ec, 105 pr otic solution, 64 pralidoxime chloride, 63 pramipexole, 38 pramipexole dihydrochloride, 38 pramlintide acetate, 68 PRAMOTIC, 64 pramoxine hcl/chloroxylenol, 64 PRANDIMET, 70 PRANDIN, 70 prascion, 55 prascion fc, 55 prascion ts, 55 prasugrel, 89 PRAVACHOL, 48 pravastatin, 48 pravastatin sodium, 48 praziquantel, 4 prazosin, 54 prazosin hcl, 54 PRECARE, 105 PRECARE CONCEIVE, 105 PRECARE PREMIER, 105 PRECISION SYRINGE EMPTY DISPOSABLE,

84 PRECOSE, 70 PRED FORTE, 111 PRED MILD, 111 PRED-G, 110 prednicarbate, 59, 60 prednisol, 111 prednisolone, 67 prednisolone acetate, 111 prednisolone acetate suspension drops, 111 prednisolone sod phosphate, 67 prednisolone sodium phosphate drops, 111

prednisolone sodium phosphate solution, 67 prednisolone solution oral, 67 prednisone, 67 prednisone intensol, 67 prednisone solution, -tablet, -tablet dose

pack, 67 PREFERA-OB, 105 PREFERA-OB ONE, 105 PREFERA-OB PLUS DHA, 105 PREFEST, 101 pregabalin, 36 PRELONE, 67 PREMARIN CREAM WITH APPLICATOR, -

TABLET, 101 PREMARIN INJECTION, 101 PREMASOL, 92 PREMESIS RX, 105 PREMPHASE, 102 PREMPRO, 102 prenacare, 105 prenafirst, 105 prenaplus, 105 prenatabs fa, 105 prenatabs obn, 105 prenatabs rx, 105 prenatal 19, 105 prenatal ad, 105 prenatal formula tablet, 105 prenatal low iron, 106 prenatal mr 90 fe, 106 prenatal multivitamin w-iron, 106 prenatal plus, 106 prenatal rx 1, 106 prenatal vit( = or > 1mg fa), 102, 103, 104,

105, 106, 107, 108 PRENATAL VITAMINS, 102 prenatal vitamins (< 1mg fa), 104, 105, 106,

108 prenatal z, 106 prenatal-u, 106 PRENATE DHA, 106 PRENATE ELITE, 106


PRENATE ESSENTIAL, 106 prenate plus, 106 PRENEXA, 106 PREPIDIL, 109 PREQUE 10, 106 PREVACID 30 MG CAPSULE DR, -30 MG

SOLUTAB, -DR 30 MG CAPSULE, 77 PREVACID DR 15 MG CAPSULE, -15 MG

SOLUTAB, 77 PREVACID IV, 77 prevalite, 49 PREVIDENT, 93 PREVIDENT 5000, 94 PREVIDENT 5000 PLUS, 94 PREVIDENT 5000 SENSITIVE, 94 previfem, 100 previt+dha, 106 previte rx, 106 PREVPAC, 76 PREZISTA 150 MG TABLET, -300 MG

TABLET, -75 MG TABLET, 5 PREZISTA 400 MG TABLET, -600 MG

TABLET, 5 PRIALT, 23 PRIFTIN, 6 PRILOSEC DR 10 MG CAPSULE, -DR 20 MG

CAPSULE, 77 PRILOSEC DR 40 MG CAPSULE, -PKT, 77 PRIMACARE, 106 PRIMACARE ADVANTAGE, 106 PRIMACARE ONE, 106 PRIMALEV, 30 primaquine, 16 PRIMAQUINE, 16 PRIMAXIN 250 MG VIAL, 10 PRIMAXIN 500 MG VIAL, 10 PRIMAXIN I.M., 10 primidone, 36 PRIMLEV, 30 PRIMSOL, 18 PRINIVIL, 43 PRINZIDE, 51

PRISTIQ, 37 PRIVIGEN, 80 PROAIR HFA, 116 PROAMATINE, 52 probenecid, 87 probenecid-colchicine, 87 procainamide, 44 procainamide hcl injection, 44 procaine, 2 PROCALAMINE, 92 procarbazine, 21 PROCARDIA, 46 PROCARDIA XL, 46 PROCENTRA, 33 PROCHIEVE, 108 prochlorperazine edisylate, 26, 27 prochlorperazine maleate suppository rectal,

-tablet, 27 PROCRIT 10,000 UNITS/ML VIAL, -2,000

UNITS/ML VIAL, -3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL, 80

PROCRIT 20,000 UNITS/ML VIAL, -40,000 UNITS/ML VIAL, 80

PROCTOCORT, 76 PROCTOCREAM-HC, 76 procto-pak, 76 proctosol-hc, 76 proctozone-hc, 76 PRODIGY INSULIN SYRINGE, 84 PRODIGY PEN NEEDLE, 84 progesterone, 108, 109 progesterone in oil, 108 progesterone injection, 109 PROGESTIN DRUGS, 108 PROGLYCEM, 67 PROGRAF 0.5 MG CAPSULE, -1 MG CAPSULE,

21 PROGRAF 5 MG CAPSULE, 21 PROGRAF INJECTION, 21 PROLASTIN, 119 PROLEUKIN, 82 PROLIA, 72


PROMACTA, 83 promethazine, 115 promethazine hcl injection, 115 promethazine hcl suppository rectal, 27 promethazine hcl syrup, -tablet, 115 promethazine vc, 114 promethegan, 27 PROMETRIUM, 109 PRONESTYL, 44 propafenone, 44 propafenone hcl, 44 propantheline bromide, 73 proparacaine, 113, 114 proparacaine hcl, 114 PROPINE, 110 propranolol, 44 propranolol hcl cap sa, -solution, -tablet, 45 propranolol hcl injection, 45 propranolol-hydrochlorothiazid, 51 propylthiouracil, 66 PROQUAD, 80 PROQUIN XR, 16 PROSCAR, 120 PROSOL, 92 PROSTIGMIN, 39 PROSTIN E2 VAGINAL SUPPOSITORY, 97 PROSTIN VR PEDIATRIC, 52 protamine, 94 PROTAMINE SULFATE, 94 PROTON PUMP INHIBITORS, 76 PROTONIX DR 20 MG TABLET, 77 PROTONIX DR 40 MG TABLET, -PKT, 77 PROTONIX IV, 77 PROTOPAM CHLORIDE, 63 PROTOPIC, 61 protriptyline, 39 protriptyline hcl, 39 PROVENTIL HFA, 116 PROVERA, 109 PROVIGIL, 33 PROZAC 10 MG PULVULE, 41 PROZAC 20 MG PULVULE, -SOLUTION, 41

PROZAC 40 MG PULVULE, 41 PROZAC WEEKLY, 41 PRUDOXIN, 61 pruet dha, 106 pruet dha ec, 106 pse/acrivas, 115 pse/desloratadine, 114 pse/fexofenadine, 114 PSORIATEC, 56 PULMICORT 180 MCG FLEXHALER, 118 PULMICORT 90 MCG FLEXHALER, 118 PURINETHOL, 21 PYLERA, 76 pyrazinamide, 6 pyridostigmine, 38, 39 pyridostigmine bromide, 39 pyrimethamine, 15 pyrimethamine/sulfadoxine, 15 QUALAQUIN, 16 quasense, 100 QUESTRAN, 49 QUESTRAN LIGHT, 49 quetiapine fumarate, 26 QUICK MIX WITH LYTES, 92 quinapril, 43 quinapril hcl, 43 quinapril/hctz, 51 quinapril-hydrochlorothiazide, 51 quinaretic, 52 quinidine gluconate injection, 44 quinidine gluconate tablet sustained action,

44 quinidine sulfate tablet, -tablet sustained

action, 44 quinine sulfate, 16 QUINOLONES, 16 quinupristin/dalfopristin, 10 QUIXIN, 112 QUTENZA, 61 QVAR, 118 RABAVERT, 80 rabeprazole sodium, 76


rabies immune globulin, 79, 80 rabies vac,pf chick-emb cell, 80 rabies vaccine,human diploid, 80 raloxifene, 71 raltegravir potassium, 5 ramelteon, 39 ramipril, 43 RANEXA, 52 ranibizumab, 113 RANICLOR, 7 ranitidine, 74 ranitidine 150 mg tablet, -300 mg tablet, -

capsule, -syrup, 74 ranitidine hcl injection, 74 ranolazine, 52 RAPAFLO, 120 RAPAMUNE, 21 rapiflux 20 mg tablet, 41 RAPTIVA, 21 rasagiline mesylate, 37 rasburicase, 20 RAZADYNE, 24 RAZADYNE ER, 24 REBETOL SOLUTION, -CAPSULE, 11 REBIF 22 MCG/0.5 ML SYRINGE, -44

MCG/0.5 ML SYRINGE, 82 REBIF TITRATION PACK, 82 RECLAST, 72 reclipsen, 100 RECOMBIVAX HB, 80 REFLUDAN, 95 REGLAN INJECTION, 73 REGLAN TABLET, 73 REGONOL, 39 REGRANEX, 61 RELAGARD, 102 RELENZA, 11 RELION NOVOLIN 70-30 VIAL, -RELION

VIAL, 68 RELION NOVOLIN N 100 UNITS/ML, -RELION

100 UNITS/ML, 68 RELION NOVOLIN R 100 UNITS/ML, 69

RELISTOR, 76 RELPAX, 34 REMERON, 37 remeven, 61 REMICADE, 21 remifentanil, 23 REMODULIN, 53 RENACIDIN, 120 renaf, 94 RENAGEL, 89 RENAMIN, 92 re-nata 29, 106 re-nata 29 ob, 106 renate, 106 renate dha, 106 renate dha extra, 106 RENVELA, 89 REOPRO, 89 repaglinide, 70 repaglinide/metformin hcl, 70 reprexain, 31 REQUIP, 38 REQUIP XL, 38 RESCRIPTOR, 5 RESECTISOL, 92 reserpine, 52 RESPIRATORY MEDICATIONS, 114 RESTASIS, 114 retapamulin, 17 RETAVASE, 52 reteplase, 52 RETIN-A, 56 RETIN-A MICRO, 56 RETIN-A MICRO PUMP, 56 RETISERT, 111 RETROVIR CAPSULE, -SYRUP, -TABLET, 5 RETROVIR INJECTION, 5 re-u40, 61 revatio (sildenafil citrate), 53 REVATIO INJECTION, 53 REVATIO TABLET, 53 REVIA, 39


REVLIMID, 21 revonto, 86 REYATAZ, 5 R-GENE 10, 92 RHEUMATREX, 21 RHINOCORT AQUA, 65 rho(d) immune globulin, 80, 81 RHOGAM, 80 RHOGAM PLUS, 80 RHOPHYLAC, 80 ribapak, 11 ribasphere 200 mg tablet, 11 ribasphere 400 mg tablet, -600 mg tablet, -

capsule, 11 RIBATAB, 11 ribavirin, 11, 12 ribavirin 200 mg tablet, 11 ribavirin 400 mg tablet, -600 mg tablet, -

capsule, 11 RIDAURA, 89 rifabutin, 6 RIFADIN CAPSULE, 6 RIFADIN INJECTION, 6 RIFAMATE, 6 rifampin, 6 rifampin capsule, 6 rifampin injection, 6 rifampin/inh/pyrazinamide, 6 rifampin/isoniazid, 6 rifapentine, 6 RIFATER, 6 rifaximin, 10 rilonacept, 82 RILUTEK, 86 riluzole, 86 rimantadine, 11 rimantadine hcl, 11 rimexolone, 111 RIMSO-50, 120 ringers injection, 92 RIOMET, 70 risedron sod/calcium carbona, 71

risedronate, 70 RISPERDAL CONSTA 12.5 MG SYR, -25 MG

SYR, 25 RISPERDAL CONSTA 37.5 MG SYR, -50 MG

SYR, 25 RISPERDAL M-TAB, 25 RISPERDAL SOLUTION, 25 RISPERDAL TABLET, 25 risperidone, 25 risperidone m-tab, 26 risperidone odt, 26 risperidone solution, 26 risperidone tablet, 26 RITALIN, 33 RITALIN LA, 33 RITALIN-SR, 33 ritonavir, 5 ritonavir/lopinavir, 5 RITUXAN, 21 rituximab, 21 rivastigmine, 24 rivastigmine tartrate, 23 rizatriptan benzoate, 34 ROBAXIN INJECTION, 86 ROBAXIN TABLET, 86 ROBAXIN-750, 86 ROBINUL FORTE, 73 ROBINUL INJECTION, 73 ROBINUL TABLET, 73 ROCALTROL, 97 ROCEPHIN, 7 ROMAZICON, 39 romycin, 112 ropinirole, 38 ropinirole hcl, 38 ropivacaine, 2 ROSAC, 56 rosaderm cleanser, 56 rosiglitazone maleate, 69 rosiglitazone maleate/glimepir, 69 rosiglitazone/metformin hcl, 69 rosuvastatin calcium, 48


ROTARIX, 80 ROTATEQ, 80 rotavirus vac, live att, 89-12, 80 rotavirus vac, live pentav, 80 rovin-nv, 106 rovin-nv dha, 106 ROWASA, 76 ROXANOL, 31 ROXICET SOLUTION, 31 roxicet tablet, 31 ROXICODONE, 31 ROXICODONE INTENSOL, 31 ROZEREM, 39 rubella vaccine, 80 rufinamide, 35 RYBIX ODT, 23 RYTHMOL, 44 RYTHMOL SR, 44 RYZOLT, 23 SABRIL, 36 sacrosidase, 76 SAFESNAP INSULIN SYRINGE, 84 SAFETYGLIDE INSULIN SYRINGE, 85 SAFETYGLIDE SYRINGE SYRINGE EMPTY

DISPOSABLE, 85 SAIZEN, 78 SALAGEN, 66 SALICYLATES AND RELATED DRUGS, 89 saliva subst combo no. 2, 65 saliva substitution combo no.3, 65 saliva substitution combo no.5, 65 salmeterol, 116 salmeterol/fluticasone, 117 salsalate, 89 SAL-TROPINE, 73 SAMSCA, 72 SANCTURA, 119 SANCTURA XR, 119 SANCUSO, 27 SANDIMMUNE CAPSULE, -SOLUTION, 22 SANDIMMUNE INJECTION, 22 SANDOSTATIN, 22

SANDOSTATIN LAR 10 MG KIT, -30 MG KIT, 22

SANDOSTATIN LAR 20 MG KIT, 22 SANTYL, 61 SAPHRIS, 26 sapropterin dihydrochloride, 72 saquinavir mesylate, 5 SARAFEM 10 MG TABLET, 41 SARAFEM 15 MG TABLET, 41 SARAFEM 20 MG TABLET, 41 sargramostim, 83 SAVELLA 100 MG TABLET, -12.5 MG TABLET,

-25 MG TABLET, -50 MG TABLET, 37 SAVELLA TITRATION PACK, 37 saxagliptin hydrochloride, 70 SCABICIDES, 57 SCALACORT, 60 scalp treatment, 56 SCOPACE, 74 scopolamine, 28, 74, 113 SCOPOLAMINE HYDROBROMIDE INJECTION,

74 SEASONALE, 100 SEASONIQUE, 100 seb-prev, 57 se-care, 106 se-care conceive, 106 se-care gesture, 106 SECONDARY AMINES, 39 SECTRAL, 45 SEDATIVE/HYPNOTIC DRUGS, 39 SELECTIVE SEROTONIN REUPTAKE

INHIBITORS, 40 SELECT-OB, 106 SELECT-OB + DHA, 106 selegiline, 35, 38 selegiline hcl capsule, -tablet, 38 selenium sulfide, 57 selenium sulfide 2.25% shampoo, -2.5%

lotion, -sulf 2.5% shampoo, 57 selenos, 57 selfemra 10 mg capsule, 41


selfemra 20 mg capsule, 41 SELSEB, 57 SELZENTRY, 5 SEMPREX-D, 115 se-natal 19, 106 se-natal 90, 106 se-natal one, 106 SENSIPAR, 72 SENSORCAINE, 2 SENSORCAINE WITH DEXTROSE, 2 SENSORCAINE WITH EPINEPHRINE, 2 SENSORCAINE-MPF, 2 SENSORCAINE-MPF EPINEPHRINE, 2 se-plete dha, 106 SEPTRA, 16 SEPTRA DS, 16 SEREVENT DISKUS, 116 SEROMYCIN, 6 SEROQUEL 100 MG TABLET, -200 MG

TABLET, -25 MG TABLET, -50 MG TABLET, 26

SEROQUEL 300 MG TABLET, -400 MG TABLET, 26

SEROQUEL XR 150 MG TABLET, -200 MG TABLET, 26

SEROQUEL XR 300 MG TABLET, -400 MG TABLET, -50 MG TABLET, 26

SEROSTIM, 78 sertaconazole nitrate, 13 sertraline, 41 sertraline hcl 100 mg tablet, -50 mg tablet,

41 sertraline hcl 25 mg tablet, 41 sertraline hcl solution, 41 se-tan dha, 106 setonet, 106 setonet-ec, 106 sevelamer, 89 sevelamer carbonate, 89 sf, 94 sf 5000 plus, 94 SFROWASA, 76

silodosin, 120 SILVADENE, 18 silver sulfadiazine, 18 SIMCOR 1,000-20 MG TABLET, -750-20 MG

TABLET, 48 SIMCOR 500-20 MG TABLET, 48 SIMPONI, 22 SIMULECT, 22 simvastatin, 48 simvastatin tablet, 48 sinecatechins, 62 SINEMET 10-100, 38 SINEMET 25-100, 38 SINEMET 25-250, 38 SINEMET CR, 38 SINGLE USE SWAB, 85 SINGULAIR, 116 sirolimus, 21 sitagliptin phos/metformin hcl, 70 sitagliptin phosphate, 70 SKELAXIN, 86 SKELID, 72 SMOKING CESSATION PRODUCTS, 42 sodium acetate, 92 sodium benzoate/na ph-acetate, 62 sodium bicarbonate, 91 sodium bicarbonate injection, 92 sodium chloride 0.45% irrig, -0.9% irrig., -

sterile saline 0.9% irr, 92 sodium chloride 0.45% soln, -0.45% soln-

excel con, -0.9% soln, -0.9% soln., -0.9% soln-excel cont, -0.9% solution, -3% iv soln, -4 meq/ml vl, -5% iv soln, -cl 2.5 meq/ml vial, 92

sodium citrate & citric acid, 96 sodium citrate/citric acid, 96 SODIUM EDECRIN, 49 sodium fluoride, 93, 94 sodium fluoride drops, -solution non-oral, -

tablet, -tablet chewable, 94 sodium fluoride/pot nitrate, 93, 94 sodium lactate, 92


sodium oxybate, 39 sodium phenylbutyrate, 62 sodium phosphate injection, 92 sodium phosphate/na biphos, 74 sodium polystyrene sulfonate, 95 sodium sulfacetamide-sulfur cleanser, -foam,

-pads medicated, -sulfacetamide-sulfur lotn, -sulf-sulfur wash, -suspensions, (not oral), 56

sodium tetradecyl sulfate, 63 sodium/calcium/mag/potassium, 113 SOLARAZE, 61 solia, 100 solifenacin succinate, 119 SOLODYN, 17 SOLU-CORTEF, 67 SOLU-CORTEF (PF), 67 SOLU-MEDROL, 67 SOLU-MEDROL (PF), 67 SOMA, 86 somatropin, 78 SOMATULINE DEPOT, 22 SOMAVERT, 72 SONATA 10 MG CAPSULE, 39 SONATA 5 MG CAPSULE, 40 sorafenib tosylate, 21 SORIATANE, 57 SORIATANE CK 10 MG KIT, 57 SORIATANE CK 25 MG KIT, 57 sorine, 50 sotalol, 50 sotalol af, 50 SOTALOL HCL, 50 SOTRADECOL, 63 sotret, 57 SPECIALIZED OB/GYN DRUGS, 109 SPECTRACEF, 7 SPIRIVA, 119 spironolactone, 53 spironolactone tablet, 53 spironolactone/hctz, 53 spironolactone-hctz, 53

SPORANOX CAPSULE, 9 SPORANOX SOLUTION, 9 sprintec, 100 SPRYCEL, 22 sps, 95 sronyx, 100 ssd, 18 ssd af, 18 stagesic, 31 STALEVO 100, 38 STALEVO 125, 38 STALEVO 150, 38 STALEVO 200, 38 STALEVO 50, 38 STALEVO 75, 38 stanimax, 94 stannous fluoride, 93 stannous fluoride solution, 94 STARLIX, 70 stavudine, 5 STAVZOR, 42 STELARA, 22 STERAPRED, 67 STERAPRED DS, 67 STIMATE, 72 STRATTERA, 39 streptomycin, 6 STREPTOMYCIN SULFATE INJECTION, 6 STRIANT, 98 STROMECTOL, 4 sublimaze, 31 SUBOXONE, 31 SUBUTEX, 31 succimer, 62 SUCCINIMIDES, 42 succinylcholine, 86 SUCRAID, 76 sucralfate, 75 sucralfate suspension oral, -tablet, 75 sufenta, 23 sufentanil citrate injection, 23 SULAR, 46


sulconazole nitrate, 13 sulfac, 112 sulfacetamide sodium, 56, 111 sulfacetamide sodium drops, 112 sulfacetamide sodium lotion, -suspension

topical, 57 sulfacetamide/prednisolone ac, 110 sulfacetamide/sulfur, 54, 55, 56 sulfacetamide-prednisolone, 110 sulfadiazine tablet, 16 sulfamethoxazole/trimethoprim, 16 sulfamethoxazole-trimethoprim injection, 16 sulfamethoxazole-trimethoprim suspension

oral, -tablet, 16 sulfamide, 112 SULFAMYLON, 18 sulfanilamide, 102 sulfasalazine, 75 sulfasalazine dr, 76 sulfasalazine tablet, 76 sulfatol c, 56 sulfatrim, 16 sulfazine, 76 sulfazine ec, 76 sulfisoxazole acetyl, 16 SULFONAMIDES, 16 sulfuric acid/sulf phenol, 65 sulindac, 87 sulindac tablet, 88 sulzee, 56 sumatriptan, 33, 34 SUMATRIPTAN 20 MG NASAL SPRAY, 34 sumatriptan 4 mg/0.5 ml kit, -4 mg/0.5 ml

refill, -4 mg/0.5 ml syrng, -6 mg/0.5 ml kit, -6 mg/0.5 ml refill, -6 mg/0.5 ml syrng, 34

sumatriptan 4 mg/0.5 ml vial, -6 mg/0.5 ml vial, 34

SUMATRIPTAN 5 MG NASAL SPRAY, 34 sumatriptan suc/naproxen sod, 34 sumatriptan succinate tablet, 34 SUMAVEL DOSEPRO, 34 SUMAXIN, 56

sunitinib malate, 22 SUPPRELIN LA, 109 SUPRAX, 7 SURE COMFORT, 85 SURE COMFORT ALCOHOL, 85 SURE-FINE PEN NEEDLES, 85 SURE-JECT INSULIN SYRINGE, 85 SURE-PREP ALCOHOL PREP PADS, 85 SURMONTIL, 42 SUSTIVA, 5 SUTENT, 22 SYMBICORT, 119 SYMBYAX, 26 SYMLIN, 68 SYMLINPEN 120, 68 SYMLINPEN 60, 68 SYNAGIS, 81 SYNALGOS-DC, 31 SYNAREL, 109 SYNERA, 3 SYNERCID, 10 SYNTHROID, 72 SYPRINE, 89 TACLONEX, 57 TACLONEX SCALP, 57 tacrine, 23 tacrolimus, 21, 61 tacrolimus 0.5 mg capsule, -1 mg capsule, 22 tacrolimus 5 mg capsule, 22 TAGAMET, 74 TALWIN INJECTION, 23 TAMBOCOR, 44 TAMIFLU 30 MG GELCAP, 12 TAMIFLU 45 MG GELCAP, -75 MG GELCAP,

12 TAMIFLU SUSPENSION, 12 tamoxifen citrate tablet, 22 tamsulosin, 120 tamsulosin hcl, 120 TANDEM DHA, 107 TANDEM OB, 107 TAPAZOLE, 66


tapentadol hcl, 30 TARCEVA, 22 TARGRETIN, 22 TARKA, 52 taron a prenatal, 107 taron ec calcium, 107 taron-c dha, 107 taron-ec cal, 107 taron-prex prenatal, 107 TASIGNA, 22 TASMAR, 38 tazarotene, 57 TAZICEF, 7 TAZORAC, 57 taztia xt, 46 TE ANATOXAL BERNA, 81 TEGRETOL, 28 TEGRETOL XR 100 MG TABLET, 28 TEGRETOL XR 200 MG TABLET, -400 MG

TABLET, 28 TEKTURNA, 52 TEKTURNA HCT, 52 telavancin, 10 telbivudine, 12 telithromycin, 8 telmisartan, 44 telmisartan/amlodipine, 52 telmisartan/hctz, 51 TEMOVATE, 60 TEMOVATE EMOLLIENT, 60 TENEX, 47 tenofovir disproxil fumarate, 5 TENORETIC 100, 52 TENORETIC 50, 52 TENORMIN, 45 TERAZOL 3 80 MG SUPPOSITORY, 19 TERAZOL 3 CREAM, 19 TERAZOL 7, 19 terazosin 1 mg capsule, -2 mg capsule, -5

mg capsule, 54 terazosin 10 mg capsule, 54 terbinafine, 9, 13

terbinafine hcl, 9 terbinafine/hydroxy chitosan, 9 TERBINEX, 9 terbutaline sulfate injection, 116 terbutaline sulfate tablet, 116 terconazole, 19 terconazole 0.4% cream, 19 terconazole 0.8% cream, 19 terconazole 80 mg suppository, 19 teriparatide, 71 TERRAMYCIN, 17 TERRAMYCIN IM, 17 TERRAMYCIN WITH POLYMYXIN, 112 TERSI FOAM, 57 TERTIARY AMINES, 42 TERUMO INSULIN SYRINGE, 85 TERUMO SURGUARD, 85 TESTIM, 98 TESTOPEL, 98 testosterone, 97, 98 testosterone cypionate, 98 testosterone cypionate injection, 98 testosterone enanthate, 98 testosterone propionate, 98 TESTRED, 98 TETANUS DIPHTHERIA TOXOIDS, 81 tetanus immune globulin, 80 tetanus toxoid adsorbed, 81 tetanus toxoid,adsorbed, 81 tetanus,diphtheria toxoid, 79, 81 TETANUS-DIPHTERIA-DECAVAC, 81 tetrabenazine, 39 tetracyc hcl/bis ss/metronid, 75 tetracycline, 17 tetracycline hcl capsule, 17 TETRACYCLINES, 17 tetrahydrozoline, 65 TEVETEN, 44 TEVETEN HCT, 52 TEV-TROPIN, 78 TEXACORT, 60 thalidomide, 63


THALITONE, 54 THALOMID, 63 THEO-24, 117 theochron, 117 theophylline, 117 theophylline anhydrous tablet sustained

release 12hr, 117 THERACYS, 22 THERAPEUTIC VITAMINS AND MINERALS, 96 thermazene, 18 THIAZIDE AND RELATED DRUGS, 53 THINPRO INSULIN SYRINGE, 85 thioguanine, 22 THIOGUANINE, 22 THIOLA, 62 thioridazine hcl, 26 thiothixene, 25, 26 THROMBATE III, 95 THROMBOPOIETIC AGENTS, 83 THYMOGLOBULIN, 81 thyroid, 72 THYROID SUPPLEMENTS, 72 thyroid tablet, 72 THYROLAR-1, 72 THYROLAR-1/2, 72 THYROLAR-1/4, 72 THYROLAR-2, 72 THYROLAR-3, 72 tiagabine, 35 TIAZAC, 46 ticarcillin/k clavulanate, 15 TICE BCG, 81 ticlopidine hcl, 89 TIGAN CAPSULE, 28 TIGAN INJECTION, 28 tigecycline, 10 TIKOSYN, 50 tilia fe, 100 tiludronate, 72 TIMENTIN, 15 timolol, 109, 110

timolol maleate drops, -gel-forming solution, 110

timolol maleate tablet, 45 TIMOPTIC, 110 TIMOPTIC OCUDOSE, 110 TIMOPTIC-XE, 110 TINDAMAX, 4 tinidazole, 4 tinzaparin sodium, porcine, 94 tiopronin, 62 tiotropium bromide, 119 tipranavir/vitamin e tpgs, 4 tirofib hc m-hyd/na chlor, 89 TIROSINT, 73 tizanidine, 86 tizanidine hcl, 86 TOBRADEX, 111 tobramycin, 4, 112 tobramycin sulfate drops, 112 tobramycin sulfate in ns, 4 tobramycin sulfate injection, 4 tobramycin sulfate/dexameth, 111 tobramycin/lotepred etab, 111 tobramycin-dexamethasone, 111 tobrasol, 112 TOBREX, 112 tocilizumab, 82 TOFRANIL, 42 TOFRANIL-PM, 42 tolazamide, 70 tolbutamide, 70 tolcapone, 38 tolmetin sodium, 88 tolterodine tartrate, 119 tolvaptan, 72 TOPAMAX, 36 TOPCARE CLICKFINE, 85 TOPCARE ULTRA COMFORT, 85 TOPICAL ANESTHETICS, 3 TOPICAL ANTIBACTERIAL DRUGS, 17 TOPICAL ANTIFUNGAL-CORTICOSTEROID

COMB., 18


TOPICAL ANTI-INFLAMMATORY DRUGS, 58 TOPICAL CORTICOSTEROID DRUGS, 58 TOPICAL DERMATOLOGICAL DRUGS, 60 TOPICORT, 60 TOPICORT LP, 60 topiragen, 36 topiramate, 36 topiramate capsule sprinkle, -tablet, 36 topisulf, 56 TOPROL XL, 45 TORADOL, 88 toremifene, 20 torsemide, 49 torsemide injection, 49 torsemide tablet, 49 TOTACILLIN-N, 15 TOVIAZ, 119 TPN ELECTROLYTES, 93 TPN ELECTROLYTES II, 93 TRACLEER, 47 tramadol, 23 tramadol hcl tablet, 23 tramadol hcl tablet sustained release 24hr,

23 tramadol hcl-acetaminophen, 23 tramadol/apap, 23 TRANDATE, 45 trandolapril, 43 trandolapril/verapamil, 52 trandolapril-verapamil, 52 tranexamic acid, 62, 63 TRANSDERM-SCOP, 28 tranylcypromine, 35 tranylcypromine sulfate, 35 TRAVASOL, 93 TRAVASOL WITH DEXTROSE, 93 TRAVASOL WITH ELECTROLYTES, 93 TRAVATAN, 110 TRAVATAN Z, 110 TRAVERT, 93 TRAVERT IN NORMAL SALINE, 93 TRAVERT-1/2 NS WITH KCL, 93

TRAVERT-ELECTROLYTE NO.2, 93 travoprost, 110 trazodone, 37 trazodone hcl tablet, 37 treagan otic, 64 TRECATOR, 6 TRELSTAR 11.25 MG SYRINGE, -3.75 MG

SYRINGE, 22 TRELSTAR 22.5 MG SYRINGE, -22.5 MG

VIAL, 22 TRELSTAR DEPOT, 22 TRELSTAR LA, 22 TRENTAL, 52 treprostinil sodium, 53 tretinoin, 22, 54, 55, 56 tretinoin 0.025% cream, -0.05% cream, -

0.1% cream, -gel, 56 tretinoin capsule, 22 tretinoin/emol cmb9/skin cln1, 56 TRETIN-X, 56 TREXALL, 22 TREXIMET, 34 trezix, 31 tri rx, 107 triadvance, 107 triamcinolone acetonide, 59, 65, 66, 111, 118 triamcinolone acetonide cream, -lotion, -

ointment, 60 triamcinolone acetonide injection, 67 triamcinolone acetonide paste, 66 triamcinolone hexacetonide, 66 triamterene, 53 triamterene-hctz, 53 TRIBENZOR, 52 TRICARE, 107 TRICARE DHA, 107 TRICARE PRENATAL DHA ONE, 107 tricitrates, 120 TRICOR, 49 triderm, 60 TRIDESILON, 60 trientine, 89


TRIESENCE, 111 trifera ob, 107 trifluoperazine hcl, 26 trifluridine, 112 TRIGLIDE, 49 trihexyphenidyl hcl, 24 TRIHIBIT, 81 tri-legest fe, 100 TRILEPTAL, 28 TRILIPIX, 49 tri-lo-sprintec, 100 trilyte with flavor packets, 76 trimesis rx, 107 trimethobenzamide, 28 trimethobenzamide hcl capsule, 28 trimethobenzamide hcl injection, 28 trimethoprim, 18 trimethoprim tablet, 18 trimipramine, 42 trimipramine maleate, 42 trinatal rx 1, 107 trinate, 107 trinessa, 100 TRI-NORINYL, 100 TRIOSTAT, 73 TRIPEDIA, 81 tripohist, 115 tri-previfem, 100 triprolidine hcl, 116 triprolidine hcl syrup, 115 triptorelin pamoate, 22 tri-sprintec, 100 triveen-one, 107 triveen-prx rnf, 107 triveen-u, 107 trivora-28, 100 TRIZIVIR, 5 TROPHAMINE, 93 tropicacyl, 114 tropicamide, 114 trospium chloride, 119 TRUSOPT, 110

TRUST NATAL DHA, 107 TRUVADA, 5 tuberculin syringes, 83 TWINJECT, 119 TWINRIX, 81 TWYNSTA, 52 TYGACIL, 10 TYKERB, 22 TYLENOL-CODEINE NO.3, 31 TYLENOL-CODEINE NO.4, 31 TYLOX, 31 TYPHIM VI, 81 typhoid vaccine, 81 TYSABRI, 22 TYZEKA, 12 TYZINE, 65 U-CORT, 60 u-kera e urea emollient, 61 ULESFIA, 58 ULORIC, 87 ULTICARE NEEDLE DISPOSABLE, -SYRINGE

EMPTY DISPOSABLE, 85 ULTIGUARD 30GX0.5 ML SYRINGE, -30GX1

ML SYRINGE, -SYRINGE EMPTY DISPOSABLE, 85

ULTILET ALCOHOL SWAB, 85 ULTILET INSULIN SYRINGE, 85 ULTILET PEN NEEDLE, 85 ultimatecare advantage, 107 ULTIMATECARE COMBO, 107 ultimatecare one, 107 ultimatecare one nf, 107 ULTIVA, 23 ULTRA COMFORT, 85 ULTRACET, 23 ULTRACOMFORT DISPOSABLE SYRINGE, -

NEEDLE DISPOSABLE, -SYRINGE EMPTY DISPOSABLE, 85

ULTRAM, 23 ULTRAM ER, 23 ULTRAVATE, 60 ULTRAVATE PAC, 60


UMECTA, 61 UMECTA PD, 61 UNASYN, 15 UNIFINE PENTIPS, 85 UNIPHYL, 117 UNIRETIC, 52 unithroid, 73 UNIVASC, 43 URAMAXIN, 61 urea, 61 urea 40, 61 urea 40% cream, -40% nail film susp, -45%

cream, -50% cream, -50% nail stick, -50% nailstik, -foam, -gel, -kit, -lotion, -ointment, -towelette, 62

urealac cream, -gel, -lotion, -soln, top, 62 URECHOLINE, 120 UREX, 18 URINARY ANTIINFECTIVES, 18 UROCIT-K, 120 UROLOGICAL MEDICATIONS, 119 UROQID-ACID NO.2, 18 UROXATRAL, 120 URSO, 76 URSO FORTE, 76 ursodiol, 75, 76 ursodiol capsule, -tablet, 76 ustekinumab, 22 utac, 18 VAGIFEM, 101 VAGINAL ANTIFUNGALS, 18 valacyclovir, 12 VALCYTE, 12 valganciclovir, 12 valproate sodium, 42 valproate sodium injection, 42 valproic acid, 42 VALPROIC ACID AND DERIVATIVES, 42 valproic acid capsule, -syrup, 42 valsartan, 44 VALTREX, 12 VALTURNA, 52

VANCOCIN HCL, 10 vancomycin, 10 vancomycin 1 gm add-van vial, -1 gm vial, -

10 gm vial, -5 gm vial, -500 mg a/v vial, -500 mg vial, -750 mg vial, 10

VANCOMYCIN HCL 1G/200 ML BAG, 10 VANCOMYCIN-D5W, 10 vandazole, 102 VANISHPOINT SYRINGE EMPTY

DISPOSABLE, 85 VANOS, 60 VANTAS, 22 VANTIN, 7 VAQTA, 81 varenicline tartrate, 42 varicella vacc/pf, 81 varicella virus vaccine live, 81 VARIVAX VACCINE, 81 VASERETIC, 52 VASODILATOR ANTIHYPERTENSIVES, 54 VASOTEC, 43 VECTICAL, 57 velaglucerase alfa, 72 VELCADE, 22 velivet, 100 venlafaxine, 37 venlafaxine hcl, 37 venlafaxine hcl er capsule sustained release

24 hr, 37 VENLAFAXINE HCL ER TAB SA, 37 VENTOLIN HFA, 116 VERAMYST, 65 verapamil, 45, 46 verapamil 360 mg cap pellet, 46 verapamil er, 46 verapamil hcl capsule 24hr sustained release

pellets, -er 120 mg capsule, -er 180 mg capsule, -er 240 mg capsule, -tablet, -tablet sustained action, 46

verapamil hcl injection, 46 VERDESO, 60 VEREGEN, 62


VERELAN, 46 VERELAN PM, 46 veripred 20, 67 VERSALON ALL PURPOSE SPONGE, 85 verteporfin, 114 VESANOID, 22 VESICARE, 119 VEXOL, 111 VFEND, 9 VFEND IV, 14 VIBATIV, 10 VIBRAMYCIN 50 MG CAPSULE, 17 VIBRAMYCIN SUSPENSION, -SYRUP, -100

MG CAPSULE, 17 VIBRA-TABS, 17 VICODIN, 32 VICODIN ES, 32 VICODIN HP, 32 VICOPROFEN, 32 VICTOZA 2-PAK, 68 VICTOZA 3-PAK, 68 VIDAZA, 22 VIDEX, 5 VIDEX EC, 5 vigabatrin, 36 VIGAMOX, 112 VIMOVO, 88 VIMPAT INJECTION, 36 VIMPAT SOLUTION, -TABLET, 36 vinacal, 107 vinate az, 107 vinate az extra, 107 vinate c, 107 vinate calcium, 107 vinate care, 107 vinate gt, 107 vinate ic, 107 vinate ii, 107 vinate iii, 107 vinate one, 107 vinate pn care, 107 vinate ultra, 107

vinate-m, 107 VIRACEPT, 5 VIRAMUNE, 5 VIRAZOLE, 12 VIREAD, 5 VIROPTIC, 112 VISICOL, 74 vis-phos n, 96 visqid a-a, 18 VISTARIL, 56 VISTIDE, 12 VISUDYNE, 114 vitafol-ob, 107 VITAFOL-OB+DHA, 108 vitafol-pn, 108 VITAMINS AND MINERALS AND RELATED

PRODUCTS, 97 vitanatal ob + dha, 108 vitaphil, 108 vitaphil + dha, 108 vitaphil + dha 90, 108 vitaphil aide, 108 vitaspire, 108 vitazol, 56 VITRASERT, 114 VIVA DHA, 108 VIVACTIL, 39 VIVAGLOBIN, 81 VIVELLE, 101 VIVELLE-DOT, 101 VIVITROL, 39 VIVOTIF BERNA, 81 VOL-TAB RX, 108 VOLTAREN DROPS, 114 VOLTAREN GEL, 58 VOLTAREN TABLET ENTERIC COATED, 88 VOLTAREN-XR, 88 VOLUVEN, 63 VOPAC, 32 voriconazole, 9, 14 vorinostat, 22 VOSOL, 64


VOSOL HC, 64 VOSPIRE ER, 116 VOTRIENT, 22 VPRIV, 72 VUSION, 13 vynatal-fa, 108 VYTORIN 10-10 MG TABLET, 48 VYTORIN 10-20 MG TABLET, -10-40 MG

TABLET, -10-80 MG TABLET, 48 VYVANSE, 33 warfarin sodium, 95 WEBCOL, 85 WELCHOL, 49 WELLBUTRIN, 37 WELLBUTRIN SR, 37 WELLBUTRIN XL, 37 WESTCORT, 60 westhroid, 73 WINRHO SDF, 81 XALATAN, 110 XENAZINE, 39 XERAC AC, 62 XIAFLEX, 63 XIBROM, 114 XIFAXAN 200 MG TABLET, 10 XIFAXAN 550 MG TABLET, 10 XODOL 10-300, 32 XODOL 5-300, 32 XODOL 7.5-300, 32 XOLAIR, 119 XOLEGEL, 13 XOLOX, 31 XOPENEX HFA, 116 x-viate, 62 XYLOCAINE 2% VIAL, 66 XYLOCAINE 2% VIAL, -0.5% VIAL, -1%

VIAL, 3 XYLOCAINE IV, 3 XYLOCAINE IV FOR CARDIAC, 3 XYLOCAINE JEL, -SOLUTION NON-ORAL, 3 XYLOCAINE WITH EPINEPHRINE, 3 XYLOCAINE-MPF, 3

XYLOCAINE-MPF WITH EPINEPHRINE, 3 XYREM, 39 XYZAL SOLUTION, 115 XYZAL TABLET, 116 YASMIN 28, 100 YAZ, 100 yellow fever vaccine, 81 YF-VAX, 81 zafirlukast, 116 zaleplon, 39, 40 zaleplon 10 mg capsule, 40 zaleplon 5 mg capsule, 40 zamicet, 32 ZANAFLEX, 86 zanamivir, 11 ZANTAC 25, 74 ZANTAC INJECTION, 74 ZANTAC SYRUP, -TABLET, 74 ZARONTIN, 42 ZAROXOLYN, 54 zatean-pn, 108 zatean-pn dha, 108 zatean-pn plus, 108 ZAVESCA, 72 ZAZOLE 0.8% VAGINAL CREAM, 19 ZAZOLE 80 MG VAGINAL SUPP, 19 ZAZOLE VAGINAL 0.4% CREAM, 19 ZEBETA, 45 ZEGERID 20 MG CAPSULE, 77 ZEGERID 20 MG PACKET, 77 ZEGERID 40 MG CAPSULE, 77 ZEGERID 40 MG PACKET, 77 ZELAPAR, 38 ZEMAIRA, 119 zema-pak, 67 ZEMPLAR CAPSULE, 97 ZEMPLAR INJECTION, 97 ZENAPAX, 82 zenchent, 100 ZENPEP, 76 ZERIT, 5 ZERLOR, 32


ZESTORETIC, 52 ZESTRIL, 43 ZETACET, 56 ZETIA, 49 ZIAC, 52 ZIAGEN, 5 ZIANA, 56 ziconotide acetate, 23 zidovudine, 5 zidovudine/lamivudine/abacavir, 5 zileuton, 116 ZINACEF, 7 ZINACEF IN ISO-OSMOTIC WATER, 7 ZINACEF ISO-OSMOTIC DEXTROSE, 7 zinc cl/b-caine/cetylpyrd cl, 65 ziprasidone, 25 ZIPSOR, 88 ZIRGAN, 114 ZITHRANOL-RR, 57 ZITHROMAX 100 MG/5 ML SUSP, 12 ZITHROMAX 200 MG/5 ML SUSP, 12 ZITHROMAX 250 MG TABLET, -250 MG Z-

PAK TABLET, 12 ZITHROMAX 500 MG TABLET, 12 ZITHROMAX INJECTION, 12 ZITHROMAX PACKET, -600 MG TABLET, 13 ZITHROMAX TRI-PAK, 13 ZMAX, 13 ZMAX ADULT-PEDIATRIC, 13 ZMAX PEDIATRIC, 13 ZOCOR, 48 ZOFRAN INJECTION, 28 ZOFRAN ODT, 28 ZOFRAN SOLUTION, 28 ZOFRAN TABLET, 28 ZOLADEX, 22 zoledronic acid, 72 ZOLINZA, 22 zolmitriptan, 34 ZOLOFT 100 MG TABLET, -50 MG TABLET,

41 ZOLOFT 25 MG TABLET, 41

ZOLOFT SOLUTION, 41 zolpidem, 39 zolpidem tartrate, 40 ZOMETA, 72 ZOMIG SPRAY NON-AEROSOL, 34 ZOMIG TABLET, 34 ZOMIG ZMT, 34 ZONALON, 62 ZONEGRAN, 36 zonisamide, 36 ZORBTIVE, 78 ZORPRIN, 89 ZORTRESS 0.25 MG TABLET, 22 ZORTRESS 0.5 MG TABLET, -0.75 MG

TABLET, 23 ZOSTAVAX, 81 ZOSYN, 15 zovia 1-35e, 100 zovia 1-50e, 100 ZOVIRAX CAPSULE, -SUSPENSION ORAL, -

TABLET, 12 ZOVIRAX CREAM, -OINTMENT, 12 ZUPLENZ, 28 ZYBAN, 42 ZYCLARA, 62 ZYDONE, 32 ZYFLO, 116 ZYFLO CR, 116 ZYLET, 111 ZYLOPRIM, 87 ZYMAR, 112 ZYMAXID, 112 ZYMINE, 116 ZYMINE XR, 116 ZYPREXA INJECTION, 26 ZYPREXA RELPREVV, 26 ZYPREXA TABLET, 26 ZYPREXA ZYDIS, 26 ZYVOX INJECTION, 10 ZYVOX SUSPENSION RECONSTITUTED

ORAL, -TABLET, 10



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